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817 THE EFFECT OF LOCAL ANESTHETIC INFILTRATION AROUND NEPHROSOMY TRACT ON POSTOPERATIVE PAIN CONTROL AFTER PERCUTANEOUS NEPHROLITHOTOMY
O11 STONES Friday, 20 March, 14.00-15.30, Room K1
817
818
The effect of local anesthetic infiltration around nephrosomy tract on postoperative pain control after percutaneous nephrolithotomy
Influence of obesity (BMI >28) on intra- und perioperative complications of percutaneous nephrolithotomy (PCNL)
Tüzel E., Kiziltepe G., Akdogan B.
Propping S., Oehlschläger S., Fröhner M., Leike S., Grimm M.O., Wirth M.
Afyon Kocatepe University, Dept. of Urology, Afyon, Turkey
University Hospital Carl Gustav Carus, Technical University, Dept. of Urology, Dresden, Germany
Introduction & Objectives: Most of the pain after percunateous nephrolithotomy (PNL) is experienced due to dilatation of the renal capsule and parenchymal tract. Previous investigations have focused on the impact of nephrostomy catheter size on postoperative pain and the effect of local anesthetic infiltration to the surgical field has not been well established for PNL. The aim of this study is to investigate the effect of a long acting local anesthetic infiltration around nephrostomy tract on pain control after PNL.
Introduction & Objectives: PCNL is the standard procedure to treat renal calculi > 20 mm. Obese patients are considered to a higher risk of comorbidity (ischaemic heart disease, hypertension) and postoperative complications (thromboembolism, pneumonia). In addition, the operative bedding and surgical procedure are affected by adiposity. We reviewed our contemporary experience to determine the safety and outcome of PCNL in such obese patients.
Material & Methods: Forty-six adult patients with kidney stones of > 2 cm undergoing single access subcostal PNL were enrolled in the study. Patients were randomized in a single blinded fashion to levobupivacaine (group I) and saline (Group II) infiltration groups. Group I patients (n=23) had 25mg/10cc levobupivacaine infiltration with a 21G needle into the subcutaneous tissues around the access site after placement of 20F re-entry Malecot catheter. Levobupivacaine injected along the nephrostomy tube in order to let the drug to diffuse partly outside the renal capsular surface. Group II patients had 10cc saline infiltrated with the same technique. Postoperatively the patients were given narcotics on demand. Pain scores were collected using a 10cm self assessed visual analog scale (VAS) with 0 being no pain and 10 being the worst pain experienced by the patient at 2, 4, 6, 8, 12 and 24 hours postoperatively. The VAS scores, time to analgesic demand, ambulation and duration of nephrostomy tube were compared between two groups. Results: The mean age was 44 and 45 years and the mean body mass index was 26 and 25 for Group I and II patients. The mean stone burden, operation time and irrigation fluid amounts for Group 1 and Group 2 patients were 508 and 473 mm2; 103 and 99 minutes; and 12.5 and 11,8 lt, respectively (p=0.54, p=0.74 and p=0.71, respectively). Success and complication rates were similar for the both groups. Comparison of pain scores at all postoperative time points was not statistically significant between the two groups. Time to first analgesic demand and total narcotic analgesic dose per patient were 1.2±1.05 and 4.04±1.57 hours; and 96 mg and 112 mg for group I and II patients (p=0.009 and p=0.41, respectively). Ambulation time and duration of nephrostomy tube were also similar.
Material & Methods: The computerised data of 376 patients (female n=176; male n=200 treated from 01/2000 to 01/2008) were analysed. A total of 468 PCNL procedures were performed by 11 urologists. The intra-, peri- and postoperative complications in two groups of patients were evaluated (group A: BMI > 28 vs. Group B: BMI ≤ 28). The average age was 56,7 ± 15,1 years, the mean ASA-score 2,1 ± 0,6. Stone analysis: 57,7% calcium oxalate, 12,2% dahllite, 9,8% uric acid, 8,5% struvite, 3,2% brushite und 2,4% cystine. Results:
operation time (min) stone size (mm) primary stone free rate (%) intra-operative complications (perforation, bleeding) peri-operative complications (bleeding, pyelonephritis)
group A n=152 (BMI >28) 58 ± 31 20,2 ± 11,5 82,9% 9,9%
group B n=205 (BMI ≤ 28) 60 ± 32 20,4 ± 11,5 78,5% 9,8%
significance n.s. n.s. n.s. n.s.
11,7%
12,6%
n.s.
Conclusions: The outcome of PCNL is independent of patients’ BMI. PCNL in obese patients yields a stone free rate comparable to non-obese patients. Complication rate and length of operation are similar. Thus, we did not find a relationship between surgical procedures and outcome and obesity.
Conclusions: Infiltration of nephrostomy tract site with levobupivacaine does not have an effect on postoperative pain control in patients undergoing PNL. However, levobupivacaine infiltrated patients demand analgesics in a later period.
819
Comparing extracorporeal shock wave lithotripsy (SWL) with percutaneous nephrolithotomy (PCNL) for lower pole stones larger than 10 mm: Hong Kong experience Ma W.K., Yu C., Lam K.M., Chu S.K., Man C.W. Tuen Mun Hospital, Dept. of Surgery, Hong Kong, Hong Kong Introduction & Objectives: To compare the efficacy of SWL and PCNL in treating lower pole renal stones larger than 10 mm in a local public hospital. Material & Methods: Retrospective analysis was conducted for a total of 59 patients receiving SWL (43 patients) or PCNL (16 patients) for symptomatic lower pole stones larger than 10 mm, from June 2006 – June 2008. SWL was performed with Dornier electromagnetic Lithotripter S while PCNL was performed by urologists or urology trainees under specialist supervision. Exclusion criteria include patients with concomitant stone(s) in other poles, stones in calyceal diverticula, anatomical anomaly (such as horseshoe kidney/ duplex system) or previous stone treatment. There is no significant difference in age and sex between the two groups (p = 0.932). Mean stone size was 14.84 mm and 20.75 mm for SWL and PCNL groups respectively (p<0.001). Successful outcome was defined as radiographically stone-free without symptoms at 3 months after treatment. Retreatment was evaluated and was defined as need for repeating same treatment modality within 3 months, while auxiliary procedure was the requirement of another treatment modality. Hospital stay and complications arising from the procedure were evaluated. Results: The overall stone-free rates after SWL and PCNL at 3 months were 48.6% and 87.5% respectively. Effectiveness Quotients (EQs) were 0.33 and 0.70 respectively. By logistic regression, it was the type of treatment (SWL vs. PCNL) (p = 0.018) but not sex, age nor stone size that correlates with the stone-free rate. Hence, PCNL was more effective in clearing lower pole stones >10 mm, even though the stone size was significantly larger than SWL group. However, the mean hospital stay for PCNL was 6.13 days, which was significantly longer than that for SWL (mean 1.21 days, p < 0.001). Overall complication rates were 31.2% (infection, clot retention and anemia) for PCNL and 14.0% (pain, bradycardia, steinstrasse and perinephric hematoma) for SWL. Treatment type does not contribute to complication rate (p = 0.146). For hospital stay, treatment type (p < 0.001), Gender (p = 0.03) & Age (p = 0.03) are all significant factors. One patient required blood transfusion for significant hemoglobin level drop after PCNL. Conclusions: PCNL is more effective in clearing lower pole stones larger than 10 mm, as shown in our study. Although hospital stay was significantly longer, high rate of successful outcome would translate to early discharge of patients from further clinic follow-ups and lower economic costs in the long run. Our study results concur with current literature and provide local data for recommendation of treatment modality to patients with lower pole renal calculi.
820
Percutaneous nephrolithotomy in kidneys with rotation and fusion anomalies: Computed tomography versus intravenous urography planned accesses Hamdy S.M.N., Abdeldaeim H.M., Sakr M., Marzouk M.E., Eid I. University of Alexandria, Dept. of Urology, Alexandria, Egypt Introduction & Objectives: PCNL has become the standard of care in the treatment of many stone diseases. Anomalous kidneys, however, continued to challenge even expert endourologists. The abnormal position and orientation of the collecting system dictate technical modifications that have been subjected to the personal experience of each surgeon. The present study was designed to compare the multiphase CT-planned vs. IVU-planned accesses in kidneys with rotation and fusion anomalies. Material & Methods: This prospective randomized study included 58 consecutive patients (60 renal units) with stones in kidneys with rotation and fusion anomalies. All patients were treated by PCNL in prone position. Patients were randomly divided into 2 groups. In group A (30 patients and 30 units); 10 of these were horseshoe kidneys: the PCNL access was planned pre-operatively based on IVU. In group B (28 patients with 30 renal units); 18 of these were horseshoe kidneys: the PCNL access was planned pre-operatively based on multiphasic CT scan. The CT was done while the patient in prone position and in full inspiration. The CT provided detailed information about the topography of the collecting system, orientation of the calyces in relation to the horizontal plane and their relations to each other. In addition, the renal vascular supply and the proximity to nearby organs were clearly delineated. The target calyx, the site of skin entry and the angle of the puncture needle were all defined based on this information. Results: The patients’ demographic data and the overall stone burden were comparable in the 2 groups. There were a total of 80 access tracts in 60 units. Seven of these 80 tracts were not planned preoperatively and all were in the IVU group. Furthermore, 8 tracts were difficult to establish and all were in the IVU group (p = 0.005). The intra-operative measures matched the CT measures except in 5 where the depth was underestimated. PCNL accesses planned on CT scan were significantly easier to establish and more suitable for stone retrieval. The mean operative times and the need for blood transfusion were comparable in both groups. However, the post-operative drop in hemoglobin was significantly less in group B than in group A (p = 0.004). CT-planned accesses group had a better stone free rate at discharge and less need for auxiliary procedures. At discharge, complete stone removal was achieved in 83.33% (76.66% in group A, and 90% in group B); this difference was of statistical significance. Fewer patients in group B required auxiliary procedures than in group A, but this difference was not statistically significant (p = 0.35). Conclusions: CT assisted access planning for PCNL is an objective, reproducible and beneficial technique in kidneys with fusion and rotation anomalies.
Eur Urol Suppl 2009;8(4):325
817
818
The effect of local anesthetic infiltration around nephrosomy tract on postoperative pain control after percutaneous nephrolithotomy
Influence of obesity (BMI >28) on intra- und perioperative complications of percutaneous nephrolithotomy (PCNL)
Tüzel E., Kiziltepe G., Akdogan B.
Propping S., Oehlschläger S., Fröhner M., Leike S., Grimm M.O., Wirth M.
Afyon Kocatepe University, Dept. of Urology, Afyon, Turkey
University Hospital Carl Gustav Carus, Technical University, Dept. of Urology, Dresden, Germany
Introduction & Objectives: Most of the pain after percunateous nephrolithotomy (PNL) is experienced due to dilatation of the renal capsule and parenchymal tract. Previous investigations have focused on the impact of nephrostomy catheter size on postoperative pain and the effect of local anesthetic infiltration to the surgical field has not been well established for PNL. The aim of this study is to investigate the effect of a long acting local anesthetic infiltration around nephrostomy tract on pain control after PNL.
Introduction & Objectives: PCNL is the standard procedure to treat renal calculi > 20 mm. Obese patients are considered to a higher risk of comorbidity (ischaemic heart disease, hypertension) and postoperative complications (thromboembolism, pneumonia). In addition, the operative bedding and surgical procedure are affected by adiposity. We reviewed our contemporary experience to determine the safety and outcome of PCNL in such obese patients.
Material & Methods: Forty-six adult patients with kidney stones of > 2 cm undergoing single access subcostal PNL were enrolled in the study. Patients were randomized in a single blinded fashion to levobupivacaine (group I) and saline (Group II) infiltration groups. Group I patients (n=23) had 25mg/10cc levobupivacaine infiltration with a 21G needle into the subcutaneous tissues around the access site after placement of 20F re-entry Malecot catheter. Levobupivacaine injected along the nephrostomy tube in order to let the drug to diffuse partly outside the renal capsular surface. Group II patients had 10cc saline infiltrated with the same technique. Postoperatively the patients were given narcotics on demand. Pain scores were collected using a 10cm self assessed visual analog scale (VAS) with 0 being no pain and 10 being the worst pain experienced by the patient at 2, 4, 6, 8, 12 and 24 hours postoperatively. The VAS scores, time to analgesic demand, ambulation and duration of nephrostomy tube were compared between two groups. Results: The mean age was 44 and 45 years and the mean body mass index was 26 and 25 for Group I and II patients. The mean stone burden, operation time and irrigation fluid amounts for Group 1 and Group 2 patients were 508 and 473 mm2; 103 and 99 minutes; and 12.5 and 11,8 lt, respectively (p=0.54, p=0.74 and p=0.71, respectively). Success and complication rates were similar for the both groups. Comparison of pain scores at all postoperative time points was not statistically significant between the two groups. Time to first analgesic demand and total narcotic analgesic dose per patient were 1.2±1.05 and 4.04±1.57 hours; and 96 mg and 112 mg for group I and II patients (p=0.009 and p=0.41, respectively). Ambulation time and duration of nephrostomy tube were also similar.
Material & Methods: The computerised data of 376 patients (female n=176; male n=200 treated from 01/2000 to 01/2008) were analysed. A total of 468 PCNL procedures were performed by 11 urologists. The intra-, peri- and postoperative complications in two groups of patients were evaluated (group A: BMI > 28 vs. Group B: BMI ≤ 28). The average age was 56,7 ± 15,1 years, the mean ASA-score 2,1 ± 0,6. Stone analysis: 57,7% calcium oxalate, 12,2% dahllite, 9,8% uric acid, 8,5% struvite, 3,2% brushite und 2,4% cystine. Results:
operation time (min) stone size (mm) primary stone free rate (%) intra-operative complications (perforation, bleeding) peri-operative complications (bleeding, pyelonephritis)
group A n=152 (BMI >28) 58 ± 31 20,2 ± 11,5 82,9% 9,9%
group B n=205 (BMI ≤ 28) 60 ± 32 20,4 ± 11,5 78,5% 9,8%
significance n.s. n.s. n.s. n.s.
11,7%
12,6%
n.s.
Conclusions: The outcome of PCNL is independent of patients’ BMI. PCNL in obese patients yields a stone free rate comparable to non-obese patients. Complication rate and length of operation are similar. Thus, we did not find a relationship between surgical procedures and outcome and obesity.
Conclusions: Infiltration of nephrostomy tract site with levobupivacaine does not have an effect on postoperative pain control in patients undergoing PNL. However, levobupivacaine infiltrated patients demand analgesics in a later period.
819
Comparing extracorporeal shock wave lithotripsy (SWL) with percutaneous nephrolithotomy (PCNL) for lower pole stones larger than 10 mm: Hong Kong experience Ma W.K., Yu C., Lam K.M., Chu S.K., Man C.W. Tuen Mun Hospital, Dept. of Surgery, Hong Kong, Hong Kong Introduction & Objectives: To compare the efficacy of SWL and PCNL in treating lower pole renal stones larger than 10 mm in a local public hospital. Material & Methods: Retrospective analysis was conducted for a total of 59 patients receiving SWL (43 patients) or PCNL (16 patients) for symptomatic lower pole stones larger than 10 mm, from June 2006 – June 2008. SWL was performed with Dornier electromagnetic Lithotripter S while PCNL was performed by urologists or urology trainees under specialist supervision. Exclusion criteria include patients with concomitant stone(s) in other poles, stones in calyceal diverticula, anatomical anomaly (such as horseshoe kidney/ duplex system) or previous stone treatment. There is no significant difference in age and sex between the two groups (p = 0.932). Mean stone size was 14.84 mm and 20.75 mm for SWL and PCNL groups respectively (p<0.001). Successful outcome was defined as radiographically stone-free without symptoms at 3 months after treatment. Retreatment was evaluated and was defined as need for repeating same treatment modality within 3 months, while auxiliary procedure was the requirement of another treatment modality. Hospital stay and complications arising from the procedure were evaluated. Results: The overall stone-free rates after SWL and PCNL at 3 months were 48.6% and 87.5% respectively. Effectiveness Quotients (EQs) were 0.33 and 0.70 respectively. By logistic regression, it was the type of treatment (SWL vs. PCNL) (p = 0.018) but not sex, age nor stone size that correlates with the stone-free rate. Hence, PCNL was more effective in clearing lower pole stones >10 mm, even though the stone size was significantly larger than SWL group. However, the mean hospital stay for PCNL was 6.13 days, which was significantly longer than that for SWL (mean 1.21 days, p < 0.001). Overall complication rates were 31.2% (infection, clot retention and anemia) for PCNL and 14.0% (pain, bradycardia, steinstrasse and perinephric hematoma) for SWL. Treatment type does not contribute to complication rate (p = 0.146). For hospital stay, treatment type (p < 0.001), Gender (p = 0.03) & Age (p = 0.03) are all significant factors. One patient required blood transfusion for significant hemoglobin level drop after PCNL. Conclusions: PCNL is more effective in clearing lower pole stones larger than 10 mm, as shown in our study. Although hospital stay was significantly longer, high rate of successful outcome would translate to early discharge of patients from further clinic follow-ups and lower economic costs in the long run. Our study results concur with current literature and provide local data for recommendation of treatment modality to patients with lower pole renal calculi.
820
Percutaneous nephrolithotomy in kidneys with rotation and fusion anomalies: Computed tomography versus intravenous urography planned accesses Hamdy S.M.N., Abdeldaeim H.M., Sakr M., Marzouk M.E., Eid I. University of Alexandria, Dept. of Urology, Alexandria, Egypt Introduction & Objectives: PCNL has become the standard of care in the treatment of many stone diseases. Anomalous kidneys, however, continued to challenge even expert endourologists. The abnormal position and orientation of the collecting system dictate technical modifications that have been subjected to the personal experience of each surgeon. The present study was designed to compare the multiphase CT-planned vs. IVU-planned accesses in kidneys with rotation and fusion anomalies. Material & Methods: This prospective randomized study included 58 consecutive patients (60 renal units) with stones in kidneys with rotation and fusion anomalies. All patients were treated by PCNL in prone position. Patients were randomly divided into 2 groups. In group A (30 patients and 30 units); 10 of these were horseshoe kidneys: the PCNL access was planned pre-operatively based on IVU. In group B (28 patients with 30 renal units); 18 of these were horseshoe kidneys: the PCNL access was planned pre-operatively based on multiphasic CT scan. The CT was done while the patient in prone position and in full inspiration. The CT provided detailed information about the topography of the collecting system, orientation of the calyces in relation to the horizontal plane and their relations to each other. In addition, the renal vascular supply and the proximity to nearby organs were clearly delineated. The target calyx, the site of skin entry and the angle of the puncture needle were all defined based on this information. Results: The patients’ demographic data and the overall stone burden were comparable in the 2 groups. There were a total of 80 access tracts in 60 units. Seven of these 80 tracts were not planned preoperatively and all were in the IVU group. Furthermore, 8 tracts were difficult to establish and all were in the IVU group (p = 0.005). The intra-operative measures matched the CT measures except in 5 where the depth was underestimated. PCNL accesses planned on CT scan were significantly easier to establish and more suitable for stone retrieval. The mean operative times and the need for blood transfusion were comparable in both groups. However, the post-operative drop in hemoglobin was significantly less in group B than in group A (p = 0.004). CT-planned accesses group had a better stone free rate at discharge and less need for auxiliary procedures. At discharge, complete stone removal was achieved in 83.33% (76.66% in group A, and 90% in group B); this difference was of statistical significance. Fewer patients in group B required auxiliary procedures than in group A, but this difference was not statistically significant (p = 0.35). Conclusions: CT assisted access planning for PCNL is an objective, reproducible and beneficial technique in kidneys with fusion and rotation anomalies.
Eur Urol Suppl 2009;8(4):325