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Introduction: <br/>Stone disease represents a health and financial burden and has high prevalence among urology clinic patients. <br/>In the past, open surgery and stone retrieval was the main line of treatment with high complication rate and long recovery time. <br/>In recent years, with the development of medical equipment and medical technology, extracorporeal shock wave lithotripsy (ESWL), RIRS, percutaneous nephrolithotomy (PNL) and other minimally invasive or non-invasive treatment methods emerged.<br/>In the American Urological Association (AUA) guidelines 2024, percutaneous nephrolithotomy (PNL) is recommended as the first line of treatment of renal stones more than 2cm in diameter and more complicated stones.<br/>Even PNL has high efficacy, but it has more morbidity complications such as bleeding that may require blood transfusion or angioembolization, organ injury, urinary fistula and urinoma.<br/>RIRS is introduced as an alternative for treatment of renal stones with minimal invasiveness, better safety and acceptable stone free rate largely, because of technological advancements with laser lithotripsy systems, innovative endoscopic baskets and suction sheath. <br/>Hence, we analyzed the efficacy (stone free rate) and safety of RIRS versus PNL in management of renal stones 2-3 cm in diameter.<br/>Aim:<br/>To compare RIRS versus PNL as a primary treatment for renal stones from 2-3 cm regarding safety and efficacy.<br/>Patient and methodology:<br/>The study conducted in the Urology Department of Kasr Alainy hospitals medical school, Cairo University from 1/1/2022 to 1/8/2023.<br/>A total number of 126 patients were enroued in the study. 4 patients were discarded due to 3 missed follow up and one aborted procedure due to extravasation. So, 122 patients completed the study and divided randomly into two groups using program (random number generator plus version 2.4.8). group A (RIRS) contained 61 patients and group B (PNL) contained 61 patients. <br/>Stone characteristics and anatomical data observation based on the preoperative computed tomography (CT). stone size calculated by measuring largest diameter.<br/>The follow-up evaluation was undertaken one month after the operation using computed tomography (CT). Success was defined as the absence of residual stone fragments larger than 4 mm in PNL and 2 mm in RIRS.<br/>The surgical interventions RIRS and PNL carried out by urologist with 5 years experiences or a trainee urologist under the supervision of a senior urologist.<br/>Stone-free rate, operation time, and length of hospital stay, financial burden and possible complications (as fever, sepsis, hematuria, hemoglobin changes, organ injury and renal pelvis perforation). compared between the PNL and RIRS groups.<br/>Results:<br/>According to demographic data, the mean age of patients in the RIRS group was 44.02 years, while in the PNL group, it was slightly higher at 47.26 years with no significant difference. the mean stone size in the RIRS group was 2.11 cm, while in the PNL group was 2.12 cm with no significant difference. Hounsfield unit (HU) values were nearly identical between the two groups, with no significant difference observed. However, the number of stones was significantly higher in the PNL group compared to the RIRS group (p=0.047). Most stones in both groups were radio-opaque (90.2% in the RIRS group and 87.1% in the PNL group). Overall, while the stone size and density were comparable, the number of stones and hydronephrosis differed between the two groups. <br/>There was no significant difference between the two groups concerning stone free rate (p=0.840). The mean operative time was also comparable, with 100.25 minutes in the RIRS group and 102.54 minutes in the PNL group (p=0.777). However, laser lithotripsy time was significantly longer in RIRS group (84.75 minutes) compared to pneumatic lithotripsy time in PNL group (72.95 minutes) (p=0.019). The total energy used in retrograde intrarenal surgery (RIRS) was reported only for the RIRS group, with a median of 1600.00 units. five cases in RIRS (8⁒) had tight ureter, so needed pre-operative DJF and second operation after 2 weeks. One case in PNL aborted after ureteric catheter insertion due to massive extravasation and failed localization. Regarding hemoglobin levels, the PNL group experienced a more substantial decrease, with a mean change of 0.79 g/dl compared to just 0.03 g/dl in the RIRS group (p<0.001). Regarding pain levels measured by the Visual Analog Scale (VAS), the mean pain score was significantly lower in the RIRS group, with a mean of 5.52, compared to the PNL group, which had a mean score of 8.26 (p<0.001). Other complications such as extravasation (3.3%), perforation (6.6%), subcutaneous hematoma (3.3%), and urinary leakage (6.6%) observed only in the PNL group, while none of these complications were reported in the RIRS group. Additionally, perforation, as well as urinary leakage were also present only in the PNL group, though these were less common (1.6% each). The absence of complications was significantly more frequent in the RIRS group, with 98.4% of patients experiencing no complications, compared to 73.8% in the PNL group (p<0.001). <br/>In terms of secondary outcomes, the length of hospital stay was significantly longer for patients in the PNL group, with a mean of 64.92 hours compared to 28.33 hours in the RIRS group (p<0.001). The incidence of fever was slightly higher in the PNL group (13.1%) than in the RIRS group (8.2%), but this was not statistically significant (p=0.557). Similarly, sepsis was rare in both groups, with no significant difference (p=0.362). one case of mortality reported in the PNL group due to colonic injury and stool leakage in the abdomen leads to exploration 2 times with wound closure on Bogota bag leads to septic shock and death. Overall, while hospital stay differed significantly, other secondary outcomes were comparable between the two groups. All cases in RIRS group were used access sheath and were inserted DJ post-operative, but all cases in PNL group were inserted ureteric stent and PCN. Only 6 cases in the PNL group needed DJF (1 case due to urinary leakage due to residual ureteric stone, 2 cases due to bleeding, 3 cases due to renal pelvis perforation). <br/>Conclusion:<br/>Considering the current study results, it concluded that the comparison between RIRS and PNL reveals that RIRS is alternative for PNL in management of renal stones from 2-3 cm, with an acceptable stone free rate and operative time, less hospital stay, less pain score and less serious complications but all patients in RIRS insert double jj, so patients need second operation for double jj removal and 8% of patients has tight ureter, so they need DJF first and reoperate after 2 weeks conversely patients in PNL insert ureteric stent and PCN in the same operation. The cost of operation was comparable between both groups (although RIRS used required more expensive supplies, but patients discharged day 1 post-operative. In contrast with PNL required less expensive supplies, but patients had longer hospital stay and more complications). |