Endopyelotomy in the Elderly

Horgan, John; Maidenberg, Marc; Smith, Arthur D.

doi:10.1016/s0022-5347(17)35698-7

Cited by 17 publications

(1 citation statement)

References 7 publications

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“…have shown that endopyelotomy is safe in patients over 65. 117 They also had an increased transfusion rate (11%) and suggest that elderly patients pose a greater risk for blood loss during percutaneous procedures due to the effects of atherosclerosis on renal blood vessels. Patient positioning must be undertaken with care.…”

Section: Special Circumstancesmentioning

confidence: 99%

Percutaneous Management of Urinary Calculi

Ramakumar

Segura

2004

The Scientific World JOURNAL

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Radiologic studies necessary for PNL are a plain x-ray (KUB) and usually an intravenous pyelogram delineating renal anatomy. In special circumstances, computerized tomography is required to determine if a safe window is present to form the percutaneous tract. Evaluation of the stone itself can be divided into three categories: stone burden, stone location and stone composition. 13 Retrospective analyses of ESWL patients have demonstrated a higher incidence of failure and need for additional procedures when the stone burden is greater than 3 cm in diameter. 14 Treatment of lower pole nephrolithaisis remains controversial. 15 Lingeman, et. al published a retrospective review and meta-analysis of the literature demonstrating a 90% stone free rate with PNL compared to 59% with ESWL. In contrast to this, a more recent study from Cass 16 recommends ESWL for lower pole stones smaller than two centimeters. His analysis reveals a lower stone-free rate than PNL, offset by a better retreatment and complication rate. An interesting technique of calyceal irrigation during ESWL for lower pole calculi has been described, but this is still investigational. 17 Further studies indicate that cystine stones are relatively resistant to shockwave therapy. 18 Generally, the only preparation required is intravenous antibiotics, usually a cephalosporin. Especially in cases of struvite stones, broader coverage is utilized with ampicillin and gentamicin. No bowel preparation is necessary, and in cases of perforation (discussed later) conservative management is effective. An analysis of coagulation factors is also warranted. PERCUTANEOUS ACCESSThe endourologist is only as good as the access tract allows. Key placement of percutaneous tract or tracts can make the difference between safe, efficient stone removal and frustrating failure. 19 Who performs the access procedure is dependent on personal preference. At our institution, the access is obtained in the radiological suite, after which the patient is transferred to the operating room. For the access procedure, patients are placed in the prone position with mild intravenous sedation. 20 The previously obtained radiologic studies should delineate the relationship between the stone and the collecting system. If the stone is located in a particular calyx or diverticulum, access should be through that particular calyx or diverticulum. 21 If this is not the case, a lateral or posterior calyx is optimal for stone extraction. In the United States, fluoroscopic guidance is typically used for access, but European interventionists prefer ultrasound guidance.Once the collecting system is entered, contrast is used for proper placement of the guide wires and later the nephrostomy tube, which at our institution is usually a Cope catheter secured to the skin. Retrograde assisted renal access has been described. 22,23 Using a flexible ureteroscope, the calyx is punctured and the wire is brought out through the skin. Snare wires have also been used for this technique. 24 Wires can be replaced and the tract...

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Section: Special Circumstancesmentioning

confidence: 99%