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Endourology/MIS

ggressive Approach to Staghorn Calculi—afety and Efficacy of Multiple Tractsercutaneous Nephrolithotomy

anish Singla, Aneesh Srivastava, Rakesh Kapoor, Nitin Gupta, Mohd S. Ansari,eepak Dubey, and Anant Kumar

BJECTIVES To evaluate the safety and efficacy of an aggressive approach to staghorn calculi using multiple-tract percutaneous nephrolithotomy.

ETHODS We retrospectively analyzed the data from 149 patients with staghorn calculi, who underwentpercutaneous nephrolithotomy using multiple (two or more) access tracts, at our institute from1999 to 2006. The data were analyzed with regard to stone burden, stone clearance, perioperativemorbidity, complications, and the number of ancillary procedures.

ESULTS A total of 164 renal units in 149 patients (118 men and 31 women, mean age 39.8 years, range12 to 65 years) were treated. Of the 164 renal units, 43 (26.2%) had a complete staghorn, 85(51.8%) had a partial staghorn and 36 (21.9%) had a borderline stone bulk. A total of 420 tractswere established in the 164 renal units. The maximal number of tracts used in a single renal unitwas six (range two to six), most required three tracts. Supracostal access was established in 98renal units (59.7%). The complications included blood transfusion in 46 patients, pseudoaneu-rysm in 4, sepsis in 8, hydrothorax in 7, hemothorax in 1, and perinephric collection in 1 patient.A complete stone clearance rate of 70.7% was achieved after a single session of percutaneousnephrolithotomy that increased to 89% after a second-look procedure (n � 30) and extracor-poreal shock wave lithotripsy (n � 16).

ONCLUSIONS The results of our study have shown that an aggressive approach to staghorn calculi using multiple-tract percutaneous nephrolithotomy is safe and effective in achieving a greater stone clearance ratewith acceptable morbidity. A supracostal approach can be used more often without increasing the risk

of significant complications. UROLOGY 71: 1039–1042, 2008. © 2008 Elsevier Inc.

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ercutaneous nephrolithotomy (PCNL) is currentlythe preferred first-line treatment for renal stonesnot amenable to extracorporeal shock wave litho-

ripsy (ESWL).1 The morbidity of PCNL with a singleract is less than that of open surgery, with better stonelearance rates.1 With increasing stone size and complex-ty, PCNL can require a longer operative time, a largerolume of irrigant fluid, and multiple tracts to achieveetter stone clearance. Therefore, an inherent fear existsf greater bleeding and complication rates compared withrocedures requiring a single tract.2

A review of previously published reports revealed aaucity of information in this regard.3,4 We, therefore,eviewed our experience of managing staghorn calculi

rom the Department of Urology and Renal Transplantation, Sanjay Gandhi Postraduate Institute of Medical Sciences, Lucknow, IndiaReprint requests: Manish Singla, MS, Department of Urology and Renal Transplan-

ation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, MRA-29, SG-GIMS Campus Rai Barely Road, Lucknow, Uttar Pradesh 226014 India. E-mail:

danishsingla76@yahoo.co.inSubmitted: May 27, 2007, accepted (with revisions): November 12, 2007

2008 Elsevier Inc.ll Rights Reserved

nd assessed the safety and efficacy of PCNL with mul-iple percutaneous tracts.

ATERIAL AND METHODS

rom 1999 to 2006, the data from 149 patients with staghornalculi who underwent PCNL requiring multiple (two or more)ccess tracts in a single sitting were reviewed. The data werenalyzed with regard to stone burden, stone clearance, periop-rative morbidity, complications, and number of ancillary pro-edures.

The stone burden was assessed by classifying the staghorntones according to the classification by Griffith et al.5 intoorderline, partial, and complete staghorn (Table 1).At PCNL, all patients had had sterile urine cultures and

eceived perioperative antibiotic coverage. Under general an-sthesia, ureteral catheterization was done on the ipsilateralide, and the patient was turned to the prone position. A firstuncture was made, after injecting contrast and or air throughhe ureteral catheter, using a bull’s eye technique under fluo-oscopic guidance. The tract was dilated with sequential orelescopic dilators. Subsequent punctures were done, if required.or supracostal access, the needle puncture was placed imme-

iately above the upper border of the lower rib to avoid damage

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o the intercostal vessels. Intracorporeal lithotripsy was per-ormed using the pneumatic lithotripter (EMS Electro Medicalystems, Nyon, Switzerland). The procedure was terminated bylacement of a 20F nephrostomy tube into the tract, which wasn a straight line with the pelvicaliceal system. If doubt aboutomplete clearance or bleeding from other tracts was present,dditional nephrostomy tubes were placed in those tracts. Foratients with a supracostal puncture, a plain chest x-ray wasoutinely done in the postoperative room. A plain abdominal,elvic, kidney x-ray was performed before removal of the ne-hrostomy tubes in the postoperative period. If residual stoneragments were noted, a decision to proceed to a second-lookephroscopy or ESWL was taken depending on the locationnd size of the residue and surgeon preference. The patientsere followed up at 1 and 6 months with plain abdominal-rays, renal function tests, and urine cultures.

ESULTStotal of 164 renal units in 149 patients (118 men and

1 women, mean age 39.8 years, range 12 to 65) werereated. The mean preoperative hemoglobin level was2.4 g/dL (range 6.9 to 17.0). The mean preoperativeerum creatinine level was 1.05 mg/dL (range 0.4 to 7.6).f the 149 patients, 22 (14.7%) had a serum creatinine

evel greater than 2 mg/dL (Table 2). Of the 164 renalnits, 43 (26.2%) had a complete staghorn, 85 (51.8%) aartial staghorn, and 36 (21.9%) a borderline stone bulk.A total of 420 tracts were established in the 164 renal

nits. The number of tracts varied from two to six in aingle renal unit. Most patients required three tracts toain access to the calculi in the various calices. Access toalices through a supracostal route was established in 98

Table 1. Classification system

Term Description

TotalRenal

Units (n)

Borderline Pelvis plus one calix 36Partial staghorn Pelvis plus two or more

calices85

Complete staghorn Entire pelvicaliceal system 43

Table 2. Patient characteristics

Characteristic Value

Total patients (n) 149Total renal units treated (n) 164Age (yr)

Mean 39.8Range 12–65

Male/female ratio 3.8:1Preoperativehemoglobin (g/dL)

Mean 12.4Range 6.9–17.0

Preoperative serum creatinine (mg/dL)Mean 1.05Range 0.4–7.6

Patients with serum creatinine �2 mg/dL (%) 22 (14.7)

enal units (59.7%): 2 patients had a supracostal 11th rib O

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pproach and 96 (58.5%), a supracostal 12th rib ap-roach (Table 3).The complications included blood transfusion in 46

atients (30.8%) in the postoperative period, pseudoan-urysm in 4, sepsis in 8, hydrothorax in 7 (4.2%), hemo-horax in 1, and perinephric collection in 1 patient. Fouratients (2.4%) had persistent bleeding postoperativelynd were found to have a pseudoaneurysm on angiogra-hy, for which angioembolization was done. All 4 pa-ients recovered well. Of the 8 patients with sepsis afterurgery, 2 had septicemic shock. All 8 patients recoveredell with intravenous antibiotics and other supportiveeasures. Of the 7 patients with hydrothorax, minimal

lunting of the costophrenic (CP) angle occurred in 3atients and was managed conservatively. Four patientseveloped significant hydrothorax and required insertionf a chest tube. In 1 patient, injury was suspected duringurgery and an intercostal chest tube was inserted at thend of procedure and drained about 400 mL of fluidTable 4). In other 3 patients with significant hydrotho-ax, it was detected on the postoperative chest x-ray. Theean duration of chest drainage was 3.6 days. The 1 case

f hemothorax, secondary to injury of the intercostalrtery, made an uneventful recovery after insertion ofhest tube and a blood transfusion. The 1 patient with aerinephric collection was treated with aspiration only.one of the patients developed visceral injury or pneu-othorax. A double-J stent was inserted in 15 patients

9.1%) because of persistent leak of urine after nephros-omy tube removal.

The mean hospital stay was 6.8 days (range 3 to 28). Thetones were completely cleared in 116 renal units (70.7%)fter one session of PCNL, and 48 had significant residue.

Table 3. Renal units requiring more than one tract andsupracostal access

Multiple Tracts in One Renal Unit (n) Renal Units (n)

2 473 734 415 26 1Supracostal access

Above 12th rib 96 (58.5%)Above 11th rib 2

Table 4. Complications

Complication Patients (%)

Blood transfusion 46 (30.8)Urosepsis 8 (5.3)Hydrothorax 7 (4.2)Hemothorax 1Angioembolization 4 (2.4)Perinephric collection 1

f these 48 renal units, 30 (18.2%) required a second-look

UROLOGY 71 (6), 2008

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rocedure, 16 (9.7%) required ESWL, and 2 requiredreterorenoscopy. Thus, 146 renal units (89.0%) were ren-ered completely stone free or had insignificant residue (2m or less) after the final procedure (Table 5). Of the

emaining 18 renal units, 10 (6.0%) had borderline residue3 to 5 mm) and were followed up.

OMMENTCNL is an integral component of the management of mosttaghorn and large-volume renal calculi. In the recentlypdated guidelines of the American Urological Associationephrolithiasis Guidelines Panel on Staghorn Calculi,1 a

rend is present toward the use of percutaneous mono-herapy using multiple tracts as the preferred treatmentption for most staghorn calculi. This approach, accordingo the guidelines report, is associated with a stone clearanceate of 74% to 83%, an acute complication rate of 15%, aransfusion rate of 14% to 24%, and an ancillary procedureate of 18% and is clearly superior to extracorporeal litho-ripsy monotherapy, combination therapy, and open sur-ery.

Although the safety of creating percutaneous renalracts is well established,6 concern is still present abouthe use of multiple tracts for the treatment of complexalculi. We studied the outcomes of PCNL incorporatinghe use of multiple tracts. The target endpoint of treat-ent for every patient undergoing PCNL at our institu-

ion is complete calculus clearance percutaneously. Ex-racorporeal lithotripsy is reserved for the occasionalatient with small residual calculi in whom percutaneousccess is technically unfeasible or the patient’s generaledical condition prohibits the use of additional percu-

aneous sessions.In this series, as many as six percutaneous tracts (me-

ian three) were created in a single operative session tochieve complete stone clearance. Complete stone clear-nce after a single session of PCNL was achieved in 116enal units (70.7%), and 30 (18.2%) required a second-ook procedure. Of the 164 renal units, 146 (89.0%) wereompletely stone free after the secondary procedure. This

Table 5. Renal units requiring second procedure and withcomplete clearance

Renal units (%)

Second-look PCNL 30 (18.2)ESWL 16 (9.7)Ureterorenoscopy 2 (1.2)Procedures done for complications

Double-J stenting 15 (9.1)Intercostal tube drainage 4 (2.4)Cystolitholapaxy 1

ClearanceAfter single sitting of PCNL 116 (70.7)After final procedure 146 (89.0)

PCNL � percutaneous nephrolithotomy; ESWL � extracorporealshock wave lithotripsy.

esult parallels the high stone free rate achieved by PCNL b

ROLOGY 71 (6), 2008

onotherapy highlighted in the American Urologicalssociation panel report.1

In this series, 46 patients (30.8%) required a blood trans-usion; however, most patients in this group had a loweraseline hemoglobin level owing to anemia of chronic dis-ase and/or baseline renal insufficiency. Most of the trans-usions were typically given on the second or third postop-rative day on an elective basis rather than emergently. Ife exclude these patients (18/46) who were transfused onn elective basis due to lower baseline hemoglobin, then theemaining 28 (18.7%) patients required blood transfusionue to the procedure itself. The occurrence of other com-lications such as urosepsis, hydrothorax, and the need forngioembolization paralleled that of other reported se-ies7–11 (Table 6).

Certain points of surgical technique merit specialmphasis.12 We believe that a critical component ofhe use of multiple tracts is the ability of the urologisto obtain percutaneous renal access. This has beenhown to reduce the need for second-look procedurend also to reduce the reliance on supplemental extracor-oreal lithotripsy. In many patients, on the basis of ourssessment of calculus configuration and collecting systemnatomy, all possible tracts were punctured right at theutset, and the guidewires were secured, because it is signif-cantly easier to confirm percutaneous needle placement inn intact collecting system. Once even a single tract haseen dilated, the extravasation of fluid and contrast makesonfirmation of precise caliceal puncture difficult. The ac-ess that was more likely to clear most of the stone burdenusually in the upper pole) was dilated first, and additionalccessory tracts were dilated subsequently, as required. Thepper caliceal tract was quite often supracostal. The supra-ostal tract in itself does not increase the morbidity of therocedure.8 In the present series, supracostal access was usedn 59.7% of the renal units without increasing the risk ofignificant complications. Thus, the supracostal approachan be used more liberally when access to the upper pole isot possible through an infracostal approach.Various techniques have been used to reduce the num-

Table 6. Comparison of complication rates from publishedreports in single tract PCNL and present series

Complication

Single-TractAccess PCNL

(Previous Series)

Multiple-TractAccess PCNL

(Present Series,n � 149)

Blood transfusion 11.2 (n � 582)11 28 (18.79)Urosepsis 0.8–2.211 8 (5.3)Hydrothorax NA 7 (4.2)Hemothorax NA 1 (0.6)Angioembolization 1.4 (n � 1854)9 4 (2.4)Perinephric

collection0.611 1 (0.6)

PCNL � percutaneous nephrolithotomy. All figures are percent-ages.

er of percutaneous tracts required to achieve calculus

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learance during PCNL. The use of flexible nephroscopyith holmium laser lithotripsy has been suggested as one

uch strategy. However the flexible nephroscope has beenound to be more useful to retrieve small caliceal calculi.or a larger stone bulk, flexible nephroscopy is usuallyedious, time-consuming, and more prone to leavingtone residue. Hence, it is preferable to create an addi-ional tract that will enable clearance of the calculusore efficiently and reliably.4

It has now been established that PCNL requiring mul-iple tracts is safe and effective; therefore, trying to douch through a single tract, especially when it is obvious

hat another tract is needed, should be avoided because itan cause injury to the pelvicaliceal system and moreleeding. Torquing a rigid nephroscope against the pel-icaliceal system to reach an inaccessible calix is theactor responsible for extravasation and bleeding.

ONCLUSIONShe results of our study have shown that an aggressivepproach to staghorn calculi using multiple tracts PCNLs safe and effective in achieving a greater stone clearanceate. With second-look PCNL and/or adjunctive ESWLn a few patients, a clearance rate of 89% was achievedith acceptable morbidity. The supracostal approach cane used more often to gain optimal access to staghorntones (usually through an upper pole) without increasing

he risk of significant complications.

042

eferences1. Preminger GM, Assimos DG, Lingeman JE, et al: AUA guideline

on management of staghorn calculi: diagnosis and treatment rec-ommendations. J Urol 173: 1991-2000, 2005.

2. Kukreja R, Desai M, Patel S, et al: Factors affecting blood lossduring percutaneous nephrolithotomy: prospective study. J En-dourol 18: 715-722, 2004.

3. Aron M, Yadav R, Goel R, et al: Multi-tract percutaneous neph-rolithotomy for large complete staghorn calculi. Urol Int 75: 327-332, 2005.

4. Hegarty NJ, and Desai MM: Percutaneous nephrolithotomy requir-ing multiple tracts: comparison of morbidity with single-tract pro-cedures. J Endourol 20: 753-760, 2006.

5. Griffith DP, and Valiquette L: PICA/burden: a staging system forupper tract urinary stones. J Urol 138: 253-257, 1987.

6. Alken P: Percutaneous nephrolithotomy. Urol A 23: 20-24, 1984.7. Gupta R, Kumar A, Kapoor R, et al: Prospective evaluation of

safety and efficacy of the supracostal approach for percutaneousnephrolithotomy. BJU Int 90: 809-813, 2002.

8. Stoller ML, Wolf JS Jr, and St. Lezin MA: Estimated blood loss andtransfusion rates associated with percutaneous nephrolithotomy.J Urol 152: 1982-1983, 1994.

9. Srivastava A, Singh K, Suri A, et al: Vascular complications afterpercutaneous nephrolithotomy: are there any predictive factors.Urology 66: 38-40, 2005.

0. Koga S, Arakaka Y, Matsuoka M, et al: Staghorn calculi: long termresults of management. Br J Urol 68: 122-124, 1991.

1. Lee WJ, Smith AD, Cubelli V, et al: Complications of percuta-neous nephrolithotomy. AJR Am J Roentgenol 148: 177-180,1987.

2. Lam HS, Lingeman JE, Mosbaugh PG, et al: Evolution of thetechnique of combination therapy for staghorn calculi: a decreasingrole for extracorporeal shock wave lithotripsy. J Urol 148: 1058-

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