Super-mini PCNL (SMP) with suction versus standard PCNL for the management of renal calculi of 1.5 cm-3 cm: a randomized controlled study from a university teaching hospital

PURPOSE

To assess the safety and efficacy of super-mini PCNL (SMP, 14 Fr) when compared to standard PCNL (sPCNL, 24-30 Fr) in the management of renal calculi of size ranging from 1.5 to 3 cm.

METHODS

From February 2021 to January 2022, a total of 100 patients were randomized to either SMP group or sPCNL group in a 1:1 ratio (50 in each group) using computer-generated simple randomization. Demographic data, stone characteristics, operative times, perioperative complications, blood transfusions, postoperative drop in haemoglobin, postoperative pain, duration of hospital stay and stone-free rates were compared between the two groups.

RESULTS

Mean stone volume (2.41 cm2 vs 2.61 cm2) and stone-free rates (98% vs 94%, p = 0.14) were similar in both the SMP and sPCNL groups, respectively. The SMP group had significantly longer mean operative times (51.62 ± 10.17 min vs 35.6 ± 6.8 min, p = 0.03). Intraoperative calyceal injury (1/50 vs 7/50, p = 0.42) and mean postoperative drop in haemoglobin (0.8 ± 0.7 g/dl vs 1.2 ± 0.81, p = 0.21) were lower in the SMP group, but not statistically significant. SMP group showed significantly lower mean postoperative pain VAS scores (5.4 ± 0.7 vs 5.9 ± 0.9, p = 0.03) and mean duration of hospital stay (28.38 ± 3.6 h vs 39.84 ± 3.7 h, p = 0.0001). Complications up to Clavien grade 2 were comparable, with grade ≥ 3 complications higher in the standard group, but not statistically significant.

CONCLUSION

Super-mini PCNL is equally effective as standard PCNL in treating renal calculi up to 3 cm, with significantly reduced postoperative pain and duration of hospital stay and lower risk of Clavien grade ≥ 3 complications, although with higher operative times.

A proposed mathematical model to help preoperative planning between RIRS and MiniPerc for renal stones between 10 and 20 mm using holmium:Yag laser (Cyber Ho): the stone management according to size-hardness (SMASH) score

To evaluate the performance of a mathematical model to drive preoperative planning between RIRS and MiniPerc (MP) for the treatment of renal stones between 10 and 20 mm. Patients with a renal stone between 10 and 20 mm were enrolled. A mathematical model named Stone Management According to Size-Hardness (SMASH) score was calculated: hounsfield units (HU) χ stone maximum size (cm)/100. Patients were divided into 4 groups: RIRS with score < 15 (Group A), RIRS with score ≥ 15 (Group B), MP with score < 15 (Group C), MP with score ≥ 15 (Group D). Cyber Ho device was always used. Stone free rate (SFR) was assessed after 3 months. Complication rate and need for auxiliary procedures were evaluated. Between January 2019 and December 2021, 350 patients were enrolled (87, 88, 82 and 93 in Groups A, B, C and D). Mean stone size was 13.1 vs 13.3 mm in Group A vs B (p = 0.18) and 16.2 vs 18.1 mm in Group C vs D (p = 0.12). SFR was 82%, 61%, 75% and 85% for Groups A, B, C and D. SFR was comparable between Groups C and D (p = 0.32) and Groups A and C (p = 0.22). SFR was significantly higher in Group A over B (p = 0.03) and in Group D over B (p = 0.02). Complication rate was 2.2%, 3.4%, 12.1%, 12.9% for Groups A, B, C, D. RIRS and MP are both safe and effective. The mathematical model with the proposed cut-off allowed a proper allocation of patients between endoscopic and percutaneous approaches.Registration number of the study ISRCTN55546280.

Influence of tract location on the outcomes of endoscopic combined intrarenal surgery: A retrospective analysis of 1000 cases

OBJECTIVES

This study aimed to investigate the influence of tract location on surgical outcomes in endoscopic combined intrarenal surgery (ECIRS), considering the location of residual stones.

METHODS

From January 2015 to December 2021, 1417 consecutive patients underwent ECIRS in three hospitals. After excluding patients with preoperative percutaneous nephrostomy, intended multi-stage procedures, those with a tract in the renal pelvis, and those with multiple tracts, 1000 patients were retrospectively analysed by comparing three groups based on tract location: group 1 (upper calyx), group 2 (middle calyx), and group 3 (lower calyx). A multivariate logistic regression model was implemented to assess whether the tract location independently affected the stone-free status.

RESULTS

Patient characteristics were significantly different among the groups in terms of age, stone laterality, presence of calyceal stones, and hydronephrosis. There were no differences in stone-free rate (SFR) among the three groups. Multivariate analysis indicated that the tract location (group 1 or 2 compared with group 3) did not significantly affect the stone-free status (odds ratio = 1.4, 0.9-1.9, p = 0.066). Surgical duration significantly varied among the groups, with the shortest time observed in group 1. Organ injury was observed exclusively in group 1 (1.13%). Residual fragments were predominantly found in the lower calyx, with the calyx associated with the tract being the second most common location.

CONCLUSIONS

Tract location does not significantly affect SFR. To improve the SFR, observation of the lower calyx and tract placement is important.

Could pain change position choice? Comparison of pain level, analgesic requirement and hospitalization time in supine and prone percutaneous nephrolithotomy

PURPOSE

Investigation of how position affects postoperative pain levels and hospitalization in patients undergoing percutaneous nephrolithotomy (PNL) surgery.

METHODS

Between August 2019 and December 2022, a total of 156 patients who underwent prone (pPNL) and supine percutaneous nephrolithotomy (sPNL) due to kidney stones were included in the study. Demographic data, preoperative CT scans, laboratory results, transfusion rates, operation durations, complication rates, stone-free rates, analgesic use, nephrostomy removal time, hospitalization duration, fluoroscopy time, hemoglobin decrease and postoperative Visual Analog Scale (VAS) scores were evaluated for all patients. By comparing these data between the sPNL and pPNL groups, the effect of position selection in PNL on pain control, analgesic requirement, and hospitalization duration was examined.

RESULTS

In the comparison of the pPNL and sPNL groups, there was a significant difference between the two groups in body mass index, hounsfield unit, complication rate, analgesic rate, nephrostomy remove time, hospitalization time, operation time, fluoroscopy time and VAS score (p = 0.025, p < 0.001, p = 0.012, p = 0.012, p < 0.001, p < 0.001, p < 0.001, p < 0.001 and p < 0.001, respectively).

CONCLUSION

The shorter operation and hospitalization time in the sPNL group could be attributed to performing surgeries in a physiological position. Additionally, sPNL seems advantageous in terms of patients' pain levels, hospitalization time and VAS scores. One reason for this could be the different areas of access in sPNL and pPNL, which may correspond to different dermatome regions. Considering the low level of pain and reduced analgesic usage, sPNL appears to be advantageous.

Tubeless PCNL versus standard PCNL for the treatment of upper urinary tract stones: a propensity score matching analysis

PURPOSE

In this study, the feasibility of tubeless percutaneous nephrolithotomy (PCNL) for the treatment of upper urinary tract stones was investigated.

METHODS

From January 2021 to December 2022, the clinical data of 273 patients who received tubeless PCNL (Group A) were studied. The control group includes clinical data from 302 patients (from January 2019 to October 2022) who received standard PCNL (Group B). The baseline characteristics were consistent between the two groups after using the propensity score matching (PSM) method. Compare the preoperative clinical characteristics, postoperative complications, residual stones, catheterization time, and hospital stay between the two groups.

RESULTS

146 pairs of patients were successfully paired through PSM. There was no statistically significant difference in operative time, blood leukocyte counts, haemoglobin decrease, fever, urinary extravasation, sepsis, bleeding, blood transfusion rates, embolism, and residual stones after surgery between the two groups; Postoperative day 1 and discharge day, the VAS pain score in Group A was significantly lower than that in Group B. The catheterization time and hospitalization time of patients in Group A were significantly lower than those in Group B.

CONCLUSION

According to the inclusion and exclusion criteria, selecting suitable patients for tubeless PCNL is safe and effective, while significantly alleviating pain and reducing catheterization time and hospital stay.

Bilateral Single-session PCNL with Minimally Invasive Technique in Pediatric Nephrolithiasis

PURPOSE

To assess outcomes of bilateral single-session percutaneous nephrolithotomy (PCNL) with minimally invasive techniques in pediatric population.

MATERIALS AND METHODS

From August 2015 to July 2021, 45 children (including 12 infants) were treated with bilateral single-session PCNL, which included miniPCNL (12-16-Fr) and Microperc (4.8-Fr). Patient, stone and operation-related characteristics, stone-free rate (SFR) and complication rate (CR) were compared using ANOVA. Independent predictors were determined using multivariate linear regression.

RESULTS

The mean stone burden was 3.2 cm in sum diameter for both kidneys. For bilateral kidneys, the mean operative time was 61.6min and SFR was 93.3%; CR was 53.3%, of which complications of Clavien grade 1 and 2 accounted for 46.7%. Bilateral Microperc, bilateral miniPCNL and Microperc plus miniPCNL was performed in 19, 14 and 12 children respectively. Both irrigation volume and postoperative stay were less in groups with Microperc. Both SFRs and CRs were satisfactory for the three groups. Self-limiting hematuria represented the most common complication of all cases (33.3%), especially in groups with miniPCNL. The stone burden was the only independent predictor for operative time (P < .001) and the postoperative complication (P = .008). Children with older age (P = .009), higher body mass index (P = .016) or a higher stone burden (P < .001) received larger irrigated fluid volume. Microperc was associated with less irrigated fluid volume (P = .001). Children with Clavien grade 3 complications (P = .004) spent prolonged postoperative hospital stay.

CONCLUSION

With favourable SFR and acceptable CR, bilateral single-session PCNL with minimally invasive techniques might be an effective and safe procedure for pediatric nephrolithiasis.

What should the optimal access site be for percutaneous treatment of anterior lower pole calyx stones?

OBJECTIVES

Compared to other stone groups, anterior calyx stones are more challenging for endourologists to treat. This study aims to evaluate the differences between our latest technique and conventional techniques for treating anterior calyx stones in the lower pole.

MATERIALS AND METHODS

Patients with isolated anterior lower pole calyx or complex lower pole stones with anterior calyx branching were included in the study. The first group included lower pole access, while the second group included percutaneous treatment through the middle or upper pole. In the first group, the posterior calyx or direct anterior calyx approach was utilised depending on whether the stone was isolated calyx, complex structure or calyx anatomy, while in the second group, percutaneous nephrolithotomy was performed through the middle or upper pole posterior calyx access.

RESULTS

There were 37 patients in Group 1 and 25 patients in Group 2. Both groups were similar regarding patient age, sex, stone burden, and stone localisation (p > 0.05). When comparing operative and post-operative data between groups, it was found that the stone clearance rate, number of accesses, and haematocrit decrease were statistically superior in the second group (p: 0.003, p: 0.002, p: 0.018), with no significant difference in mean operative time, length of hospital stay, fluoroscopy time and pain score (p > 0.05).

CONCLUSIONS

Percutaneous surgery utilising an access from a calyx distal to the stone may offer better clearance and lower morbidity rates for lower pole stones involving the anterior calyx.

Transient ureteral obstruction after mini-percutaneous nephrolithotomy is associated with stone volume and location: results from a single-center, real-life study

PURPOSE

To evaluate the rate of and predictors of ureteral obstruction after mini-percutaneous nephrolithotomy (mPCNL) for kidney stones.

METHODS

We analyzed data from 263 consecutive patients who underwent mPCNL at a single tertiary referral academic between 01/2016 and 11/2022. Patient's demographics, stone characteristics, and operative data were collected. A nephrostomy tube was placed as the only exit strategy in each procedure. On postoperative day 2, an antegrade pyelography was performed to assess ureteral canalization. The nephrostomy tube was removed if ureteral canalization was successful. Descriptive statistics and logistic regression models were used to identify factors associated with a lack of ureteral canalization.

RESULTS

Overall, median (IQR) age and stone volume were 56 (47-65) years and 1.7 (0.8-4.2) cm3, respectively. Of 263, 55 (20.9%) patients showed ureteral obstruction during pyelography. Patients without ureteral canalization had larger stone volume (p < 0.001), longer operative time (p < 0.01), and higher rate of stones in the renal pelvis (p < 0.01) than those with normal pyelography. Length of stay was longer (p < 0.01), and postoperative complications (p = 0.03) were more frequent in patients without ureteral canalization. Multivariable logistic regression analysis revealed that stone volume (OR 1.1, p = 0.02) and stone located in the renal pelvis (OR 2.2, p = 0.04) were independent predictors of transient ureteral obstruction, after accounting for operative time.

CONCLUSION

One out of five patients showed transient ureteral obstruction after mPCNL. Patients with a higher stone burden and with stones in the renal pelvis are at higher risk of inadequate ureteral canalization. Internal drainage might be considered in these cases to avoid potential complications.

Risk factors of high fluid absorption in patients treated with mini-PCNL: a single-center prospective study

BACKGROUND

The factors influencing fluid absorption in mini-percutaneous nephrolithotripsy (mini-PCNL) are still unknown. We aim to investigate the factors that influence irrigation fluid absorption during mini-PCNL.

METHODS

A total of 94 patients who underwent mini-PCNL were included in this prospective study. The endoscopic surgical monitoring system (ESMS) was used to measure the volume of irrigation fluid absorbed during the procedure. Irrigating time, the total volume of irrigation fluid, stone size, S.T.O.N.E. score, hemoglobin, electrolyte levels, and postoperative complications were recorded.

RESULTS

A significant correlation was observed between fluid absorption and the presence of postoperative fever, and based on this phenomenon, patients were divided into low and high fluid absorption groups. The serum creatinine level in the high fluid absorption group was significantly high (7 vs. 16.5, p = 0.02). Significant differences were observed between the low and high fluid absorption groups in terms of mean stone size (21.70 mm vs. 26.78 mm), presence of stone burden ≥ 800 mm2 (4% vs. 23%), S.T.O.N.E. score > 8 (4% vs. 38%), the fluid used > 18,596 ml (19% vs. 78%), irrigation time (55.61 min vs. 91.28 min), and perfusion rate (24% vs. 45%) (all p < 0.05). The rates of postoperative fever and SIRS in the high fluid absorption group were significantly high (p < 0.05).

CONCLUSIONS

Mean stone size, presence of stone burden ≥ 800 mm2, S.T.O.N.E. score > 8, the fluid used > 18596 mL, irrigation time, and perfusion rate are risk factors of intraoperative fluid absorption in mini-PCNL.

Learning curve of ultrasound-guided percutaneous nephrolithotripsy in the treatment of complex renal calculi

OBJECTIVE

This study was performed to investigate the learning curve of ultrasound-guided percutaneous nephrolithotripsy (PCNL) for the treatment of complex renal calculi.

METHODS

Seventy-two patients with complex renal stones who underwent ultrasound-guided PCNL by the same operator from November 2016 to September 2020 were retrospectively analyzed. The learning curve of PCNL for complex renal stones was analyzed using multifactorial cumulative sum (CUSUM) analysis and best-fit curves.

RESULTS

The CUSUM best-fit curve peaked at Case 36, which represented the minimum number of cumulative cases required to cross the learning curve for this surgical procedure. Accordingly, the learning curve was divided into a learning improvement period (36 cases) and a proficiency phase (36 cases). Compared with the learning improvement period, the proficiency phase was characterized by a shorter puncture time and operation time, a smaller drop in the hemoglobin level, and a lower postoperative complication rate.

CONCLUSION

The learning curve of PCNL for the treatment of complex renal calculi can be divided into a learning improvement period and a proficiency phase, and the minimum cumulative number of cases is 36.

Vacuum-assisted Mini-percutaneous Nephrolithotomy for 2-3-cm Renal Stones: A Comparative Study with Retrograde Intra-renal Surgery

PURPOSE

To compare vacuum-assisted percutaneous nephrolithotomy (VAmini-PCNL) with retrograde intra-renal surgery (RIRS) for the treatment of renal stones measuring 2-3 cm in diameter.

MATERIAL AND METHODS

This retrospective study included children receiving treatment for pyelocalyceal stones of 2-3 cm in diameter from November 2018 to September 2022. Consecutive patients undergoing VAmini-PCNL after 2020 were compared with a historically matched group undergoing RIRS. VAmini-PCNL was performed using a 12-Ch nephroscope through a 16-Ch vacuum ClearPetra access sheet. RIRS was performed using a flexible ureteroscope through a ureteral sheath. The endpoints included the need for pre-stenting, duration of surgery, complications, stone-free rate (SFR), and need for secondary procedures.

RESULTS

The patients were grouped into two with 15 patients for each group. VAmini-PCNL group was not different from the RIRS one for age at surgery [median (range) 6.6 (1-12)years vs. 7.7 (1.5-14)years], and stone diameter [median (range) 2.4 (2.0-2.9)cm vs. 2.3 (2.1-2.8)cm] and density [median (range) 577.5 (421-1068) vs. 541.5 (462-927) Hunsfield Units]. Pre-stenting was necessary in five RIRS patients (33 %). The median duration of surgery was 85.3 (76-112)min for VAmini-PCNL vs. 150.6 (132-167)min for RIRS, p = 0.00001. No major complications were observed. The SFR was 100 % after VAmini-PCNL and 60 % after RIRS, p = 0.02. All residual fragments were removed with a second RIRS.

CONCLUSION

VAmini-PCNL was feasible and safe in children aged >1 year. It allowed for a significantly higher SFR despite a significantly shorter operative time than RIRS, which also requires pre-stenting in one-third of patients and a second RIRS in 40 % of cases.

LEVEL OF EVIDENCE

III.

Percutaneous Nephrostomy as a Procedure in the Treatment of Urinary Tract Obstruction - Experiences in the University Clinic of Urology in Skopje

INTRODUCTION

Obstructive uropathy encompasses various urinary tract obstructions, leading to changes in urine flow, kidney pressure, and impaired kidney function. Predicting renal recovery from obstructive uropathy, can be challenging and necessitates treatment, as in percutaneous nephrostomy (PNS) drainage. The choice of drainage method depends on patient-specific factors and local expertise. According to the data for the Republic of North Macedonia, in the register of the European Renal Association, in the last few years, there has been an increase in the percentage of patients with obstructive nephropathy from 7.6% to 8.9% who end up on a chronic hemodialysis program. Prompt relief from urinary tract obstruction is essential to preserve renal function and prevent complications. The aim of this study is to present our initial data analysis of recent experience in the use of nephrostomies as a method for temporary or long-term resolution of obstructive nephropathy, in terms of safety and success in preserving kidney function and reducing the number of patients on hemodialysis.

MATERIALS AND METHODS

This study analyzed the medical records of 24 patients with obstructive uropathy who underwent PNS placement. Data were collected for the type and degree of obstruction from the ultrasonographic examination. A pig tail nephrostomy was used, with a dilator, guided under ultrasound and controlled with contrast and fluoroscope. Obstructive nephropathy was defined as an elevation of the serum creatinine > 109 µmol/L, before the intervention. Glomerular filtration rate (GFR) was calculated according to the formula CKD epi in ml/min. Each placement of the PNS was considered as an individual procedure and the data of 38 placed nephrostomies were analyzed. We compared the laboratory analyses from the day before (D0) PNS placement and on the seventh day (D7) after PNS placement. The reduction of values for red blood cells (RBC) and hemoglobin (Hb) baseline values from D0 to D7 and the need for transfusion after the procedure were defined as a complication-bleeding. The increase in total counts of the white blood cells (WBC) and C-reactive protein (CRP) from the baseline values from D0 to D7 were defined as a complication-infection. Standard statistical methods were used for data processing.

RESULTS

Most patients, 17 (70%), had malignant disease as the cause of obstruction. Unilateral obstruction was more common, detected in 24 (63%) of procedures, with a high degree of hydronephrosis. Obstructive nephropathy, marked by elevated serum creatinine, was observed in 23 (60%) cases before PNS placement. Complications included bleeding and infection but did not result in any fatalities. When comparing the laboratory analysis before PNS placement (D0) and seven days later (D7), a statistically significant decrease in serum creatinine (225±161 vs. 162±145, p=0.005) and an increase in GFR (47±39 vs.59±34, p= 0.005) were observed.

CONCLUSION

Percutaneous nephrostomy is a safe and effective treatment option for urinary tract obstruction, especially in patients with malignancies. Continuous monitoring is essential to assess long-term complications and the longevity of PNS functionality. This procedure offers a significant benefit in preserving renal function and minimizing the need for hemodialysis in these patients.

Three-Dimensional Virtual Reconstruction Method versus Standard Fluoroscopy as a Guiding Tool for an Optimal Puncture Rout in Patients Undergoing Percutaneous Nephrolithotomy: A Randomized Trial Study

PURPOSE

Three-Dimensional (3D) could help for planning and creating an optimal access route in percutaneous nephrolithotomy (PCNL) procedure by achieving a more accurate approach to the renal collecting system and stone treatment while decreasing the risk of complications. The aim of our study is to compare the efficacy of 3D imaging technique with standard fluoroscopy method as a guiding tool for renal stone location while striving to reduce intra-operative X-ray exposure in the former method.

MATERIALS AND METHODS

This randomised clinical trial enrolled 48 PCNL candidates who were referred to Sina Hospital (Tehran, Iran). Participants were divided into two equal groups of intervention (3D virtual reconstruction) and control, using block randomization method. Age, sex, stone type and location, X-ray exposure during the procedure, stone access accuracy rate and the necessity of blood transfusion during surgery were taken into account.

RESULTS

The Mean age of participants (n = 48) was 46.4 ± 4.8 years, 34 (70.8%) were male, 27 (56.3%) had partial staghorn stones and all participants had stones within the lower calyx. The radiation exposure time, stone access time and stone size were 2.99 ± 1.81 seconds, 272.3 ± 108.9 seconds and 23.06 ± 2.28 mm, respectively. In the intervention group, the accuracy rate for lower calyceal stone access was 91.5%. Also, X-ray exposure and time to stone access were significantly lower in the intervention group compared to the controls (P < 0.001).

CONCLUSION

We concluded that the utilization of 3D technology in the pre-operative location of renal calculi in PCNL candidates may result in a significant improvement in the accuracy and time to access the renal calculi, as well as reduction in X-ray exposure.

Medium-Term Stone Recurrence after zero-fragment transperitoneal Laparoscopic Pyelolithotomy Compared with Percutaneous Nephrolithotomy for Large Single Renal Pelvis Stones

PURPOSE

To compare medium-term stone recurrence between laparoscopic pyelolithotomy (LP) and percutaneous nephrolithotomy (PCNL).

MATERIAL AND METHODS

98 patients who underwent PCNL or LP (2015-2019) for large single renal pelvis or staghorn stones (≥ 2 cm) were selected. The stone-free rate was evaluated using a computed tomography scan at one month and then, ultrasonography at six months intervals during the first year and annually thereafter for up to three years. Time-to-stone recurrence was compared using the Kaplan-Meier estimate. Hazard ratio was estimated by Cox regression.

RESULTS

The one month stone-free rate was 93.88% in the LP group vs. 79% in the PCNL group (P = .03). The mean overall time-to-stone recurrence was 31 (CI:24-34) months in the LP vs. 28 (CI: 23-32) in the PCNL groups (P = .02). Cox regression analysis showed that PCNL increased the risk of stone recurrence with a hazard ratio of 2.3 (CI: 1.1 - 5.3) compared to the laparoscopy. (p = .03) In subgroup analysis, time-to-stone recurrence in those without previous history of intervention was estimated at 31 (CI: 27 to 35) months in the LP vs. 25 (CI:16 to 34) in PCNL groups (= 0.04). Subanalysis with a BMI cutoff of 25 kg/m2 showed an overall time-to-stone recurrence of 34 (CI:30 to 37) months in the LP group and 28 (CI:22 to 33) months in the PCNL group (= 0.04) in those with BMI higher than 25 kg/m2.

CONCLUSION

Medium-term time to stone recurrence was in favor of LP compared with PCNL for large single renal pelvis or staghorn stones.

Complications Subsequent to Urinary Tract Stent Placement: An Overview Focusing on the Imaging of Cancer Patients

Ureteral involvement by a tumor is common, and both partial and complete obstructions can result in symptoms that are distressing and debilitating, especially in cancer patients for whom the resection of the primary tumor is not considered an option. Maintaining ureteric patency in these patients is a challenge. In addition, in cases where a patient has undergone nephroureterectomy due to primary transitional cell cancer, it becomes necessary to decompress the urinary tract to preserve the contralateral kidney from irreversible damage. This is possibly due to ureteral stenting, both retrograde and anterograde, and percutaneous nephrostomy (PCN). Since imaging plays an important role in the routine monitoring of stents, their more and more increasing use requires radiologists to be familiar with these devices, their correct position, their potential complications, and their consequences. The aim of this review is to offer a comprehensive review of the imaging features of some urinary stents and to show the complications encountered in cancer patients as a direct consequence of an invasive diagnostic or therapeutic procedure. Specifically, we focus on ureteral stents and PCN.

Ureteral stent after PCNL: is leaving the threads through the percutaneous tract safe and better tolerated?

OBJECTIVE

To assess safety, urinary symptoms, and feasibility of JJ stent removal with exteriorized threads through the percutaneous tract after percutaneous nephrolithotomy (PCNL).

MATERIALS AND METHODS

Prospective, transversal, comparative, experimental, randomized 1-to-1 cohort study in 52 patients who underwent "tubeless" PCNL from October 2020 to November 2022. Group A with threads through the urethra and Group B through the percutaneous tract. The validated USSQ (Ureteral Stent Symptom Questionnaire) was applied in the Urology office a week after the procedure, and the JJ stent was withdrawn by pulling the threads. Hemoglobin and urine culture, and pre- and post-surgery were evaluated.

RESULTS

There is a statistically significant difference in favor of group B when comparing urinary symptoms (p = 0.008), body pain (p = 0.009), and general condition (p = 0.042), mainly for non-urgency incontinence, frequency of analgesic use, and dysuria. There were significant differences between groups (p = 0.028, p = 0.026, p = 0.027, respectively). There is no association with urinary infections (p = 0.603) nor an increased risk of bleeding (p = 0.321).

CONCLUSION

The removal of the JJ stent with exteriorized threads through the percutaneous tract after PCNL in the office is a feasible and safe procedure if it is removed before 8 days and has better tolerance regarding the urinary symptoms.

Antegrade flexible ureteroscopy-assisted percutaneous nephrolithotomy for staghorn calculi: a prospective randomized controlled study

The aim is to compare the efficacy and safety between single percutaneous nephrolithotomy (sPNL) and antegrade flexible ureteroscopy-assisted percutaneous nephrolithotomy (aPNL) for the treatment of staghorn calculi. A prospective randomized controlled study was conducted at the Second Hospital of Tianjin Medical University. A total of 160 eligible patients were included, with 81 in the sPNL group and 79 in the aPNL group. The study first compared the overall differences between sPNL and aPNL. Then, the patients were divided into two subgroups: Group 1 (with less than 5 stone branches) and Group 2 (with 5 or more stone branches), and the differences between the two subgroups were further analyzed. The results showed that aPNL had a higher stone-free rate (SFR) and required fewer percutaneous tracts, with a shorter operation time compared to sPNL (P < 0.05). Moreover, aPNL significantly reduced the need for staged surgery, particularly in patients with 5 or more stone branches. Moreover, there were no significant differences in the changes of hemoglobin levels and the need for blood transfusions between the sPNL and aPNL groups, and the incidence of multiple tracts was lower in the aPNL group. The two groups showed comparable rates of perioperative complications. We concluded that aPNL resulted in a higher SFR for staghorn calculi, and required fewer multiple percutaneous tracts, reduced the need for staged surgery, and had a shorter operative time than PNL alone, especially for patients with 5 or more stone branches. Furthermore, aPNL did not increase the incidence of surgical complications.

Comparison of Two Centers' Experience in Pediatric Supine and Prone Miniaturized Percutaneous Nephrolithotomy with Propensity Match Analysis

Introduction: Percutaneous nephrolithotomy (PNL) is the treatment of choice in children with complex and large stones. With the experience gained from adult practice, supine PNL is increasingly performed in children as well. We aimed to evaluate the comparative results of prone and supine mini-PNL (m-PNL) performed for large/complex stones in children. Patients and Methods: The study included children who underwent supine and prone m-PNL at two centers between September 2019 and 2022. Patients were divided into two groups with a 1:1 ratio to index supine m-PNL and prone m-PNL cases for the size, number, location of the stones, degree of hydronephrosis, and age. Operative related parameters, success, and complication rates are being discussed on a procedure-based manner. Results: Forty-two patients (21 supine and 21 prone) were included. The mean age was 9.6 ± 4 years and mean stone size was 28.8 ± 13.6 mm. Regarding the operative data, the mean duration of procedure time was 65.7 ± 17.8 minutes in supine group, whereas 86.9 ± 19.0 minutes in prone group (p = 0.001). Fluoroscopy time was shorter in supine group (p = 0.027). Tubeless PNL was performed in 11 cases of prone group (52%), whereas this number was 18 (86.7%) in supine group (p = 0.019). Stone-free rates were similar in both groups (supine m-PNL: 90.5%, prone m-PNL: 85.7%, p = 0.634). Complications were minor in nature in most of the cases of both groups, which resolved with supportive measures in a short period of time. However, there was a statistically significant difference regarding the location and number accesses between two groups (p = 0.008). Simultaneous flexible ureterorenoscopy was performed in eight patients in the supine PNL group (<0.001). Conclusions: Our current findings and the highly limited data reported in the literature indicate that as an established minimal invasive treatment alternative m-PNL procedure in supine position can also be performed with similar success and complication rates in pediatric population.

PCNL vs. two staged RIRS for kidney stones greater than 20 mm: systematic review, meta-analysis, and trial sequential analysis

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is considered the gold standard treatment for kidney stones greater than 20 mm. However, retrograde intrarenal surgery (RIRS) may achieve the same stone-free rate with repeated procedures, and potentially fewer complications. This study aimed to compare the efficacy and safety of PCNL and two-staged RIRS.

EVIDENCE ACQUISITION

We conducted a systematic search in PubMed, Embase, Scopus, Cochrane, and Web of Science for studies comparing PCNL and RIRS for kidney stones greater than 20mm. The primary outcome is stone-free rate (SFR) of PCNL and RIRS (repeated once if needed). Secondary outcomes were SFR of PCNL versus RIRS (single procedure), operative time, hospital stay, need for auxiliary procedures, and complications. We performed a subgroup analysis for randomized trials, non-randomized trials, and patients with solitary kidney. We performed a trial sequential analysis for the main outcome.

EVIDENCE SYNTHESIS

We included 31 articles, with 1987 patients in the PCNL and 1724 patients in RIRS. We confirmed the traditional result that after a single procedure PCNL has a higher SFR. We also found that comparing the SFR of PCNL and RIRS, repeated up to two times if needed, no difference in SFR was observed. Surprisingly, only 26% (CI95 23%-28%) of the patients required a second RIRS. In the trial sequential analysis, the last point of the z-curve was within futility borders. We observed that PCNL has a higher incidence of complications (RR=1.51; CI95 1.24, 1.83; P<0.0001; I2=28%), specifically CD2 (RR=1.82; CI95 1.30, 2.54; P=0.0004; I2=26%) and longer hospital stay (MD 2.57; 2.18, 2.96; P<0.00001; I2-98%). No difference was observed regarding operative time.

CONCLUSIONS

RIRS repeated up to two times is equivalent to PCNL in terms of the SFR and may have the same safety.

Percutaneous nephrolithotomy guided by 5G-powered robot-assisted teleultrasound diagnosis system: first clinical experience with a novel tele-assistance approach (IDEAL stage 1)

BACKGROUND

To demonstrate the technical feasibility of percutaneous nephrolithotomy (PCNL) guided by 5G-powered robot-assisted teleultrasound diagnosis system (RTDS) in a complex kidney-stone (CKS) cohort and present our preliminary outcomes. PCNL is highly skill-required, which hinders it popularization in primary medical units of remote regions. We designed an innovative tele-assistance approach to make PCNL easy to be operated by inexperienced surgeons.

METHODS

This was a prospective proof-of-concept study (IDEAL phase 1) on intraoperative tele-assistance provided by online urological experts via a 5G-powered RTDS. Total 15 CKS patients accepted this technology. Online experts manipulated a simulated probe to assist unskilled local operators by driving a patient-side robot-probe to guide and monitor the steps of access establishment and finding residual stones.

RESULTS

Median total delay was 177ms despite one-way network-connecting distance > 5,800 km. No perceptible delay of audio-visual communication, driving robot-arm or dynamic ultrasound images was fed back. Successful tele-assistance was obtained in all cases. The first-puncture access-success rate was 78.6% with a one-session SF rate of 71.3% and without complications of grade III-V.

CONCLUSIONS

The current technology based on 5G-powered RTDS can provide high-quality intraoperative tele-assistance, which has preliminarily shown satisfactory outcomes and reliable safety. It will break down a personal competence-based barrier to endow PCNL with more popular utilization.

TRIAL REGISTRATION

The study was approved by ethics committee of the Xinjiang Kezhou People's Hospital and ethics committee of the First Affiliated Hospital of Nanjing Medical University and was registered on http://www.chictr.org.cn (ChiCTR2200065849, 16/11/2022).

Percutaneous nephrolithotomy non-papillary puncture trends. A review of the literature

Percutaneous nephrolithotomy (PCNL) is the gold standard of treatment for large renal calculi. Papillary puncture is the mainstay of treatment for large renal calculi, but the non-papillary has been introduced and gained some interest. The aim of this study is the investigation of trends of non-papillary access for PCNL over the years. A review of the literature took place and 13 publications were included in the study. Two experimental studies investigating the feasibility of non-papillary access were found. Five cohort prospective and 2 retrospective studies for non-papillary access and 4 comparative studies between papillary and non-papillary access were included. Non papillary access is a technique that has been proved as a safe and efficient solution that keeps up with the latest endoscopic trends. A wider use of this method could be expected in the future.

Gel Rolls Increase Percutaneous Nephrolithotomy Radiation Exposure

Introduction: Despite increasing interest in reducing radiation doses during endoscopic stone surgery, there is conflicting evidence as to whether percutaneous nephrolithotomy (PCNL) positioning (prone or supine) impacts radiation. We observed clinically that a patient placed prone on gel rolls had higher than expected radiation with intraoperative CT imaging and that gel rolls were visible on the coaxial imaging. We hypothesized that gel rolls directly increase radiation doses. Methods: Anthropomorphic experiments to simulate PCNL positions were performed using a robotic multiplanar fluoroscopy system (Artis Zeego Care+Clear, Siemens) and a 5-second coaxial imaging protocol (5s BODY). A fluoroscopy phantom was placed in various positions, including prone on a gel roll; prone on blankets of equal thickness; prone and supine directly on the table; and modified supine (MS) positions using a thin gel roll or rolled blanket. Impacts of C-arm direction and use of a 1 L saline bag were also evaluated. Measured dose area product (DAP) was compared for the groups. Results: Measured DAP was found to increase by 146 μGy*m2 (287%) when prone on gel rolls compared with only 62.29 (23%) when placed on blankets of equal thickness, although the model likely both overstates the relative impact and understates the absolute impact that would be seen clinically. Measured DAP between experimental groups also varied considerably despite fluoroscopy time being held constant. Conclusions: Our experiments support our hypothesis that gel rolls directly increase radiation dose, which has not been previously reported, using an anthropomorphic model. Surgeons should consider radiolucent materials for positioning to limit radiation exposure to patients and the surgical team.

Comparing Balloon Dilation to Non-Balloon Dilation for Access in Ultrasound-Guided Percutaneous Nephrolithotomy: A Systematic Review and Meta-Analysis

PURPOSE

This study aims to evaluate the safety and efficacy of ultrasound-guided balloon dilation compared to non-balloon dilation for percutaneous nephrolithotomy (PCNL).

MATERIALS AND METHODS

A systematic review and meta-analysis were conducted by searching PubMed, EMBASE, and the Cochrane Library. Results were filtered using predefined inclusion and exclusion criteria as described and meta-analysis was performed using Review Manager 5.4 software.

RESULTS

A total of six studies involving 1189 patients who underwent PCNL were included. The meta-analysis results demonstrated that compared to non-balloon dilation, balloon dilation was associated with reduced haemoglobin drop [mean difference (MD) = -0.26, 95% CI = -0.40 ~ -0.12, P = 0.0002], decreased transfusion rate [odds ratio (OR) = 0.47, 95% CI = 0.24 ~ 0.92, P = 0.03], shorter tract establishment time (MD = -1.30, 95% CI = -1.87 ~ -0.72, P < 0.0001) and shorter operation time (MD = -5.23, 95% CI = -10.19 ~ -0.27, P = 0.04).

CONCLUSIONS

Overall, ultrasound-guided balloon dilatation offered several advantages in PCNL procedures. It facilitated faster access establishment, as evidenced by shorter access creation time. Additionally, it reduced the risk of kidney injury by minimizing postoperative haemoglobin drop and decreasing the need for transfusions. Moreover, it enhanced the efficiency of surgery by reducing the operation time. However, it is important to note that the quality of some included studies was subpar, as they did not adequately control for confounding factors that may affect the outcomes. Therefore, further research is necessary to validate and strengthen these findings.

Single Specialty-Operated Renal Stone Removal: Initial Experience from 3 Interventional Radiology Centers

This retrospective analysis of the feasibility and safety of percutaneous renal stone removal using single-use flexible ureteroscopes was conducted at 3 academic centers. Twelve patients (58% men) underwent 14 percutaneous renal stone removal procedures between December 2021 and March 2023. All patients experienced symptom improvement and resolution of obstruction after stone removal. The procedural success rate was 92%. Only 1 patient required an additional stone removal procedure. No major adverse events occurred during or after the procedures. The percutaneous nephrostomy removal rate was 92%, with a median tube removal time of 5 weeks. The median procedural and pulsed fluoroscopy times were 106.5 and 16.3 minutes, respectively. Preliminary findings demonstrated that percutaneous renal stone removal using single-use endoscopes by interventional radiologists is feasible and safe.

Impact of Renal Access Angle and Speed of Nephroscope Retrieval Movements on the Vortex Effect

OBJECTIVE

To analyze the influence of different renal access angles (AAs) and nephroscope retrieval speeds on the efficacy of the vortex effect (VE) in mini-percutaneous nephrolithotomy (mini-PCNL). This study aimed to understand the poorly understood physical components of the VE.

MATERIALS AND METHODS

A Pexiglas™ (KUS®) model was built based on the dimensions of a 15/16 F mini-PCNL set (Karl Storz). The flow rate was continuous via an automatic pump and calibrated to achieve hydrodynamic equivalence to the real equipment. One experiment consisted of manually retrieving all 30 stone phantoms (3 mm diameter) utilizing only the VE. Cumulative time to retrieve all stones was measured. An accelerometer recorded instant speeds of the nephroscope every 0.08 seconds (s), and 3 experiments were performed at each angle (0°, 45°, and 90°). A logistic regression model was built utilizing maximum speeds and access angles to predict the effectiveness of the VE.

RESULTS

Mean cumulative time for complete stone retrieval was 28.1 seconds at 0° vs 116.5 seconds at 45° vs 101.4 seconds at 90° (P < .01). We noted significantly higher speeds at 0° compared to 45° and 90° (P < .01); however, differences in average and maximum speed between 45° and 90° were not statistically significant (P = .21 and P = .25, respectively). The regression model demonstrated a negative association between increasing maximum speed and VE's effectiveness (OR 0.547, CI 95% 0.350-0.855, P < .01). When controlling for maximum speed, the 0° angle had significantly higher chances of achieving at least a partially effective VE.

CONCLUSION

Increasing the renal access angle or nephroscope extraction speed negatively impacts the effectiveness of the VE. This significantly increased procedure time in the laboratory model, suggesting that the VE is less effective at higher sheath angles.

Models to predict the surgical outcome of mini-ECIRS (endoscopic combined intrarenal surgery) for renal and/or ureteral stones

To establish a safer and more efficient treatment strategy with mini-endoscopic combined intrarenal surgery (ECIRS), the present study aimed to develop models to predict the outcomes of mini-ECIRS in patients with renal and/or ureteral stones. We retrospectively analysed consecutive patients with renal and/or ureteral stones who underwent mini-ECIRS at three Japanese tertiary institutions. Final treatment outcome was evaluated by CT imaging at 1 month postoperatively and stone free (SF) was defined as completely no residual stone or residual stone fragments ≤ 2 mm. Three prognostic models (multiple logistic regression, classification tree analysis, and machine learning-based random forest) were developed to predict surgical outcomes using preoperative clinical factors. Clinical data from 1432 ECIRS were pooled from a database registered at three institutions, and 996 single sessions of mini-ECIRS were analysed in this study. The overall SF rate was 62.3%. The multiple logistic regression model consisted of stone burden (P < 0.001), number of involved calyces (P < 0.001), nephrostomy prior to mini-ECIRS (P = 0.091), and ECOG-PS (P = 0.110), wherein the area under the curve (AUC) was 70.7%. The classification tree analysis consisted of the number of involved calyces with an AUC of 61.7%. The random forest model showed that the top predictive variable was the number of calyces involved, with an AUC of 91.9%. Internal validation revealed that the AUCs for the multiple logistic regression model, classification tree analysis and random forest models were 70.4, 69.6 and 85.9%, respectively. The number of involved calyces, and a smaller stone burden implied a SF outcome. The machine learning-based model showed remarkably high accuracy and may be a promising tool for physicians and patients to obtain proper consent, avoid inefficient surgery, and decide preoperatively on the most efficient treatment strategies, including staged mini-ECIRS.

Retained foreign body post-PCNL: an unusual complication and endoscopic management

During this era of advanced and minimally invasive procedures for treating urolithiasis, percutaneous nephrolithotomy (PCNL) remains the primary choice for removing large renal calculi. While there are various known complications associated with PCNL, such as bleeding, sepsis and injury to neighboring organs, the occurrence of retained foreign bodies as a result of the procedure is rarely reported. In this case report, we present a unique instance of encrustation involving a retained guidewire sheath following PCNL, which was initially mistaken for a residual stone fragment in imaging studies. Fortunately, the foreign body was successfully removed using retrograde intrarenal surgery.

Application of image overlapping in percutaneous nephrolithotomy

OBJECTIVE

To investigate the application of ultrasound and CT image overlap in percutaneous nephrolithotomy (PCNL).

METHODS

A total of 140 patients with complicated kidney stones requiring PCNL were prospectively enrolled, from January 2020 to December 2022. These patients were randomly divided into 2 groups, with 70 patients each in the research group and the control group. All participants underwent dual-source, non-contrast CT scan of both kidneys and pelvis before surgery. Preoperative three-dimensional CT reconstruction and simulated puncture were performed in patients from the research group. The best puncture path was determined through ultrasound and CT image overlap. Puncture guided by regular CT and ultrasound was conducted in patients from the control group. Differences in the surgical outcomes between the two groups were compared.

RESULTS

Compared to the control group, the research group had higher stone clearance rate in stage I PCNL, success rate of one-time puncture, less percutaneous channels, less reduction of hemoglobin and shorter procedure time. Complications in stage I PCNL were comparable in the two groups, and there was no significant change in the final stone clearance rates between the two groups.

CONCLUSION

An optimal puncture channel can be chosen using ultrasound and CT image overlap. PCNL can be achieved with precise puncturing, thus achieving coincidence between imaging and anatomy and reducing the amount of blood loss during stage I of PCNL. It also shortens the procedure time and improves stone clearance rate of PCNL.

[The efficiency of totally tubeless percutaneous nephrolithotomy: analysis of 40 cases]

INTRODUCTION

Previously, the placement of a nephrostomy tube was considered standard practice during percutaneous nephrolithotomy (PCNL) to ensure repeat access and kidney assessment. However, some publications have shown that in certain cases, a totally tubeless approach may be a viable alternative, provided that PCNL is performed properly and safely.

AIM

To analyze the results and complications of totally tubeless PCNL.

MATERIALS AND METHODS

A retrospective analysis of 40 patients with renal stones who underwent totally tubeless PCNL using a single percutaneous access of 16 Ch or 26 Ch at the urology department of NUZ KB "RJD-Medicine", Krasnoyarsk, Russia, from September 2021 to March 2023, was carried out. Factors that could affect the efficiency and safety of PCNL were analyzed.

RESULTS

The mean duration of the procedure was 39.6 +/- 14.4 minutes. The average decrease in hemoglobin level was 5.9 +/- 5.5. Narcotic analgesics were used postoperatively in 17.5% (7) of patients. The mean length of stay was 4.7 +/- 1.1 days. Transient fever was observed in 4 (10%) cases. In one case, an exacerbation of chronic pyelonephritis developed. There were no cases of significant bleeding during the PCNL, and no patients required blood transfusion.

CONCLUSIONS

Our results confirm that totally tubeless PNL is a safe alternative to standard procedure and is not associated with an increased risk of early postoperative complications. This technique is efficient and safe for kidney stones and may be recommended for a select group of patients.

What is the safe and effective dilator number during access in PCNL? Three-shot dilation versus classical sequential Amplatz dilation

BACKGROUND

Although PCNL has been used for a long time to treat nephrolithiasis, there is still contradictory information concerning the use of the dilation method. In this study, we aimed to compare conventional sequential Amplatz dilatation (SAD) using ten dilators and a method using three dilators (12, 20, and 30 Fr), which we named "three-shot dilatation" (3SD), in terms of fluoroscopy time (FT), operation time, bleeding and stone-free rates.

METHODS

The study included patients who underwent PCNL with the SAD and 3SD methods. A different surgeon with extensive endourology experience applied each technique. One of the surgeons operated on the patients using the SAD method with ten dilators, and the other surgeon performed the operations using the 3SD method involving three Amplatz dilators (12, 20, and 30 Fr).

RESULTS

A total of 283 patients, 138 in the 3SD group and 145 in the SAD group, were included in the study. The mean age of the patients was 47.32 ± 13.71 years. There was no statistically significant difference between the two groups regarding preoperative characteristics (p > 0.05). The FTs of access 2, total access, and total operation were significantly shorter in the 3SD group (p = 0.0001). The decrease in hemoglobin was statistically significant in the 3SD group compared to the SAD group (p = 0.022), while the blood transfusion requirements of the groups were similar (p = 0.176). There was no statistically significant difference between the two groups regarding stone-free rates (p = 0.973). In four patients in the SAD group, re-access was necessary due to the loss of passage due to the guide wire slipping out of its place.

CONCLUSION

Intraoperative FT can be shortened using the described 3SD method without compromising surgical safety. However, this method can be used as an intermediate step in the transition to one-shot dilation by surgeons experienced in performing SAD.

A comparative study of flexible ureteroscopic lithotripsy for upper urinary tract stones in patients with prior urosepsis following emergency drainage via retrograde ureteral stent or percutaneous nephrostomy

BACKGROUND

Patients with urosepsis associated with upper urinary tract stones require further stone management after emergency drainage.

OBJECTIVE

To evaluate the safety and efficacy of elective flexible ureteroscopic lithotripsy (F-URSL) for upper urinary tract stones in patients with prior urosepsis who have undergone emergency drainage using retrograde ureteral stent(RUS) or percutaneous nephrostomy (PCN).

METHOD

Between January 2017 and December 2021, clinical data were collected for 102 patients who underwent elective F-URSL following emergency drainage for urosepsis caused by upper ureteral or renal stones. The patients were categorized into two groups based on the drainage method used: the RUS group and the PCN group. The collected data included patient demographics, stone parameters, infection recovery after emergency drainage, and clinical outcomes post F-URSL. Subsequently, the data underwent statistical analysis.

RESULTS

A total of 102 patients were included in the statistical analysis, with 58 (56.86%) in the RUS group and 44 (43.14%) in the PCN group. Among the patients, 84 (82.35%) were female and 18 (17.65%) were male, with an average age of 59.36 years. Positive urine cultures were observed in 71 (69.61%) patients. Successful drainage was achieved in all patients in both groups, and there were no significant differences in the time required for normalization of white blood cell count (WBC) and body temperature following drainage. Additionally, all patients underwent F-URSL successfully, and no statistically significant differences were observed between the two groups in terms of operative time, stone-free rates, postoperative fever, and postoperative hospital stay.

CONCLUSION

Both RUS and PCN have been established as effective approaches for managing urosepsis caused by upper urinary tract stones. Furthermore, the impact of these two drainage methods on the subsequent management of stones through elective F-URSL has shown consistent outcomes.

Risk factor analysis for infection and bleeding after lateral decubitus percutaneous nephrolithotomy

This study aimed to explore the risk factors for infection and bleeding after lateral decubitus percutaneous nephrolithotomy procedures to prevent their occurrence and improve surgical outcomes. A retrospective analysis was conducted on 356 patients who underwent lateral decubitus percutaneous nephrolithotomy for the treatment of kidney stones and upper ureteral stones from January 2015 to August 2022. Among them, 290 patients had complete clinical data. General clinical data, perioperative data, and stone characteristics were collected for each patient. Univariate and multivariate logistic regression analyses were performed to identify risk factors for infection and bleeding after lateral decubitus percutaneous nephrolithotomy. The postoperative infection rate after lateral decubitus percutaneous nephrolithotomy was 19.31%, and the postoperative bleeding rate was 12.07%. Independent risk factors for postoperative infection were multiple stones (P < .001), stone size (P < .001), and stone co-infection (P = .012). Independent risk factors for postoperative bleeding were multiple stones (P = .008) and stone size (P = .014). Multiple stones, stone size, and stone co-infection are independent risk factors for postoperative infection after lateral decubitus percutaneous nephrolithotomy. Multiple stones and stone size are independent risk factors for postoperative bleeding after lateral decubitus percutaneous nephrolithotomy.

A randomized controlled trial comparing infectious complications using mini perc with and without suction for renal stones less than 3 cm in size

The purpose was to do a study to compare infectious complications in patients operated for MiniPerc or Minimally invasive Percutaneous Nephrolithotomy (MPCNL) using MIP and MPCNL with suction using Shah Superperc sheath for medium-sized renal stones less than 3 cm in size. The primary objective of this study is to compare the infectious complications and the secondary objectives are to compare stone-free rates, complication rates and operative times. A prospective randomized controlled trial with patients having proximal ureteral and renal stones of 10-30 mm size and planned for MPCNL done at a single institute. A total of 80 consecutively admitted patients with written informed consent were included for randomization with 40 patients in each arm of MPCNL and suction MPCNL. The median age in MPCNL and suction MPCNL arms were 48 and 49 years, the median stone size of 15.45 and 16.7 cm, the Median stone volume of 1576.2 vs 1752 mm3, and the median stone density of 1258 and 1250 Hu, the median hospital stay of 3 days in both arms were comparable. Infectious complications were comparable in both arms. Operative time was significantly less in the suction MPCNL group (26.5 min-IQR 17-34.8) than in the MPCNL group (34.8 min-IQR 20-45), p = 0.021 and stone-free rates (SFR), were more in Suction MPCNL arm 97.5% than in MPCNL 87.5%, p = 0.04. Overall, the complication rates were comparable in both arms. Suction MPCNL procedure resulted in shorter operating times and more SFR than conventional MPCNL with comparable complication rates.

The Consecutive 200 Cases of Endoscopic-Combined Intrarenal Surgery: Comparison between Standard and Miniature Surgeries

Background and Objectives: Percutaneous nephrolithotomy (PCNL) is still the gold-standard treatment for large and/or complex renal stones. Endoscopic combined intrarenal surgery (ECIRS) was developed with the goal of minimizing the number of access tracts of PCNL while simultaneously improving the one-step stone-free rate (SFR). The aim of this study was to share the experience of the consecutive 200 cases of ECIRS in one institute and analyze surgical outcomes of mini-ECIRS and standard ECIRS. Materials and Methods: We performed ECIRS for 200 adult patients between July 2017 and January 2020. An ECIRS was performed with the patient under general anesthesia in the intermediate-supine position. Surgeries were finished using a tubeless technique with a simple ureteral stent insertion. Results: There were significant differences in the mean maximal stone length (MSL), the variation coefficient of stone density (VCSD), the linear calculus density (LCD), the Seoul National University Renal Stone Complexity (S-ReSC), and the modified S-ReSC scores in stone characteristics, and estimated blood loss (EBL) and operation time in peri-operative outcomes between conventional and mini-ECIRS. After propensity-score matching, there was only a difference in EBL between the two groups. In logistic regression models, MSL [odds ratio (OR) 0.953; 95% confidence interval (CI) 0.926-0.979; p < 0.001], LCD (OR 4.702; 95% CI 1.613-18.655; p = 0.013) were significant factors for the success rate after ECIRS. Conclusions: In patients who underwent a mini-ECIRS, the stones were relatively smaller and less complex, and the operation time was shorter. However, if the size of stones was similar, there was no difference in the success rate, but EBL was lower in mini-ECIRS than in standard surgery.

Evaluation of the safety and efficiency of color Doppler ultrasound-guided percutaneous nephrolithotomy in clinical practice: results from a retrospective study

This study evaluated the clinical value of color Doppler ultrasound-guided percutaneous nephrolithotomy (PCNL) in avoiding bleeding caused by punctured blood vessels. Herein, we retrospectively included patients who underwent color Doppler ultrasound-guided PCNL or PCNL using the conventional channel technique from August 2018 to August 2022. The clinical characteristics of patients during surgery, complications, and hospital stay were recorded and compared. Overall, 228 patients were enrolled, with 126 patients (age, 47.6 ± 13.2 years; men: 57.14%) in the color Doppler ultrasound-guided PCNL group and 102 patients (age, 46.6 ± 12.3 years) in the B-mode ultrasound-guided puncture group. The total operation time (63.5 ± 15.5 vs. 61.3 ± 16.3 min, p = .5236) and stone clearance rate (86.50% vs. 83.33%, p = .7139) were similar between the two groups. However, the puncture time for the color Doppler ultrasound-guided PCNL group was longer than that for the B-mode ultrasound-guided puncture group (5.1 ± 2.3 vs. 2.6 ± 1.6 min, p = .0019). Moreover, the length of postoperative hospital stay in the color Doppler ultrasound-guided PCNL group reduced significantly by ∼1 day compared with that in the B-mode ultrasound-guided puncture group (4.5 ± 1.6 vs. 5.6 ± 2.1 days, p = .0087). The blood transfusion rate (1.58% vs. 4.9%, p = .0399), sedation-related adverse event rate (0.79% vs. 2.9%, p = .0332), perineal hematoma incidence (0% vs. 2.94%, p < .0001), and serum decreased hemoglobin levels (12.2 ± 9.7 vs. 23.5 ± 10.1 g/L, p < .001) after color Doppler ultrasound-guided PCNL were significantly lower than those after B-mode ultrasound-guided puncture. The stone clearance rate was similar between the two groups, with a similar operation time. Moreover, color Doppler ultrasound-guided PCNL shortened the postoperative hospital stay and decreased Hb levels, blood transfusion rate, and perineal hematoma incidence.

2022 Recommendations of the AFU Lithiasis Committee: Combined approach for the management of kidney and ureteral stones (Endoscopic Combined IntraRenal Surgery, ECIRS)

The primary objective of the combined approach is to limit the number of percutaneous access tracts for the treatment of staghorn, or complex kidney stones by simultaneous percutaneous antegrade and retrograde ureteroscopy. The other indication is the simultaneous presence of several kidney and ureteral stones or of an impacted pelvic stone. The combination of the two techniques may increase the stone-free rate and decrease the retreatment rate of complex stones compared with percutaneous nephrolithotomy alone. The patient is usually in the modified supine position. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and their adaptability to the French context.

Percutaneous nephrostomy catheter-related infections in patients with gynaecological cancers: a multidisciplinary algorithmic approach

BACKGROUND

Percutaneous nephrostomy catheters (PCNs) are commonly utilized in patients with gynaecological cancers due to intrinsic or extrinsic urinary obstruction. Unfortunately, these foreign medical devices may be associated with several infectious complications, including: pyelonephritis, renal abscess, and bacteraemia, which may lead to further delay of life-saving cancer therapy.

AIM

To evaluate the performance of our multidisciplinary algorithm for diagnosis and treatment of PCN-related infections (PCNIs) and identify risk factors for recurrent urinary device-related infections.

METHODS

Patients with gynaecological cancers having PCNIs were prospectively evaluated at our institution from July 2019 to September 2021. All patients were managed by our standardized algorithm and followed-up until reinfection or routine PCN exchange.

FINDINGS

Of 100 consecutive patients with PCNIs, 74 had adequate follow-up, and were analysed in three groups according to clinical outcome: reinfection with the same organism (26%), reinfection with a different organism (23%), and no reinfection (51%). Their median age was 54 years, and the most common cancers were cervical (65%), and ovarian (19%) with 53% being metastatic. The most frequently recovered micro-organisms were Pseudomonas (32%), Enterococcus (27%), and Escherichia (24%) species. The main risk factors for recurrent PCNI with the same organism were pelvic radiation therapy (P=0.032), pelvic fistulas (P=0.014), and a PCNI with the same pathogen within the previous year (P = 0.012).

CONCLUSIONS

Our algorithm has allowed for accurate diagnosis, staging, and treatment of and identification of several key risk factors for recurrent PCNIs. These results may lead to further preventive measures for these infections.

Endoscopic dilation using two guidewires: a novel approach for establishing access tract during percutaneous nephrolithotomy under ultrasonographic guidance

OBJECTIVE

To evaluate the efficacy and safety of a novel endoscopic dilation (END) method during percutaneous nephrolithotomy under ultrasonographic guidance.

METHODS

We retrospectively reviewed the clinical records of 138 patients who underwent percutaneous nephrolithotomy from June 2020 to December 2021. The patients were divided into three groups based on the method of nephrostomy tract creation: those who underwent fascial Amplatz serial fascial dilation (AMD) (n = 45), one-shot dilation (OSD) (n = 45), and END (n = 48). For END, a 20-Fr dilator with sheath was accessed over the first guidewire. A second guidewire was inserted into the collecting system via the endoscope. The nephroscope was then accessed to enlarge the renal puncture point using both guidewires. Demographic variables and important intraoperative and postoperative findings were compared among the three groups.

RESULTS

The preoperative characteristics were similar among the three groups. The END group had a significantly shorter access time than both the AMD and OSD groups and significantly less severe hemoglobin loss than the OSD group. There were no significant differences in the other important perioperative findings.

CONCLUSION

Use of this novel END method with two guidewires may be associated with less blood loss and a reduced access time.

Concurrent two surgeon approach for bilateral synchronous percutaneous nephrolithotomy: Initial experience at a University Teaching Hospital

Percutaneous nephrolithotomy (PNL) has long been considered the bench-mark intervention for complicated urinary stones and has undergone important advancements since it was first described. Given the proven safety and efficacy of PNL, simultaneous bilateral PNL has been attempted for bilateral renal calculi to cut down on total procedure costs. To further cut down on operative time, concurrent bilateral synchronous PNL (BS-PNL) has been performed involving two surgeons, each operating concurrently on one renal unit. We performed a retrospective study to evaluate the safety and efficacy of BS-PNL in patients who consented for the procedure. Mean operative time taken from percutaneous access to skin closure was 78 min which was lower than that taken during the single surgeon approach for simultaneous bilateral PNL. Two (12%) out of 16 renal units required multiple punctures for stone clearance. Sheath size varied between 26Fr to 30Fr depending on the stone burden. Mean duration of hospital stay was 2 days. Fourteen (88%) out of 16 renal units had complete stone clearance. Fifteen (94%) out of 16 renal units had a double J stent placed for drainage. Only two patients had complications in the form of postoperative fever. In the background of already proven safety and efficacy of SB-PNL, the concurrent two surgeon approach appears to be feasible and safe with additional advantage of reduced operative time. However, the number of patients in this series were limited and a bigger and preferably multi-institutional study would be required before we can come to a definitive conclusion.

2022 Recommendations of the AFU Lithiasis Committee: Percutaneous nephrolithotomy

Percutaneous nephrolithotomy (Labate et al.) is the standard procedure for the treatment of large (≥2cm) kidney stones. The patient can be in prone or modified supine position. The puncture is performed under fluoroscopy and/or ultrasound guidance. The stone-free rate seems to be comparable between miniaturized and standard PCNL. Procedures performed with smaller diameter instruments tend to be associated with significant lower blood loss, but longer procedure times. The limitation of the number of percutaneous tracts results in better preservation of the kidney function and lowers the risk of complications. The use of tranexamic acid during PCNL may be interesting for reducing the bleeding risk, the transfusion rate, and possibly the intervention duration. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU 2022]) and their adaptability to the French context.

Analysis of the Risk Factors for Massive Hemorrhage after PCNL in the Oblique Supine Position

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is a proven and efficient treatment method; Nevertheless, it is essential to note that there is still a risk of significant bleeding. The purpose of this paper is to explore the risk factors for massive hemorrhage after PCNL in the oblique supine position and provide a basis for the development of measures to prevent massive hemorrhage.

METHODS

The clinical data of 97 patients who underwent PCNL in the oblique supine position at Changshu No. 2 People's Hospital from January 2019 to December 2020 were retrospectively analyzed. Patients were placed in the massive hemorrhage group if their hemoglobin levels decreased by ≥20 g/L 24 h after the operation, and the other patients were placed in the nonmassive hemorrhage group. Differences in sex, age, body mass index (BMI), hypertension, diabetes, surgical side, perirenal fat stranding (PFS), calculus long diameter, surgical access, and operation time were compared between the two groups to determine the risk factors for massive bleeding. Multivariable logistic regression analysis was used to determine the risk factors for massive hemorrhage after PCNL.

RESULTS

There were no significant differences in sex, BMI, hypertension, diabetes, surgical side, or calculus long diameter between the two groups (p > 0.05), and there were statistically significant differences in age, PFS, surgical access, and operation time (p < 0.05). Multivariate logistic regression analysis indicated that PFS and extensive surgical access were independent risk factors (p < 0.05).

CONCLUSIONS

PFS and extensive surgical access were independent risk factors. Carefully reading computed tomography (CT) films before surgery and reducing the size of the surgical access area are important measures for reducing the risk of massive hemorrhages.

Needle-perc-assisted endoscopic surgery (NAES) for patients with complicated solitary kidney stones: a prospective randomized study from a single center

PURPOSE

The goal of this study is to compare traditional percutaneous nephrolithotomy (PCNL) and needle-perc-assisted endoscopic surgery (NAES) in the treatment of complicated solitary kidney stones via a single-center randomized controlled prospective study.

METHODS

A total of patients with complex (Guy's score II-IV) solitary kidney stones between July 2019 to June 2022 were enrolled in the study. Participants were stratified into two groups: needle-perc-assisted endoscopic surgery group (group A) and traditional PCNL group (group B). All procedures were finished by X-ray free technique. The clinical characteristics and outcomes were analyzed.

RESULTS

A total of 90 (44 in Group A and 46 in Group B) patients were finally included in our study. There were no statistically differences in terms of gender, age, body mass index (BMI), stone burden between two groups. The mean operative duration of Group A was significant higher than group B (95.1 ± 21.4 min vs 72.5 ± 29.5 min, p=0.02). The 1-month stone-free rate (SFR) was significant higher in Group A than B (90.9% vs 73.9%, p=0.03). A less hemoglobin drop (p=0.01), shorter postoperative in-hospital day (p=0.04), and lower severe complication (Clavien-Dindo III and above) rates (p=0.03) were observed in Group A.

CONCLUSION

For patients with solitary kidney stones, NAES technique provides a higher one-session SFR, a better renal function recovery and compared with traditional PCNL.

Modified biplanar (0-90°) endoscopic-guided puncture technique for percutaneous nephrolithtomy: refinement with endoscopic combined intrarrenal surgery to reduce fluoroscopy and operative time

INTRODUCTION

We aim to publish our innovative modified biplanar 0-90 endoscopic guided puncture technique for percutaneous nephrolithotomy in supine recorded with a GoPro® camera for standardization of the technique. It solves drawbacks of the fluoroscopic technique, i.e., in kidneys with complex anatomy, it may be challenging to distinguish calyces as they are often superposed, and it does not allow for all benefits of a combined endoscopic approach (1, 2). Our technique shortens puncture and fluoroscopic time and is easy to teach and reproduce.

METHODS

A 77-year-old female patient had previous double J insertion due to an obstructing stone in the right distal ureter. She managed to pass the distal stone but remained with the double J and a 20mm stone (1300HU) in the right renal pelvis. The shared decision was for the actual standard of care (3, 4) endoscopic combined intrarenal surgery (ECIRS). The MiniECIRS started with flexible ureteroscopy and a posterior calix which gave direct access to the stone was chosen. The tip of the flexible scope was used to mark point A with the C-arm in the 0-degree position and line B in the 90-degree position. Puncture was fast and the MiniECIRS was uneventful with a single mid-pole access guided by the flexible scope. The surgeon had a Full-HD GoPro® camera mounted on his head, controlled by the surgical staff. All essential surgical steps were recorded.

RESULTS

The quality of the recorded movie was graded as excellent, and the camera did not cause any discomfort to the surgeon. Operative and X-Ray time were 120minutes and 2minutes (7.64mGy). Hemoglobin drop was 0.8g/dL. The post-operative day-1 computed tomography scan was stone-free. The patient was discharged 24h after surgery. Kidney stent was left with a string and removed after 5days. The patient remained asymptomatic and metabolic evaluation revealed a calcium oxalate stone, low urinary volume and hypocitraturia which were treated with potassium citrate and hydration.

CONCLUSION

The Modified Biplanar (0-90 degree) Endoscopic-Guided Puncture Technique for Percutaneous Nephrolithotomy joins the reproducibility of the same technique under fluoroscopy with advantages regarding safety and efficiency of ECIRS.

A comparative analysis of the efficacy and safety of mini-percutaneous nephrolithotomy performed in the supine and prone positions for the treatment of pediatric kidney stones: a single-center experience

Mini-percutaneous nephrolithotomy (MPCNL), which has a smaller tract size (14-20 Fr) than conventional percutaneous nephrolithotomy, has been shown to be safe and effective in pediatric patients with large and complex upper urinary tract stones. This study aimed to compare the efficacy and safety of MPCNL between the supine and prone positions in a pediatric population. The data of pediatric patients who underwent MPCNL at our center between January 2010 and March 2023 were retrospectively analyzed. According to the surgical position, the patients were divided into the prone (Group P) and supine (Group S) groups. In both groups, dilatation was performed using 14-18 Fr metallic dilators. The two groups were compared in terms of perioperative data, postoperative stone-free rates (SFRs), and complications. There were 36 (59%) patients in Group P and 25 (41%) patients in Group S. Stones were mostly located in the pelvis (49.2%) and second most frequently in the lower pole (27.9%). Fluoroscopy time was shorter in Group S but did not statistically significantly differ compared to Group P (p = 0.181). However, operation time was statistically significantly shorter in Group S (73.8 ± 35 vs. 99.8 ± 37.4 min, p = 0.008). Although there was no significant difference, relatively higher SFR were detected in Group S (88% vs. 83%, p = 0.725). Endoscopic combined intrarenal surgery (ECIRS) was performed on six (24%) patients in Group S, and the SFR was 100% among these patients. There was no significant difference between the two groups in terms of the presence of complications (16.7% vs. 16%, p = 0.945). Both supine and prone MPCNL appear to be safe and effective in the pediatric age group, with similar stone-free and complication rates. In the supine procedure, the operation time is shortened compared to the prone. In addition, simultaneous retrograde access has the potential to increase the overall success rate of surgery.

Comparison of endoscopic versus CT assessment of stone-free status after percutaneous nephrolithotomy (PCNL)

This study is aimed to determine whether postoperative low dose computed tomography (LDCT) imaging is necessary after percutaneous nephrolithotomy (PCNL), or the surgeon's intraoperative assessment of residual fragments (RF) is sufficient and avoidance of postoperative imaging with reduction of radiation exposure can be achieved. Data of all 610 patients who underwent PCNL in prone position in our institution from February 2009 to September 2020 was collected. Parameters such as age, gender, BMI, ASA-Classification, stone related parameters and the surgeon's assessment of stone-free status were analyzed. The LDCT performed postoperatively was compared to the intraoperative assessment of the surgeon regarding RF. The mean age of patients was 52.82 years; the mean BMI was 28.18 kg/m2. In 418 cases, the surgeon made a clear statement about the presence of RF and postoperative LDCT was carried out. The discrepancy between the two methods (surgeon´s assessment vs. LDCT) was significant at p < 0.0001. The sensitivity, specificity, positive and negative predictive value of the surgeon when assessing RF were 24.05%, 99.45%, 98.28% and 50%. Stone free rate (SFR) after primary PCNL was 45.57%. The overall SFR at discharge was 96.23%. Although the surgeon´s assessment of RF was reliable, postoperative LDCT imaging should still be performed if endoscopic stone clearance is suspected due to the high false negative rate and the low negative predictive value. The optimal timing of postoperative imaging following PCNL remains unclear.

Interdisciplinary planning improves radiologist obtained access for percutaneous nephrolithotomy

INTRODUCTION

Proper antegrade access for percutaneous nephrolithotomy (PCNL) is essential for success but can be challenging. Previous work evaluating access obtained by interventional radiology (IR), largely in the emergent setting, has shown high rates of additional access at the time of PCNL. We hypothesize that efforts to improve pre-procedural communication between urology and IR can impact the utility of the access for subsequent PCNL.

MATERIAL AND METHODS

We conducted a retrospective review of patients undergoing PCNL at a single hospital from January 2011 to December 2022. Adult patients undergoing PCNL with established preoperative access were included.

RESULTS

A total of 141 cases were identified with preoperative access. A total of 111 patients had evidence of planning with IR prior to antegrade access. There were high rates of anatomic abnormality (50%) and staghorn calculus (53%). Patients with planned access had higher body mass index (BMI). While preoperative access was initially utilized in 97% of cases, 6% required additional access to be obtained intraoperatively; this included a low rate of new access in those that were previously discussed with IR (4% vs. 17%, p = 0.02). Overall stone free rates (91%), rates of second stage procedures (55%) and complications (14%) were similar between planned and unplanned groups.

CONCLUSION

In this retrospective study of complex patients with large stone burden presenting for PCNL with preoperative antegrade access obtained by IR, the rate of new access was far lower than prior reports. This was likely influenced by urologist involvement in planning access.

Percutaneous Nephrostomy in Neonates and Young Infants

PURPOSE

To describe a single-center experience of placing percutaneous nephrostomy (PCN) tubes in neonates and young infants aged ≤3 months.

MATERIALS AND METHODS

This retrospective study evaluated PCN placement during a 19-year period. Medical records were reviewed for patient demographics, indications, procedure details, catheter-related adverse events, and outcomes. A total of 45 primary PCN insertions were attempted in 29 children (median age, 11 days [range, first day of life to 3 months]; median weight, 3.5 kg [range, 1.4-7.0 kg]). Salvage procedures resulted in 13 secondary catheters in 6 children. The most common indication was ureteropelvic junction obstruction (40.0%), and the most common urinary tract dilation classification was P3 (88.9%).

RESULTS

Technical success for primary placements was 95.6%; both technical failures were due to loss of access in the same patient. Of primary placements, 76.7% were electively removed, 6.9% were dislodged but not replaced, and the remaining 16.3% required salvage procedures. Mechanical adverse events occurred in 20.9% of primary and 53.8% of secondary catheters, including partial retraction, complete dislodgement, and occlusion. Urinary tract infections (UTIs) occurred in 18.6% of primary and 15.4% of secondary catheters. Urosepsis occurred in 2.3% of primary and 7.7% of secondary catheters. Median primary catheter dwell time was 41 days (range, 1-182 days) and median secondary catheter dwell time was 31 days (range, 10-107 days).

CONCLUSION

PCN placement in neonates and young infants has a high technical success rate, although not without particular procedural and management challenges of catheter malfunction and UTI.

Comparison of hemodynamic and respiratory outcomes between two surgical positions for percutaneous nephrolithotomy: a prospective, randomized clinical trial

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) has become the gold standard for the treatment of large and complex kidney stones.

OBJECTIVES

The objective of this study is to evaluate the efficacy and safety of percutaneous nephrolithotomy (PCNL) for patients in the flank position versus prone position.

METHODS

In our prospective randomized trial, 60 patients who would undergo fluoroscopy and ultrasound-guided PCNL in prone or flank position were divided into two groups. Demographic features, hemodynamics, respiratory and metabolic parameters, postoperative pain scores, analgesic requirements, amount of fluid given, blood loss and transfusion, duration of operation and hospital stay, and perioperative complications were compared.

RESULTS

PaO2, SaO2, SpO2 and Oxygen Reserve İndex (ORi) at the 60th minute of the operation and in the postoperative period, Pleth Variability index (PVi) at the 60th minute of the operation, driving pressure in all time periods and the amount of bleeding during the operation were determined to be statistically significantly higher in the prone group. There was no difference between the groups in terms of other parameters. Was found to be statistically significantly higher in the prone group.

CONCLUSIONS

Due to our results the flank position can be preferred in PCNL operations, considering that the position should be chosen according to the surgeon's experience, the patient's anatomical and physiological data, positive effects on respiratory parameters and bleeding, and the operation time can be shortened as the experience increases.

Stone clearance and complication rate of micro percutaneous nephrolithotomy and retrograde intrarenal surgery for lower pole renal stone: A randomized trial

Background

The use of unhealthy food and a sedentary lifestyle increases daily health problems. Renal stones are one among others. Endourology promises the minimum complications and the highest stone clearance rate. Indications of the two procedures overlap micro-PCNL and RIRS. The objective was to evaluate stone clearance and complication rate of micro-PCNL and RIRS for lower pole renal stones.

Methods

The research design of this study was a randomized trial and was done after approval of the ethical review committee. The sampling technique was consecutive sampling at the Urology department. Patients included in the study according to inclusion criteria were 96 in number. Randomization into two groups (RIRS vs micro-PCNL) was done by even odd method. All the procedure was done by a single senior urologist.

Results

Their ratio among males and females was 2:1. Mean LOS in the RIRS group was 2.89±0.86 days and in the micro-PCNL group 2.58±0.65 days (p=0.047). The complication rate in the RIRS group was 6.2% and 8.3% in micro-PCNL (p=0.695). Mean post-operative haemoglobin was 12.30±1.07 g/dL among the RIRS group and among the micro-PCNL group it was 11.21±1.08 g/dL (p<0.001). There was an average haemoglobin drop in the micro-PCNL group of 1.09±0.01 g/dL. 75% clearance of stone after one session was achieved in the RIRS group while 79.2% was achieved in the micro-PCNL group (p=0.627).

Conclusion

Length of hospital stay (LOS) and stone clearance rate (SFR) were similar in both groups with insignificant statistical differences. There is a need to conduct more studies with a large number of study participants and involving multi-centers.

Chinese mini percutaneous nephrolithotomy for upper urinary calculi under local infiltration anesthesia

Percutaneous nephrolithotomy is generally performed under general or regional anesthesia; however, it is rarely performed under local infiltration anesthesia (LIA). This study aimed to assess the safety and effectiveness of Chinese mini percutaneous nephrolithotomy (MPCNL) for upper urinary calculi under LIA. A retrospective analysis of 52 patients with upper urinary stones who underwent MPCNL under LIA from April 2019 to May 2022 was performed. Pethidine and Phenergan were intramuscularly injected 30 minutes preoperatively. Oxybuprocaine hydrochloride gel was applied to the urethra for lubricating and mucosal anesthesia. Ropivacaine hydrochloride and lidocaine were injected into the whole percutaneous channel for local anesthesia. An 8/9.8F ureteroscope and an 18F vacuum-assisted access sheath were applied in MPCNL. All 52 patients tolerated procedures and underwent operations successfully; none of them converted the anesthesia method or required additional analgesia. The mean visual analogue scale scores intraoperatively and at 6 hours, 24 hours, and 48 hours after surgery were 3.25 ± 0.52, 3.13 ± 0.69, 2.25 ± 0.56, and 1.58 ± 0.50, respectively. The stone free rate was 84.6%. Complications were seen in 6 (11.5%) patients, including fever in 2 patients (Clavien I), renal colic in 1 patient (Clavien I), clinically insignificant bleeding in 2 patients (Clavien I), and urinary tract infection in 1 patient (Clavien II). No severe complications were observed in any patients. Chinese MPCNL under LIA was a feasible option and achieved good outcomes in appropriately selected patients, and it may become the routine procedure for general patients.