Bilateral Percutaneous Nephrolithotomy Research Articles

SINGLE SESSION BILATERAL PERCUTANEOUS NEPHROLITHOTOMY (PCNL) IN HORSESHOE KIDNEY PATIENT WITH BILATERAL STAGHORN STONES: A CASE REPORT

Objective: To analyze the outcomes of single-session bilateral PCNL in a horseshoe kidney patient with bilateral staghorn stones in terms of safety and effectiveness. Case(s) Presentation: A 64-year-old woman with bilateral staghorn stones on HSK. She had an anesthesia status of ASA 2, with type 2 diabetes mellitus (uncontrolled with oral medication), 47% of ejection fraction from echocardiography and her body mass index was 21.7 kg/m2. A single session of bilateral PCNL was performed, with 150 minutes of surgery and total blood loss of ± 50 cc. A 4.7 Fr DJ stent was placed on the right kidney, a 5 Fr ureteral catheter was left in the left kidney, and a 16 Fr foley catheter was placed as a right and left nephrostomy. Control plain abdominal x-ray showed no residual stones. Postoperatively, the patient was hospitalized for 3 days, there were no significant complaints and discharged in good condition. Discussion: The procedure was performed in the prone position for two reasons. First, is to avoid intestinal injury during puncture and dilatation, the second is to simplify the positioning of the C arm, as well as the endourology monitor, and the other instruments. Conclusion: Single-session bilateral PCNL for HSK patients with bilateral staghorn stones, in our experience, is quite safe and effective. Keywords: Horseshoe kidney, single-session bilateral percutaneous nephrolithotomy (PCNL), staghorn stone.

Bilateral Single-session PCNL with Minimally Invasive Technique in Pediatric Nephrolithiasis.

To assess outcomes of bilateral single-session percutaneous nephrolithotomy (PCNL) with minimally invasive techniques in pediatric population. From August 2015 to July 2021, 45 children (including 12 infants) were treated with bilateral single-session PCNL, which included miniPCNL (12-16-Fr) and Microperc (4.8-Fr). Patient, stone and operation-related characteristics, stone-free rate (SFR) and complication rate (CR) were compared using ANOVA. Independent predictors were determined using multivariate linear regression. The mean stone burden was 3.2 cm in sum diameter for both kidneys. For bilateral kidneys, the mean operative time was 61.6min and SFR was 93.3%; CR was 53.3%, of which complications of Clavien grade 1 and 2 accounted for 46.7%. Bilateral Microperc, bilateral miniPCNL and Microperc plus miniPCNL was performed in 19, 14 and 12 children respectively. Both irrigation volume and postoperative stay were less in groups with Microperc. Both SFRs and CRs were satisfactory for the three groups. Self-limiting hematuria represented the most common complication of all cases (33.3%), especially in groups with miniPCNL. The stone burden was the only independent predictor for operative time (P < .001) and the postoperative complication (P = .008). Children with older age (P = .009), higher body mass index (P = .016) or a higher stone burden (P < .001) received larger irrigated fluid volume. Microperc was associated with less irrigated fluid volume (P = .001). Children with Clavien grade 3 complications (P = .004) spent prolonged postoperative hospital stay. With favourable SFR and acceptable CR, bilateral single-session PCNL with minimally invasive techniques might be an effective and safe procedure for pediatric nephrolithiasis.

Analysis of Perioperative Events in Bilateral vs Unilateral Staged Percutaneous Nephrolithotomy

Introduction: Kidney stones are a common medical condition that impact approximately 10% of US population. Management of stone disease is based on size and location of stones. Percutaneous nephrolithotomy (PCNL) is typically indicated in patients with large renal stone burden (typically &gt;2 cm) or complex anatomy. In the setting of complex stones, multiple, staged PCNLs are required. We hypothesize that there is no significant difference in the perioperative change in lab values in bilateral PCNLs compared to unilateral PCNLs.&#x0D; Methods: The data was gathered by retrospectively reviewing the electronic medical record of 50 patients in the IU health system who underwent planned staged PCNLs between January and December 2018. We identified patients who underwent both bilateral and unilateral staged procedures. Data for BMI, sex, ethnicity, hemoglobin, estimated glomerular filtration rate (GFR) (typically formula CKD-EPI or MDRD), urine and stone cultures, stone composition, and bilaterality vs. unilaterality was collected. Two-tailed T-tests were performed to analyze data between bilateral and unilateral cases.&#x0D; Results: We identified a total of 50 patients, 19 men vs. 31 women; 9 men and 10 women underwent bilateral PCNLs, while 11 men and 20 women had unilateral PCNLs. BMI ranged from 14.2 to 62.3, and age ranged from 15 to 81. Significant differences were found between the changes in hemoglobin levels in patients who underwent bilateral PCNLs when compared to unilateral PCNLs (p value 0.018). No significant differences were noted when comparing changes of estimated GFR, BMI, age or any other variables.&#x0D; Conclusion: Patients who underwent bilateral staged PCNLs demonstrated a greater drop in perioperative hemoglobin compared to unilateral PCNLs without an increase in blood transfusion. This finding suggests that Bilateral PCNLs requiring multiple stages are safe in complex stone patients.

Supine Versus Prone Percutaneous Nephrolithotomy (PCNL): A Single Surgeon's Experience.

Percutaneous nephrolithotomy (PCNL) is one of the greatest advances in the field of urology and has been considered the gold standard in the treatment of renal calculi of more than 2 cm in size. While both the supine and prone positions offer their unique advantages, it is still being debated which position offers the most in terms of surgical outcomes. We have evaluated the two approaches in terms of operative time, success rate, stone clearance rate, safety, and complications. This prospective cohort study was done in the urology department of a tertiary care center in South India between January 2018 and October 2020. A total of 166 patients, with 83 in supine and 83 in prone positions, were included in the study. Both groups were matched in terms of age, body mass index, stone size and location, co-morbidities, medications taken, presence of diverticular stone, history of surgery, and baseline creatinine level. Mean operative time and pain scores were noted to be less in supine position as compared to prone. Ease of puncture was superior in supine position. Stone residue was noted to be higher in supine PCNL as well. Supine PCNLs are preferred in high-risk patients while the prone position is preferred in bilateral PCNLs, complex anatomy, or larger stone burden.

Effectiveness and morbidity of concomitant bilateral percutaneous nephrolithotomy (about 20 cases)

Percutaneous nephrolithotomy (PCN) has become the technique of choice for the treatment of large stones larger than 2 cm or after failure of other techniques. Thus, its unilateral performance has become a routine technique, but bilateral percutaneous nephrolithotomy in one stage is not common practice. This therapeutic option appears attractive in patients at high risk of recurrence and unable to tolerate a two-stage PCN, however it must be performed in expert reference centers. The objective of our study is to retrospectively evaluate the efficacy and morbidity of concomitant bilateral percutaneous nephrolithotomy and to compare the results of our series with those of an extensive and recent review of the literature. This is a retrospective study including 20 cases of concomitant bilateral percutaneous nephrolithotomy performed between January 2011 and January 2023. The mean age was 47.4 years. These were 14 men and 6 women, all had bilateral kidney stones. The mean stone size was 28.8 cm, of which 11 were coralliform. We obtained a good result (Stone-free) in 17 patients with an average duration of 130 min, the residual stones required additional treatment in 3 cases by extracorporeal lithotripsy (ECL).the main complications encountered were hemorrhagic (1 case) and infectious (2 cases), the renal function is unchanged in the end. The results of our series are consistent with those of the literature with a success rate of 85% without residual fragments greater than 4 mm.

MP39-10 SIMULTANEOUS BILATERAL PCNL: IS IT COST-EFFECTIVE?

You have accessJournal of UrologyCME1 Apr 2023MP39-10 SIMULTANEOUS BILATERAL PCNL: IS IT COST-EFFECTIVE? Kevin Wymer, Ben Johnson, Austen Slade, Daniel Heidenberg, Mitchell Humphreys, Karen Stern, and Marcelino Rivera Kevin WymerKevin Wymer More articles by this author , Ben JohnsonBen Johnson More articles by this author , Austen SladeAusten Slade More articles by this author , Daniel HeidenbergDaniel Heidenberg More articles by this author , Mitchell HumphreysMitchell Humphreys More articles by this author , Karen SternKaren Stern More articles by this author , and Marcelino RiveraMarcelino Rivera More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003277.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Large, bilateral stone burden can present a unique challenge for both the urologist and patient. When bilateral PCNL is warranted, surgical timing can lead to differences in stone free rate (SFR), complications, and costs. This study compares the cost-effectiveness of simultaneous versus staged PCNL. METHODS: A decision-analytic Markov model was used to assess the cost-effectiveness of simultaneous (bilateral PCNL during a single operative episode for the index procedure) and staged (unilateral PCNL for the index procedure followed by a separate procedure for a contralateral PCNL) PCNL for the management of large, bilateral stone burden. Model probabilities and outcomes for index procedures, including SFR, complications, operative time, and hospital length of stay (LOS), were drawn from a large-volume, single-center cohort. Outcomes for secondary procedures and utility values were obtained from the literature. Primary outcomes included costs from a Medicare standpoint with the addition of operative time and LOS costs, effectiveness (quality adjusted life years, QALYs), and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to evaluate the robustness of the model. RESULTS: At 1 year following the index procedure, costs (inclusive of index procedure, secondary procedures, and complications) per patient were $52,585 and $61,687 for simultaneous and staged PCNL, respectively. In addition to being less costly, simultaneous PCNL also resulted in slightly higher QALYs (.982) compared to staged PCNL (.977). On one-way sensitivity analyses (Figure), staged PCNL became cost-effective if the SFR increased from 56% to 88% (40% greater per renal unit relative to simultaneous PCNL) or the cost of unilateral PCNL decreased approximately 50% to $4,699 ($16,266 less than simultaneous PCNL). CONCLUSIONS: Even when assuming a modest reduction in SFR (62% vs. 44% per renal unit), longer index procedure OR time (177 vs. 116 minutes) and LOS (3.2 vs. 2.3 days) and slightly higher major (6.2% vs. 5.5%) and minor (27.2% vs. 21.3%) complication rates at index procedure, simultaneous bilateral PCNL was both less costly and more effective at 1 year follow up relative to staged bilateral PCNL. This offers further support of simultaneous bilateral PCNL in the proper clinical setting. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e538 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Wymer More articles by this author Ben Johnson More articles by this author Austen Slade More articles by this author Daniel Heidenberg More articles by this author Mitchell Humphreys More articles by this author Karen Stern More articles by this author Marcelino Rivera More articles by this author Expand All Advertisement PDF downloadLoading ...

Concurrent two surgeon approach for bilateral synchronous percutaneous nephrolithotomy: Initial experience at a University Teaching Hospital.

Percutaneous nephrolithotomy (PNL) has long been considered the bench-mark intervention for complicated urinary stones and has undergone important advancements since it was first described. Given the proven safety and efficacy of PNL, simultaneous bilateral PNL has been attempted for bilateral renal calculi to cut down on total procedure costs. To further cut down on operative time, concurrent bilateral synchronous PNL (BS-PNL) has been performed involving two surgeons, each operating concurrently on one renal unit. We performed a retrospective study to evaluate the safety and efficacy of BS-PNL in patients who consented for the procedure. Mean operative time taken from percutaneous access to skin closure was 78 min which was lower than that taken during the single surgeon approach for simultaneous bilateral PNL. Two (12%) out of 16 renal units required multiple punctures for stone clearance. Sheath size varied between 26Fr to 30Fr depending on the stone burden. Mean duration of hospital stay was 2 days. Fourteen (88%) out of 16 renal units had complete stone clearance. Fifteen (94%) out of 16 renal units had a double J stent placed for drainage. Only two patients had complications in the form of postoperative fever. In the background of already proven safety and efficacy of SB-PNL, the concurrent two surgeon approach appears to be feasible and safe with additional advantage of reduced operative time. However, the number of patients in this series were limited and a bigger and preferably multi-institutional study would be required before we can come to a definitive conclusion.

Percutaneous nephrolithotomy in a patient with a ureterosigmoidostomy diversion

In patients with bladder cancer, ureterosigmoidostomy has been used as a form of urinary diversion, and urinary lithiasis has been reported as a complication. A patient with a large bilateral kidney stone and ureterosigmoidostomy diversion is described. In 2012, a 61-year-old man had a cystectomy due to bladder cancer. He was lost to follow-up after presenting to the emergency department in 2016 with right flank pain and fever. Computed tomography (CT) scan reveals bilateral staghorn calculus. A bilateral percutaneous nephrostomy was performed. The patient was planned for bilateral percutaneous nephrolithotomy (PCNL). He declined, therefore we proposed External Shock Wave Lithotripsy (ESWL). The right kidney stone was removed, but the left kidney stone did not alter after 7 ESWL sessions, thus PCNL was scheduled. The middle calyx was punctured under fluoroscopic guidance through the nephrostomy in Valdivia’s modified position. Two 0.035” hydrophilic guide wires were passed down the renal pelvis and ureter until it ureterosigmoidostomy union was reached. Dilation was carried out with Nephromax. An Amplatz 30 Ch was placed. The holed stone was then fragmented with Laser Holmium. PCNL tubeless was performed. He was discharged two days after surgery. PCNL tubeless was performed. The hospital stay was two days. CT control two months later: Lower pole 5 cm hematoma, the residual stone of 4 mm in the upper calyx. After resolving the renal hematoma, the residual stone will be dealt with ESWL.

Innovative way to break the stone: Master lithoclast for bilateral simultaneous Percutaneous Nephrolithotomy.

The objective of our study was to evaluate the efficacy of Master Lithoclast, also known as trilogy lithoclast, in simultaneous bilateral Percutaneous Nephrolithotomy (PCNL). The study was a prospective case series, involving 40 patients undergoing bilateral simultaneous PCNL, with 20 (50%) males and 20 (50%) females. The mean age of subjects was 32.9±7.9 years. In Guy's stone scoring 7(17.5%) patients classified in Group I, 28 (70%) in group II and the remaining 5(12.5%) patients were placed in group III. Total operative time observed was 74.8±17.9 minutes. Complete stone clearance was observed in 30 (75%) patients. In conclusion, study data confirmed that Master Lithoclast provides faster stone clearance and is unaffected by the composition of stones, ease of usability, and improved tissue safety with reduced chances of fragments blocking are key factors.

Safety and Efficacy of Simultaneous Bilateral Percutaneous Nephrolithotomy

A retrospective review was conducted to evaluate intraoperative and patient outcomes following simultaneous bilateral percutaneous nephrolithotomy (SB-PCNL). Target stone characteristics, operative time, hospitalization length, post-operative complications, blood loss, opioid use, pain, and stone-free rates were evaluated. In total, 42 patients with large renal stones (&gt;20 mm2) were identified for this study, and 38% of them achieved stone-free status with no residual fragments apparent on post-operative day one CT imaging. The maximum mean residual fragment size was 3.67 mm2 and average number of residual fragments following the procedures was 1.63. The rates of blood loss, post-operative complications, opioid use, and pain from the study cohort were similar to the reported outcomes of studies conducted by others. The potential benefits of a single procedure and anesthesia to treat bilateral stone burdens, lower total pain medication prescribed, and lower hospital costs render SB-PCNL as an attractive option in the treatment of bilateral kidney stones.

Percutaneous nephrolithotomy in patients with or without previous open nephrolithotomy from the same side

Background Reintervention is typically difficult owing to perinephric anatomical changes in individuals with a history of open stone surgery. Aim The aim of the current study was to see what effect open renal surgery may have on the effectiveness and morbidity of later percutaneous nephrolithotomy (PCNL). Patients and methods PCNL was performed on 100 patients between March 2017 and March 2018. Overall, 20 of these patients were eliminated (tubeless or bilateral simultaneous PCNL). The remaining 80 patients were divided into two groups: 40 primary patients and the rest (history of open nephrolithotomy). Before intervention, a standard preoperative assessment was conducted. Statistical analysis was performed using SPSS v. 20 with the χ2 test and the independent samples t-test. P value <0.05 was considered statistically significant. Results In terms of demographics and stone load, both groups were comparable. Group 1 had fewer attempts to access the pelvicalyceal system than group 2 (1.2 ± 0.5 vs. 2.7 ± 0.9, respectively), which was statistically significant (P=0.001*). Moreover, there was a statistically significant difference in the mean operational time between the two groups (85.24 ± 19.47 vs. 128.39 ± 17.45 min, respectively), with a statistically significant difference (P=0.001*). The rate of blood transfusion was similar in both groups (P=0.396). The remaining problems in both groups were similar. Conclusion Patients with renal stone surgery might require additional attempts to reach the pelvicalyceal system and may have difficulties with tract dilatation owing to retroperitoneal fibrosis. However, the overall morbidity and efficacy are the same in both groups.

V05-04 STONE DISSOLUTION: CURRENT SAFE AND EFFECTIVE USE OF RENACIDIN

You have accessJournal of UrologyUrolithiasis & Endourology (V05)1 Sep 2021V05-04 STONE DISSOLUTION: CURRENT SAFE AND EFFECTIVE USE OF RENACIDIN Egor Parkhomenko, Vivian Williams, and Michael Kurtz Egor ParkhomenkoEgor Parkhomenko More articles by this author , Vivian WilliamsVivian Williams More articles by this author , and Michael KurtzMichael Kurtz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002012.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Struvite stones cause significant morbidity in urologic congenitalism. Though stone-free rates have improved with advanced endoscopic equipment, some anatomic circumstances make complete stone clearance impossible. Renacidin (Citric Acid, Glucono Delta-Lactone, and Magnesium Carbonate solution) to treat upper tract stones was popular in the 1960s, but after 6 deaths it was banned by the FDA and not re-approved until the 1990s. We wished to treat a patient in an extraordinary circumstance, which presented challenges as Renacidin therapy had not been used at our institution in 30 years. We present our experience and a step-by-step guide to infusion. METHODS: We conducted a literature review and collected national expert opinion. Key stakeholders from nursing, pharmacy, nephrology, infectious diseases, intensive care unit (ICU), and biomedical engineering developed a safe protocol for renacidin infusion. The patient was monitored on a 1:1 staff to patient ratio in the ICU initially. As the medication is in vials with non-sterile exteriors, pharmacy cleaned the vials and pooled it under a sterile hood. The biomedical engineering team recommended a gravity drip, elevated to 30 cm H2O above PCN tube entry site infused at 120 ml/hour (20 drips/minute) or 60 ml/hr (drop factor 10 drips/minute). A mock infusion was completed with a multidisciplinary team prior to the patient’s admission. A 27yF with severe scoliosis, reconstructed bladder, and tortuous ureter from prior ureterostomies leading to limited options for renal access had struvite stone recurrence after bilateral percutaneous nephrolithotomy. Bilateral nephrostomy tubes, an antegrade ureteral catheter, and a urethral catheter were placed. Daily electrolytes and urine cultures were drawn, and weekly CT scans performed to assess stone burden. Renacidin was infused unilaterally at full or half rate, depending on patient tolerance, during the day; nocturnal infusions were with normal saline. Continuous culture-directed IV antibiotics were administered throughout the infusion. RESULTS: Infusion was carried out for 60 days, initially on the left for 30 days (larger stone burden), and 30 days on the right. Total hospital stay was 71 days. The patient has been stone-free since end of Renacidin therapy for ∼150 days. There were no episodes of mucosal hemorrhage or sepsis. CONCLUSIONS: Renacidin infusion can be performed safely and effectively and may eliminate upper tract recurrent struvite stones in patients who have failed endoscopic therapy. An inpatient monitoring program and multidisciplinary collaboration is required for safe infusion. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e387-e387 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Egor Parkhomenko More articles by this author Vivian Williams More articles by this author Michael Kurtz More articles by this author Expand All Advertisement Loading ...

Three Years Experience of Bilateral Simultaneous Percutaneous Nephrolithotomy – A Single Center Study in Pakistan

Objective To study the outcomes of simultaneous bilateral PCNLs in adult population and discussing therapeutical benefits and complications. Design A Retrospective Study. Setting The Kidney Centre ( The Post Graduate Training Institute, Karachi). Duration of Study Three years from January 2017 to December 2019. Methodology A retrospective chart review at one of the large urology institute in Karachi was conducted. The aim was to document the demographics, operation dynamics, outcomes and complications of simultaneous bilateral PCNL in adult population. Record of 60 patients who underwent simultaneous bilateral PCNL between January 2017 and December 2019 in our hospital were evaluated. Preoperative, post-operative laboratory values, operative time, stone clearance, complications and hospital stay were recorded. SPSS IBM version 20 was used for data entry and analysis. Results The mean age was 40.0±15.1 years. The mean hospital stay was 3.5 days and mean operative time was 144 minutes. The transfusion rate was observed 16.7% and infracostal approach was most frequently used approach. Conclusion Simultaneous bilateral PCNL is a safe, efficacious, and cost-effective option in cases of bilateral renal calculi and should be considered an acceptable treatment option for patients with bilateral stones due to low morbidity, overall short hospital stays, comparable stone free rates, cost effectiveness and early return-to-normal activity time.

Bilateral simultaneous percutaneous nephrolithotomy versus staged approach: a critical analysis of complications and renal function.

Patients with bilateral kidney stones and burdened by large stones are challenging cases for endourologists. Simultaneous bilateral percutaneous nephrolithotomy (sbPCNL) is an option; however, it may be accompanied by important morbidity. An alternative is a staged PCNL, operating one side each time. Herein, we compare the impact of sbPCNL and staged PCNL on complication rates and renal function. Patients who underwent sbPCNL or staged bilateral PCNL with a frame time of 6 months were searched in our prospectively collected kidney stone database. Groups were compared for age, gender, body mass index (BMI), comorbidities (classification by the American Society of Anesthesiology - ASA), stone size, Guy's score, stone-free status, renal function, blood loss, blood transfusion rate, complication rate, and length of hospital stay. Twenty-six patients and 52 kidney units were enrolled. The mean operative time was 134.7 min. Only 11.3% of cases had complications, all of them minor (Clavien ≤ 2). Overall, the stone-free rate was 61.50%. Comparing the groups, there was a significantly longer operative time in the sbPCNL group (172.5 vs. 126.3 min; p=0.016), as well as a higher transfusion rate (12.5% vs. 5.6%; p=0.036). There was no statistically significant difference in creatinine levels between the groups. Regarding the stone-free rate, there was a significantly higher proportion of patients in the staged PCNL group (64.9% vs. 43.8%; p=0.012). sbPCNL is a safe procedure; however, when compared to staged procedures it has a higher transfusion and lower stone-free rate.

Assessment of the Contrast-Enhanced Ultrasound in Percutaneous Nephrolithotomy for the Treatment of Patients with Nondilated Collecting System.

Purpose: To investigate the clinical value of contrast-enhanced ultrasound (CEUS) in percutaneous nephrolithotomy (PCNL) for kidney stone patients without hydronephrosis. Methods: Patients with nondilated collecting system kidney stones who underwent PCNL between October 2018 and December 2019 at our hospital were enrolled in this study. Patients who met the inclusion criteria were randomized into two groups: a CEUS-guided PCNL group and a conventional ultrasound (US)-guided PCNL group. The operation results of the two groups were compared, including the number of attempts for effective puncture, duration to effective puncture, stone clearance rate, blood loss, postoperative complications, and hospital stay. Results: Fifty-six patients with a nondilated collecting system who underwent PCNL for 60 kidneys were included in this study, including 4 patients who underwent bilateral PCNL due to bilateral renal stones. There were 30 kidneys in each group. All patients successfully underwent PCNL. The CEUS-guided PCNL group had more accurate punctures, with a higher effective rate of one puncture and shorter puncture time. There was no statistically significant difference in stone clearance rate between the two groups. Four cases of double channels were established in the conventional US-guided PCNL group, while there was only one case in the CEUS-guided PCNL group. In the CEUS-guided PCNL group, most cases (96.7%, 29/30) had no or only mild complications, which were significantly better than the conventional US-guided PCNL group (76.7%, 23/30). The mean postoperative hemoglobin loss in the CEUS-guided PCNL group was 9.5 (range 1-25) g/L, which was significantly lower than 15.5 (range 5-52) g/L in the conventional US-guided PCNL group. Conclusion: The CEUS technique can improve visibility of the nondilated renal collecting system, facilitate selection of suitable calix, and identify renal calix fornix. It also benefits needle placement in patients with a nondilated collecting system.

NEPHROPLEURAL FISTULA AND URINOTHORAX AFTER PERCUTANEOUS NEPHROLITHOTOMY

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Urinothorax is a rare diagnosis caused by urinary tract obstruction or trauma resulting in leakage of urine from the retroperitoneum into the pleural space. These effusions are typically large, unilateral, and nearly always associated with a ratio of pleural fluid creatinine to serum creatinine greater than one. Definitive treatment requires correction of the uropathy, as thoracentesis or chest tube insertion alone is invariably ineffective. Here we describe a case of urinothorax due to nephropleural fistula which formed after percutaneous nephrolithotomy for staghorn calculi. CASE PRESENTATION: A 54 year-old female with morbid obesity and bilateral staghorn calculi was admitted to the hospital for elective bilateral percutaneous nephrolithotomy (PCNL) for progressive renal dysfunction. A left sided PCNL was performed and a percutaneous nephrostomy (PCN) tube was left in place. Four days post procedure, the PCN tube was removed. Six days post procedure, the patient developed severe left-sided pleuritic chest pain, orthopnea, and dyspnea at rest. She required two liters of oxygen by nasal cannula to maintain her oxygen saturation above 90%. Exam was notable for super morbid obesity (BMI of 60), mild respiratory distress, and absent left sided breath sounds with dullness to percussion. Chest x-ray showed a large left pleural effusion. Urgent bedside thoracentesis was performed, and 1.8 liters of clear, pink-tinged fluid was removed. Pleural fluid analysis revealed a transudate by Light’s criteria with a pH of 7.8, creatinine of 6.69 mg/dL, and a pleural fluid to serum creatinine ratio of 2.9. CT scan of her chest, abdomen, and pelvis revealed bilateral staghorn calculi, a large left pleural effusion, and a fistulous tract between the kidney and the posteroinferior pleural space. A chest tube was placed, and the patient underwent double J-stent placement within the urinary tract which relieved the obstruction and halted the accumulation of pleural fluid. The chest tube was removed, and the patient was discharged with plans to undergo right sided PCNL in the future. DISCUSSION: Urinothoraces can be caused by urinary tract obstruction or trauma. PCN tube placement above the 12th rib can lead to pleural transgression and injury, as in this case. Traumatic urinothoraces are typically symptomatic, unilateral, and large. In most cases, pleural fluid analysis shows an acidic transudate with a pleural fluid to serum creatinine ratio of greater than one. Diagnosis can be made on the basis of pleural fluid analysis or imaging with either CT or radionucleotide scans. Treatment with thoracentesis or chest tube drainage alone leads to unfavorable outcomes in nearly all cases; therefore, management should focus on correction of the uropathy which provides definitive treatment. CONCLUSIONS: See Discussion Reference #1: Toubes, M. E et al. Urinothorax: a systematic review. J Thorac Dis. 2017 May; 9(5): 1209-1218. Reference #2: Chandra A, Pathak A, Kapur A, Russia N, Bhasin N. Urinothorax: A rare cause of severe respiratory distress. Indian J Crit Care Med. 2014;18(5):320-2. Reference #3: Dagli M, Ramchandani P. Percutaneous nephrostomy: technical aspects and indications. Semin Intervent Radiol. 2011;28(4):424–437. DISCLOSURES: No relevant relationships by Traci Adams, source=Web Response No relevant relationships by Carlos Cardenas, source=Web Response No relevant relationships by Dylan Lovin, source=Web Response no disclosure on file for Arthi Satyanarayan

Images - Simultaneous bilateral percutaneous nephrolithotomy and encrusted ureteric stent removal in a patient with an ectopic parathyroid adenoma.

Images - Simultaneous bilateral percutaneous nephrolithotomy and encrusted ureteric stent removal in a patient with an ectopic parathyroid adenoma.

UP015 - Percutaneous tract coagulation in bilateral PCNL is a safe and effective procedure?

UP015 - Percutaneous tract coagulation in bilateral PCNL is a safe and effective procedure?

UP003 - Bilateral simultaneous PCNL for bilateral urolithiasis: The future? Evidence from a systematic review

UP003 - Bilateral simultaneous PCNL for bilateral urolithiasis: The future? Evidence from a systematic review

UP004 - Non-simultaneous bilateral percutaneous nephrolithotomy in a single procedure: Eficacy and safety

UP004 - Non-simultaneous bilateral percutaneous nephrolithotomy in a single procedure: Eficacy and safety