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MP30-20 MAJOR POSTOPERATIVE COMPLICATIONS AFTER PERCUTANEOUS NEPHROLITHOTOMY (PCNL) IN A SINGLE TERTIARY REFERRAL CENTRE
THE JOURNAL OF UROLOGYâ
e354
to review the post-operative infectious complications in a series of patients for whom our practice was compliant with AUA guidelines. METHODS: A retrospective review was performed of consecutive percutaneous nephrolithotomy procedures performed. Patients in Group 1 underwent PCNL with antibiotics given in accordance with AUA Guidelines - < 24 hours of antibiotics. Patients in Group 2 were given antibiotics for 5-7 days after surgery (mean 5.9 days). Complication rates were compared between the 2 groups. All patients were seen within 14 days of discharge. Exclusion criteria were history of struvite stone or recent history of pyelonephritis or cystitis. RESULTS: Group 1 was comprised of 52 patients compared with Group 2 which was comprised of 33 patients. Patient characteristics, operative characteristics and stone composition were similar between the 2 groups (stone size ¼ > 2.0 cm in 79% versus 80% respectively, mean OR time was 107 versus 125 minutes respectively, p¼ NS). In Group 1, 5 patients (9.6%) developed fever on POD 1 during inpatient inadmission, but all urine, serum, and stone cultures were negative. No patients in group 1 demonstrated bacteruria during hospital course or prior to follow up visit. In Group 2, 4 patients (13.3%) developed fever during inpatient admission and one of those patients had a urine culture which demonstrated bacteruria. No patients had positive blood cultures or infectious complications occurring after discharge. CONCLUSIONS: In this pilot series, compliance with AUA guidelines and use of < 24 hours of perioperative antibiotics for PCNL in patienst without a history of infection did not appear to be associated with increased infection rates. Prospective studies would be useful to confirm these findings. Source of Funding: none
MP30-19 IMPACT OF THE GUY’S STONE SCORE ON SUCESS RATES FOR PERCUTANEOUS NEPHROLITHOTOMY Fabio C. Vicentini*, Carlos Watanabe-Silva, Thiago A. C. Ferreira, ~o Paulo, Brazil Claudio B. Murta, Joaquim F. A. Claro, Sa INTRODUCTION AND OBJECTIVES: Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for large kidney stones. The aim of the study was to evaluate which variables impact the success rates of PCNL. METHODS: We performed a prospective study of consecutive patients that underwent to PCNL between July 2011 and July 2014. The variables analyzed were gender, age, body mass index (BMI), ASA score, stone diameter, Guy’s Stone Score (GSS), number of punctures, calyx puncture site, supracostal access and patient positioning. Complications were graded according to the modified Clavien Classification. Success was considered as fragments 4 mm on the first post-operative day (POD1) on CT scan. The tests used in the univariate analyzes were chi-square and Fisher Exact test for categorical measures and Student’s t-test for independent samples continuous parameters. For the multivariate analysis, we performed logistic regression. We used a 0.05 significance level. RESULTS: A total of 468 patients were included in the study and 517 PCNL were performed. The mean age was 48.312.8 years, mean BMI of 27.35.0 and 57.8% were female. According to the ASA score, 35.1% were ASA 1, 59.5% were ASA 2 and 5.4% were ASA 3. Regarding patient position, 18% were in prone position, 66.9% in complete supine position, 4.1% in classic Valdivia and 11% in Galdakao position. Most punctures were on lower and middle calyx (65.8% and 24.8%). 9.3% of the punctures were supracostal. Mean surgical time was 114.652.78 min. The overall success rate was 55.1%. According to the GSS, the success rate for GSS I was 85.1%, GSS II was 59.4%, GSS III was 40.7% and for GSS IV was 23.3% (p <0.0001). On univariate analysis, the significant variables related to success were supine position (p¼0.031), GSS (p<0.0001) and stone diameter (p<0.0001). After the multivariate analysis, it was found that only Guy’s
Vol. 193, No. 4S, Supplement, Saturday, May 16, 2015
Stone Score was statistically significant for success. Odds ratio between GSS groups: OR12 3.55 (CI95% 1.95-6.69), OR23 1.91 (CI95% 1.19-3.08), OR34 1.92 (CI95%0.97-3.89). CONCLUSIONS: The Guy’s Stone Score was the only predictive factor of success for PCNL. This instrument is easy to use and should be incorporated on stone evaluation and patient counseling. Source of Funding: none
MP30-20 MAJOR POSTOPERATIVE COMPLICATIONS AFTER PERCUTANEOUS NEPHROLITHOTOMY (PCNL) IN A SINGLE TERTIARY REFERRAL CENTRE Daniel Olvera-Posada*, Thomas Tailly, Philippe Violette, Husain Alenezi, John Denstedt, Hassan Razvi, London, Canada INTRODUCTION AND OBJECTIVES: PCNL is considered the gold standard of treatment for large kidney stones. Stone-free rates and complications are the most important outcomes. Recently, a modification of the Clavien classification was defined for PCNL. The objective of this study is to describe and evaluate the major complications (Clavien 3a) related to PCNL and to identify risk factors of morbidity according to this scale. METHODS: A prospective cohort analysis was performed using data from patients who underwent PCNL from 1990 to December 2013. Patients with incomplete perioperative information were excluded. Descriptive statistics were used to analyze patients’ characteristics, medical comorbidities and perioperative features. Complications were categorized according the Clavien Score for PCNL. Mann-Whitney and c2 tests were used as appropriate. Logistic regression analysis was performed to look for prognostic factors associated to major complications. RESULTS: A total of 2380 PCNL surgeries were performed with 2318 included in the final analysis. Mean age of the population was 53.7 years. Staghorn stone was noted in 14.8% of the cases. Multiple tracts and upper pole access were used in 8.1% and 13.2% of the cases respectively. Stone-free rate at hospital discharge was 81.6%. Overall complication rate was 18.29%. Table 1 shows complications by Clavien score. Two deaths occurred during our study period. Patients with major complications were older (mean age 58.5 vs 53.6, p¼0.02) and had a prolonged hospital stay (6.5 vs 3.6 days, p¼0.0001). After univariate logistic regression, age (OR 1.02, p¼0.021), number of comorbidities (OR 1.35, p¼0.021) and upper pole access (OR 2.07, p¼0.03) were significantly associated with major complications. Age (OR 1.02, p¼0.019) and upper pole access (OR 2.15, p¼0.023) remain as independent predictors for major Clavien complications after multivariate regression analysis. Other factors such as history of urinary tract infections, body mass index, previous PCNL performed at our centre and use of multiple tracts were not associated with a major complication. CONCLUSIONS: At our centre, PCNL is an excellent option for complex kidney stone management with a low overall complication rate. Older age and upper pole access are associated with an increased risk of a major complication. Complications according Clavien score Clavien Score
Number
Percentage
1
321
13.8%
2
52
2.2%
3A
32
1.4%
3B
15
0.6%
4A
2
0.1%
4B
0
0
5
2
0.1%
424
18.2%
Total
Source of Funding: None
e354
to review the post-operative infectious complications in a series of patients for whom our practice was compliant with AUA guidelines. METHODS: A retrospective review was performed of consecutive percutaneous nephrolithotomy procedures performed. Patients in Group 1 underwent PCNL with antibiotics given in accordance with AUA Guidelines - < 24 hours of antibiotics. Patients in Group 2 were given antibiotics for 5-7 days after surgery (mean 5.9 days). Complication rates were compared between the 2 groups. All patients were seen within 14 days of discharge. Exclusion criteria were history of struvite stone or recent history of pyelonephritis or cystitis. RESULTS: Group 1 was comprised of 52 patients compared with Group 2 which was comprised of 33 patients. Patient characteristics, operative characteristics and stone composition were similar between the 2 groups (stone size ¼ > 2.0 cm in 79% versus 80% respectively, mean OR time was 107 versus 125 minutes respectively, p¼ NS). In Group 1, 5 patients (9.6%) developed fever on POD 1 during inpatient inadmission, but all urine, serum, and stone cultures were negative. No patients in group 1 demonstrated bacteruria during hospital course or prior to follow up visit. In Group 2, 4 patients (13.3%) developed fever during inpatient admission and one of those patients had a urine culture which demonstrated bacteruria. No patients had positive blood cultures or infectious complications occurring after discharge. CONCLUSIONS: In this pilot series, compliance with AUA guidelines and use of < 24 hours of perioperative antibiotics for PCNL in patienst without a history of infection did not appear to be associated with increased infection rates. Prospective studies would be useful to confirm these findings. Source of Funding: none
MP30-19 IMPACT OF THE GUY’S STONE SCORE ON SUCESS RATES FOR PERCUTANEOUS NEPHROLITHOTOMY Fabio C. Vicentini*, Carlos Watanabe-Silva, Thiago A. C. Ferreira, ~o Paulo, Brazil Claudio B. Murta, Joaquim F. A. Claro, Sa INTRODUCTION AND OBJECTIVES: Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for large kidney stones. The aim of the study was to evaluate which variables impact the success rates of PCNL. METHODS: We performed a prospective study of consecutive patients that underwent to PCNL between July 2011 and July 2014. The variables analyzed were gender, age, body mass index (BMI), ASA score, stone diameter, Guy’s Stone Score (GSS), number of punctures, calyx puncture site, supracostal access and patient positioning. Complications were graded according to the modified Clavien Classification. Success was considered as fragments 4 mm on the first post-operative day (POD1) on CT scan. The tests used in the univariate analyzes were chi-square and Fisher Exact test for categorical measures and Student’s t-test for independent samples continuous parameters. For the multivariate analysis, we performed logistic regression. We used a 0.05 significance level. RESULTS: A total of 468 patients were included in the study and 517 PCNL were performed. The mean age was 48.312.8 years, mean BMI of 27.35.0 and 57.8% were female. According to the ASA score, 35.1% were ASA 1, 59.5% were ASA 2 and 5.4% were ASA 3. Regarding patient position, 18% were in prone position, 66.9% in complete supine position, 4.1% in classic Valdivia and 11% in Galdakao position. Most punctures were on lower and middle calyx (65.8% and 24.8%). 9.3% of the punctures were supracostal. Mean surgical time was 114.652.78 min. The overall success rate was 55.1%. According to the GSS, the success rate for GSS I was 85.1%, GSS II was 59.4%, GSS III was 40.7% and for GSS IV was 23.3% (p <0.0001). On univariate analysis, the significant variables related to success were supine position (p¼0.031), GSS (p<0.0001) and stone diameter (p<0.0001). After the multivariate analysis, it was found that only Guy’s
Vol. 193, No. 4S, Supplement, Saturday, May 16, 2015
Stone Score was statistically significant for success. Odds ratio between GSS groups: OR12 3.55 (CI95% 1.95-6.69), OR23 1.91 (CI95% 1.19-3.08), OR34 1.92 (CI95%0.97-3.89). CONCLUSIONS: The Guy’s Stone Score was the only predictive factor of success for PCNL. This instrument is easy to use and should be incorporated on stone evaluation and patient counseling. Source of Funding: none
MP30-20 MAJOR POSTOPERATIVE COMPLICATIONS AFTER PERCUTANEOUS NEPHROLITHOTOMY (PCNL) IN A SINGLE TERTIARY REFERRAL CENTRE Daniel Olvera-Posada*, Thomas Tailly, Philippe Violette, Husain Alenezi, John Denstedt, Hassan Razvi, London, Canada INTRODUCTION AND OBJECTIVES: PCNL is considered the gold standard of treatment for large kidney stones. Stone-free rates and complications are the most important outcomes. Recently, a modification of the Clavien classification was defined for PCNL. The objective of this study is to describe and evaluate the major complications (Clavien 3a) related to PCNL and to identify risk factors of morbidity according to this scale. METHODS: A prospective cohort analysis was performed using data from patients who underwent PCNL from 1990 to December 2013. Patients with incomplete perioperative information were excluded. Descriptive statistics were used to analyze patients’ characteristics, medical comorbidities and perioperative features. Complications were categorized according the Clavien Score for PCNL. Mann-Whitney and c2 tests were used as appropriate. Logistic regression analysis was performed to look for prognostic factors associated to major complications. RESULTS: A total of 2380 PCNL surgeries were performed with 2318 included in the final analysis. Mean age of the population was 53.7 years. Staghorn stone was noted in 14.8% of the cases. Multiple tracts and upper pole access were used in 8.1% and 13.2% of the cases respectively. Stone-free rate at hospital discharge was 81.6%. Overall complication rate was 18.29%. Table 1 shows complications by Clavien score. Two deaths occurred during our study period. Patients with major complications were older (mean age 58.5 vs 53.6, p¼0.02) and had a prolonged hospital stay (6.5 vs 3.6 days, p¼0.0001). After univariate logistic regression, age (OR 1.02, p¼0.021), number of comorbidities (OR 1.35, p¼0.021) and upper pole access (OR 2.07, p¼0.03) were significantly associated with major complications. Age (OR 1.02, p¼0.019) and upper pole access (OR 2.15, p¼0.023) remain as independent predictors for major Clavien complications after multivariate regression analysis. Other factors such as history of urinary tract infections, body mass index, previous PCNL performed at our centre and use of multiple tracts were not associated with a major complication. CONCLUSIONS: At our centre, PCNL is an excellent option for complex kidney stone management with a low overall complication rate. Older age and upper pole access are associated with an increased risk of a major complication. Complications according Clavien score Clavien Score
Number
Percentage
1
321
13.8%
2
52
2.2%
3A
32
1.4%
3B
15
0.6%
4A
2
0.1%
4B
0
0
5
2
0.1%
424
18.2%
Total
Source of Funding: None