Ultra-mini PCNL versus flexible ureteroscopy: a matched analysis of treatment costs (endoscopes and disposables) in patients with renal stones 10–20 mm

The Saudi urological association guidelines on urolithiasis

Aims

The Saudi Urolithiasis Guidelines are a set of recommendations for diagnosing, evaluating, and treating urolithiasis in the Saudi population. These guidelines are based on the latest evidence and expert consensus to improve patient outcomes and optimize care delivery. They cover the various aspects of urolithiasis, including risk factors, diagnosis, medical and surgical treatments, and prevention strategies. By following these guidelines, health-care professionals can improve care quality for individuals with urolithiasis in Saudi Arabia.

Panel

The Saudi Urolithiasis Guidelines Panel consists of urologists specialized in endourology with expertise in urolithiasis and consultation with a guideline methodologist. All panelists involved in this document have submitted statements disclosing any potential conflicts of interest.

Methods

The Saudi Guidelines on Urolithiasis were developed by relying primarily on established international guidelines to adopt or adapt the most appropriate guidance for the Saudi context. When necessary, the panel modified the phrasing of recommendations from different sources to ensure consistency within the document. To address areas less well covered in existing guidelines, the panel conducted a directed literature search for high quality evidence published in English, including meta analyses, randomized controlled trials, and prospective nonrandomized comparative studies. The panel also searched for locally relevant studies containing information unique to the Saudi Arabian population. The recommendations are formulated with a direction and strength of recommendation based on GRADE terminology and interpretation while relying on existing summaries of evidence from the existing guidelines.

Flexible ureteroscopy under local anesthesia for stone management: initial exploration and two-year experience

BACKGROUND

Flexible ureteroscopy (f-URS) is a minimally invasive surgical technique used for treating urinary tract stones. While general anesthesia (GA) is the standard method used, it comes with risks. Local anesthesia (LA) is a safer and more cost-effective alternative to GA, and its use in f-URS could potentially reduce patients' risks and increase accessibility to treatment. This study aims to investigate the feasibility, safety, and efficacy of using LA for f-URS in treating stones, as an initial experience in the diagnosis related group (DRG) era of China.

METHODS

Patients who met the inclusion and exclusion criteria and were continuously included in the study Between 2021 and 2023. We analyzed the stone free status, postoperative complication rate, hospitalization costs, and presented key points of the procedure performed under LA that we had summarized over the past two years.

RESULTS

A study of 614 patients undergoing f-URS under LA for urinary stones in our hospital showed 83.4% stone-free rate with a mean operative time of 44.12 ± 16.63 minutes; 18 patients experienced fever postoperatively, and 12 had ureteral injuries. No severe complication was reported. The cost of LA was found to be only 1.7% of the DRG payment, which is around $40. The highest VAS scores were observed during the sheath insertion, with STAI scores decreasing during and after surgery.

CONCLUSIONS

The study revealed that f-URS administered under LA was a well-tolerated, efficient, safe, and economical procedure. In the DRG era, this new anesthetic option for f-URS provides urologists with a more cost-effective alternative.

Perioperative Fast-Track Surgery Nursing Intervention for Patients with Kidney Stone Disease under Computed Tomography Imaging

This research aims to analyze the clinical intervention effect of perioperative fast-track surgery (FTS) nursing on patients with kidney stone disease (KSD) under computed tomography (CT) imaging. One-hundred KSD patients were selected as research objects and grouped after CT examination. These objects were randomly divided into a research group (FTS nursing intervention, n = 50) and a control group (general routine nursing intervention, n = 50). The preoperative psychological status of patients was compared between the two groups, using Self-rating Anxiety Scale and Self-rating Depression Scale. The hunger and thirst situations were compared using Numerical Rating Scale; postoperative recovery time, incidence of complications, and nursing satisfaction were also compared. The high-density shadow could be clearly observed in the right kidney of the patients in the CT imaging examination. The nursing outcomes suggested that there was no notable difference in hunger between the two groups, and anxiety, depression, and thirst in the research group were highly better than those in the control group (P < 0.01). The time of the first exhaust, the time of body temperature returning to normal, the time of getting out of bed, and the length of hospital stay in the research group were all shorter than those in the control group (P < 0.05). The total postoperative satisfaction of the research group (98.00%) was greatly better than the 88.00% in the control group (P < 0.05). As the FTS concept was applied in the perioperative nursing of KSD patients under CT imaging, the preoperative and postoperative negative emotions of patients could be improved. Thereby, the postoperative recovery rate of patients was promoted, postoperative complications and patients' pain were reduced, and the postoperative quality of life of patients was also improved.

Comparison between standard, mini and ultra-mini percutaneous nephrolithotomy for single renal stones: a prospective study

PURPOSE

Based on the current trend of miniaturization of instruments used in percutaneous nephrolithotomy (PCNL), it is necessary to compare different PCNL modalities regarding their access sheath size used. Thus, the safety and efficacy among standard, mini and ultra-mini PCNL (s-PCNL, m-PCNL, um-PCNL) were compared.

METHODS

We performed a prospective, non-randomized trial between January 2018 and July 2020. Patients with stones classified as Guy's stone score grade I were included. The set-up for s-PCNL and m-PCNL included a 30 Fr and 22 Fr percutaneous tract, respectively. In both set-ups, an ultrasonic/ballistic lithotripter was utilized. In the case of um-PCNL, a 12 Fr percutaneous tract was established. A high-power laser was used for lithotripsy. Hemoglobin drop, complication rate, length of hospital stay (LOS), stone-free rate (SFR) and operation time were evaluated.

RESULTS

A total of 84 patients, 28 patients per method, were evaluated. Hemoglobin drop was higher in the s-PCNL group when compared to m-PCNL (p = 0.008) and um-PCNL groups (p < 0.001), while um-PCNL group had the slightest hemoglobin drop. LOS was similar between s-PCNL group and m-PCNL group, but um-PCNL group required shorter hospital stay than the other two modalities (p < 0.001). The complication and transfusion rates as well as SFR did not differ between groups. Operation time in the um-PCNL set-up was longer compared to s-PCNL (p < 0.001) and m-PCNL (p = 0.011), whereas s-PCNL and m-PCNL did not differ significantly.

CONCLUSION

m-PCNL showed less hemoglobin drop, but similar operation time and SFR when compared to s-PCNL. um-PCNL showed even less hemoglobin drop, but the operation time was longer compared to the two other modalities.

Ultramini-percutaneous nephrolithotomy versus retrograde intrarenal surgery in the treatment of 10-30 mm calculi: a randomized controlled trial

The surgical management of renal stones 10-30 mm is usually performed with percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS). Standard form of percutaneous nephrolithotomy has paved the way for miniaturized PCNL in many centres. We wanted to evaluate the efficacy, safety and the cost-effectiveness of ultramini-percutaneous nephrolithotomy (UMP) versus RIRS in the treatment of renal stones with stone burden 10-30 mm. Patients with renal stone burden 10-30 mm were prospectively randomized into either UMP or RIRS. The demographic data, stone characteristic, operative time and cost of the equipment were recorded. The stone free status, analgesic requirement, deterioration of the renal function and hemoglobin and the postoperative complications as per Clavein-Dindo grade were recorded. One hundred and fifty patients met inclusion criteria. Out of these 98 underwent UMP and 46 RIRS. Six withdrew the consent before the procedure. Mean stone size was comparable in either of the groups. Mean laser time and stone extraction time was significantly less for UMP compared to RIRS (41.17 min versus 73.58 min p < 0.0001). Mean consumable costs in the UMP group were considerably less at US$45.73 compared to the RIRS group at $423.11 (p < 0.0001). The stone free rates at 1 month of follow-up were 100% for UMP group and 73% for RIRS group. There were insignificant changes to mean hemoglobin and glomerular filtration rate (GFR) in all patients and the average length of the stay was similar in both the groups. The postoperative complications revealed Grade I and II rate of 10% in the UMP group and 35% in the RIRS group, respectively. We concluded that UMP to be safe, effective and more economical to the RIRS for renal stones up to 3 cm in size.Trial registered with ISRCTN registry ID ISRCTN20935105, Retrospective.

Comparison of Ultra-Mini Percutaneous Nephrolithotomy and Retrograde Intrarenal Surgery for Renal Stones: A Systematic Review and Meta-Analysis from the KSER Update Series

Miniaturized percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) for renal stones have been developed to overcome the invasive disadvantages of PCNL. We aimed to compare the therapeutic effect and safety of ultra-mini percutaneous nephrolithotomy (UMPCNL) and RIRS for renal stones using an updated systematic review and meta-analysis. We searched clinical trials comparing UMPCNL and RIRS for renal stones using the PubMed, EMBASE, Cochrane Library, and Google Scholar databases up to October 2021. Seven studies were included in the current study. The renal stone size was 10–20 mm in three studies, 10–25 mm in one study, 10–35 mm in two studies, and not specified in one study. The stone-free rate of UMPCNL was higher than that of RIRS (p = 0.02; odds ratio (OR) = 2.01; 95% confidence interval (CI) = 1.12, 3.61). The complication rate showed no significant difference between UMPCNL and RIRS (p = 0.48; OR = 1.20; 95% CI = 0.73, 1.98). Regarding the operative time, UMPCNL was shorter than RIRS (p = 0.005; weighted mean difference (WMD) = −15.63; 95% CI = −26.60, −4.67). The hospital stay of UMPCNL was longer than that of RIRS (p = 0.0004; WMD = 1.48; 95% CI = 0.66, 2.31). UMPCNL showed higher efficacy than RIRS and similar safety to RIRS. UMPCNL may be a useful therapeutic option for moderate-sized renal stones.

Super-mini percutaneous nephrolithotomy (SMP) vs retrograde intrarenal surgery (RIRS) in the management of renal calculi ≤ 2 cm: a propensity matched study

OBJECTIVE

To compare the effectiveness and safety of Super-Mini PCNL (SMP) and Retrograde Intrarenal Surgery (RIRS) in the management of renal calculi ≤ 2 cm.

PATIENTS AND METHODS

A prospective, inter-institutional, observational study of patients presenting with renal calculi ≤ 2 cm. Patients underwent either SMP (Group 1) or RIRS (Group 2) and were performed by 2 experienced high-volume surgeons.

RESULTS

Between September 2018 and April 2019, 593 patients underwent PCNL and 239 patients had RIRS in two tertiary centers. Among them, 149 patients were included for the final analysis after propensity-score matching out of which 75 patients underwent SMP in one center and 74 patients underwent RIRS in the other. The stone-free rate (SFR) was statistically significantly higher in Group 1 on POD-1 (98.66% vs. 89.19%; p = 0.015), and was still higher in Group 1 on POD-30 (98.66% vs. 93.24%, p = 0.092) SFR on both POD-1 and POD-30 for lower pole calculi was higher in Group 1 (100 vs. 82.61%, p = 0.047 and 100 vs 92.61% p = 0.171). The mean (SD) operative time was significantly shorter in Group 1 at 36.43 min (14.07) vs 51.15 (17.95) mins (p < 0.0001). The mean hemoglobin drop was significantly less in Group 1 (0.31 vs 0.53 gm%; p = 0.020). There were more Clavien-Dindo complications in Group 2 (p = 0.021). The mean VAS pain score was significantly less in Group 2 at 6 and 12 h postoperatively (2.52 vs 3.67, 1.85 vs 2.40, respectively: p < 0.0001), whereas the mean VAS pain score was significantly less in Group 1 at 24 h postoperatively (0.31 vs 1.01, p < 0.0001). The mean hospital stay was significantly shorter in Group 1 (28.37 vs 45.70 h; p < 0.0001).

CONCLUSION

SMP has significantly lower operative times, complication rates, shorter hospital stay, with higher stone-free rates compared to RIRS. SMP is associated with more early post-operative pain though.

Comparison of cost-effectiveness and postoperative outcomes following integration of a stiff shaft glidewire into percutaneous nephrolithotripsy

Aims:

To analyze the cost effectiveness of integrating a stiff shaft glidewire (SSGW) in percutaneous nephrolithotripsy (PCNL) relative to standard technique (ST). This is prudent because healthcare providers are experiencing increased pressure to improve procedure-related cost containment.

Methods:

ST for PCNL at our institution involves a hydrophilic glidewire during initial percutaneous access and then two new stiff shaft wires. The SSGW is a hydrophilic wire used for initial access and the remainder of the procedure. We collected operating room (OR) costs for all primary, unilateral PCNL cases over a 5-month period during which ST for PCNL was used at a single institution with a single surgeon and compared with a 6-month period during which a SSGW was used. Mean costs for each period were then compared along with stone-free rates and complications.

Results:

We included 17 total cases in the ST group and 22 in the SSGW group. The average operating room supply cost for the ST group was $1937.32 and $1559.39 in the SSGW group. The net difference of $377.93 represents a nearly 20% decrease in cost. This difference was statistically significant (p = 0.031). There was no difference in postoperative stone-free rates (82.4% versus 86.4%, p = 1.0, respectively) or complications (23.5% versus 13.6%, p = 0.677, respectively) between ST and SSGW groups.

Conclusion:

Transitioning to a SSGW has reduced OR supply cost by reducing the number of supplies required. The change in wire did not affect stone-free rates or complications.

The best treatment approach for lower calyceal stones ≤ 20 mm in maximal diameter: mini percutaneous nephrolithotripsy, retrograde intrarenal surgery or shock wave lithotripsy. A systematic review and meta-analysis of the literature conducted by the European Section of Uro-Technology and Young Academic Urologists

INTRODUCTION

The highest in quality data in the literature which compared mini percutaneous nephrolithotripsy (mPCNL), retrograde intrarenal surgery (RIRS) and shock wave lithotripsy (SWL) for the management of lower pole stone (LPS) with a maximal diameter ≤20mm were investigated by means of systematic review (SR) and meta-analysis.

EVIDENCE ACQUISITION

A SR of the literature was conducted on PubMed®, Cochrane, SCOPUS® and EMBASE® in January 2020. The study complied with the PRISMA statement and recommendations of the EAU Guidelines office. Only randomized controlled trials (RCTs) comparing retrograde intrarenal surgery (RIRS), shock wave lithotripsy (SWL) and mini-percutaneous nephrolithotripsy (mPCNL) were selected for the meta-analysis. The endpoints were the efficacy of each modality, measured by stone-free rate (SFR), operative time and retreatment rate and the safety of each method, based on hospitalization time and complications. Subgroup analyses for stones with a maximal diameter <10mm and 10-20 mm were performed.

EVIDENCE SYNTHESIS

Twenty-one RCTs were included in the meta-analysis. mPCNL had the highest SFR and the lowest retreatment rate among the three modalities, while SWL had the lowest SFR and the highest retreatment rate. The operative and hospitalization time were shorter in the case of SWL, whereas they were similar in the case of mPCNL and RIRS. The highest complication rate was observed in mPCNL group, which accounted for 8.3-22.4%, while RIRS and SWL had similar complication rates, which ranged between 1.3-31.4% and 0-48.5%, respectively. Further classification of the complications according to Clavien-Dindo system revealed that SWL had lower grade II complication rates compared to mPCNL and RIRS. Regarding stones <10mm, SWL and RIRS had similar SFR, complication rate, operation and hospitalization time. SWL had higher retreatment rate.

CONCLUSIONS

For LPSs ≤20mm, mPCNL provides the highest SFR and the lowest retreatment rate. This modality has a higher complication rate and longer hospital stay in comparison to the other modalities. SWL provides the lowest SFR with the highest retreatment rate. RIRS has similar complication rate to SWL and could be preferred over SWL. For stones up to 10mm, SWL may provide a valid alternative. Despite a higher retreatment rate, its SFR is similar to RIRS.

Effect of Preoperative Double-J Ureteral Stenting before Flexible Ureterorenoscopy on Stone-free Rates and Complications

The effect of preoperative Double-J (DJ) ureteral stenting before flexible ureterorenoscopy (FURS) in the treatment for urinary stones was evaluated. We retrospectively enrolled 306 consecutive patients who underwent FURS from Jan. 2014 to Dec. 2017. All the patients were classified into two groups according to whether they had DJ ureteral stenting before FURS. Baseline characteristics (age, sex, stone location, stone size, surgical success rate, operation time, stone-free rate of the first day after surgery, stone-free rate of the first month after surgery, total complication rate) were compared using Chi-square test for categorical variables and Kruskal-Wallis test for continuous variables. In total, 306 patients were included in this study. The group of DJ stenting before FURS included 203 (66.3%) patients, and non-DJ stenting before FURS was observed in 103 (33.7%) patients. The group of DJ stenting before FURS was significantly associated with a shorter operation time (53.8 vs. 59.3 min, P<0.001), a higher stone-free rate of the first day after surgery (69.0% vs. 51.5%, P=0.003). However, statistical significant differences were not found in the age, sex, stone location, stone size, surgical success rate, stone-free rate of the first month after surgery (89.2% vs. 81.6%, P=0.065) and total complication rate (5.4% vs. 9.7%, P=0.161) between the two groups. Preoperative DJ ureteral stenting before FURS could reduce the operation time and increase stone-free rate of the first day after surgery. However, it might not benefit the stone-free rate of the first month after surgery and reduce the complication rate. Preoperative DJ stenting should be not routinely performed.

Semi-closed-circuit vacuum-assisted mini percutaneous nephrolithotomy in the pediatric population: the initial experience of two tertiary referral centers

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is the gold-standard for complex renal stones treatment in the pediatric population. While the miniaturization of PCNL reduces the risk of bleeding, it can hinder surgical and functional outcomes. The aim of the study was to assess the safety and feasibility of semi-closed-circuit vacuum-assisted Mini-PCNL (vmPCNL) in pediatric patients.

METHODS

From January 2017 to December 2018, we prospectively collected data on consecutive vmPCNLs from two European tertiary referral centers. The procedure was performed with the ClearPetra^® (Well Lead Medical Co., Ltd., Guangzhou, China) access sheath equipped with a lateral arm connected to the aspiration system (pressure setting ~120-150 cmH<inf>2</inf>O) by a 200 Ml plastic stone collector. Pre-, intra- and postoperative data and costs were analyzed. The stone-free rate (SFR) was defined as absence of residual fragments >4 mm with either ultrasound or kidney, ureter, and bladder X-ray.

RESULTS

Eighteen vmPCNLs were performed in 16 renal units of 13 children. The median age was 119 months (IQR: 97-160) and the weight was 29 Kg (IQR: 25-40). The median cumulative stone size was 32 mm (22-46) with 8 (44.4%) cases of staghorn stones. The OT was 128 min (IQR: 99-167). The basketing was unnecessary in 6/18 (33%) cases. Neither intra-operative complications nor blood transfusions occurred. Postoperative fever was observed in 5/18 (27.8%) cases; in one case a double J ureteral stent was placed for concomitant hydronephrosis. The SFR was 81.3% (13/16), rising to 93.8% (15/16) after ancillary procedures. The materials costs of a vmPCNL (734.8 €) were comparable to mini-PCNL using a reusable set (710.7 €).

CONCLUSIONS

The vmPCNL seems to be sustainable, safe and feasible for kidney stones treatment in the pediatric population.

Percutaneous nephrolithotomy versus flexible ureteroscopic lithotripsy in the treatment of upper urinary tract stones: a meta-analysis comparing clinical efficacy and safety

BACKGROUND

Upper urinary tract stones is the most common diseases in urology. Percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (fURL) are common treatment, but both their efficacy and safety are controversial. Thus we aim to evaluate the efficacy and safety of PCNL and fURL in the treatment of upper urinary tract stones, providing a reference for clinical work.

METHODS

PubMed, Web of Science, Embase and CNKI were searched through Apr. 1, 2019 to identify eligible studies. Data were analyzed by using RevMan 5.3 and Stata 12.0 software. Pooled relative risks (RRs) or weighted mean difference (WMD) with 95% confidence intervals (CIs) were calculated using fixed or random effects methods. Publication bias and sensitivity analysis were performed.

RESULTS

Four randomized controlled trials (RCTs), fifteen cohort studies involving 1822 patients were included. Stone-free rate of PCNL was significantly high than that of fURL (RR: 1.07; 95% CI: 1.03, 1.12; P = 0.0004). The decline of hemoglobin in PCNL was significantly high than that of fURL (WMD: 1.07; 95% CI: 0.54, 1.61; P < 0.0001). The number of blood transfusion was significantly greater in the PCNL compared to the fURL (RR: 5.04; 95% CI: 1.78, 14.24; P = 0.002). The incidence of postoperative bleeding or hematuria showed greater significantly difference in the PCNL compared to the fURL (RR: 2.72; 95% CI: 1.55, 4.75; P = 0.0005). Operation time, fever, infection, perforation, requiring drug analgesia was not significantly different between two surgical procedures.

CONCLUSIONS

In the treatment of upper urinary tract stones, the stones clearance rate of PCNL is higher than fURL, and the safety of fURL is higher than PCNL.

Comparative analysis of retrograde intrarenal surgery and modified ultra-mini percutaneous nephrolithotomy in management of lower pole renal stones (1.5-3.5 cm)

Background

To compare the safety and efficacy of retrograde intrarenal surgery (RIRS) and modified Ultra-mini percutaneous nephrolithotomy (UMP) in semi-supine combined lithotomy position for the management of 1.5–3.5 cm lower pole renal stones (LPSs).

Methods

A total of 63 patients with 1.5–3.5 cm LPSs who underwent RIRS (n = 33) or modified UMP (n = 30) in diameter between January 2017 and January 2019 were analyzed retrospectively. Modified UMP was performed in semi-supine combined lithotomy position and a 9.5/11.5 F ureteral access sheath (UAS) was inserted during the procedure in order to maintain low pelvic pressure and to facilitate the removal of stone fragments. Base-line parameters, stone characteristics, illness condition, operation time, postoperative hemoglobin (Hb) drop, postoperative creatinine (Cr) elevation, length of hospital stay, length of postoperative hospital stay, stone-free rate (SFR) and complications were compared between the two groups.

Results

There were no significant differences between the two groups in base-line parameters, stone characteristics and illness condition. The mean operating time of RIRS group was longer than UMP group (95.61 ± 21.9 vs. 55.0 ± 16.1 min, p < 0.001). The mean postoperative Hb drop was less in RIRS group (7.42 ± 4.7 vs. 15.70 ± 9.8 g/L, p < 0.001). The length of hospital stay and postoperative hospital stay for RIRS were shorter than UMP (4.76 ± 1.1 vs. 5.83 ± 0.8 d, p < 0.001, 2.97 ± 0.9 vs. 4.07 ± 0.9 d, p < 0.001). The Early SFR was higher in UMP group (54.5 vs. 80.0%, p < 0.050) while SFR at 1-month and 3-months postoperatively was similar in both groups (p = 0.504, p = 0.675). There were no significant differences between the two groups in complications (p = 0.228).

Conclusion

For patients with 1.5–3.5 cm LPSs, both modified UMP and RIRS are safe and viable. The modified UMP technique was used in this study, application semi-supine combined lithotomy position and the retention of UAS can improve the surgical efficiency and maintain low pressure perfusion in the kidney, which resulted in superior treatment efficacy. Therefore, we highly recommend this technique for LPSs with heavy stone burdens.

A retrospective study comparing super-mini percutaneous nephrolithotomy and flexible ureteroscopy for the treatment of 20-30 mm renal stones in obese patients

Objective

This study aimed to compare the efficacy and safety of Super-mini percutaneous nephrolithotomy (SMP) and flexible ureteroscopy (F-URS) in the treatment of 20–30 mm renal stones in obese patients.

Methods

We conducted a retrospective analysis of outcomes of patients who underwent SMP and F-URS to treat 20–30 mm renal stones from August 2017 to September 2018. Patients with BMI >30 kg/m² were enrolled into this study. Forty-eight patients underwent SMP, while 104 patients underwent F-URS by the same surgeon. The patients’ demographic data, stone characteristics, perioperative parameters and outcomes, complications, stone-free rate (SFR) and overall costs were retrospectively assessed.

Results

No significant differences were found between the two groups in terms of age, gender, BMI, operation side, stone size, number, locations, stone compositions and CT value. The mean operation time was significantly shorter in the SMP group (p < 0.001), while the F-URS group had significantly shorter postoperative stays (p < 0.001) and lower complication rates (p < 0.001). Both groups had similar SFR at a 3-month follow-up (p = 0.190), while the SMP group achieved significant higher SFR 3 days after the operation (p < 0.001). The SMP group had a significantly lower overall cost and fewer stage-2 procedures than the F-URS group.

Conclusion

SMP and F-URS are equally effective in obese patients with 20–30 mm renal stones. However, F-URS offers the advantage of a lower complication rate, while SMP performed better in terms of operation time, tubeless rate, stage-2 procedures and overall costs.

Minimally invasive percutaneous nephrolithotomy versus retrograde intrarenal surgery in surgical management of upper urinary stones - A systematic review with meta-analysis

OBJECTIVE

The purpose of this study was to retrospectively assess the efficacy and safety of minimally invasive nephrolithotomy (MPCNL) versus retrograde intrarenal surgery (RIRS) in the management of upper urinary stones.

METHODS

A comprehensive literature review of articles that investigated the efficacy and safety of MPCNL and RIRS was conducted by systematically searching PubMed, EMBASE, and Cochrane Library in March 2019. Two reviewers searched the literature, independently extracted the data and evaluated the quality of the data according to the inclusion and exclusion criteria. A meta-analysis was performed by using Review Manager 5.3 software.

RESULTS

Eight randomized controlled trials (RCTs) involving 725 patients with upper urinary stones were analysed based on the inclusion criteria. While MPCNL has a better clinical efficacy than RIRS with respect to the stone-free rate (SFR) [RR = 1.11, 95% CI (1.05-1.17), p = 0.0005], MPCNL has a higher incidence of haematoma [RR = 3.09, 95% CI (1.44-6.66), p = 0.004] and longer hospitalization time [MD = 0.89 day, 95% CI (0.07-1.72), p = 0.04]. In addition, no significant difference in operative time [MD = 2.46 min, 95% CI (-17.99 to 22.92), p = 0.81] and postoperative pain score [MD = 0.74, 95% CI (-0.45 to 1.94), p = 0.22] were observed between the two methods. Overall, the evidence was insufficient to suggest a statistically significant difference in the adverse event profile for MPCNL compared with RIRS.

CONCLUSIONS

Our data suggest that MPCNL is an effective method for treating upper urinary stones, especially lower calyceal stones that are 1-2 cm in size. Compared to RIRS, MPCNL is associated with a longer hospital stay time and a higher incidence of haematoma. In addition, both methods have proven to be safe. Nevertheless, the findings should be further confirmed through well-designed prospective RCTs with a larger patient series.

Comparison of retrograde flexible ureteroscopy and percutaneous nephrolithotomy in treating intermediatesize renal stones (2-3cm): a meta-analysis and systematic review

Purpose:

To systematically assess the effectiveness and safety of retrograde flexible ureteroscopy (FURS) versus percutaneous nephrolithotomy (PCNL) in treating intermediate-size renal stones (2-3cm).

Materials and Methods:

PubMed, Ovid MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE were researched to identify relevant studies up to May 2018. Article selection was performed through the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. The Newcastle-Ottawa Scale was applied to assess the methodological quality of case-control studies.

Results:

Six retrospective case-controlled trials were included for meta-analysis. The pooled results showed that PCNL was associated with a higher initial stone-free rate (SFR). After more complementary treatments, FURS provided a final SFR (OR: 1.69; 95% CI, 0.93-3.05; P = 0.08) comparable to that achieved by PCNL. PCNL was associated with a higher rate of overall intraoperative complications (OR: 1.48; 95% CI, 1.01-2.17; P = 0.04) and longer hospital stay (MD: 2.21 days; 95% CI, 1.11 to 3.30; P < 0.001). Subgroup analysis by Clavien-graded complication showed PCNL had significantly higher rates of minor complications (OR: 1.58; 95% CI, 1.04-2.41; P = 0.03). No significant difference was noted in major complications (OR: 1.14; 95% CI, 0.53-2.45; P = 0.73) or operative times (MD: −9.71 min; 95% CI, −22.02 to 2.60; P = 0.12).

Conclusions:

Multisession FURS is an effective and safe alternative to PCNL for the management of intermediate-size renal stones (2-3cm). It is advisable to balance the benefits and risks according to the individual characteristics of patients and to decide with patients by discussing the advantages and disadvantages of each procedure.

Outcomes of retrograde intrarenal surgery compared with ultra-mini percutaneous nephrolithotomy in the management of renal calculi

INTRODUCTION

To evaluate the outcomes of retrograde intrarenal surgery (RIRS) and ultra-mini percutaneous nephrolithotomy (umPCNL) in the management of renal calculi.

MATERIAL AND METHODS

Between March 2015 and January 2018, a total of 44 patients were treated with umPCNL. The outcomes of these patients were compared with 75 patients who underwent RIRS for renal calculi during the same time period.

RESULTS

Median stone size was 9 mm in the umPCNL group and 7 mm in the RIRS group. Stone-free rates after a single procedure were achieved in 85% of patients for the RIRS group and 98% for the umPCNL group. 16% of RIRS patients were left with a ureteric stent, whilst 7% of patients (n = 5) needed a second RIRS. One patient in the umPCNL group was left with a percutaneous nephrostomy; all other patients were left totally tubeless. The mean operative time was 66 minutes in the RIRS group and 55 minutes in the umPCNL group (p = 0.04). The minor complication rates for the RIRS and umPCNL groups were 17% and 15%, respectively. One patient in the RIRS group required postoperative nephrostomy insertion; there were no major complications in the umPCNL group. The median length of stay was 0 days in the RIRS group and 1 day in the umPCNL group.

CONCLUSIONS

The overall study showed that umPCNL has low complication rates and good stone-free rates, with a lower requirement for ancilliary procedures. UmPCNL is an acceptable alternative in selected patients with small- to moderate-sized renal calculi.

Assessing Cost-Effectiveness of New Technologies in Stone Management

Diagnosis, treatment, and follow-up are all influential in determining the overall cost to the health care system for kidney stones. New innovations in the field of nephrolithiasis have been abundant, including disposable ureteroscopes, ultrasound-guided approaches to percutaneous nephrolithotomy, and advanced laser lithotripters. Identifying cost-effective treatment strategies encourages practitioners to be thoughtful about providing value-based high-quality care and remains on important principle in the treatment of urinary stone disease.

Role of Minimally Invasive (Micro and Ultra-mini) PCNL for Adult Urinary Stone Disease in the Modern Era: Evidence from a Systematic Review

Purpose of Review

The role of PCNL and the expertise surrounding it has expanded in recent decades. Miniaturisation of equipment and instrument size has formed a part of this innovation. Although an increasing number of studies have been performed on miniaturised PCNL (Mi-PCNL) recently, a critical appraisal on these is lacking. We therefore conducted a systematic review of the literature to evaluate the efficacy, safety and feasibility of Mi-PCNL techniques (< 15 Fr).

Recent Findings

A systematic review was conducted from 1990 to March 2017 on outcomes of Mi-PCNL [micro PCNL (m-PCNL) and ultra-mini PCNL (UMP)] in adult patients. Ten studies (three on m-PCNL and seven on UMP) were included in our study. Across the three studies, 118 patients (mean age 42.2 years, male to female ratio 1.3:1) underwent m-PCNL (4.8 Fr). For a mean stone size of 13.9 mm, a mean stone-free rate (SFR) was 89% and an overall complication rate was 15.2% [Clavien classification I (44%), II (28%), III (28%)], with no Clavien IV or V complications. Across the seven studies, 262 patients (mean age 49.4 years, male to female ratio 1.5:1) underwent UMP (13–14 Fr). For a mean stone size of 18.6 mm, a mean SFR was 88.3% and an overall complication rate was 6.2% [Clavien classification I (57%), II (36%), III (7%)], with no Clavien IV or V complications. While the transfusion rates for m-PCNL was 0.85%, only one case each in m-PCNL and UMP needed conversion to mini PCNL.

Summary

Our review shows that for small- to medium-sized renal stones, Mi-PCNL can yield good stone-free rates whilst maintaining a low morbidity associated with it. There were no Clavien > III complications and no mortality with only one transfusion reported from this minimally invasive technique.

A prospective randomized comparison among SWL, PCNL and RIRS for lower calyceal stones less than 2 cm: a multicenter experience : A better understanding on the treatment options for lower pole stones

PURPOSE

To prospectively evaluate the efficacy and safety of RIRS, SWL and PCNL for lower calyceal stones sized 1-2 cm.

MATERIALS AND METHODS

Patients with a single lower calyceal stone with an evidence of a CT diameter between 1 and 2 cm were enrolled in this multicenter, randomized, unblinded, clinical trial study. Patients were randomized into three groups: group A: SWL (194 pts); group B: RIRS (207 pts); group C: PCNL (181 pts). Patients were evaluated with KUB radiography (US for uric acid stones) at day 10 and a CT scan after 3 months. The CONSORT 2010 statement was adhered to where possible. The collected data were analyzed.

RESULTS

The mean stone size was 13.78 mm in group A, 14.82 mm in group B and 15.23 mm in group C (p = 0.34). Group C compared to group B showed longer operative time [72.3 vs. 55.8 min (p = 0.082)], fluoroscopic time [175.6 vs. 31.8 min (p = 0.004)] and hospital stay [3.7 vs. 1.3 days (p = 0.039)]. The overall stone-free rate (SFR) was 61.8% for group A, 82.1% for group B and 87.3% for group C. The re-treatment rate was significantly higher in group A compared to the other two groups, 61.3% (p < 0.05). The auxiliary procedure rate was comparable for groups A and B and lower for group C (p < 0.05). The complication rate was 6.7, 14.5 and 19.3% for groups A, B and C, respectively.

CONCLUSIONS

RIRS and PCNL were more effective than SWL to obtain a better SFR and less auxiliary and re-treatment rate in single lower calyceal stone with a CT diameter between 1 and 2 cm. RIRS compared to PCNL offers the best outcome in terms of procedure length, radiation exposure and hospital stay. ISRCTN 55546280.

Early multicentre experience of ultra-mini percutaneous nephrolithotomy in the UK

Objectives:

Ultra-mini percutaneous nephrolithotomy (UMP) is a novel technique recently introduced allowing percutaneous renal access to stones using a specially modified 11 or 13 Fr sheath, a 6 Fr nephroscope, and permits laser fragmentation and stone evacuation. This study aimed to review the early practice of UMP in the UK.

Methods:

All centres in the UK which had performed UMP were contacted to submit data. Data were submitted to a central database from nine centres around the UK who performed UMP between July 2013 and December 2014. Data were collected on patient, stone, operative factors and outcomes.

Results:

A total of 32 UMP cases were performed in the contributing centres. Stone size ranged from 7 mm×5 mm to 24 mm×24 mm across the 32 cases, with a mean of 13 mm×10 mm. Stone-free rates were excellent with 31/32 cases stone-free post procedure; 26/32 patients were left without a nephrostomy tube. Complications were uncommon; there were two Clavien 1 complications in this series (6%).

Conclusion:

This study has shown the efficacy of UMP during its introduction into UK practice. It is likely that UMP will become a useful addition to the armamentarium to treat renal stones, especially smaller stones in the lower pole calyx, and in specialised cases such as paediatric stone disease and in patients with stones in calyceal diverticulae.

Superperc: A new technique in minimally-invasive percutaneous nephrolithotomy

Introduction:

Percutaneous nephrolithotomy (PCNL) has undergone significant changes in recent years in the quest for improving efficacy and reducing morbidity. Newer minimally-invasive modalities of PCNL such as mini-PCNL, ultra-mini PCNL, and micro-PCNL have evolved with advancement in optics and technology. However, with these newer advancements, migration of small fragments produced with laser lithotripsy remains a concern, which may result in incomplete stone clearance. We describe a new technique of PCNL termed “Superperc”, that utilizes suction to remove all the fragments and maintain one-way flow.

Methods:

This was a prospective observational study involving 52 consecutive patients who underwent PCNL with the Superperc technique from April 2014 to June 2015. 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, specially designed Superperc sheath (Shah Sheath) with suction mechanism and a pediatric ureteroscope (4.5/6 Fr, Richard Wolf) as nephroscope.

Results:

The mean age of the group was 41.8 years (range 6–84) with 33 males and 19 females. Mean stone size was 19.11 mm (range 10–37 mm) and mean operative time was 40.9 min (range 26–92 min). Twenty-seven renal units had upper calyceal puncture, whereas 12 had middle, 8 lower calyceal and 5 had two punctures. DJ stent was placed in 20 patients, whereas 32 patients were totally tubeless. Only three patients required a nephrostomy tube. The mean hemoglobin drop was 0.32 g with no blood transfusion. Postoperatively, three patients had a mild fever and one had transient hematuria. The stone clearance rate in our study was 96.15% and the mean hospital stay was 31.5 h (range 22–76 h).

Conclusion:

Superperc is a new technique of minimally-invasive PCNL and can be successfully done with minimal modification in armamentarium, with the potential advantage of good stone clearance.

Use of a Novel Flexible Mini-nephroscope in Minimally Invasive Percutaneous Nephrolithotomy

OBJECTIVE

To assess the feasibility and safety of a novel flexible mini-nephroscope in minimally invasive percutaneous nephrolithotomy (PCNL). Presumably, limiting the size and number of tracts during PCNL has the potential of decreasing the morbidity of the procedure. We present our experience with this new technique.

MATERIALS AND METHODS

A retrospective analysis of patients with multiple kidney stones treated with mini-PCNL combined with a novel flexible mini-nephroscope was performed. Minimally invasive PCNL was done with rigid 12 F MIP-M nephroscope, followed by flexible mini-nephroscopy for smaller stones in other inaccessible calyces. Record was made of the operating time, stone-free rates, postoperative pain, morbidity, hospital stay, time to recovery, complication rates, and ancillary procedures. Matched-pair analysis was done with cases operated by flexible ureteroscopy performed with Flex X-2 or Flex X-c scope.

RESULTS

Twenty-five patients in the study group were matched with 25 cases from the flexible ureteroscopy group. Both groups were comparable in terms of age, laterality, and mean composite stone burden. The mean operating time was 40.1 ± 10.6 minutes in the mini-PCNL group and 51.2 ± 8.8 minutes in the flexible ureteroscopy group. Mean hospital stay was similar in both groups. The primary stone clearance rate of 92% (23 of 25) in the mini-PCNL group was better than the clearance rate of 80% (20 of 25) in the flexible ureteroscopy group. Eight percent in the mini-PCNL group required ancillary procedures as compared with 20% of cases in the flexible ureteroscopy group. Postoperative pain and analgesia requirement in these patients was minimal. There were no significant complications.

CONCLUSION

Flexible mini-nephroscope is an effective adjuvant to minimally invasive PCNL in achieving high clearance rate with minimum morbidity.

Miniaturization of percutaneous nephrolithotomy Smaller, but better?

PURPOSE OF REVIEW

Miniaturized percutaneous nephrolithotomy (PCNL) procedures have reached big popularity in the past years. Following the idea that decreasing the diameter of the instruments would decrease the complication rate instruments with outer diameter down to 4,8 Fr was established. In this review, we want to take a critical insight of the most popular miniaturized procedures, regarding the key advantages and disadvantages of the miniaturized instruments.

RECENT FINDINGS

For all techniques displayed, a number of studies are available to support their effectivity in the given range of indication. Naturally, the body of evidence for M-sized instruments is largest, as it exists in the armamentarium since long, whereas studies comparing small or extrasmall and extraextrasmall to standard or among each other are rare. However, large studies comparing miniaturized procedures with conventional PCNL in randomized controlled fashion are still lacking, too.

SUMMARY

Miniaturization and attending developments such as ultrasonographic-guided puncture, single step dilatation of the tract, low irrigation pressure in open systems and a tubeless procedure lead to lower complication rates in PCNL. All of the established procedures have their own range of indication with regard to size and location of the stone. They amplified the possibility of a customized therapy for each patient.

Identification and Cost of Disposable Endourological Devices for Nephrolithiasis: A Cross-Sectional Study Among Urological Trainees

INTRODUCTION

Knowledge on health economics among urology trainees is not formally assessed. The cost of commonly utilised endourological devices may not be considered by trainees.

AIM

The present study was conducted with the aim to assess whether urology trainees were knowledgeable on identification and cost of commonly used disposable devices in the management of nephrolithiasis.

MATERIALS AND METHODS

Forty urology trainees in Ireland were invited to complete a visual online questionnaire on the identification of 10 frequently utilised disposable endourological devices. In addition, trainees were requested to estimate the cost of 12 disposable endourological devices. Responses were stratified according to trainee grade and urological subspecialty of interest. Data are presented as a mean ± standard deviation.

RESULTS

The response rate was 70% (28/40). Endourology was the subspecialty of interest in 21% (n= 6). No trainee correctly identified all 10 endourological devices and the mean test score was 5.32 ± 2.28. No trainee accurately estimated the cost for all 12 devices assessed. The cost of endourological devices was underestimated by €67.13 ± €60.76 per device. A total of 54% (n=15) of trainees underestimated the total cost of disposable devices used during standard flexible ureterorenoscopy, laser lithotripsy and JJ stent insertion by €303.66 ± €113.83.

CONCLUSION

Our findings indicate deficiencies in trainee knowledge on endourological devices and their associated costs. Incorporating a health economics module into postgraduate urology training may familiarise trainees with healthcare expenditure within their departments.

The role of ultra-mini percutaneous nephrolithotomy in the treatment of kidney stones

OBJECTIVE

In our study we aimed to evaluate outcomes of ultra-mini-percutaneous nephrolithotomy (UMP) performed for the treatment of kidney stones.

MATERIAL AND METHODS

Between October 2014 and September 2015, a single surgeon performed UMP on a total of 49 consecutive patients with symptomatic kidney stones at our center. Pregnants, anticogulant users, patients with bleeding diathesis pyonephrosis, and partial/complete staghorn stones were excluded from the study. Patient characteristics, operative data and postoperative outcomes were assessed in detail.

RESULTS

The UMP was performed on 50 (34 right/16 left) renal units of the 48 (28 male/20 female) patients included in this study. The mean age and body mass index was 36.5 (2-83) years and 26.2 (17.6-32.8) kg/m², respectively. Mean stone size was calculated as 22.2 (10-55) mm. The mean durations of the operations and fluoroscopic examination were calculated as 65.4 (20-120) minutes and 89.4 (9-322) seconds, respectively. The mean duration of hospitalization was 1.4 (1-5) days. In 52% of the patients the procedure was terminated tubeless. Mean hemoglobin drop was 0.6 (0-3) g/dL. Our series experienced a 10% complication rate. The UMP procedure was successful in 96% of the renal units at the 1^st month control visit assessment.

CONCLUSION

The outcomes of our study have demonstrated that UMP is an effective and safe treatment modality, especially in the treatment of medium-sized renal calculi.

Ultra-mini-percutaneous nephrolithotomy: A minimally-invasive option for percutaneous stone removal

Introduction:

Percutaneous nephrolithotomy (PCNL) has witnessed rapid advancements, the latest being ultra-mini-percutaneous nephrolithotomy (UMP), which makes the use of 11–13F sheaths as compared to 24–30F sizes used in conventional PCNL. This miniaturization aims to reduce morbidity and improve patient outcomes. We evaluated the safety and efficacy of UMP and report our ourtcomes.

Patients and Methods:

A total of 120 patients underwent UMP from July 2012 to March 2014. These patients had a single unilateral renal stone measuring between 8 and 20 mm. All patients underwent UMP using a 3F nephroscope, 7.5F inner sheath, and 11F or 13F outer metallic cannula, which served as the Amplatz sheath. Stone fragmentation and clearance were achieved with holmium laser. No nephrostomy or stent was used routinely.

Results:

Complete stone fragmentation was achieved in 114 out of 120 patients (95%) using UMP; whereas the remaining 6 were converted into mini-PCNL using a 12.5F nephroscope and 15F Amplatz sheath. The mean operative time was 39.7 ± 15.4 min, and the mean postoperative hospital stay was 22.3 ± 2.2 h. Postoperatively, 6 (5%) patients had residual fragments measuring ≤4 mm. At the 2 weeks follow-up, the stone-free status was >99% (119/120). There were no significant postoperative complications.

Conclusion:

This study shows UMP to be an effective and safe procedure for managing stones up to 20 mm. This procedure offers an attractive alternative to shock wave lithotripsy and retrograde intrarenal surgery for managing small stones.

Prospective Outcomes of Ultra Mini Percutaneous Nephrolithotomy: A Consecutive Cohort Study

PURPOSE

Ultra mini percutaneous nephrolithotomy is a less invasive technique of percutaneous nephrolithotomy to treat small to medium sized calculi.

MATERIALS AND METHODS

We prospectively evaluated the outcomes of ultra mini percutaneous nephrolithotomy in a single surgeon, consecutive cohort study. Data on 94 patients who underwent ultra mini percutaneous nephrolithotomy were collected.

RESULTS

Mean ± SD calculus size was 15.9 ± 4.5 mm and mean density was 1,106 ± 167 HU. Access was achieved via the upper pole in 8 cases, interpolar in 33 and lower pole in 54. Mean operative time was 54 minutes (range 28 to 120). Mean hemoglobin loss was 0.81 gm/dl and the mean creatinine increase was 0.05 mg/dl. There were no transfusions or kidney injuries. Grade I and IIIb complications were observed in 4 and 1 patients, respectively. The most serious complication was a perinephric collection. Postoperatively oral analgesia was sufficient in 86 patients (91%). Mean length of stay was 38.2 ± 15.9 hours. Nephrostomy drainage was used in 13 patients while 7 (7%) required a stent for 1 week. Intraoperatively 99% of renal units were stone free (absence of detectable calculi) on fluoroscopy, and 74% and 81% were stone free on day 1 postoperative ultrasound and 1-month computerized tomography, respectively. The 10 to 20 mm stones showed less bleeding, shorter operative time and a significantly lower requirement for nephrostomy or a Double-J(®) stent.

CONCLUSIONS

Ultra mini percutaneous nephrolithotomy appears to be effective and safe with a short length of stay. It may be a valuable addition to the armamentarium to treat 10 to 20 mm calculi in patients who wish to avoid routine nephrostomy or stents. Randomized, controlled trials are required.

Ultra-mini PCNL versus flexible ureteroscopy: a matched analysis of analgesic consumption and treatment-related patient satisfaction in patients with renal stones 10-35 mm

PURPOSE

To compare ultra-mini PCNL (UMP) and flexible ureteroscopy (fURS) for the treatment of medium- to large-sized renal stones with a focus on patients' postsurgical cumulative analgesic consumption and treatment-related satisfaction.

METHODS

Twenty-five patients treated by UMP between April 2013 and October 2014 were matched to data of 25 fURS patients from an existing database. Clinical outcome parameters were recorded prospectively. Postoperative analgesic consumption was assessed using the Cumulative Analgesic Consumption Score (CACS), and satisfaction was measured with the Freiburg Index of Patient Satisfaction (FIPS) questionnaire.

RESULTS

Perioperative outcome parameters showed no significant differences except for mean operating times (fURS 98.52 min, UMP 130.12 min [p = 0.002]) and hospital stay (fURS 67.2 h, UMP 91.5 h [p = 0.04]). Primary stone-free rate was 96 % in fURS and 92 % in UMP. Complications Clavien grade 2 or 3 occurred in 16 % of UMP patients and in 4 % of fURS patients. Postsurgical cumulative analgesic consumption was almost identical in both groups with CACSs of 6.96 (0-15) for fURS and 6.8 (0-23) for UMP. Patients' satisfaction was high in both techniques: FIPS score in fURS 1.67 (1-3) and 1.73 (1-4) in UMP (scale 1-6).

CONCLUSIONS

Treatment of medium- to large-sized renal stones is safe and highly effective by both UMP and fURS. Moreover, both treatments yield comparable postsurgical analgesic requirements and high patient satisfaction scores. Patient-related factors (anatomical and stone related) and availability of technical equipment and surgical expertise appear to be the most important determining factors in treatment planning.