SUMMARY OBJECTIVE: The aim of this study was to identify predictive factors for complications after percutaneous nephrolithotomy. METHODS: We prospectively analyzed patients who underwent percutaneous nephrolithotomy from June 2011 to October 2018. The association of preoperative and intraoperative factors with the presence of complications was assessed using univariate and multivariate analyses. The significance level was set at p<0.05. RESULTS: A total of 1,066 surgeries were evaluated, and the overall complication rate was 14.9%. In all, 105 (9.8%) surgeries were performed in the prone position, and 961 (90.2%) were performed in the supine position. Univariate analysis demonstrated that surgical position, upper pole puncture, surgical time, number of tracts, and Guys Stone Score were associated with complications. In multivariate analyses, prone position (odds ratio [OR] 2.10; p=0.003), surgical time ≥90 min (OR 1.76; p=0.014), upper pole puncture (OR 2.48; p<0.001), and Guys Stone Score 3 or 4 (OR 1.90; p=0.033) were independent predictive factors for complications after percutaneous nephrolithotomy. CONCLUSION: Performing percutaneous nephrolithotomy in the supine position, in under 90 min, and avoiding upper pole punctures may reduce complications during the treatment of large kidney stones.

ABSTRACT Background: Endoscopic combined intrarenal surgery (ECIRS) has been used to treat complex kidney stones (1). The combined use of ultrasound (US) has the potential to improve safety and reduce radiation exposure, however, it is still underutilized (2). Objectives: Our objective is to describe, in a step-by-step manner, the ultrasound-guided ECIRS (USG ECIRS) technique, in order to facilitate learning by urologists. Materials and Methods: We describe the 10 standardized steps that we recommend to achieve a good outcome, based on our previous experience on a high-volume kidney stone center. We recorded a case of a 37-year-old female patient with complex bilateral kidney stones that underwent a left simultaneous combined retrograde and antegrade approach. The 10 described steps are: 1 - case evaluation with CT scan (3); 2 - preoperative care with antibiotics and tranexamic acid; 3 - warm-up and training with phantoms; 4 - patient positioning in Barts flank free position; 5 - retrograde nephroscopy with flexible ureteroscope; 6 - US and endoscopic guided puncture; 7 - tract dilation under endoscopic view; 8 - stone fragmentation; 9 - status free checking and 10, kidney drainage. Images were captured by external and internal cameras, promoting a complete understanding of the procedure. The patient has signed a written informed consent form. Results: Puncture was achieved under US guidance with one attempt. Another puncture was necessary in the lower pole, parallel to the initial puncture, due to a large fragment. Surgical time was 140 min. Stone-free status was verified by retrograde and antegrade view. Kidney drainage was done with ureteral stent on string, removed after 7 days. Hb drop was 1.1 Hb/dL. The first postoperative day CT scan showed no residual stones and no complications. The patient was discharged after the CT and urethral catheter removal. Conclusion: The USG ECIRS seems to be a very efficient and reproducible technique for the treatment of complex kidney stones. Its use should be widespread.

SUMMARY OBJECTIVE: Mini-percutaneous nephrolithotomy is a recent advancement in the field of kidney stone treatment; however, its role has not been completely established. We aimed to compare the outcomes of initial Mini-percutaneous nephrolithotomy and flexible ureteroscopy. METHODS: A retrospective review of consecutive mini-percutaneous procedures was performed. Inclusion criteria were as follows: all percutaneous nephrolithotomy procedures performed with an access sheath up to 24Fr, kidney stone burdens up to 1550 mm3; and the presence of postoperative computed tomography (for control). The data collected for Mini-percutaneous nephrolithotomy procedures were paired 1:2 with patients treated with flexible ureteroscopy for stones between 100 and 1550 mm3, and with postoperative computed tomography for control. A 14Fr Mini-percutaneous nephrolithotomy set was used. The stone-free rate was defined as the absence of fragments on the control computed tomography, whereas success was limited to 2-mm residual fragments. Statistical analysis was performed using SPSS version 19. RESULTS: A total of 63 patients met the inclusion criteria (42 with flexible ureteroscopy and 21 with mini-percutaneous nephrolithotomy). Demographic data were comparable. The stone-free rate and success were similar between the groups (76.2 vs. 66.7%, p=0.42 and 90.5 vs. 85.7%, p=0.57). The complication rate was also similar (26.1 vs. 9.6%, p=0.188), but Mini-percutaneous nephrolithotomy had longer hospitalization and fluoroscopy time (p=0.001 in both). CONCLUSIONS: Our initial study of Mini-percutaneous nephrolithotomy showed that it is a promising procedure, with outcomes similar to flexible ureteroscopy, but with higher inpatient numbers and fluoroscopy times. A larger study population size and better equipment may improve the outcomes of mini-percutaneous nephrolithotomy.

SUMMARY OBJECTIVE: The aim of this study was to evaluate the predictive factors for success following percutaneous nephrolithotomy in the supine position. METHODS: Patients who underwent percutaneous nephrolithotomy in the supine position from June 2011 to October 2018 were evaluated. Age, sex, body mass index, the American Society of Anesthesiologists physical status classification, hemoglobin level, number of previous surgeries, stone size, and the Guy’s Stone Score were analyzed. Success was considered if no fragments were observed on the computed tomography scan on the first postoperative day. Univariate and multivariate analyses were performed to determine significant parameters. RESULTS: We evaluated 961 patients; of them, 483 (50.2%) underwent previous stone-related surgery, and 499 (51.9%) had Guy’s Stone Score 3 or 4. The overall success rate in a single procedure was 40.7%, and complication rate was 13.7%. The univariate analysis showed that the maximum diameter of the stone (25.10±10 mm; p<0.001), previous percutaneous nephrolithotomy (OR 0.52; p<0.001), number of previous percutaneous nephrolithotomy (OR 0.15; p<0.001), the Guy’s Stone Score (OR 0.28; p<0.001), and the number of tracts (OR 0.32; p<0.001) were significant. In the multivariate analysis, the number of previous percutaneous nephrolithotomy (OR 0.54; p<0.001) and the Guy’s Stone Score (OR 0.25; p<0.001) were statically significant. CONCLUSIONS: Guy’s Stone Score and the number of previous percutaneous nephrolithotomy are predictors of success with the supine position. Complex cases and with previous percutaneous interventions may require technical improvements to achieve higher stone-free rates.

ABSTRACT Objective: To show a video of a complete supine Percutaneous Nephrolithotomy (csPCNL) performed for the treatment of a staghorn calculus, from the surgeon's point of view. The procedure was recorded with a GoPro® camera, demonstrating the ten essential steps for a successful procedure. Materials and methods: The patient was a 38 years-old woman with 2.4cm of left kidney lower pole stone burden who presented with 3 months of lumbar pain and recurrent urinary tract infections. She had a previous diagnosis of polycystic kidney disease and chronic renal failure stage 2. CT scan showed two 1.2cm stones in the lower pole (Guy's Stone Score 2). She had a previous ipsilateral double J insertion due to an obstructive pyelonephritis. The csPCNL was uneventful with a single access in the lower pole. The surgeon had a Full HD GoPro Hero 4 Session® camera mounted on his head, controlled by the surgical team with a remote control. All of the mains steps were recorded. Informed consent was obtained prior to the procedure. Results: The surgical time was 90 minutes. Hemoglobin drop was 0.5g/dL. A post-operative CT scan was stone-free. The patient was discharged 36 hours after surgery. The camera worked properly and didn't cause pain or muscle discomfort to the surgeon. The quality of the recorded movie was excellent. Conclusion: GoPro® camera proved to be a very interesting tool to document surgeries without interfering with the procedure and with great educational potential. More studies should be conducted to evaluate the role of this equipment.

Mulher de 21 anos encaminhada com piora dos sintomas que vinha apresentando há anos: tontura ao levantar-se, sem sintomas vertiginosos, sem queixas de síncope ou alterações neurológicas, melhora em decúbito dorsal e repouso, após poucos minutos. O ecocardiograma transtorácico mostrava presença de massa hiperecogênica na região médio-apical da parede posterior do ventrículo esquerdo e pericárdio normal. A ressonância nuclear magnética cardíaca permitiu o diagnóstico de tumor de ventrículo esquerdo sugestivo de lipoma. Realizado tratamento cirúrgico e ressecado o tumor, a paciente apresentou boa recuperação e mantém-se assintomática.

We report the case of a 21-year-old female referred to our institution complaining of dizziness when standing up, which improved in the dorsal decubitus position and at rest, after a few minutes. The symptom, which had lasted for years, was not accompanied by vertigo, syncope, or neurological changes, but was gradually getting worse. Transthoracic echocardiogram showed a hyperechoic mass in the middle-apical region of the left ventricular posterior wall and normal pericardium. The cardiac nuclear magnetic resonance allowed the diagnosis of the left ventricular tumor suggestive of lipoma. Surgery was performed and the tumor was resected. The patient recovered well and is currently asymptomatic.