Arvind Ganpule

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

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.

Laparoendoscopic single-site donor nephrectomy: a single-center experience.

OBJECTIVES To present our experience with 13 patients undergoing laparoendoscopic single-site live donor nephrectomy. METHODS The Quadport/Triport (Advanced Surgical Concepts, Ireland) was inserted through an incision in the umbilicus. Apart from standard laparoscopic instruments, we used extra-long harmonic scalpel, suction, and bent instruments, particularly for upper pole dissection. After securing the hilum, the graft was brought near the umbilical extraction site with a grasper inserted through an extra 3- or 5-mm port and easily retrieved with the help of 2 fingers. The parameters analyzed were warm ischemia time, operative time, blood loss, postoperative visual analogue score, grafts retrieval time, and artery, vein, and ureteral length. RESULTS Mean body mass index was 22.18 +/- 3.42 kg/m(2) (range 17.9-29.78). The mean operative time, blood loss, warm ischemia time, and hospital stay were 176.9 +/- 42.47 minutes, 158 +/- 78 mL, 6.79 +/- 1.7 minutes, and 3 +/- 0.45 days (range 2-5), respectively. Graft artery, vein, and ureteral length was 3.8 +/- 0.4, 4 +/- 0.12, and 14.5 cm (range 13-16), respectively. The urine output was prompt in all cases. Visual analogue score in the donor at 2 weeks was 0/10 in all cases. Eleven patients required extra 3- or 5-mm port. Cosmesis was excellent, with the mean incision length of 5.23 +/- 0.96 cm. CONCLUSIONS The laparoendoscopic single-site donor nephrectomy in our initial experience is efficacious and a feasible, minimally invasive option for donors in renal transplantation. Further prospective studies with conventional laparoscopic donor nephrectomy are required to establish its current status.

Developments in technique and technology: the effect on the results of percutaneous nephrolithotomy for staghorn calculi

To review the development of the technique of percutaneous nephrolithotomy (PCNL), for ease of learning and development of instrumentation for staghorn calculi at our centre since 1991, and to assess the results and outcomes.

Robotic Flexible Ureteroscopy for Renal Calculi: Initial Clinical Experience

PURPOSE We report what is to our knowledge the initial clinical experience with remote robotic ureterorenoscopy and laser lithotripsy for renal calculi using a novel flexible robotic system. MATERIALS AND METHODS After institutional review board approval and informed consent 18 patients with renal calculi underwent flexible robotic ureteroscopy. Study inclusion criteria were 5 to 15 mm renal calculi. Patients with ureteral calculi or obstruction, uncontrolled infection, renal insufficiency or solitary kidney were excluded from analysis. The flexible robotic catheter system was manually introduced into the renal collecting system over a guidewire under fluoroscopic control. All intrarenal maneuvers, including stone relocation and fragmentation into 1 to 2 mm particles, were done exclusively from the remote robotic console. RESULTS All procedures were technically successful without conversion to manual ureteroscopy. Mean stone size was 11.9 mm, mean robot docking time was 7.3 minutes, mean stone localization time was 8.7 minutes, mean total robot time was 41.4 minutes and mean total operative time was 91 minutes. The mean visual analog scale rating on a scale of 1-worst to 10-best was 8.5 for robotic control, 9.0 for stability and 9.2 for fragmentation ease. There were no intraoperative complications. Postoperative complications included transient fever in 2 cases and temporary limb paresis in 1. One patient required secondary percutaneous nephrolithotomy for residual stone. Based on computerized tomogram/excretory urogram the complete stone clearance rate at 2 and 3 months was 56% and 89%, respectively. At 3 months all patients had stable renal function and unobstructed drainage. CONCLUSIONS We present a novel flexible robotic platform for retrograde ureteroscopic treatment for intrarenal calculi. Initial experience is encouraging.

Management of the staghorn calculus: multiple-tract versus single-tract percutaneous nephrolithotomy.

Purpose of review Complete removal of stones is crucial for preventing recurrence and morbidity. Currently percutaneous nephrolithotomy is the preferred treatment modality. The debate continues over the use of single tract versus multiple tract percutaneous nephrolithotomy. We review papers on the topic published over the past 12–24 months. Recent findings Articles related to single and multiple tracts were reviewed. We discuss the morbidities, advantages and disadvantages of both the approaches. To decrease the number of tracts few authors have shown the efficacy of flexible ureteroscopy and nephroscopy as an adjuvant procedure. The authors state that this option effectively decreases the disadvantages of multiple tracts, namely blood loss complications, without compromising on stone free rates. Summary Several techniques have been described for percutaneous access and stone removal, all of them associated with inherent problems. Although feasible, access to all the calices will be difficult through one percutaneous tract because of the peculiarities of the renal collecting system, in which case, multiple-access percutaneous nephrolithotomy is the mainstay of the treatment. The crucial point to understand is that all cases should be dealt with on an individual basis.

Fate of residual stones after percutaneous nephrolithotomy: a critical analysis.

PURPOSE To analyze the fate of residual stones after percutaneous nephrolithotomy (PCNL) and identify the factors that predict spontaneous passage. PATIENTS AND METHODS We retrospectively analyzed the records of 2469 patients who underwent PCNL at our center between January 2000 to January 2008. RESULTS Residual fragments (RF) were identified in 187 (7.57%) patients. The most common site of RF was lower calix (57.7%), and the mean size of RF was 38.6 +/- 52 mm(2). Eighty-four stones passed spontaneously at a mean follow-up of 24 months (range 1-100 mos). Of the stones that passed spontaneously, 65.47% did so in 3 months. RF <25 mm(2) and those situated in the renal pelvis had the best chance of clearance. Stepwise multiple regression analysis showed that a history of intervention (P < 0.006), metabolic abnormalities such as hypercalcuria (P < 0.001) and hyperuraecemia (P < 0.03), preoperative nephrostomy drainage (P < 0.05), presence of a Double-J stent, (P < 0.001), time of presentation of residue (P < 0.08), size of residue (P < 0.007), and surgeon experience (P < 0.001) were significant factors in predicting the fate of RF after PCNL. CONCLUSIONS The most common site of post-PCNL RF was the lower calix. Renal pelvic RF <25 mm(2) have the best chance of spontaneous passage. Approximately half the RF will pass spontaneously, and the majority will clear in 3 months. The size of the residual stone, history of intervention, renal failure, and metabolic hyperactivity are predictors of persistence of RF.

Questioning the wisdom of tubeless percutaneous nephrolithotomy (PCNL): a prospective randomized controlled study of early tube removal vs tubeless PCNL

Study Type – Therapy (RCT)
Level of Evidence 1b

Validation of Virtual Reality Simulation for Percutaneous Renal Access Training

OBJECTIVE The objective of this study was to assess the face, content, construct, convergent, and predictive validities of virtual reality-based simulator in acquisition of skills for percutaneous renal access. MATERIALS AND METHODS A cohort of 24 participants comprising novices (n = 15) and experts (n = 9) performed a specific task of percutaneous renal puncture using the same case scenario on PERC Mentor. All objective parameters were stored and analyzed to establish construct validity. Face and content validities were assessed by having all experts fill a standardized questionnaire. All novices underwent further repetition of the same task six times. The first three were unsupervised (pretest) and the later three after the PERC Mentor training (posttest) to establish convergent validity. A subset of five novice cohorts performed percutaneous renal access in an anesthetized pig before and after the training on PERC Mentor to assess the predictive validity. Statistical analysis was done using Students t-test (p <or= 0.05 statistically significant). RESULTS The overall useful appraisal was 4 in a scale of 1 to 5 (1 is poor and 5 is excellent). Experts were significantly faster in total performance time 187 +/- 26 versus 222 +/- 29.6 seconds (p < 0.005) and required fewer attempts to access 2.00 +/- 0.20 versus 2.8 +/- 0.4 (p < 0.001), respectively. The posttest values for the trained novice group showed marked improvement with respect to pretest values in total performance time 42.7 +/- 6.8 versus 222 +/- 29.6 seconds (p < 0.001), fluoroscopy time 66.9 +/- 10.20 versus 123.3 +/- 19.40 seconds (p < 0.0001), decreasing number of perforation 0.8 +/- 0.3 versus 1.3 +/- 0.2 (p < 0.001), and number of attempts to access 1.3 +/- 0.10 versus 2.00 +/- 0.20 (p < 0.001), respectively. Access without complication was attained by all five when compared with one with three complications (baseline vs. posttraining group, respectively) in the porcine model. CONCLUSION All aspects of validity were demonstrated on virtual reality-based simulator for percutaneous renal access.

Predicting effectiveness of extracorporeal shockwave lithotripsy by stone attenuation value.

PURPOSE The aim of this study was to evaluate the effect of stone attenuation value on the effectiveness of extracorporeal shockwave lithotripsy (SWL) for upper urinary tract stones. METHODS In this prospective study, 99 patients underwent SWL for solitary renal and upper ureteral stones from January 2007 to March 2009. All patients underwent CT scan before SWL. The mean attenuation value of stones in our study was 1213.3 +/- 314.5 Hounsfield units (HU). Group A consisted of 42 patients with stones of attenuation value <1200 HU and group B had 57 patients with stones of attenuation value >1200 HU. Stone size, location, requirement of number of shockwaves, shock intensities (power), retreatment rate, complication rate, auxiliary procedure rate, and effectiveness quotient (EQ) ratio were studied. RESULTS The mean total number of shocks required to fragment the stones in groups A and B were 1317.1 +/- 345.3 and 1646.5 +/- 610.8, respectively (p = 0.001), with a mean shock intensity of 12.2 +/- 0.7 and 12.4 +/- 0.5 kV, respectively (p = 0.03). Retreatment was not required in patients of group A, but 14.03% patients in group B required retreatment (p < 0.0001). Clearance rate in group A was 88.1%, whereas in group B it was 82.5% (p = 0.35). Auxiliary procedure rates were 9.5% and 10.5% in groups A and B (p = 0.22), respectively. EQ was 80.4% and 66.2% in groups A and B (p = 0.03), respectively. Complication rates were similar with 2.4% and 3.5% in groups A and B, respectively (p = 0.37). Significant correlation was recorded for total number and intensity of shocks with stone attenuation value. CONCLUSIONS The EQ of SWL for upper urinary tract stones was significantly better for stones with lower attenuation value. The number and intensity of shocks required to fragment these stones with lower attenuation value were also significantly lower.

Management of Non-neoplastic Renal Hemorrhage by Transarterial Embolization

OBJECTIVES To assess the role of transarterial embolization (TAE) and critically appraise its feasibility and efficacy in the management of non-neoplastic renal hemorrhage. Percutaneous TAE is an effective method for the control of hemorrhage, irrespective of the cause. Injury to the renal artery or its branch, after trauma or during open or percutaneous urologic procedures, can be accurately diagnosed using angiography and treated by percutaneous embolization techniques. Because the technique and technology have evolved, it is now possible to perform highly selective embolization of the injured vessel while preserving vascularity of the rest of the renal parenchyma. METHODS The medical records of all patients who underwent angioembolization for hemorrhagic urologic emergencies at our institute from January 1996 to December 2007 were reviewed. RESULTS A total of 41 patients, aged 7-72 years, underwent TAE because of hemorrhage after percutaneous nephrolithotomy (n = 27), open pyelolithotomy (n = 3), renal biopsy (n = 8), and spontaneous occurrence (n = 3). All patients had a normal coagulation profile before surgery. A total of 35 patients (85.3%) underwent successful embolization and none required a postprocedural blood transfusion. Of those with postpercutaneous nephrolithotomy bleeding, angioembolization failed in 6 patients. Of these, only 2 required nephrectomy to save the patients life. No serious procedure-related complications occurred. CONCLUSIONS TAE is a minimally invasive, safe, simple, and highly effective modality, in expert hands, for the management of postprocedural renal bleeding. This option should be considered early in the management of these cases because it is not only a life-saving, but ultimately a kidney-sparing, procedure.