Amplatz versus Balloon for Tract Dilation in Ultrasonographically Guided Percutaneous Nephrolithotomy: A Randomized Clinical Trial

Comparing Balloon Dilation to Non-Balloon Dilation for Access in Ultrasound-Guided Percutaneous Nephrolithotomy: A Systematic Review and Meta-Analysis

PURPOSE

This study aims to evaluate the safety and efficacy of ultrasound-guided balloon dilation compared to non-balloon dilation for percutaneous nephrolithotomy (PCNL).

MATERIALS AND METHODS

A systematic review and meta-analysis were conducted by searching PubMed, EMBASE, and the Cochrane Library. Results were filtered using predefined inclusion and exclusion criteria as described and meta-analysis was performed using Review Manager 5.4 software.

RESULTS

A total of six studies involving 1189 patients who underwent PCNL were included. The meta-analysis results demonstrated that compared to non-balloon dilation, balloon dilation was associated with reduced haemoglobin drop [mean difference (MD) = -0.26, 95% CI = -0.40 ~ -0.12, P = 0.0002], decreased transfusion rate [odds ratio (OR) = 0.47, 95% CI = 0.24 ~ 0.92, P = 0.03], shorter tract establishment time (MD = -1.30, 95% CI = -1.87 ~ -0.72, P < 0.0001) and shorter operation time (MD = -5.23, 95% CI = -10.19 ~ -0.27, P = 0.04).

CONCLUSIONS

Overall, ultrasound-guided balloon dilatation offered several advantages in PCNL procedures. It facilitated faster access establishment, as evidenced by shorter access creation time. Additionally, it reduced the risk of kidney injury by minimizing postoperative haemoglobin drop and decreasing the need for transfusions. Moreover, it enhanced the efficiency of surgery by reducing the operation time. However, it is important to note that the quality of some included studies was subpar, as they did not adequately control for confounding factors that may affect the outcomes. Therefore, further research is necessary to validate and strengthen these findings.

International Alliance of Urolithiasis (IAU) Guideline on percutaneous nephrolithotomy

The International Alliance of Urolithiasis (IAU) would like to release the latest guideline on percutaneous nephrolithotomy (PCNL) and to provide a clinical framework for surgeons performing PCNLs. These recommendations were collected and appraised from a systematic review and assessment of the literature covering all aspects of PCNLs from the PubMed database between January 1, 1976, and July 31, 2021. Each generated recommendation was graded using a modified GRADE methodology. The quality of the evidence was graded using a classification system modified from the Oxford Center for Evidence-Based Medicine Levels of Evidence. Forty-seven recommendations were summarized and graded, which covered the following issues, indications and contraindications, stone complexity evaluation, preoperative imaging, antibiotic strategy, management of antithrombotic therapy, anesthesia, position, puncture, tracts, dilation, lithotripsy, intraoperative evaluation of residual stones, exit strategy, postoperative imaging and stone-free status evaluation, complications. The present guideline on PCNL was the first in the IAU series of urolithiasis management guidelines. The recommendations, tips and tricks across the PCNL procedures would provide adequate guidance for urologists performing PCNLs to ensure safety and efficiency in PCNLs.

Recent advances in percutaneous lithotripsy techniques

PURPOSE OF REVIEW

To describe and critically discuss the most recent evidence regarding the percutaneous nephrolithotomy (PCNL) techniques.

RECENT FINDINGS

Three-dimensional printing and virtual reality are promising tools to improve surgeon experience and operative performance. Totally ultrasound-guided PCNL is feasible and can reduce the radiological risk. Growing evidence highlights the safety and advantages of the use of miniaturized instrumentations, although some related limitations place the mini PCNL (mPCNL) in direct challenge with the retrograde intrarenal surgery. LithoClast Trilogy and ClearPetra system can improve the stone clearance. Thulium laser is a new source of energy with growing expectations and promising in-vitro results.

SUMMARY

Significant advances have recently been recorded in PCNL techniques. Thulium fiber laser, LithoClast Trilogy, new suction devices, and the development of novel technologies for teaching and planning procedures may overcome mPCNL drawbacks. Further studies are needed to confirm the promising preliminary results available on the topic.

Balloon versus Amplatz for tract dilation in fluoroscopically guided percutaneous nephrolithotomy: a systematic review and meta-analysis

OBJECTIVE

To compare the safety and efficacy of balloon and Amplatz for tract dilation in fluoroscopically guided percutaneous nephrolithotomy (PCNL).

METHOD

EMBASE, PUBMED, MEDLINE and the Cochrane Central Register of Controlled Trials were searched for pertinent studies up until 30 October 2019. Pooled effects were calculated as ORs with 95% CIs or mean differences (MD) with 95% CIs. Endpoints included postoperative decrease in haemoglobin, transfusion rate, complication rate, successful dilation rate, stone-free rate, fluoroscopy time, access time, total operation time and length of postoperative hospitalisation (LPH). Bonferroni's correction was intercalated to reduce the likelihood of making a meta-analytical false positive.

RESULTS

One randomised controlled trial and five controlled clinical trials were included, which involved 1317 patients in total. We found a lower drop in postoperative haemoglobin for patients receiving balloon dilation compared with those in the Amplatz group (MD=-0.21, 95% CI -0.33 to 0.09, p=0.0005; Bonferroni correction a=0.005). Access time in the balloon group was also, on average, 2.61 min shorter than the Amplatz group (MD=-2.61, 95% CI -4.20 to 1.01, p=0.001; Bonferroni correction a=0.005). No significant differences were identified between the two dilation methods in terms of transfusion rate, complication rate, successful dilation rate, stone-free rate, fluoroscopy time, total operation time and LPH.

CONCLUSION

Balloon dilation is a safe and effective tract dilation technique for access creation during fluoroscopically guided PCNL. Both of methods have similar success rates although balloon dilation is associated with significantly less postoperative haemoglobin decline and shorter access time. Therefore, balloon dilation appears to be the superior tract dilation technique, but further confirmatory research is required to confirm these findings.

The Pros and cons of balloon dilation in totally ultrasound-guided percutaneous Nephrolithotomy

Background

To evaluate the feasibility and safety of balloon dilation (BD) in totally ultrasound-guided percutaneous nephrolithotomy (PCNL).

Methods

The data of 95 patients underwent BD were collected in this retrospective study between August 2016 and December 2018. During the same period, telescopic metal dilation was used in 1161 patients. Ninety five patients were selected as the control group and matched at a 1:1 ratio to index balloon dilation (BD) cases in regards to Guy’s stone score, age, sex, BMI, degree of hydronephrosis and stone area. Peri-operative data were compared between the two groups.

Results

Total operative time was significantly shorter in the BD group (62.2 ± 22.4 min vs. 70.2 ± 25.8 min, p = 0.024). Tract establishment time was significantly shorter in the BD group (3.4 ± 1.8 min vs. 4.3 ± 2.3 min, p < 0.001). The success rate of tract dilation by first attempt was higher in the TMD group compared with that of BD group; however the difference was not statistically significant. There was no significant difference between groups with regards to complication and stone-free rates. The cost of PCNL in the BD group was significantly higher than that of the TMD group (US $4831.4 ± 1114.8 vs. US $4328.4 ± 975.7, p = 0.012). Subsequent analysis revealed that mild or no hydronephrosis were risk factor for failure of balloon dilation under ultrasound.

Conclusions

BD has acceptable complication and stone free rates compared with those in TMD; however, BD under ultrasound is not suggested for stone cases without hydronephrosis.