tackling the percutaneous nephrolithotomy - swiu · 2017. 5. 5. · tackling the percutaneous...
TRANSCRIPT
Tackling the Percutaneous Nephrolithotomy
Amy E. Krambeck, M.D. Associate Professor of Urology
Mayo Clinic Rochester, Minnesota
Outline
• Indications • Preoperative considerations • Challenges • Complications • Review of technical aspects
• Access • Equipment • Exit strategies
Indications for PCNL
• Stone volume/ staghorn • Stone location • Stone composition (struvite, cystine) • Renal anomalies • Distal obstruction (UPJ, stricture) • Failure of other modality • Patient comorbidities
Treatment Considerations Upper Urinary Tract Calculi
• Ureteral access concerns • Neobladder • Ureteral reimplantation • Bladder neck closure
• Surgeon experience • Ureteroscopy, PCNL, SWL
• Likelihood of rendering stone free
Treatment Decision by Stone Burden
• Stone Burden • Most important factor in determining
treatment modality outcome Stone Burden
Stone Free Rate
Ancillary Procedures Retreatment
Case Volume and Stone Free Rate
•HVol = >77 cases •LVol = <77 cases
•HVol SF 82.5% •LVol SF 75.1%
•120 cases/year
Opondo D, et al. Eur Urol 62:1181-7; 2012
Contemporary PCNL Evaluation of 1585 Procedures
• Medical co-morbidities in 48.8% • Simultaneous bilateral PNL in 6.3% • Access by the urologist
• LC 66.4%, MC 19.2%, UC 14.4% • Multiple access in 8%
Duvdevani, Denstedt et al. J Endo 21:824-829, 2007
Stone-Free Results
• KUB postoperative and 3 months • 89.1% at discharge • 94.8% at 3 months
• 24.7% required 2nd procedure • 342 2nd nephroscopy • 29 SWL • 20 ureteroscopy
Duvdevani, Denstedt et al. J Endo 21:824-829, 2007
Stone-Free Rates
Surface Area (mm2)
% Stone Free (by KUB)
1-500 97.9
501-1000 94.6
1001-1500 92.9
>1500 88.6
Duvdevani, Denstedt et al. J Endo 21:824-829, 2007
Length of Hospitalization
• Mean 4.0 days (range 1-30 days)
• Length of stay decreased over time • 6 to 3 days
Duvdevani, Denstedt et al. J Endo 21:824-829, 2007
Percutaneous Nephrolithotomy for Staghorn Calculi: A Single
Center’s Experience over 15 Years
Soucy F, Ko R, Duvdevani M, Nott L, Denstedt J, Razvi H. J Endourol 23:1669-73; 2009
Staghorn Stone Free Results
• 509 partial or complete staghorns • 84% single access tract • 9% secondary PCNL • Stone-free rates (varied imaging)
• 78% discharge • 9% at 3 months
• Transfusion rate 0.8%
Soucy F et al, J Endo 23:1669-73;2009
Developments in Technique and Technology: The Effect on the Results of
Percutaneous Nephrolithotomy for Staghorn Calculi
Desai M, Jain P, Ganpule A, Sabnis R, Patel S, Shrivastav P. BJU International 104: 542-8; 2009
Staghorn Stone Free Results • Largest PCNL staghorn series
• 834 procedures in 773 patients • Evaluated outcomes over 17 years • Time, experience and technology reduced:
• Operative and hospital duration • Tract number • Reintervention • Complications • Residual calculi
• Overall stone free 86%
Desai M et al, BJU Int 104:542-548; 2009
AUA Guidelines on Management of Staghorn Calculi
• PCNL should be the 1st treatment
• If combo (i.e. sandwich) therapy PCNL should be last procedure
• SWL should not be used
• Open surgery should not be used
Morbid Obesity • Limited options
• SWL & PCNL
• Comorbidities increase stone formation
• HTN, DM
• Increased excretion calcium, oxalate, sodium, uric acid
Skin to stone distance?
PCNL in the Obese Technical Challenges
• Anesthesia and prone positioning • Total lung & functional residual capacity reduced • IVC compression reduces preload & oxygenation
• Strategies to reduce
• Lateral or supine position1
• Conscious sedation/local anesthesia2
• Awake intubation/prone patient self positioning3
1. Gofrit O et al, J Endourol 16:383-6; 2002 2. Kanaroglou A et al, Can J Urol 13: 3153-5; 2006 3. Wu S, et al, J Endourol 23: 1599-602; 2009
PCNL in the Obese Technical Challenges
• Skin to stone distance • Skin cut down – larger incision • Extra long access sheath with
flexible scope •Sequential dilation
• Upper pole access
The Clinical Research Office of the Endourological Society Percutaneous Global Study: The Influence of Body
Mass Index on Outcomes
Fuller A, Razvi H, Denstedt JD, Nott L, Pearle M, Cauda F, Bolton D, Celia A, de la
Rosette J. J Urol 188: 138-144; 2012
PCNL Outcomes Based on BMI
• 3709 patients from 96 centers CROES • Obesity associated with
• Longer OR duration • Higher retreatment rates • Lower stone free rates • Greater comorbidities
• No difference in • Hospital stay • Complications • Transfusion
Fuller A, et al. J Urol 188: 138-144; 2012
Age and PCNL
• Matched • Stone # • Size • Location • Imaging
>70 <70 P-value N 334 334 Age 74.7 46.9 <0.001 eGFR 66.4 84.6 <0.001 Transfusion 6.0 3.0 0.099 SF 78.7 81.7 0.381 LOS 5.0 4.4 0.288 Postop eGFR 60.1 78.3 <0.001 Complication 19.9 6.6 <0.001
•HV center elderly longer LOS •3.9 vs 3.5 p=0.002
Okeke Z, et al. J Endourol 2012; 26: 996-1001
Anticoagulated or Coagulopathic Patients
• Condition must be corrected preoperatively
• If not possible consider ureteroscopic stone extraction
• 27 PCNL patients1 • Stone free rate 93% • 2 (7%) significant bleeding • 1 (4%) thromboembolic event
1. Kefer JC, et al. J Urol 2009; 181: 144-148
Renal Anatomy Stone Disease
• UPJ obstruction • Horseshoe kidney • Ectopic/fusion abnormalities • Calyceal diverticulum • Lower pole calyx • Urinary diversion
Horseshoe Kidney
• 1 in 400 individuals • Isthmus prevents ascent
resulting in malrotation • 60% may form stones • URS and SWL decrease
SF results
Yohannes P and Smith AD, J Urol 168: 5-8; 2002
Horseshoe Kidney-Technique • Abnormal calyceal orientation • Aberrant vasculature &
adjacent organs • Upper pole access
• Access to upper/lower calyces, pelvis, UPJ
• 60 procedures in 47 patients • Technical difficulties
• Lower calyceal and isthmus stones • Anteromedial calyces – consider
laparoscopic approach • Must have all modalities available to
maximize likelihood of success • Overall SFR 88%
• High rate of re-intervention • Single procedure in 30% of staghorns
Symons et al, BJU International 102: 1676-80; 2008
Urolithiasis in the Horseshoe Kidney: A Single Centre Experience
Urinary Diversion
• Increase risk of stones • 11% within 3 years
• Multifactorial • Chronic UTI • Urinary stasis • Foreign body • Hyperchloremic
acidosis • Urinary ammonium
absorption
Neobladder
Ileal Conduit
33 PCNL procedures Urinary diversion associated with
• Radiologist access (40% vs 0%, p<0.001) • 2nd look nephroscopy (36% vs 16%, p=0.046) • Struvite stones (80% vs 12.5%, p=0.006) • Post-operative sepsis (8% vs 0%, p=0.038)
No significant difference in
• Stone free rates • Complications • Transfusion rates • Length of hospital stay
Fernandez A, et al. J Endourol, October 25: 1615-1618; 2011
Percutaneous Nephrolithotripsy in Patients with Urinary Diversions A Case-Control Comparison of
Perioperative Outcomes
Francisco Sampaio & Renan Uflacker: Renal Anatomy Applied to Urology, Endourology and Interventional Radiology 1993
Intrarenal Anatomy
Lower Pole Calculi Stone-Free Rates by Stone Size
Lower Pole Study Group, J Urol 66:2082, 2001
% Stone Free
0102030405060708090
100
PCNL
SWL
100
63
93
23
86
14
< 10 mm 11 - 20 mm > 20 mm
p=0.003 p=0.001 p=0.029
Management of Lower Pole Calculi • < 1 cm
• Observation, SWL, ureteroscopy • 1-2 cm
• PCNL best • Ureteroscopy in select patients
• > 2 cm • PCNL
• Body habitus, anatomy, cost and patient preference must be considered
Raman J and Pearle M, Curr Opin Urol 18:214-9; 2008
Complications
Potential Complications • SIRS up to 23%
• Urosepsis 0.3-4.7% • Transfusion rate 0.8%-30.9%
• Intervention 0.6-1.4% • Pleural injury 0-3.1% • Organ injury 0.2-0.8%
• Colon injury 0.06% • Fluid over load – unusual with sheath • Death 0.12%
Rao, Preminger, Kavanagh Urinary Tract Stone Disease 2011 Duvdevani, Denstedt et al. J Endo 21:824-829, 2007
Blood Transfusion & Embolization
• 547 PCNL patients • 21 (3.8%) blood transfusion • 5 (0.9%) embolization, 1 nephrectomy • Risk factors
• Increasing age (60 vs 55) • OR time (119 min vs. 103) • Preop UTI (23.8% vs. 16.1%)
Keoghane SR, et al. BJU Int 2013; 111:628-632
CROES Study: Hemorrhage Rates
• 5803 patients • Transfusion rate 5.7%1
• ASA scores • Stone burden • Operative duration
• 0% in solitary kidneys • 5% anomalous kidneys
1. Lopes T, et al. J Endourol 25:755-762; 2011
Urologist Gained Access and AVF
• Study of 3338 PCNLs1 • IU Health & Mayo over 10 years
• 15 (0.48%) patients (16 kidneys) required angioembolization
• Time to bleed 7 days (1-15) • Transfusion required in 9 (60%) • No risk factors identified
1. El Tayeb MM, et al. Urology Pub Pending 2015
Supracostal Access: Puncture Site
16.7% of 5803 pts CROES
De la Rosette J, et al. J Endourol 2011; 25: 11-17
Supracostal Access and Pleural Injury
Author
Overall PNL
patient
No. of supracostal punctures
(%)
Overall pleural
complication (%)
Pleural complications
treated (%)
Stone free rate (%)
Young et al, Radiol 1985; 154:633
140 24 (17) 37 4.2 N/A
Picus et al, AJR 1986; 147:393
154 50 (32) 32 8 90
Fuchs and Forsythe, Urol Clin Am 1990; 17:99
344 106 (31) N/A 4.7 N/A
Narasimham et al, Acta Radiol 1991; 32:162
231 56 (24) 9 3.5 95
Lam et al, J Urol 1992; 148:1026-1029
91 25 (27)
28 2.2 N/A
Golijanin et al, J Endourol 1998; 12:403
320 104 (36) 8.7 4.3 87
Stening et al, J Endourol 1998; 12:359-362
N/A 21 None None 75
TOTAL 1280 386 (29) 16 3.8 92
Renal Function after PCNL • 87 PCNL patients followed 19.2 years1
• Vs. 288 SWL • Vs. 288 spontaneous passage
• New onset CKD • PCNL 9 (10.6%) • SWL 14 (5.2%) • SP 25 (8.7%)
• Risk CKD SF 5%2
P=0.09
1. Krambeck AE, et al J Urol 2008; 179: 2233-7 2. El-Zoghby ZM, et al Clin J Am Soc Nephrol 2012; 7: 1409-1415
Risk Factors for CKD Post PCNL
• 265 staghorn pts followed 12 months1 • CKD status:
• Stable 66.8% • Improved 12.8% • Declined 20.4%
• Immediate change in Cr postoperative only risk factor
1. Akman T, et al. J Urol 2012; 187: 1656-1661
Case Volume and Complications
• 120 cases/year
Opondo D, et al. Eur Urol 62:1181-7; 2012
Limiting Postoperative Complications
• Negative urine ctx1 • 162 - abx • Matched to + abx
• stone size • Comorbidities • Neph tube
• Other studies less SIRS with prophylactic antibiotics 1 week preoperatively2,3
Abx No abx P-value
Fever 2.5% 7.4% 0.04
SF 86.3% 74.4% 0.006
Retx 5.6% 11.8% 0.04
Comp 1.9% 22.0% <0.001
Clavian 1 2.5% 21% <0.001
>1 0 8.8%
1. Gravas S, et al. J Urol 188: 843-847; 2012 2. Mariappan P and Tolley DA et al. BJU Int 2006; 98: 1075-9 3. Bag S, et al Urology 2011; 77: 45
Technique
Pre-Operative Imaging
• CT Scan • Limit injury to
surrounding organs • Liver, spleen, colon,
lung • 1-2% retrorenal colon
• 25% scoliosis1 • IV contrast can be
beneficial
1. Onder H, et al. Surg Radiol Anat. 2014;36:67-70
• Placement of ureteral catheter
• C-arm fluoroscopy
• Precise calyceal puncture
• Safety wire as far into the urinary tract as possible
• Amplatz sheath - always
Access: General Principles
Operating Room Set-up
Separate imaging table with C-arm preferred
Under table x-ray source (reduces operator exposure)
Selection of Renal Access Site
• Most important factors - Stone location and burden
• Maximize stone removal via rigid scope
• Lower pole generally preferred
• decrease morbidity
Anesthesia Requirements
• General anesthesia preferred - Best airway protection when prone - Allows suspension of respiratory
excursions (end expiration)
• Local anesthesia is option1 - Adjunctive intravenous sedation - 8.3F anesthesia injection catheter - Delivers local anesthetic along tract
Grasso & Taylor Textbook of Endourology, 1997:99-113
Anesthesia Injection Catheter
8.3Fr
Fluoroscopically Guided Access
• Opacification of collecting system
• Ureteral catheter placed cystoscopically on side of stone
- 5F safety (open-ended) catheter - 7F ureteral occlusion balloon
catheter
• Prone position (flank inferior to post) • Arm on stone side on arm board (flexed
90°); opposite arm against patient • Pressure points padded
Patient Positioning
Other Patient Positions
• Supine • Lateral decubitus • Reverse lithotomy • Split-leg • Flexed-prone
Supine vs. Prone PCNL • Meta-analysis • 1,469 supine vs. 4,837 prone • No difference
• Stone-free rates (82.4 vs. 82.1%) • Bleeding • Colonic injury 0.5% • Pleural injury 0%
• Op times shorter supine--smaller stones
Wu P, et al. Int Urol Nephrol 43: 67-77, 2011
Principles of Access
• Posterior calyx to permit entry into collecting system
• Aim for calyx not infundibulum
• Avoid hemorrhage from interlobar artery
Accurate Calyceal Access
• Puncture site medial to posterior axillary line (avoids colon)
• Precise mid-calyx puncture required - Avoids peri-infundibular venous plexus
Anatomical Considerations Pleural Reflection
Supra-12th rib access is transthoracic but extrapleural
• 0/72 cases had hydro/pneumothorax
Supra-11th rib access is transthoracic & transpleural
• 5/26 (19%) incidence of hydro/pneumothorax
Insure sheath position Munver R, Delvecchio F, Newman G, Preminger G: J Urol 166:1242, 2001
Upper Pole Access • Often the optimal approach
- Staghorn stones - Large upper pole stone burden - Antegrade endopyelotomy - Proximal ureteral stones - Upper pole calyceal diverticulum - Complex lower pole stones - Horseshoe kidneys
Selection of Renal Access Site
Upper Pole Access Caveats
• Puncture during expiration
• Ensure working sheath remains in place for duration of procedure to avoid fluid accumulation in chest
• Post procedure chest flouro or x-ray
Imaging Modalities for Access in OR
• Fluoroscopic - Best delineation of calyceal anatomy - Use 18-gauge diamond-tipped needle
• Techniques:
- "Eye of Needle" - Triangulation
• AP plane:
• Visualize directly over both needle and calyx
• "bull's-eye" as visualize down shaft of needle
Imaging Modalities: “Eye of the Needle”
• Oblique plane:
• Allows evaluation of needle penetration depth
Imaging Modalities: “Eye of the Needle”
• Advantages: • Easier to keep access needle centered as
puncturing direct down onto calyx
• Disadvantages: • AP view includes surgeon's hand • Acute access angle may make wire
passage difficult, increases risk of torque injury
Imaging Modalities: “Eye of the Needle”
Imaging Modalities: Triangulation Technique
• C-arm angled away from pole of access Localize calyx of puncture in two planes
- Anterior-posterior (AP) to needle - Oblique to needle
Lower Pole Access Site
• AP plane (left - right adjustments):
Imaging Modalities: Triangulation Technique
• AP plane (left - right adjustments)
Too lateral Too medial Correct alignment
Imaging Modalities: Triangulation Technique
• Oblique plane (up - down adjustments)
Imaging Modalities: Triangulation Technique
• Oblique plane (up - down adjustments)
Correct alignment Too caudad Too cephalad
Imaging Modalities: Triangulation Technique
• Advantages - Keeps hands out of field - Calyceal access "end-on" - Access to any calyx from a single point
(i.e. subcostal upper pole) • Disadvantages
- More technically demanding to learn than "eye of needle" technique
- must center in two planes
Imaging Modalities: Triangulation Technique
• Place as much wire into the urinary tract as feasible - Ureteral placement is optimal - If unable to negotiate into ureter then
coil wire into peripheral portion of collecting system
Establishing Percutaneous Access
• Nearly frictionless • Kink-resistant • Initial wire for PNL
Hydrophilic, Nitinol Core Guidewire
Guide Wires
Securing Percutaneous Access
• Placement of safety wire - Once glidewire down ureter, feed
angiographic catheter over wire - Exchange glidewire with superstiff wire - Insert 8/10 coaxial catheter set - Secure safety wire (0.035" straight)
Percutaneous Access 3 Take Home Points
1. Thoughtful and accurate tract placement in most suitable calyx
2. Upper pole approach preferred - Staghorn, horseshoe
3. Know when to stop - Bleeding, infection
Tract Dilation
• Always monitor dilation process under fluoroscopy
• Methods: - Amplatz sequential dilators - Metal telescopic dilators - Balloon dilation catheter
Tract Dilation
• Inserted sequentially over 8F portion of coaxial set
• 30F sheath inserted over dilator
• Dilation process can be cumbersome
Amplatz sequential dilators (12 to 34F)
Tract Dilation
7F Balloon dilation catheter (Nephromax) • Inflate to 18 atm of pressure, 30F sheath placed
• Radial dilation in a single step
• Incomplete dilation if scar is present (seen by waist)
Tract Dilation: Caveats
Avoid dilation of infundibulum • Risks hemorrhage
Balloons may dilate beyond radiopaque marker
When in doubt • Err on side of
dilating short • ‘Scope to get the
“lay of the land”
Tract Dilatation: Balloon
CROES Tract Dilation Controversy • Original study indicated increased
hemorrhage with balloon dilation1
• Subsequent multivariate analysis2 • Balloon dilation NOT associated with
hemorrhage • Hemorrhage associated with
• Operative duration • Stone burden • Low volume institution • Larger sheath
1. Lopes T, et al. J Endourol 25:755-762; 2011 2. Yamaguchi A, et al. J Endourol 25:933-939; 2011
Variation in Tract Size: “Mini-”, “Ultra Mini-”, “Micro-”
Tract Size Benefits Cons Stone Removal
Mini1 13 Fr Limited blood loss & transfusion risk
Limited visualization, Longer OR time, technical limitations
Active
Ultra Mini2
11-12 Limited blood loss and transfusion risk
Longer OR time, technical limitations
Passage of fragments down ureter
Micro3,4 4.85 Fr all seeing needle
Limited blood loss Limit stone size and visualization, longer OR time
Passage of Fragments down ureter
1. Li L, et al. Urology 2010; 75:56-61 2. Desai J, et al. Biomed Res Int 2013; Epub 2013 Jul 24 3. Desai MR, et al. J Urol 2011; 186:140-5 4. Sabnis RB, et al. BJU Int 2013; 112:355-361
Other Types of Perc Access
• Ultrasound guided • CT guided
• complex anatomy • Laparoscopic guided
• Pelvic or ectopic kidney
• Retrograde endoscopic guidance
Ultrasound Guided Access
• 3.5/5 MHz probe with puncture attachment
• Advantages • Limits radiation exposure • Precise calyceal puncture • Avoid adjacent structure
• Disadvantage: steep learning curve
Desai M. J Endourol 23: 1641-1643, 2009
Removal of Stone • Ultrasonic lithotripsy
• Excellent suction • Not ideal for hard stones
• Pneumatic lithotripsy • Excellent stone breakage • Requires retrieval device
• Combination device • Suction limited
• Holmium laser lithotripsy • Requires retrieval device
Ultrasonic Lithotriptor Comparison
Efficiency ratios: Olympus LUS-2 1.0 ± 0.1 Circon-ACMI USL-2000 1.1 ± 0.3 Karl Storz Calcuson 1.4 ± 0.3 Olympus LUS-1 2.1 ± 0.5 Richard Wolf 2271.004 3.6 ± 0.8
LUS-2 = USL-2000 > Calcuson > LUS-1 > Wolf Mean penetration time differences were significant (p < 0.05)
Kuo RL et al. J Urol 170: 1101-1104, 2003
Outcomes of Combination Devices Compared to Ultrasound
Krambeck AE, et al. BJU Int 107:824-8, 2010
Flexible Nephroscopy
• Perform after stone removal
• Decrease need for additional treatments
• Limits access number
• Laser lithotripsy
• Baskets
• Amplatz sheath
• Pressurize irrigant to 300 mmHg
• Contrast plus fluoroscopy to assist in orientation, documentation
Flexible Nephroscopes: Set Up
Single vs. Multiple Access for Staghorn Calculi
• Single access • Upper pole, combo rigid & flexible with
holmium laser • Stone free rate 95%
• Advantages • 2.2% transfusion rate vs. 7.9-45% • Decrease renal damage/scarring?
• Disadvantage • Longer operative time
Williams SK et al. Cur Opin Urol 18: 224-8, 2008
Nephrostomy Tube • Smaller tube less discomfort1 • No influence on hemorrhage • More likely to occlude if
significant bleeding
• CROES large & small tube comparison2
• Large tubes less bleeding/ complications
1. Kim S et al. J Endourol 19:348-352; 2005 2. Cormio L et al. World J Urol Epub October 2012
8-10 Fr
Tubeless PCNL
• Replace NT with ureteral stent • Potential advantages
• Less pain • Quicker recovery
• Potential disadvantage • Loss of tract if 2nd PCNL necessary
Bellman GC, et al J Urol 157: 1578-82; 1997
Totally Tubeless PCNL
• No ureteral stent
• No nephrostomy tube
• Highly selected patients
Purpose of Nephrostomy Tube Post PCNL
• Aid in healing of tract • Promote hemostasis • Drain urine & prevent extravasation • Drain infection • Allow re-entry
Tubeless PCNL Conventional PCNL No intraoperative hemorrhage Intraoperative bleeding
No collecting system injury Perforation
Single or straightforward access Multiple or complex tracts
Subcostal access Supracostal access
Normal renal function CKD
Normalized coagulation profile Coagulopathy/bleeding diathesis
Normal platelet count Thrombocytopenia
Stone free status Residual calculi
Zilberman et al, J Urol 184:1261-6; 2010
Considering Tubeless PCNL
Conclusions
• Current era PCNL is in general a low morbidity procedure
• Consideration of anatomy, anomalies, and comorbidities should be made
• Multiple techniques and exit strategies exist and are considered safe
Thank you
Special Thank you to Dr. Lingeman for supplying video slide material