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      Mini percutaneous nephrolithotomy in the treatment of renal and upper ureteral stones: Lessons learned from a review of the literature

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          Abstract

          The aim of this review is to present the most recent data regarding the indications of mini percutaneous nephrolithotomy (PCNL), the results and the complications of the method. Medline was searched from 1997 to January 2014, restricted to English language. The Medline search used a strategy including medical subject headings and free-text protocols. 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.

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          Complications in percutaneous nephrolithotomy.

          This review focuses on a step-by-step approach to percutaneous nephrolithotomy (PNL) and its complications and management. Based on institutional and personal experience with >1000 patients treated by PNL, we reviewed the literature (Pubmed search) focusing on technique, type, and incidence of complications of the procedure. Complications during or after PNL may be present with an overall complication rate of up to 83%, including extravasation (7.2%), transfusion (11.2-17.5%), and fever (21.0-32.1%), whereas major complications, such as septicaemia (0.3-4.7%) and colonic (0.2-0.8%) or pleural injury (0.0-3.1%) are rare. Comorbidity (i.e., renal insufficiency, diabetes, gross obesity, pulmonary disease) increases the risk of complications. Most complications (i.e., bleeding, extravasation, fever) can be managed conservatively or minimally invasively (i.e., pleural drain, superselective renal embolisation) if recognised early. The most important consideration for achieving consistently successful outcomes in PNL with minimal major complications is the correct selection of patients. A well-standardised technique and postoperative follow-up are mandatory for early detection of complications.
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            Classification of percutaneous nephrolithotomy complications using the modified clavien grading system: looking for a standard.

            A classification (modified Clavien system) has been proposed to grade perioperative complications. We reviewed our experience with percutaneous nephrolithotomy (PNL), grading the complications according to this new classification. A total of 811 PNLs were performed between 2003 and 2006, and charts were retrospectively reviewed focusing on complications observed. According to the modified Clavien classification system, perioperative complications were stratified into five grades. Grade 1 defined all events that, if left untreated, would have a spontaneous resolution or needed a simple bedside intervention. Grade 2 complications required specific medication, including antibiotics and blood transfusion. Grade 3 complications necessitated surgical, endoscopic, or radiologic intervention (3a without general anesthesia, 3b under general anesthesia). Neighboring organ injuries and organ failures were classified as grade 4, and death was considered a grade 5 complication. Kidney stones treated with PNL were also classified as simple and complex and complication rates were compared. A total of 255 perioperative complications were observed in 237 (29.2%) patients. There were 33 grade 1 (4%), 132 grade 2 (16.3%), 54 grade 3a (6.6%), 23 grade 3b (2.8%), 9 grade 4a (1.1%), and 3 grade 4b (0.3%) complications, and 1 death (0.1%). Most complications were related to bleeding and urine leakage. Grade 2 and 3a complications were significantly more common in patients with complex renal stones. A graded classification scheme for reporting the complications of PNL may be useful for monitoring and reporting outcomes. However, minor modifications concerning auxiliary treatments are needed and further studies are awaited.
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              Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position.

              Percutaneous nephroscopy is usually performed with the patient prone, which is uncomfortable for the patient and does not prevent damage to the colon. We assess the possibility of performing percutaneous nephroscopy using local anesthesia with the patient supine, and evaluate the advantages and complications. A total of 557 consecutive percutaneous nephroscopies were attempted in 221 men and 242 women in the supine position. Patient age ranged from 8 to 87 years (mean 55.1). Patients are supine with a 3 l. serum bag below the ipsilateral flank. We catheterize the affected uretheral meatus with a 5F catheter through a flexible cystoscope. The tract is infiltrated with local anesthesia. The skin is punctured in the posterior axillary line which corresponds to approximately 1 cm. above the bag. We use an Alken set to dilate the tract to 30F, which is the size of the Amplatz sheath we commonly use. Nephroscopy was performed in 519 cases (93.1%). Mean operation time was 85 minutes (range 15 to 240). Serious bleeding occurred in 3 cases. The colon was never damaged in patients treated in the supine position. Percutaneous nephroscopy using local anesthesia with the patient supine is safe and easy. According to our experience the advantages in comfort to the patient and feasibility to the surgeon justify its use.
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                Author and article information

                Journal
                Urol Ann
                Urol Ann
                UA
                Urology Annals
                Medknow Publications & Media Pvt Ltd (India )
                0974-7796
                0974-7834
                Apr-Jun 2015
                : 7
                : 2
                : 141-148
                Affiliations
                Department of Urology, Endourology and Laparascopic Urology, Korgialenio Benakio Hellenic Red Cross Hospital, Athens, Greece
                Author notes
                Address for correspondence: Dr. Nikolaos Ferakis, Solomou 3, 15562 Cholargos, Athens, Greece. E-mail: ferakis@ 123456otenet.gr
                Article
                UA-7-141
                10.4103/0974-7796.152927
                4374249
                Copyright: © Urology Annals

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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