Percutaneous Nephrolithotomy Group Research Articles

Prospective comparative study of Miniperc and standard PNL for treatment of 1 to 2 cm size renal stone

Study Type – Therapy (case series)Level of Evidence 4What’s known on the subject? and What does the study add?Standard PNL is known to have higher clearance rates for stones 1–2 cm. However, it is not promoted because of its associated morbidity, especially bleeding. Minitiarization of the PNL has spawned a new interest in this modality for treating small bulk urolithiasis.The study adds to a growing body of evidence in a prospective manner that smaller tract PNL “miniperc” is associated with a similiar efficacy of achieving stone‐clearance rates while decreasing the invasiveness of the procedure and associated morbidity.OBJECTIVE• To evaluate the results of miniperc vis‐à‐vis standard PNL in the treatment of stones of 1–2 cm in size. Miniperc may represent a reasonable procedure in patients with nonbulky urolithiasis offering a similar outcome as standard percutaneous nephrolithotomy (PNL) with advantage of reduced morbidity.PATIENTS AND METHODS• 55 procedures including 27 miniperc and 28 standard PNL were performed for renal stones 1–2 cm in size. Pediatric patient, active urinary tract infection, renal malformation, uncorrected coagulopathy and morbid obesity patients were excluded from the study.• The parameters studied were demography, operative time, postoperative analgesic requirement, hemoglobin drop, complications and stone clearance.RESULTS• Mean tract size was 18.2 ± 2 F (15–20) and 26.8 ± 2 F (24–30), P value <0.0001 in the miniperc and standard PNL, respectively. Holmium LASER and pneumatic lithotripter were the main energy sources used in miniperc and standard PNL, respectively.• Miniperc operative time was longer than that of standard PNL (45.2 ± 12.6 vs 31 ± 16.6 min, P= 0.0008 respectively).• Conversely, there was an advantage of miniperc over standard PNL in terms of a significantly reduced hemoglobin drop (0.8 ± 0.9 vs 1.3 ± 0.4 gram%, P= 0.01), analgesic requirement (55.4 ± 50 vs 70.2 ± 52 mg tramadol, P= 0.29) and hospital stay (3.2 ± 0.8 vs 4.8 ± 0.6 days, P≤ 0.001), respectively.• Intra‐ operative conversion of the procedure into a tubeless PNL was significantly more in the miniperc group (P≤ 0.001). The miniperc and standard PNL group had clearance rates of 96% and 100%, respectively at 1 month follow up.CONCLUSIONS• This study demonstrated significant advantages of the miniperc procedure in terms of reduced bleeding leading to a tubeless procedure and reduced hospital stay.• The stone free rates and the complications were similar in either group.

A Comparison of Treatment Modalities for Renal Calculi Between 100 and 300 mm2: Are Shockwave Lithotripsy, Ureteroscopy, and Percutaneous Nephrolithotomy Equivalent?

Shockwave lithotripsy (SWL) is considered a standard treatment for patients with upper-tract stones that are less than 10 mm in diameter, whereas stones that are larger than 20 mm are best managed by percutaneous nephrolithotomy (PCNL). The management of stones between these sizes remains controversial. Our purpose was to review our contemporary series of SWL, ureteroscopy (URS), and PCNL outcomes for intermediate-sized upper tract calculi (100-300 mm(2)). Analysis was restricted to those patients who were treated for a renal calculus that measured between 100 and 300 mm(2) during a 4-year span. Demographic, stone, patient, treatment, and follow-up data were collected from a prospectively maintained database. A total of 137 patients were referred with nonstaghorn calculi with an area between 100 and 300 mm(2). Fifty-three (38.7%) patients were treated with SWL, while 41 (29.9%) and 43 (31.4%) underwent ureteroscopy and PCNL, respectively. Mean stone area was higher in the PCNL group (P < 0.001), whereas stone density was higher for patients undergoing SWL (P = 0.002). Single treatment success rates were better for PCNL at 95.3%,vs 87.8% for ureteroscopy and 60.4% for SWL, P < 0.001. When allowing for two SWL treatments, the success rate improved to 79.2%, thus equalizing the success of the three treatment modalities (P = 0.66). Auxiliary treatments were more common after SWL (42.3%; P < 0.01). For intermediate-sized upper-tract stones, when allowing for up to two SWL treatments, there was no significant difference between treatment modalities. Thus, SWL is a reasonably successful treatment alternative for patients who are not fit for a general anesthetic or who prefer SWL over competing treatments, provided they accept a potentially higher number of treatments.

Doppler Ultrasound-guided Percutaneous Nephrolithotomy: A Prospective Randomized Study

To evaluate the role, safety, and effectiveness of Doppler ultrasound-guided percutaneous nephrolithotomy (PCNL). The present study was a prospectively randomized controlled trial performed from March 2007 to February 2010. A total of 131 patients, scheduled for PCNL to remove huge renal stones (diameter>35 mm) and staghorn stones, were enrolled and prospectively randomized using a random numbers table into 2 groups. Of the 131 patients, 54 were randomized to ultrasound-guided puncture PCNL (group 1). Group 2 included 57 patients who received Doppler ultrasound-guided PCNL. A total of 30 patients were excluded from the study. The preoperative data included urinalysis, urine culture, complete blood count, biochemistry study, renal ultrasonography, intravenous urography, and technetium-99m diethylenetriaminepentaacetic acid to determine the selective glomerular filtration rate. The intraoperative findings, operative time (from insertion of the puncture needle to the end of the procedure), and outcomes were also recorded. The complete blood count and serum creatinine were also checked. The modified Clavien grading system was used to evaluate the perioperative morbidity of PCNL. No difference was found between the 2 groups with regard to the serum creatinine change, length of stay, return to normal activity, Clavien grade, relative perfusion rate, or glomerular filtration rate, as determined by technetium-99m diethylenetriaminepentaacetic acid clearance, preoperatively and postoperatively. However, the hemoglobin decrease (2.33±0.46 g/dL) in the ultrasound-guided puncture group was greater than that in the Doppler ultrasound-guided group, with statistically significant difference. Doppler ultrasound-guided PCNL is accurate and safe and was associated with less blood loss. We believe that Doppler ultrasound can be an important alternative to B-mode ultrasound guidance.

Systematic Review and Meta-Analysis of Nephrostomy Placement Versus Tubeless Percutaneous Nephrolithotomy.

Abstract Purpose: We performed a systemic review with meta-analysis to compare tubeless vs conventional percutaneous nephrolithotomy (PCNL) and assess the effectiveness and safety of this innovative procedure. Materials and Methods: A systematic review of PUBMED, EMBASE, LILACS, and Cochrane Library was performed to identify all randomized controlled trials (RCTs) that compared tubeless PCNL vs conventional PCNL. The analyzed outcomes were stone-free rate, pain assessment, analgesic medication requirements, operative time, hospitalization time, blood loss, and complications. Results: A total of 10 RCTs were identified that reported 621 patients. Seven studies analyzed stone-free rates. Meta-analysis of the data resulted in no difference between tubeless and conventional PCNL. Operative time, blood transfusion, hemoglobin drop and postoperative fever did not differ between the groups. Meta-analysis of length of hospitalization and prolonged urinary drainage was analyzed and favored the tubeless PCNL group. Conclusions: Tubeless PCNL is a safe and effective procedure with a stone clearance rate comparable to that of conventional PCNL. Tubeless PCNL presented a shorter hospital stay and less postoperative urinary leakage. Pain reduction and minimization of analgesic requirements also were demonstrated.

Minimally invasive percutaneous nephrolithotomy with multiple mini tracts in a single session in treating staghorn calculi

There has been continuing controversy regarding multiple tracts in a percutaneous nephrolithotomy (PCNL) session that may bring more complications, especially severe bleeding need for transfusion, even nephrectomy. Little tracts may bring less trauma to renal parenchyma than standard PCNL tracts. We carried minimally invasive PCNL (MPCNL) in treating staghorn calculi with multiple 16Fr percutaneous tracts in a single session, in an attempt to get high stone free with little trauma, and compared the morbidity of standard PCNL procedures in a prospective trial. A total of 54 consecutive patients with staghorn calculi were prospectively randomized for MPCNL (29) and PCNL (25). The size and location of stone, operative parameters, number of tracts, stone-free rate, operating time, hospital stay and complications were analyzed. In MPCNL group, a total of 67 percutaneous tracts were established in 29 renal units, while 28 tracts in 25 renal units in PCNL group. Compared to PCNL, MPCNL was associated with higher clearance rate (89.7 vs. 68%, p = 0.049), less chance need for adjunctive procedure of SWL or second-look PCNL (24.1 vs. 60%, p = 0.007), while a similar complication rate (37.9 vs. 52%, p = 0.300). In conclusion, with the development of instruments and increased experience, judiciously made multiple percutaneous tracts in a single session of MPCNL for treating staghorn calculi were safe, feasible and efficient with an acceptable morbidity.

Totally Tubeless Percutaneous Nephrolithotomy: Is It Safe and Effective in Preschool Children?

After the introduction of tubeless percutaneous nephrolithotomy (PNL), many studies conducted in adult patients have confirmed its efficacy and safety. There are limited studies reporting that tubeless PNL can be safely applied in children, however. Furthermore, there are no reports that evaluate the use of totally tubeless PNL in children. The present study evaluates the results of totally tubeless PNL in preschool children. The data of children seen in our clinic who were considered suitable for totally tubeless PNL were analyzed. Of 16 children, 8 patients underwent totally tubeless PNL (group 1) and 8 standard PNL (group 2). The two groups of patients were compared with regard to length of hospitalization, analgesic requirements, transfusion rates, hemoglobin (Hb) decrease, and immediate, early, and late complications. The mean ages of the patients were 56.6 months (9-84 mos) and 56.0 months (5-84 mos), and the mean follow-up was 21.5 months (3-44 mos) and 43.4 months (36-54 mos) in groups 1 and 2, respectively. Both groups were similar with regard to age, stone size, Hb change, and complications. Although operation duration, hospitalization period, and analgesic requirement were less in the totally tubeless PNL group, these differences were not statistically significant. The latest application of PNL, totally tubeless PNL, is also a safe and effective procedure in very small children if they are selected properly and if the surgeon has sufficient experience with the procedure. More studies with a higher number of participants are needed, however, to confirm that totally tubeless PNL increases the comfort of pediatric patients, decreases their hospitalization period, and is more economical.

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With the intent of reducing postoperative discomfort and pain, hospital stay, and cost, totally tubeless PCNL procedure has gained popularity in recent years. We tested the hypothesis that totally tubeless PCNL is superior to standard PCNL in terms of postoperative decrease in hospital stay and analgesic requirement in elderly patients. By contrast, appropriate patients should be selected for totally tubeless PCNL. Therefore, we used criteria such as minimal bleeding, no residual stone, and intact collecting system when choosing the patients in the OR at the end of the operation. We believe that the major advantage for patients undergoing totally tubeless PCNL was the absence of stent-related flank pain and short hospital stay. The publications on PCNL in the elderly population are limited. In a recent study of patients aged >70 years, it has been shown that PCNL was a safe and effective procedure that achieved a stone-free rate of 70.8% for all types of stones. 1 Dore B. Conort P. Irani J. et al. Percutaneous nephrolithotomy (PCNL) in subjects over the age of 70: a multicentre retrospective study of 210 cases. Prog Urol. 2004; 14: 1140-1145 PubMed Google Scholar In another study of PCNL, no significant complication was observed in a group of patients aged 60 years and the stone-free rates were similar, being 89% for the elderly group and 92% for the younger patients. 2 Sahin A. Atsu N. Erdem E. et al. Percutaneous nephrolithotomy in patients aged 60 years or older. J Endourol. 2001; 15: 489-491 Crossref PubMed Scopus (61) Google Scholar As mentioned in our report, 86% of patients in the totally tubeless group and 83% of patients in the standard PCNL group were stone-free. When patients with clinically insignificant residual fragments (CIRF) <4 mm are considered, the success rate becomes 96% for group 1 and 90% for group 2. Three patients in group 1 and 2 patients in group 2 had CIRF in our study and we did not observe any complication at follow-up period. We agree with the editorial comment that the possible limitation of the tubeless PCNL is that it precludes secondary procedures to treatment residual stones. However, when a secondary percutaneous procedure for removal of residual stones is planned, the preexisting tract may not provide good access to reach the stone. In most cases, generating a new access tract may be necessary. Alternatively, residual calculi can be safely managed by SWL or retrograde intrarenal surgery in this group of patients. Editorial CommentUrologyVol. 76Issue 2PreviewThe authors are commended for their initiative, solid methodology, and review of the published data. Despite the increasingly aging population, there has been a paucity of geriatric literature concerning percutaneous nephrolithotomy (PCNL), specifically prospective randomized trials. A retrospective study in Taiwan compared tubeless PCNL in 50 geriatric (> 70 years) patients, with tubeless PCNL in 351 younger patients operated concurrently at the same institute.1 The authors showed that tubeless PCNL in 50 geriatric patients was safe regarding complications, although there was a statistically significant lower stone-free rate (68% vs 84%) and nonsignificant longer mean hospital stay (4.6 vs 3.9 days). Full-Text PDF

Does Previous Open Nephrolithotomy Affect the Efficacy and Safety of Tubeless Percutaneous Nephrolithotomy?

Introduction: Tubeless percutaneous nephrolithotomy (PCNL) in selected patients is effective and results in less postoperative discomfort without increasing complications. The challenges of PCNL in patients who had a history of open nephrolithotomy are decreased kidney mobility due to scarring around the kidney and distortion of the renal collecting system, conditions that may cause difficulty of tract access and increase retained stone and hemorrhagic complications. We compared the efficacy and safety of the tubeless versus the standard PCNL in patients who had undergone previous open nephrolithotomy. Patients and Methods: Percutaneous nephrolithotomy (PCNL) was performed in 104 patients who had a history of previous open nephrolithotomy, of which 45 received tubeless PCNL (group I) and 59 received standard PCNL with routine postoperative nephrostomy tubes (group II). All patients had only one percutaneous renal access and showed no significant bleeding, extravasation or residual stone. Of group I, PCNL was done by the standard technique with only placement of a postoperative external ureteral catheter for 48 h. The success rate, operative time, hospital stay and complications were compared between the two groups. Results: Patient’s demographic data were not different between both groups. Infundibular stenosis and ureteropelvic junction obstruction were found in 2 and 4 cases of groups I and II, respectively. The success rates, operative time and complication rates were not significantly different between both groups. Hospital stay was 3.53 and 5.39 days for groups I and II, respectively, which was significantly different. Average analgesic (meperidine) usage was significantly less in the tubeless group (39 ± 35 mg for group I and 75 ± 32 mg for group II). Conclusion: Tubeless PCNL in selected patients with previous open nephrolithotomy has a safe and effective advantage compared to standard PCNL as indicated by a decrease in length of hospital stay and analgesic usage.

1274 A PROSPECTIVE RANDOMIZED TRIAL COMPARING SAFETY AND EFFICACY OF RETROGRADE INTRARENAL SURGERY (RIRS) VS. TUBELESS PERCUTANEOUS NEPHROLITHOTOMY (PCNL) IN MANAGEMENT OF MEDIUM SIZED RENAL CALCULI (11-20 MM DIMENSION)

You have accessJournal of UrologyTechnology & Instruments: Ureteroscopy1 Apr 20101274 A PROSPECTIVE RANDOMIZED TRIAL COMPARING SAFETY AND EFFICACY OF RETROGRADE INTRARENAL SURGERY (RIRS) VS. TUBELESS PERCUTANEOUS NEPHROLITHOTOMY (PCNL) IN MANAGEMENT OF MEDIUM SIZED RENAL CALCULI (11-20 MM DIMENSION) Hemendra Shah, Manju Jain, Rajesh Verma, and Manish Bansal Hemendra ShahHemendra Shah More articles by this author , Manju JainManju Jain More articles by this author , Rajesh VermaRajesh Verma More articles by this author , and Manish BansalManish Bansal More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.845AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES With the recent advances and miniaturization of endoscopes and development of holmium laser lithotripsy, retrograde intrarenal surgery (RIRS) is gaining increasing role in the treatment of renal calculi. The aim of this study was to evaluate role of RIRS vs. tubeless PCNL in management of medium sized renal calculi (11-20 mm dimension). METHODS From May 2008 onwards, all adult patient's with renal calculi 11-20 mm in largest dimension, who chose endoscopic stone management were randomized to undergo either RIRS or tubeless PCNL at our institution. Patients opting for SWL and those not consenting for trial were excluded from study. It was our hypothesis that PCNL will be associated with better stone free rates than RIRS. A power calculation using á = 0.05 and â = 0.02 indicated that to show 10% difference in above parameter, a sample size of 30 individuals per group would be required. Randomization was done by balanced block randomization method. Patients demographic and perioperative data were analyzed. Stone free status was determined by post-operative NCCT scan done at 3-4 week interval. RESULTS Patients demographic data in both groups were comparable (table 1). RIRS was associated with longer operating time (48.33 vs. 36 minutes; p=0.00), inferior stone free rate (33.33% vs. 81.25%), and higher ancillary treatment requirement (9 vs. 1 patient). Although complications rates were comparable amongst both groups, RIRS was associated with higher incidence of postoperative fever. Table 1. Results- Parameter Tubeless PCNL group RIRS group P value Demographic data No. of patients planned to undergo procedure 32 39 No. of patients completing planned procedure 32 33 Age (years) 42.28±12.27 44.96±12.61 0.824 Sex (M : F) 22:10 19:14 0.351 Associated medical Co-morbidities 9 10 0.847 Creatinine (mg%) 1.14±0.26 1.25±0.26 0.097 Size of Stone (mm) 14±3.91 13.55±2.23 0.566 Intraoperative data Duration of Surgery (min) 36.00±6.81 48.33±12.55 0.000 Postoperative data Hemoglobin drop (gm%) 0.65±0.45 0.25±0.21 0.000 Hospital Stay (Hours) 24.71±5.00 27.18±7.58 0.129 Stone related outcome 0.003 Stone Free 26 13 Residual Fragment >4mm 5 17 Residual Fragment <4mm 1 3 Ancillary Procedure 1 9 0.007 Complications 4 9 0.137 Fever 3 9 Sepsis 1 3 Blood transfusion 0 0 Hydrothorax treated conservatively 1 0 Urinoma 0 1 CONCLUSIONS This randomized control trial confirms lower stones free rates with RIRS as compared to tubeless PCNL. However, other large, preferably multicentric trials are needed to define proper role of RIRS in management of medium sized renal calculi. Mumbai, India© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e493-e494 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hemendra Shah More articles by this author Manju Jain More articles by this author Rajesh Verma More articles by this author Manish Bansal More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Supracostal access: does it affect tubeless percutaneous nephrolithotomy efficacy and safety?

Tubeless percutaneous nephrolithotomy (PCNL) in selected patients has been found to be safe and can reduce postoperative discomfort without increasing complications. The challenges of tubeless PCNL via supracostal access are inadequate drainage and postoperative bleeding, conditions that may increase pulmonary complications. We compare the efficacy and safety of the tubeless supracostal versus the standard supracostal PCNL. Supracostal PCNL with one percutaneous renal access, no significant bleeding, extravasation and residual stone was performed in 95 patients. Of these, 43 were tubeless PCNL (Group-I) and 52 were PCNL with standard routine postoperative nephrostomy tube (Group-II). In group-I, PCNL was done by the standard supracostal technique with the placement of a postoperative external ureteral catheter for 48 hours. The operative time, success rate, hospital stay and ensuing complications were compared between group-I and group-II. Patients in the tubeless PCNL group (Group-I) were 90.7% stone -free while those with standard routine postoperative nephrostomy tube(Group-II) were 84.6% stone -free. Additionally, stone fragments of less than 4 mm in diameter were found in 9.3% of patients in group-I and 25.4% in group-II. The success rate, hematocrit change and complication were not significantly different between both groups. The analgesic requirement, operative time and hospital stay were all significantly less in the tubeless supracostal group (Group-I). None of group I and only one patient of group II needed intercostal drainage. Tubeless supracostal percutaneous nephrolithotomy in selected patients is effective with acceptable complications. This technique offers the advantage of lower analgesic requirement, shorter operative time and hospital stay. The pulmonary complication is the same as the standard supracostal percutaneous nephrolithotomy.

The influence of percutaneous nephrolithotomy on human systemic stress response, SIRS and renal function

The objective of this study is to investigate the influences of percutaneous nephrolithotomy (PNL) and open surgery nephrolithotomy on the systemic stress response, SIRS and renal function. Forty patients with kidney calculi were enrolled in the study. Twenty cases were randomized to the PNL group and the other twenty cases to the open surgery group. Levels of C-reactive protein (CRP), interleukin-6(IL-6), β(2)-microglobulin (β(2)-MG), respiration rate, heart rate, body temperature and white blood cell counts were examined. CRP and IL-6 were measured in all patients pre-operatively and on post-operative days 1, 3 and 6, respectively. There was significant difference in their pre- and post-operation levels (P < 0.05), with the peak of CRP and IL-6 observed at post-operative days 3 and 1, respectively. There was significant difference in both CRP and IL-6 between the two groups (P < 0.05). At post-operative day 1, there were 5 cases of SIRS in PNL group and 12 cases in open surgery group; there was significant difference between the two groups (P < 0.05). Serum β(2)-MG levels were measured as the same time as CRP and no significant changes were observed within or between the groups (P > 0.05). Urine β(2)-MG levels were also measured. There was significant difference between pre- and the first day post-PNL (P < 0.05); there was no significant difference between pre- and the third and sixth day post-PNL (P > 0.05). There was significant difference between pre- and first and third day post-open surgery (P < 0.05); but there was no significant difference between pre- and the sixth day post-open surgery (P > 0.05). There was significant difference between two groups at the first, third and sixth days (P < 0.05). The systemic stress response is activated both in PNL group and open surgery group to some extent. The degree of stress response of PNL is lower than that of open surgery, proving the advantages of PNL with reference to serum immunology. There were cases in both the groups with SIRS, but the degree of SIRS in PNL group was lesser than the other group. Both the groups have no obvious effect on glomerular filtration function after operation and have effect on renal tubular reabsorption in the early stage after operation; but the recovery of the PNL group is faster than the open surgery group. It is thus shown that PNL is much safer and more feasible and has lesser effect on renal function.

A Prospective, Randomized Trial of Management for Asymptomatic Lower Pole Calculi

We determined the natural course and compared the deleterious effects in kidneys of shock wave lithotripsy, percutaneous nephrolithotomy and observation for asymptomatic lower caliceal stones. Between April 2007 and August 2008 patients with asymptomatic lower caliceal calculi were enrolled in the study. To assess stone status noncontrast abdominal helical computerized tomography was done 3 and 12 months after intervention. All patients were evaluated by dimercapto-succinic acid renal scintigraphy 6 weeks and 12 months after intervention. A total of 94 patients were prospectively randomized to percutaneous nephrolithotomy (31), shock wave lithotripsy (31) and observation (32). Mean +/- SD followup was 19.3 +/- 5 months (range 12 to 29). In the percutaneous nephrolithotomy group all patients were stone-free at month 12. Scintigraphy revealed a scar in 1 patient (3.2%) on month 3 followup imaging. In the shock wave lithotripsy group the stone-free rate was 54.8%. Scintigraphy revealed scarring in 5 patients (16.1%). In the observation group 7 patients (18.7%) required intervention during followup. Median time to intervention was 22.5 +/- 3.7 months (range 18 to 26). One patient (3.1%) had spontaneous stone passage. Scintigraphy did not reveal scarring in any patient. Stone related events were noted in more than 20% of patients with asymptomatic lower caliceal stones observed expectantly. To manage lower caliceal stones percutaneous nephrolithotomy has a significantly higher stone-free rate with less renal scarring than shock wave lithotripsy. Thus, patients with asymptomatic lower caliceal stones must be informed in detail about all management options, especially focusing on percutaneous nephrolithotomy with its outstanding outcome.

Safety and Efficacy of Percutaneous Nephrolithotomy in Infants, Preschool Age, and Older Children With Different Sizes of Instruments

To compare the morbidity and success rates among different age groups of children undergoing percutaneous nephrolithotomy (PCNL) using adult- or pediatric-sized devices. PCNL for renal stones in children may present problems because of small size, mobility of the pediatric kidney, and the small size of the collecting system. Patients were categorized into 2 age groups: those < or =7 years old at the time of PCNL (group 1, n = 17 [38.6%]), and those 8-16 years old (group 2, n = 27 [61.4%]). Group 2 children were further divided into subgroups according to the use of pediatric- (group 2a, n = 12 [27.3%]) or adult-sized devices (group 2 b, n = 15 [34.1%]). Mean patient age was 4.1, 11.7, and 13.2 years in groups 1, 2a, and 2b, respectively. Fluoroscopy time, time to access the collecting system, operative time, and average postoperative hospital stay did not differ between the groups. However, hemoglobin decrease, bleeding during surgery, and blood transfusion rate was higher in group 2b. Stones were completely cleared in 82.4%, 83.3%, and 81.3% patients, and these percentages increased to 94.1%, 91.7%, and 93.7% with adjunctive shock wave lithotripsy and ureterorenoscopy in groups 1, 2a, and 2b, respectively. Endourologic intervention in children usually requires instruments specific for preschool age; however, in older children with dilated collecting system, the use of adult instruments and techniques may achieve equal results.

'Nephrostomy-free' percutaneous nephrolithotomy: experience in a UK district general hospital.

Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large and complex renal calculi. Accepted UK practice is to insert a nephrostomy tube at the end of the procedure to drain the kidney and reduce potential complications. 'Tubeless' or 'nephrostomy-free' PCNL has been advocated in selected patients as it is thought to reduce length of hospital stay, analgesia requirements and pain experienced. We present our outcomes of a consecutive series (n = 101) of 'nephrostomy-free' PCNLs compared to standard PCNL over a 4-year period. Between January 2004 and October 2006, we performed 55 standard (with nephrostomy tube) PCNLs (Group 1). From October 2006 onwards, we changed our technique and have performed 46 consecutive 'nephrostomy-free' PCNLs (JJ stent inserted), independent of patient and stone factors (Group 2). We have compared the two groups in terms of length of hospital stay (LOS), analgesia requirements, transfusion rates, haemoglobin (Hb) decrease and immediate, early and late complications. 'Nephrostomy-free' PCNL significantly reduced the length of hospital stay (2.8 vs 5.1 days; P < 0.001), morphine-based analgesia requirements (23% no morphine required vs 2.8%; P < 0.001), transfusion rate (2.5% vs 7%; P < 0.01) and mean Hb decrease (1.89 g/dl vs 2.25 g/dl; P > 0.05). Overall, no patient experienced a serious complication. All attempted 'nephrostomy-free' PCNLs were completed (stone clearance 95%) and no patient needed an unplanned nephrostomy. Only 5% in Group 2 needed their ureteric JJ stent removing earlier than planned secondary to pain. Both groups were comparable in terms of immediate, early and late complications, though three patients in Group 1 developed chronic loin pain and one patient in the 'nephrostomy-free' group developed a delayed perirenal haematoma. 'Nephrostomy-free' percutaneous nephrolithotomy is a safe, effective and feasible procedure independent of patient and stone factors. It decreases the length of hospital stay, the pain experienced and the need for morphine-based analgesia; we feel it should be the standard of care for patients undergoing a PCNL.

Use of Kuntz Laser Carrier and Sachse Urethrotome Sheath in Percutaneous Nephrolithotomy: A Point of Technique

Percutaneous nephrolithotomy (PCNL) is an established minimally invasive modality for treating large renal stones. Even with newer crushing modalities, difficulties are encountered during intrarenal manipulation of complex pelvicalyceal anatomy. We are presenting a modified technique to overcome this difficulty by using Kuntz laser carrier and Sachse urethrotome sheath. This study was carried out from January 2000 to December 2005 in 294 renal units in 288 patients (age range, 20-70 years; mean age, 43 years; male:female = 211:77) on whom PCNL was performed with Holmium laser. From January 2000 to December 2002, 96 PCNL (group I) were performed by passing laser fiber through 26F nephroscope. From January 2003 to December 2005, in 197 PCNL (group II) after initial inspection with 26F nephroscope, laser stone fragmentation was performed using Kuntz laser carrier and Hopkins II telescope. This assembly was passed through 21F Sachse urethrotome sheath. In all patients, puncture and dilatation with insertion of 30F Amplatz sheath was carried out under Image Intensifier. LISA SPHINX Holmium laser (80 watts) was used in all cases; energy used was 20 to 40 watts. All stones were radio-opaque and well viewed on X-ray and fluoroscopically. Overall stone clearance in group I was 87/96 (90.63%) and in group II was 185/197 (93.91%). Additional punctures were needed: 21/96 (21.88%) in group I and 19/197 (9.64%) in group II. Need for blood transfusion was 5/96 (5.20%) in group I and 2/197 (1.01%) in group II. Mean operating time was almost same for group I and group II. Mean stone size was 2644.70 +/- 587.07 mm(2) for group I and 2680.56 +/- 674.98 mm(2) for group II. With Kuntz laser carrier passed through Sachse sheath, precise delivery of laser energy is possible. Smaller sheath aids in increased intrarenal maneuverability; precise infundibulotomy helps in better stone clearance. Thus, requirement of additional punctures and blood transfusion rate being less in group II has been proven to be statistically significant.

SAFETY AND EFFICACY OF THE SUPERIOR CALYCEAL APPROACH IN PEDIATRIC PCNL

Tubeless percutaneous nephrolithotomy (PCNL) has been successfully performed in selected patients. We assessed its applicability for use without imposing preoperative restrictions.The study consisted of a prospective and consecutive series of 126 patients. Tubeless PCNL was performed when perforation, residual stones, and significant bleeding had been intraoperatively excluded by fluoroscopy, nephroscopy, and hemodynamic assessment. Staghorn stones, supracostal and/or multiple access, anatomic anomalies, previously operated kidneys, solitary kidneys, and operative time were not considered contraindications. The demographic, clinical, and intraoperative and postoperative data were statistically analyzed.Using this protocol, we performed 66 (52%) tubeless and 60 (48%) regular PCNLs. The average patient age (54 years versus 52 years), stone burden (924 versus 1044 mm2), operative time (116 versus 130 minutes), complication rate (9% versus 13%), hemoglobin decrease (1.2 versus 1.1 mg/dL), and immediate stone-free rate (92% versus 90%) were similar for the tubeless and regular PCNL groups, respectively (P >0.05). The reasons for performing standard PCNL were an expected second-look procedure (n = 35, 58%), an impression of active bleeding (n = 16, 27%), significant extravasation (n = 5, 8%), and suspected hydrothorax (n = 4, 7%). The overall transfusion rate was 3%. The average analgesia requirement (pethidine HCL) was 0.4 and 1.2 mg/kg (P <0.01), the median hospital stay was 1 and 4 days (P <0.0001), and the median back-to-work time was 7 and 15 days (P <0.001) for the tubeless and regular PCNL groups, respectively.The results of our study have shown that tubeless PCNL can be safely and effectively performed based on intraoperative factors, without preoperative contraindications. Compared with the standard procedure, tubeless PCNL was associated with reduced postoperative pain, hospital stay, and recovery time.

Effectiveness of totally tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized study

Compared with the standard technique, the number of percutaneous nephrolithotomy (PCNL) operations without a drainage catheter is increasing in recent years. In this prospective randomized study, we compared the morbidity of totally tubeless (tubeless and stentless) PCNL operations with the standard operation technique in a single center with a selected patient population. Ninety patients who fulfilled the criteria were included. Forty-five patients underwent totally tubeless PCNL (Group 1) and a 14F malecot nephrostomy catheter was used in another set of 45 patients (Group 2). Inclusion criteria for the study were no serious bleeding or perforation in the collecting system during the operation, stone free or clinically insignificant residual fragments (CIRF <4 mm), and no more than one access. When two groups were compared with regard to age, stone volume, postoperative hemoglobin change, transfusion rate, and operation time, no significant differences were found between the two groups. However, a significant difference was found in hospitalization time between the two groups (P < 0.05). The amount of non-steroidal analgesic (tenoxicam) needed and non-steroidal analgesia-resistant pain which was resolved with narcotic analgesics (meperidine) were significantly lower in Group 1 (P < 0.05). Complications were observed in two patients (4.5%) in Group 1 (one retroperitoneal hematoma, one long-lasting renal colic) and in six patients (13.3%) in Group 2 (five prolonged urine drainage, one long-lasting fever) (P < 0.05). Tubeless and stentless PCNL is a safe method and reduces hospitalization time and analgesic requirement, and promotes quality of life in selected patients.

Percutaneous nephrolithotomy for the treatment of lower pole renal calculi

Percutaneous nephrolithotomy for the treatment of lower pole renal calculi

Urolithiasis in the horseshoe kidney: a single‐centre experience

To report the operative management and subsequent stone-free rates of patients with urolithiasis in a horseshoe kidney and treated at one centre. We retrospectively reviewed all patients presenting to our centre with a horseshoe kidney and urolithiasis over a 15-year period. The stone burden, surgical management, complications and stone clearance rates were recorded. In all, 55 patients with urolithiasis in horseshoe kidney were treated. Percutaneous nephrolithotomy (PCNL) was used in 60 renal units in 47 patients. Five patients had extracorporeal shock wave lithotripsy (ESWL), two had flexible ureteroscopy and one had a laparoscopic pyelolithotomy for a stone extending into the isthmus. PCNL was used for large stones (mean digitized surface area = 614.32 mm(2)) and required one to four stages to achieve an overall stone clearance rate of 88%. Stones were cleared at one sitting in 77% of PCNL procedures, completely cleared in two-thirds of patients treated by ESWL, and in both who had flexible ureteroscopy and the one treated with laparoscopic pyelolithotomy. Complications were minimal, with 15% minor and 3% major complications in the PCNL group only. Appropriate management of urolithiasis within the horseshoe kidney depends not only on stone burden, but also on stone location, calyceal configuration and malrotation. Stones can be cleared successfully in almost all patients providing that all techniques are available to the operating surgeon.

Comparison of Systemic Stress Responses Between Percutaneous Nephrolithotomy (PCNL) and Open Nephrolithotomy

Stimulation of patient's immune response and therefore increasing inflammatory indices in patients who underwent invasive treatment methods for kidney stone removing can be predictable. In the present study, we tried to evaluate the differences of inflammatory indices in percutaneous nephrolithotomy (PCNL) and compared them with open stone surgery in patients with kidney stones. In a clinical trial study, 15 adult patients that scheduled to undergo PCNL and 15 patients who were candidate for open stone surgery matched for sex and age were included. Body temperature and concentrations of white blood cell, hemoglobin, C-reactive protein, interleukin-6, 24-hour urine cortisol levels, fibrinogen, TNF-alpha, and total antioxidant status (TAS) were measured. Pain severity was also measured on the basis of verbal rating scale (VRS). All measurements were recorded immediately before and 24 hours after operation. Patients that underwent open surgery had more severe pain than PCNL group (P = 0.001). Postoperative fever in the first group was more prevalent than other group (P = 0.020). Also, surgery time (P < 0.001), and total length of stay in hospital (P < 0.001) were higher in open surgery group. Differences rate of white blood cell (P = 0.003), C-reactive protein (P = 0.005), 24-hour urine cortisol level at 24 and 48 hours after open surgery were significantly more than PCNL (P = 0.02, P = 0.048, respectively). According to the higher postoperative complications and patient's inflammatory response in open stone surgery in comparison with PCNL, stone removing by PCNL has lower impact in terms of stress response in comparison to open surgery to the treatment of kidney stones.