Outcomes in a large series of minipercs: analysis of consecutive 318 patients.

BACKGROUND AND PURPOSE: The purpose of this study is to evaluate the outcomes of miniperc at our center. PATIENTS AND METHODS: This is a retrospective review of consecutive 318 minipercs done in a single tertiary urological center. The Miniperc system used was either Wolf (Richard Wolf) 14F with 20F Amplaz sheath or Storz (Karl Storz) nephroscope 12F with 15/18F sheath or 16.5/19.5F sheath. Data about the demography of patients, comorbidities, stone size, number and size of the tract, size of nephroscope, energy source used, total operative time, exit strategy, hospital stay, clearance of stones, total analgesic requirement, visual analogue pain score at 6 and 24 hours, hemoglobin drop and complications were analyzed by the chi-square test and analysis of variance test. RESULTS: The average age of patients, stone size, operative time, hemoglobin drop and hospital stay were 41.9±17.0 years, 15.26±6.35 mm, 60±19 minutes,1.0±0.6 g/dL and 2.8±1 day, respectively. Complete clearance rate was 98.7%. Fourteen (4.4%) patients had Clavien-Dindo level 1 complications and 1 (0.31%) patient had Clavien-Dindo level 2 complications. The size of the stone treated by miniperc did not affect the hemoglobin drop (p-value=0.26) or hospital stay (p-value=0.924). There is no significant increase in hemoglobin drop (p-value=0.064) or hospital stay (p-value=0.627) with increasing number of miniperc tracts. An increase in operative time is associated with the increase in hemoglobin drop (p-value=0.041). Different energy sources did not significantly affect the operative time (p-value=0.184). Placement of only ureteral catheter is associated with less analgesic requirement (p-value=0.000). CONCLUSIONS: Miniperc is a safe alternative to standard percutaneous nephrolithotomy. In carefully selected patients, the best exit strategy would be a tubeless procedure with ureteral catheter drainage.

Which is the preferred modality of renal access for a trainee urologist: ultrasonography or fluoroscopy? Results of a prospective randomized trial.

BACKGROUND AND PURPOSE: In percutaneous nephrolithotomy (PCNL), placement of the access tract into the kidney is an important aspect of the procedure and is responsible for the steep learning curve associated with the operation. The aim of the current prospective randomized trial was to assess the duration of radiation exposure along with the safety and efficacy of PCNL done by a trainee, utilizing either ultrasonography (US) or fluoroscopic guidance to obtain access. PATIENTS AND METHODS: Sixty-four patients with ≤3 cm renal calculi undergoing single-tract PCNL by trainee urologists (experience of <25 PCNL's) were randomized into US- and fluoroscopic-guided access groups (32 in each). In Group 1 (US guided), puncture was done using a 3.5/5 MHz US probe with a puncture attachment, whereas the triangulation technique with biplanar C-arm fluoroscopy was utilized in group 2 (fluoroscopic guided). Patient demographics, stone parameters, intraoperative characteristics, fluoroscopy durations, and postoperative outcomes were analyzed. RESULTS: Both groups were comparable as far as patient and stone characteristics were concerned. The fluoroscopy exposure during the puncture phase (T2) and overall (T) was significantly lower in the US group at 9.0±20.8 vs 43.8±34.8, (p<0.0001) and 204.3±84 vs 239.9±77.5, (p=0.04). Six patients in group1 required fluoroscopic adjustment (p=0.03). All other intra- and postoperative parameters were similar in both the groups. CONCLUSION: Both ultrasound and fluoroscopic guidance for renal access are equally safe and feasible in the hands of a trainee urologist. Total fluoroscopy duration and exposure time during puncture were both significantly less in the ultrasound group. Expertise in fluoroscopic-guided access is essential for a novice to effectively achieve access in all possible situations.

Evolution of shockwave lithotripsy (SWL) technique: a 25-year single centre experience of >5000 patients.

OBJECTIVE: To assess the impact of various treatment optimisation strategies in shockwave lithotripsy (SWL) used at a single centre over the last 25 years. PATIENTS AND METHODS: In all, 5017 patients treated between 1989 and 2013 were reviewed and divided into groups A, B, C and D for the treatment periods of 1989-1994 (1561 patients), 1995-2000 (1741), 2001-2006 (1039) and 2007-2013 (676), respectively. The Sonolith 3000 (A and B) and Dornier compact delta lithotripters (C and D) were used. Refinements included frequent re-localisation, limiting maximum shocks and booster therapy in group B and Hounsfield unit estimation, power ramping and improved coupling in group D. Parameters reviewed were annual SWL utilisation, stone and treatment data, retreatment, auxiliary procedures, complications and stone-free rate (SFR). RESULTS: The SFR with Dornier compact delta was significantly higher than that of the Sonolith 3000 (P < 0.001). The SFR improved significantly from 77.58%, 81.28%, 82.58% to 88.02% in groups A, B, C, and D, respectively (P < 0.001). There was a concomitant decrease in repeat SWL (re-treatment rate: A, 48.7%; B, 33.4%; C, 15.8%; and D, 10.1%; P < 0.001) and complication rates (A, 8%; B, 6.4%; C, 4.9%; and D, 1.6%; P < 0.001). This led to a rise in the efficiency quotient (EQ) in groups A-D from 50.41, 58.94, 68.78 to 77.06 (P < 0.001).The auxiliary procedure rates were similar in all groups (P = 0.62). CONCLUSION: In conclusion, improvement in the EQ together with a concomitant decrease in complication rate can be achieved with optimum patient selection and use of various treatment optimising strategies.

Prospective randomized controlled trial comparing laser lithotripsy with pneumatic lithotripsy in miniperc for renal calculi.

BACKGROUND AND PURPOSE: The energy source used for stone fragmentation is important in miniperc. In this study, we compared the stone fragmentation characteristics and outcomes of laser lithotripsy and pneumatic lithotripsy in miniperc for renal calculi. PATIENTS AND METHODS: After Institutional Review Board approval, 60 patients undergoing miniperc for renal calculi of 15 to 30 mm were equally randomized to laser and pneumatic lithotripsy groups. Miniperc was performed using 16.5F Karl Storz miniperc sheath and a 12F nephroscope. Laser lithotripsy was performed using a 550-µm laser fiber and 30 W laser with variable settings according to the need. Pneumatic lithotripsy was performed using the EMS Swiss lithoclast. Patient demographics, stone characteristics, intraoperative parameters, and postoperative outcomes were analyzed. RESULTS: The baseline patient demographics and stone characteristics were similar in both groups. The total operative time (P = 0.433) and fragmentation time (P=0.101) were similar between the groups. The surgeon assessed that the Likert score (1 to 5) for fragmentation was similar in both groups (2.1 ± 0.8 vs 1.9 ± 0.9, P=0.313). Stone migration was lower with the laser (1.3 ± 0.5 vs 1.7 ± 0.8, P=0.043), and fragment removal was easier with the laser (1.1 ± 0.3 vs 1.7 ± 1.1, P=0.011). The need for fragment retrieval using a basket was significantly more in the pneumatic lithotripsy group (10% vs 37%, P=0.002). The hemoglobin drop, complication rates, auxiliary procedures, postoperative pain, and stone clearance rates were similar between the groups (P>0.2). CONCLUSION: Both laser lithotripsy and pneumatic lithotripsy are equally safe and efficient stone fragmentation modalities in miniperc. Laser lithotripsy is associated with lower stone migration and easier retrieval of the smaller fragments it produces.

Current role of microperc in the management of small renal calculi.

'Microperc' is a recently described technique in which percutaneous renal access and lithotripsy are performed in a single step using a 16 G micropuncture needle. 'Mini-microperc' is a further technical modification in which an 8 Fr sheath is used to allow insertion of ultrasonic or pneumatic lithoclast probe with suction. The available evidence indicates that microperc is safe and efficient in the management of small renal calculi in adult and pediatric population. It can also be used for renal calculi in ectopic kidneys and bladder calculi. The high stone clearance rate and lower complication rate associated with microperc make it a viable alternative to retrograde intrarenal surgery.

Micropercutaneous nephrolithotomy (microperc) vs retrograde intrarenal surgery for the management of small renal calculi: a randomized controlled trial.

OBJECTIVE: To compare micropercutaneous nephrolithotomy (microperc) and retrograde intrarenal surgery (RIRS) for the management of renal calculi <1.5 cm with regard to stone clearance rates and surgical characteristics, complications and postoperative recovery. PATIENTS AND METHODS: Seventy patients presenting with renal calculi <1.5 cm were equally randomized to a microperc or a RIRS group between February 2011 and August 2012 in this randomized controlled trial. Randomization was based on centralized computer-generated numbers. Patients and authors assessing the outcomes were not blinded to the procedure. Microperc was performed using a 4.85-F (16-gauge) needle with a 272-µm laser fibre. RIRS was performed using a uretero-renoscope. Variables studied were stone clearance rates, operating time, need for JJ stenting, intra-operative and postoperative complications (according to the Clavien-Dindo classification system), surgeon discomfort score, postoperative pain score, analgesic requirement and hospital stay. Stone clearance was assessed using ultrasonography and X-ray plain abdominal film of kidney, ureter and bladder at 3 months. RESULTS: There were 35 patients in each group. All the patients were included in the final analysis. The stone clearance rates in the microperc and RIRS groups were similar (97.1 vs 94.1%, P = 1.0). The mean [sd] operating time was similar between the groups (51.6 [18.5] vs 47.1 [17.5], P = 0.295). JJ stenting was required in a lower proportion of patients in the microperc group (20 vs 62.8%, P < 0.001). Intra-operative complications were a minor pelvic perforation in one patient and transient haematuria in two patients, all in the microperc group. One patient in each group required conversion to miniperc. One patient in the microperc group needed RIRS for small residual calculi 1 day after surgery. The decrease in haemoglobin was greater in the microperc group (0.96 vs 0.56 g/dL, P < 0.001). The incidence of postoperative fever (Clavien I) was similar in the two groups (8.6 vs 11.4%, P = 1.0). None of the patients in the study required blood transfusion. The mean [sd] postoperative pain score at 24 h was slightly higher in the microperc group (1.9 [1.2] vs 1.6 [0.8], P = 0.045). The mean [sd] analgesic requirement was higher in the microperc group (90 [72] vs 40 [41] mg tramadol, P < 0.001). The mean [sd] hospital stay was similar in the two groups (57 [22] vs 48 [18] h, P = 0.08). CONCLUSIONS: Microperc is a safe and effective alternative to RIRS for the management of small renal calculi and has similar stone clearance and complication rates when compared to RIRS. Microperc is associated with higher haemoglobin loss, increased pain and higher analgesic requirements, while RIRS is associated with a higher requirement for JJ stenting.

Training in percutaneous nephrolithotomy.

PURPOSE OF REVIEW: Training in percutaneous nephrolithotomy (PCNL) necessitates the trainee to climb the steep learning curve of this procedure sequentially. The initial steps of the process should be the acquisition of the necessary skills in a nonintimidating skills lab. We review the current scenario of the training in PCNL and advocate the means that may improve the overall patient care. RECENT FINDINGS: The training involves a comprehensive development of the trainee. Initial process starts with the cognitive skills update through conferences and observing peers do the procedure. Rapid prototyping could be useful for resident education. The benefits of three-dimensional stereolithographic biomodeling produced from computed tomography data may aid in achieving optimal access. Skills lab involving wet and dry lab reinforce the cognitive skills. The advantage of live anesthetized porcine model is it being a more realistic model and assessment tool. The specific advantage of the dry lab simulator is of repetitive tasking and easier setup feasibility. There is a lack of guideline for the lab setup and training. Funding, location, number of models installed, curriculum, a trained mentor, and instructor are the critical components that need to be planned in advance. SUMMARY: Training in PCNL starts with cognitive knowledge, reinforcement through repetitive nonpatient basic skills acquisition in wet and dry skills lab, prototyping the technique before the actual procedure, and finally supervised training under an able mentor.

Xanthogranulomatous pyelonephritis (XGPN) mimicking a "renal cell carcinoma with renal vein thrombus and paracaval lymphadenopathy".

We present a case of Xanthogranulomatous pyelonephritis mimicking as a renal cell carcinoma. This was an elderly lady who presented with pyonephrosis due to urolithiasis. On evaluation she was found to have a space occupying mass in the right kidney. Further investigations revealed an enhancing tumor with renal vein thrombus and paracaval lymphadenopathy. Subsequent histopathology showed evidence of XGPN with no malignancy. This case report highlights the fact there are a number of imaging and clinical overlaps in the diagnosis, assessment and management of this entity.

Treating renal calculi 1-2 cm in diameter with minipercutaneous or retrograde intrarenal surgery: a prospective comparative study.

OBJECTIVE: To plan a prospective comparative case-control designed study aiming to compare minipercutaneous (miniperc) and retrograde intrarenal surgery (RIRS) for a renal calculus of size 1-2 cm. PATIENTS AND METHODS: A total of 64 cases (32 in each arm) underwent miniperc and RIRS during the study period from March 2009 to April 2011. The primary and secondary outcome objective was stone-free rate and retreatment rate, complications, operation duration, patient visual pain scores, analgesic requirement, haemoglobin drop and hospital stay, respectively. RESULTS: Miniperc and RIRS had stone clearance rates of 100% and 96.88%, respectively. In the RIRS group, one patient required retreatment at 1 month. Hospital stay (0.24) and intra-operative (0.99) and postoperative complications (0.60) were similar in both groups. Operation duration (P = 0.003) was lower in the miniperc group. Haemoglobin drop (P < 0.001), patient pain and visual analogue scale score (each P < 0.001) at 6, 24 and 48 h, as well as analgesic requirement (P < 0.003), were all lower in the RIRS group. CONCLUSIONS: The stone clearances in both modalities are high and complications are low. RIRS requires a larger operation duration, although it is associated with favourable pain scores and a lower haemoglobin drop.

Shrapnel injury due to a firecracker causing gastric and gallbladder perforation.

A 14-year-old boy presented with a penetrating injury to the abdomen after trying to light a firecracker. A piece of metal from the tin box in which he had ignited the firecracker had penetrated his abdomen. The patient, who was in a state of shock, underwent ultrasonography (USG) and radiography of the abdomen. USG revealed free fluid in the abdomen, while abdominal radiographs demonstrated free gas and a radiopaque object. Exploration revealed gastric and gallbladder perforations for which repair and cholecystectomy were done, respectively. Visceral injury following a firecracker explosion has not been reported previously. We would like to stress the importance of parental supervision to prevent irresponsible use of firecrackers, which can cause potentially life-threatening visceral injuries.

Giant hepatic hydatid cyst with sub-fascial extension treated by open minimally invasive surgery: a case report.

INTRODUCTION: Hepatic hydatid disease can be successfully treated by a variety of modalities. CASE PRESENTATION: We report a case of a 60 year old male with giant hepatic hydatid disease who presented with a huge cystic mass in the upper abdomen. Diagnosis was confirmed by serology, ultrasonography and CT scan. The patient was treated successfully by open minimally invasive surgery with minimum breaching of the peritoneal cavity using a laparoscopic trocar to evacuate the cyst. CONCLUSION: The use of a laparoscopic trocar through a small abdominal incision in selected patients with hepatic hydatid disease with subfascial extension can be a safe, minimally-invasive option of treatment.