Percutaneous Nephrolithotomy In Patients Research Articles

Comparison of Postoperative Analgesic Effect of Ultrasound-guided Erector Spinae Plane Block and Local Anaesthetic Infiltration with 0.375% Ropivacaine in Percutaneous Nephrolithotomy Patients: A Randomised Clinical Study

Introduction: The Erector Spinae Plane Block (ESPB) is a novel procedure that has shown benefits in postoperative pain management for various surgeries. It involves the systemic infiltration of anaesthesia into the surrounding tissues, which helps to suppress local pain responses. Aim: To compare the efficacy of Ultrasound-guided (USG) ESPB with local anaesthetic infiltration in postoperative pain management for patients undergoing Percutaneous Nephrolithotomy (PCNL). The comparison was based on the Numeric Rating Scale (NRS) score and the time taken for the first rescue analgesic requirement, along with its total consumption within 24 hours. Materials and Methods: A randomised clinical study was conducted in the Department of Anaesthesia at Velammal Medical College and Hospital, Madurai, Tamil Nadu, India. The duration of the study was two months, from September 2022 to October 2022. A total of 70 patients were randomly assigned to either group L (n=35) (local anaesthetic infiltration) or group E (n=35) (USG-guided ESPB). Demographic details, NRS pain scores, time taken for the first rescue analgaesia, and total consumption within 24 hours were noted and analysed. Descriptive analysis was performed, and a comparison between the groups was made using the Mann-Whitney U test or Chisquare test. Analysis was conducted using coGuide V1.0.3. Results: The mean age (mean±SD) of the study participants in group L and group E was found to be 49.31±13.96 years and 46.37±13.72 years, respectively. A total of 35 patients were included in each group, consisting of 16 (45.71%) females and 19 (54.29%) males in both groups. The difference in NRS scores was significant at 30 minutes, one hour (p-value <0.001), and six hours (p-value <0.011). The median time required for the first rescue analgesic was found to be 480 and 30 minutes in group E and group L, respectively (p-value <0.001). The median total consumption within 24 hours was 50 mg in both groups. Conclusion: The USG-guided ESPB provided a longer-lasting analgesic effect in postoperative pain management for PCNL patients, as evidenced by the NRS pain scale, postoperative opioid consumption, and time for the first rescue analgesia

Postoperative Pulmonary Complications after Percutaneous Nephrolithotomy Under Spinal Anesthesia.

To evaluate risk factors and outcomes of Pulmonary Complications (PCs) in Percutaneous Nephrolithotomy (PCNL) under Spinal anesthesia (SA). 286 patients who underwent PCNL under SA between 2017 and 2021 were identified retrospectively and divided into group 1 (clinically significant PCs) and group 2 (no clinically significant PCs). Demographic, preoperative, and intraoperative variables and postoperative outcomes were compared between both groups. Independent risk factors for PCs were evaluated by univariable and multivariable logistic regression analyses. PCs were noted in 90 patients (31.5%). Advanced age (P = .011), high body mass index (BMI) (P < .001), and the presence of chronic obstructive pulmonary disease (COPD) (P < .001) were risk factors for PCs. SA is an effective method of anesthesia for all PCNL patients and carries a lower rate of PCNL-associated PCs. Risk factors for PCs after PCNL were advanced age, obesity, and preoperative COPD.

Efficacy and safety of percutaneous nephrolithotomy in patients with body mass index over 30 kg/m2

Introduction and objective: With the increasing prevalence of urolithiasis, the world is also witnessing an epidemic of obesity. Management of such patients is challenging due to the body habitus and the presence of multiple comorbidities. It is unclear whether percutaneous nephrolithotomy (PCNL) has similar efficacy and safety in obese patients as compared to patients with normal body mass index (BMI). The objective of this study is to assess the impact of body mass index on the efficacy and safety of PCNL in patients with BMI &gt; 30 kg/m2. Material and methods: The medical records of 124 obese patients with BMI &gt; 30 kg/m2, treated between January 2017 and September 2022 were retrospectively reviewed. All patients underwent standard PCNL with ultrasound probe disintegration of stones. Data on patients preoperative characteristics, stone free rates, operating times, intra- and postoperative complications were analysed. Results: Patients’ mean age was 57.0±9.2. The majority of patients had at least one comorbidity – 53 (43.4%) had diabetes, 45 (36.3%) – hypertension and 7 (5.6%) had ischemic heart disease. 100 (80.6%) patients had BMI between 30-34 kg/m2, 12 (9.7%) – between 35-39.9 kg/m2 and 12 (9.7%) patients had BMI measured over 40 kg/m2. Mean stone length was 40.0±14.9 mm and mean stone width 29.3±28.7 mm. In the majority of patients 118 (95.2%) lower pole puncture was performed for access to the stone. 54 (43.5%) of the patients had staghorn stones and 58 (46.8%) had stones composed of uric acid. Mean operative time was 50.3±12.2 min and mean hospital stay 3.5±0.9 days. Stone-free rate after a single procedure was 80.6%. Postoperative complications were fever in 5 (4%) patients, haematuria in 2 (1.6%), formation of AV fistula in 2 (1.6%) and renal colic – in 3 (2.4%) patients. Management of these complications included medical treatment in 7 (5.6%) patients, double JJ stent insertion in 4 (3.2%) and angioembolization in 2 (1.6%). Conclusions: PCNL is safe and effective procedure in obese patients with BMI &gt; 30 kg/m2. BMI seems to have no impact the stone-free or complication rates, despite the potential difficulties in performing it in obese patients.

Incremental Healthcare Cost Implications of Retreatment Following Ureteroscopy or Percutaneous Nephrolithotomy for Upper Urinary Tract Stones: A Population-Based Study of Commercially-Insured US Adults.

This study describes the incremental healthcare costs associated with retreatment among adults undergoing ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) for upper urinary tract stones (UUTS). The IBM® MarketScan® Commercial Database was used to identify adults aged 18-64 years with UUTS treated with URS or PCNL between January 2010 and December 2019. Patients had 12 months of continuous insurance coverage before (baseline) and after (follow-up) the first (index) procedure. The primary outcome was total all-cause healthcare costs measured over the 365-day follow-up period, not inclusive of index costs. Generalized linear models were used to estimate the incremental costs associated with retreatment within 90 (early) or 91-365 days post-index (later) relative no retreatment. The models adjusted for demographics, comorbidities, stone(s) location, treatment setting, procedural characteristics (eg, 1-step vs 2-step PCNL) and index year. Approximately 23% (27,402/119,800) of URS patients were retreated (82% had early retreatments). The adjusted mean total cost was $10,478 (95% CI: $10,281-$10,675) for patients with no retreatment, $25,476 (95% CI: $24,947-$26,004) for early retreatment ($14,998 incremental increase, p<0.01), and $32,868 [95% CI: $31,887-$33,850] for later retreatment ($22,391 incremental increase, p<0.01). Approximately 36% (1957/5516) of PCNL patients were retreated (78% had early retreatments). The adjusted mean total cost was $13,446 (95% CI: $12,659-$14,273) for patients with no retreatment, $37,036 [95% CI: $34,926-$39,145]) for early retreatment ($23,570 incremental increase, p<0.01), and $35,359 (95% CI: $32,234-$38,484) for later retreatment ($21,893 incremental increase, p<0.01). Retreatment during the first year following URS or PCNL was needed in 23% and 36% of patients, respectively, and was associated with an economic burden of up to $23,500 per patient. The high rate of retreatment and associated costs demonstrate there is an unmet need to improve mid- to long-term results in URS and PCNL.

Ultrasound-guided percutaneous nephrolithotomy in patients with retrorenal colon: a single-center experience.

Retrorenal colon is a risk factor for colonic injury during percutaneous nephrolithotomy (PCNL). Our aim in this study is to report the feasibility and outcomes of ultrasound-guided percutaneous nephrolithotomy in patients with preoperatively known retrorenal colon by cross-sectional imaging. In this prospective study, all patients with large renal stones and retrorenal colon in preoperative cross-sectional imaging from September 2020 to January 2022 who were candidates for PCNL were enrolled. Percutaneous access was established by ultrasonography guidance by the freehand method with dilation of the tract by a combination of fluoroscopy and ultrasonography. Of the 1123 patients (Male = 760 and Female = 363) who underwent PCNL, 13 patients (Male = 6 and Female = 7) had retrorenal colon in the preoperative computed tomography. The series included two patients with malrotated kidneys. Complete stone clearance was achieved in 11 patients. Patients were followed up for at least 3months. No serious postoperative complications were observed during follow-up. In selected patients and experienced hands, ultrasound-guided PCNL can be an alternative option for the treatment of patients with large renal stones who have retrorenal colon in cross-sectional imaging.

Long-term evaluation of outcomes and costs of urolithiasis re-interventions after ureteroscopy, extracorporeal shockwave lithotripsy and percutaneous nephrolithotomy based on German health insurance claims data

PurposeComparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term follow-up are rare. We aimed to analyze re-intervention rates, costs and sick leave days of URS, SWL and PCNL patients within 7 years.MethodsThis retrospective cohort study was based on German health insurance claims data. We included 54,609 urolithiasis patients incidentally treated in 2008–2010. We investigated time to re-intervention, number of sick leave days and healthcare costs. We applied negative binomial, extended Cox regression and gamma models.Results54% were incidentally treated with URS, 40% with SWL and 6% with PCNL. 15% of URS, 26% of SWL and 23% of PCNL patients were re-treated within 7 years. Time to re-intervention was significantly lower for PCNL (955 days) and SWL (937 days) than URS (1078 days) patients. Costs for incident treatment were significantly higher for PCNL (2760€) and lower for SWL (1342€) than URS (1334€) patients. Yet, total costs including re-interventions were significantly higher for PCNL (5783€) and SWL (3240€) than URS (2979€) patients. Total number of sick leave days was increased for PCNL (13.0 days) and SWL (10.1 days) compared to URS (6.8 days) patients.ConclusionThis study describes outcomes after use of different intervention options for urolithiasis. URS patients showed longest time free of re-interventions and lowest number of sick leave days. Although SWL patients initially had lower costs, URS patients had lower costs in the long run. PCNL patients showed high costs and sick leave days.

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

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

Outcomes of Percutaneous Nephrolithotomy in a Tertiary Care Hospital

Introduction: Percutaneous nephrolithotomy (PCNL) is the gold standard first-line treatment for renal stones. It a successful, less invasive surgery (&gt; 90%) but with high complication rate (&gt; 10%). The study aims to see the outcome of PCNL in patients with renal stone who were treated. Materials and Methods: A retrospective study which included all the cases that presented with renal stone and who underwent PCNL for the treatment. The data included in this study was from April 2019 to December 2021. Ethical clearance was obtained from the institutional Review Committee (F-NMC/578/078-079). The data were collected from the records available in the record section We evaluated the distribution of presentation, puncture site, stone clearance, blood loss, postoperative stenting and complications of the surgery. Results: The total of 63 cases underwent PCNL in our institute. The mean age of the patients was 34.68±14.108 years and mean size of the stone was 5.7531±18.07804 cm3. Among the total cases, 52% cases presented with renal stone on the left kidney, 54% presents in the pelvic ureteric junction. In 71% cases puncture was made in the lower pole and in 63.5% single puncture was made to proceed. Complete clearance of stone was seen in 94% cases, 4.8% developed urosepsis and 6.3% required blood transfusion. Stenting was done postoperatively in 95% cases. Conclusion: The total stone clearance rate in our study was 94% which higher when compared to other study. With the increase in case flow the efficacy of the procedure will increase and along with this the outcome of the procedure will increase.

Outcome of Percutaneous Nephrolithotomy in Patients with History of Open Renal Stone Surgery

Background: Percutaneous nephrolithotomy (PCNL) in patients operated previously for renal stone are thought to pose some difficulties. Objective: To see the outcome of PCNL in patients who had undergone open surgery for renal stone. Method: This cross sectional study was conducted in the Department of Urology, Bangabandhu Sheikh Mujib Medical University, Dhaka from November 2015 to October 2016 over a period of one year. Thirty cases with recurrent stone having previous open renal stone surgery were enrolled as study subject. After PCNL all the patients were followed up at one week, one month and three months after procedure. Result: Mean age of the patients was 40.90 ± 6.08 years and mean stone size was 2.98 ± 0.65 cm. Mean operation time of the patients was 1.50 ± 0.46 hours and mean postoperative hospital stay was 3.87 ± 1.13 days. Stone was cleared from 29 (96.7%) patients. Mean drop of Haemoglobin level was 0.85 ± 0.55 mg/dl. Conclusion: Previous open stone surgery does not alter the outcome of subsequent PCNL. Bangladesh J. Urol. 2021; 24(1): 58-61

Outcome of Standard Percutaneous Nephrolithotomy and Totally Tubeless Percutaneous Nephrolithotomy for Renal Calculi: A Comparative Study

Objective: In standard PCNL usually placement of a double J stent and a nephrostomy tube is required.Several recent studies have reported the benefits of tubeless percutaneous nephrolithotomy (PCNL). Postoperatively,In standard PCNL patients have an indwelling ureteric stent placed, which is often associated with stent-related morbidity. We performed totally tubeless(without any stent or nephrostomy tube) PCNL.This study was conducted in the urology centre of Combined military Hospital,Dhaka, to evaluate the safety, effectiveness, and feasibility of totally tubeless PCNL and to compare with standard PCNL where both nephrostomy tube and double J stent were placed. Materials and Methods: From January 2018 to June 2019 , total 57 selected patients underwent standard or totally tubeless PCNL.In standard PCNL group, both D-J stent and nephrostomy tube were placed and Neither a nephrostomy tube nor a ureteral stent was placed in the totally tubeless PCNL group. We compared patient demographics and stone characteristics, operation time, length of hospital stay, analgesia requirements, stonefree rate, blood loss, change in creatinine, and postoperative complications between the standard and totally tubeless PCNL groups. Results: There were no significant differences in preoperative patient characteristics, postoperative complications, and the stone-free rate between the two groups, but the totally tubeless PCNL group showed a shorter hospital stay and a lesser analgesic requirement compared with the standard PCNL group. Blood loss and change in serum creatinine level were not significantly different between the two groups. Conclusions: Totally tubeless PCNL appears to be a safe and effective alternative for the management of renal stone in selected patients and is associated with a shorter length of hospital stay and less analgesic requirement. Bangladesh J. Urol. 2021; 24(1): 53-57

The efficacy and safety of paravertebral block for postoperative analgesia in renal surgery: A systematic review and meta-analysis of randomized controlled trials.

BackgroundParavertebral block (PVB) has been widely used in postoperative analgesia, especially in thoracic and breast surgery. However, the efficacy and safety of PVB for analgesia after renal surgery remains uncertain. Therefore, this study aimed to determine the postoperative analgesic efficacy and safety of PVB in renal surgery.MethodsPubMed, Web of Science, Embase, and the Cochrane Library databases were systematically searched up to December 20, 2021. All randomized controlled trials (RCTs) evaluating the postoperative analgesic efficacy of PVB in renal surgery were collected. The meta-analysis was performed using RevMan 5.4 and Stata/MP 14.0 software.ResultsA total of 16 RCTs involving 907 patients were included in the meta-analysis. Ten studies investigated patients under percutaneous nephrolithotomy (PCNL), and six studies were done for patients under other renal surgery (nephrectomy or pyeloplasty). Compared with control groups (no block, sham block, or other nerve blocks), meta-analysis showed that PVB reduced 24-hour postoperative opioid consumption significantly (SMD = −0.99, 95%CI: −1.60–0.38, p = 0.001, I2 = 92%) and reduced pain scores at various time points within 24 h at rest and 1 h, 4 h, and 24 h at movement after renal surgery, furthermore, PVB prolonged the time to first postoperative analgesic requirement (SMD = 2.16, 95%CI: 0.94–3.39, p = 0.005, I2 = 96%) and reduced the incidence of postoperative additional analgesia (OR = 0.14, 95%CI: 0.06∼0.33, p < 0.00001, I2 = 50%). Subgroup analysis revealed that the postoperative analgesia effect of PVB was more significant in PCNL, and the use of bupivacaine for PVB seemed to have a better performance. Besides, there was no difference in the incidence of postoperative nausea, vomiting, and itching between PVB and control groups.ConclusionThis study indicates that PVB may provide effective postoperative analgesia in patients under renal surgery, especially PCNL patients. Moreover, PVB is a safe analgesic method without significant analgesia-related complications.

The safety and efficiency of a 1470 nm laser in obtaining tract hemostasis in tubeless percutaneous nephrolithotomy: a retrospective cross-sectional study

ObjectiveIt is challenging to perform a tubeless percutaneous nephrolithotomy (PNL) in patients with tract bleeding. The present study was designed to study the safety and efficacy of the 1470 nm laser for hemostatic completion in tubeless PNL patients with tract bleeding.Patients and MethodsBetween January 2020 and October 2021, 120 patients were retrospectively included and divided into two groups. The hemostasis group included 60 patients receiving tubeless PNL, in which a 1470 nm laser was used to manage tract bleeding. The other group included 60 patients receiving tubeless PNL in which the hemostasis procedure was not performed, serving as the control group. The differences in the patients’ demographic characteristics, procedural information, and posttreatment outcomes between the two groups were statistically compared.ResultsThe differences associated with sex, age, weight, body mass index, urine culture, stone burden, calyx of puncture, degree of hydronephrosis and comorbidities between the two groups were not statistically significant. Compared with the control group, the hemostasis group showed greatly reduced blood loss (0.61 ± 0.31 vs. 0.85 ± 0.46 g/dL) and decreased postoperative hospitalization duration (2.83 ± 0.81 vs. 4.45 ± 0.91 days). The differences in operative time, stone-free rate, Visual Analogue Score and postoperative complications between the two groups were not statistically significant. In the subgroup analysis, the obese patients and patients with moderate to severe hydronephrosis in the hemostasis group also showed a significantly less blood loss (0.51 ± 0.22 vs. 0.83 ± 0.48 g/dL; 0.54 ± 0.27 vs. 0.85 ± 0.47 g/dL, respectively) and shorter length of postoperative hospitalization (2.62 ± 0.51 vs. 4.47 ± 1.19 days; 2.97 ± 0.63 vs. 4.41 ± 0.91 days, respectively) than those in the control group.ConclusionsOur results demonstrated that 1470 nm laser is a safe, feasible and effective method to obtain tract hemostasis in tubeless PNL.

Efficacy and safety of minimally invasive percutaneous nephrolithotomy in patients with lower pole kidney stones 1-2 cm in diameter

Introduction: Anatomical features of the lower pole calyces plays an important role in the treatment of urolithiasis. The optimal treatment options for lower pole stones with a diameter below 2 cm are controversially discussed. Extracorporeal shock wave lithotripsy (SWL) is non-invasive, but is hampered by low stone-free rates and a significant retreatment rate in patients with unfavourable factors for lithotripsy. Retrograde intrarenal surgery (RIRS) has been demonstrated to have high stone-free rates since the development of modern flexible endoscopes. But the long operative time in the case of a large stone burden, unfavourable anatomy and considerable costs for consumables represent limiting factors for this technique. With the miniaturization of percutaneous approach and decreasing the morbidity, minimally invasive percutaneous nephrolithotomy (miniPCNL) is a promising method for treatment of lower pole stones in one stage procedure. The objective of this study is to investigate the efficacy and safety of mini-PCNL for the treatment of lower pole stones 1-2 cm. Material and methods: The medical records of 54 patients with lower pole kidney stones 1-2 cm, treated at the Clinic of Endurology and SWL, Military Medical Academy, Sofia between January 2020 to January 2022, were retrospectively reviewed. All patients underwent mini-PCNL under spinal anesthesia in prone position with fluoroscopic guidance through 18 Fr sheath using semirigid nephroscope and Ho:YAG laser for lithotripsy. Stone-free rate was defined as absence of residual fragments ≥2 mm. Data on patients’ preoperative characterstics, stone-free rates, operating times, intra- and postoperative complications were analyzed. Results: Patients mean age was 54,68±11,99 years. Mean stone surface was 169,02±57,40mm2 and mean CT stone density was 1112,26±250,47 HU. Stone-free rate after single procedure was 96,3 % (52 patients). 14,8% of patients had preoperative urinary tract infection. Mean operative time was 27,46±12,40 min and mean hospital stay - 2,5±1,17 days. The mean Hgb drop was 11.9±15.6 g/l. Lower pole puncture was performed in all patients. Two tracts were required in 1 (1,9 %) patient. One patient had intraoperative haemorrhage at the end of the procedure. Postoperative complications were observed in 2 (3,8 %) patients: postoperative fever t &gt;38.5o C in 1 patient (1,9%) and postoperative AV-fistula in 1 (1,9%) patient, who needed hemotransfusion and selective embolization. 2 patients required auxiliary procedures: 1 patient needed stent JJ and 1 underwent ureteroscopy for fragments in ureter. Conclusion: Various factors are important for management of lower pole kidney stones and should be taken into consideration, when choosing the optimal treatment modality. The results from this study suggest that mini-PCNL is an effective and safe procedure with high stone free rates and low complication rates in patients with lower pole kidney stones unfavourable for SWL and RIRS. Key words: minimally invasive nephrolithotomy, lower pole kidney, urolithiasis

Standardizing Perioperative Medications to Be Used in an Enhanced Recovery After Surgery Program Is Feasible in Percutaneous Nephrolithotomy Patients.

Introduction: The objective of this process improvement project was to determine the effect of enhanced recovery after surgery (ERAS) protocol for percutaneous nephrolithotomy (PCNL) patients with respect to quality of life (QOL) and pain management in the postoperative recovery period. Methods: An electronic-based medical record ERAS orders protocol for PCNL was instituted at an academic medical center in July 2020. The protocol utilized a pain control regimen designed to minimize opioid medication use postoperatively. We prospectively evaluated PCNL patients' QOL through the Wisconsin Stone Quality of Life (WISQOL) survey and Patient-Reported Outcomes Measurement System (PROMIS) at routine perioperative visits. To assess any opioid reduction benefit of the ERAS protocol, we reviewed an age-matched historical cohort n = 66 (before ERAS implementation) to serve as a comparison cohort with respect to opioid usage. Results: After an inception cohort of 95 patients, 55 ERAS patients remained available for assessment with the WISQOL and PROMIS surveys. In comparison with the non-ERAS cohort, the ERAS cohort represented larger stones, more supine positioning, higher blood loss, shorter hospital stay, and more use of access sheath. ERAS patients received a significantly lower amount of opioids compared with non-ERAS patients upon discharge narcotic usage (116.13 morphine milliequivalent [MME] vs 39.57 MME, p = 0.0001). Compared with their preoperative evaluation, the ERAS cohort had significantly improved QOL scores at 1 week, which sustained through 8 weeks postoperatively. Moreover, pain intensity and pain interference scores were improved at 8 weeks postoperatively for ERAS patients compared with their preoperative time point. Conclusions: We demonstrate that standardizing medications in early efforts toward a PCNL ERAS protocol is feasible and allows for reduced opioid use by patients while achieving early and sustained postprocedure QOL.

PD32-10 KIDNEY STONE ENDOTOXIN CONCENTRATION CORRELATES WITH POST-OPERATIVE SEPSIS FOLLOWING PERCUTANEOUS NEPHROLITHOTOMY

You have accessJournal of UrologyCME1 May 2022PD32-10 KIDNEY STONE ENDOTOXIN CONCENTRATION CORRELATES WITH POST-OPERATIVE SEPSIS FOLLOWING PERCUTANEOUS NEPHROLITHOTOMY David T. Tzou, Farhan Anwar, Ava C. Wong, David T. Harris, Thomas Chi, and Gayatri Vedantam David T. TzouDavid T. Tzou More articles by this author , Farhan AnwarFarhan Anwar More articles by this author , Ava C. WongAva C. Wong More articles by this author , David T. HarrisDavid T. Harris More articles by this author , Thomas ChiThomas Chi More articles by this author , and Gayatri VedantamGayatri Vedantam More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002583.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with infected kidney stones are at risk for post-operative sepsis following surgical removal of their calculi. Of all the surgical approaches, percutaneous nephrolithotomy (PCNL) remains associated with the highest risk for experiencing post-operative SIRS (severe inflammatory response syndrome). Accurate prediction of patients at risk for SIRS after surgery would be of clinical value. While previous studies have demonstrated infected kidney stones contain variable levels of endotoxin concentrations, these were limited in their rigor and ability to correlate stone immunobiology with important clinical outcomes. The aim of this study was to quantitate endotoxin levels amongst PCNL patients who experienced and did not experience SIRS. METHODS: Between October 2020 and June 2021, urine & stone specimens from consecutive stone patients were prospectively collected as part of the Registry for Stones of the Kidneys and Ureter (ReSKU) at the University of Arizona. Clinical data including stone analyses and post-operative outcomes have been tracked. Equal weights of stones were uniformly broken using an easy-to-replicate ‘beat-beating’ homogenization approach, allowing for consistent measurement of stone endotoxin using a Pierce™ LAL Chromogenic Endotoxin Quantification Kit (ThermoFisher, Waltham, MA). Endotoxin levels from stones removed during PCNL were compared between patients who experienced and did not experience SIRS. Independent T-test was used to determine statistical significance. RESULTS: Endotoxin levels amongst 4 patients with infection calculi who experienced SIRS were compared to 16 patients who did not experience SIRS – 8 of which had infection calculi and 8 had non-infection calculi (Figure 1). In the SIRS group, the mean Endotoxin concentration was 1.084 endotoxin units (EU)/ml compared to 0.476 EU/ml in the non-SIRS group (p<0.01). CONCLUSIONS: Higher kidney stone bacterial endotoxin concentrations are present in patients who experienced SIRS after percutaneous stone removal compared to those who did not. Whether exceeding a threshold endotoxin level corresponds to patients experiencing SIRS warrants future study. Source of Funding: P30DK081943 – SUBK00015084 - NIH/NIDDK; University of Arizona Health Sciences Career Development Award © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e550 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information David T. Tzou More articles by this author Farhan Anwar More articles by this author Ava C. Wong More articles by this author David T. Harris More articles by this author Thomas Chi More articles by this author Gayatri Vedantam More articles by this author Expand All Advertisement PDF DownloadLoading ...

Posición óptima para la nefrolitotomía percutánea en el riñón en herradura: ¿prono tradicional o supino?

ObjectiveAlthough it was stated that supine percutaneous nephrolithotomy (PCNL) was associated with relatively shorter surgical times and comparable success and complication rates, there is no consensus in the current literature concerning the safety and efficacy of supine PCNL in patients with horseshoe kidneys. We aimed to compare supine and prone PCNL regarding safety and efficacy in patients with horseshoe kidneys. MethodsData of the patients with horseshoe kidneys who underwent PCNL for renal stones larger than 2cm between January 2010 and May 2021 were retrospectively reviewed. The study patients were categorized as Group1 (i.e., supine PCNL-SPCNL) and Group2 (i.e., prone PCNL-PPCNL). Both groups were compared regarding demographic, clinical, and surgical data. ResultsSixty-five patients were included. Among these patients, 31 (47.7%) were in Group1, while 34 (52.3%) were in Group2. Both groups were statistically similar in terms of demographic data, stone characteristics, perioperative parameters, and complication rates (P>.05). There was no statistical difference in terms of additional treatment rates, stone-free rates in the postoperative second-day and third-month evaluations (P>.05). Mean surgical time was significantly longer in Group2 (113±17.1minutes) than in Group1 (90.6±11.3minutes) (P=.000). ConclusionAlthough it is traditionally performed in the prone position, the supine approach is as safe and effective as the prone approach. In addition, the supine approach is associated with significantly shorter surgical times.

Optimal patient position for percutaneous nephrolithotomy in horseshoe kidneys: Traditional prone or supine?

ObjectiveAlthough it was stated that supine percutaneous nephrolithotomy (PCNL) was associated with relatively shorter surgical times and comparable success and complication rates, there is no consensus in the current literature concerning the safety and efficacy of supine PCNL in patients with horseshoe kidneys. We aimed to compare supine and prone PCNL regarding safety and efficacy in patients with horseshoe kidneys. MethodsData of the patients with horseshoe kidneys who underwent PCNL for renal stones larger than 2 cm between January 2010 and May 2021 were retrospectively reviewed. The study patients were categorized as Group 1 (i.e., supine PCNL-SPCNL) and Group 2 (i.e., prone PCNL-PPCNL). Both groups were compared regarding demographic, clinical, and surgical data. ResultsSixty-five patients were included. Among these patients, 31 (47.7%) were in Group 1, while 34 (52.3%) were in Group 2. Both groups were statistically similar in terms of demographic data, stone characteristics, perioperative parameters, and complication rates (p > 0.05). There was no statistical difference in terms of additional treatment rates, stone-free rates in the postoperative second-day and third-month evaluations (p > 0.05). Mean surgical time was significantly longer in Group 2 (113 ± 17.1 min) than in Group 1 (90.6 ± 11.3 min) (p = 0.000). ConclusionAlthough it is traditionally performed in the prone position, the supine approach is as safe and effective as the prone approach. In addition, the supine approach is associated with significantly shorter surgical times.

Finger touching combined X-ray-guided percutaneous nephrolithotomy in 640 cases: an 8-years' experience.

We aimed to evaluate the safety and efficacy of finger touching combined X-ray-guided percutaneous nephrolithotomy, and the feasibility of avoiding damage in medical staff caused by X-ray. From January 2013 to December 2020, 640 cases of percutaneous nephrolithotomy were performed through the 18-24-F channel. Among those cases, 22 (3.4%) cases were double-sided kidney stones surgeries, 294 (45.8%) cases were on the right side and 324 (50.5%) cases were on the left side. The targeted renal calyceal puncture was carried out under the combined guidance of the doctor's finger and X-ray. We assessed the X-ray exposure time of patients and doctors, average number of punctures, postoperative hospitalization, calculus removal rates, and complications. The average number of punctures was 2.8 ± 1.4. Average X-ray exposure time during procedure: 2.8 s (range: 2-8 s). Average surgical time: 106.5 ± 49.4 min. Postoperative hospitalization: 6.8 ± 4.2 d. Average reduced hemoglobin level: 5.9 g/day. Stone-free rate 4 weeks after surgeries: 95.6%. Patients with upper ureteral calculi: 395 cases (61.72%). The calculus residual rate of patients with staghorn renal calculi or multiple renal calculi complementary treatments was 82.9%, including 0 patients who received shock wave lithotripsy, 2 cases of repeated percutaneous nephrolithotomy (PCNL), and 18 cases of ureteroscopy. Postoperative placement of renal drainage tube occurred in 52 cases. As for complications, no perirenal infection occurred, two severe bleeding complication cases occurred, and one case of colon perforation occurred. Finger touching combined X-ray-guided percutaneous nephrolithotomy in patients with renal calculus is safe and can accurately guide the puncture without radiation hazards. The placement of a renal drainage tube was beneficial to reduce renal effusion, hematocele, and infections.

Nomogram for predicting risk factor of urosepsis in patients with diabetes after percutaneous nephrolithotomy

BackgroundUrosepsis is an infectious complication after percutaneous nephrolithotomy (PCNL). This study aimed to analyze the perioperative factors related to urosepsis after PCNL for upper urinary calculi and establish a nomogram to predict the probability of postoperative urosepsis based on the risk factors.MethodsThe Clinical data of one-stage PCNL for upper urinary stones in patients already diagnosed with type 2 diabetes between June 2010 and June 2020 were retrospectively analyzed. The patients were divided into two groups according to whether urosepsis occurred after surgery, and univariate and multivariate logistic regression analyses evaluated the risk factors for urosepsis. Moreover, the corresponding nomogram prediction model was determined by the regression coefficient.ResultsAll 366 patients with diabetes underwent one-stage PCNL. Seventy-one (19.4%) patients had urosepsis after surgery, and their hospitalization time was longer than that of patients without urosepsis. Moreover, the incidence of non-infection-related complications was higher. Multivariate logistic regression analysis revealed four independent risk factors associated with postoperative urosepsis, including positive urine nitrite (odds ratio [OR] = 3.326, P = 0.007), positive urine culture (OR = 2.213, P = 0.023), intraoperative hypotension (OR = 8.968, P < 0.001), and staghorn calculi (OR = 3.180, P = 0.002). The above independent risk factors were used as variables to construct the nomogram. The nomogram model was internally validated. The calculated concordance index was 0.824. The Hosmer–Lemeshow goodness-of-fit test was performed (P = 0.972 > 0.05). The area under the curve of this model was 0.831, indicating that the nomogram model had good accuracy in predicting the probability of urosepsis in patients who underwent PCNL with diabetes and had good consistency with the actual risk.ConclusionPositive urine culture, positive urine nitrite, staghorn calculi, and intraoperative hypotension were independent risk factors for urosepsis in patients who underwent one-stage PCNL with diabetes. The new nomogram could accurately assess the risk of urosepsis after PCNL in patients with diabetes.

The effect of preoperative urine culture and bacterial species on infection after percutaneous nephrolithotomy for patients with upper urinary tract stones

To study the relationship between preoperative urine culture, bacterial species and infection after percutaneous nephrolithotomy in patients with upper urinary tract stones, and summarize the clinical characteristics of different bacterial infections. From January 2014 and January 2020, 963 patients with upper urinary tract stones who underwent PCNL in the department of urology of Fujian provincial hospital were included in the study. Information included the patient’s age, gender, weight, diabetes, chronic disease history, urine routine, preoperative urine culture results, stone size, number of stones, hydronephrosis level, operation time, body temperature, heart rate, blood pressure, breathing rate, hemoglobin, serum creatinine, bilirubin, platelets and whether there was preoperative infection were recorded. 141 patients (14.6%) had a positive urine culture before surgery, and 7 of them had multiple bacterial infections. The most common pathogenic bacteria was Escherichia coli, followed by Enterococcus and Klebsiella pneumoniae. A total of 74 cases (7.7%) of 963 patients with infection after PCNL occurred, 24 cases (32.4%) of infected patients progressed to urinary septic shock. Univariate analysis shown that the probability of infection in patients with long operation time and positive urine culture was significantly higher, and the difference was statistically significant. Further multivariate logistic regression analysis shown that positive urine culture before operation and long operation time were independent risk factors for infection after PCNL. Among the 29 patients with septic shock, 18 cases (62.1%) had a positive urine culture before surgery. The incidence (43.9%) of postoperative infection in Escherichia coli positive patients was significantly higher than that in the negative group, and the difference was statistically significant. The rate of patients with Escherichia coli infection progressing to septic shock was 9 cases (60%). 2 patients with Enterococcus faecium infection and 2 patients with Klebsiella pneumoniae infection all progressed to septic shock. The age of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 58.53 ± 11.73 years, 76.5 years and 74 years.The body temperature of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 39.10 ± 0.25 °C, 39.45 °C and 38.65 °C. The highest pct value of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 80.62 ± 31.45 ng/mL, 24.32 ng/mL and 8.45 ng/mL. The nitrite positive rate of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 64.51%, 16.6% and 0. Postoperative infection of PCNL is significantly correlated with positive preoperative urine culture, and positive preoperative urine culture is an independent risk factor for postoperative infection. The most common pathogen of postoperative infection of PCNL is Escherichia coli, followed by Enterococcus and Klebsiella pneumoniae. Patients with Escherichia coli infection are often positive for nitrite before surgery, mainly manifested by high fever, and PCT is significantly increased (often exceeded 100 ng/ml). Enterococcus faecium and Klebsiella pneumoniae infections mostly occur in elderly patients and often progress to septic shock. Patients with Enterococcus faecium infection have a high fever, and the PCT value is significantly higher (often exceeded 20 ng/ml). Patients with Klebsiella pneumoniae infection have a moderate fever, and the PCT value generally does not exceeded 10 ng/ml. Long operation time is another independent risk factor for PCNL infection.