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Chew BH, Reicherz A, Krambeck AE, Miller NL, Hsi RS, Scotland KB, Miller D, Paterson RF, Wong VKF, Semins MJ, Lange D. Prospective randomized trial of 2 versus 12-weeks of postoperative antibiotics after percutaneous nephrolithotomy in complex patients with infection-related kidney stones. Int J Urol 2022; 29:1551-1558. [PMID: 36102630 DOI: 10.1111/iju.15045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/24/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Treatment of struvite kidney stones requires complete surgical stone removal combined with antibiotic therapy to eliminate urinary tract infections and preventive measures to reduce stone recurrence. The optimal duration of antibiotic therapy is unknown. We sought to determine if 2- or 12-weeks of antibiotics post percutaneous nephrolithotomy (PNL) for infection stones resulted in better outcomes for stone recurrence and positive urine cultures. MATERIAL AND METHODS This multi-center, prospective randomized trial evaluated patients with the clinical diagnosis of infection stones. Patients were randomized to 2- or 12-weeks of postoperative oral antibiotics (nitrofurantoin or culture-specific antibiotic) and included if residual fragments were ≤4 mm on computed tomography imaging after PNL. Imaging and urine analyses were performed at 3-, 6-, and 12-months post-procedure. RESULTS Thirty-eight patients were enrolled and randomized to either 2-weeks (n = 20) or 12-weeks (n = 18) of antibiotic therapy post-PNL. Eleven patients were excluded due to residual fragments >4 mm, and 3 patients were lost to follow-up. The primary outcome was the stone-free rate (SFR) at 6 months post-PNL. At 3-, 6-, and 12-months follow-up, SFRs were 72.7% versus 80.0%, 70.0% versus 57.1%, 80.0% versus 57.1% (p = ns), between 2- and 12-week-groups, respectively. At 3-, 6-, and 12-months follow-up, positive urine cultures were 50.0% versus 37.5%, 50.0% versus 83.3%, and 37.5% versus 100% between 2- and 12-week groups, respectively (p = ns). CONCLUSIONS For patients with stone removal following PNL, neither 2-weeks nor 12-weeks of postoperative oral antibiotics is superior to prevent stones and recurrent positive urine cultures.
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Affiliation(s)
- Ben H Chew
- The Stone Centre at Vancouver General Hospital, Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alina Reicherz
- The Stone Centre at Vancouver General Hospital, Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amy E Krambeck
- Department of Urology, Northwestern University, Chicago, Illinois, USA
| | - Nicole L Miller
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan S Hsi
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kymora B Scotland
- Department of Urology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - David Miller
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ryan F Paterson
- The Stone Centre at Vancouver General Hospital, Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Victor K F Wong
- The Stone Centre at Vancouver General Hospital, Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michelle J Semins
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dirk Lange
- The Stone Centre at Vancouver General Hospital, Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Single- versus Multiple-Tract Percutaneous Nephrolithotomy in the Surgical Management of Staghorn Stones or Complex Caliceal Calculi: A Systematic Review and Meta-analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8817070. [PMID: 33381587 PMCID: PMC7762636 DOI: 10.1155/2020/8817070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/18/2020] [Accepted: 11/30/2020] [Indexed: 12/29/2022]
Abstract
Objective To assess current evidence on the effectiveness and safety of single- versus multiple-tract percutaneous nephrolithotomy in the surgical management of complex caliceal calculi or staghorn stones through a comprehensive literature review. Methods A comprehensive literature review of articles investigating the clinical efficacy and safety of single- versus multiple-tract percutaneous nephrolithotomy was performed. Relevant literature was obtained by systematically searching PubMed, EMBASE, and the Cochrane Library through May 2020. We followed the search strategy based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The primary outcomes, including the stone-free rate (SFR), and secondary outcomes (peri- and postoperative complications and operative data) were evaluated using RevMan 5.3 statistical software. Results Ten studies involving 1844 patients with complex caliceal calculi or staghorn stones met the inclusion criteria. Single-tract percutaneous nephrolithotomy (STPCNL) had noninferior clinical efficacy with respect to the immediate SFR (odds ratio (OR) = 0.80, 95% confidence interval (CI) (0.46 to 1.38), p = 0.42) and 3-month SFR (OR = 1.22, 95% CI (0.38 to 3.92), p = 0.74) compared with multiple-tract percutaneous nephrolithotomy (MTPCNL). In addition, pooled analyses showed that STPCNL resulted in significantly lower hemoglobin decreases (MD = −0.46, 95% CI (-0.68 to -0.25), p < 0.0001), fewer blood transfusions (OR = 0.48, 95% CI (0.34 to 0.67), p < 0.0001), and fewer pulmonary complications (OR = 0.28, 95% CI (0.09 to 0.83), p = 0.02) than MTPCNL. However, the overall evidence was insufficient to suggest a statistically significant difference for other adverse events. Conclusion This meta-analysis indicated that STPCNL is an effective method for treating complex caliceal calculi or staghorn stones. Compared with MTPCNL, STPCNL not only yields similarly high SFRs but also is associated with many advantages, less blood loss, fewer blood transfusions, and fewer pulmonary complications without an increase in other complications. However, the findings of this study should be further confirmed by well-designed prospective randomized controlled trials (RCTs) with a larger patient series.
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Sharbaugh A, Morgan Nikonow T, Kunkel G, Semins MJ. Contemporary best practice in the management of staghorn calculi. Ther Adv Urol 2019; 11:1756287219847099. [PMID: 35173810 PMCID: PMC8842174 DOI: 10.1177/1756287219847099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 04/09/2019] [Indexed: 12/19/2022] Open
Abstract
Staghorn calculi are complex renal stones that occupy the majority of the renal collecting system. These stones are associated with high morbidity and can lead to recurrent urinary tract infections, urosepsis, renal deterioration, and death if left untreated. Managing patients with staghorn calculi can be challenging. Fortunately, advances in technology and endourology techniques have enabled urologists to effectively treat these stones with minimal morbidity to the patient. This article describes the contemporary best practices in the initial evaluation, management, and follow up of patients with staghorn calculi to help the practicing urologist navigate this complex condition.
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Affiliation(s)
- Adam Sharbaugh
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tara Morgan Nikonow
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gregory Kunkel
- Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michelle Jo Semins
- Department of Urology, University of Pittsburgh Medical Center, 1350 Locust Street, Suite G100A Building C, Pittsburgh, PA 15219, USA
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Abstract
Staghorn stones are large branching stones that fill part of all of the renal pelvis and renal calyces and they can be complete or partial depending on the level of occupancy of the collecting system. Although kidney stones are commoner in men, staghorn stones are less often reported in men compared to women and they are usually unilateral. Due to the significant morbidity and potential mortality attributed to staghorn stones, prompt assessment and treatment is mandatory. Conversely, conservative treatment has been shown to carry a mortality rate of 28% in 10-year period and 36% risk of developing significant renal impairment. Staghorn stones are, therefore, significant disease entity that should be managed aggressively and effectively. Generally, the gold standard treatment for staghorn stones is surgical with a view to achieve stone-free collecting system and preserve renal function. Percutaneous nephrolithotomy should be the recommended first-line treatment for staghorn stones. Other non-surgical options are usually considered in combination with surgery or as monotherapy only if patients are surgically unfit. The decision for optimal treatment of staghorn stones should be individualized according to the circumstances of the patient involved and in order to do so, a closer look at the advantages and disadvantages of each option is necessary.
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Affiliation(s)
- Akif Diri
- a Faculty of Medicine , Aksaray University , Aksaray , Turkey
| | - Banu Diri
- b Department of Urology and Nephrology , Aksaray University , Aksaray , Turkey
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Deutsch PG, Subramonian K. Conservative management of staghorn calculi: a single-centre experience. BJU Int 2016; 118:444-50. [DOI: 10.1111/bju.13393] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abreu LDADS, Camilo-Silva DG, Fiedler G, Corguinha GB, Paiva MM, Pereira-Correia JA, Muller VJF. Review on renal recovery after anatrophic nephrolithotomy: Are we really healing our patients? World J Nephrol 2015; 4:105-110. [PMID: 25664252 PMCID: PMC4317620 DOI: 10.5527/wjn.v4.i1.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 10/02/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023] Open
Abstract
The main goals for urinary stone treatment are to preserve renal function, reduce or avoid complications related to calculi, and to render the patient free of calculi as soon as possible. Anatrophic nephrolithotomy (ANL) is a valid and useful alternative for conventional staghorn calculi excision. Although excellent stone free rates can be achieved with ANL there are some drawbacks that may be of concern. Morbidity related to intraoperative and postoperative complications is one of them. Another, great concern is the possibility of reduction on renal function related to the procedure itself. This may be related to nephron injury during nephrotomy and parenchymal closure or to ischemic injury. In this review we assess functional results after anatrophic nephrolithotomy.
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Khater N, Abou Ghaida R, Khauli R, El Hout Y. Current minimally invasive and endourological therapy in pediatric nephrolithiasis. AFRICAN JOURNAL OF UROLOGY 2014. [DOI: 10.1016/j.afju.2014.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Abstract
Infection urinary stones resulting from urease-producing bacteria are composed by struvite and/or carbonate apatite. Bacterial urease splits urea and promotes the formation of ammonia and carbon dioxide leading to urine alkalinization and formation of phosphate salts. Proteus species are urease-producers, whereas a limited number of strains of other Gram negative and positive species may produce urease. Ureaplasma urealyticum and Corynebacterium urealyticum are urease-producers that are not isolated by conventional urine cultures, but require specific tests for identification. Primary treatment requires surgical removal of stones as complete as possible. Extracorporeal and endoscopic treatments are usually preferred, while open surgery is actually limited to few selected cases. Residual stones or fragments should be treated by chemolysis via ureteral catheter or nephrostomy or administration of citrate salts in order to achieve a stone-free renal unit. Postoperatively, recurrent urinary tract infection should be treated with appropriate antibiotic treatment although long-term antibiotic prophylaxis can cause resistance. Urinary acidification has been proposed for the prophylaxis of infection stones, but long-term acidification is difficult to achieve in urine infected by urease-producing bacteria. Urease inhibitors lead to prevention and/or dissolution of stones and encrustations in patients with infection by urea-splitting bacteria, but their use is limited by their toxicity. The administration of citrate salts involves an increase of the value of nucleation pH (pHn), that is the pH value at which calcium and magnesium phosphate crystallization occurs, in a greater way than the corresponding increase in the urinary pH due to its alkalinizing effect and resulting in a reduction of the risk of struvite crystallization. In conclusion prevention of the recurrence of infection stones can be achieved by an integrated approach tailored on the single patient. Complete clearance of the stone must be achieved by primary surgical procedure and residual fragments should be extensively treated. In the case of persistent infection, conservative measures, such as acidification and urease inhibitors or citrate administration, should be adopted to minimize its effect on urinary saturation with respect to struvite.
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Flannigan R, Choy WH, Chew B, Lange D. Renal struvite stones--pathogenesis, microbiology, and management strategies. Nat Rev Urol 2014; 11:333-41. [PMID: 24818849 DOI: 10.1038/nrurol.2014.99] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Infection stones-which account for 10-15% of all urinary calculi-are thought to form in the presence of urease-producing bacteria. These calculi can cause significant morbidity and mortality if left untreated or treated inadequately; optimal treatment involves complete stone eradication in conjunction with antibiotic therapy. The three key principles of treating struvite stones are: removal of all stone fragments, the use of antibiotics to treat the infection, and prevention of recurrence. Several methods to remove stone fragments have been described in the literature, including the use of urease inhibitors, acidification therapy, dissolution therapy, extracorporeal shockwave lithotripsy, ureteroscopy, percutaneous nephrolithotomy (PCNL), and anatrophic nephrolithotomy. PCNL is considered to be the gold-standard approach to treating struvite calculi, but adjuncts might be used when deemed necessary. When selecting antibiotics to treat infection, it is necessary to acquire a stone culture or, at the very least, urine culture from the renal pelvis at time of surgery, as midstream urine cultures do not always reflect the causative organism.
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Affiliation(s)
- Ryan Flannigan
- The Stone Centre at Vancouver General Hospital, Jack Bell Research Centre, 2660 Oak Street, Vancouver, BC V6H 3Z6, Canada
| | - Wai Ho Choy
- The Stone Centre at Vancouver General Hospital, Jack Bell Research Centre, 2660 Oak Street, Vancouver, BC V6H 3Z6, Canada
| | - Ben Chew
- The Stone Centre at Vancouver General Hospital, Jack Bell Research Centre, 2660 Oak Street, Vancouver, BC V6H 3Z6, Canada
| | - Dirk Lange
- The Stone Centre at Vancouver General Hospital, Jack Bell Research Centre, 2660 Oak Street, Vancouver, BC V6H 3Z6, Canada
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Iqbal MW, Youssef RF, Neisius A, Kuntz N, Hanna J, Ferrandino MN, Preminger GM, Lipkin ME. Contemporary Management of Struvite Stones Using Combined Endourologic and Medical Treatment: Predictors of Unfavorable Clinical Outcome. J Endourol 2013; 30:771-7. [PMID: 24251429 DOI: 10.1089/end.2013.0257] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Struvite stones have been associated with significant morbidity and mortality, yet there has not been a report on the medical management of struvite stones in almost 20 years. We report on the contemporary outcomes of the surgical and medical management of struvite stones in a contemporary series. PATIENTS AND METHODS A retrospective review of patients who were treated with percutaneous nephrolithotomy (PCNL) for struvite stones at Duke University Medical Center between January 2005 and September 2012 identified a total of 75 patients. Of these, 43 patients had adequate follow-up and were included in this analysis. Stone activity, defined as either stone recurrence or stone-related events, and predictors of activity were evaluated after combined surgical and medical treatment. RESULTS The study included 43 patients with either pure (35%) or mixed (65%) struvite stones with a median age of 55±15 years (range 21-89 years). The stone-free rate after PCNL was 42%. Stone recurrence occurred in 23% of patients. Postoperatively, 30% of patients had a stone-related event, while 60% of residual stones remained stable with no growth after a median follow-up of 22 months (range 6-67 mos). Kidney function remained stable during follow-up. Independent predictors of stone activity included the presence of residual stones >0.4 cm(2), preoperative large stone burden (>10 cm(2)), and the presence of medical comorbidities (P<0.05). CONCLUSIONS Struvite stones can be managed safely with PCNL followed by medical therapy. The majority of patients with residual fragments demonstrated no evidence of stone growth on medical therapy. With careful follow-up and medical management, kidney function can be maintained and stone morbidity can be minimized. Initial large stone burden, residual stones after surgery, and associated medical comorbidities may have deleterious effect on stone recurrence or residual stone-related events.
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Affiliation(s)
- Muhammad Waqas Iqbal
- 1 Division of Urologic Surgery, Duke University Medical Center , Durham, North Carolina
| | - Ramy F Youssef
- 1 Division of Urologic Surgery, Duke University Medical Center , Durham, North Carolina
| | - Andreas Neisius
- 1 Division of Urologic Surgery, Duke University Medical Center , Durham, North Carolina
- 2 Department of Urology, Johannes Gutenberg University Mainz , Mainz, Germany
| | - Nicholas Kuntz
- 1 Division of Urologic Surgery, Duke University Medical Center , Durham, North Carolina
| | - Jonathan Hanna
- 1 Division of Urologic Surgery, Duke University Medical Center , Durham, North Carolina
| | - Michael N Ferrandino
- 1 Division of Urologic Surgery, Duke University Medical Center , Durham, North Carolina
| | - Glenn M Preminger
- 1 Division of Urologic Surgery, Duke University Medical Center , Durham, North Carolina
| | - Michael E Lipkin
- 1 Division of Urologic Surgery, Duke University Medical Center , Durham, North Carolina
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Horuz R, Sarica K. The management of staghorn calculi in children. Arab J Urol 2012; 10:330-5. [PMID: 26558045 PMCID: PMC4442932 DOI: 10.1016/j.aju.2012.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 03/11/2012] [Accepted: 03/15/2012] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To review reports focusing on the surgical treatment of staghorn stones in children, as despite all the improvements in the surgical treatment of paediatric urolithiasis the management of staghorn calculi still represents a challenging problem in urology practice. METHODS To evaluate current knowledge about treating staghorn calculi in children, we searched PubMed for relevant articles published between 1991 and 2011, using a combination of related keywords, i.e. staghorn stone, child, kidney calculi, surgical treatment, electrohydraulic shockwave therapy (ESWL), percutaneous nephrolithotomy (PCNL), and open surgery. Reports relating to the treatment of paediatric stone disease in general (open surgery, PCNL, ESWL) were also searched with the same method. Additional references were obtained from the reference list of full-text reports. RESULTS Although open surgery had been widely used in the past for treating such stones in children, currently it has only limited indications in highly selected patients. Current published data clearly indicate that, in experienced hands, both PCNL and ESWL are now effective methods for treating staghorn calculi in children. CONCLUSIONS Due to advanced techniques and instrumentation, it is now possible to successfully treat staghorn calculi in children, with very limited safety concerns. Currently, while PCNL is recommended as the first-line surgical treatment, ESWL, open surgery and/or combined methods are valuable but secondary options in the treatment of paediatric staghorn calculi.
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Affiliation(s)
- Rahim Horuz
- Department of Urology, Kartal Training Hospital, Istanbul, Turkey
| | - Kemal Sarica
- Department of Urology, Yeditepe University Medical School, Istanbul, Turkey
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El-Nahas AR, Eraky I, Shokeir AA, Shoma AM, El-Assmy AM, El-Tabey NA, El-Kappany HA, El-Kenawy MR. Percutaneous nephrolithotomy for treating staghorn stones: 10 years of experience of a tertiary-care centre. Arab J Urol 2012; 10:324-9. [PMID: 26558044 PMCID: PMC4442967 DOI: 10.1016/j.aju.2012.03.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 03/07/2012] [Accepted: 03/10/2012] [Indexed: 11/30/2022] Open
Abstract
Objective To present the results of percutaneous nephrolithotomy (PCNL) for treating staghorn stones. Patients and methods A database was compiled from the computerised files of patients who underwent PCNL for staghorn stones between 1999 and 2009. The study included 238 patients (128 males and 110 females) with a mean (SD) age of 48.9 (14) years, who underwent 242 PCNLs, and included staghorn stones that were present in the renal pelvis and branched into two or more major calyces. PCNL was performed or supervised by an experienced endourologist. All perioperative complications were recorded. The stone-free status was evaluated after PCNL and again after 3 months. Results Multiple tracts were needed in 35.5% of the procedures, and several sessions of PCNL were needed in 30% of patients. There were perioperative complications in 54 procedures (22%); blood transfusion was needed in 34 patients (14%). The stone-free rate for PCNL monotherapy was 56.6% (137 patients). Secondary procedures were required for 51 patients (21%), and included shock-wave lithotripsy for 49 and ureteroscopy for two. The 3-month stone-free rate was 72.7% (176 patients). Multiple tracts resulted in an insignificantly higher overall complication rate than with a single tract (P = 0.219), but the reduction in the haemoglobin level was statistically significant with multiple tracts (P = 0.001). Conclusions PCNL for staghorn stones must be done by an experienced endourologist in a specialised centre with all the facilities for stone management and treatment of possible complications. The patients must be informed about the range of stone-free and complication rates, and the possibility of multiple sessions or secondary procedures.
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Affiliation(s)
- Ahmed R El-Nahas
- Urology Department, Urology & Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ibrahim Eraky
- Urology Department, Urology & Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ahmed A Shokeir
- Urology Department, Urology & Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ahmed M Shoma
- Urology Department, Urology & Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ahmed M El-Assmy
- Urology Department, Urology & Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Nasr A El-Tabey
- Urology Department, Urology & Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Hamdy A El-Kappany
- Urology Department, Urology & Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Mahmoud R El-Kenawy
- Urology Department, Urology & Nephrology Center, Mansoura University, Mansoura, Egypt
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El-Nahas AR, Eraky I, Shokeir AA, Shoma AM, El-Assmy AM, El-Tabey NA, El-Kappany HA, El-Kenawy MR. Long-term results of percutaneous nephrolithotomy for treatment of staghorn stones. BJU Int 2010; 108:750-4. [PMID: 21166763 DOI: 10.1111/j.1464-410x.2010.09942.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE • To study long-term results of percutaneous nephrolithotomy (PNL) for treatment of staghorn stones. PATIENTS AND METHODS • The records of patients who underwent PNL for staghorn stones between January 1998 and January 2008 were retrospectively reviewed. • Patients who completed follow-up for one year or more were included. Follow-up with KUB and renal ultrasonography were performed every 3-6 months. • Renal radioisotopic scan was performed for patients who had already undergone this study before doing PNL. RESULTS • The study included 122 patients (69 male and 53 female) with mean age 47.6 ± 14.5 years (5-74). They underwent 126 PNL. • Perioperative complications were encountered in 28 procedures (22%). The mean period of follow-up was 3.5 ± 2.3 years (1-11.3). Among 71 stone-free kidneys, 18 (25%) developed stone recurrence. Of 55 kidneys with residuals at the start of follow-up, 36 (65%) showed growth of these residuals. • Preoperative and postoperative renograms were performed for 71 patients. • At the last follow-up, differential GFR was stable in 53 (74.5%), improved in 12 (17%) and deteriorated in 6 (8.5%). Among patients with deteriorated renal function, 3 had undergone embolization to control severe bleeding, one developed secondary UPJO, and one had recurrent stone obstructing the kidney. CONCLUSION • Long-term functional results of PNL for staghorn stones are satisfactory as 91.5% of kidneys showed stable or improved GFR. Long-term follow-up is mandatory especially for patients with residual stones.
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Affiliation(s)
- Ahmed R El-Nahas
- Urology department, Urology & Nephrology Center, Mansoura University, Mansoura, Egypt.
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Percutaneous nephrolithotomy for complex caliceal and staghorn stones in patients with solitary kidney. ACTA ACUST UNITED AC 2010; 39:171-6. [PMID: 20967435 DOI: 10.1007/s00240-010-0321-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 10/01/2010] [Indexed: 10/18/2022]
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Desai M, Jain P, Ganpule A, Sabnis R, Patel S, Shrivastav P. Developments in technique and technology: the effect on the results of percutaneous nephrolithotomy for staghorn calculi. BJU Int 2009; 104:542-8; discussion 548. [DOI: 10.1111/j.1464-410x.2009.08472.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Saussine C, Lechevallier E, Traxer O. [Staghorn or complex calculi: surgical considerations]. Prog Urol 2008; 18:966-71. [PMID: 19033063 DOI: 10.1016/j.purol.2008.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Accepted: 09/02/2008] [Indexed: 10/21/2022]
Abstract
It is recommended to treat staghorn calculi by percutaneous nephrolithotomy (PCNL) either alone or in combination with Extra Corporeal Shockwave Lithotrips (ESWL). Antegrade or retrograde fibroscopy, multiple accesses could also improve PCNL stone-free rates. ESWL alone is limited to partial staghorn calculi in adults or to staghorn calculi in children. Open surgery has more or less completely passed.
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Affiliation(s)
- C Saussine
- Service d'urologie, hôpital Civil, 1, place de l'hôpital, 67091 Strasbourg cedex, France.
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Williams SK, Leveillee RJ. A single percutaneous access and flexible nephroscopy is the best treatment for a full staghorn calculus. J Endourol 2008; 22:1835-7; discussion 1839. [PMID: 18811459 DOI: 10.1089/end.2008.9795] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Steve K Williams
- Department of Urology, Miller School of Medicine, University of Miami, Miami, Florida 33126, USA
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Rai RS, Patrulu K, Rai R, Gupta E, Kayastha A, Sawhney S. Lithoclast(®) Master in Intracorporeal Lithotripsy during Percutaneous Nephrolithotomy : Our Experience. Med J Armed Forces India 2008; 64:232-3. [PMID: 27408153 DOI: 10.1016/s0377-1237(08)80100-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2006] [Accepted: 08/25/2007] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND This study was carried out to compare the efficacy of Lithoclast(®) Master with pneumolithotriptor during percutaneous nephrolithotomy (PNL) in the treatment of renal staghorn calculi. METHODS In this prospective study, 60 patients suffering from partial or complete staghorn renal stones were included. Patients were divided randomly in two groups : Groups I and II and underwent PNL for removal of stones. In Group I patients, standard pneumolithotriptor and in Group II, Lithoclast(®) Master was used for stone fragmentation. The patients were evaluated for rate of fragmentation/clearance, presence of residual fragments by KUB radiograph/ultrasound. Result was analyzed by Chi-square test. RESULT The rate of fragmentation using Swiss Lithoclast(®) Master was more effective and quicker in comparison to standard pneumolithotriptor. The average time taken for fragmentation and clearance in Group I using pneumolithotriptor was 65 minutes, whereas it was 58 minutes using Lithoclast® Master, which was statistically significant (p< 0.01). Only 4% patients had significant residual fragments (> 4mm) in Group II and 16 (53%) patients in Group I, which was significant (p < 0.01). The complications in both the modalities were insignificant; one (1.33%) patient had bleeding and three (10%) patients had urine leak in Group I; whereas three(10%) patients had bleeding and five (16.7%) urine leak in Group II. CONCLUSION Lithoclast(®) Master is an effective intracorporeal lithotripter during percutaneous nephrolithotomy in the treatment of renal staghorn calculi for stone fragmentation/clearance with minimal residual fragments and complications.
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Affiliation(s)
- R S Rai
- Classified Specialist (Surgery & Urology), Command Hospital (Western Command), Chandimandir-134107 (Haryana)
| | - Ksk Patrulu
- Classified Specialist (Surgery & Urology), Command Hospital (Northern Command), C/o 56 APO
| | - R Rai
- Internee Medical Officer, Government Medical College & Hospital, Chandigarh
| | - E Gupta
- Internee Medical Officer, Government Medical College & Hospital, Chandigarh
| | | | - S Sawhney
- Senior Advisor (Anaesthesiology), Command Hospital (Northern Command), C/o 56 APO
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Lehman DS, Hruby GW, Phillips C, Venkatesh R, Best S, Monga M, Landman J. Prospective randomized comparison of a combined ultrasonic and pneumatic lithotrite with a standard ultrasonic lithotrite for percutaneous nephrolithotomy. J Endourol 2008; 22:285-9. [PMID: 18208361 DOI: 10.1089/end.2007.0009] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To compare the efficiency and cost effectiveness of a combined pneumatic and ultrasonic lithotrite (Lithoclast Ultra) and a standard ultrasonic lithotrite, (LUS-1) during percutaneous nephrolithotomy. MATERIALS AND METHODS In a prospective randomized trial, 30 patients undergoing percutaneous nephrolithotomy (PCNL) were randomized to PCNL with either the combined pneumatic and ultrasonic lithotrite (PUL) or a standard ultrasonic lithotrite (SUL). Patient demographics, stone composition, location, pre- and post-operative stone burden, fragmentation rates, and device failures were compared. RESULTS There were 13 patients in the PUL group and 17 patients in the SUL group. Stone burden and location were equal. Overall, 64% of the PUL group had hard stones (defined as stones that were either pure or a mixture of cystine [3], calcium oxalate monohydrate [CaOxMono; 2], and calcium phosphate [CaPO4; 2]), and four had soft stones (3 struvite and 1 uric acid [UA]). In the SUL group, there were eight hard stones (5 CaOxMono and 3 CaPO4), and six soft stones (4 calcium oxalate dihydrate [CaOxDi] and 2 UA) (P = 0.51). Stone composition data were unavailable for five patients. Fragmentation time for the PAL was 37 minutes versus 31.5 minutes for the SUL (P = 0.22). Stone retrieval and mean operative times were similar for both groups. There were a total of three (23.1%) device-related problems in the PUL group, and eight (47%) in the SUL group. There was one (7.7%) device malfunction in the PUL group due to probe fracture. There were two (11.7%) device failures in the SUL group; one failure required the device to be reset every 30 minutes, and the second was an electrical failure. Suction tubing obstruction occurred twice (15.3%) in the PUL group and 35.3% in the SU group (P = 0.35). The stone-free rates for the PUL and SUL were 46% and 66.7%, respectively (P = 0.26). CONCLUSION Although the PUL was more costly, stone ablation and clearance rates were similar for both the combined pneumatic and ultrasonic device and the standard ultrasonic device. When stratified with respect to stone composition, the PUL was more efficient for harder stones, and the SUL was more efficient for softer stones.
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Affiliation(s)
- Daniel S Lehman
- Columbia University Medical Center, Department of Urology, New York, New York, USA
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Abstract
Percutaneous nephrolithotomy was first performed in 1976. In the past 30 years, many refinements to the procedure have been made and it has become the gold standard for the management of large and complex renal calculi. This article reviews advances made in the field and highlights the nuances of the technique. The large published series are reviewed and their results discussed.
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Affiliation(s)
- Leslie A Deane
- Department of Urology, University of California Irvine, UCI Medical Center, Orange, CA 92868, USA
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Abstract
The American Urological Association Nephrolithiasis Guidelines Panel recently conducted a critical meta-analysis of the existing literature to determine the optimal management for staghorn calculi. This article briefly discusses the pathophysiology of staghorn calculi and, based on the panel's recommendations, examines the alternative medical treatments (eg, chemolysis) and surgical treatments (eg, shock wave lithotripsy, open surgery, ureteroscopy, and percutaneous nephrolithotomy) available for staghorn patients. Considering the various modalities for staghorn disease, percutaneous nephrolithotomy should be the first-line treatment for most patients based on its superior efficacy and low morbidity.
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Affiliation(s)
- Kelly A Healy
- Department of Urology, The Emory Clinic, Emory University School of Medicine, 1365 Clifton Rd., Suite B, Atlanta, GA 30322, USA
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Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS, Wolf JS. Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol 2005; 173:1991-2000. [PMID: 15879803 DOI: 10.1097/01.ju.0000161171.67806.2a] [Citation(s) in RCA: 593] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Undre S, Olsen S, Mustafa N, Patel A. "Pass the Ball!" Simultaneous Flexible Nephroscopy and Retrograde Intrarenal Surgery for Large Residual Upper-Pole Staghorn Stone. J Endourol 2004; 18:844-7. [PMID: 15659916 DOI: 10.1089/end.2004.18.844] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Complex staghorn calculi have conventionally been treated with percutaneous nephrolithotomy, extracorporeal lithotripsy, or, occasionally, open surgery. Access to branched calculi is difficult through a single percutaneous track. We tested and make a case for a synchronous bidirectional technique combining the use of flexible instruments through percutaneous and retrograde approaches. We present a case of "pass the ball," which may have a place in tackling large, complex, or branched staghorn calculi without the need for multiple percutaneous punctures, removing larger fragments than is possible through the ureter and avoiding multiple passes through the ureter, saving time and decreasing the possibility of iatrogenic ureteral injury.
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Affiliation(s)
- Shabnam Undre
- Department of Urology, St. Mary's Hospital, Praed Street, Paddington, London W2 1NY, U.K.
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Silverstein AD, Terranova SA, Auge BK, Weizer AZ, Delvecchio FC, Pietrow PK, Munver R, Albala DM, Preminger GM. Bilateral Renal Calculi: Assessment of Staged v Synchronous Percutaneous Nephrolithotomy. J Endourol 2004; 18:145-51. [PMID: 15072621 DOI: 10.1089/089277904322959770] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Percutaneous stone removal has replaced open renal surgery and has become the treatment of choice for large or complex renal calculi. However, patients with large bilateral stone burdens still present a challenge. Simultaneous bilateral percutaneous nephrolithotomy (PCNL) has been demonstrated to be a well-tolerated, safe, cost-effective, and expeditious treatment. We present what is, to our knowledge, the first large retrospective series comparing synchronous and asynchronous bilateral PCNL. PATIENTS AND METHODS A chart review was performed on 26 patients undergoing 57 PCNLs for bilateral renal calculi over a 7-year period. Seven patients received synchronous PCNL (same anesthesia; Group 1), and 19 patients underwent asynchronous PNL (procedures separated by 1-3 months; Group 2). Complete surgical and hospital records were available on all patients. The average stone burden for Group 1 was 8.03 cm(2) on the left and 9.18 cm(2) on the right v 10.1 cm(2) on the left and 14.23 cm(2) on the right for Group 2 (P> 0.05). Variables of interest included anesthesia time, operative time, blood loss, transfusion rates, length of hospital stay, and complication rates. Each variable was evaluated per operation and per renal unit. Follow-up imaging with stone assessment was available on 20 patients. RESULTS Group 1 required 1.14 access tracts per renal unit to attempt complete clearance of the targeted stones v 1.88 tracts per renal unit in Group 2 (P> 0.05). The average operative time per renal unit was significantly less in Group 1 (83 minutes) than in Group 2 (168.5 minutes) (P< 0.0001), as was blood loss (178.5 mL v 307.4 mL, respectively; P= 0.02). However, blood loss per operation was similar at 357 mL in Group 1 and 282 mL in Group 2. Comparable transfusion rates of 28.6% and 36.8%, respectively, were noted. Forty percent of the patients in Group 1 were completely stone free compared with 36% of the patients in Group 2; however, an additional 50% and 57%, respectively, had residual stone burden <4 mm (P> 0.05). Complications occurred in 2 of 7 operations (28%) in Group 1 and 8 of 42 operations (19%) in Group 2. The total length of hospital stay was nearly doubled for patients undergoing staged PCNL (P= 0.0005). CONCLUSIONS These results demonstrate similar stone-free rates, blood loss per operation, and transfusion rates for simultaneous and staged bilateral PCNL. The reduced total operative time, hospital stay, and total blood loss, along with the requirement for only one anesthesia, makes synchronous bilateral PCNL an attractive option for select individuals. However, in patients with larger, less easily accessible stones, excessive bleeding may be encountered more frequently on the first side, thereby delaying management of the second side to a later date. Synchronous bilateral PCNL should be considered in patients in whom the first stage of stone removal is accomplished quickly and safely.
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Affiliation(s)
- Ari D Silverstein
- Comprehensive Kidney Stone Center, Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Abstract
PURPOSE To determine the current practice patterns of a large group of urologists in the treatment of large renal stones. MATERIALS AND METHODS A survey was sent to all actively practicing members of the North Central Section of the American Urological Association. The questions pertained to age, time in practice, type of practice, time devoted to treating stones, residency training, case scenarios with treatment options, and whether they or a radiologist performed percutaneous access. The data were statistically analyzed. RESULTS The response rate was 51% (564/1102 surveys returned). Three quarters (73%) of the urologists were comfortable performing percutaneous nephrolithotomy (PCNL), and 35% gave reasons they do not perform PCNL. Only 11% of those performing PCNL routinely obtained the percutaneous access themselves. Trends in the analysis included: (1) those trained to perform PCNL during residency were more often comfortable with this procedure; (2) younger urologists were more comfortable performing PCNL, even if they had been in practice for only a short time; (3) urologists in private practice were nearly as comfortable performing PCNL as were academic urologists; (4) urologists not comfortable with PCNL more often recommended SWL over PCNL as a primary treatment for moderate/large renal stones; and (5) few urologists routinely obtained percutaneous access themselves. CONCLUSIONS Many urologists trained in recent years are comfortable performing PCNL. The type of training received influences treatment recommendations, and percutaneous access is most often obtained by/in conjunction with radiologists. This information may be useful in guiding residency training programs in the preparation of residents for the treatment of large renal stones.
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Affiliation(s)
- Vincent G Bird
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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Marcovich R, Smith AD. Renal pelvic stones: choosing shock wave lithotripsy or percutaneous nephrolithotomy. Int Braz J Urol 2003; 29:195-207. [PMID: 15745522 DOI: 10.1590/s1677-55382003000300002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2002] [Accepted: 10/10/2002] [Indexed: 11/22/2022] Open
Abstract
Introduction of minimally invasive techniques has revolutionized the surgical management of renal calculi. Extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy are now both well-established procedures. Each modality has advantages and disadvantages, and the application of each should be based on well-defined factors. These variables include stone factors such as number, size, and composition; factors related to the stone's environment, including the stone's location, spatial anatomy of the renal collecting system, presence of hydronephrosis, and other anatomic variables, such as the presence of calyceal diverticula and renal anomalies; and clinical or patient factors like morbid obesity, the presence of a solitary kidney, and renal insufficiency. The morbidity of each procedure in relation to its efficacy should be taken in to account. This article will review current knowledge and suggest an algorithm for the rational management of renal calculi with shock wave lithotripsy and percutaneous nephrolithotomy.
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Affiliation(s)
- Robert Marcovich
- Department of Urology, Long Island Jewish Medical Center, New Hyde Park, New York 11040-1496, USA.
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Ugras M, Gunes A, Baydinc C. Severe renal bleeding caused by a ruptured renal sheath: case report of a rare complication of percutaneous nephrolithotomy. BMC Urol 2002; 2:10. [PMID: 12236904 PMCID: PMC128810 DOI: 10.1186/1471-2490-2-10] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2002] [Accepted: 09/18/2002] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Percutaneous nephrolithotomy is a minimally invasive intervention for renal stone disease. Complications, which are rare and usually presented as case reports, are diversified as the utilization of the procedure is expanded. The procedure causes less blood loss and less morbidity when compared to open surgical procedures. Yet, there are some reports involving severe bleeding and relevant morbidity during surgery. These are usually related with the surgical technique or experience of the surgeon. Renal sheaths are designed to cause minimal trauma inside the kidney and, to our knowledge, there are no reports presenting the rupture of a sheath causing severe bleeding during the procedure. CASE REPORT We present an adult patient who had severe bleeding during percutaneous nephrolithotomy due to parenchymal injury caused by a ruptured renal sheath. During retrieval, due probably to rough handling of the equipment, a piece of stone with serrated edges ruptured the tip of the sheath, and this tip caused damage inside the kidney. The operation was terminated and measures were taken to control bleeding. The patient was transfused with a total of 1600 ml of blood, and the stones were cleared in a second look operation. CONCLUSION Although considered to be a minimally invasive procedure, some unexpected complications may arise during percutaneous nephrolithotomy. After being fragmanted, stone pieces may damage surgical equipment, causing acute and severe harm to the kidney. Surgeons must manipulate the equipment with fine and careful movements in order to prevent this situation.
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Affiliation(s)
- Murat Ugras
- Department of Urology, Inönü University, Faculty of Medicine, Malatya, Turkey
| | - Ali Gunes
- Department of Urology, Inönü University, Faculty of Medicine, Malatya, Turkey
| | - Can Baydinc
- Department of Urology, Inönü University, Faculty of Medicine, Malatya, Turkey
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MUNVER RAVI, DELVECCHIO FERNANDOC, NEWMAN GLENNE, PREMINGER GLENNM. CRITICAL ANALYSIS OF SUPRACOSTAL ACCESS FOR PERCUTANEOUS RENAL SURGERY. J Urol 2001. [DOI: 10.1016/s0022-5347(05)65745-x] [Citation(s) in RCA: 146] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- RAVI MUNVER
- From the Comprehensive Kidney Stone Center, Division of Urology, Department of Surgery and Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - FERNANDO C. DELVECCHIO
- From the Comprehensive Kidney Stone Center, Division of Urology, Department of Surgery and Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - GLENN E. NEWMAN
- From the Comprehensive Kidney Stone Center, Division of Urology, Department of Surgery and Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - GLENN M. PREMINGER
- From the Comprehensive Kidney Stone Center, Division of Urology, Department of Surgery and Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
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Abstract
This past year produced some remarkable reports on renal (and other urinary) calculi. Randall's plaques have returned, phosphate relates to insulin and lipid metabolism, and sialic acid is out. Risk factors for astronauts, cystinuric individuals, older and indinavir patients achieve importance. Discovery by spiral computed tomography advances, teleconsultation emerges and shot-gun therapy with potassium-magnesium citrate succeeds. Endoscopic or shock wave lithotripsy vie for which is best, and both attempt to eliminate open surgery. Yet open surgery still has its place.
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Affiliation(s)
- G W Drach
- Division of Urology, University of Pennsylvania, Philadelphia 19104, USA. drachgw-mail.med.upenn.edu
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