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PCNL vs RIRS in management of stones in calyceal diverticulum: outcomes from a global multicentre match paired study that reflects real world practice

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Abstract

Introduction

Calyceal diverticulum (CD) is the outpouching of a calyx into the renal parenchyma, connected by an infundibulum. Often associated with recurrent stones, common surgical options include percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS). We aim to present the real-world practises and outcomes comparing both approaches and the technical choices made.

Materials and methods

Retrospective data including 313 patients from 11 countries were evaluated. One hundred and twenty-seven underwent mini-PCNL and one hundred and eighty-six underwent RIRS. Patient demographics, perioperative parameters, and outcomes were analysed using either T test or Mann–Whitney U test. Categorical data between groups were analysed using the Chi-squared test. Propensity score matching (PSM) was performed matching for baseline characteristics. Subgroup analyses for anomalous/malrotated kidneys and difficult diverticulum access were performed.

Results

After PSM, 123 patients in each arm were included, with similar outcomes for stone-free rate (SFR) and complications (p < 0.001). Hospitalisation was significantly longer in PCNL. Re-intervention rate for residual fragments (any fragment > 4 mm) was similar. RIRS was the preferred re-intervention for both groups. Intraoperative bleeding was significantly higher in PCNL (p < 0.032) but none required transfusion. Two patients with malrotated anatomy in RIRS group required transfusion. Lower pole presented most difficult access for both groups, and SFR was significantly higher in difficult CD accessed by RIRS (p < 0.031). Laser infundibulotomy was preferred for improving diverticular access in both. Fulguration post-intervention was not practised.

Conclusion

The crux lies in identification of the opening and safe access. Urologists may consider a step-up personalised approach with a view of endoscopic combined approach where required.

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Author information

Authors and Affiliations

  1. Department of Urology, Ng Teng Fong Hospital, NUHS, Singapore, Singapore

    Vineet Gauhar

  2. Lithiase Urinaire, Sorbonne Université, AP-HP, Hôpital Tenon, Paris, France

    Olivier Traxer

  3. Department of Urology, Singapore General Hospital, Singapore Health Services, Singapore, Singapore

    Shauna Jia Qian Woo & Ee Jean Lim

  4. Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Khi Yung Fong

  5. Department of Urology, Asian Institute of Nephrourology, Hyderabad, India

    Deepak Ragoori & Amish Wani

  6. Department of Urology, Abdul Wahab Sjahranie Hospital Medical Faculty, Muliawarman University, Samarinda, Indonesia

    Boyke Soebhali

  7. Department of Urology, Sai Urology Hospital, Aurangabad, Maharashtra, India

    Abhay Mahajan

  8. Department of Urology, Fortis Hospital Mulund, Mumbai, India

    Maheshwari Pankaj

  9. Department of Urology, Saint-Petersburg State Medical University, Saint-Petersburg, Russia

    Nariman Gadzhiev

  10. Department of Urology, Marmara University School of Medicine, Istanbul, Turkey

    Yiloren Tanidir

  11. Department of Urology, Ankara University School of Medicine, Ankara, Turkey

    İlker Gokce Mehmet

  12. Department of Urology, Hitit University School of Medicine, Training and Research Hospital, Corum, Turkey

    Cemil Aydin

  13. Department of Urology, Ondokuz Mayis University, Samsun, Turkey

    Yakup Bostanci

  14. Department of Urology, Advanced Laser Endourology at King Abdulaziz National Guard Medical City Saudi Arabia, Jeddah, Saudi Arabia

    Saeed Bin Hamri

  15. Division of Urology, Department of Surgery, Ministry of National Guard-Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia

    Fahad R. Barayan

  16. Department of Urology, University Hospital NHS Trust, Southampton, UK

    Mriganka Mani Sinha & Bhaskar K. Somani

  17. Department of Urology and Stone Center, Hara Genitourinary Hospital, Kobe, Japan

    Takaaki Inoue

  18. Department of Surgery, Faculty of Medicine, S. H. Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong, China

    Jeremy Yuen-Chun Teoh

  19. Department of Urology, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Università Politecnica delle Marche, Ancona, Italy

    Daniele Castellani

Authors
  1. Vineet Gauhar
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  2. Olivier Traxer
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  3. Shauna Jia Qian Woo
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  4. Khi Yung Fong
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  8. Abhay Mahajan
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  18. Takaaki Inoue
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  19. Jeremy Yuen-Chun Teoh
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  21. Bhaskar K. Somani
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  22. Ee Jean Lim
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Contributions

VG: project development, protocol development, manuscript editing. OT: data collection, data management. SJQW: manuscript writing, manuscript editing. KYF: data collection, data analysis. DR: data collection, data management, manuscript editing. AW: data collection, data management. SB: data collection, manuscript editing. AM: data collection, data management. MP: data collection. NG: data collection. YT: data collection. IGM: data collection, Data management. CA: protocol development, data collection. YB: data collection. BHS: data collection, data management. RBF: data management. MSM: data collection. TI: data collection, data management. JYCT: data collection. DC: data collection, data management. SB: protocol development, data collection. EJL: data analysis, protocol development, manuscript writing.

Corresponding author

Correspondence to Ee Jean Lim.

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Conflict of interest

The authors have no relevant financial or non-financial interests to disclose. The authors have no competing interests to declare that are relevant to the content of this article. All authors certify that they have no affiliations with or involvement in any organisation&& or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. The authors have no financial or proprietary interests in any material discussed in this article.

Research involving human participants and/or animals

This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Anonymized data used were maintained in the Human Investigation Committee (IRB) approved registry of global trends in PCNL and RIRS intervention for Calyceal Diverticulum, maintained by the by Asian Institute of Nephrology and Urology (AINU).

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Informed consent was obtained from all individual participants included in the study.

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Gauhar, V., Traxer, O., Woo, S.J.Q. et al. PCNL vs RIRS in management of stones in calyceal diverticulum: outcomes from a global multicentre match paired study that reflects real world practice. World J Urol 41, 2897–2904 (2023). https://doi.org/10.1007/s00345-023-04650-2

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