Journals / Türk Üroloji Dergisi/Turkish Journal of Urology / 2006 / Cilt: 32 - Sayı: 1
Percutaneous nephrolithotomy by upper pole approach in renal stone surgery
- Pages
- 78–83
- DOI
- —
Abstract
Introduction: Percutaneous nephrolithotomy (PNL) is an effective choose of treatment with or without ESWL in renal calculus disease. Percutaneous renal surgery is currently performed for complex renal calculi as well as for various other endourological indications. Access to the kidney can be achieved through lower, middle and upper calices. In many patients an upper pole nephrostomy tract allows direct access to most of the intrarenal collecting system. Upper pole percutaneous access may be obtained via the supracostal or subcostal approach. The preferred route depends on the location and size of the specific stone or lesion. Previously others have cautioned against the supracostal approach above the 12th rib and many have discouraged an approach above the 11th rib due to the concern about the increased risk of intrathoracic complications. In this study we investigated upper pole access in PNL procedure, retrospectively. Materials and Methods: Between September 2001 and June 2004, 21 patients underwent PNL with upper pole access. Second generation cephalosporins was given to all patient just before the surgery for prophylaxis. Percutaneous renal access was done under C-armed flouroscopy when patient was in prone position. The tract was dilated with Amplatz dilatators and a 34F Amplatz sheath was placed. Percutaneous stone disintegration and stone removal was performed with a 26 Fr rigid nephroscope and pneumatic lithotriptor. A nephrostomy tube was placed at the end of each procedure. Patients were evaluated with plain radiographic imaging of urinary tract on the postoperative first day. On the postoperative second day an antegrade pyelography was performed. If the passage between kidney and the bladder was seen to be secured, the nephrostomy tube was taken away. All patients were evaluated posteroanterior chest graphy for hydrohemothorax in postoperative first day. Results: Upper pole access was obtained in 21 patients (mean age 36). Totally 37 group of calices and/or renal pelvis with stones were entered via upper pole access. 12 of 37 were in middle calyx group, 19 of them were in upper calyx group, 2 were in renal pelvis. The size of the stones ranged between 200 to 2750 mm². Mean stone volume was 595mm2. Mean operation period was 109 minutes. Mean hospitalization duration was 5 days (4-15). In 9 patents accesses were only intercostal, in other 9 accesses were subcostal only. In 3 patients both subcostal and intercostal accesses were performed. Stone-free rate was 75.6% (28/37). If the stones smaller than 4 mm were ignored, this ratio became 83.7% (31/37). In postoperative period hydrohemathorax was seen in two patients. While pleural drainage was performed in one of them, other patient managed conservatively. Only in one patient blood transfusion required (2 units). Conclusion: Percutaneous nephrolithotomy has an important role in the management of upper pole stones. It may have a higher risk of pleural injury. When carefully performed this risk may be minimal.
Özet
Perkütan nefrolitotomi (PNL) böbrek taşlarının cerrahi tedavisinde tek başına veya ESWL ile birlikte uygulandığında etkili bir tedavi yöntemidir. Taşın veya lezyonun boyutuna ve yerleşimine bağlı olmakla birlikte üst pole perkütan giriş tercih edilebilir. 12. kotun üzerinden, özellikle de 11. kotun üzerinden yapılan suprakostal girişlerde intratorasik istenmeyen yan etkilerin ve fazla olması nedeniyle dikkatli olunmalıdır. Biz bu çalışmada kliniğimizde üst pol girişi ile PNL yapılan olguları geriye dönük olarak inceledik. Eylül 2001-Haziran 2004 tarihleri arasında yaş ortalaması 36 (17-70) olan toplam 21 (21/107) hastaya üst pol girişi ile PNL yapıldı. Dördü alt kaliks, 12’si orta kaliks grubu, 2’si böbrek pelvisi, 19’u üst pol olan 37 (37/145) kaliks grubuna işlem gerçekleştirildi. Ortalama taş yükü 595 mm² idi. Hastaların 9’una interkostal, 9’una subkostal, 3’üne interkostal ve subkostal yaklaşımla PNL yapıldı. Tüm yerleşimler için taşsızlık oranı %75,6 (28/37). İki hastada ameliyat sonrası hidrohemotoraks gelişti. Bunlardan bir tanesinde plevral mayi drene edilirken diğer hasta konservatif izlendi. B ir hastaya 2 ünite kan transfüzyonu yapıldı. Üst pol taşlarında PNL önemli bir yer tutmaktadır. Diğer girişlere göre daha fazla plevral yaralanma olmasına rağmen dikkatli bir şekilde uygulandığında güvenli bir yöntemdir.