Endoscopic management of Urolithiasis on a pediatric patient with a solitary kidney and an Ileal conduit

@#Management of nephrolithiasis in patients with urinary diversions pose a unique therapeutic challenge for the following reasons: 1) retrograde ureteral access is difficult to perform through a bowel diversion and 2) percutaneous renal access becomes challenging because of inability to do a retrograde pyelogram. For this reason, image-guided access through a combined ultrasound and fluoroscopic guidance are both necessary. This clinical problem becomes even more complicated when dealing with a solitary functioning kidney. Treatment should be precise in order to avoid any complications that may progress to renal failure. Presented here is a 15-year-old male adolescent who had previously undergone a radical cystectomy with an ileal conduit for a rhabdomyosarcoma of the bladder last 2008, and complained of flank pain, fever and foul-smelling urine. Imaging studies showed left obstructive hydronephrosis with ureterolithiasis and nephrolithiasis, and an atrophic contralateral kidney. A preliminary nephrostomy tube drainage was done to recover renal function, followed later by percutaneous endoscopic stone management. Discussed here are the challenges involved in his therapy as well as the advantages of a stepwise approach including the short-term outcomes.

Nefrolitotricia percutánea ambulatoria: nuestra experiencia en 156 casos / Ambulatory Percutaneous Nephrolithotomy: Our experience in 156 cases

OBJETIVOS: analizar y presentar nuestros resultados en el tratamiento de la litiasis renal mediante Nefrolitotricia Percutánea (NLP) ambulatoria en un mismo centro. MATERIALES Y MÉTODOS: entre agosto de 2013 y mayo de 2017 se realizó una recolección prospectiva de datos de los pacientes sometidos a NLP ambulatoria tubeless con catéter doble J o totally tubeless por litiasis renal. Se excluyeron aquellos pacientes con score de ASA >3. Se analizaron los datos preoperatorios, intra- y posoperatorios. Se clasificaron las complicaciones de acuerdo con el sistema de Clavien modificado. Se compararon los valores de hematocrito, hemoglobina, creatininemia y uremia pre- y posoperatoria a las 48 horas. RESULTADOS: en total, se operaron 156 pacientes, a los cuales se les dio el alta el mismo día de la cirugía. La suma de los diámetros máximos de las litiasis, en promedio, fue de 26,6 mm, 32 casos de litiasis coraliforme. La posición más utilizada fue la ventral, con un tiempo promedio de cirugía de 50 minutos. Se realizó NLP tubeless en 125 pacientes y totally tubeless en 29 casos. A 40 pacientes se les colocó un tapón de Surgicel en el tracto de acceso percutáneo. La tasa libre de cálculos fue del 84%, y en pacientes con litiasis coraliforme fue del 53%. No hubo complicaciones intraoperatorias y el 80% de los pacientes no presentó complicaciones. La tasa de reinternación fue del 3%. Si bien se hallaron diferencias significativas entre los valores pre- y posoperatorios de hematocrito y hemoglobina (40% y 13,3 g/dl vs. 39% y 12,8 g/dl; p=0,0001 y 0,0001, respectivamente), estas no fueron clínicamente significativas y solamente un paciente requirió de transfusión de sangre (0,6%). CONCLUSIONES: en nuestra experiencia, la NLP ambulatoria fue segura, con tasas libres de cálculos y complicaciones similares a las realizadas con internación.

OBJECTIVES: To assess the safety and feasibility of ambulatory percutaneous nephrolithotomy (PCNL) at a single institution. METHODS: Data collected prospectively of patients submit for ambulatory PCNL tubeless or totally tubeless between August 2013 and May 2017 were review. Exclusion criteria were patients with ASA score >3. Preoperative, intraoperative, and postoperative data were collected. Complications were classified using the Clavien sistem modified for PCNL. Properative and 48hs postoperative value of hematocrit, hemoglobin, creatininemia and uremia were compare. RESULTS: One hundred and fifty five patients underwent ambulatory PCNL. All patients were discharge the same day of surgery. The median of the sum of the maximum stone diameter was 26,6mm, 32 patients had staghorn calculus. We performed the majority of the surgerys in ventral position with a median time of 50 minutes. One hundred and twenty five patients underwent tubeless PCNL and totally tubeless 29 patients. In 40 cases we used Surgicel for sealing the percutaneous tract. Overall stone-free rate was 84% and 53% in staghorn cases. There were no intraoperative complications and 80% of the patients did not have any complications. Readmission rate was 3%. There was a significant decrease in the postoperative hematocrit and hemoglobin level (40% y 13,3 g/dl vs. 39% y 12,8 g/dl; p=0,0001 y 0,0001), this was not clinically significant. Only one patient required blood transfusion (0,6%). CONCLUSION: Ambulatory PCNL is safe with a stone-free rate, readmisions and complications similar to standard PCNL.

Analysis of risk factors for pulmonary complications in patients undergoing Upper Pole Prone Percutaneous Nephrolithotomy (uPPCNL): A single center experience

INTRODUCTION@#To determine the risk factors contributing to pulmonary complications among patients who undergo upper pole prone percutaneous nephrolithotomy (uPPCNL). This will serve as a guide to urologists who utilize uPPCNL among their patients, so that they may monitor them more closely for these events.@*METHODS@#A retrospective chart review was done on all patients who underwent uPPCNL from January 2015 to December 2017. Patient characteristics (age, gender, BMI, co-morbidity) and stone demographics (Stone size, Guy’s Stone score, laterality, stone location) were summarized as well as intraoperative parameters inclusive of operative time, number of tracts, estimated blood loss, and length of hospital stay. Point biserial correlation and Pearson Chi-square for independent tests were used to identify the independent predictors of pulmonary complications.@*RESULTS@#Nine hundred ninety-two patients underwent uPPCNL during the study period. Fifty-two (5.2%) had pulmonary complications. Sixty-seven pulmonary complications were tallied because some had two complications at one time. The most common was pleural effusion 35(48%), followed by atelectasis in 16(30%), hospital-acquired pneumonia 14(27%) and acute respiratory distress syndrome 2(4%). Forty-one (78.8%) and 11(21.2%) required medical and surgical interventions, respectively. Higher Guy’s stone scores, larger stone size, and longer hospital stay were significant predictors for developing pleural effusion. Patients with higher preoperative serum creatinine and longer hospital stay were significantly associated with surgical management (p < 0.05).@*CONCLUSION@#The incidence of pulmonary complications after uPPCNL is low and only a minority need surgical management. When risk factors are present, these patients need to be monitored closely so that a timely intervention may be done to avoid life-threatening consequences.

Supine PCNL (sPCNL): Challenging the “standard” prone (pPCNL)

@#Recently, the global endourology scene has witnessed a resurgence of interest in supine PCNL (sPCNL). The number of urologists who are attracted to this “simplified method” of PCNL is growing and its promoters are suggesting to abandon the standard prone approach. Debates on the two positions have become commonplace in endourology scientific meetings. The advocates consistently emphasize that when compared to the prone position, sPCNL has multiple advantages for the surgeon, the anesthesia team and the patient. In spite of these, it is evident that many still favor prone PCNL (pPCNL) because of its time-tested proven efficacy and safety. In fact, up to this present day, majority of PCNLs are still done in the prone position. This review article intends to analyze the “current state of affairs” of the two PCNL positions, describing their advantages and disadvantages. Presently, applying the principles of “what is safe and efficacious in one’s hands” dictates the choice of which technique is utilized to treat a patient. Conversely, it is more clinically sound if this choice was made instead, in consideration of, the interplay of the following factors such as the patient’s clinical demographics, the anatomical features of the renal collecting system, the stone burden and characteristics and ultimately, the physician’s training, skills and experience.

Balloon dilatation combined with pneumatic and ultrasound lithotripsy in the treatment of unilateral renal stones by percutaneous nephrolithotomy / 上海交通大学学报（医学版）

Objective: To investigate the application effect of balloon dilatation and percutaneous nephrolithotomy (PCNL) combined with pneumatic and ultrasound lithotripsy on the clinical treatment of unilateral kidney stones. Methods: Ninety-four patients with unilateral kidney stones who accepted PCNL in the Department of Urology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine from June 2017 to July 2019, were retrospectively analyzed and divided into group A and group B. Among them, 68 patients (group A) were subjected to balloon dilatation combined with pneumatic and ultrasound lithotripsy, while 26 patients (group B) underwent fascia dilatation combined with holmium laser lithotripsy. The clinical effects of two kinds of lithotripsy on the treatment of unilateral kidney stones were compared. Results: The operation time was shorter in group A than that in group B [(107.82±10.87) min vs (115.41±10.68) min, P=0.003]. The increase rate of postoperative white blood cell (WBC) was lower in group A than that in group B (4.41% vs 23.08%, P=0.018). The fever ( ≥ 38.5 ℃ ) rate was lower in group A than that in group B (4.41% vs 23.08%, P=0.018). There were no significant differences in hemoglobin reduction, WBC count, hospital stay, stone-free rate, blood transfusion rate and perforation rate of collection system between the two groups (all P>0.05). Conclusion: Balloon dilatation combined with pneumatic and ultrasound lithotripsy in treatment of unilateral renal stones by PCNL can shorten the operation time, and reduce the increase rate of postoperative WBC and fever rate, which is worthy of being promoted in the clinical treatment of patients with unilateral kidney stones.

Evaluación de protocolo de bajas dosis en radioscopía para nefrolitotomía percutánea. Comparación de resultados y seguridad en un estudio prospectivo y randomizado / Evaluation of low dose protocol in fluoroscopy for percutaneous nephrolithotomy. Comparison of results and safety in a prospective randomized study

INTRODUCCIÓN: Tradicionalmente, durante la Nefrolitotomía Percutánea (NPL), la radioscopía se efectúa en modo Continuo a 10 FPS (imágenes por segundo). Existe escasa experiencia en la literatura urológica sobre disminución de dosis de radiación durante la radioscopía y su efecto en el éxito de la NPL (eficacia y seguridad). Series de casos, demuestran resultados similares usando radioscopía en modo Pulsado (1-4 FPS), determinando un Tiempo de Radioscopía inferior al modo Contínuo. Dichas experiencias no son basadas en diseños randomizados, ni reportan Dosimetría Directa. Hipótesis: usando radioscopía pulsada, se logran iguales resultados y con igual seguridad, que con radioscopía Contínua, y con exposición a radiación significativamente más baja. MATERIAL Y MÉTODO: Estudio prospectivo, randomizado, ciego simple y experimental (aprobado por Comité de Ética). Muestra de 19 pacientes, entre Abril y Agosto de 2017. De forma aleatoria, aproximadamente la mitad de los pacientes fueron sometidos a NPL con radioscopía Contínua (10 FPS) y la otra mitad con modalidad Pulsada (2 FPS). Intervenidos en el mismo establecimiento, con 1 trayecto, utilizando el mismo equipo de Radioscopía. Se registró Dosimetría Directa, Tiempo de Radioscopía, resultado (Stone Free) y complicaciones, en cada procedimiento. El análisis estadístico se realizó con medidas de tendencia central, se verificó distribución normal de la muestra y comparación de variables mediante t-Test, con intervalo de confianza del 95 por ciento. RESULTADOS: En 8 pacientes se utilizó radioscopía Contínua, y en 11, radioscopía Pulsada. La Dosimetría del grupo radioscopía Contínua promedió 2,7 mSv, para radioscopía Pulsada el promedio fue 3,1 mSv. El Tiempo de Radioscopía del grupo radioscopía Contínua fue de 286,4 s, del grupo radioscopía Pulsada fue de 365,7 s. Ambas diferencias no son estadísticamente significativas (p 0,6 y p 0,3 respectivamente). En relación al Resultado y Complicaciones, no hubo diferencias entre ambos grupos. CONCLUSIONES: Para los pacientes estudiados a la fecha, no se demuestra beneficioso realizar radioscopía Pulsada: la Dosimetría Directa y el Tiempo de Radioscopía fueron mayores en el grupo de modalidad Pulsada. Nuestros resultados son diferentes a lo reportado en la literatura, lo cual hace necesario evaluar el impacto de esta intervención, y considerar otros factores que pudieran influir (AU)

INTRODUCTION: Traditionally, during Percutaneous Nephrolithotomy (PCNL), fluoroscopy is performed in Continuous mode at 10 FPS (images per second). There is little experience in the urological literature on the reduction of radiation dose during fluoroscopy and its effect on the success of the PCNL (efficacy and safety). Several case show similar results, using Pulsed radioscopy (1-4 FPS), determining a Radioscopy Time inferior to the one in Continuous mode. These experiences are not based on randomized designs, nor do they report Direct Dosimetry. Hypothesis: using pulsed fluoroscopy, the same results are obtained and equally safe than with Continuous radioscopy and with exposure to significantly lower radiation. MATERIAL AND METHOD: Prospective, randomized, simple and experimental blind study (approved by the Ethics Committee). Sample of 19 patients, between April and August 2017. Randomly, approximately half of the patients underwent PCNL with continuous radioscopy (10 FPS) and the other half with Pulsed modality (2 FPS). They were intervened in the same establishment, in one journey, using the same Radioscopy equipment. Direct Dosimetry, Radioscopy Time, and complications results (Stone Free) were registered in each procedure. The statistical analysis was performed with central trend measures, normal distribution of the sample was verified and comparison of variables by t-Test, with 95 % confidence interval. RESULTS: Continuous fluoroscopy was used on eight patients, and Pulsed radioscopy on eleven. The Dosimetry of the Continuous fluoroscopy group averaged 2.7 mSv. Pulsed fluoroscopy average was 3.1 mSv. The Radioscopy Time of the Continuous fluoroscopy group was 286.4 s. Pulsed radioscopy group time it was 365.7 s. Both differences are not statistically significant (p 0.6 and p 0.3 respectively). In relation to the Result and Complications, there were no differences between the two groups. CONCLUSIONS: Performance of Pulsed Radioscopy benefits are not shown in the patients studied to date: Direct Dosimetry and Radioscopy Time were greater in the Pulsed modality group. Our results are different from those reported in the literature, which makes it necessary to evaluate the impact of this intervention, and consider other factors that could influence.(AU)

Risk factors associated with systemic inflammatory response syndrome after percutaneous nephrolithotomy in China:A Meta-analysis / 中国内镜杂志

Objective To explore the risk factors of systemic inflammatory response syndrome crisis (SIRS) after percutaneous nephrolithotomy (PCNL) in China. Methods Databases of CNKI, CBM, WanFan and VIP were searched to retrieve studies about systemic inflammatory response syndrome after percutaneous nephrolithotomy to October, 2016. Results 18 studies involving 5,323 patients were included. The results of meta-analysis showed that:a) univariate analysis indicated that renal insufficiency [O(R) =2.78, 95%CI (1.96 to 3.95), P = 0.000], preoperative positive urine culture [O(R) = 3.41, 95%CI (1.89 to 6.15), P = 0.000], preoperative routine urine leucocyte positive [O(R) = 3.78, 95%CI (3.02 to 4.72), P = 0.000], diabetes mellitus [O(R) = 2.14, 95%CI (1.33 to 3.45), P = 0.002], pelvic positive urine culture [O(R)= 5.14, 95%CI (2.46 to 10.73), P = 0.000] and operation time ≥120 min [O(R) = 2.31, 95%CI (1.40 to 3.82), P = 0.001] were the risk factors of SIRS; b) multivariate analysis showed that, preoperative positive urine culture [O(R) = 6.83, 95%CI (2.82 to 16.57), P = 0.000], preoperative routine urine leucocyte positive [O(R) = 5.43, 95%CI (3.51 to 8.41), P = 0.000], diabetes mellitus [O(R) = 2.85, 95%CI (1.45 to 5.58), P = 0.002], pelvic positive urine culture [O(R) = 4.30, 95%CI (1.30 to 14.21), P = 0.020] and operation time ≥120 min [O(R) = 2.72, 95%CI (1.62 to 4.59), P = 0.000] were the independent risk factors of MCAT. Conclusion The independent risk factors of SIRS for patients after PCNL are diabetes mellitus, preoperative positive urine culture, preoperative routine urine leucocyte positive, pelvic positive urine culture and operation time. However, due to the quantity and low quality of the included literature, the conclusion needs the support from high quality studies.

Analysis of the Skin to Calyceal Distance (SCD) to the upper pole calyx among Filipino patients: A guide to upper pole access Percutaneous Nephrolithotomy (PCNL)

OBJECTIVE: Precise entry to the upper posterior calyx is key to a successful and safe upper pole access PCNL. The surgeon's knowledge of the average skin to calyceal distance can serve as a guide to avoid inadvertent injury to both the kidney and collateral organs during the percutaneous puncture.METHODS: The authors analyzed the radiologic images of 84 patients who underwent unenhanced 64-slice helical CT scan (Toshiba®). Skin-to-calyceal distance (SCD) to the upper posterior calyx were measured using the Vitrea® software inherent to the CT scan.RESULTS: The mean SCDs is non-hydronephrotic kidneys were 54.9 ± 13.7 mm and 61.4 ± 12.5 mm on the right and left, respectively while in hydronephrotic kidneys, the mean SCDs were 60.3 ± 11.8 mm and 58.6 ± 13.1 mm on the right and left, respectively. There was no statistically significant difference between the right and left upper pole SCD in both groups (p = 0.84).CONCLUSION: The mean SCD to the upper posterior calyx among Filipino adults is about 6.0 cm. By limiting the depth of the initial puncture to within the distance, the endourologist may avoid overshooting the targeted calyx, thus avoiding undue injury to the kidney or intraabdominal structures.

The comparative study of retroperitoneal laparoscopic pyelolithotomy and percutaneous nephrolithotomy in treating renal pelvic stone / 中华泌尿外科杂志

Objective To evaluate the efficacy of the retroperitoneal laparoscopic pyelolithotomy (RLP) and the percutaneous nephrolithotomy (PCNL) in treating renal pelvic stone.Methods The data of 89 patients diagnosed as renal pelvic stone were retrospectively reviewed from January 2009 to July 2016,of whom 43 patients underwent RLP and 46 underwent PCNL.Statistical analysis was performed regarding operation time,blood loss,mean hospital stay,complication rate,and stone-free rate.Results The operation time in RLP group and PCNL group was (117.5 ± 16.7) min and (118.3 ± 16.6) min,respectively,and there was no significant difference (P =0.547).For the two groups,the mean hospital stay was (4.5 ± 0.5) d and (6.1 ± 0.9) d,the mean hemoglobin decrease was (4.5 ± 1.2) g/L and (18.1 ± 3.4) g/L,the post-operative blood transfusion rate was 2.3％ and 14.0％,the post-operative septic shock rate was 0 and 9.3％,respectively,with significant difference between the two groups (P ＜ 0.05).The stone-free rate in both groups was 97.7％ and 95.3％ with no significant difference (P =0.557).Conclusions RLP has the advantages of quick recovery,less blood loss and lower complication rate than PCNL.It could be a minimally invasive option for the treatment of renal pelvic stone.

Analysis of the etiology and prognosis of severe complications after percutaneous nephrolithotomy / 中华泌尿外科杂志

Objective To analyze the etiology and prognosis of severe complications of percutaneous nephrolithotomy (PCNL).Methods The clinical data of patients with severe complications after PCNL from December 2004 to December 2015 were retrospectively analyzed.Age of the patients ranged from 25 to 69 years old,with an average of 41 years.There were 64 cases with 29 male and 35 female.Fifty-five cases were diagnosed as renal calculi,including 21 cases of left renal calculi,19 cases of right renal calculi;15 cases of bilateral renal calculi;2 cases of the patients were bilateral upper ureteral calculi;7 patients were renal calculi upper ureteral calculi on the other side.In all cases,the maximum diameter of calculus was 1.8-4.3 cm (mean 2.6 cm) and hydronephrosis depth was 0-5.9 cm (mean 2.3 cm);15 cases were previously treated with nephrolithotomy.The modified Clavien grading system was used to evaluate surgical complications,and ≥grade Ⅲ complications were considered as serious complications.Results Among the 64 cases,28 cases were classified as Clavien Ⅲ class.There were 2 cases of bleeding in operation due to renal parenchyma laceration or multiple access,patients were treated with later open surgery.Postoperative bleeding were revealed in 22 cases,16 of which were hemorrhage from the nephrostomy tubes,4 of which complained of discontinuity gross hematuria and 2 postoperative bleeding were encountered during the nephrostomy tube remove.All the cases received renal arteriography and were diagnosed with pseudoaneurysm,bleeding were stopped after embolization.3 cases of pleural injury were treated with closed thoracic drainage,1 colon injury was treated with open colostomy.There were 32 cases of urinary sepsis considered as Clavien Ⅳ complications,and these patients were transferred to the Intensive Care Unit.Clavien Ⅴ class 4 cases:1 died of hemorrhagic shock due to pleural injury,2 cases died of urinary sepsis and multiple organ failure and another case died of pulmonary embolism.Conclusions PCNL has high risk of serious complications,which should be always strictly follow the principles.Adequate preoperative preparation,appropriate surgery access,carefully and gently operate,appropriate antibiotic use and postoperative management are the key measures to reduce the incidence of complications.

Risk factors associated with systemic inflammatory response syndrome after percutaneous nephrolithotomy in China:A Meta-analysis / 中国内镜杂志

Objective To explore the risk factors of systemic inflammatory response syndrome crisis (SIRS) after percutaneous nephrolithotomy (PCNL) in China. Methods Databases of CNKI, CBM, WanFan and VIP were searched to retrieve studies about systemic inflammatory response syndrome after percutaneous nephrolithotomy to October, 2016. Results 18 studies involving 5,323 patients were included. The results of meta-analysis showed that:a) univariate analysis indicated that renal insufficiency [O(R) =2.78, 95%CI (1.96 to 3.95), P = 0.000], preoperative positive urine culture [O(R) = 3.41, 95%CI (1.89 to 6.15), P = 0.000], preoperative routine urine leucocyte positive [O(R) = 3.78, 95%CI (3.02 to 4.72), P = 0.000], diabetes mellitus [O(R) = 2.14, 95%CI (1.33 to 3.45), P = 0.002], pelvic positive urine culture [O(R)= 5.14, 95%CI (2.46 to 10.73), P = 0.000] and operation time ≥120 min [O(R) = 2.31, 95%CI (1.40 to 3.82), P = 0.001] were the risk factors of SIRS; b) multivariate analysis showed that, preoperative positive urine culture [O(R) = 6.83, 95%CI (2.82 to 16.57), P = 0.000], preoperative routine urine leucocyte positive [O(R) = 5.43, 95%CI (3.51 to 8.41), P = 0.000], diabetes mellitus [O(R) = 2.85, 95%CI (1.45 to 5.58), P = 0.002], pelvic positive urine culture [O(R) = 4.30, 95%CI (1.30 to 14.21), P = 0.020] and operation time ≥120 min [O(R) = 2.72, 95%CI (1.62 to 4.59), P = 0.000] were the independent risk factors of MCAT. Conclusion The independent risk factors of SIRS for patients after PCNL are diabetes mellitus, preoperative positive urine culture, preoperative routine urine leucocyte positive, pelvic positive urine culture and operation time. However, due to the quantity and low quality of the included literature, the conclusion needs the support from high quality studies.

Analysis of the Skin to Calyceal Distance (SCD) to the upper pole calyx among Filipino patients: A guide to upper pole access Percutaneous Nephrolithotomy (PCNL)

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> Precise entry to the upper posterior calyx is key to a successful and safe upper pole access PCNL. The surgeon's knowledge of the average skin to calyceal distance can serve as a guide to avoid inadvertent injury to both the kidney and collateral organs during the percutaneous puncture.<br /><strong>METHODS:</strong> The authors analyzed the radiologic images of 84 patients who underwent unenhanced 64-slice helical CT scan (Toshiba®). Skin-to-calyceal distance (SCD) to the upper posterior calyx were measured using the Vitrea® software inherent to the CT scan.<br /><strong>RESULTS:</strong> The mean SCDs is non-hydronephrotic kidneys were 54.9 ± 13.7 mm and 61.4 ± 12.5 mm on the right and left, respectively while in hydronephrotic kidneys, the mean SCDs were 60.3 ± 11.8 mm and 58.6 ± 13.1 mm on the right and left, respectively. There was no statistically significant difference between the right and left upper pole SCD in both groups (p = 0.84).<br /><strong>CONCLUSION:</strong> The mean SCD to the upper posterior calyx among Filipino adults is about 6.0 cm. By limiting the depth of the initial puncture to within the distance, the endourologist may avoid overshooting the targeted calyx, thus avoiding undue injury to the kidney or intraabdominal structures.</p>