Management of infectious complications in percutaneous nephrolithotomy

Infectious complications are one of the most frequent and feared adverse medical events in percutaneous nephrolithotomy. They represent a dangerous and life-threatening condition, especially when postoperative septicemia or severe sepsis develops. In order to limit morbidity and mortality it is crucial to recognize preoperative and intraoperative risk factors that could be clear contributors to an adverse infectious event; those factors are mainly immunosuppression caused by some comorbidities, presence of urinary infection or colonization, stone characteristics, obstruction, long-lasting operation, and high intrapelvic pressure during nephrolithotomy. Close observation during the immediate and early postoperative period must be established and a high index of suspicion must be maintained to identify a major complication. The early recognition and prompt multidisciplinary management of sepsis is mandatory to optimize the final outcome. Appropriate therapy is a continuum of management of infection, ranging from adequate drainage and broad-spectrum antibiotics to aggressive fluid resuscitation and invasive monitoring with medical management in the intensive care setting until the causative agent is found and eradicated. © Mary Ann Liebert, Inc

Intracorporeal nonlaser lithotripsy

Introduced in the 1980s, shock wave lithotripsy (SWL) is still considered a primary treatment option. Actually,minimally invasive endourological procedures may have a similar or even major role as therapeutic options. Most of the stones requiere fragmentation and the urologist has several options of intracorporeal lithotripsy technologies. The ideal lithotripter should be usable in a variety of settings, multifunctional, with adjustable energy output, effective for all stone compositions, reusable, safe, and inexpensive. To decide which is the best alternative of the nonlaser options, it appears that the election needs to be individualized to the patient population, clinical scenario and to the physician practice. � 2011 Springer-Verlag London Limited

Percutaneous renal access: The learning curve of a simplified approach

Background and Purpose: Fluoroscopically guided techniques to access the kidney percutaneously with low exposure to radiation have been used successfully for many years in our training center. The purpose of this study was to analyze the learning process and to establish the number of procedures necessary for a nonexperienced urologist to achieve competence at performing percutaneous renal access. Materials and Methods: Eighty-two percutaneous renal accesses in patients with renal stones or ureteropelvic junction obstruction were evaluated. The time needed to perform a correct puncture and the fluoroscopic screening time were recorded for each renal access. Descriptive analysis, analysis of variance, and a Markov chain were used to analyze the results. Results: The rate of success increased from 82.5% to 97.6% after the first 40 punctures. Puncture time and fluoroscopy time decreased as the number of procedures increased. Incidence of complications was 30% for the first 20 cases, decreasing to 10% in the next 20 cases and 3.7% in the last 33 cases. Conclusions: The fluoroscopy-guided approach used in this study is an effective and reproducible technique. Our analysis revealed that at least 50 procedures are needed to acquire reliable competence in obtaining access to the kidney. � 2010, Mary Ann Liebert, Inc

Pieloplastía retroperitoneoscópica. Experiencia en el Hospital Regional de Alta Especialidad del Bajío, León, Guanajuato, México

ResumenIntroducciónLa pieloplastía laparoscópica es un procedimiento que cada día se hace más popular;alcanza éxitos que van de 89 % a 100 % y tiene menor morbilidad cuando se compara con la cirugía abierta.ObjetivoPresentar nuestra experiencia en este procedimiento con abordaje retroperitoneal. La técnica realizada fue la descrita por Rasswiler J.ResultadosSe realizaron 14 pieloplastías con abordaje retroperitoneal. Diez pacientes se sometieron a técnica de pieloplastía desmembrada, y los 4 restantes a técnica de Fenger. No se presentó algún incidente transoperatorio que haya motivado conversión a cirugía abierta. No se presentaron complicaciones transoperatorias y se tuvo un rango de sangrado de 50 a 250mL. Se tuvo un tiempo quirúrgico promedio de 182 minutos. Con un seguimiento de 31 meses, se presentó falla al tratamiento en 2 casosConclusionesEl abordaje laparoscópico se ha convertido en la técnica quirúrgica de elección para la corrección de la estenosis de la unión ureteropiélica, debido a que ofrece un éxito similar a la cirugía abierta pero con las ventajas de una menor morbilidad, tiempo de recuperación más corto y resultados estéticos favorables.AbstractBackgroundLaparoscopic pyeloplasty is an increasingly popular procedure, achieving success rates of 89 % to 100 %. It has a lower morbidity rate when compared with open surgery.AimsThe aim of this article was to present our experience with this procedure using a retroperitoneal approach. The technique was that described by J. Rasswiler.ResultsFourteen pyeloplasties with retroperitoneal approach were performed. Ten patients underwent the dismembered pyeloplasty technique and the Fenger technique was used in the remaining 4 patients. No intraoperative incident meriting conversion to open surgery occurred. There were no intraoperative complications and the range of blood loss was from 50 to 250mL. Mean surgery duration was 182 minutes. Treatment failure in 2 cases presented at the thirtyfirst month follow-up.ConclusionsThe laparoscopic approach has become the surgical technique of choice for correcting ureteropelvic junction stricture because it offers a similar success rate to that of open surgery, but with the advantages of less morbidity, a shorter recovery period, and favorable esthetic results