Perioperative and long-term results of ultrasonography-guided single-and multiple-tract percutaneous nephrolithotomy for staghorn calculi

BACKGROUND It is possible that this condition will lead to urosepsis and progressive deterioration of renal function in the absence of surgical intervention.Several recent clinical studies have shown that multi-tract percutaneous nephrolithotomy(MPCNL)has a similar stone free rate(SFR)as standard percutaneous nephrolithotomy(S-PCNL).As a result,M-PCNL was also recommended as a treatment option for staghorn calculi.AIM To examine the perioperative and long-term results of ultrasonography-guided single-and M-PCNL.METHODS This was a retrospective cohort study.Between March 2021 and January 2022,the urology department of our hospital selected patients for the treatment of staghorn calculi using percutaneous nephrolithotomy.The primary outcomes were com plication rate and SFR,and the characteristics of patients,operative parameters,laboratory measurements were also collected.RESULTS In total,345 patients were enrolled in the study(186 in the S-PCNL group and 159 in the M-PCNL group).The SFR in the M-PCNL group was significantly higher than that in the S-PCNL group(P=0.033).Moreover,the incidence rates of hydrothorax(P=0.03)and postoperative infection(P=0.012)were higher in the M-PCNL group than in the S-PCNL group.Logistic regression analysis demonstrated that post-operative white blood cell count(OR=2.57,95%CI:1.90-3.47,P<0.001)and stone size(OR=1.59,95%CI:1.27-2.00,P<0.001)were associated with a higher overall complication rate in the S-PCNL group.Body mass index(OR=1.22,95%CI:1.06-1.40,P=0.004)and stone size(OR=1.70,95%CI:1.35-2.15,P<0.001)were associated with increased overall complications in the M-PCNL group.CONCLUSION Multiple access tracts can facilitate higher SFR while slightly increasing the incidence of acceptable complications.

Definition, treatment and outcome of residual fragments in staghorn stones

Technological advances in minimally invasive treatment of stone disease and its integration with concomitant clinical practice are amongst the most important achievements in urology.Despite the wealth of information accumulated over the years and the richness of existing literature,the knowledge about the definition,treatment and outcomes of residual stone fragments after percutaneous nephrolithotomy(PNL)is still insufficient.Due to the high stone load a lot of patients with staghorn stones have residual fragments(RFs)after treatment with PNL,which depends on the size of tract,definition of stone free rate(SFR),timing of evaluation and the imaging used.No consensus exists on the imaging modality or their timing in the evaluation of possible RFs.The treatment of residual stones is apparently different depending on the facilities of the department and the preference of the surgeon,which includes active surveillance,shock wave lithotripsy(SWL),retrograde intrarenal surgery(RIRS)or a second look PNL.

Percutaneous nephrolithotomy for staghorn calculi: Troubleshooting and managing complications

Staghorn calculi comprise a unique subset of complex kidney stone disease. Percutaneousnephrolithotomy (PCNL) is the gold standard treatment for staghorn stones. Despitecontinuous refinements to the technique and instrumentation of PCNL, these stones remaina troublesome challenge for endourologists and are associated with a higher rate of perioperativecomplications than that for non-staghorn stones. Common and notable intraoperativecomplications include bleeding, renal collecting system injury, injury of visceral organs, pulmonarycomplications, thromboembolic complications, extrarenal stone migration, andmisplacement of the nephrostomy tube. Postoperative complications include infection and urosepsis,bleeding, persistent nephrocutaneous urine leakage, infundibular stenosis, and death.In this review, we report recommendations regarding troubleshooting measures that can beused to identify and characterize these complications. Additionally, we include informationregarding management strategies for complications associated with PCNL for staghorn calculi.

Preoperative imaging in staghorn calculi, planning and decision making in management of staghorn calculi

Objective:Staghorn calculi present a particular and challenging entity of stone morphology.Treatment is associated with lower stone-free rates and higher complication rates compared to non-staghorn stones.In this review we looked for the most relevant data on preoperative imaging and access planning to help decision making for percutaneous surgery with this complex condition.Methods:We conducted a PubMed search of publications in the past 2 decades that include relevant information on the planning for management of staghorn stones.Non-contrast computerized tomography(NCCT)is indeed the standard imaging tool for percutaneous nephrolithotomy(PCNL);additional tools such as three-dimensional computed tomography(CT)reconstruction of the staghorn calculus may help plan access in complex cases.Ultrasound guided percutaneous access may be considered for staghorn stones when planning upper pole access in kidney malposition or complex intrarenal anatomy or with complex body habitus.Wideband doppler ultrasound and real-time virtual sonography can assist.New technologies to improve kidney access such as Uro Dyna-CT or electromagnetic sensor have been reported,but have not shown utilization in staghorn cases.Staghorn morphometry-based prediction algorithms may predict the number of tract(s)and stage(s)for PCNL monotherapy.Lower pole access can be equally effective as upper pole when planning for staghorn and complex stones,with significantly less complications rate;Stone-Tract length-Obstruction-Number of involved calyces-Essence of stone density(STONE)nephrolithometry seems to be the best system to predict outcomes of PCNL in staghorn cases.There is a growing trend of endoscopic combined intrarenal surgery(ECIRS)in concordance with PCNL to treat larger stones.Conservative management of staghorn calculi is an undesired option,but can be an alternative for a carefully selected group of high-risk patients.Conclusion:Staghorn stones may lead to deterioration of renal function and life-threatening urosepsis.This entity should be managed aggressively with planning ahead for surgery using the different tools available as the cornerstone for a successful outcome.

Multitract percutaneous nephrolithotomy in staghorn calculus

Staghorn calculi are branched stones which occupy a majority portion of the pelvicaliceal system.An untreated staghorn calculus over time can damage the kidney and deteriorate its function and/or cause life threatening sepsis.Total stone clearance is an important goal in order to eradicate any infective focus,relieve obstruction,prevent recurrence and preserve the kidney function.Percutaneous nephrolithotomy(PCNL)is currently the accepted first-line treatment option for staghorn calculi.The options available are single-tract PCNL with an auxiliary procedure like shockwave lithotripsy,single-tract PCNL with flexible nephroscopy,or multitract PCNL.Each has its own pros and cons.But the ultimate goal of treatment for any patient with staghorn calculi should be safety,cost-effectiveness,and to achieve total stone clearance.With this article,we review the management of staghorn calculi with multiple percutaneous(“multitract”)access,its advantages and disadvantages and its current position by studying the various published materials across the globe.

Metabolic evaluation and medical management of staghorn calculi

Staghorn renal calculi are large renal calculi that occupy nearly the entirety of the renal collecting system.They may be composed of metabolic or infection stone types.They are often associated with specific metabolic defects.Infection stones are associated with urease-producing bacterial urinary tract infections.The ideal treatment for staghorn calculi is maximal surgical removal.However,some patients are either unwilling or unable to proceed with that modality of treatment,and therefore other management must be used.One such technique is the metabolic evaluation with directed medical management.Based on contemporary evidence that the majority of staghorn stones are metabolic in etiology,and furthermore that even infection stones are usually associated with metabolic abnormalities,metabolic evaluation with directed medical management is recommended for all staghorn stone formers.The scientific basis of this recommendation is reviewed in the present work.

The role of ureteroscopy for treatment of staghorn calculi: A systematic review

Objective:To define the role of ureteroscopy for treatment of staghorn calculi.Methods:A systematic review was conducted using the Scopus and Medline databases.Original articles and systematic reviews were selected according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA)guidelines.Only studies relating to the role of ureteroscopy for treatment of staghorn calculi were included.Results:In five studies on ureteroscopic monotherapy,stone-free rate(SFR)ranged from 33%to 93%,with a maximum four ureteroscopy sessions per patient and no major complications.Endoscopic combined intrarenal surgery(ECIRS)was compared with percutaneous nephrolithotomy(PNL)in two studies and reached significantly higher SFR(88%e91%vs.59%e65%)and lower operative times(84e110 min vs.105e129 min).The role of salvage ureteroscopy for residual stones after primary PNL has been highlighted by two studies with a final SFR of 83%e89%.One study reported on the feasibility of ureteroscopy for ureteral stones and same-session PNL for contralateral staghorn calculi,with a SFR of 92%.Conclusion:Ureteroscopy plays a pivotal role in the setting of a combined approach to staghorn calculi.Ureteroscopy is also particularly suitable for clearance of residual stones.In specific cases,ureteroscopy may become the sole applicable therapeutic option to staghorn calculi.Technological advances and refinement of techniques suggest a major role of ureteroscopy for staghorn calculi treatment in close future.

Management of staghorn stones in special situations

Staghorn stones have always been a challenge for urologists,especially in some special situations,such as horseshoe kidney,ectopic kidney,paediatric kidney,and solitary kidney.The treatment of these staghorn stones must be aggressive because they can lead to renal function loss and serious complications.The gold-standard management for staghorn stones is surgical treatment with the aim of clearing the stones and preserving renal function.Treatment methods for staghorn stones have developed rapidly,such as extracorporeal shock wave lithotripsy,retrograde intrarenal surgery,percutaneous nephrolithotomy and laparoscopy and open surgery.Whether the standard procedures for staghorn stones can also apply to these stones in special situations is still not agreed upon.The decision should be made individually according to the circumstances of the patient.In this review,we evaluates the previous studies and comments on the management of staghorn stones under special situations in the hope of guiding the optimal choice for urologists.

Morphometry scores: Clinical implications in the management of staghorn calculi

Due to their large size,rapid growth,and attendant morbidity,staghorn calculi are complex clinical entities that impose significant treatment-related challenges.Moreover,their relative heterogeneitydin terms of both total stone burden and anatomic distributiondlimits the ability to standardize their characterization and the reporting of surgical outcomes.Several morphometry systems currently exist to define the volumetric distribution of renal stones,in general,and to predict the outcomes of percutaneous nephrolithotomy;however,they fall short in their applicability to staghorn stones.In this review,we aim to discuss the clinical utility of morphometry systems and the influence of pelvicalyceal anatomy on the management of these complex calculi.

A Novel Semi-rigid Nephroscope Percutaneous Nephrolithotomy： The Best Therapy for Renal Staghorn Calculi

Percutaneous nephrolithotomy （PCNL） has been the first-line treatment for renal staghorn calculi for many years. Several techniques have been described for percutaneous access and stone removal, but a multi-access approach is the mainstay of treatment. The main concern about PCNL is the resultant morbidity： Complications such as bleeding, parenchymal damage, and organ injury hindered the adoption of PCNL in primary hospitals in China.

Balloon dilation versus Amplatz dilation during ultrasound-guidedpercutaneous nephrolithotomy for staghorn stones

Background Amplatz dilation and balloon dilation are different methods in creating the accesses during percutaneous nephrolithotomy(PCNL). The aim of this study was to review the surgical experiences of managing staghorn calculi by Amplatz dilation and balloon dilation for 3 years.Methods We retrospectively analyzed clinical data from 125 patients(129 kidneys) with staghorn kidney stones who underwent PCNL from January 2010 to December 2012, of whom 60 patients underwent Amplatz dilation(AD group) and 65 underwent balloon dilation(BD group) during PCNL.Results The AD and BD groups were similar in age, male–female ratio, stone burden, stone type, hydronephrosis, and proportion of patients who had undergone extracorporeal lithotripsy. However, these two groups showed significant differences in terms of duration of percutaneous access(15.1±3.6) minutes vs.(10.0±3.3) minutes, one-attempt success rate of dilation via a single access 88.9%(72/81) vs. 97.8%(91/93), hemoglobin drop after surgery(3.5±0.9) g/dl vs.(1.7±0.9) g/dl, number of cases requiring intraoperative and postoperative blood transfusion 27.9%(n=17) vs. 13.2%(n=9), changes of central venous pressure before and after surgery(2.3±1.2) cmH2 O vs.(1.2±0.7) cmH2 O, number of patients who experienced postoperative fever >37.5°C 21(34.4%) vs. 13(19.1%)(all P <0.05). No injury of adjacent organs, including pleura, liver, spleen, or bowel, was noted in patients.Conclusions During ultrasound-guided PCNL for staghorn stones, balloon dilation and Amplatz dilation are all effective and safe. Compared with Amplatz dilation, balloon dilation is a better choice, as it has a higher access creation success rate, shorter access creation time less blood loss, and lower proportions of circulatory overload and postoperative fever.

预测微通道经皮肾镜碎石取石术治疗鹿角形肾结石术后严重出血的贝叶斯网络模型的建立与验证

目的探讨微通道经皮肾镜碎石取石术(M-PCNL)治疗鹿角形肾结石术后严重出血的危险因素,以此构建预测术后严重出血的贝叶斯网络模型。方法回顾性分析2020年1月—2022年1月于新乡医学院第一附属医院由同等资历术者行M-PCNL的160例鹿角形肾结石患者,采用计算机产生的随机数法以3∶1的比例将患者分为建模组(120例)和验证组(40例),将建模组患者按照术后出血情况分为严重出血组(38例)和非严重出血组(82例),比较两组患者一般资料,分析患者术后严重出血的独立危险因素,采用R软件构建贝叶斯网络模型,Netica软件进行贝叶斯网络模型推理预测;采用受试者工作特征(ROC)曲线对模型进行评价。结果对建模组进行多因素logistic回归分析,初步筛选出肾功能不全(OR:2.845,95%CI:1.563~6.515)、结石最大径≥2 cm(OR:2.063,95%CI:1.824~4.555)、手术时间≥90 min(OR:3.632,95%CI:2.365~7.114)、一期手术(OR:2.321,95%CI:1.874~6.332)、多通道取石(OR:1.842,95%CI:1.366~3.687)是影响患者术后严重出血的独立危险因素(P<0.05)。结合多因素logistic回归分析的结果,以肾功能不全、结石最大径、通道数目、手术时间、手术分期和术后严重出血建立贝叶斯网络模型。利用建模组和验证组对贝叶斯网络模型进行内、外部评价。建模组的AUC为0.879(95%CI:0.804~0.931,P<0.001),灵敏度、特异度分别为87.68%和89.63%;验证组的AUC为0.875(95%CI:0.818~0.908,P<0.001),灵敏度、特异度分别为87.55%和89.40%。模型区分度良好。结论肾功能不全、结石最大径≥2 cm、手术时间≥90 min、一期手术、多通道取石是影响患者M-PCNL后严重出血的危险因素。采用贝叶斯网络构建的鹿角形肾结石术后严重出血的预测模型具有较好的预测能力,并且能够更加直观地描述疾病与各因素间复杂的网络风险机制。

斜侧卧位下超声联合X线引导经皮肾镜碎石取石术治疗鹿角形肾结石的效果

目的:观察斜侧卧位下超声联合X线引导经皮肾镜碎石取石术(PCNL)治疗鹿角形肾结石(SC)的应用效果。方法:选取2020年1月—2022年3月南昌市人民医院收治的80例于斜侧卧位下行PCNL治疗SC的患者为研究对象,根据引导方式不同分为联合组和对照组,各40例。对照组在斜侧卧位下行常规的X线引导PCNL治疗,联合组在斜侧卧位下采用超声联合X线引导PCNL治疗。比较两组的手术情况、血清炎症应激指标、血清肾功能指标及术后指标。结果:联合组手术期间的穿刺次数、术中出血量均少于对照组,手术时间、操作通道建立时间均明显短于对照组,且操作通道建立成功率高于对照组,差异均有统计学意义(P<0.05)。术后1 d,两组皮质醇(Cor)、血尿素氮(BUN)、血清中性粒细胞明胶酶相关脂质运载蛋白(NGAL)、C反应蛋白(CRP)及降钙素原(PCT)水平均较治疗前上升,且联合组的PCT、Cor、BUN、NGAL水平均显著低于对照组,差异均有统计学意义(P<0.05)。联合组术后的并发症发生率及输血率均显著低于对照组,住院时间短于对照组,而首次结石清除率较对照组高,差异均有统计学意义(P<0.05)。结论:斜侧卧位下超声联合X线引导PCNL治疗SC效果显著,能有效降低患者术后并发症发生率。

THE FIRST CHOICE OF TREATMENT FOR URINARY INFECTED RENAL STONES

Objective To investigate the appropriate treatment of infectious renal stones. Methods Between April 1999 and June 2006, 60 patients presented to our department with infectious renal stones. Twenty-nine patients were treated by extracorporeal shock-wave lithortripsy(ESWL) only, 31 patients were given a combination therapy. Thirty-four males and 26 females were evaluated by routine urine tests including urine culture and sensitivity before ESWL treatments. The total number of shock waves varied from 1 600 to 2 800 and the energy levels ranged from 1 to 6 unit. Results The fragmentation after ESWL was 61.6%; 18.3% after 2 ESWL sessions, 8.3% after 3 ESWL sessions, 5.0% after 4 ESWL sessions, 3.3% after 7 ESWL sessions and 1.66% after 9 ESWL sessions. Only one (1.66%) patient failed and changed to open surgery. Conclusion ESWL is an effective and reliable treatment for patients with infectious renal stones. However, better effects and shorter treatment time is obtained by the combination therapy of ESWL with other therapy options.

火炬树克隆植株生长和生物量特征的研究

通过随机选取样木后进行室内外测定 ,揭示了外来种火炬树水平侧根形态特征、生物量积累格局与克隆繁殖的关系。结果表明 :火炬树克隆子株前端水平侧根直径超过后端水平侧根直径的形态不对称性随树龄而日趋显著 ,随地形起伏变化几乎呈现完全一致形态特征 ;火炬树子株前端水平侧根直径与其地径、冠幅、树高的相关性高于后端水平侧根直径 ;生长于荒山石隙生境 1～ 6a火炬树的生物量分配比例为树冠大于根系 ,单位长度水平侧根生物量却以子株前端水平侧根高于子株后端水平侧根 ,由此形成的生物量冠根复合分配格局成为火炬树克隆繁殖快速占据新生境的营养物质前提。火炬树具有营养物质在水平侧根趋前储备的特征 ,为其快速克隆繁殖准备最小空间间隔的相对充足的营养库。火炬树是一个入侵力正在表达的外来种。

输尿管镜下碎石清石术治疗输尿管上段结石

目的探讨输尿管镜下应用EMS三代碎石、清石设备处理输尿管上段结石的临床疗效。方法2004年1月～2005年12月,输尿管镜下EMS三代气压弹道联合超声负压碎石设备治疗输尿管上段结石112例。结石短径0.7～1.0cm,长径1.4～1.9cm,并发中重度肾积水73例,29例曾行体外冲击波碎石治疗。结果112例患者中101例一次碎石成功,成功率90.2%。失败的11例中有3例因进镜失败而改行经皮肾镜碎石,7例有较大的残石返回肾盂,留置D-J管后行体外冲击波碎石治疗,1例因输尿管穿孔行开放手术。结论输尿管镜下气压弹道联合超声碎石设备处理输尿管上段结石可以取得良好的治疗效果,特别是体积相对较小或距离肾盂-输尿管交界部相对较远的结石。

北京地区火炬树的萌蘖繁殖扩散

首次通过调查火炬树单株和火炬树林分的萌蘖繁殖扩散状况和小样方方法调查火炬树林下的乔木树种天然更新,了解火炬树对北京主要植被类型:油松人工林、侧柏人工林、刺槐人工林和灌木丛的扩散入侵情况。调查发现:在北京荒山爆破造林示范区,火炬树单株8a来4 5°扇形单方向扩散的最远距离为8.35 m,扩散萌蘖的最多株数达98株。立地条件差,特别是土层薄,裸露的岩石多是影响火炬树扩散能力的主要因素,但没有对火炬树萌蘖株的生长产生重要影响。扩散的群体中地径以小径阶个体占主体,说明火炬树萌蘖能力旺盛。在已有高大乔木的立地,如侧柏人工林和油松人工林,火炬树虽然能扩散进入,但只是伴生下木,很难形成优势群体;乔木林内光照明显影响火炬树的扩散数量和扩散规律;并且发现有10种北京当地乔木树种能在火炬树林下天然下种更新并且正常生长。分析表明火炬树没有对北京当地乔木群落构成威胁。火炬树能扩散进入邻近的灌木丛,并且扩散进入灌木丛的火炬树明显比扩散进乔木林内的火炬树长得高。火炬树的生物学和生态学特性决定了它是良好的荒山造林的先锋树种,不可能成为顶极群落的优势树种。所以火炬树目前对北京山区自然、半自然森林生态系统没有产生入侵危害。

输尿管软镜治疗鹿角状肾结石的疗效分析(附43例报告)

目的探讨输尿管软镜（flexible ureteroscopy,FURS）治疗鹿角状肾结石的安全性和可行性。方法回顾性分析2012年1月~2015年9月我院应用输尿管软镜治疗鹿角状肾结石43例的临床资料,术中留置输尿管软镜鞘,引入输尿管软镜进行钬激光碎石,术后1个月一期统计结石清除率,结石未清除则采取再次FURS或体外冲击波碎石。结果一期手术均能成功碎石,其中36例一期FURS,6例需行二期FURS,1例三期FURS。手术均成功置入镜鞘且寻及结石。手术时间43~136 min,平均67 min。术后住院时间2~18 d,中位数4 d。术后1个月一期结石清除率72.1%（31/43）,总结石清除率88.4%（38/43）。3例联合术后ESWL成功清除结石。1例孤立肾合并鹿角状结石术后因输尿管石街出现感染性休克和急性肾功能衰竭,1例术后肾周尿性脓肿,均治愈。术后发热2例。均无需输血,无输尿管穿孔、撕脱等并发症。总并发症发生率9.3%（4/43）。结论对于大部分鹿角状肾结石,输尿管软镜安全、可靠、有效,但为提高手术安全性及降低感染发生率,复杂性鹿角状肾结石提倡应用单通道经皮肾镜取石术联合逆行输尿管软镜治疗。

对苯二甲酸诱导大鼠膀胱结石与膀胱癌的研究

为研究对苯二甲酸致癌活性及可能的致癌机理 ,对SD大鼠连续喂饲对苯二甲酸 5 0 0 0、5 0 0、5 0mg kg染毒 90天 ,对照组给予正常饲料。结果显示 ,5 0 0 0、5 0 0mg kg剂量组分别发生 10例 (10 17)和 2例 (2 18)膀胱结石 ,5 0 0 0mg kg组雄性大鼠结石发生比例明显高于雌性 ,其它组未发生结石。 5 0 0 0mg kg组发生 4例膀胱移行细胞癌 (4 17)、5例不典型增生 (5 17)和 7例单纯增生 (7 17) ;5 0 0mg kg组有 10例不典型增生 (10 18)、5例单纯增生 (5 18) ;5 0mg kg组有 10例单纯增生 (10 17) ;对照组仅发生 1例单纯增生 (1 18) ,病变情况与染毒剂量呈明显等级正相关 (Rs=0 6 9) ,但与结石的关系不明显。未发生结石的大鼠也发生上述病理改变 ,高剂量组发生 1例膀胱白斑和 1例鳞状上皮化生 ,未见鳞癌。研究提示在本次实验条件下 ,对苯二甲酸或其代谢产物对SD大鼠可能具有致癌性 ,结石的机械刺激在肿瘤的发生过程中并非起主要作用。

微通道与标准通道经皮肾镜碎石术处理肾铸型结石疗效的比较

目的:探讨微通道和标准通道经皮肾镜碎石术(PCNL)在治疗肾铸型结石方面的临床效果。方法:收集肾铸型结石且进行了PCNL治疗的122例患者临床资料进行回顾性分析,根据不同工作通道分为微通道PCNL组和标准通道PCNL组,比较两组间术中术后情况包括手术时间、术后结石清除率、并发症等,并进行统计分析。结果:微通道PCNL组56例,标准通道组66例,微通道PCNL组手术时间长于标准通道PCNL组[(126±24.5)minvs(98±18.9)min],两组间在住院天数[(5.7±1.3)d vs(5.3±1.1)d]、出院前结石清除率(91.1%vs 89.4%)、血红蛋白下降值[(9.5±3.2)g/L vs(10.5±3.3)g/L]及手术相关并发症等方面差别并无统计学意义(P>0.05)。结论:微通道与标准通道PCNL在处理肾铸型结石的临床疗效与安全性方面无明显差别。