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| Contemporary role of multi-tract percutaneous nephrolithotomy in the treatment of complex renal calculi |
Sudharsan Balajia,Arvind Ganpulea,*( ),Thomas Herrmannb,Ravindra Sabnisa,Mahesh Desaia
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a Department of Urology, Muljhibhai Patel Urological Hospital, Nadiad, Gujarat, India
b Department of Urology, Spital Thurgau AG STGAG Kantonspital Frauenfeld and Kantonspital Münsterlingen, Thurgau, Switzerland |
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Abstract Complex renal calculi remain to be a challenge for the treating urologist due to sheer bulk and the technicalities involved. Percutaneous nephrolithotomy (PCNL) remains the treatment modality of choice in dealing with these large and complex stones. The limiting factor in their treatment continues to be the need for using additional tracts or the use of flexible nephroscopy for complete stone clearance. This systematic review focuses on the need for multi-tract PCNL for complex renal calculi. The literature review was performed using PubMed database using the keywords “multiple tract PCNL” or “multiperc”. We identified original articles published on the usage of multiple tracts for stone clearance in renal calculi between January 2000 to October 2018, and the search was restricted to available literature in English language only. Ten studies with n>20 were included for the final analysis. We analyzed the technical efficacy with respect to the number of tracts and stages that were required for stone clearance, outcomes and complications, especially, procedural bleeding and post-procedure infective complications of multiple-tract PCNL for large burden renal stones. Multiperc is found to be safe, feasible and effective for the management of large burden complex renal calculi with respect to stone clearance and morbidity associated with the procedure. It is cost effective and complete stone clearance as a single procedure is higher in comparison to flexible ureteroscopy and shockwave lithotripsy.
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Received: 18 February 2019
Available online: 28 December 2019
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Corresponding Authors:
Arvind Ganpule
E-mail: doctorarvind1@gmail.com
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Consort flow chart of included studies.
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| References | Renal units (n) | Male:Female | Mean age (year) | Stone burden*(as available in various studies) | No. of tracts | Operative time (min) | Stone clearance rate | Auxiliary procedure | | Aron et al., 2005 [6] | 121 | 88:15 | 43 | 3 089-6 012 (mean 4 800) mm2 | 2 (n=11) | 146 (100-180) | 84% | Stage II PCNL:19 | | 3 (n=68) | SWL: 8 (6.6%) | | 4 (n=39) | | 5 (n=3) | | Liatsikos et al., 2005 [7] | 100 | NA | 49 (24-72) | Complete staghorn: 90% | 2.4 (2-6) | 110 (90-180) | 87% | 13% (3 URS, 5 SWL, 3 DJS) | | Partial staghorn: 10% | | Hegarty et al., 2006 [8] | 20 | 4:16 | 54.4±12.4 (34-77) | MSA: 2 156.6±1 441.2 (55-4 720) mm2 | 2.9 (2-6) | NA | 95% | 4 (20%) | | Stage II: 3 | | Zeng et al., 2007 [9] | 100 | 69:31 | 46.6 (22-73) | 2 274.63 (1 573.64-3 482.12) mm2 | 2 (92) | 107 (43-130) | 93% | Stage II PCNL: 28 | | 3 (7) | SWL: 2 | | 4 (1) | URS: 2 | | Desai et al., 2008 [10] | 500 | 400:100 | NA | MSA>3 000 mm2 | 2-7 | 88.7±22.6 | 84.1% | NA | | Singla et al., 2008 [11] | 164 | 118:31 | 39.8 (12-65) | Borderline: 36
Partial: 85
Complete: 43 | 2-47
3-73
4-41
5-2
6-1 | NA | I stage-70.7%
II stage-89% | Stage II PCNL: 30 (18.2%)
SWL: 16 (9.7%)
URS: 2 (1.2%) | | Mishra et al., 2012 [12] | 53 | 15:38 | 47.5±8.9 | MSV: 18 835±17 924 mm3 | 2 (n=7)
>2 (n=21) | NA | 92.9% | NA | | Fei et al., 2014 [13] | 55 | 28:27 | 52.23±7.37 | MSA<3 000 mm2 | 2 (46, 83.6%)
3 (8, 14.6%)
4 (1, 1.8%) | 84.87±24.98 | 78.1% | 2 SWL (3.6%) | | Liu et al., 2016 [14] | 34 | 19:15 | 54.3±6.43 | MSA: 2 103 mm2 (1 404-5 660 mm2) | 2.38±0.70 | 86.62±26.82 (40-195) | 27 (79.4%) | 15 (44.1%)
PCNL: 12 (35.3%)
SWL: 3 (8.8%) | | Liang et al., 2017 [15] | 54 | 24:30 | 47.8 (41-63) | Largest size: 2.5-8.6 cm | 3.6 (2-7) | 78.7 (26-124) | 24 (88.9%) | Stage II PCNL: 13
Stage III PCNL: 7 |
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Ten studies reporting PCNL for complex renal calculi were reviewed.
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| Complication | Hb drop/blood loss | Blood transfusion rates | Hospital stay (day) | Infection/sepsis | | Aron et al., 2005 [6] | NA | NA | 18 (14.9%) | 4 (2-16) | Grade II-22 (21.0%)
Grade III-1 (0.8%) | | Liatsikos et al., 2005 [7] | Minor: 17%
Major: 7% | 450 mL | 45% | 4.6 (3-14) | Grade I-12.0% | | Hegarty and Desai, 2006 [8] | Minor: 30%
Major: None | 2.3 gm% | 4 (20%) | 4.25±1.74 | Grade II-2 (10.0%) | | Zeng et al., 2007 [9] | Minor-9
Major-6 | 112 mL (64-483 mL) | 3 (3%) | 9.4 (6-13) | 7 (7.0%) | | Desai et al., 2008 [10] | 23 (5%) | 2.1 gm% | 62 (12. %) | 11.1 | NA | | Singla et al., 2008 [11] | Minor-33.5%
Major-15.9% | NA | 46 (30.8%) | 6.8 (3-28) | 8 (5.3%) | | Mishra et al., 2012 [12] | 16 (30.1%) | 1.85±1.7 gm% | NA | 8.7±4.5 | Grade I: 10
Grade II: 4
Grade III: 2 | | Fei et al., 2014 [13] | 16 (30.1%) | 8.23±2.39 | 4 (7.4%) | 5.20±1.31 | Grade I: 9 (17.0%)
Grade II: 2 (3.8%) | | Liu et al., 2016 [14] | 15 (44.1%) | 2.2±1.6 gm% | 6 (17.6%) | 9.1 (4-21) | Grade I: 6 (17.6%)
Grade II: 2 (5.9%) | | Liang et al., 2017 [15] | 10 (18.5%) | 97.3 (30-250) mL | None | 18 (10-31) | Grade I: 4 (7.4%)
Grade II: 6 (11.1%) |
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The common and dreaded complications of PCNL, namely, bleeding and infection/sepsis.
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| References | Clavien Dindo Grade I | Clavien Dindo Grade II | Clavien Dindo Grade III A | Clavien Dindo Grade III B | Clavien Dindo Grade IV and V | | Aron et al., 2005 [6] | None | 22 UTI antibiotic change (21%)
18 blood transfusion (14.9%) | 5 DJS for prolonged PCN site leak
2 angioembolization
3 chest drain placement (7.1%) | None | 1 sepsis (0.8%)
2 ileus | | Liatsikos et al., 2005 [7] | 12 UTI
1 hydrothorax | 3 pneumonia (antibiotic change)
1 DVT | 3 DJS for prolonged PCN site leak
1 angioembolization | None | 1 paralytic ileus | | Hegarty and Desai 2006 [8] | NA | 2 antibiotic change (10%)
4 blood transfusion (20%) | None | None | None | | Zeng et al., 2007 [9] | 2 hydrothorax observation | 4 antibiotic change
3 blood transfusion | 2 (change in DJ/PCN)
1 angioembolization
1 chest drain placement | 2 (URS) | None | | Desai et al., 2008 [10] | NA | 19 blood transfusion (8.4%) | None | None | Not available | | Singla et al., 2008 [11] | 3 hydrothorax observation | 6 antibiotic change
46 blood transfusion (30.8%) | 15 DJS (9.1%)
4 angioembolization (2.4%)
4 chest drain insertion (2.4%)
1 aspiration of peri-nephric collection | None | 2 septic shock | | Mishra et al., 2012 [12] | 10 (18.9%) | 4 (7.5%) | 2 (3.8%) | None | None | | Fei et al., 2014 [13] | 10 (18.9%)
9 transient fever
1 PCN tube displacement | 6 (11.3%)
2 antibiotic change
4 blood transfusion | None | None | None | | Liu et al., 2016 [14] | 6 fever (17.6%) | 2 antibiotic change (5.9%)
6 blood transfusion (17.6%)
1 prolonged leak | None | None | None | | Liang et al., 2017 [15] | 2 self limited bleeding (3.7%) | 6 antibiotic change (11.1%) | None | None | None |
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