Safety and efficacy of supracostal access in tubeless percutaneous nephrolithotomy

PURPOSE: To evaluate the feasibility and safety of supracostal access in tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: From September 2004 to November 2005, tubeless PCNL using supracostal access was done for 72 patients at our institute. Patients requiring more than two percutaneous tracts or with significant intraoperative bleeding or residual stone burden were excluded from the study. The outcome of these patients was compared with that of a historic cohort of similar patients having supracostal access with routine placement of a nephrostomy tube. The two groups had comparable demographic data. RESULTS: The differences in the mean drop in hemoglobin concentration, transfusion requirement, and complication rate in the two groups were not statistically significant, with three patients in the study group and four patients in the control group requiring blood transfusion. Patients undergoing tubeless PCNL required less analgesia (P = 0.000) and were discharged a mean of 19 hours earlier (P = 0.000) than those in the control group. Complete stone clearance was achieved in 90.27% of the renal units in the study group and 86.11% of the renal units in the control group. Two patients in the study group and three patients in the control group had postoperative hydrothorax, all of whom, except for one in the control group, were managed conservatively. CONCLUSION: Supracostal access in tubeless PCNL appears to be feasible, safe, and effective, offering the advantages of a lower analgesic requirement and shorter hospital stay without increasing thoracic complications. Studies with larger numbers of patients are needed to confirm these initial findings.     

Tubeless percutaneous nephrolithotomy: 3 years of experience with 454 patients

OBJECTIVE

To present our experience with 454 patients who had tubeless percutaneous nephrolithotomy (TPCNL) over last 3 years.

PATIENTS AND METHODS

From September 2004 to August 2007, all patients aged >14 years and undergoing PCNL were considered for TPCNL. Exclusion criteria were the presence of pyonephrosis, matrix calculi, significant bleeding or residual stone burden and need for three of more percutaneous accesses. These patients had a nephrostomy tube placed after PCNL (control group). The remaining patients undergoing TPCNL (study group) had antegrade ureteric stenting. Demographic and perioperative data were compared retrospectively.

RESULTS

Of 840 patients who had PCNL during the study period, 454 had TPCNL. The two groups had comparable demographic data except for a smaller stone burden (322.8 vs 832.2 mm²) and fewer staghorn calculi (94 vs 154) in patients undergoing TPCNL (P < 0.001). The mean number of tracts per renal unit and operative duration were statistically higher in patients undergoing standard PCNL (1.5 vs 1.1, and 68.8 vs 52.2 min, respectively). The decrease in haemoglobin, complication and stone‐free rates were comparable. TPCNL was associated with less postoperative pain, analgesia requirement and earlier discharge (P < 0.001).

CONCLUSIONS

TPCNL can be used with a favourable outcome and no increase in complications in selected patients, with the potential advantages of decreased postoperative pain, analgesia requirement and hospital stay. Its application can be extended to patients with a solitary kidney, previous ipsilateral open surgery, raised serum creatinine level, in the presence of three renal accesses or supracostal access, and in patients undergoing bilateral synchronous PCNL or contralateral endourological stone treatment.     

Simultaneous bilateral tubeless percutaneous nephrolithotomy: A report of 2 cases and review of the literature

Percutaneous nephrolithotomy (PCNL) is currently the standard of care to remove large renal calculi. Traditionally, a large-bore nephrostomy tube is placed postoperatively. However, the necessity of this practice has been recently challenged. Theoretically, bilateral tubeless PCNL offers advantages of lower postoperative discomfort, shorter hospital stay and thus lower cost. We review the literature and present two cases of simultaneous bilateral tubeless PCNL from two patients who were referred to a tertiary stone centre from remote areas.     

Advances in Tubeless Percutaneous Nephrolithotomy and Patient Selection: An Update

Percutaneous nephrolithotomy (PCNL) is the gold standard for the treatment of large renal calculi. Recently, modifications to the standard PCNL with nephrostomy tube placement have evolved, most notably the introduction of tubeless PCNL. Tubeless PCNL appears to decrease postoperative discomfort and shorten hospital stays, without increasing complication rates in the appropriately selected patient population. Urologists have attempted to expand the role of tubeless PCNL in more complex clinical scenarios, including pediatric and geriatric patients, and in stones complicated by multiple access tracts, renal anomalies or previous renal surgery. In an attempt to further improve outcomes following tubeless PCNL, adjunct interventions such as the use of hemostatic agents along the percutaneous access tract and local tract anesthetic have also been evaluated. We report the most recent published data over the past year, reviewing the employment and efficacy of tubeless PCNL, and discuss the selection of appropriate patients for this modified procedure.     

Tubeless percutaneous nephrolithotomy in patients with previous ipsilateral open renal surgery: a feasibility study with review of literature

PURPOSE: To present our initial experience of tubeless percutaneous nephrolithotomy (PCNL) in patients with previous ipsilateral open renal surgery. PATIENTS AND METHODS: Twenty-five patients with previous ipsilateral open renal surgery underwent tubeless PCNL at our institute. Patients with large renal and/or upper ureteral calculi, irrespective of the number and size of the stones, amount of hydronephrosis, or the renal parameters, were selected for the procedure. Exclusion criteria were patients needing more than two percutaneous tracts, significant bleeding, and a significant residual stone burden that would necessitate a staged PCNL. The perioperative outcome of these patients (study group) was retrospectively compared with an historic cohort of the same number of patients with a history of open surgery for renal calculi who underwent ipsilateral PCNL with routine placement of a nephrostomy tube (control group). RESULTS: The two groups had comparable demographic data. Patients in the study group needed less postoperative analgesia (P = 0.000). They were discharged a mean of 10 hours earlier (P = 0.000). Two patients in both groups required blood transfusion. No urinoma or urinary leak from the nephrostomy site occurred in the study group. The incidence of other postoperative complications was comparable in both groups. Complete stone clearance was achieved in 88% of patients in the study group and 84% patients in the control group. CONCLUSION: The tubeless approach in patients with a history of open renal surgery is associated with decreased analgesia requirement and hospital stay without compromising stone-free rates or increasing the complications.     

Multi-tract percutaneous nephrolithotomy for large complete staghorn calculi

INTRODUCTION: The treatment of large complete staghorn calculi requires a sandwich combination of percutaneous nephrolithotomy (PCNL) and shockwave lithotripsy (SWL) or sometimes open surgery. Many urologists hesitate to place more than 2-3 tracts during PCNL because of the belief that this may increase complications. We present data to support multi-tract PCNL for large (surface area >3,000 mm(2)) complete staghorn calculi. PATIENTS AND METHODS: From July 1998 to October 2003, 121 renal units (103 patients) with large complete staghorn renal calculi were treated with PCNL. All procedures were performed in the prone position after retrograde ureteral catheterization. Fluoroscopy-guided punctures were made by the urologist followed by track dilation to 34 french. When multiple tracts were anticipated all punctures were usually made at the outset and preplaced wires were put into the collecting system or down the ureter. Stones were fragmented and removed using a combination of pneumatic lithotripsy and suction. Postoperative stone clearance was documented on X-ray KUB. RESULTS: 121 renal units of 103 patients (15 women and 88 men, mean age 43 years) were treated. Six patients had associated bladder calculi that were treated simultaneously. The stone surface area was 3,089-6,012 (mean 4,800) mm(2). 10 patients (9.7%) had renal insufficiency with a mean (range) serum creatinine of 3.0 (1.5-5.5) mg/dl. The number of tracts required per patient were 2 tracts in 11, 3 tracts in 68, 4 tracts in 39, and 5 tracts in 3, giving a total of 397 tracts in 121 renal units, over a total of 140 procedures (including second-look procedures in 19 renal units). The points of entry of these tracts were 121 upper calyx (30.4%), 178 middle calyx (44.8%), and 98 lower calyx (24.6%). All 121 units had one upper polar access tract of which 92 (76%) were supracostal. Complications were blood transfusion (n = 18), pseudoaneurysm (n = 2), fever (n = 22), septic shock (n = 1) and hydrothorax (n = 3). PCNL monotherapy achieved an 84% complete clearance rate that improved to 94% with SWL in 8 renal units with small residual fragments. Stone compositions were calcium oxalate (91%), uric acid (2%) and mixed (7%). CONCLUSION: Aggressive PCNL monotherapy using multiple tracts is safe and effective, and should be the first option for massive renal staghorn calculi.     

Tubeless percutaneous neprolithotomy: the new gold standard

PURPOSE: We present our experience with tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Between July 2004 and December 2006, 121 patients (82 males and 39 females) with 18-70 mm (mean 31.19 mm) renal stones underwent tubeless PCNL leaving only a 6 Fr externalized ureteric catheter. Their ages ranged between 4 and 80 years (mean 37.27). Two patients had bilateral disease, so a total of 123 renal units are included. The procedure was performed under general anesthesia in the prone (110 units) or supine position (13 units). A total of 133 punctures were performed. The punctures were single (114 units), double (8 units), or triple (1 unit). The approach was subcostal through the lower calyx (n = 110) or middle calyx (n = 10), or supracostal through the middle calyx (n = 8) or upper calyx (n = 5). RESULTS: Mean operative time was 46.30 min (range 15-100). Mean reduction in hemoglobin level was 1.57 g (range 0.3-4) with blood transfusion rate 4.13%. Complication rate was 9.9% in the form of perirenal collection (five patients), urinary leakage (two patients), fever (four patients), and hydrothorax (one patient). The ureteric catheter was left for 7-72 h (mean 45.67). Postoperative analgesia was required in 22 patients (18.2%) with mean 22.9 mg diclofenac sodium per patient. Mean hospital stay was 50.69 h (range 12-96) with 106 units (86.18%) rendered stone free, 13 (10.57%) with insignificant residuals, and four units (3.25%) were left with significant residual stones. CONCLUSIONS: Tubeless PCNL is a good option in non-complicated PCNL with the advantages of reduced hospital stay, low postoperative pain, and little need for postoperative analgesia.     

Critical analysis of supracostal access for percutaneous renal surgery

PURPOSE: Percutaneous renal surgery is currently performed for complex renal calculi as well as for various other endourological indications. In many patients an upper pole nephrostomy tract allows direct access to most of the intrarenal collecting system. Upper pole percutaneous access may be obtained via the supracostal or subcostal approach. The preferred route depends on the location and size of the specific stone or lesion. Previously others have cautioned against the supracostal approach above the 12th rib and many have discouraged an approach above the 11th rib due to concern about the increased risk of intrathoracic complications. We retrospectively assessed the morbidity associated with supracostal percutaneous renal surgery and compared and analyzed the morbidity of the supracostal and subcostal approaches. MATERIALS AND METHODS: The records of all patients who underwent upper pole percutaneous renal surgery between November 1993 and July 1999 were retrospectively reviewed. A total of 240 patients underwent percutaneous renal procedures, including 225 for managing symptomatic renal or ureteral stones, that is nonstaghorn calculi in 157, staghorn calculi in 41, proximal ureteral calculi in 12, calculi within a caliceal diverticulum in 6, calculi associated with primary ureteropelvic junction obstruction in 5 and calculi associated with a retained ureteral stent in 4. An additional 15 procedures were done for ureteropelvic junction obstruction (7), intrarenal collecting system tumors (5), a caliceal diverticulum without stones (1), a retained ureteral stent (1) and a ureteral stricture (1). RESULTS: A total of 300 nephrostomy tracts were placed to obtain access to the intrarenal collecting system via the supracostal approach in 98 (32.7%) cases and the subcostal approach in 202 (67.3%). Of the supracostal approaches 72 (73.5%) tracts were above the 12th and 26 (26.5%) were above the 11th rib. The overall complication rate irrespective of percutaneous approach was 8.3% (16.3% for supracostal and 4.5% for subcostal access). Complications included blood transfusion in 7 patients, intraoperative hemothorax/hydrothorax in 5, sepsis/bacteremia in 3, atrial fibrillation in 2, delayed nephropleural fistula in 2, renal artery pseudoaneurysm in 2, deep venous thrombosis/pulmonary embolus in 2, pneumothorax in 1 and subcapsular hematoma in 1. Seven of 8 intrathoracic complications (87.5%) developed in supracostal cases. CONCLUSIONS: Percutaneous renal surgery remains an important option for managing complex renal calculi and other upper urinary tract lesions. In our experience it is generally associated with low morbidity. The supracostal approach is often preferred for obtaining intrarenal access to complex renal and proximal ureteral pathology. Because supracostal access tracts are associated with significantly higher intrathoracic and overall complication rates compared to subcostal access tracts, this approach must be used with caution when no other alternatives are available.     

Using and choosing a nephrostomy tube after percutaneous nephrolithotomy for large or complex stone disease: a treatment strategy

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) is a well-accepted technique for removal of large or complex renal calculi. However, little attention has been paid to strategies for nephrostomy tube (NT) selection. We reviewed the reasons for selecting three types of NT after PCNL for large or complex stone disease. PATIENTS AND METHODS: A series of 106 consecutive renal units undergoing PCNL for stone burdens >2 cm by a single surgeon (JEL) were reviewed. Noncontrast CT (NCCT) was carried out on postoperative day 1, and secondary procedures were performed if fragments remained. The NTs studied were 8.5F and 10F Cope loops (CP), 20F reentry Malecot catheters (REM), and 20F circle loops (CL). Patient demographics, access site and number, complications, and stone type were examined. "Stone free" was defined as a negative NCCT or negative second-look PCNL. RESULTS: A total of 134 accesses were created in 106 renal units: 35 upper, 7 mid, and 92 lower; however, only 111 NTs were placed: 85 CP (76.6%), 19 REM (17.1%), and 7 CL (6.3%). Sixteen accesses were performed tubeless; all but two were in the upper pole. All 16 of these renal units had a concomitant NT placed in the lower pole. Multiple sites were accessed in 21 patients; 7 of these patients had CL placed. Five of ten patients with spinal-cord injury had REM/CL placed. Nineteen REM were placed: 10 for drainage of infection, and 9 for difficult anatomy. All renal units were rendered stone free: 31.1% with a single procedure and 95.6% with one or two procedures. There were no difficulties with drainage or access for secondary PCNL regardless of the NT employed. Complications included two hydrothoraces, one arteriovenous fistula, and one ureteral perforation. Three of four renal units in patients requiring transfusions underwent bilateral PCNL, and at least one renal unit required multiple accesses. Of kidneys with infection stones, 57.1% required REM or CL; only 12.0% of nonstruvite stones necessitated REM or CL. CONCLUSIONS: All patients having PCNL done for complex stone disease should have an NT placed; however, small (8.5F-10F) CP suffice in most cases and can provide greater patient comfort. To minimize pleural morbidity, tubeless upper-pole access should be considered if the kidney is judged to be stone free at the conclusion of PCNL. Circle loops are useful when multiple accesses are necessary, whereas REM are appropriate if access is difficult, gross residual stone remains, or pain is not an issue (i.e., spinal-cord injury).     

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.     

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.     

微创经皮肾穿刺取石术治疗上尿路结石

目的：探讨微创经皮肾穿刺取石术(PCNL)治疗上尿路结石的安全性及有效性。方法：对接受微创经皮肾取石术治疗的858例上尿路结石患者进行了回顾性分析。其中单发肾盂、肾盏结石213例，输尿管上段结石111例，手术后残留结石129例，肾铸型或鹿角形结石391例；双侧肾结石14例。结果：所有患者均行一期穿刺取石，共行1015次手术。其中单通道穿刺取石672侧肾，二通道186侧肾，三通道13侧肾，四通道1侧肾，结石清除率90．18％，平均手术时间98min，肾造瘘管留置时间平均6d，平均住院14d，其中2例需要输血，仅1例术后10d并发大出血，经高选择性肾动脉栓塞止血治愈，其余未出现大的并发症。结论：微创经皮肾取石术治疗上尿路结石是有效的。它与开放手术及传统经皮肾取石术相比，能减少术中、术后出血及并发症，明显提高结石的清除率，具有对患者创伤小、恢复快、缩短住院时间等优点，并对残留结石和复发结石的再次手术治疗有较大优越性。     

Safety of supracostal punctures for percutaneous renal surgery

AIM: Supracostal superior calyceal access has been shown to be the most suitable approach for staghorn calculi, calculi in the upper ureter and complex inferior calyceal calculi, as well as for antegrade endopyelotomy. However, many urologists hesitate in using this approach because of the potential for chest complications. The aim of this study was to analyze one institution's data regarding the safety and efficacy of this approach for percutaneous renal surgery. METHODS: A total of 890 renal units (762 patients) were treated with percutaneous renal surgery (849 percutaneous nephrolithotomy, 41 antegrade endopyelotomy) from July 1998 to July 2004. Supracostal access was obtained in 332 (37.3%) patients. The indications for a supracostal approach were ureteropelvic junction obstruction, staghorn and complex inferior calyceal calculi, and stones in the upper calyx or the upper ureter. All punctures were made by the urologist under C-arm fluoroscopic guidance in the prone position. RESULTS: The interspace between 11th and 12th rib was used in all except four patients in whom the puncture was made above the 11th rib. Eleven patients (3.31%) had a pleural breach presenting with fluid in the chest. Insertion of a chest tube was required in seven patients, while other four were managed conservatively. No patient had injury to the lung or other viscera. Hospital stay was not significantly prolonged as a result of the pleural breach in any patient. Except for staghorn calculi where multiple tracts were a necessity for maximal clearance, a single supracostal superior or middle posterior calyceal access served the purpose in 86% (177/205) of patients who underwent percutaneous surgery for renal or upper ureteric calculi. CONCLUSIONS: The supracostal superior calyceal approach was found to be effective as well as safe, with an acceptably low risk of chest complications.     

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.     

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.     

Need for ancillary procedures among patients undergoing tubeless percutaneous renal surgery for nephrolithiasis

PURPOSE: We routinely perform percutaneous nephrolithotomy (PCNL) without the use of nephrostomy tubes. We examined the need for secondary surgery for the treatment of residual stones in patients who underwent both tubeless surgery and PCNL with tube placement. PATIENTS AND METHODS: We retrospectively reviewed the charts of 180 patients who underwent 186 percutaneous nephrolithotomies. Among them, 125 patients had tubeless surgery, and 61 had nephrostomy tubes. We compared the need for ancillary surgical procedures for residual stone disease in the two groups. RESULTS: A total of 99 patients (79%) without tubes and 25 (41%) of those with tubes were stone free after surgery. A total of 45 ancillary procedures were performed for residual stone disease, with 15% of the tubeless and 43% of the patients with tubes requiring a second procedure. Extracorporeal shockwave lithotripsy (SWL) was the most common ancillary procedure. CONCLUSIONS: Patients who are eligible for tubeless PCNL are unlikely to need a secondary procedure, and residual stones can most often be treated with SWL. Patients who required nephrostomy tubes had more complicated disease and a greater need for subsequent surgery.     

经皮肾镜取石术后不留置肾盂造瘘管的疗效评价

目的 评价经皮肾镜取石术(PCNL)后不放置肾盂造瘘管的疗效.方法 输尿管上段或肾结石行PCNL患者240例.男147例,女93例.年龄19～64岁,平均(48.5～9.4)岁.结石直径1.2～5.6 cm,平均(2.8±1.2)cm.患者入选标准:术前无尿路感染病史、单通道、碎石术中无明显出血、无需行二次经皮肾操作者.随机分2组:A组(n=120)术后不放置肾盂造瘘管,B组(n=120)术后放置14 F肾盂造瘘管.比较2组患者术后疼痛程度、需应用镇痛药例数、术后住院时间及漏尿发生率.结果240例患者均一期手术成功.A组术后6 h、第1天、第2天的疼痛评分分别为4.2±1.5、2.1±1.6和1.2±1.0,均显著低于B组的5.5±2.4、3.9士1.5和2.5±1.5,P值均<0.01;A组需使用镇痛药者18例,B组为32例(15.0%与26.7%,P<0.05),A组术后发生尿漏3例,B组28例(2.5%与23.3%,P<0.01),术后住院时间A组(1.7±0.6)d,B组(3.1±1.1)d,P<0.01.结论对于无尿路感染、一期手术、单通道、术中无明显出血的患者,PCNL术后不放置肾盂造瘘管可减轻患者痛苦和经济负担、缩短患者恢复时间,是安全可行的治疗方法.     

Bilateral single-session percutaneous nephrolithotomy: a feasible and safe treatment

BACKGROUND AND PURPOSE: The treatment of bilateral urinary calculus disease is often staged, irrespective of the modality of the treatment. Bilateral simultaneous percutaneous nephrolithotomy (PCNL) is still considered by many to be adventurous and risky. We carried out this prospective study of bilateral PCNL under a single anesthesia to study the feasibility, success rate, and complications if any. PATIENTS AND METHOD: From September 1996 to May 1999, 25 consecutive medically fit patients with bilateral renal calculi needing PCNL were subjected to bilateral PCNL under a single anesthesia. RESULTS: The PCNL could be accomplished bilaterally in 24 patients (96%). In one patient, the second-side PCNL was abandoned because of excessive bleeding on the first side. A total of 58 tracts and 27 sessions were required for complete treatment of the 48 renal units in the 24 successfully treated patients. The average operating time required for the procedure was 122 minutes. Nineteen patients were rendered stone free in one session, and two more patients were made stone free in a second session. Four renal units in three patients with residual calculi were cleared with double-J stenting and SWL. CONCLUSION: Bilateral PCNL in a single session is feasible and safe and can be carried out without increased morbidity. We advocate that an endourologist be prepared for bilateral PCNL in the patients in whom it is indicated. The opposite-side PCNL can be done if the first-side treatment is accomplished smoothly and in a reasonable time.     

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.     

CT平扫轴向旋转视频显像在复杂性肾结石经皮肾镜取石术中的应用

目的 探讨CT平扫轴向旋转视频显像在复杂性肾结石经皮肾镜取石术(PCNL)中的应用价值. 方法 伴轻、中度肾积水的铸型多发性肾结石患者33例,单侧31例、双侧2例.术前行双肾64层螺旋CT平扫,经三维重建后合成轴向旋转视频影像,根据影像显示的结石空间分布关系,测量PCNL通道与目标肾小盏的角度,了解通道的有效覆盖范围,据此设计PCNL通道人路和数目、预测结石可能残余的数目和部位并与手术结果比较. 结果 经后组中上小盏建立第一通道22侧肾,经后组中下小盏建立第一通道13侧肾,与术前视频显像设计一致,经下盏后上小盏为第二通道入路9侧肾,经下盏后下小盏为第二通道入路5侧肾,一期行PCNL,结石清除率为80%(28/35),7侧肾残余结石与术前视频显像预测的残余结石相符.术中、术后无大出血及其他严重并发症发生.结论双肾CT平扫轴向旋转视频显像可直观地提供结石形态和空间分布等信息,有助于设计PCNL通道入路及数目,指导结石寻找,预测残余结石数目与部位,有利于复杂性肾结石PCNL结石清除和手术安全性.