Supine mini PCNL in infants using conventional cystoscope.

Percutaneous nephrolithotomy has become the standard procedure for large renal stones but still remains highly challenging due to complications such as bleeding and sepsis, even though it has high stone free rate (SFR). We report the early outcomes of more than 1000 percutaneous nephrolithotomys done in our center. A retrospective study of all patients undergoing percutaneous nephrolithotomy from January 2010 to December 2017 in single institution was conducted. All cases were stratified into three groups based on tract size; standard percutaneous nephrolithotomy with tract size ? 22 F, mini percutaneous nephrolithotomy with tract size 15 - 20 F and ultramini percutaneous nephrolithotomy with tract size ? 14 F. Age, gender, stone complexity using Guy's stone score, stone size, operative time, hemoglobin drop, hospital stay, early major and minor complications were reviewed. A total of 1074 patients had undergone percutaneous nephrolithotomy among which, 578 patients were standard percutaneous nephrolithotomy, 433 mini percutaneous nephrolithotomy and 63 had undergone ultramini percutaneous nephrolithotomy. There was even distribution of patients with Guy's stone score 1 and 2 in all three groups. However, majority of patients with Guy's stone score 3 underwent standard percutaneous nephrolithotomy or mini percutaneous nephrolithotomy and no patients with Guy's stone score 4 underwent ultramini percutaneous nephrolithotomy. Age group, gender and operative time were comparable between the groups; however, significant difference was noted in terms of less hemoglobin drop and shorter hospital stay (p-value < 0.05) in the miniaturized percutaneous nephrolithotomy group. Complications were found to be fewer in mini percutaneous nephrolithotomy and ultramini percutaneous nephrolithotomy group in comparison to standard percutaneous nephrolithotomy. Miniaturization of tract size significantly decreases post-operative complication rates, blood loss and hospital stay while maintaining high stone free rates in well selected patients undergoing Percutaneous nephrolithotomy.

Introduction: For the management of renal stones, Percutaneous nephrolithotomy (PCNL) has undergone significant changes in the last few years in the quest for improving efficacy and reducing morbidity. Minimally-invasive modalities of PCNL, such as mini- PCNL, ultra-mini PCNL, and micro-PCNL, have evolved with advancements in optics and technology. However, with these newer advancements, the migration of small fragments produced with laser lithotripsy remains a concern, which may result in incomplete stone clearance. A new technique of PCNL is termed “Superperc” that utilizes suction to remove all the fragments and maintain a one-way flow. Methods: This study involved 35 consecutive patients who underwent PCNL with the Superperc technique from March 2020 to December 2020. Surgery was performed using a pediatric ureteroscope used as a nephroscope and a specially designed sheath with a suction attachment. The Superperc uses a 10/12 F tract size, a specially designed Superperc sheath (Shah Sheath) with a suction mechanism, and a pediatric ureteroscope 4.5/6. Results: The age range is 20-65 years, with 23 males and 12 females. Stone size was 1- 3 cm, and operative time was 30-90 min. Upper calyceal punctures 7cases , 19 had middle, 6 lower calyceal and 3 had two punctures. DJ stent was placed in 7 patients, whereas 28 patients had a ureteric catheter for 24 hours. Only three patients required a nephrostomy tube. No blood transfusion. Postoperatively one patient had a mild fever, and one had transient hematuria. Complete stone clearance as per nephroscopy &amp;fluoroscopy. The hospital stay was 24-72 h. Conclusion: Superperc is a new technique of minimally-invasive PCNL and can be successfully done with minimal modification in the armamentarium, with the potential advantage of good stone clearance. Bangladesh J. Urol. 2022; 25(2): 71-75

ABSTRACTIntroduction and ObjectiveTotally tubeless percutaneous nephrolithotomy (PCNL) has been demonstrated to be feasible and safe, particularly for mini-PCNL. Having an objective test to guide patient selection could improve confidence in this practice and facilitate broader adoption. The purpose of this study was to evaluate the utility of an intraoperative methylene blue test to determine candidacy for totally tubeless PCNL.MethodsAdult patients undergoing PCNL at four institutions were included in this study. Patients with prior reconstructive surgery, chronic pain, or requiring ureteral dilation were excluded. After stone clearance, 10 mL methylene blue (MB) dye was injected into the percutaneous access tract. A positive test (“pass”) was defined as visualization of blue dye in the bladder catheter within two minutes of injection. In some standard PCNL cases, totally tubeless management was simulated by placement of a capped nephrostomy tube. Post-operative complications within 7 days were evaluated as the primary outcome.ResultsThe intraoperative MB test was performed in 91 PCNL cases: 60 mini-PCNLs (16 Fr access) and 31 standard PCNLs (24+ Fr access). Mini-PCNL cases were more likely to pass the MB test compared to standard PCNL cases (75% vs 38.7%, p = 0.001). Of the 45 mini-PCNL subjects who passed, 40 were left totally tubeless, resulting in two minor complications (urinary retention, obstructing ureteral stone fragment). In the standard PCNL cohort, 12 passed the MB test. Five were left totally tubeless and 3 simulated totally tubeless management with capped nephrostomy tubes; one subject had a transient postoperative creatinine elevation, and one required uncapping for steinstrasse. There were no other obstructive or infectious complications, and no surgical reintervention was required.ConclusionsAn intraoperative methylene blue test is a simple test with high positive-predictive value to determine candidacy for totally tubeless PCNL in real time for both mini and standard PCNLs.

Background and objectives: The management of nephrolithiasis has undergone substantial transformation with the introduction of minimally invasive endourological techniques. The objective of this research is to assess and compare the effectiveness of the two types of treatments of kidney stones mini-percutaneous nephrolithotomy versus conventional percutaneous nephrolithotomy. Methods: A randomized comparison trial that included 150 patients diagnosed with renal stones from January 2022 to January 2024. Patients who were admitted to the urology department at Rizgary teaching hospital, Zheen international hospital and Zanko hospital were systematically assigned, through a random process, into 2 separate groups: A) mini-percutaneous nephrolithotomy group, or B) standard percutaneous nephrolithotomy. Parameters such as operative time, post operative hemoglobin level, complications, duration of hospitalization and residual stone were compared. Results: The mean pre-operative hemoglobin was 13.5 ± 1.03 g/dl in patients who underwent standard Percutaneous, and 13.7 ± 0.65 g/dl in those who underwent mini-percutaneous nephrolithotomy (p&gt;0.05). However, there was a statistically significant difference between mini- percutaneous nephrolithotomy post-operative hemoglobin (12.9 ± 0.79 g/dl) and standard percutaneous nephrolithotomy post operative hemoglobin (11.7 ± 2.5 g/dl) (p&lt;0.05). There was no statistically significant difference in operative time between Group A and Group B. However, the rate of residual stone was significantly higher in standard percutaneous nephrolithotomy vs. mini-percutaneous nephrolithotomy (p&lt;0.05). Conclusions: Mini-percutaneous nephrolithotomy demonstrates enhanced efficacy in handling renal calculi, delivering a higher rate of stone clearance compared to Standard percutaneous nephrolithotomy.

Objective:The objective of the study was to present the current practice patterns on percutaneous nephrolithotomy (PCNL) in Saudi Arabia and to compare it with the international patterns and to observe the adherence to the guidelines.Materials and Methods:A survey consisting of 28 questions was sent to urologists working in Saudi Arabia using a Google Forms questionnaire. The questioner covered most aspects of performing PCNL starting from preparing the patient till discharging him.Results:One hundred and thirty-two replied to the survey. Almost 70.2% performed PCNL and 59.1% of them learned PCNL during residency. The access was obtained by the urologists in 80.3% from the participants, 68.2% of them uses fluoroscopic guidance for the puncture. The majority (80.3%) perform PCNL in the prone position. Nearly 69.7% use the balloon dilators and 16.7% use the Amplatz dilators. For kidney drainage, 60.6% place a nephrostomy tube and a double-J stent (DJ stent) together and 4.5% perform tubeless PCNL (DJ stent only). About 45.5% stated that the introduction of flexible ureteroscopy decreased the rate of doing PCNL for >20%.Conclusions:Data obtained from a group of urologists in Saudi Arabia showed that the majority of urologists practicing in Saudi Arabia perform PCNL. They usually learn PCNL during residency. We observe that the majority of urologists attach to the original patterns in PCNL, i.e., they predominantly prefer the prone position and use fluoroscopy to gain the PCNL access. Furthermore, the data showed that new trends in PCNL did not gain a lot of momentum as few practices miniaturized PCNL and tubeless PCNL. The majority use balloon dilators and combined ultrasonic/pneumatic lithotripters. The complication rate encountered by the participants is concomitance with the published international figures. The introduction of flexible ureteroscopy highly decreased the rate of doing PCNL for most urologists.

Objective To compare the efficiency between mini-percutaneous nephrolithotomy (MPCNL) and extracorporeal shock wave lithotripsy (ESWL) for monotherapy of renal calculi in infants less than 3 years.Methods Forty-six infants were treated with either SWL (22 infants) or MPCNL monotherapy (24 infants).The mean age was (22.6 ± 8.7) months vs (23.5 ± 6.6) months and the stone size was (21.4 ± 3.5) mm vs (21.7 ± 1.7) mm,and there were no significant difference.Results For MPCNL,mean operating time was (76.2 ± 23.4) min and mean hospital stay was (14.13 ± 5.8) d.The stone-free rates were 84.0％ (21/25) after first session and 96.0％ (24/25) after second-look procedure.Postoperative fever happened in 4 (16.0％) cases.Hemoglobin drop was (8.5 ± 4.4) g/L and no one needed blood transfusion.For ESWL,the stone-free rate were 31.8％ (7/22) after first session and 86.3％ (19/22) after second session for 11 infants (50.0％).Mean hospital stay was (6.6 ± 2.3) d and 10 cases (45.5％)had complications.Hemoglobin drop was (10.6 ± 12.7) g/L.MPCNL was lower than ESWL in complications rate and re-treatment rate,and the stone-free rate was higher,but the hospital stay and operation time was longer (P ＜ 0.05).GFR revealed improve or stable after operation in both groups.Conclusions For a higher success rate,lower complication rate and re-treatment rate,MPCNL was an effective option for the management of relatively larger stones in children (even in infants). Key words: Infant; Renal calculi Shock wave lithotripsy; Percutaneous nephrolithotomy

Mini-percutaneous nephrolithotomy (mini-PCNL) is a widely adopted technique for the treatment of renal stones, offering minimal invasiveness and high success rates. Efficient retrieval of stone fragments is critical for surgical success. This study compares the efficacy and safety of the whirlpool mechanism versus forceps retrieval during mini-PCNL in a tertiary care hospital in Pakistan. Objective: To evaluate the stone clearance rates, operative time, hospital stay, and complications associated with the whirlpool mechanism compared to forceps retrieval in mini-PCNL. Methods: This prospective randomized controlled trial included 90 patients undergoing mini-PCNL at the Institute of Kidney Diseases (IKD), Peshawar. Patients were randomly assigned into two groups: Group A (whirlpool mechanism) and Group B (forceps retrieval), with 45 patients each. Data on stone clearance rates, operative time, hospital stay, and complications were collected and analyzed using SPSS version 26, with a p-value ≤0.05 considered significant. Results: The stone clearance rate was significantly higher in Group A (91.1%) compared to Group B (77.8%, p=0.042). Operative time was slightly longer in Group A (90.6 ± 12.4 minutes) than in Group B (82.3 ± 10.7 minutes, p=0.032). Group A demonstrated a shorter hospital stay (2.8 ± 0.6 days) compared to Group B (3.4 ± 0.7 days, p=0.021). Complication rates, including bleeding, infection, and urinary leaks, were low and comparable between the groups. Conclusion: The whirlpool mechanism significantly enhances stone clearance rates and shortens hospital stays compared to forceps retrieval, with a comparable safety profile. These findings support the adoption of the whirlpool mechanism as a preferred method for stone fragment retrieval during mini-PCNL, particularly in resource-limited settings.

BackgroundTo evaluate the safety and efficacy of mini percutaneous nephrolithotomy (mini PCNL) and retrograde intrarenal surgery (RIRS) in treatment of kidney stones 20–30 mm.MethodsA prospective randomized study of 70 patients who presented to the urology department with calyceal or renal pelvic stone of 20–30 mm between September 2017 and September 2019. Patients were randomly divided into two groups, Group A (Mini PCNL) consists of 35 patients who were treated with mini PCNL and Group B (RIRS) consists of 35 patients who were Achieving success of the technique was considered when the patient is stone-free or has radiologically insignificant residual fragments < 4 mm.ResultsThe demographic data in this study were comparable in both groups. The stone size was 20.43 ± 2.2 mm in group A & 20.5 ± 2.1 in group B, with no statistical significance. Meanwhile, the operative time in group A was 59.71 ± 19.44 min and in group B was 80.43 ± 14.79 min with statistical significance difference (p value < 0.001), while Fluoroscopy time had a mean of 8.11 ± 2.05 min in group A & 5.8 ± 1.98 min in group B with statistically significant diffrence (p value < 0.001). The stone free rate (SFR) was 88.6% in mini PCNL and 82.9% in RIRS with no statistically significant difference (p value: 0.5).ConclusionRIRS and mini PCNL can be an effective and alternative option for treatment of renal stones 2–3 cm. Both techniques have relatively similar SFR but RIRS showed more operative time, on contrary Mini-PCNL has more operative and postoperative complications. A multicenter studies with larger numbers of patients will be more effective to confirm these results.

Holmium:Yttrium-Aluminum-Garnet (Ho:YAG) had been considered the gold standard for treating urinary tract stones. However, advancements in laser technology have introduced thulium fiber laser (TFL) as a potential alternative. Preliminary studies have indicated that TFL may have certain advantages over Ho:YAG laser in lithotripsy. This systematic review compared the clinical outcomes of TFL and Ho:YAG laser for urinary tract stone treatment, focusing on operating time, stone-free rate (SFR), retropulsion, and complications. A systematic search was conducted on PubMed and ScienceDirect for original articles published within the last 5 years, comparing the clinical outcomes of Ho:YAG and TFL in lithotripsy. Inclusion criteria were English-language studies focusing on Ho:YAG and TFL laser energy for urinary tract stones, with accessible full-text articles comparing clinical outcomes. Excluded were studies discussing lasers for conditions other than urinary tract stones or using lasers other than TFL and Ho:YAG. Four studies (544 procedures) met the criteria and underwent risk of bias assessment using Risk of Bias 2 (ROB-2) for randomized trials and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) for cohort studies. The data were presented in tables and charts. In this review, TFL demonstrated a shorter operating time compared to Ho:YAG (and higher stone-free rates in two studies. TFL also had a lower incidence of stone retropulsion. Intra-operative complication rates varied between the groups for ureterorenoscopy (URS) and retrograde intrarenal surgery (RIRS) procedures, while TFL had a higher rate of prolonged haematuria during mini percutaneous nephrolithotomy (PCNL) procedures. Postoperative complications were similar in both groups. Limitations of this review include procedural and laser setting heterogeneity, a small number of studies, and the lack of registration and protocols. In conclusion, TFL is an effective and safe alternative to Ho:YAG laser for lithotripsy, offering shorter operation time, higher stone-free rates, and reduced stone retropulsion.

Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large kidney calculi, staghorn calculi, and calculi that are multiple or resistant to shock wave lithotripsy. In many centers, PCNL is performed under general anesthesia. However, complications under spinal anesthesia can be less frequent. We evaluated the impact of spinal anesthesia on intra-operative and postoperative outcome in patients undergoing PCNL. The intra-operative and postoperative anesthetic and surgical outcomes were evaluated in 160 consecutive patients who underwent PCNL under spinal anesthesia in the prone position. The mean age of the patients was 40.0 +/-14.3 years, and the mean operative time was 95.0 +/- 37.8 minutes. The mean calculus size was 34.2 +/- 9.8 mm. Ten patients had staghorn calculi (mean size, 4.2 +/- 1.1 cm; mean operative time, 140 +/- 40 minutes). Return of sensory and motor activity took 140.0 +/- 19.7 minutes and 121.0 +/- 23.8 minutes, respectively. During the first part of anesthesia, 18 patients developed hypotension, which was controlled by ephedrine, 10 mg, intravenously. Ten patients (6.3%) needed blood transfusion and 6 complained of mild to moderate headache, dizziness, and mild low back pain for 2 to 4 days after the operation, which improved with analgesics and bed rest. Seventy percent of the patients had complete clearance of calculus or no significant residual calculi larger than 5 mm on follow-up ultrasonography. Spinal anesthesia is safe and effective for performing PCNL and is a good alternative for general anesthesia in adult patients.

ObjectiveTo recommend our clinical experiences in five important concerns which common to be met in percutaneous nephrolithotomy (PCNL), helping the beginners easy to handle this kind of procedures.MethodsReview PCNL in ten years in our hospital, we analyzed five important aspects which could influence the results of operations. Include selection of access site, loss of percutaneous access while dilation, different methods of stone fragmentation, controlling pressure of irrigation in PCNL, and management of complications.Results(I) Selection of access site. Because there are less blood vessels in most posterior lower or upper middle calyces, renal puncture through these two calyces would bleed less. It does not need to set up the third access, because of accessorial application of ESWL and RIRS. If necessary, puncture residual stone in calyx may be needed. (II) Loss of percutaneous access while dilation. If the guidewire was out of upper urinary tract collecting system, most of time it needs repeating puncture. If the sheath was not deep enough, the guidewire was still in collecting system, push the nephroscope into calyx along the guidewire, then advancing the sheath. (III) Different methods of stone fragmentation. The usual methods of stone fragmentation are pneumatic lithotripsy, ultrasonic lithotripsy and holmium laser lithotripsy. Pneumatic lithotripsy is efficacy and inexpensive. Almost all kinds of stones could be broken, except a few stones such as calcium oxalate monohydrate. It is too rigid that to be broken is very difficult. The speed of lithotripsy is slow, and the debris of stone should be clear off one by one. The ultrasonic lithotripsy could sucked away the debris of stone at same time of lithotripsy. The speed of lithotripsy is high. But bigger access has to be used, and it is difficult to break the stiffer stones. All kinds of stones could be broken by holmium laser, especially high power holmium laser, the debris of stone is less and speed of lithotripsy is higher than pneumatic lithotripter. But there is no stone removal function. (IV) Controlling pressure of irrigation in PCNL. It is very important to keep the sheath unobstructed, there is a relatively high pressure in mini PCNL with pneumatic or laser lithotripsy, a relatively lower pressure in collecting system in standard PCNL with ultrasonic lithotripsy. The irrigation pressure and flow rate could be changed according to the view and whether need to flush out the stone debris or not. (V) Management of severe complications. Review the experiences of damage of pleura, super selective renal arterial embolization for hemorrhage after PCNL, the use of antibiotics and management of respiratory and circulatory function for treatment of high fever and urosepsis, the management of injury of colon and stone combine with renal pelvic tumor.ConclusionsThe details would determine the results of PCNL. Any mistakes would result in failure of the procedure and damage of kidney, sometimes will be lethal for the patient. Pay attention to the details is the key of successful finishing the operations.

To report our single center experience in comparing mini-percutaneous nephrolithotomy versus flexible ureterorenoscopy for management of renal stones up to 2 cm in anomalous kidneys. Records of the last 30 patients with stones less than 2 cm in anomalous kidney treated by mini-percutaneous nephrolithotomy were reviewed and compared to last 30 patients treated by flexible ureterorenoscopy. Mean stone size was significantly higher in the minipercutaneous nephrolithotomy group (17.90 mm) than in flexible ureterorenoscopy group (14.97mm) (p < 0.001). Mean operative time (80.33 min vs 56.43 min) and fluoroscopy exposure time (4.49 min vs 0.84 min) were significantly higher in the mini-percutaneous nephrolithotomy group than in the flexible ureterorenoscopy group (p < 0.001). The mean post-operative drop in hemoglobin concentration was significantly higher in the mini-percutaneous nephrolithotomy group (0.47 gm versus 0.2 gm) (p < 0.001). Stone free rate after 12 weeks follow up was not statistically significant between the 2 groups (90% in minipercutaneous nephrolithotomy vs 80% in flexible ureterorenoscopy) (FEp = 0.472). Both modalities were found to be safe and effective for treatment of stones less than 2 cm in anomalous kidneys.

Introduction: Since its introduction in 1976, percutaneous renal stone surgery has undergone several modifications. Reduction in size of access sheath was one of them which was first reported by Jackman in 1998. The miniaturisation of access sheath in Mini-Percutaneous Nephrolithotomy surgery has significantly reduced the intervention related morbidity with similar outcome as of standard Percutaneous Nephrolithotomy. Methods: This is a prospective cohort study where a single surgeon without previous experience of independent PCNL surgery performed Mini PCNL under controlled condition for renal stone sized 10 to 30 mm. The outcome was measured in terms of stone free rate and postoperative complications. The association of stone free rate and drop in haemoglobin level with different preoperative and operative variables were calculated with Pearson’s correlation test and p value &lt;0.05 was considered significant. Results: Mini PCNL was performed in total of 63 renal units. The mean age was 37.8 ± 9.9 years with male: female ratio of 1.8:1. The average stone size was 16.8 ± 2.9 mm. The mean operative time was 55.2 ± 19.0 (30-110) minutes. The stone free rate was 98.2 ± 3.6 %. The mean drop in haemoglobin was 1.3 ± 0.8 and blood transfusion rate was 4.7%. The average hospital stay was 2.6 ± 1.3 days. The grade I complications was 15.8% and grade II and III was 7.9% each. Stone free rate was significantly associated with stone number (r = -0.47, p = 0.004). Similarly fall in haemoglobin was associated with total operative time (r = 0.49, p = 0.003). The stone size, hardness of stone (HU) and size of access sheath had no significant association with stone free rate and fall in haemoglobin. Conclusions: Mini PCNL is as effective as standard PCNL with higher safety margin in small and medium size stone (10 to 30 mm) during learning curve of endo-urology procedure.

This meta-analysis was performed to evaluate the efficacy and safety of percutaneous nephrolithotomy (PCNL) under regional anesthesia (RA) vs. general anesthesia (GA). A systematic literature search in the electronic databases (Cochrane CENTRAL, Medline and EMBASE) was performed up to April 2014. Twelve trials, including 1954 patients, met the inclusion criteria and were included in the final analysis. Our pooled analysis showed that PCNL under RA could reduce surgical duration (MD, -2.47; 95 % CI, -3.51 to -1.44), hospitalization period (MD, -0.48; 95 % CI -0.93 to -0.04), fluoroscopy time (MD, -0.48; 95 % CI, -0.83 to -0.14), blood transfusion (OR, 0.59; 95 % CI, 0.38-0.92), postoperative pain (MD, -1.99; 95 % CI, -2.2 to -1.78), and analgesic requirements (MD, -19.14; 95 % CI, -26.64 to -11.63). However, there was no difference between RA and GA groups with regard to stone-free rate (OR, 1.09; 95 % CI, 0.86-1.37) and postoperative complications associated with PCNL (OR, 0.95; 95 % CI 0.58-1.54). Our results show that PCNL under RA offers several potential advantages over GA in terms of surgical duration, hospitalization period, fluoroscopy time, blood transfusion, postoperative pain, and analgesic requirements, but both anesthetic techniques appear to be equivalent with regard to the stone-free rate and complication rate. Along with the suggested favorable hemodynamic profile and lower cost, RA may prove a better alternative than GA.

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