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PubMed1996

Massive haemorrhage presenting as a complication after percutaneous nephrolithotomy (PCNL).

Authors describe and discuss cases of massive haemorrhage after percutaneous nephrolithotomy. In 10 (0.3%) of 3080 patients who underwent PCNL massive haemorrhage from renal fistula drain or urinary bladder was observed. Renal arteriography was performed in this group of patients which revealed arteriovenous fistulae in 4 patients and aneurysms of renal artery branches in 2. In 4 patients arteriography did not reveal haemorrhage. In one patient nephrectomy was necessary to stop the haemorrhage.

Arteriovenous Fistula↗
PubMed2005

Safety and efficacy of bilateral simultaneous tubeless percutaneous nephrolithotomy.

OBJECTIVES: To evaluate the feasibility and safety of bilateral simultaneous tubeless percutaneous nephrolithotomy (PCNL). METHODS: From August 2004 to January 2005, 10 patients underwent bilateral simultaneous tubeless PCNL. Patients needing more than two percutaneous tracts, having significant intraoperative bleeding, or a residual stone burden were excluded from the study group. The outcome of these 10 patients was compared with a control group of 10 patients who had previously undergone bilateral simultaneous PCNL with routine placement of a nephrostomy tube. RESULTS: The two groups had comparable demographic data, except for a greater stone burden in the right renal units in patients undergoing standard PCNL. The study and control groups needed a total of 22 and 23 tracts, respectively. The difference in the mean drop in hemoglobin, transfusion requirement, and complication rate between the two groups was not statistically significant. Patients undergoing tubeless PCNL required less analgesia (P = 0.001) and were discharged 20 hours earlier (40 versus 60 hours) than those in the control group. However, the difference in mean hospital stay was not statistically significant owing to the small sample size. Complete stone clearance was achieved in 80% of the renal units in the study group and 75% of the renal units in the control group. Three renal units in the tubeless group and four in the standard PCNL group had less than 5-mm residual fragments. CONCLUSIONS: Bilateral simultaneous tubeless PCNL appears to be a feasible, safe, and effective procedure offering potential advantages of decreased analgesic requirement and hospital stay without increasing the complications. Additional clinical studies with a larger number of patients are required to confirm these potential benefits.

Adult↗
PubMed2007

The learning curve in the training of percutaneous nephrolithotomy.

OBJECTIVES: To investigate the learning curve in the training of percutaneous nephrolithotomy (PCNL). METHODS: A total of 104 PCNL cases were included in this evaluation to define the learning curve of a surgeon with no previous experience at performing solo PCNL. Two parameters of expertise were reviewed, namely the operation and fluoroscopic screening times. The operation time was calculated as the beginning of access with the needle until the nephrostomy tube was placed and secured. PCNL procedures were analyzed in seven sets of 15 cases regarding the operation and fluoroscopy times, stone size, stone clearance rate, blood transfusion rate, and estimated blood loss. RESULTS: The mean operation time was 2.4 h for the first 15 patients. It decreased to a mean of 1.5 h for cases 46 through 60. No further decrease in the operation time was observed after case 60. The fluoroscopic screening time was a peak of 17.5 min in the first 15 cases, whereas it dropped to a mean of 8.9 min for cases 46 through 60. The decline in the mean fluoroscopy screening time continued in cases 61 to 104, but the decline was not significant. There was no significant difference in stone size, stone clearance rate, blood transfusion rate, and estimated blood loss among each set of cases. CONCLUSIONS: This study suggests that the surgical competence in PCNL can be reached after 60 cases. PCNL and fluoroscopy times drop to a steady-state level after performing 60 procedures.

Clinical Competence↗
PubMed2006

Perioperative complications and risk factors of percutaneous nephrolithotomy.

OBJECTIVE: To study the risk factors of perioperative complications of PerCutaneous NephroLithotomy (PCNL). MATERIAL AND METHOD: The present prospective descriptive study was carried out in the first time operation of 128 PCNL patients after general balanced anesthesia and standard surgical technique. Irrigation fluids were 0.9% NSS (24.1 +/- 16.36 liters) at room temperature. Perioperative complications and risk factors were observed, the results were displayed as adjusted Odds Ratio (OR), 95%CI and p value. RESULTS: Intraoperative complications were hypothermia (56.2%), cardiovascular changes (57.1%) and bleeding. The first two complications statistically significantly related to volume of irrigation fluid > 20 liters (7.4, p < 0.05). Postoperative complications were electrolyte changes (but not statistically significant), pleural tear (3 cases), infection and bleeding. Septic shock was found in 4.7% (6/128) and 0.78% (1/128) died. Fever was significantly correlated with postoperative transfusion > or = 1 unit (adjusted OR 4.9, p < 0.05). Risk factors of postoperative bleeding were operation time (adjusted OR 4.4, p < 0.05), intraoperative transfusion (adjusted OR 10, p < 0.01) and postoperative fever (adjusted OR 4.9 p < 0.01). Mean was 7.3 +/- 5.22 days and the mode of Length Of Stay after operation (LOS(PO)) was 5 days. LOS(PO) was significantly related with postoperative fever > 38.5 degrees C (adjusted OR 2.7, p < 0.05). CONCLUSION: Volume of irrigation fluid at room temperature >20 liters significantly increased the rate of intraoperative hypothermia and cardiovascular changes. Infection was the most serious complication of PCNL and increased LOS(PO). Antibiotics started at the beginning of the surgery could not always prevent this event.

Aged↗
PubMed2005

Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomy for branched renal calculi.

BACKGROUND AND PURPOSE: Some patients undergoing percutaneous nephrolithotomy (PCNL) have purulent fluid in the pelvicaliceal system at the time of puncture, although preoperative features are not suggestive of infection. We report the management and outcome of 19 such patients. PATIENTS AND METHODS: Among the 639 patients who underwent PCNL at our center from July 2000 to October 2003, 19 had purulent fluid in the kidney at initial puncture. The preoperative findings, operative details, hospital course, and final outcome in these patients were analyzed. Twelve patients had stone removal at the first sitting (option 1), while seven had a nephrostomy tube placed initially with stone removal deferred for 3 to 7 days (option 2). RESULTS: With option 1, stones were cleared with one to three tracts in 45 to 120 minutes. Seven patients recovered smoothly, three had transient fever, while one had grade I and another had grade II sepsis. The purulent fluid grew E. coli in two cases and Proteus or Serratia in one case each and was sterile in eight. With option 2, stones were cleared using one to three tracts in 60 to 100 minutes. The fluid grew E. coli or Klebsiella in one case each and was sterile in five. Three patients had a smooth recovery, two had transient fever, one had grade I sepsis, and another had grade II sepsis. Risk factors for sepsis, irrespective of the option, were a recent history of febrile urinary-tract infection, borderline elevation of total leukocyte count, thick or foul pus as opposed to mere turbidity, the use of a single tube or tract or delayed creation of second tracts, and operating time >90 minutes. CONCLUSIONS: Despite normal preoperative urine and blood values, one may find purulence on puncture during PCNL, which is not always infected. If any one or more of the above risk factors is present, it is safer to drain the kidney initially, making sure that all blocked calices are drained, inserting multiple tubes if necessary.

Adult↗
PubMed1984

Percutaneous nephrolithotomy: one stage or two?

Two hundred and fifty cases of percutaneous nephrolithotomy (PNL) are described. One hundred and fifty cases were treated in two stages, 100 in a single stage. The one-stage method has been shown to be as safe as the two-stage method but should be reserved for those with experience of the technique and who possess adequate instrumentation. PNL has proved to be a preferable option to open stone surgery and a useful alternative to extracorporeal shock wave lithotripsy (ESWL).

Endoscopy↗
PubMed2006

Upper-pole access for percutaneous nephrolithotomy: comparison of supracostal and infracostal approaches.

BACKGROUND AND PURPOSE: The advantage of upper-pole access for nephrolithotomy is direct access to most of the intrarenal collecting system and upper ureter. Upper-pole access can be achieved either supracostally and subcostally. Because of the anatomic location of the kidneys, the supracostal approach is associated with a higher rate of pulmonary complications. We compared the efficacy and safety of the supracostal and infracostal upper-pole approaches. PATIENTS AND METHODS: A total 464 patients were treated with percutaneous nephrolithotomy (PCNL) via the upper pole, of which 170 punctures (group I) were performed supracostally and 294 (group II) subcostally. In both groups, PCNL was done by the standard technique with fluoroscopic guidance. The operative time, success rate, hospital stay, and complications in the two groups were compared. RESULTS: Patients were stone free in 82.2% and 77.1% of the cases in groups I and II, respectively, and had stone fragments <4 mm in 10.7% and 14.7%, respectively. The operative time, success rate, and septic and hemorrhagic complications were not significantly different in the two groups. Hydrothorax was found in 26 patients (15.3%) of group I and 4 (1.4%) of group II. Only 9 patients (5.3%) in group I needed intercostal drainage. CONCLUSION: Percutaneous nephrolithotomy via the upper pole is effective using both supracostal and infracostal approaches, with acceptable rates of complications. The rate of pulmonary complications is higher with the supracostal approach. If the supracostal approach is indicated, it should be used with caution.

Adult↗
PubMed2005

Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy.

BACKGROUND AND PURPOSE: Open stone surgery nowdays is rare. However, some patients who are treated today have in the past undergone open nephrolithotomy. The aim of this study was to determine the possible impact of open nephrolithotomy on the efficacy and morbidity of subsequent percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: We reviewed the files of all 167 patients undergoing PCNL at our institution between December 2000 and December 2003. The same surgeon performed all of the procedures. We compared 21 patients undergoing PCNL after open nephrolithotomy to the same kidney with all other patients undergoing PCNL. The groups did not differ in terms of age or stone burden (mean size, number of stones, percentage with staghorn calculi). The outcomes measured were operating time, necessity for secondary procedures, stonefree rate, and intraoperative and postoperative complications. RESULTS: The operating time (203+/-92 v 177+/-52 minutes) and percentage of secondary procedures (29% v 12%) were significantly higher in patients who had previously undergone open stone surgery. However, the stone-free rate (95% v 93%), intraoperative complication rate (10% v 9%), and postoperative complication rate (10% v 11%) did not differ significantly. CONCLUSIONS: A PCNL in a patient with a history of open nephrolithotomy may take longer and lead to a higher percentage of auxiliary procedures, probably because of scar tissue and anatomic changes in the kidney. However, the morbidity and efficacy of PCNL appear to remain the same in these patients.

Adult↗
PubMed1987

An in vitro study of intracavitary pressures during percutaneous nephrolithotomy.

Pyelorenal reflux and irrigant extravasation secondary to raised intrapelvic pressure during percutaneous nephrolithotomy account for a significant percentage of the operative morbidity. The effect of irrigant flow rate, height of irrigant reservoir, diameter of Amplatz sheath and lithotripsy on intracavitary pressures has been studied in an in vitro model. The elevation of pressures produced by these variables suggests that percutaneous techniques should be modified.

Models, Biological↗
PubMed2006

Plastic within renal pelvis on nephroscopy: a potential hazard during percutaneous nephrolithotomy.

The use of adhesive plastic drapes is common throughout laparoscopic and percutaneous surgery. We report a case in which a significant portion of the plastic drape was translocated into the renal pelvis during tract dilation for percutaneous nephrolithotomy. The complication was recognized only on endoscopy and the plastic successfully removed. The potential for morbidity in other patients in the future remains, and we recommend operators be aware of this unusual, but entirely preventable, complication. We highlight some measures to help avoid and check for this complication before the end of the procedure.

Adult↗
PubMed2004

No panacea for drainage after percutaneous nephrolithotomy.

BACKGROUND AND PURPOSE: The optimal postoperative drainage system for patients undergoing percutaneous nephrolithotomy (PCNL) has not yet been determined. Each of the different tubes available has theoretical advantages and disadvantages. The objective of this study was to determine if any one system of post-PCNL drainage has any significant advantage over the others. PATIENTS AND METHODS: Sixty patients were randomized to either a 24F Re-entry tube (Group 1), an 8F pigtail catheter (Group 2), or a double-J stent (Group 3) (N = 20 for all groups). The double-J stent patients also had an 18F Councill catheter as a nephrostomy tube, which was removed on the morning of postoperative day 1. The three groups were well-matched for age, stone size, operative time, and mean number of percutaneous tracts (P > 0.05 for all). Data collected included intraoperative findings, postoperative analog pain scores and narcotic usage, presence of extravasation on postoperative nephrostogram, presence of perinephric fluid on postoperative ultrasound scans, length of stay, and whether leakage from the nephrostomy site persisted more than 48 hours after tube removal. RESULTS: There were no statistically significant differences among the three groups in terms of change in hematocrit or number of patients requiring blood transfusion; in the incidence of tube blockage, extravasation, or presence of perinephritic fluid; or in complication rates, length of hospital stay, or persistent leakage after tube removal. There was a strong trend to less postoperative leakage with the 8F pigtail than the Reentry tube (P = 0.05). Postoperative analog pain scores and narcotic usage were equivalent for all three groups. Patients Groups 1 and 2 were free of all tubes sooner than patients in Group 3 (P < 0.001). CONCLUSIONS: This study did not demonstrate an overwhelming advantage of any one drainage system over the others. All three systems were equally tolerated by patients. There may be less chance of prolonged nephrostomy-site leakage with an 8F pigtail catheter.

Catheterization↗
PubMed1998

Evolving technique of percutaneous nephrolithotomy in a developing country: Singapore General Hospital experience.

At our institution, percutaneous nephrolithotomy (PCNL) is the preferred treatment modality for renal calculi with a large stone burden (example, staghorn calculi) and renal calculi which have failed extracorporeal shockwave lithotripsy (SWL). The aim of this paper is to present the technical refinements in PCNL and the results obtained by a single surgeon. From June 1995 to July 1997, 135 PCNL procedures were performed on 114 renal units. The mean age of the patients in the series was 51 years. The PCNL was performed on 28 complete staghorn calculi (25%), 24 partial staghorn calculi (21%), 25 large renal calculi (22%), 26 impacted ureteropelvic junction calculi (22%), 5 impacted ureteral stones (4%), and 6 symptomatic lower-pole calculi (5%). Most patients (97%) had a successful outcome (82% stone-free and 15% only insignificant residual fragments). Of the four failures, three had previous open renal split operations. The average postoperative stay was 5.2 days. Only one patient (0.7%) had urosepsis, and another had an arteriovenous fistula and was the only patient to require blood transfusion in our series. Only 21% (n = 24) required SWL after PCNL, and one patient required ureteroscopy. Technical refinements in PCNL include: (1) single-stage PCNL with percutaneous access obtained by the urologist in the operating room; (2) flexible endoscopy to inspect the whole pelvicaliceal system systematically; (3) liberal use of secondary PCNL to ensure stone-free status; and decreased reliance on SWL after PCNL. The trend is to rely on PCNL monotherapy to manage staghorn calculi rather than PCNL and SWL combination therapy.

Adult↗
PubMed2003

[Persistent hematuria after embolization for hemorrhagic complication following percutaneous nephrolithotomy: value of the study of red blood cell volume in urine].

Percutaneous nephrolithotomy is associated with a high risk of complications, particularly bleeding, which makes it a potentially invasive technique. Management of haemorrhagic complications sometimes requires the use of embolization. Recurrence after embolization can occur as a result of revascularization or recanalization of vessels, but post-embolization infarction can also lead to persistent haematuria. The authors report the clinical case of a 36-year-old patient presenting with recurrence of severe haematuria after two successive highly selective embolizations. Analysis of the mean corpuscular volume of red cells in the urine confirmed the parenchymal and non-vascular origin of the bleeding, corresponding to a post-embolization syndrome. This analysis therefore constitutes a simple way to avoid repeated embolization or surgical exploration.

Adult↗
PubMed1989

[A study on acute renal damage from percutaneous nephrolithotomy assessed by urinary NAG and gamma-GTP activities].

We performed percutaneous nephrolithotomy (PNL) on 49 patients between May, 1986 and March, 1987. To investigate acute renal damage from PNL, we measured urinary NAG (N-acetyl-beta-D-glucosaminidase) and gamma-GTP (gamma-glutamyl transpeptidase) activities before PNL and for 6 days after PNL in 24 patients. The NAG activities elevated beyond normal level in 23 patients and gamma-GTP activities in 15 patients. NAG activities showed a peak level in the third day after PNL and gamma-GTP activities in the next day of PNL. After the peak both enzyme activities got down gradually. There was no difference in NAG and gamma-GTP activities between nephrostomy and lithotripsy in 2 staged patients. And the intrapelvic pressure during operation was at the normal level in 5 patients. Therefore, we think that the cause of NAG and gamma-GTP activity elevation is a mechanical damage, not an influence of the irrigation fluid. Large stones, long operation time and 2 stage procedure were the factors that produced high enzyme activities, because, we guess, the frequency of mechanical damages to the kidney increase in such cases. Postoperative pyrexia caused a slight increase in enzyme activities but preoperative hydronephrosis exerted no influence on both enzyme activities. We also measured creatinine clearance before and after PNL but no significant change was obtained. PNL causes only slight mechanical damage to the operated kidney which is reversible when assessed by NAG and gamma-GTP activities and the glomerular function is not affected. Therefore, we conclude that PNL is a safe treatment for upper urinary tract stones.

Acetylglucosaminidase↗
PubMed2004

Factors affecting blood loss during percutaneous nephrolithotomy: prospective study.

BACKGROUND AND PURPOSE: Bleeding is a major concern during percutaneous nephrolithotomy (PCNL), especially with the use of multiple tracts. This prospective study aimed to identify factors affecting blood loss during PCNL. PATIENTS AND METHODS: Data were collected prospectively from 236 patients undergoing 301 PCNL procedures at our institute since June 2002. Blood loss was estimated by the postoperative drop in hemoglobin factored by the quantity of any blood transfusion. Various patient-related and intraoperative factors were assessed for association with total blood loss or blood transfusion requirement using stepwise multivariate regression analysis. RESULTS: The average hemoglobin drop was 1.68 +/- 1.23 g/dL. Stepwise multivariate regression analysis showed that the occurrence of operative complications (P < 0.0001), mature nephrostomy tract (P < 0.0001), operative time (P < 0.0001), method of access guidance (fluoroscopy v ultrasound) (P = 0.0001), method of tract dilatation (P = 0.0001), multiple (> or =2) tracts (P = 0.003), size of the tract (P = 0.001), renal parenchymal thickness (P = 0.05), and diabetes (P = 0.05) were significant predictors of blood loss. The overall blood transfusion rate for all patients was 7.9%. Preoperative hemoglobin, multiple tracts, stone size, and total blood loss were significant in predicting perioperative blood transfusion requirement. Factors such as age, hypertension, renal insufficiency, urinary infection, the degree of hydronephrosis, stone bulk, and the function of the ipsilateral renal unit did not have any effect on the blood loss. Technical factors such as the operating surgeon and the calix of entry also did not affect the blood loss. CONCLUSIONS: Diabetes, multiple-tract procedures, prolonged operative time, and the occurrence of intraoperative complications are associated with significantly increased blood loss. Atrophic parenchyma and past ipsilateral intervention are associated with reduced blood loss. On the basis of this evidence, maneuvers that may reduce blood loss and transfusion rate include ultrasound-guided access, use of Amplatz or balloon dilatation systems, reducing the operative time, and staging the procedure in cases of a large stone burden or intraoperative complications. Reducing the tract size in pediatric cases, nonhydronephrotic systems and those with a narrow infundibulum, and secondary tracts in a multiple-tract procedure may also reduce blood loss during PCNL.

Adolescent↗
PubMed1985

Nephro-duodenal fistula: a complication of percutaneous nephrolithotomy.

We report a case of a nephro-duodenal fistula complicating percutaneous nephrolithotomy that was managed conservatively. The patient was discharged from the hospital 14 days postoperatively, free of stone and doing well. The etiology and treatment of this problem are discussed.

Duodenal Diseases↗
PubMed2006

Safety and efficacy of supracostal access in tubeless percutaneous nephrolithotomy.

PURPOSE: To evaluate the feasibility and safety of supracostal access in tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: From September 2004 to November 2005, tubeless PCNL using supracostal access was done for 72 patients at our institute. Patients requiring more than two percutaneous tracts or with significant intraoperative bleeding or residual stone burden were excluded from the study. The outcome of these patients was compared with that of a historic cohort of similar patients having supracostal access with routine placement of a nephrostomy tube. The two groups had comparable demographic data. RESULTS: The differences in the mean drop in hemoglobin concentration, transfusion requirement, and complication rate in the two groups were not statistically significant, with three patients in the study group and four patients in the control group requiring blood transfusion. Patients undergoing tubeless PCNL required less analgesia (P = 0.000) and were discharged a mean of 19 hours earlier (P = 0.000) than those in the control group. Complete stone clearance was achieved in 90.27% of the renal units in the study group and 86.11% of the renal units in the control group. Two patients in the study group and three patients in the control group had postoperative hydrothorax, all of whom, except for one in the control group, were managed conservatively. CONCLUSION: Supracostal access in tubeless PCNL appears to be feasible, safe, and effective, offering the advantages of a lower analgesic requirement and shorter hospital stay without increasing thoracic complications. Studies with larger numbers of patients are needed to confirm these initial findings.

Equipment Safety↗