Challenge of percutaneous nephrolithotomy in patients with spinal neuropathy

Abstract

Objective: To assess the technical difficulties, associated complications and stone clearance rates in patients with spinal neuropathy undergoing percutaneous nephrolithotomy. Methods: Twenty-nine patients with spinal neuropathy underwent percutaneous nephrolithotomy in the two centers studied between October 1995 and January 2002. They were nine patients with traumatic spinal cord injury, 10 patients with spina bifida and 10 with other heterogeneous causes for their spinal neuropathy. The group included 12 men and 17 women, with an average age of 44 years (14-80). Patients' medical records were reviewed retrospectively for data relating to their renal lithiasis. Results: A total of 39 percutaneous nephrolithotomy procedures were undertaken on 32 kidneys. Thirteen procedures were for staghorn calculi. Preoperatively, eight kidneys required nephrostomy and 5 J stent decompression. The average American Society of Anesthesiologists (ASA) score was 3, and one patient had percutaneous nephrolithotomy performed under local anaesthetic as the risk of general anaesthetic was felt to be too high. The associated morbidity and mortality in this group is significant. There were two postoperative deaths. Major complications were associated with three procedures, and consisted of seizures, aspiration pneumonia and pressure necrosis. Nine patients experienced minor complications including fever, hypotension and nephrostomy site leakage. Nine patients required intensive therapy unit care postoperatively and the average hospital stay for the group was 13.32 days. Only 18 (62%) patients were rendered stone-free from their initial percutaneous nephrolithotomy. Seven patients required a further procedure for stone clearance: four underwent extracorporeal shock-wave lithotripsy, two ureteroscopy and one nephrectomy. Conclusions: Patients with spinal neuropathy and renal lithiasis pose a significant operative challenge. Technical difficulties and potential complications should be considered carefully before undertaking percutaneous nephrolithotomy in these patients.

Evidence-based management of upper tract urolithiasis in the spinal cord-injured patient

“…PCNL is the gold standard for stones measuring 2 cm and above in the renal pelvis and this remains the case in patients with SCI. Five published series [26][27][28][29][30] report stone-free rates of around 90%, which at first look appears comparable to the standard PCNL outcomes. (Table 4) However, in the Chicago series all patients had a second-look PCNL as standard, and only 19 renal units were stone free after first PCNL in the UK series.…”

“…(Table 4) However, in the Chicago series all patients had a second-look PCNL as standard, and only 19 renal units were stone free after first PCNL in the UK series. 28,30 In the earliest study from 1986, there was an average of 2.04 procedures per patient. 26 In this respect, PCNL in patients with SCI is a more complex and significantly undertaking, often requiring multiple procedures to achieve stone clearance.…”

“…The United Kingdom series reports that nine patients required intensive care admission, though no details were given regarding the reasons for admission. 30 Minor complications were also high, but again analysis is limited because of lack of standard classifications. Pyrexia, transfusion and nephrostomy tube dislodgement were the commonest reported complication, and in the major part of the more contemporary series occurred in 75% of procedures.…”

“…29 Only the UK paper gave details of hospital stay, which was a median of 13 days. 30 In a study examining all factors predisposing to systemic inflammatory response syndrome and pyrexia post-PCNL in the Netherlands, previous PCNL and spinal injury were significant factors predisposing to systemic inflammatory response syndrome post-op. 31 Chemolysis.…”

The surgical management of upper tract stone disease among spinal cord-injured patients

“…4 Percutaneous nephrolithotomy (PNL) maybe more common among SCI patients, and has been reported to be associated with significant perioperative morbidity and mortality. [5][6][7] The use of ureteroscopy was traditionally limited by the inability to position many SCI patients in the lithotomy position; however, the contemporary use of flexible ureteroscopy in this population has not been formally studied.…”