Objective: Percutaneous nephrolithotomy (PCNL) is most frequently performed procedure for renal stones 2 cm and larger. Perioperative hemorrhage being most common complication, warrants as important predicting factor of adverse outcomes. Prevention with inexpensive and safe drug like tranexamic acid (TA) would ultimately turn out to be cornerstone for establishing future guidelines. Aim of this study is to evaluate whether TA is efficacious in preventing blood loss during PCNL. Materials and Methods: Ethical review board approval taken. Sample size calculation yielded 240 patients, comprising 120 in each group. Group A receiving TA and group B receiving placebo. Age, gender, body mass index (BMI), stone size, volume and location, preoperative blood count, creatinine, urine analysis, coagulation profile and necessary radiological investigations done. Randomization through lottery method. Both patient and investigator were blinded. Hemoglobin (Hb) and hematocrit (Hct) levels done at 24 hours postoperatively and fall in values recorded. Results: Both groups were equal in characteristics like age, gender, BMI, stone size, volume and location (p>0.05). Operative variables like calyx punctured, position of puncture and operative time were also found to be similar in both groups. Median change in Hb in placebo group was 1.6 interquartile range (IQR) 4, while in TA group was 1.3 (IQR 7.8) (p=0.001). Similarly, median change in Hct level in placebo group was 3.6 (IQR 11.8) and in TA group was 2.4 (IQR 13) (p<0.001). Sixteen patients were transfused after surgery; 12 (75%) belonged to placebo group while 4 (25%) belonged to TA group (p=0.038). Hospital stay was not significantly different in both groups (p=0.177) with median of 4.0 and IQR of 0 in both groups. Conclusion: TA during PCNL reduces blood loss and minimizes blood transfusion rate.Amaç: Perkütan nefrolitotomi (PNL), 2 cm ve daha büyük böbrek taşları için en sık uygulanan prosedürdür. Perioperatif kanama en yaygın komplikasyon olup, istenmeyen sonuçların öngörülen önemli faktörüdür. Traneksamik asit (TA) gibi ucuz ve güvenli ilaçlarla önleme, nihayetinde gelecek kılavuz ilkeleri oluşturmak için temel taş haline dönüşebilir. Bu çalışmanın amacı, TA'nın PNL sırasında kan kaybını önlemede etkili olup olmadığını değerlendirmektir. Abstract Öz What's known on the subject? and What does the study add?Percutaneous nephrolithotomy is most frequently performed procedure for renal stones measuring 2 cm. Perioperative hemorrhage being most common complication, warrants as important predicting factor of adverse outcomes. Prevention with inexpensive safe drug like Tranexamic acid would ultimately turn out to be cornerstone for establishing future guidelines. Currently there is only one study published internationally highlighting this notion. Therefore this study will be beneficial for researchers in shaping the current practices.

Aim: To assess the role of Intraprostatic injection of epinephrine intra-operatively in patients undergoing TURP in decreasing blood loss and the need for subsequent blood transfusions. Design: A double-blind, randomized controlled trial. Place and duration of study: The Kidney Centre Postgraduate Training Institute, Karachi, from March till August 2020. Methodology: A total of 40 patients were chosen at random and divided into two groups of equal size. One group got an intra-prostatic injection of epinephrine, whereas the other received a standard saline injection. Both groups were evaluated in terms of prostate volume (ml), resected tissue (gms), surgical resection time (minutes), pre and post-operative Hemoglobin (HB), and Hematocrit (HCT) levels. Intra-operative blood loss was then quantified using the last two variables. Transfusion requirement in both groups was also recorded. Results: Mean +Age of patients in Group A and Group B was 66.30+9.24years and 65.65+7.43years, respectively, with no significant difference between both groups (p=0.808). Median and IQR Prostatic volume in Group A and Group B was 68.0, 15, and 64.0,21, suggesting no statistically significant difference between the two groups (p=0.372). Mean + S.D Loss of HB of patients in Group A and Group B was 1.15 + 0.42 and 1.87+1.04, respectively, with a significant difference between both groups (p=0.007). Mean + S.D of post-op HCT patients in Group A and Group B was 3.16+1.50 and 4.81+2.79, revealing a significant difference between the two groups (p=0.026). No patients in Group A needed blood transfusions, whereas six patients in Group B had blood transfusions, indicating a statistical distinction between the two groups (p=0.001). Conclusion: The use of intra-prostatic injection of epinephrine leads to reduced blood loss and subsequently reduced operative time, irrigation fluid usage, and blood transfusion during TURP. It also allows a greater amount of prostatic tissue to be resected. Keywords: Transurethral resection of Prostate, Epinephrine, Blood transfusion, Hemoglobin, Hematocrit.

Aim: To find out the role of listening to music during extracorporeal shockwave lithotripsy to reduce pain and anxiety during the procedure. Design: A randomised controlled trial. Place and Duration of Study: Lithotripsy department at The Kidney Centre Postgraduate Training Institute, Karachi, from January to July 2021. Methodology: One hundred ten patients were randomly assigned into two groups of fifty-five patients each; Group-M (first session of ESWL with music and second session without music) and Group-X (first session of ESWL without music and second session with music). Patients with the music group were provided headphones with soothing music throughout their procedure. Routine analgesic (intravenous nalbuphine 0.1mg/kg) was administered to patients as per treatment guidelines. Each patient received a total of 4000 shockwaves with energy levels varying from 11.45 to 13.1 kilovolts and frequency ranging between 2 to 3 Hertz. Patients filled out two questionnaires, Visual Analogue Scale (VAS) and State-Trait Anxiety Inventory (STAI). Baseline data for all patients was calculated and compared between the two groups. Data were analysed using IBM SPSS ver. 20. Results: Ninety-eight were males while twelve were females. Gender distribution between groups does not differ significantly (p = 0.862). The mean age in Group-M was 36.22 + 9.78 while in Group-X was 36.13 + 9.89 without any significant difference between groups (p = 0.422). BMI of Group-M patients (25.34 + 4.64) was not significantly different from Group-X (25.41 + 4.80) (p = 0.327). Median stone size of Group-M was 1.0 ; 0.30 while that of Group-X was 1.1; 0.40 (p=0.997). Stone laterality was not significantly different among the two groups (p = 0.961). The distribution of stone location among both groups was not significantly different from each other (p=0.949). In Group-M, first session patients (with music) had significantly lower median VAS score (2; 1) as compared to second session patients without music (4; 2), (p < 0.001). In Group-X, first session patients (without music) had significantly higher median VAS score (6; 1) as compared to second session patients with music (4; 2), (p < 0.001). Conclusion: Music therapy during ESWL sessions reduces both pain and anxiety and also improves overall compliance of stone disease patients by eradicating the fear of the procedure. Keywords: ESWL, Lithotripsy, Visual Analogue Scale, Renal calculi.

Background: Nephrostomy tract itself is the most common source of hemorrhage during percutaneous nephrolithotomy, which can be avoided by puncturing through the calyx with minimal angulation between calyceal system and the nephroscope shaft. Smaller the sheath diameter, lesser would be the bleeding. Our objective was to compare mean change in hemoglobin (HB) level in patients undergoing percutaneous nephrolithotomy (PCNL) with 24 versus 30 French Amplatz sheath. Methods: In this study, 142 patients were randomly divided into Group A undergoing procedure with 24 French Amplatz sheath; and Group B with 30 French sheath. At the end of procedure in both groups, nephrostomy tube was kept for 24 hours. On first post-operative day, patients’ HB was checked and compared with pre-operative data, along with blood transfusion rates. SPSS 20 was used for data analysis and p-value < 0.05 was considered significant. Results: Median age and interquartile range of Group-A and Group-B patients was (40; 18) and (41; 21) years respectively. While stone size of Group-A and Group-B patients reported as (2.0; 0.60) and (2.1; 0.70) cm. The operative time and interquartile ratio of Group-A and Group-B patients was (75; 45) and (85; 45) minutes and we found significant change in HB of Group-A (0.90; 0.80) with Group-B patients (1.90; 0.70) gm/dl respectively [p = 0.000]. Conclusion: It was observed that use of 24 French Amplatz sheath lead to less renal hemorrhage and less hemoglobin drop compared to standard 30 French Amplatz sheath. Thus, small size Amplatz sheath in percutaneous nephrolithotomy may be considered effective and safe option for treatment of renal stones.

Objective: To determine the scope of tubeless (TL) supracostal percutaneous nephrolithotomy (PCNL) in terms of safety through a randomized controlled trial. Materials and Methods: Adult patients (>14 years) undergoing supracostal PCNL were randomized into two groups (25 patients each), by randomizing odd number for supracostal PCNL with tube (WT) as group A and for TL supracostal PCNL as group B. Both groups received injectable analgesia on operative day and oral analgesia from the first post-operative day. Pain severity was objectively assessed by a visual analogue scale (VAS). Chest X-ray and kidney ultrasonography were done to detect any pleural effusion and perinephric collection. These complications along with thoracostomy and endotracheal intubation were compared between the groups. Results: The mean (VAS) score in group A and B was 7.88±0.83 and 4.12±0.83, respectively (p=0.01). Four of 25 (16%) patients in group A and 1 of 25 (4%) patients in group B developed pleural effusion. Two patients (8%) in group A and 1 patient (4%) in group B required tube thoracostomy (p=0.56). One patient (4%) in group A and 2 patients (8%) in group B developed perinephric collection (p=0.56). A single patient in each group (2%) developed respiratory distress needing elective intubation and ventilation (p=1.00). The mean hospital stay in group B (4.12±0.52 days) was shorter than in group A (4.68±0.85 days) (p=0.01). Conclusion: Tubeless supracostal PCNL is less painful than supracostal PCNL WT, without difference in complication rates. Supracostal PCNL (TL) has a shorter hospital stay. Keywords: Percutaneous nephrolithotomy, Supracostal, Pleural effusion, Thoracostomy Amaç: Tüpsüz suprakostal perkütan nefrolitotominin (PNL), randomize kontrollü çalışma ile güvenlik açısından kapsamını belirlemek. Gereç ve Yöntem: Suprakostal PNL uygulanan erişkin hastalar (>14 yıl), tüplü suprakostal PNL için A grubu olarak ve tüpsüz suprakostal PNL için B grubu olarak iki gruba tek sayı randomize edildi (her biri 25 hasta). İki grup ameliyat günü enjektabl analjezi ve operasyon sonrası ilk günden itibaren oral analjezi aldı. Ağrı şiddeti görsel analog ölçeği (GAÖ) ile objektif olarak değerlendirildi. Plevral efüzyon ve perinefrik koleksiyonu saptamak için göğüs X-ray ve böbrek ultrasonu yapıldı. Torakostomi ve endotrakeal entübasyon ile birlikte bu komplikasyonlar gruplar arasında karşılaştırıldı. Bulgular: Grup A ve B ortalama GAÖ skoru sırasıyla 7,88±0,83 ve 4,12±0,83 idi (p=0,01). Grup A'da 25 hastanın 4'ünde (%16) ve grup B'de 25 Supracostal PCNL-Standard Nephrostomy with Day Long Pain Versus Painless TubelessGün Boyu Ağrılı Standart Nefrostomiye Karşı Ağrısız Tüpsüz-Suprakostal PNL Supracostal access during percutaneous nephrolithotomy has become a fear factor among the urological fraternity. leaving a drainage tube postoperatively has become a beacon of safety. But the evidence proving this notion is feeble. This study adds to the evidence which proves that drainage is not necessary in supracostal access during a very common urological...