Number of Tracts or Stone Size: Which Influences Outcome of Percutaneous Nephrolithotomy for Staghorn Renal Stones?
Hasheminejad Clinical Research Development Center, Tehran, Iran. Urologia Internationalis
(Impact Factor: 1.43).
05/2012; 89(1):103-6. DOI: 10.1159/000338645
Percutaneous nephrolithotomy (PCNL) is the recommended first-line treatment for staghorn stones. To achieve complete stone clearance, PCNL may require using multiple tracts.
To evaluate outcome of PCNL in patients with staghorn calculi and its correlation with the number of tracts and stone features.
One hundred consecutive patients with staghorn renal stone who underwent PCNL were included in the study. Perioperative and postoperative features were recorded. Correlation of the variables with number of tracts and stone size was assessed.
Mean age (± SD) was 49.6 ± 14.7 years. Our patients were ASA class I. The mean cumulative stone burden was 365.9 ± 156.5 mm(2). The mean number of tracts was 2.4 (range: 1-7), and stone-free rate was 83%. The stone-free rate (p = 0.026) and hospital stay (p = 0.005) correlated with stone size, but not with number of tracts. Postoperative fever correlated with stone size (p = 0.017) and number of tracts (p = 0.037).
PCNL using multiple tracts seem to be effective and safe in treatment of staghorn calculi. Most outcome measures correlated with stone size rather than number of tracts.
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ABSTRACT: Several techniques have been described for percutaneous access and stone removal. The method of choice depends on the available instrumentation, stone burden in given caliceal anatomy, and the surgeon's preference, depending on his or her level of training. The argument for multiple strategic tracts vs single-tract percutaneous nephrolithotomy (PCNL) with or without flexible instrumentation for complete clearance of the stones is ongoing. The "multiperc" or multiple tract approach offers clearance of stones without the added cost of sophisticated instrumentation; further, a surgeon who can achieve a primary tract can easily create secondary tracts. This does not require a learning curve to be overcome. The argument against the multiperc approach is a potential for increased bleeding, which has not been substantiated in any published series. The single-tract approach without need for flexible instrumentation, currently published, is for small burden and partial staghorn stone where multiple tracts are not really necessary. Use of single-tract PCNL with flexible instrumentation, such as ureteroscopy and nephroscopy, ideally needs a supracostal approach with its attendant morbidity. The success of this procedure depends on the collecting system anatomy. Few studies published to date report suboptimal stone clearance rates with the advantages of shorter hospital stay and less blood loss. The currently available literature is not sufficient because of mostly retrospective studies, fewer patient accrual, and paucity of staghorn cases. Proper prospective studies with head-on comparisons are needed to prove or disprove the advantages and disadvantages of either approach.
Journal of endourology / Endourological Society 09/2009; 23(10):1675-8. DOI:10.1089/end.2009.1535 · 1.71 Impact Factor
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To evaluate whether renal parenchymal thickness (RPT) has an effect on the outcomes of percutaneous nephrolithotomy (PNL).
We performed a retrospective analysis of 144 patients with lower pole and/or renal pelvic stones who underwent PNL. The relationship between RPT and peri- and postoperative measures was evaluated.
The average age was 45.94 ± 14.47 (15-76) years. The mean BMI was calculated as 27.47 ± 4.73 (16.9-44.9) kg/m(2). The mean stone burden was 293 ± 126 (150-800 mm(2)). The mean RPT was measured as 17.33 ± 5.32 (6-35) mm. No correlation was detected between the RPT and the operation or fluoroscopy times or the duration of hospitalization (p = 0.63, 0.52, 0.08, respectively). The mean drop in hemoglobin level was 1.45 ± 1.25 (0-9) g/dl. A negative correlation was detected between hemoglobin drop and RPT (p = 0.01, r = -0.23). However, the RPT was similar in patients who did or did not require a blood transfusion (p = 0.09). The RPT was found to have no impact on success rate (p = 0.4).
The postoperative hemoglobin drop increases in parallel with the increase in RPT. However, no relationship was detected between the RPT and blood transfusion, overall success rate or any other perioperative parameters.
Urologia Internationalis 01/2013; 90(4). DOI:10.1159/000346336 · 1.43 Impact Factor
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ABSTRACT: The aim of this study is to identify surgical, patient- and stone-related factors predictive of clinical success and complications after percutaneous nephrolithotomy (PCNL).
We prospectively studied 100 consecutive PCNL procedures. Univariate and multiple regression models were used in order to identify which variables could act as independent predictors of PCNL outcomes. Success was defined as complete absence of fragments in a non-contrast CT. The Clavien-modified grading system was used to classify the complications.
Univariate analysis showed that patients rendered stone-free had a significantly lower stone burden, shorter operating times, single stones and non-struvite composed calculi. Patient age, nephrostomy tract dilation with high pressure balloon and a stone composition different to struvite behaved as significant protective factors for complications. Logistic regression models revealed that the main independent prognostic factor for success was stone surface (OR = 0.997 per mm2, p = 0.000), followed by multiple stones (OR = 0.203, p = 0.050). On the other hand, struvite composition (OR = 5.911, p = 0.028) was an independent predictor for the development of complications, whilst age (OR = 0.936, p = 0.012) and high pressure balloon dilation (OR = 0.041, p = 0.007) were rendered independent protective variables.
Stone burden and multiple calculi in the kidney affect the immediate stone-free rate, whilst Amplatz dilation, struvite stones and young patients lead to a higher incidence of postoperative complications. This information can be very useful for patient counseling, regarding percutaneous kidney stone management.
The Canadian Journal of Urology 12/2013; 20(6):7050-7059. · 0.98 Impact Factor
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