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JU INSIGHT Displacement of Lower Pole Stones During Retrograde Intrarenal Surgery Improves Stone-free Status
By: Alan J. Yaghoubian, MD, Icahn School of Medicine at Mount Sinai, New York, New York; Harry Anastos, MD, Icahn School of Medicine at Mount Sinai, New York, New York; Johnathan A. Khusid, MD, Icahn School of Medicine at Mount Sinai, New York, New York; Roman Shimonov, BS, Icahn School of Medicine at Mount Sinai, New York, New York; Dara J. Lundon, MD, PhD, MBA, Icahn School of Medicine at Mount Sinai, New York, New York; Raymond Khargi, MD, Icahn School of Medicine at Mount Sinai, New York, New York; Blair Gallante, MPH, Icahn School of Medicine at Mount Sinai, New York, New York; Kyra Gassmann, MD, Downstate Health and Sciences University, College of Medicine, Brooklyn, New York; Jacob N. Bamberger, MD, Downstate Health and Sciences University, College of Medicine, Brooklyn, New York; Ryan Chandhoke, MD, Kaiser Permanente, San Diego, California; Anna Zampini, MD, Cleveland Clinic, Ohio; William Atallah, MD, MPH, Icahn School of Medicine at Mount Sinai, New York, New York; Mantu Gupta, MD, Icahn School of Medicine at Mount Sinai, New York, New York | Posted on: 04 May 2023
Yaghoubian AJ, Anastos H, Khusid JA, et al. Displacement of lower pole stones during retrograde intrarenal surgery improves stone-free status: a prospective randomized controlled trial. J Urol. 2023;209(5):963-970.
Study Need and Importance
Retrograde intrarenal surgery (RIRS) is a mainstay in the surgical management of stone disease. Despite a plethora of technological advancements over the last several decades, stones within the lower pole of the kidney continue to present a challenge to urologists. Indeed, lower pole stones are associated with the lowest stone-free status (SFS) of any location in the urinary tract. To avoid laser lithotripsy in the lower pole, many urologists use a basket to displace lower pole stones into a more accessible upper or interpolar calyx. We investigated whether displacing stones out of lower pole calyces would improve SFS for patients during RIRS.
What We Found
A total of 138 patients with lower pole stones were randomized to undergo RIRS with laser lithotripsy in situ or with basket displacement. Ultimately 124 patients (62 in each group) followed up for postoperative imaging. SFS was significantly higher in the basket displacement group (95% vs 74%, P = .003). There were no significant differences between groups in operative time, laser energy usage, complications, emergency department visits, or hospital readmissions (see Table). Multivariate analysis showed that only study group allocation was associated with SFS (P = .024).
Table. Primary and Secondary Outcomes
| Displacement group (n=69) |
In situ group (n=69) |
Odds ratio | P value | |
|---|---|---|---|---|
| Stone-free status, No./total No. (%)a | 59/62 (95) | 46/62 (74) | 0.15 (0.03;0.50) |
.003 |
| Operative time, median (IQR), min | 65.0 (51.0;84.0) | 55.0 (34.0;82.0) | 0.99 (0.98;1.01) |
.11 |
| Total laser energy used, median (IQR), kJ | 2.80 (1.53;6.20) | 1.84 (0.64;5.16) | 0.94 (0.87;1.01) |
.11 |
| Complication (Clavien grade), No. (%) | 0.48 (0.12;1.64) |
.3 | ||
| None | 61 (88) | 65 (94) | ||
| II | 7 (10) | 3 (4.4) | ||
| IIIb | 0 (0) | 1 (1.5) | ||
| IVa | 1 (1.5) | 0 (0) | ||
| 30-Day ED visit, No. (%) | 8 (12) | 4 (5.8) | 0.48 (0.12;1.64) | .4 |
| 30-Day hospital readmission, No. (%) | 3 (4.4) | 3 (4.4) | 1 (0.17;6.01) | 1 |
| Abbreviations: ED, emergency department; IQR, interquartile range. Bolded P values indicate statistical significance. aA total of 14 patients (7 in each group) did not receive follow-up imaging to determine stone-free status. |
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Limitations
Despite lower sensitivity for detecting residual stone fragments compared with computerized tomography, we chose to use abdominal x-ray and renal ultrasound to avoid additional costs to patients. Additionally, there was an element of procedural variability, as patients were enrolled by 2 different surgeons without standardization of certain aspects of the procedure. Despite these limitations, our data suggest that displacement of lower pole stones during RIRS maximizes SFS.
Interpretation for Patient Care
Moving lower pole stones into more accessible parts of the kidney maximizes SFS during RIRS. The technique is simple, safe, and requires no additional equipment costs and little additional operative time. We encourage all urologists to displace lower pole stones during RIRS to improve patient outcomes.
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