32.1.10 Percutaneous Nephrolithotomy (PCNL) in Adult Patients: Our Initial Experience at Teaching Hospital Dera Ghazi Khan

Original Article

 

PCNL in Adult Patients

Percutaneous Nephrolithotomy (PCNL) in Adult Patients: Our Initial Experience at Teaching Hospital Dera Ghazi Khan

Amjad Ali Siddiqui1, Muhammad Asif1, Zahra Imran1, Muhammad Khalid1, Muhammad Hammad Hassan1 and Samah Fatima Qaisrani2

ABSTRACT

Objective: To evaluate our initial experience of PCNL for the management of renal stones in terms of stone clearance and complications.

Study Design: Prospective Observational Study

Place and Duration of Study: This study was conducted at the Urology department of Tertiary Care Teaching Hospital Dear Ghazi Khan between July 2018 to July 2020.

Materials and Methods: We included  72  adults patients with renal stones 15-50 mm. PCNL was  performed in prone position under general anesthesia. Patients with anomalous kidney, stage horn stones, and simultaneous PUJ narrowing, bleeding diathesis cardiopulmonary diseases, obese and pediatric age were excluded.

Results: The mean age of patients was 33 years with 12±sd and mean stone size was 24mm with 8.4± sd. Mostly were male 68% (n=49).Highest percentage of stones found in renal Pelvis (71%).Single stone was in 71% patients. Upper pole was the most common site of puncture (73.6%), while single puncture was done in 80% patients. Regarding the stone clearance 90.3% have complete  stone clearance while 6 patients (8.3%) has residual stones ranging  from 6mm- 15 mm. Procedure  was abandoned in one patient due to failure tract access. Patients with residual stones (n=6) 8.3% underwent ancillary procedure later on. Three patients (4.2%) developed urinoma managed by URS and DJ stent insertion. One patient got urosepsis and one developed paralytic ileus. Only 2(2.8%) patients needed blood transfusion.

Conclusion: PCNL was new treatment modality at our set up yet this technique encourages us to say good bye to open surgery in future. PCNL being standard and safe procedure, is to be adapted at least at every district level hospital

Key Words: Renal stone, Percutaneous nephrolithotomy, Pneumatic lithoclast and D.J stent.

Citation of article: Siddiqui AA, Asif M, Imran Z, Khalid M, Hassan MH, Qaisrani SF. Percutaneous Nephrolithotomy (PCNL) in Adult Patients: Our Initial Experience at Teaching Hospital Dera Ghazi Khan. Med Forum 2021;32(1):40-43.

 

 

INTRODUCTION

Urinary stone disease is a major urological concern. Endourologic techniques have influenced the clinical approach and outcomes. Open surgery holds a historic importance in the management of most of the conditions. 1Before the endourology era, the main approach has relied on conservative surveillance or open stone removal.

Since the advancement of technology, refinements of surgical instruments and endourologic options, the management of renal stones had a paradigm shift from

 

 

1. Department of Urology / Anatomy2, DHQ, Teaching Hospital/ D.G.Khan Medical College, D.G. Khan.

 

 

Correspondence: Dr. Muhammad Hammad Hassan, Senior Registrar Urology, DHQ, Teaching Hospital/ D.G.Khan Medical College, DG Khan.

Contact No: 03336496325

Email: hammadhassan20@yahoo.com

 

 

Received:  September, 2020

Accepted:  November, 2020

Printed:      January, 2021

 

 

open surgery to the minimally invasive endourological surgery. One of them is percutaneous nephrolithotomy (PCNL) which is now considered as a standard and first line treatment according to various international guidelines specially for stone≥ 20 mm in size.  Whereas for stones of size 10 to 20mm can be treated with  extra corporeal  shock wave lithotripsy (ESWL), retrograde intra renal surgery (RIRS) in addition to  PCNL.2,3  In 1976, a new  horizon opened up before us when Fernstorm and Johansson first  performed  removal of renal  stone  through a nephrostomy tract4 leading to PCNL the most commonly performed  procedure for the management of renal stones. Besides minimum incision to skin and muscles the  PCNL directly  approaches  the collecting system/stone with less trauma to  the kidney and adjacent organs  as compared to the  pyelolithotomy  and hence a great deal of surgical expertise is required for percutaneous access to the kidney and stone removal5. Being minimally invasive surgery PCNL has lower morbidity, higher postoperative patient comfort, shorter convalescence, and lesser cost than open techniques, besides up to 85 % clearance rate of stones6,7. But Complication rates can be as high as 15%, including severe bleeding, infection, urinary extravasation, and injury to adjacent organs, most notably the colon. 8 The learning curve of PCNL is slow as this technique involves multiple steps yet if learned with efforts, it proves to be safe and effective treatment. We conducted this study to evaluate our initial experience of PCNL regarding stone clearance and complication encountered.

MATERIALS AND METHODS

This prospective observational study was carried out at urology department of tertiary care teaching hospital Dear Ghazi Khan between July 2018 to July 2020. After ethical approval we recruited 72 patients irrespective of gender, all were ≥ 17 years old with normal renal function. Patients demographic data, puncture site, no. of punctures, no. of stones, size of stones, residual stones, complications, nephrostomy/D.J placement and post-operative blood transfusion were recorded on questionnaire .We included renal stone  size  range from 15 mm -50 mm ,patient with both primary &recurrent renal stones. All the patients were evaluated with history, physical examination, laboratory investigation including urine culture & sensitivity, ultrasonography and radiological contrast studies for stone disease. Complete pre–operative evaluation done .All the patients were operated under general anesthesia. Pre-operative broad spectrum antibiotics were injected to all patients. Initially lithotomy position was made and ureteric catheter of 06 Fr was placed on the side to be operated for contrast study. Then patient was turned to the prone position. The puncture was done with nephrostomy needle of 16 gauge under fluoroscopic guidance. Guide wire of 0.032 inches was placed then track was dilated with Alken dilators up to 27 FR and Amplants sheath of 28 gauge was placed. The nephroscope was introduced in the collecting system of kidney and stone was fragmented by pneumatic lithoclast. Larger pieces of stone were removed with the help of stone grasper. At the end of procedure D.J (Double J) ureteric stent was placed in most of the cases alone and in some cases D.J stent along with nephrostomy tube was placed. In a few cases only nephrostomy was placed. These patients observed post operatively to check any hemodynamic instability due to excessive blood loss. Blood was transfused after proper blood grouping and cross matching in the patients where required. Residual stone were confirmed post operatively by X-ray KUB and Ultrasound KUB. Patients with anomalous kidney, stage horn stones, simultaneous PUJ narrowing, bleeding diathesis, cardiopulmonary diseases, obese and pediatric age were excluded.

Statistical Analysis: Data was entered in SPSS version 24.0 and analyzed. Frequency with percentage was calculated for qualitative parameters and mean + standard deviation calculated for quantitative parameters. Chi-square was applied to assess the significant relation among gender, age groups and outcome categories on the base of nephrolithotomy parameters.

RESULTS

The mean age of patients was 33 years with ±12 standard deviation and mean stone size was 24mm with 8.4± standard deviation. Male gender was predominant with 68% (n=49) while females were 32% (n= 23). Highest percentage of stones found in renal Pelvis (71%). Single stone found in 71% patients. Upper pole was the most common site of puncture (73.6%), while single puncture was done in 80% patients. Both DJ stent and nephrostomy were placed in 23 patients (32%) placed in cases of residual stones. Table-1.

Table No.1: Stone Demographics

 

 

Frequency

(%)age

Stone location

Renal pelvis

51

71

Upper Pole

1

1.4

Lower pole

3

4.2

Combined upper +lower +middle pole

17

23.6

Stone number

Single Stone

51

70.8

Multiple stones

21

29

Site of puncture

Upper Pole

53

73.6

Lower Pole

6

8.3

Multiple location

13

18

Number  of puncture

One  puncture

58

80.6

2 puncture

11

15.3

3 puncture

3

4.2

Stone primary /recurrent

Primary

63

87.5

Recurrent Post ESWL

2

2.8

Recurrent Post Pyelolithotomy

7

9.7

DJ stent only

Nephrostomy only

Both DJ +Nephrostomy

None

14

20

31

43

23

32

4

5.5

Regarding the stone clearance 90.3% have complete  stone clearance with no  residual stone while 6 patients (8.3%) has residual stones ranging  from 6mm- 15 mm. Procedure  was abandoned in one patient due to failure to access the collecting system in spite of multiple punctures and simultaneously per operative bleeding . This patient referred to a center where PCNL was a routine practice for many years.

Patients with residual stones (n=6) 8.3% underwent ancillary procedure  later on .ESWL was performed in 3 patients , URS and stone extraction performed  in 2 patients while one patient lost follow up. Regarding post-operative complications Three patient (4.2%) developed urinoma that was managed by URS and DJ stent insertion. One patient got urosepsis and one developed paralytic ileus both were managed conservatively. Only 2 patients needed blood transfusion. Table-2.

Table No.2: Outcomes and Complication

 

 

Frequency

(%)age

Outcomes

Complete clearance

65

90.3

Abandon

1

1.4

Residual 6mm-15mm

6

8.3

Complications

No Complications

67

93.1

Paralytic Ileus

1

1.4

Urinoma

3

4.2

Urosepsis

1

1.4

Blood transfusion

No

70

97.2

Yes

2

2.8

DISCUSSION

In the last 2 decades the evolution of renal stone treatment from open surgery (with significant  post-operative  morbidity)  to  minimally invasive techniques like PCNL and  retrograde  intra renal surgery ( with less morbidity and good outcomes)  is significant . PCNL is now considered the standard treatment for nephrolithiasis .The important factors in PCNL which affect the outcomes of kidney stone treatment in terms of stone clearance are stone size, its location and expertise of surgeon. In this study we shared our initial experience of PCNL in adult patients. Similar study was published by Malik MA, et al about their initial experience. Complete stone clearance rate  was  85.7%  while three (8.6%) patients had  residual stones while two(5.8%) patients had PCNL failure due to failed tract access. 7 While  in our study  complete clearance ( no residual stone) was achieved in 90% patients and  9% had partial clearance ( residual stone 6mm-15 mm) ,In one patient procedure was abandoned due to failed tract access . In a study by Atta Ullah in his study mentioned stone clearance in 78.8% patients with single session of PCNL. 9

In another study  stone free rate (SFR)  in PCNL was compared to SFR of ESWL , which was 80% in PCNL and   27.5%  in ESWL  , stone size was in the range of 15-25 mm . 10 The overall stone-free rate of 91.7% is also reported in literature which was in accordance with our study. 11

We did standard PCNL with standard endourology gadgets and when standard PCNL was compared to mini PCNL the difference in stone free rate was insignificant among the two. Although Mini-PCNL has advantages of significantly less bleeding and hospital stay. 12 Similarly the current and evolving techniques i.e. tubeless PCNL and total tubeless PCNL are   in current practice and under discussion. The advantages of both techniques is decreased transfusion rate and length of hospital stay and no leakage of urine from the wound   which are favorable as compare the  standard PCNL with nephrostomy  tube . But regarding Stone-free rate, both techniques have equal results of  91%-97%, almost same like standard PCNL result of our study.13 but we being infantile, introduced nephrostomy in majority of patients and even both DJ and nephrostomy tube, where we felt difficulty or lack of surety of stones clearance per operatively.

Though in different studies the commonest complication encountered was bleeding in 4/52 (7.7%) patients necessitating blood transfusion.9 and even high percentage 18.3% in a study.14 the reasons of low blood transfusion (2.8%) in our study, are single stone, single puncture site and strict inclusion criteria.  The study conducted by Malik MA, et al coincides with our study as their (2.9%) patients required a pint of blood transfusion due to excessive bleeding7.

We also performed PCNL in previously operated kidney (pyelolithotomy) and found no difference in stone clearance and complications in these and virgin cases. Although number of previously operated patient were quite low (n=7) in our study as compared (n= 66) patients in study by Siddiq A.A et al yet safety and efficacy pf PCNL in both studies are comparable .15

The complication of urinoma was found in 3 patients (4.2%)  in our study ,in literature the incidence  of  renal collecting system injury during PCNL  resulting in  extravasation and absorption of irrigation fluid , occurs in up to 8% of patients .16

The rate of sepsis is much lower, ranging from 0% to 3% in patients treated with appropriate perioperative antibiotics. 17 also in our study it was similar i.e. in a one patient (1.4%).

CONCLUSION

PCNL was new treatment modality for us yet  this technique encourages us to say good bye to open  surgery in future  at our set up . PCNL being standard and safe procedure, is to be adapted at least to every district level hospital.

Author’s Contribution:

Concept & Design of Study:

Amjad Ali Siddiqui

Drafting:

Muhammad Asif, Zahra Imran, Muhammad Khalid

Data Analysis:

Muhammad Hammad Hassan, Samah Fatima Qaisrani

Revisiting Critically:

Amjad Ali Siddiqui, Muhammad Asif

Final Approval of version:

Amjad Ali Siddiqui

Conflict of Interest: The study has no conflict of interest to declare by any author.

REFERENCES

1.     Çakici ÖU, Ener K, Keske M, Altinova S, Canda AE, Aldemir M, et al. Open stone surgery: a still-in-use approach for complex stone burden. Central Eur J Urol 2017;70(2):179–184. https://doi.org/ 10.5173/ceju.2017.1205

2.     Türk C, Petřík A, Sarica K, Seitz C, Skolarikos A, Straub M, Knoll T. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis.  Eur Urol 2016;69(3):468–474. https://doi.org/10.1016/ j.eururo.2015.07.040

3.     Assimos D, Krambeck A, Miller NL, Monga M, Murad MH, Nelson CP, et al. Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART I.  J Urol 2016;196(4):1153–1160. https://doi. org/ 10.1016/j.juro.2016.05.090

4.     Fernström I, Johansson B. Percutaneous pyelolithotomy. A new extraction technique.  Scandinavian J Urol Nephrol 1976;10(3):257–259. https://doi.org/10.1080/21681805.1976.11882084

5.     Malik I, Wadhwa R. Percutaneous Nephrolithotomy: Current Clinical Opinions and Anesthesiologists Perspective. Anesthesiol Res Pract 2016;ID 9036872, 7. https://doi.org/10. 1155/2016/9036872.

6.     Liu C, Zhou H, Jia W, Hu H, Zhang H, Li L. The Efficacy of Percutaneous Nephrolithotomy Using Pneumatic Lithotripsy vs. the Holmium Laser: a Randomized Study. Indian J Surg. 2017 Aug;79(4):294-298. doi: 10.1007/s12262-016-1473-2. Epub 2016 Mar 19. PMID: 28827902; PMCID: PMC5549040.

7.     Malik MA, Jamil MN, Farooq U, Mahmood MF. Initial experience of percutaneous nephrolithotomy in Hazara region. J Ayub Med Coll Abbottabad 2018;30(2):241–4.

8.     Patel NH, Schulman AA, Bloom JB, Uppaluri N, Phillips JL, Konno S, et al. Device-Related Adverse Events During Percutaneous Nephrolithotomy: Review of the Manufacturer and User Facility Device Experience Database. J Endourol 2017;31(10):1007–1011. https://doi.org /10.1089/end.2017.0343

9.     Ullah A, Khan MK, Rahman AU, Rehman RU. Percutaneous nephrolithotomy: A minimal invasive surgical option for the treatment of staghorn renal calculi. Khyber Med Univ J 2012;4(4):156-160.

10.            Gadelmoula M, Elderwy AA, Abdelkawi IF, Moeen AM, Althamthami G, Abdel-Moneim AM. Percutaneous nephrolithotomy versus shock wave lithotripsy for high-density moderate-sized renal stones: A prospective randomized study. Urol Ann 2019;11:426-31.

11.            El-Tabey MA, Abd-Allah OAW, Ahmed AS, El-Barky EM, Abdel-Sattar Y. Noureldin Curr Urol. 2014;7(3): 117–121. Published online 2014 Feb 10. doi: 10.1159/000356261

12.            Thapa BB, Niranjan V. Mini PCNL Over Standard PCNL: What Makes it Better? Surg J (New York, NY) 2020;6(1):e19–e23. https://doi.org/10.1055/s-0040-1701225.

13.            Aghamir S, Heidari R, Bayesh S, Salavati A, Elmimehr R. Are Nephrostomy and Ureteral Stent Necessary after Multi-Access Percutaneous Nephrolithotomy? Current Urol 2019;13(3):141–144. https://doi.org/10.1159/000499279

14.            Ullah S, Ali S, Karimi S, et al. Frequency of Blood Transfusion in Percutaneous Nephrolithotomy. Cureus 2020;12(10): e11086. doi:10.7759/ cureus.11086

15.            Awan AS, Mithani S, Yousuf F, Haseeb S, Hassan W, Kumar S. Percutaneous Nephrolithotomy in a Previously Operated Kidney. J Coll Physicians Surg Pak 2020;30(11):1201-1205.

16.            Taylor E, Miller J, Chi T, Stoller ML. Complications associated with percutaneous nephrolithotomy. Transl Androl Urol 2012;1(4): 223–228.

17.            el-Nahas AR, Eraky I, Shokeir AA, et al. Factors affecting stone-free rate and complications of percutaneous nephrolithotomy for treatment of staghorn stone. Urol 2012;79:1236-41.