Date Published: February 13, 2018
Publisher: Public Library of Science
Author(s): Shinnosuke Kuroda, Hiroki Ito, Kentaro Sakamaki, Tadashi Tabei, Takashi Kawahara, Atsushi Fujikawa, Kazuhide Makiyama, Masahiro Yao, Hiroji Uemura, Junichi Matsuzaki, Xin Gao.
This study aimed to develop a prediction model for the operative time of flexible ureteroscopy (fURS) for renal stones. We retrospectively evaluated patients with renal stones who had been treated successfully and had stone-free status determined by non-contrast computed tomography (NCCT) 3 months after fURS and holmium laser lithotripsy between December 2009 and September 2014 at a single institute. Correlations between possible factors and the operative time were analyzed using Spearman’s correlation coefficients and a multivariate linear regression model. The P value < 0.1 was used for entry of variables into the model and for keeping the variables in the model. Internal validation was performed using 10,000 bootstrap resamples. Flexible URS was performed in 472 patients, and 316 patients were considered to have stone-free status and were enrolled in this study. Spearman’s correlation coefficients showed a significant positive relationship between the operation time and stone volume (ρ = 0.417, p < 0.001), and between the operation time and maximum Hounsfield units (ρ = 0.323, p < 0.001). A multivariate assessment with forced entry and stepwise selection revealed six factors to predict the operative time of fURS: preoperative stenting, stone volume, maximum Hounsfield unit, surgeon experience, sex, and sheath diameter. Based on this finding, we developed a model to predict operative time of fURS. The coefficient of determination (R2) in this model was 0.319; the mean R2 value for the prediction model was 0.320 ± 0.049. To our knowledge, this is the first report of a model for predicting the operative time of fURS treatment of renal stones. The model may be used to reliably predict operative time preoperatively based on patient characteristics and the surgeons’ experience, plan staged URS, and avoid surgical complications.
According to the latest guidelines, treatment recommendations for urolithiasis have shifted to endourologic procedures, such as flexible ureteroscopy (fURS) and percutaneous nephrolithotomy (PCNL). Consequently, shock wave lithotripsy (SWL) has lost its place as the first-line modality for many indications. Flexible URS has become a standard treatment for renal and ureteral calculi less than 20 mm . Given the advancement in surgical techniques and devices in fURS, successful outcomes and low complication rates have been reported, even in complicated cases, such as solitary kidney patients [2–6]. However, operative time can influence surgical outcomes, especially complications in the fURS procedure . In endourological surgeries, such as URS or PCNL, several severe perioperative and postoperative complications can occur, including sepsis, perforation, and massive bleeding [8–11]. A previous study reported that the severe adverse events after URS were associated with a longer operative time and lower number of the URS surgeries being performed at the hospital . Therefore, it is important to understand the clinical preoperative parameters that prolong the operative time of fURS procedures.
Among the 472 patients in whom fURS procedures were performed, 316 (66.9%) were considered to have SF status following fURS (S1 File). Table 1 shows the comparison of patient and stone characteristics among the procedures with different outcomes. The patients who had non-SF status were divided into the following two groups: residual fragments (RF) less than 4 mm and RF more than 4 mm. Significant differences were found between SF and RF less than 4 mm with respect to the following parameters: In the SF group, stone volume was smaller (651.6 mm3 vs. 1286.8 mm3, P = 0.002), there were fewer stones in the lower pole calculi (57.0% vs. 84.7%, P < 0.001), both maximum and mean HUs were lower (1150.4 HU vs. 1298.4 HU; P = 0.022, 937.4 HU vs. 1077.3 HU; P = 0.015, respectively), and operative time was shorter (P < 0.001). In addition to the parameters above, the number of stones (2.7 vs. 3.3, P < 0.001) and access sheath diameter (P < 0.001) were significantly different in the SF group than in the group with RF more than 4 mm. Successful and eligible outcomes of fURS have been well demonstrated, even in cases of large and multiple renal stones, and show low complication and morbidity rates [2–6]. Nonetheless, severe complications (septic shock, cardiovascular events, and blood loss) could still be associated with fURS; a longer operative time is one of the crucial risk factors of these complications . Sugihara et al. reported that adverse events significantly increased when the operation time exceeded 90 min . Thus, especially in cases of large or multiple stones, it is important to accurately predict operative time and arrange the operative plan more precisely so that we can achieve SF within a reasonable operative time. In the present study, we have developed the prediction model of operation time based on preoperative clinical factors. The model consists of six clinical factors: stone volume, maximum HUs, operator experience, sex, preoperative stenting, and ureteral sheath diameter. We have developed a model to predict the operative time during fURS, and to our knowledge, this is the first study to report such a model. This model utilizes 6 preoperative characteristics: stone volume, maximum HUs, operator experience, sex, preoperative stenting, and ureteral sheath diameter. The model may be used to reliably predict operative time preoperatively based on patient characteristics and surgeons’ experience of the procedure, plan staged URS, and avoid surgical complications. Source: http://doi.org/10.1371/journal.pone.0192597