Is TUBELESS PERCUTANEOUS NEPHROLITHOTOMY (PCNL) is really

worthwhile?

Original Article;

Authors

1) Dr Muhammad Muzammil Tahir

Assistant Professor Urology
Federal Post Graduate Medical Institute
Lahore

2) Dr Ghazi Khan
Senior Registrar Urology Department
Shaikh Zayed Hospital Lahore

3) Dr Muhammad Usman Khan

Professor of Urology
Federal Post Graduate Medical Institute
Lahore Pakistan

4) Dr Jamshed Rahim
Asisstant Professor Urology
Federal Post graduate medical Institute
Lahore

Correspondence to;
Dr Muhammad Muzammil Tahir
Assistant Professor Urology
Federal Post Graduate Medical Institute
Lahore
Tel; 03214979631
E mail; dr_muzamil@yahoo.com
 Is tubeless percutaneous nephrolithotomy (PCNL) is really

worthwhile?

Abstract

Aims and objectives; To compare standard and tubeless PCNL in our patients

in term of need for analgesia, urinary leakage from nephrostomy site, hospital

stay and urinoma formation.

Material and methods; This is prospective study carried out in urology

department Shaikh zayed hospital Lahore. Sixty patients from both sexes,

underwent standard PCNL, and compare with similar number of the patients

whom we performed tubeless PCNL from Aug 2007 to march 2008. Patients

with multiple puncture site, residual stones, and bleeding were excluded from this

study.

Results; We compare both groups. The need for analgesia, inj pethadine

sulphate for group I, patients was 400mg while for group II patients, it was just

100 mg. Leakage from the nephrostomy site occurred in 08 patients while in

group II, there was no leakage. 03 patients suffer from urinoma formation in

group I, while in group II only 01 patient develops urinoma. As for as the

hospitalization is concerned, patients in group I had an average of 5.5 days

hospital stay, while it is 03 days for group II patients.

Conclusion; Tubeless PCNL is a safe, effective, with very little morbidity. It is

very well accepted by the patients. It is excellent procedure in experience hands.

2
Original Article

Is tubeless percutaneous nephrolithotomy (PCNL) is really worthwhile ??

To get rid of stone from the kidneys is really a gigantic task, both for treating

physician and the patient. It involves a lot of effort on both sides, and really it is

confusing for the patient to follow the modalities for stone treatment. Because

there is advantage of one procedure over the other and there is definitely edge

on following one modality over the other.

Apart from the decade old procedures like pyelolithotomy, nephrolithotomy, new

modalities, like percutaneous nephrolithotomy (PCNL), extracorporeal

shockwave lithotripsy (ESWL) are on strong footing in getting rid of stone burden

from the kidney.

For large stones percutaneous nephrolithotomy (PCNL), is emerging as the

treatment of choice, when considering morbidity and hospital stay of the patients.

As standard PCNL, tubeless PCNL, total tubeless and PCNL in supine position

are different modalities of PCNL, one having edge over the other.

Objective

To compare standard and tubeless PCNL in our patients in term of need for

analgesia, urinary leakage from nephrostomy site, hospital stay and urinoma

formation.

3
Material and methods

60 consecutive cases performed from August 2007 to 30th march 2008, who

underwent tubeless PCNL and assigned them Group II. The stone burden,

number, location of the stone, or renal function was not considered. A similar

number of patients who were assigned Group I, underwent , standard PCNL.

Inclusion criteria in our study were, complete clearance of stone, up to 02

puncture sites. Exclusion criteria was, more than 02 tract, residual stones, and

significant bleeding

In standard PCNL, we undergone

Preoperative preparation includes, complete blood examination, urine complete

examination, serum cretanin, urine for culture sensitivity , PT, APTT was

performed. All patients underwent IVU and ultrasonography, those who had

abnormal renal function, underwent isotope renal scan. Patients who had

deranged liver function, with disturbed PT and APTT were excluded from this

procedure. PCNL was performed under general anesthesia, preoperative

antibiotic Cefotaxime sodium 1 gm was administered. An open ended 6Fr uretral

catheter was passed on guide wire and secured to a foley’s catheter. Uretral

catheter allows the injection of contrast material or air to opacify and distends the

collecting system, further more the catheter will prevent fragment from falling into

the ureter.

4
Once the catheter is inserted the patient is placed in a prone position, the

percutaneous puncture placed in post axillary’s line into appropriate calyx, under

fluoroscopic guidance. Once the puncture needle reaches the calyx, the stylet is

removed and a 0.035 inch floppy J tipped guide wire inserted into needle, then

needle removed and 1 cm incision made at wire site. Sequential dilatation up to

28 Fr, with metal dilators was done, followed by placement of the amplatz

sheath . through which 26fr, rigid nephroscope (karl storz™ ) was passed.

Either the stone extracted straightway or following disintegration by pneumatic

lithoclast (karl storz™). To reduce the number of residual fragments continuous

removal of small fragments by suction or extraction is performed. Large stone

fragments were removed by grasping forcep. At the end of the procedure, a 20Fr

nephrostomy tube was left in situ in group I, ( patients who underwent standard

PCNL). We use, Foley catheter 22Fr with balloon channel arm amputated. But in

group II, whom underwent tubeless PCNL, the nephrostomy tube was not placed,

instead the wound was closed with silk 2/0. after sure on fluoroscope, that there

was no residual stone.

The ureteric catheter was removed with in 24 hour, while PCN tube was kept for

48 hours in group I, in group II, the ureteric catheter was left for 48 hour.

Patients were followed in out door clinic regularly every 03 month, with plain X

ray KUB, ultrasound, and urine C/E., till the patient was declared either stone

free, or with insignificant residual fragments.

Results

5
a comparison was made regarding need for analgesia, leakage from the

nephrostomy site and urinoma formation.

the need for analgesia, inj pethadine for group I, in these patients was, 400mg

while for group II patients, it was just 100 mg. Leakage from the nephrostomy

site occurred in 08 patients while in group II, there was no leakage. 03 patients

suffer from urinoma formation in group I, while in group II only 01 patient

develops urinoma. As for as the hospitalization is concerned, patients in group I

had an average of 5.5 days hospital stay, while it is 3 days for group II patients.

Patient Morbidity Standard PCNL (n-60) Tubeless PCNL (n-60)

Need for analgesia 400mg of inj Pethadine 100mg inj Pethadine

Hospitalization 5.5 days, Post Op 03 days Post Op

Leakage from the 08 Pt (4.8%) Nil

nephrostomy site
Urinoma 03 Pt (5%) 01 Pt (1.66%)

Discussion.

In a standard percutaneous nephrolithotomy, the ureteric stent, or double J,

stent, are left in along with nephrostomy tube at the end of procedure. In tubeless

PCNL, only the ureteric stent was left in place, while nephrostomy tube was

omitted. Nephrostomy tube is kept to keep the system open, and let it drain for

48 hour in standard PCNL, while ureteric stent is kept for only 24 hour in most of

6
the cases. We kept the ureteric stent for 48 hour in tubeless PCNL, and

compare there results. Our results were very encouraging, in tubeless PCNL.

Average hospital stay In our study was 03 days. In a larger study the hospital
3,4,9
stay were 2.5 to 3.63 days . In those institutions, where they are using JJ
5,4,8
stent, it is reduced to 24-26 hours . In our patients the time is a few hours

more than other studies, the reason is that we keep the ureteric stent for 48h, we

remove the stent before discharging the patient, as our patients are from far flung

areas, so they opted to stay for a day in hospital after removal of all the stents.

Other alike studies keep the JJ stent, for a few weeks, a similar study by Agrawal

et al4, compared standard and tubeless PCNL, used the JJ stent instead of

ureteric catheter there results show hospital stay for standard PCNL 54.2 +/-

5hours, while for tubeless PCNL it is 21.8 +/- 3.9 hours. Rana et al 10, kept the

ureteric stent for 16-20hour, and discharged the patient immediately after

removing the stent, they have average hospital stay of 16-20 hour, which Is much

less than our study.

There is marked difference for the analgesia requirement between both groups,

in our study, there is 400 mg of inj Pethadine sulphate was required for the

group I while for group II it was 100 mg, which is similar to many studies in

which analgesic requirement between both groups vary in the ratio of 2:1, to

3.5:12,6. There is wide variation in analgesic requirement between both groups in

different studies, it is due to the length of stay of nephrostomy tube, size, and

type of nephrostomy tube.

7
Leakage from the nephrostomy site in group I patient in our study was 4.8%,

while for group II it was nil, which is similar to other studies4,5. The urinoma

formation in our study in group I was 5%, while for group II it was 1.66%, which is

significantly less. Other studies, also give similar results3,7.

Conclusion

Tubeless PCNL is an effective and safe procedure, with much less morbidity,3, 4,
5,7
. It is safe and effective even in patients with a solitary kidney, in patients where

multiple tract are made and in with supracostal access,5. We recommend this

modality, following sufficient experience with standard PCNL procedure.

References

1. Candela J, Davidoff R, Gerspach J, Bellman GC; “Tubeless”

Percutaneous surgery: a new advance in the technique 0f percutaneous

renal surgery;tech Urol 1997 Spring: 3(1):6-11.

2. Bellman GC, Davidoff R, Candela J, Kurtz S, Stout L; Tubeless

percutaneous renal surgery; J Urol 1997 May; 157(5): 1578-82.

3. Karami H, Jabbari M, Arbab AH: Tubeless Percutaneous nephrolithotomy:

5 year experience in 201 patients; J Endourol 2007 Dec; 21(12): 1411-3.

8
4. Agrawal MS, Agrawal M, gupta A, Bansal S, Yadav A, Goyal J; A

randomized comparison of tubeless and standard percutaneous

nephrolithotomy: J endourol, 2008 Mar;22(3): 439-42.

5. Shah HN, Kausik VB, Hegde SS, Shah JN, Bansal MB; Tubeless

percutaneous nephrolithotomy: a prospective feasibility study and review

of previous reports; BJU int, 2005 Oct; 96(6):879-83.

6. Mandhani A, Goya R, Vijjan V, Dubey D, Kapoor R; Tubeless

Percutaneous nephrolithotomy-should a stent be an integral part?: J urol.

2007 sep; 178(3pt 1):921-4. Epub 2007 Jul 16.

7. Mouracade P, Spie R, Lang H, Jacqmin D, Saussine C; Tubeless

percutaneous nephrolithotomy: a series of 37 cases. Prog Urol, 2007

Nov;17(7):1351-4.

8. Limb J, Bellman GC: Tubeless Percutaneous renal surgery: review of first

112 patients; Urology 2002 April;59(4);527-31;discussion 531.

9. Lejanapiwat B, Soonthornphan S, Wudhikarn S; Tubeless percutaneous

nephrolithotomy in selected patients; J Endourol 2001 Sep;15(7):711-3.

10. Rana AM, Mithani S; Tubeless Percutaneous nephrolithotomy: call of the

day; J eEndourol; 2007 feb;21(2): 169-72.

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riginal Paper

Treatment modalities and outcome for Ureterovaginal fistula

inflicted in obstetrical and gynaecological practice

List of the contributors

• Dr Ghazi Khan FCP

Registrar Urology dept

Shaikh Zayed Hospital Lahore

• Dr Farah Yousaf

ex Associate Prof Gynae Obstetrics

Post graduate Medical Institute Lahore

• Dr Muhammad Muzammil Tahir

Asisstant Professor Urology

Shaikh Zayed Hospital Lahore

• Prof Dr Sajjad Husain

Prof of Urology/Principle

Punjab Post Graduate Medical Institute Lahore

10
 Original Paper

Treatment modalities and outcome for Ureterovaginal fistula

inflicted in obstetrical and gynaecological practice

Abstract
Objectives; To find out optimal procedure of repair of uretervaginal fistula and
there outcome in gynaecology and obstetric practice.

Material and Methods; In this study 18 patients with diagnosis of ureterovaginal

fistula secondary to gynaecology or obstetric procedure were included. All the
patients were admitted and detailed history, physical examination and
investigation were done. Ivu, in all patients, and in certain inconclusive patients,
retrograde pyelography was performed, method opted for surgery was decided
on these investigation basis. We passed only JJ stent in 03 patients, 10
underwent ureteric implantation, and remaining 03 boari flap with psoas hitch.

Results; Ureteric implantation was done in 10 Patients, success was 100%,

Boari flap with psoas hitch in 05 patients, with 80% success, only JJ stent was
performed in 03 patients with 100% outcome.

Conclusion; Always try to treat the patients conservatively in ureteric injury, with
stenting if possible, patients with conservative management, along with ureteric
implantation group have good results, while in those with adjuvant maneuver
like Boari flap have fair success rate, in experienced hands.

11
 Treatment modalities and outcome for Ureterovaginal fistula
inflicted in obstetrical and gynaecological practice

Introduction;

The close anatomical relationship between the urinary tract and internal genital
organs predisposes the distal ureter to iatrogenic injury during pelvic and
gynaecological surgery. The incidence of ureteric injury during hysterectomy for
benign disease is 1:500 cases, which rises to 1% in cases of malignancy. The
risk of ureteric injury is higher during abdominal compared to vaginal
hysterectomies. Repeat caesarean sections and postpartum hysterectomies are
also associated with increased risk of injury to the lower urinary tract. Most of the
uterine injuries occur at the lower one third of the ureter5.

Aims & Objectives

To find out optimal procedure of repair of Ureterovaginal fistula in
gynaecology and obstetric practice.

Material and methods

Descriptive hospital based clinical study, conducted at the department

of Urology Mayo Hospital Lahore from November 2002 to October 2003.
and department of gynae obstetrics Lahore General hospital from May
2005 to Nov 2006. 18 patients with diagnosis of ureterovaginal fistulae
secondary to obstetrics or gynaecological procedures without any
previous attempt of repair were included in this study, Patients having
urinary fistulae with previous attempt of repair, fistula secondary to
radiotherapy, malignancy, fistula due to surgery other than obstetric and
surgery, gunshot, road traffic accident or stab injury were excluded from
study.

All the patients were admitted. A detailed history of the patients regarding
mode of gynecological or obstetrical procedure was obtained. History of surgery,
cause, type of injury was taken. Duration between the infliction of injury and
development of symptoms was recorded. This was followed by thorough clinical
examination including general physical examination, systemic and pelvic
examination. In the pelvic examination both per vaginal examination and
speculum examination were performed and the findings were recorded. In
addition to routine investigations, ultrasonography and intravenous urography

12
was done to evaluate the upper tract, status of bladder, ureter and any leakage.
In patients where intravenous urography was inadequate to demonstrates
ureteral anatomy then retrograde pyelography was performed.

Patients with ureterovaginal fistulae double J stent was tried to pass at the
initial stage. Where we were unable to pass the ureteric stent, the distance
between the ureteric orifice and the site of injury were noted. On the basis of
these findings the decision, regarding mode of procedure was made, where the
distance was 2-3 cm we go for ureteric reimplantation with double J stent, Boari
flap with Psoas hitch and double J stent was performed for distance more than 4-
5 cm. For suturing vicryl 4/0 was used for end to end ureteric anastomosis over
JJ stent. JJ stent was removed on 6th post operative week. Patients were
assessed for outcome.

Results

Table 1 Different surgical approaches adopted in repair of UVF (n=18)

Surgical Procedure No. of patients %age

Ureteric Reimplantation 10 55.55%
Boari's flap 2 11.11%
JJ stent 3 16.66%
Ureteric reimplantation with psoas hitch 3 16.66%

Out of 18 patients of UVF ureteric catheter was passed in 3 patients

with a little resistence felt between 2-4 cm and this catheter was
replaced with JJ stent. Post operative x-ray kidney, ureter and bladder
(KUB) were performed to see the position of the JJ. In 10 patients
ureteric catheter was not passed beyond 2-3 cm and ascending
pyelogram shows, stricture 2-3 cm away from ureterovesical junction, so
ureteric reimplantation was done. In 5 patients ureteric catheter failed to
go beyond 4-6 cm and in these patients surgical repair with Boari's flap
was performed.

In UVF patients , whom underwent ureteric reimplantation all were

successful. Out of 5 patients in which Boari's flap was made, four patients
recovered and one was a failure. The JJ stent was passed in 3 patients and they
remained dry. Stent was removed in these patients after 6 weeks, ascending
pyelogram shows no residual stricture. The JJ stents were used in all patients in
which repair of UVF was done. These patients were discharged from the hospital

13
with JJ stents and they were called after six weeks for removel of JJ stent. The
average hospital stay of the patients after different procedures for the UVF was
4.66 days.

Table 2, Success Rate in UVF Repair (n=18)

Procedure No. of Success Percantage

pt. rate
Ureteric Reimplantation 10 10 100%

Boari's Flap 2 1 50%

JJ Stent 3 3 100%
Ureteric reimplantation with psoas 3 3 100%
hitch
Total 18 17 87.50%

Discussion

Ureter is the most commonly injured organ after urinary bladder,

during gynecological and obstetrical surgery1. Mostly injury occurs at the
lower third of ureter5. There are three places, where ureter is very close
to the vagina, (1) the distal ureter just lateral to vagina where the uterine
artry crosses ventral over the ureter to enter the uterus, (2) over the
pelvic brim where the ovarian vessels crosses the ureters in the
infunfibulo pelvic ligament, (3) at the angle of vaginal fornix. True
incidence of ureteral injury is unknown, however results from various
studies suggest a ranges from of 0.02 to 2.5%.1,2,3 The most common
cause of ureteric injury was abdominal hysterectomy 4,7. The risk of
ureteric injury is higher after Laproscopic hysterectomy compared with
traditional hysterectomy13. We performed intravenous urography (IVU)
to see the site of injury followed by cystoscopy to exclude the possible
vesical injury and retrograde ureterography to see the site and nature of
injury. This is standard procedure recommended in many studies14.

14
 The uretrovaginal fistulae may be treated with internal stents, end to
end anastamosis of ureter if the distance is short, ureteric reimplantation
with JJ stenting, ureteric reimplantation with psoas hitch or Boeri flap 6.
If damage is extensive and involving the distal ureter and gap is more, it
is difficult to mobilize the ureter sufficiently to anastamose it without
tension then Psoas hitch, Boari flap or combined procedure are the
treatment of choice. We performed ureteric reimplantation in 10
patients with good results, managed with just JJ stent, in 3 patients with
good success, in 3 patients we performed ureteric implantation
(submucosal tunnel) with psoas hitch, with 100% success rate while 02
patients underwent boeri flap with JJ stent, with success rate of 50%.
The success in these patients depends on many factors, included,
following surgical principles, infection free and most importantly
experience of the surgeon.

The overall success rate in present study is 87.50% for uretrovaginal

fistulae where as international data shows that in developed countries
the success rate for ureterovaginal fistulae ranges from 93.9 to 95%
after first attempt9,11. No technique is considered superior to the other.
The optimal approach is that works best in the surgeons' hand. The
route of approach is also best tailored to the individual patient.

The use of interposition graft is likely to contribute towards better

outcome as international studies in which these grafts were used
showed better out come.

In all the patients JJ stents were used for splinting the ureteric
repair. It prevent the post operative urinary leakage, and reduces the
postoperative morbidity10, however controversies exist in the use of JJ
stent, in uncomplicated cases. In survey of American urological
association of 1453 cases, about 75% used splints for ureteric repairs
the consensus view is that, there use do a lot of good than to harm the
patient 12. we use only jj stent to manage these patients conservatively,
with good result.

Conclusion;

Intra operative identification of ureteric injuries is a rare feature, The iatrogenic

ureteric injury is inevitable, due to close proximity of the ureter to the internal
genital organ. Outcome depends on the site, size, location of the injury, and
expertise of the surgeon. So prompt diagnosis, appropriate surgical repair, better
endourological techniques, along with experience of the surgeon, is the

15
associated with better outcome.

References

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surgery: a ten year review in a community hospital. Am J obstet-gynaecol-
1995, june(6):1817-20, discussion 1820-22.

2. dark Mj, Nobble-JG: ureteric trauma in gynaecologic surgery. Int

Urogynaecol-J-Pelvic Floor -Dysfunct 1998, 9(2):108-17.

3. Nawaz FA, Khan ZE, Rizvi J: Urinary tract injuries during obstetrics and
gynaecological surgical procedures at the Agha khan university hospital
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4. Smith GL, William G.Vesicovaginal fistula. BJU int. 1999; 83(5):

564-70.

5. Selzmann-AA, Spirnak-JP: Iatrogenic ureteral injury, a 20 year experience

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MA.Management of Ureteric injuries due to gynecological procedures.
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.7. Mteta KA, Mbwambo J, Mvungi M; Iatrogenic ureteric and bladder

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8. Turk SK, Muneer L. Memon AS. Ttreatment of gynaeclological and

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9. Sanchez-Merino JM, Guillan-Maquieira C, Parra-Muntaner L, Gonez-

Cisneros SC, Laguna-Pes MP, Gracia-Alonso J. Transvesical repair of
non complicated vesicoveginal fistulae. Actas Urol Esp 2000; 24: 185-9.

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 10. Cormio L; Ureteric injuries, clinical and experimental studies; Scand-J-
Urol-Nephrol-Supp;1955;171:1-66

11. Al-Awadi K, Kehinde EO, Al-Hunayan A, Al-Khayat A; Iatrogenic

ureteric injuries: incidence, aetiological factors and the effect of early
management on subsequent outcome:Int Urol Nephrol, 2005;37(2):235-
41.

12. Turner MD, Witherington R, Carswell JJ, Ureteric splinting,

Result of a survey. J Urology 1982, 127:654-656.

13.Harkki-Siren-P, Sjoberg-J, Titinen-A, Urinary tract injuries after

hysterectomy. OBSTET-GYNECOL.1998.Jul:92(1) 113-8.

14. WU-K, WU2, HAN-Z; Diagnosis and treatment of iatrogenic

urinary injury.Chung-Hua-Wai-Ko-Tsa-Chih 1996; Dec.34(12)
720-2.

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