Large Renal Stones Research Articles

Complications of retrograde intrarenal surgery for the treatment of large renal stone burdens: A prospective observational study

Objective: Retrograde intrarenal surgery (RIRS) is a less invasive method of treating renal calculi. Despite its widespread use, there is little research on RIRS safety address large renal stone burdens (≥21 mm). This study sought to evaluate the perioperative complications associated with RIRS. Methodology: A prospective evaluation of stone characteristics and perioperative outcomes was conducted on 55 patients each having a stone burden of ≥21 mm and treated with RIRS between November 2019 and October 2021. Patients were divided into three groups according to stone burdens (21–30 mm, 31–40 mm, and >40 mm). Chemoprophylaxis and surgery were performed according to standard procedures. All of these patients were followed up on for a minimum of three months. Results: The mean stone burden was 32.36 ± 10.20 mm. The mean cumulative endoscopy time was 142.0 ± 74.7 min. The overall stone-free rate (SFR) was 78.2%, with an average of 1.58 sessions of RIRS. The majority of the post-operative complications were minor (Clavien-Dindo I and II). Clavien-Dindo IIIa complications reported in 9%. Conclusions: RIRS is a safe treatment alternative with low morbidity for addressing large renal stone burdens in a subset of patients who are unfit for other therapeutic options.

A Feasibility Study on the Efficacy and Safety of a Novel Tip-Flexible Suction Ureteral Access Sheath Combined with Flexible Ureteroscopic Lithotripsy for Treating Kidney Stones ≥30 mm.

Objective: To evaluate the efficacy and safety of a novel tip-flexible suction ureteral access sheath (NTFS-UAS) combined with flexible ureteroscopic lithotripsy (FURS) for treating kidney stones ≥30 mm in a large cohort. Methods: The clinical data of 206 patients with renal calculi ≥30 mm treated by NTFS-UAS combined with FURS from June 2021 to September 2023 were analyzed retrospectively. The outcomes under investigation encompassed demographic information, stone-related characteristics, operative time, stone-free rates (SFRs), and postoperative complications. Results: The median operation duration was 110 minutes (interquartile 84.00-146.25 minutes). Immediate and 1-month SFRs were 83.98% and 85.44%, respectively. Multivariate analysis revealed five risk factors independently affecting stone clearance rate: stone size (≥50 mm, odds ratio [OR] = 3.826, p = 0.039), stone number (multiple: OR = 8.745, p = 0.015), stone location (multiple calyces: OR = 10.371, p = 0.045; lower calyx: OR = 9.615, p = 0.047), severe hydronephrosis (OR = 8.338, p = 0.002), and the Resorlu-Unsal scoring system (RUSS) score (6-7: OR = 10.829, p = 0.009; 4-5: OR = 4.223, p = 0.008). The incidence of Clavien-Dindo grade II-III complication was 5.82%. Positive preoperative urine culture (OR = 9.533, p = 0.012) and RUSS score (6-7: OR = 25.678, p = 0.026; 4-5: OR = 11.444, p = 0.038) were identified as the most important variables that may contribute to the development of high-grade postoperative complications. Conclusion: NFTS-UAS combined with FURS achieved satisfactory outcomes with good efficacy and safety for treating large renal stones ≥30 mm, and it can be utilized as an effective treatment option for patients having contraindications or preference against percutaneous nephrolithotomy. In addition, clinical factors, such as stone size, severe hydronephrosis, positive preoperative urine culture, and RUSS stone score that likely affected the outcomes of NFTS-UAS, should be fully taken into account when the surgeon performing FURS using NFTS-UAS.

Single site multi puncture supine (SMS) PCNL procedure in patient with complex renal stone: One incision, why should more?

Since percutaneous nephrolithotomy (PCNL) was introduced in 1976, it has been the standard procedure for large renal stones. Over time, the PCNL technique changed and developed into various techniques. We introduce single-site multipuncture supine (SMS) PCNL to give a cosmetic advantage due to less tissue injury in complex renal stones. This study aimed to determine the outcome of SMS PCNL procedure in patients with complex renal stones diseases. This study was a retrospective study including all patients with kidney stones who had undergone SMS PCNL at the Urology Department of Saiful Anwar General Hospital from March 2019 until December 2022. All SMS PCNL procedures were performed by a single operator. The patients were divided into three groups that included that were treated with 2, 3, and 4 punctures. The data were collected using SPSS ver. 25. Ninety-three patients were included in this study. The characteristics of the patient, such as gender, age, and BMI, were not significantly different among the groups. The outcome of the SMS PCNL procedure showed a low complication rate during operation in 2-,3-, and 4-puncture groups (3.2%, 7.4%, and 0%, respectively). The Stone Free Rate (SFR) showed no significant difference between the 3 groups (p = 0.496). The SFR was 85.7% in 2-puncture, 77.8% in 3-puncture, 66.7% in 4-puncture group. The AUC of Guy's Stone Score with cut-off value was 3.5 (AUC = 0.549, p-value = 0.541, CI 95%). Single-Site Multi Puncture PCNL is a safe and efficient approach to complex renal stones. Single-Site Multipunctures Supine PCNL is comparable with other techniques of PCNL and gives minimal tissue injury that would benefit for cosmetic.

Preoperative Immersive Virtual Reality (iVR) Applied to Percutaneous Nephrolithotomy: A Prospective Randomized Clinical Study of Surgical Planning and Clinical Outcomes.

Percutaneous nephrolithotomy (PCNL) is the procedure of choice for the management of complex or large renal stones. A major challenge for the surgeon, however, is the need to assimilate the nearly 2000 static images from a CT scan into a functional mental image to enable surgical planning. Accordingly, we investigated the potential of immersive virtual reality (iVR) to enhance surgical planning and its impact on the outcomes among patients undergoing PCNL. Between 2019-2023, 175 patients undergoing PCNL were pre-operatively randomized into a CT-only group (N=89) or a CT+iVR group (N=86). CT scans were rendered into iVR models that allowed the surgeon not only to visualize and manipulate each patient's relevant anatomy, but also simulate the percutaneous approach to the proposed calyx. Post-operative CT scans were defined as absolute stone-free, <2mm remnants or 2.1-4mm remnants. Pre-operative visualization of the iVR model resulted in a changed calyx of entry in 30% of cases. The CT+iVR group had a significant improvement in absolute stone-free rate (33.70% vs. 20.22%, p=0.043) and overall <4mm remnant rate (62.79% vs. 48.20%, p=0.044). Clavien-Dindo II+IIIa complications were less in the iVR group (3.48% vs. 12.30%, p=0.03). The results were independent of the surgeon's years of PCNL experience. Pre-operative iVR model visualization benefited surgeons and patients alike. From a surgical standpoint, viewing the iVR model resulted in a safer, more effective percutaneous stone removal procedure.

Comparative analysis of retro vs. transperitoneal laparoscopic pyelolithotomy for large renal stones.

The objective of this study is to compare the outcomes and complications of retroperitoneal and transperitoneal laparoscopic pyelolithotomy (RLP and TLP, respectively) in the treatment of large kidney stones. In this retrospective cohort effort, data of all patients who underwent laparoscopic pyelolithotomy for renal pelvic stone (N = 273) in three referral urology hospitals were retrieved. Operation duration, length of hospital stay, postoperative stone-free rate, hemoglobin (Hb) and creatinine (Cr) changes and complications were compared between the two groups before and after propensity score matching. A total of 199 TLP and 74 RLP cases were examined. Stone size was significantly higher in the TLP vs. RLP group (29.8 ± 10.9 vs. 26.5 ± 8.8mm; P = .022). Length of operation and hospital stay were comparable (P = .672 and P = .396, respectively). Rate of conversion to open surgery, postoperative blood transfusion rate, postoperative urinary leakage, postoperative stone-free rate, Hb drop and Cr change were similar between the two groups (P = .348, 0.190, 0.828, 0.411, 0.780 and 0.134, respectively). Postoperative fever was significantly more prevalent in TLP compared to RLP (21.6% vs. 0.0%, respectively; P < .001). Propensity score matched analyses showed similar results in all aspects; particularly demonstrating higher postoperative fever in TLP compared to RLP (18.9% vs. 0.0%, respectively; P < .001). RLP can be considered as an alternative to TLP; especially owing to a lower chance of postoperative fever.

Retroperitoneal vs transperitoneal laparoscopic pyelolithotomy; a single surgeon's experience.

To compare the outcomes of transperitoneal and retroperitoneal laparoscopic pyelolithotomy procedures. A total of 104 consecutive laparoscopic pyelolithotomy surgeries performed by a single surgeon on patients with staghorn or renal pelvic calculi larger than 20mm were evaluated. Intraoperative and postoperative clinical parameters from two groups, transperitoneal (TLPL) (N = 55) and retroperitoneal (RLPL) (N = 49), were compared. The surgeon performed TLPL for the first five years and then switched to the RLPL approach for the next five years. There were no significant differences in general demographic variables and stone size (26.55 vs. 24.73mm, P = 0.8). Operation time and change in serum creatinine levels did not significantly differ between the two approaches. However, patients who underwent TLPL had longer hospital stays than RLPL (3.23 ± 1.21 vs. 2.36 ± 1.10 days, P = 0.0001). Additionally, TLPL was associated with a greater drop in hemoglobin levels (1.53 ± 1.04 vs. 1.17 ± 0.68, P = 0.04), higher rates of postoperative fever (12.7% vs. 0.0%, P = 0.01). The retroperitoneal approach in laparoscopic pyelolithotomy for large renal pelvic stones resulted in fewer postoperative fevers, reduced hemoglobin drops, and shorter hospital stays than the transperitoneal approach. However, the stone-free rates were similar for both groups.

Robotic pyelolithotomy for the treatment of large renal stones: a single-center experience over seven years.

Urolithiasis prevalence varies globally between 1-20%, influenced by regional factors. Robotic pyelolithotomy (RPL) presents an interesting alternative to PCNL, considered the gold standard for symptomatic stones smaller than 20 mm, as it carries a risk of significant complications. However, studies on RPL are limited, especially in anatomically complex cases, where RPL proves to be particularly useful. The study aims to update and review outcomes of RPL in a high-volume robotic center. A retrospective analysis of 153 patients treated with RPL for staghorn kidney stones at a single center from February 2016 to December 2023 was conducted. Data including demographics, preoperative renal function, stone characteristics, operative and postoperative outcomes, and costs were collected. Stone-free rates (SFR) and complications were assessed at follow-up intervals up to 12 months post-surgery. The study showed an initial 3-month stone-free rate (SFR) of 93.5%, which decreased to 83.5% at 12-months. This trend may reflect new stone formation rather than procedure failure. Sub-analysis revealed a significant difference in SFR between patients with pelvic and pyelocalyceal stones at each follow-up. Multivariate regression analysis identified in the pyelocalyceal group that higher BMI and larger stones were associated with higher failure rates at both 6 and 12 months. RPL is a safe and effective treatment for large renal stones, offering a high SFR and low complication rate. It is particularly beneficial in cases with complex anatomy or requiring concurrent renal procedures. However, patient selection is crucial, considering factors like stone location and size. Further research is needed to compare RPL with other treatment methods.

Outcomes and complications of percutaneous nephrolithotomy as primary versus secondary procedure for kidney stones: A prospective cohort study

Introduction: Currently, percutaneous nephrolithotomy (PCNL) is the gold standard of treatment for large renal stones. The high prevalence of urolithiasis is associated with a high recurrence rate increasing the risk of re-intervention. This study aimed to compare the effectiveness and complications of PCNL among patients with previous therapeutic interventions for renal stones. Methods: Between August 2018 and September 2023, 245 patients were prospectively enrolled in this study and who underwent PCNL for renal stones at our institution. We compared patients who had no previous renal surgery (group1: n=171) with those who had a history of open renal surgery (group2: n=45) or previous PCNL on the ipsilateral kidney (group 3: n=31). All patients underwent surgery in the Galdakaomodified Valdivia position. Data on stone characteristics and perioperative and postoperative parameters were collected. Technical features, the success rates and morbidity were analysed and compared between the groups. Results: The fluoroscopy time was significantly longer in the group of patients with previous open surgery than in groups 1 and 3 (161.47±52.44, 223.05±33.29, 172.27±30.51sec, P&lt;0.001). Similarly, the operative time was longer in group 2 (138.20±38.86 min, P&lt;0.001). The immediate stone-free rates in groups 1, 2, and 3 were 74.8%, 72.1%, and 77.4%, respectively(P=0.945). At 1- month, these rates increased to 98.8%, 96.2% and 96.8%, respectively (P=0.857). No difference was detected between the groups in terms of complication rate. The average Hb variation was 1.08±0.82, 1.34±1.01 and 0.94±0.69 g/dL for groups 1, 2 and 3, respectively(P=0.082). Hospital stay was longer in group 2 than in groups 1 and 3 (2.17±1.03, 2.53±1.22, 1.88±1.00 d, P=0.07), respectively. Conclusion: PCNL in patients with a history of renal surgery was associated with longer fluoroscopy and operative time. However, the success and morbidity rates as a secondary procedure were similar to those of PCNL in patients with no previous intervention.

Systemic vs. in-irrigation tranexamic acid in percutaneous nephrolithotomy A systematic review, Bayesian network meta-analysis, and meta-regression.

Percutaneous nephrolithotomy (PCNL) is the gold-standard treatment for large renal stones. One potentially significant complication of PCNL is blood loss, which can result in transfusion requirement and poorer stone-free outcomes. Tranexamic acid (TXA) has emerged as a promising intervention, administered systemically (TXA-S) or as part of irrigation fluid (TXA-I) in endourology. This study aimed to comprehensively analyze existing evidence regarding the applications of TXA in PCNL through a Bayesian network meta-analysis, offering insights into its efficacy and comparative effectiveness. In February 2022, a PRISMA-compliant systematic review (PROSPERO registration number CRD 42021270593) was performed to identify randomized controlled clinical trials (RCT) on TXA as either systemic therapy or in irrigation fluid. Studies in languages other than English and Spanish were not considered. A Bayesian network was built using results from identified studies to create models that were later run through Markov Chain Monte Carlo sampling through 200 000 iterations. Eight RCTs compared TXA-S vs. placebo, one TXA-I vs. placebo, and one TXA-I vs. TXA-S. TXA-I had lower risk of transfusion (relative risk [RR] 0.63 [0.47,0.84], SUCRA 0.950) than TXA-S (RR 0.79 [0.65,0.95], SUCRA 0.545). TXA-I had a lower risk of complications (RR 0.38 [0.21,0.67], SUCRA=0.957) compared to TXA-S (RR 0.55 [0.39, 0.78], SUCRA 0.539). TXA-I had a lower postoperative decrease in hemoglobin (mean difference [MD] -1.2 [1.3, 1.0], SUCRA 0.849) compared to TXA-S (MD -0.97 [-1.0, -0.93], SUCRA 0.646]). TXA, regardless of the route of administration, is an effective intervention in decreasing bleeding, postoperative complications, and risk of transfusion when compared with placebo. Further studies directly comparing TXA-S to TXA-I would be useful to determine the optimal route of delivery.

Efficacy Of Retrograde Intra-Renal Surgery For The Treatment Of Large Renal Stone Burdens: A SingleCenter Experience

Background: Retrograde intra-renal surgery (RIRS) has gained popularity as a result of technological advances. Although widely used, the literature on its feasibility for the treatment of large renal stone burdens is limited. This study aimed to assess the efficacy of RIRS for the treatment of large renal stone burdens.. Materials and Methods: Fifty-five patients with stone burdens ≥21 mm and treated with RIRS between November 2019 and October 2021 were evaluated for patient demographics, stone characteristics, and stonefree rates (SFR). Patients were divided into three groups according to stone burdens (21–30 mm, 31–40 mm, and &gt;40 mm). A standard protocol for surgery and chemoprophylaxis was followed. The SFR was determined if there were no residual stones or fragments on follow-up images. All these patients were followed up on for a minimum of 3 months. Results: The mean age of patients was 54.11 ± 11.75 years. The mean stone burden and mean stone density were 32.36 ± 10.20 mm and 966 ± 337 HU, respectively. The mean cumulative endoscopy time was 142.0 ± 74.7 minutes per case. Endoscopy time was longer for stone densities &gt;1000 HU. The overall SFR was 78.2%, with an average of 1.58 sessions of RIRS. SFRs for 21–30 mm, 31–40 mm, and &gt;40 mm groups were 92.9%, 68.8%, and 54.5%, respectively. Conclusion: RIRS is an effective therapeutic option for treating stone burdens of 21–30 mm with overall SFR of 92.9%. When the stone burden exceeds 30 mm, RIRS should only be offered to individuals who are not candidates for other therapeutic options. To better counsel the patient for a staged approach, stone hardness (HU-Hounsfield units) should be considered in surgery planning

Evaluation of the Efficacy of Mini Percutaneous Nephrolithotomy in Comparison with Standard Percutaneous Nephrolithotomy for the Management of Large Renal Stones, a Randomized Controlled Clinical Trial

Abstract Background Management of renal calculi targets complete clearance without any residual fragments, along with pain relief and eradication of the causative micro- organisms. Percutaneous nephrolithotomy (PNL) is currently the standard treatment option for patients with complex and large renal stones. However, innovations in instruments and techniques have resulted in “miniperc”, which was found to be safe and effective. Aim and Objectives to compare between mini PNL and the standard PNL in management of renal stones (20-40 mm) regarding operative time, fluoroscopy time, blood loss, stone free rate, and postoperative complications according to modified Clavein system. Subjects and Methods This prospective randomized comparative study was carried out at Urology department Ain Shams University hospitals, from 2019 to 2022 on 93 patients coming for renal stone management. Patients were divided into 2 groups: Group A included 44 patients who underwent standard PNL, whereas Group B included 49 patients who underwent mini PNL. Result The standard PNL yielded shorter operating time 70.1 ± 13.9 min vs 96.4 ±14.3 min,p &amp;lt;0.001) Patients in the standard PNL group also had longer hospitalization time, nephrostomy time and catheterization time(4 vs 3 days, 36 vs 24 hours and 5 vs 4 days respectively, p &amp;lt; 0.001). The mean drop in hemoglobin level that necessitated blood transfusion was significantly lower in the mini PNL group (0.7 vs 1.6 gm/dl, p &amp;lt; 0.0001). Although the stone-free rate was higher in the standard PNL group, but this was statistically insignificant (79.5 vs 61.2%, p = 0.054) According to modified Clavien–Dindo classification, no statistical difference was detected between the 2 groups in terms of complication rates The postoperative pain and the need for postoperative analgesia were significantly more in standard PNL patients. Visual Analogue Score (VAS) was 7.4 and 5.2 in standard PNL and mini PNL respectively. Conclusion We compared the standard PNL and mini PNL regarding the safety and efficacy in management of large renal stones. Standard PNL achieved higher stone free rate and shorter operative time while mini PNL has the advantage of shorter hospitalization time and low incidence of postoperative complications and pain.

Turning up the HEAT Surgical simulation of the Moses 2.0 laser in an anatomic model.

With advancements in laser technology, urologists have been able to treat urinary calculi more efficiently by increasing the energy delivered to the stone. With increases in power used, there is an increase in temperatures generated during laser lithotripsy. The aim of this study was to evaluate the thermal dose and temperatures generated with four laser settings at a standardized power in a high-fidelity, anatomic model. Using high-fidelity, 3D-printed hydrogel models of a pelvicalyceal collecting system with a synthetic BegoStone implanted in the renal pelvis, surgical simulation of ureteroscopic laser lithotripsy was performed with the Moses 2.0 holmium laser. At a standard power (40 W) and irrigation pressure (100 cm H2O), we evaluated operator duty cycle (ODC) variations with different time-on intervals at four different laser settings. Temperature was measured at two separate locations: at the stone and ureteropelvic junction. Greater cumulative thermal doses and maximal temperatures were achieved with greater ODCs and longer laser activation periods. There were statistically significant differences between the thermal doses and temperature profiles of the laser settings evaluated. Temperatures were greater closer to the tip of the laser fiber. Laser energy and frequency play an important role in the thermal loads delivered during laser lithotripsy. Urologists must perform laser lithotripsy cautiously when aggressively treating large renal pelvis stones, as dangerous temperatures can be reached. To reduce the risk of causing thermal tissue injury, urologists should consider reducing their ODC and laser-on time.

The Association between S.T.O.N.E. Nephrolithometry Score and Hemoglobin Drop in Patients Undergoing Percutaneous Nephrolithotomy

Nephrolithiasis is a very common condition with significant burden to patients. Percutaneous nephrolithotomy (PCNL) is safe procedure considered as gold standard for large renal stones. The most common complication of PCNL is bleeding which can require blood transfusion to angioembolization and may even need nephrectomy. The purpose of this study is to assess if STONE Nephrolithometry Score can predict hemoglobin drop in PCNL procedure. A total of 104 patients who underwent PCNL during one year period from October of 2022 to September of 2023 were taken using consecutive sampling method. All patients with renal stones underwent routine blood tests including complete blood counts, renal function and electrolytes. CT scans were then done and STONE nephrolithometry Score was evaluated. PCNL was performed and hemoglobin investigation was sent at 24 hours postoperatively. The two data were compared with the STONE nephrolithometry Score and other factors. More than three-fourths (78.8%) of the patients had comorbidities with hypertension being the commonest (76.9%). There was a significant association of drop of hemoglobin more than 1 g/dl with age &lt;30 years (p &lt;0.034), higher preoperative hemoglobin (p &lt;0.046), larger stone size (p &lt;0.001), shorter tract length (p=0.017) and STONE Score greater than 10 (p&lt;0.001). On correlation study only STONE score (p = 0.015) and larger stone size (p = 0.002) were associated with hemoglobin drops of more than 1 g/dl. STONE Nephrolithometry score is a good predictor of bleeding complications during PCNL and higher score is associated with more drop in hemoglobin levels.

The Effect of Antibiotic Therapy Before Percutaneous Nephrolithotomy on the Frequency of Postoperative Complications: A Retrospective Cross-Sectional Study

Background: Percutaneous nephrolithotomy (PCNL) is commonly used in the treatment of large renal stones. Postoperative infections are a common consequence of these procedures. Objectives: The purpose of this study is to evaluate the effects of antibiotic therapy before PCNL on the possibility of developing fever and common complications after the procedure. Methods: We carried out a retrospective cross-sectional study involving 708 patients who had undergone PCNL at Razi Hospital in Rasht, covering the period from 2012 to 2022. Patients were allocated into two groups: Group 1 included 454 patients who had received antibiotic therapy, and group 2 included 254 patients who had not received pre-operative antibiotic therapy. Results: In group 1, there were 241 males (53.1%) and 213 females (46.9%), while in group 2, there were 138 males (54.3%) and 116 females (45.7%). In group 1, 82.7% of patients treated with antibiotics had a negative culture. The hospitalization time was 4.00 ± 1.75 days for group 1 and 2.26 ± 1.56 days for group 2. Fever was observed in 39 patients (11.2%) in group 1. Sepsis was seen in only one patient (0.3%) in group 1. There is a significant relationship between total hospitalization time (P = 0.000), hospitalization after the operation (P = 0.000), hypertension (P = 0.009), ischemic heart disease (P = 0.050), history of shock wave lithotripsy (P = 0.003), hydronephrosis (P = 0.000), age (P = 0.004), and hemoglobin levels (P = 0.000) with antibiotic therapy. Conclusions: Surgeon overprescription of antibiotics may lead to resistance, complicating outcomes and extending hospital stays after PCNL. Some complications remain unaffected by antibiotic therapy due to surgical experience.

Clinical efficacy analysis of tip‑flexible suctioning ureteral access sheath combined with disposable flexible ureteroscope to treat 2-4cm renal stones.

This study aims to evaluate the clinical efficacy of using a tip‑flexible suctioning ureteral access sheath (TFS-UAS) in combination with a traditional ureteral access sheath (T-UAS) and a disposable flexible ureteroscope (DFU) for treating large renal stones (2-4cm in diameter). We retrospectively collected clinical data from 238 patients who underwent retrograde intrarenal surgery (RIRS) at Ganzhou People's Hospital between January 2019 and October 2023. The study included 238 patients who met the inclusion criteria, with 125 in the observation group using TFS-UAS and 113 in the control group using T-UAS. We compared differences in the stone-free rate (SFR), complication rates, surgery duration, and average hospital stay between the two groups. All 238 surgeries were successfully completed. The stone-free rates for the observation group at the first and thirtieth day post-surgery were 87.20% and 95.20%, respectively, whereas for the control group, the rates were 73.45% and 85.84%, showing statistically significant differences (P < 0.05). The overall complication rates were 1.6% for the observation group and 14.16% for the control group, also statistically significant (P < 0.001). The surgical times for stone removal were (101.17 ± 25.64) minutes for the observation group and (86.23 ± 20.35) minutes for the control group, with significant differences (P < 0.05). Compared to T-UAS, combining TFS-UAS with DFU for treating renal stones of 2-4cm diameter, although more time-consuming, resulted in higher SFRs and improved safety.

Large renal stone with ureteral stone caused by 15 years of forgotten stent

Introduction: Ureteral stents are commonly placed in urologic surgeries, and are especially indispensable in endourologic surgeries. But if it remains for more than 6 months, the probability of migration and calculus formation of the stent increases substantially. Case description: A 57-year-old female came to the urology outpatient clinic due to left flank pain. She had a history of open left nephrolithotomy 15 years ago and had ureteral stent placed. She also had a history of open vesicolithotomy surgery 4 years ago and was told to have a follow-up surgery for the remaining kidney stone but she didn’t come because of the limited level of local medical services and her pain tolerance. NCCT study showed moderate left hydronephrosis with a high volume renal stone measuring 60x35x20 mm (HU 1.021), two proximal ureteral stones measuring 40x10x10 mm (HU 1.021) and 60x5x5 mm (HU 1.021) with ureteral stent shadow in the center. She had elevated urea nitrogen and creatinine levels, microscopic hematuria, leukocyturia, and positive urine bacteria. The patient underwent percutaneous nephrolithotomy (PCNL) with endoscopic combined intra-renal surgery (ECIRS) for stone removal. Postoperative recovery was successful with no residual stones and significant pain relief. Conclusion: The case underscores the need for patient compliance, adequate practitioner counseling, and timely medical attention. The prevention of complications is the best treatment, and multimodal endourologic approaches can safely remove forgotten, encrusted double J stents.

Outcomes and considerations for retrograde intrarenal surgery (RIRS) in the setting of multiple and large renal stones (>15 mm) in children: Findings from multicentre and real-world setting.

The aim of this study is to evaluate the outcomes of retrograde intra renal surgery (RIRS) in the setting of large or multiple stones in children (<18 years). Retrospective analysis was performed of paediatric RIRS cases at nine centres worldwide over a 6-year period. Patients were divided into two groups: Group 1 had a single stone <15 mm. Group 2 had either multiple stones, maximum stone diameter of >15 mm, or both. Outcomes included stone free rate (SFR) and complications within 30 days. In total, 344 patients were included with 197 and 147 in Groups 1 and 2, respectively. Ureteric access sheaths were more frequently used in Group 2 (39.5% vs. 56.8%, p = 0.021). The operation time was significantly longer in Group 2 (p < 0.001). SFR after a single procedure was 84.7% in Group 1 and 63.7% in Group 2. Overall complication rates in Groups 1 and 2 were 7.6% and 33.3%, respectively. The most frequently reported complication in both groups was post-operative fever (4.4% vs. 14%, p = 0.004). The rate of Clavien I/II complications in groups 1 and 2 was 6% and 25.1%, respectively (p < 0.05). The rate of Clavien ≥ III complications in groups 1 and 2 was 1.6% and 8.1%, respectively (p < 0.05). On multivariate analysis, total operation time, stone size and multiplicity were significant predictors of residual fragments. RIRS can be performed in paediatric cases with large and multiple stone burdens, but the complication rate is significantly higher when compared to smaller stones.

Percutaneous Nephrolithotomy 500 Cases in High-Risk and Altered Renal Function Test: Our Experience at Tertiary Care Centre

Introduction The study aims to evaluate the results of percutaneous nephrolithotomy (PCNL) in high-risk patients and patients with altered renal function tests (RFT) and complications in the management of renal stones in our hospital. Methods We retrospectively analyzed the outcomes of 500 patients who underwent PCNL between September 2020 and September 2023. We have analyzed data regarding patient details, investigations, PCNL puncture site, operative duration, number of punctures, stone-free rates (SFRs), duration of hospital stay, and complications. Results Out of 500 patients, 384 (76.87%) were males and 116 (23.13%) were females, with a male-to-female ratio of 3.32:1. The average age was 40.8±10.4 (mean±SD) (range: 24 to 74-years). The average operative time was 127±37 min (mean±standard deviation (SD)). The radiation exposure was from 1 min 30 sec to 3 min, with a mean (±SD) of 30 sec. The mean duration of the hospital stay was 2.7±1.6 days. Complete stone clearance was 87%, whereas SFRs defined by no identifiable stone on a plain radiograph or ultrasound or residual fragments &lt;5 mm were 90.93%. The complication rate was 2.2%. Conclusion The usual course of treatment for renal stones larger than 2 cm is PCNL. Significant factors influencing the stone-free rate include stone burden, stone type, PCNL puncture, number of punctures, and operative time. With the development of several lithotripsy procedures and the miniaturization of instruments, PCNL continues to be an excellent therapeutic option for patients with large renal stones, comorbidities, and changed RFT, with tolerable rates of complications.

Turning up the HEAT: Surgical simulation of the Moses 2.0 laser in an anatomic model.

With advancements in laser technology, urologists have been able to treat urinary calculi more efficiently by increasing the energy delivered to the stone. With increases in power used, there is an increase in temperatures generated during laser lithotripsy. The aim of this study was to evaluate the thermal dose and temperatures generated with four laser settings at a standardized power in a high-fidelity, anatomic model. Using high-fidelity, 3D printed hydrogel models of a pelvicalyceal collecting system with a synthetic BegoStone implanted in the renal pelvis, surgical simulation of ureteroscopic laser lithotripsy was performed with the Moses 2.0 holmium laser. At a standard power (40 W) and irrigation pressure (100 cm H2O), we evaluated operator duty cycle (ODC) variations with different time-on intervals at four different laser settings. Temperature was measured at two separate locations: at the stone and ureteropelvic junction. Greater cumulative thermal doses and maximal temperatures were achieved with greater ODCs and longer laser activation periods. There were statistically significant differences between the thermal doses and temperature profiles of the laser settings evaluated. Temperatures were greater closer to the tip of the laser fiber. Laser energy and frequency play an important role in the thermal loads delivered during laser lithotripsy. Urologists must perform laser lithotripsy cautiously when aggressively treating large renal pelvis stones, as dangerous temperatures can be reached. To reduce the risk of causing thermal tissue injury, urologists should consider reducing their ODC and laser-on time.

A Cross-Sectional Study Comparing Tubed PCNL And Tubeless PCNL: An Experience at the Institute of Kidney Diseases (IKD), Peshawar

Background: Percutaneous Nephrolithotomy (PCNL) has revolutionized the treatment of large renal and proximal ureteric stones, offering a minimally invasive alternative to open surgery. The introduction of tubeless PCNL, which omits the placement of a nephrostomy drainage tube, has generated discussion regarding its efficacy and safety compared to the traditional tubed PCNL. Objective: This study aims to compare the outcomes of tubed versus tubeless PCNL in terms of post-operative complications, recovery time, and efficacy in stone removal. Methods: A retrospective cross-sectional analysis was conducted on 110 patients who underwent PCNL at the Institute of Kidney Disease, Peshawar, from January 2017 to December 2020. Patients were allocated into two groups, tubed PCNL (n=50) and tubeless PCNL (n=50), based on 1:1 sequential randomization. The inclusion criteria were ASA I and ASA II classification, age between 5 to 70 years, and single tract procedure with complete clearance without the need for a second look nephrostomy. Exclusion criteria included patients with a solitary kidney, active urinary tract infections, and congenital malformations. Data on age, gender, co-morbidities, history of ESWL, stone size, location, quantity, and post-operative outcomes were collected and analyzed using SPSS version 25. Results: No significant differences were found in patient demographics or stone characteristics between the two groups. The tubeless PCNL group demonstrated a significantly lower rate of post-operative ESWL sessions (4% vs. 22%, p=0.02) and a trend towards shorter hospital stays, although not statistically significant. The drop in hemoglobin levels post-operation was less in the tubeless group (0.84 ± 1.87 mg/dl) compared to the tubed group (1.56 ± 0.91 mg/dl), but this was not statistically significant (p=0.17). Conclusion: Tubeless PCNL offers a viable alternative to traditional tubed PCNL, particularly for patients with smaller renal stones. It is associated with a lower need for post-operative ESWL sessions and potentially shorter hospital stays, suggesting an advantage in terms of recovery and post-operative comfort. Further prospective studies are warranted to confirm these findings and explore the long-term outcomes of the tubeless technique.