Tricks and Tips in Urology: Use of a Semi-rigid Ureteroscope for Super-mini Percutaneous Nephrolithotomy

Percutaneous nephrolithotomy (PCNL) is a standard technique for the management of renal stones, and its evolution has been marked by progressive instrument miniaturization and advances in laser technology.Super-Mini Percutaneous Nephrolithotomy (SMP) represents a miniaturized form of PCNL characterized by the use of a small-caliber percutaneous access, generally ranging from 10 to 14 Fr.This approach aims to preserve the efficacy of stone fragmentation and removal while reducing renal parenchymal trauma and postoperative morbidity.In this context, the use of a small-caliber semi-rigid ureteroscope through a 10-Fr access sheath represents an attractive alternative when dedicated SMP equipment is unavailable.The procedure begins with ureteral catheterization using a 7-Fr Chevassu catheter (Coloplast, Humlebæk, Denmark), allowing retrograde pyelography and passive reduction of intrarenal pressure.Percutaneous renal puncture is then performed, followed by progressive tract dilation up to 10 Fr according to the surgeon's preference.A 10-Fr access sheath (Innovative access sheath) is subsequently inserted, allowing passage of a 9.5-Fr semirigid ureteroscope (Karl Storz, Tuttlingen, Germany).Renal stones, particularly those smaller than 2 cm, are fragmented using a 275-µm Holmium laser fiber (Boston Scientific, Marlborough, USA) in dusting mode.Intrarenal pressure can be intermittently reduced using aspiration syringes, which also facilitate evacuation of fragments generated during laser lithotripsy.SMP offers several features that may improve procedural tolerance.The reduced percutaneous tract diameter may decrease renal parenchymal trauma and postoperative blood loss, potentially reducing transfusion requirements and bleeding-related complications.Active aspiration and fragment evacuation are additional features of this technique.Miniaturization may also contribute to shorter hospital stays, reduced analgesic requirements, and faster recovery.In selected patients, a tubeless approach or outpatient management may be possible.From an economic perspective, SMP assessment should not be limited to the initial cost of specialized equipment.The costs of laser fibers, access sheaths, and miniaturized instruments should be considered alongside potential benefits such as fewer complications, reduced transfusion requirements, shorter hospital stays, and fewer secondary procedures.In resource-limited healthcare systems, reusable instruments and readily available equipment may improve cost-effectiveness.Therefore, using a semi-rigid ureteroscope through a small-caliber access sheath may provide a simple, accessible alternative when dedicated supermini nephroscopes and specialized access systems are unavailable.Overall, Super-Mini PCNL appears feasible, effective, and potentially less morbid for managing selected renal stones.Its small percutaneous tract, laser lithotripsy, active fragment evacuation, and potential reduction in postoperative morbidity make it an attractive minimally invasive approach.Moreover, adapting available equipment, particularly a 9-Fr semi-rigid ureteroscope with a 10-Fr access sheath (Innovative access sheath), may facilitate implementation while reducing procedural costs.This approach could represent a practical alternative to dedicated SMP instrumentation, particularly where specialized equipment is limited.