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PURPOSE: to identify risk factors for urinary septic shock in patients who underwent percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: Data from PCNL procedures performed between January 2009 and February 2020 were retrospectively analyzed. The study included all patients over 18 years old with kidney stones larger than 15 mm who underwent PCNL. Patients who underwent mini-PCNL or combined surgeries, such as ureteroscopy or bilateral procedures, were not included in the study. Logistic regression was conducted to determine the risk factors for urinary septic shock within 30 days post-operation in patients who underwent PCNL. RESULTS: Urinary septic shock was observed in 8 out of the 1,424 patients analyzed (0.56%). The presence of comorbidities, evaluated using the Charlson Comorbidity Index (CCI) (OR 1.46 [CI 95% 1.15-1.86], p=0.01), larger stones (41.0 mm [IQR 30.0-47.5 mm] vs. 24.0 mm [IQR 17.0-35.0 mm], OR 1.03 [CI 95% 1.01-1.06], p=0.04), and a positive preoperative urine culture (OR 8.53 [CI 95% 1.71-42.45], p < 0.01) were shown to significantly increase the risk of postoperative urinary septic shock. Patients with a CCI > 2, larger stones (≥ 35 mm), and a positive preoperative urine culture were at even higher risk of urinary septic shock (OR 15.40 [CI 95% 1.77-134.21], p=0.01). CONCLUSION: Patients with larger stones, positive preoperative urine culture, and a higher CCI are at risk for urinary septic shock after PCNL. These findings are of utmost importance for optimizing the perioperative care of these patients to prevent life-threatening complications.
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Cálculos Renais , Nefrolitotomia Percutânea , Complicações Pós-Operatórias , Choque Séptico , Humanos , Choque Séptico/etiologia , Nefrolitotomia Percutânea/efeitos adversos , Feminino , Masculino , Fatores de Risco , Estudos Retrospectivos , Pessoa de Meia-Idade , Cálculos Renais/cirurgia , Adulto , Complicações Pós-Operatórias/etiologia , Idoso , Modelos LogísticosRESUMO
OBJECTIVE: To compare the outcomes of retrograde flexible ureteroscopy (fURS) with retroperitoneal laparoscopic ureterolithotomy (RLU) for large proximal ureteric stones. PATIENTS AND METHODS: A prospective randomised trial was conducted from January 2018 through December 2022 including patients with impacted proximal ureteric stones of 15-25 mm. Patients underwent fURS or RLU. Primary outcome was the stone-free rate. Demographic data, stone features, and complications rates were also compared between groups. RESULTS: A total of 64 patients were enrolled, 32 in each group. The mean impacted stone time was similar between groups, as well as stone size (17 mm) and stone density (>1000 Hounsfield Units). The ureteric stone-free rates between the two groups (93.7% in fURS vs 96.8% in RLU; odds ratio [OR] 0.72, 95% confidence interval [CI] -1.72 to 3.17; P = 0.554), and overall success rates, which take into account residual fragments in the kidney (84.3% in fURS vs 93.7% in RLU; OR 1.02, 95% CI -0.69 to 2.74; P = 0.23), were similar. Operative time was also not statistically significantly different between groups (median 80 vs 82 min; P = 0.101). There was no difference in hospital length of stay. Retropulsion rate was higher with fURS (65.6% vs 3.1%; p < 0.001). Residual hydronephrosis (34.3% each group) and complication rates did no differ according to treatment. CONCLUSION: Flexible URS and RLU are both highly efficient and present low morbidity for large impacted proximal ureteric stone treatment. RLU is not superior to fURS.
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ABSTRACT Background: Success rates in endourological procedures, notably percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), have demonstrated suboptimal outcomes, leading to more reinterventions and radiation exposure. Recently, the use of intraoperative computed tomography (ICT) scans has been hypothesized as a promising solution for improving outcomes in endourology procedures. With this considered, we conducted a comprehensive systematic review and meta-analysis encompassing all available studies that evaluate the impact of the use of intraoperative CT scans on surgical outcomes compared to conventional fluoroscopic-guided procedures. Methods: This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were systematically searched up to December of 2023. This study aimed to directly compare the use of an ICT scan with the standard non-ICT-guided procedure. The primary endpoint of interest was success rate, and the secondary endpoints were complications and reintervention rates, while radiation exposure was also evaluated. Data extraction and quality assessment were performed following Cochrane recommendations. Data was presented as an Odds ratio with 95%CI across trials and a random-effects model was selected for pooling of data. Results: A comprehensive search yielded 533 studies, resulting in the selection of 3 cohorts including 327 patients (103 ICT vs 224 in non-ICT). Primary outcome was significantly higher in the experimental group versus the control group (84.5% vs 41.4% respectively, 307 patients; 95% CI [3.61, 12.72]; p<0.00001; I2=0). Reintervention rates also decreased from 32.6% in the control to 12.6% in the ICT group (OR 0.34; 95%CI [0.12,0.94]; p =0.04; I2= 48%), whereas complication rates did not exhibit significant differences. Radiation exposure was also significantly reduced in two of the included studies. Conclusion: This meta-analysis highlights a favorable outcome with intraoperative CT scan use in PCNL procedures, showing a considerable increase in SFR when compared to standard fluoroscopy and nephroscopy. Despite limited studies, our synthesis underscores the potential of ICT scans to significantly reduce residual stones and their consequences for endourology patients, as reinterventions and follow-up ionizing radiation studies.
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INTRODUCTION: Ureteral stricture is often a consequence of urolithiasis or previous endourological procedures (1-3). Precisely delineating the stricture zone intraoperatively is crucial to minimize ureter shortening and target only the affected tissue (4, 5). Flexible ureteroscopy offers a significant advantage in this regard. OBJECTIVE: This video aims to demonstrate the step-by-step technique of flexible ureteroscopic guided laparoscopic ureteroplasty for treating ureteral stricture caused by urolithiasis and prior endourological interventions. PATIENT AND METHODS: We present a case of a 36-year-old male with a history of urolithiasis and unsuccessful endourological treatments, including endoureterotomy and balloon dilation, diagnosed with re-stenosis of the proximal ureter of 1 cm through ureteroscopy and pyelography. He underwent a successful laparoscopic ureteroplasty. While the lead surgeon performed the laparoscopy, an assistant conducted the flexible ureteroscopy. Intraoperatively, using transillumination facilitated by the flexible ureteroscope, we can precisely identify the narrowed area, allowing for resection of only the damaged segment. Subsequently, we perform the end-to-end ureteroplasty, confirming its patency through the seamless passage of the ureteroscope. Upon completion, we employ a fat patch to safeguard the anastomosis. RESULTS: The patient was discharged on the third postoperative day. Double J stent was removed six weeks after surgery. Symptoms resolved. Renal function improved: eGFR 49 to 67 ml/min. Furthermore, improvement was observed in the DTPA scan, and a decrease in hydronephrosis was noted on the follow-up tomography. CONCLUSION: Flexible ureteroscopy effectively identifies the stricture zone in laparoscopic ureteroplasty, enhancing surgical precision and outcomes. This approach is safe, effective, and reproducible, offering a valuable technique in the surgical treatment of ureteral strictures.
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Laparoscopia , Obstrução Ureteral , Ureteroscopia , Humanos , Masculino , Adulto , Ureteroscopia/métodos , Laparoscopia/métodos , Obstrução Ureteral/cirurgia , Resultado do Tratamento , Ureter/cirurgia , Constrição Patológica/cirurgia , Ureteroscópios , Urolitíase/cirurgiaRESUMO
ABSTRACT Purpose: The aim of this study is to perform a high-quality meta-analysis using only randomized controlled trials (RCT) to better define the role of postoperative antibiotics in patients undergoing percutaneous nephrolithotomy (PCNL). Materials and Methods: A literature search for RCTs in EMBASE, PubMed, and Web of Science up to May 2023 was conducted following the PICO framework: Population—adult patients who underwent PCNL; Intervention—postoperative antibiotic prophylaxis until nephrostomy tube withdrawal; Control—single dose of antibiotic during the induction of anesthesia; and Outcome—systemic inflammatory response syndrome (SIRS) or sepsis and fever after PCNL. The protocol was registered on the PROSPERO database (CRD42022361579). We calculated odds ratios (OR) and 95% confidence intervals (CI). A random-effects model was employed, and the alpha risk was defined as < 0.05. Results: Seven articles, encompassing a total of 629 patients, were included in the analysis. The outcome of SIRS or sepsis was extracted from six of the included studies, while the outcome of postoperative fever was extracted from four studies. The analysis revealed no statistical association between the use of postoperative antibiotic prophylaxis until nephrostomy tube withdrawal and the occurrence of SIRS/sepsis (OR 1.236, 95% CI 0.731 - 2.089, p=0.429) or fever (OR 2.049, 95% CI 0.790 - 5.316, p=0.140). Conclusion: Our findings suggest that there is no benefit associated with the use of postoperative antibiotic prophylaxis until nephrostomy tube withdrawal in patients undergoing percutaneous nephrolithotomy (PCNL). We recommend that antibiotic prophylaxis should be administered only until the induction of anesthesia in PCNL.
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BACKGROUND: Success rates in endourological procedures, notably percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), have demonstrated suboptimal outcomes, leading to more reinterventions and radiation exposure. Recently, the use of intraoperative computed tomography (ICT) scans has been hypothesized as a promising solution for improving outcomes in endourology procedures. With this considered, we conducted a comprehensive systematic review and meta-analysis encompassing all available studies that evaluate the impact of the use of intraoperative CT scans on surgical outcomes compared to conventional fluoroscopic-guided procedures. METHODS: This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were systematically searched up to December of 2023. This study aimed to directly compare the use of an ICT scan with the standard non-ICT-guided procedure. The primary endpoint of interest was success rate, and the secondary endpoints were complications and reintervention rates, while radiation exposure was also evaluated. Data extraction and quality assessment were performed following Cochrane recommendations. Data was presented as an Odds ratio with 95%CI across trials and a random-effects model was selected for pooling of data. RESULTS: A comprehensive search yielded 533 studies, resulting in the selection of 3 cohorts including 327 patients (103 ICT vs 224 in non-ICT). Primary outcome was significantly higher in the experimental group versus the control group (84.5% vs 41.4% respectively, 307 patients; 95% CI [3.61, 12.72]; p<0.00001; I2=0). Reintervention rates also decreased from 32.6% in the control to 12.6% in the ICT group (OR 0.34; 95%CI [0.12,0.94]; p =0.04; I2= 48%), whereas complication rates did not exhibit significant differences. Radiation exposure was also significantly reduced in two of the included studies. CONCLUSION: This meta-analysis highlights a favorable outcome with intraoperative CT scan use in PCNL procedures, showing a considerable increase in SFR when compared to standard fluoroscopy and nephroscopy. Despite limited studies, our synthesis underscores the potential of ICT scans to significantly reduce residual stones and their consequences for endourology patients, as reinterventions and follow-up ionizing radiation studies.
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Nefrolitotomia Percutânea , Tomografia Computadorizada por Raios X , Ureteroscopia , Humanos , Tomografia Computadorizada por Raios X/métodos , Nefrolitotomia Percutânea/métodos , Nefrolitotomia Percutânea/efeitos adversos , Ureteroscopia/métodos , Ureteroscopia/efeitos adversos , Cálculos Renais/cirurgia , Cálculos Renais/diagnóstico por imagem , Cuidados Intraoperatórios/métodos , Resultado do Tratamento , Fluoroscopia/métodos , Exposição à Radiação/análiseRESUMO
PURPOSE: We searched for perioperative renal function deterioration risk factors in patients that underwent bilateral flexible ureteroscopy (fURS) for kidney stones. METHODS: From August 2016 to February 2020, symptomatic patients > 18 years old with bilateral kidney stones up to 20 mm in each side were prospectively studied. Serum creatinine samples were collected on admission to surgery, immediate postoperative (IPO), on POD 3, 10, and 30. Estimated glomerular filtration rate (eGFR) was calculated using Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI) without a race coefficient. RESULTS: Thirty patients underwent bilateral fURS. Comparing to preoperative eGFR, median IPO and POD3 eGFR (p < 0.001) were significantly lower, and POD10 (p = 0.092) and POD30 (p = 0.648) were similar to preoperative eGFR. During follow-up, 22/30 (73.3%), 14/30 (46.7%), and 7/30 (23.3%) of the patients presented a decrease > 10% eGFR, > 20% eGFR, and > 30% eGFR, respectively. Multivariate analysis demonstrated that lower preoperative eGFR is a risk factor for eGFR < 60 mL/min/1.73 m2, p = 0.019 [1.021-1.263; 1.136]; ASA > 1 is a risk factor for decrease of eGFR > 10%, p = 0.028 [1.25-51.13; 8.00]; longer operative time is a risk factor for decrease of eGFR > 20%, p = 0.042 [1.00-1.05; 1.028]; and operative time ≥ 120 min is a risk factor for decrease of eGFR > 30%, p = 0.026 [0.016-0.773; 0.113]. CONCLUSIONS: Renal function suffers a reversible decrease after bilateral fURS. Our study suggests that adequate selection of patients and maintaining operative time < 120 min are relevant factors in preventing acute renal function deterioration following bilateral fURS.
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Cálculos Renais , Insuficiência Renal Crônica , Humanos , Adolescente , Ureteroscopia/efeitos adversos , Cálculos Renais/etiologia , Ureteroscópios , Insuficiência Renal Crônica/etiologia , Taxa de Filtração Glomerular , Rim/cirurgiaRESUMO
PURPOSE: The aim of this study is to perform a high-quality meta-analysis using only randomized controlled trials (RCT) to better define the role of postoperative antibiotics in patients undergoing percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: A literature search for RCTs in EMBASE, PubMed, and Web of Science up to May 2023 was conducted following the PICO framework: Population-adult patients who underwent PCNL; Intervention-postoperative antibiotic prophylaxis until nephrostomy tube withdrawal; Control-single dose of antibiotic during the induction of anesthesia; and Outcome-systemic inflammatory response syndrome (SIRS) or sepsis and fever after PCNL. The protocol was registered on the PROSPERO database (CRD42022361579). We calculated odds ratios (OR) and 95% confidence intervals (CI). A random-effects model was employed, and the alpha risk was defined as < 0.05. RESULTS: Seven articles, encompassing a total of 629 patients, were included in the analysis. The outcome of SIRS or sepsis was extracted from six of the included studies, while the outcome of postoperative fever was extracted from four studies. The analysis revealed no statistical association between the use of postoperative antibiotic prophylaxis until nephrostomy tube withdrawal and the occurrence of SIRS/sepsis (OR 1.236, 95% CI 0.731 - 2.089, p=0.429) or fever (OR 2.049, 95% CI 0.790 - 5.316, p=0.140). CONCLUSION: Our findings suggest that there is no benefit associated with the use of postoperative antibiotic prophylaxis until nephrostomy tube withdrawal in patients undergoing percutaneous nephrolithotomy (PCNL). We recommend that antibiotic prophylaxis should be administered only until the induction of anesthesia in PCNL.
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Antibioticoprofilaxia , Nefrolitotomia Percutânea , Complicações Pós-Operatórias , Sepse , Síndrome de Resposta Inflamatória Sistêmica , Humanos , Nefrolitotomia Percutânea/efeitos adversos , Nefrolitotomia Percutânea/métodos , Antibioticoprofilaxia/métodos , Complicações Pós-Operatórias/prevenção & controle , Síndrome de Resposta Inflamatória Sistêmica/prevenção & controle , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Sepse/prevenção & controle , Sepse/etiologia , Fatores de Risco , Antibacterianos/uso terapêutico , Antibacterianos/administração & dosagem , Ensaios Clínicos Controlados Aleatórios como Assunto , Febre/etiologiaRESUMO
Introduction: The American Urological Association guidelines state that continuing anticoagulant (AC) and antiplatelet (AP) agents during ureteroscopy (URS) is safe. Through a multi-institutional retrospective study, we sought to determine whether pre-stenting in patients on AP or AC was associated with fewer URS bleeding-related complications. Methods: A series of 8614 URS procedures performed across three institutions (April 2010 to September 2017) was electronically reviewed for AC/AP use at time of URS. Records indicating AC or AP use at time of URS were then manually reviewed to characterize intraoperative and 30-day postoperative (intraoperative bleeding, postoperative hematuria, emergency department visits, hospital readmission, unplanned reoperation, phone calls, and other minor 30-day complications). Results: A total of 293 identified URS procedures were completed on patients on AC/AP therapy-112 cases were on AC only (38 were pre-stented), 158 on AP only (51 pre-stented), and 23 on both AP and AC (8 pre-stented). Patient characteristics and comorbidities were similar between the pre-stented and non-pre-stented groups. For AC and AP subjects, pre-stenting did not decrease the composite risk of bleeding complications (10.3% pre-stent vs 12.2% non-prestent, p = 0.6). Pre-stented patients did have a significantly lower likelihood of requiring an unplanned reoperation (1.0% vs 5.6%, p = 0.04). In the subgroup of patients on AP alone, pre-stented patients had significantly fewer episodes of intraoperative bleeding (0% vs 9%, p = 0.04), unplanned reoperations (0% vs 6.5%, p = 0.02), and 30-day complications (14% vs 27%, p = 0.05). In the subgroup of patients on AC alone, there were no significant differences in outcomes based on stent status. Conclusions: In this multi-institutional study, we found that pre-stenting before URS was not associated with fewer bleeding complications. However, pre-stenting appeared to be associated with improved outcomes for those patients on AP therapy. These results suggest a need for prospective studies to clarify the role of pre-stenting for URS.
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Cálculos Ureterais , Ureteroscopia , Humanos , Ureteroscopia/efeitos adversos , Ureteroscopia/métodos , Inibidores da Agregação Plaquetária/efeitos adversos , Cálculos Ureterais/cirurgia , Estudos Retrospectivos , Estudos Prospectivos , Anticoagulantes/efeitos adversos , Hemorragia/etiologia , Stents/efeitos adversos , Resultado do Tratamento , Complicações Pós-Operatórias/etiologiaRESUMO
OBJECTIVE: The aim of this study was to identify predictive factors for complications after percutaneous nephrolithotomy. METHODS: We prospectively analyzed patients who underwent percutaneous nephrolithotomy from June 2011 to October 2018. The association of preoperative and intraoperative factors with the presence of complications was assessed using univariate and multivariate analyses. The significance level was set at p<0.05. RESULTS: A total of 1,066 surgeries were evaluated, and the overall complication rate was 14.9%. In all, 105 (9.8%) surgeries were performed in the prone position, and 961 (90.2%) were performed in the supine position. Univariate analysis demonstrated that surgical position, upper pole puncture, surgical time, number of tracts, and Guys Stone Score were associated with complications. In multivariate analyses, prone position (odds ratio [OR] 2.10; p=0.003), surgical time ≥90 min (OR 1.76; p=0.014), upper pole puncture (OR 2.48; p<0.001), and Guys Stone Score 3 or 4 (OR 1.90; p=0.033) were independent predictive factors for complications after percutaneous nephrolithotomy. CONCLUSION: Performing percutaneous nephrolithotomy in the supine position, in under 90 min, and avoiding upper pole punctures may reduce complications during the treatment of large kidney stones.
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Cálculos Renais , Nefrolitotomia Percutânea , Nefrostomia Percutânea , Masculino , Humanos , Nefrolitotomia Percutânea/efeitos adversos , Nefrostomia Percutânea/efeitos adversos , Resultado do Tratamento , Cálculos Renais/cirurgia , Cálculos Renais/complicações , Posicionamento do Paciente/efeitos adversos , Decúbito Ventral , Decúbito Dorsal , Estudos Retrospectivos , Complicações Pós-Operatórias/etiologiaRESUMO
ABSTRACT Purpose The aim of this meta-analysis is to assess the efficacy of extended dose of preoperative antibiotics to reduce infectious risk in patients undergoing percutaneous nephrolithotomy (PCNL). Materials and Methods A literature search for prospective case-control studies or randomized controlled trials was done. PICO framework was used. Population: adult patients that underwent to PCNL; Intervention: extended dose preoperative antibiotic prophylaxis before PCNL; Control: short dose preoperative antibiotic prophylaxis before PCNL; and Outcome: systemic inflammatory response syndrome (SIRS) or sepsis, fever after PCNL and positive intraoperative urine and stone culture. This meta-analysis was registered in PROSPERO database under the number: CRD42022359589. Results Three RCT and two prospective studies (475 patients) were included. SIRS/sepsis outcome was retrieved from all studies included. Seven days preoperative oral antibiotics for PCNL was a protective factor for developing SIRS/sepsis (OR 0.366, 95% CI 0.234 - 0.527, p < 0.001). There was no statistical association between seven-day use of antibiotics and fever (OR 0.592, 95% CI 0.147 - 2.388, p = 0.462). Patients who received seven days preoperative antibiotics had lower positive intraoperative urine culture (OR 0.284, 95% CI 0.120 - 0.674, p = 0.004) and stone culture (OR 0.351, 95% CI 0.185 - 0.663, p = 0.001) than the control group. Conclusion one week of prophylactic oral antibiotics based on local bacterial sensitivity pattern plus a dose of intravenous antibiotics at the time of surgery in patients undergoing PCNL reduces the risk of infection.
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PURPOSE: The aim of this meta-analysis is to assess the efficacy of extended dose of preoperative antibiotics to reduce infectious risk in patients undergoing percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: A literature search for prospective case-control studies or randomized controlled trials was done. PICO framework was used. POPULATION: adult patients that underwent to PCNL; Intervention: extended dose preoperative antibiotic prophylaxis before PCNL; Control: short dose preoperative antibiotic prophylaxis before PCNL; and Outcome: systemic inflammatory response syndrome (SIRS) or sepsis, fever after PCNL and positive intraoperative urine and stone culture. This meta-analysis was registered in PROSPERO database under the number: CRD42022359589. RESULTS: Three RCT and two prospective studies (475 patients) were included. SIRS/sepsis outcome was retrieved from all studies included. Seven days preoperative oral antibiotics for PCNL was a protective factor for developing SIRS/sepsis (OR 0.366, 95% CI 0.234 - 0.527, p < 0.001). There was no statistical association between seven-day use of antibiotics and fever (OR 0.592, 95% CI 0.147 - 2.388, p = 0.462). Patients who received seven days preoperative antibiotics had lower positive intraoperative urine culture (OR 0.284, 95% CI 0.120 - 0.674, p = 0.004) and stone culture (OR 0.351, 95% CI 0.185 - 0.663, p = 0.001) than the control group. CONCLUSION: one week of prophylactic oral antibiotics based on local bacterial sensitivity pattern plus a dose of intravenous antibiotics at the time of surgery in patients undergoing PCNL reduces the risk of infection.
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Cálculos Renais , Nefrolitotomia Percutânea , Nefrostomia Percutânea , Sepse , Adulto , Humanos , Nefrolitotomia Percutânea/efeitos adversos , Antibacterianos/uso terapêutico , Estudos Prospectivos , Nefrostomia Percutânea/efeitos adversos , Cálculos Renais/cirurgia , Síndrome de Resposta Inflamatória Sistêmica/tratamento farmacológico , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Complicações Pós-Operatórias/etiologiaRESUMO
SUMMARY OBJECTIVE: The aim of this study was to identify predictive factors for complications after percutaneous nephrolithotomy. METHODS: We prospectively analyzed patients who underwent percutaneous nephrolithotomy from June 2011 to October 2018. The association of preoperative and intraoperative factors with the presence of complications was assessed using univariate and multivariate analyses. The significance level was set at p<0.05. RESULTS: A total of 1,066 surgeries were evaluated, and the overall complication rate was 14.9%. In all, 105 (9.8%) surgeries were performed in the prone position, and 961 (90.2%) were performed in the supine position. Univariate analysis demonstrated that surgical position, upper pole puncture, surgical time, number of tracts, and Guys Stone Score were associated with complications. In multivariate analyses, prone position (odds ratio [OR] 2.10; p=0.003), surgical time ≥90 min (OR 1.76; p=0.014), upper pole puncture (OR 2.48; p<0.001), and Guys Stone Score 3 or 4 (OR 1.90; p=0.033) were independent predictive factors for complications after percutaneous nephrolithotomy. CONCLUSION: Performing percutaneous nephrolithotomy in the supine position, in under 90 min, and avoiding upper pole punctures may reduce complications during the treatment of large kidney stones.
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OBJECTIVE: Mini-percutaneous nephrolithotomy is a recent advancement in the field of kidney stone treatment; however, its role has not been completely established. We aimed to compare the outcomes of initial Mini-percutaneous nephrolithotomy and flexible ureteroscopy. METHODS: A retrospective review of consecutive mini-percutaneous procedures was performed. Inclusion criteria were as follows: all percutaneous nephrolithotomy procedures performed with an access sheath up to 24Fr, kidney stone burdens up to 1550 mm3; and the presence of postoperative computed tomography (for control). The data collected for Mini-percutaneous nephrolithotomy procedures were paired 1:2 with patients treated with flexible ureteroscopy for stones between 100 and 1550 mm3, and with postoperative computed tomography for control. A 14Fr Mini-percutaneous nephrolithotomy set was used. The stone-free rate was defined as the absence of fragments on the control computed tomography, whereas success was limited to 2-mm residual fragments. Statistical analysis was performed using SPSS version 19. RESULTS: A total of 63 patients met the inclusion criteria (42 with flexible ureteroscopy and 21 with mini-percutaneous nephrolithotomy). Demographic data were comparable. The stone-free rate and success were similar between the groups (76.2 vs. 66.7%, p=0.42 and 90.5 vs. 85.7%, p=0.57). The complication rate was also similar (26.1 vs. 9.6%, p=0.188), but Mini-percutaneous nephrolithotomy had longer hospitalization and fluoroscopy time (p=0.001 in both). CONCLUSIONS: Our initial study of Mini-percutaneous nephrolithotomy showed that it is a promising procedure, with outcomes similar to flexible ureteroscopy, but with higher inpatient numbers and fluoroscopy times. A larger study population size and better equipment may improve the outcomes of mini-percutaneous nephrolithotomy.
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Cálculos Renais , Nefrolitotomia Percutânea , Nefrostomia Percutânea , Humanos , Nefrolitotomia Percutânea/métodos , Ureteroscopia/métodos , Análise por Pareamento , Resultado do Tratamento , Cálculos Renais/diagnóstico por imagem , Cálculos Renais/cirurgiaRESUMO
ABSTRACT Background: Endoscopic combined intrarenal surgery (ECIRS) has been used to treat complex kidney stones (1). The combined use of ultrasound (US) has the potential to improve safety and reduce radiation exposure, however, it is still underutilized (2). Objectives: Our objective is to describe, in a step-by-step manner, the ultrasound-guided ECIRS (USG ECIRS) technique, in order to facilitate learning by urologists. Materials and Methods: We describe the 10 standardized steps that we recommend to achieve a good outcome, based on our previous experience on a high-volume kidney stone center. We recorded a case of a 37-year-old female patient with complex bilateral kidney stones that underwent a left simultaneous combined retrograde and antegrade approach. The 10 described steps are: 1 - case evaluation with CT scan (3); 2 - preoperative care with antibiotics and tranexamic acid; 3 - warm-up and training with phantoms; 4 - patient positioning in Barts flank free position; 5 - retrograde nephroscopy with flexible ureteroscope; 6 - US and endoscopic guided puncture; 7 - tract dilation under endoscopic view; 8 - stone fragmentation; 9 - status free checking and 10, kidney drainage. Images were captured by external and internal cameras, promoting a complete understanding of the procedure. The patient has signed a written informed consent form. Results: Puncture was achieved under US guidance with one attempt. Another puncture was necessary in the lower pole, parallel to the initial puncture, due to a large fragment. Surgical time was 140 min. Stone-free status was verified by retrograde and antegrade view. Kidney drainage was done with ureteral stent on string, removed after 7 days. Hb drop was 1.1 Hb/dL. The first postoperative day CT scan showed no residual stones and no complications. The patient was discharged after the CT and urethral catheter removal. Conclusion: The USG ECIRS seems to be a very efficient and reproducible technique for the treatment of complex kidney stones. Its use should be widespread.
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SUMMARY OBJECTIVE: Mini-percutaneous nephrolithotomy is a recent advancement in the field of kidney stone treatment; however, its role has not been completely established. We aimed to compare the outcomes of initial Mini-percutaneous nephrolithotomy and flexible ureteroscopy. METHODS: A retrospective review of consecutive mini-percutaneous procedures was performed. Inclusion criteria were as follows: all percutaneous nephrolithotomy procedures performed with an access sheath up to 24Fr, kidney stone burdens up to 1550 mm3; and the presence of postoperative computed tomography (for control). The data collected for Mini-percutaneous nephrolithotomy procedures were paired 1:2 with patients treated with flexible ureteroscopy for stones between 100 and 1550 mm3, and with postoperative computed tomography for control. A 14Fr Mini-percutaneous nephrolithotomy set was used. The stone-free rate was defined as the absence of fragments on the control computed tomography, whereas success was limited to 2-mm residual fragments. Statistical analysis was performed using SPSS version 19. RESULTS: A total of 63 patients met the inclusion criteria (42 with flexible ureteroscopy and 21 with mini-percutaneous nephrolithotomy). Demographic data were comparable. The stone-free rate and success were similar between the groups (76.2 vs. 66.7%, p=0.42 and 90.5 vs. 85.7%, p=0.57). The complication rate was also similar (26.1 vs. 9.6%, p=0.188), but Mini-percutaneous nephrolithotomy had longer hospitalization and fluoroscopy time (p=0.001 in both). CONCLUSIONS: Our initial study of Mini-percutaneous nephrolithotomy showed that it is a promising procedure, with outcomes similar to flexible ureteroscopy, but with higher inpatient numbers and fluoroscopy times. A larger study population size and better equipment may improve the outcomes of mini-percutaneous nephrolithotomy.
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OBJECTIVE: The aim of this study was to evaluate the predictive factors for success following percutaneous nephrolithotomy in the supine position. METHODS: Patients who underwent percutaneous nephrolithotomy in the supine position from June 2011 to October 2018 were evaluated. Age, sex, body mass index, the American Society of Anesthesiologists physical status classification, hemoglobin level, number of previous surgeries, stone size, and the Guy's Stone Score were analyzed. Success was considered if no fragments were observed on the computed tomography scan on the first postoperative day. Univariate and multivariate analyses were performed to determine significant parameters. RESULTS: We evaluated 961 patients; of them, 483 (50.2%) underwent previous stone-related surgery, and 499 (51.9%) had Guy's Stone Score 3 or 4. The overall success rate in a single procedure was 40.7%, and complication rate was 13.7%. The univariate analysis showed that the maximum diameter of the stone (25.10±10 mm; p<0.001), previous percutaneous nephrolithotomy (OR 0.52; p<0.001), number of previous percutaneous nephrolithotomy (OR 0.15; p<0.001), the Guy's Stone Score (OR 0.28; p<0.001), and the number of tracts (OR 0.32; p<0.001) were significant. In the multivariate analysis, the number of previous percutaneous nephrolithotomy (OR 0.54; p<0.001) and the Guy's Stone Score (OR 0.25; p<0.001) were statically significant. CONCLUSIONS: Guy's Stone Score and the number of previous percutaneous nephrolithotomy are predictors of success with the supine position. Complex cases and with previous percutaneous interventions may require technical improvements to achieve higher stone-free rates.
Assuntos
Cálculos Renais , Nefrolitotomia Percutânea , Nefrostomia Percutânea , Índice de Massa Corporal , Humanos , Cálculos Renais/complicações , Cálculos Renais/diagnóstico por imagem , Cálculos Renais/cirurgia , Nefrolitotomia Percutânea/efeitos adversos , Nefrolitotomia Percutânea/métodos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
SUMMARY OBJECTIVE: The aim of this study was to evaluate the predictive factors for success following percutaneous nephrolithotomy in the supine position. METHODS: Patients who underwent percutaneous nephrolithotomy in the supine position from June 2011 to October 2018 were evaluated. Age, sex, body mass index, the American Society of Anesthesiologists physical status classification, hemoglobin level, number of previous surgeries, stone size, and the Guy's Stone Score were analyzed. Success was considered if no fragments were observed on the computed tomography scan on the first postoperative day. Univariate and multivariate analyses were performed to determine significant parameters. RESULTS: We evaluated 961 patients; of them, 483 (50.2%) underwent previous stone-related surgery, and 499 (51.9%) had Guy's Stone Score 3 or 4. The overall success rate in a single procedure was 40.7%, and complication rate was 13.7%. The univariate analysis showed that the maximum diameter of the stone (25.10±10 mm; p<0.001), previous percutaneous nephrolithotomy (OR 0.52; p<0.001), number of previous percutaneous nephrolithotomy (OR 0.15; p<0.001), the Guy's Stone Score (OR 0.28; p<0.001), and the number of tracts (OR 0.32; p<0.001) were significant. In the multivariate analysis, the number of previous percutaneous nephrolithotomy (OR 0.54; p<0.001) and the Guy's Stone Score (OR 0.25; p<0.001) were statically significant. CONCLUSIONS: Guy's Stone Score and the number of previous percutaneous nephrolithotomy are predictors of success with the supine position. Complex cases and with previous percutaneous interventions may require technical improvements to achieve higher stone-free rates.