Comparing The Clinical Efficacy Of Tubeless MPCNL In The Treatment Of Upper Urinary Calculi With Different Degrees Of Hydronephrosis

BackgroundIn 1941,Rupel and Brown first described the removal of stones through previ ously established nephrostomy.By 1955,Goodwin et al described percutaneous nep hrostomy for drainage of severe hydronephrosis [1].There was no radiographic gui dance at the time,and these operations were conducted without imaging guidance.It was not until 1976 that Fernstrom and Johannson actually reported the establis hment of percutaneous nephrostomy for removal of renal calculi,namely percutane ous nephrolithotomy(PCNL)[2].With the continuous improvement of endoscope,im aging equipment and internal lithotriptor,a series of major improvements have bee n made in the percutaneous nephrolithotomy to make it an important method for t he treatment of upper urinary calculi [3,4].At present,the development trend of P CNL is small channel PCNL and tubeless PCNL.Small channel MPCNL could si gnificantly reduce the incidence of renal injury,perforation of the renal pelvis,and the incidence of intraoperative and postoperative bleeding.Since Wu Kaijun and Li Xun first proposed and established microchannel percutaneous nephrolithotripsy i n China in the early 1990 s,the effect is not only to reduce the surgical trauma of the patients as much as possible,but also to make the patients achieve and mai ntain the best internal environment as soon as possible.Tubeless MPCNL is that t he ureteral stents was placed without indwelling nephrostomy tubes after miniaturiz ed percutaneous nephrolithotomy,or ureteral stents or nephrostomy tubes were not indwelled after operation(totally tubeless PCNL).At present,there are several pr ospective randomized trials to compare the tubeless PCNL with the standard PCNL or MPCNL.The results show that the tubeless PCNL has obvious advantages in clinical effect.It is very important for patients with upper urinary tract calculi to choose the right way of treatment.In addition,some scholars have extended the in dication of tubeless PCNL technology through practice [6].Jou et al.reported that,as long as D-J tube was well placed,the tiny perforation of collecting system w as not contraindication of tubeless PCNL [7],and the stone size was not a real li miting factor [8],D-J tube could also reduce the incidence of urinary leakage.The refore,many scholars suggested that the drainage of D-J tube should be retained a fter operation [8-10].Shoma and Elshal also found that tubeless PCNL could bene fit patients through an tubeless PCNL prospective trial [11].Ayhan et al.suggested that the longer the indwelling of a renal nephrostomy tubes,the longer the urine exosmosis and its duration,and extended hospital stay [12].Zilberman comprehensively analyzed the literature on tubeless PCNL and found that there was no significant difference in complications between tubeless PCNL and standard PCNL.Tubeless mPCNL could significantly reduce postoperative pain and shorten hospital stay.Zhu Chaowei et al.believe that PCNL is the first choice of endoscopic method for the treatment of proximal ureteral calculi in patients with severe hydronephrosis [14].Karatag et al.also thinks that hydronephrosis did not affect the success rate and operation time of MPCNL[15].Vahit et al.reported that the size of stones and the degree of hydronephrosis did not significantly affect the fluid absorption during PCNL [16].In a prospective study by SHAH et al.,which did not take into account the degree of hydronephrosis and the changes of renal factors in patients,it was concluded that tubeless PCNL was also safe and feasible for solitary kidney,multi-channel and supracostal puncture [10].However,there is still no uniform standard for the indication of tubeless PCNL,and there are different opinions at home and abroad on the treatment of severe hydronephrosis with tubeless PCNL.Therefore,the purpose of this study is to compare the clinical efficacy of tubeless mPCNL in the treatment of upper urinary calculi with different degrees of hydronephrosis,providing clinical practice evidence for the further development of tubeless mPCNL and patient selectivity.PurposeComparing the clinical efficacy of tubeless MPCNL in the treatment of upper urinary calculi with different degrees of hydronephrosis and providing clinical practice evidence of tubeless MPCNL for the treatment of upper urinary tract stones.MethodIn this study,patients who were treated with tubeless mPCNL for upper urinary tract calculi with mild,moderate,or severe hydronephrosis were retrospectively selected from June 2015 to January 2018 in the Department of Urology,Haiyin Branch of the First Affiliated Hospital of Guangzhou Medical University.A total of 132 patients were included in the inclusion criteria.They were divided into three groups: mild hydronephrosis group,moderate hydronephrosis group and severe hydronephrosis group.The postoperative hospitalization time,postoperative hemoglobin drop,serum creatinine change,postoperative complications,postoperative analgesic use and other related indicators were compared among the three groups.ResultAmong the 132 patients,there were 45 patients with mild hydronephrosis,49 patients with moderate hydronephrosis,and 38 patients with severe hydronephrosis.There was no significant difference in preoperative general data among the three groups: sex,age,BMI,history of upper urinary tract surgery in the affected side,co-morbidity,location of stones,surface area of stones,etc.There was no significant difference in operation time,postoperative hemoglobin decrease value and serum creatinine change value among the three groups(p > 0.05),and there was no significant difference in postoperative hospitalization time among the three groups.The incidence of postoperative pain,urine extravasation and perirenal effusion were significantly different among the three groups(P< 0.05).The postoperative usage of analgesic drugs in severe hydronephrosis group was more than that in mild hydronephrosis group and moderate hydronephrosis group.There was significant difference about complication Clavien?(P<0.05).Complications(Clavien?,Clavien ?)according to the modified Clavien systems shows no statistical significance among the three groups(P> 0.05).No complications of Clavien ? and Clavien ? were found in the three groups.ConclusionAll the patients in the three groups were treated with tubeless mPCNL and recovered quickly after operation,but the patients with severe hydronephrosis needed more postoperative analgesia than those with mild hydronephrosis and moderate hydronephrosis.The incidence of complications of urinary extravasation and perirenal effusion was higher than that of mild hydronephrosis and moderate hydronephrosis.Therefore,patients with upper urinary tract stones complicated with mild or moderate hydronephrosis can benefit more from tubeless MPCNL.When patients with severe hydronephrosis and upper urinary tract stones are treated with tubeless mPCNL,the smooth drainage of D-J tube should be ensured after operation.In order to avoid urinary extravasation and perirenal effusion and other complications.In view of this,patients with severe hydronephrosis and upper urinary tract calculi should be carefully treated with tubeless mPCNL.