Percutaneous Nephrolithotomy In Terms Research Articles

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.

The effect of anesthesia type on the outcomes of percutaneous nephrolithotomy in elderly males

Objective: To compare the anaesthesia methods in percutaneous nephrolithotomy in terms of safety and effectiveness in elderly men. Methods: Elderly male patients who had undergone percutaneous nephrolithotomy were screened retrospectively and divided into 2 groups: percutaneous nephrolithotomy under combined spino-epidural anaesthesia (Group CSEA, n = 70) and percutaneous nephrolithotomy under general anaesthesia (Group GA, n = 114). Preoperative, perioperative and postoperative outcome measures were examined. Results: Between the two groups, there was no statistically significant difference in terms of stone burden, stone location, presence of the previous operation in the same kidney, presence of staghorn stones, mean American Society of Anesthesiologists scores and presence of abnormal kidney (p > 0.05). The mean duration time in the operation room and post-anaesthesia care unit (PACU) was statistically shorter in the Group CSEA (p < 0.01). There was no significant difference between the two groups in terms of Clavien Grade 1 and above complications (p > 0.05). Stone-free rates and success rates were similar in both groups (p = 0.133 and p = 0.273, respectively). Conclusion: The type of anaesthesia does not affect the success rate and complication rate of percutaneous nephrolithotomy in elderly male patients. Patients who underwent percutaneous nephrolithotomy under CSEA needed less analgesic injection during the postoperative period. CSEA can shorten the time a patient spends in the operating room and PACU, which provides more effective use of operation room working hours.

Comparative Study of Prone Position Variations for Percutaneous Nephrolithotomy.

In this comparative study, we evaluated the results of flat prone and prone hip flexed percutaneous nephrolithotomy in terms of efficacy and safety to contribute to the optimal prone percutaneous nephrolithotomy position. Data of the patients who underwent percutaneous nephrolithotomy operations in a flat-prone or prone hip flexed positions due to renal pelvis and/or ≥2 Calix filling stones between January 2016 and January 2022 were collected retrospectively. Demographic data of the patient groups in different prone positions as well as clinical findings, stone characteristics and operative data were analyzed. The groups were also compared in terms of post-operative findings and complications. The average age and CROES scores of patients included in the study were 47.15±15.6 years and 221.76±62.49, respectively. There was no statistically significant difference between the two groups in terms of patient demographic data, stone-free status and complication rates. Operation Room Time (ORT) (min) in flat prone PCNL group was shorter in average (100.57±32.74 min vs 92.32±28.75 min, p = 0.041) and duration with nephrostomy (days) and hospitalization (days) parameters were statistically significantly shorter in prone hip flexed PCNL (respectively, p < 0.001; p = 0.005). Flat-prone PCNL provides significantly shorter ORT. However, the time with nephrostomy and hospitalization with the prone hip flexed PCNL were shorter than flat-prone position. The findings will guide the optimal prone PCNL position.

Is laparoscopic pyelolithotomy an alternative to percutaneous nephrolithotomy for treatment of kidney stones larger than 2.5cm in pediatric patients?

The aim was to compare laparoscopic pyelolithotomy and percutaneous nephrolithotomy in terms of efficacy and safety for the treatment of renal pelvis stones larger than 2.5cm in pediatric patients. Our study consisted of two groups. Group 1 included 33 patients who underwent laparoscopic pyelolithotomy (LPL) between January 2013 and March 2022, and group 2 included 39 patients who underwent percutaneous nephrolithotomy (PCNL). The basic clinical parameters of the patients were recorded. Mean operation time, stone size, estimated blood loss, blood transfusion rate, postoperative hospital stay, stone-free rate, postoperative analgesia requirements, intraoperative complications, and early and late postoperative complications were compared between the two groups. In our study, the mean age of the patients in groups 1 and 2 was 8.89 ± 1.58years and 9.1 ± 1.85years, respectively (p = 0.657). The mean stone size was 2.37 ± 0.38cm in group 1 and 2.55 ± 0.45cm in group 2 (p = 0.64). The mean operation time was 85.65 ± 20.55min in group 1, while it was 76.11 ± 13.12min in group 2 (p = 0.08). The stone-free rate was 100% in both groups. Intraoperative mean blood loss, need for postoperative analgesia, blood transfusion and intraoperative complication rates were significantly higher in the PCNL group (p < 0.01, p = 0.02, p < 0.01, p < 0.01, respectively). Our results show that laparoscopic pyelolithotomy is a safe and effective method for pediatric patients with large kidney stones.

Tubeless versus conventional minimally invasive percutaneous Nephrolithotomy: A comparative study

PCNL (Percutaneous Nephrolithotomy) and MPCNL (Miniaturized Percutaneous Nephrolithotomy) are minimally invasive surgical procedures used to treat kidney stones. Both PCNL and MPCNL are effective treatments for kidney stones, but the choice of procedure depends on the size, location, and number of stones, as well as the patient&#39;s medical history and overall health. The present study was aimed to assess the safety and efficacy of tubeless PCNL compared to conventional PCNL in terms of Postoperative pain, hospital stay, Drop in Haemoglobin levels, Operative time, Stone free rate, Post operative fever. Methodology: A Prospective comparative interventional study has been done in Department of Urology, Mamata Super Specialty Hospital, Khammam with a total of 50 patients who were randomized into two groups of 25 each undergoing tubeless mini PCNL and conventional mPCNL respectively. Results: The mean age was 43.76 years and 41.92 years for mini PCNL and conventional mPCNL groups respectively, the mean calculus size in the tubeless PCNL group was 2.028 cm, while in the conventional PCNL group, it was 2.452 cm. There was significantly lesser operative time taken in conventional PCNL group when compared with Tubeless PCNL group. Stone free clearance rate 97% in tubeless PCNL. The mean hospital stay in tubeless PCNL group was significantly more than that in conventional PCNL. Conclusion: Both tubeless mPCNL and conventional mPCNL had similar surgical outcomes, but tubeless mPCNL had reduced surgery time, stone clearance, and hospital stay, indicating its potential for wider use.

Does surgical position affect infective complications in percutaneous nephrolithotomy?

The downward orientation of the access sheath during supine percutaneous nephrolithotomy (PCNL) allows the faster evacuation of fluids and stone fragments. It theoretically can contribute to the reduction of the high intrarenal pressure-associated complications. We aimed to investigate whether there is a difference between prone and supine PCNL in terms of infective complications. This retrospective study includes 182 patients who underwent supine and prone PCNL due to kidney stones in our clinic between April 2020 and May 2022. Demographic (age, sex, body mass index, comorbidities), radiological (cumulative stone burden, stone density, number of stones, stone localization, stone laterality, presence of hydronephrosis), clinical (previous stone surgery, previous urinary tract) and perioperative (prone or supine position, surgery duration, hospitalization, success, non-infective and infective complications) data of all patients were evaluated. All patients were divided into two groups, the prone position group, and the supine position group. These two groups were compared in terms of pre and postoperative data above. Infective complications were observed in 16 (18%) patients in the prone position group and in 7 (7.5%) patients in the supine position group, and this difference was statistically significant (p = 0.034). Surgery duration (OR = 1.041; 95% CI 1.021-1.061; p < 0.001), number of stones (OR = 4.09; 95% CI 1.093-7.309; p = 0.036), previous urinary tract infection (OR = 6.272; 95% CI 1.936-9.317; p = 0.002) and prone position (OR = 4.511; 95% CI 1.265-7.087; p = 0.02) were found as independent risk factors for infective complications. Prone position was proved as an independent predictor of postoperative infectious events. Supine PCNL will be further adopted as the standard PCNL approach by a continuously growing proportion of endourologists.

Is retrograde intrarenal surgery a safer and more efficient alternative treatment to percutaneous nephrolithotomy in terms of higher stone-free rates and shorter hospital stay among adults with kidney stones 20 mm or greater?

This review aims to evaluate whether retrograde intrarenal surgery (RIRS) is a safe and efficient alternative treatment to percutaneous nephrolithotomy (PCNL) for stones 20 mm or greater in terms of stone-free rate (SFR) and shorter hospital stay due to lower complications. Research conducted in the years 2007–2017 was considered relevant. Numerous search engines were used to acquire the eight papers included in this meta-analysis. From the eight key papers that were considered, one was a meta-analysis, one was a prospective clinical controlled trial (CCT), and the other six were retrospective CCTs. All studies found higher SFRs in PCNL but the difference was statistically significant in only two of the included studies. This improvement was not reported in any of the studies, including the meta-analysis. As a result, this reflects an inconsistency in the evidence produced. When evaluating hospital stay, all researchers found a statistically significantly shorter stay in the RIRS group compared to the PCNL group, this being potentially attributed to higher rates in minor complications. Due to the inconsistencies evaluated from the key papers, it was concluded that study results ought to be interpreted with caution. RIRS seems to be a safe and effective surgical procedure for selected patients as RIRS offers a comparable initial SFR success as PCNL. This is a cautious statement, drawn in view of inconsistent evidence regarding its superiority over PCNL in this regard. Furthermore, consistent evidence is available, demonstrating its ability to significantly reduce hospital stay without increasing complications. Therefore, RIRS may be considered an alternative to PCNL in selected patients. With that being said, more research is required on this evaluation given that a definite conclusion cannot be reached.

Single vs Serial Dilatation of Access Tract in Percutaneous Nephrolithotomy: A Randomised Control Study on Its Feasibility and Effects in Management of Renal Calculi

Introduction: Percutaneous Nephrolithotomy (PCNL) is the recommended treatment for renal calculi. The tract dilatation method has a significant effect on the surgical outcome. One- shot Dilatation (OSD) involves dilatation using the dilator and Amplatz of desired size, while Serial Dilatation (SD) involves increasing the dilator size progressively up to the desired size. Aim: To compare the success and complication rates of SD techniques and OSD technique using Amplatz dilators. Materials and Methods: This was a randomised control study, conducted in a Tertiary Care Centre, of Bharati Hospital, Pune, Maharashtra, India, from March 2020 to December 2021. A non-probability sampling technique was followed and hundred consecutive patients of renal calculus were included in the study. The patients were then randomly allocated using random number table to undergo PCNL via a One-shot Dilatation (OSD-group I) or Serial Dilatation (SD-group II) of access tract. After the initial work up, the patients underwent PCNL, tract dilated as per the group enrolled. The two groups were then compared for patient demographics, stone characteristics (size, number, location), dilatation type, access time, tract size, access quality, bleeding at entry, operative time, radiation time, postoperative analgesic requirement, tube or tubeless procedure, time for removal of the nephrostomy tube and double ‘J’ stent placement. The statistical inference was obtained by Analysis of Variance (ANOVA) , Kruskall- Wallis t-test, Fisher’s exact test or Chi-square test. Significance was termed as a p-value&lt;0.05. The analysis was performed on Pvalue.io. Results: In the patients from group I, there was lesser blood loss (Haemoglobin drop 0.9 vs 1.3 gm/dL), clot at entry( 6% vs 28%), and radiation exposure ( 60.9 sec vs 94.1 sec) as compared to group II patients. This was also reflected in reduced mean operative time (46.2 min vs 57.1 min) and lesser duration of hospital stay (3 vs 4 days) among group I patients. conclusion: The OSD was found to be superior to SD using Amplatz dilatation in PCNL in terms of having reduced blood loss and reduced exposure to radiation for the patient.

A modern view on tubeless percutaneous nephrolithotomy

Urolithiasis ranks second among urological diseases, after inflammatory processes, and first among surgical interventions in urological hospitals. The problem of this disease treatment is a long-term rehabilitation and disablement, which entails a significant increase in costs and requires changes in the tactics of treatment of patients. Since its introduction until today, percutaneous nephrolithotomy (PCNL) is the standard treatment for nephrolithiasis with a stone size of more than 1.5–2.0 cm. In its standard version, PCNL ends with the placement of nephrostomy catheter through the formed parenchymal channel, but there are techniques of the surgery completion either without nephrostomy catheter with a JJ stent – tubeless PCNL, or without nephrostomy and JJ stent at all – totally tubeless PCNL. However, nowadays, the use of tubeless and totally tubeless techniques is one of the most controversial topics in percutaneous nephrolithotomy in terms of safety and efficacy in their application. Aim. To analyze the results and safety of percutaneous nephrolithotomy by means of tubeless and totally tubeless techniques based on scientific evidence. Analysis of the scientific literature shows that tubeless and totally tubeless PCNL techniques are a safe method of percutaneous surgery and their application reduces pain and analgesic requirements in the postoperative period, shortens the length of postoperative hospital stay, and enhances recovery after surgery in patients, therefore resulting in cost-saving treatment. Conclusions. Tubeless and totally tubeless PCNLs are recommended for widespread use in urological practice, but it is worth to mention that these techniques should be performed in selected patients and by an operating surgeon with significant experience in percutaneous surgery.

Supine Versus Prone Percutaneous Nephrolithotomy – A Randomised Comparative Study

Percutaneous Nephrolithotomy (PCNL) is the standard procedure for large renal stones. This study was conducted to compare the conventional Prone position PCNL with the newer concept of Supine PCNL. A prospective, randomised controlled, double blind study was conducted in 100 patients planned for PCNL. They were randomised into 2 groups with 50 patients each and PCNL was performed either in the prone or supine position. The patient groups were compared for the length of hospital stay, duration of surgery, postoperative and intra operative complications, postoperative stone free status, and requirement of adjunctive procedures. Stone free rates were significantly better for the supine PCNL group. Post operative complications such as fever was more for Prone PCNL group. The other parameters that were not statistically significant were mean operating time which was less for the supine group and duration of hospital stay which was less for the supine group. There was no difference in the other complication rates between the two procedures. The requirement of additional procedures for stone clearance were also same between both the groups. To conclude, Our study demonstrates that supine PCNL is a better technique than prone PCNL in terms of stone free rates, post-operative complications such as fever, lesser number of punctures required for stone clearance and more tubeless procedures.

Comparative Evaluation of Outcomes After Standard versus “Modified Large PCNL”- Is Larger Better…?

Objectives To comparatively evaluate the outcomes of standard percutaneous nephrolithotomy (PCNL) versus a 36 Fr PCNL in terms of operative time, complications, hospital stay, and stone free rates. Patients and Methods The data of 125 PCNL cases, out of the 168 PCNLs done from January 2014 to December 2015, was retrospectively analyzed within two subsets, namely group-A (standard PCNL with 22-32 Fr Amplatz) and group-B (modified large PCNL with 36 Fr Amplatz). The demographic profile, stone characteristics, operative and laboratory parameters, and stone clearance rate were analyzed to determine the safety and efficacy of the modified large PCNL as against standard PCNL. Results Group-A comprised 88 patients with 100 renal units, while group-B comprised 37 patients with 45 renal units. The mean age of the patients in Group-A was 49.1 + 13.1 years, and in Group-B was 52.4 + 11.4 years (range 25-84 years) with a male to female ratio of 4:1. 54.5% and 75.7% unilaterally intervened, group-A and group-B patients respectively, required &lt; 90 minutes for the procedure. Nine patients (10.2%) each of unilaterally and bilaterally intervened group-A cases had an operative time that exceeded 120 minutes compared to only two (5.4%) bilaterally intervened group-B cases. For patients with stone burden &gt;1000 mm2, there was statistically significant (p = &lt; 0.0001) higher complete stone clearance rates with the 36Fr PCNL compared to standard PCNL. Conclusion Our retrospective analysis revealed that 36 Fr PCNL is safe and efficacious in carefully selected patients with large stone burdens providing the advantage of better stone-free rates, less operative time, lesser need for additional punctures without increasing blood transfusion and complications rates. However, more extensive prospective randomized trials are needed to confirm this perceived benefit.

Analgesic efficacy of ultrasound guided paravertebral block in percutaneous nephrolithotomy patients: a randomized controlled clinical study

BackgroundParavertabral blocks (PVB) are in use to adequately manage pain arising from a variety of operations on the thorax, abdomen or pelvis. PVB is straightforward, efficacious in operations performed. This study was undertaken to evaluate how efficacious ultrasound-guided thoracic paravertebral block is when used in patients undergoing percutaneous nephrolithotomy (PCN).MethodsA total of 44 patients, falling in categories I to III of the American Society of Anesthesiologists, and aged between 18 and 65 years, who were scheduled for PCN, were randomly distributed into two groups. The anaesthetic intervention group (PVB) contained 22 individuals, who were injected at level T8-T9 with 20 mL 0.25% bupivacaine as a single administration. In the control group C, also containing 22 individuals, the intervention was not carried out. The groups were compared after PCN in terms of opioid use, pain score, opioid adverse effects profile and the need for supplemental analgesia.ResultsVisual analogue scale pain scores whilst at rest or moving were lower at the level of statistical significance in the PVB group compared to controls at 2 and 4 h post-surgery. At 6 and 8 h post-surgery, the control group had a lower VAS score when moving, and this result reached statistical significance (p < 0.05). The controls used more opioid relief than the PVB group and had lower scores for satisfaction (p < 0.05).ConclusionUltrasound-guided PVB using bupivacaine and an in-plane technique provides effective analgesia in PNL. It is associated with high scores on patient satisfaction and minimal complications.Trial registrationClinicalTrials.gov, NCT04406012. Registered retrospectively, on 27 May 2020.

Clinical outcomes of the simultaneous bilateral percutaneous nephrolithotomy (PCNL) in patients with kidney stones: A prospective cohort study.

BackgroundUrinary tract stones is one of the most frequent medical emergencies which leads to life-threatening complications, namely obstructive uropathy as well as renal failure in some situations. Previously, bilateral stones were treated with either open surgery or percutaneous nephrolithotomy (PCNL). However, these treatment options were associated with lengthy operation time, need for more anesthesia, further bleeding, and long hospitalization. Therefore, much effort has been made to treat both sides simultaneously.ObjectiveThe aim of this study was an attempt to prospectively review cases undergoing simultaneous bilateral PCNL in terms of the therapy outcomes, complications, and consequences.MethodsIn this prospective cohort study, 39 adult patients with bilateral renal stones were randomly recruited at Imam Reza hospital in Mashhad, Iran between January 2016 and January 2017. Adult patients with bilateral renal stones were included in this study. Exclusion criteria were as follows: Patients with severe heart or lung disease, patients with coagulation disorders, pregnant women, and cases with any contraindications for general anesthesia. After insertion of bilateral ureteral catheters, all patients underwent simultaneous bilateral PCNL in prone position. Transureteral lithotripsy was performed for patients with ureteral stones. The surgery was initially carried out on the symptomatic side and then iterated on the remaining kidney. Major complications including bleeding, fever, pain, urine leakage, and residual stones were recorded. SPSS software was used for data analysis. Data were expressed as percentage and mean ± SD. P value less than 0.05 was considered significant.ResultsA total of 39 patients (27 males with mean age of 37.6 years and 12 females with mean age of 45.7 years) were studied. As many as 15 (38%) patients received a unilateral nephrostomy. Three underwent totally tubeless surgery. Bleeding (41.0%) was the most common complication, followed by residual stones (20.5%) and fever (20.5%), urine leakage (15.3%), pain (12.8%), blood transfusion (2.5%) and colon perforation (2.5%).ConclusionsIt was concluded that simultaneous bilateral PCNL was not associated with higher morbidity than the unilateral method.

Percutaneous Nephrolithotomy in Obese Patients, Is There Any Challenge?

Percutaneous nephrolithotomy (PNL) is a safe and effective procedure in the treatment of large renal stones in obese and non-obese patients with low rate of morbidity and high success rate in different groups of body mass index (BMI), some surgeons believe that morbid obesity increases the risk of complications of PNL, but different recent studies showed there were no significant differences. Objective: To analyze the outcomes of PNL in patients with different BMI and to assess the effects of obesity in the result of PNL in terms of efficacy & safety regarding total operative time, blood transfusion, organ injury, stone clearance, hospital stay, and the need of auxiliary procedures. Patients and methods: This is a prospective study on patients with different body mass indexes need PNL. Age above 18 years with no co-morbidity had been included in this study from Jan 2015-Oct 2016 in governmental & two private hospitals in Sulaimania, after application of exclusion and inclusion criteria. All patients had a questioner’s paper to agree on participation in this study. Patients were classified into 3 groups according to the World Health Organization (WHO) classification of body mass index (BMI). Standard PNL with ideal instruments had been used. Intra operative and post-operative findings recorded in Excel data sheet. The patients were followed for one month. The outcomes in these 3 groups were compared. Results & analysis of the data: A total 117 patients had PNL. There was no any statistically significant difference between different BMI groups intra operatively & post operatively in this study with (P value < 0.05) regarding stone clearance, operative time, hospital stay, organ injury, Hemoglobin drop, post-operative renal impairment, and post-operative fever. Conclusion: PNL operation is a relatively safe & efficacious treatment for patients having renal stone with different BMI range from normal to obese patients without significant challenge.

A study of paediatric percutaneous nephrolithotomy in a tertiary care center

Aims: To evaluate the technique of Paediatric Percutaneous Nephrolithotomy in terms of safety, outcome and efficacy in age group 1 to 14 years. Material & Methods: The observational study was donefrom October 2011 to October 2014 in Chirayu Medical College Bhopal. 25cases of renal stone in paediatric age group were admitted in our hospital and evaluated for size of the stone, number of stones, associatedcongenital anomalies and complications. PCNL was done by standard technique. Results: A total number of 25 children were operated. Sex distribution in our study was male 15 and female 10, most of the patients were of age group 10-14 years 15(60%).Most of the children15(60%) had large stones >2cm stones and small stone was seen in 6(24%) cases.Malrotated kidney having stone was seen in 8(32%) cases.Complications as fever and haematuria was observed in 1 (4%) case. The maximum sheath size used inchildren was 24 F. Out of 25 children, only one patient required blood transfusion. Conclusion: Paediatric PCNL is safe procedure in expert and experienced hands. Minimal invasive procedures are beneficial in paediatric age group because of longer life expectancy andmore riskof recurrence.

ECIRS (Endoscopic Combined IntraRenal Surgery) in the Galdakao-modified supine Valdivia position: a new life for percutaneous surgery?

Percutaneous nephrolithotomy (PNL) is still the gold-standard treatment for large and/or complex renal stones. Evolution in the endoscopic instrumentation and innovation in the surgical skills improved its success rate and reduced perioperative morbidity. ECIRS (Endoscopic Combined IntraRenal Surgery) is a new way of affording PNL in a modified supine position, approaching antero-retrogradely to the renal cavities, and exploiting the full array of endourologic equipment. ECIRS summarizes the main issues recently debated about PNL. The recent literature regarding supine PNL and ECIRS has been reviewed, namely about patient positioning, synergy between operators, procedures, instrumentation, accessories and diagnostic tools, step-by-step standardization along with versatility of the surgical sequence, minimization of radiation exposure, broadening to particular and/or complex patients, limitation of post-operative renal damage. Supine PNL and ECIRS are not superior to prone PNL in terms of urological results, but guarantee undeniable anesthesiological and management advantages for both patient and operators. In particular, ECIRS requires from the surgeon a permanent mental attitude to synergy, standardized surgical steps, versatility and adherence to the ongoing clinical requirements. ECIRS can be performed also in particular cases, irrespective to age or body habitus. The use of flexible endoscopes during ECIRS contributes to minimizing radiation exposure, hemorrhagic risk and post-PNL renal damage. ECIRS may be considered an evolution of the PNL procedure. Its proposal has the merit of having triggered the critical analysis of the various PNL steps and of patient positioning, and of having transformed the old static PNL into an updated approach.

Prospective comparative study of Miniperc and standard PNL for treatment of 1 to 2 cm size renal stone

Study Type – Therapy (case series)Level of Evidence 4What’s known on the subject? and What does the study add?Standard PNL is known to have higher clearance rates for stones 1–2 cm. However, it is not promoted because of its associated morbidity, especially bleeding. Minitiarization of the PNL has spawned a new interest in this modality for treating small bulk urolithiasis.The study adds to a growing body of evidence in a prospective manner that smaller tract PNL “miniperc” is associated with a similiar efficacy of achieving stone‐clearance rates while decreasing the invasiveness of the procedure and associated morbidity.OBJECTIVE• To evaluate the results of miniperc vis‐à‐vis standard PNL in the treatment of stones of 1–2 cm in size. Miniperc may represent a reasonable procedure in patients with nonbulky urolithiasis offering a similar outcome as standard percutaneous nephrolithotomy (PNL) with advantage of reduced morbidity.PATIENTS AND METHODS• 55 procedures including 27 miniperc and 28 standard PNL were performed for renal stones 1–2 cm in size. Pediatric patient, active urinary tract infection, renal malformation, uncorrected coagulopathy and morbid obesity patients were excluded from the study.• The parameters studied were demography, operative time, postoperative analgesic requirement, hemoglobin drop, complications and stone clearance.RESULTS• Mean tract size was 18.2 ± 2 F (15–20) and 26.8 ± 2 F (24–30), P value &lt;0.0001 in the miniperc and standard PNL, respectively. Holmium LASER and pneumatic lithotripter were the main energy sources used in miniperc and standard PNL, respectively.• Miniperc operative time was longer than that of standard PNL (45.2 ± 12.6 vs 31 ± 16.6 min, P= 0.0008 respectively).• Conversely, there was an advantage of miniperc over standard PNL in terms of a significantly reduced hemoglobin drop (0.8 ± 0.9 vs 1.3 ± 0.4 gram%, P= 0.01), analgesic requirement (55.4 ± 50 vs 70.2 ± 52 mg tramadol, P= 0.29) and hospital stay (3.2 ± 0.8 vs 4.8 ± 0.6 days, P≤ 0.001), respectively.• Intra‐ operative conversion of the procedure into a tubeless PNL was significantly more in the miniperc group (P≤ 0.001). The miniperc and standard PNL group had clearance rates of 96% and 100%, respectively at 1 month follow up.CONCLUSIONS• This study demonstrated significant advantages of the miniperc procedure in terms of reduced bleeding leading to a tubeless procedure and reduced hospital stay.• The stone free rates and the complications were similar in either group.

Postoperative morbidity of tubeless versus conventional percutaneous nephrolithotomy: a prospective comparative study

Percutaneous Nephrolithotomy (PNL) is an established technique for the treatment of renal calculi. Some reports have challenged the need for a nephrostomy tube at the end of the procedure, arguing that it accounts for a longer hospital stay and increased postoperative pain. During the last years, several series have addressed the feasibility and safety of tubeless PNL, where a double-J ureteral stent is left in place after the end of intervention instead of a nephrostomy tube. The aim of our study was to compare conventional versus tubeless PNL in terms of postoperative morbidity. Eighty-five patients who underwent PNL at a single center met the inclusion criteria (complete intraoperative stone clearance, no evidence of active intraoperative bleeding, single percutaneous access, and operative time shorter than 2 h) and were randomized at the end of the procedure to have placed either a nephrostomy tube (group 1) or a double-J ureteral stent (group 2). Outcomes assessed were postoperative pain, bleeding complications, leakage complications, and length of hospital stay. The patients in the tubeless group had a shorter hospital stay (3.7 vs. 5.8 days; P < 0.001), and less postoperative pain at postoperative days 2 and 3 (P < 0.001). No significant difference in bleeding or leakage complications was observed. This study supports the feasibility and safety of tubeless PNL in a selected group of the patients, suggesting some intraoperative criteria to be considered when performing it. However, further controlled studies will have to determine its impact on stone-free rates prior to be considered the standard technique in these selected cases.

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With the intent of reducing postoperative discomfort and pain, hospital stay, and cost, totally tubeless PCNL procedure has gained popularity in recent years. We tested the hypothesis that totally tubeless PCNL is superior to standard PCNL in terms of postoperative decrease in hospital stay and analgesic requirement in elderly patients. By contrast, appropriate patients should be selected for totally tubeless PCNL. Therefore, we used criteria such as minimal bleeding, no residual stone, and intact collecting system when choosing the patients in the OR at the end of the operation. We believe that the major advantage for patients undergoing totally tubeless PCNL was the absence of stent-related flank pain and short hospital stay. The publications on PCNL in the elderly population are limited. In a recent study of patients aged >70 years, it has been shown that PCNL was a safe and effective procedure that achieved a stone-free rate of 70.8% for all types of stones. 1 Dore B. Conort P. Irani J. et al. Percutaneous nephrolithotomy (PCNL) in subjects over the age of 70: a multicentre retrospective study of 210 cases. Prog Urol. 2004; 14: 1140-1145 PubMed Google Scholar In another study of PCNL, no significant complication was observed in a group of patients aged 60 years and the stone-free rates were similar, being 89% for the elderly group and 92% for the younger patients. 2 Sahin A. Atsu N. Erdem E. et al. Percutaneous nephrolithotomy in patients aged 60 years or older. J Endourol. 2001; 15: 489-491 Crossref PubMed Scopus (61) Google Scholar As mentioned in our report, 86% of patients in the totally tubeless group and 83% of patients in the standard PCNL group were stone-free. When patients with clinically insignificant residual fragments (CIRF) <4 mm are considered, the success rate becomes 96% for group 1 and 90% for group 2. Three patients in group 1 and 2 patients in group 2 had CIRF in our study and we did not observe any complication at follow-up period. We agree with the editorial comment that the possible limitation of the tubeless PCNL is that it precludes secondary procedures to treatment residual stones. However, when a secondary percutaneous procedure for removal of residual stones is planned, the preexisting tract may not provide good access to reach the stone. In most cases, generating a new access tract may be necessary. Alternatively, residual calculi can be safely managed by SWL or retrograde intrarenal surgery in this group of patients. Editorial CommentUrologyVol. 76Issue 2PreviewThe authors are commended for their initiative, solid methodology, and review of the published data. Despite the increasingly aging population, there has been a paucity of geriatric literature concerning percutaneous nephrolithotomy (PCNL), specifically prospective randomized trials. A retrospective study in Taiwan compared tubeless PCNL in 50 geriatric (> 70 years) patients, with tubeless PCNL in 351 younger patients operated concurrently at the same institute.1 The authors showed that tubeless PCNL in 50 geriatric patients was safe regarding complications, although there was a statistically significant lower stone-free rate (68% vs 84%) and nonsignificant longer mean hospital stay (4.6 vs 3.9 days). Full-Text PDF

A Randomized Trial Evaluating Type of Nephrostomy Drainage after Percutaneous Nephrolithotomy: Small Bore v Tubeless

To compare the outcome of tubeless percutaneous nephrolithotomy (PCNL) with small-bore nephrostomy drainage after PCNL. We tested the hypothesis that tubeless PCNL is superior to small-bore nephrostomy drainage after PCNL in terms of postoperative pain, analgesic requirement, and hospital stay. To show a 10% difference in these parameters, a sample size of 30 persons per group would be needed. All patients undergoing PCNL from September 2005 to May 2006 were included in the study. Patients meeting the inclusion and exclusion criteria were then randomized to either a tubeless approach with insertion of a ureteral stent or placement of an 8F nephrostomy tube without insertion of a ureteral stent. The perioperative outcomes of patients in the two groups were compared. Tubeless PCNL was performed in 33 patients, and an 8F nephrostomy tube was placed in 32 patients. The two groups had comparable demographic data. The hemoglobin drop and complication rate between the two groups were comparable. Patients undergoing tubeless PCNL experienced less postoperative pain (P = 0.001), needed less analgesia (P = 0.006), and were discharged 9 hours earlier than patients in the other group. Complete stone clearance was achieved in 87.87% patients in the tubeless group and 87.5% patients in the nephrostomy group. In the tubeless group, 39.4% of patients had bothersome stent-related symptoms, of whom 61.5% needed analgesics and/or antispasmodic agents. Tubeless PCNL offers the potential advantages of decreased postoperative pain, analgesic requirement, and hospital stay without increasing the complications. It was associated with stent-related discomfort in 39% of patients.