The outcome of percutaneous nephrolithotomy on ≥50 mm staghorn and multiple calyceal stones

Evaluating outcomes of complete supine percutaneous nephrolithotomy for staghorn vs multiple non-staghorn renal stones: a 10-year study

PURPOSE

To evaluate the outcomes of complete supine percutaneous nephrolithotomy (csPCNL) for staghorn stones and multiple large non-staghorn stones.

METHODS

The records of 886 patients who underwent csPCNL from September 2009 to October 2019 were considered. Out of them, 201 cases met the eligibility criteria and they were divided into three groups: 63 cases of staghorn, 68 cases of multiple medium (20 mm < diameter ≤ 30 mm) non-staghorn and 70 cases of multiple large non-staghorn (> 30 mm) stones. Almost all outcomes and stone-related factors were analyzed.

RESULTS

There was not any significant difference regarding age, body mass index, history of urinary tract infection, transfusion rate, complication rate, pre and post-surgery serum creatinine, hemoglobin drop and total hospital stay between the three groups. Stone free rate was 98.5% in multiple medium group, 97.1% in multiple large group and 84.1% in staghorn group (P = 0.001). The operation duration was significantly shorter for the multiple medium group (P < 0.001) but it was not significantly different between the multiple large non-staghorn and staghorn group.

CONCLUSION

The results demonstrated that almost all outcomes were not significantly different between the three groups (especially between staghorn and larger non-staghorn ones). These findings reveal that surgeons could choose csPCNL for treatment of staghorn stones and multiple large non-staghorn stones and consider staghorn stones as challenging as multiple large (especially diameter > 30 mm) non-staghorn stones.

Intraoperative and postoperative surgical complications after ureteroscopy, retrograde intrarenal surgery, and percutaneous nephrolithotomy: a systematic review

INTRODUCTION

Retrograde ureteroscopy (URS), intra-renal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) represent routine interventions for the treatment of ureteral and renal stones, although at times associated with serious adverse events. Of note, the evidence on perioperative complications after these procedures remains sparse and controversial. Moreover, there is a lack of standardized reporting of adverse events using uniform systems. The aim of the present study was to systematically review of the available evidence on URS/RIRS and PCNL for the surgical treatment of urinary stone, assessing the incidence of intra- and postoperative events, classified according to the modified Clavien-Dindo scale.

EVIDENCE ACQUISITION

A systematic review of the literature was performed according to PRISMA recommendations and was conducted on intra- and postoperative complications, as well as on their management, following URS, RIRS and PCNL procedures, particularly focusing on major events.

EVIDENCE SYNTHESIS

Overall, 26 studies (13 on URS/RIRS and 11 on PCNL) met the inclusion criteria and were evaluated. The highest intraoperative complication rate was 11.5% and 8.5% for RIRS and PCNL, respectively. Major complication rate following URS/RIRS and PCNL ranged between 0.3-31.7% and 2-17.1%, respectively. The most frequent adverse events were obstructive pyelonephritis or urinary leakage requiring the placement of a double J stent or a drainage. Among PCNLs series, life-threatening adverse events have also been reported, including bleeding requiring renal angioembolization and urothorax.

CONCLUSIONS

Despite the inclusion of series using a standardized reporting system, the complication rate after URS/RIRS/PCNL remains extensively heterogeneous in the literature; in addition, a non-negligible proportion of studies did not characterize the adverse events nor report the actual management strategy to solve them. Future research is needed to standardize the classification and reporting of surgical complications after endourological procedures (taking into consideration the surgeon's experience and skills), aiming to improve patient counseling and potentially the strategy for their prevention.

Frequency of Blood Transfusion in Percutaneous Nephrolithotomy

Introduction

Percutaneous nephrolithotomy (PNL) has replaced open surgery for the treatment of kidney stones due to its less invasive nature. Bleeding still occurs due to renal vascular injuries, dependent upon the access route of the procedure. Several other factors are also related to the increased risk of bleeding. This study aims to find the association between blood transfusion and other factors such as age, gender, body mass index (BMI), size of the stone, operative time, preoperative hemoglobin (Hb) level, stone surface area, hypertension, and diabetes mellitus.

Materials and methods

This was a descriptive cross-sectional study conducted over a period of six months between November 2019 and April 2020 at a tertiary care hospital in Karachi, Pakistan. The sample size of 131 patients was calculated using open-source epidemiological software (Open-Epi). Inclusion criteria included patients from both genders and ages between 26 and 70 years. Patients ≤25 years, having a liver disease or bleeding disorders, or refusing to participate in the study, were excluded. Laboratory data included preoperative routine complete blood count, serum creatinine (normal 0.5-1.5 mg/dL), platelet count, bleeding and coagulation profile, and urine culture. All patients also underwent renal ultrasound scans. Treatment was postponed until a negative urine culture was obtained from patients with a positive urine culture. 

Results

The mean age of the patients was 42.4 ± 15.65 years. One third (29.8%) of the patients were females. The stone size was 850 ± 121.43 mm², the mean operative time of the procedure was 125.76 ± 53.4 minutes, and the mean number of cell packs transfused was 1.10 ± 0.31 units. Blood transfusion was done in 24 (18.3%) of the patients. Gender, diabetes mellitus, stone size, preoperative Hb level, and operative time were significantly related to blood transfusion. 

Conclusions

Increased bleeding risk while performing PNL has been associated with many factors such as operating time, the gender of the patients, and stone size. Therefore, these factors should be controlled for the procedure to decrease the risk of bleeding and the need for blood transfusion. Furthermore, the kidney vasculature should not be compromised while performing the procedure.

The role of ureteroscopy for treatment of staghorn calculi: A systematic review

Objective

To define the role of ureteroscopy for treatment of staghorn calculi.

Methods

A systematic review was conducted using the Scopus and Medline databases. Original articles and systematic reviews were selected according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only studies relating to the role of ureteroscopy for treatment of staghorn calculi were included.

Results

In five studies on ureteroscopic monotherapy, stone-free rate (SFR) ranged from 33% to 93%, with a maximum four ureteroscopy sessions per patient and no major complications. Endoscopic combined intrarenal surgery (ECIRS) was compared with percutaneous nephrolithotomy (PNL) in two studies and reached significantly higher SFR (88%-91% vs. 59%-65%) and lower operative times (84-110 min vs. 105-129 min). The role of salvage ureteroscopy for residual stones after primary PNL has been highlighted by two studies with a final SFR of 83%-89%. One study reported on the feasibility of ureteroscopy for ureteral stones and same-session PNL for contralateral staghorn calculi, with a SFR of 92%.

Conclusion

Ureteroscopy plays a pivotal role in the setting of a combined approach to staghorn calculi. Ureteroscopy is also particularly suitable for clearance of residual stones. In specific cases, ureteroscopy may become the sole applicable therapeutic option to staghorn calculi. Technological advances and refinement of techniques suggest a major role of ureteroscopy for staghorn calculi treatment in close future.

Dynamic thiol/disulfide homeostasis as a novel indicator of oxidative stress in patients with urolithiasis

Purpose

A dynamic thiol/disulfide balance is pivotal in organizing anti-oxidant defense, detoxification, apoptosis, and enzyme activities, as well as transcription and cellular signal-transfer mechanisms. The connection between urolithiasis and oxidant/antioxidant status, which can be assessed through thiol-disulfide homeostasis (TDH), has not yet been examined. In this study, we evaluated the effects of TDH on the formation, size, and location of stones by examining the associations between TDH parameters and urolithiasis.

Materials and Methods

Patients with urolithiasis and healthy controls were recruited. The patients were divided into subgroups in terms of stone size (>15 mm or ≤15 mm) and stone location (nephrolithiasis or ureterolithiasis). TDH parameters were measured using a novel automatic and spectrophotometric method and compared statistically.

Results

TDH parameters were different between the urolithiasis and control groups. TDH tended towards the disulfide side in the urolithiasis group. Stone size increased an average 0.14 mm with a 1 µmol/L increase in disulfide level and decreased an average 0.058 mm with a 1 µmol/L increase in native thiol level. Disulfide and native thiol levels were found to be different across patients with stone size >15 mm, ≤15 mm, and controls (p<0.001 and p<0.001, respectively). However, the nephrolithiasis and ureterolithiasis groups were similar in respect of TDH parameters.

Conclusions

In this study, it was found that patients with urolithiasis displayed oxidative stress characterized by a TDH tendency towards the disulfide side, and an inadequate antioxidant response identified by a lower level of native thiol as compared with healthy controls.