Abstract
BackgroundRenal staghorn stones are challenging for urologists to ensure maximum stone clearance and minimal morbidity. Percutaneous nephrolithotomy (PCNL) has become the gold standard treatment for renal staghorn stones. To assess the safety and efficacy of a novel integrated rigid and flexible percutaneous nephroscope(Rigi-flex nephroscope) in PCNL for renal staghorn stones.We present our initial experience with this new technique.MethodsFrom March to July 2016, a prospective analysis of 3 patients with staghorn stones treated with Rigi-flex nephroscope in PCNLunder totally ultrasound guidance by paravertebral block (PVB) anesthesia was done. PCNL was performed with the rigid section of a 13-Fr Rigi-flex nephroscope firstly and the stones were disintegrated into fragments by holmium laser.Then the stones were removed by active flushout, followed by a search for residual stones in other inaccessible calyces with the flexible section. Finally, the residual stones were disintegrated into small fractions by holmium laser in situ or repositioned with a set of disposable retrieval baskets to pelvic or other accessible areas. The whole procedure was accomplished via only one nephrostomy tract. The operating time, stone-free rates (SFR), postoperative hemoglobin drop, complications, length of hospitalization, were recorded.ResultsThe operation time were 89, 62 and 45 min, respectively, the postoperative hemoglobin drop was 1, 0.8 and 0.9 mg/dl, respectively.The postoperative Kidney-Ureter-Bladder (KUB) radiograph of the three patients showed no residual fragment >3 mm. No patients needed blood transfusion and suffered significant complications. The length of hospitalization was 9, 6 and 4 days, respectively. No patient needed multiple tracts PCNL or staged auxiliary measures one month after the operation.ConclusionsThe application of Rigi-flex nephroscope in PCNL under ultrasound guidance for staghorn stones has its unique advantages as monotherapy with increasing procedural stone free rate (SFR) via single nephrostomy tract, hence there is less morbidity as it does not require additional tracts dilation and staged auxiliary procedures combination. However, SFR should also be evaluated at a longer follow-up, particularly for staghorn stone, further large-scale multicenter prospective clinical trial are needed to verify its feasibility.
Highlights
Renal staghorn stones are challenging for urologists to ensure maximum stone clearance and minimal morbidity
Most of staghorn stones were approached with Percutaneous nephrolithotomy (PCNL) primarily in accordance with existing techniques, but the large stone burden volume and scattered distribution in various parts of the pelvocalyceal system are challenging for most urologists to ensure maximum stone clearance and minimal morbidity.As a rigid endoscope, conventional nephroscope or semi-rigid ureteroscope can not access the renal calyces situated at an acute angle with the calyx of entry, which may increase needs of multiple tracts PCNL or staged auxiliary measures(PCNL or extracorporeal shock wave lithotripsy (ESWL) or Retrograde intrarenal surgery (RIRS) et al.)
It is necessary to explore a new concept and definition of PCNL.So we proposed that PCNL is redefined beyond a surgical technique as a new requirement for the operation procedure:P-Patient oriented, C-Cost efficient, NNew features, L-Less invasive
Summary
Renal staghorn stones are challenging for urologists to ensure maximum stone clearance and minimal morbidity. Percutaneous nephrolithotomy (PCNL) has become the gold standard treatment for large renal stones and currently is recommended for staghorn stones, as it has stone-free rate three times higher than extracorporeal shock wave lithotripsy (ESWL), along with lower morbidity, shorter length of hospital stayand operating time as well as faster return to work than open stone extraction surgery [1,2,3].Retrograde intrarenal surgery (RIRS) is becoming popular, due to the advances in flexible ureteroscope and holmium laser lithotripsy. Most of staghorn stones were approached with PCNL primarily in accordance with existing techniques, but the large stone burden volume and scattered distribution in various parts of the pelvocalyceal system are challenging for most urologists to ensure maximum stone clearance and minimal morbidity.As a rigid endoscope, conventional nephroscope or semi-rigid ureteroscope can not access the renal calyces situated at an acute angle with the calyx of entry, which may increase needs of multiple tracts PCNL or staged auxiliary measures(PCNL or ESWL or RIRS et al.). The preoperative decision of therapeutic schedule should be made to accurately balance cost-efficacy and safety
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