Tubeless PNL in the supine position / Sirt ustu pozisyonunda tupsuz PNL.
Percutaneous nephrolithotomy (PNL) is a well-established technique for the treatment of renal stones. Percutaneous nephrolithotomy has replaced open stone surgery for large renal calculi because it is a less invasive technique. After completion of the last stage of PCNL, the nephrostomy tube is placed according to the standard procedure. (1). The purpose is to provide hemostasis along the tract, avoid urinary extravasation and maintain adequate drainage of the kidney. (2) Several modifications of PCNL have been considered in attempts to decrease pain, hospital stay and morbidity. It has been shown that using a small-caliber nephrostomy tube, a miniperc, an internal stent, and tubeless PCNL can decrease postoperative pain and the length of the hospital stay. (3) The term "tubeless percutaneous nephrolithotomy" was first used by Bellman et al. (4). The tubeless PCNL involves internalization of the postoperative renal drainage by placement of an internal stent (either ureteric or JJ catheter) and bladder catheter instead of the traditional nephrostomy tube. (5) Karami and Gholamrezaie (6) and Aghamir et al. (7) reported a technique for a completely tubeless PCNL without any externalized ureteral catheter or double-J stent. They found that this technique is safe and effective, requires a shorter hospital stay and less administration of analgesics and leads to a fast recovery time.
In this prospective study, we evaluated the safety, feasibility and efficacy of tubeless PCNL in the supine position in selected cases of renal stones.
Materials and methods
This study included 120 patients who presented to the Urology Department at Benha Faculty of Medicine with renal stones in the period between June 2009 and June 2010. Informed written consent was obtained from all participants, and the study protocol was approved by the Research Ethical Committee of the Faculty. The following inclusion criteria were applied: patients with renal stones that were removed without significant (more than 4 mm) residual fragments, no perforation in the pelvicalyceal system during PCNL and patients with single access. The following exclusion criteria were applied: patients with stage horn and complex renal stones, multiple percutaneous tracts (>1), pelvicalyceal system perforation, significant bleeding and/ or clinically significant residual fragments at the end of the procedure and the use of bilateral PCNL or PCNL in a solitary kidney. All patients were evaluated according their history, physical examination, KUB, pelviabdominal U/S, spiral CT of the abdomen and pelvis without contrast or IVP in selected cases.
Supine PCNL technique
PCNL in the supine position was performed under general anesthesia. The patient was placed in the supine position with the side harboring the stone close to the operating table (Figure 1). The ipsilateral flank was elevated with a water bag, and the ipsilateral arm was laid on the thorax. Intravenous access was established in the contralateral arm after a standard cystourethroscopy, and a 6 Fr open tip ureteral catheter was inserted into the ipsilateral ureteral orifice.
[FIGURE 1 OMITTED]
Kidney puncture was performed under fluoroscopy after distending the pelvicalyceal system with diluted contrast medium from the ureteric catheter. The puncture site and path were chosen in the mid axillary line; then, an 18-gauge puncture needle was advanced into the appropriate calyx.
A 0.38 floppy-tipped guide wire was advanced into the chosen calyx, and tract dilatation was performed after opacification of the PCS with the contrast medium in a retrograde fashion under fluoroscopic guidance, using Alken dilators up to 27 Fr. A 30 Fr Amplatz sheath was used, and then a standard 26 Fr rigid nephroscope was used for stone retrieval (Figure 2).
[FIGURE 2 OMITTED]
Fragmentation of the stone was performed when needed by a pneumatic lithoclast. Finally, antegrade pyelography was performed in all cases to check the integrity of the collecting system and detect any perforation. The amplatz sheath was then removed, leaving the urethral and ureteric catheters in for 24 hrs. The patients were followed up for postoperative pain, leakage and fever, and perinephric collection with U/S, Hb% and hematocrit were performed after 12 hours.
The collected data were tabulated and analyzed using the Statistical Package for the Social Sciences (SPSS) version 17 software. Suitable statistical values were computed (frequencies, mean, standard deviation and range).
The preoperative patient characteristics are shown in Table 1. No significant difference was found in age or stone size. Table 2 shows the stone criteria. Access to the stones was achieved through the lower calyx (70.8%) and the middle calyx (29.2%). Stone clearance was successful in 100% of the cases with no need for a 2nd session. Operative time, hospital stay, outcome, intra & postoperative complications are listed in Table 3. There was no bleeding from the nephrostomy site. Three cases had perinephric collection <100 cc, which was managed conservatively and resolved within one week. Prolonged leakage occurred in three cases and also resolved spontaneously within five days. Three cases required a one-unit blood transfusion postoperatively due to a low Hb% and hematocrit drop.
Table 1. Patients' criteria Variable Mean[+ or -]SD Range Age 47.02[+ or -]4.15 (40-55) years Gender No. (n=120) (100%) Male 93 77.5 female 27 22.5 Recurrent cases No. (n=51) (42.5%) After PCNL 21 17.5 After open surgery 30 25.0 Table 2. Stone criteria Stone size Mean[+ or -]SD Range 2.6[+ or -]1.08 (1- 4.5) cm Stone number No. (n=120) (100%) Single 80 66.7 Multiple 40 33.3 Stone site Pelvis 80 66.7 Pelvis & upper calyx 5 4.1 Pelvis & lower calyx 15 12.5 Upper & lower calyx 20 16.7 Radio-opacity Radio-opaque 113 94.2 Radio-lucent 7 5.8 Table 3. Operative and postoperative variables Variable No. % Access Lower calyx 85 70.8 Middle calyx 35 29.2 Variable Mean[+ or -]SD Range Operative time 67.1[+ or -]19.2 (35-100) min. Hospital stay 3.4[+ or -]1.7 (1-7) days Outcome No. % Stone free 120 100.0 Residual stones 0 0.0 Postoperative analgesics No. % NSAID Single dose 30 25 1st day Postoperative complications No. % Prenephric collection 3 2.5 Fever 7 5.8 Leakage 3 2.5 Blood transfusion No. % Needed (500 mL) 3 2.5 Not needed 117 97.5
Stone-free status was achieved in all cases. Ureteric catheters were removed after 24 hours, except in 6 cases (3 cases with prolonged leakage and 3 cases with perinephric collection).
PCNL has revolutionized the management of large renal stones by decreasing the morbidity and reducing the length of the hospital stay when compared with open surgery. (8) Valdivia et al., (9) effectively demonstrated that elevation of the desired flank in the supine position enables safe PCNL with low risk of colon injury.
In this study sample, PCNL was performed in 120 patients without the use of a nephrostomy tube; only a ureteric catheter was inserted for 24 hrs. The access was achieved through the lower calyx in 85 patients (70.8%) and through the middle calyx in 35 patients (29.2%).
The operative time ranged from 35-100 minutes (67.1[+ or -]19.2) (Mean[+ or -]SD), and the hospital stay ranged from 1-7 days with a mean of 3.4[+ or -]1.7. This result is in agreement with that of the study by Istanbulluoglu et al., (2) who reported that the mean operative time for tubeless supine PCNL was 51.79[+ or -]25.23 minutes, and the mean hospital stay was 2.09[+ or -]1.75 days. Our results are also in agreement with the findings of Kara et al. (10) who found that the mean operative time was (22-50 min). However, in the present study, the mean patient hospital stay (3.4[+ or -]1.7) may be considered too long in comparison to that reported by Limb and Bellman, (5) who reported a mean of 1.25 days. On the other hand, the insertion of the double -J stent has some disadvantages, such as urinary tract difficulties, in addition to the need for cystoscopy to remove it, making the process more costly (11). Leibovici et al. (11) also reported that quality of life was affected in 45% of their patients due to flank pain, symptoms in the lower urinary tract, anxiety and sleep disturbance in cases with internal stents. Only 30 patients of the patients in this study required a single dose of NSAID as the postoperative analgesia. This result is in agreement with that of Shah et al. (12) who reported that tubeless PCNL decreased the postoperative analgesia requirement and hospital stay.
The stone-free rate was 100% in our study. This result is comparable to that reported by Kara et al., (10) (96%), but it is higher than those reported by Shoma et al. (13) (89%), Shah et al. (13) (93.3%), and Sofer et al. (14) (91%.).
Hemorrhage is the most significant complication of PCNL. (15) A concern of many urologists with the tubeless technique is the lack of a tamponade effect in the nephrostomy tract. (16)
Another concern regarding the tubeless PCNL technique is the inability to monitor excessive hemorrhage and tract hemostasis. (17)
Nephrostomy tube placement at the end of the standard PCNL is thought to decrease these complications. (6) Omitting the nephrostomy tube placement may expose the patient to significant morbidity and, therefore, increase the need for sealing the tract. To date, the use of sealing materials remains controversial because many studies have failed to demonstrate a significant decrease in urinary extravasation or bleeding. (18), (19) In contrast, in a prospective study, Maheshwari and coworkers demonstrated no significant increase in the postoperative bleeding in 20 patients who underwent a one-stage tubeless PCNL. (20)
In the present study, 3 of 120 cases (2.5%) developed perinephric collection ranging from 50-100 cc. These cases were managed conservatively, and the collections resolved spontaneously within one week. Prolonged leakage developed in 3 cases and persisted for 5 days. Blood transfusion was needed in 3 cases due to a drop in the Hb% and hematocrit values postoperatively (2.5%). This result is in agreement with that reported by Wickham et al., (21) who reported transfusions in 6%, while Zilberman et al. (22) reported a 0-11.9% transfusion rate in tubeless PCNL.
Therefore, our current study represents an additional step towards extending the applicability of tubeless PNL. We believe that this study will contribute to the further popularization of the tubeless technique for the benefit of the patients, medical teams and the health care system.
In conclusion, tubeless PCNL with the patients in the supine position can be used in selected cases with a favorable outcome and minimal morbidity, with the potential advantage of decreased postoperative pain, analgesia requirements and hospital stay.
The authors are grateful to colleagues in Urology Department of University Hospital in Benha, Egypt for their help.
Conflict of interest
No conflict of interest was declared by the authors.
Department of Urology, Faculty of Medicine, Benha University, Benha, Egypt
10 Elashraf Street, Benha Elgdeeda, Benha, Egypt
[c]Copyright 2012 by Turkish
Association of Urology Available online at www.turkishjournalofurology.com
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