==inizio objective==

The retrograde intrarenal surgery (RIRS) is as alternative to percutaneous lithopaxy (PCNL) in patients with renal stones below 2 cm. Compared to PCNL, RIRS reduced incidence of postoperative complications but postoperative fever (POF) or sepsi can be present in a high percentage of patients.
In this study patients underwent to RIRS o PCNL, in terms of stone free rate and complications, were compared.
The aims of our study is to find the predictive parameters of stone free rate and postoperative fever or sepsis between PCNL and RIRS treatments, to identify better the patients who could benefit from these treatments and to evaluate the risk of POF or sepsi in these patients.

==fine objective==

==inizio methodsresults==

A total of 177 medical records of single session patients were included. Among 177 patients, (62 in PCNL and 115 in RIRS group). All patients were treated by two urologists having some experience of treating more than 50 cases in our hospital. We recorded data and clinical parameters as age, gender, number of stones, location, stone diameter, volume, area, density and operation time. Previous history of treatment and complications were also recorded. All patients were evaluated with blood and urine analysis and those with urinary infection were treated five days before surgery with specific antibiotics, the others with third generation cephalosporine or fluorchinolone preoperative prophylaxis.The percutaneous access was performed by the urologist. The renal puncture was done under fluoroscopic and ultrasonography control. The telescopic dilation in prone position was used under fluoroscopic control through the calix and when a supine procedure was done a pneumatic balloon for dilation was used. A 24 F Amplatz sheath was positioned, and an ultrasonic or pneumatic lithotripter used for lithotripsy. Nefroscope of 22 ch with continuous flow irrigation was used. A disconnectable nephrostomy tube of 16 or 18 ch was inserted into the renal pelvis. The operative time was evaluated from the puncture to removal of Amplatz sheath. In RIRS treatment a flexible URS 7.5 ch with holmium laser lithotripsy was used. After a urinary stent DJ was inserted and was removed within two weeks. When the operation time was longer more than the 90 minutes, the RIRS procedure was stopped and a DJ was inserted. Stone free status of patients was declared as stone free when a single stone is completely clear or a stone size < 4 mm on postoperative ultrasound and KUB after 3 month. The data analysis was performed using R 3.0.3 statistical software. P-levels < 0.05 were considered significant. ==fine methodsresults== ==inizio results== The stone free rate was higher in PCNL group. Stone diameter is an important predictor and significantly influence on stone free rates in PCNL (p=0.018) as well RIRS (p=0.008). SFR of PCNL in terms of stone diameter for 2 cm and 4 cm were 98% and 85% and 81% and 24% for RIRS. However, until 2 cm of stone diameter RIRS also provides very good stone free rates (81%). Incidence of postoperative POF and sepsi was respectively 14,8% and 17,7% in RIRS and PCNL group. The most predictive factors for sepsis were age (p=0.011), gender (p=0.020), nefrostomy tube, and Double J and operation time (p=0.026) for PCNL. The odds of women developing POF or sepsis after a PCNL intervention are 9.1 times higher than those of men. The odds of women developing sepsis after a RIRS intervention are 2.4 times higher than those of men and the data was statistically significant (p=0.011) and (p=0.026). Younger patients in both of the treatments had a higher risk, very high after PCNL, where a steep decline at 35 yrs. and increased again after 65. A 20 years old patients of RIRS has 47% risk if she is female and 27% risk if he is male, whereas in PCNL 20 years old patients 98% and 90% risk for females and males respectively. The highest risk for both of the treatments was found for age group 20 to 35 years patient. In RIRS we also found two ureteral stenosis (Clavien III B), one perirenal hematoma in a woman with hypotrophic kidney repeatedly treated in the past (Clavien III A). In PCNL group a bleeding treated with endovascular embolization was also recorded. No blood transfusions were needed or others complications were present and no patient needed to be admitted to intensive unit care in both groups. ==fine results== ==inizio discussions== In our study, we found that patients age is one of the most important predictor factor that significantly increases the risk of sepsis after RIRS and PCNL treatment. The odds of stone diameter 0.115 in PCNL treatment shows that with each additional one cm increase in stone diameter, the stone free rates decreased by 10.9%, whereas the odds of RIRS 0.129 shows higher decreasing percentage 12.1. Another thing we found that in PCNL treatment, stone free probability was significantly lower for stone location middle calice (p=0.018), whereas stone free rates of all other stone locations (upper calice, middle calice and renal pelvis) were comparatively higher. Our finding shows that younger patients have great risk of developing sepsis and older peoples have very low risk. However, we also investigated that after PCNL very older people 65 and over again slightly developing sepsis infection. Gutierrez [1] in a recent study concludes that along with preoperative positive urine culture, younger age, preoperative nephrostomy, diabetes and staghorn stones were predictive factors for post-operative fever among PCNL patients. Sepsis has reported as one of important cause of mortality among patients particularly women after PCNL and Ureteroscopy, a study by OKeeffe et al [2] reported that among 700 patients who treated by PCNL or endoscopic procedure for upper UTI stones 9 of patients developed sepsis and all they were females , 7 of them died, therefore mortality rate 66% was reported in that study among women. In our study, we found that post-PCNL was very high compared to RIRS among women patients therefore, we will particularly focus on the risk factors that increses the post-PCNL sepsis risk among women patients. One of the cross sectional study based on 217 PCNL patients reported in their study that the important predictors associated with post-PCNL fever risk were female gender, use of nephrostomy tube and preoperative positive urine culture. They concluded that higher fever among females might be due to the propensity of urinary tract infection [3]. In our present study we have found that during PCNL treatment, longer operation time is significantly associated (p=0.026) with the probability of sepsis incidence. The probability of sepsis complications was relatively higher when the operation time was longer than the 40 minutes and where higher sepsis rates were observed among women gender. Wang [4] reported the result of their study that operation time longer than 90 minutes is strongly associated (p = 0.01) with the incidence of septic shock and renal bleeding (0.017) based on 420 PCNL renal stone patients. One of the resent study published [5] concludes that, the important risk factors related with postoperative sepsis risk in PCNL treatment are operation time, stone size and presence of bacteriuria. ==fine discussions== ==inizio conclusion== The risk of POF or sepsi after endourologic procedure for renal stones is high. Anyway if we compare patients underwent to RIRS or PCNL the incidence is higher in PCNL group. The age, gender, presence of nefrostomy tube or double J and operation time (only in PCNL group) can be considered favorable factors Women and young patients develop postoperative fever more easily than older men. The operative time hasn’t influenced the onset of sepsi in RIRS group. In PCNL group a longer operative time (more than 40 min) influence negatively onset of POF or sepsi. . Incidence of post-operative fever in RIRS is lower than PCNL group. A correct preoperative evaluation of the patient, related risk factors, and analysis of urine are important. Adequate preoperative antibiotic prophylaxis to prevent the development of infections and adverse events and onset of complications. More studies are needed to explain the higher incidence of fever in younger female patients. ==fine conclusion== ==inizio references== 1) Gutierrez, J., Smith, A., Geavlete, P., Shah, H., Kural, A. R., de Sio, M., Sesmero, J. H. A., Hoznek, A., de la Rosette, J., Group, C. P. S., et al. Urinary tract infections and post-operative fever in percutaneous nephrolithotomy. World journal of urology 31, 5 (2013), 1135–1140. 2) O’keeffe, N., Mortimer, A., Sambrook, P., and Rao, P. Severe sepsis following percutaneous or endoscopic procedures for urinary tract stones. British journal of urology 72, 3 (1993), 277–283. 3) Aghdas, F. S., Akhavizadegan, H., Aryanpoor, A., Inanloo, H., and Karbakhsh, M. Fever after percutaneous nephrolithotomy: contributing factors. Surgical infections 7, 4 (2006), 367–371. 4) Wang, Y., Jiang, F., Hou, Y., Zhang, H., Chen, Q., Xu, N., Lu, Z., Hu, J., Lu, J., Wang, X., et al. Post-percutaneous nephrolithotomy septic shock and severe hemorrhage: a study of risk factors. Urologia internationalis 88, 3 (2012), 307–310. 5) Kreydin, E. I., and Eisner, B. H. Risk factors for sepsis after percutaneous renal stone surgery. Nature Reviews Urology 10, 10 (2013), 598–605. ==fine references==

==inizio objective==

According to the most recent guidelines, the percutaneous nephrolithotomy (PCNL) is the standard procedure for large renal stones(1). Intraoperative and postoperative bleedings are common complications associated with PCNL(2).
Sometimes PCNL procedures have to be interrupted if a severe intraoperative hemorrhage occurs. Mild bleedings after PCNL may be treated by brief clamping of the nephrostomy tube and adequate hydration. The superselective embolization of the segmental renal artery may become necessary in the case of severe bleedings. When embolization fails, urgent open exploration with an high probability of nephrectomy may become necessary. Sometimes a postoperatively bleeding may occurs at the time of nephrostomic tube removal(3). Hemostatic agents are usually used for nephrostomy tract closure after tubeless PCNL(4) but they are not described in scientific literature as devices usefull at the time of nephrostomic tube removal. The aim of this study was to evaluate our series of haemorrhagic complications during PCNL procedures and to descrive our experience in the use of the hemostatic agents at the time of nephrostomic tube removal.

==fine objective==

==inizio methodsresults==

From January 2010 to January 2015, 481 patients underwent a PCNL procedure at our department. 477 procedures were performed in a prone position and 4 procedures were performed in a supine position. A standard access tract (24-30 Fr) was used in 476 (99%) patients. The nephrostomy access was commonly achieved with the telescoping metal dilators of Alken. The pneumatic balloon dilator (Nephromax®) was used in 52 patients (10,8%). Stone fragmentation was achieved with the use of an ultrasonic device or a combined ultrasound/pneumatic lithotrite device. 16 out of 481 (3,3%) patients underwent a totally tubeless PCNL and “FloSeal® Hemostatic Matrix” was used for nephrostomy tract closure in 7 procedures (43,8%). In the standard procedures a 5-Fr-ureteral catheter was placed at the beginning of the procedure and a modified 20-Fr-Foley catheter was placed at the end of the procedure as nephtrostomic tube.

==fine methodsresults==

==inizio results==

Severe intraoperative bleedings occurred in 13 patients (2,7%) and in 2 patients (0,4%) we had to interrupt the procedure. Postoperative bleedings occurred in 39 patients (8,1%). 32 out of 39 bleedings (82,1%) were mild and were solved by clamping of the nephrostomy tube and adequate hydration. 7 out of 39 bleedings (17,9%) were severe and the patients underwent a diagnostic angiography. Of these, 5 patients underwent a superselective embolization of a vascular lesions or a pseudoaneurysm (Image 1) and 2 patients experienced a spontaneous endogenous hemostasis during angiography, probably due to a vasospasm(5). 8 out of 481 patients (1,7%) underwent blood transfusions for severe anemia. Postoperatively bleedings at the time of nephrostomic tube removal occurred in 14 patients (2,9%). In 2 patients (14,3%) we have repositioned the nephrostomic tube. In 1 patient (7,1%) haemostasis was achieved with the help of “TachoSil® Medicated Sponge” and in 11 patients (78,6%) with the help of “FloSeal® Hemostatic Matrix”.

==fine results==

==inizio discussions==

Most common risk factors for severe bleedings are described in scientific literature: upper caliceal puncture, solitary kidney, staghorn stone, kidney inflammation, multiple punctures, angular movement in order to search distal caliceal stone and inexperienced surgeon(6). Additional risk factors shown to increase the risk of bleeding during or after PCNL include diabetes mellitus, prolonged operative time, utilization of a mature nephrostomy tract, concomitant surgical complications, modality of access guidance (ultrasound versus fluoroscopic), and access tracts which traverse atrophic parenchima(7),(8). In our opinion the right planning of the procedure and the surgeon experience can reduce the hemorrhagic complications during a PCNL. In our series the intraoperative bleeding complication rate was very low and severe postoperative bleedings occurred only in 1,5% of the patients. Moreover the blood transfusion rate was similar to the most important series in scientific literature(9).

==fine discussions==

==inizio conclusion==

PCNL is the standard procedure for large renal stones. PCNL is a feasible procedure with a low rate of intraoperative and postoperative complications in high volume centers. Despite this, during the procedure, hemorrhagic complications can occur, in particular in some categories of patients or when the procedure is particularly difficult. In our opinion, surgeon experience and the right planning of the procedure can reduce the hemorrhagic complications during a PCNL. The “FloSeal® Hemostatic Matrix”, commonly used for nephrostomy tract closure after tubeless PCNL, is an useful device in the management of postoperative bleedings at the time of nephrostomic tube removal.

==fine conclusion==

==inizio references==

1- C. Türk , T. Knoll, A. Petrik, K. Sarica, A. Skolarikos, M. Straub, C. Seitz, Guidelines on Urolithiasis, 2015.

2- Seitz C, Desai M, Hacker A, Hakenberg OW, Liatsikos E, Nagele U, Tolley D. Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy. Eur Urol 2012 Jan;61(1):146-58

3- Ruoppolo M, Bellorofonte C, Dell’Acqua S, Zaatar C, Ferri PM, Tagliaferri A, Tombolini P.Complications of percutaneous litholapaxy. Arch Ital Urol Nefrol Androl. 1990 Dec;62(4):399-410.

4-Yu C, Xu Z, Long W, Longfei L, Feng Z, Lin Q, Xiongbing Z, Hequn C. Hemostatic agents used for nephrostomy tract closure after tubeless PCNL: a systematic review and meta-analysis. Urolithiasis. 2014 Oct;42(5):445-53. doi: 10.1007/s00240-014-0687-7. Epub 2014 Jul 27.

5- Yuan KC, Wong YC, Lin BC, Kang SC, Liu EH, Hsu YP. Negative catheter angiography after vascular contrast extravasations on computed tomography in blunt torso trauma: an experience review of a clinical dilemma. Scand J Trauma Resusc Emerg Med. 2012;20(1):46.

6- El-Nahas AR, Shokeir AA, El-Assmy AM, Mohsen T, Shoma AM, Eraky I, El-Kenawy MR, El-Kappany HA. Post-percutaneous nephrolithotomy extensive hemorrhage: A study of risk factors. J Urol. 2007;177:576–9.

7-Wang Y, Jiang F, Wang Y, Hou Y, Zhang H, Chen Q, Xu N, Lu Z, Hu J, Lu J, Wang X, Hao Y, Wang C. Post-percutaneous nephrolithotomy septic shock and severe hemorrhage: a study of risk factors. Urol Int 2012;88:307-10.

8-Kukreja R., Desai M., Patel S., Bapat S, Desai M. Factors affecting blood loss during percutaneous nephrolithotomy: prospective study. J Endourol 2004;18:715-22.

9- Soucy F, Ko R, Duvdevani M, Nott L, Denstedt JD, Razvi H.. Percutaneous nephrolithotomy for staghorn calculi: a single center’s experience over 15 years. J Endourol 2009;23:1669-73

==fine references==

==inizio objective==

Percutaneous nephrolithotomy (PCNL), is widely used for the treatment of large kidney stones. It has been always debated what is the best anesthetic method for PCNL.
General anesthesia (GA) is the most common anesthetic method applied in PCNL procedure (1). Despite this, GA can cause pulmonary complications, drug side effects, and increased intraoperative hemorrhages (2),(3),(4). Consequently in many hospitals there is a trend toward the use of spinal anesthesia (SA) for PCNL procedures, in an effort to decrease morbidity and mortality(5), (6), (7), (8).
As time goes by, we have observed a progressive growth of the use of SA in recent years at our institution, in particular for kidney stones with high surgical complexity as kidney stones in an horseshoe kidney or in pediatric patients.
The aim of this study is to investigate the effect of spinal anesthesia (SA) on the safety and efficiency of percutaneous nephrolithotomy (PCNL).

==fine objective==

==inizio methodsresults==

From January 2010 to December 2015, 481 PCNL were performed at our department. All procedures were performed in a prone position, except for 4 procedures that were performed in a supine position. 3 out of 481 patients underwent a GA for contraindications to the SA. Spinal anesthesia with hyperbaric levobupivacaine 0.5% was performed in the sitting position in all 478 patients. The anaesthetic dosage was based on anthropometric characteristics of patients and on American Society of Anesthesiologists (ASA) Physical Status classification system. Spinal anesthesia was performed at the L2 – L3 or L3 – L4 interspace using a 25-gauge or 27-gauge Whitacre needle.

==fine methodsresults==

==inizio results==

Mean age of patients who underwent a SA was 48.7 years (range,14-75). Mean duration of the procedure was 58.0 minute (range, 32-120). 8 of out 478 patients (1,7%) required blood transfusions. TUR (Trans Urethral Resection) Syndrome never occurred. We use only sodium chloride solution during the PCNL. There were no important changes in sodium or potassium concentration after the procedure in the others patients. No side effects related to SA occurred in all patients. In our experience all patients showed excellent compliance with SA. We experienced that the common duration of hospitalization, operation, and fluoroscopy of patients reduced over the years with the shift from a GA to a SA. The visual analogue scale (VAS) was inferior to three in all patients after full resolution of the spinal block. Moreover no patients required analgesic drugs during the first two hours after the procedures.

==fine results==

==inizio discussions==

Patient compliance has been critical for a successful access to calix. As the kidney moves with breathing, the voluntary control of respiration can help the surgeon to perform an easier access to calix. Subarachnoid anesthesia allows continuous monitoring of the state of consciousness, preventing the onset of a possible “reabsorption syndrome ” and allows a rapid identification of other complications like pleural lesions. Moreover the peripheral vasodilatation related to SA reduces the circulatory overload. SA avoids complications related to GA (drug side effects, intraoperative risk of hemorrhage) and the rate of postoperative lung infections above all in patients with lung diseases. SA provides a good analgesia during the first hours after surgery. SA showed better efficacy in suppressing cortisol response as compared to the technique of GA. Based on metabolic, hormonal, and hemodynamic responses, SA proved more effective than GA in suppressing stress response during elective surgical procedures (9). SA reduce deep vein thrombosis risks by improving blood flow through the legs secondary to a sympathectomy-induced vasodilatation. In addiction SA reduce the perioperative hypercoagulability that occurs as a result of the surgical stress response (10).

==fine discussions==

==inizio conclusion==

SA is a safe and effective method for PCNL in high volume centers. In our experience no absolute surgical contraindications were found. For example we usually perform a SA also in patients with renal abnormality like an horseshoe kidney. Only anesthesiological contraindications can suggest to avoid a SA: anatomical disorders of the spine, bleeding disorders, thrombocytopaenia or not collaborative patients. A limitation of this study is the small cohort of patients who underwent a GA in the last years . As a consequence we can not compare the two technique in the same period but we can only refer to our past experience.

==fine conclusion==

==inizio references==

1-Lingeman JE, Matlaga BR, Evan AP. In: Kavoussi LR, Novick AC, Partin AW, Peters CA, Wein AJ, editors. Campbell-Walsh Urology. 9. Philadelphia: Saunders-Elsevier; 2007. pp. 1431–1507.

2- Modig J, Karlstrom G. Intra- and post-operative blood loss and haemodynamics in total hip replacement when performed under lumbar epidural versus general anaesthesia. Eur J Anaesthesiol. 1987;4:345-355.

3- Scott NB, Kehlet H. Regional anaesthesia and surgical morbidity. Br J Surg. 1988;75:299-304.

4- Karacalar S, Bilen CY, Sarihasan B, Sarikaya S. Spinal-epidural anesthesia versus general anesthesia in the management of percutaneous nephrolithotripsy. J Endourol. 2009;23:1591-1597.

5- Tangpaitoon T, Nisoog C, Lojanapiwat B. Efficacy and safety of percutaneous nephrolithotomy (PCNL): a prospective and randomized study comparing regional epidural anesthesia with general anesthesia. Int Braz J Urol. 2012;38:504-511.

6- Kuzgunbay B, Turunc T, Akin S, Ergenoglu P, Aribogan A, Ozkardes H. Percutaneous nephrolithotomy under general versus combined spinal-epidural anesthesia.J Endourol. 2009;23:1-5.

7- Mehrabi S, Shirazi KK. Results and complications of spinal anesthesia in percutaneous nephrolithotomy. Urol J. 2010;7:22-25.

8- Singh V, Sinha RJ, Sankhwar SN, Malik A. A prospective randomized study comparing percutaneous nephrolithotomy under combined spinal-epidural anesthesia with percutaneous nephrolithotomy under general anesthesia. Urol Int. 2011;87:1-6.

9- Milosavljevic SB, Pavlovic AP, Trpkovic SV, Ilić AN, Sekulic AD Influence of spinal and general anesthesia on the metabolic, hormonal, and hemodynamic response in electivesurgical patients. Med Sci Monit. 2014 Oct 6;20:1833-40. doi: 10.12659/MSM.890981.

10- Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis. Anesth Analg. 2006 Oct. 103(4):1018-25.

==fine references==

==inizio objective==

The technique RIRS (Retrograde Intra-Renal Surgery) in few years arose among other surgical techniques for the treatment of renal stones, even the complex ones.
From literature we found comparative studies between RIRS and other techniques such as ESWL (External Shock Wave Lithotripsy) and PCNL (PerCutaneous Lithotripsy), this one for the treatment of big stones; compared to ESWL, RIRS provides higher stone-free rate and lower retreatment rate without increase in the incidence of complications. (1)
Although serious complications such as perioperative massive bleeding, urine leakage, bowel injury, hemothorax, and fistula are rare, increasing attention has been paid to the need for other minimally invasive surgical options to compensate for the shortcomings of PCNL.
Up to now RIRS should be considered as standard therapy for stones < 2 cm (2), and for selected patients, RIRS may represent an alternative theraphy to PCNL, with acceptable efficacy and low morbility (3). Satisfactory outcomes can be achieved with multi-session RIRS in the treatment of 2-4 cm renal stones; RIRS can be used as an alternative treatment to PCNL in selected cases with larger renal stones (4). RIRS is a refined, gentle, precise, complex surgery and it takes extreme concentration and patience; it needs a dedicated instrumentation and dedicated surgeons to give the best results. Our study, retrospective and observational, has the target to compare operative times between surgeons of different experience, to see if the endoscopical training is feasable in relatively short period. ==fine objective== ==inizio methodsresults== We introduced RIRS since January 2014. Patients' characteristics vary in number, location ad dimension of stones. The surgeons dedicated to the Endourology are named as Surgeon A, B and C. We considered as data the operative times, independent from the characteristic of stones and patients. We considered the RIRS procedurs from January 2014 up to December 2015: a total number of 131 RIRS for a total amount of 98 renal units. We used Holmium laser (green) with fiber 270 micron. We treated 14 retreatment and 7 cases of three treatment to obtain the complete stone free. The surfaces of stones trated varies from 15 mm2 to 810 mm2. In 2014 we realized 50 procedures: 47 with Surgeon A and 3 with Surgeon B. Every procedures involves Surgeons A and B contemporary. In 2015 we realized 81 RIRS divided as follows: Surgeon A: 52 procedures Surgeon B: 24 procedures (the last 15 alone) Surgeon C: 5 procedures (with A as tutor, in 2015). ==fine methodsresults== ==inizio results== Total medium surgical time about the whole 131 procedures during the biennium 2014-2015 was 48,1 minutes; Surgeon A 48,8 minutes, Surgeon B 43,8 minutes, Surgeon C 58,2 minutes. Total medium surgical time stratified for years was of 49,8 minute in 2014 and 46,9 in 2015. Medium time stratified for each surgeon is described as follows: Surgeon A: in 2014 50,6 min in 2015 47,06 min Surgeon B: in 2014 37,6 min in 2015 43,3 min Surgeon C: in 2015 58,2 min We evaluated the difference between medium time of A and B during the biennium: the difference was of 13 minutes in 2014 and of 3,76 minute in 2015. ==fine results== ==inizio discussions== The increasing time of B in 2015 could be due to the progressive increasing in the complexity of the cases treated during the training period. The procedures involded a more complex renal stones, with the higher surface treated of 810 mm2. We reconsider the statistic with the evaluation Surgeon B medium time of the last 15 cases (which were performed without tutor): medium time resulted 41,8 minutes. As number os cases treated increas as we observed a more homogeneous medium time, which corresponds to a more confidence with the procedure. Surgeon B had a training also as second surgeon with surgeon A as trainer for 50 procedures. ==fine discussions== ==inizio conclusion== We considered RIRS as first option for the treatment of renal stones. We consider it an involving therapeutichal approach which will improve in the future due to the technical improvements of instrumentations. It is a refined technique and an expertise surgeon is needed to preserve the precious instrumentation from rupture, to avoid kindey injuries and to optimized surgical times. As long as the surgeon practices, the surgical position becomes more ergonomic and the procedure easier. A constant and progressive training allows the surgeon to learn the tecnique in a relatively short time, with the creation of self sufficient surgeons in about 30 procedures. ==fine conclusion== ==inizio references== 1. Zheng C, Yang H, Luo J, Xiong B, Wang H, Jiang Q. Extracorporeal shock wave pithoptipsy versus retrograde intrarenal surgery for treatment for renal stones1-2 cm: a meta-analysis. Urolithiasis 2015 Nov (6): 549-56, 2. De Sio S, Autorino R, Zargar H, Laydner H, Balsamo R, Torricelli FC, Di Palma C, Molina WR, Monga M, De Sio M. Percutaneous nephrolithotomy versus retrograde intrarenal surgery: a systematic review and meta.analysis. Eur Urol Jan; 67(1): 125-37. 3. Bozkurt OF, Resorlu B, Yildiz Y, Can CE, Unsal A. Retrograde intrarenal surgery versus percutaneous nephrolithotomy in the management of lower-pole renal stones with a diameteer of 15 to 20 mm. J Endourol 2011 Jul; 25(7): 1131-5. 4. Akman T, Binbay M, Ozgor F, Ugurlu M, Tekinarslan E, Kezer C, Aslan R, Muslumanoglu AY. Comparison of percutaneous nephrolithotomy and retrograde flexible nephrlithotripsy for the management of 2-4 cm stones: a matched-pair analysis. BJU Int. 2012 May; 109(9): 1384-9. ==fine references==

==inizio objective==

Retrograde intrarenal surgery (RIRS) represents an intriguing technique that allows urologist to treat kidney stones. The objectives of this study are to present our experience with RIRS and to report results and complications.

==fine objective==

==inizio methodsresults==

The outcomes of 200 consecutive patients who underwent RIRS with the indication of renal stone, between January 2013 and January 2016, have been retrospectively analysed and recorded in an excel spreadsheet. Patients data include age, sex, relevant medical history, stone side, location and size. The patients were evaluated with physical examination, routine blood culture, x-ray kidney ureter and bladder (KUB), urinary ultrasonography (USG) and non contrasted computed tomography (CT). All patients were operated in the standard lithotomy position, under general and spinal anesthesia. We always used ureteral access sheath (UAS), where possible. RIRS was performed on patients with sterile urine cultures under antibiotic prophylaxis (second generation intravenous cephalosporin). Ureterorenoscope was performed to exclude presence of any ureteral pathology and dilate the ureter using semirigid ureterorenoscopy 7 Fr. Fluroscopy was always performed in all cases. A 7.2 Fr flexible ureteroscope and a 272-micron laser fiber were used. The treatment consisted in stone fragmentation or dusting, performed with holmium laser which was set at an energy level of 0.5–0.8 J and at a rate of 15–20 Hz. Continuous irrigation was used to obtain and sustain a clear operative visual field. Fragments larger than 3 mm were removed using a 2.2 F zero-tipped nitinol stone basket. At the end of the procedure a 4-6 Fr double J stent was placed. Stone free rates (SFR) of all patients were evaluated after 1 month following the procedure using KUB and USG. Success was determined as stone-free status or presence of residual fragments smaller 3 mm. Complications were classified according to the Clavien-Dindo Classification system.

==fine methodsresults==

==inizio results==

RIRS was performed on a total of 200 patients (male, n= 129; female, n= 71). The median age was 54 years (range 24-84). Stones were located in the right (n= 78), left (n= 122) kidney; in particular stones were located in the lower (n= 137), middle (n= 44), and upper (n= 24) poles, renal pelvis (n= 76). The median stone diameter was 12,2 mm (5-30 mm). In 27 patients, access sheath could not be advanced from distal to proximal ureteral, and the procedure was performed without access sheath. We used: UAS 9,5 Fr (n=2), 10-12 Fr (n= 53), 11-13 Fr (n= 4), 12-14 (n= 78), 13-15 Fr (n= 36). None of the patients underwent balloon dilatation. The median operative time was 72 minutes (18-140). 133 patients and 67 underwent spinal and general anesthesia, respectively. Median hospitalization was 1,8 days (1-19). 29 patients (14%) underwent a second look and only one patient underwent a third RIRS. The overall stone-free rates after procedures one and two were 85 % and 92 %, respectively. None complication was observed during the operation. Post-operative complications were reported in 8 (4%) patients. 4 showed intolerance to the double J stent and or flank pain; one had a cerebrospinal fluid leak after spinal anaesthesia (Grade I Clavien-Dindo). Two patients (1%), with infection were hospitalized to continue intravenous antibiotherapy (Grade II). In one patient (0,5%) we observed a subcapsular renal haematoma (SRH) associated with pulmonary embolism, after two days from the procedure (Grade IIIa). The latter received two units of packed red blood cells for low haematocrit level. Subsequently the patient underwent in the first place angiography, which did not show any blood spill, and secondly to surgery for placement of vena cava filter. At 6 months of follow-up, the SRH was resolved.

==fine results==

==inizio discussions==

Over the last 10 years, the retrograde intrarenal surgery has become an increasingly important option for the treatment of all kidney stones [1]. Many authors emphasized ureteroscopy treatment of intrarenal calculi has a low complication rate, regardless of calculus size and can be
performed as an outpatient procedure [2]. In the literature, success rates have been indicated to range between 65% and 92%. In our study SFR was 85% according to the literature. The operative time of RIRS ranged from 43,1 to 67,5 minutes [3]. In our study the median operative time was 72 minutes. Beneficial effects, and convenience of using recently popularized access sheaths have been debated [4]. Access sheaths have been used to facilitate recurrent entries into, and exits from renal collecting systems. In a study where effectiveness of these access sheaths was evaluated, its routine intraoperative use during RIRS was recommended in that it decreases costs, and duration of operations, and causes minimal morbidity [5]. In our study, we use access sheaths for nearly all of our patients. As to complications, the most frequently developed complication following RIRS is infection as it can be observed in other urological interventions. We used the Clavien-Dindo Classification system to standardize it [6]. Complications rates ranged from 0% to 25% where common complications of RIRS were fever with prolonged antibiotic use (2%-28%) [7]. The potential infections should be treated with appropriate antibiotics. In our study, since all patients received appropriate antibiotic prophylaxis, a serious infection was not encountered. Only 2 patients had high fever at postoperative first day which was relieved with appropriate antibiotherapy (Grade II). In only one patient we have a subcapsular renal haematoma in postoperative time. SRH is an unusual complication rarely described in the literature and the incidence is about 0,4% [8]. Nowadays, the reason for this event is unclear. In our patient, there was no obvious trauma to the pelvicalyceal system or renal parenchyma and operative procedure was uneventful. We think, according to Nuttall at al. [9], the hematoma was probably caused by the change of intrapelvic pressure which induced the sudden expansion and rupture of renal parenchyma and/ or capsular vessels.

==fine discussions==

==inizio conclusion==

According to the EAU guidelines, RIRS represents an alternative to percutaneous nephrolithotomy (PNL) in the treatment of renal calculi up to 2 cm in diameter. Flexible ureteroscopy is an effective and safe treatment method for the active removal of kidney stones and it is associated to a low rate of complications. A renal subcapsular hematoma was the only significant complication we recorded, which has been thoroughly studied and reported after ESWL; however, following ureteroscopy, it is a far less common complication, rarely described in the literature. Although currently PNL remains the gold standard treatment for large intrarenal stones, RIRS may allow decreased morbidity and hospital stay with a stone-free rate similar to that of PNL. However PNL remains superior to flexible ureteroscopy in terms of the number of treatments required to clear a stone.

==fine conclusion==

==inizio references==

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==fine references==