Safety and efficacy of supracostal access in percutaneous renal surgery

BACKGROUND AND PURPOSE: During percutaneous renal surgery, subcostal access is preferred because it carries no risk of injury to either the lungs or pleura. However, in some situations, a supracostal approach may provide more direct access and achieve a more satisfactory result than the subcostal approach. In this prospective study, we evaluated the safety and efficacy of supracostal approaches in percutaneous renal surgery. MATERIALS AND METHODS: Between 2004 and 2006, 30 patients underwent percutaneous renal surgery with a supracostal approach either as the sole or as a secondary access. The indications were staghorn stones, upper caliceal stones, upper ureteral stones, secondary ureteropelvic junction obstruction, disturbed lower caliceal anatomy, and high-lying kidneys. The puncture was above the eleventh rib in six procedures and above the twelfth rib in 24 procedures. All patients were examined for equal air entry on both sides of the chest, and all had chest radiography performed immediately after surgery to exclude pneumothorax or hydrothorax. Bleeding was assessed with evaluation of preoperative and postoperative hemoglobin, levels and vital signs; urine was also examined for gross hematuria. A routine nephrostogram was obtained for all patients. RESULTS: Supracostal was the sole access in 63.3% of patients and a secondary access in 36.7% of patients. Intraoperatively, bleeding occurred in one patient. Hydrothorax in another patient necessitated insertion of an intercostal chest drain. A renopleural fistula developed in another patient 2 days postoperatively that necessitated placement of a chest drain and Double J stent. Access in both patients with pleural complications had been above the eleventh rib. The mean drop in hemoglobin level was 0.79 +/- 0.72 g/dL. Our overall stone-free rate was 88.9%. CONCLUSION: Supracostal access above the twelfth rib is relatively safe; however, access above the eleventh rib should be limited to necessity because a higher incidence of pleural complications can be expected. A chest radiograph should be obtained immediately postoperatively for early detection of hydrothorax or pneumothorax.     

肾上盏入路经皮肾镜取石术的安全性及效果分析

目的 总结肾上盏入路经皮肾镜取石术(PCNL)的安全性和有效性.方法 回顾性分析237例应用肾上盏入路PCNL治疗肾或输尿管上段结石的患者资料.男135例,女102例.年龄8-76岁,平均42岁.其中结石长径＞1.5 cm或嵌顿性输尿管上段结石94例,长径≥2.0 cm或嵌顿性肾盂结石26例,鹿角形结石或多发性结石68例,复杂性肾下盏结石13例,不适合行体外冲击波碎石术(ESWL)或输尿管镜碎石术(URS)的肾上盏结石12例,肾上盏憩室结石3例,肾结石并肾盂输尿管连接部(UPJ)梗阻或输尿管上段狭窄8例,过度肥胖结石患者3例,马蹄肾肾结石6例,移植肾肾输尿管结石4例.其中经第12肋上入路175例(73.8％),第11肋上入路46例,第12肋下入路12例,移植肾患者经下腹部入路4例.结果 采用单一通道结石完全清除176例(74.3％),同期或分期建立多通道取石55例,联合ESWL 6例.术后3个月复查结石清除209例(88.2％).出现胸膜损伤16例(6.8％),行胸腔穿刺术8例,行胸腔闭式引流术5例,保守治愈3例.拔除肾造瘘管后出现胸膜刺激征12例(5.1％),予对症处理.无肺及其他内脏损伤.输血5例,其中行选择性肾动脉造影及拴塞术2例.结论 肾上盏入路PCNL操作视野开阔、硬镜操作方便、结石清除率高,可选择性地应用于治疗输尿管上段结石和部分复杂性肾结石.     

Tubeless percutaneous nephrolithotomy: safe even in supracostal access

PURPOSE: This study was designed to determine the outcome and safety of tubeless percutaneous nephrolithotomy (PCNL) in the treatment of renal calculi. PATIENTS AND METHODS: Between November 2005 and March 2006, 48 patients were randomized to either an 18F Re-entry nephrostomy tube (group 1) or a 6F Double-J stent (group 2). The two groups were well matched for age, sex, stone size, stone laterality, and number of previous renal procedures. All PCNL procedures were performed by the same surgeon. Postoperative visual analog pain scale (VAS) scores at 8 and 24 hours and 14 days after surgery, in-hospital analgesic use, length of hospital stay, success rate, blood transfusion rate, and postoperative complications were compared for the two groups. RESULTS: The mean hospital stays in groups 1 and 2 were 3.1 and 1.6 days, respectively (P = 0.003). The mean VAS scores 8 and 24 hours after surgery were significantly lower in group 2 than in group 1 (P = 0.001). The postoperative analgesic requirement (diclofenac sodium) was significantly higher in group 1 (263 mg) than in group 2 (120 mg; P = 0.02). The rate of blood transfusion in the two groups was similar (P = NS). There was no difference between the groups in VAS scores on postoperative day 14. The number of supracostal accesses was significantly higher in group 2 than in group 1 (P = 0.02). The stone-free rates and the numbers of patients with insignificant residual fragments were similar in the two groups. There was no urine leakage or formation of urinoma in patients with Double-J stents. CONCLUSION: Tubeless PCNL is safe and effective even after supracostal access and is associated with less postoperative pain and a shorter hospital stay.     

肾上盏入路经皮肾镜取石术的疗效与安全性探讨

目的 评价经肾上盏入路行PCNL的疗效及安全性.方法 2007年10月至2009年10月行经肾上盏入路PCNL治疗肾结石患者42例.其中鹿角形结石10例,肾盂结石22例,肾上盏结石7例,下盏多发结石3例;合并输尿管上段结石4例,合并肾盂输尿管连接部狭窄(UPJO)2例;结石长径2.0～6.5 cm,平均3.4 cm.B超引导下选取肾上盏穿刺,穿刺点选在第10或11肋间,建立经皮肾通道(16～26 F).经皮肾镜或输尿管镜下气压弹道或钬激光碎石. 结果 42例均一期成功建立经皮肾通道并碎石.单通道取石36例(85.7%),双通道取石6例(14.3%).手术时间30～140 min,平均65 min.术后发热4例(9.5%),输血1例(2.4%),肾盂穿孔1例(2.4%).无气胸、血胸、腹腔脏器损伤.一期结石清除率88.1%(37/42),3例(7.1%)行二次肾镜取石,2例(4.8%)辅助体外冲击波碎石(ESWL)治疗. 结论经肾上盏入路PCNL活动范围大,对于部分复杂性肾结石碎石取石方便,是一种安全有效的方法.

Abstract：

Objective To evaluate the efficacy and safety of percutaneous nephrolithotomy (PCNL)guided by ultrasonography through upper pole access. Methods From October 2007 to October 2009, 42 patients with upper urinary tract calculi underwent PCNL through upper pole access.Among these cases, there were 10 cases of staghorn calculi, 22 cases of renal pelvis calculi, 7 cases of the upper calyx calculi, 3 cases of the lower calyx calculi, 4 cases combined with ureter calculi and 2 cases combined with ureteropelvic junction obstruction. The stone measured from 2.0 to 6.5 cm (average: 3.4 cm) in length. Working tunnels (F16-F26) were established through the 10th or llth intercostals. Pneumatic or holmium laser lithotripsy was used to disintegrate and remove stones by nephroscopy or ureteroscopy. Clinical data including operation time, complications and stone free rate were analyzed retrospectively. Results All the operations were completed in one session, single tract was used in 36 cases(85.7%), double tracts were used in the other 6 cases(14.3%). The stonefree rate after one session was 88.1% (37/42), 3 cases(7.1%) received a second-session PCNL, 2 cases (4.8%)underwent ESWL after operation. The mean operative time was 65 min(30- 140 min).Postoperative surgery-related infection rate was 9. 5% (4/42). One patient (2. 4%)required blood transfusion. Perforation of the pelvis occurred in 1 patient(2.4 %). No pleural or important organ injury occurred. Conclusion The upper pole access for PCNL can be convenient to remove stones,this method is a highly efficient and safe technique.     

无管化经皮肾镜取石术的安全性和疗效评价

目的:对无管化经皮肾镜取石术(PCNL)的安全性和疗效进行评价,探讨其优势及应用前景。方法:对我院2010年8月～2011年7月所开展的192例无管化微创PCNL进行回顾性研究,总结分析术后住院时间、疼痛模糊评分(VAS)、止痛药物应用、术后出血、发热、漏尿等数据和指标。结果:依据无管化PCNL的适应证,192例采用无管化方式,无管化率为65.5%。192例无管化PCNL者术后平均住院3.8d,疼痛模糊评分(VAS)为2.4mm。术后严重出血5例(含1例巨大肾周血肿),4例保守治疗,1例行超选择性肾动脉栓塞;输血3例,发热2例;无漏尿者,术后应用止痛药1例。结论:无管化经皮肾镜适合于大多数PCNL,是对传统PCNL术后引流方式的改进,是安全有效的,能有效减轻患者术后疼痛不适,减少对止痛药的需求,缩短住院时间,而并发症也并未明显增加,值得临床推广。     

Safety and efficacy of tubeless percutaneous nephrolithotomy in patients on anti-platelet therapy and cirrhotic patients

Without the temponade effect over nephrostomy tube, postoperative hemorrhage is a major concern to the safety of tubeless percutaneous nephrolithotomy (PCNL) in patients with bleeding tendency. In this study, we would like to report our experience of performing tubeless PCNLs in these patients. At the end of PCNL, we cauterized the bleeding points in access tract for hemostasis to facilitate the achievement of tubeless PCNL. We identified and reviewed 16 patients under antiplatelet agent therapy and 6 patients with liver cirrhosis from 598 tubeless PCNLs performed in a single institute. Among the 16 patients undergoing anti-platelet therapy, the average stone size was 2.8 cm. The average operation time was 84.7 min. The stone-free rate was 87.5%. The average postoperative hospital stay was 3.8 days. Two patients (12.5%) experienced urinary tract infections after operation. There was no uncontrolled hemorrhage during and after operation and only one patient needed postoperative blood transfusion. No patient experienced any thromboembolic complication. Of the six patients with liver cirrhosis, the average stone size was 3.3 cm. The average operation time was 77.5 min. The stone-free rate is 83.4%. The average postoperative hospital stay was 4.0 days. No patient received blood transfusion after operation. There was no patient experiencing urinary tract infection after operation. Our results suggest that with careful hemostasis, tubeless PCNL is a safety modality in the treatment of urinary stone disease in patients on chronic anti-platelet therapy and cirrhotic patients.     

Upper-pole access for percutaneous nephrolithotomy: comparison of supracostal and infracostal approaches

BACKGROUND AND PURPOSE: The advantage of upper-pole access for nephrolithotomy is direct access to most of the intrarenal collecting system and upper ureter. Upper-pole access can be achieved either supracostally and subcostally. Because of the anatomic location of the kidneys, the supracostal approach is associated with a higher rate of pulmonary complications. We compared the efficacy and safety of the supracostal and infracostal upper-pole approaches. PATIENTS AND METHODS: A total 464 patients were treated with percutaneous nephrolithotomy (PCNL) via the upper pole, of which 170 punctures (group I) were performed supracostally and 294 (group II) subcostally. In both groups, PCNL was done by the standard technique with fluoroscopic guidance. The operative time, success rate, hospital stay, and complications in the two groups were compared. RESULTS: Patients were stone free in 82.2% and 77.1% of the cases in groups I and II, respectively, and had stone fragments <4 mm in 10.7% and 14.7%, respectively. The operative time, success rate, and septic and hemorrhagic complications were not significantly different in the two groups. Hydrothorax was found in 26 patients (15.3%) of group I and 4 (1.4%) of group II. Only 9 patients (5.3%) in group I needed intercostal drainage. CONCLUSION: Percutaneous nephrolithotomy via the upper pole is effective using both supracostal and infracostal approaches, with acceptable rates of complications. The rate of pulmonary complications is higher with the supracostal approach. If the supracostal approach is indicated, it should be used with caution.     

Safety and efficacy of tubeless percutaneous nephrostolithotomy

The experience at this institution with tubeless percutaneous nephrostolithotomy was reviewed to determine its safety and efficacy. Between April 1997 and June 1998, 33 “tubeless” percutaneous nephrostolithotomies were performed. All procedures were performed by a single surgeon (R.W.W). All patients had an internal ureteral stent placed at the time of surgery, and a Foley catheter remained in place overnight. All patients had their nephrostomy tube removed in the OR at the end of their surgery. The length of hospitalization, operative time, patients' comorbid conditions, pre- and postoperative hematocrits, transfusion requirements, reasons for a stay of longer than 24 h, complications, stone burdens treated, residual stone disease, any additional procedures required, and postoperative analgesia requirements were reviewed. All 33 percutaneous procedures were performed without significant complication. No transfusion was required. The average length of hospital stay was 1.5 days, with two-thirds of patients staying less than 24 h. A 94% stone-free rate was achieved, and patients had minimal analgesia requirements. This experience with the “tubeless” percutaneous nephrostolithotomy indicates that it is a safe and effective means of stone management. It will likely have an expanding role in the treatment of stone disease and other urologic problems of the upper urinary tract.     

Totally tubeless percutaneous nephrolithotomy

PURPOSE: We evaluated the requirement for routine placement of a ureteral stent and a nephrostomy tube following percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: A total of 43 patients underwent totally tubeless PCNL and was compared with a control group of 43 age-, sex-, weight-, and procedure-matched patients who had previously undergone PCNL with placement of a ureteral stent and a nephrostomy tube. Exclusion criteria for the tubeless approach were more than two percutaneous accesses, significant perforation of the collecting system, a large residual stone burden, significant postoperative bleeding, ureteral obstruction, and renal anomaly. The incidence of complications, length of hospitalization, analgesia requirements, and interval to return to normal activities were compared in the two groups. RESULTS: All 43 percutaneous procedures were performed without significant complications. None of the patients demonstrated urinoma in postoperative renal ultrasound scans. The average length of hospital stay was 1.6 days, with two-thirds of the patients staying <1 day for the study group, and 5.2 days for the controls (P < 0.001). The average analgesia requirement was 9.8 mg and 28.4 mg of morphine, respectively (P < 0.001). Patients returned to normal activities with 12.7 days v 24.6 days for the controls (P < 0.001). CONCLUSION: Totally tubeless PCNL is a safe and effective procedure. The hospitalization and analgesia requirements are less and the return to normal activities faster with this technique.     

Safety and efficacy of tubeless percutaneous renal surgery

PURPOSE: We challenge the requirement for routine placement of a nephrostomy tube after percutaneous renal surgery, assessing the outcome, safety, and efficacy of tubeless procedures. PATIENTS AND METHODS: A total of 128 patients underwent tubeless percutaneous renal surgery from May 2001 to May 2004: stone extraction in 120 patients and endopyelotomy +/- stone extraction in 8. The stone sizes ranged from 2 to 7 cm with a mean of 4.1 cm. An external ureteral catheter was used in 120 patients and was removed after 24 hours if a retrograde study revealed no extravasation. An antegrade Double-J stent was used in 8 patients and removed 4 to 6 weeks postoperatively. Among the 128 patients treated by the tubeless technique, we met situations that mandated insertion of a nephrostomy tube in 18. RESULTS: The stone free-rate was 90.4%. The mean hospital stay was 1.7 days. The incidence of significant intraoperative bleeding was 1.5% and that of significant postoperative hematuria was 4.6%. Postoperative sonography revealed a small perirenal collection (<50 mL) in 10 patients (7.8%) and significant perirenal collections (100-250 mL) in 3 (2.3%). The postoperative retrograde study revealed minor extravasation in 14 patients (12%) and significant extravasation in 3 (2.3%) CONCLUSION: Tubeless percutaneous renal surgery with an externalized ureteral catheter is a safe procedure that is suitable for any patient who can be rendered stone free with a single procedure regardless of the initial stone burden.     

留置输尿管外支架的无管化经皮肾镜取石术的安全性和效果分析

目的：探讨留置输尿管外支架的无管化经皮肾镜取石术（tubeles spercutaneous nephrolithotomy,tubelessPCNL）的安全性和有效性。方法：回顾性分析43例留置输尿管外支架的tubelessPCNL治疗肾或输尿管上段结石的患者资料。男23例,女20例,平均年龄44．9岁。其中肾盂结石22例,输尿管上段结石18例,肾多发性结石3例。结石最大径为（2．4±1．1）cm。合并患肾轻度积液4例,中度积液21例,重度积液18例。在经皮肾镜取石术结束时,通过B超和c臂x线证实结石已经完全清除,然后把逆行插入的输尿管导管的头端调整至肾盂的中央,让扩张鞘退至肾造瘘通道以外,证实瘘道无活动性出血,最后拔除扩张鞘,并用丝线缝合皮肤伤口。结果：43例患者,其中41例结石完全清除,2例为无意义残留结石。手术时间30～75min,平均45min。手术引起血红蛋白平均下降6．5g／L。术后第1天视觉疼痛评分为（3．0±1．4）分。术后平均住院天数为3d。术后出现急迫性尿失禁1例,。肾周血肿1例,发热2例,持续性肉眼血尿2例,轻度尿外渗2例。结论：在严格掌握手术适应证的前提下,留置输尿管外支架的tubeless PCNL是安全和有效的。     

Simultaneous bilateral tubeless percutaneous nephrolithotomy

We present what is to our knowledge the first reported case of simultaneous bilateral tubeless (no nephrostomy tube) percutaneous nephrolithotomy. The 64-year-old man was rendered stone free with a single general anesthetic and discharged within 24 hours. The role, indications, and potential benefits of this novel technique are discussed.     

Bilateral simultaneous tubeless percutaneous nephrolithotomy

A case of bilateral inferior calyceal calculi treated with simultaneous bilateral tubeless percutaneous nephrolithotomy is presented. The patient had an uneventful recovery and was discharged in twenty-three hours.     

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.     

无管微创经皮肾镜取石术临床评价

目的 评价微创经皮肾镜取石(MPCNL)术后不放置肾造瘘管的可行性. 方法 选择MPCNL后符合单通道、无集合系统穿孔、B超无明显结石残留,无明显出血患者40例,碎石操作结束后随机分成2组.留置肾造瘘管组(A组)20例,其中肾内结石16例,输尿管上段结石4例,结石直径1.3～8.6 cm,平均3.4 cm.不留置造瘘管组(B组)20例.其中肾结石14例,输尿管上段结石6例,结石直径1.1～7.9 cm,平均3.1 cm.2组均留置6 F双J管.比较2组患者术后Hb下降幅度、疼痛不适及并发症发生情况. 结果 2组结石直径比较差异无统计学意义(P=0.23).2组手术时间分别为(98±29)和(92±31)min(P=0.63),术后Hb下降幅度为(3.3±1.6)%和(3.1±1.6)%(P=0.49).术后疼痛评分采用视觉模拟评分,2组术后第1天分别为3.6±1.8和3.3±1.5(P=0.66)、术后第3天为1.6±1.2和1.8±1.3(P=0.62).2组各有1例术后出现发热,B组出现1例穿刺通道周围血肿.2组均未输血,术后均未发生肾绞痛. 结论 选择符合特定条件者不放置肾造瘘管行MPCNL是安全的.     

Delayed pneumothorax after tubeless percutaneous nephrolithotomy

Percutaneous nephrolithotomy is the treatment of choice for large urinary stone and staghorn stone. Supracostal access through the upper calyx provides a straight tract along the long axis of the kidney and is the optimal route for the treatment of staghorn stone. However, the supracostal access bears higher risk for pleural or lung injury resulting in hydrothorax or pneumothorax. Percutaneous nephrolithotomy induced pneumothorax usually occurs immediately after operation. We report a case of delayed pneumothorax after tubeless percutaneous nephrolithotomy for a complete staghorn stone.