Factors affecting stone free rate of primary percutaneous nephrolithotomy on staghorn calculi: a single center experience of 15 years

Widi Atmoko; Ponco Birowo; Nur Rasyid

doi:10.12688/f1000research.9509.2

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Research Article

Revised

Factors affecting stone free rate of primary percutaneous nephrolithotomy on staghorn calculi: a single center experience of 15 years

[version 2; peer review: 2 approved]

Widi Atmoko ¹, Ponco Birowo¹, Nur Rasyid¹

PUBLISHED 30 Sep 2016

Author details Author details

¹ Department of Urology, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, 10430, Indonesia

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Objectives: Percutaneous nephrolithotomy on staghorn calculi is challenging for urologists because it is difficult to remove all of the stones. The purpose of this study was to evaluate the associated factors of stone-free rate after primary percutaneous nephrolithotomy on staghorn calculi in a large series of patients at a single, tertiary referral, endourologic stone center.
Methods: We collected data from medical record between January 2000 and December 2015. A total of 345 primary percutaneous nephrolithotomy procedures were performed for patients with staghorn calculi. This study included both and made no distinction between partial and complete staghorn calculi. Stone-free is defined as the absence of residual stones after undergoing percutaneous nephrolithotomy for the first time. Significant factors from univariate analysis that correlated with stone-free rate after primary percutaneous nephrolithotomy of staghorn stone were further analyzed using multivariate regression analysis.
Results: The mean patient age was 52.23±10.38 years. The stone-free rate of percutaneous nephrolithotomy monotherapy was 62.6%. The mean operating time was 79.55±34.46 minutes. The mean length of stay in hospital was 4.29±3.00 days. Using the chi-square test, history of ipsilateral open renal stone surgery (p = 0.01), stone burden (p = < 0.001), and type of anesthesia (p = 0.04) had a significant impact on the stone-free. From multivariate analysis, the history of ipsilateral open renal stone surgery [OR 0.48; 95% CI 0.28-0.81; p 0.01] and the stone burden [OR 0.28; 95% CI 0.18-0.45; p 0.00] were significant independent risk factors for stone-free.

Keywords

primary percutaneous nephrolithotomy, staghorn calculi, stone-free rate

Corresponding authors: Widi Atmoko, Ponco Birowo

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2016 Atmoko W et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Data associated with the article are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

How to cite: Atmoko W, Birowo P and Rasyid N. Factors affecting stone free rate of primary percutaneous nephrolithotomy on staghorn calculi: a single center experience of 15 years [version 2; peer review: 2 approved]. F1000Research 2016, 5:2106 (https://doi.org/10.12688/f1000research.9509.2) First published: 30 Aug 2016, 5:2106 (https://doi.org/10.12688/f1000research.9509.1) Latest published: 30 Sep 2016, 5:2106 (https://doi.org/10.12688/f1000research.9509.2)

Revised Amendments from Version 1

In this version, the following revisions were made:

Material and Methods
We mentioned the surgeon's level of experience.

Results
- In Table 2, we corrected data regarding number of PCNL access. Before we corrected, it was duplicated with the above row.
- In Table 2, we deleted data regarding nephrostomy tube size because it wasn't correlated to stone free status. The tube size most likely depends on surgeon’s preference and other factors such as bleeding or requirement for postoperative drainage.

This Results correction didn't change the previous raw data

Discussion
We added some weaknesses of this study regarding the imaging of stone free status.

To read any peer review reports and author responses for this article, follow the "read" links in the Open Peer Review table.

Introduction

Staghorn calculus are large and branching kidney stones that occupy a large proportion of the renal pelvis and some or all of the renal calices. Surgical treatment of staghorn calculi involves complete stone removal minimising morbidity. Because untreated staghorn calculus have a tendency to destroy the kidney and cause life-threatening urosepsis, the American Urological Association (AUA) recommends to actively treat all newly diagnosed patients^1,2. In patients with staghorn calculi who are treated conservatively, the mortality rates have been reported to range around 28% to 47.5%^3–6. It is crucial to completely remove all staghorn calculi, because residual stones can form nuclei for stone recurrence (85% recurrence rate) that may lead to infection⁷.

Percutaneous nephrolithotomy (PCNL) has become the recommended treatment for staghorn calculi as it has stone-free rate three times higher than extracorporeal shock wave lithotripsy (ESWL) and has lower morbidity, shorter length of hospital stay, shorter operating time, and time to return to work faster than open surgery^1,8. Nevertheless, the management of staghorn calculi with PCNL remains challenging. Stone-free rates were lower, complications more frequent, and operative time and hospital stay were longer in patients with staghorn stones compared to nonstaghorn stones⁹.

However, PCNL is still the mainstay treatment for staghorn calculi, despite the complete removal of staghorn calculi by PCNL being a high skill-demanding surgical procedure and a challenging task for urologists. In this study, we evaluated the stone-free rate and the factors that influence the effectiveness of primary PCNL performed in our national tertiary referral hospital.

Methods

Patients

From January 2000 to December 2015, the data from 345 patients with staghorn calculi who had undergone PCNL surgery at the Cipto Mangunkusumo Hospital by one of two surgeons (NR and PB) were reviewed. NR did PCNL surgery since 2000 until now, while PB did PCNL surgery since 2009 until now. This study included both and made no distinction between partial and complete staghorn calculi. Patients who were eligible for the study were adult patients (≥ 18 years old) and those who had PCNL for primary treatment for nephrolithiasis who agreed to enroll by written informed consent. The patients meeting the below criteria were excluded: 1) Patients who had systemic hemorrhagic disease without correction; 2) Patients with severe heart disease and pulmonary incompetence who could not undertake the operation; 3) Uncontrolled diabetes and hypertension patients as well as tuberculosis patients; 4) Patients with renal anatomic malformations, such as horse-shoe and ectopic kidneys, with coexisting staghorn calculi; 5) Lordosis or scoliosis patient who could not tolerate the prone position; 6) Patients who had history of ipsilateral PCNL for secondary or tertiary PCNL. The study protocol was approved by the Ethical Committee, Faculty of Medicine, Universitas Indonesia (No.513/UN2.F1/ETIK/2016).

Preoperative preparation

Preoperative laboratory examination undertaken included urinalysis, urine culture, serum creatinine, and complete peripheral blood. Plain abdominal radiography of kidneys, ureters, and bladder (KUB) and intravenous urography (IVU) were the primary radiological investigations. Non-contrast computed tomography (NCCT) was performed for patients with high serum creatinine (>1,6 mg/dL) or those allergic to iodinated contrast. Stone burden was assessed pre-operatively by multiplying sum of length and width by means of imaging. Patients with urinary tract infections treated with antibiotics appropriate preoperative urine culture 5 days prior to PCNL. Other patients who had negative urine cultures receiving intravenous antibiotics prior to anesthesia.

Surgical technique

Following anesthesia, patients were placed in lithotomy position and a 22.5F rigid cystoscope (OLYMPUS) was used to pass a 5F open-end ureteral catheter (Selectip, 62450200; Angiomed, Bard, Murray Hill, NJ) under fluoroscopic guidance, into the renal pelvis, to allow injection of contrast material to delianeate the intrarenal collecting system. A 16F Foley catheter was inserted into the bladder to provide drainage during the procedure and the ureteral catheter was fixed to the Foley catheter. Then the patient was moved to prone position and the side of kidneys to be operated was positioned higher 30°. Percutaneous puncture to gain access to the kidney was done with the help of C-arm control fluoroscopy. Calyx puncture was performed through a superior, media, or inferior, using 18-gauge, diamond-tip needle (Cook Urological, Spencer IN). The needle was positioned so that the target puncture, the needle tip, and the base of the needle was in a position in line. The depth of puncture was controlled using fluoroscopy in the anteroposterior position. After the needle of puncture had been confirmed in the pelvicalyceal system, then a 0.038 guidewire was inserted. After that, the tract was then dilated to 30F using metal dilators (Telescope Bougie Set, 27290A, Karl Storz, Tuttlingen, Germany), fascial dilator and malleable dilators (Amplatz Renal Dilator Set, 075000, Cook Urological, Spencer IN). After inspection by 24-F rigid nephroscope (HOPKINS Wide-Angle Straight Forward Telescope 6°, 27293 AA, Karl Storz, Tuttlingen, Germany), mechanical lithotripsy (Vibrolith, Elmed, Orlando, FL) could be done by breaking the stone. Stone forceps were used to take a hard rock fragments.

Post operative evaluation

Postoperative imaging were performed 1 or 2 days after PCNL with either Kidney Ureter Bladder (KUB) photos, computed tomography (CT) scan, or antegrade pyelography (APG). Stone-free is defined as the absence of residual stones after undergoing PCNL for the first time. Patients who required additional treatment after their first PCNL, such as secondary PCNL and or ESWL, were automatically excluded from the stone-free group. We also evaluated the transfusion rate and the incidence of postoperative complications, such as infection, urine leakage on operative wounds, intestinal perforation, and bleeding.

Data analysis

Bivariate analysis was performed by correlating the numerical variables with stone free rates. Those with P value <0.25 were further analyzed with multivariate analysis of logistic regression. Data were analyzed using the Statistical Package for the Social Sciences, version 17 (SPSS Inc., Chicago, IL). The analysis considered significant when P <0.05.

Results

From January 2000 to December 2015, a total of 345 patients with staghorn calculi had undergone primary PCNL procedures at the Cipto Mangunkusumo Hospital. The mean patient age was 52.23±10.38 years. The stone-free rate of PCNL monotherapy was 62.6%. This value was the result just after the 1st stage of PCNL. The mean operating time was 79.55±34.46 minutes. The mean length of stay in hospital was 4.29±3.00 days. Perioperative transfusions were performed in 11% of patients (Table 1).

Table 1. Patient characteristics.

Variable	Mean ± SD or no. (%) cases
No. patients	345
Age (year)	52.23±10.38
Stone burden (mm²)	51.85±23.54
Body mass index < 25 kg/m² 25.29.9 kg/m² ≥ 30 kg/m²	185 (53.6) 98 (28.4) 62 (18.0)
History of ipsilateral renal stone open surgery	85 (24.6)
Calyx target for PCNL access Inferior calyx Other than inferior calyx	312 (90.4) 33 (9.6)
Amount of PCNL access Single Multiple	333 (96.5) 12 (3.5)
Anesthesia Spinal General	281 (81.4) 64 (18.6)
Nephrostomy tube usage Large tube Small tube Tubeless	56 (16.2) 183 (53.0) 106 (30.7)
Stone-free PCNL	216 (62.6)
Operative time (minute)	79.55±34.46
Length of hospital stay (days)	4.29±3.00
Perioperative transfusion	38 (11.0)
Complications Infection Urine leakage at the operative wound Intestinal perforation Bleeding	1 (0.3) 3 (0.9) 1 (0.3) 17 (4.9)

From the univariate analysis, there was significant association between history of ipsilateral renal stone open surgery, stone burden, and type of anesthesia with the stone-free rate (p = 0.01; p < 0.001; p = 0.04, respectively). The univariate analyses are illustrated in Table 2. Stepwise multivariate regression analysis which included variables with p-value < 0.25 showed that the stone burden was the most influential predictor of stone-free (OR 0.28, 95% CI 0.18–0.45, p=0.00) (Table 3).

Table 2. Univariate analysis of factors that associated with the stone-free rate.

Variable	Stone-free rate (%)		P
	Stone-free	Residual stone
Sex Male Female	58.8 41.2	64.3 35.7	0.31*
Age < 65 years ≥ 65 years	87.0 13.0	88.4 11.6	0.72*
Body mass index < 25 kg/m² 25–29.9 kg/m² ≥30 kg/m²	50.9 29.6 19.4	58.1 26.4 15.5	0.40*
Stone burden ≤ 52 mm² > 52 mm²	69.9 30.1	41.1 58.9	0.00*
History of ipsilateral renal stone open surgery Yes No	20.4 79.6	31.8 68.2	0.01*
Calys target for PCNL access Inferior calyx Other calyx	91.2 9.8	89.1 10.9	0.53*
Number of PCNL access Single Multiple	98.1 1.9	93.8 6.2	0.26**
Kidney morphology No hydronephrosis Hydronephrosis	44.4 55.6	41.9 58.1	0.64*
Anestesia General Spinal	16.2 83.8	22.5 77.5	0.15*

*Chi-Square test

**Fisher test

Table 3. Multivariate analysis (logistic regression model) of factors independently predictive of stone-free rate.

Step	Preoperative factor	Coefficient	p value	OR (CI 95%)
Step 1	History of ipsilateral open renal stone surgery No (reference) Yes	-0.741	0.01	0.48 (0.28–0.80)
	Stone burden ≤ 52 mm (reference) > 52 mm	-1.246	0.00	0.29 (0.18–0.46)
	Anesthesia General (reference) Spinal	-0.263	0.37	1.30 (0.73–2.33)
Step 2	History of ipsilateral open renal stone surgery No (reference) Yes	-0.738	0.01	0.48 (0.28–0.81)
Step 2	Stone burden ≤ 52 mm (reference) > 52 mm	-1.267	0.00	0.28 (0.18–0.45)

Patient Number	Sex	Age range (years)	Stone burden (mm2)	Body mass index (kg/m2)	Kidney morphology	History of ipsilateral renal stone open surgery	Calyx target for PCNL access	Amount of PCNL access	Anesthesia	Nephrostomy tube usage	Stone-free	Operative time (minute)	Length of hospital stay (days)	Perioperative transfusion	Complications
1	male	31-50	65	30.11	hydronephrosis	no	inferior	single	general	large tube	no	45	7	no	no
2	male	31-50	93	19.05	hydronephrosis	no	inferior	single	general	large tube	no	170	7	no	no
3	male	31-50	93	24.22	hydronephrosis	no	inferior	single	general	large tube	no	95	7	no	no
4	female	31-50	59	31.25	hydronephrosis	yes	inferior	single	general	large tube	no	150	11	no	no
5	male	51-70	76	20.03	hydronephrosis	no	inferior	single	general	large tube	no	60	7	yes	no
6	male	31-50	70	25.22	hydronephrosis	no	inferior	single	spinal	large tube	yes	120	12	no	no
7	female	18-30	64	31.25	hydronephrosis	yes	inferior	single	general	small tube	no	180	3	no	no
8	male	31-50	30	31.25	hydronephrosis	no	inferior	single	general	large tube	no	90	6	no	no
9	male	31-50	35	31.25	hydronephrosis	no	inferior	single	general	large tube	no	120	6	no	no
10	female	31-50	40	31.25	No hydronephrosis	no	inferior	single	general	large tube	yes	160	4	no	no
11	female	51-70	56	28.52	No hydronephrosis	no	inferior	single	general	large tube	no	210	15	yes	bleeding
12	female	51-70	73	25	hydronephrosis	no	inferior	single	general	tubeless	yes	210	31	yes	bleeding
13	male	51-70	36	27.06	hydronephrosis	no	inferior	single	general	large tube	no	60	6	yes	bleeding
14	male	51-70	56	25.39	hydronephrosis	no	inferior	single	general	large tube	yes	120	6	no	no
15	female	51-70	55	20.28	hydronephrosis	no	inferior	single	general	large tube	yes	120	4	no	no
16	male	31-50	41	30.11	No hydronephrosis	no	inferior	single	spinal	large tube	yes	60	4	no	no
17	male	31-50	65	19.05	hydronephrosis	no	inferior	single	general	large tube	yes	60	4	no	no
18	male	31-50	64	24.22	hydronephrosis	no	inferior	single	general	large tube	no	120	4	no	no
19	male	31-50	43	31.25	No hydronephrosis	yes	inferior	single	general	large tube	no	80	8	no	no
20	male	31-50	64	20.03	hydronephrosis	no	inferior	single	general	large tube	no	120	3	no	no
21	male	31-50	45	25.22	hydronephrosis	no	inferior	single	general	large tube	yes	90	3	no	urine leakage at the operative wound
22	male	31-50	46	31.25	No hydronephrosis	no	other than inferior	single	general	large tube	yes	90	4	no	no
23	male	31-50	55	31.25	hydronephrosis	yes	inferior	single	general	large tube	yes	90	6	no	no
24	male	51-70	50	31.25	No hydronephrosis	no	inferior	single	general	large tube	no	75	5	no	no
25	female	51-70	42	31.25	hydronephrosis	no	inferior	single	general	large tube	yes	120	3	no	no
26	male	31-50	60	28.52	hydronephrosis	no	inferior	single	spinal	large tube	no	120	7	no	no
27	female	31-50	68	25	hydronephrosis	no	inferior	single	general	small tube	no	90	5	no	no
28	male	51-70	47	27.06	hydronephrosis	no	inferior	single	general	large tube	yes	120	2	no	no
29	female	51-70	22	25.39	hydronephrosis	no	inferior	single	general	large tube	yes	120	7	no	no
30	male	31-50	100	20.28	hydronephrosis	yes	other than inferior	multiple	spinal	large tube	no	120	4	no	no
31	female	51-70	27	30.11	hydronephrosis	yes	inferior	single	spinal	large tube	yes	60	6	no	no
32	male	51-70	80	19.05	hydronephrosis	no	inferior	single	spinal	large tube	no	60	5	no	no
33	female	51-70	67	24.22	hydronephrosis	no	inferior	single	spinal	large tube	yes	60	4	no	no
34	female	18-30	70	19.11	hydronephrosis	no	inferior	single	general	small tube	no	120	12	no	intestinal perforation
35	male	31-50	60	31.59	hydronephrosis	no	inferior	single	general	large tube	no	105	7	no	no
36	female	31-50	57	30.11	hydronephrosis	no	inferior	single	general	small tube	yes	70	5	no	no
37	male	51-70	40	19.05	No hydronephrosis	yes	inferior	single	general	small tube	no	60	3	no	no
38	male	51-70	32	24.22	hydronephrosis	yes	inferior	single	general	small tube	yes	30	2	no	no
39	male	? 71	40	31.25	hydronephrosis	no	inferior	single	general	small tube	yes	90	4	no	no
40	male	31-50	56	20.03	hydronephrosis	no	other than inferior	single	general	small tube	no	90	6	no	no
41	male	31-50	45	25.22	No hydronephrosis	yes	inferior	single	spinal	small tube	yes	45	4	no	no
42	male	31-50	55	31.25	hydronephrosis	no	inferior	single	spinal	large tube	yes	60	2	no	no
43	male	51-70	56	31.25	hydronephrosis	no	inferior	single	spinal	small tube	no	90	5	no	no
44	female	51-70	47	31.25	hydronephrosis	yes	inferior	single	spinal	small tube	no	60	4	no	no
45	female	51-70	38	31.25	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	2	no	no
46	female	51-70	60	28.52	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	5	no	no
47	female	31-50	60	25	hydronephrosis	no	inferior	single	general	large tube	no	90	3	no	bleeding
48	male	31-50	83	27.06	No hydronephrosis	no	inferior	single	general	large tube	yes	90	4	no	no
49	male	31-50	76	25.39	hydronephrosis	yes	inferior	single	general	large tube	no	75	4	no	no
50	male	31-50	40	20.28	hydronephrosis	yes	inferior	single	general	large tube	no	120	5	no	no
51	male	31-50	35	30.11	hydronephrosis	yes	inferior	single	general	small tube	yes	60	4	no	no
52	male	51-70	54	19.05	No hydronephrosis	yes	inferior	single	general	small tube	yes	90	4	no	no
53	male	51-70	54	24.22	No hydronephrosis	no	inferior	single	general	small tube	yes	90	3	no	no
54	female	51-70	71	31.25	hydronephrosis	no	inferior	single	general	small tube	yes	60	3	yes	bleeding
55	male	51-70	29	20.03	No hydronephrosis	yes	inferior	single	general	large tube	yes	40	7	no	no
56	female	51-70	70	25.22	hydronephrosis	no	other than inferior	multiple	general	small tube	no	60	3	yes	bleeding
57	male	51-70	58	31.25	hydronephrosis	no	inferior	single	general	small tube	yes	90	3	no	no
58	female	18-30	52	31.25	hydronephrosis	yes	inferior	single	spinal	small tube	yes	120	6	no	no
59	male	31-50	70	31.25	hydronephrosis	yes	other than inferior	multiple	spinal	small tube	no	90	4	no	no
60	female	31-50	40	31.25	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	4	yes	no
61	male	51-70	42	28.52	hydronephrosis	yes	inferior	single	spinal	small tube	yes	70	6	no	no
62	male	51-70	45	25	hydronephrosis	no	inferior	single	spinal	small tube	no	45	5	no	no
63	female	51-70	32	27.06	hydronephrosis	yes	other than inferior	multiple	spinal	small tube	yes	60	4	no	no
64	male	51-70	38	25.39	hydronephrosis	no	inferior	single	spinal	small tube	no	80	5	no	no
65	female	51-70	31	20.28	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	10	no	no
66	male	51-70	30	30.11	hydronephrosis	no	inferior	single	spinal	large tube	yes	40	2	no	no
67	male	51-70	45	19.05	No hydronephrosis	no	inferior	single	spinal	small tube	yes	40	4	no	no
68	female	? 71	50	24.22	hydronephrosis	no	other than inferior	single	spinal	small tube	yes	90	7	no	no
69	male	? 71	32	31.25	No hydronephrosis	no	inferior	single	spinal	small tube	yes	45	2	no	no
70	male	51-70	32	20.03	hydronephrosis	no	inferior	single	general	large tube	yes	40	7	no	no
71	male	51-70	45	25.22	No hydronephrosis	no	inferior	single	general	large tube	yes	60	5	no	no
72	male	51-70	51	31.25	hydronephrosis	no	inferior	single	general	small tube	no	60	2	no	no
73	male	31-50	67	31.25	No hydronephrosis	no	inferior	single	spinal	small tube	yes	90	4	no	no
74	male	31-50	55	31.25	hydronephrosis	no	inferior	single	spinal	small tube	yes	90	3	no	no
75	male	31-50	39	31.25	hydronephrosis	yes	inferior	single	spinal	small tube	no	60	5	no	no
76	female	31-50	46	28.52	No hydronephrosis	no	inferior	single	spinal	small tube	yes	45	4	no	no
77	male	51-70	43	25	hydronephrosis	no	inferior	single	spinal	small tube	yes	70	5	no	no
78	male	51-70	40	27.06	hydronephrosis	no	inferior	single	spinal	small tube	no	60	2	no	no
79	female	51-70	69	25.39	No hydronephrosis	no	inferior	single	spinal	small tube	no	120	2	no	no
80	male	51-70	81	20.28	No hydronephrosis	no	inferior	single	spinal	small tube	yes	60	5	no	no
81	male	51-70	30	22.86	No hydronephrosis	yes	inferior	single	spinal	small tube	yes	60	5	no	no
82	male	51-70	40	26.45	hydronephrosis	no	inferior	single	spinal	small tube	yes	90	3	no	no
83	female	51-70	80	19.53	hydronephrosis	no	inferior	single	spinal	small tube	no	120	2	no	no
84	female	51-70	55	17.9	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	2	no	no
85	female	51-70	55	19.53	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	2	no	no
86	female	51-70	42	17.9	No hydronephrosis	no	inferior	single	spinal	small tube	yes	65	3	no	no
87	female	51-70	75	17.9	No hydronephrosis	no	inferior	single	spinal	small tube	no	150	5	yes	no
88	male	18-30	89	20.89	hydronephrosis	no	inferior	single	general	large tube	no	60	4	no	no
89	female	31-50	49	20.89	hydronephrosis	yes	inferior	single	general	large tube	no	90	8	no	no
90	male	31-50	80	22.04	No hydronephrosis	yes	inferior	single	general	large tube	no	90	6	no	no
91	female	31-50	42	20.89	hydronephrosis	yes	other than inferior	single	general	large tube	yes	60	2	no	no
92	female	31-50	35	29.43	hydronephrosis	no	inferior	single	general	large tube	yes	60	5	no	no
93	male	31-50	87	23.88	No hydronephrosis	no	inferior	single	general	large tube	no	90	4	no	no
94	male	31-50	98	23.88	No hydronephrosis	no	inferior	single	general	large tube	yes	90	4	no	no
95	male	31-50	75	20.89	No hydronephrosis	no	other than inferior	single	general	large tube	yes	30	2	no	no
96	female	51-70	35	31.99	hydronephrosis	no	inferior	single	general	large tube	yes	30	3	no	no
97	male	51-70	45	25.71	No hydronephrosis	no	inferior	single	general	large tube	yes	60	6	no	urine leakage at the operative wound
98	male	51-70	45	23.53	hydronephrosis	no	inferior	single	general	large tube	yes	60	2	no	no
99	female	51-70	55	25.71	hydronephrosis	no	inferior	single	general	large tube	yes	60	5	no	no
100	male	31-50	25	25.71	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	3	no	no
101	male	31-50	40	20.2	hydronephrosis	no	inferior	single	spinal	small tube	yes	160	4	no	no
102	male	31-50	30	24.61	hydronephrosis	yes	inferior	single	spinal	small tube	yes	60	4	no	no
103	male	31-50	46	21.22	No hydronephrosis	no	inferior	single	spinal	small tube	no	45	4	no	no
104	male	31-50	65	30.8	hydronephrosis	no	inferior	single	spinal	small tube	no	60	2	no	no
105	male	31-50	42	25.71	No hydronephrosis	yes	inferior	single	spinal	small tube	yes	45	5	no	no
106	female	51-70	43	26.56	No hydronephrosis	yes	inferior	single	spinal	small tube	no	90	3	no	no
107	male	51-70	75	21.3	No hydronephrosis	no	inferior	single	spinal	small tube	yes	45	2	no	no
108	male	51-70	43	30.42	hydronephrosis	no	inferior	single	spinal	large tube	yes	90	2	no	no
109	male	51-70	64	25.71	hydronephrosis	no	inferior	single	spinal	small tube	no	40	4	no	no
110	male	51-70	56	19.78	hydronephrosis	no	inferior	single	spinal	small tube	no	45	2	no	no
111	female	? 71	70	21.36	No hydronephrosis	yes	other than inferior	single	spinal	small tube	yes	60	9	no	infection
112	male	? 71	49	26.99	hydronephrosis	no	inferior	single	spinal	small tube	yes	30	2	no	no
113	male	51-70	35	25.71	No hydronephrosis	no	inferior	single	spinal	small tube	yes	180	2	no	no
114	male	31-50	23	25.71	hydronephrosis	no	inferior	single	general	small tube	yes	45	6	no	no
115	male	51-70	20	25.71	hydronephrosis	no	inferior	single	general	small tube	yes	100	3	no	no
116	female	51-70	20	25.71	hydronephrosis	no	inferior	single	general	large tube	yes	80	3	no	no
117	male	18-30	15	25.71	No hydronephrosis	no	inferior	single	spinal	small tube	yes	60	4	no	no
118	male	31-50	55	23.72	No hydronephrosis	no	inferior	single	spinal	tubeless	yes	60	2	no	no
119	male	31-50	40	25.99	hydronephrosis	no	inferior	single	spinal	tubeless	no	60	4	no	no
120	male	31-50	25	23.88	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	2	no	no
121	female	31-50	25	20.34	hydronephrosis	no	inferior	single	spinal	small tube	yes	150	5	no	no
122	male	31-50	80	18.37	No hydronephrosis	no	inferior	single	spinal	tubeless	no	90	2	yes	no
123	male	31-50	56	13.96	hydronephrosis	no	inferior	single	spinal	small tube	no	180	2	no	no
124	female	31-50	45	18.37	hydronephrosis	no	inferior	single	spinal	small tube	no	120	1	yes	no
125	female	31-50	55	21.48	No hydronephrosis	yes	inferior	single	spinal	small tube	yes	60	2	yes	no
126	male	31-50	35	25.95	hydronephrosis	no	inferior	single	spinal	small tube	yes	120	3	no	no
127	female	31-50	30	18.37	hydronephrosis	no	inferior	single	spinal	small tube	yes	45	3	no	no
128	male	51-70	40	18.37	hydronephrosis	no	inferior	single	spinal	small tube	yes	150	3	no	no
129	male	51-70	52	25.39	hydronephrosis	no	inferior	single	spinal	small tube	no	60	4	no	no
130	male	51-70	45	18.37	No hydronephrosis	no	inferior	single	spinal	tubeless	yes	80	2	no	no
131	male	51-70	40	18.37	No hydronephrosis	yes	inferior	single	spinal	small tube	yes	90	3	no	no
132	male	51-70	40	18.37	No hydronephrosis	no	inferior	single	spinal	tubeless	no	120	4	no	no
133	male	51-70	50	29.4	No hydronephrosis	no	inferior	single	spinal	small tube	no	60	5	no	no
134	male	51-70	30	21.48	hydronephrosis	yes	inferior	single	spinal	small tube	yes	60	13	no	no
135	male	51-70	60	25.1	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	2	no	no
136	female	51-70	20	18.37	hydronephrosis	no	inferior	single	spinal	large tube	yes	110	8	yes	no
137	female	51-70	66	18.37	No hydronephrosis	no	inferior	single	spinal	small tube	yes	100	2	no	no
138	female	51-70	45	27.77	hydronephrosis	no	inferior	single	spinal	tubeless	yes	60	3	no	no
139	male	? 71	51	20.03	No hydronephrosis	yes	inferior	single	spinal	small tube	no	60	5	no	no
140	female	31-50	75	18.37	No hydronephrosis	yes	inferior	single	spinal	tubeless	yes	120	5	yes	no
141	male	31-50	53	27.55	hydronephrosis	no	inferior	single	spinal	tubeless	yes	60	2	no	no
142	male	51-70	38	18.37	hydronephrosis	no	inferior	single	spinal	tubeless	yes	60	3	no	no
143	male	51-70	63	18.37	hydronephrosis	no	inferior	single	spinal	small tube	no	60	2	no	no
144	male	51-70	30	18.37	hydronephrosis	no	inferior	single	spinal	small tube	yes	120	4	no	no
145	male	51-70	68	19.83	hydronephrosis	no	inferior	single	spinal	small tube	no	120	6	no	no
146	male	51-70	62	30.49	No hydronephrosis	no	inferior	single	spinal	small tube	no	120	4	no	no
147	female	31-50	42	22.22	hydronephrosis	no	inferior	single	spinal	small tube	no	60	13	no	no
148	female	31-50	26	22.22	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	5	no	no
149	male	51-70	43	30.49	No hydronephrosis	no	other than inferior	single	spinal	tubeless	yes	60	2	no	no
150	male	31-50	35	30.49	hydronephrosis	no	inferior	single	general	tubeless	yes	60	2	no	no
151	female	31-50	40	22.5	No hydronephrosis	yes	inferior	single	spinal	small tube	yes	60	4	no	no
152	male	31-50	37	24.77	hydronephrosis	yes	inferior	single	spinal	tubeless	yes	70	2	no	no
153	female	31-50	67	30.47	hydronephrosis	no	other than inferior	multiple	spinal	small tube	no	90	3	no	no
154	male	31-50	30	32.08	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	3	no	no
155	female	31-50	54	18.37	hydronephrosis	no	other than inferior	multiple	spinal	small tube	no	120	6	no	no
156	female	31-50	60	30.49	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	4	no	no
157	male	31-50	70	24.77	hydronephrosis	no	inferior	single	spinal	small tube	no	90	3	no	no
158	male	31-50	35	30.49	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	4	no	no
159	male	31-50	55	31.22	hydronephrosis	no	other than inferior	multiple	spinal	tubeless	no	60	3	no	no
160	male	31-50	49	29.05	hydronephrosis	no	inferior	single	spinal	small tube	no	60	2	no	no
161	female	31-50	50	34.38	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	5	yes	no
162	male	31-50	25	23.44	hydronephrosis	no	other than inferior	single	spinal	tubeless	yes	40	3	no	no
163	female	31-50	60	23.44	hydronephrosis	no	inferior	single	spinal	tubeless	yes	60	3	no	no
164	female	31-50	85	30.11	hydronephrosis	no	other than inferior	multiple	spinal	small tube	yes	80	3	no	no
165	male	31-50	56	19.05	No hydronephrosis	no	inferior	single	spinal	large tube	no	75	11	yes	no
166	male	31-50	75	24.22	hydronephrosis	no	inferior	single	spinal	tubeless	yes	60	3	no	no
167	male	31-50	57	31.25	hydronephrosis	no	inferior	single	spinal	small tube	yes	80	7	no	no
168	female	31-50	40	20.03	hydronephrosis	no	inferior	single	spinal	tubeless	no	50	5	no	no
169	female	31-50	30	25.22	No hydronephrosis	no	other than inferior	multiple	spinal	small tube	yes	60	4	no	no
170	male	51-70	45	31.25	hydronephrosis	no	inferior	single	spinal	small tube	no	60	3	no	no
171	female	51-70	25	31.25	hydronephrosis	yes	inferior	single	spinal	small tube	yes	60	3	no	no
172	female	51-70	25	31.25	hydronephrosis	yes	inferior	single	spinal	small tube	yes	60	4	no	no
173	female	51-70	30	31.25	hydronephrosis	no	other than inferior	multiple	spinal	tubeless	yes	90	5	no	no
174	male	51-70	30	28.52	No hydronephrosis	no	inferior	single	spinal	small tube	yes	45	3	no	no
175	female	51-70	54	25	hydronephrosis	yes	other than inferior	single	spinal	small tube	no	150	4	no	no
176	female	51-70	45	27.06	No hydronephrosis	no	inferior	single	spinal	small tube	yes	60	5	no	no
177	male	51-70	52	25.39	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	5	no	no
178	male	51-70	63	20.28	No hydronephrosis	yes	inferior	single	spinal	tubeless	yes	40	3	no	no
179	female	51-70	20	19.36	hydronephrosis	no	inferior	single	spinal	tubeless	yes	20	3	no	no
180	male	51-70	45	27.68	No hydronephrosis	yes	inferior	single	spinal	small tube	yes	60	11	yes	no
181	male	51-70	43	21.34	No hydronephrosis	no	other than inferior	single	spinal	tubeless	yes	50	3	no	no
182	male	51-70	50	29.4	No hydronephrosis	yes	inferior	single	spinal	small tube	no	60	7	no	no
183	male	51-70	22	27.68	hydronephrosis	no	inferior	single	spinal	tubeless	yes	60	7	no	no
184	female	51-70	30	27.68	hydronephrosis	no	inferior	single	spinal	tubeless	yes	80	5	no	no
185	male	51-70	30	21.48	hydronephrosis	yes	inferior	single	spinal	small tube	yes	60	14	no	no
186	male	51-70	50	27.68	No hydronephrosis	no	inferior	single	spinal	tubeless	no	60	4	no	no
187	female	51-70	54	27.68	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	3	no	no
188	male	51-70	35	27.68	No hydronephrosis	no	inferior	single	spinal	tubeless	yes	60	16	no	no
189	female	51-70	67	19.49	No hydronephrosis	no	inferior	single	spinal	tubeless	no	60	3	no	no
190	female	51-70	55	24.97	hydronephrosis	no	inferior	single	spinal	tubeless	yes	60	4	no	no
191	male	51-70	50	22.49	hydronephrosis	no	inferior	single	spinal	small tube	yes	90	5	yes	no
192	female	51-70	70	22.22	hydronephrosis	no	inferior	single	spinal	tubeless	no	60	4	no	no
193	male	51-70	33	20.76	hydronephrosis	no	inferior	single	spinal	small tube	yes	60	3	no	no
194	male	51-70	41	20.96	hydronephrosis	yes	inferior	single	spinal	small tube	no	60	3	no	no
195	male	51-70	22	23.12	No hydronephrosis	yes	inferior	single	spinal	tubeless	yes	50	2	no	no
196	male	51-70	50	28.13	hydronephrosis	yes	inferior	single	spinal	small tube	yes	80	5	no	no
197	male	? 71	45	22.09	No hydronephrosis	no	inferior	single	spinal	tubeless	no	90	4	no	no
198	male	51-70	47	19.53	No hydronephrosis	no	other than inferior	single	spinal	tubeless	yes	90	8	no	no
199	female	51-70	125	21.23	No hydronephrosis	yes	inferior	single	general	tubeless	no	180	3	no	no
This is a portion of the data; to view all the data, please download the file.

Dataset 1.Raw data for Table 1, Table 2, and Table 3 of 'Factors affecting stone free rate of primary percutaneous nephrolithotomy on staghorn calculi: a single center experience of 15 years’.

All the raw data used in univariate and multivariate analises are provided.

Discussion

Since the introduction of PCNL to treat kidney stones, there has been a rapid development in techniques and instruments that can be used to treat staghorn calculi and complex stone. In 1983, Clayman et al. reported the capability and safety of PCNL in treating staghorn calculi¹⁰. Currently, PCNL is the preferred treatment option for patients with staghorn calculi, complex stone, and big stone^1,11,12. The goal treatment of staghorn calculi is stone-free thoroughly with minimal morbidity^1,11. PCNL in patients with staghorn calculi still represents a procedural challenge, thus requiring the surgeon to perform complete removal of the stone while keeping morbidity to a minimum¹³.

Stone-free rate after PCNL monotherapy for staghorn calculi is reported to range between 49% to 78%¹³. In this study, the stone-free rate after PCNL monotherapy was 64.6%. This is higher than the stone-free rate reported by Al - Kohlany et al. (49%)⁸ because they only considered and treated complete staghorn calculi, whereas in this study we included both patients with partial staghorn calculi and complete staghorn calculi and we made no distinction between partial and complete staghorn calculi. Stone-free rate in our study was not very different from the research conducted by El-Nahas et al.¹⁴ (56.6%) and Desai et al.⁹ (56.9%). They included subject criteria similar to our study, namely the complete and partial staghorn calculi¹⁴. However, the stone-free rate of our study was lower than that reported by Soucy et al.¹³ who reported higher stone-free rate (78%). That study incorporated branched stone in just one calyx (borderline staghorn calculi) found in 67% of their patients, so that the majority of patients had a lower burden stone and were easier to treat¹³.

The duration of the operation is an important factor in determining and comparing various procedural techniques¹⁵, as the duration of anesthesia and the risk of pulmonary complications after surgery can indirectly affect the operation outputs (amount of blood loss, decrease of hemoglobin, and blood transfusion requirements)^16,17 and complications^18,19 associated with PCNL. The mean length of surgery in this study was 79.55±34.46 minutes with a median value of 60 (range 20–210) minutes. The mean operating time on research conducted by Huang et al.²⁰ was 63.5±11.8 minutes with a range of 29–103 minutes. The duration of operation on that research was shorter because Huang et al. did not use a ureteral catheter or balloon catheter before PCNL. According to Huang et al., direct puncture to the stone without previous insertion of ureteral catheter can be done so as to save operating time and reduce complications¹⁵.

Potential significant morbidity or even mortality of PCNL have been reported in a large-scale study^16,21,22. Kidney stone management panel of AUA guidelines mentioned that the staghorn calculi have 7–27% complication and transfusion rate reaching 18%¹. Previous studies reported that blood transfusion was needed at 14–24% in PCNL with staghorn calculi, depending on the surgical technique, patient population, indications for transfusion, and the opinion of the surgeon to perform transfusion^23,24. El-Nahas et al. reported that the staghorn calculi is a risk factor for the occurrence of severe bleeding in PCNL²⁵. The bleeding complications in our study that required transfusion were lower in numbers than previously reported. As shown in Table 1 and Dataset 1, we observed 4.9% of bleeding cases and 11% cases of perioperative transfusion. Total complications observed in our study amounted to 6.4%.

El-Nahas et al.²⁶ found an association between the stone burden (partial and complete staghorn calculi) and secondary calyx stones with a stone-free rate. In our study, no distinction was made between the data entries of complete and partial staghorn calculi but we devided the category of stone burden into two groups, the first group was ≤ 52 mm and the second group was > 52 mm. From our multivariate analysis, we found that the stone burden was associated with the stone-free rate (OR 0.28; 95% CI 0.18-0.45; p 0.00). In our study, we didn’t perform S.T.O.N.E nephrolithometry that was found to be the predictor for stone-free rate after PCNL for staghorn stones²⁷. El-Nahas et al.²⁶ stated that the stone is branched and secondary stones require multiple access or use flexible nephroscopy to achieve stone-free, but sometimes this technique is not enough. The surgeon must determine whether to increase the number of access PCNL to take the entire residual stone or to treat residual stone with ESWL²⁶. The more the number of PCNL access, the higher the incidence of bleeding complications¹⁶.

In this study, we found that history of ipsilateral renal stone open surgery was significantly associated with stone-free rate. This is different from the previous study conducted by Kurtulus et al.²⁸ that compared patients who undergone PCNL for the first time with patients who had previous history of open renal stone surgery. In patients who have a history of open renal stone surgery, infundibulum stenosis, perinephric fibrosis, bowel displacement, and incisional hernia are the major factors that should be taken into account by the surgeon^29,30. As long as the safety rules are strictly followed, PCNL can still be performed with minimal complication and high success rates despite the technical and access difficulties encountered in secondary or tertiary cases due to anatomic positional differences of the kidney and fibrosis as mentioned by Kurtulus et al.²⁸. In their study, the residual stone rate wasn’t significantly different between patients who had previous history of ipsilateral open renal stone surgery and patients who undergone PCNL for the first time (5% vs 3%, p>0.05). Kurtulus et al. had difficulty in dilating percutaneous tract in patients with history of ipsilateral open renal stone surgery. With the help of newly developed high-pressure balloons, assistance of fascial dilators, or by mechanical dilators, difficulty in establishing access may be overcomed²⁸. In some other studies, it had been reported that open stone surgery can increase PCNL failure rate³¹, while others showed that previous open stone surgery does not affect PCNL outcome^32–34.

The type of anesthesia was not significantly associated with stone-free rate in our multivariate analysis. This finding was in accordance with other studies. Astram et al. compared 220 PCNL procedures using general anesthesia and 540 PCNL using spinal anesthesia. They found the stone-free rate in the general anesthesia group was 71.37%, similar to the spinal anesthesia group 72.97% (p > 0.05)³⁵. Kuzgunbay et al.³⁶ and Tangpaitoon et al.³⁷ also found that combined spinal-regional anesthesia is a feasible technique in PCNL operations because the efficacy and safety were not affected compared to PCNL with general anesthesia. Selection of anesthesia is important because it can affect the patient's postoperative recovery and a consideration for the urologist to discharge a patient from the hospital in a safe condition as soon as possible³⁸. In our study, the majority of PCNL was performed under spinal anesthesia (81.4%) and no conversion from spinal to general anesthesia was recorded. It was found that the use of spinal anesthesia can reduce the need for PCNL postoperative analgetic, decrease nausea³⁹, and the patient can cooperate when operation being held³⁶. General anesthesia on the other hand, may increase complications in PCNL when the patient changes position⁴⁰. Additionaly, performing PCNL on staghorn calculi under general anesthesia can induce diluted anemia, hypothermia, higher blood loss, as well as the possibility of fluid absorption and electrolyte imbalance³⁸. In short, lower dose of analgesia demand, duration of surgery, well-maintained hemodynamic stability during and after operation with faster patient recovery shows the promising aspect of spinal anesthesia to be virtually used in most PCNL procedures⁴¹.

This study bears the common problems of retrospective studies, including selection bias and missing of important clinical data, like partial or complete staghorn stone. The results reported here are different from those published in the study conducted by El-Nahas et al²⁶. They found that independent risk factors for residual stones were complete staghorn calculi and presence of secondary calyceal stones (relative risks were 2.2 and 3.1, respectively). In our study, we didn’t distinct between partial and complete staghorn calculi and this type of analysis could not be done. Besides that, stone free status was a primary endpoint. However, it was evaluated by either plain KUB radiograph, CT scan, or antegrade pyelography. There would be bias on these images since it could probably missed 3–4 mm residual fragment on a plain KUB film. It could be difficult to evaluate stone free status accurately with plain KUB film in an early postoperative period since fluid leakage around the kidney may obscure residual fragments. In addition, the low metabolic evaluation in patients is a weakness of this study because the stone analysis and the metabolic tests are not used routinely on all patients. No follow-up data collection on secondary treatment (such as ESWL, ureterorenoscopy (URS), and secondary PCNL) is also a shortcoming of this study because from those data we ccould analyse the effectiveness of combination therapy with ESWL, secondary PCNL effectiveness rate, and other therapies.

Conclusions

Percutaneous nephrolithotomy is the mainstay for treating staghorn calculi. History of ipsilateral renal stone surgery and stone burden are prognostic factors determining stone clearance after PCNL on staghorn stones.

Data availability

F1000Research: Dataset 1. Raw data for Table 1, Table 2, and Table 3 of 'Factors affecting stone free rate of primary percutaneous nephrolithotomy on staghorn calculi: a single center experience of 15 years’, 10.5256/f1000research.9509.d134117⁴²

Consent

Written informed consent to participate in the study and publish clinical data was obtained by the patients.

Abbreviations & acronyms

APG: Antegrade Pyelography

AUA: American Urological Association

ESWL: Extracorporeal Shock Wave Lithotripsy

IVU: Intravenous Urography

KUB: Kidneys, Ureters, and Bladder

NCCT: Non Contrast Computed Tomography

PCNL: Percutaneous Nephrolithotomy

URS: Ureterorenoscopy

Author contributions

WA - study concepts, design of study, data acquisition, data interpretation, statistical analysis, manuscript preparation. PB – study concepts, design of study, manuscript review, funds collection. NR - design of study, manuscript review, funds collection. All authors have agreed to publish this final manuscript.

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

F1000 recommended

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25. El-Nahas AR, Shokeir AA, El-Assmy AM, et al.: Post-percutaneous nephrolithotomy extensive hemorrhage. A study of risk factors. J Urol. 2007; 177(2): 576–9. PubMed Abstract | Publisher Full Text
26. el-Nahas AR, Eraky I, Shokeir AA, et al.: Factors affecting stone-free rate and complications of percutaneous nephrolithotomy for treatment of staghorn stone. Urology. 2012; 79(6): 1236–1241. PubMed Abstract | Publisher Full Text
27. Sfoungaristos S, Gofrit ON, Pode D, et al.: Percutaneous nephrolithotomy for staghorn stones: Which nomogram can better predict postoperative outcomes? World J Urol. 2016; 34(8): 1163–8. PubMed Abstract | Publisher Full Text
28. Kurtulus FO, Fazlioglu A, Tandogdu Z, et al.: Percutaneous nephrolithotomy: primary patients versus patients with history of open renal surgery. J Endourol. 2008; 22(12): 2671–5. PubMed Abstract | Publisher Full Text
29. Shah HN, Mahajan AP, Hegde SS, et al.: Tubeless percutaneous nephrolithotomy in patients with previous ipsilateral open renal surgery: a feasibility study with review of literature. J Endourol. 2008; 22(1): 19–24. PubMed Abstract | Publisher Full Text
30. Margel D, Lifshitz DA, Kugel V, et al.: Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy. J Endourol. 2005; 19(10): 1161–1164. PubMed Abstract | Publisher Full Text
31. Jones DJ, Russell GL, Kellett MJ, et al.: The changing practice of percutaneous stone surgery. Review of 1000 cases 1981-1988. Br J Urol. 1990; 66(1): 1–5. PubMed Abstract | Publisher Full Text
32. Basiri A, Karrami H, Moghaddam SM, et al.: Percutaneous nephrolithotomy in patients with or without a history of open nephrolithotomy. J Endourol. 2003; 17(4): 213–216. PubMed Abstract | Publisher Full Text
33. Sofikerim M, Demirci D, Gülmez I, et al.: Does previous open nephrolithotomy affect the outcome of percutaneous nephrolithotomy? J Endourol. 2007; 21(4): 401–403. PubMed Abstract | Publisher Full Text
34. Reddy SV, Shaik AB: Outcome and complications of percutaneous nephrolithotomy as primary versus secondary procedure for renal calculi. Int Braz J Urol. 2016; 42(2): 262–269. PubMed Abstract | Publisher Full Text | Free Full Text
35. Astram A, Birowo P, Rasyid N, et al.: Success of percutaneous nephrolithotomy: comparing spinal anesthesia with general anesthesia. Indonesian Journal of Urology. 2015; 22(2): 5–9. Reference Source
36. Kuzgunbay B, Turunc T, Akin S, et al.: Percutaneous nephrolithotomy under general versus combined spinal-epidural anesthesia. J Endourol. 2009; 23(11): 1835–8. PubMed Abstract | Publisher Full Text
37. Tangpaitoon T, Nisoog C, Lojanapiwat B: Efficacy and safety of percutaneous nephrolithotomy (PCNL): a prospective and randomized study comparing regional epidural anesthesia with general anesthesia. Int Braz J Urol. 2012; 38(4): 504–511. PubMed Abstract | Publisher Full Text
38. Rozentsveig V, Neulander EZ, Roussabrov E, et al.: Anesthetic considerations during percutaneous nephrolithotomy. J Clin Anesth. 2007; 19(5): 351–5. PubMed Abstract | Publisher Full Text
39. Andreoni C, Olweny EO, Portis AJ, et al.: Effect of single-dose subarachnoid spinal anesthesia on pain and recovery after unilateral percutaneous nephrolithotomy. J Endourol. 2002; 16(10): 721–725. PubMed Abstract | Publisher Full Text
40. Basiri A, Mehrabi S, Kianian H: Blind puncture in comparison with fluoroscopic guidance in percutaneous nephrolithotomy: a randomized controlled trial. Urol J. 2007; 4(2): 79–83; discussion 83–5. PubMed Abstract
41. Movasseghi G, Hassani V, Mohaghegh MR, et al.: Comparison between spinal and general anesthesia in percutaneous nephrolithotomy. Anesth Pain Med. 2014; 4(1): e13871. PubMed Abstract | Publisher Full Text | Free Full Text
42. Atmoko W, Birowo P, Rasyid N: Dataset 1 in: Factors Affecting Stone Free Rate of Primary Percutaneous Nephrolithotomy on Staghorn Calculi: A Single Center Experience of 15 Years. F1000Research. 2016. Data Source

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¹ Department of Urology, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, 10430, Indonesia

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© 2016 Atmoko W et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Data associated with the article are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

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Atmoko W, Birowo P and Rasyid N. Factors affecting stone free rate of primary percutaneous nephrolithotomy on staghorn calculi: a single center experience of 15 years [version 2; peer review: 2 approved]. F1000Research 2016, 5:2106 (https://doi.org/10.12688/f1000research.9509.2)

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Reviewer Report 07 Oct 2016

Manint Usawachintachit, Department of Urology, University of California San Francisco, San Francisco, CA, USA

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https://doi.org/10.5256/f1000research.10400.r16734

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Reviewer Report 16 Sep 2016

Manint Usawachintachit, Department of Urology, University of California San Francisco, San Francisco, CA, USA

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https://doi.org/10.5256/f1000research.10243.r15959

The authors present a retrospective study looking for associated factors of stone free rate following PCNL on staghorn stones. The primary endpoint was stone free status evaluated at an early postoperative period. It’s interesting data in that the number of ... Continue reading

The authors present a retrospective study looking for associated factors of stone free rate following PCNL on staghorn stones. The primary endpoint was stone free status evaluated at an early postoperative period. It’s interesting data in that the number of procedures is high (345).

Overall, the paper was written concisely with a good methodology in research design and statistical analysis. I would recommend this article is indexed after addressing some issues enumerated below:

Introduction

No specific comments.

Material and Methods

This is a retrospective study over a time period of 15 years. The authors didn’t mention about the surgeon’s level of experience so I wonder if there will be any effect on stone free rate by the surgeons’ learning curve.
Stone free status was a primary endpoint and a main focus in this study. However, it was evaluated by either plain KUB radiograph, CT scan, or antegrade pyelography. Could there be any bias based on these images, since we probably missed 3-4 mm residual fragment on a plain KUB film?
Additionally, it could be difficult to evaluate stone free status accurately with plain KUB film in an early postoperative period. Fluid leakage around the kidney may obscure residual fragments.

Results

In Table 2, data regarding Number of PCNL access was duplicated with the above row.
How would nephrostomy tube size correlate to stone free status? I think the tube size most likely depends on surgeon’s preference and other factors such as bleeding or requirement for postoperative drainage.

Discussion

No specific comments.

Competing Interests: No competing interests were disclosed.

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Reviewer Report 09 Sep 2016

Frederick Singer, John Wayne Cancer Institute, Providence Saint Johns Health Center, Santa Monica, CA, USA

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https://doi.org/10.5256/f1000research.10243.r15960

This is a large retrospective analysis of the recurrence rate over 15 years of staghorn calculi after removal of staghorn calculi by percutaneous nephrolithotomy which examines the factors which appear to influence the recurrence rate. Univariate analysis indicated that a ... Continue reading

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Frederick Singer, Providence Saint Johns Health Center, Santa Monica, USA
Manint Usawachintachit, University of California San Francisco, San Francisco, USA

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Manint Usawachintachit, Department of Urology, University of California San Francisco, San Francisco, CA, USA

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Manint Usawachintachit, Department of Urology, University of California San Francisco, San Francisco, CA, USA

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Approved

The authors present a retrospective study looking for associated factors of stone free rate following PCNL on staghorn stones. The primary endpoint was stone free status evaluated at an early postoperative period. It’s interesting data in that the number of procedures is high (345).

Overall, the paper was written concisely with a good methodology in research design and statistical analysis. I would recommend this article is indexed after addressing some issues enumerated below:

Introduction

No specific comments.

Material and Methods

This is a retrospective study over a time period of 15 years. The authors didn’t mention about the surgeon’s level of experience so I wonder if there will be any effect on stone free rate by the surgeons’ learning curve.
Stone free status was a primary endpoint and a main focus in this study. However, it was evaluated by either plain KUB radiograph, CT scan, or antegrade pyelography. Could there be any bias based on these images, since we probably missed 3-4 mm residual fragment on a plain KUB film?
Additionally, it could be difficult to evaluate stone free status accurately with plain KUB film in an early postoperative period. Fluid leakage around the kidney may obscure residual fragments.

Results

In Table 2, data regarding Number of PCNL access was duplicated with the above row.
How would nephrostomy tube size correlate to stone free status? I think the tube size most likely depends on surgeon’s preference and other factors such as bleeding or requirement for postoperative drainage.

Discussion

No specific comments.

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

13 Views

09 Sep 2016 | for Version 1

Frederick Singer, John Wayne Cancer Institute, Providence Saint Johns Health Center, Santa Monica, CA, USA

13 Views Cite this report Responses(0)

Approved

This is a large retrospective analysis of the recurrence rate over 15 years of staghorn calculi after removal of staghorn calculi by percutaneous nephrolithotomy which examines the factors which appear to influence the recurrence rate. Univariate analysis indicated that a history of ipsilateral open renal stone surgery, stone burden and the type of anesthesia were significant factors in determining a stone-free outcome whereas multivariate analysis eliminated the type of anesthesia as a risk factor. The authors pointed out that they did not have adequate data concerning the metabolic factors that could have made a significant contribution to the recurrence rate. Nevertheless this is an otherwise worthwhile contribution to understanding the appropriate treatment of staghorn calculi.

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[1] 1. Preminger GM, Assimos DG, Lingeman JE, et al.: Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol. 2005; 173(6): 1991–2000. PubMed Abstract | Publisher Full Text

[2] 2. Healy KA, Ogan K: Pathophysiology and management of infectious staghorn calculi. Urol Clin North Am. 2007; 34(3): 363–74. PubMed Abstract | Publisher Full Text

[3] 3. Koga S, Arakaki Y, Matsuoka M, et al.: Staghorn calculi--long-term results of management. Br J Urol. 1991; 68(2): 122–124. PubMed Abstract | Publisher Full Text

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[9] 9. Desai M, Lisa AD, Turna B, et al.: The clinical research office of the endourological society percutaneous nephrolithotomy global study: staghorn versus nonstaghorn stones. J Endourol. 2011; 25(8): 1263–1268. PubMed Abstract | Publisher Full Text

[10] 10. Clayman RV, Surya V, Miller RP, et al.: Percutaneous nephrolithotomy. An approach to branched and staghorn renal calculi. JAMA. 1983; 250(1): 73–5. PubMed Abstract | Publisher Full Text

[11] 11. Desai M, Jain P, Ganpule A, et al.: Developments in technique and technology: the effect on the results of percutaneous nephrolithotomy for staghorn calculi. BJU Int. 2009; 104(4): 542–8; discussion 548. PubMed Abstract | Publisher Full Text

[12] 12. Morris DS, Wei JT, Taub DA, et al.: Temporal trends in the use of percutaneous nephrolithotomy. J Urol. 2006; 175(5): 1731–6. PubMed Abstract | Publisher Full Text

[13] 13. Soucy F, Ko R, Duvdevani M, et al.: Percutaneous nephrolithotomy for staghorn calculi: a single center's experience over 15 years. J Endourol. 2009; 23(10): 1669–73. PubMed Abstract | Publisher Full Text

[14] 14. El-Nahas AR, Eraky I, Shokeir AA, et al.: Percutaneous nephrolithotomy for treating staghorn stones: 10 years of experience of a tertiary-care centre. Arab J Urol. 2012; 10(3): 324–329. PubMed Abstract | Publisher Full Text | Free Full Text

[15] 15. Falahatkar S, Moghaddam KG, Kazemnezhad E, et al.: Factors affecting operative time during percutaneous nephrolithotomy: our experience with the complete supine position. J Endourol. 2011; 25(12): 1831–1836. PubMed Abstract | Publisher Full Text

[16] 16. Kukreja R, Desai M, Patel S, et al.: Factors affecting blood loss during percutaneous nephrolithotomy: Prospective study. J Endourol. 2004; 18(8): 715–722. PubMed Abstract | Publisher Full Text

[17] 17. Akman T, Binbay M, Sari E, et al.: Factors affecting bleeding during percutaneous nephrolithotomy: Single surgeon experience. J Endourol. 2011; 25(2): 327–333. PubMed Abstract | Publisher Full Text

[18] 18. de la Rosette JJ, Zuazu JR, Tsakiris P, et al.: Prognostic factors and percutaneous nephrolithotomy morbidity: a multivariate analysis of a contemporary series using the Clavien classification. J Urol. 2008; 180(6): 2489–2493. PubMed Abstract | Publisher Full Text

[19] 19. Ozden E, Mercimek MN, Yakupoglu YK, et al.: Modified Clavien classification in percutaneous nephrolithotomy: Assessment of complications in children. J Urol. 2011; 185(1): 264–268. PubMed Abstract | Publisher Full Text

[20] 20. Huang SW, Chang CH, Wang CJ: Percutaneous nephrolithotomy for the treatment of complete staghorn stones. JTUA. 2005; 16: 169–173. Reference Source

[21] 21. Michel MS, Trojan L, Rassweiler JJ: Complications in percutaneous nephrolithotomy. Eur Urol. 2007; 51(4): 899–906. PubMed Abstract | Publisher Full Text

[22] 22. Duvdevani M, Razvi H, Sofer M, et al.: Third prize: contemporary percutaneous nephrolithotripsy: 1585 procedures in 1338 consecutive patients. J Endourol. 2007; 21(8): 824–9. PubMed Abstract | Publisher Full Text

[23] 23. Koga S, Arakaki Y, Matsuoka M, et al.: Staghorn calculi--long-term results of management. Br J Urol. 1991; 68(2): 122–124. PubMed Abstract | Publisher Full Text

[24] 24. Stoller ML, Wolf JS Jr, St Lezin MA: Estimated blood loss and transfusion rates associated with percutaneous nephrolithotomy. J Urol. 1994; 152(6 Pt 1): 1977–1981. PubMed Abstract

[25] 25. El-Nahas AR, Shokeir AA, El-Assmy AM, et al.: Post-percutaneous nephrolithotomy extensive hemorrhage. A study of risk factors. J Urol. 2007; 177(2): 576–9. PubMed Abstract | Publisher Full Text

[26] 26. el-Nahas AR, Eraky I, Shokeir AA, et al.: Factors affecting stone-free rate and complications of percutaneous nephrolithotomy for treatment of staghorn stone. Urology. 2012; 79(6): 1236–1241. PubMed Abstract | Publisher Full Text

[27] 27. Sfoungaristos S, Gofrit ON, Pode D, et al.: Percutaneous nephrolithotomy for staghorn stones: Which nomogram can better predict postoperative outcomes? World J Urol. 2016; 34(8): 1163–8. PubMed Abstract | Publisher Full Text

[28] 28. Kurtulus FO, Fazlioglu A, Tandogdu Z, et al.: Percutaneous nephrolithotomy: primary patients versus patients with history of open renal surgery. J Endourol. 2008; 22(12): 2671–5. PubMed Abstract | Publisher Full Text

[29] 29. Shah HN, Mahajan AP, Hegde SS, et al.: Tubeless percutaneous nephrolithotomy in patients with previous ipsilateral open renal surgery: a feasibility study with review of literature. J Endourol. 2008; 22(1): 19–24. PubMed Abstract | Publisher Full Text

[30] 30. Margel D, Lifshitz DA, Kugel V, et al.: Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy. J Endourol. 2005; 19(10): 1161–1164. PubMed Abstract | Publisher Full Text

[31] 31. Jones DJ, Russell GL, Kellett MJ, et al.: The changing practice of percutaneous stone surgery. Review of 1000 cases 1981-1988. Br J Urol. 1990; 66(1): 1–5. PubMed Abstract | Publisher Full Text

[32] 32. Basiri A, Karrami H, Moghaddam SM, et al.: Percutaneous nephrolithotomy in patients with or without a history of open nephrolithotomy. J Endourol. 2003; 17(4): 213–216. PubMed Abstract | Publisher Full Text

[33] 33. Sofikerim M, Demirci D, Gülmez I, et al.: Does previous open nephrolithotomy affect the outcome of percutaneous nephrolithotomy? J Endourol. 2007; 21(4): 401–403. PubMed Abstract | Publisher Full Text

[34] 34. Reddy SV, Shaik AB: Outcome and complications of percutaneous nephrolithotomy as primary versus secondary procedure for renal calculi. Int Braz J Urol. 2016; 42(2): 262–269. PubMed Abstract | Publisher Full Text | Free Full Text

[35] 35. Astram A, Birowo P, Rasyid N, et al.: Success of percutaneous nephrolithotomy: comparing spinal anesthesia with general anesthesia. Indonesian Journal of Urology. 2015; 22(2): 5–9. Reference Source

[36] 36. Kuzgunbay B, Turunc T, Akin S, et al.: Percutaneous nephrolithotomy under general versus combined spinal-epidural anesthesia. J Endourol. 2009; 23(11): 1835–8. PubMed Abstract | Publisher Full Text

[37] 37. Tangpaitoon T, Nisoog C, Lojanapiwat B: Efficacy and safety of percutaneous nephrolithotomy (PCNL): a prospective and randomized study comparing regional epidural anesthesia with general anesthesia. Int Braz J Urol. 2012; 38(4): 504–511. PubMed Abstract | Publisher Full Text

[38] 38. Rozentsveig V, Neulander EZ, Roussabrov E, et al.: Anesthetic considerations during percutaneous nephrolithotomy. J Clin Anesth. 2007; 19(5): 351–5. PubMed Abstract | Publisher Full Text

[39] 39. Andreoni C, Olweny EO, Portis AJ, et al.: Effect of single-dose subarachnoid spinal anesthesia on pain and recovery after unilateral percutaneous nephrolithotomy. J Endourol. 2002; 16(10): 721–725. PubMed Abstract | Publisher Full Text

[40] 40. Basiri A, Mehrabi S, Kianian H: Blind puncture in comparison with fluoroscopic guidance in percutaneous nephrolithotomy: a randomized controlled trial. Urol J. 2007; 4(2): 79–83; discussion 83–5. PubMed Abstract

[41] 41. Movasseghi G, Hassani V, Mohaghegh MR, et al.: Comparison between spinal and general anesthesia in percutaneous nephrolithotomy. Anesth Pain Med. 2014; 4(1): e13871. PubMed Abstract | Publisher Full Text | Free Full Text

[42] 42. Atmoko W, Birowo P, Rasyid N: Dataset 1 in: Factors Affecting Stone Free Rate of Primary Percutaneous Nephrolithotomy on Staghorn Calculi: A Single Center Experience of 15 Years. F1000Research. 2016. Data Source

Factors affecting stone free rate of primary percutaneous nephrolithotomy on staghorn calculi: a single center experience of 15 years

Abstract

Keywords

Revised Amendments from Version 1

Introduction

Methods

Patients

Preoperative preparation

Surgical technique

Post operative evaluation

Data analysis

Results

Table 1. Patient characteristics.

Table 2. Univariate analysis of factors that associated with the stone-free rate.

Table 3. Multivariate analysis (logistic regression model) of factors independently predictive of stone-free rate.

Discussion

Conclusions

Data availability

Consent

Abbreviations & acronyms

Author contributions

Competing interests

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References

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