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![Micro PCNL UMP
overall complication rate was 15.2%
[Clavien classification
I (44%), II (28%), III (28%)]
overall complication rate
was 6.2% [Clavien classification I (57%), II
(36%), III
(7%)], with](https://image.slidesharecdn.com/rirsvspnl2-241024111350-c47242b4/85/RIRS-VS-PNL-2-point-counter-point-ppt-55-320.jpg)
![Results: From January 2001 to December 2015, 114,789 ureteroscopy or pyeloscopy procedures for stone
extraction in adult patients were performed in Australia. During the same period, 48,209 SWL and 6956 PCNL
procedures were performed. Ureteroscopy and pyeloscopy procedures have been increasing by an average of
9.3% year-on-year, population adjusted, while SWL has decreased by 3.5% and PCNL by 6.4% every year over
the same period. In absolute terms, scope procedures have increased yearly by an average of 3.9 per 100,000 of
population (confidence interval [95% CI]: 3.2, 4.5), while SWL has changed by -0.77 (95% CI: -0.88, -0.65)
and PCNL by -0.16 (95% CI: -0.17, -0.14).
Conclusion: Over the past 15 years in Australia, the total number of stone treatment procedures has increased
significantly. Considerable increases in ureteroscopy were observed with relative and absolute reductions in
SWL and PCNL. Regional variations in urolithiasis management strategies highlight the need for consensus on
stone treatments within Australia.](https://image.slidesharecdn.com/rirsvspnl2-241024111350-c47242b4/85/RIRS-VS-PNL-2-point-counter-point-ppt-71-320.jpg)
![Nano-robots
• endoscopic application nearly atraumatic and
improve treatment precision and quality.
• Recent technical progress has made this former
science-fiction scenario a potential reality.
• Nanomotors, -pumps, and -electromechanical
manipulation devices are being developed for
future use in the human body [52,53].
• These techniques should comprise next
generation treatment approaches for urolithiasis.](https://image.slidesharecdn.com/rirsvspnl2-241024111350-c47242b4/85/RIRS-VS-PNL-2-point-counter-point-ppt-77-320.jpg)
Uploaded byAhmed Eliwa
RIRS VS PNL (2) point counter point ppt
Percutaneous nephrolithotomy (PCNL) faces challenges as alternative methods like retrograde intrarenal surgery (RIRS) and flexible ureteroscopy (FURS) gain popularity due to their safety and reduced complications. Analysis of procedures from 2001 to 2015 in Australia reveals an increase in ureteroscopy and a decline in PCNL and shockwave lithotripsy (SWL), indicating a shift in treatment paradigms. Future advancements in robotic assistance and nanotechnology may further influence surgical approaches in managing renal stones.
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RIRS VS PNL (2) point counter point ppt
- 2.
- 3. Renal Stone PCNL ishere to stay PCNL will go away
- 6. The territories ofRenal Stone disease Small less than 10 mm Medium 10-20 mm Large more than 20 mm Special situations
- 7. 2007 200 8 2009 2010 20112019 Stone less than 300 mm 2 • ESWL • PNL Stone MORE than 300 mm 2 • PNL • ESWL WITH OR WITHOUT PNL • PNL with or without ESWL • Open Stone less than 300 mm 2 • ESWL • PNL • RIRS • LAP • OS Stone MORE than 300 mm 2 • PNL • ESWL WITH OR WITHOUT PNL • PNL with or without ESWL • LAP In lower pole • ESWL • PNL • RIRS • Are competing 1b A ESWL refractory stone • RIRS 1b A 2011 2012 2019
- 9. Small less than10 mm Medium 10-20 mm Large more than 20 mm Special situations
- 10. • Large andcomplex upper urinary tract calculi can be addressed safely and efficiently with retrograde endoscopic techniques.
- 11. obesity Anatomy previous treatment failure poorcandidates for PCNL) •73.9% of patients were stone free (88% lower pole) •8.7% progressed to further intervention. •more than 4 cm predicted treatment failure (40%).
- 12. Bansal P, SehgalA (2017) Expanding Indications of Flexible Ureteroscopy in Renal and Ureteral Stones. J Urol Ren Dis 2017: 147. DOI: 10.29011/2575-7903.000147 • Senior Consultant Urologist, RG Stone and Super Speciality Hospital, Ludhiana, India
- 15. • Multisession FURScould provide a comparable final SFR and shorter recovery time with fewer overall complications in the treatment of intermediate-size renal stones (2-3cm), which could indicate that FURS is an effective and safe alternative to PCNL in the treatment of patients with intermediate-size (2-3cm) renal stones.
- 16.
- 17.
- 18. The indications ofPCNL is getting less and narrowed by more contraindications PCNL ESWL RIRS
- 19. Small less than10 mm Medium 10-20 mm Large more than 20 mm Special situations
- 20. PCNL contra indications •Untreated infection. • Coagulopathies • bowel interposition. • Tumour in the tract area. • Pregnancy
- 23. • Retrograde intrarenalsurgery (RIRS) and other MIT has become more and more fashionable because of its high safety and repeatability
- 24. INDICATIONS of RIRS •failure of previous SWL • lower calyx stones • smaller than 1.5 cm. Ben Van Cleynenbreugel1, Özcan Kılıç2, Murat Akand Retrograde intrarenal surgery for renal stones - Part 1 Turk J Urol 2017; 43(2): 112-21 “However, the limitations in the indication of RIRS has been reduced recently” • Medium-sized stones those are not suitable for SWL or PCNL • SWL-resistant stones • Non-opaque stones • Existence of anatomic abnormalities • Co-existence of renal and ureteral stones • Need of treating bilateral renal stones successfully in a single session • Multiple kidney stones including nephrocalcinosis • Bleeding disorders • patients with urinary diversion • Combined or ancillary procedures following PCNL • Renoureteral malformations • Patient habitus (obese, musculoskeletal deformities) • Stones >3 cm (may require two or more sessions) Ben Van Cleynenbreugel1, Özcan Kılıç2, Murat Akand Retrograde intrarenal surgery for renal stones - Part 1 Turk J Urol 2017; 43(2): 112-21
- 26. Small less than10 mm Medium 10-20 mm Large more than 20 mm Special situations
- 27. Today, fURS isquickly evolving from a procedure for exclusive use of enthusiast to a mainstay of treatment for the majority of urinary stones even in the most complicated clinical scenarios. Volume 36, Part D, December 2016, Pages 681-687
- 29. Minimally invasive • Highsuccess rate at accepted cost and complications • Easy to perform • Short learning curve • Reproducible • Amenable to technical refinements I thought its going to be minimally invasive surgery
- 30. • 4th grade penetratingrenal trauma Controlled????
- 32. Complications • Acute Hemorrhage •Delayed Hemorrhage • Collecting System Injury • Visceral Injury • Pleural Injury • Metabolic Complications • Postoperative Fever and Sepsis • Neuromusculoskeletal • Venous Thromboembolism • Tube Dislodgement • Collecting System Obstruction • Loss of Renal Function • Death Position related (pulmonary dysfunction 5-10%. Atelectasis and decreased functional capacity both sides) Technique related : Pneumothorax<5% Hypotension hemorrhage <10% residual stone and migration, ureteral and vascular injuries Post op.: prolonged leakage, hemorrhage, decreased renal function and stone recurrence . ( Bodner and Resnick, 1990) PCNL Open
- 34. A total complicationrate of up to 83% following percutaneous nephrolithotomy was recognized. These complications were mostly clinically insignificant including minor bleeding or fever.
- 35. The PCNL operationwas found to have a significantly higher risk for readmission when compared to RIRS (27.1% vs. 20.4%, respectively, p = 0.0041). Complications Residual stones
- 36. Colonic injury Persistentleakage requiring Stenting bleeding Grade l (7.9%), Grade 2 (3.17%), Grade 3a (4.76%) and Grade 3b (1.58%).
- 38. The issue ofpre-op stenting
- 39.
- 40. retrospective review of421 patients undergoing ureteroscopy from February 2014 to present was conducted. Prestenting did not influence operative time (P = 0.8534) or stone free ‑ rates (P = 0.2241). dURS patients were more likely to call the nurse; however, psURS versus dURS yielded no difference in return to the ED or readmission within 90 days. Conclusions: In this study, preoperative stenting offered few operative advantages and did not meaningfully influence returns to the ED and readmissions within 90 days after ureteroscopy.
- 41. A total of 11,239 patients fromnine studies SFR OR time Compliations
- 42. UAS • no differencein SFR • ureteral injury or hemorrhage did not increase • postoperative infection decreased CROES
- 43. Learning curve • 24PCNL procedures to obtain a good proficiency • Competence at after 60 cases • excellence is obtained at >100 cases. PCNL is the most complicated stone surgery technique to teach.
- 44. An improvement inoperation duration was observed, and absence of complications was achieved after 45 cases. The improvement in stone clearance was observed up to the last subjects. Competence and excellence were achieved after 45 and 105 operations, respectively.
- 46. OPEN SURGEY pyelolithotomy PCNL Not trulyminimally invasive All happen in urine
- 49. Complications didn’t change alongtime and experience
- 50.
- 52. •Midi-PCNL •mini-PCNL •ultra-mini-PCNL (UMP) •mini-micro-PCNL •micro-PCNL (m-PCNL) •super-mini-PCNL(SMP) • confusing and misleading • there is no standardized • longer OR time • potentially higher intrarenal pressure may limit the benefit of super miniaturized systems.
- 54. • higher costeffectiveness compared to flexible ureteroscopy
- 55. Micro PCNL UMP overallcomplication rate was 15.2% [Clavien classification I (44%), II (28%), III (28%)] overall complication rate was 6.2% [Clavien classification I (57%), II (36%), III (7%)], with
- 57. 6 of 67patients (8.95%) suffered from significant hemorrhage in this study, 4 of the patients (5.9%) required blood transfusion.
- 58. Taking all thesefactors into account, we could treat a small stone in a low risk stone former with a big access PCNL, harvesting the stone en bloc to reduce future stone formation and at the same time do a flexible approach even in larger stone burden in high-risk stone formers, knowing that these patients suffer from future stones anyway.
- 59.
- 61. • The scopeand digital image acquisition • Accessories • Disposable scopes • Robotic RIRS • Hybrid techniques
- 62. Conclusions: fURS withholmium laser lithotripsy without fluoroscopy was a feasible and safe treatment for kidney stones. There was no difference between the use of fluoroscopy or not regarding complications or SFR. Thus, we can reduce the risks of radiation exposure to patients and medical staff whilst maintaining surgical success. However, multicentre randomised controlled studies are necessary to evaluate fluoroless URS further and to confirm our present results.
- 64. Who is theStrongest bully ?الفتوة
- 68. Future algorithm Renal stone Less than20 mm RIRS ESWL 20-40 mm Extra-renal pelvis No previous scar Low stone score LAP-RAP RIRS Intrarenal pelvis Previous scar High stone score PCNL RIRS ECIRS special clinical situation RIRS LAP RAP PCNL Lower pole stone RIRS PCNL ESWL More than 40 mm PCNL RIRS ECIRS Open surgery-LAP
- 69. MIT RENAL Stone PCNL SUPINE SUPINE IN STAGHORN SUPRACOST ALSUPINE RIRS MINI PERC VS FURS in lower CX MINI Vs URS in PELVIC St Lap pyelolith otomy
- 70. • The complicationsof PCNL are still present and did not disappear with miniaturization of the track • The learning and teaching • The cost • The literature effect, and nothing new • PCNL limitations ? • RIRS is the future ? • What are the limitations of RIRS , and are they really considered limitations ?
- 71. Results: From January2001 to December 2015, 114,789 ureteroscopy or pyeloscopy procedures for stone extraction in adult patients were performed in Australia. During the same period, 48,209 SWL and 6956 PCNL procedures were performed. Ureteroscopy and pyeloscopy procedures have been increasing by an average of 9.3% year-on-year, population adjusted, while SWL has decreased by 3.5% and PCNL by 6.4% every year over the same period. In absolute terms, scope procedures have increased yearly by an average of 3.9 per 100,000 of population (confidence interval [95% CI]: 3.2, 4.5), while SWL has changed by -0.77 (95% CI: -0.88, -0.65) and PCNL by -0.16 (95% CI: -0.17, -0.14). Conclusion: Over the past 15 years in Australia, the total number of stone treatment procedures has increased significantly. Considerable increases in ureteroscopy were observed with relative and absolute reductions in SWL and PCNL. Regional variations in urolithiasis management strategies highlight the need for consensus on stone treatments within Australia.
- 73. • Common (greaterthan 1 in 10) • Mild burning or bleeding on passing urine for short period after operation • Temporary insertion of a bladder catheter • Insertion of a stent with a further procedure to remove it • The stent may cause pain, frequency and bleeding in the urine • Recurrence of stones • Occasional (between 1 in 10 and 1 in 50) • Inability to retrieve the stone or movement of the stone back into kidney where it • is not retrievable • Kidney damage or infection needing further treatment • Failure to pass the telescope if the ureter is narrow • Rare (less than 1 in 50) • Damage to the ureter with need for open operation or tube placed into kidney • directly from back to allow any leak to heal • Very rarely, scarring or stricture of the ureter requiring further procedures
- 74. into increased efficacyand safety, and— sometimes—decreased costs. Furthermore, the evolution of endoscopes, and ancillary device and instruments has resulted in considerable expansion of indications for ureterorenoscopic treatments.
- 76. the data todate and the ongoing development of new robotic devices are encouraging for robotic stone surgery in the near future. Therefore, in the authors’ opinion, especially regarding the field of endourological surgery, there will be a shift towards the use of robotic (assistance) devices.
- 77. Nano-robots • endoscopic applicationnearly atraumatic and improve treatment precision and quality. • Recent technical progress has made this former science-fiction scenario a potential reality. • Nanomotors, -pumps, and -electromechanical manipulation devices are being developed for future use in the human body [52,53]. • These techniques should comprise next generation treatment approaches for urolithiasis.
- 78.
- 79.
- 80. A continuous reductionof tract size is not the only revolution of the last years. There is constant ongoing interest in developing new efficient miniature instruments, intracorporeal lithotripters and sophisticated tract creation methods. We can summarize that, PCNL represents a valuable well-known tool in the field of endourology. We should be open minded to future changes in surgical approaches and technological improvements. inlet
Editor's Notes
- #2 The title refers to the idea that the nature of evil has changed, and old value systems no longer apply.
- #10 Territories large stone
- #11 Territories large stone
- #17 The Will Rogers phenomenon is obtained when moving an element from one set to another set raises the average values of both sets. It is based on the following quote, attributed (perhaps incorrectly)[1] to comedian Will Rogers: When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states.
- #25 Special situations
- #33 Pcnl complications are heavy
- #35 Complications with pcnl
- #52 Reducing the instrument size less than 10 Fr takes away the possibility of stone extraction and potentially raises the intrarenal pressure into pathological levels. Sheath sizes less than 14 Fr tend to have a longer operation time and decreasing SFR in larger stones. Therefore, it is questionable whether miniaturization below 18 Fr improves outcome and safety in a standard patient.
- #58 For many years endourologists are searching for the most efficient and least traumatic stone treatment. More and more miniaturized instruments and innovative stone disintegration tools are continuously expanding our armamentarium [1, 2]. Meanwhile, currently available modern imaging modalities are able to detect more and smaller residual fragments postoperatively. In that way, the average stone-free rates are decreasing dramatically despite our new sophisticated treatment options [3]. Dealing with this dilemma we have to take into consideration that in first-time stone formers complete stone-free status seems to be of uttermost importance since even residual fragments smaller than 4 mm could be responsible for acute symptoms in the future [4–6]. But what are the possibilities to offer the best solution to our patients? Which technologies fit the need for the least traumatic but most efficient procedure in stone surgery? Accessing almost every part of the kidney is possible with new flexible multiple-use and disposable instruments. Pressure control can be achieved by the use of access sheaths and irrigation/suction devices. New high-frequency and lowpower laser technologies enable us to dust stones of any composition and size in reasonable time and minimum risk. Yet late postoperative radiologic control after 1–3 months is discouraging [3, 7]. A significant number of patients suffer from residual fragments and their consequences, namely renal colic and stone growth [6, 8]. A number of well-known factors may play a role in postoperative stone clearance, like patient mobility, kidney geometry, and fluid intake [9]. Nevertheless, a straightforward prediction of a stone-free status cannot always be made preoperatively. Recent knowledge about different tract dilation methods might relativize the theory of size-related bleeding complications in PCNL [10]. The most effective method does avoid residual fragments by achieving stone extraction in one piece. Risk stratification of stone patients in high and low-risk stone formers and its impact on new stone formation might help us to predict the necessity of a stone-free status in low-risk patients [6]. On the other hand, in the case of high-risk stone formers, fragments can be removed in minimum time, leaving eventually dust and plaques behind but reducing an intervention-dependent risk.
- #62 New in furs