A randomized control trial evaluating efficacy of nephrostomy tract infiltration with bupivacaine after tubeless percutaneous nephrolithotomy.

PURPOSE: We conducted a randomized controlled trial to assess the efficacy of nephrostomy tract infiltration with bupivacaine in tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: All adult patients undergoing unilateral tubeless PCNL from July 1, 2007 to October 31, 2007 were included in the study. Patients were randomized to receive infiltration of bupivacaine in the nephrostomy tract at the end of the procedure or not to receive bupivacaine. To show a 10% difference in postoperative pain, a sample size of 30 persons per group would be needed. Postoperatively, the pain score were obtained at 4 and 24 hours by a nurse who was blinded to the protocol. The perioperative outcome of these patients (study group) was compared with those undergoing tubeless PCNL without nephrostomy tract infiltration of bupivacaine (control group). RESULTS: Patient demographics and intraoperative parameters in both groups were comparable. Supracostal access was needed in 65.7% and 72.7% patients in the study and control group, respectively. The nephrostomy tract were infiltrated with bupivacaine in 31 patients. The visual analogue pain score at 4 hours and 24 hours for the study group was 2.66 ± 1.07 & 2.23 ± 0.50 respectively, while in control group was 5.15 ± 1.52 and 3.22 ± 1.11, respectively (P=0.000). There was a trend toward lesser analgesia requirement in the study group (94.8 vs 124.2 mg of diclofenac sodium). There was no difference in the duration of postoperative catheterization, hospital stay, stone-free rates, and complication between both groups. CONCLUSIONS: Nephrostomy tract infiltration of bupivacaine in tubeless PCNL is associated with less postoperative pain and analgesia requirement.

Tubeless percutaneous nephrolithotomy: 3 years of experience with 454 patients.

OBJECTIVE: To present our experience with 454 patients who had tubeless percutaneous nephrolithotomy (TPCNL) over last 3 years. PATIENTS AND METHODS: From September 2004 to August 2007, all patients aged >14 years and undergoing PCNL were considered for TPCNL. Exclusion criteria were the presence of pyonephrosis, matrix calculi, significant bleeding or residual stone burden and need for three of more percutaneous accesses. These patients had a nephrostomy tube placed after PCNL (control group). The remaining patients undergoing TPCNL (study group) had antegrade ureteric stenting. Demographic and perioperative data were compared retrospectively. RESULTS: Of 840 patients who had PCNL during the study period, 454 had TPCNL. The two groups had comparable demographic data except for a smaller stone burden (322.8 vs 832.2 mm(2)) and fewer staghorn calculi (94 vs 154) in patients undergoing TPCNL (P < 0.001). The mean number of tracts per renal unit and operative duration were statistically higher in patients undergoing standard PCNL (1.5 vs 1.1, and 68.8 vs 52.2 min, respectively). The decrease in haemoglobin, complication and stone-free rates were comparable. TPCNL was associated with less postoperative pain, analgesia requirement and earlier discharge (P < 0.001). CONCLUSIONS: TPCNL can be used with a favourable outcome and no increase in complications in selected patients, with the potential advantages of decreased postoperative pain, analgesia requirement and hospital stay. Its application can be extended to patients with a solitary kidney, previous ipsilateral open surgery, raised serum creatinine level, in the presence of three renal accesses or supracostal access, and in patients undergoing bilateral synchronous PCNL or contralateral endourological stone treatment.

The management of renal matrix calculi: a single-centre experience over 5 years.

OBJECTIVE: To define incidence of renal matrix calculi in patients undergoing percutaneous nephrolithotomy (PCNL), and describe its clinical, laboratory and radiological features; we also studied the efficacy of PCNL in managing this rare entity. PATIENTS AND METHODS: We retrospectively reviewed the records of 1368 PCNLs performed from April 2003 to March 2008, and identified 17 patients (mean age 44.3 years; 11 women and six men) having matrix calculi. The patients' clinical, laboratory and radiological features were studied, and the perioperative outcome and follow-up data analysed. RESULTS: Flank pain was commonest mode of presentation (15) followed by recurrent urinary tract infection (five). Pyuria was present in 14 patients and urine culture showed significant growth in 10. A plain X-ray showed a small radio-opaque calculus (10 renal units) and faint laminated calcification (four). Intravenous urography showed a filling defect and non-visualized system in nine and five patients, respectively. Non-contrast computed tomography and magnetic resonance urography diagnosed calculi in two and one patient, respectively, on haemodialysis. PCNL was abandoned initially in four patients due to pyonephrosis. The mean hospital stay was 3.4 days and decrease in haemoglobin was 0.89 g/dL. One patient developed sepsis. Of 11 stones analysed, two were composed entirely of proteins and the remaining nine had crystalline components. At a mean follow-up of 12.6 months, no patients had recurrence of stone. CONCLUSIONS: Matrix calculi occurred in 1.24% of patients undergoing PCNL. Although considered radiolucent, plain X-ray showed a small radio-opaque calculi or faint laminated calcifications in 10 of 17 patients. PCNL rendered patients stone-free with minimum morbidity.

Post-radical prostatectomy rectourethral fistula: endosopic management.

Rectal injuries diagnosed during radical prostatectomy are readily treated with primary closure and omental interposition. However, once this fails and a fistula develops, the treatment gets more complex. Various surgeries have been described to manage these fistulae, but these are not done frequently and require a great deal of expertise. We report a patient with post-radical prostatectomy rectourethral fistula, treated with cyanoacrylate glue injected through a colonoscope as the fistulous tract was well visualized per rectum. The patient is voiding well per urethra with no rectal leakage 3 months post-catheter removal. Thus, use of cyanoacrylate glue as a minimally invasive non-surgical technique for management of rectourethral fistula appears to be a good option which can be tried before embarking on major surgery.

A randomized trial evaluating type of nephrostomy drainage after percutaneous nephrolithotomy: small bore v tubeless.

PURPOSE: To compare the outcome of tubeless percutaneous nephrolithotomy (PCNL) with small-bore nephrostomy drainage after PCNL. PATIENTS AND METHODS: We tested the hypothesis that tubeless PCNL is superior to small-bore nephrostomy drainage after PCNL in terms of postoperative pain, analgesic requirement, and hospital stay. To show a 10% difference in these parameters, a sample size of 30 persons per group would be needed. All patients undergoing PCNL from September 2005 to May 2006 were included in the study. Patients meeting the inclusion and exclusion criteria were then randomized to either a tubeless approach with insertion of a ureteral stent or placement of an 8F nephrostomy tube without insertion of a ureteral stent. The perioperative outcomes of patients in the two groups were compared. RESULTS: Tubeless PCNL was performed in 33 patients, and an 8F nephrostomy tube was placed in 32 patients. The two groups had comparable demographic data. The hemoglobin drop and complication rate between the two groups were comparable. Patients undergoing tubeless PCNL experienced less postoperative pain (P = 0.001), needed less analgesia (P = 0.006), and were discharged 9 hours earlier than patients in the other group. Complete stone clearance was achieved in 87.87% patients in the tubeless group and 87.5% patients in the nephrostomy group. In the tubeless group, 39.4% of patients had bothersome stent-related symptoms, of whom 61.5% needed analgesics and/or antispasmodic agents. CONCLUSIONS: Tubeless PCNL offers the potential advantages of decreased postoperative pain, analgesic requirement, and hospital stay without increasing the complications. It was associated with stent-related discomfort in 39% of patients.

Endoscopic management of adult orthotopic ureterocele and associated calculi with holmium laser: experience with 16 patients over 4 years and review of literature.

PURPOSE: To retrospectively evaluate the safety and effectiveness of holmium laser endoscopic incision and laser lithotripsy in adults with orthotopic ureterocele and associated calculi. PATIENTS AND METHODS: From May 2003 to August 2007 at our center, 16 adults underwent transurethral incision of an ureterocele and intracorporeal holmium laser lithotripsy for associated calculi. The perioperative data of these patients were retrospectively analyzed. The literature was reviewed to identify all the reported options for management of this relatively rare condition. RESULTS: Ureterocele was associated with a single system in 13 patients. Two patients had bilateral ureteroceles. Four patients had associated upper tract stones. The procedure was uneventful in all patients. The average postoperative hospital stay was 19.3 hours. All patients were stone free after the procedure. Eleven patients were available for follow-up at 3 and 6 months. None of these patients had any evidence of residual ureterocele and/or hydronephrosis when evaluated with intravenous urography at 3 months. Micturating cystourethrography (MCU) at 3 months revealed low-grade vesicoureteral reflux (VUR) in four patients; no reflux was found with MCU at 6 months. CONCLUSIONS: Laser endoscopic management of adult orthotopic ureterocele and associated calculi effectively decompressed ureterocele and removed stones in all patients without any significant postoperative morbidity. Low-grade VUR that may occur postoperatively resolved at 6 months. A literature review suggests that the ability of the holmium laser to manage both ureterocele and calculi simultaneously should make holmium laser management a procedure of choice at centers that possess the equipment.

Influence of prostate size on the outcome of holmium laser enucleation of the prostate.

OBJECTIVE: To analyse the effect of prostate size on the outcome of holmium laser enucleation of prostate (HoLEP, an established procedure for treating symptomatic benign prostatic hypertrophy, BPH), in the initial 354 patients at 1 year of follow-up. PATIENTS AND METHODS: We retrospectively reviewed the records of 354 patients who had HoLEP at our institution from April 2003 to March 2007. In 235 patients the prostate weighed <60 g (group 1), in 77 it weighed 60-100 g (group 2) and in 42 >100 g (group 3). Demographic data and perioperative variables were recorded and compared among the three groups. RESULTS: The mean prostate size was 38.1, 76.4 and 133.5 g for groups 1, 2 and 3, respectively (P < 0.001), and the respective mean weight of resected prostate was 18.47, 40.8 and 82.76 g, respectively (P < 0.001). The mean procedure efficiency increased from 0.36 g/min in group 1 to 0.49 g/min in group 2 and 0.58 g/min in group 3 (P < 0.001). The decrease in haemoglobin level after HoLEP was greater in group 3 than in the other groups. Overall, HoLEP resulted in a 75% reduction in American Urologic Association symptom score, a 225% increase in peak urinary flow rate and an 86% decrease in postvoid residual urine volume at 1 year of follow-up. Perioperative complications were evenly distributed among the three groups, except for a higher incidence of superficial bladder mucosal injury and stenotic complications in group 3. CONCLUSIONS: HoLEP is a safe and effective procedure for treating symptomatic BPH, independent of prostate size, and is associated with low morbidity. The efficiency of HoLEP increases with increasing prostate size.