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Super Mini PCNL for
Renal Stones
Dr Zamari Noori
MD Urolgy and Endourology
Pros and Cons for PCNL
Pros
• High stone-free rate
Cons
• High complications(Bleeding,
Urosepsis…)
Miniaturized percutaneous
nephrolithotomy
• miniaturized PCNL techniques appear to be
• safe and effective
• alternatives to conventional PCNL for both
• adult and pediatric patients.
They aim to reduce percutaneous tract size in order to
lower complication rates,
high stone-free rates.
. mini-PCNL, minimally invasive PCNL (MIP)
• Chinese mini-PCNL (MPCNL),
• ultra-mini-PCNL (UMP),
• micro-PCNL,
• mini-micro-PCNL, and
• super-mini-PCNL (SMP).
How to decrease bleeding
following PCNL
• Always make a puncture - From fornix
• Never from infundibulum
8% vein injury
No artery injury
8% vein injury
No artery injury
How to decrease bleeding
following PCNL
• Small size access
• Different mini-perc techniques were
developed
Mircro-Perc(Fr 4.85)
UMP(Fr 11-13)
SMP(Fr 10-14)
New problems for Mini-Perc
• Lower irrigation flow
• Small size access-miniature endoscopes -Small size irrigation
channel
• Increased difficulty in stone extraction
• Passive egress of the stone fragments with pressure pump
• Compromised endoscopic view
• Lower irrigation flow, specially insertion of laser fiber and
basket…
• High intra-renal pressure
• Pressure pump
• How to deal with all problems?
Irrigation-suction sheath system
• This system consists of 2 parts:
straight sheath and handle part.
• Sheath consists of 2 layers metal
sheath, which form a tiny gap in
between for irrigation .
• 8 tiny holes are located at the tip
of sheath for fluid outflow.
• There is a vent on the handle
part ,which controls negative
pressure by it’s opening or closure.
Irrigation-suction sheath system
• Good entry and exit of the irrigation fluid
Irrigation inflow is from sheath, and not from irrigation
Channel in endoscope, irrigation outflow with the suction sheath
• Clear endoscopic view
Continuous suction and good irrigation flow
• Effective evacuation of stone fragments
One-way suction-active removal of stone fragments
Mostly no need any forcep and basket
outflow
inflow
Nephroscope
Irriga
tion
pum
p
Irrigation-suction sheath
SMP system
Traditional mini-PCNL
outflow
inflow
Nephroscope
Irrigation
pump
Sheath
inflow
outflow
stone fragments
The hydrodynamic mechanisms for retrieval fragments in new generation
SMP system and traditional mini-PCNL SMP system
RPP in new-generation SMP
• Basic RPP (mmHg) 8.94±3.58
• Intraoperative RPP (mmHg) 20.02±3.58
• Number of patients who had one episode of RPP ≥ 30 mmHg 81.5%
• Accumulated time of RPP ≥ 30 mmHg (s) 114.89±132.65
Irrigation Pressure: 200-250mmHg
Suction Pressure: 150-200mmHg
Lower intra-renal pressure: less than 30mmHg
Good space for operation
Indications for SMP
• Stone size less than 3cm
• Failed SWL or RIRS
• Especially for pediatric patients resistant
to SWL
SMP for adult nephrolithiasis
22 years old male, solitary right functioning kidney, multiple stones
located in lower calyx and upper ureter, anuria, the DJ stent was left for
40 days.
How to manage it?
First choice: SWL? RIRS? PCNL?
Multiple-tracts SMP - totally
tubeless
Multiple-tracts SMP - totally tube
RIRS failed
SMP (n=2012) vs. mini-PCNL (n=1513) for ≥
2cm renal stones
SMP could be a safer and more efficacious option for the treatment of renal
stones of 2–3 cm, with the advantage of a shorter hospital stay.
SMP for pediatric nephrolithiasis
Girl, 2 years old, right kidney stone 2cm, SWL failure, stone composition
analysis :cystine stone
How to manage it?
First choice: RIRS? PCNL?
SMP for pediatric patients
• Patients data (111 cases)
• Gender: 71 boys and 41 girls
• Age: 3.90± 3.53 yrs (0.5~15).
• Stone burden (cm):1.4±0.6 (0.8-4.8)
• Stone location, n (%)
Upper ureter 33 (29.7%)
Pelvis 26 (23.4%)
Upper calyx 14 (12.6%)
Middle calyx 9 (8.1%)
Lower calyx 21 (18.9%)
Multiple 8 (7.2%)
• Positive preoperative urine culture 16 (14.4%)
• HU value: 735.2±329.1 (288-1378)
Results
• Single tract: 111 (100%)
• Operative time: 39.4±26.2 mins (7~105)
• SFR (1 day after procedure) : 101 (91.0%)
• SFR (3 months after procedure) : 106
(95.5%)
• Hb dropped (g/L) : 10.2±7.1 (0~25)
• Access size: 10F 2(1.8%), 12F
94(84.7%),14F 15(13.5%)
• Puncture site:
Results
• Complications: fever (>38.5 °C) 7 (6.3%)
• Transfusion:0%.
• Total tubeless PCNL: 95 (85.6%)
• Hospital stay (days): 2.7±1.5
• Stone composition (84 cases available):
Calcium phosphate 4 (4.8%)
Magnesium ammonium phosphate 6 (7.1%)
Carbonate apatite 1 (1.2%)
Uric acid 10 (11.9%)
Calcium oxalate 25 (29.8%)
Ammonium urate 37 (44.0%)
Cystine 1 (1.2%)
For pediatric stones of 10–20 mm, SMP could be an ideal choice with
a high stone-free rate and minimal invasiveness.
Half-day surgery SMP
SMP under paravertebral block anesthesia
• Fast recovery
– Totally “tubeless”, short hospital stay and no need to come back for
stent removal.
– Discharged post-operative 5-6 hours.
• Low risk of cross-infection of COVID-19
– Safe for doctors: No need to use ventilators
– Safe for patients: One-day surgery, no need to stay overnight in the
hospital
• Comfortable and cost-effective
Summary
SMP-another definition
Safe………...............S
Meaningful……....…M
Practical…………......P
Conclusion
• New SMP solve all drawbacks in Mini-Perc
• Achieve an excellent clinical outcome
 High SFR
 High total tubeless or tubeless rate
 Short hospital stay
 Less complications
 Less(0.5%) Blood transfusion
Best
Culmination
New
SMP
dr noori smp.ppt
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dr noori smp.ppt

  • 1. Super Mini PCNL for Renal Stones Dr Zamari Noori MD Urolgy and Endourology
  • 2.
  • 3. Pros and Cons for PCNL Pros • High stone-free rate Cons • High complications(Bleeding, Urosepsis…)
  • 4. Miniaturized percutaneous nephrolithotomy • miniaturized PCNL techniques appear to be • safe and effective • alternatives to conventional PCNL for both • adult and pediatric patients. They aim to reduce percutaneous tract size in order to lower complication rates, high stone-free rates.
  • 5. . mini-PCNL, minimally invasive PCNL (MIP) • Chinese mini-PCNL (MPCNL), • ultra-mini-PCNL (UMP), • micro-PCNL, • mini-micro-PCNL, and • super-mini-PCNL (SMP).
  • 6.
  • 7. How to decrease bleeding following PCNL • Always make a puncture - From fornix • Never from infundibulum 8% vein injury No artery injury 8% vein injury No artery injury
  • 8. How to decrease bleeding following PCNL • Small size access • Different mini-perc techniques were developed Mircro-Perc(Fr 4.85) UMP(Fr 11-13) SMP(Fr 10-14)
  • 9. New problems for Mini-Perc • Lower irrigation flow • Small size access-miniature endoscopes -Small size irrigation channel • Increased difficulty in stone extraction • Passive egress of the stone fragments with pressure pump • Compromised endoscopic view • Lower irrigation flow, specially insertion of laser fiber and basket… • High intra-renal pressure • Pressure pump • How to deal with all problems?
  • 10.
  • 11. Irrigation-suction sheath system • This system consists of 2 parts: straight sheath and handle part. • Sheath consists of 2 layers metal sheath, which form a tiny gap in between for irrigation . • 8 tiny holes are located at the tip of sheath for fluid outflow. • There is a vent on the handle part ,which controls negative pressure by it’s opening or closure.
  • 12. Irrigation-suction sheath system • Good entry and exit of the irrigation fluid Irrigation inflow is from sheath, and not from irrigation Channel in endoscope, irrigation outflow with the suction sheath • Clear endoscopic view Continuous suction and good irrigation flow • Effective evacuation of stone fragments One-way suction-active removal of stone fragments Mostly no need any forcep and basket
  • 13. outflow inflow Nephroscope Irriga tion pum p Irrigation-suction sheath SMP system Traditional mini-PCNL outflow inflow Nephroscope Irrigation pump Sheath inflow outflow stone fragments The hydrodynamic mechanisms for retrieval fragments in new generation SMP system and traditional mini-PCNL SMP system
  • 14. RPP in new-generation SMP • Basic RPP (mmHg) 8.94±3.58 • Intraoperative RPP (mmHg) 20.02±3.58 • Number of patients who had one episode of RPP ≥ 30 mmHg 81.5% • Accumulated time of RPP ≥ 30 mmHg (s) 114.89±132.65 Irrigation Pressure: 200-250mmHg Suction Pressure: 150-200mmHg Lower intra-renal pressure: less than 30mmHg Good space for operation
  • 15. Indications for SMP • Stone size less than 3cm • Failed SWL or RIRS • Especially for pediatric patients resistant to SWL
  • 16. SMP for adult nephrolithiasis 22 years old male, solitary right functioning kidney, multiple stones located in lower calyx and upper ureter, anuria, the DJ stent was left for 40 days. How to manage it? First choice: SWL? RIRS? PCNL?
  • 17. Multiple-tracts SMP - totally tubeless Multiple-tracts SMP - totally tube RIRS failed
  • 18. SMP (n=2012) vs. mini-PCNL (n=1513) for ≥ 2cm renal stones
  • 19. SMP could be a safer and more efficacious option for the treatment of renal stones of 2–3 cm, with the advantage of a shorter hospital stay.
  • 20. SMP for pediatric nephrolithiasis Girl, 2 years old, right kidney stone 2cm, SWL failure, stone composition analysis :cystine stone How to manage it? First choice: RIRS? PCNL?
  • 21.
  • 22. SMP for pediatric patients • Patients data (111 cases) • Gender: 71 boys and 41 girls • Age: 3.90± 3.53 yrs (0.5~15). • Stone burden (cm):1.4±0.6 (0.8-4.8) • Stone location, n (%) Upper ureter 33 (29.7%) Pelvis 26 (23.4%) Upper calyx 14 (12.6%) Middle calyx 9 (8.1%) Lower calyx 21 (18.9%) Multiple 8 (7.2%) • Positive preoperative urine culture 16 (14.4%) • HU value: 735.2±329.1 (288-1378)
  • 23. Results • Single tract: 111 (100%) • Operative time: 39.4±26.2 mins (7~105) • SFR (1 day after procedure) : 101 (91.0%) • SFR (3 months after procedure) : 106 (95.5%) • Hb dropped (g/L) : 10.2±7.1 (0~25) • Access size: 10F 2(1.8%), 12F 94(84.7%),14F 15(13.5%) • Puncture site:
  • 24. Results • Complications: fever (>38.5 °C) 7 (6.3%) • Transfusion:0%. • Total tubeless PCNL: 95 (85.6%) • Hospital stay (days): 2.7±1.5 • Stone composition (84 cases available): Calcium phosphate 4 (4.8%) Magnesium ammonium phosphate 6 (7.1%) Carbonate apatite 1 (1.2%) Uric acid 10 (11.9%) Calcium oxalate 25 (29.8%) Ammonium urate 37 (44.0%) Cystine 1 (1.2%) For pediatric stones of 10–20 mm, SMP could be an ideal choice with a high stone-free rate and minimal invasiveness.
  • 25. Half-day surgery SMP SMP under paravertebral block anesthesia • Fast recovery – Totally “tubeless”, short hospital stay and no need to come back for stent removal. – Discharged post-operative 5-6 hours. • Low risk of cross-infection of COVID-19 – Safe for doctors: No need to use ventilators – Safe for patients: One-day surgery, no need to stay overnight in the hospital • Comfortable and cost-effective
  • 27. Conclusion • New SMP solve all drawbacks in Mini-Perc • Achieve an excellent clinical outcome  High SFR  High total tubeless or tubeless rate  Short hospital stay  Less complications  Less(0.5%) Blood transfusion Best Culmination New SMP