Original Paper
Urologia Internationalis
Received: April 7, 2014 Accepted after revision: May 25, 2014 Published online: August 19, 2014
Urol Int 2014;93:411–416 DOI: 10.1159/000364834
Single-Stage Multiple-Tract Percutaneous Nephrolithotomy in the Treatment of Staghorn Stones under Total Ultrasonography Guidance Xiang Fei a Jianxing Li b Yan Song a Bin Wu a a
Urology Division, Sheng Jing Hospital, China Medical University, Shenyang, and b Urology Division, People’s Hospital, Peking University, Beijing, PR China
Key Words Ultrasound · Percutaneous nephrolithotomy · Kidney stone
Abstract Objective: To evaluate the safety and efficacy of single-stage multiple-tract percutaneous nephrolithotomy (PCNL) in the treatment of staghorn stones solely guided by ultrasonography (US). Patients and Methods: From May 2007 to July 2012, 55 single-stage multiple-tract PCNL procedures were performed (53 patients, of whom 2 had bilateral stones). Caliceal puncture and dilatation were performed under US guidance in all cases. The procedure was evaluated for access success, length of postoperative hospital stay, complications (modified Clavien system), and stone clearance. Results: The mean (±SD) operating time was 84.87 ± 24.9 min, with a mean (±SD) postoperative hospital stay of 5.2 ± 1.31 days. The patients experienced a mean (±SD) decrease in hemoglobin level of 8.23 ± 2.39 g/l and the stone-free rate after single-stage surgery was 78.18%. Extracorporeal shock wave lithotripsy was indicated in 2 cases as an auxiliary treatment. There were 10 grade 1 (62.5%) and 6 grade 2 (37.5%) complications; however, there were no complications above grade 3. Conclusion: Total US-guided single-stage multiple-tract PCNL for treating staghorn calculi in selected cases is safe,
© 2014 S. Karger AG, Basel 0042–1138/14/0934–0411$39.50/0 E-Mail [email protected] www.karger.com/uin
feasible, and may be performed with an acceptable morbidity and with the advantage of preventing radiation hazards and damage to adjacent organs. © 2014 S. Karger AG, Basel
Introduction
Staghorn calculi are branched and generally infected stones that occupy the renal pelvis and contain one or more caliceal extensions [1]. Percutaneous nephrolithotomy (PCNL) has been widely recognized as the preferred treatment for renal staghorn calculi [2]. With increasing stone size and complexity, PCNL can require a longer operative time, a larger volume of irrigant fluid, and multiple tracts to achieve better stone clearance. The risk of extended radiation exposure during therapeutic procedures using fluoroscopy is well known [3]. Moreover, the creation of multiple percutaneous tracts has the potential risk of bleeding and organ injury [4]. The use of ultrasonography (US) can avoid radiation exposure and provides a reliable method for the localization of renal stones, especially nonopaque stones that are not visible via fluoroscopy. Moreover, colored US can be used as a tool for localization of intrarenal arterWu Bin, MD Urology Division, Sheng Jing Hospital China Medical University Shenyang (PR China) E-Mail Wu_bin918 @ 163.com
ies and helps to avoid their puncture by a Chiba needle [5–7]. In this study, we reviewed our experience of managing staghorn calculi by single-stage multiple-tract PCNL and assessed the safety and efficacy of totally US-guided PCNL.
Patients and Methods From April 2007 to March 2012, a total of 53 patients with staghorn stones (2 patients had bilateral stones) were identified (fig. 1). Prophylactic antibiotics were administered to all the patients, and patients with infection were treated according to the antibiogram results. Patients were not excluded if they had a history of open renal stone surgery or if they had impaired renal function. Patients with ectopic kidney or urosepsis were excluded from the study. The patients’ demographic characteristics are listed in table 1. Information on the patients’ age, sex, stone type, stone burden, degree of hydronephrosis, and history of urolithiasis and treatment was recorded. Patient assessment included a medical history, physical examination, urine analysis, urine culture, renal function test, and a coagulation test. All patients underwent unenhanced computed tomography (CT) to clarify the size and location of the calculi and the grade of hydronephrosis before undergoing surgery. One surgical team performed all the operations. An institutional review board approved the retrospective chart review of the patients at this institution, and informed consent was obtained from all cases prior to surgery. Stone-free status was defined as the absence of visible fragments in a CT scan. Clinically insignificant residual fragments (CIRF) were defined as those that were 4 mm 2 3.64 (2/55)
Pelvicaliceal system access was successful in all cases. Of the total patient population, 49 (92.45%) patients were treated in the prone or supine and 4 (7.55%) in the lateral flank position. A total of 120 percutaneous access tracts were established in 55 renal units. The number of tracts varied from 2 to 4 in a single renal unit. Forty-six renal units were treated via 2 tracts, 8 renal units required 3 tracts, and 1 renal unit required 4 tracts. The points of entry of these tracts were in 58 cases (58/120, 48.33%) the upper calyx, in 50 (50/120, 41.67%) the middle calyx, and in 12 (12/120, 10%) the lower calyx. The mean (±SD) drop in hemoglobin level was 8.23 ± 2.39 g/l. The mean (±SD) hospital stay after the operation (day) was 5.20 ± 1.31 days. The stones were completely cleared in 43 renal units (78.18%), 10 (18.18%) had insignificant residue after one session of PCNL. Thus, 53 renal units (96.36%) were rendered completely stone-free or had insignificant residue (4 mm or less) after the procedure (table 2). For the remaining 2 renal units, extracorporeal shock wave lithotripsy was thus required and the cases were followed up. There were 10 grade 1 (62.5%) and 6 grade 2 (37.5%) complications, and complications above grade 3 were not encountered. The most common complication in the grade 1 group was transient postoperative fever in 9 cases (56.25%). Among the patients experiencing grade 2 complications, 4 required blood transfusions during or after the procedure. Bleeding resulted from the prolonged operation time required for staghorn stones. Blood transfusions were given during the operation if hemodynamic change was noticed while blood testing was performed. The minimum hemoglobin level preoperatively was 78 g/l. We did not have patients with serious anemia in this study. Infections necessitating antibiotics in addition to the prophylactic drugs were also classified as grade 2 complications. Postoperative fever (>38 ° C) was detected in 2 patients due to culture-positive urinary tract infections and was controlled by parenteral administration of anti-
biotics and antipyretic agents within 3 days. However, both of these 2 patients had sterile preoperative urine cultures; none of the patients developed septic shock. Selective embolization or nephrectomy to control bleeding was not required in this study (table 3).
Ultrasound-Guided Percutaneous Nephrolithotomy
Urol Int 2014;93:411–416 DOI: 10.1159/000364834
a
No statistical significance between preoperative and postoperative cystatin C level.
Table 3. Complications of percutaneous nephrolithotomy classi-
fied according the modified Clavien system Variables
Patients n
%
Total 16 30.19 (16/53) Grade 1 10 18.87 (10/53) Nephrostomy tube displacement 1 1.89 (1/53) Transient fever 700 cases. BJU Int 2013;112:965–971. 9 de la Rosette JJ, Opondo D, Daels FP, et al: Categorisation of complications and validation of the Clavien score for percutaneous
Urol Int 2014;93:411–416 DOI: 10.1159/000364834
10
11
12
13
nephrolithotomy. Eur Urol 2012; 62: 246– 255. Hegarty NJ, Desai MM: Percutaneous nephrolithotomy requiring multiple tracts: comparison of morbidity with single-tract procedures. J Endourol 2006;20:753–760. Kumari G, Kumar P, Wadhwa P, Aron M, Gupta NP, Dogra PN: Radiation exposure to the patient and operating room personnel during percutaneous nephrolithotomy. Int Urol Nephrol 2006;38:207–210. Hellawell GO, Mutch SJ, Thevendran G, Wells E, Morgan RJ: Radiation exposure and the urologist: what are the risks? J Urol 2005; 174:948–952. Basiri A, Ziaee AM, Kianian HR, Mehrabi S, Karami H, Moghaddam SM: Ultrasonographic versus fluoroscopic access for percutaneous nephrolithotomy: a randomized clinical trial. J Endourol 2008;22:281–284.
415
14 Aron M, Goel R, Kesarwani PK, Seth A, Gupta NP: Upper pole access for complex lower pole renal calculi. BJU Int 2004;94:849–852. 15 Wong C, Leveillee RJ: Single upper-pole percutaneous access for treatment of > or = 5-cm complex branched staghorn calculi: is shockwave lithotripsy necessary? J Endourol 2002; 16:477–481. 16 Clayman RV, Elbers J, Miller RP, Williamson J, McKeel D, Wassynger W: Percutaneous nephrostomy: assessment of renal damage associated with semi-rigid (24F) and balloons (36F) dilation. J Urol 1987;138:203–206. 17 Traxer O, Smith TG 3rd, Pearle MS, Corwin TS, Saboorian H, Cadeddu JA: Renal parenchymal injury after standard and mini percutaneous nephrostolithotomy. J Urol 2001;165: 1693–1695.
416
Urol Int 2014;93:411–416 DOI: 10.1159/000364834
18 Marguet CG, Springhart WP, Tan YH, et al: Simultaneous combined use of flexible ureteroscopy and percutaneous nephro-lithotomy to reduce the number of access tracts in the management of complex renal calculi. BJU Int 2005;96:1097–1100. 19 Cheng F, Yu W, Zhang X, Yang S, Xia Y, Ruan Y: Minimally invasive tract in percutaneous nephrolithotomy for renal stones. J Endourol 2010;24:1579–1582. 20 Zhong W, Zeng G, Wu K, Li X, Chen W, Yang H: Does a smaller tract in percutaneous nephrolithotomy contribute to high renal pelvic pressure and postoperative fever? J Endourol 2008;22:2147–2151.
21 Liatsikos EN, Kapoor R, Lee B, Jabbour M, Barbalias G, Smith AD: ‘Angular percutaneous renal access’. Multiple tracts through a single incision for staghorn calculous treatment in a single session. Eur Urol 2005; 48: 832–837. 22 Kukreja R, Desai M, Patel S, Bapat S, Desai M: Factors affecting blood loss during percutaneous nephrolithotomy: prospective study. J Endourol 2004;18:715–722. 23 Maghsoudi R, Etemadian M, Shadpour P, Radfar MH, Ghasemi H, Shati M: Number of tracts or stone size: which influences outcome of percutaneous nephrolithotomy for staghorn renal stones? Urol Int 2012;89:103–106. 24 Chandhoke PS: Cost-effectiveness of different treatment options for staghorn calculi. J Urol 1996;156:1567–1571.
Fei/Li/Song/Wu
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Urologia Internationalis
Received: April 7, 2014 Accepted after revision: May 25, 2014 Published online: August 19, 2014
Urol Int 2014;93:411–416 DOI: 10.1159/000364834
Single-Stage Multiple-Tract Percutaneous Nephrolithotomy in the Treatment of Staghorn Stones under Total Ultrasonography Guidance Xiang Fei a Jianxing Li b Yan Song a Bin Wu a a
Urology Division, Sheng Jing Hospital, China Medical University, Shenyang, and b Urology Division, People’s Hospital, Peking University, Beijing, PR China
Key Words Ultrasound · Percutaneous nephrolithotomy · Kidney stone
Abstract Objective: To evaluate the safety and efficacy of single-stage multiple-tract percutaneous nephrolithotomy (PCNL) in the treatment of staghorn stones solely guided by ultrasonography (US). Patients and Methods: From May 2007 to July 2012, 55 single-stage multiple-tract PCNL procedures were performed (53 patients, of whom 2 had bilateral stones). Caliceal puncture and dilatation were performed under US guidance in all cases. The procedure was evaluated for access success, length of postoperative hospital stay, complications (modified Clavien system), and stone clearance. Results: The mean (±SD) operating time was 84.87 ± 24.9 min, with a mean (±SD) postoperative hospital stay of 5.2 ± 1.31 days. The patients experienced a mean (±SD) decrease in hemoglobin level of 8.23 ± 2.39 g/l and the stone-free rate after single-stage surgery was 78.18%. Extracorporeal shock wave lithotripsy was indicated in 2 cases as an auxiliary treatment. There were 10 grade 1 (62.5%) and 6 grade 2 (37.5%) complications; however, there were no complications above grade 3. Conclusion: Total US-guided single-stage multiple-tract PCNL for treating staghorn calculi in selected cases is safe,
© 2014 S. Karger AG, Basel 0042–1138/14/0934–0411$39.50/0 E-Mail [email protected] www.karger.com/uin
feasible, and may be performed with an acceptable morbidity and with the advantage of preventing radiation hazards and damage to adjacent organs. © 2014 S. Karger AG, Basel
Introduction
Staghorn calculi are branched and generally infected stones that occupy the renal pelvis and contain one or more caliceal extensions [1]. Percutaneous nephrolithotomy (PCNL) has been widely recognized as the preferred treatment for renal staghorn calculi [2]. With increasing stone size and complexity, PCNL can require a longer operative time, a larger volume of irrigant fluid, and multiple tracts to achieve better stone clearance. The risk of extended radiation exposure during therapeutic procedures using fluoroscopy is well known [3]. Moreover, the creation of multiple percutaneous tracts has the potential risk of bleeding and organ injury [4]. The use of ultrasonography (US) can avoid radiation exposure and provides a reliable method for the localization of renal stones, especially nonopaque stones that are not visible via fluoroscopy. Moreover, colored US can be used as a tool for localization of intrarenal arterWu Bin, MD Urology Division, Sheng Jing Hospital China Medical University Shenyang (PR China) E-Mail Wu_bin918 @ 163.com
ies and helps to avoid their puncture by a Chiba needle [5–7]. In this study, we reviewed our experience of managing staghorn calculi by single-stage multiple-tract PCNL and assessed the safety and efficacy of totally US-guided PCNL.
Patients and Methods From April 2007 to March 2012, a total of 53 patients with staghorn stones (2 patients had bilateral stones) were identified (fig. 1). Prophylactic antibiotics were administered to all the patients, and patients with infection were treated according to the antibiogram results. Patients were not excluded if they had a history of open renal stone surgery or if they had impaired renal function. Patients with ectopic kidney or urosepsis were excluded from the study. The patients’ demographic characteristics are listed in table 1. Information on the patients’ age, sex, stone type, stone burden, degree of hydronephrosis, and history of urolithiasis and treatment was recorded. Patient assessment included a medical history, physical examination, urine analysis, urine culture, renal function test, and a coagulation test. All patients underwent unenhanced computed tomography (CT) to clarify the size and location of the calculi and the grade of hydronephrosis before undergoing surgery. One surgical team performed all the operations. An institutional review board approved the retrospective chart review of the patients at this institution, and informed consent was obtained from all cases prior to surgery. Stone-free status was defined as the absence of visible fragments in a CT scan. Clinically insignificant residual fragments (CIRF) were defined as those that were 4 mm 2 3.64 (2/55)
Pelvicaliceal system access was successful in all cases. Of the total patient population, 49 (92.45%) patients were treated in the prone or supine and 4 (7.55%) in the lateral flank position. A total of 120 percutaneous access tracts were established in 55 renal units. The number of tracts varied from 2 to 4 in a single renal unit. Forty-six renal units were treated via 2 tracts, 8 renal units required 3 tracts, and 1 renal unit required 4 tracts. The points of entry of these tracts were in 58 cases (58/120, 48.33%) the upper calyx, in 50 (50/120, 41.67%) the middle calyx, and in 12 (12/120, 10%) the lower calyx. The mean (±SD) drop in hemoglobin level was 8.23 ± 2.39 g/l. The mean (±SD) hospital stay after the operation (day) was 5.20 ± 1.31 days. The stones were completely cleared in 43 renal units (78.18%), 10 (18.18%) had insignificant residue after one session of PCNL. Thus, 53 renal units (96.36%) were rendered completely stone-free or had insignificant residue (4 mm or less) after the procedure (table 2). For the remaining 2 renal units, extracorporeal shock wave lithotripsy was thus required and the cases were followed up. There were 10 grade 1 (62.5%) and 6 grade 2 (37.5%) complications, and complications above grade 3 were not encountered. The most common complication in the grade 1 group was transient postoperative fever in 9 cases (56.25%). Among the patients experiencing grade 2 complications, 4 required blood transfusions during or after the procedure. Bleeding resulted from the prolonged operation time required for staghorn stones. Blood transfusions were given during the operation if hemodynamic change was noticed while blood testing was performed. The minimum hemoglobin level preoperatively was 78 g/l. We did not have patients with serious anemia in this study. Infections necessitating antibiotics in addition to the prophylactic drugs were also classified as grade 2 complications. Postoperative fever (>38 ° C) was detected in 2 patients due to culture-positive urinary tract infections and was controlled by parenteral administration of anti-
biotics and antipyretic agents within 3 days. However, both of these 2 patients had sterile preoperative urine cultures; none of the patients developed septic shock. Selective embolization or nephrectomy to control bleeding was not required in this study (table 3).
Ultrasound-Guided Percutaneous Nephrolithotomy
Urol Int 2014;93:411–416 DOI: 10.1159/000364834
a
No statistical significance between preoperative and postoperative cystatin C level.
Table 3. Complications of percutaneous nephrolithotomy classi-
fied according the modified Clavien system Variables
Patients n
%
Total 16 30.19 (16/53) Grade 1 10 18.87 (10/53) Nephrostomy tube displacement 1 1.89 (1/53) Transient fever 700 cases. BJU Int 2013;112:965–971. 9 de la Rosette JJ, Opondo D, Daels FP, et al: Categorisation of complications and validation of the Clavien score for percutaneous
Urol Int 2014;93:411–416 DOI: 10.1159/000364834
10
11
12
13
nephrolithotomy. Eur Urol 2012; 62: 246– 255. Hegarty NJ, Desai MM: Percutaneous nephrolithotomy requiring multiple tracts: comparison of morbidity with single-tract procedures. J Endourol 2006;20:753–760. Kumari G, Kumar P, Wadhwa P, Aron M, Gupta NP, Dogra PN: Radiation exposure to the patient and operating room personnel during percutaneous nephrolithotomy. Int Urol Nephrol 2006;38:207–210. Hellawell GO, Mutch SJ, Thevendran G, Wells E, Morgan RJ: Radiation exposure and the urologist: what are the risks? J Urol 2005; 174:948–952. Basiri A, Ziaee AM, Kianian HR, Mehrabi S, Karami H, Moghaddam SM: Ultrasonographic versus fluoroscopic access for percutaneous nephrolithotomy: a randomized clinical trial. J Endourol 2008;22:281–284.
415
14 Aron M, Goel R, Kesarwani PK, Seth A, Gupta NP: Upper pole access for complex lower pole renal calculi. BJU Int 2004;94:849–852. 15 Wong C, Leveillee RJ: Single upper-pole percutaneous access for treatment of > or = 5-cm complex branched staghorn calculi: is shockwave lithotripsy necessary? J Endourol 2002; 16:477–481. 16 Clayman RV, Elbers J, Miller RP, Williamson J, McKeel D, Wassynger W: Percutaneous nephrostomy: assessment of renal damage associated with semi-rigid (24F) and balloons (36F) dilation. J Urol 1987;138:203–206. 17 Traxer O, Smith TG 3rd, Pearle MS, Corwin TS, Saboorian H, Cadeddu JA: Renal parenchymal injury after standard and mini percutaneous nephrostolithotomy. J Urol 2001;165: 1693–1695.
416
Urol Int 2014;93:411–416 DOI: 10.1159/000364834
18 Marguet CG, Springhart WP, Tan YH, et al: Simultaneous combined use of flexible ureteroscopy and percutaneous nephro-lithotomy to reduce the number of access tracts in the management of complex renal calculi. BJU Int 2005;96:1097–1100. 19 Cheng F, Yu W, Zhang X, Yang S, Xia Y, Ruan Y: Minimally invasive tract in percutaneous nephrolithotomy for renal stones. J Endourol 2010;24:1579–1582. 20 Zhong W, Zeng G, Wu K, Li X, Chen W, Yang H: Does a smaller tract in percutaneous nephrolithotomy contribute to high renal pelvic pressure and postoperative fever? J Endourol 2008;22:2147–2151.
21 Liatsikos EN, Kapoor R, Lee B, Jabbour M, Barbalias G, Smith AD: ‘Angular percutaneous renal access’. Multiple tracts through a single incision for staghorn calculous treatment in a single session. Eur Urol 2005; 48: 832–837. 22 Kukreja R, Desai M, Patel S, Bapat S, Desai M: Factors affecting blood loss during percutaneous nephrolithotomy: prospective study. J Endourol 2004;18:715–722. 23 Maghsoudi R, Etemadian M, Shadpour P, Radfar MH, Ghasemi H, Shati M: Number of tracts or stone size: which influences outcome of percutaneous nephrolithotomy for staghorn renal stones? Urol Int 2012;89:103–106. 24 Chandhoke PS: Cost-effectiveness of different treatment options for staghorn calculi. J Urol 1996;156:1567–1571.
Fei/Li/Song/Wu
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
