Is multiple tracts percutaneous nephrolithotomy (PCNL) safe modality in management of complex renal stones: A prospective study? Single center experience

Objectives

To evaluate and analyze the efficacy and the safety of multiple tracts PCNL in management of complex renal calculi.

Outpatient tubeless percutaneous nephrolithotomy: the initial case series

Introduction:

Percutaneous nephrolithotomy (PCNL) has traditionally been performed on an inpatient basis. To the best of our knowledge, this is the first report of tubeless PCNL on a completely outpatient basis. The purposes of this study were to assess the safety and efficacy of outpatient PCNL.

Methods:

We reviewed the initial consecutive outpatient tubeless PCNLs performed at our institution by a single surgeon. Patients were discharged home the day of surgery only after meeting strict discharge criteria. Preoperative, intraoperative and postoperative data were collected prospectively.

Results:

Outpatient tubeless PCNL was performed in 3 patients. The mean maximum stone diameter was 14 mm. The average hospital stay was 175 minutes. All 3 patients were discharged home in stable condition after meeting all of the inclusion criteria. There were no emergency room visits or hospital readmissions postoperatively. The mean follow-up period was 47 days. All stones were calcium oxalate and the stone free rate was 100%. There were no minor or major complications.

Conclusion:

In properly selected patients, outpatient tubeless PCNL is safe and effective. Our initial experience with outpatient PCNL has been favourable and warrants further investigation in a larger patient population.     

Contemporary practice of percutaneous nephrolithotomy: review of practice in a single region of the UK

INTRODUCTION

Most series of percutaneous nephrolithotomy (PCNL) from single specialised centres represent optimum results achievable and may not reflect outcomes of everyday practice. We analysed the practice in our region.

PATIENTS AND METHODS

Medical records of 178 patients undergoing PCNL in 2002 in 12 participating hospital trusts were retrospectively analysed.

RESULTS

Even outside the tertiary referral centres, there was a 6-fold difference between trusts in the frequency of PCNL. In 28% of cases, another stone-removing modality had been tried first. Failed renal puncture was a major cause of abandoning surgery (9%). An indication of the difficulty in obtaining complete stone clearance is that only 107 (60%) operation notes recorded complete clearance, while 75 (42%) patients required a subsequent procedure (13% a secondary PCNL). Use of supra 12th rib punctures was small (6%) as was the rate of ‘tube-less’ PCNL (4%). Some 22% had simultaneous ureteric stent insertion. Approximately 8% of cases required a blood transfusion. Thirty-eight patients (23%) had a proven infection (UTI) pre-operatively (> 10⁴ organisms; > 10 white blood cells) with almost all patients receiving antibiotics at anaesthesia induction. Postoperative sepsis rates (temperature > 38.5°C) were similar in those with and without a pre-operative UTI (18.4% versus 14.3%) and pre-operative antibiotics appeared to have little extra protective effect. Severe sepsis was rare with no patient requiring intensive care admission for this reason. Median length of stay postoperatively was 5 days.

CONCLUSIONS

These results present important figures to quote when counselling patients pre-operatively, albeit that the degree of difficulty (and hence the likelihood of problems) is identifiable from stone and anatomical configurations. In addition, the present data are a more accurate reflection of urinary stone surgery in non-tertiary, general urological practice.     

Are Adult Ureteroscopes Safe in the Management of Urolithiasis in a Pediatric Population?

Introduction

Debate remains regarding the optimal caliber of ureteroscopes in the management of pediatric urolithiasis, ranging from pediatric scopes to standard scopes. The aim of this study was to assess the safety and efficacy of stone management in a pediatric population using standard adult ureteroscopes.

Methods

A retrospective review of all ureteroscopic procedures in patients under the age of 16 years was carried out. Standard adult 7.5 French semi-rigid and 6 French flexible ureteroscopes were used.

Results

During the study period, 8 patients underwent 21 ureteroscopic procedures. Two patients had rigid ureteroscopy, seven had flexible ureterorenoscopy and one had a subsequent open procedure. No patients required ureteric dilation. Double J ureteric stents were utilized in 7 patients. There were no complications. All patients required extra corporeal shock wave lithotripsy. Stone clearance was achieved in all patients.

Conclusion

Our series demonstrates that, in skilled hands, adult ureteroscopes can be use safely for the treatment of urolithiasis in pediatric patients.Key Words: Urolithiasis, Paediatric urolithiasis, Ureteroscopy     

Supra-costal tubeless percutaneous nephrolithotomy is not associated with increased complication rate: a prospective study of safety and efficacy of supra-costal versus sub-costal access

Background

To assess the morbidities of tubeless percutaneous nephrolithotomy (PCNL) using supra-costal access and re-evaluate traditional concept of increased complications with supra-costal access.

Methods

From January 2010 to December 2014, a single surgeon performed 118 consecutive one-stage fluoroscopic guided PCNL’s for complex renal and upper ureteral stone. Our definition for complex renal stone is defined as partial or complete staghorn stone, multiple renal stones in more than 2 calyxes, obstructive uretero-pelvic stone >?2?cm, and a renal stone in single functional kidney. Inclusion criteria include: staghorn stones, renal calculi >?2?cm in diameter, upper ureteral stone >?1.5?cm in diameter. Exclusion criteria for tubeless PCNL include: significant bleeding or perforation of the collecting system, large residue stone, multiple PCNL tract and obstructive renal anatomy. Morbidity, operation time, analgesia requirement, length of hospital stay, stone- free rate, were analyzed.

Results

Of the 118 consecutive PCNL, eighty-six patients underwent tubeless PCNL (56 supra-costal and 30 sub-costal) and included in our prospective follow-up period. The mean age, operation side, stone locations were similar. The male to female ratio is higher in supra-costal than sub-costal. Large renal stones and staghorn stones makes up for most patients (supra-costal: 75%, sub-costal: 80%). The stone–free rate of supra-costal group was 59% (33/56) and in sub-costal group was 50% (15/30). The operative times, length of stay, post-op analgesic use, hematocrit change was similar in both groups. The overall complication rate is 6% [supra-costal (1/56), sub-costal (4/30)] with the majority being infectious complications.

Conclusions

Supra-costal access above 12th rib during tubeless PCNL is safe and effective procedure and is not associated with higher incidence of post-op complications in experience hands.

     

Pulmonary Complications following Percutaneous Nephrolithotomy: A Prospective Study

Introduction

Pulmonary complications may occur in the post-operative period and are a significant cause of morbidity and mortality in patients undergoing anesthesia and surgery. Complication rates vary according to different procedures and different types of anesthesia and may be affected by the patient condition. The purpose of this study was to examine pulmonary complications following percutaneous nephrolithotomy (PCNL) and to search for associations between the pre- and intra-operative factors and the risk of post-operative pulmonary complications (PPC).

Patients and Methods

This was a prospective observational study of 100 consecutive adult patients who underwent PCNL surgery. We collected data of the patient, surgery and anesthesia and analyzed it to find correlations with PPC.

Results

Eight (8%) patients had PPC following PCNL, 7 patients had pneumothorax and 1 had atelectasis and pleural effusion. The latter patient died at post-operative day 24 due to respiratory failure. It was found that patients who had PCNL on the right kidney were at lower risk for PPC. In addition it was found that younger patients had a higher incidence of PPC.

Conclusions

Based on this study the most common type of post-operative complication following PCNL is pulmonary, with pneumothorax being the main complication. PPC may result in patient mortality. The side of the operation and the patient''s age might affect the risk of PPC.Key Words: Percutaneous nephrolithotomy, Anesthesia, Post-operative Pulmonary complications     

The Use of the Amplatz Sheath in Percutaneous Nephrolithotomy: Does Amplatz Sheath Size Matter?

Objectives

To evaluate the effect of Amplatz sheath size used in percutaneous nephrolithotomy (PCNL) on postoperative outcome, bleeding, and renal impairment rates.

Materials and Methods

One-hundred and ten patients who underwent uneventful percutaneous nephrolithotomy between November 2011 and October 2012 were included in the study. The patients were divided into 5 groups based on Amplatz sheath size (22, 24, 26, 28 and 30 Fr). Groups were comppared in terms of pre- and post-operative mean hemoglobin, creatinine, nephrostomy time, nephrostomy tube diameter, operative time, and fluoroscope time.

Results

Mean operative time, preoperative hemoglobin and creatinine values were similar in all groups. Postoperative mean hemoglobin level was significantly lower and postoperative mean creatinine level was significantly higher in patients who were treated with a larger Amplatz sheath when compared to a smaller size (p < 0.05). It was observed that nephrostomy time and nephrostomy tube size significantly increased as the Amplatz sheath size increased. Seven patients presented with postoperative infection (1, 2, 1, 0 and 3 patients in Group I, II, III, IV, and V respectively), 13 patients presented with bleeding requiring blood transfusion (2, 4, and 7 patients in Group III, IV, and V respectively), and residual stone was observed in 9 patients (5, 2, 0, 1, and 1 patients in Group I, II, III, IV, and V respectively).

Conclusion

Although the use of a larger Amplatz sheath for larger stones seems to be suitable, this is not the case for smaller stones. For smaller stones, a smaller Amplatz sheath size would be useful to decrease the bleeding and renal impairment rates.Key Words: Percutaneous nephrolithotomy, Nephrostomy, Amplatz sheath, Treatment outcome     

Considerations in Minimally Invasive Surgery for Renal and Ureteric Calculi: A Bicenter Quality Control Study

Background

The use of minimally invasive surgery is increasing. Evaluating the quality of care brings new sights in the optimization of operating techniques.

Methods

We included all procedures performed in two hospitals during 2010 and 2011. A total of 264 patients were included in the ureterorenoscopy (URS) group and 77 patients in the percutaneous nephrolitholapaxy (PCNL) group. Data were gathered by retrospectively reviewing medical records.

Results

Mean stone diameter in the URS group was 9 mm. Patients suffered from a single stone in 79% of the cases. Calculi in the distal ureter, defined as the part of the ureter below the lower border of the sacroiliac joint, were most likely to be removed. A stone-free status was reached in 69% of the cases using URS. Mean stone diameter in the PCNL group was 23 mm. PCNL was successful in 70% of the cases in Haga Hospital versus 53% in Medisch Centrum Haaglanden. Incidence of complications was comparable between the hospitals (p = 0.5). Outcome and quality of both PCNL and URS was not influenced by sex, age or body mass index.

Conclusion

The clinical results were comparable with results in the literature. Further improvement can be made by optimization of technical aspects and centralization of treatment by urologists experienced in minimally invasive techniques.Key Words: Urolithiasis, Percutaneous nephrolithotomy, Ureterorenoscopy, Minimally invasive surgery     

‘Nephrostomy-Free’ Percutaneous Nephrolithotomy: Experience in a UK District General Hospital

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large and complex renal calculi. Accepted UK practice is to insert a nephrostomy tube at the end of the procedure to drain the kidney and reduce potential complications. ‘Tubeless’ or ‘nephrostomy-free’ PCNL has been advocated in selected patients as it is thought to reduce length of hospital stay, analgesia requirements and pain experienced. We present our outcomes of a consecutive series (n = 101) of ‘nephrostomy-free’ PCNLs compared to standard PCNL over a 4-year period.

PATIENTS AND METHODS

Between January 2004 and October 2006, we performed 55 standard (with nephrostomy tube) PCNLs (Group 1). From October 2006 onwards, we changed our technique and have performed 46 consecutive ‘nephrostomy-free’ PCNLs (JJ stent inserted), independent of patient and stone factors (Group 2). We have compared the two groups in terms of length of hospital stay (LOS), analgesia requirements, transfusion rates, haemoglobin (Hb) decrease and immediate, early and late complications.

RESULTS

‘Nephrostomy-free’ PCNL significantly reduced the length of hospital stay (2.8 vs 5.1 days; P < 0.001), morphine-based analgesia requirements (23% no morphine required vs 2.8%; P < 0.001), transfusion rate (2.5% vs 7%; P < 0.01) and mean Hb decrease (1.89 g/dl vs 2.25 g/dl; P > 0.05). Overall, no patient experienced a serious complication. All attempted ‘nephrostomy-free’ PCNLs were completed (stone clearance 95%) and no patient needed an unplanned nephrostomy. Only 5% in Group 2 needed their ureteric JJ stent removing earlier than planned secondary to pain. Both groups were comparable in terms of immediate, early and late complications, though three patients in Group 1 developed chronic loin pain and one patient in the ‘nephrostomy-free’ group developed a delayed perirenal haematoma.

CONCLUSIONS

‘Nephrostomy-free’ percutaneous nephrolithotomy is a safe, effective and feasible procedure independent of patient and stone factors. It decreases the length of hospital stay, the pain experienced and the need for morphine-based analgesia; we feel it should be the standard of care for patients undergoing a PCNL.     

Managing Small Ureteral Stones: A Retrospective Study on Follow-Up,Clinical Outcomes and Cost-Effectiveness of Conservative Management vs. Early Surgery

Introduction

The management of ureteral calculi has evolved over the past decades with the advent of new surgical and medical treatments. The current guidelines support conservative management as a possible approach for ureteral stones sized = 10 mm.

Objectives

We purport to follow the natural history of ureteral stones managed conservatively in this retrospective study, and attempt to ascribe an estimated health-care and cost-effectiveness, from presentation to time of being stone-free.

Materials and methods

192 male and female patients with a single ureteral stone sized = 10 mm were included in this study. The clinical and cost-related outcome was analyzed for different stone sizes (0-4, 4-6 and 6-10 mm). The effectiveness of selected follow-up (FU) scans was also analyzed.

Results

Stone size was found to be related to the degree of hydronephrosis and to the likelihood of need for a surgical management. Conservative management was found to be clinically effective, as 88% of the patients did not require surgery for their stone. 96.1% of the patients with a stone 0-4mm managed to expel their ureteral stone. Bigger ureteral stones were found to be more costly. The cost-effectiveness of the single FU scans was found to be related to their efficiency, while the global cost-effectiveness of conservative management vs. early surgery was higher for smaller stones (26.8 vs. 17.32% for stones 0-4 vs. 6-10 mm).

Conclusion

Conservative management is clinically effective with a significant cost-benefit, particularly for the subgroup of stones sized 0-4 mm, where a need for FU scans is in dispute.Key Words: Conservative management, Cost-effective, Tamsulosin, Ureteral calculus, Urolithiasis     

Changes in Urolithiasis Referral Patterns for Shock Wave Lithotripsy over a Decade: Was There Adherence to AUA/EAU Guidelines?

Objective

The primary objective was to assess changes in referral patterns of urolithiasis for shock wave lithotripsy (SWL) over a decade. The secondary objective was to evaluate the effect of the number of years of practice of referring physicians on these referral patterns.

Methods

A retrospective review of SWL database was performed for consecutive referrals for SWL at a tertiary stone center between December 1999 and December 2013. Patient demographics and stone characteristics were assessed. The stone location at the time of referral was used as the reference. Retreatments were excluded. In addition, years of practice of the referring physicians were calculated. The 2007 AUA/EAU guidelines on urolithiasis were considered as a reference.

Results

A total of 8,992 SWL treatments were included. After December 2007, there was a significant increase in the percentage of renal pelvic stones referred for SWL (23.0 vs. 27.1%, p < 0.001). Conversely, proximal ureteral stones significantly decreased after 2007 (24 vs. 18.2%, p < 0.001) including stones > 10 mm (5.1 vs. 2.9%, p < 0.001). Otherwise, there were no changes in the referral patterns for SWL of other stone locations before and after December 2007 (p > 0.05). Furthermore, percentage of stones referred for SWL by urologists practicing for less than 10 years significantly decreased after December 2007 (29.5 vs. 22.8%, p < 0.001).

Conclusions

The significant reduction in the referral of proximal ureteral stones after December 2007 corresponds to the latest AUA/EAU guidelines on management of ureteral stones.Key Words: Shock waves, Lithotripsy, Urolithiasis, Referral, Guidelines     

La NLPC en d��cubitus dorsal modifi�� : notre exp��rience

Purpose:

Percutaneous nephrolithotomy (PCNL) is conventionally performed with the patient in the prone position. In this study, we assess the safety and efficacy of PCNL in the supine position.

Methods:

Between November 2004 and January 2010, we performed 159 percutaneous nephrolithotomies. The patient is placed in a supine modified position with an air bag underneath the operating flank. If necessary, a modified lithotomy position allowing the simultaneous antegrade and retrograde endourological access was used. The access has been realized with progressive Alken dilators or with the one-shot technique. Operative times, mean stay in hospital, complications and success rates were analyzed.

Results:

The mean age was 47 ± 13.1 years (range: 22–70). Twenty-one patients had previous kidney surgery. Twenty-one had solitary kidneys and 3 patients had congenital renal abnormalities. The mean stone size was 3.4 ± 1.9 cm (range: 1.3–5.4). Twenty patients (29.5%) had complete staghorn stones. Ten patients (11.4%) also had ureteral stones and underwent concomitant ureteroscopy. The mean operative time was 60 ± 29 min, including patient positioning. In 2 patients it was necessary to suspend the procedure due to of bleeding. Postoperative complications included prolonged fever in 3 patients, nephrocutaneous fistula requiring double pigtail stent placement. Arterial embolization was never required. The colon was never damaged and we had no cases of hydrothorax or kidney loss. A second early treatment using the same percutaneous access during the same hospital stay was needed in 8 patients. The stone-free rate was 91.8%.

Conclusions:

Percutaneous nephrolithotripsy with the patient in a modified supine position is effective and safe. It offers obvious advantages from the point of view of the patient’s comfort and use of anesthetic. There is no risk of vitiated positions or traumatisms due to the change of bed-position and no thoracic compression occurs, which makes the procedure safe in patients with associated cardiorespiratory pathologies or obese patients. Also, the risk of colon perforation is reduced, which allowed for allows access to the entire urinary collecting system.     

Endoscopic combined intrarenal surgery in prone split-leg and inclined supine positions to treat renal cast and multiple calyx stones: An invited commentary

This Invited Commentary discusses the following article:Mulay A, Mane D, Mhaske S, Shah AS, Krishnappa D, Sabale V. Supine versus prone percutaneous nephrolithotomy for renal calculi: Our experience. Curr Urol 2022;16 (1):25-29. doi: 10.1097/CU9.0000000000000076.

Urolithiasis is a common disease encountered in urology. Its incidence is 0.1%-14.8% in Western countries and 5.94%-9.15% in China, with a significantly higher incidence in South China than in North China. In some areas of South China, the incidence of calculi exceeds 20%.^[1] Currently, percutaneous nephrolithotomy (PCNL) is the preferred treatment option for patients with multiple complex, renal cast, and multiple calyx stones.^[2] Complex multiple stones are associated with a lower stone clearance rate and a higher complication rate.^[3] Multichannel lithotripsy and endoscopic combined intrarenal surgery (ECIRS) in prone split-leg and inclined supine positions can improve the stone clearance rate.^[4] The 2016 American Urological Association guidelines established multi-channel PCNL as a safe and effective treatment for complex stones. In a previous study, the stone-free rate in a single operation was 79%, but the size and number of channels increased, followed by an increased risk of bleeding.^[5]In the article “Supine versus prone percutaneous nephrolithotomy for renal calculi—Our experience,” Mulay et al. evaluated the efficacy and safety of PCNL in modified supine and prone positions and showed that PCNL and ECIRS can be performed simultaneously in the supine position. In 1992, Ibarluzea et al. introduced ECIRS in the modified supine position.^[6] With the improvement and development of various urological surgical techniques and instruments, retrograde intrarenal surgery (RIRS) is no longer just an adjunctive or alternative surgery but an important part of clinical treatment. Better clinical outcomes and minimization of surgery-related complications can be achieved by combining RIRS with PCNL. A systematic review of 14 ECIRS cases showed that ECIRS had a stone-free rate of 61%-97%, a complication rate of 5.8%-42%, and a reduced risk of bleeding. Moreover, the bleeding risk was not correlated with the PCNL puncture channel size.^[7] Modified supine ECIRS has the following advantages over multichannel PCNL:

1. No position adjustment is required after anesthesia.
2. Direct vision puncture can be performed, and the puncture needle and dilator can enter the collecting system without being too deep under the direct vision of the transurethral ureteroscope, ensuring the safety and effectiveness of the puncture and reducing the incidence of complications when the channel is established.
3. The first choice for percutaneous renal puncture in ECIRS is the inferior calyx approach, and flexible ureteroscopy is performed to treat stones in the middle and upper calyces, which are relatively easy to access. Simultaneously, the advantages of flexible ureteroscopy for exploration include treating parallel calyx stones. For lower parallel calyx stones, the stone basket under the flexible scope can be used to move the stone to a position that can be treated with nephroscopy, after which the stone can be crushed and extracted.
4. Stone fragments entering the ureter can be treated without position adjustment, thereby reducing the rate of reoperation.
5. Combined PCNL and RIRS can treat ureteral and kidney stones simultaneously.
6. The stone clearance rate improves without increasing the risk of bleeding.
7. Combined with ureteral twisting and stenosis, it is difficult to insert the double J stent tube from the PCNL channel after lithotripsy. The double J stent tube can be placed retrogradely through the urethra using the ECIRS without position adjustment.

ECIRS can also be performed in the prone split-leg position, which has several advantages compared to the modified supine position as follows:

1. The prone split-leg position fully exposes the percutaneous renal puncture area of the affected kidney at the waist.
2. This position is simpler than the modified supine position and effectively reduces the workload of medical staff.
3. The peripheral organs, such as the intestines, are lowered by gravity, reducing the risk of organ damage.
4. The intrarenal perfusion effect is better in the prone position; therefore, the operative field of view is unaffected.
5. The modified supine position typically has a longer PCNL tract, particularly in patients with obesity, with decreased nephroscopic mobility and greater renal parenchymal mobility; thus, the bleeding risk is high, and extra-long devices should be provided.

However, the prone split-leg or inclined supine position is not significantly superior in terms of urological parameters, such as the stone clearance or complication rate.^[8]PCNL technology has evolved mainly owing to improvements in puncture technology, endoscopic instruments, lithotripsy devices, and drainage management. The introduction of the split-leg prone and improved supine positions is also part of the development. The development of ECIRS reflects the individualized management of patients with stones. ECIRS in split prone and modified supine positions is associated with a higher stone clearance rate, less blood loss, shorter operative time, and reduced perioperative complications when treating renal cast and multiple calyx stones. This is a new, safe, and effective procedure for PCNL.     

Training in percutaneous nephrolithotomy--a critical review

Aim

To study factors influencing training and maintaining skills in performing percutaneous nephrolithotomy (PCNL).

Methods

We matched key words, throughout Medline, MeSH, and Cochrane databases including: renal stone, percutaneous, nephrostomy, endourology, educational, training, learning curve, expertise, skill, residency, practice, survey, simulator, and robotics. For this topic we defined, if possible, levels of evidence based on International Consultation on Urological Diseases (ICUD) and World Health Organization recommendations.

Results

Obtaining renal access is one of the most important factors in training for PCNL. A resident has to perform about 24 PCNL procedures to obtain a good proficiency during the residence period. Competence at performing PCNL is reached after 60 cases and excellence is obtained at >100 cases. Stone centers providing all the endoscopic treatment options seem to provide the best conditions to ensure a sufficient volume of patients recruited. Virtual reality simulators may have a potential in training for PCNL. To maintain one's expertise, participation in continuing educational programs is recommended.

Conclusion

PCNL is currently the most complicated stone surgery technique to teach. The steep learning curve is mainly related to obtaining renal access. The traditional method of acquiring surgical skills is by apprenticeship in the absence of validated virtual simulators. Given the complexity of the treatment of renal stones, one may consider a centralized renal stone treatment in dedicated stone centers.     

Computed tomography versus ureteroscopy in identification of renal tract stone with ureteral stent in situ

INTRODUCTION

The aim of this study was to validate the use of non-contrast computed tomography (CT) with a ureteral stent in situ instead of ureteroscopy for identification of renal tract stones.

METHODS

All patients who had stents inserted for renal tract stones and underwent non-contrast CT with the stent in situ followed by ureteroscopy between May 2008 and October 2009 at The Canberra Hospital, Australia, were analysed retrospectively. Statistical analysis was performed to compare any differences between CT and ureteroscopy in the identification of stones.

RESULTS

Overall, 57 patients were included in the study. The difference between CT and ureteroscopy findings was statistically significant. CT identification of stones with a stent in situ had a sensitivity of 86%, a specificity of 46%, a positive predictive value of 63%, a negative predictive value of 76% and an accuracy of 67%.

CONCLUSIONS

Our study suggests that non-contrast CT is inferior to the ‘gold standard’ of ureteroscopy. It lacks sensitivity, specificity, positive predictive value, negative predictive value and accuracy. Therefore, we cannot recommend using non-contrast CT to replace ureteroscopy.     

Is there a need for early post-operative x-rays in primary total knee replacements? Experience of a centre in the UK

INTRODUCTION

Early post-operative x-rays are often taken in total knee replacements (TKRs). Patient mobilisation may be delayed until these x-rays are obtained and this may prolong discharge. The aim of this study was to assess the value of such early x-rays and whether they influenced the early post-operative management of these patients.

METHODS

A total of 624 consecutive TKRs performed at the Blackpool Victoria Hospital over a 34-month period were evaluated. Plain anteroposterior and lateral x-rays were examined.

RESULTS

Two patients were found to have significant abnormalities: an undisplaced peri prosthetic tibial fracture and a partial inferior pole patellar avulsion. Neither of these required further treatment or influenced mobility. No other complications were noted that changed routine post-operative management.

CONCLUSIONS

These results question the need for immediate x-rays in primary TKRs.     

Laparoscopic Pyelolithotomy in a Pelvic Kidney: A Case Report and Review of the Literature

Background and Objectives:

Laparoscopic pyelolithotomy was performed in a pelvic kidney with a large renal pelvis calculus.

Methods and Results:

Laparoscopic pyelolithotomy was successfully performed in a pelvic kidney with an operative time of 310 minutes. The use of intraoperative fluoroscopy and a semi-automatic suturing device greatly facilitated the procedure. The patient''s operative pain was managed with 3 doses of ketorolac; she resumed a regular diet the day after surgery, and was discharged on the first postoperative day.

Conclusions:

For patients with a large stone in the renal pelvis of an ectopic kidney, laparoscopic pyelolithotomy provides an effective approach.     

Day-case rigid and flexible ureteroscopy

INTRODUCTION

The aim of this study was to evaluate the feasibility of rigid and flexible ureteroscopy as a day-surgery procedure.

PATIENTS AND METHODS

All patients requiring elective ureteroscopy from March 2004 were considered for a day-surgery procedure. The standard day-surgery exclusions existed but there were no urological criteria for exclusion. A single consultant urologist performed or supervised all procedures.

RESULTS

A total of 64 patients underwent 50 rigid and 14 flexible procedures. Six diagnostic ureteroscopies were performed. There was a 96% stone clearance rate. Five patients required an unplanned admission within the first 2 weeks'' postoperatively. Three of these patients were admitted on the day of surgery, two for pain and one for social reasons. Two patients were admitted at 24 h and 48 h, respectively, for urinary retention.

CONCLUSIONS

Ureteroscopy, both rigid and flexible, is a safe procedure for the day-surgery setting. Routine use of prophylactic antibiotics, intravenous non-steroidal anti-inflammatory drugs resulted in an acceptable re-admission rate.