Multiple-tract Percutaneous Nephrolithotomy Research Articles

Perioperative and long-term results of ultrasonography-guided single- and multiple-tract percutaneous nephrolithotomy for staghorn calculi.

It is possible that this condition will lead to urosepsis and progressive deterioration of renal function in the absence of surgical intervention. Several recent clinical studies have shown that multi-tract percutaneous nephrolithotomy (M-PCNL) has a similar stone free rate (SFR) as standard percutaneous nephrolithotomy (S-PCNL). As a result, M-PCNL was also recommended as a treatment option for staghorn calculi. To examine the perioperative and long-term results of ultrasonography-guided single- and M-PCNL. This was a retrospective cohort study. Between March 2021 and January 2022, the urology department of our hospital selected patients for the treatment of staghorn calculi using percutaneous nephrolithotomy. The primary outcomes were complication rate and SFR, and the characteristics of patients, operative parameters, laboratory measurements were also collected. In total, 345 patients were enrolled in the study (186 in the S-PCNL group and 159 in the M-PCNL group). The SFR in the M-PCNL group was significantly higher than that in the S-PCNL group (P = 0.033). Moreover, the incidence rates of hydrothorax (P = 0.03) and postoperative infection (P = 0.012) were higher in the M-PCNL group than in the S-PCNL group. Logistic regression analysis demonstrated that post-operative white blood cell count (OR = 2.57, 95%CI: 1.90-3.47, P < 0.001) and stone size (OR = 1.59, 95%CI: 1.27-2.00, P < 0.001) were associated with a higher overall complication rate in the S-PCNL group. Body mass index (OR = 1.22, 95%CI: 1.06-1.40, P = 0.004) and stone size (OR = 1.70, 95%CI: 1.35-2.15, P < 0.001) were associated with increased overall complications in the M-PCNL group. Multiple access tracts can facilitate higher SFR while slightly increasing the incidence of acceptable complications.

Contemporary Management of Large and Complex Renal Calculi: Have we found the Perfect Solution Yet?

AbstractThis review provides a thorough overview of contemporary treatment strategies for complex renal calculi, including large-volume stones, stones with increased hardness and greater number, or stones with abnormal anatomy. The development of tailored treatment plans for stone removal is essential for treatment success. A literature search was conducted on PubMed using the Keyword “complex renal calculi” along with “percutaneous nephrolithotomy (PCNL),” “retrograde intrarenal surgery (RIRS),” “endoscopic combined intrarenal surgery (ECIRS),” “stone free rate,” and “complications.” Based on the findings, the use of “minimally invasive PCNL,” “multiple-tract PCNL,” “staged RIRS,” and “ECIRS” is proposed in addition to the traditional PCNL suggested using the European Association of Urology guidelines. Renal calculi in patients with solitary kidneys or who underwent kidney transplants are considered to be complex, and treatment options that allow preservation of their remaining renal function should be considered.

Effects of single versus multiple tracts on Percutaneous Nephrolithotomy outcomes

Objectives: The study designed to compare outcomes and morbidities in patient undergoes multi tracts percutaneous nephrolithotomy (PCNL) versus single tract PCNL.&#x0D; Methods: From October 2019 to September 2020, 50 patients were prospectively investigated at Azadi Teaching Hospital and Vajeen Private Hospital in Duhok, Iraq. Group A included 25 patients who received single tract PCNL while group B had 25 patients who underwent multiple tract PCNL. Complex renal stones are treated with single or multiple tract PCNL depending on stone configurations and urinary system architecture utilising Guy's stone score. Laboratory and imaging data were correlated with stone size, stone-free rate, mean haemoglobin decrease, operation time, hospital stay, and postoperative problems.&#x0D; Results: 64% of cases are male and 36% are female. The mean stone size in Group A was 3.3 cm (ranges 2.0 - 4.9 cm), but in Group B it was 5.1 cm (ranges 3.3 - 7.4 cm), which is substantially bigger. Group A's mean operational time was 64.4 minutes (ranges from 30-115 minutes), which is statistically significant compared to multiple tracts' 80.2 minutes (ranges from 45-120minutes). The decline in mean hemoglobin between the two groups is statistically significant. Group A and B had 8% and 12% blood transfusions, which is not significant. Group A had a mean hospital stay of 28.2 hours (20-48 hours), whereas group B had 40.8 hours (ranges 24-96 hours). In group A, 16% of patients experienced post-operative fever, whereas in group B, 20% did. 84% of single tract PCNL and 88% of multiple tract PCNL were stone-free.&#x0D; Conclusion: Complex renal stones treated by multiple tracts PCNL; is efficient and safe with acceptable postoperative outcomes and complications in comparison to single tract PCNL.

Comment on "Comparison of safety and efficacy between single-tract and multiple-tract percutaneous nephrolithotomy treatment of complex renal calculi: a systematic review and meta-analysis"

article: Comment on “Comparison of safety and efficacy between single-tract and multiple-tract percutaneous nephrolithotomy treatment of complex renal calculi: a systematic review and meta-analysis” - Minerva Urology and Nephrology 2021 December;73(6):849-50 - Minerva Medica - Journals

Comparison of safety and efficacy between single-tract and multiple-tract percutaneous nephrolithotomy treatment of complex renal calculi: a systematic review and meta-analysis.

A systematic review and meta-analysis was conducted to explore the safety and efficacy of single-tract and multiple-tract percutaneous nephrolithotomy (PCNL) in complex renal calculi treatment. PubMed, Web of Science, Embase, EBSCO, and Cochrane library databases (updated November 2020) were searched for studies assessing the effect of different numbers of tracts on cases that underwent PCNL. The search strategy and study selection process were managed according to the PRISMA statement. Five comparative studies were included in the meta-analysis. The multiple-tract PCNL group had a significantly increased total complications rate than the single-tract group (OR=2.35, 95% CI=1.71, 3.25; P<0.00001) with insignificant heterogeneity (I2=0%, P=0.52). Subgroup analysis showed there were different incidence of complications, mainly because the multiple-tract PCNL group was significantly associated with a higher rate of blood transfusion (OR=2.99, 95% CI=1.95, 4.57; P<0.00001) with insignificant heterogeneity (I2=9%, P=0.35). There were no differences in operation time (MD=12.04, 95% CI=6.36, 17.72; P<0.0001) or hospitalization (MD=0.54, 95% CI=0.14, 0.95, P=0.008). However, the single-tract group had a higher stone-free rate (OR=0.37, 95% CI=0.19, 0.74; P=0.005) with heterogeneity (I2=51%, P=0.08), as stones in the single-tract group were smaller than those in the multiple-tract group. The current research did not find that the multiple-tract group had a higher stone-free rate. Additionally, multiple-tract PCNL was associated with a higher incidence of blood transfusion and negative impact on renal function.

Single- versus Multiple-Tract Percutaneous Nephrolithotomy in the Surgical Management of Staghorn Stones or Complex Caliceal Calculi: A Systematic Review and Meta-analysis.

Objective To assess current evidence on the effectiveness and safety of single- versus multiple-tract percutaneous nephrolithotomy in the surgical management of complex caliceal calculi or staghorn stones through a comprehensive literature review. Methods A comprehensive literature review of articles investigating the clinical efficacy and safety of single- versus multiple-tract percutaneous nephrolithotomy was performed. Relevant literature was obtained by systematically searching PubMed, EMBASE, and the Cochrane Library through May 2020. We followed the search strategy based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The primary outcomes, including the stone-free rate (SFR), and secondary outcomes (peri- and postoperative complications and operative data) were evaluated using RevMan 5.3 statistical software. Results Ten studies involving 1844 patients with complex caliceal calculi or staghorn stones met the inclusion criteria. Single-tract percutaneous nephrolithotomy (STPCNL) had noninferior clinical efficacy with respect to the immediate SFR (odds ratio (OR) = 0.80, 95% confidence interval (CI) (0.46 to 1.38), p = 0.42) and 3-month SFR (OR = 1.22, 95% CI (0.38 to 3.92), p = 0.74) compared with multiple-tract percutaneous nephrolithotomy (MTPCNL). In addition, pooled analyses showed that STPCNL resulted in significantly lower hemoglobin decreases (MD = −0.46, 95% CI (-0.68 to -0.25), p < 0.0001), fewer blood transfusions (OR = 0.48, 95% CI (0.34 to 0.67), p < 0.0001), and fewer pulmonary complications (OR = 0.28, 95% CI (0.09 to 0.83), p = 0.02) than MTPCNL. However, the overall evidence was insufficient to suggest a statistically significant difference for other adverse events. Conclusion This meta-analysis indicated that STPCNL is an effective method for treating complex caliceal calculi or staghorn stones. Compared with MTPCNL, STPCNL not only yields similarly high SFRs but also is associated with many advantages, less blood loss, fewer blood transfusions, and fewer pulmonary complications without an increase in other complications. However, the findings of this study should be further confirmed by well-designed prospective randomized controlled trials (RCTs) with a larger patient series.

Is multiple tract percutaneous nephrolithotomy a safe approach for staghorn calculi?

To explore the safety of multiple tract percutaneous nephrolithotomy (PNL) in terms of complication and draw a nomogram to predict the possibility of significant renal function decline (SRFD). Patients with complex renal calculi appropriate for PNL at our institution between August 2016 and February 2018 were included in the study. The outcome of single and multiple tract PNL was analyzed retrospectively. A nomogram was created to predict the probability of SRFD. 793 (88.4%) patients were treated with single tract PNL (Group 1) and 104 patients (11.6%) treated with multiple tract PNL (Group 2). Group 2 had a significantly greater hemoglobin reduction (16.0 ± 12.5 vs. 11.4 ± 11.8g/L, p < 0.001), higher rate of postoperative fever (19.2% vs. 11.9%, p = 0.034) and longer duration of the operation (110.6 ± 39.6 vs. 97.8 ± 34.5min, p < 0.001). A nomogram for predicting the probability of SRFD was constructed based on identified risk factors: patients' age, positive urine culture (UC +), hemoglobin reduction and embolization. The area of receiver operating characteristic (ROC) curve was 70%. Bootstrapping technique utilized to make the calibration plot showed a high reliability of the nomogram. Multiple tract PNL had a higher risk of hemoglobin reduction and postoperative fever than single tract PNL. Multiple tracts had no effect on SRFD, but old age, UC + , hemoglobin reduction and embolization were risk factors for SRFD. A nomogram with the aim of predicting the probability of SRFD based on these parameters demonstrated good uniformity in internal validation.

The feasibility of multiple-tract mini-percutaneous nephrolithotomy as an overnight surgery for the treatment of complex kidney stones.

To demonstrate the feasibility of applying multiple-tract percutaneous nephrolithotomy (PCNL) as an overnight surgery for treatment of complex kidney stones. We reviewed a prospectively collected database of all multiple-tract PCNL planned as overnight surgery performed by a single surgeon since 2018. A clinical pathway including the removal of nephrostomy tube and discharge on the morning after surgery was carried out. A definition for tube removal was outlined. Ability to adhere to the pathway and achieving the described parameters and whether any resulting complications occurred were determined. A total of 136 consecutive patients were enrolled with mean stone burden of 960.5mm2 and 5.1cm. Mean operative time was 71.7 ± 30.7min. The average hemoglobin drop was 17.6 ± 12.2g/L, and the incidence of drop > 25g/L was 21.9%. Overall, 125 patients (91.9%) but 11 patients were discharge on postoperative day 1. One case required readmission. Among the 11 patients, 7 patients (5.1%) underwent a delayed tube removal (≥ 2days) and 4 patients underwent complications after next-day nephrostomy tube removal, including renal colic (2 cases), hydrothorax (1 case), and fever (1 case). Postoperative fever or severe hematuria was the major reason for delayed nephrostomy tube removal. The total complication rate was 8.8% (n = 12). Multiple-tract PCNL as an overnight surgery can be safely performed by experienced surgeons in most patients. An early nephrostomy tube removal could be achieved in nearly 95% patients.

Multiple-tract percutaneous nephrolithotomy as a day surgery for the treatment of complex renal stones: an initial experience.

The purpose of this study was to evaluate the safety and efficiency of multiple-tract percutaneous nephrolithotomy (PCNL) as a day surgery for the treatment of complex renal stones. PATIENTS ANDMETHODS: A mature protocol for day surgery was implemented. Forty-six patients who underwent planned day-surgery PCNL via multiple tracts for the treatment of complex renal stones were retrospectively reviewed. All procedures were performed by an experienced surgeon. The outcomes were recorded. The mean stone size and burden were 4.8cm and 990.2 mm2, respectively. There were 26 (56.5%) and 20 (43.5%) patients with staghorn stones and multiple stones, respectively. Totals of two, three, and more than three tracts (with up to 7 tracts) were established in 22, 11, and 13 patients, respectively. The tract sizes ranged from 14 to 24 Fr. One to four nephrostomy tubes were placedin most patients, and a tubeless process was accomplished in only 3 (6.5%) patients. The mean surgery time was 116min with a hemoglobin drop of 22.1 ± 16.8g/L. Eight (17.4%) patients developed postoperative complications, with severe complications (Clavien grades III-IV) in two cases (4.4%). 39 (84.8%) patients were discharged within 24h after surgery, and 7 (15.2%) patients were fully admitted. Only 1 (2.2%) patient required readmission. The stone clearance rate was 84.8%. Day-surgery PCNL can be safely performed via multiple percutaneous tracts by experienced surgeons and is an efficient strategy for the treatment of complex renal stones.

Day-surgery percutaneous nephrolithotomy: a high-volume center retrospective experience.

Percutaneous nephrolithotomy (PCNL) is traditionally performed on an inpatient basis. We determine the safety and outcome of day-surgery PCNL by experienced surgeon hands. A protocol for day-surgery PCNL was undertaken. A retrospective analysis of all 86 cases of planned day-surgery PCNL accomplished by an experienced surgeon who followed this protocol between May 2017 and March 2019 was performed. Patient demographics, operative data, complications, and readmission rates were recorded. Day-surgery PCNL was defined as discharge of patients either the same day or within 24h after surgery. The average stone burden was 361.1mm2 and 70 (81.4%) of patients had multiple stones or staghorn stones. 82 (95.4%) patients achieved same-day discharge or received overnight observation prior to discharge, and 4 patients (4.6%) required full admission (longer than 24h). The readmission rate was 2.3% (2 patients). The postoperative complications occurred in 10 (11.6%) patients, including 7, 2, 2 of grade I, II, III complications. The average operation time was 64min and the hemoglobin drop was 15.7 ± 16.9g/L. The established tracts size ranged from 16 to 22Fr. The stone clearance rate was 90.7%. The tubeless without nephrostomy tube was performed in 60.5%. Eight cases were performed by multiple-tracts PCNL with 2-4 tracts, with only two case required full admission. Experienced surgeons who performed day-surgery PCNL experience excellent patient outcomes in appropriately selected patients. Most complications can be treated conservatively and only a few required intervention or readmission.

Is multiple tracts percutaneous nephrolithotomy (PCNL) safe modality in management of complex renal stones? A prospective study: Single center experience

ObjectivesTo evaluate and analyze the efficacy and the safety of multiple tracts PCNL in management of complex renal calculi. Patients and MethodsThe study was conducted during the period between March 2016 till January 2017 on 265 patients with complex renal stones, all patients underwent multiple tracts PCNL, either with double or triple punctures, preoperative and postoperative laboratory and radiological results were compared together in correlation to the stone size, shape and site. ResultsThe results of our study have shown that increased size and complexity of stones is associated with increased number of punctures needed to achieve stone clearance, and the aggressive approach to complex renal calculi using multiple tracts PCNL is a safe and effective modality in management of complex renal calculi with acceptable complications. ConclusionNumber of percutaneous tracts needed for stone clearance was increased with the increase in stone size and complexity. Surgeon experience, accurate choosing puncture site and carefully performed multiple tracts will decrease the intra-operative and postoperative complications or transfusion requirements.

Systemic inflammatory response syndrome after percutaneous nephrolithotomy: an assessment of risk factors

Objective To identify risk factors of systemic inflammatory response syndrome (SIRS) after percutaneous nephrolithotomy (PCNL). Methods We retrospectively reviewed 438 renal calculi patients after PCNL from August 2015 to July 2016. Among them, there were 251 men and 187 women, the mean age was (49.4±11.1)years. The positive preoperative urine WBC, culture and nitrite rates were 29.7%(130), 12.1%(53) and 15.1%(66), respectively.The stone size was (851.2±663.6)mm2, the stone CT value was (960.4±303.4) HU, the operative time was (63.5±33.4)min, 124 (28.3%) were infection stones and multiple-tracts PCNL was performed in 69(15.8%) patients. Univariate and multivariate logistic regression analysis were used to analyze perioperative predictors after PCNL. Results Thirty-nine patients developed SIRS (8.9%) after PCNL. The univariate analysis showed that positive preoperative urine WBC, nitrite, culture, operation time, stone size and transfusion had significantly impacts on the outcome of postoperative SIRS after PCNL (P<0.05). Multivariable logistic analysis showed that positive preoperative urine nitrite (OR=5.990, P<0.001), stone size (OR=2.251, P=0.027) and transfusion (OR=7.501, P=0.007) were independently related to the postoperative SIRS. Conclusion The positive preoperative urine nitrite, stone size and transfusion are independent risk factors for postoperative SIRS after PCNL. Key words: Percutaneous nephrolithotomy; Kidney stone; Systemic inflammatory response syndrome; Risk factors

The application of a novel integrated rigid and flexible Nephroscope in percutaneous nephrolithotomy for renal staghorn stones

BackgroundRenal staghorn stones are challenging for urologists to ensure maximum stone clearance and minimal morbidity. Percutaneous nephrolithotomy (PCNL) has become the gold standard treatment for renal staghorn stones. To assess the safety and efficacy of a novel integrated rigid and flexible percutaneous nephroscope(Rigi-flex nephroscope) in PCNL for renal staghorn stones.We present our initial experience with this new technique.MethodsFrom March to July 2016, a prospective analysis of 3 patients with staghorn stones treated with Rigi-flex nephroscope in PCNLunder totally ultrasound guidance by paravertebral block (PVB) anesthesia was done. PCNL was performed with the rigid section of a 13-Fr Rigi-flex nephroscope firstly and the stones were disintegrated into fragments by holmium laser.Then the stones were removed by active flushout, followed by a search for residual stones in other inaccessible calyces with the flexible section. Finally, the residual stones were disintegrated into small fractions by holmium laser in situ or repositioned with a set of disposable retrieval baskets to pelvic or other accessible areas. The whole procedure was accomplished via only one nephrostomy tract. The operating time, stone-free rates (SFR), postoperative hemoglobin drop, complications, length of hospitalization, were recorded.ResultsThe operation time were 89, 62 and 45 min, respectively, the postoperative hemoglobin drop was 1, 0.8 and 0.9 mg/dl, respectively.The postoperative Kidney-Ureter-Bladder (KUB) radiograph of the three patients showed no residual fragment >3 mm. No patients needed blood transfusion and suffered significant complications. The length of hospitalization was 9, 6 and 4 days, respectively. No patient needed multiple tracts PCNL or staged auxiliary measures one month after the operation.ConclusionsThe application of Rigi-flex nephroscope in PCNL under ultrasound guidance for staghorn stones has its unique advantages as monotherapy with increasing procedural stone free rate (SFR) via single nephrostomy tract, hence there is less morbidity as it does not require additional tracts dilation and staged auxiliary procedures combination. However, SFR should also be evaluated at a longer follow-up, particularly for staghorn stone, further large-scale multicenter prospective clinical trial are needed to verify its feasibility.

Single-Stage Multiple-Tract Percutaneous Nephrolithotomy in the Treatment of Staghorn Stones under Total Ultrasonography Guidance

Objective: To evaluate the safety and efficacy of single-stage multiple-tract percutaneous nephrolithotomy (PCNL) in the treatment of staghorn stones solely guided by ultrasonography (US). Patients and Methods: From May 2007 to July 2012, 55 single-stage multiple-tract PCNL procedures were performed (53 patients, of whom 2 had bilateral stones). Caliceal puncture and dilatation were performed under US guidance in all cases. The procedure was evaluated for access success, length of postoperative hospital stay, complications (modified Clavien system), and stone clearance. Results: The mean (±SD) operating time was 84.87 ± 24.9 min, with a mean (±SD) postoperative hospital stay of 5.2 ± 1.31 days. The patients experienced a mean (±SD) decrease in hemoglobin level of 8.23 ± 2.39 g/l and the stone-free rate after single-stage surgery was 78.18%. Extracorporeal shock wave lithotripsy was indicated in 2 cases as an auxiliary treatment. There were 10 grade 1 (62.5%) and 6 grade 2 (37.5%) complications; however, there were no complications above grade 3. Conclusion: Total US-guided single-stage multiple-tract PCNL for treating staghorn calculi in selected cases is safe, feasible, and may be performed with an acceptable morbidity and with the advantage of preventing radiation hazards and damage to adjacent organs.

Multiple tracts percutaneous nephrolithotomy assisted by LithoClast master in one session for staghorn calculi: report of 117 cases

The objective of the study is to evaluate the safety, efficacy and outcome of multiple tracts percutaneous nephrolithotomy (PCNL) assisted by LithoClast master (the third-generation Electro Medical System) in one session for the treatment of staghorn calculi. From October 2011 to March 2013, 117 patients with staghorn calculi underwent multiple tracts PCNL in our hospital. The combined pneumatic and ultrasonic powered lithotripter (EMS LithoClast master) was used to fragment and remove the calculi. The data were retrospectively analyzed with regard to stone burden, number of tracts, operation time, total operative blood loss, postoperative hospital stay, complications rate, and stone clearance rate. A total of 142 renal units in 117 patients (63 men and 54 women) were treated. Of the 142 renal units, 77 (54.2 %) had complete staghorn calculi, and 65 (45.8 %) had partial staghorn calculi. A total of 416 tracts were established in the 142 renal units. The mean number of tracts used in a single renal unit was 2.8 (range 2-4), most required three tracts. The mean (range) operating time is 72 (55-130) min. The mean (range) duration of postoperative hospital stay is 5.5 (3-9) days. Mean estimated operative blood loss is 150 (60-350) mL. The complications included blood transfusion in 9 (7.7 %) patients, high fever in 12 (10.3 %), sepsis in 5 (4.3 %), hydrothorax in 4 (3.4 %), and pseudoaneurysm in 3 (2.6 %). A complete stone clearance rate of 87.2 % (102/117) was achieved after one session of PCNL. This rate increased to 94.0 % after a secondlook procedure. In conclusion, multiple tracts PCNL assisted by EMS LithoClast master in one session is safe and effective in achieving a great stone clearance rate with acceptable morbidity for the treatment of staghorn calculi.

Combination of debulking single-tract percutaneous nephrolithotomy followed by retrograde intrarenal surgery for staghorn stones in solitary kidneys

Objective. The aim of this study was to report a therapeutic approach comprising a combination of debulking single-tract percutaneous nephrolithotomy (PCNL) and subsequent retrograde intrarenal surgery (RIRS) for treatment of staghorn stones in patients with solitary kidney. Materials and methods. A retrospective review was undertaken of 56 patients with staghorn stones in a solitary kidney who underwent the above-mentioned combination therapy. PCNL was first performed for stone debulking and RIRS was then used to remove residual stones after an interval of 2–4 days. Data were collected on operative parameters, stone-free rate (SFR), complications and renal functions. Results. The staghorn stones had a mean stone burden of 2548 ± 1028 mm2 (range 1438–3956 mm2). The SFR after 3 months was 89.3%. The overall blood transfusion rate was 7.1%. Complications were observed in nine patients (16.1%), including selective renal artery embolization, fever, gross haematuria and steinstrasse in one, two, three and three cases, respectively. At a mean follow-up of 31 months, available in 38 patients, kidney function was stable in 71%, improved in 26.3% and worsened in 2.7%, according to serum creatinine levels that remained within ±20%, or that increased or decreased outside this range. No patient required haemodialysis. Conclusions. Combining single-tract PCNL with subsequent RIRS was an effective strategic option for treating staghorn stones in solitary kidneys. The method gave an excellent SFR, satisfactory preservation of renal function, reduced bleeding risk and potentially less morbidity than that associated with multiple-tract PCNL.

1685 EFFECT OF MULTIPLE ACCESS TRACTS DURING PCNL ON RENAL FUNCTION: BASELINE CREATININE AND GLOMERULAR FILTRATION RATE ARE IMPORTANT PREDICTORS

INTRODUCTION AND OBJECTIVES: To assess the impact of multiple access tracts during percutaneous nephrolithotomy (PCNL) on renal function, and to determine risk factors predicting renal function deterioration and/or recovery in patients undergoing this procedure. METHODS: Patients undergoing PCNL with multiple punctures between July 2009 and February 2011 were prospectively enrolled. Preoperative evaluation included DMSA and DTPA renography. Patients were classified according to baseline renal function into patients with normal ( 1.4 mg/dL) serum creatinine (group A) and patients with elevated ( 1.4 mg/dL) serum creatinine (group B). Patients were followed postoperatively with serial serum creatinine measurements and a repeat renography at 12 months. Factors evaluated for possible impact on renal function included age, preoperative serum creatinine, preoperative GFR, hypertension, and diabetes. Paired t-test and General Linear Model (GLM) Repeated Measures procedure were used as appropriate. RESULTS: One hundred and two patients aged 21 to 62 years (mean 39.9) underwent PCNL with multiple (2-4) access tracts. Mean ( SD) preoperative serum creatinine for the whole cohort was 1.66 ( 0.71) mg/dL and Mean ( SD) GFR (of the involved renal unit) was 48.7 ( 12.9) mL/min. Fifty patients had normal preoperative serum creatinine (group A) and had no significant change in serum creatinine after PCNL (1.02 ( 0.19) preoperatively to 1.01 ( 0.13) post-operatively), while there was a small decline in GFR (57.9 ( 11.1) to 53.8 ( 11.4)). Fifty two patients had baseline renal impairment (group B), and they experienced a significant worsening of serum creatinine (2.30 ( 0.36) preop. to 2.65 ( 0.42) at 12 months) (p 0.001) and a more important decline in GFR (39.4 ( 6.0) preop. to 32.9 ( 6.3) at 12 months)(p 0.001). Patients with diabetes and/or hypertension had a larger rise in serum creatinine (1.90 ( 0.52) preoperatively to 2.24 ( 0.76) at 12 months) and a larger drop in GFR (45.4 ( 13.1) to 38.1 ( 14.1)), compared to patients without these comorbidities (creatinine from 1.52 ( 0.65) to 1.58 ( 0.81) and GFR from 50.4 ( 12.5) to 46.0 ( 13.3), p 002). CONCLUSIONS: PCNL with multiple access tracts carries a risk of affecting renal function. Patients with preoperative baseline renal impairment are particularly susceptible to renal function deterioration after the procedure, and so are patients with diabetes and hypertension. Alternatives to multiple tracts PCNL (flexible or combined retrograde/antegrade approaches) may be preferable in these patients.

Comparison of Outcomes After Percutaneous Nephrolithotomy of Staghorn Calculi in Those with Single and Multiple Accesses

To analyze the early outcome after single tract vs multiple tracts percutaneous nephrolithotomy (PCNL) in the management of staghorn calculi. The records of 413 patients with staghorn calculi (223 [54%] had complete and 190 [46%] had partial) who underwent PCNL were reviewed retrospectively. A total of 244 (59%) patients were managed by single access (group 1); meanwhile, multiple accesses were necessary in 169 (41%) patients (group 2). Both groups were compared in terms of perioperative findings and postoperative outcomes. Patients and stone-related factors affecting the number of accesses performed were analyzed. The mean number of percutaneous accesses was 2.42 +/- 0.74 (range 2-6) in group 2. Mean durations of fluoroscopy screening time and operative time were significantly longer in group 2 (P = 0.002, P < 0.0001, respectively). Supracostal access was necessary in 30.7% in group 2 and in 6.9% in group 1 (P = 0.001). Success was achieved in 70.1% in group 1 and in 81.1% for group 2 after one session of PCNL (P = 0.012). The most common complication was bleeding for both groups, and it was higher in group 2 (P < 0.0001). The mean preoperative and postoperative creatinine concentrations were 1.03 mg/dL and 1.08 mg/dL in group 1, and 0.9 mg/dL and 1.03 mg/dL in group 2, respectively. The mean changes in creatinine values were not statistically significant between the groups (P = 0.16). The impact of PCNL using either single or multiple access tracts on renal function is similar and of a temporary nature. PCNL with multiple accesses is a highly successful alternative with considerable complication rates in the management of staghorn calculi.

Renal Functional Effects of Multiple-Tract Percutaneous Access

Percutaneous nephrolithotomy (PCNL) can involve establishing more than one access into the urinary collecting system. The present study examined whether multiple percutaneous accesses results in a more severe reduction in renal function than that after single-percutaneous access. Adult female pigs were anesthetized, and percutaneous access to the left urinary collecting system was achieved by puncturing the lower pole calyx (single-tract access, n = 16) or serially puncturing the lower pole, interpolar region, and upper pole calyces [multiple (three)-tract access, n = 11]. Renal function measurements included glomerular filtration rate and effective renal plasma flow, and were taken immediately before and 1.5 and 4.5 hours after percutaneous access. We also examined glomerular function in a group of adult patients with normal preoperative serum creatinine (Cr) levels (<or=1.4 mg/dL) who underwent either unilateral single-tract PCNL (23 patients) or unilateral multiple (two)-tract PCNL (10 patients). Access tracts were dilated to 30F with a NephroMax balloon dilator system in animal and human patients. Single- and multiple-tract percutaneous access procedures in pigs resulted in a similar renal functional response; both glomerular filtration rate and effective renal plasma flow significantly declined by approximately 60% immediately after access and remained depressed throughout the experimental observation period. A retrospective analysis of patients with normal serum Crs (<or=1.4 mg/dL) who underwent single- or multiple-tract PCNL demonstrated that the procedures produced similar and significant increases in serum Cr on postoperative day 1 (0.33 +/- 0.09 [standard error of mean] mg/dL and 0.39 +/- 0.11 mg/dL, respectively) and day 2 (0.33 +/- 0.09 mg/dL and 0.25 +/- 0.09 mg/dL, respectively). Multiple-tract access does not lead to a more severe reduction in renal function than single-tract access; that is, the acute renal hemodynamic response to PCNL appears independent of the number of access tracts.

Management of the staghorn calculus: multiple-tract versus single-tract percutaneous nephrolithotomy

Complete removal of stones is crucial for preventing recurrence and morbidity. Currently percutaneous nephrolithotomy is the preferred treatment modality. The debate continues over the use of single tract versus multiple tract percutaneous nephrolithotomy. We review papers on the topic published over the past 12-24 months. Articles related to single and multiple tracts were reviewed. We discuss the morbidities, advantages and disadvantages of both the approaches. To decrease the number of tracts few authors have shown the efficacy of flexible ureteroscopy and nephroscopy as an adjuvant procedure. The authors state that this option effectively decreases the disadvantages of multiple tracts, namely blood loss complications, without compromising on stone free rates. Several techniques have been described for percutaneous access and stone removal, all of them associated with inherent problems. Although feasible, access to all the calices will be difficult through one percutaneous tract because of the peculiarities of the renal collecting system, in which case, multiple-access percutaneous nephrolithotomy is the mainstay of the treatment. The crucial point to understand is that all cases should be dealt with on an individual basis.