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.     

Percutaneous nephrolithotomy in children before school age: experience of a Pakistani centre

OBJECTIVE: To review our experience of percutaneous nephrolithotomy (PCNL) in children before school age, and determine its efficacy and safety in this age group. PATIENTS AND METHODS: The records of children aged < or = 5 years undergoing PCNL were reviewed. Variables assessed included stone number, size, location and type. The PCNL puncture site and number were also recorded. We reviewed stone clearance with PCNL, ancillary procedures used, complication rates and follow-up status of the children. RESULTS: There were 30 renal units in 29 children (median age 3.8 years, range 1.4-5). Because of poor growth the mean (SD) body weight of the children was only 12.2 (2.8) kg, which is near the 50th percentile for children of mean age 3.5 years. The median (range) stone burden was 2.35 (1.3-6) cm; 60% of the patients had single stones while 28% had more than five. There were five staghorn stones. All PCNL was primary and with one puncture, using a 17 F angled nephroscope; stones were fragmented using a pneumatic lithoclast. After PCNL stones were completely cleared in 60% of the renal units, which increased to 100% after combining it with extracorporeal shockwave lithotripsy. The median (range) follow-up was 24.9 (4-51) months; the overall complication rate was 6%. In the long follow-up hypertension was not detected in any child and isotopic renograms in 17 kidneys detected no new scarring or loss of renal function. CONCLUSION: PCNL is a safe and effective for treating renal stones in very young children.     

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.     

复杂性肾结石开放性手术后残石的延期微创治疗

目的：探讨复杂性肾结石开放性手术取石后残石采用经术中放置的肾造瘘管进行延期微创治疗的优势、技术特点及治疗效果。方法：回顾性总结2001年9月一2002年7月13例采用经术中放置肾造瘘管进行延期微创治疗肾结石开放性手术后残石患者的操作方法、途径及成功经验。结果：本组13例治疗后11例患肾无结石残留，2例肾下盏残留细小结石，4个月后结石排净。结论：复杂性肾结石开放性手术后残石应用延期微创治疗具有出血少，可重复取石，操作时间短，患者痛苦小等优点。     

复杂肾结石经皮肾镜取石术后结石残留的原因与处理

目的:探讨复杂肾结石PCNL术后结石残留的原因及处理方法.方法:回顾分析我院行二期PCNL取石的35例复杂肾结石患者的临床资料,既往有开放手术史17例,2例因术中出血影响视野改二期手术,合并肾盏憩室内结石2例.结果:除2例需辅助ESWL治疗外,其余33例在B超和输尿管镜辅助下,行二期PCNL全部成功取净残留结石.其中3例因残留结石所在肾盏位置远离经皮肾通道或在与皮肾通道平行的肾盏内,重新建立另一通道取石;1例行3通道取石.结论:术中出血、肾盏憩室内结石、既往开放手术史和肾内集合系统解剖异常,是PCNL术后结石残留的主要原因;术中B超及软镜的应用,可以清楚显示有无残留结石及其所在肾盏的位置;了解结石与经皮肾通道的位置关系,帮助引导最大限度地清除结石.     

Tubeless percutaneous nephrolithotomy: 5 years of experience in 201 patients

BACKGROUND AND PURPOSE: Our aim was to evaluate the safety, effectiveness, and feasibility of tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: From June 2000 to September 2005, 201 patients with renal stones >2 cm underwent tubeless PCNL by a single surgeon. We report details of the outcomes. RESULTS: The complete stone clearance rate was 91.04% (183 patients). After surgery, 18 patients (8.96%) had stones (mean size = 7 mm) detected on a plain abdominal radiograph or ultrasonographic examination and were referred for shockwave lithotripsy. The mean stone size was 30 mm (range 20-40 mm). The mean operative time was 35 minutes (range 30-60 min), and the mean hospital stay was 3.5 days (range 2-5 days). Postoperative ultrasonography did not reveal considerable fluid collection. There were no visceral injuries. Twenty-two (10.9%) patients received a transfusion, and 16 (7.9%) patients had urinary tract infection. CONCLUSION: In our experience, tubeless PCNL is safe, effective, and feasible without any discomfort for patients.     

以肾中盏为目标肾盏行气压弹道联合超声碎石治疗鹿角形结石的效果及安全性

目的：探讨以肾中盏为目标肾盏,采用气压弹道联合超声碎石方式治疗鹿角形结石的效果及安全性。方法：取俯卧位,采用气压弹道联合超声碎石的方式,以肾中盏为目标肾盏行经皮肾镜碎石术（percutaneous nephrolithotomy,PCNL）治疗鹿角形结石患者145例184侧,其中不完全性鹿角形结石115例侧,完全性鹿角形结石69例侧。观察结石的排除率及并发症。结果：144例侧行一期单通道碎石（中盏）,7例侧行一期双通道碎石（中盏及下盏5例,中盏及上盏2例）;2例侧残留肾盏结石未进一步处理,自动出院;31例侧行二期碎石,单通道者29例,其中4例先行ESWL再行PCNL碎石;双通道者2例（中盏及上盏1例,中盏及下盏1例）。151例侧排尽结石,其中完全性鹿角形结石54例侧,不完全性鹿角形结石97例侧,结石清除率82．1％。手术时间120～330min,平均（147±23）min。血红蛋白下降1～4g／L,平均下降（2．0±0．6）g／L,术中输血22例,术后输血5例;术后肾盂内感染3例,合并肾周感染、单侧分肾功能受损1例。平均住院时间（13．0±3．5）天。结论：以肾中盏为目标肾盏行PCNL治疗鹿角形结石是非常有效和安全的;气压弹道联合超声碎石对鹿角性结石的清除率较高,治疗时问短,并发症少。     

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.     

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 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.     

标准通道与微通道经皮肾镜碎石取石术治疗肾结石的疗效分析(附视频)

目的 探讨标准通道经皮肾镜取石术(PCNL)与微通道经皮肾镜取石术(MPCNL)治疗肾结石的临床疗效及其优缺点.方法 回顾性分析323例肾结石患者,其中178例采用MPCNL,145例采用标准通道PCNL,对两组手术时间、一期手术成功率、结石清除率、手术并发症、肾功能、输血率、住院时间等指标进行比较分析.结果 两组患者分别成功建立了18 F和24 F肾穿刺通道并一期行碎石术.MPCNL组手术时间较PCNL组延长(P＜0.05),但肾盏多发性结石患者结石清除率高于标准通道PCNL组(P＜0.05),而单纯肾盂结石患者结石清除率则低于标准通道PCNL组(P＜0.05).两组鹿角型结石患者一期结石清除率比较无统计学意义(P＞0.05).两组术后手术并发症、肾功能、输血率、住院时间等均无显著性差异(P＞0.05).结论 MPCNL与标准通道PCNL均具有术中损伤小、住院时间短、结石清除率高、并发症低、对肾功能无明显影响等优点.标准通道PCNL较适合处理较大的肾盂结石,MPCNL较适合治疗肾盏多发结石,两者联合应用可提高鹿角型结石的治疗疗效.     

经皮肾镜取石术治疗肾脏感染性结石的疗效分析(附127例报告)

目的:评价经皮肾镜取石术(PCNL)治疗肾脏感染性结石的方法和疗效。方法:对我院2009年1月~2013年6月127例肾感染性结石患者行PCNL的临床资料进行回顾分析,男52例,女75例,结石直径为2~5cm,均为鹿角形或多发性结石。结果:在B超引导下穿刺建立F20~22通道,采用输尿管镜钬激光碎石,105例一次取净结石,平均手术时间为134min,10例结石残余直径1cm,1周后经原通道取石,12例结石残余直径1cm,选择联合体外冲击波碎石术(ESWL)治疗或药物排石治疗,总住院时间10~17d,平均为13d,1个月后复查KUB,116例未见明显结石残余,结石总清除率91.3%。22例患者术后出现发热,其中8例为寒颤高热(39.5℃),6例为低热(38.0℃),2例为菌血症,1例患者术后出现肾脏持续性出血行栓塞治疗,1例出现尿瘘,未出现脓毒血症、腹腔脏器损伤、腹腔积液、胸腔积液、气胸、肾动静脉瘘等严重并发症发生。结论:通过充分的术前准备,改进术中操作细节,有效的术后护理及抗感染治疗,认为PCNL采用输尿管镜钬激光碎石术具有结石排净率高、创伤小、恢复快、并发症少等优点,是治疗肾脏感染性结石的一种安全有效的方法。     

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.     

无管化标准通道经皮肾镜取石术治疗上尿路结石67例

目的探讨无管化标准通道经皮肾镜取石术在治疗上尿路结石方面的疗效及安全性。方法回顾性分析2008年1月至2013年7月采用无管化标准通道经皮肾镜取石术治疗67例上尿路结石患者的临床资料。其中单发肾结石24例,多发肾结石13例,不完全性鹿角形结石8例,连接部及输尿管上段结石22例,结石最大直径0．9～3．0cm。我们对于非复杂型上尿路结石,肾皮质厚度≥1cm、无严重尿路感染、无活动性出血、无集合系统穿透性损伤及满意的清石病例,术后仅留置双J管而不放置肾造瘘管。结果所有患者均一期手术成功。平均手术时间36．7±2．3min;术后第l天疼痛评分为2．9±1．5mm,术后平均住院时间（4．1±0．8）d;术前、后平均血红蛋白下降值为（1．0±0．5）μ/L;结石清除率100％。无输血病例及选择性肾动脉栓塞病例;无感染性休克和肾周积液发生。结论在经过严格筛选病例基础上,无管化标准通道经皮肾镜取石术治疗上尿路结石是安全可行的。     

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.     

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.     

Percutaneous nephrolithotomy in patients with scoliosis: our institutional experience

It is challenging to treat renal stones in patients with scoliosis. The present study was designed to study the safety and efficacy of minimally invasive percutaneous nephrolithotomy (mPCNL, 18 Fr) and standard tract PCNL (24 Fr) in patients with scoliosis. Twenty cases treated with mPCNL and 18 cases with standard tract PCNL were included in the present study. Laboratory data included preoperative routine complete blood count, serum creatinine, urine bacterial culture, etc. KUB, intravenous urography or CT scanning was done. Fifteen had lumbar and 23 had thoracolumbar scoliosis. Pulmonary function test was performed in all cases. Demographic and clinical details, operative characteristics and complications were studied and compared between two groups retrospectively. The stone burdens of two groups were averagely 754.4 and 816.2 mm², respectively (P = 0.194). Pulmonary function test indicated that 18 (47 %) out of 38 patients had decreased function for surgery and anesthesia. The stone clearance rates were 55 and 67 %, respectively, after the first session (P = 0.522). The requirements of auxiliary treatments including second-look PCNL procedure or SWL (shock wave lithotripsy) were not significantly different for both groups. All patients from both groups achieved final stone clearance after auxiliary treatments. Complications of urinary collecting system injury or fever were observed in one and two cases in each group, respectively, (P = 0.548). There were no injuries to neighboring organs or pneumothorax. The requirement of blood transfusion for four cases in mPCNL group and three cases in the standard tract PCNL group, respectively, indicated no significant difference between two groups (P = 0.999). We are able to successfully and safely perform both mPCNL and standard tract PCNL in patients with scoliosis in our hospital. Compared with mPCNL, standard tract PCNL is even more efficient due to its shorter operative time.     

Cauterization of access tract for nephrostomy tube-free percutaneous nephrolithotomy

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) is now a popular method for removal of renal and ureteral stones. Placement of a nephrostomy tube after the completion of PCNL has been considered a standard procedure by most urologists, but some authors have recently challenged this practice. Bleeding is one of the most prevalent problems after nephrostomy tube-free percutaneous renal surgery. To diminish the possibility of postoperative bleeding, we cauterized the PCNL tract to make it bloodless. The efficacy and safety of this procedure were reviewed in this study. PATIENTS AND METHODS: From March 2001 to March 2003, 51 patients underwent PCNL with a one-stage procedure and a single access tract. The stone size ranged from 1.0 to 7.0 cm (mean 2.7 +/- 1.4 cm). A holmium:YAG laser and pneumatic lithotripter were used. After stone extraction, a 6F double-J catheter was inserted antegrade. The access tract was checked, and the bleeding points were cauterized. No nephrostomy tube was inserted, but a Penrose drain was left overnight. Perforation of the collecting system was not a contraindication to tubeless PCNL. RESULTS: The stone-free rate was 80.4%, including five patients with complete staghorn stones. Twenty-one patients required postoperative analgesics. Only one patient had urine leakage for longer than 24 hours. Transient low fever was noted in five patients, but no patient experienced severe urinary tract infection. Delayed hemorrhage (1 week after the operation) secondary to irritation by the double-J ureteral stent was noted in one patient. The average postoperative hospital stay was 2.2 days (range 1-3 days). No patient required a blood transfusion. No urinoma was noted on the postoperative ultrasound follow-up. CONCLUSION: Nephrostomy tube-free percutaneous renal surgery is a safe and effective procedure for selected patients with minimal hemorrhage after PCNL. Cauterization of tract bleeding points may make this modification a more secure procedure and make it suitable for more patients.     

Tubeless percutaneous nephrolithotomy: call of the day

PURPOSE: We challenge the routine placement of nephrostomy tube after percutaneous nephrolithotomy (PCNL) without taking into consideration the size, burden, and multiplicity of the stones; the degree of obstruction of the pelvicaliceal system, or any anatomic variations of the kidney in shape or position. PATIENTS AND METHODS: Between January 2005 to March 2006, 110 patients underwent PCNL, 77% of whom had multiple stones. The mean size of the single stones was 4.3 cm (range 2.8-6.5 cm), and the mean single-stone burden was 7.2 cm2 (range 5.6-14.3 cm2). The mean burden of multiple stones was 11.4 cm2 (range 8-23 cm2). Among the patients, 18 had had previous renal surgery, 12 had renal insufficiency, and 7 had a solitary functioning kidney. One patient each had horseshoe kidney and malrotated kidney. In 106 patients, no nephrostomy drain was placed, only an externalized 5F ureteral catheter for 16 to 20 hours. Two patients had simultaneous bilateral tubeless PCNL. The outcome was evaluated prospectively. The frequency of complications, length of hospital stay, and stone-free status were assessed. RESULTS: A stone-free rate of 80% was achieved using PCNL as monotherapy. The mean postoperative hospital stay was 16 to 20 hours. Three patients required placement of a nephrostomy tube because of significant bleeding and one because of purulent renal discharge. In four patients, a ureteral catheter was replaced by a stent because of significant residual stone burdens. The initial 18 patients underwent ultrasound examination on the first postoperative day, and none demonstrated any extrarenal collection, so routine ultrasound examination was omitted in succeeding patients. One patient required exploration because of a retroperitoneal hematoma. CONCLUSION: Omission of a nephrostomy tube after PCNL while retaining an externalized ureteral catheter for 16 to 20 hours is sufficient and safe irrespective of the stone characteristics. Shape, position, and function of the kidneys are also irrelevant with regard to tubeless PCNL.