RIRS VS PNL (2).pptx

RIRS vs PNL crossfire lecture

1. PCNL FADING AWAY

2. Renal Stone PCNL is here to stay PCNL will go away

3. The territories of Renal Stone disease Small less than 10 mm Medium 10-20 mm Large more than 20 mm Special situations

4. 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

5. Small less than 10 mm Medium 10-20 mm Large more than 20 mm Special situations

6. Large and complex upper urinary tract calculi can be addressed safely and efficiently with retrograde endoscopic techniques.

7. obesity Anatomy previous treatment failure poor candidates 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 %).

8. Bansal P, Sehgal A (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

9. Multisession FURS could 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 .

10. ?

11. Will Rogers phenomenon

12. The indications of PCNL is getting less and narrowed by more contraindications PCNL ESWL RIRS

13. Small less than 10 mm Medium 10-20 mm Large more than 20 mm Special situations

14. PCNL contra indications Untreated infection. Coagulopathies bowel interposition. Tumour in the tract area. Pregnancy

15. Retrograde intrarenal surgery (RIRS) and other MIT has become more and more fashionable because of its high safety and repeatability

16. 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

17. Small less than 10 mm Medium 10-20 mm Large more than 20 mm Special situations

18. Today, fURS is quickly 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

19. Minimally invasive High success 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

20. 4 th grade penetrating renal trauma Controlled????

21. 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

22. A total complication rate of up to 83% following percutaneous nephrolithotomy was recognized. These complications were mostly clinically insignificant including minor bleeding or fever.

23. The PCNL operation was 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

24. Colonic injury Persistent leakage requiring Stenting  bleeding Grade l (7.9%), Grade 2 (3.17%), Grade 3a (4.76%) and Grade 3b (1.58%).

25. The issue of pre-op stenting

26. Urology. 2012 Dec;80(6):1214-9.

27. retrospective review of 421 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.

28. A total of 11,239 patients from nine studies SFR OR time Compliations

29. UAS no difference in SFR ureteral injury or hemorrhage did not increase postoperative infection decreased CROES

30. Learning curve 24 PCNL 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.

31. An improvement in operation 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.

32. OPEN SURGEY pyelolithotomy PCNL Not truly minimally invasive All happen in urine

33. Complications didn’t change along time and experience

34. 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 .

35. higher cost effectiveness compared to flexible ureteroscopy

36. 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

37. 6 of 67 patients (8.95%) suffered from significant hemorrhage in this study, 4 of the patients (5.9 %) required blood transfusion.

38. Taking all these factors 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.

39. x inlet

40. The scope and digital image acquisition Accessories Disposable scopes Robotic RIRS Hybrid techniques

41. Conclusions: fURS with holmium 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.

42. Who is the Strongest bully الفتوة ?

43. Future algorithm

44. The complications of 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 ?

45. 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.

46. Common (greater than 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

47. into increased efficacy and 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.

48. the data to date 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.

49. 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.

50. Cx diverticulum

51. Miniaturization didn’t add

52. A continuous reduction of 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