Suctioning versus traditional minimally invasive percutaneous nephrolithotomy to treat renal staghorn calculi: A case-matched comparative study

Suction in Percutaneous Nephrolithotripsy: Evolution, Development, and Outcomes from Experimental and Clinical studies. Results from a Systematic Review

CONTEXT

Controversy exists regarding the therapeutic benefit of suction use during percutaneous nephrolithotripsy (PCNL).

OBJECTIVE

To review and highlight the options available in the use of suction for PCNL, and to discuss their strengths and limitations.

EVIDENCE ACQUISITION

A systematic literature search was performed using Scopus, EMBASE, and PubMed. Thirty four studies were included. There was one ex vivo study. Among clinical studies, 24 used a vacuum/suctioning sheath and nine a handpiece suction device/direct-in-scope suction. The suction technique was employed in standard, mini-PCNL, supermini-PCNL, and enhanced supermini‑PCNL techniques.

EVIDENCE SYNTHESIS

Handpiece suction devices demonstrated better safety and efficiency in treating large stones than nonsuction PCNL and in a much shorter time. Trilogy and ShockPulse-SE were equally effective, safe, and versatile for standard PCNL and mini-PCNL. The heavier handpiece makes Trilogy less ergonomically friendly. Laser suction handpiece devices can potentiate laser lithotripsy by allowing for better laser control with simultaneous suction of small fragments and dust. Integrated suction-based sheaths are available in reusable and disposable forms for mini-PCNL only. Mini-PCNL with suction reported superior outcomes for operative time and stone-free rate to mini-PCNL. This also helped minimize infectious complications by a combination of intrarenal pressure reduction and faster aspiration of irrigation fluid reducing the risk of sepsis, enhance intraoperative vision, and improve lithotripsy efficiency, which makes it a very attractive evolution for PCNL.

CONCLUSIONS

Suction devices in PCNL are reforming the way PCNL is being done. Adding suction to mini-PCNL reduces infectious complications and improves the stone-free rate. Our review shows that despite the limited evidence, suction techniques appear to improve PCNL outcomes.

PATIENT SUMMARY

In this review, we looked at the intra- and perioperative outcomes of percutaneous nephrolithotripsy (PCNL) with the addition of suction. With better stone fragmentation and fewer postoperative infections, this technology is very useful particularly for mini-PCNL.

A novel double-sheath negative-pressure versus conventional minimally invasive percutaneous nephrolithotomy for large kidney stone

This study aims to evaluate the therapeutic efficacy of a novel double-sheath negative-pressure minimally invasive percutaneous nephrolithotomy (D-mPCNL) compared to conventional minimally invasive percutaneous nephrolithotomy (C-mPCNL) for large kidney stones. A total of 132 patients diagnosed with large kidney stones in our hospital were included in the study. Among them, sixty-eight patients underwent D-mPCNL, while sixty-four underwent C-mPCNL. Parameters such as operative duration, stone-free rate, incidence of postoperative complications, and the need for auxiliary procedures were evaluated between the two groups. Compared to the C-mPCNL group, the D-mPCNL group demonstrated a significantly shorter operative time (41.97 ± 8.24 min vs. 52.30 ± 13.72 min; P < 0.000), lower rates of auxiliary procedures (5.9% vs. 17.2%; P = 0.041), and lower fever rates (2.9% vs. 14.1%; P = 0.021). The group also had a significantly higher primary stone-free rate (85.3% vs. 70.3%; P = 0.038). However, there were no statistically significant advantages in terms of the final stone-free rate, hemoglobin drops, and stone composition in the D-mPCNL group (P > 0.05). D-mPCNL is a novel surgical method that is safe and effective, reducing operative time, improving stone-free efficiency, and decreasing postoperative complications.

Vacuum-assisted access sheath in supine mini-percutaneous nephrolithotomy (mini-PCNL)

INTRODUCTION

The vacuum-assisted access sheath is a new device for the treatment of kidney stones with percutaneous nephrolithotomy (PCNL).

OBJECTIVE

Our aim was to compare the stone-free rate (SFR) and complications between standard mini percutaneous nephrolithotomy (Mini-PCNL) and vacuum-assisted PCNL (Va-PCNL).

METHODS

Retrospective study of patients undergoing Mini-PCNL and Va-PCNL from January 2018 to June 2022. Va-PCNL was performed with a disposable sheath (ClearPetra®) with continuous high-flow irrigation and vacuum fluid dynamics for easier stone fragment removal. Baseline patient characteristics, surgical outcomes, perioperative and postoperative data were collected. We compared SFR and complications.

RESULTS

A total of 136 patients were identified, 57 (41,9%) underwent Va-PCNL and 79 (58,15%) Mini-PCNL. Mean operative time was significantly shorter in the Va-PCNL group (95 min.) than in Mini-PCNL (146 min; P = ,001) group. The tubeless technique was performed more frequently in Va-PCNL group (61,4% vs. 34,2%; P = ,002). We did not observe any differences in postoperative complications. The mean hospital stay was significantly lower in Va-PCNL with 1,7 ± 1,9 days per patient compared with 2,7 ± 1,5 days in the Mini-PCNL group (P = ,001). There were no differences in SFR at 3 months between Va-PCNL (71,9%) and Mini-PCNL (71,8%; P =v ,848).

CONCLUSION

Patients treated with Va-PCNL had comparable results to Mini-PCNL, showing equal SFR with similar infectious complications rates. Potential benefits of Va-PCNL include shorter operative time and postoperative stay.

A randomized controlled trial comparing infectious complications using mini perc with and without suction for renal stones less than 3 cm in size

The purpose was to do a study to compare infectious complications in patients operated for MiniPerc or Minimally invasive Percutaneous Nephrolithotomy (MPCNL) using MIP and MPCNL with suction using Shah Superperc sheath for medium-sized renal stones less than 3 cm in size. The primary objective of this study is to compare the infectious complications and the secondary objectives are to compare stone-free rates, complication rates and operative times. A prospective randomized controlled trial with patients having proximal ureteral and renal stones of 10-30 mm size and planned for MPCNL done at a single institute. A total of 80 consecutively admitted patients with written informed consent were included for randomization with 40 patients in each arm of MPCNL and suction MPCNL. The median age in MPCNL and suction MPCNL arms were 48 and 49 years, the median stone size of 15.45 and 16.7 cm, the Median stone volume of 1576.2 vs 1752 mm3, and the median stone density of 1258 and 1250 Hu, the median hospital stay of 3 days in both arms were comparable. Infectious complications were comparable in both arms. Operative time was significantly less in the suction MPCNL group (26.5 min-IQR 17-34.8) than in the MPCNL group (34.8 min-IQR 20-45), p = 0.021 and stone-free rates (SFR), were more in Suction MPCNL arm 97.5% than in MPCNL 87.5%, p = 0.04. Overall, the complication rates were comparable in both arms. Suction MPCNL procedure resulted in shorter operating times and more SFR than conventional MPCNL with comparable complication rates.

Miniaturization in percutaneous nephrolithotomy: What is new?

Objective

To summarize recent advancements in mini-percutaneous nephrolithotomy (mini-PCNL) in surgical technique, stone removal strategy, lithotripsy, and surgical model from the current literature.

Methods

We conducted a narrative review of relevant English-language articles up to October 2022 using the PubMed and Web of Science databases. The following keywords were used in the search: "percutaneous nephrolithotomy", "minimally invasive percutaneous nephrolithotomy", "mini-PCNL", "mini-perc", "mPCNL", and "miniaturization".

Results

A series of new progress has been made in many aspects of mini-PCNL, such as further reduction of tract size-needle perc and further improvement of robotic-assisted PCNL-artificial intelligence-powered robotic devices.

Conclusion

Many studies and trials have been conducted to reduce morbidity and increase the safety and effectiveness of mini-PCNL. It is crucial to realize that miniaturization of PCNL requires not only a smaller percutaneous tract size, but also an adjustment strategically in renal access, stone removal, lithotripsy, and surgical model in general. More large-scale prospective research needs to be carried out to further validate and optimize the safety and effectiveness of mini-PCNL.

Comparison of Vacuum Suction Sheath and Non-Vacuum Suction Sheath in Minimally Invasive Percutaneous Nephrolithotomy: A Meta-Analysis

Objective To evaluate the clinical efficacy of minimally invasive percutaneous nephrolithotomy (mPCNL) with vacuum suction sheath in the treatment of renal calculi. Methods: We collected relevant studies of vacuum suction sheath and non-vacuum sheath mPCNL from PubMed, Embase, and Cochrane databases for a meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results: 7 studies were included (4 randomized controlled studies, 3 retrospective studies involving 1803 patients). The final meta-analysis results showed that the operative time (Standardised Mean Difference [SMD] = -0.84, 95% CI [-1.20; -0.48], P < 0.001), auxiliary procedures (Odds Ratio [OR] = 0.61, 95% CI [0.46; 0.81], P < 0.001) and complications in the vacuum suction sheath group were significantly lower than those in the non-vacuum sheath group. The immediate and final stone-free rates (OR = 1.69, 95% CI [1.30; 2.18], P < 0.001; OR = 1.44, 95% CI [0.98; 2.13], P = 0.039) were also significantly lower in the vacuum suction sheath group. Conclusion: This study indicates that the application of vacuum suction sheath in mPCNL can significantly shorten the operative time and patient hospitalization, reduce auxiliary procedures and complications (especially fever, urinary tract infection, and pain).

Percutaneous nephrolithotomy with suction: is this the future?

PURPOSE OF REVIEW

The armamentarium of percutaneous nephrolithotomy (PCNL) and the strategy to perform the procedure is constantly evolving. The innovation and development in techniques lead to further miniaturization in PCNL devices and change the lithotripsy and stone removal strategy. Suctioning in PCNL offers urologist a new conception in renal stone management. The present review evaluates the latest results on efficacy, safety and feasibility of suctioning PCNL techniques.

RECENT FINDINGS

Recent literature reported the outcomes of different suctioning PCNL techniques. Most of these studies demonstrated good efficacy when comparing conventional PCNL. Suctioning PCNL improving the lithotripsy efficiency to enhance the stone-free rate (SFR) and reducing renal pelvic pressure to attenuate postoperative infectious complications. The advantage of suction also helps overcome the limitation of potentially higher intrarenal pressure and prolonged operative time in Mini-PCNL.

SUMMARY

PCNL with suctioning represents a valuable new tool in the armamentarium of modern endourologists. This innovative approach can offer improved safety and efficacy with lower complications rates and higher cost effectiveness than the traditional PCNL technique.