original research

Percutaneous nephrolithotomy with one-shot dilation method:

Is it safe in patients who had open surgery before?

Tufan Süelözgen, MD; Cemal Selcuk Isoglu, MD; Hakan Turk, MD; Mehmet Yoldas, MD;

Mustafa Karabicak, MD; Batuhan Ergani, MD; Hayal Boyacioglu, MD; Yusuf Ozlem Ilbey, MD; Ferruh Zorlu, MD

Tepecik Training and Research Hospital Department of Urology, Izmir, Turkey; Department of Urology, Faculty of Medicine, Dumlupinar University, Evliya Celebi Training and Research Hospital, Kütahya,

Turkey; Ege University Faculty of Science, Department of Statistics, Izmir, Turkey

Cite as: Can Urol Assoc J 2016;10(3-4):E132-5. http://dx.doi.org/10.5489/cuaj.3301

dilatation technique is as safe in patients with a history of

open-stone surgery as it is in patients without previous open

renal surgery.

Abstract

Introduction: This study aimed to evaluate whether one-shot dila-

tation technique is as safe in patients with a history of open-stone

surgery as it is in patients without previous open-stone surgery.

Methods: Between January 2007 and February 2015, 82 patients

who underwent percutaneous nephrolithotomy (PNL) surgery with

one-shot dilation technique who previously had open-stone surgery

were retrospectively reviewed and evaluated (Group 1). Another

Methods

Study patients were divided into two groups and data was

retrospectively reviewed. Group 1 consisted of 82 patients

who had PNL with one-shot dilation technique for the ﬁrst

time between January 2007 and February 2015 and who

had a history of open-stone surgery. Age, gender, type of

stone, duration of surgery, radiation exposure time, as well

as bleeding status requiring perioperative transfusion were

noted. Postoperative complications were analyzed separa-

tely. Group 2, the control group, consisted of another 82

randomly selected patients who had PNL with one-shot dila-

tion technique, but with no history of open surgery.

Additional contrast-enhanced imaging was not performed

in the patients who were already scheduled to undergo sur-

gery with preoperative non-contrast abdominal computed

tomography (CT). Dimercaptosuccinic acid (DMSA) scintig-

raphy was not needed because CT imaging pointed out no

uncertainty in terms of kidney functions. None of the inclu-

ded patients had non-opaque kidney stones. PNL decision

was made according to the size of the stone or failure of the

previously performed extracorporeal shock wave lithotripsy

(ESWL) treatment. Because this was a retrospective study,

information regarding the number of previous open surgeries

the patients had was not avaiable.

Isolated renal pelvis or calyx stones were considered

simple stones; pelvis + calyx or staghorn stones were con-

sidered complex. Complete blood count, biochemical analy-

ses, coagulation tests, and urine culture were performed

for all the patients preoperatively. Appropriate antibiotic

therapy was given to patients with positive urine culture

and all the patients were operated with urine culture sterile.

A 6-French (6F) open-ended ureteral catheter was inserted

under cystoscopic guidance while the patient was in the

lithotomy position under general anesthesia, following which

2 patients were selected randomly among patients who had PNL

with one-shot dilation technique, but with no history of open renal

surgery (Group 2). Age, gender, type of kidney stone , duration of

surgery, radiation exposure time, and whether or not there was

any bleeding requiring perioperative and postoperative transfusion

were noted for each patient .

Results: The stone-free rates, operation and ﬂuoroscopy time, and

peroperative and postoperative complication rates were similar in

both groups (p>0.05).

Conclusions: Our experience indicated that PNL with one-shot

dilation technique is a reliable method in patients with a history

of open-stone surgery.

Introduction

Percutaneous nephrolithotomy (PNL) is a minimally invasive

surgical procedure used in the treatment of kidney stones.

In current practice, PNL has almost completely replaced

open surgery.

Creation of the nephrostomy tract is one of the important

steps of PNL.Various methods have been deﬁned for this

purpose, among them the one-shot technique, which has

been shown to shorten operating times and reduce radiation

exposure. In this technique, tract dilatation is performed by

a one-step 25‒30F dilatator, following an initial 6F dilation.

However, dilatation with one-shot technique in patients who

previously underwent open-stone surgery is controversial.

The objective of this study is to evaluate whether one-shot

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CUAJ • March-April 2016 • Volume 10, Issues 3-4

2016 Canadian Urological Association

Pꢀꢁꢂutꢃꢄꢀꢅuꢆ ꢄꢀpꢇꢁꢅꢈꢉtꢇꢅtꢅmy wꢉtꢇ ꢅꢄꢀ-ꢆꢇꢅt dꢉꢈꢃtꢉꢅꢄ

the patient was placed in prone position. After opaque mate-

rial was instilled through the ureteral catheter, access was

obtained from the selected calyx to the intrarenal collecting

system by an access needle under ﬂuoroscopic guidance.

After the placement of the guide catheter, tract was created

by ﬁrst dilating using a 6F Amplatz dilator set, then with

one-shot method by using 25‒30F dilator. Access failure

did not developed in any of the patients. Access was not per-

formed blindly. The stones were broken up with ultrasonic

lithotripter in all patients. A 14F Malecot drain was routinely

placed following the completion of the operation. If not at

postoperative Day 1, the nephrostomy tube was withdrawn

at postoperative Day 3 if extravasation of opaque material

was determined out of the tract by sonoscopy. All patients

were re-evaluated by non-contrast abdominal tomography at

the ﬁrst postoperative month. The operation was considered

successful if there were no fragments at all or if the fragments

were smaller than 4 mm.

Five patients (6.1%) in Group 1 and 12 patients (14.6%)

in group 2 had postoperative fever (p=0.122). Double J stent

was inserted because of prolonged postoperative urinary

tract drainage in two patients (2.4%) in Group 1. The stents

were removed after four weeks and no additional interven-

tion was required.

Patients without any postoperative complications were

discharged and were controlled with abdominal contrast

CT after one month. Residue stones of ≥4 mm size were

detected in 17 (20.7%) of Group 1 and in 12 (14.6%) of

Group 2 patients (p=0.40). There were no signiﬁcant diffe-

rences between two groups in terms of operation success

and postoperative complications (Table 2).

Discussion

Since the ﬁrst series of PNL operations were reported by

Wickham in 1981, open-stone surgery has become a very

rarely applied method. Creation of the nephrostomy tract is

certainly one of the ﬁrst and most important stages of PNL.

Three types of dilators are available: Amplatz fascial dilator,

telescopic metal dilator, and balloon dilator. Balloon dila-

tors are limited in use because of their high costs, although

Statistical analysis

Summary statistics were used for continuous variables (mean,

standard deviation, standard error). Associations between

categorical variables were analysed using χ2 test. When the

expected number of observations in one or more categories

was ≤5, we used the Fisher’s exact test. Independent-samples

t test and Mann-Whitney U test were used to compare diffe-

rences between two independent groups. Data were analyzed

using SPSS version 15.0 software (SPSS Inc., Chicago, IL).

All p values <0.05 were considered statistically signiﬁcant.

they are safe and widely accepted. Amplatz and telescopic

metal dilators are less expensive, but dilation takes longer,

increasing radiation exposure. It was reported that retro-

peritoneal ﬁbrosis associated with the past operations can

cause difﬁculties in creating a percutaneous nephrostomy

tract and prolong nephrostomy access time. Operation time

and access time were not calculated separately in our study

so we don’t have the data for the time spent during access;

however, there was no statistical difference between the two

groups in terms of total operation time (p=0.176).

Results

Of 82 patients in Group 1, 47 were men and 35 were

women. The mean age was 48.2 ± 14 years (range 19‒75

years); mean operation time 102 ± 266 minutes (range

Lojanapiwat reported that gradual dilation technique with

Amplatz dilators can be comfortably used in patients with

a history of open-stone surgery. However, frequent and

0‒270 minutes); and ﬂuoroscopy time 230 ± 294 seconds

widespread use of PNL procedure has created exposure-

related concerns among urologists and other surgical team

members, leading to search for new alternatives. Various

studies have reported that one-shot technique — described

(range 28‒300 seconds).The type of kidney stone was simple

in 42 patients (51.2%) and complex in 40 patients (48.8%).

Group 2 included 82 patients, 46 men and 36 women.

The mean age was 44.05 ± 17 years (range 21‒70 years);

mean operation time 134 ± 44 minutes (range 35 ‒210);

and ﬂuoroscopy time 194 ± 44 seconds (range 40‒263).

Of Group 2 patients, 43 (52.4%) had simple and 39 (47.6%)

had complex stones. There was no signiﬁcant difference in

terms of these data between the groups (p> 0.05) (Table 1).

A second access was required due to a complex stone in

ﬁve patients (6.1%) in Group 1 and 12 patients (14.6%) in

Group 2 (p=0.122).

Table 1. Demographic data of the study patients

Group 1

n=82)

Group 2

(n=82)

Variable

p value

(

Mean age (years ± SD)

Women (%)

48.24 ± 14

35 (42.7)

47 (57.3)

29.1 ± 5.2

54 ( 65.9)

28 (34.1)

42 (51.2)

40 (48.8)

44.04 ± 17

36 (43.9)

46 (56.1)

29 ± 7.4

0.96

0.87

0.93

0.92

Men (%)

BMI (kg/m2 ± SD)

Right kidney (%)

Lefy kidney (%)

Simple stone (%)

42 (51.2)

40 (48.8)

43 (52.4)

39 ( 47.6)

One patient (1.2%) in both groups required blood trans-

fusion peroperatively (p=1). Blood transfusion was required

because of postoperative hemodynamic instability in three

patients (3.7%) of Group 1, whereas none of Group 2 pati-

ents required transfusion (p=0.245).

Complex stone (%)

SD: standard deviation.

CUAJ • March-April 2016 • Volume 10, Issues 3-4

E133

süꢀꢈözꢊꢀꢄ ꢀt ꢃꢈ.

Table 2. Signiꢀcant preoperative and postoperative ꢀndings

Variable

Group 1 (n=82)

102 ± 266

230 ± 294

5 (6.1)

Group 2 (n=82)

134 ± 44

194 ± 44

12 (14.6)

1 (1.2)

p value

0.17

0.36

0.12

Mean operation time (minutes ± SD)

Mean ꢀuoroscopy time (seconds ± SD)

Need for multiple access (%)

Preoperative blood transfusion (%)

Postoperative blood transfusion (%)

Postoperative fever (%)

1 (1.2)

3 (3.6)

0.24

0.12

0.4

5 (6.09)

12 (14.6)

70 (85.3)

Operation success (%)

65 (79.2)

2 (2.4)

Additional intervention after discharge (double j stent implantation) (%)

0.24

SD: standard deviation.

as acute dilatation with 25‒30F after initial 6F dilatation

drainage discontinued. Although this complication was not

observed in Group 2 and these groups indeed did not show

any difference (p=0.24), this situation may be correlated

with retarded healing of the urinary tract area due to scar

development. When the groups were compared in terms of

operation success, residual fragments ≥4 mm were detected

in 17 patients (20.7%) in Group 1 and 12 patients (14.6%)

in Group 2; there was no statistically signiﬁcant difference

between the two groups (p=0.4).

with a view to reduce radiation exposure and operation

time — was a safe method.

Frattini et al have stated that, because of the development

of retroperitoneal scar, dilatation with the one-shot tech-

nique generallyfails in patients with a history of open-stone

surgery and, therefore, balloon or metal dilatation techniqu-

es are preferred in this patient group. In their study of 112

patients, Falahatkar et al examined one-shot technique by

using a PVC dilator (Amplatz) and reported that nephros-

tomy access failed in three patients who had open-stone

Ziaae et al have stated that one-shot dilation technique

is applicable in almost all adult patients. Amirhassani et al

have expressed that PNL with one-shot technique is a safe

and tolerable method due to low complication rate and radi-

surgery; they nevertheless commented that it was an effe-

ctive and reliable method. However, access failure did not

occur in any of the patients and no other dilatation method

was needed.

ation exposure. Our results for PNL with one-shot method

performed in patients who had and had not had previous

open surgery were similar to the results in the literature.

The primary limitation of our study is its retrospective

nature. The access time could not be calculated separately

from the operation time. Due to the lack of preoperative

data, the number of open operations that patients underwent

was not known.

Amjadi et al have shown that the one-shot dilatation

technique can be safely applied in patients who previously

underwent open surgery and is a risk-free method with less

exposure to radiation. In our study, we determined no dif-

ference between the groups in terms of radiation exposure

(

p=0.361).

Bleeding is one of the most important complications of

PNL. Reasonable amount of bleeding can occur during renal

access. Bleeding requiring transfusion must be regarded as

a more serious complication; it has been reported in rates

Conclusion

One-shot dilation technique with PVC dilators could beco-

me a standard method for all patient groups in the near

future; however, further studies with larger study groups

are required.

of 0‒20 %. In our study, transfusion was needed in four

patients (4.8%), one perioperatively and three postoperati-

vely. These patients had staghorn stones, which is a known

risk factor for bleeding.

Fever is seen commonly after PNL, with an incidence of

Competing interests: The authors declare no competing ꢀnancial or personal interests.

‒32.1%. In our study, ﬁve patients (6.1%) in Group 1 had

postoperative fever, but none of them developed urosepsis.

When the nephrostomy tube is removed, urine drainage

from the urinary tract is considered normal until the colle-

cting system is healed. The prolonged drainage, however,

should be considered as a complication. It occurs at an

incidence of 1.5‒3%, generally in the presence of perip-

heral obstruction related with stones or clots, and requires

This paper has been peer-reviewed.

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Correspondence: Dr. Hakan Turk, Department of Urology, Faculty of Medicine, Dumlupinar

University, Evliya Celebi Training and Research Hospital, Kütahya, Turkey; hkntrk000@hotmail.com

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