Supine percutaneous nephrolithotomy (s-PCNL) as an alternative to conventional prone approach

Objectives: Percutaneous Nephrolithotomy(PCNL) is conventionally performed in the prone position. However supine PCNL(s-PCNL) may be more advantageous in terms of facilitating simultaneous flexible ureterorenoscopy and negating the need for a second percutaneous renal access for complex stones. It may reduce the cardio-respiratory compromise seen in the prone position. We reviewed our experience of performing supine percutaneous nephrolithotomy (s-PCNL) in the management of large or complicated renal calculi.Methods: Data was prospectively collected on 103 consecutive cases of s-PCNL performed at our institution from September 2014 to December 2015. Stone fragmentation was done using Lithoclast Master and inaccessible stones were manipulated simultaneously using a flexible ureterorenoscopy. Stone clearance was assessed with CT-KUB.Results: The mean age and BMI were 53.2 years (range 27 – 81) and 29kg/m2(range 20 – 34), respectively. Calculi size ranged from 16-41 mm (mean 23 mm) which included staghorn, calyceal, diverticular, pelvis and upper ureteric calculi. Lower pole calyx was utilized as the most frequent form of access (63%), followed by upper pole(7%) and interpolar(30%) access. Simultaneous flexible ureterorenoscopy was used in 15% of patients. Median operative time and hospital stay were 80 min (range 40 – 240 min) and 3 days(range 3 – 15 days) respectively. Complications noted were pyrexia, renal derangement and pulmonary embolism (0.97% each). Interval CT KUBs confirmed complete stone clearance in 91% of patients.Conclusions: s-PCNL is safe and effective in treating renal calculi. Patient benefits include a comfortable position, lack of major complications (in our series) and favourable stone clearance rates. We would advocate the supine, extended lithotomy position in centers performing PCNL

Is minimally invasive surgery safe, to treat significant upper urinary tract obstructive uropathy due to urolithiasis: Single centre experience

Objectives: Upper urinary tract obstruction (UTO) is a urological emergency. Failure in timely intervention results in nephron loss, urosepsis and death. The objective was to assess the safety and efficacy of minimally invasive surgery in UTO.Methods: Prospective Descriptive Study was carried out at professorial surgical unit of Sri Jayewardenepura Hospital. All patients presenting with upper tract urolithiais from January 2014 to January 2015, with significant upper tract obstruction (moderate to severe hydronephrosis) were included. CT KUB±Urogram confirmed the obstructing calculus and the degree of hydronephrosis. Patients with significant UTO were analyzed by presentation, interventions, complications and outcome.Results: Out of 224 patients, 25% (n=57) had significant UTO. Of them 41%, and 14% had Diabetes mellitus and chronic kidney disease respectively. Eighteen patients (32%) had UTO complicated with urosepsis and/or acute kidney injury, out of them each underwent PCN insertion (n=7) and retrograde stenting (n=7) followed by secondary ureteroscopic lasertripsy (URSL) while 4 patients underwent Primary URSL in 4±2 days. Uncomplicated UTO patients (n=39) underwent Percutaneous nephrolithotomy (n=6), primary URSL (n=23), laparoscopic ureterolithotomy (n=8) and open surgery (n=2) as definitive treatment in 32±11 days. Two patients with complicated UTO underwent nephrectomy. There were no intervention related major complications including renal loss or deaths. 95% had fovourable renal recovery by 6 month of follow upConclusions: One in four patients who present with UTO has significant obstruction. Timely management of complicated UTO by immediate urinary diversion or decompression saves lives and kidneys. Significant UTO can be effectively managed with minimally invasive surgical techniques by careful patient selection and prioritization.