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Comparison between Ultrasound and Fluoroscopy-guided Percutaneous Nephrolithotomy (PCNL) at Raden Mattaher Jambi Hospital

Comparison between Ultrasound and Fluoroscopy-guided Percutaneous Nephrolithotomy (PCNL) at Raden... Purpose To investigate the effectiveness and safety of ultrasound-guided and Percutaneous Nephrolithotomy (PCNL) compared to the standard fluoroscopy-guided PCNL. Methods This study is a comparative retrospective study obtained from medical records within the last 5 years of Raden Mattaher Hospital, Jambi. Patients were divided into 2 groups, fluoroscopy- and ultrasonography-guided PCNL with large kidney stone > 20 mm. Patient characteristics were divided into pre- and post-operative procedures and analyzed using SPSS ver. 25.0 (SPSS Inc., Chicago, IL, USA). Data were analyzed using Kolmogorov–Smirnov, chi-square and/ Fischer’s exact test and p value < 0.05 was considered statistically significant. Results Of 201 patients’ data from medical records were divided into ultrasound-guided and fluoroscopy-guided groups. Ultrasound-guided group were consisted of 89 patients and fluoroscopy-guided were of 112 patients. US Guided significantly identifies the severity of hydronephrosis compared to PCNL. The demographic data obtained age, sex, body mass index, and preoperative hemoglobin levels showed a normal distribution. On the post-operative results, significant results occurred in post-PCNL stent placement. Installation of a DJ stent alone is more commonly performed on fluoroscopy-guided PCNL procedures compared to ultrasound-guided PCNL. This had a positive impact on post-procedure outcomes, meaning that the post-operative outcome of ultrasound-guided PCNL was bet- ter than that of fluoroscopy-guided PCNL. Conclusion The reported data demonstrate that PCNL and ultrasound-guided has similar efficacy and complication rates with PCNL fluoroscopy-guided. This could be a good alternative in urological centers with no access to fluor - oscopy. However, ultrasound-guided group was still associated with higher rate nephrostomy tube placement and longer surgery duration. Keywords Ultrasound, Percutaneous nephrolithotomy, Fluoroscopy, Treatment, Renal stones 1 Background Percutaneous Nephrolithotomy (PCNL) is one of the first-line endourology procedure for patients who *Correspondence: encounter more than 20  mm kidney stone [1]. The use Raga Manduaru of PCNL can use the approach of fluoroscopy and ultra - manduaru@gmail.com sound methods. This method approach is based on sev - Department of Urology, Raden Mattaher Hospital, Jambi, Indonesia Department of Urology, Faculty of Medicine, Cipto Mangunkusumo eral considerations of the patient’s condition. The use of National Referral Hospital, University of Indonesia, Depok City, Indonesia ultrasound-guided PCNL and fluoroscopy-guided PCNL © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Fauzan et al. African Journal of Urology (2023) 29:19 Page 2 of 6 has its own advantages and disadvantages. In the use ultrasound group, the target calyx selection was identi- of fluoroscopy-guided, it is more precise and does not fied prior to the operation based on the stone location depend on the skill of the operator in using ultrasound and surgeon preference. Successful puncture was con- but has the risk of radiation exposure [2]. Meanwhile, firmed with urine flow from the puncture needle. Under ultrasound-guided has no risk of radiation exposure ultrasound-guided, a guidewire (0.035-inch J-shaped and widely available in areas with limited technology. stiff-guidewire) was inserted into the collecting system. In terms of cost, the use of ultrasound also has lower The needle was then withdrawn. Fascial dilatation was cost compared to the use of fluoroscopy-guided [1]. In performed with 8-Fr until 18-Fr fascial dilators. Urine this study, we compared the effectiveness and safety of flow from the dilators confirmed that we had reached using ultrasound-guided vs fluoroscopy-guided PCNL in the collecting system. Amplatz sheath was then pushed patients with kidney stones [2–4]. on into the collecting system. In the ultrasound group, ultrasonography was used solely in all procedures, that is, evaluation of the kidney and stone, assistance 2 Methods of kidney puncture, and tract dilatation. In the fluor - 2.1 Study population oscopy group, all those steps were performed under This study is a comparative retrospective study obtained fluoroscopy-guidance. from medical records within the last 5  years of Raden A 16-Fr rigid nephroscope was used during the PCNL Mattaher Hospital, Jambi. Patients’ data who under- procedure. Stone fragmentation was performed using went PCNL were divided into 2 groups based on type of holmium laser. Stone forceps were used to evacuate the guidance, fluoroscopy and ultrasonography. All patients stone fragments. In the ultrasound group, both ultra- included in this study were presented at the hospital sonography and nephroscopy were used to identify resid- with > 20 mm kidney stone and went through PCNL pro- ual stones, infundibular laceration, or extravasation of cedures between January 2019 and March 2022. All the urine. In the fluoroscopy group, those procedures were patients with uncomplete medical record data, uncor- done under fluoroscopic guidance. Upon conclusion of rected coagulopathy, congenital kidney anomalies, and the PCNL procedure, nephrostomy tube, double J (DJ) intraoperative conversion to open were excluded from stent, or externalized ureteral catheter were placed based this study. We evaluated and divided the data into demo- on any significant bleeding, residual stone fragments, or graphic parameters, stone characteristics, pre- and post- debris. Some patients had both nephrostomy tube and DJ operative procedures. stent. 2.2 Procedures All patients underwent the same laboratory tests includ- 2.3 Evaluations ing blood routine, and renal function tests before the In this study, we compared the demographic param- surgery. Preoperative computed tomography (CT) urog- eters, stone characteristics, and operative and post- raphy was routinely performed to evaluate the stone operative outcomes between ultrasound group dan location, kidney anatomy, and position of surrounding fluoroscopy group. All patients had post-operative kid - important structures. Stone burden was measured by ney-ureter-bladder (KUB) photo determine the stone- combining the largest diameter of each stone in all sec- free status. KUB photo could missed residual stone tions [5]. fragments ≤ 4  mm, [12] however patients with residual All PCNL procedures were accomplished by a team stone fragments ≤ 4 mm were clinically insignificant and of endourologists consisting of three different main sur - considered to be stone-free in this study [6]. geons. PCNL ultrasound-guided and fluoroscopy-guided were performed in supine (Galdakao-modified Valdivia) position. All patients received preoperative prophylactic 2.4 Statistical analysis antibiotics. PCNL was performed under general anes- Data presented in this paper were analyzed using SPSS thesia. For ureteral access, retrograde open-end ure- ver. 25.0 (SPSS Inc., Chicago, IL, USA). Data shown in teral catheter (5 Fr) was applied. The ureteral catheter the table were mean (standard deviation) and number was used for injection of aquadest or contrast agent. (percentage) based on the type of the data. Data were Aquadest injection through continuous pump would divided into two groups of patients and analyzed using dilate the collecting system, enabling artificial hydro - Kolmogorov–Smirnov to test whether the data were nor- nephrosis and facilitating needle puncture, especially in mally distributed. Qualitative variables were compared PCNL fluoroscopy-guided. statistically using chi-square or Fischer’s exact test and p Percutaneous renal access was accomplished using values < 0.05 was considered statistically significant. a 20-cm puncture needle (1.3  mm/17.5  G). In the F auzan et al. African Journal of Urology (2023) 29:19 Page 3 of 6 Table 1 Demographic Data Variable Ultrasound-guided PCNL (N = 89) Fluoroscopy-guided PCNL (N = 112) p value Age (year) 49.6 ± 1.2 49.2 ± 1.07 0.59 Sex Male 60 (67.4%) 70 (62,5%) 0.74 Female 29 (32.6%) 42 (37,5%) Body mass index (BMI) (kg/m ) 25.4 ± 1.19 25.57 ± 1.34 0.76 Preoperative hemoglobin (g/dL) 13.4 ± 0.11 13.5 ± 0.11 0.82 *p value > 0.05 indicates that data normally distributed Normality test used Kolmogorov–Smirnov test of the patients were not having any complication, but 3 Results post-operative fever was experienced by 11.24% patients We collected 201 patients’ data from medical records in ultrasound-guided PCNL and 12.5% in Fluoroscopy- who fulfilled the inclusion and exclusion criteria from Guided PCNL. Raden Mattaher Hospital, Jambi and divided the data into 2 groups, Ultrasound-guided and Fluoroscopy- 4 Discussion guided groups. Ultrasound-guided group were consisted Percutaneous nephrolithotomy (PCNL) is the treatment of 89 patients and Fluoroscopy-guided groups were con- of choice for staghorn stones and large renal stones, sisted of 112 patients. The demographic characteristics of which is recommended as the standard procedure for the groups are presented in Table 1. upper urinary tract stones larger than 2 cm [2]. It is tra- The data in Table  1 shows the results of the analysis ditionally guided by fluoroscopy and may pose a risk of test with the Kolmogorov–Smirnov test on the number radiation to patient and staff in the center. The use of of subjects > 50. The results of the p value indicate that ultrasonography in PCNL was first described as early as each variable has a value > 0.05, which means that each the 1970s. In the recent years, its trend has grown with variable, namely age, sex, body mass index, and preop- erative hemoglobin levels has a normal distribution of Table 2 Stone Characteristics data, there is no value in the data that is extreme or dif- fers greatly from one data to another. Variable Ultrasound Fluoroscopy- p value guided PCNL guided PCNL The data in Table  2 show significant results for the (N = 89) (N = 112) identification of hydronephrosis that is already in severe degrees, namely hydronephrosis grades 3 and 4. In con- Multiple stone ditions of severe hydronephrosis, or in more advanced Yes 7 (7.87%) 12 (10.71%) 0.49 conditions, there is a significant change in the anatomi - No 82 (92.13%) 100 (89.29%) cal structure, namely changes in ballooning and flatten - Classification of stone ing of the renal calyces pelvis, so that this condition can Staghorn 26 (29.21%) 26 (23.21%) 0.34 facilitate the identification of hydronephrosis through Non-staghorn 63 (70.79%) 86 (76.79%) ultrasound-guided PCNL, while in mild hydronephrosis Hydronephrosis conditions, there is usually no significant change in the None 67 (75.28%) 104 (92.85%) 0.01* anatomical structure of the renal pelvis, so this may be Grade I 1 (1.12%) 2 (1.79%) difficult to identify by ultrasound, so this examination Grade II 0 (0,00%) 0 (0,00%) is more common on fluoroscopy. This is supported by Grade III 15 (16.85%) 4 (3.57%) the analysis test results which show significant results Grade IV 6 (6.75%) 2 (1.79%) (Table 3). Side of stone From the various parameters tested/analyzed in the Right 29 (32.59%) 49 (43.75%) 0.16 table, it was found that significant results occurred in Left 55 (61.79%) 54 (48.21%) post-PCNL stent placement. Installation of a DJ stent Both 5 (5.62%) 9 (8.04%) alone is more commonly performed on fluoroscopy- Previous stone surgery guided PCNL procedures compared to ultrasound- Yes 11 (12.36%) 13 (11.61%) 0.87 guided PCNL. Meanwhile, the installation of a DJ stent No 78 (87.64%) 99 (88.39%) and a nephrostomy is more required for ultrasound- Initial stone burden 19.75 ± 8.24 18.23 ± 7.43 0.70 guided PCNL procedures. This indicates a significant (mm) result or test. Table  4 shows complication followed after * p < 0.05 indicates statistically significant the procedure classified by Clavien–Dindo system. Most Fisher’s test Fauzan et al. African Journal of Urology (2023) 29:19 Page 4 of 6 Table 3 Operative and Post-Operative Outcome Variable Ultrasound-guided PCNL (N = 89) Fluoroscopy-guided PCNL (N = 112) p value Surgery duration 115.00 ± 3.12 100.00 ± 1.99 0.38 Blood loss 105.00 ± 3.54 115.00 ± 3.11 0.64 Post-operative hemoglobin (g/dL) 12.95 ± 0.08 13.00 ± 1.62 0.59 Post-procedural stenting DJ stent 55 (61.80%) 99 (88.29%) < 0.001 DJ stent and nephrostomy 34 (38.20%) 13 (11.71%) Length of stay 3.00 ± 0.05 4.00 ± 0.12 0.91 Stone-free status Yes 71 (79.78%) 100 (89.29%) 0.06 No 18 (20.22%) 12 (10.71%) Complication (Fever) Yes 10 (11.24%) 14 (12.5%) 0.587 No 79 (88.76%) 98 (87.5%) *p < 0.05 indicates statistically significant Chi-Square test radiation exposure may have detrimental effects on Table 4 Complication classified by a modified Clavien–Dindo system exposed patients and health staff. As an alternative imag - ing method, ultrasound-guided has been proven to be Variable Ultrasound-guided Fluoroscopy-guided p value effective and safe for PCNL and experienced increasing PCNL (N = 89) PCNL (N = 112) distribution [9]. Its advantages include no radiation expo- Complication sure, real-time monitoring of the collecting system, renal Grade I (post- 10 (11.24%) 14 (12.5%) 0.587 parenchyma and surrounding organs, detection of radio- operative fever) lucent stones and avoid vascular injury with Doppler flow No 79 (88.76%) 98 (87.5%) imaging. However, ultrasound-guided PCNL remains challenging in patients with no apparent hydronephrosis, because it is difficult to visualize the targeted calyces suit - multiple case series demonstrating its feasibility, safety able for puncture [9]. and efficacy [3]. These have led to 2 randomized clini - Previous studies have shown that intraoperative use cal trials that showed a more accurate puncture and less of contrast-enhanced ultrasound (CEUS) in the prone radiation exposure for the patients and staff in ultra - position can achieve better visibility of nondilated col- sound-guided PCNL [4]. Some studies reported that lecting systems and facilitate more accurate puncture. PCNL under ultrasonography guidance in the flank or However, the puncture accuracy and safety of CEUS- prone position has high success rates and limited com- guided PCNL in flank position has not been investi - plications and can be a safe and effective alternative to gated so far. The acknowledged about ideal location fluoroscopy in experienced hands [7]. Previous study for renal puncture is through cup of the renal calyx, showed that the use of ultrasound in percutaneous which is associated with minimal vascular injury and nephrolithotomy (PCNL) has not been shown to trans- offer optimal access to stone clearance. In the presence late to better clinical and stone outcomes; however, the of hydronephrosis, the renal calyx fornix is easy to dis- study conducted by Ng et  al. 2017 showed that the use tinguish since it demonstrates as a hyperechoic area of ultrasonography to guide access puncture during adjacent to the hypoechoic urinary space. However, it is PCNL eliminates the risk of inadvertent organ injuries. difficult to identify this structure in nondilated collect - Similar operative and stone outcomes show that ultra- ing system under US guidance, due to the poor imaging sound-guided is minimal risk compared to conventional affected by the peripelvic fat. There were several other fluoroscopy-guided. Fluoroscopic guidance, traditionally advantages of CEUS-guided PCNL in the treatment of used for renal access, allows accurate identification of kidney stone patients with no apparent hydronephro- the targeted calyx for puncture. The main disadvantage sis. The efflux of urine through the puncture needle was of fluoroscopic guidance is lack of real-time visualiza - sometimes difficult to observe even successful renal tion of adjacent viscera, which may increase the risk of surrounding structures injury [8]. Moreover, its ionizing F auzan et al. African Journal of Urology (2023) 29:19 Page 5 of 6 puncture was performed, especially in patients with Research conducted by Birowo et  al. [13] in 2020 unobvious artificial hydronephrosis [10]. showed that ultrasound-guided PCNL in the supine Based on Ng et al., there were higher rates of upper pole position could be a good alternative compared to fluor - (5.6% vs. 3.6%), mid pole (8.3% vs. 2.7%) and multiple oscopy-guided PCNL because it has been shown to have pole punctures (4.2% vs. 0%) in ultrasound-guided PCNL good efficacy and lower complication rates in patients compared to Fluoroscopy-guided PCNL (p = 0.027). with kidney stones. Of the 120 patients enrolled, the There was no difference in the stone-free rates of both population was divided into the supine ultrasound- groups in univariate analysis. Those who had Fluor - guided PCNL, supine fluoroscopy-guided PCNL, and oscopic-guided PCNL were 2.26 times more likely to prone fluoroscopy-PCNL groups (each N = 40). The require a second-look procedure compared to ultra- supine ultrasound-guided PCNL group had higher punc- sound-guided PCNL on univariate analysis, but not on ture attempts, nephrostomy tube placement, and longer multivariate analysis. No patient with ultrasound-guided surgery duration than both the supine and prone fluor - PCNL group experienced organ injuries during puncture oscopy-guided PCNL groups. However, the stone-free compared to 1 patient in the fluoroscopy-guided. Moreo - rate was similar in all groups (85%, supine ultrasound- ver, although fluoroscopy allows accurate identification guided PCNL; 72.5%, supine fluoroscopy-guided PCNL; of the desired calyx for puncture, it does not allow for 77.5% prone fluoroscopy-guided PCNL; p = 0.39). No real-time simultaneous bi-plane fluoroscopy, making the significant difference was found in the complication rate process of obtaining accurate puncture into the desired and length of stay among the three groups, while it was calyx more difficult. Access with ultrasound-guided thought because of there were limitations in this study puncture during PCNL allows real-time simultaneous bi- that the comparison groups, which were composed of plane tracking of the route of puncture into the desired patients who underwent supine and prone fluoroscopy- calyx, while avoiding accidental injuries to vital adjacent guided PCNL, were historical control groups identi- organs. A less optimal entry into the collecting system fied from their PCNL database [13]. While other studies will therefore lead to increased bleeding complications reported that ultrasound-guided PCNL had high stone- and decreased post-operative stone-free rates [11]. free rate and low complication rate, and it was reported Gamal et  al. [3] reported 25 cases of moderate hydro- to be an effective and safe alternative to fluoroscopy nephrosis and 9 cases of severe hydronephrosis, all with when done by experts. Under ultrasound-guided, we single stone, while that was also revealed difficulties in could confirm the tip of the puncture needle enters the ultrasound-guided PCNL with a nondistended collect- collection system after seeing a bright contrast outflow ing system. It concludes that ultrasound-guided PCNL along with the needle, either by retrograde injection or can be performed better for patients with a single stone antegrade injection of the contrast agent. Before the at the renal pelvis in a moderately to markedly dilated guide wire placement and dilation, we could also evalu- pelvicalyceal system. Therefore, the 4 special structures ate the puncture quality by observing the angle between of the kidney (pelvis, calices, medulla, cortex), each hav- the puncture needle and the axis of the renal calyx to ing different anatomy-physiologic properties, should be the calyx neck. Another advantage of ultrasound-guided taken into account in determining the severity of hydro- is that multiple injections can be performed during one nephrosis. The Onen grading system has evidence-based operation, owing to the short half-life (5–7  min) of US standardized objectives and reproducible parameters. contrast, which was feasible for urologists to start this It includes two categories of kidney findings. The first is new technology [14]. dilation of the pelvicalyceal system; the second which is This study was limited to the effects of radiation expo - the most important category is the quality of the renal sure on the patients. Further research was suggested to parenchyma (thickness and appearance) [10]. This grad - study the effects of radiation exposure to the post-oper - ing system divides thinning of the renal parenchyma into ative outcome. two grades: medullary thinning and cortical thinning. In addition, the appearance of the parenchyma (echogenic-5 Conclusion ity, cortical cysts, corticomedullary differentiation) which Access with ultrasound-guided puncture during PCNL is suggestive of renal damage is also taken into account allows real-time simultaneous bi-plane tracking of the in this grading system. It was proposed on the basis of route of puncture into the desired calyx, while avoid- a well-known tight association between the severity of ing accidental injuries to vital adjacent organs. A less hydronephrosis and prognosis [12]. Renal deteriora- optimal entry into the collecting system will therefore tion may occur in severe hydronephrosis not timely and lead to increased bleeding complications and decreased promptly treated. post-operative stone-free rates. PCNL ultrasound-guided has similar efficacy and complication rates with PCNL Fauzan et al. African Journal of Urology (2023) 29:19 Page 6 of 6 6. Shaker H, Ismail MAA, Kamal AM, Safa M, Refaat H, Abdelsalam A et al fluoroscopy-guided. This could be a good alternative in (2015) Value of computed tomography for predicting the outcome after urological centers with no access to fluoroscopy. How - percutaneous nephrolithotomy. Electron Phys 7:1511–1514. https:// doi. ever, ultrasound group was still associated with higher org/ 10. 19082/ 1511 7. Liu ZQ, Xie J, Zhao CB, Liu YF, Li ZS, Guo JN, Jiang HT, Xiao KF (2022) Feasi- rate nephrostomy tube placement and longer surgery bility of contrast-enhanced ultrasound and flank position during percu- duration. taneous nephrolithotomy in patients with no apparent hydronephrosis: a randomized controlled trial. World J Urol 40(4):1043–1048. https:// doi. org/ 10. 1007/ s00345- 022- 03933-4 Abbreviations 8. Beiko D, Razvi H, Bhojani N, Bjazevic J, Bayne DB, Tzou DT, Stoller ML, Chi T PCNL Percutaneous nephrolithotomy (2020) Techniques—ultrasound-guided percutaneous nephrolithotomy: CT Computed tomography how we do it. Can Urol Assoc J 14(3):E104–E110. https:// doi. org/ 10. 5489/ DJ Double J cuaj. 6076 KUB Kidney-ureter-bladder 9. Falahatkar S, Allahkhah A, Kazemzadeh M, Enshaei A, Shakiba M, Moghad- BMI Body mass index das F (2016) Complete supine PCNL: ultrasound vs. fluoroscopic guided: a CEUS Contrast-enhanced ultrasound randomized clinical trial. Int Braz J Urol 42(4):710–716. https:// doi. org/ 10. 1590/ S1677- 5538. IBJU. 2014. 0291 Acknowledgements 10. Jiang Y, Zhang J, Kang N, Niu Y, Li Z, Yu C, Zhang J (2021) Current trends Not applicable. in percutaneous nephrolithotomy in China: a spot survey. Risk Manag Healthc Policy 14:2507–2515. https:// doi. org/ 10. 2147/ RMHP. S3014 84 Author contributions 11. Malik I, Wadhwa R (2016) Percutaneous nephrolithotomy: current clini- RM contributed to methodology, software, validation, original draft prepara- cal opinions and anesthesiologists perspective. Anesthesiol Res Pract. tion, formal analysis for the study, and also project administration together https:// doi. org/ 10. 1155/ 2016/ 90368 72 with WR. Together with RM, A conducted investigations, provided resources, 12. Karami H, Rezaei A, Mohammadhosseini M, Javanmard B, Mazloomfard and visualization. On the other hand, A and HH are doing data curation and M, Lotfi B (2010) Ultrasonography-guided percutaneous nephroli- review editing. Also, HH and WR as supervision. thotomy in the flank position versus fluoroscopy-guided percutaneous nephrolithotomy in the prone position: a comparative study. J Endourol Funding 24:1357–1361 The study received no external funding. 13. Birowo P, Raharja PAR, Putra HWK, Rustandi R, Atmoko W, Rasyid N (2020) X-ray-free ultrasound-guided versus fluoroscopy-guided percutaneous Availability of data and materials nephrolithotomy: a comparative study with historical control. Int Urol The datasets used and analyzed during the study are available from the cor- Nephrol 52(12):2253–2259. https:// doi. org/ 10. 1007/ s11255- 020- 02577-w responding author on reasonable request. 14. Falahatkar S, Allahkhah A (2010) Recent developments in percutaneous nephrolithotomy: benefits of the complete supine position. Urotoday Int J. https:// doi. org/ 10. 3834/ uij. 1944- 5784. 2010. 04. 03 Declarations Ethics approval and consent to participate Publisher’s Note The study was approved by Institutional ethics Committee of Raden Mattaher Springer Nature remains neutral with regard to jurisdictional claims in pub- Hospital Jambi with letter number S. 71/SPE/IX/2022. A written informed lished maps and institutional affiliations. consent was taken from all patients. Consent for publication No consent was taken from patients during their enrollment into the study. Competing interests The authors have no competing interest to declare. Received: 1 November 2022 Accepted: 9 March 2023 References 1. Turk C, Knoll T, Petrik A, Sarica K, Skolarikos A, Straub M, Seitz C (2022) EAU guidelines on urolithiasis. Eur Urol 63:475 2. Ng FC, Yam WL, Lim TYB, Teo JK, Ng KK, Lim SK (2017) Ultrasound-guided percutaneous nephrolithotomy: advantages and limitations. Investig Clin Urol 58(5):346–352. https:// doi. org/ 10. 4111/ icu. 2017. 58.5. 346 3. Gamal WM, Hussein M, Aldahshoury M, Hammady A, Osman M, Moursy E et al (2011) Solo ultrasonography-guided percutanous nephrolithotomy for single stone pelvis. J Endourol 25:593–596 4. Nguyen HT, Benson CB, Bromley B, Campbell JB, Chow J, Coleman B, Cooper C et al (2014) Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system). J Pediatr Urol 10:982–999. https:// doi. org/ 10. 1016/j. jpurol. 2014. 10. 002 5. De Treigny OM, Bou Nasr E, Almont T, Tack I, Rischmann P, Soulié M et al (2015) The cumulated stone diameter: a limited tool for stone burden estimation. Urology 86:477–481. https:// doi. org/ 10. 1016/j. urolo gy. 2015. 06. 018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png African Journal of Urology Springer Journals

Comparison between Ultrasound and Fluoroscopy-guided Percutaneous Nephrolithotomy (PCNL) at Raden Mattaher Jambi Hospital

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10.1186/s12301-023-00347-5
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Abstract

Purpose To investigate the effectiveness and safety of ultrasound-guided and Percutaneous Nephrolithotomy (PCNL) compared to the standard fluoroscopy-guided PCNL. Methods This study is a comparative retrospective study obtained from medical records within the last 5 years of Raden Mattaher Hospital, Jambi. Patients were divided into 2 groups, fluoroscopy- and ultrasonography-guided PCNL with large kidney stone > 20 mm. Patient characteristics were divided into pre- and post-operative procedures and analyzed using SPSS ver. 25.0 (SPSS Inc., Chicago, IL, USA). Data were analyzed using Kolmogorov–Smirnov, chi-square and/ Fischer’s exact test and p value < 0.05 was considered statistically significant. Results Of 201 patients’ data from medical records were divided into ultrasound-guided and fluoroscopy-guided groups. Ultrasound-guided group were consisted of 89 patients and fluoroscopy-guided were of 112 patients. US Guided significantly identifies the severity of hydronephrosis compared to PCNL. The demographic data obtained age, sex, body mass index, and preoperative hemoglobin levels showed a normal distribution. On the post-operative results, significant results occurred in post-PCNL stent placement. Installation of a DJ stent alone is more commonly performed on fluoroscopy-guided PCNL procedures compared to ultrasound-guided PCNL. This had a positive impact on post-procedure outcomes, meaning that the post-operative outcome of ultrasound-guided PCNL was bet- ter than that of fluoroscopy-guided PCNL. Conclusion The reported data demonstrate that PCNL and ultrasound-guided has similar efficacy and complication rates with PCNL fluoroscopy-guided. This could be a good alternative in urological centers with no access to fluor - oscopy. However, ultrasound-guided group was still associated with higher rate nephrostomy tube placement and longer surgery duration. Keywords Ultrasound, Percutaneous nephrolithotomy, Fluoroscopy, Treatment, Renal stones 1 Background Percutaneous Nephrolithotomy (PCNL) is one of the first-line endourology procedure for patients who *Correspondence: encounter more than 20  mm kidney stone [1]. The use Raga Manduaru of PCNL can use the approach of fluoroscopy and ultra - manduaru@gmail.com sound methods. This method approach is based on sev - Department of Urology, Raden Mattaher Hospital, Jambi, Indonesia Department of Urology, Faculty of Medicine, Cipto Mangunkusumo eral considerations of the patient’s condition. The use of National Referral Hospital, University of Indonesia, Depok City, Indonesia ultrasound-guided PCNL and fluoroscopy-guided PCNL © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Fauzan et al. African Journal of Urology (2023) 29:19 Page 2 of 6 has its own advantages and disadvantages. In the use ultrasound group, the target calyx selection was identi- of fluoroscopy-guided, it is more precise and does not fied prior to the operation based on the stone location depend on the skill of the operator in using ultrasound and surgeon preference. Successful puncture was con- but has the risk of radiation exposure [2]. Meanwhile, firmed with urine flow from the puncture needle. Under ultrasound-guided has no risk of radiation exposure ultrasound-guided, a guidewire (0.035-inch J-shaped and widely available in areas with limited technology. stiff-guidewire) was inserted into the collecting system. In terms of cost, the use of ultrasound also has lower The needle was then withdrawn. Fascial dilatation was cost compared to the use of fluoroscopy-guided [1]. In performed with 8-Fr until 18-Fr fascial dilators. Urine this study, we compared the effectiveness and safety of flow from the dilators confirmed that we had reached using ultrasound-guided vs fluoroscopy-guided PCNL in the collecting system. Amplatz sheath was then pushed patients with kidney stones [2–4]. on into the collecting system. In the ultrasound group, ultrasonography was used solely in all procedures, that is, evaluation of the kidney and stone, assistance 2 Methods of kidney puncture, and tract dilatation. In the fluor - 2.1 Study population oscopy group, all those steps were performed under This study is a comparative retrospective study obtained fluoroscopy-guidance. from medical records within the last 5  years of Raden A 16-Fr rigid nephroscope was used during the PCNL Mattaher Hospital, Jambi. Patients’ data who under- procedure. Stone fragmentation was performed using went PCNL were divided into 2 groups based on type of holmium laser. Stone forceps were used to evacuate the guidance, fluoroscopy and ultrasonography. All patients stone fragments. In the ultrasound group, both ultra- included in this study were presented at the hospital sonography and nephroscopy were used to identify resid- with > 20 mm kidney stone and went through PCNL pro- ual stones, infundibular laceration, or extravasation of cedures between January 2019 and March 2022. All the urine. In the fluoroscopy group, those procedures were patients with uncomplete medical record data, uncor- done under fluoroscopic guidance. Upon conclusion of rected coagulopathy, congenital kidney anomalies, and the PCNL procedure, nephrostomy tube, double J (DJ) intraoperative conversion to open were excluded from stent, or externalized ureteral catheter were placed based this study. We evaluated and divided the data into demo- on any significant bleeding, residual stone fragments, or graphic parameters, stone characteristics, pre- and post- debris. Some patients had both nephrostomy tube and DJ operative procedures. stent. 2.2 Procedures All patients underwent the same laboratory tests includ- 2.3 Evaluations ing blood routine, and renal function tests before the In this study, we compared the demographic param- surgery. Preoperative computed tomography (CT) urog- eters, stone characteristics, and operative and post- raphy was routinely performed to evaluate the stone operative outcomes between ultrasound group dan location, kidney anatomy, and position of surrounding fluoroscopy group. All patients had post-operative kid - important structures. Stone burden was measured by ney-ureter-bladder (KUB) photo determine the stone- combining the largest diameter of each stone in all sec- free status. KUB photo could missed residual stone tions [5]. fragments ≤ 4  mm, [12] however patients with residual All PCNL procedures were accomplished by a team stone fragments ≤ 4 mm were clinically insignificant and of endourologists consisting of three different main sur - considered to be stone-free in this study [6]. geons. PCNL ultrasound-guided and fluoroscopy-guided were performed in supine (Galdakao-modified Valdivia) position. All patients received preoperative prophylactic 2.4 Statistical analysis antibiotics. PCNL was performed under general anes- Data presented in this paper were analyzed using SPSS thesia. For ureteral access, retrograde open-end ure- ver. 25.0 (SPSS Inc., Chicago, IL, USA). Data shown in teral catheter (5 Fr) was applied. The ureteral catheter the table were mean (standard deviation) and number was used for injection of aquadest or contrast agent. (percentage) based on the type of the data. Data were Aquadest injection through continuous pump would divided into two groups of patients and analyzed using dilate the collecting system, enabling artificial hydro - Kolmogorov–Smirnov to test whether the data were nor- nephrosis and facilitating needle puncture, especially in mally distributed. Qualitative variables were compared PCNL fluoroscopy-guided. statistically using chi-square or Fischer’s exact test and p Percutaneous renal access was accomplished using values < 0.05 was considered statistically significant. a 20-cm puncture needle (1.3  mm/17.5  G). In the F auzan et al. African Journal of Urology (2023) 29:19 Page 3 of 6 Table 1 Demographic Data Variable Ultrasound-guided PCNL (N = 89) Fluoroscopy-guided PCNL (N = 112) p value Age (year) 49.6 ± 1.2 49.2 ± 1.07 0.59 Sex Male 60 (67.4%) 70 (62,5%) 0.74 Female 29 (32.6%) 42 (37,5%) Body mass index (BMI) (kg/m ) 25.4 ± 1.19 25.57 ± 1.34 0.76 Preoperative hemoglobin (g/dL) 13.4 ± 0.11 13.5 ± 0.11 0.82 *p value > 0.05 indicates that data normally distributed Normality test used Kolmogorov–Smirnov test of the patients were not having any complication, but 3 Results post-operative fever was experienced by 11.24% patients We collected 201 patients’ data from medical records in ultrasound-guided PCNL and 12.5% in Fluoroscopy- who fulfilled the inclusion and exclusion criteria from Guided PCNL. Raden Mattaher Hospital, Jambi and divided the data into 2 groups, Ultrasound-guided and Fluoroscopy- 4 Discussion guided groups. Ultrasound-guided group were consisted Percutaneous nephrolithotomy (PCNL) is the treatment of 89 patients and Fluoroscopy-guided groups were con- of choice for staghorn stones and large renal stones, sisted of 112 patients. The demographic characteristics of which is recommended as the standard procedure for the groups are presented in Table 1. upper urinary tract stones larger than 2 cm [2]. It is tra- The data in Table  1 shows the results of the analysis ditionally guided by fluoroscopy and may pose a risk of test with the Kolmogorov–Smirnov test on the number radiation to patient and staff in the center. The use of of subjects > 50. The results of the p value indicate that ultrasonography in PCNL was first described as early as each variable has a value > 0.05, which means that each the 1970s. In the recent years, its trend has grown with variable, namely age, sex, body mass index, and preop- erative hemoglobin levels has a normal distribution of Table 2 Stone Characteristics data, there is no value in the data that is extreme or dif- fers greatly from one data to another. Variable Ultrasound Fluoroscopy- p value guided PCNL guided PCNL The data in Table  2 show significant results for the (N = 89) (N = 112) identification of hydronephrosis that is already in severe degrees, namely hydronephrosis grades 3 and 4. In con- Multiple stone ditions of severe hydronephrosis, or in more advanced Yes 7 (7.87%) 12 (10.71%) 0.49 conditions, there is a significant change in the anatomi - No 82 (92.13%) 100 (89.29%) cal structure, namely changes in ballooning and flatten - Classification of stone ing of the renal calyces pelvis, so that this condition can Staghorn 26 (29.21%) 26 (23.21%) 0.34 facilitate the identification of hydronephrosis through Non-staghorn 63 (70.79%) 86 (76.79%) ultrasound-guided PCNL, while in mild hydronephrosis Hydronephrosis conditions, there is usually no significant change in the None 67 (75.28%) 104 (92.85%) 0.01* anatomical structure of the renal pelvis, so this may be Grade I 1 (1.12%) 2 (1.79%) difficult to identify by ultrasound, so this examination Grade II 0 (0,00%) 0 (0,00%) is more common on fluoroscopy. This is supported by Grade III 15 (16.85%) 4 (3.57%) the analysis test results which show significant results Grade IV 6 (6.75%) 2 (1.79%) (Table 3). Side of stone From the various parameters tested/analyzed in the Right 29 (32.59%) 49 (43.75%) 0.16 table, it was found that significant results occurred in Left 55 (61.79%) 54 (48.21%) post-PCNL stent placement. Installation of a DJ stent Both 5 (5.62%) 9 (8.04%) alone is more commonly performed on fluoroscopy- Previous stone surgery guided PCNL procedures compared to ultrasound- Yes 11 (12.36%) 13 (11.61%) 0.87 guided PCNL. Meanwhile, the installation of a DJ stent No 78 (87.64%) 99 (88.39%) and a nephrostomy is more required for ultrasound- Initial stone burden 19.75 ± 8.24 18.23 ± 7.43 0.70 guided PCNL procedures. This indicates a significant (mm) result or test. Table  4 shows complication followed after * p < 0.05 indicates statistically significant the procedure classified by Clavien–Dindo system. Most Fisher’s test Fauzan et al. African Journal of Urology (2023) 29:19 Page 4 of 6 Table 3 Operative and Post-Operative Outcome Variable Ultrasound-guided PCNL (N = 89) Fluoroscopy-guided PCNL (N = 112) p value Surgery duration 115.00 ± 3.12 100.00 ± 1.99 0.38 Blood loss 105.00 ± 3.54 115.00 ± 3.11 0.64 Post-operative hemoglobin (g/dL) 12.95 ± 0.08 13.00 ± 1.62 0.59 Post-procedural stenting DJ stent 55 (61.80%) 99 (88.29%) < 0.001 DJ stent and nephrostomy 34 (38.20%) 13 (11.71%) Length of stay 3.00 ± 0.05 4.00 ± 0.12 0.91 Stone-free status Yes 71 (79.78%) 100 (89.29%) 0.06 No 18 (20.22%) 12 (10.71%) Complication (Fever) Yes 10 (11.24%) 14 (12.5%) 0.587 No 79 (88.76%) 98 (87.5%) *p < 0.05 indicates statistically significant Chi-Square test radiation exposure may have detrimental effects on Table 4 Complication classified by a modified Clavien–Dindo system exposed patients and health staff. As an alternative imag - ing method, ultrasound-guided has been proven to be Variable Ultrasound-guided Fluoroscopy-guided p value effective and safe for PCNL and experienced increasing PCNL (N = 89) PCNL (N = 112) distribution [9]. Its advantages include no radiation expo- Complication sure, real-time monitoring of the collecting system, renal Grade I (post- 10 (11.24%) 14 (12.5%) 0.587 parenchyma and surrounding organs, detection of radio- operative fever) lucent stones and avoid vascular injury with Doppler flow No 79 (88.76%) 98 (87.5%) imaging. However, ultrasound-guided PCNL remains challenging in patients with no apparent hydronephrosis, because it is difficult to visualize the targeted calyces suit - multiple case series demonstrating its feasibility, safety able for puncture [9]. and efficacy [3]. These have led to 2 randomized clini - Previous studies have shown that intraoperative use cal trials that showed a more accurate puncture and less of contrast-enhanced ultrasound (CEUS) in the prone radiation exposure for the patients and staff in ultra - position can achieve better visibility of nondilated col- sound-guided PCNL [4]. Some studies reported that lecting systems and facilitate more accurate puncture. PCNL under ultrasonography guidance in the flank or However, the puncture accuracy and safety of CEUS- prone position has high success rates and limited com- guided PCNL in flank position has not been investi - plications and can be a safe and effective alternative to gated so far. The acknowledged about ideal location fluoroscopy in experienced hands [7]. Previous study for renal puncture is through cup of the renal calyx, showed that the use of ultrasound in percutaneous which is associated with minimal vascular injury and nephrolithotomy (PCNL) has not been shown to trans- offer optimal access to stone clearance. In the presence late to better clinical and stone outcomes; however, the of hydronephrosis, the renal calyx fornix is easy to dis- study conducted by Ng et  al. 2017 showed that the use tinguish since it demonstrates as a hyperechoic area of ultrasonography to guide access puncture during adjacent to the hypoechoic urinary space. However, it is PCNL eliminates the risk of inadvertent organ injuries. difficult to identify this structure in nondilated collect - Similar operative and stone outcomes show that ultra- ing system under US guidance, due to the poor imaging sound-guided is minimal risk compared to conventional affected by the peripelvic fat. There were several other fluoroscopy-guided. Fluoroscopic guidance, traditionally advantages of CEUS-guided PCNL in the treatment of used for renal access, allows accurate identification of kidney stone patients with no apparent hydronephro- the targeted calyx for puncture. The main disadvantage sis. The efflux of urine through the puncture needle was of fluoroscopic guidance is lack of real-time visualiza - sometimes difficult to observe even successful renal tion of adjacent viscera, which may increase the risk of surrounding structures injury [8]. Moreover, its ionizing F auzan et al. African Journal of Urology (2023) 29:19 Page 5 of 6 puncture was performed, especially in patients with Research conducted by Birowo et  al. [13] in 2020 unobvious artificial hydronephrosis [10]. showed that ultrasound-guided PCNL in the supine Based on Ng et al., there were higher rates of upper pole position could be a good alternative compared to fluor - (5.6% vs. 3.6%), mid pole (8.3% vs. 2.7%) and multiple oscopy-guided PCNL because it has been shown to have pole punctures (4.2% vs. 0%) in ultrasound-guided PCNL good efficacy and lower complication rates in patients compared to Fluoroscopy-guided PCNL (p = 0.027). with kidney stones. Of the 120 patients enrolled, the There was no difference in the stone-free rates of both population was divided into the supine ultrasound- groups in univariate analysis. Those who had Fluor - guided PCNL, supine fluoroscopy-guided PCNL, and oscopic-guided PCNL were 2.26 times more likely to prone fluoroscopy-PCNL groups (each N = 40). The require a second-look procedure compared to ultra- supine ultrasound-guided PCNL group had higher punc- sound-guided PCNL on univariate analysis, but not on ture attempts, nephrostomy tube placement, and longer multivariate analysis. No patient with ultrasound-guided surgery duration than both the supine and prone fluor - PCNL group experienced organ injuries during puncture oscopy-guided PCNL groups. However, the stone-free compared to 1 patient in the fluoroscopy-guided. Moreo - rate was similar in all groups (85%, supine ultrasound- ver, although fluoroscopy allows accurate identification guided PCNL; 72.5%, supine fluoroscopy-guided PCNL; of the desired calyx for puncture, it does not allow for 77.5% prone fluoroscopy-guided PCNL; p = 0.39). No real-time simultaneous bi-plane fluoroscopy, making the significant difference was found in the complication rate process of obtaining accurate puncture into the desired and length of stay among the three groups, while it was calyx more difficult. Access with ultrasound-guided thought because of there were limitations in this study puncture during PCNL allows real-time simultaneous bi- that the comparison groups, which were composed of plane tracking of the route of puncture into the desired patients who underwent supine and prone fluoroscopy- calyx, while avoiding accidental injuries to vital adjacent guided PCNL, were historical control groups identi- organs. A less optimal entry into the collecting system fied from their PCNL database [13]. While other studies will therefore lead to increased bleeding complications reported that ultrasound-guided PCNL had high stone- and decreased post-operative stone-free rates [11]. free rate and low complication rate, and it was reported Gamal et  al. [3] reported 25 cases of moderate hydro- to be an effective and safe alternative to fluoroscopy nephrosis and 9 cases of severe hydronephrosis, all with when done by experts. Under ultrasound-guided, we single stone, while that was also revealed difficulties in could confirm the tip of the puncture needle enters the ultrasound-guided PCNL with a nondistended collect- collection system after seeing a bright contrast outflow ing system. It concludes that ultrasound-guided PCNL along with the needle, either by retrograde injection or can be performed better for patients with a single stone antegrade injection of the contrast agent. Before the at the renal pelvis in a moderately to markedly dilated guide wire placement and dilation, we could also evalu- pelvicalyceal system. Therefore, the 4 special structures ate the puncture quality by observing the angle between of the kidney (pelvis, calices, medulla, cortex), each hav- the puncture needle and the axis of the renal calyx to ing different anatomy-physiologic properties, should be the calyx neck. Another advantage of ultrasound-guided taken into account in determining the severity of hydro- is that multiple injections can be performed during one nephrosis. The Onen grading system has evidence-based operation, owing to the short half-life (5–7  min) of US standardized objectives and reproducible parameters. contrast, which was feasible for urologists to start this It includes two categories of kidney findings. The first is new technology [14]. dilation of the pelvicalyceal system; the second which is This study was limited to the effects of radiation expo - the most important category is the quality of the renal sure on the patients. Further research was suggested to parenchyma (thickness and appearance) [10]. This grad - study the effects of radiation exposure to the post-oper - ing system divides thinning of the renal parenchyma into ative outcome. two grades: medullary thinning and cortical thinning. In addition, the appearance of the parenchyma (echogenic-5 Conclusion ity, cortical cysts, corticomedullary differentiation) which Access with ultrasound-guided puncture during PCNL is suggestive of renal damage is also taken into account allows real-time simultaneous bi-plane tracking of the in this grading system. It was proposed on the basis of route of puncture into the desired calyx, while avoid- a well-known tight association between the severity of ing accidental injuries to vital adjacent organs. A less hydronephrosis and prognosis [12]. Renal deteriora- optimal entry into the collecting system will therefore tion may occur in severe hydronephrosis not timely and lead to increased bleeding complications and decreased promptly treated. post-operative stone-free rates. PCNL ultrasound-guided has similar efficacy and complication rates with PCNL Fauzan et al. African Journal of Urology (2023) 29:19 Page 6 of 6 6. Shaker H, Ismail MAA, Kamal AM, Safa M, Refaat H, Abdelsalam A et al fluoroscopy-guided. This could be a good alternative in (2015) Value of computed tomography for predicting the outcome after urological centers with no access to fluoroscopy. How - percutaneous nephrolithotomy. Electron Phys 7:1511–1514. https:// doi. ever, ultrasound group was still associated with higher org/ 10. 19082/ 1511 7. Liu ZQ, Xie J, Zhao CB, Liu YF, Li ZS, Guo JN, Jiang HT, Xiao KF (2022) Feasi- rate nephrostomy tube placement and longer surgery bility of contrast-enhanced ultrasound and flank position during percu- duration. taneous nephrolithotomy in patients with no apparent hydronephrosis: a randomized controlled trial. World J Urol 40(4):1043–1048. https:// doi. org/ 10. 1007/ s00345- 022- 03933-4 Abbreviations 8. Beiko D, Razvi H, Bhojani N, Bjazevic J, Bayne DB, Tzou DT, Stoller ML, Chi T PCNL Percutaneous nephrolithotomy (2020) Techniques—ultrasound-guided percutaneous nephrolithotomy: CT Computed tomography how we do it. Can Urol Assoc J 14(3):E104–E110. https:// doi. org/ 10. 5489/ DJ Double J cuaj. 6076 KUB Kidney-ureter-bladder 9. Falahatkar S, Allahkhah A, Kazemzadeh M, Enshaei A, Shakiba M, Moghad- BMI Body mass index das F (2016) Complete supine PCNL: ultrasound vs. fluoroscopic guided: a CEUS Contrast-enhanced ultrasound randomized clinical trial. Int Braz J Urol 42(4):710–716. https:// doi. org/ 10. 1590/ S1677- 5538. IBJU. 2014. 0291 Acknowledgements 10. Jiang Y, Zhang J, Kang N, Niu Y, Li Z, Yu C, Zhang J (2021) Current trends Not applicable. in percutaneous nephrolithotomy in China: a spot survey. Risk Manag Healthc Policy 14:2507–2515. https:// doi. org/ 10. 2147/ RMHP. S3014 84 Author contributions 11. Malik I, Wadhwa R (2016) Percutaneous nephrolithotomy: current clini- RM contributed to methodology, software, validation, original draft prepara- cal opinions and anesthesiologists perspective. Anesthesiol Res Pract. tion, formal analysis for the study, and also project administration together https:// doi. org/ 10. 1155/ 2016/ 90368 72 with WR. Together with RM, A conducted investigations, provided resources, 12. Karami H, Rezaei A, Mohammadhosseini M, Javanmard B, Mazloomfard and visualization. On the other hand, A and HH are doing data curation and M, Lotfi B (2010) Ultrasonography-guided percutaneous nephroli- review editing. Also, HH and WR as supervision. thotomy in the flank position versus fluoroscopy-guided percutaneous nephrolithotomy in the prone position: a comparative study. J Endourol Funding 24:1357–1361 The study received no external funding. 13. Birowo P, Raharja PAR, Putra HWK, Rustandi R, Atmoko W, Rasyid N (2020) X-ray-free ultrasound-guided versus fluoroscopy-guided percutaneous Availability of data and materials nephrolithotomy: a comparative study with historical control. Int Urol The datasets used and analyzed during the study are available from the cor- Nephrol 52(12):2253–2259. https:// doi. org/ 10. 1007/ s11255- 020- 02577-w responding author on reasonable request. 14. Falahatkar S, Allahkhah A (2010) Recent developments in percutaneous nephrolithotomy: benefits of the complete supine position. Urotoday Int J. https:// doi. org/ 10. 3834/ uij. 1944- 5784. 2010. 04. 03 Declarations Ethics approval and consent to participate Publisher’s Note The study was approved by Institutional ethics Committee of Raden Mattaher Springer Nature remains neutral with regard to jurisdictional claims in pub- Hospital Jambi with letter number S. 71/SPE/IX/2022. A written informed lished maps and institutional affiliations. consent was taken from all patients. Consent for publication No consent was taken from patients during their enrollment into the study. Competing interests The authors have no competing interest to declare. Received: 1 November 2022 Accepted: 9 March 2023 References 1. Turk C, Knoll T, Petrik A, Sarica K, Skolarikos A, Straub M, Seitz C (2022) EAU guidelines on urolithiasis. Eur Urol 63:475 2. Ng FC, Yam WL, Lim TYB, Teo JK, Ng KK, Lim SK (2017) Ultrasound-guided percutaneous nephrolithotomy: advantages and limitations. Investig Clin Urol 58(5):346–352. https:// doi. org/ 10. 4111/ icu. 2017. 58.5. 346 3. Gamal WM, Hussein M, Aldahshoury M, Hammady A, Osman M, Moursy E et al (2011) Solo ultrasonography-guided percutanous nephrolithotomy for single stone pelvis. J Endourol 25:593–596 4. Nguyen HT, Benson CB, Bromley B, Campbell JB, Chow J, Coleman B, Cooper C et al (2014) Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system). J Pediatr Urol 10:982–999. https:// doi. org/ 10. 1016/j. jpurol. 2014. 10. 002 5. De Treigny OM, Bou Nasr E, Almont T, Tack I, Rischmann P, Soulié M et al (2015) The cumulated stone diameter: a limited tool for stone burden estimation. Urology 86:477–481. https:// doi. org/ 10. 1016/j. urolo gy. 2015. 06. 018

Journal

African Journal of UrologySpringer Journals

Published: Apr 17, 2023

Keywords: Ultrasound; Percutaneous nephrolithotomy; Fluoroscopy; Treatment; Renal stones

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