David A. Tolley

Incidence, Prevention, and Management of Complications Following Percutaneous Nephrolitholapaxy

CONTEXT Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus. OBJECTIVE To review the epidemiology of complications and their prevention and management. EVIDENCE ACQUISITION A literature review was performed using the PubMed database between 2001 and May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols with the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, and Clavien, and the MeSH terms nephrostomy, percutaneous/adverse effects, and intraoperative complications or postoperative complications. EVIDENCE SYNTHESIS Assessing the epidemiology of complications is difficult because definitions of complications and their management still lack consensus. For a reproducible quality assessment, data should be obtained in a standardized manner, allowing for comparison. An approach is the validated Dindo-modified Clavien system, which was originally reported by seven studies. No deviation from the normal postoperative course (Clavien 0) was observed in 76.7% of PNL procedures. Including deviations from the normal postoperative course without the need for pharmacologic treatment or interventions (Clavien 1) would add up to 88.1%. Clavien 2 complications including blood transfusion and parenteral nutrition occurred in 7%; Clavien 3 complications requiring intervention in 4.1.%; Clavien 4, life-threatening complications, in 0.6%; and Clavien 5, mortality, in 0.04%. High-quality data on complication management of rare but potentially debilitating complications are scarce and consist mainly of case reports. CONCLUSIONS Complications after PNL can be kept to a minimum in experienced hands with the development of new techniques and improved technology. A modified procedure-specific Clavien classification should be established that would need to be validated in prospective trials.

The long-term outcome after laparoscopic nephroureterectomy: a comparison with open nephroureterectomy.

Objectives To assess the long‐term outcome of the endourological management of upper tract transitional cell carcinoma (TCC) by laparoscopic nephroureterectomy (LNU) or open nephroureterectomy (ONU).

Laparoscopic Radical Nephroureterectomy: Results of an International Multicenter Study

OBJECTIVE To report a multicenter analysis after laparoscopic radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma. MATERIALS AND METHODS A total of 116 patients (72 males; mean age 68 years) underwent laparoscopic radical nephroureterectomy at five international institutions: 51 transperitoneally, 65 retroperitoneally. Location of the primary tumor was pelvicalyceal in 70 patients (60%), ureteral in 27 (23%), and multifocal in 19 (17%). In 18 patients (15%), transurethral resection was performed for concomitant bladder tumor. The median follow-up time was 25 months (range 3-93). A minimum follow-up of 1 and 2 years was available in 77 and 41 patients, respectively. RESULTS Five patients (4%) were converted to open surgery. The specimen was extracted intact in all 116 patients: using an Endocatch bag in 78 patients, a Lapsac in 5, and manually in 33. Pathologic staging was pTis in 5 (4%), pTa in 41 patients (35%), pT1 in 31 (26%), pT2 in 18 (15%), pT3 in 16 (13%), and pT4 in 5 (4%). Pathological grade was grade I in 26 patients (23%), grade II in 41 (35%), grade III in 34 (29%) and grade IV in 15 (12%). Histopathology revealed a positive surgical margin in five patients (4.5%): renal hilum (one), periureteral soft tissue (two), distal edge of the ureter/ bladder cuff (two). Local recurrence was noted in two patients (1.7%). Bladder recurrence was noted in 28 patients (24%) with a mean time to recurrence of 13.9+/-11.5 months. Distant metastases occurred in 11 patients (9%): lung (5), liver (3), bones (2), adrenal (1); mean time to metastasis was 13 months. Overall, 23 patients (20%) died. One-year and 2-year cancer-specific survival was 92% and 87%, respectively. Two-year cancer-specific survival according to pathologic stage was 89% for patients with pT1 disease, 86% for pT2, 77% for pT3, and 0% for pT4 (p=0.0001). Two-year survival according to pathologic grade was 88% for grade I, 90% for grade II, 80% for grade III, and 90% for grade IV (p>0.05). CONCLUSION Laparoscopic radical nephroureterectomy appears to be an effective minimally invasive treatment for select patients with upper tract transitional cell carcinoma. Although the 2-year survival data reported herein are encouraging, longer follow-up is needed before laparoscopy can be considered as a standard treatment.

ONE WEEK OF CIPROFLOXACIN BEFORE PERCUTANEOUS NEPHROLITHOTOMY SIGNIFICANTLY REDUCES UPPER TRACT INFECTION AND UROSEPSIS: A PROSPECTIVE CONTROLLED STUDY

Urosepsis after percutaneous nephrolithotomy (PCNL) is a severe complication, and its avoidance can sometimes be difficult despite antibiotic prophylaxis. Authors from the UK with a considerable experience in this procedure describe a prospective controlled study using ciprofloxacin for 1 week before PCNL, and found that it significantly reduces the risk of urosepsis.

Ureteroscopic and percutaneous management of upper tract urothelial carcinoma (UTUC): systematic review.

Whats known on the subject? and What does the study add?

Clearance of Lower-Pole Stones following Shock Wave Lithotripsy: Effect of the Infundibulopelvic Angle

Objective: To assess the effect of anatomic factors, especially the angle of the lower-pole infundibulum, on stone clearance following shock wave lithotripsy (SWL) in order to determine selection criteria for percutaneous nephrolithotomy. Methods: We retrospectively analyzed 116 patients with single lower-pole stones measuring 11–20 mm treated with SWL. Intravenous urograms were reviewed to measure the infundibulopelvic angle, the angle of the infundibulum to the vertical, and the anatomy of lower-pole calyces. Results: The overall stone-free rate was 52%. Factors most closely associated with a stone-free status were obtuse infundibulopelvic angle, lack of calyceal distortion, and a large infundibular diameter. The infundibulopelvic angle was the only factor to attain significance in predicting stone-free status (p = 0.012). The size of the stone did not predict eventual stone-free status (p = 0.911), but larger stones were more likely to require intervention after SWL. Conclusion: For solitary lower-pole stones 11–20 mm in size, the angle of the lower-pole infundibulum as it relates to the pelvis plays a role in eventual stone clearance and should be taken into account before choosing a mode of treatment.

A comparison of the pathology of transitional cell carcinoma of the bladder and upper urinary tract.

To clarify the histopathological patterns of upper and lower urinary tract transitional cell carcinomas (TCCs), as previous reports suggest that upper urinary tract TCCs have a greater tendency towards high‐grade disease than bladder TCCs, of which most are low‐grade and low‐stage tumours.

Long-term endoscopic management of upper tract urothelial carcinoma: 20-year single-centre experience

Study Type – Therapy (case series)

Outcomes using a fourth-generation lithotripter: a new benchmark for comparison?

To evaluate the efficacy of a fourth‐generation lithotripter, the Sonolith Vision (Technomed Medical Systems, Vaulx‐en‐Velin, France) for treating single previously untreated renal calculi, and to compare the results with the reference standard HM‐3 (Dornier MedTech Europe GmbH, Wessling, Germany) in the same population originally studied by the USA Cooperative Study Group in 1986.

The British Association of Urological Surgeons: guidelines for training in laparoscopy

To report the guidelines of the British Association of Urological Surgeons (BAUS), commissioned by the National Institute for Health and Clinical Excellence (NICE) in response to safety concerns about the rapid uptake of new, complex laparoscopic procedures.