A Prospective, Randomized Trial Evaluating the Safety and Efficacy of Fibrin Sealant in Tubeless Percutaneous Nephrolithotomy

Thulium laser-based hemostasis during percutaneous nephrolithotomy: a prospective observational multicentric study

PURPOSE

Percutaneous nephrolithotomy (PNL) is a controlled grade IV renal trauma and intraoperative bleeding is the most crucial complication. Contemporarily, pulsed mode thulium laser has been reported to confer adequate hemostasis. Therefore, the primary outcome of this study was to assess safety and efficacy of thulium laser-based hemostasis during PNL.

METHODS

This was a prospective observational study including all patients, aged  ≥ 18 years old with renal stone(s)  ≥ 20 mm in the maximal dimension, candidate for PNL. Pregnant patients or those with uncorrected coagulopathy were excluded. All procedures were performed in the prone position and in case of a well-defined active blood spurter, and hemostasis was deployed by thulium laser. Hence, the patients were further classified into group (A): required thulium laser-based hemostasis and group (B): did not require hemostasis. A comparison was made between the groups regarding patients' history, PNL outcomes and complications.

RESULTS

Seven hundred and thirty three patients underwent the procedure and abided by the follow-up regimen. Eighty-eight patients required hemostasis (12%) for tract spurters (51 patients, 58% of group A), renal unit spurters (18 patients, 20.5% of group A) and spurters of both (19 patients, 21.5% of group A). Twenty-two patients (3.1%) received blood transfusion during the study and there was no statistically significant difference between both groups regarding the outcomes and complications. Additionally, there was no statistically significant difference between the preoperative and postoperative value of the mean glomerular filtration rate.

CONCLUSION

Thulium laser-based hemostasis is safe and effective for controlling the intraoperative bleeding during PNL.

A Comparison of the Alken Metallic Telescopic Dilator and Amplatz Serial Dilator for Renal Access in Percutaneous Nephrolithotomy

BACKGROUND

Access to the renal calyx is a challenging and crucial step for a successful percutaneous nephrolithotomy (PCNL). There are different methods of access tract dilatation, and there is no consensus on which method is the best. We conducted a comparative retrospective study on the safety and efficacy of the Alken metallic dilator and Amplatz dilator for renal access in PCNL.

METHODS

We retrospectively reviewed the medical records of 80 patients who underwent PCNL between March 2023 and February 2024, and they were divided into two groups. Group A (n=42) comprised patients where Alken dilators were used, while group B (n=38) comprised patients where Amplatz dilators were used. Safety parameters, that is, perioperative bleeding, blood transfusion, access time, postoperative fever, and urosepsis, were compared between the groups. Efficacy in terms of successful renal access and stone clearance was also compared.

RESULTS

The mean access time (mins) was longer in group B than group A (8.1 vs. 7.3, p=0.012). The intraoperative bleeding was more in group B (15.7% vs. 4.7%, p<0.001). Group B had more hemoglobin (g/dl) drop (1.3 vs. 0.7, p<0.001) and need for blood transfusion (18.4% vs. 7.14%, p<0.001) and VAS score (p<0.001) than group A. Postoperative urosepsis was more common in group B. Efficacy in terms of successful renal access and stone clearance was comparable.

CONCLUSION

The Alken dilator group has a lower rate of blood transfusion and postoperative VAS score. The Amplatz dilator group had more incidences of postoperative urosepsis. The efficacy in both groups was comparable.

Advancements in Performance of Percutaneous Nephrolithotomy in Ambulatory Surgery Centers: Outcomes and Lessons From 1250+ Cases

OBJECTIVE

To evaluate the safety and efficacy of routine ambulatory percutaneous nephrolithotomy (PCNL) in a freestanding ambulatory surgical center.

METHODS

Patients were treated between 2015 and 2022 by one of three experienced endourologists in Maryland. The surgery center is free-standing, with the nearest hospital approximately 10 minutes away. Patient characteristics and surgical datapoints, including need for transfer, were gathered prospectively at the time of surgery. Subset analyses were performed in patients with staghorn calculi or elevated body mass index, as they represent higher-risk populations.

RESULTS

A total of 1267 patients underwent ambulatory PCNL with a median stone diameter of 32 mm. The average recovery time was 87 minutes, with 1.7% of patients requiring transfer to the hospital, generally for postoperative hypotension or inadequate pain control. 166 patients with body mass index >40 were safely treated, with no significant difference in transfer rate (P = .5). 2.8% of patients had a complication, with the majority being Clavien-Dindo grade I or II. 88 patients with staghorn calculi were treated, with a 6% transfer rate. Staghorn calculi were the only factor found on multivariable analysis to be a significant predictor of transfer (OR 3.56 (1.17-10.82) P < .05).

CONCLUSION

Ambulatory PCNL may safely be performed in a surgery center in most patients. These outcomes reflect the real-world experience of high-volume surgeons and demonstrate a multiyear paradigm shift in PCNL from an inpatient procedure to an outpatient procedure in a surgery center.

Totally tubeless, tubeless, and tubed percutaneous nephrolithotomy for treating kidney stones

BACKGROUND

Percutaneous nephrolithotomy (PNL) is the standard of care for removing large kidney stones (> 2 cm). Once the procedure is complete, different exiting strategies exist to manage the percutaneous tract opening, including placement of an external nephrostomy tube, placement of an internal ureteral stent, or no external or internal tube. The decision to place or not place a tube is handled differently among clinicians and may affect patient outcomes.

OBJECTIVES

To assess the effects of tubeless PNL (with ureteral stenting), totally tubeless PNL (without ureteral stenting or nephrostomy), and standard PNL (nephrostomy only) for the treatment of kidney stones in adults.

SEARCH METHODS

We performed a systematic literature search in multiple biomedical databases (CENTRAL, MEDLINE, Embase, Web of Science), as well as in two clinical trial registries. We also handsearched reference lists of relevant publications and conference proceedings. We applied no language restrictions. The latest search update was conducted in September 2022.

SELECTION CRITERIA

We included randomized controlled and quasi-randomized controlled trials of adult patients who received tubeless, totally tubeless, or standard PNL for treating kidney stones. We defined tubeless PNL as no nephrostomy tube, but ureteral stenting, while totally tubeless PNL meant no nephrostomy tube or ureteral stenting. Both interventions were compared to standard PNL with placement of a nephrostomy tube (only). We considered access tubes of any sizes. We only considered unilateral PNL with single-tract access. There were no exclusions on stone composition, size, or location.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the literature, extracted data, assessed risk of bias, and rated the certainty of evidence using GRADE. Primary outcomes were severe adverse events and postoperative pain, and secondary outcomes were operating time, length of hospital stay, and stone-free rate. We used the random-effects model for meta-analysis.

MAIN RESULTS

We included 10 studies in the review. Participant age varied among studies, ranging from 20 to 60 years. Detailed information on stone characteristics was rarely presented. Tubeless PNL versus standard PNL We are very uncertain whether there is a difference in severe adverse events (SAEs) between tubeless PNL and standard PNL (risk ratio (RR) 1.53, 95% confidence interval (CI) 0.14 to 16.46; I2 = 42%; 2 studies, 46 participants; very low-certainty evidence). Tubeless PNL may have little to no effect on pain on postoperative day one (mean difference (MD) 0.56 lower, 95% CI 1.34 lower to 0.21 higher; I2 = 84%; 4 studies, 186 participants; low-certainty evidence), and probably results in little to no difference in operating room time (MD 0.40 longer (in minutes), 95% CI 4.82 shorter to 5.62 longer; I2 = 0%; 3 studies, 81 participants; moderate-certainty evidence). Tubeless PNL may reduce length of hospital stay (MD 0.90 shorter, 95% CI 1.45 shorter to 0.35 shorter; I2 = 84%; 6 studies, 238 participants; low-certainty evidence). We are very uncertain of the effect of tubeless PNL on blood transfusions (RR 0.64, 95% CI 0.16 to 2.52; I2 = 0%; 4 studies, 161 participants; very low-certainty evidence), sepsis or fever (RR 0.50, 95% CI 0.05 to 4.75; I2 = not applicable; 2 studies, 82 participants; very low-certainty evidence), or readmissions (RR 1.00, 95% CI 0.07 to 14.21; I2 = not applicable, 1 study, 24 participants; very low-certainty evidence). Totally tubeless versus standard PNL Totally tubeless PNL may result in lower SAE rates (RR 0.49, 95% CI 0.19 to 1.25; I2 = 0%; 2 studies, 174 participants; low-certainty evidence) and pain on postoperative day one (MD 3.60 lower, 95% CI 4.24 lower to 2.96 lower; I2 = Not applicable; 1 study, 50 participants; low-certainty evidence). Totally tubeless PNL may result in little to no difference in operating room time (MD 6.23 shorter (in minutes), 95% CI 14.29 shorter to 1.84 longer; I2 = 72%; 2 studies, 174 participants; moderate-certainty evidence) and sepsis or fever (RR 0.33, 95% CI 0.01 to 7.97; I2 = not applicable; 1 study, 90 participants; low-certainty evidence). Totally tubeless PNL likely shortens the length of hospital stay (MD 1.55 shorter, 95% CI 1.82 shorter to 1.29 shorter; I2 = 0%; 4 studies, 274 participants; moderate-certainty evidence). We are very uncertain of the effect of totally tubeless PNL on blood transfusions (RR 0.62, 95% CI 0.26 to 1.48; I2 = 0%; 4 studies, 274 participants; very low-certainty evidence) or readmissions (RR not estimable, 95% CI not estimable; I2 = not applicable; 1 study, 50 participants; very low-certainty evidence). We found no studies comparing tubeless mini versus standard mini-PNL or totally tubeless mini versus standard mini-PNL.

AUTHORS' CONCLUSIONS

When comparing tubeless to standard PNL with regard to the predefined primary outcomes of this review, there may be little difference in early postoperative pain, while we are very uncertain of the effect on SAEs. People treated with tubeless PNL may benefit from a reduced length of stay compared to standard PNL. When comparing totally tubeless to standard PNL, early postoperative pain and severe adverse events may be reduced with totally tubeless PNL. The certainty of evidence by outcome was mostly very low (range: moderate to very low) for the comparison of tubeless to standard PNL and low (range: moderate to very low) for the comparison of totally tubeless to standard PNL. The most common reasons for downgrading the certainty of the evidence were study limitations, inconsistency, and imprecision. We did not find randomized trial evidence for other comparisons. Overall, further and higher-quality studies are needed to inform clinical practice.

Are hemostatic agents for selective cases of tubeless percutaneous nephrolithotomy necessary for access tract control? A randomized control trial

PURPOSE

To evaluate the efficacy of percutaneous nephrolithotomy (PCNL) access tract sealing agent. Fibrin glue and Tachosil^® were used for sealing the access tract and compared to the control. Post operative computed tomography (CT) scan was used to evaluate those efficacies.

METHODS

A total of 108 patients were randomized to three groups: In group 1, the access tract was sutured, and compressive dressing was done. In group 2, the fibrin glue was injected into the access tract with a tip applicator at the end of operation. And group 3, Tachosil^® was rolled on its longitudinal axis and plugged into the access tract. Non-contrast CT at POD 1 was taken and perirenal hematoma thickness was measured and graded. Hemoglobin, hematocrit, VAS score, stone-free status, and hospital stay were analyzed.

RESULTS

Preoperative demographic differences were not significant in all three arms. Postoperative CT scans in all groups demonstrated mostly minimal grade access tract hematomas. Mean perirenal hematoma thickness showed no significant differences (2.66 ± 3.74, 2.73 ± 3.85, 2.54 ± 4.37 mm, p = 0.981), respectively. Postoperative hemoglobin drop (0.75 ± 0.58, 0.84 ± 0.47, 0.91 ± 0.60 g/dl, p = 0.74), stone-free rate (93.75, 87.87, 87.87%, p = 0.121), VAS (p = 0.499) and hospital stay (1.81 ± 0.84, 1.48 ± 0.71, 1.59 ± 0.75 day, p = 0.127) were not significantly different between the groups.

CONCLUSION

Fibrin glue and Tachosil^® in tubeless PCNL were not necessary for postoperative access tract control.

International Alliance of Urolithiasis (IAU) Guideline on percutaneous nephrolithotomy

The International Alliance of Urolithiasis (IAU) would like to release the latest guideline on percutaneous nephrolithotomy (PCNL) and to provide a clinical framework for surgeons performing PCNLs. These recommendations were collected and appraised from a systematic review and assessment of the literature covering all aspects of PCNLs from the PubMed database between January 1, 1976, and July 31, 2021. Each generated recommendation was graded using a modified GRADE methodology. The quality of the evidence was graded using a classification system modified from the Oxford Center for Evidence-Based Medicine Levels of Evidence. Forty-seven recommendations were summarized and graded, which covered the following issues, indications and contraindications, stone complexity evaluation, preoperative imaging, antibiotic strategy, management of antithrombotic therapy, anesthesia, position, puncture, tracts, dilation, lithotripsy, intraoperative evaluation of residual stones, exit strategy, postoperative imaging and stone-free status evaluation, complications. The present guideline on PCNL was the first in the IAU series of urolithiasis management guidelines. The recommendations, tips and tricks across the PCNL procedures would provide adequate guidance for urologists performing PCNLs to ensure safety and efficiency in PCNLs.

The safety and efficiency of a 1470 nm laser in obtaining tract hemostasis in tubeless percutaneous nephrolithotomy: a retrospective cross-sectional study

Objective

It is challenging to perform a tubeless percutaneous nephrolithotomy (PNL) in patients with tract bleeding. The present study was designed to study the safety and efficacy of the 1470 nm laser for hemostatic completion in tubeless PNL patients with tract bleeding.

Patients and Methods

Between January 2020 and October 2021, 120 patients were retrospectively included and divided into two groups. The hemostasis group included 60 patients receiving tubeless PNL, in which a 1470 nm laser was used to manage tract bleeding. The other group included 60 patients receiving tubeless PNL in which the hemostasis procedure was not performed, serving as the control group. The differences in the patients’ demographic characteristics, procedural information, and posttreatment outcomes between the two groups were statistically compared.

Results

The differences associated with sex, age, weight, body mass index, urine culture, stone burden, calyx of puncture, degree of hydronephrosis and comorbidities between the two groups were not statistically significant. Compared with the control group, the hemostasis group showed greatly reduced blood loss (0.61 ± 0.31 vs. 0.85 ± 0.46 g/dL) and decreased postoperative hospitalization duration (2.83 ± 0.81 vs. 4.45 ± 0.91 days). The differences in operative time, stone-free rate, Visual Analogue Score and postoperative complications between the two groups were not statistically significant. In the subgroup analysis, the obese patients and patients with moderate to severe hydronephrosis in the hemostasis group also showed a significantly less blood loss (0.51 ± 0.22 vs. 0.83 ± 0.48 g/dL; 0.54 ± 0.27 vs. 0.85 ± 0.47 g/dL, respectively) and shorter length of postoperative hospitalization (2.62 ± 0.51 vs. 4.47 ± 1.19 days; 2.97 ± 0.63 vs. 4.41 ± 0.91 days, respectively) than those in the control group.

Conclusions

Our results demonstrated that 1470 nm laser is a safe, feasible and effective method to obtain tract hemostasis in tubeless PNL.

Infectious complications of endourological treatment of kidney stones: A meta-analysis of randomized clinical trials

OBJECTIVE

Endourological treatment is associated with a risk of postoperative febrile urinary tract infections and sepsis. The aim of this study was to review the reported rate of infectious complications in relation to the type and modality of the endourologic procedure.

METHODS

This systematic review was conducted in accordance with the PRISMA guidelines. Two electronic databases (PubMed and EMBASE) were searched. Out of 243 articles retrieved we included 49 studies after full-text evaluation.

RESULTS

Random-effects meta-analysis demonstrated that retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) were associated with not significantly different odds of getting fever (OR = 1.54, 95% CI: 0.99 to 2.39; p = 0.06) or sepsis (OR = 1.52, 95% CI: 0.37 to 6.20, p = 0.56). The odds of getting fever were not significantly different for mini PCNL compared to standard PCNL (OR = 1.11, 95% CI: 0.85 to 1.44; p = 0.45) and for tubeless PCNL compared to standard PCNL (OR = 1.34 95% CI: 0.61 to 2.91, p = 0.47). However, the odds for fever after PCNL with suctioning sheath were lower than the corresponding odds for standard PCNL (OR = 0.37, 95% CI: 0.20 to 0.70, p = 0.002). The odds of getting fever after PCNL with perioperative prophylaxis were not different from the corresponding odds after PCNL with perioperative prophylaxis plus a short oral antibiotic course (before or after the procedure) (OR = 1.31, 95% CI: 0.71 to 2.39, p = 0.38).

CONCLUSIONS

The type of endourological procedure does not appear to be decisive in the onset of infectious complications, although the prevention of high intrarenal pressure during the procedure could be crucial in defining the risk of infectious complications.   on behalf of U-merge Ltd. (Urology for emerging countries), London-Athens-Dubai.

The Pattern of Day Case (Ambulatory) Percutaneous (PCNL): A Descriptive Retrospective Study from a Tertiary Care Hospital

Background: Percutaneous nephrolithotomy (PCNL) has experienced remarkable development and alteration since it was first described in 1976 by Fernstorm et al. It has also experienced miniaturization of equipment, improvement in operative systems, and refining renal access methods leading to the achievement of maximum clearance of stone while causing minimal morbidity. For example, in endourological practice, when the patient is subjected to PCNL, he traditionally needs programmed inpatient admission, as part of their recovery, it is applicable as an outpatient method in properly selected cases. Objectives: We aimed at evaluating the safety and applicability of the outpatient PCNL procedure. Methods: This retrospective study was done on 210 cases of tubeless PCNL performed by a single urologist at our institute from January 2016 to January 2019. Patients’ mean age (134 males and 76 females) was 57 ± 11.8 years, and 7 patients aged 8 - 12 years. There were 71 pelvic or calyceal solitary stones, 62 non-complete staghorn stones, 17 ureteral stones, 32 renal + ureteric stones (simultaneous renal and ureteral stones) , and 28 complete staghorn stones. The average stone size was 3.5 ± 2.8 (range: 0.7 to 11.8 cm). Results: The mean operation duration was 85.0 ± 29.4 min, and the mean hospital stay was 21.7 ± 3.4 h. Out of 210 patients, 6 patients had longer stay due to high-grade fever and 3 patients due to severe pain, and also 7 patients refused discharge due to personal and social reasons. Our ambulatory PCNL rate was 97 % ( 194 out of 210). Within 72 h, 5 patients were readmitted due to high-grade fever, 3 patients due to haematuria, and 4 patients due to pain and dysuria, and all patients were discharged 2 - 4 days after conservative treatment. Thus, the readmission rate was 6.18% (12 cases were readmitted out of 194 cases). Patients showed a blood transfusion rate of 1.4 %. Also, 19 cases (9.02%) were found with post-operative fever, and no urosepsis was reported. No pulmonary complications and mortality were noted. No re-exploration was done, and no major leak was noted. The angio-embolization rate was 0.59%. We did not use HEMO-SEAL technology, cautery, or suture in the tracks. Conclusions: In conclusion, the outpatient PCNL procedure is an applicable and feasible procedure under selected criteria; however, more investigations using a larger sample size are needed.

Tranexamic acid in patients with complex stones undergoing percutaneous nephrolithotomy: a randomised, double-blinded, placebo-controlled trial

OBJECTIVES

To assess the efficacy and safety of single-dose tranexamic acid on the blood transfusion rate and outcomes of patients with complex kidney stones undergoing percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

In a randomised, double-blinded, placebo-controlled trial, 192 patients with complex kidney stone (Guy's Stone Scores III-IV) were prospectively enrolled and randomised (1:1 ratio) to receive either one dose of tranexamic acid (1 g) or a placebo at the time of anaesthetic induction for PCNL. The primary outcome measure was the occurrence rate of perioperative blood transfusion. The secondary outcome measures included blood loss, operative time, stone-free rate (SFR), and complications. ClinicalTrials.gov identifier: NCT02966236.

RESULTS

The overall risk of receiving a blood transfusion was reduced in the tranexamic acid group (2.2% vs 10.4%; relative risk, 0.21, 95% confidence interval [CI] 0.03-0.76, P = 0.033; number-needed-to-treat: 12). Patients randomised to the tranexamic acid group had a higher immediate and 3-month SFR compared with those in the placebo group (29% vs 14.7%, odds ratio [OR] 2.37, 95% CI 1.15-4.87, P = 0.019, and 46.2% vs 28.1%, OR 2.20, 95% CI 1.20-4.02, P = 0.011, respectively). Faster haemoglobin recovery occurred in patients in the tranexamic acid group (mean, 21.3 days; P = 0.001). No statistical differences were found in operative time and complications between groups.

CONCLUSIONS

Tranexamic acid administration is safe and reduces the need for blood transfusion by five-times in patients with complex kidney stones undergoing PCNL. Moreover, tranexamic acid may contribute to better stone clearance rate and faster haemoglobin recovery without increasing complications. A single dose of tranexamic acid at the time of anaesthetic induction could be considered standard clinical practice for patients with complex kidney stones undergoing PCNL.

Comparison of outcomes in totally tubeless percutaneous nephrolithotomy according to nephrostomy tract sealing with fibrin versus gelatin matrix: a propensity score matching study

To investigate and compare surgical outcomes in totally tubeless percutaneous nephrolithotomy (ttPCNL) patients according to the type of sealant during nephrostomy tract closure, the records of 158 patients who underwent ttPCNL were retrospectively reviewed. Fibrin sealant [Tisseel^®; n = 107, fibrin-only sealant (FS)] or gelatin matrix hemostatic sealant [FloSeal^®; n = 51, gelatin matrix sealant (GS)] was applied during tract closure according to surgeon's preference. On the first postoperative day, computed tomography (CT) was scanned for all patients. Unsatisfactory radiological outcome (URO) was defined as any postoperative hematoma or urinoma (≥ 2 cm) on the CT. Unsatisfactory clinical outcome (UCO) was defined as any adverse event requiring additional intervention. Both UROs and UCOs were sub-classified as either hemorrhage or drainage related. 2:1 propensity score matching was applied according to clinical parameters. Median age was 58 (19-78) years and a mean stone size was 2.1 ± 1.1 cm. The treatment success rate (stone free or < 4 mm residual) among all patients was 91.1% (144/158). UROs and UCOs occurred in 35.4% (86/158) and 11.4% (18/158) of all cases, respectively. Neither of the frequency of URO nor hemorrhage-related UCO was different according to sealant type. However, drainage-related UCOs were more prevalent among the GS group, mainly due to the higher postoperative ureter stenting rate. The postoperative pain severity and the length of hospitalization were comparable between groups. In summary, using GS rather than FS during tract closure did not worsen hemorrhage-related outcomes. However, the clinical risk of ureter occlusion requiring additional temporary ureteral stenting was increased.

Re-evaluation of the efficacy of tranexamic acid in reducing blood loss in percutaneous nephrolithotomy: a randomized clinical trial

BACKGROUND

Tranexamic acid was reported to reduce bleeding in patients undergoing percutaneous nephrolithotomy (PCNL). The current study was performed to re-evaluate the efficacy and safety of tranexamic acid in reducing PCNL-related blood loss.

METHODS

A total of 132 consecutive patients were randomized into two groups; the case group received 1 g of intravenous tranexamic acid before induction, followed by IV infusion of a fixed dose of 1 gr tranexamic acid at 8-hour intervals for the first 48 hours after the procedure, while the control group received normal saline as placebo. Demographic and clinical characteristics of patients were recorded. The collected data were then analyzed using χ2, t-test, and multivariate regression analysis with IBM SPSS Statistics software.

RESULTS

There was no significant difference in demographic characteristics of the two groups. Mean hemoglobin drop was 2.2±1.5 g/dL in tranexamic acid group and 2.4±1.5 g/dL in controls (P=0.312). The blood loss did not show significant difference between tranexamic acid and control groups (751±523 mL vs. 826±525 mL, P=0.416). Multivariate analysis has revealed that multiple access tracts is a risk factor for increased blood loss (P=0.014).

CONCLUSIONS

Tranexamic acid administration is not associated with significant reduction of PCNL-related blood loss. Our findings are unlike the results of few recent studies, thus warranting further investigations and new trials before the widespread use of this drug is considered safe in patients undergoing PCNL.

Percutaneous nephrolithotomy: complications and how to deal with them

Percutaneous nephrolithotomy is a common surgical treatment for large and complex stones within the intrarenal collecting system. A wide variety of complications can result from this procedure, including bleeding, injury to surrounding structures, infection, positioning-related injuries, thromboembolic disease, and even death. Knowledge of the different types of complications can be useful in order to prevent, diagnose, and treat these problems if they occur. This review describes the diversity of complications with the goal of improving their avoidance and treatment.

Tubeless versus standard percutaneous nephrolithotomy: an update meta-analysis

Background

To update a previously published systematic review and meta-analysis on the efficacy and safety of tubeless percutaneous nephrolithotomy (PCNL).

Methods

A systematic literature search of EMBASE, PubMed, Web of Science, and the Cochrane Library was performed to confirm relevant studies. The scientific literature was screened in accordance with the predetermined inclusion and exclusion criteria. After quality assessment and data extraction from the eligible studies, a meta-analysis was conducted using Stata SE 12.0.

Results

Fourteen randomized controlled trials (RCTs) involving 1148 patients were included. Combined results demonstrated that tubeless PCNL was significantly associated with shorter operative time (weighted mean difference [WMD], −3.79 min; 95% confidence interval [CI], −6.73 to −0.85; P = 0.012; I² = 53.8%), shorter hospital stay (WMD, −1.27 days; 95% CI, −1.65 to −0.90; P < 0.001; I² = 98.7%), faster time to return to normal activity (WMD, −4.24 days; 95% CI, −5.76 to −2.71; P < 0.001; I² = 97.5%), lower postoperative pain scores (WMD, −16.55 mm; 95% CI, −21.60 to −11.50; P < 0.001; I² = 95.7%), less postoperative analgesia requirements (standard mean difference, −1.09 mg; 95% CI, −1.35 to −0.84; P < 0.001; I² = 46.8%), and lower urine leakage (Relative risk [RR], 0.30; 95% CI 0.15 to 0.59; P = 0.001; I² = 41.2%). There were no significant differences in postoperative hemoglobin reduction (WMD, −0.02 g/dL; 95% CI, −0.04 to 0.01; P = 0.172; I² = 41.5%), stone-free rate (RR, 1.01; 95% CI, 0.97 to 1.05; P = 0.776; I² = 0.0%), postoperative fever rate (RR, 1.05; 95% CI, 0.57 to 1.93; P = 0.867; I² = 0.0%), or blood transfusion rate (RR, 0.79; 95% CI, 0.36 to 1.70; P = 0.538; I² = 0.0%). The results of subgroup analysis were consistent with the overall findings. The sensitivity analysis indicated that most results remained constant when total tubeless or partial tubeless or mini-PCNL studies were excluded respectively.

Conclusions

Tubeless PCNL is an available and safe option in carefully evaluated and selected patients. It is significantly associated with the advantages of shorter hospital stay, shorter time to return to normal activity, lower postoperative pain scores, less analgesia requirement, and reduced urine leakage.

Tubeless versus standard percutaneous nephrolithotomy: an update meta-analysis

BACKGROUND

To update a previously published systematic review and meta-analysis on the efficacy and safety of tubeless percutaneous nephrolithotomy (PCNL).

METHODS

A systematic literature search of EMBASE, PubMed, Web of Science, and the Cochrane Library was performed to confirm relevant studies. The scientific literature was screened in accordance with the predetermined inclusion and exclusion criteria. After quality assessment and data extraction from the eligible studies, a meta-analysis was conducted using Stata SE 12.0.

RESULTS

Fourteen randomized controlled trials (RCTs) involving 1148 patients were included. Combined results demonstrated that tubeless PCNL was significantly associated with shorter operative time (weighted mean difference [WMD], -3.79 min; 95% confidence interval [CI], -6.73 to -0.85; P = 0.012; I² = 53.8%), shorter hospital stay (WMD, -1.27 days; 95% CI, -1.65 to -0.90; P < 0.001; I² = 98.7%), faster time to return to normal activity (WMD, -4.24 days; 95% CI, -5.76 to -2.71; P < 0.001; I² = 97.5%), lower postoperative pain scores (WMD, -16.55 mm; 95% CI, -21.60 to -11.50; P < 0.001; I² = 95.7%), less postoperative analgesia requirements (standard mean difference, -1.09 mg; 95% CI, -1.35 to -0.84; P < 0.001; I² = 46.8%), and lower urine leakage (Relative risk [RR], 0.30; 95% CI 0.15 to 0.59; P = 0.001; I² = 41.2%). There were no significant differences in postoperative hemoglobin reduction (WMD, -0.02 g/dL; 95% CI, -0.04 to 0.01; P = 0.172; I² = 41.5%), stone-free rate (RR, 1.01; 95% CI, 0.97 to 1.05; P = 0.776; I² = 0.0%), postoperative fever rate (RR, 1.05; 95% CI, 0.57 to 1.93; P = 0.867; I² = 0.0%), or blood transfusion rate (RR, 0.79; 95% CI, 0.36 to 1.70; P = 0.538; I² = 0.0%). The results of subgroup analysis were consistent with the overall findings. The sensitivity analysis indicated that most results remained constant when total tubeless or partial tubeless or mini-PCNL studies were excluded respectively.

CONCLUSIONS

Tubeless PCNL is an available and safe option in carefully evaluated and selected patients. It is significantly associated with the advantages of shorter hospital stay, shorter time to return to normal activity, lower postoperative pain scores, less analgesia requirement, and reduced urine leakage.

Small-calibre percutaneous nephrolithotomy (SC-PCNL). Therapeutic decision algorithm

INTRODUCTION

The progressive reduction in the calibre of the tract in percutaneous kidney surgery to the point of miniaturisation has expanded its use to smaller stones that until now have been treated with extracorporeal shock wave lithotripsy (ESWL) and retrograde intrarenal surgery (RIRS).

OBJECTIVE

To provide an update on the various techniques of small-calibre nephrolithotomy (SC-PCNL) analyse their efficacy, safety and indications and determine their degree of implantation at this time.

MATERIAL AND METHODS

We performed a review in PubMed of Spanish and English medical literature on the various techniques of SC-PCNL.

RESULTS

The use of SC-PCNL has reduced the morbidity associated with standard PCNL, particularly bleeding, and has enabled tubeless nephrolithotomy with greater safety. There are various techniques with blurred terminology (Miniperc, Microperc, Mini-microperc, Ultraminiperc), which differ in terms of gauge employed and in certain technical aspects that require their indications be specified. Currently, SC-PCNL competes with techniques that are less invasive than standard PCNL such as ESWL and the RIRS in treating small stones, but the role of SC-PCNL is still not sufficiently understood and continues to be the subject of debate.

CONCLUSIONS

The indications for PCNL are expanding to small stone sizes due to the miniaturisation of the technique. PCNL competes in this field with ESWL and RIRS. Larder studies are needed to establish the specific indications for PCNL in treating nephrolithiasis.

Is standard percutaneous nephrolithotomy still the standard treatment modality for renal stones less than three centimeters?

OBJECTIVE

The aim of study was to compare the efficiency and safety of standard percutaneous nephrolithotomy (sPNL) and miniaturized percutaneous nephrolithotomy (mPNL) in lower calyx and/or pelvic stones smaller than three centimeters.

MATERIAL AND METHODS

From October 2010 to August 2015, 108 mPNL and 176 sPNL procedures were performed for renal stones smaller than three cm and located in the lower calyx and/or renal pelvis. All patients were evaluated preoperatively with intravenous pyelography and/or computed tomography. Intraoperative parameters, post-operative results and complications were recorded. Postoperative success was defined as complete stone clearance and/or clinically insignificant residual fragments at 3^rd month.

RESULTS

Preoperative characteristics were similar between sPNL and mPNL groups except previous renal stone operation history and gender. The mean operation time was significantly shorter in the sPNL group (p<0.001). The mean hemoglobin drop was significantly less in the mPNL group (p=0.001), we found a 1.27±1.4 and 0.5±1.3 decrease in mean hemoglobin levels (mg/dL) in the sPNL and mPNL groups, respectively. Transfusion rate was 1.9% in mPNL and 5.6% in sPNL groups, and the difference was statistically significant (p=0.048). Only one patient in the sPNL group needed angiography and embolization. Postoperative JJ stent insertion rate was significantly higher in the mPNL group (p=0.03).

CONCLUSION

Both sPNL and mPNL are safe and effective surgical procedures for lower calyx and/or pelvis stones smaller than 3 cm. However, use of smaller caliber instruments was associated with a lesser hemoglobin drop and need for transfusion.

Percutaneous Nephrolithotomy with Amplatz and Alken Dilators: An Eight-Year Single Tertiary Care Centre Experience

Background

Percutaneous nephrolithotomy (PNL) is the standard procedure for patients with renal stones over 2 cm in diameter. We analyzed complications after this procedure focusing on two different methods of tract dilation.

Material/Methods

Between August 2008 and April 2016 222 percutaneous nephrolithotomies were performed in a total of 208 patients. The Group I (n=123) comprised patients where Alken dilatators were used, while Group II (n=99) comprised patients where Amplatz dilators were used. Efficacy was examined based on ultrasound and x-ray examination one month after the procedure. Complications were recorded using Clavien Dindo classification.

Results

Efficacy was 85.3% and 86.8% in group I and II, respectively (p=0.77). Grade I complications were present in 14.6% and 3%, grade II were present in 9.7% and 8%, grade IIIa were present in 2.4% and 2%, grade IIIb were present in 1.6% and 2%, grade IVa were present in 1.6% and 7%, grade IVb were present in 3.2% and 1% in Group I and Group II, respectively. These differences were statistically significant (p=0.03).

Conclusions

Efficacy was comparable between Alken dilator and Amplatz dilator groups. In group I, there were more postoperative fevers >38.5 °C and a higher rate of urosepsis. On the other hand, in group II we observed more pleural injuries. All differences resulted from the type of access to the kidney (inter/infracostal), punctured calyx, and utilization (or not) of access sheath rather than type of dilators itself.

Hemostatic agents for access tract in tubeless percutaneous nephrolithotomy: Is it worth?

INTRODUCTION

The role of hemostatic agents as an adjunct for closure of the nephrostomy tract in tubeless percutaneous surgery (tubeless percutaneous nephrolithotomy [tPNL]) has been previously evaluated, observing a potential benefit in terms of reduced bleeding and urinary leakage. We assessed the rate of postoperative complications after the use of hemostatic agents for sealing the nephrostomy tract in patients undergoing tPNL at our institution.

SUBJECTS AND METHODS

We performed a retrospective analysis of 52 consecutive patients undergoing tPNL at our center between January 2010 and December 2013. No substance was placed within the tract in 25 patients (Group 1). A cylinder of Surgicel(®) in addition to 1 unit of Gelita(®) were placed within the access tract in 27 patients (Group 2). We accounted for demographic variables, stone size, operative time, postoperative pain, development of hematoma, postoperative hematocrit drop, urinary leakage, residual lithiasis, and hospital stay length.

RESULTS

Age and sex differed significantly between the two groups (P = 0.0002 and P = 0.048 respectively). However, there were no significant differences in terms of body mass index and stone burden. No significant differences between groups were found with regards to operative time, postoperative hematocrit drop, postoperative pain and presence of residual lithiasis.

CONCLUSION

The use of Gelita(®) and Surgicel(®) as hemostatic agents in tPNL is safe, but we were not able to demonstrate any significant benefit in terms of postoperative morbidity after comparing the use of these agents in tPNL. We concluded that the uses of hemostatic agents needed to be evaluated in prospective randomized trials to define its benefits.

Recent advancement or less invasive treatment of percutaneous nephrolithotomy

Since its initial introduction in 1976, percutaneous nephrolithotomy (PCNL) has been widely performed for the management of large renal stones and currently is recommended for staghorn calculi, kidney stones larger than 2 cm, and shock wave lithotripsy-resistant lower pole stones greater than 1 cm. However, except for open and laparoscopic surgery, PCNL is the most invasive of the minimally invasive stone surgery techniques. Over the years, technical and instrumental advances have been made in PCNL to reduce morbidity and improve effectiveness. A thorough review of the recent literature identified five major areas of progress for the advancement of PCNL: patient positioning, method of percutaneous access, development of lithotriptors, miniaturized access tracts, and postoperative nephrostomy tube management. This review provides an overview of recent advancements in PCNL and the outcomes of each area of progress and notes how much we achieve with less invasive PCNL. This information may allow us to consider the future role and future developments of PCNL.

The management of the access tract after percutaneous nephrolithotomy

PURPOSE

To describe the evolution of the current technique in percutaneous nephrolithotomy (PCNL) with a special focus on access tract closure techniques.

METHODS

A systematic review of outcomes and complications of tubeless PCNL was conducted using the MEDLINE and Pubmed databases between 1976 and 2014.

RESULTS

During the past decade, PCNL underwent fundamental modifications due to miniaturization of the instruments and advancements in technique. The routine use of the nephrostomy tube after PCNL has been subsequently questioned. Currently, the nephrostomy tube is increasingly omitted, and the access tract is usually sealed by haemostatic agents. An additionally ureteric stent is commonly inserted at the end of the procedure. However, the application of haemostatic sealants increases the immediate costs significantly. Still there are inconsistent data because of small study populations, lack of randomization, retrospective character and further more heterogeneous surgical techniques.

CONCLUSION

The current body of literature does not provide high-level evidence for the preferred treatment of the access tract in PCNL. However, most authors agree that a tract sealing can be omitted without increasing the risk of complication in uncomplicated procedures.

Advances in percutaneous stone surgery

Treatment of large renal stones has changed considerably in recent years. The increasing prevalence of nephrolithiasis has mandated that urologists perform more surgeries for large renal calculi than before, and this has been met with improvements in percutaneous stone surgery. In this review paper, we examine recent developments in percutaneous stone surgery, including advances in diagnosis and preoperative planning, renal access, patient position, tract dilation, nephroscopes, lithotripsy, exit strategies, and post-operative antibiotic prophylaxis.

Hemostatic agents used for nephrostomy tract closure after tubeless PCNL: a systematic review and meta-analysis

To evaluate the role of hemostatic agents used for nephrostomy tract closure after tubeless percutaneous nephrolithotomy (PCNL). A systematic review of Pubmed, Embase and Cochrane was performed. All studies that compared hemostatic agents with common methods (silk stitch or pressure dressing) were included. The analyzed outcomes were hospital stay, operative time, blood loss, transfusion rate, fever rate, and complication rate. A total of eight articles including six RCTs met our criteria. Hemostatic agents showed short hospital stay (MD -4.54, 95 % CI -6.78 to -2.36, p < 0.0001). There was no difference between hemostatic agents and common methods on operative time (MD 2.00, 95 % CI -17.32 to 21.33, p = 0.84), blood loss (MD -0.19, 95 % CI -0.41 to 0.03, p = 0.08), transfusion rate (OR 1.42, 95 % CI 0.34-5.96, p = 0.63), fever rate (OR 1.02, 95 % CI 0.33-3.12, p = 0.97) and complication rate (OR 1.02, 95 % CI 0.33-3.12, p = 0.97). Eight studies including six RCTs showed that use of hemostatic agents was safe. Hemostatic agents showed short hospital stay. There were no difference between hemostatic agents and common methods on blood loss, transfusion rate, fever rate, and complication rate.

[Complications in percutaneous lithotomy]

BACKGROUND

Percutaneous lithotomy is the gold standard in the treatment of large kidney stones. Several steps of the operation might cause severe complications. Safe procedures depend on careful planning, accurate performance, recognition of problems and knowledge of how to handle them.

OBJECTIVES

Relevant steps of percutaneous stone treatment with possible complications and their management are presented.

MATERIALS AND METHODS

Current topics in percutaneous stone treatment taking into consideration the relevant literature are discussed. Furthermore, rare complications and strategies for safe management are presented.

RESULTS

Careful planning and adequate preoperative diagnostic workup are essential for safe procedures. Puncture of the renal calyceal system and tract dilation might lead to severe complications. Bleeding and infectious complications are the most common problems. Availability of interventional radiology provides ideal emergency treatment in case of severe bleeding and helps to avoid surgical revision with high risk of organ loss.

CONCLUSIONS

Percutaneous stone treatment is a safe and effective therapy in an experienced physician's hands. Careful planning and accurate performance help to avoid severe complications.

Percutaneous nephrolithotomy: Large tube, small tube, tubeless, or totally tubeless?

The role of percutaneous nephrostomy tube for drainage after percutaneous nephrolithotomy (PCNL) procedure has come under scrutiny in recent years. The procedure has been modified to use of small diameter tubes, ‘tubeless’ PCNL, and even ‘totally tubeless’ PCNL. A review of the available literature confirms that the chosen method of drainage after PCNL has a bearing upon the post-operative course. It is generally recognized now that small tubes offer benefit in terms of reduced post-operative pain and morbidity. Similarly, nephrostomy-free or ‘tubeless’ PCNL, using a double-J stent or ureteric catheter as alternative form of drainage, can be used with a favorable outcome in selected patients with the advantage of decreased postoperative pain, analgesia requirement, and hospital stay. Although the tubeless technique has been applied for extended indications as well, the available evidence is insufficient, and needs to be substantiated by prospective randomized trials. In addition, ‘totally tubeless’ approach has also been shown to be feasible in selected patients.

Assessing the use of haemostatic sealants in tubeless percutaneous renal access and their effect on renal drainage and histology: an experimental porcine study

OBJECTIVE

To evaluate the mid-term effects of haemostatic sealant application during tubeless percutaneous nephrolithotomy (PCNL) on renal drainage and histology in an in vivo porcine study.

MATERIALS AND METHODS

Bilateral percutaneous access was established in 28 porcine renal units. At the end of the procedure, a type 1 absorbable fish origin collagen powder, a human fibrinogen- and thrombin-coated sponge or a cross-linked gelatin granule/topical thrombin matrix were randomly placed on the nephrostomy tracts. Four nephrostomy accesses were left intact and served as controls. No percutaneous tube, ureteric stent or bladder catheter was left in place postoperatively. Computed tomography urography on postoperative days 1, 15, 30 and 40 was used to access renal drainage. On postoperative day 40, all animals were killed and both kidneys from each animal were harvested for histological evaluation.

RESULTS

Evidence of risk for drainage occlusion after sealant application was found. The use of haemostatic sealants was associated with significant histological lesions in the renal parenchyma, regardless of which sealant was used. No sealant was identified as superior to the others. Nephrostomy tracts that were left without sealant application (control group) were associated with no morbidity and fewer histopathological changes.

CONCLUSIONS

Based on these experimental results, the safety of the application of haemostatic sealants in tubeless PCNL should be reassessed, focusing not only on the potential of such materials to occlude urinary drainage but also on their effect on renal histology. Further investigation is considered necessary.

TachoSil(®) sealed tubeless percutaneous nephrolithotomy to reduce urine leakage and bleeding: outcome of a randomized controlled study

PURPOSE

We determined the efficacy and safety of TachoSil(®) in sealing the tract after percutaneous nephrolithotomy compared to nephrostomy tube placement.

MATERIALS AND METHODS

A total of 100 consecutive patients scheduled for percutaneous nephrolithotomy were randomized 1:1 to receive a 16Fr nephrostomy tube (group 1) or TachoSil in the tract (group 2). All patients received a mono-J ureteral catheter. The primary study end points were bleeding and urinary leakage rates. The secondary end points were pain as assessed by the 0 to 10-point visual analog scale, analgesic requirement and hospital stay.

RESULTS

The groups were comparable for preoperative and operative variables. In group 1, 3 patients were excluded intraoperatively because of relevant bleeding, and in group 2, 1 patient was excluded intraoperatively because of hydrothorax. Tract complications were significantly more frequent in group 1 than in group 2 (25.5% vs 2%, p <0.001). However, the difference in urinary leakage reached statistical significance (19.1% vs 2%, p = 0.007), whereas that in perirenal hematoma formation did not (6.4% vs 0%, p = 0.113). There was no difference between the groups in mean ± SD number of analgesic doses (1.17 ± 1.56 vs 1.20 ± 1.69, p = 0.791) and visual analogue scale scores (4.77 ± 2.28 vs 4.24 ± 2.32, p = 0.270). Postoperative hospital stay was significantly shorter in group 2 than in group 1 (5.15 ± 1.74 vs 2.75 ± 1.78 days, p <0.0001).

CONCLUSIONS

Although failing to reduce pain and analgesic requirement, TachoSil provided better tract control and a shorter hospital stay than nephrostomy tube placement, thus allowing the extension of indications for tubeless percutaneous nephrolithotomy to most procedures.

Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy

CONTEXT

Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus.

OBJECTIVE

To review the epidemiology of complications and their prevention and management.

EVIDENCE ACQUISITION

A literature review was performed using the PubMed database between 2001 and May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols with the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, and Clavien, and the MeSH terms nephrostomy, percutaneous/adverse effects, and intraoperative complications or postoperative complications.

EVIDENCE SYNTHESIS

Assessing the epidemiology of complications is difficult because definitions of complications and their management still lack consensus. For a reproducible quality assessment, data should be obtained in a standardized manner, allowing for comparison. An approach is the validated Dindo-modified Clavien system, which was originally reported by seven studies. No deviation from the normal postoperative course (Clavien 0) was observed in 76.7% of PNL procedures. Including deviations from the normal postoperative course without the need for pharmacologic treatment or interventions (Clavien 1) would add up to 88.1%. Clavien 2 complications including blood transfusion and parenteral nutrition occurred in 7%; Clavien 3 complications requiring intervention in 4.1.%; Clavien 4, life-threatening complications, in 0.6%; and Clavien 5, mortality, in 0.04%. High-quality data on complication management of rare but potentially debilitating complications are scarce and consist mainly of case reports.

CONCLUSIONS

Complications after PNL can be kept to a minimum in experienced hands with the development of new techniques and improved technology. A modified procedure-specific Clavien classification should be established that would need to be validated in prospective trials.

A randomized trial of aprotinin-free fibrin sealant versus absorbable hemostat

BACKGROUND

This study evaluated the safety and hemostatic effectiveness of a tranexamic acid- and aprotinin-free fibrin sealant versus an absorbable hemostat in soft tissue during elective retroperitoneal or intra-abdominal surgery.

MATERIALS AND METHODS

This randomized, active-controlled, multicenter study enrolled patients who were undergoing elective retroperitoneal or intra-abdominal surgery and required adjunctive hemostatic measures at the target bleeding site (TBS). Patients were randomized (time = 0 minutes) to receive fibrin sealant or absorbable hemostat. The primary endpoint was the absence of bleeding at the TBS at 10 minutes. Secondary endpoints included the absence of bleeding at 4 and 7 minutes and the incidence of treatment failure (bleeding at 10 minutes or brisk bleeding requiring additional hemostatic measures), and the incidence of complications potentially related to bleeding. Adverse events were assessed.

RESULTS

Patients (N = 124) were randomized to receive fibrin sealant (n = 62) or absorbable hemostat (n = 62). A higher percentage of patients who received fibrin sealant versus absorbable hemostat achieved hemostasis within 10 minutes (95.2% vs 82.3%; 95% CI, 1.02-1.35) and also at 4 (74.2% vs 54.8%; 95% CI, 1.04-1.80) and 7 (90.3% vs 77.4%; 95% CI, 1.00-1.39) minutes. A lower incidence of treatment failure was observed for patients receiving fibrin sealant. Similar incidences of adverse events and complications potentially related to bleeding were observed.

CONCLUSIONS

This tranexamic acid- and aprotinin-free fibrin sealant is safe and effective for achieving hemostasis in soft tissue during elective retroperitoneal or intra-abdominal surgery.

Tubeless vs standard percutaneous nephrolithotomy: a meta-analysis

OBJECTIVE

To systematically review and compare tubeless percutaneous nephrolithotomy (PCNL) with standard PCNL.

MATERIALS AND METHODS

We conducted a review of the English language literature on studies involving randomized controlled trials for PCNL. The studies chosen to be included in our review compared tubeless PCNL with standard PCNL and described the advantages of each in the outcomes. Two reviewers independently screened the studies for eligibility, evaluated their quality and extracted the data from the eligible studies, with confirmation by cross-checking. Data were processed using RevMan 5.0.

RESULTS

Seven studies involving 1365 cases met the inclusion criteria, and these were included in the meta-analysis. The patients' baseline characteristics were comparable in all the studies. By comparing the four common characteristics, we found no difference in efficacy between the two surgical approaches in terms of mean operation duration and postoperative haematocrit change (P > 0.05). We found that the mean analgesic requirement and number of days in hospital were lower for tubeless PCNL (P < 0.05).

CONCLUSIONS

Our results show that tubeless PCNL is a good option in non-complicated cases, with the advantages of reduced hospital stay and little need for postoperative analgesia. There was no difference between the two approaches in operation duration, or haematocrit change after surgery. As only few studies with small study populations were available, more high quality larger trials with longer follow-up are recommended.

Percutaneous nephrolithotomy for 1-2 cm lower-pole renal calculi

Objectives:

The most appropriate management of patients with lower-pole calyceal (LC) stones remains controversial. In this review we discuss the role of percutaneous nephrolithotomy (PCNL) in the management of LC stones 1–2 cm in maximum dimension.

Materials and Methods:

A detailed literature review was performed to summarize the recent technical developments and controversies in PCNL. The results of PCNL for 1-2 cm LC calculi were reviewed.

Results:

PCNL is increasingly employed as a primary modality in the treatment of LC calculi. It has a high success rate and acceptably low percentage of major complications in experienced hands. Supine position is found to be as safe and effective as prone position. Urologist-acquired access is associated with fewer access-related complications and better stone-free rates. Ultrasound is increasingly employed as an imaging modality for obtaining access. There have been increasing reports of tubeless PCNL in the literature. Most patients undergoing tubeless PCNL do not need hemostatic agents as an adjuvant for hemostasis. Non-contrast computed tomography does not yield statistically valuable increase in the diagnosis of significant residual stones compared with that of plain X-ray and linear tomography. Comprehensive metabolic evaluation and aggressive medical management can control new stone recurrences and growth of residual fragments following PCNL.

Conclusions:

PCNL is a highly effective procedure with consistently high stone-free rates when compared with extracorporeal shockwave lithotripsy or retrograde intrarenal surgery. The results also do not depend on anatomic factors and stone size. It is associated with low morbidity in experienced hands.

Percutaneous nephrolithotomy: Current concepts

Percutaneous nephrolithotomy (PNL) is the procedure of choice for large renal stones. Since its introduction in 1976, many aspects of the operative technique and the endoscopic equipments have had constant evolution, increasing the success rates of the procedure. We performed a literature search using Entrez Pubmed from January 2000 to July 2007 concerning PNL and many aspects related to all steps of the procedure.

We could verify that PNL in supine position has been proved as an acceptable option, but more worldwide experience is necessary. Urologists must be trained to gain their own renal tract access. Minipercutaneous PNL still needs equipments improvements for better results. Tubeless PNL is increasing in popularity and different tract sealants have been studied. Medical prevention is proved to be effective against stone recurrence and should be always used after PNL.

Although the evolution of the technique in the last 20 years, urologists must continue to improve their skills and develop new technologies to offer to the patients more and more a safe and effective option to treat large renal stones.

New instrumentation in percutaneous nephrolithotomy

Percutaneous nephrolithotomy (PCNL) is the procedure of choice for removing large, complex, and/or multiple renal calculi. Since its first description in 1976, PCNL techniques and equipment have evolved to maximize procedural efficacy, safety, and reproducibility. We reviewed current literature from January 2004 to November 2009 using Medline search regarding PCNL instrumentation and technology. Additional equipment discovered during the review process without published Medline evidence was summarized from manufacturer brochures and data. Included in this review are summaries of intracorporeal lithotriptors and accessory equipment, stone manipulation devices, PCNL tract sealants, and a digital rigid nephroscope. The evolution of these devices from their predecessors has increased the instrumentation options for the treating urologist and may represent more effective technology for the percutaneous treatment of large renal stones.

Tubeless percutaneous nephrolithotomy

Introduction and Objective:

Placement of a percutaneous nephrostomy tube for drainage has been an integral part of the standard percutaneous nephrolithotomy (PCNL) procedure. However, in recent years, the procedure has been modified to what has been called ‘tubeless’ PCNL, in which nephrostomy tube is replaced with internal drainage provided by a double-J stent or a ureteral catheter. The objective of this article is to review the evidence-based literature on ‘nephrostomy-free’ or ‘tubeless’ PCNL to compare the safety, effectiveness, feasibility, and advantages of tubeless PCNL over standard PCNL.

Materials and Methods:

We performed a MEDLINE database search to retrieve all published articles relating to ‘tubeless’ PCNL. Cross-references from retrieved articles as well as articles from urology journals not indexed in MEDLINE, were also retrieved.

Results:

The majority of the studies have shown ‘tubeless’ PCNL to be a safe and economical procedure, with reduced postoperative pain and morbidity and shorter hospital stay. tubeless PCNL has been found to be safe and effective even in patients with multiple stones, complex staghorn stones, concurrent ureteropelvic junction obstruction, and various degrees of hydronephrosis. The technique has been successful in obese patients, children, and in patients with recurrent stones after open surgery.

Conclusion:

Tubeless PCNL can be used with a favorable outcome in selected patients (stone burden <3 cm, single tract access, no significant residual stones, no significant perforation, minimal bleeding, and no requirement for a secondary procedure), with the potential advantages of decreased postoperative pain, analgesia requirement, and hospital stay. However, for extended indications, like supine PCNL, multiple, complex and staghorn stones, and concurrent PUJ obstruction, the evidence is insufficient and should come from prospective randomized trials.

Hemostatic sandwich to control percutaneous nephrolithotomy tract bleeding

BACKGROUND AND PURPOSE

Significant bleeding necessitating use of a tamponade balloon, embolization, or renal exploration is a rare but catastrophic complication after percutaneous nephrolithotomy (PCNL). The purpose of this study is to review the success of a novel, minimally invasive technique for controlling percutaneous tract bleeding that is refractory to conventional measures.

MATERIALS AND METHODS

A retrospective review was performed on four patients with refractory tract hemorrhage that was managed with a novel gelatin matrix hemostatic sandwich technique. In this technique, a 5F angiographic reentry catheter was placed through the kidney into the bladder and a 22F Councill-tip catheter balloon was passed over this catheter and positioned so that the inflated balloon would occlude the inner surface of the nephrostomy tract. Next, a 16F Councill-tip catheter was placed over a second wire so that the uninflated balloon was just underneath the skin surface. Gelatin matrix hemostatic sealant was then injected to fill the tract. Inflation of the outer balloon completely sealed the tract, completing the hemostatic sandwich.

RESULTS

This technique was successfully applied to four patients with tract bleeding that would not stop with pressure or a conventional nephrostomy tube alone. The average estimated blood loss was 562 mL, and three of four patients avoided transfusion. All postoperative hemoglobin values stabilized within 2 days of surgery. There were no major or minor complications after use of this technique. No patients needed angioembolization or renal exploration.

CONCLUSIONS

This novel hemostatic sandwich technique should be considered as an option for the control of refractory tract hemorrhage after PCNL.

Systematic Review and Meta-Analysis of Nephrostomy Placement Versus Tubeless Percutaneous Nephrolithotomy

Abstract Purpose: We performed a systemic review with meta-analysis to compare tubeless vs conventional percutaneous nephrolithotomy (PCNL) and assess the effectiveness and safety of this innovative procedure. Materials and Methods: A systematic review of PUBMED, EMBASE, LILACS, and Cochrane Library was performed to identify all randomized controlled trials (RCTs) that compared tubeless PCNL vs conventional PCNL. The analyzed outcomes were stone-free rate, pain assessment, analgesic medication requirements, operative time, hospitalization time, blood loss, and complications. Results: A total of 10 RCTs were identified that reported 621 patients. Seven studies analyzed stone-free rates. Meta-analysis of the data resulted in no difference between tubeless and conventional PCNL. Operative time, blood transfusion, hemoglobin drop and postoperative fever did not differ between the groups. Meta-analysis of length of hospitalization and prolonged urinary drainage was analyzed and favored the tubeless PCNL group. Conclusions: Tubeless PCNL is a safe and effective procedure with a stone clearance rate comparable to that of conventional PCNL. Tubeless PCNL presented a shorter hospital stay and less postoperative urinary leakage. Pain reduction and minimization of analgesic requirements also were demonstrated.

Tubeless percutaneous nephrolithotomy--the new standard of care?

PURPOSE

Traditionally the placement of a nephrostomy tube at the conclusion of percutaneous nephrolithotomy is considered the standard of care. However, the need for nephrostomy tube placement has been questioned by numerous authors. We evaluated the literature regarding tubeless percutaneous nephrolithotomy, and determined potential candidates for tubeless percutaneous nephrolithotomy and whether this procedure can be considered the new standard of care for complex stone removal.

MATERIALS AND METHODS

A MEDLINE search was conducted between May 1997 and January 2010 to detect studies reporting tubeless percutaneous nephrolithotomy. "Nephrolithiasis," "percutaneous nephrolithotomy," "tubeless" and "lithotripsy" were used as medical subject headings (MeSH) key words. Additional citations were identified by reviewing the reference lists of the included articles. All relevant articles were reviewed for indications, outcomes and complications.

RESULTS

The data obtained from 50 reports document comparable complication rates between tubeless and standard percutaneous nephrolithotomy. Tubeless percutaneous nephrolithotomy demonstrated advantages such as less pain, less debilitation, less costs and a shorter hospital stay. Mean stone-free rates for tubeless percutaneous nephrolithotomy were as high as 89%.

CONCLUSIONS

Tubeless percutaneous nephrolithotomy appears to be safe and efficacious in uneventful procedures, in children, in obese patients, in simultaneous bilateral procedures, in supracostal access and in renal units with coexisting anatomical anomalies. Nephrostomy tube placement should still be considered in certain cases such as those with more than 2 nephrostomy access tracts, those necessitating a second look and those with intraoperative complications such as significant bleeding or collecting system perforation.