Salvage Percutaneous Nephrolithotomy: Analysis of Outcomes following Initial Treatment Failure

Ultrasound-Guided PCNL - Why Are We Still Performing Exclusively Fluoroscopic Access?

PURPOSE OF REVIEW

While urologists are traditionally taught to perform percutaneous nephrolithotomy (PCNL) utilizing exclusively fluoroscopy, ultrasound has emerged as a safe alternative. This article showcases the major reasons why ultrasound-guided access should be considered the first-line approach for performing access for PCNL.

RECENT FINDINGS

There continues to be a need to further reduce radiation exposure in the management of kidney stone patients. This review showcases how performing ultrasound-guided PCNL has been associated with a shorter learning curve, increased patient safety, and the ability to perform x-ray free PCNL. Ultrasound-guided PCNL is not only an achievable skill for urologists to learn but provides multiple advantages over traditional fluoroscopic access. As every effort should be given to help reduce radiation exposure for kidney stone patients as well as performing surgeons and operating theater personnel, endourologists should strive to add this technique to their armamentarium.

Comparative study between a new screwed Amplatz sheath and the ordinary one in percutaneous nephrolithotomy

Objective

The objective of the article is to compare the results of using new screwed Amplatz sheath with results of the conventional Amplatz sheath regarding success and complications during percutaneous nephrolithotomy.

Methods

100 patients aged more than 18 years with renal calculi more than 2 cm with guy's score 1 from December 2018 till July 2020 were randomly stratified by closed envelope in group A (50 patients) with using conventional sheath and group B (50 patients) with new screwed sheath. We exclude morbid obese patients and patients with contraindication for PNL.

Results

There were no significant differences between both groups regarding patients demographic and stone demographic. Operative time and fluoroscopy time were significantly lower in group B rather than group A. Tract stability was in favor of group B as no tract loss recorded while in group A, 5 cases were recorded. In overall complications there were no significant differences between both groups. Bleeding was higher in group A (14%) than in group B (4%), but it was not statistically significant. Success rates were 78% for group A and 88% for group B but it was not statistically significant.

Conclusion

The screwed Amplatz sheath had showed less operative and fluoroscopy time. Also it enables urologists to have stable PNL tract. So it may be a promising tool to make PNL easier with higher success rate and lower complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03806-2.

Outcomes of second-look percutaneous nephrolithotomy in renal calculi-a single centre experience

OBJECTIVE

Percutaneous nephrolithotomy (PCNL) carries significant potential for morbidity. Scant data exists on indications and outcomes of second-look PCNL after a failure to completely clear renal stones at the first attempt. We present our experience with second-look PCNL.

MATERIAL AND METHODS

This was a retrospective record review of 922 patients who underwent unilateral PCNL at a tertiary care center in South India. Baseline patient, stone characteristics and outcomes were compared between 844 patients undergoing primary PCNL and 78 patients requiring second-look PCNL.

RESULTS

Increased stone complexity in terms of Guy stone score (GSS), stone size, staghorn calculi and stones in multiple locations were significantly associated with primary treatment failure (p<0.001). Operative time >75 min had a significant association with need for second-look PCNL and complications. Initial PCNL was discontinued due to bleeding (28; 35.9%), pelvicalyceal system perforation (3; 3.9%) and purulent urine leading to urosepsis and hemodynamic instability (2; 2.6%). Staged PCNL was done in 44 (56.3%) patients. During second-look PCNL, new access tracts were necessary in majority (42; 53.9%) of the patients and multiple tracts in 20 (25.6%) patients. In second-look PCNL, complications were comparable to primary PCNL (p=0.289).

CONCLUSION

Second-look PCNL should be advocated in patients where the initial PCNL was discontinued due to bleeding, perforation of collecting system, prolonged operative time (>75 min) and in patients with large stone burden.

Safety and Feasibility of Salvage Endoscopic Combined Intrarenal Surgery in Embolized Kidney

Background: Although endoscopic combined intrarenal surgery (ECIRS) is well established as primary approach to complex lithiasis, no evidences are still available on its use in salvage context.

Case Presentation: A male patient, of 55 years of age, underwent many unsuccessful surgical procedures to treat large and multiple right kidney stones, including percutaneous nephrolithotomy (PCNL). The latter was complicated by severe postoperative hemorrhage, managed with super-selective renal artery embolization (SRAE). Therefore he came to our institution to achieve a complete resolution of the urolithiasis. Preoperative evaluation included CT scan and renal scintigraphy to establish kidney and stone morphologic features and residual renal function. Salvage ECIRS was performed and postoperative assessment showed a complete resolution of lithiasis and absence of renal function impairment.

Conclusion: To our knowledge, this is the first case of salvage ECIRS reported in literature after previous failed PCNL. Even after SRAE, this procedure appears as safe and as efficacious as standard salvage PCNL when performed by experienced hands.