Clinical Study on the Treatment of Paravesical Cysts Combined with Renal Calculi using ureteroscopy with super-pulsed thulium fiber laser

doi:10.21203/rs.3.rs-3558398/v1

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Clinical Study on the Treatment of Paravesical Cysts Combined with Renal Calculi using ureteroscopy with super-pulsed thulium fiber laser

https://doi.org/10.21203/rs.3.rs-3558398/v1

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Objective

To investigate the safety and feasibility of super-pulsed thulium fiber laser under transurethral flexible ureteroscopy in the treatment of parapelvic cysts combined with renal stones.

Patients and methods

Twelve patients with parapelvic cysts combined with renal stones admitted from October 2022 to May 2023 were treated with super-pulsed thulium fiber laser under transurethral flexible ureteroscopy and internal incision and drainage simultaneously. CT scans were performed at 1, 3, and 6 months postoperative to assess the cysts and stones, respectively.

Results

The mean age of the patients was 61.5 ± 7.5 years. The mean size of parapelvic cysts was 5.6 ± 0.7 cm. The mean size of the renal stones was 15.6 ± 3.2 mm. The mean CT density of all stones was 1,464.9 ± 656.5 HU. All patients underwent successful one-stage surgery without serious complications. The mean operative time was 41.2 ± 9.5 min. The average intraoperative bleeding was 6.7 ± 3.0 mL, and the average hospital stay was 2.0 ± 0.7 d. The postoperative CT reexamination indicated that the stone clearance rate was 100%, with no obvious residual stone, and the parapelvic cysts basically disappeared.

Conclusion

Super-pulsed thulium fiber laser under transurethral flexible ureteroscopy is a safe, feasible, and effective treatment method for parapelvic cysts combined with renal stones, with the advantages of high stone clearance rates and low intraoperative bleeding.

thulium fiber laser

transurethral flexible ureteroscopy

parapelvic cysts

renal stones

Renal cysts are a very common renal disease with an increasing incidence as people age; 50% of adults over the age of 50 suffer from renal cysts, while 66% of adults will develop renal cysts by the age of 80[1]. Parapelvic cysts are a specific type of renal cystic disease in which the cyst originates in the renal sinus and bypasses the renal pelvis or renal sinus[2, 3]. Parapelvic cysts can be diagnosed by imaging examinations such as ultrasound, enhanced computed tomography (CT), and magnetic resonance imaging (MRI)[4]. Parapelvic cysts are usually slow-progressing benign lesions with atypical clinical symptoms[5]. If the cyst is tiny, the patient presents no clinical symptoms, no complications are observed, and the imaging examination shows no obvious renal pelvic compression, it usually does not require any treatment, and conservative monitoring and regular follow-up may be an option[6]. Parapelvic cysts can compress the renal artery or renal pelvis due to their unique location, which can cause urinary obstruction, hydronephrosis, hematuria, lumbar discomfort, high renin hypertension, and secondary stone formation. When symptoms caused by compression appear, aggressive treatment should be initiated[7].

For symptomatic parapelvic cysts of large size, current treatment strategies mainly include laparoscopic unroofing of renal cyst, ultrasound-guided percutaneous sclerotherapy, percutaneous resection or ablation, and internal drainage under flexible ureteroscopy[8, 9]. Due to the complexity of parapelvic cysts and proximity to renal hilar structures, laparoscopic unroofing of renal cysts is quite invasive, and the procedure is challenging and highly risky; ultrasound-guided percutaneous sclerotherapy may induce perinephric inflammation or even lead to ureteropelvic junction obstruction (UPJO)[10]. Transurethral endoscopic surgery is more advantageous in avoiding damage to renal hilar structures and requiring no complex surgical techniques of laparoscopic surgery[5, 11]. For patients with parapelvic cysts combined with secondary renal stones, studies have reported that they can be treated by transurethral flexible ureteroscopy with super-pulsed thulium fiber laser safely and effectively[12]. In recent years, with the development of minimally invasive techniques and medical laser equipment, thulium fiber laser (TFL) has outperformed holmium laser in urology, with excellent hemostatic and lithotriptic effects, especially for soft tissues and calculi[13]. However, no study of its application to parapelvic cysts combined with renal stones has been reported. Therefore, this study explored the treatment of 12 patients with parapelvic cysts combined with secondary renal stones through transurethral flexible ureteroscopy with super-pulsed thulium fiber laser, and the patients were followed up to determine the clinical safety and efficacy.

Study population

This study was approved by the Medical Ethics Research Committee of the Chinese PLA General Hospital. Informed consent in writing was obtained from all patients after a full explanation of the procedures. Eight patients with parapelvic cysts combined with renal stones were treated at our institution between October 2022 and May 2023 with super-pulsed thulium fiber laser lithotripsy under transurethral flexible ureteroscope and internal incision and drainage of parapelvic cysts. The parapelvic cysts and renal stones were diagnosed by CT. CT urography (CTU) was performed when necessary.

Study design

We performed surgical treatment on these patients according to the following indications: (A) free renal stones larger than 6 mm; and (B) recurrent or persistent pain that did not improve with conservative treatment; (C) pararenal renal cyst greater than 4 cm in diameter:(D) pararenal cyst inducing urinary tract obstruction and effusion. (E) renal cyst causing complications such as hemorrhage, vascular compression, and renin-mediated hypertension. Our study excluded patients with severe cardiac, hepatic, pulmonary, and cerebral dysfunction, intolerance to general anesthesia, and those with suspected cystic renal cell carcinoma.

Surgical procedure

The urine culture was routinely performed before surgery, and those who were positive were treated with antibiotics. The patients were placed prone and underwent surgery under general anesthesia. For the flexible electronic ureteroscope (STORZ FLEX-XC, Germany), the ureteral access sheath (12/14F, Cook) was placed into the renal pelvis through a 0.035-inch guide wire to examine the renal pelvis and each renal calyx, and to locate renal stones and parapelvic cysts. A 200 µm thulium laser fiber (Raykeen Laser Technology Limited Corporation, Shanghai, China) was placed to pulverize the renal stones first. Depending on the stone hardness, we used a thulium laser with a frequency of 10–100 HZ and an energy of 0.3–3.0 J to crush the stones, which were completely pulverized (Fig. 1A-B). Subsequently, the parapelvic cysts were located. The typical morphology of parapelvic cysts under the flexible ureteroscope was blue and translucent; the renal pelvis would be compressed and deformed, with localized bulging accompanied by wave sense (Fig. 1C-D). For parapelvic cysts with thick walls that were not easy to distinguish, we performed ultrasound-guided percutaneous puncture aspiration, injected methylene blue into the cyst cavity, and observed the color change endoscopically (methylene blue staining could make the cyst wall appear blue). An incision of 2–4 cm in length was made on the cyst wall by thulium laser with a frequency of 100 HZ and an energy of 0.2 J. The incision was extended proximally and distally along the area of the maximum tension to the fatty layer of the renal sinus. If necessary, a cruciate incision was made, leaving the incision fully exposed and cave-in-like to avoid stenosis formed by postoperative scar contracture of the incision. The flexible electronic ureteroscope was inserted into the cyst cavity to observe the condition inside the cyst and exclude the tumor. F6 Double-J stent tube was routinely indwelled after the operation with the proximal end coiled in the cyst cavity for drainage and removed after 2–4 weeks. Abdominal plain CT was performed at 1 d postoperative to clarify whether the ureteral Double-J tube was properly positioned. CT scans were performed at 1, 3, and 6 months postoperative to assess the cyst and stones, respectively.

In this study, there were a total of 12 patients with parapelvic cysts combined with renal stones, including 3 females and 9 males. The mean age of the patients was 61.5 ± 7.5 years. Renal stones and parapelvic cysts were diagnosed by CT. The mean size of the parapelvic cysts was 5.6 ± 0.7 cm, and that of the renal stones was 15.6 ± 3.2 mm. The mean CT density of all stones was 1464.9 ± 656.5 HU. All patients underwent successful one-stage surgery without serious complications. The mean operative time was 41.2 ± 9.5 min. The average intraoperative bleeding was 6.7 ± 3.0 mL, and the average hospital stay was 2.0 ± 0.7 d (Table 1). Intraoperative ultrasound-guided percutaneous puncture aspiration was performed on 1 patient by injecting methylene blue into the cyst cavity to turn the cyst wall blue and assist in its correct identification. In five of the patients, two parapelvic cysts were identified and treated by intraoperative incision and drainage. Abdominal plain CT was performed at 1 d postoperative to clarify whether the ureteral Double-J tube was properly positioned and proximally located in the cyst cavity. CT reexamination was performed at 1 month postoperative. The stone clearance rate was 100%, with no obvious residual stone; the parapelvic cysts basically disappeared, and the cyst size was 0.23 ± 0.17 cm. The symptoms of 8 patients with lower back discomfort disappeared after the operation. Overall, all patients were satisfied with the therapeutic effect. The clinical characteristics of these patients are shown in Table 1. Typical CT images before and after treatment are shown in Fig. 2.

Table 1

patients’ clinical characteristics
Variable	Value(n = 12)
Age (Years)	61.5 ± 7.5
Sex
Male (%)	9(75)
Female (%)	3(25)
Body mass index (kg/m2)	22.14 ± 2.24
Renal cyst’s location
Left kidney (%)	7(58)
Right kidney (%)	5(42)
Renal cyst’s number	1.5 ± 0.5
Stone size (cm)	15.6 ± 3.2
Stone CT density (HU)	1464.9 ± 656.5
The stone-free rate (%)	100
Preoperative cyst size (cm)	5.6 ± 0.7
Surgical time (min)	41.2 ± 9.5
Blood loss (ml)	6.7 ± 3.0
Hospitalization time (days)	2.0 ± 0.7
Postoperative cyst size (cm)	0.23 ± 0.17
*Data are presented as mean ± SD or number (percent)

Treatments for parapelvic cysts include percutaneous sclerotherapy, open surgical unroofing, laparoscopic decortication, and ureteroscopic drainage[9, 14]. Compared with simple renal cysts, parapelvic cysts are relatively difficult to treat due to their deep location adjacent to the renal pelvis and blood vessels[10, 11]. Laparoscopic unroofing of parapelvic cysts is challenging and highly risky, prone to intraoperative damage to the renal pelvis and renal blood vessels; its incidence of pelvic injury is 9.5%, according to a study report[7]. Percutaneous puncture sclerotherapy, on the other hand, may lead to severe pyelonephritis or secondary UPJO[15–17]. In the past, laparoscopic unroofing of renal cysts was the treatment of choice for parapelvic cysts. However, most surgeons found laparoscopic unroofing challenging and risky. With the continuous advancement of endoscopic techniques and laser devices, Basiri et al. recently reported the application of holmium laser incision and drainage under ureteroscopy in the treatment of parapelvic cysts. The results indicate that ureteroscopic treatment of simple parapelvic cysts is safe and feasible[18]. Compared with laparoscopic unroofing of parapelvic cysts, holmium laser incision and drainage under transurethral flexible has the advantages of shorter operative time, less intraoperative blood loss, and reduced hospital stay[5, 19].

Urinary tract obstruction and stone formation are common complications of parapelvic cysts. For the treatment of renal stones, shock wave lithotripsy (SWL) is recommended by the EAU and AUA as the first-line treatment option for renal stones < 20 mm[20]. However, in patients with parapelvic cysts combined with renal stones, extracorporeal shock wave lithotripsy (ESWL) cannot achieve a satisfactory stone clearance rate due to the obstruction caused by the parapelvic cysts[12]. Similarly, for flexible ureteroscopic lithotripsy, the obstruction caused by parapelvic cysts may interfere with the access of the flexible ureteroscope to the target renal calyces. Without treatment of the parapelvic cysts, a satisfactory stone clearance rate cannot be achieved[12]. Hu et al. reported that percutaneous nephrolithotomy (PCNL) combined with intrarenal laser incision and drainage was a safe and feasible method for the treatment of renal stones and upper ureteral stones combined with ipsilateral renal cysts[21]. Wen et al. reported that holmium laser under flexible ureteroscopy was safe and feasible in treating 28 patients with parapelvic cysts combined with renal stones[12].

The key to surgery for parapelvic cysts and secondary renal stones under flexible ureteroscopy is to identify the location of cysts. The typical ureteroscopic presentation of a parapelvic cyst is a cyst with a pale blue or translucent wall that projects into the renal pelvis[22]. In cases where the cyst wall was relatively thick and not easy to identify the cyst location, we chose the prone position to facilitate intraoperative ultrasound-assisted localization. We performed ultrasound-guided percutaneous puncture aspiration, injected methylene blue into the cyst cavity, and observed the color change endoscopically (methylene blue staining could make the cyst wall appear blue) to assist in accurate localization[22]. In this study, the parapelvic cyst of a patient was accurately located by this method.

The holmium laser was considered the gold standard for laser lithotripsy in the past. Despite its advantages, it still has some limitations. Stone displacement during lithotripsy is a major limitation, leading to lower stone ablation rates and longer operative time. Hence, reducing stone movement is the key to improving the performance of laser lithotripsy[23]. The super-pulsed thulium fiber laser used in this study is a very promising new laser that is becoming a new player in the treatment of urinary system-related diseases[24–26]. With many advantages over the holmium laser, the super-pulsed thulium fiber laser operates at a wavelength of 1,940 nm, which is very close to that of the absorption peak in water. It has an absorption coefficient five times that of the holmium laser (wavelength 2,100 nm), which reduces the threshold for stone ablation by a factor of four compared to the holmium laser[24, 27]. Therefore, the higher absorption coefficient in water translates into greater stone ablation efficiency[28, 29]. Studies have indicated that thulium fiber lasers have better lithotripsy performance than holmium lasers, especially in terms of ablation speed, stone size, and stone displacement[30–32]. Studies have shown that the super-pulsed thulium fiber laser is a safe and efficient lithotripsy tool with minimal intraoperative stone displacement and smaller stone fragments, regardless of stone type and hardness[32]. In the present study, super-pulsed thulium fiber laser was used to pulverize the stones in 12 patients with parapelvic cysts combined with renal stones and achieved better effects than holmium laser lithotripsy, with a postoperative stone clearance rate of 100%. Moreover, super-pulsed thulium fiber laser can be used at finer fiber diameters, which saves the limited working channel, improves the perfusion volume, and also facilitates the treatment of lower calyceal calculus with greater bending when combined with flexible ureteroscope[33, 34]. More importantly, thulium fiber laser can provide fast, precise incision and more carbonation by cutting at a shallower depth during tissue ablation[35], and therefore has a good hemostatic effect on parapelvic cyst incision. In addition, laparoscopic unroofing of parapelvic cysts does not allow simultaneous treatment of renal stones and carries the risk of intraoperative rupture of renal pelvic structures. Our application of super-pulsed thulium fiber laser under transurethral flexible ureteroscopy enabled simultaneous treatment of parapelvic cysts combined with renal stones, reduced the risk of anesthesia associated with reoperation, and lowered the treatment cost for the patient. The short-term postoperative follow-up suggested that after treatment with super-pulsed thulium fiber laser under transurethral flexible ureteroscopy, the parapelvic cysts basically disappeared, with a 100% stone clearance rate and good clinical efficacy.

In conclusion, super-pulsed thulium fiber laser incision under transurethral flexible ureteroscopy is a safe and effective treatment method for parapelvic cysts combined with renal stones. It has avoided the defect of previous laparoscopy, which can only deal with parapelvic cysts but not renal stones, and is worthy of clinical promotion and application. However, its long-term efficacy still requires further follow-up studies.

Funding

No funding was received to assist with the preparation of this manuscript.

Competing interests

The authors have no relevant financial or non-financial interests to disclose.

Ethics approval

This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The present study was approved by the Ethics Committee Of Chinese PLA General Hospital.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Availability of data and materials

Anonymised data and materials are available on request.

Author contributions

WC and HM conceived the manuscript; NZ and BC carried out data collection; NZ and XC performed data analysis; WC wrote the manuscript; HM and XZ critically reviewed the manuscript; All authors reviewed and approved the final manuscript.

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No competing interests reported.

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You are reading this latest preprint version

Clinical Study on the Treatment of Paravesical Cysts Combined with Renal Calculi using ureteroscopy with super-pulsed thulium fiber laser

Status:

Version 1

Abstract

Objective

Patients and methods

Results

Conclusion

Figures

Introduction

Patients and methods

Study population

Study design

Surgical procedure

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1