الفهرس 
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Abstract
R
enal stone is one of the most common renal diseases worldwide. There are several modalities for treatment of renal stone disease, one of these modalities is the use of percutaneous nephrolithatomy (PCNL) surgery which can be done either under fluoroscopic or ultrasonic or even combined fluoroscopic and ultrasonic guidiness.
This prospective randomized clinical trial study was conducted on 40 patients subjected to treatment for a stone(s) located in the kidney more than 2 cm or refractory to shockwave therapy at Urology department, Faculty of medicine, Ain Shams University and Urology department, Theodor Bilharz Research Institute.
The patients were divided into two groups:
• group I: 20 patients subjected to Ultrasound-guided in combination with Fluoroscopy for Percutaneous Nephrolithotomy.
• group II: 20 patients subjected to standard Percutaneous Nephrolithotomy (Fluoroscopy-guided PCNL).
Regarding demographic data in studied groups, the mean age of group I was 41 ± 10.6 years and the mean age of group II was 43.7 ± 12.7 years with no significant difference. there were 13 males (65%) and 7 females (35%) while in group II there were 10 males (50%) and 10 females (50%) with no significant difference. The mean BMI was 28.5 ± 3.5 kg/m 2 in group I and 27.3 ± 4.6 kg/m 2 in group II with no significant difference. Statistically significant (p=0.013) increased percentage of positive medical history in group II (9 patients, 45%) when compared with group I (2 patients, 10%). Statistically significant (p= 0.017) increased percentage of DM in group II (5 patients, 25%) when compared with group I (0 patients, 0%). while, there was no statistical significant difference between studied groups (group I & group II) as regard HTN, IHD and CKD.
As regard clinical data in studied groups, the mean stone size was 2.6 ± 0.6 cm in group I and 2.9 ± 0.5 cm in group II with no significant difference. As regard stone site, renal pelvis stone was recorded in 18 patients (90%) of group I versus16 patients (80%) of group II. Lower calyceal stone was recorded in 10 patients (50%) of group I versus12 patients (60%) of group II. Middle calyceal stone was recorded in 1 patient (5%) of group I versus3 patients (15%) of group II. Upper calyceal stone was recorded in 0 patients (0%) of group I versus1 patient (5%) of group II.
Concerning pre-operative studied laboratory data in studied groups, the mean Hb was 13.2 ± 1.3 g/dl in group I and 13.3 ± 1.5 g/dl in group II. The mean creatinine was 1.1 ± 0.3 mg/dl in group I and 1.3 ±0.6 mg/dl in group II. The mean urea was 28.6 ± 7.2 mg/dl in group I and 34.5 ±17.7 mg/dl in group II. No statistical significant difference between studied groups regarding pre-operative laboratory data.
With reference to intra-operative data in studied groups, the mean operative time 78.7 ± 10.8 min in group I and 72.2 ± 14.9 min in group II. There was highly statistical significant (p-value < 0.001) decreased x-ray exposure time in group I (43.2 ± 11.3 sec) when compared with group II (314 ± 84.2 sec). There was statistical significant (p-value = 0.003) increased stone extraction time in group I (59.8 ± 15.3 min) when compared with group II (45.2 ± 13.5 min). As regard technique of dilatation, all patient (100%) in group I were dilated by acute dilatation technique while in group II, there were 18 patient (90%) were dilated by acute dilatation technique and the remaining 2 patients (10%) were dilated by sequential dilatation technique.
As regard intra-operative complications, in group I, there was 1 patient (5%) with intra-operative complication while in group II, there were 5 patient (25%) with intra-operative complication. The patient with intra-operative complication in group I was due to extravasation which was managed by DJ fixation. The complicated cases in group II were as follows: 1 patient with lower calyceal trauma causing bleeding, 2 patients with extravasation, 1 patient with intra-operative bleeding and 1 patient with difficult access.
Regarding post-operative studied laboratory data in studied groups, there was statistical significant (p-value = 0.042) decreased post-operative Hb in group II (11.6± 1.6 g/dl) when compared with group I (12.6 ± 1.3 g/dl). While, the mean creatinine was was 1.09 ± 0.3 mg/dl in group I and 1.3 ±0.6 mg/dl in group II with no significant difference.
Concerning post-operative pain and need for analgesia in studied groups, there was a highly statistical significant (p-value < 0.001) increased post-operative VAS in group II (7.5 ± 1.05) when compared with group I (5.7 ± 0.6). Also, highly statistical significant (p-value<0.001) increased percentage of post-operative need of analgesia in group II (20 patients, 100%) when compared with group I (9 patients, 45%). Finally, as regard post-operative analgesia type usage, the 9 patients in group I which needed post-operative analgesia used NSAID versus 7 patients (35%) in group I. The remaining 13 patients (65%) in group II used post-operative Pethidine with statistical significant difference (p-value = 0.001).
As regard post operative complications in studied groups, in group I, there were 3 patients (75%) with post-operative fever versus 4 patients (66.7%) in group II. In group I, there was 1 patient (25%) with post-operative leakage versus 3 patients (50%) in group II. In group II, there was 1 patient (16.7%) with post-operative blood transfusion versus 0 patients (0%) in group I with no statistical difference.
With respect to post-operative hospital stay and need for second operation between studied groups, there was a highly statistical significant (p-value < 0.001) increased post-operative hospital stay in group II (3.5 ± 1.05) when compared with group I (1.9 ± 0.9). While, as regard need for second operation and type of the operation, there were no statistical differences between the studied groups.
CONCLUSION
from the current study, it was concluded that:
Combined ultrasonic and fluoroscopic guided PCNL was more safer and effective in comparison to solely fluoroscopic guided PCN because of that:
• Combined ultrasonic and fluoroscopic guided PCNL had shorter x-ray exposure time.
• Combined ultrasonic and fluoroscopic guided PCNL had less Hb DROP and intraoperative complications. However it still had longer surgery duration.
• Combined ultrasonic and fluoroscopic guided PCNL showed less postoperative pain and analgesic consumption.
• Combined ultrasonic and fluoroscopic guided PCNL had shorter hospital stay.
• Regarding the outcome and complications, in general, there is no statistical significant difference between these two groups.
The PCNL can use the approach of fluoroscopy and ultrasound methods. This method approach is based on several considerations of the patient’s condition. The use of ultrasound-guided PCNL and fluoroscopy-guided PCNL has its own advantages and disadvantages. Therefore, we recommend that:
• Further prospective and comparative researches with large sample size are needed to more accurately detect the outcomes of Combined ultrasonic and fluoroscopic guided PCNL.
• Urologists showed consider general condition of patient factors when making decision regard option of treatment.
• The usage of ultrasonography rather than fluoroscopy to avoid exposing the radiation.