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Journal of Endourology Comparison of monoplanar and biplanar access techniques for percutaneous nephrolithotomy (doi: 10.1089/end.2015.0166) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

1 Introduction Percutaneous nephrolithotomy (PCNL) is an essential technique in the management of various types of renal stone diseases that is commonly performed in daily urologic practice 1. Although it is a minimally invasive surgical procedure, recent efforts have been made to modify PCNL to make it simpler, more profitable, and to have less potential complications. During the PCNL procedure successfully obtaining percutaneous renal access to the collecting system is the first step, as this is directly associated with surgical outcomes and complication rates. Several techniques have been used for guidance for entrance to the pelvicalyceal system, including fluoroscopy, computed tomography (CT), and ultrasonography (US); however, the most commonly used technique is antegrade fluoroscopy-guided percutaneous renal access

2-4

. Biplanar access is based on the

cephalad-caudad and mediolateral movements of the needle; the depth of the needle is adjusted with using fluoroscopic imaging, including 300 and vertically positions 5, 6. There are two well-defined techniques of fluoroscopic guidance for antegrade percutaneous access, including the “eye-of-the needle (i.e., bull’seye)” technique and the “triangulation” technique 5. Recently, Hatipoglu et al. described a novel monoplanar access technique

7

that is different from other methods in that it utilizes only fluoroscopic

projections maintained on a vertical plane. The “eye-of-the needle” technique and the “triangulation” technique were analyzed for many parameters such as outcomes and complications. It was found that neither has a clear advantage over the other, except that the triangulation technique results in lower blood loss 8. The current study aims to present the influence of the biplanar (eye-of-the needle) and monoplanar access techniques on operative outcomes. To our knowledge, there is no study in literature that directly compares these methods; therefore, in this study, we intended to carefully examine the favorable and unfavorable aspects of each. Patients and methods The local ethics committee approved this study, which included a total of 661 consecutive patients who underwent percutaneous nephrolithotomy for stone diseases by the same surgical team at our institution between November 2012 and January 2014. The data were analyzed retrospectively. The patients underwent PCNL using either the monoplanar (Group 1) access or biplanar (Group 2) access techniques. The technique used was determined by the preferences of the surgeon. The patient demographics and the perioperative and postoperative variables (e.g., operative time, puncture time, fluoroscopy screening time (FST), hematocrit drop, complication rates, success rates, and duration of hospitalization for both groups were recorded and compared. Patients with anomalous kidneys were excluded from the study. Informed consent was obtained from all patients prior to the start of the study. All patients were evaluated according to their medical history, physical examination, complete blood count, plasma urea and creatinine values, coagulation profiles, urinalysis and urine cultures, and imaging methods (i.e., plain radiograph, ultrasonography, intravenous urography and/or computed tomography). Since a negative urine culture was required before surgery, positive urine cultures were adequately treated with appropriate antibiotics. Puncture time was defined as the time from the start of the fluoroscopic localization of the renal unit to the time when urine discharge came through the needle. The

1

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Journal of Endourology Comparison of monoplanar and biplanar access techniques for percutaneous nephrolithotomy (doi: 10.1089/end.2015.0166) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

2 maximum diameter of the stone was defined as the stone size. Stone size was estimated as the sum of the longest axis of each stone if the patient had multiple calculi.

Ultrasound was used to assess the

classification of hydronephrosis. Surgical procedure Rigid cystoscopy was performed to place a ureteral catheter while the patient was in the lithotomy position. After catheter insertion, the patient was placed in the prone position, and percutaneous access was achieved under the guidance of C-arm fluoroscopy. One of the two access techniques described previously (monoplanar or biplanar) was used for renal puncture 5-7. The collecting system in the biplanar technique was visualized with diluted contrast agent and a fluoroscopy C-arm was used to determine the calyx to be punctured with an 18-gauge needle. Firstly, the arm of fluoroscopy was rotated to 30 0 through to desired calyxes. This maneuver was targeted to Brodel’s line that is accepted relatively avascular area. Once the eye of the needle (or bull’s-eye appearance) was maintained, then the fluoroscopy device was retaken to the position of 90 0 in a vertical position and the needle is inserted until the hemostat clamp to understand the deepness of the needle. The obturator was removed when the tip of the needle reached the targeted calix. Proper positioning was confirmed by an efflux of urine. The monoplanar technique, which was previously described by Hatipoglu and associates 7, relies on known anatomic landmarks. During the procedure, a C-arm fluoroscope was brought into vertical position to access the lower poles, the collecting system was visualized with contrast agent, and the stone location was marked with a clamp. The needle was placed with a 30 0 angle according to the sagittal plane. The angle of the needle, which was parallel to the ground, was defined as 90 0 in the coronal plane. The needle was inserted into the targeted calyxes without changing the angle in both the sagittal and horizontal planes. A curved renal appearance was observed during access into the kidney. If intervention failed, the needle was not drawn completely away from the skin; but was retracted approximately 1 cm intracorporeally, its angle of entry was adjusted on the same vertical plane, and the needle was reinserted. Amplatz dilators was used for tract dilatation (Microvasive, Natick, MA) up to 30F, and a 30F sheath (Amplatz) accompanied by fluoroscopic image.A pneumatic lithotripter (Lithoclast; EMS, Nyon, Switzerland) and retrieval graspers were used to remove stone fragments through a rigid nephroscope (26F, Karl Storz®). All patients were given a nephrostomy tube at the end of the procedure. This nephrostomy tube was removed on approximately first days and the patient was discharged the following day. Stone clearance was assessed with a plain radiograph or via ultrasonography one day and a spiral CT 3 months after surgery in an outpatient clinic setting. Asymptomatic stones smaller than 3 mm were considered as clinically insignificant residual fragments (CIRFs). Patients were classified as stone free, having CIRFs, or as unsuccessful (residual stones). Complications were classified according to the modified Clavien grading system 9. All statistical evaluations were performed with Statistical Package for Social Sciences (SPSS) for Windows 16.0. Variables were investigated using visual (histograms,

2

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Journal of Endourology Comparison of monoplanar and biplanar access techniques for percutaneous nephrolithotomy (doi: 10.1089/end.2015.0166) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

3 probability plots) and analytical methods to determine if they were normally distributed. Data regarding normally distributed variables are presented as means ± standard deviations (S.D.); categorical variables are shown as frequencies. The Independent Samples T test was used to compare parameters between the two groups, while Pearson’s x2 method was performed for categorical variables. Two-sided values of p < 0.05 were considered statistically significant. Results The monoplanar technique was performed in 310 patients (Group 1), and the biplanar technique was performed in 351 patients (Group 2). The demographic values, preoperative and perioperative measures including presence of hydronephrosis, diagnostic imaging methods, laterality, operation type, number and type of access, and fluoroscopy time were prospectively recorded into a patient entry system. These two groups were compared in terms of age, stone location and size, and grade of hydronephrosis. The result of analysis of demographic data was found similar between the groups and were summarized in table 1. In addition, the mean operative times and hematocrit drop values were not different between the groups. The average length of hospital stay was 3.4±1.3 days for group 1 (monoplanar) and 3.2±1.3 days for group 2 (biplanar) (p:0.94). Further, there was no significant difference between the groups with regards to degree of hydronephrosis (p>0.05). The mean puncture time was significantly lower in group 1 (monoplanar) when compared with group 2 (biplanar) (p:0.04). The monoplanar and biplanar groups had similar success rates of 88% and 89%, respectively (p>0.05). The patients with residual stones (38 patients in group 1 (monoplanar) and 40 patients in group 2 (biplanar)) underwent schock wave lithotripsy (SWL) as an additional treatment modality. The nephrostomy tube was removed after a mean of 2.1±0.5 days in group 1 (monoplanar) and after 2.1±0.42 days in group 2 (biplanar) (p:0.97). The perioperative and postoperative findings are summarized in Table 2. The complication rates of the two groups were similar; when the complications were re-evaluated by the Modified Clavien System, there was no statistical difference between the groups (Table 3). Discussion For the past 35 years, PCNL has been used with proven reliability and effectiveness for various types of renal stone diseases 1. There are some variables regarding the success and complications associated with percutaneous access, including the type of operator (radiologist vs. urologist), imaging modality used for guidance (fluoroscopy vs. US vs. others), and access type. The percutaneous renal access is performed by urologists or radiologists in different countries10-12. Watterson et al

12

retrospectively compared accesses obtained by urologists vs. those obtained by

radiologists and concluded that urologist-acquired percutaneous access resulted in fewer access-related complications and improvements in stone-free rates. Tomaszewski and associates

11

reported a

significantly higher stone-free rates in patients whose access was performed by urologists, but complication rates were reported similar between urologists and radiologists. . Another study reported no

3

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Journal of Endourology Comparison of monoplanar and biplanar access techniques for percutaneous nephrolithotomy (doi: 10.1089/end.2015.0166) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

4 significant differences between urologists and radiologists in terms of success and complication rates13. Although there is some controversy regarding the success and complications associated with percutaneous access obtained by urologists and radiologists, results indicate that urologists should direct the access for effective subsequent percutaneous procedures. Ultrasound (US), computerized tomography (CT), and antegrade fluoroscopy guidance have all been described for percutaneous access, with the latter being the most commonly employed; the method of choice is based on patient characteristics and physician preference 2, 4. Compared with fluoroscopy, US has the advantages of portability, real-time appreciation of topographical anatomy, the ability to rapidly evaluate different aspects of the kidney, the ability to avoid puncture of adjacent organs, and has a reduction in radiation exposure 14. However, the widespread use of US is restricted by a limited field of view and difficulty in monitoring the subsequent steps of the procedure. Recently reported articles indicate that the use of color doppler US for guidance during PCNL reveals significantly decreased complications related with percutaneous access such as bleeding and transfusion rates. leeding complication15. Ultrasound-guided access to the kidney is the first choice when retrograde access cannot be obtained or is difficult to obtain, such as in cases with urinary diversions, anatomic abnormalities, transplanted kidneys, or when radiation exposure is a concern, such as in pregnant patients and in children. In some complex cases, CT-guided percutaneous access may be an alternative; this approach is especially useful in cases with anatomic abnormalities or when other techniques are not feasible or have failed 4. While a literature review indicates that several alternative access techniques have been used safely and efficiently, the eye of the needle and triangulation techniques are the two primary procedures used to achieve proper percutaneous renal access under fluoroscopic guidance

2, 4

. In both of these techniques,

multiplanar fluoroscopic imaging is essential and repeated rotation of the C-arm is needed during the procedure 5, 6. Furthermore, it may be difficult to maintain the needle’s orientation, especially in situations of prolonged access time and radiation exposure. In addition, gaining access sometimes requires multiple attempts. It should be emphasized that the ionizing radiation presents a small but very real risk. Mues and colleagues 16 used fluoroscopic projections directed at an angle of 300 to the head of the patient for lower pole entries and at 200 toward the opposite side of the surgeon for middle and upper pole entries. They described a modification that did not require rotation of the C-arm, which diminished radiation exposure. Radiation exposure is a major limitation of the access techniques performed under fluoroscopic guidance. This is especially true in biplanar accesses, where fluoroscopic projections are directed from both the vertical plane and at an angle of 300 to the horizontal plane. When images are taken from an angle of 30 0, the surgeon is directly exposed to high doses of radiation, particularly to the upper part of his/her body. Studies comparing anteroposterior or posteroanterior projections with lateral fluoroscopic projections indicate that the latter exposes the patient and the operating room staff to 3–7 times higher radiation doses than do the other techniques

17, 18

. In our current study, monopolar fluoroscopy was used during the

creation of an access tract, and therefore, fluoroscopic projections at an angle of 30 0 were not needed. When using the monoplanar technique, our average fluoroscopy screening time and puncture times were comparatively shorter than those when we used the biplanar technique; we believe that the fluoroscopic

4

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Journal of Endourology Comparison of monoplanar and biplanar access techniques for percutaneous nephrolithotomy (doi: 10.1089/end.2015.0166) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

5 exposure time in the monoplanar technique is relatively decreased during the puncture procedure. However, even if the surgeon works under fluoroscopy with short puncture times, his/her fingers must be adequately protected from excessive radiation. In a study comparing access obtained by triangulation and eye of the needle procedures in an animal model, the authors observed that both procedures had similar learning curves, but that the triangulation technique had higher fluoroscopy time

19, 20

. Tepeler et al.

8

analyzed and compared these

two access techniques with regards to outcomes and complications in a clinical study and reported that both access techniques had similar hospitalization times, operative times, success and complication rates; the only difference was decrease in hemoglobin with the triangulation technique. The authors hypothesized that this difference may be due to better alignment of the access tract with the infundibulum, which decreases the necessity for exerting excessive force. There are some limitations to the current study, as it was not a prospective study and patients were not selected randomly. In addition, our results suggest that monoplanar access exposes the patient and operating room staff to less radiation exposure, but we did not measure the radiation level. The monoplanar access technique is a newly described method. To our knowledge, the current study is the first to compare the monoplanar and biplanar methods. Monoplanar access is safe to use, decreases puncture time, and minimizes the surgeon’s direct exposure to radiation. Our data supports that monoplanar access is safe and effective for the management of renal stones with PCNL and has similar complication rates as those seen with biplanar access. Conflict of interest: The authors declare that they have no conflict of interest.

References:

1. Turk C KT, Petrik A, et al. . EAU Guidelines on Urolithiasis. 2011. 2. Yang RM, Morgan T, Bellman GC. Radiation protection during percutaneous nephrolithotomy: a new urologic surgery radiation shield. Journal of endourology / Endourological Society. 2002 Dec;16(10):727-31. PubMed PMID: 12542875. Epub 2003/01/25. eng. 3. Hosseini MM, Hassanpour A, Farzan R, Yousefi A, Afrasiabi MA. Ultrasonographyguided percutaneous nephrolithotomy. Journal of endourology / Endourological Society. 2009 Apr;23(4):603-7. PubMed PMID: 19335156. Epub 2009/04/02. eng. 4. Matlaga BR, Shah OD, Zagoria RJ, Dyer RB, Streem SB, Assimos DG. Computerized tomography guided access for percutaneous nephrostolithotomy. The Journal of urology. 2003 Jul;170(1):45-7. PubMed PMID: 12796641. Epub 2003/06/11. eng. 5. Miller NL, Matlaga BR, Lingeman JE. Techniques for fluoroscopic percutaneous renal access. The Journal of urology. 2007 Jul;178(1):15-23. PubMed PMID: 17574053. Epub 2007/06/19. eng. 6. Steinberg PL, Semins MJ, Wason SE, Matlaga BR, Pais VM. Fluoroscopy-guided percutaneous renal access. Journal of endourology / Endourological Society. 2009 Oct;23(10):1627-31. PubMed PMID: 19785549. Epub 2009/09/30. eng. 7. Hatipoglu NK, Bodakci MN, Penbegul N, et al. Monoplanar access technique for percutaneous nephrolithotomy. Urolithiasis. 2013 Jun;41(3):257-63. PubMed PMID: 23564416. Epub 2013/04/09. eng. 5

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Journal of Endourology Comparison of monoplanar and biplanar access techniques for percutaneous nephrolithotomy (doi: 10.1089/end.2015.0166) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

6 8. Tepeler A, Armagan A, Akman T, et al. Impact of percutaneous renal access technique on outcomes of percutaneous nephrolithotomy. Journal of endourology / Endourological Society. 2012 Jul;26(7):828-33. PubMed PMID: 22283962. Epub 2012/01/31. eng. 9. Tefekli A, Ali Karadag M, Tepeler K, et al. Classification of percutaneous nephrolithotomy complications using the modified clavien grading system: looking for a standard. European urology. 2008 Jan;53(1):184-90. PubMed PMID: 17651892. Epub 2007/07/27. eng. 10. Lashley DB, Fuchs EF. Urologist-acquired renal access for percutaneous renal surgery. Urology. 1998 Jun;51(6):927-31. PubMed PMID: 9609628. Epub 1998/06/03. eng. 11. Tomaszewski JJ, Ortiz TD, Gayed BA, Smaldone MC, Jackman SV, Averch TD. Renal access by urologist or radiologist during percutaneous nephrolithotomy. Journal of endourology / Endourological Society. 2010 Nov;24(11):1733-7. PubMed PMID: 20919919. Epub 2010/10/06. eng. 12. Watterson JD, Soon S, Jana K. Access related complications during percutaneous nephrolithotomy: urology versus radiology at a single academic institution. The Journal of urology. 2006 Jul;176(1):142-5. PubMed PMID: 16753389. Epub 2006/06/07. eng. 13. El-Assmy AM, Shokeir AA, Mohsen T, et al. Renal access by urologist or radiologist for percutaneous nephrolithotomy--is it still an issue? The Journal of urology. 2007 Sep;178(3 Pt 1):916-20; discussion 20. PubMed PMID: 17632136. Epub 2007/07/17. eng. 14. Lu MH, Pu XY, Gao X, Zhou XF, Qiu JG, Si-Tu J. A comparative study of clinical value of single B-mode ultrasound guidance and B-mode combined with color doppler ultrasound guidance in mini-invasive percutaneous nephrolithotomy to decrease hemorrhagic complications. Urology. 2010 Oct;76(4):815-20. PubMed PMID: 20579695. Epub 2010/06/29. eng. 15. Tzeng BC, Wang CJ, Huang SW, Chang CH. Doppler ultrasound-guided percutaneous nephrolithotomy: a prospective randomized study. Urology. 2011 Sep;78(3):535-9. PubMed PMID: 21316089. Epub 2011/02/15. eng. 16. Mues E, Gutierrez J, Loske AM. Percutaneous renal access: a simplified approach. Journal of endourology / Endourological Society. 2007 Nov;21(11):1271-5. PubMed PMID: 18042013. Epub 2007/11/29. eng. 17. Theocharopoulos N, Perisinakis K, Damilakis J, Papadokostakis G, Hadjipavlou A, Gourtsoyiannis N. Occupational exposure from common fluoroscopic projections used in orthopaedic surgery. The Journal of bone and joint surgery American volume. 2003 Sep;85a(9):1698-703. PubMed PMID: 12954827. Epub 2003/09/05. eng. 18. Miller ME, Davis ML, MacClean CR, Davis JG, Smith BL, Humphries JR. Radiation exposure and associated risks to operating-room personnel during use of fluoroscopic guidance for selected orthopaedic surgical procedures. The Journal of bone and joint surgery American volume. 1983 Jan;65(1):1-4. PubMed PMID: 6848524. Epub 1983/01/01. eng. 19. Tepeler A, Binbay M, Yuruk E, et al. Factors affecting the fluoroscopic screening time during percutaneous nephrolithotomy. Journal of endourology / Endourological Society. 2009 Nov;23(11):1825-9. PubMed PMID: 19811060. Epub 2009/10/09. eng. 20. Li X, Liao S, Yu Y, Dai Q, Song B, Li L. Stereotactic localisation system: a modified puncture technique for percutaneous nephrolithotomy. Urological research. 2012 Aug;40(4):395-401. PubMed PMID: 22057205. Epub 2011/11/08. eng.

Abbrevations CT= Computerized tomography 6

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Journal of Endourology Comparison of monoplanar and biplanar access techniques for percutaneous nephrolithotomy (doi: 10.1089/end.2015.0166) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

7 FST= Fluoroscopy screening time KUB= Radiological studies included kidney ureter bladder PCNL= Percutaneous nephrolithotomy PN= Percutaneous nephrostomy RIRS= Retrograde intrarenal surgery USG = Abdominal ultrasonography URS= Ureterorenoscopy SWL= Schock wave lithotripsy

Table I: Demographic data and stone characteristics Group I (monoplanar) (n=310) 34.5±17.9

Group II (biplanar) (n=351) 38.2±21.4

p value

162 /148

183/168

0.124

25.2±3.67

28.4±8.2

0.062

History of stone surgery, n (%)

48 (15%)

59 (17%)

0.423

History of SWL, n (%)

33 (10%)

54 (15%)

0.034

Solitary kidney, n (%)

21 (7%)

18 (5%)

0.048

Radiopacity of stone, n (%)

286 (91%)

317 (90%)

0.837

Non-opaque Opaque Semiopaque Degree of hydronephrosis

24 (%7) 244 (78%) 42 (13%)

34 (9%) 291 (83%) 26 (7%)

0.743 0.064 0.026

Nil or mild Moderate or severe Stone laterality Right/left (n) Stone size (mean ±SD) (mm2)

237 (76%) 73 (24%) 148/162

256 (73%) 94 (27%) 166/185

0.246 0.184 0.743

247.37±68.1

268.24±79.6

0.087

Age (mean ±SD) (years) Gender Male/Female (n) Mean BMI (kg/m2)

0.562

7

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Journal of Endourology Comparison of monoplanar and biplanar access techniques for percutaneous nephrolithotomy (doi: 10.1089/end.2015.0166) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

8 Stone location, n (%) Renal pelvis Lower calix Middle calix Upper calix Multicaliceal

113 (36%) 35 (11%) 12 (3%) 24 (7%) 128 (41%)

119(34%) 57(16%) 24(7%) 18(5%) 133(38%)

0.453 0.031 0.023 0.056 0.068

SD: standard deviation

Table II: Perioperative and postoperative data

Group I (monoplanar) (n=310)

Group II

p value

(biplanar) (n=351)

Operation time (min)

76.9±38.8

82.7±46.3

0.063

Puncture time (min)

1.09±0.27

2.03±0.46

0.042

5.7±1.6

0.037

4.08±2.53

4.11±2.13

0.084

Lower

270 (87%)

312(89%)

0.74

Middle

21 (7%)

18(5%)

0.66

Upper

18 (6 %)

18(5%)

0.51

Stone free

244 (79%)

287(82%)

0.541

CIRF

28 (9%)

24(7%)

0.187

Rest

38 (12%)

40(11%)

0.859

Nephrostomy removal time (mean ±SD) (day)

2.1±1.4

2.2±1.4

0.971

Hospitalization time (mean ±SD) (day)

3.4±1.3

3.2±1.3

0.940

Fluoroscopy screening time (min) Hematocrit drop (%)

4.4±1.7

Entrance calix, n (%)

Stone-free status (%)

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Journal of Endourology Comparison of monoplanar and biplanar access techniques for percutaneous nephrolithotomy (doi: 10.1089/end.2015.0166) This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

9 Auxiliary procedure, n (%)

37 (12 %)

56 (14%)

0.164

SWL

12(4%)

12(3%)

0.110

URS

8 (2%)

16(4%)

0.09

Re-PNL

28 (9%)

28(7%)

0.212

Table III: Complications of PNL classified according to the modified Clavien system Group I (monoplanar) (n=)

Group II (biplanar)

p value

(n=)

Complications (n) Grade I Fever

34 (11%)

31 (9%)

0.312

Blood transfusion

27 (9 %)

24 (7%)

0.214

Urine leakage

27 (7 %)

32 (9 %)

0.226

Urinary tract infection

13 (4 %)

14 (4%)

0.847

Double-J placement for urine leakage

9 (2%)

11(3%)

0.410

Grade IV

-

-

-

-

-

-

Grade II

Grade III

Urosepsis Neighboring organ injury (colon)

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Comparison of Monoplanar and Biplanar Access Techniques for Percutaneous Nephrolithotomy.

The aim of this study was to compare the positive aspects and complications of monoplanar and biplanar access techniques used in percutaneous nephroli...
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