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PubMed2005

Management of pelvic stones larger than 20 mm: laparoscopic transperitoneal pyelolithotomy or percutaneous nephrolithotomy?

UNLABELLED: Large pelvic stones are frequently managed with percutaneous nephrolithotomy (PCNL) but laparoscopic transperitoneal pyelolithotomy (LTP) can be an alternative. We compared PCNL and LTP for the treatment of pelvic stones >20 mm in diameter. PATIENTS AND METHODS: Between November 1999 and November 2004, 16 consecutive patients, mean age 42, with a single pelvic stone >20 x 10 mm (group I), underwent LTP as first-line treatment or after shockwave lithotripsy failure. They were compared with a similar population of 16 consecutive patients, mean age 45 (group II), who underwent PCNL for the same indication and were assessed retrospectively. We evaluated operative characteristics, complications, and results for each technique. RESULTS: There was no difference between the two groups regarding the characteristics of patients and stones. Operative time duration was significantly longer in group I (129 vs. 75 min; p = 0.001) and conversion was required in 2 patients (12%). The main postoperative complications were urinary leakage (2 patients, 12%) in group I and bleeding (3 patients, 18%) in group II, but only 1 required blood transfusion. Mean hospital stay was respectively 6.5 and 5.6 days in groups I and II (p = 0.17). Stone-free rates were assessed at 3 months and were not different between group I and group II (88 vs. 82%). CONCLUSIONS: The operative time of LTP is longer and the results of both techniques are comparable but postoperative morbidity is different. Specific indications of each technique must be determined although PCNL remains the gold standard for most large pelvic stones.

Adult↗
PubMed2003

Combined percutaneous and retrograde approach to staghorn calculi with application of the ureteral access sheath to facilitate percutaneous nephrolithotomy.

PURPOSE: We describe our technique and clinical experience with application of the ureteral access sheath for single access ablation of staghorn and partial staghorn calculi. MATERIALS AND METHODS: We retrospectively reviewed our experience with 9 patients who underwent percutaneous nephrolithotomy for staghorn (6) or partial staghorn (3) renal calculi using a combined antegrade and retrograde approach. Patient data, operative parameters, efficacy of stone ablation and convalescence parameters were reviewed. RESULTS: Mean operative time for the primary procedure was 3.1 hours with a mean estimated blood loss of 290 ml. Postoperatively, the mean analgesic requirement was 33.2 mg. MSO(4) equivalents. Hospital stay was 3.2 days. There were no major and 4 minor (44%) complications. No patient required transfusion. Complete stone clearance was achieved in 7 of the 9 cases (78%) using a single percutaneous nephrostomy tract. CONCLUSIONS: Our preliminary clinical experience using the ureteral access sheath during percutaneous nephrolithotomy for simultaneous antegrade and retrograde stone treatment has been favorable. A large renal stone burden can be successfully managed with a single percutaneous access and limited blood loss.

Humans↗
PubMed2005

Percutaneous nephrolithotomy (PCNL) in kidneys with fusion and rotation anomalies.

OBJECTIVES: Fusion and rotation anomalies are among the most common anomalies of the kidneys especially the horseshoe kidneys that have abnormal mixtures of malrotation, ectopia and fusion. Percutaneous nephrolithotomy (PCNL) in horseshoe kidney and malrotation kidney is challenging. We report PCNL in 10 horseshoe kidneys and 4 kidneys with congenital malrotation. MATERIAL AND METHOD: PCNL was done in 14 kidneys of 12 patients who had horseshoe kidneys (6 patients) and malrotation kidneys (4 patients). Two patients with horseshoe kidney had bilateral calculi. One patient had simultaneous PCNL. Upper pole access was done in 12 kidneys under fluoroscopic guidance with modified PCNL technique. Tubeless PCNL was done in 7 kidneys. RESULTS: Stone-free rate was 86% and the fragment of stones less than 4 mm was 14%. Only minimal pleural effusion was found in one patient that no intervention was needed. Average hospital stay was 3.3 days. CONCLUSION: Percutaneous nephrolithotomy (PCNL) in horseshoe kidney and malrotation kidney is effective and a safe method in wish only a minor modified technique is needed. Upper pole access was used in most of the cases. No increasing of the complications of PCNL in horseshoe kidneys and malrotion kidneys is found comparing to the same procedure done in the normal kidney.

Adult↗
PubMed1999

Autologous blood use in percutaneous nephrolithotomy.

OBJECTIVES: Preoperative autologous blood (AUB) donation has decreased patient exposure to allogenic blood (ALB) products and associated infectious risk. The risk of contracting hepatitis C and human immunodeficiency virus is 1 in 103,000 and 1 in 678,000, respectively, after receiving 1 U ALB. Elective surgical procedures require surgeons to offer preoperative AUB donation in California. Unused AUB is discarded. We report our use of AUB obtained for percutaneous nephrolithotomy. METHODS: A retrospective study of 144 consecutive patients who underwent 193 percutaneous nephrolithotomies between January 1994 and April 1998 at one of four teaching hospitals at the University of California, San Francisco was performed. Preoperative AUB donation, transfusion rates, hemoglobin levels, blood use, and costs were analyzed. RESULTS: Ninety-six units of blood were collected from 63 patients (44%) and were available for 70 procedures (36%). The overall transfusion rate per procedure was 7%, with 13 patients receiving a total of 24 U, 7 AUB and 17 ALB. Eighty-nine units (92.7%) of AUB were discarded, and the transfusion rate in donors and nondonors was similar. There was no significant difference in preoperative hemoglobin or operative blood loss between donors and nondonors. The 13 transfused patients had a lower preoperative hemoglobin ( 11.5 versus 12.8 g/dL; P = 0.029) and higher operative blood loss as measured by hemoglobin level (3.2 versus 1.6 g/dL; P <0.001). Blood bank charges for ALB and AUB were $ 119/U and $244 to $498/U, respectively, depending on transportation and thawing charges. CONCLUSIONS: Routine preoperative blood donation adds substantial cost for minimal benefit, given the low infectious risk of ALB and the two- to fourfold higher cost of AUB. In our series, women had an increased incidence of blood transfusion compared with men. AUB donation may provide peace of mind but is rarely used and is discarded 93% of the time.

Adolescent↗
PubMed2001

Prospective randomized study of various techniques of percutaneous nephrolithotomy.

OBJECTIVES: To compare the modifications of the technique of percutaneous nephrolithotomy (PCN), including "mini-PCN" and tubeless PCN, to establish which technique is associated with the least morbidity and complications. METHODS: We performed a prospective randomized trial to assess the efficacy and morbidity of each method of percutaneous renal access. Standard PCN involved tract dilation to 30F for passage of a 34F working sheath, and our "mini-PCN" involved tract dilation to 22F for passage of a 26F sheath. Tubeless PCN involved the use of a double-J stent for internal drainage without the use of a nephrostomy tube for external drainage at termination of the procedure. Thirty patients (10 patients in each group) were enrolled, and 27 patients completed the study. All three groups were compared with regard to postoperative pain using a validated pain questionnaire comprised of a visual analogue scale and a verbal rating scale. The operative time, estimated blood loss, stone burden, procedure success rate, stone-free rate, length of hospitalization, total procedural cost, and complications were also compared for each technique. RESULTS: The tubeless PCN population required less morphine use, had a decreased length of hospitalization, and had a smaller total procedural cost compared with the other two groups. One complication was noted in both the standard and mini-PCN groups, consisting of renal bleeding requiring a 2 and 3-U blood transfusion in the standard and mini-PCN groups, respectively. CONCLUSIONS: The tubeless technique is associated with the least amount of morbidity and the greatest cost efficiency compared with the other techniques. No overall advantage was found for the mini-PCN versus the standard technique, but the mini-PCN is at a slight disadvantage because of poorer visualization and optics and difficulty with use of the nephroscopic graspers.

Cost-Benefit Analysis↗
PubMed1988

Percutaneous nephrolithotomy. Experience with renal and proximal ureteral calculi at Tygerberg Hospital.

Percutaneous nephrolithotomy (PCN) enables the urologist to remove upper urinary tract stones through a percutaneous nephrostomy tract. The principal advantages of PCN are the low morbidity, shortened hospital stay and rapid recovery. Percutaneous puncture failed in 5 (11%) of the first 44 patients with upper tract urolithiasis treated by PCN at Tygerberg Hospital. In 35 patients (80%) PCN cleared the kidney of stones but in 4 patients (9%) all stone fragments were not removed during the procedure. If the puncture and dilatation was successful, then 90% of patients were stone-free after PCN. Complications were minimal except for a diabetic who died of septicaemia. PCN is an alternative to open renal surgery in the management of most upper urinary tract stones. The technique is readily mastered by any urologist experienced in endoscopic surgery.

Adolescent↗
PubMedDate not supplied

[Percutaneous nephrolithotomy for coralliform lithiasis in a patient with bilateral triplicated ureters].

We report on a rare case of bilateral ureteral triplicity with a definitive urinary diversion (Brickner loop ureteroileostomy) who presented a staghorn stone in the upper calyx of the left kidney. The patient was submitted to percutaneous nephrolithotomy with direct access to the upper calyx of the anomalous kidney. We discuss the indication for this treatment, which resolved the lithiasis in a single session and with no complications. Furthermore, this treatment modality is compared with ESWL and open surgery, which we reserve for failures or those cases where the percutaneous approach is contraindicated. Percutaneous nephrolithotomy can be considered a therapeutic alternative for lithiasis in patients with congenital malformation and/or urinary diversion.

Adult↗
PubMed2006

Percutaneous nephrolithotomy for complex caliceal calculi and staghorn stones in children less than 5 years of age.

BACKGROUND AND PURPOSE: Treatment of children with staghorn and complex caliceal calculi is one of the most challenging problems in urology. We present our experience with percutaneous nephrolithotomy (PCNL) monotherapy for staghorn and complex caliceal calculi in children less than 5 years of age. PATIENTS AND METHODS: Between 1991 and 2004, 27 boys and 9 girls aged 11 months to 4.5 years underwent PCNL for staghorn (33%) or complex caliceal (67%) calculi. The average bulk of the stones was 140.17 +/- 42.16 mm(2) (range 61-253 mm(2)). Staging of the procedure was preferred in children with renal insufficiency, urinary-tract infection, fragmentation time >60 minutes, or a stone burden requiring more than two tracts. Essential steps of the technique were a dynamic contrast study to select the appropriate-size Amplatz sheath and ultrasound guidance for renal access. RESULTS: The average operative time was 72.11 +/- 28.86 minutes. The stone-free rate was 86%, the mean hemoglobin drop was 2.2 +/- 0.95 g/dL, and the mean hospital stay was 3.5 days. Less than half of the patients (42%) were treated in a single stage, the remainder requiring multiple procedures. Only 39% could be treated with a single tract. There was statistically significant increase in the blood loss in patients requiring multiple tracts (P = 0.008); however, staging the procedure did not increase the blood loss (P = 0.06). CONCLUSION: Percutaneous nephrolithotomy is safe and effective in children less than 5 years of age. Staging the procedure, instrument modification, the timed "multi mini-perc" technique, and ultrasound-guided access help in achieving maximum stone clearance with minimal morbidity.

Child, Preschool↗
PubMed2001

Management of colonic perforation during percutaneous nephrolithotomy in horseshoe kidney.

Few cases of colonic injury during percutaneous nephrolithotomy (PCNL) have been reported in orthotopic kidneys and none in horseshoe kidney, and the management protocol has not been standardized. A plain film on postoperative day 1 following PCNL showed contrast medium in the descending colon, leading to the diagnosis of colonic injury in a 53-year-old male patient with horseshoe kidney and multiple bilateral stones. He was asymptomatic and was treated successfully by minimally invasive techniques. An asymptomatic patient with a colonic injury following PCNL can be treated by minimal manipulations. Computed tomography imaging is necessary prior to percutaneous surgery on a horseshoe kidney.

Colon↗
PubMed2004

Nephroureterostomy-drained percutaneous nephrolithotomy: modification combining safety with decreased morbidity.

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) has become well established as the standard procedure for the management of certain renal calculi. To minimize patient discomfort and reduce the hospital stay, a novel modification of our previous technique was evaluated. A smaller internal/external nephroureterostomy catheter (NUC) placed at the completion of the procedure was compared with the larger Malecot nephrostomy tube. PATIENTS AND METHODS: We conducted a 2:1 matched cohort study with historical controls. In 2002, a consecutive series of 30 PCNL procedures at a single teaching hospital were carried out in the conventional fashion. At the end of the procedure, an 8.5F/6.0F internal/external NUC was placed in the percutaneous tract instead of the traditional 24F Malecot tube. These patients were compared with a cohort of matched cases (60) performed between 1992 and 1997 on the basis of age, sex, and site of access (supracostal or infracostal). The endpoints were patient discomfort (morphine equivalents used), safety (postoperative hemoglobin drop), and length of hospital stay. RESULTS: The mean morphine equivalents used in the first 24 postoperative hours were significantly different in the two groups (study 16.5 mg and controls 47.8 mg; P<0.001). The percentage difference between the preoperative and postoperative hemoglobin values was comparable in the two groups (mean study 12.8% and mean controls 13.4%; P=0.80). The median length of hospital stay was significantly shorter in the study group than in the control group, 1 v 4 days, respectively (P<0.001). CONCLUSION: Our data suggest that the NUC diminishes postoperative pain while maintaining ureteral patency and nephrostomy access and decreases hospital stay.

Female↗
PubMed2004

Totally tubeless percutaneous nephrolithotomy in selected patients.

PURPOSE: Significant early postoperative discomfort after percutaneous procedures is usually secondary to nephrostomy tubes and externalized ureteral catheters. We describe our modification of the traditional percutaneous nephrolithotomy (PCNL) approach that we name "totally tubeless PCNL." PATIENTS AND METHODS: Between June 2000 and May 2001, 60 consecutive PCNLs were performed at our centers. At the end of the surgery, we omitted the nephrostomy tube and removed the externalized catheter in selected patients: no solitary kidney, stone size <3 cm, and without any obstructions or arterial bleeding. A total of 30 patients underwent totally tubeless PCNL (group 1). We compared their results with those of a control group of 30 patients who underwent standard PCNL (group 2). The incidence of complications, analgesic requirements, length of hospitalization, and time to return to normal activities were compared in the two groups. RESULTS: In both groups, PCNL was performed successfully without any significant complications. A 90% stone-free rate was achieved in both groups, and in the remaining patients, small residual stones (<4 mm) were detected. No urinoma was demonstrated by postoperative ultrasound scanning in group 1. The average length of hospitalization was 1.5 days for group 1 and 3 days for group 2. The average analgesic requirements were 30 mg of pentazosin in group 1 and 90 mg in group 2. No transfusion was needed. There were three complications: 2 patients (6.6%) had urinary tract infection in group 1 and 1 (3.3%) in group 2. All were managed medically. CONCLUSIONS: Omitting the percutaneous nephrostomy tube and removing ureteral catheter at the end of surgery in selected patients were safe and accompanied by significantly reduced postoperative discomfort, length of hospitalization, and analgesic requirements. Further studies are needed to determine the role of this technique.

Adult↗
PubMedDate not supplied

Treatment of caliceal diverticular stones: transdiverticular percutaneous nephrolithotomy with creation of a neoinfundibulum.

PURPOSE: To evaluate transdiverticular percutaneous nephrolithotomy (TDPN) with creation of a neoinfundibulum in the treatment of caliceal diverticular stones. PATIENTS AND METHODS: Between 1990 and 1998, 18 patients with symptomatic calculi in caliceal diverticula underwent TDPN. Transdiverticular puncture into the renal collecting system with creation of a neoinfundibulum was used, eliminating the need for prolonged probing with a wire for the neck of the diverticulum. Eight diverticula were upper polar, six were interpolar, and four were in the lower pole. Stones were endoscopically treated with use of Lithoclast (Electromedical Systems, Lausanne, Switzerland), graspers, ultrasound, or a combination of these methods. RESULTS: Sixteen kidneys (89%) were rendered stone-free at discharge. Two kidneys (11%) were left with stone fragments of 5 mm or smaller. Hospital stay ranged from 3 to 15 days (average, 7 days). Procedure time ranged from 45 to 169 minutes (average, 87 minutes). One patient developed a left renal-pleural fistula, which closed 1 week after chest tube drainage. No other complications were encountered for an overall complication rate of 6%. CONCLUSION: TDPN is a safe and effective method for treating caliceal diverticular stones, with a complication rate comparable to other methods.

Adult↗
PubMed2006

Success in treating renal calculi with single-access, single-event percutaneous nephrolithotomy: is a routine "second look" necessary?

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) is an effective procedure for the treatment of large renal calculi. An important consideration for patients undergoing PCNL is the management of any residual stone burden, which may include "second-look" nephroscopy. The utility of this practice is unproven, and we present our data on a series of patients in which second-look procedures were not performed. PATIENTS AND METHODS: We retrospectively reviewed the records of 43 consecutive patients undergoing a total of 45 procedures by a single surgeon at a tertiary-care center. Patients were considered stone free if no calculi were evident by either plain film or noncontrast CT scan. Statistical analysis was used to look for correlations between radiographic stone clearance and various patient and stone characteristics. RESULTS: Of these procedures, 15% had immediate postoperative evidence of residual fragments. At a mean follow-up of 8 months, 32.5% had residual or recurrent stone. There were statistically significant correlations between both patient age and stone size and the risk of recurrent or residual stone. CONCLUSIONS: In our study, PCNL was effective for the single-stage treatment of large renal calculi. Aggressive stone clearance obviated the need for routine second-look nephroscopy. Factors leading to an increased risk of residual or recurrent calculi included the presence of a staghorn calculus and younger patient age. The excellent stone-free rates achieved suggest that routine second-look nephroscopy may not be necessary for the majority of patients undergoing PCNL.

Adolescent↗
PubMed2005

Treatment of complete staghorn stones: a prospective randomized comparison of open surgery versus percutaneous nephrolithotomy.

PURPOSE: We studied the role of open surgery versus percutaneous nephrolithotomy (PCNL) in the treatment of complete staghorn stones in a prospective randomized manner. MATERIALS AND METHODS: A total of 79 patients with 88 complete staghorn stones, defined as filling the entire collecting system or at least 80% of it, were prospectively randomized for PCNL (43) or open surgery (45). Intraoperative and postoperative morbidity, operative time, hospital stay, and stone clearance at discharge home and followup were compared for both methods. Patients with significant residuals in both groups were subjected to extracorporeal shock wave lithotripsy (Dornier Medical Systems, Inc., Marietta, Georgia) on an outpatient basis. Followup was completed for all cases with a mean duration +/- SD of 4.9 +/- 2.5 months (range 3 to 14). Renal function was evaluated by Tc-mercaptoacetyltriglycine renogram before and after treatment in both groups. RESULTS: Intraoperative complications in terms of bleeding requiring blood transfusion, and pleural, vascular or ureteral injuries were recorded in 7 patients (16.3%) in the PCNL and 17 (37.8%) in the open surgery groups, a difference of significant value (p <0.05). Major postoperative complications including massive hematuria requiring blood transfusion, septicemia, urinary leakage and wound infection were observed in 8 patients (18.6%) in the PCNL group and in 14 (31.1%) in the open surgery group, a difference of no significant value. PCNL was associated with shorter operative time (127 +/- 30 vs 204 +/- 31 minutes, p <0.001), shorter hospital stay (6.4 +/- 4.2 vs 10 +/- 4.2 days, p <0.001) and earlier return to work (2.5 +/- 0.8 vs 4.1 +/- 1 weeks, p <0.001). On the other hand both treatment groups were comparable in regard to stone-free rates at discharge home (49% vs 66%) and at followup (74% vs 82%). At followup renal function improved or remained stable in 91% and 86.7% in the PCNL and open surgery groups, respectively. CONCLUSIONS: PCNL is a valuable treatment option for complete staghorn stones with a stone-free rate approaching that of open surgery. Moreover, it has the advantages of lower morbidity, shorter operative time, shorter hospital stay and earlier return to work.

Adult↗
PubMed2006

Percutaneous nephrolithotomy requiring multiple tracts: comparison of morbidity with single-tract procedures.

PURPOSE: To compare the morbidity of percutaneous nephrolithotomy (PCNL) requiring multiple percutaneous tracts with that of procedures requiring a single tract for calculus clearance. PATIENTS AND METHODS: Data from 20 patients undergoing PCNL through two or more percutaneous renal tracts over a 1-year period were compared with a contemporary cohort of 20 patients undergoing PCNL requiring a single tract. The mean stone size was 2157 mm(2) v 423 mm(2) (P < 0.0001), the baseline serum creatinine concentration was 1.67 mg/dL v 1.13 mg/dL (P < 0.05), and the baseline hemoglobin concentration was 11.8 g/dL v 13.4 g/dL (P < 0.05) in the multiple- and single-tract groups, respectively. RESULTS: All single-tract and 95% of multiple-tract patients were rendered stone free. The mean drop in hemoglobin was similar in the two groups (2.3 g/dL for single tract v 2.1 g/dL for multiple tracts; P = 0.55). Complications occurred in two patients in each group. Four multiple-tract patients required blood transfusion. The need for transfusion correlated with lower preoperative hemoglobin and higher preoperative serum creatinine. There was a significant rise in serum creatinine (1.67 mg/dL to 1.91 mg/dL; P < 0.05) and drop in creatinine clearance (76.9 mL/min to 67.2 mL/min; P < 0.05) in the multiple-tract group; this was more pronounced in patients with existing renal insufficiency. No significant change in renal function was seen in the single-tract group. CONCLUSIONS: Monotherapy with PCNL utilizing multiple percutaneous tracts is highly effective in the treatment of staghorn and other large-volume renal calculi. Blood loss and complication rates with such an aggressive approach are comparable to those of PCNL incorporating a single percutaneous tract for more straightforward calculi.

Adult↗
PubMed2005

Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy: a prospective clinical study.

PURPOSE: Urosepsis due to manipulation during percutaneous nephrolithotomy (PCNL) can be catastrophic despite prophylactic antibiotic coverage, and negative midstream urine culture and sensitivity testing (C&S). It has been postulated that bacteria in the stone may be responsible for systemic infection. In this prospective study we determined the correlation between different sites of urine sampling, including stones, and also ascertained which is more predictive of urosepsis. MATERIAL AND METHODS: All patients undergoing PCNL who fulfilled our selection criteria were recruited. The samples collected were 1) midstream urine and bladder urine at cystoscopy, 2) renal pelvic urine collected at percutaneous puncture of the pelvicaliceal system and 3) extracted and later fragmented stones. They were sent immediately for C&S. Patients were monitored for systemic inflammatory response syndrome (SIRS). RESULTS: A total of 54 procedures were suitable for analysis. Midstream urine C&S was positive in 11.1% of cases, stone C&S was positive in 35.2% and pelvic C&S was positive in 20.4% (p = 0.009). Pelvic urine C&S predicted infected stones better than bladder urine C&S. Of the patients 37% had SIRS and 3 experienced septic shock. Patients with infected stones or pelvic urine were found to be at a relative risk for urosepsis that was at least 4 times greater (p = 0.0009). Bladder urine did not predict SIRS. Stone C&S had the highest positive predictive value of 0.7. Preoperative hydronephrosis correlated with infected pelvic urine. No patients with urosepsis had positive blood C&S. CONCLUSIONS: The results of this study suggest that positive stone C&S and pelvic urine C&S are better predictors of potential urosepsis than bladder urine. Therefore, routine collection of these specimens is recommended.

Adult↗
PubMed1988

Percutaneous nephrolithotomy in patients with previous renal surgery.

Although safe and effective, nephrolithotomy sometimes is difficult. 224 patients have undergone percutaneous stone extraction surgery. Two groups were established according to previous open renal surgery. 79 patients had had previous surgery and 145 patients were initially treated by percutaneous nephrolithotomy. Bleeding and operative time, i.e. puncture of the kidney, dilation of the tract and lithotripsy were greater in the group with previous renal surgery. However, no statistical difference was verified. In conclusion, percutaneous lithotripsy is a safe and effective method with minimal morbidity even in patients with previous renal surgery.

Female↗