![]() Medical Therapy, Surgical Therapy, Preoperative Details. In the past, removal of large complex renal calculi required either anatrophic nephrolithotomy (bivalving the kidney on the lateral aspect) or pyelolithotomy (opening the renal pelvis). ![]() These are both major open operations with attendant morbidity. Moreover, these procedures did not always ensure complete stone removal, with the incidence rate of residual fragments ranging from 1. The advent of minimally invasive modalities to treat renal stones revolutionized the approach to staghorn calculi. These include extracorporeal shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PNL). Extracorporeal shockwave lithotripsy. SWL was introduced in 1. Struvite calculi are effectively broken by SWL because of the multiple laminations within the stones. Childhood Kidney Diseases. The most common kidney diseases in children are present at birth. They include: Posterior urethral valve obstruction: This narrowing or. The purpose of PCNL is the removal of renal calculi in order to relieve pain, bleeding into or obstruction of the urinary tract, and/or urinary tract infections. A renal biopsy is a procedure used to extract kidney tissue for laboratory analysis. The word “renal” describes the kidneys. A renal biopsy is also called a. Kidney stones, or renal calculi, are solid masses made of crystals. Kidney stones usually originate in your kidneys, but can develop anywhere along your urinary tract. Renal hypertension is caused by a narrowing in the arteries that deliver blood to the kidney. One or both kidneys' arteries may be narrowed. This is a condition. However, even with excellent stone fragmentation by primary SWL, repeat therapy via SWL must be performed in 5. If multiple sessions are anticipated, the renal pelvis should be treated first. Real- time monitoring of stone fragmentation using fluoroscopy is important to target and shock all areas of the stone. In addition, the potential for urinary obstruction during spontaneous stone passage usually requires the placement of an indwelling ureteral stent. ![]() In up to 4. 0% of patients, a percutaneous nephrostomy (PCN) tube is subsequently required to allow adequate renal drainage. If the renal infundibula are narrow, stone fragments that stem from SWL are unlikely to pass and remain in the calyces. Percutaneous nephrolithotomy (PNL) is the preferred surgical therapy in these cases. Large, wide infundibula that permit easy passage of fragments increase the stone- free rate and overall success of SWL treatment for staghorn calculi. Percutaneous nephrolithotomy. PNL refers to the creation of a tract from the skin to the renal collecting system, thus permitting use of a nephroscope and instruments via this tract to fragment and remove stones. More recently, flexible ureteroscopes combined with small holmium laser fibers have allowed retrograde access to the kidney for stone destruction. PNL was developed and popularized in the 1. Access to the kidney is obtained under ultrasound or fluoroscopic guidance, and the tract is typically dilated to 2. F. Through this tract, a rigid nephroscope is introduced to visualize the stone and collecting system and to guide fragmentation. Energy sources for this purpose include ultrasonic, electrohydraulic, and pneumatic lithotrites and laser. The use of a flexible nephroscope allows examination of the entire kidney and helps ensure complete stone removal. Multiple PCN tracts may be used in cases of branched, complex staghorn calculi. ![]() ![]() After PNL, a PCN tube is placed to optimize urinary and fragment drainage. The first photo below illustrates the results of the patient shown in the second image. Right PNL was performed via a single lower- pole access during a single session, rendering the patient stone free. The left stone was later treated using SWL. Some practices have advocated placing the patient in a flexed prone or supine position in preference to a flat prone position, to more easily access the stone percutaneously and clear a larger stone burden. ![]() ![]() In addition to possibly improving stone clearance, these positions may provide better comfort for the surgeon during the procedure. Both laser and electrohydraulic ureteroscopic lithotripsy are possible and can significantly fragment staghorn calculi. Case reports describe a synchronous bidirectional technique that combines percutaneous nephroscopy and retrograde intrarenal surgery to successfully treat complex, branched staghorn calculi, lessening the need for multiple flank punctures. As with SWL, the passage of a large stone burden requires an indwelling ureteral stent, and multiple treatments may be required. For both monotherapy SWL and retrograde ureteroscopic lithotripsy, rendering the patient stone free is difficult, especially in the setting of dilated collecting systems and dependent lower pole calyces. Surgical principles. Although multiple surgical approaches to staghorn calculi are available, several principles must be kept in mind. First, complete removal of all stone material is the goal of any procedure. Simple debulking does not prevent future infections, stone formation, or impairment of renal function. Second, the patient should be counseled that multiple interventions may be required. If ureteroscopy or SWL is the primary treatment modality, the need for subsequent SWL, ureteroscopy, or PNL must be discussed. Use of combination therapy is a reasonable approach to ensure removal of all residual fragments. An example of this is the so- called sandwich technique, with initial PNL followed by SWL and then second- look PNL. Patient outcomes have been demonstrated to improve with increasing PNL experience. Third, the immediate use of adjunctive measures can be considered. Postoperative oral acetohydroxamic acid (AHA) and antibiotics may delay the regrowth of struvite stones. In addition, direct irrigation of the collecting system is possible through the nephrostomy tube after PNL. Lavage chemolysis for residual fragments consists of acidification of the urine with solutions such as Suby G or hemiacidrin (Renacidin). Although in vitro and in vivo data support some efficacy of direct acidification and ion exchange of stone calcium for magnesium, caution must be used when performing irrigation to ensure sterile urine, low intrarenal pressure, and normal serum magnesium levels. Hypermagnesemia (and associated toxicity) is more common in patients with compromised renal function. Recommendations. A guideline on the surgical treatment of stones from the American Urological Association and the Endourological Society, issued in 2. PNL as first treatment for most patients with staghorn calculi. Compared with open surgery for staghorn calculi, PNL provides comparable stone- free rates, decreased intraoperative and postoperative complications, decreased length of hospital stay, earlier return to work, and a much smaller surgical incision. Complete stone removal should be the ultimate goal. SWL or URS should be offered to patients with symptomatic lower pole renal stones that are .
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. Archives
November 2017
Categories |