‘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.     

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     

Endoscopic Combined Intrarenal Surgery in Galdakao-Modified Supine Valdivia Position: A New Standard for Percutaneous Nephrolithotomy?

Background

Percutaneous nephrolithotomy (PCNL), the gold standard for the management of large and/or complex urolithiasis, is conventionally performed with the patient in the prone position, which has several drawbacks. Of the various changes in patient positioning proposed over the years, the Galdakao-modified supine Valdivia (GMSV) position seems the most beneficial. It allows simultaneous performance of PCNL and retrograde ureteroscopy (ECIRS, Endoscopic Combined Intra-Renal Surgery) and has unquestionable anaesthesiological advantages.

Objective

To prospectively analyse the safety and efficacy of endoscopic combined intrarenal surgery (ECIRS) in GMSV position for the treatment of large and/or complex urolithiasis.

Design, setting, and participants

From April 2004 to December 2007, 127 consecutive patients who were followed in our department for large and/or complex urolithiasis were selected for surgery (American Society of Anesthesiologists [ASA] score 1–3, no active urinary tract infection [UTI], any body mass index [BMI]).

Intervention

All the patients underwent ECIRS in GMSV position. Technical choices about percutaneous access, endoscopic instruments and accessories, and postoperative renal and ureteral drainage are detailed.

Measurements

Patients’ mean age plus or minus standard deviation (± SD) was 53.1 yr ± 14.2. Of the 127 patients, 5.5% had congenital renal abnormalities, 3.9% had solitary kidneys, and 60.6% were symptomatic for renal colics, haematuria, and recurrent UTI. Mean stone size ± SD was 23.8 mm ± 7.3 (range: 11–40); 33.8% of the calculi were calyceal, 33.1% were pelvic, 33.1% were multiple or staghorn, and 4.7% were also ureteral.

Results and limitations

Mean operative time ± SD was 70 min ± 28, including patient positioning. Stone-free rate was 81.9% after the first treatment and was 87.4% after a second early treatment using the same percutaneous access during the same hospital stay (mean ± SD: 5.1 d ± 2.9). We registered overall complications at 38.6% with no splanchnic injuries or deaths and no perioperative anaesthesiological problems.

Conclusions

ECIRS performed in GMSV position seems to be a safe, effective, and versatile procedure with a high one-step stone-free rate, unquestionable anaesthesiological advantages, and no additional procedure-related complications.     

The Role of Percutaneous Nephrolithotomy in the Management of Medium-Sized (1–2 cm) Lower-Pole Renal Calculi

Objectives : The objective of this study was to determine the efficacy (defined by stone-free rates) and safety of percutaneous nephrolithotomy (PNL) in the treatment of medium sized (1–2 cm) symptomatic lower pole renal calculi, and establishment of the short-term morbidity.

Methods : We performed a retrospective analysis of 60 evaluable patients who had undergone PNL for 1 to 2 cm diameter lower-pole (LP) stones between November 2006 to March 2009 and compared these results with other treatment modalities in published literature.

Results : In all cases, stones were located in the lower calix. Thirty-six procedures were performed on the left side, and 24 were performed on the right side. The mean time to access the collecting system was 20.4 minutes (range 8–70 min) and mean operative time was 62.2 minutes (range 13–155 min). Abdominal radiography performed on postoperative day 1 demonstrated a stone free status in 56 (93.3%) patients. However, 4 patients (6.7%) required ancillary procedures (secondary PNL in 1, retrograde intrarenal surgery in 1, and SWL in 2). After this secondary procedures a complete stone-free status was achieved in 98.3% of patients. The morbidity of patients undergoing PNL at our hospital was minimal, with a mean hospital stay of 3.7 days.

Conclusions : We demonstrated that, PNL is a safe and effective method for medium sized (1 to 2 cm) lower pole renal calculi and percutaneous removal should be considered the primary approach for lower pole stones greater than 10 mm.     

Minimally Invasive (“Mini”) Percutaneous Nephrolithotomy: Classification,Indications, and Outcomes

Minimally invasive endoscopic procedures are often employed for the surgical removal of kidney stones. Traditionally, large stones are removed by (standard) percutaneous nephrolithotomy (SPCNL). Although effective for the clearance of large stone burdens, SPCNL is associated with significant morbidity. Therefore, in an effort to reduce this morbidity, while preserving efficacy, mini-PCNL (MPCNL) with a smaller tract size (<20 French) was developed. Several studies suggest that MPCNL has a comparable stone-free rate to SPCNL. However, the question of lower morbidity with MPCNL remains unanswered. In this review, we describe the equipment, indications, and efficacy of MPCNL with particular attention to its value over traditional minimally invasive stone removal techniques.     

Can Preemptive Kidney Transplantation Guarantee Longer Graft Survival in Living-Donor Kidney Transplantation? Single-Center Study

Introduction

The benefit of preemptive kidney transplantation (KTx) for graft survival compared with nonpreemptive KTx is controversial.

Objective

To analyze the influence of preemptive KTx on graft survival.

Patients and Methods

The study included 476 of 531 patients who had undergone living-donor KTx between January 2000 and June 2007. Pediatric patients and those who had previously undergone KTx were excluded. Recipients were divided into 2 groups; group 1 included 413 patients (86.8%) who received grafts after institution of maintenance dialysis, and group 2 included 63 patients (13.2%) who underwent preemptive KTx.

Results

Donor type and HLA mismatch demonstrated significant differences between the 2 groups. Group 1 had more living donors and fewer HLA mismatches. Warm ischemia time in group 2 was significantly shorter than in group 1. The serum creatinine concentration in group 1 on postoperative day 7 was significantly higher than in group 2. Five- and 10-year graft survival in groups 1 and 2, respectively, were 95.3% and 81.3% vs 92.9% and 92.9%. Graft survival was not significant insofar as duration and method of dialysis. At our institution, independent risk factors for graft survival in living-donor KTx are primary end-stage renal disease, acute cellular rejection episodes, and recipient age.

Conclusion

We observed no benefit on graft survival in recipients of living-donor KTx insofar as whether they had undergone previous dialysis.     

TGF-β/Smad Signaling in Kidney Disease

Chronic progressive kidney diseases typically are characterized by active renal fibrosis and inflammation. Transforming growth factor-β1 (TGF-β1) is a key mediator in the development of renal fibrosis and inflammation. TGF-β1 exerts its biological effects by activating Smad2 and Smad3, which is regulated negatively by an inhibitory Smad7. In the context of fibrosis, although Smad3 is pathogenic, Smad2 and Smad7 are protective. Under disease conditions, Smads also interact with other signaling pathways, such as the mitogen-activated protein kinase and nuclear factor-κB pathways. In contrast to the pathogenic role of active TGF-β1, latent TGF-β1 plays a protective role in renal fibrosis and inflammation. Furthermore, recent studies have shown that TGF-β/Smad signaling plays a regulating role in microRNA-mediated renal injury. Thus, targeting TGF-β signaling by gene transfer of either Smad7 or microRNAs into diseased kidneys has been shown to retard progressive renal injury in a number of experimental models. In conclusion, TGF-β/Smad signaling plays a critical role in renal fibrosis and inflammation. Advances in understanding of the mechanisms of TGF-β/Smad signaling in renal fibrosis and inflammation during chronic kidney diseases should provide a better therapeutic strategy to combat kidney diseases.     

Complement Polymorphisms in Kidney Transplantation: Critical in Graft Rejection?

The complement system, as part of the innate immune system, plays an important role in renal transplantation. Complement is involved in the protection against foreign organisms and clearance of apoptotic cells but can also cause injury to the renal allograft, for instance, via antibody binding or in ischemia–reperfusion injury. Numerous polymorphisms in complement factors have been identified thus far; some of them result in different functionalities or alter complement levels. In this review, we provide an overview of the literature on the role of complement polymorphisms in renal transplantation. Furthermore, we discuss functional complement polymorphisms that have not yet been investigated in kidney transplantation. By investigating multiple polymorphisms both in donor and recipient at the same time, a complotype can be constructed. Because the combination of multiple polymorphisms is likely to have a greater impact than a single one, this could provide valuable prognostic information.     

Percutaneous nephrolithotomy in children: does age matter?

Purpose  

To compare the outcomes of percutaneous nephrolithotomy (PCNL) in 2 age groups.     

Preemptive Kidney Transplantation—A Team Experience in Uruguay

Kidney transplantation is the best treatment for end-stage chronic renal disease. In Uruguay, the prevalence of patients on dialysis is 757 patients per millon inhabitants, plus 316 alive with a functioning renal graft. We install a preemptive renal transplantation program. Twenty-five patients received grafts without dialysis from 2004 to 2013, 5 receiving their 2nd transplantation and 17 from cadaveric donors, with 7.4 ± 7.7 months in the waiting list. At 24 months, patients' survival rate was 100% and the grafts' 97%, with a serum creatinine of 1.4 ± 0.6 mg%. The developed programs of dialysis and renal health care contributed install our preemptive kidney transplantation. Kidney transplantation should be proposed to selected patients with chronic renal failure as primary therapy of substitution of renal function.     

Kidney Transplantation in Alström Syndrome: Case Report

The Alström syndrome is a rare genetic disorder, inherited in an autosomal recessive manner. It has recently been classified as a ciliopathic disorder. Alström syndrome is a multiorgan pathology characterized by cone-rod dystrophy, hearing loss, childhood truncal obesity, insulin resistance and hyperinsulinemia, type 2 diabetes mellitus, dyslipidemia, short stature in adulthood, hypothyroidism, hypogonadism, dilated or restrictive cardiomyopathy, and progressive pulmonary, hepatic, and renal dysfunction. End-stage renal disease can occur as early as the late teens and is the leading cause of death. More than 900 people with Alström syndrome have been reported worldwide. We present a case of a 42-year-old man affected by this syndrome with end-stage renal disease, type 2 diabetes mellitus, and loss of visual function and hearing who received a kidney transplant from a cadaveric donor. Basiliximab and steroid were used as induction therapy. Tacrolimus, mycophenolate mofetil, and steroid were used as maintenance therapy. No complications were reported during the recovery. In selected patients affected by Alström syndrome, renal transplantation can be a successful treatment for chronic kidney disease.     

Regulatory T Cells in Kidney Transplantation: New Directions?

The contribution of regulatory T cells in the maintenance of kidney graft survival is of major interest. Although many experimental models suggest a role in the induction of graft tolerance, reproducing these findings in clinic is less clear. While modulation of the regulatory T cell response is a promising therapeutic concept in transplantation, a better understanding of function, phenotype and biology is needed to be able to optimally exploit these cells in order to induce graft tolerance. With this in mind, we review here the current understanding of the phenotypic‐functional delineation of Tregs and how Tregs can contribute to graft survival. We highlight their potential role in long‐term graft survival and kidney operational tolerance. We also discuss the mechanisms needed for the molecular development of regulatory T cells: A combination of FOXP3 molecular partners, epigenetic, metabolic, and posttranslational modifications are necessary to generate well‐functioning regulatory T cells and maintain their core identify. We discuss how an improved understanding of these mechanisms will permit the identification of new potent therapeutic strategies to improve kidney graft survival.