P-BN50 Transcystic CBD Exploration: The First-Line Treatment of CBD Stone - A Single Centre 12-month Review of Practice

Background In the UK around 15% of the population will have gallstones and as such biliary pathology makes up a significant proportion of emergency and elective general surgical practice. Within this 10% will have choledocholithiasis; the management of which remains widely varied. A single-stage laparoscopic cholecystectomy with transcystic common bile duct exploration has been shown to be a safe and efficient option avoiding a choledochotomy and risks associated with ERCP. The aim of this study was a 12-month review of data following the adoption of this approach; assuming that laparoscopic transcystic CBD exploration was the ideal treatment for CBD stones. Methods This was a retrospective, single-centre, observational study. All patients who underwent a laparoscopic transcystic CBD exploration from June 2020 to June 2021 were included both in the elective and emergency setting. Patient demographics were varied with ages ranging from 15 to 76 and ASA classification of 1 -3, showing a significant proportion with comorbidities. Data collection was done through a review of a contemporaneous operative database and a follow-up morbidity period of 30 days was cross-referenced with electronic healthcare records. The primary outcome studied was CBD stone clearance. With secondary outcomes measures including complications, length of stay and the role of preoperative imaging versus intraoperative cholangiogram. Results A total of 49 patients were included within the study, of which 61% were emergency. The primary outcome of CBD stone clearance was achieved in all elective patients with one emergency patient requiring ERCP for a retained fragment at day 8. There were no other complications in the remaining 48 patients, making the 30-day morbidity 2% upon review of electronic care records. One patient was converted to open due to concern with regards to potential CBD injury but this was demonstrated not to be the case. The median duration of hospital admission was 3 days with a range from 0- 15, with the median stay for elective cases being 1 day. Finally, 39 patients underwent intraoperative cholangiograms prior to duct exploration as a means of identifying CBD calculi and delineating anatomy. Those 10 that did not; all had an MRCP within 30 days of surgery demonstrating CBD calculi and as such proceeded straight to CBD exploration. Conclusions Laparoscopic cholecystectomy and transcystic CBD exploration, with adequate training and exposure, is a viable and safe first-line approach for all cases of choledocholithiasis both in the elective and emergency setting; demonstrating advantages by avoiding additional procedures thereby reducing costs, inpatient bed days and a risk of further complications and being truly minimally invasive. The principal findings of this study were that the transcystic CBD exploration route can achieve successful CBD stone clearance rates in close to 98 per cent of patients with a low morbidity rate, and a short median length of hospital stay. This study of course has several potential limitations; given it was a retrospective single-centre observational study there is likely a degree of selection bias and although follow up was complete in all patients to 30 days via electronic care record it was not routine practice to offer face to face follow up given the low incidence of delayed complications. On the basis of this review, the transcystic approach has become the primary strategy for patients with common bile duct stones within this unit.

Comparison of stone clearance rate in patients with distal ureteric stones, undergoing URS with and without a safety guide wire.

Objective: To compare stone clearance rate in patients with distal ureteric stones, undergoing URS with safety guide wire and without safety guide wire. Study Design: Randomized Clinical Trial study. Setting: Department of Urology, Pir Abdul Qadir Shah Institute of Medical sciences. Period: January, 2020 to December 2020. Material & Methods: The study patients fulfilling the inclusion criteria were divided into two groups using the lottery method. Group A: Patients underwent URS with insertion of safety guidewire (SGW). Group B: These patients underwent URS without safety guidewire (SGW). Patients in both groups were compared for stone clearance. Results: Mean age in Group A was 37.79±12.44 years and in Group B were 33.31±11.48 years. Group wise distribution of gender showed 79 (73.83%) male and 28 (26.17%) females in Group A and 70(65.42%) male and 37 female (34.57%) in Group B. In comparison of both groups, 65.42% stone clearance was noted in Group A while 78.50% stone clearance was found in Group B and p-value found to be significant (P=0.033). Conclusion: Our study concluded that stone clearance in patients with distal ureteral stones undergoing URS without SGW is higher in comparison to URS with SGW, without any added advantage.

Comparison between different techniques for management of renal stones in horseshoe kidneys

Objective To report the operative management , intra and post operative complications and subsequent stone-free rates of patients with urolithiasis in a horseshoe kidneys. Materials and Methods We retrospectively reviewed all patients presenting to our centre with a horseshoe kidney and urolithiasis over a 20-year period. The stone burden, surgical management, complications and stone clearance rates were recorded. Results In all, 80 patients with urolithiasis in horseshoe kidney were treated. Percutaneous nephrolithotomy (PCNL) was used in 28 patients. 12 patients had laparoscopic assisted PCNL , 8 had flexible ureteroscopy and 18 had laparoscopic pyelolithotomy . PCNL was used for large stones = (mean digitized surface area= 614.32 mm 2 ) and required one to four stages to achieve an overall stone clearance rate of 88%. Stones were cleared at one sitting in 77% of PCNL procedures. only 33% of patients treated with flexible ureteroscopy was cleared from stones in one session and surprisingly, 89% of patients treated with laparoscopic pyelolithotomy was stone free after one session Complications were minimal, with 15% minor and 3% major complications in the PCNL group only.. Conclusions Appropriate management of urolithiasis within the horseshoe kidney depends not only on stone burden, but also on stone location, calyceal configuration and malrotation. Stones can be cleared successfully in almost all patients providing that all techniques are available to the operating surgeon.

Comparison of retrograde intrarenal surgery and mini-percutaneous nephrolithotomy for lower calyx renal stones

Background: Due to the anatomic characteristics of the lower calyx, lower polar stones are difficult to be removed through the ureter, retrograde intrarenal surgery (RIRS) can be used to deal with lower polar stones, while mini-percutaneous nephrolithotomy(mini-PCNL) is mainly used to deal RIRS failed to eliminate the stone. Aims and Objectives: Prospective comparison of mini-PCNL and retrograde intrarenal surgery outcomes in lower calyx managementwith respect to surgery duration, pain score (visual analog score), analgesic requirement, hemoglobin drop, and hospital stay. Materials and Methods: This is a prospective study in 50 patients (25 cases of RIRS and 25 cases of MINIPERC) over 2 years who came to the urology departme with lower calyx stone of size up to 20mm. The selection of the management methods was primarily based on the patient’s preferences. Preoperatively, all patients underwent routine workup and CT KUB plain. The primary and secondary objective was stone clearance rates, retreatment rate, complications, surgical duration, pain score (visual analog score [VAS]), analgesic requirement, hemoglobin drop, and hospital stay. Results: Miniperc and RIRS had stone clearance rates of 100% and 96%, respectively. In the RIRS group, one patient required retreatment for 1month. Hospital stay, intraoperative and post-operative complications were non-significant between both groups. Operative duration (P=0.003) was lower in the Miniperc group. Hemoglobin drop (P<0.0013), patient pain, and visual analog scale score at 6, 24, and 48 h, as well as an analgesic requirement (P<0.020), were all lower in the RIRS group. Conclusion: The stone clearance rates in both modalities are high, and complications are low. RIRS requires a longer operative duration, and it is associated with favorable pain scores and a lower hemoglobin drop.

Comparison of Standard Percutaneous Nephrolithotomy with Mini-Percutaneous Nephrolithotomy for Removal of Renal Stones in Adults

Renal stones are the third most common problem affecting about 10% of global population. The management of nephrolithiasis has undergone a complete transformation since the 1980s. Percutaneous nephrolithotomy (PCNL) has established itself an effective and safe technique that delivers high stone-free rate as well as overall shorter treatment time. We aim to compare the outcome of mini-PCNL with standard-PCNL in patients presenting with renal stones. In all, 90 patients fulfilled the selection criteria and randomized into two groups. Group A underwent mini-PCNL whereas Group B underwent standard-PCNL. Pre-operative hemoglobin level was recorded. Duration of procedure as well as drop in hemoglobin level was also recorded. A kidney, ureter, and bladder (KUB) X-ray was performed to confirm the presence of of stone and stone-free status. The mean age of patients in mini-PCNL group was 43.11 years and in standard-PCNL group, it was 36.91 years. The mean stone size in patients of mini-PCNL group was 29.53 mm and 31.58 mm in standard-PCNL group. The mean duration of renal stone in mini-PCNL group was 1.91 years and that in standard-PCNL group 1.80 years. The mean operative time in mini-PCNL group was 59.56 min and 61.22 min in standard-PCNL group. The mean fall in hemoglobin in mini-PCNL group was 0.38 g/dL and that in standard-PCNL group 0.51 g/dL. In mini-PCNL group, stone clearance was observed in 42 (93.3%) patients, while in standard-PCNL group, it was observed in 45 (100%) patients. This difference was insignificant (P > 0.05). Mini-PCNL and standard-PCNL have no significant differences in terms of outcome, operative time, and stone clearance, although fall in hemoglobin level was less in mini-PCNL group, which showed less blood loss in this group, thereby making it a more appropriate method for renal stone removal.

Effectiveness and Safety of Percutaneous Nephrolithotomy (PCNL) in Malrotated Kidneys

Background and Aim: The renal stones of any size could be effectively managed through an essential surgical technique known as Percutaneous Nephrolithotomy (PCNL). The large size renal stones with abnormal kidneys imposed additional challenges for PNCL in anomalous kidneys. The present study aimed to evaluate the effectiveness and safety of Percutaneous Nephrolithotomy in malrotated kidneys. Place and Duration: Conducted at Urology department of Mian Gul Abdulhaq Jehanzeb Kidney Hospital Manglawar, Swat for duration of two years (from May 2019 to April 2021). Materials and Methods. This single-centered retrospective study was conducted on 80 patients who underwent percutaneous nephrolithotomy with malrotation kidneys. The individuals with anomalous kidneys and complex calculi were enrolled in this study. These patients had kidneys anomalies such as horseshoe kidneys, crossed fused ectopia, malrotation kidneys, pelvic and complete stone clearance. Posterior or anterior approaches were followed for the procedure after preoperative evaluation in kidney anomalies. Retrograde catheterization was carried out under spinal and general anesthesia with the patients. For all the patients, stone size and clearance were measured. Results: Of the total 80 kidneys anomalies patients, 55 (68.7%) were male and 25 (31.3%) were females. Overall mean age was 35.26 ± 13.51. The stone size varied from 1.3cm to 7 cm. Patients were categorized into two groups based on stone sizes such as group I (1.3-2.5 cm) had 42 (52.5%) and group II (25-7cm) 38 (47.5%) patients. The patients included renal pelvis 19 (23.6%), the pelvic ureteric junction (PUJ) 8 (10%), horseshoe kidneys 2 (2.5%), crossed fused ectopia 9 (11.3%), and malrotation kidneys 3 (3.8%).The stone clearance was completed in 77 (96.3%) patients. The statistically significant factor for complete clearance was the staghorn stone calculus. Conclusion: Percutaneous nephrolithotomy is a safe and effective procedure for large renal stones management in patients of anomalous kidneys. Higher renal stones clearance can be achieved with minimum morbidity by suitable preoperative evaluation and technical experts. Keywords: Malrotated kidney; Nephrostomy, Percutaneous; Nephrolithiasis; Abnormality

Introducing in clinical practice a new laser suction handpiece for percutaneous nephrolithotomy

Objective: To assess a novel combined laser suction handpiece (LSH) for performing PCNL in a clinical setting. Methods: The study comprised 40 consecutive PCNLs performed between May 2019 and February 2020. The first 20 procedures (Group A) were performed with conventional ultrasonic or pneumatic devices and the other 20 (Group B) were performed with the use of the new LSH. All patients were treated by tubeless supine PCNL. The groups were compared for demographics, clinical data, operative time, lithotrite effectiveness, stone clearance rate (SCR), and outcome. Results: Groups A and B were similar in age, and in stone size, complexity, and density (Hounsfield units) ( p < 0.05). The average operative time was 99 and 78 min, SCR 143 and 200 mm3/min, hospital stay 1.6 and 1.1 days, and stone-free rate 90% and 95%, respectively. Despite a trend toward better results with the new LSH, none of these comparisons reached statistical significance. Ineffective lithotripsy with the initial device (ultrasonic) requiring conversion to another modality (ballistic) occurred in six (30%) procedures in Group A, while all procedures were effectively accomplished with the LSH in Group B ( p = 0.02). There were two complications in Group A and none in Group B ( p > 0.05). Conclusions: The LSH is as effective and safe as the traditional lithotrites for performing PCNLs. This new tool completes the capabilities of the holmium laser high-power machines, enabling them to serve as the sole platform for all endourological treatments.