BÖYRƏK DAŞLARI OLAN MORBİD OBEZ XƏSTƏLƏRDƏ TAMAMİLƏ BORUSUZ VƏ STANDART PERKUTAN NEFROLİTOTOMİYA ƏMƏLIYYATLARI ARASINDA GÜVƏNLİK VƏ EFFEKTİVLİYİN MÜQAYİSƏLİ TƏDQİQİ

10-04-2017

Introduction: Obesity, i.e. a body mass index (BMI) of >30 kg/m2, has become an epidemic condition around the world (1). Over the past few decades, obesity, defined as a body mass index (BMI, kg/m2) greater than 30, has become increasingly prevalent, reaching epidemic proportions (1). Given the association between obesity, metabolic syndrome, and kidney stones (2,3). Percutaneous nephrolithotomy (PNL) is the first-line treatment for large and complex renal calculi. First time in 1976, Fenstrom and Johansson published their report on the new stone surgery, which they called percutaneous pyelolithotomy (4). Using a nephrostomy tube for drainage has been considered the standard procedure after PNL (5). Over the past 40 years, it has happened significant improvements in PNL surgery technique with experience and technological developments. The placement of a nephrostomy tube and/or internal ureteral stent after PNL has been considered standard practice^6,7. The purposes of the tube placements are to allow the renal puncture to heal, and to provide proper drainage of urine, and to permit access to the collecting system, if a secondary procedure is required (6,7).

Material and methods:A total of 78 obese patients with body mass index over 35 were included in the study who had indication for PNL. We retrospectively analyzed 37 morbidly obese patients (male/ female 21/16; 37 renal unite) undergone totally tubeless PNL (no nephrostomy, no ureteral stent, Group 1) and 41 morbidly obese patients (male/female: 22/19 : 41 renal unite) undergone standart PNL (Group 2) in our clinic between January 2015 and April 2017.

Totally tubeless PNL was performed in uncomplicated cases, when there was no significant bleeding or residual stone load, an intact pelvicaliceal system, and no evidence of a residual ureteral stone. Totally tubeless PNL was performed in 23 patients due to stone in right kidney and  in 14 patients due to stone in left kidney. None of patients underwent bilateral PNL. Percutaneous access was done in prone position.

Preoperatively, patients were evaluated with urine analysis and culture, serum creatinine and biochemistry, complete blood count, coagulation tests, USG and noncontrast computerized tomography (CT). The stone size (mm²) was calculated by a millimeter graph paper tracing of the anteroposterior stone projection on a plain skiagram or CT.

PNL technique was performed in the following manner. Under general anesthesia a 6 French ureteral catheter was placed to the operation side, then a prone position was given to the patient. Gonads were protected with a lead apron. After selecting the most appropriate calyx in order to reach the stone, access was created by an 20 gauge needle with the help of retrograde pyelography. The nephrostomy tract was formed with plastic amplatz dilators under fluoroscopic image. In all patients 26 French working sheaths were used to perform the operation by an 24 French rigid nephroscope (Karl Storz, Tuttlingen,Germany). Stone disintegration was performed with a pneumatic lithotriptor or an ultrasonic lithotriptor. Anterograde pyelography was performed to evaluate the collecting system and assess the amount of extravasations. In the case of totally tubeless PNL (Group1), nephrostomy and ureteral stents were not placed. In group 2, 16 French catheter was inserted as nephrostomy tube.

Operative findings, stone size, duration of hospital stay, postoperative pain scores using a visual analog scale and analgesia requirement and success rates, return to normal activity of the patients, decrease in hematocrit and Clavien-Dindo complications (8,9), were retrospectively analyzed performed with totally tubeless and standart PNL. Pain scores were performed using the Visual Analog Scale (10). In group 2, patients were checked for residual fragments by X-ray and in addition to this, renal ultrasound was performed to patients in Group 1 for urinoma, hematoma or clinically significant residual fragments.

Data analysis was performed using SPSS for Windows, version 22. The data was shown as mean ± standard deviation for continuous variables. Categorical variables were presented in percentages. Means were compared using

Mann Whitney U test. For categorical comparisons, Chi-square or Fisher’s Exact test were used, where appropriate. P < 0.05 was considered statistically significant.

Results: The mean age of the patients at receipt of the surgical procedure was 53.9±4.89 vs 55.7±3.51, respectively. The mean stone  size was 405± 102.7mm² vs 395± 160.8 mm² and stone-free rate was 93,3% vs 91.7% for group 1 and 2, respectively (p > 0.05). No significant differences were observed in age, gender, stone size, and surgery side between the groups (p > 0.05). Fluoroscopy time and decrease in hematocrit were similar in 2 groups (p =0.15). No blood transfusions were needed. Characteristics of patients and stones are summarized in Table 1.

Table 1.

Characteristics of patients and stones

 

The complication rate was 12% in the standard PNL group and 9.7% in the totally tubeless PNL group (p = 0.62). The operation time was significantly lower in the totally tubeless PNL group than in the standard PNL group (p = 0.001). The mean hospitalization time was 1.5±0.2 and 3.4± 0.7 days, respectively (p< 0.01). The visual analogue pain score at 4 hours for the study groups were 3.22 ± 0.50 and 5.15 ± 1.07, respectively (p=0.001). The mean analgesia requirement (pethidine HCl) was 1.0 and 1.7 mg/kg in Group 1 and Group 2, respectively (p < 0.01). Return to normal activity was described as total number of in-patient and outpatient days from time of admission to the point which the patients returns to normal life activity such as going to job, were found 5.3±1.6 vs 10.4± 2.5  days, respectively (p = 0.001). Parameters concerning the operation are summarized in Table 2.

 

Table 2.

Postoperative outcomes

VAS: Visual  Analog  Scale¹⁰

Discussion:Percutaneous nephrolithotomy (PNL) has gained acceptance as the gold standard for the treatment of large renal calculi (10,11). After completion of stone removal, traditionally, a nephrostomy tube is placed. This helped in tamponade of  bleeding, drainage of urine, tract recovery, and a guide for second look nephroscopy if needed (4). Although nephrostomy tubes provide postoperative drainage of urine from the collecting system, they can cause discomfort and increase hospital stay.

In the literature, tubeless PNL studies are reported but only a few are totally tubeless PNL. Totally tubeless PNL was first described by Wickham et al. in 1984  (12). Winfield and colleagues in 1986 showed that  totally tubeless PNL prolongs hospital stay with an increase in complication rates (7). After that, discouraging study, totally tubeless PNL operations were interrupted till 1997 when Bdesha (13) and Bellman (14) showed that tubeless PNL is a safe procedure with minimal morbidity. After this reports, the tubeless PNL gained popularity and subsequent case series confirmed the efficacy of the procedure (15,16). In a study by Agrawal et al., the mean pain score was 5.9 and 3.1 in standard and tubeless groups, respectively (p≤ 0.01) (17). Agrawal et al. also showed mean opioid analgesic requirement with significant difference between standard and tubeless groups (p = 0.001) (17,18). Crook et al (19) performed a randomized controlled trial comparing totally tubeless PNL with standard  nephrostomy tube placement in 25 patients, and reported no differences in hemorrhage, infection, and other parameters. Mean length of stay was 2.3 versus 3.4 days (p > 0.05). Mandhani et al (20) compared the outcome of tubeless percutaneous nephrolithotomy with or without double-J stent in 52 patients. Mean pain score, analgesic requirement, hospital stay, and incidence of urinary leak were comparable in both the groups. These studies concluded that PNL without  nephrostomy tube or stent was a safe and well-tolerated procedure in selected patients. In other studies, it has been reported that totally tubeless PNL, has advantages and safety procedure (21). In the study by Yang et al (22) 133 patients under tubeless PNL were enrolled including 24.9%  obese subjects and the success rate was same across the obese and none-obese subjects. Also the obese subjects in our study demonstrated good outcomes in our study. Agrawal et al (23) reported in a review study that PNL results are not related to BMI and obesity among under-operation subjects (24).

Conclusions: Totally tubeless PNL, is also a safe and effective procedure in select group of morbidly obese patients and  if  the surgeon has sufficient experience with the procedure. Omitting the percutaneous nephrostomy tube and removing ureteral catheter at the end of surgery in selected patients were safe and accompanied by significantly reduced postoperative discomfort, length of  hospitalization, operation time  and analgesic requirements. However, the tubeless decision should be taken intraoperatively in selected patients. Prospective randomized studies with large series are necessary for further evaluation of the procedure.

e-mail:[email protected]

 

ƏDƏBİYYAT- ЛИТЕРАТУРА– REFERENCES:

 

1.Ogden CL, Carroll MD, Flegal KM. Prevalence of obesity in the United States. JAMA 2014;312:189–190.
2.Semins MJ, Shore AD, Makary MA, et al. The association of increasing body mass index and kidney stone disease. J Urol 2010;183:571–575.
3.Taylor EN, Stampfer MJ, Curhan GC. Obesity, weight gain, and the risk of kidney stones. JAMA 2005;293:455–462.
4.Fernstrom I, Johansson B. Percutenous pyelolithotomy:A new extraction technique. Scand J Urol Nephrol1976;10:257-259.
5.Tirtayasa PMW, Yuri P, Birowo P, et al. Safety of tubeless or totally tubeless drainage and nephrostomy tube as a drainage following percutaneous nephrolithotomy: A comprehensive review. Asian J Surg. 2016;doi: https://doi.org /10.1016/j.asjsur.2016.03.003.
6.Aghamir SM, Hosseini SR, Gooran S: Totally tubeless percutaneous nephrolithotomy. J Endourol 2004, 18, 647–648.
7.Winfield HN. Weyman P. Clayman RV: Percutaneous nephrolithotomy: Complications of premature nephrostomy  tube removal. J Urol 1986, 136, 77–79.
8.Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery. 1992;111:518–26.
9.Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.
10.Turk C, Knoll T, Petrˇı´k A, et al. EAU guidelines on urolithiasis 2017. Arnhem, The Netherlands: European Association of Urology; 2017.
11.Kıraç M, Tepeler A, Bozkurt OF, Elbir F, Ozluk C, Armagan A, Unsal A, Biri H (2013) The efficacy of bupivacaine infiltration on the nephrostomy tract in tubeless and standard percutaneous nephrolithotomy: a prospective, randomized, multicenter study. Urology 82:526–531.
12.Wickham JE, Miller RA, Kellett MJ et al (1984) Percutaneous nephrolithotomy: one stage or two? Br J Urol 56:582–585.
13.BdeshaAS, Jones CR, North EA et al (1997) Routine placement of a nephrostomy tube is not necessary after percutaneous nephrostolithotomy. Br J Urol 79;11:32-37.
14.Bellman GC, Davidoff R, Candela J, et al. Tubeless percutaneous renal surgery. J Urol. 1997;157:1578–82.
15.Limb J, Bellman GC. Tubeless percutaneous renal surgery: review of first 112 patients. Urology. 2002;59:527–31.
16.Delnay KM, Wake RW. Safety and efficacy of tubeless percutaneous nephrostolithotomy. World J Urol. 1998;16:375–7.
17.Agrawal MS, Agrawal M, Gupta A, et al. A randomized comparison of tubeless and standard percutaneous nephrolithotomy. J Endourol. 2008;22:439–42.
18.Paul EM, Marcovich R, Lee BR, Smith AD. Choosing the ideal nephrostomy tube. BJU Int. 2003;92:672–7.
19.Crook TJ, Lockyer CR, Keoghane SR, Walmsley BH. Totally tubeless percutaneous nephrolithotomy. J Endourol. 2008;22:267–71.
20.Mandhani A, Goyal R, Vijjan V, Dubey D, Kapoor R. Tubeless percutaneous nephrolithotomy-should a stent be an integral part? J Urol. 2007;178:921–4.
21.Karami H, Gholamrezaie HR. Totally tubeless percutaneous nephrolithotomy in selected patients. J Endourol 2004;18:475-476.
22.Yang RM, Bellman GC. Tubeless percutaneous renal surgery in obese patients. Urology. 2004;63:1036–41
23.Agrawal MS, Agarwal M. Percutaneous nephrolithotomy: Large tube, small tube, tubeless, or totally tubeless? Indian J Urol. 2013;29:219–24.
24.Agrawal MS, Agarwal M. Percutaneous nephrolithotomy: Large tube, small tube, tubeless, or totally tubeless? Indian J Urol. 2013;29:219–24.
25.KuntzNJ, Neisius A, Astroza GM. Does body mass index impact the outcomes of tubeless percutaneous nephrolithotomy? BJU Int. 2014;114:404–11.