Multi-tract percutaneous nephrolithotomy combined with EMS lithotripsy for bilateral complex renal stones: our experience

Comparative Analysis of Super-Mini Percutaneous Nephrolithotomy Combined with Flexible Ureteroscopic Lithotripsy versus Flexible Ureteroscopic Lithotripsy Alone for Treating Complex Kidney Stones: A Retrospective Study of 205 Patients

BACKGROUND This retrospective study aimed to compare outcomes from super-mini percutaneous nephrolithotomy (SMP) combined with flexible ureteroscopic lithotripsy (FURL) and FURL alone in 205 patients with 2.5-4.2 cm diameter complex kidney stones. MATERIAL AND METHODS Between January 2018 and December 2022, 92 patients were treated with SMP combined with FURL (group A), and 113 patients were treated with FURL alone (group B). The stone-free rate (SFR), retreatment ratio, operation time, mean decline in hemoglobin level, postoperative pain visual analogue scale (VAS), and postoperative hospitalization time and complications were analyzed and compared between the 2 groups. RESULTS The SFR 3 days after the operation was 85.87% in group A, which was significantly higher than that in group B (72.57%) (P=0.021). The rate of retreatment in group A (3.26%) was significantly lower than that in group B (10.62%) (P=0.044). The SFR after 90 days was higher in group A (94.57%) than in group B (90.27%) (P=0.254). The mean decrease in hemoglobin, postoperative hospitalization duration, and VAS score 6 hours after the operation were all significantly higher in group A than in group B (P<0.05). However, there was no significant difference in operation time, VAS score at 12 and 24 hours after the operation, and complication rate. CONCLUSIONS In the treatment of complex renal stones, compared with FURL, SMP combined with FURL in the oblique supine lithotomy position has the advantages of a higher early SFR with no increased risk of complications.

The efficacy and safety of one-stage endoscopy combined with intrarenal surgery (mini-nephrostomy tract) in the prone split-leg position for complex renal calculi

Background

The goal of this study was to determine the safety and efficacy of endoscopic combined intrarenal surgery (ECIRS) performed in the prone split-leg position for the treatment of complex renal stones.

Materials and methods

A mature ECIRS protocol was designed. Retrospective analysis was conducted of medical records between January 2020 and December 2021 of patients with complex renal stones at one center who underwent ECIRS by 2 skilled surgeons using retrograde flexible ureteroscopy and mini-percutaneous nephrolithotomy in the prone split-leg position.

Results

A total of 44 patients were included in this study. Mean stone size was 26.1 ± 12.7 mm, and the number of calyces involved was 4.36 ± 2.09. Mean operative time was 71.1 ± 21.8 minutes. Postoperative decline in hemoglobin was 15.8 ± 9.8 g/L. Seventy-five percent of patients achieved stone-free status. The mean number of residual stones was 2.8 ± 2.3, and the mean residual stone size was 10.30 ± 4.76 mm. Six patients (13.6%) developed postoperative complications, including 4 with fever during the first 2 days postoperatively and 2 patients with transient postoperative pain. No patients developed severe complications.

Conclusions

Endoscopic combined intrarenal surgery in the prone split-leg position can be performed safely by experienced surgeons using retrograde flexible ureteroscopy in conjunction with mini-percutaneous nephrolithotomy as a successful technique for the treatment of complex renal stones.

Can we identify the risk factors for SIRS/sepsis after percutaneous nephrolithotomy? A meta‑analysis and literature review

With the increase in percutaneous interventions such as percutaneous nephrolithotomy (PCNL) for renal lithiasis, infectious complications are becoming more frequent. The present study performed a systematic Medline and Embase databases search, using the following words: 'PCNL' [MeSH Terms] AND ['sepsis' (All Fields) OR 'PCNL' (All Fields)] AND ['septic shock' (All Fields)] AND ['urosepsis' (MeSH Terms) OR 'Systemic inflammatory response syndrome (SIRS)' (All Fields)]. Because of the technological advances in endourology, articles published between 2012 and 2022 were searched. Of the 1,403 results of the search, only 18 articles, representing 7,507 patients in which PCNL was performed, met the criteria to be included in the analysis. All authors applied antibiotic prophylaxis to all patients and, in some cases, the infection was treated preoperatively in those with positive urine cultures. According to the analysis of the present study, the operative time has been significantly longer in patients who developed SIRS/sepsis post-operatively (P=0.0001) with the highest heterogeneity (I²=91%) compared with other factors. Patients with a positive preoperative urine culture had a significantly higher risk of developing SIRS/sepsis following PCNL (P=0.00001), OD=2.92 (1.82, 4.68) and there was also a high degree of heterogeneity (I²=80%). Performing a multi-tract PCNL also increased the incidence of postoperative SIRS/sepsis (P=0.00001), OD=2.64 (1.78, 3.93) and the heterogeneity was a little smaller (I²=67%). Diabetes mellitus (P=0.004), OD=1.50 (1.14, 1.98), I²=27% and preoperative pyuria (P=0.002), OD=1.75 (1.23, 2.49), I²=20%, were other factors that significantly influenced postoperative evolution. A total of two factors analyzed, body mass index and patient's age, did not influence the outcome, P=0.45, I²=58% and P=0.98, I²=63%.

Multitract percutaneous nephrolithotomy in the management of staghorn stones

Background

Staghorn stones are difficult to manage with a risk of significant renal impairment and urosepsis. Percutaneous nephrolithotomy is the first-line treatment for staghorn stones. Often, multiple access tracts are needed to render the patient stone-free. PCNL has been combined with SWL, flexible URS (ECIRS), and mini-PCNL to access residual fragments without the need of additional tracts. However, in a country with limited access to technology and a restraint on resources, multitract PCNL still is the preferred option. The aim of this study was to assess the safety and efficacy of multitract PCNL in such an environment.

Methods

We analyzed data on sixty-five patients with staghorn calculus who underwent multitract PCNL for a staghorn calculus. Data included demographics, stone parameters, intraoperative parameters, complications and clinical outcomes. Hb-drop and creatinine changes were assessed pre- and post-OP. Complications were graded according to the modified Clavien-Dindo classification.

Results

In a total of 65 patients [47 males (72%)], 154 percutaneous access tracts were used in 66 renal units. The number of tracts varied between 2 and 4 in a single renal unit. The stone-free rate was 85%. 20% of patients developed grade I, 14% grade II, and 3% grade III b complications. There were no grade IV and V complications.

Conclusion

Multitract PCNL is safe and efficient, with a good stone-free rate and an acceptable complication rate. When auxiliary combination treatments are not available, multitract standard PCNL remains an option.

Multiple-tract percutaneous nephrolithotomy as a day surgery for the treatment of complex renal stones: an initial experience

PURPOSE

The purpose of this study was to evaluate the safety and efficiency of multiple-tract percutaneous nephrolithotomy (PCNL) as a day surgery for the treatment of complex renal stones. PATIENTS AND METHODS: A mature protocol for day surgery was implemented. Forty-six patients who underwent planned day-surgery PCNL via multiple tracts for the treatment of complex renal stones were retrospectively reviewed. All procedures were performed by an experienced surgeon. The outcomes were recorded.

RESULTS

The mean stone size and burden were 4.8 cm and 990.2 mm², respectively. There were 26 (56.5%) and 20 (43.5%) patients with staghorn stones and multiple stones, respectively. Totals of two, three, and more than three tracts (with up to 7 tracts) were established in 22, 11, and 13 patients, respectively. The tract sizes ranged from 14 to 24 Fr. One to four nephrostomy tubes were placed in most patients, and a tubeless process was accomplished in only 3 (6.5%) patients. The mean surgery time was 116 min with a hemoglobin drop of 22.1 ± 16.8 g/L. Eight (17.4%) patients developed postoperative complications, with severe complications (Clavien grades III-IV) in two cases (4.4%). 39 (84.8%) patients were discharged within 24 h after surgery, and 7 (15.2%) patients were fully admitted. Only 1 (2.2%) patient required readmission. The stone clearance rate was 84.8%.

CONCLUSIONS

Day-surgery PCNL can be safely performed via multiple percutaneous tracts by experienced surgeons and is an efficient strategy for the treatment of complex renal stones.

Contemporary role of multi-tract percutaneous nephrolithotomy in the treatment of complex renal calculi

Complex renal calculi remain to be a challenge for the treating urologist due to sheer bulk and the technicalities involved. Percutaneous nephrolithotomy (PCNL) remains the treatment modality of choice in dealing with these large and complex stones. The limiting factor in their treatment continues to be the need for using additional tracts or the use of flexible nephroscopy for complete stone clearance. This systematic review focuses on the need for multi-tract PCNL for complex renal calculi. The literature review was performed using PubMed database using the keywords "multiple tract PCNL" or "multiperc". We identified original articles published on the usage of multiple tracts for stone clearance in renal calculi between January 2000 to October 2018, and the search was restricted to available literature in English language only. Ten studies with n>20 were included for the final analysis. We analyzed the technical efficacy with respect to the number of tracts and stages that were required for stone clearance, outcomes and complications, especially, procedural bleeding and post-procedure infective complications of multiple-tract PCNL for large burden renal stones. Multiperc is found to be safe, feasible and effective for the management of large burden complex renal calculi with respect to stone clearance and morbidity associated with the procedure. It is cost effective and complete stone clearance as a single procedure is higher in comparison to flexible ureteroscopy and shockwave lithotripsy.

Research progress of percutaneous nephrolithotomy

Percutaneous nephrolithotomy (PCNL) is generally accepted as the gold standard treatment for the treatment of large kidney stones (> 2 cm). For nearly 40 years, with the continuous progress of technology and the constant updating of ideas, PCNL has made great progress. In this review, we discuss the current research progress, recent advancement and hot spot of the whole process of PCNL including anesthesia, position, puncture, dilation, lithotripsy approaches, perfusate, tube placement, hospitalization time, drug, treatment of residual stones, prognosis judgment and operation evaluation by summarizing the related research in this article.