Micropercutaneous nephrolithotomy. A new therapeutic option for pediatric renal lithiasis | Actas Urológicas Españolas (English Edition)

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A new therapeutic option for pediatric renal lithiasis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "483" "paginaFinal" => "487" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "D. Pérez-Fentes, B. Blanco-Gómez, C. García-Freire" "autores" => array:3 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Pérez-Fentes" "email" => array:2 [ 0 => "danielfentes@gmail.com" 1 => "daniel.adolfo.perez.fentes@sergas.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Blanco-Gómez" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "García-Freire" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Urología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nefrolitotomía micropercutánea: una nueva opción terapéutica para la litiasis renal pediátrica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1138 "Ancho" => 1033 "Tamanyo" => 172401 ] ] "descripcion" => array:1 [ "en" => "(A) Galdakao-modified supine Valdivia position for right percutaneous access. (B) Microperc® micropercutaneous surgery equipment." ] ] ] "textoCompleto" => "IntroductionThe goal of treatment of renal lithiasis should be the removal of the stone burden, with no or minimal harm to the patient, providing a benefit in quality of life and reducing the risk of disease recurrence as much as possible.These premises should guide our decision tree, now being able to choose between different options: observation, extracorporeal shock wave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PNL).Percutaneous surgery is the technique that provides the best results in terms of absence of residual stones, but at the expense of higher morbidity than other treatment options. The main complications of PNL are derived from the creation of the percutaneous tract. In this regard, the decrease in the size of the access probe has demonstrated a lower incidence of complications, mainly at the expense of bleeding reduction.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Technological advances have enabled us, mainly through the miniaturization of endoscopes and litofragmentation and extraction systems, to walk to the minimal invasiveness in the treatment of kidney stones. This fact becomes even more important when facing the treatment of renal lithiasis in a pediatric patient, wherein the disease is usually chronic, associated with anatomical abnormalities or metabolic disorders, and where recurrence is the norm.The aim of this paper is to present the first case performed in our country of micropercutaneous nephrolithotomy in a pediatric patient, describe the technique and discuss the possible indications of this novel approach. To date this is the first case in the literature performed in supine position in a kidney in orthotopic location, and larger pediatric lithiasis successfully resolved through micropercutaneous surgery.Materials and methodsWe report the case of a 14-year-old patient, with a body mass index of 19.3kg/m2, hypercalciuria in thiazide therapy, and history of right renal stones treated by extracorporeal shock wave lithotripsy. The patient had mild intermittent hematuria and occasional right lumbar pain pictures. Sonographically, lithiasis is seen in the right renal sinus, with minimal associated calyceal ectasia. Plain abdominal X-ray is requested, in which an intensely radiopaque 35mm×28mm stone becomes evident (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Initially, ESWL is indicated as first-line treatment, not achieving fragmentation thereof. Given the large lithiasic volume and failed lithotripsy treatment, it is proposed for right percutaneous nephrolithotomy. Being a pediatric patient with recurrent lithiasis and several failed treatments on this renal unit, we decided to perform the approach using micropercutaneous surgery, given its theoretically lower aggressiveness.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Surgical techniqueThe procedure is performed under general anesthesia and in Galdakao-modified supine Valdivia position (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Initially right ureteral catheterization is performed with 6Ch catheter, to darken the excretory tract. Percutaneous puncture is made with the 16 gauge (G) needle of the Microperc® micropercutaneous surgery equipment (PolyDiagnost, Pfaffenhofen, Germany), under ultrasound and radiological control, through the papilla of the lower calyx.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The micropercutaneous surgical equipment has an initial puncture needle (4.85Ch) whose sheath has a three-way connector attached. One of the lights (usually the central one) is used for the 0.9-mm and 10,000-pixel reusable optical fiber, which provides an excellent vision with 120° visual field. The second way is used to implement the laser fiber. The third one is for the irrigation system. In cases of poor vision or large stones an 8Ch sheath can be used, easily replaceable from the 4.85Ch one. Through this sheath, we can use laser fibers of greater caliber or even remove small lithiasic fragments for analysis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).Lasertripsy begins with 200μm Ho:YAG laser fiber through the 4.85Ch sheath. A combination of 0.6–0.8J and 8–10Hz was used to get a pulverizer effect of the stone, not fragmentation thereof. Given the large lithiasic size and its hardness, at 60min of the operation we decided to increase the size of the access probe using an 8Ch sheath. This maneuver allowed us, as well as for better irrigation for vision, to introduce a 500-μm fiber.ResultsThe procedure is completed in a surgical time of 170min, using 3.9min of fluoroscopy and a dose-area product of 882cGy/cm2. Before the end of surgery a right double J catheter is placed to prevent the development of obstructive uropathy due to stone fragments or clots. The patient is discharged at 24h, showing only minimal hematuria without clots. At 72h he presents a picture of renal colic resolved with first-level oral analgesia at home (Clavien I). The return to school life occurs on the fifth day. The double J catheter was removed after two weeks on an outpatient basis. In control ultrasound a month after the intervention, only a 4-mm remnant is evidenced at the level of the lower calyx.DiscussionBader et al.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> presented at the 2010 Congress of the American Urological Association a system for optical control of the puncture, through a 16-G needle. In their series all the cases were subsequently performed by conventional percutaneous surgery. In 2011, Desai et al.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> showed that the procedure could be completed safely through this optical system, with a hole of 4.85Ch, coining the term ‘microperc’.Since then, several groups<a class="elsevierStyleCrossRefs" href="#bib0020">4–11</a> have published their results in micropercutaneous surgery of the lithiasis, in both adult and pediatric population. Most use the access of the puncture needle (4.85Ch), although in cases of large lithiasis most choose the 8Ch sheath of the Microperc® set. In summary, successful procedure of 83–100% has been described, with a low incidence of complications, requiring in 10% of cases reconversion to minipercutaneous surgery. The results of these studies are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The system of visual control of the puncture makes it possible to verify the correct entry of the needle into the access probe and reduce the risk of puncture of other joining guts. By using small-caliber sheaths, and since the technique is performed through the obturator of the puncture needle and it does not require dilation maneuvers of the percutaneous tract, the risk of bleeding, perforation of the tract, and infundibular injury is reduced, as well as the need for radiological exposure, of special interest in the pediatric population. In addition, the ‘microperc’ surgery is performed without percutaneous drainage, with benefit in postoperative pain and hospital stay.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> Moreover, irrigation itself through the needle favors the washing and output of fragments in anterograde direction, contributing to the cleaning of the kidney.However, the micropercutaneous technique is not without limitations. First, the lithiasic size determines the surgical time and the need to leave a double J catheter to avoid the risk of obstructive uropathy due to fragments. Given the minimum size of the working channel, which the camera, the laser fiber and the irrigation share, the vision of this device is limited when bleeding occurs. In these cases, and in those in which a considerable lithiasic burden is intended to be treated, we recommend using the 8Ch sheath. The working strategy in the ‘microperc’ technique is spraying the stone, not fragmentation thereof. To do this we recommend using 0.6–0.8J energies and 8–10Hz frequencies, thus preventing the formation of fragments that cannot be removed through the 4.85Ch sheath. Another potential limitation, which would force us to convert the process into conventional percutaneous surgery or perform RIRS is migration of the stone to a non-accessible area from the percutaneous access.Finally, one of the main risks of the technique is the development of intrarenal hypertension and pyelo-venous reflux. To prevent this it is advisable to keep an ureteral drainage, preferably multiperforated, throughout the procedure. We have used an irrigation system by gravity, placed at 1m height of the operating table and maintaining a 6Ch open-tip ureteral catheter until the end of the procedure, through which a gentle suction was performed intermittently. Thus, and despite having had surgery for longer than 2h, we have not experienced any problems. Micropercutaneous surgery might be contraindicated in cases of complete obstruction of the urinary tract, in which a simultaneous drainage of the excretory pathway is not achieved, since the intrarenal pressure produced could be very high.Although the experience with the ‘microperc’ technique to date is limited to define its indications in the treatment of kidney stones, it looks as if it could be an excellent alternative as first-line treatment in pediatric kidney stones, producing minimal damage to the renal parenchyma, have a high percentage of success in a single surgical procedure, and avoid ureteral instrumentation. Desai et al.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> published in 2011 the first case of micropercutaneous surgery performed successfully in the pediatric patient. The broadest series in the literature is that of Hatipoglu et al.,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> who compared the treatment of kidney stones with ESWL and ‘microperc’ in 108 and 37 children, respectively. Despite treating larger stones, the ‘microperc’ group presented a percentage of absence of stones a month similar to the group treated with lithotripsy, finding no significant differences in the development of perioperative complications between both techniques. However, it should be clarified that patients in the ESWL group had to receive two sessions in 28.7% of the cases and three in 5%, while those treated by micropercutaneous nephrolithotomy did so in a single act. These retreatments involve, in the case of the pediatric patient, a greater number of anesthesias, increased analgesic consumption for longer, and greater stress for children and their families, besides an increase in radiological exposure. Our case is, to date, the greater size stone treated by micropercutaneous nephrolithotomy and the first performed in supine position in a kidney in orthotopic situation. Desai and Gasamoni previously described the use of the supine-oblique position for the micropercutaneous access of ectopic kidneys.<a class="elsevierStyleCrossRefs" href="#bib0015">3,6</a>In adults this technique would compete with ESWL, RIRS, and minipercutaneous surgery (with 12–20Ch accesses) in the treatment of kidney stones.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a> A reasonable clinical application of ‘microperc’ would be its use after failure of lithotripsy and RIRS in kidneys with complex pyelo-calicial anatomy (long and narrow infundibula, acute infundibulum-pelvic angles) in which RIRS has limited access and ESWL a poor outcome in cases of calyceal diverticula, horseshoe or ectopic kidneys (as a first step of a conventional percutaneous surgery to verify that it has correctly entered the cavity before performing the dilation), or its combined use with RIRS or as second access of a conventional PNL.The ideal lithiasis for the ‘microperc’ approach is the calyceal and/or pyelic lithiasis, which is aligned with the axis of the percutaneous route, so that it can be fully treated through this single access. The lithiasic volume is not an absolute contraindication for this technique, but it will condition the surgical time indeed, this also depending on the surgeon's experience in percutaneous surgery. In order to decrease it we recommend, in stones over 2cm in diameter, using the 8Ch sheath and 365–500μm laser fibers, as well as systematically leaving a double J postoperative catheter, to prevent the risk of obstructive uropathy due to fragments.Finally, given the novelty of the technique and the limited scientific evidence available to date, we believe it necessary to conduct further studies and collaborative work in our country to help define precise indications, potential applications, know the Microperc ® equipment durability, and analyze its cost-effectiveness compared to other treatments, as well as to optimize the surgical technique of micropercutaneous nephrolithotomy, improving its results and reducing the risk of complications.ConclusionsMicropercutaneous nephrolithotomy is a safe and effective technique in the pediatric population, and it may be performed in the supine position in the case of orthotopic kidneys. The ‘microperc’ technique is a new alternative in the treatment of kidney stones, which will soon be included in their treatment algorithms, both exclusively and in combination with other current treatment options. In this sense, micropercutaneous nephrolithotomy is a new step toward the pursuit of lower invasiveness in the treatment of kidney stones.Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres364416" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec344019" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres364415" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec344020" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack90753" "titulo" => "Acknowledgment" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-12-01" "fechaAceptado" => "2014-02-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec344019" "palabras" => array:4 [ 0 => "Percutaneous nephrolithotomy" 1 => "Urinary calculi" 2 => "Pediatrics" 3 => "Surgical technique" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec344020" "palabras" => array:4 [ 0 => "Nefrolitotomía percutánea" 1 => "Cálculos urinarios" 2 => "Pediatría" 3 => "Técnica quirúrgica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "IntroductionMicropercutaneous nephrolithotomy is an evolution from the conventional percutaneous surgery in which pyelocaliceal access is obtained through minimum bore holes. Its objective is the complete removal of the calculi, lowering the morbidity associated with larger bore percutaneous tracts. Materials and methodsWe present the case of a micropercutaneous nephrolithotomy performed in a 14-year-old female patient with a 35mm diameter kidney stone located in the renal pelvis. Surgery was performed in the Galdakao-modified supine Valdivia position. Puncture was done under ultrasound and fluoroscopic guidance. The 4.85Ch needle of the Microperc® set was used, completing the procedure through the 8Ch working shaft. Lasertripsy was done with the Ho:YAG laser. An indwelling double J stent was placed at the end of the procedure. ResultsOperating time was 170min. Hospital stay was one day. She suffered renal colic after 72h, which was resolved with oral analgesic treatment at home (Clavien I). She returned to school on the fifth postoperative day. The double J was removed at two weeks. At one month of the surgery, the patient is asymptomatic, a 4mm lower calyx residual stone being observed in the abdominal ultrasound. ConclusionMicropercutaneous nephrolithotomy is a step forward toward the search for a less invasive kidney stone treatment. It is a safe and effective technique in the pediatric population, and it can be performed in the supine position, even in orthotropic kidneys. Future studies and collaborative works will help to better define its indications, to optimize its technique and to analyze its cost-effectiveness compared with other treatment options." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa nefrolitotomía micropercutánea es una evolución de la cirugía percutánea convencional en la que se accede al sistema pielocalicial mediante orificios de mínimo calibre. Su objetivo es la completa eliminación del cálculo, disminuyendo la morbilidad producida por la realización de trayectos percutáneos de mayor diámetro. Material y métodosPresentamos la realización de una nefrolitotomía micropercutánea en una paciente de 14 años con litiasis renal de 35mm de diámetro situada en la pelvis renal. La cirugía se realiza en posición supina de Valdivia modificada en Galdakao. Punción guiada por ultrasonidos y fluoroscopia. Se emplea la aguja 4,85 Charrière (Ch) del set de Microperc®, completando el procedimiento a través de la vaina 8Ch. Lasertricia con láser Ho:YAG. Se deja catéter doble J al finalizar el procedimiento. ResultadosTiempo quirúrgico de 170min. Estancia hospitalaria de un día. Cólico renal a las 72h resuelto con analgesia en domicilio (Clavien I). Reincorporación a la vida escolar al 5.° día. Retirada del catéter doble J a las 2 semanas. La paciente está asintomática al mes de la intervención, observándose en la ecografía abdominal un resto de 4mm en el cáliz inferior. ConclusiónLa nefrolitotomía micropercutánea es un nuevo paso adelante hacia la búsqueda de la menor invasividad en el tratamiento de la litiasis renal, siendo una técnica segura y efectiva en la población pediátrica, pudiendo ser realizada en decúbito supino en riñones ortotópicos. Futuros estudios y trabajos colaborativos ayudarán definir mejor sus indicaciones, a optimizar su técnica quirúrgica y a analizar su coste-efectividad comparada con otros tratamientos." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Pérez-Fentes D, Blanco-Gómez B, García-Freire C. Nefrolitotomía micropercutánea: una nueva opción terapéutica para la litiasis renal pediátrica. Actas Urol Esp. 2014;38:483–487." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1021 "Ancho" => 1033 "Tamanyo" => 105562 ] ] "descripcion" => array:1 [ "en" => "Plain abdominal radiography. 35mm×28mm radiopaque lithiasis in the right renal pelvis." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1138 "Ancho" => 1033 "Tamanyo" => 172401 ] ] "descripcion" => array:1 [ "en" => "(A) Galdakao-modified supine Valdivia position for right percutaneous access. (B) Microperc® micropercutaneous surgery equipment." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Authors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Lithiasic size<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Ages<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Hospital stay<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Success (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Complications Clavien III (no. cases) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Reconversion (no. cases) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Desai et al.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> (2011) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6–25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9–63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Piskin et al.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> (2012) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7–18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3–47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Armagan et al.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> (2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10–30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3–69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5±0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ganesamoni et al.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> (2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13–23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57–60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hatipoglu et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> (2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6–32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sabnis et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> (2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1±0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39±15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1±0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Silay et al.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> (2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7–32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">89.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tepeler et al.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> (2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9–29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7–69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.6±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab546879.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "The results are presented as mean±standard deviation or range, depending on the availability of data in the respective studies." ] ] ] "descripcion" => array:1 [ "en" => "Main results of the micropercutaneous nephrolitotomy series." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Operating times and bleeding complications in percutaneous nephrolithotomy: a comparison of tract dilation methods in 5,537 patients in the Clinical Research Office of 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Skill and talent

Micropercutaneous nephrolithotomy. A new therapeutic option for pediatric renal lithiasis

Nefrolitotomía micropercutánea: una nueva opción terapéutica para la litiasis renal pediátrica

D. Pérez-Fentes

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danielfentes@gmail.com
daniel.adolfo.perez.fentes@sergas.es

Corresponding author.

, B. Blanco-Gómez, C. García-Freire

Servicio de Urología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain

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    "titulo" => "Micropercutaneous nephrolithotomy&#46; A new therapeutic option for pediatric renal lithiasis"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Galdakao-modified supine Valdivia position for right percutaneous access&#46; &#40;B&#41; Microperc<span class="elsevierStyleSup">&#174;</span> micropercutaneous surgery equipment&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The goal of treatment of renal lithiasis should be the removal of the stone burden&#44; with no or minimal harm to the patient&#44; providing a benefit in quality of life and reducing the risk of disease recurrence as much as possible&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">These premises should guide our decision tree&#44; now being able to choose between different options&#58; observation&#44; extracorporeal shock wave lithotripsy &#40;ESWL&#41;&#44; retrograde intrarenal surgery &#40;RIRS&#41; and percutaneous nephrolithotomy &#40;PNL&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Percutaneous surgery is the technique that provides the best results in terms of absence of residual stones&#44; but at the expense of higher morbidity than other treatment options&#46; The main complications of PNL are derived from the creation of the percutaneous tract&#46; In this regard&#44; the decrease in the size of the access probe has demonstrated a lower incidence of complications&#44; mainly at the expense of bleeding reduction&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Technological advances have enabled us&#44; mainly through the miniaturization of endoscopes and litofragmentation and extraction systems&#44; to walk to the minimal invasiveness in the treatment of kidney stones&#46; This fact becomes even more important when facing the treatment of renal lithiasis in a pediatric patient&#44; wherein the disease is usually chronic&#44; associated with anatomical abnormalities or metabolic disorders&#44; and where recurrence is the norm&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this paper is to present the first case performed in our country of micropercutaneous nephrolithotomy in a pediatric patient&#44; describe the technique and discuss the possible indications of this novel approach&#46; To date this is the first case in the literature performed in supine position in a kidney in orthotopic location&#44; and larger pediatric lithiasis successfully resolved through micropercutaneous surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We report the case of a 14-year-old patient&#44; with a body mass index of 19&#46;3<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; hypercalciuria in thiazide therapy&#44; and history of right renal stones treated by extracorporeal shock wave lithotripsy&#46; The patient had mild intermittent hematuria and occasional right lumbar pain pictures&#46; Sonographically&#44; lithiasis is seen in the right renal sinus&#44; with minimal associated calyceal ectasia&#46; Plain abdominal X-ray is requested&#44; in which an intensely radiopaque 35<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>28<span class="elsevierStyleHsp" style=""></span>mm stone becomes evident &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Initially&#44; ESWL is indicated as first-line treatment&#44; not achieving fragmentation thereof&#46; Given the large lithiasic volume and failed lithotripsy treatment&#44; it is proposed for right percutaneous nephrolithotomy&#46; Being a pediatric patient with recurrent lithiasis and several failed treatments on this renal unit&#44; we decided to perform the approach using micropercutaneous surgery&#44; given its theoretically lower aggressiveness&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical technique</span><p id="par0035" class="elsevierStylePara elsevierViewall">The procedure is performed under general anesthesia and in Galdakao-modified supine Valdivia position &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Initially right ureteral catheterization is performed with 6<span class="elsevierStyleHsp" style=""></span>Ch catheter&#44; to darken the excretory tract&#46; Percutaneous puncture is made with the 16 gauge &#40;G&#41; needle of the Microperc<span class="elsevierStyleSup">&#174;</span> micropercutaneous surgery equipment &#40;PolyDiagnost&#44; Pfaffenhofen&#44; Germany&#41;&#44; under ultrasound and radiological control&#44; through the papilla of the lower calyx&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The micropercutaneous surgical equipment has an initial puncture needle &#40;4&#46;85<span class="elsevierStyleHsp" style=""></span>Ch&#41; whose sheath has a three-way connector attached&#46; One of the lights &#40;usually the central one&#41; is used for the 0&#46;9-mm and 10&#44;000-pixel reusable optical fiber&#44; which provides an excellent vision with 120&#176; visual field&#46; The second way is used to implement the laser fiber&#46; The third one is for the irrigation system&#46; In cases of poor vision or large stones an 8<span class="elsevierStyleHsp" style=""></span>Ch sheath can be used&#44; easily replaceable from the 4&#46;85<span class="elsevierStyleHsp" style=""></span>Ch one&#46; Through this sheath&#44; we can use laser fibers of greater caliber or even remove small lithiasic fragments for analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Lasertripsy begins with 200<span class="elsevierStyleHsp" style=""></span>&#956;m Ho&#58;YAG laser fiber through the 4&#46;85<span class="elsevierStyleHsp" style=""></span>Ch sheath&#46; A combination of 0&#46;6&#8211;0&#46;8<span class="elsevierStyleHsp" style=""></span>J and 8&#8211;10<span class="elsevierStyleHsp" style=""></span>Hz was used to get a pulverizer effect of the stone&#44; not fragmentation thereof&#46; Given the large lithiasic size and its hardness&#44; at 60<span class="elsevierStyleHsp" style=""></span>min of the operation we decided to increase the size of the access probe using an 8<span class="elsevierStyleHsp" style=""></span>Ch sheath&#46; This maneuver allowed us&#44; as well as for better irrigation for vision&#44; to introduce a 500-&#956;m fiber&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The procedure is completed in a surgical time of 170<span class="elsevierStyleHsp" style=""></span>min&#44; using 3&#46;9<span class="elsevierStyleHsp" style=""></span>min of fluoroscopy and a dose-area product of 882<span class="elsevierStyleHsp" style=""></span>cGy&#47;cm<span class="elsevierStyleSup">2</span>&#46; Before the end of surgery a right double J catheter is placed to prevent the development of obstructive uropathy due to stone fragments or clots&#46; The patient is discharged at 24<span class="elsevierStyleHsp" style=""></span>h&#44; showing only minimal hematuria without clots&#46; At 72<span class="elsevierStyleHsp" style=""></span>h he presents a picture of renal colic resolved with first-level oral analgesia at home &#40;Clavien I&#41;&#46; The return to school life occurs on the fifth day&#46; The double J catheter was removed after two weeks on an outpatient basis&#46; In control ultrasound a month after the intervention&#44; only a 4-mm remnant is evidenced at the level of the lower calyx&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Bader et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> presented at the 2010 Congress of the American Urological Association a system for optical control of the puncture&#44; through a 16-G needle&#46; In their series all the cases were subsequently performed by conventional percutaneous surgery&#46; In 2011&#44; Desai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> showed that the procedure could be completed safely through this optical system&#44; with a hole of 4&#46;85<span class="elsevierStyleHsp" style=""></span>Ch&#44; coining the term &#8216;microperc&#8217;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Since then&#44; several groups<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;11</span></a> have published their results in micropercutaneous surgery of the lithiasis&#44; in both adult and pediatric population&#46; Most use the access of the puncture needle &#40;4&#46;85<span class="elsevierStyleHsp" style=""></span>Ch&#41;&#44; although in cases of large lithiasis most choose the 8<span class="elsevierStyleHsp" style=""></span>Ch sheath of the Microperc<span class="elsevierStyleSup">&#174;</span> set&#46; In summary&#44; successful procedure of 83&#8211;100&#37; has been described&#44; with a low incidence of complications&#44; requiring in 10&#37; of cases reconversion to minipercutaneous surgery&#46; The results of these studies are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The system of visual control of the puncture makes it possible to verify the correct entry of the needle into the access probe and reduce the risk of puncture of other joining guts&#46; By using small-caliber sheaths&#44; and since the technique is performed through the obturator of the puncture needle and it does not require dilation maneuvers of the percutaneous tract&#44; the risk of bleeding&#44; perforation of the tract&#44; and infundibular injury is reduced&#44; as well as the need for radiological exposure&#44; of special interest in the pediatric population&#46; In addition&#44; the &#8216;microperc&#8217; surgery is performed without percutaneous drainage&#44; with benefit in postoperative pain and hospital stay&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Moreover&#44; irrigation itself through the needle favors the washing and output of fragments in anterograde direction&#44; contributing to the cleaning of the kidney&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">However&#44; the micropercutaneous technique is not without limitations&#46; First&#44; the lithiasic size determines the surgical time and the need to leave a double J catheter to avoid the risk of obstructive uropathy due to fragments&#46; Given the minimum size of the working channel&#44; which the camera&#44; the laser fiber and the irrigation share&#44; the vision of this device is limited when bleeding occurs&#46; In these cases&#44; and in those in which a considerable lithiasic burden is intended to be treated&#44; we recommend using the 8<span class="elsevierStyleHsp" style=""></span>Ch sheath&#46; The working strategy in the &#8216;microperc&#8217; technique is spraying the stone&#44; not fragmentation thereof&#46; To do this we recommend using 0&#46;6&#8211;0&#46;8<span class="elsevierStyleHsp" style=""></span>J energies and 8&#8211;10<span class="elsevierStyleHsp" style=""></span>Hz frequencies&#44; thus preventing the formation of fragments that cannot be removed through the 4&#46;85<span class="elsevierStyleHsp" style=""></span>Ch sheath&#46; Another potential limitation&#44; which would force us to convert the process into conventional percutaneous surgery or perform RIRS is migration of the stone to a non-accessible area from the percutaneous access&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally&#44; one of the main risks of the technique is the development of intrarenal hypertension and pyelo-venous reflux&#46; To prevent this it is advisable to keep an ureteral drainage&#44; preferably multiperforated&#44; throughout the procedure&#46; We have used an irrigation system by gravity&#44; placed at 1<span class="elsevierStyleHsp" style=""></span>m height of the operating table and maintaining a 6<span class="elsevierStyleHsp" style=""></span>Ch open-tip ureteral catheter until the end of the procedure&#44; through which a gentle suction was performed intermittently&#46; Thus&#44; and despite having had surgery for longer than 2<span class="elsevierStyleHsp" style=""></span>h&#44; we have not experienced any problems&#46; Micropercutaneous surgery might be contraindicated in cases of complete obstruction of the urinary tract&#44; in which a simultaneous drainage of the excretory pathway is not achieved&#44; since the intrarenal pressure produced could be very high&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Although the experience with the &#8216;microperc&#8217; technique to date is limited to define its indications in the treatment of kidney stones&#44; it looks as if it could be an excellent alternative as first-line treatment in pediatric kidney stones&#44; producing minimal damage to the renal parenchyma&#44; have a high percentage of success in a single surgical procedure&#44; and avoid ureteral instrumentation&#46; Desai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> published in 2011 the first case of micropercutaneous surgery performed successfully in the pediatric patient&#46; The broadest series in the literature is that of Hatipoglu et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> who compared the treatment of kidney stones with ESWL and &#8216;microperc&#8217; in 108 and 37 children&#44; respectively&#46; Despite treating larger stones&#44; the &#8216;microperc&#8217; group presented a percentage of absence of stones a month similar to the group treated with lithotripsy&#44; finding no significant differences in the development of perioperative complications between both techniques&#46; However&#44; it should be clarified that patients in the ESWL group had to receive two sessions in 28&#46;7&#37; of the cases and three in 5&#37;&#44; while those treated by micropercutaneous nephrolithotomy did so in a single act&#46; These retreatments involve&#44; in the case of the pediatric patient&#44; a greater number of anesthesias&#44; increased analgesic consumption for longer&#44; and greater stress for children and their families&#44; besides an increase in radiological exposure&#46; Our case is&#44; to date&#44; the greater size stone treated by micropercutaneous nephrolithotomy and the first performed in supine position in a kidney in orthotopic situation&#46; Desai and Gasamoni previously described the use of the supine-oblique position for the micropercutaneous access of ectopic kidneys&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In adults this technique would compete with ESWL&#44; RIRS&#44; and minipercutaneous surgery &#40;with 12&#8211;20<span class="elsevierStyleHsp" style=""></span>Ch accesses&#41; in the treatment of kidney stones&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> A reasonable clinical application of &#8216;microperc&#8217; would be its use after failure of lithotripsy and RIRS in kidneys with complex pyelo-calicial anatomy &#40;long and narrow infundibula&#44; acute infundibulum-pelvic angles&#41; in which RIRS has limited access and ESWL a poor outcome in cases of calyceal diverticula&#44; horseshoe or ectopic kidneys &#40;as a first step of a conventional percutaneous surgery to verify that it has correctly entered the cavity before performing the dilation&#41;&#44; or its combined use with RIRS or as second access of a conventional PNL&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The ideal lithiasis for the &#8216;microperc&#8217; approach is the calyceal and&#47;or pyelic lithiasis&#44; which is aligned with the axis of the percutaneous route&#44; so that it can be fully treated through this single access&#46; The lithiasic volume is not an absolute contraindication for this technique&#44; but it will condition the surgical time indeed&#44; this also depending on the surgeon&#39;s experience in percutaneous surgery&#46; In order to decrease it we recommend&#44; in stones over 2<span class="elsevierStyleHsp" style=""></span>cm in diameter&#44; using the 8<span class="elsevierStyleHsp" style=""></span>Ch sheath and 365&#8211;500<span class="elsevierStyleHsp" style=""></span>&#956;m laser fibers&#44; as well as systematically leaving a double J postoperative catheter&#44; to prevent the risk of obstructive uropathy due to fragments&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Finally&#44; given the novelty of the technique and the limited scientific evidence available to date&#44; we believe it necessary to conduct further studies and collaborative work in our country to help define precise indications&#44; potential applications&#44; know the Microperc <span class="elsevierStyleSup">&#174;</span> equipment durability&#44; and analyze its cost-effectiveness compared to other treatments&#44; as well as to optimize the surgical technique of micropercutaneous nephrolithotomy&#44; improving its results and reducing the risk of complications&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">Micropercutaneous nephrolithotomy is a safe and effective technique in the pediatric population&#44; and it may be performed in the supine position in the case of orthotopic kidneys&#46; The &#8216;microperc&#8217; technique is a new alternative in the treatment of kidney stones&#44; which will soon be included in their treatment algorithms&#44; both exclusively and in combination with other current treatment options&#46; In this sense&#44; micropercutaneous nephrolithotomy is a new step toward the pursuit of lower invasiveness in the treatment of kidney stones&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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            3 => "T&#233;cnica quir&#250;rgica"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Micropercutaneous nephrolithotomy is an evolution from the conventional percutaneous surgery in which pyelocaliceal access is obtained through minimum bore holes&#46; Its objective is the complete removal of the calculi&#44; lowering the morbidity associated with larger bore percutaneous tracts&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We present the case of a micropercutaneous nephrolithotomy performed in a 14-year-old female patient with a 35<span class="elsevierStyleHsp" style=""></span>mm diameter kidney stone located in the renal pelvis&#46; Surgery was performed in the Galdakao-modified supine Valdivia position&#46; Puncture was done under ultrasound and fluoroscopic guidance&#46; The 4&#46;85<span class="elsevierStyleHsp" style=""></span>Ch needle of the Microperc<span class="elsevierStyleSup">&#174;</span> set was used&#44; completing the procedure through the 8<span class="elsevierStyleHsp" style=""></span>Ch working shaft&#46; Lasertripsy was done with the Ho&#58;YAG laser&#46; An indwelling double J stent was placed at the end of the procedure&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Operating time was 170<span class="elsevierStyleHsp" style=""></span>min&#46; Hospital stay was one day&#46; She suffered renal colic after 72<span class="elsevierStyleHsp" style=""></span>h&#44; which was resolved with oral analgesic treatment at home &#40;Clavien I&#41;&#46; She returned to school on the fifth postoperative day&#46; The double J was removed at two weeks&#46; At one month of the surgery&#44; the patient is asymptomatic&#44; a 4<span class="elsevierStyleHsp" style=""></span>mm lower calyx residual stone being observed in the abdominal ultrasound&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Micropercutaneous nephrolithotomy is a step forward toward the search for a less invasive kidney stone treatment&#46; It is a safe and effective technique in the pediatric population&#44; and it can be performed in the supine position&#44; even in orthotropic kidneys&#46; Future studies and collaborative works will help to better define its indications&#44; to optimize its technique and to analyze its cost-effectiveness compared with other treatment options&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La nefrolitotom&#237;a micropercut&#225;nea es una evoluci&#243;n de la cirug&#237;a percut&#225;nea convencional en la que se accede al sistema pielocalicial mediante orificios de m&#237;nimo calibre&#46; Su objetivo es la completa eliminaci&#243;n del c&#225;lculo&#44; disminuyendo la morbilidad producida por la realizaci&#243;n de trayectos percut&#225;neos de mayor di&#225;metro&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Presentamos la realizaci&#243;n de una nefrolitotom&#237;a micropercut&#225;nea en una paciente de 14 a&#241;os con litiasis renal de 35<span class="elsevierStyleHsp" style=""></span>mm de di&#225;metro situada en la pelvis renal&#46; La cirug&#237;a se realiza en posici&#243;n supina de Valdivia modificada en Galdakao&#46; Punci&#243;n guiada por ultrasonidos y fluoroscopia&#46; Se emplea la aguja 4&#44;85 Charri&#232;re &#40;Ch&#41; del set de Microperc<span class="elsevierStyleSup">&#174;</span>&#44; completando el procedimiento a trav&#233;s de la vaina 8<span class="elsevierStyleHsp" style=""></span>Ch&#46; Lasertricia con l&#225;ser Ho&#58;YAG&#46; Se deja cat&#233;ter doble J al finalizar el procedimiento&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Tiempo quir&#250;rgico de 170<span class="elsevierStyleHsp" style=""></span>min&#46; Estancia hospitalaria de un d&#237;a&#46; C&#243;lico renal a las 72<span class="elsevierStyleHsp" style=""></span>h resuelto con analgesia en domicilio &#40;Clavien I&#41;&#46; Reincorporaci&#243;n a la vida escolar al 5&#46;&#176; d&#237;a&#46; Retirada del cat&#233;ter doble J a las 2 semanas&#46; La paciente est&#225; asintom&#225;tica al mes de la intervenci&#243;n&#44; observ&#225;ndose en la ecograf&#237;a abdominal un resto de 4<span class="elsevierStyleHsp" style=""></span>mm en el c&#225;liz inferior&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La nefrolitotom&#237;a micropercut&#225;nea es un nuevo paso adelante hacia la b&#250;squeda de la menor invasividad en el tratamiento de la litiasis renal&#44; siendo una t&#233;cnica segura y efectiva en la poblaci&#243;n pedi&#225;trica&#44; pudiendo ser realizada en dec&#250;bito supino en ri&#241;ones ortot&#243;picos&#46; Futuros estudios y trabajos colaborativos ayudar&#225;n definir mejor sus indicaciones&#44; a optimizar su t&#233;cnica quir&#250;rgica y a analizar su coste-efectividad comparada con otros tratamientos&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; P&#233;rez-Fentes D&#44; Blanco-G&#243;mez B&#44; Garc&#237;a-Freire C&#46; Nefrolitotom&#237;a micropercut&#225;nea&#58; una nueva opci&#243;n terap&#233;utica para la litiasis renal pedi&#225;trica&#46; Actas Urol Esp&#46; 2014&#59;38&#58;483&#8211;487&#46;</p>"
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1021
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            "Tamanyo" => 105562
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Plain abdominal radiography&#46; 35<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>28<span class="elsevierStyleHsp" style=""></span>mm radiopaque lithiasis in the right renal pelvis&#46;</p>"
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Galdakao-modified supine Valdivia position for right percutaneous access&#46; &#40;B&#41; Microperc<span class="elsevierStyleSup">&#174;</span> micropercutaneous surgery equipment&#46;</p>"
        ]
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
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                  \t\t\t\t" style="border-bottom: 2px solid black">Authors&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46; cases&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Lithiasic size<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Ages<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Hospital stay<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Success &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Complications Clavien III &#40;no&#46; cases&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Reconversion &#40;no&#46; cases&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Desai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> &#40;2011&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6&#8211;25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#8211;63&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#8211;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">88&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Piskin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> &#40;2012&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#8211;18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#8211;47&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#8211;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">85&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">Armagan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> &#40;2013&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&#8211;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">83&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Ganesamoni et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> &#40;2013&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13&#8211;23&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">57&#8211;60&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Hatipoglu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> &#40;2013&#41;&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0110" class="elsevierStylePara elsevierViewall">The authors acknowledge Presurgy S&#46;L&#46; for the transfer of the Microperc<span class="elsevierStyleSup">&#174;</span> equipment to perform this procedure&#46;</p>"
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Article information

ISSN: 21735786
Original language: English

DOI:10.1016/j.acuroe.2014.06.001

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Year/Month	Html	Pdf	Total

2019 April	1	2	3
2018 February	10	3	13
2018 January	7	1	8
2017 December	14	0	14
2017 November	11	1	12
2017 October	16	1	17
2017 September	9	1	10
2017 August	11	1	12
2017 July	29	4	33
2017 June	16	1	17
2017 May	19	4	23
2017 April	13	14	27
2017 March	13	22	35
2017 February	16	2	18
2017 January	10	0	10
2016 December	23	7	30
2016 November	12	6	18
2016 October	28	9	37
2016 September	17	6	23
2016 July	0	1	1
2016 June	0	5	5
2016 May	0	3	3
2016 April	0	5	5
2016 March	0	8	8
2016 February	0	9	9
2016 January	0	9	9
2015 December	0	4	4
2015 November	2	7	9
2015 August	0	1	1
2015 July	0	1	1
2014 October	0	1	1
2014 September	1	1	2
2014 August	1	1	2

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