Abstract
PurposeTo evaluate the balance between existing evidence and expert opinions on the safety and efficacy of new technological improvements in lithotripsy techniques for percutaneous nephrolithotomy (PCNL).MethodsA scoping review approach was applied to search literature in Pubmed, Embase, and Web of Science. Consensus by key opinion leaders was reached at a 2-day meeting entitled “Consultation on Kidney Stones: Aspects of Intracorporeal Lithotripsy” held in Copenhagen, Denmark, in September 2019.ResultsNew-generation dual-mode single-probe lithotripsy devices have shown favourable results compared with use of ballistic or ultrasonic lithotripters only. However, ballistic and ultrasonic lithotripters are also highly effective and safe and have been the backbone of PCNL for many years. Compared with standard PCNL, it seems that mini PCNL is associated with fewer bleeding complications and shorter hospital admissions, but also with longer operating room (OR) time and higher intrarenal pressure. Use of laser lithotripsy combined with suction in mini PCNL is a promising alternative that may improve such PCNL by shortening OR times. Furthermore, supine PCNL is a good alternative, especially in cases with complex renal stones and large proximal ureteric stones; in addition, it facilitates endoscopic combined intrarenal surgery (ECIRS).ConclusionRecent technological improvements in PCNL techniques are promising, but there is a lack of high-level evidence on safety and efficacy. Different techniques suit different types of stones and patients. The evolution of diverse methods has given urologists the possibility of a personalized stone approach, in other words, the right approach for the right patient.
Highlights
Percutaneous nephrolithotomy (PCNL) was first described in 1976 by Fernström and Johansson as an operative technique for the removal of kidney stones through a percutaneous nephrostomy tract [1]
An randomized controlled trial (RCT) performed by Lehman et al compared a combined ultrasonic and ballistic lithotripter (Swiss Lithoclast® Master) with a standard ultrasonic lithotripter in PCNL [13], and the results demonstrated that the dual mode was faster for fragmentation of hard stones but slower for soft stones, and there was no difference in operating room (OR) time or stone-free rates (SFRs)
PCNL is not standardized in terms of technical considerations such as access tract size and devices used for stone disintegration
Summary
Percutaneous nephrolithotomy (PCNL) was first described in 1976 by Fernström and Johansson as an operative technique for the removal of kidney stones through a percutaneous nephrostomy tract [1]. Only two RCTs were included in that review, and those trials differed with regard to the tract sizes used and the type of stones treated [30, 31] In another RCT, Ganesamoni et al compared ballistic lithotripsy with laser lithotripsy in mini PCNL and found that the former approach created larger fragments and more stone migration, and required more stone retrieval, whereas the two approaches did not differ with respect to fragmentation time and SFR [32]. Differences in the techniques used, tract size, stone size and complexity, definitions of SFR, modality of defining SFR (US/KUB/CT) and the time point at which SFR is evaluated are often not reported in a uniform manner, which makes comparisons problematic From this perspective, evidence-based medicine (EBM) with regard to aspects of lithotripsy in PCNL will to a large extent have to rely on clinical expertise and patient’s preference, values, and expectations rather than on high-level scientific evidence (Fig. 1). These investigators found lower rates of postoperative fever in the supine group than in the prone group, which confirms data from the large CROES PCNL study [49]
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