Use Of Percutaneous Nephrolithotomy Research Articles

Safety and Efficacy of Percutaneous Nephrolithotomy in Solitary Functioning Kidneys: A Retrospective Cohort Study in an Asian Population.

Objective The aim of the study was to assess the safety of preserved renal function after standard percutaneous nephrolithotomy (PCNL) in patients with a single functional kidney. The main parameters to focus on were serum creatinine levels and any associated complications. Materials and methods This retrospective cohort study was conducted in an Eastern population in a single center from 2016 through 2023 at The Kidney Centre Postgraduate Training Institute, Karachi, Pakistan. Results Out of the total 1,550 PCNL procedures performed on adult patients, 47 patients had a solitary functioning kidney with stones, which were evaluated. The stone clearance rate was 95.74% (45 patients), with a mean operative time of 85.96 minutes. Most patients, i.e., 33 (70.21%), had an infracostal approach, and single tract management was sufficient for 45 (95.74%) patients. The most common complication was transfusion, which was required in five (10.64%) patients. Mean preoperative hemoglobin dropped by 1.43mg/dL postoperatively, and mean serum creatinine decreased from 2.45mg/dL to 1.97mg/dL. Among the 24 (51.06%) analyzed stones, all were calcium oxalate. Conclusion In challenging situations such as a solitary kidney with a large stone, PCNL is the procedure of choice. However, the refined technique is of paramount importance. Overall, the use of PCNL in these unique conditions is safe and rewarding.

The role of mini-PCNL as primary approach for the treatment of pediatric kidney stones in a high-income country. Ten-year single-center report.

To describe our experience in the use of percutaneous nephrolithotomy (PCNL) as a primary treatment for paediatric kidney stones and to highlight its benefits. The design was retrospective and observational. All the children treated for kidney stones from 2011 to 2021 were included. The population was divided into Group A (PCNL) and Group B (retrograde intrarenal surgery, RIRS). The outcomes were stone-free rate (SFR), the rate of procedures per patient, the rate of failure and the rate of complications. Twenty-eight patients with 33 kidney units were included. Eighteen of them (64%) were males. The median age was 10 (IQR 6.8-13) years. Forty-seven procedures were performed. Twenty-four of them (51%) were mini-PCNL. Group A included 17 patients (61%). Group A presented a higher SFR (p = 0.007) and a lower number of procedures (p < 0.001). RIRS failed in five cases (45%) because of non-compliant ureter. Two urinary tract infections (UTI) were reported after PCNL and four UTIs after RIRS (p = 0.121). No major complications were reported. Mini-PCNL should be suggested as a primary approach for pediatric kidney stones. This technique presented a better effectiveness with a reduced number of procedures when compared to RIRS.

Initial Experience of Simultaneous Combined use of Percutaneous Nephrolithotomy and Flexible Ureteroscopy in Complex Renal Calculi: A Novel Surgical Technique of 'Through-Through' Approach.

For complex branched renal calculi, the endoscopic combined intrarenal surgery (ECIRS) is worldwide prevalent. This study aimed to present a novel surgical technique of percutaneous nephrolithotomy combined with antegrade flexible ureteroscopy which is named 'Through-through' approach. We retrospectively analyzed the data of 68 patients with complex renal calculi who underwent combined PNL and flexible ureteroscopy surgery using 'Through-through' approach at our center between August 2019 and December 2021. The 'Through-through' approach to surgery was indicated in residual calyceal calculi that neither rigid nephroscope nor retrograde flexible ureteroscope could reach. The brief procedure of this technique involved determining the direction of targeted calyces with the nephroscope first, followed by putting flexible ureteroscope into the targeted calyx through the nephroscope instrument channel and basketing or dusting residual calculi through the flexible ureteroscope instrument channel. The mean maximum stone diameter was 4.0 ± 0.4cm. The mean operative duration was 100.1 ± 18.0minutes, and mean hemoglobin loss was 21.4 ± 5.1g/L. In all 68 patients, calculi were cleared in 62 patients, and the stone free rate was 91.2%. Five patients underwent further surgery after 2weeks because of significant residual calculi. One patient that had a 6mm residual stone chose observational follow-up. Ten patients emerged with postoperative fever but did not progress to uroseptic shock. There were no Clavien grade ≥ III complications, and none of the patients required blood transfusion. The 'Through-through' approach is safe, feasible and effective for complex renal calculi patients. It is a complementary solution to the failed endoscopic combined intrarenal surgery.

MP23-20 THIRTY-YEAR TRENDS IN THE MANAGEMENT OF UROLITHIASIS IN THE UNITED STATES

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making III (MP23)1 Sep 2021MP23-20 THIRTY-YEAR TRENDS IN THE MANAGEMENT OF UROLITHIASIS IN THE UNITED STATES Ridwan Alam, Jared Winoker, Ayman Alam, and Brian Matlaga Ridwan AlamRidwan Alam More articles by this author , Jared WinokerJared Winoker More articles by this author , Ayman AlamAyman Alam More articles by this author , and Brian MatlagaBrian Matlaga More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002014.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the past 30 years, the field of endourology has seen an explosion of technological advancements that has significantly changed the management of stone disease. We sought to determine if the constant refinement and increased familiarity with endoscopic procedures has led to a concomitant shift in treatment practices for both upper and lower urinary tract calculi. METHODS: In this population-based cohort study, we used data from TriNetX, a large health research network with real-time updates of electronic medical records (EMR) from 49 health care organizations in the United States. Due to the dependence on EMR, data from participating institutions prior to the implementation of an electronic record system are not included. Patients with upper tract stones who underwent shock wave lithotripsy (SWL), ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), or open surgery were identified based on Current Procedural Terminology (CPT) codes. Similarly, patients with lower tract stones who underwent cystolitholapaxy or cystolithotomy were separately identified and analyzed. RESULTS: SWL was the primary mode of treatment for patients with upper tract stones until 2000, after which URS saw a dramatic increase that has persisted through 2020 (Figure 1). During this time, PCNL has remained relatively stable, representing about 10% of upper tract stone procedures. For patients with lower tract stones, cystolitholapaxy has always been favored over cystolithotomy, and the gap continues to increase over time (Figure 2). CONCLUSIONS: URS has gained considerable popularity at the expense of SWL for the management of upper tract calculi. However, the use of PCNL has been largely unaffected by this shift in practice patterns. The relative stability of PCNL may be a reflection of its surgical invasiveness when compared to SWL and URS, or may be due to less overlap in clinical indication with its less invasive counterparts, among other reasons. Minimally invasive approaches have always been and continue to be favored for the treatment of lower tract calculi. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e410-e410 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ridwan Alam More articles by this author Jared Winoker More articles by this author Ayman Alam More articles by this author Brian Matlaga More articles by this author Expand All Advertisement Loading ...

Percutaneous Nephrolithotomy in the 80 Years of Age and Older Population

ObjectiveTo evaluate feasibility of percutaneous nephrolithotomy (PCNL) for complex nephrolithiasis in patients 80 years of age and older compared to younger individuals. MethodsFrom an institutional IRB-approved database, 1,647 patients were identified who underwent PCNL from 1999 to 2019. Patients were stratified by age: group 1 (20-59), group 2 (60-79), and group 3 (>80). Statistics were performed using chi-square and ANOVA to compare outcomes. ResultsOf the 1,647 patients, median age was 46, 66, and 83, respectively (P <0.0001). Three patients within group 3 were 90 or older. Females made up 54%, 46%, 56% of patients (P = 0.02). Average stone size with SD was 2.6 ± 2.2, 2.5 ± 2.3, 2.2± 1.9 cm for each group (P = 0.06). Mean preoperative hemoglobin (Hgb) was significantly lower in the 80+ group (13.8, 13.4, 13.1 g/dL, P <.0001). Change in Hgb was not significantly different. There were more Clavien II-IV complications (10.4, 14.4, 28.8%; P = 0.02) and transfusions (2.3, 4.7, 10.2%; P <0.001) in the elderly. The most common complications in the 80+ group were bleeding related (10.1%). No difference in readmission rates or ICU admissions was noted. ConclusionPCNL is feasible in the extremely elderly; however with a higher rate of complications and longer hospitalizations. No long-term sequelae or deaths in the 80 and older cohort were seen. This study allows us to appropriately counsel older patients on a realistic postoperative course and supports use of PCNL as the best means of long-term survival.

Surgical Treatment Methods of Urolithiasis in the Pediatric Population

Urolithiasis in the pediatric population represents a major challenge associated with both the diagnosis and therapy of the condition. Over the past 25 years, the incidence has increased. The average age of pediatric patients with stones is about 7-8 years and the recurrence rate is 24%-50%. More than 80% of the stones are eliminated spontaneously. The remaining ones require conservative or surgical treatment. Choosing the most appropriate treatment depends on many factors. Surgical procedures in children are the same as in adults. These include extracorporeal shockwave lithotripsy (ESWL), ureterolithotripsy (URSL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL) and laparoscopic or open surgery. ESWL is a method of choice for the treatment of stones with a diameter of ≤20 mm located in the upper urinary tract, while PCNL is used in the treatment of deposits ≥1.5 cm located in the upper pole of the kidney, deposits of ≥1.0 cm located in the lower pole of the kidney, as well as hard stones such as cystic or struvite ones. URSL/RIRS is a method for ureteral and renal stones. Open surgery is indicated in cases when anatomical anomalies coexist with urolithiasis, or when the use of PCNL or ESWL is impossible. The ideal procedure should be effective, safe and allow the complete evacuation of the stones after the 1st procedure.

MP68-15 THE EVOLUTION OF PERCUTANEOUS NEPHROLITHOTOMY: ANALYSIS OF A SINGLE INSTITUTION EXPERIENCE OVER 25 YEARS

You have accessJournal of UrologyStone Disease: Surgical Therapy IV1 Apr 2018MP68-15 THE EVOLUTION OF PERCUTANEOUS NEPHROLITHOTOMY: ANALYSIS OF A SINGLE INSTITUTION EXPERIENCE OVER 25 YEARS Jennifer Bjazevic, Linda Nott, John Denstedt, and Hassan Razvi Jennifer BjazevicJennifer Bjazevic More articles by this author , Linda NottLinda Nott More articles by this author , John DenstedtJohn Denstedt More articles by this author , and Hassan RazviHassan Razvi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2219AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The incidence of nephrolithiasis and the use of percutaneous nephrolithotomy (PCNL) has risen significantly over the years. PCNL aims to achieve a high stone-free rate with a low risk of complications. The objective of our study was to determine the impact of changes in patient demographics and surgical techniques over a 25-year time period, on PCNL outcomes. METHODS A retrospective analysis on a prospectively maintained database, including 2554 consecutive PCNL treatments in 2486 patients from July 1990 to July 2015 was undertaken. Collected data included patient demographics, comorbidities, stone and procedure characteristics, adverse events, and stone-free status at three-month follow-up. Adverse events were categorized according to the Clavien-Dindo classification. Patients were divided into equal terciles, each representing 852 consecutive procedures, ordered chronologically. Chi squared test was used to evaluate changes in patient characteristics and surgical techniques over time. A multivariate logistic regression was used to identify the effect of time on operative duration, adverse events, stone-free rate and hospital length of stay. RESULTS Our cohort had a mean age of 54 ± 15 years, was 66.6% male, had a mean body mass index (BMI) of 31 ± 8, and a mean stone surface area of 895 ± 602 mm2. Medical comorbidities were present in 46.9% of patients, most commonly hypertension (22%), diabetes (14%), and cardiac disease (13%). Overall complication rate was 15.6%, including a 2.5% rate of major complications (Clavien grade 3-5). Three-month follow-up of 1873 available patients showed residual stones in 13.3%. Over time there was a statistically significant increase in patient age, BMI, comorbidities, and ASA score. Over time, both OR duration (mean Δ 16 mins, p<0.001) and hospital length of stay (mean Δ 3 days, p<0.001) decreased significantly. Intra-operatively, there was an increase in the use of the balloon dilator and ultrasonic lithotripter (p<0.001). Stone-free rate decreased significantly over time (OR 1.09, p<0.001), but was correlated with an increased use of CT scans for follow-up imaging. There was an increased complication rate with time (OR 1.15, p=0.010); however, this was correlated with the increased rate of medical comorbidities. The overall transfusion rate was 1.0% and did not change over time (p=0.131). CONCLUSIONS Despite an increasingly complex patient population, PCNL remains a safe and effective procedure for the management of large and complex urolithiasis; resulting in a high stone-free rate and low risk of complications. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e922 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Jennifer Bjazevic More articles by this author Linda Nott More articles by this author John Denstedt More articles by this author Hassan Razvi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Percutaneous Nephrolithotomy in Patients With BMI >50: Single Surgeon Outcomes and Feasibility

To evaluate the use of percutaneous nephrolithotomy (PNL) and technical approach in the super obese population (body mass index [BMI] ≥ 50). We performed a retrospective review of 31 consecutive PNL cases with a BMI > 50 from a single surgeon (SYN) from 1995 to 2013. Procedures were performed in the prone position, and upper pole access was used. Operative time, length of hospital stay, stone burden, complication rates, and stone-free rates were measured. Of the 31 patients who underwent PNL (age 51.2 ± 12; 71% female), the mean BMI was 59.1 ± 6 kg/m(2) (range 50.4-71.7 kg/m(2)). Mean stone burden was 3.8 cm ± 2. The majority of patients (90.3%) had an upper pole puncture site for access with an operative time of 122.1 ± 75 minutes. The technique was similar to non-obese patients; however, there was a need for extra-long instrumentation. The overall stone-free rate was 71%, with utilization of a second-look PNL in 11 cases. The complication rate, Clavien grade 3 or higher, was 9.7% (3 of 31). PNL is technically feasible, safe, and effective in patients with a BMI ≥ 50. The complication rate, length of hospital stay, and stone-free rate with use of second-look PNL in super obese patients are comparable to severely obese patients. Intervention should not be automatically ruled out or delayed based on the patient's BMI alone.

Outcomes following ‘mini’ percutaneous nephrolithotomy for renal calculi in children. A single-centre study

This retrospective review was undertaken to identify the postoperative outcomes of children undergoing 'mini' percutaneous nephrolithotomy (MPCNL) at a single institution. Outcomes measured included: percentage of stone clearance, postoperative analgesia requirements, the need for intraoperative or postoperative blood transfusion, length of stay and morbidity. A total of 46 patients were reviewed over a two-and-a-half-year period; the mean age was 7.3 years (range: 1-16 years). The MPCNL was performed with a radiological-guided peripheral puncture, followed by dilatation of the nephrostomy tract to a maximum Amplatz sheath size of 16-French; an 11-French nephroscope was used. Stone disintegration was achieved either with pneumatic or laser lithotripsy. Complete stone clearance was achieved in 35/46 children (76%). The remaining 11 children had a stone clearance rate of over 80%. No patients required intraoperative/postoperative blood transfusion. A total of 39% of patients were managed on simple/non-opiate based analgesia, with 54% requiring opioid analgesia postoperatively for less than 24 h. There were no procedure-related complications and no mortalities. The mean length of stay was 2.24 days. The management of urolithiasis can be challenging in children. The use of percutaneous nephrolithotomy, is becoming increasingly popular in the treatment of paediatric urolithiasis. The stone clearance rate in children undergoing standard PCNL, has been reported to be 50-98% in the literature [1,2,3,4]. Samad et al. [2] in 2006, reported their experience in 188 consecutive PCNLs, using a 17Fr or 26Fr nephroscope. Their largest sub group included children aged >5-16 yrs. Within this group, 57% were treated with a 17Fr nephroscope and 43% with the 26Fr nephroscope, achieving stone clearance of only 47% with PCNL monotherapy. In this group the transfusion rate was 3% [2]. Badawy et al., reported their experience of 60 children in 1999, using a 26 or 28Fr Amplatz sheath. They reported an 83.3% stone clearance with single session PCNL, with only one procedure being abandoned due to intraoperative bleeding requiring blood transfusion [3]. In 2007, Bilen et al. reported their experience and compared the use of 26Fr, 20Fr and 14Fr (mini) PCNL. Stone size, previous surgery and the mean haemoglobin drop postoperatively did not change between the groups, however the blood transfusion rate was higher in the 26Fr and 20Fr Amplatz sheath groups. The stone clearance was highest in the 'mini PCNL' group at 90%, compared to 69.5% in the 26Fr and 80% in the 20Fr group [4]. MPCNL has become increasingly popular over recent years, with stone clearance reported as 80-85% [5-7] following a single session of MPCNL as monotherapy. In 2012, Yan et al. reported 85.2% stone clearance with mini PCNL monotherapy (tract size 14-16Fr), with no children requiring blood transfusion [6]. Zeng et al. reported their experience of 331 renal units in children, with stone clearance rates reaching 80.4% and a blood transfusion rate of 3.1% [8]. In our centre, we do not perform postoperative haemoglobin levels as a matter of routine and any investigations are performed on an intention to treat principle. Bilen et al. reported no blood transfusions being required in their cohort of patients undergoing MPCNL [4] and this is supported by Yan et al. [6]. Mini PCNL is an effective and safe procedure for the treatment of paediatric renal stones. In the present series, all children achieved greater than 80% stone clearance, none received a blood transfusion (intra/postoperatively) and there were no mortalities. Postoperative pain was managed with simple analgesia in 39%; however, the majority required opiate analgesia for less than 24 hours.

Contemporary practice patterns associated with percutaneous nephrolithotomy among certifying urologists.

Percutaneous nephrolithotomy (PCNL) is the treatment of choice for patients with complex stone burdens. We performed a study to assess the effect of urologist-specific parameters on the use of PCNL-both the access component of the procedure as well as the stone removal. We also examined trends in PCNL utilization over time. We analyzed self-reported 6-month case logs submitted to The American Board of Urology (ABU) for urologists who certified or recertified between 2004 and 2013. Surgeons performing PCNL were identified by Current Procedural Terminology coding. Urologist-specific data, including fellowship training, practice type, and practice population, were used to further stratify this cohort. Trends were examined over the study period. A total of 7278 urologists submitted case logs to the ABU between 2004 and 2013. The median ages of the initial certification group, first recertification group, and second recertification group were 36.0, 43.7, and 53 years, respectively. A greater proportion of newly certified urologists performed PCNL (53%) compared with urologists in the first (41%) and second (29%) recertification groups; initially certified urologists were also more likely to be high volume (>10) PCNL surgeons. Urologists with fellowship training were more likely to use PCNL (66%) and be high-volume surgeons (26.4%). PCNL utilization increased significantly during the study period, with 1330 procedures performed in 2004 and 2888 procedures performed in 2012 (117% increase). Younger and fellowship-trained urologists are the primary users of PCNL; the majority of senior urologists do not perform this operation. Overall, the use of PCNL and urologist-directed access has increased in the previous decade.

PD7-07 CONTEMPORARY PRACTICE PATTERNS ASSOCIATED WITH PERCUTANEOUS NEPHROLITHOTOMY AMONG CERTIFYING UROLOGISTS

You have accessJournal of UrologyStone Disease: Therapy I1 Apr 2014PD7-07 CONTEMPORARY PRACTICE PATTERNS ASSOCIATED WITH PERCUTANEOUS NEPHROLITHOTOMY AMONG CERTIFYING UROLOGISTS Gautam Jayram and Brian R. Matlaga Gautam JayramGautam Jayram More articles by this author and Brian R. MatlagaBrian R. Matlaga More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.696AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Percutaneous nephrolithotomy (PNL) is a specialized surgical procedure utilized for patients with complex stone burdens. Our understanding of factors affecting the utilization of this procedure is limited. We studied the impact of urologist training and practice parameters on the utilization of PNL and urologist-directed access over time. METHODS We analyzed self-reported 6 month case logs submitted to The American Board of Urology (ABU) for urologists certifying or re-certifying between 2004 and 2013. Surgeons performing PNL were identified by CPT coding: 50080 and 50081; percutaneous access was identified by CPT 50395. Urologist-specific data, including fellowship training, practice type, and practice population, were used to further stratify the cohort performing these procedures. RESULTS A total of 7,278 urologists submitted case logs to the ABU between 2004-2013. The median ages of the initial certification group, first recertifying group and second recertifying group were 36.0, 43.7 and 53 years, respectively. A greater proportion of newly certified urologists performed PNL (53%) compared to urologists in the 1st (41%) and 2nd (29%) recertification groups; newly certified urologists were also more likely to be high volume (> 10) PNL surgeons. Urologists with fellowship training in stones were much more likely to utilize PNL (66%) and be high-volume surgeons (26.4%). Non-private and heavily populated (>1,000,000) practice settings also had significantly more high-volume PNL surgeons. PNL utilization increased significantly during the study period, with 1,330 procedures performed in 2004 and 2,888 procedures performed in 2012 (117% increase). Older urologists' utilization of PNL increased over time. Urologist access concordantly increased over time, with 14.5% of PNL cases utilizing urologist access in 2004 and 20.4% in 2012, a 29% increase (see figure 1). Certification status did not correlate with urologist access. CONCLUSIONS Younger and fellowship-trained urologists are the primary utilizers of PNL, and the majority of senior urologists do not perform this operation. Overall, the use of PNL and urologist-directed access has increased in the previous decade. Our findings can serve to inform future discussions on the regionalization of specialized urologic care. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e186 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Gautam Jayram More articles by this author Brian R. Matlaga More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Kids with stones—data on causes and treatment safety

Two retrospective studies published recently in The Journal of Urology add to the body of evidence on paediatric upper-tract stone disease. The first study shows that obesity is not a significant risk factor for urolithiasis in children, whereas the second confirms the use of percutaneous nephrolithotomy (PCNL) as a safe and effective treatment modality.

Percutaneous Nephrolithotomy Use Is Increasing in the United States: An Analysis of Trends and Complications

To report the use and complication rates of percutaneous nephrolithotomy (PCNL) performed in the United States between 1998 and 2009. The Nationwide Inpatient Sample database was analyzed from 1998 to 2009 to identify all PCNL cases performed in adults ≥18 years old. Descriptive statistics were used for potential covariates: Demographics, comorbidities, academic/community hospital, rural/urban location, and U.S. geographic region. Common complications encoded by International Classification of Diseases-9 codes after PCNL were reported over time, and those found to be statistically significant were evaluated in the multivariate regression. Linear regression was used to analyze surgical trends. Multivariate regression was performed to identify covariates that predicted any surgical complication. The use of PCNL among inpatients increased significantly from 15 to 27 surgeries/100,000 discharges between 1998 and 2009 (P<0.001), and this increase was seen in all geographic regions of the United States. The increase in adoption of PCNL was accompanied by an increase in complications (14% to 19%, P<0.001). Higher comorbidity (Charlson ≥3) was the strongest predictor of complications in multivariate analysis (odds ratio=2.22, P<0.001). This is the first study to demonstrate an increase in PCNL use in the United States over the last decade. While there was an increase in surgical complications during this same period, the complication rate found reported is commensurate with other international reports. PCNL is safe and use of percutaneous surgery in the United States will most likely continue to increase.

Trends in the Utilization of Percutaneous and Open Nephrolithotomy in the Treatment of Renal Calculi

To evaluate trends in the use of percutaneous nephrolithotomy (PCNL) and nephrolithotomy (NL) in patients with renal pelvis calculi. An analysis of the 5% Medicare Public Use Files (years 2001, 2004, 2007, and 2010) was performed to assess changes in the use of PCNL and NL over a 10-year period. Patients were identified using the International Classification of Diseases-9 (cm) and Current Procedure Terminology codes. Statistical analyses, including the Fisher and chi-square tests and multivariate regression analyses, were performed using SAS 9.3 (SAS Institute Inc, Cary, NC) and SPSS v20 (IBM Corp., Armonk, NY). A total of 26,100 patients underwent either PCNL or NL. Use of PCNL and NL decreased from 3.1% to 2.5% in patients with a diagnosis of stones (P<0.0001). Women (odds ration [OR]=1.19, P=0.003) were more likely to undergo surgery. Patients aged ≥65 years were less likely to be treated (OR=0.65-0.71, P<0.05). Patients treated after 2004 were less likely to undergo surgery (OR=0.77-0.84, P<0.05). The use of PCNL exceeded NL at a stable 10:1 ratio. The use of PCNL and NL for treatment of patients with stone disease slightly decreased from 2001 to 2010, although the number of patients with renal calculi increased. The use of PCNL vs NL was unchanged during this period. Multiple inequalities existed in overall surgical treatment rates and were influenced by sociodemographic factors such as age and sex.

Trends in Percutaneous Nephrolithotomy Use and Outcomes in the United States

We investigated recent trends in the use and perioperative outcomes of percutaneous nephrolithotomy in the United States in a population based cohort. We obtained the records of patients treated with percutaneous nephrolithotomy between 1999 and 2009 from the Nationwide Inpatient Sample (NIS). A weighted sample was used to estimate national utilization rates. Trends in age, comorbidity, perioperative complications and in-hospital mortality were analyzed. Temporal trends were quantified by the estimated annual percent change. We evaluated the association between patient and hospital characteristics, including complications, prolonged length of stay and in-hospital mortality, using logistic regression models adjusted for clustering. During 1999 to 2009, percutaneous nephrolithotomy use increased in men and women from 3.0/100,000 and 2.99/100,000 to 3.63/100,000 and 4.07/100,000, respectively. Women showed the largest increases in percutaneous nephrolithotomy use with an estimated annual percent change of 4.49% (95% CI 2.7-6.3, p <0.001) vs 2.90% (95% CI 1.5-4.3, p = 0.003) in men. Baseline comorbidity in patients undergoing percutaneous nephrolithotomy increased with time. Overall complications increased from 12.2% to 15.6% (p <0.001), while mortality remained stable at 0.0% to 0.4%. The transfusion rate was 4.0%. Sepsis increased from 1.2% to 2.4% of cases (p <0.001). Patients were at risk for complications if they were older, more ill and treated in more recent years. Age was significantly associated with increased odds of mortality. Percutaneous nephrolithotomy use in the United States has increased and females are now the majority gender. Although mortality remains low, rates of sepsis and overall complications have increased. Broad use of percutaneous nephrolithotomy, especially in older and more ill patients, may account for these changes.

Management of 1-2 cm renal stones.

Introduction:The preferred treatment of >1cm stone is shockwave lithotripsy (SWL), while that of stone <2 cm is percutaneous nephrolithotomy (PCNL), but treatment of 1-2 cm renal stones is a controversial issue. We searched the literature to present a comprehensive review on this group.Material and Methods:Pubmed search of literature was done using the appropriate key words. We separately discussed the literature in lower polar and non lower polar stone groups.Results:For non lower polar renal stones of 1-2 cm, SWL is preferred approach, while for the lower polar stones; literature favors the use of PCNL. Retrograde intrarenal surgery (RIRS) is emerging as a promising technique for these calculi.Conclusions:Treatment of renal stone disease depends on stone and patient related, as well as on renal anatomical factors. Treatment should be individualized according to site of stone and available expertise.

Percutaneous nephrolithotomy combined with endoscopic balloon dilation in the treatment of upper ureterostenosis with recurrent renal calculi

Objective To analyze the technique and clinical effect of percutaneous nephrolithotomy combined with endoscopic balloon dilation in the treatment of upper ureterostenosis with recurrent renal calculi. Methods From June 2008 to June 2011,18 ureteral stenosis patients with the history of ureteral open surgery,postoperative residual or recurrent kidney stones were treated.There were 8 males and 10 females with the age of 27 -48 years.Fourteen cases were with hydronephrosis of 2 -4 cm,3 cases were with hydronephrosis of 5 -6 cm and 1 case was with hydronephrosis ＞6 cm.Subsequent stone size ＜ 1 cm was found in 15 cases,1 -3 cm in 3 cases,＞3 cm in 1 case.All patients were treated with percutaneous nephrolithotomy ultrasonic lithotripsy combined with balloon dilatation.The stone clearance rate,hydronephrosis changes,complications and IVP situation before and after surgery were analyzed. Results All the 18 cases were completed surgery successfully.There was 1 (6％) case with renal hemorrhage 3 days after the surgery and controlled with DSA hemostasis.There was 1 case accepted adjusting double-J tube by ureteroscopy.Sixteen (89％) patient's stones were completed removed.One case with residual calyceal stones size ＜5 mm was not further treated.There was 1 case treated with nephrectomy because of renal stone with infection.The patients were followed up for 6 to 36 months.Fourteen cases with hydmnephrosis improved significantly; 3 cases with no significant changes but improved following balloon dilation.All patients achieved significant improvement in imaging study comparing of preoperative and postoperative data. Conclusion The use of percutaneous nephrolithotomy combined with endoscopic balloon dilation is a safe and efffective treatment option in the treatment of kidney stones with ureteral stenosis. Key words: Nephrostomy,percutaneous; Percutaneous nephrolithotomy; Balloon dilation; Hydronephrosis; Ureteral stenosis

Melamine Related Bilateral Renal Calculi in 50 Children: Single Center Experience in Clinical Diagnosis and Treatment

We investigated the clinical diagnosis and treatment features of bilateral renal calculi in young children who ingested melamine tainted infant milk formula. We retrospectively analyzed clinical data on 50 children (mean +/- SE age 23.4 +/- 3.1 months) with a history of ingesting melamine tainted infant milk formula and suffering from bilateral renal calculi. All patients underwent ultrasound and renal function evaluation. Treatment included cessation of melamine tainted formula consumption, hydration, urine basification and hemodialysis if necessary. Bilateral renal calculi peaked in 6 to 18-month-olds (58% of cases). The male-to-female ratio was 3.1:1.0. Calculi ranged in diameter from 4 to 10 mm in 33 patients (66%) and 2.5 to 4 mm in 17 (34%). Of the 11 patients with renal failure 8 underwent 1 to 4 sessions of hemodialysis. Of the 9 bilateral obstruction cases with renal failure 8 did not require surgical intervention but 1 required ureteral catheterization to drain the renal pelvis. All children experienced a good outcome and were discharged home after a mean +/- SE hospitalization of 8.1 +/- 0.7 days. Melamine related urinary calculi were most often seen in patients 6 to 18 months old. Conservative management has been sufficient in most cases. However, these children need to be monitored for long-term effects of melamine tainted milk formula consumption.

Percutaneous Nephrolithotomy in Children

To review the history of percutaneous nephrolithotomy (PCNL) in children, describe technical considerations, including advancements in equipment, and discuss future directions. A comprehensive literature review was performed using MEDLINE/PubMed to evaluate the use of PCNL in the pediatric population, including historical background, indications, operative techniques, and outcomes. PCNL was first applied to the pediatric population in the 1980s using adult-size instruments. Although there is still concern for potential renal damage in relatively small kidneys, initial investigations have demonstrated its safety and efficacy in children. Operative techniques are similar to those used in adult patients, but considerations specific to pediatric populations must be addressed. Modifications in technique including "mini-perc" access have reduced postoperative morbidity without an appreciable difference in outcomes. Technologic improvements, including miniaturization of endoscopes and advances in energy sources for stone fragmentation, have facilitated stone-free rates comparable to those of adult populations with PCNL monotherapy and sandwich shockwave lithotripsy therapy with minimal postoperative morbidity. Technologic advancements and refinements in technique have facilitated the successful application of PCNL in the pediatric population. As a result, PCNL has now replaced open surgery as the treatment of choice for large stone burdens in children of all ages.

Contemporary Surgical Management of Upper Urinary Tract Calculi

Upper urinary tract calculi are treated with multiple technologies including shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy. Our knowledge of surgical practice patterns in the treatment of these calculi is limited. We performed a study of the surgical practice logs submitted to the American Board of Urology by candidates for initial certification and recertification to characterize the manner in which renal and ureteral calculi are treated. Logs from initial certification, first recertification and second recertification cohorts were reviewed. CPT codes were used as search criteria, and included 50590 (shock wave lithotripsy), 52352 (ureteroscopy, stone removal), 52353 (ureteroscopy, lithotripsy), 50080 (percutaneous nephrolithotomy for stones less than 2 cm) and 50081 (percutaneous nephrolithotomy for stones greater than 2 cm). For the initial certification cohort surgical logs from 2004 to 2008 were reviewed and 1,065 individuals were identified. For the 2 recertification cohorts logs from 2003 to 2007 were reviewed, with 1,120 individuals identified in the first recertification cohort, and 831 identified in the second recertification cohort. Candidates for initial certification used ureteroscopy in the majority of stone removal procedures (52.0%), and candidates for first and second recertification used shock wave lithotripsy in the majority of their procedures (57.4% and 60.5%, respectively). There was a decreasing use of percutaneous nephrolithotomy across the cohorts with 6.8% in the initial, 4.5% in the first and 2.6% in the second recertification cohort. Provider specific attributes may affect how upper tract calculi are treated. Urologists in the initial certification cohort claimed the greatest use of endoscopic treatment modalities and most commonly performed ureteroscopy. Shock wave lithotripsy was more commonly used by the 2 recertification cohorts, comprised of more senior urologists.