Percutaneous Nephrostolithotomy Research Articles

Primary hyperoxaluria type 1: urologic and therapeutic management.

ABSTRACTWhile the surgical approaches available in primary hyperoxaluria (PH) are common to all patients requiring intervention for urolithiasis, the indications for treatment and their corresponding toxicities are unique. Being a rare disease, we are guided by case series. This review summarizes the available literature highlighting the important disease-specific considerations. Shockwave lithotripsy (SWL) is of particular interest. It is generally the first-line treatment for stones in children, but here the stones produced will be relatively resistant to fragmentation. In addition, there are concerning reports in children of sudden unilateral decline in function in the treated kidney as measured by nuclear renography. Percutaneous nephrostolithotomy might intuitively seem favorable given the shortest drain duration and the ability to treat larger stones efficiently but, similar to SWL, rapid chronic kidney disease (CKD) progression has been seen postoperatively. Ureteroscopy is therefore generally the safest option, but considerations regarding stent encrustation, the growth of residual fragments and the large volume of stone often faced may limit this approach. The surgeon must balance the above with consideration of the patient's CKD status when considering a plan of monitoring and treating stones in PH.

Urine for a Surprise!

A 51-year-old male with known left ureteral staghorn calculus presented to undergo elective cystoscopy, ureteral catheter placement, and left percutaneous nephrostolithotomy. He was previously healthy. The patient complained of left lower quadrant abdominal pain on postoperative day 1 and noncontrast computed tomography (CT) of the abdomen and pelvis revealed mild left hydronephrosis, periureteral stranding, and fluid accumulation without evidence of drainable collection. A small left pleural effusion was also noted.

AORN Position Statement on Managing Distractions and Noise During Perioperative Patient Care

<scp>AORN</scp> Position Statement on Managing Distractions and Noise During Perioperative Patient Care

The effect of hemorrhage and safety of perioperative aspirin administration on minimal percutaneous nephrostolithotomy

Objective To study the effect of hemorrhage and safety on minimal percutaneous nephrostolithotomy(MPCNL) in patients receiving aspirin. Methods The clinic data of 84 patients with renal calculus or upper ureteral calculus who underwent MPCNL from July 2014 to July 2017 were analyzed. The patients meet the indications of percutaneous surgery with the diameter of calculus or the total diameter of multiple calculuses in patients were less than 3 cm. The patients were divided into 4 groups. Group 1: 15 patients stopping receiving aspirin. Group 2: 28 patients receiving aspirin. Group 3: 16 patients receiving aspirin and underwent emergent nephrostomy and secondary MPCNL. Group 4: 25 patients never receiving aspirin. The Hb concentration was measured and the amount of bleeding was estimated. The amount of bleeding between each group was analyzed by using one-way ANOVA. Results Compared with the group 2 and group 3, the bleeding amount of group 1 had no difference(P>0.05). Compared with the group 2 and group 3, the bleeding amount of group 4 had no difference(P>0.05). One patient of group 1 got cerebral infarction. One patient of group 5 got pulmonary embolism and another one got arterial bleeding in the channel of MPCNL. Conclusions For patients suffer from MPCNL, the bleeding amount of aspirin stopping group and non-aspirin group are not less than aspirin groups. Aspirin stopping may result in infarcted disease. Key words: Urinary Calculi; Nephrostomy, Percutaneous; Aspirin

Comparative Outcomes of Conventional and Miniaturized Percutaneous Nephrostolithotomy for the Treatment of Kidney Stones—Does a Miniaturized Tract Improve Quality of Care?

IntroductionPercutaneous nephrostolithotomy is the method of choice to treat renal stones larger than 2 cm due to its high stone-free rates but it has potentially increased blood loss, postoperative pain and hospital stay compared to other treatments. Miniaturizing the percutaneous tract has recently gained interest. We performed a quality improvement study to investigate whether mini percutaneous nephrostolithotomy would reduce postoperative analgesic use, blood loss, operative time and/or hospital stay relative to the conventional approach while maintaining stone-free rates in our patient population. MethodsThe outcomes of 29 consecutive mini percutaneous nephrostolithotomies were compared to 27 conventional procedures performed by a single surgeon at our institution. Inclusion criteria were age 18 years or older, body mass index 18 to 40 kg/m2 and first look percutaneous nephrostolithotomy for stones 1 to 3.5 cm. Conventional percutaneous nephrostolithotomy was performed through a 30Fr tract, whereas the mini approach was done through a 16.5Fr tract. All percutaneous access was performed by the surgeon. ResultsA total of 17 patients in the conventional percutaneous nephrostolithotomy group and 19 in the mini approach group were stone-free after 1 procedure. There was no significant difference in residual stone burden, operative time or postoperative analgesic use between groups. There was significantly less blood loss (p = 0.02) in the mini percutaneous nephrostolithotomy group. ConclusionsConventional and mini percutaneous nephrostolithotomies are effective methods of removing renal stones 1 to 3.5 cm in greatest dimension. There is no difference in residual stone volume, postoperative analgesic use or operative time between the 2 modalities, but blood loss is less in the mini percutaneous nephrostolithotomy group.

The Impact of Operating Room Noise Upon Communication During Percutaneous Nephrostolithotomy.

Equipment and personnel contribute to the overall noise level in the operating room (OR). This study aims to determine intraoperative noise levels during percutaneous nephrostolithotomy (PCNL) and the effects of this noise upon intraoperative communication. A PCNL benchtop model was used to measure intraoperative noise and determine its effect upon communication in three progressively increasing sound environments (baseline ambient noise, ambient noise with PCNL equipment, and ambient noise with both PCNL equipment and music). Five trials with 20 different medical words/phrases were spoken by the surgeon and responses were recorded by the first assistant, anesthesiologist, and circulating nurse. In addition, noise levels during PCNL were compared to common environmental noise levels. In the bench top model, noise levels were 53.49 A-weighted decibels (dBA) with ambient noise, 78.79 dBA with equipment in use, and 81.78 dBA with equipment and music. At the ambient noise level, the first assistant, anesthesiologist, and circulator correctly recorded 100%, 100%, and 96% of the words, respectively. The correct response rate by the subjects decreased to 97% (p = 0.208), 81% (p = 0.012), and 56% (p < 0.001) upon addition of PCNL equipment, and 90% (p = 0.022), 48% (p = 0.002), and 13% (p < 0.001) upon addition of music and PCNL equipment in the first assistant, anesthesiologist, and circulator, respectively. In the simulated OR model, PCNL noise level (81.78 dBA) was comparable to a passing freight train at 30 feet (82.2 dBA, p = 0.44). Noise pollution decreases effective intraoperative communication during PCNL. It is important for surgeons to understand the effect noise can have on attempted communication to prevent errors due to miscommunication. In addition, methods to decrease intraoperative noise pollution and improve communication in the OR could improve patient safety and outcomes.

PD18-05 COMPARATIVE OUTCOMES OF CONVENTIONAL PCNL AND MINIATURIZED PCNL IN THE TREATMENT OF KIDNEY STONES

You have accessJournal of UrologyStone Disease: Surgical Therapy II1 Apr 2016PD18-05 COMPARATIVE OUTCOMES OF CONVENTIONAL PCNL AND MINIATURIZED PCNL IN THE TREATMENT OF KIDNEY STONES Jessica Lange and Jorge Gutierrez-Aceves Jessica LangeJessica Lange More articles by this author and Jorge Gutierrez-AcevesJorge Gutierrez-Aceves More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1184AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Percutaneous nephrostolithotomy (PCNL) is the preferred method to treat large renal stones. PCNL has excellent stone free rates, but it known to have increased blood loss, postoperative pain, and hospital stay relative to other treatment modalities. In recent years, techniques used to create a smaller percutaneous tract have gained interest. Miniaturized PCNL (mini-PCNL) requires dilation of a smaller percutaneous tract, potentially leading to less blood loss, less postoperative pain, and shortened hospital stay. In this study, we compare efficacy and outcomes of conventional and mini-PCNL at our institution. METHODS The outcomes of 29 consecutive mini-PCNLs were compared to 27 conventional PCNLs performed by a single surgeon at our institution. Study inclusion criteria included age ≥ 18 years, BMI 18-40 kg/m2, and first look PCNL for stones 1-3.5 cm in greatest dimension. Conventional PCNL required percutaneous tract dilation to 30 French and stone fragmentation using pneumatic and/or ultrasonic lithotrites and/or holmium:YAG laser. Mini-PCNL was performed using the minimally invasive percutaneous access set (Storz®), dilating the tract to 16 French, and using holmium:YAG laser for stone fragmentation. RESULTS There were no significant differences between the groups in baseline age (PCNL 55.5 ± 15.3 years, mini-PCNL 53.0 ± 15.8 years) or BMI (PCNL 28.5 ± 5.7, mini-PCNL 29.0 ± 6.0 kg/m2). There was no significant difference in preoperative stone burden between groups though the mini-PCNL mean stone burden was slightly smaller. Seventeen patients in the conventional PCNL group and 19 patients in the mini-PCNL group were stone free (defined as residual stone fragments < 2 mm on postoperative CT scan) after one procedure. There was no significant difference in residual stone burden, total operative time, or postoperative analgesic use between groups. There was a significant difference in blood loss, but no patients required blood transfusion. CONCLUSIONS Both conventional PCNL and mini-PCNL are effective methods of removing renal stones 1-3.5 cm. There appears to be no difference in residual stone volume, postoperative analgesic use, or operative time between the two techniques. Blood loss was less in the mini-PCNL group though this may have little clinical significance. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e405 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Jessica Lange More articles by this author Jorge Gutierrez-Aceves More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP22-12 THE RELATIONSHIP BETWEEN OPERATIVE TIMES AND COMPLICATION RATES IN PERCUTANEOUS NEPHROSTOLITHOTOMY PROCEDURES

You have accessJournal of UrologyStone Disease: Surgical Therapy I1 Apr 2016MP22-12 THE RELATIONSHIP BETWEEN OPERATIVE TIMES AND COMPLICATION RATES IN PERCUTANEOUS NEPHROSTOLITHOTOMY PROCEDURES Julie Stein, Kaitlan Cobb, John Michael DiBianco, and Patrick Mufarrij Julie SteinJulie Stein More articles by this author , Kaitlan CobbKaitlan Cobb More articles by this author , John Michael DiBiancoJohn Michael DiBianco More articles by this author , and Patrick MufarrijPatrick Mufarrij More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.700AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prolonged operative time has long been associated with postoperative complications. Percutaneous nephrostolithotomy (PCNL) is a common approach for the treatment of complex stone disease, often requiring lengthy operative times and/or multiple surgical stages. Complications of PCNL, including hemorrhage, injury to adjacent organs/structures, and infection, have been reported to occur at higher rates in procedures that have had prolonged operative times. Additionally, some of these complications may limit the duration of PCNL procedures, thereby decreasing stone-free rates or requiring more surgical stages. We aimed to investigate the relationship between operative times and postoperative complications as classified by the Clavien-Dindo System of Surgical Complications. METHODS A retrospective review was performed on 66 patients who underwent PCNL by a single endourologist at George Washington University Hospital and Sibley Memorial Hospital in Washington, D.C. from October 2012 to December 2014. Data on basic patient demographics and characteristics, operative times, and complications were collected. Operative time was defined by surgery start time and stop time as recorded by the anesthesiologist. Complications were classified by the Clavien-Dindo system on a scale of 0 to 5. RESULTS Mean age of patients was 57.3 +/- 12.2 years. Overall complication rate was 14.9% with 0% Clavien I, 9.0% Clavien II, 0% Clavien III, 6.0% Clavien IV, and 0% Clavien V. Mean operative time was 232.0 +/- 72.7 minutes. A simple linear regression model revealed that operative time accounted for 6.1% of the variance in Clavien score (R2 = .061, p < 0.05). One-way Analysis of Variance (ANOVA) demonstrated that the presence of infection stones differed significantly between Clavien classes (F(2, 60) = 3.32, p = 0.043). Post-hoc analyses showed that infection stones were associated with a Clavien II complication (p = 0.05), but not with a Clavien IV complication (p > 0.05). CONCLUSIONS In our investigation, increased operative time of PCNL procedures was not associated with an increase in complications. The increase in mid-level complications observed in patients identified to have infection-based stones corroborates previous data on this particular group of stone patients. While, in general, it is advisable to minimize operative duration, this data does not suggest an increased complication risk with lengthier PCNL procedures. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e257-e258 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Julie Stein More articles by this author Kaitlan Cobb More articles by this author John Michael DiBianco More articles by this author Patrick Mufarrij More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Hospital-level Variation in the Quality of Benign Inpatient Urologic Surgery

To examine hospital-level variation in outcomes following benign urologic surgeries given that hospital-level variation in surgical outcomes can portend quality and appropriateness of care concerns and identify quality improvement opportunities in perioperative care. Using the Washington State Comprehensive Hospital Abstract Reporting System, we identified patients who underwent transurethral resection of the prostate (TURP), percutaneous nephrostolithotomy (PCNL), and pyeloplasty from 2003 to 2008. We classified prolonged postoperative length of stay (LOS) as that exceeding the 75th percentile, and we measured the rate of Agency for Healthcare Quality Patient Safety Indicators, readmissions, and death. We calculated hospital-specific observed-to-expected event rates using random effects multilevel multivariable models adjusted for age and comorbidity. We identified 6699 TURP patients at 54 hospitals, 2541 PCNL patients at 45 hospitals, and 584 pyeloplasty patients at 36 hospitals. Complication rates were highest after PCNL (22.9% prolonged LOS vs 17.3% for TURP and 13.9% for pyeloplasty, P < .001; 3.4% 90-day mortality vs 0.6% for TURP and 0% for pyeloplasty). Hospital-level variation was most substantial for LOS after TURP and pyeloplasty (8.1% and 14.3% of variance in prolonged LOS, respectively). Hospital-level variation is common after benign inpatient urologic surgeries and may relate to difference in perioperative provider practice patterns. The morbidity of PCNL in this study was higher than expected and merits further investigation.

MP30-11 PERINEPHRIC FAT DISTRIBUTION AND ANATOMICAL CONSIDERATIONS WHEN PERFORMING PERCUTANEOUS NEPHROLITHOTOMY IN OBESE PATIENTS

INTRODUCTION AND OBJECTIVES: Tools and equipment utilized during endourologic surgery contribute significantly to noise pollution in the operating room (OR) during percutaneous nephrostolithotomy (PCNL). The purpose of this study was to determine OR baseline noise and noise contributed by endourologic equipment during PCNL; then, to determine the effect of this noise upon the effectiveness of communication. METHODS: Ambient noise in the operating room was measured using a digital decibel meter. Noise levels were determined by the sequential addition of normal conversation, highpressure suction, ultrasonic lithotripter, and background music. Three subjectsdthe surgical assistant (0.8m from the surgeon), anesthesiologist (1.8m), and the circulator (2.5m) were placed in the operating room to simulate positioning during PCNL. Five trials of 20 different medical words/phrases were spoken by the surgeon. Trials were performed with three sound categories. The first category included ambient sound alone, the second included ambient sound, suction and lithotryptors, and the third included ambient sound, suction, lithotripsy and loud music. In addition, the OR noise was compared to commonly encountered environmental noise; including cars (n1⁄412) and trucks (n1⁄418) driving 40 mph at 30 ft, and freight trains (n1⁄48) traveling 55 mph at 30 and 45 feet. Statistical analyses were performed using a student t-test. RESULTS: The average baseline noise was 53.49dB(A). As conversation, suction/lithotripsy, and music were added, noise levels were 61.82dB(A), 77.96dB(A), and 87.33dB(A), respectively. At baseline noise, the surgical assistant, anesthesiologist and circulating nurse correctly recorded 100%, 100% and 96% of the words, respectively. The correct response rate by the subjects decreased to 97%(p1⁄40.172), 81%(p<0.001) and 56%(p<0.001) with suction/lithotripsy and 90%(p1⁄40.006), 48%(p<0.001) and 13%(p<0.001) with suction/lithotripsy/music. By comparison, total PCNL noise (conversation/suction/lithotripsy/music) [87.33 dB(A)] was louder than the measured car [67.8 dB(A); p<0.001] and pickup truck noise [69.2 dB(A); p<0.001] but similar to a freight train at 30 feet [82.2 dB(A); p1⁄40.44]. CONCLUSIONS: Endourologic instruments and music utilized during PCNL may significantly contribute to noise pollution in the operating room environment and this noise may significantly degrade the effectiveness of communication. An understanding of the role that noise and distance play in affecting the success of communication may reduce operating room errors and patient complications.

MP30-12 POST PERCUTANEOUS NEPHROLITHOTOMY, WHAT DEFINES CLINICAL INSIGINIFICANT RESIDUAL FRAGMENTS

INTRODUCTION AND OBJECTIVES: Tools and equipment utilized during endourologic surgery contribute significantly to noise pollution in the operating room (OR) during percutaneous nephrostolithotomy (PCNL). The purpose of this study was to determine OR baseline noise and noise contributed by endourologic equipment during PCNL; then, to determine the effect of this noise upon the effectiveness of communication. METHODS: Ambient noise in the operating room was measured using a digital decibel meter. Noise levels were determined by the sequential addition of normal conversation, highpressure suction, ultrasonic lithotripter, and background music. Three subjectsdthe surgical assistant (0.8m from the surgeon), anesthesiologist (1.8m), and the circulator (2.5m) were placed in the operating room to simulate positioning during PCNL. Five trials of 20 different medical words/phrases were spoken by the surgeon. Trials were performed with three sound categories. The first category included ambient sound alone, the second included ambient sound, suction and lithotryptors, and the third included ambient sound, suction, lithotripsy and loud music. In addition, the OR noise was compared to commonly encountered environmental noise; including cars (n1⁄412) and trucks (n1⁄418) driving 40 mph at 30 ft, and freight trains (n1⁄48) traveling 55 mph at 30 and 45 feet. Statistical analyses were performed using a student t-test. RESULTS: The average baseline noise was 53.49dB(A). As conversation, suction/lithotripsy, and music were added, noise levels were 61.82dB(A), 77.96dB(A), and 87.33dB(A), respectively. At baseline noise, the surgical assistant, anesthesiologist and circulating nurse correctly recorded 100%, 100% and 96% of the words, respectively. The correct response rate by the subjects decreased to 97%(p1⁄40.172), 81%(p<0.001) and 56%(p<0.001) with suction/lithotripsy and 90%(p1⁄40.006), 48%(p<0.001) and 13%(p<0.001) with suction/lithotripsy/music. By comparison, total PCNL noise (conversation/suction/lithotripsy/music) [87.33 dB(A)] was louder than the measured car [67.8 dB(A); p<0.001] and pickup truck noise [69.2 dB(A); p<0.001] but similar to a freight train at 30 feet [82.2 dB(A); p1⁄40.44]. CONCLUSIONS: Endourologic instruments and music utilized during PCNL may significantly contribute to noise pollution in the operating room environment and this noise may significantly degrade the effectiveness of communication. An understanding of the role that noise and distance play in affecting the success of communication may reduce operating room errors and patient complications.

MP30-10 INTRAOPERATIVE NOISE POLLUTION AND ITS EFFECT UPON COMMUNICATION DURING PERCUTANEOUS NEPHROSTOLITHOTOMY

You have accessJournal of UrologyStone Disease: Surgical Therapy III1 Apr 2015MP30-10 INTRAOPERATIVE NOISE POLLUTION AND ITS EFFECT UPON COMMUNICATION DURING PERCUTANEOUS NEPHROSTOLITHOTOMY Kristene Myklak, Hayley Mowery, Muhannad Alsyouf, Roger Li, Michelle Lightfoot, Chase Atiga, David Tryon, Herbert Hodgson, Carol Conceicao, Daniel Faaborg, Javier L. Arenas, Nazih Khater, Herbert C. Ruckle, D. Daniel Baldwin, and D. Duane Baldwin Kristene MyklakKristene Myklak More articles by this author , Hayley MoweryHayley Mowery More articles by this author , Muhannad AlsyoufMuhannad Alsyouf More articles by this author , Roger LiRoger Li More articles by this author , Michelle LightfootMichelle Lightfoot More articles by this author , Chase AtigaChase Atiga More articles by this author , David TryonDavid Tryon More articles by this author , Herbert HodgsonHerbert Hodgson More articles by this author , Carol ConceicaoCarol Conceicao More articles by this author , Daniel FaaborgDaniel Faaborg More articles by this author , Javier L. ArenasJavier L. Arenas More articles by this author , Nazih KhaterNazih Khater More articles by this author , Herbert C. RuckleHerbert C. Ruckle More articles by this author , D. Daniel BaldwinD. Daniel Baldwin More articles by this author , and D. Duane BaldwinD. Duane Baldwin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.592AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Tools and equipment utilized during endourologic surgery contribute significantly to noise pollution in the operating room (OR) during percutaneous nephrostolithotomy (PCNL). The purpose of this study was to determine OR baseline noise and noise contributed by endourologic equipment during PCNL; then, to determine the effect of this noise upon the effectiveness of communication. METHODS Ambient noise in the operating room was measured using a digital decibel meter. Noise levels were determined by the sequential addition of normal conversation, high-pressure suction, ultrasonic lithotripter, and background music. Three subjects—the surgical assistant (0.8m from the surgeon), anesthesiologist (1.8m), and the circulator (2.5m) were placed in the operating room to simulate positioning during PCNL. Five trials of 20 different medical words/phrases were spoken by the surgeon. Trials were performed with three sound categories. The first category included ambient sound alone, the second included ambient sound, suction and lithotryptors, and the third included ambient sound, suction, lithotripsy and loud music. In addition, the OR noise was compared to commonly encountered environmental noise; including cars (n=12) and trucks (n=18) driving 40 mph at 30 ft, and freight trains (n=8) traveling 55 mph at 30 and 45 feet. Statistical analyses were performed using a student t-test. RESULTS The average baseline noise was 53.49dB(A). As conversation, suction/lithotripsy, and music were added, noise levels were 61.82dB(A), 77.96dB(A), and 87.33dB(A), respectively. At baseline noise, the surgical assistant, anesthesiologist and circulating nurse correctly recorded 100%, 100% and 96% of the words, respectively. The correct response rate by the subjects decreased to 97%(p=0.172), 81%(p<0.001) and 56%(p<0.001) with suction/lithotripsy and 90%(p=0.006), 48%(p<0.001) and 13%(p<0.001) with suction/lithotripsy/music. By comparison, total PCNL noise (conversation/suction/lithotripsy/music) [87.33 dB(A)] was louder than the measured car [67.8 dB(A); p<0.001] and pickup truck noise [69.2 dB(A); p<0.001] but similar to a freight train at 30 feet [82.2 dB(A); p=0.44]. CONCLUSIONS Endourologic instruments and music utilized during PCNL may significantly contribute to noise pollution in the operating room environment and this noise may significantly degrade the effectiveness of communication. An understanding of the role that noise and distance play in affecting the success of communication may reduce operating room errors and patient complications. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e351 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kristene Myklak More articles by this author Hayley Mowery More articles by this author Muhannad Alsyouf More articles by this author Roger Li More articles by this author Michelle Lightfoot More articles by this author Chase Atiga More articles by this author David Tryon More articles by this author Herbert Hodgson More articles by this author Carol Conceicao More articles by this author Daniel Faaborg More articles by this author Javier L. Arenas More articles by this author Nazih Khater More articles by this author Herbert C. Ruckle More articles by this author D. Daniel Baldwin More articles by this author D. Duane Baldwin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP30-17 NATURAL HISTORY OF RESIDUAL FRAGMENTS FOLLOWING PERCUTANEOUS NEPHROSTOLITHOTOMY

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

MP30-01 PATIENTS ARE AT RISK FOR PYELOVENOUS BACKFLOW DURING PERCUTANEOUS NEPHROSTOLITHOTOMY

INTRODUCTION AND OBJECTIVES: The pressure in the renal pelvis may have a significant effect upon patient outcomes during percutaneousnephrostolithotomy (PCNL). Pressures greater than 30mm Hg can cause pyelovenous backflow with its increased risk for urosepsis. Meanwhile, low renal pelvic pressure (RPP) can lead to collapse of the collecting system, impaired visualization and greater blood loss. The purpose of this study was to determine the influence of nephroscope type and the use of suction upon renal pelvic pressures obtained duringPCNL. METHODS: During PCNL performed in the prone split leg position, ureteroscopic directed US guidance was utilized to establish a 30 Fr access sheath. Once the access was established the working channel of the ureteroscope was connected to a pressure transducer and utilized to determine RPP at baseline, when irrigating using a 26 Fr rigid nephroscope with and without suction, and during irrigation with a 16 Fr flexible nephroscope. Pressure readings were randomly obtained during the case. Patient demographics and access location were also recorded. A Mann-Whitney U test was used to compare the RPP during rigid and flexible nephroscopy, with p<0.05 considered statistically significant. RESULTS: A total of 148 measurements were recorded in 16 patients undergoing PCNL. Mean patient age was 53.6 years (20-71) and BMI was 33.0 (18-53.3). All patients had single tract access including 14 patients with upper pole and 2 patients with lower pole access. Rigid nephroscopy resulted in significantly higher average RPP compared to flexible nephroscopy (30.4 vs. 11.6 mmHg; p<0.001). The mean RPP was greater than 30 mmHg (the threshold for pyelovenous backflow) in 5 patients (31.3%) using the rigid nephroscope and in no patient using the flexible nephroscope. The use of suction resulted in significantly lower renal pelvic pressure (1.0 mmHg) when compared to both rigid (p<0.001) and flexible nephroscopy (p<0.001). CONCLUSIONS: Use of the rigid nephroscope resulted in renal pelvic pressure greater than the threshold for pyelovenous backflow in 31.3% of patients. The RPP is significantly lowered by the use of the flexible nephroscope or suction. Knowledge of the factors that influence RPP and methods to control the pressure extremes may improve patient safety during PCNL.

Effect of percutaneous nephrostolithotomy combined with flexible ureteroscopy on renal function in elderly patients with renal calculi

To detect the levels of neutrophil gelatinase-associated lipocalin (NGAL), cystatin C (Cys-C ) in blood and the level of kidney injury molecule 1 (KIM-1) in urine in elderly patients with renal calculi at diff erent times, and to explore the eff ect of percutaneous nephrostolithotomy (PCNL) combined with flexible ureteroscopy (FU) on early postoperative renal function. A total of 46 patients with renal calculi were selected, and their blood or urine specimens were collected respectively at preoperative and postoperative 2, 12, 24, 48, and 72 h. The concentrations of NGAL, Cys-C, KIM-1 were detected. The levels of NGAL and Cys-C began to increase respectively at postoperative 2 and 12 h, and reached peak at postoperative 12 to 24 h. There was significant difference in the levels of NGAL and Cys-C between the postoperative 12 and 2 h or between postoperative 48 and 24 h (all P<0.05). The levels of NGAL and Cys-C began to decline and eventually returned to preoperative levels respectively at postoperative 48 and postoperative 72 h. The KIM-1 began to increase at postoperative 2 h and peaked at postoperative 24 h, which was significant difference between the postoperative 24 and 12 h or postoperative 48 and 24 h (both P<0.05). The level of KIM-1 began to decline and eventually returned to preoperative levels at postoperative 48 h. After the combined treatment of percutaneous nephrostolithotomy with flexible ureteroscopy, the concentrations of NGAL, Cys-C and KIM-1 are significantly increased, suggesting injuries on renal function. The time of renal tubular injury and recovery is earlier than that of renal glomerulus.

Overuse of Antimicrobial Prophylaxis in Community Practice Urology

We examined index urological surgeries to assess utilization patterns of antimicrobial prophylaxis in a large, community based population. From the Premier Perspectives Database we identified patients who underwent inpatient urological surgeries that are considered index procedures by the ABU (American Board of Urology), including radical prostatectomy, partial or radical nephrectomy, radical cystectomy, ureteroscopy, shock wave lithotripsy, transurethral resection of the prostate, percutaneous nephrostolithotomy, transvaginal surgery, inflatable penile prosthesis, brachytherapy, transurethral resection of bladder tumor and cystoscopy. Procedures were identified based on ICD-9 procedure codes for 2007 to 2012. Antimicrobial administration, class and duration were abstracted from patient billing data. The class and duration of antimicrobials concordant with the 2008 AUA Best Practice Policy Statement was used to determine compliance. The overall compliance rate was 53%, ranging from 0.6% for radical cystectomy to 97% for shock wave lithotripsy. Antimicrobial use consistent with AUA Best Practices included the appropriate class in 67% of cases (range 34% to 80%) and the recommended duration in 78% (range 1.2% to 98%). Average prophylaxis duration for procedures for which it is recommended ranged from 1.1 days after brachytherapy to 10.3 days after radical cystectomy. The compliance rate increased from 46% overall in 2007 to 59% overall in 2012. We documented considerable variation in antimicrobial prophylaxis for urological surgery. Compliance with AUA Best Practices increased with time but overall rates remain less than 60%. Efforts are needed to better understand the reasons for variation from recommended antimicrobial prophylaxis for common inpatient urological procedures to help decrease resultant complications and improve outcomes.

Editorial Comment

This study highlights that even small residual stone fragments (RFs) after postpercutaneous nephrolithomy (PCNL) are a significant risk factor for subsequent ancillary surgical interventions. In particular, although other groups have demonstrated that RFs >2 mm are associated with stone events, 1 Raman J.D. Bagrodia A. Gupta A. et al. Natural history of residual fragments following percutaneous nephrostolithotomy. J Urol. 2009; 181: 1163-1168 Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar these authors highlight that even fragments <2 mm pose a significant risk for repeat procedures with a cumulative retreatment rate of 33.3% over 7 years. Furthermore, the risk of retreatment is greater if RFs are non–calcium based with a cumulative retreatment rate of 56.4%. These data continue to raise the question of whether any RF can be accurately classified as clinically insignificant. Retreatment After Percutaneous Nephrolithotomy in the Computed Tomographic Era: Long-term Follow-upUrologyVol. 84Issue 2PreviewTo examine the long-term retreatment rates and explore prognostic factors after percutaneous nephrolithotomy (PCNL) in the computed tomographic era. Full-Text PDF ReplyUrologyVol. 84Issue 2PreviewWe appreciate the thoughtful comments. Full-Text PDF

1033 Is preoperative UTI associated with increased risks of UTI after ureteroscopic lithotripsy? A nationwide population-based study

INTRODUCTION AND OBJECTIVES: The AUA offers Best Practice recommendations for antimicrobial prophylaxis for urologic surgeries. Despite these recommendations, the duration and class of antibiotics administered by urologists varies considerably. Improper administration of antibiotics may lead to increased costs, antibiotic resistance, predispose to hospital-acquired infections, and induce adverse drug reactions. We examined index urologic procedures and assessed compliance with AUA guidelines for antibiotic class and duration. METHODS: From the Premier Perspectives Database, we identified 53,450 patients undergoing radical prostatectomy (RP), 4,732 undergoing radical cystectomy (RC), 44,133 undergoing partial or radical nephrectomy (Nephx), 202,740 undergoing ureteroscopy/shock wave lithotripsy (SWL), 91,279 undergoing transurethral resection of the prostate (TURP), 21,469 undergoing percutaneous nephrostolithotomy (PCNL), 54,908 undergoing transvaginal surgery, 8,612 undergoing penile prosthesis (IPP), 11,487 patients undergoing brachytherapy, and 114,132 undergoing transurethral resection of bladder tumors (TURBT), based on ICD-9 procedure codes, from 2007-2012. Antibiotic class and duration were abstracted from patient billing data. Overall compliance with the AUA Best Practice Policy Statement was defined as receiving the appropriate antibiotic class (or antibiotic class combination) in conjunction with duration not extending beyond 24 hours post-surgery as detailed in the AUA Best Practice Policy Statement. RESULTS: Surgery-specific rates of compliance with AUA guidelines for selected procedures are listed in the Table. Correct antibiotic class was ordered in 67% of cases (range 34-80% for the different procedures). The correct duration (<24 hours post-surgery) was observed in 78% of cases overall (range 1.2-98%). Average length of antibiotic prophylaxis ranged from 1.1 days after brachytherapy to 10.3 days following RC. Overall compliance was 53.4%, ranging from 0.6% in RC to 68.3% in ESWL. Over time, compliance increased, ranging from a low of 46.2% overall compliance in 2007 to 58.9% overall compliance in 2012. CONCLUSIONS: The administration of antibiotic prophylaxis after surgery is subject to considerable variation. Increased compliance in recent years may relate to better dissemination of AUA guidelines. Efforts are needed to further improve standardization of antibiotic administration for common urologic procedures.

MP73-11 DECREASED RENAL FUNCTION IN PATIENTS UNDERGOING MULTI-ACCESS PERCUTANEOUS NEPHROSTOLITHOTOMY

INTRODUCTION AND OBJECTIVES: The impact of percutaneous nephrostolithotomy (PCNL) on renal function has long been a concern especially in the setting of multi-tract access. Previous studies have demonstrated minimal renal injury with PCNL when using serum creatinine and GFR as markers. Tc99m-MAG3 nuclear renography is a superior marker of renal function and may better elucidate injury. We hypothesize that multi-tract PCNL could negatively affect renal function as compared to single-access PCNL. METHODS: We performed a retrospective review of 307 consecutive patients undergoing PCNL from 2011-2012 at Wake Forest Baptist Health. A comparison of single and multi-access ( 2) PCNL was undertaken using Tc99m-MAG3 nuclear renogram parameters in addition to serum creatinine values. Other variables assessed include age, sex, and BMI. Data collected was within a year of PCNL treatment. Statistical analysis was performed with Statsplus . RESULTS: A total of 110 patients (74 single access, 36 multiple access) were identified for which pre and post-PCNL renograms were available. There was no significant differences in age, gender, BMI, serum creatinine, or MAG3 renogram derived T/2 between these cohorts. We noted a significant decrease in Tc99m-MAG3 split function in the operated kidney for patients with multiple access versus single access PCNL (-2.28%, p 0.05, respectively). Successive decrease in renal function was suggested with increasing number of percutaneous accesses into the kidney although this was not statistically significant (likely due to the low number of cases with more than 2 accesses [F(2,107)1⁄41.487, p1⁄40.23]). CONCLUSIONS: We present one of the largest series of renal function assessment with Tc99m-MAG3 nuclear renography in patients undergoing single versus multi-access percutaneous nephrostolithotomy. Multi-tract PCNL appears to be associated with a significant decline in renal function as assessed by Tc99m-MAG3 nuclear renography. This suggests that numerous accesses may exacerbate perioperative renal injury. Further review of patient and peri-operative parameters is needed to both further elucidate and to confirm this relationship.

MP6-18 THE IMPACT OF UNPLANNED POST-PROCEDURE VISITS ON THE MANAGEMENT OF PATIENTS WITH URINARY STONES

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I1 Apr 2014MP6-18 THE IMPACT OF UNPLANNED POST-PROCEDURE VISITS ON THE MANAGEMENT OF PATIENTS WITH URINARY STONES Charles Scales, Christopher Saigal, Janet Hanley, Andrew Dick, Claude Setodji, and Mark Litwin Charles ScalesCharles Scales More articles by this author , Christopher SaigalChristopher Saigal More articles by this author , Janet HanleyJanet Hanley More articles by this author , Andrew DickAndrew Dick More articles by this author , Claude SetodjiClaude Setodji More articles by this author , and Mark LitwinMark Litwin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.252AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Unplanned follow-up care is the focus of intense health policy interest, as evidenced by recent financial penalties imposed for hospital re-admissions under the Affordable Care Act. To date, however, unplanned post-procedural care remains poorly characterized, particularly for patients with kidney stones. Our objective was to describe the frequency, variation and financial impact of unplanned, high-acuity follow-up visits in the treatment of patients with renal and ureteral stones. METHODS We identified privately insured patients undergoing percutaneous nephrostolithotomy, ureteroscopy, or shock wave lithotripsy for stone disease. The primary outcome (an unplanned visit) was occurrence of an emergency department visit or hospital admission within 30 days of the procedure. Admissions for second-look percutaneous nephrostolithotomy were excluded. Multivariable models estimated the odds of an unplanned visit and the incremental cost of those visits, controlling for important covariates. RESULTS We identified 93,523 initial procedures to fragment or remove stones. Among these patients, 54,267 (58%) were male, and most (71%) were aged between 31 and 55 years. Overall, 1 in 7 patients had an unplanned post-procedural visit. The most common diagnoses for these visits included pain, infection, bleeding and renal failure. Unplanned visits were least common following shock wave lithotripsy (12%), and occurred with similar frequency after ureteroscopy and percutaneous nephrostolithotomy (15%). Procedures at high-volume facilities were substantially less likely to result in an unplanned visit (OR 0.80, 95% CI 0.74–0.87, P<0.001). Patients with greater comorbidity were more likely to experience an unplanned visit. When an unplanned visit occurred, adjusted incremental expenditures per episode were greater after shock wave lithotripsy [$32,156 (95% CI $30,453–33,859)] than after ureteroscopy [$23,436 (95% CI $22,281–24,590)]. CONCLUSIONS Patients not infrequently experience an unplanned, high-acuity visit after low-risk procedures to remove urinary stones, and the cost of these encounters is substantial. Interventions are indicated to identify and reduce preventable unplanned visits. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e63 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Charles Scales More articles by this author Christopher Saigal More articles by this author Janet Hanley More articles by this author Andrew Dick More articles by this author Claude Setodji More articles by this author Mark Litwin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...