Madhu S. Agrawal

A Randomized Comparison of Tubeless and Standard Percutaneous Nephrolithotomy

PURPOSE We present a randomized study of tubeless or nephrostomy-free percutaneous nephrolithotomy (PCNL), a modification of the standard technique, compared with standard PCNL to evaluate the role of tubeless PCNL in minimizing postoperative discomfort and reducing duration of hospital stay. PATIENTS AND METHODS Two hundred and two patients undergoing PCNL were randomized to two groups: Group A (standard PCNL) with nephrostomy tube placement postoperatively, and group B (tubeless PCNL) with antegrade placement of a Double-J stent without nephrostomy. Inclusion criteria were: normal renal functions, single tract procedure with complete clearance, and minimal bleeding at completion. The two groups were comparable in age and sex and in metabolic and anatomic features. Factors evaluated included postoperative pain, analgesia requirement, blood loss, postoperative morbidity, hospital stay, and time to recovery. RESULTS All patients had an uneventful postoperative recovery. The average visual analogue scale pain score on postoperative day 1 for group A patients was 59 +/- 5.1 compared with 31 +/- 4.8 in group B (P < 0.01). The mean analgesia requirement for group A (meperidine 126.5 +/- 33.3 mg) was significantly more compared with group B (meperidine 81.7 +/- 24.5 mg) (P < 0.01). The difference in average blood loss and urinary infection for the two groups was not statistically significant. The incidence of urinary leakage from the nephrostomy site was significantly less for the tubeless group (0/101), compared with the standard PNL group (7/101). The average hospital stay in the tubeless group (21.8 +/- 3.9 hours) was significantly shorter than that of the standard PCNL group (54.2 +/- 5 hours) (P < 0.01). Tubeless group patients took 5 to 7 days for complete convalescence whereas standard PCNL patients recovered in 8 to 10 days. No long-term sequelae were noticed in the median follow-up period of 18 months in any patient. CONCLUSION Nephrostomy-free or tubeless PCNL reduces postoperative urinary leakage and local pain related to the drainage tube. It also minimizes hospital stay; the majority of patients were discharged from the hospital in fewer than 24 hours.

Safety and efficacy of ultrasonography as an adjunct to fluoroscopy for renal access in percutaneous nephrolithotomy (PCNL)

Study Type – Therapy (case series)

A prospective randomized study comparing alfuzosin and tamsulosin in the management of patients suffering from acute urinary retention caused by benign prostatic hyperplasia

Objective: Prospective randomized study to compare the efficacy and safety of alfuzosin and tamsulosin in patients suffering from acute urinary retention caused by benign prostatic hyperplasia (BPH). Methods: Patients with acute urinary retention (AUR) due to BPH (total 150) were catheterized and randomized into three groups: Group A: alfuzosin 10 mg (50 patients), Group B: tamsulosin 0.4 mg (50 patients), Group C: placebo (50 patients). After three days, catheter was removed, and patients were put on trial without catheter (TWOC). Patients with successful TWOC were followed up for three months, taking into account the prostate symptom score (AUA Score), post-void residual urine volume (PVRV), and peak flow rate (PFR). ANOVA was used for statistical analysis. Results: Both group A (alfuzosin) and group B (tamsulosin) had similar results of TWOC (group A – 66%, group B – 70%), which were significantly superior than group C (placebo) – 36%. In follow up, three (9.1%) patients in group A, three (8.6%) patients in group B and eight (44.4%) patients in group C had retention of urine, requiring recatheterization. These patients were withdrawn from the study. After three months, alfuzosin- or tamsulosin-treated patients showed a significant decrease in AUA score and PVRV; and a significant increase in PFR as compared to placebo. Conclusions: TWOC was more successful in men treated with either alfuzosin or tamsulosin and the subsequent need for recatheterization was also reduced. Tamsulosin was comparable to alfuzosin in all respects, except a small but significant side effect of retrograde ejaculation.

A Randomized Study of Aspiration and Sclerotherapy Versus Laparoscopic Deroofing in Management of Symptomatic Simple Renal Cysts

PURPOSE To perform a prospective randomized study to evaluate aspiration and sclerotherapy vs. laparoscopic deroofing in the management of symptomatic simple renal cysts. PATIENTS AND METHODS Forty patients with symptomatic simple renal cysts were randomized to treatment either by ultrasonography-guided aspiration and sclerotherapy (group A-20 patients) or by laparoscopic deroofing (group B-20 patients). Two patients in group A and one patient in group B had a parapelvic cyst. Patients were evaluated by urine analysis, serum creatinine level, coagulation profile, ultrasonography, and CT urography. In group A patients, after aspiration, 1% polidocanol in a volume equivalent to 10% of cyst volume was instilled. In group B patients, laparoscopic deroofing was performed. All patients were followed up by ultrasonography up to 1 year after treatment. RESULTS In group A, aspiration and sclerotherapy was performed on an outpatient basis, and none of the patients needed postoperative analgesia. Eighteen of 20 patients had complete regression; two of these had parapelvic cyst. Partial regression with relief of pain was noted in one patient, whereas treatment failed in one patient. None of the patients had any significant complication and none required analgesia. All the patients were discharged two hours after the procedure. In group B, laparoscopic deroofing was successfully performed in 19 of 20 patients. Laparoscopic deroofing could not be performed in one patient with parapelvic cyst because of failure of access. The mean analgesic requirement was 285 ± 57.98 (200-400) mg tramadol, and average hospital stay was 2.1 ± 0.32 (2-3) days. CONCLUSION Percutaneous aspiration and sclerotherapy with polidocanol is an effective, safe, and minimally invasive therapeutic option for symptomatic simple renal cysts, with equal efficacy and lower morbidity and hospital stay in comparison with laparoscopic deroofing.

Tubeless percutaneous nephrolithotomy.

Introduction and Objective: Placement of a percutaneous nephrostomy tube for drainage has been an integral part of the standard percutaneous nephrolithotomy (PCNL) procedure. However, in recent years, the procedure has been modified to what has been called ‘tubeless’ PCNL, in which nephrostomy tube is replaced with internal drainage provided by a double-J stent or a ureteral catheter. The objective of this article is to review the evidence-based literature on ‘nephrostomy-free’ or ‘tubeless’ PCNL to compare the safety, effectiveness, feasibility, and advantages of tubeless PCNL over standard PCNL. Materials and Methods: We performed a MEDLINE database search to retrieve all published articles relating to ‘tubeless’ PCNL. Cross-references from retrieved articles as well as articles from urology journals not indexed in MEDLINE, were also retrieved. Results: The majority of the studies have shown ‘tubeless’ PCNL to be a safe and economical procedure, with reduced postoperative pain and morbidity and shorter hospital stay. tubeless PCNL has been found to be safe and effective even in patients with multiple stones, complex staghorn stones, concurrent ureteropelvic junction obstruction, and various degrees of hydronephrosis. The technique has been successful in obese patients, children, and in patients with recurrent stones after open surgery. Conclusion: Tubeless PCNL can be used with a favorable outcome in selected patients (stone burden <3 cm, single tract access, no significant residual stones, no significant perforation, minimal bleeding, and no requirement for a secondary procedure), with the potential advantages of decreased postoperative pain, analgesia requirement, and hospital stay. However, for extended indications, like supine PCNL, multiple, complex and staghorn stones, and concurrent PUJ obstruction, the evidence is insufficient and should come from prospective randomized trials.

Sclerotherapy for hydrocele revisited: a prospective randomised study

PurposeA prospective randomised trial to study the efficacy and safety of hydrocele sclerotherapy with phenol and polidocanol.MethodsEighty-six patients with unilateral primary vaginal hydroceles were randomised into three groups: group 1 (phenol sclerotherapy) — 29 patients, group 2 (polidocanol sclerotherapy) — 29 patients and group 3 (operative treatment) — 28 patients. Sclerotherapy was performed on outpatient basis using either 5–10 ml of 5% phenol or 2–4 ml of 1% polidocanol, while patients in group 3 underwent surgical repair of hydrocele (Jaboulay’s procedure). Statistical analysis was performed using ANOVA.ResultsThe cure rates in group 1, 2 and 3 were 96.5%, 51.7% and 100%, respectively. The pain scores (visual analogue scale) in group 1, 2 and 3 at 1 week and 1 month were 14.5 and 1.8; 10.1 and 1.3; 64.0 and 10.6, respectively. There was significant difference among the three groups in mean hospital stay (1.8, 1.5 and 9.7 hours, respectively) and time to work resumption (1.3, 1.1 and 12.7 days, respectively). Statistically significant differences in pain scores and complications were observed between sclerotherapy and operative groups.ConclusionFive percent phenol is a better sclerosant than 1% polidocanol and is as efficacious as operative treatment, with lesser morbidity and similar safety profile.

Are Multiple Nephrostomy Tubes Necessary After Multitract Percutaneous Nephrolithotomy? A Randomized Comparison of Single Versus Multiple Nephrostomy Tubes

PURPOSE Placement of multiple nephrostomy tubes is the standard practice after completion of multitract percutaneous nephrolithotomy (PCNL) for complex/staghorn calculi. We conducted a study to see whether use of a single nephrostomy tube in comparison with multiple tubes reduces postoperative discomfort without compromising safety of the procedure. PATIENTS AND METHODS One hundred and ninety-two patients with complex/staghorn renal calculi who were treated with PCNL requiring multiple tracts were included in the study. The inclusion criteria included normal renal function, complete clearance of calculi, and no significant intraoperative complication. Patients were randomized into two groups on operation table at completion of procedure-group A, single nephrostomy tube placement after multitract PCNL; group B, one nephrostomy tube for each tract. RESULTS Postoperative analgesia requirement in group A was significantly less than that in group B (111.9 +/- 27.4 mg meperidine in group A; 165.8 +/- 34.4 mg in group B) (p < 0.001). The difference in average blood loss for two groups was not statistically significant (drop in hemoglobin: group A, 0.48 gm%; group B, 0.51 gm%) (p = 0.55). Three patients in group A and four in group B required blood transfusion (p = 0.65). The average hospital stay in group A (42.4 +/- 8.6 hours) was significantly shorter than that in group B (68.1 +/- 6 hours) (p < 0.001). No long-term squealae were noticed in the median follow-up of 18 months in any patient. CONCLUSION The present study demonstrates that use of a single nephrostomy tube in multitract PCNL is safe and as effective as the conventional practice of placing multiple tubes. In addition, a single tube minimizes postoperative morbidity related to the drainage tubes.

Ultra-mini-percutaneous nephrolithotomy: A minimally-invasive option for percutaneous stone removal.

Introduction: Percutaneous nephrolithotomy (PCNL) has witnessed rapid advancements, the latest being ultra-mini-percutaneous nephrolithotomy (UMP), which makes the use of 11-13F sheaths as compared to 24-30F sizes used in conventional PCNL. This miniaturization aims to reduce morbidity and improve patient outcomes. We evaluated the safety and efficacy of UMP and report our ourtcomes. Patients and Methods: A total of 120 patients underwent UMP from July 2012 to March 2014. These patients had a single unilateral renal stone measuring between 8 and 20 mm. All patients underwent UMP using a 3F nephroscope, 7.5F inner sheath, and 11F or 13F outer metallic cannula, which served as the Amplatz sheath. Stone fragmentation and clearance were achieved with holmium laser. No nephrostomy or stent was used routinely. Results: Complete stone fragmentation was achieved in 114 out of 120 patients (95%) using UMP; whereas the remaining 6 were converted into mini-PCNL using a 12.5F nephroscope and 15F Amplatz sheath. The mean operative time was 39.7 ± 15.4 min, and the mean postoperative hospital stay was 22.3 ± 2.2 h. Postoperatively, 6 (5%) patients had residual fragments measuring ≤4 mm. At the 2 weeks follow-up, the stone-free status was >99% (119/120). There were no significant postoperative complications. Conclusion: This study shows UMP to be an effective and safe procedure for managing stones up to 20 mm. This procedure offers an attractive alternative to shock wave lithotripsy and retrograde intrarenal surgery for managing small stones.

Percutaneous nephrolithotomy: Large tube, small tube, tubeless, or totally tubeless?

The role of percutaneous nephrostomy tube for drainage after percutaneous nephrolithotomy (PCNL) procedure has come under scrutiny in recent years. The procedure has been modified to use of small diameter tubes, ‘tubeless’ PCNL, and even ‘totally tubeless’ PCNL. A review of the available literature confirms that the chosen method of drainage after PCNL has a bearing upon the post-operative course. It is generally recognized now that small tubes offer benefit in terms of reduced post-operative pain and morbidity. Similarly, nephrostomy-free or ‘tubeless’ PCNL, using a double-J stent or ureteric catheter as alternative form of drainage, can be used with a favorable outcome in selected patients with the advantage of decreased postoperative pain, analgesia requirement, and hospital stay. Although the tubeless technique has been applied for extended indications as well, the available evidence is insufficient, and needs to be substantiated by prospective randomized trials. In addition, ‘totally tubeless’ approach has also been shown to be feasible in selected patients.

Super-mini percutaneous nephrolithotomy (SMP) vs retrograde intrarenal surgery for the treatment of 1-2 cm lower-pole renal calculi: an international multicentre randomised controlled trial

To compare the safety and effectiveness of super‐mini‐percutaneous nephrolithotomy (SMP) and retrograde intrarenal surgery (RIRS) for the treatment of 1–2 cm lower‐pole renal calculi (LPC).