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PCNL

PREOP REVIEW POINTS
Sterile urine cultures or properly treated
Can be prone, supine or lateral
Access types include "eye of the needle" or "trangulation" using 21 or 18ga Chiba needle or an 18ga diamond tip needle
Place a safety wire, dilate tract with Amplatz dilators or balloon
Access should be superior and posterior, attempting to go through plane of Brodel
Bleeding commonly comes from comes from renal pelvis or infundibular dilation, can be venous or arterial
Venous bleeding gets pressure from balloon dilator. arterial gets IR embolization
If significant collecting system injury, end procedure as quickly as possible, place nephrostomy tube or stent
Use saline
F/u imaging 6-8wks after surgery (some get CT scan before neph tube removed)

GENERAL
This is an excellent review of PCNL technique. (10)
COMPLICATIONS
Bacteremia has been reported to occur in up to 37% of patients and 74% of patients have postoperative fever after PCNL, overt fulminant sepsis occurs in only 0.2-1.3% of patients.  Post operative hemorrhage occurs in 0.4-11% of patients undergoing PCNL. Hydropneumothorax occurs in 5-16% of cases involving supracostal access. Bowel injury occurs in less than 0.5% of cases.
 (9)

INTERESTING STUDIES
Two clinical trials demonstrated a benefit of 1 week of antibiotic therapy prior to PCNL, even in the setting of a negative pre-operative urine culture. (7,8,9)
​
The PCNL Global Study showed transfusion rates at 5.7%, earlier studies showed higher rates between 12-23%. (6)

A study of 67 patients showed PCNL while patient was still on aspirin had no statistically significant increase in bleeding complicaitons, major complications or transfusions. (1) Other studies have also reported continuing aspirin to be safe. (2,3,4,5)
  1. Otto, Brandon J., et al. "The Effect of Continued Low Dose Aspirin Therapy in Patients Undergoing Percutaneous Nephrolithotomy." The Journal of urology 199.3 (2018): 748-753.
  2. Jou, Yeong-Chin, et al. "Safety and efficacy of tubeless percutaneous nephrolithotomy in patients on anti-platelet therapy and cirrhotic patients." Urological research 39.5 (2011): 393-396.
  3. Nerli, R. B., et al. "Percutaneous nephrolithotomy in patients on chronic anticoagulant/antiplatelet therapy." Chonnam medical journal 48.2 (2012): 103-107.
  4. Leavitt, David A., et al. "Percutaneous Nephrolithotomy During Uninterrupted Aspirin Therapy in High–cardiovascular Risk Patients: Preliminary Report." Urology 84.5 (2014): 1034-1038.
  5. Leavitt, David A., et al. "Second Prize: Continuing Aspirin Therapy During Percutaneous Nephrolithotomy: Unsafe or Under-Utilized?." Journal of endourology 28.12 (2014): 1399-1403.
  6. Rosette, Jean de la, et al. "The clinical research office of the endourological society percutaneous nephrolithotomy global study: indications, complications, and outcomes in 5803 patients." Journal of endourology 25.1 (2011): 11-17.
  7. Mariappan P and Tolley DA et al. One week of ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study. BJU Int 2006; 98: 1075-9.
  8. Bag S, et al. Risk factors for urosepsis following percutaneous nephrolithotomy: role of 1 week of nitrofurantoin in reducing the risk of urosepsis. Urology 2011; 77: 45
  9. AUA Core Curriculum. Accessed October 21, 2018.
  10. Ibrahim, Ahmed, et al. "Technique of Percutaneous Nephrolithotomy." Journal of endourology 32.S1 (2018): S-17.
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