All posts by World Endourology Training Institute

Mini percutaneous nephrolithotomy in the treatment of renal and upper ureteral stones

PCNL is a well-established treatment option for patients with large and complex renal calculi. In order to decrease morbidity associated with larger instruments like blood loss, postoperative pain and potential renal damage, a modification of the technique of standard PCNL has been developed. This is performed with a miniature endoscope via a small percutaneous tract (11–20 F) and was named as minimally invasive or mini-PCNL. This method was initially described as an alternative percutaneous approach to large renal stones in a pediatric patient population. Furthermore, it has become a treatment option for adults as well, and it is used as a treatment for calculi of various sizes and locations. However, the terminology has not been standardized yet, and the procedure lacks a clear definition. Nevertheless, mini-PCNL can achieve comparable stone-free rates to the conventional method, even for large stones. It is a safe procedure, and no major complications are reported. Although less invasiveness has not been clearly demonstrated so far, mini-PCNL is usually related to less blood loss and shorter hospital stay than the standard method.

In order to decrease morbidity associated with larger instruments like blood loss, postoperative pain and potential renal damage, a modification of the technique of standard PCNL has been developed. This is performed with a miniature endoscope via a small percutaneous tract (11–20 F) and was named as minimally invasive PCNL or mini-PCNL or mini Perc.

CONCLUSION
Mini-PCNL was introduced as an alternative to the standard procedure in order to reduce morbidity associated with larger access tracts. Although less invasiveness has not been clearly demonstrated so far, mini-PCNL is related to less blood loss and shorter hospitalization. It is recommended for treatment of large renal stones in children and can be implemented in adults as well. Mini-PCNL seems to be a reasonable alternative for patients with a small-to-medium-sized stones, especially when a tubeless procedure is considered. Mini-PCNL is safe and is not related to serious complications.

Holmium Laser Enucleation of the Prostate (HoLEP)

Holmium Laser Enucleation of the prostate (HoLEP) is a modern alternative to the standard Transurethral Resection of the Prostate (TURP) procedure for bladder outflow obstruction due to BPH. It requires a short period of hospitalisation and an anaesthetic.

HoLEP can be performed on men of any age with urinary outflow obstruction caused by an enlarged prostate. It is particularly indicated in men with large prostates (over 60mls in size) and men on medications to thin the blood such as warfarin, aspirin or clopidogrel.

Advantages of HoLEP

  • There is no upper size limit of prostate that can be dis-obstructed – traditionally men with prostates over 100ml in size needed major open surgery
  • There is often less bleeding than after a TURP
  • Discharge is often quicker than after TURP at 1-2 days
  • The chance of recurrence requiring further surgery is very low
  • Unlike greenlight laser operations, large quantities of prostate tissue are sent for pathological analysis
  • The PSA generally drops to very low levels after HoLEP operations.

AIM OF HoLEP
The aim of HoLEP is to relieve pressure on the tube through which the urine drains (urethra) by anatomically enucleating the majority of excess benign prostate tissue. This is done under a general anaesthetic with the help of a telescopic camera inserted through the penis. The three lobes of the prostate that are cored out intact are pushed into the bladder before being sucked up (morcellated) by a special instrument inserted through the telescopic camera. The pieces are sent for laboratory analysis just in case they might be found to be cancerous. A catheter is placed into the bladder to drain the urine while the raw surface heals, then left in place for around 24 hours before being removed on the day of discharge from hospital. Sterile saline fluid is also irrigated into the bladder through the catheter to dilute any blood in the urine and prevent clots from forming.

Laparoscopic Pyeloplasty

Laparoscopic Pyeloplasty provides patients with a safe and effective way to perform reconstructive surgery of a narrowing or scarring where the ureter (the tube that drains urine from the kidney to the bladder) attaches to the kidney through a minimally invasive procedure. This operation is used to correct a blockage or narrowing of the ureter where it leaves the kidney. This abnormality is called a ureteropelvic junction (UPJ) obstruction which results in poor and sluggish drainage of urine from the kidney. UPJ obstruction can potentially cause abdominal and flank pain, stones, infection, high blood pressure and deterioration of kidney function. When compared to the conventional open surgical technique, laparoscopic pyeloplasty has resulted in significantly less post-operative pain, a shorter hospital stay, earlier return to work and daily activities, a more favorable cosmetic result and outcomes identical to that of the open procedure.

The Surgery
Laparoscopic pyeloplasty is performed under a general anesthetic. The typical length of the operation is 3-4 hours. The surgery is performed through 3 small (1cm) incisions made in the abdomen. A telescope and small instruments are inserted into the abdomen through these keyhole incisions, which allow the surgeon to repair the blockage/narrowing without having to place his hands into the abdomen.


Ureteropelvic Junction (UPJ) Obstruction

A small plastic tube (called a ureteral stent) is left inside the ureter at the end of the procedure to bridge the pyeloplasty repair and help drain the kidney. This stent will remain in place for 4 weeks and is usually removed in the doctor’s office. A small drain will also be left exiting your flank to drain away any fluid around the kidney and pyeloplasty repair.

An Overview of Ureteroscopy and Flexible Uretero-Renoscopy

A special telescope is passed through the urethra, bladder, and into the ureter to the stone or to view the area of interest. The telescope may be rigid or flexible. The procedure is usually performed under general anaesthesia. A stone breaker, grasper or laseris passed up the ureteroscope to perform the procedure. This is a minimally invasive procedure that makes use of natural channels in the body; there are no cuts to the skin. It is a well tolerated and frequently performed procedure.

Ureteroscopy is performed for the following reasons:

  • Stones typically in the distal or middle ureter by rigid ureteroscopy that are unlikely to pass spontaneously or are causing significant discomfort.
  • Stones in the kidney that are not treatable by ESWL
  • To determine the reason for blood in the urine

Advantages of ureteroscopy

  • The stone is usually directly seen allowing the delivery of special instruments or lasers to break the stone. The ureteroscope is passed through natural channels in the body and involve no skin incisions. Providing the stone can be seen, there is a very high chance that the stone will be broken in one session.
  • Flexible ureteroscopy allows entry into all parts of the kidney so that all stones can be removed or vaporised provided they are of an appropriate size and accessible.

Success rates of ureteroscopy – The success rate of ureteroscopy is over 90% for the majority of stones that are treated this way. Success depends

  • Whether there is 1 or more stones present
  • How long the stone has been stuck
  • The location of the stone (where in the kidney or ureter)
  • The size of the stone
  • Whether you have had previous surgery on the kidney
  • The experience of the urologist treating you

Risks factors of ureteroscopy

  • Urine infection: this usually requires antibiotics only
  • Bleeding: this usually settles quickly
  • Damage to the ureter resulting in narrowing of the ureter (‘stricture’) or perforation: this is rare and may require stretching by a balloon and insertion of a JJ stent
  • Failure to break and retrieve the stone: an alternative procedure may be necessary
  • Perforation of the ureter: usually a JJ stent is required for a few weeks after such an injury
  • Detachment (‘avulsion’) of the ureter from kidney: this is very rare and is sometimes unavoidable, but may require open surgery to repair
  • Abdominal or back discomfort
  • Side-effects due to a JJ stent

Difference between rigid and flexible ureteroscopy

Rigid Ureteroscopy Flexible Ureteroscopy
Rigid ureteroscopy is performed literally with a rigid telescope. As such, it look only in a straight line. Flexible ureteroscopy is performed with a very thin and flexible telescope that can perform almost a 180° turn and look back on itself. It is sometimes known as flexible uretero-renoscopy, because it is possible to look into various parts of the inside of the kidney. Using a laser, stones can be vapourised and removed. Flexible uretero-renoscopy tends to be used for stones in the kidney and near the kidney in the upper ureter.
Rigid ureteroscopy is mainly used for stones in the lower and mid ureter closer to the bladder. Flexible ureter-renoscopy is more gentle than rigid ureteroscopy.

Precautions

  • Drink more fluid (especially 2 hours after meals and at night)
  • Adopt a diet appropriate to the type of stone. See calcium stone diet
  • Periodic X-rays or ultrasound to determine if more stones are being formed
  • Follow up in a stone clinic