Percutaneous Nephrolithotomy For Staghorn Calculi 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.

Antegrade flexible ureteroscopy-assisted percutaneous nephrolithotomy for staghorn calculi: a prospective randomized controlled study

The aim is to compare the efficacy and safety between single percutaneous nephrolithotomy (sPNL) and antegrade flexible ureteroscopy-assisted percutaneous nephrolithotomy (aPNL) for the treatment of staghorn calculi. A prospective randomized controlled study was conducted at the Second Hospital of Tianjin Medical University. A total of 160 eligible patients were included, with 81 in the sPNL group and 79 in the aPNL group. The study first compared the overall differences between sPNL and aPNL. Then, the patients were divided into two subgroups: Group 1 (with less than 5 stone branches) and Group 2 (with 5 or more stone branches), and the differences between the two subgroups were further analyzed. The results showed that aPNL had a higher stone-free rate (SFR) and required fewer percutaneous tracts, with a shorter operation time compared to sPNL (P < 0.05). Moreover, aPNL significantly reduced the need for staged surgery, particularly in patients with 5 or more stone branches. Moreover, there were no significant differences in the changes of hemoglobin levels and the need for blood transfusions between the sPNL and aPNL groups, and the incidence of multiple tracts was lower in the aPNL group. The two groups showed comparable rates of perioperative complications. We concluded that aPNL resulted in a higher SFR for staghorn calculi, and required fewer multiple percutaneous tracts, reduced the need for staged surgery, and had a shorter operative time than PNL alone, especially for patients with 5 or more stone branches. Furthermore, aPNL did not increase the incidence of surgical complications.

P0975 - Application of Artificial Intelligence-based classifiers to predict the outcome measures and stone-free status following percutaneous nephrolithotomy for staghorn calculi: Cross-validation of data and estimation of accuracy

P0975 - Application of Artificial Intelligence-based classifiers to predict the outcome measures and stone-free status following percutaneous nephrolithotomy for staghorn calculi: Cross-validation of data and estimation of accuracy

Application of Artificial Intelligence-Based Classifiers to Predict the Outcome Measures and Stone-Free Status Following Percutaneous Nephrolithotomy for Staghorn Calculi: Cross-Validation of Data and Estimation of Accuracy

Objective: To develop a decision support system (DSS) for the prediction of the postoperative outcome of a kidney stone treatment procedure, particularly percutaneous nephrolithotomy (PCNL) to serve as a promising tool to provide counseling before an operation. Materials and Methods: The overall procedure includes data collection and prediction model development. Pre-/postoperative variables of 100 patients with staghorn calculus, who underwent PCNL, were collected. For feature vector, variables and categories including patient history variables, kidney stone parameters, and laboratory data were considered. The prediction model was developed using machine learning techniques, which include dimensionality reduction and supervised classification. Multiple classifier scheme was used for prediction. The derived DSS was evaluated by running the leave-one-patient-out cross-validation approach on the data set. Results: The system provided favorable accuracy (81%) in predicting the outcome of a treatment procedure. Performance in predicting the stone-free rate with the Minimum Redundancy Maximum Relevance feature (MRMR) treatment extracting top 3 features using Random Forest (RF) was 67%, with MRMR treatment extracting top 5 features using RF was 63%, and with MRMR treatment extracting top 10 features using Decision Tree was 62%. The statistical significance using standard error between the best area under the curves (AUCs) obtained from the Linear Discriminant Analysis (LDA) and MRMR. The results obtained from the LDA approach (0.81 AUC) was statistically significant (p = 0.027, z = 2.21) from the MRMR (0.64 AUC) (p = 0.05). Conclusion: The promising results of the developed DSS could be used in assisting urologists to provide counseling, predict a surgical outcome, and ultimately choose an appropriate surgical treatment for removing kidney stones.

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

The Role of Tranexamic Acid in Controlling Bloodloss During PCNL for Staghorn Calculi

The aim of this paper is to assess the efficiency and safety of the tranexamic acid in reducing blood loss and the need for transfusion in patients diagnosed with staghorn calculi treated by percutaneous nephrolithotomy. Percutaneous nephrolithotomy (PCNL) is a minimally invasive technique used for large kidney stones. Hemorrhagic complications and urinary sepsis are serious complications associated with this type of surgery. Tranexamic acid is an antifibrinolytic drug that has the property of reducing intra or postoperative bleeding. The experience with tranexamic acid in preventing blood loss during percutaneous nephrolithotomy for is limited. The use tranexamic acid in percutaneous nephrolithotomy for staghorn type stones is safe and is associated with reduced blood loss and a lower transfusion rate.

Perioperative and long-term results of retroperitoneal laparoscopic pyelolithotomy versus percutaneous nephrolithotomy for staghorn calculi: a single-center randomized controlled trial.

To compare the perioperative and long-term outcomes of retroperitoneal laparoscopic pyelolithotomy (RLP) and percutaneous nephrolithotomy (PCNL) for the treatment of staghorn calculi. From May 2011 to March 2017, eligible patients with staghorn calculi were randomly assigned to two groups: RLP and PCNL. Patients underwent the operations prospectively. Subsequently, a follow-up protocol was performed. Perioperative data related to the efficacy, safety and long-term outcomes (stone recurrence and functional changes in the affected kidney) were comparatively analyzed between the two groups. Overall, 105 patients underwent surgical treatment, including 51 in the RLP group and 54 in the PCNL group. There was no difference in demographics or stone characteristics between the two groups. The single-session stone-free rate (SFR) was higher (88.2% vs. 64.8%), the mean hemoglobin drop was lower (0.4 ± 0.3 vs. 1.7 ± 0.9g/dL), the rate of postoperative fever was lower (5.9% vs. 20.4%), but operative time was longer (135.7 ± 35.5 vs. 101.9 ± 41.2min) and the total cost was more expensive (5546 ± 772 vs. 3861 ± 402 USD)in the RLP group than in the PCNL group (all p < 0.05). The mean increase in the split function (8.3 ± 3.1 vs. 4.2 ± 2.4mL/min) and the rate of improvement of the affected kidney (56.3% vs. 35.3%) were significantly higher in the RLP group than in the PCNL group at 1year after surgery (both p < 0.05). However, the rate of stone recurrence was similar between the groups at a mean follow-up of 47.3 ± 18.6months. PCNL remains the first-line treatment for most cases of staghorn calculi. Nevertheless, in some selected cases with the extrarenal and dilated pelvis, RLP can be considered as an alternative management of staghorn calculi, which was associated with a high single-session SFR, low rates of complications, and better functional preservation of the affected kidney.

Abstract No. 570 Nephroureteral access prior to percutaneous nephrolithotomy for staghorn calculi: comparative study with non-staghorn calculi on feasibility, safety, and surgical outcomes

To compare the feasibility and safety of nephroureteral (NU) access, and surgical outcomes between patients with staghorn calculi (SC) and those with nonstaghorn calculi (non-SC) who were treated with percutaneous nephrolithotomy (PCNL). Between April 2012 and December 2016, 152 kidneys in 139 patients (71 male 68 female, median age: 55 years) were percutaneously accessed for PCNL. Of these, 48 kidneys (32.6%) had SC (SC group) and 104 kidneys (68.4%) had non-SC (Non-SC group). A stone-bearing calyx was generally accessed at the referring urologist’s request. More than one access was obtained and used for PCNL in 9 kidneys (5.9%). The lower pole calyx was most frequently accessed (n = 116, 76.3%). Technical success rates of NU access (overall and through a stone-bearing calyx), fluoroscopy time (minutes), and incidence of complications related to NU access resulting in cancellation of scheduled PCNL were compared between groups. Stone clearance (no residual stones > 5 mm on post-PCNL imaging) and incidence of complications related to PCNL were also compared. The overall technical success rate of NU access and access through a stone-bearing calyx were not statistically different between groups (SC vs Non-SC: 93.8% vs 97.1% (P = .28), 87.5% vs 89.8% (P = .68), respectively). The mean fluoroscopy time (16.6 vs 14.6 minutes, p = .98) and incidence of NU access-related complications (10.4% vs 6.7%, p = .31) did not significantly differ between groups. Complications of NU access included urosepsis (5/48 vs 4/104, P = .11), bleeding (1/48 vs 2/104, P = .68) and others (n = 2 in Non-SC group). Stone clearance was significantly less achieved in SC group than Non-SC group (Stone clearance rate: 43.5% vs 67.3%, P = .01). Incidence of PCNL-related complications was not significantly different between groups (33.3% vs 23.8%, P = .22). NU access in patients with SC was as feasible as that with Non-SC without significant difference in incidence of complications or fluoroscopy time. Technical modifications of NU access (multiple accesses, upper pole access, etc.) may be necessary to increase stone clearance rate in patients with SC.

Prognostic Impact of Stone-Scoring Systems After Percutaneous Nephrolithotomy for Staghorn Calculi: A Single Center's Experience Over 10 Years.

To investigate the prognostic factors associated with stone-free rate (SFR) and complications after percutaneous nephrolithotomy (PCNL) for the treatment of staghorn stone and to compare the predictive value and accuracy of three stone-scoring systems for the treatment success of staghorn stone. We retrospectively reviewed all patients undergoing PCNL at our center from June 2003 to June 2014. On the basis of noncontrast computed tomography (NCCT) scan images, we calculated Guy's score, S.T.O.N.E. nephrolithometry, and Clinical Research Office of the Endourological Society (CROES) nomogram to assess the association with stone-free status and complications. For statistical evaluation, univariate and multivariate logistic regression analyses were used. During the study period, 886 cases had medical records available. Cases who underwent PCNL for the treatment of staghorn calculi accounted for 34.4% (305/886 cases). Preoperative NCCT was performed in 217 cases. The 217 procedures (205 patients, 12 simultaneous bilateral PCNLs) had a mean stone size of 1358.3 ± 760.7 mm(2), with 111 (51.2%) partial staghorn and 106 (48.8%) complete staghorn stones. The initial and overall SFRs of PCNL were 53.9% and 70.1%, respectively. The overall complication rate was 32.7% (71/217 cases). On a multivariate logistic regression analysis, independent predictors for SFR were number of involved calices, S.T.O.N.E. nephrolithometry, and pre-existent urinary tract infection (UTI) (odds ratios [ORs] = 1.311, 1.933, and 2.340, respectively). Stone burden was an independent risk factor for the development of complications on multivariate analysis (OR = 2.846 and p = 0.001). The results of this study show that multiple involved calices, high grades of S.T.O.N.E. nephrolithometry, and pre-existent UTIs were associated with lower SFR after PCNL for staghorn calculi. Stone burden was an independent risk factor for the development of complications.

Safety and Efficacy of Percutaneous Nephrolithotomy for Staghorn Calculi in Patients 70 Years and Older

Safety and Efficacy of Percutaneous Nephrolithotomy for Staghorn Calculi in Patients 70 Years and Older

Factors Affecting Kidney Function and Stone Recurrence Rate After Percutaneous Nephrolithotomy for Staghorn Calculi: Outcomes of a Long-Term Followup

There are few studies of the long-term outcome of percutaneous nephrolithotomy for staghorn calculi. We report the long-term outcome of percutaneous nephrolithotomy in patients with staghorn calculi. A total of 265 study patients (272 renal units) were followed in the long term for greater than 12 months. The estimated glomerular filtration rate was calculated using the 4-variable modification of diet in renal disease equation. Cases were staged for chronic kidney disease by National Kidney Foundation guidelines. The impact of patient and procedure related factors on renal function as well as stone recurrence was analyzed retrospectively. At a mean ± SD followup of 37.3 ± 25.4 months the chronic kidney disease stage classification was maintained in 177 patients (66.8%) while the classification of 34 (12.8%) and 54 (20.4%) had improved and deteriorated, respectively. Multivariate analysis revealed that an immediate postoperative change in the estimated glomerular filtration rate was the only factor predicting a change in renal function in the long term. Stones recurred in 73 of the 234 kidneys (31.2%) that were stone free 3 months after percutaneous nephrolithotomy. Stone size increased in 24 of the 38 kidneys (63.2%) with residual stones after intervention. Recurrent urinary infections during followup and diabetes were associated with stone recurrence and residual stone enlargement. In almost 80% of patients with staghorn stones renal function was improved or maintained after percutaneous nephrolithotomy, as documented during long-term followup. Stones recurred in a third of the patients with staghorn calculi.

Percutaneous Nephrolithotomy for Staghorn Calculi: A Single Center's Experience over 15 Years

Percutaneous nephrolithotomy (PCNL) for staghorn calculi is one of the more challenging endourologic procedures. Although excellent stone-free rates are universally reported in the literature, complication rates vary widely, especially related to the need for blood transfusion. The purpose of this study was to evaluate the outcomes of PCNL for patients with staghorn calculi in a large series of patients at a single, tertiary referral, endourologic stone center. Between July 1990 and December 2005, 1338 patients underwent PCNL for renal stone disease at our institution. Among this group, 509 procedures were performed for patients with a partial or complete staghorn calculus. Data analysis included procedure time, length of hospital stay, number of access tracts, transfusion rates, other early and late complications, and stone-free status. Mean patient age was 53.8 years (range 4-84 yrs). The average procedure time was 104 minutes. Sixteen percent of the cases needed multiple access tracts (range 2-5), with the lower calix being the most commonly used in 64.1%, followed by the upper calix in 18.5% and the middle calix in 17.4%. Various intracorporeal lithotriptors were used, including ultrasound, pneumatic, electrohydraulic, and holmium:yttrium-aluminium-garnet laser. The transfusion rate among this group was 0.8%. There was no statistically significant difference in transfusion rates (0.7%-1.2% P = 0.24) or other major complications in patients who were treated with either a single tract or among those needing multiple tracts. Stone-free rates at hospital discharge and at 3 months follow-up were 78% and 91%, respectively. PCNL is a safe and effective procedure in the management of staghorn calculi, with outcomes similar to those reported for percutaneous management of smaller volume nonstaghorn stones. Attention to accurate tract selection and placement as well as possession of the full array of endourologic equipment are essential to achieving an excellent outcome.

Developments in technique and technology: the effect on the results of percutaneous nephrolithotomy for staghorn calculi

To review the development of the technique of percutaneous nephrolithotomy (PCNL), for ease of learning and development of instrumentation for staghorn calculi at our centre since 1991, and to assess the results and outcomes. We retrospectively analysed the hospital records of 773 patients (632 males and 141 females, 834 renal units) who underwent PCNL for staghorn calculi at our centre from January 1991 to August 2008. We divided the patients into three groups depending on the changes in treatment policy, global trends and advances in equipment as follows: the first 200 cases (group I) from January 1991 to December 1996 (216 renal units); the next 200 (group II) from January 1997 to December 2001 (212 renal units); and the last 373 (group III) from January 2002 to August 2008 (406 renal units). The mean (sd, range) operative duration in groups I, II and III, respectively, were 138.2 (52.7, 60-310), 121.4 (42.8, 70-250) and 112.5 (51.5, 55-310) min; the decrease in haemoglobin level was 3.2, 2.6 and 1.6 g/dL, respectively, and continued to decrease with improvements in technique. With increasing experience, the number of stages required for stone clearance and the number of tracts required decreased exponentially. Most of the severe complications occurred early in our experience. The stone clearance rate in groups I, II and III was 81%, 86% and 93%, respectively, after completing the procedure; the overall clearance rate with observation/auxiliary procedures was 86%, 89% and 96%, respectively. The mean hospital stay for groups I, II and III was 11.1 (3.9, 7-25), 9.5 (3.4, 5-22) and 7.1 (3.6, 4-28) days, respectively. The percutaneous management of staghorn calculi requires considerable expertise. Our data suggest that 'multiperc' PCNL is difficult to learn and requires experience. Although over the years our results improved, complete clearance remains a challenge. A constant review and application of newer techniques and results will improve the overall clearance rates further.

Carcinoma de células escamosas en pelvis renal bífida, tras nefrolitotomía percutánea

To describe the clinical case of a patient presenting a squamous cell carcinoma in a duplicated renal pelvis, after percutaneous nephrolithotomy. 60-year-old male patient who was diagnosed of a squamous cell carcinoma of the renal pelvis in the pathological study of a lower pole nephrectomy after percutaneous nephrolithotomy for staghorn calculi in the left lower pole renal moiety. The patient suffered a bladder recurrence one year and a half later. A radical cystoprostatectomy was performed, but the patient died in a few months due to metastasis. Squamous cell carcinoma of the renal pelvis is a rare tumor with poor prognosis, associated with stone disease and chronic infection. Taking biopsies from suspicious lesions during percutaneous nephrolithotomy may help early diagnosis and improve survival.

Post-Percutaneous Nephrolithotomy Extensive Hemorrhage: A Study of Risk Factors

We identified risk factors predicting severe bleeding due to percutaneous nephrolithotomy. Computerized data on 2,909 patients who underwent a total of 3,878 percutaneous nephrolithotomy procedures between January 1995 and December 2005 were retrospectively reviewed. Data on patients who experienced severe bleeding requiring angiographic renal embolization were compared with those on other patients using univariate and multivariate analyses. We tested the characteristics of patients, kidneys and stones together with details of the operative procedure and surgeon experience. Severe bleeding complicated a total of 39 procedures (1%) in 25 males and 14 females with a mean age of 50.7 +/- 12.6 years. Associated morbidity included shock in 6 patients and perirenal hematoma in 4. Renal angiography revealed pseudoaneurysm in 20 patients, arteriovenous fistula in 9, the 2 lesions in 8 and arterial laceration in 2. Bleeding could be controlled with superselective embolization in 36 patients (92.3%). Followup was available on 33 patients (mean 21 +/- 15 months). Renal function was stable in all patients except 3 who had a post-embolization increase in serum creatinine, of whom all had a solitary kidney and none required renal replacement therapy. Significant risk factors for severe bleeding were upper caliceal puncture, solitary kidney, staghorn stone, multiple punctures and inexperienced surgeon. Percutaneous nephrolithotomy should be performed by an experienced endourologist in patients at risk for severe bleeding, such as those with a solitary kidney or staghorn stones.

Nephrolithiasis: "Scope," Shock or Scalpel?

To evaluate treatment preferences for complex urinary calculi. A questionnaire was sent to 174 members of the Minnesota Urological Society. Three case scenarios were presented: a 1.5-cm lower-pole calculus with unfavorable anatomy, a 1.4-cm proximalureteral calculus, and a staghorn calculus. The treatment options offered were extracorporeal shockwave lithotripsy (SWL), ureteral stenting, ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and open surgery. Our survey response rate was 49%. A PCNL for staghorn calculi was more likely to be offered by urologists in metropolitan (100%; P<0.001) and urban (100%; P=0.003) settings than rural settings (57%). Whereas only 22% of urban and metropolitan urologists would offer anatrophic nephrolithotomy, 43% of rural urologists would include this among their treatment options. A PCNL was more likely to be offered by urologists trained after 1980 (100%) than by urologists trained before 1980 (81%; P=0.004). For a large lower-pole calculus with unfavorable anatomy, urologists with >50% managed-care practices were more likely (91%) than urologists with <50% managed-care practices (65%) to select PCNL for such stones (P=0.034). Whereas 82% of metropolitan urologists would select PCNL, 43% of rural urologists would consider SWL as initial therapy. A URS was more likely to be offered by urologists trained after 1980 (16%) than by urologists trained before 1980 (0; P=0.044). For a large proximal-ureteral calculus, metropolitan urologists were most likely (64%) to use stents initially (urban 28%; P=0.014; rural 14%; P=0.017). Rural urologists were more likely to offer SWL (100%) than were metro urologists (55%; P=0.024). Initial therapy for nephrolithiasis differs significantly according to geographic location, year of residency completion, and the percentage of managed-care patients in a urologist's practice. Future emphasis should be placed on increasing the availability of endoscopic techniques in rural settings.

Single upper-pole percutaneous access for treatment of > or = 5-cm complex branched staghorn calculi: is shockwave lithotripsy necessary?

Percutaneous nephrolithotomy for staghorn calculi is reported to have a residual stone rate of 28%, while shockwave lithotripsy alone results in residual stones in approximately 50% of cases. Combination therapy, sandwich therapy, and multiple percutaneous accesses have also been advocated for staghorn stones. We believe these stones can often be removed with a staged procedure via a single upper-pole percutaneous access using flexible nephroscopy and the holmium:YAG laser. Our experience is reviewed. The hospital records of patients having a cumulative stone burden > or =5 cm who underwent percutaneous nephrolithotripsy (PCNL) for a single complex staghorn calculus were reviewed. There were 15 male and 34 female patients having 45 complete and 7 partial staghorn calculi constituting a mean stone burden of 6.7 cm (range 5.0-10.0 cm). A calix was punctured that would provide access to the majority of the involved calices. Thirty-five renal units were approached through a single upper-pole percutaneous access, and four and six renal units were accessed through single middle or lower-pole calices, respectively. The remaining seven renal units were treated with multiple percutaneous accesses. In the renal units having only a single access, a mean of 1.6 (range 1-3) procedures were required to achieve stone-free status. The mean operating room time was 2.9 hours (range 2.0-3.5 hours). For the second PCNL, the mean operating room time was 63 minutes (range 30-90 minutes). Two patients (two renal units) had residual stones <1 cm in diameter. One refused additional surgery, and the other is awaiting further treatment. The mean estimated blood loss was 238 mL (range 50-800 mL), with only one procedure (2.2%) necessitating a blood transfusion. One (2.8%) hydrothorax developed among the 35 upper-pole puncture cases. Six patients had transient oral temperature readings >101 degrees F with negative blood cultures. Other early complications included single cases of leg cellulitis, atrial fibrillation, and noncardiac chest pain. There were no delayed surgical complications. Patients were discharged from the hospital a mean 2 days (range 1-10 days) after the first PCNL. Use of flexible nephroscopy with holmium:YAG laser lithotripsy and Nitinol basket stone extraction has allowed us to render staghorn-containing renal units stone free in a mean of 1.6 procedures. Of the 45 renal units treated through a single percutaneous access, 43 (95%) were rendered stone free. The holmium:YAG laser appears to be a safe lithotrite for the kidney, as no complications occurred from its use.

Endoscopic pulsed-dye laser lithotripsy: 159 consecutive cases.

The application of the coumarin-based pulsed-dye laser has allowed the endoscopist to employ more delicate instruments with smaller working channels in treating urinary and biliary calculi. We have previously reported our first 100 patients treated with this laser. In 159 consecutive patients, 176 renal, ureteral, bladder, urethral, and biliary calculi with an average size of 1.6 cm were treated with the pulsed-dye laser in antegrade or retrograde fashion using rigid (6.9F-11.5F) or flexible (8.5-10.5F) endoscopes. The laser fibers ranged from 200 to 550 microns and the energy from 60 to 200 mJ. In some cases, the laser was used as an adjunct to percutaneous nephrolithotomy for staghorn calculi, to fragment bladder calculi without anesthesia, to free encrusted ureteral catheters, or as a lithotrite in the biliary tree. Only 4 stones (2.5%) could not be fragmented. There were no complications directly attributable to the use of laser energy. The pulsed-dye laser is safe and efficacious as an endoscopic lithotrite.