Collaborative Review – Stone DiseaseIncidence, Prevention, and Management of Complications Following Percutaneous Nephrolitholapaxy
Introduction
Percutaneous nephrolitholapaxy (PNL) has been an essential technique for 35 yr for kidney stone removal, avoiding complications of open surgery [1]. PNL is the first-line approach for large, multiple, or inferior calyx renal stones according to the European Association of Urology (EAU) guidelines [2]. PNL generally is safe and effective and associated with a few but specific complications. However, definitions of complications of PNL and their management still lack consensus. The literature was systematically reviewed for the incidence, prevention, and management of complications following PNL.
The terms minor and major complications for percutaneous procedures are not standardized, and therefore comparison is difficult. For a reproducible quality assessment, relevant data on complication rates should be obtained in a standardized manner, allowing for comparison. A rational approach is to stratify complications by timing (intraoperative or postoperative). A useful tool is the Dindo-modified Clavien system, which was validated in 6336 patients for quality assessment in surgery worldwide [3].
While using standardized complication reporting to compare techniques and results, it must be understood that there are definite limitations of this approach with PNL where there are manifold technical differences in surgical technique, often based on different surgical traditions in different countries. For access, fluoroscopy is used in countries with Anglo-Saxon surgical traditions and ultrasound in others, puncture may be done by a radiologist or by the urologist, a mono-J or an occlusion ureteral catheter may be placed, an Amplatz sheath with low intrarenal fluid pressure or direct nephroscope insertion after Alken telescope tract dilatation may be used. In addition, the size of the tract and the scope and size of the nephrostomy tube inserted afterward add further variables that make direct comparisons difficult if not impossible. With an awareness of these differences, the literature search was evaluated as follows.
Section snippets
Material and methods
Medline was searched from 2001 until May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols.
Search strategy
A literature review using the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, Clavien, and the MeSH terms nephrostomy, percutaneous/adverse effects, and intraoperative complications or postoperative complications resulted in 635 records (Fig. 1).
Studies
Grading system for complications
Standardizing complications is necessary to allow comparison among different centers and within a center over time. The Dindo-modified Clavien system was proposed as a grading system for perioperative complications in general surgery [3]. According to this classification system, perioperative complications were stratified into five grades (Table 1).
In PNL there are some limitations in classifying complications because auxiliary treatments (eg, second-look PNL, ureterorenoscopy, and
Conclusions
Ensuring that PNL is performed for the appropriate indications, together with careful selection and preparation of patients, significantly lowers complication rates. Reduction of the risk of UTI by preoperative urine culture and appropriate antibiotic therapy and prophylaxis in patients with sterile urine together with a meticulous technique for access tract establishment are key preventive measures for complications. Stone burden, the number and size of access tracts, duration of the
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