Outcomes of percutaneous nephrolithotomy: Comparison of elderly and younger patients

Efficacy and safety of percutaneous nephrolithotripsy in elderly patients: a retrospective study

Background

Percutaneous nephrolithotripsy (PCNL) is difficult to perform for elderly patients; thus, this study aimed to assess its efficacy and safety in elderly patients aged > 70 years, note any associations between outcomes and patient characteristics, and summarize relevant themes and observations.

Methods

Data from patients older than 70 years who had undergone PCNL for upper urinary tract calculi between January 2016 and January 2021 was retrospectively analyzed. Risk factors for postoperative complications and residual stones were analyzed using multivariate logistic regression.

Results

A total of 116 elderly patients underwent 122 PCNL operations, of which six underwent secondary PCNL operations, and all of which were successfully completed. The average age was 74.6 ± 4.3 years; the average stone size and operation time were 3.5 ± 1.8 (1.2–11 cm), and 71.8 ± 34.1 min, respectively. Of the participants, 16 or 13.8% had postoperative complications and 29 (25%) had residual stones after operation. The stone free rate was 75%. Multivariate analysis revealed that an American Score of Anesthesiology III was an independent risk factor for postoperative complications (odds ratio [OR] = 4.453, p = 0.031), and staghorn calculi were independent risk factors for postoperative residual calculi (OR = 31.393, p = 0.001).

Conclusion

PCNL was shown to be safe and effective for elderly patients aged > 70 years. Further, ASA III was an independent risk factor for postoperative complications, and staghorn calculi were independent risk factors for postoperative residual calculi in elderly patients.

Ultrasound-guided percutaneous nephrolithotomy without indwelling ureteral catheter in older adults with upper urinary calculi: A retrospective study

Retention of ureteral catheter to establish artificial hydronephrosis is a routine step of percutaneous nephrolithotomy procedure, which can improve the success rate of puncture, but it can prolong the procedure time and increase the risk of postoperative infection, especially for immunocompromised elderly patients. Therefore, this study aims to investigate the safety and effectiveness of ultrasound-guided percutaneous nephrolithotomy without indwelling ureteral catheter for older patients with upper urinary calculi. The clinical data of 119 older patients admitted to the Affiliated Hospital of Jining Medical University for percutaneous nephrolithotomy from January 2019 to December 2021 were retrospectively analyzed. The patients were divided into study and control groups according to whether the physician decided to use ureteral catheter during the procedure, and the differences in the success rate of one-time puncture, operative time, single-stage stone removal rate, postoperative hospital stay, and complication rate were compared between the 2 groups. There were no significant differences in the success rate of one-time puncture and single-stage stone removal rate between the 2 groups (P > .05). The operation time were significantly shorter in the study group [(30.0-61.0) minute vs (54.8-106.8) minute, P = .00], and the intraoperative bleeding was less in the study group [(5-20) mL vs (10-30) mL, P = .03]. The postoperative hospital stay was shorter in the study group [(2.5-4.0) days vs (3.0-5.0) days, P = .00], and the medical expenses were lower in the study group [(17,309.5-22,652.7) yuan vs (19,148.0-24,407.6) yuan, P = .02]. The incidence of systemic inflammatory response syndrome was lower in the study group (3.5% vs 19.4%, P = .007). There were no statistically significant differences in complications such as postoperative fever, renal artery embolism and blood transfusion between the two groups (P > .05). Ultrasound-guided percutaneous nephrolithotomy without indwelling ureteral catheter for elderly patients with upper urinary stones is safe and feasible.

Comparison of Outcomes of Percutaneous Nephrolithotomy (PCNL) Between Adults and Pediatrics Population: A Single-Center Retrospective Study

Introduction: Percutaneous nephrolithotomy (PCNL) has almost completely replaced open surgery for kidney stones because of continuous advancements in the method since the first PCNL was performed in 1976. The aim of this study is to compare the characteristics and outcomes of adult patients and pediatric patients who had undergone PCNL.

Methodology: A retrospective study was conducted at the Sindh Institute of Urology and Transplantation (SIUT) Hospital in Karachi, Pakistan. It included the data of patients who underwent PCNL from January 2015 to January 2022 at the SIUT hospital. The primary outcome variable was the stone-free rate (SFR). Secondary outcomes included length of hospital stay, and complications were assessed using modified Clavien classification system

Results: There is no significant difference in the SFR at discharge between pediatric and adult patients (86.67% vs 88.69%, p=0.634). There is no significant difference between the two groups in relation to the total length of hospital stay (p=0.446). Moreover, 12.50% and 11.11% of adults and children developed complications, respectively, after the procedure. The percentages are not significantly different between the two groups (p=0.266).

Conclusion: The current study using standardized and consistent PCNL techniques shows that SFR is similar in both adults and children, and there is no difference in complications between adults and children.

Comparison of mini-PCNL and retrograde intrarenal surgery in the treatment of kidney stone over 50 years old patients

Mini-Percutaneous Nephrolithotomy (M-PCNL) and Retrograde Intrarenal Surgery (RIRS) are commonly used methods in treatment of kidney stones. The aim of our study is to compare the efficacy and safety of M-PCNL and RIRS in kidney stone treatment over 50 years old patients. A total of 125 patients, 65 of whom had RIRS, and 60 of whom had M-PCNL, were included in the study. Age, gender, BMI (Body-Mass Index), ASA (American Society of Anesthesiology) scores of the patients; stone size, stone location, operation side, ESWL history, HU (Hounsfield Unit) values, hospital stay durations, SFR, complication rates according to Clavien modification system, postoperative hemoglobin loss, postoperative transfusion rates, and patients who needed a secondary operation were recorded. SFR values were calculated in the postoperative third and sixth months. The data between the two groups had similar characteristics in terms of age, gender, BMI, HU, stone size, operation side, stone location, ESWL history, operation time, postoperative transfusion rate, postoperative Clavien complications (p > 0.05). When the ASA categories were evaluated, the mean ASA scores, ASA I, and ASA II data had similar characteristics in both groups (p > 0.05). When the ASA 3 scores were evaluated, the number of ASA III patients in the RIRS group was statistically significantly higher (p < 0.05). When hospital stay duration and postoperative hemoglobin loss were examined, RIRS group was found to be advantageous (p < 0.05). Postoperative third month SFR and Postoperative sixth month values were statistically significantly higher in M-PCNL group (p < 0.05). M-PCNL and RIRS are methods that can be used safely and effectively over 50 years old patients in kidney stone surgery. M-PCNL has been found to be more advantageous in terms of SFR rates and as it requires less secondary intervention. RIRS is advantageous in terms of short hospital stay, postoperative hemoglobin loss, and applicability to patients who are not suitable for the prone position.

Utility of Frailty Assessment in Urologic Stone Surgery: A Review of the Literature

Introduction & Objective As life expectancy continues to rise, the prevalence of frailty is also increasing. The idea of frailty and its effect on the operative patient has been previously studied, but not regularly incorporated into routine practice. We present a review on frailty metrics in the literature, validated assessment methods, and simplified screening tools, to better predict and optimize patient outcomes. Methods An online Pubmed search was conducted by 3 authors (TA, TB, MM) for all frailty, frailty assessment, and pre-operative risk assessment. Only English publications were included in the analysis. Full text analysis was then conducted by all three authors to validate the data. Results An abundance of literature was found on frailty. Even though some methods are validated as very effective for assessing frailty, they may be time consuming and require a specialist. various quick screening methods are also present, many already validated, and should be utilized by urologist more regularly. Conclusions Multiple studies demonstrate the relationship between frailty and surgical patients' outcome. Many quick, office based, validated tools to screen for frailty are described, and should be incorporated into our practice in appropriate patients. Future research is now focused on the concept of "prehabilitation" to improve patient frailty status in the pre-operative setting, and consequently operative outcomes.

Frailty as predictor of complications in patients undergoing percutaneous nephrolithotomy (PCNL)

INTRODUCTION & OBJECTIVE

Surgical complications are difficult to predict, despite existing tools. Frailty phenotype has shown promise estimating postoperative risk among the elderly. We evaluate the use of frailty as a predictive tool on patients undergoing percutaneous renal surgery.

METHODS

Frailty was prospectively analyzed using the Hopkins Frailty Index, consisting of 5 components yielding an additive score: patients categorized not frail, intermediate, or severely frail. Primary outcomes were complications during admission and 30-day complication rate. Secondary outcomes included overall hospital length of stay (LOS) and discharge location.

RESULTS

A total of 100 patients recruited, of whom five excluded as they did not need the procedure. A total of 95 patients analyzed; 69, 10, and 16 patients were not frail, intermediate, and severely frail, respectively. There were no differences in blood loss, number of dilations, presence of a staghorn calculus, laterality, or location of dilation. Severely frail patients were likely to be older and have a higher American Society of Anesthesiologists score and Charlson comorbidity index. Patients of intermediate or severe frailty were more likely to exhibit postoperative fevers, bacteremia, sepsis, and require ICU admissions (P < 0.05). Frail patients had a longer LOS (P < 0.001) and tended to require skilled assistance when discharge (p < 0.0001).

CONCLUSIONS

Frailty assessment appears useful stratifying those at risk of extended hospitalization, septic complications, and need for assistance following percutaneous renal surgery. Risks of sepsis, bacteremia, and post-operative hemorrhage may be higher in frail individuals. Preoperative assessment of frailty phenotype may give insight into treatment decisions and represent a modifiable marker allowing future trials exploring the concept of "prehabilitation".

Percutaneous nephrolithotomy is safe and effective in aging male patients: a single center experience

OBJECTIVE

To assess the safety and effectiveness of percutaneous nephrolithotomy in aging male patients.

METHODS

Two hundred eighty-three male patients over the years of forty undergoing percutaneous nephrolithotomy between December 2009 and September 2014 were evaluated, retrospectively. The patients were stratified by four age groups [40-49 (group-1), 50-59 (group-2), 60-69 (group-3), ≥70 years (group-4)]. The groups were compared regarding stone size, mean operation time, mean access number, mean nephrostomy removal time, hospitalization duration, stone-free rate, and complications rate. The patients were also evaluated with regard to glomerular filtration rate levels preoperatively and in the sixth month after surgery.

RESULTS

Mean stone size was 810 ± 490 mm² in group-1, 840 ± 500 mm² in group-2, 845 ± 480 mm² in group-3, and 800 ± 460 mm² in group-4 (p = .02). There was no statistical difference between the four groups in terms of mean operation time, access number, hemorrhage, nephrostomy removal time, and hospital stay duration (p > .05). After additional interventions; no significant difference was detected for final stone-free rates among the groups (p = .12). A significant improvement was detected in glomerular filtration rate levels in the sixth month after surgery in all groups (p < .05).

CONCLUSION

These results indicate that percutaneous nephrolithotomy is a safe and effective method in aging male patients.

The safety and effectiveness of percutaneous nephrolithotomy in solitary kidney aging male patients: our single-center experience

OBJECTIVE

To assess the safety and effectiveness of percutaneous nephrolithotomy (PCNL) in aging male patients with a solitary kidney.

METHODS

Among the patients undergoing PCNL between December 2009 and September 2014, 16 patients with solitary kidney (group 1) over the age of 40 were included in the analysis. Twenty patients with bilateral kidney patients (group 2) were included in the analysis, which constituted an age-matched control group. The patients' characteristics, stone characteristics, intraoperative and postoperative outcomes, including bleeding and transfusion rates, operative time, complications, hospital stay, stone-free rates (SFR) and renal function were evaluated.

RESULTS

Mean age of the patients in groups 1 and 2 were 63.7 (range 48-73) and 64.8 (range 48-77). Mean stone size was 814 ± 390 mm² in group 1, and 820 ± 405 mm² in group 2 with no statistical significance (p = .35). The final SFR in the solitary kidney and bilateral kidney group was 87.5 and 90% (p = .07). Bleeding requiring transfusion, prolonged leakage from nephrostomy tract, mean operation time and access number were comparable between two groups (p > .05). However, the nephrostomy removal and hospital stay time were longer in the solitary kidney group (p < .05). The rate of perioperative DJ insertion was also higher in solitary kidney patients. A significant improvement was detected in creatinine and glomerular filtration rate levels in the sixth months after surgery in solitary kidney patients (p < .05).

CONCLUSION

These results indicate that PCNL is a safe and effective method in aging male patients with a solitary kidney.

Outcomes of percutaneous nephrolithotomy in elderly versus young patients under regional anesthesia: A comparative study

Introduction

Surgical management of elderly patients with renal calculi is inherently challenging. We compared the efficacy and safety of percutaneous nephrolithotomy (PCNL) performed under regional anesthesia between elderly patients (age >65 years) and patients aged <65 years.

Materials and Methods

Between July 2015 and June 2016, fifty patients aged >65 years with renal stones (size >1.5 cm) were treated with PCNL under regional anesthesia (elderly group). We retrospectively compared the outcomes with those obtained in an equal number of patients aged <65 years (younger group) who underwent PCNL under regional anesthesia. Patients with staghorn stones and pyonephrosis and falling under the American Society of Anesthesiologists (ASA) Grade IV were excluded. Data pertaining to demographic characteristics, body mass index, stone bulk, operative time, tract size, number of tracts required, blood loss, clearance rates, complications, and length of hospital stay were analyzed.

Results

The mean age at presentation in the elderly and younger groups was 66.8 ± 2.1 years and 38.7 ± 11 years, respectively; 56% of the patients in the elderly age group had ASA Grade II, whereas 58% in the younger age group had ASA Grade I. The mean stone size and the number of tracts were comparable in both the groups, whereas operative time was slightly longer in the elderly group (58.54 ± 18 vs. 51.98 ± 18 min; P < 0.05). Postoperative complications and stone-free rates (94% vs. 92%, respectively) were comparable in the two groups.

Conclusions

Age itself should not deter the treatment of elderly patients with renal stones as PCNL under regional anesthesia is safe and effective in elderly patients; outcomes in elderly and younger patients were comparable in this study.

Percutaneous Nephrolithotomy in the 80 Years of Age and Older Population

OBJECTIVE

To evaluate feasibility of percutaneous nephrolithotomy (PCNL) for complex nephrolithiasis in patients 80 years of age and older compared to younger individuals.

METHODS

From an institutional IRB-approved database, 1,647 patients were identified who underwent PCNL from 1999 to 2019. Patients were stratified by age: group 1 (20-59), group 2 (60-79), and group 3 (>80). Statistics were performed using chi-square and ANOVA to compare outcomes.

RESULTS

Of the 1,647 patients, median age was 46, 66, and 83, respectively (P <0.0001). Three patients within group 3 were 90 or older. Females made up 54%, 46%, 56% of patients (P = 0.02). Average stone size with SD was 2.6 ± 2.2, 2.5 ± 2.3, 2.2± 1.9 cm for each group (P = 0.06). Mean preoperative hemoglobin (Hgb) was significantly lower in the 80+ group (13.8, 13.4, 13.1 g/dL, P <.0001). Change in Hgb was not significantly different. There were more Clavien II-IV complications (10.4, 14.4, 28.8%; P = 0.02) and transfusions (2.3, 4.7, 10.2%; P <0.001) in the elderly. The most common complications in the 80+ group were bleeding related (10.1%). No difference in readmission rates or ICU admissions was noted.

CONCLUSION

PCNL is feasible in the extremely elderly; however with a higher rate of complications and longer hospitalizations. No long-term sequelae or deaths in the 80 and older cohort were seen. This study allows us to appropriately counsel older patients on a realistic postoperative course and supports use of PCNL as the best means of long-term survival.

Contemporary best practice in the management of staghorn calculi

Staghorn calculi are complex renal stones that occupy the majority of the renal collecting system. These stones are associated with high morbidity and can lead to recurrent urinary tract infections, urosepsis, renal deterioration, and death if left untreated. Managing patients with staghorn calculi can be challenging. Fortunately, advances in technology and endourology techniques have enabled urologists to effectively treat these stones with minimal morbidity to the patient. This article describes the contemporary best practices in the initial evaluation, management, and follow up of patients with staghorn calculi to help the practicing urologist navigate this complex condition.

Ureteroscopy and stone treatment in the elderly (≥70 years): prospective outcomes over 5- years with a review of literature

Objective:

To assess outcomes of ureteroscopy for treatment of stone disease in the elderly. Ureteroscopy (URS) is an increasingly popular treatment modality for urolithiasis and its applications are ever expanding with the development of newer technologies. Its feasibility and outcomes within the elderly population to our knowledge remain under-reported.

Materials and Methods:

We examined the patient demographics and surgical outcomes from our prospective database for patients ≥70 years who underwent URS for urolithiasis, in a 5-year period between March 2012 and December 2016.

Results:

A total of 110 consecutive patients underwent 121 procedures (1.1 procedure/patient) with a mean age of 77.2 years (range: 70-91 years). Stone location was in the kidney/ pelviureteric junction (PUJ) in 29%, ureter in 37% and in multiple locations in 34%. The initial and final stone free rate (SFR) was 88% and 97% respectively. While 73% were done as true day case procedures, 89% patients were discharged within 24 hours. Eleven patients (9%) underwent complications of which 10 were Clavien I/II including acute urinary retention, urinary tract infection, stent symptoms and pneumonia. One patient underwent Clavien IV complication where they needed intensive care unit admission for urosepsis but fully recovered and were discharged home subsequently.

Conclusion:

Ureteroscopy is a safe and effective method of managing urolithiasis in elderly patients. Although most patients are discharged within 24-hours, consideration needs to be made for patients where social circumstances can impact their discharge planning.

A retrospective, observational study of supine percutaneous nephrolithotomy

Objective:

The objective of this study is to assess stone clearance and perioperative complication rates of supine percutaneous nephrolithotomy (PCNL).

Methods:

This was a retrospective, observational study of supine PCNL performed in a surgical unit at a district general hospital by two surgeons in the United Kingdom. Data collected included patient demographics, comorbidities, complexity of renal calculi, perioperative complications and stone clearance rates.

Results:

A total of 112 supine PCNL procedures were observed in this study. The mean (SD) American Society of Anesthesiologists (ASA) grade and Guy’s Stone Score were 2.0 (0.75) and 2.3 (1.06) respectively. The median (interquartile range (IQR)) duration of in-patient admission was four (one) nights. Complete stone clearance was achieved in 74 (67.3%) of the procedures, while more than 90% clearance of the renal stone burden was achieved in a further eight (7.3%). The most common perioperative complications recorded were blood loss requiring blood transfusion (three (2.7%)) and postoperative fever (two (1.8%)).

Conclusion:

This case series shows that supine PCNL can lead to good stone clearance and low complication rates.

Percutaneous Nephrolithotomy in Immunocompromised Patients: Outcomes from a Matched Case-Control Study

OBJECTIVE

To compare the outcomes of percutaneous nephrolithotomy (PCNL) in immunocompromised patients with those of PCNL in healthy population.

PATIENTS AND METHODS

A matched case-control study was performed from January 2009 through December 2014 using our prospectively collected kidney stone database. Patients with positive serology to human immunodeficiency virus (HIV), hepatitis C (cellular immune dysfunction), and patients on high dose of immunosuppressive drugs for treatment of autoimmune diseases composed the case group. Control group included patients with kidney stones and no other comorbidity. Patients were randomly matched based on Guy's score as a surrogate of case complexity.

RESULTS

Sixty-two patients were enrolled in this study, 21 cases and 42 controls. There were no significant differences in age, gender, and body mass index between groups. Regarding PCNL technique, there were no differences in patient positioning, number of accesses, and operative time. Complication rate was higher in the case group (38.1% vs 14.3%; p = 0.032); however, major complications, defined by Clavien score ≥3, were not statistically different (4.8% vs 2.4%; p = 0.611). There was a tendency of more postoperative urinary tract infection in the case group (19% vs 4.8%; p = 0.069). Mean decrease in hemoglobin level (3.3 vs 2.4 mg/dL; p = 0.037) and blood transfusion rate (23.8% vs 4.8%; p = 0.036) was significantly higher in the case group. Immunocompromised patients had a 2.8-fold increased risk of complications (odds ratio [OR] = 2.0, 95% confidence interval [CI] 1.01, 7.74) and a 5.8-fold increased risk of blood transfusion (OR = 5.8, 95% CI 1.29, 26.55). There were no differences in stone-free rate, nephrostomy tube time, and length of hospital stay.

CONCLUSION

Immunocompromised patients are at higher risk for complications such as bleeding after PCNL.

Does aging affect the outcome of percutaneous nephrolithotomy?

To investigate whether aging affects surgical outcomes by comparing the results of two patient groups undergoing PNL: those over 60 and those under 60. A retrospective screen was made for patients undergoing conventional PNL surgery for renal stones performed in two separate centers between 2010 and 2013. 520 patients included were classified into age groups: patients aged 18-59 comprised Group-1 and those aged over 60 comprised Group-2. Those between 60-69 years (sexagenarian) were assigned to Group-2a; 70-79 years (septuagenarian) to Group-2b; and 80-89 years (octogenarian) to Group-2c. Patients' demographic characteristics (accompanying comorbidities, ASA scores, body mass indices and stone size) and perioperative values (duration of surgery and hospital stay, success and complication rates) were compared between the groups. Mean stone size was similar in groups (30.1 ± 15.5 vs. 31.5 ± 15.4 mm, p = 0.379). The mean ASA value for the patients in Group-1 was 1.61; significantly lower than that in the other groups (p = 0.000). The level of accompanying comorbidities in Group-1 was significantly lower than that of the other groups (p = 0.000). The mean duration of surgery, postoperative hematocrit drop, complication and success rate were statistically similar in Groups 1 and 2 (p = 0.860, p = 0.430, p = 0.7, and p = 0.66, respectively). The duration of hospital stay was significantly shorter in the patients in Group-1 compared to those in Group-2 (p = 0.008). In experienced hands, PNL can be safely and reliably performed in the treatment of renal stones in elderly patients.