Percutaneous Stone Treatment Research Articles

Complications in percutaneous lithotomy

Percutaneous lithotomy is the gold standard in the treatment of large kidney stones. Several steps of the operation might cause severe complications. Safe procedures depend on careful planning, accurate performance, recognition of problems and knowledge of how to handle them. Relevant steps of percutaneous stone treatment with possible complications and their management are presented. Current topics in percutaneous stone treatment taking into consideration the relevant literature are discussed. Furthermore, rare complications and strategies for safe management are presented. Careful planning and adequate preoperative diagnostic workup are essential for safe procedures. Puncture of the renal calyceal system and tract dilation might lead to severe complications. Bleeding and infectious complications are the most common problems. Availability of interventional radiology provides ideal emergency treatment in case of severe bleeding and helps to avoid surgical revision with high risk of organ loss. Percutaneous stone treatment is a safe and effective therapy in an experienced physician's hands. Careful planning and accurate performance help to avoid severe complications.

Percutaneous nephrolithotomy under combined sonographic/radiologic guided puncture: results of a learning curve using the modified Clavien grading system

Aim of our study was to evaluate the results of percutaneous nephrolithotomy (PNL) with sonographic/fluoroscopic guided puncture during a learning curve and to compare them to an expert. The first 75 consecutive patients undergoing conventional PNL or Mini-PNL by a novice percutaneous surgeon without direct supervision by an expert were evaluated and divided into three groups of 25 patients each. The results were compared to 50 cases treated by an expert. For mean stone sizes of 22.3 ± 12.9, 22.7 ± 14.9, and 31.1 ± 25.5 mm, the OR-time was 124 ± 35, 106 ± 37, and 99 ± 31 min for the novice groups 1, 2, and 3, respectively. In contrast, the expert required an OR-time of 85 ± 28 min for a mean stone size of 19.7 ± 4.2 mm (p < 0.001; p < 0.01; n.s.). Stone free rates were 100, 96, and 100%; however, second-look procedures were necessary in 24, 16, and 20% of cases, whereas the expert needed only 8% second-look procedures. No complications Clavien IIIb-V occurred. 16, 4, and 8% of patients required a double-J placement (Clavien IIIa) due to hydronephrosis or urine leakage. One patient in the novice group 2 needed transfusion (Clavien II). Other minor complications (Clavien I) occurred in 28, 20 and 12% in the novice groups 1, 2 and 3, respectively, in comparison with 22% in the expert group. Percutaneous stone treatment under combined sonographic/fluoroscopic guided puncture can be performed safe and efficiently during the learning curve. The lower expertise causes longer operation times and a higher re-intervention rate without compromising the patients' safety.

Percutaneous treatment of stones in pediatrics: A retrospective multicenter study

Purpose This study was conducted to investigate the cons and pros of percutaneous stone treatment in a large population of children in a retrospective manner. Material and methods Three centers with experience in pediatric stone disease were included in this study. The data regarding the patients, stones, surgery and postoperative course were collected from each center. Results 346 renal units were operated in 311 (M:211, F:100) pediatric patients. The ages ranged from 9 months to 16 year old (mean:8.6). The mean stone area was 338.7 mm 2 (25-2075). Five had horseshoe kidneys, 2 had stones in caliceal diverticula, 9 had solitary kidney and 5 children had chronic renal failure. The procedure was carried out using different sizes of instruments within a mean surgery time of 90 min (10-270) and a mean fluoroscopy time of 12.9 min. (1.5-53). 267 (77%) renal units were rendered completely stonefree without major complications. The mean hospitalization time was 5.1 days (2-31). Blood transfusion rate was 14.7%, re-PCNL was performed in 8, adjuvant SWL was done in 6. Two had nonfunctional kidneys on follow-up. Conclusions Percutaneous nephrolithotomy is a standard treatment option for most of the large stones in pediatrics with acceptable morbidity. The technique is well established and is no longer of concern for this age group. Future studies should focus on randomized comparative trials with SWL.

Die Verwendung von Gelatine-Thrombin-Matrix zum Verschluss des Arbeitskanals bei der nephrostomielosen minimal-invasiven perkutanen Nephrolitholapaxie

The spectrum of percutaneous stone treatment was significantly widened following the introduction of the miniaturized percutaneous nephrolitholapaxy. At the end of the procedure usually a nephrostomy tube was placed to avoid urine paravasation and prolonged bleeding. In this work the tube-less mini-PCNL with direct closure of the access tract was compared to traditional mini-PCNL with placement of the nephrostomy tube. Twenty consecutive patients undergoing mini-PCNL with placement of a nephrostomy tube at the end of the procedure were compared to 20 consecutive patients with direct closure of the access tracts following percutaneous stone removal. Clinical data like decrease in Hb, complications, need for analgesics and duration of hospital stay were compared. Both groups underwent the procedure without complications. There was no need for blood transfusions. The difference in total analgetic dose was not statistically significant; however, patients in the nephrostomy group needed analgetics for a longer period of time. There was no difference in duration of hospital stay (3.2 days in the tube-less group versus 3.4 days in the nephrostomy group). The primary stone-free rate was higher in the group with direct closure of the access tract (95 versus 85%). Closure of the percutaneous access following mini-PCNL with a gelatine-thrombin-haemostatic sealant is a safe alternative to the commonly used nephrostomy tube and can help to reduce postoperative pain and patient discomfort.

Lower pole calculi larger than one centimeter: Retrograde intrarenal surgery

Controversy remains on how to treat lower pole calculi between 1 and 2 cm of size. Treatment options like shock wave lithotripsy (SWL) or percutaneous stone treatment (PCNL) are associated with poor stone-free rates or high morbidity.Due to the ongoing development in endourologic technology, especially in flexible renoscopy, laser technique and grasping devices (tipless Nitinol baskets) retrograde intrarenal surgery (RIRS) has become an option in treating these patients.Based on personal experience and an overview of the published literature we discuss RIRS as a valuable alternative to PCNL in treating patients with larger calculi of the lower pole.The technical developments in laser technology as well as significant improvement in flexible renoscopes have made RIRS for larger lower pole stones possible. The low complication rate gives RIRS for lower pole stones superiority over the invasive percutaneous approach, which is associated with significant morbidity, even in experienced hands.

Diagnosis and treatment of urological complications in kidney transplantation.

Between January 1973 and January 1990 we carried out 1,038 kidney transplantations using a transvesical end-to-side implantation of the ureter in the bladder without an antireflux mechanism. Moreover, 30 transplantations were done in 26 patients with a urinary diversion. We examined the urological complications in these 1,068 consecutive transplants. Urinary leakage and obstruction were the two main urological posttransplant complications. Severe leakage occurred in 21 patients (2.0%), and was treated by open surgery; 2 patients had a urinary diversion. The treatment of choice is a pyeloureterostomy (anastomosis between the transplant renal pelvis and the native ureter). There were 35 patients (3.3%) with severe ureteral obstruction of whom 5 had a urinary diversion. In 30 patients open surgical treatment of the obstruction was necessary and in 7 patients a percutaneous endourologic treatment was done (dilatation of a confined ureteral stricture in 6 patients and percutaneous stone treatment in 1). The postoperative mortality in the patients treated for leakage or obstruction was low: 4 patients (7%) died, 3 of septicemia due to leakage and 1 of pulmonary embolism after repair of the obstruction. The results of surgical treatment were good. The graft survival after 2 years in the group of urologically complicated transplants was 68% for the patients with leakage and 80% for those with obstruction. The 2-year graft survival in the patients without complications was 67% and 71% for the patients with a urinary diversion. We conclude from these results that urological complications after renal transplantation can be treated successfully by surgical (or percutaneous) correction.

Surgical treatment of urologic complications in kidney transplantation

Between January 1973 and December 1987 we carried out 846 kidney transplants using a transvesical end-to-side implantation of the ureter in the bladder without an antireflux mechanism. Moreover, 22 transplantations were carried out in 19 patients with a urinary diversion. We examined the urologic complications in these 868 consecutive transplants. Urinary leakage and obstruction were the two main urologic posttransplant complications. Severe leakage occurred in 17 patients (1.9%) and was treated by open surgery; the treatment of choice is a pyeloureterostomy (anastomosis between the transplant renal pelvis and the native ureter). There were 33 patients (3.8%) with severe ureteral obstructions. In 28 patients, open surgical treatment of the obstruction was necessary, and 5 patients required percutaneous endourologic treatment (dilitation of a confined ureteral stricture in 4 patients and percutaneous stone treatment in 1). The postoperative mortality was low: three patients (6%) died, two of septicemia due to leakage and one of pulmonary embolism after repair of the obstruction. The results of surgical treatment were good. The graft survival after 2 years in the group of urologically complicated transplants was 69.2% for the patients with leakage and 82.4% for those with obstructions. We conclude from these results that urologic complications after renal transplantation can be successfully treated by surgical (or percutaneous) correction.