Hindawi Publishing Corporation Advances in Urology Volume 2017, Article ID 3483172, 5 pages http://dx.doi.org/10.1155/2017/3483172
Research Article Percutaneous Nephrolithotomy under Ultrasound Guidance in Patients with Renal Calculi and Autosomal Dominant Polycystic Kidney Disease: A Report of 11 Cases Xiao Wan Xiao Wang, g,1 Xuech Xuecheng eng Yang,1 Xiulo Xiulong ng Zhong Zhong,, 1 Zhe Zhenli nlin n Wan Wang, g,1 Senyao Sen yao Xue Xue,,2 Weifeng Yu, 1 an and d Zh Zhen en Do Dong ng 1 �
Department of Urology, Te Affiliated Hospital of Qingdao University, Qingdao, China Department of Urology, Yidu Central Hospital of Weifang, Shandong, China
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Correspondence should be addressed to Zhen Dong;
[email protected] [email protected] Received �� September ����; Revised �� December ����; Accepted � January ����; Published �� February ���� Academic Editor: Mohammad H. Ather Copyright © ���� Xiao Wang et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction reproduction in any medium, provided the original work is properly cited. Nephrolithia Nephrol ithiasis sis acce accelera lerates tes the renal ailure ailure in the patients patients with ADPKD. ADPKD. In ord order er to evalu evaluate ate the role o perc percutan utaneous eous nephrolithotomy in management o calculus in these patients, �� patients with autosomal dominant polycystic kidney disease and renal stones were included in the study. wo patients had bilateral renal stones. All patients were treated by percutaneous nephrolithotomy under ultrasound guidance. �� percutaneous nephrolithotomy procedures were perormed in � stage by the urology team under ultrasound guidance. � people received second operation with �exible nephroscopy in lateral position. Te success rate and morbidity and mortality o the technique and hospital stay were recorded. Results Results.. Te puncture procedure was ullyy suc ull succes cessu sull in all cas cases. es. Te re renal nal un uncti ction on imp impro roved ved in the these se pa patie tient nts. s. � pa patie tientshad ntshad mod modera erate te ev ever er af afer er the sur surgery gery.. � pa patie tient ntss received �exible nephroscopy to take out the residual calculi. � persons had ESWL therapy afer the surgery. Conclusion Conclusion.. PCNL is an ideal, sae, and effective method to remove the stones rom those patients with no de�nite increase in the risk o complication. Te outcome and stone-ree rate are satisactory comparable to the PCNL in the patients without ADPKD. ADPKD.
1. Introduction Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the progressive development o multiple renal re nal cys cysts ts tha thatt des destro troyy the re renal nal par parenc enchy hyma. ma. It is the most common genetic disorder leading to end stage renal diseas dis ease. e. Tis dis diseas easee is ca cause used d by ger germlin mlinee mu muta tatio tions ns in PKD� (��%) and PKD� (��%) and is typically diagnosed later in lie than autosomal recessive polycystic kidney disease. Approximately Appr oximately ��% o patients with ADPKD will progress to renal ailure at a median age o �� [ �]. In the early stages o ADPKD, most o the patients show a stable period o mild to moderate renal ailure, which later on hastened by urinary inection and nephrolithiasis [� nephrolithiasis [�]. ]. ��% patients with ADPKD may have nephrolithiasis in this period [ �]. Although percutaneous nephrolithotomy is considered as the most effective treatment or the patients with larger upper up per uri urinarycalcul narycalculii in the these se da days, ys, the there re ar aree sti still ll man manyy peo people ple
doubts about the saety and efficacy or this technique in the patients with ADPKD and nephrolithiasis. Some reports showed sho wed PCN PCNL L had the sam samee the thera rapeu peutic tic effe effect ct wit withou houtt increasing complication. In or order der to sho show w tha thatt PCN PCNL L und under er ult ultras rasoun ound d gui guidan dance ce is an ide ideal, al, sa sae, e, and effe effecti ctive ve met method hod to rem remov ovee the st stone oness ro rom m the patients with ADPKD and nephrolithiasis, we present our experience experience in the treatment treatment o �� patie patients nts with ADPKD and nephr nephrolith olithiasis iasisby by PCNL under underultra ultrasoundguidance soundguidance.. Te data o the success rate and intraoperative and immediate postop pos topera erativ tivee mor morbid bidity ity wer weree ass asses essed sed.. We also eval evalua uated ted the saety and efficacy o this procedure.
2. Materials and Methods �� med medica icall rec recor ords ds o nep nephro hrolit lithia hiasis sis wit with h ADP ADPKD KD sin since ce ��� ���� � were reviewed. wo patients had bilateral stones. Tereore,
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Advances in Urology ���� �: Patient demographics and present symptoms.
Feature Gender M F Age Average Preop comorbidities Proteinuria Hypertension Presenting symptoms Hematuria Flank pain Asymptomatic Stone burden Unilateral Bilateral
���� �: Indications or PCNL.
Number
Pts (%)
� � ��–��
�� ��
50 ± 13
� �
�� ��
� � �
�� �� ��
� �
�� ��
�� PCNL procedures were perormed under ultrasound guidance. All patients were evaluated with X-ray KUB (kidney, ureter, and bladder) and urinary ultrasonography. In view o the renal unction, Urinary C Scan and intravenous urogram were used or evaluating o the renal anatomy and size and location o the stone. Te hemogram, urinalysis, urine culture and sensitivity, renal unction test, liver unction test, levels o serum electrolyte, blood glucose and lipids, and coagulation pro�le were perormed. Te patients with positive urinary culture received oral antibiotics therapy under sensitivity indication until urinary culture became sterile. Te PCNL were perormed under general anesthesia in all patients. Afer anesthesia, the patients underwent ureteric catheterization under cystoscopy. Te dilution o methylene blue was efflux reely into renal pelvis by the ureteric catheter. Ten the patients were turned into prone position and received puncture procedure by the urologists under ultrasound guidance. Only the blue �uid re�uxing rom puncture needles was con�rmed as correct puncture. Te tract was dilated to �� Fr by Amplatz ascial dilators. Rigid nephroscopy was used to complete the procedure. Pneumatic and ultrasound disintegration were perormed in all patients. Te residual stones were evaluated with Urinary C Scan � days afer surgery. � people received second operation with �exible nephroscopy in lateral position. Tese patients got another Urinary C Scan � days afer the second surgery. Te postoperation hemoglobin level and serum creatinine were assessed. Te auxiliary procedure as ESWL was recorded. Te successul treatment and postoperative complications were also recorded.
3. Result Te mean age o patients was �� (range ��–�� years). able � showed the patients demographics and present symptoms. O
Indication Large stone burden ( >� cm) Partial staghorn stone Large lower renal calculi ( >� cm) Failed ESWL Impacted stone at UPJ or lumbar ureter
Renal units () � � � � �
the �� people, � were male and � were emale. As to preoperative comorbidities, � patients had proteinuria; � patients had hypertension. � patients had no symptoms and were ound incidentally. All the patients had normalrenal unction beore operation. Mean serum creatinine was �.�� mg (+�.�� mg). able � indicates the characteristics and location o the stone in these patients. � patients had large stone burden, � patients had partial staghorn stone, and � patients looked or surgery because o the ESWL treatment ailure. able � showed the perioperative, operative, and postoperative characteristics and outcomes. Te mean operative time is ��� min; � patients received transusion or the correction o hematocrit. � cases got subcostal cutaneous puncture; � case received supracostal puncture; � cases required � cutaneous tract access both subcostal and supracostal in order to clean the stone as much as possible. able � showed postoperative characteristics and outcomes. One patient had heavy bleeding when the renal drainage was removed. Te bleeding happened soon afer the drainage tube was taken out; the same tube was inserted into renal pelvis through the previous path and the bleeding was controlled immediately. � patients had moderate ever afer the surgery. Among these people, � persons had con�rmed urinary inection by urinary culture. � patients received �exible nephroscopy to take out the residual calculi. � persons had ESWL therapy afer the surgery. Even afer these therapies, � patients had con�rmed residual calculi by Urinary C Scan. � persons had more than � mm residual calculi. According to the Clavien-Dindo classi�cation o surgical complications, � patients with ever afer surgery are Grade I. � patients are Grade �: one patient got paralytic ileus; � patients got urinary inection afer the procedure. Te patient with severe bleeding is Grade � who receives cystoscopy therapy without transusion. Figure � showed a patient with lef renal calculus and multiple cysts. Figure � showed no calculi exist afer PCNL treatment. He still kept the nephrectomy tube at that time.
4. Discussion Te incidence o renal calculi in patient with ADPKD is approximately �� to ��%. Many ADPKD patients have urinary calculi. Nephrolithiasis aggravates the renal unction damage and accelerates renal ailure in these patients [�].Te common presenting symptoms o the calculi patients were hematuria and �ank pain; � persons had hematuria. Among these patients, � persons had gross hematuria. Most patients also had proteinuria and hypertension, which should have cautious treatment beore operation.
Advances in Urology
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���� �: Stone characteristics and puncture locations. Characteristics Units Side Right Lef Stone location Renal pelvis Caliceal Multiple sites Stone multiplicity Single Multiple Partial staghorn Stone opacity Opaque Lucent Nature o stones Primary Recurrent Cutaneous tract access Subcostal Supracostal Both Failed
Renal units
� � � � � � � � F����� �: C scan: lef renal calculus with multiple cysts. �� � �� � � � � �
���� �: Postoperative characteristics and outcomes. Characteristics and outcomes Severe hematuria Fever Paralytic ileus ESWL Flexible nephroscopy Urinary inection Effective residual calculi Residual calculi Preoperation Scr (mg/dL) Postoperation Scr (mg/dL) Preoperation Hb (mg/dL) Postoperation Hb (mg/dL)
� � � � � � � � 1.01 ± 0.18 1.08 ± 0.21 14.32 ± 2.12 12.86 ± 1.49
Percutaneous nephrolithotomy and ESWL are the main therapy orcalculi patients with ADPKD. As ESWL treatment has some controversy with renal parenchymal damage [�, �], nevertheless, the effects o ESWL were very poor in most reported research, in which the stone-ree rate has been only ��–��% at � months. Multiple, large, branched calculus cannot be solved by ESWL therapy [ �]. PCNL was considered to be the ideal method to remove the stones rom the patients with ADPKD. We preer ultrasound guidance which is popular nowadays. Under ultrasound guidance you can control the whole puncture pathway and avoid the
F����� �: Nephrectomy tube afer PCNL treatment.
in�uence o the cysts. As we all know, PCNL is a little difficult in these patients. Te caliceal space can be elongated by the compressive effect o the parenchymal cysts. With the ultrasound guidance, multiple cysts in�uence the recognition o the caliceal aim. Te dilution o methylene blue was very good method to con�rm the puncture [�]. Only the continuous efflux blue liquid can be de�nite proo that you get the desirous calices. I you have not got the right calices, the use o ultrasound contrast agent may help you out o the dilemma. In act, it is a great challenge or us to establish the percutaneous tract under ultrasound guidance in these ADPKD patients. First, you need to con�rm the calix you want to puncture and the cysts nearby under the ultrasound. In my opinion, the use o ultrasound contrast agent is not as good as they said in act. When ��% meglumine diatrizoate was injected directly into the renal calices some turbulent �ow re�ection can be ound by the ultrasound. Fluid in those polycysts never showed any turbulent �ow re�ection. Sometimes i the procedure cannot be achieved smoothly, you can puncture the stone directly. You may select the
� pathway through the cysts to the stone you aim at. Te pathway may be long but there is not any bleeding danger but you should careully �x you puncture tube in case o pathway loss. Te patients with recurrent kidney stone disease can greatly damage the glomerular �ltration rate. Te recurrence rates o the renal stone disease were as high as ��% within � years [�]. Te use o �exible nephroscopy was very important in the PCNL with ADPKD in orderto attain a complete stoneree status. As most patients with ADPKD have anatomical renal distortion and caliceal elongation, only one access tract cannot reach different portions o the collecting system in the PCNL procedure. Ten comprehensive careul inspection o the renal collecting system should be perormed with a �exible nephroscope [��]. Most portions o the collecting system can be reached by using a �exible nephroscope that might not have been reached with a rigid instrument. I bleeding makes the operation �eld not clear or the instant inspection, a second-look nephroscopy can be arranged. Te most concerned complication o PCNL perormance is bleeding. Singh et al. reported that the average hemoglobin drop afer the procedure was �.�–�.� mg/dL [�]. Most bleeding can stop automatically afer the surgery, but some patients need to receive another perormance o superselective angioembolization to control the bleeding. Te incidence o acute bleeding requiring a blood transusion is considered as the indication o saety or the patient with nephrolithiasis and AKPKD. Al-Kandari ound the blood transusion during or afer the treatment was very low and there were no patient’s needs or blood transusion afer their PCNL treatment in these �� patients [ ��]. Tus the risk o nephrectomy is very rare and gross bleeding is not de�nitely associated with these complications in the present studies. Te renal unction in these patients can be damaged by urinary obstruction and inection due to stones. Complete stone-ree status is the best way to rescue renal unction. Te perormance o PCNL had no de�nite in�uence in the renal unction o these patients with AKPKD [ ��]. In this study, all the patients had normal renal unction afer operation. Te mean serum creatinine level has no difference compared with that beore operation in �-month ollow-up. Te renal unction keeps stable over the period o ollow-up in this research. Srivastava et al. �nd the renal unction o �� patients with obstructive uropathy improved afer PCNL perormance, and there are no evidences o stone recurrence and renal unction deterioration during a median ollowup o �� months [�]. Paryani and Ather believe that serum creatinine level improved afer the aggressive treatment, but the patients without any surgical intervention would have advanced to renal insufficient quickly [��]. Yet large multicenter studies are required to con�rm this result in the patients with ADPKD and nephrolithiasis. Te patients with ADPKD and nephrolithiasis had great difficulty in achieving stone-ree status. Umbreitet al. showed ��% patients were stone-ree and ��% had small stone ragment remain. Nearly hal patients received repeat percutaneous endoscopy in order to become stone-ree [��]. Srivastava et al. believed relook PCNL and ESWL were needed to achieve stone-ree status. Only ��% patients
Advances in Urology achieve stone-ree afer the �rst procedure. Nevertheless all patients were completely stone-ree with relook and ESWL therapy [�]. Lei et al. claimed ��.�% patients were stone-ree afer the primary MPCNL. Afer the second-look MPCNL, only �.�% o patients still had residual stone [ ��]. Compared with �exible ureteroscopy and holmium laser lithotripsy therapy, PCNL has the same stone-ree rate. Liu et al. showed ��.�% stone-ree rate afer the �rst �exible ureteroscopy and holmium laser lithotripsy therapy. Te stone-ree rate can reach ��.�% afer the second procedure [ ��]. Nishiura et al. ound C scan shows the most sensitivity and speci�city compared with any other modalities in renal calculi evaluation [�]. Te most components o the renal stone in the patients with ADPKD are calcium oxalate and uric acid. As many expanding renal cysts distort the intrarenal caliceal system, the urinary stasis and urinary crystals acilitated the ormation and aggregation o renal calculus. Te urinary oxalate and urinary crystallization were signi�cantly higherin patients with ADPKDand nephrolithiasis. Lei et al. ound the most common stone composition was calcium oxalate; uric acid and magnesium ammonium phosphate were also detected in some patients [ ��]. Liu et al. treat the patients with calculus and ADPKD with �exible ureteroscopy and holmium laser lithotripsy therapy, but the mean size o the stone was �.� mm [��]. However, �exible ureteroscopy and holmium laser lithotripsy therapy can be perormed with the natural pathway which is better or the patients with renal unction dysunction and coagulation deect.
5. Conclusion Nephrolithiasis accelerates the renal ailure in the patients with ADPKD [�]. Based on the small number o cases and correspondence reports, PCNL under ultrasound guidance is an ideal, sae, and effective method to remove the stones rom those patients with no de�nite increase in the risk o complication. Te outcome and stone-ree rate are satisactory comparable to the PCNL in the patients without ADPKD.
Competing Interests No competing �nancial interests exist.
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