Neoinfundibulotomy for the management of symptomatic caliceal diverticula

PURPOSE: Direct percutaneous access provides effective treatment for complex caliceal diverticula. Yet, access into the diverticulum alone is usually tenuous and passage of a guide wire across a stenotic infundibulum is often impossible. An alternative technique is described which creates a "neoinfundibulum" to assist in the management of symptomatic caliceal diverticula. MATERIALS AND METHODS: During a 6-year period 22 patients with symptomatic caliceal diverticula were treated via a percutaneous approach, of whom 21 had calculi within the diverticula. After accessing the diverticulum directly, it was impossible to pass a guide wire through the stenotic infundibulum in 18 (82%) patients, prompting advancement of the access needle through the diverticular wall into the renal pelvis. Once secure access was established, balloon dilation was performed to 30Fr to create the "neoinfundibulum." Percutaneous ultrasonic lithotripsy was performed in the usual fashion. A 22Fr Councill catheter was placed to keep the infundibular tract open for 5 to 7 days to allow complete epithelialization and drainage. Stone-free, symptom-free and complication rates were assessed. RESULTS: Pain, recurrent urinary tract infections and hematuria were the presenting complaints in the subgroup of patients undergoing "neoinfundibulotomy." Average stone burden was 11.7 x 12 mm. and average hospital stay was 2.8 days. Of the patients 94% were symptom-free at 6-week followup, and 80% were stone-free on followup excretory urography. The remaining patients had residual stone fragments less than 3 mm. in diameter. Complications related to access were identified in 2 patients who sustained a pneumothorax after a supra-11th rib access, which was successfully managed with tube thoracostomy. CONCLUSIONS: Percutaneous management of complex caliceal diverticula provides a safe and effective option for symptomatic patients. When the stenotic infundibulum cannot be traversed with a guide wire, creation of a new infundibulum offers a secure alternative for accessing the collecting system, while providing equally effective results.     

Treatment of stones in caliceal diverticula: extracorporeal shock wave lithotripsy versus percutaneous nephrolitholapaxy.

Stones in caliceal diverticula may cause symptoms for which treatment is indicated. Both extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolitholapaxy (PNL) are recommended. We have evaluated the results of ESWL treatment of stone-containing caliceal diverticula and compared these with the results obtained by percutaneous surgery. In the ESWL group, 15 patients were treated with an electromagnetic lithotriptor (Siemens Lithostar). After 3 months, plain abdominal X-rays revealed that only 2 patients were both stone-free and symptom-free. Of the 13 patients with residual fragments, 7 had no symptoms. The remaining 6 were treated by a lower pole resection (n = 3), a percutaneous procedure (n = 2) and long-term administration of antibiotics (n = 1). Sixteen patients were treated percutaneously. Puncture failed in 3 and they underwent a lumbotomy. In the remaining 13 patients the stones were reached by direct puncture (n = 12) or via an adjacent calix (n = 1). After 3 months, 10 patients were stone-free and had no symptoms. Morbidity consisted of post-operative bleeding (n = 3) and high fever (n = 1). It was concluded that caution should be exercised in the treatment of stone-containing caliceal diverticula. Only in symptomatic cases is treatment indicated and ESWL is the first choice. If ESWL fails (residual stones and persistent symptoms), PNL should be performed, although it is associated with a higher morbidity rate.     

Stone treatment and coagulopathy

OBJECTIVE: The aim of this retrospective study was to evaluate treatment protocols and results of upper tract stone treatment in patients with clotting disorders. METHODS: In a 6-year period, 6,827 stone interventions (ESWL or endourologic procedures) were performed in 5,739 patients. Thirty-five (0.61%) patients suffered from a variety of systemic clotting disorders or were anti-coagulated. Clotting disorders were corrected by specific therapy prior to any intervention. A total of 76 interventions were performed consisting of ESWL, ureteroscopy (URS), percutaneous nephrolithotomy (PNL), ureteric stenting or percutaneous nephrostomy. RESULTS: All patients became stone-free within 3 months or had clinically insignificant residual fragments. Severe complications were observed in 10/76 (13.1%) interventions. ESWL was successful in 88.9% (16/18) of patients, but associated with a 33.3% (6/18) complication rate; 27.8% (5/18) of patients required auxiliary procedures. URS and PNL were successful in all cases and complications occurred in 0% (0/7) and 33% (1/3) of patients, respectively. Time to complete stone clearance after ESWL was 32.0+/-49.3 days compared with a mean of 19.4+/-28.6 days in a non-coagulopathy control group; no difference was observed for endourologic procedures. Average costs of treatment in patients undergoing ureteroscopy was higher in patients with coagulopathy (4,611 versus 2,342); however, the difference was less pronounced compared with ESWL (6,070 versus 1,731). CONCLUSION: Patients with coagulopathy have a higher rate of complications despite apparently normal clotting parameters during treatment and hospitalisation was prolonged. The efficacy of ESWL was lower in patients with coagulopathy and we currently favour endoscopic procedures for stone removal in this patient group.     

Ureteroscopy for symptomatic hydrocalices: a case series

BACKGROUND: Hydrocalix is an uncommon condition that typically is treated with percutaneous dilation of the stenotic infundibulum. Ureteroscopy has the advantage of minimizing invasiveness. METHODS: We reviewed our experience with 12 retrograde ureteroscopies for hydrocalix in 10 patients. RESULTS: Access to the hydrocalix could not be achieved in one. Of the remaining 11, the original infundibulum was dilated in all but one, in whom neoinfundibulotomy was performed with a laser. The laser was used in eight cases, balloon dilation with cautery in two, and cautery alone in one. Of the seven hydrocalices bearing stones, four were rendered stone free. Immediate symptomatic success was achieved after 6 of the 11 evaluable procedures (one patient was lost to follow-up after a technically successful procedure). Of the five symptomatic failures, three went on to additional treatment (one ureteroscopy and two percutaneous), one elected against treatment despite recurrence of stenosis, and one had persistent pain owing to stones even though the hydrocalix was cured. Of the six symptomatic successes, three were without symptoms at a mean 25 months of follow-up, two have had recurrences necessitating additional treatment (both percutaneous) a mean of 51 months later, and one did not have adequate imaging follow-up. CONCLUSION: Ureteroscopy for hydrocalix achieved technical success in most patients, but relief of symptoms followed only about half of the procedures. A trial of ureteroscopy does not preclude subsequent success with a percutaneous approach. Ureteroscopy is a reasonable option for hydrocalix for patients who wish to avoid percutaneous surgery.     

The roles of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy in the management of pyelocaliceal diverticula

Various combinations of extracorporeal shock wave lithotripsy (ESWL*) and percutaneous nephrostolithotomy were used in the treatment of 40 stone-containing caliceal diverticula in 39 patients (16 men and 23 women). Only 1 of 26 patients (4%) treated with ESWL as a single modality became stone-free, although 9 (36%) became asymptomatic. Ten patients undergoing ESWL primarily eventually required percutaneous nephrostolithotomy due to persistence of symptoms and all became stone-free. A total of 14 patients underwent a percutaneous approach as a single modality, and the diverticula in 13 of these patients became stone-free, although 2 patients did have residual parenchymal fragments. Therefore, 21 of 24 patients (87.5%) became completely free of stones using the percutaneous approach. All patients managed with percutaneous nephrostolithotomy became free of symptoms. The complex nature of access during percutaneous nephrostolithotomy favors a 1-stage approach with direct puncture into the stone-containing diverticulum. Simultaneous fulguration of the diverticulum at percutaneous nephrostolithotomy is favored, since all 17 patients in whom this technique was used had complete obliteration of the diverticulum on followup contrast studies. These data suggest that caliceal diverticula should be managed with percutaneous nephrostolithotomy, since ESWL monotherapy is unlikely to produce a stone-free or symptom-free status.     

Percutaneous nephrolithotomy for caliceal diverticular calculi: a novel single stage approach

PURPOSE: Current percutaneous treatment of symptomatic caliceal diverticular calculi involves renal access, stone removal, dilation of the diverticular communication, fulguration of the cavity and placement of a nephrostomy tube. We reviewed the outcomes of patients undergoing a novel single stage percutaneous nephrolithotomy technique for radiopaque caliceal diverticular stones that eliminates ureteral catheterization and entry into the renal collecting system. MATERIALS AND METHODS: A total of 21 patients (8 male and 13 female including 1 bilateral) with a mean age of 42.4 years underwent percutaneous nephrolithotomy for caliceal diverticular stones from February 2001 to May 2003. Of the diverticula 12 were upper pole, 4 were interpolar and 6 were lower pole. Infracostal access was established by the urologist directly onto the radiopaque stones without the aid of a ureteral catheter. After balloon tract dilation a 30Fr Amplatz sheath was placed and following stone removal the diverticulum was fulgurated. The infundibulum was neither cannulated nor dilated. A 20Fr red rubber catheter or an 8.5Fr Cope loop was placed into the diverticulum. Stone-free status was assessed by noncontrast computerized tomography on postoperative day 1 (POD1). The drainage tube was removed if there was no urine drainage and the kidney was stone-free. Excretory urography was performed at 3 months to evaluate diverticular resolution. RESULTS: Of 21 patients 20 were discharged home tubeless on POD1 and 18 of 21 (85.7%) renal units were stone- free on POD1 noncontrast computerized tomography. Mean operative time was 58.5 minutes and mean stone burden was 138.9 mm. Mean stone diameter was 11.6 mm and mean diverticular diameter was 15.3 mm. Of 22 renal units 16 had followup excretory urography. All diverticula decreased in size and 14 (87.5%) had complete resolution. CONCLUSIONS: In patients with symptomatic radiopaque caliceal diverticular stones, a single stage procedure without the need for ureteral catheterization combined with direct infracostal diverticular puncture allows for a rapid procedure with little morbidity.     

Percutaneous ablation of caliceal diverticulum: long-term followup

PURPOSE: A caliceal diverticulum is a nonsecretory cavity that serves as a conduit for urinary stasis and its ensuing complications. Indications for intervention and modes of therapy are controversial. We report a series of patients treated with a percutaneous endourological approach to ablation of the diverticular cavity. MATERIALS AND METHODS: A total of 14 patients underwent percutaneous ablation of a caliceal diverticulum for flank pain a mean of 15.5 months in duration. These caliceal diverticula were associated with urinary tract infection in 43% of cases and/or renal calculi in 78%. Mean calculus diameter was 10.2 mm. and mean diverticular diameter was 10.9 mm. An open ended ureteral catheter was placed into the renal pelvis via cystoscopy. Retrograde instillation of radiopaque contrast medium facilitated the localization of a percutaneous renal puncture made directly into the caliceal diverticulum. A flexible tip guide wire was coiled in the diverticulum, and no effort was made to traverse the infundibulum and establish continuity with the remainder of the collecting system. Tract dilation into the caliceal diverticulum was performed, and percutaneous stone fragmentation and extraction were accomplished. The lining of the caliceal diverticulum was electrocauterized using a roller ball electrode. A balloon nephrostomy tube consisting of a Foley catheter with the tip cut off was positioned into the diverticulum. An indwelling ureteral stent was placed and a Foley catheter provided bladder drainage for 48 hours to maintain a low pressure system. The nephrostomy tube was removed after 24 to 48 hours and the ureteral stent was removed after 2 to 4 weeks. RESULTS: Mean operative time was 162 minutes and mean hospital stay was 2.3 days. Obliteration of the diverticular infundibulum and cavity was documented by contrast radiography (excretory urography or retrograde pyelography), and noncontrast and contrast enhanced computerized tomography, respectively, in all 14 patients. No patients have had recurrent symptoms, calculi or urinary tract infection at a mean 38-month followup. CONCLUSIONS: Percutaneous electrocautery ablation of caliceal diverticula without cannulation or dilation of the diverticular infundibulum represents a safe and effective mode of therapy. Careful patient selection and preparation optimize the efficacy of this technique.     

Diverticular calculi of the kidney calices--extracorporeal shockwave lithotripsy, percutaneous extraction or open surgery

The incidence of caliceal diverticula, mostly found on routine excretory urography, is very low. The indications for treatment include chronic or recurrent pyelonephritis, pain, gross hematuria and renal damage. There is controversy as to which treatment is best: extracorporeal shock-wave lithotripsy (ESWL), percutaneous techniques, or traditional open surgery. Since 1984, 27 patients with 28 caliceal diverticula calculi have been treated. Ten patients underwent ESWL, 13 patients percutaneous treatment, and 4 patients open surgery. The success rates as far as a stone-free status is concerned were: 1 patient (ESWL), 10 (percutaneous), and 4 (open surgery). There were no complications due to ESWL or open surgical treatment. Direct traumata such as severe bleeding in two and hydrothorax in one patient occurred during the training phase of the percutaneous techniques. Due to the low complication rate, non-invasive ESWL treatment should be tried first. The indications for percutaneous removal of calculi in caliceal diverticula depend on two aspects: it should be possible to puncture the caliceal diverticula via by a short parenchymal route coaxial to the axis of the calix and, if the intercostal approach is used, a pleural lesion must be excluded. If these requirements cannot be fulfilled, open surgical treatment should be performed, especially if the diverticula are located in the upper and anterior part of the kidney.     

Simultaneous combined use of flexible ureteroscopy and percutaneous nephrolithotomy to reduce the number of access tracts in the management of complex renal calculi

OBJECTIVE: To present early experience in managing complex renal calculi using a combined ureteroscopic and percutaneous approach, as complex and branched renal calculi often require multiple access tracts during percutaneous nephrolithotomy (PNL), and the combined use of flexible ureteroscopy and PNL has the potential to reduce the inherent morbidity of several tracts. PATIENTS AND METHODS: The study included seven patients (mean age 54 years) with multiple, branched, large-volume renal calculi suitable for management with PNL. Preoperative data, including patient demographics, stone location and stone surface area, were recorded. After informed consent, the patients underwent combined PNL and ureteroscopy in one session. Intraoperative data, including the location of PNL puncture sites, operative duration and complications, were analysed. Stone-free rates were determined by follow-up imaging at 3 months. RESULTS: All patients had either two or more stones in separate locations in the collecting system, or staghorn stones involving multiple calyces. The mean stone burden was 666 mm(2). All patients had only one percutaneous access tract. The mean operative duration was 142 min and the mean blood loss 79 mL. Two patients had small residual stones (< 3 mm), that required ureteroscopic intervention as they failed to pass spontaneously by 3 months after the initial combined procedure. The convalescence was similar to that in our current PNL practice; imaging showed that five of the patients were stone-free. CONCLUSIONS: Combined PNL and ureteroscopic management can effectively reduce the number of percutaneous access tracts which would otherwise be required for managing complex and branched renal calculi, as stones in an unfavourable location relative to the access tract can be relocated and fragmented within easy reach of the single nephrostomy tract. This manoeuvre reduces potential patient morbidity and blood loss but with no significant effect on stone-free rates and operative durations.     

Percutaneous management of caliceal diverticular calculi: technique and outcome

OBJECTIVE: Symptomatic renal calculi found within caliceal diverticula are difficult to treat. We present a single-surgeon cohort of 21 consecutive patients undergoing percutaneous treatment of stones within caliceal diverticula over a 12-year period. PATIENTS AND METHODS: Each patient was managed by a one-stage percutaneous nephrolithotomy (PCNL). The majority of diverticula were situated at the upper pole. Access was gained via a direct target puncture, a Y puncture from a parallel calix, or through the diverticular stalk in the neighboring calix. The approach was commonly supracostal. A single-stage dilator was used to establish the track. Stones were removed intact or fragmented with ultrasonic lithotripsy, and the diverticular necks were treated with endoscopic division or dilation and splinted with a 22F nephrostomy tube for several days. RESULTS: Total stone clearance was obtained by PCNL alone in 95% of cases. The only case with incomplete clearance was cleared successfully with shockwave lithotripsy (SWL). Twenty patients were assessed with an intravenous urogram at 3 months and then annual plain films and clinical assessment. Further imaging was performed in selected cases. The diverticula were obliterated or had improved drainage in 85% of assessable cases. Three patients developed recurrent stones and were treated with SWL, laparoscopic diverticulectomy, on partial nephrectomy. One further patient required partial nephrectomy for poor drainage and ongoing pain. Of the 21 patients, 17 have remained stone, symptom, and infection free with clinical and radiologic follow-up ranging from 6 months to 12 years. CONCLUSIONS: This series demonstrates that percutaneous surgery can clear calculi from caliceal diverticula and, in most cases, correct or remove the underlying anatomic abnormality.     

Quality of life after percutaneous nephrolithotomy for caliceal diverticulum and secluded lower-pole renal stones

BACKGROUND AND PURPOSE: The treatment of caliceal diverticulum and deeply secluded lower-pole stones is challenging, and the indications are controversial. This study assessed the changes in the quality of life (QoL) of patients undergoing percutaneous nephrolithotomy (PCNL) for symptomatic caliceal diverticula and deep lower-pole calculi to determine whether there is a change in the "bother factor" in order to improve treatment strategies for this group of patients. PATIENTS AND METHODS: Twenty-two patients undergoing PCNL were evaluated prospectively using the SF36 QoL questionnaire before and 6 weeks after PCNL. The results before and after PCNL were compared individually and by group and analyzed statistically. A P value 相似文献   

Prospective, randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less

PURPOSE: The optimal management of lower pole renal calculi is controversial. We compared shock wave lithotripsy (SWL) and ureteroscopy (URS) for the treatment of patients with small lower pole stones in a prospective, randomized, multicenter trial. MATERIALS AND METHODS: A total of 78 patients with 1 cm or less isolated lower pole stones were randomized to SWL or URS. The primary outcome measure was stone-free rate on noncontrast computerized tomography at 3 months. Secondary outcome parameters were length of stay, complication rates, need for secondary procedures and patient derived quality of life measures. RESULTS: A total of 67 patients randomized to SWL (32) or URS (35) completed treatment. The 2 groups were comparable with respect to age, sex, body mass index, side treated and stone surface area. Operative time was significantly shorter for SWL than URS (66 vs 90 minutes). At 3 months of followup 26 and 32 patients who underwent SWL and URS had radiographic followup that demonstrated a stone-free rate of 35% and 50%, respectively (p not significant). Intraoperative complications occurred in 1 SWL case (unable to target stone) and in 7 URS cases (failed access in 5 and perforation in 2), while postoperative complications occurred in 7 SWL and 7 URS cases. Patient derived quality of life measures favored SWL. CONCLUSIONS: This study failed to demonstrate a statistically significant difference in stone-free rates between SWL and URS for the treatment of small lower pole renal calculi. However, SWL was associated with greater patient acceptance and shorter convalescence.     

Lithotripsy for calculi in caliceal diverticula?

There is continuing debate about the optimum management of patients with calculi in caliceal diverticula. Extracorporeal piezoelectric lithotripsy (EPL) has the advantage of being non-invasive, whereas endourological management can treat the underlying anatomical problem. A total of 20 patients with calculi in caliceal diverticula were treated with EPL. Twelve of 16 patients with symptoms (75%) were rendered symptom-free but only 5 (25%) became stone-free. This information should be of value in counselling patients before selecting the appropriate treatment.     

Management of painful caliceal stones by extracorporeal shock wave lithotripsy

One hundred and seven patients with caliceal stones causing flank pain were treated by extracorporeal shock wave lithotripsy (ESWL), followed up and reviewed. The total stone-free rate 3 months after ESWL was 38.8%. The total pain-free rate was 50.5%. The pain-free rate was 85% in the stone-free group and 29% in the group with residual stones. No significant differences between the stone-free rate and the duration of pain or age was noted. Patients with abnormal intravenous pyelography (IVP) had a lower stone-free rate than patients with normal IVP (16 vs. 45%, p less than 0.05). The complications included: 6 cases of stone street formation with spontaneous passage; 1 case of stone street formation needing percutaneous nephrolithotomy for drainage; 1 perirenal hematoma; 9 cases of severe colic pain following ESWL; 3 cases of fever following ESWL, and 4 cases of hydronephrosis due to a stone in the ureterovesicle junction. These results show that ESWL is an effective, noninvasive treatment for painful caliceal stones.     

经皮肾镜碎石术治疗症状性肾盏憩室结石11例报告

目的：探讨经皮肾镜碎石术治疗肾盏憩室结石的安全性及有效性.方法：回顾性分析11例接受经皮肾镜碎石治疗肾盏憩室结石患者的临床资料：采用标准通道经皮肾镜术4例,微通道肾镜术7例.10例行Ⅰ期直接穿刺憩室碎石术,1例因通道出血改为Ⅱ期碎石.6例术中用自制电钩切开肾盏憩室颈口.结果：手术时间平均为（1.83±0.49）h,结石直径平均为（1.73±0.71）cm,2例中盏憩室结石取净,术后未留置D-J管,1例中盏憩室结石术后完全无管化.术后复查KUB平片,9例取净,2例残留,结石直径均小于4 mm,未行碎石,结石清除率为81.8%,尤并发症发生.随访3个月～1年,8例症状缓解,3例减轻.结论：经皮肾镜碎石术治疗症状性肾盏憩室结石安全可行,可做为选择性治疗方法.     

ESWL与输尿管镜治疗输尿管下段结石的比较

目的：比较体外冲击波碎石术（ＥＳＷＬ）与输尿管治疗输尿管下段结石的结石排净率和并发症。方法：治疗输尿管下段结石患者３９０例,其中用ＥＳＷＬ治疗２１０例,输尿管镜治疗１８０例。结果：两组患者术后１个月的结石排净率分别为７８．１％和９３．３％（Ｐ〈０．０５）;ＥＳＷＬ组的主要并发症为再次治疗率高（１１．９％）,而输尿管镜组的主要并发症为输尿管穿孔（３．３％）。结论：输尿管镜治疗输尿管下段结石的疗效优于     

Outcome of percutaneous nephrolithotomy: effect of body mass index

OBJECTIVE: The surgical management of renal and upper ureteral calculi presents unique challenges in obese patients. We reviewed our recent experience with percutaneous nephrolithotomy (PNL) in obese patients to determine the safety and outcome of this procedure in such group of patients. PATIENTS AND METHODS: The surgical records of 1121 patients treated with PNL between 2000 and 2004 were reviewed. Patients were stratified into four groups according to the World Health Organization classification of body mass index (BMI): <25 (average), 25-29.9 (overweight), 30-39.9 (obese), and >40 kg/m(2) (morbidly obese). The outcomes of PNL in these four groups were compared. RESULTS: A total of 1287 procedures were performed on 1155 renal units (1.1 procedures per renal unit). The overall stone-free rate was 85.1% and the mean hospital stay was 3.3+/-2.6 d. Major complications were seen in 72 patients (6.4%). No statistically significant differences were found in decrease in haemoglobin concentration, hospital stay, and complication rate among the four study groups. The need for auxiliary procedures and stone-free rates were comparable. CONCLUSIONS: PNL in obese and morbidly obese patients yields a stone-free rate that is comparable to that achieved in nonobese patients. The complication rate and length of hospital stay are also similar.     

Treatment for extended-mid and distal ureteral stones: SWL or ureteroscopy? Results of a multicenter study

PURPOSE: In a randomized study, we analyzed the treatment results of ureterorenoscopy (URS) and shockwave lithotripsy (SWL) for extended-mid and distal ureteral stones. We investigated also, for reasons of cost effectiveness, the factors influencing the outcome, the complications, and the need for auxiliary procedures. PATIENTS AND METHODS: In three regional hospitals, we selected 156 patients with extended-mid and distal ureteral stones. After randomization, 87 were treated with URS, and 69 with SWL. The treatment results were studied in relation to complications, the need for auxiliary procedures and stone factors, urinary tract infection (UTI), dilatation, and kidney function. RESULTS: After retreatment of 45% of the patients, the stone-free rate after 12 weeks in the SWL group was 51%. After a retreatment rate of 9% of the patients in the URS group, the stone-free rate was 91%. Including the number of auxiliary procedures, we calculated the Efficiency Quotient (EQ) as 0.50 for SWL and 0.38 for URS. After correction and redefinition of auxiliary procedures, the EQ was 0.66. The mean treatment time for SWL was 52 minutes and for URS 39 minutes. General anesthesia was more frequently needed in URS patients. Complications occurred more often in the URS group (22 v 3 and 24 v 13, respectively). These were mostly mild, and all could be treated with a double-J stent, antibiotics, or analgetics. A lower stone-free rate was achieved in patients with larger (> or =11 mm) stones (75% v 85% for smaller stones in the URS group and 17% v 73% in the SWL group. In the URS group, the stone-free rate of patients with extended-mid ureteral stones was lower than that of patients with distal ureteral stones. Calculating the costs for URS and SWL appeared impossible because of the differences in available equipment. CONCLUSION: The stone-free rate after URS is much higher than after SWL, and the EQ in our series was strongly dependent on definitions. The decision about how to treat a patient with an extended-mid or distal ureteral stone therefore should not be made primarily on the basis of cost effectiveness but rather on the basis of the availability of proper equipment, the experience of the urologist, and the preference of the patient.     

Computerized tomography guided access for percutaneous nephrostolithotomy

PURPOSE: Access for percutaneous nephrostolithotomy (PNL) using conventional fluoroscopic guidance may carry an increased risk of damage to surrounding organs in patients with renal calculi and aberrant anatomy. In these situations cross-sectional anatomical imaging may facilitate safe percutaneous access. We describe our experience with computerized tomography (CT) guided percutaneous access for such patients undergoing PNL. MATERIALS AND METHODS: Between June 2000 and December 2001, 154 patients underwent PNL at our institution. Five of these patients (3%) required a total of 6 percutaneous access tracks under CT guidance. All patients in this group had anatomical abnormalities precluding standard access to the collecting system without risk to adjacent organs. These abnormalities included a retrorenal colon in 2 and a severely distorted body habitus due to spinal dysraphism in 3. RESULTS: Percutaneous access was achieved without complication in all cases. At subsequent PNL 5 of the 6 renal units (83%) were rendered completely stone-free. CONCLUSION: CT guided percutaneous access is infrequently required for PNL. However, there is a select group of patients with anatomical anomalies that may predictably require this procedure to facilitate safe and efficacious PNL.     

Percutaneous nephrolithotomy with ultrasonography-guided renal access: experience from over 300 cases

OBJECTIVE: To report our experience with over 300 patients treated with percutaneous nephrolithotomy (PNL), for although PNL was established as a treatment in the 1970s, its use diminished with the introduction of extracorporeal shockwave lithotripsy (ESWL); clinical experience with ESWL showed its limitations, and the role of PNL for treating urolithiasis was redefined, which with improvements in instruments and lithotripsy technology has expanded the capability of percutaneous stone disintegration. PATIENTS AND METHODS: The study included 315 patients (156 males, 159 females, aged 13-85 years) treated with PNL in our department between 1987 and 2002. The mean (range) stone diameter was 27 (7-52) mm. The kidney was punctured under ultrasonography guidance via a lower-pole calyx whenever possible. The working channel was dilated using an Alken dilator under X-ray control. If necessary, a flexible renoscope was used. Ultrasonic, pneumatic and laser probes were used for lithotripsy. RESULTS: Four weeks after treatment the total stone-free rate was 96.5%; 45.7% of all patients were primarily stone-free, 21.3% had clinically insignificant residual stones that passed spontaneously within 4 weeks after PNL, and 33% of the patients needed auxiliary measures (a second PNL, ESWL, ureterorenoscopy). Overall, the early complication rate was 50.8%, the most common complications being transient fever (27.6%), clinically insignificant bleeding (7.6%) or both (3.2%); 3.5% of the patients developed urinary tract infections (with no signs of urosepsis), 3.2% had renal colic and 2.9% upper urinary tract obstruction. One patient (0.3%) developed acute pancreatitis after PNL; one died from urosepsis and one needed selective angiographic embolization of the punctured kidney due to bleeding. No patient required transfusions and there were no injuries to neighbouring organs. CONCLUSIONS: These results show that PNL causes no significant blood loss or major complications in almost all patients. Two aspects may especially reduce the potential complications: ultrasonography-guided renal puncture and using PNL in an experienced centre. PNL is a highly efficient procedure that provides fast and safe stone removal.