A new variable emerges to guide the decision when choosing surgical options for renal stones larger than 20 mm

Abstract

Renal stones pose a significant health burden affecting many of the global population. When stones exceed 20 mm, invasive urological interventions become necessary. The study aimed to compare the effectiveness of percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) in managing renal stones above 20 mm. Methods. This prospective interventional study was conducted over four years (June 2019 - June 2023) in multiple centers including Ghazi Al-Hariri Hospital, a Beirut private hospital, and a private clinic in Baghdad. A total of 240 patients with renal stones sized 20-40 mm were enrolled, excluding those with specific medical conditions. Patients were divided into two groups: 116 underwent RIRS and 124 underwent PCNL. The evaluation included sociodemographic and medical history, clinical and laboratory assessments, imaging studies, and follow-ups for three months post-surgery. Statistical analysis was performed using SPSS version 26. Results. The mean surgical time was significantly lower in the RIRS group (83.51 ± 21.7 minutes) compared to the PCNL group (98.12 ± 22.1 minutes) (p = 0.001). The mean hospital stay was also significantly shorter in the RIRS group (1.9 ± 1.0 days) compared to the PCNL group (3.2 ± 1.3 days) (p = 0.001). The prevalence of minor complications (Clavien I) was higher in the RIRS group (15.5%) than in the PCNL group (6.5%) (p = 0.037). However, moderate to severe complications (Clavien II and III) were higher in the PCNL group (Clavien II: 10.5% vs. 3.4%, p = 0.033; Clavien III: 4.8% vs. 0%, p = 0.016). The stone-free rate in the RIRS group was significantly higher among patients with longitudinal stones (93.8%) compared to globular stones (54.3%) (p = 0.001). No significant differences were detected in BMI (p = 0.065) and stone size (p = 0.112) between those with successful and unsuccessful procedures in the RIRS group. Conclusions. Stone shape, especially longitudinal, is a crucial factor in choosing between RIRS and PCNL for renal stones >20 mm. RIRS offers advantages in surgical time, hospital stay, and minor complications, with higher success rates for longitudinal stones. Future research should focus on multivariate analyses considering stone size, shape, and configuration to determine the most effective treatment strategies for large stones.