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Comparative evaluation of upper versus lower calyceal approach in percutaneous nephrolithotomy for managing complex renal calculi

Comparative evaluation of upper versus lower calyceal approach in percutaneous nephrolithotomy... stones. The success of PCNL is highly related to optimal renal access. Upper calyceal puncture being more difficult and more demanding have relatively few studies presented. Aims and Objectives: This prospective study was carried out to evaluate the effectiveness and safety of upper calyceal versus lower calyceal puncture for the removal of complex renal stones through PCNL. Materials and Methods: A total of 94 patients underwent PCNL for complex renal stone in our institute. Fifty‑one of them underwent lower calyceal, while 43 underwent upper calyceal puncture. The two approaches are compared as per total duration of surgery, intraoperative blood loss, infundibular/pelvic tear, rate of complete clearance and rate of postoperative complications (pulmonary, bleeding, fever and sepsis, etc.). Observation and Results: In our study, the success rate was 76.47% for those in the lower, 90.70% for those in the upper calyceal access group. Thoracic complications (hydrothorax) occurred to 1 patient in upper calyceal supracostal access group. Bleeding requiring blood transfusion happened to 5 patients in lower calyceal access and 1 in upper calyceal group. Conclusion: In our study for the management of complex renal calculi, we conclude that in a previously th unoperated kidney, upper calyceal puncture through subcostal or supra 12  rib is a feasible option minimizing lung/pleural rupture and gives a better clearance rate. We suggest that with due precautions, there should not be any hesitation for upper calyceal puncture in indicated patients. Key Words: Percutaneous nephrolithotomy, staghorn, supracostal puncture Address for correspondence: Dr. Bhupender Kadyan, Department of Urology, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune ‑ 411 018, Maharashtra, India. E-mail: drkadyan@yahoo.com Received: 04.03.2014, Accepted: 14.04.2014 INTRODUCTION treatment of choice for renal stones, and some upper ureteric stones. It has been performed since 1980s, with overall [1] Percutaneous nephrolithotomy (PCNL) is considered as success rates exceeding 90%. Improvements in technique and instruments have diminished complication rates associated with Access this article online [2] this procedure. However, complications such as hemorrhage, Quick Response Code: encountered in 1‑23% of cases, intrathoracic complications, Website: www.urologyannals.com observed in 2‑12.5%, and other organ injuries, observed [1,2] in <1%, are being reported with percutaneous renal surgery. DOI: Complex renal calculi as described by us are renal stones 10.4103/0974-7796.148591 occupying the renal pelvis and at least two of the three Urology Annals | Jan - Mar 2015 | Vol 7 | Issue 1 31 Singh, et al.: Supracostal approach for complex renal calculi major calyceal systems. It can be the extension of the pelvic Each patient underwent PCNL under general anesthesia, and stone (staghorn) or a multiple primary or secondary renal was performed by the same team of operating urologists. [3] Beginning with cystoscopy and insertion of 6Fr ureteral calculi occupying the calyceal group. The successful removal of stones requires the accurate placement of a percutaneous catheter to allow contrast material delineation of the renal tract that provides direct access to the stone (optimal kidney collecting system. The desired calyx was chosen according to access). Inferior calyceal stones are usually approached through the general principle for access site selection stated by Lingeman [6] the posterior inferior calyx. In complex renal calculi, complete et al., that percutaneous access to the kidney should allow maximal stone removal using a rigid nephroscope. All lower clearance may often not be possible through a single tract calyceal [Figure 1] and upper calyceal infracostal punctures in an inferior calyx because of problems in negotiating the were made staying in between the posterior axillary line and acute angles between calyces. However, inferior lower calyceal para spinal line. All upper calyceal supracostal punctures were punctures are being performed more commonly because it has th [4] made in 11 intercostals space at mid scapular line [Figure 2]. fewer complications. In obese patients, the puncture site was lateral to mid scapular The supracostal upper pole access and multiple accesses line. During supracostal punctures, skin and subcutaneous provide a good approach and straight access to staghorn calculi, puncture was made during the expiratory phase, whereas renal proximal ureteral calculi, and calculi associated with primary parenchymal puncture was done during deep inspiration. Proper ureteropelvic junction obstruction, and calculi associated with calyceal puncture was confirmed by free flow of urine through retained ureteral stents. The upper pole of the kidney is aligned the needle and appropriate placement of teremo guidewire. medially and posterior to the lower pole, making the upper For the patient in whom we believed a second puncture was [5] pole a shorter and easier access route. However, staghorn necessary for complete clearance, we preferred to pass another calculi are the most difficult cases, take a longer time to be guidewire at this stage of the procedure to be used later for completely removed. Furthermore, complications are set to be the creation of the second access tract. Dilatation of the more frequent in supracostal puncture group cases. initial tract was done using alken’s metal dilator system up to 24Fr followed by the introduction of an amplatz sheath. MATERIALS AND METHODS Rigid nephroscope (stortz 17/22Fr) was used and stones were fragmented by Swiss Lithoclast Master (Electro Medical All patients having complex renal stones as defined above Systems, Nyon, Switzerland). After fragmentation and were included in our prospective study and underwent PCNL. stone removal, the collecting system was examined by direct Patients in the pediatric age group (<15 years), patients with, nephroscopy and fluoroscopy for residual stones. Antegrade comorbid conditions (diabetes mellitus, hypertension, and on double‑J stenting and nephrostomy placement is done in all anticoagulant therapy), associated pyonephrosis, and congenital cases. anomalies (pelvi ureteric junction obstruction, bifid pelvis, megaureter, horseshoe kidney, etc.) were excluded from the In the postoperative period, patients having upper calyceal study. Patients were divided into two groups as per the primary supracostal puncture, were closely monitored for dyspnea, calyceal punctures taken during PCNL. Institutional Ethical tachypnea, chest pain or clinically decreased air entry. All Committee approval was obtained prior to commencement of patients with upper calyceal supracostal punctures had the study. Written and informed consent was taken from all patients undergoing PCNL. History of previous open renal surgery of the same unit where we plan PCNL in our study was evaluated as a predictor of surgical outcome. Preoperative complete blood count, serum creatinine, platelet count, bleeding and coagulation profile, and urine culture were obtained from all patients. Radiological evaluation included ultrasonography (USG), intravenous urography and in addition computed tomography (CT), if needed in certain patients having radiolucent calculi. The stone burden was measured as the sum of the largest linear dimensions of all stones based on kidneys, ureters, and bladder (KUB)/CT films. Prophylactic antibiotics (ceftriaxone 1 g) was given intravenously at the time of induction of anesthesia and continued for 2 days. Figure 1: Subcostal puncture 32 Urology Annals | Jan - Mar 2015 | Vol 7 | Issue 1 Singh, et al.: Supracostal approach for complex renal calculi postoperative chest X‑ray done. On suspicion of thoracic RESULTS complications, intercostal drainage was planned if required. In our study, 94 patients underwent PCNL for complex renal Hemoglobin (Hb) was checked and X‑ray KUB was done on calculi. These patients were grouped in two, as per the selection day one after surgery in all patients. of primary calyceal puncture site. Patient’s demographics are Relook PCNL, if required for residual stones were done after summarized in Table 1. 48 h. We made a division, whether a new puncture was taken or not during second look, to assess the overall success rate of both In upper calyceal puncture group patients, supracostal puncture the approaches in our study as defined below. All the patients in was made in 21 patients, whereas the remaining 22 achieved whom the stones could be removed during second look through upper calyceal puncture through infracostal approach (just the same tract, was because of the following reasons: th below 12 rib). • Better visualization during second look that got hampered during first PCNL because of bleeding The results of operative time, secondary puncture required, • The stone in the inaccessible calyx was pushed into complications, and hospital stay are summarized in Table 2. an accessible zone through stone puncture via initial puncture IP needle and flushed by normal saline (PCN We found a significant Hb drop (P < 0.0001) in the subgroup flush) of patients undergoing previous open surgery and having • With fresh surgical mind, by using smaller pelvicalyceal tear in upper calyceal group when compared to the nephroscope/ureteroscope, inaccessible stones were same type of patients in lower calyceal group as summarized managed. in Table 3. Procedure was evaluated in terms of operative time, complete Complete clearance after PCNL was achieved in 77 patients; clearance, Hb drop, blood transfusion required, secondary out of 77, 36 (83.72%) were in the upper calyceal group and procedure required, fever and sepsis, hospital stay and success 41 (80.39%) were in the lower calyceal group. Secondary rate. In our study, complete clearance is set to be achieved procedure required in 7 (16.28%) patients in upper calyceal if the postoperative X‑ray KUB showed no radio‑opaque group, while 10 (19.61%) patients were in lower calyceal group, shadow or the residual stone size is <4 mm on postoperative which further requires ancillary procedure as summarized in USG/CT. Blood transfusion was given, if the postoperative Table 4. Hb drops below 8 g/dl. We defined the success rate as the number of patients achieving complete clearance, either after DISCUSSION PCNL with <2 tracts or second look cases not requiring any new punctures during second look. A proper selection of an ideal access tract is the prerequisite for maximum clearance during PCNL in kidneys having large stone The statistical inference was obtained by computing Z test, burdens. Until date, many studies have been conducted comparing Mann‑Whitney test, t‑test for the difference between any two upper and lower calyceal punctures in achieving maximum values and considered as statistically significant if the P < 0.05. clearance with minimal acceptable complications (potential thoracic complication in supracostal approach). The success rate achieved in our study was 90.70% in upper calyceal group patients, whereas it was 76% in lower Table 1: Patients demographics Characteristics Upper calyceal Lower calyceal Total P value puncture (n=43) puncture (n=51) Number of 43 (45.7) 54 (54.3) 94 patient (%) Age 39.84 (±10.42) 39.53 (±10.23) >0.05 Male 28 33 61 Female 15 18 33 Right side 22 27 49 Left side 21 24 45 Previous open 4 (9.30) 7 (13.73) 6 >0.05 surgery (%) Stone size (mm) 39.02±6.27 39.53±7.17 ‑ >0.05 Figure 2: Supracostal puncture Urology Annals | Jan - Mar 2015 | Vol 7 | Issue 1 33 Singh, et al.: Supracostal approach for complex renal calculi Table 2: Operative parameters of difficulty in manipulating within the pelvicalyceal system Characteristics Upper calyceal Lower calyceal P value due to restricted renal movement in a patient having previously puncture (n=43) puncture (n=51) open renal surgery. This led to the necessity of going for extra Operative time (min) 71.70±8.53 73.02±8.86 >0.05 punctures for tackling the stones in inaccessible calyces. In Secondary puncture 6 (13.95) 13 (25.49) >0.05 [8] required (%) their study Margel et al. they found higher percentage of Hospital stay in days 4.74±1.33 4.69±1.32 >0.05 ancillary procedures required to achieve complete clearance in Complications (%) a patient with a history of open nephrolithotomy probably due Pelvicalyceal tear 2 (4.65) 5 (9.80) >0.05 BT required 1 (2.33) 5 (9.80) >0.05 to scarred surrounding tissues and anatomical changes leading Hydrothorax 1 (2.33) 0 >0.05 to restricted renal movement. Fever/sepsis 9 (20.93) 8 (15.69) >0.05 Hb drop (g) 1.64±0.59 1.56±0.53 >0.05 The incidence of thoracic complication during supracostal BT: Blood transfusion, Hb: Hemoglobin [9,10] punctures in various studies range between 3% and 16%. Table 3: Hb% drop in subgroups In our study, out of 21 patients who underwent upper calyceal Characteristics Upper calyceal Lower calyceal P value supracostal puncture, only 1 patient developed subclinical puncture (n=43) puncture (n=51) hydrothorax diagnosed on postoperative chest X‑ray. He Previous open surgery 2.89±0.21 (n=4) 1.66±0.64 (n=7) <0.0001 did not develop any clinical symptom and was managed Pelvicalyceal tear 2.10 (n=2) 1.44±0.32 (n=5) <0.0001 nd conservatively without requiring intercostal drainage placement. Required 2 puncture >0.05 2.20±0.88 (n=6) 1.97±0.45 (n=13) Anatomically the parietal pleura crosses the middle of the Hb: Hemoglobin th th 12 rib posteriorly and 11 rib at posterior axillary line. It th Table 4: Surgical outcome makes the 11 intercostal space lateral to mid scapular line a Complete clearance Upper calyceal Lower calyceal safe zone with a minimal risk of any pleural injury. We believe achieved after group (n=43) group (n=51) th that our site of supracostal puncture at 11 intercostal space PCNL at/lateral to mid scapular line and technique of puncturing the 1 tract 30 28 skin and subcutaneous tissue during expiration whereas renal 2 tracts 5 9 >2 tracts 1 4 parenchyma puncture during inspiration (for adequate renal Secondary procedure descent) makes this puncture as safe as infracostal punctures, nd 2 look using 4 2 reducing the risk of thoracic complication as minimum. previous tract nd 2 look using new 1 3 tract We did not find any statistical significance between the type ESWL 2 5 of puncture and blood loss. All the 6 patients requiring Overall result (%) Success rate 39 (90.70) 39 (76.47) blood transfusion in our study were found to have low Failure rate 4 (9.30) 12 (23.53) preoperative Hb (mean 9.2 g%) which dropped below 8 g% PCNL: Percutaneous nephrolithotomy, ESWL: Extracorporeal shock after surgery. However, when the amount of blood loss was wave lithotripsy evaluated between patients with history of previous open renal surgery and intraoperative pelvicalyceal tear, there was calyceal group. We found easier accessibility to many calyces significant blood loss seen in upper calyceal puncture group when an approach is made through upper calyx that favors as compared with lower calyceal group. This can be explained good manipulations of the nephroscope and forceps within due to the injury caused to upper infundibulum either during pelvicalyceal system. The same is not true when a tract was puncture to upper calyx or excessive torque during intrarenal established through lower calyx, requiring undue angulation, manipulations leading to upper infundibular tear. Sampaio and and torque. We believe that this difference is because of the [11] Aragao stated that upper infundibulum is almost completely straight tract of upper infundibulum along the long axis of involved, both anteriorly and posteriorly by segmental or the kidney and the anatomical lie of the kidney over iliopsoas interlobar (infundibular) arteries in 86.6% of cases, whereas muscle that cause the upper pole positioned more posterior in 62% of the cases the posterior aspect of the lower major as compared with the lower pole. These two factors provide calyceal infundibulum was free from arteries. Sampaio excellent visualization of the pelvicalyceal system when an [7] [12] et al. in a different study reported injury to an interlobar approach is made through upper calyx. Netto et al. and Aron [4] vessel in two‑thirds of the kidney puncturing the upper pole et al. in their respective studies found similar results when infundibulum, while only 13% had an arterial injury when upper calyceal approach was made. punctured through the lower pole infundibulum. Apart from the renal and pelvicalyceal anatomy, we found that the free mobility of the renal unit is also an important factor in In our study, the main complication seen in both groups achieving better clearance through PCNL. We felt some degree was fever/sepsis (20.93% in upper calyceal and 15.69% in 34 Urology Annals | Jan - Mar 2015 | Vol 7 | Issue 1 Singh, et al.: Supracostal approach for complex renal calculi [13] creation on incidence of renal hemorrhage. J Urol 1997;157:1229‑31. lower calyceal group). Wong and Leveillee had 11.54% of [14] 3. Segura JW. The role of percutaneous surgery in renal and ureteral stone incidence of fever, whereas Raza et al. had 19.12% incidence removal. J Urol 1989;141:780‑1. [15] of septicemia/pyrexia in their respective studies. Olbert et al. 4. Aron M, Goel R, Kesarwani PK, Seth A, Gupta NP. Upper pole access for in their study did not find any evidence for a relationship of complex lower pole renal calculi. BJU Int 2004;94:849‑52. 5. Gupta R, Kumar A, Kapoor R, Srivastava A, Mandhani A. Prospective urinary tract infection (UTI) with the outcome of PCNL. evaluation of safety and efficacy of the supracostal approach for He mentioned that postoperative fever seems to be a frequent percutaneous nephrolithotomy. BJU Int 2002;90:809‑13. phenomenon in the postoperative course of PCNL, but the 6. Lingeman JE, Lifshitz DA, Evan AP. Surgical management of urinarylithiasis. progression to sepsis is uncommon and it appears to be quite In: Walsh PC, Retik AB, Vaughan ED, editors. Campbell’s Urology. Philadelphia: WB Saunders Company; 2002. p. 3361‑451. difficult to predict who is likely to develop an infectious 7. Netto NR Jr, Ikonomidis J, Ikari O, Claro JA. Comparative study of complication and who is not. In our study, none of our patient percutaneous access for staghorn calculi. Urology 2005;65:659‑62. progressed to urosepsis. All the patients, in our study underwent 8. Margel D, Lifshitz DA, Kugel V, Dorfmann D, Lask D, Livne PM. Percutaneous nephrolithotomy in patients who previously underwent open preoperative urine culture and any preoperative UTI was treated [16] nephrolithotomy. J Endourol 2005;19:1161‑4. accordingly based on culture report. Mariappan et al. found 9. Sukumar S, Nair B, Ginil KP, Sanjeevan KV, Sanjay BH. Supracostal access that 1 week prophylactic course of ciprofloxacin in spite of for percutaneous nephrolithotomy: Less morbid, more effective. Int Urol negative urine culture prior to PCNL significantly reduced Nephrol 2008;40:263‑7. 10. Lojanapiwat B, Prasopsuk S. Upper‑pole access for percutaneous upper UTI and urosepsis in the postoperative period. We, in nephrolithotomy: Comparison of supracostal and infracostal approaches. our study did not make any antibiotic course mandatory to all J Endourol 2006;20:491‑4. the patients unless the urine culture comes positive. 11. Sampaio FJ, Aragao AH. Anatomical relationship between the intrarenal arteries and the kidney collecting system. J Urol 1990;143:679‑81. CONCLUSION 12. Sampaio FJ, Zanier JF, Aragão AH, Favorito LA. Intrarenal access: 3‑dimensional anatomical study. J Urol 1992;148:1769‑73. 13. Wong C, Leveillee RJ. Single upperp ‑ ole percutaneous access for treatment In our study, the success rate was found to be better in upper of > or = 5‑cm complex branched staghorn calculi: Is shockwave lithotripsy calyceal puncture group than lower calyceal puncture group for necessary? J Endourol 2002;16:477‑81. the management of complex renal calculi. The safety of both 14. Raza A, Moussa S, Smith G, Tolley DA. Upper‑pole puncture in percutaneous nephrolithotomy: A retrospective review of treatment safety the punctures was same with a better efficacy of upper calyceal and efficacy. BJU Int 2008;101:599‑602. puncture. In complex/large staghorn calculi, upper calyceal 15. Olbert PJ, Hegele A, Schrader AJ, Scherag A, Hofmann R. Pre‑and puncture is a handy technique and should always be kept in perioperative predictors of short‑term clinical outcomes in patients mind. In a mobile kidney, upper calyceal puncture through supra undergoing percutaneous nephrolitholapaxy. Urol Res 2007;35:225‑30. th 16. Mariappan P, Smith G, Moussa SA, Tolley DA. One week of ciprofloxacin before 12 rib is a feasible option minimizing lung/pleural injury and percutaneous nephrolithotomy significantly reduces upper tract infection and gives a better clearance rate. We suggest that there should not be urosepsis: A prospective controlled study. BJU Int 2006;98:1075‑9. any hesitation for upper calyceal puncture in indicated patients. How to cite this article: Singh R, Kankalia SP, Sabale V, Satav V, Mane D, REFERENCES Mulay A, et al. Comparative evaluation of upper versus lower calyceal approach in percutaneous nephrolithotomy for managing complex renal calculi. Urol Ann 2015;7:31-5. 1. Alken P, Hutschenreiter G, Günther R, Marberger M. Percutaneous stone manipulation. J Urol 1981;125:463‑6. Source of Support: Nil, Conflict of Interest: None. 2. Davidoff R, Bellman GC. Influence of technique of percutaneous tract Urology Annals | Jan - Mar 2015 | Vol 7 | Issue 1 35 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Urology Annals Pubmed Central

Comparative evaluation of upper versus lower calyceal approach in percutaneous nephrolithotomy for managing complex renal calculi

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0974-7796
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10.4103/0974-7796.148591
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Abstract

stones. The success of PCNL is highly related to optimal renal access. Upper calyceal puncture being more difficult and more demanding have relatively few studies presented. Aims and Objectives: This prospective study was carried out to evaluate the effectiveness and safety of upper calyceal versus lower calyceal puncture for the removal of complex renal stones through PCNL. Materials and Methods: A total of 94 patients underwent PCNL for complex renal stone in our institute. Fifty‑one of them underwent lower calyceal, while 43 underwent upper calyceal puncture. The two approaches are compared as per total duration of surgery, intraoperative blood loss, infundibular/pelvic tear, rate of complete clearance and rate of postoperative complications (pulmonary, bleeding, fever and sepsis, etc.). Observation and Results: In our study, the success rate was 76.47% for those in the lower, 90.70% for those in the upper calyceal access group. Thoracic complications (hydrothorax) occurred to 1 patient in upper calyceal supracostal access group. Bleeding requiring blood transfusion happened to 5 patients in lower calyceal access and 1 in upper calyceal group. Conclusion: In our study for the management of complex renal calculi, we conclude that in a previously th unoperated kidney, upper calyceal puncture through subcostal or supra 12  rib is a feasible option minimizing lung/pleural rupture and gives a better clearance rate. We suggest that with due precautions, there should not be any hesitation for upper calyceal puncture in indicated patients. Key Words: Percutaneous nephrolithotomy, staghorn, supracostal puncture Address for correspondence: Dr. Bhupender Kadyan, Department of Urology, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune ‑ 411 018, Maharashtra, India. E-mail: drkadyan@yahoo.com Received: 04.03.2014, Accepted: 14.04.2014 INTRODUCTION treatment of choice for renal stones, and some upper ureteric stones. It has been performed since 1980s, with overall [1] Percutaneous nephrolithotomy (PCNL) is considered as success rates exceeding 90%. Improvements in technique and instruments have diminished complication rates associated with Access this article online [2] this procedure. However, complications such as hemorrhage, Quick Response Code: encountered in 1‑23% of cases, intrathoracic complications, Website: www.urologyannals.com observed in 2‑12.5%, and other organ injuries, observed [1,2] in <1%, are being reported with percutaneous renal surgery. DOI: Complex renal calculi as described by us are renal stones 10.4103/0974-7796.148591 occupying the renal pelvis and at least two of the three Urology Annals | Jan - Mar 2015 | Vol 7 | Issue 1 31 Singh, et al.: Supracostal approach for complex renal calculi major calyceal systems. It can be the extension of the pelvic Each patient underwent PCNL under general anesthesia, and stone (staghorn) or a multiple primary or secondary renal was performed by the same team of operating urologists. [3] Beginning with cystoscopy and insertion of 6Fr ureteral calculi occupying the calyceal group. The successful removal of stones requires the accurate placement of a percutaneous catheter to allow contrast material delineation of the renal tract that provides direct access to the stone (optimal kidney collecting system. The desired calyx was chosen according to access). Inferior calyceal stones are usually approached through the general principle for access site selection stated by Lingeman [6] the posterior inferior calyx. In complex renal calculi, complete et al., that percutaneous access to the kidney should allow maximal stone removal using a rigid nephroscope. All lower clearance may often not be possible through a single tract calyceal [Figure 1] and upper calyceal infracostal punctures in an inferior calyx because of problems in negotiating the were made staying in between the posterior axillary line and acute angles between calyces. However, inferior lower calyceal para spinal line. All upper calyceal supracostal punctures were punctures are being performed more commonly because it has th [4] made in 11 intercostals space at mid scapular line [Figure 2]. fewer complications. In obese patients, the puncture site was lateral to mid scapular The supracostal upper pole access and multiple accesses line. During supracostal punctures, skin and subcutaneous provide a good approach and straight access to staghorn calculi, puncture was made during the expiratory phase, whereas renal proximal ureteral calculi, and calculi associated with primary parenchymal puncture was done during deep inspiration. Proper ureteropelvic junction obstruction, and calculi associated with calyceal puncture was confirmed by free flow of urine through retained ureteral stents. The upper pole of the kidney is aligned the needle and appropriate placement of teremo guidewire. medially and posterior to the lower pole, making the upper For the patient in whom we believed a second puncture was [5] pole a shorter and easier access route. However, staghorn necessary for complete clearance, we preferred to pass another calculi are the most difficult cases, take a longer time to be guidewire at this stage of the procedure to be used later for completely removed. Furthermore, complications are set to be the creation of the second access tract. Dilatation of the more frequent in supracostal puncture group cases. initial tract was done using alken’s metal dilator system up to 24Fr followed by the introduction of an amplatz sheath. MATERIALS AND METHODS Rigid nephroscope (stortz 17/22Fr) was used and stones were fragmented by Swiss Lithoclast Master (Electro Medical All patients having complex renal stones as defined above Systems, Nyon, Switzerland). After fragmentation and were included in our prospective study and underwent PCNL. stone removal, the collecting system was examined by direct Patients in the pediatric age group (<15 years), patients with, nephroscopy and fluoroscopy for residual stones. Antegrade comorbid conditions (diabetes mellitus, hypertension, and on double‑J stenting and nephrostomy placement is done in all anticoagulant therapy), associated pyonephrosis, and congenital cases. anomalies (pelvi ureteric junction obstruction, bifid pelvis, megaureter, horseshoe kidney, etc.) were excluded from the In the postoperative period, patients having upper calyceal study. Patients were divided into two groups as per the primary supracostal puncture, were closely monitored for dyspnea, calyceal punctures taken during PCNL. Institutional Ethical tachypnea, chest pain or clinically decreased air entry. All Committee approval was obtained prior to commencement of patients with upper calyceal supracostal punctures had the study. Written and informed consent was taken from all patients undergoing PCNL. History of previous open renal surgery of the same unit where we plan PCNL in our study was evaluated as a predictor of surgical outcome. Preoperative complete blood count, serum creatinine, platelet count, bleeding and coagulation profile, and urine culture were obtained from all patients. Radiological evaluation included ultrasonography (USG), intravenous urography and in addition computed tomography (CT), if needed in certain patients having radiolucent calculi. The stone burden was measured as the sum of the largest linear dimensions of all stones based on kidneys, ureters, and bladder (KUB)/CT films. Prophylactic antibiotics (ceftriaxone 1 g) was given intravenously at the time of induction of anesthesia and continued for 2 days. Figure 1: Subcostal puncture 32 Urology Annals | Jan - Mar 2015 | Vol 7 | Issue 1 Singh, et al.: Supracostal approach for complex renal calculi postoperative chest X‑ray done. On suspicion of thoracic RESULTS complications, intercostal drainage was planned if required. In our study, 94 patients underwent PCNL for complex renal Hemoglobin (Hb) was checked and X‑ray KUB was done on calculi. These patients were grouped in two, as per the selection day one after surgery in all patients. of primary calyceal puncture site. Patient’s demographics are Relook PCNL, if required for residual stones were done after summarized in Table 1. 48 h. We made a division, whether a new puncture was taken or not during second look, to assess the overall success rate of both In upper calyceal puncture group patients, supracostal puncture the approaches in our study as defined below. All the patients in was made in 21 patients, whereas the remaining 22 achieved whom the stones could be removed during second look through upper calyceal puncture through infracostal approach (just the same tract, was because of the following reasons: th below 12 rib). • Better visualization during second look that got hampered during first PCNL because of bleeding The results of operative time, secondary puncture required, • The stone in the inaccessible calyx was pushed into complications, and hospital stay are summarized in Table 2. an accessible zone through stone puncture via initial puncture IP needle and flushed by normal saline (PCN We found a significant Hb drop (P < 0.0001) in the subgroup flush) of patients undergoing previous open surgery and having • With fresh surgical mind, by using smaller pelvicalyceal tear in upper calyceal group when compared to the nephroscope/ureteroscope, inaccessible stones were same type of patients in lower calyceal group as summarized managed. in Table 3. Procedure was evaluated in terms of operative time, complete Complete clearance after PCNL was achieved in 77 patients; clearance, Hb drop, blood transfusion required, secondary out of 77, 36 (83.72%) were in the upper calyceal group and procedure required, fever and sepsis, hospital stay and success 41 (80.39%) were in the lower calyceal group. Secondary rate. In our study, complete clearance is set to be achieved procedure required in 7 (16.28%) patients in upper calyceal if the postoperative X‑ray KUB showed no radio‑opaque group, while 10 (19.61%) patients were in lower calyceal group, shadow or the residual stone size is <4 mm on postoperative which further requires ancillary procedure as summarized in USG/CT. Blood transfusion was given, if the postoperative Table 4. Hb drops below 8 g/dl. We defined the success rate as the number of patients achieving complete clearance, either after DISCUSSION PCNL with <2 tracts or second look cases not requiring any new punctures during second look. A proper selection of an ideal access tract is the prerequisite for maximum clearance during PCNL in kidneys having large stone The statistical inference was obtained by computing Z test, burdens. Until date, many studies have been conducted comparing Mann‑Whitney test, t‑test for the difference between any two upper and lower calyceal punctures in achieving maximum values and considered as statistically significant if the P < 0.05. clearance with minimal acceptable complications (potential thoracic complication in supracostal approach). The success rate achieved in our study was 90.70% in upper calyceal group patients, whereas it was 76% in lower Table 1: Patients demographics Characteristics Upper calyceal Lower calyceal Total P value puncture (n=43) puncture (n=51) Number of 43 (45.7) 54 (54.3) 94 patient (%) Age 39.84 (±10.42) 39.53 (±10.23) >0.05 Male 28 33 61 Female 15 18 33 Right side 22 27 49 Left side 21 24 45 Previous open 4 (9.30) 7 (13.73) 6 >0.05 surgery (%) Stone size (mm) 39.02±6.27 39.53±7.17 ‑ >0.05 Figure 2: Supracostal puncture Urology Annals | Jan - Mar 2015 | Vol 7 | Issue 1 33 Singh, et al.: Supracostal approach for complex renal calculi Table 2: Operative parameters of difficulty in manipulating within the pelvicalyceal system Characteristics Upper calyceal Lower calyceal P value due to restricted renal movement in a patient having previously puncture (n=43) puncture (n=51) open renal surgery. This led to the necessity of going for extra Operative time (min) 71.70±8.53 73.02±8.86 >0.05 punctures for tackling the stones in inaccessible calyces. In Secondary puncture 6 (13.95) 13 (25.49) >0.05 [8] required (%) their study Margel et al. they found higher percentage of Hospital stay in days 4.74±1.33 4.69±1.32 >0.05 ancillary procedures required to achieve complete clearance in Complications (%) a patient with a history of open nephrolithotomy probably due Pelvicalyceal tear 2 (4.65) 5 (9.80) >0.05 BT required 1 (2.33) 5 (9.80) >0.05 to scarred surrounding tissues and anatomical changes leading Hydrothorax 1 (2.33) 0 >0.05 to restricted renal movement. Fever/sepsis 9 (20.93) 8 (15.69) >0.05 Hb drop (g) 1.64±0.59 1.56±0.53 >0.05 The incidence of thoracic complication during supracostal BT: Blood transfusion, Hb: Hemoglobin [9,10] punctures in various studies range between 3% and 16%. Table 3: Hb% drop in subgroups In our study, out of 21 patients who underwent upper calyceal Characteristics Upper calyceal Lower calyceal P value supracostal puncture, only 1 patient developed subclinical puncture (n=43) puncture (n=51) hydrothorax diagnosed on postoperative chest X‑ray. He Previous open surgery 2.89±0.21 (n=4) 1.66±0.64 (n=7) <0.0001 did not develop any clinical symptom and was managed Pelvicalyceal tear 2.10 (n=2) 1.44±0.32 (n=5) <0.0001 nd conservatively without requiring intercostal drainage placement. Required 2 puncture >0.05 2.20±0.88 (n=6) 1.97±0.45 (n=13) Anatomically the parietal pleura crosses the middle of the Hb: Hemoglobin th th 12 rib posteriorly and 11 rib at posterior axillary line. It th Table 4: Surgical outcome makes the 11 intercostal space lateral to mid scapular line a Complete clearance Upper calyceal Lower calyceal safe zone with a minimal risk of any pleural injury. We believe achieved after group (n=43) group (n=51) th that our site of supracostal puncture at 11 intercostal space PCNL at/lateral to mid scapular line and technique of puncturing the 1 tract 30 28 skin and subcutaneous tissue during expiration whereas renal 2 tracts 5 9 >2 tracts 1 4 parenchyma puncture during inspiration (for adequate renal Secondary procedure descent) makes this puncture as safe as infracostal punctures, nd 2 look using 4 2 reducing the risk of thoracic complication as minimum. previous tract nd 2 look using new 1 3 tract We did not find any statistical significance between the type ESWL 2 5 of puncture and blood loss. All the 6 patients requiring Overall result (%) Success rate 39 (90.70) 39 (76.47) blood transfusion in our study were found to have low Failure rate 4 (9.30) 12 (23.53) preoperative Hb (mean 9.2 g%) which dropped below 8 g% PCNL: Percutaneous nephrolithotomy, ESWL: Extracorporeal shock after surgery. However, when the amount of blood loss was wave lithotripsy evaluated between patients with history of previous open renal surgery and intraoperative pelvicalyceal tear, there was calyceal group. We found easier accessibility to many calyces significant blood loss seen in upper calyceal puncture group when an approach is made through upper calyx that favors as compared with lower calyceal group. This can be explained good manipulations of the nephroscope and forceps within due to the injury caused to upper infundibulum either during pelvicalyceal system. The same is not true when a tract was puncture to upper calyx or excessive torque during intrarenal established through lower calyx, requiring undue angulation, manipulations leading to upper infundibular tear. Sampaio and and torque. We believe that this difference is because of the [11] Aragao stated that upper infundibulum is almost completely straight tract of upper infundibulum along the long axis of involved, both anteriorly and posteriorly by segmental or the kidney and the anatomical lie of the kidney over iliopsoas interlobar (infundibular) arteries in 86.6% of cases, whereas muscle that cause the upper pole positioned more posterior in 62% of the cases the posterior aspect of the lower major as compared with the lower pole. These two factors provide calyceal infundibulum was free from arteries. Sampaio excellent visualization of the pelvicalyceal system when an [7] [12] et al. in a different study reported injury to an interlobar approach is made through upper calyx. Netto et al. and Aron [4] vessel in two‑thirds of the kidney puncturing the upper pole et al. in their respective studies found similar results when infundibulum, while only 13% had an arterial injury when upper calyceal approach was made. punctured through the lower pole infundibulum. Apart from the renal and pelvicalyceal anatomy, we found that the free mobility of the renal unit is also an important factor in In our study, the main complication seen in both groups achieving better clearance through PCNL. We felt some degree was fever/sepsis (20.93% in upper calyceal and 15.69% in 34 Urology Annals | Jan - Mar 2015 | Vol 7 | Issue 1 Singh, et al.: Supracostal approach for complex renal calculi [13] creation on incidence of renal hemorrhage. J Urol 1997;157:1229‑31. lower calyceal group). Wong and Leveillee had 11.54% of [14] 3. Segura JW. The role of percutaneous surgery in renal and ureteral stone incidence of fever, whereas Raza et al. had 19.12% incidence removal. J Urol 1989;141:780‑1. [15] of septicemia/pyrexia in their respective studies. Olbert et al. 4. Aron M, Goel R, Kesarwani PK, Seth A, Gupta NP. Upper pole access for in their study did not find any evidence for a relationship of complex lower pole renal calculi. BJU Int 2004;94:849‑52. 5. Gupta R, Kumar A, Kapoor R, Srivastava A, Mandhani A. Prospective urinary tract infection (UTI) with the outcome of PCNL. evaluation of safety and efficacy of the supracostal approach for He mentioned that postoperative fever seems to be a frequent percutaneous nephrolithotomy. BJU Int 2002;90:809‑13. phenomenon in the postoperative course of PCNL, but the 6. Lingeman JE, Lifshitz DA, Evan AP. Surgical management of urinarylithiasis. progression to sepsis is uncommon and it appears to be quite In: Walsh PC, Retik AB, Vaughan ED, editors. Campbell’s Urology. Philadelphia: WB Saunders Company; 2002. p. 3361‑451. difficult to predict who is likely to develop an infectious 7. Netto NR Jr, Ikonomidis J, Ikari O, Claro JA. Comparative study of complication and who is not. In our study, none of our patient percutaneous access for staghorn calculi. Urology 2005;65:659‑62. progressed to urosepsis. All the patients, in our study underwent 8. Margel D, Lifshitz DA, Kugel V, Dorfmann D, Lask D, Livne PM. Percutaneous nephrolithotomy in patients who previously underwent open preoperative urine culture and any preoperative UTI was treated [16] nephrolithotomy. J Endourol 2005;19:1161‑4. accordingly based on culture report. Mariappan et al. found 9. Sukumar S, Nair B, Ginil KP, Sanjeevan KV, Sanjay BH. Supracostal access that 1 week prophylactic course of ciprofloxacin in spite of for percutaneous nephrolithotomy: Less morbid, more effective. Int Urol negative urine culture prior to PCNL significantly reduced Nephrol 2008;40:263‑7. 10. Lojanapiwat B, Prasopsuk S. Upper‑pole access for percutaneous upper UTI and urosepsis in the postoperative period. We, in nephrolithotomy: Comparison of supracostal and infracostal approaches. our study did not make any antibiotic course mandatory to all J Endourol 2006;20:491‑4. the patients unless the urine culture comes positive. 11. Sampaio FJ, Aragao AH. Anatomical relationship between the intrarenal arteries and the kidney collecting system. J Urol 1990;143:679‑81. CONCLUSION 12. Sampaio FJ, Zanier JF, Aragão AH, Favorito LA. Intrarenal access: 3‑dimensional anatomical study. J Urol 1992;148:1769‑73. 13. Wong C, Leveillee RJ. Single upperp ‑ ole percutaneous access for treatment In our study, the success rate was found to be better in upper of > or = 5‑cm complex branched staghorn calculi: Is shockwave lithotripsy calyceal puncture group than lower calyceal puncture group for necessary? J Endourol 2002;16:477‑81. the management of complex renal calculi. The safety of both 14. Raza A, Moussa S, Smith G, Tolley DA. Upper‑pole puncture in percutaneous nephrolithotomy: A retrospective review of treatment safety the punctures was same with a better efficacy of upper calyceal and efficacy. BJU Int 2008;101:599‑602. puncture. In complex/large staghorn calculi, upper calyceal 15. Olbert PJ, Hegele A, Schrader AJ, Scherag A, Hofmann R. Pre‑and puncture is a handy technique and should always be kept in perioperative predictors of short‑term clinical outcomes in patients mind. In a mobile kidney, upper calyceal puncture through supra undergoing percutaneous nephrolitholapaxy. Urol Res 2007;35:225‑30. th 16. Mariappan P, Smith G, Moussa SA, Tolley DA. One week of ciprofloxacin before 12 rib is a feasible option minimizing lung/pleural injury and percutaneous nephrolithotomy significantly reduces upper tract infection and gives a better clearance rate. We suggest that there should not be urosepsis: A prospective controlled study. BJU Int 2006;98:1075‑9. any hesitation for upper calyceal puncture in indicated patients. How to cite this article: Singh R, Kankalia SP, Sabale V, Satav V, Mane D, REFERENCES Mulay A, et al. Comparative evaluation of upper versus lower calyceal approach in percutaneous nephrolithotomy for managing complex renal calculi. Urol Ann 2015;7:31-5. 1. Alken P, Hutschenreiter G, Günther R, Marberger M. Percutaneous stone manipulation. J Urol 1981;125:463‑6. Source of Support: Nil, Conflict of Interest: None. 2. Davidoff R, Bellman GC. Influence of technique of percutaneous tract Urology Annals | Jan - Mar 2015 | Vol 7 | Issue 1 35

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Urology AnnalsPubmed Central

Published: Nov 1, 168

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