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Article of the week: Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community and a visual abstract prepared by a trainee urologist; we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, we recommend this one. 

Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy

Manuel Armas-Phan*, David T. Tzou*†, David B. Bayne*, Scott V. Wiener*, Marshall L. Stoller* and Thomas Chi*

*Department of Urology, University of California, San Francisco, CA and †Division of Urology, University of Arizona, Tucson, AZ, USA

Read the full article

Abstract

Objectives

To compare clinical outcomes in patients who underwent percutaneous nephrolithotomy (PCNL) with renal tract dilatation performed under fluoroscopic guidance vs renal tract dilatation with ultrasound guidance.

Patients and Methods

We conducted a prospective observational cohort study, enrolling successive patients undergoing PCNL between July 2015 and March 2018. Included in this retrospective analysis were cases where the renal puncture was successfully obtained with ultrasound guidance. Cases were then grouped according to whether fluoroscopy was used to guide renal tract dilatation or not. All statistical analyses were performed using Stata version 15.1 including univariate (Fisher’s exact test, Welch’s t‐test) and multivariate analyses (binomial logistic regression, ordinal logistic regression, and linear regression).

Results

A total of 176 patients underwent PCNL with successful ultrasonography‐guided renal puncture, of whom 38 and 138 underwent renal tract dilatation with fluoroscopic vs ultrasound guidance, respectively. There were no statistically significant differences in patient age, gender, body mass index (BMI), preoperative hydronephrosis, stone burden, procedure laterality, number of dilated tracts, and calyceal puncture location between the two groups. Among ultrasound tract dilatations, a higher proportion of patients were placed in the modified dorsal lithotomy position as opposed to prone, and a significantly shorter operating time was observed. Only modified dorsal lithotomy position remained statistically significant after multivariate regression. There were no statistically significant differences in postoperative stone clearance, complication rate, or intra‐operative estimated blood loss. A 5‐unit increase in a patient’s BMI was associated with 30% greater odds of increasingly severe Clavien–Dindo complications. A 5‐mm decrease in the preoperative stone burden was associated with 20% greater odds of stone‐free status. No variables predicted estimated blood loss with statistical significance.

Conclusions

Renal tract dilatation can be safely performed in the absence of fluoroscopic guidance. Compared to using fluoroscopy, the present study demonstrated that ultrasonography‐guided dilatations can be safely performed without higher complication or bleeding rates. This can be done using a variety of surgical positions, and future studies centred on improving dilatation techniques could be of impactful clinical value.

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Editorial: Zero‐radiation stone treatment

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In this month’s BJUI, Armas‐Phan et al. [1] report on a prospective observational trial of fluoroscopic vs ultrasound (US)‐guided tract dilatation during percutaneous nephrolithotomy (PCNL). A total of 176 patients underwent successful initial US‐only guided puncture; of these patients, 138 had US‐only dilatation, while in 38 fluoroscopy was required. The authors found no difference in patient factors (e.g. age, gender, body mass index [BMI]) or stone factors (hydronephrosis, stone burden, number of tracts or puncture location). On multivariate analysis, US dilatation was more likely to be performed in the modified dorsal lithotomy position (compared to prone), but there was no significant difference in important outcomes such as stone clearance, complication rates or blood loss.

Whilst only reporting on access (and not necessarily dilatation), the Clinical Research Office of the Endourological Society PCNL Global Study shows us that worldwide fluoroscopic access is by far the most common (88.3% of cases) [2] and there are relatively few reports of US‐guided dilatation in the literature. The technique does produce technical challenges as the surgeon needs to confidently identify the depth of the dilators or balloon and be sure of its location relative to calyceal anatomy. Whilst dilating short is not usually a problem as simply re‐dilating can be done, dilating too far carries serious risk of perforation of the pelvicalyceal system and vascular injury. The authors’ described technique does rely on good kidney and guidewire visualisation, and if this is not possible then fluoroscopy is used instead. Thus, even in this series with experts at this technique, 38 (22%) underwent fluoroscopic dilatation after US‐guided puncture, and of the 138 with intended US dilatation, seven (5%) were converted to fluoroscopy. Furthermore, 115 patients never entered this series as they underwent initial fluoroscopic‐guided puncture. Thus, it is important to realise that this is a series of select patients being treated by expert enthusiasts of this technique and fluoroscopy should be available in the operating theatre, as it is not possible to do this technique for all patients. In particular, obesity limits the visualisation under US and the authors have previously shown that renal access drops from 76.9% of normal‐weight patients (BMI <25 kg/m2) to 45.6% for those classified as obese (BMI >30 kg/m2) [3]. An alternative strategy to avoid radiation is to use endoscopic combined intrarenal surgery (ECIRS), as the depth of dilatation can be monitored by direct visualisation via the flexible ureteroscope.

Patients and healthcare professionals are increasingly aware of the risks posed by ionising radiation. Ferrandino et al. [4] analysed radiation exposure of patients presenting with acute stone episodes in an American setting. The mean dose was a staggering 29.7 mSv and 20% of patients received >50 mSV. There is also awareness of risk to the operating staff from endourological procedures and although doses are relatively low [5], these can accumulate during a lifetime of operating, with risks of not only malignancy but also cataract formation [6]. Whilst I am sure we all wear protective lead gowns in the operating theatre, how many people wear lead glasses? A recent study showed that, at typical workload, the annual dose to the lens of the eye was 29 mSv in interventional endourology [7].

As urologists, we should all be aware of these risks and follow the ALARA (As Low As Reasonably Achievable) principals of keeping doses to a minimum. Thus, this paper [1] is particularly welcome and shows zero‐radiation procedures can be safely performed. The authors now attempt this technique for all PCNL procedures and achieve US‐only puncture and dilatation in over half of their patients. Hopefully, this paper will inspire us all to look at reducing or eliminating radiation usage in our stone procedures and this will be good for patients and surgeons alike.

by Matt Bultitude

 

References

  1. Armas‐Phan M, Tzou DT, Bayne DB et al. Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy. BJUI 2019; 125: 284-91
  2. De La Rosette J, Assimos D, Desai M et al. The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: indications, complications, and outcomes in 5803 patients. J Endourol 2011; 25: 11– 7
  3. Usawachintachit M, Masic S, Chang H, Allen I, Chi T. Ultrasound guidance to assist percutaneous nephrolithotomy reduces radiation exposure in obese patients. Urology 2016; 98: 32– 8
  4. Ferrandino MN, Bagrodia A, Pierre SA et al. Radiation exposure in the acute and short‐term management of urolithiasis at 2 academic centers. J Urol 2009; 181: 668– 72
  5. Galonnier F, Traxer O, Rosec M et al. Surgical staff radiation protection during fluoroscopy‐guided urologic interventions. J Endourol 2016; 30: 638– 43
  6. Hartmann J, Distler F, Baumuller M et al. Risk of radiation‐induced cataracts: investigation of radiation exposure to the eye lens during endourologic procedures. J Endourol 2018; 32: 897– 903
  7. Hristova‐Popova J, Zagorska A, Saltirov I et al. Risk of radiation exposure to medical staff involved in interventional endourology. Radiat Prot Dosimetry 2015; 165: 268– 71

 

 

Visual abstract: Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy

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USANZ 2018: Melbourne

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G’day! The 71st  annual USANZ Congress, was held in Melbourne and had the biggest attendance on record for the past 6 years. The Urological Nurse’s congress: ANZUNS ran concurrently, encouraging multi disciplinary learning. An excellent and varied educational programme was masterminded by Declan Murphy, Nathan Lawrentschuk and their organising committee. Melbourne provided a great backdrop and soon felt like home with a rich and busy central business district, cultural and sporting venues, the Yarra river flowing past the conference centre, edgy graffiti and hipster coffee shops, plus too many shops, bars and restaurants to visit.

The programme included a day of masterclasses on a range of subjects, including: urological imaging, advanced robotic surgery with a live case from USC, metastatic prostate cancer and penile prosthetics. These were well attended by trainees and consultants alike. The PCNL session (pictured) with Professor Webb was popular and he generously gave his expertise.  The session was supported by industry and provided an opportunity to use the latest nephroscopes on porcine models and innovative aids to realistically practice different puncture techniques.

Two plenary sessions were held each morning covering the breadth and depth of urology and were well attended. Dr Sotelo is always a highlight; he presented, to an auditorium of collective gasps, a unique selection of ‘nightmare’ cases  His cases gave insight in how intraoperative complications occur and how they can be avoided.  Tips, such as zooming out to reassess in times of anatomical uncertainty during laparoscopy or robotic surgery have great impact when you witness the possible consequences. Tim O’Brien shared his priceless insights on performing IVC thrombectomy highlighting the need for preoperative planning, early control of the renal artery and consideration of pre-embolisation.  His second plenary on retroperitoneal fibrosis provided clarity on the management of this rare condition highlighting the role of PET imaging and, as with complex upper tract surgery, the importance of a dedicated team.

Tony Costello’s captivating presentation covered several myths in robotic prostate surgery, plus the importance of knowing your own outcome figures and a future where robotics will be cost equivalent to laparoscopy. Future technology, progress in cancer genomics and biomarkers were also discussed in various sessions.  One example of new technology was Aquablation of the prostate; Peter Gilling presented the WATER trial results suggesting non-inferiority to TURP.  A welcome addition to the programme was Victoria Cullen (pictured), a psychologist and Intimacy Specialist who provides education, support and strategies for sexual  rehabilitation. She described her typical consultation with men with sexual dysfunction and how to change worries about being ‘normal’ to focusing on what is important to the individual.

Joint plenary sessions with the AUA and EAU were a particular highlight. Prof Chris Chapple confirmed the need for robust, evidence guidelines which support clinical decision making; and in many cases can be used internationally. He suggested collaboration is crucial between us as colleagues and scientists working in the field of urology. Stone prevention and analysis of available evidence was described by Michael Lipkin; unfortunately stone formers are usually under-estimaters of their fluid intake so encouragement is always needed! Amy Krambeck presented evidence for concurrent use of anticoagulants and antiplatelets during BOO surgery and suggested there can be a false sense of security when stopping these medications as it isn’t always safe. She championed HoLEP as her method of BOO surgery and continues medications, although the evidence does show blood transfusion rate may be higher. She also uses a fluid warming device which has less bleeding and therefore improved surgical vision; importantly it is preferred by her theatres nurses! MRI of the prostate was covered  by many different speakers, however Jochen Walz expertly discussed the limitations of MRI in particular relating negative predictive value (pictured). He eloquently explained the properties of cribiform Gleason 4 prostate cancer and how this variant contributed to the incidence of false negatives.

Moderated poster and presentation sessions showcased research and audit projects from the UK, Australia, New Zealand and beyond, mainly led by junior urologists. The best abstracts submitted by USANZ trainees were invited to present for consideration of Villis Marshall and Keith Kirkland prizes. These prestigious prizes were valiantly fought for and reflected high quality research completed by the trainees. Projects included urethral length and continence, no need for lead glasses, obesity and prostate cancer, multi-centre management of ureteric calculi, mental health of surgical trainees and seminal fluid biomarkers in prostate cancer. This enthusiasm for academia will undoubtedly stand urology in good stead for the future; this line up (pictured) is one to watch!

The Trade hall provided a great networking space to be able to meet with friends and colleagues and engage with industry. It also hosted poster presentation sessions, with a one minute allocation for each presenter – which really ensures a succinct summary of the important findings (pictured)! It was nice to meet with Australian trainees and we discussed the highs and lows of training and ideas for fellowships. Issues such as clinical burden and operative time, selection into the specialty, cost of training, burn out and exam fears were discussed and shared universally; however there is such enthusiasm, a passion for urology and inspirational trainers which help balance burdens that trainees face. Furthermore, USANZ ‘SET’ Trainees were invited to meet with the international faculty in a ‘hot seat’ style session which was an enviable opportunity to discuss careers and aspirations.

In addition to the Congress I was fortunate to be invited for a tour and roof-top ‘barbie’ at the Peter Mac Cancer centre; plus a visit to Adelaide with Rick (Catterwell, co-author) seeing his new hospital and tucking into an inaugural Aussie Brunch. Peter Mac and Royal Adelaide Hospital facilities indicated an extraordinary level of investment made by Federal and State providers; the Peter Mac in particular had impressive patient areas, radiotherapy suites and ethos of linking clinical and research. However beyond glossy exteriors Australian public sector clinicians voiced concerns regarding some issues similar to those we face in the NHS.

Despite the distance of travelling to Melbourne and the inevitable jet lag the world does feels an increasingly smaller place and the Urological world even more so. There is a neighbourly relationship between the UK, Australia and New Zealand as evidenced by many familiar faces at USANZ who have worked between these countries; better for the new experiences and teaching afforded to them by completing fellowships overseas. The Gala Dinner was a great chance to unwind, catch up with friends and celebrate successes in the impressive surrounding of Melbourne Town Hall (pictured); the infamous organ played particularly rousing rendition of Phantom of the Opera on arrival.

The enthusiasm to strive for improvement is similar both home and away and therefore collaboration both nationally and internationally is integral for the progress of urology. The opening address by USANZ President included the phrase ‘together we can do so much more’ and this theme of collaboration was apparent throughout the conference. The future is bright with initiatives led by enthusiastic trainee groups BURST and YURO to collect large volume, high quality data from multiple centres, such as MIMIC which was presented by Dr Todd Manning. Social media, telecommunications and innovative technology should be used to further the specialty, especially with research and in cases of rare diseases – such as RPF.  Twitter is a tool that can be harnessed and was certainly used freely with the hashtag #USANZ18. Furthermore, utilisation of educational learning platforms such as BJUI knowledge and evidence based guidelines help to facilitate high quality Urological practice regardless of state or country.

So we’d like to extend a huge thank you to Declan, Nathan and the whole team, and congratulate them for a successful, educational and friendly conference; all connections made will I’m sure last a lifetime and enable us to do more together.

Sophie Rintoul-Hoad and Rick Catterwell

 

Urolithiasis around the world

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Stone disease is a highly prevalent condition that unites all countries around the world, although surgical management will depend on many factors including availability of different technologies. However, percutaneous nephrolithotomy (PCNL) remains the cornerstone for the management of larger renal stones in all parts of the world, and Rizvi et al. [1] report on a huge cohort of PCNL procedures – 3 402 to be precise from Karachi. This is a single-centre series, over an 18-year period, reporting real-life data and showing a stone clearance rate of ~80%, as assessed by plain abdominal radiograph of the kidneys, ureters and bladder, and ultrasonography (US). Whilst the definition of stone-free and imaging modality used to judge it remains a contentious issue, this paper reflects the excellence of high-volume surgery in specialist centres.

Recently, the BJUI became the affiliated journal for the International Alliance of Urolithiasis (IAU), whose annual meeting takes place in Shaoxing this month. To celebrate this, we are proud to publish a ‘Best of Urolithiasis’ issue, which features some of the top stone papers published in the BJUI over the last few years [2]. Choosing articles for this was quite a task given the quality and whilst we have attempted to recognise submissions that potentially change practice, the geographical diversity of the work shows not only the global nature of stone disease but also the excellent research that is being done worldwide and in different healthcare systems to improve care and outcomes. Of particular importance are randomised trials that are often lacking in surgical areas. One such paper from China addressed the question of US vs fluoroscopy for PCNL access during mini-PCNL [3]. Whilst the truth is that surgeons should use whatever gives the best outcomes, the authors in a very high-volume centre were able to demonstrate the effectiveness of US-only punctures, although a combination may be better in complex stone burdens. Another randomised controlled trial (RCT) of clinical importance was from the USA, where the authors conducted a good quality double-blind RCT of NSAID use before ureteric stent removal under local anaesthesia [4]. Whilst a small study, the incidence of severe pain in the 24 h after stent removal was 55% in the placebo group vs 0% in the NSAID group – as such this simple study should have changed practice for all who perform this procedure.

Other papers worthy of inclusion include a single-centre experience of the conservative management of staghorn calculi, which challenges the dogma that all staghorn stones should be treated [5]. This single-centre series showed a conservative policy could be adopted in highly selected patients. Is this practice changing? Maybe … but it certainly gives an evidence base for stone surgeons in making decisions in very high-risk patients. Manoj Monga and his group recently reported on the accuracy of US for the detection of renal stones [6]. This again is a very important topic and a question that commonly arises. In a series of >500 patients with US-detected stones who subsequently underwent CT scanning, 22% of patients would have been inappropriately counselled about their stone based on US alone. Again, the message is clear … US is a good screening tool but do not rely on it for treatment decisions.

I hope you take the time to check out the virtual issue on urolithiasis and read the other papers I could not mention here. Please continue to send your high-quality stone papers to the BJUI and maybe your submission will feature in our next ‘Best of Urolithiasis’ issue.

Matthew Bultitude, BJUI Associate Editor

 

Guy’s and St Thomas’ NHS Foundation Trust, London, UK

 

References

 

1 Rizvi SA, Hussain M, Askari SH, Hashmi A, Lal M, Zafar MN. Surgical outcomes of percutaneous nephrolithotomy in 3402 patients and results of stone analysis in 1559 patients. BJU Int 2017; 120: 702–9

 

2 BJU International. Virtual Issues Page. Available at: https://bit.ly/BJUI-VIs. Accessed September 2017

 

3 Zhu W, Li J, Yuan J et al. A prospective and randomised trial comparing fluoroscopic, total ultrasonographic, and combined guidance for renal access in mini-percutaneous nephrolithotomy. BJU Int 2017; 119: 612–8

 

4 Tadros NN, Bland L, Legg E, Olyaei A, Conlin MJ. A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-  controlled trial. BJU Int 2013; 111: 101–5

 

5 Deutsch PG, Subramonian K. Conservative management of staghorn calculi: a single-centre experience. BJU Int 2016; 118: 444–50

 

6 Ganesan V, De S, Greene D, Torricelli FC, Monga M. Accuracy of ultrasonography for renal stone detection and size determination: is it good enough for management decisions? BJU Int 2017; 119: 464–9

 

Article of the Month: Surgical outcomes of PCNL and results of stone analysis

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Every Month the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Surgical outcomes of percutaneous nephrolithotomy in 3402 patients and results of stone analysis in 1559 patients

Syed Adibul Hasan Rizvi*, Manzoor Hussain*, Syed Hassan Askari*, Altaf Hashmi*,Murli Lal* and Mirza Naqi Zafar†

 

*Departments of Urology, and †Pathology, Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi, Pakistan
Read the full article

Abstract

Objective

To report our experience of a series of percutaneous nephrolithotomy (PCNL) procedures in a single centre over 18 years in terms of patient and stone characteristics, indications, stone clearance and complications, along with the results of chemical analysis of stones in a subgroup.

Patients and Methods

We retrospectively analysed the outcomes of PCNL in 3402 patients, who underwent the procedure between 1997 and 2014, obtained from a prospectively maintained database. Data analysis included patients’ age and sex, laboratory investigations, imaging, punctured calyx, duration of operation, volume of irrigation fluid, radiation exposure time, blood transfusion, complications and stone-free status at 1-month follow-up. For the present analysis, outcomes in relation to complications and success were divided in two eras, 1997–2005 and 2006–2014, to study the differences.

Results

Of the 3402 patients, 2501 (73.5%) were male and 901 (26.5%) were female, giving a male:female ratio of 2.8:1. Staghorn (partial or complete) calculi were found in 27.5% of patients, while 72.5% had non-staghorn calculi. Intracorporeal energy sources used for stone fragmentation included ultrasonography in 917 patients (26.9%), pneumatic lithoclast in 1820 (53.5%), holmium laser in 141 (4.1%) and Lithoclast® master in 524 (15.4%). In the majority of patients (97.4%) a 18–22-F nephrostomy tube was placed after the procedure, while 69 patients (2.03%) underwent tubeless PCNL. The volume of the irrigation fluid used ranged from 7 to 37 L, with a mean of 28.4 L. The stone-free rate after PCNL in the first era studied was 78%, vs 83.2% in the second era, as assessed by combination of ultrasonography and plain abdominal film of the kidney, ureter and bladder. The complication rate in the first era was 21.3% as compared with 10.3% in the second era, and this difference was statistically significant. Stone analysis showed pure stones in 41% and mixed stones in 58% of patients. The majority of stones consisted of calcium oxalate.

Conclusions

This is the largest series of PCNL reported from any single centre in Pakistan, where there is a high prevalence of stone disease associated with infective and obstructive complications, including renal failure. PCNL as a treatment method offers an economic and effective option in the management of renal stone disease with acceptable stone clearance rates in a resource-constrained healthcare system.

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Editorial: Management of urolithiasis in South Asia

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The article by Rizvi et al. [1] makes a great read. The authors deserve credit for their work and the data presented. A few points merit mention to summarise and put the article in perspective.

First, the authors present a mammoth database from a public sector hospital in Pakistan. In the initial era, as noted by the authors, they adopted extracorporeal shockwave lithotripsy (ESWL) as their mainstay for treating stones. ESWL as the least invasive, safe and readily available method remained the preferred option initially. However, stones seen in South Asia differ from those in the West. In this geographical area, the stone bulk is large and often not amenable to ESWL. In the subsequent period, the authors changed to percutaneous surgery. The reason for this shift, apart from large stone burden, may also have been influenced by local facto required to be travelled by patients to reach a healthcare facility and the lack of resources and infrastructure in remote locations. In such situations, the treatment option that offers rapid, safe, and efficacious results would be preferred. These criteria are fulfilled with the percutaneous approach to renal stones and this is what the authors did!

Second, it is worthwhile noting that that the need for embolisation and/or nephrectomy is a miniscule number in this series [1]. This emphasises the importance of the basic tenet in percutaneous renal surgery that a perfect initial access is the secret to successful percutaneous removal of stones. It should be noted that in this large series the complications across all Clavien–Dindo complication grades reduced as the authors ascended the learning curve.

Third, we feel the major limitation of this study [1] was the means of assessing the stone-free rate. The authors used a combination of ultrasonography and plain abdominal radiograph of the kidneys, ureters and bladder. As acknowledged by the authors this could have possibly overestimated the stone-free rates and skewed the data and interpretation. The authors can substantiate these findings in further prospective studies.

Fourth, the paper exemplifies that stone composition, choice of approach, and patient preferences vary from region to region globally. The findings in the study [1] are similar to the results of Desai et al. [2] from India.

Last but not the least, the AUA guidelines [3] state that the optimal strategy for stone management must take into consideration patient health and economic outcomes. Stone-free requirement is global but economic implications are regional. In this context, the treatment options for similar sized stones may vary for a particular patient located in Europe or Asia. Hence, we feel this paper could be considered as a benchmark for future multicentre trials investigating treatment options and strategies for urolithiasis in South Asia.

Mahesh R. Desai and Arvind P. Ganpule
Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

 

Read the full article

 

References

 

1 Rizvi SA, Hussain M, Askari SH, Hashmi A, Lal M, Zafar MN. Surgical outcomes of percutaneous nephrolithotomy in 3402 patients and results of stone analysis in 1559 patients from a single centre in Pakistan. BJUInt 2017; 120: 702–9

 

2 Desai M, Jain P, Ganpule A, Sabnis R, Patel S, Shrivastav P. Developments in technique and technology: the effect on the results of percutaneous nephrolithotomy for staghorn calculi. BJU Int 2009; 104:542–8

 

3 Assimos D, Krambeck A, Miller NL et al. Surgical management of stones: American Urological Association/Endourological Society Guideline. Available at: https://www.auanet.org/guidelines/surgical-management-of-stones-(aua/endourological-society-guideline-2016). Accessed August 2017

 

Video: Surgical outcomes of PCNL and results of stone analysis

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Surgical outcomes of percutaneous nephrolithotomy in 3402 patients and results of stone analysis in 1559 patients

Read the full article

Abstract

Objective

To report our experience of a series of percutaneous nephrolithotomy (PCNL) procedures in a single centre over 18 years in terms of patient and stone characteristics, indications, stone clearance and complications, along with the results of chemical analysis of stones in a subgroup.

Patients and Methods

We retrospectively analysed the outcomes of PCNL in 3402 patients, who underwent the procedure between 1997 and 2014, obtained from a prospectively maintained database. Data analysis included patients’ age and sex, laboratory investigations, imaging, punctured calyx, duration of operation, volume of irrigation fluid, radiation exposure time, blood transfusion, complications and stone-free status at 1-month follow-up. For the present analysis, outcomes in relation to complications and success were divided in two eras, 1997–2005 and 2006–2014, to study the differences.

Results

Of the 3402 patients, 2501 (73.5%) were male and 901 (26.5%) were female, giving a male:female ratio of 2.8:1. Staghorn (partial or complete) calculi were found in 27.5% of patients, while 72.5% had non-staghorn calculi. Intracorporeal energy sources used for stone fragmentation included ultrasonography in 917 patients (26.9%), pneumatic lithoclast in 1820 (53.5%), holmium laser in 141 (4.1%) and Lithoclast® master in 524 (15.4%). In the majority of patients (97.4%) a 18–22-F nephrostomy tube was placed after the procedure, while 69 patients (2.03%) underwent tubeless PCNL. The volume of the irrigation fluid used ranged from 7 to 37 L, with a mean of 28.4 L. The stone-free rate after PCNL in the first era studied was 78%, vs 83.2% in the second era, as assessed by combination of ultrasonography and plain abdominal film of the kidney, ureter and bladder. The complication rate in the first era was 21.3% as compared with 10.3% in the second era, and this difference was statistically significant. Stone analysis showed pure stones in 41% and mixed stones in 58% of patients. The majority of stones consisted of calcium oxalate.

Conclusions

This is the largest series of PCNL reported from any single centre in Pakistan, where there is a high prevalence of stone disease associated with infective and obstructive complications, including renal failure. PCNL as a treatment method offers an economic and effective option in the management of renal stone disease with acceptable stone clearance rates in a resource-constrained healthcare system.

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Royal Society of Medicine: Key issues in Endourology

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The RSM section of Urology #RSMUrology hosted a day on the Key issues in Endourology on 20th October. This was the first meeting of the academic year under President Roland Morley. Sri Sriprisad put together a complete endourology day with key subject areas of  “PCNL and stones”, “upper tract TCC” and “BPH and retention”. Speakers from India, America and Spain provided expert opinions from around the globe.

The day started with the evolution of stone and urological laparoscopic surgery. Showing an insight into the challenges with the initial introduction of laparoscopic urological surgery. In order to allow surgeons the chance to discuss their experiences and troubleshoot and develop surgical techniques the SLUG forum (southern laparoscopic urology group) was created, which is still running today in the annual AUA meeting.

PCNL techniques were the subject for several debate lectures. Access for PCNL tracts was debated by Dr Janak Desai, visiting from Samved Urology hospital in India, arguing for fluoroscopic puncture with over 10,000 cases to date! Jonathan Glass, from Guy’s and St. Thomas’ Hospital, spoke for the prone position for the majority of PCNL, but selecting the supine position in 5-10% of cases depending on the anatomy and stone position. Dr Desai also spoke on ultra-mini PCNL, which he advocates using to treat solitary kidney stones under 2 cm in preference to flexible ureteroscopy.

The future of ESWL was debated and the audience voted that it is still “alive and clicking” by a narrow margin. However, although up to 80% clearance rates are quoted for upper pole stones less than 2 cm, the problem is that results of treatment are varied and unpredictable, and real-life success rates are far inferior. The variation in results may in part be due to the fact that there are no formal training courses for specialist radiographers nor SAC requirements for specialist registrars. Professor Sam McClinton presented on clinical research in stone disease with results from the TISU trial on primary ESWL vs. ureteroscopy for ureteric stones due out next year. The results will be fascinating and may help to decide if ESWL has a future in the UK.

Professor Margaret Pearle, visiting from the University of Texas Southwestern Medical Centre, explained the importance of treating residual fragments. With data showing that 20 – 36% of >2 mm residual stones after ureteroscopy required repeat surgery within 1 year. In a thought provoking lecture, she presented data showing that ureteroscopy may not be as good as we think and when critically examined, true stone-free rates maybe no better than ESWL. Maybe miniaturised PCNL is the way forward after all?

The follow up of small kidney stones is an uncertain area with very little written in either the EAU or AUA guidelines. Data from a meta-analysis by Ghani et al. shows that for every year of follow up on small kidney stones 7% may pass, 14% grow and 7% will require intervention. However, it is not possible in most health systems to follow everyone up forever and Mr Bultitude advocated increasing discharge rates from stone clinics to primary care after an agreed time of stability, allowing more on the complex and metabolic stone formers.Figure 1- Stone follow up algorithm

The expert stone panel then debated several challenging cases including “the encrusted stent”, stones in a pelvic kidney or calyceal diverticulum. These cases certainly are a challenge and require an individualized approach usually with multi-modality treatments.

Figure 2 – Stone expert panel

Upper tract urological biopsies are notoriously inaccurate, with only 15% of standard biopsies quantifiable histologically. Low grade tumours, are potentially suitable for endoscopic management with laser ablation. Dr Alberto Breda, from the urology department of Fundacio Puigvert Hospital in Spain, presented a novel solution for the future. This promising new technology uses confocal endomicroscopy to grade upper tract urological cancer. Initial results show 90% accuracy in diagnosing low grade tumours, which could then be safely managed endoscopically avoiding nephron-ureterectomy for some patients.

 

Figure 3 – Confocal endomicroscopy for upper tract malignancy

In the final session, a debate on BPH treatment, the audience preferred the bipolar resection technique for treating “the 60 year old with retention, with a 90 gram prostate and on rivaroxaban”, although HOLEP came a close second, with that talk giving the quote of the day “I spend more time with the morcellator than the wife.”

Figure 4 – Bipolar TURP wins the day

 

Nishant Bedi

ST4 Specialist urology registrar

 

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