The evolution of percutaneous nephrolithotomy: Analysis of a single institution experience over 25 years
Introduction: Over time, the incidence of nephrolithiasis has risen significantly, and patient populations have become increasingly complex. Our study aimed to determine the impact of changes in patient demographics on percutaneous nephrolithotomy (PCNL) outcomes.
Methods: A retrospective analysis of a prospectively collected database was carried out from 1990–2015. Patient demographics, comorbidities, stone and procedure characteristics were analyzed. Multivariate logistic regression was used to evaluate differences in operative duration, complications, stone-free rate, and length of stay.
Results: A total of 2486 patients with a mean age of 54±15 years, body mass index (BMI) of 31±8, and stone surface area of 895±602 mm2 were analyzed; 47% of patients had comorbidities, including hypertension (22%), diabetes mellitus (14%), and cardiac disease (13%). Complication rate was 19%, including a 2% rate of major complications (Clavien grade III–V). There was a statistically significant increase in patient age, BMI, and comorbidities over time, which was correlated with an increased complication rate (odds ratio [OR] 1.15; p=0.010). The overall transfusion rate was 1.0% and remained stable (p=0.131). With time, both OR duration (mean D 16 minutes; p<0.001) and hospital length of stay (mean D 2.4 days; p<0.001) decreased significantly. Stone-free rate of 1873 patients with available three-month followup was 87% and decreased significantly over time (OR 1.09; p<0.001), but was correlated with an increased use of computed tomography (CT) scans for followup imaging.
Conclusions: Despite an increasingly complex patient population, PCNL remains a safe and effective procedure with a high stone-free rate and low risk of complications.
Scales CD, Smith AC, Hanley JM, et al. Prevalence of kidney stones in the United States. Eur Urol 2012;62:160–5.
Stamatelou KK, Francis ME, Jones CA, et al. Time trends in reported prevalence of kidney stones in the United States: 1976-1994. Kidney Int 2003;63:1817-3.
Sorkin I, Mamoulakis C, Miyazawa K. Epidemiology of stone disease across the world. World J Urol 2017;35:1301-20.
Antonelli JA, Maalouf NM, Pearle MS, et al. Use of the National Health and Nutrition Examination Survey to calculate the impact of obesity and diabetes on cost and prevalence of urolithiasis in 2030. Eur Urol 2014;66:724-9.
Makdad AH, Bowman BA, Ford ES et al. The Continuing epidemics of obesity and diabetes in the United States. JAMA 2001;286:1195-200.
Unsal A, Resorlu B, Atmaca AF, et al. Prediction of morbidity and mortality after percutaneous nephrolithotomy by using the Charlson comorbidity Index. Urology 2012; 79:55-60.
Michel MS, Trojan L, Rassweiler JJ. Complications in percutaneous nephrolithotomy. Eur Urol 2007;51:899-906.
Olvera-Posada D, Tailly T, Alenezi H, et al. Risk factors for postoperative complications of percutaneous nephrolithotomy at a tertiary referral center. J Urol 2015;194:1646-51.
Seitz C, Desai M, Hacker A, et al. Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy. Eur Urol 2012;61:146-58.
Labate G, Modi P, Timoney A, et al. The percutaneous nephrolithotomy global study: classification of complications. J Endourol 2011;25:1275-80.
Moreno-Palacios J, Maldonado-Alcaraz E, Montoya-Martinez G, et al. Prognostic factors of morbidity in patients undergoing percutaneous nephrolithotomy. J Endourol 2014; 28:1078-84.
Ghani KR, Andonian S, Bultitude M, et al. Percutaneous nephrolithotomy: Update, trends, and future directions. Eur Urol 2016;70:382-96.
Ordon M, Urbach D, Mamdani M. The surgical management of kidney stone disease: A population based time series analysis. J Urol 2014;192:1450-6.
Geraghty RM, Jones P, Somani BK. Worldwide trends of urinary stone disease treatment over the last two decades: A systematic review. J Endourol 2017;31:547-56.
Lam HS, Lingeman JE, Barron M, et al. Staghorn calculi: analysis of treatment results between initial percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy monotherapy with reference to surface area. J Urol 1992;147:1219–25.
Ko R, Soucy F, Denstedt JD, et al. Percutaneous nephrolithotomy made easier: a practical guide, tips and tricks. BJU Int 2008;101:535–9.
Mirheydar HS, Kerrin LP, Derweesh IH, et al. Percutaneous nephrolithotomy use is increasing in the United States: An analysis of trends and complications. J Endourol 2013;27:979-83.
Stern KL, Tyson MD, Abdul-Muhsin HM, et al. Contemporary trends in percutaneous nephrolithotomy in the United States: 1998-2011. Urology 2016;91:41-5.
Leow JJ, Meyer CP, Wang Y, et al. Contemporary trends in utilization and perioperative outcomes of percutaneous nephrolithotomy in the United States from 2003 to 2014. J Endourol 2017;31:742-50.
Ghani KR, Sammon JD, Bhojani N, et al. Trends in percutaneous nephrolithotomy use and outcomes in the United States. J Urol 2013;190:558-64.
Trudeau V, Karakiewicz PI, Boehm K, et al. The effect of obesity on perioperative outcomes following percutaneous nephorlithotomy. J Endourol 2016;30:864-70.
Rosette J, Assimos D, Desai M, et al. The clinical research office of the Endourological Society percutaneous nephrolithotomy global study: Indications, complications, and outcomes in 5803 patients. J Endourol 2011;25:11-7.
Kukreja R, Desai M, Patel S, et al. Factors affecting blood loss during percutaneous nephrolithotomy: prospective study. J Endourol 2004;18:715–22.
Akman T, Binbay M, Sari E, et al. Factors affecting bleeding during percutaneous nephrolithotomy: single surgeon experience. J Endourol 2011;25:327–33.
Lee JK, Kim BS, Park YK. Predictive factors for bleeding during percutaneous nephrolithotomy. Korean J Urol 2013;54:448–53.
Yamaguchi A, Skolarikos A, Buchholz N-PN, et al. Operating times and bleeding complications in percutaneous nephrolithotomy: a comparison of tract dilation methods in 5,537 patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study. J Endourol 2011;25:933–9.
Kessaris DN, Bellman GC, Pardalidis NP, et al. Management of hemorrhage after percutaneous renal surgery. J Urol 1995;153:604–8.
Keoghane SR, Cetti RJ, Rogers AE, et al. Blood transfusion, embolisation and nephrectomy after percutaneous nephrolithotomy (PCNL). BJU Int 2013;111:628–32.
Okeke Z, Smith A, Labate G, et al. Prospective comparison of outcomes of percutaneous nephrolithotomy in elderly patients versus younger patients. J Endourol 2012;26:996-1001.
Tefekli A, Kurtoglu H, Tepeler K, et al. Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy? J Endourol 2008;22:35-40.
De S, Autorino R, Kim FJ, et al. Percutaneous nephrolithotomy versus retrograde intrarenal surgery: a systematic review and meta-analysis. Eur Urol 2015;67:125–37.
Skolarikos A, Alivizatos G, Rosette J. Percutaneous nephrolithotomy and its legacy. Eur Urol 2005;47:22-8.
Raman JD, Bagrodia A, Gupta A, et al. Natural history of residual fragments following percutaneous nephrostolithotomy. J Urol 2009;181:1163-8.
Gokce MI, Ozden E, Suer E, et al. Comparison of imaging modalities for detection of residual fragments and prediction of stone related events following percutaneous nephrolithotomy. Int Braz J Urol 2015:41:86-90.
Thomas K, Smith NC, Hegarty N, et al. The Guy’s stone score – Grading the complexity of percutaneous nephrolithotomy procedures. Urology 2011;78:277-81.
Vicentini FC, Marchini GS, Mazzuchhi E, et al. Utility of the Guy’s stone score based on computed tomogrpahic scan findings for percutenaous nephrolithotomy outcomes. Urology 2014;83:1248-53.
Fuller A, Razvi H, Denstedt JD, et al. The CROES percutaneous nephrolithotomy global study: The influence of body mass index on outcome. J Urol 2012;188:138-44.
You, the Author(s), assign your copyright in and to the Article to the Canadian Urological Association. This means that you may not, without the prior written permission of the CUA:
- Post the Article on any Web site
- Translate or authorize a translation of the Article
- Copy or otherwise reproduce the Article, in any format, beyond what is permitted under Canadian copyright law, or authorize others to do so
- Copy or otherwise reproduce portions of the Article, including tables and figures, beyond what is permitted under Canadian copyright law, or authorize others to do so.
The CUA encourages use for non-commercial educational purposes and will not unreasonably deny any such permission request.
You retain your moral rights in and to the Article. This means that the CUA may not assert its copyright in such a way that would negatively reflect on your reputation or your right to be associated with the Article.
The CUA also requires you to warrant the following:
- That you are the Author(s) and sole owner(s), that the Article is original and unpublished and that you have not previously assigned copyright or granted a licence to any other third party;
- That all individuals who have made a substantive contribution to the article are acknowledged;
- That the Article does not infringe any proprietary right of any third party and that you have received the permissions necessary to include the work of others in the Article; and
- That the Article does not libel or violate the privacy rights of any third party.