Rigid Nephroscope Research Articles

A Novel Device to Prevent Stone Fragment Migration During Percutaneous Lithotripsy: Results from an In Vitro Kidney Model.

We developed a polyethylene sack (the PercSac) that fits over the shaft of a rigid nephroscope and is deployed into the collecting system to capture a stone and contain fragments during percutaneous nephrolithotomy (PCNL). We previously reported our results using the PercSac in a percutaneous cystolithopaxy model. In this study, we compare the efficiency of stone fragmentation with and without the PercSac in an anatomically correct in vitro PCNL model. The PCNL model consisted of a human collecting system model created on a 3D printer. Ten BegoStones made in spherical molds of 2.0 cm diameter, matched for weight, were fragmented in the model using a 24F rigid nephroscope and an ultrasonic lithotripter, including five with and five without the PercSac. The total times for stone fragmentation and complete stone clearance, gross assessment of the stone-free status, and need for flexible nephroscopy to achieve a stone-free state were recorded. The median time for stone fragmentation was significantly shorter in the PercSac group compared with the control group (217 seconds [IQR = 169-255] vs 340 seconds [IQR = 310-356], [p = 0.028]). Likewise, the total time for complete stone clearance from the kidney was significantly shorter for the PercSac group (293 seconds [IQR = 244-347] vs 376 seconds [IQR = 375-480], [p = 0.047]). In one trial with the PercSac, residual dust remained in the kidney, while in all five trials without the PercSac small residual fragments remained. All trials without the PercSac required flexible nephroscopy with basket extraction to become stone free, while none of the trials with the PercSac required flexible nephroscopy for stone clearance. Ultrasonic lithotripsy using the novel PercSac stone entrapment device is more efficient and efficacious than traditional ultrasonic lithotripsy in an in vitro PCNL model. The advantage may be even more pronounced during clinical PCNL where residual fragments migrate into difficult-to-access calices. Further in vivo testing is underway.

Safety and efficacy of cystoscopically guided percutaneous suprapubic cystolitholapaxy without fluoroscopic guidance

ObjectiveTo evaluate the safety and efficacy of percutaneous cystolitholapaxy (PCCL) under cystoscopic guidance and without fluoroscopy for the management of large or multiple bladder stones. Patients and methodsProspectively collected data were reviewed for patients undergoing PCCL with cystoscopic guidance and without fluoroscopy. Patients with a bladder stone burden of ⩾30mm were included. Stone fragmentation was achieved using a pneumatic lithotripter through a rigid nephroscope and the fragments were removed with peanut forceps. Patients with concomitant bladder malignancy, previous pelvic radiotherapy, previous pelvic–abdominal surgery, or benign prostate enlargement of >80mL were excluded from the study. ResultsIn all, 40 male patients were included between July 2011 and June 2014 with a mean (SD) age of 36.9 (17.6) years. A single bladder stone was detected in 22 (55%) patients, whilst 18 (45%) had multiple bladder stones, with a mean (range) stone size of 35 (32–45) mm. The stone-free rate was 100% and the procedure was well tolerated by all patients. No intraoperative bladder perforation, bleeding or major perioperative adverse events were recorded. The mean (SD) hospital stay was 2.2 (0.41) days and the catheterisation time was 1.2 (0.6) days. At 4weeks postoperatively, no significant stone fragments were found in any of the patients. ConclusionPCCL under cystoscopic control and without fluoroscopy seems to be an effective and safe technique to remove large or multiple bladder calculi. It represents an alternative treatment option, especially in situations where fluoroscopy is not available, and radiation hazards can be avoided.

V6-04 FULL IMMERSION SIMULATED PERCUTANEOUS NEPHROLITHOTOMY USING 3D PRINTING TECHNOLOGY

flexible nephroscope. The technique requires pressure irrigation to 300mmHg and an Amplatz sheath to allow free egress of the fragments. J-wire is particularly useful for calyces that are difficult to reach with the rigid nephroscope and allows for quick and atraumatic removal of small fragments. J-wire also allows relocation of stone fragments to a position that can be easily reached with a rigid nephroscope and lithotriptor. CONCLUSIONS: Techniques demonstrated in this video can aid in improving PCNL stone clearance.

The Impact of Transtomal Rigid Endoscopy in Continent Cutaneous Urinary Diversions

To determine if transtomal rigid endoscopy damages the continence mechanism of continent cutaneous reservoirs. We report the largest and longest series to date from a single institution demonstrating the safety of transtomal rigid endoscopy. We conducted an institutional review board-approved retrospective review of a prospectively accrued database of all patients with urinary diversions that underwent rigid endoscopic procedures for various reasons between 2000 and 2013. Pre- and postoperative continence, difficulty with catheterization, and need for surgical revision post procedure were evaluated. From 2000 to 2013, 71 patients with continent cutaneous diversions underwent 191 endoscopic procedures by a single surgeon. Mean follow-up was 603 days. Mean age was 58.4 years. The mean number of procedures per patient was 2.7 (1-7). All procedures were performed by gaining access through the stoma with an offset rigid nephroscope and a 28-30Fr access sheath. Two patients reported incontinence postoperatively; 1 patient was treated conservatively by way of indwelling catheter for 1 week and full continence returned. The second patient had small-volume incontinence preoperatively that worsened postoperatively. The procedure uncovered an existing efferent limb-cutaneous fistula. Patients undergoing repeated procedures were not at any higher risk of incontinence. There were no patients that had difficulty with catheterization postoperatively. No surgical revisions were required for worsened continence postoperatively. Transtomal rigid endoscopic procedures do not negatively affect the continence mechanism in continent cutaneous diversions. Transtomal rigid endoscopy allows for safe endoscopic access in these difficult to treat patients.

MP30-01 PATIENTS ARE AT RISK FOR PYELOVENOUS BACKFLOW DURING PERCUTANEOUS NEPHROSTOLITHOTOMY

INTRODUCTION AND OBJECTIVES: The pressure in the renal pelvis may have a significant effect upon patient outcomes during percutaneousnephrostolithotomy (PCNL). Pressures greater than 30mm Hg can cause pyelovenous backflow with its increased risk for urosepsis. Meanwhile, low renal pelvic pressure (RPP) can lead to collapse of the collecting system, impaired visualization and greater blood loss. The purpose of this study was to determine the influence of nephroscope type and the use of suction upon renal pelvic pressures obtained duringPCNL. METHODS: During PCNL performed in the prone split leg position, ureteroscopic directed US guidance was utilized to establish a 30 Fr access sheath. Once the access was established the working channel of the ureteroscope was connected to a pressure transducer and utilized to determine RPP at baseline, when irrigating using a 26 Fr rigid nephroscope with and without suction, and during irrigation with a 16 Fr flexible nephroscope. Pressure readings were randomly obtained during the case. Patient demographics and access location were also recorded. A Mann-Whitney U test was used to compare the RPP during rigid and flexible nephroscopy, with p<0.05 considered statistically significant. RESULTS: A total of 148 measurements were recorded in 16 patients undergoing PCNL. Mean patient age was 53.6 years (20-71) and BMI was 33.0 (18-53.3). All patients had single tract access including 14 patients with upper pole and 2 patients with lower pole access. Rigid nephroscopy resulted in significantly higher average RPP compared to flexible nephroscopy (30.4 vs. 11.6 mmHg; p<0.001). The mean RPP was greater than 30 mmHg (the threshold for pyelovenous backflow) in 5 patients (31.3%) using the rigid nephroscope and in no patient using the flexible nephroscope. The use of suction resulted in significantly lower renal pelvic pressure (1.0 mmHg) when compared to both rigid (p<0.001) and flexible nephroscopy (p<0.001). CONCLUSIONS: Use of the rigid nephroscope resulted in renal pelvic pressure greater than the threshold for pyelovenous backflow in 31.3% of patients. The RPP is significantly lowered by the use of the flexible nephroscope or suction. Knowledge of the factors that influence RPP and methods to control the pressure extremes may improve patient safety during PCNL.

593 Upper calyx approachability using rigid nephroscopes through a lower calyx access: Comparison between prone and supine PCNL and assessment of anatomical factors that may influence this approach as measured by multidetector CT with 3D reconstructions

593 Upper calyx approachability using rigid nephroscopes through a lower calyx access: Comparison between prone and supine PCNL and assessment of anatomical factors that may influence this approach as measured by multidetector CT with 3D reconstructions

Supine pediatric percutaneous nephrolithotomy (PCNL)

Many authors reported their experience with supine PCNL in adult population comparing the outcome with prone PCNL and they found that the stone free rate and the operative time were in favor of prone PCNL with a lower patient morbidity among patients with supine PCNL. This encouraged us to perform supine PCNL in pediatric population. In this study we evaluated the safety and efficacy of supine PCNL in pediatric population. Between April 2011 and February 2014 a total of 27 children (6 girls and 21 boys) presented with renal calculi. The stones were single pelvic stone in 14 cases, pelvic stone with lower calyceal stones in 7 cases and pelvic stone with upper calyceal stones in 6 cases. The mean stone size was 32 mm (range 20-47 mm). All patients were managed with supine PCNL performed by a single surgeon. Marking the posterior axillary line in standing position before the operation is a mandatory initial step. The patients were placed in supine position with elevation of the ipsilateral shoulder and hip by means of two bags one underneath the shoulder and the other underneath the hip to widen the operative field. The technique was performed using a sheathless 19 fr. Richard wolf rigid nephroscope after acute tract dilation by amplatz dilators. Complications (intraoperative and postoperative) and stone free rate rates were reported. A single lower calyceal access was used in all cases through which we could successfully remove even the upper calyceal stones. Kinking of the guide wire during tract dilatation were encountered in 4 cases and the guide wire was successfully exchanged using a small Teflon dilator in 2 cases while ultrasonographic guided lower calyceal repuncture was done in 2 cases. The average operative time (from the beginning of the puncture trial to nephrostomy tube insertion) was (41 ± 15) min. The operation was successfully completed as planned in all cases with two cases of intraoperative complications (one case of pelvicalyceal system perforation and another case of intraoperative bleeding and blood transfusion). The initial stone free rate was (92.5%). Postoperative complications was reported in the form of 2 cases of fever that respond to medical treatment for 72 h. The main advantages of supine pediatric PCNL is that it is comfortable for the surgeon, the anesthetist and the child. The main disadvantages of supine pediatric PCNL is that it is not familiar for most urologists and small field of operation. The short outcome of our study is the small number of cases and the lack of comparative study with prone pediatric PCNL. Pediatric supine PCNL is a safe and effective method for management of pediatric renal stones. It carries the advantages of easily upper calyx access through the lower calyceal tract, low incidence of fluid absorption or hypothermia and easy anesthesia monitoring. However a larger number of cases are needed to be evaluated.

Concurrent stone stabilization improves ultrasonic and pneumatic efficacy during cystolithopaxy: an in vitro analysis.

Objective To identify whether stabilization of larger bladder stones would improve the efficacy of combination (ultrasonic/pneumatic) lithotripsy in a phantom bladder stone model for percutaneous cystolithopaxy.Materials and Methods Using 1cm phantom Bego stones, a spherical model bladder was used to simulate percutaneous bladder access. A UroNet (US Endoscopy, USA) was placed alongside a Swiss Lithoclast probe through the working channel of a Storz 26Fr rigid nephroscope. Using a 30Fr working sheath, the stone was captured, and fragmented for 60seconds. Resulting fragments and irrigation were filtered through a 1mm strainer, and recorded. Five trials were performed with and without the UN. Durability was then assessed by measuring net defects, and residual grasp strength of each instrument. Descriptive statistics (mean, standard deviations) were used to summarize the data, and Student’s t-tests (alpha<0.05) were used to compare trials.Results The mean time to stone capture was 12s (8-45s). After fragmentation with UN stabilization, there were significant improvements in the amount of residual stone (22% dry weight reduction vs 8.1% without UN, p<0.001), number of fragments (17.5 vs 5.0 frag/stone, p=0.0029), and fragment size (3.6mm vs. 7.05 mm, p=0.035). Mesh defects were noted in all nets, ranging from 2-14 mm, though all but one net retained their original grip strength (36.8N).Conclusions Bladder stone stabilization improved fragmentation when used in conjunction with ultrasonic/pneumatic lithotripsy. However, due to limitations in maneuverability and durability of the UN, other tools need to identified for this indication.

A novel device to prevent stone fragment migration during percutaneous lithotripsy.

We developed a novel device to capture stones in vivo in an enclosed bag (PercSac) to prevent dispersion of stone fragments during percutaneous nephrolithotomy (PCNL) or cystolitholapaxy. We report on our initial feasibility trials of the PercSac device. PercSac consists of a specially designed polyethylene bag that is fitted over the shaft of a rigid nephroscope. The bag is used to first entrap the target stone, then tighten around it to allow fragmentation within the bag. Matched pairs of 10 canine bladder stones (2.5 cm maximum diameter) were fragmented in a human bladder model using the CyberWand (Olympus America, Inc.), and the procedure was assessed for markers of efficiency and effectiveness. Median time to entrap the stone within the PercSac was 67 seconds (range 51-185 sec). Median time for stone fragmentation was significantly shorter with the PercSac than without (182.0 sec [range 108-221] vs 296.5 sec [range 226-398], P=0.004). Overall, however, there was no significant difference in the total time to entrap and fragment the stones between the two groups. A stone-free state was not achieved for any trial without the PercSac, while 9 of 10 trials with the PercSac resulted in a stone-free state. Use of the PercSac in conjunction with stone fragmentation has the potential to reduce the occurrence of residual fragments after PCNL or cystolitholapaxy. Further in vitro testing in a kidney model is planned.

Experiencia en nefrolitotomía percutánea con manejo ambulatorio vs hospitalización en un centro urológico, Pereira, 2009-2012

ObjectiveTo report the experience in percutaneous nephrolithotomy (PCNL), reviewing demographic and surgical variables in ambulatory and hospitalized patients. MethodsRetrospective cohort study was performed by analyzing data from 95 patients who underwent PCNL from June/2009 to May/2012. The variables included, type of stones, anesthesia, calyx puncture, residual stones, and intra -and postoperative complications. Technique: ureteral catheter and contrast medium, access to collector with 0.38-F guide, dilation with Alken, and placement of 28-F Amplatz. A 26-F rigid nephroscope and nephrostomy was used in all patients. Clinical outcome variables were evaluated in the outpatient vs hospitalization groups in the week following the procedure. Statistical analysis was performed using STATA11, P<.05. ResultsMean age was 47.09 years, and 55.79% of patients were women. A total of 58.95% of stones were at left location. Two surgeons performed the procedures, with 80% of patients in prone position, and under general anesthesia in 77.89%. The most common access was lower calyx (58.95%), and the estimated intraoperative bleeding was < 200mL in 93.68%. After the procedure, 37 patients were hospitalized and 58 were managed as outpatients. There was one case of bowel perforation, which resolved with conservative management. Postoperative pain during the week following the procedure was an average of 2 for outpatients, and 3.70 for hospitalized. Most variables were not associated with any of the initial treatment. ConclusionsPCNL is a safe technique for the management of large stones, even in patients treated on an outpatient basis with nephrostomy.© 2013 Sociedad Colombiana de Urología. Published by Elsevier España, S.L. All rights reserved.

MP20-05 VARIATIONS IN INTRAPELVIC RENAL PRESSURES DURING PERCUTANEOUS NEPHROLITHOTOMY – A PORCINE STUDY

INTRODUCTION AND OBJECTIVES: It has been established that high intrapelvic pressures (IPP) may cause possible spread of infection through pyelo-venous backflow while lower pressures can hinder surgeon’s visualization, decrease venous tamponade and result in increased bleeding. The purpose of this study is to characterize IPP during percutaneous nephrolithotomy. METHODS: A porcine model was utilized to test IPP during rigid and flexible nephroscopy. Pressures were compared in a variety of conditions including single versus two tract access, rigid versus flexible nephroscopy and presence versus absence of suction. Twenty trials were performed for each condition. An independent samples MannWhitney U test was used to compare parameters, with p<0.05 considered statistically significant. RESULTS: In the single tract model, rigid nephroscopy resulted in significantly higher mean pressure (31.35 mmHg) compared to flexible nephroscopy (10.7 mmHg; p < 0.001). The pressure was higher when using a rigid nephroscope in a single tract (31.35 mmHg) compared to when two tracts were present (9.35 mmHg; p < 0.001). In contrast, there was no difference between the flexible nephroscope in a single tract (10.7 mmHg) versus with two tracts (10.9 mmHg; p 1⁄4 0.63) Use of suction with the rigid nephroscope resulted in significantly lower pressure when only one tract was present (-1.3 mmHg) compared to when two tracts were present (1.8 mmHg; p 1⁄4 0.004). CONCLUSIONS: This study demonstrates that addition of a second tract may result in significant alterations in renal IPP, with much lower pressures when using irrigation but higher pressures when using suction when compared to a single tract. This may explain in part why transfusion rates are significantly higher with multiple accesses during PCNL.

PD37-03 PERCSAC: A NOVEL DEVICE TO PREVENT STONE FRAGMENT MIGRATION DURING PERCUTANEOUS LITHOTRIPSY

You have accessJournal of UrologyStone Disease: New Technology II1 Apr 2014PD37-03 PERCSAC: A NOVEL DEVICE TO PREVENT STONE FRAGMENT MIGRATION DURING PERCUTANEOUS LITHOTRIPSY Jodi Antonelli, Justin Friedlander, Jeffrey Gahan, Heather Beardsley, Margaret Pearle, and Jeffrey Cadeddu Jodi AntonelliJodi Antonelli More articles by this author , Justin FriedlanderJustin Friedlander More articles by this author , Jeffrey GahanJeffrey Gahan More articles by this author , Heather BeardsleyHeather Beardsley More articles by this author , Margaret PearleMargaret Pearle More articles by this author , and Jeffrey CadedduJeffrey Cadeddu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2021AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Up to 50% of patients with residual fragments after percutaneous nephrolithotomy (PCNL) experience a stone-related event. We developed a polyethylene sack (the PercSac) that fits over the shaft of a rigid nephroscope and is deployed in the collecting system to capture a stone, thereby containing fragments generated during PCNL and allowing for efficient and complete removal. We compared the efficiency of stone fragmentation and retrieval with and without the PercSac device in an in vitro percutaneous cystolitholapaxy model. METHODS Using a Limbs & Things® bladder model into which a 30F Amplatz working sheath was placed, 20 canine bladder stones matched for weight and volume were fragmented using a 24F rigid nephroscope and an ultrasonic lithotripter with and then without the PercSac. The total time for complete stone fragmentation and a gross assessment of the stone-free status of the bladder were recorded for each stone. RESULTS The mean stone weight and volume for the PercSac group was 2.63 +/- SD 0.95g and 1.68 +/- SD 0.63cm3, respectively. Similarly, the mean stone weight and volume for the group without the PercSac was 2.57 +/- SD 0.89g and 1.78 +/- SD 0.68cm3. The median time for complete stone fragmentation was significantly shorter in the PercSac group compared with the control group [182.0 sec (IQR= 108-221) vs 296.5 sec (IQR= 226-398), p= 0.004]. Likewise, the total time from insertion of the nephroscope into the bladder to completion of stone fragmentation was shorter for the PercSac group but this did not reach statistical significance [254.5 sec (IQR= 173-302) vs 296.5 sec (IQR= 226-398) respectively, p= 0.112]. The stone-free rate for the PercSac group was 100 vs 0% for the control group. CONCLUSIONS Ultrasonic lithotripsy using the PercSac device is more efficient and efficacious than traditional ultrasonic lithotripsy in a bladder model. This advantage may be even more pronounced during clinical PCNL where residual fragments migrate into difficult-to-access calyces. Further in vitro and in vivo testing in both kidney and bladder models is underway. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e946-e947 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Jodi Antonelli More articles by this author Justin Friedlander More articles by this author Jeffrey Gahan More articles by this author Heather Beardsley More articles by this author Margaret Pearle More articles by this author Jeffrey Cadeddu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP5-15 MAINTENANCE OF CONTINENCE WITH RIGID ENDOSCOPIC PROCEDURES IN CONTINENT CUTANEOUS URINARY DIVERSIONS

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion1 Apr 2014MP5-15 MAINTENANCE OF CONTINENCE WITH RIGID ENDOSCOPIC PROCEDURES IN CONTINENT CUTANEOUS URINARY DIVERSIONS Charles Metcalfe, Jeffery Loh-Doyle, Sameer Chopra, Wesley Yip, Vannita Simma-Chiang, and Matthew Dunn Charles MetcalfeCharles Metcalfe More articles by this author , Jeffery Loh-DoyleJeffery Loh-Doyle More articles by this author , Sameer ChopraSameer Chopra More articles by this author , Wesley YipWesley Yip More articles by this author , Vannita Simma-ChiangVannita Simma-Chiang More articles by this author , and Matthew DunnMatthew Dunn More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.398AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There is concern that using rigid endoscopes through the stoma of a continent cutaneous urinary diversion damages the continence mechanism. We report the largest and longest series to date from a single institution demonstrating the safety of trans-stomal rigid endoscopy. METHODS We performed an IRB approved retrospective review of a prospectively accrued database of all patients with urinary diversions that underwent rigid endoscopic procedures for various reasons between 2000-2013. Pre and postoperative continence, difficulty with catheterization, and need for surgical revision post procedure were evaluated. RESULTS From 2000-2013, seventy-one patients with continent cutaneous diversions underwent 191 endoscopic procedures by a single surgeon. Mean follow up was 603 days (33 days - 6.3 years). Mean age was 58.4 (38-94 years) and 58% were female. The mean number of procedures per patient was 2.7 (1-7). All procedures were performed by gaining access through the stoma with an offset rigid nephroscope and a 24-28Fr access sheath. The majority of indications for treatment included afferent valve stenosis and pouch calculi. Two patients reported continence issues post operatively; one patient was treated conservatively by way of indwelling catheter for one week and the continence returned completely. The second patient had small volume incontinence pre-operatively which worsened postoperatively. The procedure uncovered an already existent pouch-cutaneous fistula, which was revised surgically and resolved the incontinence. Patients with repeated procedures were not found to be at any higher risk of incontinence. There were no patients that had difficulty with catheterization post operatively. No surgical revisions were required for worsened continence post operatively except for the patient. CONCLUSIONS Trans-stomal rigid endoscopic procedures do not negatively affect the continence mechanism in continent cutaneous urinary diversions. Trans-stomal rigid endoscopy allows for safe endoscopic access in this difficult to treat patient population. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e87 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Charles Metcalfe More articles by this author Jeffery Loh-Doyle More articles by this author Sameer Chopra More articles by this author Wesley Yip More articles by this author Vannita Simma-Chiang More articles by this author Matthew Dunn More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A critical appraisal of complications of percutaneous nephrolithotomy in paediatric patients using adult instruments

To evaluate the complications (using the CROES Clavien scoring system) and various factors affecting them in children undergoing percutaneous nephrolithotomy (PCNL). We analysed prospectively maintained data of paediatric PCNL (patients ≤17 years) from January 2008 to December 2012. Stone complexity was defined according to validated Guy's stone score (GSS). Procedures were performed in the prone position by experienced urologists. The tract was dilated (24-30F) under fluoroscopic guidance, and an adult rigid nephroscope complemented with a cystoscope/ureteroscope were used. Complications were recorded according to the CROES-Clavien score, recently defined by the Clinical Research Office of the Endourological Society (CROES) Study Group. The study group comprised 158 procedures performed in 153 children (98 boys and 55 girls), with a mean (range) age 10.03 ± 4.51 (2-17) years. The mean (range) stone burden was 376.68 ± 265.23 (150-2400) mm(2) . The distribution of cases according to the GSS was 31% grade I, 35.4% grade II, 19% grade III, and 14.6% grade IV. The stone-free rate of PCNL monotherapy was 85.4%, which increased to 93.7% after relook PCNL/extracorporeal shock wave lithotripsy. In all, 62 children (39.2%) had operative complications; 84% were minor, i.e. Clavien grade 1/2, and managed conservatively. Stone size, GSS, tract size, number of punctures and operation duration were significantly associated with complications on univariate analysis (P < 0.05). However, on multivariate logistic regression analysis, operation duration was the only independent risk factor associated with complications (95% confidence interval: 1.013-1.065, odds ratio = 1.04; P = 0.038). Percutaneous nephrolithotomy in children using adult instruments is an effective and safe procedure for managing simple as well as complex renal calculi. Assignment of specific Clavien scores to all possible PCNL complications by the CROES PCNL Study Group have improved precision in reporting complications in a standard objective format, including the minor ones. Such models are very useful for making inter-observer comparisons to obtain clinically relevant inferences. Mean operation duration is the only independent factor affecting complications of the procedure.

Use of rigid tubal ligation scope: Serendipity in laparoscopic common bile duct exploration.

AIM:To assess the feasibility, safety of rigid tubal ligation scope in laparoscopic common bile duct (CBD) exploration.MATERIALS AND METHODS:Rigid nephroscope was used for laparoscopic CBD exploration until one day we tried the same with the rigid tubal ligation scope, which was passed easily into CBD both proximally and distally visualising the interior of the duct for presence of stone that were removed using endoscopic retrograde cholangiopancreaticography (ERCP) basket. This serendipity led us to use this scope for numerous patients from then on. A total of 62 patients, including male and female, underwent laparoscopic CBD exploration after choledochotomy with rigid tubal ligation scope between March 2007 and December 2012 followed by cholecystectomy. All the patients had both cholelithiasis and choledocholithiasis with minimum duct diameter of 12 mm. A total of 48 patients were given T-tube through choledochotomy and closed, and the remaining 14 patients had primary closure of choledochotomy.RESULTS:There were no intra-operative complications in any of the patients like CBD injury or portal vein injury. Post-operatively graded clamping of T-tube was done and was removed after 15 days in the patients who were given T-tube. None had retained the stone after T-tube cholangiography, which was done before removing the tube. Mean duration of follow up was 6 months. No patients had any complaints during the follow up.CONCLUSION:Laparoscopic CBD exploration is also feasible with rigid tubal ligation scope. With experienced surgeons, CBD injury is very minimal and stone clearance can be achieved in almost all patients. This rigid tubal ligation scope can be an alternative to other rigid and flexible scopes.

Nephrolithotomy Performed Concurrently With Laparoendoscopic Single-site Pyeloplasty

The objective of the present study was to evaluate the results of laparoendoscopic single-site (LESS) pyeloplasty and pyelolithotomy, which were performed concurrently in patients with pelviureteric junction obstruction (PUJO) and renal stones. Four patients with PUJO and renal stones underwent pyelolithotomy performed concurrently with LESS pyeloplasty. In 3 patients, a 2.5-cm incision was made in the umbilical region. In the fourth patient, the 2.5-cm vertical incision was made at a site 7cm below the umbilical region because of a stone in the right lower calyx. After dissection of the pelviureteric junction, an incision of approximately 1cm was made along the presumed transection line of the renal pelvis. The pyelolithotomy was performed using a 24F rigid nephroscope through a SILS port. Dismembered pyeloplasty was performed after extraction of the renal stones was completed. The mean operation time was 277minutes (range, 225-373), and the mean lithotomy time was 31minutes (range, 20-50). No intraoperative or postoperative complications were observed. For all 4 patients, discharge from the hospital was possible after a mean of 3.4 postoperative days (range, 3-4). All patients became stone free. Postoperative ultrasound revealed that hydronephrosis improved in all patients. In all patients, resolution of the symptoms was confirmed. LESS nephrolithotomy with pyeloplasty is a safe and effective procedure with a good cosmetic result for patients with PUJO and renal stones.

Concomitant Treatment of Ureteropelvic Junction Obstruction and Renal Calculi With Robotic Laparoscopic Surgery and Rigid Nephroscopy

The treatment of ureteropelvic junction obstruction (UPJO) and concomitant calculus poses a technically challenging situation. We present our experience with using rigid nephroscopy for renal calculi removal during robot-assisted pyeloplasy (RAP) for UPJO. From December 2010 to November 2012, 25 patients with UPJO had RAP at our institution; 9 of those had concurrent renal calculi, which were simultaneously treated with rigid nephroscopy. For stone extraction, a rigid ureteroscope was passed through an assistant trocar under laparoscopic vision directly into a previously created pyelotomy. The stones were extracted using a rigid grasper or stone basket through the rigid ureteroscope. For the removal of the stones within the upper and lower calyces, the rigid ureteroscope was introduced into the incised renal pelvis through robotic trocars if the "assistant trocar" route failed. Complete stone clearance was achieved in 8 of 9 patients. Residual calculi in 1 patient were removed with a single session of extracorporeal shock wave lithotripsy. At the mean follow-up of 10.2 months, no patients had obstruction or recurrent stones. The mean operative time was 187.1 minutes, which was 40.9 minutes longer than the mean operative time in patients without renal calculi. There was no significant difference in blood loss, hospital stay, complications, and success rates between patients with and without renal calculi. Our data suggest that the use of a concomitant rigid nephroscope and RAP is a safe and feasible option for the treatment of UPJO complicated with renal calculi.

Novel technique of cytolithotripsy for large bladder stones

We evaluated a minimally invasive surgical technique involving a single percutaneous access with a laparoscopic trocar under video-cystoscopic vision for managing large bladder stones. All patients were candidates for open surgery. Fourteen patients with bladder stones larger than 3 cm in diameter or multiple stones were treated with this technique. The procedure involved the percutaneous placement of a laparoscopic trocar under cystoscopic control and the introduction of a rigid nephroscope into the bladder. Stones were cleansed via fragmentation or direct removal. The technique was successful in all cases, resulting in controlled, stone-free bladders; there were no surgical complications. The mean operation time was comparable to that of standard management. All patients discharged uneventfully. None reported urethral stricture during the 24-month follow-up period. Percutaneous cystolithotripsy under endoscopic control is easy to perform and should be considered as an alternative for large or multiple bladder stones as it decreases the risk of urethral stricture.

Predicting calyceal access for percutaneous nephrolithotomy with computed tomography multiplanar reconstruction

OBJECTIVES:Objective parameters in computed tomography (CT) scans that could predict calyceal access during percutaneous nephrolithotomy have not been evaluated. These parameters could improve access planning for percutaneous nephrolithotomy. We aimed to determine which parameters extracted from a preoperative multiplanar reconstructed CT could predict renal calyceal access during a percutaneous nephrolithotomy.METHODS:From January 2009 through April 2011, 230 patients underwent 284 percutaneous nephrolithotomies at our institution. Sixteen patients presented with complete staghorn calculi, and 11 patients (13 renal units) were analyzed. Five parameters were extracted from a preoperative reconstructed CT and compared with the surgical results of percutaneous nephrolithotomy.RESULTS:Fifty-eight calyces were studied, with an average of 4.4 calyces per procedure. A rigid nephroscope was used to access a particular calyx, and a univariate analysis showed that the entrance calyx had a smaller length (2.7 vs. 3.98 cm, p = 0.018). The particular calyx to be accessed should have a smaller length (2.22 vs. 3.19 cm, p = 0.012), larger angles (117.6 vs. 67.96, p<0.001) and larger infundibula (0.86 vs. 0.61 cm, p = 0.002). In the multivariate analysis, the only independent predictive factor for accessing a particular calyx was the angle between the entrance calyx and the calyx to be reached (OR 1.15, 95% confidence interval [CI], 1.053–1.256, p = 0.002).CONCLUSION:The angle between calyces obtained by multiplanar CT reconstruction is the only predictor of calyx access.

Modified-PCNL Without Modified Instruments: A Description of Technique

Mini-PCNL was developed to reduce the morbidity of PCNL by using smaller tract sizes. Most mini-techniques, however, require specialized instruments and use ureteroscopes as surrogates for nephroscopes, resulting in decreased visualization, poor irrigation, and difficult fragment extraction. We describe our modified technique (mPCNL) that allows for the use of standard PCNL equipment through a tract that is smaller than standard PCNL (sPCNL) but larger than previously reported for mini-PCNL. After ureteral access with a coaxial anti-retropulsion device, the patient is placed in the prone position. After percutaneous access under fluoroscopic guidance, a 24F balloon dilating catheter is used to place a 24F Amplatz sheath. A standard 26F rigid nephroscope is used to complete the entire procedure, with the modification of selectively removing the outer sheath to allow the scope to fit in the smaller tract. Standard lithotripters and graspers are used, as necessary. ROLE IN PRACTICE: We have performed this technique on 52 patients with a mean stone burden of 19.4 mm. Overall stone-free rate was 100%, even for stones >2 cm. This technique allows for improved visualization and irrigation compared with other mini-PCNL procedures and obviates the need to purchase specialized equipment.