JCU - January 2022 - 10

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Journal of Clinical Urology 15(1)
Mean operation time was significantly shorter in the
antegrade group (49.8±10.4 minutes vs. 63.0±12.2 minutes;
p<0.001). There was also a considerable difference
in the analgesic requirement (pethidine hydrochloride
0.6±.02 mg/kg in antegrade vs. 1.2±.04 mg/kg in retrograde;
p<0.001), but there were no differences between
the two groups with regard to length of hospital stay (2.6
days vs. 2.6 days; p=0.91).
Discussion
One of the most critical parts of PCNL is access to the
collecting system. However, in recent studies, Kallidonis
et al. concluded that infundibular (non-papillary) puncture
was as safe as papillary puncture in PCNL.12,13 The
antegrade approach under fluoroscopic or ultrasonic
guide for the management of renal stones and retrieval of
ureteral stents has been reported in many studies. Tzeng
et al.7 introduced Doppler ultrasound-guided PCNL as a
safe and effective technique with minimal blood loss,
especially for patients at higher risk of bleeding and associated
complications.
Aravantinos et al.14 reported their experience in antegrade
retrieval of renal pelvis stones >2 cm under assisted
local anaesthesia using a 24 Fr rigid nephroscope and a
ballistic lithotripter without retrograde pyelography.
Moreover, Fernandez et al.15 performed antegrade PCNL
in patients with urinary diversions and showed that intraoperative
percutaneous renal access was facilitated by retrograde
pyelography in only 12.1% of patients.
Along with these studies, our stone-directed antegrade
technique showed several advantages over the conventional
retrograde pyelography method in PCNL access.
The operation time reduced considerably using this surgical
approach, and there was no need to use a ureteral catheter.
This result comes while many studies have linked
longer operative time with a higher rate of postoperative
complications.16-19 In their study, Reich et al.20 also found
that a longer operative time was associated with a negative
surgical outcome in major non-cardiac surgery. We did not
find these complications in our study. Shortening the operative
time in our study explains this.
Tubeless PCNL has been the subject of some studies. In
tubeless PCNL, a nephrostomy tube is not inserted, but in
the totally tubeless procedure, neither a nephrostomy tube
nor a ureteral stent is used.21 Zhong et al.2 performed a metaanalysis
to evaluate the efficacy and safety of totally tubeless
PCNL. They found a significantly reduced hospital stay
and analgesic requirement as well as absence of complications
in this group. Aghamir et al.22 and Chien-Hsing Chang
et al.23 found the same result when performed studies on
totally tubeless PCNL. Similar to these results, as the totally
tubeless procedure was done significantly more in the antegrade
group, it may explain a statistically significant difference
in analgesic requirement between the two groups.
On the other hand, Minamia et al.24 compared tubeless
and totally tubeless PCNL with conventional PCNL in terms
of postoperative hospital stay, duration of analgesic use,
UTI and blood transfusion. They concluded that tubeless
PCNL was superior only in terms of length of hospital stay.
Single puncture adequacy was comparable in both groups
in calyceal, diverticular and staghorn stones. This can be
explained by the use of the 'bull'seye' technique in the antegrade
group, which allowed us to reach the stone in the appropriate
calyx in just one puncture. In the antegrade group, the
rate of double puncture was significantly higher compared to
the retrograde group. This was because in the antegrade technique,
we approached the renal pelvis stones in the first puncture,
and after performing antegrade pyelography, we entered
the desired calyx in the second puncture. Opacification of the
pyelocalyceal system due to retrograde injection of contrast
media to improve the targeting of the appropriate calyx before
needle insertion can explain the difference.
Furthermore, in order to minimize the risk of vascular
injury in cases of renal pelvis stone, we used a 23-gauge
Chiba needle instead of 18-gauge needle for the first puncture.
It is well known that certain complications of PCNL,
such as intrarenal vascular injuries and arteriovenous fistula
formation, which may cause severe bleeding, are associated
with more needle punctures.25,26 However, we did
not find any statistically significant difference in the risk
of haemoglobin drop and need for blood transfusion
between the two groups.
While a large number of stones were expected to migrate
to the ureter after the application of the antegrade technique,
no significant difference was noted between the two groups
in this regard. We also expected to find a significantly
increased radiation time during access in the antegrade
group using the same technique (the 'bull's eye' technique)
during access in both groups, which guaranteed the entrance
to the collecting system in the very first needle insertion,
and which can explain this insignificant difference. A statistically
insignificant risk of postoperative pyelonephritis was
reported in the retrograde group. This could be due to the
introduction of bacteria from the lower urinary tract into the
upper tract during ureteral catheter insertion.
The present study has some limitations. The stone-directed
antegrade technique is not suitable for all patients, particularly
those with complete radiolucent renal stones. Also, in
patients with renal pelvis stones, at least two punctures are
needed to enter the desired calyx using the stone-directed
method. This act may increase the risk of intrarenal vascular
injury and postoperative bleeding. While we did not find
these complications in our study, renal access with retrograde
pyelography is more advisable in these patients. Alternatively,
access under ultrasonographic guidance or intraoperative
intravenous pyelography under fluoroscopic guidance can be
used to perform the antegrade method in these cases.
Finally, although it is well advised that performing
PCNL with retrograde ureteral catheter insertion and

JCU - January 2022

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