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The management of medium-sized (1–2 cm) lower poles renal stone has been a contentious topic for endourologists. There are limited evidences to answer the best management options for medium-sized lower pole renal stone. This network meta-analysis provided high-level evidences on efficacy and safety of profile of PCNL, Mini-PCNL, Ultra-PCNL, RIRS, Micro-PCNL, SWL for management of medium-sized lower pole renal stone. Systemic review and network meta-analysis (NMA) of randomized control trials was conducted. The PICOS (Population, Interventions, Comparison, Outcomes, and Study) approach was used to look for relevant studies. Searches were conducted at major electronic databases like Medline via PubMed, Embase, Google Scholar, SCOPUS, ScienceDirect, Cochrane library, Web of Science, and ClinicalTrials.gov to find relevant articles from the inception to April 19, 2023. Fourteen randomized control trials involving 2194 patients were among these studies that met the eligibility criteria. Pooled SFR was Mini-PNCL 98% (95% CI 96–99%), Ultara-PCNL 96% (95% CI 93–98%), RIRS 90% (95% CI 88–92%), PCNL 88% (95% CI 85–92%), Micro-PCNL 77% (61–88%) and SWL 69% (95% CI 65–74%). Mini-PCNL provided a statistically significant higher SFR compared to RIRS (RR = 2.43 91.52; 3.89)), Micro-PCNL (RR = 3.19 (1.09; 9.38)), and SWL (RR = 6.17 (3.65; 10.44)), but there was no statistical significance with standard PCNL (RR = 1.06 (0.52; 2.16)) and Ultra-PCNL (RR = 1.37 (0.75; 2.51)) for management of medium-sized lower pole renal stone. The order of SUCRA values for complication rate was as follows: PCNL(90%), Micro-PCNL(70%), Mini-PCNL(50%), Ultra-PCNL(50%), RIRS(40%), and SWL(10%). The current pooled evidence from fourteen randomized control trials revealed that Mini-PCNL, Ultra-PCNL, and standard PCNL are likely the best treatments for medium-sized lower poles when SFR over a short period of minimal session is a priority. These treatment options have a higher rate of complications, longer hospital stays, and acceptable operations time. RIRS and SWL treatment have acceptable efficacy stone-free rate with low complication rate, short hospital stays, and operation time. These treatment option would be the best fit for solitary kidney, coagulopathy, and comorbidity.

Our study was aimed to evaluate the postoperative outcomes of Mini Percutaneous Nephrolithotomy (Mini-PCNL) and Standard Percutaneous Nephrolithotomy (Standard-PCNL) to determine the optimum option for patients with renal calculi. For publications published between January 2010 and April 2021, a comprehensive search of the PubMed, Cochrane Library, Web of Science, and EMBASE databases was done. The literatures were chosen based on the criteria for inclusion and exclusion. After the data were retrieved and the quality was assessed, the meta-analysis was performed using Review Manager Software (RevMan 5.4.1, Cochrane Collaboration, Oxford, UK). We selected 20 trials with a total of 4953 people out of 322 studies. There were 2567 patients treated with Mini-PCNL and 2386 patients treated with Standard-PCNL. Meta-analysis results showed no difference in stone-free rates (SFR, P = 0.93), fever (P = 0.83), and postoperative pain (VAS score) (P = 0.21) between Mini-PCNL and Standard-PCNL. Patients in the Mini-PCNL group experienced shorter hospital stay (P < 0.0001), less hemoglobin drop (P < 0.00001), less blood transfusion (P < 0.00001), higher postoperative tubeless (P = 0.0002), and fewer complications including bleeding (P = 0.01), perforation (P = 0.03), and leakage (P = 0.01). Compared with Standard-PCNL, operative time was longer in the Mini-PCNL group (P = 0.0005). Mini-PCNL had a shorter hospital stay, less hemoglobin drop, less blood transfusion, greater postoperative tubeless, fewer complications, and a longer operational time when compared to Standard-PCNL. SFR, fever, and postoperative pain were similar in both of them. Mini-PCNL may be a superior option for patients with proper size renal calculi.

Mahir Akram, Bhaskar Somani Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UKCorrespondence: Bhaskar Somani, Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK, Email bhaskarsomani@yahoo.comAbstract: Nephrolithiasis is a common global urological disorder, with incidence rates being as high as 13% in some regions of North America, contributing to substantial healthcare burdens. In 2021, 106 million new cases were reported worldwide, predominantly in men, reflecting a 27% rise since 2000. Regional disparities are notable, with Eastern Europe showing the highest rates (3,560 per 100,000). Management has evolved from open surgery to minimally invasive, precision endourological techniques, driven by innovations such as advanced lasers, digital ureteroscopes, artificial intelligence, virtual reality training, and robotic-assisted procedures, these advances have enhanced stone-free rates and reduced complications This review provides a comprehensive analysis of the epidemiology and contemporary management of kidney stone disease especially analysing variables affecting the disease including gender, age, geography and climate, occupational exposure, dietary lifestyle, and systemic diseases. Understanding the multifactorial epidemiology of nephrolithiasis is essential for effective prevention, while modern technological interventions are reshaping treatment standards and improving patient outcomes by offering individualized treatment options.Keywords: kidney calculi, epidemiology, ureteroscopy, PCNL, incidence, laser

Objective: This study aimed at assessing current efficacy and safety of endoscopic combined intrarenal surgery (ECIRS) for the treatment of large and/or complex urolithiasis and identifying relevant tips and tricks able to improve its outcomes, mainly deriving from the adjunct of retrograde flexible ureteroscopy to the traditional antegrade approach of percutaneous nephrolithotomy (PNL). Material and methods: A systematic review was conducted using relevant databases (Ovid Medline, PubMed, Scopus, and Web of Sciences), employing “ECIRS” as the search term in all cases, and then adding “endoscopic combined intrarenal surgery” and “flexible ureteroscopy AND percutaneous nephrolithotomy” as search terms for PubMed and Scopus. Original articles and systematic reviews were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Additionally, the reference lists of the selected publications were checked manually. Results: A total of 14 studies were selected for analysis: two systematic reviews, one randomized controlled trial, five nonrandomized comparative studies, three prospective case series, and three retrospective case series. ECIRS achieves high stone-free rates and rather low/low Clavien-Dindo grade complication rates, confirming the role of retrograde ureteroscopy in the maximization of its efficacy and safety. A narrative synthesis of the most recognized tips and tricks of ECIRS is provided. Conclusion: The contribution of retrograde flexible ureteroscopy during PNL is essential. It plays a dual role, both diagnostic and active, allowing tailoring of the procedure to the patient, urolithiasis, and anatomy of the collecting system and optimization of the PNL efficacy and safety. This is ECIRS: an updated, complete, and versatile version of PNL. Cite this article as: Cracco CM, Scoffone CM. Endoscopic combined intrarenal surgery (ECIRS) - Tips and tricks to improve outcomes: A systematic review. Turk J Urol 2020; 46(Supp. 1): S46-S57.

Abstract Objective: Percutaneous nephrolithotomy (PCNL) carries significant potential for morbidity. Scant data exists on indications and outcomes of second-look PCNL after a failure to completely clear renal stones at the first attempt. We present our experience with second-look PCNL. Material and methods: This was a retrospective record review of 922 patients who underwent unilateral PCNL at a tertiary care center in South India. Baseline patient, stone characteristics and outcomes were compared between 844 patients undergoing primary PCNL and 78 patients requiring second-look PCNL. Results: Increased stone complexity in terms of Guy stone score (GSS), stone size, staghorn calculi and stones in multiple locations were significantly associated with primary treatment failure (p<0.001). Operative time >75 min had a significant association with need for second-look PCNL and complications. Initial PCNL was discontinued due to bleeding (28; 35.9%), pelvicalyceal system perforation (3; 3.9%) and purulent urine leading to urosepsis and hemodynamic instability (2; 2.6%). Staged PCNL was done in 44 (56.3%) patients. During second-look PCNL, new access tracts were necessary in majority (42; 53.9%) of the patients and multiple tracts in 20 (25.6%) patients. In second-look PCNL, complications were comparable to primary PCNL (p=0.289). Conclusion: Second-look PCNL should be advocated in patients where the initial PCNL was discontinued due to bleeding, perforation of collecting system, prolonged operative time (>75 min) and in patients with large stone burden. Cite this article as: Kumar S, Karthikeyan VS, Mallya A, Keshavamurthy R. Outcomes of second-look percutaneous nephrolithotomy in renal calculi-a single centre experience. Turk J Urol 2018; 44(5): 406-10.

Objective To evaluate the efficacy and safety of adding 0.1% tranexamic acid (TXA) to irrigation fluid in reducing perioperative blood loss during mini‐percutaneous nephrolithotomy (mini‐PCNL). Patients and Methods In this prospective, randomised study, 40 patients undergoing mini‐PCNL were allocated to receive irrigation fluid containing either 0.1% TXA (n = 20) or distilled water (placebo; n = 20). The outcomes assessed included changes in haemoglobin, estimated blood loss, operative duration, irrigation volume, length of hospital stay, transfusion requirements, stone clearance and TXA‐related adverse events. Results Baseline characteristics were comparable between the two groups. The TXA group had significantly less haemoglobin decline (0.5 g/dl vs. 1.5 g/dl) and lower estimated blood loss (91.7 ml vs. 169.0 ml) compared with the placebo group (both p < 0.05). Operative time and hospital stay were also shorter in the TXA group (p < 0.05). Transfusion rate and irrigation volume were lower in the TXA group, while stone clearance rates were comparable between the groups (90% vs. 85%; p = 0.633). No TXA‐related adverse events were observed. Conclusion The addition of 0.1% TXA to irrigation fluid during mini‐PCNL significantly reduces perioperative blood loss and appears to be safe in this pilot cohort, without increasing complications observed in the study.

PurposeThis study aims to evaluate the non-papillary puncture for mini-PCNL in terms of safety and efficacy.MethodsA total number of 32 patients were subjected to mini-PCNL by the performance of non-papillary punctures over 6 months. One-step track dilation to 22 Fr took place in all cases. An 18 Fr nephroscope (Slender, Karl Storz GmbH, Germany) and an ultrasound lithotripter (Lithoclast Master, EMS S.A, Switzerland) with 9.9 Fr probe was used. Demographics and perioperative data are prospectively collected from an institutional board-approved database and the presented data were retrospectively collected.ResultsThe average cumulative stone size was 23.53 ± 6.6 mm. Mean operative time was 44.6 ± 13.44 min and primary stone-free rate after PCNL was 96% and 85.7% for single and multiple access, respectively. Second access was performed in seven cases, all of which had multiple stones. Mean hemoglobin drop was 1.23 ± 0.88 gr/dL. The patients stayed 2.56 ± 0.98 days in the hospital. Overall complication rate was 9.37%, without encountering any severe bleeding complication.ConclusionUsing non-papillary access for mini-PCNL did not result in significant blood loss and need for transfusions. The respective data were directly comparable to contemporary literature and the safety of mini-PCNL by a non-papillary approach could be advocated.

Minimally invasive percutaneous nephrolithotomy (PCNL) was introduced to decrease the morbidity of the standard PCNL (sPCNL). Thereafter, many modifications and techniques have been presented with the introduction of different miniaturized PCNL (mPCNL) techniques, such as micro-PCNL and ultra-mini-PCNL (UMP). As of present, none of the techniques has displaced the sPCNL. Nonetheless, mini-PCNL has continuously widening indications and has been proposed to have significant advantages over sPCNL. In the current review, each technique is presented while discussing the advantages and disadvantages of each approach. A comprehensive review of the current literature has been performed. Articles related to the topic were retrieved and critically analyzed. Less peri-operative bleeding and shorter hospital stay were the most important advantages advocated for mini-PCNL. Although the performance of mini-PCNL is safe, the utilization of micro-PCNL and UMP should be done with caution. Cite this article as: Kallidonis P, Tsaturyan A, Lattarulo M, Liatsikos E. Minimally invasive percutaneous nephrolithotomy (PCNL): Techniques and outcomes. Turk J Urol 2020; 46(Supp. 1): S58-S63.

Guglielmo Mantica,1,2 Marco Martiriggiano,1,2 Raquel Diaz,2,3 Enrico Vecchio,1,2 Lorenzo Lo Monaco,1,2 Giorgia Granelli,1,2 Benedetta Col,1,2 Francesca Ambrosini,1 Federica Balzarini,1 Rafaela Malinaric,1 Daniele Panarello,1 Carlo Terrone1,2 1Department of Urology, IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy; 2Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy; 3Department of General Surgery, IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, ItalyCorrespondence: Guglielmo Mantica, Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Largo Rosanna Benzi 10, Genova, 16132, Italy, Email guglielmo.mantica@gmail.comAbstract: Percutaneous nephrolithotomy (PCNL) is the preferred treatment for large or complex renal stones, but the optimal patient positioning remains debated. While the traditional prone position offers excellent access to posterior calyces, it can limit ventilation and increase anesthetic complexity. Supine modifications improve airway management but may reduce access efficacy. We propose the “GENOA” Prone Modified Position, a novel setup combining the advantages of both approaches. In this preliminary study, three patients underwent PCNL using this technique, which involves prone positioning with a 30-45° rotation obtained by placing gel pads under the thoracic and abdominal regions contralateral to the affected kidney. This alignment brings the renal axis parallel to the floor, facilitating a safer and more ergonomic puncture. All punctures were performed below the costal margin, accessing the lower calyces in four of six renal units. Mean operative time was 72.2 minutes, and two patients achieved complete stone clearance. No complications or opioid use were recorded, and the average hospital stay was 4.3 days. The GENOA Prone Modified Position appears to be a feasible and effective solution that enhances access to posterior calyces while minimizing ventilatory risk. Further studies are needed to validate its reproducibility and long-term benefits in larger cohorts.Keywords: PCNL, urolithiasis, prone PCN, kidney stones, staghorn stones

The objective of this prospective observational study was to assess the clinical significance of neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR) and lymphocyte–monocyte ratio (LMR) as potential biomarkers to identify post-PNL SIRS or sepsis. Demographic data and laboratory data including hemoglobin (Hb), total leucocyte count (TLC), serum creatinine, urine microscopy and culture were collected. The NLR, LMR and PLR were calculated by the mathematical division of their absolute values derived from routine complete blood counts from peripheral blood samples. Stone factors were assessed by non-contrast computerized tomography of kidneys, ureter and bladder (NCCT KUB) and included stone burden (Volume = L × W × D × π × 0.167), location and Hounsfield value and laterality. Intraoperative factors assessed were puncture site, tract size, tract number, operative time, the need for blood transfusion and stone clearance. Of 517 patients evaluated, 56 (10.8%) developed SIRS and 8 (1.5%) developed sepsis. Patients developing SIRS had significantly higher TLC (10.4 ± 3.5 vs 8.6 ± 2.6, OR 1.19, 95% CI 1.09–1.3, p = 0.000002), higher NLR (3.6 ± 2.4 vs 2.5 ± 1.04, OR 1.3, 95% CI = 1.09–1.5, p = 0.0000001), higher PLR (129.3 ± 53.8 vs 115.4 ± 68.9, OR 1.005, 95% CI 1.001–1.008, p = 0.005) and lower LMR (2.5 ± 1.7 vs 3.2 ± 1.8, OR 1.18, 95% CI 1.04–1.34, p = 0.006). Staghorn stones (12.8 vs 3.24%, OR 4.361, 95% CI 1.605–11.846, p = 0.008) and long operative times (59.6 ± 14.01 vs 55.2 ± 16.02, OR 1.01, 95% CI 1.00–1.03, p = 0.05) had significant association with postoperative SIRS. In conclusion, NLR, PLR and LMR can be useful independent, easily accessible and cost-effective predictors for early identification of post-PNL SIRS/sepsis.