Role of Pyelolithotomy in modern era

• 18 Feb 2020 02:41:55 PM
• |General Urology

65 yr Male with normal renal function came with bilateral flank pain. This was his X-ray KUB. 

Comments(13)

• 

  Dr. Anil Takvani

  18 Feb 2020 03:01:41 PM

  Utsav Shah, 

  First of all, let me congratulate you.

  You are the first trainee to post on uroacademy.org.

  Is this patient has history of renal stone surgery in past?

  As his renal function is normal, please provide IVU or CT IVU films...

  Also USG details of amount of HN and details of cortical thickness on either side.

• 

  Utsav Shah

  18 Feb 2020 05:25:51 PM

  Ok sir. I shall get back to u with the details in a day

• 

  Dr. Md. Mazedur Rahman

  19 Feb 2020 12:17:15 AM

  I think, Bilateral standard PCNL will be most beneficial stone clearance management for this patient, in addition preventive measure according to analysis.

• 

  Utsav Shah

  19 Feb 2020 09:38:57 AM

  Attaching the images of CT KUB(P). Excretory imaging not done.

  
  

  Severe cortical thinning in both the kidneys with maximum measurable parenchymal thickness 8.5-9mm
  

  
  

  
  

  

• 

  Pankaj N Maheshwari

  19 Feb 2020 12:46:45 PM

  Interesting case

  Right PCNL is easy: may need two tracks

  Left very difficult to make stone free both by open or by PCNL. In view of intra-renal pelvis, i would prefer PCNL

  Few precautions for the left PCNL:

  Will need a supra-costal access

  Look for spleen (in one coronal image, it appears in the line of the PCNL tract)

• 

  Sunil Moteria

  19 Feb 2020 01:06:11 PM

  Interesting case Utsav,

  will like to have some more additional information 

  Sr Creatinine ??.. though you have put Normal Renal function but looking to the CT findings it should not be expected to be normal get it Checked again

  Second any previous surgery ?? 

  and lastly answer to your main query ..Definitely YES if you have a Good Mentor go ahead with Open Surgery, Rt Side it will require a Pyelonephrolithotomy which is likely to clear in a SIngle Stage but for  Lt side a Multiple Nephrotomies 

  I personally  would not recommend an Open Surgery for Lt side as this the morbidity of Multiple tract PCNL would be definitely less than Open Upper Pole Nephrolithotomy and presence of multiple secondary stone in Mid andLower calyces .

  hope this will help you 

  
  

• 

  Utsav Shah

  19 Feb 2020 07:55:17 PM

  Thanks sirs !!

• 

  Ajay Bhandarkar

  19 Feb 2020 11:23:56 PM

  Dear Utsav,

  
  

  Nice case for discussion. 

  Management for such case needs proper planning. No PCNL plan can be final without proper RGU picture. Like, Pankaj said two punctures can clear Right side, but, left PCS looks tricky. Is there a history of previous intervention on left side ? Anyways more then two punctures, careful supracostal access can offer clearance. We need to think of proper drainage of left PCS post clearance.

  
  

  With availability of many efficient energy sources, large bulk of stone volume is not a deterrent to PCNL. Open surgery can be avoided, provided you have good experience of  PCNL and able to puncture desired calyx in aggressive PCNL.

• 

  Gyanendra Sharma

  20 Feb 2020 09:15:47 AM

  First of all Kudos to Utsav for bring fore the topic of pyelolithotomy

  With the widespread availability of expertise & instrumentation for endourology--open surgery  for stone disease is getting  less & less common

  In general surgery the residents do not get a chance to see Pyelolithotomy  ( in many centers) leave aside doing one

  In Urology residency--such challenging cases are done by the seniors & again residents get to assist or see such cases

  There are certain other concerns which I would like to raise

  1. The overall fitness of the patient to undergo a major procedure  in prone position

  2. If PCNL is planned-- care taken to prevent sepsis, RGP before the procedure, Which side to be addressed first, explanation to the patient that even on one side a two stage PCNL may be needed. Time interval  between the one side & then the other side PCNL

  3. If the surgeon feels that he can have good clearance with open surgery--I feel there is no shame in doing an open surgery for such cases, especially if the anesthetic concerns are addressed

  The reason I am raising the anesthesia issue is that duration of anesthesia in a 65 year old patient who may be having associated ailments should be considered by the surgeon as it can have significant implications in post op period

  This becomes even more important if the surgeon is in a nursing home & not in gig institutes

  
  

  As regards PCNL I fully agree with what Dr. Pankaj & Dr. Ajay have written

• 

  Utsav Shah

  20 Feb 2020 01:53:24 PM

  Thank you for your opinion sirs..

  
  

• 

  Nitesh Jain

  20 Feb 2020 08:58:42 PM

  Looking at CT and plain X-ray it doesnot look like this patient is having a normal renal function 

  
  

  Will put a PCN bilaterally and assess the kidney function to plan any thing definitive 

  
  

  Regarding the role of pyelolithotomy at present - indications are hardly any except 

  1. When needs to be combined with Pyeloplasty

  2. Combined with any other open surgical procedure or partial Nephrectomy for a tumor 

  3. I feel the current generation is more used to PCNL than pyelolitjotomy and probably will be more comfortable in doing that rather than struggling with once a blue moon procedure 

  
  

  **** request you to recheck the RFT again 

• 

  Dr. Anil Takvani

  21 Feb 2020 12:51:56 PM

  Please re-check RFT

  Right side I am very much comfortable with extended(Gilvernet) pyelolithotomy.

  That will be almost bloodless and as rightly said by Sunil can be a single stage solution for complete clearance. Left side is tricky, put the PCN as Nitesh has mentioned. Decompress the system. Check how much urine left kidney is producing. Do the nephrostogram if kidney is functioning well and decide punctures. We have to explain multi puncture , multi sitting PCNL.

  Thanks

• 

  Ravindra Sabnis

  24 Feb 2020 09:11:18 AM

  Likely that cr may be raised.  Left side - why is hydronephrosis is not clear.  Is there stone in puj? I could not see that. Bilat pcn first will be safer.   Dilated system pcnl is easy. Both sides can be managed by endourology.  

  Your specific question - role of pyelolitjotomy in modern era ( which means all expertise & all equipments are available)  - if I have to answer - then answer is "NO"