title: Endoscopic combined intrarenal surgery for large calculi: simultaneous use of flexible ureteroscopy and mini-percutaneous nephrolithotomy overcomes the disadvantageous of percutaneous nephrolithotomy monotherapy.
abstract: OBJECTIVE
  Percutaneous nephrolithotomy (PCNL) is considered the standard procedure for the removal of large renal calculi. The development of the "minimally invasive PCNL" (mini-PCNL) has reduced the complications of the surgery; it also appears to be associated with less morbidity than the conventional PCNL (con-PCNL). This study aimed at evaluating the efficacy of endoscopic intrarenal surgery, using the prone-split leg position, using flexible ureteroscopy and mini-PCNL (mini- endoscopic combined intrarenal surgery [ECIRS]) by retrospectively comparing this technique with mini-PCNL and con-PCNL.
  
  
  METHODS
  In total, 161 consecutive patients who were observed for the follow-up of large renal calculi between February 2004 and January 2013 were selected for mini-ECIRS (60), mini-PCNL (19), or con-PCNL (82). Mini-ECIRS was performed with patients in the prone split-leg position via 18F minipercutaneous tract and 14F ureteral access sheath. The mini-PCNL was performed via 18F percutaneous tract and con-PCNL performed via the 30F tract. Mean size of the renal calculi removed via mini-ECIRS, mini-PCNL, and con-PCNL were 39.2, 38.4, and 34.6 mm, respectively.
  
  
  RESULTS
  Average surgical time for mini-ECIRS was shorter than that for mini-PCNL and con-PCNL (120.5 vs. 181.9 vs 134.1 min, respectively; P<0.001). The stone-free rate for mini-ECIRS was significantly higher than that of the other procedures (initial rates 81.7% vs. 38.9% vs. 45.1%, respectively; P<0.001; rates after further treatment 86.7% vs. 61.1% vs. 61.0%, respectively; P=0.002). Only one patient in the mini-ECIRS group needed blood transfusions. The decrease in hemoglobin during mini-ECIRS and mini-PCNL was significantly lower than that during con-PCNL (P=0.011).
  
  
  CONCLUSIONS
  Mini-ECIRS is better than monotherapy with mini-PCNL or con-PCNL. The study results show that mini-ECIRS is a safe, efficient, and versatile procedure that can be effective for the management of renal calculi.
authors.affiliation: 1 Department of Nephrourology, Nagoya City University Graduate School of Medical Sciences , Nagoya, Japan .
authors.forename: Shuzo
authors.initials: S
authors.lastname: Hamamoto
authors.forename: Takahiro
authors.initials: T
authors.lastname: Yasui
authors.forename: Atsushi
authors.initials: A
authors.lastname: Okada
authors.forename: Kazumi
authors.initials: K
authors.lastname: Taguchi
authors.forename: Noriyasu
authors.initials: N
authors.lastname: Kawai
authors.forename: Ryosuke
authors.initials: R
authors.lastname: Ando
authors.forename: Kentaro
authors.initials: K
authors.lastname: Mizuno
authors.forename: Yasue
authors.initials: Y
authors.lastname: Kubota
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Kamiya
authors.forename: Keiichi
authors.initials: K
authors.lastname: Tozawa
authors.forename: Kenjiro
authors.initials: K
authors.lastname: Kohri
mesh_terms: D000328:Adult; D004724:Endoscopy / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D005260:Female; D006801:Humans; D007669:Kidney Calculi / Q000453:epidemiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D011183:Postoperative Complications; D012189:Retrospective Studies; D018666:Ureteroscopy / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods