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1
SCULPTURING IN UROLOGY OR HOW TO MAKE PCNL CASE EASIER
1) Gadzhiev, Nariman (Corresponding Author), VCERM, Saint-Petersburg, Russian Federation , [email protected] Phone number - +79214311436 2) Brovkin, Sergei, VCERM, Saint-Petersburg, Russian Federation, [email protected] 3) Grigoryev, Vladislav, VCERM , Russian Federation VCERM, Urology Saint-Petersburg, Russian Federation, [email protected] 4) Tagirov, Nair, Saint Elizabeth Hospital, Saint-Petersburg, Russian Federation, [email protected] 5) Korol, Valeriy, VCERM, Saint-Petersburg, Russian Federation, [email protected] 6) Petrov, Sergei, VCERM, Saint-Petersburg, Russian Federation, [email protected]
VCERM – “The Nikiforov All Russian Center of Radiative and Emergency medicine” Saint-Petersburg, Opticov str., 54. Postal code 197374, Russian Federation. Phone number +7812 648 24 08 Saint Elizabeth Hospital, Saint-Petersburg, Vavilovih str., 14, Postal code 195257, Russian Federation.
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2
Phone number - +7 (812) 556-77-22 Abstract Objective: to investigate the usefulness of plasticine biomodeling in surgical percutaneous treatment of complex renal stone cases.
Materials and Methods: a total of 32 patients were included in this study from 2012 to 2013 with complex renal stones (complete staghorn stones or partial staghorn stone with multiple calyceal stones). CT urography with 3D reconstructions was used as a standard preoperative imaging in all patients. Preoperatively, plasticine replication of the pelvicalyceal system was performed by the operating surgeon himself, based on the gathered 3D reconstructions. Then, it was taken to the operating room and used as a reference model in a sterile polyethylene bag during the operation.
Results: Percutaneous renal access was achieved successfully in all cases. 29 (91%) patients were treated in the prone and only 3 (9%) in supine position. 18 patients (56%) had a single tract, 9 patients (28%) had 2 tracts, 3 patients (9%) had 3 tracts, and one patient (3%) required 4 tracts. The mean operating time was 92 (±26) min. Second look PCNL was required in 9 out of 32 patients (28%). All second-look sessions were performed in 2-3 days and/or on a normalized temperature. 6 out of 11 (54.5%) patients with complete staghorn stone patients required a second-look PCNL session. Complete stone clearance was, confirmed by low dose CT, performed at 24 h after surgery, 89.4% of the patients treated by a single PCNL session and 82% in those needed second-look sessions. The overall SFR in the study after second looks was 87.3%.
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3 Conclusions: Proposed plasticine 3D model seems to provide better preoperative renal collecting system appreciation and to serve as a reference tool during the operation which in turn might increase stone free rates and lowering complications rate after PCNL.
Introduction
Since the first case of percutaneous nephroscopy was presented by Rupel and Brown in 1941 percutaneous surgery went through significant improvements being nowadays the first-line surgical treatment for renal stones more than 2 cm (Rupel & Brown 1941)(Türk et al. 2014) Adequate preoperative planning is mandatory for a successful PCNL, which is based on consideration of the patient’s performance status, comorbidities and optimal imaging. Today preoperative imaging for the best depiction of renal calculi is a computed tomography with or without contrast enhancement (Olcott et al. 1997). However a contrast study is recommended if stone removal is planned and the anatomy of the renal collecting system needs to be assessed, moreover 3D CT reconstruction of the collecting system, as well as measurement of stone density and skin-to-stone distance is possible. (Türk et al. 2014) In that way, a better awareness of three-dimensional (3D) anatomy of pelvicalyceal system (PCS) with different CT reconstructing techniques is obtained (Ghani et al. 2004). In the operating theater, preoperative CT- scans, with 3D reconstruction of PCS and stone, on a monitor have several limitations: to keep confident orientation in the kidney during the operation one has to constantly hold in mind those three-dimensional (3D) images of renal collecting system or periodically be distracted to compare intra-operative findings with CT films. To overcome this obstacle, several attempts were made by creations of stereo-lithographic
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4 biomodel, using laser and 3D printing of the PCS (Radecka et al. 2006)(Turney 2014). However, despite the approved benefit, this techniques didn’t gain widespread recognition because their creation was time-consuming and required additional expenditures as well. Attempts to get a more efficient intraoperative reference tool have lead to a simple idea of plasticine biomodeling, which is created by the surgeon himself from 3D CT reconstruction of pelvicalyceal system. It is cheaper, faster to get, and crucially, since it is made by the surgeon will give him a thorough and deep knowledge of the collecting system anatomy. The aim of this study was to investigate the usefulness of plasticine biomodeling in surgical treatment of complex renal stone cases.
Material and methods
After institutional ethical committee approval a total of 32 patients were included in this study from 2012 to 2013 with complex renal stones (complete staghorn stones or partial staghorn stone with multiple calyceal stones). Patients with coagulation disorders and/or active infection were excluded from the study. Patient characteristics are shown in Table 1. Preoperative laboratory tests included complete blood cell count, serum chemistry panel, coagulation screening tests, urinalysis and urine culture. All patients were presented either with sterile urine or were treated according to the antibiotic sensitivity tests at least for 7 days before the operation (Mariappan et al. 2006) CT urography with 3D reconstructions was used as a standard preoperative imaging in all patients. Data acquisition was performed using a 64-row CT unit “Somatom Definition AS”
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5 (Siemens, Germany) with the patient supine. Stone types were classified as staghorn calculi, either with or without multiple calyceal stones. Complete staghorn stones were defined as stones occupying the renal pelvis and all the calyceal system or more than 80% of the renal collecting system. Whereas partial staghorn stones were defined as stones occupying the renal pelvis and at least 2 calyces.(Mishra et al. 2014) Preoperatively, plasticine replication of the PCS was performed by the operating surgeon himself, based on the gathered 3D reconstructions (Fig 1). The average time needed for model creation was 20±6 min. The cost of plasticine required for a single model in Russia is less than 5$ - which is quite cheap. Stepwise depiction of modeling process is shown below (Fig 2).Then, it was taken to the operating room and used as a reference model in a sterile polyethylene bag during the operation (Fig 3).. The surgeons did not have any special training in sculpturing beforehand. The same surgical team performed all PCNL cases. Under general anesthesia in the lithotomy position a ureteric catheter was placed into the ipsilateral kidney, under cystoscopic guidance. Subsequently, the patient was turned to the prone position, which is the preferred in out center, or left in supine position in case of morbid obesity or cardiac diseases. This was up to discretion of the attending surgeon and anesthesiologist. Percutaneous access was achieved under fluoroscopic guidance. After calyx puncture, a 0.035 hydrophilic guidewire was inserted into the PCS. Maximum efforts was made to direct the guidewire down the ureter, thus to have a through and through access. A pre- dilation of the percutaneous tract was performed using an 11 -F fascial dilator, and the 8 Fr radiopaque TFE catheter was inserted over the guidewire. After all with a “single-step” tract dilation a 30 F sheath was introduced. Nephroscopy was performed with a rigid 28-F nephroscope (Karl Storz, Germany).
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6 Fragmentation of the stone burden was accomplished with an ultrasonic lithotriptor predominantly (Swiss LithoClast Master, Switzerland), which has a pneumatic lithotripsy option as well. A bi-prong forceps (Karl Storz, Germany) and/or “PERC NCIRCLE” nitinol tipples stone extractor (Cook Medical, USA) were used to remove stone fragments when needed. Additional tracts were created during the same session if indicated. A total duration of nephroscopy was no more than 2 hours. At the end of the procedure, the patient’s stone-free status was double-checked using fluoroscopy and a flexible nephroscope final inspection. A 9-F nephrostomy tube was placed at the conclusion of the most cases. If intraoperative bleeding was a concern then large bore nephrostomy tube was considered. Peritubal tract infiltration with a local anesthetic “Ropivacain” 0.25% was used for postoperative pain alleviation (Jonnavithula et al. 2009). A blood count, creatinine, serum electrolytes, the Foley catheter removal and the patient activation were performed on the first postoperative day.
All patients were assessed for stone clearance at 24 h after surgery using low-dose non-enhanced CT protocol. The stone-free status was defined as the absence of fragments on CT or for clinically insignificant residual fragments (CIRFs), which are defined as less than 38 °C) in 2 patients (6.25%) was successfully managed with additional antibiotic administration. The grade 3 complications were presented by one patient (3%) who underwent chest tube placement for pneumothorax and was due to 11-th
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8 intercostal access, and by another patient (3%) who required a stent placement for clot ureteral obstruction in the early postoperative period (Table 3).
Discussion According to existing guidelines percutaneous nephrolithotomy is the primary procedure for the management of patients with renal stones more than 2 cm. (2) The success of PCNL largely depends on adequate planning, meticulous technique and confident knowledge of renal collecting system anatomy (Turney 2014). Adequate planning being the mainstay depends on optimal imaging, which are predominantly IVU or CT. Nevertheless, because CT provides superior detection capabilities for renal and ureteral stones, it has progressively replaced IVU in many institutions (Miller et al. 1998)(Memarsadeghi et al. 2005). Successful management of a renal calculus depends on a relationship of the calculus with individual pelvicalyceal anatomy and requires mental reconstruction of PCS during percutaneous access and stone removal...This relationship can be gained by 3D CT reconstruction of the calyceal anatomy and stones, which undoubtedly helps to select the most appropriate approach. (Ghani et al. 2004) Thus enhanced CT with volume rendering techniques is the preferred imaging modality in our and many other centers, in complex stone cases. Rendered images provide a clear representation of the anterior and posterior direction of calyces, information which was impossible to determine using the IVU. The combination of the diagnostic accuracy of CT with 3D modeling for appreciation of the calculus location and calyceal anatomy may displace the IVU completely (Park & Pearle 2006) During the PCNL, especially dealing with complex renal stone cases, surgeon needs to hold in mind continuously CT volume reconstructions, that is not so easy, considering that human collecting systems can be very varied. Taking into account abovementioned access gaining and
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9 PCS navigation sometimes can be a quite challenging task. The overall stone-free rate of percutaneous nephrolithotomy found in the CROES PCNL database was only 76 % (Kamphuis et al. 2014). Given this percentage the ways for improvement are still wanted. Recent reports trying to solve this problem as an IPad-assisted navigation, 3D-augmented virtual reality (Rassweiler et al. 2012), the locator system (Lazarus & Williams 2011), Real-Time Tracking Sensors (Rodrigues et al. 2013) are reflecting the real need in gaining intraoperative confidence which is today very from ideal.
Another direction to improve SFR are attempts to create renal collecting system replication utilizing different techniques: 3D printing, although was used as a step in a creation of a perc trainer(Turney 2014), 3D resin biomodel created by liquid-bed laser curing system (Radecka et al. 2006), and it has been suggested that a 3D biomodel may be helpful in accurate access puncture planning (Radecka et al. 2006) Although recent advances in technology have enabled production of 3D printed models their production still needs additional equipment as a 3D printer and a necessity of special converting software, which imposes additional costs. The liquid-bed laser curing system used to produce the biomodel from plastic photopolymer resin also requires additional expenditures. Moreover it is time-consuming requiring about 2-3 days for biomodel production. These are main obstacles hindering its wide spread. For some time, the idea of biomodeling is utilized in different fields of medicine such as preoperative planning in complex orthopedic, craniofacial and neurosurgery (Y Y Yau 1995)(D’Urso et al. 1999)(Byram et al. 2013) The question to combine biomodeling, which will alleviate requirement in mental reconstruction of pelvicalyceal anatomy and improve collecting system anatomy recognition was raised. An
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10 interesting experience in the field of medical teaching has attracted our attention. Using a model of the hip joint, participants attached the structures out of plasticine to the bony landmarks. In their experience plasticine models created an interactive learning experience that was relevant to surgical practice. Participants felt an improvement in their appreciation of three dimensional anatomical associations (Asp et al. 2013) We took the same principle and used plasticine pelvicalyceal system biomodel from 3D CT reconstructions before each operation was done. Creation of a model took no more than 20 minutes on average. By creating the model surgeon acquires a perfect comprehension of the renal collecting system anatomy, sensation of so called intrarenal “road map” which is extremely important especially in the treatment of complex renal stone cases. This model was taken into the operating room and placed in the sterile transparent polyethylene bag, which permitted to use it intraoperatively as a reference tool if needed.3D CT preoperative scans, with corresponding models and postoperative scans are shown below (Fig 4). Plasticine biomodeling according to our preliminary results and our sensation was very useful in the treatment of complex renal stone cases by PCNL with providing obvious benefit for planning and intraoperative technique when used as a reference tool during the surgery. Thus improvement in preoperative planning and operative technique might lead hypothetically to the shortening of operation duration, minimization of a blood loss, risk of infection, and postoperative complications as well. Some obvious drawbacks of this technique have to be highlighted. First concern is the radiation dose received by the patients. However, CT in many centers is the standard in preoperative imaging, thus imposing no requirement in additional visualizing methods. The second concern is plasticine on your hands, which is simply removed with warm water. In summary it is fast to produce, it is cheap and it gives better appreciation of collecting system anatomy that might improve SFR and reduce operating time and as a consequence reduce
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11 complications.
Conclusion Proposed plasticine 3D model seems to provide better preoperative renal collecting system appreciation and to serve as a reference tool during the operation which in turn might increase stone free rates and lowering complications rate after PCNL.
Acknowledgments We are very thankful to Arvind Ganpule, Vladimir Khvorov, Mohammed Lezrek and John J. Knoedler for paper revision and advises given.
Disclosure Statement None References: Asp, A.R.M., Myint, Y. & Gandhe, A., 2013. Back to school anatomy: just add Plasticine. BMJ, 347(dec17 4), pp.f6924–f6924. Available at: http://www.bmj.com/content/347/bmj.f6924 [Accessed August 14, 2014]. Byram, I.R. et al., 2013. Characterizing bone tunnel placement in medial ulnar collateral ligament reconstruction using patient-specific 3-dimensional computed tomography modeling. The American journal of sports medicine, 41(4), pp.894–902. Available at: http://ajs.sagepub.com/content/41/4/894.short [Accessed August 14, 2014].
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12 D’Urso, P.S. et al., 1999. Spinal biomodeling. Spine, 24(12), pp.1247–51. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10382253 [Accessed August 14, 2014]. Ghani, K.R. et al., 2004. Three-dimensional imaging in urology. BJU international, 94(6), pp.769–73. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15476506 [Accessed August 14, 2014]. Jonnavithula, N. et al., 2009. Efficacy of peritubal local anesthetic infiltration in alleviating postoperative pain in percutaneous nephrolithotomy. Journal of endourology / Endourological Society, 23(5), pp.857–60. Available at: http://online.liebertpub.com/doi/abs/10.1089/end.2008.0634 [Accessed August 14, 2014]. Kamphuis, G.M. et al., 2014. Lessons learned from the CROES percutaneous nephrolithotomy global study. World journal of urology. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25100624 [Accessed August 14, 2014]. De la Rosette, J.J.M.C.H. et al., 2012. Categorisation of complications and validation of the Clavien score for percutaneous nephrolithotomy. European urology, 62(2), pp.246–55. Available at: http://www.europeanurology.com/article/S0302-2838(12)004538/fulltext/categorisation-of-complications-and-validation-of-the-clavien-score-forpercutaneous-nephrolithotomy [Accessed August 14, 2014]. Lazarus, J. & Williams, J., 2011. The Locator: novel percutaneous nephrolithotomy apparatus to aid collecting system puncture--a preliminary report. Journal of endourology / Endourological Society, 25(5), pp.747–50. Available at: http://online.liebertpub.com/doi/abs/10.1089/end.2010.0494 [Accessed August 14, 2014]. Mariappan, P. et al., 2006. One week of ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study.
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13 BJU international, 98(5), pp.1075–9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17034608 [Accessed August 14, 2014]. Memarsadeghi, M. et al., 2005. Unenhanced multi-detector row CT in patients suspected of having urinary stone disease: effect of section width on diagnosis. Radiology, 235(2), pp.530–6. Available at: http://pubs.rsna.org/doi/abs/10.1148/radiol.2352040448 [Accessed August 14, 2014]. Miller, O.F. et al., 1998. Prospective comparison of unenhanced spiral computed tomography and intravenous urogram in the evaluation of acute flank pain. Urology, 52(6), pp.982–987. Available at: http://www.goldjournal.net/article/S0090429598003689/fulltext [Accessed August 14, 2014]. Mishra, S. et al., 2014. Staghorn classification: Platform for morphometry assessment. Indian journal of urology : IJU : journal of the Urological Society of India, 30(1), pp.80–3. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3897060&tool=pmcentrez&ren dertype=abstract [Accessed August 14, 2014]. Olcott, E.W., Sommer, F.G. & Napel, S., 1997. Accuracy of detection and measurement of renal calculi: in vitro comparison of three-dimensional spiral CT, radiography, and nephrotomography. Radiology, 204(1), pp.19–25. Available at: http://www.ncbi.nlm.nih.gov/pubmed/9205217 [Accessed August 14, 2014]. Park, S. & Pearle, M.S., 2006. Imaging for percutaneous renal access and management of renal calculi. The Urologic clinics of North America, 33(3), pp.353–64. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16829270 [Accessed August 14, 2014].
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14 Radecka, E. et al., 2006. Pelvicaliceal biomodeling as an aid to achieving optimal access in percutaneous nephrolithotripsy. Journal of endourology / Endourological Society, 20(2), pp.92–101. Available at: http://online.liebertpub.com/doi/abs/10.1089/end.2006.20.92 [Accessed August 14, 2014]. Rassweiler, J.J. et al., 2012. iPad-assisted percutaneous access to the kidney using marker-based navigation: initial clinical experience. European urology, 61(3), pp.628–31. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22209052 [Accessed August 14, 2014]. Rodrigues, P.L. et al., 2013. Collecting system percutaneous access using real-time tracking sensors: first pig model in vivo experience. The Journal of urology, 190(5), pp.1932–7. Available at: http://www.jurology.com/article/S0022534713043851/fulltext [Accessed August 14, 2014]. Rupel, E. & Brown, R., 1941. Nephroscopy with removal of stone following nephrostomy for obstructive calculous anuria. J Urol, 47, pp.177–182. Available at: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Nephroscopy+with+remo val+of+stone+following+nephrostomy+for+obstructive+calculous+anuria#0 [Accessed August 13, 2014]. Türk, C. et al., 2014. Guidelines on urolithiasis. European Association of Urology (EAU), pp.62– 99. Turney, B.W., 2014. A new model with an anatomically accurate human renal collecting system for training in fluoroscopy-guided percutaneous nephrolithotomy access. Journal of endourology / Endourological Society, 28(3), pp.360–3. Available at: http://online.liebertpub.com/doi/abs/10.1089/end.2013.0616 [Accessed August 14, 2014].
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15 Y Y Yau, J.F.A., 1995. Technical note: maxillofacial biomodelling--preliminary result. The British journal of radiology, 68(809), pp.519 – 23.
Table I. Preoperative Patient Characteristics
Mean age, years
54 (±7)
Gender: male
14 (44%)
female
18 (56%)
Stone type: complete
11 (34%)
partial (with multiple calyceal)
21 (66%)
Previous open renal stone surgeries
9 (28%)
Laterality: left
12 (37.5%)
right
15 (46.8%)
bilateral
5 (15.7%)
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ASA class:
I 8 (25%)
II 17 (53%)
III 7 (22%)
Table II. PCNL Characteristics
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Mean operating time
92 (±26) min.
Position: Prone
29 pts (91%)
Supine
3 pts (9%)
Second look PCNL:
9 pts (28 %)
With complete staghorn stone
6 out of 11 (54.5%)
With partial staghorn stones
3 out of 21 (14.2%)
Tract number: 1
18 pts (56%)
2
9 pts (28%)
3
3 pts (9%)
4
1 pt (3%)
Complete clearance by a single PCNL session
89.4%
Complete clearance by a more than one PCNL session
82%
Overall stone clearance in the study
87.3%
Table III. Postoperative complications (CLAVIEN classification)
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Overall complications encountered:
12 pts (37.5%) 18
Grade 1
6 pts (18.7%)
Transient postoperative fever?
5 pts (15.7%)
Transient creatinine rise
1 pts (3 %)
Grade 2
4 pts (12.5% )
Hemorrhage
2 pts (6.25%)
Postoperative fever >38?
2 pts (6.25%)
Grade 3
2 pts (6%)
Pneumothorax
1 pt (3%)
Ureteral stent placement for clot ureteral obstruction
1 pt (3%)
CT – computed tomography PCNL – percutaneous nephrolithotomy SFR – stone free rate PCS - pelvicalyceal system TFE – tetrafluoroethylene CIRF - clinically insignificant residual fragments IVU – intravenous urography
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Figure 1. Preoperative 3D reconstruction (1a) and plasticine biomodel (1b) of complete
staghorn stone.
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Figure 2. Stepwise depiction of modeling
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Figure 3. Intraoperative navigation
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Figure 4. Before and after PCNL
4a 3D reconstruction
4b Plasticine model
4c Postoperative CT
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1
SCULPTURING IN UROLOGY OR HOW TO MAKE PCNL CASE EASIER
1) Gadzhiev, Nariman (Corresponding Author), VCERM, Saint-Petersburg, Russian Federation , [email protected] Phone number - +79214311436 2) Brovkin, Sergei, VCERM, Saint-Petersburg, Russian Federation, [email protected] 3) Grigoryev, Vladislav, VCERM , Russian Federation VCERM, Urology Saint-Petersburg, Russian Federation, [email protected] 4) Tagirov, Nair, Saint Elizabeth Hospital, Saint-Petersburg, Russian Federation, [email protected] 5) Korol, Valeriy, VCERM, Saint-Petersburg, Russian Federation, [email protected] 6) Petrov, Sergei, VCERM, Saint-Petersburg, Russian Federation, [email protected]
VCERM – “The Nikiforov All Russian Center of Radiative and Emergency medicine” Saint-Petersburg, Opticov str., 54. Postal code 197374, Russian Federation. Phone number +7812 648 24 08 Saint Elizabeth Hospital, Saint-Petersburg, Vavilovih str., 14, Postal code 195257, Russian Federation.
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2
Phone number - +7 (812) 556-77-22 Abstract Objective: to investigate the usefulness of plasticine biomodeling in surgical percutaneous treatment of complex renal stone cases.
Materials and Methods: a total of 32 patients were included in this study from 2012 to 2013 with complex renal stones (complete staghorn stones or partial staghorn stone with multiple calyceal stones). CT urography with 3D reconstructions was used as a standard preoperative imaging in all patients. Preoperatively, plasticine replication of the pelvicalyceal system was performed by the operating surgeon himself, based on the gathered 3D reconstructions. Then, it was taken to the operating room and used as a reference model in a sterile polyethylene bag during the operation.
Results: Percutaneous renal access was achieved successfully in all cases. 29 (91%) patients were treated in the prone and only 3 (9%) in supine position. 18 patients (56%) had a single tract, 9 patients (28%) had 2 tracts, 3 patients (9%) had 3 tracts, and one patient (3%) required 4 tracts. The mean operating time was 92 (±26) min. Second look PCNL was required in 9 out of 32 patients (28%). All second-look sessions were performed in 2-3 days and/or on a normalized temperature. 6 out of 11 (54.5%) patients with complete staghorn stone patients required a second-look PCNL session. Complete stone clearance was, confirmed by low dose CT, performed at 24 h after surgery, 89.4% of the patients treated by a single PCNL session and 82% in those needed second-look sessions. The overall SFR in the study after second looks was 87.3%.
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3 Conclusions: Proposed plasticine 3D model seems to provide better preoperative renal collecting system appreciation and to serve as a reference tool during the operation which in turn might increase stone free rates and lowering complications rate after PCNL.
Introduction
Since the first case of percutaneous nephroscopy was presented by Rupel and Brown in 1941 percutaneous surgery went through significant improvements being nowadays the first-line surgical treatment for renal stones more than 2 cm (Rupel & Brown 1941)(Türk et al. 2014) Adequate preoperative planning is mandatory for a successful PCNL, which is based on consideration of the patient’s performance status, comorbidities and optimal imaging. Today preoperative imaging for the best depiction of renal calculi is a computed tomography with or without contrast enhancement (Olcott et al. 1997). However a contrast study is recommended if stone removal is planned and the anatomy of the renal collecting system needs to be assessed, moreover 3D CT reconstruction of the collecting system, as well as measurement of stone density and skin-to-stone distance is possible. (Türk et al. 2014) In that way, a better awareness of three-dimensional (3D) anatomy of pelvicalyceal system (PCS) with different CT reconstructing techniques is obtained (Ghani et al. 2004). In the operating theater, preoperative CT- scans, with 3D reconstruction of PCS and stone, on a monitor have several limitations: to keep confident orientation in the kidney during the operation one has to constantly hold in mind those three-dimensional (3D) images of renal collecting system or periodically be distracted to compare intra-operative findings with CT films. To overcome this obstacle, several attempts were made by creations of stereo-lithographic
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4 biomodel, using laser and 3D printing of the PCS (Radecka et al. 2006)(Turney 2014). However, despite the approved benefit, this techniques didn’t gain widespread recognition because their creation was time-consuming and required additional expenditures as well. Attempts to get a more efficient intraoperative reference tool have lead to a simple idea of plasticine biomodeling, which is created by the surgeon himself from 3D CT reconstruction of pelvicalyceal system. It is cheaper, faster to get, and crucially, since it is made by the surgeon will give him a thorough and deep knowledge of the collecting system anatomy. The aim of this study was to investigate the usefulness of plasticine biomodeling in surgical treatment of complex renal stone cases.
Material and methods
After institutional ethical committee approval a total of 32 patients were included in this study from 2012 to 2013 with complex renal stones (complete staghorn stones or partial staghorn stone with multiple calyceal stones). Patients with coagulation disorders and/or active infection were excluded from the study. Patient characteristics are shown in Table 1. Preoperative laboratory tests included complete blood cell count, serum chemistry panel, coagulation screening tests, urinalysis and urine culture. All patients were presented either with sterile urine or were treated according to the antibiotic sensitivity tests at least for 7 days before the operation (Mariappan et al. 2006) CT urography with 3D reconstructions was used as a standard preoperative imaging in all patients. Data acquisition was performed using a 64-row CT unit “Somatom Definition AS”
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5 (Siemens, Germany) with the patient supine. Stone types were classified as staghorn calculi, either with or without multiple calyceal stones. Complete staghorn stones were defined as stones occupying the renal pelvis and all the calyceal system or more than 80% of the renal collecting system. Whereas partial staghorn stones were defined as stones occupying the renal pelvis and at least 2 calyces.(Mishra et al. 2014) Preoperatively, plasticine replication of the PCS was performed by the operating surgeon himself, based on the gathered 3D reconstructions (Fig 1). The average time needed for model creation was 20±6 min. The cost of plasticine required for a single model in Russia is less than 5$ - which is quite cheap. Stepwise depiction of modeling process is shown below (Fig 2).Then, it was taken to the operating room and used as a reference model in a sterile polyethylene bag during the operation (Fig 3).. The surgeons did not have any special training in sculpturing beforehand. The same surgical team performed all PCNL cases. Under general anesthesia in the lithotomy position a ureteric catheter was placed into the ipsilateral kidney, under cystoscopic guidance. Subsequently, the patient was turned to the prone position, which is the preferred in out center, or left in supine position in case of morbid obesity or cardiac diseases. This was up to discretion of the attending surgeon and anesthesiologist. Percutaneous access was achieved under fluoroscopic guidance. After calyx puncture, a 0.035 hydrophilic guidewire was inserted into the PCS. Maximum efforts was made to direct the guidewire down the ureter, thus to have a through and through access. A pre- dilation of the percutaneous tract was performed using an 11 -F fascial dilator, and the 8 Fr radiopaque TFE catheter was inserted over the guidewire. After all with a “single-step” tract dilation a 30 F sheath was introduced. Nephroscopy was performed with a rigid 28-F nephroscope (Karl Storz, Germany).
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6 Fragmentation of the stone burden was accomplished with an ultrasonic lithotriptor predominantly (Swiss LithoClast Master, Switzerland), which has a pneumatic lithotripsy option as well. A bi-prong forceps (Karl Storz, Germany) and/or “PERC NCIRCLE” nitinol tipples stone extractor (Cook Medical, USA) were used to remove stone fragments when needed. Additional tracts were created during the same session if indicated. A total duration of nephroscopy was no more than 2 hours. At the end of the procedure, the patient’s stone-free status was double-checked using fluoroscopy and a flexible nephroscope final inspection. A 9-F nephrostomy tube was placed at the conclusion of the most cases. If intraoperative bleeding was a concern then large bore nephrostomy tube was considered. Peritubal tract infiltration with a local anesthetic “Ropivacain” 0.25% was used for postoperative pain alleviation (Jonnavithula et al. 2009). A blood count, creatinine, serum electrolytes, the Foley catheter removal and the patient activation were performed on the first postoperative day.
All patients were assessed for stone clearance at 24 h after surgery using low-dose non-enhanced CT protocol. The stone-free status was defined as the absence of fragments on CT or for clinically insignificant residual fragments (CIRFs), which are defined as less than 38 °C) in 2 patients (6.25%) was successfully managed with additional antibiotic administration. The grade 3 complications were presented by one patient (3%) who underwent chest tube placement for pneumothorax and was due to 11-th
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8 intercostal access, and by another patient (3%) who required a stent placement for clot ureteral obstruction in the early postoperative period (Table 3).
Discussion According to existing guidelines percutaneous nephrolithotomy is the primary procedure for the management of patients with renal stones more than 2 cm. (2) The success of PCNL largely depends on adequate planning, meticulous technique and confident knowledge of renal collecting system anatomy (Turney 2014). Adequate planning being the mainstay depends on optimal imaging, which are predominantly IVU or CT. Nevertheless, because CT provides superior detection capabilities for renal and ureteral stones, it has progressively replaced IVU in many institutions (Miller et al. 1998)(Memarsadeghi et al. 2005). Successful management of a renal calculus depends on a relationship of the calculus with individual pelvicalyceal anatomy and requires mental reconstruction of PCS during percutaneous access and stone removal...This relationship can be gained by 3D CT reconstruction of the calyceal anatomy and stones, which undoubtedly helps to select the most appropriate approach. (Ghani et al. 2004) Thus enhanced CT with volume rendering techniques is the preferred imaging modality in our and many other centers, in complex stone cases. Rendered images provide a clear representation of the anterior and posterior direction of calyces, information which was impossible to determine using the IVU. The combination of the diagnostic accuracy of CT with 3D modeling for appreciation of the calculus location and calyceal anatomy may displace the IVU completely (Park & Pearle 2006) During the PCNL, especially dealing with complex renal stone cases, surgeon needs to hold in mind continuously CT volume reconstructions, that is not so easy, considering that human collecting systems can be very varied. Taking into account abovementioned access gaining and
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9 PCS navigation sometimes can be a quite challenging task. The overall stone-free rate of percutaneous nephrolithotomy found in the CROES PCNL database was only 76 % (Kamphuis et al. 2014). Given this percentage the ways for improvement are still wanted. Recent reports trying to solve this problem as an IPad-assisted navigation, 3D-augmented virtual reality (Rassweiler et al. 2012), the locator system (Lazarus & Williams 2011), Real-Time Tracking Sensors (Rodrigues et al. 2013) are reflecting the real need in gaining intraoperative confidence which is today very from ideal.
Another direction to improve SFR are attempts to create renal collecting system replication utilizing different techniques: 3D printing, although was used as a step in a creation of a perc trainer(Turney 2014), 3D resin biomodel created by liquid-bed laser curing system (Radecka et al. 2006), and it has been suggested that a 3D biomodel may be helpful in accurate access puncture planning (Radecka et al. 2006) Although recent advances in technology have enabled production of 3D printed models their production still needs additional equipment as a 3D printer and a necessity of special converting software, which imposes additional costs. The liquid-bed laser curing system used to produce the biomodel from plastic photopolymer resin also requires additional expenditures. Moreover it is time-consuming requiring about 2-3 days for biomodel production. These are main obstacles hindering its wide spread. For some time, the idea of biomodeling is utilized in different fields of medicine such as preoperative planning in complex orthopedic, craniofacial and neurosurgery (Y Y Yau 1995)(D’Urso et al. 1999)(Byram et al. 2013) The question to combine biomodeling, which will alleviate requirement in mental reconstruction of pelvicalyceal anatomy and improve collecting system anatomy recognition was raised. An
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10 interesting experience in the field of medical teaching has attracted our attention. Using a model of the hip joint, participants attached the structures out of plasticine to the bony landmarks. In their experience plasticine models created an interactive learning experience that was relevant to surgical practice. Participants felt an improvement in their appreciation of three dimensional anatomical associations (Asp et al. 2013) We took the same principle and used plasticine pelvicalyceal system biomodel from 3D CT reconstructions before each operation was done. Creation of a model took no more than 20 minutes on average. By creating the model surgeon acquires a perfect comprehension of the renal collecting system anatomy, sensation of so called intrarenal “road map” which is extremely important especially in the treatment of complex renal stone cases. This model was taken into the operating room and placed in the sterile transparent polyethylene bag, which permitted to use it intraoperatively as a reference tool if needed.3D CT preoperative scans, with corresponding models and postoperative scans are shown below (Fig 4). Plasticine biomodeling according to our preliminary results and our sensation was very useful in the treatment of complex renal stone cases by PCNL with providing obvious benefit for planning and intraoperative technique when used as a reference tool during the surgery. Thus improvement in preoperative planning and operative technique might lead hypothetically to the shortening of operation duration, minimization of a blood loss, risk of infection, and postoperative complications as well. Some obvious drawbacks of this technique have to be highlighted. First concern is the radiation dose received by the patients. However, CT in many centers is the standard in preoperative imaging, thus imposing no requirement in additional visualizing methods. The second concern is plasticine on your hands, which is simply removed with warm water. In summary it is fast to produce, it is cheap and it gives better appreciation of collecting system anatomy that might improve SFR and reduce operating time and as a consequence reduce
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11 complications.
Conclusion Proposed plasticine 3D model seems to provide better preoperative renal collecting system appreciation and to serve as a reference tool during the operation which in turn might increase stone free rates and lowering complications rate after PCNL.
Acknowledgments We are very thankful to Arvind Ganpule, Vladimir Khvorov, Mohammed Lezrek and John J. Knoedler for paper revision and advises given.
Disclosure Statement None References: Asp, A.R.M., Myint, Y. & Gandhe, A., 2013. Back to school anatomy: just add Plasticine. BMJ, 347(dec17 4), pp.f6924–f6924. Available at: http://www.bmj.com/content/347/bmj.f6924 [Accessed August 14, 2014]. Byram, I.R. et al., 2013. Characterizing bone tunnel placement in medial ulnar collateral ligament reconstruction using patient-specific 3-dimensional computed tomography modeling. The American journal of sports medicine, 41(4), pp.894–902. Available at: http://ajs.sagepub.com/content/41/4/894.short [Accessed August 14, 2014].
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12 D’Urso, P.S. et al., 1999. Spinal biomodeling. Spine, 24(12), pp.1247–51. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10382253 [Accessed August 14, 2014]. Ghani, K.R. et al., 2004. Three-dimensional imaging in urology. BJU international, 94(6), pp.769–73. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15476506 [Accessed August 14, 2014]. Jonnavithula, N. et al., 2009. Efficacy of peritubal local anesthetic infiltration in alleviating postoperative pain in percutaneous nephrolithotomy. Journal of endourology / Endourological Society, 23(5), pp.857–60. Available at: http://online.liebertpub.com/doi/abs/10.1089/end.2008.0634 [Accessed August 14, 2014]. Kamphuis, G.M. et al., 2014. Lessons learned from the CROES percutaneous nephrolithotomy global study. World journal of urology. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25100624 [Accessed August 14, 2014]. De la Rosette, J.J.M.C.H. et al., 2012. Categorisation of complications and validation of the Clavien score for percutaneous nephrolithotomy. European urology, 62(2), pp.246–55. Available at: http://www.europeanurology.com/article/S0302-2838(12)004538/fulltext/categorisation-of-complications-and-validation-of-the-clavien-score-forpercutaneous-nephrolithotomy [Accessed August 14, 2014]. Lazarus, J. & Williams, J., 2011. The Locator: novel percutaneous nephrolithotomy apparatus to aid collecting system puncture--a preliminary report. Journal of endourology / Endourological Society, 25(5), pp.747–50. Available at: http://online.liebertpub.com/doi/abs/10.1089/end.2010.0494 [Accessed August 14, 2014]. Mariappan, P. et al., 2006. One week of ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study.
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13 BJU international, 98(5), pp.1075–9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17034608 [Accessed August 14, 2014]. Memarsadeghi, M. et al., 2005. Unenhanced multi-detector row CT in patients suspected of having urinary stone disease: effect of section width on diagnosis. Radiology, 235(2), pp.530–6. Available at: http://pubs.rsna.org/doi/abs/10.1148/radiol.2352040448 [Accessed August 14, 2014]. Miller, O.F. et al., 1998. Prospective comparison of unenhanced spiral computed tomography and intravenous urogram in the evaluation of acute flank pain. Urology, 52(6), pp.982–987. Available at: http://www.goldjournal.net/article/S0090429598003689/fulltext [Accessed August 14, 2014]. Mishra, S. et al., 2014. Staghorn classification: Platform for morphometry assessment. Indian journal of urology : IJU : journal of the Urological Society of India, 30(1), pp.80–3. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3897060&tool=pmcentrez&ren dertype=abstract [Accessed August 14, 2014]. Olcott, E.W., Sommer, F.G. & Napel, S., 1997. Accuracy of detection and measurement of renal calculi: in vitro comparison of three-dimensional spiral CT, radiography, and nephrotomography. Radiology, 204(1), pp.19–25. Available at: http://www.ncbi.nlm.nih.gov/pubmed/9205217 [Accessed August 14, 2014]. Park, S. & Pearle, M.S., 2006. Imaging for percutaneous renal access and management of renal calculi. The Urologic clinics of North America, 33(3), pp.353–64. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16829270 [Accessed August 14, 2014].
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14 Radecka, E. et al., 2006. Pelvicaliceal biomodeling as an aid to achieving optimal access in percutaneous nephrolithotripsy. Journal of endourology / Endourological Society, 20(2), pp.92–101. Available at: http://online.liebertpub.com/doi/abs/10.1089/end.2006.20.92 [Accessed August 14, 2014]. Rassweiler, J.J. et al., 2012. iPad-assisted percutaneous access to the kidney using marker-based navigation: initial clinical experience. European urology, 61(3), pp.628–31. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22209052 [Accessed August 14, 2014]. Rodrigues, P.L. et al., 2013. Collecting system percutaneous access using real-time tracking sensors: first pig model in vivo experience. The Journal of urology, 190(5), pp.1932–7. Available at: http://www.jurology.com/article/S0022534713043851/fulltext [Accessed August 14, 2014]. Rupel, E. & Brown, R., 1941. Nephroscopy with removal of stone following nephrostomy for obstructive calculous anuria. J Urol, 47, pp.177–182. Available at: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Nephroscopy+with+remo val+of+stone+following+nephrostomy+for+obstructive+calculous+anuria#0 [Accessed August 13, 2014]. Türk, C. et al., 2014. Guidelines on urolithiasis. European Association of Urology (EAU), pp.62– 99. Turney, B.W., 2014. A new model with an anatomically accurate human renal collecting system for training in fluoroscopy-guided percutaneous nephrolithotomy access. Journal of endourology / Endourological Society, 28(3), pp.360–3. Available at: http://online.liebertpub.com/doi/abs/10.1089/end.2013.0616 [Accessed August 14, 2014].
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15 Y Y Yau, J.F.A., 1995. Technical note: maxillofacial biomodelling--preliminary result. The British journal of radiology, 68(809), pp.519 – 23.
Table I. Preoperative Patient Characteristics
Mean age, years
54 (±7)
Gender: male
14 (44%)
female
18 (56%)
Stone type: complete
11 (34%)
partial (with multiple calyceal)
21 (66%)
Previous open renal stone surgeries
9 (28%)
Laterality: left
12 (37.5%)
right
15 (46.8%)
bilateral
5 (15.7%)
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ASA class:
I 8 (25%)
II 17 (53%)
III 7 (22%)
Table II. PCNL Characteristics
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Mean operating time
92 (±26) min.
Position: Prone
29 pts (91%)
Supine
3 pts (9%)
Second look PCNL:
9 pts (28 %)
With complete staghorn stone
6 out of 11 (54.5%)
With partial staghorn stones
3 out of 21 (14.2%)
Tract number: 1
18 pts (56%)
2
9 pts (28%)
3
3 pts (9%)
4
1 pt (3%)
Complete clearance by a single PCNL session
89.4%
Complete clearance by a more than one PCNL session
82%
Overall stone clearance in the study
87.3%
Table III. Postoperative complications (CLAVIEN classification)
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Overall complications encountered:
12 pts (37.5%) 18
Grade 1
6 pts (18.7%)
Transient postoperative fever?
5 pts (15.7%)
Transient creatinine rise
1 pts (3 %)
Grade 2
4 pts (12.5% )
Hemorrhage
2 pts (6.25%)
Postoperative fever >38?
2 pts (6.25%)
Grade 3
2 pts (6%)
Pneumothorax
1 pt (3%)
Ureteral stent placement for clot ureteral obstruction
1 pt (3%)
CT – computed tomography PCNL – percutaneous nephrolithotomy SFR – stone free rate PCS - pelvicalyceal system TFE – tetrafluoroethylene CIRF - clinically insignificant residual fragments IVU – intravenous urography
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Figure 1. Preoperative 3D reconstruction (1a) and plasticine biomodel (1b) of complete
staghorn stone.
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Figure 2. Stepwise depiction of modeling
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Figure 3. Intraoperative navigation
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Figure 4. Before and after PCNL
4a 3D reconstruction
4b Plasticine model
4c Postoperative CT
