British Journal of Urology ( 1992). 69,470475 01992 British Journal of Urology
Percutaneous Nephrolithotripsy for Renal Stones in over 1000 Patients M. R. EL-KENAWY, H. A. EL-KAPPANY, T. A. EL-DIASTY and M. A. GHONEIM Urology and Nephrology Centre, Mansoura, Egypt
Summary-Over a period of 5 consecutive years, 1039 renal units were treated by percutaneous nephrolithotripsy for stone disease of the kidney. The success rate was 93.7%. Residual stones remained in 4.2% of patients and in 2.1% we failed to remove the stones. The complication rate was 17.8%. Complications were treated conservatively in most cases but nephrectomy was required on one occasion to control severe bleeding. The average hospital stay was 6.9 days. Follow-up of 339 renal units (333 patients), for a minimum of 60 months, revealed minor late sequelae such as pelviureteric junction obstruction in 1 patient (0.3%) and post-catheterisation strictures of the anterior urethra in 4 (1.2%).Stone recurrence was observed in 9.1%of patients. Percutaneous nephrolithotripsy is an effective, safe treatment for renal stones with minimal late sequelae and is still required even in the era of extracorporeal shock wave lithotripsy.
The management of upper urinary tract calculi has undergone a dramatic change following the introduction of percutaneous nephrolithotomy (PCNL) and extracorporeal shock wave lithotripsy (ESWL). Goodwin et al. (1955) described the percutaneous establishment of a nephrostomy tract with a trocar into a hydronephrotic kidney. The first percutaneous tract created specifically for the removal of a stone was reported by Fernstrom and Johansson (1976). By the early 1980s the development of instruments designed to operate through such tracts permitted percutaneous techniques to evolve to a point where, at least theoretically, any stone could be removed from the urinary tract with an acceptable degree of morbidity (Alken er al., 1981;Segura et al., 1983). Today, despite the pervasiveness of shock wave lithotripsy, percutaneous stone removal remains the procedure of choice in many clinical situations and a viable alternative in others. We present our experience with percutaneous nephrolithotorny in more than 1000 patients, with special emphasis on long-term results and complications.
Patients and Methods
Over 5 consecutiveyears (1984-1 989), 4000 patients with renal stones were treated at this centre; 1024 of these patients (25.6%) were treated by percutaneous nephrolithotripsy; 742 were male and 282 were female. Their ages ranged between 9 and 76 years (mean 42.0 f 11 ). The stones were on the right side in 464 patients, on the left in 545 and bilateral in 15; 1039 renal units were thus treated. The site of the stones is indicated in Table 1. The stones were single in 767 cases (73.973, multiple in 272 (26.1%) and recurrent in 333 (32%). Most of the stones were radio-opaque, and were radiolucent in only 27 patients (3.8%). Fifty-three patients had a solitary kidney. Abnormal renal morphology (seen in 30 patients) Table 1 Distribution of Renal Stones
Accepted for publication 8 April 1991
470
Site
No. (%)
Pelvis Caliceal Pelvicaliceal Branching
790 (76.0) 65 (6.3) 178 (17.1) 6 (0.6)
47 1
PERCUTANEOUS NEPHROLITHOTRIPSY FOR RENAL STONES IN OVER I 0 0 0 PATIENTS
included horseshoe kidney in 10, malrotation in 15 ultrasound disintegration and mechanical extracand a duplex system in 5 . tion was employed for larger stones. The entire Puncture was carried out in the radiology suite procedure was carried out under fluoroscopic under local anaesthesia. The kidney was opacified control. by intravenous urography or by retrograde pyelogFollowing removal of the stones a 22F nephrosraphy. Precise anatomical puncture through the tomy tube was inserted through the sheath of the proper calix was controlled by biplane fluoroscopy. endoscope to the renal pelvis. A control X-ray and This was of particular importance in patients with an antegrade study were performed to ensure abnormal renal morphology (Fig. 1). A flexible J complete removal of the fragments and to exclude guide wire was then threaded down the sheath of any extravasation. This tube was removed when the needle and either guided down the ureter or the drainage became clear, usually within 2 to 3 coiled in the upper calix. In recurrent cases a stiff days. guide wire (Lunderquist-exchange guide wire) was In all, 333 patients were followed up for a preferable to avoid bending during dilatation. minimum period of 60 months. A thorough physical Malleable fascia1dilators were subsequently passed examination, measurement of blood pressure, urine over the wire, dilating the tract to 10-12F. This analysis, urine culture, intravenous urography and was followed by fixation of an 8-10F pigtail renal ultrasonography were carried out. Digital catheter. In the majority of cases, definitive dilata- vascular imaging was indicated whenever there tion of the tract and nephroscopy were carried out was clinical evidence of hypertension of recent within 24 to 48 h. In 362 cases (35%) the whole onset. procedure was completed on the same day. Definitive dilatation of the tract and lithotripsy Results were carried out in the endoscopy suite under general or spinal anaesthesia. The technique was a Complete removal of the stones was achieved in standard one as described by Alken (1982) and 973 of 1039 renal units, a success rate of 93.7%. Marberger (1983). The tract was dilated to 3 2 F Complete clearance was possible in one session in with fixation of an Amplatz sheath. Glycine was the majority of cases (79.8%) but some patients used for irrigation at a head pressure of 60 cm HzO. required 2 or 3 sessions to remove residual stones The patients were infused with 12g mannitol to or gravel following ultrasound disintegration. Radiological evidence of residual stones was seen protect the kidney from pyelotubular backflow. Small stones were removed by forceps. Combined in 44 patients (4.2%). In a further 22 cases it was not possible to remove the stones because of failure to establish good access ( 5 patients) or inability to visualise the stone during endoscopy (17). Complications included those inflicted during puncture, during definitive endoscopy or during the post-operative period. Creation of the percutaneous tract was associated with 42 complications (Table 2). All were conservatively managed and did not interfere with further nephroscopic manipulation. Fracture of the guide wire was seen in 5 cases (Fig. 2). This was encountered during difficult dilatation of recurrent Table 2 Complications Following Puncture
Fig. 1 Placement of percutaneous tract in horseshoe kidney.
Complications
No.
Pelvic tear Bleeding Septicaemia Fractured guide wire
20 12 5 5
Total
42 (4%)
472
BRITISH JOURNAL OF UROLOGY
Fig. 2 Plain X-ray showing fractured guide wire duringcreation of a percutaneous tract.
fibrous tracts and the guide wires were later mechanically extracted during nephroscopy. Of the complications encountered during nephroscopy, the most frequent was pelvic tear (31 patients) and this was treated by nephrostomy drainage. Sixteen patients required a transfusion because of per-operative bleeding. A supracostal approach to remove a stone in a high-lying kidney resulted in hydrothorax in 1 patient. This was treated conservatively by nephrostomy and chest drainage. Colonic perforation was encountered in 4 patients (Fig. 3), all of whom underwent successful conservative treatment consisting of drainage of the pelvis by a wide ureteric catheter, nasogastric suction, administration of a broad spectrum antibiotic as well as anal dilatation (Lord's manoeuvre) to avoid build-up of pressure in the large intestine. The ultrasound probe was fractured in 1 case and the forceps in another. Post-operative bleeding from the nephrostomy tube, or haematuria after its removal, was observed in 34 patients. Five required blood transfusion and were conservatively treated. Three required radiological intervention with embolisation. This procedure was successful in 2 cases (Fig. 4), but nephrectomy was necessary in the third. Postoperative pyrexia was recorded in 55 patients and they were treated with the appropriate antibiotic. No mortality was reported in association with
Fig. 3 Renocolonic fistula inflicted during percutaneous nephrolithotripsy.
the procedure. The average hospital stay was 6.9 days. Of the 333 patients with a minimal follow-up of 5 years, stone recurrence was documented in 31 (9.1%). Of these, 70% had a past history of recurrent renal stones on the same side. Sixteen patients (4.8%) were discharged with small fragments after initial therapy. These were judged to be surgically insignificant. Spontaneous passage of these fragments was documented in 7 cases and 6 remained unchanged. In 3 cases the residual stones increased in size and were later treated by ESWL. Four patients developed post-catheterisation' stricture of the anterior urethra; this was managed
PERCUTANEOUS NEPHROLITHOTRIPSY FOR RENAL STONES IN OVER 1000 PATIENTS
473
have non-infected urine at follow-up. Evidence of urinary tract infection was found in 32 patients (9.6%), always in association with underlying pathology : residual or recurrent stone, urethral stricture or pelviureteric junction obstruction. One patient who was previously normotensive became hypertensive. There was a family history of hypertension. Digital vascular imaging and renography failed to reveal any vascular abnormality.
Discussion
Fig. 4 (A). Selective renal arteriography showingextravasation of dye from an injured lower polar artery. (B). Selective embolisation of the injured artery. (C). Selective renal arteriography after embolisation showing no blood flow through the injured artery.
by visual internal urethrotomy. Obstruction of the pelviureteric junction was reported in 1 patient with a solitary kidney and this was corrected by an endopyelotomy. All patients whose urine was sterile pre-operatively, and who were free of stones, continued to
A properly located percutaneous nephrostomy is a prerequisite for successful stone removal. Multiple tracts may be required to remove mobile, multiple caliceal or staghorn stones (Hulbert and Lange, 1985). In our experience, this can be achieved with a high degree of precision by good opacification of the pelvicaliceal system and the use of biplane radiography. This is of particular importance in cases of abnormal renal morphology such as malrotation, a horseshoe kidney or a duplex collecting system. Alken el al. (1981) suggested ultrasound-guided puncture. This may prove difficult in non-dilated systems and there remains the need for subsequent X-ray for placement of the guide wire and control of the dilatation. Staging the procedure would prolong the hospital stay by 24 to 48 h, although subsequent dilatation and visualisation would then be easier. It would also allow readjustment of the tract (if required) before embarking on the definitive procedure. Wickham et al. (1984) reported that a one-stage
474 procedure would necessitate a second session in 20% of patients because of failed puncture, perforation or poor visualisation. Nevertheless, a onestage procedure could be adopted when sufficient experience in the technique has been gained and it is mandatory when only an unstable tract can be established, as in cases of peripheral caliceal stones where it is often difficult to thread the guide wire into the major collecting system. Failure of access, resulting in failure to remove the stones, was reported in 1.7% of patients by Segura et al. (1985), in 8% by Whitfield and Mills (1985) and in 6.4% by Jones et al. (1990). In our series the failure rate was 2.1%. Post-operative complication rates ranged between 3.2%(Segura et al., 1985) and 13.2%(Jones et al., 1990). This wide variation probably reflects different methods of reporting. In the present series the rate was 8.6%.The most common complication following the procedure was bleeding. In most cases it is minor and does not require transfusion. Blood transfusion was necessary in 21 of our patients (279, a figure which compares favourably with the 3% reported by Segura et al. (1985) and 5.8% by Jones et al. (1990). Angiographic embolisation for an arteriovenous fistula was necessary in 3 patients (0.3%).Segura et al. (1985) and Jones et al. (1990) reported that this was necessary in 0.6 and 0.4%of their patients respectively. In this series, the incidence of residual fragments was 4.2%.Comparable results have been reported by White and Smith (1984) (2.5%),Brannen et al. (1985) (2.8%)and Segura etal. (1985) (8.1%). The number of staghorn stones treated by percutaneous surgery in this series was limited. We prefer open surgery (extended pyelolithotomy with or without radial nephrotomy) for the management of these patients. This is because complete stone removal is almost guaranteed with open surgery, particularly when “on table” X-rays are taken. When staghorn stones were treated by percutaneous surgery alone the reported incidence of residual fragments ranged between 16%(Segura etal., 1985) and 23% (Eisenberger et al., 1987). When percutaneous nephrolithotripsy was combined with ESWL, the incidence of residual stones was reported as 21.5% by Schulze et al. (1986), 40% by Eisenberger et al. (1987) and 77%by Segura et al. (1987). These procedures tend to prolong the hospital stay and are associated with higher costs than open surgery (Di Silverio et al., 1990). The incidence of stone recurrence following this procedure among patients who were followed up for 5 years was 9.1%. This is similar to the 10%
BRITISH JOURNAL OF UROLOGY
reported by Segura (1 989). Iatrogenic pelviureteric junction obstruction following percutaneous nephrolithotripsy was observed by Hidalgo et al. (unpublished observations), who reported an incidence of 0.9%. We noted this complication in 1 patient (0.3%).A possible cause is injury during the course of stone manipulation. Endopyelotomy provides a logical and uncomplicated method of managing this complication. We encountered no case of hypertension which could be attributed to the procedure. Marberger et al. (1985) made a similar observation. Despite the installation of an ESWL machine in this centre, we still perform open surgery and percutaneous nephrolithotripsy in approximately one-third of patients with stones. This is significantly higher than the proportion reported in Europe and America (Chaussy and Fuchs, 1989), who claimed that open sugery was required in less than 5% of their patients. This was due to the larger bulk of stones and/or associated pathology requiring surgery. There is no doubt that the frequency of percutaneous surgery for stone disease will diminish with the adoption of ESWL. Nevertheless, the procedure will still be indicated in some instances : large stones > 3 cm, stones in a calix or caliceal diverticulum, stones with pelviureteric obstruction and branching stones. In other words, endoscopic manipulation will be required for the more difficult stones, as reported by Jones et al. (1990), who observed that the post-operative complication rate for percutaneous stone surgery increased from 13.6 to 24% after the introduction of ESWL. Thus the treatment of renal stone disease by percutaneous surgery is a technique which should not to be forgotten but has to be perfected. Furthermore, in developing countries it will be some time before treatment with ESWL becomes widely available, and percutaneous nephrolithotripsy will remain the method of choice for a significant proportion of renal stones.
References Alken, P. (1982). Percutaneous ultrasonic destruction of renal calculi. Urol. Clin. North Am.,9, 145-151. Alken, P., Hutschenreiter, G., Gunther, R. er crl. (1981) Percutaneous stone manipulation. J . Urol., 125,463466. Brannen, G. E., Bush, W. H. Correa, R. J. et aL (1985). Kidney stone removal : percutaneous versus surgical lithotomy. J . Urol., 133,6-12. Chrussy, C. G . and Fuchs, G . J. (1989). Current state and future developments of non-invasive treatment of human urinary stones with extracorporeal shock wave lithotripsy. J . Urol., 141,782-789.
PERCUTANEOUS NEPHROLITHOTRIPSY FOR RENAL STONES IN OVER I000 PATIENTS Di Silverio, F., Gallucci, M. and Alpi, G. (1990). Staghorn calculi of the kidney: classification and therapy. Br. J. Urol.,65,449452. Eisenberger,F.,Rauweiler, J.,Bub,P.etaL (1987). Differentiated approach to staghorn calculi using extra-corporeal shock wave lithotripsy and percutaneous nephrolithotomy : an analysis of 15 I consecutive cases. WorldJ. Urol., 5,248-254. Fernstrom, 1. and Johansson, B. (1976). Percutaneous pyelolithotomy: a new extraction technique. Scand. J. Urol. Nephrol., 10,257-259. Goodwin, W. E., Casey, W. C. and Woolf, W. (1955). Percutaneous trocar (needle) nephrostomy in hydronephrosis. J . A . M . A . ,157.891-894. Hulbert, J. C. and Lange, P. H. (1985). The percutaneous removal of difficult upper urinary tract calculi. WorldJ. Urol., 3, 19-23. Jones, D. J., Russell, G. L., KeUett, M. J. et al. (1990). The changing practice of percutaneous stone surgery. Review of l000cases 1981-1988.Br.J. Urol.,66, 1-5. Marberger, M. (1983). Disintegration of renal and ureteral calculi with ultrasound. Urol. Clin. Norrh Am., 10, 729-742. Marberger, M.,Stackl, W., Hruby, W. eral. (1985). Late sequelae of ultransonic lithotripsy of renal calculi. J. Urol., 133, 170173. Schulze, H., Hertle, L., Graff, J. et al. (1986). Combined treatment of branched calculi by percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. J. Vrol.,135, 1138-1 141. S e p r a , J. W. (1989). The role of percutaneous surgery in renal and ureteral stone removal. J. Urol., 141,780-781.
475
Segura, J. W., Patterson, D. E., LeRoy, A. J. et UL (1983). Percutaneous lithotripsy. J. Urol., 130, 1051-1054. Segura, J. W., Patterson, D. E., LeRoy, A. J. er UL (1985). Percutaneous removal of kidney stones: review of 100 cases. J . Urol., 134, 1077-1081. Segura, J. W., Patterson, D. E., LeRoy, A. J. (1987). Combined percutaneous ultrasonic lithotripsy and extracorporeal shock wave lithotripsy for struvite staghorn calculi. World J . Urol,, 5,245-247. White, E. C. and Smith, A. D. (1984). Percutaneous stone extraction from 200 patients. J. Urol., 132,437-438. Whiffield, H.N. and Mills, V. A. (1985). Percutaneous nephrolithotomy : a report of I50 cases. Br. J. Urol., 57,603-604. Wickham, J. E. A., Miller, R. A., Kellett, J. E. er al. (1984). Percutaneous nephrolithotomy: one stage or two. Br. J . Urol., 56,582-585.
The Authors M. R. El-Kenawy, MD, Lecturer, Department of Urology. H. A. El-Kappany, MD, Assistant Professor, Department of Urology. T. A. El-Diasty, MD, Consultant Radiologist. M. A. Ghoneim, MD(Hon), Professor, Department of Urology. Requests for reprints to: M. A. Ghoneim, Urology and Nephrology Centre, Mansoura, Egypt.
Percutaneous Nephrolithotripsy for Renal Stones in over 1000 Patients M. R. EL-KENAWY, H. A. EL-KAPPANY, T. A. EL-DIASTY and M. A. GHONEIM Urology and Nephrology Centre, Mansoura, Egypt
Summary-Over a period of 5 consecutive years, 1039 renal units were treated by percutaneous nephrolithotripsy for stone disease of the kidney. The success rate was 93.7%. Residual stones remained in 4.2% of patients and in 2.1% we failed to remove the stones. The complication rate was 17.8%. Complications were treated conservatively in most cases but nephrectomy was required on one occasion to control severe bleeding. The average hospital stay was 6.9 days. Follow-up of 339 renal units (333 patients), for a minimum of 60 months, revealed minor late sequelae such as pelviureteric junction obstruction in 1 patient (0.3%) and post-catheterisation strictures of the anterior urethra in 4 (1.2%).Stone recurrence was observed in 9.1%of patients. Percutaneous nephrolithotripsy is an effective, safe treatment for renal stones with minimal late sequelae and is still required even in the era of extracorporeal shock wave lithotripsy.
The management of upper urinary tract calculi has undergone a dramatic change following the introduction of percutaneous nephrolithotomy (PCNL) and extracorporeal shock wave lithotripsy (ESWL). Goodwin et al. (1955) described the percutaneous establishment of a nephrostomy tract with a trocar into a hydronephrotic kidney. The first percutaneous tract created specifically for the removal of a stone was reported by Fernstrom and Johansson (1976). By the early 1980s the development of instruments designed to operate through such tracts permitted percutaneous techniques to evolve to a point where, at least theoretically, any stone could be removed from the urinary tract with an acceptable degree of morbidity (Alken er al., 1981;Segura et al., 1983). Today, despite the pervasiveness of shock wave lithotripsy, percutaneous stone removal remains the procedure of choice in many clinical situations and a viable alternative in others. We present our experience with percutaneous nephrolithotorny in more than 1000 patients, with special emphasis on long-term results and complications.
Patients and Methods
Over 5 consecutiveyears (1984-1 989), 4000 patients with renal stones were treated at this centre; 1024 of these patients (25.6%) were treated by percutaneous nephrolithotripsy; 742 were male and 282 were female. Their ages ranged between 9 and 76 years (mean 42.0 f 11 ). The stones were on the right side in 464 patients, on the left in 545 and bilateral in 15; 1039 renal units were thus treated. The site of the stones is indicated in Table 1. The stones were single in 767 cases (73.973, multiple in 272 (26.1%) and recurrent in 333 (32%). Most of the stones were radio-opaque, and were radiolucent in only 27 patients (3.8%). Fifty-three patients had a solitary kidney. Abnormal renal morphology (seen in 30 patients) Table 1 Distribution of Renal Stones
Accepted for publication 8 April 1991
470
Site
No. (%)
Pelvis Caliceal Pelvicaliceal Branching
790 (76.0) 65 (6.3) 178 (17.1) 6 (0.6)
47 1
PERCUTANEOUS NEPHROLITHOTRIPSY FOR RENAL STONES IN OVER I 0 0 0 PATIENTS
included horseshoe kidney in 10, malrotation in 15 ultrasound disintegration and mechanical extracand a duplex system in 5 . tion was employed for larger stones. The entire Puncture was carried out in the radiology suite procedure was carried out under fluoroscopic under local anaesthesia. The kidney was opacified control. by intravenous urography or by retrograde pyelogFollowing removal of the stones a 22F nephrosraphy. Precise anatomical puncture through the tomy tube was inserted through the sheath of the proper calix was controlled by biplane fluoroscopy. endoscope to the renal pelvis. A control X-ray and This was of particular importance in patients with an antegrade study were performed to ensure abnormal renal morphology (Fig. 1). A flexible J complete removal of the fragments and to exclude guide wire was then threaded down the sheath of any extravasation. This tube was removed when the needle and either guided down the ureter or the drainage became clear, usually within 2 to 3 coiled in the upper calix. In recurrent cases a stiff days. guide wire (Lunderquist-exchange guide wire) was In all, 333 patients were followed up for a preferable to avoid bending during dilatation. minimum period of 60 months. A thorough physical Malleable fascia1dilators were subsequently passed examination, measurement of blood pressure, urine over the wire, dilating the tract to 10-12F. This analysis, urine culture, intravenous urography and was followed by fixation of an 8-10F pigtail renal ultrasonography were carried out. Digital catheter. In the majority of cases, definitive dilata- vascular imaging was indicated whenever there tion of the tract and nephroscopy were carried out was clinical evidence of hypertension of recent within 24 to 48 h. In 362 cases (35%) the whole onset. procedure was completed on the same day. Definitive dilatation of the tract and lithotripsy Results were carried out in the endoscopy suite under general or spinal anaesthesia. The technique was a Complete removal of the stones was achieved in standard one as described by Alken (1982) and 973 of 1039 renal units, a success rate of 93.7%. Marberger (1983). The tract was dilated to 3 2 F Complete clearance was possible in one session in with fixation of an Amplatz sheath. Glycine was the majority of cases (79.8%) but some patients used for irrigation at a head pressure of 60 cm HzO. required 2 or 3 sessions to remove residual stones The patients were infused with 12g mannitol to or gravel following ultrasound disintegration. Radiological evidence of residual stones was seen protect the kidney from pyelotubular backflow. Small stones were removed by forceps. Combined in 44 patients (4.2%). In a further 22 cases it was not possible to remove the stones because of failure to establish good access ( 5 patients) or inability to visualise the stone during endoscopy (17). Complications included those inflicted during puncture, during definitive endoscopy or during the post-operative period. Creation of the percutaneous tract was associated with 42 complications (Table 2). All were conservatively managed and did not interfere with further nephroscopic manipulation. Fracture of the guide wire was seen in 5 cases (Fig. 2). This was encountered during difficult dilatation of recurrent Table 2 Complications Following Puncture
Fig. 1 Placement of percutaneous tract in horseshoe kidney.
Complications
No.
Pelvic tear Bleeding Septicaemia Fractured guide wire
20 12 5 5
Total
42 (4%)
472
BRITISH JOURNAL OF UROLOGY
Fig. 2 Plain X-ray showing fractured guide wire duringcreation of a percutaneous tract.
fibrous tracts and the guide wires were later mechanically extracted during nephroscopy. Of the complications encountered during nephroscopy, the most frequent was pelvic tear (31 patients) and this was treated by nephrostomy drainage. Sixteen patients required a transfusion because of per-operative bleeding. A supracostal approach to remove a stone in a high-lying kidney resulted in hydrothorax in 1 patient. This was treated conservatively by nephrostomy and chest drainage. Colonic perforation was encountered in 4 patients (Fig. 3), all of whom underwent successful conservative treatment consisting of drainage of the pelvis by a wide ureteric catheter, nasogastric suction, administration of a broad spectrum antibiotic as well as anal dilatation (Lord's manoeuvre) to avoid build-up of pressure in the large intestine. The ultrasound probe was fractured in 1 case and the forceps in another. Post-operative bleeding from the nephrostomy tube, or haematuria after its removal, was observed in 34 patients. Five required blood transfusion and were conservatively treated. Three required radiological intervention with embolisation. This procedure was successful in 2 cases (Fig. 4), but nephrectomy was necessary in the third. Postoperative pyrexia was recorded in 55 patients and they were treated with the appropriate antibiotic. No mortality was reported in association with
Fig. 3 Renocolonic fistula inflicted during percutaneous nephrolithotripsy.
the procedure. The average hospital stay was 6.9 days. Of the 333 patients with a minimal follow-up of 5 years, stone recurrence was documented in 31 (9.1%). Of these, 70% had a past history of recurrent renal stones on the same side. Sixteen patients (4.8%) were discharged with small fragments after initial therapy. These were judged to be surgically insignificant. Spontaneous passage of these fragments was documented in 7 cases and 6 remained unchanged. In 3 cases the residual stones increased in size and were later treated by ESWL. Four patients developed post-catheterisation' stricture of the anterior urethra; this was managed
PERCUTANEOUS NEPHROLITHOTRIPSY FOR RENAL STONES IN OVER 1000 PATIENTS
473
have non-infected urine at follow-up. Evidence of urinary tract infection was found in 32 patients (9.6%), always in association with underlying pathology : residual or recurrent stone, urethral stricture or pelviureteric junction obstruction. One patient who was previously normotensive became hypertensive. There was a family history of hypertension. Digital vascular imaging and renography failed to reveal any vascular abnormality.
Discussion
Fig. 4 (A). Selective renal arteriography showingextravasation of dye from an injured lower polar artery. (B). Selective embolisation of the injured artery. (C). Selective renal arteriography after embolisation showing no blood flow through the injured artery.
by visual internal urethrotomy. Obstruction of the pelviureteric junction was reported in 1 patient with a solitary kidney and this was corrected by an endopyelotomy. All patients whose urine was sterile pre-operatively, and who were free of stones, continued to
A properly located percutaneous nephrostomy is a prerequisite for successful stone removal. Multiple tracts may be required to remove mobile, multiple caliceal or staghorn stones (Hulbert and Lange, 1985). In our experience, this can be achieved with a high degree of precision by good opacification of the pelvicaliceal system and the use of biplane radiography. This is of particular importance in cases of abnormal renal morphology such as malrotation, a horseshoe kidney or a duplex collecting system. Alken el al. (1981) suggested ultrasound-guided puncture. This may prove difficult in non-dilated systems and there remains the need for subsequent X-ray for placement of the guide wire and control of the dilatation. Staging the procedure would prolong the hospital stay by 24 to 48 h, although subsequent dilatation and visualisation would then be easier. It would also allow readjustment of the tract (if required) before embarking on the definitive procedure. Wickham et al. (1984) reported that a one-stage
474 procedure would necessitate a second session in 20% of patients because of failed puncture, perforation or poor visualisation. Nevertheless, a onestage procedure could be adopted when sufficient experience in the technique has been gained and it is mandatory when only an unstable tract can be established, as in cases of peripheral caliceal stones where it is often difficult to thread the guide wire into the major collecting system. Failure of access, resulting in failure to remove the stones, was reported in 1.7% of patients by Segura et al. (1985), in 8% by Whitfield and Mills (1985) and in 6.4% by Jones et al. (1990). In our series the failure rate was 2.1%. Post-operative complication rates ranged between 3.2%(Segura et al., 1985) and 13.2%(Jones et al., 1990). This wide variation probably reflects different methods of reporting. In the present series the rate was 8.6%.The most common complication following the procedure was bleeding. In most cases it is minor and does not require transfusion. Blood transfusion was necessary in 21 of our patients (279, a figure which compares favourably with the 3% reported by Segura et al. (1985) and 5.8% by Jones et al. (1990). Angiographic embolisation for an arteriovenous fistula was necessary in 3 patients (0.3%).Segura et al. (1985) and Jones et al. (1990) reported that this was necessary in 0.6 and 0.4%of their patients respectively. In this series, the incidence of residual fragments was 4.2%.Comparable results have been reported by White and Smith (1984) (2.5%),Brannen et al. (1985) (2.8%)and Segura etal. (1985) (8.1%). The number of staghorn stones treated by percutaneous surgery in this series was limited. We prefer open surgery (extended pyelolithotomy with or without radial nephrotomy) for the management of these patients. This is because complete stone removal is almost guaranteed with open surgery, particularly when “on table” X-rays are taken. When staghorn stones were treated by percutaneous surgery alone the reported incidence of residual fragments ranged between 16%(Segura etal., 1985) and 23% (Eisenberger et al., 1987). When percutaneous nephrolithotripsy was combined with ESWL, the incidence of residual stones was reported as 21.5% by Schulze et al. (1986), 40% by Eisenberger et al. (1987) and 77%by Segura et al. (1987). These procedures tend to prolong the hospital stay and are associated with higher costs than open surgery (Di Silverio et al., 1990). The incidence of stone recurrence following this procedure among patients who were followed up for 5 years was 9.1%. This is similar to the 10%
BRITISH JOURNAL OF UROLOGY
reported by Segura (1 989). Iatrogenic pelviureteric junction obstruction following percutaneous nephrolithotripsy was observed by Hidalgo et al. (unpublished observations), who reported an incidence of 0.9%. We noted this complication in 1 patient (0.3%).A possible cause is injury during the course of stone manipulation. Endopyelotomy provides a logical and uncomplicated method of managing this complication. We encountered no case of hypertension which could be attributed to the procedure. Marberger et al. (1985) made a similar observation. Despite the installation of an ESWL machine in this centre, we still perform open surgery and percutaneous nephrolithotripsy in approximately one-third of patients with stones. This is significantly higher than the proportion reported in Europe and America (Chaussy and Fuchs, 1989), who claimed that open sugery was required in less than 5% of their patients. This was due to the larger bulk of stones and/or associated pathology requiring surgery. There is no doubt that the frequency of percutaneous surgery for stone disease will diminish with the adoption of ESWL. Nevertheless, the procedure will still be indicated in some instances : large stones > 3 cm, stones in a calix or caliceal diverticulum, stones with pelviureteric obstruction and branching stones. In other words, endoscopic manipulation will be required for the more difficult stones, as reported by Jones et al. (1990), who observed that the post-operative complication rate for percutaneous stone surgery increased from 13.6 to 24% after the introduction of ESWL. Thus the treatment of renal stone disease by percutaneous surgery is a technique which should not to be forgotten but has to be perfected. Furthermore, in developing countries it will be some time before treatment with ESWL becomes widely available, and percutaneous nephrolithotripsy will remain the method of choice for a significant proportion of renal stones.
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The Authors M. R. El-Kenawy, MD, Lecturer, Department of Urology. H. A. El-Kappany, MD, Assistant Professor, Department of Urology. T. A. El-Diasty, MD, Consultant Radiologist. M. A. Ghoneim, MD(Hon), Professor, Department of Urology. Requests for reprints to: M. A. Ghoneim, Urology and Nephrology Centre, Mansoura, Egypt.
