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1822 PERCUTANEOUS NEPHROLITHOTOMY OF CALYCEAL DIVERTICULI CALCULI: A SINGLE CENTRE'S 17 YEAR EXPERIENCE
Vol. 185, No. 4S, Supplement, Tuesday, May 17, 2011
prone-flexed positions. The trajectory of nephrostomy access was virtually positioned at a 30 degree angle off the vertical axis lateral to the paraspinal muscles. RESULTS: In the prone-flexed position, the left kidney was displaced lower than the right in 92.3% of cases, such that it would have lowered an upper pole puncture from above the 11th rib to one above the 12th rib in 5 of 11 patients (45.5%). When comparing the prone-flexed to the prone position, the mean skin-upper calyx distances were 8.4 mm and 13.4 mm shorter for the right and left kidneys, respectively (p⬍0.001). For lower pole punctures, the right and left kidneys were significantly lower (11.6 mm and 9.8 mm, respectively) in the prone-flexed as compared to prone position, p⬍0.001. The proneflexed position moved the kidney further from the adjacent organs such that the planned trajectory was 13.6 degrees further away from the liver on the right side and 11.3 degrees further from the spleen on the left side (both p⬍0.001). In the prone-flexed position, the mean angle of trajectory of a rigid nephroscope from an upper pole puncture into the lower calyx was 101.3 degrees, whereas from a lower pole puncture into an upper pole calyx was more acute at 96.1 degrees (p⬍0.01). CONCLUSIONS: In comparison to the standard prone position for PCNL, the prone-flexed modification shortens the skin-to-kidney distance, lowers the kidneys in relation to the ribs to minimize supracostal punctures, moves the liver and spleen away from potential upper pole punctures and flattens the natural lumbar lordosis to facilitate instrumentation from a lower pole puncture. Lastly, we demonstrate that there exists less infundibular torque during upper pole punctures when instrumenting lower pole calyces due to the more obtuse angle. Source of Funding: None
1822 PERCUTANEOUS NEPHROLITHOTOMY OF CALYCEAL DIVERTICULI CALCULI: A SINGLE CENTRE’S 17 YEAR EXPERIENCE Carlos Mendez-Probst*, Linda Nott, John Denstedt, Hassan Razvi, London, Canada INTRODUCTION AND OBJECTIVES: Calyceal diverticulae are renal anomalies present in approximately in 0.6% of the population and may be associated with urinary stone formation in up to 40% of cases. Various treatment options exist each with their own advantages and disadvantages. Percutaneous nephrolithotomy (PCNL) is considered a first line option by many but can be technically demanding. The ability to cannulate the diverticular neck and relieve the obstructive element is not always possible. At our centre, PCNL has been our therapeutic option of choice and herein we present our 17 year experience. METHODS: Data on all patients with calyceal diverticular stones who underwent PCNL between 1992 and 2009 were retrospectively reviewed. Outcomes assessed included the technique of percutaneous access including successful cannulation of the diverticular neck versus a transdiverticular approach, whether fulguration of the diverticular lining was performed, post operative complications and stone free rates at 1 month post treatment. RESULTS: 74 patients were treated during the study interval. The mean age was 43 (17 to 72). The mean stone area was 583 mm2. The average OR time was 75 min (23 to 169) with an average hospital stay of 4.7 days. There were 22 complications with 11 requiring intervention (2 urinary tract perforations, 1 RBC transfusion, 8 pneumothorax). Stone free rates were 77% and 89% including fragments less than 5 mm. The surgical approach was direct puncture in 47, transdiverticular in 20, retrograde in 8 and unknown in 2 patients, 8 patients underwent lining fulguration. CONCLUSIONS: The percutaneous management of calyceal diverticular calculi is highly effective and can be accomplished with a relative low morbidity. Source of Funding: None
THE JOURNAL OF UROLOGY姞
e731
1823 PERCUTANEOUS NEPHROLITHOTOMY (PCNL) IN THE SEPTUAGENARIAN, OCTOGENARIAN AND NONAGENARIAN IS SAFE: OUTCOMES AND COMPLICATIONS Shubha De*, Halifax, Canada; Simone Thavaseelan, Gyan Pareek, George Haleblian, Providence, RI INTRODUCTION AND OBJECTIVES: PCNL is the standard of care for large volume upper tract stone disease. Patients presenting in their eighth to tenth decades of life with large stone burdens can be felt to be at increased risk of peri-operative complications and poorer outcomes. Safety and efficacy in higher risk patients have been reported, though age has not been investigated in terms of outcomes. Our objective is to compare outcomes and complications of PCNL in septuagenarian, octogenarian and nonagenarians, compared to a younger population matched for stone burden. METHODS: The records of 231 consecutive PCNLs performed from 2006 to 2010 were reviewed. Demographics, age, ASA score, length of stay (LOS), and location of access were assessed. Stone size, clearance and complications were investigated. All patients over 70 years old were compared to a stone size matched, age adjusted control group of 20 patients between 30 and 60 years old. Descriptive statistics and student’s T-tests were used. RESULTS: A total of 32 PCNLs in 28 patients over 70 years (n⫽15 aged 71–79, 9 aged 80 – 89, and 4 aged 90 –94) were performed. This cohort’s mean age was 77y, ASA of 2.63, and had 2.86 comorbidities per patient. The control group had a mean age of 47.1 years, and significantly reduced ASA scores of 1.78, with 1.10 comorbidities (p⫽0.001 and p⫽0.0001 respectively). Those ⬎70y had significantly increased cardiovascular disease, hypertension, atrial fibrillation and cancer (p⬍0.05). Frequency of stone related risk factors, first time presenters, composition, size and side of stone burden were not significantly different. Stone free rate was 63.3% in those ⬎70y and 74% in the control group, without differences in surgical time or LOS. Though there was an increase in the frequency of complications (33%, n⫽12), and an increased mean Clavien class of 2.08 (5 grade I, 1 grade II, 6 grade III, 0 grade IV) they did not differ significantly from controls (n⫽3, p⫽0.29). CONCLUSIONS: In patients over 70 years old, we have demonstrated that the efficacy and safety of PCNL is equivalent to a younger population. Given this is a retrospective case controlled study, subtle trends may not have been appreciated. Since there were no significant differences in complication rates, age alone should not a excluding criteria. Concerns regarding multiple anesthetics, prone positioning, bleeding and hospitalization should be considered individually, rather than favoring second line therapies based on advanced age. Source of Funding: None
1824 INTERNATIONAL COOPERATION IN ENDOUROLOGY: PERCUTANEOUS AND FLEXIBLE URETEROSCOPIC TREATMENT OF LOWER POLE KIDNEY STONES Alberto Breda*, Francesco Sanguedolce, Barcelona, Spain; Cesare Scoffone, Turı´n, Italy; Panagiotis Kallidonis, Evangelos LIatsikos, Patras, Greece; Raimundas Sabockis, Marianne Brehmer, Stockholm, Sweden; Jan Jessen, Thomas Knoll, Germany, Germany; Matthias Franke, Palle Osther, Fredericia, Denmark; Olivier Traxer, Paris, France; Thomas Hermann, Axel Merseburger, Hannover, Germany; Udo Nagele, Austria, Austria; Felix Milla´n, Barcelona, Spain INTRODUCTION AND OBJECTIVES: Studies have proved that ureteroscopy (URS) is an efficacious alternative to ESWL for lower pole stones ⬍2 cm, however this is not reflected by both the European and American guidelines. The aim of this study is to present the results of a large series of flexible ureteroscopies and PCNLs for lower pole kidney stones from high volume centers.
prone-flexed positions. The trajectory of nephrostomy access was virtually positioned at a 30 degree angle off the vertical axis lateral to the paraspinal muscles. RESULTS: In the prone-flexed position, the left kidney was displaced lower than the right in 92.3% of cases, such that it would have lowered an upper pole puncture from above the 11th rib to one above the 12th rib in 5 of 11 patients (45.5%). When comparing the prone-flexed to the prone position, the mean skin-upper calyx distances were 8.4 mm and 13.4 mm shorter for the right and left kidneys, respectively (p⬍0.001). For lower pole punctures, the right and left kidneys were significantly lower (11.6 mm and 9.8 mm, respectively) in the prone-flexed as compared to prone position, p⬍0.001. The proneflexed position moved the kidney further from the adjacent organs such that the planned trajectory was 13.6 degrees further away from the liver on the right side and 11.3 degrees further from the spleen on the left side (both p⬍0.001). In the prone-flexed position, the mean angle of trajectory of a rigid nephroscope from an upper pole puncture into the lower calyx was 101.3 degrees, whereas from a lower pole puncture into an upper pole calyx was more acute at 96.1 degrees (p⬍0.01). CONCLUSIONS: In comparison to the standard prone position for PCNL, the prone-flexed modification shortens the skin-to-kidney distance, lowers the kidneys in relation to the ribs to minimize supracostal punctures, moves the liver and spleen away from potential upper pole punctures and flattens the natural lumbar lordosis to facilitate instrumentation from a lower pole puncture. Lastly, we demonstrate that there exists less infundibular torque during upper pole punctures when instrumenting lower pole calyces due to the more obtuse angle. Source of Funding: None
1822 PERCUTANEOUS NEPHROLITHOTOMY OF CALYCEAL DIVERTICULI CALCULI: A SINGLE CENTRE’S 17 YEAR EXPERIENCE Carlos Mendez-Probst*, Linda Nott, John Denstedt, Hassan Razvi, London, Canada INTRODUCTION AND OBJECTIVES: Calyceal diverticulae are renal anomalies present in approximately in 0.6% of the population and may be associated with urinary stone formation in up to 40% of cases. Various treatment options exist each with their own advantages and disadvantages. Percutaneous nephrolithotomy (PCNL) is considered a first line option by many but can be technically demanding. The ability to cannulate the diverticular neck and relieve the obstructive element is not always possible. At our centre, PCNL has been our therapeutic option of choice and herein we present our 17 year experience. METHODS: Data on all patients with calyceal diverticular stones who underwent PCNL between 1992 and 2009 were retrospectively reviewed. Outcomes assessed included the technique of percutaneous access including successful cannulation of the diverticular neck versus a transdiverticular approach, whether fulguration of the diverticular lining was performed, post operative complications and stone free rates at 1 month post treatment. RESULTS: 74 patients were treated during the study interval. The mean age was 43 (17 to 72). The mean stone area was 583 mm2. The average OR time was 75 min (23 to 169) with an average hospital stay of 4.7 days. There were 22 complications with 11 requiring intervention (2 urinary tract perforations, 1 RBC transfusion, 8 pneumothorax). Stone free rates were 77% and 89% including fragments less than 5 mm. The surgical approach was direct puncture in 47, transdiverticular in 20, retrograde in 8 and unknown in 2 patients, 8 patients underwent lining fulguration. CONCLUSIONS: The percutaneous management of calyceal diverticular calculi is highly effective and can be accomplished with a relative low morbidity. Source of Funding: None
THE JOURNAL OF UROLOGY姞
e731
1823 PERCUTANEOUS NEPHROLITHOTOMY (PCNL) IN THE SEPTUAGENARIAN, OCTOGENARIAN AND NONAGENARIAN IS SAFE: OUTCOMES AND COMPLICATIONS Shubha De*, Halifax, Canada; Simone Thavaseelan, Gyan Pareek, George Haleblian, Providence, RI INTRODUCTION AND OBJECTIVES: PCNL is the standard of care for large volume upper tract stone disease. Patients presenting in their eighth to tenth decades of life with large stone burdens can be felt to be at increased risk of peri-operative complications and poorer outcomes. Safety and efficacy in higher risk patients have been reported, though age has not been investigated in terms of outcomes. Our objective is to compare outcomes and complications of PCNL in septuagenarian, octogenarian and nonagenarians, compared to a younger population matched for stone burden. METHODS: The records of 231 consecutive PCNLs performed from 2006 to 2010 were reviewed. Demographics, age, ASA score, length of stay (LOS), and location of access were assessed. Stone size, clearance and complications were investigated. All patients over 70 years old were compared to a stone size matched, age adjusted control group of 20 patients between 30 and 60 years old. Descriptive statistics and student’s T-tests were used. RESULTS: A total of 32 PCNLs in 28 patients over 70 years (n⫽15 aged 71–79, 9 aged 80 – 89, and 4 aged 90 –94) were performed. This cohort’s mean age was 77y, ASA of 2.63, and had 2.86 comorbidities per patient. The control group had a mean age of 47.1 years, and significantly reduced ASA scores of 1.78, with 1.10 comorbidities (p⫽0.001 and p⫽0.0001 respectively). Those ⬎70y had significantly increased cardiovascular disease, hypertension, atrial fibrillation and cancer (p⬍0.05). Frequency of stone related risk factors, first time presenters, composition, size and side of stone burden were not significantly different. Stone free rate was 63.3% in those ⬎70y and 74% in the control group, without differences in surgical time or LOS. Though there was an increase in the frequency of complications (33%, n⫽12), and an increased mean Clavien class of 2.08 (5 grade I, 1 grade II, 6 grade III, 0 grade IV) they did not differ significantly from controls (n⫽3, p⫽0.29). CONCLUSIONS: In patients over 70 years old, we have demonstrated that the efficacy and safety of PCNL is equivalent to a younger population. Given this is a retrospective case controlled study, subtle trends may not have been appreciated. Since there were no significant differences in complication rates, age alone should not a excluding criteria. Concerns regarding multiple anesthetics, prone positioning, bleeding and hospitalization should be considered individually, rather than favoring second line therapies based on advanced age. Source of Funding: None
1824 INTERNATIONAL COOPERATION IN ENDOUROLOGY: PERCUTANEOUS AND FLEXIBLE URETEROSCOPIC TREATMENT OF LOWER POLE KIDNEY STONES Alberto Breda*, Francesco Sanguedolce, Barcelona, Spain; Cesare Scoffone, Turı´n, Italy; Panagiotis Kallidonis, Evangelos LIatsikos, Patras, Greece; Raimundas Sabockis, Marianne Brehmer, Stockholm, Sweden; Jan Jessen, Thomas Knoll, Germany, Germany; Matthias Franke, Palle Osther, Fredericia, Denmark; Olivier Traxer, Paris, France; Thomas Hermann, Axel Merseburger, Hannover, Germany; Udo Nagele, Austria, Austria; Felix Milla´n, Barcelona, Spain INTRODUCTION AND OBJECTIVES: Studies have proved that ureteroscopy (URS) is an efficacious alternative to ESWL for lower pole stones ⬍2 cm, however this is not reflected by both the European and American guidelines. The aim of this study is to present the results of a large series of flexible ureteroscopies and PCNLs for lower pole kidney stones from high volume centers.