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      Mini percutaneous nephrolithotomy in the treatment of renal and upper ureteral stones: Lessons learned from a review of the literature.

      Urology Annals
      Complications, mini percutaneous nephrolithotomy, modified Clavien system, stone-free rate, urolithiasis

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          Abstract

          The aim of this review is to present the most recent data regarding the indications of mini percutaneous nephrolithotomy (PCNL), the results and the complications of the method. Medline was searched from 1997 to January 2014, restricted to English language. The Medline search used a strategy including medical subject headings and free-text protocols. PCNL is a well-established treatment option for patients with large and complex renal calculi. In order to decrease morbidity associated with larger instruments like blood loss, postoperative pain and potential renal damage, a modification of the technique of standard PCNL has been developed. This is performed with a miniature endoscope via a small percutaneous tract (11-20 F) and was named as minimally invasive or mini-PCNL. This method was initially described as an alternative percutaneous approach to large renal stones in a pediatric patient population. Furthermore, it has become a treatment option for adults as well, and it is used as a treatment for calculi of various sizes and locations. However, the terminology has not been standardized yet, and the procedure lacks a clear definition. Nevertheless, mini-PCNL can achieve comparable stone-free rates to the conventional method, even for large stones. It is a safe procedure, and no major complications are reported. Although less invasiveness has not been clearly demonstrated so far, mini-PCNL is usually related to less blood loss and shorter hospital stay than the standard method.

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          Complications in percutaneous nephrolithotomy.

          This review focuses on a step-by-step approach to percutaneous nephrolithotomy (PNL) and its complications and management. Based on institutional and personal experience with >1000 patients treated by PNL, we reviewed the literature (Pubmed search) focusing on technique, type, and incidence of complications of the procedure. Complications during or after PNL may be present with an overall complication rate of up to 83%, including extravasation (7.2%), transfusion (11.2-17.5%), and fever (21.0-32.1%), whereas major complications, such as septicaemia (0.3-4.7%) and colonic (0.2-0.8%) or pleural injury (0.0-3.1%) are rare. Comorbidity (i.e., renal insufficiency, diabetes, gross obesity, pulmonary disease) increases the risk of complications. Most complications (i.e., bleeding, extravasation, fever) can be managed conservatively or minimally invasively (i.e., pleural drain, superselective renal embolisation) if recognised early. The most important consideration for achieving consistently successful outcomes in PNL with minimal major complications is the correct selection of patients. A well-standardised technique and postoperative follow-up are mandatory for early detection of complications.
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            Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy.

            Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus. To review the epidemiology of complications and their prevention and management. 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. 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. 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. Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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              Classification of percutaneous nephrolithotomy complications using the modified clavien grading system: looking for a standard.

              A classification (modified Clavien system) has been proposed to grade perioperative complications. We reviewed our experience with percutaneous nephrolithotomy (PNL), grading the complications according to this new classification. A total of 811 PNLs were performed between 2003 and 2006, and charts were retrospectively reviewed focusing on complications observed. According to the modified Clavien classification system, perioperative complications were stratified into five grades. Grade 1 defined all events that, if left untreated, would have a spontaneous resolution or needed a simple bedside intervention. Grade 2 complications required specific medication, including antibiotics and blood transfusion. Grade 3 complications necessitated surgical, endoscopic, or radiologic intervention (3a without general anesthesia, 3b under general anesthesia). Neighboring organ injuries and organ failures were classified as grade 4, and death was considered a grade 5 complication. Kidney stones treated with PNL were also classified as simple and complex and complication rates were compared. A total of 255 perioperative complications were observed in 237 (29.2%) patients. There were 33 grade 1 (4%), 132 grade 2 (16.3%), 54 grade 3a (6.6%), 23 grade 3b (2.8%), 9 grade 4a (1.1%), and 3 grade 4b (0.3%) complications, and 1 death (0.1%). Most complications were related to bleeding and urine leakage. Grade 2 and 3a complications were significantly more common in patients with complex renal stones. A graded classification scheme for reporting the complications of PNL may be useful for monitoring and reporting outcomes. However, minor modifications concerning auxiliary treatments are needed and further studies are awaited.
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                Author and article information

                Journal
                25837662
                4374249
                10.4103/0974-7796.152927

                Complications,mini percutaneous nephrolithotomy,modified Clavien system,stone-free rate,urolithiasis

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