Urolithiasis DOI 10.1007/s00240-015-0805-1

ORIGINAL PAPER

Prospective randomized comparison between superior calyceal access versus inferior calyceal access in PCNL for inferior calyceal stones with or without pelvic stones Vishwajeet Singh1 · Yogesh Garg1 · Kuldeep Sharma1 · Rahul Janak Sinha1 · Saurabh Gupta1 

Received: 7 May 2015 / Accepted: 1 July 2015 © Springer-Verlag Berlin Heidelberg 2015

Abstract  The objective of this study is to assess the efficacy of superior calyceal access versus inferior calyceal access for inferior calyceal calculi with or without pelvic calculi. A total of 100 patients with inferior calyceal calculi or inferior calyceal calculi with pelvic calculi were included in this prospective randomized study. In 50 patients (Group 1), a fluoroscopy-assisted superior calyceal puncture was made, and in other 50 patients (Group 2), access was obtained through a fluoroscopy-assisted inferior calyceal puncture. The stone-free rates, hemoglobin drop, operative duration, requirement for additional tracts, complications, and auxiliary procedures in the two groups were compared. Stone clearance rates and hemoglobin drop values were better in group 1, though they were not statistically significant. The mean operative duration, number of tracts required, and the relook procedure rate were significantly in favor of Group 1. Only one patient (2 %) in Group 1 developed hydropneumothorax related to supracostal puncture and required intercostal tube drainage. Superior calyceal puncture (supracostal or infracostal) provides favorable access to inferior calyceal stones, providing

* Yogesh Garg [email protected] Vishwajeet Singh [email protected] Kuldeep Sharma [email protected] Rahul Janak Sinha [email protected] Saurabh Gupta [email protected] 1



Department of Urology, King George’s Medical University, Lucknow 226003, Uttar Pradesh, India

better and faster clearance with less requirement of secondary tracts and auxiliary procedures. Keywords  Superior calyceal access · Inferior calyceal access · Percutaneous nephrolithotomy · Inferior calyceal calculi

Introduction The aim of any urologist while treating renal calculi is to remove the maximum stone burden and that too with minimal morbidity to the patient. Several modalities have been used to achieve this, like shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and retrograde intrarenal surgery (RIRS) [1, 2]. The preferred approach for stones 2 cm, PCNL is the favored option, but the management of stones of 1–2 cm is still controversial [3]. PCNL is recommended for renal stones larger than 2 cm, staghorn calculi and some upper ureteric calculi [4]. SWL is less likely to clear stones located in the inferior calyces even when stone size approaches 1 cm, because the small residual stone fragments may be retained in these calyces due to their dependent position. These further act as a nidus for stone formation. Hence, it is preferable to remove inferior calyceal stones larger than 1 cm via percutaneous nephrolithotomy [5, 6]. Ever since it was introduced more than 30 years ago, PCNL remains a landmark procedure with a high success rate and acceptably low complication rate [7]. The success of PCNL for treatment of inferior calyceal calculi does not depend on the anatomic factors that usually affect the outcome of SWL and RIRS making it a better treatment option [8]. We herein wish to analyze the impact of the access

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Urolithiasis

tract for inferior calyceal calculi by studying 100 successive patients of inferior calyceal calculi treated with PCNL at our center from Jan 2010 to Dec 2013.

Materials and methods We prospectively evaluated and followed 100 consecutive patients with inferior calyceal calculi or inferior calyceal calculi with pelvic calculi who underwent PCNL at our center from Jan 2010 to Dec 2013. Inclusion criteria included the following: 1. inferior calyceal calculi and 2. inferior calyceal calculi with pelvic calculi. Exclusion criteria included the following: 1. 2. 3. 4.

staghorn calculi, superior calyceal calculi, middle calyceal calculi, and stones in multiple calyces. Patients were divided into two groups:

Group 1 Patients who underwent PCNL via fluoroscopyguided superior calyceal puncture, Group 2 Patients who underwent PCNL via fluoroscopyassisted stone-guided inferior calyceal puncture. Full informed consent of the patients was taken before including them in the study, and a complete note was made of demographic and preoperative variables like age, sex, duration of symptoms, history of any previous intervention, USG (ultrasonography) findings, IVU (intra venous urography) findings, laterality of stone disease, and the stone burden which was calculated from the plain X-ray by measuring largest single dimension of stone. Patients were then taken up for surgery and every alternate patient was assigned into Group 1 or 2 by using 1:1 randomization. All patients underwent surgery under general anesthesia with standard PCNL technique. Initially, retrograde ureteric catheterization was done on the target side under fluoroscopy guidance in all patients. Subsequently the patients were turned prone and retrograde pyelography was done to outline the pelvicalyceal anatomy. A little amount of air was injected retrogradely via the ureteric catheter which outlined the posterior calyces. Fluoroscopy-guided puncture was then made in the desired calyx in the fashion depending upon the group to which patient belonged. Aspiration of urine confirmed the puncture of the collecting system. Through this puncture, we placed a hydrophilic guide wire (0.035′) into the collecting system.

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Tract was dilated over the guide wire and a 28 Fr Amplatz sheath was placed. Another guide wire was placed retrogradely through the ureteric catheter which was universalized and its one end was pulled out through the puncture tract. Subsequently the stone retrieval was done using 24 Fr nephroscope. A 5 Fr JJ stent and 18 Fr nephrostomy tube were inserted at the end of procedure. JJ stent was placed in the cases in which the pelvic stone was impacted at the pelviureteric junction or in case of persistent small residues at the end of procedure or in cases where the PCS (pelvicalyceal system) was perforated. For few patients in whom there was evident incomplete stone clearance we maintained ureteric catheter in situ to facilitate relook surgery at a later date. Intraoperative variables were also recorded and these included type of anesthesia; puncture—supra costal vs infra costal; number of additional punctures; duration of surgery; stone migration if any; stone clearance; any intraoperative complications like hemorrhage and hydro pneumothorax; placement of JJ stent or maintenance of ureteric catheter. A note was also made of any difficulty encountered during the procedure with regard to torque we experienced in maneuvering the nephroscope. The duration of surgery was calculated from the time of retrograde ureteric catheter placement till the placement of nephrostomy tube. On postoperative day 1, all patients underwent routine investigations like haemogram and renal function test as a part of our institutional protocol. An abdominal radiograph and a renal ultrasound were obtained on postoperative day 2 to look for any clinically significant residual stone fragments. Nephrostomy was removed the same day if complete clearance was evident on radiograph or in cases where residual fragments were present but looked amenable to ESWL. But it was maintained in cases with hematuria or those cases who had clinically significant residual stone fragments to facilitate relook PCNL through same tract. JJ stent was removed 2 weeks after the surgery. Postoperative variables recorded were radiograph findings, hemoglobin drop, ultrasound findings, day of nephrostomy tube removal, hospital stay in days, and auxiliary procedures if any. The results are presented as mean ± SD for the continuous data which were analyzed using Unpaired t test. Categorical data were analyzed using Fischer’s exact test. The P value

Prospective randomized comparison between superior calyceal access versus inferior calyceal access in PCNL for inferior calyceal stones with or without pelvic stones.

The objective of this study is to assess the efficacy of superior calyceal access versus inferior calyceal access for inferior calyceal calculi with o...
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