Some Criteria to Attempt Second Side Safely in Planned Bilateral Simultaneous Percutaneous Nephrolithotomy

Updates in endourological management of urolithiasis

Urinary stone disease, or urolithiasis, is a very common disease with increasing prevalence and incidence. With the advancement of endoscopic techniques, the treatment outcomes of ureteroscopy (or transureteral lithotripsy) and percutaneous nephrolithotomy are continuously improving. In recent years, there have been many new developments in the field, including new endoscopy design, more effective auxiliary tools, improvement in treatment protocols, introduction of robotic technology, combining both ureteroscopy and percutaneous nephrolithotomy (endoscopic combined intrarenal surgery or transureteral lithotripsy-assisted percutaneous nephrolithotomy), improvement in laser technology, and so on. All these new inputs will further improve the treatment efficacy and safety of the procedures, thus benefiting our patients. In the present review, we briefly go through the main steps of ureteroscopy and percutaneous nephrolithotomy, with a concise description and application of these new advances.

Simultaneous bilateral percutaneous nephrolithotomy: Effectiveness and safety

OBJECTIVES

To evaluate the effectiveness and safety of simultaneous bilateral percutaneous nephrolithotomy performed in patients affected with bilateral renal calculi.

MATERIALS AND METHODS

This is a prospective study from September 2012 to November 2016. Patients diagnosed of bilateral kidney stones with abdominal CT scan were included. Surgical technique prone position, renal puncture guided by fluoroscopy and tract dilation up to 24Ch. We reviewed demographic and stone characteristics, stone free rate, clinical success, complications and follow-up.

RESULTS

During the study period, 732 percutaneous nephrolithotomies were performed. Eighteen patients were included (36 renal units, 2.5%), 13 men and 5 women, with a median age of 58 years and an interquartile range (IQR) of 40-66. Median stone burden was 228mm² (IQR 134-389); median operative time, 150minutes (IQR 97-180); and median hospital stay, 5 days (IQR 5-15). Stone free rate was 80%. Residual calculi were encountered in 8 renal units (22.2%) and required other complementary techniques for their complete tesolution 4 external shockwave lithotripsies, one open ureterolithotomy, 2 ureteroscopies and one second look. Major complications included 4 cases of severe hemorrhage managed with angiographic embolization. The median follow-up was 36 months (range 26-46).

CONCLUSIONS

Simultaneous bilateral percutaneous nephrolithotomy is an effective and safe procedure in patients affected with bilateral renal calculi. It is a surgical challenge that should be performed in selected patients and in centers with experience.

Bilateral single-session retrograde intra-renal surgery: A safe option for renal stones up to 1.5 cm

Introduction:

Assessment of treatment outcomes in patients undergoing bilateral single-session retrograde intra-renal surgery (RIRS) for bilateral renal stones up to 1.5 cm.

Materials and Methods:

Retrospective analysis of 74 patients was done with bilateral renal calculi, who underwent bilateral single-session RIRS at our stone referral hospital from December 2011 to May 2014. The selection criteria for this intervention were patient's preference, failure of other treatments and stone up to 1.5 cm. Patients with creatinine more than 2, pyonephrosis sepsis, bilateral impacted pelviureteric junction calculi were excluded from study. All patients were evaluated with serum biochemistry, urinalysis, urine culture, plain radiography of kidney-ureter-bladder, intravenous urography, renal ultrasonography (USG) and/or computed tomography (CT). Follow-up evaluation included serum biochemistry and postoperative plain film and renal USG. The success rate was defined as patients who were stone-free or only had a residual fragment of less than 4 mm. CT was conducted only in patients with residual stones, which were present in seven patients.

Results:

A total of 74 patients (50 male, 24 female) with a mean age 39.2 ± 15.2 were included in the present study. The mean stone size was 11.7 ± 2.4 mm. The stone-free rates were 86.84% and 97.29% after the first and second procedures, respectively. In eight patients (10.8%), minor complications were observed, whereas no major complications were noted in the studied group. There was no significant difference in pre- and post-operative serum creatinine levels.

Conclusion:

In patients with bilateral renal stones up to 1.5 cm bilateral single-session RIRS with flexible ureteroscope can be safely performed with low complication rate.

Same-session bilateral retrograde intrarenal surgery for upper urinary system stones: safety and efficacy

PURPOSE

We present our experience with same-session retrograde intrarenal surgery (RIRS) for the management of bilateral upper urinary system stones (UUSS) in terms of clearance of stones, operative times, duration of hospital stay, and complications.

MATERIALS AND METHODS

Between November 2007 and January 2013, a total of 44 simultaneous bilateral RIRS were performed at our hospital. Initially, symptomatic sides of the patients were operated on, and, when asymptomatic, the greater stone burden was treated first. Having completed stone fragmentation with a holmium:YAG laser, larger fragments were extracted with a nitinol basket. All patients underwent noncontrast CT scanning or urinary ultrasonography 2 months after the removal of the stent to detect any residual fragments. The stone-free status was defined as no fragments and/or the presence of asymptomatic fragments <4 mm in the urinary system.

RESULTS

The total stone number was 201 with a mean stone burden per patient of 30.0±15.4 mm (range 10-85 mm). The overall stone-free rate (SFR) was 88.6% after all procedures. The patients in this study were divided into two groups according to stone burden: Although the overall SFR was 100% for a stone burden <25 mm, the SFR was 80% for a stone burden ≥25 mm (P=0.006). A Double-J stent was not placed in two patients, and they developed postoperative anuria; both cases were treated with Double-J stent placement.

CONCLUSION

Bilateral same-session RIRS is a safe and effective procedure that can be considered a first-line treatment for bilateral UUSS in select patients. The SFR is satisfactory, especially in patients with a stone burden <25 mm. At minimum a unilateral Double-J stent should be placed in patients undergoing bilateral RIRS to avoid postrenal failure.

Tubeless simultaneous bilateral percutaneous nephrolithotomy: safety, feasibility and efficacy in an Indian setting

OBJECTIVES

To study the safety, feasibility and efficacy of tubeless simultaneous bilateral percutaneous nephrolithotomy.

METHODS

We retrospectively studied 85 patients who underwent tubeless simultaneous bilateral percutaneous nephrolithotomy in the Department of Urology, Kasturba Medical College, Manipal, Karnataka, India, from July 2006 to June 2013. The demographic profile and outcomes were compared with the other existing series reported in the literature.

RESULTS

A total of 65 male and 20 female patients with a mean age of 45.7 ± 11.6 years underwent tubeless simultaneous bilateral percutaneous nephrolithotomy. The mean stone burden was 299 mm(2), with 12 staghorn calculi. Mean operative time was 87.6 ± 35.5 min. A total of 95% of stones were cleared with single access tracts. The success rate of tubeless simultaneous bilateral percutaneous nephrolithotomy (stone clearance) was 95.2%. Mean hemoglobin drop was 1.1 ± 0.9 gm% per patient, with 10.5% of patients requiring blood transfusion. Mean hospital stay was 69.6 ± 28.4 h. Complications included urosepsis (Clavien grade 4), acute kidney injury requiring hemodialysis (grade 3), pneumonia (grade = 2) and hydrothorax requiring intercostal drainage tube insertion (grade 3). On follow up, 4.7% of the renal units required ancillary procedures.

CONCLUSIONS

Our findings confirm that tubeless simultaneous bilateral percutaneous nephrolithotomy is a safe and effective modality of treatment. It allows obviating a second anesthetic exposure, thus reducing analgesic requirement, hospitalization time and costs. This translates into a significant socioeconomic impact on the outlook of Indian patients presenting with bilateral renal stone disease.

Simultaneous bilateral percutaneous nephrolithotomy in children: no need to delay

BACKGROUND AND PURPOSE

Children with bilateral kidney stones are generally treated using staged percutaneous nephrolithotomy (PCNL). Reports related to simultaneous bilateral PCNL (SBPCNL) in children are scarce. We aimed to evaluate the efficacy and safety of SBPCNL in children.

PATIENTS AND METHODS

The children who underwent SBPCNL applications between January 2007 and February 2010 in our clinic were evaluated. Patient data were collected from the retrospective reviews of hospital records.

RESULTS

SBPCNL was conducted in five patients for bilateral renal stones. The mean age of the patients was 6.28 years (range 0.75-15 y), and the mean follow-up was 10.6 months (range 1-36 mos). The mean renal stone burden was 19 mm (range 11-22 mm). Four children underwent bilateral standard PCNL, and one child underwent bilateral tubeless PCNL. The mean duration of SBPCNL was 75 minutes (range 55-120 min), and the hospitalization time was 4 days (range 2-5 d). No blood transfusion was necessary in any patient. Except for the patient with complex renal stones, all patients were stone free after the intervention, and none needed a conversion to open surgery.

CONCLUSION

SBPCNL is a safe and effective procedure in children if they are selected properly and if the surgeon has sufficient experience with the procedure. More studies with a higher number of participants are needed, however, for further evaluation of the procedure.

Renal functional effects of simultaneous bilateral single-tract percutaneous access in pigs

OBJECTIVE

To present our findings of simultaneous bilateral percutaneous nephrolithotomy (sbPCNL) on bilateral renal haemodynamic and excretory function in an in vivo pig model, as despite sbPCNL being a treatment strategy for patients with bilateral renal stones, the functional response of both kidneys to such a procedure is unknown.

MATERIALS AND METHODS

Nine anaesthetized female pigs ( approximately 70 kg) had a single-tract PCNL procedure in the left kidney and then the right kidney in one session (sbPCNL). Percutaneous access was achieved by a 30 F balloon dilator system. Bilateral renal function was measured before, 1.5 and 4.5 h after sbPCNL and included glomerular filtration rate (GFR), effective renal plasma flow (RPF), renal extraction of para-aminohippurate (EPAH, a measure of the efficiency of tubular organic anion transport), urine flow (UV), absolute sodium excretion (UNaV) and fractional sodium excretion (FENa).

RESULTS

Both kidneys had similar baseline haemodynamic and excretory function, and showed comparable changes after sbPCNL. Bilateral GFR and RPF decreased by approximately 35% at 1.5 and 4.5 h after sbPCNL; EPAH was reduced to a similar degree in both kidneys at 1.5 h after sbPCNL and remained depressed throughout the observation period; bilateral UV and UNaV progressively decreased by approximately 30% and approximately 60% at 1.5 and 4.5 h after sbPCNL, respectively; bilateral FENa did not significantly change at 1.5 h after sbPCNL but decreased significantly by approximately 50% at 4.5 h.

CONCLUSIONS

Both kidneys responded in a similar fashion after sbPCNL, with declines in haemodynamic and excretory function. These bilateral functional responses were comparable to those previously reported after unilateral PCNL, and help to reduce concerns that PCNL of both kidneys in one session could lead to greater functional complications, at least acutely.