Stesura Seveso 253Archivio Italiano di Urologia e Andrologia 2014; 86, 4 ORIGINAL PAPER Percutaneous nephrolithotomy in patients with a solitary kidney Tufan Süelözgen, Salih Budak, Orcun Celik, Okan Yalbuzdag, Oguz Mertoglu, Selcuk Isoglu, Mehmet Yoldas, Yusuf Ozlem Ilbey Tepecik Training and Research Hospital, Urology Clinic, Izmir, Turkey. Material and method: The results of percutaneous nephrolithotomy applied to 716 patients in our clinic between January 2008 and January 2014 were retrospectively evaluated. Age, gender, urinary calculi size (mm2), urinary calculi localization, ESWL history, operation duration (min), flu- oroscopy duration (sec), access type, reason of solitary kidney, hemoglobin drawdown (g/dl) and operation suc- cess of the patients with a solitary kidney were recorded. The patients having no preoperative and postoperative non contrast abdominal tomography were excluded from the study. Results: Fifteen of nineteen patients (79%) were men and 4 of them (21%) were women. The average age of the patients was 42.52 ± 16.72 (14-72). Ten patients had anatomical solitary kidney and nine patients had physio- logical solitary kidney. In fact counter kidney was non functional in 9 patients (47%) whereas there was agenesis in 2 (11%) and outcome of nephrectomy in 8 (42%) patients. In our study, presence of residual stone less than 4 mm at 1st month postoperative non contrast abdominal tomography was accepted as a successful result and accordingly our success rate was detected as 84%. Mean urinary calculi size was 405 ± 252.9 mm2; urinary calculi localization was pelvic, lower pole, upper-middle pole, middle-lower pole and staghorn in 11 (58%), 4 (21%), 1 (5%), 1 (5%) and 1 (5%) patients, respectively; previous ESWL history was 16%; operation duration was 55.47-± 28.1 min and fluoroscopy duration 131.10 ± 87.6 sec; access type was subcostal in 79%, supracostal in 10.5% and multiple in 10.5%; hemoglobin drawdown was 1.75 ± 0.97 mg/dl. Conclusions: PNL can be effectively and safely adminis- tered for the treatment of solitary kidney. In the treat- ment of large urinary calculi in patients with a solitary kidney, PNL has some advantages such as short surgery duration, less complication, acceptable hemoglobin draw- down and high success rates. According to our study, PNL operation in patients with a solitary kidney is a good option for carefully and poisedly selected cases. KEY WORDS: Percutaneous nephrolithotomy; Solitary kidney; Urinary calculi. Submitted 21 July 2014; Accepted 18 August 2014 Summary No conflict of interest declared. INTRODUCTION Urinary tract calculus disease continues to be a major health problem in our country. In a study conducted in 2011, calculus prevalence was determined as 11.1% and it was emphasized that our country has been among endemic countries (1). It was stated that 2.2% of general population was treated due to urinary tract calculus dis- ease and 16% of them had more than one procedure (2). Percutaneous nephrolithotomy (PNL) in the trratment of urinary calculi was firstly described by Fernström and Johansson in 1976 (3). Since it was first developed, PNL procedure has been refined by means of improvements of optical system, endo-camera, lithotripsy energy systems, design of the nephroscope and advances in its acces- sories. As a result of all these improvements, need for open surgery in current urology practice is decreased to 0.7-4% and PNL has replaced it as first choice in the treatment of large urinary calculi (4). In this study, we retrospectively examined the patients with a solitary kidney who underwent PNL operation and we evaluated the results of the treatment. MATERIAL AND METHODS The results of percutaneous nephrolithotomy applied to 716 patients in our clinic between January 2008 and January 2014 were retrospectively evaluated. Nineteen patients with a solitary kidney were included in the study. In our clinic, preoperative complete blood count, biochemical tests, including urea and creatinine levels, and urine culture are carried out for all patients who are planned to be treated with PNL. The patients were informed about operation and informed consent was obtained. One hour before the operation, antibiotic pro- phylaxis was carried out via parenteral administration of second generation cephalosporin. Age, gender, urinary calculi size (mm2), urinary calculi localization, extracor- poreal shock wave lithotripsy (ESWL) history, operation duration (min), fluoroscopy duration (sec), access type, reason of solitary kidney, hemoglobin drawdown (mg/dl) and operation success of the patients with a solitary kid- ney were recorded. The patients having no preoperative and postoperative non contrast abdominal tomography were excluded from the study. DOI: 10.4081/aiua.2014.4.253 Budak_Stesura Seveso 15/01/15 12:56 Pagina 253 Archivio Italiano di Urologia e Andrologia 2014; 86, 4 T. Süelözgen, S. Budak, O. Celik, O. Yalbuzdag, S. Isoglu, S. Isoglu, M. Yoldas, Y.Ozlem Ilbey 254 In lithotomy position, a 5 F open-end catheter was inserted in the ureter via a 22 F cystoscope under gener- al anesthesia and set to a Foley catheter by a silk suture. Then, prone position was given to the patient. Collecting system was visualized with fluoroscopy by injection of opaque contrast through the ureteral catheter. Percutaneous needle access to the urinary tract was obtained by bi-planar planning of the access site. Tract was dilated with Amplatz dilators over guide wire and a 30 F Amplatz sheath was placed. Kidney collecting sys- tem was entered by a 22 F rigid nephroscope. Ultrasonic lithotripter was preferred for litotripsy and pneumatic lithotripter was used when necessary. After evaluation of the last fluoroscopy images, a 14 F Malecot nephrostomy catheter was placed and the oper- ation was completed. All patients were followed up with non contrast abdominal tomography one month after operation. RESULTS Fifteen of nineteen patients (79%) were men and 4 of them (21%) were women. The average age of the patients was 42.52 ± 16.72 (14- 72). Ten patients had anatomical solitary kidney and 9 patients had physiological solitary kidney. In fact count- er kidney was non functional in 9 patients (47%) where- as there was agenesia in 2 (11%) and outcome of nephrectomy in 8 (42%) patients. There was no previous history of surgery of the solitary kidney in all the patients. ESWL was administered to three patients (16%) but it was not successful. Stones location was pelvic, lower pole, upper-middle pole, middle-lower pole and staghorn in 11 (58%), 4 (21%), 1 (5%), 1 (5%) and 1 (5%) patients, respectively. Average stone size was 405 ± 252.9 mm2 (100-1050). Subcostal lower calyx access was performed in 15 of 19 patients (79%). Intercostal upper pole access was carried out in two patients (10.5%) and multiple intercostal and subcostal accesses were required in two patients (10.5%). Average operation duration was 55.47 ± 28.1 (21-139) minutes and average duration of fluoroscopy use was 131.10 ± 87.6 (35-351) seconds. Average decrease in hemoglobin level of patients was 1.75 ± 0.97 (03-4.4) g/dl in postoperative period, but blood transfu- sion was not required. Three patients developed fever in postoperative period. No further complication developed. At follow-up of the patients, residual stones were detected in 4 patients (21%) at non contrast abdominal tomography one month after operation. Three of these (75%) were larger than 4 mm and 1% (25%) was less than 4 mm. Presence of residual stones less than 4 mm was consid- ered as a successful result and therefore our success rate was estimated as 84%. No Age Gender Stone-size Stone ESWL Operation Skope Approach Why soliter Decrease of Operation (mm2) location history time(min) time(sec) time hemoglobine succes 1 43 M 625 Pelvis No 67 94 Subcostal Nonfunctional 1.4 Residue (more than 4 mm) 2 53 M 277 Upper middle Pole No 90 222 Multiple access Nonfunctional 3.7 Stonefree 3 20 M 625 Pelvis No 55 141 Subcostal Nonfunctional 0.9 Stonefree 4 66 M 280 Pelvis No 28 82 Subcostal Nonfunctional 0.5 Stonefree 5 21 M 256 Middle-lower Pole No 56 86 Subcostal Nephrectomy 1.2 Stonefree 6 39 F 280 Pelvis Yes 60 89 Subcostal Nonfunctional 1,7 Stonefree 7 45 M 900 Pelvis No 60 354 Subcostal Nonfunctional 2 Stonefree 8 65 M 500 Pelvis No 60 138 Subcostal Nonfunctional 0,7 Stonefree 9 38 M 350 Pelvis No 60 53 Subcostal Nonfunctional 1,2 Residue (more than 4 mm) 10 19 F 130 Lower Pole No 64 105 Subcostal Agenesis 0,3 Stonefree 11 33 M 300 Pelvis Yes 77 96 Subcostal Nephrectomy 2,8 Residue (less than 4 mm) 12 55 M 175 Middle Pole No 30 139 Intercostal Nephrectomy 1,9 Stonefree 13 43 M 250 Pelvis No 65 140 Intercostal Nonfunctional 1,6 Stonefree 14 72 F 1050 Staghorn No 139 340 Multiple access Nephrectomy 4.4 Residue (more than 4 mm) 15 41 M 350 Lower Pole No 25 45 Subcostal Nephrectomy 1,8 Stonefree 16 38 M 297 Lower Pole No 40 150 Subcostal Nephrectomy 1,2 Stonefree 17 44 M 100 Lower Pole Yes 21 93 Subcostal Nephrectomy 2 Stonefree 18 59 M 600 Pelvis No 27 31 Subcostal Agenesis 1,5 Stonefree 19 14 F 300 Pelvis No 30 93 Subcostal Nephrectomy 1,5 Stonefree Table 1. Characteristics and clinical outcome of percutaneous nephrolithotomy in patients with a solitary kidney. Budak_Stesura Seveso 15/01/15 12:56 Pagina 254 DISCUSSION The main aim of PNL is to clear more calculi with the least morbidity. Although PNL is accepted as a minimal invasive treatment method, severe complications such as bleeding requiring transfusion, internal organ injuries, hydrothorax and sepsis can occur. Nephrectomy may be necessary due to uncontrollable bleeding. This event in a patient with solitary kidney involve that the patient will become anephric. A multi-center study of complications occurring after PNL was coordinated by the CROES (Clinical Research Office of the Endourological Society). The Global PNL Study Group published it in 2011 reporting that general complication rate of PNL was 25% (1175/5724); 80% of these were minor and 20% major complications and the most common complications were fever and bleeding (5, 6). Some studies showed that access to calyceal system can lead to a decrease in hemoglobin levels (2.1-3.3 g/dl.) (7). Bleeding after PNL can be prevented by clamping the nephrostomy tube. When bleeding cannot be stopped, selective arterial occlusion may be required (8, 9). Staghorn and large calculi, obesity, prolonged opera- tion time and absence of hydronephrosis were reported as the risk factors causing excessive bleeding during PNL (10). In our study, average decrease in hemoglobin levels in postoperative period was 1.75 g/dl. In the treatment of staghorn calculi, more severe bleeding can occur due to need for multiple access (11). In fact the patient with staghorn calculus and multiple accesses was the patient with the most severe bleeding which caused a < 4.4 g/dl decrease in the hemoglobin level. It was stated that 28.7% of the patients with negative preoperative urine culture who had prophylactic antibi- otic therapy developed fever after PNL and that urgent bacteriological evaluation was not necessary if hemody- namic stability was balanced in patients with negative preoperative urine culture who had fever higher than 38.5°C and started to receive prophylactic antibiotic therapy (12). In our series, 3 of 19 patients (15%) devel- oped fever after PNL, however none of them had sepsis. Pulmonary complications after PNL are usually seen in case of supracostal access. It was stated that pneumoth- orax and hydrothorax rate after PNL was about 6-12% (6). Four patients needed supracostal access in our study, but we did not face with any pulmonary complication. Success rate after PNL ranges between 40% and 90% depending on number of stones, location, chemical structure and experience of the surgeon (12). Escape of the calculus or of its fragments to an unapproachable calyx and termination of operation due to bleeding or prolonged time can be the reasons for not providing a complete calculus clearance in PNL. Residual calculus fragments imply postoperative risks such as pain, uri- nary infection, calculus enlargement, obstruction and need for secondary surgery to patient. Therefore, it is quite important to obtain a stone-free status after PNL and non-contrast abdominal tomography was recom- mended for evaluation of stone-free situation (13). In our study, our success rate was estimated as 84% at first month postoperative control. Modern treatment of upper urinary tract calculi of soli- tary kidneys includes mini-invasive techniques as ESWL, PNL and retrograde intrarenal surgery (RIRS). In solitary kidney calculi, the results of ESWL treatment are prom- ising and it was stated that ESWL was a safe and feasible method with low complications rates in the patients hav- ing only one kidney (14). Efficiency of ESWL was report- ed as 92% for kidney calculi smaller than 10 mm, 59- 89% for 10-20 mm calculi and 39-70% for calculi larger than 20 mm (15). RIRS is a good option to remove kid- ney calculus in the patients having one kidney due to its high success and low morbidity rates. However, more than one procedure can be required for the patients hav- ing large urinary calculi (16, 17). Yet, there are limiting factors such as that RIRS is not available everywhere, operation duration is relatively longer, requires experi- ence and is more suitable for 1.5-2 cm calculi. Although PNL is today accepted as a safe and minimal invasive treatment method for treatment of urinary calculi, it is recommended that it should be always administered in high case-volume centers and by expert urologists in the patients with solitary kidney because of the risk of causing an anephric condition in case of severe complica- tions (18). In the literature, success rates of PNL and its complications in the patients with a solitary kidney were reported in the range of acceptable levels (19, 20). CONCLUSIONS PNL can be effectively and safely administered for the treatment of solitary kidney. In the treatment of large uri- nary calculi in patients with a solitary kidney, PNL has some advantages such as short surgery duration, less complication, acceptable hemoglobin drawdown and high success rates. According to our study, PNL opera- tion in patients with a solitary kidney is a good option for carefully and poisedly selected cases. REFERENCES 1. 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Percutaneous nephrolithotomy in patients with solitary kidney. Urology journal. 2009; 5:24-27. 19. Akman T, Binbay M, Tekinarslan E, et al. Outcomes of percuta- neous nephrolithotomy in patients with solitary kidneys: a single- center experience. Urology. 2011; 78:272-276. 20. Bucuras V, Gopalakrishnam G, Wolf JS, et al. The clinical research office of the endourological society percutaneous nephrolithotomy global study: nephrolithotomy in 189 patients with solitary kidneys. J Endourol. 2012; 26:336-341. Correspondence Tufan Süelözgen, MD tsuelozgen@hotmail.com Salih Budak,MD (Corresponding Author) salihbudak1977@gmail.com Orcun Celik, MD orcuncelik82@hotmail.com Okan Yalbuzdag, MD Oguz Mertoglu, MD Selcuk Isoglu, MD selcukisoglu@hotmail.com Mehmet Yoldas, MD myoldas@hotmail.com Yusuf Ozlem Ilbey, MD, Associate Prof. ozlemyusufilbey@hotmail.com Tepecik Training and Research Hospital, Urology Clinic, Izmir, Turkey Budak_Stesura Seveso 22/01/15 10:28 Pagina 256