Surgical Interventions for Symptomatic Urinary Stones During Pregnancy: A Retrospective Analysis

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Surgical Interventions for Symptomatic Urinary Stones During Pregnancy: A Retrospective Analysis

Symptomatic urinary stone events during pregnancy present significant clinical challenges, affecting an estimated 1/200 to 1/2000 pregnancies globally. While conservative management remains the first-line approach, approximately one-third of cases necessitate active intervention due to complications such as infection, intractable symptoms, or obstetric risks. This study evaluates the efficacy and safety of surgical interventions, including temporary drainage and definitive stone procedures, in a cohort of pregnant women from China, offering critical insights into contemporary management strategies.

Patient Cohort and Clinical Context

Between April 2017 and May 2019, 35 pregnant women with symptomatic urinary calculi who failed initial conservative therapy underwent active interventions at a single institution. The cohort’s median age was 29 years (range: 23–39 years), with gestational ages spanning all trimesters (11–37 weeks). Indications for intervention included infection, bilateral obstruction, solitary or transplanted kidney, and obstetric complications such as premature labor or pre-eclampsia.

Temporary drainage procedures were prioritized during the first trimester or late third trimester to minimize risks. Definitive stone surgeries were considered for patients intolerant to prolonged drainage or those opting for immediate resolution. Treatment modalities were selected based on stone location, size, and patient preference.

Treatment Modalities and Outcomes

1. Temporary Drainage Procedures

  • Ureteral Stent Insertion (USI):
    Performed under local anesthesia, USI achieved a success rate of 92% (22/24 cases). Two failures occurred due to impacted ureteral stones, necessitating conversion to mini-percutaneous nephrolithotomy (mini-PCNL). Among successful cases, 15 patients transitioned to definitive surgery due to intolerance to frequent stent exchanges, while seven retained stents until postpartum.
  • Percutaneous Nephrostomy (PCN):
    PCN was successfully performed in three third-trimester patients under local anesthesia. These cases highlighted the utility of ultrasound-guided nephrostomy for managing obstructed or infected systems in advanced pregnancy.

2. Definitive Stone Surgeries

Definitive procedures were performed in 25 patients, comprising:

  • Ureteroscopic Lithotripsy (URSL):
    Eight patients underwent semi-rigid ureteroscopy, primarily for distal ureteral stones (median size: 10 mm). The stone-free rate (SFR) at one month was 87.5% (7/8), with two Clavien I complications (transient hematuria).
  • Flexible Ureteroscopic Lithotripsy (FURSL):
    Nine patients with proximal ureteral or renal stones (median size: 11 mm) underwent FURSL, achieving an SFR of 89% (8/9). Operative time averaged 55 minutes, with one Clavien II complication (postoperative fever).
  • Mini-Percutaneous Nephrolithotomy (mini-PCNL):
    Six patients with larger renal stones (median size: 17.5 mm) underwent mini-PCNL. Despite longer hospitalization (median: 5 days) and greater hemoglobin decline (median: 6.7 g/L), SFR reached 83% (5/6) with one Clavien II complication.
  • Microperc:
    Two cases utilized microperc for smaller renal stones (median size: 15.5 mm), achieving 100% SFR without complications.

Comparative Analysis

Definitive surgeries revealed key differences:

  • Operative Time: Mini-PCNL procedures were significantly faster (median: 42.5 minutes) compared to FURSL (55 minutes, P < 0.05).
  • Stone Burden and Hospital Stay: Mini-PCNL managed larger stones but required longer hospitalization (P < 0.05).
  • Complications: No significant difference in complication rates was observed between FURSL and mini-PCNL (P = 1.000).

Stone Composition and Follow-Up

Stone analysis in 17 cases revealed:

  • Calcium oxalate monohydrate (3/17),
  • Hydroxyapatite (10/17),
  • Mixed compositions (4/17).
    All pregnancies culminated in healthy full-term deliveries, with no maternal or fetal morbidity attributable to interventions.

Clinical Implications and Guidelines

Temporary vs. Definitive Management

Temporary drainage remains a cornerstone for high-risk pregnancies, offering rapid relief with minimal invasiveness. However, definitive procedures are increasingly viable, particularly for patients prioritizing quality of life and avoiding multiple interventions.

Role of Ureteroscopy

Guidelines from the Chinese Urological Association (CUA), European Association of Urology (EAU), and American Urological Association (AUA) endorse ureteroscopy as a primary intervention for ureteral stones during pregnancy. This study corroborates these recommendations, demonstrating high SFR (87.5–100%) and low complication rates.

Controversies in PCNL

While EAU guidelines contraindicate PCNL during pregnancy, this study and CUA recommendations suggest selective use in experienced centers. Ultrasound guidance, minimized tract size (e.g., mini-PCNL, microperc), and regional anesthesia mitigate traditional concerns about radiation and prone positioning.

Conclusions

Conservative management remains first-line for uncomplicated urinary stones in pregnancy. However, surgical intervention is safe and effective for refractory cases, with ureteroscopy and mini-PCNL offering high success rates and favorable outcomes. Definitive procedures reduce healthcare costs, avoid prolonged drainage, and enhance parental focus on postnatal care. This study underscores the importance of individualized treatment plans guided by stone characteristics, gestational age, and patient preferences. Future multicenter studies are warranted to validate these findings and refine clinical protocols.

doi.org/10.1097/CM9.0000000000001648

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