CC BY
14UDC: 616.613-003.7-0898.878
EVALUATION OF THE EFFECTIVENESS OF ABSOLUTELY DRAINLESS PERCUTANEOUS NEPHROLITHOTRIPSY
F.Yu. Yuldashev1, F.R. Nasirovl, J.Kh. Mirkhamidov1 'Tashkent Medical Academy, Tashkent, Uzbekistan
Abstract
The presence of drains in the urinary tract, installed in percutaneous nephrolithotripsy, is fraught with a number of complications and causes inconvenience for the patient. Absolutely drainless percutaneous nephrolithotripsy can significantly reduce the incidence of catheter-associated urinary tract infection, reduce the need for analgesics in the postoperative period, and reduce the length of hospital stay and the cost of medical services.
Key words: urolithiasis, endoscopic treatment, complications.
АБСОЛЮТТУК ДРЕНИРСИЗ ПЕРКУТУРАЛЫК НЕФРОЛИТОТРИПСИЯНЫН НАТЫЙЖАЛУУЛУГУН
БААЛОО
Ф.Ю. Юлдашев1, Ф.Р. Насиров1, Дж.Х. Мирхамидов1 'Ташкент медициналык академия, Ташкент, Узбекистан
Аннотация
Заара чыгаруу жолдорунда тери астындагы нефролитотрипсия менен орнотулган дренаждардын болушу бир катар татаалдашуулар менен коштолуп, бейтапка ьщгайсыздык жаратат. Терссиз дренажсыз перфетитотрипсия катетер менен байланышкан заара жолунун инфекциясын азайтууга, операциядан кийинки мезгилде анальгетиктерге болгон муктаждыкты азайтууга жана ооруканада болуу узактыгын жана медициналык кызматтардын баасын темендотууге мумкундук берет.
Ачкыч сездвр: уролития, эндоскопиялык дарылоо, оорулар.
ОЦЕНКА ЭФФЕКТИВНОСТИ АБСОЛЮТНО БЕЗДРЕНАЖНОЙ ПЕРКУТАННОЙ НЕФРОЛИТОТРИПСИИ
Ф.Ю. Юлдашев1, Ф.Р. Насиров1, Дж.Х. Мирхамидов1 Ташкентская медицинская академия, Ташкент, Узбекистан
Address for Correspondence: Yuldashev Faizulla Yuldashevich, Doctor of Medical Sciences, Professor of the Department of Surgery of the Fergana Branch of the Tashkent Medical Academy. Tel. (+99890) 272-00-87.
Аннотация
Наличие дренажей в мочевых путях, устанавливаемых при перкутанной нефролитотрипсии, чревато рядом осложнений и вызывает неудобства для больного. Абсолютно бездренажная перкутанная нефролитотрипсия позволяет значимо снизить частоту развития катетер-ассоциированной инфекция мочевого тракта, уменьшить потребность в анальгетиках в послеоперационном периоде, сократить сроки пребывания больных в стационаре и стоимость медицинских услуг.
Ключевые слова: мочекаменная болезнь, эндоскопическое лечение, осложнения.
Introduction
After percutaneous nephrolithotripsy (PCNLT), as well as after any other surgical intervention, various complications, in some cases life-threatening, may occur [1,2,8]. One ofthese complications is catheter-associated urinary tract infections (CAMI). Most patients with nosocomial urinary tract infections (BMI) have a history of either some kind of manipulation of the genitourinary tract (about 10-20%), or prolonged catheterization (about 80%), or both ofthese factors [4,9].
Most often, catheter-associated BMI develops from the patient's own intestinal flora [6]. Every day, on average, 3-10% of patients with drains in the urinary tract develop asymptomatic bacteriuria [10]. 25% of patients with asymptomatic bacteriuria subsequently develop symptomatic BMI, and 3% develop bacteremia [13]. The best method for the prevention of KAIMT is the refusal to use urinary drains or their early removal [5].
In this regard, in recent years, attention has been paid to the use of a tubeless endourological method for removing kidney stones [11].
Based on the listed problems of endoscopic treatment of urinary stones, the purpose of our study was to assess the effectiveness and safety of using absolutely drainless PCNLT in the treatment of patients with ICD.
Design, location and research participants
This study was based on the results of examination and treatment of 134 patients with urolithiasis, including 68 (50.7%) men and 66 (49.3%) women who applied to the Fergana Regional Urology Center in the period from January 2017 to December 2019. ... The age of the patients ranged from 11 to 76 years (on average, 38.3 ±3.4 years).
From the anamnestic data, it was found that 28 (20.9%) patients had previously been operated on for kidney stones and upper urinary tract stones, of
which one (0.7%) patient underwent extracorporeal shock wave lithotripsy (ESWL), 14 (10 , 4%) -endoscopic interventions and 13 (9.7%) - traditional operations. By the nature of stone formation, primary stones were present in 107 (79.9%) patients, recurrent - in 23 (17.2%) and residual - in 4 (2.9%).
A history of urinary tract infections (BMI) was followed in 59 (44.0%) patients. When contacting the clinic, body temperature was normal in 121 (90.3%) patients, subfebrile - in 3 (2.2%), febrile - in 10 (7.5%). According to the results of clinical and laboratory studies, when applying to the clinic, pyuria was detected in 90 (67.2%) patients, bacteriuria - in 75 (55.9%). The species of microflora was identified in 14 (10.4%) patients.
In the preoperative period, patients with BMI, in accordance with the results of the antibioticogram, received antibiotic therapy. Patients in whom it was not possible to identify the type of microflora, antibacterial therapy was carried out with antibiotics of a broad spectrum of action, mainly drugs from the group of cephalosporins and fluoroquinolones.
In the clinic, before the main operation, due to the lack of kidney function, 20 (14.9%) patients underwent preventive percutaneous nephrostomy, one of them from 2 sides. X-ray radiological studies showed that abnormalities in the development of the kidneys and upper urinary tract were present in 5 (3.7%) patients, of which 2 (1.5%) had a horseshoe-shaped kidney, another 2(1.5%) had a double kidney, 1 (0.7%) - lumbar dystopia of the kidney.
In the right kidney, stones were present in 44 (32.8%) patients, in the left - in 69 (51.5%), bilateral ureteral stones - in 1 (0.7%), in the right ureter - in 3 (2.2 %), in the left ureter - in 8 (6.0%) patients, ipsilateral stones on the left - in 7 (5.2%), ipsilateral stones on the right - in 2 (1.5%). The stones were 7-65 (26.3 ± 1.3) mm in size. The operations were performed under one of the types of anesthesia accepted in the clinic. Spinal anesthesia was performed in 102
(76.1%) patients, intravenous anesthesia - 10 (7.5%), endotracheal anesthesia - 10 (7.5%) and combined-12(8.9%).
All patients underwent single-access PCNLT according to the standard technique. In the presence of ipsilateral stones, the ureteral calculus was relocated to the pelvis, then PCNLT was performed. Small stones were removed entirely using forceps through the working channel of the nephroscope. Larger stones were disintegrated, for which, depending on the density of the stone, pneumatic and / or ultrasonic lithotripters were used. Large stone fragments were removed with forceps, and small ones with an aspirator. The operation was completed without installing a nephrostomy drainage or ureteral catheter. A Foley 16-20 Ch catheter was installed in the bladder to monitor the nature of urine in the postoperative period. One day after the operation, the Foley catheter was removed.
The efficacy and safety of absolutely drainless PCNLT was assessed according to the following parameters: stone free rate; duration of the operation; the frequency, nature and severity of intra- and postoperative complications within 1 month of observation after surgery; the length of stay of the patient in the hospital after surgery
(number of beds / days); the need for blood transfusion; the presence and severity of pain syndrome (the need for diclofenac in mg); performing additional interventions (when leaving residual stones); frequency of catheter-associated urinary tract infection, severity of postoperative complications according to the adapted Clavien-Dindo classification [7].
Results
The use of absolutely drainless PCNLT for the removal of kidney stones in the form of monotherapy made it possible to completely get rid of stones in 129 (96.3%) patients (Table 1).
Analysis of the reasons for the presence of residual stones after non-drainage PCNLT showed that residual stones in the amount of 1 to 2, size from 4 to 7 mm were present in 5 (3.7%) patients, all of them were in the cups. The cause of residual stones in all cases was the inaccessibility of the calyx.
Subsequently, 1 (0.7%) patient with residual calculus underwent additional intervention (ESWL). In 4 (3.0%) patients, residual stones were regarded as clinically insignificant; therefore, no additional interventions were performed to remove them.
Table 1. Results of treatment of patients with absolutely drainless PCN LT(n= 134).
Index results
Stone clearance rate, n (%) 129 (96.3±1.6%)
Residual stones, n (%) 5 (3.7±1.4%)
Operation duration (in minutes) 58.9±3.1
Length of stay of the patient in the hospital (bed-days) 3.4±0.2
Need for analgesics (diclofenac in mg) 265.3±14.4
Additional interventions for residual stones, n (%) 2(1.5±1.1%)
Catheter-associated infection, n (%) 10 (7.5±3.4%)
Analysis of the research results showed that the average duration of operations was 58.9 ± 3.1 (from 30 to 120) minutes. The average length of hospital stay after surgery was 3.4 ± 0.2 bed-days (from 1 to 12) (Table 1).
When performing absolutely drainless PCNLT, both during the operation and in the postoperative period, significant blood loss was not observed, and therefore, there was no need for replacement therapy.
In the postoperative period, 106 (79.1%) patients required analgesia (on average, 265.3 ± 14.4 mg of sodium diclofenac per patient) (Table 1).
KAIMT was detected in 10 (7.5 ± 3.4%) of 59 initially uninfected patients. It should be noted that in order to detect CAMT in natients who underwent al
"---------J ------------ ------7 ------- ------X----f->---
analysis was performed simultaneously with the removal of the urethral catheter.
No intraoperative complications were observed when performing absolutely drainless PCNLT
Assessment of postoperative complications in accordance with the adapted classification of surgical complications by Clavien-Dindo revealed:
Complications of the 1st degree were observed in 8
(6.0%) patients, of which: 7 had a one-day fever, which required the appointment of antipyretic drugs; one patient had hematuria through the ureteral catheter, requiring additional (more than 1 liter) infusion therapy and the appointment of diuretics and hemostatics.
Complications of the II degree developed in 6 (4.5%) patients, of which: 2 developed an infectious-inflammatory process in the urinary tract, requiring additional antimicrobial and infusion-detoxification therapy, which extended the patient's stay in the hospital; 4 patients required analgesia for more than 48 hours due to the surgery.
Complications of III a degree were not observed. Complications of grade III b were observed in 2 (1.5%) patients, of which one - the presence of a
for
tne removal oi "simple" stones and additional interventions; another patient underwent percutaneous nephrostomy due to bleeding.
Complications IVa, IVb and V degrees were not observed. Thus, according to the Clavien-Dindo classification, in the postoperative period when performing absolutely drainless PCNLT, 16 (11.9 ± 2.8%) complications were distributed according to the severity as follows (Table 2):
Table 2. The incidence of postoperative complications of absolutely drainless PCNLT according to
I II Ilia Illb IVa IVb V
grade grade grade grade grade grade grade
8 6 - 2 - - -
(6.0%) (4.5%) (1.5%)
Discussion
To develop and clarify the indications for the implementation of an absolutely drainless method of endoscopic treatment of patients with nephrolithiasis and introduction into clinical practice, an assessment of its effectiveness and safety was carried out.
According to the results of the study, it was determined that when using absolutely drainless PCNLT, the degree of completeness of getting rid of stones is 96.3%. Due to the inaccessibility of the
cups, residual stones were left in 5 (3.7%) patients. Only in 1 (0.7%) patient, the residual stone was regarded as clinically significant, and additional intervention was performed to remove it. In other cases, residual stones were regarded as clinically insignificant, and therefore no additional interventions were performed to remove them. Based on the above, it can be considered that one of the contraindications for performing an absolutely drainless PCNLT is the presence of clinically significant residual stones.
According to Sh.I. Giyasov (2015), the likelihood of pyelonephritis is significantly higher in patients with an initial MEP infection, intraoperative and other postoperative complications [3]. In this regard, we did not use the non-drainage technique during the endoscopic treatment of patients with nephrolithiasis who had intraoperative complications.
The results of multicenter studies also showed that the absence of intraoperative complications should serve as a criterion for the possibility of using the drainage-free PCNLT technique [14].
One of the reasons that prompted urologists to develop and introduce into practice a drainless PCNLT method was a catheter-associated urinary tract infection [11]. The same reason was for us the basis for the development of an absolutely drainless PCNLT method.
Nevertheless, after the intervention, 10 (7.5%) patients were observed to have a catheter-associated infection, which, in our opinion, was associated with the installation, at the end of the operation, of an indwelling urethral catheter for visual observation of the nature of urine discharge. Wang J. et al (2011) when removing large kidney stones larger than 3 cm, do not recommend performing non-drainage PCNLT [15]. The results of our studies have proven that non-drainage methods of percutaneous nephrolithotripsy can be performed with stones larger than 3 cm.
Conclusion. Absolutely drainless PCNLT is an acceptable, affordable and effective method in the treatment of patients with nephrolithiasis, it allows to reduce the incidence of catheter-associated urinary tract infection. Postoperative complications of absolutely drainless PCNLT, according to the Clavien-Dindo classification, are more often of mild severity. This method of percutaneous nephrolithotripsy should be performed in the absence of intraoperative complications and organic obstruction of the upper urinary tract, as well as in the absence of stones.
References
1. Akilov F.A., Giyasov Sh.I., Mukhtarov Sh.T., Nasirov F.R., Mirkhamidov D.Kh. Evaluation of complications of endoscopic surgery of nephrolithiasis from the perspective of the Clavien-Dindo classification. // Experimental and Clinical Urology. - 2012. -No. 3.-S.26-29.
2. Akilov F.A., Mukhtarov Sh.T., Giyasov Sh.I., Mirkhamidov
D.Kh., Nasirov F.R., Muratova N.B. Postoperative infectious and inflammatory complications of endoscopic operations for urolithiasis. // Urology. - 2013. - No. 1. - p. 89-91.
3. Giyasov Sh.I. Complications of endoscopic surgery of nephrolithiasis: causes, classification, tactics, prognosis. // Autoref. diss... doct. honey, sciences. Tashkent, 2015.
4. AsherEF, Oliver BG, Fry DE. Urinary tract infections in the surgicalpatient. //Am. Surg. -1988; 54:466-9.
5. Cortellini P., Frattini A., Ferretti S., Larosa M. Major complications of percutaneous nephrolithotripsy (PCNL). Analysis of our cases. //Minerva Urol. Nefrol. - 1997; 49 (4): 203-236.
6. Garibaldi RA, Burke JP, Britt MR, Miller MA, Smith CB. Meatal colonization and catheter-associated bacteriuria. // N. Engl. J. Med. -1980; 303:316-8.
7. Daniel Dindo, MD, Nicolas Demartines, MD, and Pierre-Alain Clavien, MD, PhD, FRCS, FACS. Classification of Surgical Complications A New Proposal With Evaluation in a Cohort of6336Patients and Results ofa Survey. //. Ann Surg2004; 240:205-13.
8. Gremmo E., Ballanger P., Dore B., Aubert J. Hemorrhagic complications during percutaneous nephrolithotomy. Retrospective studies of772 cases. //Prog. Urol. - 1999; 9 (3): 460-463.
9. KriegerJN, Kaiser DL, WenzelRP. Urinary tract etiology of
bloodstream infections in hospitalizedpatients. //J. Infect. Dis.-1983; 148:57-62.
10. Khasigov A.V., Belousov I.I., Kogan M.I. Comparative analysis of the efficacy and safety of percutaneous nephrolithotomy forstaghorn calculi. //Urology, 2013. Vol. 81, No. 5.p. 1081-5.
11. Lojanapiwat B. Percutaneous nephrolithotomy (PCNL) in kidneys with fusion and rotation anomalies. // J. Med. Assoc. Thai. - 2005, Oct; 88 (10): 1426-9.
12. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. //Am. J. Infect. Control. - 2000; 28:68-75.
13. SaintS., SavelR. H. etal. "Enhancing the safety of critically ill patients by reducing urinary and central venous catheter-related infections." // Am. J. Respir. Crit. Care. Med. - 2002,165 (11): 1475-1479.
14. Seitz Ch., Fajkovic H., Remzi M. et al. Rapid extracorporeal shock wave lithotripsy treatment after a first colic episode. //Eur. Urol. 2006:49 (6): 1099-1106.
15. Wang J., Zhao C., Zhang C., Fan X., Lin Y., Jiang Q. Tubeless vs standard percutaneous nephrolithotomy: a meta-analysis. //BJUInt. - 2011; 109:918-924.
16.WeinA.J., KavoussiL.R., NovickA.C., PartinA.W., Peters C.A. Campbell-Walsh Urology. 10th ed. Philadelphia: Saunders. 2012.P.1325-1356.
17. Moosanejad N.. Firouzian A.. Hashemi S.A.. Bahari M. Fazli M. Comparison of totally tubeless percutaneous nephrolithotomy and standard percutaneous
nephrolithotomy for kidney stones: a randomized, clinical trial. // Braz J Med Biol Res. 2016;49(4):e4878. doi: 10.1590/1414-431X20154878. Epub 2016 Mar 18.
18. Jou Y.C.. Lu C.L.. Chen EH.. Shen C.H.. Cheng M.C.. Lin S.H.. Chuang S.C.. Li Y.H. Contributing factors for fever after tubeless percutaneous nephrolithotomy. // Urology. -2015 Mar;85(3):527-30.
19. Crook T.J., Lockyer C.R., Keoghane S.R., Walmsley B.H. Otally tubeless percutaneous nephrolithotomy. // J. Endourol. -2008;22(2) -.267-271.
20. Falahatkar S., Khosropanah I., Roshani A. Tubeles percutaneus nephrolithotomy for staghorn stones. // J. Endocrinol. 2008; 22 (7): 1447-1451.
21. Bjerklund Johansen TE, CekM, NaberK, Stratchounski L, Svendsen MV, TenkeP. PEP andPEAP study investigators; European Society of Infections in Urology. Prevalence of hospital-acquired urinary tract infections in urology departments. //Eur. Urol. - 2007; 51:1100—11 [discussion 1112].
22. BonzaE., San Juan R., Munoz P., VossA., KluytmansJ. Cooperative Group of the European Study Group on Nosocomial Infections. A European perspective on nosocomial urinary tract infections II. Report on incidence, clinical characteristics and outcome (ESGNI-004 study). European Study Group on Nosocomial Infection. //Clin. Microbiol. Infect. -2001; 7:532-42.
23. Choi S.W.. Bae W.J.. Ha U.S.. Hong S.H.. Lee J.Y.. Kim S.W.. Cho H.J. Prediction of stone-free status and complication rates after tubeless percutaneous nephrolithotomy: a comparative and retrospective study using three stone-scoring systems and preoperative parameters. // World J Urol. 2016 Jul 12. [Epub ahead of print]
24. Aghamir S.M., Hamidi M., Aloosh M, Mohammadi A., Nikoobakht M.R., Meysamie A. Efficacy and morbidity following PCNL in patients with renal anomalies: the outcome from a randomized study comparing different imaging modalities for assessment. // Minerva Urol. Nefrol.-2011;63:207-212.
