Percutaneous nephrolithotomy: spinal cord injury vs. ambulatory patients

PCNL in neurogenic bladder: A challenging population for both clinical management and analysis

Objectives

To review the management of patients with neurogenic bladder undergoing percutaneous nephrolithotomy (PCNL) at our institution with the aim of assessing peri-operative morbidity.

Subjects/patients and methods

We conducted a retrospective review of all neurogenic bladder patients who underwent PCNL at our hospital in the last decade with the aim of assessing peri-operative morbidity.

Results

A total of 298 PCNL were performed during the study period of which 58 were in patients with a neurogenic bladder or urinary diversion, 33 of which were in SCI patients. Preoperative demographic and stone characteristics, intraoperative data and postoperative length of stay and complications are summarised in table form.

Conclusion

PCNL remains an acceptably safe and efficacious treatment for upper tract stone disease in patients with neurogenic bladders and will continue to have a valuable role where SCI prevents alternative approaches such as ureteroscopy.

Flexible ureteroscopic laser lithotripsy for upper urinary tract stone disease in patients with spinal cord injury

The objective of this study is to present the outcomes of flexible ureteroscopic laser lithotripsy (URS) for upper urinary tract stone disease in spinal cord injury (SCI) patients performed by a single surgeon. A retrospective analysis was performed for SCI patients treated with flexible URS for proximal ureter and kidney stone disease by a single surgeon between 2003 and 2013. Patient characteristics, operative outcomes, metabolic evaluation, and stone analyses were assessed in detail. A total of 27 URS procedures were performed for urolithiasis in 21 renal units of 19 patients. The mean age was 52.1 ± 15.6 years (16-72) and mean BMI was 29.2 ± 7.3 kg/m(2) (20-45.7). Etiology of SCI was trauma (n: 10), multiple sclerosis (n: 6), cerebrovascular accident (n: 1), or undetermined (n: 2). The mean stone size was 15.9 ± 8.6 (6-40) mm. In the 27 URS procedures, stones were located in the ureter (n: 5), the kidney (n: 14), and both areas (n: 8). Mean hospitalization time was 2.0 ± 2.4 (0-10) days. Postoperative complications were observed in 6 cases (22.2%). Three major complications included urosepsis (n: 1) and respiratory failure (n: 2), that were observed postoperatively and required admission to the intensive care unit. The 2 minor complications were hypotension, fever and UTI, and required medical treatment. Fourteen (66.6%) of the 21 renal units were stone free. Calcium phosphate carbonate (n: 9) and struvite (n: 5) were the primary stone compositions detected. Hypocitraturia (n: 6), hypercalciuria (n: 5), hypernaturia (n: 5), hyperoxaluria (n: 4), and hyperuricosuria (n: 1) were common abnormalities in 24-h urine analysis. Ureteroscopic laser lithotripsy can be an effective treatment modality for SCI patients with upper urinary tract calculi.

Surgical management of urolithiasis in spinal cord injury patients

Urolithiasis is a common condition in patients with spinal cord injury (SCI). Surgical management of stones in this population is more challenging and associated with lower clearance rates than the general population. The rate of complications - specifically infectious complications - is also high due to the chronic bacterial colonization. Shock wave lithotripsy (SWL) has a low clearance rate of 44-73 %. Percutaneous nephrolithotripsy is indicated for larger nephrolithiasis, but multiple procedures may be required to clear the stones. Ureteroscopy has been associated with low success rates because of difficulty in obtaining ureteral access. Historically, bladder stones were managed with open surgery or SWL. Recently, good results have been reported with the combination of endoscopic and laparoscopic techniques. Surgical management of urolithiasis in patients with SCI should be performed in high-volume centers in light of the technical challenges and higher rate of perioperative complications.

Risk factors for sepsis after percutaneous renal stone surgery

Since its introduction into the endourologist's armamentarium almost 40 years ago, percutaneous nephrolithotomy (PCNL) has become the standard of care for patients with large-volume nephrolithiasis. Postoperative infection is one of the most common complications of the procedure, and postoperative sepsis is one of the most detrimental. A number of factors have been found to increase the risk of postoperative sepsis. These include patient characteristics that are known preoperatively, such as urine culture obtained from the bladder or from the renal pelvis if percutaneous access to the renal pelvis is obtained in advance to the procedure. Neurogenic bladder dysfunction secondary to spinal cord injury and anatomical renal abnormalities, such as pelvicalyceal dilatation, have also been associated with increased incidence of fever and sepsis after the procedure. Several intraoperative factors, such as the average renal pressure sustained during PCNL and the operative time, also seem to increase the risk of sepsis. Finally, the contribution of postoperative factors, such as presence of a nephrostomy tube or a urethral catheter, has also been investigated. A short preoperative course of antibiotics has been found to significantly decrease the rate of postoperative fever and sepsis. Novel agents targeted at sepsis prevention and treatment, such as anti-endotoxin antibodies and cholesterol-lowering drugs statins, are currently under investigation.

Morbidity and efficacy of ureteroscopic stone treatment in patients with neurogenic bladder

PURPOSE

There is a lack of information on the safety and efficacy of ureteroscopy in the neurogenic bladder population. We hypothesized that ureteroscopy in patients with neurogenic bladder would be associated with an increased risk of complications and a lower stone clearance rate than in patients without neurological impairment.

MATERIALS AND METHODS

We reviewed a local registry of patients with ICD-9 codes for urolithiasis between 2004 and 2012. The study cohort was assembled from all eligible patients with neurogenic bladder and a randomly selected control group that had undergone ureteroscopy. Statistical analysis of demographic variables and surgical outcomes was performed. Complications were classified according to the Clavien system. Clearance was defined by computerized tomography, renal/bladder ultrasound or direct ureterorenoscopy.

RESULTS

Ureteroscopy was performed a total of 173 times in 127 controls and a total of 45 times in 20 patients with neurogenic bladder. There was no difference between presenting episodes by gender (p = 1.0), race (p = 0.654) or body mass index (p = 0.519). Bacteriuria was associated with the stone episode in 16.4% of controls and 67% of neurogenic bladder cases (p <0.001). Median operative time was significantly longer in those with neurogenic bladder (80.5 minutes, IQR 50-110.5 vs 52, IQR 33-78, p = 0.0003). The proportion of complications was significantly different (p = 0.013). Stones cleared in 86.6% of controls compared to 63% of neurogenic bladder cases (p = 0.004).

CONCLUSIONS

Patients with neurogenic bladder have increased morbidity after ureteroscopy for upper tract calculi compared to neurologically unaffected controls. Infection has a role in this morbidity. The clearance rate is lower but the stone burden is more significant in those with neurogenic bladder.

A new scoring system for predicting stone-free rate after retrograde intrarenal surgery: the "resorlu-unsal stone score"

OBJECTIVE

To investigate the prognostic factors associated with the treatment efficacy of retrograde intrarenal surgery (RIRS) and develop a scoring system for predicting the stone-free rate after this surgery.

METHODS

We performed a retrospective analysis of 207 patients who underwent RIRS for renal stones between January 2009 and September 2011. Patient age, gender, body mass index, stone size, stone side, stone location, stone composition, number of stones, lower pole infundibulopelvic angle, using anticoagulant therapy, abnormal skeletal anatomy, and abnormal renal anatomy were investigated as potential preoperative predictive factors.

RESULTS

The present study included 111 (53.6%) men and 96 (46.4%) women. Mean patient age was 32.9 ± 18.8 years (range 1-74) and mean stone size was 16.2 ± 4.1 mm (range 8-40). Overall, 178 of the 207 (86%) patients were stone free after the initial treatment. Univariate analysis showed that stone size (P <.001), stone location (P = .025), stone composition (P = .01), stone number (P = .049), renal malformations (P = .042), and lower pole infundibulopelvic angle (P = .003) had significant influence on the stone-free rate after RIRS. Multivariate analysis excluded stone location from the logistic regression model, whereas other factors maintained their statistically significant effect on success rate, indicating that they were independent predictors.

CONCLUSION

Our study demonstrated that stone size, stone number, stone composition, infundibulopelvic angle, and renal malformations are significant predictors of RIRS outcome. A scoring system based on these factors helps separate patients into outcome groups and facilitates treatment planning.

Retrograde intrarenal surgery in patients with spinal deformities

PURPOSE

To present our experience with retrograde intrarenal surgery (RIRS) for managing renal stones in patients with spinal deformities.

PATIENTS AND METHODS

We retrospectively reviewed the records of eight patients with congenital scoliosis (n=6), ankylosing spondylitis (n=1), or spina bifida (n=1) who had undergone RIRS for renal stones. Stone-free status was determined by CT 30 days after the procedure and was defined as the absence of stones in the kidney or residual fragments ≤ 1 mm.

RESULTS

Mean patient age was 32.5 years (8-51 years), and mean stone size was 15.8 mm (9-20 mm). The average operative time was 46.5 minutes (25-75 min), and postoperative hospital stay was 1.12 days (1-2 days). A stone-free status was obtained in six (75%) patients, and two patients were considered to have treatment failure. A Double-J stent was placed at the end of the procedure in five (62.5%) patients. Double- J stent discomfort was reported by one (20%) patient who was treated conservatively. No severe complications, either from anesthesia or the surgical procedure, were observed, and no blood transfusion was reported.

CONCLUSIONS

The good clearance rate with a low incidence of complications shown by the present study has demonstrated that RIRS is a safe and effective procedure for renal stones in patients with spinal deformities.

Renal stone disease in spinal-cord-injured patients

Renal stone disease is common among patients with spinal cord injury (SCI). They frequently have recurrent stones, staghorn calculi, and bilateral stone disease. The potential risk factors for stones in the SCI population are lesion level, bladder management strategy, specific metabolic changes, and frequent urinary tract infections. There has been a reduction in struvite stones among these patients, likely as a result of advances in their urologic care. The clinical presentation of stone disease in patients with SCI may involve frequent urinary infections or urosepsis, and at the time of presentation patients may need emergency renal drainage. The proportion of patients who have their stones treated with different modalities is largely unknown. Shockwave lithotripsy (SWL) is commonly used to manage stones in patients with SCI, and there have been reports of stone-free rates of 50% to 70%. The literature suggests that the morbidity associated with percutaneous nephrolithotomy in these patients is considerable. Ureteroscopy is a common modality used in the general population to treat patients with upper tract stone disease. Traditional limitations of this procedure in patients with SCI have likely been overcome with new flexible scopes; however, the medical literature has not specifically reported on its use among patients with SCI.

Percutaneous nephrolithotomy in patients with spinal deformities

BACKGROUND AND PURPOSE

To assess the feasibility and efficacy of percutaneous nephrolithotomy (PCNL) in patients with spinal deformities.

PATIENTS AND METHODS

Between 1999 and 2008, eight patients (nine renal units) with spinal deformities underwent 10 PCNLs. Mean stone burden was 372 mm(2) (160-840 mm(2)). Preoperative investigation of the respiratory function, evaluation of anatomy by intravenous pyelography or CT spiral scan, and preoperative planning of the percutaneous access by ultrasonography (US) were performed in all patients. Patients were either in a prone (n = 5) or supine (n = 5) position during PCNL. US-guided fluoroscopic adjusted percutaneous puncture of the desired calix was performed in all the patients.

RESULTS

There was a 40% complication rate related to the number of procedures, with 20% of patients needing blood transfusion and 10% experiencing major complications. Complete stone clearance per kidney after one PCNL was 55.5% (5/9 PCNLs), increasing to 66.6% (6/9 PCNLs) after a second PCNL. Four of nine (44.4%) renal units needed additional procedures after one PCNL (shockwave lithotripsy [SWL], retrograde intrarenal surgery [RIRS], combined simultaneous PCNL and RIRS). At the 3-month follow-up, the overall stone-free rate was 88.8% (eight renal units).

CONCLUSION

PCNL in patients with spinal deformities is challenging. Accurate preoperative evaluation of the anatomy and respiratory function and a precise preoperative planning are mandatory. US-guided puncture of the collecting system permits avoiding visceral injury. Supine PCNL offers advantages in terms of patient comfort, protection of cardiorespiratory function, and the ability to perform a simultaneous combined ureteroscopic approach, although the prone position, if feasible with the patient's body habitus, may offer a wider space for percutaneous access. Combination therapy with either SWL or RIRS after PCNL improves stone-free rates.

Chapitre A-3 - Lithiase du haut appareil et vessie neurologique: spécificités thérapeutiques

Upper tract stones are a frequent complication in neurourology and require specific treatment according to modalities adapted to the clinical setting. All modern treatment modalities for stones can be proposed: extracorporeal lithotripsy (ESWL), percutaneous nephrolithotomy and open surgery depending on the local conditions. The treatment objectives in the neurologically disabled population must be to combine a maximum of fragmentation and elimination in the same treatment session. ESWL therefore has a more limited place in this population. On the other hand, a renal stone measuring 1.5 cm must be treated by percutaneous surgery. Finally, management of upper tract stones depends on evaluation and stabilization of the lower tract (pressures, urinary tract infection, residual urine) to decrease the risk of recurrent stones.

Challenge of percutaneous nephrolithotomy in patients with spinal neuropathy

OBJECTIVE

To assess the technical difficulties, associated complications and stone clearance rates in patients with spinal neuropathy undergoing percutaneous nephrolithotomy.

METHODS

Twenty-nine patients with spinal neuropathy underwent percutaneous nephrolithotomy in the two centers studied between October 1995 and January 2002. They were nine patients with traumatic spinal cord injury, 10 patients with spina bifida and 10 with other heterogeneous causes for their spinal neuropathy. The group included 12 men and 17 women, with an average age of 44 years (14-80). Patients' medical records were reviewed retrospectively for data relating to their renal lithiasis.

RESULTS

A total of 39 percutaneous nephrolithotomy procedures were undertaken on 32 kidneys. Thirteen procedures were for staghorn calculi. Preoperatively, eight kidneys required nephrostomy and 5 J stent decompression. The average American Society of Anesthesiologists (ASA) score was 3, and one patient had percutaneous nephrolithotomy performed under local anaesthetic as the risk of general anaesthetic was felt to be too high. The associated morbidity and mortality in this group is significant. There were two postoperative deaths. Major complications were associated with three procedures, and consisted of seizures, aspiration pneumonia and pressure necrosis. Nine patients experienced minor complications including fever, hypotension and nephrostomy site leakage. Nine patients required intensive therapy unit care postoperatively and the average hospital stay for the group was 13.32 days. Only 18 (62%) patients were rendered stone-free from their initial percutaneous nephrolithotomy. Seven patients required a further procedure for stone clearance: four underwent extracorporeal shock-wave lithotripsy, two ureteroscopy and one nephrectomy.

CONCLUSIONS

Patients with spinal neuropathy and renal lithiasis pose a significant operative challenge. Technical difficulties and potential complications should be considered carefully before undertaking percutaneous nephrolithotomy in these patients.

Urolithiasis in patients with spinal cord injuries: risk factors, management, and outcomes

PURPOSE OF REVIEW

Despite major advances in the urological care of spinal cord injury patients, the incidence of urolithiasis has not changed. Although the incidence of kidneys lost to staghorn calculus disease has decreased considerably, stone disease is still a significant cause of morbidity and concern. The purpose of this review is to summarize the risk factors for the development of stone diseases in the spinal cord injury patient population and present the outcomes of current endourologic treatment modalities.

RECENT FINDINGS

Recurrent urinary tract infections, indwelling catheters, vesicoureteral reflux, and immobilization hypercalcuria are a few of the major risk factors for the development of urolithiasis among spinal cord injury patients. Retrograde endourologic techniques are often not possible to address stone disease due to lower extremity contractures, spinal curvature, and pelvic tilt. Extracorporeal shockwave lithotripsy success rates vary from 50 to 90%, but clearance rates are often delayed. Success rates for percutaneous nephrolithotomy match those quoted in the general population ( > 90%), but at the expense of a higher rate of complications (6-20%). Meticulous planning with regard to appropriate prophylactic antibiotics and body position will maximize efficacious outcomes.

SUMMARY

Early identification and treatment of urolithiasis in spinal cord injury patients will aid in preserving renal function and minimizing associated complications. Despite variation in common urological practices between spinal cord injury units and the lack of clear cut guidelines for follow-up, the increased incidence of risks associated with urolithiasis lends support for routine genitourinary imaging in order to identify and treat those individuals at highest risk.

Outcome from percutaneous nephrolithotomy in patients with spinal cord injury, using a single-stage dilator for access

OBJECTIVE

To present our experience of percutaneous nephrolithotomy (PCNL) for treating urolithiasis in patients with spinal cord injury (SCI) using a single-stage dilator for percutaneous access.

PATIENTS AND METHODS

A prospective database of patients with SCI having PCNL using the single-stage dilator was assessed, analysing patient data, stone-free rates, morbidity and the follow-up outcome.

RESULTS

In all, 26 patients had 54 PCNLs on 32 kidneys; 20 had unilateral and six bilateral stone disease; there were many staghorn calculi (24/54). Major complications occurred in three of 54 PCNLs (6%). The complete stone-clearance rate was 87% for PCNL alone, rising to 29 of 32 kidneys (91%) or 24 of 26 patients (92%) with adjuvant procedures. A further three kidneys required no further treatment and were monitored, having residual fragments of < or = 2 mm.

CONCLUSIONS

PCNL has a high success rate and acceptable complication rate compared to extracorporeal shock-wave lithotripsy, and remains a valid first-line treatment option for kidney stones in patients with SCI.

Using and Choosing a Nephrostomy Tube after Percutaneous Nephrolithotomy for Large or Complex Stone Disease: A Treatment Strategy

BACKGROUND AND PURPOSE

Percutaneous nephrolithotomy (PCNL) is a well-accepted technique for removal of large or complex renal calculi. However, little attention has been paid to strategies for nephrostomy tube (NT) selection. We reviewed the reasons for selecting three types of NT after PCNL for large or complex stone disease.

PATIENTS AND METHODS

A series of 106 consecutive renal units undergoing PCNL for stone burdens >2 cm by a single surgeon (JEL) were reviewed. Noncontrast CT (NCCT) was carried out on postoperative day 1, and secondary procedures were performed if fragments remained. The NTs studied were 8.5F and 10F Cope loops (CP), 20F reentry Malecot catheters (REM), and 20F circle loops (CL). Patient demographics, access site and number, complications, and stone type were examined. "Stone free" was defined as a negative NCCT or negative second-look PCNL.

RESULTS

A total of 134 accesses were created in 106 renal units: 35 upper, 7 mid, and 92 lower; however, only 111 NTs were placed: 85 CP (76.6%), 19 REM (17.1%), and 7 CL (6.3%). Sixteen accesses were performed tubeless; all but two were in the upper pole. All 16 of these renal units had a concomitant NT placed in the lower pole. Multiple sites were accessed in 21 patients; 7 of these patients had CL placed. Five of ten patients with spinal-cord injury had REM/CL placed. Nineteen REM were placed: 10 for drainage of infection, and 9 for difficult anatomy. All renal units were rendered stone free: 31.1% with a single procedure and 95.6% with one or two procedures. There were no difficulties with drainage or access for secondary PCNL regardless of the NT employed. Complications included two hydrothoraces, one arteriovenous fistula, and one ureteral perforation. Three of four renal units in patients requiring transfusions underwent bilateral PCNL, and at least one renal unit required multiple accesses. Of kidneys with infection stones, 57.1% required REM or CL; only 12.0% of nonstruvite stones necessitated REM or CL.

CONCLUSIONS

All patients having PCNL done for complex stone disease should have an NT placed; however, small (8.5F-10F) CP suffice in most cases and can provide greater patient comfort. To minimize pleural morbidity, tubeless upper-pole access should be considered if the kidney is judged to be stone free at the conclusion of PCNL. Circle loops are useful when multiple accesses are necessary, whereas REM are appropriate if access is difficult, gross residual stone remains, or pain is not an issue (i.e., spinal-cord injury).

Safety and efficacy of percutaneous nephrolithotomy in patients with neurogenic bladder dysfunction

OBJECTIVES

To review our experience performing percutaneous nephrolithotomy (PNL) on patients with neurogenic bladder dysfunction with special attention paid to the risks of surgical complications and stone recurrence. Patients with neurogenic bladder dysfunction with or without urinary diversion are at increased risk of urolithiasis, surgical complications, and recurrent stone disease.

METHODS

We retrospectively reviewed the 23 patients with neurogenic bladder dysfunction who underwent PNL at our institution. Neurologic lesions included spina bifida, traumatic spinal cord injury, exstrophy/epispadias, neonatal meningitis, stroke, and spine chondrosarcoma. Bladder management included ileal conduit (n = 8), intermittent catheterization (n = 7), indwelling catheter (n = 7), and ureterosigmoidostomy (n = 1).

RESULTS

We performed 100 procedures on 47 renal units (17 bilateral, 7 with recurrent stones). Urinary tract infection/colonization was seen in 21 of 23 patients, most of whom had more than one organism. The stone-free rate was 96%. Six patients required three or more procedures, each had a complete staghorn calculus. In an average of 36 months of follow-up, 10 patients (46%) had recurrent stone disease requiring intervention, and 5 patients (23%) underwent repeat PNL. The stone composition analysis revealed mainly infection-related stones.

CONCLUSIONS

PNL in patients with neurogenic voiding dysfunction is safe and effective, with outcomes comparable to that of patients without such lesions. The complication rate is small but statistically significant. It is important to obtain adequate urine cultures, because renal pelvis and bladder culture data may differ and affect the outcome. Risk factors for recurrent stone disease include a high spinal cord lesion, indwelling urinary catheter, and ureterosigmoidostomy.

Atrophy of kidney following extra corporeal shock wave lithotripsy of renal calculus in a paraplegic patient with marked spinal curvature

OBJECTIVES

To discuss a rare complication of extra corporeal shock wave lithotripsy (ESWL) of renal calculus in a paraplegic patient, who had marked curvature of thoracic and lumbar spine.

DESIGN

A case report of a paraplegic patient, who developed renal atrophy and hypertension after undergoing ESWL of staghorn calculus.

SETTING

Regional Spinal Injuries Centre, Southport and Mersey Regional Lithotripsy Unit, Royal Liverpool University Hospital, Liverpool, UK.

PARTICIPANT

A 28-year-old male with spina bifida, paraplegia at L-1 level and considerable curvature of spine and tilting of pelvis.

METHOD

ESWL was carried out in three sessions by delivering 1934, 1876, and 2025 shock waves respectively. Localisation of the staghorn calculus was difficult because of spinal curvature and pelvic tilt.

RESULTS

A follow-up IVU, performed 3 months after last ESWL treatment, revealed no residual stone in the left kidney, apart from a little low-density calcification in the renal parenchyma adjacent to the lower pole calyx. There were no calculi in the left ureter. The left kidney had become small, though still functioning. MAG-3 isotope renogram showed the left kidney to be markedly atrophic. Relative renal function: right kidney, 94%; and left kidney, 6%. He developed hypertension and a laparoscopic left nephrectomy was performed at another hospital.

CONCLUSION

Difficulty in localisation of renal calculi for ESWL must be anticipated in spinal bifida and spinal cord injury patients, who have significant spinal curvature. Because of problems in the positioning of a patient with marked curvature of spine and pelvic tilt, and consequent difficulties in accurate localisation of renal calculi for lithotripsy, these patients may be at increased risk of developing renal parenchymal and vascular damage following ESWL.