Vendrik J. (Joep) (2013) Flexibele ureterorenoscopie met Holmium:YAG laser bij de behandeling van proximale ureter- en nierstenen >2cm. thesis, Medicine.
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Abstract
Background: Urolithiasis (urinary stones) is a common disease in the general population with an increasing incidence. Extracorporeal shock-wave lithotripsy (ESWL), percutaneous nephrolithotomy (PNL) and flexible ureterorenoscopy (URS) are the most common interventions used to treat urinary stones. Due to many developments in flexible URS techniques over the last 20 years, the use of flexible URS in the treatment of upper renal and proximal ureteral stones has increased. The main advantage of PNL are higher stonefree rates for larger stones. Therefore, as stated in the European Association of Urology (EAU) guidelines, PNL is recommended as first-line treatment for stones >2cm. However, PNL is a more invasive procedure than URS with higher morbidity. Recent clinical experience with last-generation ureterorenoscopes show better stonefree rates though. EAU guidelines state that, depending on operator skills, stones up to 3 cm can be treated efficiently by flexible URS. Hypothesis. We expect that flexible URS shows non-inferior stonefree rates compared to literature-based figures for PNL; 70% for stones >2cm or 86% for stones 2-3cm. Objective: To investigate if flexible URS could match the stonefree rates of PNL for stones >2cm and if flexible URS shows less complications than PNL. Methods. Patients who underwent a retrograde flexible URS with Holmium: YAG laser for renal or upper ureteric (above the pelvic brim) stones with a stoneburden >2cm (sum of largest diameter of all calculi), in the UMCG during 2006 -2012, were retrospectively analysed. We compared literature-based stonefree rates after PNL with stonefree rates after flexible URS of our own population, using a one-sided binominal test for non-inferiority (margin of non-inferiority of 10%) or a one-sample test for a proportion. Complication rates after flexible URS in the UMCG were compared with common complication rates after URS. Complication rates for fever and sepsis after flexible URS were compared with rates for fever and sepsis after PNL. Results: Data of 35 patients with 54 flexible ureterorenoscopies was obtained. The stonefree rate for the stoneburden category 2-3cm (76%) was significantly non-inferior compared to the non-inferiority proportion for PNL (60%). Compared to the other non-inferiority proportion (76%) this category was not significantly different. Both the stonefree rate for the whole group (50%) and for the category >3cm (32,4%) are significantly lower than the 70% for PNL. None of the complications had a significantly higher or lower incidence in the UMCG than complications rates described in the literature. We observed a trend of a lower incidence of fever for flexible URS than for PNL. Conclusion: The efficacy of the flexible URS appears to be comparable with the efficacy of PNL for stones between 2-3cm. For stones >3cm PNL is probably a better alternative, given the lower stonefree rates for flexible URS after treatment. The trend of a lower complications rate for flexible URS than for PNL might be a reason to prefer providing flexible URS above PNL for patients with stones 2-3cm.
| Item Type: | Thesis (Thesis) |
|---|---|
| Supervisor name: | Breeuwsma, Dr. A.J. and Jong, Dr. I.J. de |
| Faculty: | Medical Sciences |
| Date Deposited: | 25 Jun 2020 10:40 |
| Last Modified: | 25 Jun 2020 10:40 |
| URI: | https://umcg.studenttheses.ub.rug.nl/id/eprint/146 |
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