conventional mini super mini ultra mini micro PCNL conventional mini super mini ultra mini micro Doddy M. Soebadi DMSOEBADI FIESTA 2015

Evolution of pcnl Variety of Tract & Scope size? Access sheath size Nephroscope size Fragmentation method Baskets & Forceps Tract & Scope size? Conventional Mini Micro Ultra Mini Super Mini? DMSOEBADI FIESTA 2015

Nomenclature Schilling et al 2015

Mini PCNL Small instruments & small sheaths Variety in size 11F to 20 F Semi rigid ureteroscope, nephroscope, flexible scope Prone & supine possible Tubeless vs nephrostomy, with/without DJ stent Effectiveness? Complications? DMSOEBADI FIESTA 2015

Miniperc 2 step PNL dilation with smaller instruments Chan & Jarrett (2000) 13 Fr ureteroscopy sheath , <10 Fr uretero/cystoscope Monga & Oglevie (2000) 20 Fr sheath, 9.5 Fr ureteroscope Lithotripsy – laser, basket, forceps Small fragments pass through sheath DJ stenting and/or nephrostomy DMSOEBADI FIESTA 2015

High resolution telescope 1.0 mm 13 F outer sheath High resolution telescope 1.0 mm 62 Patients up to 20 mm 1 mo stone free 86.66% DMSOEBADI FIESTA 2015

Super mini pcnl (guangzhou) 7Fr nephroscope, 10-14 Fr access sheath Holmium laser lithothripsy Success 141 of 146 pats, 5 pats converted to larger tract Stone size 2,2 +/- 0,6 cm operative time 45,6 mins SFR 90,1 immediate – 3 months 95,8% Zeng G, Wan S, Zhao Z, Zhu J, Tuerxun A, Song C, Zhong L, Liu M, Xu K, Li H, Jiang Z, Khadgi S, Pal SK, Liu J, Zhang G, Liu Y, Wu W, Chen W, Sarica K. Super-Mini Percutaneous Nephrolithotomy (SMP): A new concept in technique and instrumentation. BJU Int. 2015 Jul 27. doi: 10.1111/bju.13242. [Epub ahead of print] PubMed PMID: 26220396. DMSOEBADI FIESTA 2015

Indications & contraindications Similar to conventional PCNL Secondary access to residual PCNL fragments Contraindications = PCNL DMSOEBADI FIESTA 2015

MINI PCNL series DMSOEBADI FIESTA 2015

High stone free rate combined with all procedures DMSOEBADI FIESTA 2015

Mini vs PCNL Retrospective < 2 cm stones 13 F amplatz Miniperc longest operative time (155.5 vs 106.6) Shorter hospital stay Stone free rate miniperc 77.5% vs standard 94% DMSOEBADI FIESTA 2015

MiniPCNL – 18 F amplatz 12 F nephroscope Stone size > 20 mm (36.7 ± 23.37), 61.4% complex stones, Multiple puncture 12% Stone free simple (96.9%), complex 66.7% Complications simple stones 37.5%, complex 19.6% DMSOEBADI FIESTA 2015

Complications – Clavien-Dindo None - Level 1 - Level 2 Stone size 15.26 ± 6.35 <1cm 1-2 cm >2 cm 58 228 32 Single Tract Multiple Tract 305 13 Operative time 60 ± 19 Haemoglobin drop 1.04 ± 0.62 Hospital stay 2.8 ± 1 Complications – Clavien-Dindo None - Level 1 - Level 2 303 – 14 – 1 cases Stone free 98.74% N= 318 Stone size 15.26 ± 6.35 <1cm 1-2 cm >2 cm 58 228 32 Single Tract Multiple Tract 305 13 Operative time 60 ± 19 Haemoglobin drop 1.04 ± 0.62 Hospital stay 2.8 ± 1 Complications – Clavien-Dindo None - Level 1 - Level 2 303 – 14 – 1 cases Stone free 98.74% DMSOEBADI FIESTA 2015

Nephroscopes 12/14 Fr, Sheaths 15-20 Fr Largest series – 2009-2013 318 consecutive mini PCNL Nephroscopes 12/14 Fr, Sheaths 15-20 Fr Center of excellence – Very high stone free rate DMSOEBADI FIESTA 2015

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Microperc (2011) All seeing needle, 0.9 mm telescope One step no dilation Ureteral catheter 5Fr Micro optic with Holmium laser Stone size 14.3 ± 6.3 mm 8/10 clear, 2 pats fragments <4mm DMSOEBADI FIESTA 2015

Tract Size Conventional 26-30 Fr Mini PCNL 16-20 Fr Ultra Mini PCNL Micro PCNL 4.85 Fr DMSOEBADI FIESTA 2015 MicroPerc

Lower tract size Less complications. Less bleeding. Less Sepsis Lower tract size Less complications? Less bleeding? Less Sepsis? Less invasive? Quicker return to work? DMSOEBADI FIESTA 2015

MPCNL (12 F scope 15 F amplatz) 165 consecutive patients MPCNL (12 F scope 15 F amplatz) No difference in TNF-alpha, IL-6, IL-10, CRP and serum amyloid A (SAA) DMSOEBADI FIESTA 2015 UROLOGY 75: 56–61, 2010.

n=55 Mini Standard p Cases 27 28 Operative time (mins) 45.2 ±12.6 31 ±16.6 Tubeless 21 4 0.0008 Complications Bleeding 0 Fever 2 Bleeding 4 Fever 4 0.11 0.66 Stone free at 1 month 96% 100% 0.49 Hemoglobin drop 0.8 ±12.6 1.3 ± 0.4 0.0098 Tramadol use (mg) 55.4 ± 50 70.2 ± 52 0.28 Hospital stay 3.2 ± 0.8 4.8 ± 0.6 <0.0001 DMSOEBADI FIESTA 2015

Average stone burden cm3 Mini Standard p Sheath Nephrostomy 26 F 22 F 34 F Average stone burden cm3 4.9 8.4 3 staghorn stones OR time (mins) 130 ±12 129 ± 8 0.87 Stone free at 1 month 62.5% 37.5% 0.49 Haematocrit drop 5.7 ± 1.0 6.9 ± 1.1 0.47 Morphine use (mg) 24.0 ± 7.5 52.0 ± 22.5 0.05 Hospital stay 3.22 ± 0.22 4.1 ± 0.55 <0.0001 DMSOEBADI FIESTA 2015 UROLOGY 58: 345–350, 2001

Fluoroscopy time (sec) Micro (N=58) Mini (N=40) p Sheath 4.8 F Most cases DJ stent 15-20 Fr Stone size1-2 cm 13.9 ± 3.6 16.1 ± 6.9 0.078 Procedure time (mins) Fluoroscopy time (sec) 43.02 ± 27.98 112.05 ± 72.5 52.25 ± 23.09 138.5 ± 56.4 0.006 Stone free rate 86.2% 82.5% 0.669 Haematocrit drop 1.96 ± 1.73 3.98 ± 2.44 <0.001 Morphine use (mg) 24.0 ± 7.5 52.0 ± 22.5 0.05 Hospital stay 1.55 ± 0.95 2.63 ± 1.31 <0.01 Complications 5.1% 7.5 0.57 DMSOEBADI FIESTA 2015 Conversion to mini/standard PCNL – impaired vision, short optic

4 standard PCNL – 4 Mini – 1 Micro 10 studies, 2 randomised Cases PCNL 727 vs RIRS 454 4 standard PCNL – 4 Mini – 1 Micro PCNL techniques – higher stone free rate Higher complications DMSOEBADI FIESTA 2015

Large variation between studies – learning curve / surgeon volume? PCNL had higher stone free rate vs RIRS (with higher complication rate) RIRS had better SFR than minimally invasive percutaneous procedures (OR: 1.70; 95% CI, 1.07–2.70), but there was no difference in complication rate or the need for auxiliary procedures. Large variation between studies – learning curve / surgeon volume? DMSOEBADI FIESTA 2015

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Informed consent Alternatives: SWL – Flexible URS – mini PCNL – PCNL Incresed stone free vs SWL & fURS Need for reintervention Nephrostomy - Ureteral catheter – DJ stents possible Urinary tract infection, fever, sepsis Bleeding with rare need for transfusion Severe bleeding very rare – need for embolization/nephrectomy Injury of adjacent organs Injury of ureter DMSOEBADI FIESTA 2015

Take home messages Future – miniaturization of instruments. BUT stones not getting smaller! Smaller tract – less pain, shorter hospital stay Stone free rates? Complications? Surgeon experience crucial – Proper informed consent Common difficulty in surgical research Durability of instruments? Time will tel Trend – choice between ‘miniature’ PNL vs fURS DMSOEBADI FIESTA 2015

DMSOEBADI FIESTA 2015

Conventional PCNL Fashionable minipcnl