Comparison of mini percutaneous nephrolithotomy and standard percutaneous nephrolithotomy for renal stones &gt;2cm: a systematic review and meta-analysis

Qin, Pengfei; Zhang, Dong; Huang, Ting; Fang, Li; Cheng, Yue

doi:10.1590/S1677-5538.IBJU.2021.0347

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REVIEW ARTICLE • Int. braz j urol 48 (4) • Jul-Aug 2022 • https://doi.org/10.1590/S1677-5538.IBJU.2021.0347 copy

Comparison of mini percutaneous nephrolithotomy and standard percutaneous nephrolithotomy for renal stones >2cm: a systematic review and meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Background

The purpose is to compare the efficacy and safety of mini percutaneous nephrolithotomy (mini-PCNL) versus standard percutaneous nephrolithotomy (standard-PCNL) in patients with renal stones >2cm.

Materials and Methods

A systematic literature search was conducted in PubMed, Web of Science, Scopus, and the Cochrane Library databases to identify relevant studies before March 8, 2021. Stone-free rate (SFR), operation time, fever rate, hemoglobin drop, blood transfusion rate, and hospitalization time were used as outcomes to compare mini-PCNL and standard-PCNL. The meta-analysis was performed using the Review Manager version 5.4.

Results

Seven randomized controlled trials were included in our meta-analysis, involving 1407 mini-PCNL cases and 1436 standard-PCNL cases. Our results reveal that, for renal stones >2cm, mini-PCNL has a similar SFR (risk ratio (RR)=1.01, 95% confidence interval (CI): 0.98 to 1.04, p=0.57) and fever rate (RR=1.22, 95% CI: 0.97-1.51, p=0.08). Standard-PCNL was associated with a significantly shorter operating time (weighted mean difference (WMD)=8.23, 95% CI: 3.44 to 13.01, p <0.01) and a longer hospitalization time (WMD=-20.05, 95% CI: -29.28 to -10.81, p <0.01) than mini-PCNL. Subgroup analysis showed hemoglobin drop and blood transfusion for 30F standard-PCNL were more common than mini-PCNL (WMD=-0.95, 95% CI: -1.40 to -0.50, p <0.01; RR=0.20, 95% CI: 0.07 to 0.58, p <0.01).

Conclusion

In the treatment of >2cm renal stones, mini-PCNL should be considered an effective and reliable alternative to standard-PCNL (30F). It achieves a comparable SFR to standard-PCNL, but with less blood loss, lower transfusion rate, and shorter hospitalization. However, the mini-PCNL does not show a significant advantage over the 24F standard-PCNL. On the contrary, this procedure takes a longer operation time.

Trial registration

This meta-analysis was reported consistent with the PRISMA statement and was registered on PROSPERO, with registration number 2021CRD42021234893.

Nephrolithotomy, Percutaneous; Kidney Calculi; Meta-Analysis as Topic

Study	Country	Study period	Study design	LE	Cases, n		Definition of SFR
					Mini	Standard
Güler et al. ( ¹⁸18. Güler A, Erbin A, Ucpinar B, Savun M, Sarilar O, Akbulut MF. Comparison of miniaturized percutaneous nephrolithotomy and standard percutaneous nephrolithotomy for the treatment of large kidney stones: a randomized prospective study. Urolithiasis. 2019; 47:289-95. )	Turkey	2016.01-2017.04	RCT	2b	51	46	complete clearance of stones
Kandemir et al. ( ⁵5. Kandemir E, Savun M, Sezer A, Erbin A, Akbulut MF, Sarılar Ö. Comparison of Miniaturized Percutaneous Nephrolithotomy and Standard Percutaneous Nephrolithotomy in Secondary Patients: A Randomized Prospective Study. J Endourol. 2020; 34:26-32. )	Turkey	2016.11-2018.09	RCT	2b	76	72	complete clearance of stones or with residual fragments <4 mm
Wu et al. ( ¹⁹19. Wu C, Hua LX, Zhang JZ, Zhou XR, Zhong W, Ni HD. Comparison of renal pelvic pressure and postoperative fever incidence between standard- and mini-tract percutaneous nephrolithotomy. Kaohsiung J Med Sci. 2017; 33:36-43. )	China	2014.03-2015.07	RCT	2b	114	114	complete clearance of stones or with residual fragments <4 mm
Zeng et al. ( ¹²12. Zeng G, Cai C, Duan X, Xu X, Mao H, Li X, et al. Mini Percutaneous Nephrolithotomy Is a Noninferior Modality to Standard Percutaneous Nephrolithotomy for the Management of 20-40mm Renal Calculi: A Multicenter Randomized Controlled Trial. Eur Urol. 2021; 79:114-21. )	China	2016.01-2019.08	RCT	2b	978	966	complete clearance of stones or <4mm asymptomatic, noninfectious, and non-obstructive residual stones at 1 month after the removal of the J-J stent
Sakr et al. ( ⁶6. Sakr A, Salem E, Kamel M, Desoky E, Ragab A, Omran M, et al. Minimally invasive percutaneous nephrolithotomy vs standard PCNL for management of renal stones in the flank-free modified supine position: single-center experience. Urolithiasis. 2017; 45:585-9. )	Egypt	2010.09-2013.12	RCT	2b	75	75	complete clearance of stones or with residual fragments <4 mm
Cheng et al. ( ²⁰20. Cheng F, Yu W, Zhang X, Yang S, Xia Y, Ruan Y. Minimally invasive tract in percutaneous nephrolithotomy for renal stones. J Endourol. 2010; 24:1579-82. )	China	2004.05-2007.12	RCT	2b	69	111	complete clearance of stones or with residual fragments <4 mm
Song et al. ( ²¹21. Song L, Chen Z, Liu T, Zhong J, Qin W, Guo S, et al. The application of a patented system to minimally invasive percutaneous nephrolithotomy. J Endourol. 2011; 25:1281-6. )	China	2008.08-2009.08	RCT	2b	30	30	complete clearance of stones or with residual fragments <4 mm

Study	Mean age		Mean stone burden		Access sheath size		Dilator		Nephroscope size		Lithotripsy
	Mini	Standard	Mini	Standard	Mini	Standard	Mini	Standard	Mini	Standard	Mini	Standard
Güler et al. ( ¹⁸18. Güler A, Erbin A, Ucpinar B, Savun M, Sarilar O, Akbulut MF. Comparison of miniaturized percutaneous nephrolithotomy and standard percutaneous nephrolithotomy for the treatment of large kidney stones: a randomized prospective study. Urolithiasis. 2019; 47:289-95. )	46.9 ± 13.7	47.4 ± 13.9	38.7 ± 13.1mm	42.8 ± 22.5mm	16.5/20F	30F	AD	BD/ AD	12F	26F	Laser	Pneumatic and ultrasonic
Kandemir et al. ( ⁵5. Kandemir E, Savun M, Sezer A, Erbin A, Akbulut MF, Sarılar Ö. Comparison of Miniaturized Percutaneous Nephrolithotomy and Standard Percutaneous Nephrolithotomy in Secondary Patients: A Randomized Prospective Study. J Endourol. 2020; 34:26-32. )	47.0 ± 13.9	46.7 ± 14.2	32.6 ± 8.1mm	33.1 ± 10.9mm	16.5/20F	30F	AD	BD/ AD	12/14F	26F	Laser	Pneumatic, ultrasonic, laser
Wu et al. ( ¹⁹19. Wu C, Hua LX, Zhang JZ, Zhou XR, Zhong W, Ni HD. Comparison of renal pelvic pressure and postoperative fever incidence between standard- and mini-tract percutaneous nephrolithotomy. Kaohsiung J Med Sci. 2017; 33:36-43. )	47.6 ± 8.2	48.1 ± 7.9	3.4 ± 1.0cm	3.3 ± 1.1cm	16F	24F	FD	AD	8/9.8F	20.8F	Ultrasonic	Ultrasonic
Zeng et al. ( ¹²12. Zeng G, Cai C, Duan X, Xu X, Mao H, Li X, et al. Mini Percutaneous Nephrolithotomy Is a Noninferior Modality to Standard Percutaneous Nephrolithotomy for the Management of 20-40mm Renal Calculi: A Multicenter Randomized Controlled Trial. Eur Urol. 2021; 79:114-21. )	51.0 (43.0, 59.0)^a	51.0 (44.0, 60.0)^a	29.0 (23.0, 35.0)mm^a	29.0 (25.0, 35.0)mm^a	18F	24F	FD	FD	12F	20.8F	Pneumatic, ultrasonic, laser	Pneumatic, ultrasonic, laser
Sakr et al. ( ⁶6. Sakr A, Salem E, Kamel M, Desoky E, Ragab A, Omran M, et al. Minimally invasive percutaneous nephrolithotomy vs standard PCNL for management of renal stones in the flank-free modified supine position: single-center experience. Urolithiasis. 2017; 45:585-9. )	43.8 ± 9.5	40.2 ± 8.3	2.7 ± 0.2cm	2.6 ± 0.6cm	16.5F	30F	TMD	TMD	12F	26F	Pneumatic	Pneumatic
Cheng et al. ( ²⁰20. Cheng F, Yu W, Zhang X, Yang S, Xia Y, Ruan Y. Minimally invasive tract in percutaneous nephrolithotomy for renal stones. J Endourol. 2010; 24:1579-82. )	37.2	39.6	9.54cm²	9.62cm²	16F	24F	TMD	TMD	8/9.8F	20.8F	Pneumatic	Pneumatic and ultrasonic
Song et al. ( ²¹21. Song L, Chen Z, Liu T, Zhong J, Qin W, Guo S, et al. The application of a patented system to minimally invasive percutaneous nephrolithotomy. J Endourol. 2011; 25:1281-6. )	NA	NA	8.57 ± 2.2cm²	8.65 ± 2.0cm²	16F	24F	FD	FD + TMD	NA	24F	Laser	Pneumatic and ultrasonic

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[1] Correspondence address: Yue Cheng, MD Department of Urology, The Center for Uro-nephrological Diseases, Ningbo First Hospital, Ningbo, Zhejiang, China E-mail: dongbaba8@hotmail.com