PCNL for stones in

solitary kidney

DR. AJMAL KHAN

UROLOGY RESIDENT
Key clinical objectives

 Stone in a solitary kidney represent a management

dilemma for endourologist.

 Maximum preservation of excisting renal function.

 High stone clearance

 Minimizing post procedure complications

INTRODUCTION

 In modern era PCNL has emerged the gold standard

intervention for large burden and complex renal
stone disease

 PCNL is associated with highest stone free rate

usually with only single procedure being done
 However potentially significant complication
include:

 Bleeding(requiring transfusion or
embolozation )
 Sepsis

 Pleural

 Visceral injury.
Criteria for inclusion and exclusion

 All studies reporting on their treatment of adult patients

who had stones in a solitary kidney were included

 Studies needed to have performed standard PCNL

monotherapy and not in conjuction with another
procedure.

 Animal studies and articles not published in the english

language were excluded.
Methodology( search strategy)

 Cochrane collabotation guidelines and systemic review

and meta-analysis guidelines were used to conduct the
review

 Electronic bibliographic databases were searched

 Medline, google scholar, embase, biomed central as well

as individual journal between may 1996 and may 2016.
Data extraction

Primary outcome

 Stone free rate (initial and final)

 Pre-operative and post-operative renal function

 Pre-operative and post-opertive hemoglobin levels

 Operative time and hospital stay

 Secondary outcomes

Complication rates (classified using clavien grading

system ) in order to evaluate procedural safety.

 The
following information if (available )was also extracted
Age
Body mass index
Aetiology of the solitary kidney
Results

 In total ,115 articles were screened and 6 of these were

considered to be original studies ,which satisfied
predetermined inclusion criteria.

 These all were level 111 ,retrospective cohort studies

published between 2011 and 2015 .

 4 of the 6 studies related to experiences from single centre

 The other 2 representing data from multi-institutional

 Baseline characteristics

 In total 905 patients with solitary kidney underwent PCNL

were included

 Regarding the aetiology of the solitary kidney ,in majority of

cases it was due to non functiong contralateral kidney
(confirmed by DMSA )

 Insufficient information was published on stone location ,stone

composition ,previous procedure ,dilatation method
(telescopic or baloon) ,
Outcome measures

 Main initial stone free rate was 78.1%(65.4-84.5%)

compared to an overall SFR (after an ancillary
procedure ) of 86.8% ( range 67- 95.3 )

 The definition of stone free rate varied across studies

with 3 studies providing no clear definition of stone free

 Imaging modality varied between x-ray, ultrasound and

non contrast computed tomography
 Time between surgery and imaging ranged from day 1
post procedure to 6 months later

 Majority 84% of procedure used a single tract.

 16% of procedure using multiple tract access

 Mean operating time was 91.2 minute (ranged 43 -175
mint)

 Hospital stay 3.5 days (ranged 1-5 days )

 Serum parameter showed

 Mean increase in creatinine of 0.31 mg /dl (range 0.1-
0.55)
 Mean drop of haemoglobin of 2g/dl
Complication

 Over all compliction rate was 30.6%.

 277 complication were recorded of which the largest

propotion were clavien Grade 1 (100/277, 36.1%) .

 69/277 (24.9%)complication were clavien grade 111

and there for required surgical ,endoscopic or
radiological intervention .
Complication

 Postoperative fever was the commonest recorded adverse

event in this category.

 51 (5.6 %) cases required blood transfusion

 7 patients suffered sever bleeding necessitating angio-

embolization
Complication

 No patient underwent subsequent partial or total

nephrectomy

 In total 2 deaths were reported

 However hosseini et al provided no further details on

these fatalities whether they were deemed to be
associated with the procedure
Discussion : findings and implications

 The result of this study have confirmed the efficacy of

PCNL for stone disease in a solitary kidney with initial
and overall SFRs of 78% and 86.8% respectively .

 A recent systemic review investigating URS revealed a

similar overall stone free rate of 87.2 %
 However it should be noted that PCNL results
Include clearance of complex stones including partial
and complete staghorn calculi.
Alternative surgical Interventions

2 main alternative treatment

Minimally invasive alternatives to PCNL.

 Extracorporeal shockwave lithotripsy

 URS/RIRS
Extracorporeal shockwave lithotripsy

 Feasibility limited in patients with high BMI

 Limited for stones <2cm

 Few intraoperative complication

 High number of repeat session to achieve free stone status

 Can lead to obstruction.

Extracorporeal shockwave lithotripsy

 SWL is associated with a higher rate of Stone re-formation

and re-growth (5-55%) compared with other procedures
URS

Day case procedure

Its use now extended in

 Pregnancy
 Obese patients
 Pediatric stone disease
 El-Assmy et al

In 2008, El-Assmy et al reported from 156 undergoing SWL

monotherapy, the largest series to date.

 At 3 months the SFR was 80.8% and 62.8% achieved stone

clearance after only 1 session.

 In regards to complications, 8.9% experienced steinstrasse

causing post SWL obstruction.
In 2015, Yuruk et.al

 In 2015, Yuruk et al recorded a final SFR of 73.3% in

a cohort of 30 patients with a solitary kidney who
underwent SWL.

 Stone clearance was achieved in a mean of 2.2

sessions, however 7 patients (23.3%) in the study
group required salvage URS.
Ct….

 While there have been previous concerns regarding

long term renal function after this treatment modality,
a recent systematic review determined

 There to be no strong evidence that SWL causes long

term deleterious effects on renal function
 A systematic review of URS in 116 patients with
solitary kidneys (mean stone size 16.8mm), recorded
mean SFR of 87.2% and 1.2 procedures per patient.

 Complications occurred in 28% of patients, of which

75% were Clavien Grade I.

 The efficacy and safety of URS in solitary kidneys with

a large stone therefore remains to be established.
Safety of PCNL IN SOLITARY kidney

 As for any surgery, minimising post-operative morbidity

and mortality is also paramount in the case of a solitary
kidney.

 It is fair to say that not withstanding their solitary kidney,

these patients are already a high risk population given
higher rates of other pre-existing medical co-morbidities
Such diabetes, hypertension and chronic kidney disease.
 Patients undergoing PCNL have higher rates of struvite and
Cysteine stone which pre-disposes them to higher rates of
stone recurrence accordingly.

 EL-nahas et al determined a solitary kidney to be a

significant risk factor for for hemorrhage.

 This is considered to be in part due to the compensatory

hypertrophy and dilatation of the remaining renal
parenchyma.
PCNL In Solitary and implication on renal function

 Our results suggest that there is no overall change in the

renal function, which seemed to be better post-operatively

 However, while Basiri et al reported an acute deterioration

in renal function after 48 hours, at 6 months follow up it
was either preserved or improved.
 Akman et al have postulated this decline to be a
temporary insult only, which could potentially be due to
anaesthetic agents or other medications such as
antibiotics.

 The argument for long term stabilisation or improvement

of renal function after PCNL has been supported by a
number of studies.
 However, non-indexed patients with co-morbidities such
as atherosclerosis and diabetes appear to be risk factors for
deterioration.

 Nuclear renography has been suggested as a more accurate

tool for assessment of renal function compared to
measurement of creatinine.
 According to multivariate-analysis carried out by El-Tabey
et al, identified multiple punctures (increased area of
parenchyma damaged) and bleeding to be independent risk
factors for renal dysfunction.

 While the use of flexible nephroscopes may reduce the need

for multiple punctures, large stones may necessitate it.
 This is even more relevant in patients with two kidneys,
as the contra lateral renal unit will compensate for any
insult to glomerular filtration and may not therefore be
obvious when measured using creatinine alone
Limitations and implications for future practice

 An obvious limitation of this study was the limited

number of eligible studies.

 This largely reflects the small number of centres with

sufficient experience in managing this clinical scenario.

 However, this review does draw on results from nearly

1000 patients.
 Furthermore, it is the first systematic review to address
this important clinical research question.

 Other limitations include lack of standardised

endpoints and imaging modalities.
Conclusion

 PCNL for stones in solitary kidney seems to have a good

stone free rate.

 Although the overall complication rates are slightly higher

than those reported for patients with two functioning kidneys,
the renal function seem to be relatively unaltered in these
patients.

 Given the complexity of these patients, they should

preferably be done in centers with a high caseload of PCNL
 Conclusion

 Surgical management of solitary kidney lithiasis is a

complex “grey” area.

 The selected intervention needs to provide a high

clearance rate balanced with an acceptable safety profile.

 This review has found PCNL to strike such a balance and

should be considered by urologists as an effective
therapeutic choice for patients presenting with large
burden stone disease