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Year : 2011  |  Volume : 27  |  Issue : 3  |  Page : 433-434
 

Is there a role of post percutaneous nephrolithotomy routine computer tomography scan to anticipate complication?


Department of Urology, C.S.M. Medical University (Upgraded King George's Medical College), Lucknow - 226 003, Uttar Pradesh, India

Date of Web Publication26-Sep-2011

Correspondence Address:
Apul Goel
Department of Urology, C.S.M. Medical University (Upgraded King George's Medical College), Lucknow - 226 003, Uttar Pradesh
India
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How to cite this article:
Mandal S, Sankhwar S N, Goel A. Is there a role of post percutaneous nephrolithotomy routine computer tomography scan to anticipate complication?. Indian J Urol 2011;27:433-4

How to cite this URL:
Mandal S, Sankhwar S N, Goel A. Is there a role of post percutaneous nephrolithotomy routine computer tomography scan to anticipate complication?. Indian J Urol [serial online] 2011 [cited 2014 Nov 22];27:433-4. Available from: http://www.indianjurol.com/text.asp?2011/27/3/433/85463

Semins MJ, Bartik L, Chew BH, Hyams ES, Humphreys M, Miller NL, et al. Multicenter analysis of postoperative CT findings after percutaneous nephrolithotomy: Defining complication rates. Urology 2011;78:291-4.



   Summary Top


In this multicentric, retrospective study the authors analyzed the findings of post percutaneous nephrolithotomy (PCNL) computed tomography (CT) images to look for post-operative complications. Patients undergoing PCNL and non-contrast CT scan within 24 hrs of operation were included in the study (n = 197). All CT scan were reviewed by radiologist in the respective institution. Seventy patients had staghorn calculus, 72 had calculus >2 cm, and 55 had calculus <2 cm in size.

Thoracic complications were seen in 115 (58.4%) patients. It included atelectasis, pleural effusion, pneumothorax, hemothorax, and hydrothorax in 88, 17, 3, 2, and 1 patient, respectively. Hydrothorax (n = 1) was identified intra-operatively and chest tube was placed. All other complications were clinically asymptomatic and were managed conservatively with chest physiotherapy.

Renal complications were seen in 32 (16.2%) patients. It included perinephric hematoma (n = 15), collecting system perforation (n = 4), sub-capsular hematoma (n = 3), urinoma (n = 2), and pseudo-aneurysm (n = 1). The pseudo-aneurysm was managed with angioembolization. All other complications identified were clinically asymptomatic and was managed conservatively.

There was one transplenic nephrostomy track without splenic hematoma (0.5%). This was managed conservatively, with prolonged nephrostomy drainage. There were no other solid organ injuries. No injuries to hollow viscera were detected. Two patients (1.3%) were found to have ascites, and 8 patients (4%) were found to have dislodged nephrostomy tubes. The ascites cases were asymptomatic and managed conservatively and the dislodged nephrostomy tubes were removed.

This is the first, comprehensive multi-institutional study to evaluate post-PCNL complications by CT scan. Most complications detected were asymptomatic and managed conservatively. The high rate of atelectasis highlights the importance of post-PCNL baseline respiratory evaluation and attention to pulmonary physiotherapy. Thus authors conclude that the findings of the study may help with pre-operative counseling, intra-operative decision making, and post-operative care.


   Comment Top


Complications are a part of surgical care. In a multicenter study by Michel et al ., [1] from Germany involving 1000 patients who underwent PCNL, the authors reported fever in 21-32.1% cases, blood transfusion in 11.2-17.5%, extravasation in 7.2%, septicemia in 0.3-4.7%, colonic injury in 0.2-08%, and pleural injury in 0.0-3.1% cases. Co-morbidities like renal insufficiencies, diabetes, gross obesity, and pulmonary diseases increased complications.

In search of standard model for defining complications after PCNL Tefeki [2] et al ., used the modified Clavien grading system, [3] which is helpful for reporting and monitoring outcomes after surgery. The use of this classification can facilitate evaluation and comparison of surgical outcomes among different surgeons and centers. In the Clavien grading system, Grade 1 complications includes fever and transient elevation of serum creatinine, Grade 2 includes blood transfusion, urine leak for less than 12 hours and infections requiring additional antibiotics, Grade 3a includes double-J stent placement for urine leakage for more than 24 hours, double-J stent placement for uretero-pelvic junction and pelvis injury, urinoma, pneumothorax, retention and colic due to blood clots. Grade3b complications includes post-PCNL residual ureteral or bladder stone, calyx neck stricture, ureteropelvic junction obstruction, Arteriovenous fistula, perirenal hematoma needing intervention, perinephric abscess, perioperative bleeding requiring quitting the operation. Grade 4a complications include neighboring organ injury, myocardial infarction, nephrectomy and lung failure, Grade 4b includes urosepsis and Grade 5 includes death. They stratified grade 1 and 2 complications as minor and grade 3, 4, 5 as major complications.

Since the authors used NCCT, differentiating between urinoma and collecting duct injury seems difficult. Most complications were minor and asymptomatic and were managed conservatively.

The need of routine postoperative CT imaging after PCNL is an unsolved issue. Patient exposure to ionizing radiation is a concern whenever CT scans are performed, and at present there is no level 1 evidence in favour of routine CT imaging after PCNL. Further studies devoted to the identification of predictors of post-operative complications are required, so that CT imaging may be used in a judicious manner. This study helps to define clinically silent postoperative complications. The majority of these complications was managed conservatively and did not affect the clinical outcome of the surgery, although there were several cases in the present study in which CT imaging altered patient care in the perioperative period. Major post-PCNL complications detected by CT are uncommon, and when encountered are generally amenable to conservative management. Minor complications, although commonly detected on CT, did not affect the patient's post-operative recovery. However, the high proportion of atelectasis reported in this series does enforce the need for close attention to pulmonary physiotherapy in the early post-operative period after PCNL.

 
   References Top

1.Michel MS, Trojan L, Rassweiler JJ. Complications in percutaneous nephrolithotomy. Eur Urol 2007;51:899-906.  Back to cited text no. 1
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2.Tefekli A, Ali Karadag M, Tepeler K, Sari E, Berberoglu Y, Baykal M, et al. Classification of percutaneous nephrolithotomy complications using the modified clavien grading system: Looking for a standard. Eur Urol 2008;53:184-90.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of a 6336 patients and results of a survey. Ann Surg 2004;240:205-13.  Back to cited text no. 3
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