Endoscopic Combined Intrarenal Surgery Research Articles

Endoscopic combined intrarenal surgery without ureteral access sheath performed for renal stone after Cohen reimplantation

IntroductionEndoscopic combined intrarenal surgery after anti‐reflux operation is rarely performed.Case presentationA 37‐year‐old female was referred to our hospital for treatment of left renal stone. She underwent anti‐reflux surgery (Cohen reimplantation) for left vesicoureteral reflux at the age of 10 years. Computed tomography revealed a 17 × 11 mm left inferior calyceal calculus. The patient received retrograde double‐J stent insertion under radiographic guidance and underwent ultra‐mini endoscopic combined intrarenal surgery without ureteral access sheath. The patient was discharged on postoperative Day 5 with no postoperative complications. Postoperative cystography showed no recurrence of vesicoureteral reflux. One month after the operation, kidney–ureter‐bladder radiography and computed tomography scan revealed no residual stones or hydronephrosis.ConclusionUltra‐mini endoscopic combined intrarenal surgery without ureteral access sheath is an effective method for treating renal stones after Cohen reimplantation.

Effect of nephrostomy sheath size on renal pelvic pressure during endoscopic combined intrarenal surgery: artificial kidney model study

BackgroundThis study aimed to evaluate the intrarenal pelvic pressure in endoscopic combined intrarenal surgery using an artificial kidney model.MethodsAn artificial kidney model was created using the Urovac evacuator™. Four sizes of nephrostomy sheaths (MIP-L: 25/26 Fr, MIP-M: 16.5/17.5 Fr, MIP-S: 11/12 Fr, MIP-XS: 8.5/9.5 Fr) and two sizes of ureteral access sheaths (12/14 Fr and 10/12 Fr) were installed into the model. For each combination of nephrostomy and ureteral access sheath, renal pelvic pressure was measured with and without insertion of the retrograde flexible ureteroscope. Irrigation from the nephroscope was adjusted to 40–160 mmHg using an automatic irrigation device, and the irrigation of the ureteroscope was by spontaneous dripping at 80 cmH2O. Conditions were measured six times, and the renal pelvic pressure was compared in different conditions.ResultsWithout ureteroscope insertion through the ureteral access sheath, the renal pelvic pressure never exceeded 30 mmHg. Meanwhile, when the ureteroscope was inserted, the renal pelvic pressure increased as the nephrostomy sheath and ureteral access sheath became narrower and as the irrigation pressure increased. Intrarenal pelvic pressure exceeded 30 mmHg when the irrigation pressure was increased in 12/14 Fr ureteral access sheath when MIP-XS was used, and in 10/12 Fr ureteral access sheath when MIP-XS and MIP-S were used.ConclusionsThe use of a thin nephrostomy sheath in endoscopic combined intrarenal surgery can lead to increased intrarenal pelvic pressure. Although our results are from an artificial kidney model, special care is suggested to be required when using a retrograde flexible ureteroscope simultaneously in treatment of patients.

Mini Endoscopic Combined Intra-Renal Surgery (MiniECIRS) with endoview puncture in A 12 month boy. A safe but challenging procedure

Associating minipercutaneous nephrolithotomy and retrograde flexible ureteroscopy (fURS) is called Mini Endoscopic Combined Intra-Renal Surgery (miniECIRS). It's a safe and efficient technique, also in children. The video describes miniECIRS in a 12 month-old boy with an infectious pelvic left stone (16mm) and multiple caliceal stones. The UAS used was a 10FR and the percutaneous access was a 14Fr with Clear-Petra® sheath. The operative time was 180min and blood losses were virtually absent. There were no intra- or post-operative complications and the patient was discharged at the 5th day. After 1 month, double J was removed having a stone free status. MiniECIRS with endoview puncture is a safe and efficient technique when performed by experienced hands. Therefore, it is an alternative to consider for the treatment of complex lithiasis in the pediatric population.

Prone Split-Leg vs Galdakao-Modified Supine Valdivia Position During Endoscopic Combined Intrarenal Surgery: A Noninferiority Design Randomized Controlled Trial

Purpose: Endoscopic combined intrarenal surgery (ECIRS) combines percutaneous nephrolithotomy and ureteroscopy. This procedure has become common with the development of the prone split-leg (PRO) and Galdakao-modified supine Valdivia (GMSV) positions. In this study, we evaluated the surgical outcomes of these positions during ECIRS. Materials and Methods: A noninferior randomized controlled trial was performed in accordance with the Consolidated Standards of Reporting Trials. The eligibility criteria were age 20 to 80 years and presence of > 15-mm renal and/or ureteral stones. They were assigned to the PRO or GMSV groups and underwent ECIRS in the PRO or GMSV position, respectively. The primary outcome was stone-free rate (SFR) 3 months after surgery. The secondary outcomes were surgical outcomes—surgery time, percutaneous access time, and complication rate. A noninferiority margin of 30% was used. Results: Eighty-six patients (46 in the PRO group and 43 in the GMSV group) were analyzed. The SFR was 91.3% and 90.7% in the PRO and GMSV groups, respectively. No between-group differences were observed regarding the overall complication rates. Percutaneous access time was longer in the PRO group than in the GMSV group for upper calyx punctures, whereas surgery and percutaneous access times were shorter in the PRO group for those with a middle calyx puncture. Conclusions: Surgical position did not affect the success rates. There was no difference in complications between the groups, except for perinephric hematoma formation.

Nonpapillary Prone Endoscopic Combined Intrarenal Surgery (ECIRS): Five-Year Experience and Outcomes from a High-Volume Center.

Endoscopic combined intrarenal surgery (ECIRS) provides simultaneous retrograde and percutaneous access to the upper urinary tract. The purpose of this study is to present revised data, tips and tricks, and technique modifications arising from our five-year experience with ECIRS. The data of 62 patients who underwent nonpapillary prone ECIRS from January 2019 to November 2023 were prospectively collected. All cases were performed in the prone position. Inclusion criteria were complex stone cases with stones in multiple calyces requiring either multiple accesses or multiple sessions to achieve stone-free status. Patients' mean age was 54.4 ± 12.39 years, while the mean stone size was 39.03 ± 13.93 mm. The mean operative time was 51.23 ± 17.75 min. Primary and final stone-free rates were 83.8% and 90.3%, respectively. In total, nine patients presented with postoperative complications, which were all Grade II ones. The holmium-YAG laser type during retrograde lithotripsy was associated with significantly shorter operative times compared to the thulium fiber laser. Nonpapillary prone ECIRS is a feasible, safe, and efficient approach for patients with specific stone and anatomy characteristics. The implementation of more, higher-evidence studies is of utmost importance so that safer conclusions can be drawn.

Endoscopic combined intrarenal surgery composed of micro-perc and retrograde intrarenal surgery in the treatment of complex kidney stones in children.

This research aims to explore the efficiency and safety of endoscopic combined intrarenal surgery (Micro-ECIRS) composed of micro-percutaneous nephrolithotomy (Micro-perc) and retrograde intrarenal surgery (RIRS) in the Galdakao-modified supine Valdivia (GMSV) position for a single session for the treatment of complex nephrolithiasis in children. This study retrospectively reviewed patients aged < 18years who underwent Micro-ECIRS in the GMSV position for renal stones larger than 2cm under ultrasound guidance between August 2020 to May 2022 at our institution. A total of 13 patients (8 males and 5 females) received Micro-ECIRS for renal stones under ultrasound guidancewhile adopting the GMSV position. The average stone size was 2.7cm (range: 2.1-3.7cm). Among them, 6 patients had left kidney stones, 5 patients had right kidney stones, and 2 patients had bilateral kidney stones. The mean operative time was 70.5min (range: 54-93min). The mean hospital stay was 6.4days (range: 4-9days). The mean hemoglobin decrease was 8.2g/L (range: 5.1-12.4g/L). The total number of kidneys that had complete stone clearance was 8 kidneys at 48h postoperatively, 11 kidneys at 2weeks postoperatively, and 14 kidneys at 1month postoperatively. Our results demonstrate that Micro-ECIRS while patients are in the GMSV position is a safe and effective method for the treatment of complex children nephrolithiasis. However, all children made three hospital visits and received anesthesia three times. Further research is needed to confirm these findings.

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

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

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.

A new training model using the self-healing properties of supramolecular hydrogels for endoscopic combined intrarenal surgery.

The combination of hydronephrosis formation, ureteroscopic imaging, and ultrasound delineation has not been included in any non-biological training model of percutaneous nephrolithotomy or endoscopic combined intrarenal surgery. We aimed to develop a realistic kidney phantom using the self-healing properties of supramolecular hydrogels for percutaneous nephrolithotomy and endoscopic combined intrarenal surgery and evaluate its suitability as a training model.Expert and resident urologists performed ultrasound-guided renal pelvic punctures and flexible ureteroscopies for endoscopic combined intrarenal surgery using a training model. Subsequently, the training model was evaluated using a 17-item Likert scale questionnaire (range, 1-5 points). After being filled with carrageenan, the collecting system was inflated, and the relationship between the collecting system volume and collecting system pressure was determined. The durability of the model was verified by repeatedly inserting a 16-Fr access sheath. Five novices and seven urology experts performed the procedure. The mean questionnaire score was 4.25 (standard deviation, 0.37). The model was able to hold 50mL of air, and the pressure in the collecting system ranged from 6 to 33mmHg. Repeated punctures were possible even when a 16-Fr access sheath was inserted. Our new training model included the self-healing properties of supramolecular hydrogels, which are tough and flexible and can be evaluated using ultrasonography. According to the questionnaire score, the model was highly satisfactory and has potential as a new educational tool.

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.

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 ± 37.4min, 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.

Percutaneous nephrolithotomy in supine position with less than 24-hour hospital stay; a single-center experience

ABSTRACT Objectives To report our initial experience of day care percutaneous nephrolithotomy (PCNL) with early hospital discharge within less than 24 hours of the procedure. Patients and Methods The files of patients treated with PCNL between 1st January 2020 till 31st December 2022 were retrospectively reviewed. Day care PCNL was defined as the discharge of patients either on the same day or within 24 hours after surgery. Patient age, ASA score, body mass index, stone diameter, laterality, stone burden, Hounsfield unit, and Guy’s score were analyzed. Operative time, size of the access tract, method of lithotripsy, estimated blood loss, and length of hospital stay were also recorded. Postoperative complications were stratified according to the Dindo-Clavien classification. The primary outcome was to evaluate the feasibility and safety of early discharge within 24 hours after PCNL compared to the in-patients who were kept in hospital for at least 2 days after surgery. Results A total of 85 patients underwent PCNL at our center of whom 36 patients were discharged within 24 hours (day care PCNL) of the procedure and 49 patients were kept for at least 2 days (in-patient PCNL). In the day care group, median stone burden was 465 mm2 (360-980) and 18 patients (50%) had Guy’s stone score ≥ III. The median tract size was 24 (13-30) and endoscopic combined intrarenal surgery (ECIRS) was performed in 7 cases in the day care group. Tubeless PCNL was carried out in 88.8% of the day care surgery group compared to 37.5% in the in-patient group (p < 0.0001). The postoperative complication rate was comparable between both groups (13.8% vs 22.4% for day care vs in-patient group, respectively, p = 0.08). Conclusions Day care PCNL is feasible and safe for selected patients including those having large stone burden without increasing the risk of complications or readmission rate.

Combined endoscopic approaches in management of complicated forgotten double J stent: A case report

Forgotten Double J (DJ) ureteric stent with encrustation is a source of morbidity and unrequired admission. It is prevalent due to a lack of patient education and follow-up in third-world countries like Nepal. A case is reported of 30 years gentleman who had underwent right pyelolithotomy for large staghorn calculus and placement of DJ stent after surgery. The patient presented with encrusted, retained DJ stent which was managed with endoscopic combined intrarenal surgery with retrieval of the forgotten DJ stent.

Endoscopic management of encrusted ureteral stents: outcomes and tips and tricks.

To report our experience in the management of encrusted ureteral stents (EUS) and provide technical insight of our endourological approaches for difficult scenarios posed by this entity. A retrospective evaluation of a longitudinally collected database of 58 patients with encrusted US between December 2012 and May 2022 was performed. The ureteral stents were initially inserted due to obstructive uropathy, pyelonephritis or after a successful endoscopic procedure for urolithiasis. A combination of antegrade/retrograde treatment in single or multiple sessions took place for the retrieval of the encrusted stents. Non-contrast enhanced computer tomography was used for the follow-up of the patients at 1-month after the removal of the encrusted stent. Overall 58 patients, 39 males and 19 females with a median age of 51years old were included in the study. Indwelling time was < 6months, 6-12months and > 12months in 22%, 57% and 21% of the cases, respectively. All US were successfully removed. Semi-rigid ureteroscopy (URS) and flexible ureteroscopy (fURS) were used in 90% of the cases. In 10% of the cases, a second-stage percutaneous nephrolithotomy (PCNL) or endoscopic combined intrarenal surgery (ECIRS) was performed. All US were successfully released. Stone-free rate was 84% at 1-month. Overall complication rate was 10.5% (mostly postoperative fevers, 5.4%). Removal of the encrusted US is a challenging procedure. Appropriate decision-making and knowledge of specific tricks may result in safe and successful management of significant EUS.

MP23-17 COMPARISON OF INTRA PELVIC PRESSURE DEPENDED ON SUPINE AND PRONE POSITION IN ENDOSCOPIC COMBINED INTRARENAL SURGERY: EX-VIVO STUDY OF PORCINE KIDNEY

You have accessJournal of UrologyCME1 Apr 2023MP23-17 COMPARISON OF INTRA PELVIC PRESSURE DEPENDED ON SUPINE AND PRONE POSITION IN ENDOSCOPIC COMBINED INTRARENAL SURGERY: EX-VIVO STUDY OF PORCINE KIDNEY Takaaki Inoue, Satoshi Imai, Shimpei Yamashita, and Masato Fujisawa Takaaki InoueTakaaki Inoue More articles by this author , Satoshi ImaiSatoshi Imai More articles by this author , Shimpei YamashitaShimpei Yamashita More articles by this author , and Masato FujisawaMasato Fujisawa More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003248.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intra pelvic pressure (IPP) over than 30 mmHg during endourological procedures for upper urinary tract stones is regarded as risk factor of postoperative fever and sepsis. Although endoscopic combined intrarenal surgery (ECIRS) has been currently developing, there is no evidence regarding with IPP during ECIRS by supine or prone position. We aimed to measure and compare the dynamic change of IPP in supine and prone position during ECIRS by using porcine kidney. METHODS: We created the porcine kidney in which pressure sensor and 15/16F metal tract sheath were placed through renal capsule to renal collecting system, and the ureteral access sheath (UAS; 11/13F) was indwelled through the ureter. Prone position was defined as the tract was oriented upward at vertical position to the kidney. Supine position was defined as the tract was oriented downward at horizontal position to the kidney. 12F Nephroscope was inserted through metal tract with or without flexible ureteroscope (fURS) through UAS. Irrigation pressure of saline in nephroscope and fURS were controlled with the range of 40-160 mmHg and 80 cm H2O, respectively. On each position, we measured the dynamic change of IPP fifth times for 30 seconds in pure percutaneous nephrolithotomy (PCNL-group) with closed UAS, ECIRS with inserting fURS though UAS (fECIRS group), and ECIRS without fURS (non-fECIRS group) RESULTS: In any of three groups, IPP in supine position was significantly lower than in prone position (p<0.01). IPP in non-fECIRS group was significantly lower than in PCNL and fECIRS group in any position (p<0.01). In addition, irrigation volume excreted from tract sheath and UAS was significantly larger in non-fECIRS group (p<0.01). On the other hand, IPP in PCNL and fECIRS group almost changed equivalently. The threshold of antegrade irrigation pressure of saline which exceeds the 30mmHg IPP in PCNL and fECIRS group was 95mmHg under prone position, and 130mmHg under supine position. However, IPP in non-fECIRS group did not exceed over 30 mmHg IPP in any position (Figure 2). CONCLUSIONS: Supine position was lower IPP than prone position. Surprisingly, change of IPP in PCNL and fECIRS group demonstrated same dynamic state. Irrigation pressure might be required to set appropriately depending on kind of positions and procedures. Source of Funding: No © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e313 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Takaaki Inoue More articles by this author Satoshi Imai More articles by this author Shimpei Yamashita More articles by this author Masato Fujisawa More articles by this author Expand All Advertisement PDF downloadLoading ...

V02-04 MINI-PCNL FOR TRANSPLANT NEPHROLITHIASIS

You have accessJournal of UrologyCME1 Apr 2023V02-04 MINI-PCNL FOR TRANSPLANT NEPHROLITHIASIS Kavita Gupta, Kevin Liu Kot, Dima Raskolnikov, Charbel Chalouhy, and Alexander Small Kavita GuptaKavita Gupta More articles by this author , Kevin Liu KotKevin Liu Kot More articles by this author , Dima RaskolnikovDima Raskolnikov More articles by this author , Charbel ChalouhyCharbel Chalouhy More articles by this author , and Alexander SmallAlexander Small More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003232.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical management of transplant nephrolithiasis has many challenges. Technically, access to the kidney is limited by the neoureteral orifice, tortuous ureteral path and variable orientation of the kidney. We present a case of a 72-year old man with history of liver and kidney transplant 6 years prior who was found to have 1.9 cm and 0.9 cm stones in the transplant kidney. We demonstrate how endoscopic combined intrarenal surgery (ECIRS) and mini-percutaneous nephrolithotomy (mPCNL) can help improve stone clearance in transplant kidneys. METHODS: Percutaneous access to the kidney was previously obtained and a nephrostomy tube had been placed. In the operating room, the patient was positioned into lithotomy position. During cystoscopy, the transplant ureteral orifice in the right dome was accessed with an angled 0.038" hybrid wire. Retrograde pyelogram and nephrostogram showed an upside down lie of the kidney and a sharp angle at the ureteropelvic junction (UPJ). A 22 cm 12/14 Fr ureteral access sheath was placed up to the mid ureter and a flexible ureteroscope was passed into the kidney. There was sharp angulation at the UPJ which limited mobility of the scope. An impacted stone was visualized within the renal pelvis. Percutaneous access to the lower pole was established using the nephrostomy tube. Dilation was performed with an 18 Fr balloon and a sheath was placed. The Storz MIPS 12 Fr rigid nephroscope was placed into the field and the stones were visualized. Using the 200 um Holmium laser fiber, we fragmented the stones at a setting 1 J×20 Hz. The fragments were vortexed out and extracted with the nitinol basket. Simultaneously, retrograde ureteroscopy was used to ensure complete clearance of the stones. Additional stone fragments were encountered in the extreme lower pole below the sheath and further fragmented and extracted until stone-free. The scope was removed and a nephrostomy tube was placed. A 6 Fr×22 cm ureteral stent was advanced retrograde. A foley catheter was placed. RESULTS: Estimated blood loss was minimal. A CT abdomen and pelvis without contrast on post-operative day 1 showed no residual stone burden. The nephrostomy tube and foley catheter were removed, and the patient was discharged home. His ureteral stent was removed in the office one month later. The patient remained symptom free. CONCLUSIONS: Our video demonstrates the utility of ECIRS and mPCNL during transplant PCNL due to the complexity of the anatomy. In addition, ECIRS can improve stone clearance and overcome some of the challenges of transplant endoscopic surgery. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e169 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kavita Gupta More articles by this author Kevin Liu Kot More articles by this author Dima Raskolnikov More articles by this author Charbel Chalouhy More articles by this author Alexander Small More articles by this author Expand All Advertisement PDF downloadLoading ...

PD45-10 A MULTICENTER PROPENSITY SCORE MATCHED PAIR STUDY IN 313 PATIENTS COMPARING PERCUTANEOUS NEPHROLITHOTOMY VERSUS RETROGRADE INTRA RENAL SURGERY FOR MANAGEMENT OF UROLITHIASIS IN CALYCEAL DIVERTICULUM

You have accessJournal of UrologyCME1 Apr 2023PD45-10 A MULTICENTER PROPENSITY SCORE MATCHED PAIR STUDY IN 313 PATIENTS COMPARING PERCUTANEOUS NEPHROLITHOTOMY VERSUS RETROGRADE INTRA RENAL SURGERY FOR MANAGEMENT OF UROLITHIASIS IN CALYCEAL DIVERTICULUM Ee Jean Lim, Danielle Castellani, Olivier Traxer, Deepak Ragoori, Yiloren Tanidir, Bhaskar Kumar Somani, Khi Yung Fong, Mriganka Mani Sinha, Boyke Soebhali, Abhay Mahajan, Pankaj N Maheshwari, Nariman Gadjiev, Saeed Bin Hamri, Yakup Bostanci, Mehmet Ilker Gokce, Cemil Aydin, Innoue Takaki, and Vineet Gauhar Ee Jean LimEe Jean Lim More articles by this author , Danielle CastellaniDanielle Castellani More articles by this author , Olivier TraxerOlivier Traxer More articles by this author , Deepak RagooriDeepak Ragoori More articles by this author , Yiloren TanidirYiloren Tanidir More articles by this author , Bhaskar Kumar SomaniBhaskar Kumar Somani More articles by this author , Khi Yung FongKhi Yung Fong More articles by this author , Mriganka Mani SinhaMriganka Mani Sinha More articles by this author , Boyke SoebhaliBoyke Soebhali More articles by this author , Abhay MahajanAbhay Mahajan More articles by this author , Pankaj N MaheshwariPankaj N Maheshwari More articles by this author , Nariman GadjievNariman Gadjiev More articles by this author , Saeed Bin HamriSaeed Bin Hamri More articles by this author , Yakup BostanciYakup Bostanci More articles by this author , Mehmet Ilker GokceMehmet Ilker Gokce More articles by this author , Cemil AydinCemil Aydin More articles by this author , Innoue TakakiInnoue Takaki More articles by this author , and Vineet GauharVineet Gauhar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003358.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although calyceal diverticulum is commonly associated with stone formation, the majority of patients tend to be asymptomatic. Choice of management is chiefly based on stone location and mainly encompasses retrograde intrarenal surgery (RIRS) or Percutaneous nephrolithotomy (PCNL). We aimed to assess complications and outcomes of treatment via both approaches. METHODS: Retrospective data of 313 patients from 10 countries were evaluated for patient demographics, peri-operative parameters and outcomes using t-test for continuous normal variables and a Mann–Whitney U test for variables without normal distribution. Categorical data between groups were analysed using the chi-squared test. Propensity score-matching (PSM) was then performed matching for baseline characteristics of age, gender, stone type (single <1cm, single >1cm, or multiple), diverticulum location, and stone size classification.Two subgroup analyses for anomalous (malrotated) kidneys and difficult diverticulum access done. RESULTS: As a cohort, PCNL was the preferred choice for single stones of any size, malrotated kidneys. RIRS was preferred in recurrent stone formers with multiple stones. Access and mode of identification of the opening was similar for both groups. Irrespective of the route of contrast or methylene blue for delineation, guide wire coiling into the divert was equally and successfully utilized by both routes. Post intervention, there was significantly higher residual fragments (RF) (OR 0.12 95% CI 0.03 – 0.36,p<0.001) if no dilatation/widening of diverticulum mouth was performed. 15(8.1%) RIRS cases needed conversion to either PCNL or Endoscopic combined intrarenal surgery (ECIRS) for completion and only 6(4.7%) PCNL cases needed ECIRS.After PSM was applied, significantly more PCNL patients had transient intra-op bleeding but did not require additional surgery. Post operative bleeding, sepsis, perirenal collections and overall stone free rate was similar. On Multivariate analysis, using a Thulium ber laser(TFL) had a higher SFR(OR 3.43 95% CI 1.41 – 9.25, p=0.009) 74 patients had difficult diverticulum access where pain was the main presenting complaint. RIRS was preferred here especially in lower pole and had a signicantly higher SFR(78%, p=0.031). CONCLUSIONS: Our series is the first multicenter study to compare and contrast the utility of the two endourological approaches for renal diverticular urolithiasis. Traditionally, PCNL was the intervention of choice but currently RIRS seems to be equally effective and even preferred when the access particularly in lower pole is difficult. TFL laser complements the surgery and helps improve SFR. A key step is widening of the opening post intervention to minimize residual fragments. Source of Funding: NIL © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1166 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ee Jean Lim More articles by this author Danielle Castellani More articles by this author Olivier Traxer More articles by this author Deepak Ragoori More articles by this author Yiloren Tanidir More articles by this author Bhaskar Kumar Somani More articles by this author Khi Yung Fong More articles by this author Mriganka Mani Sinha More articles by this author Boyke Soebhali More articles by this author Abhay Mahajan More articles by this author Pankaj N Maheshwari More articles by this author Nariman Gadjiev More articles by this author Saeed Bin Hamri More articles by this author Yakup Bostanci More articles by this author Mehmet Ilker Gokce More articles by this author Cemil Aydin More articles by this author Innoue Takaki More articles by this author Vineet Gauhar More articles by this author Expand All Advertisement PDF downloadLoading ...

V02-11 ENDOSCOPIC COMBINED INTRARENAL SURGERY FOR REMOVAL OF ERODED HEM-O-LOK CLIPS AFTER ROBOTIC PARTIAL NEPHRECTOMY

You have accessJournal of UrologyCME1 Apr 2023V02-11 ENDOSCOPIC COMBINED INTRARENAL SURGERY FOR REMOVAL OF ERODED HEM-O-LOK CLIPS AFTER ROBOTIC PARTIAL NEPHRECTOMY Willian Ito, Bristol Whiles, Daniel Igel, Kenneth Schmanke, Crystal Valadon, Donald Neff, David Duchene, and Wilson Molina Willian ItoWillian Ito More articles by this author , Bristol WhilesBristol Whiles More articles by this author , Daniel IgelDaniel Igel More articles by this author , Kenneth SchmankeKenneth Schmanke More articles by this author , Crystal ValadonCrystal Valadon More articles by this author , Donald NeffDonald Neff More articles by this author , David DucheneDavid Duchene More articles by this author , and Wilson MolinaWilson Molina More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003232.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although metallic and Hem-O-Lok™ clips have consistently shown their safety and efficacy, especially in laparoscopic surgery, some rare complications may arise, oftentimes requiring complex surgical procedures. This video describes the utilization of miniaturized endoscopic combined intrarenal surgery (mini-ECIRS) to remove Hem-O-Lok™ clips that eroded into the collecting system as a late complication of robotic partial nephrectomy. METHODS: We present a 68-year-old male patient that underwent a robotic-assisted laparoscopic partial nephrectomy in 2015 to address a small renal mass (2.0×1.9 cm) on the right side. Pathology revealed the tumor to be an oncocytoma. Then, the patient was lost to follow-up but returned to the urologic clinic 7 years later due to gross hematuria and right-sided flank pain. Cystoscopy was negative for lesions or tumors, and a CT scan demonstrated a right-sided calculus (1.3×1.4 cm) in the renal pelvis. RESULTS: Considering the size and location of the stone (≤2 cm), the patient underwent a flexible ureteroscopy. However, a calcified Hem-O-Lok clip was found to be free-floating in the right renal pelvis. As the size of the clip precluded its prompt removal through the ureter, we decided to perform right-side mini-percutaneous nephrolithotomy by gaining access through the mid pole with a 15/16Fr access sheath. The clip was then removed with a grasper in one piece. During the routine final endoscopic survey, we found another clip in the process of erosion. This time, we first utilized a holmium-YAG laser to dissect it from the surrounding urothelium to subsequently remove it through the renal tract. The total operative time was 81 min and the laser pedal time 1 min. No complications were noted, and the patient was discharged on the first postoperative day. CONCLUSIONS: Erosion of surgical clips is a rare complication in modern-era surgery, although it may require complex surgical procedures to address it. This case demonstrates the safety and feasibility of mini-ECIRS to remove surgical clips after partial nephrectomy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e171 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Willian Ito More articles by this author Bristol Whiles More articles by this author Daniel Igel More articles by this author Kenneth Schmanke More articles by this author Crystal Valadon More articles by this author Donald Neff More articles by this author David Duchene More articles by this author Wilson Molina More articles by this author Expand All Advertisement PDF downloadLoading ...

V02-06 ULTRA-LOW DOSE FLUOROSCOPY DURING PCNL: HOW LOW CAN YOU GO?

You have accessJournal of UrologyCME1 Apr 2023V02-06 ULTRA-LOW DOSE FLUOROSCOPY DURING PCNL: HOW LOW CAN YOU GO? Vance Gentry, Kanha Shete, Ala'a Farkouh, Alphie Rotinsulu, Matthew Buell, Rose Leu, Akin S. Amasyali, Matthew Wilson, Joel Pearson, and D. Duane Baldwin Vance GentryVance Gentry More articles by this author , Kanha SheteKanha Shete More articles by this author , Ala'a FarkouhAla'a Farkouh More articles by this author , Alphie RotinsuluAlphie Rotinsulu More articles by this author , Matthew BuellMatthew Buell More articles by this author , Rose LeuRose Leu More articles by this author , Akin S. AmasyaliAkin S. Amasyali More articles by this author , Matthew WilsonMatthew Wilson More articles by this author , Joel PearsonJoel Pearson More articles by this author , and D. Duane BaldwinD. Duane Baldwin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003232.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients diagnosed with renal stones may be subjected to substantial doses of ionizing radiation during diagnosis, treatment, and follow-up. Physicians and other healthcare workers are also exposed to radiation during procedures, such as percutaneous nephrolithotomy (PCNL). This puts both patients and surgeons at the risk of developing radiation-related deleterious outcomes, like malignancies. The purpose of this video is to demonstrate tips and tricks that can be used to reduce radiation exposure during PCNL. METHODS: In this video, we demonstrate techniques to reduce radiation exposure to both patients and surgeons, in an 86-year-old female with a 2 cm renal pelvic and 8 mm lower pole stones who underwent PCNL at an academic center. These steps include planning for surgery, equipment set-up and calibration, use of personal protective equipment (PPE), use of multiple modalities to guide access into the renal pelvis, omitting fluoroscopy from various steps of the surgery, and a low dose CT for follow-up imaging. RESULTS: This video demonstrates a successful PCNL with a total fluoroscopy time of 5.6 seconds. Radiation reduction was achieved preoperatively by reviewing CT scans before surgery to plan access. Intraoperatively all of the following were employed: using a sterile ultrasound to map out a safe zone, relying on tactile feedback instead of fluoroscopy for retrograde glidewire placement into renal pelvis, use of endoscopic combined intrarenal surgery (ECIRS) for renal access, tract dilation, and sheath placement, appropriate use of lead shielding, using pulsed low-dose fluoroscopy, and using laser to guide percutaneous access into the renal pelvis. Post-operatively, ultra-low-dose 7.5 mAs CT scan was used to check for residual stones. CONCLUSIONS: This video has demonstrated many radiation-reducing techniques to both patient and surgeon, all of which can be easily incorporated into daily practice. By following these techniques, we effectively lowered radiation exposure to half the dose of a KUB. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e169 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vance Gentry More articles by this author Kanha Shete More articles by this author Ala'a Farkouh More articles by this author Alphie Rotinsulu More articles by this author Matthew Buell More articles by this author Rose Leu More articles by this author Akin S. Amasyali More articles by this author Matthew Wilson More articles by this author Joel Pearson More articles by this author D. Duane Baldwin More articles by this author Expand All Advertisement PDF downloadLoading ...

Initial Experience of Simultaneous Combined use of Percutaneous Nephrolithotomy and Flexible Ureteroscopy in Complex Renal Calculi: A Novel Surgical Technique of 'Through-Through' Approach.

For complex branched renal calculi, the endoscopic combined intrarenal surgery (ECIRS) is worldwide prevalent. This study aimed to present a novel surgical technique of percutaneous nephrolithotomy combined with antegrade flexible ureteroscopy which is named 'Through-through' approach. We retrospectively analyzed the data of 68 patients with complex renal calculi who underwent combined PNL and flexible ureteroscopy surgery using 'Through-through' approach at our center between August 2019 and December 2021. The 'Through-through' approach to surgery was indicated in residual calyceal calculi that neither rigid nephroscope nor retrograde flexible ureteroscope could reach. The brief procedure of this technique involved determining the direction of targeted calyces with the nephroscope first, followed by putting flexible ureteroscope into the targeted calyx through the nephroscope instrument channel and basketing or dusting residual calculi through the flexible ureteroscope instrument channel. The mean maximum stone diameter was 4.0 ± 0.4cm. The mean operative duration was 100.1 ± 18.0minutes, and mean hemoglobin loss was 21.4 ± 5.1g/L. In all 68 patients, calculi were cleared in 62 patients, and the stone free rate was 91.2%. Five patients underwent further surgery after 2weeks because of significant residual calculi. One patient that had a 6mm residual stone chose observational follow-up. Ten patients emerged with postoperative fever but did not progress to uroseptic shock. There were no Clavien grade ≥ III complications, and none of the patients required blood transfusion. The 'Through-through' approach is safe, feasible and effective for complex renal calculi patients. It is a complementary solution to the failed endoscopic combined intrarenal surgery.