Cost-Effectiveness of Different Treatment Options for Lower Calyceal Stones
Condition: Renal Calculi
MeSH terms: Kidney Calculi; Nephrolithiasis; Calculi
Study type: Interventional

Summary: 
      The aim of the present study to perform a full cost analysis for the complete clearance of
      calyceal stones by retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy
      (PNL) for the treatment of lower calyceal stones between 1 and 2 centimeters (cm) in size.
    

Detailed description: 
      The lifelong prevalence of urinary system stone disease is approximately 15%. The lower calyx
      is the most common location where renal calculi occur. Because anatomical factors preclude
      spontaneous passage in this area, the need for treatment is more likely in lower calyceal
      stones. The European Association of Urology (EAU) suggests percutaneous nephrolithotomy (PNL)
      for stones larger than 2 centimeters (cm) and shock wave lithotripsy (SWL) or retrograde
      intrarenal surgery (RIRS) for stones smaller than 1cm as a first option, but controversy
      continues regarding the best treatment option for medium-sized lower calyceal stones of
      between 1cm and 2cm.

      Medical costs are divided into two components: direct and indirect. Direct costs encompass
      all medical expenditures (e.g., drugs, hospital bed, all consumable and non-consumable
      materials used during the operation), while indirect costs include loss of working days for
      the patient. The stone-free rates (SFR) are reported as approximately 60% and 90% for one
      session of RIRS and PNL, respectively; however, no physician can guarantee a 100% SFR for one
      session. For this reason, a full cost analysis must include the direct and indirect costs of
      both the first and all auxiliary procedures.

      The aim of this study was to perform a full cost analysis for the complete clearance of
      calyceal stones by RIRS and all PNL types for the treatment of lower calyceal stones between
      1cm and 2cm in size.
    

Intervention name(s): Retrograde intrarenal surgery; Micro-PNL; Ultra-mini PNL; Mini-PNL; Standard PNL
Intervention type(s): Procedure; Procedure; Procedure; Procedure; Procedure
Intervention description(s): The procedure was performed with the patient in the dorsal lithotomy position under general anesthesia. Firstly, diagnostic ureteroscopy was done with a 6/7.5 Fr semi-rigid ureteroscope (Richard Wolf, Knittlingen, Germany). A 0.035mm double-tipped sensor guidewire was placed to the renal pelvis. A 10/12 Fr ureteric access sheath (Cook Medical, Indiana, USA) was used. A 7.5 Fr flexible ureteroscope (Flex X2, Karl Storz, Tuttlingen, Germany) was used for the main procedure. The stones were fragmented using a Holmium:Yttrium Aluminum Garnet laser (272 microns). At the end of each procedure, a double-j ureteric catheter and urethral catheter were routinely placed.; The PNL procedures were performed with the patient in the prone position under general anesthesia. A 6-F ureteric catheter was placed at the beginning of the procedure. Calyceal access was provided using a 22-G Chiba needle. A 0.038mm sensor-tipped guidewire was inserted through the calyceal puncture into the renal pelvis. After tract dilatation, a sheath was inserted. The instruments used were a 4.8 Fr for micro PNL (PolyDiagnost, Pfaffenhofen, Germany). Stone fragmentation was carried out using laser in micro PNL. No nephrostomy was placed in any patient whom underwent micro PNL surgical technique. A double- j stent was placed in necessary (e.g., pelvis perforation, rest stone, stone migration to ureter). A urethral catheter was placed routinely in all patients.; The PNL procedures were performed with the patient in the prone position under general anesthesia. A 6-F ureteric catheter was placed at the beginning of the procedure. Calyceal access was provided using a 22-G Chiba needle. A 0.038mm sensor-tipped guidewire was inserted through the calyceal puncture into the renal pelvis. After tract dilatation, a sheath was inserted. The instruments used were a 7.5 Fr for ultramini PNL (Karl Storz, Tuttlingen, Germany). Stone fragmentation was carried out using laser in ultramini PNL. No nephrostomy was placed in any patient whom underwent ultramini PNL surgical technique. A double- j stent was placed in necessary (e.g., pelvis perforation, rest stone, stone migration to ureter). A urethral catheter was placed routinely in all patients.; The PNL procedures were performed with the patient in the prone position under general anesthesia. A 6-F ureteric catheter was placed at the beginning of the procedure. Calyceal access was provided using a 22-G Chiba needle. A 0.038mm sensor-tipped guidewire was inserted through the calyceal puncture into the renal pelvis. After tract dilatation, a sheath was inserted. The instruments used were a 12 Fr for mini PNL (Karl Storz, Tuttlingen, Germany). Stone fragmentation was carried out using pneumatic, ultrasonic or laser in mini PNL. No nephrostomy was placed in any patient whom underwent mini PNL surgical technique. A double- j stent was placed in necessary (e.g., pelvis perforation, rest stone, stone migration to ureter). A urethral catheter was placed routinely in all patients.; The PNL procedures were performed with the patient in the prone position under general anesthesia. A 6-F ureteric catheter was placed at the beginning of the procedure. Calyceal access was provided using a 22-G Chiba needle. A 0.038mm sensor-tipped guidewire was inserted through the calyceal puncture into the renal pelvis. After tract dilatation, a sheath was inserted. The instruments used were a 24 Fr for standard PNL (Karl Storz, Tuttlingen, Germany). Stone fragmentation was carried out using pneumatic, ultrasonic or laser in standard PNL. A nephrostomy was placed in all standard PNL patients at the end of the procedure
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Patients who had a lower calyceal stone between 1cm and 2cm in size
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Lower calyceal stone; cost-effectiveness; percutaneous nephrolithotomy; retrograde intrarenal surgery