Conventional vs. tubeless percutaneous nephrolithotomy. Is the urinary diversion really necessary?

Introducción La nefrolitotomía percutánea (NLP) convencional utiliza derivación con nefrostomía para mejorar el drenaje de orina, facilitar la hemostasia postoperatoria y permitir un trayecto seguro para intervenciones adicionales futuras. Sin embargo, en los últimos años el procedimiento de NLP se ha modificado: ahora permite el retiro del uso del catéter de nefrostomía o de derivación urinaria, procedimiento conocido como tubeless. El presente estudio pretende evaluar la experiencia institucional en cuanto a seguridad, eficacia y ventajas de la NLP tubeless. Materiales y métodos Entre agosto de 2012 y mayo de 2014 se reclutó a 51 pacientes del Hospital Universitario San Ignacio y Clínica Fundadores para manejo con nefrolitotomía percutánea. Se incluyó a 49 pacientes con litiasis renal menor de 5cm de diámetro y mayor de 2cm con punción única o múltiple. Se aleatorizaron en 2 grupos: grupo A sin derivación (no nefrostomía no catéter doble J) 26 pacientes, grupo B con derivación (nefrostomía sonda Foley 18 Fr) 23 pacientes. Los desenlaces evaluados fueron: efectividad verificada mediante revisión de imágenes postoperatorias y definida como cálculo residual menor de 5mm, sangrado postoperatorio con medición de hemoglobina durante las primeras 24 h después de cirugía, valoración de dolor con escala visual análoga, necesidad de analgésicos durante las primeras 4 h, cantidad de rescates de analgésico durante las primeras 24 h de cirugía. Los datos se analizaron mediante el paquete estadístico IBM SPSS versión 20, utilizando estadística no paramétrica con la prueba de Wilcoxon Mann-Whitney una vez se determinó que la muestra no tenía una distribución normal. Las variables dicotómicas se analizaron utilizando la prueba de Chi2. Resultados Las características de base de los pacientes son comparables: la edad promedio en el grupo A fue de 44,73 años y en el B de 50,26 años (p=0,186), el peso en el grupo A fue de 75,96 kg y en el B de 71,96 kg (p=0,054), el tamaño de los cálculos en el A fue de 28,23mm en promedio y en el B de 29,69mm, sin diferencia estadísticamente significativa (p=0,517). No hubo diferencias significativas en cuanto a efectividad en ambos grupos: en el A el porcentaje de lito residual fue de 1,15% y en el B de 0,87% (p=0,713). No hubo diferencias estadísticamente significativas en cuanto a sangrado postoperatorio (p=0,566), pero sí se observó mayor dolor, requerimiento de analgésicos y mayor número de rescates en los pacientes a los cuales se les dejó derivación mediante nefrostomía. Discusión Nuestro trabajo demuestra que la NLP sin derivación urinaria es una técnica segura en aquellos pacientes en los cuales se logra una extracción completa del cálculo, con sangrado comparable a la cirugía convencional y, adicionalmente, con el beneficio de menor dolor y menor requerimiento de analgésico postoperatorio.Q4Artículo original5-9Introduction Conventional percutaneous nephrolithotomy (PNL) uses a nephrostomy derivation to improve the drainage of urine, facilitate postoperative hemostasis and allow a safe course for future additional surgical interventions. However, in recent years the PNL procedure has been modified to avoid the use of a nephrostomy catheter or any other urinary diversion. This procedure is known as tubeless. This study aims to assess the institutional experience in safety, efficiency and advantages of tubeless PNL. Materials and methods Between August 2012 and May 2014, 51 patients were recruited in San Ignacio University Hospital and Fundadores Clinic to be treated with PNL. Forty-nine patients with kidney lithiasis less than 5cm of diameter and greater than 2cm with single or multiple puncture were included. They were randomised into 2 groups: group A no derivation (no nephrostomy catheter, no double J) 26 patients, group B with derivation (18 Fr Foley nephrostomy catheter) 23 patients. The evaluated outcomes were: Effectiveness verified by reviewing postoperative images and defined as a residual stone less than 5mm of diameter, postoperative bleeding with hemoglobin measurement during the first 24h after surgery, pain assessment with the visual analog scale, need for analgesics during the first 4h, amount of analgesic rescues during the first 24h of surgery. Data were analyzed using the statistical package SPSS version 20, using the nonparametric statistical test Wilcoxon Mann-Whitney 11 it was determined that the sample does not have a normal distribution, the dichotomous variables were analyzed using Chi2 test. Results Baseline characteristics of patients are comparable: The average age in the group A was 44.73 and 50.26 years in the group B (P=.186), average weight in group A and B was 75.96kg and 71.96kg, respectively (P=.054), the average size of the stones in group A was 28.23mm and 29.69mm in group B with no statistically significant difference (P=.517). There were no significant differences in effectiveness in both groups, in group A the percentage of residual lithiasis was 1.15% and 0.87% in group B (P=.713). There were no statistically significant differences in postoperative bleeding (P=.566), although pain, analgesic requirement and number of rescues needed were greater in patients who were left with a nephrostomy derivation. Discussion Our work shows that percutaneous nephrolithotomy without urinary diversion is a safe procedure in patients in whom a complete stone removal is achieved, with bleeding comparable to conventional surgery, and additionally with the benefit of less pain and less postoperative analgesic requirement

Assessing safety and efficacy of flexible ureteroscopy and laser lithotripsy in elderly patients

Objective: The objective of the study was to determine the efficacy and safety of flexible ureteroscopy (F-URS) for the management of intrarenal or proximal ureteral lithiasis in aged patients. Materials and methods: In this retrospective, multicenter observational study, we collected the anonymized clinical data of patients who underwent F-URS at two institutions in Cali, Colombia between June 2015 and May 2018. The patients were divided into two groups based on age: Group A defined as aged patients (> 65 years) and Group B as patients of non-advanced age (< 65 years). Results: A total of 201 patients were included in this study. The average age for Group A was 75 years (± 4.5) and for Group B was 51 years (± 10). The anesthetic risk classification (American Society of Anesthesiology [ASA]) and comorbidities were significantly higher for Group A with an ASA II and III of 74% versus 50% in Group B. No significant differences were shown in the stone-free rates (SFRs) or significant ureteral injury (Grade III and IV). There was no difference in intraoperative or post-operative complications between both groups. Conclusions: Age > 65 years was not associated with a negative impact on the outcomes of F-URS for the management of intrarenal or proximal ureteral lithiasis in this cohort of patients. F-URS appears as a safe and effective procedure and should not be withheld from older patients