Single puncture percutaneous nephrolithomy for management of complex renal stones

Assessment of lower calyceal single-access percutaneous nephrolithotomy for staghorn stones: A single-surgeon and a single-center experience at KAMC, Riyadh

Introduction:

Percutaneous nephrolithotomy (PCNL) is still the mainstay and the treatment of choice for most complex renal stones. The success of PCNL is defined by achieving a stone-free rate (SFR). Lower calyceal access PCNL is established to be the safest percutaneous access to the renal system, but controversy is present when it comes to SFR in comparison to upper calyceal and middle calyceal accesses.

Aim:

We aim to prove that lower calyceal access PCNL is the safest PCNL access and has the same efficacy as upper calyceal access PCNL for staghorn stones.

Methodology:

All lower calyceal access PCNLs done from May 2012 to August 2017 were included in the study. Postoperative complications were reported using the modified Clavien Grading System.

Results:

Sixty-seven patients were included in the study. The mean age was found to be 49.39 years; most (36 [53.73%]) patients were male. The prevalence of diabetes, hypertension, dyslipidemia, and chronic kidney disease was 40.91%, 47.76%, 37.31%, and 20.00%, respectively. The mean hospital stay was 7.9 days; mean operative time was 138.52 min. The mean staghorn stone burden was 476.34 mm². About 80.59% (n = 54) of patients had complete stone resolution after the first session. Only 3 (4.47%) patients had complications and classified as Grade 2 on the modified Clavien Grading System and the remainder were classified as Grade 1, two patients needed postoperative blood transfusion, and one had a renal pelvis perforation.

Conclusion:

When it comes to safety and efficacy, the use of lower calyceal single-access PCNL has a very low complication rate compared to upper calyceal access PCNL, especially pneumothorax and bleeding.

The Efficacy of Percutaneous Nephrolithotomy Using Pneumatic Lithotripsy vs. the Holmium Laser: a Randomized Study

The objective of the study is to compare the efficacy of percutaneous nephrolithotomy using holmium laser vs pneumatic lithotripsy. From August 2010 to March 2014, 200 patients with double kidney and single kidney stones without previous operations or other diseases were randomized into two groups according to the type of lithotripter used: pneumatic (n = 100) and laser (n = 100). The preoperative, intraoperative, and post-operative follow-up findings were analyzed and compared. The average stone size was similar in both the pneumatic and holmium laser lithotripsy groups (202.8 ± 52.6 mm² vs. 200.3 ± 50.8 mm²). No significant difference was found between the operation time for the two groups (55.9 ± 16.5 min vs. 62.4 ± 17.6 min). The concentrations of creatinine in both groups increased 2-24 h after the operation and decreased to a normal level 1-4 days after the operation in both groups. Renal diuretic scan revealed that the peak and the renal index were both abnormal after the operation but became normal 4 days after the operation in both groups. No significant difference of creatinine concentration or the diuresis renogram was observed between the two groups. However, two cases in the holmium laser group had almost lost the renal function of the operated kidney 1 year later. Both pneumatic and holmium laser lithotripsy can be associated with acute renal injury in some patients after the operation without any significant difference. However, some infrequent severe renal function damage in laser lithotripsy should be noted.

Middle calyx access in complete supine percutaneous nephrolithotomy

BACKGROUND

Middle calyx access has been underused in percutaneous nephrolithotomy (PCNL), especially in the supine position. We compared the safety and efficacy outcomes between middle calyx and lower calyx accesses in the complete supine PCNL in a non-randomized single-surgeon clinical study.

METHODS

Between February 2008 and October 2011, 170 patients underwent posterior subcostal single tract complete supine PCNL with one-shot dilation and middle calyx (n = 48) and lower calyx (n = 122) accesses. Stone location and surgeon decision determined target calyx for access. Inclusion criteria were pelvis stones, staghorn stones and multiple location stones. Exclusion criteria were renal anomalies, only upper calyx stones, only middle calyx stones and only lower calyx stones. Important parameters were compared between the two groups. A p value of <0.05 was considered significant.

RESULTS

Two groups were similar in important patient- and stone-related parameters. Mean operative time (60.7 minutes), mean postoperative hospital stay (1.84 days) and mean hemoglobin drop (0.67 g/dL) in the middle calyx group were significantly lesser than in the lower calyx group (80.1 minutes, 2.19 days, 1.36 g/dL). The middle calyx group (89.6%; 79.6%) had a higher stone-free rate (p = 0.054) and efficiency quotient than the lower calyx group (76.2%; 61.6%). In the middle calyx group (10.4%; 2.1%), complication and transfusion rates were lesser (p > 0.05) than lower calyx group (14.8%; 7.4%). No significant difference (p = 0.40) was seen between two groups using the modified Clavien classification of complications.

INTERPRETATION

Middle calyx can be an optimal access in PCNL with the complete supine position for many of upper urinary tract stones due to its superior outcomes.