Micro Percutaneous

Nephrolithotomy “Microperc” :

How small can you go?

Dr Mahesh Desai President, Endourology Society Inc.

Past President, Societe Internationale D’urologie Medical Director,Muljibhai Patel Urological Hospital,

Nadiad, Gujarat India

Mannheim 2007

URS 57% ESWL 30%

Open 2% PCNL 10%

MPUH : STONE MANAGEMENT

Till March 2011 (24107)

Wake Foret 2005-2007

Parameters Leveillee Landman Preminger

No. of renal units 35 9 7

Stone-free rate 95% 78% 71.4%

Blood transfusion 2.2% 0% 0%

Complications 2.8% 22.2% Nil

Hospital Stay (mean-days) 2 (1-10) 3.2 Not mentioned

Chest complications 2.8% 11.1% Nil

Table 3 : Studies of Single-access Percutaneous Nephrolithotomy

Multiperc Vs Single Perc with Flexible Instrumentation for

Staghorn Calculi Arvind Ganpule, Shashikant Mishra, Mahesh Desai et al.

Muljibhai Patel Urological Hospital, Nadiad, India

J.Endo. Vol 23, No 10, Oct.2009

Paarameters Aron Lintisikos Guohua Hegarty Singla

No of renal units 121 100 100 20 149

Stone-free rate 84% 87% 93% 95% 88.9%

Blood transfusion 14.8% 45% 3% 20% 46%

Complications (major) 4.1% 10% 4% 10% 14%

Hospital stay (mean-

days)

Not

mentioned

4.6 (3-14) 9.4 (6-13) 4.25 ± 1.74

6.8 (3-28)

Table 1 : Studies of use of Multiple tracts for staghorn calculus management

Parameters Single tract (%)

(n=225)

Multiple tract

(%)

(n=500)

P value

Clearance rates 194 ( 86.4%) 420 (84.1%) 0.06

Blood transfusion 19 (8.4%) 62 (12.4%) <0.01

Hemoglobin drop (g%) 1.4 2.1 0.06

Complications 10 (4.6%) 23 (5%) 0.92

Hospital stay (days-mean) 7.4 11.1 <0.001

Table 2: Differences in use of Single or Multiple tracts

Multiperc Vs Single Perc with Flexible Instrumentation for

Staghorn Calculi Arvind Ganpule, Shashikant Mishra, Mahesh Desai et al.

Muljibhai Patel Urological Hospital, Nadiad, India

J.Endo. Vol 23, No 10, Oct.2009

Factor Affecting Blood Loss During Percutaneous Nephrolithotomy : Prospective Study Kukreja, Desai et al

J Endourol, vol 18,Number 8: Oct 2004

Does size of tract matter?

Size of tracts

(Fr)

Ave Hb drop

(gm%)

P value

30-32 ( n=4) 2.2 ± 2.1

0.20 26-28 (n=72) 1.59 ± 1.09

<24 (n=16) 1.37 ± 1.33

Adult

Subgroups Hb drop

(gm%)

P value

Single tract (<22 Fr) 1.1 ± 0.45

<0.01 Single tract (>22 Fr) 1.61 ± 0.42

Pediatric

Complications of PCNL

Bleeding

Perforation

Calyceal tear

Infundibular tear

Persistant leak

Pain

Nephron loss

All can be attributed to size of tract

Helal – 1997 – Peel away sheath for miniperc in

children

Jackman 1998 – small sheath with standard

scope

Negle – 2000 – new design miniperc

Miniperc – A new way to

look at PCNL

Miniperc : Conclusion

Similar clearance rate as standard PNL for sizes

1 to 2 cm.

Longer operative time but ends more frequently

in tubeless procedure.

Significantly less bleeding

Similar safety profile as of standard PNL and

results in shorter hospital stay.

Treating renal calculi 1 - 2 cm in diameter with miniperc or retrograde

intrarenal surgery (RIRS): A prospective comparative study.

Sabnis R, Jagtap J, Mishra S, Desai MR. BJUI 2011( Ahead of print)

Miniperc RIRS P value

Renal units 32 32

Sex, (Male: Female) 19:13 25:7 0.18

Age, years (Mean ± SD) 44.48±12.36 49.28±12.19 0.07

Stone size, cm (Mean ± SD) 1.52±0.33 1.42±0.34 0.24

Laterality (Left: Right) 10:22 16:16 0.20

Site of stone

Pelvis

Upper calyx

Middle calyx

Lower calyx

Multiple

14

1

0

10

7

8

3

1

9

11

0.19

0.63

1.0

1.0

0.40

Miniperc RIRS p-value

Operative time; minutes

(Mean ± SD)

40.81 ± 13.79 50.63 ± 19.21 0.003*

Intraoperative complications

Pelvic perforation

1 O 0.99

Pain Visual analogue score (1to 10mm)

At 6 hours

At 24 hours

At 48 hours

4.26 ± 1.26

2.74 ± 0.89

1.90 ± 0.70

3.16 ± 1.17

2.00 ± 0.92

1.22 ± 0.42

< 0.0001*

< 0.0001*

< 0.0001*

Analgesic requirement; mg Tramadol 66.13 ± 62.43 28.13 ± 42.00 0.003*

Hemoglobin drop; gm/dL 1.43 ± 1.01 0.40 ± 0.63 < 0.0001*

Postoperative complications 1 3 0.60

Hospital stay; days 2.07 ± 0.68 1.94 ± 0.76 0.24

Complete stone clearance 32/32 (100%) 31/32 (96.88%) 0.99

Retreatment 0/32 (0%) 1/32 (3.13%) 1.00

Miniperc : MPUH Experience

( Under publication- J Endourol)

Miniperc

Renal units 156

Sex, (Male: Female) 102:54

Age, years (Mean ± SD) 42.2±17.1

Stone size, cm (Mean ± SD) 2.3±1.2

Laterality (Left: Right) 72:84

Site of stone

Pelvis

Upper calyx

Middle calyx

Lower calyx

Multiple

61

21

28

41

5

Miniperc

Operative time; minutes

(Mean ± SD)

55.14 ± 17.81

Complications

Pelvic perforation

Bleeding

Perinephric collection

Post operative transient fever

1

1

3

6

Tubeless 141(90%)

Analgesic requirement; mg Tramadol 78.4 ± 51.8

Hemoglobin drop; gm/dL 1.68 ± 0.85

Hospital stay; days 2.65 ± 1.02

Complete stone clearance 154/156 (98.7%)

Retreatment 2/156 (2.25%)

LOWER POLE I : A PROSPECTIVE RANDOMIZED TRIAL OF

EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY AND PERCUTANEOUS

NEPHROSTOLITHOTOMY FOR LOWER POLE NEPHROLITHIASIS—INITIAL

RESULTS

Only size matters!

DAVID M. ALBALA, DEAN G. ASSIMOS, RALPH V. CLAYMAN, JOHN D. DENSTEDT, MICHAEL GRASSO, JORGE

GUTIERREZ-ACEVES, ROBERT I. KAHN, RAYMOND J. LEVEILLEE, JAMES E. LINGEMAN, JOSEPH N. MACALUSO,

LARRY C. MUNCH, STEPHEN Y. NAKADA, ROBERT C. NEWMAN, MARGARET S. PEARLE, GLENN M. PREMINGER,

JOEL TEICHMAN and JOHN R. WOODS J of Urology Volume 166, Issue 6, Pages 2072-2080 (December 2001)

Lower Pole stone study II

109 pts enrolled

Group 1 (<1 cm)

(N=67)

Group 2 (>1-2.5 cm)

(N=42)

SWL

(n=32)

URS

(n=35)

URS

(n=20)

PCNL

(n=22)

Stone-free using CT criteria

Lower Pole stone study II

< 1 cm N= 72 > 1-2.5 cm N=47

SWL

(n=32)

URS

(n=35)

URS

(n=20)

PCNL

(n=22)

OR time (min) 66 90 125 121

Stone Free 35% 52% 40% 74%

2° proc 24% 7% 18% 5%

Intraop Complication 3% 20% 15% 9%

Postop Complication 23% 21% 10% 25%

LOS (days) 0 0.06 0 2.5

100% recovery time (d) 8 16 15 18

Korbet SMPercutaneous renal biopsy. Semin

Nephrol. 2002 May;22(3):254-67.

Although it has been shown that complication

rates have improved with the use of smaller

needles, it has been suggested that post-biopsy

complications may be even less frequent with

the use of smaller gauge needles (16- or 18-

gauge needles compared with the 14-gauge

needle).

Effect of needle gauge, level of anticoagulation, and target organ

on bleeding associated with aspiration biopsy. Work in progress. Gazelle GS, Haaga JR, Rowland DY. Department of Radiology, Case Western Reserve University

Hospitals, Cleveland.

Radiology. 1992 May;183(2):509-13.

Multiple biopsy procedures were performed on the livers

and kidneys of anesthetized pigs with 14-22-gauge Chiba-

type needles.

The procedures were performed under direct vision at

laparotomy, and blood loss was measured.

While larger needles generally produced more bleeding, the

differences were statistically significant only when

comparing 14- with 16-gauge needles and 16-gauge needles

with the group of 18-, 20-, and 22-gauge needles in the liver.

In the kidney, no significant difference was noted

between,18-, 20-, and 22-gauge needles.

In Laparoscopy, a fibre optic equipped 3 mm safety needle

allows visually controlled access to the abdominal cavity

Schaller G et al . Minim Invasive Ther Allied Technol 1994; 3: 253.

We duplicated the concept of optical visualization

of the tract in Laparoscopic surgery

Presented at AUA 2010 San Francisco,

(J.Urol. Vol. 183 (4): Supplement Page 734)

Presented at AUA 2010 San Francisco,

(J.Urol. Vol. 183 (4): Supplement Page 734)

Ectopic Pelvic Kidney with calculus

60 year old male,

Left flank pain for last 2 years,

July 2009,CT urography

revealed left pelvic kidney with

calculus,

Feb 2010, Failed RIRS attempt,

in UK.

No co-morbidity.

No. of cases 76

Male : Female 54:22

BMI (Kg/m2) 25.2± 3.8

Laterality - Right : Left 32: 44

Operative Details

Micro PCNL

Mini micro PCNL

42

34

Mean Operative Time 66.33± 31.81

DJ Stent, n(%) 27 (35.52%)

Nephrostomy (10 IFT) 6 (7.89%)

Conversion to Miniperc/std PCNL 5 (6.57%) (Intraoperative bleeding)

Post operative Period

Mean Haemoglobin drop 0.6 gm/dl

Mean Vas score

6 hours

12 hours

24 hours

5

2

1

Post operative Fever 9

Complete clearance 4 week, n(%)

Complete Clearance

Residual Calculi

CIRF

66 (86.84%)

6 (7.89%)

4 (5.2%)

Auxiliary procedure 1 ( DJ Stenting ), 1-RIRS

Hospital stay (hrs, (mean(SD) 62.5 ± 23.4

MPUH- Microperc - Results

Patient demographics and clinical

characteristics Variable Microperc (n=31) RIRS (n=31) p value

Age (years), mean (SD) 37.4 (15.2) 43.1 (12.3) 0.11

Sex (male:female) 20:11 21:10 0.78

BMI (kg/m2), mean (SD) 23.7 (4.9) 24.9 (4.5) 0.31

Co-morbidities

Diabetes mellitus 2 4 0.39

Hypertension 3 7 0.17

Ischemic heart disease 0 1 0.31

Chronic kidney disease 1 2 0.55

Stone characteristics in both the

groups of patients

Variable Microperc (n=31) RIRS (n=31) p value

Stone size (cm),

mean (SD)

1.11 (0.25) 1.01 (0.31) 0.08

Laterality

(right:left)

17:14 16:15 0.79

HU, mean (SD) 1327 (206) 1239 (225) 0.11

Site of stone

Pelvis 14 12 0.74

Upper calyx 3 2 0.64

Middle calyx 3 3 1.0

Lower calyx 11 14 0.61

Comparison of intra-operative and

postoperative parametes Parameter Microperc RIRS p value

Operative time, min 51.5 (18.8) 46.7 (18.2) 0.31

Double J stenting, n (%) 7 (22.5) 22 (70.9) < 0.001

Intra-operative complications

Pelvic perforation, n (%) 1 (3.2) 1 (3.2) 1.0

Bleeding (Clavien I), n (%) 2 (6.4) 0 0.16

Conversion to miniperc, n (%) 1 (3.2) 0 0.31

Pain visual analogue score (1 –

10), mean (SD)

At 6 hr 4.9 (1.6) 3.9 (1.1) 0.003

At 12 hr 3.4 (2.0) 2.3 (0.9) 0.008

At 24 hr 1.9 (1.1) 1.4 (0.8) 0.046

Analgesic requirement (mg of

tramadol), mean (SD)

116 (63) 67 (33) 0.002

Comparison of intra-operative and

postoperative parametes Parameter Microperc RIRS p value

Haemoglobin drop (g/dL), mean

(SD)

0.95 (0.47) 0.52 (0.32) < 0.001

Postoperative complications

Fever (Clavien I), n (%) 3 (9.7) 4 (12.9) 0.72

Bleeding, n (%) 0 0 -

Hospital stay (days), mean (SD) 58.3 ± 22.1 48.9 ± 19.0 0.08

Auxiliary procedures, n (%)

RIRS 1 (3.2) 0 0.31

Double J stenting 1 (3.2) 0 0.31

Stone clearance at 4 weeks, n (%)

Complete clearance 26 (86.7) 28 (90.3) 0.45

Residual calculi 1 (3.2) 3 (9.7) 0.30

CIRF 4 (12.9) 0 0.039

Multi-centric study on Microperc

feasibility Centres (other than MPUH) : 7

Total Case :70

Micro :62

Mini micro : 8

Adult : Pediatric :68 : 2

Stone size (Avg.) : 1.2 cm

Stone clearance : 100%

Complication

Clavien 1 : 5 (Fever 1 day, Hematuria-1 day)

Clavien 2 : 2 (Fever, Requiring change of antibiotic)

Clavien 3 : 0

Clavien 4 : 0

Irrigation flow rates (milliliters per minute) at different

pressure points (10000-pixel optic inserted)

Intra-renal pressure simulation

Ciba needle, outer canula dia. 1.65 mm

Microoptic 0.97 mm

Metal wire 0.42 mm, simulating laser fiber

Sheath with 9 Fr. ID

3 way adapter with haemostatic valves

Ureteral catheter 8 Fr. (4.5 Fr. ID)

Roller pump with 40 ml fixed flow

1.2 ID suction canula to simulate ultrasonic ‘miniperc’

probe

Intra-renal pressure simulation

PC with Data Logger software for pressure recording

Further areas of research

Pressure reducing mechanisms..

Improving optics… 10,000 to 20,000 pixels

Further RCTs with ESWL and RIRS….

Multicentric trial

Cost analysis …..

Microperc through

4.5 Fr needle for stone < 1.5 cm Ca Oxalate

Di -hydrate/ LASER

8 Fr sheath for stone 1-2.5 cm Ca Oxalate

Mono- hydrate Ultrasound/Lithoclast

Patient selection

Lower calyceal unfavorable anatomy

Pediatric patient

Ectopic kidney

Calyceal diverticulum

Initial conclusion

YOU ARE THE STONE YOU ARE THE CHISEL

YOU ARE THE SCULPTOR

Thank You