INTRODUCTION AND OBJECTIVE

The endoscopic management of staghorn calculi is very challenging owing to its complex anatomical configuration. The authors analyzed the clinical efficacy and safety of a single upper pole access PCNL (SUPA-PCNL) for Guy Stone Score (GSS) 3-4 staghorn calculi.

Prospective data collection was done on 56 consecutive patients who with GSS 3-4 staghorn calculi. All cases were treated with a standardized technique of a single upper pole access PCNL in the prone position. The patient demographics, stone characteristics, perioperative and postoperative outcomes were analyzed.

The cohort exhibited diversity in age (51.7+12), gender (male to female ratio of 5.5:4.5) comorbidities, and stone burden (4.82+1.96 cm). SUPA-PCNL demonstrated a high median stonefree rate (99.5%, IQR 90-100) with minimal complications, low blood loss with a of 200cc (IQR 100-300), and median hospital stay of 3.5 days (IQR 3-5). Stone characteristics did not significantly influence outcomes. A subset required secondary treatments (12%, n=7), but overall morbidity was low (16%, n=9): (7% n=4) of which required blood transfusion, and (9% n=5) due to sepsis. The following factors were associated with increased odds of perioperative morbidity: preoperative creatinine >3 mg/dl (OR 4.19 95% Cl 0.59 – 29.71 p=0.152) and a history of endoscopic surgery (OR 7.33 95% Cl 1.20-44.96 p=0.031).

SUPA-PCNL is effective and safe for the treatment of staghorn calculi. In select patients, this approach obviates the need for a multi-tract access or an endoscopically-combined intrarenal surgery (ECIRS).

Augmentation intestinal cystoplasty is usually the preferred method. However, this is complicated by mucus production, recurrent infection and cystolithiasis. In this report, the authors present a unique case of laparoscopically-assisted ureterocystoplasty and describe the operative technique and its advantages.

A 68-year-old female with a contracted urinary bladder and a solitary functioning kidney was diverted with a percutaneous nephrostomy tube for the past ten years. She consulted for a possible reconstructive procedure.

After a comprehensive preoperative evaluation, she underwent laparoscopically-assisted ureterocystoplasty. The operative time was 265 minutes with minimal blood loss. She had an unremarkable postoperative course. On follow-up, a voiding diary revealed urine volume of around 300 milliliters at 3 hour intervals, preservation of renal function, and no evidence of urinary infection.

Ureterocystoplasty was done using a combination of minimally invasive and open techniques. This procedure spared the patient a lifelong diversion with a nephrostomy tube and provided a better quality of life.

Introduction and Objective: Percutaneous Nephrolithotomy (PCNL) is the standard of care for renal stones >2cm. Kidneys with anatomical disparities resulting from fusion (horseshoe), malrotation, ectopic location (allografts) and bifid collecting systems present as a challenge because variations in vasculature, calyceal rotation and intervening viscera may make percutaneous access treacherous. Reported here is the authors’ experience with PCNL in these types of kidneys. Methods: A chart review was done on all patients who underwent PCNL at the National Kidney and Transplant Institute (NKTI) from 2012-2016. Those with anatomical variations were identified and analyzed. Patient demographics (age, gender, co-morbidity) and stone characteristics (Guy’s stone score, laterality) were summarized. Intraoperative parameters such as location of puncture site (upper, mid, inferior calyces), number of tracts (single vs. multiple), operative time, estimated blood loss (EBL), and length of hospital stay (LOS) were analyzed. The primary endpoints were stone-free and complication rates according to the Clavien-Dindo (CD) classification. Results: A total of 1,657 PCNLs were performed during the study period, of which 42 had anatomical variants. The mean age was 45.2±8.8 (R= 28-65) with a male to female ratio of 3:1. There were 18 horseshoe (42.9%), 15 bifid (35.7%), 7 malrotated (16.7%) and 2 renal allografts (4.8%.); Laterality- wise, 28 (67%) were left-sided, 12 (29%) were right-sided and 2 (5%) had right-sided pelvic kidneys (allografts). The Guy stone scores were 3 and 4 in 13 (30%) and 29 (70%) patients, respectively. The mean stone diameter was 3.8±0.6 cms. (R=2.5-5.5). Majority, n=37 (88%) were treated with an upper pole access. Thirty-six (86%) needed a single tract and while six (14%) required multiple tracts (bifid pelvis). The mean operative time was 111.5±28.1 mins. (R=65-188), EBL was 461±278.4 cc (R=200-1300). LOS was 3.6±0.94 days (R=2-7). The stone-free rate was 95%. Twenty-five (59.5%) complications were documented. Fifteen (35.7%) had fever: Grade I CD, and 10 (23.8%) required transfusion: Grade II CD. There was no mortality. Conclusion PCNL still persists as the treatment of choice for nephrolithiasis in kidneys with variations in anatomy or position. A high stone clearance rate can be achieved while minimizing complications.
Nephrolithotomy, Percutaneous

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is the standard of care for the treatment of renal stones >2cm and staghorn calculi. This minimally invasive procedure however has intraoperative hemorrhage as one of its most dreaded complications. OBJECTIVE: To analyze the rate of hemorrhage and transfusion requirements among patients undergoing either PCNL or open stone surgery (OSS). METHODS: This was a retrospective study conducted at the National Kidney and Transplant Institute Medical Records Department. Data were collected for the period of January 2018 to December 2019. RESULTS: One hundred forty cases were included, 102 patients in the PCNL group and 38 in the OSS. The mean age 50.84±11.89 vs. 50.50±10.09 with male to female ratio of 1.2:1 for PCNL and open surgery, respectively. The most common comorbidity was hypertension (89, 63.6%). As regards stone size, majority had >4 cm stone size (61; 43.9%). In PCNL, there was no significant change noted in the hemoglobin (14.69±13.3 vs 12.03±1.91, p= 0.099) as compared to OSS, where there was significant decline (12.77±2.64 vs. 11.06±2.52; = .000. The number of packed red cell units for transfusion was also significantly higher in OSS compared to PCNL group (.526±.861 vs. 159±.502, p .020.) CONCLUSION In the treatment of staghorn calculi, PCNL incurs less blood loss and lower transfusion requirements compared to open stone surgery.
percutaneous nephrolithotomy ; blood transfusion ; hemorrhage

Background. Despite being a clean-contaminated procedure, performed only in patients with sterile urine preoperatively, percutaneous nephrolithotripsy (PCNL) is associated with significant infectious perioperative complications. A local antibiogram is of paramount importance in optimizing antibiotic prophylaxis in PCNL because of the substantial variation in bacterial distribution and antibiotic sensitivity worldwide.

Objectives. The incidence of post-PCNL infectious complications, microorganism distribution, and antibiotic sensitivities from patients admitted for PCNL was determined. The risk factors associated with positive cultures and the development of fever and bacteremia were also analyzed.

Methods. A retrospective study of 102 patients who underwent PCNL under a surveillance protocol was done. The susceptibility of isolates from different specimens was evaluated against the most common antibiotics in the hospital. Chi-square and Student's t-test were used to determine differences in the frequencies and means for other risk factors for those who developed fever and urosepsis and those who did not.

Results. The incidence of fever and urosepsis was 25% and 4%, respectively. The most common organism on urine specimens was Escherichia coli which showed high sensitivity to aminoglycosides. The most common isolate on stones was Pseudomonas aeruginosa, which showed higher sensitivities to the fluoroquinolones. The isolates showed nearly consistent resistance to ceftriaxone. No significant association was found between the clinical variables studied and the occurrence of infectious complications.

Conclusion. There are comparable rates of infectious complications to published literature. A change in antibiotic prophylaxis was warranted, given the high resistance to ceftriaxone and the predominance of Pseudomonas aeruginosa on stone isolates. Further surveillance is required to identify significant risk factors for the development of post-PCNL infectious complications.

BACKGROUND: The optimal treatment for large impacted proximal ureteral stones remains controversial. The aim of this study was to evaluate the efficacy, safety, and potential complications of mini-percutaneous nephrolithotomy (MPCNL) and retroperitoneal laparoscopic ureterolithotomy (RPLU) in the treatment of impacted proximal ureteral stones with size greater than 15 mm. METHODS: A total of 268 patients with impacted proximal ureteral stones greater than 15 mm who received MPCNL or RPLU procedures were enrolled consecutively between January 2014 and January 2019. Data on surgical outcomes and complications were collected and analyzed. RESULTS: Demographic and ureteral stone characteristics found between these two groups were not significantly different. The surgical success rate (139/142, 97.9% vs. 121/126, 96.0%, P = 0.595) and stone-free rate after 1 month (139/142, 97.9% vs. 119/126, 94.4%, P = 0.245) of RPLU group were marginally higher than that of the MPCNL group, but there was no significant difference. There was no significant difference in the drop of hemoglobin between the two groups (0.8 ± 0.6 vs. 0.4 ± 0. 2 g/dL, P = 0.621). The mean operative time (68.2 ± 12.5 vs. 87.2 ± 16.8 min, P = 0.041), post-operative analgesics usage (2/121, 1.7% vs. 13/139, 9.4%, P = 0.017), length of hospital stay after surgery (2.2 ± 0.6 vs. 4.8 ± 0.9 days, P < 0.001), double J stent time (3.2 ± 0.5 vs. 3.9 ± 0.8 days, P = 0.027), time of catheterization (1.1 ± 0.3 vs. 3.5 ± 0.5 days, P < 0.001), and time of drainage tube (2.3 ± 0.3 vs. 4.6 ± 0.6 days, P < 0.001) of MPCNL group were significantly shorter than that of the RPLU group. The complication rate was similar between the two groups (20/121, 16.5% vs. 31/139, 22.3%, P = 0.242). CONCLUSIONS MPCNL and RPLU have similar surgical success and stone clearance in treating impacted proximal ureteral stones greater than 15 mm, while patients undergoing MPCNL had a lower post-operative pain rate and a faster recovery.
Humans ; Laparoscopy ; Length of Stay ; Nephrolithotomy, Percutaneous/adverse effects* ; Retroperitoneal Space/surgery* ; Treatment Outcome ; Ureteral Calculi/surgery*

Humans ; Kidney Calculi/surgery* ; Nephrolithotomy, Percutaneous ; Nephrostomy, Percutaneous ; Obesity, Morbid/surgery* ; Radiography ; Retrospective Studies ; Treatment Outcome

OBJECTIVE: To compare the short-term effects and long-term outcomes of incisional procedure and dilatation procedure to manage diverticular neck in percutaneous nephrolithotomy for diverticular stones. METHODS: Clinical data of 61 patients with diverticular stones who underwent percutaneous nephrolithotomy from June 2009 to January 2019 were retrospectively collected and analyzed, which was as follous: (1) basic information: age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) classifications and preoperative symptoms.(2)stone characteristic and procedure-related data: location and size of stone, skinned renal access length and procedure time.(3)perioperative clinical data: hemoglobin drop, Clavien's classification and stone-free rate. Long-term follow-ups were performed for more than 5 years after the patients were discharged. RESULTS: Fifty-three patients were included based on the inclusion and exclusion criteria, and were divided into the dilation group (n=37) and the incision group (n=16) by the treatment methods of diverticular neck. There were 24 male patients (45.3%) and 29 female patients (54.7%), with a mean age of 39.96±12.88 years. Stones were mainly located in the upper pole (n=32, 60.38%) and posterior area (n=41, 77.4%), with a predominance of single stone (n=36, 67.9%). There was no statistically significant difference in demographic data and stone characteristics between the two groups except for age and stone burden. Forty-five patients (84.9%) reached stone-free status after surgeries, and 44 patients (83.0%) postoperative symptoms improved. Twelve patients were lost to the follow-ups, and 41 cases were followed up for an average of 77 months. One recurrence occurred 1 year after surgery. Fifteen patients underwent operations within the past 5 years and the overall 5-year recurrence rate for the remaining 26 patients was 34.6%. There was no statistically significant difference in the incidence of perioperative complications, postoperative stone-free rate and recurrence rate between the two groups, and the recurrence rate was significantly higher 5 years postoperatively than 1 year postoperatively. The proportion of the patients who remained lithotripsy-free and residual stone status decreased significantly. CONCLUSION Both incisional and dilatation procedures in percutaneous nephrolithotomy to manage diverticular neck could bring the satisfactory postoperative stone free rate. The recurrence rate was about 30% to 40% 5 years after surgery.
Adult ; Female ; Humans ; Kidney Calculi/surgery* ; Male ; Middle Aged ; Nephrolithotomy, Percutaneous ; Nephrostomy, Percutaneous ; Retrospective Studies ; Treatment Outcome

Recently, the global endourology scene has witnessed a resurgence of interest in supine PCNL (sPCNL). The number of urologists who are attracted to this “simplified method” of PCNL is growing and its promoters are suggesting to abandon the standard prone approach. Debates on the two positions have become commonplace in endourology scientific meetings. The advocates consistently emphasize that when compared to the prone position, sPCNL has multiple advantages for the surgeon, the anesthesia team and the patient. In spite of these, it is evident that many still favor prone PCNL (pPCNL) because of its time-tested proven efficacy and safety. In fact, up to this present day, majority of PCNLs are still done in the prone position. This review article intends to analyze the “current state of affairs” of the two PCNL positions, describing their advantages and disadvantages. Presently, applying the principles of “what is safe and efficacious in one’s hands” dictates the choice of which technique is utilized to treat a patient. Conversely, it is more clinically sound if this choice was made instead, in consideration of, the interplay of the following factors such as the patient’s clinical demographics, the anatomical features of the renal collecting system, the stone burden and characteristics and ultimately, the physician’s training, skills and experience.
Nephrolithotomy, Percutaneous

: The current standard in the management of large burden renal stones is conventional percutaneous nephrolithotomy. Mini-percutaneous nephrolithotomy (mini-PCNL) is a procedure developed to decrease complications of standard PCNL by decreasing the size of access. Recent studies have shown high stone free rates with minimal complications in utilizing mini-PCNL in larger stones. OBJECTIVE: This study aims to assess the safety and efficacy of mini-PCNL for stones with sizes 2 cm and above versus standard PCNL. METHODS: This is a meta-analysis comparing mini-PCNL and standard PCNL in the management of renal stones 2 cm and above. A PUBMED search was done to acquire randomized controlled trials (RCTs), prospective and retrospective studies of mini-PCNL and standard PCNL assessing large burden renal stones, defined as 2 cm and above. Two authors independently assessed the studies for selection. Comparison of mini-PCNL and standard PCNL was done according to following parameters: stone-free rate, operative time, postoperative decrease in hemoglobin levels, length of hospital stay, rate of transfusion, occurrence of fever, postoperative pain scores, and occurrence of urine leakage. RESULTS: Results of this meta-analysis showed that standard percutaneous nephrolithotomy has an advantage over mini percutaneous nephrolithotomy only in terms of having a shorter operative time for larger stones (MD: 8.44 min, 95% CI 6.36 – 10.52 min, p < 0.00001). No difference was found in the outcomes of postoperative pain scores (MD 0.19 VAS score, %CI 0.16 – 0.54, p = 0.29), occurrence of postoperative fever (OR 0.33, 95% CI 0.18 – 0.61, p = 0.06) and the stone-free rate (OR 0.97, 95% CI 0.67 – 1.41, p = 0.88). Mini-percutaneous nephrolithotomy has advantage over standard percutaneous nephrolithotomy for large-burden stones in terms of shorter length of postoperative hospital stay (MD 1.44 day, 95% CI 1.22-1.66, P <0.00001), lower hemoglobin drop (MD 0.48 mg/dl, 95% CI 0.39–0.66, p < 0.00001), lower rate of transfusion (OR 0.40, 95% CI 0.20 – 0.99, p = 0.01), urine leakage (OR 0.11, 95% CI 0.03 – 0.39, p = 0.0008) and an overall lower occurrence of complications (OR 0.42, 95% CI 0.28 – 0.62, p < 0.0001). CONCLUSION Mini-percutaneous nephrolithotomy is a safe and effective intervention in large-burden stones 2 cm in size and above.
Nephrolithotomy, Percutaneous