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Abella Serra A, Colom Feixas S, Torrecilla Ortiz C, Cuadrado Campaña JM, De Fuentes Beltruz N, Cabrera Coma A, Sánchez Allueva A, Castells Esteve M, Vigués Julià F. Initial results of the implementation of an ambulatory mini percutaneous nephrolithotomy program. Actas Urol Esp 2023; 47:450-456. [PMID: 37315769 DOI: 10.1016/j.acuroe.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/20/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To present our program for ambulatory mini percutaneous nephrolithotomy (mini-PCNL) and evaluate its initial results. MATERIAL AND METHODS We analyzed the implementation of the protocol into the clinical practice with the first 30 outpatient mini-PCNL cases performed in our center between April 2021 and September 2022. Demographic characteristics, perioperative variables, complications and need for unplanned health care, stone-free rate (SFR), stone type and patient satisfaction with the major ambulatory surgery (MAS) process were collected. RESULTS A total of 30 patients with a mean age of 60.2 ± 11.6 years who met the inclusion criteria underwent surgery. The mean stone size was 15 mm [range: 5-20]. No intraoperative complications were recorded. All patients except one were discharged the same day of surgery as planned. In the month following discharge, the rate of complications, emergency department (ED) revisits or hospital readmissions rates were 0%. Stone-free-rate (SFR) at 3 months was 83%. Overall satisfaction with the whole perioperative process was assessed with the EVAN-G questionnaire, obtaining 124.3 points out of a maximum of 150, which is equivalent to a 78.6% level of satisfaction. CONCLUSION Ambulatory mini-PCNL can be implemented as a treatment option in centers with experience in endourology, an established MAS Unit, and strictly selected patients. Our initial results show an adequate safety profile and high overall satisfaction perceived by patients undergoing the ambulatory approach.
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Affiliation(s)
- A Abella Serra
- Servicio de Urología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - S Colom Feixas
- Servicio de Urología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - C Torrecilla Ortiz
- Servicio de Urología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J M Cuadrado Campaña
- Servicio de Urología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - N De Fuentes Beltruz
- Servicio de Urología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - A Cabrera Coma
- Servicio de Anestesiología y Reanimación. Hospital Universitari de Bellvitge. L'Hospitalet de Llobregat, Barcelona, Spain
| | - A Sánchez Allueva
- Servicio de Anestesiología y Reanimación. Hospital Universitari de Bellvitge. L'Hospitalet de Llobregat, Barcelona, Spain
| | - M Castells Esteve
- Servicio de Urología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - F Vigués Julià
- Servicio de Urología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Thakker PU, Mithal P, Dutta R, Carreno G, Gutierrez-Aceves J. Comparative outcomes and cost of ambulatory PCNL in select kidney stone patients. Urolithiasis 2022; 51:22. [PMID: 36571653 PMCID: PMC9791625 DOI: 10.1007/s00240-022-01392-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/02/2022] [Indexed: 12/27/2022]
Abstract
Limited hospital resources and access to care during the COVID-19 pandemic led us to implement a quality-improvement study investigating the feasibility, safety, and costs of same-day discharge after PCNL. The outcomes of 53 consecutive first-look PCNL patients included in a same-day discharge protocol during COVID-19 were compared to 54 first-look PCNL patients admitted for overnight observation. Control group had a similar comorbidity profile. Demographics, operative details, 30 day outcomes and readmissions, complications, and cost were compared between the two groups. Same-day discharge and one-day admission post-PCNL patients did not have significantly different baseline characteristics. The study group were more likely to have mini-PCNL (81% vs 50%, p < 0.01). Operative characteristics including median pre-operative stone burden (1.4 vs 1.7 cm3, p = 0.47) and post-operative stone burden (0.14 vs 0.18 cm3, p = 0.061) were similar between the two groups. Clavien-Dindo complication rates were lower in the study group compared to controls (0 vs 7%, p = 0.045). Readmission rates (2 vs 4%, p = 0.569) and ED visits (4 vs 6%, p = 0.662) were similar between the two groups. Total cost ($6,648.92 vs $9,466.07, p < 0.01) was significantly lower and operating margin ($4,475.96 vs $1,742.16, p < 0.01) was significantly higher for the same-day discharge group. Percutaneous nephrolithotomy may be performed in select patients without an increase in short-term complications, ED visits, or readmissions. Patients undergoing mini-PCNL are particularly amenable to same-day discharge, however, standard PCNL patients should not be excluded from consideration. Avoiding overnight admission decreases total cost and increased hospital operating margin.
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Affiliation(s)
- Parth U. Thakker
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC 27101 USA
| | - Prabhakar Mithal
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC 27101 USA
| | - Rahul Dutta
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC 27101 USA
| | - Gabriel Carreno
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC 27101 USA
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Lee MS, Assmus MA, Agarwal D, Rivera ME, Large T, Krambeck A. Ambulatory PCNL may be cost-effective compared to Standard PCNL. J Endourol 2021; 36:176-182. [PMID: 34663076 DOI: 10.1089/end.2021.0482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background COVID-19 changed the practice of medicine in America. During the March 2020 lockdown, elective cases were cancelled to conserve hospital beds/resources resulting in financial losses for health systems and delayed surgical care. Ambulatory percutaneous nephrolithotomy (aPCNL) has been shown to be safe and could be a strategy to: ensure patients receive care that has been delayed, conserve hospital resources, and maximize cost-effectiveness. We aimed to compare the safety and cost-effectiveness of patients undergoing ambulatory percutaneous nephrolithotomy (aPCNL) against standard PCNL (sPCNL). Materials and Methods 98 patients underwent PCNL at Indiana University Methodist hospital, a tertiary referral center, by three expert surgeons from January 2020 to September 2020. The primary outcome of the study was to compare the 30-day rates of ED-visits, readmissions, and complications between sPCNL and aPCNL. Secondary outcomes included: cost analysis and stone free rates (SFRs). Prospensity-score matching was performed to ensure the groups were balanced. Statistical analyses were performed using SAS 9.4 using independent t-tests for continuous variables and chi-square analyses for categorical variables. Results 98 patients underwent PCNL during the study period (sPCNL=75 and aPCNL=23). After propensity-score matching, 42 patients were available for comparison (sPCNL=19 and aPCNL=23). We found no difference in 30-day ED-visits, readmissions, or complications between the two groups. aPCNL resulted in cost savings of $5327±442 per case. Stone free rates were higher for aPCNL compared to sPCNL. Conclusions aPCNL appears safe to perform and does not have a higher rate of ED-visits or readmissions compare to sPCNL. aPCNL may also be cost-effective compared to sPCNL.
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Affiliation(s)
- Matthew S Lee
- Northwestern University Feinberg School of Medicine, 12244, Urology, 675 N. St. Clair, STE 20-150, Chicago, Illinois, United States, 60611.,Northwestern University Feinberg School of Medicine;
| | - Mark A Assmus
- Indiana University Department of Urology, 372831, Urology, 1801 Senate Blvd., Suite 220, Indianapolis, Indiana, United States, 46202;
| | - Deepak Agarwal
- Indiana University School of Medicine, Urology, Indianapolis, Indiana, United States;
| | - Marcelino E Rivera
- Indiana University Health Methodist Hospital, 22535, Urology, 1801 Senate Blvd, Ste 220, Indianapolis, Indiana, United States, 46202;
| | - Tim Large
- Indiana University School of Medicine, 12250, Urology, 1801 N Senate Blvd, Suite 220, Indianapolis, Indiana, United States, 46202;
| | - Amy Krambeck
- Indiana University Department of Urology, 372831, Urology, 1801 N Senate Blvd, Ste 220, Indianapolis, Indiana, United States, 46202-5289;
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Dar MA, Malik SA, Dar YA, Wani PM, Wani MS, Hamid A, Khawaja AR, Sofi KP. Comparison of percutaneous nephrolithotomy under epidural anesthesia versus general anesthesia: A randomized prospective study. Urol Ann 2021; 13:210-214. [PMID: 34421253 PMCID: PMC8343281 DOI: 10.4103/ua.ua_82_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 12/30/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction: PCNL has revolutionized the treatment of renal calculi putting almost an end to the era of open stone surgery. The procedure can safely be carried out under general anesthesia (GA) or regional anesthesia viz. spinal anesthesia (SA), epidural anesthesia (EA) or combined spinal and epidural anesthesia (CSE). Aims and Objectives: We evaluated the surgical outcome after PCNL in two groups of patients randomly divided to undergo procedure under GA or EA. Patients and Methods: Two hundred and thirty patients with American Society of Anesthesiologists (ASA) score <3 were randomly divided into two groups according to the type of anesthesia: i.e. GA (n=110) or EA (n=120). All patients underwent PCNL in prone position. Puncture was done using Bulls eye technique under fluoroscopic guidance and tract dilated using serial dilators up to 24Fr-28 Fr. Demographics, perioperative and postoperative parameters were noted and data analysed. Results: The two groups were comparable in terms of mean age, distribution of stone location, and stone burden. The stone free rate was 90.9% in GA group and 89.2% in EA group and the difference was statistically insignificant (P= 0.659). The requirement for auxiliary procedures was similar between the two groups. A significant difference in pain score was seen in favor of EA group during early post-operative period (P< 0.05). Conclusion: It seems that PCNL can be performed safely and effectively under regional epidural anesthesia with results comparable to general anesthesia with the added advantage of less immediate postoperative pain and analgesic requirement.
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Affiliation(s)
- Manzoor Ahmad Dar
- Department of Urology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Sajad Ahmad Malik
- Department of Urology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Yaser Ahmed Dar
- Department of Urology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Prince Muzafer Wani
- Department of Urology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Mohammad Saleem Wani
- Department of Urology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Arif Hamid
- Department of Urology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Abdul Rouf Khawaja
- Department of Urology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Khalid Parvez Sofi
- Department of Anaesthesia, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Danis E, Polat EC, Bozkurt M, Erkoc M, Can O, Altunrende F, Otunctemur A. Application of S.T.O.N.E. Nephrolithometry Score for Prediction of Stone-Free Status and Complication Rates in Patients Who Underwent Percutaneous Nephrolitotomy for Renal Stone. J Laparoendosc Adv Surg Tech A 2021; 32:372-377. [PMID: 34283645 DOI: 10.1089/lap.2021.0197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Renal stone disease is a common disorder in urology practice. Kidney stone has various treatment methods such as extracorporeal shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy (PCNL). In this study, we aimed to determine the value of S.T.O.N.E. nephrolithometry score, which is considered as a new scoring system for predicting residual stone rate and complications in patients undergoing PCNL due to renal calculi. Materials and Methods: A total of 120 patients >18 years old who underwent PCNL were evaluated prospectively. Five parameters available from preoperative noncontrast-enhanced computed tomography were measured: stone size (S), tract length (T), obstruction (O), number of involved calices (N), and essence or stone density (E) and then S.T.O.N.E. nephrolithometry score was calculated. The prediction of the stone-free rates and complication rates of this scoring was evaluated statistically. Results: When the age, gender, body mass index, comorbidities, and American Society of Anesthesiologists scores of the patients were evaluated according to the patients' postoperative stone-free status, no statistical difference was found between the groups. Patients had a stone-free rate of 78%. Patients' mean neuropilitometry score was calculated to be 7.75 S.T.O.N.E. nephrolithometry score statistically significant (P = .001) for prediction of stone-free status. S.T.O.N.E. nephrolithometry score was significantly correlated with operation time, estimated blood loss, duration of fluoroscopy, duration of hospital stay, and number of punctures. Complications were seen in 13 patients. Conclusions: S.T.O.N.E. nephrolithometry score can be used as an objective criterion for predicting the complexity of the PCNL process. In addition, this scoring system is expected to provide more objective preoperative counseling and can provide standardization in academic studies.
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Affiliation(s)
- Eyyup Danis
- Department of Urology, Basaksehir Cam and Sekura State Hospital, Istanbul, Turkey
| | - Emre Can Polat
- Department of Urology, Prof. Dr Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Muammer Bozkurt
- Department of Urology, Basaksehir Cam and Sekura State Hospital, Istanbul, Turkey
| | - Mustafa Erkoc
- Department of Urology, Basaksehir Cam and Sekura State Hospital, Istanbul, Turkey
| | - Osman Can
- Department of Urology, Basaksehir Cam and Sekura State Hospital, Istanbul, Turkey
| | - Fatih Altunrende
- Department of Urology, Prof. Dr Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Alper Otunctemur
- Department of Urology, Prof. Dr Cemil Tascioglu City Hospital, Istanbul, Turkey
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Aarthy P, Thangarasu M, Prakash JS, Raghavan D, Jain N, Balakrishnan A, Chandranathan M, Bafna S, Paul R, Selvaraj N. Safety and efficacy of mini-percutaneous nephrolithotomy as daycare procedure: a prospective observational study. AFRICAN JOURNAL OF UROLOGY 2021. [DOI: 10.1186/s12301-020-00115-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To evaluate the safety, feasibility of mini-percutaneous nephrolithotomy (mPCNL) being carried out as a daycare surgery and to study the re-admission, stone clearance rate and complication rates following mPCNL. We also sought to find out the rate of requirement of ancillary procedure, after mPCNL.
Methods
In this prospective observational study, easily accessible patients above 18 years of age with renal and/or upper ureteric calculi, who underwent mPCNL between September 2018 and February 2020, were included. Seventy patients were selected, as per statistical methods. Preoperative evaluation including history, blood and urine investigations and radiological images was collected. Intra-operative and post-operative events were analyzed. Written consent was obtained from the patients to participate in the study and to publish their data. Institutional Ethical and scientific committee clearance was obtained.
Results
Out of 70 patients who underwent mPCNL in the study, in the age group ranging from 24–68 years, most of the cases were partial staghorn with maximum size of stone up to about 3.5 cm. Inferior calyx was most frequently punctured. Six cases had multipuncture mPCNL, four patients had bilateral procedure, and two had supra-costal puncture. Eighteen patients had tubeless mPCNL, of which four were totally tubeless procedures. Four patients had hematuria, none requiring transfusion. Two patients had sepsis, managed with higher antibiotics. Limitation of the study was the sample size. To derive a sturdy conclusion, large scale studies are recommended.
Conclusions
We can conclude that mPCNL can be safely done as daycare or ambulatory surgery in properly selected patients. In centers with experienced urologists, bilateral and multipuncture mPCNL can be done as an ambulatory surgery. Thus, this addresses the stone disease as well as cost containment, without patient safety being compromised. Bed occupancy rate is reduced, helping effective utilization of hospital resources.
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7
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Are Routine Laboratory Investigations Necessary Following Percutaneous Nephrolithotomy? Urology 2020; 143:80-84. [DOI: 10.1016/j.urology.2020.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 11/18/2022]
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Beiko D, Honey RJD, Pace KT, Denstedt JD, Razvi H, Hosking DH, Norman RW, Wilson JWL. Celebrating 75 years. Can Urol Assoc J 2019; 14:12-16. [PMID: 31364975 DOI: 10.5489/cuaj.5747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Following the introduction of shock wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL), the subspecialty of endourology was born in the late 1970s. The purpose of this study was to report milestones in Canadian endourology, highlighting Canada's contributions to the field. METHODS A review of the literature was performed from the late 1970s to the present. The literature review included bibliographic and digital resources. Additionally, records and recollections by various individuals were used, including some who were directly involved. RESULTS Endourology was born in Canada when SWL, URS, and PCNL emerged as minimally invasive treatment options for stones in the early to mid-1980s. According to our research, the first PCNL was performed at the University of Toronto in 1981. Dr. Joachim Burhenne, a Harvard-trained radiologist from Germany, first used extracorporeal SWL in Canada at the University of British Columbia (UBC) for the treatment of biliary stones. Treatment for urinary tract stones followed at UBC and Dalhousie University. The first worldwide use of the holmium laser for lithotripsy of urinary tract calculi took place at the University of Western Ontario. Other endourology milestones in Canada include the formation of the Canadian Endourology Group and the emergence of the Endourological Society-accredited fellowship programs at the University of Toronto and Western University in the 1990s. Canada hosted the 21st and 35th World Congress of Endourology and Shock Wave Lithotripsy annual meeting in Montreal and Vancouver, respectively. CONCLUSIONS Canadian urologists have led many advances in SWL, URS, and PCNL over the past four decades and, for a relatively small community, have made significant contributions to the field. Through the training of the next generation of endourologists at Canadian institutions, the future of endourology in Canada is bright.
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Affiliation(s)
- Darren Beiko
- Department of Urology, Queen's University, Kingston, ON, Canada
| | - R John D'A Honey
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kenneth T Pace
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - John D Denstedt
- Division of Urology, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Hassan Razvi
- Division of Urology, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Denis H Hosking
- Department of Surgery, Section of Urology, University of Manitoba, Winnipeg, MB, Canada
| | - Richard W Norman
- Department of Urology, Dalhousie University, Halifax, NS, Canada
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9
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Schoenfeld D, Zhou T, Stern JM. Outcomes for Patients Undergoing Ambulatory Percutaneous Nephrolithotomy. J Endourol 2019; 33:189-193. [PMID: 30489147 DOI: 10.1089/end.2018.0579] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Multiple studies have concluded that ambulatory percutaneous nephrolithotomy (aPCNL) is safe. However, selection criteria remain vague and no investigators have assessed the practicality of using various post-procedural drainage strategies in the ambulatory setting. In this study we establish a set of inclusion and exclusion criteria for aPCNL, compare outcomes between aPCNL patients and those admitted following PCNL, and incorporate a variety of "exit" strategies including Double-J stent, ureteropelvic junction (UPJ) stent and totally tubeless techniques. METHODS We developed inclusion and exclusion criteria to determine patient eligibility for aPCNL. Between January 2014 and December 2016, 52 out of 145 patients met criteria for aPCNL and 47 of these patients were ultimately discharged on the same day. Forty-seven of the remaining 98 patients who were admitted following PCNL were randomly selected as a control group. Primary outcomes included stone-free status, emergency department (ED) visits and hospital readmissions within the 6-week post-operative period. Statistical analysis was performed using Student's t-tests, chi square tests, and Fischer's exact tests. RESULTS Both groups had similar age (P = 0.91), sex (P = 0.68), body mass index (P = 0.91), and stone burden (P = 0.12). Patients in the ambulatory group had a lower Charlson Comorbidity score (aPCNL CCS = 0.11, inpatient PCNL CCS = 0.62, P = 0.002). Seventy three percent of ambulatory patients and 62% of standard PCNL patients had no residual stone burden 6 weeks following PCNL (P = 0.33). The average residual stone fragment in our ambulatory and standard PCNL group was 3.5 and 3.2 mm, respectively. Five patients (11%) from the aPCNL group and 4 (9%) from the standard PCNL group presented to the ED (P = 0.76). One aPCNL (2%) and three standard PCNL (6%) patients were re-admitted to the hospital (P = 0.62). CONCLUSIONS In this study we establish specific inclusion and exclusion criteria for aPCNL. Using these criteria we then demonstrated the practicality of using various exit strategies to facilitate aPCNL. Future randomized control trials would be beneficial in confirming the safety and efficacy of aPCNL in select patients.
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Affiliation(s)
- Daniel Schoenfeld
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine , Bronx, New York
| | - Tian Zhou
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine , Bronx, New York
| | - Joshua M Stern
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine , Bronx, New York
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10
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Kroczak T, Pace KT, Andonian S, Beiko D. Ambulatory percutaneous nephrolithotomy in Canada: A cost-reducing innovation. Can Urol Assoc J 2018; 12:427-429. [PMID: 30273115 DOI: 10.5489/cuaj.5416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Tad Kroczak
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
| | - Kenneth T Pace
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
| | - Sero Andonian
- Division of Urology, Department of Surgery, McGill University, Montreal, QC
| | - Darren Beiko
- Department of Urology, Queen's University, Kingston, ON; Canada
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11
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Bechis SK, Han DS, Abbott JE, Holst DD, Alagh A, DiPina T, Sur RL. Outpatient Percutaneous Nephrolithotomy: The UC San Diego Health Experience. J Endourol 2018; 32:394-401. [DOI: 10.1089/end.2018.0056] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Seth K. Bechis
- Department of Urology, UC San Diego Health, La Jolla, California
| | - Daniel S. Han
- Department of Urology, UC San Diego Health, La Jolla, California
| | - Joel E. Abbott
- Chesapeake Urology Associates, University of Maryland, Baltimore, Baltimore, Maryland
| | - Daniel D. Holst
- Department of Urology, UC San Diego Health, La Jolla, California
| | - Amy Alagh
- UC San Diego School of Medicine, La Jolla, California
| | - Thomas DiPina
- Department of Urology, UC San Diego Health, La Jolla, California
| | - Roger L. Sur
- Department of Urology, UC San Diego Health, La Jolla, California
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12
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Winship BB, Preminger GM. Editorial Comment on: Outpatient Percutaneous Nephrolithotomy: The UC San Diego Health Experience by Bechis et al. J Endourol 2018; 32:402. [PMID: 29571267 DOI: 10.1089/end.2018.0195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Brenton B Winship
- Department of Urology, Duke University Medical Center , Durham, North Carolina
| | - Glenn M Preminger
- Department of Urology, Duke University Medical Center , Durham, North Carolina
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13
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Abbott JE, Davalos JG. Outpatient Tubeless Percutaneous Nephrolithotomy Performed in a Freestanding Ambulatory Surgery Center. J Endourol Case Rep 2018; 4:28-31. [PMID: 29503872 PMCID: PMC5831992 DOI: 10.1089/cren.2017.0136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Percutaneous nephrolithotomy (PNL) is a procedure that has traditionally been performed in an inpatient or hospital setting. Many surgical procedures have evolved over time from an inpatient/hospital setting to outpatient procedures performed in surgical centers. Outpatient PNL has become an accepted standard in select patients, but to date, the procedure has not been performed in an outpatient surgical center. Case Presentation: We describe our initial experience managing large renal stone burden with PNL performed completely outpatient in a freestanding ambulatory surgery center. The patient was carefully selected as a young, healthy, thin patient with straightforward renal stone burden and favorable anatomy per CT. Access was achieved with a combination of fluoroscopic and endoscopic needle guidance. The procedure was performed with several modifying factors to enable an effective outpatient discharge. Conclusion: Our experience reinforces the outpatient feasibility of PNL and incites the possibility of transitioning the procedure to an ambulatory surgical center in select patients to provide healthcare savings and an improved patient experience.
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Affiliation(s)
- Joel E Abbott
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.,Advanced Kidney Stone Center of the Americas, Chesapeake Urology Associates, Hanover, Maryland
| | - Julio G Davalos
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.,Advanced Kidney Stone Center of the Americas, Chesapeake Urology Associates, Hanover, Maryland
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14
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Can percutaneous nephrolithotomy be performed as an outpatient procedure? Arab J Urol 2017; 15:1-6. [PMID: 28275511 PMCID: PMC5329725 DOI: 10.1016/j.aju.2016.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 11/21/2016] [Accepted: 11/27/2016] [Indexed: 11/22/2022] Open
Abstract
Objectives To examine the safety and effectiveness of percutaneous nephrolithotomy (PCNL) as an outpatient procedure, as in most centres PCNL is performed as an inpatient procedure that necessitates postoperative hospital admission. Patients and methods Our study included 186 patients undergoing PCNL for renal calculi. Only those who met strict inclusion criteria were discharged home on the same day. Preoperative eligibility criteria for outpatient management included no complex medical problem, normal renal function, and easy access to an emergency room. Patients were divided into two groups. The outpatient group (Group 1) included those patients discharged on the same day as the PCNL and the hospitalised group (Group 2) included those who were considered appropriate for outpatient management but needed to be hospitalised. Results In all, 162 patients (87%) fulfilled the inclusion criteria for outpatient management and 146 of these patients (90.1%) planned for outpatient management were discharged on the same operative day (Group 1). The mean time to discharge home was 8.97 h. In all, 16 patients who opted for the outpatient approach subsequently required hospitalisation (Group 2). In the hospitalised group the mean operative time was longer, which was probably related to its higher stone burden. Conclusion PCNL can be safely performed with excellent outcomes as an outpatient procedure. Outpatient PCNL offers several advantages including a more rapid patient convalescence, reduced healthcare expenditure, decreased postoperative nosocomial infections with no additional morbidity for the patient, and with no compromising of the stone-free rate.
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Kumar S, Singh S, Singh P, Singh SK. Day care PNL using 'Santosh-PGI hemostatic seal' versus standard PNL: A randomized controlled study. Cent European J Urol 2016; 69:190-7. [PMID: 27551557 PMCID: PMC4986304 DOI: 10.5173/ceju.2016.792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/24/2016] [Accepted: 05/12/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION To compare the outcomes of tubeless day care PNL using hemostatic seal in the access tract versus standard PNL. MATERIAL AND METHODS It was a prospective randomized controlled study. Cases were randomized to either the day care group with hemostatic seal (DCS) or the control group where patients were admitted and a nephrostomy tube was placed at the conclusion of surgery. RESULTS A total of 180 cases were screened and out of these, 113 were included in the final analysis. The stone clearance rates were comparable in both the groups. The mean drop in hemoglobin was significantly lower in DCS group than the control group (1.05 ±0.68 vs. 1.30 ±0.58 gm/dl, p = 0.038).Mean postoperative pain score, analgesic requirement (paracetamol) and duration of hospital stay were also significantly lower in the DCS group (3.79 ±1.23 vs. 6.12 ±0.96, 1.48 ±0.50 vs. 4.09 ±1.11 grams and 0.48 ±0.26 vs. 4.74 ±1.53 days respectively; p <0.05). The incidence of urine leakage through the access tract site was significantly lower in the DCS subgroup when compared to the controls (3.6% vs. 21.1%, p <0.05). Cases in the DCS group resumed their normal activities in a significantly shorter time (8.05 ±3.05 vs.18.42 ±4.42 days; p <0.05). Higher proportion of cases in the DCS group got re-admitted, although it was not a statistically significant number (7.1% vs. 1.8%; p = 0.21). CONCLUSIONS Tubeless day care PNL with composite hemostatic tract seal is considered safe. It resulted in a significant reduction of blood loss and analgesic requirement with significantly reduced hospital stay, nephrostomy tube site morbidity and time required to resume normal activity when compared to the standard PNL. However, patients must be compliant with the given instructions and should have access to a health care facility, as few of them may need re-admission.
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Affiliation(s)
- Santosh Kumar
- Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivanshu Singh
- Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prashant Singh
- Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shrawan Kumar Singh
- Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Beiko D, Andonian S. [Not Available]. Can Urol Assoc J 2015; 9:E559-61. [PMID: 26609334 DOI: 10.5489/cuaj.3233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Darren Beiko
- Department of Urology, Queen's University, Kingston, ON
| | - Sero Andonian
- Division of Urology, Department of Surgery, McGill University, Montreal, QC
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Beiko D, Andonian S. Getting started with ambulatory PCNL: A CanMEDS perspective. Can Urol Assoc J 2015; 9:223-5. [PMID: 26316901 DOI: 10.5489/cuaj.3198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Darren Beiko
- Department of Urology, Queen's University, Kingston, ON
| | - Sero Andonian
- Division of Urology, Department of Surgery, McGill University, Montreal, QC
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Beiko D, Elkoushy MA, Kokorovic A, Roberts G, Robb S, Andonian S. Ambulatory Percutaneous Nephrolithotomy: What Is the Rate of Readmission? J Endourol 2015; 29:410-4. [DOI: 10.1089/end.2014.0584] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Darren Beiko
- Department of Urology, Queen's University, Kingston, Canada
| | - Mohamed A. Elkoushy
- Division of Urology, Department of Surgery, McGill University, Montreal, Canada
- Department of Urology, Suez Canal University, Ismailia, Egypt
| | | | | | - Sylvia Robb
- Department of Urology, Queen's University, Kingston, Canada
| | - Sero Andonian
- Division of Urology, Department of Surgery, McGill University, Montreal, Canada
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Lehmann KJ, Beiko D. Outpatient tubeless percutaneous nephrolithotomy and concomitant cystolitholapaxy. Can Urol Assoc J 2014; 8:E179-80. [PMID: 24678360 DOI: 10.5489/cuaj.1675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Percutaneous nephrolithotomy (PCNL) is a widely employed endourologic procedure to remove renal stones. Traditionally, PCNL has been performed on an inpatient basis, with patients routinely hospitalized postoperatively. Given the ongoing rising healthcare costs, a shift toward outpatient surgery is desirable. We report the case of a 21-year-old female who was safely discharged a few hours following uncomplicated tubeless PCNL and concomitant cystolitholapaxy for a stent with encrustation on its distal coil. To the best of our knowledge, this is the first published case of tubeless PCNL with concomitant cystolitholapaxy performed on an entirely outpatient basis.
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Affiliation(s)
- Kyle J Lehmann
- Department of Urology, Dalhousie University, Halifax, NS
| | - Darren Beiko
- Department of Urology, Queen's University, Kingston General Hospital, Kingston, ON
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Fathelbab T, Abd EL Hamid A, Galal E. Percutaneous nephrolithotripsy under assisted local anaesthesia for high risk patients: Is it effective? AFRICAN JOURNAL OF UROLOGY 2013. [DOI: 10.1016/j.afju.2013.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Sharma AK, Nagabhushan M, Girish GN, Kamath AJ, Ratkal CS, Venkatesh GK. Analysis of the Feasibility and Efficacy of Ambulatory/Day Care Percutaneous Nephrolithotomy: An Initial Experience. ACTA ACUST UNITED AC 2013. [DOI: 10.3834/uij.1944-5784.2013.08.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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The feasibility of regional anesthesia in the percutaneous nephrolithotomy with supracostal approach and its comparison with general anesthesia. Urolithiasis 2012; 41:53-7. [PMID: 23532424 DOI: 10.1007/s00240-012-0528-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 12/08/2012] [Indexed: 10/27/2022]
Abstract
There are various approaches for the percutaneous nephrolithotomy (PCNL). Supracostal approach is a well known technique for doing of it. This approach is being done commonly under general anesthesia (GA). In this retrospective study, we evaluated the feasibility of supracostal PCNL under regional anesthesia (RA) and compared it with the same procedure under GA. Since March 2000 to March 2005, a total of 123 renal stone cases underwent PCNL with supracostal access in our center. GA was selected in 69 cases (56 %) (Group 1), spinal anesthesia (SA) in 45 cases (36.5 %), and epidural anesthesia (EA) in 9 cases (7.5 %) (Group 2). The operative time, success rate, hospital stay, and ensuing complications were compared between group 1 and group 2. There were no significant differences between groups 1 and 2 among surgical parameters, including age, stone area, anesthesia time, and hospitalization time (P > 0.05). There was no difference in the rate of complications or success rate between GA and RA cases (P > 0.05). Overall complete stone free rate, regardless of stone size, in relation to type of anesthesia was as follows: 88.4 % for GA, 88.9 % for EA, and 91.1 % for SA (P > 0.05). Conversion to GA was not needed in any patient with RA. The results showed that the supracostal PCNL with regional anesthesia was feasible but without evident advantages versus general anesthesia in this population, and possible advantages of the procedure in patients with pulmonary co-morbidities have still to be evaluated. The anesthesia related complications of RA were negligible and easily controllable.
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Alyami F, Norman RW. Is an overnight stay after percutaneous nephrolithotomy safe? Arab J Urol 2012; 10:367-71. [PMID: 26558051 PMCID: PMC4442911 DOI: 10.1016/j.aju.2012.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 07/15/2012] [Accepted: 07/24/2012] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To establish a clinical care pathway that plans for hospital discharge the day after percutaneous nephrolithotomy (PCNL), to evaluate the safety, effectiveness and feasibility of this pathway, and to identify factors associated with a postoperative length of hospital stay (LOS) of >1 day. PCNL is the treatment of choice for patients with large kidney stones and those in whom extracorporeal shockwave lithotripsy has failed, and the mean LOS is typically 2-5 days. PATIENTS AND METHODS We retrospectively reviewed the charts of 109 patients (mean age 57.4 years; 58 men, 53%) who had PCNL between 2006 and 2009. All had nephrostomy tubes placed after surgery. The patients' demographics, LOS, incidence of complications, clinical outcomes, stone-free rates, number of early postoperative emergency-room visits, need for subsequent admission and/or other procedures, were noted and analysed. The modified Clavien classification was used to describe the postoperative complications. Bivariate analyses were used to test for associations between LOS and other variables. RESULTS The mean (range) stone size was 2.2 (0.9-5.9) cm, and the mean (SEM) LOS was 1.7 (0.13) days. Of the 109 patients, 20% had a LOS of >1 day for surgical, 3% for medical and 5% for social reasons. The stone-free rate was 89%. There was no difference in the number of subsequent hospital visits or ancillary procedures for patients discharged after one or more postoperative nights. No variables were associated with a longer LOS. CONCLUSIONS An overnight hospital stay after PCNL is safe and represents an effective strategy for improved bed use in selected patients. A longer LOS was not affected by patient age or body mass index, stone size or operative time. We continue to use our clinical care pathway, as supported by these data.
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Affiliation(s)
| | - Richard W. Norman
- Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada
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Chen Y, Zhou Z, Sun W, Zhao T, Wang H. Minimally invasive percutaneous nephrolithotomy under peritubal local infiltration anesthesia. World J Urol 2011; 29:773-7. [PMID: 21779834 DOI: 10.1007/s00345-011-0730-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 07/07/2011] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To evaluate the feasibility and safety of performing minimally invasive percutaneous nephrolithotomy (MPCNL) under peritubal local infiltration anesthesia. PATIENTS AND METHODS From December 2007 to December 2009, 88 patients with upper urinary calculi underwent MPCNL with ultrasonography (US)-guided renal access in the lateral decubitus flank position under peritubal local infiltration anesthesia. All patients were informed about the possibility of experiencing short periods of discomfort or pain and completed visual analog pain scale (VAS) questionnaires during the intra-operation and at 4, 24, and 48 h postoperatively. Postoperative narcotic usage was recorded at 24 and 48 h postoperatively. RESULTS Eighty-two patients (93.2%, 82/88) underwent MPCNL under local anesthetic infiltration, 6 patients were converted to general anesthesia (2.2%, 2/88) or epidural anesthesia (4.4%, 4/88) because of serious pain or discomfort. The average VAS scores intra-operation and at 4, 24, and 48 h postoperatively were 3.1, 3.0, 2.4, and 2.1, respectively. Six patients (7.3%, 6/82) and 2 patients (2.4%, 2/82) were administered pethidine (75 mg) at 24 and 48 h postoperatively, respectively. The stone clearance rate was 88.3% (91/103) before discharge with MPCNL mono-therapy. The mean operative time was 89 min (range 56-145 min). CONCLUSION MPCNL under peritubal local infiltration anesthesia is well-tolerated and feasible alternative to the same procedure under general or epidural anesthesia.
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Affiliation(s)
- Yong Chen
- Department of Urology, Fuling Central Hospital, Chongqing, Peoples' Republic of China.
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Beiko D, Lee L. Outpatient tubeless percutaneous nephrolithotomy: the initial case series. Can Urol Assoc J 2011; 4:E86-90. [PMID: 20694090 DOI: 10.5489/cuaj.886] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Darren Beiko
- Department of Urology, Queen's University, Kingston, ON
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Kuzgunbay B, Turunc T, Akin S, Ergenoglu P, Aribogan A, Ozkardes H. Percutaneous nephrolithotomy under general versus combined spinal-epidural anesthesia. J Endourol 2010; 23:1835-8. [PMID: 19630480 DOI: 10.1089/end.2009.0261] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE We analyzed the results of patients who underwent percutaneous nephrolithotomy (PCNL) for management of kidney stone disease under combined spinal-epidural anesthesia and compared surgical parameters and outcomes with a matched control group who underwent PCNL under general anesthesia. PATIENTS AND METHODS A total of 82 patients were studied in two groups. Group 1 (n = 45) consisted of the patients who underwent general anesthesia, and group 2 (n = 37) comprised those who received combined spinal-epidural anesthesia. RESULTS The mean ages of patients in groups 1 and 2 were 45 +/- 15 and 44 +/- 15 years, respectively. The mean areas of the stones in groups 1 and 2 were 734 +/- 386 mm(2) and 731 +/- 394 mm(2), respectively. There were no significant differences between groups 1 and 2 among surgical parameters, including age, stone area, operative time, irrigation fluids, fluoroscopy time, delta hemoglobin, and hospitalization time (P = 0.439). At the end of the surgery, stone-free rates were 76% in group 1 and 81% in group 2; clinically insignificant residue fragments rates were 24% in group 1 and 19% in group 2. The difference was statistically insignificant between the groups (P = 0.543). CONCLUSIONS We consider that combined spinal-regional anesthesia is a feasible technique in PCNL operations because the efficacy and safety were not affected. Further investigations with larger series are needed.
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Affiliation(s)
- Baris Kuzgunbay
- Faculty of Medicine, Department of Urology, Baskent University, Ankara, Turkey.
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Karami H, Jabbari M, Arbab AHMM. Tubeless percutaneous nephrolithotomy: 5 years of experience in 201 patients. J Endourol 2008; 21:1411-3. [PMID: 18052821 DOI: 10.1089/end.2007.0406] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Our aim was to evaluate the safety, effectiveness, and feasibility of tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS From June 2000 to September 2005, 201 patients with renal stones >2 cm underwent tubeless PCNL by a single surgeon. We report details of the outcomes. RESULTS The complete stone clearance rate was 91.04% (183 patients). After surgery, 18 patients (8.96%) had stones (mean size = 7 mm) detected on a plain abdominal radiograph or ultrasonographic examination and were referred for shockwave lithotripsy. The mean stone size was 30 mm (range 20-40 mm). The mean operative time was 35 minutes (range 30-60 min), and the mean hospital stay was 3.5 days (range 2-5 days). Postoperative ultrasonography did not reveal considerable fluid collection. There were no visceral injuries. Twenty-two (10.9%) patients received a transfusion, and 16 (7.9%) patients had urinary tract infection. CONCLUSION In our experience, tubeless PCNL is safe, effective, and feasible without any discomfort for patients.
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Affiliation(s)
- Hossein Karami
- Department of Urology, Urology and Nephrology Research Center, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Ugras MY, Toprak HI, Gunen H, Yucel A, Gunes A. Instillation of Skin, Nephrostomy Tract, and Renal Puncture Site with Ropivacaine Decreases Pain and Improves Ventilatory Function after Percutaneous Nephrolithotomy. J Endourol 2007; 21:499-503. [PMID: 17523902 DOI: 10.1089/end.2006.0335] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND PURPOSE Pain after percutaneous nephrolithotomy (PCNL) is well investigated, but no optimal management strategy has yet been defined. Ventilatory changes after uncomplicated PCNL remain obscure. We investigated whether pain can be managed with a combination of a parenteral non-narcotic drug and instillation of a local anesthetic into the operative field. We also measured ventilatory changes early after PCNL to determine whether this analgesic modality improves ventilatory status. PATIENTS AND METHODS In a randomized blinded study, 34 well-matched patients underwent PCNL with single subcostal access. At the end of the operation, 30 mL of either 0.02% ropivacaine or saline was instilled into the renal puncture site, nephrostomy tract, and skin. Postoperatively, patients received parenteral metamizol (dipyrone) (500 mg/dose) on demand. Pain visual analog score (VAS), peak expiratory flow rate (PEF), and blood-gas analysis were performed at 2, 6, and 24 hours postoperatively. The number of analgesic doses required was recorded. RESULTS The VAS at 6 hours, time to first analgesic demand, and total analgesic need were significantly lower (P=0.001, 0.008, and 0.001, respectively) in the ropivacaine group, whereas the PEF at 2 and 6 hours was significantly higher (P=0.001 for each). Analgesic use in the first 12 and 24 hours was lower in this group. Blood-gas analysis was within the normal range in both groups. Time of surgery and hemoglobin decrease were not significantly different. CONCLUSIONS A decrease in PEF indicating restricted ventilation appears early after PCNL. Because these patients were chosen carefully to have normal function preoperatively, this decrease was attributed to nociception. A combination of ropivacaine instillation with metamizol decreases pain and analgesic use and improves PEF more than use of metamizol alone. Such a multimodal pain-management strategy is effective in minimizing postoperative opioid use with proper pain management, resulting in better ventilation.
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Affiliation(s)
- Murat Yahya Ugras
- Department of Urology, Inonu University Faculty of Medicine, Malatya, Turkey.
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Aravantinos E, Karatzas A, Gravas S, Tzortzis V, Melekos M. Feasibility of Percutaneous Nephrolithotomy under Assisted Local Anaesthesia: A Prospective Study on Selected Patients with Upper Urinary Tract Obstruction. Eur Urol 2007; 51:224-7; discussion 228. [PMID: 16842905 DOI: 10.1016/j.eururo.2006.06.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Accepted: 06/16/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the feasibility of performing percutaneous nephrolithotomy (PCNL) under local anaesthesia in selected patients. METHODS Twenty-four patients with unilateral renal obstruction due to pelvic stones > or =2.0 cm were enrolled in our study. First a percutaneous nephrostomy to decompress the obstructed kidney was performed using local anaesthesia (lignocaine). A 16-Fr nephrostomy tube was left in place for 1 wk, and then the second stage was carried out. After having infiltrated the tract and the renal parenchyma with lignocaine, dilatation of the nephrostomy tract was performed. Subsequently, PCNL was done using a 24-Fr rigid nephroscope and a ballistic lithotripter. All patients were premedicated with pethidine HCl intramuscularly 30 min before the beginning of both stages. Diazepam was given (0.1mg/kg orally) to patients before the second stage. Pain scores were collected using 10-cm linear visual analogue scale (VAS) after the completion of both procedures. RESULTS The procedure was well tolerated. One patient needed further treatment with midazolam during PCNL. The mean VAS score was 38 mm (range: 17-60 mm) for the first stage and 36 mm (13-69 mm) for the second stage. The mean operative time, including both stages, was 127 min (85-155 min). No anaesthesia-related complications occurred. CONCLUSION Our study indicates that PCNL under assisted local anaesthesia is safe and effective in selected patients.
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Affiliation(s)
- Evangelos Aravantinos
- Department of Urology, University Hospital of Larissa, Feidiou 6-8, 412 21 Larissa, Greece
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Abstract
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.
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Affiliation(s)
- S M K Aghamir
- Department of Urology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Matlaga BR, Hodges SJ, Shah OD, Passmore L, Hart LJ, Assimos DG. PERCUTANEOUS NEPHROSTOLITHOTOMY: PREDICTORS OF LENGTH OF STAY. J Urol 2004; 172:1351-4. [PMID: 15371840 DOI: 10.1097/01.ju.0000138286.91104.2c] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Percutaneous nephrostolithotomy (PNL) is commonly used to treat patients with complex renal calculi. A goal at our medical center is to discharge patients home less than 24 hours after PNL. We performed a study to determine factors that caused patients to be hospitalized longer than this period. MATERIAL AND METHODS The available hospital records and office charts of 133 consecutive patients undergoing initial PNL at our institution between January 1, 1999 and December 31, 2000 were reviewed. All PNL procedures were performed by one of us using a (DGA) 1-stage technique. Mean patient age was 52 years (range 25 to 84). Of the subjects 85 were male and 48 were female. RESULTS A total of 91 patients (68%) were discharged home less than 24 hours after surgery. The overall stone-free rate was 91%. Mean length of stay in the entire group was 1.97 days. Mean length of stay in those hospitalized longer than 24 hours was 4.12 days. Mean operative time, including time to obtain access, was 188.6 minutes. Multivariate analysis demonstrated that neurogenic bladder, endocrine comorbidity and perioperative complications were factors associated with a length of stay of greater than 24 hours. Univariate analysis demonstrated that preoperative urinary tract infection and infection related calculi were also associated with a length of stay of greater than 24 hours. CONCLUSIONS The majority of patients undergoing PNL can be discharged home less than 24 hours after surgery. Patients with neurogenic bladder, those with endocrine comorbidity, those who sustain significant perioperative complications and those harboring stones associated with urinary tract infection or preoperative urinary tract infection are more likely to require longer hospitalization.
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Affiliation(s)
- Brian R Matlaga
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
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Abstract
PURPOSE Significant early postoperative discomfort after percutaneous procedures is usually secondary to nephrostomy tubes and externalized ureteral catheters. We describe our modification of the traditional percutaneous nephrolithotomy (PCNL) approach that we name "totally tubeless PCNL." PATIENTS AND METHODS Between June 2000 and May 2001, 60 consecutive PCNLs were performed at our centers. At the end of the surgery, we omitted the nephrostomy tube and removed the externalized catheter in selected patients: no solitary kidney, stone size <3 cm, and without any obstructions or arterial bleeding. A total of 30 patients underwent totally tubeless PCNL (group 1). We compared their results with those of a control group of 30 patients who underwent standard PCNL (group 2). The incidence of complications, analgesic requirements, length of hospitalization, and time to return to normal activities were compared in the two groups. RESULTS In both groups, PCNL was performed successfully without any significant complications. A 90% stone-free rate was achieved in both groups, and in the remaining patients, small residual stones (<4 mm) were detected. No urinoma was demonstrated by postoperative ultrasound scanning in group 1. The average length of hospitalization was 1.5 days for group 1 and 3 days for group 2. The average analgesic requirements were 30 mg of pentazosin in group 1 and 90 mg in group 2. No transfusion was needed. There were three complications: 2 patients (6.6%) had urinary tract infection in group 1 and 1 (3.3%) in group 2. All were managed medically. CONCLUSIONS Omitting the percutaneous nephrostomy tube and removing ureteral catheter at the end of surgery in selected patients were safe and accompanied by significantly reduced postoperative discomfort, length of hospitalization, and analgesic requirements. Further studies are needed to determine the role of this technique.
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Affiliation(s)
- Hossein Karami
- Department of Urology, Shohada & Chamran Medical Centers, Shahid Behesti & Azad University of Medical Sciences, Tehran, Iran
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Dalela D, Goel A, Singh P, Shankhwar SN. Renal Capsular Block: A Novel Method for Performing Percutaneous Nephrolithotomy under Local Anesthesia. J Endourol 2004; 18:544-6. [PMID: 15333218 DOI: 10.1089/end.2004.18.544] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Most of the pain of percutaneous nephrolithotomy is caused by dilatation of the renal capsule and parenchymal tract. We evolved a technique to block renal capsular sensations by infiltration of lignocaine (lidocaine) at the site of renal entry, permitting the procedure to be done with local anesthesia.
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Affiliation(s)
- D Dalela
- Department of Urology, CSM Medical University, Upgraded King George's Medical College, Lucknow (UP), India
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Combined percutaneous and retrograde approach to staghorn calculi with application of the ureteral access sheath to facilitate percutaneous nephrolithotomy. J Urol 2003; 169:64-7. [PMID: 12478104 DOI: 10.1016/s0022-5347(05)64036-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We describe our technique and clinical experience with application of the ureteral access sheath for single access ablation of staghorn and partial staghorn calculi. MATERIALS AND METHODS We retrospectively reviewed our experience with 9 patients who underwent percutaneous nephrolithotomy for staghorn (6) or partial staghorn (3) renal calculi using a combined antegrade and retrograde approach. Patient data, operative parameters, efficacy of stone ablation and convalescence parameters were reviewed. RESULTS Mean operative time for the primary procedure was 3.1 hours with a mean estimated blood loss of 290 ml. Postoperatively, the mean analgesic requirement was 33.2 mg. MSO(4) equivalents. Hospital stay was 3.2 days. There were no major and 4 minor (44%) complications. No patient required transfusion. Complete stone clearance was achieved in 7 of the 9 cases (78%) using a single percutaneous nephrostomy tract. CONCLUSIONS Our preliminary clinical experience using the ureteral access sheath during percutaneous nephrolithotomy for simultaneous antegrade and retrograde stone treatment has been favorable. A large renal stone burden can be successfully managed with a single percutaneous access and limited blood loss.
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Combined Percutaneous And Retrograde Approach To Staghorn Calculi With Application Of The Ureteral Access Sheath To Facilitate Percutaneous Nephrolithotomy. J Urol 2003. [DOI: 10.1097/00005392-200301000-00016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Landman J, Venkatesh R, Ragab M, Rehman J, Lee DI, Morrissey KG, Monga M, Sundaram CP. Comparison of intrarenal pressure and irrigant flow during percutaneous nephroscopy with an indwelling ureteral catheter, ureteral occlusion balloon, and ureteral access sheath. Urology 2002; 60:584-7. [PMID: 12385911 DOI: 10.1016/s0090-4295(02)01861-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine the differential effects on renal pressures and irrigation flow associated with the application of different ureteral catheters during percutaneous nephrolithotomy. METHODS Using ex vivo fresh cadaveric tissue, we established a percutaneous nephrolithotomy model. After obtaining lower pole percutaneous access, we recorded the pressure and irrigant flow measurements. Measurements were made with an empty ureter, 6F ureteral catheter, occlusion balloon catheter, and ureteral access sheaths (10/12F and 12/14F). Three 1-minute trials for each condition were recorded in each of four kidneys. RESULTS Ureteral catheterization with both the 10/12F and the 12/14F ureteral access sheaths resulted in significantly decreased intrarenal pressures in the pressure range tested compared with an empty ureter, a ureteral catheter, or an occlusion balloon application. Total irrigant flow for the 12/14F ureteral access sheath was significantly higher than for the empty ureter, ureteral catheter, or occlusion balloon in the entire pressure range evaluated. CONCLUSIONS In this in vitro cadaveric model, application of the ureteral access sheath during percutaneous nephrolithotomy resulted in decreased intrarenal pressures and increased irrigant flow.
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Affiliation(s)
- Jaime Landman
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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37
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Lojanapiwat B, Soonthornphan S, Wudhikarn S. Tubeless percutaneous nephrolithotomy in selected patients. J Endourol 2001; 15:711-3. [PMID: 11697402 DOI: 10.1089/08927790152596299] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Placement of the nephrostomy tube is the last step after completion of percutaneous nephrolithotomy (PCNL). We were able to demonstrate in selected patients who had undergone PCNL that the use of an externalized ureteral catheter can reduce postoperative discomfort without complications. PATIENTS AND METHODS A total of 37 patients underwent tubeless PCNL with an externalized 6F ureteral catheter for 48 hours. Inclusion criteria were use of a single access site where the renal unit was not obstructive, no significant perforation and bleeding, and no need for a second look. The stone burden was not taken into account. RESULTS The procedure was performed successfully without major complications. The average length of hospitalization was 3.63 days: 25 patients stayed for 4 days, with the final day reserved for observation after removal of the catheter. The remaining 12 patients stayed only 3 days and could be discharged on the day the catheter was removed. The average intramuscular analgesic requirement was 38.57 mg of meperidine, and none of the patients needed a blood transfusion or required the emergency placement of a nephrostomy tube. CONCLUSION In properly selected patients, tubeless PCNL with only an externalized ureteral catheter was found to be safe and just as economical as tubeless PCNL with the same outcome.
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Affiliation(s)
- B Lojanapiwat
- Department of Surgery, Chiengmai University, Thailand.
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Affiliation(s)
- Gary C. Bellman
- From the Department of Urology, Kaiser Permanente, Los Angeles, California
| | - Ramin Davidoff
- From the Department of Urology, Kaiser Permanente, Los Angeles, California
| | - Joseph Candela
- From the Department of Urology, Kaiser Permanente, Los Angeles, California
| | - Jill Gerspach
- From the Department of Urology, Kaiser Permanente, Los Angeles, California
| | - Steven Kurtz
- From the Department of Urology, Kaiser Permanente, Los Angeles, California
| | - Lisa Stout
- From the Department of Urology, Kaiser Permanente, Los Angeles, California
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Abstract
Surgical management of urinary calculous disease has changed dramatically in the past decade. The development of percutaneous nephrostomy techniques has allowed new access to upper tract stones. Percutaneous removal of large calculi was made possible by the development of ultrasonic and electrohydraulic lithotripsy. All upper tract calculi can now be removed in 70 to 100 per cent of cases with minimal complications. Nephrostolithotomy has reduced transfusion rates and hospitalization costs and has markedly shortened convalescence periods compared with open surgery. Ureteroscopy followed nephrostolithotomy as advanced fiberoptic technology allowed the development of the small-caliber instruments required for this procedure. With experience, successful stone retrieval has occurred in 90 per cent or more of cases, again with minimal complications. As nephrostolithotomy and ureteroscopy have become available, the subspecialty of endourology has emerged and significantly changed the management of urinary tract calculi. Perhaps the most significant advance in stone therapy has been the design and implementation of extracorporeal shock wave lithotripsy. With this noninvasive technique, most renal and proximal ureteral calculi can be effectively treated with minimal morbidity and convalescence. Research in lithotripter design is continuing, with more advanced and effective machines on the horizon. The applicability of extracorporeal therapy for the treatment of biliary tract calculi is currently under investigation. Finally, one should not disparage medical therapy for recurrent nephrolithiasis. A comprehensive metabolic evaluation combined with selective medical therapy provides almost complete relief from recurrent stone formation and makes medical therapy an integral component of treating the patient with renal or ureteral calculi.
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Affiliation(s)
- R D Brown
- Department of Surgery, University of Texas Southwestern Medical Center, Southwestern Medical School, Dallas
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Abstract
Management of urolithiasis in children remains a challenge despite newer technological innovations. During the last 3 years we have treated 19 children with a combination of extracorporeal shock wave lithotripsy, percutaneous stone extraction and ureteroscopy, as well as with traditional methods. The newer technological methods perfected in adults are equally applicable to children in experienced hands.
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Affiliation(s)
- P Shepherd
- Department of Urology, Tulane University School of Medicine, New Orleans, Louisiana
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Preminger GM, Miller RH, Curry T. Entrapment of renal calculi by Malecot nephrostomy tubes. Br J Radiol 1988; 61:81-3. [PMID: 3349244 DOI: 10.1259/0007-1285-61-721-81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- G M Preminger
- Department of Radiology, University of Texas Health Science Center, Dallas 75235
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