Comparing Bleeding Complications of Double and Single Access Totally Tubeless PCNL: Is It Safe to Obtain More Accesses?

PURPOSE: To assess bleeding complications in totally tubeless double-access percutaneous nephrolithotomy (PCNL) and compare it with the single-access method. METHODS: One hundred and seven patients with large or scattered renal stones were enrolled in this cohort study. Totally tubeless PCNL with one access (group A, 70 cases) or two accesses (group B, 37 cases) was done and bleeding was assessed by measuring the hemoglobin drop of the patients, blood transfusion rate and need for performing angioembolization. RESULTS: The mean (SD) hemoglobin drops in groups A and B were 1.97 (1.24) and 2.31 (1.24), respectively; p = 0.176. Blood transfusion rates in two groups were 7.1 and 10.8% (p = 0.716), respectively. None of our patients required angioembolization. The average hemoglobin drop and blood transfusion rate with double tracts were approximately near to those in single tract group and in acceptable ranges. The average hospital stay in groups A and B were 3.1 and 3.2 days (p = 0.074), respectively. There was no leakage from puncture site/s and stone free rates in the two groups were 85.7 and 97.3% (p = 0.093). CONCLUSION: Totally tubeless double-access PCNL is feasible and bleeding complications are comparable to single access totally tubeless PCNL making it an effective strategy to achieve more stone free rates.

Totally tubeless percutaneous nephrolithotomy is feasible in morbidly obese patients.

OBJECTIVE: Regarding technical difficulties that obese body habitus might impose to percutaneous nephrolithotomy (PNL) success and higher risk of peri-operative complications in this group of patients, we decided to retrospectively gather data from our patients during past 8 years to determine the stone free and complication rates. MATERIAL AND METHODS: Between January 2007-December 2015, seventy-eight obese patients with body mass index over 35 who had indication for PNL including stones larger than 2 cm in pelvi-calyceal system or smaller extracorporeal shock wave lithotripsy (ESWL) resistant stones or who were not a fit candidate for ESWL due to increased skin to target distance, with no contraindication of PNL (including bleeding diathesis, inability to be positioned in prone) were enrolled. They were randomly assigned to group 1 (standard PNL with nephrostomy and ureteral stent) or group 2 (totally tubeless PNL with no ureteral stent and no nephrostomy). The outcomes were compared. RESULTS: The transfusion rate, operation time, and the hemoglobin drop were same across the groups (p>0.05). Total analgesic use was equivalent of 33.8 vs. 14.7 mgs of morphine sulfate (18-77 mg) and was significantly lower in total tubeless group (p=0.001). Return to normal activity was described as total number of in-patient and outpatient days from time of admission to the point which the patients returns to normal life activity such as going to job or school and was 19.4 vs. 9.3 days (6-30 days, p=0.001). CONCLUSION: Totally tubeless PNL in obese subjects would have lower analgesic use and return to normal activity versus standard PNL. Totally tubeless PNL is recommended for obese patients.

Is intravenous urography required when ultrasonography and KUB evidence a ureteroscopy plan?

PURPOSE: To determine whether pre-ureteroscopic stone extraction (USE) evaluation by intravenous urography (IVU) can change the clinical decision made on the basis of a plain X-ray of the kidneys, ureters, and bladder (KUB) plus an ultrasonography in the case of ureteral calculi. MATERIALS AND METHODS: From October 2005 to November 2007, 139 USE candidates were selected based on ultrasonography and KUB, and were randomly divided into two groups. Each group was assessed by an expert urologist to decide about the treatment plans. Thereafter, all the patients underwent an IVU pre-operatively and were evaluated for the second time by the other urologist considering IVU. Presence of a hydronephrotic kidney on the ultrasonography, existence of a density in the probable tract of the ureter on KUB, and previous episodes of renal colic were considered as inclusion criteria. Exclusion criteria were non-opaque stones on KUB, hypersensitivity to contrast media, and serum creatinine > 1.5 mg/dL. RESULTS: On the basis of ultrasonography and KUB assessment, all of the patients were identified candidate for USE. According to secondary IVU-based planning, of 139 patients, 127 (91.3%) required USE, 10 (7.1%) ureteroscopy, and 2 (1.4%) non-operative treatment. About 8.7% of treatment plans was changed by IVU, which was not statistically significant (P = .35). Positive predictive value of ultrasonography plus KUB to diagnose a ureteral stone which needed USE was 92.8% while IVU is the gold standard (95% confidence interval: 92.38 to 93.22). CONCLUSION: Intravenous urography is not useful enough to be performed routinely before entire USEs.

Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access.

PURPOSE: To assess the outcome and safety of the totally tubeless percutaneous nephrolithotomy (PCNL) from subcostal access in patients with renal stone in the upper pole of the kidney. PATIENTS AND METHODS: Seventy patients with upper pole renal stones were enrolled in a randomized clinical trial from April 2003 to November 2008. The inclusion criteria were the existence of solely upper pole stones, stone size >1.5 cm, extracorporeal shockwave lithotripsy failure or stone in closed calix and diverticulum, and successful subcostal access for reaching the stone. The exclusion criteria were unsuccessful subcostal access, more than two percutaneous accesses, prominent collecting system perforation, intraoperative significant bleeding, ureteral obstruction, and renal anomaly. The totally tubeless procedure was performed on 35 patients (group A); another 35 patients (group B) underwent standard PCNL. The incidence of complications, hospital stay, transfusion rate, stone-free rate, and analgesics use as well as return to normal activity were compared during a 1-month study period. RESULTS: The mean stone burden was 2.81 (standard deviation [SD] = 0.59) in group A vs 2.87 (SD = 0.62) cm(2) in group B. Hospitalization averaged 1.49 (SD = 0.7) vs 2.89 (SD = 0.99) days (P < 0.001), and the average analgesics use was 8.2 (SD = 3.59) mg vs 14.3 (SD = 5.99) mg of morphine, respectively (P < 0.001). The patients returned to normal activity in 11 (SD = 4.2) days in group A vs 17.6 (SD = 4) days in group B (P < 0.001). Operative time, transfusion rate, complications, re-treatment, and the overall stone-free rate were not different significantly, and no major complication was seen in the study as well. CONCLUSION: Totally tubeless PCNL for the upper pole renal stone from subcostal access is accompanied by decreased hospital stay and analgesics use and a rapid return to normal activity. It can be considered as an accepted and cost-beneficial procedure for upper pole renal stones.