1890 THE “ALL-SEEING NEEDLE“ – AN OPTICAL PUNCTURE SYSTEM CONFIRMING PERCUTANEOUS ACCESS IN PCNL

"Microperc" micropercutaneous nephrolithotomy: a review of the literature

Recent years have seen innovations in working armamentarium of percutaneous nephrolithotomy (PCNL) leading to development of novel modifications such as miniperc, ultra miniperc, and microperc. Amongst these microperc appears to be least invasive and various authors, off late, have reported their experience with the technique. Literature on microperc was reviewed by a MEDLINE/PubMed search with articles in the English language since 2011 in published peer-reviewed journals. Articles comprised of case series, comparative, and noncomparative studies. Different facets encompassing the technique were analyzed including contemporary indications, technique and its modifications, outcomes, and comparison with other modalities. Technique is reported to be associated with high success rate (82-100%) and short hospital stay (1-2 days). Studies have reported minimal hemoglobin drop (0.1-1.4 gm%) and fewer complications of lower Clavien grades. Going small in PCNL has gone a long way to present day 4.85F puncture system. Utilization of this novel modification is on rise with larger case series and comparative analysis being reported in past 2 years. Technique boasts of high clearance rate, lower morbidity and short hospital stay. In the present era, this innovation in percutaneous stone management appears to be another milestone in quest for "knife to cannula to needle to nothing".

A prospective randomized comparison of micropercutaneous nephrolithotomy (Microperc) and retrograde intrarenal surgery (RIRS) for the management of lower pole kidney stones

OBJECTIVE

To make a comparison between the safety and efficacy of micropercutaneous nephrolithotomy (microperc) and retrograde intrarenal surgery (RIRS) for the management of lower pole kidney stones up to 15 mm.

PATIENTS AND METHODS

60 patients presenting with solitary lower pole kidney stones up to 15 mm were included in the study between March 2013 and December 2015. Patients were randomized into Microperc or RIRS groups with computer-generated numbers.

RESULTS

The mean stone size was 10.6 (5-15) and 11.5 (7-15) mm for Microperc and RIRS groups, respectively (P = 0.213). In the Microperc group, the scopy time was 158.5 s, while in the RIRS group, the scopy time was 26.6 s (P = 0.001). The hospitalization period in the Microperc group was 542 h, while it was 19 h in the RIRS group (P = 0.001). No statistical differences were observed during the operating time, pre-operative-post-operative hemoglobin (Hb), serum creatinine, and estimated glomerular filtration speed (e-GFR) values and stone-free rates. No intraoperative complications were observed in either of the groups, while post-operative complications were observed in six patients in Microperc Group and five patients belonging to the RIRS Group (P = 0.922).

CONCLUSIONS

Both Microperc and RIRS are safe and effective alternatives, and have similar stone clearance and complication rates for the management of lower pole kidney stones up to 15 mm in diameter. However, prolonged hospital stay and scopy times are the main disadvantages of Microperc and further research is needed to evaluate the renal tubular damages caused by both of these methods.

Initial report of microperc in the treatment of pediatric nephrolithiasis

BACKGROUND/PURPOSE

To report the first technical feasibility and safety of microperc in the treatment of pediatric nephrolithiasis.

METHODS

A multicenter prospective trial was initiated and microperc was performed in 19 children from four different centers. In all cases, 4.85-Fr all-seeing needle was used to access the collecting system under direct vision. Stone fragmentation was performed using a 200-μm holmium: YAG laser fiber either through the same needle sheath or an 8-Fr microsheath. Patient- and procedure-related factors and perioperative and postoperative parameters were analyzed.

RESULTS

The mean age of the children was 7.5 ± 4.4 years. Mean stone size was 14.8 ± 6.8mm. Conversion to Mini-PNL was required in two patients because of optical default in one and the high stone burden in the other. The mean hospital stay was 1.8 ± 0.8 days and the mean hemoglobin decrease was 0.1 mg/dl. The overall stone-free rate at 1 month was 89.5%. In one patient with obstructed ureteropelvic junction, intravasation of the irrigation fluid has led to abdominal distention and managed with percutaneous drainage intraoperatively. No other postoperative complication was recorded and no ancillary procedure was required.

CONCLUSIONS

Microperc is a safe and effective procedure in the treatment of pediatric kidney stones.

The all-seeing needle instead of the Veress needle in pediatric urologic laparoscopy

PURPOSE

To investigate the feasibility of the all-seeing needle for safe entry and creation of pneumoperitoneum in pediatric urologic laparoscopy.

PATIENTS AND METHODS

A total of 14 children underwent various transperitoneal urologic laparoscopic procedures. The all-seeing needle, which is 4.85F in diameter, was used for safe entry into the abdominal cavity at the site of the umblicus in all cases. The microoptic was integrated with the light system and connected via a zoom ocular enabling direct visualization of the layers between the skin and the peritoneal cavity. Once the intraperitoneal access was obtained, CO2 pneumoperitoneum was created from one port of the three-way connector attached to the proximal part of the needle. Then the laparoscopic trocars were placed under vision of the microoptical system.

RESULTS

Mean age of the children was 4.5 ± 2.9 years. In all children, the all-seeing needle was safely introduced into the abdominal cavity under direct vision. Then, CO2 pneumoperitoneum was succesfully performed. The mean time for optical puncture was calculated as 1.1 ± 0.8 minutes. No complication was encountered during the introduction of the needle, creation of the pneumoperitoneum, and placement of the trocars.

CONCLUSIONS

The all-seeing needle appears to be beneficial in safe entry and for creating pneumoperitoneum in laparoscopic pediatric urology cases. It eliminates the disadvantages of the Veress needle, which is blunt insertion, and may possibly prevent complications.

Single-step percutaneous nephrolithotomy (microperc): the initial clinical report

PURPOSE

To our knowledge we report the first technical feasibility and safety study of 1-step percutaneous nephrolithotomy using the previously described 4.85Fr all-seeing needle (PolyDiagnost, Pfaffenhofen, Germany). We defined microperc as modified percutaneous nephrolithotomy in which renal access and percutaneous nephrolithotomy are done in 1 step using the all-seeing needle.

MATERIALS AND METHODS

Microperc was performed in 10 cases using the 4.85Fr all-seeing needle to achieve collecting system access under direct vision. Percutaneous nephrolithotomy was done through the same 16 gauge needle sheath with a 3-way connector allowing irrigation, and passage of a flexible telescope and a 200 μm holmium:YAG laser fiber. We prospectively analyzed preoperative, intraoperative and postoperative parameters.

RESULTS

Mean calculous size was 14.3 mm. Two of the 10 patients were of pediatric age, and 1 each had an ectopic pelvic kidney, chronic kidney disease and obesity. Microperc was feasible in all cases with mean ± SD surgeon visual analog score for access of 3.1 ± 1.2, a mean 1.4 ± 1.0 gm/dl hemoglobin decrease and a mean hospital stay of 2.3 ± 1.2 days. The stone-free rate at 1 month was 88.9%. In 1 patient intraoperative bleeding obscured vision, requiring conversion to mini percutaneous nephrolithotomy. There were no postoperative complications and no auxiliary procedures were required.

CONCLUSIONS

Microperc is technically feasible, safe and efficacious for small volume renal calculous disease. Further clinical studies and direct comparison with available modalities are required to define the place of microperc in the treatment of nonbulky renal urolithiasis.