Comparative study of retrograde intrarenal surgery and micropercutaneous nephrolithotomy in the treatment of intermediate-sized kidney stones | Actas Urológicas Españolas (English Edition)

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Ramón de Fata, A. García-Tello, G. Andrés, C. Redondo, E. Meilán, H. Gimbernat, J.C. Angulo" "autores" => array:7 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Ramón de Fata" "email" => array:1 [ 0 => "frfata@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "García-Tello" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Andrés" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Redondo" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Meilán" ] 5 => array:2 [ "nombre" => "H." "apellidos" => "Gimbernat" ] 6 => array:2 [ "nombre" => "J.C." "apellidos" => "Angulo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Urología, Hospital Universitario de Getafe, Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio comparativo entre cirugía retrógrada intrarrenal y micro-nefrolitotomía percutánea en el tratamiento de la litiasis renal de tamaño intermedio" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 664 "Ancho" => 996 "Tamanyo" => 99701 ] ] "descripcion" => array:1 [ "en" => "Almost imperceptible 8Ch microperc incision after the surgery." ] ] ] "textoCompleto" => "IntroductionThe different therapeutic options available for the treatment of medium-sized renal strictures are extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS).<a class="elsevierStyleCrossRef" href="#bib0005">1</a> ESWL has a limited stone clearance rate, especially in lithiases in a lower caliceal group. Besides, it often requires several treatment sessions and its results are highly dependent on the nature of the calculus (size, location and composition), the anatomy of the pyelocaliceal system and the patient's features.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Despite its theoretical lower morbidity, the arguments described above contribute to the existence of an increasingly critical attitude among the urological community when choosing ESWL as the first therapeutic option, particularly in adverse situations which significantly reduce its effectiveness.RIRS is a safe procedure, with a high success rate proven in renal strictures ≤2cm regardless of their location and composition. The standardization of the procedure and the development of next-generation materials have enabled to broaden its range of therapeutic possibilities, constituting an alternative to PCNL for medium-sized calculi with lower morbidity, although it takes more operative time and sometimes requires second procedures.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>PCNL, a procedure introduced in the mid 70s which has replaced open surgery in the treatment of large renal strictures, has the highest stone clearance rate, although it is associated with increased morbidity, mainly bleeding, regarding the establishment of a percutaneous renal access route, and postoperative pain.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> With the intention of decreasing complications, the calibers of the instruments used have been progressively reduced and the mini-PCNL technique (miniperc) has been developed with 11–20 Fr materials, 15- and 18-Fr being the most commonly used ones. Another emerging minimally invasive technique is micro-PCNL (microperc) which further reduces the percutaneous access route using a 4.85–8Ch needle.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> The aim of this work was to assess the feasibility of microperc for treating medium-sized renal calculi, taking RIRS, a minimally invasive procedure of proven safety and effectiveness, as a comparative standard.Materials and methodsWe conducted a prospective comparative study between microperc and RIRS in 20 consecutive patients with renal stones of 1–3cm who had been treated during the period from September to December 2013. Eight microperc and 12 RIRS were performed.Lithiasis size was defined using the formula for the surface area of the calculus (SC=length×width×π×0.25), measures obtained through a CT of the abdomen without intravenous contrast. All patients with a sterile preoperative urine culture were given intravenous prophylactic antibiotics or specific treatment in the following situations: bacterial growth in the preoperative urine culture, patients with a urethral catheter or patients diagnosed with ectasia of the excretory duct in the imaging study.Microperc: surgical techniqueThe microperc procedure is performed under general anesthesia in the modified supine position. A mono-J urethral catheter (8Ch) is inserted into the collecting system under radiological control in order to contrast the excretory duct and perform the puncture, avoid the migration of fragments toward the proximal ureter and to reduce intrarenal pressure. The puncture of the renal papilla of the desired calyx (either of the calyx where the calculus is located or of a calyx aligned with the renal pelvis in the case of calculi with a pyelic localization) is performed with a 16G needle under ultrasound and/or fluoroscopic control. The micro-percutaneous surgical equipment (PolyDiagnost, Pfaffenhofen, Germany) consists of a 16G puncture needle (4.85Ch) with a three-duct connection (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), through which a 0.9mm optical fiber, with 10,000 pixel resolution and 120° vision (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), is inserted into the central duct. The other two connection ducts were used for the continuous irrigation system and for a 200-μm laser fiber.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>In most procedures, as we are talking about adult patients with calculi >1cm, we replaced the 4.85Ch needle with a 8Ch sheath, which improved visualization thanks to its higher irrigation flow and enabled the use of a 550-μm laser fiber to accelerate the pulverization of calculi (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) and of nitinol baskets to extract small lithiasic fragments. Since fragment extraction is more difficult than in other percutaneous procedures, the main objective is to pulverize the stone using a Ho:YAG laser (0.6J 15Hz; Megapulse 30W, Richard Wolf Gmbh, Knittlingen, Germany) in fragments less than 2mm, which could be spontaneously discharged. In all cases, we used an irrigation pump with manual perfusion control in order to work with low intrarenal pressure. A double-J ureteral stent was placed at the end of the procedure. The 8-Ch microperc incision was virtually imperceptible after surgery (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Retrograde intrarenal surgery: surgical techniqueUnder general anesthesia, and with the patient in the lithotomy position, rigid ureteroscopy is performed following the insertion of a 0.035-in. hydrophilic safety guide wire into renal cavities. This maneuver makes it possible to rule out the presence of synchronous urethral strictures and to dilate the hole and the intramural ureter under vision, before inserting the ureteral access sheath. A second 0.035 “hydrophilic guide wire is inserted, as a working guide, and over this latter guide wire, the 11/13 Fr Navigator ureteral access sheath (Boston Scientific, Natick, Massachusetts, USA) is placed under fluoroscopic control. In the event a 12/14 Fr Re-Trace access (Coloplast, Humlebæk, Denmark) is used, no second guide is necessary, since once its obturator has been removed, the working guide is placed in parallel, acting as a safety guide wire. A cobra dual-channel flexible ureteroscopy with a continuous irrigation pump (Richard Wolf Gmbh, Knittlingen, Germany) was used in all procedures (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). All renal cavities were revised in an organized way, and in the case of lower calyceal strictures, they are mobilized to the renal pelvis or to the superior calyceal group in order to work with no forced deflection and, therefore, prolong the life of flexible instruments. A new 200-μm Flexiva TracTip atraumatic laser fiber (Boston Scientific, Natick, Massachusetts, USA) allows users to work with the ureteroscopy in a bent position (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). A Ho:YAG laser (Megapulse 30W, Richard Wolf Gmbh, Knittlingen, Germany and Versapulse 20W, Lumenis Ltd, Yokneam, Israel) with 200- and 272-μm fibers was customarily used for lithotripsy.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>Once the calculus had been fragmented, significant fragments were extracted using a 1.9Ch ZeroTip nitinol basket (Boston Scientific, Natick, Massachusetts, USA) for further analysis (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). It is important to remove the ureteral access sheath under endoscopic visual control in order to rule out unnoticed ureteral lesions which might require ureteral catheter placement for a longer time. At the end of the procedure, a double-J ureteral stent is inserted, and is generally removed within 7 days. If there are no complications within the first 24h, the bladder catheter is removed and the patient is discharged.The stone clearance rate is intraoperatively assessed with endoscopic visualization and fluoroscopy, in the immediate post-surgery period (24h) by simple radiography of the urinary system and after 3 months by CT scanning of the abdomen without i.v. contrast.Study designThe perioperative variables analyzed were the following: demographic data of the patients, calculus characteristics, body mass index (BMI) and anesthetic risk as defined by the American Society of Anesthesiologists (ASA). The main intraoperative parameters collected were surgical time, need for auxiliary procedures and aspects related to the surgical technique used. Finally, the postoperative results assessed were the percentage of lithiasis removal, complications according to the Clavien–Dindo classification and hospital stay.The quantitative variables for the statistical analysis were described using the median and the interquartile range (IQR) and their normalcy was established using the Kolmogorov–Smirnov and Shapiro–Wilk tests. Student's-t was used for continuous quantitative variables with a normal distribution and the Mann–Whitney U test for continuous variables which do not follow a normal distribution. The Chi-square and Fisher's exact tests were used to study the association between categorical variables. A p-value<0.05 was considered statistically significant.ResultsThe demographic characteristics of the patients and of the strictures treated were very similar, with no statistically significant differences between the groups (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>). The surgical times for both procedures were also similar, with no differences of statistical significance, the median being 120min (88.7–167.5) for microperc and 120min (111.2–148.7) for RIRS; p=0.8. Two patients treated with microperc (25%) required additional procedures (simultaneous RIRS and flexible nephroscopy after percutaneous tract dilation, respectively) for treating a significant fragment that had migrated to a superior calyx inaccessible through the percutaneous approach. One patient in the RIRS group (8.3%) also required miniperc due to unfavorable inferior infundibular-calyceal anatomy; p=0.54. The supplementary techniques were always performed in the same surgical procedure.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The average percentage of lithiasis removal at 3 months follow-up was 95±14.5% for RIRS and 96.9±8.8% for microperc, both medians (IQR) being 100 (100–100); p=0.8. One patient in the RIRS group (8.3%) had postoperative fever (Clavien I) which resolved in 24h without having to change the previously established intravenous antibiotic pattern, and one patient in the microperc group (12.5%) showed postoperative colic pain that required intravenous analgesic treatment (Clavien I), which also resolved in the first 24h. No patient required blood transfusion. The hospital stay with microperc was slightly higher (1.5 [1–3.5] days) than with RIRS (1 [1–2] day), although it did not reach statistical significance; p=0.33 (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). In the microperc group, we used the 4.85-Ch needle in one case (12.5%) and it was replaced with the 8-Ch sheath in 7 cases (87.5%). We used a double-J ureteral stent in all procedures, which was removed on an outpatient basis on the seventh postoperative day. All the microperc procedures and the case treated with rescue miniperc after RIRS were performed without the need for percutaneous nephrostomy (tubeless).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionAccording to the clinical guidelines of the European Association of Urology, the different options available for the treatment of medium-sized renal strictures are ESWL, RIRS and PCNL.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The effectiveness of ESWL is conditioned by the calculus size and other variables, such as composition and hardness of the stone, the anatomy of the excretory system (length, width of the infundibulum and the infundibulo-pyelic angle) and the patient's characteristics (BMI, skeletal deformities, blood clotting disorders). Still, guidelines recommend it as a first-line treatment for renal stones <2cm mainly due to its theoretical low morbidity and because it is an outpatient procedure which does not require anesthesia, but the reality is that its limited effectiveness, especially in the case of strictures located in the lower calyceal group has resulted in an increasingly restrictive attitude from the urological community. Besides, technical developments and the experience acquired in endourological procedures such as RIRS and PCNL has contributed to its widespread use, especially in the circumstances where the results of ESWL are uncertain. A meta-analysis conducted in 2009 by Srisubat et al.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> (Cochrane database), comparing ESWL, RIRS and PCNL, determined that the stone clearance rate of ESWL was lower. The differences between RIRS and PCNL were less evident.The experience acquired with RIRS and the development of next-generation endoscopes, with a 270° active deflection, which enable us to reach and work in all renal cavities in most cases, have allowed for systematizing the treatment of medium-sized renal strictures with good results and low morbidity. In recent years, some authors have documented its usefulness in strictures >2cm, usually treated with PCNL, obtaining excellent stone clearance rates at the expense of an increase in surgical time and the need for second procedures.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> The main disadvantages of RIRS lie in the occasional need for inserting a double-J stent and postponing the procedure in case of a narrow ureter which impedes the passage of a ureteral access sheath,<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a> as well as the risk for ureteral lesions, severe in some cases, which require prolonged ureteral catheterization. This situation is more frequent in older men and has been documented in up to 13.3% of cases in large series, so it is highly advisable to remove the ureteral access sheath under endoscopic vision at the end of the procedure.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Another constraint of RIRS is the cost derived from using disposable ancillary materials and the average life of flexible ureteroscopes, which can reach 50–60 procedures with good practice and excellent care.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>PCNL shows the highest stone clearance rate with just one procedure, but also shows the highest morbidity, although fortunately the rate of major complications is low. The analysis of complications carried out by the Clinical Research Office of the Endourological Society (CROES) in 5803 patients revealed that the main complications of PCNL were the following: clinically relevant bleeding (7.8%), perforation of the excretory tract (3.4%), hydrothorax (1.8%) and need for transfusion (5.7%).<a class="elsevierStyleCrossRef" href="#bib0070">14</a> In a register of the Spanish Association of Urology conducted in 397 patients who had undergone PCNL in the supine position, the transfusion rate was 5.5%.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Most of these complications are related to the creation of the percutaneous passage, and bleeding in particular is directly related to its caliber.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> In 1997, Helal et al.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> described the miniperc technique for the treatment of renal lithiasis in pediatric patients, and in 1998, Jackman et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> used it in an adult population to decrease surgical trauma and, therefore, bleeding. Miniperc entails a shorter hospital stay and less drop in hemoglobin, with a similar stone clearance rate when compared with standard PCNL.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> When miniperc is compared with RIRS, the effectiveness and morbidity of both procedures in medium-sized strictures are overlapped.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>The progressive trend toward the miniaturization of the surgical instruments for percutaneous surgery seeks primarily to simplify the puncture, reducing morbidity and radiological exposure. Bader et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> published in 1991 their initial experience with a 0.9-mm microscopic optics inserted through the working channel of a 16G (4.85Ch) puncture needle, which enabled them to carry out the PCNL procedure in a single step without the need for dilation of the percutaneous tract. Desai et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> subsequently defined this concept and developed a technique where the percutaneous access and lithiasic fragmentation were performed in a one-stage procedure, using an all seeing needle.In this feasibility study, the stone clearance rate was similar in both groups, and in line with that obtained by other authors.<a class="elsevierStyleCrossRefs" href="#bib0105">21–24</a> Sabnis et al., in a comparative study between microperc and RIRS, obtained a resolution rate of 97.1 and 94.3%, respectively.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> Despite being a new procedure, it can be performed with excellence by any urologist with experience in percutaneous renal surgery. In our experience, the surgical times in both groups were also similar. The 4.85Ch needle only allows to disintegrate the calculus, so that there is a subsequent spontaneous removal of fragments. In the case of strictures >1cm, its replacement with a 8Ch metal sheath improves visibility; thanks to its greater sectioning strength it enables us to use a 550-μm laser fiber, which accelerates fragmentation and enables the extraction of 2–3mm fragments for the analysis of the calculus.Microperc enables access to unfavorable anatomy calyxes (an acute angle, narrow or excluded hydrocalyxes) where RIRS presents greater difficulties.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Nonetheless, RIRS is the preferable option for patients with morbid obesity,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> where percutaneous instruments reach the excretory tract with greater difficulty, or for patients with cardiovascular diseases under anticoagulant therapy, a situation where both PCNL and ESWL are contraindicated.On the other hand, the image quality offered by RIRS, especially with our current means (digital endoscopes), with a higher image resolution than that of fiber optics and less fragility, also translates into a lower long-term cost and less operative time per procedure.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>ConclusionsAlthough this is a limited experience, this study confirms the feasibility of microperc in the treatment of medium-sized renal strictures (1–3cm), so it is an effective and safe alternative, taking the RIRS technique as a reference point. There is no doubt that having both techniques available increases the versatility and complementarity of endourological treatment. The percentage of stone removal and the complication rate are similar in both procedures, but larger-scale studies are needed in order to find out if microperc requires auxiliary procedures more frequently or if it entails a longer hospital stay. It is also necessary to assess the cost-effectiveness of both treatments, as well as the possibility of combining them in the supine position.Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:2 [ "identificador" => "xres378200" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Material and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec357253" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres378201" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec357254" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Microperc: surgical technique" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Retrograde intrarenal surgery: surgical technique" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Study design" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 13 => array:2 [ "identificador" => "xack98569" "titulo" => "Acknowledgements" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-21" "fechaAceptado" => "2014-04-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec357253" "palabras" => array:5 [ 0 => "Kidney stone" 1 => "Retrograde intrarenal surgery" 2 => "Micropercutaneous nephrolithotomy" 3 => "Technique" 4 => "Results" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec357254" "palabras" => array:5 [ 0 => "Litiasis renal" 1 => "Cirugía retrógrada intrarrenal" 2 => "Micro-nefrolitotomía percutánea" 3 => "Técnica" 4 => "Resultados" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectiveRetrograde intrarenal surgery (RIRS) has proven efficacy with minimal morbidity in the treatment of intermediate-sized kidney stones. The aim of this study was to examine the feasibility of micropercutaneous nephrolithotomy (microperc) for this indication and evaluate its results compared with those of RIRS. Material and methodsFrom September to December 2013, we performed a comparative prospective study between RIRS and microperc, with 20 consecutive patients with intermediate-sized (1–3cm) kidney stones. We employed a flexible dual-channel ureteroscope (Cobra, RichardWolf GmbH) and a Microperc 4.85/8 Fr (with the patient supine) with flexible fiberoptics (0.9mm, 120 and 10,000 pixels) (PolyDiagnost GmbH). The study variables were demographic data, stone characteristics, percentage of stone elimination, complications (Clavien–Dindo), surgical time, hospital stay and need for auxiliary procedures. ResultsThe patients underwent RIRS (n=12) or microperc (n=8). There were no differences in the demographics or stone characteristics between the two groups. The percentage of stone elimination with RIRS and microperc was 91.7% and 87.5% (P=1), respectively. One of the patients who underwent RIRS (8.3%) experienced postoperative fever; one of the patients who underwent microperc (12.5%) experienced postoperative colic pain (both cases were classified as Clavien I). The operative times were similar: 120min (111.2–148.7) and 120 (88.7–167.5) min for RIRS and microperc (P=.8), respectively. None of the patients required a blood transfusion. The hospital stays were also equivalent: 1 day (1–2) and 1.5 days (1–3.5) for RIRS and microperc (P=.33), respectively. Two patients treated with microperc (25%) required auxiliary procedures (simultaneous RIRS and flexible nephroscopy after percutaneous trajectory dilation to treat, in both cases, a significant fragment that had migrated to an inaccessible calyx), and 1 patient in the RIRS group (8.3%) required percutaneous nephrolithotomy due to unfavorable infundibular-calyceal anatomy (P=.54). ConclusionsMicroperc is a minimally invasive method that is emerging as an effective and safe treatment for intermediate-sized kidney stones. Studies are needed to better evaluate its cost-effectiveness, the need for complementary treatments and its possible complementarity with RIRS when working with patients in the supine position." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivoLa cirugía retrógrada intrarrenal (CRIR) muestra eficacia contrastada con mínima morbilidad en el tratamiento de la litiasis renal de tama¿no intermedio. Se pretende estudiar la viabilidad de micro-nefrolitotomía percutánea (microperc) en esta indicación y evaluar sus resultados de forma comparativa a CRIR. Material y métodosDesde septiembre a diciembre de 2013 realizamos un estudio compara-tivo prospectivo entre CRIR y microperc, en 20 pacientes consecutivos con litiasis renal detama¿no intermedio (1-3 cm). Se empleó ureteroscopio flexible de doble canal (Cobra, RichardWolf GmbH) y Microperc 4,85/8 Fr en posición supino con fibra óptica flexible de 0,9 mm y 120∘, 10.000 píxeles (PolyDiagnost GmbH). Las variables analizadas fueron: datos demográficos,características del cálculo, porcentaje de eliminación de litiasis, complicaciones (Clavien-Dindo), tiempo quirúrgico, estancia hospitalaria y necesidad de procedimientos auxiliares. ResultadosLos pacientes recibieron CRIR (n = 12) o microperc (n = 8). No existieron diferencias demográficas ni en las características de la litiasis entre ambos grupos. El porcentaje de eli-minación de litiasis con CRIR fue 91,7% y con microperc 87,5% (p = 1). Un paciente tratado conCRIR (8,3%) tuvo fiebre postoperatoria y otro con microperc (12,5%) dolor cólico postoperato-rio (ambos Clavien I). Los tiempos operatorios fueron similares: CRIR 120min (111,2---148,7) ymicroperc 120min (88,7---167,5) (p = 0,8). Ningún paciente necesitó transfusión sanguínea. Laestancia hospitalaria fue también equivalente: CRIR 1 día (1---2) y microperc 1,5 días (1---3,5) (p = 0,33). Dos pacientes tratados con microperc (25%) necesitaron procedimientos accesorios (CRIR simultánea y nefroscopia flexible tras dilatación del trayecto percutáneo para tratar enambos casos un fragmento significativo migrado a un cáliz no accesible) y uno en el grupo CRIR (8,3%) precisó nefrolitotomía percutánea por anatomía infundíbulo-calicial desfavorable (p = 0,54). ConclusionesMicroperc es un método mínimamente invasivo emergente, eficaz y seguro paratratar litiasis renal de tama¿no intermedio. Se precisan estudios que evalúen mejor coste-efectividad, la necesidad de tratamientos complementarios y su posible complementariedadcon CRIR cuando se trabaja en posición supina." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ramón de Fata F, García-Tello A, Andrés G, Redondo C, Meilán E, Gimbernat H, et al. Estudio comparativo entre cirugía retrógrada intrarrenal y micro-nefrolitotomía percutánea en el tratamiento de la litiasis renal de tamaño intermedio. Actas Urol Esp. 2014;38:576–583." ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 679 "Ancho" => 995 "Tamanyo" => 123342 ] ] "descripcion" => array:1 [ "en" => "Specific material used for microperc (PolyDiagnost, Pfaffenhofen, Germany): 8Ch sheath with 3-way connector." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 664 "Ancho" => 996 "Tamanyo" => 86586 ] ] "descripcion" => array:1 [ "en" => "Specific material used for microperc (PolyDiagnost, Pfaffenhofen, Germany): fiber optic 0.9mm/10,000 pixels/120°/telescopic articulated arm for holding the camera and light cable." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 602 "Ancho" => 1800 "Tamanyo" => 190627 ] ] "descripcion" => array:1 [ "en" => "(A) and (B) Progressive fragmentation of 3-cm pelvic lithiasis by means of 8-Ch microperc. (C): Stone-free pelvis with mono-J catheter." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 664 "Ancho" => 996 "Tamanyo" => 99701 ] ] "descripcion" => array:1 [ "en" => "Almost imperceptible 8Ch microperc incision after the surgery." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 705 "Ancho" => 1306 "Tamanyo" => 142162 ] ] "descripcion" => array:1 [ "en" => "Retrograde intrarenal surgery. (A) Flexible Cobra Ureteroscope (Richard Wolf GmbH, Germany). (B) Detail with 1.9Ch Escape Nitinol Basket (Boston Scientific, USA) and atraumatic Flexiva TracTip 200 Micron Laser Fiber (Boston Scientific, USA)." ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ASA, American Society of Anesthesiologists; RIRS, retrograde intrarenal surgery; BMI, body mass index; kg/m2, kilograms per square meter; IQR, interquartile range." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Microperc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">RIRS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">P value \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No. of patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age, yearsMedian (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53.5 (45.7–58.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 (41.7–67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.91 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender, male:female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4:4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5:7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.53 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMI, kg/m2Median (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (25.4–35.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.1 (24.1–30.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ASA, n (%)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab575306.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical and demographic characteristics of patients in each group." ] ] 6 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "cm2, square centimeters; RIRS, retrograde intrarenal surgery; LCG, lower calyceal group; IQR, interquartile range." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Microperc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">RIRS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">P value \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surface, cm2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.9 (0.8–3.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 (0.6–2.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Median (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Side, right:left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3:5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5:7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Location, n (%)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal pelvis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (42) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.53 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LCG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (58) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab575307.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Features of the lithiases in each group." ] ] 7 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "RIRS, retrograde intrarenal surgery; min, minutes; IQR, interquartile range." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Microperc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">RIRS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical time, minMedian (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120 (88.7–167.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120 (111.2–148.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complications, n (%)Colic pain (Clavien I)Fever (Clavien I) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1(12.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1(8.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hospital stay, daysMedian (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 (1–3.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Auxiliary procedures, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (8.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RIRS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (12.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flexible nephroscopy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (12.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Miniperc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (8.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lithiasic clearance, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (100–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (100–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab575305.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Operative results and complications in each group." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines on urolithiasis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. 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Original article

Comparative study of retrograde intrarenal surgery and micropercutaneous nephrolithotomy in the treatment of intermediate-sized kidney stones

Estudio comparativo entre cirugía retrógrada intrarrenal y micro-nefrolitotomía percutánea en el tratamiento de la litiasis renal de tamaño intermedio

F. Ramón de Fata

Corresponding author

frfata@hotmail.com

Corresponding author.

, A. García-Tello, G. Andrés, C. Redondo, E. Meilán, H. Gimbernat, J.C. Angulo

Servicio de Urología, Hospital Universitario de Getafe, Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The different therapeutic options available for the treatment of medium-sized renal strictures are extracorporeal shock wave lithotripsy &#40;ESWL&#41;&#44; percutaneous nephrolithotomy &#40;PCNL&#41; and retrograde intrarenal surgery &#40;RIRS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> ESWL has a limited stone clearance rate&#44; especially in lithiases in a lower caliceal group&#46; Besides&#44; it often requires several treatment sessions and its results are highly dependent on the nature of the calculus &#40;size&#44; location and composition&#41;&#44; the anatomy of the pyelocaliceal system and the patient&#39;s features&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Despite its theoretical lower morbidity&#44; the arguments described above contribute to the existence of an increasingly critical attitude among the urological community when choosing ESWL as the first therapeutic option&#44; particularly in adverse situations which significantly reduce its effectiveness&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">RIRS is a safe procedure&#44; with a high success rate proven in renal strictures &#8804;2<span class="elsevierStyleHsp" style=""></span>cm regardless of their location and composition&#46; The standardization of the procedure and the development of next-generation materials have enabled to broaden its range of therapeutic possibilities&#44; constituting an alternative to PCNL for medium-sized calculi with lower morbidity&#44; although it takes more operative time and sometimes requires second procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">PCNL&#44; a procedure introduced in the mid 70s which has replaced open surgery in the treatment of large renal strictures&#44; has the highest stone clearance rate&#44; although it is associated with increased morbidity&#44; mainly bleeding&#44; regarding the establishment of a percutaneous renal access route&#44; and postoperative pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> With the intention of decreasing complications&#44; the calibers of the instruments used have been progressively reduced and the mini-PCNL technique &#40;miniperc&#41; has been developed with 11&#8211;20 Fr materials&#44; 15- and 18-Fr being the most commonly used ones&#46; Another emerging minimally invasive technique is micro-PCNL &#40;microperc&#41; which further reduces the percutaneous access route using a 4&#46;85&#8211;8<span class="elsevierStyleHsp" style=""></span>Ch needle&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> The aim of this work was to assess the feasibility of microperc for treating medium-sized renal calculi&#44; taking RIRS&#44; a minimally invasive procedure of proven safety and effectiveness&#44; as a comparative standard&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We conducted a prospective comparative study between microperc and RIRS in 20 consecutive patients with renal stones of 1&#8211;3<span class="elsevierStyleHsp" style=""></span>cm who had been treated during the period from September to December 2013&#46; Eight microperc and 12 RIRS were performed&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Lithiasis size was defined using the formula for the surface area of the calculus &#40;SC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>length<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>width<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#960;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;25&#41;&#44; measures obtained through a CT of the abdomen without intravenous contrast&#46; All patients with a sterile preoperative urine culture were given intravenous prophylactic antibiotics or specific treatment in the following situations&#58; bacterial growth in the preoperative urine culture&#44; patients with a urethral catheter or patients diagnosed with ectasia of the excretory duct in the imaging study&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Microperc&#58; surgical technique</span><p id="par0030" class="elsevierStylePara elsevierViewall">The microperc procedure is performed under general anesthesia in the modified supine position&#46; A mono-J urethral catheter &#40;8<span class="elsevierStyleHsp" style=""></span>Ch&#41; is inserted into the collecting system under radiological control in order to contrast the excretory duct and perform the puncture&#44; avoid the migration of fragments toward the proximal ureter and to reduce intrarenal pressure&#46; The puncture of the renal papilla of the desired calyx &#40;either of the calyx where the calculus is located or of a calyx aligned with the renal pelvis in the case of calculi with a pyelic localization&#41; is performed with a 16G needle under ultrasound and&#47;or fluoroscopic control&#46; The micro-percutaneous surgical equipment &#40;PolyDiagnost&#44; Pfaffenhofen&#44; Germany&#41; consists of a 16G puncture needle &#40;4&#46;85<span class="elsevierStyleHsp" style=""></span>Ch&#41; with a three-duct connection &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; through which a 0&#46;9<span class="elsevierStyleHsp" style=""></span>mm optical fiber&#44; with 10&#44;000 pixel resolution and 120&#176; vision &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; is inserted into the central duct&#46; The other two connection ducts were used for the continuous irrigation system and for a 200-&#956;m laser fiber&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In most procedures&#44; as we are talking about adult patients with calculi &#62;1<span class="elsevierStyleHsp" style=""></span>cm&#44; we replaced the 4&#46;85<span class="elsevierStyleHsp" style=""></span>Ch needle with a 8<span class="elsevierStyleHsp" style=""></span>Ch sheath&#44; which improved visualization thanks to its higher irrigation flow and enabled the use of a 550-&#956;m laser fiber to accelerate the pulverization of calculi &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; and of nitinol baskets to extract small lithiasic fragments&#46; Since fragment extraction is more difficult than in other percutaneous procedures&#44; the main objective is to pulverize the stone using a Ho&#58;YAG laser &#40;0&#46;6<span class="elsevierStyleHsp" style=""></span>J 15<span class="elsevierStyleHsp" style=""></span>Hz&#59; Megapulse 30<span class="elsevierStyleHsp" style=""></span>W&#44; Richard Wolf Gmbh&#44; Knittlingen&#44; Germany&#41; in fragments less than 2<span class="elsevierStyleHsp" style=""></span>mm&#44; which could be spontaneously discharged&#46; In all cases&#44; we used an irrigation pump with manual perfusion control in order to work with low intrarenal pressure&#46; A double-J ureteral stent was placed at the end of the procedure&#46; The 8-Ch microperc incision was virtually imperceptible after surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Retrograde intrarenal surgery&#58; surgical technique</span><p id="par0040" class="elsevierStylePara elsevierViewall">Under general anesthesia&#44; and with the patient in the lithotomy position&#44; rigid ureteroscopy is performed following the insertion of a 0&#46;035-in&#46; hydrophilic safety guide wire into renal cavities&#46; This maneuver makes it possible to rule out the presence of synchronous urethral strictures and to dilate the hole and the intramural ureter under vision&#44; before inserting the ureteral access sheath&#46; A second 0&#46;035 &#8220;hydrophilic guide wire is inserted&#44; as a working guide&#44; and over this latter guide wire&#44; the 11&#47;13 Fr Navigator ureteral access sheath &#40;Boston Scientific&#44; Natick&#44; Massachusetts&#44; USA&#41; is placed under fluoroscopic control&#46; In the event a 12&#47;14 Fr Re-Trace access &#40;Coloplast&#44; Humleb&#230;k&#44; Denmark&#41; is used&#44; no second guide is necessary&#44; since once its obturator has been removed&#44; the working guide is placed in parallel&#44; acting as a safety guide wire&#46; A cobra dual-channel flexible ureteroscopy with a continuous irrigation pump &#40;Richard Wolf Gmbh&#44; Knittlingen&#44; Germany&#41; was used in all procedures &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; All renal cavities were revised in an organized way&#44; and in the case of lower calyceal strictures&#44; they are mobilized to the renal pelvis or to the superior calyceal group in order to work with no forced deflection and&#44; therefore&#44; prolong the life of flexible instruments&#46; A new 200-&#956;m Flexiva TracTip atraumatic laser fiber &#40;Boston Scientific&#44; Natick&#44; Massachusetts&#44; USA&#41; allows users to work with the ureteroscopy in a bent position &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; A Ho&#58;YAG laser &#40;Megapulse 30<span class="elsevierStyleHsp" style=""></span>W&#44; Richard Wolf Gmbh&#44; Knittlingen&#44; Germany and Versapulse 20<span class="elsevierStyleHsp" style=""></span>W&#44; Lumenis Ltd&#44; Yokneam&#44; Israel&#41; with 200- and 272-&#956;m fibers was customarily used for lithotripsy&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Once the calculus had been fragmented&#44; significant fragments were extracted using a 1&#46;9<span class="elsevierStyleHsp" style=""></span>Ch ZeroTip nitinol basket &#40;Boston Scientific&#44; Natick&#44; Massachusetts&#44; USA&#41; for further analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; It is important to remove the ureteral access sheath under endoscopic visual control in order to rule out unnoticed ureteral lesions which might require ureteral catheter placement for a longer time&#46; At the end of the procedure&#44; a double-J ureteral stent is inserted&#44; and is generally removed within 7 days&#46; If there are no complications within the first 24<span class="elsevierStyleHsp" style=""></span>h&#44; the bladder catheter is removed and the patient is discharged&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The stone clearance rate is intraoperatively assessed with endoscopic visualization and fluoroscopy&#44; in the immediate post-surgery period &#40;24<span class="elsevierStyleHsp" style=""></span>h&#41; by simple radiography of the urinary system and after 3 months by CT scanning of the abdomen without i&#46;v&#46; contrast&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study design</span><p id="par0055" class="elsevierStylePara elsevierViewall">The perioperative variables analyzed were the following&#58; demographic data of the patients&#44; calculus characteristics&#44; body mass index &#40;BMI&#41; and anesthetic risk as defined by the American Society of Anesthesiologists &#40;ASA&#41;&#46; The main intraoperative parameters collected were surgical time&#44; need for auxiliary procedures and aspects related to the surgical technique used&#46; Finally&#44; the postoperative results assessed were the percentage of lithiasis removal&#44; complications according to the Clavien&#8211;Dindo classification and hospital stay&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The quantitative variables for the statistical analysis were described using the median and the interquartile range &#40;IQR&#41; and their normalcy was established using the Kolmogorov&#8211;Smirnov and Shapiro&#8211;Wilk tests&#46; Student&#39;s-<span class="elsevierStyleItalic">t</span> was used for continuous quantitative variables with a normal distribution and the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test for continuous variables which do not follow a normal distribution&#46; The Chi-square and Fisher&#39;s exact tests were used to study the association between categorical variables&#46; A <span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered statistically significant&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">The demographic characteristics of the patients and of the strictures treated were very similar&#44; with no statistically significant differences between the groups &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;&#46; The surgical times for both procedures were also similar&#44; with no differences of statistical significance&#44; the median being 120<span class="elsevierStyleHsp" style=""></span>min &#40;88&#46;7&#8211;167&#46;5&#41; for microperc and 120<span class="elsevierStyleHsp" style=""></span>min &#40;111&#46;2&#8211;148&#46;7&#41; for RIRS&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#46; Two patients treated with microperc &#40;25&#37;&#41; required additional procedures &#40;simultaneous RIRS and flexible nephroscopy after percutaneous tract dilation&#44; respectively&#41; for treating a significant fragment that had migrated to a superior calyx inaccessible through the percutaneous approach&#46; One patient in the RIRS group &#40;8&#46;3&#37;&#41; also required miniperc due to unfavorable inferior infundibular-calyceal anatomy&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;54&#46; The supplementary techniques were always performed in the same surgical procedure&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The average percentage of lithiasis removal at 3 months follow-up was 95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;5&#37; for RIRS and 96&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;8&#37; for microperc&#44; both medians &#40;IQR&#41; being 100 &#40;100&#8211;100&#41;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#46; One patient in the RIRS group &#40;8&#46;3&#37;&#41; had postoperative fever &#40;Clavien I&#41; which resolved in 24<span class="elsevierStyleHsp" style=""></span>h without having to change the previously established intravenous antibiotic pattern&#44; and one patient in the microperc group &#40;12&#46;5&#37;&#41; showed postoperative colic pain that required intravenous analgesic treatment &#40;Clavien I&#41;&#44; which also resolved in the first 24<span class="elsevierStyleHsp" style=""></span>h&#46; No patient required blood transfusion&#46; The hospital stay with microperc was slightly higher &#40;1&#46;5 &#91;1&#8211;3&#46;5&#93; days&#41; than with RIRS &#40;1 &#91;1&#8211;2&#93; day&#41;&#44; although it did not reach statistical significance&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;33 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; In the microperc group&#44; we used the 4&#46;85-Ch needle in one case &#40;12&#46;5&#37;&#41; and it was replaced with the 8-Ch sheath in 7 cases &#40;87&#46;5&#37;&#41;&#46; We used a double-J ureteral stent in all procedures&#44; which was removed on an outpatient basis on the seventh postoperative day&#46; All the microperc procedures and the case treated with rescue miniperc after RIRS were performed without the need for percutaneous nephrostomy &#40;tubeless&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">According to the clinical guidelines of the European Association of Urology&#44; the different options available for the treatment of medium-sized renal strictures are ESWL&#44; RIRS and PCNL&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The effectiveness of ESWL is conditioned by the calculus size and other variables&#44; such as composition and hardness of the stone&#44; the anatomy of the excretory system &#40;length&#44; width of the infundibulum and the infundibulo-pyelic angle&#41; and the patient&#39;s characteristics &#40;BMI&#44; skeletal deformities&#44; blood clotting disorders&#41;&#46; Still&#44; guidelines recommend it as a first-line treatment for renal stones &#60;2<span class="elsevierStyleHsp" style=""></span>cm mainly due to its theoretical low morbidity and because it is an outpatient procedure which does not require anesthesia&#44; but the reality is that its limited effectiveness&#44; especially in the case of strictures located in the lower calyceal group has resulted in an increasingly restrictive attitude from the urological community&#46; Besides&#44; technical developments and the experience acquired in endourological procedures such as RIRS and PCNL has contributed to its widespread use&#44; especially in the circumstances where the results of ESWL are uncertain&#46; A meta-analysis conducted in 2009 by Srisubat et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> &#40;Cochrane database&#41;&#44; comparing ESWL&#44; RIRS and PCNL&#44; determined that the stone clearance rate of ESWL was lower&#46; The differences between RIRS and PCNL were less evident&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The experience acquired with RIRS and the development of next-generation endoscopes&#44; with a 270&#176; active deflection&#44; which enable us to reach and work in all renal cavities in most cases&#44; have allowed for systematizing the treatment of medium-sized renal strictures with good results and low morbidity&#46; In recent years&#44; some authors have documented its usefulness in strictures &#62;2<span class="elsevierStyleHsp" style=""></span>cm&#44; usually treated with PCNL&#44; obtaining excellent stone clearance rates at the expense of an increase in surgical time and the need for second procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> The main disadvantages of RIRS lie in the occasional need for inserting a double-J stent and postponing the procedure in case of a narrow ureter which impedes the passage of a ureteral access sheath&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> as well as the risk for ureteral lesions&#44; severe in some cases&#44; which require prolonged ureteral catheterization&#46; This situation is more frequent in older men and has been documented in up to 13&#46;3&#37; of cases in large series&#44; so it is highly advisable to remove the ureteral access sheath under endoscopic vision at the end of the procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Another constraint of RIRS is the cost derived from using disposable ancillary materials and the average life of flexible ureteroscopes&#44; which can reach 50&#8211;60 procedures with good practice and excellent care&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">PCNL shows the highest stone clearance rate with just one procedure&#44; but also shows the highest morbidity&#44; although fortunately the rate of major complications is low&#46; The analysis of complications carried out by the Clinical Research Office of the Endourological Society &#40;CROES&#41; in 5803 patients revealed that the main complications of PCNL were the following&#58; clinically relevant bleeding &#40;7&#46;8&#37;&#41;&#44; perforation of the excretory tract &#40;3&#46;4&#37;&#41;&#44; hydrothorax &#40;1&#46;8&#37;&#41; and need for transfusion &#40;5&#46;7&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In a register of the Spanish Association of Urology conducted in 397 patients who had undergone PCNL in the supine position&#44; the transfusion rate was 5&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Most of these complications are related to the creation of the percutaneous passage&#44; and bleeding in particular is directly related to its caliber&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In 1997&#44; Helal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> described the miniperc technique for the treatment of renal lithiasis in pediatric patients&#44; and in 1998&#44; Jackman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> used it in an adult population to decrease surgical trauma and&#44; therefore&#44; bleeding&#46; Miniperc entails a shorter hospital stay and less drop in hemoglobin&#44; with a similar stone clearance rate when compared with standard PCNL&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> When miniperc is compared with RIRS&#44; the effectiveness and morbidity of both procedures in medium-sized strictures are overlapped&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The progressive trend toward the miniaturization of the surgical instruments for percutaneous surgery seeks primarily to simplify the puncture&#44; reducing morbidity and radiological exposure&#46; Bader et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> published in 1991 their initial experience with a 0&#46;9-mm microscopic optics inserted through the working channel of a 16G &#40;4&#46;85<span class="elsevierStyleHsp" style=""></span>Ch&#41; puncture needle&#44; which enabled them to carry out the PCNL procedure in a single step without the need for dilation of the percutaneous tract&#46; Desai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> subsequently defined this concept and developed a technique where the percutaneous access and lithiasic fragmentation were performed in a one-stage procedure&#44; using an all seeing needle&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In this feasibility study&#44; the stone clearance rate was similar in both groups&#44; and in line with that obtained by other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;24</span></a> Sabnis et al&#46;&#44; in a comparative study between microperc and RIRS&#44; obtained a resolution rate of 97&#46;1 and 94&#46;3&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Despite being a new procedure&#44; it can be performed with excellence by any urologist with experience in percutaneous renal surgery&#46; In our experience&#44; the surgical times in both groups were also similar&#46; The 4&#46;85<span class="elsevierStyleHsp" style=""></span>Ch needle only allows to disintegrate the calculus&#44; so that there is a subsequent spontaneous removal of fragments&#46; In the case of strictures &#62;1<span class="elsevierStyleHsp" style=""></span>cm&#44; its replacement with a 8<span class="elsevierStyleHsp" style=""></span>Ch metal sheath improves visibility&#59; thanks to its greater sectioning strength it enables us to use a 550-&#956;m laser fiber&#44; which accelerates fragmentation and enables the extraction of 2&#8211;3<span class="elsevierStyleHsp" style=""></span>mm fragments for the analysis of the calculus&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Microperc enables access to unfavorable anatomy calyxes &#40;an acute angle&#44; narrow or excluded hydrocalyxes&#41; where RIRS presents greater difficulties&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Nonetheless&#44; RIRS is the preferable option for patients with morbid obesity&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> where percutaneous instruments reach the excretory tract with greater difficulty&#44; or for patients with cardiovascular diseases under anticoagulant therapy&#44; a situation where both PCNL and ESWL are contraindicated&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">On the other hand&#44; the image quality offered by RIRS&#44; especially with our current means &#40;digital endoscopes&#41;&#44; with a higher image resolution than that of fiber optics and less fragility&#44; also translates into a lower long-term cost and less operative time per procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">Although this is a limited experience&#44; this study confirms the feasibility of microperc in the treatment of medium-sized renal strictures &#40;1&#8211;3<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; so it is an effective and safe alternative&#44; taking the RIRS technique as a reference point&#46; There is no doubt that having both techniques available increases the versatility and complementarity of endourological treatment&#46; The percentage of stone removal and the complication rate are similar in both procedures&#44; but larger-scale studies are needed in order to find out if microperc requires auxiliary procedures more frequently or if it entails a longer hospital stay&#46; It is also necessary to assess the cost-effectiveness of both treatments&#44; as well as the possibility of combining them in the supine position&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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    "tienePdf" => true
    "fechaRecibido" => "2014-04-21"
    "fechaAceptado" => "2014-04-28"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec357253"
          "palabras" => array:5 [
            0 => "Kidney stone"
            1 => "Retrograde intrarenal surgery"
            2 => "Micropercutaneous nephrolithotomy"
            3 => "Technique"
            4 => "Results"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec357254"
          "palabras" => array:5 [
            0 => "Litiasis renal"
            1 => "Cirug&#237;a retr&#243;grada intrarrenal"
            2 => "Micro-nefrolitotom&#237;a percut&#225;nea"
            3 => "T&#233;cnica"
            4 => "Resultados"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Retrograde intrarenal surgery &#40;RIRS&#41; has proven efficacy with minimal morbidity in the treatment of intermediate-sized kidney stones&#46; The aim of this study was to examine the feasibility of micropercutaneous nephrolithotomy &#40;microperc&#41; for this indication and evaluate its results compared with those of RIRS&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">From September to December 2013&#44; we performed a comparative prospective study between RIRS and microperc&#44; with 20 consecutive patients with intermediate-sized &#40;1&#8211;3<span class="elsevierStyleHsp" style=""></span>cm&#41; kidney stones&#46; We employed a flexible dual-channel ureteroscope &#40;Cobra&#44; RichardWolf GmbH&#41; and a Microperc 4&#46;85&#47;8 Fr &#40;with the patient supine&#41; with flexible fiberoptics &#40;0&#46;9<span class="elsevierStyleHsp" style=""></span>mm&#44; 120 and 10&#44;000 pixels&#41; &#40;PolyDiagnost GmbH&#41;&#46; The study variables were demographic data&#44; stone characteristics&#44; percentage of stone elimination&#44; complications &#40;Clavien&#8211;Dindo&#41;&#44; surgical time&#44; hospital stay and need for auxiliary procedures&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The patients underwent RIRS &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#41; or microperc &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41;&#46; There were no differences in the demographics or stone characteristics between the two groups&#46; The percentage of stone elimination with RIRS and microperc was 91&#46;7&#37; and 87&#46;5&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; respectively&#46; One of the patients who underwent RIRS &#40;8&#46;3&#37;&#41; experienced postoperative fever&#59; one of the patients who underwent microperc &#40;12&#46;5&#37;&#41; experienced postoperative colic pain &#40;both cases were classified as Clavien I&#41;&#46; The operative times were similar&#58; 120<span class="elsevierStyleHsp" style=""></span>min &#40;111&#46;2&#8211;148&#46;7&#41; and 120 &#40;88&#46;7&#8211;167&#46;5&#41; min for RIRS and microperc &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;8&#41;&#44; respectively&#46; None of the patients required a blood transfusion&#46; The hospital stays were also equivalent&#58; 1 day &#40;1&#8211;2&#41; and 1&#46;5 days &#40;1&#8211;3&#46;5&#41; for RIRS and microperc &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;33&#41;&#44; respectively&#46; Two patients treated with microperc &#40;25&#37;&#41; required auxiliary procedures &#40;simultaneous RIRS and flexible nephroscopy after percutaneous trajectory dilation to treat&#44; in both cases&#44; a significant fragment that had migrated to an inaccessible calyx&#41;&#44; and 1 patient in the RIRS group &#40;8&#46;3&#37;&#41; required percutaneous nephrolithotomy due to unfavorable infundibular-calyceal anatomy &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;54&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Microperc is a minimally invasive method that is emerging as an effective and safe treatment for intermediate-sized kidney stones&#46; Studies are needed to better evaluate its cost-effectiveness&#44; the need for complementary treatments and its possible complementarity with RIRS when working with patients in the supine position&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a retr&#243;grada intrarrenal &#40;CRIR&#41; muestra eficacia contrastada con m&#237;nima morbilidad en el tratamiento de la litiasis renal de tama¿no intermedio&#46; Se pretende estudiar la viabilidad de micro-nefrolitotom&#237;a percut&#225;nea &#40;microperc&#41; en esta indicaci&#243;n y evaluar sus resultados de forma comparativa a CRIR&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Desde septiembre a diciembre de 2013 realizamos un estudio compara-tivo prospectivo entre CRIR y microperc&#44; en 20 pacientes consecutivos con litiasis renal detama¿no intermedio &#40;1-3 cm&#41;&#46; Se emple&#243; ureteroscopio flexible de doble canal &#40;Cobra&#44; RichardWolf GmbH&#41; y Microperc 4&#44;85&#47;8 Fr en posici&#243;n supino con fibra &#243;ptica flexible de 0&#44;9 mm y 120&#8728;&#44; 10&#46;000 p&#237;xeles &#40;PolyDiagnost GmbH&#41;&#46; Las variables analizadas fueron&#58; datos demogr&#225;ficos&#44;caracter&#237;sticas del c&#225;lculo&#44; porcentaje de eliminaci&#243;n de litiasis&#44; complicaciones &#40;Clavien-Dindo&#41;&#44; tiempo quir&#250;rgico&#44; estancia hospitalaria y necesidad de procedimientos auxiliares&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los pacientes recibieron CRIR &#40;n &#61; 12&#41; o microperc &#40;n &#61; 8&#41;&#46; No existieron diferencias demogr&#225;ficas ni en las caracter&#237;sticas de la litiasis entre ambos grupos&#46; El porcentaje de eli-minaci&#243;n de litiasis con CRIR fue 91&#44;7&#37; y con microperc 87&#44;5&#37; &#40;p &#61; 1&#41;&#46; Un paciente tratado conCRIR &#40;8&#44;3&#37;&#41; tuvo fiebre postoperatoria y otro con microperc &#40;12&#44;5&#37;&#41; dolor c&#243;lico postoperato-rio &#40;ambos Clavien I&#41;&#46; Los tiempos operatorios fueron similares&#58; CRIR 120<span class="elsevierStyleHsp" style=""></span>min &#40;111&#44;2---148&#44;7&#41; ymicroperc 120<span class="elsevierStyleHsp" style=""></span>min &#40;88&#44;7---167&#44;5&#41; &#40;p &#61; 0&#44;8&#41;&#46; Ning&#250;n paciente necesit&#243; transfusi&#243;n sangu&#237;nea&#46; Laestancia hospitalaria fue tambi&#233;n equivalente&#58; CRIR 1 d&#237;a &#40;1---2&#41; y microperc 1&#44;5 d&#237;as &#40;1---3&#44;5&#41; &#40;p &#61; 0&#44;33&#41;&#46; Dos pacientes tratados con microperc &#40;25&#37;&#41; necesitaron procedimientos accesorios &#40;CRIR simult&#225;nea y nefroscopia flexible tras dilataci&#243;n del trayecto percut&#225;neo para tratar enambos casos un fragmento significativo migrado a un c&#225;liz no accesible&#41; y uno en el grupo CRIR &#40;8&#44;3&#37;&#41; precis&#243; nefrolitotom&#237;a percut&#225;nea por anatom&#237;a infund&#237;bulo-calicial desfavorable &#40;p &#61; 0&#44;54&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Microperc es un m&#233;todo m&#237;nimamente invasivo emergente&#44; eficaz y seguro paratratar litiasis renal de tama¿no intermedio&#46; Se precisan estudios que eval&#250;en mejor coste-efectividad&#44; la necesidad de tratamientos complementarios y su posible complementariedadcon CRIR cuando se trabaja en posici&#243;n supina&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ram&#243;n de Fata F&#44; Garc&#237;a-Tello A&#44; Andr&#233;s G&#44; Redondo C&#44; Meil&#225;n E&#44; Gimbernat H&#44; et al&#46; Estudio comparativo entre cirug&#237;a retr&#243;grada intrarrenal y micro-nefrolitotom&#237;a percut&#225;nea en el tratamiento de la litiasis renal de tama&#241;o intermedio&#46; Actas Urol Esp&#46; 2014&#59;38&#58;576&#8211;583&#46;</p>"
      ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Specific material used for microperc &#40;PolyDiagnost&#44; Pfaffenhofen&#44; Germany&#41;&#58; 8<span class="elsevierStyleHsp" style=""></span>Ch sheath with 3-way connector&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Specific material used for microperc &#40;PolyDiagnost&#44; Pfaffenhofen&#44; Germany&#41;&#58; fiber optic 0&#46;9<span class="elsevierStyleHsp" style=""></span>mm&#47;10&#44;000 pixels&#47;120&#176;&#47;telescopic articulated arm for holding the camera and light cable&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; and &#40;B&#41; Progressive fragmentation of 3-cm pelvic lithiasis by means of 8-Ch microperc&#46; &#40;C&#41;&#58; Stone-free pelvis with mono-J catheter&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Almost imperceptible 8<span class="elsevierStyleHsp" style=""></span>Ch microperc incision after the surgery&#46;</p>"
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      4 => array:7 [
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Retrograde intrarenal surgery&#46; &#40;A&#41; Flexible Cobra Ureteroscope &#40;Richard Wolf GmbH&#44; Germany&#41;&#46; &#40;B&#41; Detail with 1&#46;9<span class="elsevierStyleHsp" style=""></span>Ch Escape Nitinol Basket &#40;Boston Scientific&#44; USA&#41; and atraumatic Flexiva TracTip 200 Micron Laser Fiber &#40;Boston Scientific&#44; USA&#41;&#46;</p>"
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      5 => array:7 [
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">ASA&#44; American Society of Anesthesiologists&#59; RIRS&#44; retrograde intrarenal surgery&#59; BMI&#44; body mass index&#59; kg&#47;m<span class="elsevierStyleSup">2</span>&#44; kilograms per square meter&#59; IQR&#44; interquartile range&#46;</p>"
          "tablatextoimagen" => array:1 [
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                  <table border="0" frame="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Microperc&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">RIRS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age&#44; years</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">53&#46;5 &#40;45&#46;7&#8211;58&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">51 &#40;41&#46;7&#8211;67&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;91&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#58;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&#58;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;53&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">BMI&#44; kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">29 &#40;25&#46;4&#8211;35&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">28&#46;1 &#40;24&#46;1&#8211;30&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ASA&#44; n</span> &#40;&#37;&#41;</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab575306.png"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Clinical and demographic characteristics of patients in each group&#46;</p>"
        ]
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      6 => array:7 [
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">cm<span class="elsevierStyleSup">2</span>&#44; square centimeters&#59; RIRS&#44; retrograde intrarenal surgery&#59; LCG&#44; lower calyceal group&#59; IQR&#44; interquartile range&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Microperc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">RIRS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;9 &#40;0&#46;8&#8211;3&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;3 &#40;0&#46;6&#8211;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Side&#44; right&#58;left</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#58;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#58;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Location&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Renal pelvis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LCG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Features of the lithiases in each group&#46;</p>"
        ]
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      7 => array:7 [
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">RIRS&#44; retrograde intrarenal surgery&#59; min&#44; minutes&#59; IQR&#44; interquartile range&#46;</p>"
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            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Microperc&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">RIRS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Surgical time&#44; min</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120 &#40;88&#46;7&#8211;167&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120 &#40;111&#46;2&#8211;148&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Complications&#44; n &#40;&#37;&#41;</span><span class="elsevierStyleHsp" style=""></span>Colic pain &#40;Clavien I&#41;<span class="elsevierStyleHsp" style=""></span>Fever &#40;Clavien I&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hospital stay&#44; days</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5 &#40;1&#8211;3&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#8211;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Auxiliary procedures&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>RIRS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Flexible nephroscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Miniperc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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        "texto" => "<p id="par0125" class="elsevierStylePara elsevierViewall">To Mr&#46; Stefan Guille &#40;Richard Wolf GmbH&#44; Knittlingen&#44; Germany&#41; and Mr&#46; Alberto Al&#243;s &#40;Presurgy S&#46;L&#46;&#44; Madrid&#44; Spain&#41; for their instrumental support for the completion of this work&#46; To Mr&#46; Jos&#233; Dom&#237;nguez &#40;Documentation&#44; Getafe University Hospital&#41; for his assistance in the work of illustration&#46;</p>"
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Article information

ISSN: 21735786
Original language: English

DOI:10.1016/j.acuroe.2014.09.007

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