Original Paper
Urologia Internationalis
Urol Int 2014,92:422–426 DOI: 10.1159/000354427
Received: March 4, 2013 Accepted after revision: July 16, 2013 Published online: March 13, 2014
Standard-Tract Combined with Mini-Tract in Percutaneous Nephrolithotomy for Renal Staghorn Calculi Yanbo Wang Yuchuan Hou Fengming Jiang Yan Wang Qihui Chen Zhihua Lu Jinghai Hu Xiaoqing Wang Ji Lu Chunxi Wang Department of Urology, First Hospital of Jilin University, Changchun, PR China
Abstract Purpose: To compare the safety and efficacy of standardtract combined with mini-tract to single standard-tract in percutaneous nephrolithotomy (PCNL) for renal staghorn calculi. Methods: The records of 216 patients with staghorn calculi (110 (50.9%) had complete and 106 (49.1%) had partial) who received PCNL were reviewed retrospectively. 58 patients received standard-tract combined with mini-tract PCNL (group A) and 158 patients underwent single standard-tract PCNL (group B). Both groups had comparable demographic data. Operation time, stone-free rate, blood transfusion rate, hospital stay and complications were analyzed. Results: Postoperative Clavien score in the two groups was similar. The rate of blood transfusion and perioperative bleeding requiring superselective embolization were not statistically significant between the groups (p = 0.557, 0.463, respectively). The mean operation time was comparable between groups in the standard-tract combined with mini-
© 2014 S. Karger AG, Basel 0042–1138/14/0924–0422$39.50/0 E-Mail [email protected] www.karger.com/uin
tract group. The stone-free rate was significantly higher (89.7 vs. 78.5%, p = 0.044) in group A than in group B. The rate of second PCNL was higher in group B. Conclusion: The standard-tract combined with mini-tract results had higher success rates with no increase in the incidence of complications, and should be the first option for renal staghorn calculi. © 2014 S. Karger AG, Basel
Recently, percutaneous nephrolithotomy (PCNL) has become the preferred first-line treatment for large and complex renal calculi [1, 2]. However, the treatment of renal staghorn calculi is still one of the biggest difficulties in PCNL. The debate continues over the use of singletract versus multiple-tract PCNL in these cases. Some scholars believed that aggressive PCNL monotherapy using multiple tracts was safe and effective [3, 4], and should be the first option for massive renal staghorn calculi. However, Manohar et al. [5] found that greater blood loss occurred in patients requiring multiple tracts. Netto et al.
Y. Wang, Y. Hou, Y. Wang and C. Wang contributed equally to this work.
Chunxi Wang, PhD Department of Urology The First Hospital of Jilin University 71 Xinmin ST, Changchun, Jilin Province (PR China) E-Mail chunxi_wang @ 126.com
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/13/2014 3:09:05 PM
Key Words Percutaneous nephrolithotomy · Standard-tract · Mini-tract · Standard-tract combined with mini-tract · Staghorn calculi
[6] showed a higher transfusion rate when multiple tracts were employed. In this study, we performed a retrospective analysis of renal staghorn calculi patients treated with standardtract combined with mini-tract or single standard-tract PCNL.
Patients and Methods
Fig. 1. First wire and second wire.
Color version available online
PCNL Procedure The entire procedure was performed with the patient under general anesthesia. A 5-Fr external ureteral catheter was inserted retrograde to the pelvicalyceal system and the patient was then turned prone. The appropriate calyx for puncture was selected using an 18-gauge needle (Cook Inc., USA) under ultrasound guidance (Aloka 5 multicolor ultrasound instrument with transducer frequency 3.5 MHz, Japan) based on the anatomy of the stone configuration and the intrarenal collecting system. Once the pelvicalyceal system was entered, a first guidewire (Boston Scientific Corporation, USA) was manipulated down the ureter if possible, or coiled in a distant calyx. The first access was dilated as the standard-tract. However, we routinely performed another puncture and a preplaced second wire was put into the collecting system as a potential mini-tract (fig. 1). Tract dilation was accomplished using Amplatz (Cook Inc., USA) or balloon dilators (BCR Inc., USA) of up to 16 Fr (mini-tract) or 24 Fr (standard-tract) in size (fig. 2). A cybersonics double-catheter system (Cybersonics Inc., USA) or holmium laser was used to fragment and remove the stone through a rigid 20-Fr nephroscope or 9-Fr ureteroscope. The operations were completed when residual fragments were not detected on fluoroscopic imaging and rigid nephroscopic control. At the end of the procedure, a clamped 20- or 14-Fr Foley catheter was inserted to act as a nephrostomy tube and kept open for 24 h. If there was no extravasation, the tube was removed 4 days after surgery. A double-J tube was routinely inserted into the ureter and removed about 1 month later in the out-patient clinic. Stone clearance was documented on plain radiograph on the next morning. Patients with postoperative residual fragments ≤4 mm were accepted as stone-free (clinically insignificant residual fragments).
A total of 216 patients with staghorn calculi, including 117 males and 99 females, were treated with PCNL (table 1), of which 110 (50.9%) had complete and 106 (49.1%) partial staghorn calculi. A total of 58 (26.9%) patients were treated with standard-tract combined with
Standard-Tract Mini-Tract PCNL Staghorn Stones
Urol Int 2014;92:422–426 DOI: 10.1159/000354427
Fig. 2. Standard-tract and mini-tract.
Statistical Analysis SPSS software package (versions 13.0, SPSS, Inc., Chicago, Ill., USA) was used for all statistical analyses. Comparisons were made using Student’s t tests and Pearson’s χ2 tests, where appropriate. p < 0.05 was considered statistically significant.
Results
423
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/13/2014 3:09:05 PM
Clinical Data We reviewed the records of 216 patients who had undergone PCNL for staghorn calculi in our department between May 2005 and May 2012, including 58 standard-tract combined with minitract procedures (group A) and 158 single standard-tract PCNL (group B). Staghorn calculi included complete staghorn stone (filling the renal pelvis and all of the calyceal system or occupying ≥80% of the renal collecting system) and partial staghorn stone (filling the renal pelvis and at least one calyceal system). All patients were definitively diagnosed preoperatively by plain film X-rays, intravenous pyelogram or CT scan. Patients’ demographics, including age, sex, BMI, history of surgery, presence of hydronephrosis, stone position and stone burden were recorded. All operations were performed by one surgeon, with at least 5 years of experience with PCNL.
Table 1. Patient characteristics
Parameters
Group A
Group B
p value
Total patients M/F ratio Mean age, years (range) Mean BMI Complete staghorn stone Partial staghorn stone Side, right/left, n Mean maximum stone diameter, cm (range) Hydronephrosis, yes/no History of surgery, n (%)
58 32:26 43.6 (22–70) 25.3 (20–28) 28 30 30:28 5.9 (3.8–11.6) 42/16 4 (6.9)
158 85:73 44.5 (23–69) 24.9 (21–28) 82 76 80:78 6.2 (3.9–10.8) 110:48 10 (6.3)
0.857 0.712 0.383 0.637 0.637 0.887 0.425 0.690 0.881
Group A = Standard-tract combined with mini-tract; group B = single standard-tract.
Table 2. Intraoperative and postoperative parameters
Parameters
Group A
Group B
p value
Mean operating time, min (range) Stone-free rate, % Analgesic requirement (tramadol), mg Mean hospital stay, days (range) II phase PCNL, n (%)
78.8 (55–155) 52 (89.7) 190 (50–300) 8.3 (6–12) 2 (3.4)
81.3 (55–165) 124 (78.5) 180 (50–300) 8.2 (6–12) 20 (12.7)
0.178 0.044 0.789 0.745 0.047
Complications, n (%) Clavien grade 1 Transient fever Clavien grade 2 Blood transfusion Infections requiring additional antibiotics Clavien grade 3 Perioperative bleeding requiring superselective embolization
8 (13.8)
13 (8.2)
0.221
5 (8.6) 10 (17.2)
10 (6.3) 21 (13.3)
0.557 0.463
1 (1.7)
2 (1.3)
0.799
Group A = Standard-tract combined with mini-tract; group B = single standard-tract.
424
Urol Int 2014;92:422–426 DOI: 10.1159/000354427
the single standard-tract group. Compared to the standard-tract combined with mini-tract group, the rate of repeat PCNL was significantly higher in the single standard-tract group (p < 0.05).
Discussion
Staghorn calculi are branched stones that fill the renal pelvis and branch into several or all of the calices [7, 8]. Despite the widespread appeal of PCNL in the management of large-volume renal stones, its application in paWang/Hou/Jiang/Wang/Chen/Lu/Hu/ Wang/Lu/Wang
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/13/2014 3:09:05 PM
mini-tract PCNL (group A), and the remaining (73.1%) patients underwent single standard-tract PCNL (group B). The mean age of the patients, stone size, BMI, and exist of hydronephrosis were similar between groups (table 1). Postoperative Clavien score in the two groups was similar (table 2). There was no statistical difference in operation time between the groups. Mean hospital stay, postoperative analgesic requirement and hospitalization expenses were comparable in the two groups. The stonefree rate was significantly higher (89.7 vs. 78.5%, p < 0.05) in the standard-tract combined with mini-tract than in
tients with staghorn calculi is one of the more challenging endourologic procedures. Complete removal of the stone to relieve the obstruction and restoration of kidney function with minimal morbidity is the objective of any interventional procedure [9–12]. Mahesh Desai et al. [13] found that stone-free rates were lower, complications more frequent, and operative time and hospital stay longer in patients with staghorn stones. In order to elevate the stone-free rate, many scholars attempted multitract accesses in PCNL. Manohar et al. [5] described the technique of ‘multi-miniperc’. They found that the stone-free rate was 86%. However, only 39% of the patients could be rendered stone free with a single tract. The authors concluded that although increasing the number of tracts exponentially increases the blood loss, it does not add to the overall complication rate. A similar conclusion was drawn by Cho et al. [14]. Their study showed that multitract PCNL for appropriately chosen stones has similar safety and effectiveness as single PCNL in patients with smaller and less complex stones. However, Akman et al. [15] retrospectively reviewed 413 patients with staghorn calculi. A total of 244 (59%) patients were managed by single access (group 1); meanwhile, multiple accesses were necessary in 169 (41%) patients (group 2). They found that operative time was significantly longer and bleeding was the most common complication in group 2 (p < 0.0001). In our study, the rate of blood transfusion and perioperative bleeding requiring superselective embolization were similar between the standard-tract combined with mini-tract and the single standard-tract group. We believed that this was due to the benefits of standard-tract combined with mini-tract instead of multi-standard tracts. Elevating the stone-free rate was one of the most important aspects based on the safety of PCNL. Our study showed that the stone free rate was significantly higher (89.7 vs. 78.5%, p < 0.05) in the standard-tract combined
with mini-tract than in the single standard-tract group. The rate of second PCNL was higher in the single standard-tract group. The mean operation time was comparable between groups instead of longer in the standard-tract combined with mini-tract group. We argued that the preplaced wire into the collecting system as the potential mini-tract contributed to reduction of time. Ultrasound may be unable to pinpoint the exact position of the stone remnants due to intraoperative hemorrhage and exudation, which may result in puncture failure or prolonged puncture. Several standard tracts could improve the stone clearance rate, but the risk of bleeding and blood transfusion are high. While multiple mini-tracts could reduce the risk of bleeding and blood transfusion, they may also reduce the stone clearance rate. Standard-tract combined with mini-tract is the best choice for staghorn stones in PCNL. The limitations of this study are as follows. It is a retrospective study and a selection bias is inherent. The number of cases in the study was comparatively small, which results in a lack of enough confidence in the statistical analysis of the data. Moreover, we did not evaluate changes in renal function after surgery.
Conclusion
The standard-tract combined with mini-tract method results in higher success rates with no increase in the incidence of complications, and should be the first option for renal staghorn calculi. The preplaced wire into the collecting system as the potential mini-tract contributes to the reduction in time.
Disclosure Statement There are no conflicts of interest.
1 Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS, Wolf JS Jr: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol 2005;173:1991–2000. 2 Ganpule AP, Desai M: Management of the staghorn calculus: multiple-tract versus single-tract percutaneous nephrolithotomy. Curr Opin Urol 2008;18:220–223. 3 Aron M, Yadav R, Goel R, Kolla SB, Gautam G, Hemal AK, Gupta NP: Multi-tract percu-
Standard-Tract Mini-Tract PCNL Staghorn Stones
taneous nephrolithotomy for large complete staghorn calculi. Urol Int 2005;75:327–332. 4 Akman T, Sari E, Binbay M, Yuruk E, Tepeler A, Kaba M, Muslumanoglu AY, Tefekli A: Comparison of outcomes after percutaneous nephrolithotomy of staghorn calculi in those with single and multiple accesses. J Endourol 2010;24:955–960. 5 Manohar T, Ganpule AP, Shrivastav P, Desai M: Percutaneous nephrolithotomy for complex caliceal calculi and staghorn stones in
Urol Int 2014;92:422–426 DOI: 10.1159/000354427
children less than 5 years of age. J Endourol 2006;20:547–551. 6 Netto NR Jr, Ikonomidis J, Ikari O, Claro JA: Comparative study of percutaneous access for staghorn calculi. Urology 2005; 65: 659– 662. 7 Soucy F, Ko R, Duvdevani M, Nott L, Denstedt JD, Razvi H: Percutaneous nephrolithotomy for staghorn calculi: a single center’s experience over 15 years. J Endourol 2009; 23: 1669–1673.
425
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/13/2014 3:09:05 PM
References
426
Urol Int 2014;92:422–426 DOI: 10.1159/000354427
11 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. 12 Wang Y, Jiang F, Wang Y, Hou Y, Zhang H, Chen Q, Xu N, Lu Z, Hu J, Lu J, Wang X, Hao Y, Wang C: Post-percutaneous nephrolithotomy septic shock and severe hemorrhage: a study of risk factors. Urol Int 2012;88: 307–310.
13 Desai M, De Lisa A, Turna B, Rioja J, Walfridsson H, D’Addessi A, Wong C, Rosette on Behalf of the Croes PCNL Study Group J: The clinical research office of the Endourological Society Percutaneous Nephrolithotomy Global Study: staghorn versus nonstaghorn stones. J Endourol 2011;25:1263–1268. 14 Cho HJ, Lee JY, Kim SW, Hwang TK, Hong SH: Percutaneous nephrolithotomy for complex renal calculi: is multi-tract approach OK? Can J Urol 2012;19:6360–6365. 15 Akman T, Sari E, Binbay M, Yuruk E, Tepeler A, Kaba M, Muslumanoglu AY, Tefekli A: Comparison of outcomes after percutaneous nephrolithotomy of staghorn calculi in those with single and multiple accesses. J Endourol 2010;24:955–960.
Wang/Hou/Jiang/Wang/Chen/Lu/Hu/ Wang/Lu/Wang
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/13/2014 3:09:05 PM
8 Pevzner M, Stisser BC, Luskin J, Yeamans JC, Cheng-Lucey M, Pahira JJ: Alternative management of complex renal stones. Int Urol Nephrol 2011;43:631–638. 9 Akman T, Binbay M, Kezer C, Yuruk E, Tekinarslan E, Ozgor F, Sari E, Aslan R, Berberoglu Y, Muslumanoglu AY: Factors affecting kidney function and stone recurrence rate after percutaneous nephrolithotomy for staghorn calculi: outcomes of a long-term followup. J Urol 2012;187:1656–1661. 10 El-Nahas AR, Eraky I, Shokeir AA, Shoma AM, El-Assmy AM, El-Tabey NA, El-Kappany HA, El-Kenawy MR: Long-term results of percutaneous nephrolithotomy for treatment of staghorn stones. BJU Int 2011; 108: 750– 754.
Urologia Internationalis
Urol Int 2014,92:422–426 DOI: 10.1159/000354427
Received: March 4, 2013 Accepted after revision: July 16, 2013 Published online: March 13, 2014
Standard-Tract Combined with Mini-Tract in Percutaneous Nephrolithotomy for Renal Staghorn Calculi Yanbo Wang Yuchuan Hou Fengming Jiang Yan Wang Qihui Chen Zhihua Lu Jinghai Hu Xiaoqing Wang Ji Lu Chunxi Wang Department of Urology, First Hospital of Jilin University, Changchun, PR China
Abstract Purpose: To compare the safety and efficacy of standardtract combined with mini-tract to single standard-tract in percutaneous nephrolithotomy (PCNL) for renal staghorn calculi. Methods: The records of 216 patients with staghorn calculi (110 (50.9%) had complete and 106 (49.1%) had partial) who received PCNL were reviewed retrospectively. 58 patients received standard-tract combined with mini-tract PCNL (group A) and 158 patients underwent single standard-tract PCNL (group B). Both groups had comparable demographic data. Operation time, stone-free rate, blood transfusion rate, hospital stay and complications were analyzed. Results: Postoperative Clavien score in the two groups was similar. The rate of blood transfusion and perioperative bleeding requiring superselective embolization were not statistically significant between the groups (p = 0.557, 0.463, respectively). The mean operation time was comparable between groups in the standard-tract combined with mini-
© 2014 S. Karger AG, Basel 0042–1138/14/0924–0422$39.50/0 E-Mail [email protected] www.karger.com/uin
tract group. The stone-free rate was significantly higher (89.7 vs. 78.5%, p = 0.044) in group A than in group B. The rate of second PCNL was higher in group B. Conclusion: The standard-tract combined with mini-tract results had higher success rates with no increase in the incidence of complications, and should be the first option for renal staghorn calculi. © 2014 S. Karger AG, Basel
Recently, percutaneous nephrolithotomy (PCNL) has become the preferred first-line treatment for large and complex renal calculi [1, 2]. However, the treatment of renal staghorn calculi is still one of the biggest difficulties in PCNL. The debate continues over the use of singletract versus multiple-tract PCNL in these cases. Some scholars believed that aggressive PCNL monotherapy using multiple tracts was safe and effective [3, 4], and should be the first option for massive renal staghorn calculi. However, Manohar et al. [5] found that greater blood loss occurred in patients requiring multiple tracts. Netto et al.
Y. Wang, Y. Hou, Y. Wang and C. Wang contributed equally to this work.
Chunxi Wang, PhD Department of Urology The First Hospital of Jilin University 71 Xinmin ST, Changchun, Jilin Province (PR China) E-Mail chunxi_wang @ 126.com
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/13/2014 3:09:05 PM
Key Words Percutaneous nephrolithotomy · Standard-tract · Mini-tract · Standard-tract combined with mini-tract · Staghorn calculi
[6] showed a higher transfusion rate when multiple tracts were employed. In this study, we performed a retrospective analysis of renal staghorn calculi patients treated with standardtract combined with mini-tract or single standard-tract PCNL.
Patients and Methods
Fig. 1. First wire and second wire.
Color version available online
PCNL Procedure The entire procedure was performed with the patient under general anesthesia. A 5-Fr external ureteral catheter was inserted retrograde to the pelvicalyceal system and the patient was then turned prone. The appropriate calyx for puncture was selected using an 18-gauge needle (Cook Inc., USA) under ultrasound guidance (Aloka 5 multicolor ultrasound instrument with transducer frequency 3.5 MHz, Japan) based on the anatomy of the stone configuration and the intrarenal collecting system. Once the pelvicalyceal system was entered, a first guidewire (Boston Scientific Corporation, USA) was manipulated down the ureter if possible, or coiled in a distant calyx. The first access was dilated as the standard-tract. However, we routinely performed another puncture and a preplaced second wire was put into the collecting system as a potential mini-tract (fig. 1). Tract dilation was accomplished using Amplatz (Cook Inc., USA) or balloon dilators (BCR Inc., USA) of up to 16 Fr (mini-tract) or 24 Fr (standard-tract) in size (fig. 2). A cybersonics double-catheter system (Cybersonics Inc., USA) or holmium laser was used to fragment and remove the stone through a rigid 20-Fr nephroscope or 9-Fr ureteroscope. The operations were completed when residual fragments were not detected on fluoroscopic imaging and rigid nephroscopic control. At the end of the procedure, a clamped 20- or 14-Fr Foley catheter was inserted to act as a nephrostomy tube and kept open for 24 h. If there was no extravasation, the tube was removed 4 days after surgery. A double-J tube was routinely inserted into the ureter and removed about 1 month later in the out-patient clinic. Stone clearance was documented on plain radiograph on the next morning. Patients with postoperative residual fragments ≤4 mm were accepted as stone-free (clinically insignificant residual fragments).
A total of 216 patients with staghorn calculi, including 117 males and 99 females, were treated with PCNL (table 1), of which 110 (50.9%) had complete and 106 (49.1%) partial staghorn calculi. A total of 58 (26.9%) patients were treated with standard-tract combined with
Standard-Tract Mini-Tract PCNL Staghorn Stones
Urol Int 2014;92:422–426 DOI: 10.1159/000354427
Fig. 2. Standard-tract and mini-tract.
Statistical Analysis SPSS software package (versions 13.0, SPSS, Inc., Chicago, Ill., USA) was used for all statistical analyses. Comparisons were made using Student’s t tests and Pearson’s χ2 tests, where appropriate. p < 0.05 was considered statistically significant.
Results
423
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/13/2014 3:09:05 PM
Clinical Data We reviewed the records of 216 patients who had undergone PCNL for staghorn calculi in our department between May 2005 and May 2012, including 58 standard-tract combined with minitract procedures (group A) and 158 single standard-tract PCNL (group B). Staghorn calculi included complete staghorn stone (filling the renal pelvis and all of the calyceal system or occupying ≥80% of the renal collecting system) and partial staghorn stone (filling the renal pelvis and at least one calyceal system). All patients were definitively diagnosed preoperatively by plain film X-rays, intravenous pyelogram or CT scan. Patients’ demographics, including age, sex, BMI, history of surgery, presence of hydronephrosis, stone position and stone burden were recorded. All operations were performed by one surgeon, with at least 5 years of experience with PCNL.
Table 1. Patient characteristics
Parameters
Group A
Group B
p value
Total patients M/F ratio Mean age, years (range) Mean BMI Complete staghorn stone Partial staghorn stone Side, right/left, n Mean maximum stone diameter, cm (range) Hydronephrosis, yes/no History of surgery, n (%)
58 32:26 43.6 (22–70) 25.3 (20–28) 28 30 30:28 5.9 (3.8–11.6) 42/16 4 (6.9)
158 85:73 44.5 (23–69) 24.9 (21–28) 82 76 80:78 6.2 (3.9–10.8) 110:48 10 (6.3)
0.857 0.712 0.383 0.637 0.637 0.887 0.425 0.690 0.881
Group A = Standard-tract combined with mini-tract; group B = single standard-tract.
Table 2. Intraoperative and postoperative parameters
Parameters
Group A
Group B
p value
Mean operating time, min (range) Stone-free rate, % Analgesic requirement (tramadol), mg Mean hospital stay, days (range) II phase PCNL, n (%)
78.8 (55–155) 52 (89.7) 190 (50–300) 8.3 (6–12) 2 (3.4)
81.3 (55–165) 124 (78.5) 180 (50–300) 8.2 (6–12) 20 (12.7)
0.178 0.044 0.789 0.745 0.047
Complications, n (%) Clavien grade 1 Transient fever Clavien grade 2 Blood transfusion Infections requiring additional antibiotics Clavien grade 3 Perioperative bleeding requiring superselective embolization
8 (13.8)
13 (8.2)
0.221
5 (8.6) 10 (17.2)
10 (6.3) 21 (13.3)
0.557 0.463
1 (1.7)
2 (1.3)
0.799
Group A = Standard-tract combined with mini-tract; group B = single standard-tract.
424
Urol Int 2014;92:422–426 DOI: 10.1159/000354427
the single standard-tract group. Compared to the standard-tract combined with mini-tract group, the rate of repeat PCNL was significantly higher in the single standard-tract group (p < 0.05).
Discussion
Staghorn calculi are branched stones that fill the renal pelvis and branch into several or all of the calices [7, 8]. Despite the widespread appeal of PCNL in the management of large-volume renal stones, its application in paWang/Hou/Jiang/Wang/Chen/Lu/Hu/ Wang/Lu/Wang
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/13/2014 3:09:05 PM
mini-tract PCNL (group A), and the remaining (73.1%) patients underwent single standard-tract PCNL (group B). The mean age of the patients, stone size, BMI, and exist of hydronephrosis were similar between groups (table 1). Postoperative Clavien score in the two groups was similar (table 2). There was no statistical difference in operation time between the groups. Mean hospital stay, postoperative analgesic requirement and hospitalization expenses were comparable in the two groups. The stonefree rate was significantly higher (89.7 vs. 78.5%, p < 0.05) in the standard-tract combined with mini-tract than in
tients with staghorn calculi is one of the more challenging endourologic procedures. Complete removal of the stone to relieve the obstruction and restoration of kidney function with minimal morbidity is the objective of any interventional procedure [9–12]. Mahesh Desai et al. [13] found that stone-free rates were lower, complications more frequent, and operative time and hospital stay longer in patients with staghorn stones. In order to elevate the stone-free rate, many scholars attempted multitract accesses in PCNL. Manohar et al. [5] described the technique of ‘multi-miniperc’. They found that the stone-free rate was 86%. However, only 39% of the patients could be rendered stone free with a single tract. The authors concluded that although increasing the number of tracts exponentially increases the blood loss, it does not add to the overall complication rate. A similar conclusion was drawn by Cho et al. [14]. Their study showed that multitract PCNL for appropriately chosen stones has similar safety and effectiveness as single PCNL in patients with smaller and less complex stones. However, Akman et al. [15] retrospectively reviewed 413 patients with staghorn calculi. A total of 244 (59%) patients were managed by single access (group 1); meanwhile, multiple accesses were necessary in 169 (41%) patients (group 2). They found that operative time was significantly longer and bleeding was the most common complication in group 2 (p < 0.0001). In our study, the rate of blood transfusion and perioperative bleeding requiring superselective embolization were similar between the standard-tract combined with mini-tract and the single standard-tract group. We believed that this was due to the benefits of standard-tract combined with mini-tract instead of multi-standard tracts. Elevating the stone-free rate was one of the most important aspects based on the safety of PCNL. Our study showed that the stone free rate was significantly higher (89.7 vs. 78.5%, p < 0.05) in the standard-tract combined
with mini-tract than in the single standard-tract group. The rate of second PCNL was higher in the single standard-tract group. The mean operation time was comparable between groups instead of longer in the standard-tract combined with mini-tract group. We argued that the preplaced wire into the collecting system as the potential mini-tract contributed to reduction of time. Ultrasound may be unable to pinpoint the exact position of the stone remnants due to intraoperative hemorrhage and exudation, which may result in puncture failure or prolonged puncture. Several standard tracts could improve the stone clearance rate, but the risk of bleeding and blood transfusion are high. While multiple mini-tracts could reduce the risk of bleeding and blood transfusion, they may also reduce the stone clearance rate. Standard-tract combined with mini-tract is the best choice for staghorn stones in PCNL. The limitations of this study are as follows. It is a retrospective study and a selection bias is inherent. The number of cases in the study was comparatively small, which results in a lack of enough confidence in the statistical analysis of the data. Moreover, we did not evaluate changes in renal function after surgery.
Conclusion
The standard-tract combined with mini-tract method results in higher success rates with no increase in the incidence of complications, and should be the first option for renal staghorn calculi. The preplaced wire into the collecting system as the potential mini-tract contributes to the reduction in time.
Disclosure Statement There are no conflicts of interest.
1 Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS, Wolf JS Jr: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol 2005;173:1991–2000. 2 Ganpule AP, Desai M: Management of the staghorn calculus: multiple-tract versus single-tract percutaneous nephrolithotomy. Curr Opin Urol 2008;18:220–223. 3 Aron M, Yadav R, Goel R, Kolla SB, Gautam G, Hemal AK, Gupta NP: Multi-tract percu-
Standard-Tract Mini-Tract PCNL Staghorn Stones
taneous nephrolithotomy for large complete staghorn calculi. Urol Int 2005;75:327–332. 4 Akman T, Sari E, Binbay M, Yuruk E, Tepeler A, Kaba M, Muslumanoglu AY, Tefekli A: Comparison of outcomes after percutaneous nephrolithotomy of staghorn calculi in those with single and multiple accesses. J Endourol 2010;24:955–960. 5 Manohar T, Ganpule AP, Shrivastav P, Desai M: Percutaneous nephrolithotomy for complex caliceal calculi and staghorn stones in
Urol Int 2014;92:422–426 DOI: 10.1159/000354427
children less than 5 years of age. J Endourol 2006;20:547–551. 6 Netto NR Jr, Ikonomidis J, Ikari O, Claro JA: Comparative study of percutaneous access for staghorn calculi. Urology 2005; 65: 659– 662. 7 Soucy F, Ko R, Duvdevani M, Nott L, Denstedt JD, Razvi H: Percutaneous nephrolithotomy for staghorn calculi: a single center’s experience over 15 years. J Endourol 2009; 23: 1669–1673.
425
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/13/2014 3:09:05 PM
References
426
Urol Int 2014;92:422–426 DOI: 10.1159/000354427
11 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. 12 Wang Y, Jiang F, Wang Y, Hou Y, Zhang H, Chen Q, Xu N, Lu Z, Hu J, Lu J, Wang X, Hao Y, Wang C: Post-percutaneous nephrolithotomy septic shock and severe hemorrhage: a study of risk factors. Urol Int 2012;88: 307–310.
13 Desai M, De Lisa A, Turna B, Rioja J, Walfridsson H, D’Addessi A, Wong C, Rosette on Behalf of the Croes PCNL Study Group J: The clinical research office of the Endourological Society Percutaneous Nephrolithotomy Global Study: staghorn versus nonstaghorn stones. J Endourol 2011;25:1263–1268. 14 Cho HJ, Lee JY, Kim SW, Hwang TK, Hong SH: Percutaneous nephrolithotomy for complex renal calculi: is multi-tract approach OK? Can J Urol 2012;19:6360–6365. 15 Akman T, Sari E, Binbay M, Yuruk E, Tepeler A, Kaba M, Muslumanoglu AY, Tefekli A: Comparison of outcomes after percutaneous nephrolithotomy of staghorn calculi in those with single and multiple accesses. J Endourol 2010;24:955–960.
Wang/Hou/Jiang/Wang/Chen/Lu/Hu/ Wang/Lu/Wang
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/13/2014 3:09:05 PM
8 Pevzner M, Stisser BC, Luskin J, Yeamans JC, Cheng-Lucey M, Pahira JJ: Alternative management of complex renal stones. Int Urol Nephrol 2011;43:631–638. 9 Akman T, Binbay M, Kezer C, Yuruk E, Tekinarslan E, Ozgor F, Sari E, Aslan R, Berberoglu Y, Muslumanoglu AY: Factors affecting kidney function and stone recurrence rate after percutaneous nephrolithotomy for staghorn calculi: outcomes of a long-term followup. J Urol 2012;187:1656–1661. 10 El-Nahas AR, Eraky I, Shokeir AA, Shoma AM, El-Assmy AM, El-Tabey NA, El-Kappany HA, El-Kenawy MR: Long-term results of percutaneous nephrolithotomy for treatment of staghorn stones. BJU Int 2011; 108: 750– 754.
