PNL in FFMSP FOR SHS

1. Ahmed M Eliwa ,Lotfy Bendary,
E A Desoky, Ashraf M.S Shahin, Mahmoud El Adl
PERCUTANEOUS NEPHROLITHOTOMY
IN
FLANK FREE MODIFIED SUPINE POSITION
FOR TREATMENT OF
STAGHORN STONES

2. • Staghorn stones are large, branched stones that fill all
or part of the renal pelvis and extend into the majority
of the renal calices
Kelly et al 2007
• If left untreated, staghorn calculi may lead to
deterioration of renal function, end-stage renal disease,
and life-threatening urosepsis.
Preminger et al 2005

3. • PCNL considered treatment of choice for the
management of staghorn calculi especially in the terms
of cost-effect, need for blood transfusion, hospital stay,
and return to work.
Gleeson et al 1991

4. • To further improve outcomes with PCNL, several
technical refinements have been advocated for
staghorn stones, including multiple percutaneous
accesses and the use of flexible nephroscopy
Chibber 1993
Aron et al. 2005

5. • PCNL is performed in the prone or position.
• The advantage of PCNL in supine position are
easier introduction to anesthesia the possibility
of using retrograde (ureterorenoscopy) and
antegrade method (nephroscopy).
Vavic et al 2010

6. • The supine position and its modification had
limitation of narrow field for renal puncture as
the flank is usually occupied by cushion

8. • This study was conducted in Urology department
faculty of medicine Zagazig University during the
period from October 2009 till March 2012

9. • The study included 37 patients (11 females and
26 males) with a mean age of 39.67y [±8.28SD]
• all had staghorn calculi (stone that occupy renal
pelvis and at least one major calyx).

10. • We had 9 (24.32%) patients with a stone
occupying renal pelvis and one major calyx, 22
(59.45%) patients with a stone in the renal pelvis
and 2 major calyces and 6 (16.21%) patients
with stone occupying renal pelvis and more than
two major calyces.

11. • The patients were positioned in the flank free modified
supine position [originally described at our department].
• Average stone size was 37.7mm[±8.43SD]
• It is achieved by putting a suitable cushion according to
patient body mass under the ipsilateral shoulder, fixing
ipsilateral arm over the thorax, and crossing the
extended patient ipsilateral leg over the contralateral
leg.

13. • After reviewing the imaging of each patients a
preplanned tracts were decided for each patient
• Initial Fluoroscopic guided puncture or punctures
were done and a safety wires were inserted in
both tracts.

14. • Dilatation of the primary tract (the lower posterior calyx)
tract and performing nephroscopy.
• The secondary tract was dilated and nephroscopy was
performed when needed.
• We used pneumatic lithoclast for stone fragmentation
and stone retrieval with stone forceps.
• At the end of the procedure 20 French nephrostomy
tubes was inserted and left for 24-48 hours.

16. • Follow up radiology was done at 24-48 hours and
accordingly:
• 2nd session PNL was planed if the residual stone fragment
was more than 2 cm and done not less than 48 hours after
first intervention
• On the other hand ESWL was done if residual fragments
are less than 2 cm

17. • The patients is regarded stone free if there were
no detectable fragments or fragments less than
4 mm after any modality of treatment.

18. • The mean operative time was 110.7 [±17.0SD]
minutes.
• Single tract [the primary access tract] was done in 32
patients (86.49%) while 5 (13.51%) patients needed
dilatation of the secondry tract.

19. Stone Morphology Patient number
Number
of the
planned
tracts
Single tract
1st look
More than one
tract
Cleared at
2nd stage
after 48
hours
For
auxiliary
procedur
e
cleared Not cleared
9 1 9 0 8 1 0 1
22 2
19
[11+4+
1+3]
3
14
[11 one
tract and 3
two tracts}
4 2nd &cleared
1 2nd and not
cleared
3 for ESWL]
4 4
6 2 4 2 2
4
[1 for 2nd look
+3 for
ESWL]
1 3
32
[86.4%]
5
[13.51%]
SFR at 24 h
24
(64.8%)
SFR At
discharge
29(78.3%)

20. Stone
Morphology
Patient number
Number of the
planned tracts
Single tract
1st look
More than one tract
9 1 9
0
22 2 19 3
6 2 4 2
32
[86.4%]
5
[13.51%]

21. Cleared at 2nd stage after
48 hours
For auxiliary procedure
cleared Not cleared
8 1 0 1
14
[11 one tract and 3
two tracts]
8
[5 for 2nd look
+
3 for ESWL]
4 4
2 [two tracts]
4
[1 for 2nd look +3 for
ESWL]
1 3
SFR at 24 h
24 (64.8%)
SFR At discharge
29 (78.3%)

22. • Twenty four patients were stone free after the first
session of PCNL [SFR at 24 h 64.8%].
• Six patients [16.21%] were scheduled for second look
after 48 hours, five [31.51%] of them were stone free at
hospital discharge and one was scheduled for ESWL
making the stone free rate at hospital discharge
(78.3%).

23. • The mean pre-operative hemoglobin was 12.16gmml
[±0.89] while the mean post-op hemoglobin was 10.97
gmml [±1.11] and there was no statistical difference
between both values (P=2.44).
• only three patients received 1-2 units of blood.
• Finally no colonic injury was reported.

24. CONCLUSION
• Staghorn stones are complex stones that represent a
challenge to both endourologist and the patients
especially in clearing the calyceal part of the stone

25. • Flank free modified supine position in treating staghorn
stones is a feasible procedure that harboring both
accepted safety and efficacy
• More than one puncture and/or tract can be done in this
position safely.

26. THANK YOU