PCNL vs RIRS in Management of Stones in Calyceal Diverticulum: Outcomes from a Global Multicentre Match Paired Study That Reflects Real World Practice
PCNL与RIRS在肾盏憩室结石治疗中的比较：一项全球多中心配对研究的结果，反映了真实世界的实践
背景
Calyceal diverticular stones present potentially tricky and technically challenging scenarios, with no consensus on the best management strategies in view of the paucity of evidence. Percutaneous Nephrolithotomy (PCNL) has been time tested with a high success rate of stone extraction and good stone-free rates of up to 83%.
由于缺乏证据，对最佳管理策略没有达成共识，因此，肾盏憩室结石的管理可能会很棘手且具有技术挑战性。经皮肾镜取石术（PCNL）经过了时间的考验，取石成功率高，无结石率（SFR）高达83%。
However, with the advent of modern endourology, Retrograde intrarenal surgery (RIRS) has become a popular choice for the management of renal stones and is widely accepted as a safe procedure even in anomalous anatomy. The question remains whether these minimally invasive alternatives can stand against these traditional techniques in the case of diverticular calculi. On top of comparing both methods with our global multicentre match paired study, we wanted to highlight the technical differences in methods used by specialists in reference to identifying the diverticular opening, accessing the diverticulum as well as lithotripsy and exit strategy.
然而，随着现代泌尿外科的出现，逆行肾内手术（RIRS）成为管理肾结石时较受欢迎的选择，即使面对解剖结构异常的患者，也广泛具有安全性。但是在面对憩室结石时，这些微创替代方案是否可以与传统技术相较。我们在全球多中心配对研究中比较了这两种方法，我们想强调这两种术式在识别憩室开口、进入憩室以及碎石和退出憩室方面存在技术差异。
研究结果
Retrospective data was collated spanning 11 countries representing various ethnic and cultural groups across both western and eastern populations. Propensity-score matching was performed between groups who underwent mini-PCNL (PCNL) vs RIRS for pre-operative variables including demographics, stone characteristics, intra-operative techniques as well as post-operative complications. Where available, data was compared regarding how the diverticulum was identified, methods for access as well as exit strategies.
回顾性数据来自11个国家，包含了西方和东方不同的种族和文化群体。对于术前变量，包括人口统计学特征、结石特征、术中技术以及术后并发症，在mini-PCNL（PCNL组）与RIRS组之间进行倾向评分匹配。比较了识别憩室、进入憩室以及退出憩室时使用的方法。
Our analysis shows no significant difference in SFR between both groups (71.5% in PCNL vs 74% in RIRS, p = 0.775) as well as similar re-intervention rates for residual fragments, regardless of stone size, number, and location of the diverticulum. Factors influencing outcomes include multiplicity of stones but interestingly not stone size. The location of the diverticulum also was an important factor, with higher odds of residual fragments in lower pole diverticular stones (OR 0.474, p < 0.041). Conversion to ECIRS for an endoscopic combined approach was performed for 4.7% of PCNL cases and 6.5% of RIRS cases.
分析显示，两组之间的SFR无显著差异（PCNL 71.5% vs RIRS 74%，p=0.775），无论结石多大、有多少，憩室位置如何，残留碎石的再干预率相似。影响结局的因素包括结石数量，有趣的是，结石大小并不会影响结局。憩室的位置也是一个重要因素，下极憩室结石发生碎石残留的几率较高（OR 0.474，p＜0.041）。PCNL组和RIRS组中转而进行内镜联合肾内手术（ECIRS）的发生率分别为4.7%和6.5%。
Table Univariate Analysis of SFR (After PSM)
表 SFR的单变量分析（PSM后）
Some notable differences were found regarding intra-operative techniques. In PCNL, typically the diverticular neck is identified with contrast administration antegrade or retrograde through infusion of indigo carmine dye. In RIRS, the methylene blue dye is classically used if the diverticulum is not identified with contrast. Interestingly in our study, the blue-dye test was used more frequently in the PCNL group (8.4%) than the RIRS group (4.9%) – potentially indicating that a combination of direct visualization with the flexible scope and guidewire introduction under vision may preclude the use of these techniques. With regards to fulguration of the diverticulum, evidence also remains controversial. There have been reports of 87.5% obliteration at 3 months follow up with higher obliteration rates than dilation alone. Others believe electrocautery would traumatize the calyceal lining. In our series, none of the specialists used fulguration or electrocautery. Instead, laser infundibulotomy was done for 20.8% of PCNL patients and 63.1% in RIRS patients. Unfortunately, in our series, no laser settings were reported, but this remains the first real-world large case series advocating the use of laser for both approaches as compared to electrocautery in the past.
两组在术中技术方面存在一些显著差异。在PCNL中，通常通过注入靛蓝胭脂红染料顺行或逆行造影来识别憩室颈。在RIRS中，如果造影后未识别出憩室，则通常使用亚甲蓝染料。有趣的是，在我们的研究中，PCNL组的亚甲蓝染料使用率高于RIRS组（8.4% vs 4.9%），这可能表明在输尿管软镜直接可视化和导丝引导的帮助下，RIRS可能用不上上述技术。憩室电灼方面的证据也仍然存在争议。据报道，随访3个月时电灼的憩室闭合率为87.5%，高于单纯扩张。但也有人认为电灼会对肾盏造成创伤。在我们的病例系列研究中，没有一位专家使用电灼。与之形成对比的是，PCNL组和RIRS组分别对20.8%的患者和63.1%的患者进行了激光漏斗切开术。遗憾的是，我们的系列研究没有关于激光设置的说明，但这是首项真实世界大型病例系列研究，我们认为，不管是PCNL还是RIRS，都提倡使用激光而不是电灼。
结论
Overall, both PCNL and RIRS present safe options for the effective management of calyceal diverticulum stones with similar SFR. Urologists may determine the best modality based on the number of stones as well as the location of the diverticulum but also based on their own technical proficiencies. Although PCNL currently has slightly longer hospitalization duration (3.86 ± 1.94 vs 1.04 ± 0.20 days for RIRS group; p <0.001) and bleeding-related complication rates, future further miniaturization may still alter the playing field in this rapidly-developing arena. Modern endourologists should always be adept at multiple techniques for various circumstances, and flexible to change the operative plan in the event of any challenges.
总之，对于肾盏憩室结石，PCNL和RIRS都具有有效性和安全性。泌尿科医生可以根据结石数量、憩室位置以及技术熟练程度来决定最佳管理方式。虽然目前PCNL的住院时间稍长（PCNL组为3.86±1.94天vs RIRS组为1.04±0.20天；p<0.001），出血相关并发症发生率更高，但未来医疗器械微型化可能会使之发生改变。现代腔道泌尿外科医生应始终掌握各种情况下的多种技术，并在遇到任何挑战时灵活改变手术计划。
Reference:
Gauhar V, Traxer O, Woo SJQ, Fong KY, Ragoori D, Wani A, Soebhali B, Mahajan A, Pankaj M, Gadzhiev N, Tanidir Y, Mehmet İG, Aydin C, Bostanci Y, Bin Hamri S, Barayan FR, Sinha MM, Inoue T, Teoh JY, Castellani D, Somani BK, Lim EJ. 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. 2023 Nov;41(11):2897-2904. doi: 10.1007/s00345-023-04650-2. Epub 2023 Oct 21. PMID: 37864647.
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