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Is Ureteroscopy Using MOSES Laser Lithotripsy Comparable to Percutaneous Nephrolithotomy?
Amir I. Khan, MD, Ankur U. Choksi, MD, Mursal Gardezi, BA, Michael Jalfon, BA, Christopher S. Hayden, MD, Olamide Olawoyin, MD, Jeffrey A. Carbonella, MD, Shayan Smani, BA, Syed N. Rahman, MD, Vinaik Sundaresan, BA, Gregory L. Lacy, MD, Piruz Motamedinia, MD, Dinesh Singh, MD.
Yale School of Medicine, New Haven, CT, USA.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is a mainstay surgery for large renal stones. Ureteroscopy with laser lithotripsy also remains a common treatment option. With the advent of newer holmium lasers, such as the MOSES laser, we sought to compare PCNL and ureteroscopy using MOSES (mURS) in terms of stone-free rate (SFR) for renal stones >10 mm. METHODS: We retrospectively analyzed our institutional database for patients with renal stone burden between 10 and 30 mm that underwent PCNL or mURS October 2020-June 2022. The primary outcome was SFR (< 3 mm residual stone burden) on follow up imaging. We also examined length of stay, estimated blood loss (EBL), radiation exposure, operative time, stone clearance rate (mm of stone/operative time), and complications. Student's t-test and Pearson chi squared were used for statistical analysis. RESULTS: We identified 50 patients and 44 patients who underwent PCNL and mURS, respectively. Perioperative characteristics are described in Tables 1 and 2. Patients who underwent PCNL were more likely to have recurrent urinary tract infections (p < 0.01), obstructive sleep apnea (p = 0.01), and larger stone size (mean 21.11 mm 5.27 vs. 15.77 6.36, p < 0.01). Patients who underwent PCNL had longer length of stay (2 days vs 0 days, p < 0.01), higher EBL (69.2 vs 7.5 cc, p < 0.01), greater radiation exposure (25.69 vs 9.64 mGy, p = 0.02), and longer operative time (100.8 vs 78.4 min, p = 0.01). There were no significant differences between stone clearance rate (0.28 vs. 0.22 mm/min, p = 0.06). Postoperative complications were not statistically different (p = 0.11). On follow-up imaging, 40 (80.0%) patients who underwent PCNL were stone-free compared to 37 (84.1%) for mURS (p = 0.12). CONCLUSIONS: Our study suggests that there are no significant differences in SFR for patients with >10 mm renal stone burden who undergo PCNL vs. mURS. PCNL was associated with greater length of stay, EBL, radiation exposure, and operative time. Randomized control trials with non-inferiority study designs are warranted.

PCNLmURSp-value
Number of Patients5044
Age 59.12 14.2357.22 16.830.55
Gender (Male)27 (54.0%)19 (43.2%)0.30
Past Medical History
CKD2 (4.0%)7 (15.9%)0.05
Obesity17 (34.0%)13 (29.6%)0.64
Hypertension25 (50.0%)15 (34.1%)0.12
Diabetes9 (18.0%)7 (15.6%)0.78
Gout4 (8.0%)1 (2.2%)0.22
Recurrent UTIs15 (30.0%)4 (9.1%)< 0.01
OSA13 (26.0%)3 (6.8%)0.01
Migraines3 (6.0%)0 (0.0%)n/a
CAD8 (16.0%)6 (13.6%)0.75
Anti-Coagulation0.62
None35 (70.0%)36 (81.8%)
ASA819 (18.0%)5 (11.4%)
Anti-Platelet2 (4.0%)1 (2.27%)
Direct Oral Anticoagulation4 (8.0%)2 (4.55%)
Stone size (mm)21.11 5.2715.77 6.36< 0.01
Hounsfield Units1066.88 400.52953.66 307.800.13

Table 1: Preoperative characteristics for patients undergoing PCNL and mURS
PCNLmURSp-value
Length of Stay (days)1.96 1.240.05 0.21< 0.01
Estimated Blood Loss (ml)69.20 67.777.50 4.38<0.01
Fluoroscopy time (sec)59.24 63.1125.16 28.41< 0.01
Radiation Exposure (mGy)25.69 40.439.64 25.670.02
Operative Time (min)100.84 34.3778.43 39.59< 0.01
Stone Clearance Rate (mm/min)0.25 0.210.22 0.090.38
Stone-Free Rate40 (80.0%)37 (84.1%)0.61
Complication (Clavien Grade)0.20
034 (68.0%)36 (81.8%)
111 (22.0%)7 (15.9%)
24 (8.0%)1 (2.3%)
31 (2.0%)0 (0.0%)
40 (0.0%)0 (0.0%)

Table 2: Perioperative outcomes for patients undergoing PCNL and mURS


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