RENAL CALCULI: Percutaneous Management

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Over the last 25 years, the management of renal calculi has changed dramatically. Almost all stones are treated with minimally invasive techniques, with the rare exception requiring open surgery. The following indications for percutaneous management of renal calculi have been established35, 44:

  • Stone size

  • Hard or cystine stone

  • Lower caliceal stone

  • Stones associated with obstruction

  • Infection stones

  • Certainty of the final result

  • Shock wave lithotripsy (SWL) failure or contraindication to SWL

  • Anatomic variation

This article also updates some of the advances in patient selection and technique that have occurred recently.

Section snippets

Stone Size

Although most small renal stones can be treated effectively with SWL, the success rate decreases as the stone volume increases. Percutaneous nephrolithotomy (PNL) clearly has advantages in the removal of larger stones with minimal morbidity.37 This point of transition generally was believed to be 2 cm. A more accurate measurement of staghorn stones was performed by Lam et al.23 By using computer analysis, the stone surface area was measured in patients treated with PNL with or without SWL and

BILATERAL PERCUTANEOUS NEPHROLITHOTOMY

Once proficiency is achieved for unilateral PNL, simultaneous bilateral PNL can be performed safely.1, 10 The authors tell all patients that the second-side procedure will be postponed if there were problems with the first side. Morbidity is similar to the unilateral procedure, with hospital days approximately the same.

TUBELESS PERCUTANEOUS NEPHROLITHOTOMY

The nephrostomy tube placed postoperatively is not entirely benign; it may cause significant discomfort and inadvertently may become dislodged.43 The tube provides adequate renal drainage to promote healing and may tamponade bleeding. It also allows the nephrostomy tract to mature and makes second-look nephroscopy easier. The nephrostomy tube may be omitted in certain situations. Candela et al3 have described their technique of tubeless PNL. In their series, 50 patients underwent percutaneous

PERCUTANEOUS NEPHROLITHOTOMY IN CHILDREN

It is reasonable to treat children with renal nephrolithiasis and to treat associated anatomic abnormality with open surgery and correction of the obstruction; however, in children who are prone to recurrence, a minimally invasive approach should be considered. Shock wave lithotripsy has been used successfully in children with small stone burden, but general anesthesia is required and there is the potential for renal and pulmonary damage. Reports demonstrate the safety and efficacy of PNL in

EVALUATION OF RESIDUAL FRAGMENTS

Twenty-four to 48 hours after PNL, the authors perform a nephrostogram to assess residual stone burden and the integrity of the collecting system. Denstedt et al8 have shown that the plain abdominal radiograph and renal CT overestimated the stone-free rate by 35% and 17%, respectively, as compared with flexible nephroscopy. Using flexible nephroscopy as the gold standard, Pearle et al31 compared the results of plain film radiography and helical noncontrast CT scanning for the detection of

COST-EFFECTIVENESS

It is difficult to predict the costs involved in renal stone removal because prices and outcomes across the world are variable. Chandhoke5 has created a cost-effectiveness model for the treatment of staghorn calculi. Overall, PNL and combined sandwich therapy were more cost-effective than SWL monotherapy. When the stone surface area was less than 500 mm2, combined sandwich therapy and SWL monotherapy were equal; however, when the stone burden exceeded 500 mm2, combined therapy became more

SUMMARY

Percutaneous nephrolithotomy has established indications and is performed with high success and minimal morbidity. Patients who have large or hard stones or stones associated with urinary obstruction are candidates for a percutaneous procedure. When the certainty of the final result is important, the patient should have a PNL. In general, the best treatment for SWL failure is not more SWL; such patients usually should have an endoscopic procedure.

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    Address reprint requests to Joseph W. Segura, MD, Department of Urology, Mayo Clinic 200 1st Street SW, Rochester, MN 55905, e-mail: [email protected]

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    Department of Urology, Mayo Clinic, Rochester, Minnesota

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