الفهرس 
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Abstract
The incidence of renal stones is rising worldwide. Renal stones are associated with chronic kidney disease.
At present, the primary treatment modalities for urinary stones include Extracorporeal Shock Wave Lithotripsy (ESWL), rigid ureteroscopy (URS), flexible ureteroscopy (FUS), percutaneous nephrolithotomy (PNL), laparoscopic and open surgery.
Among these approaches, PNL is regarded as the first-line treatment for renal stones larger than 2 cm owing its higher stone clearance and cost-effectiveness compared with other treatment alternatives. However, PNL can cause serious complications and morbidities, including bleeding, organ injury, pain, infection, vascular embolism and accidental death.
In an effort to reduce complications related to PNL or to make the procedure more suitable for children, mini PNL, which uses a smaller tract, was introduced to treat urinary stones. Mini PNL has advantages over standard PNL, including faster recovery and shorter hospital stay.
Although mini PNL was more likely to be associated with fewer complications, there was still controversy about its relative efficiency in the clearance of stones compared to standard PNL, as the smaller tract may hinder the required instrumental manipulations for stone removal, especially for large calculi.
The aim of the present study is to compare between the mini PNL and the standard PNL in management of renal stones (20-40 mm) regarding: operative time, fluoroscopy time, blood loss, stone free rate, and postoperative complications according to modified Clavein system.
This is prospective randomized comparative study, was carried out at urology department Ain Shams university hospitals, from 2019 to 2021 on 93 Patients coming for renal stone management divided into 2 groups: (group A): included 44 patients, standard PNL was done, (group B): included 49 patients, Mini-PNL was done.
The main results of the study revealed that:
There was no statistically significant difference in patient’s characteristics between both groups.
Left sided renal stones represent the majority of the cases, 56.8% in group A and 65.3% in group B respectively.
The mean stone size in group A and group B was 29.3 mm and 28.4 mm respectively with no significant difference.
The stone density measured in the spiral CT was 960 Hounsfield units in group A and was 994 Hounsfield units in group B with no significant difference between both groups.
Regarding the fluoroscopy time, it was 4.7 minutes and 4.5 minutes in group A and B respectively with no significant difference between both groups.
The operative time in group A (standard PNL, 70.1 minutes) was significantly shorter than the operative time in group B (mini PNL, 96.4 minutes).
Patients in group A had significantly longer catheterization time, nephrostomy time and hospital stay than patients in group B.
On the 1st postoperative day, 9 patients in group A were found to have residual stones. In the follow up visit 4 weeks later, 7 patients become totally free and ESWL was done for two patients who have residual stones ≥ 4 mm in group B.
In group B, residual stones were found in 19 patients on the 1st postoperative day. 4 patients passed the stones spontaneously but 15 patients underwent ESWL by the 4th postoperative week.
Postoperative fever that required additional antibiotics (instead of prophylactic) occurred in 5 patients (11.3%) and 9 patients (18.4%) of group A and group B respectively. Fever in both groups resolved by conservative measures (fluid, antibiotics and antipyretics).
There was no incidence of colonic, pleural or other organ injury in both groups. Also, there was no incidence of urinoma or delayed hematuria during post-operative follow up of both groups.
There is a significant difference between both groups regarding preoperative and postoperative DROP in hemoglobin level (0.7 vs 1.6 in group A and B respectively).
There is no significant difference between both groups regarding preoperative and postoperative serum Na and K levels.
The postoperative pain and the need for postoperative analgesia were significant in patients of group A. The visual analogue scale (VAS) was 7.4 and 5.2 in group A and B respectively and the patient felt more comfortable group B.
We divided the patients in the mini PNL group into two subgroups according to the lithotripsy method used (B1 & B2). We used the pneumatic lithotriptor in 23 patients (group B1) while we used laser as a method of lithotripsy in 26 patients (group B2).
The operative time in group B1(pneumatic, 88.6 minutes) was significantly shorter than the operative time in group B2(laser, 103.2).
There is no significant difference between both groups regarding the fluoroscopy time, catheterization time, nephrostomy time and duration of hospital stay.
Both methods of lithotripsy achieved similar success rate. There is no significant difference between both groups as regard to the stone clearance.
There was significant difference between both groups regarding the postoperative fever which occurred more frequently in group B2.
There is no significant difference between both groups regarding other complications.
There was no significant difference between both groups regarding VAS or hemoglobin drop.
Based on our results we recommend further studies on larger number of patients and longer period of follow up to emphasize our conclusion.