Mini percutaneous nephrolithotomy for staghorn stone with a vacuum-assisted suction access sheath utilizing a digital disposable mini nephroscope: A novel case report

Abstract

Digital disposable nephroscopes represent a recent advancement in percutaneous nephrolithotomy (PCNL) procedures, offering several benefits over their reusable counterparts, such as reducing cross-contamination risks, ensuring high image quality and offering added advantage of a plug & play platform minimising need for cables & additional processors thereby reducing upfront capital investment. With a worldwide shift to single use scopes as seen in flexible ureteroscopy we present an interesting case perhaps the first in world where a 53/male with a complete staghorn stone measuring 3.8 cm/guys score 4 underwent mini PCNL with a digital nephroscope & suction sheath.

1 Introduction

Cross-contamination from reusable urological instruments has been a longstanding concern, attributed to issues like inadequate sterilization, biofilm formation, complex instrument designs, insufficient disinfectants including potential instrument damage during sterilization & per-operatively. The global shift to digital single use flexible ureteroscopy is well established but the same is not reported for nephroscopes. ^, A digital nephroscope can similarly overcome concerns with sterility, availability, and reprocessing, which we report the first use of this technology.

2 Case report

A 53-year-old male presented with right flank pain accompanied by nausea, vomiting, and dysuria for 10 days. Right flank tenderness was positive suggestive of possible inflammation or obstruction & warranted additional evaluation. The patient had no significant medical or surgical history.

A plain X-ray of the kidney, ureter, and bladder (KUB) identified a large radio-opaque shadow in the right kidney region. The ultrasonography revealed a renal stone in pelvis of the right kidney, along with resultant mild hydronephrosis. Computed tomography (CT) confirmed a right staghorn stone measuring 38 x 27 × 18 mm in right renal pelvis with a secondary stone of size 9 mm in the right upper calyx [ Fig. 1 – a,b]. The total stone volume of the staghorn stone was 9669.82 mm ³ . Routine blood tests, including serum biochemistry, were normal except for mild elevated total white blood counts. Pre-op positive Urine culture was treated as per antibiogram and patient was counselled for mini PCNL and RIRS. He chose mini-PCNL which was planned with a digital single use nephroscope and a suction nephrostomy sheath.

Intraoperative procedure, in the lithotomy position, a 5-Fr ureteric catheter was inserted using the same disposable mini nephroscope by virtue of its large 6 fr working channel and shaft length of 23 cm allowed us to avoid the unnecessary need to open a separate lower tract cystoscopy set. Then, the patient was placed in a supine position i.e. the flank-oblique modified lithotomy position (FOSML). Under fluoroscopic guidance and using the triangulation technique, the right kidney was punctured with track created using Teflon dilators, and two tracks of 18-Fr and 16-Fr vacuum-assisted suction access sheath (VASS) in upper and lower calyx were respectively placed [ Fig. 2 – a,b]. The suction apparatus was connected to the access sheath, the same digital disposable mini nephroscope was used to access the pelvi calyceal system & stone was located in the pelvis and upper calyx of the right kidney. Fragmentation was done using a 550 μm Holmium laser fibre & fragments were aspirated via the VASS. Total operative time was 45 minutes with 100 % on table clearance confirmed by visual inspection. No additional baskets were required for stone extraction, as the large working channel of the lightweight digital nephroscope enables the simultaneous use of a laser and instrument without compromising the irrigation. The digital nephroscope could successfully access all parts of the pelvicalyceal system with perfect image quality maintained even during laser lithotripsy. Kidney was completely cleared of stones under fluoroscopic guidance. Post PCNL a 5fr DJ stent was placed as part of routine practice for tubeless PCNL. Tract access was under 3 mm, and no closure was required for the skin wound. The tract was visualised completely by withdrawing the digital scope to ensure there were no missed bleeders & day 1 POD a X-ray KUB and NCCT confirmed 100 % stone free rate [ Fig. 2 – c, d].