Effectiveness and Safety of Ureteroscopic Lithotripsy in Young,Old-Old,and Oldest Old Patients

Abstract

Objectives:

To investigate the efficacy and safety of ureteroscopic lithotripsy (URSL) in young, old-old, and oldest old patients.

Materials and Methods:

We enrolled 157 patients who underwent URSL. We divided the patients into young (<65 years), old-old (65–84 years), and oldest old (≥85 years) groups and compared the safety of surgery between young vs old-old and young vs oldest old, separately.

Results:

In the <65 group, 65 to 85 group, and ≥85 group, respectively, the mean stone diameters were 8.9 ± 4.9, 10.8 ± 7.7, and 11.4 ± 6.3 mm; mean operative time was 76.6 ± 33.1, 86.7 ± 44.7, and 84.0 ± 44.5 min; the stone-free rates were 95.9%, 94.4%, and 96.3%; and the complication rates were 8.2%, 9.8%, and 3.7%.

Conclusions:

In this study, we showed the feasibility and safety of URSL for elderly people. Although oldest old (≥85 years) people had multiple comorbidities with low performance status, URSL could be performed with acceptable complication rates. Clinical Trial Registration Number: 1809-1

Introduction

With increased elderly populations worldwide, ureteroscopic lithotripsy (URSL) in this group has increased. Developments in the ureteroscope and other peripheral devices have resulted in better surgical outcomes; however, the efficacy and safety of URSL are controversial for the elderly, especially those >80 and >90 years of age. Some studies^1

–5 reported the efficacy and safety of URSL for the elderly, stating that URSL is a safe and effective method of managing urolithiasis in these patients. However, elderly patients were generally defined as ≥65 years old or ≥70 years old in these studies. Fornara and colleagues⁶ classified elderly patients into young-old (65–74 years), old-old (75–84 years), and oldest old (≥85 years) groups to compare laparoscopic nephrectomy outcomes between the groups. In contrast, Haberal and colleagues⁷ classified patients into young (18–64 years), young-old (65–69 years), old-old (70–79 years), and oldest old (≥80 years) groups to compare percutaneous nephrolithotomy outcomes between the groups. We conducted this study to confirm that the outcomes of URSL in the elderly are not inferior to outcomes in younger people.

Materials and Methods

This study was approved by our institutional review board (authorization no.: 1809-1). This study conformed to the provisions of the Declaration of Helsinki (as revised in Fortaleza, Brazil, October 2013).

We performed a retrospective review of prospectively collected data for 157 patients who underwent URSL from March 2017 to March 2019. Enrolled patients were continuous, and no patients were excluded.

All patients received general anesthesia. Three endourologists performed URSL, and the URSL procedure was standardized as follows: We approached the calculi using a guide wire and semirigid ureteroscope (6.5F/8.5F; Richard Wolf, Knittlingen, Germany). For proximal ureteral and renal stones, we placed a ureteral access sheath under fluoroscopic guidance and fragmented the calculi with a holmium YAG laser (5–10 Hz and 0.5–1.0 J; VersaPulse 30 W; Lumenis, San Jose, CA). All fragments ≥2 mm in size were extracted using a tipless basket with a flexible ureteroscope (URF-P5; Olympus, Tokyo, Japan).

The ureteral access sheath was a Flexor 12F/14F (Cook Medical, Bloomington, IN) or Navigator 11F/13F (Boston Scientific, Natick, MA). For mid- and distal ureteral calculi, we performed the same procedure as described above without a ureteral access sheath. No cases required dilation of the ureteral orifice or ureter, and a Double-J stent was left in situ after the procedure.

The primary endpoint of the study was the safety of URSL in the elderly. We divided the patients into young (<65 years), old-old (65–84 years), and oldest old (≥85 years) groups and compared the safety of surgery between young vs old-old and young vs oldest old, separately. We defined the following as complications: fever, perforation, stricture, postoperative pneumonia, postoperative delirium, and postoperative deep vein thrombosis.

The secondary endpoint was the stone-free rate, which was determined 1 month postoperatively with CT. Stone free was defined as residual stones <2 mm in diameter. A total of 157 patients underwent URSL with holmium laser lithotripsy, as follows: <65 group: 49 patients, 65 to 84 group: 81 patients, and ≥85 group: 27 patients (including 20 patients who were ≥90 years old).

The patients' demographics and operative outcomes between the elderly and young (<65 group vs 65–84 group, and <65 group vs ≥85 group) were compared using either the t-test or χ² test. The IBM SPSS Statistics V21.0 software package (IBM Corp., Armonk, NY) was used for statistical analysis, and the significance level was set at p < 0.05.

We also investigated the factors predicting complications, using multivariate analysis. We used logistic regression analysis to assess the associations between complications and predictive factors (age, performance status [PS], preoperative stent placement, preoperative urinary tract infection, and operation time).

Results

Table 1 shows the demographics of the three groups. In the ≥85 group, the mean age was 87.8 ± 5.5 years, the number of male patients was 4 (14.8%), the number of PS4 patients was 19 (70.4%), the number of preoperative urinary tract infections was 19 (70.4%), and the number of patients with a preoperative stent was 22 (81.5%).

Table 1.

Demographics in Each Group

	All	<65 group	65–84 group	≥85 group	p
	n (%) or mean ± SD				<65 vs 65–84	<65 vs ≥85
Patients	157	49	81	27
Age	68.9 ± 16.3	49.0 ± 9.2	71.2 ± 5.6	87.8 ± 5.5	<0.001	<0.001
Sex
Male	71 (45.2)	32 (65.3)	35 (43.2)	4 (14.8)	0.01	<0.001
Female	86 (54.8)	17 (34.7)	46 (56.8)	23 (85.2)
Body mass index (kg/m²)	23.1 ± 4.6	25.6 ± 3.9	22.8 ± 4.0	21.0 ± 4.7	<0.001	<0.001
Performance status
0 or 1	106 (67.5)	49 (100)	53 (65.4)	4 (14.8)	<0.001	<0.001
2 or 3	7 (4.5)	0	3 (3.6)	4 (14.8)
4	44 (28.0)	0	25 (31.0)	19 (70.4)
American Society of Anesthesiologists physical status
1	54 (34.4)	29 (59.2)	25 (30.9)	0	<0.001	<0.001
2	94 (59.9)	17 (34.7)	52 (64.2)	25 (92.6)
3	9 (5.7)	3 (6.1)	4 (4.9)	2 (7.4)
4 or 5	0	0	0	0
Preoperative urinary tract infection	70 (44.6)	9 (18.4)	42 (53.4)	19 (70.4)	<0.001	<0.001
Preoperative stent	82 (52.2)	13 (26.5)	47 (58.0)	22 (81.5)	<0.001	<0.001
Indication for stenting
Infection	49 (31.2)	4 (8.2)	28 (34.6)	17 (63.0)	0.11	0.02
Pain control	15 (9.6)	5 (10.2)	7 (8.6)	3 (11.1)
Planned prestenting	18 (11.5)	4 (8.2)	12 (14.8)	2 (7.4)
Duration of prestenting (day)	33.6 ± 21.7	32.2 ± 24.5	34.3 ± 20.1	33.0 ± 23.2	0.39	0.78
Multiple stone	41 (26.1)	10 (20.4)	23 (28.4)	8 (29.6)	0.31	0.37
Stone location
Renal	74 (47.1)	19 (36.7)	49 (60.5)	13 (48.1)	0.11	0.42
Ureter	89 (56.7)	32 (65.3)	41 (49.4)	17 (62.9)	0.08	0.84
Lower pole stone	44 (28.0)	10 (20.4)	28 (34.6)	6 (22.2)	0.09	0.85
Stone diameter (mm)	10.6 (6.9)	8.9 ± 4.3	10.8 ± 7.7	11.4 ± 6.3	0.37	0.01
CT value	716 ± 308	781 ± 343	705 ± 304	571 ± 217	0.29	0.13

SD = standard deviation.

There were significant differences among the three groups (<65 vs 65–84 group, <65 vs ≥85 group) for some parameters, namely mean age (p < 0.001), sex (p = 0.01, p < 0.001), body mass index (p < 0.001), PS (p < 0.001), American Society of Anesthesiologists physical status (ASA-PS) (p < 0.001), preoperative urinary tract infection (p < 0.001), and preoperative stent (p < 0.001). There was also a significant difference between the <65 and ≥85 groups for stone diameter (8.9 mm ±4.3 vs 11.4 ± 6.3, respectively; p = 0.01).

Table 2 shows the operative outcomes in each group. There were no significant differences in the stone-free and complication rates. The complication rates and 95% confidence intervals were 8.2% (0.5%–15.9%), 9.8% (3.3%–16.3%), and 3.7% (0.0%–10.8%) in the <65, 65 to 84, and ≥85 groups, respectively.

Table 2.

Operative Outcomes in Each Group

	All	<65 group	65–84 group	≥85 group	p
	n (%) or mean (SD)				<65 vs 65–84	<65 vs ≥85
Use of ureteral access sheath	137 (87.3)	39 (79.6)	74 (91.4)	24 (88.9)	0.05	0.30
Operation time (min)	84.7 ± 43.6	76.6 ± 35.1	86.7 ± 44.7	84 ± 44.5	0.35	0.21
Complications	13 (8.3)	4 (8.2)	8 (9.8)	1 (3.7)	0.74	0.45
Fever	12 (7.6)	4 (8.2)	7 (8.6)	1 (3.7)	0.92	0.45
Perforation	1 (0.6)	0	1 (1.2)	0	0.45
Stricture	0	0	0	0
Postoperative pneumonia	0	0	0	0
Postoperative delirium	0	0	0	0
Postoperative deep vein thrombosis	0	0	0	0
Clavien-Dindo ≥grade 3	0	0	0	0
Stone free	149 (94.9)	47 (95.9)	76 (93.8)	26 (96.3)	0.61	0.94
Duration of stent (day)	15.2 ± 13.8	11.8 ± 6.3	17.1 ± 15.6	15.8 ± 15.9	0.12	0.55
Duration of hospital (day)	7.1 ± 5.4	4.6 ± 2.0	7.5 ± 5.3	10.1 ± 6.7	<0.001	<0.001

When we investigated the factors predicting complications using multivariate analysis, in the multiple logistic regression analysis, all factors, including age, were not significant predictive factors for complications (data not shown).

Discussion

We demonstrated that URSL in the oldest old (≥85 years) was effective and safe. To the best of our knowledge, this is the first report showing the operative outcomes of URSL in the oldest old (≥85 years).

Some studies^2,4,5 reported the efficacy and safety of URSL for the elderly. Yoshioka and colleagues² reported that the stone-free rate and postoperative pyelonephritis rate in the 65 to 74 years group and in the ≥75 years group were similar to those of the <65 years group. Berardinelli and colleagues⁴ evaluated the safety and efficacy of URSL by comparing older patients ≥65 years of age (91 patients) with those <65 years of age (308 patients). The authors found no difference between the elderly patient group and the younger patient group.

Prattley and colleagues⁵ reported similar outcomes after URSL between elderly patients (≥70 years) and younger patients. The final stone-free rate was 97%, and the overall complication rate was 9% in 110 patients ≥70 years who underwent URSL. Although the definition of “elderly” varied between reports, these data supported our outcomes; furthermore, our data extended the range of safety and efficacy to the oldest old (≥85 or ≥90 years).

Anesthetic risks are more prevalent among elderly patients than among younger patients. Many elderly people have significant comorbidities that can affect postoperative and perioperative management.⁸ Our data showed similar results; the ASA-PS of the elderly people was worse than that for the younger people.

In our institution, anesthesiologists are in charge of anesthesia for all URSL procedures, and all patients underwent general anesthesia to achieve sufficient anesthesia in accordance with the policy of anesthesiologists. Therefore, we consult with anesthesiologists to determine whether patients can be anesthetized. We believe that coordinating with anesthesiologists is important for URSL in the elderly.

In this study, many elderly patients received stents before URSL. In the ≥85 group, 81.5% of the patients received stents before URSL. Nevo and colleagues⁹ reported that preoperative stents are a risk factor for postureteroscopy sepsis, and Yuk and colleagues¹⁰ reported that preoperative ureteral stenting did not affect operative outcomes. In contrast, Jessen and colleagues¹¹ reported that preoperative stents positively affected the safety and efficacy of URSL. In addition, Yang and colleagues¹² reported that preoperative Double-J stent placement significantly improved the stone-free rate in a systematic review and meta-analysis.

These differences indicate the controversy regarding the effect of preoperative stents on URSL, and it is possible that preoperative stents affect the efficacy and safety of URSL for the elderly. In this study, complications occurred in one case (3.7%), and 81.5% of the patients received stents before URSL in the ≥85 group. However, the sample size in this group was small, and our findings did not show that prestenting improved the complication rate in the ≥85 group. Furthermore, there was no significant factor (including preoperative stent placement) associated with complications in the multiple logistic regression analysis.

However, there was a tendency toward significance regarding using ureteral access sheaths (79.6%, 91.4%, and 88.9% in the <65 group, 65–84 group, and ≥85 group, respectively). We consider that prestenting caused the ureter to expand, which affected the use of ureteral access sheaths. A ureteral access sheath has several advantages,^13,14 such as reduced intrarenal pressure and improved visibility, and we consider that prestenting may have improved the complication rate in this study.

We consider that the support of anesthesiologists and preoperative stenting may be key factors to complete URSL in the oldest old. We also consider that there are other factors. First, we are careful regarding renal pelvic pressure during surgery because elevated renal pelvis pressures during URSL are a risk factor for infection.¹⁵ The outside diameter of the URF-P5 ureteroscope is larger than that of the URF-P6 (which our institution does not have), and we consider that using the small diameter ureteral access sheath may increase the pressure in the renal pelvic.

For that reason, we used an 11F/13F or 12F/14F ureteral access sheath in our institution. Second, if the preoperative urine culture is positive, antibiotics are given the day before surgery. Blackmur and colleagues¹⁶ reported that a positive preoperative urine culture was significantly associated with postoperative urosepsis by logistic regression and matched-pair analysis. We consider that these factors might have affected the surgical outcomes in this study as well.

The complication rates in this study were 8.2%, 9.8%, and 3.7% in the <65 group, 65 to 84 group, and ≥85 group, respectively. According to the guidelines of the European Association of Urology, the overall complication rate after URSL is 9% to 25%.^17
–19 Moreover, the risk of fever in this study was 8.2%, 8.6%, and 3.7% in the <65 group, 65 to 84 group, and ≥85 group, respectively. Bhojani and colleagues²⁰ performed systematic searches of urosepsis after URSL and reported that the risk of postoperative urosepsis was 5.0%. There were no cases of postoperative urosepsis in this study, and we consider that our data indicated acceptable outcomes compared with these reports.

We consider that extracorporeal shockwave lithotripsy (SWL) is the least invasive method for the surgical management of urolithiasis. Dasgupta and colleagues²¹ reported a pragmatic multicenter noninferiority randomized controlled trial comparing SWL with URSL and concluded that SWL is noninferior to URSL. Therefore, SWL is preferred for elderly patients.

However, there are some points that must be considered. SWL is not free of complications,²² and age can affect the stone-free rate. Although Al-Ansari and colleagues²³ reported that renal morphology, congenital anomalies, stone size, stone site, and the number of treated stones are prognostic factors predicting the success rate of SWL, Abdel-Khalek and colleagues²⁴ reported that patient age; stone size, location, and number; radiological renal features; and congenital renal anomalies were predictors of SWL in a multivariate analysis.

In addition, Mazzon and colleagues²⁵ evaluated the prognostic factors for SWL in patients with ureteric stones, and reported that age, severe hydronephrosis, time elapsed from obstruction onset to treatment, and stone density were independent predictive factors of SWL failure in a multivariate analysis.

Furthermore, SWL may not be appropriate if the patient has severe dementia or a PS of 4. In this study, the number of patients with a score of PS4 was 19 (70.4%) in the ≥85 group; the remaining eight patients had severe dementia or had impacted stones. We chose URSL and not SWL for 27 patients (≥85 years). As a result, complications occurred in only one patient, and the stone-free rate was 96.3% in the ≥85 group, with good surgical outcomes.

This study has limitations. The first limitation was the retrospective design, and the second was that the definition of “elderly” varied in previous reports. In this study, we divided patients into three groups by age (years) (<65 group, 65–84 group, and ≥85 group) to investigate the efficacy and safety of URSL in the elderly. The definition of elderly varied in previous reports from 60 to 80 years; therefore, caution is warranted when comparing the results of our study with results observed in other reports. Third, the patients' backgrounds were not uniform. In particular, many elderly patients received stents before URSL, and it is possible that preoperative stents affect the efficacy and safety of URSL for the elderly.

Fourth, no patients experienced postoperative delirium in this study; however, dementia may have masked the presence of postoperative delirium, and the incidence of postoperative delirium may have been underestimated. Finally, the duration of hospitalization for elderly patients was significantly longer than that for nonelderly patients. The reason is that it may take longer for the elderly to be discharged owing to social circumstances (such as family reasons) even if they are improved sufficiently to be discharged. However, we consider that URSL is an effective and safe treatment method for elderly patients.

Conclusions

We investigated the efficacy and safety of URSL in the elderly (≥85 years old). However, our study has limitations, and the anesthesia risk and the need for surgery must be further investigated. Therefore, we do not recommend performing URSL for all elderly people >85 years of age. However, we consider that URSL is a treatment option if surgery is needed and if SWL is inappropriate, in elderly people >85 years of age.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this research.

Abbreviations Used

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