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44 7° Congresso Nazionale Associazione Italiana di Endourologia Renal stones equal or less than 1,5 cm diameter ESWL-refractory renal stones Adjuvant procedure during standard PNL Pediatric PNL Antegrade LASER endopyelothomy rigid ureteroscope (at the beginning of our experience) using a ballistic probe for lithotripsy or a LASER probe, or better a 14 Fr rigid nephroscope (6 Fr operative channel) and all flexible instrumentation. It depends on the instrument’s availability of each department. Our indication for MIPP are: renal stones equal or less than 1,5 cm diameter as first choice or SWL-refractory; as adjuvant procedure during standard percutaneous Nephrolitotripsy if it’s necessary a second access for complicated lithiasis or infra-costal approach; anterograde management of uro-enteric strictures in neobladder or ileal conduit with flexible ureteroscope and LASER incision or pneumatic dilation; antegrade endopielotomy; anterograde access to kidney transplanted for renal/ureteral lithotripsy or anastomotic strictures; pediatric nephrolithotripsy; anterograde ureteral lithotripsy when it’s impossible or complicated to a classic retrograde ureteral access; foreign body extraction (when the retrograde way is not possible); treatment of caliceal diverticula with or without calculus inside; endourological treatment of pyelocaliceal superficial transitional cell carcinoma less than 1,5 cm (Table 1). When it’s necessary to minimize a renal damage for example in patients whit renal failure or coagulation’s disorders. From January 2002 to December 2006, we treated with Archivio Italiano di Urologia e Andrologia 2007, 79, 3, Supplemento 1 Table 2. Clinical Experience. First choice Nephrolithotripsy 38 pts (1 transplanted kidney; 2 with antegrade LASER endopyelothomy; 1 with lumbar stenosis dilation) ESWL- refractory stones 7 pts Adjuvant Nephrolithotripsy 9 pts Anterograde ureteroscopy for stones 1 pts Caliceal diverticula coagulation 2 pts Uretero-intestinal stenosis 4 pts (1 transplanted kidney in neobladder) Ablation of small, low grade renal TCC 1 pt Foreign body extraction 1 pt Table 1. MIPP: Our indications. Management of anastomotic strictures in entero- urinary diversions Antegrade ureteral lithotripsy Foreign body extraction when retrograde way is not possible Management of caliceal diverticula Management of small, superficial, low grade pyelocaliceal TCC MIPP, 63 patients (27 female and 36 male), mean age 45+17 years (range 2-76 years); 37/63 percutaneous procedures were performed in supine position. Percutaneous lithotripsy was performed in 57/63 patients, for stones of 21+10 mm burden (range 6-55 mm); 1/57 was transplanted kidney; of these in 38/57 pts was effected percutaneous lithotripsy as a first choice procedure; in 7/57 pts after ESWL procedure; in 2/57 pt was associated an endopyelotomy procedure with electric incision, in 2/57 pts a medial caliceal diverticulum was treated with diathermy; in 1/57 pt an infundibular stenosis was pneumatically dilated; 9/57 pts underwent adjuvant nephrolithotripsy with double access in complicated lithiasis; 2/57 pt needed a retrograde ureterolithotripsy with rigid ureteroscope for unaccesible ureter by retrograde access; 1/57 pneumatic dilation for a lombar stenosis after ureterolithotomy; 4/63 pts underwent a new recanalization for uroenteric strictures in 3 neobladders (1 kidney transplant in a neobladder) and 1 ileal conduit, after MIPP access a flexible ureteroscope allowed a pneumatic dilation of stenosis and a secondary LASER incision of the stenotic tract; double pig- tail stent was left for 3 weeks; in 1/63 pt was performed a LASER ablation of a small superficial transitional cell carcinoma; in 1/63 pt was extracted a ureteral stent migrated to the pelvis (Table 2).
RESULTS All patients are alive; for 57 nephrolithotripsy procedures stone-free rate was 98.3%; in 1 pt (1,7%) the procedure was unsuccessful (impossibility to perform nephrostomic access); in 3 pts (5,2%) occured bleeding with bladder plugging at drainage remove (3rd postoperative day) that needed stenting (mono J catheter for some days) and in two patients (2/3 pts) blood transfusion (3 units of heterologous blood in 1 pt and 1 unit of autologous blood in 1 pt); in 5 patients (8,7%) the postoperative anaemia without evidence of significant bleeding needed blood transfusion (2 units of autologous blood each in 4 patients and 1 unit of heterologous blood in 1 patient); totally, 7/63 pts were transfused (11%); in 1 patient in 7th postoperative day hydronephrosis without evidence of residual stones, that needed stenting; for residual procedures (6 patients) there were no complications; the mean extimated blood loss was 0,65 + 1,05 g/dL HB (range 0,1- 3,9 g/dL HB); the mean hospital stay was 4,2 + 2,8 days (range 2- 14 days). DISCUSSION The recent introduction on the market of miniaturized instruments has given strong evidence to the possibilities of being less invasive in the percutaneous procedures. This was made possible by the small diameter probes suitable to be used with L.A.SE.R., which proves very useful in lithotripsy. Besides the presence of flexible fibroscopes is highly suitable for the exploration of the renal cavities. All this has led to the construction of operative nephroscopes, aimed to obtaining the same results with the least possible parenchymal loss. Until the last year the few experiences of “minipercutaneous procedures” had to be effected with a technology unfit for this purpose, but adapted to the specific case, as in our experience, with obvious limitations in use and indication. In literature too very little has been said about mini percutaneous but only about single or rare experiences, often in the pediatric field, without the necessary directions for the standardization of the technical and instrumental characteristics required by any procedure for an objective analysis of the result. If all the Authors mentioned have agreed on the need of being as least invasive as possible towards the kidney by effecting nephrostomic approach of small diameter, there is always the problem of using different instruments, so in the pediatric experience. Even if Traxers experimental reports do not show, after 6 weeks, different functional results in terms of parenchimal damage, utilizing different sized nephrostomy tract (11 or 30 Fr)(1). Jackman et al (2). Helal et al (3) described initially the technique in children with the use of 11 Fr to 15 Fr peelaway and subsequently the use of a 13 Fr ureteroscopy sheath for working access. Feng et.(4) al in a prospective randomized trial to assess the efficacy and morbidity through standard PCN involved tract dilation to 30 Fr for passage of a 34 Fr working sheath and their 2 mini- 7° Congresso Nazionale Associazione Italiana di Endourologia PCN involved tract dilation to 22 Fr for passage of a 26 Fr sheath with tubeless procedure, no overall advantage was found for the mini-PCN versus the standard technique, imputing however the disadvantages of the microprocedures to the poorer visualization and optics and difficulty with the use of the nephroscopic graspers. Chan et al.(5) describes the use mini-PCN by means of 13 Fr ureteroscopy and stresses how the procedure reduces morbidity compared with the standard procedure in terms of efficiency and effectiveness for stone removal. In the abstract “role of Miniperc in the management of urolithiasis”, Bhargava et al. (6) evaluate the effectiveness of the procedure with 14 Fr (19 cm Length) access ureteric sheath and the use of the ureteroscopy of 8 Fr and pneumatic lithotripsy in 30 patients. They conclude that ”Miniperc” is a safe and very useful procedure. Also Monga et al.(7) describes the miniaturization of percutaneous nephrolithotomy, a natural evolution of the gold standard by using of 20 Fr compared with the traditional 30 Fr sheath. The Author points out that the reduction of the approach allows less bleeding and postoperative pain in 16 patients. Desai et al. (8) refers to a paediatric surgery experience with 45 renal Units in 40 cases using the paediatric nephroscope 14 Fr with a 2,4 mm working channel with dilatation of the approach from 18,5 to 24 Fr according to the age of the children. The Authors describes this procedure as safe ed appropriate option in the modern management of paediatric urolithiasis. Also Zattoni (9) in his personal experience (with the new 17 Fr nephroscope in renal stone and nephrostomic channel of 20 Fr) of 9 cases including 6 children suggests that paediatric nephroscope should be considered a standard part of the endourologic equipment. In our experience, the miniperc procedures allows significant reduction in blood loss: in a previous study of our group (10) we have compared three groups of patients that’s undergoes percutaneous procedures with various techniques of nephrostomy tract dilation to 34 Fr: 105 total patients, of which 59 progressive dilation with Amplatz metallic dilators, 36 with One- Shot technique and 15 with pneumatic dilation: in first group the extimated blood loss was 2,08 + 1,43 g/dL HB (0,3- 8,7 g/dL), in second group 1,64 + 0,95 g/dL HB (0- 3,9 g/dL), in third group 1,90 + 1,12 g/dL (0,2- 3,7 g/dL); in our actual series the extimated blood loss was 0,65 + 1,05 g/dL (0,1- 3,9 g/dL); the data are particularly significant in comparison with first group (p < 0,001), but remains also significant in comparison with second group (p < 0,05) and third group (p < 0,02) (Table 3). In our previous study we have also evaluated mean operating times, that were respectively 38 minutes with Alken metallic dilators, and 29 minutes with One-Shot or pneumatic dilation. In actual series mean operating times are more of 60 minutes: a demonstration (statistically significant, but also intuitive) of major expensiveness in operating time of miniperc procedures in comparison with standard nephrostomy tract accesses, independently of dilation technique. The mean hospital stay in present study was 4,2 + 2,8 days (range 2- 14 days); in previous study was 5,74 +3,54 days (range 2-20 days) Archivio Italiano di Urologia e Andrologia 2007, 79, 3, Supplemento 1 45
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Periodico trimestrale - Spedizione
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7° Congresso Nazionale Associazion
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16 Settembre 2007 7° Congresso Naz
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Ore 17:30-18:30 Golden video Tratta
Page 11 and 12: Aula Rossa Video Laparoscopia 1 Mod
Page 13 and 14: Quale TURP: mono o bipolare? C. Ter
Page 15 and 16: 19 settembre 2007 Ore 8:00-9:00 Aul
Page 17 and 18: Ore 9:00-13:30 AUDITORIUM 7° Congr
Page 19 and 20: ABSTRACTS Golden Communications 18
Page 21 and 22: in due casi è stata effettuata una
Page 23 and 24: Materiali e Metodi: con un doppio c
Page 25 and 26: in tutte le altre forme di neoplasi
Page 27 and 28: trissia; in 5 casi sono state utili
Page 29 and 30: manovre endourologiche per la rimoz
Page 31 and 32: matica. Non sono state registrate c
Page 33 and 34: Materiali e Metodi: Presentiamo il
Page 35 and 36: elativamente semplice, riproducibil
Page 37 and 38: Conclusioni: L’incisione laser pe
Page 39 and 40: ma è poco indicata per le fistole
Page 41 and 42: metriosi vescicale. Successivamente
Page 43 and 44: emostasi GYRUS è stata introdotta
Page 45 and 46: mento di scelta per la sua mininvas
Page 47 and 48: stent in quanto in 1 sono stati pos
Page 49 and 50: ilaterale in 3 casi, diretta e bila
Page 51 and 52: vaso di urina è stato trattato con
Page 53 and 54: endovision è piu’ sicura nell’
Page 55 and 56: Il terzo tempo è costituito dal po
Page 57 and 58: mente ricavato tra retto e vagina.
Page 59 and 60: The role of fluorescent cystoscopy
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Page 67 and 68: low-up. The increase in the mean Qm
Page 69 and 70: REFERENCES 1. Reich O, Gratzke C, S
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