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Objective: To compare the risks of fever from different lithotrites after percutaneous nephrolithotomy (PNL)., Materials and Methods: The Clinical Research Office of the Endourological Society (CROES) PNL database is a prospective, multi-institutional, international PNL registry. Of 5,803 total patients, 4,968 received preoperative antibiotics, were supplied with complete information and included in this analysis. The lithotrites assessed included no fragmentation, ultrasonic, laser, pneumatic and combination ultrasonic/pneumatic. Risk of fever was estimated using multivariate logistic regression with adjustment for diabetes, steroid use, a history of positive urine culture, the presence of staghorn calculi or preoperative nephrostomy, stone burden and lithotrite., Results: The overall fever rate was 10%. Pneumatic lithotrites were used in 43% of the cohort, followed by ultrasonic (24%), combination ultrasonic/pneumatic (17.3%), no fragmentation (8.4%) and laser (7.3%). Fever rates were no different between patients who underwent no or any fragmentation (p = 0.117), nor among patients when stratified by lithotrite (p = 0.429). On multivariate analysis, fragmentation was not significantly associated with fever [Odds Ratio (OR) 1.17, p = 0.413], while diabetes (OR 1.32, p = 0.048), positive urine culture (OR 2.08, p < 0.001), staghorn calculi (OR 1.80, p < 0.001) and nephrostomy (OR 1.65, p < 0.001) increased fever risk. Fever risk among lithotrites did not differ (p ≥ 0.128)., Conclusions: Risk of post-PNL fever was not significantly different among the various lithotrites used in the CROES PNL study., (Copyright © 2013 S. Karger AG, Basel.)

Objectives: There are few reports on the use of PCNL for staghorn calculi in children. We evaluated the safety and efficacy of this technique, using adult equipment, in children below 16 years of age., Methods: Data for pediatric patients undergoing PCNL for staghorn renal calculi was prospectively recorded. A staghorn calculus was defined as a branched stone occupying more than one part of the collecting system. A standard fluoroscopy guided PCNL was performed in the prone position using adult nephroscopes. Stone clearance was assessed on fluoroscopy and X-ray in all patients and an ultrasound or CT scan in selected cases., Results: Beginning October 2007, 33 pediatric patients underwent 34 PCNLs at our center. 12 of these children had staghorn calculi. All patients had normal renal function and no metabolic abnormality. One child had a solitary kidney. In 5 children, the primary tract was placed into the superior calyx and 4 of these were above the 12th rib. A 21Fr nephroscope was used through a 24Fr tract in 9 children while a 26Fr nephroscope was used through a 30Fr tract in 3 cases. 10 children were managed through a single tract. One patient each required SWL and ureteroscopy for residual fragments. 11 patients had complete clearance while 1 had insignificant residue. One child required intravenous antibiotics for post-operative fever while another developed an abdominal collection that was managed conservatively., Conclusions: PCNL is safe and effective in the management of pediatric staghorn calculi., (Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: Early results indicate that robot assisted laparoscopic surgery (RALS) may be useful in managing upper tract (UT) urolithiasis. We reviewed our experience of managing 50 cases of UT urolithiasis with or without reconstruction using RALS., Materials and Methods: We performed a record review of 50 cases of RALS for UT urolithiasis performed in two institutions from July 2006 to June 2009. The RALS procedures included pyeloplasty with pyelolithotomy (29 cases), ureterolithotomy, tailoring and reimplantation for megaureters (5 cases), ureterolithotomy with ureteral stricture reconstruction (1 case), primary UT stone surgeries (8 cases), partial nephrectomy (1 case) and ablative surgeries (6 cases). Data pertaining to indications, operative details, and complications were analyzed., Results: The average operating time was 105 min (86 min-135 min) for pyeloplasty with pyelolithotomy, 140 min (115 min-195 min) for ureterolithotomy, tailoring and ureteroneocystostomy and 106 min (88 min-174 min) for extended pyelolithotomy (5 cases). Mean blood loss was 77 mL (50 mL-250 mL). Stone clearance rate was 93.2%. One case of extended pyelolithotomy had hematuria requiring selective angioembolization. There was one conversion and no other major complication., Conclusions: RALS for UT urolithiasis is safe and efficacious. It is particularly useful when stone removal is combined with reconstruction. It is a reasonable alternative for treating a solitary partial staghorn or a large pelvic stone including those in pelvic/anomalous kidneys. RALS did not seem substantially better than pure laparoscopy for isolated ureterolithotomy and for nephrectomy for a nonfunctioning kidney. Its role in the treatment of large, multiple or complete staghorn calculi needs further investigation.

Ectopic pelvic kidneys with ureteropelvic junction obstruction and stones present a treatment challenge for the minimally invasive surgeon. A pure laparoscopic approach is less invasive than an open approach but is technically difficult with longer operative time. The use of the da Vinci robotic interface has the potential to refine the laparoscopic technique and improve outcomes. Here, we present successful management using the robotic technique of one such case of concomitant pyeloplasty and pyelolithotomy.

Purpose: To assess the effect of shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) on renal morphology and function in children undergoing therapy for upper-tract urolithiasis., Patients and Methods: Fourteen patients less than 13 years of age with renal or upper-ureteral calculi who were found suitable for primary SWL or PCNL were evaluated for alteration of renal morphology and function after treatment. Of the 18 renal units treated, SWL and PCNL were performed in 9 units each. The average stone size was 880.2 mm2 (range 110-3800 mm2; median 660 mm2). All children underwent ultrasonic estimation of renal length and parenchymal thickness, 99m technetium dimercaptosuccinic acid (DMSA) and 99m Tc-ethylene dicystine (EDC) scintigraphy, and glomerular filtration rate (GFR) estimation prior to intervention and at 3 and 6 months of follow-up., Results: Extracorporeal lithotripsy achieved complete clearance in 8 renal units (88%), requiring an average of 6333 shockwaves and an average of 2.2 sessions per renal unit. The efficiency quotient was 42. Percutaneous surgery likewise achieved complete stone clearance in 88% of renal units, with three units requiring more than one tract. Mixed calcium oxalate monohydrate and dihydrate accounted for the majority of the stones. The mean preintervention GFR was 78.3 +/- 14.6 mL/min/1.73 m2 (median 82.5 mL/min/1.73 m2; range 54-98.6 mL/min/1.73 m2), whereas the mean GFR at 3 months was 78.95 +/- 14.4 mL/min/1.73 m2 (median 78.95 mL/min/1.73 m2; range 52-98 mL/min/1.73 m2). A marginal improvement of an average of 0.65 mL/min was noted. Split function EDC scans demonstrated improved drainage in five cases after intervention; the rest were unchanged. Preintervention DMSA scans revealed renal cortical scars in three children. None of the renal units had developed fresh scars at follow-up scans. None of the children developed new-onset hypertension, proteinuria, or alteration in renal size., Conclusion: In the present study, pediatric SWL and PCNL were not found to cause adverse renal morphologic or functional alteration. Stone clearance resulted in marginally improved function and better drainage.

Management of large calculi in ectopic pelvic kidneys poses a challenge to the urologist. Risk of injury to surrounding abdominal viscera and vasculature makes open surgery as well as percutaneous nephrostolithotomy in an ectopic kidney a challenging procedure. Laparoscopic management avoids open surgery and associated morbidity and offers added safety. We report the management of symptomatic stones in a pelvic ectopic kidney lying anterior to the L5 vertebra and sacrum by transmesocolic laparoscopic pyelolithotomy in an 11-year-old child. Complete stone clearance was achieved with no complications and an uneventful postoperative recovery. The patient was discharged 72 hours after the surgery.

Two patients presented with calculi in ectopic kidneys. Complete clearance of calculi was achieved by laparoscopic assisted percutaneous nephrolithotomy (PCNL), by different but related techniques. In one patient with prior history of open pyelolithotomy, the anterior surface of the kidney was exposed by mobilizing the overlying sigmoid colon laparoscopically and the percutaneous tract was established into the desired calyx under combined laparoscopic and fluoroscopic control. In the second patient, the tract was established between the major mesenteric vessels without any mobilization of the bowel. Herein, we outline the nuances of these two related techniques, and the indications and contraindications for their use for laparoscopic assisted PCNL in ectopic kidneys.

Background and Purpose: To evaluate the safety and efficacy of percutaneous nephrolithotomy (PCNL) for the management of complete staghorn calculi in children

Objective: To evaluate the usefulness of urinary calculi attenuation values from non-contrast computed tomography (NCCT) in predicting the outcome of treatment by extracorporeal shock wave lithotripsy (ESWL)., Patients and Methods: We evaluated 112 patients with solitary renal and upper ureteric calculi of 0.5-2 cm undergoing ESWL. All patients had NCCT at 120 kV and 240 mA on a spiral CT scanner. During each ESWL session 3000 shock waves were given to a maximum of 3.0 kV. A final X-ray of the kidney, ureters and bladder was taken 12 weeks after the last ESWL session. Fragments of < or = 5 mm were regarded as clinically insignificant residual fragments (CIRF). The calculi retrieved were analysed by X-ray diffraction and the results assessed by comparing the mean density (as measured in Hounsfield units, HU) with the number of ESWL sessions and clearance., Results: In all, 82 (76%) patients had complete clearance of stones and 26 (24%) had CIRF. There was a linear relationship between the calculus density and number of ESWL sessions required. Of patients with calculi of < or = 750 HU, 41 (80%) needed three or fewer ESWL sessions and 45 (88%) had complete clearance. Of patients with calculi of > 750 HU, 41 (72%) required three or more ESWL sessions, and 37 (65%) had complete clearance. The best outcome was in patients with calculus diameters of < 1.1 cm and mean densities of < or = 750 HU; 34 (83%) needed three or fewer ESWL sessions, and the clearance rate was 90%. The worst outcome was in patients with calculus densities of > 750 HU and diameters of > 1.1 cm; 23 (77%) needed three or more ESWL sessions and the clearance rate was only 60%. The calculus density was a stronger predictor of outcome than size alone., Conclusions: The use of NCCT for determining the attenuation values of urinary calculi before ESWL might help to predict the treatment outcome, and so might help in planning alternative treatment in patients with a likelihood of a poor outcome from ESWL.

Background and Purpose: Some patients undergoing percutaneous nephrolithotomy (PCNL) have purulent fluid in the pelvicaliceal system at the time of puncture, although preoperative features are not suggestive of infection. We report the management and outcome of 19 such patients., Patients and Methods: Among the 639 patients who underwent PCNL at our center from July 2000 to October 2003, 19 had purulent fluid in the kidney at initial puncture. The preoperative findings, operative details, hospital course, and final outcome in these patients were analyzed. Twelve patients had stone removal at the first sitting (option 1), while seven had a nephrostomy tube placed initially with stone removal deferred for 3 to 7 days (option 2)., Results: With option 1, stones were cleared with one to three tracts in 45 to 120 minutes. Seven patients recovered smoothly, three had transient fever, while one had grade I and another had grade II sepsis. The purulent fluid grew E. coli in two cases and Proteus or Serratia in one case each and was sterile in eight. With option 2, stones were cleared using one to three tracts in 60 to 100 minutes. The fluid grew E. coli or Klebsiella in one case each and was sterile in five. Three patients had a smooth recovery, two had transient fever, one had grade I sepsis, and another had grade II sepsis. Risk factors for sepsis, irrespective of the option, were a recent history of febrile urinary-tract infection, borderline elevation of total leukocyte count, thick or foul pus as opposed to mere turbidity, the use of a single tube or tract or delayed creation of second tracts, and operating time >90 minutes., Conclusions: Despite normal preoperative urine and blood values, one may find purulence on puncture during PCNL, which is not always infected. If any one or more of the above risk factors is present, it is safer to drain the kidney initially, making sure that all blocked calices are drained, inserting multiple tubes if necessary.

A 35-year-old man with a left ectopic pelvic kidney and a prior history of open pyelolithotomy presented with recurrent multiple stones in the pelvic kidney. Complete clearance of calculi was achieved by laparoscopy-assisted PCNL (percutaneous nephrolithotomy). To the best of our knowledge this is the first report of laparoscopy-assisted PCNL in a previously operated ectopic pelvic kidney.

Introduction: The treatment of large complete staghorn calculi requires a sandwich combination of percutaneous nephrolithotomy (PCNL) and shockwave lithotripsy (SWL) or sometimes open surgery. Many urologists hesitate to place more than 2-3 tracts during PCNL because of the belief that this may increase complications. We present data to support multi-tract PCNL for large (surface area >3,000 mm(2)) complete staghorn calculi., Patients and Methods: From July 1998 to October 2003, 121 renal units (103 patients) with large complete staghorn renal calculi were treated with PCNL. All procedures were performed in the prone position after retrograde ureteral catheterization. Fluoroscopy-guided punctures were made by the urologist followed by track dilation to 34 french. When multiple tracts were anticipated all punctures were usually made at the outset and preplaced wires were put into the collecting system or down the ureter. Stones were fragmented and removed using a combination of pneumatic lithotripsy and suction. Postoperative stone clearance was documented on X-ray KUB., Results: 121 renal units of 103 patients (15 women and 88 men, mean age 43 years) were treated. Six patients had associated bladder calculi that were treated simultaneously. The stone surface area was 3,089-6,012 (mean 4,800) mm(2). 10 patients (9.7%) had renal insufficiency with a mean (range) serum creatinine of 3.0 (1.5-5.5) mg/dl. The number of tracts required per patient were 2 tracts in 11, 3 tracts in 68, 4 tracts in 39, and 5 tracts in 3, giving a total of 397 tracts in 121 renal units, over a total of 140 procedures (including second-look procedures in 19 renal units). The points of entry of these tracts were 121 upper calyx (30.4%), 178 middle calyx (44.8%), and 98 lower calyx (24.6%). All 121 units had one upper polar access tract of which 92 (76%) were supracostal. Complications were blood transfusion (n = 18), pseudoaneurysm (n = 2), fever (n = 22), septic shock (n = 1) and hydrothorax (n = 3). PCNL monotherapy achieved an 84% complete clearance rate that improved to 94% with SWL in 8 renal units with small residual fragments. Stone compositions were calcium oxalate (91%), uric acid (2%) and mixed (7%)., Conclusion: Aggressive PCNL monotherapy using multiple tracts is safe and effective, and should be the first option for massive renal staghorn calculi.

Objectives: To assess the efficacy of superior pole access for complex lower pole calyceal calculi., Patients and Methods: In all, 102 patients with complex inferior calyceal calculi were included in a prospective unrandomized study. Complex inferior calyceal calculi were defined as multiple calculi in two or more inferior calyces of the lower polar group, with each calyx draining through a separate infundibulum and at an acute angle to each other. In 33 patients (32%; group 1) an inferior calyceal puncture was made and in 69 (68%; group 2) access was obtained through a superior calyceal puncture. The stone-free rates, decrease in haemoglobin, operative duration, requirement for additional tracts and second procedures in the two groups were compared., Results: Stone clearance rates and blood loss values were better in group 2, although they were not significantly different. The mean operative duration, number of tracts required and the re-look procedure rate was significantly less in group 2. Two patients (3%) in group 2 had hydrothorax related to supracostal puncture and required chest tube insertion., Conclusions: Superior calyceal puncture (supracostal or infracostal) affords optimum access to complex inferior calyceal stones, providing faster and better clearance with a single puncture, and less requirement for second-look procedures.

A case of bilateral inferior calyceal calculi treated with simultaneous bilateral tubeless percutaneous nephrolithotomy is presented. The patient had an uneventful recovery and was discharged in twenty-three hours.

Objectives: To assess the significance of asymptomatic residual stone fragments of less than 4 mm (clinically insignificant residual fragments [CIRFs]) after extracorporeal shock wave lithotripsy (ESWL)., Methods: Eighty-one patients were followed up for 6 to 60 months (mean 15) after ESWL to determine the fate of the CIRFs., Results: Of the 81 patients, 6 were lost to follow-up, leaving 75 patients. During follow-up, fragments passed spontaneously in 18 patients, remained stable in 13 patients, and became clinically significant in 44 patients who developed one or more complications. For the latter patients, repeated ESWL was done in 16, percutaneous nephrolithotomy in 3, and ureteroscopic stone removal in 4 patients. The remaining 21 patients were treated conservatively with analgesics. We found that 53% of the CIRFs located in the pelvis passed spontaneously, and most of the CIRFs in caliceal location became clinically significant. Also, as the stone burden and number of stone fragments increased, the risk of CIRFs becoming clinically significant increased. The outcome was the same whether a metabolic abnormality was present or not, provided the patient received appropriate treatment. The clearance rate was highest in the first 6 months. Finally, as the duration of follow-up increased, the rate of complications increased., Conclusions: Patients with residual stones after ESWL require close follow-up and timely adjuvant therapy. As the number and size of residual fragments increased, the risk of complications increased. A pelvic location was a favorable factor for spontaneous passage. Metabolic defects, if treated adequately, did not increase the regrowth rate. Although the complete clearance rate of CIRFs with repeated ESWL was lower than for the operative interventions, most patients improved with this modality.