Abstract
PurposeSevere haemorrhage in percutaneous nephrolithotomy (PCNL) is an alarming event, and preventing injury to renal major vessels is a challenge. We evaluated the efficiency of a blunt needle in renal puncture procedures.MethodsWe first retrospectively reviewed the embolization images of post-PCNL patients to analyse the types of arteries injured, which were considered target arteries. Then, either a blunt needle or a conventional needle was used to directly puncture target arteries in ex vivo porcine kidneys and to establish renal access ex vivo and in vivo. The primary outcome was the incidence of target artery injuries, which were observed by digital subtraction angiography, nephroscopy and 3-dimensional endocasts. The secondary outcome was the rate of excreted fluid per access.ResultsThe segmental and interlobar arteries were the most common types of injured arteries that needed to be embolized after PCNL. When these arteries were punctured directly, blunt needles reduced injury (1/20 vs. 16/20; OR 4.750; 95% CI 1.966–11.478; P < .001) by 76% compared to injuries induced by conventional needles. Moreover, the blunt needle group also had a significantly lower incidence of these arteries’ injuries ex vivo due to renal puncture and yielded a lower rate of excreted fluid in ex vivo and in vivo renal puncture procedures.ConclusionA blunt needle for renal puncture can be effective in reducing injury to renal major arteries and the accompanying haemorrhage. We propose the concept of blunt puncture, which may be a promising method for achieving safe renal access in PCNL.
Highlights
Percutaneous nephrolithotomy (PCNL) is the surgical standard for the treatment of large or complex renal stones [1, 2]
◂Fig. 2 Procedure for puncturing the target artery directly and confirmation of the target artery injury. a While digital subtraction angiography (DSA) showed a normal renal artery, the target artery was directly punctured, and the direction of the puncture was vertical from the ventral area to the dorsal area. b There was obvious contrast agent that leaked rapidly from the target artery; after establishment of renal access, more contrast agent leaked, and the injured target artery was found by nephroscopy. c national practical patent (No) or a small amount contrast agent leaked; after establishment of renal access, there was still no obvious contrast agent that leaked and the target artery was exposed but did not demonstrate any injury under the nephroscope. d The target artery was intact, and some small arteries were injured
The overall incidences of injuries to the target arteries (1/20 vs. 16/20; OR 4.750; 95% CI 1.966–11.478; P < 0.001), segmental artery (1/10 vs. 9/10; OR 9.000; 95% CI 1.386–58.443; P < 0.001), and interlobar artery (0/10 vs. 7/10; OR 3.338; 95% CI 1.293–8.591; P = 0.003) were all significantly lower in the blunt needle group than in the conventional needle group
Summary
Percutaneous nephrolithotomy (PCNL) is the surgical standard for the treatment of large or complex renal stones [1, 2]. Urologists’ concerns about severe bleeding complications hinder the application and popularisation of PCNL, especially in medical institutions without a digital subtraction angiography (DSA) device. Regarding ways to reduce the risk of bleeding in PCNL, the current areas of focus are mainly on how to reduce the number and size of access tracts to make the surgery as minimally invasive as possible [3,4,5] and the use of various technical means to improve the success rate of the centre of renal papillae access puncture [6,7,8]. The effect of puncture needles on bleeding complications of PCNL is often ignored.
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