Percutaneous nephrolithotomy in pelvic kidneys: is the ultrasound-guided puncture safe?

Is There Still a Place for Percutaneous Nephrolithotomy in Current Times?

Background: Percutaneous nephrolithotomy (PCNL) and its miniaturized modifications are usually considered the standard surgical options for large (>20 mm) staghorn and infected stones. Moreover, PCNL is a viable alternative to retrograde intrarenal surgery (RIRS) for smaller stones (<20 mm) in the presence of anatomical malformations or inaccessible lower pole stones. However, due to the advancements in laser and scope technology, RIRS is expanding its indications with the potential benefits of lower complications and a shorter hospital stay. Methods: A literature search using the PUBMED database from inception to June 2022 was performed to explore the current role of PCNL in endourology. The analysis involved a narrative synthesis. Results: PCNL confirmed its role in the treatment of large and complex stones; moreover, miniaturized PCNL has become more competitive, gaining space among classic indications of flexible ureteroscopy. Conclusions: considering all the evaluated subgroups, we can conclude that PCNL is an old fascinating procedure and is here to stay.

The safety and efficacy of mini-percutaneous nephrolithotomy vs. retrograde intrarenal surgery for treatment of renal lithiasis in pelvic ectopic kidney: an exploratory pilot study

Background

To compare the safety and efficacy of mini-percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) for the treatment of renal lithiasis in patients with pelvic ectopic kidney.

Methods

From January 2015 to October 2017, mini-PCNL and RIRS were performed in ten patients diagnosed with lithiasis in pelvic ectopic kidneys, including three cases under laparoscopy-assisted mini-PCNL. Patient demographics and perioperative characteristics (age, gender, BMI, side of pelvic kidney, stone size, stone number, stone location, special medical history, and ASA physical status classification), and operative and post-operative related details (operation time, hospital stay, blood loss, VAS, analgesic requirement, complications, and stone free outcome) were reviewed.

Results

Although the mean operation time of mini-PCNL (71.3 min) was shorter than RIRS (85.3 min), the mean operation time of laparoscopy assisted mini-PCNL (92 min) was longer than patients without laparoscopy-assisted mini-PCNL (55.8 min). However, the use of mini-PCNL allowed for larger lithiasis to be dealt with (1.9 cm in laparoscopy assisted mini-PCNL and 2.4 cm in mini-PCNL without laparoscopy-assist) compared with RIRS (1.2 cm). In addition, although the mean hospital-stay time, blood loss, and analgesic requirement of patients undergoing RIRS were less than those receiving mini-PCNL, the success rate of RIRS was only 50% (3/6) in comparison to 100% (7/7) for mini-PCNL. Except for pain and urinary tract infection after the operation, there were no significant intraoperative and postoperative complications, and no residual lithiasis were seen in any patient.

Conclusions

Although RIRS was less time-consuming and invasive, mini-PCNL can deal with the bigger lithiasis and more complex situations with a higher success rate. Both mini-PCNL and RIRS are feasible and safe treatments for pelvic ectopic kidney lithiasis with each carrying unique advantages. Hence in practice, an appropriate individualized treatment should be selected depending on patient characteristics.

Laparoscopic transmesocolic pyelolithotomy and pyeloplasty in an ectopic pelvic kidney: Case report and review of literature

Renal ectopia is a developmental anomaly with pelvic kidney being the commonest location (55%). The incidence of uretero-pelvis junction (UPJ) obstruction, nephrolithiasis, and reflux are higher in ectopic kidneys than their counterparts. We herein report a case of left ectopic pelvic kidney with large stone associated with UPJ narrowing managed successfully simultaneously with laparoscopic transmesocolic pyelolithotomy and pyeloplasty in a 45-year female. This is the largest stone reported in the literature in an ectopic pelvic kidney managed successfully with favorable outcome.

Patient positioning during percutaneous nephrolithotomy: what is the current best practice?

Percutaneous nephrolithotomy (PCNL) is the gold standard procedure for treatment of large stones and complex kidney disorders, but its morbidity remains the highest among stone treatment procedures. In pursuit of minimizing complication rates, surgeons have developed different variations of the classic prone position in which PCNL is usually performed; one among them is supine position. In this study, we review the literature and present all available evidence on different variations in positioning during PCNL, in an effort to identify if there is a position that can minimize the morbidity of this procedure.

Changing trends in the endourological management of urolithiasis in anomalous kidneys

OBJECTIVES

To present our single-centre experience of urolithiasis management in anomalous kidneys, highlighting the need for an algorithm-based approach in deciding the appropriate treatment method for each type.

PATIENTS AND METHODS

We retrospectively reviewed the data of all the patients who presented to our renal unit with urolithiasis in an anomalous kidney between January 1990 and July 2014. The peri-operative characteristics of all the patients, along with management approach, were studied.

RESULTS

Percutaneous nephrolithotomy (PCNL) was the most common surgical technique used, followed by flexible ureterorenoscopy (URS). Pain was the most common presentation in these patients. The overall stone clearance rate associated with PCNL and flexible URS was 85.8% in cases of anomalous kidneys in this series. The stone clearance rates in ectopic kidneys, horseshoe kidneys, malrotated kidneys and autosomal dominant polycystic kidneys associated with PCNL and flexible URS were similar: 86%, 88%, 76% and 83%, respectively, and 81.2%, 80%, 92% and 100%, respectively . Based on our results, we developed a stone management algorithm.

CONCLUSION

The management of renal calculi in patients with renal anomalies may vary based on the stone size, location, density, pelvicalyceal system anatomy and drainage. An algorithm-based approach could help surgeons decide the appropriate treatment in this population.

Prone Versus Supine Percutaneous Nephrolithotomy: What Is Your Position?

PURPOSE OF REVIEW

Percutaneous nephrolithotomy (PCNL) is the gold standard surgical procedure for treating large, complex renal stones. Due to its challenging nature, PCNL has undergone many modifications in surgical technique, instruments, and also in patient positioning. Since the first inception of PCNL, prone position has been traditionally used. However, alternative positions have been proposed and assessed over the years. This is a comprehensive review on the latest developments related to positioning in the practice of PCNL.

RECENT FINDINGS

The prone position and its modifications are the most widely used positions for PCNL, but with the introduction of various supine positions, the optimal position has been up for debate. Recent meta-analysis has shown a superior stone-free rate in the prone position and comparable complication rates to the supine position. The advantage of ease of access to the urethra for simultaneous retrograde techniques in the supine position is also possible with modifications in the prone position such as the split-leg technique. Modern-day PCNL has transformed from an operation traditionally undertaken in the prone position to a procedure in which a prone or supine position may be employed; however, published data have not shown significant superiority of either approach.