A 50 year old lady presented with pain in the right flank of 2 years duration.
On investigations there was with right sided staghorn calulcus.
She was taken up for Mini-PCNL.The access was done through posterior-inferior calyx. A J-tip PTFE guide wire was placed in the system.Serial dilatation was done till 15 Fr and 15 Fr Sheath was introduced. The sheath has a offshoot Luer-Lock outflow for reduction of intra-pelvic pressure so as to reduce the incidence of sepsis.A wide angle straight forward telescope 12 ° with angled eyepiece (Karl Storz, Tuttingen, Germany) was used as nephrosocpe.Holmium LASER energy was used as energy for stone dis-integration.
The procedure took 60 minutes and the procedure was completed with the intoduction of small bore nephrostomy tube .The post-operative X-ray showed near total clearance of the calculus.
Stones of the renal pelvis can be treated either by extracorporeal shock wave lithotripsy (SWL) or percutaneous nephrolithotomy (PCNL). As a low-risk procedure with a longer treatment period, SWL often leads to persistent residual stone fragments, whereas conventional PCNL achieves a higher stone-free rate and allows a shorter treatment period albeit with a somewhat higher surgical risk. To reduce the invasiveness of conventional PCNL, the application of a miniaturised instrument for PCNL (MPCNL) has come in vogue.
Miniature percutaneous (mini-perc) access was first described in the pediatric population by Jackman et al (1997) as an alternative to standard PCNL. Generally, it consists of downsizing to smaller percutaneous access sheaths with the intention of decreasing blood loss, postoperative pain, and the hospital stay in patients undergoing nephroscopic procedures. Feng et al (2001) found that PCNL performed via the mini-perc technique was disadvantageous with regard to visibility and optics compared with PCNL performed through the standard access diameter. Deane and Clayman (2007) published a review on PCNL and concluded that PCNL performed via the mini-perc technique appears to have little value, except in children.
In our experience we have found that mini-PCNL with Holmium LASER application can complete the procedure even in larger stone burden in a reasonable time.The bleeding has been remarkably less than the conventional PCNL.In some cases we can always stage the procedure in the safety of the patient.The post-operative pain and the requirements of the analgesia has been less.As far as visibility is concerned ;as the shearing of renal parenchyma is less during dilatation,the tract bleeding is less so the pelvi-calyceal system most-often is clear.This clarity of vision allows s to use gretaer power Holmium for stone pulverisation and the clearance is rapid.We are a referral centre here in Hyderabad and most often get difficult stagorn calculi but in most of the cases we could clear stones with miniature PCNL without having to resort to a large 28 or 30 Fr tract.