Retrograde intrarenal surgery versus percutaneous nephrolithotomy for the surgical removal of kidney stones

Abstract

Background: Kidney stone disease is the third most common urinary tract disorder (Karakoç et al., 2015). According to European Association of Urology (EAU, 2015) guidelines, the minimal-ly invasive procedure, Percutaneous Nephrolithotomy (PCNL) is recommended as a first-line surgical treatment for stones 20mm or larger. Yet PCNL is associated with various post-operative complications. This has increased attention towards the non-invasive surgical proce-dure, Retrograde Intrarenal Surgery (RIRS), as an alternative to PCNL to reduce post-operative complications (Atis, Pelit, Yildirim & Caskurlu, 2017). The aim of this review is to evaluate whether RIRS is a safe and efficient alternative treatment to PCNL, for stones 20mm or greater, in terms of stone-free rate and shorter hospital stay due to lower complications. The Research Question: “Amongst Adults with Kidney Stones 20mm or greater, is Retrograde Intrarenal Sugery associated with higher stone free rates and shorter hospital stay than Percuta-neous Nephrolithotomy?” The PICO Elements: The Population (P) studied was adult patients with kidney stones 20mm or greater. The Intervention (I) observed was Retrograde Intrarenal Surgery (RIRS) and this was Compared (C) with Percutaneous Nephrolithotomy (PCNL). The outcomes analyzed were higher stone free rates and shorter hospital stay. Method: Key elements of the PICO question were utilized to generate synonyms. Boolean Op-erator was then utilized to combine these synonyms and limiters were applied to make the search more specific. Research conducted from the year 2007-2017 was considered relevant. The search strategy was then conducted by making use of various databases and the PRISMA 2009 checklist was used to eliminate irrelevant articles. Eight papers met the inclusion and exclusion criteria and the CASP tools were used to critically appraise the chosen articles. Results: From the eight key papers, one was a meta-analysis, one was a prospective clinical con-trolled trial (CCT) and the other six were retrospective CCTs. All studies found higher stone free rates in PCNL but the difference was statistically significant in only two of the included studies. This improvement was not reported in any of the studies including the meta-analysis. This re-flects an inconsistency in the evidence produced. When evaluating hospital stay all researchers found a statistically significantly shorter stay in RIRS group compared to the PCNL group, this being potentially attributed to higher rates in minor complications. Due to the inconsistencies evaluated from the key papers, it was concluded that study results ought be interpreted with cau-tion. Conclusion: RIRS seems to be a safe and effective surgical procedure for selected patients as RIRS offers a comparable initial SFR success as PCNL. This is a cautious statement, drawn in view of inconsistent evidence regarding its superiority over PCNL in this regard. Furthermore, consistent evidence is available demonstrating its ability to significantly reduce hospital stay without increasing complications. Therefore it seems that RIRS may be an alternative to PCNL in selected patients. Yet more research is required to answer the PICO question as a definite con-clusion cannot be concluded. Implications and Recommendations: Further research is required to observe and assess the safety and efficiency of RIRS in stones particularly if it will benefit certain cohorts of the popu-lation such as patients with coagulopathy or those who are receiving anticoagulant/antiplatelet treatment or diabetic patients. Further education is required to teach professionals problem solv-ing skills to make the best clinical decisions.