Pulmonary Complications following Percutaneous Nephrolithotomy: A Prospective Study

Acute liver injury and contralateral pleural effusion as two rare complications following percutaneous nephrolithotomy: a case report

INTRODUCTION

Percutaneous Nephrolithotomy (PCNL) is a widely used surgical intervention for removing large and complex renal calculi. While considered a safe and effective procedure, it can still lead to severe and rare complications, including bleeding, pulmonary complications, and liver dysfunction.

CASE PRESENTATION

This case report presents a case who underwent PCNL for a kidney stone and subsequently developed a series of rare and severe complications. Following the PCNL procedure, the patient experienced significant bleeding, a known but uncommon complication of PCNL, pulmonary complications, a common complication that may carry a risk of death, and acute liver failure, an exceedingly rare consequence of PCNL.

CONCLUSION

In summary, while PCNL is a valuable technique for treating kidney stones, it is not without risk. This case underscores the importance of recognizing and managing rare complications following PCNL surgery, highlighting the need for vigilance, multidisciplinary care, and timely interventions to ensure favorable patient outcomes.

Renal Location Within the Retroperitoneum in Various Body Positions Using Magnetic Resonance Imaging: Implications for Percutaneous Nephrostolithotomy

OBJECTIVES

To assess the difference in cranio-caudal renal position in both the supine and prone position, as well as the effect of arm position on renal location, using magnetic resonance imaging in subjects with BMI <30.

METHODS

In a prospective IRB approved trial, healthy subjects underwent magnetic resonance imaging in the supine, prone position with arms at the side, and prone position with arms up using vertically placed towel bolsters. Images were obtained with end expiration breath holds. Distances between the kidney and other anatomical landmarks, including the diaphragm (KDD), top of the L1 vertebra (KVD) and lower edge of the 12^th rib (KRD), were recorded. Nephrostomy tract length (NTL) and other measures for visceral injury were also assessed. Wilcoxon signed rank test was used for analysis (p <0.05).

RESULTS

Ten subjects (5 male, 5 female) with median age of 29 years and BMI of 24 kg/m² were imaged. Right KDD was not significantly different between positions, but KRD and KVD noted significant cephalad movement when prone, as compared to supine. Left KDD noted caudal movement with prone positioning with no difference in KRD or KVD. Arm position did not affect any measurements. Right lower NTL was shorter when prone.

CONCLUSIONS

In subjects with BMI<30, prone positioning led to significant cephalad right renal movement, but not left renal movement. Arm position had no effect on anticipated renal position. Pre-operative end expiration supine CT may reliably predict left kidney location and be used to improve pre-operative counseling and/or surgical planning.

Should the Erector Spinae Plane Block Be Applied in the Pain Management of Percutaneous Nephrolithotomy?

Introduction

This prospective, randomized controlled study aimed to investigate the efficacy and respiratory effects of postoperative pain management with an erector spinae plane block in patients undergoing percutaneous nephrolithotomy.

Methods

Sixty American Society of Anesthesiologists (ASA) I-II patients aged 18-65 years, scheduled to undergo percutaneous nephrolithotomy, were randomized either to the erector spinae plane block (ESPB) or control group. Fifteen mL 0.5% bupivacaine at the T11 level was administered preoperatively using the in-plane technique in the ESPB group. In both groups, 1 gr of intravenous paracetamol was administered intraoperatively. Postoperative pain and agitation were evaluated using the visual analog scale (VAS), dynamic VAS at zero, six, and 24 hours, and the Riker sedation-agitation scale at the 0th hour after surgery. Peak expiratory flow rate (PEFR) and oxygen saturation (SpO₂) were measured in preoperative examination and at the 0th, 6th, and 24th hours postoperatively. The time and number of the analgesic requirement, mobilization, and discharge time were also recorded.

Results

A significantly lower VAS and dynamic VAS were observed at the 0th, 6th, and 24th hours in the ESPB group (p<0.05 for each timepoint). The postoperative/preoperative PEFR ratio was lower and there were more agitated patients in the control group (p<0.05).

Conclusion

An erector spinae plane block may have additional clinical advantages while providing effective analgesia in patients who underwent percutaneous nephrolithotomy compared to intravenous analgesia.

Costovertebral angle as a novel tool for predicting the thoracic complication risk following percutaneous nephrolithotomy requiring supracostal access

INTRODUCTION

The objective of this study was to determine whether the costovertebral angle (CVA) and other factors can predict the risk of thoracic complications following percutaneous nephrolithotomy (PCNL).

METHODS

The data of patients who underwent prone PCNL with supracostal access at Suleyman Demirel University Hospital between January 2015 and December 2019 were retrospectively reviewed. Patients' demographics information (age, sex, body mass index [BMI], stone size, and stone location), operative data (supracostal access site, renal puncture site, and laterality), and postoperative thoracic complications (pleural injury) were evaluated. The CVA was measured on preoperative posteroanterior chest X-ray images. The mean CVA of patients with and without thoracic complications was evaluated.

RESULTS

A total of 89 patients (mean age 46.12±15.66 years; 59 men and 30 women) with supracostal access were included in the study. Thoracic complications occurred in 17 (19.1%) patients. Nine (52.9%) hemothorax cases, five (29.4%) pneumothorax cases, and three (17.7%) urinothorax cases were detected. There was a statistically significant difference in the complication rate compared to the percutaneous access site (10^th-11^th supracostal vs. 11^th-12^th supracostal, p=0.004). The mean CVA was significantly lower in patients with complications (45.47±3.59) than in those without complications (53.26±5.98) (p=0.000). No association was found (p>0.05) with age, sex, BMI, laterality, stone surface area, and access site among patients with and without thoracic complications.

CONCLUSIONS

Preoperative CVA can be an effective tool in predicting the risk of postoperative thoracic complications.

Percutaneous nephrolithotomy for staghorn calculi: Troubleshooting and managing complications

Staghorn calculi comprise a unique subset of complex kidney stone disease. Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for staghorn stones. Despite continuous refinements to the technique and instrumentation of PCNL, these stones remain a troublesome challenge for endourologists and are associated with a higher rate of perioperative complications than that for non-staghorn stones. Common and notable intraoperative complications include bleeding, renal collecting system injury, injury of visceral organs, pulmonary complications, thromboembolic complications, extrarenal stone migration, and misplacement of the nephrostomy tube. Postoperative complications include infection and urosepsis, bleeding, persistent nephrocutaneous urine leakage, infundibular stenosis, and death. In this review, we report recommendations regarding troubleshooting measures that can be used to identify and characterize these complications. Additionally, we include information regarding management strategies for complications associated with PCNL for staghorn calculi.

Propensity Score-Matched Analysis Comparing Retrograde Intrarenal Surgery with Percutaneous Nephrolithotomy for Large Stones in Patients with a Solitary Kidney

PURPOSE

To evaluate the clinical efficacy, safety, and cost of retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) in the treatment for large renal stones in patients with a solitary kidney.

PATIENTS AND METHODS

In this study, 117 patients with a solitary kidney who had undergone PCNL or RIRS for renal stones larger than 2 cm between January 2010 and December 2016 were retrospectively evaluated. The patients' demographic data, clinical characteristics, and perioperative outcomes were collected through a review of their medical records. Forty-three patients treated with PCNL were compared to 43 patients treated with RIRS by propensity score-matched analysis. The stone-free rate, retreatment rate, complication rate, and efficacy quotient (EQ) were assessed in both groups.

RESULTS

Initial stone-free rate of the PCNL group after a single procedure was significantly higher compared with the RIRS group (74.42% vs 34.88%, p < 0.001), whereas there was no significant difference in the final stone-free rate after repeated procedures (90.70% vs 88.37%, p = 0.713). PCNL had a significantly lower retreatment rate than RIRS (16.28% vs 63.79%, p < 0.001), and the PCNL group underwent fewer procedures than the RIRS group (p < 0.001). Thus, PCNL group had a higher EQ (78.00% vs 53.52%). Although cost per procedure of PCNL was significantly higher compared with RIRS (p < 0.001), the total costs were comparable. Complication rate of RIRS was lower compared with PCNL with no statistical significance (p = 0.193), and acute kidney injury rates were also comparable (PCNL vs RIRS: 13.95% vs 6.98%, p = 0.533).

CONCLUSIONS

With fewer repeated surgical procedures, higher EQ, and comparable total costs, PCNL is recommended as the first choice for the treatment of large renal calculi in patients with a solitary kidney. As for specific indications such as anticoagulant drugs, RIRS is a safer choice with fewer complications and acceptable final stone-free rate.

Mortality from kidney stone disease (KSD) as reported in the literature over the last two decades: a systematic review

INTRODUCTION

Current trends show a rising incidence of kidney stone disease (KSD) globally, with a lifetime risk of 10% and increasing hospital admissions. However, it is not perceived as a life-threatening condition and there are no publications examining its mortality rate. The aim of this review was to report on the number of KSD mortalities in the literature from the past two decades, identify risk factors, and to summarize their key learning points.

METHODS

A search was conducted for full-text English language articles that reported on KSD associated mortality, following intervention or conservative treatment, published between 1999 and 2017, using PubMed, MEDLINE, EMBASE, Scopus, CINAHL, Clinicaltrials.gov, Google Scholar and The Cochrane Library. Study quality and risk of bias assessment was undertaken using a validated critical appraisal tool from the Joanna Briggs Institute.

RESULTS

Of the 2786 articles identified, 34 were included. Of the total number of reported mortalities (2550), 21% were related to intervention. Sepsis was the leading cause of mortality. Risk factors identified were patients with multiple co-morbidities, spinal cord injury or neurogenic bladder and high stone burden. The main recommendations suggested were to treat pre-operative UTI or use prophylactic antibiotics and to reduce operative duration. The included studies were of moderate to good quality.

CONCLUSION

Pre-procedural optimization of the patients is the key to avoiding KSD mortality, and care should be taken in patients with multiple co-morbidities. Surgeons should meticulously plan for patients with high stone burden to reduce their operative time, as mortality can be procedural related.

Risk factors for pulmonary complications after percutaneous nephrolithotomy: A retrospective observational analysis

Although percutaneous nephrolithotomy is minimally invasive, it is associated with several complications, including extravasation of fluid and urine, the need for a blood transfusion, and septicemia. However, little is known about pulmonary complications after this procedure. Therefore, we aimed to evaluate the risk factors for and outcomes of pulmonary complications after percutaneous nephrolithotomy.All consecutive patients who underwent percutaneous nephrolithotomy between 2001 and 2014 were identified and divided into group A (no clinically significant pulmonary complications) and group B (clinically significant pulmonary complications). Preoperative and intraoperative variables and postoperative outcomes were evaluated. Independent risk factors for postoperative pulmonary complications were evaluated by univariate and multivariate logistic regression analyses.The study included 560 patients: 378 (67.5%) in group A and 182 (32.5%) in group B. Multivariate logistic regression analysis revealed that the independent risk factors for pulmonary complications after percutaneous nephrolithotomy were a higher body mass index (odds ratio = 1.062, P = 0.026), intraoperative red blood cell transfusion (odds ratio = 2.984, P = 0.012), and an intercostal surgical approach (odds ratio = 3.046, P < 0.001). Furthermore, the duration of hospital stay was significantly longer (8.4 ± 4.3 days vs 7.6 ± 3.4 days, P = 0.010) and the intensive care unit admission rate was significantly higher [13 (7.1%) vs 1 (0.3%), P < 0.001] in group B than in group A.Risk factors for pulmonary complications after percutaneous nephrolithotomy were a higher body mass index, intraoperative red blood cell transfusion, and an intercostal surgical approach. Postoperative pulmonary complications were associated with poor outcomes. These results may provide useful information for the perioperative management of pulmonary complications after percutaneous nephrolithotomy.

Comparison of Retrograde Intrarenal Surgery and Percutaneous Nephrolithotomy: From the View of an Anesthesiologist

PURPOSE

To determine the differences among the hemodynamics, neuroendocrine stress response (NESR), and postoperative visual analogue scale (VAS) scores of pain between the procedures of retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PNL) for lower pole kidney stones.

PATIENTS AND METHODS

Fifty-six patients undergoing RIRS and PNL with lower puncture approach, under general anesthesia, were prospectively enrolled in our study. Perioperative blood pressure (systolic, diastolic, and mean), heart rate, and peripheral oxygen saturation (SpO2) values were recorded at intervals. Arterial blood gas (ABG) and blood glucose, serum insulin, and cortisol levels as stress response markers were analyzed in the perioperative period. Postoperative VAS scores were recorded at 30 minutes and 2, 4, 6, and 12 hours after extubation. Duration of surgery, stone sizes, and stone-free rates (SFRs) were noted.

RESULTS

SFRs were 93.3% in the PNL group (28/30 patients) and 88.5% in the RIRS group (23/26 patients) (p = 0.52). There was no statistical difference between the hemodynamics of both groups. Perioperative ABGs and NESRs were similar between groups (p > 0.05). Postoperative VAS scores and analgesic consumptions were also similar between groups (p > 0.05). Duration of surgery was significantly shorter in the RIRS group (p = 0.001). Stone size was significantly higher in the PNL group (p = 0.013).

CONCLUSION

Although the PNL is assumed to be more invasive than the RIRS procedure among urologists and anesthesiologists, both techniques may have similar perioperative outcomes in terms of hemodynamics, ABG, NESR, and pain scores in the management of lower pole stones with lower pole approach.