Discussion
The increase in the average human life expectancy and aging population
will result in more geriatric patients with kidney stones admitted for
treatment. Developments in technology, especially in endoscopy and optic
quality, have led to numerous stone treatment modalities in elderly
patients.13 PCNL and RIRS have become important
management modalities in this area. PCNL is considered to be an
effective and safe treatment option for large renal
stones.14 Despite proof of the effectiveness of the
procedure, complications ranging from 20 - 83% were reported in the
literature, including hemorrhage requiring transfusion, pleural injury
and colonic injury. Technological innovations have meant that RIRS has
become accepted as important treatment modality of renal stones, with
higher success and lower complication rates. Previous studies clearly
demonstrated that RIRS can be successfully performed for moderate size
renal stones.15 In a different study, Gupta and
colleagues concluded that PCNL provides better one-time stone-free rates
(>90%) compared to other procedures.16Knoll et al. emphasized that one in two patients receiving RIRS required
two procedures for a mean stone size of 19 mm.17 This
is undesireable because multiple anesthesia exposure is problematic for
elderly patients.
Although many studies have investigated outcomes of either RIRS or PCNL
in elderly patients, there is lack of comparative studies. To our
knowledge, the present study is the first on the effect of CCI on
complications and outcomes in elderly patients. Ozgor et al. evaluated a
total of 118 elderly patients, 60 of them underwent RIRS and 58, mPCNL,
and reported stone-free rates of 81.7% and 77.6%,
respectively.18 Akman et al., found similar success
rate between PCNL and RIRS in geriatric patients with moderate-size
renal stones (92.8% and 82.1%, respectively).15 In
contrast, in the present study, the stone free rate was significantly
higher in PCNL than RIRS (92% and 77.8%, respectively) (p=0.021).
Similar to our results, comparing the effectiveness of RIRS and mPCNL in
older patients, Hu found that the success rate was statically
significantly in favor of mPCNL (p = 0.025).13 The
present study showed no correlation between CCI and success in either
group.
In this study, the mean operative time was longer in PCNL group compared
with f-URS group, but this difference was not statistically
significant.In contrast, many previous studies reported longer operative
times in the RIRS group.19-21 In a study involving 56
geriatric patients comparing standard PCNL and RIRS, Akman et al. found
that operative duration was longer in favour of f-URS (64.5 ± 20.9 and
40.7 ± 10.7 min).15 Another study by Hu et al. found
no significant difference in terms of operative time in older patients
following mPCNL and RIRS.13 This variability can be
attributed to surgical competence and experience, positioning and
patient-dependent factors during operation. There are mixed results on
the correlation between operative times and CCI. A study conducted by
Resorlu et al.22 reported that CCI was not a
predictive factor for operative duration of PCNL in elderly patients,
however, Unsal et al.23 noted a positive correlation.
In our study, we found that CCI was not a predictor on operative times
for either PCNL or RIRS group.
Previous reports emphasized that PCNL has a longer hospitalization times
compared to RIRS.13,15,18 In contrast to the high
morbidity of PCNL, for patients undergoing RIRS, there are lower rates
of pain, hemoglobin drop, and requirement for blood transfusion
requirement, and the absence of nephrostomy tubes seem to accelerate
postoperative recovery, accounting for the reduced hospital stay.The
effect of age and patients’ comorbidities on hospitalization stay is a
controversial issue. Okeke et al. stated that, after PCNL,
hospitalization time was longer in older compared to younger
patients.24 In contrast, studies conducted by Karami
et al. and Sahin et al. report no significant difference between older
and younger patients undergoing PCNL in terms of hospitalization
time.25,26 Ozgor et al. found a significantly longer
hospitalization time following mPCNL (56.5 hours) compared to RIRS (23.1
hours) in elderly patients (p < 0.001).18 In
accordance with the literature, our study revealed PCNL was associated
with longer hospitalization stay in older patients. Unsal et
al.22 and Resorlu et al.23 found CCI
has no effect on hospitalization times after PCNL, but the present study
reported a significant positive correlation in both PCNL and RIRS.
Elderly patients are more prone to comorbid disease, making them more
vulnerable to bleeding and septic complications.15Such complications can be fatal. The use of minimally invasive surgical
techniques to achieve complete stone clearance with minimal morbidity is
an important advance in the management of nephrolithiasis in older
patients. de la Rosette et al. and Tefekli et al. reported that overall
complication rates in PCNL were 43.8% and 29.2%,
respectively.27,28 In the present study, the overall
complication rate (32.6%) was in accordance with other series on PCNL,
but it was slightly higher than these afor ementioned studies. This can
be explained the ages of the patients, a position supported by Okeke’s
series, which resulted in significantly higher complication rates in
elderly patients compared with younger patients in
PCNL.24 Previous reports emphasized similar and
acceptable complication rates for both PCNL and RIRS. Akman et al.
reported no difference in complication rates in elderly patients
following PCNL and RIRS.15 In studies, conducted by
Ozgor et al. and Hu et al., no significant difference in terms of
complication rates was detected between older patients undergoing mPCNL
and those undergoing RIRS.13,18 However, in present
study, overall complication rates were significantly higher in PCNL
group (p=0.034), and here, the Clavien-Dindo grade >2
complications were mainly observed in PCNL group (p=0.043). Another
study by Unsal et al. evaluated the efficacy of CCI on PCNL to predict
of morbidity and mortality, and found the CCI to be a predictive
factor.23 Aykac et al. observed that a CCI score of
2.5 was the cut-off value for medical complications of RIRS in geriatric
patients.29 In the current study, overall complication
and major complications rates were significantly higher in CCI score ≥2
patients who underwent PCNL. Furthermore, there was significant positive
correlation between CCI and complication rates in both PCNL and RIRS.
The first is its retrospective design with small number of patients,
which is a possible cause of bias. Second, we used CCI, an index
designed to predict mortality using 19 comorbid conditions, to predict
surgical complications only, and not medical complications. Another
limitation is short patient follow up, with no long-term comparison of
complications. There is a need for prospective studies in geriatric
patients with a larger series, focusing on medical complications.