Retrograde Intra-Renal Surgery: A Prospective Observational Study At A Tertiary Care Hospital In Kashmir Valley- Our Initial Experience

Abstract

Background: Urinary calculi is a common affliction of the urinary tract, removal of which is one of the most important clinical aspect of a urologist. A variety of procedures like shockwave lithotripsy (SWL), flexible ureterorenoscopy (FURS) and percutaneous nephrolithotomy (PCNL) have been employed for removal of stones. A new procedure in this list is Retrograde intrarenal surgery (RIRS). 

Aims: To describe our experience and outcome of RIRS for the treatment of Urolithiasis and  to assess its effectiveness and safety in terms of Stone Free Rate/ Operation Time/  Hospital Stay/ Post-Operative blood Transfusion/ Sepsis/ Need For Second Session of  RIRS/Auxiliary Procedures.

Methods: Prospective observational study of 23 months duration (March 2021 to January 2023)  which included patients presenting with single stones ≤ 2 cm or multiple stones with  conglomerate diameter ≤2 cm or unsuccessful ESWL for stones ≤ 2cm or residual  stone after PCNL ≤ 2cm or based on patient preference. Patients who were pregnant,  with active urinary tract infection or uncorrected coagulopathy were excluded from the study. Pre-operative stenting was done using  5F/26cm DJ stent within 2 weeks of the date of procedure Standard surgical procedure  of RIRS/ FURSL was done. Follow up was done after 1 week and 4 weeks. After 4  weeks NCCT KUB was done. If stone was cleared, DJ stent was removed.  Demographic parameters, Side/ number/ size/ location/ anatomy/ HU characteristics of  stones were noted. Indication of RIRS, pre-op stenting duration, ease of access were noted. Main outcome was stone clearance. Other parameters noted were sepsis,  bleeding, duration of hospital stay, findings on follow Up NCCT for residual stones,  management of residual stone and post-operative stent duration were all noted.  Results:Majority Of the patients  had no  comorbidities (59%) among the study population. Stones were more right sided than left side (59.8% vs 40.2%), single (72%) and had an average stone size of 14.86+6.2 mm, with 52.6% belonging to 15-20 mm group and 42.1% belonging to 10-15mm group. Common location of the stones were pelvis (26.3%), upper ureter (21%), lower calyx (19.7%) followed by other locations.  Majority of the patients had normal anatomy (63.15%). Bifid PCS was noted in 2.63%, blocked infundibulum noted in 3.94% and narrow infundibulum noted in 3.28%. RIRS was done as a primary procedure in majority of the cases  (81%). There was difficulty encountered in access sheath placement in 3% of the patients. The average time taken for operative procedure was 78.51±27.2 minutes.  Complete stone clearance was obtained in 93% of the patients. (141/152).

Conclusion: RIRS is applicable to wide range of location of stones and characteristics of stones. Only minor complications like mild-grade sepsis and haemorrhage are expected in a small group of patients. Patients undergoing RIRS require only minimal hospital stay (2-3 days). RIRS appears to be an excellent modality for treatment of renal stones.