The impact of lasers in percutaneous nephrolithotomy outcomes: results from a systematic review and meta-analysis of randomized comparative trials

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.

2022 Recommendations of the AFU Lithiasis Committee: Laser - utilization and settings

Endocorporeal lithotripsy has progressed thanks to the development of lasers. Two laser sources are currently available: Holmium:YAG (Ho:YAG) and more recently Thulium Fiber Laser (TFL). The settings generally used are dusting, fragmentation, and "pop-corning". These are the first recommendations on laser use for stone management and their settings. Settings must be modulated and can be changed during the treatment according to the expected and obtained effects, the location and stone type that is treated. METHODOLOGY: These recommendations have been developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether or not the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU Guidelines on urolithiasis. 2022]) and their adaptability to the French context.

Lithotripsy devices for percutaneous nephrolithotomy (PNL) - new developments

PURPOSE OF REVIEW

Percutaneous nephrolithotomy (PNL) is the mainstay of surgery for renal calculi>2 cm or complex multiple calculi and is a technique that has been around since 1976. We review recent literature surrounding novel lithotripsy devices and technology used in PNL.

RECENT FINDINGS

At present, the Holmium:yttrium-aluminum-garnet (Ho:YAG) laser is widely accepted as the gold standard laser lithotripsy for PNL. SwissLithoClast Trilogy offers a range of probes with a trifecta of electromagnetic, ultrasonic energy with surgeon-controlled suction. The Olympus Shockpulse-SE is a similar lithotripter that relies on continuous ultrasonic energy with pulsed ballistic energy to break stones. Thulium Fiber Laser (TFL) offers an alternative laser energy source to the Holmium laser, which has been shown to be very effective at producing small stone fragments and dust. The Moses technology is another addition in a long list of improvements to the Ho:YAG laser, forming vaporization bubble through which more effective energy can be applied to stones.

SUMMARY

Trilogy, Shockpulse, TFL and Moses pulse modulation technology for the Holmium laser all provide improvements compared with older lithotripsy devices. In particular, they convey a safer, efficient and more effective way to manage and clear stones.

Complications and outcomes of tubeless versus nephrostomy tube in percutaneous nephrolithotomy: a systematic review and meta-analysis of randomized clinical trials

We aimed to perform a systematic review of randomized trials to summarize the evidence on the safety and stone-free rate after Tubeless percutaneous nephrolithotomy (PCNL) (ureteral stent/catheter, no nephrostomy) compared to Standard PCNL (nephrostomy, with/without ureteral stent/catheter) to evaluate if the tubeless approach is better. The inverse variance of the mean difference with a random effect, 95% Confidence Interval (CI), and p values was used for continuous variables. Categorical variables were assessed using Cochran-Mantel-Haenszel method with the random effect model, and reported as Risk Ratio (RR), 95% CI, and p values. Statistical significance was set at p < 0.05 and a 95% CI. 26 studies were included. Mean operative time was significantly shorter in the Tubeless group (MD-5.18 min, 95% CI - 6.56, - 3.80, p < 0.00001). Mean postoperative length of stay was also significantly shorter in the Tubeless group (MD-1.10 day, 95% CI - 1.48, - 0.71, p < 0.00001). Incidence of blood transfusion, angioembolization for bleeding control, pain score at the first postoperative day, the number of patients requiring postoperative pain medication, fever, urinary infections, sepsis, perirenal fluid collection, pleural breach, hospital readmission, and SFR did not differ between the two groups. Incidence of postoperative urinary fistula was significantly lower in the Tubeless group (RR 0.18, 95% CI 0.07, 0.47, p = 0.0005). This systematic review shows that tubeless PCNL can be safely performed and the standout benefits are shorter operative time and hospital stay, and a lower rate of postoperative urinary fistula.