Ultrasound-guided percutaneous nephrolithotomy: Advantages and limitations

Abstract

PurposeThe use of ultrasound in percutaneous nephrolithotomy (PCNL) has not been shown to translate to better clinical and stone outcomes. To compare the operative outcomes, postoperative outcomes and complication rates of ultrasound-guided access PCNL (USGA-PCNL) versus fluoroscopy-guided access PCNL (FGA-PCNL).Materials and MethodsA total of 184 consecutive patients who underwent PCNL from July 2008 to September 2014 were identified from our PCNL database. Seventy-two patients underwent USGA-PCNL and 112 FGA-PCNL.ResultsThe patients were similar in age, sex, race, American Society of Anesthesiologists physical status classification, mean largest stone diameters, side of PCNL, number of stones and the degree of hydronephrosis between both groups. There were higher rates of upper pole (5.6% vs. 3.6%), mid pole (8.3% vs. 2.7%) and multiple pole punctures (4.2% vs. 0%) in USGA-PCNL compared to FGA-PCNL (p=0.027). There was no difference in the stone free rates of both groups in univariate analysis. Those who had FGA-PCNL were 2.26 (95% confidence interval, 1.09–4.75; p=0.029) times more likely to require a second-look procedure compared to USGA-PCNL on univariate analysis but not on multivariate analysis. There were no differences in Clavien-Dindo complications. No patient in the USGA-PCNL group experienced organ injuries during puncture compared to 1 patient in the FGA-PCNL group who had pneumothorax requiring urgent chest tube insertion.ConclusionsThe use of ultrasonography to guide access puncture during PCNL eliminates the risk of inadvertent organ injuries. Similar operative and stone outcomes show that the learning curve for USGA is minimal compared to conventional FGA.

Ultrasound for kidney access in percutaneous nephrolithotomy: a contemporary review

“…Complications were similar, but a significant decrease in bleeding and need for transfusion for the USGA arms was reported in two studies [29,30]. Length of hospital stay data was contradictory, Andonian et al [29] reporting a mean of 5.3 days for USGA PCNL versus 3.5 days for FGA and Ng et al [22] 2.9 days for the USGA group versus 4.6 days for the FGA group. The results of Ng et al [22] do not correlate with the SFR or with complication or retreatment rate.…”

“…Length of hospital stay data was contradictory, Andonian et al [29] reporting a mean of 5.3 days for USGA PCNL versus 3.5 days for FGA and Ng et al [22] 2.9 days for the USGA group versus 4.6 days for the FGA group. The results of Ng et al [22] do not correlate with the SFR or with complication or retreatment rate. On the other hand, Wang et al [30] found no significant difference in hospital stay between the two groups in their me- N -number of patients; RCT -randomized controlled trial; CCT -clinical control trial; META -meta-analysis; USGA -ultrasound guided access; FGA -fluoroscopy guided access; SFR -stone free rate; NA -not available; xModified Clavien-Dindo classification system.…”

“…These findings are sustained by the results of CROES (The Clinical Research Office of the Endourological Society) PCNL Global study [33], that showed a significantly higher access rate failure for FGA compared with USGA (2.9 vs. 0.7%) in their complex analysis of almost 6000 patients. The most important parameter of the outcome of PCNL is the SFR, which seems to be higher in the USGA PCNL groups, owing to the superiority of ultrasound in depicting renal anatomy and the ability of identifying radiolucent stones [22,29,30]. Another advantage of USGA is the use of Doppler mode, which can depict renal vasculature and can facilitate needle puncture without injury to significant vessels that can lead to severe bleeding.…”

“…The main disadvantage of USGA is the puncture of the non-dilated collecting system [9], which was overcome by placing an uretheral catheter and injecting saline solution, sometimes with some contrast agent [22,28,31], or even a small amount of atmospheric air, for better visualization of the caliceal anatomy [27]. Moreover, the ureteral catheter prevents the migration of stone fragments to the ureter through the PCNL procedure.…”

“…The use of ultrasonography for access (USGA) in PCNL was first described in the 1970s, with increasing popularity and growing literature data demonstrating its advantages in terms of efficacy, safety and feasibility for upper urinary tract lithiasis [22]. The first ultrasound guided PCNL was reported almost 20 years ago by Desai et al [23] on a pediatric patients series.…”