(UroToday.com) During the plenary session, a debate occurred concerning standard percutaneous nephrolithotomy (PCNL) status. Four experts compared the safety and advantages and disadvantages of different types of PCNL surgery, and at the end, moderators asked audiences their opinion about the role of standard PCNL.
Dr. Karen Stern from Mayo Clinic Arizona, a strong advocate for standard PCNL, began her presentation by comparing the stone-free rate, hospital stay duration, and operative time of mini PCNL versus standard PCNL. She found no superiority for mini PCNL in these aspects.
Time efficiency is crucial, and she showed a video that a well-trained urologist could remove a 1.3 cm kidney stone with a grasper within seconds, minimizing the need for longer operative times. This can also help reduce the risk of infections. Additionally, concerns about increased intrarenal pressure associated with mini PCNL were raised. Dr. Stern also mentioned that ambulatory PCNL is a safe practice in standard PCNL and presented a study in support of this approach. Another advantage of standard PCNL is its superior visualization, and a flexible cystoscope fits in the standard PCNL tract.
Then Dr. Lahme from Goldstadt Private Clinic, Germany, took the stage as a proponent of mini PCNL. He mentioned that current guidelines recommend mini-PCNL for stones and presented a study showing fewer complication rates for mini-PCNL. He attributed these lower complication rates to less diameter of the tract. Interestingly he claimed that mini-PCNL is more cost-effective than standard PCNL, and he attributed this to a reduction of operative time due to ease of sheath insertion, no need for graspers and forceps, reusable equipment, and the possibility of performing the surgery on an outpatient basis.
Interestingly, Dr. Lahme suggested that mini PCNL may be more cost-effective than standard PCNL, as it reduces operative time, eliminates the need for graspers and forceps, and allows for the use of reusable equipment. Additionally, he noted that performing the surgery on an outpatient basis can further reduce costs. Overall, he emphasized the importance of individualizing the approach to each patient, taking into account factors such as stone size, location, and patient comorbidities, when selecting between standard and mini PCNL.
Dr. Marcelino Rivera from Indiana University, who advocates for mini PCNL, spoke next. He stated that the only indication for standard PCNL currently is for stones larger than 4 cm. According to him, mini PCNL has an equivalent stone-free rate and no difference in terms of the need for ancillary procedures.
Although operative time is longer with mini PCNL, it has a lower transfusion rate and fewer complications. He also discussed the feasibility and safety of mini-PCNL in obese patients, even with a BMI of 36, as well as in patients for whom renal parenchyma preservation is crucial and those who cannot tolerate bleeding (such as the elderly and those with chronic kidney disease).
Dr. Brad Schwartz, the final speaker and a proponent of standard PCNL, emphasized the advantages of this method over mini PCNL. He cited a survey of 331 urologists with and without formal endourology training, which demonstrated that greater knowledge in percutaneous surgery correlated with a higher interest in performing standard PCNL. Dr. Schwartz argued that standard PCNL offered advantages such as lower intrarenal pressure during surgery, faster and larger fragment removal, and shorter operating time with no difference in transfusion rate.
Additionally, standard PCNL was associated with less infection and bacterial dissemination and less tissue injury due to reduced manipulation.
After the discussion, Dr. Gutierrez-Aceves surveyed the audience to determine their preference for PCNL techniques. The results showed that almost all the audience members believed that there is still a significant role for standard PCNL despite some advantages of mini-PCNL.
Presented by:
Karen Stern, MD, Mayo Clinic Arizona
Sven Lahme, Prof. Dr. med, Goldstadt Private Clinic, Germany
Marcelino Rivera, MD, Indiana University
Bradley Schwartz, DO, Southern Illinois University
Jorge Gutierrez-Aceves, MD, Cleveland Clinic
Written By: Seyed Hossein Hosseini Sharifi, MD, Department of Urology, University of California Irvine, @Sharifi_shh on Twitter during the 2023 American Urological Association (AUA) Annual Meeting, April 29, 2023, Chicago, Illinois.