Management Of Large Renal Calculi Research Articles

Mini percutaneous nephrolithotomy treat the large upper ureteric stones

Background. The incidence of kidney stones has been raised all over the world. Nephrolithiasis is the most common cause of illnesses in western countries and has been rising in its incidence in developing countries. PCNL describe the management of large renal calculi when measuring >20 mm and even for smaller ones of lower pole with excellent stone-free rate reach to 98%. Aim. To evaluate the mini-percutaneous nephrolithotomy (mini-PCNL) safety used to cure upper ureteral and renal stones with assessing the complication and procedure outcome in Iraqi patients. Method. This is a prospective study done between October 2022 and September 2023 in Ghazi Al-Hariri for Surgical Specialties Hospital, Medical city, with 100 patients enrolled who underwent mini-PCNL. All patients had upper ureteral and renal stones (size ≥20 mm). The nephroscope tube was utilized. The stones were destroyed by pneumatic lithotripter. Complications and outcomes were determined immediately postoperative via X-ray of the ureters, kidneys and bladder. Ultra-sonography also used to determined safety and efficacy of procedure. Results. The cases mean age was 55.8 ± 12.3 years, and their BMI was 29.5 ± 5.9 kg/m2. The size of mean stone was 22.5 ± 17.9 mm. The stone-free rate (SFR) was 94.7%. The post-operative hospital stay mean was 3.6 ± 2.7 days. The Hb drop mean was 0.6 ± 0.3 g/dL. There were none of our cases had organ trauma or any complications. Thirty cases required additional subsequent extra-corporeal shock wave lithotripsy. Conclusion. The mini-PCNL is effective and safe in cases of upper ureteral and renal stones ≥20 mm. Researches with a larger multi-center cohorts may be needed to validate these techniques.

Comparative Evaluation of Upper Pole and Non-Upper Pole Puncture Techniques in Percutaneous Nephrolithotomy (PCNL): A Retrospective Analysis of Efficacy and Safety Parameters

Background: Percutaneous nephrolithotomy (PCNL) is a critical intervention in the management of large renal calculi, with the choice of calyx puncture technique impacting the efficacy and safety of the procedure. While the upper pole approach is associated with better visualization and stone clearance, it is used with caution due to a perceived increase in complication rates. Objective: This study aimed to compare the upper pole calyx puncture technique's efficacy and safety with that of the non-upper pole (middle and lower) puncture techniques in PCNL. Methods: A retrospective analysis was conducted on 173 patients who underwent PCNL at the Urology and Transplant Unit A of The Institute of Kidney Diseases in Peshawar from January 2017 to December 2020. Data on demographics, stone characteristics, perioperative findings, and postoperative outcomes were collected. Statistical significance was determined using Chi-square tests with SPSS version 25. Results: The average stone size was 21.38 mm (±11.2 mm) overall, with the upper pole group presenting a smaller average size of 19.8 mm (±7.6 mm) compared to 21.55 mm (±10.8 mm) for the non-upper pole group (p=0.032). Pre-operative hemoglobin levels were slightly lower in the upper pole group (12.5 ± 1.8 mg/dl) than in the non-upper pole group (12.9 ± 1.8 mg/dl, p=0.007). Complete clearance rates were comparable between groups. Post-operative blood transfusion was required more frequently in the non-upper pole group (12.1%, n=12) versus the upper pole group (4.0%, n=3, p=0.04). Conclusion: The upper pole approach in PCNL may afford a higher rate of stone clearance and reduced operative times with acceptable safety when compared to non-upper pole approaches. The selection of puncture technique should be tailored to individual patient anatomy and stone characteristics, with consideration given to the surgeon's experience and skill.

A Retrospective Comparison of the Balloon Dilator and the Telescopic Metal Dilator for Tract Dilatation during Percutaneous Nephrolithotomy

Background: Percutaneous nephrolithotomy (PCNL) is the procedure of choice for the management of large renal calculi. Nephrostomy tract dilatation is an essential step in PCNL. However, the types of dilatations used depend on the surgeon’s preference. Objective: To compare the effectiveness and safety of the balloon dilator (BD) against the telescopic metal dilator. Materials and Methods: The present study involved 238 patients that underwent PCNL between January 2011 and February 2020. They were divided into two groups based on the adopted tract dilatation technique. The balloon dilatation group included 69 cases, and the telescopic metal dilator group included 169 cases. They were analyzed in terms of demographics and perioperative outcomes. Results: The two PCNL groups were similar in age, stone burden, and stone density. There was no statistically significant differences in the stone-free status at 59.4% versus 56.8% (p=0.711), tract dilatation failure rates at 1.5% versus 0.6% (p=0.511), estimated blood loss at 200 mL versus 200 mL (p=0.311), blood transfusion rates at 11.6% versus 8.9% (p=0.520), and total operation time at 120 minutes versus 120 minutes (p=0.573) for the balloon dilatation group and the telescopic metal dilator group, respectively. The duration of the nephrostomy placement in the balloon dilatation group was significant longer than the telescopic metal dilator group at 3 days versus 4 days (p=0.005). Conclusion: Both BD and telescopic metal dilator possess equivalent effectiveness and safety for PCNL. Keywords: Percutaneous nephrolithotomy; Renal calculus; Balloon dilator; Telescopic metal dilator

Trigonometric Concept of Fluoroscopy-Guided Percutaneous Renal Access.

Percutaneous nephrolithotomy is the standard surgical management of large renal calculi. Percutaneous renal access using the triangulation method has been an enigma for the endourologist to master and teach. This surgical conundrum is due to the uncertainty in the angle and depth required to puncture the target calyx. We describe a novel trigonometric method of renal access where both the angle and the depth of puncture are easily determined before the puncture.

Retrograde Ureteroscopic Management of Large Renal Calculi: A Single Institutional Experience and Concise Literature Review

Advances in flexible ureteroscope design and accessory instrumentation have allowed for more challenging cases to be treated ureteroscopically. Here, we evaluate our experience with ureteroscopy (URS) for the management of large renal calculi (≥2 cm) and provide a concise review of recent reports. A retrospective review was undertaken of all URS cases between 2004 and 2014 performed by the endourologic team at a single academic tertiary care institution. We identified patients with at least one stone ≥2 cm managed with retrograde URS. Stone size was defined as the largest linear diameter of the index stone. Small diameter flexible ureteroscopes were used primarily with holmium laser. Patient demographics, intraoperative data, and postoperative outcomes were evaluated. We evaluated 167 consecutive patients who underwent URS for large renal stones ≥2 cm. The initial reason for choosing URS included patient preference (29.5%), failure of other therapies (8.2%), anatomic considerations/body habitus (30.3%), and comorbidities (28.8%). Mean patient age was 55.5 years (22-84). The mean stone size was 2.75 cm with mean number of procedures per patient of 1.65 (1-6). The single session stone-free rate was 57.1%, two-stage procedure stone-free rate was 90.2% and three-stage stone-free rate was 94.0%. Access sheaths were used in 47% of patients. An association was identified between stone size and patient outcomes; smaller stones correlated with decreased number of procedures. Postoperative complications were minor. Single or multi-stage retrograde ureteroscopic lithotripsy is a safe and effective mode of surgical management of large renal calculi. Total stone burden is a reliable predictor of the need for a staged procedure and of stone-free rate.

Synchronous Twin-Tract Percutaneous Nephrolithotomy

Introduction: Percutaneous nephrolithotomy (PCNL) is the standard technique for management of large renal calculi. Our main goal is to achieve complete stone clearance, which can be attained in single stage or multiple stages. Large bulk stone clearance by PCNL has considerable morbidity, namely, prolonged operative times, increased intraoperative blood loss, and need for secondary procedures. Therefore, to further minimize morbidity and to achieve maximum stone clearance for these difficult stones, we investigated the feasibility of a synchronous twin-tract approach. Patient and Methods: Thirty-six-year-old man presented with right ureteric and left complete staghorn calculus. He underwent right pushbang for the ureteric stone earlier and underwent synchronous twin-tract PCNL for the left complete staghorn calculus. Initial ultrasound-guided localization and puncture was achieved in the upper and lower calix, and both the tracts were dilated synchronously. PCNL was performed by two operative surgeons simultaneously. Results: Complete stone clearance was achieved. Total operative time was 80 mins and hemoglobin drop was 1.5 gm%. There were no intra- or perioperative complications noted. Postoperative X-ray confirmed complete clearance. Conclusion: Synchronous twin-tract PCNL is a potentially ideal operation for complete clearance of large bulk renal calculi with minimal morbidity. There is a need for two experienced operating teams working in tandem with two sets of endoscopic equipment, energy sources, and television monitors, which would limit this technique to hospitals where these logistics can be met. No competing financial interests exist. Runtime of video: 5 mins 46 secs

MP-07.10: Safety and Outcome of Percutaneous Nephrolithotomy in Infants and Preschool Children: Retrospective Comparison to Adult Patient Group

Percutaneous nephrolithotomy (PNL) for renal stones in children may present problems because of small size, mobility of the pediatric kidney and the small size of the collecting system. In this study, we present our experience with PNL for management of large renal calculi in children less than 7 years old, and determine its safety and efficacy.

Current Role of Robot-Assisted Pyelolithotomy for the Management of Large Renal Calculi: A Contemporary Analysis

The scope of robot-assisted surgery continues to expand with the application of these systems to management of large upper-tract urinary stones, with or without concomitant pyeloplasty. The known advantages of the robot-assisted approach, including enhanced optics, dexterity, wristed instrumentation, and ergonomics, can facilitate complex reconstruction of the collecting system, including uteropelvic junction repair. With the favorable outcomes of contemporary robot-assisted pyeloplasty series, robot-assisted applications have been translated to pyelolithotomy with or without concomitant upper-tract reconstruction. The early results of robot-assisted lithotomy reveal the procedure is a safe and efficacious approach for patients with large renal stones; nevertheless, the technique has met limited success in cases of large staghorn calculi. Our purpose was to evaluate the current role of robot-assisted pyelolithotomy for the management of large renal calculi. Given the known advantages of the robotic system in conjunction with its reconstructive capabilities, the applications of robot-assisted pyelolithotomy, although encouraging, warrant further longitudinal, multi-institutional investigation. This technique is in its early stage of implementation and randomized trials that compare robot-assisted outcomes with other minimally invasive techniques are needed to define clinical efficacy as it pertains to subsets of patients with variable stone size, location, and consistency.

Letter to the Editor

Letter to the Editor

Experience of percutaneous nephrolithotomy using adult-size instruments in children less than 5 years old

We present our experience with percutaneous nephrolithotomy (PCNL) for management of large renal calculi in children less than 5 years old, and determine its safety and efficacy when using an adult-size device. Twenty patients younger than 5 years old underwent PCNL between August 2003 and July 2008. After retrograde catheterization, the nephrostomy tract dilated up to 26Fr. Then a 24-Fr rigid nephroscope was used and stones were fragmented with a pneumatic lithotripter. Twenty patients with a mean age of 3.1 years underwent 26 PCNL procedures on 24 renal units. Four patients had bilateral renal stones. Five patients (20%) had staghorn stones, as did five of the other cases with multiple stones. Four patients had undergone previous stone surgery on the same side. All of the patients were managed with only one tract. The mean stone size was 33 (20-46)mm and average operative time was 93.25 (78-174)min. Stones were completely cleared in 79.16% of patients, which increased to 91.67% with adjunctive shockwave lithotripsy. The overall complication rate was 15.38% and mean hospital stay was 5.26 (3-8) days. PCNL is an effective and safe treatment for renal calculi in children less than 5 years old, even when using instruments designed for adults.

What is the Role of Retrograde Ureteroscopy in the Management of Large Renal Calculi?

Background and purpose: The management of large renal calculi has traditionally been with percutaneous nephrolithotomy (PCNL) or occasionally extracorporeal shock wave lithotripsy (ESWL). We present our experience of ureteroscopic treatment of large renal calculi in patients where PCNL/ESWL were contraindicated, refused or failed. Patients and methods: Data from 30 patients with intra-renal calculi ≥20 mm was prospectively entered onto a database and analysed. Patients were treated with rigid and flexible ureteroscopy (URS) using holmium laser or lithoclast (pneumatic) lithotripsy. Results: Mean stone size was 2.8cm (range 2.0–6.0cm). The most common indications were ESWL failure (40%), anatomical reasons (20%), patient choice (10%) and failed PCNL access (7%). Stone clearance (no fragments >3 mm on follow-up imaging) was observed after one URS treatment alone in 30% of patients and a further 27% with a post-operative session of ESWL. Two URS sessions alone were used in 23% of patients, with a single patient needing two URS and post-operative ESWL. Three URS sessions plus ESWL was used in 7% of patients. Three patients (10%) required PCNL. Median operative time was 60min. Complications were minimal: four patients had urinary tract infection, one failed trial without catheter, one atrial fibrillation, and one stent migration. Conclusion: Where PCNL is not favoured for any reason, patients with a large stone burden can be safely and effectively managed with retrograde URS, either with the intention of stone clearance or de-bulking prior to ESWL.

Staged Retrograde Endoscopic Lithotripsy as Alternative to PCNL in Select Patients with Large Renal Calculi

Percutaneous nephrolithotomy (PCNL) is currently the gold standard for management of large renal calculi. PCNL is associated, however, with a higher complication rate, degree of risk, and longer recovery period compared with ureteroscopy. In a selected group of patients who were not ideal candidates for PCNL because of extenuating health factors, a staged retrograde endoscopic approach was used to manage upper urinary tract calculi. We conducted a retrospective review of 23 patients (selected because of comorbidities, obesity, anatomy, and previous treatment failure as poor candidates for PCNL) who underwent staged retrograde endoscopic lithotripsy to manage upper urinary tract calculi. Lithotripsy was based on the application of small-diameter fiberoptic ureteroscopes and the holmium laser. Successful therapy was defined as total fragmentation of stone burden on repeated imaging. Data were analyzed using descriptive statistics. Of the 468 patients who underwent ureteroscopy at our institution from 2003 to 2006, 23 patients (52% men, 57.70 +/- 11.44 years of age) were treated with retrograde endoscopic procedures for upper urinary tract calculi (52.2% lower pole). Stone burden at the initial procedure was 2.13 +/- 2.34 stones with a total linear length of 30.91 +/- 14.28 mm and an estimated total stone volume of 12,040.78 +/- 11101.54 cc (median value, 7,234.00 cc). There were no intraoperative complications; three patients were admitted postoperatively for observation. Ten 43.5%) patients (progressed to second-stage procedures (34.6 +/- 10.8 days apart). After repeated imaging, 73.9% of patients were stone free (88% lower pole), and 8.7% progressed to further intervention. Total linear stone length <4 cm and estimated calculus volume > or =15,000 cc predicted treatment failure (40%, 42.9%). Percutaneous methods of managing renal stones have an increased rate of complications compared with ureteroscopy. In patients with complex medical histories, upper urinary tract calculi <4 cm can be safely and effectively managed using a staged retrograde endoscopic approach.

Editorial comment

Despite the increased availability of shock wave lithotriptors and holmium lasers, percutaneous renal surgery remains a necessary tool for the successful management of large renal calculi. Although confidence in performing this procedure has grown significantly since the late 1970s, bleeding and, more specifically, hemorrhage requiring angiographic intervention, remain feared complications.