Percutaneous stone surgery using a tubeless technique with fibrin sealant: report of our first 107 cases.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Small case series support the safety and efficacy of tubeless PCNL with fibrin sealant. However, there is a paucity of data from larger case series supporting this approach. To our knowledge, this is among the largest tubeless PCNL series. We found the use of fibrin sealant for tubeless PCNL was associated with excellent stone-free rates (approaching 90%), short hospitalisation, and low complication rates. Tubeless PCNL with nephrostomy tract fibrin sealant appears to be viable option for appropriately select patients. OBJECTIVE: • To report on our first 107 cases of tubeless percutaneous nephrolithotomy (PCNL) using fibrin sealant as a haemostatic agent within the access tract. PCNL is the preferred treatment for patients with large renal stones, and the tubeless technique with the use of fibrin sealant has recently gained popularity. PATIENTS AND METHODS: • We performed a retrospective review of single-access, PCNL cases performed without a nephrostomy tube from January 2002 to July 2008. • Nephrostomy tracts were sealed at the conclusion of each procedure with fibrin-containing haemostatic agents. • We evaluated demographic variables, tracked complications, and compared pre- and postoperative haemoglobin, haematocrit and creatinine levels. • On postoperative day 1 computed tomography was used to determine stone-free rates. • Student's t-test calculations were used to determine statistical significance at P ≤ 0.05. RESULTS: • In all, 59 men and 48 women with a mean age of 43 years were included in the analysis of 107 cases. The mean stone size was 2.9 cm(2) and the average hospital stay was 1.07 days. • Pre- and postoperative changes in serum haemoglobin and serum creatinine were not statistically different. Postoperative haematocrit declined by a mean of 4.5% (P ≤ 0.05), but no patients required a transfusion. • Stone-free rates were 72% overall, and 90% when excluding patients with residual fragments of <4 mm. • Complications included seven asymptomatic subcapsular haematomas, one pseudoaneurysm requiring selective embolization, one urine leak, and five return visits to the emergency room for pain. CONCLUSIONS: • The use of fibrin sealant in this large tubeless PCNL series was associated with favourable stone-free rates, short hospital stays, and low complication rates with no significant bleeding. • Tubeless PCNL with nephrostomy tract fibrin sealant appears to be a viable option for appropriately selected patients, but future randomised trials are warranted.

Genitourinary abnormalities in an asymptomatic screening population: findings on virtual colonoscopy.

INTRODUCTION: The true incidences of genitourinary conditions in the modern era are not completely known. We sought to determine the incidence of genitourinary abnormalities in a group of asymptomatic adult patients undergoing axial imaging with virtual colonoscopy. METHODS: We performed a post-hoc analysis of imaging results from a prospective, IRB-approved study that randomized patients to screening "virtual" CT colonography (CTC) followed by standard endoscopic colonoscopy. CTC scans were reviewed separately by an independent radiologist and a urologist for genitourinary abnormalities. Genitourinary abnormalities were characterized as of minor, moderate, or major clinical significance. Identified nephroliths were categorized by location, laterality, size, and number. Student's t-tests and Fisher's exact-tests were used for continuous and categorical variables as appropriate. RESULTS: Of 490 patients undergoing CTC and eligible for analysis, no genitourinary abnormalities were found in 294 (60%), minor genitourinary abnormalities were found in 100 (20.4%), moderate genitourinary abnormalities were found in 86 (17.6%), and major genitourinary abnormalities were found in 10 (2%). Renal cysts (n = 60, 12%) were the most common minor urologic findings. Moderate and major genitourinary findings of nephrolithiasis, adrenal adenomas, and renal masses were noted in 13.9%, 3%, and 2% of the population, respectively. The largest stone was 1.2 cm, and the smallest was 1 mm; while 59% had stones < 3mm, 20% between 3 mm and 5 mm, 18% between 5 mm and 10 mm, and 3% > 10 mm in size. Unilateral stones were found in 85%, while bilateral were found in 15%, and the average number of stones was 2, (range 1 - 16). Age and male sex were significantly associated with moderate or major genitourinary findings p = 0.04 and p = 0.05, respectively. CONCLUSIONS: CT colonography in an asymptomatic screening population helped to identify nephrolithiasis in 13.9%. Moderate and major urologic abnormalities were found in 20% of the cohort. Risk factors included male sex and older age.

Retroperitoneal robotic-assisted laparoscopic reimplantation of a ureter into an ileal conduit.

A novel technique for managing ureteroenteric strictures is robotic-assisted retroperitoneal laparoscopic reimplantation. A 63-year-old morbidly obese male underwent a left nephroureterectomy and cystoprostatectomy after neoadjuvant chemotherapy for transitional cell carcinoma of both the bladder and left kidney. His single right ureter was anastomosed to the ileal conduit. Postoperatively, he developed acute renal failure and hydronephrosis. An antegrade pyelogram demonstrated a distal stricture that failed two attempts at endoscopic management. In an effort to avoid the morbidity of an open repair, we present a minimally invasive option that replicates the steps of an open reimplantation.