Impact of Percutaneous Access Point Number and Location on Complication and Success Rates in Percutaneous Nephrolithotomy

Abstract

Objectives: Percutaneous nephrolithotomy (PNL) is sometimes associated with complications, especially in patients with complex stones. Herein, we review our experience with PNL to determine the impact of percutaneous access number and location on success and complication rates. Patients and Methods: During a 2-year period, a total of 275 patients with a mean age of 42.3 ± 14.8 (range: 13–75) years underwent PNL. Stones were classified as simple in 51.6%, and complex (staghorn calculi or renal pelvis stones coexisting with caliceal stones) in 48.4%. Percutaneous access was done under C-armed fluoroscopy and the tract was formed with a high-pressure balloon dilation system. One single percutaneous access was sufficient in 210 (76.4%), while 2 accesses were utilized in 44 (16%), and ≧3 accesses in 21 cases (7.6%). Supracostal access was performed in 23 (8.4%) patients. Results: An overall success rate of 94.9% was achieved. Stone location, but not the access point location, was the major determinant for success, which was 99.3 and 90.2% in patients with simple and complex stones, respectively (p < 0.01). Significant complications included bleeding necessitating blood transfusion in 28 (10.2%), and hydropneumothorax in 2 (0.7%) patients. Bleeding was observed in 39.1 and 7.5% of patients managed with supracostal access, and subcostal access, respectively (p < 0.01). An increased number of access points significantly augmented the risk for bleeding. Bleeding was encountered in 7.6% of patients managed with 1 percutaneous access point, and in 18.5% of cases managed with ≧2 access points (p < 0.05). Hydropneumothorax occurred in patients with supracostal access. Conclusion: Supracostal access as well as multiple punctures may be needed especially in the management of complex stones, and the need for multiple access points and supracostal access significantly increases complication rates.

Initial Experience of Percutaneous Nephrolithotomy at Lumbini Medical College

“…In our study most common location of the stones were 22 Average operating time was 78 minutes for 60 PCNL cases, out of which mean operating time for single stones was 52 minutes (range 45-60 minutes), multiple stones was 70 minutes (range 60-90 minutes) and for staghorn 110 minutes (range 90-120 minutes). Patients with large renal stones needed blood transfusions (Table 4).…”

“…20 The major concern in PCNL surgery involves serious postoperative complications such as blood loss, adjacent organ injuries and life threatening infection. 21,22 Lee et al reported the complications of PCNL in 582 patients, they report major complications in 6.8% and minor complications in more than 50% with 11.2% requiring blood transfusion. 23 In study by Osman et al, the complication rate was 50.8% with the most common complication being transient pyrexia in 27.6%, however we report 8% transient post-operative pyrexia and this is explained by the restriction to the selection of patients with preoperative documentation of absence of infection or one week antibiotic treatment according to sensitivity in case of presence of urinary tract organism.…”

Does renal parenchymal thickness affect bleeding in percutaneous nephrolithotomy?

“…Bleeding was found in 39.1% and 7.5% of patients managed with supracostal access and subcostal access, respectively (P < 0.01). Puncture to upper calices can cause injury of posterior segmental artery braches, leading to increased risk of bleeding (24). Akman et al reported similar results; the number of access points was detected as an independent predictive factor for bleeding in multivariate analysis.…”

The Influence of Access on the Efficacy and Complications in PCNL for Renal Calculi

“…There were 63 supracostal punctures which work out to 38% of all punctures. In a study by Yadav R et al Supracostal access was obtained in 332 (37.3%) out of 890 PCNL [14]. In a study by Sukumar S et al 565 patients underwent PCNL, of whom 110 (19.5%) had a supracostal access [15].…”

“…The 93.5% includes three patients with CIRF also. When success rates after multiple interventions was analyzed by Aron et al in 2005 with combined approach a total success rate of 94% (including 4 renal units with insignificant residue) was achieved [17].…”