Session: PD45: Stone Disease Surgical Therapy (including ESWL) IV
PD45-10: A multicenter propensity score matched pair study in 313 patients comparing percutaneous nephrolithotomy versus retrograde intra renal surgery for management of urolithiasis in calyceal diverticulum
Introduction: Although calyceal diverticulum is commonly associated with stone formation, the majority of patients tend to be asymptomatic. Choice of management is chiefly based on stone location and mainly encompasses retrograde intrarenal surgery (RIRS) or Percutaneous nephrolithotomy (PCNL). We aimed to assess complications and outcomes of treatment via both approaches. Methods: Retrospective data of 313 patients from 10 countries were evaluated for patient demographics, peri-operative parameters and outcomes using t-test for continuous normal variables and a Mann–Whitney U test for variables without normal distribution. Categorical data between groups were analysed using the chi-squared test. Propensity score-matching (PSM) was then performed matching for baseline characteristics of age, gender, stone type (single <1cm, single >1cm, or multiple), diverticulum location, and stone size classification. Two subgroup analyses for anomalous (malrotated) kidneys and difficult diverticulum access done. Results: As a cohort, PCNL was the preferred choice for single stones of any size, malrotated kidneys. RIRS was preferred in recurrent stone formers with multiple stones. Access and mode of identification of the opening was similar for both groups. Irrespective of the route of contrast or methylene blue for delineation, guide wire coiling into the divert was equally and successfully utilized by both routes. Post intervention, there was significantly higher residual fragments (RF) (OR 0.12 95% CI 0.03 – 0.36,p < 0.001) if no dilatation/widening of diverticulum mouth was performed. 15(8.1%) RIRS cases needed conversion to either PCNL or Endoscopic combined intrarenal surgery (ECIRS) for completion and only 6(4.7%) PCNL cases needed ECIRS. After PSM was applied, significantly more PCNL patients had transient intra-op bleeding but did not require additional surgery. Post operative bleeding, sepsis, perirenal collections and overall stone free rate was similar. On Multivariate analysis, using a Thulium ber laser(TFL) had a higher SFR(OR 3.43 95% CI 1.41 – 9.25, p=0.009) 74 patients had difficult diverticulum access where pain was the main presenting complaint. RIRS was preferred here especially in lower pole and had a signicantly higher SFR(78%, p=0.031). Conclusions: Our series is the first multicenter study to compare and contrast the utility of the two endourological approaches for renal diverticular urolithiasis. Traditionally, PCNL was the intervention of choice but currently RIRS seems to be equally effective and even preferred when the access particularly in lower pole is difficult. TFL laser complements the surgery and helps improve SFR. A key step is widening of the opening post intervention to minimize residual fragments. SOURCE OF Funding: NIL
