The Efficacy of Percutaneous Nephrolithotomy in ...

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The Efficacy of Percutaneous Nephrolithotomy in renal and upper ureteric calculi. Sarhad Khan, Liaqat Ali Toori, Khursheed Anwer. Department of Urology ...
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Pakistan J. Med. Res. Vol. 44, No. 2, 2005

ORIGINAL ARTICLE

The Efficacy of Percutaneous Nephrolithotomy in renal and upper ureteric calculi Sarhad Khan, Liaqat Ali Toori, Khursheed Anwer Department of Urology, Pakistan Institute of Medical Sciences, Islamabad.

ABSTRACT Objectives: To determine the efficacy of Percutaneous Nephro-Lithotomy (PCNL) in clearance of symptomatic renal and upper ureteric calculi and study the frequency of postoperative complications associated with it..

Methods: A descriptive study conducted in the Department of Urology at Pakistan Institute of Medical Sciences (P.I.M.S) Islamabad from 1990 to 2001. Two hundred patients with symptomatic renal and upper ureteric calculi were selected with the technique of non-probability convenient sampling. All Patients were subjected to PCNL. The data was analyzed on SPSS version 10. Results: The mean age of patients was 37 years with a range of 18-75 years. The mean size of the stone was 2.7cm with a range of 1.5 to 3.5cm. The mean operation time was 90 minutes with range of 40 to 120 minutes. The stone clearance was successfully achieved in 194 patients (97%). Failure was noted in 6 patients (3%). Majority (189) of patients required only a single session for the complete clearance. Postoperative complications were recorded in 24 patients (12%). Only 8 patients (4%) required blood transfusion, 8 patients (4%) had bacteriemia, 4 patients (2%) had prolonged ileus of more than 72 hours and 4 patients (2%) developed urinary fistula. No mortality was recorded. Conclusion: PCNL is a minimally invasive, effective and safe modality for the removal of renal and upper Ureteric calculi.

Key words: Percutaneous Nephro-Lithotomy (PCNL), Renal tract stones, Complications.

INTRODUCTION

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he formation of stones in the urinary tract is an ancient disease known to the mankind for ages. Hippocrates was the first urologist who removed an infected stone from a perinephric abscess1. Roman, Egyptian and Muslim Physicians further advanced the treatment of Urinary tract stone disease2. The surgical management of urinary calculus disease has evolved considerably over the past two decades. Specifically, the introduction and refinement of percutaneous and ureteroscopic access to the upper tracts, along with the nearly simultaneous development of both extracorporeal and intracorporeal lithotripsy, has relegated the role of open surgery to less than 1% of patients undergoing intervention for their stone disease3. In countries like Pakistan, the mere unavailability of ESWL and PCNL makes the open surgery as most common modality used for the removal of renal stones4. However it is an established fact that percutaneous surgery can be the best alternative to open surgery and it can be used alone or in combination with ESWL. The advantages of PCNL are small incisions, minimum operative and postoperative complications, short hospital stay and early resumption of

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daily routine work3,5. The department of Urology, Pakistan Institute of Medical Sciences is the pioneer to start this kind of minimal invasive surgery in Pakistan. The first successful PCNL was performed in Pakistan at this institute in April 1988. In the West, it is the Radiologist who carries out the initial puncture and tract dilation followed by a Urologist who performs Nephroscopy and retrieval of stones3,5. In the present study, a single Urologist has performed all the integral steps of PCNL without the help of a Radiologist.

PATIENTS AND METHODS The study was conducted in the department of Urology at Pakistan Institute of Medical Sciences (P.I.M.S) Islamabad from Januaury1990 to December 2001. A total of 200 patients were selected for the study with technique of non-probability convenient sampling. All patients were above 12 years of age, irrespective of gender, with diagnosis of symptomatic renal and upper ureteric calculi of not more than 3.5cm .Complete history was obtained including information on symptoms, past history, biosocial features, dietary habits and family history. Thorough physical examination was performed with special respect to

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genito-urinary system. The patients were subjected to PCNL under strict aseptic and radiation protection measures. The procedure was performed in a purpose built operating room with state of the art facilities of uroradiological imaging. The procedure comprised of six integral steps: • • • • • •

Opacification of the tract Puncture of the pelvicalceal system Dilatation of the tract Nephroscopy with standard W.M Nephroscope PCNL with offset nephroscopes, using different modalities of insitu lithotripsy Placement of nephrostomy at the end of the procedures.

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Pelvis calyces ureter patrial staghorn Figure 1: Showing the relative distribution of stones.

The opacification of the tract was mainly achieved by retrograde ureteric catheter. In 10 patients, tract was opacified by percutaneous chiba needle. The teflon facial and metallic dilators were used for the tract dilatation. The operative procedure was performed in prone position under general anesthesia. Structured proforma was filled and data was analyzed on SPSS.

RESULTS The mean age of the patients was 37 years (range: 18 to 75 years). There were 140 (70%) males and 60 (39%) females Out of 200 patients, 110(55%) had right sided stone, and 90(45%) had left sided stone. The stone distribution is shown in the figure 1. The mean size of the stone was 2.7cm (range: 1.5cm to 3.5cm). Majority (185) of the stones were opacified by retrograde ureteric catheter and 15 (7.5%) were opacified by percutaneous puncture with Chiba needle. Stone retrieval was accomplished by PCNL alone in 70 (35%) patients, while 130 (65%) patients required some sort of intracorporeal lithotripsy in addition to PCNL. In this group of 130 patients, ultrasonic lithotripter (USL) was used in 80 (61.5%) and electrohydraullic lithotripsy (EHL) in 20 (15.3%). Both the modalities were used in combination in 30 (23.07%) patients. The mean operation time was 90 minutes (range: 40 to 120 minutes). Complete stone clearance was achieved in 194 patients (97%). Failure was recorded in only 6 patients (3%) of whom 2 had failure of puncture, failure of tract dilation and failure of extraction. Of 194 successfully operated cases, 184 patients (94.8%) required only single session for the successful stone clearance, while 8 patients (4.1%) required more than 2 sessions of PCNL for successful stone clearance.

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Significant postoperative complications were observed in 24 patients (12%). Eight patients (4%) required blood transfusion due to primary hemorrhage; 8 patients (4%) developed urosepsis; which was treated with culture specific parenetral antibiotics; 4 patients (2%) had prolonged ileus for more than 72 hours; and 4 patients (2%) developed urinary fistula which was treated conservatively with nephrostomy drainage for 15 days. The mean period of nephrostomy drainage was 5 days with the range of 0-15 days and the mean hospital stay was 5 days (range: 3-10 days). There were no external organ injury and mortality recorded in the present study.

DISCUSSION The surgical management of the renal tract stone disease has been revolutionized during the last two decades after the introduction of minimal invasive techniques, like ESWL and PCNL.The Percutaneous Nephro-Lithotomy PCNL was first described by Rupel and Brown in 19416.However, removal of a renal calculus via a percutaneous tract, was not performed until Fernstrom and Johansson7 used such a technique successfully in three patients 30 years later. Percutaneous nephrolithotomy is safe and effective. In a community setting, approximately 90% of targeted stones can be removed successfully, and at experienced subspecialty care centers, this rate can approach 100%3. Renal tract stone disease generally is the ailment of relatively younger people, and this was also observed in present study where the mean age of patients was 37yrs. A success rate of 98.3% had been reported from Mayo clinic in a series of 1000 patients for the small symptomatic calculi of upper ureter and renal pelvis8.

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In the present study, the overall stone clearance on discharge was 97%. These results are comparable with different studies conducted by Wickham, Whitfield and Clayman9-11, respectively. Their results of successful stone clearance varied from 80 to 92% according to the size, nature and chemical composition of the stones. In the present study, among 194 successfully operated cases, 184 patients (94.8%) required only single session for complete stone clearance, while 8 patients (4.1%) required more than two sessions of PCNL. This efficacy of stone clearance in a single session is attributed to the use of intracorporeal electrohydruallic and ultrasonic lithotripters. In one of his famous work, Payene et al12 reviewed 450 patients of PCNL and reported successful removal of stones in 93% at first session and rising to 98% with subsequent PCNL. Failure was noted in 6 patients (3%) in the present study. Among these 2 patients had failed puncture, in 2 patients tract could not be dilated and in 2 patients extraction was unsuccessful The failure rate of 3.8% to 5% for failed access and extraction had been reported by Jones5 and Wickham10. Percutaneous nephrolithotomy is generally accepted as a safe procedure. The overall morbidity ranges from 7.5% to 18% depending upon the sample size and the presence of complicated renal stones13-15. Significant postoperative complications were observed in 24 patients (12%). Eight patients (4%) required blood transfusion due to primary hemorrhage. The blood transfusion requirement ranged from 2-18% according to the literature and the need for selective embolization or open intervention was done in 1-1.5%16. Fortunately, in present study, no patient required selective embolization or nephrectomy. The febrile UTIs were observed in 8 patients (4%), which were treated conservatively with parentral antibiotics. Li MK14 and Lames S17 have reported symptomatic urinary tract infection in 5.5-9.2%. The overall mortality of PCNL ranges from 0.5% to 1.1%, and is generally attributed to severe hemorrhage, urosepsis or pulmonary embolism13,14,18. No mortality was recorded in the present study, thus highlighting the fact that PCNL is a safe and effective treatment modality in experienced hands.

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Khan FA, Khan JH. Stone survey of Punjab hospitals. Pak Post Med J 1990; 1:7-13. Jones DJ, Russel GL, Kellett MJ, Wickham JEA. The changing practice of percutaneous stone surgery. Review of 1000 cases. Br J Urol 1986; 58:581-4. Rupel E, Brown. Nephroscopy with removal of stone following for obstructive calculus anuria. J Urol 1941; 46:177. Fernstrom I, Johansson B. Percutaneous pyelolithotomy. Scand J Urol Nephrol 1976; 10: 257-9. Segura JW, Patterson DE, LeRoy AJ.. Percutaneous removal of kidney stones: review of 1000 cases. J Urol 1985; 134:1077-81. Whitfield HN, Mills VA. Percutaneous nephrolithotomy. Br J Urol 1985; 57:603-4. Wickham JEA, Miller RA, Kellet MJ. Percutaneous nephrolithotomy: results and cost effectiveness. Br J Urol 1983; 55:103-6 Clayman RV, Surya V and Miller RP et al. Percutaneous nephrolithotomy: extraction of renal and ureteral calculi from 100 patients. J Urol 1984; 131:868-71. Payne SR, Ford TF, Wickham JEA. Endoscopic management of upper urinary tract stones. Br J Surg 1986; 72:822-4. Jemni M, Bacha K, Ben Hassine L, Karray MS, Ayed M. Results of the treatment of renal lithiasis by percutaneous nephrolithotomy: apropos of 115 cases. Prog Urol. 1999 ; 9: 52-60. Li MK, Wong MY, Toh KL, Ho GH, Foo KT. Percutaneous nephrolithotomy results and clinical experience. Ann Acad Med Singapore 1996;25:683-6. Sahin A, Atsu N, Erdem E, Oner S, Bilen C, Bakkaloglu M, et al. Percutaneous nephrolithotomy in patients aged 60 years or older. J Endourol 2001; 15: 489-91. Gremmo E, Ballanger P, Dore B, Aubert J. Hemorrhagic complications during percutaneous nephrolithotomy. Retrospective studies of 772 cases. Prog Urol 1999 Jun; 9: 460-3. Lahme S, Bichler KH, Strohmaier WL, Gotz T. Minimally invasive PCNL in patients with renal pelvic and calyceal stones. Eur Urol 2001 Dec; 40: 619-24. Corbel L, Guille F, Cipolla B, Staerman F, Leveque JM, Lobel B. Percutaneous surgery for lithiasis: results and perspectives. Apropos of 390 operations. Prog Urol 1993;3:658-65.

REFERENCES 1.

2. 3.

Dimopoulous C, Gialias A, Likourinas M, Androutsos A and Kostakopoulos A. Hippo crates: founder and pioneer of urology. Br J Urol 1986; 73-4. Joly JS. Stone and calculus diseases of urinary organs. London: Heinemann; p. l-7. Rassweller JJ, Renner C, Eisenberger F. The management of complex renal stones. Br J Urol 2000; 86:919-28.

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