Supine versus Prone Percutaneous Nephrolithotomy for Complex Stones: A Multicenter Randomized Controlled Trial.

PURPOSE: High-quality evidence comparing supine to prone percutaneous nephrolithotomy (PCNL) for the treatment of complex stones is lacking. This study aimed to compare the outcomes of supine position (SUP) and prone position (PRO) PCNL. MATERIALS AND METHODS: A noninferior randomized controlled trial was performed according to the CONSORT (Consolidated Standards for Reporting Trials) criteria. The inclusion criteria were patients over 18 years of age with complex stones. SUP was performed in the Barts flank-free modified position. Except for positioning, all the surgical parameters were identical. The primary outcome was the difference in the success rate on the first postoperative day (POD1) between groups. The secondary outcome was the difference in the stone-free rate (SFR) on the 90th postoperative day (final SFR). A noninferiority margin of 15% was used. Demographic, operative, and safety variables were compared between the groups. Statistical significance was set at p <0.05. RESULTS: Overall, 112 patients were randomized and their demographic characteristics were comparable. The success rates on POD1 were similar (SUP: 62.5% vs PRO: 57.1%, p=0.563). The difference observed (-5.4%) was lower than the predefined limit. The final SFRs were also similar (SUP: 55.4% vs PRO: 50.0%, p=0.571). SUP had a shorter operative time (mean±SD 117.9±39.1 minutes vs 147.6±38.8 minutes, p <0.001) and PRO had a higher rate of Clavien ≥3 complications (14.3% vs 3.6%, p=0.045). CONCLUSIONS: Positioning during PCNL for complex kidney stones did not impact the success rates; consequently, both positions may be suitable. However, SUP might be associated with a lower high-grade complication rate.

Percutaneous nephrolithotomy in patients with spinal cord injury: should all these patients be automatically assigned a Guy's stone score of 4?

PURPOSE: To assess the complication and stone-free rates of PCNL in patients with spinal cord injury (SCI) and to evaluate whether this population should be assigned a Guy's stone score (GSS) of 4. METHODS: A case-control study was conducted, and electronic charts were reviewed to search for patients with SCI, bladder dysfunction, and kidney stones who had undergone PCNL. Control cases were randomly selected from among patients with complete staghorn calculus (GSS = 4). RESULTS: One hundred and seventeen patients were included. Patients with SCI had a significant shorter operative time (119 vs. 141 min; p = 0.018). There were no significant differences between the groups in terms of the patients' position, number of renal tracts, bleeding or transfusion rate; however, there was a significantly higher complication rate (23.1% vs. 7.8%; p = 0.009) and a longer hospital stay (5.8 vs. 3.1 days; p = 0.002) among patients with SCI. With regards to the stone-free rate in patients with different grades of GSS patients with SCI who had a GSS of 1 had a stone-free rate of 85.7%, while those with a GSS of 2, 3, or 4 had 50%, 50%, and 31.5%, respectively (p = 0.024). Only patients with a GSS of 4 in the SCI group had outcomes that were similar to those of control patients (31.5% vs. 31.6%). CONCLUSION: Patients with SCI should not be automatically assigned GSS 4. Stone-free rate is related to stone burden in these patients, although they do show a higher complication rate and a longer hospital stay than non-neurological patients.

Utility of the Guy's stone score based on computed tomographic scan findings for predicting percutaneous nephrolithotomy outcomes.

OBJECTIVE: To evaluate the ability of the Guy's stone score (GS) to predict the success rates and complications on the basis of the computed tomographic (CT) scan findings for renal stones treated with percutaneous nephrolithotomy (PCNL). METHODS: From 2008 to 2012, a total of 147 consecutive patients (155 renal units) who underwent PCNL in a completely supine position were prospectively evaluated. All patients underwent a CT scan preoperatively, and the stones were classified according to the GS. All PCNLs were analyzed to determine the association between the GS and treatment outcomes on the basis of CT findings and complications, according to the Clavien criteria. RESULTS: Of the 155 PCNLs, 27% were classified as GS1, 28.4% as GS2, 27% as GS3, and 17.6% as GS4. Only the largest diameter of the stones differed among the groups (GS1=21.4, GS2=26.5, GS3=31.4, and GS4=50.5 mm; P<.001). After stratification according to the GS, the groups differed significantly regarding their operative times (GS1=63±28.5, GS2=101.4±40.8, GS3=127.6±47.6, and GS4=153.3±56 minutes; P<.001), tubeless rates (GS1=54.8%, GS2=45.4%, GS3=28.6%, and GS4=7.4%; P<.001), blood transfusion rates (GS1=0%, GS2=2.3%, GS3=4.8%, and GS4=22.2%; P=.01), complications (GS1=4.8%, GS2=9.1%, GS3=26.2%, and GS4=44.4%; P<.001), immediate success rates (GS1=95.2%, GS2=79.5%, GS3=59.5%, and GS4=40.7%; P<.001), and number of auxiliary procedures (GS1=0.05±0.32, GS2=0.28±0.6, GS3=0.35±0.66, and GS4=0.43±0.59; P=.031). The final success rates after the auxiliary procedures were similar among the groups (GS1=97.6%, GS2=86.4%, GS3=90.5%, and GS4=74.5%; P=.19). CONCLUSION: The GS based on CT findings accurately predicted success rates and complications after PCNL for renal stones.

Modified complete supine percutaneous nephrolithotomy: solving some problems.

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for patients with renal stones larger than 2 cm. In this article, we aim to describe our modified technique with the patient in a complete supine position for PCNL (csPCNL). PATIENTS AND METHODS: A total of 117 patients (120 renal units) who underwent csPCNL for large stones from November 2008 to November 2011 were prospectively evaluated. One surgeon worked in two different institutions and performed all operations. All patients underwent CT preoperatively, and the stones were classified according to the Guy score. Patients were placed in the supine decubitus position with the posterior axillary line located just outside the border of the surgical table, and the flank was extended to increase the space between the last rib and the iliac crest. The csPCNL was performed without a rolled towel under the flank, and the patients remained in the same position during the entire procedure. Success was evaluated based on CT findings at the end of follow-up. RESULTS: There was no failure of access. The median operative time was 100 (20-240) minutes. The immediate and final success rates were 72.5% and 90.4%, respectively. The complication rate was 16.8% (12.7% of Clavien I or II and 4.1% of Clavien III or IV). There were no colon injuries or deaths. The median hospital stay was 48 (24-840) hours. CONCLUSION: Modified csPCNL is a safe and effective procedure with excellent outcomes and a low rate of major complications. It provides a good area for renal puncture and surgical instrumentation.

Single port transvesical prostatectomy.

PURPOSE: To describe a case of a transvesical prostatectomy performed by a single port technique. PATIENT AND METHODS: JLS, 64y, diabetic and hypertense, under treatment of LUTS for 8 years with 4mg doxazosin and 5mg finasteride. The IPSS score was 26. The digital rectal exam showed a more than 60g benign prostate. The Body Mass Index was 28.9. The total PSA was 5.4ng/mL and the free/total PSA was 22%. A 12-fragments prostate biopsy showed BPH. The sonography revealed a 106g prostate and the maximum urinary flow was 12 mL/s. The patient was under general anesthesia and was positioned in dorsal decubitus with Trendelemburg. The bladder was filled until that a bexigoma was visible. A 2 cm longitudinal infra-umbelical incision was done. The Gel Point Single Port System (Applied, Ca, USA) was placed inside the bladder and the pneumovesicum was done until 10mmHg. A peri-bladder neck incision was done and the adenoma dissection was performed until its remotion. The hemostasia was done under vision. A 3-way 24-Fr Foley catheter and an 8-Fr plastic catheter were placed inside the bladder. The adenoma was removed and the bladder and the abdominal wall were closed. RESULTS: The procedure took 55 minutes and the blood loss was 180 ml. The patient evolved uneventfully, the bladder irrigation stayed for 24 h, the hemoglobin drop was 2.4g/dL and the patient was discharge after 36 hours. The urethral catheters stayed for 5 days. The postoperative IPSS was 6 and the maximum flow was 26 ml/s. CONCLUSION: The surgery was safe and effective, showing that the single port transvesical prostatectomy can be an option in the surgical treatment of large prostates.