Review Article

Mini percutaneous nephrolithotomy in the treatment of

renal and upper ureteral stones: Lessons learned from a
review of the literature
Nikolaos Ferakis, Marios Stavropoulos
Department of Urology, Endourology and Laparascopic Urology, Korgialenio Benakio Hellenic Red Cross Hospital, Athens, Greece

Abstract The aim of this review is to present the most recent data regarding the indications of mini percutaneous
nephrolithotomy (PCNL), the results and the complications of the method. Medline was searched from
1997 to January 2014, restricted to English language. The Medline search used a strategy including medical
subject headings and free‑text protocols. PCNL is a well‑established treatment option for patients with
large and complex renal calculi. In order to decrease morbidity associated with larger instruments like
blood loss, postoperative pain and potential renal damage, a modification of the technique of standard
PCNL has been developed. This is performed with a miniature endoscope via a small percutaneous
tract (11–20 F) and was named as minimally invasive or mini‑PCNL. This method was initially described as
an alternative percutaneous approach to large renal stones in a pediatric patient population. Furthermore,
it has become a treatment option for adults as well, and it is used as a treatment for calculi of various
sizes and locations. However, the terminology has not been standardized yet, and the procedure lacks
a clear definition. Nevertheless, mini‑PCNL can achieve comparable stone‑free rates to the conventional
method, even for large stones. It is a safe procedure, and no major complications are reported. Although
less invasiveness has not been clearly demonstrated so far, mini‑PCNL is usually related to less blood loss
and shorter hospital stay than the standard method.

Key Words: Complications, mini percutaneous nephrolithotomy, modified Clavien system, stone‑free rate,
urolithiasis

Address for correspondence:

Dr. Nikolaos Ferakis, Solomou 3, 15562 Cholargos, Athens, Greece. E‑mail: [email protected]
Received: 18.09.2014, Accepted: 27.10.2014

INTRODUCTION in the USA, with a lifetime prevalence of 5–10%.[1] Moreover,

kidney stones are a recurrent disorder, with lifetime recurrence
Urinary stone disease has affected humankind since antiquity. risks reported to be as high as 50%.[2] Therefore, urolithiasis is
In addition, the incidence of kidney stones has been increased in considered to be a disorder with significant socioeconomical
western societies in the last decades in association with economic parameters, which influences the quality of life. Major
development. Nephrolithiasis is a common cause of morbidity technological advances have improved the treatment of kidney
stones and minimally invasive techniques, such as extracorporeal
Access this article online
shock wave lithotripsy (ESWL), retrograde intrarenal
Quick Response Code:
Website: surgery (RIRS), percutaneous nephrolithotomy (PCNL) and
www.urologyannals.com laparoscopic ureterolithotomy, have now largely replaced open
surgery.[3]
DOI:
10.4103/0974-7796.152927 According to the updated European Association of
Urology (EAU) guidelines, PCNL is recommended as

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 Ferakis and Stavropoulos: Mini-PCNL in renal and upper ureteral stones

the therapy of choice for large renal calculi (>20 mm) INDICATIONS AND CONTRAINDICATIONS
and also for smaller stones (10–20 mm) of the lower
renal pole when unfavorable factors for ESWL exist. [3] Percutaneous nephrolithotomy with the use of appropriate
Excellent stone‑free rates (SFR) following PCNL have size instruments is recommended by the EAU guidelines as
been reported, which range from 76% to 98%.[4] However, the first‑line treatment for renal pelvic or caliceal stones with
PCNL is still a challenging surgical technique and can a diameter larger than 20 mm in children.[3] It is performed as
be associated with significant complications, that may monotherapy in most cases, but it is suggested as an adjunctive
compromise its efficacy. procedure as well. However, further indications for mini‑PCNL
have not been clearly defined. It is true that the use of smaller
In order to decrease morbidity associated with larger instruments via smaller access tracts has contributed to a wider
instruments like blood loss, postoperative pain and potential use of percutaneous techniques, even for stones smaller than
renal damage, a modification of the technique of standard 20 mm.[10,11] Nevertheless, mini‑PCNL has not only been
PCNL has been developed. This is performed with a miniature used for the removal of small lower caliceal stones, but for
endoscope via a small percutaneous tract (11–20 F) and the treatment of large impacted proximal ureteral stones and
was named as minimally invasive PCNL or mini‑PCNL or staghorn calculi as well.[12‑16]
mini Perc. Helal et al. were the first to describe a technique
for pediatric nephrolithotomy performed on a 2‑year‑old General indications for mini‑PCNL that may also exist for
premature female child with the use of instruments with smaller the conventional method include previous failure of ESWL
access diameters.[5] The method involved sequential dilation or ureteroscopic lithotripsy, cystine calculi and anatomic
to 16 F followed by use of a 15 F vascular peel‑away sheath. abnormalities precluding retrograde access or the distal passage
A 10 F pediatric cystoscope and grasper were used to remove of stones.[8] Mini‑PCNL may also be useful in patients with
the stones. However, mini‑PCNL technique was first developed a narrow (<5 mm) or long (>30 mm) infundibulum or as a
and accomplished by Jackman et al. in the pediatric population secondary access for inaccessible or residual fragments resulting
with the use of an 11 F access tract.[6] Since then, the method from standard PCNL.[8,17]
has become a treatment option for adults as well.[7‑9] Usually,
the term mini‑PCNL is used for access sheaths below 20 F. Anticoagulant therapy must be discontinued before the
However, the terminology has not been standardized yet, and procedure.[3] Patients receiving aspirin, for example, should
the procedure lacks a clear definition. discontinue it 7 days before mini‑PCNL while those on warfarin
need to discontinue the drug 5 days before mini‑PCNL. Other
The literature was systematically reviewed for the indications, important contraindications include untreated urinary tract
technique, success rates, and complications regarding infections (UTIs), pregnancy, atypical interposition of visceral
mini‑PCNL. organs (bowel, spleen or liver), tumor in the probable access
tract area and potential malignant renal tumor.[3]
EVIDENCE ACQUISITION
TECHNIQUE
Medline was searched from 1997 to January 2014, restricted
to English language. The Medline search used a strategy The common denominator of the mini‑PCNL technique
including medical subject headings (MeSH) and free‑text is the use of small instruments and small diameter sheaths.
protocols. Access sizes ranging from 11 F to 20 F have been reported in
the literature.[18] The use of a great variety of endoscopes has
A literature review using the keywords mini‑PCNL, minimal been described by different authors for stone disintegration
invasive PCNL, mini PNL, urolithiasis, indications and and removal of fragments. The most common instruments
contraindications, technique, SFR, efficacy, complications, used are an 8/9.8 F rigid or semi‑rigid ureteroscope and
Clavien, and the MeSH terms nephrostomy, percutaneous/ a specially designed 12 F mini nephroscope with a 6 F
indications, and technique, and efficacy, and adverse effects, and working channel and automatic pressure control. [10,15,18]
intraoperative complications or postoperative complications Hydrodynamic effects of a specially designed metallic
was accomplished. Amplatz sheath (15 F/16.5 F/18 F/20 F) placed over a
one‑step metallic dilator were used to evacuate fragmented
Small (<25 patients) single‑center trials, case reports, stones without additional pressure or suction.[10] If the angle
insufficient methodology, insufficient reporting of indications of the percutaneous tract precludes a direct approach to stone
and contraindications and/or technique and/or success rates fragments, a 15.5 F flexible cystonephrocope or 7.5 F flexible
and/or complications were excluded. ureteroscope may also be utilized.[17]

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 Ferakis and Stavropoulos: Mini-PCNL in renal and upper ureteral stones

Traditionally, PCNL has been performed in the prone when a stone free status is achieved. Assumed advantages
position, and it is a well‑established technique. Valdivia Uría of a tubeless procedure are better patient comfort, less
et al. first described the supine position as an alternative, postoperative pain, shorter hospital stay and quicker recovery.
considering anesthesiologic advantages for patients at A randomized prospective trial evaluated the efficacy and
higher risk for cardiopulmonary complications.[19] Liu et al. safety of tubeless (JJ stent but no nephrostomy drainage
performed a systematic review and meta‑analysis of standard tubes) versus conventional mini‑PCNL (JJ stent and drainage
PCNL for patients in the supine versus prone position tubes). [25] In this series with 32 patients, the tubeless
and found that both positions appeared to be equivalent mini‑PCNL group had significantly shorter hospital stays and
with regard to efficacy and safety.[20] The only difference experienced significantly less back pain than the conventional
found was a significantly shorter operative time in the mini‑PCNL group. There were no significant differences in
supine position, attributed to the time‑consuming patient operation time, stone clearance and complications.[25] Less
positioning. Additionally, Zhan et al. conducted a randomized postoperative pain and consequently less need for analgesia
trial comparing the effectiveness and safety of the supine were also confirmed in the group of patients who underwent
lithotomy position for mini‑PCNL versus the traditional tubeless (JJ stent but no nephrostomy tubes) mini‑PCNL in a
prone position.[21] In their series, including 109 patients, prospective comparative study.[26] The morbidity of JJ‑stents,
similar results were reported. The mean operative time was however can be significant. Stent related discomfort is
significantly shortened in the supine position, but both reported in 39% of patients.[27] Totally tubeless mini‑PCNL
positions seemed to be equally effective and safe.[21] Operating should be performed to achieve the best results in terms of
in the supine position may also facilitate a combined approach pain but in selected cases.[26] Two meta‑analyses of tubeless
with simultaneous retrograde ureteroscopic and/or intrarenal versus standard PCNL have been published so far.[28,29] A
access.[20,22,23] The traditional prone position, on the other similar meta‑analysis regarding mini‑PCNL may offer useful
hand, provides access to the posterior calyx with less risk of conclusions.
parenchymal bleeding or perforation and neighboring organ
injuries.[22] The position also eases the creation of multiple The type of care of the nephrostomy tract in order to
access tracts and obviates obscured visibility caused by the prevent hemorrhage or persisting urinary leakage is being
pelvicaliceal collapse noted in the supine position.[22,23] discussed. The application of different hemostatic agents
is mentioned in several studies. The use of gelatin matrix
In general, percutaneous puncture of the kidney and dilation hemostatic sealant, which gains popularity recently, seems to
techniques do not usually differ from standard PCNL. Renal prevent bleeding and urine extravasation.[26,30,31] The necessity
access is usually achieved by the lower posterior calyx or for sealant use, however remains controversial and has not
sometimes by the calyx with the largest stone burden.[8,10,17] A been confirmed yet.
posterior middle calyx puncture via the 11th intercostal space
between the posterior axillary line and scapula line is usually EFFICACY
preferred in the Chinese modification of the method.[15,16,18]
For staghorn stones, multiple tracts are usually necessary The effectiveness of mini‑PCNL is still under debate.
and are created in the same session.[14,15] Access is gained Proponents of the method mention limited blood loss,
under the fluoroscopic and/or ultrasonographic control. increased maneuverability, decreased postoperative pain and
Intracorporeal lithotripsy devices include ultrasonic, limited hospital stay. Limitations of the procedure include the
pneumatic and laser lithotriptors.[3] Most stone fragments necessity to disintegrate stones into small enough fragments
can be flushed out along with the backflow through the to fit through a reduced‑size sheath which results in longer
aforementioned specially designed metallic Amplatz seath operative times.
without increasing intrarenal pressure.[10] Bigger fragments
can be extracted with stone forceps or tipless baskets.[12,24] Even in the first series regarding mini‑PCNL, the SFR was high
In a series published by Chinese high‑volume centers, an enough although the stone burden was relatively low. Jackman
endoscopic pulsed perfusion pump is specially designed for et al. reported an SFR of 85% in children and 89% in adults
retrieval of fragments. Renal pelvic pressure remained lower with a stone burden 1.2 cm2 and 1.5 cm2, respectively.[6,7] Similar
than the level needed for causing a pyelovenous backflow SFRs between mini‑PCNL and PCNL have been reported by
during these procedures.[15] most authors except Giusti et al. who reported lower SFRs
despite longer operative times.[32]
The even less invasive character of the mini‑PCNL due to
smaller access tracts makes the procedure feasible in a tubeless As the indications for mini‑PCNL expanded, newer data
or totally tubeless manner, especially in uncomplicated cases were published recently. In Table 1, there is an overview of the

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Table 1: Data regarding stone free rates of mini‑PCNL published in recent series with more than 25 patients
Authors Year n (patients) Stone Operative Initial Percentage of auxiliary procedures Final Definition
burden time (min) SFR % SFR % of SFR
Sung et al.[24] 2006 72 7.18 cm2 NR 80.6 15.3 (12.5 ESWL, 1.4 ESWL+PCNL, 1.4 URS) 87.5 NR
Giusti et al.[32] 2007 40 2.8 cm2 155.5 77.5 NR NR NR
Nagele et al.[10] 2008 29 1.6 cm2 54 96.5 3.4 (3.4 URS) 100 NR
Li et al.[18] 2009 3,610 NR 78 89 PCNL, ESWL 91 NR
Knoll et al.[26] 2010 25 1.8 cm 48 96 4 (4 PCNL) 100 NR
Zhong et al.*[14] 2011 29 11.7 cm2 116 82.8 24.1 (13.8 PCNL, 10.3 ESWL) 89.7 No RF
Resorlu et al.[33] 2012 106 2.37 cm 76.3 85.8 9.4 (5.6 ESWL, 3.8 PCNL) 94.3 No RF
Huang et al.[34] 2012 41 (solitary kidney) 9.12 cm2 71.3 85.4 14.6 (9.7 ESWL, 4.9 URS) 97.6 RF ≤4 mm
Yang et al.*[13] 2012 91 1.58 cm2 27.4 97.8 0 100 RF <4 mm
Zeng et al.[15] 2013 12,482 14.56 cm2 83 78.6 23.1 (17 PCNL, 3.2 ESWL, 2.9 URS) 94.8 RF ≤4 mm
Abdelhafez et al.[35] 2013 172 2.5 cm 82.9 83.8 13.1 (8.9 URS, 3.7 PCNL, 0.5 ESWL) 96.9 No RF
Long et al.[12] 2013 163 1.84 mm 37 95.7 NR NR RF <4 mm
Pan et al.[36] 2013 59 2.2 cm 62.4 96.6 3.4 (3.4 PCNL) NR RF ≤2 mm
Gu et al.*[37] 2013 30 1.7 cm 50 93.3 20 100 RF <4 mm
Kirac et al.[11] 2013 37 1.05 cm 53.7 91.9 NR 97.2 RF <3 mm
*Randomized controlled trials. ESWL: Extracorporeal shock wave lithotripsy, URS: Ureterorenoscopy, PCNL: Percutaneous nephrolithotomy,
SFR: Stone‑free rate, RF: Residual fragment, NR: Nonreferred

recently published SFRs. However, comparison of the data postoperatively (84% vs. 31.8%).[42] When mini‑PCNL is
is difficult because of the different definition of SFR with compared to RIRS for the treatment of large renal calculi
regard to the time of the stone‑free state and the real definition (20–30 mm), it seems that mini‑PCNL can achieve significantly
of stone‑free (true stone‑free or clinically insignificant higher SFR (96.6% vs. 71.4%).[36] Similar effectiveness of the
fragments [CIRFs]). CIRFs are usually considered as stone two methods is reported when smaller stones are treated.[11,43]
fragments smaller than 3 mm although it is believed that if the Superiority of mini‑PCNL over RIRS was found in the
CIRFs are left untreated; approximately half of the patients treatment of large impacted proximal ureteral stones (≥15 mm)
will experience a stone‑related event for which more than 50% as well (93.3% vs. 41.4%).[37] Operative times of RIRS seem
will also need further intervention.[38] Furthermore, there is to be significantly longer in general (66.4 min, 73.1 min and
wide variation in the imaging used to assess postoperative 106 min vs. 53.7 min, 62.4 min and 59 min respectively)
stone‑free status. Most authors use ultrasonography or plain with comparable stone burden.[11,36,43] However, combination
X‑ray of kidneys, ureters and bladder. Nephrography and of RIRS and mini‑PCNL is better than monotherapy with
computed tomography (CT) are used less common.[15,26] CT is mini‑PCNL for large calculi (>30 mm), even with shorter
more accurate although it carries more radiation exposure and operative times (initial SFR 81.7% vs. 38.9%) (120.5 min vs.
is more expensive. Patients, who could not achieve stone‑free 181.9 min).[44] The patient is put in prone split‑leg position
status will undergo auxiliary procedures such as second look for combined retrograde and antegrade access with the use
PCNL, RIRS or ESWL. of 14 Fr ureteral access sheath of length measuring 35 cm
in females and 55 cm in males advanced to the ureteropelvic
No significant differences in SFR between the mini‑PCNL junction to facilitate passage of stone fragments after renal
and PCNL has been demonstrated. However, a better stone access and stone fragmentation at low intrapelvic pressure.
clearance rate was demonstrated for multiple caliceal stones
when mini‑PCNL was performed (85.2% vs. 70%).[39] Higher COMPLICATIONS
SFR was achieved in the treatment of staghorn stones with
mini‑PCNL and the creation of multiple access tracts (89.7% The concept behind mini‑PCNL was based on the assumption
vs. 68%).[14] Nevertheless, longer operative times are usually that the use of smaller tracts would decrease morbidity observed
associated with mini‑PCNL (155.5 min and 45 min vs. in the conventional method. Such an advantage of mini‑PCNL
106.6 min and 31 min respectively). [32,40] Mini‑PCNL has been firstly reported in infants.[45‑47] Controversy still exists
seems to be more effective when treating smaller (<20 mm) on whether mini‑PCNL is less invasive than standard PCNL.
rather than larger (>20 mm) renal stones (SFR 90.8% vs. Li et al. prospectively evaluated the systemic response to
76.3%).[35] It also shows better SFR than ESWL especially mini‑PCNL and PCNL.[48] Based on experimental findings that
for stones >10 mm.[41,42] In specific, when the efficacy acute‑phase reaction is proportional to surgery‑induced tissue
of ESWL and mini‑PCNL in treating renal stones sized damage, they perioperatively measured acute phase markers
15–25 mm in infants <3 years were compared, significantly such as tumor necrosis factor‑a, interleukin‑6/10, C‑reactive
higher SFR was observed in the mini‑PCNL Group I month protein and serum amyloid A. No significant differences were

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 Ferakis and Stavropoulos: Mini-PCNL in renal and upper ureteral stones

noted between mini‑PCNL and PCNL and their data failed surgical procedure or anesthesia.[15] Moreover, it has been shown
to demonstrate a significant advantage of mini‑PCNL in that the postoperative hospitalization increased with higher
terms of reduced surgical trauma and associated invasiveness Clavien complications.[51] Nevertheless, complication rates are
compared with standard PCNL.[48] Moreover, Traxer et al. not always recorded according to the Clavien grading system
measured and compared the extent of renal parenchyma by the authors in recently published literature.
injury in pigs undergone 11 F and 30 F percutaneous
nephrostomy.[49] The difference between the fibrotic scar Total complication rates published in a recent series of
volumes and the corresponding loss of parenchyma induced by mini‑PCNL according to the Clavien system range from 11.9%
the two tracts was not significant. The authors also concluded to 37.9%. Clavien Grades I, II, III, IV, and V are observed in
that renal parenchyma damage resulting from the creation of 2.7–20.8%, 1.4–17.3%, 0–10.3%, 0–0.05% and 0–0.02% of
a nephrostomy tract is small compared to overall renal volume the patients, respectively. In comparison, total complication rates
regardless of the size of the nephrostomy tract.[49] However, in series of conventional PCNL range from 16.2% to 60.3%
the benefit of mini‑PCNL remains as the use of smaller and Clavien rates I, II, IIIa, IIIb, IVa, IVb and V are noted in
access sheaths resulted in reduced intraoperative blood loss, 4–41.2%, 4.5–17.6%, 0–6.6%, 0–2.8%, 0–1.1%, 0–0.5%,
less postoperative pain and shorter hospital stay. An advantage 0–0.1%, respectively.[52] It is of interest to mention that the
of mini‑PCNL over the conventional procedure was noted in total complication rate has not been found significantly different
terms of a significantly reduced hemoglobin drop (0.53 g/dl between patients undergone mini‑PCNL for small (<20 mm)
and 0.8 g/dL vs. 0.97 g/dL and 1.3 g/dL respectively)[39,40] and or large (>20 mm) renal stones (19.4% vs. 26.9%) and
the need for blood transfusion (1.4% vs. 10.4%).[39] Analgesic that no Grade IV or V complications occurred.[35] When
requirement has also been found significantly decreased in simple (mean stone burden 10.18 cm2) and complex (mean
mini‑PCNL when compared to standard PCNL (55.4 g vs. stone burden 17.63 cm2) were compared, Grade I, II, III, IV and
70.2 g tramadol).[40] Hospital stay was significantly shorter after V complications were noted in 17.1% versus 16.6%, 4.29%
mini‑PCNL (3.8 days and 3.2 days vs. 6.9 days and 4.8 days versus 5.58%, 3.82% versus 4.06%, 0.02% versus 0.07%, and
respectively).[26,40] 0% versus 0.04% with regard to stone size, respectively.[15,16]
However, blood transfusion (Grade II) (2.2% vs. 3.2%) and
Although, mini‑PCNL has not a proven clear advantage over arterial embolization (Grade III) (0.28% vs. 0.67%) were
the conventional procedure in terms of lower invasiveness, observed more often in patients with complex stones. This
it remains a safe method. Table 2 shows an overview of the can be probably attributed to the larger stone burden of these
recently published complication rates. Complications can patients and the consequent need for multiple tracts.[15,16]
occur during and after the procedure and can be related to Total complication rate of mini‑PCNL was similar even in
renal access and stone removal.[4] Since 2007, the modified patients with a solitary kidney and renal calculi.[34] A significant
Clavien grading system has been used to report perioperative improvement in GFR was detected from the preoperative
complications of conventional PCNL.[50] In addition, de la period to 1‑month follow‑up. Adequate drainage in patients
Rosette categorization of complications and validation of the with a solitary kidney after mini‑PCNL was proposed with
Clavien score for PCNL was published.[51] It was demonstrated the placement of both a JJ stent and a nephrostomy tube.[34]
that the validity of the Clavien grading system is the highest
for Grade V and the lowest for Grade I. It had also been As mentioned before, mini‑PCNL is recommended for the
proposed that many of the low‑grade complications may not treatment of large renal calculi in children. This specific
be specifically related to PCNL and can be attributed to any category of patients has usually lower co‑morbidities than

Table 2: Data regarding complication rates of mini‑PCNL according to modified Clavien grading system, published in recent
series with more than 25 patients
Authors Year n (patients) n (renal units) Total complication rate (%) I (%) II (%) III (%) IV (%) V (%)
Knoll et al.[26] 2010 25 25 28 24 4 0 0 0
Cheng et al.*[39] 2010 69 72 23.6 20.8 1.4 1.4 0 0
Zhong et al.*[14] 2011 29 29 37.9 10.3 17.3 10.3 0 0
Knoll et al.[43] 2011 25 25 16 16 0 0 0
Resorlu et al.[33] 2012 106 106 17 17 0 0 0
Zeng et al.[16] 2013 12,482 13,984 25.9 16.8 5 3.9 0.05 0.02
Kirac et al.[11] 2013 37 37 16.2 2.7 13.5 0 0 0
Long et al.[12] 2013 163 163 23.1 14.6 8.5 0 0 0
Pan et al.[36] 2013 59 59 11.9 3.4 8.5 0 0 0
Abdelhafez et al.[35] 2013 172 191 23 12 5.8 5.2 0 0
*Randomized controlled trials. I, II, III, IV, V: Grades of complications according to modified Clavien classification system.[50] PCNL: Percutaneous
nephrolithotomy

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 Ferakis and Stavropoulos: Mini-PCNL in renal and upper ureteral stones

adults. However, there is always a serious concern about stone burden, UTI and impaired renal function have a higher
the effect of the chosen treatment option on the growing probability to require longer hospitalization time.[52] There is
kidney. The less robust pelvicaliceal system of children and no extensive analysis in the literature of various risk factors
a limited tolerance for blood loss make the procedure more that may influence the occurrence of complications. Body
challenging.[53] When mini‑PCNL performed in children mass index has been studied thoroughly, but it does not seem
and adults were compared, there was no significant difference to correlate with higher complication rates.[11,26,35,36,43] Some
in perioperative total complication rate.[53] However, major believe that more severe complications (Grade III or higher)
complications (Grade IV and V) were not observed in children. should be quite rare and are more likely related to surgical
On the other hand, intraoperative bleeding was significantly techniques and the level of experience.[15] The experience curve
correlated with operative time, stone burden and sheath size is also reported to have a significant impact on the rates of
in pediatric patients.[46] Higher hemoglobin drop has been intraoperative bleeding.[47]
reported in children undergone PCNL when nephrostomy
tracts used exceeded 22 F (1.6 g/dl vs. 1.1 g/dl).[47] In a CONCLUSION
large series of 331 mini‑PCNL in pediatric population a
significant increase in hemoglobin drop and transfusion Mini‑PCNL was introduced as an alternative to the standard
rate was also noticed in children with multiple nephrostomy procedure in order to reduce morbidity associated with larger
tracts (2.7 g/dl vs. 2 g/dl and 18.8% vs. 4.5% respectively).[53] access tracts. Although less invasiveness has not been clearly
Zeng et al. compared ESWL and mini‑PCNL for the treatment demonstrated so far, mini‑PCNL is related to less blood loss
of renal stones sized 15–25 mm in infants younger than and shorter hospitalization. It is recommended for treatment of
3 years old. Total complication rate was significantly higher in large renal stones in children and can be implemented in adults
the ESWL group (45.5% vs. 16%).[42] Recently mini‑PCNL as well. Mini‑PCNL seems to be a reasonable alternative for
has been compared to RIRS for the treatment of renal calculi patients with a small‑to‑medium‑sized stones, especially when
of different sizes.[36,37,43,47] No major complications occurred a tubeless procedure is considered. Mini‑PCNL is safe and is
during or after the two procedures. Overall, complication rates not related to serious complications.
were not significantly different between mini‑PCNL and RIRS
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How to cite this article: Ferakis N, Stavropoulos M. Mini percutaneous
54. Xu S, Shi H, Zhu J, Wang Y, Cao Y, Li K, et al. A prospective comparative nephrolithotomy in the treatment of renal and upper ureteral stones: Lessons
study of haemodynamic, electrolyte, and metabolic changes during learned from a review of the literature. Urol Ann 2015;7:141-8.
percutaneous nephrolithotomy and minimally invasive percutaneous
Source of Support: Nil, Conflict of Interest: None.
nephrolithotomy. World J Urol 2014;32:1275‑80.

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