==inizio objective==

The mininvasive approach for the treatment of renal stones is higher and higher grown during the last few years, becoming a standard procedure even in big stones. The standard approach involves a General Anesthesia (GA), due to the need of a controlled breath of patient, regarding to the safety of procedure. Unfortunately, not all the patient are great candidates to GA.
In literature there are few studies concerning RIRS (Retrogrede Intra Renal Surgery) with Spinal Anesthesia (1). We propose to compare procedure’s results in the few cases treated, concerning patients with complex comorbidities due to which GA wasn’t indicated.

==fine objective==

==inizio methodsresults==

Since 2014 up to 31st october 2017 we performed 335 RIRS for the treatment of renal stones; 331 were performed under genereal anesthesia and only 4 patients with spinal anestehsia (2 men and 2 women, medium age 72, medium stone size surface 180 mm2). Two patients had stent previously to procedure.
Preliminary anesthesiological evaluation extimated these patients as high risk for intubation with American Society of Anesthesiologists (ASA) Physical Status classification system of 3-4, which for this reason was not indicated. The comorbilities was: 2 plegic with many comorbilities; 1 advanced Parkinson disease; 1 compromised from the cardiocirulatory view point.
We use uretheral sheets 35mm 10-12 ch diameter, flexible ureterorenoscopes and usual RIRS procedure, with Holmium laser 30 Watt fiber 270 microm.
All patients underwent to antibiothical therapy by the association of cefaolosporin and gentamicin for up to 3 days in the postoperative, as our standars indicate.

==fine methodsresults==

==inizio results==

Medium operatory time was 40 minutes, all patients were stone free at the end of the surgery. No stent was left, only a temporary uretheral cathether for 48-36 hours in the postoperatory.
Visual analog scale (VAS) 1-10 in the postoperative : medium value of 3.

==fine results==

==inizio discussions==

Traditionally, RIRS procedures are performed under General Anesthesia (GA). The reason for this is unclear, but it may be referred to a larger tidal volume under Spinal Anestehsia, resulting in greater diaphragm and renal movement and this could cause instability to reach stones with a greater risk of renal damage during laser lithotripsy (1); even if it is proven that apnea during RIRS facilitates the procedure (2), a high confident surgeon could modulated the procedure with no significantly improve in operating times.
Nevertheless PerCutaneousNephroLithotripsy (PCNL), a higher risk procedure for bleeding instead of RIRS, has many studies which proven its faseability under Spinal Anesthesia (SA).
Some studies confirm that RIRS with SA can be completed with no anesthetic conversions and with the same efficacy and safety compared with GA, with high stone free rates and low morbidity in patients with different ASA physical status (3).

==fine discussions==

==inizio conclusion==

Even few in numbers we performed RIRS with SA with stone free results in patients with ASA value 3-4 with many comorbidities; we obtained a good pain control, referring to VAS scale. The spontaneus ventilation of the patients and the greater tidal volume could create some difficulties during surgery, but we didn’t have any complication intra and postoperatory.
We could consider that RIRS could be safetely done under SA, in selected high risk patient for GA.

==fine conclusion==

==inizio reference==

1. Guohua Zeng, Zhijan Zaho, Fengquan Yang, Wen Zhong, Wenqi Wu, Wenzhong Chen: “Retrograde Intrarenal Surgery with Combined Spinal-Epidural vs general Anesthesia: a prospective randomized controlled trial” J endourol vol 29, n ° 4 April 2015 401-405.

2. Tuna Katarag, Abdulkadir Tepeler, Ibrahim Buldu, Muzaffer Akcay, Muhammed Tosun, Mustafa Okan Istanbulluoglu, Abdullah Armagan: “Is micro-percutaneous nephrolithotomy surgery technically feasible and efficient under spinal anesthesia?” Urolithiasis (2015) 43: 249-54

3. Guzel O, Tuncel A, Balci M, Karakoyunlu N, Aslan Y, Erkan A, Senel C: “Retrograde Intrarenal Surgery is equally efficient and safe in patients with different American Society of Anestehsia physical status” Ran Fail (2016) ; 38(4): 503-7.

==fine reference==

==inizio objective==

A case report to evaluate the role of open transparenchimal nephrolithotomy access in order to reduce the risk of uroseptic events in a patient with high number of comorbidities and recurrent urosepsis.

==fine objective==

==inizio methodsresults==

We describe the case of a 67 year old women with chronic kidney disease, unilateral poorly functioning kidneys with functional exclusion of left kidney, bilateral staghorn kidney stones, percutaneous bilateral nephrostomy and right double J, recurrent urosepsis, alcoholism, lung resection for tumor, serious cachexia.
Uroculture was recurrent colonized with Klebsiella and Pseudomonas and The cultures guided us in antibiotic choice.
We used CT scans for classification of stone size, location and density (1) Additionally, in planning the operative approach.
Surgery in patients with this number of comorbidities has always been challenging and requires special care with a multidisciplinary approach (3-4). In this case report we described the management of a patient with bilateral staghorn kidney stones , elevated rates of comorbidities and recurrent urosespis.
We known that Sepsis secondary to urinary tract infection can significantly increase morbidity and mortality in patients who have undergone PCNL.
We examine CT scans and the elevated rates of comorbidities of the patient for the pre operative planning and the strategies to perform in operating room. Specially we considered the High risk of urosepsis.
In relation to that, we decided to perform a open transparenchimal nephrolithotomy access in order to reduce the risk of uroseptic events (2).
We describe renal access, patient position, tract dilatation, nephroscopes, litothripsy and post operative management.
The procedure was Performed in lateral recumbent position with a minimal lombotomy incision. We isolated the vascular peduncula, urether and so we are able to mobilize the kidney. We performe a Ultrasound guided puncture of the inferior calix and than, after a contrastography, we done a Access to the collecting system using successive Amplatz dilators for the tract dilatation. The access sheath finally was 24 fr and we used nephroscope 18 fr. To fragment the stone we used Pneumatic lithotripter and than we remove fragments with N-Perc device.

==fine methodsresults==

==inizio results==

The operative time was been of 130 minutes. The blood loss of 150 cc. The average rate used to irrigate was 20 litres of physiologic saline solution. The patient was afebrile during the recovery period.
Renal drainage upon termination PCNL leaving nephrostomy 8 fr and bladder drainage .
The recovery time was 6 days and the serum levels of creatinine decrease from 5,8 mg/dl to 1,8 mg/dl.

==fine results==

==inizio discussions==

After 20 days since the procedure , we decided to do a CT scan and the result was that into the right kidney there are only small fragments inferior to 5 millimeter. The patient is good, is asintomathic without nephrostomy and we decided to perform in the next mounth a nephrectomy at the other side for the unfunctional left kidney.

==fine discussions==

==inizio conclusion==

Although there are not enough data and evidence to make a clear conclusion, we suggest that transparenchimal nephrolithotomy can be performed safely in this kind of patients with high risk of urosepsis and elevated number of comorbidities.

==fine conclusion==

==inizio reference==

1. Advances in percutaneous stone surgery
Christopher Hartman, Nikhil Gupta, David Leavitt, David Hoenig, Zeph Okeke, Arthur Smith
Hofstra North Shore-LIJ School of Medicine, The Arthur Smith Institute for Urology, New Hyde Park, NY, USA
Asian Journal of Urology 2015, Vol. 2 Issue (1): 26-32

2. Management of multiple/staghorn kidney stones: Open surgery versus PCNL (with or without ESWL).
Agrawal MS1, Singh SK, Singh H.
Indian J Urol. 2009 Apr;25(2):284-5.

3. Percutaneous Nephrolithotomy in Rare Bleeding Disorders: A Case Report and Review of the Literature.
Zumrutbas AE, Toktas C, Baser A, Tuncay OL.
J Endourol Case Rep. 2016 Nov 1;2(1):198-203. eCollection 2016.

4. Percutaneous nephrolithotomy success rate and complications in patients with previous open stone surgery.
Khorrami M1, Hadi M1, Sichani MM2, Nourimahdavi K1, Yazdani M1, Alizadeh F1, Izadpanahi MH1, Tadayyon F1.
Urol J. 2014 Jul 8;11(3):1557-62.

==fine reference==

==inizio objective==

To confirm safety and feasibility of double J stent (DJ) insertion under local anesthesia and to assess the effect of detailed explanation and observing double J stent insertion on pain experience of male patients

==fine objective==

==inizio methodsresults==

Over a period of six months, from January to June 2017, forty-seven patients who attended urinary stone disease clinic and have indications for DJ insertion (intractable renal pain or ureteric colic, fever and pyuria, moderate to severe degree of hydronephrosis, pre external shock wave lithotripsy for renal stone more than 2 cm and anuria due to urinary stone) were included in this study and were randomized by drawing lots to observe or not to observe their DJ stent insertion. Patients were grouped into group A (those patients who were to view their procedure) (n=20) and group B (those patients who were not allowed to view their procedure) (n=27). For group A, a video monitor was placed so that both patient and operating urologist could see the procedure. For group B, the monitor was positioned so that only the operating surgeon could visualize the procedure and not the patient. The procedure was performed in urology operating room in by the same urologist. After positioning of the patient (lithotomy position) and scrubbing with povidone-iodine solution and standard draping, 2% of lidocaine gel was instilled in urethra and DJ stent was inserted in all subjects in standard fashion, with fluoroscopy guidance, using 22 F rigid cystoscope with 30 degree lens with favorable outcomes. Patients’ pre- and post- procedure pulse rate, systo/diastolic blood pressure and procedure time were recorded. Immediately after surgery asked patients to record their pain experience using a 10 cm unmarked Visual Analogic Scale (VAS).

==fine methodsresults==

==inizio results==

The pulse rate and systolic and diastolic blood pressures before the procedures were found to be comparable for both groups of patients as well as the duration of the procedure were not much different for the two groups. Among the cardiovascular parameter recorded after the surgery only the systolic blood pressure increase was statistically different (p≤0,05) between the group (+ 15±4 mmHg – groupA vs + 35±6 mmHg – groupB). The mean pain score experienced by the patients from groupB is almost two times higher than the mean pain score of groupA (4±1 vs 8±1; p≤0,05). Five patients from groupA experienced no compared to none from group B. Eleven patients from group B experienced severe pain as compared with only one patient in group A. These findings confirm that those patients who could view the procedure experience less pain as compared to those who did not view the procedure.

==fine results==

==inizio discussions==

DJ stent is generally inserted in operating room with or without fluoroscopic guidance using either flexible or rigid cystoscopy as both tolerated well and no significant difference in outcomes. Local/regional or general anesthesia is still an issue of discussion despite a higher rate of side effects than local/regional anesthesia, general anesthesia remains the most commonly used anesthetic technique for this surgery. Pain during cystoscopy can be influenced by type, volume, time, and temperature of lubricant used, viewing and detailed explanation of the procedure. Cornel et al. demonstrated in their study that history of cystoscopy is unlikely to affect the pain experience during the procedure(1). On the opposite side, other studies, showed that viewing the procedure has effect on pain experience of patients(2,3). Many published studies tested the pain during diagnostic, followed up cystoscopy and minor therapeutic procedure (DJ removal), and assessed the feasibility of DJ stent insertion under local anesthesia. To our best knowledge only pew work has assessed feasibility of DJ stent insertion under local anesthesia and tested the effect of detailed explanation and real-time video monitoring of the procedure on pain experience as one subject(2,3). VAS is a valid tool with good responsivity and acceptability and it has been used extensively in the medical literature. Our study shows that patients who had the chance to view
the procedures experience less pain compared to those who did not. Overall, there is an increase in the means of the vital signs after the procedure, but it seems that group B has experienced
a more significant increase if compared to group A (systolic blood pressure)

==fine discussions==

==inizio conclusion==

DJ stent insertion under local anesthesia is safe and feasible. We recommended self-watching and detailed explanation to patients who underwent DJ stent insertion to reduce the pain associated to the procedure.

==fine conclusion==

==inizio reference==

(1)Cornel E. B., Oosterwijk E., Kiemeney L. A. The effect on pain experienced by male patients of watching their office-based flexible cystoscopy. BJU Int. 2008 Nov;102(10):1445-6.
(2)Hussein NS, Norazan MR. Impact of self watching double j stent insertion on pain experience of male patients: a randomized control study using visual analog scale. ISRN. Urol 2013;15:523625.
(3)Patel A. R., Jones J. S., Angie S., Babineau D. Office based flexible cystoscopy may be less painful for men allowed to view the procedure, J Urol. 2007; 178(6):2703-4

==fine reference==

==inizio objective==

Pediatric urolithiasis is an endemic problem in developing countries, but the incidence is increasing in industrialized countries as well [1]. The management of pediatric urolithiasis is nowadays increasing in the current urologic practice. Treatment of this disease follows the same surgical procedures as in adults. We report our experience in retrograde treatment (URS / RIRS) of pediatric urolithiasis.

==fine objective==

==inizio methodsresults==

We have retrospectively reviewed all the kidney units (URs) which underwent to URS / RIRS at our center from January 2009 to December 2016 up to 16 years of age. The data reported include: lithiasic volume, radiological exposure, operative time, complications according to Clavien classification at 3 months from intervention and stone free rate.

==fine methodsresults==

==inizio results==

We have performed 47 procedures (30 RIRS and 17 URS) in 40 URs with an average age of 8.46 years (range: 2-16 years).
The URs treated in pre-school age (0-4 yy) were 11 with an average age of 3.72 years; 19 in pre-puberty (5-11yy) with an average age of 8.1 years and 10 in puberty (12-16 yy) with an average age of 14.3 years.
In 22 cases a pre-operative uretheral stent was applied (9 cases with age <4, 8 between 5-11 and 5 between 12-16). The average lithiasic volume was 1.154 cm2 [2]. The mean operative time was 78.4 ± 41.64 minutes (range: 15-140 min) with a radiological exposure of 24 "± 28" (range: 5 "-1'20"). At the end of the procedure a Double J (DJ) was applied in 25 cases and a Mono J (MJ) in 22 cases. The stone-free rate after one procedure has been 82.5% (33/40). Seven patients required a second intervention to achieve a complete lithiasic remediation. All of these 7 cases had single or multiple lithiasis with a volume greater than 1.767 cm2. The complications recorded at 90 days from the intervention include a case (2.1%) of migration of a fragment in the urether causing hydronephrosis and renal colics after 49 days to the operation (Clavien 3b) that was treated with URS; 5 cases (10.6%) which required the administration of painkillers during the first 48 hours postoperative (Clavien I); 2 cases of urinary tract infections during hospitalization (4.2%) treated with antibiotic therapy (Clavien II). ==fine results== ==inizio discussions== The miniaturization of the instruments, the increasing use of the retrograde approach to treat voluminous lithiasis in adults associated with the increased incidence of pediatric urolithiasis have led the endourologist to treat more patients in pediatric age. However, particular attention should be paid to treatment planning in patients under 6 years of age, where, based on our experience and the literature data [3], it is useful to apply a uretheral stent for kidney stones or proximal and mid-lumbar ureteral stones before surgery. In our cases, in only three patients under 6 years of age, no pre-operative DJ stent has been required, since it were two patients with stones located in the distal part of the ureter. In pre-puberty cases (5-11 years), a preoperative DJ has been required in 44%, of which 37.5% were patients under 8 years of age. Another consideration should be the choice of the type of uretheral stent to be applied at the end of the intervention (DJ versus MJ) to avoid excessive use of painkillers or access to the hospital for intolerance associated to the presence of the stent, bearing in mind the need to submit the patient to an additional anesthesia for DJ removal. In 60% of patients under the age of 5 years we preferred to apply a MJ, leaving a DJ alone in cases requiring a second intervention, where the procedure lasted more than an hour or where there was the presence of lithiasic sand related to the dusting of the stone. ==fine discussions== ==inizio conclusion== Our experience shows how retrograde access is safe even in the pediatric patient with stone free-rate rates that can be matched with the adult population [4-5]. ==fine conclusion== ==inizio reference== 1- Sas D. An update on the changing epidemiology and metabolic risk factors in pediatric kidney stone disease. Clin J Am Soc Nephrol 2011;6(8):2062-8 2- Tiselius HG, Andersson A. Stone burden in an average Swedish population of stone formers requiring active stone removal: how can the stone size be estimated in the clinical routine? Eur Urol 2003;4(3):275-81. 3- Elgammal MA, Safwat AS, Elderwy A, El-Azab AS, Abdelkader MS, Hammouda HM. Primary versus secondary ureteroscopy for pediatric ureteral stones. J Pediatr Urol. 2014 Dec;10(6):1193-8. 4- Ishii H, Griffin S, Somani BK. Ureteroscopy for stone disease in the paediatric population: a systematic review. BJU Int. 2015 Jun;115(6):867-73. 5- Ishii H, Griffin S, Somani BK. Flexible ureteroscopy and lasertripsy (FURSL) for paediatric renal calculi: results from a systematic review. J Pediatr Urol. 2014 Dec;10(6):1020-5. ==fine reference==