Small Residual Stones Research Articles

Transperitoneal Laparoscopic Pyelolithotomy in Pelvic Ectopic Kidneys: Experience From a Northern Indian Tertiary Care Institution.

Introduction The ectopic pelvic kidneys have a higher likelihood of developing renal stones due to urinary stasis caused by the abnormal position of the renal pelvis, altered course of the ureter, and kidney malrotation. This retrospective study highlights the safety, efficacy, and feasibility of performing transperitoneal laparoscopic pyelolithotomy in cases of pelvic ectopic kidney. Methodology The 15 patients with ectopic pelvic kidneys and nephrolithiasis underwent laparoscopic pyelolithotomy. The kidney was exposed either by moving the bowel or using a trans-mesocolic approach. A surgical procedure was performed to remove stones from the renal pelvis using laparoscopic forceps. Following the placement of a double J stent, the incision in the renal pelvis was closed. The procedure was completed after the intraperitoneal drain was inserted. Results A total of 15 patients underwent the transperitoneal laparoscopic pyelolithotomy procedure, with a male-to-female ratio of 3:2. The average age of the patients was 41 (25-58) years, while the average size of the stones was 3.8 cm. Additionally, seven (46.6%) patients had the presence of caliceal stones in conjunction with the pelvic stone. Out of the 15 patients, some had stones on the left side (n = 9, 60%), while others had stones on the right side (n= 6, 40%). The operation with an average duration was 125 minutes with a range of (90-190). Fourteen (93.3%) patients were found to be free of stones. A patient required extracorporeal shock wave lithotripsy (ESWL) to address a small caliceal residual stone measuring 8 mm. After just one session of ESWL, this stone was completely cleared. All stones were successfully removed, resulting in a 100% stone-free rate. Conclusions Laparoscopic pyelolithotomy is a highly effective and efficient procedure for treating large and numerous stones in the ectopic pelvic kidney. This method has a significant level of efficiency in removing stones with limited consequences.

Laparoscopic pyelotomy combined with ultrasonic lithotripsy via a nephroscope for the treatment of complex renal stones.

The purpose of the study was to introduce a novel surgical approach of combining laparoscopic pyelotomy with ultrasonic lithotripsy via a nephroscope for the treatment of complex renal stones. Between May 2021 and April 2023, 32 patients underwent laparoscopic pyelotomy combined with ultrasonic lithotripsy via a nephroscope and their perioperative variables were retrospectively collected and outcomes were assessed. Dissection and incision of the anterior renal pelvis wall was performed via a laparoscope. A 19.5F nephroscope was introduced into the renal pelvis through a laparoscopic trocar from the incision. Stones were fragmented and sucked out using a 3.3mm ultrasonic probe placed through the nephroscope. All operations were completed successfully and the stone-free rate at 3 days after operation was 87.5% (28/32). Four (12.5%, 4/32) patients with staghorn stones had a small residual stone in the lower calyx after operation and did not require reintervention. No patient required perioperative transfusion and four (12.5%, 4/32) patients with struvite stones developed postoperative fever, which was successfully treated with intravenous antibiotics. The mean follow-up time was 14.0 ± 7.2months, with no patient developing long-term complications. This approach offers a safe and effective treatment option for complex renal stones, as the method exhibits a high clearance rate with few complications.

Natural history of small asymptomatic kidney and residual stones over a long-term follow-up: systematic review over 25 years.

To systematically review the natural history of small asymptomatic kidney and residual stones, as the incidental identification of small, asymptomatic renal calculi has risen with increasing use of high-resolution imaging. We reviewed the natural history of small asymptomatic kidney and residual stones using the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. We searched MEDLINE, Scopus, EMBASE, EBSCO, Cochrane library and Clinicaltrials.gov using themes of 'asymptomatic', 'nephrolithiasis', 'observation', 'symptoms', 'admission', 'intervention' and similar allied terms for all English language articles from 1996 to 2020 (25 years). Inclusion criteria were studies with ≥50 patients, stones ≤10 mm, and a mean follow-up of ≥24 months. Primary outcomes were occurrence of symptoms, emergency admission, and interventions. Our literature search returned 2247 results of which 10 papers were included in the final review. Risk of symptomatic episodes ranged from 0% to 59.4%. Meta-analysis did not identify any significant difference in the likelihood of developing symptoms when comparing stones <5 mm to those >5 mm, nor those <10 mm to those >10 mm. Risk of admission varied from 14% to 19% and the risk of intervention from 12% to 35%. Meta-analysis showed a significantly decreased likelihood of intervention for stones <5 vs >5 mm and <10 vs >10 mm. Studies had variable risk of bias due to heterogeneous reporting of outcome measures with significant likelihood that observed differences in results were compatible with chance alone (Symptoms: I2 =0%, Cochran's Q = 3.09, P = 0.69; Intervention: I2 =0%, Cochran's Q = 1.76, P = 0.88). The present systematic review indicates that stone size is not a reliable predictor of symptoms; however, risk of intervention is greater for stones >5mm vs <5 mm and >10 vs <10 mm. This review will inform urologists as they discuss management strategies with patients who have asymptomatic renal stones and offer insight to committees during the development of evidence-based guidelines.

MP68-01 USE OF DUSTING TECHNIQUE: RISK OF REPEAT INTERVENTION AFTER URETEROSCOPY FOR RENAL AND URETERAL STONES

You have accessJournal of UrologyStone Disease: Surgical Therapy IV1 Apr 2018MP68-01 USE OF DUSTING TECHNIQUE: RISK OF REPEAT INTERVENTION AFTER URETEROSCOPY FOR RENAL AND URETERAL STONES Viacheslav Iremashvili, Shuang Li, Sean P. Hedican, Sara L. Best, and Stephen Y. Nakada Viacheslav IremashviliViacheslav Iremashvili More articles by this author , Shuang LiShuang Li More articles by this author , Sean P. HedicanSean P. Hedican More articles by this author , Sara L. BestSara L. Best More articles by this author , and Stephen Y. NakadaStephen Y. Nakada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2205AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Some patients who undergo ureteroscopy and laser lithotripsy (URS) have residual stone fragments (RFs). The goal of this study was to find out if the presence of RFs increased the risk of repeat surgery in the same renal unit among patients who underwent URS at our institution. METHODS The study included 215 patients who had URS for nephrolithiasis at out hospital between 2008 to 2016, had imaging within 3 months after the intervention and at least one year of follow-up. Dusting technique of laser lithotripsy was used. Patients were divided into subgroups based on the presence of RFs and the size of the largest fragment seen on the first postoperative imaging. Most patients had plain abdominal X-rays (71%), while computerized tomography was done in 16% and ultrasound in 13%. Multivariate Cox regression analysis was performed to compare the risk of repeat surgery among patients with different volumes of residual nephrolithiasis to that in patients with no stones on the first postoperative imaging. RESULTS No RFs were found in 134 (62.3%) patients while 17 (7.9%), 21 (9.8%), 14 (6.5%) and 29 (13.5%) had stones of up to 2 mm, 3-4 mm, 5-6 mm and more than 6 mm respectively. Over a median follow-up of 2.2 years (mean 2.9, IQR 1.5-3.9 years) 61 (28.4%) patients required another surgery on the same renal unit for symptomatic stone disease. Table 1 demonstrates results of the multivariate Cox regression analysis which compared the treatment-free survival depending on the postoperative stone burden. The risk of repeat surgery was increased in all subgroups of patients with RFs, however it was lowest among patients with stones less than 2 mm and 3-4 mm in size. These patients were combined into one group for the Figure 1 which shows the repeat surgery-free survival curves. CONCLUSIONS Our findings suggest that even small residual stone burden seen on the imaging after URS is associated with increased risk of repeat surgical interventions. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e916 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Viacheslav Iremashvili More articles by this author Shuang Li More articles by this author Sean P. Hedican More articles by this author Sara L. Best More articles by this author Stephen Y. Nakada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A preliminary study on laparoscopic anatrophic nephrolithotomy for renal staghorn stone

Objective To evaluate the feasibility and effectiveness of laparoscopic anatrophic nephrolithotomy (LAN) managing renal staghorn stone. Methods Forty patients whose age ranged from 17 to 73 years (median 46 years), who underwent LAN for renal staghorn stone were included in the retrospective study at Affiliated Hospital of Guizhou Medical University in the period between May 2011 and January 2015, including 24 males and 16 females. The body mass index ranged from18.4 to 27.3 kg/m2. The date of operative time, warm ischemia time, estimated blood loss, mean stone size, stone surface area, stone-free rate, rate of operative complications, postoperative hospital stay was collected. Functional imaging studies including GFR of operated kidney, serum creatinine (SCr), renal cortical thickness were obtained before the operation and compared to that of a follow-up of 6 months. Results A total of 40 patients were completed laparoscopically and none required conversion to open surgery. Operative time ranged from 87 to 142 min (median 102.5 min). The warm ischemia time ranged from 14 to 36 min (median 20.3 min). The estimated blood loss ranged from 20 to 120 ml (median 50 ml). The mean stone area (SA) ranged from 550 to 1583 mm3 (median 796 mm3). The largest diameter of the stones ranged from 34 to 72 mm (median 59 mm). The average postoperative hospital stay was (9.2±2.1) days, ranged from 6 to 12 days. The rate of operative complications was 17.5% (7/40), including 4 patients got urinary leak and 3 patients with bacteriaemia, no patients showed perioperation urosepsis, delayed renal hemorrhage, death and other severe complication. All patients cleared from their stones except 5 patients had small residual stones managed by extracorporeal shock wave lithotripsy 3 months later, of which three patients had a favorable effect and the last 2 patients got rid of small residual fragments automatically a few weeks later, the stone-free rate was 87.5% determined by KUB or CT on postoperative day 3. After a mean follow-up of 6 months, however, there was a significant mean decrease of (13.3±3.7) ml/min(P<0.05)in GFR of effected renal afterward and a significant mean decrease of 27.5μmol/L in SCr(P<0.05). Nevertheless, the atrophy of renal cortical was not obvious, the hydronephrosis was decreased compared to that of pre-treatment and with a significant improvement on renal function in all patients at follow-up IVU and CT. Conclusions The LAN is a feasible alternative for renal staghorn stone besides PCNL in minimal invasive methods for it has some advantages of high stone-free rate, less operative complications and less influence on renal function of affected kidney. Key words: Renal staghorn stone; Laparoscopic anatrophic nephrolithotomy; Operative complication

Editorial Comment

This study highlights that even small residual stone fragments (RFs) after postpercutaneous nephrolithomy (PCNL) are a significant risk factor for subsequent ancillary surgical interventions. In particular, although other groups have demonstrated that RFs >2 mm are associated with stone events, 1 Raman J.D. Bagrodia A. Gupta A. et al. Natural history of residual fragments following percutaneous nephrostolithotomy. J Urol. 2009; 181: 1163-1168 Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar these authors highlight that even fragments <2 mm pose a significant risk for repeat procedures with a cumulative retreatment rate of 33.3% over 7 years. Furthermore, the risk of retreatment is greater if RFs are non–calcium based with a cumulative retreatment rate of 56.4%. These data continue to raise the question of whether any RF can be accurately classified as clinically insignificant. Retreatment After Percutaneous Nephrolithotomy in the Computed Tomographic Era: Long-term Follow-upUrologyVol. 84Issue 2PreviewTo examine the long-term retreatment rates and explore prognostic factors after percutaneous nephrolithotomy (PCNL) in the computed tomographic era. Full-Text PDF ReplyUrologyVol. 84Issue 2PreviewWe appreciate the thoughtful comments. Full-Text PDF

Laparoscopic stone surgery with the aid of flexible nephroscopy.

PurposeTo report the outcome of laparoscopic pyelo- and ureterolithotomies with the aid of flexible nephroscopy.Materials and MethodsA retrospective analysis was performed in 71 patients with complex renal stones or large and impacted proximal ureteral stones. Patients underwent laparoscopic pyelo- or ureterolithotomies with or without the removal of small residual stones by use of flexible nephroscopy between July 2005 and July 2010. Operative success was defined as no residual stones in the intravenous pyelogram at 12 weeks postoperatively. Perioperative results and surgical outcomes were analyzed.ResultsThe patients' mean age was 54.7±13.7 years, and 53 males (74.6%) and 18 females (25.4%) were included. The mean maximal stone size was 19.4±9.4 mm. A total of 47 cases were complex renal stones and 24 cases were impacted ureteral stones. Mean operative time was 139.0±63.7 minutes. Stones were completely removed in 61 cases (85.9%), and no further ancillary treatment was needed for clinically insignificant residual fragments in 7 cases (9.9%). For complex renal stones, the complete stone-free rate and clinically significant stone-free rate were 80.9% and 93.6%, respectively. Multivariate analysis showed that the use of flexible nephroscopy for complex renal stones can reduce the risk of residual stones. A major complication occurred in one case, in which open conversion was performed.ConclusionsLaparoscopic stone surgery is a safe and minimally invasive procedure with a high success rate, especially with the aid of flexible nephroscopy, and is not associated with procedure-specific complications.

Focused Ultrasonic Propulsion of Kidney Stones.

Introduction: Our research group is studying a noninvasive transcutaneous ultrasound device to expel small kidney stones or residual post-treatment stone fragments from the kidney.1-3 The purpose of this study was to evaluate the efficacy and safety of ultrasonic propulsion in a live porcine model. Materials and Methods: In domestic female swine (50-60 kg), human stones (calcium oxalate monohydrate) and metalized glass beads (2-8 mm) were ureteroscopically implanted.4 Target stones and beads were placed in the lower half of the kidney and a reference bead was placed in the upper pole. Ultrasonic propulsion was achieved through a single ultrasound system that allowed targeting, stone propulsion, and ultrasound imaging using a Philips HDI C5-2 commercial imaging transducer and a Verasonics diagnostic ultrasound platform. Stone propulsion was achieved through the delivery of 1-second bursts of focused, ultrasound pulses, which consist of 250 finely focused pulses 0.1 milliseconds in duration. Stone propulsion was then observed using fluoroscopy, ultrasound, and visually with the ureteroscope. The kidneys were then perfusion-fixed with glutaraldehyde, embedded in paraffin, sectioned, and stained. Samples were histologically scored for injury by a blinded independent expert. Using the same pulsing scheme, while varying acoustic intensities, an injury threshold and patterns of injury were determined in additional pigs.5,6 Results: Stones were successfully implanted in 14 kidneys. Overall, 17 of 26 (65)% stones/beads were moved the entire distance to the renal pelvis, ureteropelvic junction (UPJ), or proximal ureter. The average procedure time for successfully repositioned stones was 14.2±7.9 minutes with 23±16 push bursts. No gross or histologic damage was identified from the ultrasound propulsion procedure. Under this pulsing scheme, a maximum exposure of 2400 W/cm2 was delivered during each treatment. An intensity threshold of 16,620 W/cm2 was determined at which, above this level, tissue injury consistent with emulsification, necrosis, and hemorrhage appeared to be dose dependent. Conclusions: Ultrasonic propulsion is effective with most stones being relocated to the renal pelvis, UPJ, or proximal ureter in a timely fashion. The procedure appears safe with no evidence of injury. The acoustic intensities delivered at maximum treatment settings are well below the threshold at which injury is observed. The angle and alignment of directional force are the most critical factors determining the efficacy of stone propulsion. We are now pursuing FDA approval for a human feasibility study. No competing financial interests exist. Runtime of video: 5 mins 44 secs Acknowledgments: This work was supported by NIH DK43881, DK092197, NSBRI through NASA NCC 9-58, the Coulter Foundation, and the University of Washington. This material is the result of work supported by resources from the VA Puget Sound Health Care System, Seattle, Washington. We are very grateful for the help of a large team at the University of Washington and the Consortium for Shock Waves in Medicine, which we cannot list in detail.

Factors Affecting Complication Rates of Percutaneous Nephrolithotomy in Children: Results of a Multi-Institutional Retrospective Analysis by the Turkish Pediatric Urology Society

We assessed factors affecting complication rates of percutaneous nephrolithotomy in children. We retrospectively evaluated data on 1,205 renal units in 1,157 children treated with percutaneous nephrolithotomy at 16 Turkish centers between 1991 and 2012. Of the patients 28.3% had a history of urolithiasis. Complications were evaluated according to the Satava classification system and modified Clavien grading system. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. A total of 515 females and 642 males were studied. Mean ± SD patient age was 8.8 ± 4.7 years (range 4 months to 17 years). Mean ± SD stone size, operative time and postoperative hospital stay were 4.09 ± 4.06 cm(2), 93.5 ± 48.6 minutes and 5.1 ± 3.3 days, respectively. Postoperative stone-free rate was 81.6%. A total of 359 complications occurred in 334 renal units (27.7%). Complications were intraoperative in 118 cases and postoperative in 241. While univariate analysis revealed that stone history, positive urine culture, operative time, length of hospitalization, treatment success, punctured calyx and location of the stone significantly affected the complication rates (p <0.05), operative time, sheath size, mid calyceal puncture and partial staghorn formation were the statistically significant parameters affecting complication rates on multivariate logistic regression analysis. Percutaneous nephrolithotomy is the treatment of choice for most renal calculi in children. The technique is effective and safe in children, with a high success rate and a low rate of major complications. The significant factors identified should be considered by clinicians to decrease associated complication rates.

Are small residual stone fragments really insignificant in children?

ObjectivesTo assess the significance of asymptomatic residual stone fragments of less than 4mm (clinically insignificant residual fragments [CIRFs]) after shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PNL), and retrograde intrarenal surgery (RIRS) in children. Patients and MethodsEighty-five children were followed up for 6 to 50months (median 22). Outcomes measured were fragment re-growth, stone events (emergency department visits, hospitalization, or additional interventions) and spontaneous fragment passage. ResultsDuring follow-up, 22 children (25.8%) passed residual fragments spontaneously. Highest spontaneous passage rate was found for renal pelvis stones and the lowest for the lower pole stones (57.1% vs. 16.1%; p<0.001). When the number of the fragments increased, the chance of the spontaneous passage decreased (30% vs 20%; p<0.05). Symptomatic episodes including renal colic, hematuria, or urinary tract infection were documented in 34 (40%) patients, and re-growth of fragments was observed in 18 (21.2%). Stone size had no significant effect on spontaneous passage (p=0.079), stone growth (p=0.528), and symptomatic episodes (p=0.402). Twenty-five patients (29.4%) required secondary intervention for stone re-growth or stone related events and the remaining 20 patients (23.5%) needed medical treatment for bothersome symptoms or complications. ConclusionsOur results suggest that 40% of children with CIRFs will become symptomatic and 20% will develop stone re-growth over the following 6months. Only one fifth of the fragments will pass spontaneously without any complications. Therefore, the use of the term “CIRF” is not appropriate for postoperative residual fragments in children.

Laparoscopic Pyelolithotomy for Partial Staghorn Stones

Objective: To confirm the feasibility and safety of laparoscopic pyelolithotomy in partial staghorn stones. Patients and Methods: Seventeen patients who underwent laparoscopic pyelolithotomy for partial staghorn stone were included in the prospective study at King Abdulaziz University Hospital in the period between May 2007 and Feb 2009. Preoperatively all patients had blood work, urine culture, ultrasonography and CT renal stone study. Inclusion criteria included stones with largest diameter of more than 25 mm (measured by CT), branching into one or more group of calices, and no contraindication for laparoscopic surgery. All patients underwent cystoscopy, double J stent insertion prior to the procedure, while prophylactic antibiotics were provided for all the patients with or without positive urine culture. Results: All patients were completed laparoscopically where none required conversion to open surgery or developed intraoperative complications. The largest diameter of the stones varied between 29 and 48 mm with mean diameter of 41 mm, and the number of stones removed was 1–4 with mean of 1.3. The mean operative time was 175 minutes (range 125–240 minutes) and the estimated blood loss was 20–150 ml with mean of 49 ml. All patients cleared from their stones except 2 patients had small residual stones of 5 and 7 mm which were managed later by extracorporeal shock wave lithotripsy. One patient developed ileus postoperatively. Conclusion: Laparoscopic removal of partial staghorn stones is safe and feasible and has an equal outcome to open surgery.

Are there roles for intraductal US and saline solution irrigation in ensuring complete clearance of common bile duct stones?

Persistent small common bile duct (CBD) stones after endoscopic sphincterotomy (EST) and stone extraction may be a nidus for stone growth and could be detected by intraductal US (IDUS). CBD saline solution irrigation may flush out residual stones. Our purpose was to determine the frequency of residual CBD stones after EST and basket/balloon extraction by using IDUS and to assess the effectiveness of saline solution irrigation in clearing remnant CBD stones. Prospective study. General Hospital Singapore. Seventy patients (mean age 62 years, 51% male) were recruited. In the presence of CBD stones, EST and stone extraction were performed, followed by IDUS. If residual stones were detected, a catheter was inserted into the proximal CBD, saline solution irrigation performed, and IDUS repeated. (1) The frequency of residual stones detected by IDUS after EST and basket/balloon extraction and (2) the effect of saline solution irrigation in clearing residual CBD stones. Cholangiogram showed CBD stones in 38 of 70 patients (median 1 [range 1-5], mean size 7.6 mm [range 3.0-12.0 mm]). IDUS showed CBD stones in 32 of 32 with normal cholangiogram (median 2 [range 1-8], mean size 2.6 mm [range 0.9-7.2 mm]). After EST and stone extraction, IDUS showed persistent stones in 28 of 70 (median: 2 [range 1-5], mean size 2.2 mm [range 1.1-4.6 mm]). The CBD was irrigated with a mean of 48 mL of saline solution. Repeat IDUS showed persistent CBD stones in 2 of 70, and these were flushed out by further saline solution irrigation. Single-center study. IDUS detected small residual CBD stones that persisted after EST and basket/balloon extraction. Saline solution irrigation appeared useful in clearing residual small stones.

Clinical utility of intraductal US to decrease early recurrence rate of common bile duct stones after endoscopic papillotomy

The aim of the present study was to determine whether additional intraductal ultrasound (IDUS) to confirm complete stone clearance decreases the recurrence rate of common bile duct stones for a 3-year period after endoscopic papillotomy (EPT). IDUS was carried out with a thin-caliber ultrasonic probe (diameter 2.0 mm, frequency 20 MHz) via transpapillary route after stone extraction. If IDUS showed evidence of residual stones and/or sludge, endoscopic management was performed until IDUS examination was negative. A prospective study was conducted on 59 consecutive patients undergoing additional IDUS after stone extraction between January 1996 and May 2003 (IDUS group). The recurrence rate of common bile duct stones was compared with a historical control group (August 1988 to December 1995) consisting of cases that did not undergo IDUS (non-IDUS group). Potential risk factors for recurrence of common bile duct stones were assessed by univariate and multivariate analysis on logistic regression. In 14 of 59 patients (23.7%), IDUS detected small residual stones not seen on cholangiography. The recurrence rate was 13.2% (17 of 129 patients) in the non-IDUS group and 3.4% (two of 59 patients) in the IDUS group (P < 0.05). Multivariate analysis subsequently identified non-IDUS status as an independent risk factor for recurrence (odds ratio 5.12, 95% CI 1.11-23.52, P = 0.036). Additional IDUS to confirm complete stone clearance after EPT decreases the early recurrence rate of common bile duct stones.

Pediatric Ureteroscopic Management of Intrarenal Calculi

Data addressing ureteroscopic management of intrarenal calculi in prepubertal children are limited. We reviewed our experience from January 2002 through December 2007. We retrospectively reviewed ureteroscopic procedures for intrarenal calculi in children younger than 14 years. Stone-free status was determined with postoperative imaging. Multiple logistic regression analysis was used to assess the influence of preoperative factors on initial stone-free status and the need for additional procedures. Intrarenal calculi were managed ureteroscopically in 52 kidneys in 50 children with a mean age of 7.9 years (range 1.2 to 13.6). Mean stone size was 8 mm (range 1 to 16). Stone-free rate after a single ureteroscopic procedure was 50% (25 of 50 patients) on initial postoperative imaging and 58% (29 of 50) with extended followup. Initial stone-free status was dependent on preoperative stone size (p = 0.005) but not stone location. Additional stone procedures were required in 18 upper tracts. Younger patient age (p = 0.04) and larger preoperative stone size (p = 0.002) were associated with the need for additional procedures. Additional procedures were required in more than half of the stones 6 mm or larger but in no stone smaller than 6 mm. Ureteroscopy is a safe method for the treatment of intrarenal calculi in the prepubertal population. Our ureteroscopic stone-free rate for intrarenal stones is lower than that reported for ureteral stones. Parents should be informed that additional procedures will likely be required, especially in younger patients and those with stones larger than 6 mm.

Percutaneous Lithotripsy for Removing Difficult Bile Duct Stones Using Endoscopy

Purpose: To describe efficacy of percutaneous lithotripsy for removing difficult bile duct stones using endoscopy. Materials and Methods: A total of 88 patients with difficulties for the removal of bile duct stones using endoscopy (an impacted stone, stone size >15 mm, intrahepatic duct (IHD) stone, stone size to bile duct diameter ratio >1.0), were enrolled in this study. A 12 Fr sheath was inserted through the percutaneous transhepatic biliary drainage (PTBD) tract, and then nitrol stone baskets and a 0.035” snare wire were used to capture, fragment and remove the stones. The technical and clinical success rates were analyzed, together with an analysis of any complications. Results: The overall technical success rate of stone removal was achieved in 79 of 88 patients (89.8%). In five of nine patients with failed stone removal, small residual IHD stones were noted on a cholangiogram. Even if stone removal failed in these cases, cholangitic symptoms were improved and the drainage catheter was successfully removed. Therefore, clinical success was achieved in 84 of 88 patients (95.5%). There were no significant procedure-related complications, except for sepsis in one case. Conclusion: Billiary stone removal using the stone basket and guide-wire snare technique through the PTBD tract is a safe and effective procedure that can be used as a primary method in patients with difficulties for the removal of bile duct stones using endoscopy.

Tubeless percutaneous nephrolithotomy in children

Objective To assess the effectiveness of tubeless percutaneous nephrolithotomy (PCNL) as an alternative to extracorporeal shock-wave lithotripsy (ESWL) in the management of urolithiasis in children. Materials and methods In 2003–2005 we operated on 20 cases that met the inclusion criteria. Extensive follow-up tests were performed in all patients; stone clearance was defined as the absence of residual fragments on plain abdominal X-ray and renal ultrasound. Pain-scale ruler (0–10) was used to evaluate pain postoperatively. Comparison was made with a group of 10 patients with very similar criteria operated upon with PCN tube. Results Mean follow-up period was 9 months (3–18 months) and mean age 7.5 years (4–15 years). Mean operative time was 115 min (45–180) with no significant bleeding intra- or postoperatively. Conversion to open surgery was necessary in one case. There were no major perioperative complications. In the tubeless group the pain score was 3–6 (mean 4.6), there was no need for IV analgesia, and median hospital stay was 1.7 days (1–4 days); urine leakage occurred in one patient. In the group with PCN tube the pain score was 5–8 (mean 5.5), IV analgesia was mandatory in four patients, and median hospital stay was 2.8 days (3–4 days); urine leakage occurred in five patients and a small residual stone was detected in one child. Conclusion Tubeless PCNL in children has the advantages of being less painful, less troublesome and shortening the hospital stay of the child. The decision to use this procedure is best made intraoperatively and depends on the experience of the surgeon.

Simultaneous combined use of flexible ureteroscopy and percutaneous nephrolithotomy to reduce the number of access tracts in the management of complex renal calculi

To present early experience in managing complex renal calculi using a combined ureteroscopic and percutaneous approach, as complex and branched renal calculi often require multiple access tracts during percutaneous nephrolithotomy (PNL), and the combined use of flexible ureteroscopy and PNL has the potential to reduce the inherent morbidity of several tracts. The study included seven patients (mean age 54 years) with multiple, branched, large-volume renal calculi suitable for management with PNL. Preoperative data, including patient demographics, stone location and stone surface area, were recorded. After informed consent, the patients underwent combined PNL and ureteroscopy in one session. Intraoperative data, including the location of PNL puncture sites, operative duration and complications, were analysed. Stone-free rates were determined by follow-up imaging at 3 months. All patients had either two or more stones in separate locations in the collecting system, or staghorn stones involving multiple calyces. The mean stone burden was 666 mm(2). All patients had only one percutaneous access tract. The mean operative duration was 142 min and the mean blood loss 79 mL. Two patients had small residual stones (< 3 mm), that required ureteroscopic intervention as they failed to pass spontaneously by 3 months after the initial combined procedure. The convalescence was similar to that in our current PNL practice; imaging showed that five of the patients were stone-free. Combined PNL and ureteroscopic management can effectively reduce the number of percutaneous access tracts which would otherwise be required for managing complex and branched renal calculi, as stones in an unfavourable location relative to the access tract can be relocated and fragmented within easy reach of the single nephrostomy tract. This manoeuvre reduces potential patient morbidity and blood loss but with no significant effect on stone-free rates and operative durations.

How significant are clinically insignificant residual fragments following lithotripsy?

Extracorporeal shock-wave lithotripsy had revolutionized the treatment of kidney stones. Residual fragments smaller than 4 or 5 mm which are asymptomatic and likely to pass spontaneously are termed as clinically insignificant residual fragments. This article reviews the current literature with regards to the management of clinically insignificant residual fragments. However, the term is controversial because no consensus has been reached regarding its exact definition or interval after extracorporeal shock-wave lithotripsy to evaluate its presence. While most small residual stone fragments might be managed expectantly, a significant number of patients might become symptomatic or require intervention. These so-called clinically insignificant residual fragments have the potential to cause obstruction and are important risk factors for stone recurrence and re-growth. Residual fragments require close monitoring for stone growth, potential complications and subsequent intervention. Secondary procedures may be applied selectively to those patients who have significant symptoms of obstruction associated with the residual stone. Medical therapy might play an important role in the management of residual fragments.

OUTCOME OF SMALL RESIDUAL STONE FRAGMENTS FOLLOWING SHOCK WAVE LITHOTRIPSY IN CHILDREN

We evaluate the outcome of small residual stone fragments (RF) following extra-corporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc., Marietta, Georgia) in children. The medical records of 39 boys and 44 girls (88 renal units) with urolithiasis who underwent ESWL were reviewed. Median patient age was 7 years. Average stone burden was 14 mm. Mean followup was 46 months. After the first ESWL 40 of the 88 (46%) renal units became stone-free and 18 (20%) had RF 5 mm or less. The remaining 30 (34%) units required further treatment using ESWL or ancillary surgical procedures that rendered 12 of them stone-free and 8 with RF. The 26 renal units with RF constitute our study subjects. Adverse outcomes such as growth of RF, symptomatic episodes or calculi recurrence in stone-free cases were recorded. Of the 26 renal units with RF 5 mm or less, 18 (69%) had an adverse clinical outcome (symptoms or RF growth) and 8 (31%) patients were asymptomatic and had no stone growth. Patients with RF had a significant increase in adverse clinical outcome compared to stone-free subjects, with an odds ratio of 3.9 (95% CI 1.5-9.6). The presence of metabolic disorders was associated with RF growth (odds ratio 11.4, 95% CI 1.5-79). Small RF after ESWL is clinically significant in children and increase the chance of adverse clinical outcome. These patients require close followup, particularly those with identifiable predisposing disorders.

Totally tubeless percutaneous nephrolithotomy in selected patients.

Significant early postoperative discomfort after percutaneous procedures is usually secondary to nephrostomy tubes and externalized ureteral catheters. We describe our modification of the traditional percutaneous nephrolithotomy (PCNL) approach that we name "totally tubeless PCNL." Between June 2000 and May 2001, 60 consecutive PCNLs were performed at our centers. At the end of the surgery, we omitted the nephrostomy tube and removed the externalized catheter in selected patients: no solitary kidney, stone size <3 cm, and without any obstructions or arterial bleeding. A total of 30 patients underwent totally tubeless PCNL (group 1). We compared their results with those of a control group of 30 patients who underwent standard PCNL (group 2). The incidence of complications, analgesic requirements, length of hospitalization, and time to return to normal activities were compared in the two groups. In both groups, PCNL was performed successfully without any significant complications. A 90% stone-free rate was achieved in both groups, and in the remaining patients, small residual stones (<4 mm) were detected. No urinoma was demonstrated by postoperative ultrasound scanning in group 1. The average length of hospitalization was 1.5 days for group 1 and 3 days for group 2. The average analgesic requirements were 30 mg of pentazosin in group 1 and 90 mg in group 2. No transfusion was needed. There were three complications: 2 patients (6.6%) had urinary tract infection in group 1 and 1 (3.3%) in group 2. All were managed medically. Omitting the percutaneous nephrostomy tube and removing ureteral catheter at the end of surgery in selected patients were safe and accompanied by significantly reduced postoperative discomfort, length of hospitalization, and analgesic requirements. Further studies are needed to determine the role of this technique.