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Brandt MP, Lehnert T, Czilwik T, Borgmann H, Gruber-Rouh T, Thalhammer A, Adam EH, Thomas C, Bartsch G, Haferkamp A, Vogl TJ, Tsaur I. CT-guided nephrostomy-An expedient tool for complex clinical scenarios. Eur J Radiol 2018; 110:142-147. [PMID: 30599852 DOI: 10.1016/j.ejrad.2018.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 11/09/2018] [Accepted: 11/22/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION & OBJECTIVES Percutaneous nephrostomy [1] has emerged as a pivotal approach in the therapeutic management of the obstructed urinary tract. A consecutive incorporation of ultrasonic and radiographic guidance, the approach experienced an almost ubiquitious distribution while most centers currently applying either one or both of these tools jointly. However, success of ultrasound-guidance is limited in obese patients and non-dilated uropathy. In turn, fluoroscopy usually requires an opacification of the urinary collecting system by intravenous or antegrade contrast media injection, which might be harmful for already impaired renal function, raise intrapelvic pressure and augment the risk of sepsis and hemorrhage. CT-guided PCN aids in overcoming these limitations. In the current study, we present the experience of a tertiary referral center with this technique. MATERIALS & METHODS Epidemiological and clinical data of all patients treated with a CT-guided PCN of native kidneys at the University Hospital Frankfurt between October 2003 and October 2013 were retrospectively collected from the patient charts. Procedural parameters including radiological aspects, technical and therapeutic success, complication and mortality rate have been analyzed statistically. RESULTS In total, 140 PCN procedures have been performed in 77 patients with a median age of 69 (± 13). The median body mass index was 27 with 66.6% of patients being overweight or obese. Charlson comorbidity index was 7 ranging 0-16. Indications for PCNs were obstructive uropathy (62.9), urine extravasation (22.9%), urinary tract fistulas (11.4%) and technical reasons (2.8%). In 68.8% of patients, initial diagnosis was malignancy. 56.4% of kidneys were non-dilated before puncture. In 78.4% prone position, otherwise supine oblique position (17.3%) or supine position (4.3%) was used. 71.4% of PCNs were carried out solely under local anesthesia. Technical success has been achieved in 90% with a complication rate of 3.6% (all grade minor B) and was not significantly different between dilated and non-dilated kidneys. 42.9% of fistulas and 64.3% of urinary tract leakages, healed after PCN placement. 30 days mortality rate was 5.2% without being directly associated with the PCN procedure itself. CONCLUSION CT-guided PCN is a feasible approach associated with low morbidity. It is particularly useful in complex clinical scenarios e.g. critically ill, newly operated or obese patients as well as non-dilated kidneys. Moreover, it represents a minimally-invasive option for treating leakages and fistulas of the urinary tract.
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Affiliation(s)
- Maximilian Peter Brandt
- Department of Urology and Pediatric Urology, Mainz University Medical Center, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Thomas Lehnert
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Theresa Czilwik
- Department of Ear, Nose and Throat, St. Elisabethen Hospital, Frankfurt am Main, Germany
| | - Hendrik Borgmann
- Department of Urology and Pediatric Urology, Mainz University Medical Center, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Tatjana Gruber-Rouh
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Axel Thalhammer
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Elisabeth Hannah Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Thomas
- Department of Urology and Pediatric Urology, Mainz University Medical Center, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Georg Bartsch
- Department of Urology and Pediatric Urology, Mainz University Medical Center, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Axel Haferkamp
- Department of Urology and Pediatric Urology, Mainz University Medical Center, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Thomas Joseph Vogl
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Igor Tsaur
- Department of Urology and Pediatric Urology, Mainz University Medical Center, Langenbeckstraße 1, 55131 Mainz, Germany
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Basiri A, Mirjalili M, Kardoust Parizi M, Moosa Nejad N. Supplementary X-Ray for Ultrasound-Guided Percutaneous Nephrolithotomy in Supine Position versus Standard Technique: A Randomized Controlled Trial. Urol Int 2013; 90:399-404. [DOI: 10.1159/000345796] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 11/13/2012] [Indexed: 11/19/2022]
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Sommer C, Huber J, Radeleff B, Hosch W, Stampfl U, Loenard B, Hallscheidt P, Haferkamp A, Kauczor H, Richter G. Combined CT- and fluoroscopy-guided nephrostomy in patients with non-obstructive uropathy due to urine leaks in cases of failed ultrasound-guided procedures. Eur J Radiol 2011; 80:686-91. [DOI: 10.1016/j.ejrad.2010.09.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 09/27/2010] [Indexed: 11/16/2022]
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Ultrasound-guided X-ray free percutaneous nephrolithotomy for treatment of simple stones in the flank position. ACTA ACUST UNITED AC 2010; 39:205-12. [PMID: 21069310 DOI: 10.1007/s00240-010-0336-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2010] [Accepted: 10/20/2010] [Indexed: 12/18/2022]
Abstract
The purpose of this study was to examine the effectiveness and safety of percutaneous nephrolithotomy with ultrasonography-guided renal access in the flank position without the use of fluoroscopy in any stage of the procedure. Percutaneous nephrolithotomy was performed in flank position under the guidance of ultrasound (USG) without the use of fluoroscopy between December 2008 and January 2010 on 43 patients who had kidney stones bigger than 20 mm. Access to the kidney's proper calyx was achieved by dilatation through the guide wire placed after insertion of the needle through the needle director under the guidance of transrectal ultrasound probe placed on the patient's flank area. A convex USG probe was used for imaging during dilatation and lithotripsy instead of fluoroscopy. Access to the targeted calyx was achieved successfully in all patients (100%). The percentage stone free rate was 86.1% (37 patients). Residual stones were detected in six patients. Their dimensions ranged from 5 to 12 mm. The mean stone diameter was 29 (20-41) mm, duration of surgery was 87.1 ± 43.2 (55-210) min and duration of hospital stay was 3.1 (2-8) days. Blood transfusions were given to two patients; none of the patients had major intraoperative or postoperative complications. In comparison with standard percutaneous nephrolithotomy, percutaneous nephrolithotomy in flank position under ultrasonographic imaging instead of using fluoroscopy seems to be safe and effective. This procedure has to be limited to selected cases with one or maximum two big stones in the pelvis or in a single calyx in absence of complex intrarenal anatomy. Both surgical team and the patients were protected from the harmful effects of radiation. Regarding anesthesia, flank position is more comfortable for the patient than prone position.
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Karami H, Rezaei A, Mohammadhosseini M, Javanmard B, Mazloomfard M, Lotfi B. Ultrasonography-Guided Percutaneous Nephrolithotomy in the Flank Position Versus Fluoroscopy-Guided Percutaneous Nephrolithotomy in the Prone Position: A Comparative Study. J Endourol 2010; 24:1357-61. [DOI: 10.1089/end.2009.0099] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hossein Karami
- Urology and Nephrology Research Center (UNRC), Shohada Medical Center, Shahid Beheshti University, M.C. (SBMU), Tehran, Islamic Republic of Iran
| | - Alireza Rezaei
- Urology and Nephrology Research Center (UNRC), Shohada Medical Center, Shahid Beheshti University, M.C. (SBMU), Tehran, Islamic Republic of Iran
| | - Mojtaba Mohammadhosseini
- Urology and Nephrology Research Center (UNRC), Shohada Medical Center, Shahid Beheshti University, M.C. (SBMU), Tehran, Islamic Republic of Iran
| | - Babak Javanmard
- Urology and Nephrology Research Center (UNRC), Shohada Medical Center, Shahid Beheshti University, M.C. (SBMU), Tehran, Islamic Republic of Iran
| | - Mohsen Mazloomfard
- Urology and Nephrology Research Center (UNRC), Shohada Medical Center, Shahid Beheshti University, M.C. (SBMU), Tehran, Islamic Republic of Iran
| | - Behzad Lotfi
- Urology and Nephrology Research Center (UNRC), Shohada Medical Center, Shahid Beheshti University, M.C. (SBMU), Tehran, Islamic Republic of Iran
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El-Husseiny T, Moraitis K, Maan Z, Papatsoris A, Saunders P, Golden B, Masood J, Buchholz NPN. Percutaneous endourologic procedures in high-risk patients in the lateral decubitus position under regional anesthesia. J Endourol 2009; 23:1603-6. [PMID: 19747056 DOI: 10.1089/end.2009.1525] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE The prone position is the most commonly used position for percutaneous endourologic procedures. It is usually combined with a general anesthesia. In high-risk patients, this approach can lead to circulatory and respiratory compromises. Operating on such patients in a full lateral position will minimize the hemodynamic and respiratory risks and-if combined with spinal anesthesia-will allow for increased patient comfort and safety. PATIENTS AND METHODS After rigorous preoperative assessment, 27 medical high-risk patients (12 men) with a mean age of 62 years and an American Society of Anesthesiologists score of 3+ were included in this study. The majority (78%) had regional anesthesia and were fully awake and alert during the operation. The procedures consisted of an initial retrograde renal study/filling with contrast medium with the patient in the lithotomy position to aid kidney puncture. The percutaneous procedure was then performed with the patient in the lateral decubitus position, and access was performed under fluoroscopic and/or ultrasonographic guidance. RESULTS Twenty-two percutaneous nephrolithotomies (PCNL), 3 anterograde endopyelotomies (AEP), 1 percutaneous resection of renal pelvic transitional-cell carcinoma, and 1 percutaneous renal cyst sclerotization were performed. After PCNL, 11 patients were stone free postoperatively, and a further 8 were stone free after adjuvant shockwave lithotripsy. Two patients needed temporary Double-J stents. One renal access failed. Two procedures were aborted because of hemorrhage. One patient died in the recovery room from uncontrollable renal bleeding. A renal scan after 3 months showed relief of obstruction in the three patients who had undergone AEP. Ultrasonography confirmed complete resolution of the sclerotized renal cyst. Neither of the patients with regional anesthesia needed conversion to general anesthesia. In two patients who experienced moderate pain, a "top-up" with local anesthesia solved the problem. CONCLUSION The full lateral position-while necessitating expertise and some learning for renal puncture from an unusual angle-is safe in medical high-risk patients. It can be safely performed using regional anesthesia, avoiding the risks of general anesthesia and allowing for patient-anesthetist communication throughout the procedure. Cardiac and respiratory parameters are improved, stable, and easily controlled. As opposed to the supine position, the awake patient is more comfortable, and morbid obesity is not a problem.
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Affiliation(s)
- Tamer El-Husseiny
- Endourology and Stone Services, Barts and The London NHS Trust , London, UK
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Basiri A, Mohammadi Sichani M, Hosseini SR, Moradi Vadjargah A, Shakhssalim N, Kashi AH, Kamranmanesh M, Nasseh H. X-ray-free percutaneous nephrolithotomy in supine position with ultrasound guidance. World J Urol 2009; 28:239-44. [PMID: 19641923 DOI: 10.1007/s00345-009-0451-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 07/07/2009] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Supine percutaneous nephrolithotomy (PCNL) has numerous benefits compared to the prone position, including lower anesthesia risk, shorter operating time, and better ergonomic position for the surgeon. It is also comparable to prone position regarding vascular and bowel injuries. This study was conducted to add some more benefits by omitting X-ray in PCNL in a supine position. METHODS Nineteen consecutive adult patients underwent ultrasound-guided PCNL in supine position. All patients were placed under ultrasound guidance in supine position. The tract was dilated over a guidewire in a single shot technique under ultrasound guidance from anterior abdominal wall. Once the procedure ended, residual stone was controlled using ultrasound with anterior abdominal wall window. Residual stones less than 5 mm were considered insignificant. No X-ray was used in any setting of the procedure. RESULTS The pelvicaliceal system could be successfully approached in all patients. The posterior calices were the most common sites of entry. Mean (range) of operation time was 111 (70-180) min. Mean + or - SD hemoglobin before PCNL was 14.0 + or - 2.2 mg/dl, and after the procedure it was 12.3 + or - 1.6 mg/dl. Only one patient required blood transfusion. Mean + or - SD creatinine before PCNL was 1.03 + or - 0.24 mg/dl, and after the procedure it was 1.11 + or - 0.22 mg/dl. None of the patients suffered visceral injury. The total stone-free rate was 84%. CONCLUSIONS Even in our first report with limited experience, it seems that the efficacy of PCNL with ultrasonography in supine position is comparable to PCNL in prone position with fluoroscopy with no more complications.
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Affiliation(s)
- Abbas Basiri
- Department of Urology, Urology and Nephrology Research Center (UNRC), Shahid Labbafinejad Medical Center, Shahid Beheshti University, M.C. (SBMU), No.101, Boostan 9th St., Pasdaran Ave., P.O. Box 1666677951, Tehran, Iran.
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Totally Ultrasonography-Guided Percutaneous Nephrolithotomy in the Flank Position. J Endourol 2008; 22:1453-7. [DOI: 10.1089/end.2007.0391] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Gupta S, Gulati M, Suri S. Ultrasound-guided percutaneous nephrostomy in non-dilated pelvicaliceal system. JOURNAL OF CLINICAL ULTRASOUND : JCU 1998; 26:177-9. [PMID: 9502043 DOI: 10.1002/(sici)1097-0096(199803/04)26:3<177::aid-jcu13>3.0.co;2-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Percutaneous placement of nephrostomy catheters in patients with non-dilated pelvicaliceal systems remains problematic. We successfully performed ultrasound-guided percutaneous nephrostomies in 5 such patients after intravenous administration of a diuretic agent. Diuresis resulted in transient dilatation of the calyces, facilitating the procedures, which were performed under real-time sonographic guidance using the Seldinger technique. No complications were encountered.
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Affiliation(s)
- S Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Coddington CC, Thomas JR, Hoskins WJ. Percutaneous nephrostomy for ureteral obstruction in patients with gynecologic malignancy. Gynecol Oncol 1984; 18:339-48. [PMID: 6204911 DOI: 10.1016/0090-8258(84)90046-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Reversible ureteral obstruction is not an infrequent complication of gynecologic malignancy or its treatment. In the past, open nephrostomy has been the standard method of management in such patients. This paper discusses the nonoperative technique of percutaneous nephrostomy which allows placement of either an external nephrostomy tube or an internal ureteral stent under local anesthesia. Six illustrative cases are presented and the indications and technical aspects of the procedure are discussed.
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