The 3-finger technique in establishing percutaneous renal access: a new and simple method for junior trainees.

INTRODUCTION AND OBJECTIVES: Urology trainees may lack experience in gaining renal access during percutaneous nephrolithomy (PCNL). Establishing the correct depth of initial percutaneous needle insertion is one of the major obstacles. As such, we have identified an easy technique, which can be performed, to establish correct depth adjustment allowing easier access. MATERIALS AND METHODS: An initial attempt is made to insert the percutaneous needle into the desired posterior calyx in the antero-posterior (AP) plane. If the needle does not traverse into the desired calyx immediately, it is concluded that the needle track must be too shallow or too deep. The C-arm is then rotated 20 to 30 degrees from the vertical, in the axial plane, towards the operating surgeon and, using the image intensifier, very careful note is made of the end of the needle in this plane, compared with the end of the needle initially in the AP plane, to see if it has moved "medially" or "laterally." The 3-finger technique is then performed by the surgeon, to establish if the needle path is too deep or too shallow. This technique is currently being performed by trainees under direct consultant supervision with 13 successful cases so far. RESULTS: The 3-finger technique has been successfully used to demonstrate and teach PCNL access to urology trainees. In all 13 cases, percutaneous renal access was achieved successfully by trainees without immediate or late complications. Also, positive and encouraging feedbacks were received from those trainees, and all expressed willingness to continue using the same new technique in the future. CONCLUSIONS: Our new technique is cheap, safe, easy to learn and use, and of particular benefit to junior trainees who are beginning to perform PCNL access.

Sixteen years of experience with stone management in horseshoe kidneys.

INTRODUCTION: Horseshoe kidney is the commonest congenital renal fusion anomaly, and is often complicated by urolithiasis. We focus on our 16 years of experience with stone management in horseshoe kidneys. MATERIALS AND METHODS: We reviewed the progress of 44 patients treated between 1987 and 2002. Shock wave lithotripsy (SWL) was used in 25 patients; the average stone surface area was 91 (range 10-1,600) mm2 and average follow-up was 36.5 (range 1-91) months. 19 patients underwent percutaneous nephrolithotomy (PCNL); the average stone surface area was 197 (range 6-2,400) mm2. Follow-up data are available for 8 patients and the average follow-up was 42.3 (range 3-144) months. RESULTS: In the SWL group the 3-month stone-free rate (SFR) was only 31%. In the PCNL group the SFR was 75% on the postoperative day-1 KUB. Complications occurred in 9 patients. CONCLUSIONS: Stone management in horseshoe kidneys is challenging: PCNL produces a higher SFR with minimal major complications and failed access. PCNL thus appears to be the preferred management option in patients with urolithiasis in horseshoe kidneys.

One week of ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study.

OBJECTIVE: To evaluate whether 1 week of ciprofloxacin before percutaneous nephrolithotomy (PCNL) in patients with stones of > or = 20 mm or pelvicalyceal dilatation, reduces urosepsis, as we previously reported that such patients have four times the risk of urosepsis after PCNL. PATIENTS AND METHODS: Patients undergoing PCNL, and who fulfilled strict selection criteria, were recruited prospectively into a study which was conducted in two phases. The study methods were similar to those previously described; patients with dilated pelvicalyceal systems and/or stones of > or = 20 mm from phase 1 (previously published) acted as controls. In the subsequent phase, the same selection criteria applied and only those with stones of > or = 20 mm and/or dilated pelvicalyceal systems were given ciprofloxacin 250 mg twice daily for 1 week before PCNL and comprised the treatment arm. Midstream urine samples, renal pelvic urine and fragmented stones were collected to assess culture and sensitivity. Systemic inflammatory response syndrome (SIRS) was used to define urosepsis after PCNL. The urologists monitoring the patients after PCNL and conducting the analysis were all unaware of the characteristics of the stones or intravenous urography findings before PCNL. In all, 115 patients (54 in phase 1 and 61 in phase 2) were recruited, of whom 46 in phase 1 and 52 in phase 2 had stones of > or = 20 mm and/or a dilated pelvicalyceal system, and became the control and treatment arms, respectively. RESULTS: The patient demographics were similar in both arms. There was three times less risk of upper tract infection (relative risk 3.4, 95% confidence interval 1.0-11.8, P = 0.04) and SIRS (2.9, 1.3-6.3, P = 0.004) in the patients receiving ciprofloxacin (treatment arm). CONCLUSIONS: The administration of oral ciprofloxacin for 1 week before PCNL in patients with stones of > or = 20 mm or dilated pelvicalyceal systems significantly reduced the risk of urosepsis.

Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy: a prospective clinical study.

PURPOSE: Urosepsis due to manipulation during percutaneous nephrolithotomy (PCNL) can be catastrophic despite prophylactic antibiotic coverage, and negative midstream urine culture and sensitivity testing (C&S). It has been postulated that bacteria in the stone may be responsible for systemic infection. In this prospective study we determined the correlation between different sites of urine sampling, including stones, and also ascertained which is more predictive of urosepsis. MATERIAL AND METHODS: All patients undergoing PCNL who fulfilled our selection criteria were recruited. The samples collected were 1) midstream urine and bladder urine at cystoscopy, 2) renal pelvic urine collected at percutaneous puncture of the pelvicaliceal system and 3) extracted and later fragmented stones. They were sent immediately for C&S. Patients were monitored for systemic inflammatory response syndrome (SIRS). RESULTS: A total of 54 procedures were suitable for analysis. Midstream urine C&S was positive in 11.1% of cases, stone C&S was positive in 35.2% and pelvic C&S was positive in 20.4% (p = 0.009). Pelvic urine C&S predicted infected stones better than bladder urine C&S. Of the patients 37% had SIRS and 3 experienced septic shock. Patients with infected stones or pelvic urine were found to be at a relative risk for urosepsis that was at least 4 times greater (p = 0.0009). Bladder urine did not predict SIRS. Stone C&S had the highest positive predictive value of 0.7. Preoperative hydronephrosis correlated with infected pelvic urine. No patients with urosepsis had positive blood C&S. CONCLUSIONS: The results of this study suggest that positive stone C&S and pelvic urine C&S are better predictors of potential urosepsis than bladder urine. Therefore, routine collection of these specimens is recommended.

Treatment of lower ureteral stones using the Dornier Compact Delta lithotripter.

BACKGROUND AND PURPOSE: Lithotripsy using new-generation machines requires minimal anesthesia and so can easily be given in an outpatient setting. We report our experience with the Dornier Compact Delta lithotripter in the primary management of lower ureteral stones. PATIENTS AND METHODS: We identified 128 patients treated with SWL for lower-ureteral stones between April 1999 and August 2001. Complete follow-up was available for 112 patients. Their ages ranged from 19 to 78 years, with women accounting for 23%. Only three patients had a ureteral stent in situ. All patients were routinely followed up at 2 weeks with a plain film. The timing of further follow-up depended on the initial response to treatment. RESULTS: Fragmentation occurred in 83 of 112 stones (74%): 93% of the successful cases and 43% of the unsuccessful ones. A total of 59 patients (53%) were stone free after one treatment. This figure increased to 73 (65%) after a second treatment. The mean size of the successfully treated stones was less than that of the failed stones (7.6 v 8.7 mm), although the difference did not reach statistical significance. Stone-free rates decreased as stone size increased, being 71% for the 28 stones < or =5 mm in diameter, 65% for the 52 stones 6 to 9 mm, 64% for the 25 stones 10 to 14 mm, and 42% for the 7 stones > or =15 mm. CONCLUSIONS: When SWL can be delivered promptly in an outpatient setting, it remains a useful first-line treatment for lower ureteral stones. Although it is not as effective as ureteroscopy, its use can avert the need for more invasive treatment in half to two thirds of patients. It should be limited to stones <15 mm.

The Dornier Compact Delta lithotripter: the first 500 renal calculi.

BACKGROUND AND PURPOSE: Extracorporeal Shockwave Lithotripsy (SWL) is now the best noninvasive treatment for renal calculi, rendering many patients stone free. This prospective study was performed to evaluate the short-term results of patients undergoing SWL with the Dornier Compact Delta lithotripter for all renal calculi. PATIENTS AND METHODS: Between April 1999 and May 2000, there were 500 renal calculi treated in 166 female and 334 male patients with a mean age of 53 +/- 15 years. All patients who completed treatment were entered in the study and assessed at 1 and 3 months with a plain film of the kidneys, ureters, and bladder. Stone-free rate and final outcome have been evaluated. Final outcome is defined as stone free or residual fragments 4 mm or less. Analysis has been made according to stone size, location, number of treatments per stone, and number of shocks per stone. The analgesia requirements during each treatment and complications have also been analyzed. RESULTS: The overall stone-free rate for stones <10 mm was 62% at 1 month and 76% at 3 months. For stones 10 to 20 mm, these rates were 53% and 66%, while the rates for stones >20 mm were 41% and 47%, respectively. The final outcome for stones <10 mm was 90% at 1 month and 93% at 3 months, for stones 10 to 20 mm 73% and 84%, and for stones >20 mm 57% and 67%, respectively. The effectiveness quotient for calculi <10 mm was 60%. For calculi 10 to 20 mm, it was 51%, and for those >20 mm, it was 31%. Oral analgesia was given routinely; however, additional intravenous analgesia was necessary in 22% of treatments. No serious complications have been seen. CONCLUSIONS: These results show that with proper patient selection, good results at 1 and 3 months can be achieved with minimal anesthesia during treatment and low retreatment rates. We do not recommend SWL as primary therapy for stones >20 mm.