Holmium:yttrium-aluminium-garnet laser with MOSES technology is more efficient than thulium fibre laser in supine mini-percutaneous nephrolithotomy.

OBJECTIVES: To address the paucity of literature comparing outcomes achieved with utilisation of the high-power holmium:yttrium-aluminium-garnet (Ho:YAG) laser with MOSES technology vs those achieved with the thulium fibre laser (TFL) in mini-percutaneous nephrolithotomy (PCNL). METHODS: A retrospective review was performed of patients undergoing supine mini-PCNL between August 2021 and May 2023. Exclusion criteria were urinary diversion, simultaneous utilisation of >1 laser platform, use of any other form of fragmentation, and ureteric stones. The Ho:YAG platform (Lumenis Pulse P120H™ with MOSES technology, 120W; Boston Scientific®) and the TFL (Soltive SuperPulsed Thulium Fibre [SPTF], 60W; Olympus®) were compared. Data on stone-free rate (SFR) were determined by computed tomography performed on the first postoperative day and presented as absence of stone fragments, no fragments larger than 2 mm, or no fragments larger than 4 mm. RESULTS: A total of 100 patients met the inclusion criteria, 51 mini-PCNLs with the Ho:YAG laser and 49 with the SPTF laser. No significant differences in demographics or stone characteristics were detected between the two groups. The Ho:YAG laser utilised less energy and time, resulting in higher ablation efficiency (P < 0.05) and less total operating time (P < 0.05). Overall, there was no difference in SFR in any category between the Ho:YAG group and the SPTF group (no fragments: relative risk [RR] 0.81, 95% confidence interval [CI] 0.59-1.12, P = 0.21; fragments <2 mm: RR 0.86, 95% CI 0.67-1.10, P = 0.23; fragments <4 mm: RR 0.96, 95% CI 0.80-1.15, P = 0.67). CONCLUSIONS: Although we observed an equivalent postoperative SFR, this study supports a shorter operating time and greater intra-operative laser efficiency with the Ho:YAG laser over the SPTF laser in mini-PCNL.

Extracorporeal shock wave lithotripsy, ureterolithotripsy, and percutaneous nephrolithotripsy challenges in managing spinal cord neuropathy patients. Lessons learned from a scoping review.

Introduction: We aim to review the outcomes of shock wave lithotripsy (SWL), ureteroscopy, and percutaneous nephrolithotripsy (PCNL) for renal and ureteral stones in spinal cord neuropathy patients (SNP). Material and methods: A literature search was performed on 8th March 2023 using PubMed, EMBASE, and Google Scholar with no date limit. Preclinical/animal studies, reviews, letters to the editor, case reports, and meeting abstracts were excluded. Only English papers were accepted. Results: Thirty-five articles were accepted. Five studies focused on SWL, 17 on PCNL, and 6 on ureteroscopy. The remaining articles employed more than one procedure. Stone composition has shifted from struvite to the more common calcium phosphate. SWL showed a very poor stone-free rate (SFR) likely due to challenges in patient positioning, stone visualization, localization, and inability to pass fragments spontaneously. Flexible ureteroscopy and PCNL were associated with a high incidence of infectious complications, long hospital stays, high blood transfusion rate, and intensive care admissions. There were also cases of death. Both procedures were challenging due to genitourinary reconstruction, scoliosis and kyphosis, rib-cage deformity, lower limb contractures, and severe comorbidity which also affected anesthesia. SFR was lower than in non-neurological patients. Conclusions: SWL, ureterolithotripsy, and PCNL should be considered challenging procedures in SNP due to positioning issues, an increased risk of intra and peri-operative morbidity, and even mortality. Computed tomography should be recommended to assess residual fragments as it becomes imperative to minimize a re-intervention in SNP who should be preferably treated in referral centers.

Risk factors of high fluid absorption in patients treated with mini-PCNL: a single-center prospective study.

BACKGROUND: The factors influencing fluid absorption in mini-percutaneous nephrolithotripsy (mini-PCNL) are still unknown. We aim to investigate the factors that influence irrigation fluid absorption during mini-PCNL. METHODS: A total of 94 patients who underwent mini-PCNL were included in this prospective study. The endoscopic surgical monitoring system (ESMS) was used to measure the volume of irrigation fluid absorbed during the procedure. Irrigating time, the total volume of irrigation fluid, stone size, S.T.O.N.E. score, hemoglobin, electrolyte levels, and postoperative complications were recorded. RESULTS: A significant correlation was observed between fluid absorption and the presence of postoperative fever, and based on this phenomenon, patients were divided into low and high fluid absorption groups. The serum creatinine level in the high fluid absorption group was significantly high (7 vs. 16.5, p = 0.02). Significant differences were observed between the low and high fluid absorption groups in terms of mean stone size (21.70 mm vs. 26.78 mm), presence of stone burden ≥ 800 mm2 (4% vs. 23%), S.T.O.N.E. score > 8 (4% vs. 38%), the fluid used > 18,596 ml (19% vs. 78%), irrigation time (55.61 min vs. 91.28 min), and perfusion rate (24% vs. 45%) (all p < 0.05). The rates of postoperative fever and SIRS in the high fluid absorption group were significantly high (p < 0.05). CONCLUSIONS: Mean stone size, presence of stone burden ≥ 800 mm2, S.T.O.N.E. score > 8, the fluid used > 18596 mL, irrigation time, and perfusion rate are risk factors of intraoperative fluid absorption in mini-PCNL.

Learning curve of ultrasound-guided percutaneous nephrolithotripsy in the treatment of complex renal calculi.

OBJECTIVE: This study was performed to investigate the learning curve of ultrasound-guided percutaneous nephrolithotripsy (PCNL) for the treatment of complex renal calculi. METHODS: Seventy-two patients with complex renal stones who underwent ultrasound-guided PCNL by the same operator from November 2016 to September 2020 were retrospectively analyzed. The learning curve of PCNL for complex renal stones was analyzed using multifactorial cumulative sum (CUSUM) analysis and best-fit curves. RESULTS: The CUSUM best-fit curve peaked at Case 36, which represented the minimum number of cumulative cases required to cross the learning curve for this surgical procedure. Accordingly, the learning curve was divided into a learning improvement period (36 cases) and a proficiency phase (36 cases). Compared with the learning improvement period, the proficiency phase was characterized by a shorter puncture time and operation time, a smaller drop in the hemoglobin level, and a lower postoperative complication rate. CONCLUSION: The learning curve of PCNL for the treatment of complex renal calculi can be divided into a learning improvement period and a proficiency phase, and the minimum cumulative number of cases is 36.

A case of bleeding shock induced by injury of the intercostal artery following percutaneous nephrolithotripsy.

Introduction: The risk of postoperative bleeding complications should be concerned to perform percutaneous nephrolithotripsy. Most of the vascular injuries occurred at the peripheral renal artery in the previous reports. We experienced a case of bleeding shock induced by the injury of the intercostal artery in the abdominal wall following percutaneous nephrolithotripsy. Case presentation: A 56-year-old woman had been in the bleeding shock status on the 2nd day after percutaneous nephrolithotoripsy. Emergently, contrast-enhanced computed tomography was performed and extravasation of contrast agents was seen in the abdominal wall. Injuries of the intercostal artery were identified in the angiography and controlled by transcatheter arterial embolization. Conclusion: The intercostal arteries could be injured in the anterolateral zone of the abdominal wall over the end of the ribs. Contrast-enhanced computed tomography was useful to detect the bleeding point. Transcatheter arterial embolization was an effective and safe method to control bleedings from them.

Radiation protection measures during endourological therapies.

Objective: The objective of this narrative review was to search the existing literature for studies reporting measures to minimize radiation use during endoscopic management of stone disease and present ways of reducing the exposure of both patients and operating room staff. Methods: A literature review in PubMed was performed to identify studies describing protocols or measures to reduce radiation received during endourological procedures from January 1970 to August 2022. Eligible studies were those that reported outcomes for ureteroscopy or percutaneous nephrolithotripsy regarding measures to minimize radiation doses used intraoperatively, performed either in real-life theatres or using phantoms. Both comparative and non-comparative studies were deemed eligible. Results: Protection can be achieved initially at the level of diagnosis and follow-up of patients, which should be done following an algorithm and choice of more conservative imaging methods. Certain protocols, which follow principles for minimized fluoroscopy use should be implemented and urologists as well as operating room staff should be continuously trained regarding radiation damage and protection measures. Wearing protective lead equipment remains a cornerstone for personnel protection, while configuration of the operating room and adjusting X-ray machine settings can also significantly reduce radiation energy. Conclusion: There are specific measures, which can be implemented to reduce radiation exposure. These include avoiding excessive use of computed tomography scans and X-rays during diagnosis and follow-up of urolithiasis patients. Intraoperative protocols with minimal fluoroscopy use can be employed. Staff training regarding dangers of radiation plays also a major role. Use and maintenance of protective equipment and setting up the operating room properly also serve towards this goal. Machine settings can be customized appropriately and finally continuously monitoring of exposure with dosimeters can be adopted.

[The use of laser doppler flowmetry to assess the microcirculation of the kidney before and after percutaneous nephrolithotomy].

AIM: To evaluate intraoperative changes in renal microcirculation during percutaneous nephrolithotomy (PCNL), as well as its dynamics in the early postoperative period. MATERIALS AND METHODS: A total of 240 patients treated in the Urology Clinic of the Saratov State Medical University in 2021-2022 were included in the study. All patients underwent PCNL. In the first group (n=105) the standard PCNL through 30 Ch access was done. In the second group (n=135), the procedure was performed through an access of 16 Ch. Intraoperatively, intrapelvic pressure was evaluated according to the authors method, which consists in direct measurement in the collecting system during the procedure, allowing for a faster and more accurate assessment. Prior to surgery, Doppler mapping of the renal blood flow was performed, and indirect registration of the microcirculation index (MCI) was done directly on the operating table using laser Doppler flowmetry (LDF). The diagnostic study was performed at the point of intersection of the 12th rib and the psoas muscle, both on the ipsilateral and contralateral side. In addition, during the procedure, a registration of MI of the mucosa of the calyceal fornix accessible in the direct vision through the access tract for 4 minutes was carried out twice. RESULTS: The index of microcirculation (IM) in the fornix of the upper calyx before the fragmentation of the stone in the 1st group of patients was 26.67+/-4.7 pf.u. compared to 25.4+/-5.9 pf.u. in the second group. At the same time, the value recorded on the skin was 13.08+/-1.2 pf.u. in the first group compared to 13.1+/-0.77 pf.u. in the second group (p>0.05). During the initial registration, the PM immediately after stone fragmentation was 19.5 +/- 1.2 pf.u, while on the overlying skin it was 11.2 +/- 0.9 pf.u. In the contralateral kidney area, IM was 10.2+/-0.9 pf.u. In the case of an intraoperative increase in intrapelvic pressure, IM was 22.3+/-1.6 pf.u. compared to 12.1+/-0.7 pf.u on the skin. The dynamics of IM on the skin tended to further decrease and returned to normal values of 10.3 +/- 0.7 pf.u on the 3rd day. When intraoperative intrapelvic pressure exceeded the normal value, IM by the 5th day was 10.1+/-0.4 pf.u. When determining the correlation of IM with RI of the ipsilateral kidney, a direct moderate correlation was revealed (r=+0.516). CONCLUSION: The measurement of microcirculation in the intra- and postoperative period allows to assess changes in the intrarenal microcirculation both directly and indirectly. This method can be used as an additional tool for assessing obstructive changes and the activity of pyelonephritis. A significant correlation between IM and RI indicates that functional changes in the renal and skin microcirculation tend to develop simultaneously.

Effect of target-controlled pressure-controlled ventilation on percutaneous nephrolithotripsy patients under general anesthesia: a retrospective study.

Background: Prone position surgery tends to limit chest wall mobility with decreased compliance and increased airway pressure, which can increase the incidence of postoperative pulmonary complications, including atelectasis, pneumonia, and respiratory failure. There is a lack of guidelines recommending mechanical ventilation parameters in prone position surgery. The present study aimed to investigate the effect of pressure-controlled ventilation (PCV) with end-inspiratory flow rate as the target on percutaneous nephrolithotripsy patients under general anesthesia in the prone position. Methods: From January 2020 to December 2021, a total of 154 patients admitted to Sichuan Provincial Rehabilitation Hospital of Chengdu University of TCM were retrospectively enrolled. All patients received percutaneous nephrolithotripsy. According to the type of mechanical ventilation given during surgery, the patients were divided into a fixed-respiration-ratio-PCV group (n=78) and a target-controlled-PCV group (n=76). The hemodynamics, postoperative pulmonary complications (PPCs), and serum inflammation levels between the two groups were compared. Results: The overall incidence of PPCs was significantly lower in the target-controlled-PCV group than in the fixed-respiration-ratio-PCV group (3.95% vs. 14.10%, P=0.028). There were no significant differences in peak airway pressure, airway plateau pressure, or dynamic lung compliance at T0 (P>0.05). However, at T1, T2, and T3, the peak airway pressure and airway platform pressure in the target-controlled-PCV group were significantly reduced (P<0.05), and the dynamic pulmonary compliance was significantly increased (P<0.05) compared with the fixed-respiration-ratio group. There was no significant difference in preoperative interleukin 6 (IL-6) and C-reactive protein (CRP) levels between the two groups (P>0.05). IL-6 and CRP levels at 1 and 3 days postoperatively were significantly reduced in the target-controlled-PCV group compared with the fixed-respiration-ratio-PCV group (P<0.05). Conclusions: Pressure-controlled ventilation with end-inspiratory flow rate as the target can reduce postoperative pulmonary complications and inflammatory levels in patients undergoing percutaneous nephrolithotripsy under general anesthesia in the prone position.

Progress in the study of biomarkers for early prediction of systemic inflammatory response syndrome after percutaneous nephrolithotomy.

Urolithiasis is a common and frequent disease in urology. Percutaneous nephrolithotomy (PCNL) is preferred for the treatment of upper urinary tract stones and complicated renal stones >2 cm in diameter, but it has a higher rate of postoperative complications, especially infection, compared with other minimally invasive treatments for urinary stones. Complications associated with infection after percutaneous nephrolithotomy include transient fever, systemic inflammatory response syndrome (SIRS), and sepsis, which is considered one of the most common causes of perioperative death after percutaneous nephrolithotomy. In contrast, SIRS serves as a sentinel for sepsis, so early intervention of SIRS by biomarker identification can reduce the incidence of postoperative sepsis, which in turn reduces the length of stay and hospital costs for patients. In this paper, we summarize traditional inflammatory indicators, novel inflammatory indicators, composite inflammatory indicators and other biomarkers for early identification of systemic inflammatory response syndrome after percutaneous nephrolithotomy.

Pediatric cystine stone successfully treated by mini-percutaneous nephrolithotripsy and antegrade ureteroscopy.

Introduction: Cystinuria is often diagnosed by large renal stone for pediatric patients. The patients suffer from recurrence of stone disease, develop the chronic kidney disease and fall into end-stage renal failure. Total removal of stone at the first intervention and prevention of recurrence are essential. Although, it is difficult to treat the pediatric stone patients for their anatomical feature. Case presentation: We report three cases of pediatric cystine stone patients (two 4-year-old boys and a 9-year-old girl) successfully treated by mini-percutaneous nephrolithotripsy and antegrade ureteroscopy. We could remove stones completely in all three cases, and the patients did not suffer from major complications. Conclusion: It is essential to select the surgical approach, the endourological device, and the patient's position which is suitable for the age, the body size, and the condition of stones at the initial intervention of pediatric cystine stone.

Assessment of single-probe dual-energy lithotripters in percutaneous nephrolithotomy: a systematic review and meta-analysis of preclinical and clinical studies.

PURPOSE: To evaluate the safety and efficacy of single-probe dual-energy (SPDE) lithotripters in patients undergoing percutaneous nephrolithotripsy (PCNL) through a systematic review and meta-analysis. METHODS: We searched PubMed, Cochrane Library, Scopus and Embase databases until July 2022 for any preclinical or clinical studies, exploring the safety and efficacy of different SPDE lithotripters in patients undergoing PCNL. We performed a meta-analysis to compare stone-free rate, bleeding, or other complications and mean operative time between SPDE lithotripters and other lithotripters (PROSPERO: CRD42021285631). RESULTS: We included 16 studies (six preclinical, seven observational and three randomized with 625 participants) in the systematic review and four in the meta-analysis. Preclinical studies suggest that SPDE lithotripters are safe and effective for the management of renal stones. Among clinical studies, four studies assessed Trilogy with no comparative arm, two compared Trilogy or ShockPulse with a dual-probe dual-energy lithotripter, two compared Trilogy with a laser, one compared ShockPulse with a pneumatic lithotripter, and one directly compared Trilogy with ShockPulse. Comparing SPDE lithotripters to other lithotripters, no significant differences were demonstrated in stone free rate (OR 1.13, 95% CI 0.53-2.38, I2 = 0%), postoperative blood transfusion (OR 1.33, 95% CI 0.34-5.19, I2 = 0%), embolization (OR 0.45, 95% CI 0.02-12.06), operative time (WMD: 2.82 min, 95% CI -7.31-12.95, I2 = 78%) and postoperative complications based on the Clavien-Dindo classification. CONCLUSIONS: SPDE lithotripters represent a promising treatment modality for patients requiring PCNL. Despite the initial encouraging findings of preclinical and isolated clinical studies, it seems that Trilogy or ShockPulse provide similar efficiency compared to older generation devices.

Abdominal compartment syndrome after endoscopic combined intrarenal surgery.

Introduction: We report a case of abdominal compartment syndrome due to hydroperitoneum after endoscopic combined intrarenal surgery. Case presentation: A 56-year-old woman with a left staghorn calculus underwent endoscopic combined intrarenal surgery as a two-staged procedure and developed a distended abdomen, cyanosis of both legs, and hypotension immediately after the second operation. A computed tomography scan showed hydroperitoneum. We performed urgent laparotomy and evacuated approximately 2 L of nearly transparent fluid. No peritoneal injury was detected. Postoperatively, she required intensive care for shocked liver and acute kidney injury. Conclusion: Hydroperitoneum after endoscopic combined intrarenal surgery is a rare complication and may lead to abdominal compartment syndrome or a condition where intra-abdominal pressure exceeds 20 mmHg, causing impaired organ perfusion. Delayed drainage can be fatal.

Endoscopic combined intrarenal surgery for renal allograft lithiasis using "sheath-connection technique": A case report.

A 66-year-old man was diagnosed with renal allograft lithiasis. Although retrograde intrarenal surgery was attempted, a ureteral access sheath (UAS) was difficult to insert. Subsequently, we planned the endoscopic combined intrarenal surgery (ECIRS) using the "Sheath-connection technique." We indwelled the two UAS anterogradely and retrogradely, unified them at the bladder and the junction of the two UAS was passed through the ureterovesical junction. We successfully performed ECIRS.

Post-operative pain following percutaneous nephrolithotripsy- clinical correlates.

OBJECTIVES: Management of postoperative pain following percutaneous nephrolithotripsy (PCNL) is a significant goal. We sought to identify risk factors and clinical correlates of postoperative pain in order to improve perioperative management and patient satisfaction. MATERIALS AND METHODS: A single-center, retrospective analysis, from a prospectively maintained database, of all consecutive patients who underwent PCNL for renal calculi between January 2011 and August 2018. Postoperative pain was assessed using the visual analog scale (VAS) and analgesic use. We considered VAS score above 4 as meaningful. Pain management was standardized according to patirnt reported VAS scores. Multivariable logistic regression was performed to identify risk factors and clinical correlates. RESULTS: A total of 496 patients were analyzed. Younger age was associated with VAS above 4 on the operative day and the first postoperative following PCNL (p = 0.003 and p < 0.001, respectively). Female gender was associated with VAS above 4 in the first 2 days following the operation (p < 0.001). CONCLUSIONS: Younger age and female gender would most likely benefit from pre-emptive improved pain management protocols following PCNL.

Efficacy and safety of transurethral flexible ureteroscopy combined with single channel minimally invasive percutaneous nephroscopy in the treatment of complex renal calculi / 国际外科学杂志

Objective:To investigate the clinical efficacy and safety of transurethral flexible ureteroscopy combined with single channel minimally invasive percutaneous nephroscopy in the treatment of complex renal calculi.Methods:A total of 72 patients with complex renal calculi admitted to Beijing Friendship Hospital, Capital Medical University from November 2019 to April 2022 were prospective selected, which were randomly divided into study group and control group by the random number table method, with 36 cases in each group. The control group underwent single channel minimally invasive percutaneous nephrolithotomy, while the study group underwent transurethral flexible ureteroscopy combined with single channel minimally invasive percutaneous nephrolithotomy. The perioperative indexes (operation time, postoperative hospital stay, intraoperative blood loss), stone removal effect, renal function indicators [blood urea nitrogen (BUN), serum creatinine (SCr)] and complication rate were compared between the two groups. Measurement data were expressed as mean ± standard deviation ( ± s), and t-test was used for inter-group comparison. The Chi-square test or Fisher exact probability method were used to compare the count data of two groups. Results:The operation time [(101.05±11.34) min vs (107.84±10.28) min] and postoperative hospital stay [(8.54±3.15) d vs (12.36±4.08) d] in the study group were significantly shorter than those in the control group, and the difference were statistically significant ( P<0.05). The amount of intraoperative bleeding was close to that in the control group, but the difference was not statistically significant ( P>0.05). The primary stone clearance rate and summary stone clearance rate in the study group were 91.67% (33/36) and 100.0% (36/36), respectively, which were significantly higher than 69.44% (25/36) and 83.33% (30/36) in the control group, and the differences were statistically significant ( P<0.05). The postoperative BUN and SCr levels in the study group were (5.24±0.31) mmol/L and (90.65±25.57) μmol/L, respectively, the control group was (7.69±0.78) mmol/L and (131.96±37.80) μmol/L, respectively. BUN and SCr levels in the study group were significantly lower than those in the control group, and the differences were statistically significant ( P<0.05). The total incidence of postoperative complications in the study group was significantly lower than that in the control group (5.56% vs 16.67%), and the difference was statistically significant ( P<0.05). Conclusion:Transurethral flexible ureteroscopy combined with single channel minimally invasive percutaneous nephroscopy is an ideal method for the treatment of complex renal calculi, which has good removal effect, less complications and helps to improve renal function.

[Roadmap of ultrasound-guided percutaneous access to the renal collecting system].

INTRODUCTION: The key point of successful PCNL is getting access to the renal collecting system. Ureteral catheterization and injection of contrast material provide an important advantage of visualizing and dilating the collecting system. However, catheterization increases the operation time, exposure to anesthesia, and requires additional reusable and disposable medical supplies. The purpose of the study was to develop a surgical algorithm for accessing the renal collecting system for mini-PCNL without catheterization. MATERIALS AND METHODS: We analyzed the treatment results of 82 patients with a single kidney stone, who underwent mini-PCNL without prior catheterization of the ureter. The percutaneous access was obtained according to the roadmap we had developed. The puncture was performed under X-ray control and US guidance. For a calyx stone, the puncture was performed "to the stone". For a pelvis stone, the targeted calyx was accessed using the following algorithm where each next step was performed if the puncture had been impossible at the previous one: 1. 30 min before the operation: infusion load of normal saline, 1000 ml. 2. Intraoperatively: intravenous furosemide, 60 mg. 3. Puncture "to the pelvic stone", injecting contrast material into the collecting system and correcting the access puncture through the required calyx. RESULTS: In all 82 cases, puncture access was performed without ureteral catheterization. In 20 patients with calyceal stones, puncture onto a stone was successfully performed in 100% of the cases. Of 62 patients with pelvic stones, preliminary infusion was enough to allow a successful puncture in 49 (79%), access after intravenous administration of furosemide was obtained in 13 (21%), and a primary puncture onto a pelvic stone had to be done in 6 (10%) patients. CONCLUSIONS: Our proposed algorithm for accessing the PCS of the kidney was successfully used in 100% of the cases. It makes possible to avoid routine ureteral catheterization and thus reduce the overall operation time and the risk of complications, as well as save medical supplies. Clearly, such results require that the surgeon should have significant experience with puncture interventions under ultrasound control.

Efficacy and safety of percutaneous nephrolithotripsy in elderly patients: a retrospective study.

BACKGROUND: Percutaneous nephrolithotripsy (PCNL) is difficult to perform for elderly patients; thus, this study aimed to assess its efficacy and safety in elderly patients aged > 70 years, note any associations between outcomes and patient characteristics, and summarize relevant themes and observations. METHODS: Data from patients older than 70 years who had undergone PCNL for upper urinary tract calculi between January 2016 and January 2021 was retrospectively analyzed. Risk factors for postoperative complications and residual stones were analyzed using multivariate logistic regression. RESULTS: A total of 116 elderly patients underwent 122 PCNL operations, of which six underwent secondary PCNL operations, and all of which were successfully completed. The average age was 74.6 ± 4.3 years; the average stone size and operation time were 3.5 ± 1.8 (1.2-11 cm), and 71.8 ± 34.1 min, respectively. Of the participants, 16 or 13.8% had postoperative complications and 29 (25%) had residual stones after operation. The stone free rate was 75%. Multivariate analysis revealed that an American Score of Anesthesiology III was an independent risk factor for postoperative complications (odds ratio [OR] = 4.453, p = 0.031), and staghorn calculi were independent risk factors for postoperative residual calculi (OR = 31.393, p = 0.001). CONCLUSION: PCNL was shown to be safe and effective for elderly patients aged > 70 years. Further, ASA III was an independent risk factor for postoperative complications, and staghorn calculi were independent risk factors for postoperative residual calculi in elderly patients.

Could retrograde intrarenal surgery be a safe and effective alternative to mini-percutaneous nephrolithotomy in the management of relatively large (20-30 mm) stones? A critical evaluation.

PURPOSE: To compare the outcomes of mini-percutaneous nephrolithotomy (mPCNL) and retrograde intrarenal surgery (RIRS) in patients with renal stones sizing 2-3 cm. METHODS: A total of 566 patients from 6 institutions who underwent mPCNL (n = 440) and RIRS (n = 126) procedures were enrolled in our study. The retrospective patient cohort was reviewed and compared. Binary logistic regression analysis was performed to determine factors predicting success in the RIRS group. RESULTS: The stone-free rates were 91.1 and 77% for the mPCNL and RIRS groups, respectively (p < 0.001). The auxiliary procedure rates were 4.5 and 39.7% in the mPCNL and RIRS groups, respectively (p < 0.001). Mean values of hemoglobin decrease, fluoroscopy time, and hospitalization time were significantly higher in the mPCNL group (p < 0.001). While the Clavien grade 1-2 complication rates were 10.9 and 34.1% (p < 0.001) in two groups, these values were 2.7 and 1.6% (p = 0.539), respectively, for Clavien grade 3-4 complication rates. Although three patients in the mPCNL group received blood transfusions, none of the patients in the RIRS groups were transfused. The stone location and stone density parameters were found to be the independent predictive factors for RIRS success. CONCLUSIONS: mPCNL provided a higher stone-free rate, less need for the auxiliary procedure, and lower complication rates compared to RIRS in patients with 2-3 cm stones. Blood loss, radiation exposure, and a hospital stay of mPCNL can be significantly reduced with the RIRS technique in selected patients.

Tranexamic Acid Use for Hemorrhagic Events Prevention in Percutaneous Nephrolithotomy: Systematic Review and Meta-Analysis.

Purpose: Analyze the impact of tranexamic acid (TXA) use after percutaneous nephrolithotomy (PCNL) on blood loss and transfusion rate (TR), and secondary outcomes, complications rate and stone-free rates (SFRs), operative time (OT), and length of hospital stay (LOS). Materials and Methods: Search made in the Medline (PubMed), Embase, and Central Cochrane for studies published up to August 2021. The study protocol was registered at prospective register of ongoing systematic reviews (CRD42020182197). Eligibility criteria were defined based on Patient, Intervention, Comparison, Outcomes, Study Design acronym (PICOS). Articles included were those who assessed the effect of intravenous TXA in patients submitted to percutaneous nephrolithotripsy (PCNL). Only randomized placebo-controlled trial that included patients with and without TXA perioperatively. Results: A total of 1151 patients were included in seven studies. Six studies presented a lower blood TR for the TXA group (p < 0.00001). Four studies presented similar results in relationship to a lower SFRs (p = 0.004) and similar results regarding overall complication rate for the control group (p = 0.03). Regarding the "major complication rate" (Clavien-Dindo ≥3), no difference was found (p = 0.07). Four studies showed a higher mean OT for the control group (159 × 151 minutes, respectively, p = 0.003). Six studies found a lower mean LOS in the TXA group (4.0 × 3.5 days, respectively, p = 0.03). Conclusions: The benefit of TXA use in the setting of PCNL perioperatively is clear. Our study showed favorable results to TXA use in relationship to TR, SFR, complication rate, OT, and LOS, but these results did not translate into a lower major complication rate. Further studies evaluating the complexity of the calculi and events unrelated to PCNL may help us select which patients will benefit from the use of TXA.