Original Article Bilateral same session renal stone surgery tolerance and complications Abdulmalik Addar, Ahmed Aljuhayman1, Yahya Ghazwani2,3,4, Abdullah Al Khayal2,3,4, Ahmed Alasker2,3,4, Esteban Emiliani5,6, Saeed Bin Hamri2,3,4,5 Department of Urology, McGill University Health Center, McGill University, Montreal, QC, Canada, 1Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia, 2Division of Urology, Department of Surgery, Ministry of the National Guard ‑ Health Affairs, 3King Abdullah International Medical Research Center, 4College of Medicine, King Saud bin Abdulaziz University for Health Sciences, 5PETRA-UROGROUP, Riyadh, Saudi Arabia, 6Endourology and Urolithiasis Unit, Fundacio Puigvert, Barcelona, Spain Abstract Introduction: The prevalence rate of upper urinary tract calculi in Saudi Arabia is one of the highest globally. Bilateral renal stone management is an option but is still controversial. Methodology: The study was a retrospective study, including 31 patients with bilateral renal or ureteric stones who underwent bilateral same‑session ureterorenoscopy (BSS‑URS). The data collected included age, gender, body mass index (BMI), stone burden bilaterally, operative time bilaterally, hospital stay, stone location, type of anesthesia, stone history, renal anomaly as well as pre‑ and postoperative JJ stenting. In addition, data related to complications (ureteric injury, renal failure, urinary tract infection, pain requiring an emergency department visit within 1 week of the procedure), the stone‑free rate (defined as £ 3 mm asymptomatic stone fragment identified with computed tomography Kidney, Ureter and Bladder 3 months after surgery was also collected. The data were collected from the electronic patient record system, entered in an Excel spreadsheet, and descriptive analysis was done. Results: In total, 31 patients were included, with the majority (80.6%, n = 25) male. The mean age was 41.6 years, the mean BMI 28.7 ± 5.59, the mean operative time for each renal unit 46.53 ± 25.69 min, and the mean hospital stay 17.87 ± 8.43 h. The majority (96.7%, n = 30) received general anesthesia. Less than half (40.3%, n = 25) of the renal units had stones in multiple calyces and the majority (90.3%, n = 56) of the renal units were stone free at the 3‑month follow‑up. A small proportion (3.2%, n = 2) of the renal units were polycystic. Prestenting was documented in 40.3% (n = 25) of the renal units and the majority (95.2%, n = 59) were stented postoperatively. Conclusion: BSS‑URS is a safe and a highly effective management option for bilateral renal stones. Keywords: Endourology, lithiasis, lithotripsy, ureteroscopy Address for correspondence: Dr. Saeed Bin Hamri, 2682 Prince Muteb Bin Abdulah Street, Ar Rimayah, Riyadh 14611, Saudi Arabia. E‑mail: sbinhamri@gmail.com Received: 08.08.2020, Accepted: 25.01.2021, Published: 02.09.2021 This is an open access journal, and articles are distributed under the terms of the Creative Access this article online Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit Quick Response Code: Website: is given and the new creations are licensed under the identical terms. www.urologyannals.com For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com DOI: How to cite this article: Addar A, Aljuhayman A, Ghazwani Y, Al Khayal A, 10.4103/UA.UA_128_20 Alasker A, Emiliani E, et al. Bilateral same session renal stone surgery tolerance and complications. Urol Ann 2021;13:336-9. 336 © 2021 Urology Annals | Published by Wolters Kluwer - Medknow Addar, et al.: Bilateral renal stone surgery outcome INTRODUCTION asymptomatic stone fragment identified with computed tomography kidney, ureter, and bladder (CT KUB) 3 Urolithiasis is a disease with the global health problem. In months after surgery was also collected. A renal US was the recent past, the prevalence and incidence of urinary done 9 months post‑procedure to rule out hydronephrosis. tract stones increased with a significant number of patients The data were collected, entered in an Excel spreadsheet, presenting with bilateral stones.[1,2] The treatment options, and analyzed with descriptive statistics. particularly retrograde intrarenal surgeries, have evolved extensively, though the management of bilateral stones We used a Storz Flex X2 flexible ureteroscope for all the remains controversial due to safety concerns. patients with a 10/12F ureteric access sheath. All patients received prophylactic antibiotics on the induction of the Extracorporeal Shock Wave Lithotripsy (ESWL) is the anesthesia. The patients were discharged home as per least invasive intervention with a reasonable success rate, departmental protocol for postoperative analgesia and given however in cases of multiple or high burden stones, the an appointment for removal of the JJ stent 2 weeks later. success rate is reduced and secondary procedures,[3] such as Percutaneous Nephrolithotomy (PCNL) and Flexible RESULTS Ureterorenoscopy (FURS) may be required. Staged and simultaneous bilateral PCNL are both feasible options for In total, 31 patients were included in the study with upper urinary tract stones. Although performing PCNL the majority (80.6%, n = 25) male. The mean age was bilaterally in the same operation saves patients from multiple 41.6 ± 11.81 years, the mean BMI 28.7 ± 5.59 kg/m2 [Table 1], operative procedures, reduces the length of hospital stay, and the mean operative time for each renal unit 46.53 ± 25.69 min accelerates their recovery, it is of limited use in cases with [Table 2]. The majority (96.7%, n = 30) was done under concurrent renal and ureteral stones.[4] FURS has an improved general anesthesia. Less than half (40.3%, n = 25) of the renal success rate compared to ESWL, is less invasive than PCNL units had stones in multiple calyces, and the majority (90.3%, and it is possible to reach both ureteral and renal stones.[5] n = 56) [Table 3] of the renal units were stone free at the However, bilateral same‑session ureterorenoscopy (BSS‑URS) 3‑month follow‑up. A small proportion of renal units (3.2%, is not widely accepted due to the potential risk of bilateral n = 2) were polycystic. The mean hospital stay was 17.87 ± 8.43 ureteral injuries which could cause significant morbidity. h [Table 1]. No patient had hydronephrosis at the 9‑month follow‑up renal US. Prestenting was done in 40.3% (n = 25) Saudi Arabia has one of the highest rates of urinary tract of the renal units with the majority (95.2%, n = 59) stented stones, attributed to various environmental and nutritional postoperatively [Table 2]. Two patients (3.45%) developed a factors.[6] If BSS‑URS is proven to be a feasible and safe UTI postoperatively which required antibiotic treatment as management option for bilateral renal stones, it can be an outpatient. The mean fluoroscopy time per unit was 57.6 implemented in practice to reduce cost, working days lost, s with a maximum 135 s. and the need for subsequent interventions. The aim of this study is to evaluate the outcome and safety of BSS‑URS DISCUSSION in the management of bilateral renal stones. FURS is a huge technological advancement developed for METHODOLOGY the management of renal stones. Since it was introduced, ureteroscopy was used to treat only distal ureteric stones. This was a retrospective study, including 31 patients Henceforth, recently it is used with all types of stones with bilateral renal or ureteric stones, 62 renal units, who including renal and proximal ureteric stones due to underwent BSS‑URS at King Abdulaziz Medical City in technological advances in scopes and the maneuvers used.[7] Riyadh from June 2016 till June 2018. The goal in the management of urolithiasis is to render patients stone‑free, using the least invasive procedure with The data collected included age, gender, body mass the lowest complications rate, and financially cost‑effective. index (BMI), stone burden bilaterally, operative time Bilateral ureteroscopy has a stone‑free rate of more than bilaterally, hospital stay, stone location, type of anesthesia, 85%, saving patients the need for subsequent procedures.[8,9] stone history, renal anomaly as well as pre‑and postoperative In the current study, the stone‑free rate was 90.3%, which JJ stenting. In addition, data related to complications (ureteric agrees with other reported series.[10] injury, renal failure, urinary tract infection [UTI], pain requiring an emergency department visit within 1 week of A stone‑free rate is defined as £3 mm asymptomatic stone the procedure) and the stone free rate defined as < 3mm fragment identified with CT KUB 3 months after surgery. Urology Annals | Volume 13 | Issue 4 | October-December 2021 337 Addar, et al.: Bilateral renal stone surgery outcome Table 1: Demographic information of the sample reach stones can be fragmented and extracted more easily Variable Units due to new innovations in laser and basket technologies.[13] Males n (%) 25 (80.6) Females n (%) 6 (19.4) The mean operative time per patient in the current study BMI mean, median±SD 28.47, 28.40±5.59 Age mean, median±SD 41.06, 40±11.81 was approximately 90 min. A recent study published by Stone burden (mm) mean, median±SD 11.79, 11±4.79 Knipper et al. reported that a longer operative time may Hospital stay (hours) mean, median±SD 17.87, 24±8.43 be associated with a higher complication rate which is true General anesthesia n (%) 30 (96.77) Spinal anesthesia n (%) 1 (3.33) for minor complications. The rate of major complications UTI n (%) 2 (3.45) is low regardless of the operative time.[14] This study has limitations. First, the sample size was small, Table 2: Stone location the setting a specialized tertiary care hospital, and all Renal Unit Characteristics n (%) Pre stenting 25 (40.3) BSS‑URS procedures were done by a fellowship‑trained Stent post op 59 (95.2) endourologist which may affect the operative time and Stone history 22 (35.5) stone clearance rate. The same may not be applicable Stone free rate 56 (90.3) Renal anomalies (polycystic kidney) 2 (3.2) to nonfellowship trained urologists. Second, we did not Operative time (minutes) bilateral 46.53, 45±25.69 compare the BSS‑URS with staged therapy or the cost of kidneys (mean, median±SD) such treatment. The current study is one of few studies Table 3: Renal Unit Characteristics related to BSS‑URS but with a relatively large sample Stone Location n (%) size. Follow‑up was intermediate as all patients were Upper calyx 1 (1.6) followed up to 9 months with no significant complications, Middle calyx 5 (8.1) hydronephrosis, and the stone‑free rate was high as (90%). Lower calyx 4 (6.5) Renal pelvis 8 (12.9) Multiple calyces 25 (40.3) In conclusion, BSS‑URS is a safe procedure with tolerable Upper ureter 13 (21) complications if done by an experienced endourologists. It Multiple 6 (9.7) Total 62 (100) is a judicious option, saving patients the inconvenience of subsequent procedures. With ureteroscopy being the most used procedure for urolithiasis management, it is crucial to This is a matter of controversy as some authors define find the best approach to achieve a stone‑free status with stone free as zero fragments or residual on noncontrast CT the least number of sessions. BSS‑URS has been proven to KUB. It is difficult to justify the origin of our criteria.[11] be a reasonable, safe option with low a complication rate Huang et al., in a retrospective analysis with 25 patients and in selected patients, preferred above‑staged therapy. who underwent BSS‑URS for multiple intrarenal stones, We recommend randomized control trials to explore this reported a stone‑free rate of 72% after the first session novel approach in treating patients with bilateral renal and 92% after the second session. They defined stone free stones compared with staged therapy including the financial as the absence of fragments <1 mm using an ultrasound aspects of both therapies. scan.[9] In the current study, 90.3% (n = 56) of the renal units were deemed stone free at the 3‑month follow‑up Acknowledgment with CT scan.[9] This study was funded and supported by King Abdullah International Medical Research Center, Riyadh, Saudi A recent systematic review done by Geraghty et al. explored Arabia. Study approval number RC18/318/R. the use of BSS‑URS versus staged therapy and concluded the outcomes identical, with the additional advantage for Financial support and sponsorship BSS‑URS of reduced cost, hospital stay, and operative Nil. time. In terms of complications, BSS‑URS had fewer Conflicts of interest complications than staged therapy.[10] There are no conflicts of interest. Currently, new endourological modalities exist which has REFERENCES made BSS‑URS a more feasible option. For example, ureteral access sheaths that reduce intrarenal pressure 1. Romero V, Akpinar H, Assimos DG. Kidney stones: A global picture of prevalence, incidence, and associated risk factors. Rev Urol facilitates an easier introduction of the ureteroscope as well 2010;12:e86‑96. as removing the stone fragments.[12] In addition, hard to 2. Lee S, Koh L, Ng K, Ng F. 318 incidence of computed tomography (CT) 338 Urology Annals | Volume 13 | Issue 4 | October-December 2021 Addar, et al.: Bilateral renal stone surgery outcome detected urolithiasis: An update. European Urology Supplements 8. Drake T, Ali A, Somani BK. Feasibility and safety of bilateral 2013;12:e318‑9. same‑session flexible ureteroscopy (FURS) for renal and ureteral stone 3. Abe T, Akakura K, Kawaguchi M, Ueda T, Ichikawa T, Ito H, et al. disease. Cent European J Urol 2015;68:193‑6. Outcomes of shockwave lithotripsy for upper urinary‑tract stones: 9. Huang Z, Fu F, Zhong Z, Zhang L, Xu R, Zhao X. Flexible A large‑scale study at a single institution. J Endourol 2005;19:768‑73. ureteroscopy and laser lithotripsy for bilateral multiple intrarenal 4. Silverstein AD, Terranova SA, Auge BK, Weizer AZ, Delvecchio FC, stones: Is this a valuable choice? Urology 2012;80:800‑4. Pietrow PK, et al. Bilateral renal calculi: Assessment of staged 10. Geraghty RM, Jones P, Somani BK. Simultaneous bilateral endoscopic v synchronous percutaneous nephrolithotomy. J Endourol surgery (SBES) for bilateral urolithiasis: The future? Evidence from a 2004;18:145‑51. systematic review. Curr Urol Rep 2019;20:15. 5. Resorlu B, Unsal A, Ziypak T, Diri A, Atis G, Guven S, et al. 11. Ghani KR, Wolf JS. What is the stone‑free rate following Comparison of retrograde intrarenal surgery, shockwave lithotripsy, flexible ureteroscopy for kidney stones? Nature Reviews Urology and percutaneous nephrolithotomy for treatment of medium‑sized 2015;12:281‑8. radiolucent renal stones. World J Urol 2013;31:1581‑6. 12. Kourambas J, Byrne RR, Preminger GM. Does a ureteral access sheath 6. Robertson WG, Hughes H. Epidemiology of Urinary Stone Disease in facilitate ureteroscopy? J Urol 2001;165:789‑93. Saudi Arabia. In: Ryall R, Bais R, Marshall VR, Rofe AM, Smith LH, 13. Preminger GM. Management of lower pole renal calculi: Shock Walker VR. (eds) Urolithiasis 2. Springer, Boston, MA 1994. https:// wave lithotripsy versus percutaneous nephrolithotomy versus flexible doi.org/10.1007/978-1-4615-2556-1_174. ureteroscopy. Urol Res 2006;34:108‑11. 7. Su LM, Sosa RE. Ureteroscopy and retrograde ureteral access. 14. Knipper S, Tiburtius C, Gross AJ, Netsch C. Is prolonged operation Walsh PC, Retik AB, Vaughan ED, Wein AJ, editors. Campbell’s time a predictor for the occurrence of complications in ureteroscopy? Urology. 8th ed. Philadelphia, PA; WB Saunders: 2002: p. 3306‑18. Urol Int 2015;95:33‑7. Urology Annals | Volume 13 | Issue 4 | October-December 2021 339