Safety and efficacy of percutaneous nephrolithotomy for the treatment of paediatric urolithiasis

INTRODUCTION

Paediatric percutaneous nephrolithotomy (PCNL) has revolutionised the treatment of paediatric nephrolithiasis. Paediatric PCNL has been performed using both adult and paediatric instruments. Stone clearance rates and complications vary according to the technique used and surgeon experience. We present our experience with PCNL using adult instruments and a 28Fr access tract for large renal calculi in children under 18 years.

METHODS

All patients undergoing PCNL at our institution between 2000 and 2009 were reviewed. Demographics, surgical details and post-operative follow-up information were obtained to identify stone clearance rates and complications.

RESULTS

PCNL was performed in 32 renal units in 31 patients (mean age: 10.8 years). The mean stone diameter was 19mm (range: 5–40mm). Twenty-six cases required single puncture and six required multiple tracts. Overall, 11 staghorn stones, 10 multiple calyceal stones and 11 single stones were treated. Twenty-seven patients (84%) were completely stone free following initial PCNL. Two cases had extracorporeal shock wave lithotripsy for residual fragments, giving an overall stone free rate of 91% following treatment. There was no significant bleeding or sepsis encountered either during the operation or in the post-operative setting. No patient required or received a blood transfusion.

CONCLUSIONS

Paediatric PCNL can be performed safely with minimal morbidity using adult instruments for large stone burden, enabling rapid and complete stone clearance.     

Critical prospective appraisal of renal morphology and function in children undergoing shockwave lithotripsy and percutaneous nephrolithotomy

PURPOSE: To assess the effect of shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) on renal morphology and function in children undergoing therapy for upper-tract urolithiasis. PATIENTS AND METHODS: Fourteen patients less than 13 years of age with renal or upper-ureteral calculi who were found suitable for primary SWL or PCNL were evaluated for alteration of renal morphology and function after treatment. Of the 18 renal units treated, SWL and PCNL were performed in 9 units each. The average stone size was 880.2 mm2 (range 110-3800 mm2; median 660 mm2). All children underwent ultrasonic estimation of renal length and parenchymal thickness, 99m technetium dimercaptosuccinic acid (DMSA) and 99m Tc-ethylene dicystine (EDC) scintigraphy, and glomerular filtration rate (GFR) estimation prior to intervention and at 3 and 6 months of follow-up. RESULTS: Extracorporeal lithotripsy achieved complete clearance in 8 renal units (88%), requiring an average of 6333 shockwaves and an average of 2.2 sessions per renal unit. The efficiency quotient was 42. Percutaneous surgery likewise achieved complete stone clearance in 88% of renal units, with three units requiring more than one tract. Mixed calcium oxalate monohydrate and dihydrate accounted for the majority of the stones. The mean preintervention GFR was 78.3 +/- 14.6 mL/min/1.73 m2 (median 82.5 mL/min/1.73 m2; range 54-98.6 mL/min/1.73 m2), whereas the mean GFR at 3 months was 78.95 +/- 14.4 mL/min/1.73 m2 (median 78.95 mL/min/1.73 m2; range 52-98 mL/min/1.73 m2). A marginal improvement of an average of 0.65 mL/min was noted. Split function EDC scans demonstrated improved drainage in five cases after intervention; the rest were unchanged. Preintervention DMSA scans revealed renal cortical scars in three children. None of the renal units had developed fresh scars at follow-up scans. None of the children developed new-onset hypertension, proteinuria, or alteration in renal size. CONCLUSION: In the present study, pediatric SWL and PCNL were not found to cause adverse renal morphologic or functional alteration. Stone clearance resulted in marginally improved function and better drainage.     

Pediatric urolithiasis: 15 years of local experience with minimally invasive endourological management of pediatric calculi

PURPOSE: We sought to identify whether changes in technology and local practice have improved outcomes in the minimally invasive management of pediatric stone disease. MATERIALS AND METHODS: We reviewed retrospectively case notes and imaging from 1988 to 2003, noting treatment modality, stone-free rates, ancillary therapy and complications. RESULTS: A total of 122 children (140 renal units) with a mean age of 7.7 years underwent 209 extracorporeal shock wave lithotripsy (SWL) sessions. Stone size ranged from 6 to 110 mm. Stone-free rates were 84% for cases involving stones smaller than 20 mm, and 54% for those involving stones 20 mm or greater. For complex calculi 40% of patients were stone-free and 45% required ancillary procedures, with an overall complication rate of 26%. A total of 37 children (43 renal units) with a mean age of 6.4 years underwent 46 percutaneous nephrolithotomies (PCNLs). Stone size ranged from 8 to 155 mm. The overall stone-free rate was 79%. Of these patients 34% required ancillary procedures, with a major complication rate of 6%. A total of 35 children (35 renal units) with a mean age of 5.9 years underwent 53 ureteroscopies. Holmium laser was the most effective treatment modality in this group, with a 100% stone-free rate and no complications. CONCLUSIONS: For most renal stones smaller than 20 mm SWL was the most effective primary treatment modality. There was no statistical difference between the 2 lithotriptors for stone-free or ancillary procedure rate. The stone-free rate was dependent on stone size rather than type of lithotriptor. For renal stones 20 mm or greater and staghorn calculi we switched from SWL to PCNL as primary treatment, as stone-free rates were higher and the ancillary procedure and re-treatment rates were lower with PCNL. Electrohydraulic lithotripsy and pulse dye laser were initially used to treat ureteral stones. However, with the introduction of holmium laser technology we achieved higher stone-free rates and lower complication rates. Holmium laser lithotripsy is now used as a primary treatment modality for ureteral stones.     

Paediatric percutaneous nephrolithotomy: setting new frontiers

OBJECTIVE: To assess the safety and outcome of paediatric percutaneous nephrolithotomy (PCNL) for atypical cases and compare the results with 'standard' unilateral paediatric PCNL. PATIENTS AND METHODS: We retrospectively reviewed children who had had a PCNL between December 1997 and December 2004. Patients were grouped as follows: group 1, aged >5-16 years with normal anatomy and normal renal function undergoing unilateral PCNL or staged bilateral PCNL; group 2, < or = 5 years with normal anatomy and renal function undergoing unilateral PCNL; group 3, undergoing bilateral simultaneous PCNL; group 4, impaired renal function in addition to renal stone disease; group 5, renal anatomical abnormality with calculi in the same kidney. Demographics, stone profile, procedure and outcome indicators were analysed for each group. RESULTS: In all, 188 consecutive PCNLs in 169 children were included (mean age 3.3-10.3 years, mean stone burden 19.1-33.3 mm in the five groups). The mean duration of PCNL was 69-115 min. Stone clearance was satisfactory with single tract access in 90-100% of patients. Transient postoperative fever was the commonest complication (12.5-51%) followed by hyponatraemia and hypokalaemia. Blood transfusion was required in 0-7.7%. The mean stone clearance rates were 47-90% in the five groups; additional extracorporeal shockwave lithotripsy increased the cumulative clearance rates to 90-100%. CONCLUSION: PCNL is safe for treating renal stones, with excellent results and minimal complications. Comparable results are achieved in the very young child, children with anatomically abnormal kidneys, children with impaired renal function and children with bilateral renal stones undergoing simultaneous bilateral PCNL. Hence none of these factors should be considered as relative contraindications.     

The management of paediatric urolithiasis

OBJECTIVE: To evaluate the efficacy and safety of the management of paediatric urolithiasis by extracorporeal shock wave lithotripsy (ESWL), endoscopic ureterolithotomy, percutaneous nephrolithotomy (PCNL) and open nephrolithotomy. PATIENTS AND METHODS: In a 3-year period (1997-1999), 59 children were treated for urolithiasis and underwent a total of 79 procedures. Thirty-two ESWL sessions were performed in 23 children (mean age 7.4 years, median 6.0). PCNL was undertaken in 30 renal units in 25 children (mean age 6.4 years, median 4.0). Eight patients (mean age 7.8 years, median 5) underwent 17 ureteroscopic procedures, six of which involved the use of a holmium laser. Three children with staghorn calculi underwent open nephrolithotomy under conditions of renal ischaemia and hypothermia. RESULTS: Of the 23 children treated using ESWL, 21 (91%) became stone-free; 17 underwent one ESWL session (74%), three had two sessions and three (13%) had three sessions. All eight patients who underwent ureteroscopy became stone-free. Four patients in whom the stone could not be reached by ureteroscopy initially had a JJ stent inserted, and the stone and stent subsequently removed. Stones were cleared using PCNL in 27 of 30 renal units (90%); three patients who had residual stone fragments were rendered stone-free by ESWL. Two of three children undergoing open nephrolithotomy were stone-free after surgery and the remaining one rendered stone-free with ESWL. Metabolic evaluation showed that 25 of 45 children (55%) had a urinary infection, eight (18%) had hyperoxaluria, three (7%) had hypercalciuria, two (4%) had cystinuria, and no identifiable cause was found in seven (16%). Treatment by a single modality rendered 52 of the 59 children (88%) stone-free; when the different modalities were combined, 57 of 59 patients (97%) were cleared of their stones. CONCLUSIONS: Technological advances in ESWL, ureteroscopy and PCNL have had a significant effect on the management of urolithiasis in children, allowing a safe and successful outcome. The comprehensive care of children with urolithiasis should include a full metabolic evaluation. Anatomical anomalies contribute to the complexity of many cases, necessitating a close liaison between adult and paediatric urologists, nephrologists and radiologists to optimize stone management in children.     

Single upper-pole percutaneous access for treatment of > or = 5-cm complex branched staghorn calculi: is shockwave lithotripsy necessary?

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy for staghorn calculi is reported to have a residual stone rate of 28%, while shockwave lithotripsy alone results in residual stones in approximately 50% of cases. Combination therapy, sandwich therapy, and multiple percutaneous accesses have also been advocated for staghorn stones. We believe these stones can often be removed with a staged procedure via a single upper-pole percutaneous access using flexible nephroscopy and the holmium:YAG laser. Our experience is reviewed. PATIENTS AND METHODS: The hospital records of patients having a cumulative stone burden > or =5 cm who underwent percutaneous nephrolithotripsy (PCNL) for a single complex staghorn calculus were reviewed. There were 15 male and 34 female patients having 45 complete and 7 partial staghorn calculi constituting a mean stone burden of 6.7 cm (range 5.0-10.0 cm). A calix was punctured that would provide access to the majority of the involved calices. Thirty-five renal units were approached through a single upper-pole percutaneous access, and four and six renal units were accessed through single middle or lower-pole calices, respectively. The remaining seven renal units were treated with multiple percutaneous accesses. RESULTS: In the renal units having only a single access, a mean of 1.6 (range 1-3) procedures were required to achieve stone-free status. The mean operating room time was 2.9 hours (range 2.0-3.5 hours). For the second PCNL, the mean operating room time was 63 minutes (range 30-90 minutes). Two patients (two renal units) had residual stones <1 cm in diameter. One refused additional surgery, and the other is awaiting further treatment. The mean estimated blood loss was 238 mL (range 50-800 mL), with only one procedure (2.2%) necessitating a blood transfusion. One (2.8%) hydrothorax developed among the 35 upper-pole puncture cases. Six patients had transient oral temperature readings >101 degrees F with negative blood cultures. Other early complications included single cases of leg cellulitis, atrial fibrillation, and noncardiac chest pain. There were no delayed surgical complications. Patients were discharged from the hospital a mean 2 days (range 1-10 days) after the first PCNL. CONCLUSION: Use of flexible nephroscopy with holmium:YAG laser lithotripsy and Nitinol basket stone extraction has allowed us to render staghorn-containing renal units stone free in a mean of 1.6 procedures. Of the 45 renal units treated through a single percutaneous access, 43 (95%) were rendered stone free. The holmium:YAG laser appears to be a safe lithotrite for the kidney, as no complications occurred from its use.     

Prospective evaluation of safety and efficacy of the supracostal approach for percutaneous nephrolithotomy

OBJECTIVE: To prospectively evaluate the safety and efficacy of the supracostal approach for percu-taneous nephrolithotomy (PCNL), as it is usually avoided because of concerns about potential chest complications. PATIENTS AND METHODS: Between August 1998 and August 2001, 465 patients underwent PCNL. Supracostal access was obtained in 62 patients (63 renal units), comprising 13% of the procedures. The indications for a supracostal approach were staghorn, upper ureteric, superior calyceal stones and high-lying kidneys. The data were analysed for stone clearance, need for additional punctures and the complications associated with supracostal puncture. RESULTS: The supracostal was the only access in 63% of the PCNL procedures. Additional punctures were required mainly for staghorn stones (15 of 23). Overall, 90% of the patients were rendered stone-free or had clinically insignificant residuals with PCNL alone. In patients with staghorn stones, they were completely cleared in 84% of renal units. Significant chest complications developed in three (5%) patients, which required insertion of a chest tube. One (2%) patient developed haemothorax secondary to injury of the intercostal artery. All the patients recovered uneventfully. CONCLUSIONS: These results indicate that supracostal access provides high clearance rates with acceptable complications; it should not be avoided for fear of chest complications. A chest X-ray after surgery should be routine, to detect any complication.     

三种经皮肾穿刺取石术治疗上尿路结石对照分析

目的：比较李氏肾镜与标准经皮肾镜及微创经皮肾输尿管镜治疗上尿路结石的有效性与安全性,提高上尿路结石的治疗水平.方法：2005年1月～2009年1月,三种经皮肾穿刺取石术治疗上尿路结石132例,其中包括肾结石87例（包括肾脏单发及多发结石56例,鹿角型结石31例）,输尿管上段结石45例.标准经皮肾镜取石术34例,年龄34～78岁,平均57岁;结石大小2.3～5.8 cm,平均3.5 cm;鹿角型结石14例.微创经皮肾输尿管镜取石术52例,年龄31～77岁,平均51岁;结石大小2.1～5.0 cm,平均3.3 cm;鹿角型结石8例.经皮李氏肾镜取石术46例,年龄29～81岁,平均55岁;结石大小2.0～5.5 cm,平均3.0 cm;鹿角型结石9例.对三组患者手术时间、留置造瘘管时间、I期结石清除率及手术出血进行比较.结果：李氏肾镜治疗输尿管上端结石（L4）手术时间（56±5）min,治疗上尿路结石I期手术清除率为80.43%,出血量为（156±38）ml,输血率2.17%,与标准经皮肾镜及微创经皮肾输尿管镜比较,差异均有统计学意义（P＜0.05）.对李氏肾镜治疗6例肾盂单发结石患者实行＂无管化＂,均恢复较好,无一例发生出血、漏尿及感染.结论：李氏肾镜在微造瘘经皮肾手术中较标准肾镜和输尿管镜代肾镜具有操作更简化、手术效率更高、剩余结石更少、并发症减少等优点.     

Percutaneous nephrolithotomy for treating renal calculi in children

OBJECTIVE: To report our experience with the percutaneous management of renal stone disease in children. PATIENTS AND METHODS: The medical and radiological records of children up to 18 years old who were treated for renal calculi by percutaneous nephrolithotomy (PCNL) at our institution between March 1995 and April 2003 were reviewed. For stone removal a special paediatric 18 F access sheath was used. RESULTS: In all, 26 PCNLs were used in 23 patients (10 boys and 13 girls, aged 1.7-16.8 years). The presenting symptoms were urinary tract infection, abdominal pain and/or haematuria. Of the 23 patients, 17 (75%) had associated metabolic disease or underlying urological anatomical abnormalities. Urinary tract infections were found in 15 patients (65%). The mean (range) stone burden was 6.0 (0.5-18.2) cm2, and the operative duration 127 (50-260) min. The primary stone-free rate was 58%, which increased to 81% after treating residual fragments. One blood transfusion was required and one patient developed urosepsis after PCNL, which was treated with antibiotics. CONCLUSION: PCNL is an effective alternative for treating renal stones in children, and is the treatment of choice for stones refractory to extracorporeal shock wave lithotripsy.     

超声引导下针状肾镜联合标准通道PCNL治疗鹿角形结石的安全性和有效性

目的总结超声引导下针状肾镜联合标准通道经皮肾镜取石术(percutaneous nephrolithotomy,PCNL)治疗鹿角形结石的初步临床应用经验,探讨其安全性和有效性。方法回顾性分析2017年12月至2019年6月北京清华长庚医院收治的65例鹿角形结石患者的临床资料。男41例,女24例。年龄(53.5±8.9)岁。体质指数(25.1±2.9)kg/m2。结石最大径(10.9±3.1)cm。双侧鹿角形结石3例,完全鹿角形结石38例。术前无积水或轻度积水36例。既往有同侧肾结石手术史12例。孤立肾9例。65例均行超声引导下针状肾镜联合标准通道PCNL。手术采用全麻,患者取俯卧位。超声引导下经皮肾穿刺扩张后建立F24标准皮肾通道,肾镜下应用气压弹道联合超声负压吸引清石系统处理鹿角形结石主体。针状肾镜由F4.2针状金属外鞘和通过螺旋接口相连接的三通管针柄组成,三通管的3个接头可分别置入0.6 mm视频光纤、200μm钬激光光纤和连接液体灌注装置。标准通道肾镜碎石后残留的平行盏结石采用超声引导下针状肾镜穿刺进入目标盏后,连接钬激光光纤进行碎石。结果本研究65例中,3例为双侧结石,共68侧手术。中位手术时间为79.8(45~129)min。通道建立时间中位值为4.8(2.5~9.6)min。术中标准通道建立中位值为1.5(1~3)个,针状肾镜穿刺中位值为1.0(1~3)次。术后第1天血红蛋白下降中位值为10.6(0~25.9)g/L。术后住院时间中位值为5.5(4~7)d。总并发症发生率为10.3%(7例),其中ClavienⅠ级5例,包括术后发热2例,镇痛剂使用3例;ClavienⅡ级2例,均为输血。一期结石清除率79.4%(54/68)。14例有残石者中,9例行二期手术治疗,其中7例残石被清除,最终结石清除率为89.7%(61/68)。结论采用超声引导下针状肾镜联合标准通道PCNL治疗鹿角形结石是安全、有效的,术后早期清石率较高,并发症发生率较低。     

经皮肾输尿管镜下气压弹道碎石术治疗儿童肾结石

目的探讨经皮肾输尿管镜下气压弹道碎石术治疗儿童肾结石的疗效与安全性。方法肾结石患儿15例,均为14岁以下,其中单侧8例,双侧7例,共22个肾脏。全部病例使用全身麻醉下经皮肾输尿管镜下气压弹道碎石术治疗。术后行X线摄片观察疗效,术后48h查血红蛋白。所有病例均行代谢评估,术后使用枸橼酸钾预防结石复发。术后随访2～3年。结果20个肾脏（91％）的结石完全清除。2个有残石的肾脏经体外冲击波碎石术治疗,结石完全清除。14例患儿术后有轻、中度发热（〈39℃,〈2d）,1例术后高热（〉39℃,〉2d）。患儿术后血红蛋白较术前平均下降10．0g／L。无输血病例。平均住院5．2d。全部病例术后半年行静脉肾盂造影检查,肾功能均平稳或有改善。无远期并发症。结论对儿童肾结石行经皮肾输尿管镜下气压弹道碎石术安全、有效。     

Supra-costal tubeless percutaneous nephrolithotomy is not associated with increased complication rate: a prospective study of safety and efficacy of supra-costal versus sub-costal access

Background

To assess the morbidities of tubeless percutaneous nephrolithotomy (PCNL) using supra-costal access and re-evaluate traditional concept of increased complications with supra-costal access.

Methods

From January 2010 to December 2014, a single surgeon performed 118 consecutive one-stage fluoroscopic guided PCNL’s for complex renal and upper ureteral stone. Our definition for complex renal stone is defined as partial or complete staghorn stone, multiple renal stones in more than 2 calyxes, obstructive uretero-pelvic stone >?2?cm, and a renal stone in single functional kidney. Inclusion criteria include: staghorn stones, renal calculi >?2?cm in diameter, upper ureteral stone >?1.5?cm in diameter. Exclusion criteria for tubeless PCNL include: significant bleeding or perforation of the collecting system, large residue stone, multiple PCNL tract and obstructive renal anatomy. Morbidity, operation time, analgesia requirement, length of hospital stay, stone- free rate, were analyzed.

Results

Of the 118 consecutive PCNL, eighty-six patients underwent tubeless PCNL (56 supra-costal and 30 sub-costal) and included in our prospective follow-up period. The mean age, operation side, stone locations were similar. The male to female ratio is higher in supra-costal than sub-costal. Large renal stones and staghorn stones makes up for most patients (supra-costal: 75%, sub-costal: 80%). The stone–free rate of supra-costal group was 59% (33/56) and in sub-costal group was 50% (15/30). The operative times, length of stay, post-op analgesic use, hematocrit change was similar in both groups. The overall complication rate is 6% [supra-costal (1/56), sub-costal (4/30)] with the majority being infectious complications.

Conclusions

Supra-costal access above 12th rib during tubeless PCNL is safe and effective procedure and is not associated with higher incidence of post-op complications in experience hands.

     

Safety and efficacy of percutaneous nephrolithotomy in the pediatric population

PURPOSE: We reviewed our experience with percutaneous nephrolithotomy (PCNL) in patients in the pediatric age group and compared its efficacy and safety over a 5-year period. PATIENTS AND METHODS: We studied retrospectively and prospectively 31 patients who were treated with PCNL for renal stones larger than 1.5 cm. Variables assessed were stone bulk, size, location, and type. Metabolic and anatomic factors were also assessed. PCNL punctures and number of tracts were recorded. Clearance with PCNL and ancillary procedures was recorded. RESULTS: There were 31 renal units. Mean age of the patients was 9.6 years (range 1.5-15 years). Fifteen (48.4%) patients had single calculi; eight (25.8%) patients had staghorn calculi. Lower-pole access was the preferred route of entry, and upper-pole access was used only when necessary. We used a 22F nephroscope for the procedure. We dilated the tract to 30F in the majority of patients, but limited dilation to 24F when appropriate. If needed, we used a ureteroscope. Complete clearance was achieved in 83.9% of patients after PCNL and in 90.32% of patients after dual therapy (PCNL + shockwave lithotripsy). Average hemoglobin drop was less than 1 g/dl. Factors responsible were the size of the tract (larger than 24F) and the number of tracts. Six patients were treated for an anatomic abnormality. A metabolic abnormality was diagnosed in three patients. CONCLUSION: PCNL is effective in children, with a clearance rate of 83% and, with dual therapy, more than 90%. We recommend that tract dilation be restricted to 24F or smaller whenever possible. Approximately 40% of patients had either an anatomic or metabolic abnormality.     

Percutaneous nephrolithotomy in children: early and late anatomical and functional results

PURPOSE: We report our experience with percutaneous nephrolithotomy (PCNL) in children, and evaluate its early and late anatomical and functional results. MATERIALS AND METHODS: A total of 65 children with renal calculi were treated with PCNL. Patient age at operation ranged from 9 months to 16 years (mean +/- SD of 5.9 +/- 0.9 years), and 27 (41.5%) were younger than 5 years. Seven patients had bilateral renal stones and, therefore, the number of kidneys treated by PCNL was 72. The patients were followed regularly every 3 months during year 1 and every 6 months thereafter. Renal scans using technetium dimercapto-succinic acid for detection of renal scarring and technetium diethylenetetramine-pentaacetic acid for determination of selective glomerular filtration rate (GFR) were performed in all patients at least once during followup, which ranged from 6 to 72 months (mean +/- SD 40 +/- 10). RESULTS: Early complications included significant intraoperative bleeding in 1 case, renal pelvis perforation in 1 and transient fever in 2. Mean hospital stay +/- SD was 3 +/- 1.2 days (range 2 to 21). Of the renal units 62 (86%) were stone-free after a single PCNL, and the remaining 10 with residual stones were treated with a second look PCNL (4) and shock wave lithotripsy (6). Stone-free rates at hospital discharge and at 3 months were 93% and 100%, respectively. During followup 6 patients (9%) had recurrence of small renal stones and were successfully treated with shock wave lithotripsy. None of the kidneys had scarring on dimercapto-succinic acid renal scan. All of the kidneys except 1 showed improvement or stabilization of the corresponding GFR determined by diethylenetetraminepentaacetic acid renal scan. Comparison of the mean preoperative GFR of the corresponding kidney (28.8 +/- 11.2 ml per minute) with mean value at followup (36.1 +/- 9.9) showed an increase of statistical significance (p <0.01). CONCLUSIONS: PCNL is a safe and effective procedure for the treatment of children with renal calculi. At long-term followup the procedure improves renal function without renal scarring.     

侧卧位B超引导经皮肾镜取石术治疗复杂性肾结石

目的 评价侧卧位B超引导下经皮肾镜取石术(PCNL)治疗复杂性肾结石的疗效及安全性. 方法 复杂性肾结石患者650例.男512例,女138例.平均年龄38(11～78)岁.结石位于左肾366例,右肾284例.单发121例,多发42例,部分鹿角形结石392例,全鹿角形结石95例.肾结石平均长径31(20～58)mm.均行侧卧位B超引导下PCNL治疗. 结果 650例手术顺利.B超引导下穿刺均成功,Ⅰ期微通道气压弹道碎石术493例,标准通道气压弹道和(或)超声联合碎石清石术157例.Ⅰ期结石取净563例(86.6 0%),Ⅱ期取净65例(10.0%),Ⅲ期取净6例,有残余结石者16例联合使用ESWL治疗.Ⅰ期PCNL平均手术时间72(35～145)min.未发生气胸、结肠损伤、肾盂穿孔、水中毒、肾周感染等合并症.平均住院时间18(9～32)d. 结论 侧卧位B超引导下PCNL治疗复杂性肾结石安全有效,患者耐受性好,便于麻醉管理,医护人员和患者避免x线辐射损伤,是一种值得推荐的微创治疗方法.     

Percutaneous nephrolithotomy outcomes: Re‐audit in 2005

Aim: To evaluate the outcomes of percutaneous nephrolithotomy (PCNL) for upper urinary tract stones in 2005 in our hospital and to compare with the results obtained in 2000. Methods: The present study reviewed the outcomes of standardized PCNL, a one‐stage procedure under sedo‐analgesia, for upper urinary tract stones in 2000 and 2005 in Queen Elizabeth Hospital. In 2000, 74 PCNL were carried out using holmium laser, Swiss lithoclast or electrohydraulic lithotripsy (EHL) for stone fragmentation. Thirty to 40% of staghorn stones and 80–100% of complicated renal and upper ureteric stones achieved stone‐free clearance after single‐session PCNL. In 2005, 82 PCNL were performed after the introduction of three strategies, namely: multiple tract access, flexible nephroscopic exploration and the new‐generation ultrasonic lithotripter. The outcomes were evaluated and compared to those in 2000 according to the different categories of stones. Results: The results in 2005 were improved in terms of increased overall stone‐free rates (20% in single session and 5% after the final session), retreatment rate reduction (15%), and raised efficiency quotient (21.5), while the overall complication rate remained low (13.9%) compared to that in 2000. In 2005, in particular, the single‐session stone‐free rates of staghorn stones and renal pelvis stones were significantly improved to 70–80% (30–40% in 2000) and 100%, respectively (50–60% in 2000). Single‐session stone‐free rates for other stones remained at 90–100%. Conclusion: Our outcomes improvement could be attributed to the maturation of the PCNL technique, use of multiple tract access, use of flexible nephroscopy, and ultrasonic lithotripsy.     

Percutaneous nephrolithotomy in patients with normal versus impaired renal function

This study aimed to compare the results of percutaneous nephrolithotomy (PCNL) in patients with impaired renal function (IRF) and normal renal function (NRF). Records of 300 consecutive patients who underwent PCNL from July 2002 to July 2005 were retrospectively reviewed. Nineteen patients (6.3%) had serum creatinine values higher than 1.5 mg/dl before surgery (IRF Group). Nineteen gender and age matched patients with normal renal function were chosen as controls (NRF Group). The surgical parameters, outcome, and complication rates were compared. The effect of PCNL on the renal function was assessed in patients with IRF. There were 13 male and 6 female patients in both groups. In the IRF group, seven patients had a solitary kidney and three had bilateral stones. Thus, PCNL was performed on 22 kidneys. No patients in the NRF Group had solitary kidney or bilateral stones and PCNL was performed on 19 kidneys. There were no statistically significant differences between the two groups for success and complication rates (P = 0.376 and P = 0.184, respectively). In a mean follow-up of 15.6 months, mean serum creatinine decreased from 2.8 to 2.6 mg/dl (P = 0.273) in patients of the IRF group. Similar stone clearance and complication rates were obtained with PCNL in patients with impaired and normal renal function. Surgery does not cause biochemical deterioration in patients with compromised renal function before treatment.     

How do increasing stone surface area and stone configuration affect overall outcome of percutaneous nephrolithotomy?

BACKGROUND AND PURPOSE: Studies reporting the outcome of percutaneous nephrolithotomy (PCNL) in relation to stone burden and configuration are limited. We analyzed our stone-free and complication rates of PCNL with regard to stone surface area and configuration. PATIENTS AND METHODS: Data of 234 patients who underwent PCNL were analyzed retrospectively. Patients were stratified into six groups according to stone burden and into four groups in relation to stone configuration. Groups were compared with respect to the number of tracts, success of therapy, complications, requirement for secondary procedures, drop in hematocrit, and blood transfusion requirement. RESULTS: The overall stone-free rate was 78.6% with a complication rate of 34.6%. Stone-free rates decreased with increasing stone size (P = 0.001) and with increasing caliceal component in complex stones (P = 0.01). The total number of complications rose with increasing stone surface area (P = 0.0001); however, stone distribution within the kidney did not affect the complication rate (P = 0.2). The mean operative time rose with increasing stone burden (P < 0.05) and increasing caliceal involvement by complex stones (P < 0.01). The need for multiple tracts also rose with increasing stone burden (P < 0.05). CONCLUSION: There is a decrease in the overall stone-free rate, as well as an increase in the complication rate, the secondary procedure rate, the mean operative time, and the need for multiple tracts, with increasing stone surface area with PCNL. With regard to stone configuration, there is a decrease in the stone-free rate, as well as an increase in the operative time, with increasing caliceal component in complex renal stones.     

Percutaneous nephrolithotomy for complex caliceal and staghorn stones in patients with solitary kidney

Treatment of patients with solitary kidney having complex stones is one of the most challenging problem in urology. We present our experience with percutaneous nephrolithotomy (PCNL) in treating 16 patients with staghorn stones in a solitary kidney to determine long-term renal functional results. We retrospectively reviewed the records of 16 patients with complex caliceal or staghorn stones in a solitary kidney treated with PCNL. Demographic data, number and location of accesses, hemoglobin values, stone analyses, and complications were studied. Serum creatinine, glomerular filtration rate (GFR), systolic and diastolic blood pressure, new onset hypertension, and kidney morphology were determined preoperatively and postoperatively at 1 month and 1 year. Male to female ratio was 14:2 and mean age was 49.6 years (range 31–55). Of these, 10 (62.5%) patients required a single tract, while 6 (37.5%) required multiple tracts. The calculi were extracted or fragmented successfully in 13 (81.3%) patients and complete stone clearance was achieved after the first stage. In two patients with residual calculi, a double-J catheter was inserted and extracorporeal shock wave lithotripsy (SWL) was performed. There were no significant intraoperative problems except in one patient, who had bleeding from an infundibular tear attributable to torquing. During the 1-year study period, none of the patients progressed to end-stage renal disease requiring dialysis. We demonstrated a significant improvement in creatinine and GFR levels from preoperatively to 1-year follow-up. The number of patients with hypertension before PCNL was 5 and by the end of follow-up there was no new onset hypertension. The demonstrated effectiveness, small number of complications at short-term, not any poorly effect on renal function and blood pressure at the long-term follow-up confirm that PCNL is not only effective but is also safe in the solitary kidney with staghorn calculi.     

Pediatric percutaneous nephrolithotomy: assessing impact of technical innovations on safety and efficacy.

OBJECTIVES: To assess the safety and efficacy of percutaneous nephrolithotomy (PCNL) in the pediatric age group and the impact of certain technical modification on the ultimate outcome. PATIENTS AND METHODS: We studied 45 renal units in 40 patients under 15 years of age who underwent PCNL at our institute. The average age was 9.2 years (range 11 months-15 years). There were 5 bilateral, 11 multiple, and 9 staghorn calculi. The average calculus size was 2.04 (0.9-4.5) cm. The PCNL was done with an ultrasound-guided peripheral puncture, a planned staged approach in some cases, and minimal tract dilatation with the use of a pediatric nephroscope and a specially designed slender probe for pneumatic intracorporeal lithotripsy. RESULTS: Complete stone clearance was achieved in 41 of the 45 renal units, giving an overall clearance rate of 91%. Minor pyrexia (<100 degrees F/<2 days) was seen in 10 patients, whereas serious pyrexia was seen in 5. One patient had a prolonged leak from the nephrostomy site, which responded to double-J stenting, and one patient had a pelvic perforation with hyponatremia, which responded to conservative treatment. The average fall in hemoglobin was 1.6 g/dL, but none of the patients required blood transfusion. CONCLUSION: We believe that our alterations in the standard technique of PCNL with the use of pediatric instruments can make it a safe and effective option in the modern management of pediatric urolithiasis.