Comparative analysis on the efficacy and safety profile of upper calyceal versus lower calyceal access in the percutaneous nephrolithotomy (PCNL): A retrospective cross-sectional study

INTRODUCTION: The goal of PCNL is to achieve a high stone-free rate while minimizing complications. Its success results from an interplay of patient, stone and renal anatomical characteristics, the access site and the level of surgical expertise. Data comparing upper versus lower calyceal PCNL as regard to efficacy and safety are limited.OBJECTIVE: To compare the clinical efficacy and safety outcomes of upper versus lower calyceal access in patients who underwent PCNL at St. Luke's Medical Center.METHODS: A retrospective chart review was done on patients who underwent PCNL at SLMC from January 2010-January 2015. The patients were classified based on the renal access site: Group 1 (upper calyceal) and Group 2 (lower calyceal). The stones were classified according to Guy Stone score and complications were summarized using the modified Clavien classification.RESULTS: A total pf 91 patients underwent PCNL during the study period. Of these, only 84 patients were analyzed. Seven were excluded due to lack or incomplete postoperative imaging on follow up. Forty-one were included in Group 1, while 43 were included in Group 2. According to the Guy Stone score, the stones in Group 1 were 21(IV), 6(III), 7(II) and 6(I) while in Group 2, 18(IV), 5(III), 8(II), 12(I) (p-value=0.52) with a mean stone volume of 38.2± 44.24cm3 and 28.0± 31.04cm3 in Groups 1 and 2 respectively (p-value= 0.23). Success rate was 80.5% and 83.7% for Groups 1 and 2 (p-value=0.70), respectively and mean stone clearance rates of 98.5% and 95.8% (p-value=0.13),respectively. The mean operative time was 181.0±82.26 and 169.5±52.12mins for Groups 1 and 2 (p-value=0.451),respectively. A total of 36 complications (13 from Group 1 and 23 from Group 2) were evaluated. Fever (Grade 1) occurred in 10 (24%) and 17(39%) for Groups 1 and 2, respectively. Blood transfusion (Grade 2) was observed in 4(9%) patients and 3(7%) in Groups 1 and 2, respectively. Two patients (5%) in Group 2 required postoperative double-J sent insertion due to ureteral stone migration (Grade 3). There was no significant difference noted among the groups as regards complication rates (p-value=0.097) and length of hospital stay (p-value=0.687). There was no mortality in either group.CONCLUSION: Based on our experience, both upper and lower calyceal access PCNL achieve equivalent efficacy and comparable safety profile in the treatment of complex renal stones.

The clinical safety and efficacy of upper pole access percutaneous nephrolithotomy (uPPCNL) for inferior pole stones

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> Traditionally, percutaneous nephrolithotomy (PCNL) for a lower pole stones are directly removed through an inferior polar access. The authors preferentially treated inferior pole calculi with an upper polar access and evaluated the clinical outcomes.<br /><strong>METHODS:</strong> Between January 2010 and April 2016, 32 patients with inferior calyceal stones were treated uPPCNL. All stones were diagnosed using an unenhanced CT scan. The efficacy (stone-free rate) was determined by comparing the preoperative and postoperative imaging. Clinical safety was assessed based on intraoperative parameters pertaining to operative time, blood loss, urinary extravasation, calyceal injury, pelvic perforation and other untoward events. These complications were summarized using the Clavien-Dindo grading system.<br /><strong>RESULTS:</strong> The male to female ratio is 1.1:1. All stones included in the study were pure inferior calyceal in location. The average stone size was 1.65±0.84cm (Range:0.6-4.4) with a mean durility of 936±298HU (Range: 350-1500). Stone-free rate was 96.8% (31/32) after a single session of PCNL. The mean operative time was 97±43 minutes (Range:40-230). According to the Clavien-Dindo classification, 26(81.3%) had no complication, 5 (15.6%) had Grade 1 (fever), and 1 (3.1%) had Grade 2.<br /><strong>CONCLUSION:</strong> uPPCNL is effective and safe for patients with inferior calyceal stones and confers the following advantages 1) shorter skin-to-calyceal distance 2) straight line to the UPJ and inferior pole 3) a panoramic view of the collecting system 4) less stone migration 5) minimal torque of the nephroscope. This minimally invasive procedure achieves a high stone clearance rate with acceptably low complication rates.</p>

The effectiveness and safety of percutaneous nephrolithotomy (PCNL) for solitary kidneys: A single-center experience

OBJECTIVE: To evaluate the outcomes of percutaneous nephrolithotomy in patients with solitary kidneys. METHODOLOGY: Between January 2009 and December 2013, 31 patients with renal stones in solitary kidneys were treated with PCNL. All stones were diagnosed using an unenhanced CT scan. The solitary functioning status of the kidney was congenital absence of the contralateral kidney in 7(22%); opposite nephrectomy in 15(48%); and nonfunctional contralateral kidneys in 9(29%) as detected by nuclear scintigraphy. The serum creatinine and hemoglobin were monitored at regular intervals. The stones were classified using the Guy Stone Score while the complications were analyzed using the Clavien-Dindo Grading System. The mean follow-up in months was 21.3±12.26 (4-48). RESULTS: The male to female ratio is 1.2:1. According to the Guy Stone Score, the stones were Grade 1 in 54.8% (17/31), Grade 2 in 16.1% (5/31), Grade 3 in 6.4% (2/31) and Grade 4 in 22.5% patients, respectively. The stone-free status was determined with a postop CT scan. Complete stone clearance was achieved in 90.3% (28/31) after a single session of PCNL. The mean operative time was 151±36.7(90-230) minutes. According to the Clavien-Dindo Classification, 19 (59.3%) had no complication, 4 (12.9%) had Grade 1 (fever), 7 (29.2%) had Grade 2 (blood transfusion) and 1(3%) had Grade 5 (postoperative hemodialysis, sepsis and death). The rest had stable or improved renal function without postoperative hemodialysis. The mean rise in serum creatinine was 0.67±1.01 (0.1-3.5) mg/dL. Mean drop in hemoglobin was 1.6±0.89(0.5-3.8) gm/dL. CONCLUSION: PCNL is effective and safe for patients with nephrolithiasis in solitary kidneys. This minimally invasive procedure achieves a high stone clearance rate with acceptably low morbidity and mortality.