Outcomes of percutaneous nephrolithotomy: comparison of elderly and younger patients.

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) in elderly patients is challenging due to the high prevalence of comorbidity and single kidney. We compared the results and complications of patients who were submitted to PCNL according to age (higher than and lower than 65 years old). MATERIALS AND METHODS: A total of 61 patients aged more than 65 years old (group I) and 385 patients aged 65 years old or less (group II) were treated with PCNL. PCNL was performed by a standard technique under fluoroscopic guidance. The operative time, length of hospital stay, success rate, auxiliary treatment and complications of both groups were compared. RESULTS: Patients older than 65 years old (group I) had more comorbidities mainly diabetes mellitus, hypertension and higher level of ASA classification (P < 0.001). The success rate was 85.24% and 86.24% of groups I and II, respectively. Four patients (6.56%) of group I and 55 patients (14.29%) of group II needed auxiliary treatment (P = 0.098). Among the complications, only sepsis was significantly higher in group I (6.56% of group I and 1.3% of group II, P = 0.007). The operative time, success rate, hospital stay and complications except sepsis episode did not significantly differ between the two groups. CONCLUSION: Percutaneous nephrolithotomy is effective and safe in elderly patients even though with more comorbidities. Sepsis is the only more frequent common complication following PCNL in elderly.

Outcomes of percutaneous nephrolithotomy: Comparison of elderly and younger patients

Background and purpose Percutaneous nephrolithotomy (PCNL) in elderly patients is challenging due to the high prevalence of comorbidity and single kidney. We compared the results and complications of patients who were submitted to PCNL according to age (higher than and lower than 65 years old). Materials and Methods A total of 61 patients aged more than 65 years old (group I) and 385 patients aged 65 years old or less (group II) were treated with PCNL. PCNL was performed by a standard technique under fluoroscopic guidance. The operative time, length of hospital stay, success rate, auxiliary treatment and complications of both groups were compared. Results Patients older than 65 years old (group I) had more comorbidities mainly diabetes mellitus, hypertension and higher level of ASA classification (P < 0.001). The success rate was 85.24% and 86.24% of groups I and II, respectively. Four patients (6.56%) of group I and 55 patients (14.29%) of group II needed auxiliary treatment (P = 0.098). Among the complications, only sepsis was significantly higher in group I (6.56% of group I and 1.3% of group II, P = 0.007). The operative time, success rate, hospital stay and complications except sepsis episode did not significantly differ between the two groups. Conclusion Percutaneous nephrolithotomy is effective and safe in elderly patients even though with more comorbidities. Sepsis is the only more frequent common complication following PCNL in elderly. .

Efficacy and safety of percutaneous nephrolithotomy (PCNL): a prospective and randomized study comparing regional epidural anesthesia with general anesthesia.

OBJECTIVE: To compare the efficacy and safety of regional epidural anesthesia and general anesthesia in patients who underwent PCNL. MATERIALS AND METHODS: Fifty patients submitted to percutaneous nephrolithotomy (PCNL) were randomized into two groups: Group I (N = 26) received general anesthesia and Group II (N = 24) received regional epidural anesthesia. Demographic and operative data including age, BMI, stone position, stone size, postoperative pain, amount of postoperative analgesic usage, length of hospital stay, patient satisfaction, preoperative and postoperative hemoglobin and hematocrit, adverse effects and surgical complications were compared between both groups. RESULTS: Average pain score at 1 hour. was 6.88 in group I and 3.12 in group II (p < 0.001), at 4 hours. 5.07 in group I and 3.42 in group II (p = 0.025). Less morphine was required in the regional epidural anesthesia group compared to the general anesthesia group. Higher satisfaction was found in the regional epidural group. 6 (23.07 %) patients in Group I and 1 patient (4.19 %) in Group II had postoperative nausea and vomiting, respectively (p = 0.05). Pain score at 12 hours, 24 hours, 48 hours, 72 hours, preoperative and postoperative hemoglobin and hematocrit, length of hospital stay, and adverse effects were no different between the two groups. CONCLUSION: Regional epidural anesthesia is an alternative technique for PCNL which achieves more patient satisfaction, less early postoperative pain and less adverse effects from medication with the same efficacy and safety compared to general anesthesia.

Efficacy and safety of percutaneous nephrolithotomy (PCNL): a prospective and randomized study comparing regional epidural anesthesia with general anesthesia

OBJECTIVE: To compare the efficacy and safety of regional epidural anesthesia and general anesthesia in patients who underwent PCNL. MATERIALS AND METHODS: Fifty patients submitted to percutaneous nephrolithotomy (PCNL) were randomized into two groups: Group I (N = 26) received general anesthesia and Group II (N = 24) received regional epidural anesthesia. Demographic and operative data including age, BMI, stone position, stone size, postoperative pain, amount of postoperative analgesic usage, length of hospital stay, patient satisfaction, preoperative and postoperative hemoglobin and hematocrit, adverse effects and surgical complications were compared between both groups. RESULTS: Average pain score at 1 hour. was 6.88 in group I and 3.12 in group II (p < 0.001), at 4 hours. 5.07 in group I and 3.42 in group II (p = 0.025). Less morphine was required in the regional epidural anesthesia group compared to the general anesthesia group. Higher satisfaction was found in the regional epidural group. 6 (23.07%) patients in Group I and 1 patient (4.19%) in Group II had postoperative nausea and vomiting, respectively (p = 0.05). Pain score at 12 hours, 24 hours, 48 hours, 72 hours, preoperative and postoperative hemoglobin and hematocrit, length of hospital stay, and adverse effects were no different between the two groups. CONCLUSION: Regional epidural anesthesia is an alternative technique for PCNL which achieves more patient satisfaction, less early postoperative pain and less adverse effects from medication with the same efficacy and safety compared to general anesthesia.

Alkaline citrate reduces stone recurrence and regrowth after shockwave lithotripsy and percutaneous nephrolithotomy.

OBJECTIVE: To evaluate the preventive effects of alkaline citrate on stone recurrence as well as stone growth post-ESWL or PCNL in patients with calcium-containing stones. MATERIALS AND METHODS: A total of 76 patients with calcium calculi who were stone-free or had residual stones less than 4 mm following ESWL and PCNL were enrolled. All patients were independently randomized into two groups. The treated group (N = 39) was given 81 mEq per day of oral potassium-sodium citrate (27 mEq three times a day), and the untreated group (N = 37) serving as controls. Blood, twenty-four hour urine analysis, and plain KUB were measured and compared at the baseline and after 12 months. RESULTS: At baseline, hypocitraturia was found in 20 of 39 patients (46.05%) of Group I and 15 of 37 patients (40.5%) of Group II. At 12 months, hypocitraturia was found in 3 of 39 (7.69%) and 14 of 37 (37.83%) of Group I and Group II, respectively (p = 0.007). At the 12 month follow-up, of the stone-free group, 92.3% of the treated group and 57.7% of the control group were still stone free. Of the residual stone group, 30.8% and 9.1% of treated and control group were stone-free, respectively. The increased stone size found in 7.7%) and 54.5%) of treated and control groups, respectively. CONCLUSION: Sodium-potassium citrate provides positive effects on stone-forming activities in calcium stone patients suffering from urolithiasis following treatment with ESWL and PCNL procedures at the 12-month follow-up.

Alkaline citrate reduces stone recurrence and regrowth after shockwave lithotripsy and percutaneous nephrolithotomy

OBJECTIVE: To evaluate the preventive effects of alkaline citrate on stone recurrence as well as stone growth post-ESWL or PCNL in patients with calcium-containing stones. MATERIALS AND METHODS: A total of 76 patients with calcium calculi who were stone-free or had residual stones less than 4 mm following ESWL and PCNL were enrolled. All patients were independently randomized into two groups. The treated group (N = 39) was given 81 mEq per day of oral potassium-sodium citrate (27 mEq three times a day), and the untreated group (N = 37) serving as controls. Blood, twenty-four hour urine analysis, and plain KUB were measured and compared at the baseline and after 12 months. RESULTS: At baseline, hypocitraturia was found in 20 of 39 patients (46.05 percent) of Group I and 15 of 37 patients (40.5 percent) of Group II. At 12 months, hypocitraturia was found in 3 of 39 (7.69 percent) and 14 of 37 (37.83 percent) of Group I and Group II, respectively (p = 0.007). At the 12 month follow-up, of the stone-free group, 92.3 percent of the treated group and 57.7 percent of the control group were still stone free. Of the residual stone group, 30.8 percent and 9.1 percent of treated and control group were stone-free, respectively. The increased stone size found in 7.7 percent and 54.5 percent of treated and control groups, respectively. CONCLUSION: Sodium-potassium citrate provides positive effects on stone-forming activities in calcium stone patients suffering from urolithiasis following treatment with ESWL and PCNL procedures at the 12-month follow-up.

Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy.

OBJECTIVE: To identify the pre- and intraoperative factors that affect the development of postoperative systemic inflammatory response syndrome (SIRS) following percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: A total of 200 patients were treated with PCNL, 56 of which developed postoperative SIRS (group I) and 144 did not (group II). For these 2 groups, the patient factor, operative factor, preoperative urine culture, pelvic urine culture, and stone culture were compared. RESULTS: Average age, stone size, operative time, success rate, and number of tubeless PCNL were not significantly different between the 2 groups. However, preoperative urine culture, pelvic urine culture, and stone culture, respectively, were positive in 66.1, 46.4 and 48.2% of the patients in group I, but only 10.4, 3.5 and 3.5% for the corresponding specimens in group II. In addition, 5 patients in group I developed clinical septic shock, 4 of which were positive for all cultures and 1 positive only for stone culture. CONCLUSION: Infection following PCNL is common, but only a few cases progress to septic shock. Positive preoperative urine, intraoperative pelvic urine and stone cultures are important factors indicating the development of postoperative SIRS. Intraoperative cultures are important for decision-making about the treatment of postoperative infection complications.

Efficacy of tamsulosin 0.4 mg/day in relieving double-J stent-related symptoms: a randomized controlled study.

This study evaluated the efficacy of tamsulosin in improving stent-related symptoms and quality of life in patients with in-dwelling double-J ureteral stents. A total of 42 patients (15 males and 27 females) with ureteral stent placement following ureteroscopy, percutaneous nephrolithotomy or balloon dilatation, were prospectively randomized into two groups of 21 patients. Group I received 0.4 mg tamsulosin once daily for 4 weeks and group II was a non-placebo, non-treatment control. All patients completed the International Prostate Symptom Score (IPSS) and SF-36 questionnaires at 2 and 4 weeks post-operatively. The IPSS scores for irritative and obstructive symptoms were significantly lower in group I than group II at both 2 and 4 weeks. Among the eight domains of SF-36, role limitation due to physical health and bodily pain was significantly better in group I at 2 and 4 weeks. General health was also significantly better in group I at 2 weeks. Tamsulosin improved both urinary symptoms and quality of life without causing serious side-effects.

Does previous open nephrolithotomy affect the efficacy and safety of tubeless percutaneous nephrolithotomy?

INTRODUCTION: Tubeless percutaneous nephrolithotomy (PCNL) in selected patients is effective and results in less postoperative discomfort without increasing complications. The challenges of PCNL in patients who had a history of open nephrolithotomy are decreased kidney mobility due to scarring around the kidney and distortion of the renal collecting system, conditions that may cause difficulty of tract access and increase retained stone and hemorrhagic complications. We compared the efficacy and safety of the tubeless versus the standard PCNL in patients who had undergone previous open nephrolithotomy. PATIENTS AND METHODS: Percutaneous nephrolithotomy (PCNL) was performed in 104 patients who had a history of previous open nephrolithotomy, of which 45 received tubeless PCNL (group I) and 59 received standard PCNL with routine postoperative nephrostomy tubes (group II). All patients had only one percutaneous renal access and showed no significant bleeding, extravasation or residual stone. Of group I, PCNL was done by the standard technique with only placement of a postoperative external ureteral catheter for 48 h. The success rate, operative time, hospital stay and complications were compared between the two groups. RESULTS: Patient's demographic data were not different between both groups. Infundibular stenosis and ureteropelvic junction obstruction were found in 2 and 4 cases of groups I and II, respectively. The success rates, operative time and complication rates were not significantly different between both groups. Hospital stay was 3.53 and 5.39 days for groups I and II, respectively, which was significantly different. Average analgesic (meperidine) usage was significantly less in the tubeless group (39 +/- 35 mg for group I and 75 +/- 32 mg for group II). CONCLUSION: Tubeless PCNL in selected patients with previous open nephrolithotomy has a safe and effective advantage compared to standard PCNL as indicated by a decrease in length of hospital stay and analgesic usage.

Erectile dysfunction as a sentinel marker of endothelial dysfunction disease.

INTRODUCTION: Vascular disease is the major underlying cause of erectile dysfunction (ED). Endothelial dysfunction acts as a marker of "peripheral vascular disease" that occurs prior to clinical vascular disease. ED is the first clinical manifestation of endothelial disease due to the small size of the penile artery. Brachial flow-mediated vasodilation (FMD) is one of the accurate tests for evaluating endothelial function. We compared the endothelial function by FMD between ED patients without clinical signs of vascular disease and non-ED patients. METHODS: 41 ED patients and 30 age-matched normal control subjects were assessed for cardiovascular risks and endothelial function. We measured the FMD in order to evaluate the endothelial function, by comparing the percentage change of the brachial arterial diameter after the brachial arterial occlusion. RESULTS: There were no significant differences in baseline characteristics, cardiovascular risks and lipid values between both groups, except that the high-density lipoprotein cholesterol was higher in the control group. The percentage change of the FMD was 8.7 +/- 1.0 percent and 5.1 +/- 0.6 percent in ED patients and control subjects, respectively (p-value is 0.007). CONCLUSION: ED is the first clinical presentation of sub-clinical endothelial dysfunction disease prior to the appearance of clinical cardiovascular disease or cardiovascular risk factors. ED can be the sentinel marker of early cardiovascular and other systemic vascular diseases and it should thus be employed in preventive strategies.

Effectiveness of low-dose and standard-dose tamsulosin in the treatment of distal ureteric stones: a randomized controlled study.

Low-dose (0.2 mg/day) and standard-dose (0.4 mg/day) tamsulosin were studied in a randomized controlled trial of 75 out-patients with distal ureteroliths in Thailand. Group 1 (n = 25; control) received oral sodium diclofenac 50 mg twice a day for 10 days; group 2 (n = 25) received oral sodium diclofenac 50 mg twice a day for 10 days, with oral tamsulosin 0.2 mg once a day up to 28 days; and group 3 (n = 25) received oral sodium diclofenac 50 mg twice a day for 10 days, with oral tamsulosin 0.4 mg once a day up to 28 days. For groups 1, 2 and 3, respectively, the expulsion rates were 4%, 40% and 68% (significantly different for group 1 vs group 2, and for group 1 vs group 3) and mean expulsion times were 23.00, 9.30 and 10.76 days. Both doses of tamsulosin increased stone expulsion rate and decreased expulsion time in comparison with the control, and have been shown to be safe and effective in Asian patients.

Clinics in diagnostic imaging (114). Rupture of the right testis.

A 22-year-old man, who was kicked in the scrotum during Thai kickboxing, presented with a painful swelling of the right hemiscrotum. Scrotal ultrasonography (US) showed an enlarged right testis with heterogeneous echogenicity and irregular contours. Colour Doppler US showed vascularity in the upper pole of the right testis and avascularity in the lower pole. Emergency exploration of the right hemiscrotum revealed laceration of the lower pole of the right testis. Debridement and repair of the right testis were performed. The clinical manifestations, role of US and US findings of scrotal trauma are discussed.

Colonization of internal ureteral stent and bacteriuria.

To demonstrate the infection rates, colonization rates following the internal ureteral stent placement; the correlation of indwelling time with the infection, bacterial colonization and the value of urine culture to identify colonizing bacteria One hundred and forty-eight stents of 146 patients were evaluated for the bacteriuria and colonization after internal ureteral placement average 8.6 weeks according to the indication. All patients were ambulatory and were examined in an outpatient clinic. Urine culture and 1 cm of proximal and distal ends was taken for culture for bacterial evaluation. The rate of colonization is 33, 50 and 54% when indwelling time is less than 4 weeks, 4-6 weeks and more than 6 weeks, respectively. Urine culture can detect colonization in 69%. Colonization was not found if the indwelling time was less than 2 weeks. Escherichia coli, Enterobacter and Pseudomonas spp. were the most common colonized organisms. Colonization is common if the indwelling time is more than 2 weeks, urine culture can detect colonization in about two to three of the patients. Even if the culture is negative, prophylactic antibiotic that cover gram-negative and gram-positive organisms should be administrated when the patients require further procedures.

Upper-pole access for percutaneous nephrolithotomy: comparison of supracostal and infracostal approaches.

BACKGROUND AND PURPOSE: The advantage of upper-pole access for nephrolithotomy is direct access to most of the intrarenal collecting system and upper ureter. Upper-pole access can be achieved either supracostally and subcostally. Because of the anatomic location of the kidneys, the supracostal approach is associated with a higher rate of pulmonary complications. We compared the efficacy and safety of the supracostal and infracostal upper-pole approaches. PATIENTS AND METHODS: A total 464 patients were treated with percutaneous nephrolithotomy (PCNL) via the upper pole, of which 170 punctures (group I) were performed supracostally and 294 (group II) subcostally. In both groups, PCNL was done by the standard technique with fluoroscopic guidance. The operative time, success rate, hospital stay, and complications in the two groups were compared. RESULTS: Patients were stone free in 82.2% and 77.1% of the cases in groups I and II, respectively, and had stone fragments <4 mm in 10.7% and 14.7%, respectively. The operative time, success rate, and septic and hemorrhagic complications were not significantly different in the two groups. Hydrothorax was found in 26 patients (15.3%) of group I and 4 (1.4%) of group II. Only 9 patients (5.3%) in group I needed intercostal drainage. CONCLUSION: Percutaneous nephrolithotomy via the upper pole is effective using both supracostal and infracostal approaches, with acceptable rates of complications. The rate of pulmonary complications is higher with the supracostal approach. If the supracostal approach is indicated, it should be used with caution.

Previous open nephrolithotomy: does it affect percutaneous nephrolithotomy techniques and outcome?

BACKGROUND AND PURPOSE: The consequences of open nephrolithotomy are scar tissue around the kidney and in the retroperitoneum and distortion of the pelvicaliceal anatomy that may affect the techniques and outcome of percutaneous nephrolithotomy (PCNL). We compared the results and complications of patients undergoing PCNL who had and had not previously undergone open nephrolithotomy. PATIENTS AND METHODS: A total of 178 calculi in 175 patients who had previously had open nephrolithotomy (group I) and 178 calculi in 175 patients who had never had a renal operation (group II) were treated with PCNL. The average time between open nephrolithotomy and PCNL was 8.5 years (range 4 months-22 years). In both groups, PCNL was done by a standard technique with serial Amplatz dilator enlargement of the tract to 30F. Upper-pole access under fluoroscopic guidance was done in most patients. The operative time, success rate, hospital stay, and complications in the two groups were compared. RESULTS: The stone-free rates were 80.3% and 82.6% in groups I and II, respectively, and the rate of residual fragments < or =4 mm was 14.6% and 8.4%. The operative time, success rate, hospital stay, and complications did not differ significantly in the two groups. CONCLUSION: Percutaneous nephrolithotomy is effective and safe in patients who have previously had open nephrolithotomy with no more complications than are seen with PCNL of kidneys that have not been operated on.

Tuberculosis of the genitourinary tract: imaging features with pathological correlation.

The prevalence of pulmonary and extrapulmonary tuberculosis (TB) has been increasing over the past decade, due to the rising number of people with acquired immunodeficiency syndrome and the development of drug-resistant strains of Mycobacterium tuberculosis. The genitourinary tract is the most common site of extrapulmonary TB. Diagnosis is often difficult because TB has a variety of clinical and radiological findings. It can mimic numerous other disease entities. A high level of clinical suspicion and familiarity with various radiological manifestations of TB allow early diagnosis and timely initiation of proper management. This pictorial essay illustrates the spectrum of imaging features of TB affecting the kidney, ureter, bladder, and the female and male genital tracts.

The painful scrotum: an ultrasonographical approach to diagnosis.

Many disease processes, including inflammation, testicular torsion, testicular trauma, and testicular cancer, may have a similar clinical presentation as a painful scrotum. Differentiation of these disease processes is important for proper management. High-resolution ultrasonography (US) combined with colour Doppler ultrasonography (CDUS) is the imaging modality of choice in evaluating these patients. Gray-scale US helps to better characterise scrotal lesions. CDUS demonstrates testicular perfusion which aids in reaching a specific diagnosis. This pictorial essay is intended to review the causes, US appearances of disease processes causing the painful scrotum, and examination pitfalls of scrotal US.

Intravesicle formalin instillation with a modified technique for controlling haemorrhage secondary to radiation cystitis.

OBJECTIVE: Intractable haemorrhage, secondary to radiation cystitis, is a serious complication of radiotherapy for pelvic malignancies. Formalin instillation is often effective for intractable haemorrhage unresponsive to other agents, but carries the risk of significant morbidity. The placement of formalin-soaked pledgets is a modified technique for the treatment of this complication. We compare the effectiveness and complications of both techniques. METHODS: Eleven patients with intractable haemorrhage secondary to radiation cystitis were treated by intravesicle 4% formalin instillation [Group I] and eight were treated by the endoscopic placement of 10% formalin-soaked pledgets on the bleeding points for 15 minutes [Group II]. RESULTS: Cessation of bleeding was 9 of 11 [82%] and 6 of 8 [75%] in Group I and Group II, respectively. One patient in Group II required two treatments, due to recurrent haemorrhage. Four major and several minor complications were found in Group I, and only three minor complications were found in Group II. CONCLUSION: Formalin instillation is effective in controlling severe bladder haemorrhage after radiation of the pelvis, but the complications secondary to the fixative properties are severe. Topical application of formalin-soaked pledgets is as effective in controlling the haemorrhage as conventional intravesicle formalin instillation, with fewer complications. This technique should be the initial treatment for this complication.

Tubeless percutaneous nephrolithotomy in selected patients.

BACKGROUND: Placement of the nephrostomy tube is the last step after completion of percutaneous nephrolithotomy (PCNL). We were able to demonstrate in selected patients who had undergone PCNL that the use of an externalized ureteral catheter can reduce postoperative discomfort without complications. PATIENTS AND METHODS: A total of 37 patients underwent tubeless PCNL with an externalized 6F ureteral catheter for 48 hours. Inclusion criteria were use of a single access site where the renal unit was not obstructive, no significant perforation and bleeding, and no need for a second look. The stone burden was not taken into account. RESULTS: The procedure was performed successfully without major complications. The average length of hospitalization was 3.63 days: 25 patients stayed for 4 days, with the final day reserved for observation after removal of the catheter. The remaining 12 patients stayed only 3 days and could be discharged on the day the catheter was removed. The average intramuscular analgesic requirement was 38.57 mg of meperidine, and none of the patients needed a blood transfusion or required the emergency placement of a nephrostomy tube. CONCLUSION: In properly selected patients, tubeless PCNL with only an externalized ureteral catheter was found to be safe and just as economical as tubeless PCNL with the same outcome.