Antibiotic prophylaxis in pacemaker surgery--a prospective study

To evaluate the effect of antibiotic prophylaxis in pacemaker surgery, 100 patients were randomly assigned to a prophylaxis group receiving cloxacillin or to a control group with no antibiotics. Cloxacillin was given intravenously (2 g) 2 hours before operation, followed by 1 g every 6 hours for 2 days and the same dose perorally for 8 more days postoperatively. Adequate plasma concentrations were obtained in all patients. The follow-up time was 1-43 months. The infection rate was 2% (1/50) in the prophylaxis group and 14% (7/50) in the control group (p less than 0.05). The interval from operation to manifest infection was 9-35 days. In the control group the causal microorganism was Staphylococcus aureus in two patients, Staphylococcus epidermidis in two and unknown in three patients. In the only patient with infection in the prophylaxis group, a methicillin-resistant S. epidermidis was isolated. Infection was initially localized to the pacemaker pocket in seven patients, but septicemia developed in one of them and endocarditis in another. In one patient septicemia appeared initially, without local signs of infection. This study suggests that cloxacillin prophylaxis is of value in routine pacemaker surgery.     

Effectiveness of totally tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized study

Objectives  Compared with the standard technique, the number of percutaneous nephrolithotomy (PCNL) operations without a drainage catheter is increasing in recent years. In this prospective randomized study, we compared the morbidity of totally tubeless (tubeless and stentless) PCNL operations with the standard operation technique in a single center with a selected patient population. Methods  Ninety patients who fulfilled the criteria were included. Forty-five patients underwent totally tubeless PCNL (Group 1) and a 14F malecot nephrostomy catheter was used in another set of 45 patients (Group 2). Inclusion criteria for the study were no serious bleeding or perforation in the collecting system during the operation, stone free or clinically insignificant residual fragments (CIRF <4 mm), and no more than one access. Results  When two groups were compared with regard to age, stone volume, postoperative hemoglobin change, transfusion rate, and operation time, no significant differences were found between the two groups. However, a significant difference was found in hospitalization time between the two groups (P < 0.05). The amount of non-steroidal analgesic (tenoxicam) needed and non-steroidal analgesia-resistant pain which was resolved with narcotic analgesics (meperidine) were significantly lower in Group 1 (P < 0.05). Complications were observed in two patients (4.5%) in Group 1 (one retroperitoneal hematoma, one long-lasting renal colic) and in six patients (13.3%) in Group 2 (five prolonged urine drainage, one long-lasting fever) (P < 0.05). Conclusions  Tubeless and stentless PCNL is a safe method and reduces hospitalization time and analgesic requirement, and promotes quality of life in selected patients.     

Totally tubeless percutaneous nephrolithotomy: a prospective randomized controlled study

The purpose of this study was to perform a randomized controlled trial to evaluate the role, safety, and effectiveness of totally tubeless PCNL and whether this procedure is less morbid in terms of analgesia requirement, related complications and convalescence. A total of 131 patients, with impacted ureteropelvic junction stone or single renal pelvic stone larger than 20 mm, were prospectively randomized (using random numbers table) into two groups, and underwent conventional (63 patients) or totally tubeless (68 patients) PCNL. Preoperative data included urinalysis, urine culture, complete blood count, biochemistry study, renal ultrasonography, intravenous urography and Tc 99m DTPA clearance for determination of selective glomerular filtration rate. Intraoperative findings, operative time, and outcome were also recorded. All patients were followed regularly at clinic every 3 months during year 1 and every 6 months, thereafter, and Tc 99m DTPA clearance for the determination of selective glomerular filtration rate, renal ultrasonography and intravenous urography was performed to assess the kidney function 6 months later. There was no difference between the groups with regard to serum creatinine change, hemoglobin decrease, morphology improvement, resumption of normal activity and complication grading. The length of stay, pain visual analog scale and analgesic requirements favored the tubeless group with statistical significance. There was significant statistical difference in relative perfusion rate between preoperative and postoperative in both groups. This trial demonstrates that totally tubeless PCNL is safe and well tolerated in selected patients and associated with decreases in length of stay, postoperative pain and analgesia requirement. Most importantly, patients undergoing uncomplicated PCNL are not mandated to have a nephrostomy or ureteral stent placed for specific indications.     

Factors affecting blood loss during percutaneous nephrolithotomy: prospective study

BACKGROUND AND PURPOSE: Bleeding is a major concern during percutaneous nephrolithotomy (PCNL), especially with the use of multiple tracts. This prospective study aimed to identify factors affecting blood loss during PCNL. PATIENTS AND METHODS: Data were collected prospectively from 236 patients undergoing 301 PCNL procedures at our institute since June 2002. Blood loss was estimated by the postoperative drop in hemoglobin factored by the quantity of any blood transfusion. Various patient-related and intraoperative factors were assessed for association with total blood loss or blood transfusion requirement using stepwise multivariate regression analysis. RESULTS: The average hemoglobin drop was 1.68 +/- 1.23 g/dL. Stepwise multivariate regression analysis showed that the occurrence of operative complications (P < 0.0001), mature nephrostomy tract (P < 0.0001), operative time (P < 0.0001), method of access guidance (fluoroscopy v ultrasound) (P = 0.0001), method of tract dilatation (P = 0.0001), multiple (> or =2) tracts (P = 0.003), size of the tract (P = 0.001), renal parenchymal thickness (P = 0.05), and diabetes (P = 0.05) were significant predictors of blood loss. The overall blood transfusion rate for all patients was 7.9%. Preoperative hemoglobin, multiple tracts, stone size, and total blood loss were significant in predicting perioperative blood transfusion requirement. Factors such as age, hypertension, renal insufficiency, urinary infection, the degree of hydronephrosis, stone bulk, and the function of the ipsilateral renal unit did not have any effect on the blood loss. Technical factors such as the operating surgeon and the calix of entry also did not affect the blood loss. CONCLUSIONS: Diabetes, multiple-tract procedures, prolonged operative time, and the occurrence of intraoperative complications are associated with significantly increased blood loss. Atrophic parenchyma and past ipsilateral intervention are associated with reduced blood loss. On the basis of this evidence, maneuvers that may reduce blood loss and transfusion rate include ultrasound-guided access, use of Amplatz or balloon dilatation systems, reducing the operative time, and staging the procedure in cases of a large stone burden or intraoperative complications. Reducing the tract size in pediatric cases, nonhydronephrotic systems and those with a narrow infundibulum, and secondary tracts in a multiple-tract procedure may also reduce blood loss during PCNL.     

Tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized comparison

Objectives To prospectively compare the outcome of standard and tubeless percutaneous nephrolithotomy (PNL) in a selected group of patients with renal stones. Methods Patients with simple, isolated renal pelvis or lower pole caliceal stones and no significant hydronephrosis were randomly enrolled to undergo either standard PNL, in which routine nephrostomy tube was placed at the end of operation, or tubeless PNL. Occurrence of intraoperative complications, total operative time exceeding 2 h, indication for additional access or second-look PNL due to residual stones were exclusion criteria. Results There were 11 isolated lower pole caliceal stones (mean stone burden: 3.1 cm²) and 6 isolated renal pelvis stones (mean stone burden: 2.8 cm²) in the tubeless PNL group (n: 17), and 9 isolated lower pole caliceal stones (mean stone burden: 3.4 cm²) and 9 isolated renal pelvis stones (mean stone burden: 3.1 cm²) in the standard PNL group (n: 18). Mean operation time was 59.6 ± 9.1 (range: 50–90) min in the tubeless group, and 67.3 ± 10.1 (range: 60–115) min in the standard PNL group (P > 0.05). Successful stone removal was achieved in all patients, and no significant complication was observed in any case. The mean postoperative analgesic requirement was significantly less in the tubeless group (P < 0.05). Mean hospital stay was 1.6 ± 0.4 (range: 1–3) days in the tubeless group, and 2.8 ± 0.9 (range: 2–4) days in the former group (P < 0.05). Conclusion Our results indicate that tubeless PNL is safe in the management of selected patients and that mean analgesic requirement as well as hospitalization time is diminished with this modification. Presented at the 23rd World Congress on Endourology and SWL, August 23–26, 2005, Amsterdam, The Netherlands     

Re: Totally tubeless percutaneous nephrolithotomy: a prospective randomized controlled study

The study is unique in terms of defining the safety of totally tubeless percutaneous nephrolithotomy (PNL). Furthermore, the authors state that the tubeless group has an advantage of less pain. However, we interpreted the results of pain-related comparisons different than that the authors had. In our opinion, the results gained show that there is no difference in terms of pain in both groups. The authors state that they have inserted a double J catheter to patients that were included in the tubeless group in addition to the nephrostomy as a conventional procedure. However, routine Double-J placement in addition to nephrostomy is not a common procedure. Additionally, the large-bore nephrostomy tube preferred is certain to cause pain, as stated in the previous studies. It has been shown that small-bore tubes cause less pain. It may have been more appropriate to compare the groups in such a manner. Even though we have stated our comments with respect to pain issues, it is evident that the study is unique in terms of defining the safety of a totally tubeless procedure.     

Tubeless percutaneous nephrolithotomy: a prospective feasibility study and review of previous reports

OBJECTIVE: To evaluate the status of tubeless percutaneous nephrolithotomy (PCNL) in managing renal and upper ureteric calculi, from initial experience and a review of previous reports. PATIENTS AND METHODS: From September 2004 to December 2004, 46 patients were scheduled for tubeless PCNL in a prospective study. Patients with solitary kidney, or undergoing bilateral simultaneous PCNL or requiring a supracostal access were also enrolled. Patients needing more than three percutaneous access tracts, or with significant bleeding or a significant residual stone burden necessitating a staged second-look nephroscopy were excluded. At the end of the procedure, a JJ ureteric stent was placed antegradely and a nephrostomy tube avoided. The patients' demographic data, the outcomes during and after surgery, complications, success rate, and stent-related morbidity were analysed. Previous reports were reviewed to evaluate the current status of tubeless PCNL. RESULTS: Of the 46 patients initially considered only 40 (45 renal units) were assessed. The mean stone size in these patients was 33 mm and 23 patients had multiple stones. Three patients had a serum creatinine level of >2 mg/dL (>177 micromol/L). Five patients had successful bilateral simultaneous tubeless PCNL. In all, 51 tracts were required in 45 renal units, 30 of which were supracostal. The mean decrease in haemoglobin was 1.2 g/dL and two patients required a blood transfusion after PCNL. There was no urine leakage or formation of urinoma after surgery, and no major chest complications in patients requiring a supracostal access tract, except for one with hydrothorax, managed conservatively. The mean hospital stay was 26 h and analgesic requirement 40.6 mg of diclofenac. Stones were completely cleared in 87% of renal units and 9% had residual fragments of < 5 mm. Two patients required extracorporeal lithotripsy for residual calculi. In all, 30% of patients had bothersome stent-related symptoms and 60% needed analgesics and/or antispasmodics to treat them. CONCLUSION: Tubeless PCNL was safe and effective even in patients with a solitary kidney, or with three renal access tracts or supracostal access, or with deranged renal values and in those requiring bilateral simultaneous PCNL. The literature review suggested a need for prospective, randomized studies to evaluate the role of fibrin sealant and/or cauterization of the nephrostomy tract in tubeless PCNL.     

Postoperative morbidity of tubeless versus conventional percutaneous nephrolithotomy: a prospective comparative study

Percutaneous Nephrolithotomy (PNL) is an established technique for the treatment of renal calculi. Some reports have challenged the need for a nephrostomy tube at the end of the procedure, arguing that it accounts for a longer hospital stay and increased postoperative pain. During the last years, several series have addressed the feasibility and safety of tubeless PNL, where a double-J ureteral stent is left in place after the end of intervention instead of a nephrostomy tube. The aim of our study was to compare conventional versus tubeless PNL in terms of postoperative morbidity. Eighty-five patients who underwent PNL at a single center met the inclusion criteria (complete intraoperative stone clearance, no evidence of active intraoperative bleeding, single percutaneous access, and operative time shorter than 2 h) and were randomized at the end of the procedure to have placed either a nephrostomy tube (group 1) or a double-J ureteral stent (group 2). Outcomes assessed were postoperative pain, bleeding complications, leakage complications, and length of hospital stay. The patients in the tubeless group had a shorter hospital stay (3.7 vs. 5.8 days; P < 0.001), and less postoperative pain at postoperative days 2 and 3 (P < 0.001). No significant difference in bleeding or leakage complications was observed. This study supports the feasibility and safety of tubeless PNL in a selected group of the patients, suggesting some intraoperative criteria to be considered when performing it. However, further controlled studies will have to determine its impact on stone-free rates prior to be considered the standard technique in these selected cases.     

Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 129 patients

The efficacy of a single dose of cefotiam, a cephalosporin of the second generation, as prophylaxis for postoperative infection was analyzed in a prospective randomized study of 129 patients undergoing cerebrospinal fluid shunting. The main focus of interest was the rate of shunt infection requiring operative shunt removal. Data were evaluated in the total group and subgroups formed for normal and high risk patients, respectively. The overall rate of shunt infection was 7.5% in the cefotiam group and 12.9% in the control group. In the high risk subgroup infection rate was 14.3% with and 26.3% without cefotiam as opposed to 4.3% and 6.9%, respectively, in the normal risk subgroup. Although our results do not reach statistical significance, there is a noticeable difference of infection rate between those patients who receive the antibiotic and those who do not. Therefore, we favor single dose antibiotic prophylaxis in shunting procedures.     

A prospective comparative study of haemodynamic,electrolyte, and metabolic changes during percutaneous nephrolithotomy and minimally invasive percutaneous nephrolithotomy

Objectives

To report the haemodynamic, electrolyte, and metabolic changes of a prospective clinical trial comparing minimally invasive percutaneous nephrolithotomy (MPCNL) with percutaneous nephrolithotomy (PCNL) for renal stones.

Methods

In all, 71 patients who had undergone MPCNL (37) or PCNL (34) were prospectively assessed. Heart rate and arterial blood pressure were monitored, and samples for electrolyte estimation and arterial blood gas analysis were drawn at the start, 30th, 60th, 90th, and 120th min of irrigation and 24 h later after both procedures.

Results

In the PCNL group, no significant changes occurred in heart rate, arterial blood pressure, electrolytes, and pH. In the MPCNL group, heart rate, arterial blood pressure, and serum sodium levels kept stably during and after irrigation; the decrease in potassium levels was found from the 30th to 120th min of irrigation and did not recovery until 24 h later after operation (P < 0.05), but the potassium levels was normal during the entire observation period; the increase in Cl^? levels was noted at the 120th min of irrigation (P < 0.05); there was a decreasing trend of pH from the start to the 120th min of irrigation (P < 0.05) and 24 h later after operation this trend attenuated (P < 0.05); the changes in base excess levels were in accordance with those in pH levels.

Conclusions

Although haemodynamic and electrolyte changes remains stable, a trend towards metabolic acidosis is obvious as the irrigation time goes by during MPCNL compared with PCNL. Therefore, arterial blood gases should be monitored during and after MPCNL in patients with prolonged irrigation time.     

Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 152 hydrocephalic patients

The authors report a prospective, randomized 18-month study on the effect of prophylactic antibiotic treatment in 152 hydrocephalic patients in whom clean shunt operations or revisions were done. The treated group received methicillin (totally 200 mg/kg) divided into six i.v. doses during 24 hours starting at the induction of anesthesia. Patients allergic to penicillin received erythromycin instead. Seventy-nine patients received antibiotics, and 73 (the control group) received none. All patients were followed at least 6 months after operation or to their death. Eleven patients developed signs of infection, giving an overall infection rate of 7.2%; however, the infection occurred less than 1 month after the operation in only half of these. Six of the patients had septicemia, 4 had peritonitis, and 1 had meningitis. In the treated group, the infection rate was 8.9%; in the control group, the rate was 5.5%. There was no statistically significant difference. The prophylactic antibiotic regimen in this investigation did not reduce the infection rate connected with cerebrospinal fluid shunting procedures.     

Simultaneous bilateral tubeless percutaneous nephrolithotomy of staghorn stones: a prospective randomized controlled study

A randomized controlled study was performed to evaluate the feasibility and outcome of staged versus simultaneous bilateral tubeless PCNL for bilateral renal staghorn stones. A total of 99 patients, with bilateral renal staghorn stones, were prospectively randomized into two groups, and underwent staged tubeless PCNL (49 patients) or simultaneous bilateral tubeless PCNL (50 patients). Preoperative data included urinalysis, urine culture, complete blood count, biochemistry study, renal ultrasonography, intravenous urography, and Tc 99m DTPA clearance for the determination of selective glomerular filtration rate. Intraoperative findings, operative time, and outcome were also recorded. All patients were followed regularly at clinic every 3 months during year 1 and every 6 months thereafter, and Tc 99m DTPA clearance for determination of selective glomerular filtration rate was performed to assess the kidney function 6 months later. There was no difference between the groups with regard to serum creatinine change, hemoglobin decrease, and complication grading. The length of stay, convalescence period, pain visual analog scale, analgesic requirements, and direct cost favored the simultaneous bilateral tubeless group with statistical significance. There was no significant statistical difference in relative perfusion rate between preoperative and postoperative in both groups. This study demonstrates that simultaneous bilateral tubeless PCNL is a safe, efficacious, and cost-effective option in bilateral renal staghorn calculi, which is associated with low morbidity, short hospital stay, high stone-free rate, and early return-to-normal activity.