In vitro evaluation of the Lithoclast Ultra Vario combination lithotrite

Rigid intracorporeal lithotrites can be invaluable in the removal of large stone burdens during percutaneous nephrolithotomy. One such device, the Lithoclast Ultra Vario (LUV) has an outer ultrasound probe and inner pneumatic-ballistic probe. The ballistic probe can be advanced or retracted and run at 1-12 Hz. Since it can be difficult to predict optimal settings with any new device, we asked if in vitro testing could give insight into how best to operate this lithotrite. We tested the LUV under hands-free conditions that simulate treatment of fixed stones and freely movable stones. A fixed-stone test system measured the time to penetrate a gypsum model stone placed atop the probe and a movable-stone system determined time for comminution of a stone within a confined space. In addition, the time to evacuate 2-mm stone particles was measured. For hands-on testing, model stones were placed in a plastic dish submerged in water and the time to comminution was measured. Penetration time of fixed stones was faster with the ballistic probe extended 2.5 mm than when retracted (5.30 ± 0.85 vs. 8.75 ± 1.07 s, p < 0.0001). Comminution of free stones was faster with the ballistic probe retracted than when it was extended 1 mm or 2.5 mm (9.7 ± 0.9, 13.8 ± 1.3, 23.7 ± 3.2 s, p < 0.0001). In hands-on testing, extending the ballistic probe substantially reduced the efficiency of comminution (36.7 ± 6.4 vs. 131.3 ± 15.3 s, p < 0.0001). Clearance of fragments was considerably faster when the pneumatic-ballistic rate was 12 Hz compared to 1 Hz (12.3 ± 1.1 vs. 28.3 ± 2.2 s, p < 0.0001). These in vitro findings suggest ways to take advantage of the positive features while minimizing potential limitations of this lithotrite. Extending the ballistic probe is an advantage when the stone is immobile, as would be the case in treating a large stone that can be isolated against the wall of the pelvicalyceal system, but is a distinct disadvantage--due to retropulsion--when the stone is free to move. Operation of the LUV at fast ballistic rate significantly improved its ability to aspirate stone fragments

Treatment of renal stones by extracorporeal shockwave lithotripsy - An update

Aim: Despite the extensive experience with minimal invasive stone therapy, there are still different views on the ideal management of renal stones. Materials and Methods: Analysis of the literature includes more than 14,000 patients. We have compared these data with long-term results of two major stone centers in Germany. The results have been compared concerning the anatomical kidney situation, stone size, stone localization and observation time. Results: According to the importance of residual fragments following extracorporeal shock wave lithotripsy (ESWL), we have to distinguish between clinically insignificant residual fragments and clinically significant residual fragments (CIRF). 24 months following ESWL stone passage occurs as a continous process, and if there are no clinical symptoms, any endoscopic procedure should be considered as overtreatment. According to these results, stone-free rates of patients increase in longer follow-up periods. Newer ESWL technology has increased the percentage of CIRF. Conclusion: We consider ESWL in most patients with renal calculi as first-line treatment, except in patients with renal calculi bigger than 30 mm in diameter. Copyright (C) 2001 S. Karger AG, Basel

Prospective study comparing the safety and efficacy of totally tubeless percutaneous nephrolithotomy vs standard percutaneous nephrolithotomy

Background: To evaluate the feasibility and safety of totally tubeless percutaneous nephrolithotomy (PCNL) Vs standard PCNL.Methods: From August 2014 to January 2016, 66 patients underwent PCNL in our institute. Of this group, 35 patients underwent traditional nephrostomy drainage following PCNL. A tubeless procedure was performed in the remaining 31 patients. These  groups were compared with respect to age, stone burden, intraoperative events, postoperative pain, analgesic requirements, soakage, postoperative change in hemoglobin, hospitalization time and complication rates.Results: Two groups were comparable with respect to age, stone burden (2.03 cm Vs. 2.12 cm) and intraoperative events. The mean pain score (day2 - 4.95 vs. 2.95) (day3 - 4.33 vs. 1.44) and analgesic requirement (mg diclofenac) (day2 - 140.22 vs. 65.31) (day3 - 124.44 vs. 43.89) was significantly less for group 2 on day 2 and 3. There was significant problem of soakage from nephrostomy tract in group 1. Patients in group 2 returned faster to normal activities but there was no difference found in drop in hemoglobin, complication rates even in subset of patients with large stone burden. No patient required readmission in the follow-up for pain, obstruction or infection in group 2. One patient developed urinoma which resolved conservativelyConclusions: In selected cases totally tubeless PCNL is feasible and safe

Management of Clinically Insignificant Residual Fragments following Shock Wave Lithotripsy

Clinically insignificant residual fragments (CIRFs) are small fragments (less than 5 mm) that are present in upper urinary tract at the time of regular post-SWL followup. The term is controversial because they may remain silent and asymptomatic or become a risk factor for stone growth and recurrence, leading to symptomatic events, and need further urologic treatment. Although a stone-free state is the desired outcome of surgical treatment of urolithiasis, the authors believe that the presence of noninfected, nonobstructive, asymptomatic residual fragments can be managed metabolically in order to prevent stone growth and recurrence. Further urologic intervention is warranted if clinical indications for stone removal are present

Whether retrograde pyelography mandatory for percutaneous nephrolithotomy: a randomized clinical trial

Background: Percutaneous nephrolithotomy (PCNL) technique was introduced a new era in the management of renal calculi, and day by day many changes occurred regarding the puncture points to an opaque stone as a guided landmark. We aim at comparing the outcome of many renal calculi with or without retrograde pyelography (RGP).Methods: In a randomized clinical trial 110 cases with opaque renal calculi for PCNL with stone in the calyces, in the pelvis, both in the calyx and pelvis, simultaneously, included in 2 year study. They were randomized in 2 groups, non RGP (56) and RGP (54), called interventional and control group respectively.Results: 2 groups are analyzed according to gender, age, duration of operation and hospital stay, past history of any surgical intervention on kidney and stone size. Outcome was evaluated with plain x-ray and USG abdomen. No differences in outcome were observed in between the two groups.Conclusions: Present findings conclude that there is no difference in major clinical outcome between the 2 groups. So we can say RGP is not mandatory for selected patients while doing PCN

Mini percutaneous nephrolithotomy: its role in the management of renal stone and our tertiary care centre experience

Background: Miniaturized percutaneous nephrolithotomy (PCNL) procedures for urolithiasis have gained increased popularity in recent years. To decrease the complications of conventional PCNL by  reduced tract size led to the development of Mini PCNL, which makes the use of 15-18F sheaths in place of 24-30F of conventional PCNL. It has developed rapidly and become a popular technique of renal stone management with reduced morbidity and excellent outcome. Authors report our experience with Mini PCNL for the treatment of renal stone.Methods: In between his August 2015 and January 2018, sixty patients with the diagnosis of unilateral single medium size (8-20mm) renal stone were identified. Patient’s demographical, clinical, diagnostic and procedural data were recorded.  All patients were evaluated by history taking, physical examination and laboratory investigations. Radiological evaluation was done with X ray kidney, ureter and bladder region (KUB) and also with renal ultrasonography followed by computed tomography (CT). All patients underwent Mini PCNL using 12F nephroscope and 16.5/17.5F sheath. Holmium: YAG laser was used for stone fragmentation. No nephrostomy tube was used routinely. Treatment outcome was assessed in terms of operative time, haemoglobin drop, hospital stay and stone free rate.Results: Complete stone fragmentation was achieved in 41 out of 60 patients using Mini PCNL, so initial stone free rate was 68.3%. After 4 weeks of surgery total 53 patients were stone free (88.3%), 5 patients required some auxiliary procedure for complete clearance of stone and other 2 were managed conservatively. The mean operative time was 48.28 min, mean haemoglobin drop was 0.74gm/l and mean postoperative hospital stay was 54.22 hours. After 12 weeks postoperatively all patients were stone free. There were no significant postoperative complications, and all had good quality of life.Conclusion: Mini PCNL technique appears to be safe and effective alternative to conventional PCNL for moderate size renal calculi. It is usually related to less blood loss and shorter hospital stay than the standard method. It can achieve good stone-free rates with minimal complications and low morbidity. Mini PCNL can also be considered as a good alternative to retrograde intrarenal surgery and shockwave lithotripsy in selected cases. However, further high quality studies with larger sample size are required in future