Temporary Ureter Occlusion with Simultaneous Urinary Diversion via a Single-Access Route Using a 4-French Balloon Catheter and a Pigtail Nephrostomy Drainage Catheter.

Background and Objectives: This study evaluated the efficacy and safety of temporary ureteral occlusion combined with urinary diversion using a single-access route created by inserting a balloon catheter through a pigtail nephrostomy drainage catheter. With this approach, we aimed to offer an alternative for patients with ureteral leaks who are suboptimal surgical candidates. Materials and Methods: This retrospective study included nine patients (eight of which were bilateral cases and one was unilateral, totaling seventeen cases) who underwent the surgery between September 2023 and March 2024. The method involved gaining percutaneous access to the pelvicalyceal system, inserting a 4-French Fogarty balloon catheter through a pigtail nephrostomy catheter, and inflating the balloon at the proximal or mid-ureter. Results: All 17 cases achieved technical successful with no major complications. The procedure effectively relieved symptoms associated with urinary leakage in most patients. However, the significant deflation of the balloon catheter occurred in five cases (29.4%), with three (17.6%) experiencing complete deflation. In these five cases, the final balloon size was 5.81 mm (range: 0-8.9 mm), confirming a 25.0% decrease in size from pre- to post-procedure. Ureteral occlusion was 28.3 d long on average (range: 8-57 d). All patients experienced symptom relief during temporary ureteral occlusion. Except for two patients lost to follow-up, three patients showed symptom improvement with only PCN and four patients underwent surgical closure of the fistula tract before or after balloon catheter removal. Conclusions: This study confirms that this approach is safe and effective.

Graft kidney hydronephrosis caused by transplant ureter inguinal hernia: A case report.

RATIONALE: Ureteral obstruction of the graft kidney is a common complication of kidney transplantation. However, ureteral obstruction caused by inguinal hernia has rarely been reported. We present a rare case of ureteral obstruction with allograft dysfunction caused by an inguinal hernia. PATIENT CONCERNS: A 76-year-old man, who was a renal transplant recipient, presented with bilateral pitting oedema, reduced urine output, and right inguinal hernia. DIAGNOSES: Abdominal computed tomography revealed severe hydroureteronephrosis of the kidney allograft. A right inguinal hernia with ureteral incarceration was observed. INTERVENTIONS: The patient underwent graft percutaneous nephrostomy, followed by antegrade insertion of a double-J tube (DJ). Gradual improvement was observed in his renal function. Right inguinal herniorrhaphy was performed 5 days later. OUTCOMES: The renal function returned to normal after percutaneous nephrostomy and insertion of the DJ. A right inguinal direct-type hernia with ureter adhesion to the hernial sac was observed during the surgery. The posterior wall defect was repaired by the McVay technique. The DJ was removed after 1 month. The patient's renal function remained stable at 6-month follow-up. LESSONS: The orientation of the graft kidney has a significant influence on the location of the ureter. Upward orientation of the hilum will result in superficial location of the ureter, rendering it close to the hernial sac and susceptible to incarceration. The transplant surgeon should be aware of such a presentation of graft dysfunction with inguinal hernia to prevent a delay in the diagnosis and graft loss.

Percutaneous nephrolithotomy in children.

INTRODUCTION: The high success rates of percutaneous nephrolithotomy (PCNL) in the clearance of large renal calculi has made it a primary mode of surgical management in adults. Similarly, in children too PCNL has been gaining ground and the indications for the same are on the rise. We retrospectively evaluated the safety and efficacy of this technique, in children below 18 years of age. MATERIALS AND METHODS: We retrospectively reviewed the inpatient, outpatient records, imaging films of all children with renal stones undergoing PCNL at our hospital. RESULTS: During the study period, 123 children underwent 129 PCNL at our centre for renal calculi. The mean age was 11.06 years and 87 (70.73%) of the children were males. The size of the stones varied from 15 to 37 mms in the longest diameter. A complete staghorn was noted in six (4.65%) and a partial staghorn in nine (6.97%) children. Supine PCNL was performed in 21 (16.2%) children and remaining 102 (83.7%) children underwent PCNL in prone position. The mean drop in haemoglobin was 1.24 gm%. Stone clearance was achieved in 122 (94.5%) children. Post-operatively four (3.1%) children needed blood transfusions due to excessive bleeding. CONCLUSIONS: Refinements in percutaneous access techniques, miniaturization of instruments, and technologic advances in energy sources for lithotripsy have led to improvement of outcomes and have lowered the morbidity rates in children following PCNL. It is a safe and effective means of clearing large volumes of renal calculi with minimal morbidity.

Comparison of two different minimally invasive percutaneous nephrostomy sheaths for the treatment of staghorn stones.

OBJECTIVE: To compare the safety and effectiveness of using a conventional nephrostomy sheath (NS) vs using a new NS with suction and evacuation functions in minimally invasive percutaneous nephrolithotomy (MPCNL) for the treatment of staghorn stones. PATIENTS AND METHODS: A prospective and randomised study of 60 patients with staghorn stones randomly assigned into two groups of 30 patients. One group underwent MPCNL using conventional NS, whereas the other group underwent MPCNL with suction-evacuation NS (SENS). Patient demographics, stone characteristics, intraoperative data, perioperative data, and surgical results were collected and analysed. RESULTS: The patient demographics and stone characteristics were similar amongst the two groups. The SENS group had a significantly lower peak and a significantly lower average renal pelvic pressure (RPP) throughout the procedure. The SENS group was more efficient for stone removal and had a much shorter stone treatment time, a lesser use of the stone extractor, and ultimately a higher stone-free rate (SFR). The effects of a lower RPP and shorter stone treatment time translated into less severe postoperative complications as measured per modified Clavien grade. CONCLUSION: Using SENS in MPCNL for the treatment of staghorn stones has the advantages of lower RPP, increased effectiveness in stone retrieval, decreased surgery related complications, and an improved SFR.

Trans-tract electrocoagulation can decrease the need for postoperative nephrostomy tube after endoscopic combined intrarenal surgery.

AIM: To assess the efficacy and safety of trans-tract electrocoagulation at the end of endoscopic combined intrarenal surgery for renal or ureteral stones. METHODS: The present study included patients who underwent endoscopic combined intrarenal surgery from May 2010 to March 2018. After June 2013, the trans-tract electrocoagulation procedure, to coagulate bleeding from the access tract using a resectscope was carried out at the end of the operation. We compared the patients' background and surgical outcomes between patients with and without trans-tract electrocoagulation. RESULTS: Between the trans-tract electrocoagulation (n = 225) and non-trans-tract electrocoagulation (n = 72) groups, the stone number was significantly smaller (1:2:3 or more, 126:72:27 vs 59:10:3, P = 0.001) and the initial stone-free rates were significantly higher (80% vs 72%, P = 0.006) in the trans-tract electrocoagulation group than in the non-trans-tract electrocoagulation group. Patients experienced a higher nephrostomy tube-free rate (67% vs 26%, P < 0.0001), shorter postoperative catheterization time (2.8 ± 3.8 vs 5.4 ± 5.0 days, P = 0.002) and shorter hospital stay (6.5 ± 3.6 vs 8.8 ± 5.0 days, P = 0.0001) in the trans-tract electrocoagulation group than in the non-trans-tract electrocoagulation group. CONCLUSIONS: Trans-tract electrocoagulation in endoscopic combined intrarenal surgery is a safe and efficient procedure that decreases the need for nephrostomy tube placement after surgery.

Safety and Effectiveness of Externalized Ureteral Catheter in Tubeless Percutaneous Nephrolithotomy.

PURPOSE: To review the safety and effectiveness of tubeless percutaneous nephrolithotomy (PCNL) with an externalized ureteral catheter (EUC) compared with standard PCNL with nephrostomy tube and tubeless PCNL with double-J (DJ) stent following uncomplicated PCNL and the absence of residual stones. MATERIALS AND METHODS: Patients with kidney stones who underwent uncomplicated PCNL between January 2000 to December 2017 and had no residual stones were retrospectively evaluated. The 766 patients were divided into standard PCNL with nephrostomy tube (group 1; 350 patients), tubeless PCNL with DJ stent (group 2; 189 patients), and tubeless PCNL with EUC (group 3; 227 patients). Demographic characteristics, stone-related factors, perioperative and postoperative parameters were analyzed. RESULTS: Demographic and stone-related characteristics were comparable. The differences in the mean operative time and complication rates were not significant. Postoperative hospitalization period was shorter in group 3 (3.19 ± 2.2 days) compared with group 1 (4.12 ± 2.4 days; p < .001) but not to that of group 2 (3.44 ± 2.8 days; p = .680). Postoperative pain score was lower in group 3 (3.24 ± 1.1) compared with both group 1 (6.36 ± 1.7; p < .001) and group 2 (4.85 ± 1.1; p < .001). Urine leakage complication was lower in group 3 (0.4%) compared with group 1 (2.9%, p = .038) but not to that of group 2 (0.5%; p = .897). CONCLUSIONS: Tubeless PCNL is effective and safe for uncomplicated PCNL in the absence of residual stones. Tubeless PCNL with EUC is associated with decreased pain, hospitalization time, and urine leakage compared with standard PCNL. However, it is only associated with decreased pain when compared with tubeless PCNL with DJ stent.

The Effect of Irrigation Power and Ureteral Access Sheath Diameter on the Maximal Intra-Pelvic Pressure During Ureteroscopy: In Vivo Experimental Study in a Live Anesthetized Pig.

Objectives: To assess the effect of irrigation settings and the size of ureteral access sheath (UAS) on the maximal intra-pelvic pressure (IPPmax) during ureteroscopy (URS) in pigs. Materials and Methods: In supine position, three anesthetized female pigs underwent cystoscopy to insert a 6F ureteral catheter in each ureter. Pigs were then turned to prone position to establish a percutaneous access, insert a 10F nephrostomy tube in the kidney, and connect it to a urodynamic device. An 8F semi-rigid ureteroscope or the Flex-X2 Flexible Ureteroscope was used with two irrigation settings: gravity flow and manual pumping using a commercial pump. URS was performed without UAS and with the UAS 9.5/11, 12/14, 14/16 at the ureteropelvic junction and the IPPmax was recorded. Results: Under gravity irrigation, the recorded IPPmax during semi-rigid URS in the distal ureter and the renal pelvis was 0 and 30 cmH2O, respectively. Further, the IPPmax during flexible URS in the renal pelvis without UAS, with UAS 9.5/11.5, with UAS 12/14, and with UAS 14/16 was 23, 6, 2, and 1 cmH2O, respectively. Under manual pumping, the IPPmax during semi-rigid URS in the distal ureter and the renal pelvis was 84 and 105 cmH2O, respectively. Further, the IPPmax during flexible URS in the renal pelvis without UAS, with UAS 9.5/11.5, with UAS 12/14, and with UAS 14/16 was 45, 46, 18, and 1 cmH2O, respectively. Conclusion: Manual pumping can significantly increase the IPPmax to unsafe levels during URS. The UAS can significantly decrease the IPPmax, even under manual pumping. The larger the UAS, the lower the IPPmax. The use of UAS can render URS safer by acting as a safeguard against the consequences of increased IPP, even under forced irrigation.

Application of a Self-Made Equipment for Patient Positioning during Percutaneous Nephroscopy in the Oblique-Supine Position.

BACKGROUND: The oblique-supine position for percutaneous nephrolithotomy (PCNL) has advantages, but the position fixation methods are inadequate. This study aimed to analyze the PCNL outcomes using a patented self-made frame for oblique-supine position. METHODS: This was a prospective study of patients scheduled to undergo PCNL at 2 hospitals in China between November 2009 and December 2016. The patients underwent PCNL in the oblique-supine position using the self-made position frame (n = 94). Operative time, stone clearance rate, intraoperative average systolic pressure, intraoperative average heart rate, intraoperative average airway pressure, intraoperative average intrapelvic pressure, and complications were observed. RESULTS: The patients were 45.3 ± 19.7 years old and 71% were male. Stones were of the size 2.5 ± 1.1 cm. The operative time was 95.6 min and the stone clearance rate was 81.9%. Intraoperative systolic blood pressure was 15.13 ± 1.68 kPa. Intraoperative airway pressure was 15.5 ± 2.3 cm H2O. Postoperative fever was observed in 3.2% of the patients. None had organ injury. Postoperative stay was 4.8 ± 0.6 days. The nephrostomy tube was routinely removed on the 5th day after surgery and the patients were discharged on the following day. CONCLUSION: The self-made surgical position frame met the position requirements for the oblique-supine PCNL operation. This surgical position frame deserves clinical application and promotion.

Clinical application of fluoroscopic guided percutaneous antegrade ureteral stents placement for the treatment of malignant ureteral obstruction.

OBJECTIVE: To investigate the clinical efficacy and safety of fluoroscopic guided percutaneous antegrade ureteral stents placement used for treatment of malignant ureteral obstruction. METHODS: Between April 2016 and March 2018, fluoroscopic guided percutaneous ureteral stents was performed in 25 patients, including 7 patients (28%) with bilateral obstruction. The most common cancer diagnoses were cervical cancer (28%), rectal cancer (24%) and colon cancer (16%) among these patients. Clinical data were retrospectively analyzed with respect to the efficacy, safety and outcome of this treatment method. RESULTS: Percutaneous antegrade placement of ureteral stents was performed in all cases, including 12 ureters that failed in the initial retrograde ureteral stents placement. The median stent patency time for the antegrade ureteral stents were 10.4 (95% CI: 8.3-12.6) months. The primary complications included mild flank pain and discomfort (44%), hematuria (44%), urinary tract infection (8%), bladder irritation symptoms (4%), and arterial bleeding (4%). CONCLUSION: Fluoroscopic guided percutaneous ureteral stents placement is a safe, efficient procedure and has a high success rate in patients with malignant ureteral obstruction.

Percutaneous antegrade ureteral stent placement: single center experience.

PURPOSE: We aimed to present our clinical experience with percutaneous antegrade ureteral stent placement in a single center. METHODS: Electronic records of patients who underwent percutaneous image-guided ureteral stent placement between September 2005 and April 2017 were reviewed. A total of 461 patients (322 males, 139 females; age range, 19-94 years; mean age, 61.4±15 years) were included in the study. Patients were classified into two main groups: those with neoplastic disease and those with non-neoplastic disease. Failure was defined as persistence of high level of serum creatinine or an inability to place stents percutaneously. Postprocedural complications were grouped as percutaneous nephrostomy and stent placement related complications. RESULTS: A total of 727 procedures in 461 patients were included in the study: 654 procedures (90%) in 407 patients (88.3%) were in the neoplastic group and 73 procedures (10%) in 54 patients (11.7%) were in the non-neoplastic group. Our technical success rates were 97.7% and 100% and complication rates were 3.1% and 4.1% in neoplastic and non-neoplastic groups, respectively. Seven stents retrievals and 112 balloon dilatations were performed successfully. CONCLUSION: Percutaneous antegrade ureteral stent placement is a safe and effective method for management of ureteral injuries and obstructions due to both malignant and benign causes when the retrograde approach has failed.

Ureteral Catheter Versus Nephrostomy Tube for Patients Undergoing Percutaneous Nephrolithotomy Under Spinal Anesthesia: A Prospectively Randomized Trial.

PURPOSE: The aim of this study is to evaluate overnight ureteral catheterization vs nephrostomy tube for urinary diversion in patients undergoing percutaneous nephrolithotomy (PNL) under spinal anesthesia. MATERIALS AND METHODS: Patients were enrolled using block randomization between February 2016 and July 2016. Patients with renal stones >2 cm confirmed via noncontrast-enhanced CT were included. All patients underwent PNL under spinal anesthesia. Group 1 refers to patients who had a nephrostomy tube following PNL, whereas group 2 refers to overnight ureteral catheterization. Those who refuse spinal anesthesia, <18 years of age, >70 years of age, and anomalous kidneys (ectopic pelvic kidney, horseshoe kidney, etc.) were excluded. In group 1, nephrostomy tube (14F) was removed 48 hours after surgery, whereas the ureteral catheter (6F) was removed at postoperative 12th hour in group 2. Visual analogue scores (VASs) at 24th hour and mean narcotic analgesic (tramadol) amounts were compared. RESULTS: There were 30 patients in both groups. Mean age, mean body mass index, and stone area were not significant between groups (p > 0.05, for all). With regard to operative measures, mean duration of surgery, mean number of accesses, and mean drop in Hb levels were comparable. Besides, mean hospitalization period in group 1 was 68.8 ± 12 hours, whereas it was 54.5 ± 10 hours in group 2 (p < 0.001). No patients in either group needed transfusion. Stone-free rates were similar in both groups (83% vs 90%, p = 0.391). Mean 24th hour VAS was 6.17 ± 1.4 in group 1 and 3.37 ± 1.4 in group 2 (p < 0.001). Also, there was a statistically significant difference in mean tramadol requirements between groups (181.67 ± 56.45 vs 86.67 ± 57.13, groups 1 and 2, respectively). CONCLUSION: In patients undergoing PNL under spinal anesthesia, using an open-ended ureteral catheter to be removed at early postoperative period reduces analgesic requirement and duration of hospital stay without compromising surgical outcomes and complication rates.

Are Emergently Placed Nephrostomy Tubes Suitable for Subsequent Percutaneous Endoscopic Renal Surgery?

OBJECTIVE: To determine the percentage of emergently placed nephrostomy tubes (NT) that were subsequently deemed usable for definitive percutaneous nephrolithotomy or percutaneous antegrade ureteroscopy in patients presenting with nephrolithiasis. METHODS: A multi-institutional retrospective database review was completed to identify patients who underwent emergent NT placement and then subsequent percutaneous nephrolithotomy or percutaneous antegrade ureteroscopy. Demographic, operative, and postoperative data were collected. Complications were classified using the Clavien-Dindo system. RESULTS: A total of 36 patients with 41 NTs met inclusion criteria. Indications for emergent NT placement were: obstruction with evidence of urinary tract infection/pyelonephritis (61%) and obstruction with acute kidney injury (39%). After recovery from the acute event and NT placement and during subsequent percutaneous surgical procedures, 9 NTs (22%) were sufficient without need for additional percutaneous access, 2 NTs (5%) were partially sufficient and were used in conjunction with an additional percutaneous access tract, and 30 NTs (73%) were unusable. CONCLUSION: In this multi-institutional review, only 22% of NTs placed for emergent indications were sufficient for subsequent percutaneous surgery without the creation of additional percutaneous tracts. Urologists should be prepared to obtain additional access during definitive percutaneous renal surgery in patients who have had a tube placed under emergent conditions.

Ureteroscope-aided Reinsertion of Dislodged Pigtail Nephrostomy Tube Through Collapsed Tract.

PURPOSE: To introduce an alternative method for the reinsertion of pigtail catheter for collapsed nephrostomy tract. MATERIALS AND METHODS: Between January 2013 and October 2016, a total of ten patients with collapsed nephros-tomy tract underwent ureteroscope-aided reinsertion of the pigtail catheter after the failure of manual reinsertion by guidewire. Under local anesthesia, the ureteroscope was inserted through a percutaneous nephrostomy (PCN) opening. The access path was obtained by careful tracing for prior placement of pigtail catheter. The clinical features of these ten patients, including operation time, success rate and complications, were evaluated by retro-spective chart review. The Clavien classification was applied to define the grade of complications after one-month follow-up. RESULTS: Among the ten cases of difficult PCN revision, eight underwent the procedure within 24 hours of the dislodgement. The remaining two patients underwent the procedure within 2 days and 8 days. The period of pigtail tube dwelling ranged from 2 weeks to 10.5 months. The procedure was successful in nine cases and the operation time ranged from 10 to 30 minutes. No fluoroscope was used in any patient. All of the nine patients had a good drainage function after tube reinsertion. Complications occurred only in one patient who had postoperative fever classified as Clavien grade 2. CONCLUSION: Reinserting the dislodged pigtail nephrostomy tube with the aid of an ureteroscope is an alternative method that may decrease the necessity of new tract creation.

Experience of percutaneous nephrolithotomy with the creation of nephrostomy tract by plasma vaporization.

PURPOSE: To share our 7-year experiences of a safe and effective method for tract creation in percutaneous nephrolithotomy (PCNL). METHODS: A total of 143 patients had received this kind of method for renal stone disease at our institute from May 2010 to December 2016. Finally, 130 patients with complete data were included. All patients underwent a bipolar resectoscope mounted with a plasma vaporization (PV) button electrode for tract creation. Data analysis included procedure time, length of hospital stays, blood transfusion rate, any early and late complications, renal function, and stone-free rate. RESULTS: The mean age of patients was 56.5 years (range 26-84 years). Noticeably, no blood transfusion was necessary in this series. Mean length of post-operative stay duration was 2.6 ± 1.1 days. The average operating time was 46 min. Stone-free rate was 93.3% in the non-staghorn calculi group. There was no significant difference in change in renal function after the operation (P = 0.884). All posto-perative complications were Clavien grade 1 including fever (16.9%) and urine leak (1.5%) etc. There was no major complication. CONCLUSIONS: Based on zero blood transfusion rate, no major complication, and shorter post-operative stay duration (2.6 days), the PV technique is safe and effective for less blood loss in comparison with other techniques for creating the nephrostomy tract for PCNL.

The Clinical Efficacy of Dual-Lumen Catheter Technique in Retrograde Intrarenal Surgery for the Management of Nephrolithiasis: A Propensity Score Analysis.

OBJECTIVE: To assess the clinical efficacy of dual-lumen catheter technique in retrograde intrarenal surgery (RIRS) in terms of stone-free rate. METHODS: The data of 172 patients who underwent RIRS for renal stones between 2010 and 2017 were retrospectively reviewed. Patients were classified into two groups depending on whether the dual-lumen catheter technique was used (group 1, n = 25) or not (group 2, n = 147) during RIRS. In turn, all patients of group 1 were compared with those of group 2 using propensity score analysis methods. Clinical variables, including post-RIRS residual fragments (RFs) (≥2 mm) and dusts (sandy stones) (≤1 mm), were compared between both groups. Logistic regression analyses were conducted to identify the predictors of postoperative RFs and dusts. RESULTS: According to propensity score analysis, no other clinical variables were significantly different between the two groups, except the dust-free rate was significantly higher in group 1 than in group 2 (92% vs 40%, p < 0.001). In multivariate analysis, the performance of dual-lumen catheter technique was an independent predictor of the absence of dusts after RIRS (odds ratio [OR], 0.040; 95% confidence interval [CI], 0.070-0.220). In addition, on performing multivariate analyses in another matched population, it was found that although the technique adversely affected the removal of RFs (OR, 4.711; 95% CI, 1.203-18.447), it showed an excellent effect on the evacuation of dusts (OR, 0.049; 95% CI, 0.007-0.347). CONCLUSION: Our analyses suggest that the use of dual-lumen catheter during RIRS can facilitate the evacuation of sandy stones. However, further prospective randomized trials are required to verify the usefulness of this technique in real clinical practice.

[The Efficacy of a Released Ultrasonic Lithotripsy in Percutaneous Nephrolithotomy : Randomized Trial Comparing Swiss LithoClast® Master Versus Swiss LithoClast®].

We prospectively randomized total 29 patients with renal stones into two groups between Aug 2014 and March 2016. The US group was treated using a ultrasonic lithotripter (Swiss LithoClast® Master) and the PN group was treated with a pneumatic lithotripter (Swiss LithoClast® ). We compared treatment outcomes in these groups. The US group consisted of 17 patients and the PN group 12 patients. There was no significant difference between the groups in baseline characteristics (age, sex, body mass index, side, stone size, and density). There was no significant difference in total operative time (p＝0.63), stone-free rate (p＝ 0.19), hemoglobin deficit (p＝0.49), or rate of postoperative sepsis (p＝0.99) between the two groups. However, intracorporal stone disintegration and removal time was significantly shorter in the US group than the PN group (p＝0.029). These results suggest that the ultrasonic lithotripter can be superior to the existing pneumatic lithotripter in saving intracorporal stone disintegration and removal time in percutaneous nephrolithotomy.

Retrograde intrarenal surgery in the management of pediatric cystine stones.

OBJECTIVE: To investigate the efficacy and safety of retrograde intrarenal surgery (RIRS) in the treatment of pediatric cystine stones. STUDY DESIGN: Data of the pediatric patients who underwent RIRS for kidney stones were retrospectively evaluated. A total of 14 children with cystine stones managed with RIRS were identified. In addition to the patient demographics and stone characteristics, all retrospectively obtained operative data were evaluated and discussed in detail, with an emphasis on the success and complication rates. RESULTS: Mean age of the 14 cases was 10.9 ± 2.2 years (range: 7-15). Mean stone size was 13.6 ± 2.4 mm (range: 10-18) (Summary table). Of these stones, four were located in the renal pelvis, three were in the lower, three were in the middle and the remaining four were located in upper calyx. Ureteral access sheath was used in 12 (85.7%) patients. The double-J ureteral stent was placed pre-operatively in one case and was inserted postoperatively in 12 cases. Mean operation time was 38.2 ± 7.2 min (range: 30-50). Complications were observed in two cases: mild ureteral laceration in the first and fever on the second postoperative day in the second patient. All of the patients were stone free on sonographic evaluation at the 4-week follow-up evaluation. Although potassium citrate treatment was initiated in 11 patients, tiopronin treatment was initiated in four patients for recurrence prophylaxis during long-term follow-up. During a mean follow-up period of 25.7 ± 5.2 months, stone recurrence was noted in one patient. DISCUSSION: Treatment of patients with cystine stones is challenging, due to high risk of rapid recurrence in the presence of residual fragments. Besides allowing complete stone clearance in all cases in the current series, RIRS is a highly reproducible method that can be safely performed, even in recurrences. The major limitations of the current study were low number of patients and short follow-up period. CONCLUSION: The results clearly indicated that RIRS is a safe treatment modality in the management of pediatric cystine stones.

Ultra-mini PNL (UMP): Material, indications, technique, advantages and results.

Stone disease has afflicted mankind since centuries; records from ancient civilisations of India and Egypt have shown stones in human bodies. The scientific mind of humans has always made smart endeavours to remove the kidney stones. From large instruments made like the beaks of different animals and birds in 600 BC (Indian civilisation) to extremely sophisticated and miniaturised endoscopic intruments of today the human race has travelled a long way. The theme has always been to remove the stones with minimal morbidity and mortality and with minimum pain to the patient. The article takes you through the journey of instruments used in 600 BC until today. The story of instrumentation is a symbiosis of the medical minds along with engineering advances. The story of miniaturisation could not have moved further without the development of lasers, fiberoptics and sophisticated cameras. As the field stands today, we remove more complex stones by larger endoscopic intervention and smaller stones by miniaturised instruments. The article discusses all the merits and shortcomings of various techniques: from open surgery to standard PCNL to Mini PCNL to Ultra- Mini PCNL to Micro-PCNL.