Retrograde vs. antegrade flexible nephroscopy for detection of residual fragments following PNL: A prospective study with computerized tomography control

Abstract

Introduction: The main aim of stone surgery is to establish stone free status. Performing flexible nephroscopy is an effective tool in this manner. The aim of this study was to evaluate the role of retrograde flexible nephroscopy for detection of residual fragments following percutaneous nephrolithotomy (PNL) in comparison with antegrade approach. Materials and Methods: Data of 137 patients underwent ECIRS was collected prospectively. In all cases following stone clearance, collecting system was checked for residual fragments. First antegrade than retrograde flexible nephroscopy was performed and success rates to reach all calices and detection of residual fragments were noted. All patients underwent CT and success rate of antegrade and retrograde approaches were compared. PPV and NPV of retrograde approach to detect residual fragments were calculated. Results: Antegrade and retrograde nephroscopy successfully accessed all of the calices in 101 (73.7%) and 130 (94.9%) patients respectively (p<0.0001). Residual fragments were observed in 18 (13.1%) patients following antegrade flexible nephroscopy. Retrograde approach identified residual stones in 17 more cases. These cases were treated with flexible nephroscopy or secondary percutaneous tract. Postoperative CT revealed residual stones in 10 (7.3%) patients. PPV and NPV of retrograde flexible nephroscopy were 83.3% and 96.2%. Conclusions: Flexible nephroscopy effectively detects residual fragments following PNL. Retrograde approach was more successful than antegrade approach to reach all calices. We recommend performing retrograde flexible nephroscopy following PNL especially in complex cases as it has the potential to increase SFR, decrease the need for second look surgery and unnecessary postoperative imaging.