Volume 10, Issue 1
Review Article / Published: July 2022
О. Gatsev, V. Todorova, K. Hristov, P. Petrov, K.Petkova, I.Saltirov
Department of Urology and Nephrology, Military Medical Academy, Sofia, Bulgaria
Introduction: Anatomical features of the lower pole calyces plays an important role in the treatment of urolithiasis. The optimal treatment options for lower pole stones with a diameter below 2 cm are controversially discussed. Extracorporeal shock wave lithotripsy (SWL) is non-invasive but is hampered by low stone-free rates and a significant retreatment rate in patients with unfavorable factors for lithotripsy. Retrograde intrarenal surgery (RIRS) has been demonstrated to have high stone-free rates since the development of modern flexible endoscopes. But the long operative time in the case of a large stone burden, unfavorable anatomy, and considerable costs for consumables represent limiting factors for this technique. With the miniaturization of the percutaneous approach and decreasing the morbidity, minimally invasive percutaneous nephrolithotomy (mini-PCNL) is a promising method for the treatment of lower pole stones in one stage procedure. The objective of this study is to investigate the efficacy and safety of mini-PCNL for the treatment of lower pole stones 1-2 cm.
Material and methods: The medical records of 54 patients with lower pole kidney stones 1-2 cm, treated at the Clinic of Endourology and SWL, Military Medical Academy, Sofia between January 2020 to January 2022, were retrospectively reviewed. All patients underwent mini-PCNL under spinal anesthesia in a prone position with fluoroscopic guidance through 18 Fr sheath using a semirigid nephroscope and Ho: YAG laser for lithotripsy. The stone-free rate was defined as the absence of residual fragments ≥2 mm. Data on patients’ preoperative characteristics, stone-free rates, operating times, and intra- and postoperative complications were analyzed.
Results: Patients’ mean age was 54,68±11,99 years. The mean stone surface was 169,02±57,40mm2 and the mean CT stone density was 1112,26±250,47 HU. Stone-free rate after a single procedure was 96,3 % (52 patients). 14,8% of patients had preoperative urinary tract infections. The mean operative time was 27,46±12,40 min and the mean hospital stay – 2,5±1,17 days. The mean Hgb drop was 11.9±15.6 g/l. Lower pole puncture was performed in all patients. Two tracts were required in 1 (1,9 %) patient. One patient had an intraoperative hemorrhage at the end of the procedure. Postoperative complications were observed in 2 (3,8 %) patients: postoperative fever t >38.5o C in 1 patient (1,9%) and postoperative AV-fistula in 1 (1,9%) patient, who needed hemotransfusion and selective embolization. 2 patients required auxiliary procedures: 1 patient needed stent JJ and 1 underwent ureteroscopy for fragments in ureter.
Conclusion: Various factors are important for the management of lower pole kidney stones and should be taken into consideration when choosing the optimal treatment modality. The results from this study suggest that mini-PCNL is an effective and safe procedure with high stone-free rates and low complication rates in patients with lower pole kidney stones unfavorable for SWL and RIRS.
Results: The comparative analysis of the preoperative characteristics of both groups did not reveal significant statistical differences. There were comparatively similar indicators for surgical intervention and regional anesthesia in both groups. Both anesthesia techniques showed a safety profile with hemodynamic stability, without additional medicine administration and lack of early post-anesthesia complications. The pain did not occur during insertion and moving the US probe into the anal canal and puncturing the perineal skin and the underlying tissues. 50% (3) of the patients in Group 2 had pain during the puncture of the prostate gland and biopsy extraction, while in Group 1 – 0% (0) of the patients reported the presence of pain. There was a slightly delayed onset of the first postoperative pain in Group 1 – 113.17 ± 15.11 min. compared to Group 2 – 99.83 ± 11.51 min. Conclusion: The saddle block anesthesia with 20 mg prilocaine hydrochloride 2% hyperbaric solution in combination with intravenous fentanyl at a dose of 1 mcg/kg is a safe anesthesia technique, associated with an excellent analgesic profile, low incidence of anesthesia-related complications and rapid recovery in patients undergoing MRI/US-TPB.
- Trinchieri ACG et al (2003) Epidemiology. Stone disease. Health Publications, Paris
- A. Skolarikos, A. Neisius, A. Petřík, members of the EAU Guidelines on Urolithiasis Panel. EAU Guidelines on urolithiasis. Available at: https://uroweb.org/guidelines/urolithiasis. Accessed 01 August 2022.
- Perlmutter AE, Talug C, Tarry WF, Zaslau S, Mohseni H, Kandzari SJ. Impact of stone location on success rates of endoscopic lithotripsy for nephrolithiasis. Urology. 2008 Feb;71(2):214-7. doi: 10.1016/j.urology.2007.09.023. PMID: 18308086.
- Jackman SV, Docimo SG, Cadeddu JA, Bishoff JT, Kavoussi LR, Jarrett TW. The „mini-perc“ technique: a less invasive alternative to percutaneous nephrolithotomy. World J Urol. 1998;16(6):371- 4. doi: 10.1007/s003450050083. PMID: 9870281.
- Monga M, Oglevie S. Minipercutaneous nephrolithotomy. J Endourol. 2000 Jun;14(5):419-21. doi: 10.1089/end.2000.14.419. PMID: 10958563.
- Zhang W, Zhou T, Wu T, Gao X, Peng Y, Xu C, Chen Q, Song R, Sun Y. Retrograde Intrarenal Surgery Versus Percutaneous Nephrolithotomy Versus Extracorporeal Shockwave Lithotripsy for Treatment of Lower Pole Renal Stones: A Meta-Analysis and Systematic Review. J Endourol. 2015 Jul;29(7):745-59. doi: 10.1089/ end.2014.0799. Epub 2015 Feb 5. PMID: 25531986.
- Ruhayel Y, Tepeler A, Dabestani S, MacLennan S, Petřík A, Sarica K, Seitz C, Skolarikos A, Straub M, Türk C, Yuan Y, Knoll T. Tract Sizes in Miniaturized Percutaneous Nephrolithotomy: A Systematic Review from the European Association of Urology Urolithiasis Guidelines Panel. Eur Urol. 2017 Aug;72(2):220-235. doi: 10.1016/j. eururo.2017.01.046. Epub 2017 Feb 23. PMID: 28237786.
- Breda A, Ogunyemi O, Leppert JT, Schulam PG. Flexible ureteroscopy and laser lithotripsy for multiple unilateral intrarenal stones. Eur Urol. 2009 May;55(5):1190-6. doi: 10.1016/j.eururo.2008.06.019. Epub 2008 Jun 13. PMID: 18571315.
- Earle MS, Lingeman JE, Leveillee R, Kuo R, Preminger GM, Nadler RB, Macaluso J, Monga M, Kumar U, Dushinski J, Albala DM, Wolf JS Jr, Assimos D, Fabrizio M, Munch LC, Nakada SY, Auge B, Honey J, Ogan K, Pattaras J, McDougall EM, Averch TD, Turk T, Pietrow P, Watkins S. Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. J Urol. 2005 Jun;173(6):2005-9. doi: 10.1097/01. ju.0000158458.51706.56. PMID: 15879805.
- Traxer O. Flexible ureterorenoscopic management of lower-pole stone: does the scope make the difference? J Endourol. 2008 Sep;22(9):1847-50; discussion 1855. doi: 10.1089/end.2008.9792. PMID: 18811464.
- Yuri P, Hariwibowo R, Soeroharjo I, Danarto R, Hendri AZ, Brodjonegoro SR, Rasyid N, Birowo P, Widyahening IS. Meta-analysis of Optimal Management of Lower Pole Stone of 10 – 20 mm: Flexible Ureteroscopy (FURS) versus Extracorporeal Shock Wave Lithotripsy (ESWL) versus Percutaneus Nephrolithotomy (PCNL). Acta Med Indones. 2018 Jan;50(1):18-25. PMID: 29686172.
- De la Rosette J, Assimos D, Desai M et al (2011) The clinical research office of the еndourological society percutaneous nephrolithotomy global study: indications, цomplications, and outcomes in 5803 patients. J Endourol 25(1):11–17. https://doi. org/10.1089/end.2010.0424
- Nagele U, Schilling D, Sievert KD, Stenzl A, Kuczyk M. Management of lower-pole stones of 0.8 to 1.5 cm maximal diameter by the minimally invasive percutaneous approach. J Endourol. 2008 Sep;22(9):1851-3; discussion 1857. doi: 10.1089/end.2008.9791. PMID: 18811465.
- Osman M, Wendt-Nordahl G, Heger K, Michel MS, Alken P, Knoll T. Percutaneous nephrolithotomy with ultrasonography-guided renal access: experience from over 300 cases. BJU Int. 2005 Oct;96(6):875-8. doi: 10.1111/j.1464-410X.2005.05749.x. PMID: 16153221.
- Srisubat A, Potisat S, Lojanapiwat B, Setthawong V, Laopaiboon M. Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD007044. doi: 10.1002/14651858.CD007044.pub2. Update in: Cochrane Database Syst Rev. 2014;11:CD007044. PMID: 19821393.
- Mishra S, Sharma R, Garg C, Kurien A, Sabnis R, Desai M. Prospective comparative study of miniperc and standard PNL for treatment of 1 to 2 cm size renal stone. BJU Int. 2011 Sep;108(6):896- 9; discussion 899-900. doi: 10.1111/j.1464-410X.2010.09936.x. Epub 2011 Apr 8. PMID: 21477212.
- Elbahnasy AM, Shalhav AL, Hoenig DM, Elashry OM, Smith DS, McDougall EM, Clayman RV. Lower caliceal stone clearance after shock wave lithotripsy or ureteroscopy: the impact of lower pole radiographic anatomy. J Urol. 1998 Mar;159(3):676-82. PMID: 9474124.
- Inoue T, Murota T, Okada S, Hamamoto S, Muguruma K, Kinoshita H, Matsuda T; SMART Study Group. Influence of Pelvicaliceal Anatomy on Stone Clearance After Flexible Ureteroscopy and Holmium Laser Lithotripsy for Large Renal Stones. J Endourol. 2015 Sep;29(9):998-1005. doi: 10.1089/end.2015.0071. Epub 2015 May 15. PMID: 25879676.
- Davidoff K, Popov E, Zlatanov D, Roglev A, Popov A, Stoyanov N. Pediatric extracorporeal shock wave lithotripsy: Efficacy, morbidity and procedure parameters compared to ESWL in adults. Eur Urol Suppl 2017; 16(7):e2550
- Davis NF, Quinlan MR, Poyet C, Lawrentschuk N, Bolton DM, Webb D, Jack GS. Miniaturised percutaneous nephrolithotomy versus flexible ureterorenoscopy: a systematic review and meta-analysis comparing clinical efficacy and safety profile. World J Urol. 2018 Jul;36(7):1127-1138. doi: 10.1007/s00345-018-2230-x. Epub 2018 Feb 16. PMID: 29450733.Kumar A, Kumar N, Vasudeva P,
- Kumar Jha S, Kumar R, Singh H. A prospective, randomized comparison of shock wave lithotripsy, retrograde intrarenal surgery and miniperc for treatment of 1 to 2 cm radiolucent lower calyceal renal calculi: a single center experience. J Urol. 2015 Jan;193(1):160-4. doi: 10.1016/j. juro.2014.07.088. Epub 2014 Jul 24. PMID: 25066869.
- Kruck S, Anastasiadis AG, Herrmann TR, Walcher U, Abdelhafez MF, Nicklas AP, Hölzle L, Schilling D, Bedke J, Stenzl A, Nagele U. Minimally invasive percutaneous nephrolithotomy: an alternative to retrograde intrarenal surgery and shockwave lithotripsy. World J Urol. 2013 Dec;31(6):1555-61. doi: 10.1007/s00345-012- 0962-6. Epub 2012 Oct 11. PMID: 23064981.
- Akbulut F, Kucuktopcu O, Kandemir E, Sonmezay E, Simsek A, Ozgor F, Binbay M, Muslumanoglu AY, Gurbuz G. Comparison of flexible ureterorenoscopy and mini-percutaneous nephrolithotomy in treatment of lower calyceal stones smaller than 2 cm. Ren Fail. 2016;38(1):163-7. doi: 10.3109/0886022X.2015.1128792. Epub 2016 Jan 4. PMID: 26727075.
- Гъцев О, Христофоров С, Петров П, Петрова Д, Петкова К, Салтиров И. Сравнително проучване на минимално- инвазивната перкутанна нефролитотрипсия със стандартен и модифициран аспирационен шафт за достъп. Ендоурология и минимално инвазивна хирургия. 2018; 6(2): 11-18.
- Гъцев О, Христофоров С, Петров П, Петкова К, Петрова Д, Салтиров И. Сравнително проучване на минимално- инвазивна и стандартна перкутанна нефролитотрипсия при лечението на бъбречни камъни с размер 20 до 40 mm в диаметър. Ендоурология и минимално инвазивна хирургия. 2019; 7(1): 17-24.
- Abd El-Wahed М, Shouman АМ, Мosharafa A, Morsy AM. Minimally Invasive Percutaneous Nephrolithotomy in Management of Lower Pole Renal Stones 2cm or Less. Med J Cairo Univ, 2018; 86(8): 4525-4529. doi: 10.21608/mjcu.2018.63154
minimally invasive nephrolithotomy, lower pole kidney, urolithiasis
How to cite this article:
Gatsev О, Todorova V, Hristov K, Petrov P, Petkova K, Saltirov I. Efficacy and safety of minimally invasive percutaneous nephrolithotomy in patients with lower pole kidney stones 1-2 cm in diameter. Journal of Endourology and Minimally Invasive Surgery (Bulgaria), 2022; 10(1):25-32
Dr. Ognyan Gatsev
Department of Urology and Nephrology; Military Medical Academy Sofia
Address: Blvd“ Georgi Sofiiski” 6; Sofia-1606, Bulgaria
E-mail: gatsev @ gmail.com