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| Multi-aspect analysis of ureteral access sheath usage in retrograde intrarenal surgery: A RIRSearch group study |
Oktay Özmana,*( ),Hacı M. Akgülb,Cem Başataçc,Önder Çınard,Eyüp B. Sancake,Cenk M. Yazıcıb,Bülent Önalf,Haluk Akpınarc,on behalf of the RIRSearch Study Group
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aGaziosmanpasa Training and Research Hospital, Urology Clinic, İstanbul, Turkey
bTekirdağ Namık Kemal University, School of Medicine, Department of Urology, Tekirdağ, Turkey
cGroup Florence Nightingale Hospitals, Department of Urology, İstanbul, Turkey
dZonguldak Bulent Ecevit University, School of Medicine, Department of Urology, Zonguldak, Turkey
eÇanakkale Onsekiz Mart University, School of Medicine, Department of Urology, Çanakkale, Turkey
fİstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Department of Urology, İstanbul, Turkey |
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Abstract Objective: To evaluate the effect of ureteral access sheath (UAS) use and calibration change on stone-free rate and complications of retrograde intrarenal surgery (RIRS). Methods: Data from 568 patients undergoing RIRS for kidney or upper ureteral stones were retrospectively included. Firstly, patients were compared after 1:1 propensity score matching, according to UAS usage during RIRS (UAS used [+] 87 and UAS non-used [−] 87 patients). Then all UAS+ patients (n=481) were subdivided according to UAS calibration: 9.5-11.5 Fr, 10-12 Fr, 11-13 Fr, and 13-15 Fr. Primary outcomes of the study were the success and complications of RIRS. Results: Stone-free rate of UAS+ patients (86.2%) was significantly higher than UAS− patients (70.1%) after propensity score matching (p=0.01). Stone-free rate increased with higher caliber UAS (9.5-11.5 Fr: 66.7%; 10-12 Fr: 87.0%; 11-13 Fr: 90.6%; 13-15 Fr: 100%; p<0.001). Postoperative complications of UAS+ patients (11.5%) were significantly lower than UAS− patients (27.6%) (p=0.01). Complications (8.7%) with 9.5-11.5 Fr UAS was lower than thicker UAS (17.2%) but was not statistically significant (p=0.09). UAS usage was an independent factor predicting stone-free status or peri- and post-operative complications (odds ratio [OR] 3.654, 95% confidence interval [CI] 1.314-10.162; OR 4.443, 95% CI 1.350-14.552; OR 4.107, 95% CI 1.366-12.344, respectively). Conclusion: Use of UAS in RIRS may increase stone-free rates, which also increase with higher caliber UAS. UAS usage may reduce complications; however, complications seemingly increase with higher UAS calibration.
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Received: 24 May 2021
Available online: 20 January 2024
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Corresponding Authors:
*E-mail address: ozmanoktay@hotmail.com (O.Özman).
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| Characteristic | Before propensity score matching | After propensity score matching | | UAS+ | UAS? | p-Value | UAS+ | UAS? | p-Value | | Patient, n | 481 | 87 | | 87 | 87 | | | Age, mean±SD, year | 48.5±14.3 | 47.6±13.9 | 0.66 | 51.3±13.6 | 47.6±13.9 | 0.16 | | Gender (male), n (%) | 279 (58.0) | 52 (59.8) | 0.85 | 57 (65.5) | 52 (59.8) | 0.39 | | BMI, mean±SD, kg/m2 | 27.3±4.3 | 27.1±2.6 | 0.75 | 26.4±3.0 | 27.1±2.6 | 0.18 | | Side (right), n (%) | 241 (50.1) | 36 (41.4) | 0.13 | 39 (44.8) | 36 (41.4) | 0.65 | | Stone burden, median (IQR), mm3 | 577 (237-1133) | 189 (119-781) | 0.004 | 221 (132-918) | 189 (119-781) | 0.22 | | Stone density, mean±SD, HU | 1004±321 | 1095±398 | 0.24 | 1018±330 | 1095±398 | 0.37 | | Localization, n (%) | | | 0.01 | | | 0.41 | | Lower calyx | 106 (22.0) | 26 (29.9) | | 20 (23.0) | 26 (29.9) | | | Multiple localization | 63 (13.1) | 19 (21.8) | | 17 (19.5) | 19 (21.8) | | | Others | 312 (64.9) | 42 (48.3) | | 50 (57.5) | 42 (48.3) | | | Multiple stones, n (%) | 195 (40.5) | 47 (54.0) | 0.01 | 41 (47.1) | 47 (54.0) | 0.57 | | Preoperative double-J stent, n (%) | 152 (31.6) | 15 (17.2) | 0.007 | 27 (31.0) | 15 (17.2) | 0.05 | | Failed SWL for the same stone, n (%) | 152 (31.6) | 35 (40.2) | 0.15 | 25 (28.7) | 35 (40.2) | 0.15 | | Perioperative basket usage, n (%) | 362 (75.3) | 30 (34.5) | <0.001 | 42 (48.3) | 30 (34.5) | 0.064 |
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Change in patient characteristics according to access sheath usage status.
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| Characteristic | Before propensity score matching | After propensity score matching | | UAS+ | UAS? | p-Value | UAS+ | UAS? | p-Value | | Operating timea, min | 74.8±30.2 | 76.9±44.0 | 0.48 | 85.2±36.4 | 76.9±44.2 | 0.041 | | Fluoroscopy timea, s | 16.3±78.5 | 8.1±6.2 | 0.06 | 11.3±9.3 | 8.9±6.1 | 0.33 | | Length of hospitalitya, day | 1.6±1.9 | 1.4±0.8 | 0.90 | 1.9±1.7 | 1.4±0.8 | 0.079 | | Overall complicationsb, n (%) | 78 (16.2) | 26 (29.9) | 0.002 | 16 (18.4) | 26 (29.9) | 0.08 | | Perioperative | 35 (7.3) | 15 (17.2) | 0.005 | 7 (8.0) | 15 (17.2) | 0.11 | | Postoperative | 47 (9.8) | 24 (27.6) | 0.008 | 10 (11.5) | 24 (27.6) | 0.01 | | Stone-free rate, n (%) | 412 (85.7) | 61 (70.1) | <0.001 | 75 (86.2) | 61 (70.1) | 0.01 | | Auxiliary procedure, n (%) | 61 (12.7) | 30 (34.5) | <0.001 | 9 (10.3) | 30 (34.5) | <0.001 |
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Comparison of peri- and post-operative outcomes according to ureteral access sheath usage status.
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| Characteristic | <10-12 Fr UAS | ≥10-12 Fr UAS | p-Value | | 9.5-11.5 Fr | 10-12 Fr | 11-13 Fr | 13-15 Fr | | Overall complicationsa, n/N (%) | 6/69 (8.7) | 71/412 (17.2)b | | 0.09c | | Perioperative | 4/69 (5.8) | 17/269 (6.3) | 12/139 (8.6) | 1/4 (25) | 0.62 | | Postoperative | 4/69 (5.8) | 43/412 (10.4)b | | 0.23d | | Stone-free status, n/N (%) | 46/69 (66.7) | 234/269 (87.0) | 126/139 (90.6) | 4/4 (100) | <0.001 |
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Comparison of results according to different UAS calibers.
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| Outcomes | OR | 95% CI for OR | p-Value | | Lower | Upper | | Stone-free status | | Usage | 3.654 | 1.314 | 10.162 | 0.013 | | Calibration increase | 2.387 | 1.431 | 3.984 | 0.001 | | Peri-operative complications | | Non-usage | 4.443 | 1.350 | 14.552 | 0.014 | | Calibration increase | 1.613 | 0.925 | 2.815 | 0.092 | | Post-operative complications | | Non-usage | 4.107 | 1.366 | 12.344 | 0.012 | | Calibration increase | 1.215 | 0.713 | 2.066 | 0.470 |
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Multivariable analyses of UAS related parameters to predict RIRS outcomes.
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