Management of hemorrhage after percutaneous renal surgery

Endovascular management of a large renal artery aneurysm: a case report and review of the literature

Background

A renal artery aneurysm is a rare clinical presentation that can be found incidentally on imaging or during workup for refractory hypertension. Its presentation can be similar to that of a renal artery pseudoaneurysm, but the etiologies of the two vascular lesions differ. We present a patient who had an incidental finding of a large renal artery aneurysm that was managed with endovascular embolization. We also describe the literature surrounding the etiology, presentation and management of both renal artery aneurysms and renal artery pseudoaneurysms.

Case presentation

A 62-year-old man was referred to a urologic oncologist for workup of a newly found renal mass. Initial imaging with computed tomography showed a homogenous, well-circumscribed mass arising from the right kidney. Further evaluation with Doppler ultrasonography demonstrated pulsatile flow within the renal mass that was concerning for a renal artery pseudoaneurysm. The patient initially underwent a diagnostic angiogram by interventional radiology and was found to have a true renal artery aneurysm. Interventional radiology considered placement of a covered stent or angioembolization, but treatment was deferred due to concern for compromising the patient’s renal function. Patient was subsequently transferred to a neighboring hospital for management by vascular surgery. After considering both open surgical and endovascular approaches, the patient ultimately underwent angioembolization of the renal artery aneurysm. Short-term follow-up showed successful exclusion of the aneurysm with minimal adverse effects to the patient.

Conclusions

Our case report documents a unique case of an incidentally found large renal artery aneurysm that was successfully managed with endovascular embolization. Renal artery aneurysms and renal artery pseudoaneurysms, which can present similarly on imaging, are important diagnostic considerations in a patient presenting with a new renal mass. While open surgical approaches can be used to repair aneurysms, endovascular approaches using stenting or angioembolization are safe and effective options for treating renal aneurysms and renal pseudoaneurysms.

Long term renal function following selective angioembolization for iatrogenic vascular lesions after partial nephrectomy: A matched case-control study

Purpose

Partial nephrectomy is associated with a 1%–2% risk of renal iatrogenic vascular lesion (IVL) that are commonly treated with selective angioembolization (SAE). The theoretical advantage of SAE is preservation of renal parenchyma by targeting only the bleeding portion of the kidney. Our study aims to assess the long-term effect of SAE on renal function, especially that this intervention requires potentially nephrotoxic contrast load injection.

Materials and Methods

A retrospective review of patients undergoing partial nephrectomy between 2002 and 2018 was performed, and patients who developed IVL were identified. A 1:4 matched case-control analysis was performed. Paired t-test and χ² test were used for continuous and categorical variables, respectively. Multivariable logistic and Cox proportional hazards regression analyses were used to identify risk factors and confounders for SAE and postoperative renal function.

Results

Eighteen patients found to have an IVL after partial nephrectomy were matched with 72 control patients. IVL's were more common in patients after minimally invasive partial nephrectomy (89% vs. 70%, p=0.008) and in those with higher RENAL nephrometry scores (8.8±2.0 vs. 6.5±1.8, p<0.001). On multivariable analysis, lower RENAL scores proved to decrease the odds of requiring postoperative SAE. No significant difference in renal function outcomes was seen at 24 months of follow-up after surgery.

Conclusions

SAE for the management of IVL following partial nephrectomy is a safe and efficient procedure with no significant impact on short or long-term renal function. Less complex renal tumors with lower RENAL scores are less likely to require postoperative SAE.

Safety and efficacy of superior calyceal access versus inferior calyceal access for pelvic and/or lower calyceal renal calculi- a prospective observational comparative study

Objective

To compare efficacy and safety between superior calyceal access and inferior calyceal access for pelvic and/or lower calyceal renal stones.

Methods

Consecutive patients presenting with Pelvic and/or inferior calyceal renal calculi were allocated to the superior calyceal access (group 1) or inferior calyceal access (group 2) treatment arm. Allocation of treatment access was based on the surgeon’s preference. Variables studied included stone free rate, operating time, intraoperative and postoperative complications. Statistical analysis was executed using SPSS, Version 16.0. The statistical significance was evaluated at 5% level of significance (p value < 0.05).

Results

Between July 2018 and February 2019, 63 patients were included in each group. The percutaneous inserted guidewire entered the ureter in 92% in group1 and 74.6% in group 2 (p = 0.034). Stone fragments migrated to the middle calyx in 3.2% in group1 and 9.5% in group 2 (p = 0.033). A second puncture was required in one patient in group 1 and in 5 patients in group 2 (p = 0.04). The operative duration (minutes) was 13.46 ± 1.09 in the group 1 while 16.58 ± 1.44 in the group 2 (p = 0.002). Thoracic complications (hydropneumothorax) occurred to 2 patients in superior calyceal access group managed with intercostal tube drainage (p = 0.243).Post operatively blood transfusion was required in two patients in group 2 (p = 0.169). Angioembolization was done in one patient among the inferior calyceal access approach (p = 0.683). Complete stone clearance assessed at 3 months was 96.8% in group 1 and 85.7% in group 2 (p = 0.046).

Conclusions

Superior calyceal access is a safe and most efficacious in terms of achieving complete stone clearance rate with reduced operative time, minimal blood loss, less need for a second puncture and auxiliary procedures at minimal complications.

Study registration

Clinical trials registry – INDIA; CTRI/2018/07/014,687.

Decreased hemoglobin as a quantifiable indicator of renal arterial embolization in post-percutaneous nephrolithotomy hemorrhage

To determine quantifiable indicators for post-percutaneous nephrolithotomy (PCNL) renal arterial embolization. A total of 2043 patients who underwent PCNL from September 2012 to March 2018 were reviewed retrospectively. Post-operative hemorrhage patients were extracted and divided into two groups according to treatment methods (conservative methods or super-selective renal arterial embolization [SRAE]). Demographic characteristics and hemorrhage outcomes were compared between the two groups by univariable analysis. Multivariable logistic regression was used to reveal the association between hemorrhage outcome factors and SRAE. A receiver operating characteristic (ROC) curve was drawn to determine the optimized cut-off value for SRAE. We identified 71 patients who had post-PCNL hemorrhage. Seventeen and 54 patients comprised the SRAE and conservative groups, respectively. No significant differences in demographic characteristics were found between the two groups. Univariate analysis showed that the differences in decreased hemoglobin (Hb), hemorrhage types, and transfusion were significant between the two groups (p < 0.001). Multivariable analysis showed that the decreased Hb was closely associated with the risk of SRAE. The ROC curve showed that an adjusted Hb decrease of 3.45 g/dL was an optimum indicator (AUC = 0.925). Decreased Hb is an indicator for SRAE after PCNL. When the adjusted decrease in Hb is ≥ 3.45 g/dL, SRAE should be performed regardless of the manifestations of hemorrhage.

Peri-Operative Factors Affecting Blood Transfusion Requirements During PCNL: A Retrospective Non-Randomized Study

Background

Percutaneous nephrolithotomy (PCNL) is accepted as the gold standard of care for the treatment of large renal calculi. Kidney hemorrhage, which requires blood transfusion, is one of the most common complications after percutaneous kidney stone surgery.

Objective

To evaluate perioperative factors associated with transfusion requirements during PCNL.

Materials and Methods

A total of 226 patients with kidney calculi undergoing PCNL between January 2011 and December 2019 were reviewed retrospectively. We analyzed the impact of perioperative clinical factors on the necessity of blood transfusion during PCNL.

Results

The overall blood transfusion rate was 9.29%. Multiple perioperative determinants were significantly correlated with the application of packed red blood cells (PRCs), including larger stone size (p = 0.006), multiple tract punctures (p = 0.029), presence of staghorn calculi (p = 0.026), and long operative time (OT; p = 0.017). Multivariate analysis demonstrated that only multiple tract punctures independently affected blood transfusion requirements during PCNL (p = 0.038).

Conclusion

In accordance with the present study, only the multiple tract punctures were associated with blood transfusion requirements in PCNL.

Balloon versus Amplatz for tract dilation in fluoroscopically guided percutaneous nephrolithotomy: a systematic review and meta-analysis

OBJECTIVE

To compare the safety and efficacy of balloon and Amplatz for tract dilation in fluoroscopically guided percutaneous nephrolithotomy (PCNL).

METHOD

EMBASE, PUBMED, MEDLINE and the Cochrane Central Register of Controlled Trials were searched for pertinent studies up until 30 October 2019. Pooled effects were calculated as ORs with 95% CIs or mean differences (MD) with 95% CIs. Endpoints included postoperative decrease in haemoglobin, transfusion rate, complication rate, successful dilation rate, stone-free rate, fluoroscopy time, access time, total operation time and length of postoperative hospitalisation (LPH). Bonferroni's correction was intercalated to reduce the likelihood of making a meta-analytical false positive.

RESULTS

One randomised controlled trial and five controlled clinical trials were included, which involved 1317 patients in total. We found a lower drop in postoperative haemoglobin for patients receiving balloon dilation compared with those in the Amplatz group (MD=-0.21, 95% CI -0.33 to 0.09, p=0.0005; Bonferroni correction a=0.005). Access time in the balloon group was also, on average, 2.61 min shorter than the Amplatz group (MD=-2.61, 95% CI -4.20 to 1.01, p=0.001; Bonferroni correction a=0.005). No significant differences were identified between the two dilation methods in terms of transfusion rate, complication rate, successful dilation rate, stone-free rate, fluoroscopy time, total operation time and LPH.

CONCLUSION

Balloon dilation is a safe and effective tract dilation technique for access creation during fluoroscopically guided PCNL. Both of methods have similar success rates although balloon dilation is associated with significantly less postoperative haemoglobin decline and shorter access time. Therefore, balloon dilation appears to be the superior tract dilation technique, but further confirmatory research is required to confirm these findings.

Can tranexamic acid reduce the blood transfusion rate in patients undergoing percutaneous nephrolithotomy? A systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis was conducted to explore the efficacy of tranexamic acid (TXA) in reducing transfusion events in patients undergoing percutaneous nephrolithotomy (PCNL).

METHODS

PubMed, Web of Science, Embase, EBSCO, and Cochrane library databases from January 1980 to October 2019 were searched for randomized controlled trials (RCTs) that assessed TXA efficacy in reducing transfusion events during PCNL. Intervention treatments include using TXA compared with placebo (or no intervention) for patients who underwent PCNL. The search strategy and study selection process were managed in accordance with the PRISMA statement.

RESULTS

Six RCTs are included in the meta-analysis. Overall, TXA intervention groups showed a significant reduction in blood transfusion events (RR = 0.34; 95% confidence interval [CI] = 0.19 to 0.62), hemoglobin decrease (MD = -0.80; 95% CI = -1.32 to -0.28), operative time (MD = -12.62; 95% CI = -15.62 to -9.61), and length of hospital stay (MD = -0.73; 95% CI = -1.36 to -0.10) compared with control groups after PCNL. However, TXA had no substantial impact on the rate of stone clearance (RR = 1.10; 95% CI = 1.00 to 1.21).

CONCLUSIONS

TXA can effectively reduce the transfusion rate and blood loss during PCNL.

Percutaneous nephrolithotomy for staghorn calculi: Troubleshooting and managing complications

Staghorn calculi comprise a unique subset of complex kidney stone disease. Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for staghorn stones. Despite continuous refinements to the technique and instrumentation of PCNL, these stones remain a troublesome challenge for endourologists and are associated with a higher rate of perioperative complications than that for non-staghorn stones. Common and notable intraoperative complications include bleeding, renal collecting system injury, injury of visceral organs, pulmonary complications, thromboembolic complications, extrarenal stone migration, and misplacement of the nephrostomy tube. Postoperative complications include infection and urosepsis, bleeding, persistent nephrocutaneous urine leakage, infundibular stenosis, and death. In this review, we report recommendations regarding troubleshooting measures that can be used to identify and characterize these complications. Additionally, we include information regarding management strategies for complications associated with PCNL for staghorn calculi.

Effectiveness and safety of four tract dilation methods of percutaneous nephrolithotomy: A meta-analysis

Percutaneous nephrolithotomy (PCNL) has become a routine surgical procedure for treating patients with large kidney stones; the fundamental step in this process is the creation of the nephrostomy tract. In the present study, a meta-analysis was performed to compare the effectiveness and safety of different tract dilation techniques for PCNL. Databases were searched from inception to 1 April 2019 to identify relevant randomized controlled trials. The X-ray exposure time, hemoglobin decrease, stone-free rate, transfusion rate, hospital stay and the complication rate associated with the various techniques were analyzed. A total of 11 studies comprising 1,415 cases were enrolled in the meta-analysis. Significant differences in X-ray exposure time [weighted mean difference (WMD), 30.67; 95% confidence interval (CI), 20.08-41.26; P<0.001] and hemoglobin decrease (WMD, 0.19; 95%CI, 0.15-0.23; P<0.001) were identified between metal telescopic dilation (MTD) and one-shot dilation (OSD). A significantly lower hemoglobin decrease was observed in the balloon dilation (BD) vs. fascial Amplatz dilation (AD) group [WMD, -0.65; 95%CI, -(0.77-0.52); P<0.001]. The transfusion rate was similar between these techniques. The MTD had an obviously higher successful dilation rate compared with that of the OSD, but no significant differences in stone-free rate and transfusion rate were obtained. The present study determined that, compared with other methods, OSD was safer in almost every adult patient, including those that had previously undergone renal surgery; though it is recommended that this should be performed by experienced surgeons. BD was reported to be effective and safer in patients without a history of renal surgery compared to other methods. The present study proposed AD and MTD as safer methods of dilation for patients who have previously undergone kidney surgery.

Failure of initial superselective renal arterial embolization in the treatment of renal hemorrhage after percutaneous nephrolithotomy: A respective analysis of risk factors

Superselective renal arterial embolization (SRAE) is a well-established method for the treatment of severe hemorrhage following percutaneous nephrolithotomy (PCNL). However, there remains a significant rate of failures requiring repeat SRAE or nephrectomy. To identify risk factors for initial treatment failure of SRAE, the data of patients who had undergone SRAE for severe bleeding due to PCNL between August 2005 and June 2016 were retrospectively analyzed. A total of 98 patients required SRAE for bleeding control following PCNL. Renal arteriography revealed pseudoaneurysm in 65 patients, arteriovenous fistula in 6 patients, and a combination of both in 11 patients. Free extravasation was observed in 11 patients; 8 of these patients exhibited coexisting pseudoaneurysm. Vascular aberration/tortuosity was identified in 10 patients. A total of 17 patients (17.3%) experienced initial treatment failure and underwent repeat SRAE. Multivariate analysis identified percutaneous tract size, number of bleeding sites and vascular aberration/tortuosity as significant predictors of initial treatment failure. The results from the present study suggested that repeated SRAE is preferred for patients who have experienced initial treatment failure with recurrent hemorrhage following PCNL. Large tract size, multiple bleeding sites and renal vascular aberration/tortuosity were significantly associated with increased risk of initial treatment failure of SRAE. These data may assist interventional radiologists in the planning and execution of SRAE in the treatment of PCNL.

The evolution of percutaneous nephrolithotomy: Analysis of a single institution experience over 25 years

INTRODUCTION

Over time, the incidence of nephrolithiasis has risen significantly, and patient populations have become increasingly complex. Our study aimed to determine the impact of changes in patient demographics on percutaneous nephrolithotomy (PCNL) outcomes.

METHODS

A retrospective analysis of a prospectively collected database was carried out from 1990-2015. Patient demographics, comorbidities, stone and procedure characteristics were analyzed. Multivariate logistic regression was used to evaluate differences in operative duration, complications, stone-free rate, and length of stay.

RESULTS

A total of 2486 patients with a mean age of 54±15 years, body mass index (BMI) of 31±8, and stone surface area of 895±602 mm² were analyzed; 47% of patients had comorbidities, including hypertension (22%), diabetes mellitus (14%), and cardiac disease (13%). Complication rate was 19%, including a 2% rate of major complications (Clavien grade III-V). There was a statistically significant increase in patient age, BMI, and comorbidities over time, which was correlated with an increased complication rate (odds ratio [OR] 1.15; p=0.010). The overall transfusion rate was 1.0% and remained stable (p=0.131). With time, both OR duration (mean Δ 16 minutes; p<0.001) and hospital length of stay (mean Δ 2.4 days; p<0.001) decreased significantly. Stone-free rate of 1873 patients with available three-month followup was 87% and decreased significantly over time (OR 1.09; p<0.001), but was correlated with an increased use of computed tomography (CT) scans for followup imaging.

CONCLUSIONS

Despite an increasingly complex patient population, PCNL remains a safe and effective procedure with a high stone-free rate and low risk of complications.

One-shot dilation versus serial dilation technique for access in percutaneous nephrolithotomy: a systematic review and meta-analysis

OBJECTIVE

The purpose of this study was to systematically review the outcomes of the use of one-shot dilation (OSD) and serial tract dilation for percutaneous nephrolithotomy (PCNL).

METHODS

A systematic review and meta-analysis was conducted. The randomised controlled trials (RCTs) included in the study were identified from EMBASE, MEDLINE and the Cochrane Central Register of Controlled Trials. The last search was performed on 30 April 2018. Summary effects were calculated as risk ratios (RRs) with 95% CIs or mean differences (MDs) with 95% CIs. The endpoints included access time, fluoroscopy time, successful dilation rate, stone-free rate, postoperative decrease in haemoglobin levels, transfusion rate, complication rate and length of postoperative hospital stay.

RESULTS

A total of seven RCTs were included in the study, with clinical data reported for 697 patients. The overall access time was approximately 110 s shorter in the OSD group than in the serial dilation group (MD, -110.14; 95% CI -161.99 to -58.30; p<0.0001). The fluoroscopy time was shorter with OSD in all RCTs. In addition, the decrease in postoperative haemoglobin levels was approximately 2.3g/L less in patients in the OSD group than in those in the serial dilation group (MD, -0.23; 95% CI-0.39 to -0.07; p=0.004). No relationship was found between the successful dilation rate, stone-free rate, transfusion rate, or complication rate and the method of tract dilation.

CONCLUSION

OSD is a safe and efficacious tract dilation technique that can reduce the access time, fluoroscopy time and postoperative decrease in haemoglobin level. No difference was found in the successful dilation rate, stone-free rate, transfusion rate or rate of complications between the OSD and serial dilation groups. The difference in the length of postoperative hospital stay was uncertain. OSD may be a better method of tract creation for PCNL.

Same-day angiography and embolization in delayed hematuria following percutaneous nephrolithotomy: an effective, safe, and time-saving approach

Purpose

To evaluate the results of prompt, same-day selective angiography and transcatheter angioembolization (TAE) on delayed post-percutaneous nephrolithotomy (PCNL) hematuria.

Materials and methods

Between 2011 and 2017, 21 patients with a mean age of 37 years (range, 21–60 years; males, 18) underwent digital subtraction angiography (DSA) and TAE to control delayed gross hematuria following PCNL. Discharged patients who following an uneventful PCNL presented to the emergency room with gross, brisk hematuria were included in the study and taken up for prompt, same-day DSA and same-session TAE with N-butyl-2-cyanoacrylate glue, without resorting to any initial conservative measures. All patient data were retrieved from medical records.

Results

Angiography revealed vascular lesions in all the cases (pseudoaneurysms, 14 cases; arteriovenous fistula, 2; mixed lesions, 5). The mean time of onset of delayed hemorrhage was 10.10±2.67 days. The average time from onset of bleeding to TAE was 4.31±0.64 hours (range 3.5–5.5 hours). Bleeding was controlled in all the cases without any recurrence or the need for further embolization. There were no procedural complications except for transient elevation of serum creatinine in four cases.

Conclusion

Primary DSA and TAE is a safe, effective, and time-saving alternative to conservative management for post-PCNL, delayed, gross hematuria.

The Analysis of Risk Factors for Hemorrhage Associated with Minimally Invasive Percutaneous Nephrolithotomy

Objective

This study investigated the risk factors for bleeding during minimally invasive percutaneous nephrolithotomy, so as to prevent the occurrence of bleeding and improve the surgical effect.

Patients and Methods

The data of 396 patients who underwent percutaneous nephrolithotomy by an experienced surgeon between May 2014 and December 2017 were retrospectively analyzed. To identify the risk factors for bleeding during percutaneous nephrolithotomy, each group was stratified according to the decrease in median hemoglobin. Age, gender, body mass index, stone size, operation time, stone type, degree of hydronephrosis, number of accesses, puncture guidance, underlying disease (diabetes; hypertension), and previous surgical history were evaluated. Univariate analysis was performed to calculate the potential factors. In order to determine the independence of each factor, we finally selected stone size, staghorn stone, degree of hydronephrosis, and operation time. Multivariate logistic regression analysis was used to identify the risk factors for bleeding during minimally invasive percutaneous nephrolithotomy.

Results

A total of 396 patients were successfully treated with percutaneous nephrolithotomy. The univariate analysis demonstrated that the potential risk factors for bleeding during percutaneous nephrolithotomy included stone size, type of stone, operative time, and degree of hydronephrosis. According to the previous studies, stone size, staghorn stone, degree of hydronephrosis, and operation time were ultimately selected. Multivariate logistic regression analysis was used to identify the risk factors for bleeding during percutaneous nephrolithotomy. According to the outcome of logistic regression analysis, stone size, staghorn stone, operation time, and degree of hydronephrosis were the risk factors for bleeding during minimally invasive percutaneous nephrolithotomy.

Conclusions

Percutaneous nephrolithotomy is an effective method for the treatment of upper urinary calculi with few complications. According to the results achieved by an experienced surgeon, the size of stone, staghorn stone, operation time, and degree of hydronephrosis were associated with the bleeding during minimally invasive percutaneous nephrolithotomy.

Predictors for severe hemorrhage requiring angioembolization post percutaneous nephrolithotomy: A single-center experience over 3 years

Context and Aim

About 1% of the patients undergoing percutaneous nephrolithotomy (PCNL) have bleeding severe enough to require angioembolization. We identified factors which could predict severe bleeding post-PCNL and reviewed patients who underwent angioembolization for the same.

Settings and Design

This is a single-institutional, retrospective study over a period of 3 years.

Subjects and Methods

We retrospectively studied 583 patients undergoing PCNL at our institute from 2013 to 2016. We analyzed nine patients (three from our institute and six referred patients) who underwent angioembolization for severe bleeding post-PCNL. We analyzed the preoperative characteristics, intraoperative findings, and postoperative course of these patients and compared this with those patients who did not have a severe post-PCNL bleeding.

Statistical Analysis Used

Fischer's exact test and Chi-square test were used in univariate analysis. Logistic regression analysis was used in multivariate analysis with a value of P < 0.05 considered statistically significant.

Results

Three of the 583 patients (0.51%) who underwent PCNL at our institute required embolization to control bleeding. Preoperative characteristics that were significant risk factors for severe bleeding were a history of ipsilateral renal surgery (P = 0.0025) and increased stone complexity (P = 0.006), while significant intraoperative factors were injury to the pelvicalyceal system (P = 0.0005) and multiple access tracts (P = 0.022). Angiography revealed arteriovenous fistula in two patients and a pseudoaneurysm in seven patients. All patients underwent successful superselective angioembolization with preserved renal perfusion in six patients on control angiography postembolization.

Conclusions

History of ipsilateral renal surgery, increased stone complexity, multiple access tracts, and injury to the pelvicalyceal system are risk factors predicting severe renal hemorrhage post-PCNL. Early angiography followed by angioembolization should be performed in patients with severe post-PCNL bleeding who fail to respond to conservative measures.

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.

Effects of previous unsuccessful extracorporeal shockwave lithotripsy treatment on the performance and outcome of percutaneous nephrolithotomy

OBJECTIVE

To evaluate the effects of previous unsuccessful extracorporeal shockwave lithotripsy (ESWL) treatment on the performance and outcome of percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

Of 1625 PCNL procedures performed in our clinic, 393 renal units with similar stone burden and number of accesses was included in the present study. We categorised the study patients into two groups according to whether they underwent ESWL within 1 year prior to PCNL or not. Accordingly, Group 1 comprised 143 (36.3%) ESWL-treated patients and Group 2 comprised 250 (63.7%) non-ESWL-treated patients.

RESULTS

Residual stones were detected in 36 (25.1%) of the ESWL-treated patients (Group 1) and in 60 (24%) of non-ESWL-treated patients (Group 2). There were no statistically significant differences between the groups for length of hospital stay (LOS), nephrostomy tube removal time, and the presence of residual stones. When we evaluated the groups for both the preoperative and postoperative haemoglobin (Hb) drop and blood transfusion rate, manifest Hb declines and more transfusions were required in the ESWL-treated patients (both P = 0.01).

CONCLUSIONS

In our study, previous ESWL treatment had no influence on the PCNL stone-free rate, operation time, incidence of postoperative complications, and LOS, in patients with similar stone burdens. However, bleeding during PCNL was more prevalent in the ESWL-treated patients, so close attention should be paid to bleeding in patients who have been pretreated with ESWL.

Percutaneous nephrolithotomy; alarming variables for postoperative bleeding

OBJECTIVES

To evaluate factors contributing to bleeding after percutaneous nephrolithotomy (PCNL) and ways of managing this complication, as bleeding is a serious sequela that requires prompt management.

PATIENTS AND METHODS

The demographic and procedural data of 200 patients, who underwent unilateral PCNL during a 20-month period, were prospectively collected. Preoperative, operative, and postoperative details were recorded. The preoperative variables analysed included: age, sex, body mass index (BMI), the presence of hypertension, diabetes mellitus, serum creatinine, degree of hydronephrosis, previous ipsilateral open renal surgery, stone size and complexity. The operative variables analysed included: number of tracts, operative time, size of Amplatz sheath, type of anaesthesia, and complications such as calyceal and pelvic perforation.

RESULTS

The variables of age, sex, BMI, diabetes, hypertension, and a preoperative creatinine level of >1.4 mg/dL had no significant effect on blood loss (all P > 0.05). However, the rate of bleeding was significantly higher (P ⩽ 0.05) in patients who had a history of previous open renal surgery, intraoperative pelvicalyceal perforations, and Guy's Stone Score (GSS) grade 3 and 4 complex stones; however, absence of hydronephrosis, larger stone size, operative time (>83 min), more than one puncture, and size of the Amplatz sheath (26-30 F) did not maintain their significance in multivariate analysis.

CONCLUSION

According to our present results stone complexity (GSS grade 3 and 4), history of ipsilateral renal stone surgery, and occurrence of intraoperative pelvicalyceal perforation are alarming variables for post-PCNL bleeding.

A double-blind, placebo-controlled randomized clinical trial to evaluate the efficacy of tranexamic acid in irrigant solution on blood loss during percutaneous nephrolithotomy: a pilot study from tertiary care center of North India

PURPOSE

To evaluate the efficacy and safety of 0.1% tranexamic acid in irrigant fluid in reducing blood loss during PCNL.

MATERIALS AND METHODS

The study involved 400 patients who were planned for PCNL and were prospectively randomized into two equal groups. In tranexamic group, 0.1% tranexamic acid was given in irrigant fluid, while in placebo group, distilled water was added to irrigant fluid during surgery. Operative data were recorded which included fall in hemoglobin, total blood loss, operative time, irrigation fluid, length of stay in hospital, requirement of blood transfusion, complications related to PCNL and adverse events of tranexamic acid.

RESULTS

Baseline parameters were comparable between two groups. The fall in hemoglobin and total blood loss in the tranexamic group was significantly lower than placebo group (1.71 vs. 2.67 gm/dL, 154.55 vs. 212.61 mL, respectively, p < 0.0001). Operative time, amount of irrigation fluid used and hospital stay of tranexamic group were significantly less compared to placebo (p < 0.05). Complete stone clearance rate was 88% in tranexamic group versus 82% in placebo (p = 0.12). The blood transfusion requirement was significantly lower in the tranexamic group versus placebo (5 vs. 12.5%, p = 0.012), as was the complication rate (19 vs. 28%, p = 0.044). The requirement of angioembolization in the tranexamic group was significantly less as compared to placebo (0.5 vs. 4%, p = 0.03). No adverse events related to administration of tranexamic acid were noted.

CONCLUSIONS

0.1% tranexamic acid in irrigant fluid is safe and significantly reduces perioperative blood loss and requirement of blood transfusion during percutaneous nephrolithotomy. It is associated with lower perioperative complication rates.

Renal functional outcomes are not adversely affected by selective angioembolization following percutaneous nephrolithotomy

Objective

Selective angioembolization (SAE) effectively diagnoses and treats iatrogenic vascular complications following percutaneous nephrolithotomy (PCNL).

Methods

We retrospectively reviewed 1329 consecutive PCNLs and identified patients who underwent SAE following PCNL with at least 12-month follow-up. Estimated glomerular filtration rate (eGFR) was calculated for all patients preoperatively, postoperatively and at last follow-up. A 1:2 matched cohort analysis was performed.

Results

Twenty-three patients underwent SAE and matched to 46 controls. There was no statistically significant difference in preoperative, postoperative, and follow-up eGFR when comparing patients who underwent SAE and those with an uneventful course.

Conclusion

Long-term eGFR is comparable in patients who undergo uncomplicated PCNL and those requiring SAE.

Efficacy and safety of mini percutaneous nephrolithotomy in obese patients

Purpose

We aimed to evaluate the effect of obesity on surgical outcomes of mini percutaneous nephrolithotomy (Mini-PNL).

Methods

Hundred and eighty two Mini-PNL procedures were performed between May 2013 and January 2015 and their results were evaluated retrospectively. Patients were classified as non-obese (BMI, 18.5–30 kg/m²) and obese (≥30 kg/m²) groups. Obese and non-obese patients were compared according to pre-operative demographic values, intra-operative surgery techniques and post-operative results.

Results

BMI values of 133 patients were lower than 30 kg/m² while 49 patient’s BMI values were higher than 30 kg/m². There were no significant difference between operation time, fluoroscopy time, number of access and access sites when two groups were compared. No significant difference was found in total length of hospital stay, hemoglobin drop, and complication rates. Stone-free rates were 70.7 % in the non-obese and 71.4 % in the obese group (p = 0.9).

Conclusions

Mini-PNL procedure is a safe and effective treatment modality, which should be strongly considered for obese patients with appropriate sized stones.

The effects of previous open renal stone surgery types on PNL outcomes

INTRODUCTION

Our aim was to demonstrate the effect of insicion of renal parenchyma during open renal stone surgery (ORSS) on percutaneous nephrolithotomy (PNL) outcomes.

METHODS

Patients with history of ORSS who underwent PNL operation between June 2005 and June 2015 were analyzed retrospectively. Patients were divided into two groups according to their type of previous ORSS. Patients who had a history of ORSS with parenchymal insicion, such as radial nephrotomies, anatrophic nephrolithotomy, lower pole resection, and partial nephrectomy, were included in Group 1. Other patients with a history of open pyelolithotomy were enrolled in Group 2. Preoperative characteristics, perioperative data, stone-free status, and complications were compared between the groups. Stone-free status was defined as complete clearance of stone(s) or presence of residual fragments smaller than 4 mm. The retrospective nature of our study, different experience level of surgeons, and lack of the evaluation of anesthetic agents and cost of procedures were limitations of our study.

RESULTS

123 and 111 patients were enrolled in Groups 1 and 2, respectively. Preoperative characteristics were similar between groups. In Group 1, the mean operative time was statistically longer than in Group 2 (p=0.013). Stone-free status was significantly higher in Group 2 than in Group 1 (p=0.027). Complication rates were similar between groups. Hemorrhage requiring blood transfusion was the most common complication in both groups (10.5% vs. 9.9%).

CONCLUSIONS

Our study demonstrated that a history of previous ORSS with parenchymal insicion significantly reduces the success rates of PNL procedure.

Does previous open renal surgery or percutaneous nephrolithotomy affect the outcomes and complications of percutaneous nephrolithotomy

In this study, we aim to evaluate the effectiveness and safety of PNL in patients with a history of open renal surgery or PNL by comparing with primary patients and to compare impact of previous open renal surgery and PNL on the success and complications of subsequent PNL. Charts of patients, who underwent PNL at our institute, were analyzed retrospectively. Patients were divided into three groups according to history of renal stone surgery. Patients without history of renal surgery were enrolled into Group 1. Other patients with previous PNL and previous open surgery were categorized as Group 2 and Group 3. Preoperative characteristic, perioperative data, stone-free status, and complication rates were compared between the groups. Stone-free status was accepted as completing clearance of stone and residual fragment smaller than 4 mm. Eventually, 2070 patients were enrolled into the study. Open renal surgery and PNL had been done in 410 (Group 2) and 131 (Group 3) patients, retrospectively. The mean operation time was longer (71.3 ± 33.5 min) in Group 2 and the mean fluoroscopy time was longer (8.6 ± 5.0) in Group 3 but there was no statistically significant difference between the groups. Highest stone clearance was achieved in primary PNL patients (81.62%) compared to the other groups (77.10% in Group 2 and 75.61% in Group 3). Stone-free rate was not significantly different between Group 2 and Group 3. Fever, pulmonary complications, and blood transfusion requirement were not statically different between groups but angioembolization was significantly higher in Group 2. Percutaneous nephrolithotomy is a safe and effective treatment modality for patients with renal stones regardless history of previous PNL or open renal surgery. However, history of open renal surgery but not PNL significantly reduced PNL success.

Standardizing the reporting of percutaneous nephrolithotomy complications

Accurate reporting of complications is an essential component to critical appraisal and innovation in surgery and specifically with percutaneous nephrolithotomy (PCNL). We review the evolution of complication reporting for PCNL and suggest future directions for innovation. A selective review was carried out using Pubmed. Key search terms and their combinations included percutaneous, anatrophic, nephrolithotomy, PCNL, complications, Clavien, Martin score, bleeding, bowel injury, perforation, fever, sepsis. The references from relevant papers and reviews as well as AUA and EAU guidelines were also scanned for inclusion. PCNL has become the procedure of choice for large renal stones owing to decreased morbidity over alternative procedures. Both common and rare complications have been described in large case series, small randomized controlled trials, and case reports in an unstandardized form. Although these reports have provided an informative starting point, a standardized complication reporting methodology is necessary to enable appropriate comparisons between institutions, time periods, or innovations in technique. The Clavien-Dindo grading system has become widely accepted in urology and has facilitated the study of PCNL complications. Future research should focus on adaptions of this system to render it more comprehensive and applicable to PCNL.

Percutaneous Nephrolithotomy in Autosomal Dominant Polycystic Kidney Disease: Is it Different from Percutaneous Nephrolithotomy in Normal Kidney?

OBJECTIVES

Nephrolithiasis has been reported in 20-28% of patients, of whom 50% are symptomatic for stone disease and 20% require definite urologic intervention. The management of nephrolithiasis includes oral alkali dissolution therapy, extracorporeal shock wave lithotripsy and surgical treatment. In such patients, percutaneous nephrolithotomy (PNL) as a method of stone treatment has been reported in few cases with limited experience. The aim of this study is to present our experience of PNL in autosomal dominant polycystic kidney disease (ADPKD) and assessing the outcome results.

MATERIAL AND METHODS

From 2002 to 2011, 22 patients (26 renal units) suffering from ADPKD with stone were managed by PNL. Demographic characteristics, operative parameters and postoperative complications were recorded and analysed.

RESULT

The overall success rate of PNL was 82.1% and PNL with extracorporeal shock wave lithotripsy for clinically significant residual fragments was 92.85% respectively. The hematuria required blood transfusion (n = 9), postoperative fever due to cyst infection (n = 4) and paralytic ileus (n = 3) were recorded.

CONCLUSION

The PNL in ADPKD PNL is safe and effective but have more postoperative complications such as bleeding requiring transfusions, fever due to cyst infection and paralytic ileus.

Predictive factors for bleeding during percutaneous nephrolithotomy

Purpose

Although percutaneous nephrolithotomy (PCNL) has been accepted as a standard method for the management of large renal stones, the incidence of renal hemorrhage is relatively high. This study investigated the variables that affect bleeding during PCNL.

Materials and Methods

The medical records of 370 patients who underwent PCNL by a single surgeon from January 2005 to December 2010 were reviewed retrospectively. All patients were divided into two groups according to median blood loss (lesser bleeding group and higher bleeding group). Various clinical and perioperative factors including age, sex, stone size and position, degree of hydronephrosis, operative time, underlying disease, history of anticoagulant medication, presence of previous nephrostomy catheter, stone composition, and thickness of the renal cortex were assessed. For statistical assessment, univariate and multivariate logistic regression analyses were used.

Results

The mean patient age was 48.8 years (range, 22 to 75 years). Forty-three patients (11.6%) received a transfusion and 9 patients (2.4%) underwent angioembolization after surgery. The mean blood loss was 511.8±341.3 mL. Body mass index (BMI), stone size, stone position, operation time, and degree of preoperative hydronephrosis were predictive factors for severe bleeding during PCNL.

Conclusions

On the basis of the results achieved by a single surgeon, staghorn stones, high BMI, large stones, prolonged operation time, and absence of hydronephrosis were significantly associated with the risk of severe bleeding during PCNL.

Superselective renal artery embolization in the treatment of renal hemorrhage

BACKGROUND

Renal hemorrhage is a potentially life-threatening event that may follow trauma, operation, biopsy, and sudden spontaneous rupture of renal tumors or aneurysms. Superselective renal artery embolization (SRAE) is a well-established method for such cases.

OBJECTIVES

To assess the effectiveness of SRAE in the treatment of renal hemorrhage at our institute.

MATERIALS AND METHODS

We respectively reviewed the medical records of patients who underwent SRAE for renal hemorrhage from January 2005 to June 2012. Data on patients' characteristics, indications, requirement of pre-embolization blood transfusion, angiographic finding, location of bleeding site, embolization agents, post-embolization transfusion requirement, complications and the outcome were recorded.

RESULTS

A total of 46 patients, aged 26-73 years, underwent SRAE because of hemorrhage after percutaneous nephrolithotomy (n = 25), partial nephrectomy (n = 6), renal biopsy (n = 2), trauma (n = 2), rupture of angiomyolipoma (n = 4), renal aneurysm (n = 1), and renal ateriovenous malformations (n = 6). A total of 41 patients (80.8 %) underwent successful embolization. Treatment failed in 5 patients with hemorrhage caused by percutaneous nephrolithotomy. Of these, four patients underwent a secondly superselective embolization and had a successful outcome. The remaining one was managed by conservative therapy with repeated blood transfusions. No patient required nephrectomy to save the life of the patient. No serious procedure-related complications occurred.

CONCLUSIONS

SRAE is an effective and minimal invasive method for the control of renal hemorrhage. Our experience strongly recommended the first-line use of SRAE for severe renal hemorrhage.

Monoplanar access technique for percutaneous nephrolithotomy

Percutaneous renal access is the most important step in percutaneous nephrolithotomy (PNL), and the adequacy of access directly affects the success and complication rates of this procedure. We use a monoplanar access technique that is different from biplanar method in that we utilize only fluoroscopic projections maintained on a vertical plane. The aim of this study is to evaluate the effects of this monoplanar access technique on operative outcomes. From October 2009 to December 2011, a total of 200 patients who had renal stones and underwent monoplanar PNL which done by the same surgical team were included in this study. Patient and procedure-related factors were recorded, as well as perioperation and postoperation variables such as operation time, puncture time, fluoroscopy screening time, complication rates, success rates, and duration of hospitalization. The average patient age at the time of procedure was 30.32 years. Mean operation and puncture time were 79.8 and 0.83 min, respectively. Stone-free rate was 80.5 % in postoperative day 1. After additional procedures such as shock wave lithotripsy (SWL), ureterorenoscopy and re-PNL final success rate was 98 % at third month including patients with clinically insignificant residual fragments. There were no severe complications except one patient in whom adjacent organ injury (colon) was observed. Monoplanar access is a safe and effective technique in PNL procedure. Furthermore less puncture time is an advantage of this technique.

Migrated embolization coil: A rare cause of urinary tract obstruction

Refractory bleeding following percutaneous nephrolithotomy (PCNL) is mainly due to formation of pseudoaneurysm. Transarterial embolization is required to control the bleeding in such cases. We report a case of post-PCNL hematuria in whom angioembolization was done. An early erosion of the embolization coil from the renal vasculature into the urinary collecting system occurred, causing urinary tract obstruction and urinary tract infection (UTI). The coil was retrieved ureteroscopically after control of UTI with antibiotics. Migration of embolization coil into urinary collecting system is a rare but important cause of urinary tract obstruction. The treating physician as well as the patient should be aware of this complication.

Percutaneous nephrolithotomy in patients on chronic anticoagulant/antiplatelet therapy

Percutaneous nephrolithotomy (PCNL) is an integral component in the management of large volume renal stone disease either as monotherapy or in combination with shock wave lithotripsy. Stone disease in patients on chronic anticoagulation/antiplatelet therapy, however, poses a difficult scenario. Bleeding is a major concern for any patient undergoing PCNL. We retrospectively analyzed our series of patients with renal calculi who were on chronic anticoagulant therapy and who underwent PCNL. We reviewed the case records of patients undergoing PCNL during the period from January 2005 to December 2011. We analyzed the changes in preoperative and postoperative hemoglobin, serum creatinine, and clotting parameters, as well as intraoperative and postoperative bleeding and thromboembolic complications. During the 5-year study period, a total of 36 patients (30 males and 6 females) with a mean age of 46.33±9.96 years (range, 29-61 years) who were on chronic anticoagulant/antiplatelet therapy underwent PCNL for urolithiasis. The mean size of the stone was 6.40±1.98 cm² (range, 2.8-9 cm²). The mean operating time was 62.08±10.10 min. The bleeding was successfully managed in all patients and the anticoagulant/antiplatelet agents were restarted after an appropriate duration. The mean rise in serum creatinine at discharge was 0.05±0.03 mg/dl and the mean fall in serum hemoglobin was 1.63±0.77 g/dl. At 3 months after surgery, the stone-free rate was 100%. With careful preoperative care and regulation of anticoagulation/antiplatelet therapy and appropriate intraoperative management, PCNL can be performed safely and successfully in properly selected patients with renal calculi who are on chronic anticoagulant/antiplatelet therapy.

Chinese minimally invasive percutaneous nephrolithotomy for intrarenal stones in patients with solitary kidney: a single-center experience

OBJECTIVE

To report our experience with Chinese minimally invasive percutaneous nephrolithotomy (Chinese MPCNL) to manage patients with intrarenal stones in solitary kidney, and evaluate the safety, efficiency and feasibility of this technique.

METHODS

Forty-one patients with intrarenal stones in solitary kidney underwent Chinese MPCNL in our department from March 2009 to February 2011. Demographic characteristics, operative parameters, number of tracts, stone-free rates (SFRs), stone analyses, hemoglobin levels, nephrostomy tube removal time, hospitalization time, and complications were evaluated. Serum creatinine (Scr) and glomerular filtration rate (GFR) were measured preoperatively, postoperatively at 1 month, and each follow-up visit. The 5-stage classification of chronic kidney disease (CKD) was used according to the National Kidney Foundation guidelines.

RESULTS

The initial stone-free status was achieved in 35 (85.4%) patients after Chinese MPCNL. The mean follow-up time was 16.9 ± 4.7 months (range: 12-24), and the final SFR improved to 97.6% after auxiliary procedures. Among all patients, complex stones were detected in 26 (63.4%) patients, and 9 (22.0%) required multiple tracts. The mean operative time and mean hospitalization time were 71.3 ± 23.5 min (range: 40-139) and 6.1 ± 0.5 days (range: 5-11), respectively. During preoperative period and postoperative period (1 month), Scr were 132.1 ± 41.3 umol/L (range: 78.2-231.4) and 108.9 ± 30.7 umol/L (range: 71.6-136.9), respectively (P<0.05), while GFR were 74.9 ± 24.2 ml/min (range: 35-110) and 83.9 ± 27.4 ml/min (range: 65-110), respectively (P<0.05). According to CKD classification, the renal function was stable, improved, and worse in 29 (70.7%), 11 (26.8%), and 1 (2.5%) patients, compared with the preoperative levels. No patient progressed to end-stage renal disease requiring dialysis.

CONCLUSIONS

Our experience with Chinese MPCNL demonstrates that it is safe, feasible and efficient for managing the intrarenal calculi in solitary kidney with a low complication rate. At long-term follow-up, renal function stabilized or even improved in the majority of patients with solitary kidney.

Dengue hemorrhagic fever as a rare cause of bleeding following percutaneous nephrolithotomy

Post percutaneous nephrolithotomy (PNL) bleeding is an uncommon yet serious complication and is almost always related to a surgical cause. Nevertheless, medical cause of bleeding is rarely encountered as a cause of this dangerous complication. Dengue has been rarely reported as a cause of post operative bleeding. Bleeding diathesis in dengue occurs not only due to thrombocytopenia but also due to dysfunctional surviving platelets and increased fibrinolysis. We report a patient who developed bleeding after an uneventful PNL due to dengue hemorrhagic fever. Medical causes of bleeding such as locally endemic viral hemorrhagic fevers should also be kept in mind and evaluated especially when a surgical cause of the bleed is not found or suspected in bleeding after any surgery.

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.

Radiological treatment of a spontaneously ruptured inferior adrenal artery aneurysm

BACKGROUND

A 70-year-old man with a history of hypertension presented with severe epigastric discomfort that radiated to his back. CT revealed cystic kidney disease and a large retroperitoneal hemorrhage, and CT angiography identified an active bleeding point in the region of the left adrenal gland. Selective left renal angiography identified a small inferior adrenal artery aneurysm with active hemorrhage. The patient underwent successful transcatheter embolization with microcoils and polyvinyl alcohol microparticles to control the bleeding.

INVESTIGATIONS

Blood tests, urinalysis, electrocardiography, triphasic CT with CT angiography.

DIAGNOSIS

Ruptured left inferior adrenal artery aneurysm.

MANAGEMENT

Access to the inferior adrenal artery was achieved with a microcatheter, followed by transcatheter embolization using a combination of polyvinyl alcohol microparticles distally and microcoils proximally to the aneurysm.

Percutaneous nephroscopic surgery

With the development of techniques for percutaneous access and equipment to disintegrate calculi, percutaneous nephroscopic surgery is currently used by many urologists and is the procedure of choice for the removal of large renal calculi and the management of diverticula, intrarenal strictures, and urothelial cancer. Although it is more invasive than shock wave lithotripsy and retrograde ureteroscopic surgery, percutaneous nephroscopic surgery has been successfully performed with high efficiency and low morbidity in difficult renal anatomies and patient conditions. These advantages of minimal invasiveness were rapidly perceived and applied to the management of ureteropelvic junction obstruction, calyceal diverticulum, infundibular stenosis, and urothelial cancer. The basic principle of endopyelotomy is a full-thickness incision of the narrow segment followed by prolonged stenting and drainage to allow regeneration of an adequate caliber ureter. The preferred technique for a calyceal diverticulum continues to be debated. Excellent long-term success has been reported with percutaneous, ureteroscopic, and laparoscopic techniques. Each approach is based on the location and size of the diverticulum. So far, percutaneous ablation of the calyceal diverticulum is the most established minimally invasive technique. Infundibular stenosis is an acquired condition usually associated with inflammation or stones. Reported series of percutaneously treated infundibular stenosis are few. In contrast with a calyceal diverticulum, infundibular stenosis is a more difficult entity to treat with only a 50-76% success rate by percutaneous techniques. Currently, percutaneous nephroscopic resection of transitional cell carcinoma in the renal calyx can be applied in indicated cases.

Should percutaneous nephrolithotripsy be considered the primary therapy for lower pole stones?

PURPOSE

The efficacy of percutaneous nephrolithotripsy (PCNL) as a primary therapy for the treatment of lower pole caliceal lithiasis was determined.

MATERIALS AND METHODS

We reviewed 144 consecutive files of patients, over a period of 10 years, with noncomplicated lower pole calculi, who underwent PCNL after a single unsuccessful session of extracorporeal shockwave lithotripsy (SWL).

RESULTS

The stone-free rate for stones less than 10 mm was 95%. A 97% rate was accomplished for stones between 11 and 20 mm and a 98% rate for stones larger than 20 mm. PCNL achieved a mean overall stone-free rate of 96.7% after a 3-month follow-up, regardless of stone size. PCNL outclasses SWL, when stratified by stone burden and lower pole location. No significant postoperative complications were encountered.

CONCLUSION

PCNL is a safe and effective procedure for the management of lower pole caliceal calculi after a single unsuccessful SWL session. This procedure should be considered the primary method for the treatment of lower pole stones.

Impact of percutaneous access point number and location on complication and success rates in percutaneous nephrolithotomy

OBJECTIVES

Percutaneous nephrolithotomy (PNL) is sometimes associated with complications, especially in patients with complex stones. Herein, we review our experience with PNL to determine the impact of percutaneous access number and location on success and complication rates.

PATIENTS AND METHODS

During a 2-year period, a total of 275 patients with a mean age of 42.3 +/- 14.8 (range: 13-75) years underwent PNL. Stones were classified as simple in 51.6%, and complex (staghorn calculi or renal pelvis stones coexisting with caliceal stones) in 48.4%. Percutaneous access was done under C-armed fluoroscopy and the tract was formed with a high-pressure balloon dilation system. One single percutaneous access was sufficient in 210 (76.4%), while 2 accesses were utilized in 44 (16%), and > or =3 accesses in 21 cases (7.6%). Supracostal access was performed in 23 (8.4%) patients.

RESULTS

An overall success rate of 94.9% was achieved. Stone location, but not the access point location, was the major determinant for success, which was 99.3 and 90.2% in patients with simple and complex stones, respectively (p < 0.01). Significant complications included bleeding necessitating blood transfusion in 28 (10.2%), and hydropneumothorax in 2 (0.7%) patients. Bleeding was observed in 39.1 and 7.5% of patients managed with supracostal access, and subcostal access, respectively (p < 0.01). An increased number of access points significantly augmented the risk for bleeding. Bleeding was encountered in 7.6% of patients managed with 1 percutaneous access point, and in 18.5% of cases managed with > or =2 access points (p < 0.05). Hydropneumothorax occurred in patients with supracostal access.

CONCLUSION

Supracostal access as well as multiple punctures may be needed especially in the management of complex stones, and the need for multiple access points and supracostal access significantly increases complication rates.

Endovascular control of haemorrhagic urological emergencies: an observational study

BACKGROUND

Transarterial embolisation (TAE) is an effective method in control of haemorrhage irrespective of the nature of urological emergency. As the technique and technology have evolved, it is now possible to perform highly selective embolisation. The aim of this study was to critically appraise feasibility and efficacy of therapeutic TAE in control of haemorrhagic urological emergencies using selective and non-selective embolisation. Specifically, we aimed to assess the impact of timing of embolisation on the requirement of blood transfusion and long-term morphological and functional follow-up of embolised organs.

METHODS

This is a single institutional observational study carried out between March 1992 and March 2006. Records of all patients who underwent selective and non-selective angioembolisation to control bleeding in urological emergencies were reviewed. Data on success rate, periprocedural complications, timing of embolisation, requirement of blood transfusion and the long-term morphological and functional outcomes of embolised organs was recorded.

RESULTS

Fourteen patients underwent endovascular control of bleeding as a result of trauma, iatrogenic injury and spontaneous perinephric haemorrhage during a period of 14 years. All these patients would have required emergency open surgery without the option of embolisation procedure. The mean time between the first presentation and embolisation was 22 hours (range 30 minutes to 60 hours). Mean pre-embolisation transfusion requirement was 6.8 units (range 0-22 units). None of the patients with successful embolisation required post-procedural blood transfusion. Permanent haemostasis was achieved in all but one patient, who required emergency nephrectomy. There were no serious procedure related post-embolisation complications.

CONCLUSION

Endovascular control using transarterial angioembolisation is an effective method for managing haematuria or haemorrhage in urological emergencies. Wherever and whenever indicated, this option should be considered early in the management of these cases.

The "mini-perc" technique of percutaneous nephrolithotomy with a 14-Fr peel-away sheath: 3-year results in 72 patients

OBJECTIVE

To assess the efficacy and safety of a "mini-perc" technique of percutaneous nephrolithotomy using a 14-Fr peel-away sheath for the removal of pyelocaliceal stones, and to determine appropriate inclusion criteria.

MATERIALS AND METHODS

From July 1999 to June 2002, the medical records and radiographic images of 72 patients who underwent the "mini-perc" technique of percutaneous nephrolithotomy with a 14-Fr peel-away sheath, were reviewed to determine clinical history, stone characteristics, immediate stone free rate, final stone free rate after additional procedures, complications, and hospital stay. We also analyzed the effect of the longest stone diameter, the cumulative longest diameter of stones, the cumulative stone burden, and the stone density on the immediate stone free rate using a Fisher exact test.

RESULTS

The only major complication, arterial bleeding, occurred in a patient with Child A liver cirrhosis and was successfully treated by embolization with coils and a gelatin sponge. The immediate stone free rate was 80.6 %, which was significantly influenced by stone diameter but not stone density. The mean hospital stay after the procedure was 3.97 days.

CONCLUSION

The "mini-perc" technique of percutaneous nephrolithotomy, which uses the 14-Fr peel-away sheath, is a safe and effective modality for treating renal calculi.

Nephrostomy tract dilation using a balloon dilator in percutaneous renal surgery: experience with 95 cases and comparison with the fascial dilator system

INTRODUCTION

Nephrostomy tract dilation is one of the important steps of percutaneous renal surgery. In this study, we present our initial experience with the balloon dilator in 95 patients and compare our results retrospectively with a group of 30 patients in whom Amplatz dilators were used.

PATIENTS AND METHODS

The medical records of 95 patients who underwent percutaneous renal operations, including percutaneous nephrolithotomy and antegrade endopyelotomy, between September 1999 and September 2002 were reviewed. All procedures were performed using balloon dilators. The operative technique is the same as the other dilation procedures. Thirty consecutive patients who had previously undergone percutaneous renal surgery using the Amplatz dilators were taken as the control group and their charts were reviewed retrospectively, and the results compared with the results of patients in whom balloon dilation was used.

RESULTS

There were no major perioperative complications or deaths in both groups. The mean operative time and tract formation times for the balloon dilation group and the Amplatz dilation group were 106.8 +/- 41.4 and 11.2 +/- 3.0, and 116.4 +/- 23.7 and 16.3 +/- 2.4 min, respectively. Thirteen (13.7%) patients had significant bleeding and required blood transfusion in the balloon dilation group, whereas 5 (16.6%) patients had significant bleeding in the Amplatz dilation group. Collecting system perforation due to too far advancement of the dilator occurred in 11 (11.6%) patients but there was no major parenchymal or vascular injury medially in the balloon dilation group. On the other hand, collecting system perforation occurred during sequential Amplatz dilation in 5 (16.6%) patients.

CONCLUSION

We believe that the balloon system allows one-step dilation and shortens the dilation procedure. It may minimize bleeding which can occur during the stepwise fascial dilation. When using fascial dilators it is sometimes possible to go out of the collecting system by changing the size of the dilators. We think that balloon dilation may prevent these intraoperative and time-consuming situations.

Vascular injuries after percutaneous renal procedures: treatment by transcatheter embolization

Percutaneous renal procedures have become the standard technique for diagnosis and treatment of a number of renal pathologies. Hemorrhage and vascular lesions are the most serious complications. We report our experience with 15 patients treated by hyperselective vascular embolization. Fifteen patients (10 men and 5 women; mean age 55 years) had severe perioperative hemorrhage after percutaneous renal procedures, due to arterial renal major injury. All patients underwent duplex US, CT, and renal arteriography demonstrating the presence of arteriovenous fistulas (n=2), renal hematoma (n=3), pseudoaneurysms (n=3), and hematoma with pseudoaneurysm (n=7). Four patients showed transient renal dysfunction, with an increase in serum creatinine levels. One patient had a solitary transplanted kidney. Hyperselective arterial embolization was performed successfully by means of coils (n=14), associated with gelfoam in 4 cases; homologous blood clot was used in 1 patient. No major complications occurred, and renal function rapidly normalized in the 4 patients with transient renal failure. Imaging follow-up confirmed the successful devascularization of the lesion. Renal arterial hemorrhage following percutaneous procedures is a rare but severe complication. Hyperselective renal artery embolization, with particles and/or coils, represents the first-choice treatment option, being safe and effective in stopping the bleeding.

Severe renal bleeding caused by a ruptured renal sheath: case report of a rare complication of percutaneous nephrolithotomy

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.

Haemorrhagic complications of percutaneous lithotripsy: original methods of treatment

698 patients treated for nephrolithiasis with the application of percutaneous lithotripsy were analysed. In 32 cases increased bleeding in the course of the procedure occurred. It was controlled without surgery with blood transfusion, constant renal saline flow maintenance, electrocoagulation, kidney parenchyma pressing with thick drain and approach canal tamponade. In one case the approach to the kidney was obtained surgically and the kidney parenchyma was stitched with haemostatic suture. One patient required selective embolization due to kidney haemorrhage after nephrostomy drain removal.