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There has been recent introduction of novel lithotripters and high-power lasers for stone disintegration. With miniaturization of PCNL, there is need of effective disintegration and faster stone-clearance. This study aimed to evaluate efficiency of Trilogy™ and Thulium fibre laser (TFL) in mini-percutaneous nephrolithotomy (mini-PCNL). This is prospective study comparing efficiency and outcomes of Trilogy™ and TFL in mini-PCNL between January 2019 and February 2020. Primary objective was to compare stone fragmentation rates, with secondary objectives beings stone-free rates and complications. There were 60 mini-PCNL with suction using either Trilogy™ or TFL energy source. Mean stone size and density were 27.60 ± 10.17 mm, 22.04 ± 9.69 mm (p = 0.05) and 1172.9 ± 313.5HU, 1308.9 ± 333.9HU (p = 0.10) for Trilogy™ and TFL, respectively. Using 3D doctor imaging software from CT images, mean stone volumes were 3718.9 ± 3038.7mm3 for Trilogy™ and 3425.9 ± 3096.1mm3 for TFL(p = 0.77). Using probe-activation time or lasing time, stone-fragmentation rate was 5.98 ± 4.25mm3/sec for Trilogy™ and 3.95 ± 1.00mm3/sec for TFL(p = 0.015). Treatment time (puncture to complete clearance) was 32.48 ± 15.39 min for Trilogy™ and 28.63 ± 18.56 min for TFL(p = 0.38). Haemoglobin drop was 1.19 ± 0.76gm/dl for Trilogy™ and 0.99 ± 0.74gm/dl for TFL (p = 0.30). Trilogy™ arm had 96.6% complete clearance and TFL had 76.6% in TFL at 48 h. One patient in Trilogy™ arm required auxiliary RIRS for residual stone. Both arms had complete stone clearance at 1 month follow-up. Trilogy™ arm had 3 Clavien–Dindo grade-II complications while TFL had 2 Clavien–Dindo grade-II complications (UTI requiring antibiotics). There was no blood transfusion in either of arm. Trilogy™ had significantly better stone fragmentation rate than TFL in managing renal stones. However, stone-free rates and complications were comparable for Trilogy™ and TFL.

To report safety and efficacy of mini-PCNL with suction attached to sheath combined with high-power Thulium Fibre laser (TFL). The secondary aim was to evaluate optimal laser settings for maximum stone dusting. Prospective, single arm study was conducted from June 2019–December 2019 using miniPCNL with suction and TFL in 54 patients with renal stones 3 mm) and weighed. Xray/CT scan imaging was performed in all patients within 48 h and 30 days to assess stone clearance. Optimal laser settings were evaluated for maximum dusting. Mean stone size was 18.32 ± 6.37 mm, volume was 2337.75 ± 1996.84mm3 and stone density was 1300.55 ± 435.32 HU. Total operative time was 39.85 ± 20.52 min, laser time was 10.08 ± 7.41 min and stone fragmentation rate was 5.02 ± 3.93 mm3/s. The procedure was completely tubeless in 37.04%, nephrostomy tube in 37.04% and DJ stent placed in 25.92%. Postoperatively, three patients had urinary infection (Clavien 2). Complete stone clearance at 48 h was achieved in 35 (64.8%) cases. 19 patients (35.2%) who had residual fragments at 48 h, had 100% clearance at one month on CT/Xray KUB. MiniPCNL using a nephrostomy sheath with suction along with high power Thulium Fibre Laser is safe and effective modality for lithotripsy. An initial laser setting of 0.2 J and 125–200 Hz was optimal for maximum dusting and simultaneous aspiration. Randomized comparative studies with other energy sources are being considered.

In the original publication of the article, we inadvertently left the author Kay Thomas of the submission

The main aim of the paper is to report a single-centre experience with RAKT, focusing on surgical, perioperative and functional outcomes at a median follow-up of 2.8 years. Data of 26 RAKT patients was prospectively collected from December 2014 to February 2019 with follow-up of up to 55 months. All donors were done laparoscopically. We followed Vattikuti–Medanta technique with modification of using pfannenstiel incision instead of Gelpoint and patient positioned in steep Trendelenburg position (30°) with leg split position. Hypothermia was maintained using a “modified graft hypothermia jacket”. The engrafted kidney is oriented with the vessels being tagged with Prolene sutures. The mean BMI was 26.1 ± 4.7. The mean warm, cold and total ischemia times were 4.8 ± 1.1, 113.8 ± 20.9 and 118.7 ± 21.2 min, respectively. Mean rewarming time was 62.5 ± 10 min. The mean post-operative day (POD) 1, 3, 7, 30, 6 months, 1 year and most recent creatinine was 3.4, 2.4, 1.8, 1.4,1.2, 1.2 and 1.69 mg/dl. There was no case of delayed graft dysfunction (DGF) with graft survival of 1.8-55 months. The mean GFR at POD 1, 1 month and 1 year was 24, 53.16 and 64.6. We had two intraoperative complications—one topsy turvy graft placement with anastomosis of donor ureter to native ureter and other had to be converted to open technique after anastomosis to control graft surface bleeding. Three postoperative complications—one patient has graft pyelonephritis which was managed conservatively with antibiotics. Two patients had lymphocele. One patient was managed with just aspiration while the other required laparoscopic de-roofing of the lymphocele. The mean hospital stay was 13.5 ± 3 days. RAKT is feasible and safe only if performed by surgeons with appropriate background in robotic surgery and kidney transplantation after proper surgical training at experienced centres in the mid-term follow-up. Further studies need to confirm the long-term safety of RAKT.

Flexible uretero-renoscopy (FURS) is an accepted modality for management of renal calculi in orthotopically placed kidney. Though it has been used in management of calculi in anomalous kidneys, the literature is scarce.To define the role of FURS in the management of stones in anomalous kidneys.We performed a retrospective analysis of all the patients with anomalous kidneys who primarily underwent FURS from January 2010 to December 2015 at our institute. In our study, we included patients with anomalies of lie, fusion and rotation. A total of twenty-five patients with twenty-five renal units having renal calculi in anomalous kidneys were evaluated. Indications for FURS included stone size less than or equal to 2 cm, contraindication to PCNL like bleeding tendencies, patients on anticoagulants or patients who refused ESWL and PCNL. Complete clearance of stone was defined as no residual fragment greater than 2 mm at the end of 4 weeks. The parameters evaluated were patient demographics, type of renal anomaly, stone size, location, laterality, patient's presentation, need for preoperative stenting, operative time, need for postoperative DJ stent, hospital stay, analgesic requirement, number of stages or auxiliary procedures required for stone clearance, success rate and complications.Twenty-five patients with calculi in anomalous kidneys were managed with FURS. These 25 patients had a total of 37 stones. Out of 25 patients, 14 had ectopic kidneys with 19 stones, 5 had malrotated kidneys with 6 stones, 5 had horseshoe kidneys with 11 stones and one had a left-to-right crossed fused ectopia with a single stone. Average age of presentation was 38.28 ± 12.59 years. Majority of the patients had the stones located in pelvis (n = 11) or lower calyx (n = 11). Eight stones were in middle calyx (n = 8), five in upper calyx (n = 5) and two in upper ureter (n = 2). Fifteen patients had a single stone, and 10 of them had 2 or more stones. Average size of stone was 14.71 ± 4.11 mm and average density being 1210.8 ± 237.7 Hounsfield units. Five patients had a preplaced DJ stent. Average Operative time was 74 ± 21.2 min, and patients had an average hospital stay of 59.48 ± 17.8 h. DJ stent was placed postoperatively in 21 patients, and four were managed with a ureteric catheter. Complete clearance was achieved in 22 (88 %) patients, three patients required two stages and one required the third stage. Three patients (12 %) could not be managed with FURS and required percutaneous stone clearance.Primary FURS is an effective and less invasive modality for management of renal calculi less than 2 cm in kidneys with anomalies of lie, fusion and rotation. It can offset the low clearance rate and high complication rate of ESWL and PCNL, respectively. Ureteral access sheath is an important tool to overcome anatomical challenges of anomalous kidney. Basket and Laser are indispensable accessories for FURS in anomalous kidneys.

Urolithiasis is a significant worldwide source of morbidity, constituting a common urological disease that affects between 10 and 15% of the world population. Recent technological and surgical advances have replaced the need for open surgery with less invasive procedures. The factors which determine the indications for percutaneous nephrolithotomy include stone factors (stone size, stone composition, and stone location), patient factors (habitus and renal anomalies), and failure of other treatment modalities (ESWL and flexible ureteroscopy). The accepted indications for PCNL are stones larger than 20 mm2, staghorn and partial staghorn calculi, and stones in patients with chronic kidney disease. The contraindications for PCNL include pregnancy, bleeding disorders, and uncontrolled urinary tract infections. Flexible ureteroscopy can be one of the options for lower pole stones between 1.5 and 2 cm in size. This option should be exercised in cases of difficult lower polar anatomy and ESWL-resistant stones. Flexible ureteroscopy can also be an option for stones located in the diverticular neck or a diverticulum. ESWL is the treatment to be discussed as a option in all patient with renal stones (excluding lower polar stones) between size 10 and 20 mm. In addition, in lower polar stones of size between 10 and 20 mm if the anatomy is favourable, ESWL is the option. In proximal ureteral stones, ESWL should be considered as a option with flexible ureteroscopy Active monitoring has a limited role and can be employed in post-intervention (PCNL or ESWL) residual stones, in addition, asymptomatic patients with no evidence of infection and fragments less than 4 mm can be monitored actively.

To evaluate effect of intraperitoneal bupivacaine on postoperative pain in patients undergoing laparoscopic live donor nephrectomy. Hundred patients undergoing laparoscopic live donor nephrectomy were included in the study and were divided randomly into two groups based on computer-generated randomization chart of fifty each. Patients were made familiar with VAS chart preoperatively. Group A received 20 mL of 0.5 % bupivacaine, while group B patients received 20 mL of 0.9 % normal saline intraperitoneally Postoperatively, patients were assessed based on VAS and requirement of rescue analgesic, hemodynamic parameters and presence of any adverse effects. Student’s t test was used for statistical analysis. At all-time interval, mean pain scores were higher in group B than group A. The difference between the mean pain scores was statistically significant (p

To compare outcomes of robotic versus conventional laparoscopic pyeloplasty in children less than 20 kg by weight. Nineteen patients undergoing RP and twenty-five LP under 20 kg by weight were compared retrospectively with respect to demographics and operative, postoperative, and follow-up data. For all cases, a lateral transperitoneal approach was used and all anastomoses were stented. Success was defined as the resolution of preoperative symptoms and hydronephrosis postoperatively. If either case is not fulfilled, a renogram was obtained postoperatively. Student’s t test was used for statistical analysis. Forty-four patients underwent forty-seven pyeloplasties (19 RP and 25 LP), with three patients undergoing bilateral simultaneous laparoscopic procedure with mean age of 2.7 and 2.4 years in RP and LP, respectively. The robotic procedures were superior in terms of shorter mean hospital stay by one and half day on an average. Minimum time taken for RP was 60 min, while for LP it was 90 min. Both procedures were comparable in terms of complication rate, success rate as well as operating time. This comparative study confirms the feasibility, efficacy, and safety of robotic pyeloplasty in infants and toddlers. The obvious advantage is being shorter hospital stay. Further prospective studies will be needed to show its superiority over LP.

The indications for PCNL have seen a paradigm shift in the past decade. In the earlier years, PCNL was done for large-volume stones such as complex multiple calyceal calculi, staghorn stones. The advent of miniaturization of instruments ushered in smaller scopes, smaller retrieval devices, and energy sources. The miniaturization of instruments also was responsible in the paradigm shift in the indications for PCNL. These miniaturized instruments and accessories obviate the need to dilate the tract beyond 20 Fr. Various studies in the past have confirmed that reducing the tract size potentially also reduces the complications of percutaneous surgery.In this article, we discuss the new developments in percutaneous surgery in the past decade with emphasis on techniques of Microperc, Miniperc, and Ultraminiperc.The newer techniques with Miniperc are suited for stones 1.5-2 cm in size. Microperc and Ultraminiperc may be suitable for stone sizes1.5 cm. These are also suited for special situations such as diverticular stones and pediatric moderate-sized stones. The indications of these newer techniques compete with those of extracorporeal shockwave lithotripsy and flexible ureteroscopy.

“Big” scars for stone removal are only needed in unusual circumstances. This is true given the fact that technology is fast evolving and instruments becoming smaller and smaller. The management of urolithiasis in children has undergone a paradigm shift in the past decade. Management of pediatric urolithiasis necessitates a balance between stone clearance and morbidity related to the procedure. A variety of treatment options are available, which include shock wave lithotripsy (SWL), percutaneous Nephrolithotomy (PCNL), and retrograde intra renal surgery (RIRS) and open surgery. Concerns regarding endourologic treatment include eVect on the renal development and function, the side eVects of radiation, and the implications of residual stones. Children with pediatric urolithiasis need to be worked up metabolically to prevent recurrence. The treatment options should be chosen with prudence, as each of the treatment options has its share of problems. SWL has been the treatment of choice for renal calculi less than 15 mm in size. The stone-free rates range from 68 to 84% [1]. In our study, ESWL was found to be safe and eVective in children as was in adults for solitary renal and upper ureteric stones less than 2 cm in size. We found that children required fewer and lower energy shock waves to achieve equivalent results. Considering that long-term data are awaited regarding functional consequences of shock waves on pediatric kidneys, it would be prudent to shock these kidneys as little as possible. In this context, we feel to minimize the “shock loss,” and optimizing the number and energy of shock waves, the patient should be given optimum anaesthesia with the use of ultrasound and Xuoroscopy for localizing and monitoring of stone fragmentation [2]. PCNL remains the most eVective option for treating large stones in this age group. The obvious downside of this approach is the potential for life-threatening complications such as bleeding; hence, surgeon experience is paramount in deciding the number and site of access. Stone-free rates of more than 90% have been shown in pediatric age group [3]. Percutaneous Nephrolithotomy has been described even in children as small as 11 months, having complex calyceal stones and/or staghorn calculi. The method to gain access, ultrasound or Xuoroscopy, is a matter of experience and personal preference. Ultrasound oVers the advantage of visualization of spleen and liver and avoids injury. It also minimizes radiation to these kids. The key to success in PCNL in these small patients is staging the procedure if required, miniaturization of instruments, and using ultrasound as the method of achieving access. PCNL oVers a good clearance rates with acceptable morbidity. Miniaturization of instruments particularly smaller nephroscopes and newer energy sources will decrease the morbidity of PCNL. The question is how small is small enough! In this regard, in our opinion, microperc is the “new kid on the block.” It has a role to play in percutaneous management of these small patients. Essentially, “microperc” involves performing the procedure through the eye of the needle. The microoptics of 0.9 mm diameter are used. The assembly has a integrated light head inserted through the working sheath of the needle, and PCNL can be done through the same needle sheath with a 3-way needle allowing irrigation, passage of Xexible telescope and a laser Wbre [4]. Although investigational, larger multicentre trials that are already underway will prove its utility. M. Desai (&) Nadiad, India e-mail: mrdesai@mpuh.org