COMPARISON THE SUCCESS AND COMPLICATIONS OF TUBELESS PERCUTANEOUS NEPHRO- LITHOTOMYIN PRONE AND SUPINE POSITION UNDER SPINAL ANESTHESIA

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1 Acta Medica Mediterranea, 2016, 32: 2079 COMPARISON THE SUCCESS AND COMPLICATIONS OF TUBELESS PERCUTANEOUS NEPHRO- LITHOTOMYIN PRONE AND SUPINE POSITION UNDER SPINAL ANESTHESIA SADROLLAH MEHRABI *, LEILA MANZOURI *, RAZIEH GANJI **, FARHAD MEHRABI *** * Social Determinant of Health Research center, Yasuj University of Medical Sciences, Yasuj, Iran - ** Student research committee, Yasuj University of Medical Sciences, Yasuj, Iran - *** Student research committee, Shiraz University of Medical Sciences, Shiraz, Iran Abstract Introduction: Nowadays Percutaneous Nephrolithotomy(PCNL) is the first line treatment for large renal stones upper ureteral stones (more than mm) resistant stones to Extracorporeal Shock Wave Lithotripsy) ESWL (multiple staghorn kidney stones. This procedure is usually performed in prone accompany with inserting nephrostomy tube but recent studies suggested that tubeless PCNL in supine is as well as and in some ways are better than the standard PCNL in prone. So, this study was conducted to compare the success and complications of tubeless PCNL in prone and supine. Materials and methods: In this randomized clinical trial 64 patients aged 18 years and over with renal or upper ureteral stones that were referred toshahidbeheshti hospital of Yasuj from 2013 march to 2015 February for PCNL and met inclusion criteria,were randomly assigned to undergo surgery in supine or prone after taking informed consent. All PCNLs were done with fluoroscopy-guided by one urologist. After operation without inserting any tube Amplatz dilator removed and patients were transferred to recovery and ward. In the first postoperative day, if there were no complications, patients were discharged. One week later, patients were visited again and Kidney- ureters- bladder (KUB) plain radiography and ultrasonography were done for assessing the success rate. Data were analyzed by SPSS21 software using descriptive and analytical statistics. Results: Mean size of stones in patients underwent surgery in supine and prone were 32.81±5.2 mm and 36.25±4.3 mm, respectively(p=0.47). Mean time of operation in supine and prone were 81.68±26.45 and 94.68±21.88 minutes, respectively (p=0.1). There wasn t significant difference in partial and complete success rate between supine (53.1%, 46.9%) and prone (43.8%,56.2%) (p=0.45). Mean length of hospital stay was 1.37±0.65 and1.43±0.87 days in prone and supine, respectively (p=0.74). There wasn t significant difference in complications after PCNL between supine (12.5%) and prone (12.9%) (p=0.32). Conclusion: Tubeless PCNL in supine is a safe procedure with similar performance compared to prone for the treatment of urolithiasis stones. Keywords: Tubeless percutaneous nephrolithotomy success complications. Received April 30, 2016; Accepted July 02, 2016 Introduction In urology and in many fields of surgery, applying endoscopicsurgery has replacedwith open incisional operations. In fact, physicians try to use methods with better resultsandfewer complications for the patient, as well as less cost and shorter hospital stay. Today s percutaneous nephrolithotomy (PCNL) is the first-line therapy in renal and upper ureteral stones (size more than mm), multiple stones, resistant stones toshockwave lithotripsy and Staghorn stones (1-6). This procedure is usually performed in the prone, although it can be done in oblique prone, oblique supine and supine, and in recent years operations were done in these s (6-7). Prone has several advantages, including reducing damage to the abdominal viscera, providing a large surface area for puncturing skin to reach the kidneys and easy access to different part of urinary system (7). The drawback of this method can lead topatient discomfort during the procedure; need to change the patient s during operation and breathing problems during

2 2080 Sadrollah Mehrabi, Leila Manzouri et Al anesthesia, especially in obese patients. To resolvethese problems, PCNL can beperformed in supine (8). Despite the fact that the standard method for PCNLis prone, but recent studies suggested that in most cases the supine has similar performance and in some ways are better than the prone. In supine,patients with cardiovascular disease and obesity are more suitable and the time of operation is less (9-10). At the end of operation surgeons must decide to insert nephrostomy tube in tract or perform tubeless PCNL (7-11). Previously, all of endourologist tended to insert nephrostomy tube after operation but recently, some researchers prefer to do surgerywithout any tube (tubeless PCNL). In many of these studies, researchers concluded that Tubeless PCNL is asafe and efficient method thatreduces postoperative pain and Hb drop with less narcotic requirement (12-14). So the aim of this study was Comparison the success and complications of Tubeless PCNL in prone and supine. Materials and methods It was a randomized clinical trial. 64 patients aged18 years and over with renal or upper ureteral stones that were referred to ShahidBeheshti hospital of Yasuj from 2013 march to 2015 February for PCNL (upper ureteral stonesmore than mm stones resistant to ESWL multiple stones and the staghorn kidney stones) and met inclusion criteria, were randomly assigned to undergo surgery in supine or prone after taking informed consent. Inclusion criteria s were Patients with no cardiovascular or pulmonary disease, no uncontrolled coagulopathy, no scoliosis or kyphosis, non-pregnant and don t have any contraindication for general or spinal anesthesia. History and complete physical examination and basic serum samples including Hb and kidney function tests (BUN, Cr), were checked for all of them. Urine cultures were obtained and if positive, antibiotics were prescribed for 1 week. Urine cultures were repeated to obtainsterile urine. In Group 1 (prone ) after prep of patients under spinal anesthesia (2-2.5 milliliter of bupivacaine and 0.5 milliliter of fentanyl) ureteral catheter 5-6F was inserted in ureter in the lithotomy by urologists.then the patient was changed with care and with the help of anesthesiologist in prone and with fluoroscopic guidance PCNL was performed using standard methods. In the second group (Supine ) spinal anesthesia was similar to the first group and after inserting ureteralcatheter 5-6 F in the lithotomy, the patient was changed to supine and PCNL was done same as first group. All PCNLs were done with fluoroscopy-guided by one urologist. In both groups,with using neuroleptic drugs and sedatives such as Ketamine operationcontinued up to 3 hours and inthe lack of any specific complicationoperation was terminated without a nephrostomy tube. In the event of any adverse events associated with vascular, visceral and pulmonary operationwas terminated and standard treatment was performed for patient. If there wasn t any problem, uncomplicated patients hospitalized for one day. 24 hours aftersurgeryhb, BUN and Cr was checked and in absence of fever, urine leakage or any complication patientswere discharged.one week after surgerythe patients visited again and ultrasonography and KUB was performed for assessing success rate. Being free of stone or having residual stones smaller than 4 millimeters were reported as complete success and if the residual stones were larger than 4 millimeters,partial successes were reported.all data were analyzed by SPSS18 software using descriptive (frequency, mean and standard deviation) and analytical (independent sample T test, chi-square) statistics. P< 0.05 was considered as significant level. Results In this study, 64 patients underwent PCNL without nephrostomy tube (32 in prone and 32 in supine ).Mean age of patients in supine and prone were 46.28±14.49 and 50.25±120.34, respectively (p=0.24). In supine and prone group, 53.1% (17) and 50% (16) were male, respectively (p=0.8). Mean size of stones in patients underwent surgery in supine and prone were 32.81±5.2 mm and 36.25±4.3 mm, respectively (p=0.47). There wasn t any significant difference in location (p=0.49) and side of renal and ureter stones (p=0.49) between two groups. Success rate of PCNL in two groups is shown in table 1. Complication after PCNL developed in 12.9% (7) of patients in supine and 12.5% (4) in prone (p=0.32).comparison the complication of PCNL in two groups is shown in table 2.

3 Comparision the success and complications of tubeless percutaneous nephrolithotomyin prone and supine Success rate*** * supine Prone Complete success 46.9%(15) 56.2%(18) Partial success 53.1%(17) 43.8%(14) failure - - P- value 0.45 Table1: Comparison the success rate of PCNL in supine and prone. *analyzed by chi-square test *** *Complete response means clearance of stones or residual stones <4 mm and partial response means residual stone more than 4 mm. Mean length of hospital stay in patients underwent surgery in supine and prone s were1.43±0.87 and1.37±0.65 days, respectively(p=0.74).complication after PCNL developed in 12.9% (7) of patients in supine and 12.5% (4) in prone (p=0.32). complication supine prone Urinary leakage 3.12%(1) 6.25%(2) fever 15.62%(5) 12.53% (4) Colon injury 3.12%(1) - No complication 87.1%(25) 87.5%(21) p-value 0.51 Table 2: Comparison the complications of PCNL in supine and prone. *analyzed by chi-square test variable supine prone p-value** * Hb 1.12± ± BUN 2.57± ± Creatinine 0.137± ± Table 3: Comparison the mean difference±sem of Hb, BUN and Creatinine after PCNL in supine and prone *Standard Error of Mean ***analyzed by independent samples T test Colon injury was repaired with laparotomy 15.6%(5) patients in supine and 3.15% (1) in prone needed to blood transfusion (p=0.86). Mean consumption of narcotic in patients of supine and prone was 37.5 ± 16.8 and 38.28±23.74mg pethidine, respectively(p=0.88). Mean time of operation in supine and prone were 84.68±26.45 and 94.67±21.88 minutes, respectively (P = 0.10). The mean difference of Hb, BUN and Creatinine before and after PCNL in two groups is shown in table 3. Discussion Percutaneous nephrolithotomy is the first-line therapy in renal and upper ureteral stones (size more than mm), resistant stones to ESWL,multiple stones and staghorn kidney stones (6,10). Although the most widely accepted for PCNL is prone, but the drawback of this method can lead to patient discomfort during the procedure, need to change the patient's during operation and breathing problems during anesthesia, especially in obese patients. To resolve these problems PCNL can be performed in supine (8). In this study, results and complication rates were similar between patients underwent surgery in supine and prone. Although in our study the complete stones-free rate was similar in both groups like other studies, but our stone - free rate was lower than those reported by others. De Sio et al reported a stone clearance rate of 88.7% in supine vs. 91.6% in prone (p = 0.12) (7). Shoma et al reported 89% stone-free rate in supine vs 84% in prone (8). Mazzucchi et al reported Stone-free rate on the first postoperative day was 50% in the prone and 46.9% in the supine (P=1.0). Final stone-free rates were 83.3% and 78.1%, respectively (P=0.74) (15). But the result of Valdivia J. et al was in contrast with our and other studies and the stone-free rate was significantly higher for prone vs supine (77.0% vs 70.2%) (16). It must be remembered that lower stone-free rate in our study may be related to this point that we didn t excluded complete staghornstones and stones requiring multiple percutaneous renal access. On the other hand, it must be noted that we didn t have access to flexible nephroscope in our study that is one of the necessary tools to increase success. Reported complications in our study were urinary leakage, fever and colon injury that there was no significant difference between two s. The experience of Mazzucchi et al (15) and Maccahy et al (17) showed no difference in complication between two groups, too. Although it has confirmed that in the supine, the colon is more distant from the kidney than in the prone (7), happening colon injury in one case in supine was due to anatomical abnormality because in postoperative CT scan she has retrorenal colon. But De Sioet al (7) and Vicentinia et al (18) reported that in their studies, there

4 2082 Sadrollah Mehrabi, Leila Manzouri et Al wasn t any damage to colon and colonic perforation. Wu P et al reported that the rate of colonic injury in supine PCNL was approximately 0.5% (19). Operative time in our study was lower in supine. Although there wasn t significant difference in operative time between two s, but it can be clinically important. This difference just reflects the time lost to turn the patient at the beginning and end of the procedures in the prone.results of our study are consistent with previous studies. Maccahy et al reported lower operative time in supine (86 vs 116.6minutes) (17). In Wu P et al study, operation time in supine (65±15 minutes) was lower than prone (90±15 minutes) (19) and Liu L et al reported the same results (20), too. In study of De Sio et al mean operative time in supine (43 minutes) was significantly lower than prone(68 minutes) (p<0.001) (7). Mean operative time was minutes in the prone and minutes in the supine (P=0.0017) in Mazzucchi et al (15) study. But the result of Valdivia J et al was in contrast with our and other studies andthe mean operative time was significantly lower for prone vs supine PCNL (82.7 min vs 90.1 min) (16). It seems that significant difference in operation time in two recent studies may be related to urologist s skill.in our study mean length of hospital stay post PCNL in both s was similar.our results are consistent with Shoma et al (2.7 in supine vs 2.5 days in prone) (8), De Sio (4.3 in supine vs 4.1 days in prone, p = 0.18)(7) and Wu P(4.0 ± 1.3 days vs. 3.8 ± 1.1 days; P = 0.51) (19). In Mazzucchi et al study, like our and other studies mean length of hospital stay was lower in prone s (2.68 days vs4.38 days) but the difference was significant(p=0.01) (15). It may be due to setting of study like enrollment of obese patients. Need to blood transfusion was similar in both slikemazzucchi et al that reported transfusion rate 0% and 8.3% in supine and prone, respectively (p=0.1) (15). In Wu P et al study no statistically significant difference was found between supine and prone group in bleeding requiring transfusion [8.8 vs. 4.3%; P = 0.08], too (19) but the result of Valdivia J et al was in contrast with our and other studies andcompared with supine patients, prone patients exhibited higher rates of blood transfusions (6.1% vs 4.3%) (16). Position of operation didn t have any effect on need to narcotic use after PCNL. So, the surgeons can easily choose any according to patient s condition.in our experience like De Sio et al (7), change in Hb value in both s was similar. Also, in our study there wasn t any significant change in BUN and Creatinine value, too. Conclusion In this study, the result of tubeless PCNL in supine was similar to prone. So, we believe that any urologist can perform PCNL in either according to patient s condition and his/her interest, skill and experience. References 1) Stroller M (2008) urinary stone disease in: Tanago A mcaninch J: smith general urology 1 seventeen edition new York ) Isac W, Rizkala E, Liu X, Noble M, Monga M. (2014). Tubeless percutaneous nephrolithotomy: outcomes with expanded indications. International braz j urol, 40(2), ) Tadayyon, Farhad; Sabbagh, Mehdi. The Prevalence of Kidney Stone Different Com in Patients Referred to the Lithotripsy Wards. Source: Journal of Isfahan Medical School. 3/14/2011, Vol. 28 Issue 122, p p. 4) Siavash Falahatkar,, KeivanGholamjaniMoghaddam,, Ehsan Kazemnezhad, Alireza Farzan, Hamidreza Baghani Aval, Ali Ghasemi, et al. Factors affecting complications according to the modified Clavien classification in complete supine percutaneous nephrolithotomy. Can UrolAssoc J Jan-Feb; 9(1-2): e83-e92. doi: /cuaj ) Khoshrang H, Falahatkar S, IlatS, Hossein Akbar M, ShakibaM, FarzanA, RastjouHerfehN, Allahkhah A. (2012). Comparative study of hemodynamics electrolyte and metabolic changes during prone and complete supine percutaneous nephrolithotomy. Nephrourology monthly, 4(4), ) Almeida G.et al Complications in percutaneous nephrolithotomy.actas Urológicas Españolas (English Edition) 1(1) ) De Sio M, Autorino R, Quarto G, Calabro F, Damiano R, Giugliano F, Mordente S, D ArmientoM (2008). Modified Supine versus Prone Position in Percutaneous Nephrolithotomy for Renal Stones Treatable with a Single Percutaneous Access: A Prospective Randomized Trial. European Urology 54 (1) ) Shoma AM, Eraky I, El-Kenawy MR, El-Kappany HA (2002) Percutaneous nephrolithotomy in the supine : technical aspects and functional outcome compared with the prone technique. Urology 60 (3) ) Duty B, Okhunov Z, Smith A, Okeke Z. (2011). The Debate Over Percutaneous Nephrolithotomy Positioning: A Comprehensive Review. The Journal of Urology 186 (1) ) Mehrabi S1, Mousavi Zadeh A, AkbartabarToori M, Mehrabi F. General versus spinal anesthesia in percu-

5 Comparision the success and complications of tubeless percutaneous nephrolithotomyin prone and supine taneous nephrolithotomy. Urol J winter; 10(1): ) Ün S, Cakır V, Köse O, Türk H, & Yılmaz Y. (2015). Colon perforation during percutaneous nephrolithotomy and fistula closure with Spongostan following conservative therapy. Canadian Urological Association Journal, 9(5-6), ) Isac W, Rizkala E, Liu X, Noble M, Monga M. (2014). Tubeless percutaneous nephrolithotomy: outcomes with expanded indications. International braz j urol, 40(2), ) Rana A, Bhojwani J, Junejo N, Bhagia S. (2008). Tubeless PCNL with patient in supine : procedure for all seasons?-with comprehensive technique. Urology, 71(4), ) Kara C., Resorlu B, Bayindir M, Unsal A. (2010). A randomized comparison of totally tubeless and standard percutaneous nephrolithotomy in elderly patients. Urology, 76(2), ) Mazzucchi E, Vicentini FC, Marchini GS, Danilovic A, Brito AH, Srougi M.(2012). Percutaneous Nephrolithotomy in Obese Patients: Comparison between the Prone and Total Supine Position. Journal of Endourology 26 (11) ) Valdivia JG1, Scarpa RM, Duvdevani M, Gross AJ, Nadler RB, Nutahara K, de la Rosette JJ (2011). Supine versus prone during percutaneous nephrolithotomy: a report from the clinical research office of the endourological society percutaneous nephrolithotomy global study. Journal of Endourology, 25(10), ) Mccahy P, Rzetelski-West K, Gleeson J (June 2013). Complete Stone Clearance Using a Modified Supine Position: Initial Experience and Comparison with Prone Percutaneous Nephrolithotomy. Journal of Endourology, 27(6) ) VicentiniF, Torricelli F, Mazzucchi E, Hisano M, Murta C, Danilovic A, Claro J, Srougi M (2013). Modified Complete Supine Percutaneous Nephrolithotomy: Solving Some Problems. Journal of Endourology 27(7) ) Wu P, Wang L, Wang K (2011). Supine versus prone in percutaneous nephrolithotomy for kidney calculi: a meta-analysis. International Urology and Nephrology 43 (1) ) Liu L, Zheng S, Xu Y Wei Q. (2010). Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone. Journal of Endourology, 24(12), Acknowledgment: We present our appreciation to respected vice president technical and research department of Yasuj university of medical sciences and the clinical and developmental research unit of ShahidBeheshti hospital of Yasuj that provide the facility to perform this project by their material and ethical support, also we thank all anesthesia experts who assisted us in patients anesthesia. Corresponding author SADROLLAH MEHRABI urology Department, Yasuj University of Medical Sciences, Yasuj sadrollahm@yahoo.com (Iran)