TY - JOUR
T1 - Confident Intraoperative Decision Making During Percutaneous Nephrolithotomy
T2 - Does This Patient Need a Second Look?
AU - Portis, Andrew J.
AU - Laliberte, Mark A.
AU - Holtz, Cindy
AU - Ma, Wenjun
AU - Rosenberg, Michael S.
AU - Bretzke, Carl A.
N1 - Copyright:
Copyright 2008 Elsevier B.V., All rights reserved.
PY - 2008/2
Y1 - 2008/2
N2 - Objectives: To evaluate intraoperative decision making regarding the necessity of second-look nephroscopy after percutaneous nephrolithotomy. Methods: Percutaneous nephrolithotomy was performed cooperatively by a urologist and radiologist equipped with a high-resolution C-arm. Ultrasonic lithotripsy was performed followed by thorough flexible nephroscopy and fluoroscopy. At conclusion patients were prospectively classified as radiologically and/or endoscopically stone free. If confident that complete stone clearance had been atruamatically achieved, a ureteral stent was placed. If there was suspicion of trauma or residual calculi, a nephrostomy tube was inserted. Postoperative CT was performed and allowed fragment classification as stone free, less than 2 mm, 2 to 4 mm, or 4 mm or greater. Results: Average stone dimensions were 640.2 ± 412.5 mm2 in 39 consecutive renal units. Computed tomographic imaging demonstrated that 26 renal units (66.7%) were stone free after primary procedure, with 5 (12.8%), 5 (12.8%), and 3 (7.7%) having fragments less than 2 mm, 2 to 4 mm, and greater than 4 mm, respectively. Of the 34 renal units considered endoscopically and fluoroscopically stone free, postoperative CT demonstrated 9 with residual fragments, all less than 4 mm. Of the 5 renal units not considered radiologically and endoscopically stone free, 4 had fragments on CT. Nephrostomy tubes were avoided in 33 patients. This intraoperative decision was supported by negative predictive values of 100%, 88%, and 73% at postoperative CT fragment detection thresholds of 4 mm, 2 mm, and 0 mm, respectively. Conclusions: Rigorous fragment detection allows confident intraoperative decision making regarding the necessity of second-look nephroscopy.
AB - Objectives: To evaluate intraoperative decision making regarding the necessity of second-look nephroscopy after percutaneous nephrolithotomy. Methods: Percutaneous nephrolithotomy was performed cooperatively by a urologist and radiologist equipped with a high-resolution C-arm. Ultrasonic lithotripsy was performed followed by thorough flexible nephroscopy and fluoroscopy. At conclusion patients were prospectively classified as radiologically and/or endoscopically stone free. If confident that complete stone clearance had been atruamatically achieved, a ureteral stent was placed. If there was suspicion of trauma or residual calculi, a nephrostomy tube was inserted. Postoperative CT was performed and allowed fragment classification as stone free, less than 2 mm, 2 to 4 mm, or 4 mm or greater. Results: Average stone dimensions were 640.2 ± 412.5 mm2 in 39 consecutive renal units. Computed tomographic imaging demonstrated that 26 renal units (66.7%) were stone free after primary procedure, with 5 (12.8%), 5 (12.8%), and 3 (7.7%) having fragments less than 2 mm, 2 to 4 mm, and greater than 4 mm, respectively. Of the 34 renal units considered endoscopically and fluoroscopically stone free, postoperative CT demonstrated 9 with residual fragments, all less than 4 mm. Of the 5 renal units not considered radiologically and endoscopically stone free, 4 had fragments on CT. Nephrostomy tubes were avoided in 33 patients. This intraoperative decision was supported by negative predictive values of 100%, 88%, and 73% at postoperative CT fragment detection thresholds of 4 mm, 2 mm, and 0 mm, respectively. Conclusions: Rigorous fragment detection allows confident intraoperative decision making regarding the necessity of second-look nephroscopy.
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U2 - 10.1016/j.urology.2007.08.063
DO - 10.1016/j.urology.2007.08.063
M3 - Article
C2 - 18308087
AN - SCOPUS:39549110195
SN - 0090-4295
VL - 71
SP - 218
EP - 222
JO - Urology
JF - Urology
IS - 2
ER -