Complete Supine Percutaneous Nephrolithotomy with Lung Inflation Avoids the Need for a Supracostal Puncture

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.

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.

Supine pediatric percutaneous nephrolithotomy (PCNL)

INTRODUCTION/BACKGROUND

Many authors reported their experience with supine PCNL in adult population comparing the outcome with prone PCNL and they found that the stone free rate and the operative time were in favor of prone PCNL with a lower patient morbidity among patients with supine PCNL. This encouraged us to perform supine PCNL in pediatric population.

AN OBJECTIVE

In this study we evaluated the safety and efficacy of supine PCNL in pediatric population.

STUDY DESIGN (SUBJECTS/PATIENTS/MATERIALS/METHODS)

Between April 2011 and February 2014 a total of 27 children (6 girls and 21 boys) presented with renal calculi. The stones were single pelvic stone in 14 cases, pelvic stone with lower calyceal stones in 7 cases and pelvic stone with upper calyceal stones in 6 cases. The mean stone size was 32 mm (range 20-47 mm). All patients were managed with supine PCNL performed by a single surgeon. Marking the posterior axillary line in standing position before the operation is a mandatory initial step. The patients were placed in supine position with elevation of the ipsilateral shoulder and hip by means of two bags one underneath the shoulder and the other underneath the hip to widen the operative field. The technique was performed using a sheathless 19 fr. Richard wolf rigid nephroscope after acute tract dilation by amplatz dilators. Complications (intraoperative and postoperative) and stone free rate rates were reported.

RESULTS

A single lower calyceal access was used in all cases through which we could successfully remove even the upper calyceal stones. Kinking of the guide wire during tract dilatation were encountered in 4 cases and the guide wire was successfully exchanged using a small Teflon dilator in 2 cases while ultrasonographic guided lower calyceal repuncture was done in 2 cases. The average operative time (from the beginning of the puncture trial to nephrostomy tube insertion) was (41 ± 15) min. The operation was successfully completed as planned in all cases with two cases of intraoperative complications (one case of pelvicalyceal system perforation and another case of intraoperative bleeding and blood transfusion). The initial stone free rate was (92.5%). Postoperative complications was reported in the form of 2 cases of fever that respond to medical treatment for 72 h.

DISCUSSION

The main advantages of supine pediatric PCNL is that it is comfortable for the surgeon, the anesthetist and the child. The main disadvantages of supine pediatric PCNL is that it is not familiar for most urologists and small field of operation. The short outcome of our study is the small number of cases and the lack of comparative study with prone pediatric PCNL.

CONCLUSIONS

Pediatric supine PCNL is a safe and effective method for management of pediatric renal stones. It carries the advantages of easily upper calyx access through the lower calyceal tract, low incidence of fluid absorption or hypothermia and easy anesthesia monitoring. However a larger number of cases are needed to be evaluated.

Supine lithotomy versus prone position in minimally invasive percutaneous nephrolithotomy for upper urinary tract calculi

OBJECTIVE

To compare operative time, safety and effectiveness of minimally invasive percutaneous nephrolithotomy (MPCNL) in the supine lithotomy versus prone position.

METHODS

Between January 2008 and December 2010, a total of 109 consecutive patients with upper urinary tract calculi were enrolled and randomly divided into group A (53 patients, supine lithotomy position) and group B (56 patients, prone position). The MPCNL procedures were performed under the guidance of real-time grayscale ultrasound system. The preoperative characteristics, intraoperative and postoperative parameters were analyzed and compared.

RESULTS

All patients were successfully operated. There was no significant difference between the two groups in stone-free rate (group A 90.1 vs. group B 87.5%, p = 0.45), mean blood loss, number of access tracts, calyx puncture, mean hospital stay (group A 6 ± 1.1 vs. group B 6 ± 1.5 days, p = 0.38) and complications. But the operative time was significantly shortened in supine lithotomy position (group A 56 ± 15 vs. group B 86 ± 23 min, p < 0.001).

CONCLUSIONS

The effectiveness and safety of the supine lithotomy position for MPCNL were similar to the prone position. However, the supine lithotomy position has an important advantage of reducing the operative time. The supine lithotomy position could be a good choice to perform MPCNL.

[Learning of percutaneous nephrolithotomy in supine position. An observational multicenter study]

OBJECTIVE

To prospectively study the post-operative results and complications of percutaneous nephrolithotomy (PNL) in supine position to assess difficulty of learning it and how experience affects the results. To establish a relative comparison with the data published in the literature on the prone position.

MATERIAL AND METHODS

A prospective observational multicenter study on PNL in Valdivia position or in its Galdakao variant was performed. Demographic variables and specific variables related to the lithiasis were collected. Technical aspects, surgery time, success rate and complications according to the Clavien-Dindo classifications were assessed.

RESULTS

A total of 335 PNL in supine position conducted in 13 Spanish centers were registered from September 2008 to June 2011. The man:woman ratio was 1:1.28 and mean age 51.3+14.5 years. 211 (63%) cases were performed by urologists with experience in >50 cases and 124 (37%) by urologists with less experience. Mean operation time was 113.3 ± 46.4 min, 106.6 ± 38.2 for the experienced ones vs. 124.9 ± 56.2 in the novice ones (P<.002). No difference was detected in the mean size of the lithiasis. However, in the experienced group, there was a greater proportion of coraliform cases and multiple lithiasis than in the novice group (P<.001). Success rate evaluated as total absence of lithiasic residuals was 69.6%, without differences between groups (68.2 vs. 71.8%). In 102 (30.6%) patient had residual lithiasis and 60 (17,9%) required complementary treatment. Relative global success rate was 82.1% and complications rate 25.4%, without detecting differences between groups. However, the novel group had more major complications (P>.001).

CONCLUSION

The PNL in supine position is obtaining rapid and consolidated diffusion in our setting and its effectiveness and safety seems to be equivalent to that described in the literature for PNL in prone position. It is possible to obtain good results with a modest learning curve. The rate of greater complications associated to the procedure decreases with experience.

Positions for percutaneous nephrolithotomy: Thirty-five years of evolution

Objectives

To present the chronological development of the different positions described for percutaneous nephrolithotomy (PCNL), in an attempt to identify the reasons for their development and to highlight their specific advantages and disadvantages.

Methods

Previous reports were identified by a non-systematic search of Medline and Scopus.

Results

The classic prone position for PCNL was first described in 1976. The technique was gradually standardised and PCNL with the patient prone became the generally accepted standard approach. In the next 35 years many other positions were described, with the patient placed prone, lateral or supine in various modifications. Modifications of the classic prone position in the early 1990s aimed to provide the option of a simultaneous retrograde approach during the procedure. As PCNL became more popular the lateral position was first described in 1994, to allow the application of PCNL to patients who were unable to tolerate being prone because of their body habitus. The supine position for percutaneous access was originally described even before 1990, but become more popular after 2007 when the Galdakao modification was reported. Several other modifications of the supine position have been described, with the latest being the flank-free modified supine position, which allows the best exposure of the flank among the supine positions. Each position has its specific advantages and disadvantages.

Conclusion

Urologists who perform PCNL should be familiar with the differences in the positions and be able to use the method appropriate to each case.

The safety and efficacy of PCNL with supracostal approach in the treatment of renal stones

OBJECTIVE

Supracostal superior calyceal access has been shown to be the most suitable approach for staghorn calculi, calculi in the upper ureter, and complex inferior calyceal calculi. It is a good choice for direct access for most of the intrarenal collecting system and upper ureter. The aim of this retrospective study was to evaluate a single center data regarding the safety and efficacy of this approach for percutaneous renal stone surgery.

MATERIALS AND METHODS

A total of 597 renal units (597 cases) were treated with percutaneous nephrolithotomy from the March of 2000 to March of 2005. Supracostal approach was selected in 123 cases and infracostal approach in remaining 474 cases. The indications of supracostal approach in our cases were staghorn and complex inferior calyceal stones, and stones in the upper calyx or the upper ureter. All punctures were made by the urologist under C-arm fluoroscopic guidance in the prone position. The interspace between 11th and 12th rib was used in 116 patients (94%) and 10th-11th interspace in 7 cases (6%). The operative time, success rate, hospital stay, and complications were evaluated.

RESULTS

The complete and relative success rates were 89.4 and 10.6%, respectively. The total complication rate was 13%. The success rate in the 10th-11th rib access and 11th-12th interrib access was 77 and 90%, respectively. Complete success rate was 100% in stone sizes less than 2 cm in diameter of upper ureteral and renal pelvic areas, and 77.4% of staghorn calculi. The total complication rate was 13% (16 cases), in which the most common of it was perioperative bleeding (5.7%; 7 cases).

CONCLUSION

The supracostal approach was found to be effective as well as safe, with acceptable complications. It gives high stone clearance rates with acceptable morbidity rates and should be attempted in selected cases. The rate of pulmonary complications is higher with the supracostal approach. If the supracostal approach is indicated, it should be used with caution.