Comparison of postoperative outcomes of mini percutaneous nephrolithotomy and standard percutaneous nephrolithotomy: a meta-analysis

Simultaneous single-tract bilateral percutaneous nephrolithotomy in bilateral large complex renal stones is not associated with increased complications: series of 36 consecutive patients

BACKGROUND

Simultaneous bilateral percutaneous nephrolithotomy (PCNL) offers the advantage of treating stones in both kidneys, thereby reducing the need for multiple surgeries. Due to the limited number of cases, simultaneous PCNL has unwarranted safety and efficacy concerns. This study aimed to evaluate the complications and stone-free rates of simultaneous bilateral PCNL in the treatment of bilateral large complex stones and to compare different access methods.

METHOD

Between January 2012 and December 2022, 36 consecutive patients who underwent simultaneous bilateral PCNL for large complex renal stones were enrolled. Guy's stone score (GSS) was used to assess the complexity of stone. The preoperative, intraoperative, and post-operative parameters were assessed. The patients were first categorized based on channel size (conventional vs. mini-PCNL), and then further sub-grouped according to specific combinations of tract size and dilation method for comparative analysis.

RESULTS

Thirty-six consecutive patients (72 renal units) underwent simultaneous bilateral PCNL. The median stone burden was 602.43 mm2 (interquartile range: 225-1332.72 mm2), mean surgical duration was 70.9 ± 29.6 minutes for each renal unit (range, 30-140 minutes), and the mean hematocrit reduction was 6.8±8.4%. The mean length of stay was four days, and the stone-free rate was 81.9%. Notably, eGFR (estimated Glomerular filtration rate) values showed significant improvement at one-year follow-up (p < 0.001), with 29.4% of patients showing clinical downstaging. The overall complication rate was 16.7%, with the majority of complications being transient fever. Mini-PCNL had a shorter length of stay (p < 0.05). The complication rates for Amplatz, balloon, and mini-PCNL were 13.3%, 23.1%, and 12.5%, respectively. The post-operative radiographic stone-free rate (SFR) for 72 renal units was 81.9%, with the highest rate in the mini-PCNL group (93.7%).

CONCLUSIONS

There was no increase in the rate of complications compared to unilateral PCNL. This study provides valuable insights into surgical outcomes using different access methods.

Safety and efficacy of standard vs. tubeless percutaneous nephrolithotomy in pediatric populations: an updated systematic review and meta-analysis

OBJECTIVE

This study aims to compare the safety and efficacy of standard versus tubeless percutaneous nephrolithotomy (PCNL) in pediatric populations.

METHODS

A systematic search was conducted in the Web of Science, Cochrane Library, PubMed, and Embase databases to identify studies that met the inclusion criteria. Two authors independently screened the literature and extracted data. A meta-analysis was performed using RevMan 5.4 software. This study has been prospectively registered with PROSPERO (ID: CRD42024622238). Sensitivity analysis was performed using Stata 17.0 to assess the impact of low-quality studies, and publication bias was evaluated using funnel plots.

RESULTS

A total of 3 randomized controlled trials and 10 case-control studies were included, comprising 661 cases. The meta-analysis revealed that, in pediatric populations, the tubeless PCNL group had significantly shorter hospital stays compared to the standard PCNL group (WMD = -1.60, 95% CI: -2.27 to -0.92, P < 0.01), as well as shorter operative times (WMD = -2.06, 95% CI: -4.02 to -0.10, P = 0.04). The stone clearance rate was higher in the tubeless PCNL group than in the standard group (OR = 2.18, 95% CI: 1.09 to 4.34, P = 0.03). Additionally, the tubeless PCNL group had lower rates of postoperative fever (OR = 0.46, 95% CI: 0.27 to 0.78, P < 0.01) and postoperative urine leakage (OR = 0.20, 95% CI: 0.08 to 0.50, P < 0.01) compared to the standard group. The tubeless PCNL group also had shorter pain management times (WMD = -2.00, 95% CI: -2.44 to -1.56, P < 0.01) and lower visual analog scale (VAS) scores (WMD = -2.52, 95% CI: -2.81 to -2.22, P < 0.01). However, no significant differences were observed between the two groups in terms of hemoglobin decline, overall complications (including perinephric fluid collections, urinary tract infections, and blood transfusion requirements), and reoperation rates.

CONCLUSION

In children with kidney stones and low stone burden or an uneventful procedure, tubeless PCNL offers clear clinical advantages, including shorter hospital stays, higher stone clearance rates, and lower postoperative fever. Additionally, it improves surgical efficiency, reduces postoperative complications, and decreases the need for analgesia. These benefits suggest that tubeless PCNL can be safely applied in pediatric patients, yielding outcomes comparable to standard PCNL, provided that indications are properly managed".

CLINICAL TRIAL NUMBER

Not applicable.

Modified amplatz sheath with suction versus standard sheath in percutaneous nephrolithotomy for treating large renal stones > 2 cm: a prospective randomized trial

PURPOSE

To evaluate the efficacy and safety of using a modified amplatz as an access sheath in percutaneous nephrolithotomy (PCNL) compared to the standard Amplatz sheath for the treatment of renal stones larger than 2 cm.

METHODS

This prospective randomized study was conducted on 240 patients with renal stones larger than 2 cm who underwent PCNL. Patients were randomized into two equal groups: Group I (standard Amplatz sheath) and Group II (modified Amplatz sheath). Outcomes measured included operative time, stone-free rate (SFR), complications, and hospital stay.

RESULTS

The modified Amplatz sheath group had a significantly shorter mean operative time compared to the standard sheath group (56 ± 12 vs. 83 ± 17 min, respectively; P < 0.001). The SFR was higher in the modified sheath group (90.8% vs. 80%; P = 0.017). Postoperative complications, such as fever (4.2% vs. 10.8%) and pain (13.3% vs. 20.8%), were significantly lower in the modified sheath group (P = 0.036). The modified sheath group also had a shorter hospital stay, with 93.3% discharged within two days compared to 85% in the standard group (P = 0.038). Multivariate analysis indicated that the use of the modified sheath reduced the risk of residual stones by 91% (OR = 0.086, 95% CI = 0.027-0.280, P < 0.001).

CONCLUSIONS

The use of a modified Amplatz sheath in PCNL significantly reduces operative time, increases the SFR, and decreases postoperative complications compared to the standard Amplatz sheath.

Mini-percutaneous nephrolithotomy vs flexible ureteroscopy for 1-2 cm lower pole renal stones: a randomised controlled trial

OBJECTIVE

To compare the safety and efficacy of flexible ureteroscopy (f-URS) and ambulatory tubeless mini-percutaneous nephrolithotomy (mini-PCNL) in the treatment of 1-2 cm lower calyceal renal stones.

PATIENTS AND METHODS

Patients who underwent f-URS and mini-PCNL for the treatment of 1-2 cm lower calyceal renal stones between October 2020 and November 2023 were evaluated in a randomised controlled trial. A total of 72 patients were included in the study. All patients underwent a computed tomography renal colic scan preoperatively, on postoperative Day 1 (POD 1), and at 3 months follow-up. We compared perioperative outcomes, including operative time and hospital stay. Additionally, we evaluated follow-up outcomes, such as the stone-free rate (SFR) and complications. All patients were discharged home on the same operative day.

RESULTS

There were no significant differences in preoperative baseline data between the two surgical groups. A significantly longer median operative time was reported in the mini-PCNL group (P = 0.04). The median hospital stay was 5 h and 4 h in the mini-PCNL and f-URS groups, respectively (P = 0.14). On POD 1, the SFR, defined as the absence of residual fragments measuring 0 cm, was 50% for mini-PCNL vs 11.1% for f-URS (P < 0.001). When a total cut-off of <0.4 cm was utilised, the SFR was 75% in the mini-PCNL group vs 22.2% in the f-URS cohort (P < 0.001). At 3 months follow-up, the SFR remained favourable for mini-PCNL at 72.2% vs 37.1% for f-URS (P = 0.003), with a cut-off of 0 cm, and it increased to 86.1% for mini-PCNL vs 65.7% for f-URS (P = 0.04) when a total cut-off of <0.4 cm was applied. There was no significant difference in postoperative complications between the two groups. Two patients (5.7%) in the f-URS group required re-treatment. [Correction added on 5 November 2024, after first online publication: Within the Results section, '<4 cm' has been corrected to '<0.4 cm'.] CONCLUSIONS: Ambulatory tubeless mini-PCNL and f-URS are effective treatment options for 1-2 cm lower calyceal renal stones. Both techniques have a comparable hospital stay and complication rates, with a significantly better SFR with mini-PCNL.

Comparison of Trifecta Outcomes in Standard Versus Mini Percutaneous Nephrolithotomy for Renal Stone Management

INTRODUCTION

Urolithiasis is a common urological condition, and percutaneous nephrolithotomy (PCNL) is a widely used treatment option for renal stones. The trifecta analysis, which includes the complete stone-free rate (SFR), absence of complications (Clavien-Dindo classification), and no need for auxiliary procedures, provides a standardized method for comparing outcomes. This study evaluates the trifecta outcomes of standard PCNL versus mini PCNL Methodology: This prospective cohort study was conducted at the Department of Urology, Institute of Kidney Diseases, Peshawar, from January 2022 to March 2024. A total of 180 consecutive patients who underwent PCNL were enrolled in the study. Using a lottery method, patients were randomly assigned to two equal groups (standard PCNL and mini PCNL). Both groups consisted of 90 patients each. Patients who required a change in the planned surgical procedure were replaced with new participants from the sample frame. A structured proforma was used to record preoperative, perioperative, and postoperative data for the trifecta analysis. Data were analyzed using IBM SPSS Statistics for Windows, Version 23.0 (Released 2015; IBM Corp., Armonk, NY, United States). Logistic regression was performed to assess predictive factors for the trifecta, and the odds ratio (OR), confidence interval (CI), and p-value were calculated.

RESULTS

The mean age in the standard PCNL group was 43.21 ± 3.51 years vs 44.03 ± 3.17 years in the mini PCNL group (p = 0.10). The mean stone size in the standard PCNL group was 30.62 ± 5.88 mm vs 30.28 ± 6.03 mm in the mini PCNL group (p = 0.70). The mean stone density in the standard PCNL group was 1366.25 ± 74.28 HU vs 1342.66 ± 107.34 HU in the mini PCNL group (p = 0.08). Stones were completely cleared in 84 (93.3%) patients in the standard PCNL group and 69 (76.7%) in the mini PCNL group (p = 0.02). Auxiliary procedures, including extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and repeat double J (DJ) stenting, were required in four patients (4.4%) in the standard PCNL group compared to 20 patients (20%) in the mini PCNL group. Regarding complications, the standard PCNL group recorded complications in 16 patients (17.77%), including Grade 1 (six patients), Grade 2 (five patients), and Grade 3 (five patients), according to the Clavein-Dindo classification. In the mini PCNL group, six patients (6.66%) experienced postoperative complications, including Grade 1 (five patients) and Grade 2 (one patient) (p = 0.02). The overall trifecta success rate was 71.12% in the standard PCNL group vs 50.03% in the mini PCNL group.

CONCLUSION

The trifecta analysis indicates that standard PCNL has a higher SFR, while mini PCNL is safer but requires more auxiliary procedures.

Pain management in percutaneous nephrolithotomy - an approach rooted in pathophysiology

Pain related to percutaneous nephrolithotomy (PCNL) is multifactorial and poorly elucidated. However, understanding the pathophysiology of pain can enable a practical approach to pain management, which can be tailored to each patient. A number of potential mechanisms underlie pain perception in PCNL, and these mechanisms can be leveraged at various points on the perioperative care pathway. These interventions provide opportunities for modulation of pain associated with PCNL but must take into account various technical, pharmacological and patient-related considerations. Technical considerations include the influence of percutaneous access, stone removal and drainage techniques. Pharmacological aspects include the use of various analgesics and anaesthesia approaches. Patient factors include consideration of the biopsychosocial model in pain experience to understand each individual's response to pain. By understanding the contemporary evidence surrounding the physiology of postoperative pain and identifying tangible intervention points, we can seek to mitigate postoperative pain in patients undergoing PCNL.

Asymptomatic migration of ureteral stent to superior vena cava after ultrasound-guided percutaneous nephrolithotomy: An extremely rare case and review of the literature

Ureteral stent migration should be considered a rare complication of urologic procedures. We report a 69-year-old woman diagnosed with ureteral stent migration two weeks after undergoing percutaneous nephrolithotomy while she was symptom-free. The stent passed through the heart and extended to the superior vena cava and right brachiocephalic vein. After excluding thrombus formation, the stent was retrieved using an endovascular approach. Stent migration to the superior vena cava while being asymptomatic is extremely rare. Considering this complication is crucial to prevent consequent fatal events. This case report highlights this rare complication of ureteral stent placement and reviews its management.

Comparison of the efficacy and safety of mini-percutaneous nephrolithotomy versus retrograde intrarenal surgery for the treatment of kidney stones in overweight or obese patients: a systematic review and meta-analysis

OBJECTIVE

To discuss the differences in the effectiveness and security of kidney stones in overweight or obese patients by mini percutaneous nephrolithotomy (MiniPCNL) and retrograde intrarenal surgery (RIRS).

MATERIALS AND METHODS

We exhaustively searched numerous databases, including PubMed, Embase, Web of Science, Cochrane Library, and CNKI, covering all records from their initiation date until September 2023. This included controlled trials focusing on the use of MiniPCNL and RIRS in the treatment of kidney stones in overweight or obese patients. The gathered data was then analyzed using the Review Manager 5.4 software.

RESULTS

9 studies including 1122 patients were included. Meta-analysis showed that: The MiniPCNL group had higher overall complications, grade I complications, length of hospital stay(LOS), first stone-free rate (SFR), and final SFR in obese patients, with no significant difference between the two groups in terms of operative time(OT), hemoglobin drop, and grade II complication rate. There were more overall complications, grade I complications, final SFR, and LOS with MiniPCNL in patients with stones > 2 cm compared to no significant difference in grade II complications. MiniPCNL performed in the prone position had higher final SFR, less OT, hemoglobin drop, and no statistically significant difference in overall complications or LOS. Sheaths using > 14 F had higher overall complication rates, final SFR, and LOS, and no statistical differences in OT and first SFR between the two modalities. In the MiniPCNL subgroup aged ≤ 50 years, there were higher first SFR, final SFR, and shorter OT, and in the MiniPCNL subgroup aged > 50 years, there were more OT, LOS, and hemoglobin drop, with no statistical difference in overall complications between the two groups.

CONCLUSION

Our study showed that MiniPCNL in obese patients had higher initial SFR and final SFR, fewer procedures, but more postoperative complications, LOS, and grade I complications compared with RIRS. Similar results were seen in patients in the prone position, with stones > 2 cm and age ≤ 50 years.

SYSTEMATIC REVIEW REGISTRATION

[ https://www.crd.york.ac.uk/PROSPERO/ ], identifier PROSPERO (CRD42023467284).

History of Renal Stone Surgery: A Narrative Review

Untreated obstruction of the urinary tract can result in urinary stasis, hydronephrosis, and infection, which in turn lead to tissue damage, chronic renal failure, and potentially death. Renal stones have afflicted humanity throughout history, with surgical approaches evolving significantly over time. This review explores the origins and major developments in surgical techniques for renal stones, enhancing our understanding of how modern procedures have evolved. These techniques were refined over time, driven by improved anatomical knowledge and surgical experimentation. The ancient perineal lithotomy remained a standard treatment until the late 19th century, when advancements in anesthesia and antisepsis emerged. These innovations allowed surgeons to attempt more ambitious procedures, aided by early methods for visualizing internal organs. In the 20th century, innovations in radiology, imaging technologies, and surgical instruments ushered in the era of minimally invasive surgery.

International Alliance of Urolithiasis (IAU) consensus on miniaturized percutaneous nephrolithotomy

Over the past three decades, there has been increasing interest in miniaturized percutaneous nephrolithotomy (mPCNL) techniques featuring smaller tracts as they offer potential solutions to mitigate complications associated with standard PCNL (sPCNL). However, despite this growing acceptance and recognition of its benefits, unresolved controversies and acknowledged limitations continue to impede widespread adoption due to a lack of consensus on optimal perioperative management strategies and procedural tips and tricks. In response to these challenges, an international panel comprising experts from the International Alliance of Urolithiasis (IAU) took on the task of compiling an expert consensus document on mPCNL procedures aimed at providing urologists with a comprehensive clinical framework for practice. This endeavor involved conducting a systematic literature review to identify research gaps (RGs), which formed the foundation for developing a structured questionnaire survey. Subsequently, a two-round modified Delphi survey was implemented, culminating in a group meeting to generate final evidence-based comments. All 64 experts completed the second-round survey, resulting in a response rate of 100.0%. Fifty-eight key questions were raised focusing on mPCNLs within 4 main domains, including general information (13 questions), preoperative work-up (13 questions), procedural tips and tricks (19 questions), and postoperative evaluation and follow-up (13 questions). Additionally, 9 questions evaluated the experts' experience with PCNLs. Consensus was reached on 30 questions after the second-round survey, while professional statements for the remaining 28 key questions were provided after discussion in an online panel meeting. mPCNL, characterized by a tract smaller than 18 Fr and an innovative lithotripsy technique, has firmly established itself as a viable and effective approach for managing upper urinary tract stones in both adults and pediatrics. It offers several advantages over sPCNL including reduced bleeding, fewer requirements for nephrostomy tubes, decreased pain, and shorter hospital stays. The series of detailed techniques presented here serve as a comprehensive guide for urologists, aiming to improve their procedural understanding and optimize patient outcomes.

Safety and efficacy of ambulatory tubeless mini-percutaneous nephrolithotomy in the management of 10-25 mm renal calculi A retrospective study

INTRODUCTION

This study aimed to assess the safety and efficacy of ambulatory minipercutaneous nephrolithotomy (mini-PCNL) in a totally tubeless exit (without a nephrostomy tube or an internal stent) and tubeless exit (without a nephrostomy tube but with an internal stent) for the treatment of renal calculi 10-25 mm in size.

METHODS

We conducted a retrospective analysis of patients who underwent mini-PCNL at our institution between September 2018 and September 2022. The study included a cohort of 95 patients diagnosed with renal calculi measuring 10-25 mm. All patients underwent a computed tomography (CT) renal colic scan preoperatively, on postoperative day one (POD 1), and at three-month followup. Patient demographics and outcome parameters were recorded, including stone characteristics, operative time, hospital stay, stone-free rate (SFR), complication rates, and subsequent emergency room (ER) visits. Patients were considered stone-free if they had no fragments or residual fragments measuring <4 mm.

RESULTS

The median maximum stone diameter was 16 mm (10-25 mm). Twenty-nine patients (30.5%) had multiple renal calculi. The median operative time was 64 (38-135) minutes. Eighty-six patients (90.5%) underwent a totally tubeless procedure, without a nephrostomy tube or an internal stent. All patients were discharged home on the same operative day with a median hospitalization time of six hours. Seven (7.4%) postoperative ER visits were recorded, and two (2.1%) led to hospital readmission. The frequency of grade I, II, and III Clavien-Dindo complications were 18 (18.9%), one (1.1%), and one (1.1%), respectively. The SFR on POD 1 and three-month followup was 73.7% and 92.6%, respectively. Two patients in the study required retreatment.

CONCLUSIONS

Ambulatory tubeless mini-PCNL is a safe and effective treatment option for 10-25 mm renal stones. Experienced institutions can safely adopt ambulatory mini-PCNL as a treatment option without an increased risk of postoperative complications, ER visits, or hospital readmissions.

Endoscopic combined intrarenal surgery versus percutaneuos nephrolithotomy for complex pediatric stone disease: A comparative analysis of efficacy and safety

INTRODUCTION

Decision-making for complex pediatric urinary system stone disease is still a challenge for pediatric urologists. The interest in supine percutaneous nephrolithotomy (PCNL) is increasing among centers to achieve high surgical success rates with less morbidity. Despite advanced retrograde intrarenal surgery armamentarium, percutaneous approaches remain the first-line surgical treatment modality for >2 cm and complex renal stones. There are no comparative studies yet in the literature for pediatric endoscopic combined intrarenal surgery (ECIRS) OBJECTIVE: In this study, we aimed to contribute to the literature by evaluating the safety and efficacy of ECIRS by comparing it with PCNL.

STUDY DESIGN

Patients under 18 years of age who underwent PCNL and ECIRS for urinary tract stone disease at our Pediatric Urology department between 2012 and 2024 were included. Preoperative (demographic characteristics, stone characteristics, biochemical parameters), perioperative (duration of surgery, number of accesses, lasing and fluoroscopy times, endoscopic and fluoroscopic stone-free rates) and postoperative (hospital stay, urinary tract infection, complication and radiological stone-free rates) parameters were retrospectively evaluated.

RESULTS

A total of 68 children [28 (41%) girls and 40 (59%) boys] aged 5 (0-17) years were included in the study. ECIRS was performed in 19 (28%), supine in 28 (41%) and prone PCNL in 21 (30%) patients. Age (p = 0.029), Guy's stone score (p < 0.001), S.T.O.N.E. (p < 0.001), and Seoul National University Renal Stone Complexity (S-ReSC) scores (p = 0.001) for preoperative parameters were found to be higher in ECIRS group over both PCNL methods (Summary Table). However, Clinical Research Office of the Endourological Society (CROES) score was seen lower for ECIRS group patients compared to other groups (p = 0.028). Surgery time (in favor of supine over prone PCNL), fluoroscopy time (in favor of ECIRS and Supine PCNL over Prone PCNL), preferred laser type (prone PCNL group was mostly performed with holmium laser, whereas other groups were balanced between Holmium and Thulium Fiber Laser) and exit strategy (the preferred exit strategy was DJ Stent in most of the ECIRS patients, whereas nephrostomy tube was used in some of the PCNL group) showed significant difference among the groups as perioperative parameters (p = 0.042, <0.001, <0.001, <0.001, respectively). Surgery time was lower for supine PCNL compared to prone PCNL. For postoperative parameters, stone-free rates, complication rates and urinary tract infections were similar between the 3 groups, while a difference was detected in terms of length of hospital stay in favor of ECIRS over both supine and prone PCNL (p = 0.006).

DISCUSSION

The current trial suggests that stone-free and complication rates of ECIRS and supine PCNL were similar in the pediatric complex stone patients. Although, the stones in the ECIRS group we found to be more complex. Also, ECIRS was superior to PCNL in terms of fluoroscopy exposure and hospital stay.

CONCLUSION

With the widespread use of new generation ureteral access sheaths and flexible ureterorenoscopes, ECIRS may have an important role in treatment of complex pediatric kidney stones.

The predictive ability of Mayo adhesive probability score for evaluating intraoperative bleeding in standard percutaneous nephrolithotomy in adult patients

Mayo adhesive probability (MAP) score is one of the commonest tool to predict the adherence status of perirenal fat. The association between MAP score and intraoperative hemorrhage in patients undergoing micropercutaneous nephrolithotomy was comfirmed in a recent well designed study. We aimed to investigate if MAP score may predict the possibility for significant intraoperative bleeding in supine percutaneous nephrolithotomy (PCNL) performed with a 26 Fr rigid nephroscope. In this observational retrospective study, demographic, clinical, laboratory, radiological, perioperative (operation duration, hospitalization, intraoperative bleeding, success) and MAP score (perinephric fat stranding, posterior perinephric fat thickness and total MAP score) data of all patients who underwent supine PCNL between June 2021 and July 2023 were evaluated. The patients were divided into 2 groups according to their MAP scores (79 [54.1%] patients with MAP score < 3 [low MAP score] and 67 [54.1%] patients with MAP score ≥ 3 [high MAP score]). The rate of patients with intraoperative bleeding was 47.8% in the patient group with a high MAP score, while it was 22.8% in the patient group with a low MAP score (p = 0.002). In multivariate logistic regression analysis, anticoagulant drug use history (OR = 2.525; 95% CI = 1.025-6.224; p = 0.044), presence of multiple stones (OR = 3.015; 95% CI = 1.205-7.543; p = 0.018), calyx localization of the stone (OR = 2.871;95% CI = 1.166-7.068; p = 0.022), higher renal parenchymal thickness (OR = 1.119; 95% CI = 1.049-1.193; p = 0.001) and MAP score > 3 (OR = 3.486; 95% CI = 1.579-7.696; p = 0.002) were defined as independent risk factors for significant intraoperative bleeding. In clinical practice, the MAP score can be used to predict bleeding before PCNL.

Related factors of perioperative low body temperature and incidence of postoperative shivering in patients undergoing complex percutaneous nephrolithotomy and the effect analysis of composite insulation nursing intervention

This study aimed to analyze the factors associated with intraoperative hypothermia and postoperative shivering rates in patients undergoing complex percutaneous nephrolithotomy (PCNL) and investigate the effects of combined insulation nursing intervention. A total of 168 patients were included, with 103 patients in the control (Ctrl) group receiving routine care and 65 patients in the nursing (Nur) group receiving combined insulation nursing intervention measures. General information, surgical data, temperature, intraoperative hypothermia incidence, postoperative shivering, and complication rates were statistically analyzed between the two groups. Patient temperature, blood pressure, and blood gas indicators including pH value, bicarbonate, and lactate levels were recorded at admission (T0), before anesthesia (T1), 30 min after spinal-epidural combined anesthesia (T2), 60 min (T3), 90 min (T4), 120 min (T5), and postoperatively (T6). The results demonstrated that the average intraoperative temperature of patients in the Nur group was significantly higher than that of the Ctrl group (P < 0.001), and their incidence of hypothermia was significantly lower than that of the Ctrl group (P < 0.01). Additionally, the Nur group exhibited shorter recovery time (18.36 ± 3.58 min), extubation time (28.01 ± 3.12 min), and length of hospital stay (8.45 ± 2.14 days) compared to the Ctrl group (P < 0.05). The incidence of postoperative shivering was 4.62 %, significantly lower than that of the Ctrl group (P < 0.001). Multifactorial analysis revealed that age ≥60 years, stone diameter ≥3.0 cm, irrigation volume ≥3000 mL, nursing intervention measures, and surgical duration were the main factors influencing the occurrence of intraoperative hypothermia. Age ≥60 years, nursing intervention measures, surgical duration, and intraoperative temperature<36 °C are identified as major risk factors for postoperative shivering. This indicates that specialized nursing care and combined insulation nursing intervention measures in patients undergoing complex percutaneous nephrolithotomy contribute to reducing the incidence of intraoperative hypothermia and postoperative shivering. It is recommended to promptly address the risk factors associated with hypothermia and shivering during and after surgery to mitigate the risk of perioperative complications.

Micro cost-effectiveness analysis of standard vs. mini percutaneous nephrolithotomy A single Canadian institution's experience

INTRODUCTION

Mini-percutaneous nephrolithotomy (mPCNL ) has been described as an alternative to standard nephrolithotomy (sPCNL ) for select stones. Studies suggest that mPCNL has comparable stone-free rates, with potential for decreased complications and shorter hospital stay. Costs associated with both procedures present a challenge to Canadian institutions due to capital acquisitions of equipment and ongoing disposables. The objective of this study was to compare the cost-effectiveness of both procedures at our institution.

METHODS

A decision tree analytic model was developed to compare costs and outcomes of both procedures. Primary outcomes included assessment of total capital, operative, and hospitalization costs. Cost and outcome of peri- and postoperative parameters were obtained using a retrospective analysis of 20 mPCNL and 84 sPCNL procedures on 1-2.5 cm stones between January 2020 and June 2022, and supplemented with internal hospital expenditure records and literature outcome data. Descriptive statistics and regression models were performed.

RESULTS

The estimated total cost-per-patient was $7427.05 and $5036.29 for sPCNL and mPCNL, respectively, resulting in cost-savings of $2390.76 in favor of mPCNL, with a comparable stone-free rate. The savings were due to lower costs associated with complications and hospital stay. mPCNL had higher capital costs ($95 116.00) compared to sPCNL ($78 517.00), but per-procedure operative costs were lower for mPCNL ($2504.48) compared to sPCNL ($3335.72). Cost-per-case regression of total costs intersected at 5.51 cases when accounting for operative and hospitalization costs, and at 20 cases when only considering operative costs.

CONCLUSIONS

Despite higher upfront costs, mCPNL may represent a valid, cost-effective alternative to sPCNL for select stones due to clinical and economic benefits in Canadian institutions.

Is percutaneous nephrolithotomy effective and safe in infants younger than 2 Years old? Comparison of mini standard percutaneous nephrolithotomy

BACKGROUND

In this study, we aimed to compare the operative outcomes, postoperative outcomes, stone-free status and complications of SPCNL and MPCNL in infants younger than two years of age.

METHODS

We retrospectively analyzed 163 patients younger than two years of age who underwent percutaneous nephrolithotomy (PCNL) in our institution between September 1999 and March 2022. The patients were divided into two groups depending on the tract size. The MPCNL group consisted of 73 patients with a tract of 22 Fr or less, and the SPCNL consisted of 90 patients with a tract greater than 22 Fr.

RESULTS

The median age of 163 patients included in the study was 17.3 (range 7-24) months. Although the median stone size was lower in the SPCNL group, no statistically significant difference was found between the two groups in terms of stone size (p = 0.073). The median operative time was 74.8 min in the MPCNL group and 62.8 min in the SPCNL group, with a statistically significant difference (p = 0.002). Stone free rates (SFR) were 89 % and 90.8 % in the MPCNL and SPCNL groups, and the clinically insignificant residual fragments (CIRF) rates were 11 % and 4.6 %, respectively (p = 0.064). The fluoroscopy time, nephrostomy withdrawal time, and hospitalization stay were similar in the two PCNL groups (p = 0.535, p = 0.253, and p = 0.143, respectively). Postoperative fever was similar in MPCNL and SPCNL groups (p = 0.504). Although bleeding (6.7%-2.7 %) and blood transfusion (3.3%-1.4 %) rates were higher in the SPCNL group, there was no statistically significant difference (p = 0.248 and p = 0.420, respectively). Prolonged urinary leakage occurred in 6 (8.2 %) patients in the MPCNL group and 1 (1.1 %) patient in the SPCNL group, with a statistically significant difference (p = 0.026).

CONCLUSIONS

With the development of MPCNL, the use of SPCNL in infants has decreased considerably. However, SPCNL continues to be an effective and reliable method when needed in suitable patients. Although PCNL in infants shows some differences from adults, it is an effective and safe method for suitable patients.

LEVEL OF EVIDENCE

Although we created our study by retrospectively examining the pediatric urology data that we created prospectively, our study is of a retrospective nature. Therefore the Level of Evidence is 3.

Intraoperative computed tomography for detection of residual stones in endourology procedures: systematic review and meta-analysis

BACKGROUND

Success rates in endourological procedures, notably percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), have demonstrated suboptimal outcomes, leading to more reinterventions and radiation exposure. Recently, the use of intraoperative computed tomography (ICT) scans has been hypothesized as a promising solution for improving outcomes in endourology procedures. With this considered, we conducted a comprehensive systematic review and meta-analysis encompassing all available studies that evaluate the impact of the use of intraoperative CT scans on surgical outcomes compared to conventional fluoroscopic-guided procedures.

METHODS

This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were systematically searched up to December of 2023. This study aimed to directly compare the use of an ICT scan with the standard non-ICT-guided procedure. The primary endpoint of interest was success rate, and the secondary endpoints were complications and reintervention rates, while radiation exposure was also evaluated. Data extraction and quality assessment were performed following Cochrane recommendations. Data was presented as an Odds ratio with 95%CI across trials and a random-effects model was selected for pooling of data.

RESULTS

A comprehensive search yielded 533 studies, resulting in the selection of 3 cohorts including 327 patients (103 ICT vs 224 in non-ICT). Primary outcome was significantly higher in the experimental group versus the control group (84.5% vs 41.4% respectively, 307 patients; 95% CI [3.61, 12.72]; p<0.00001; I2=0). Reintervention rates also decreased from 32.6% in the control to 12.6% in the ICT group (OR 0.34; 95%CI [0.12,0.94]; p =0.04; I2= 48%), whereas complication rates did not exhibit significant differences. Radiation exposure was also significantly reduced in two of the included studies.

CONCLUSION

This meta-analysis highlights a favorable outcome with intraoperative CT scan use in PCNL procedures, showing a considerable increase in SFR when compared to standard fluoroscopy and nephroscopy. Despite limited studies, our synthesis underscores the potential of ICT scans to significantly reduce residual stones and their consequences for endourology patients, as reinterventions and follow-up ionizing radiation studies.

Prevention of complications in endourological management of stones: What are the basic measures needed before, during, and after interventions?

Objective

This narrative review aims to describe measures to minimise the risk of complications during percutaneous nephrolithotomy (PCNL), ureteroscopy, and retrograde intrarenal surgery.

Methods

A literature search was conducted from the PubMed/PMC database for papers published within the last 10 years (January 2012 to December 2022). Search terms included "ureteroscopy", "retrograde intrarenal surgery", "PCNL", "percutaneous nephrolithotomy", "complications", "sepsis", "infection", "bleed", "haemorrhage", and "hemorrhage". Key papers were identified and included meta-analyses, systematic reviews, guidelines, and primary research. The references of these papers were searched to identify any further relevant papers not included above.

Results

The evidence is assimilated with the opinions of the authors to provide recommendations. Best practice pathways for patient care in the pre-operative, intra-operative, and post-operative periods are described, including the identification and management of residual stones. Key complications (sepsis and stent issues) that are relevant for any endourological procedure are then be discussed. Operation-specific considerations are then explored. Key measures for PCNL include optimising access to minimise the chance of bleeding or visceral injury. The role of endoscopic combined intrarenal surgery in this regard is discussed. Key measures for ureteroscopy and retrograde intrarenal surgery include planning and technique to minimise the risk of ureteric injury. The role of anaesthetic assessment is discussed. The importance of specific comorbidities on each step of the pathway is highlighted as examples.

Conclusion

This review demonstrates that the principles of meticulous planning, interdisciplinary teamworking, and good operative technique can minimise the risk of complications in endourology.

Mini-percutaneous nephrolithotomy: Is smaller better for kidney stones in patients with neurogenic bladder?

INTRODUCTION

Patients with neurologic bladder are at an increased risk for urolithiasis, and currently, data on mini-percutaneous nephrolithotomy in this population are limited. Our objective was to compare mini (15F)-percutaneous nephrolithotomy, standard (24F)-PCNL and flexible ureteroscopy in terms of efficacy and safety in treatment of kidney stones in patients with neurogenic lower urinary tract dysfunction (NLUTD).

METHODS

We conducted a retrospective monocentric study in our neuro-urological referral centre. All consecutive patients with NLUTD and a cumulative size of renal calculi greater than 15mm or 10mm in the lower calyx, who had extraction surgery between 2005 and 2020, were included. The primary endpoint was the one-session stone-free rate (SFR) at 3 months on a CT scan. The secondary endpoints were complication (Clavien-Dindo grading system), operative time, blood loss and length of hospital stay.

RESULTS

We performed 76 standard PCNL (sPCNL), 46 flexible ureteroscopy lithotripsy (fURL) and 25 miniaturized PCNL (mPCNL). The one-session SFR was 37.5% for the mPCNL group, 38.2% for the sPCNL group and 37% for the fURL group with no significant difference between the three procedures (P=0.99). Early complications, blood loss and transfusion rates were lower in the mPCNL group than in the sPCNL group (P=0.047) and comparable to fURL group. The final SFRs after a second intervention for mPCNL, sPCNL and fURL were 48%, 61.8% and 63%, respectively (P=0.67).

CONCLUSION

The efficacy of mPCNL in patients with NLUTD was not different from other techniques, but a significantly lower rate of complications than sPCNL was observed.

LEVEL OF PROOF

3.

A novel double-sheath negative-pressure versus conventional minimally invasive percutaneous nephrolithotomy for large kidney stone

This study aims to evaluate the therapeutic efficacy of a novel double-sheath negative-pressure minimally invasive percutaneous nephrolithotomy (D-mPCNL) compared to conventional minimally invasive percutaneous nephrolithotomy (C-mPCNL) for large kidney stones. A total of 132 patients diagnosed with large kidney stones in our hospital were included in the study. Among them, sixty-eight patients underwent D-mPCNL, while sixty-four underwent C-mPCNL. Parameters such as operative duration, stone-free rate, incidence of postoperative complications, and the need for auxiliary procedures were evaluated between the two groups. Compared to the C-mPCNL group, the D-mPCNL group demonstrated a significantly shorter operative time (41.97 ± 8.24 min vs. 52.30 ± 13.72 min; P < 0.000), lower rates of auxiliary procedures (5.9% vs. 17.2%; P = 0.041), and lower fever rates (2.9% vs. 14.1%; P = 0.021). The group also had a significantly higher primary stone-free rate (85.3% vs. 70.3%; P = 0.038). However, there were no statistically significant advantages in terms of the final stone-free rate, hemoglobin drops, and stone composition in the D-mPCNL group (P > 0.05). D-mPCNL is a novel surgical method that is safe and effective, reducing operative time, improving stone-free efficiency, and decreasing postoperative complications.

Erector spinae plane blocks for analgesia after percutaneous nephrolithotomy A pathway to reduce opioids

INTRODUCTION

Despite its minimally invasive nature, percutaneous nephrolithotomy (PCNL ) may be associated with significant pain. Challenges in pain control may prevent timely discharge (and expose patients to adverse effects of opioid use). We sought to evaluate whether our patients who underwent erector spinae plane (ESP) regional blocks experienced improved postoperative pain control and decreased opioid use after PCNL (compared with those who did not receive blocks).

METHODS

We retrospectively reviewed consecutive PCNL cases on patients admitted for greater than 24 hours without pre-existing opioid regimens for chronic pain. Cases were completed by a single high-volume surgeon. Patients who accepted an ESP block were compared to those who did not receive a block. Patients received either a single injection or a disposable pump delivering intermittent boluses of ropivacaine 0.2%. Demographic and perioperative data were analyzed. The primary outcomes were opioid use measured in morphine milligram equivalent (MME ) and patient-reported pain scores during the first 24 hours of hospitalization.

RESULTS

From March 2019 to August 2021, 44 patients were identified who met criteria - 28 of whom received an ESP block (including 14 continuous blocks). The patients who received blocks had significantly decreased opioid use (18.3 vs. 81.3 MME, p=0.004) and a longer mean time to first non-zero pain score (p=0.004). Continuous blocks had similar opioid use to single shot blocks (21.0 vs. 15.6 MME, p=0.952).

CONCLUSIONS

ESP regional blocks appear to offer an effective adjunct method for pain control after PCNL and may reduce post-PCNL opioid use while maintaining adequate patient analgesia.

Application of Bipolar Cauterization During Standard Percutaneous Nephrolithotomy

Introduction: We aimed to evaluate the efficacy of bipolar cauterization for tract site bleeding during standard percutaneous nephrolithotomy (PCNL). Methods and Materials: We defined tract site bleeding as when the visual field across the parenchymal tract starts to bleed while the sheath of a balloon dilator is being withdrawn just before the operation is completed. Among 181 patients, 90 patients showed no significant bleeding, and 91 patients required further procedures to resolve tract site bleeding. In cases of unresolved tract site bleeding, either nephrostomy placement (n = 60) or cauterization (n = 31) was performed. The outcomes of three groups (no procedure group, nephrostomy group and cauterization group) were compared. Results: The median decrease in hemoglobin at 2-hour intervals postoperatively was -1.75, -1.0, and -0.2 in the nephrostomy, cauterization, and no procedure groups, respectively (P < .001). There were 25 patients (41.7%) who received transfusions in the nephrostomy group, whereas only 1 patient (3.2%) received a transfusion in the cauterization group (P < .001). Conclusion: The bipolar cauterization of bleeding points at the end of PCNL could efficiently decrease tract site bleeding and reduce the need for transfusion. Clinical Research Information Service (https://cris.nih.go.kr/cris; No. KCT0008303).

Percutaneous management of upper tract stones: from mini to maxi percutaneous nephrolithotomy

PURPOSE OF REVIEW

Percutaneous nephrolithotomy (PCNL) continues as the gold standard for the surgical management of large renal stones. This short review is intended to highlight recent publications on PCNL of all tract sizes, from mini to standard.

RECENT FINDINGS

Literature on PCNL in the last 2 years has focused on several main themes - decreasing complications, improving postoperative pain control, and new technology to improve outcomes. Mini-PCNL continues to prove effective and safe, with a new vacuum sheath showing promise of improving stone-free rates and decreasing infections. In terms of infections, preoperative midstream urine culture continues to be a poor indicator of postoperative infection. One of the biggest changes to PCNL practice is the reintroduction of tranexamic acid, which has shown to significantly decrease bleeding and improve outcomes. In terms of postoperative pain control, local blocks are effective and low risk.

SUMMARY

There are many options for surgeons when it comes to PCNL from sheath size to pain management to preoperative medication to decrease bleeding. Future research will continue to highlight, which advances are the most beneficial.

Efficacy and safety of various endosurgical procedures for management of large renal stone: a systemic review and network meta-analysis of randomised control trials

Urolithiasis is the most common benign urological health condition. It has contributed sizeable burden of morbidity, disability, and medical health expenditure worldwide. There is limited high level of evidence on the efficacy and safety of treatment options of large renal stones. This network meta-analysis has examined the effectiveness and safety of various large renal stone management strategies. Systematic review and network meta-analysis (NMA) study design was employed to summarize comparative randomized controlled trials on humans with a diagnosis of renal stone larger than or equal to 2 cm in size. Our searching strategy was based on the Population, Interventions, Comparison, Outcomes, and Study (PICOS) approach. Medline via PubMed, Embase, Google scholar, SCOPUS, Science Direct, Cochrane library, Web of Science, and ClinicalTrials.gov were searched from inception to March 2023 to find eligible articles. Data extraction, screening, selection and risk of bias assessment were conducted by two independent reviewers. We found ten randomised control trials which consists 2917 patients, nine of them were labeled as low risk and one article was high risk. This network meta-analysis found that SFR was 86% (95% CI 84-88%) for Mini-PCNL, 86% (95% CI 84-88%) for standard PCNL, 79% (95% CI:73-86%) for RIRS, and 67% (95%CI:49-81 for staged URS for management of large renal stone. Overall complication rate was 32% (95% CI 27-38%) for standard PCNL, 16% (95% CI 12-21%) for Mini-PCNL, and 11% (95% CI 7-16%) for RIRS. Mini-PCNL (RR = 1.14 (95% CI 1.01-1.27) and PCNL (RR = 1.13 (95% CI 1.01-1.27)) were statistically associated with a higher SFR compared to RIRS. The pooled mean hospital stays were 1.56 days (95% CI 0.93-2.19) for RIRS, 2.96 days (95% CI 1.78-4.14) for Mini-PCNL, 3.9 days (95% CI 2.9-4.83) for standard PCNL, and 3.66 (95% CI 1.13-6.2) for staged URS. Mini-PCNL and standard PCNL were the most effective treatment options with significant morbidity and length of hospital stay, while RIRS was the safest management option with acceptable SFR, low morbidity, and short hospital stay.

The feasibility of ultrasound-guided mini-percutaneous nephrolithotomy for ESWL-resistant lower calyx renal stones of up to two centimeters: a single center experience

Lower pole renal stones present a significant challenge in urologic practice due to difficulty in accessing the calyx and eliminating fragments. Management options for these stones include watchful waiting for asymptomatic stones, extracorporeal shock wave lithotripsy (ESWL), ureterorenoscopy (URS), and percutaneous nephrolithotomy (PCNL). Mini-PCNL is a newer modification of conventional PCNL. The study aimed to assess the feasibility of mini-PCNL in treating lower pole renal stones equal to or less than 20mm that were not responsive to ESWL therapy. We included 42 patients (24 male and 18 female) with a mean age of 40±2.3 who underwent mini-PCNL at a single urology center between June 2020 and July 2022 and assessed operative and postoperative outcomes. The mean total operative time was 47±3.11 minutes, ranging from 40 to 60 minutes. The stone-free rate was 90%, and the overall complication rate was 26%, which included minor bleeding (5%), hematuria (7%), pain (12%), and fever (2%). The mean hospital stay was 80±3.34 hours (3-4 days). Our findings suggest that mini-PCNL is an effective treatment option for lower pole renal stones that are not responsive to ESWL therapy. The immediate stone-free rate was high, with minimum non-serious complications.

Place of extracorporeal shockwave lithotripsy in the treatment of urolithiasis in the region of Gharb Chrarda Bni Hssen (Morocco)

The extracorporeal shockwave lithotripsy (ESWL) is a minimally invasive therapeutic approach which has been widely used through the last years. The aim of this study was to evaluate the effectiveness of ESWL in the treatment of nephrolithiasis in Gharb Chrarda Bni Hssen area (North of Morocco). A retrospective study of 590 patients with urinary stone was conducted between February 2009 and January 2013 in the Centre of Lithotripsy Anoual Clinic Kenitra. The treatment consisted in one or several sessions of ESWL. Evaluation of efficiency was based on radiological examinations using abdominal echography during the consultation with the urologist after the last session. There were 306 males and 184 females aged 17-79 years. The medium size of stone was 12.3 ± 5 mm. The average number of sessions and shock waves were 4 and 2490, respectively. The shockwave session was continued until stone fragmentation was observed when 4000 shocks were given. Failure of stone fragmentation or the presence of fragments larger than 4 mm were indications of repeat ESWL sessions. 92% of patient stones were completely cleared (p < 0,05%). The majority of patients were asymptomatic. This data show that the ESWL is extremely successful in treating human kidney stone. It is the first line of choice as a treatment modality for this pathology by the population of this area.

Totally X-ray-Free Ultrasound-Guided Mini-Percutaneous Nephrolithotomy in Galdakao-Modified Supine Valdivia Position: A Novel Combined Surgery

We introduced a novel surgery that combines ultrasound guidance, miniaturization and Galdakao-modified supine Valdivia (GMSV) position in percutaneous nephrolithotomy (PCNL) and evaluated the safety and efficacy. This retrospective, single-center study retrospectively reviewed 150 patients who underwent ultrasound-guided mini-PCNL in the GMSV position from November 2019 to March 2022. All perioperative parameters were collected. Stone-free status was defined as no residual stones or clinically insignificant residual fragments (CIRF) <0.4 cm on postoperative day one. Among the 150 patients, the mean age was 56.96 years. The mean stone size was 3.19 cm (427 mm2). The mean S.T.O.N.E. score was 7.61, including 36 patients (24%) with scores ≥9. The mean operative time was 66.22 min, and the success rate of renal access creation in the first attempt was 88.7%. One hundred and forty (93.3%) patients were stone free. The mean decrease in Hemoglobin was 1.04 g/dL, and no patient needed a blood transfusion. Complications included transient hematuria (n = 13, 8.7%), bladder blood clot retention (n = 2, 1.3%), fever (n = 15, 10%) and sepsis (n = 2, 1.3%). Totally X-ray-free ultrasound-guided mini-PCNL in the GMSV position is feasible, safe and effective for patients with upper urinary tract stones, indicating the synergistic and complementary effects of the three novel techniques.