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worthwhile?
Original Article;
Authors
2) Dr Ghazi Khan
Senior Registrar Urology Department
Shaikh Zayed Hospital Lahore
4) Dr Jamshed Rahim
Asisstant Professor Urology
Federal Post graduate medical Institute
Lahore
Correspondence to;
Dr Muhammad Muzammil Tahir
Assistant Professor Urology
Federal Post Graduate Medical Institute
Lahore
Tel; 03214979631
E mail; dr_muzamil@yahoo.com
Is tubeless percutaneous nephrolithotomy (PCNL) is really
worthwhile?
Abstract
Aims and objectives; To compare standard and tubeless PCNL in our patients
in term of need for analgesia, urinary leakage from nephrostomy site, hospital
department Shaikh zayed hospital Lahore. Sixty patients from both sexes,
underwent standard PCNL, and compare with similar number of the patients
whom we performed tubeless PCNL from Aug 2007 to march 2008. Patients
with multiple puncture site, residual stones, and bleeding were excluded from this
study.
Results; We compare both groups. The need for analgesia, inj pethadine
sulphate for group I, patients was 400mg while for group II patients, it was just
100 mg. Leakage from the nephrostomy site occurred in 08 patients while in
group II, there was no leakage. 03 patients suffer from urinoma formation in
2
Original Article
To get rid of stone from the kidneys is really a gigantic task, both for treating
physician and the patient. It involves a lot of effort on both sides, and really it is
confusing for the patient to follow the modalities for stone treatment. Because
there is advantage of one procedure over the other and there is definitely edge
Apart from the decade old procedures like pyelolithotomy, nephrolithotomy, new
shockwave lithotripsy (ESWL) are on strong footing in getting rid of stone burden
treatment of choice, when considering morbidity and hospital stay of the patients.
As standard PCNL, tubeless PCNL, total tubeless and PCNL in supine position
are different modalities of PCNL, one having edge over the other.
Objective
To compare standard and tubeless PCNL in our patients in term of need for
analgesia, urinary leakage from nephrostomy site, hospital stay and urinoma
formation.
3
Material and methods
60 consecutive cases performed from August 2007 to 30th march 2008, who
underwent tubeless PCNL and assigned them Group II. The stone burden,
number, location of the stone, or renal function was not considered. A similar
puncture sites. Exclusion criteria was, more than 02 tract, residual stones, and
significant bleeding
examination, serum cretanin, urine for culture sensitivity , PT, APTT was
performed. All patients underwent IVU and ultrasonography, those who had
abnormal renal function, underwent isotope renal scan. Patients who had
deranged liver function, with disturbed PT and APTT were excluded from this
catheter was passed on guide wire and secured to a foley’s catheter. Uretral
catheter allows the injection of contrast material or air to opacify and distends the
collecting system, further more the catheter will prevent fragment from falling into
the ureter.
4
Once the catheter is inserted the patient is placed in a prone position, the
percutaneous puncture placed in post axillary’s line into appropriate calyx, under
fluoroscopic guidance. Once the puncture needle reaches the calyx, the stylet is
removed and a 0.035 inch floppy J tipped guide wire inserted into needle, then
28 Fr, with metal dilators was done, followed by placement of the amplatz
sheath . through which 26fr, rigid nephroscope (karl storz™ ) was passed.
fragments were removed by grasping forcep. At the end of the procedure, a 20Fr
nephrostomy tube was left in situ in group I, ( patients who underwent standard
PCNL). We use, Foley catheter 22Fr with balloon channel arm amputated. But in
group II, whom underwent tubeless PCNL, the nephrostomy tube was not placed,
instead the wound was closed with silk 2/0. after sure on fluoroscope, that there
The ureteric catheter was removed with in 24 hour, while PCN tube was kept for
48 hours in group I, in group II, the ureteric catheter was left for 48 hour.
Patients were followed in out door clinic regularly every 03 month, with plain X
ray KUB, ultrasound, and urine C/E., till the patient was declared either stone
Results
5
a comparison was made regarding need for analgesia, leakage from the
the need for analgesia, inj pethadine for group I, in these patients was, 400mg
while for group II patients, it was just 100 mg. Leakage from the nephrostomy
site occurred in 08 patients while in group II, there was no leakage. 03 patients
had an average of 5.5 days hospital stay, while it is 3 days for group II patients.
nephrostomy site
Urinoma 03 Pt (5%) 01 Pt (1.66%)
Discussion.
stent, are left in along with nephrostomy tube at the end of procedure. In tubeless
PCNL, only the ureteric stent was left in place, while nephrostomy tube was
omitted. Nephrostomy tube is kept to keep the system open, and let it drain for
48 hour in standard PCNL, while ureteric stent is kept for only 24 hour in most of
6
the cases. We kept the ureteric stent for 48 hour in tubeless PCNL, and
compare there results. Our results were very encouraging, in tubeless PCNL.
Average hospital stay In our study was 03 days. In a larger study the hospital
3,4,9
stay were 2.5 to 3.63 days . In those institutions, where they are using JJ
5,4,8
stent, it is reduced to 24-26 hours . In our patients the time is a few hours
more than other studies, the reason is that we keep the ureteric stent for 48h, we
remove the stent before discharging the patient, as our patients are from far flung
areas, so they opted to stay for a day in hospital after removal of all the stents.
Other alike studies keep the JJ stent, for a few weeks, a similar study by Agrawal
et al4, compared standard and tubeless PCNL, used the JJ stent instead of
ureteric catheter there results show hospital stay for standard PCNL 54.2 +/-
5hours, while for tubeless PCNL it is 21.8 +/- 3.9 hours. Rana et al 10, kept the
ureteric stent for 16-20hour, and discharged the patient immediately after
removing the stent, they have average hospital stay of 16-20 hour, which Is much
There is marked difference for the analgesia requirement between both groups,
in our study, there is 400 mg of inj Pethadine sulphate was required for the
group I while for group II it was 100 mg, which is similar to many studies in
which analgesic requirement between both groups vary in the ratio of 2:1, to
different studies, it is due to the length of stay of nephrostomy tube, size, and
7
Leakage from the nephrostomy site in group I patient in our study was 4.8%,
while for group II it was nil, which is similar to other studies4,5. The urinoma
formation in our study in group I was 5%, while for group II it was 1.66%, which is
Conclusion
Tubeless PCNL is an effective and safe procedure, with much less morbidity,3, 4,
5,7
. It is safe and effective even in patients with a solitary kidney, in patients where
multiple tract are made and in with supracostal access,5. We recommend this
References
8
4. Agrawal MS, Agrawal M, gupta A, Bansal S, Yadav A, Goyal J; A
5. Shah HN, Kausik VB, Hegde SS, Shah JN, Bansal MB; Tubeless
Nov;17(7):1351-4.
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riginal Paper
• Dr Farah Yousaf
Prof of Urology/Principle
10
Original Paper
Abstract
Objectives; To find out optimal procedure of repair of uretervaginal fistula and
there outcome in gynaecology and obstetric practice.
Conclusion; Always try to treat the patients conservatively in ureteric injury, with
stenting if possible, patients with conservative management, along with ureteric
implantation group have good results, while in those with adjuvant maneuver
like Boari flap have fair success rate, in experienced hands.
11
Treatment modalities and outcome for Ureterovaginal fistula
inflicted in obstetrical and gynaecological practice
Introduction;
The close anatomical relationship between the urinary tract and internal genital
organs predisposes the distal ureter to iatrogenic injury during pelvic and
gynaecological surgery. The incidence of ureteric injury during hysterectomy for
benign disease is 1:500 cases, which rises to 1% in cases of malignancy. The
risk of ureteric injury is higher during abdominal compared to vaginal
hysterectomies. Repeat caesarean sections and postpartum hysterectomies are
also associated with increased risk of injury to the lower urinary tract. Most of the
uterine injuries occur at the lower one third of the ureter5.
All the patients were admitted. A detailed history of the patients regarding
mode of gynecological or obstetrical procedure was obtained. History of surgery,
cause, type of injury was taken. Duration between the infliction of injury and
development of symptoms was recorded. This was followed by thorough clinical
examination including general physical examination, systemic and pelvic
examination. In the pelvic examination both per vaginal examination and
speculum examination were performed and the findings were recorded. In
addition to routine investigations, ultrasonography and intravenous urography
12
was done to evaluate the upper tract, status of bladder, ureter and any leakage.
In patients where intravenous urography was inadequate to demonstrates
ureteral anatomy then retrograde pyelography was performed.
Patients with ureterovaginal fistulae double J stent was tried to pass at the
initial stage. Where we were unable to pass the ureteric stent, the distance
between the ureteric orifice and the site of injury were noted. On the basis of
these findings the decision, regarding mode of procedure was made, where the
distance was 2-3 cm we go for ureteric reimplantation with double J stent, Boari
flap with Psoas hitch and double J stent was performed for distance more than 4-
5 cm. For suturing vicryl 4/0 was used for end to end ureteric anastomosis over
JJ stent. JJ stent was removed on 6th post operative week. Patients were
assessed for outcome.
Results
13
with JJ stents and they were called after six weeks for removel of JJ stent. The
average hospital stay of the patients after different procedures for the UVF was
4.66 days.
Discussion
14
The uretrovaginal fistulae may be treated with internal stents, end to
end anastamosis of ureter if the distance is short, ureteric reimplantation
with JJ stenting, ureteric reimplantation with psoas hitch or Boeri flap 6.
If damage is extensive and involving the distal ureter and gap is more, it
is difficult to mobilize the ureter sufficiently to anastamose it without
tension then Psoas hitch, Boari flap or combined procedure are the
treatment of choice. We performed ureteric reimplantation in 10
patients with good results, managed with just JJ stent, in 3 patients with
good success, in 3 patients we performed ureteric implantation
(submucosal tunnel) with psoas hitch, with 100% success rate while 02
patients underwent boeri flap with JJ stent, with success rate of 50%.
The success in these patients depends on many factors, included,
following surgical principles, infection free and most importantly
experience of the surgeon.
In all the patients JJ stents were used for splinting the ureteric
repair. It prevent the post operative urinary leakage, and reduces the
postoperative morbidity10, however controversies exist in the use of JJ
stent, in uncomplicated cases. In survey of American urological
association of 1453 cases, about 75% used splints for ureteric repairs
the consensus view is that, there use do a lot of good than to harm the
patient 12. we use only jj stent to manage these patients conservatively,
with good result.
Conclusion;
15
associated with better outcome.
References
3. Nawaz FA, Khan ZE, Rizvi J: Urinary tract injuries during obstetrics and
gynaecological surgical procedures at the Agha khan university hospital
Karachi, Pakistan: a 20 year review;Urol int.2007;78(2):106-11.
564-70.
16
10. Cormio L; Ureteric injuries, clinical and experimental studies; Scand-J-
Urol-Nephrol-Supp;1955;171:1-66
763399839
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