Failure of ureteral access sheath insertion in primary flexible ureteroscopy for renal stones: is there any relation with inflammation?

Abstract

Purpose To investigate the relationship between failure to insert a ureteral access sheath (UAS) with inflammation and other clinical parameters in patients treated with flexible ureteroscopy for renal stones.

Methods This study included patients who underwent flexible ureteroscopy for the treatment of renal stones in our centre between 2015 and 2020. Patients who underwent any surgical procedure on the ipsilateral ureter and had a history of spontaneous stone passage were excluded. Patients were divided into two groups based on UAS insertion success (group 1) or failure (group 2). Both groups were compared with a view to clinical characteristics, preoperative neutrophil, lymphocyte, monocyte and platelet counts and ratios of these counts, all being considered inflammatory markers. A multivariate logistic regression analysis was performed to determine the independent variables affecting UAS insertion success.

Results There were 113 (59.1%) patients in group 1, while group 2 consisted of 78 (40.9%) patients. The rates of male gender, coronary artery disease and preoperative ipsilateral hydronephrosis were significantly higher in group 2, while platelet counts and platelet-lymphocyte ratios were significantly lower. Our analysis revealed four independent predictors for UAS insertion failure: female gender (odds ratio [OR]=2.1) increased the rate of UAS insertion success, while hydronephrosis (OR=1.6), low platelet counts and PLR increased the rate of UAS insertion failure (OR=0.99, OR=0.98, respectively).

Conclusion Our results suggest that male gender and ipsilateral hydronephrosis are associated with increased UAS insertion failure. Although we found a relationship between relatively low platelet levels and UAS insertion failure, we think that further studies are needed to investigate this matter.

Zusammenfassung

Einführung Untersuchung des Zusammenhangs zwischen Versagen des Vorschiebens einer Harnleiterschleuse (HLS) und entzündlichen Prozessen sowie anderen klinischen Parametern bei Patienten, die wegen Nierensteinen mit flexibler Ureteroskopie behandelt wurden.

Methoden Zielgruppe dieser Studie waren Patienten, die zwischen 2015 und 2020 in unserem Zentrum durch flexible Ureterorenoskopie operiert wurden. Patienten, bei denen ein chirurgischer Eingriff in den ipsilateralen Harnleiter durchgeführt wurde und in der Vergangenheit eine spontane Steinpassage aufgetreten war, wurden ausgeschlossen. Die Patienten wurden je nach Erfolg (Gruppe 1) oder Misserfolg (Gruppe 2) des HLS-Vorschiebens in 2 Gruppen eingeteilt. Es erfolgte ein Vergleich beider Gruppen hinsichtlich klinischer Merkmale sowie präoperativer Neutrophilen-, Lymphozyten-, Monozyten- und Thrombozytenzahlen und der Verhältnisse dieser Zahlen, die alle als Entzündungsmarker angesehen wurden. Eine multivariate logistische Regressionsanalyse wurde durchgeführt, um die unabhängigen Variablen zu bestimmen, die den Erfolg des HLS-Vorschiebens beeinflussen.

Ergebnisse Gruppe 1 bestand aus 113 (59,1 %) Patienten, Gruppe 2 aus 78 (40,9 %) Patienten. Gruppe 2 wies signifikant höhere Raten von Patienten männlichen Geschlechts, koronarer Herzkrankheit und präoperativer ipsilateraler Hydronephrose auf, während die Thrombozytenzahlen und Thrombozyten-Lymphozyten-Verhältnisse in Gruppe 2 signifikant niedriger waren. Unsere Analyse ergab vier unabhängige Prädiktoren für ein Versagen des HLS-Vorschiebens: Das weibliche Geschlecht (Odds Ratio [OR] = 2,1) erhöhte die Erfolgsrate des Einführens der HLS, während Hydronephrose (OR = 1,6), niedrige Thrombozytenzahlen und PLR die Versagensrate beim Einführen der HLS erhöhten (OR = 0,99 bzw. OR = 0,98).

Schlussfolgerungen Unsere Ergebnisse legen nahe, dass männliches Geschlecht und ipsilaterale Hydronephrose mit einem erhöhten Versagen des Einführens einer HLS verbunden sind. Obwohl wir einen Zusammenhang zwischen relativ niedrigen Thrombozytenwerten und HLS-Insertionsversagen nachweisen konnten, sind wir der Ansicht, dass weitere Studien zu diesem Thema erforderlich sind.

Schlüsselwörter

Entzündung - Thrombozyten - Ureterorenoskopie - Ureteroskopie - Ureterzugangsschleuse

Keywords

inflammation - platelets - ureteral access sheath - ureteroscopy - ureterorenoscopy

Publication History

Received: 28 January 2021

Accepted after revision: 26 October 2021

Article published online:
21 December 2021

• References

• 1 Kaplan AG, Lipkin ME, Scales CD. et al. Use of ureteral access sheaths in ureteroscopy. Nat Rev Urol 2016; 13: 135-140 DOI: 10.1038/nrurol.2015.271. (PMID: 26597613)
• 2 Auge BK, Pietrow PK, Lallas CD. et al. Ureteral access sheath provides protection against elevated renal pressures during routine flexible ureteroscopic stone manipulation. J Endourol 2004; 18: 33-36 DOI: 10.1089/089277904322836631. (PMID: 15006050)
• 3 Ambani SN, Faerber GJ, Roberts WW. et al. Ureteral stents for impassable ureteroscopy. J Endourol 2013; 27: 549-553 DOI: 10.1089/end.2012.0414. (PMID: 23066997)
• 4 Shields JM, Tunuguntla HS, Bhalani VK. et al. Construction-related differences seen in ureteral access sheaths: comparison of reinforced versus nonreinforced ureteral access sheaths. Urology 2009; 73: 241-244 DOI: 10.1016/j.urology.2008.07.055. (PMID: 18845320)
• 5 Mogilevkin Y, Sofer M, Margel D. et al. Predicting an effective ureteral access sheath insertion: a bicenter prospective study. J Endourol 2014; 28: 1414-1417 DOI: 10.1089/end.2014.0215. (PMID: 25244070)
• 6 Viers BR, Viers LD, Hull NC. et al. The Difficult Ureter: Clinical and Radiographic Characteristics Associated With Upper Urinary Tract Access at the Time of Ureteroscopic Stone Treatment. Urology 2015; 86: 878-884
• 7 Fuller TW, Rycyna KJ, Ayyash OM. et al. Defining the Rate of Primary Ureteroscopic Failure in Unstented Patients: A Multi-Institutional Study. J Endourol 2016; 30: 970-974 DOI: 10.1089/end.2016.0304. (PMID: 27301268)
• 8 Whelan P, Hwang T, Coogan C. Preoperative factors associated with failure in unstented primary ureteroscopy for nephrolithiasis. Can J Urol 2018; 25: 9389-9394 (PMID: 30125517)
• 9 Hubosky SG, Healy KA, Grasso M. et al. Accessing the difficult ureter and the importance of ureteroscope miniaturization: history is repeating itself. Urology 2014; 84: 740-742 DOI: 10.1016/j.urology.2014.06.029. (PMID: 25150179)
• 10 Chen L, Deng H, Cui H. et al. Inflammatory responses and inflammation-associated diseases in organs. Oncotarget 2017; 9: 7204-7218 DOI: 10.18632/oncotarget.23208. (PMID: 29467962)
• 11 Muneer A, Macrae B, Krishnamoorthy S. et al. Urogenital tuberculosis - epidemiology, pathogenesis and clinical features. Nat Rev Urol 2019; 16: 573-598 DOI: 10.1038/s41585-019-0228-9. (PMID: 31548730)
• 12 Grimes MD, Tesdahl BA, Schubbe M. et al. Histopathology of Anterior Urethral Strictures: Toward a Better Understanding of Stricture Pathophysiology. J Urol 2019; 202: 748-756 DOI: 10.1097/JU.0000000000000340. (PMID: 31091176)
• 13 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205-213
• 14 Fuganti PE, Pires S, Branco R. et al. Predictive factors for intraoperative complications in semirigid ureteroscopy: analysis of 1235 ballistic ureterolithotripsies. Urology 2008; 72: 770-774 DOI: 10.1016/j.urology.2008.05.042. (PMID: 18632141)
• 15 Traxer O, Thomas A. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol 2013; 189: 580-584 DOI: 10.1016/j.juro.2012.08.197. (PMID: 22982421)
• 16 Loftus CJ, Ganesan V, Traxer O. et al. Ureteral Wall Injury with Ureteral Access Sheaths: A Randomized Prospective Trial. J Endourol 2020; 34: 932-936 DOI: 10.1089/end.2018.0603. (PMID: 30526031)
• 17 Lee KS, Ha JS, Koo KC. Significance of Neutrophil-to-Lymphocyte Ratio as a Novel Indicator of Spontaneous Ureter Stone Passage. Yonsei Med J 2017; 58: 988-993 DOI: 10.3349/ymj.2017.58.5.988. (PMID: 28792143)
• 18 Conti P, Shaik-Dasthagirisaeb Y. Atherosclerosis: a chronic inflammatory disease mediated by mast cells. Cent Eur J Immunol 2015; 40: 380-386 DOI: 10.5114/ceji.2015.54603. (PMID: 26648785)
• 19 do Amaral RJFC, Balduino A. Platelets in Tissue Regeneration. In: Kerrigan SW, Moran N, eds. The Non-Thrombotic Role of Platelets in Health and Disease. IntechOpen 2015; 2015: 221-237
• 20 De Pascale MR, Sommese L, Casamassimi A. et al. Platelet derivatives in regenerative medicine: an update. Transfus Med Rev 2015; 29: 52-61 DOI: 10.1016/j.tmrv.2014.11.001. (PMID: 25544600)
• 21 Liu Y, Chen S, Sun Y. et al. Clinical characteristics of immune thrombocytopenia associated with autoimmune disease: A retrospective study. Medicine (Baltimore) 2016; 95: e5565 DOI: 10.1097/MD.0000000000005565. (PMID: 27977588)
• 22 Sonmez O, Sonmez M. Role of platelets in immune system and inflammation. Porto Biomed J 2017; 2: 311-314 DOI: 10.1016/j.pbj.2017.05.005. (PMID: 32258788)
• 23 Rhee E, Santiago L, Park E. et al. Urinary IL-6 is elevated in patients with urolithiasis. J Urol 1998; 160: 2284-2288 DOI: 10.1097/00005392-199812010-00101. (PMID: 9817385)
• 24 Kaler KS, Lama DJ, Safiullah S. et al. Ureteral Access Sheath Deployment: How Much Force Is Too Much? Initial Studies with a Novel Ureteral Access Sheath Force Sensor in the Porcine Ureter. J Endourol 2019; 33: 712-718 DOI: 10.1089/end.2019.0211. (PMID: 31161788)
• 25 Wong VK, Aminoltejari K, Almutairi K. et al. Controversies associated with ureteral access sheath placement during ureteroscopy. Investig Clin Urol 2020; 61: 455-463 DOI: 10.4111/icu.20200278. (PMID: 32869562)
• 26 Sener TE, Cloutier J, Villa L. et al. Can We Provide Low Intrarenal Pressures with Good Irrigation Flow by Decreasing the Size of Ureteral Access Sheaths? [published correction appears in J Endourol. 2017 Jan;31(1):110]. J Endourol 2016; 30: 49-55 DOI: 10.1089/end.2015.0387. (PMID: 26381037)
• 27 Monga M, Bodie J, Ercole B. Is there a role for small-diameter ureteral access sheaths? Impact on irrigant flow and intrapelvic pressures. Urology 2004; 64: 439-442
• 28 Dessyn JF, Balssa L, Chabannes E. et al. Flexible Ureterorenoscopy for Renal and Proximal Ureteral Stone in Patients with Previous Ureteral Stenting: Impact on Stone-Free Rate and Morbidity. J Endourol 2016; 30: 1084-1088 DOI: 10.1089/end.2016.0045. (PMID: 27527667)
• 29 Yuk HD, Park J, Cho SY. et al. The effect of preoperative ureteral stenting in retrograde Intrarenal surgery: a multicenter, propensity score-matched study. BMC Urol 2020; 20: 147 DOI: 10.1186/s12894-020-00715-1. (PMID: 32928162)
• 30 Komeya M, Usui K, Asai T. et al. Outcome of flexible ureteroscopy for renal stone with overnight ureteral catheterization: a propensity score-matching analysis. World J Urol 2018; 36: 1871-1876 DOI: 10.1007/s00345-018-2328-1. (PMID: 29761227)
• 31 Fankhauser CD, Hermanns T, Lieger L. et al. Extracorporeal shock wave lithotripsy versus flexible ureterorenoscopy in the treatment of untreated renal calculi. Clin Kidney J 2018; 11: 364-369 DOI: 10.1093/ckj/sfx151. (PMID: 29992018)
• 32 Chen HQ, Chen ZY, Zeng F. et al. Comparative study of the treatment of 20–30 mm renal stones with miniaturized percutaneous nephrolithotomy and flexible ureterorenoscopy in obese patients. World J Urol 2018; 36: 1309-1314 DOI: 10.1007/s00345-018-2258-y. (PMID: 29536158)