IMPACT OF BRANCH NUMBER ON PNL FOR STAGHORN CALCULI 7. Hegarty NJ, Desai MM. Percutaneous nephrolithotomy requiring multiple tracts: Comparison of morbidity with single tract procedures. J Endourol 2006;20:753–760. 8. Xu GB, Li X, He ZH, et al. Factors affecting blood loss during minimally invasive percutaneous nephrolithotomy. Chin J Urol 2007;28:456–459. 9. Mishra S, Sabnis RB, Desai M. Staghorn morphometry: A new tool for clinical classification and prediction model for percutaneous nephrolithotomy monotherapy. J Endourol 2012;26:6–14. 10. Ghani KR, Patel U, Anson K. Computed tomography for percutaneous renal access. J Endourol 2009;23:1633–1639. 11. Xu G, Li X, He Y, et al. Staged single-tract minimally invasive percutaneous nephrolithotomy and flexible ureteroscopy in the treatment of staghorn stone in patients with solitary kidney. Urol Res 2012;40:745–749. 12. Barnaba D, Grossi FS, Raguso M, et al. Percutaneous treatment of staghorn stone a retrospective case-control study with evaluation of single vs multiple access to the kidney. Arch Ital Urol Androl 2009;81:40–42. 13. Al-Kohlany KM, Shokeir AA, Mosbah A, et al. Treatment of complete staghorn stones: A prospective randomized comparison of open surgery versus percutaneous nephrolithotomy. J Urol 2005;173:469–473. 14. Soucy F, Ko R, Duvdechai M, et al. Percutaneous nephrolithotomy for staghorn calculi: A single center experience of 15 years. J Endourol 2009;10:1–5. 15. Preminger GM, Assimos DG, Lingeman JE, et al. (AUA Nephrolithiasis Guideline Panel Chapter 1). AUA guideline on management of staghorn calculi: Diagnosis and treatment recommendations. J Urol 2005;173:1991–2000. 16. Desai M, De Lisa A, Turna B, et al. The clinical research office of the endourological society percutaneous nephrolithotomy global study: Staghorn versus nonstaghorn stones. J Endourol 2011;25:1263–1268. 17. Desai M, Jain P, Ganpule A, et al. Developments in technique and technology: The effect on the results of percutaneous nephrolithotomy for staghorn calculi. BJU Int 2009; 104:542–548. 18. El-Nahas AR, Shokeir AA, El-Assmy AM, et al. Post-percutaneous nephrolithotomy extensive hemorrhage: A study of risk factors. J Urol 2007;177:576–579.
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19. Ganpule AP, Mishra S, Desai MR. Multiperc versus single perc with flexible instrumentation for staghorn calculi. J Endourol 2009;23:1675–1678. 20. Shen P, Liu Y, Wang J. Nephrostomy tube-free versus nephrostomy tube for renal drainage after percutaneous nephrolithotomy: A systematic review and meta-analysis. Urol Int 2012;88:298–306. 21. Yuan H, Zheng S, Liu L, et al. The efficacy and safety of tubeless percutaneous nephrolithotomy: A systematic review and meta-analysis. Urol Res 2011;39:401–410. 22. Wang CJ, Chang CH, Huang SW. Simultaneous bilateral tubeless percutaneous nephrolithotomy of staghorn stones: A prospective randomized controlled study. Urol Res 2011;39:289–294. 23. Clark DL, Connors BA, Handa RK, et al. Pretreatment with low-energy shock waves reduces the renal oxidative stress and inflammation caused by high-energy shock wave lithotripsy. Urol Res 2011;39:437–442.
Address correspondence to: Yong Xu, MD Department of Urology Second Hospital of Tianjin Medical University Tianjin Institute of Urology 23 Pingjiang Road, Hexi District Tianjin 300211 China E-mail: [email protected]
Abbreviations Used 3DR ¼ three-dimensional reconstruction CIRF ¼ clinically insignificant residual fragment CT ¼ computed tomography IVU ¼ intravenous urogram KUB ¼ kidney-ureter-bladder PCS ¼ pelvicalyceal collecting system PNL ¼ percutaneous nephrolithotomy SWL ¼ extracorporeal shock wave lithotripsy
DOI: 10.1089/end.2013.0687
Editorial Comment for Shiyong et al. James E. Lingeman, MD, FACS
T
he authors report yet another system for classifying staghorn calculi and the resulting outcomes after percutaneous stone removal. Using three-dimensional (3-D) computed tomography (CT) reconstruction, they report a strong correlation between increasing number of branches of the
Methodist Hospital, Indianapolis, Indiana.
staghorn stone and worsening outcomes. Their findings are similar to multiple other authors who correlate by various methods increasing complexity of staghorn stones with longer operative times, a greater need for multiple access, lower stone-free outcomes, etc. The main issue here is whether we
158 should be using 3-D reconstruction before percutaneous stone removal to help plan the operation and to counsel patients about what they might expect with their percutaneous procedure. I certainly concur that all patients undergoing a percutaneous procedure should have a preoperative CT for planning purposes. With current picture archiving and communication system machines, however, it is a simple matter using axial, coronal, and sagittal images to glean the necessary information for planning the percutaneous procedure and, therefore, I see little value in the time and expense associated with 3-D reconstruction. The stone-free outcomes in this large series are, in my view, less than ideal and deserve a few comments emphasizing the principles of percutaneous renal surgery for staghorn stones. The stone-free outcomes reported are particularly disappointing, because the authors used multiple access in about two-thirds of their procedures, a much higher incidence of multiple access than reported by most authors. In our experience, multiple access is used in about 20% of cases. Shiyong and colleagues typically used an interpolar calix for initial access in most cases. In our institution, about twothirds of our cases are performed initially with lower pole access. One wonders if this has any impact on the outcomes reported in this series. The authors are not in the custom of using an Amplatz sheath, which, in my view, is critical to maximizing stone clearance. The authors report that they did use the flexible nephroscope during the percutaneous procedure, and I would have expected better stone clearance with such an approach. A possible explanation for lack of effective use of the flexible nephroscope might be the use of a smaller metal nephroscope sheath as their primary access sheath. It is also important during flexible nephroscopy that
LINGEMAN the irrigant be pressurized and that there be an adequate sized sheath present to allow free egress of the irrigation fluid. One of the most important advantages of percutaneous stone removal is the lack of need for ureteral stent placement. In this series, however, a Double-J stent was placed antegradely in all patients. I realize that there may be some cultural issues or customs that impact the reasons for the approach chosen by Shiyong and associates. Other than in unusual circumstances, however, I would strongly advise against the routine practice of ureteral stent placement during percutaneous stone removal because patients hate stents. A final comment addresses the issue of the use of extracorporeal shockwave lithotripsy (SWL) in conjunction with staghorn stone management. In the current era of endourology, it is my view that there is nothing that cannot be accomplished percutaneously with flexible nephroscopes, the holmium laser, and additional access more efficiently than with the use of SWL. In our institution, the use of SWL in conjunction with staghorn treatment was abandoned 20 years ago, and it is our custom to perform a secondary look-in, if necessary, through the established access 2 or 3 days after the initial percutaneous procedure. Patient acceptance is very high with this strategy, because it provides the most definitive outcome in the shortest time. Address correspondence to: James E. Lingeman, MD, FACS Methodist Hospital 1801 North Senate Blvd., Suite 220 Indianapolis, IN 46202 E-mail: [email protected]
157
19. Ganpule AP, Mishra S, Desai MR. Multiperc versus single perc with flexible instrumentation for staghorn calculi. J Endourol 2009;23:1675–1678. 20. Shen P, Liu Y, Wang J. Nephrostomy tube-free versus nephrostomy tube for renal drainage after percutaneous nephrolithotomy: A systematic review and meta-analysis. Urol Int 2012;88:298–306. 21. Yuan H, Zheng S, Liu L, et al. The efficacy and safety of tubeless percutaneous nephrolithotomy: A systematic review and meta-analysis. Urol Res 2011;39:401–410. 22. Wang CJ, Chang CH, Huang SW. Simultaneous bilateral tubeless percutaneous nephrolithotomy of staghorn stones: A prospective randomized controlled study. Urol Res 2011;39:289–294. 23. Clark DL, Connors BA, Handa RK, et al. Pretreatment with low-energy shock waves reduces the renal oxidative stress and inflammation caused by high-energy shock wave lithotripsy. Urol Res 2011;39:437–442.
Address correspondence to: Yong Xu, MD Department of Urology Second Hospital of Tianjin Medical University Tianjin Institute of Urology 23 Pingjiang Road, Hexi District Tianjin 300211 China E-mail: [email protected]
Abbreviations Used 3DR ¼ three-dimensional reconstruction CIRF ¼ clinically insignificant residual fragment CT ¼ computed tomography IVU ¼ intravenous urogram KUB ¼ kidney-ureter-bladder PCS ¼ pelvicalyceal collecting system PNL ¼ percutaneous nephrolithotomy SWL ¼ extracorporeal shock wave lithotripsy
DOI: 10.1089/end.2013.0687
Editorial Comment for Shiyong et al. James E. Lingeman, MD, FACS
T
he authors report yet another system for classifying staghorn calculi and the resulting outcomes after percutaneous stone removal. Using three-dimensional (3-D) computed tomography (CT) reconstruction, they report a strong correlation between increasing number of branches of the
Methodist Hospital, Indianapolis, Indiana.
staghorn stone and worsening outcomes. Their findings are similar to multiple other authors who correlate by various methods increasing complexity of staghorn stones with longer operative times, a greater need for multiple access, lower stone-free outcomes, etc. The main issue here is whether we
158 should be using 3-D reconstruction before percutaneous stone removal to help plan the operation and to counsel patients about what they might expect with their percutaneous procedure. I certainly concur that all patients undergoing a percutaneous procedure should have a preoperative CT for planning purposes. With current picture archiving and communication system machines, however, it is a simple matter using axial, coronal, and sagittal images to glean the necessary information for planning the percutaneous procedure and, therefore, I see little value in the time and expense associated with 3-D reconstruction. The stone-free outcomes in this large series are, in my view, less than ideal and deserve a few comments emphasizing the principles of percutaneous renal surgery for staghorn stones. The stone-free outcomes reported are particularly disappointing, because the authors used multiple access in about two-thirds of their procedures, a much higher incidence of multiple access than reported by most authors. In our experience, multiple access is used in about 20% of cases. Shiyong and colleagues typically used an interpolar calix for initial access in most cases. In our institution, about twothirds of our cases are performed initially with lower pole access. One wonders if this has any impact on the outcomes reported in this series. The authors are not in the custom of using an Amplatz sheath, which, in my view, is critical to maximizing stone clearance. The authors report that they did use the flexible nephroscope during the percutaneous procedure, and I would have expected better stone clearance with such an approach. A possible explanation for lack of effective use of the flexible nephroscope might be the use of a smaller metal nephroscope sheath as their primary access sheath. It is also important during flexible nephroscopy that
LINGEMAN the irrigant be pressurized and that there be an adequate sized sheath present to allow free egress of the irrigation fluid. One of the most important advantages of percutaneous stone removal is the lack of need for ureteral stent placement. In this series, however, a Double-J stent was placed antegradely in all patients. I realize that there may be some cultural issues or customs that impact the reasons for the approach chosen by Shiyong and associates. Other than in unusual circumstances, however, I would strongly advise against the routine practice of ureteral stent placement during percutaneous stone removal because patients hate stents. A final comment addresses the issue of the use of extracorporeal shockwave lithotripsy (SWL) in conjunction with staghorn stone management. In the current era of endourology, it is my view that there is nothing that cannot be accomplished percutaneously with flexible nephroscopes, the holmium laser, and additional access more efficiently than with the use of SWL. In our institution, the use of SWL in conjunction with staghorn treatment was abandoned 20 years ago, and it is our custom to perform a secondary look-in, if necessary, through the established access 2 or 3 days after the initial percutaneous procedure. Patient acceptance is very high with this strategy, because it provides the most definitive outcome in the shortest time. Address correspondence to: James E. Lingeman, MD, FACS Methodist Hospital 1801 North Senate Blvd., Suite 220 Indianapolis, IN 46202 E-mail: [email protected]
