Objective: To determine if supracostal renal access above the 11th rib during percutaneous nephrolithotomy (PCNL) is a safe option in carefully selected patients determined by preoperative computed tomography (CT) ima...Objective: To determine if supracostal renal access above the 11th rib during percutaneous nephrolithotomy (PCNL) is a safe option in carefully selected patients determined by preoperative computed tomography (CT) imaging. Patients and Methods: We retrospectively isolated 142 patients who underwent access above the eleventh rib during PCNL, which we term “high supracostal renal access.” We then compared these patients to 113 individuals who underwent access below the twelfth rib. Renal access was achieved by the operative surgeon with fluoroscopic guidance in conjunction with pre-operative computed tomography (CT) scan. Outcomes were compared. Results: Overall surgical outcomes were equivalent when comparing high supracostal versus subcostal access sites. As expected due to proximity, pleural complications occurred in 4% of the high supracostal group (n = 6) compared with 0% of the control (subcostal) group (p = 0.035). Of these six complications, three were managed conservatively with observation and two required cardio-thoracic intervention with video-assisted thoracoscopic pleural repair (1%). In the remaining case, the patient was preoperatively consented for placement of a thoracostomy tube, which was placed during the procedure, due to the difficult location of her upper pole stone and closely adjacent low-lying pleura, and the planned transpleural approach. Hospital stay was not significantly pro-longed between the high supracostal access and subcostal access groups, with an average length of stay of 2.2 ± 2.1 days and 2.0 ± 1.9 days (p = 0.59) respectively. Conclusions: Careful, systematic preoperative planning based on CT and fluoroscopic imaging allows for a confident understanding of a “safety zone” in placement and dilatation of renal access points during PCNL. We have shown that planned upper pole renal access above the 11th rib is achievable with acceptable morbidity and excellent success rates.展开更多
Cardiorenal syndromes (CRS) have been subclassified as five defined entities which represent clinical circumstances in which both the heart and the kidney are involved in a bidirectional injury and dysfunction via a f...Cardiorenal syndromes (CRS) have been subclassified as five defined entities which represent clinical circumstances in which both the heart and the kidney are involved in a bidirectional injury and dysfunction via a final common pathway of cell-to-cell death and accelerated apoptosis mediated by oxidative stress. Types 1 and 2 involve acute and chronic cardiovascular disease (CVD) scenarios leading to acute kidney injury or accelerated chronic kidney disease. Types 2 and 3 describe acute and chronic kidney disease leading primarily to heart failure, although it is possible that acute coronary syndromes, stroke, and arrhythmias could be CVD outcomes in these forms of CRS. Finally, CRS type 5 describes a simultaneous insult to both heart and kidneys, such as sepsis, where both organs are injured simultaneously. Both blood and urine biomarkers are reviewed in this paper and offer a considerable opportunity to enhance the understanding of the pathophysiology and known epidemiology of these recently defined syndromes.展开更多
文摘Objective: To determine if supracostal renal access above the 11th rib during percutaneous nephrolithotomy (PCNL) is a safe option in carefully selected patients determined by preoperative computed tomography (CT) imaging. Patients and Methods: We retrospectively isolated 142 patients who underwent access above the eleventh rib during PCNL, which we term “high supracostal renal access.” We then compared these patients to 113 individuals who underwent access below the twelfth rib. Renal access was achieved by the operative surgeon with fluoroscopic guidance in conjunction with pre-operative computed tomography (CT) scan. Outcomes were compared. Results: Overall surgical outcomes were equivalent when comparing high supracostal versus subcostal access sites. As expected due to proximity, pleural complications occurred in 4% of the high supracostal group (n = 6) compared with 0% of the control (subcostal) group (p = 0.035). Of these six complications, three were managed conservatively with observation and two required cardio-thoracic intervention with video-assisted thoracoscopic pleural repair (1%). In the remaining case, the patient was preoperatively consented for placement of a thoracostomy tube, which was placed during the procedure, due to the difficult location of her upper pole stone and closely adjacent low-lying pleura, and the planned transpleural approach. Hospital stay was not significantly pro-longed between the high supracostal access and subcostal access groups, with an average length of stay of 2.2 ± 2.1 days and 2.0 ± 1.9 days (p = 0.59) respectively. Conclusions: Careful, systematic preoperative planning based on CT and fluoroscopic imaging allows for a confident understanding of a “safety zone” in placement and dilatation of renal access points during PCNL. We have shown that planned upper pole renal access above the 11th rib is achievable with acceptable morbidity and excellent success rates.
文摘Cardiorenal syndromes (CRS) have been subclassified as five defined entities which represent clinical circumstances in which both the heart and the kidney are involved in a bidirectional injury and dysfunction via a final common pathway of cell-to-cell death and accelerated apoptosis mediated by oxidative stress. Types 1 and 2 involve acute and chronic cardiovascular disease (CVD) scenarios leading to acute kidney injury or accelerated chronic kidney disease. Types 2 and 3 describe acute and chronic kidney disease leading primarily to heart failure, although it is possible that acute coronary syndromes, stroke, and arrhythmias could be CVD outcomes in these forms of CRS. Finally, CRS type 5 describes a simultaneous insult to both heart and kidneys, such as sepsis, where both organs are injured simultaneously. Both blood and urine biomarkers are reviewed in this paper and offer a considerable opportunity to enhance the understanding of the pathophysiology and known epidemiology of these recently defined syndromes.
