Improve The Stone-free Rates Of Staghorn Calculi By Percutaneous Nephrolithotomy Monotherapy

PrefaceStaghorn calculi are branched stones that occupy a large portion of the collecting system.Typically, they fill the renal pelvis and branch into several or all of the calices. an untreated staghorn calculus is likely to destroy the kidney and/or cause lifethreate-ing sepsis. Complete removal of the stone is an important goal in order to eradicate any causative organisms, relieve obstruction, prevent further stone growth and any associated infection, and preserve kidney function, Percutaneous nephrolithotomy (PCNL) is the first treatment utilized for most patients with staghorn calculi based on superior outcomes and acceptably low morbidity. How to improve the stone-free rates of Staghorn calculi by percutaneous nephrolithotomy monotherapy? The clinic study would be divided into three parts:First to find the cause of residual stone after PCNLSecond how to reduce residual stone of staghorn treated by PCNLThird improve the stone-free rates of Staghorn calculi by PCNLFirst partCauses of residual stones after PCNLAbstractObjective:To investigate the cause of residual stone after PCNLMethods:The computerized database of 683 patients who underwent the first stage of PCNL for treatment of upper struct stones between January 2010 and De-cember 2012 was retrospectively analyzed.The stone-free rate was evaluated with KUB plain film radiography 2-4day after treating with primary PCNL, residual stones were found in 93 patients.Results:The cause of residual stone after primary PCNL was retrospectively analyzed.58 patients with residual stone need secondary procedures because of staghorn calculi or multiple kidney stones, or complex pelvicaliceal system, or the heavy stones burden, or prolonged operative time,or increase tract,19 patients early termination of the case due to poor visualization secondary to bleeding,4 patients early termination of the case due to the early symptom of urosepsis,3 patients had intraoperative migration of a stone fragment into the middle or lower ureter, residual stones of 9 patients due to the skip of intraoperative fragment detection during Percutaneous Nephrolithotomy by C-arm. The stone-free rates(SFR) of staghorn calculi was 59.6%(87/146), multiple kidney stones was 83.3%(115/138), single pelvis or calyces stone was 96.4%(190/197), upper ureteral calculi was 98.4% (187/190), calyceal diverticular calculi was 91.6%(11/12).Conclusion:The residual stone fragments can be left behind for several main reasons:heavy stones burden (staghorn calculi, multiple kidney stones), complex pelvicaliceal system, bleeding, urosepsis, intraoperative stones migration, skip use of C-arm to confident intraoperative decision. These measures are critical for redu-cing the residual stones after percutaneous nephrolithotomy, including accurate assessment of stones distribution preoperative, Care is taken to choose the optimal port of entry into the kidney, planned percutaneous access (location and quantity), the needle into the fornix calyx, Carefully dilate, avoid bleeding, control urinary tract infection before surgery, maintaining low intrarenal pressure, reduce the inci-dence of urosepsis; prevent intraoperative stones migration, using C-arm to determine no residual before operation conclusion, etc.Second part1 The significance of non-enhanced CT staghorn calculi before percutaneous nephrolithotomyObjective To discuss the clinical application and significance of non-enhanced computed tomography in PCNL for staghorn calculi.Methods:68 staghorn calculi patients were divided into two groups prospec tively from january 2012 to December 2012, the group was divided by whether non-enhanced computed tomography be done or not preoperatively, routine group and CT group. staghorn calculi stratified into complete staghorn calculi and partial stag-horn calculi, each group had 34 cases,in which complete staghorn calculi were 14 cases, partial staghorn calculi were 20 cases. PCNL accesses were designed, to Calculate the rate of the expected target calyx in comply with the actual calyx, and the stone-free rate. Statistical Methods:SPSS13.0, fourfold table of χ2 testResults:the Coincidence rate designed calyx to actual calyx was 67.6%(23/34) in the routine group,of which the Coincidence rate is was 57.1%(8/14)and 75.0% (15/20) in complete staghorn calculi subgroup and partial staghorn calculi subgroup respectively., The stone-free rate was 38.2%(13/34) in the routine group, of which the stone-free rate was 21.4%(3/14) and 50%(10/20) in complete staghorn calculi subgroup and partial staghorn calculi subgroup respectively,one pleural injury occurred in one patient with complete staghorn calculi,. the Coincidence rate design-ed calyx to actual calyx was 88.2%(30/34) in the CT group,of which the Coinci-dence rate is was 85.7%(12/14) and 90%(18/20) in complete staghorn calculi subgroup and partial staghorn calculi subgroup respectively., The stone-free rate was 64.7%(22/34) in the CT group, of which the stone-free rate was 57.1%(8/14) and 70.0%(14/20) in complete staghorn calculi subgroup and partial staghorn calculi subgroup respectively. No adjacent organ damage occurs.The Coincidence rate (χ2=4.191, P=0.041) and stone-free rate (χ2=4.125, P=0.044) between the two groups were statistically significant.Conclusion:Non-enhanced CT provided the detail information relevant to stone size and exact location within the pelvicalyceal system, especially the distribution of anterior and posterior branch of caliceal, and surrounding kidney adjacent tissue or organs. all of which are considered valuable information, not only for deciding on the appropriate access, but also improve the stone-free rates of Staghorn calculi by percu-taneous nephrolithotomy monotherapy, and may reduce the incidence of adjacent or-gan damage and ensuring operation safety.2 The impact of negative pressure system to fever after the second stage percutane-ous nephrolithotomy treatment of calculus pyonephrosisObjective:To evaluate the impact of negative pressure system to fever after the second stage percutaneous nephrolithotomy(PCNL) treatment of calculus pyonephrosis.Method:From January 2012 to December 2013, a total 44 upper urinary tract calculi combined with pyonephrosis patients who underwent second stage PCNL after the first stage percutaneous nephrostomy to drain pyonephrosis and use sensitive antibiotics or empirical antibiotics evaluated in a prospective manner, were randomly divided into two groups:22 patients used negative pressure system, and 22 patients underwent conventionally, the 2 groups were similar with regard to patient characteristics, maximum diameter and types of the stones. Results in two groups were compared regarding incidence of postoperative fever and urosepsis, stone free rate, and mean operative time.Result:In the negative pressure group, there was no urosepsis,one patient had fever, but two cases urosepsis and another five fever in the conventional group, there were statistically significant difference in incidence of fever (P=0.045) but no statistically significant difference was found in incidence of urosepsis (P=0. 488),stone free rate in negative pressure group was 86.4%(19/22) and higher than conventional group 59.1%(13/22) with a significant statistical difference (2=4. 125, P=0.042), mean operative time in negative pressure group was 51.09±30.12 minutes and less than conventional group (66.64 ± 35.83 minutes) although no significant statistical difference (T=-1.558, P=0.127)Conclusion:Use the negative pressure system during the second stage percutaneous nephrolithotomy treatment of calculus pyonephrosis can reduce incidence of fever, and improve stone free rate.3 The efficacy of C-arm to determine the residual stones during percutaneous nephrolithotomyObjective:To evaluate the efficacy of C-arm determine the residual stones during percutaneous nephrolithotomy Methods:From August 2011 to March 2013, the 466 patients with upper urinary tract radiopaque stones were treated by PCNL,of which there were 96 upper ureteral stones,85 solitary renal pelvic stones,48 single calyx stones, including 29 lower calyceal stones,7 middle calyceal stones,12 upper calyceal stones,98 staghorn calculi,139 multiple kidney stones, after indwelling ureteral stents, when patient’s vital signs are stable, Field of intrarenal view was clear, three was endoscopical stone free. Of which there were 94 upper ureteral stones,84 solitary renal pelvic stones,46 single calyx stones,74 staghorn calculi,121 multiple kidney stones. then C-arm was used to determine the residual stone. If find any residual stone, PCNL contiue until confirmed no stone or change to secondary procedure. Calculated the stone free-rate before and after C-arm check respectively. Statistical methods: McNemartest.Results:There were stone fragments reflux to the lower calceal in 2 upper ureteral calculi, stone fragments migrated in 4 renal pelvis stones, of which 1 lower calceal,1 upper calceal,2 middle calceal, There were residual stone in 3 calyx stones, one residual stone in lower calceal from upper calceal, two residual stone in lower calceal remain, The residual fragments of upper ureteral stones, solitary renal pelvis, calyx stone were larger than 4mm, all except one lower residual fragments were removed successfully, staghorn calculi had 24 cases residual stones, which were larger than 4mm,15 cases were removed successfully by percutaneous nephrolithotomy again, there were stone fragments in 29 cases multiple kidney stones, 20 cases were removed successfully by percutaneous nephrolithotomy again. All patients had KUB radiography postoperative 2-4 days, all residual stones diagnostic by C-arm intraoperative were confirmed by KUB radiography postoperative, in addition, there are two cases of small residual stone fragments less than 4mm in solitary renal pelvis or calyx stones, of 15 staghorn calculi removed there are two cases of residual stones still larger than 4mm, and another four cases had small residual stone fragments less than 4mm, of 19 multiple kidney stone considered stone-free there are three cases of residual stones larger than 4mm, and four patients had residual stone fragments less than 4mm.By using C-arm technique to determine more residual calculi, the stone-free rate of ureteral calculi from 95.8%(92/96) rose to 97.9%(94/96), the stone-free rate of single pelvis rate from 94.1%(80/85) rose to 98.8%(84/85), the stone-free rate of single calyceal stone from 91.4%(43/48) rose to 93.8%(45/48), the stone-free rate of staghorn calculi from 50%(49/98) rose to 64.3%(63/98), the stone-free rate of multiple kidney calculi from 68.3%(95/139) increased to 80.6%(112/139). the stone-free rates of staghorn calculi and multiple kidney calculi before and after C-arm had statistical differences.Conclusion:It is necessary to confirm the residual stones by C-arm intra percutaneous nephrolithotomy,especially for staghorn calculi and multiple kidney stones, can significantly improve the stone-free rate.Third partSeveral strategies of Improve the stone-free rate of staghorn calculi by percutaneous nephrolithotomyObjective:To improve the stone-free rate of staghorn calculi by percutaneous nephrolithotomyMethods:From February 2013 to February 2014,83 cases of staghorn calculi were treated by percutaneous nephrolithotomy, of which the complete staghorn calculi 34 cases,49 cases of partial staghorn calculus, calculus maximum diameter from 2.1cm to 10.8cm, average 5.3cm, every patient had kidney CT scan preoperative, and IVU or KUB, B-ultrasound, during pcnl when the expansion of the ipsilateral ureter found, two 5F ureteral catheter were indwelled, preventing stone fragments migration to the middle or lower ureteral stones, guided by B-ultrasound target calcel fornix was puncture, indwelling guidewire, and expand the tract combined with X-ray, if combination urinary tract infection, according to the results of urine culture sensitive antibiotics or empiric use of antibiotic were used to treat infections, no fever more than three days before surgery, blood showed WBC normal, together with a suction device during PCNL if preoperative diagnosis of urinary tract infection or find cloudy urine or merge multiple tiny stones intraoperative, with pneumatic lithotripsy device " orderly " shattered stone, combined with holmium laser when stones harder, the C-arm required use to confirm the residual stones before the end of PCNL, if residual stones had found, PCNL continue otherwise to conclusion,2-4 days postoperative, KUB radiography were used to determine the stone free-rate statistics,if necessary, second stage PCNL after 5-7 days performed, or auxiliary ESWL or close follow-up, sometimes, thrid stage PCNL needed.Results:After the first stage PCNL, staghorn calculi of 56 patients were clear (67.5%,56/83),20 patients with residual stone underwent second stage PCNL staghorn calculi of 12 patients were clear (81.9%,68/83), after the third stage PCNL, one patient stone of 2 patients was free (83.1%,69/83),7 patients underwent ESWL after first or second stage PCNL, only one patient’s stone completely discharged during follow-up period, and the other six cases follow-up,5 patients with residual stones regular follow-up. The mean operative time 81 minutes (28-142 minutes), mean hemoglobin decrease 2.3g/dl (0-5.4g/d),3 patients with mild anemia preoperative had blood transfusion 1-3U, otherpatient without blood transfusion,1 patient postoperative hemoglobin declining had renal arteriography and super selective embolization, seven cases had fever postoperative, no urosepsis occurs, no colon, pleura, liver, spleen and other organs injury happened, no patient dead.Conclusion:kidney CT scan preoperative, needle through the target calyx fornix into the collection system, reduce bleeding, use of antibiotic to resistant infections preoperative, two indwelling ureteral catheterization, if necessary, together with a suction device, orderly crushed stone, the C-arm used to confirm residual stone before the end of PCNL, all of above comprehensive measures can improve the stone free-rate of staghorn calculi by PCNL...