Pelvic Perforation Research Articles

Use of Moses 2.0 with extended frequency and optimized Moses vs. high-power laser in MiniPCNL: a randomized controlled trial

The aim of the study was to compare standard high-power laser (with < 80Hz) to extended frequency (> 100Hz) lithotripsy during miniPCNL. 40 patients were randomized in to two groups undergoing MiniPCNL. For both groups, the Holmium Pulse laser Moses 2.0 (Lumenis) was used. For group A, standard high-power laser with < 80Hz, with Moses distance was set using up to 3J. For Group B, extended frequency (100-120Hz) was used allowing up to 0.6J. All patients underwent MiniPCNL using an 18 Fr balloon access. Demographics were comparable between groups. Mean stone diameter was 19mm (14-23) with no differences between groups (p = 0.14). Mean operative time was 91 and 87min for group A and B (p = 0.71), mean laser time was similar in both groups, 6.5min and 7.5min, respectively (p = 0.52) as well as the number of laser activations during the surgery (p = 0.43). Mean Watts used was 18 and 16 respectively being similar in both groups (p = 0.54) as well as the total KJoules (p = 0.29). Endoscopic vision was good in all surgeries. The endoscopic and radiologic stone free rate was achieved in all patients expect for two in both groups (p = 0.72). Two Clavien I complications were seen, a small bleeding for group A and a small pelvic perforation in group B. The use of high-power holmium laser with extended frequency and optimized Moses was effective and safe being comparable to standard high-power laser for MiniPCNL allowing more versatility with the setting range.

A novel spherical-headed fascial dilator is feasible for second-stage ultrasound guided percutaneous nephrolithotomy: A pilot study

ObjectiveIn second-stage percutaneous nephrolithotomy (PCNL), because the hydronephrosis has been decompressed, the dilated renal pelvis has resolved and the space is small. Consequently, introduction of the tip of the Amplatz dilator can cause injury to the opposite side of the renal-pelvic mucosa. In this study, we report the experimental and initial clinical performance of a spherical-headed fascial dilator developed specifically for second-stage PCNL. MethodsThe novel spherical-headed dilator was compared with existing tapered-headed dilators in configuration and in puncture resistance utilizing a static puncture test. Subsequently, a pilot clinical study was conducted during which patients scheduled to undergo second-stage PCNL from June 2019 to October 2019 in our center were enrolled. A typical ultrasound guided PCNL procedure was performed with the exception that the new spherical-headed fascial dilator was substituted for a tapered-headed one. ResultsExperimentally, stab resistance against polyethylene film was significantly increased using the novel spherical-headed dilator compared to the traditional tapered-headed dilators (p<0.005). In the clinical study, the novel dilators were successfully introduced into the renal pelvis and passed down the collecting system in all eight second-stage PCNL cases. There were no cases of renal pelvic perforation or brisk hemorrhage nor need for transfusion. ConclusionThe design of the novel spherical-headed fascial dilator avoided the concentration of pressure at the tapered tip of the current Amplatz dilator by increasing the contact area and uniformly distributing and diffusing the pressure. Therefore, it is feasible to use the spherical-headed fascial dilator for second-stage PCNL.

Renal pelvic perforation due to double J stent insertion in a nine year old child: An unusual complication of a routinely done procedure

Double J (DJ) stenting is a routinely done procedure in endourology for various indications. Though a commonly done procedure DJ stenting is not without complications. We present a case of renal pelvic perforation due to DJ stenting and stent malposition leading to morbidity to a nine year old child. This case reiterate the importance of use of fluoroscopy in all cases of DJ stenting and use of retrograde pyelography whenever there is difficulty in DJ stenting.

Pediatric Percutaneous Nephrolithotomy in a Peripheral Tertiary Care Center in Nepal

Introduction: Pediatric nephrolithiasis though uncommon, poses clinical management dilemma due to anatomical and physiological factors. Percutaneous Nephrolithotomy (PCNL) is well established in adults and miniaturization of the instruments has helped to expand its indication for uses in pediatric population with equivalent results. The aim of our study is to evaluate the application of the procedure in our settings. Methods: This was a retrospective study done at Nepalgunj Medical College teaching hospital from June 2017 to April 2020. Total of 75 patients with 76 renal units under 18 year of age were evaluated. PCNL was done in prone position in all patients using fluoroscopy for initial puncture and subsequently for clearance. The size of the tract varying from 15 Fr to 24 Fr was decided based on the degree of hydronephrosis. Results: Mean stone volume was 372 mm2. With mean operative time of 58 min, 96% of stone clearance rate was achieved. Mini PCNL was done in most of the cases. Single tract was used in 84% cases mostly with subcostal puncture. Major complications were pelvic perforation in 4% cases and two patients required restaging. Conclusion: PCNL in pediatric population is safe with good stone free rate with minimal complications. Application of miniaturized instruments has further improved the outcome with comparable morbidity.

Pediatric Percutaneous Nephrolithotomy in a Peripheral Tertiary Care Center in Nepal

Introduction Pediatric nephrolithiasis though uncommon, poses clinical management dilemma due to anatomical and physiological factors. Percutaneous Nephrolithotomy (PCNL) is well established in adults and miniaturization of the instruments has helped to expand its indication for uses in pediatric population with equivalent results. The aim of our study is to evaluate the application of the procedure in our settings.&#x0D; MethodsThis was a retrospective study done at Nepalgunj Medical College teaching hospital from June 2017 to April 2020. Total of 75 patients with 76 renal units under 18 year of age were evaluated. PCNL was done in prone position in all patients using fluoroscopy for initial puncture and subsequently for clearance. The size of the tract varying from 15 Fr to 24 Fr was decided based on the degree of hydronephrosis.&#x0D; ResultsMean stone volume was 372 mm2. With mean operative time of 58 min, 96% of stone clearance rate was achieved. Mini PCNL was done in most of the cases. Single tract was used in 84% cases mostly with subcostal puncture. Major complications were pelvic perforation in 4% cases and two patients required restaging.&#x0D; ConclusionPCNL in pediatric population is safe with good stone free rate with minimal complications. Application of miniaturized instruments has further improved the outcome with comparable morbidity.

Retrospective analysis of the results of transurethral contact pyelocalycolithotripsy in patients with kidney stones

Transurethral contact lithotripsy is a promising treatment method and occupies an important place among endoscopic methods for removing kidney stones.&#x0D; The aim of the study was to identify the advantages and disadvantages of transurethral contact pyelocalycolithotripsy in patients with kidney stones based on retrospective analysis.&#x0D; Material and methods. A retrospective analysis of 178 clinical cases of treating patients aged from 19 to 71 years who suffered from kidney stones and underwent transurethral contact pyelocalycolithotripsy was performed. All patients were diagnosed with calculi of the pyelocaliceal system with the diameter ranging from 10 to 20 mm according to multispiral CT data. Renal calculi had different composition and their density varied from 460 HU to 1440 HU. Pneumatic and laser energy was used for lithotripsy in 102 (57.3%) and 76 (42.7%) patients respectively.&#x0D; Results. The obtained data show that complete destruction of the stones and the removal of fragments within 2 weeks after transurethral contact pyelocalycolithotripsy was noted in 143 (80.3%) patients. In 140 (78.7%) cases positive results were achieved in one surgical intervention and in 38 (21.3%) patients after two procedures. Complications of this treatment method were relatively rare and included intraoperative bleeding, pelvic perforation, acute pyelonephritis, stent migration, postoperative bleeding, and residual stones.&#x0D; Conclusion. Transurethral contact pyelocalycolithotripsy is a promising method due to the fact that in most cases it allows you to simultaneously rid a patient of kidney stones with minimal complications

Safety and efficacy of supracostal superior calyceal approach for percutaneous renal surgery.

Supracostal access is avoided for fear of potential intrathoracic complications and subcostal approach is favored as it carries minimal or no risk of intrathoracic complication. The aim of this study was to evaluate safety and efficacy of supracostal approach for percutaneous renal surgery. A total of 60 cases were enrolled and studied prospectively in this study. The patients had upper (n=10), and lower (n=12) calyceal, pelvic (n=12), proximal ureteral (n=14) stones, and pelviureteric junction obstruction (n=12). All the punctures were made by urologist under fluoroscopy. All the punctures were made between 11th and 12th ribs (supra-12th); none of the punctures was made above 11th rib. The overall complication rate in our study was 26.7%. Four patients (6.7%) had pleural rupture and all the four presented with hydrothorax. The other complications included intraoperative hemorrhage in 1 (1.7%), and pelvic perforation in 1 patient (1.7%), Amplatz sheath migration/loss of tract was detected in 1 (1.7%), postoperative fever in 2 (3.3%), prolonged hematuria in 3 (5%) and residual disease in 4 (6.7%) patients CONCLUSION: Supracostal approach should be used whenever indicated which was found to be both effective and safe as far as intrathoracic and other complications are concerned.

2213 Spinal Rod Migration and Pelvic Perforation in a Patient with Severe Cerebral Palsy and Scoliosis

Video Objective To describe a rare occurrence of spinal hardware migration and perforation into the pelvic peritoneum. To describe the evaluation of the pelvic organs with perforating trauma. Setting Academic university affiliated tertiary care center. Interventions Cerebral palsy refers to a heterogeneous group of conditions involving permanent nonprogressive central motor dysfunction that affect muscle tone, posture, and movement. It can be associated with neuromuscular scoliosis which can cause large curves in the spine and pelvic obliquity necessitating spinal and pelvic fusion and fixation. Hardware failures from these surgeries are rare however do occur with increased incidence in patients with risk factors such as ongoing severe contractures of the spine. Specifically, the Luque rod has been associated with complications and even pelvic cortex perforation. This video describes a rare occurrence of a Luque rod perforation from the spine and bony pelvis into the retroperitoneum and perforation into the pelvis. We show an evaluation of the potential trauma sites and highlight the location of this rod in relation to the surrounding vital pelvic structures. Conclusion We report a rare occurrence of spinal hardware migration and perforation into the pelvic peritoneal cavity. Multispecialty surgical planning and coordination is extremely important. Many contingent surgical plans are necessary prior to the operating room for optimal outcomes.

Modified tubeless minimally invasive percutaneous nephrolithotomy for management of renal stones in children: A single-centre experience

ABSTRACTObjectives: To evaluate the safety, effectiveness and morbidity, as well as the usefulness of a modified supine mini-percutaneous nephrolithotomy (PCNL) for managing renal stones in children.Patients and methods: We studied 50 children, from September 2017 to September 2018, who were aged 4–16 years with a single renal pelvic or calyceal stone of <2 cm. We used a 9-F short ureteroscope through a 16-F metal access sheath with an alternative approach that allows a second percutaneous procedure using the same tract. If a residual stone was present, we recovered the track back through the exteriorised ureteric catheter at the flank.Results: Of all 50 patients, 48 (96%) underwent the modified supine mini-PCNL technique, which produced a primary stone-free rate of 80% that increased to 100% after treating the residual stones by a second look. The mean operative and fluoroscopic times were 89.10 and 7.68 min, respectively. One case (2%) had significant bleeding and one case (2%) had pelvic perforation; and a nephrostomy tube was inserted in both cases. The mean haemoglobin drop was 0.91 g/dL (P < 0.001). The mean hospital stay was 1.42 days and the mean pain score was 2.08, the pain score was 5 in the two cases in which a nephrostomy tube was inserted.Conclusion: The modified supine mini-PCNL is a safe and effective method for managing renal stones in children, with less postoperative pain and discomfort, less analgesic requirement, and provides access back for a second look.Abbreviations: ESWL: extracorporeal shockwave lithotripsy; Hb: haemoglobin: PCNL: percutaneous nephrolithotomy; SFR: stone-free rate

Safety and Efficacy of Supracostal Approach for Percutaneous Nephrolithotomy (A Prospective Study)

AbstractBackground: The management of large kidney stones is still one of today's topics in endourology. Supracostal Percu-taneous Nephrolithotomy (PCNL) is found to be a highly effective procedure in treatment of renal calculi. However, many factors are affecting the safety and efficacy of the procedure.Aim of Study: The aim of this study was to evaluate the factors that affect the safety and efficacy of supracostal PCNL in kidney stones.Patients and Methods: Fifteen patients with renal calculi underwent supracostal percutaneous nephrolithotomy either with single access or multiple accesses. Pre-operative, operative and post-operative data were reported. Multivariate analyses as well as univariate analyses were used to investigate the effects of different variables on residual stones and blood transfusion rate. These factors include age, sex, laterality, body mass index, history of ipsilateral open renal surgery, operative time, and stone density.Results: The study included 15 patients with mean stone size is 2.5cm±0.6, all stones were radiopaque with mean HFU 969±134, R, 4 patients had upper calyceal stone (26.7%), 9 patients had stone pelvis and upper calyx (60%), and 2 patients had complex stone. (13.3%), 9 patients had multiple kidney punctures (60%) and 6 patients had single kidney puncture (40%), one case had positive signs of hydrothorax intraoper-atively (6.7%) by fluoroscopy, one case had pelvic perforation (6.7%), mean operative time was 105 minutes ±0.23, post-operative chest X-ray revealed positive signs in 2 cases (13.4%) with mild symptoms and needed no intervention, 1 case had significant post-operative bleeding (6.7%) and needed blood transfusion, mean hospital stay time was 2.7 days ±1.8, residual stones were encountered in 4 cases (27%).Conclusion: Supracostal PCNL is a safe and effective procedure for kidney stones more than 2cm. The stone free rate in the study was related mainly to patient’s comorbidities like BMI, stone size and site. Chest complications needed intervention in only one case, later on was completely free.

Safety and efficacy of mini-percutaneous nephrolithotomy in the treatment of large impacted proximal ureteral stones

Background: To evaluate the efficacy and safety of Mini-Percutaneous Nephrolithotomy (PCNL) in the treatment of large (≥15mm) impacted proximal ureteral stones.Methods: This was a prospective observational study and was conducted in the Postgraduate Department of Surgery, Govt. Medical College, Srinagar. A total of 60 patients were included in this study.Results: The mean age (in years) of patients was 38.5±9.31 and range 22-58, the male female ratio was 40:20, the disease laterality (right: left) was 48:12, the mean stone size (in mms) was 17.6±2.11. All the patients were having hydronephrotic kidneys, however, all the renal units were functional. The mean operative time (in minutes) was 62±9.62. The overall success rate was 96.7% after one month of follow-up the stone free rate was 96.7% while as the stone free rate on discharge was 86.7%. The mean hospital stays (in days) was 2.8±1.08. The overall complication rate in this study was 15 patients (25%) which include post-operative fever in 5 patients (8.33%), prolonged hematuria in 4 patients (6.67%), residual stone/disease after 4weeks of follow-up was seen in 2 patients (3.33%) and in 4 patients (6.67%) thoracic complication was seen. However, no ureteral injury, hollow visceral or pelvic perforation was noted. The post-operative analgesic requirement was 100±40.45mgs of Inj. Tramadol. The need of auxiliary procedures was required in 3.3% of patients.Conclusions: Mini-PCNL is both safe as well as an effective therapy for large impacted proximal ureteral stones with a higher success, stone clearance rate and with acceptable complications.

Percutaneous nephrolithotomy; alarming variables for postoperative bleeding

ObjectivesTo evaluate factors contributing to bleeding after percutaneous nephrolithotomy (PCNL) and ways of managing this complication, as bleeding is a serious sequela that requires prompt management. Patients and methodsThe demographic and procedural data of 200 patients, who underwent unilateral PCNL during a 20-month period, were prospectively collected. Preoperative, operative, and postoperative details were recorded. The preoperative variables analysed included: age, sex, body mass index (BMI), the presence of hypertension, diabetes mellitus, serum creatinine, degree of hydronephrosis, previous ipsilateral open renal surgery, stone size and complexity. The operative variables analysed included: number of tracts, operative time, size of Amplatz sheath, type of anaesthesia, and complications such as calyceal and pelvic perforation. ResultsThe variables of age, sex, BMI, diabetes, hypertension, and a preoperative creatinine level of >1.4mg/dL had no significant effect on blood loss (all P>0.05). However, the rate of bleeding was significantly higher (P⩽0.05) in patients who had a history of previous open renal surgery, intraoperative pelvicalyceal perforations, and Guy’s Stone Score (GSS) grade 3 and 4 complex stones; however, absence of hydronephrosis, larger stone size, operative time (>83min), more than one puncture, and size of the Amplatz sheath (26–30 F) did not maintain their significance in multivariate analysis. ConclusionAccording to our present results stone complexity (GSS grade 3 and 4), history of ipsilateral renal stone surgery, and occurrence of intraoperative pelvicalyceal perforation are alarming variables for post-PCNL bleeding.

Micropercutaneous nephrolithotomy (microperc) vs retrograde intrarenal surgery for the management of small renal calculi: a randomized controlled trial

To compare micropercutaneous nephrolithotomy (microperc) and retrograde intrarenal surgery (RIRS) for the management of renal calculi <1.5 cm with regard to stone clearance rates and surgical characteristics, complications and postoperative recovery. Seventy patients presenting with renal calculi <1.5 cm were equally randomized to a microperc or a RIRS group between February 2011 and August 2012 in this randomized controlled trial. Randomization was based on centralized computer-generated numbers. Patients and authors assessing the outcomes were not blinded to the procedure. Microperc was performed using a 4.85-F (16-gauge) needle with a 272-μm laser fibre. RIRS was performed using a uretero-renoscope. Variables studied were stone clearance rates, operating time, need for JJ stenting, intra-operative and postoperative complications (according to the Clavien-Dindo classification system), surgeon discomfort score, postoperative pain score, analgesic requirement and hospital stay. Stone clearance was assessed using ultrasonography and X-ray plain abdominal film of kidney, ureter and bladder at 3 months. There were 35 patients in each group. All the patients were included in the final analysis. The stone clearance rates in the microperc and RIRS groups were similar (97.1 vs 94.1%, P = 1.0). The mean [sd] operating time was similar between the groups (51.6 [18.5] vs 47.1 [17.5], P = 0.295). JJ stenting was required in a lower proportion of patients in the microperc group (20 vs 62.8%, P < 0.001). Intra-operative complications were a minor pelvic perforation in one patient and transient haematuria in two patients, all in the microperc group. One patient in each group required conversion to miniperc. One patient in the microperc group needed RIRS for small residual calculi 1 day after surgery. The decrease in haemoglobin was greater in the microperc group (0.96 vs 0.56 g/dL, P < 0.001). The incidence of postoperative fever (Clavien I) was similar in the two groups (8.6 vs 11.4%, P = 1.0). None of the patients in the study required blood transfusion. The mean [sd] postoperative pain score at 24 h was slightly higher in the microperc group (1.9 [1.2] vs 1.6 [0.8], P = 0.045). The mean [sd] analgesic requirement was higher in the microperc group (90 [72] vs 40 [41] mg tramadol, P < 0.001). The mean [sd] hospital stay was similar in the two groups (57 [22] vs 48 [18] h, P = 0.08). Microperc is a safe and effective alternative to RIRS for the management of small renal calculi and has similar stone clearance and complication rates when compared to RIRS. Microperc is associated with higher haemoglobin loss, increased pain and higher analgesic requirements, while RIRS is associated with a higher requirement for JJ stenting.

Isolated Upper Pole Access in Percutaneous Nephrolithotomy: A Large-Scale Analysis from the CROES Percutaneous Nephrolithotomy Global Study

We analyzed the indications for and outcomes of percutaneous nephrolithotomy using upper pole access. Between 2007 and 2009 prospective data were collected by the Clinical Research Office of the Endourological Society (CROES) from consecutive patients at 96 centers globally. Data on 4,494 patients were included in this analysis. Patients were divided into upper and lower pole access groups based on the location of percutaneous renal access. Preoperative characteristics and outcomes were compared between the 2 groups by univariate and multivariate tests. The upper pole access group had more staghorn stones (21.7% vs 15.5%, p <0.001) and a greater stone burden (mean ± SD 476 ± 390.5 vs 442 ± 344.9 mm(2), p = 0.091). Mean operative time was 92.4 ± 46.1 and 75.1 ± 41.3 minutes in the upper and lower pole groups, respectively (p <0.001). The stone-free rate was lower in the upper pole access group (77.1% vs 81.6%, p = 0.030). The overall complication rate was higher in the upper pole group with a higher incidence of hydrothorax (5.8% vs 1.5%) but a lower incidence of pelvic perforation (1.8% vs 3.2%). Mean hospital stay was longer in the upper pole group (p = 0.048). Success and complication rates were similar in upper pole access subgroups, defined as definitive (staghorn and isolated upper calyceal stones) and elective (pelvic, middle calyceal and lower pole stones) indications. Isolated upper pole access is indicated in a select group of patients with complex stones. Upper calyceal and staghorn stones are more commonly managed by upper pole access, which is associated with a higher complication rate and longer hospital stay as well as a lower stone-free rate due to procedure complexity.

Spontaneous and uncomplicated anal elimination of a hip pin—a case report

In 2005 a 78-year-old woman was admitted with an undisplaced proximal femoral fracture and was operated with osteosynthesis by 2 hip pins (Smith and Nephew, Tuttlingen, Germany). Postoperatively, she was allowed full weight bearing and left hospital 14 days later. At first follow-up, 8 weeks after surgery, the patient walked with an ambulatory device and admitted that she had some pain. The radiographs showed a displaced fracture (Figure 1A-C). The patient was informed about possible prognosis outcome, but she was satisfied with the progress thus far and refused any kind of further treatment at this point. Figure 1. A. Undislocated primary fracture. B. The day after surgery, showing dislocation. C. Two months postoperatively. D. Six years postoperatively. Follow-ups at 5 and 8 months revealed further displacement of an unhealed fracture. The patient was still not motivated to have further treatment, and no additional follow-up was planned. In June 2011, the patient felt moderate anal discomfort. During defecation the following day, she experienced pain and needed aid from her home-based nurse to extract a foreign body which slipped into the toilet bowl with a metallic sound. With suspicions about the origin of the screw, it was presented to the patient’s GP and she was admitted to our outpatient clinic for further investigation. The patient was completely asymptomatic in the abdomen, and her anal discomfort had disappeared. The radiograph (Figure 1D) revealed only 1 remaining hip pin and the screw presented to us was confirmed to be identical to the missing distal screw implanted in the patient’s left hip 6 years earlier. The fracture was greatly displaced, with no sign of healing and the remaining screw was still in situ; it was displaced, but without any major migration. The skin showed no recent scars or signs of perforation. To avoid further complications, including pelvic migration, the remaining screw was easily removed percutaneously under local anesthesia. In order to reveal any possible intrapelvic damage, and at the same time hoping to track the pathway of the migrated screw, we performed a CT scan (Figure 2A-C) with 3D reconstructions (Figure 3A and B). The CT scans left no doubt regarding the pathway of the screw. The femoral head was perforated with a canal similar to the diameter of the screw and there was a crater in the pelvic bone located in line with the perforation through the femoral head. There was no sign of bowel perforation, but some scar tissue was located between the rectum and the crater surrounding the pelvic perforation. The location of the scar tissue and the pelvic bone perforation indicated a migration into the extraperitoneal part of the colon. Figure 2. CT scans showing the canal through which the hip pin had migrated through the femoral head and the pelvic bone before entering the abdomen. Figure 3. CT reconstruction (3D) of the entry hole through the pelvic bone, identifying the entry point of the screw to the abdomen before entering the rectum on its way to defecation.

Spontaneous expulsion of a screw: An unusual complication 3 years after internal fixation of posterior acetabular wall fracture

Although cases have been documented describing wires extracorporeal expulsion associated with osteosynthesis, interference screw disengaging from the tibial tunnel in anterior cruciate ligament reconstructions, screw migration from the symphysis to the bladder in pelvic fractures and oesophageal perforation from anterior cervical instrumentation, no reports have noted migration of a failed implant after acetabular fractures. In this report, we present a novel case in which an acetabular screw spontaneously migrated 3 years after the surgery, undergoing subsequent transcutaneous expulsion.

The Percutaneous Nephrolithotomy Global Study: Classification of Complications

This study evaluated postoperative complications of percutaneous nephrolithotomy (PCNL) and the influence of selected factors on the risk of complications using the Clinical Research Office of the Endourological Society (CROES) PCNL Global Study database. The CROES PCNL Global Study collected prospective data for consecutive patients who were treated with PCNL at centers around the world for 1 year. Complications were evaluated by the modified Clavien classification system. Of 5724 patients with Clavien scores, 1175 (20.5%) patients experienced one or more complications. The most frequent complications were fever and bleeding. Urinary leakage, hydrothorax, hematuria, urinary tract infection, pelvic perforation, and urinary fistula also occurred in ≥20 patients in each group. The majority of complications (n=634, 54.0%) were classified as Clavien grade I. Two patients died in the postoperative period. The largest absolute increases in mean Clavien score were associated with American Society of Anesthesiologists (ASA) physical status classification IV (0.75) or III (0.34), anticoagulant medication use (0.29), positive microbiologic culture from urine (0.24), and the presence of concurrent cardiovascular disease (0.15). Multivariate regression analysis revealed that operative time and ASA score were significant predictors of higher mean Clavien scores. The majority of complications after PCNL are minor. Longer operative time and higher ASA scores are associated with the risk of more severe postoperative complications in PCNL.

Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis

Supine position and prone position were the choice for percutaneous nephrolithotomy (PCNL). However, there is still no consensus on the optimal position for PCNL. A systematic literature review was performed, searching Pubmed, Embase, CENTRAL and reference lists for relevant studies. Data from all selected articles were extracted independently by two reviewers and analyzed by RevMan 5 software. Four comparative studies involving 389 cases and 27 case series studies including 1,469 renal units of supine position and 4,837 renal units of prone position were identified. With reference to comparative studies, the mean stone length and the proportions of staghorn and multiple stones were comparable between two positions. There was no significant difference in terms of stone-free rate (risk ratio=1.00, 95% confidence interval: 0.92 to 1.09; 82.4 vs. 82.1%) and bleeding. The rate of colonic injury in supine PCNL was approximate 0.5% and incidence of pleural injury of 0% was noted for both positions. Pelvic perforation and failed access were comparable between supine and prone position. The operative times of supine position significantly decreased (65±15 vs. 90±15min; mean difference=-24.76, 95% confidence interval: -39.36 to -10.15), but no significant difference was found in mean days hospital stay. Analysis based on the case series showed larger proportion of staghorn and multiple calculi in prone position (45.8 vs. 31.7%), the supine PCNL had slightly lower bleeding and similar stone-free rate compared with the prone position. For general patients with kidney calculi, PCNL in supine position has similar stone-free rate compared with prone. Supine PCNL do not increase related complications. The operative times significantly decrease in supine position.

Percutaneous nephrolithotomy in horseshoe Kidneys: is rigid nephroscopy sufficient tool for complete clearance? a case series study

Backgroundthis study represents a case series to evaluate how successful is the rigid percutaneous nephroscopy as a tool for clearance of all stones in various locations in horseshoe kidneys.MethodsBetween 2005 and 2009, we carried out PCNL (percutaneous nephrolithotomy) for calculi in horseshoe kidneys in 21 renal units (17 patients) in our department. The indications were large stone burden in 18 units and failed SWL(shock wave lithotripsy) in 3 renal units. All procedures were done under general anesthesia; using fluoroscopic guidance for localization and standard alkan dilatation followed by rigid nephroscopy and stone extraction with or without stone disintegration. We analyzed our results regarding the site and number of the required access, the intra and postoperative complications, the presence of any residual stones, as well as their location.ResultsThe procedure was completed, using a single access tract in 20 renal units, with the site of puncture being the upper calyx in nine units and the posterior middle calyx in eleven units. Only in one renal unit, two access tracts (an upper and a lower calyceal) were required for completion and a supracostal puncture was required in another case. There was no significant intraoperative bleeding and no blood transfusion was required in any patient. A pelvic perforation occurred in one case, requiring longer PCN (percutaneous nephrostomy) drainage. One patient with infection stones suffered urosepsis postoperatively which was successfully managed. Three cases had residual stones, all located in the renal isthmus, all residuals were un approachable with the rigid instrument; resulting in a overall stone-free rate of 85.7% at discharge.ConclusionPercutaneous nephrolithotomy is generally safe and successful in the management of stones in horseshoe kidneys. However, location of the stones in these patients is crucial to decide the proper tool for optimal stone clearance result.

Commentary on Flexible robotic retrograde renoscopy: Description of novel robotic device and preliminary laboratory experience

To describe a novel flexible robotic system for performing retrograde intrarenal surgery. Remote robotic flexible ureterorenoscopy was performed bilaterally in 5 acute swine (10 kidneys). A novel 14F robotic catheter system, which manipulated a passive optical fiberscope mounted on a remote catheter manipulator was used. The technical feasibility, efficiency, and reproducibility of accessing all calices were assessed. Additionally, laser lithotripsy of calculi and laser ablation of renal papillae were performed. The robotic catheter system could be introduced de novo in 8 ureters; 2 ureters required balloon dilation. The ureteroscope could be successfully manipulated remotely into 83 (98%) of the 85 calices. The time required to inspect all calices within a given kidney decreased with experience from 15 minutes in the first kidney to 49 seconds in the last (mean 4.6 minutes). On a visual analog scale (1, worst to 10, best), the reproducibility of caliceal access was rated at 8, and instrument tip stability was rated at 10. A renal pelvic perforation constituted the solitary complication. Histologic examination of the ureter showed changes consistent with acute dilation without areas of necrosis. A novel robotic catheter system is described for performing retrograde ureterorenoscopy. The potential advantages compared with conventional manual flexible ureterorenoscopy include an increased range of motion, instrument stability, and improved ergonomics. Ongoing refinement is likely to expand the role of this technology in retrograde intrarenal surgery in the near future.