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“Ambulatory PCNL” (Tubeless PCNL under Regional Anesthesia) – A Preliminary Report of 10 Cases

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“Ambulatory PCNL” (Tubeless PCNL under Regional Anesthesia) – A Preliminary Report of 10 Cases
  ‘‘Ambulatory PCNL’’ (tubeless PCNL under regional anesthesia) – Apreliminary report of 10 cases Iqbal Singh, Ashok Kumar & Praveen Kumar Division of Urology, Department of Surgery & Anesthesiology University College of Medical Sciences(University of Delhi) & GTB Hospital, Delhi-95. Abstract.  Aim:  We report the technique, safety, outcome and efficacy of ‘‘tubeless percutaneous nephro-lithotomy (PCNL) performed under regional anesthesia’’ in selected cases.  Methods:  Patients satisfying theentry criteria for the regional block (spinal low-dose anesthesia with low-dose Bupivacaine plus Fentanyl)and tubeless procedure were subjected to a tubeless spinal PCNL The patients were followed up the nextday for an ultrasonography and an x-ray of the KUB region.  Results:  All the ten patients were dischargeduneventfully the next day (mean hospital stay-40 h). No blood transfusion and postoperative analgesics(mean post op visual analogue pain score was 2.4) were required. The mean time to return of S 1  sensation,motor block and walking were 183,118 and 196.6 min respectively. There was complete stone clearance inall the cases with a mean collection of 14.5 cc was seen on the post op ultrasound.  Conclusions:  The presentcases were reported to highlight that in a select group of patients tubeless PCNL under regional block istechnically feasible and viable option. Regional block has the advantage of avoidance of general anesthesiaand anaphylaxis due to use of multiple drugs. Tubeless PCNL has the advantage of avoidance of neph-rostomy tube related postoperative pain discomfort and urosepsis. This synergistically (spinal + tubelessPCNL) speeds up the recovery, shortens the length of hospitalization and the analgesic requirement. Key words:  Percutaneous nephrolithotomy (PCNL), Percutaneous nephrostomy, Regional anesthesia,Tubeless PCNL Introduction Percutaneous nephrolithotomy (PCNL) has nowbeen in vogue for over 20 years. Several changesand modifications have taken place in the last fewyears in an attempt to further refine the procedureand to lower the morbidity, analgesic requirementsand duration of hospitalization. These include useof regional blocks, single step dilatations, ‘‘mini-perc’’ technique, tubeless PCNL and sandwichtherapy [1–8]. There exists inadequate publishedliterature [4–6], however, with regard to the use of regional anesthesia in patients undergoing PCNLand this forms the basis of our current study. Patient and methods The entry criteria for a regional block included (i)low grade or Grade 1 A.S.A patients with goodsafety margins, (ii) limited stone burden where ashort procedure was contemplated and stones lo-cated in the middle or inferior calyx. The criteriafor tubeless PCNL were (i) minimal stone burdenup to 2 cm, (ii) pelvicalyceal morphology favoringsingle step dilatation and single tract direct stoneaccess, (iii) procedure accompanied by minimal orno tract bleeding, (iv) no pelvicalyceal systemperforation and (v) complete stone clearanceobviating any relook.Prone position PCNL was performed in all thecases under prophylactic antibiotics (Inj Amikacin500 mg IV) and regional block (spinal anesthesiausing 1.2 ml [6 mg] of 0.5% Bupivacaine-heavyand 25  l g of Fentanyl, diluted to a total volume of 3 ml of isotonic saline injected over a period of 2–3 min via the L2/3 interspinous space using a25G pencil–point Whitacre TM needle). At thecompletion of the procedure the Amplatz sheath International Urology and Nephrology (2005) 37:35–37    Springer 2005DOI 10.1007/s11255-004-6706-9  was removed leaving the guidewire in place and adirect tract nephroscopy was performed to lookfor any major tract bleeders. Major bleeders in thetract were controlled by diathermy using a dia-thermy wire introduced via the nephroscope. Anindwelling temporary ureteral catheter was left atthe end of the procedure that was removed after6 h. A check ultrasound KUB was performed thenext day prior to discharge to rule out any col-lection/urinoma. Results The patient ages were (35–60) mean-48.1 years. The stone burden was 100–250 mm 2 (mean-161 mm 2 ) and the mean operating time(ORT) was 48.4 min, an average of 4.5 l of normalsaline irrigant was used and check fluoroscopyshowed complete stone clearance in all the cases.The post op recovery was smooth except forcomplaints of mild pruritis at the tip of the noseand upper chest in 7 cases that resolved within 3 h.The mean time taken for (i) return of S 1  sensationto pin prick was 183 min; (ii) return of the motorblock (Bromage scale) to 0 was 118 min and (iii)return to walking was 196.6 min. An ultrasoundperformed the next day showed a mean 14.5 cc(10–25 cc) collection. No postoperative analgesiawas required (postoperative visual analogue scalescore was 2–3 on a 0–10 cm scale). All the patientswere discharged uneventfully at the end of the 1stpostoperative day (mean hospital stay 40 h). Pro-phylactic oral Gatifloxacin (400 mg,OD) wascontinued for 5 days in all the cases. Discussion Tubeless PCNL [1, 2] or PCNL without a percu-taneous nephrostomy tube (PNT) in situ is not anew procedure. While it is widely recognizedthat the major morbidity of the procedure stemsfrom the placement of a residual PNT often placedat the termination of the procedure with theoverall morbidity may be as high as 18% [3], neverthe less, the PNT has several advantages: (i)unimpeded drainage of any infected urine, (ii) al-lows a relook in case of any residual stones, (iii)tamponades any tract hemorrhage, and (iv) it alsoprevents the development of adjacent organeffusion/collection/urinoma. In addition a pro-longed PCNL carries the attendant risks of sepsisand irrigant fluid imbibitions. Thus we suggestthat if these problems can be prevented then onemay safely omit the placement of a PCN (tubelessPCNL) in a carefully group of selected patientssuch as above to decrease the postoperative mor-bidity. Tubeless PCNL was considered in thesecases because (i) there was no major tract hemor-rhage at the end of the procedure, (ii) there was nopevicalyceal system perforation, (iii) there were noresidual stones, (iv) a single direct access tract wasused, (v) the procedure was short which reducedthe hazard of sepsis and fluid imbibition, and lastly(v) we wanted to lower the post-op analgesiarequirement and post op patient pain/discomfort.Other options available to further diminishthe morbidity of PCNL include, (i) using regionalanesthesia, [4, 5,6]and(ii) usingthe ‘‘mini-perc’’[7]technique.Optionsavailableforregionalanesthesiainclude ‘interpleural block, [4] and spinal anaes-thesia [5] or both may be combined [6]. Whilstspinal subarachnoid anesthesia [5] has been used inthe past, interpleural block [4, 6] is a relativelynewer addition. The use of spinal blocks has shownto statistically significantly reduce the postopera-tive pain and parenteral pain medication leading toan earlier ambulation [5]. The latter interpleuralblock technique though reported [4, 6] as promisinghas largely only an adjuvant effect to spinal anal-gesia and cannot be used in isolation [6]. We con-templated the use of regional block as (i) all ourpatients were ASA Grade 1 patients with an excel-lent safety margin, (ii) the stone burden was limitedand a short procedure was contemplated (iii) wewanted to further cut down on the duration of hospitalization, and (iv) reduce the rising episodesof risks of anaphylaxis [8] related to use of multipleanesthetic drugs required for general anesthesia.Saiedet al.[6]haveusedaveryhighdose(15 mg)of 0.5% heavy Bupivacaine for spinal anesthesia inPCNL patients [6], but this would have resulted inprolonged recovery times and hence would beunsuitable foran ambulatoryPCNL.In an effort toreduce the duration of hospitalization, we used acombination of {low-dose (6 mg) Bupivacaine-heavy (0.5%) and 25  l g of Fentanyl (liophilic opi-oid)} thereby reducing the recovery time, thusmaking spinal anesthesia more suitable andacceptable for an ambulatory PCNL. Few pub-lished reports exist in the literature regarding the36  use of spinal anesthesia for PCNL [4–6]. Andreoni& Clayman et al. [5] had also concluded that asingle preoperative dose of subarachnoid spinalanalgesia reduces the postoperative pain, paren-teral pain medication, nausea and encourages ear-lier ambulation. Recent experience with intrathecalSufentanil (another liophilic opioid) [9–12] alonefor spinal anesthesia suggests it may offer excellentanesthesia and analgesia for SWL patients [9–12],however it remains to be seen whether this willsuffice for PCNL too.By substituting general anesthesia with regional(spinal subarachnoid block) anesthesia, a tubelessprocedure and an external ureteral access catheterin these selected ten patients we were able to avoidany complications, post op analgesics, and dis-charge them on the 1st PO day (within 48 h). Nopost op analgesics were needed in all our cases (asthe mean postoperative visual analogue pain scorewas 2.4).Whilst we have not compared our data withthose PCNL patients in whom the procedure wasdone under general anesthesia with a PNT,the post op recovery, pain, parenteral analgesicrequirement and duration of hospitalization didcertainly seem to be on the lower side. Selectedpatients for such a ‘‘more ambulatory tubelessPCNL with regional block’’ could be those with aminimal stone burden, single tract direct stoneaccess with single step dilatation, minimal or notract bleeding and complete stone clearance obvi-ating a re-look. Conclusions By the omission of the percutaneous nephrostomytube and adopting regional (spinal low-doseanesthesia low-dose Bupivacaine plus Fentanyl) inplace of general anesthesia in selected patients, onemay further reduce the morbidity without com-promising effectiveness and safety. A greaternumber of cases would be definitely needed tobetter define these modifications before their use inselected patients can be recommended on a routinebasis and further studies would be needed toobjectively confirm these possibilities before thesemodifications can be fully incorporated in toPCNL as a more ‘‘ambulatory PCNL’’. Never theless in carefully counseled and meticulouslyselected cases we advocate the use of ‘‘tubelessPCNL under regional anesthesia’’. References 1. Lojanapiwat B, Soonthornphan S, Wudhikarn S. Tubelesspercutaneous nephrolithotomy in selected patients. J En-dourol 2001; 15: 711–713.2. Goh M, Wolf JS Jr.Almost totally tubeless percutaneousnephrolithotomy: further evolution of the technique.J Endourol 1999; 13: 177–180.3. Corbel L, Guille F, Cipolla B, Staerman F, Leveque JM,Lobel B. Percutaneous surgery for lithiasis: results andperspectives. Prog Urol 1993; 3: 658–665.4. Trivedi NS, Robalino J, Shevde K. Interpleural block: anew technique for regional anaesthesia during percutane-ous nephrostomy and nephrolithotomy. Can J Anaesth1990; 37: 479–481.5. Andreoni C, Olweny EO, Portis AI, Sundaram CP, MonkT, Clayman RV. Effect of single-dose subarachnoid spinalanesthesia on pain and recovery after unilateral percuta-neous nephrolithotomy. J Endourol 2002; 16: 721–725.6. Saied MM, Sonbul ZM, el-Kenawy M, Atallah MM.Spinal and interpleural bupivacaine for percutaneousnephrolithotomy. Middle East J Anesthesiol 1991; 11:259–264.7. Jackman SV, Hedican SP, Peters CA, Docimo SG.Percutaneous nephrolithotomy in infants and preschoolage children: experience with a new technique. Urology1998; 52: 697–701.8. Artagnan J, Milon D, Corbel L et al. Acquired experiencein anesthesia and perioperative intensive care in percuta-neous nephrolithotomy. Current approach in the endo-scopic treatment of lithiasis and pyelo-ureteral junctionanomalies. Prog Urol 1994; 4: 56–62.9. Lau WC, Green CR, Faerber GJ, Tait AR, GolembiewskiJA. Intrathecal sufentanil for extracorporeal shockwavelithotripsy provides earlier discharge of the outpatientthan intrathecal lidocaine. Anesth Analg 1997; 84:1227–1231.10. Eaton MP, Krintensen E. Subarachnoid sufentanil forextracorporeal shock lithotripsy. Reg Anesth 1997; 22:86–88.11. Eaton MP, Chibber AK, Green DR. Subarachnoidsufentanil versus lidocaine spinal anaesthesia for extracor-poreal shockwave lithotripsy. Reg Anesth 1997; 22:515–520.12. Eaton MP. Intrathecal sufentanil analgesia for extracor-poreal shockwave lithotripsy in three paients with aorticstenosis. Anesth Analg 1998; 86: 943–944. Address for correspondence : Dr. Iqbal Singh, M.S., D.N.B.(Surgery). D.N.B. (Genitourinary surgery), M.Ch (Urology,AllMS), Consultant Urologist, Professor, Department of Sur-gery, UCMS & GTBH, Mailing: F-14 South Extension Part-2,New Delhi-110049. IndiaPhone: 0091-11-26257693; Fax: 91-11-22590495E-mail: 37
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