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G. Giusti, O. Maugeri, G. Taverna, A. Benetti, S. Zandegiacomo, R. Peschechera, P. GraziottiTable 4.Tubeless PCNL rate throughout years.2002 4/20 (20%)2003 12/48 (25%)2004 17/51 (33,3%)2005 20/40 (50%)2006 28/43 (65,1%)2007 18/27 (66,6%)Tubeless/standard PCNL (rate)enced urinomas. Instead, the potential hazard of placingonly an internal double-J stent has become the key pointto avoid prolonged urinary leakage through percutaneoustract and consequently to allow for reduction inhospitalization.Our series indicated that tubeless PCNL results weresuperior in terms of less patient discomfort and reducedhospital stay. Patients who underwent tubeless PCNLrequired significantly less analgesics than the standardPCNL group, and the tubeless group had lower VAS andVRS pain scores on the first postoperative day as well.This finding suggests that the discomfort is mainly relatedto the presence of the tube itself, rather than to itsbore (5, 16-18).Based on these encouraging results, our confidence intubeless technique increased with time and similarly raisedthe percentage of PCNL carried out in tubeless fashion(Table 4). As such, tubeless PCNL has become a routineprocedure at our institution and actually is feasible in nearlytwo-thirds of patients with renal calculi suitable for percutaneoustreatment.CONCLUSIONIn this series, omitting placement of nephrostomy in rigorouslyselected patients did not result in serious intraoperativecomplications. In addition, the tubeless approachoffered significant advantages in terms of reduced amountof analgesics, less discomfort, and shorter hospital stayand time to return to normal activities.REFERENCES1. Bellman GC, Davidoff R, Candela J, et al. Tubeless percutaneousrenal surgery. J Urol 1997; 157:1578-82.2. Feng MI, Tamaddon K, Mikhail A, et al. Prospective randomizedstudy of various techniques of percutaneous nephrolithotomy.Urology 2001; 58:345-50.3. Limb J, Bellman GC. Tubeless percutaneous renal surgery: reviewof the first 112 patients. Urology 2002; 59:527-531.4. Desai MR, Kukreja RA, Desai MM, et al. A prospective randomizedstudy of type of nephrostomy drainage following percutaneousnephrostolithotomy: large bore versus small bore versus tubeless. JUrol 2004; 172:565-7.CorrespondenceGuido Giusti, MDResponsabile dello “Stone Center”U.O. di Urologia, Istituto Clinico Humanitas, Studi Medici EstVia Manzoni 56, 20089 Rozzano (Milano), Italyguido.giusti@humanitas.it36Archivio Italiano di Urologia e Andrologia 2010; 82, 1
PRESENTATIONHigh burden and complex renal calculi:Aggressive percutaneous nephrolithotomyversus multi-modal approaches.Glenn M. PremingerThe Comprehensive Kidney Stone Center, Department of Urology, Duke University Medical Center Durham,North Carolina, USASummaryIntroduction: Percutaneous nephrolithotomy (PNL) remains the treatment of choice formanaging patients with large or complex renal calculi, especially staghorn stones composedof struvite. Recent advances in the PNL technique appear to improve post-operativeoutcomes and reduce patient morbidity.Materials and methods: A thorough review of the recent urologic literature was performedto identify results and benefits of percutaneous nephrolithotomy versus either combinationPNL and shock wave lithotripsy or SWL alone. A brief description of these three modalitiesis presented.Results: Published series from several different centers, as well as the 2004 report from theAUA Nephrolithiasis Guidelines Panel have demonstrated superior stone-free rates, improvedcomplication rates and a reduced need for secondary procedure in those patients treated withPNL monotherapy. Combination techniques or SWL treatment may be benefical in patients withlow-volume renal stone disease.Conclusions: Further advances in the PNL technique will not only increase stone-free outcomesand reduce post-operative complications, but also significantly reduce peri-operative patientmorbidity. PNL monotherapy should be considered first line therapy for those patients withlarge or complex renal calculi.KEY WORDS: PCNL; SWL; Staghorn stones.Submitted 9 May 2009; Accepted 30 June 2009INTRODUCTIONOver time, an untreated staghorn calculus is likely todestroy the kidney and/or cause life-threatening sepsis.Therefore, complete removal of the stone is imperative toeradicate any causative organisms, relieve obstruction,prevent further stone growth and any associated infection,and preserve kidney function. Thus, completestone removal should remain the primary therapeuticgoal, especially when a struvite/calcium carbonate/apatite stone is present.There are four modalities that must be considered toremove staghorn calculi:• percutaneous nephrolithotomy (PNL) monotherapy;• combinations of PNL and shock-wave lithotripsy(SWL);• SWL monotherapy; and• open surgery – (typically anatrophic nephrolithotomy).The following manuscript compares percutaneousnephrolithotomy to multimodal approaches for stoneremoval.MATERIALS AND METHODSPercutaneous nephrolithotomyPNL is usually performed with the patient in a proneposition and may be divided into two components,access and stone removal. To achieve percutaneousaccess a small hollow needle is placed into the kidneyand a flexible guide wire is manipulated though the needleunder fluoroscopic control into the kidney and downthe ureter. Care is taken to choose the optimal port ofentry into the kidney. Upper pole entry usually providesaccess to the majority of the collecting system and mayArchivio Italiano di Urologia e Andrologia 2010; 82, 137
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