Percutaneous nephrolithotomy with ultrasonography-guided renal access in the lateral decubitus flank position.

PURPOSE: Our aim was to evaluate the safety and efficacy of percutaneous nephrolithotomy (PCNL) with ultrasonography (US)-guided renal access in the lateral decubitus flank position. PATIENTS AND METHODS: From July 2006 to March 2008, 40 patients with renal stones > 2 cm underwent PCNL with US-guided renal access in the lateral decubitus flank position by a single surgeon. We report our technique and the outcomes in detail. RESULTS: Successful access was achieved in 40 patients (100%). Complete stone clearance rate was 85% (34 patients). After surgery, six (15%) patients had stones (6-11 mm) detected by plain abdominal radiography or sonography and were referred for shockwave lithotripsy. The mean stone size was 29 mm (range 22-43 mm). The mean operative time was 45 minutes (range 32-75 min), and the mean hospital stay was 2.8 days (range 2-4 d). Postoperative US did not reveal considerable fluid collection. There were no visceral injuries. Also, there was no significant bleeding that led to transfusion intraoperatively and postoperatively. CONCLUSION: PCNL with US-guided renal access in the lateral decubitus flank position is safe and convenient, and prevents harmful effects of radiation for the surgeon, the surgical team, and the patient.

Tubeless percutaneous nephrolithotomy: 5 years of experience in 201 patients.

BACKGROUND AND PURPOSE: Our aim was to evaluate the safety, effectiveness, and feasibility of tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: From June 2000 to September 2005, 201 patients with renal stones >2 cm underwent tubeless PCNL by a single surgeon. We report details of the outcomes. RESULTS: The complete stone clearance rate was 91.04% (183 patients). After surgery, 18 patients (8.96%) had stones (mean size = 7 mm) detected on a plain abdominal radiograph or ultrasonographic examination and were referred for shockwave lithotripsy. The mean stone size was 30 mm (range 20-40 mm). The mean operative time was 35 minutes (range 30-60 min), and the mean hospital stay was 3.5 days (range 2-5 days). Postoperative ultrasonography did not reveal considerable fluid collection. There were no visceral injuries. Twenty-two (10.9%) patients received a transfusion, and 16 (7.9%) patients had urinary tract infection. CONCLUSION: In our experience, tubeless PCNL is safe, effective, and feasible without any discomfort for patients.

Impacted upper-ureteral calculi >1 cm: blind access and totally tubeless percutaneous antegrade removal or retrograde approach?

PURPOSE: To compare blind access and totally tubeless percutaneous antegrade removal and pneumatic transurethral ureterolithotripsy for the management of impacted upper-ureteral calculi >1 cm. PATIENTS AND METHODS: Seventy patients (41 male, 29 female) with impacted upper-ureteral calculi >1 cm were selected in randomized order for pneumatic transurethral ureterolithotripsy (35 patients) or blind access and totally tubeless percutaneous nephrolithotomy (PCNL) (35 patients). Ultrasonography and intravenous urography were performed for all patients before surgery. After operation, plain films and ultrasonography were done. RESULTS: In the PCNL group, blind access was achieved from the lumbar notch area in all 35 patients, but in 3 patients, the exposure was not optimal for approaching the ureteropelvic junction (UPJ). So we injected contrast material into the collecting system, and, under fluoroscopic control, another access was achieved. In 33 patients (94.3%), intact removal of the stones was performed. In the other two patients, we fragmented the stones with the Swiss Lithoclast by an antegrade approach. The success rate thus was 100%. The mean operative time was 38 minutes (range 25-48 minutes). In the transurethral lithotripsy group, 12 stones (34.2%) migrated upward to the pelvis of kidney, and 5 stones (14.2%) fragmented incompletely. In these cases, a double- J stent was inserted, and SWL was performed. In follow-up, plain films and ultrasonography showed complete clearance in these patients. Eighteen calculi (51.4%) fragmented completely with the Lithoclast. The mean operative time in this group was 34 minutes (range 20-58 minutes). CONCLUSION: In the presence of moderate to severe hydronephrosis, blind access and totally tubeless PCNL is an effective option for large, impacted upper-ureteral calculi. Flexible ureteroscopy with laser lithotripsy is expensive and not readily available. Pneumatic transurethral ureterolithotripsy has a back-pressure effect and pushes back the calculi to the kidney. Thus, this procedure does not have satisfactory results in the management of these calculi.