Percutaneous nephrolithotomy for staghorn stones: a randomised trial comparing high‐power holmium laser versus ultrasonic lithotripsy

Abstract

ObjectiveTo compare high-power holmium laser lithotripsy (HP-HLL) and ultrasonic lithotripsy (US-L) for disintegration of staghorn stones during percutaneous nephrolithotomy (PCNL). Patients and MethodsA non-inferiority randomised controlled trial was conducted between August 2011 and September 2014. Inclusion criteria were patients' aged >18 years who had complete staghorn stones (branching to the three major calyces), without contraindications to PCNL. Eligible patients were randomised between two groups: HP-HLL and US-. A standard PCNL in the prone position was performed for all patients. The only difference between the treatment groups was the method of stone disintegration. In the first group (HP-HLL), a laser power of 40-60 W (2 J, 20-30 Hz) was used to pulverise the staghorn stone into very small fragments, which could pass through the Amplatz sheath with the irrigation fluid. US-L, with suction of the fragments, was used in the second group. The primary outcome (stone-free rate) was evaluated with non-contrast computed tomography after 3 months. Secondary outcomes of complications, blood transfusion, operative time, and haemoglobin deficit were compared. The outcome assessor was 'blinded' to the treatment arm. ResultsThe study included 70 patients (35 in each group). The baseline characteristics (age, sex, body mass index, side, stone volume, and density) and operative technique (number, size of tracts, and need for second PCNL session) were comparable for both groups. Operative time was significantly shorter in US-L group, at a mean (SD) of 130 (34) vs 148.7 (35) min (P = 0.028). The haemoglobin deficit was significantly more with in the US-L group, at a mean (SD) of 1.7 (0.9) vs 1.3 (0.6) g/dL (P = 0.037). The differences in blood transfusion (17% for US-L vs 11% for HP-HLL) and the complication rates (34% for US-L vs 23% for HP-HLL) were not significant (P = 0.495 and P = 0.290, respectively). The stone-free rates at 3 months were comparable (60% for US-L and 66% for HPL-L; P = 0.621). ConclusionsCompared with US-L for intracorporeal lithotripsy of staghorn stones during PCNL, HP-HLL showed comparable safety and efficacy with a lower haemoglobin deficit but longer operative time.

Comparison of two different minimally invasive percutaneous nephrostomy sheaths for the treatment of staghorn stones

“…We may have a lower threshold to use this treatment than other institutions. Our ISFR, based on NRS, was much lower when compared with the SFR based on CIRF and as compared with other reported series using the same criteria on staghorn stones [11]. This showed that it was difficult to remove all the CIRF using pressurised irrigation and the stone extractor, especially when there was a large stone burden.…”

A Usability Comparison of Laser Suction Handpieces for Percutaneous Nephrolithotomy

“…Perhaps more importantly, stone free rates were similar regardless of energy source used for lithotripsy. 14 While our experience in an animal model suggests that stone fragmentation at the time of PCNL using LSHP is feasible, several limitations may impact its widespread acceptance. First, the mechanics of such devices, namely a small bore suction tube (11-12F) limit the ability to evacuate larger stone fragments.…”

Present indications and techniques of percutaneous nephrolithotomy: What the future holds?

“…This characteristic is less pronounced in PCNL where mostly rigid nephroscopes are used. In a study comparing high powered holmium laser (2 J, 20–30 Hz) and ultrasonic device for PCNL for the management of complete staghorn calculi showed that the use of the laser led to a significantly longer operative time (148 vs. 130 min, p = 0.03) with no change in postoperative complications or stone-free rates at 3 months of follow-up [52] . Miniaturization of access tracts in ultra-mini PCNL and the longer operation time has led to the increased demand for powerful laser lithotripsy devices.…”