Dr. Sri Sivalingam of the Cleveland Clinic compares minimally invasive PCNL and ureteroscopy, especially for treating stones from 1 to 2 cm. Stone-free rates, bleeding risk, ergonomics, and tubeless options are discussed.
today I want to talk a little bit about minimally invasive PCL versus Urus Copy, and you know we'll start and talk a little bit about indications and guidelines for the p c N L procedure. Andi, look into some clinical considerations and outcomes and then also some other considerations. So as we all know about the EU and the EU, a guidelines state that for stones greater than two centimeters, PC and L should be the first line treatment. But what's debatable is for those stones that are between 10 and 20 millimeters. You know what is the most appropriate procedure, where both theory Doris copy or peace, you know, seem to be appropriate. So really, you know, what are the indications for the for the purposes of this talk for many P, C N l. And my view is that for stones greater than one centimeter or for multiple smaller stones, uh, this is a appropriate and perfect technique further when you look into lower poll stones, the guidelines of the way suggests that any stones greater than 10 millimeters in the lower poll would be ideal for PC and L, which has higher stone free rates. Although with greater morbidity. So my own pathway into utilizing minimally invasive P c N L. When, when compared to Euro Doris copy stemmed from a few thoughts. One is the duration of stone extraction for these larger stones. What you read auras copy tends to be a little bit, uh, laborious. At times, the ergonomics of this could be a little bit challenging where sometimes, especially with lower poll stones, as we heard about this morning as well in some of the discussions could be quite strenuous. There are also challenges associated with stents, where most procedures, after most serious Coptic procedures dio require stand and that's associated with a lot of discomfort for patients. And, of course, we have to consider a stone where scope, wear and tear as well. So with all of these thoughts, I was intrigued by technique that could potentially bridge bridge the gap between a Yuri Doris copy and a standard PC. No technique. When we do a pub med surgeon on the word many p. C N l, you can see the evolution off publications over the last few years on certainly seems to be some interest and utilization of this technique, so What are some of the perceived benefits off versus you? Re Doris Copy. Which is what? I'm gonna focuses on top of this discussion on today for larger than one centimeter stones. So for Mitt, the pros are that you know, the efficiency is greater and I'm talking specifically with respect O r. Time associated with stone removal. Three ergonomics are arguably better. You can have a totally to bliss procedure which I'll talk about, and I find it more enjoyable. The cons, of course, is that there's an incision. There's a greater risk of blood loss requires a greater skill set in that we do have to gain access. And there's ah, need to see a stop all anti coagulation with your Itera Skopje. The obvious pros air that it's an outpatient procedure with no incision and minimal bleeding risk. And there's it remains the only surgical stone removal text make that has no contraindications or anti coagulation. The cons I find are that there's a prolonged procedure time with with respect to stone removal itself. Economic challenges and the stents are often necessary. But what about stone free rates? Is there really a difference between these two techniques? because, after all, that's what we're trying to achieve here. So there are numerous randomized control trials and meta analyses to this, and I'll just highlight a few. This is a study that came out in 2012. A randomized prospective study looking at many peace in L versus uh, you re Doris Copy. And what they found for stones greater than one 0.5 centimeters was that the operative time was lower in the mini perk arm. But there was, ah, larger drop in hemoglobin and postoperative pain in in the urine. Rosco P. R. Here's another study that looks at your, uh, your Rina Rosco P versus many P C N l. And they looked at larger stones between 2 to 3 centimeters, and what they found was ultimately, with similar total medical cost, many PC NL's achieved a faster stone clearance and lower re treatment rate. Yeah, and here's another study, a prospective again, Another end of my study looking at both with all three techniques minimal. Many piece, you know, Shockwave with a trip, see, and and you're a Doris copy. And what they found here was that both Giridharadas copy and had a more effective stone free rate, but with more complications operative time and radiation and length of stay in the minimally invasive PCL arm. So you know, these studies go on and on and really it z difficulty. Oh, look at the data and and come up with one solid conclusions. So looking at some meta analysis on these topics here, a few select meta analysis This study, published in European urology in 2015 looked at professional versus you read Ross Copy. And what they concluded was that given the added morbidity and lower efficacy of nips, you Rita Ross copy should be considered the standard therapy for stones less than two centimeters until more randomized controlled trials were performed. And to that. And there were several more randomized controlled trials that have come out since that time. And this meta analysis, published in 2017 found that Nip was actually significant, was associated with significantly higher stone free rates compared to Yuri Doris Copy. And this advantage was even more obvious with the lower poll stones again. Another meta analysis in 2019 showed that Mitt had a greater success than you read. Roscoe PICO stones tend to 20 millimeters in the lower pole with a similarly a similar safety profile and no difference in operative time for Oscar P time or Hospital State and the overall complication rates were also similar. So putting all the data together, really, I think the best role for Mitt, maybe for stones between one and two centimeters. And perhaps we need to consider multiple intermediate side stones totaling, you know, stone volume, our largest own volume Memphis. So it seems to be associated with slightly better stone free rates while you you read auras copy seems to be associated with lower bleeding risks and a shorter hospital stay. Although a doctor Douglas is gonna talk, talk a little bit more about outpatient MIPS as well today. So in all the good news here is that there is no significant differences in major complications. And this is also shown in the Crow's data with about 6000 patients that there weren't any major differences in complication rates. Some other considerations with these two techniques, as I talked about before anti coagulation, is an issue which must be held before MIPS, just like in any PC NL while you re Doris copies safe and anti coagulated patients. So these air cases where you might have to consider your Rita Ross copy. Um, stem symptoms remain a major source of discomfort and postoperative er visits after you read Harasta P. And, you know, this is a slide from a prior presentation of mind which we looked at all the different things that we do to try to mitigate stem symptoms with none of these actually eliminating these symptoms. So one advantage off. But it might be that, you know, we we do a lot of these procedures with a totally Tulis approach. So this might be yet another benefit for postoperative convalescence. Cost is another issue. Of course, when we look at Mitt versus you are as the capital costs are there for both, you know, they aren't they aren't that far off, and I'm not gonna get into details of it. But capital costs aside, we have to look at the other operational costs. So MIPs are associated with minimal adjunct equipment like Seth mentioned in his talk. So there is a definite cost advantage there, whereas you read auras copies really sent it around a lot of disposables and adjunct equipment. So that really adds to the cost. Um, one thing to consider is, if you're doing, I are acquired access, then that will certainly add to the cost of your procedure. And of course, if you're admitting your patient and make you and if there's a hospital stay associated with that, then that also brings up the cost with you. Rita Ross copies. We know that there is a predictable repair and maintenance expense, and the scopes also tend to have a limited life. As we heard about this morning, What about the carbon footprint? I think this is also important to consider. One of the beauties off this procedure is that most of the equipment is reusable, chief dilator and scope on. Really the only disposable aspect is disposable. Component is a laser fiber, and some of those can be even be reused. Whereas with the arena Rosco P, most of the items, such as the laser fiber baskets, access sheets, stands are all disposable. In some centers, you know, even the scope itself is disposable, so that's something to consider as we way out our options on and finally, the ergonomics. Between these two procedures, I find that there's less repetitive strain injury a repetitive strain associated with Mitt. Less, less risk strain associated with scope NuvaRing less time spent with stone removal and met and less hands needed for the procedure. So this is sort of an extreme example of Ah Arena Ross copy where one pair of hands is operating the scope. One pair of hands is operating the basket and perhaps the fifth hand with intermittent irrigation. So this could be quite cumbersome, especially for those challenging stones. So I wanted to just hide that a couple of examples where you know really stands out over your ead, Rosco p in my view. So for consider this 1.4 centimeter lower poll stone. You know, we do a retrograde and you see, the anatomy is quite complex. The stone is located right here in the lower pull, you know, with and you could see the scope here, the angle that we must work at. And this is one of those stones you can't extract because of the long, narrow infant nebula. So you know, when you struggle with this case and this is one of the this is the case where it would look like this and then ultimately, you might end up with the scope that looks like this. So you know these air considerations that we should take into account whereas, you know, in the same stone we got access with the minimally with many, uh, PCL access. And certainly the procedure, you know, went a lot more, um, smoothly compared Teoh, you know, that laborious basket ing procedure in, say, authorities sort of talked about this. I'll skip over this, but this was that cases with that. Still, here's another situation where MIPs might It might be a lot more advantages. And where we have on these cases are often seen where we have multiples scattered calculate throughout the kidney. And so again, this is a case where I think, you know, you can try and do you read auras copy. And it could be a little bit, uh, painful and laborious. Or you can try to do it this way with with which I think goes a lot more smoothly and one of the things about Memphis that with the access you really have the ability Thio Thio approach almost all calluses with the single axis compared to a standard PC and also for these kind of stones. I think this is, Ah, great advantage for a minute. So in summary, both procedures, of course, suitable for stones between one and two centimeters. You know, the data state. It shows that there's mild or mildly higher bleeding risk with MIP. But this might be offset by better stone free rates, less surgeon strain and possibly a totally to bliss procedure. I think certainly an experience with the procedure may shift the paradigm. Ultimately, a za we move forward into the future in favor off and and one other thing I urge everyone to consider are the cost and carbon footprint off disposables associated to put stone removal procedures on. I'd like to end with that, thank you very much.