Asunto(s)
Cálculos Renales , Nefrostomía Percutánea , Sepsis , Estudios de Cohortes , Humanos , Estudios ProspectivosRESUMEN
INTRODUCTION: Between 5 and 10% of patients undergoing percutaneous nephrolithotomy (PCNL) develop postoperative sepsis 1, 2. Strategies to prevent infectious complications are based on information provided by preoperative midstream urine cultures (PMUC). The aim of this study is to evaluate the concordance of the microbiologic findings of PMUC, cultures of the renal stone (RSC) and urine obtained directly from the renal pelvis (RPUC) in patients undergoing PCNL. MATERIALS AND METHODS: This is a multicenter prospective study. The study included all patients who underwent PCNL from May 2013 to July 2015 in three academic hospitals. All patients underwent a PMUC. Samples for RPUC were obtained by renal puncture for PCNL. Stone fragments extracted during the procedure were sent for culture (RSC). Clinical variables, stone configuration, burden and microbiology reports of cultures were recorded. We analyzed concordance between cultures and association with infectious complications. RESULTS: One hundred and twenty-two patients underwent PCNL. Twenty-four percent had positive culture, 3.2% (4/122) PMUC, 14.7% (18/122) RPUC and 13.9% (17/122) RSC. Positive PMUC demonstrated multidrug-susceptible Escherichia coli and Staphylococcus aureus, while RPUC showed multidrug-resistant pathogens and/or fungus. Seven patients (5.7%) developed postoperative infectious complications prior to discharge. There was a weak correlation between PMUC and intraoperative urine cultures (RPUC and RSC). Concordance rate between RPUC and RSC was 83.3%. The most common isolated pathogens were multidrug-resistant bacteria or fungus. CONCLUSIONS: PMUC did not reflect the microbiological environment found in stones and urine directly obtained from the renal pelvis. Patients with postoperative infectious complications had negative PMUC with positive RPUC or RSC. RPUC and RSC can help guide prompt and appropriate antibiotic treatment for patients who develop postoperative infectious complications after PCNL.
Asunto(s)
Bacteriuria/microbiología , Cálculos Renales/microbiología , Nefrostomía Percutánea/efectos adversos , Complicaciones Posoperatorias/microbiología , Sepsis/microbiología , Adulto , Anciano , Candida albicans/aislamiento & purificación , Farmacorresistencia Bacteriana Múltiple , Enterococcus faecalis/aislamiento & purificación , Escherichia coli/aislamiento & purificación , Femenino , Fiebre/microbiología , Humanos , Cálculos Renales/cirugía , Cálculos Renales/orina , Pelvis Renal/microbiología , Klebsiella/aislamiento & purificación , Masculino , Persona de Mediana Edad , Periodo Preoperatorio , Estudios Prospectivos , Proteus mirabilis/aislamiento & purificación , Staphylococcus aureus/aislamiento & purificación , Streptococcus/aislamiento & purificaciónRESUMEN
Introducción: Entre el 50 por ciento a 10 por ciento de los pacientes sometidos a nefrolitotomía percutánea (NLP) presentará sepsis. Las estrategias de prevención de complicaciones infecciosas actuales, se basan en la información entregada por los cultivos de orina preoperatorios. El objetivo de este estudio es comparar los perfiles microbiológicos entre los cultivos de orina tradicionales preoperatorios, con cultivos del microambiente del cálculo renal (orina de pelvis renal y del cálculo) de pacientes sometidos a NLP.(AU)
Introduction. Between 50 pertcent to 10 pertcent of patients undergoing percutaneous nephrolithotomy (PCNL) will present sepsis. Current strategies for preventing infectious complications are based on the information provided by preoperative urine cultures. The aim of this study is to compare the microbiological profiles from traditional preoperative urine cultures with cultures from renal microenvironment (renal pelvis urine and kidney stone) of patients undergoing PCNL. Material y Methods. International multicenter prospective clinical trial. The study was conducted from December 2012 to May 2014 in three teaching hospitals, two from Chile and one from Argentina. All patients undergoing PCNL during that period were included. In a prospective fashion, preoperative urine culture, microbiological study of extracted urinary stones and cultures from renal pelvis urine were requested. In each hospital, data regarding patients was submitted through an online questionnaire: Age, sex, comorbidities, type of stone (staghorn or not), size of the stone, isolated bacteria, resistance profile and postoperative infectious complications were filled.(AU)
Asunto(s)
Humanos , Nefrolitotomía Percutánea , SepsisRESUMEN
Introducción: La mitomicina C es un agente quimiotera-péutico en virtud a su actividad antiproliferativa y anti-biótica. Se evalúa el resultado de la cervicotomía radial endoscópica combinada con la inyección intralesional de mitomicina C para el tratamiento de las estenosis severas de cuello vesical luego del fracaso del trata-miento tradicional. Materiales y método: Revisión retrospectiva de los pa-cientes con estenosis severa de cuello vesical intervenidos entre julio de 2013 y agosto de 2015 con la utilización de mitomicina C. El 54.5% de los pacientes había fracasado al menos una vez con la realización de cervicotomía interna y/o resección endoscópica de cuello vesical. En nuestra intervención se realizaron tres o cuatro incisiones endoscópicas con corte frío en el cuello de la vejiga, seguido por la inyección intralesional de 0.3 a 0.4 mg/ml de mitomicina C en cada sitio de incisión. Resultados: Un total de 11 pacientes fueron tratados con incisión endoscópica con corte frío en el cuello de la vejiga combinado con la inyección de mitomicina C. Antes de la operación, 4 pacientes (36%) eran usuarios de cistotomía. En un seguimiento medio de 9 meses (rango 1-20) 9 pacientes (82%) se encuentran con micción espontánea posterior a un procedimiento, mientras que 2 pacientes (18%) lograron dicho objetivo después de 2 procedimientos con utilización de mitomicina C. Conclusiones: El tratamiento para la estenosis del cuello vesical con cervicotomía radial endoscópica con corte frío combinada con inyección intralesional de mitomicina C, resultó en la permeabilidad del cuello vesical en el 82% de los pacientes después de 1 procedimiento y en el 100% después de 2 procedimientos. Aunque los primeros resultados son prometedores, se requiere de estudios prospectivos y aleatorizados con seguimiento prolongado en el tiempo para validar estos hallazgos.
Introduction: The mitomycin C is a chemotherapeutic agent by virtue of its antiproliferative and antibiotic ac-tivity. We evaluated the outcome of endoscopic radial cervicotomy combined with intralesional mitomycin C injection for the treatment of severe bladder neck ste-nosis after traditional treatment failure.Materials and methods: It was a retrospective review of patients with severe bladder neck stenosis who had a surgery between July 2013 and August 2015 with mi-tomycin C. The 54.5% of patients had failed at least 1 time with internal cervicotomy and/or endoscopic re-section of the bladder neck. In our intervention, three or four endoscopic incisions were performed with a cold cut in the neck of the bladder, followed by intralesio-nal injection of 0.3 to 0.4 mg / ml of the mitomycin C at each incision site.Results: A total of 11 patients were treated with endos-copic incision with a cold cut in the neck of the bladder combined with mitomycin C injection. Before the sur-gery 4 patients (36%) were cystostomy users. At a mean follow-up of 9 months (range 1-20), 9 patients (82%) had spontaneous urine after 1 procedure, while 2 patients (18%) achieved this goal after 2 procedures using mi-tomycin C.Conclusions: The treatment for bladder neck stenosis with endoscopic radial cervicotomy with cold cut com-bined with intralesional mitomycin C injection resulted in bladder neck permeability in 82% of patients after 1 procedure and 100% after 2 procedures. Although the first results are promising, some prospective and rando-mized studies with long-term monitoring are required to validate these findings.
Asunto(s)
Humanos , Anciano , Obstrucción del Cuello de la Vejiga Urinaria , Mitomicina , Constricción Patológica , Endosonografía , Cistotomía , AntibacterianosRESUMEN
INTRODUCTION: The role of hemostatic agents as an adjunct for closure of the nephrostomy tract in tubeless percutaneous surgery (tubeless percutaneous nephrolithotomy [tPNL]) has been previously evaluated, observing a potential benefit in terms of reduced bleeding and urinary leakage. We assessed the rate of postoperative complications after the use of hemostatic agents for sealing the nephrostomy tract in patients undergoing tPNL at our institution. SUBJECTS AND METHODS: We performed a retrospective analysis of 52 consecutive patients undergoing tPNL at our center between January 2010 and December 2013. No substance was placed within the tract in 25 patients (Group 1). A cylinder of Surgicel(®) in addition to 1 unit of Gelita(®) were placed within the access tract in 27 patients (Group 2). We accounted for demographic variables, stone size, operative time, postoperative pain, development of hematoma, postoperative hematocrit drop, urinary leakage, residual lithiasis, and hospital stay length. RESULTS: Age and sex differed significantly between the two groups (P = 0.0002 and P = 0.048 respectively). However, there were no significant differences in terms of body mass index and stone burden. No significant differences between groups were found with regards to operative time, postoperative hematocrit drop, postoperative pain and presence of residual lithiasis. CONCLUSION: The use of Gelita(®) and Surgicel(®) as hemostatic agents in tPNL is safe, but we were not able to demonstrate any significant benefit in terms of postoperative morbidity after comparing the use of these agents in tPNL. We concluded that the uses of hemostatic agents needed to be evaluated in prospective randomized trials to define its benefits.
RESUMEN
The conventional technique for percutaneous nephrolithotomy (PNL) ends by placing a nephrostomy tube within the access tract. However, feasibility and safety of tubeless PNL have been widely demonstrated. In this modification, a ureteral stent is usually left in place instead of the nephrostomy tube. The aim of this study is to compare the use of a postoperative indwelling double-J stent versus an overnight-externalized ureteral catheter in patients undergoing tubeless PNL. Sixty-eight patients undergoing tubeless PNL were randomized either for a postoperative double-J stent (group 1) or for an overnight-externalized ureteral catheter (group 2). Outcomes evaluated included postoperative pain, hospital stay length, incidence of hemorrhagic complications, residual lithiasis and urinary leakage. Groups were similar according to age, sex, body mass index and stone burden. There were no significant differences in terms of postoperative pain, incidence of perirenal hematomas, residual lithiasis and urinary leakage. However, patients in group 1 presented longer hospital stays (3.7 ± 1.7 vs. 1.9 ± 0.3 days; p < 0.001) and greater hematocrit drops (4.9 ± 2.2 vs. 2.1 ± 1.8 %; p < 0.001). Our results confirm that among patients undergoing tubeless PNL, both alternatives (i.e. leaving a double-J stent or an overnight-externalized ureteral catheter) are reliable and safe. However, further considerations, like the need of double-J stent removal under cystoscopy, need to be taken into account when deciding which modality to use.
Asunto(s)
Litotricia/efectos adversos , Nefrostomía Percutánea/efectos adversos , Stents/efectos adversos , Catéteres Urinarios/efectos adversos , Hemorragia/etiología , Humanos , Cálculos Renales/cirugía , Litotricia/instrumentación , Litotricia/métodos , Morbilidad , Nefrostomía Percutánea/instrumentación , Nefrostomía Percutánea/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios ProspectivosRESUMEN
BACKGROUND: Outcome of Extracorporeal Shockwave Lithotripsy (SWL) is determined by physical factors that affect stone fragmentation and clearance. PURPOSE: To evaluate the predictive value of the Lithotripsy Table Height (LTH) in SWL outcome. Lithotripsy Table Height (LTH) is a variable that represents skin to therapy head distance, and it is proportional to the energy that reaches the stone. MATERIALS AND METHODS: A prospective study enrolled patients undergoing SWL for radiopaque urinary stones. All procedures were performed using a Modulith SLX (Karl Storz, Germany) Lithotripter. Patient weight, height and age; stone location and size; number of shock waves delivered, and LTH were recorded. One month post-procedure a KUB was obtained. Logistic regression analysis was used to evaluate the effects of these variables on stone-free outcome. A ROC curve was plotted. RESULTS: Fifty-six patients were enrolled. After one month follow-up, overall success rate (Stone Free) was 83.9% (n = 47). LTH was the only independent predictor of outcome in both univariate and multivariate analysis (p = 0.029). Stone size (p = 0.45) and BMI (p = 0.32) were not significant. In the ROC curve, LTH showed an Area under the Curve = 0.791. Patients with LTH < 218 (n = 8) had relative risk of residual stones = 7.5, odds Ratio: 6.6 (Stone free rate 37.5% vs. 91.5%). CONCLUSION: LTH appears to be an independent predictor of SWL outcome. High success rates can be expected if LTH > 218. Patients with lower LTH had a less effective therapy, therefore, worse stone fragmentation and clearance. These findings may help improve patient selection for SWL therapy.
Asunto(s)
Litotricia/instrumentación , Mesas de Operaciones/normas , Cálculos Urinarios/terapia , Adulto , Estatura , Peso Corporal , Chile , Diseño de Equipo/normas , Femenino , Humanos , Litotricia/métodos , Masculino , Persona de Mediana Edad , Posicionamiento del Paciente/instrumentación , Posicionamiento del Paciente/métodos , Estudios Prospectivos , Curva ROC , Análisis de Regresión , Cálculos Urinarios/patologíaRESUMEN
BACKGROUND: Outcome of Extracorporeal Shockwave Lithotripsy (SWL) is determined by physical factors that affect stone fragmentation and clearance. PURPOSE: To evaluate the predictive value of the Lithotripsy Table Height (LTH) in SWL outcome. Lithotripsy Table Height (LTH) is a variable that represents skin to therapy head distance, and it is proportional to the energy that reaches the stone. MATERIALS AND METHODS: A prospective study enrolled patients undergoing SWL for radiopaque urinary stones. All procedures were performed using a Modulith SLX (Karl Storz, Germany) Lithotripter. Patient weight, height and age; stone location and size; number of shock waves delivered, and LTH were recorded. One month post-procedure a KUB was obtained. Logistic regression analysis was used to evaluate the effects of these variables on stone-free outcome. A ROC curve was plotted. RESULTS: Fifty-six patients were enrolled. After one month follow-up, overall success rate (Stone Free) was 83.9 percent (n = 47). LTH was the only independent predictor of outcome in both univariate and multivariate analysis (p = 0.029). Stone size (p = 0.45) and BMI (p = 0.32) were not significant. In the ROC curve, LTH showed an Area under the Curve = 0.791. Patients with LTH < 218 (n = 8) had relative risk of residual stones = 7.5, odds Ratio: 6.6 (Stone free rate 37.5 percent vs. 91.5 percent). CONCLUSION: LTH appears to be an independent predictor of SWL outcome. High success rates can be expected if LTH > 218. Patients with lower LTH had a less effective therapy, therefore, worse stone fragmentation and clearance. These findings may help improve patient selection for SWL therapy.
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Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Litotricia/instrumentación , Mesas de Operaciones , Cálculos Urinarios , Estatura , Peso Corporal , Chile , Diseño de Equipo , Litotricia/métodos , Estudios Prospectivos , Posicionamiento del Paciente/instrumentación , Posicionamiento del Paciente/métodos , Análisis de Regresión , Curva ROC , Cálculos Urinarios/patologíaRESUMEN
Percutaneous Nephrolithotomy (PNL) is an established technique for the treatment of renal calculi. Some reports have challenged the need for a nephrostomy tube at the end of the procedure, arguing that it accounts for a longer hospital stay and increased postoperative pain. During the last years, several series have addressed the feasibility and safety of tubeless PNL, where a double-J ureteral stent is left in place after the end of intervention instead of a nephrostomy tube. The aim of our study was to compare conventional versus tubeless PNL in terms of postoperative morbidity. Eighty-five patients who underwent PNL at a single center met the inclusion criteria (complete intraoperative stone clearance, no evidence of active intraoperative bleeding, single percutaneous access, and operative time shorter than 2 h) and were randomized at the end of the procedure to have placed either a nephrostomy tube (group 1) or a double-J ureteral stent (group 2). Outcomes assessed were postoperative pain, bleeding complications, leakage complications, and length of hospital stay. The patients in the tubeless group had a shorter hospital stay (3.7 vs. 5.8 days; P < 0.001), and less postoperative pain at postoperative days 2 and 3 (P < 0.001). No significant difference in bleeding or leakage complications was observed. This study supports the feasibility and safety of tubeless PNL in a selected group of the patients, suggesting some intraoperative criteria to be considered when performing it. However, further controlled studies will have to determine its impact on stone-free rates prior to be considered the standard technique in these selected cases.
Asunto(s)
Cálculos Renales/terapia , Nefrostomía Percutánea/instrumentación , Nefrostomía Percutánea/métodos , Complicaciones Posoperatorias/epidemiología , Adulto , Estudios de Factibilidad , Humanos , Incidencia , Tiempo de Internación , Persona de Mediana Edad , Morbilidad , Dolor Postoperatorio/epidemiología , Seguridad del Paciente , Hemorragia Posoperatoria/epidemiología , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
PURPOSE: To compare the efficacy of ureteroscopy and extracorporeal shock wave lithotripsy (ESWL) in treating distal ureteral calculi and evaluate the best treatment alternative for this disease. MATERIAL AND METHODS: A total of 104 patients with distal ureteral calculi requiring surgical intervention were enrolled and observed in a prospective follow-up. For ESWL, a Modulix SLX Storz lithotriptor was used and for ureteroscopy, a Storz 33 cm semi-rigid ureteroscope with a diameter of 7,5 to 9,5 french and a 6-degree optic. Out of the patient total, 54 patients underwent ESWL and 50 underwent ureteroscopy. 62 patients were men and 42 women; mean age in the ESWL group was 49.72, and in the ureteroscopy group, 52,16. Mean calculus size for ESWL was 8.29 mm and 8,96 mm for ureteroscopy. A P< .05 was considered statistically significant. RESULTS: Mean procedure time for ESWL was 55 minutes in men and 45 minutes in women. For ureteroscopy, procedure time was 80 minutes for men and 55 minutes for women. For ESWL, the mean hospital stay was 4.8 hours (same-day discharge for all patients). Mean hospital stay for ureteroscopy patients was 22 hours. 7% of ESWL patients experienced complications compared with 7.9% of those undergoing ureteroscopy. At the 30-day follow up, 74.3% of ESWL patients were stone free, while 92,3% of the ureteroscopy patients were stone free (P< .05). CONCLUSIONS: Based on the results of this study, ureteroscopy is a better method for treating distal ureteral calculi because of its stone free rates and because the difference in complication rates was not significant.
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Litotricia , Cálculos Ureterales/terapia , Ureteroscopía , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Renal abscesses are infrequent event and may occasionally be fatal. In order to characterize its main clinical features, its diagnosis and evolution, a retrospective-descriptive study was done with cases identified between 1996 and 2006 in a teaching hospital. Forty-four cases were collected (mean age 49.9 years). Diabetes mellitus was present in 38.6%, urinary calculi in 36.4%, and previous urinary tract infection in 11.4% of the studied population. Enterobacteriaceae were the most frequent isolated microorganisms (44.4%), and 33.3% had a poli-microbial culture in abscess samples. S. aureus was rarely identified. Main therapeutic approaches were minimally invasive procedures (pigtails, percutaneous drainage or nephrostomy) in 50% followed by surgical interventions (nephrectomy or surgical debridement) in approximately 30%. Only 20.5% of patients were treated exclusively by antibiotics. Minimally invasive procedures were applied progressively after 2001 (p < 0.005). In this series case-fatality rate was 4.5%; 13.6% (n = 6) developed septic shock. Nephrectomy was performed in 9 cases (20.5%). Patients selected for nephrostomy had a lower risk for ICU admission (Odds Ratio 0.083 IC95 0.008-0.911). Renal abscesses are cause of morbidity but had a low case-fatality ratio; the therapeutic approach has changed in recent years favoring at present minimally invasive procedures.