Large Stone Burden Research Articles

Laparoscopic Ureterolithotomy with Concomitant Pyelolithotomy Using Flexible Cystoscope.

To report and discuss the treatment of ipsilateral upper ureteral and renal stones by laparoscopic ureterolithotomy with concomitant pyelolithotomy using flexible cystoscope. A total of 19 patients (14 men and 5 women) underwent laparoscopic retroperitoneal ureterolithotomy with concomitant pyelolithotomy using flexible cystoscope through the ureterotomy site. The mean age of the patients was 37.9 (22-61) years. Stones were on the right side in 12, on the left side in 7, and multiple in 6 patients. All ureteral stones were located in the upper ureter. Most renal stones were in the pelvis or in the calices. All procedures were completed laparoscopically without conversion to open surgery. Mean operation duration was 86.5 (range: 80-93) minutes, thus operation duration was prolonged by a mean of 24.4 minutes in patients with concomitant stone extraction. Fifteen cases were treated using flexible cystoscope and a nitinol basket; in the remaining four cases holmium laser lithotripsy was performed. Complete stone clearance was confirmed by postoperative imaging in all patients. Laparoscopic ureterolithotomy with concomitant pyelolithotomy is a feasible and effective technique for patients with large ureteral stone and low renal stone burden.&nbsp.

Pre- and Postoperative Predictors of Infection-Related Complications in Patients Undergoing Percutaneous Nephrolithotomy.

We aim to describe pre- and postoperative predictors of infection-related complications in individuals undergoing percutaneous nephrolithotomy (PCNL). Patients treated with PCNL from 2009 to 2013 were reviewed. Patients with positive urine or stone cultures received extended antimicrobial treatment. All others received 7 days of empirical therapy preoperatively and postoperatively. Pre- and postoperative predictors of infectious complication were identified. We identified 227 patients who underwent primary PCNL with infectious complications occurring in 37 (16%): 11 (5%) urinary tract infection/pyelonephritis, 21 (9%) systemic inflammatory response syndrome (SIRS), and 2 (0.9%) sepsis. There were no significant differences between those with and without infectious complication with regard to age, gender, stone size, presence of diabetes, or procedure duration. Those with infectious complication were more likely to have a positive intraoperative stone culture (p = 0.01), struvite stone composition (p < 0.01), staghorn calculi (p < 0.001), and multiple stones (p = 0.02). Preoperatively, on multivariable analysis, only the presence of a staghorn calculus remained independently associated with increased risks of fever/SIRS/sepsis (odds ratio [OR] 3.14; p = 0.02) and total infectious complications (OR 2.53; p = 0.02) following PCNL. After controlling for pre- and post-PCNL risk factors, again, only staghorn calculi remained significantly associated with fever/SIRS/sepsis (OR 3.41; p = 0.01) and total infectious complications (OR 2.91; p = 0.01), with presence of multiple stones approaching significance (OR 4.2, confidence interval [CI]: 0.96, 18.6; p = 0.06). In individuals undergoing PCNL on preoperative antibiotics, risk of SIRS/sepsis was low. The presence of a staghorn calculus confers a greater than threefold increased risk of postoperative infection with multiple stones approaching a significant risk. Patients with large stone burdens should be counseled appropriately regarding these risks.

Mini-percutaneous nephrolithotomy with high-power holmium YAG laser in pediatric patients with staghorn and complex calculi

Shock wave lithotripsy (SWL) is the treatment of choice for most cases of renal lithiasis in children. Some cases, however, are refractory to SWL and may be associated with anatomic and metabolic changes or a large stone burden. In these circumstances, mini-percutaneous nephrolithotomy (mini-PCNL) is an option. The aim was to assess the safety and efficacy of high-power holmium YAG (Ho:YAG) laser in mini-PCNL for staghorn calculi. The clinical records relating to 35 mini-PCNLs (Table) performed between January 2008 and December 2012 in 33 patients (27 boys and 6 girls; mean age 7 years, range 2-18 years) were retrospectively reviewed. Twenty-two (66.7%) of the patients had undergone a previous SWL (28.6% three sessions). The mini-PCNL puncture technique used involved fluoroscopic guidance with the C arm at 0-90° in the supine position. An 18F tract was used. Stone fragmentation was performed with a high-power Ho:YAG laser (Lumenis 100W). Ten of the mini-PCNLs (28.6%) were right sided, and 25 were left sided (71.4%). Stones were located in the lower calyceal group in 64% of patients and in the renal pelvis in 50%. The mean stone size was 4.46cm(2) (range 3-13.20cm(2)). The number of stones varied between one and 20, and 83.3% were radiopaque. The laser was set at 70W (range 50-100W) (3.5J/pulse with a frequency of 20pulses/s). The mean surgical time was 150min. In 78% of patients, complete stone clearance was achieved, and the overall stone-free rate rose to 85% when residual stones were treated with either SWL or retrograde intrarenal surgery. No perioperative complications were seen. There are few reports in the literature concerning the use of a high-power laser for treatment of complex stones and the few that do exist relate to adults have similar results, showing it to be highly effective and safe, with low morbidity. Some limitations of the present study must be acknowledged. It was retrospective and a relatively small number of patients were included. However, randomized prospective studies are required to confirm our findings and conclusions. In the pediatric population, mini-PCNL with high-power Ho:YAG laser is feasible and safe and represents the technique of choice for complex renal stones.

PD23-08 URETERAL ACCESS SHEATHS AND URETERAL WALL INJURY: A RANDOMIZED DOUBLE-BLIND CLINICAL TRIAL

You have accessJournal of UrologyStone Disease: Surgical Therapy IV1 Apr 2016PD23-08 URETERAL ACCESS SHEATHS AND URETERAL WALL INJURY: A RANDOMIZED DOUBLE-BLIND CLINICAL TRIAL Christopher J. Loftus, Vishnuvardhan Ganesan, Olivier Traxer, Jesse Schold, Mark Noble, Sri Sivalingam, Nicolas Muruve, and Manoj Monga Christopher J. LoftusChristopher J. Loftus More articles by this author , Vishnuvardhan GanesanVishnuvardhan Ganesan More articles by this author , Olivier TraxerOlivier Traxer More articles by this author , Jesse ScholdJesse Schold More articles by this author , Mark NobleMark Noble More articles by this author , Sri SivalingamSri Sivalingam More articles by this author , Nicolas MuruveNicolas Muruve More articles by this author , and Manoj MongaManoj Monga More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1747AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteral access sheaths have been suggested to improve outcomes with flexible ureteroscopy, yet placement may be difficult or associated with ureteral injury. We conducted a randomized trial of the Boston Scientific Navigator HDTM and Cook FlexorTM ureteral access sheaths to evaluate ease of placement and risk of ureteral wall trauma. METHODS Ninety patients were consented and randomized to ureteroscopy with the Cook Flexor or the Boston Scientific Navigator HD 12/14Fr sheaths. Pre-stented patients were excluded. At the completion of the procedure, video of the intraluminal ureter was recorded as the sheath was withdrawn. Videos were analyzed by two blinded staff endourologists who scored ureteral injury on a standard 5-point scale (0 to 4). If the initial sheath failed to advance, the patient was crossed over to the other sheath for a trial of passage and excluded from video review. RESULTS Patients had a mean cumulative stone diameter of 13.1±10.9mm and stone surface area burden of 1165±1065mm2. The success rate for initial sheath placement was 86.6%; placement rate and did not differ for sheaths groups. In no case did the Flexor sheath advance where the Navigator had failed while the Navigator was successful in passage in 50% (3/6) of the Flexor failures. The Navigator HD was subjectively rated as easier to place (3.4 vs 2.9, p=0.029). Grade 1 injury was seen in 24.6%, grade 2 in 11.5% and grade 3 in 6.5%; there was no difference in rate of injury between sheaths. There were no grade 4 injuries. Male gender, large stone burden, longer time of sheath insertion and a more difficult subjective rating for sheath placement were associated with high grade (grade 2 or 3) ureteral injury. Post-operative complication rate was 11.1% and similar between zero/low and high grade injury groups. CONCLUSIONS No significant difference in the risk of ureteral wall injury was noted between the two sheaths tested. Both a subjectively difficult sheath placement and a longer time of placement were associated with high grade injury, suggesting that surgeons should carry a low threshold for switching to a smaller sheath when resistance is felt. Though ureteral wall injury was not associated with any perioperative complications, long-term follow-up will be required to monitor for risk of stricture formation. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e508-e509 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Christopher J. Loftus More articles by this author Vishnuvardhan Ganesan More articles by this author Olivier Traxer More articles by this author Jesse Schold More articles by this author Mark Noble More articles by this author Sri Sivalingam More articles by this author Nicolas Muruve More articles by this author Manoj Monga More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD23-03 A PROSPECTIVE AND RANDOMIZED COMPARISON OF FLUOROSCOPIC, SONOGRAPHIC OR COMBINED APPROACH FOR RENAL ACCESS IN MINIMALLY INVASIVE PERCUTANEOUS NEPHROLITHOTOMY

INTRODUCTION AND OBJECTIVES: There is increasing use of systemic antiplatelet and anticoagulant agents, potentially complicating the surgical management of patients with large stone burdens. Although published case series have reported successful PCNL in those on uninterrupted aspirin, the risks of clinically significant bleeding after PCNL in those with iatrogenic bleeding diatheses are not fully elucidated. We sought to assess the effect of uninterrupted antiplatelet or anticoagulation therapy within the first 24 hours following PCNL on risk of requiring interventional radiologic embolization. METHODS: We reviewed a retrospective cohort of 540 patients undergoing PCNL at 2 academic medical centers between 2006-2015. From within this cohort, we performed a nested case-control study, matching non-bleeding controls 3:1 by age, gender and stone complexity (as assessed by the Guy’s Stone Score) to the subset of patients suffering a clinically significant bleeding complication (transfusion or embolization). Logistic regression was then used to assess the odds ratio for embolization. RESULTS: The overall risk of bleeding complication requiring transfusion or embolization was 3.3% within the entire cohort. There were a total of 18 patients who experienced clinically significant bleeding following PCNL. Of these, 10 underwent embolization. After matching these 18 patients as described, the odds of requiring postoperative IR embolization were significantly increased in those with continued peri-operative anticoagulation/antiplatelet therapy (OR 15, 95% CI 1.23-187.85). CONCLUSIONS: Although the safety of continued aspirin during PCNL has been reported, our findings suggest increased risk of clinically significant bleeding associated with systemic antiplatelet and anticoagulant therapy within the first 24 hours post-operatively. Prospective studies are needed to further define risks of continuing antiplatelet/anticoagulant therapy in patients undergoing PCNL.

MP22-11 SAFETY AND SURGICAL OUTCOMES OF PERCUTANEOUS NEPHROLITOTOMY IN PATIENTS WITH POOR RENAL FUNCTION.

You have accessJournal of UrologyStone Disease: Surgical Therapy I1 Apr 2016MP22-11 SAFETY AND SURGICAL OUTCOMES OF PERCUTANEOUS NEPHROLITOTOMY IN PATIENTS WITH POOR RENAL FUNCTION. Alexander Heinze, Miguel Villalobos, Eduardo Cruz-Nuricumbo, Lizzette Gomez de Regil, Rodrigo Suarez-Ibarrola, Carlos Otilio García-Jiménez, María Teresa del Carmen Moreno y Suarez, Eddie Noj-Moreno, Maria Dolores Alsina, Joey Piccolo, and Kassandra Oliva Alexander HeinzeAlexander Heinze More articles by this author , Miguel VillalobosMiguel Villalobos More articles by this author , Eduardo Cruz-NuricumboEduardo Cruz-Nuricumbo More articles by this author , Lizzette Gomez de RegilLizzette Gomez de Regil More articles by this author , Rodrigo Suarez-IbarrolaRodrigo Suarez-Ibarrola More articles by this author , Carlos Otilio García-JiménezCarlos Otilio García-Jiménez More articles by this author , María Teresa del Carmen Moreno y SuarezMaría Teresa del Carmen Moreno y Suarez More articles by this author , Eddie Noj-MorenoEddie Noj-Moreno More articles by this author , Maria Dolores AlsinaMaria Dolores Alsina More articles by this author , Joey PiccoloJoey Piccolo More articles by this author , and Kassandra OlivaKassandra Oliva More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.699AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Percutaneous nephrolitotomy (PCNL) is today's standard of care for patients with kidney stones >20mm. Recently studies have been focused on preventing complications and predicting surgical outcomes. Urolithiasis is frequently associated to chronic kidney disease due to its obstructive and infectious implications. The glomerular function rate (GFR) can be calculated from various formulas and is used to evaluate renal function and be staged accordingly (KDIGO, Kidney Disease Improving Global Outcomes). We investigated surgical outcomes of percutaneous nephrolitotomy (PCNL) in patients with poor renal function (GFR <60 mL/min/1.73m2) in a reference center with a high proportion of staghorn stones and large stone burden (mean stone diameter 39.8, range 5-89mm). METHODS We systematically reviewed all patients who underwent PCNL in our center from June 2009 to May 2015. We assed patients renal function using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. Then classified them into their KDIGO stage. Posteriorly we subdivided them in two different groups, group 1 (KDIGO 1 and 2) and group 2 (KDIGO 3, 4 and 5). We analyze both groups and compared them according to sociodemographic, biochemical, surgical, and clinical outcomes. RESULTS A total of 257 patients were reviewed in the present study. 181 patients in group 1 and 76 into group 2. When classified according to KDIGO, 110, 56, 42, 13 and 14 were in stage 1 to 5, respectively. Group 2 had significantly higher mean patient age (49.2 vs 42.4 yrs in group 1), higher proportion of single kidney (26% vs 0.6% in group 1, p<0.001), lower levels of preoperative hemoglobin (11.9 vs 12.77mg/dl in group 1, p=0.001), larger stone diameter (43.6 vs 38.2 mm in group 1, p=0.001), nephroscopy time (113 min compared to 87 min in group 1, p=0.003), higher incidence of incidental purulent urine (35.53% vs 17.67% in group 1, p=0.002) and lower stone-free rate (27.1 vs 47.0% in group 2, p=0.005). No statistical difference was found in estimated blood loss, need for blood transfusion, nor surgical complications as evaluated by Clavien-Dindo classification. CONCLUSIONS PCNL in patients with poor renal function are usually older, have lower hemoglobin levels although this does not translate into higher transfusion rate. Their stones are larger and have a higher incidence of purulent urine. Importantly, PCNL can be performed safely in this subgroup of patients. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e257 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Alexander Heinze More articles by this author Miguel Villalobos More articles by this author Eduardo Cruz-Nuricumbo More articles by this author Lizzette Gomez de Regil More articles by this author Rodrigo Suarez-Ibarrola More articles by this author Carlos Otilio García-Jiménez More articles by this author María Teresa del Carmen Moreno y Suarez More articles by this author Eddie Noj-Moreno More articles by this author Maria Dolores Alsina More articles by this author Joey Piccolo More articles by this author Kassandra Oliva More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Minimally invasive versus conventional large-bore percutaneous nephrolithotomy in the treatment of large-sized renal calculi: Surgeon’s preference?

Objective: The aim of this study was to compare the efficacy and safety of minimally invasive percutaneous nephrolithotomy (MIP) and conventional percutaneous nephrolithotomy (PCNL) in the treatment of patients with large renal stone burden. MIP has proven its efficacy and safety in the management of small renal calculi. However, conventional PCNL is still considered the standard method for treatment of large renal stones in the upper urinary tract. Materials and methods: A search of two longitudinal databases in two tertiary referral centres for complex stone disease identified 133 consecutive patients who were treated by either MIP or PCNL for renal stones 20 mm or larger between January 2009 and August 2012. Clinical data and outcome measures of the two methods were compared by Student’s t test, chi-squared test or Fisher’s exact test. A p value less than 0.05 was considered statistically significant. Results: Operative time was significantly shorter and hospital stay was significantly longer in conventional PCNL compared to MIP (p = 0.002 and < 0.001, respectively). There were no significant differences in primary stone-free rate or complication rate between the two methods. Only higher graded complications (above Clavien grade II) were significantly more common in conventional PCNL (p = 0.02). Conclusion: MIP is equally effective as conventional PCNL in the treatment of large renal calculi. Both methods have a similar complication rate. The shorter operative time in PCNL may be based on the larger diameter and quicker retrieval of large fragments; the longer mean hospital stay may be caused by the handling of the nephrostomy tube. The current data suggest that the choice of the method mainly depends on the surgeon’s preference.

3:00 PMAbstract No. 286 - Multiple-tract percutaneous nephroureteral access prior to percutaneous nephrolithotomy/-tripsy (PCNL) for large stone burden does not increase periprocedural morbidity compared to traditional single-tract access

3:00 PMAbstract No. 286 - Multiple-tract percutaneous nephroureteral access prior to percutaneous nephrolithotomy/-tripsy (PCNL) for large stone burden does not increase periprocedural morbidity compared to traditional single-tract access

Minimally Invasive ("Mini") Percutaneous Nephrolithotomy: Classification, Indications, and Outcomes.

Minimally invasive endoscopic procedures are often employed for the surgical removal of kidney stones. Traditionally, large stones are removed by (standard) percutaneous nephrolithotomy (SPCNL). Although effective for the clearance of large stone burdens, SPCNL is associated with significant morbidity. Therefore, in an effort to reduce this morbidity, while preserving efficacy, mini-PCNL (MPCNL) with a smaller tract size (<20French) was developed. Several studies suggest that MPCNL has a comparable stone-free rate to SPCNL. However, the question of lower morbidity with MPCNL remains unanswered. In this review, we describe the equipment, indications, and efficacy of MPCNL with particular attention to its value over traditional minimally invasive stone removal techniques.

Two-port Laparoscopic Cholecystectomy: An Initial Experience of 25 Cases with a New Technique

Background: In Nepal, it is quite common to find patients with large stone burden and thick gallbladder wall which often leads to incision extension. We have used this extended incision to our advantage. The present technique of two-port Laparoscopic cholecystectomy not only helps overcoming the specimen extraction difficulties but also contributes to better cosmesis. Patients and methods: Total of 25 patients were underwent the surgery in 2008 to 2010. Results: The mean operating time was 50 minutes. None had significant procedural blood loss, iatrogenic injury, perforation of gallbladder, bile spillage, significant gas leak or subcutaneous emphysema at either port site. All patients were comfortable in the postoperative period and were routinely discharged on 2nd postoperative day except for 2 patients who has surgical site infection and fever respectively. Although 3 cases were converted to standard four-port technique, none required conversion to open cholecystectomy. Out of 25 patients, 7 cases have completed 3 months follow up and did not show any complication like port site hernia.

Laparoscopic-assisted mini percutaneous nephrolithotomy in the ectopic pelvic kidney: Outcomes with the laser dusting technique.

Introduction:The treatment of renal lithiasis has undergone a sea change with the advent of extracorporeal shock wave lithotripsy (ESWL) and endourological procedures such as percutaneous nephrolithotomy (PCNL), ureterorenoscopy and retrograde intrarenal surgery (RIRS). The presence of anatomical anomalies, such as ectopic pelvic kidney, imposes limitations to such therapeutic procedures. This study is aimed to find a simple and effective way to treat the stones in ectopic kidney.Materials and Methods:From 2010 to 2014, nine patients underwent laparoscopic-assisted mini PCNL with Laser dusting for calculi in ectopic pelvic kidneys at our hospital. Retrograde pyelography was done to locate the kidney. Laparoscopy was performed and after mobilizing the bowel and peritoneum, the puncture was made in the kidney and using rigid mini nephroscope, and stones were dusted with Laser.Results:The median interquartile range (IQR) stone size was 18 (6.5) mm. Median (IQR) duration of the procedure was 90 (40) min. The median (IQR) duration of postoperative hospital stay was 4 (2) days. The stone clearance in our series was 88.9%, with only one patient having a residual stone. No intra- or post-operative complications were encountered.Conclusion:Laparoscopy-assisted mini PCNL with Laser dusting offers advantages in ectopic pelvic kidneys in achieving good stone clearance, especially in patients with a large stone burden or failed ESWL or RIRS.

Supracostal Punctures for PCNL: Factors that Predict Safety, Success and Stone Free Rate in Stag Horn and Non-Stag Horn Stones: A Single Centre Experience and Review of Literature.

Supra-costal Percutaneous Nephrolithotomy (PCNL) procedure has now become an established standard of care in patients with renal stone disease, in terms of morbidity, stone clearance, duration of stay and shorter convalescence period. Gone are the days when supracostal punctures were considered to be associated with a high morbidity. With increased expertise gained in performing multiple punctures and further refinements in focusing techniques, more and more of these procedures are being performed with an intention to achieve a maximum stone clearance with least morbidity. To prospectively analyze the various factors that predict the safety, efficacy and stone clearance rate in patients who have undergo supracostal punctures for PCNL procedures. Three hundred seventy six patients underwent PCNL for renal stones. Ninety two (n=92) of them needed supra-costal puncture. All patients were subdivided into groups 1 and 2 based on the size, location of the stone and the stone burden. In all, 132 tracts were established. About 83% of patients achieved a complete stone free rate after initial PCNL. Stones more than 3 centimeters were found to be associated with significant residual stones. Radio opacity under image intensifier also had a significant impact on the ultimate stone free status. About 23% of those (n=5/22) who needed longer duration of surgery had a clinically significant residual stones, needing ancillary procedures. Fifteen patients (16%) had complications related to the procedure, of which 13 were in group 1 (87%). High percentage of complications in patients with larger stone burden was found to be statistically significant. In about 76% (n=70), the procedure required only less than 90 minutes. Also, in those 22 patients in whom the duration of procedure exceeded 90 minutes, 12 of them had complications, with a p-value of <0.0001. Supra-costal punctures are safe and effective options in a selected group of patients. The overall results are almost on par with that of the infra costal punctures, with an acceptable morbidity.

Comparison on efficacy and safety of percutaneous nephrolithotomy for the treatment of renal stones: modified supine Valdivia versus prone position

Objective To compare the efficacy and safety of percutaneous nephrolithotomy (PCNL) in modified supine Valdivia and traditional prone positions for the treatment of renal stones. Methods Clinical data of 80 consecutive patients with renal calculi who accepted PCNL from December 2012 to September 2014 were retrospectively reviewed.They were divided into modified supine Valdivia group (n=44) and prone position group (n=36) according to the position during surgery.There was no significant difference between the 2 groups in age, sex, ASA class, stone location and size (P>0.05). Total operative time, ratio of multi-access, blood loss, perioperative complications and stone-free rate were compared between the 2 groups. Results All punctures were performed successfully.No case was converted to open surgery.No severe complications such as colon injury, pleura or peritoneum perforation, or death occurred intra- and post-operatively.In prone position, 1 patient was found to develop high intra-trachea pressure because of large stone burden and prolonged operative time (130 min). This procedure was stopped and the patient received the second session of PCNL 1 week later.The mean total operative time was significantly shorter in the modified supine than in the prone position (67.7±24.5 min versus 91.5±29.8 min, P 0.05). Conclusion PCNL in modified supine Valdivia is as safe and effective as that of prone position for the treatment of renal stones, but the former is more time-saving than the latter. Key words: Nephrostomy, percutaneous; Supine position; Prone position; Retrospective studies

A comparison of outcomes after percutaneous nephrolithotomy in children and adults: A matched cohort study

Percutaneous nephrolithotomy (PCNL) has surpassed open stone surgery as the operation of choice for large and complex stone burdens (figure). Although the procedure was developed in adults, its principles have been extrapolated to children. There is a paucity of literature comparing outcomes of PCNL in adults and children for similar stone burdens. The purpose of this study was to evaluate outcomes following PCNL among children and adults with similar stone burdens. Data on patient characteristics and outcomes for 2196 consecutive patients undergoing PCNL at a single institution were collected prospectively from January 1992 to July 2013. Thirty-one pediatric patients undergoing 39 PCNLs were identified. Each pediatric PCNL was matched in a ratio of 1:4 to adult PCNLs by year of surgery and stone burden characteristics (staghorn, partial staghorn, number of stones). All PCNLs were performed by two fellowship-trained endourologists who operate on both adult and pediatric patients. Ultrasonic lithotripsy was used primarily. The primary outcome measure was stone-free rate (SFR) at hospital discharge. Secondary outcomes included the need for second-look nephroscopy, length of hospital stay, complication rate, and blood transfusion rate. The Student t test was used for continuous variables and the Fisher exact for categorical variables. The median age for the pediatric group was 13.9 ± 4.30 years and for the adult group was 55.4 ± 15.1 years. Pediatric patients tended to present with metabolic stones, with no difference in rates of infection stones. No difference was found in SFR at time of hospital discharge (86.1% vs. 86.4%, p = 0.2). More pediatric patients required a second access tract than adult patients (15.4% vs. 4.52%, p = 0.02). There was no significant difference in the need for second-look nephroscopy, length of stay, or complication rates (overall and by Clavien classification subgroup) between both groups. The rates of blood transfusion were low in both groups (0% vs. 0.6%, p = 0.80). There was no difference in primary and secondary outcomes among children compared with adults undergoing PCNL in our study. The outcomes reported in this study were similar to published literature. A limitation of this study is the low number of pediatric patients. However, it is unique to have a single-center study that compares PCNL outcomes in both adult and pediatric patient and accounts for stone burden characteristics. Although principles of PCNL were developed in adults, this study affirms the safety and efficacy of PCNL in both pediatric and adult patients.

MP38-16 OUTCOMES OF UROLITHIASIS TREATMENT IN PATIENTS WITH RENAL INSUFFICIENCY

You have accessJournal of UrologyStone Disease: Surgical Therapy IV1 Apr 2015MP38-16 OUTCOMES OF UROLITHIASIS TREATMENT IN PATIENTS WITH RENAL INSUFFICIENCY Haresh Thummar, Usama Khater, V. Joshi, P. Kansagra, and Mantu Gupta Haresh ThummarHaresh Thummar More articles by this author , Usama KhaterUsama Khater More articles by this author , V. JoshiV. Joshi More articles by this author , P. KansagraP. Kansagra More articles by this author , and Mantu GuptaMantu Gupta More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1391AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES If obstructing urinary stones are not treated in a timely manner, permanent renal dysfunction and/or infection can result. There is scanty data in the literature regarding the outcome of these patients after definitive intervention. METHODS We studied 210 patients with urolithiasis with serum creatinine (Cr) greater than 1.5 mg/dl (1.5 to 34 mg/dl). All patients underwent standard treatment with stent placement, percutaneous nephrostomy (PCN) or dialysis when indicated. Once nadir Cr was achieved definitive surgery was performed. Age, gender, stone size/location, imaging, hydronephrosis, laboratory parameters, comorbidies, infection, therapeutic procedures, complications, stone free rates (SFR), and renal function were reviewed. RESULTS 88/210 (41.9%) patients were placed on dialysis initially. 62 required PCN and 42 stent placement. Definite surgery was ureteroscopic lithotripsy for ureteral stones (URSL) in 72 cases, percutaneous nephrolithotomy (PCNL) in 158, and retrograde intrarenal surgery (RIRS) in 26 cases. Complete clearance was achieved in a single session in 186 (88.6%). At 6 months, 118 had improved renal function compared to nadir Cr, 66 had stabilization and 26 had deterioration. All who exhibited deterioration had nadir Cr greater than 9, cortical atrophy, recurrent infections and late presentation with large stone burden and proteinuria. CONCLUSIONS Patients with renal insufficiency with stone disease requires aggressive multimodal approach to unobstruct urinary tract, control infection, and achieve complete stone clearance; despite this, pts. presenting with CKD 5 have poor prognosis. Age 4-88 years (36.8) No of patients 210 Comorbidity DM 85 (40.5%) HTN 122 (58.1%) CAD 44 (20.9%) CKD 26 (12.4%) Obesity 34 (16.2%) Calculus type Complete staghorn 32 Partial staghorn 34 Pelvic 48 Complex 18 Ureteric 72 Calyceal 48 Cr after surgery Cr Number of patients 1.0-2.0 mg/dl 122 (58.1%) 2.1-4.0 mg/dl 37 (17.6%) 4.1-6.0 mg/dl 25 (11.9%) > 6.0 mg/dl 26(12.4%) DM-Diabetes Mellitus HT-Hypertension CKD-Chronic kidney Disease CAD-Coronary Artery Disease © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e452 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Haresh Thummar More articles by this author Usama Khater More articles by this author V. Joshi More articles by this author P. Kansagra More articles by this author Mantu Gupta More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP17-05 PROSPECTIVE CLINICAL TRIAL EVALUATING ANTEGRADE NEPHROSTOGRAPHY TO ASSESS URINE FLOW AFTER PERCUTANEOUS NEPHROLITHOTOMY

INTRODUCTION AND OBJECTIVES: Percutaneous nephrolithotomy (PNL) remains an effective treatment for patients with a large stone burden. When a nephrostomy tube (NT) is left in place postoperatively, antegrade flow of urine is often confirmed with antegrade nephrostography (ANG) as edema from a chronically obstructing stone can resolve in variable amounts of time. Alternatively, antegrade flow can be estimated by injecting methylene blue dye into the NT or performing a NT capping trial. We compared the methylene blue dye test and capping trial against ANG to assess antegrade urine flow. METHODS: Consecutive patients undergoing PNL at 2 hospitals were prospectively enrolled between July and October, 2014. A cap was placed on the NT on the morning of postoperative day 1 (POD1). Capping trial failure was defined as need to uncap NT for any reason including increased pain or fever. 2 hours after capping, 7cc of methylene blue was injected into the NT and the tube recapped. Positive test was defined as the presence of blue per urethral Foley. Later that afternoon, ANG was performed to radiographically document antegrade urine flow. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated comparing capping and methylene blue tests against ANG. RESULTS: 34 subjects underwent PNL. 55.9% were left sided and 73.5% were lower pole punctures (mean age 54.9 13.9 years; mean BMI 31.7 12.7kg/m2; mean stone size 2.86 1.42cm). Capping trial was successful in 86.7% of patients. Compared to ANG, it had a sensitivity of 94.4% (CI 83.9-100%), specificity 25.0% (CI 0.5-49.5%), PPV 65.4% (47.1-83.7%), and NPV 75.0% (CI 32.6-100%) to predict antegrade urine flow. The methylene blue test was positive in 41.4% of patients. Compared to ANG, it had a sensitivity of 52.9% (CI 29.2-76.7%), specificity 75.0% (CI 50.5-99.5%), PPV 75.0% (CI 50.5-99.5%), and NPV 52.9% (CI 29.2-76.7%) to predict antegrade urine flow. CONCLUSIONS: Compared to ANG, a capping trial and methylene blue test are 94% and 53% sensitive and 25% and 75% specific respectively for confirming antegrade urine flow following PNL. In clinical practice, these tests may potentially be used in combination to obviate the need for ANG, which can be redundant and timeconsuming.

MP80-08 METABOLIC CHARACTERISTICS OF BRUSHITE STONE FORMERS

You have accessJournal of UrologyStone Disease: Evaluation II1 Apr 2015MP80-08 METABOLIC CHARACTERISTICS OF BRUSHITE STONE FORMERS Tracy Marien, S. Duke Herrell, and Nicole Miller Tracy MarienTracy Marien More articles by this author , S. Duke HerrellS. Duke Herrell More articles by this author , and Nicole MillerNicole Miller More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2844AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Brushite nephrolithiasis is an especially aggressive form of stone disease associated with larger stone burden, more frequent stone episodes and kidney injury. In addition to surgical intervention most brushite stone formers require medical management. Several recent studies have shown the number of brushite stone formers to be increasing. It is important for urologists to be aware of the implications of this stone type and the consequences of untreated metabolic derangements. The aim of this study is to characterize the metabolic abnormalities of brushite stone formers. METHODS A retrospective chart review was performed of all patients at our institution who have a history of brushite stones. Twenty-four hour urine studies done prior to being placed on medical therapy were captured. Patient demographics and stone event history was also reviewed. RESULTS Of 118 brushite stone formers, 49 patients were identified who completed a 24 hour urine analysis prior to starting medical therapy. These patients' stone disease characteristics are presented in Table 1. Every patient had at least one metabolic abnormality. The most common abnormality was elevated urinary pH (73%), followed by elevated urinary sodium (71%), hypercalciuria (67%), hypocitraturia (65%), and low urinary volume (61%) (see Table 1). Fourteen (88%) of the 16 patients who did not have hypercalciuria had hypocitraturia. Both of the patient who did not have hypercalciuria or hypocitraturia had a very high urinary pH (6.4 and 6.7) in addition to a urinary sodium of 310 mmol/d in one and low urine volume in the other. All patients were counseled on dietary preventative measures and 28 patients (57%) were started on medical therapy. CONCLUSIONS All brushite stone formers have significant metabolic derangements on 24 hour urine testing. The most commonly abnormalities in this series were elevated urine pH and high urinary sodium. We recommend metabolic evaluation in all of these patients with aggressive dietary modifications and medical therapy to decrease incidence of recurrent stone episodes and long-term kidney damage. The role of citrate replacement remains uncertain in the hypocitraturic brushite stone former due to concern for further raising urine pH. Table 1. Brushite Stone Former Characteristics Patients (n = 49) Spontaneous passage∗ 30 (79%) Surgical intervention 49 (100%) No. of surgical interventions/pt, average (range) Total 8.5 (1-57) PCNL 1.0 (0-7) Ureteroscopy 3.8 (0-17) ESWL 3.7 (0-40) Pyelithotomy (2 patients) 0.4 (0-1) Family history∗ 26 (59%) Age at first stone event ∗ (yo) 26.1 (6-51) Gender Female 23 (47%) Male 26 (53%) BMI (kg/mˆ2) 29.5 (20-43) Serum creatinine (mg/dL) 0.91 (0.51-1.36) Length of follow-up (mo) 47.1 (1-221) 24 hour urine Hypercalciuria∗∗ 33 (67%) Hypocitraturia∗∗ 32 (65%) Hyperoxaluria (> 40 mg/d) 9 (18%) Hyperuricosuria∗∗ 15 (31%) Elevated sodium (> 150 mmol/d) 35 (71%) Elevated phosphate (> 1.2 mmol/d) 21 (43%) Low volume (< 2L) 30 (61%) Elevated urine pH (> 6.2) 36 (73%) Patients started on medical therapy Total 28 (57%) Thiazide diuretic 20 (41%) Citrate therapy 4 (8%) Combined therapy 4 (8%) Elevated serum calcium 4 (8%) Elevated parathyroid hormone 3/22 (14%) Abbreviations: Pt, patient; PCNL, percutaneous nephrolithotomy; ESWL, extracorporeal shockwave lithotripsy; yo, years old; BMI, body mass index; kg, kilograms; m, meters; mg, milligrams; dL, deciliter; mo, months; d, day; mmol, millimoles; L, liter; g, grams. ∗ History of stone passage was available for 38 patients, family history was available for 44 patients, and age at first stone event was known for 35 patients. ∗∗ Hypercalciuria was defined as greater than 250 mg/d in men and greater than 200 md/d in women. Hypocitraturia was defined as less than 450 mg/d in men and less than 550 mg/d in women. Hyperuricosuria was defined as greater then 0.80 g/d in men and greater than 0.75 g/d in women. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1021-e1022 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tracy Marien More articles by this author S. Duke Herrell More articles by this author Nicole Miller More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V6-08 LARGE UPPER-CALYX STONE: CAN SUPRA-TWELFTH PCNL APPROACH BE AVOIDED?

You have accessJournal of UrologyUrolithiasis1 Apr 2015V6-08 LARGE UPPER-CALYX STONE: CAN SUPRA-TWELFTH PCNL APPROACH BE AVOIDED? Jose Agudelo, Euro Arias, Nasser Ktech, Jhonan Chirinos, Manuel Riveros, Luis Sanchez, Eduardo Pena, and Ricardo Montiel Jose AgudeloJose Agudelo More articles by this author , Euro AriasEuro Arias More articles by this author , Nasser KtechNasser Ktech More articles by this author , Jhonan ChirinosJhonan Chirinos More articles by this author , Manuel RiverosManuel Riveros More articles by this author , Luis SanchezLuis Sanchez More articles by this author , Eduardo PenaEduardo Pena More articles by this author , and Ricardo MontielRicardo Montiel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.473AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A large renal stone is considered any calculi larger than 2 cm. When this burden is located in the upper calyx, a supracostal PCNL approach has to be considered. However, many urologists hesitate to use this access because of the potential for intrathoracic complications. As a result, other techniques to avoid the supracostal approach and access the upper pole have been described. Most of them required staged or auxiliary procedures. We present our series of large upper calyx stone, and we will evaluate if it is a good option to avoid a supracostal approach in terms of efficacy. METHODS We will illustrate in the videotape, the decision process in the treatment of a large upper calyx stone. We have applied this evaluation to 22 consecutive patients with a mean stone burden of 3529 mm3. We outlined the method with a 48 years old male and a large upper calyx stone burden. After evaluating all the endourological alternatives to treat a stone with this feature, we decided to offer him a supracostal PCNL approach. Following informed consent, the patient was placed prone after an open end ureteral catheter was introduced. A supra twelfth rib puncture was accomplished, and sequential metal dilation was done. It was followed by insertion of a 24 french amplatz sheath. A direct access to the stone was observed. Initially, laser lithotripsy was applied for debulking the stone. It was followed by ultrasonic lithotripsy, and removal of the fragments. A nephrostomy tube was placed at the end of the surgery. RESULTS Supracostal access was performed in all 22 patients in this series. Mean operating time was 74.4 minutes. A high stone clearance of 86.3% was achieved. Not major complications were observed. There were just two pleural effusions demonstrated on posoperative X rays, that did not require interventions. CONCLUSIONS The concern for potential morbidity associated with supracostal punctures, precludes many endourologists from performing these approaches. In some cases like large upper calyx stones, the supracostal access is the most effective option, and the surgeon has to be prepared to offer this procedure within a safe margin. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e579 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jose Agudelo More articles by this author Euro Arias More articles by this author Nasser Ktech More articles by this author Jhonan Chirinos More articles by this author Manuel Riveros More articles by this author Luis Sanchez More articles by this author Eduardo Pena More articles by this author Ricardo Montiel More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

MP30-17 NATURAL HISTORY OF RESIDUAL FRAGMENTS FOLLOWING PERCUTANEOUS NEPHROSTOLITHOTOMY

You have accessJournal of UrologyStone Disease: Surgical Therapy III1 Apr 2015MP30-17 NATURAL HISTORY OF RESIDUAL FRAGMENTS FOLLOWING PERCUTANEOUS NEPHROSTOLITHOTOMY Kyle Wood, Marc Colaco, Juan Mainez, Ilya Gorbachinsky, Miguel Osorio, Eliud Sanchez, Majid Mirzazadeh, Dean Assimos, and Jorge Gutierrez-Aceves Kyle WoodKyle Wood More articles by this author , Marc ColacoMarc Colaco More articles by this author , Juan MainezJuan Mainez More articles by this author , Ilya GorbachinskyIlya Gorbachinsky More articles by this author , Miguel OsorioMiguel Osorio More articles by this author , Eliud SanchezEliud Sanchez More articles by this author , Majid MirzazadehMajid Mirzazadeh More articles by this author , Dean AssimosDean Assimos More articles by this author , and Jorge Gutierrez-AcevesJorge Gutierrez-Aceves More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.599AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Percutaneous Nephrostolithotomy (PCNL) is the method of choice to treat large kidney stones. Large stone burdens require staged PCNL procedures to remove residual fragments. This study evaluates the natural history of residual fragments after PCNL. METHODS Data was retrospectively collected from all patients whom underwent PCNL between January 2009 and January 2014. For patients that underwent a multiple stage procedures, data was collected from the final stage of their treatment. Demographic information regarding age, gender, BMI, medical comorbidity, and stone composition were collected. Computerized tomography (CT) scans were taken after the final stage. Each CT was analyzed as to remnant number, size, and location. All cases were then cross-referenced for other stone-related events (defined as symptomatic presentation resulting in the need for an additional stone treatment) occurring within 1 year of initial treatment. RESULTS A total of 515 patients were included of which 420 patients had complete data. There was no significant difference in gender or rates of co-morbidities between groups. Patients with no remnant stone demonstrated a significantly lower reintervention rate than those in whom remnants were found (7.7% reintervention rate versus 28.9%, p<0.0001). These differences remained true when controlled for age, gender, and comorbidity status. For patients that did demonstrate remnants, substratification by number of stone remnants showed that patients with multiple stone remnants had significantly more reintervention than patients with a single stone remnant regardless of total stone burden (36.8% reintervention versus 21.0%, p=0.05). Single stone remnants found in the lower calyces demonstrated significantly lower reintervention rates than those left in the middle or upper calyces (p<0.01). Reintervention rates were 16.75, 28.6%, 36.8%, 45.8% for lower, upper, pelvic/multiple, middle calyx respectively. A total of 300 patients had BMI data. Average BMI of all patients was 30.3. Patients with a higher BMI (>25) had more need for second procedures (22.8% versus 11.2%, p=0.02). CaOx stones are less likely to require a second treatment than CaP (9.4% versus 22.2%, p<0.01). CaOx stones had significantly less residuals than CaP stones (42.5% versus 52.7%, p < 0.05). CONCLUSIONS This study defined parameters seen on postsurgical CT scans as well as patient characteristics and stone type that can help in defining risk of future stone events and determine need for staged PCNL. Using these variables, the odds ratio of a future stone event can be calculated. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e353 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kyle Wood More articles by this author Marc Colaco More articles by this author Juan Mainez More articles by this author Ilya Gorbachinsky More articles by this author Miguel Osorio More articles by this author Eliud Sanchez More articles by this author Majid Mirzazadeh More articles by this author Dean Assimos More articles by this author Jorge Gutierrez-Aceves More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Systemic inflammatory response syndrome after flexible ureteroscopic lithotripsy: a study of risk factors.

To evaluate the risk factors for systemic inflammatory response syndrome (SIRS) after flexible ureteroscopic lithotripsy (FUL). Patients who underwent FUL between October 2012 and November 2013 were studied. Complete data was available for 260 adult patients who met this criteria. Preoperative and intraoperative risk factors that potentially contribute to SIRS were compared in patients who developed postoperative SIRS and those who did not. Furthermore, multivariable logistic regression analysis was performed and the odds ratio (OR) and 95% confidence interval (CI) were calculated to identify the independent risk factors for SIRS after FUL. The incidence of SIRS after FUL was 8.1%. In the univariate test analysis, significant correlation between SIRS and four factors was noted: sex of the patient (P<0.001), stone size (P=0.001), irrigation flow rate (P<0.001), and irrigation volume (P<0.001). Multivariable logistic regression analysis identified stone size (OR=1.691; 95% CI,0.879-3.255), small-caliber ureteral access sheath (UAS) (OR=2.293; 95% CI, 0.730-7.200), irrigation flow rate (OR=1.161; 95% CI, 1.096-1.230), and struvite calculi (OR=3.331; 95% CI, 0.971-11.426) as independent risk factors for SIRS after FUL. We recommend that the length of lithotripsy be well controlled in patients with large stone burden and struvite calculi. Staging procedures are also required. Additionally, irrigating with a low flow rate and low pressure and using a large-caliber UAS for better drainage are required to keep a low renal pelvic pressure during FUL procedures.