Abstract

ABSTRACT:
BACKGROUND:
Percutaneous nephrolithotomy (PCNL) mean extraction of renal calculi through nephrostomy tracts placed percutaneously ,it was reported in the early 1970s. Percutaneous nephrolithotomy is widely accepted, more safe and effective treatment modality and it is the procedure of choice for removing large, complex, and/or multiple renal PCNL has lower morbidity and postoperative patient discomfort.
OBJECTIVE:
To evaluate the initial experience of PCNL in al jumhoori teaching hospital, taking 21 patients with renal stones of different sizes ,with it is complications.
METHODS:
Between May 2012 and July 2013 a case series study was applied in AL- Jumhori Teaching Hospital, PCNL was used in 21 patients (Mean age was 55 years, ranging between 16-63 years, 15 men and 6 women) while only one child of 8 year old was enrolled. All cases have renal stone of different size varied from (21mm-60 mm). Preoperative evaluation included , history, clinical examination and routine labarotory investigation, all patients had intravenous urography( IVU), some of them have non contrast or enhanced CT scan of urinary tract to evaluate the cortical thick -ness of the kidney, anatomical abnormalities, stone location, burden and radiolucency of the stone. All patients submitted to PCNL in AL-Jumhoori teach ing hospital ,under general anesthesia in prone position, subcostal approach, using fluoroscopic guidance(c-arm.),and irrigation fluid (0.9% N.S.) at body tempreture was used . Steps of PCNL include(1) Ureteric and urethral catheterisation (supine)(2) Percutaneous renal access in the posterior axillary line ,guide wire must always be in place to maintain access and to get (3) Tract dilatation .A track has been dilated and a 34 F working sheath is being advanced over a 30F metal dilator. Tracts can be dilated with either metalic, telescopic, plastic or balloon dilators. Balloon dilatation is quicker and perhaps less traumatic(4) Endoscopic stone fragment extraction (rigid-flexible endoscopy)(5) Post-extraction drainage (nephrostomy, ureteric catheter or tubeless)(6) Wound dressing and care.
RESULT:
The mean age was (55 years), with a male to female ratio of 2.5:1. The stone burden varied from 21-60mm most of them were radio-opaque (85.7%). The range of operative time varied from 75-200 minutes with a mean of 120 minutes, including cystoscopic and stenting procedure. The duration of exposure to radiation was ranging from 1.1minutes - 4.5minutes, with a mean of 2.1 minutes. The mean ±SD value of irrigant fluid was19.00±3.98 liters ranging from 12 -25 liters. In the present study the clearance rate was 76%, where 16 patients out of 21 had complete clearance together with stone < 5 mm. In 5 patients (24%) ESWL sessions were needed since they were already have staghorn calculus > 3cm or renopelvic plus multiple stones. The clearance rate for staghorn (62%), non staghorn calculus varied between 75% - 100% .
Tow months later all patients except 2 became stone free;(one of them had multiple stone resist ESWL and other one had duplex of pelvicalyseal system and his residual stone was located in the upper mieoty) both of them probably need second PCNL. The range of hospital stay was 1-5 days, with a mean of 2.2 days. Nephrostomy tube were removed on 1st, 2nd or even 3rd post operative day. All patients had double J (DJ) placement except 3 patients who regarded as tubeless PCNL.
CONCLUSION:
With the development of new devices for renal access, lithotripsy and renal drainage systems the procedure PCNL has become the first choice treatment modality for renal stones larger than 1.5 cm by the urologists worldwide. To avoid complications during the procedure and to gain successful outcomes after the procedure, proper patient selection, maintenance of available instruments, training and experience of the surgeon are critical.