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

2. 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

3. Nomenclature
Schilling et al 2015

4. 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

5. 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
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6. 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%
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7. Super mini pcnl (guangzhou)
7Fr nephroscope, 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 Jul 27. doi: /bju [Epub ahead of print] PubMed PMID:
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8. Indications & contraindications
Similar to conventional PCNL
Secondary access to residual PCNL fragments
Contraindications = PCNL
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9. MINI PCNL series
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10. High stone free rate combined with all procedures
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11. 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%
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12. 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%
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13. 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%
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14. Nephroscopes 12/14 Fr, Sheaths 15-20 Fr
Largest series –
318 consecutive mini PCNL
Nephroscopes 12/14 Fr, Sheaths Fr
Center of excellence – Very high stone free rate
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15. DMSOEBADI FIESTA 2015

16. 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
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17. Tract Size Conventional 26-30 Fr Mini PCNL 16-20 Fr Ultra Mini PCNL
Micro PCNL
4.85 Fr
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MicroPerc

18. Lower tract size Less complications. Less bleeding. Less Sepsis
Lower tract size Less complications? Less bleeding? Less Sepsis? Less invasive? Quicker return to work?
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19. 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.

20. 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
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21. 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
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UROLOGY 58: 345–350, 2001

22. 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
± 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

23. 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
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24. 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?
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25. DMSOEBADI FIESTA 2015

26. DMSOEBADI FIESTA 2015

27. 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
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28. 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
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29. DMSOEBADI FIESTA 2015

30. Conventional
PCNL
Fashionable
minipcnl