Perkutan nefrolitotomi (pcnl) sonras ı antegrad pyelografi çekilmeli mi?

Should antegrade pyelography be taken after percutaneous nephrolithotomy (pcnl)?

KEREM TAKEN,Necip PİRİNÇÇİ,İlhan GEÇİT,Serhat TANIK,Recep ERYILMAZ,Mustafa GÜNEŞ

Özet

Amaç: Perkütan nefrolitotomi(pcnl) sonras ı nda gereksiz antegrad e pyelografiden kaç ı nmak. Gereç-Yöntem: Temmuz 2010-A ğ ustos 2011 tarihleri aras ı nda PCNL uygulanm ı ş 85 hasta de ğ erlendirildi. Hastalarda; amplatz dilatörler ile k ı lavuz tel üzerinden 30F dilatasyon uygulanarak perkütan yol olu ş turuldu. Ta ş k ı rma i ş lemi 26F rijid nefroskop (Wolf, Alman ya) ve pnömotik litotriptör (Vibrolith- Elmed, Türkiye) kullan ı larak gerçekle ş tirildi. Üretere aç ı k uçlu 5fr veya 6 fr üreter kateteri yerle ş tirildi. Post operatif 1.gün üriner sistem grafisi (DÜSG) çekildi ve üreter kateterleri al ı nd ı . Nefrostomi klemplenip rezidü takibi yap ı ld ı . 2-4 saat sonras ı rezidü<50cc ise nefrostomi çek ildi. Nefrostomi kateteri al ı nd ı ktan sonra nefrostomi trakt ı ndan idrar gelen hastalara üreteral Double J (DJ) stent uyguland ı . Bulgular: Hastalar ı n 68i erkek, 17si bayand ı . Ya ş ortalamas ı 40.1 ± 12.15 (13-70) y ı ld ı . Ta ş lar ı n %74ü (n:64) basit böbrek ta ş ı , %26s ı (n:21) kompleks ta ş grubundayd ı . Ortalama ta ş yükü 320 mm² olarak hesapland ı . Olgular ı m ı z ı n % 70inin tamamen ta ş tan ar ı nd ı ğ ı , %23ünde klinik önemsiz art ı k ta ş parçalar ı oldu ğ u, ve %7sinde ise ba ş ar ı s ı zl ı kla sonuçland ı ğ ı gözlemledik. Nefrostomi tüpünün ortalama çekilme süresi 2.7 (1-5) gün, ortalama hastanede kalma sü resi ise 3.2 (2-6) gündü. Hiçbir hastaya antegrade pyelografi çekilmesine gerek kalmad ı . Nefrostomi tüpü çekilmesi sonras ı 7 hastada 24 saatten fazla trakttan ı slatma devam etti. 3 hastada 2 gün, 2 hastada 4 gün, 1 hastada 8 gün, 1 hastada ise 12 gün sürdü. Bu hastalar ı n hepsine double-J (DJ) kateter konuldu. 2 hastada ise post op 1.gün de üreter kateteri mevcut durumunda çekilen DÜSGde t ı kay ı c ı oldu ğ u dü ş ünülen ta ş fragmanlar ı saptanmas ı üzerine DJ stent uyguland ı . Sonuç: Perkütan nefrolitotomi sonras ı nda rezidü takibi yap ı larak gereksiz antegrade pyelografilerden kaç ı nabiliriz. Böylece gereksiz radyasyon al ı m ı n ı ve kontrast madde kullan ı m ı n ı önlemi ş oluruz.

Abstract

Objective: To avoid the unnecessary antegrade pyelography after percut aneous nephrolithotomy (PCNL). Material-Method: Between July 2010-August 2011, 85 patients who were pe rformed PCNL were evaluated. In patients; percutaneous way was created by applying the dilation of 30F over a guide wire with Amplatz dilators. The process of crushing stone was carried out by using 26F rigid nephroscope (Wolf, Germany) and pneumatic lithotripter (Vibrolith- Elmed, Turkey). Open-ended 5fr or 6 fr ureteral catheter was placed into the ureter. Urinary tract radiography (DUSG) was taken in the 1 st post- operative day and the uret eral catheters were removed. Nephrostomy was clamped and the follow- up of residue was done. Nephrostomy was taken if the residue were <50cc after 2- 4 hours. Ureteral Double J (DJ) stent was applied to the patients who had urine from their nephrostom y tract after the removal of the nephrost omy catheter. Results: 68 of the patients were male and 17 of them were female. The mean age was 40.1 ± 12.15 (13-70) years. 74% of the stones (n: 64) was in the group of simple renal stone, but 26% of them (n = 21) was in the complex stone group. Th e mean stone burden was calculated as 320 mm ². We observed that 70% of our cases were entirely purified from the stone, there were clinically the pieces of insignificant stone at 23% of them, and it was resulted in failure at 7% of them. The average remo val duration of the nephrostomy tube was 2.7 (1 -5) days, but the average duration of hospital stay was 3.2 (2-6) days. There was no need to take the antegrade pyelography for none of the patients. Wetting from the tract went on in 7 patients for more than 24 hours after the withdrawal of the nephrostomy tube. It lasted for 2 days in 3 patients, 4 days in 2 patients, 8 days in 1 patient and 12 days in 1 patient. Double-J (DJ) catheter was placed to all of these patients. DJ stent was performed due to the detection of the stone fragments considered to be obstructive in DUSG taken in the available state of the ureteral catheter in the 1st day of post-surgery in 2 patients. Conclusions: We can avoid from unnecessary antegrade pyelographies by doing the residual follow- up after the percutaneous nephrolithotomy. Thus, we have prevented the intake of unnecessary radiation and the use of the contrast material.