Key words

Hasan Nedim Goksel Goktug

_{, Suleyman Yesıl}

_,

Ufuk Öztürk

_{, Can Tuygun}

_{, M. Abdurrahim Imamoglu}

Totally Tubeless Percutaneous Nephrolithotomy

– Selecting for Success in Children

Przezskórna nefrolitotomia bez stosowania drenażu

– optymalny dobór pacjentów pediatrycznych

1 _{Department of Urology, Ministry of Health, Ankara Diskapi Yildirim Beyazit Education and Research Hospital,}

Ankara, Turkey

2 _{Gazi University School of Medicine, Urology Department, Ankara, Turkey}

A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation;

D – writing the article; E – critical revision of the article; F – final approval of article; G – other

Abstract

Background. The placement of a nephrostomy tube or internal ureteral stent after PCNL has been considered standard practice.

Objectives. To investigate the inclusion criteria for totally tubeless PCNL in pediatric cases.

Material and Methods. A total of 27 children who underwent PCNL included in the study: twelve of the 27 patients who underwent totally tubeless PCNL (group 1; tubeless and stentless), and the remaining 15 patients underwent Standard PCNL (group 2; tube with or without stent). Whether or not to perform totally tubeless technique was decided intraoperatively. The length of hospitalization, drop in hemoglobin level, the operation time, stone burden and the fluoroscopy time of group 1 and 2 were compared statistically. Also stone free and complication rates were evaluated in both groups.

Results. The mean age was 5 years and 9.5 years in group 1 and 2, respectively (p = 0.01). The mean operative time was 15.83 min in group 1, and 48.6 min in group 2 (p = 0.0001). The mean change in hemoglobin levels between preoperative and postoperative measurements was –1.83 mg/dl for group1, and –5.2 mg/dl for group 2 (p = 0.0001). No blood transfusion was needed during or after the operation in any cases for group 1. The mean length of hospital stay was 1.83 day in group 1 and 5.53 day in group 2 (p = 0.001). Stone free rate for group 1 was 100% (12/12) and 93.3% (14/15) for group 2. There were no major operative or postoperative complications in both groups.

Conclusions. Provided an optimal patient selection, the success and safety rates of PCNL’s performed via totally tubeless technique are similar to those (Adv Clin Exp Med 2013, 22, 4, 565–570).

Key words: tubeless PCNL, inclusion criteria, children.

Streszczenie

Wprowadzenie. Wprowadzenie drenu nefrostomijnego lub wewnętrznego stentu moczowodowego po zabiegu PCNL zostało uznane za standardową praktykę.

Cel pracy. Ocena kryteriów włączenia do przezskórnej nefrolitotomii bez stosowania drenażu u dzieci.

Materiał i metody. Do badań włączono 27 dzieci, u których przeprowadzono zabieg PCNL: 12 z 27 pacjentów, u których przeprowadzono przezskórną nefrolitotomię bez stosowania drenażu (grupa 1 – bez drenu ani stentu) oraz 15 pozostałych, u których przeprowadzono standardowy zabieg PCNL (grupa 2 – dren z/bez stentu). Decyzję o przeprowadzeniu bądź nie przezskórnej nefrolitotomii bez stosowania drenażu podejmowano śródoperacyjnie. Długość hospitalizacji, zmniejszenie stężenia hemoglobiny, czas operacji, ciężar kamienia i czas fluoroskopii w gru-pie 1 i 2 porównano statystycznie. Również doszczętność usunięcia kamienia i odsetek powikłań oceniano w obu grupach.

Wyniki. Średnia wieku wynosiła 5 lat i 9,5 roku w grupie 1 i 2 (p = 0,01). Średni czas operacji wynosił 15,83 min w grupie 1, a 48,6 min w grupie 2 (p = 0,0001). Średnia zmiana stężenia hemoglobiny między pomiarem

przedope-Adv Clin Exp Med 2013, 22, 4, 565–570 ISSN 1899–5276

ORIGINAL PAPERS

The prevalence of renal stone disease in chil-dren, which generally depends on metabolic dis-turbances, anatomic abnormalities and urinary tract infections, is 5–15% [1]. Although western-ized lifestyle and dietary changes include higher salt intake and decreased water consumption con-sider being at high risk for urinary system stone development and high recurrence rate [2]. Extra-corporeal shock wave lithotripsy (ESWL) has been accepted as the first line treatment choice for pe-diatric stone disease [3]. But, patients with dilated obstructed kidneys, large stone burden, infection or staghorn calculi have not been suitable candi-dates for ESWL [4]. In such cases, percutaneous nephrolithotomy (PCNL) has been preferred as the first line treatment.

The placement of a nephrostomy tube and/or internal ureteral stent after PCNL has been con-sidered standard practice [5]. The purposes of the tube placements are to allow the renal puncture to heal, and to provide proper drainage of urine, and to permit access to the collecting system, if a sec-ondary procedure is required [6]. On the other hand, in some patients, the placement of a neph-rosthomy tube and ureteral stent can be omitted. Thus, these modifications in PCNL procedures al-low earlier discharge from the hospital, and leads to more rapid recovery [5]. Moreover, the compli-cations of internal stenting such as ureteral paraly-sis and ureteral obstruction may be avoided [7].

Since the late 1990s, there is a challenge for many authors to minimize PCNL – related mor-bidity [8–10]. Then, it has been stated that totally tubeless PCNL could be a safe approach especial-ly in selected adult patients, which many studies indicate shorter hospitalization time for patients undergoing totally tubeless PCNL [11, 12]. To date it has not been extensively reported in pedi-atric patients whether totally tubeless PCNL was performed [13].

In this study, the authors aimed to investigate the inclusion criteria for totally tubeless PCNL in pediatric cases.

Material and Methods

Between 2009 and 2011 years, 27 patients who underwent PCNL for renal stones aged 15 years

or younger were included in the study and divid-ed into two groups as totally tubeless PCNL (no nephrostomy tube and no ureteral stent) (group 1, n = 12 patients) and standard PCNL (nephrosto-my tube with or without ureteral stent) (group 2, n = 15 patients). The demographic data of patients and stones are summarized in Table 1. The stone composition of 23 patients was calcium oxalate and 4 of them were uric acid. The institutional re-view board approved the study and informed con-sent was provided from all patients.

The criteria to perform totally tubeless PCNL were determined according to the present experi-ence in adult patients and previous reports [5, 8, 9, 11]. Inclusion criteria for PCNL surgery were stone size greater than 1 centimeter (cm) for lower pole, 1.5 cm for upper pole or renal pelvis, stones that do not respond to ESWL or pelvicaliceal anatomy was not favorable for clearance after ESWL, or parents prefer PCNL as first line treatment. The inclusion criteria for the totally tubeless PCNL during the operationwere a lack of perforation in the collect-ing system, no serious bleedcollect-ing, no more than one access, no serious extravasations at the end of the PCNL, a stone free state or clinically insignificant residual fragments (CIRF) (less than 4 millimeters, -mm-), no bleeding for 5 minutes after operation were considered as inclusion criteria (Fig. 1).

Preoperatively, patients were evaluated with urine analysis and culture, serum creatinine and biochemistry, complete blood count, coagulation tests, intravenous urography (IVU) and USG. Non-contrast computerized tomography (CT) was per-formed in patients with nonopaque stones. The stone size (mm²) was calculated by a millimeter graph paper tracing of the anteroposterior stone projection on a plain skiagram or CT.

PCNL technique was performed in the follow-ing manner.Under general anesthesia a 5 French ureteral catheter was placed to the operation side, then a prone position was given to the patient. Go-nads were protected with a lead apron. After select-ing the most appropriate calyx in order to reach the stone, access was created by an 18 gauge needle with the help of retrograde pyelography. The nephrosto-my tract was formed with plastic amplatz dilators under fluoroscopic image. In all patients 20 French working sheaths were used to perform the operation by an 18 French nephroscope. Stone fragmentation racyjnym i pooperacyjnym to –1,83 mg/dl dla grupy 1 i –5,2 mg/dl w grupie 2 (p = 0,0001). W grupie 1 transfuzja krwi nie była konieczna podczas lub po zabiegu w żadnym przypadku. Średnia długość pobytu w szpitalu wynosiła 1,83 dni w grupie 1 i 5,53 dni w grupie 2 (p = 0,001). Odsetek wolny od kamienia dla grupy 1 wynosił 100% (12/12) i 93,3% (14/15) dla grupy 2. Nie było poważnych powikłań śród- ani pooperacyjnych w obu grupach.

Wnioski. Pod warunkiem optymalnego wyboru pacjenta, odsetek sukcesu i bezpieczeństwa zabiegu PCNL wyko-nywanego techniką bez stosowania drenażu są podobne (Adv Clin Exp Med 2013, 22, 4, 565–570).

was carried out with a pneumatic lithotripter. At the end of the procedure, a C-arm multidirectional fluoroscopy was used to decide between stone-free patients and patients with CIRF. Anterograde py-elography was performed to evaluate the collecting system and assess the amount of extravasations. No internal or external catheter was used in group 1. In group 2, 14 French re-entry catheter was inserted as nephrostomy tube.

Perioperative and postoperative parameters were related to morbidity, which included the length of hospitalization, drop in hemoglobin lev-el, the operation time which was defined as the

time to obtain access to the desired calyx, stone fragmentation and removal of stone, the presence of hydronephrosis, stone burden, the fluorosco-py time of group 1 and 2 were compared. Stone clearance was defined as the absence of any residu-al fragments greater than 4 millimeters on urinary system plain radiography, postoperatively. The follow-up examinations in all patients were done using a plain skiagram on the first postoperative day and month. USG was also performed in pa-tients in group 2 on the first postoperative day and month for perirenal hematoma, urinoma or resid-ual stones.

Table 1. The characteristics of patients and stones

Tabela 1. Cechy pacjentów i kamieni

Group 1 (Grupa 1) Group 2 (Grupa 2) p Number of patients (Liczba pacjentów) 12 15

Male/Female (Płeć męska/żeńska) 4/8 11/4 0.06

Age – years, mean (range) (Wiek – lata, średnia (zakres)) 5.25 (1–9) 9.4(5–15) 0.01 Body mass index – kg/m², mean (range)

(Wskaźnik masy ciała – kg/m², średnia (zakres)) 25.99 (17.7–33.3) 19.96 (16.96–27.07) 0.0001 Stone location (Umiejscowienie kamienia)

pelvis calices pelvis + calices

8 1 3

6 6 3

0.44

Stone side; left/right – % (Strona kamienia; lewa/prawa – %) 3/9 (25/75) 6/9 (40/60) 0.68 Stone burden – mm², mean (range)

(Ciężar kamienia – mm², średnia (zakres)) 199 (100–320) 402.67 (95–1550) 0.07 Hydronephrosis – % (Wodonercze – %) 11(91.7) 7(46.7) 0.01 Stone opacity (Przezroczystość kamienia)

radiopaque (%)

radiolucent (%) 11(91.7)1 (8.3) 12(80)3 (20)

0.61

Fig. 1. After PCNL procedure was completed, the authors waited for 5 minutes and when no hemorrhage was observed, the procedure of the 5-year old patient ended totally tubeless

In this study, the authors aimed to investigate the inclusion criteria for totally tubeless PCNL in pediatric cases. Data analysis was performed us-ing SPSS for Windows, version 15. The data was shown as mean ± standard deviation for continu-ous variables. Categorical variables were present-ed in percentages. Means were comparpresent-ed using Mann Whitney U test. For categorical compari-sons, Chi-square or Fisher’s Exact test were used, where appropriate. P < 0.05 was considered statis-tically significant.

Results

The mean age was 5 years (range, 1–9 years) and 9.5 years (range, 5–15 years) in group 1 and 2, respectively (p = 0.01). Of the 27 children, the fe-male fe-male ratio was 4:5 (12 fefe-male, 15 fe-male).

The operative data is summarized in Table 2. The mean operative time was 15.83 min. (range, 3–25 min.) in group 1, and 48.6 min. (Range, 10– –80 min.) in group 2 (p = 0.0001). The mean flu-oroscopy time was 2.24 min. (range, 1–3 min.) in group 1, and 4.99 min. (range, 2–13 min.) in group 2 (p = 0.0001). The mean change in he-moglobin levels between preoperative and post-operative measurements was –1.83 mg/dl (range, 0–5) for group 1, and –5.2 mg/dl (range, 2–10) for group 2 (p = 0.0001). No blood transfusion was needed during or after operation in any cases for group 1. Only one patient in group 2 required blood transfusion. The mean length of hospital stay was 1.83 (range, 1–4 days) in group 1 and 5.53 (range, 1–12 days) in group 2 (p = 0.001) (Table 3).

All PCNL procedures were done via one ac-cess and subcostal approach. In Group 2, one pa-tient had a residual stone of 6 mm, two papa-tients had suspected perforations in the collecting sys-tem, and five patients had considerable extravasa-tions at the end of the procedure. Seven patients had considerable bleeding and had to be managed by a nephrostomy tube. Stone free rate for group 1 was 100% (12/12) and 93.3% (14/15) for group 2 was stone free. There were no major operative or postoperative complications in both groups. How-ever, postoperative fever was detected in 2 patients in group 2 and managed medically using antibiotic prophylaxis, and no urosepsis was developed. No patients had urinoma and/or perirenal hematoma.

Discussion

The results of this study have shown that to-tally tubeless PCNL may be performed safely and effectively in selected pediatric patients with renal stones. The choice of patients to perform totally tubeless PCNL was essential for the successful out-come and minimal morbidity.

The first series of standard PCNL in children was successfully performed by Woodside et al. in 1985. In more recent years, due to the emergence of new instruments such as new generation dila-tators, lithotripters and flexible nephroscope and due to the development of more effective energy sources such as holmium lasers, new techniques such as tubeless mini PCNL (no neprostomy, with ureteral stent) have been developed to treat selected children with renal stones. As reported

Table 3. Postoperative data

Tabela 3. Dane pooperacyjne

Group 1 (Grupa 1) Group 2 (Grupa 2) p Hospitalization time – days, mean (range)

(Czas kospitalizacji – doby, średnia (zakres)) 1.83 (1–4) 5.53 (1–12) 0.001 Drop in hemoglobin – mg/dl, mean (range)

(Zmniejszenie stężenia hemoglobiny – mg/dl, średnia (zakres) 1.83 (0–5) 5.2(2–10) 0.0001

Table 2. Operative data

Tabela 2. Dane operacyjne

Group 1 (Grupa 1) Group 2 (Grupa 2) p Mean operation time – min (Średni czas operacji – min) 15.83 48.6 0.0001 Mean fluoroscopy time – min (Średni czas fluoroskopii – min) 2.24 4.99 0.0001 Access site (Miejsce dostępu)

lower pole (%)

in the literature, these developments have suc-ceeded in lowering the factors affecting morbid-ity levels compared to standard PCNL, including such factors as blood loss, hospitalization lengths and wound healing [14, 15]. In another study that seems to support authors’ conclusion, tubeless PCNL was performed on a group of 20 pediatric stone patients and the tubeless option was report-ed as being safe and having resultreport-ed in and shorter hospitalization periods [7].

In a recent study, Ozturk et al. compared, for the first time, the retrospective results obtained from 8 cases, each totally tubeless and standard PCNL procedures performed on a group of 16 children with renal stones [13]. While the study found the totally tubeless technique to be a safe and effective method, because of the insufficient number of cas-es, they found no statistically significant reduction vis-à-vis the standard technique in morbidity relat-ed preoperative and postoperative parameters. Al-though there are similarities in the selection of the cases for the totally tubeless method in these two studies, the authors suspect that the larger number of cases in this study heavily contributed to the dif-ference in the findings. Furthermore, they believe that surgical competence was also among the fac-tors leading to the difference in the findings.

As reported in Bilen et al. study, after surgeries in tubeless mini PCNL operations, the lack of bleed-ing or minimal bleedbleed-ing may indicate that there is no need for a nephrostomy tube or that placing a urethral stent might be sufficient and even less invasive [16]. In the present study, under the same conditions, not only did the authors not use neph-rostomy tubes but they did not use urethral stents

either. Furthermore, there remained no need for a secondary entry for ureteral stent. The patient at-tributes and factors the authors used to determine when to perform the tubeless technique are simi-lar to those used by Khiary & Salem in their appli-cation of pediatric tubeless PCNL [7], as well as to those used by Ozturk et al. in the selection of total-ly tubeless technique [13].

Preoperative stone size was not a statistically significant predictor in the decision to use totally tubeless PCNL. However, clinically speaking, as the stone burden decreases, one may expect a bias to-wards totally tubeless technique. Operative times, in Group 2 are significantly higher than in group 1. The authors believe it is because of the higher stone burden in the second group. As a preoperative fac-tor, stone localization was not a determining factor in the selection of totally tubeless technique. Cur-rently, from a preoperative point of view, there are no patient attributes that can be used to pre-deter-mine when to select the totally tubeless PCNL. Per-haps future studies involving larger number of cas-es will shed more light on this subject.

The authors concluded that tubeless PCNL alone is not yet a standard approach to treating children with renal stones. However, provided an optimal patient selection, the success and safe-ty rates of PCNL’s performed via totally tubeless technique are similar to those obtained from the standard technique, and more advantageous when accounting for factors affecting the morbidity lev-els. Nevertheless, the authors believe cases involv-ing tubeless PCNL’s are also ideal candidates for the totally tubeless technique and they invite more research along these lines.

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Address for correspondence:

Ufuk Ozturk Ministry of Health

Ankara Dışkapı Yıldırım Beyazit Education and Research Hospital Department of Urology

Ankara Turkey

Tel.: +903125962243

E-mail: [email protected]

Conflict of interest: None declared