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      Recent advancement or less invasive treatment of percutaneous nephrolithotomy

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          Since its initial introduction in 1976, percutaneous nephrolithotomy (PCNL) has been widely performed for the management of large renal stones and currently is recommended for staghorn calculi, kidney stones larger than 2 cm, and shock wave lithotripsy-resistant lower pole stones greater than 1 cm. However, except for open and laparoscopic surgery, PCNL is the most invasive of the minimally invasive stone surgery techniques. Over the years, technical and instrumental advances have been made in PCNL to reduce morbidity and improve effectiveness. A thorough review of the recent literature identified five major areas of progress for the advancement of PCNL: patient positioning, method of percutaneous access, development of lithotriptors, miniaturized access tracts, and postoperative nephrostomy tube management. This review provides an overview of recent advancements in PCNL and the outcomes of each area of progress and notes how much we achieve with less invasive PCNL. This information may allow us to consider the future role and future developments of PCNL.

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          Most cited references 97

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          Percutaneous pyelolithotomy. A new extraction technique.

          Recurrent renal calculous disease is often troublesome to treat because of technical difficulties associated with reoperation. Attempts to dissolve the stones by irrigation with various solutions has not had much success. A new extraction technique has therefore been devised whereby the stones can be removed through a percutaneous nephrostomy umder radiological control. Three cases are described.
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            Factors affecting blood loss during percutaneous nephrolithotomy: prospective study.

            Bleeding is a major concern during percutaneous nephrolithotomy (PCNL), especially with the use of multiple tracts. This prospective study aimed to identify factors affecting blood loss during PCNL. Data were collected prospectively from 236 patients undergoing 301 PCNL procedures at our institute since June 2002. Blood loss was estimated by the postoperative drop in hemoglobin factored by the quantity of any blood transfusion. Various patient-related and intraoperative factors were assessed for association with total blood loss or blood transfusion requirement using stepwise multivariate regression analysis. The average hemoglobin drop was 1.68 +/- 1.23 g/dL. Stepwise multivariate regression analysis showed that the occurrence of operative complications (P or =2) tracts (P = 0.003), size of the tract (P = 0.001), renal parenchymal thickness (P = 0.05), and diabetes (P = 0.05) were significant predictors of blood loss. The overall blood transfusion rate for all patients was 7.9%. Preoperative hemoglobin, multiple tracts, stone size, and total blood loss were significant in predicting perioperative blood transfusion requirement. Factors such as age, hypertension, renal insufficiency, urinary infection, the degree of hydronephrosis, stone bulk, and the function of the ipsilateral renal unit did not have any effect on the blood loss. Technical factors such as the operating surgeon and the calix of entry also did not affect the blood loss. Diabetes, multiple-tract procedures, prolonged operative time, and the occurrence of intraoperative complications are associated with significantly increased blood loss. Atrophic parenchyma and past ipsilateral intervention are associated with reduced blood loss. On the basis of this evidence, maneuvers that may reduce blood loss and transfusion rate include ultrasound-guided access, use of Amplatz or balloon dilatation systems, reducing the operative time, and staging the procedure in cases of a large stone burden or intraoperative complications. Reducing the tract size in pediatric cases, nonhydronephrotic systems and those with a narrow infundibulum, and secondary tracts in a multiple-tract procedure may also reduce blood loss during PCNL.
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              Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position.

              Percutaneous nephroscopy is usually performed with the patient prone, which is uncomfortable for the patient and does not prevent damage to the colon. We assess the possibility of performing percutaneous nephroscopy using local anesthesia with the patient supine, and evaluate the advantages and complications. A total of 557 consecutive percutaneous nephroscopies were attempted in 221 men and 242 women in the supine position. Patient age ranged from 8 to 87 years (mean 55.1). Patients are supine with a 3 l. serum bag below the ipsilateral flank. We catheterize the affected uretheral meatus with a 5F catheter through a flexible cystoscope. The tract is infiltrated with local anesthesia. The skin is punctured in the posterior axillary line which corresponds to approximately 1 cm. above the bag. We use an Alken set to dilate the tract to 30F, which is the size of the Amplatz sheath we commonly use. Nephroscopy was performed in 519 cases (93.1%). Mean operation time was 85 minutes (range 15 to 240). Serious bleeding occurred in 3 cases. The colon was never damaged in patients treated in the supine position. Percutaneous nephroscopy using local anesthesia with the patient supine is safe and easy. According to our experience the advantages in comfort to the patient and feasibility to the surgeon justify its use.

                Author and article information

                Korean J Urol
                Korean J Urol
                Korean Journal of Urology
                The Korean Urological Association
                September 2015
                07 September 2015
                : 56
                : 9
                : 614-623
                Department of Urology, Kyungpook National University School of Medicine, Daegu, Korea.
                Author notes
                Corresponding Author: Bum Soo Kim. Department of Urology, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea. TEL: +82-53-200-5855, FAX: +82-53-421-9618, urokbs@ 123456knu.ac.kr
                © The Korean Urological Association, 2015

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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