Comparison of percutaneous nephrolithotomy using pneumatic lithotripsy (lithoclast®) alone or in combination with ultrasonic lithotripsy

Comparison of Swiss LithoClast Trilogy™ and Pneumatic Swiss LithoClast™ in Mini-Percutaneous Nephrolithotomy in Terms of Stone Free Rate and Complications: A Single-Center Experience From a Stone Belt Country

Background Renal calculi therapy has advanced significantly in recent years, with mini-percutaneous nephrolithotomy (PCNL) emerging as a minimally invasive treatment modality. Mini-PCNL has been subjected to several modifications to achieve the best possible outcomes and reduce morbidity. This study aimed to compare the efficacy and safety of Swiss LithoClast Trilogy™ and pneumatic Swiss LithoClast™ in managing renal stones with mini-PCNL. Methodology This descriptive retrospective study was conducted at the Department of Urology, Lady Reading Hospital, from January 1, 2023, to December 31, 2023. A record of male and female patients aged more than 18 years who underwent mini-PCNL for renal stones was retrieved. The following two groups of patients were created: group A (n = 25) mini-PCNL with Swiss LithoClast Trilogy™ and group B (n = 26) mini-PCNL with pneumatic Swiss LithoClast™. The efficacy and safety profile of both groups was compared. Results A total of 51 patients were enrolled, with 25 in group A and 26 in group B. Groups A and B had mean ages of 45.2 and 47.5 years, respectively. Male participants outnumbered females in both groups, 72% (n = 18) in group A and 77% (n = 20) in group B. Group A had a mean stone size of 15.8 mm, and group B had a mean stone size of 16.5 mm. Stone-free rate on postoperative day one was 88% (n = 22) in group A and 84.6% (n = 22) in group B, with no statistically significant difference (p > 0.05). At the end of three months, 96% of participants in group A and 84.6% of patients in group B were found to be free of stones, and the difference between the two groups was not statistically significant (p > 0.05). Intraoperative hemorrhage occurred in 12% (n = 3) of group A and 15.4% (n = 4) of group B patients, with no significant difference (p > 0.05). Conclusions There were no significant differences in stone-free rates, complication rates, or intraoperative/postoperative complications between mini-PCNL with Swiss LithoClast Trilogy™ or Pneumatic Swiss LithoClast™.

First Clinical Experience of a Novel Pulsed Solid-State Thulium:YAG Laser during Percutaneous Nephrolithotomy

INTRODUCTION

Laser lithotripsy during Mini-PCNL is one treatment option in urinary stone disease. In recent years, a new era in stone treatment has been initiated with the introduction of new pulsed thulium lasers. The aim of this study was to investigate the safety and efficacy of laser lithotripsy with a new pulsed solid-state thulium:YAG laser during mini-PCNL.

MATERIALS AND METHODS

All patients, regardless of stone size, who were treated with a Mini-PCNL using the new pulsed thulium laser were prospectively enrolled. Operation times, stone size, laser time, and laser settings were noted. The stone-free rate was assessed postoperatively with sonography and either X-ray or computed tomography as a clinical standard. The complications were analyzed using the Clavien-Dindo classification.

RESULTS

A total of 50 patients with a mean age of 52 years were included. 31 (62 %) patients were male. The average stone size was 242.3 (±233.1) mm2 with an average density of 833 (±325) Hounsfield units. The mean operating time was 30.56 (±28.65) min, and the laser-on-time was 07:07 (± 07:08) min. The most commonly used settings were 0.4 J and 115 Hz (46 W). The mean total energy for stone ablation was 14,166 (±17,131) kJ. The total stone-free rate was 84 %, with an overall complication rate of 32% according to Clavien-Dindo (grade 1: n = 9, grade 2: n = 6, 3b: n = 1). In the group of patients with singular stones (n = 25), the stone-free rate was 88%.

SUMMARY

The new pulsed solid-state Thulium:YAG laser allows a safe and effective lithotripsy during Mini-PCNL. The stone-free rates were high regardless of stone size with a comparable low rate of complications.

An ex-vivo assessment of a new single probe triple modality (Trilogy) lithotripter

Introduction and objectives

This Swiss LithoClast^® Trilogy lithotrite is a new lithotrite for percutaneous nephrolithotomy (PCNL). It has four modifiable settings; impact, frequency, ultrasound and suction. We aim to determine the optimal device settings for the fastest stone clearance.

Materials and methods

Kidney stone phantoms were made with Begostone in a powder to water ratio (15:3–15:6). Complete stone clearance (seconds) was calculated and impact and frequency were adjusted and repeated N = 3. Intra renal pressure (IRP) was then measured in a porcine kidney model.

Results

Stone phantoms with physical properties similar to struvite were cleared best with 100% impact and frequency of 12 Hz. Both uric acid stone phantoms and calcium phosphate stone phantoms were cleared most efficiently with an impact of 30% and a frequency of 4 Hz. The mean time to clear uric acid stone phantoms was 83 s versus 217 s for calcium phosphate stone phantoms. Similarly, for calcium oxalate stone phantoms, an impact of 30% and a frequency of 4 Hz was associated with the fastest clearance time, mean 204 s. However, the differences between 4, 8 and 12 Hz were not statistically significant. At a suction level of 60% or higher, IRP became negative.

Conclusion

These results indicate that stone phantoms of hard kidney stones are cleared more efficiently at lower impact and frequency settings. With regard to suction, a setting of ≤ 50% appears to be the optimal setting.

Pediatric Stone Surgery: What Is Hot and What Is Not

PURPOSE OF REVIEW

We aim to highlight recent advances in technology and techniques for surgical management of urinary tract calculi in pediatric patients.

RECENT FINDINGS

Percutaneous nephrolithotomy (PCNL) is classically performed in the prone position. The supine PCNL was first attempted to overcome the shortcomings of difficult airway access, patient and surgeon discomfort. The supine PCNL, and subsequent modifications, has been successfully described in the pediatric population. Classically, PCNL has also been classically concluded with obligate placement of a nephrostomy tube and bladder catheter. Recently, tubeless and totally tubeless PCNL reduces pain and duration of hospitalization with satisfactory surgical outcomes in children. Finally, we describe the use of thulium laser technology, which offers improved efficacy in stone treatment and may supplant the current dominant technologies in coming years. Recent advances in pediatric stone surgery include supine PCNL, miniaturized PCNL instrumentation, tubeless procedures, and thulium laser technology.

Does combined lithotripter show superior stone-success rate than ultrasonic or pneumatic device alone during percutaneous nephrolithotrotomy? A meta-analysis

OBJECTIVES

To compare the stone clearance rate and stone-success rate among lithotripter with ultrasonic lithotripter alone, pneumatic lithotripter alone and combined mechanisms.

METHODS

Up till 2021 May, we conducted a literature search among several widely used database around the world, including Pubmed, Embase (Ovid Version), Medline (Ovid Version) and Cochrane Central Register of Controlled Trials. Only English literature was considered. Pediatric patients were excluded. Reviews and protocols without any published data were excluded. Conference abstracts and articles with unrelated contents were also excluded.

RESULTS

Fifteen articles were included in our final meta-analysis, with 9 RCTs and 6 cohort studies. In Lithoclast combined with ultrasonic device vs pneumatic device subgroup, overall stone-success rate yielded insignificant difference. As for subgroup of Shock Pulse vs pneumatic device, pooled analysis yielded a higher 1-month stone-success rate for Shock Pulse (RR = 1.10, 95% CI: 1.01-1.19). In Lithoclast combined with ultrasonic device vs ultrasonic device subgroup and Cyberwand vs ultrasonic device subgroup, both overall stone-success rate did not differ from one another. We found Lithoclast with ultrasonic device was more efficient in stone clearance rate than pneumatic device (mean difference = 8.23, 95% CI: 4.99-11.47). The same situation was applied to the comparison between Lithoclast with ultrasonic device and ultrasonic device (mean difference = 13.02, 95% CI: 4.57-21.46).

CONCLUSIONS

Combined lithotripter was more efficient in clearing stones than pneumatic or ultrasonic device alone. However, when it came to stone-success rate, no obvious superiority was seen in combined one.

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.

Comparison between shockpulse and pneumatic lithotripsy in percutaneous nephrolithotomy

PURPOSE

To compare the effectiveness and safety of shockpulse with pneumatic lithotripsy in percutaneous nephrolithotomy.

METHODS

A prospective randomized comparative study was performed in Department of Urology, Bir Hospital for 1-year duration with 61 patients in shockpulse (Group 1) and 58 patients in pneumatic lithoclast (Group 2) groups, respectively. Patient's demographics, stone characteristics, hemoglobin drop, hospital stay, operative duration, stone fragmentation time and postoperative complications were compared.

RESULTS

The two groups did not differ significantly in terms of patient's demographic and stone characteristics. The mean hemoglobin drop was 1.96 ± 1.48 g/dl in Group 1 and 2.32 ± 1.38 g/dl in Group 2 (p = 0.16) and hospital stay was 3.14 ± 1.42 days in Group 1 and 3.29 ± 1.82 days in Group 2 (p = 0.62). The number of cases that required multiple tracts were six (9.8%) in Group 1 and 12 (20.68%) in Group 2 (p = 0.12). The stone-free rates were 78.69% in Group 1 and 74.13% in Group 2 (p = 0.66). Mean total operation time was 43.23 ± 18.49 min in Group 1 as compared to 51.53 ± 19.48 min in Group 2 (p = 0.0188). Mean stone fragmentation time was 17.95 ± 15.25 min in Group 1 and 24.37 ± 11.12 min in Group 2 (p = 0.0096). Overall complications were not significant between the two Groups (p = 0.58). On sub-analysis of the patients with single tracts in both groups the results were comparable to patients with single and multiple tracts combined.

CONCLUSIONS

Despite similar stone-free rates and complications between the two Groups, shockpulse has significantly lower stone fragmentation time and total operation time as compared to pneumatic lithotripsy.

Use of a Novel Vacuum-Assisted Access Sheath in Minimally Invasive Percutaneous Nephrolithotomy: A Feasibility Study

Objective: To assess the safety and efficacy of a novel vacuum-assisted access sheath (VAAS) in minimally invasive percutaneous nephrolithotomy (MPCNL). Materials and Methods: Seventy-five consecutive patients with single renal pelvic stone were treated with MPCNL combined with a novel VAAS. Patients' demographics and surgical outcomes, as well as perioperative and postoperative data, were recorded. Matched-pair analysis in a 1:1 scenario was done in patients who underwent MPCNL by peel-away access sheath (PAAS). All MPCNL was done with a rigid 12F mini-nephroscope and an 18F access sheath. MINDRAY-PM9000 monitor was used to record the renal pelvic pressure (RPP) data. Results: Patients' demographics, stone size, burden, and density (HU) were comparable between the two groups. Operative time was significantly shorter in the study group, at a mean of 32.4 ± 9.6 vs 46.2 ± 11.8 minutes (p < 0.001). The immediate stone-free rate was 89.3% for the VAAS group and 77.3% for the PAAS group (p = 0.049). Patients in the VAAS group had a lower visual analogue pain scale score at postoperative 6 and 24 hours. Mean perioperative RPP was lower in the VAAS group (10.3 ± 4.3 vs 17.8 ± 5.1 mmHg, p < 0.001). More than 50 seconds of accumulative time of high RPP (>30 mmHg) was shown in 13 patients of the VAAS group vs 30 of the PAAS group (p = 0.002). Conclusion: Combining VAAS with high-power holmium laser in MPCNL significantly improves the efficiency of stone retrieval with low RPP. This novel approach also reduces operative time, postoperative fever, and pain due to its simultaneous suction property.

EMS Lithoclast Trilogy™: an effective single-probe dual-energy lithotripter for mini and standard PCNL

PURPOSE

Several energy sources are available to clear stones during PCNL. Required improvements are faster stone clearance, optimized suction and ease of use while maintaining high patient safety standard. EMS LithoClast^® Trilogy, is the first device combining electromagnetic impactor with ultrasonic energy and suction, all-in-one probe. Animal studies and in vitro phantom stone studies have proven safety and efficacy of this device. We aim to study safety and clinical efficacy of Trilogy in our patients.

METHODS

31 patients with renal stones were included. Amplatz sheath sizes/Trilogy probe size was 22-28 Fr/10.2 Fr for standard PNL (n = 20) and 15 Fr./5.7 Fr for mini PNL access (n = 11). Analysis was done with respect to demography, stone characteristics, operation duration (total time and lithotripter activation time), post op Hb drop, clearance rate and adverse events. Stone area/volume was calculated based on CT using 3D doctor. Efficacy was determined by stone volume clearance rate (mm³/min).

RESULTS

Male:female ratio was 6:5 and 16:4 for mini (MPNL)/standard PNL (SPNL). Stone densities were 1229 ± 206 vs. 1168 ± 344 HU (MPNL vs. SPNL). Mean stone volumes were 3776.1 ± 2132 mm³ for MPNL and 7096 ± 6441 for SPNL. Mean stone volume clearance ratios were 370.5 ± 171 mm³/min and 590.7 ± 250mm³/min for MPNL and SPNL, respectively. Hb drop was 1.24 ± 0.64 g/dL (MPNL) and 1.23 ± 0.89gm/dL (SPNL). Total procedure time/lithotripter activation time was 53.4 ± 23.8/14.7 ± 12.4 min for MPNL and 65.2 ± 23.5/12.0 ± 8.9 for SPNL. Immediate post-operative/1 month stone clearance rates were 93%/96% with one clinically insignificant residual fragment (< 3 mm) and no necessity for auxiliary procedures. No device failure occured and three Clavien grade I and one grade II complications were observed.

CONCLUSION

Swiss LithoClast^® Trilogy provides fast stone clearance in standard/mini-PCNL procedures. Ease of use, high tissue safety and optimized suction that avoids fragment blockings are other key features.

Device-Related Adverse Events During Percutaneous Nephrolithotomy: Review of the Manufacturer and User Facility Device Experience Database

INTRODUCTION AND OBJECTIVES

Percutaneous nephrolithotomy (PCNL) is an established technique for removal of large stones from the upper urinary tract. It is a complex multistep procedure requiring several classes of instruments that are subject to operator misuse and device malfunction. We report device-related adverse events during PCNL from the Manufacturer and User Facility Device Experience (MAUDE) database using a recently developed standardized classification system.

MATERIALS AND METHODS

The MAUDE database was queried for "percutaneous nephrolithotomy" from 2006 to 2016. The circumstances and patient complications associated with classes of devices used during PCNL were identified. We then utilized a novel MAUDE classification system to categorize clinical events. Logistic regression analysis was performed to identify associations between device classes and severe adverse events.

RESULTS

A total of 218 device-related events were reported. The most common classes included: lithotripter 53 (24.3%), wires 43 (19.7%), balloon dilators 30 (13.8%), and occlusion balloons 28 (12.8%). Reported patient complications included need for a second procedure 12 (28.6%), bleeding 8 (19.0%), retained fragments 7 (16.7%), prolonged procedure 4 (9.5%), ureteral injury 2 (4.8%), and conversion to an open procedure 3 (7.1%). Using a MAUDE classification system, 176 complications (81%) were Level I (mild/none), 26 (12%) were Level II (moderate), 15 (7%) were Level III (severe), and 1 (0.5%) was Level IV (life threatening). On univariate analysis, balloon dilators had the highest risk of Level II-IV complications compared with the other device classes [odds ratio: 4.33, confidence interval: 1.978, 9.493, p < 0.001]. The device was evaluated by the manufacturer in 93 (42.7%) cases, with 54.8% of reviewed cases listing the source of malfunction as misuse by the operator.

CONCLUSIONS

PCNL is subject to a wide range of device-related adverse events. A MAUDE classification system is useful for standardized, clinically-relevant reporting of events. Our findings highlight the importance of proper surgeon training with devices to maximize efficiency and decrease harm.

Comparing the Efficacy and Safety of Ultrasonic Versus Pneumatic Lithotripsy in Percutaneous Nephrolithotomy: A Randomized Clinical Trial

BACKGROUND

Percutaneous nephrolitotomy (PCNL) is the preferred treatment for large renal stones. There is a need for more comparative data for different lithotripters used in PCNL.

OBJECTIVE

To evaluate the comparative safety and efficacy of ultrasonic and pneumatic lithotripsy in patients undergoing PCNL.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at Labbafinejad University Hospital, Tehran, Iran. A total of 180 patients were selected and divided randomly into two groups: 88 patients to pneumatic and 92 to ultrasonic lithotripsy.

INTERVENTION

Standard fluoroscopy-guided PCNL was performed using pneumatic or ultrasonic lithotripsy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was the procedure success rate. We also evaluated other outcome measures including operation time, stone fragmentation and removal time (SFRT), length of hospital stay, and postoperative complications. We used SPSS software version 18.0 for data analysis.

RESULTS AND LIMITATIONS

The two groups were similar in baseline characteristics. There were no significant differences between the groups in stone fragmentation and removal time (p=0.63), stone free rate (p=0.44), and hospital stay (p=0.66). SFRT for hard stones was shorter using pneumatic lithotripsy (p<0.001). By contrast, ultrasonic lithotripsy was associated with a shorter SFRT for soft stones (p<0.001). Postoperative complications were similar in the two groups. A limitation of this study might be the 3-mo follow-up period.

CONCLUSIONS

In general, there were no significant differences in the success rate and complications between pneumatic and ultrasonic lithotripsy. SFRT was significantly shorter using pneumatic lithotripsy for hard stones, and ultrasonic lithotripsy for soft stones.

PATIENT SUMMARY

We found no significant differences in the success rate and complications of percutaneous nephrolitotomy using pneumatic and ultrasonic lithotripsy. Ultrasonic and pneumatic lithotripsy differed in the time for stone fragmentation and removal for hard and soft stones.

Histologic impact of dual-modality intracorporeal lithotripters to the renal pelvis

OBJECTIVE

To test the hypothesis that dual-modality intracorporeal lithotripters used during percutaneous nephrolithotomy create a degree of tissue trauma in the dual-modality mode (ballistic and ultrasonic) similar to that in the single-modality mode (ultrasonic).

MATERIALS AND METHODS

The lithotripter devices tested were the Cyberwand and Swiss LithoClast Select. The activated probes, in both single- and dual-modality modes, were applied directly to the renal pelvis of 11 fresh nephrectomy specimens. The treated tissue sites were then processed for light microscopy and reviewed by a single genitourinary pathologist.

RESULTS

Microscopic examination of the renal pelvis after 2 seconds of direct contact showed minimal denudation of the urothelium, with no changes noted in the subepithelial or muscle layers for the 2 devices evaluated. Direct contact for 4 seconds showed urothelial denudation and subepithelial changes (n = 13 of 23). Muscle injury was observed in some dual-modality specimens (n = 6 of 12). Increasing the contact time to 8 seconds resulted in fragmentation of the muscle layers more frequently with both settings (n = 15 of 22), except for when the Cyberwand was used at the small stone setting (n = 0 of 7).

CONCLUSION

In the ex vivo setting, minimal differences were noted in the degree of histologic trauma between the Cyberwand and Swiss LithoClast Select at 2 seconds. However, both dual-modality devices resulted in muscle damage at 4 and 8 seconds of contact time. Care should be taken during clinical procedures to avoid prolonged contact with the renal pelvis to minimize the potential for tissue trauma.