Simultaneous combined use of flexible ureteroscopy and percutaneous nephrolithotomy to reduce the number of access tracts in the management of complex renal calculi

In a joint study between Duke University, North Carolina and London, a simultaneous combination of flexible ureteroscopy and percutaneous nephrolithotomy was used to reduce the number of access tracts required to manage complex renal calculi. This was found to be an effective method which reduced morbidity and blood loss, without increasing operating time, but without increasing stone‐free rates. Authors from the USA carried out an experimental study to determine whether an electrode array with a bipolar radiofrequency ablation energy source could be used for partial nephrectomy, simultaneously ablating and coagulating renal tissue. They found that this system could indeed be used in a bloodless fashion with no collecting system injury. OBJECTIVE To present early experience in managing complex renal calculi using a combined ureteroscopic and percutaneous approach, as complex and branched renal calculi often require multiple access tracts during percutaneous nephrolithotomy (PNL), and the combined use of flexible ureteroscopy and PNL has the potential to reduce the inherent morbidity of several tracts. PATIENTS AND METHODS The study included seven patients (mean age 54 years) with multiple, branched, large‐volume renal calculi suitable for management with PNL. Preoperative data, including patient demographics, stone location and stone surface area, were recorded. After informed consent, the patients underwent combined PNL and ureteroscopy in one session. Intraoperative data, including the location of PNL puncture sites, operative duration and complications, were analysed. Stone‐free rates were determined by follow‐up imaging at 3 months. RESULTS All patients had either two or more stones in separate locations in the collecting system, or staghorn stones involving multiple calyces. The mean stone burden was 666 mm 2 . All patients had only one percutaneous access tract. The mean operative duration was 142 min and the mean blood loss 79 mL. Two patients had small residual stones (<3 mm), that required ureteroscopic intervention as they failed to pass spontaneously by 3 months after the initial combined procedure. The convalescence was similar to that in our current PNL practice; imaging showed that five of the patients were stone‐free. CONCLUSIONS Combined PNL and ureteroscopic management can effectively reduce the number of percutaneous access tracts which would otherwise be required for managing complex and branched renal calculi, as stones in an unfavourable location relative to the access tract can be relocated and fragmented within easy reach of the single nephrostomy tract. This manoeuvre reduces potential patient morbidity and blood loss but with no significant effect on stone‐free rates and operative durations.