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Tasa de complicaciones, sistema de Clavien modificado, seleccion del paciente, falta de equipo inadecuado, errores tecnicos relacionados al acceso y remocion litiasica
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Katherine HenriacutequezUROLOGIacuteA
11 julio 2012
1955 Goodwin Primera puncioacuten renal
1975 Harris Uso de broncoscopio como
nefroscopio
1976 Fernstrom y Johansson Tracto percutaacuteneo para
remocioacuten litiaacutesica
Goodwin WE Casey WC Woolf W Percutaneous trocar (needle) nephrostomy in hydronephrosis J Am Med Assoc1955 Mar 12157(11)891-4Harris RD McLaughlin AP 3rd Harrell JH Percutaneous nephroscopy using fiberoptic bronchoscope removal of renal calculus Urology 1975 Sep6(3)367-9
Limitaciones de litotripsia extracorpoacuterea con ondas de choque
Mejora de eficacia en desintegracioacuten percutaacutenea litiaacutesica
Cirugiacutea miacutenimamente invasiva
Primera liacutenea de tratamiento litiasis renal grande y muacuteltiple yo localizada en caacuteliz inferior
Fuente de Complicaciones
Seleccioacuten del Paciente Falta de Equipo
Adecuado
Errores Teacutecnicos
Tasa de complicaciones hasta 83
Complicaciones tempranas 508 Mayoriacutea se resuelven sin secuelas
Tasa de mortalidad a 30 diacuteas 03
Complicaciones Menores 25 Complicaciones Mayores 7
Fiebre transitoria 321 Sepsis urinaria 03
Sangrado cliacutenicamente insignificante
76 Sangrado con intervencioacuten angiograacutefica
03
M Michel L Trojan J Rassweiler Complications in Percutaneous Nephrolithotomy European urology 51 ( 2007 ) 899ndash906
M Michel L Trojan J Rassweiler Complications in Percutaneous Nephrolithotomy European urology 51 ( 2007 ) 899ndash906
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele D Tolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
Sistema de Clavien Modificado
Dindo D Demartines N Clavien PA Classification of surgical complications a new proposal with evaluation in a cohort of a 6336 patients and results of a survey Ann Surg 2004240205ndash13
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
1955 Goodwin Primera puncioacuten renal
1975 Harris Uso de broncoscopio como
nefroscopio
1976 Fernstrom y Johansson Tracto percutaacuteneo para
remocioacuten litiaacutesica
Goodwin WE Casey WC Woolf W Percutaneous trocar (needle) nephrostomy in hydronephrosis J Am Med Assoc1955 Mar 12157(11)891-4Harris RD McLaughlin AP 3rd Harrell JH Percutaneous nephroscopy using fiberoptic bronchoscope removal of renal calculus Urology 1975 Sep6(3)367-9
Limitaciones de litotripsia extracorpoacuterea con ondas de choque
Mejora de eficacia en desintegracioacuten percutaacutenea litiaacutesica
Cirugiacutea miacutenimamente invasiva
Primera liacutenea de tratamiento litiasis renal grande y muacuteltiple yo localizada en caacuteliz inferior
Fuente de Complicaciones
Seleccioacuten del Paciente Falta de Equipo
Adecuado
Errores Teacutecnicos
Tasa de complicaciones hasta 83
Complicaciones tempranas 508 Mayoriacutea se resuelven sin secuelas
Tasa de mortalidad a 30 diacuteas 03
Complicaciones Menores 25 Complicaciones Mayores 7
Fiebre transitoria 321 Sepsis urinaria 03
Sangrado cliacutenicamente insignificante
76 Sangrado con intervencioacuten angiograacutefica
03
M Michel L Trojan J Rassweiler Complications in Percutaneous Nephrolithotomy European urology 51 ( 2007 ) 899ndash906
M Michel L Trojan J Rassweiler Complications in Percutaneous Nephrolithotomy European urology 51 ( 2007 ) 899ndash906
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele D Tolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
Sistema de Clavien Modificado
Dindo D Demartines N Clavien PA Classification of surgical complications a new proposal with evaluation in a cohort of a 6336 patients and results of a survey Ann Surg 2004240205ndash13
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Limitaciones de litotripsia extracorpoacuterea con ondas de choque
Mejora de eficacia en desintegracioacuten percutaacutenea litiaacutesica
Cirugiacutea miacutenimamente invasiva
Primera liacutenea de tratamiento litiasis renal grande y muacuteltiple yo localizada en caacuteliz inferior
Fuente de Complicaciones
Seleccioacuten del Paciente Falta de Equipo
Adecuado
Errores Teacutecnicos
Tasa de complicaciones hasta 83
Complicaciones tempranas 508 Mayoriacutea se resuelven sin secuelas
Tasa de mortalidad a 30 diacuteas 03
Complicaciones Menores 25 Complicaciones Mayores 7
Fiebre transitoria 321 Sepsis urinaria 03
Sangrado cliacutenicamente insignificante
76 Sangrado con intervencioacuten angiograacutefica
03
M Michel L Trojan J Rassweiler Complications in Percutaneous Nephrolithotomy European urology 51 ( 2007 ) 899ndash906
M Michel L Trojan J Rassweiler Complications in Percutaneous Nephrolithotomy European urology 51 ( 2007 ) 899ndash906
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele D Tolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
Sistema de Clavien Modificado
Dindo D Demartines N Clavien PA Classification of surgical complications a new proposal with evaluation in a cohort of a 6336 patients and results of a survey Ann Surg 2004240205ndash13
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Fuente de Complicaciones
Seleccioacuten del Paciente Falta de Equipo
Adecuado
Errores Teacutecnicos
Tasa de complicaciones hasta 83
Complicaciones tempranas 508 Mayoriacutea se resuelven sin secuelas
Tasa de mortalidad a 30 diacuteas 03
Complicaciones Menores 25 Complicaciones Mayores 7
Fiebre transitoria 321 Sepsis urinaria 03
Sangrado cliacutenicamente insignificante
76 Sangrado con intervencioacuten angiograacutefica
03
M Michel L Trojan J Rassweiler Complications in Percutaneous Nephrolithotomy European urology 51 ( 2007 ) 899ndash906
M Michel L Trojan J Rassweiler Complications in Percutaneous Nephrolithotomy European urology 51 ( 2007 ) 899ndash906
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele D Tolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
Sistema de Clavien Modificado
Dindo D Demartines N Clavien PA Classification of surgical complications a new proposal with evaluation in a cohort of a 6336 patients and results of a survey Ann Surg 2004240205ndash13
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Tasa de complicaciones hasta 83
Complicaciones tempranas 508 Mayoriacutea se resuelven sin secuelas
Tasa de mortalidad a 30 diacuteas 03
Complicaciones Menores 25 Complicaciones Mayores 7
Fiebre transitoria 321 Sepsis urinaria 03
Sangrado cliacutenicamente insignificante
76 Sangrado con intervencioacuten angiograacutefica
03
M Michel L Trojan J Rassweiler Complications in Percutaneous Nephrolithotomy European urology 51 ( 2007 ) 899ndash906
M Michel L Trojan J Rassweiler Complications in Percutaneous Nephrolithotomy European urology 51 ( 2007 ) 899ndash906
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele D Tolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
Sistema de Clavien Modificado
Dindo D Demartines N Clavien PA Classification of surgical complications a new proposal with evaluation in a cohort of a 6336 patients and results of a survey Ann Surg 2004240205ndash13
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
M Michel L Trojan J Rassweiler Complications in Percutaneous Nephrolithotomy European urology 51 ( 2007 ) 899ndash906
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele D Tolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
Sistema de Clavien Modificado
Dindo D Demartines N Clavien PA Classification of surgical complications a new proposal with evaluation in a cohort of a 6336 patients and results of a survey Ann Surg 2004240205ndash13
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele D Tolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
Sistema de Clavien Modificado
Dindo D Demartines N Clavien PA Classification of surgical complications a new proposal with evaluation in a cohort of a 6336 patients and results of a survey Ann Surg 2004240205ndash13
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Sistema de Clavien Modificado
Dindo D Demartines N Clavien PA Classification of surgical complications a new proposal with evaluation in a cohort of a 6336 patients and results of a survey Ann Surg 2004240205ndash13
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
A Tefekli M Karadag K Tepeler E Sari Y Berberoglu M Baykal O Sarilar A Yaser Classification of Percutaneous Nephrolithotomy Complications Using the Modified Clavien Grading System Looking for a Standard European urology 53 ( 2 0 0 8 ) 184ndash190
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
C Seitza M Desai A Hacker O Hakenberg E Liatsikos U Nagele Dtolley Incidence Prevention and Management of Complications Following Percutaneous Nephrolitholapaxy EUROPEAN UROLOGY 6 1 (2 01 2 ) 1 4 6 ndash 1 5 8
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
J De La Rosette D Assimos M Desai J Gutierrez J Lingeman R Scarpa A Tefekli The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study Indications Complications and Outcomes in 5803 Patients JOURNAL OF ENDOUROLOGY Volume 25 Number 1 January 2011
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Tiempo operatorio
Nuacutemero de accesos
Dilatacioacuten del tracto
Hemoglobina preoperatoria
Factores Variables
Ozden E Mercimek MN BostancıY Yakupoglu YK Yılmaz AF Sarıkaya S Ondokuz MayısUniversity Faculty of Medicine Dept of Urology Samsun Turkey Factors affecting success and complications in percutaneousnephrolithotomy A multivariate analysis of a 1117 procedures Eur Urol Suppl 201110(2)70
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Nefrolitotomiacutea Percutaacutenea
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
La seleccioacuten cuidadosa y preparacioacuten preoperatoria del paciente
es importante para disminuir las complicaciones
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Evaluacioacuten Diagnoacutestica
Definicioacuten del tamantildeo litiaacutesicobull Radiografiacutea abdomenbullUltrasonido renal
Anatomiacutea del sistema colectorbullUrografiacutea excretorabullUrotomografiacuteabull Pielograma retroacutegrado
Urianaacutelisis y urocultivo
Creatinina seacuterica pruebas de coagulacioacuten
Centelleo renal
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Contraindicaciones Preoperatorias
Coagulopatiacutea no tratada
Infeccioacuten de viacuteas urinarias no tratada
Interposicioacuten intestinal atiacutepica
Tumor en al aacuterea presuntiva de acceso al tracto
Tumor potencial renal maligno
Embarazo
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Comorbilidades Diabetes
Enfermedad pulmonar o cardiovascular
Mayor volumen litiaacutesico
Anomaliacutea renal Rintildeones en herradura
Malrotacioacuten renal
Factores de Riesgo
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Diabetes e hipertensioacuten
118 complicaciones mayores
28 veces maacutes comuacuten las complicaciones
uarr necesidad de meacutetodos auxiliares
Siacutendrome Metaboacutelico
Tefekli A Kurtoglu H Tepeler K et al Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy J Endourol 20082235ndash40
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
No diferencia significativa
Tiempo hospitalario y complicaciones
Tasa libre de litiasis
Obesidad
Bagrodia A Gupta A Raman JD Bensalah K Pearle MS LotanY Impact of body mass index on cost and clinicaloutcomes after percutaneous nephrostolithotomy Urology 2008 Oct72(4)756-60Alyami FA Skinner TA Norman RW Impact of body mass index on clinical outcomes associated with percutaneousnephrolithotomy Can Urol Assoc J 2012 May 151-5Tomaszewski JJ Smaldone MC SchusterT Jackman SV AverchTD Outcomes of percutaneous nephrolithotomystratified by body mass index J Endourol 2010 Apr24(4)547-50
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
No se asocia a mayor morbilidad ni menor eficacia
Mayor tiempo quiruacutergico
Dificultad de dilatacioacuten por cicatrizacioacuten retroperitoneal
Mayor porcentaje de procedimientos auxiliares
Mayores intentos de acceso
Margel D Lifshitz DA Kugel V Dorfmann D Lask D Livine PM Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy J Endourol 2005101ndash4Gupta R Gupta A Singh G Suri A Mohan SK Gupta CL PCNL--A comparative study in nonoperated and in previously operated (open nephrolithotomypyelolithotomy) patients--a single-surgeon experience Int Braz J Urol 2011 Nov-Dec37(6)739-44
Cirugiacutea Previa Renal
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Nefrolitotomiacutea Percutaacutenea
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Complicaciones muacutesculo-esqueleacutetica rarr Cuidadoso relleno de soporte Cabeza neutral sin extensioacuten
Plexopatiacutea braquial No abducir hombros y codo gt 90deg
Lesioacuten por compresioacuten de nervios perifeacutericos Elevar tobillos
Posicioacuten del Paciente
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Punta con faceta de corte
Visualizacioacuten con ultrasonido
Cubierta de silicona flexible
Manipulacioacuten maacutes faacutecil al insertar la guiacutea
Tipo de Aguja y Cubierta
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Revisar dilatadores pinzas y nefroscopio
Funcionabilidad de litotriptores Disponible al menos 2
modalidades (ultrasoacutenico baliacutestica laacuteser)
Instrumentos
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Nefrolitotomiacutea Percutaacutenea
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Guiado por ultrasonido fluoroscopia
Determinar eje renal
Puncioacuten de Sistemas Colectores
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Eleccioacuten del caacuteliz para manipulacioacuten litiaacutesica oacuteptima
Abordaje subcostal vs supracostal
Puncioacuten de Sistemas Colectores
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Evitar perforacioacuten de pelvis renal (hasta 72)
Preferible guiacutea J Punta suave
Nuacutecleo interno
Incisioacuten paralela de fascia
Colocacioacuten de Guiacutea
Kim SC Kuo RL Lingeman JE Percutaneous nephrolithotomy an update Curr Opin Urol 200313235ndash41
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Sangrado del pareacutenquima renal
Lesioacuten a oacuterganos Pleura
Colon
Sepsis urinaria
Extravasacioacuten y absorcioacuten de fluido
Relacionadas al acceso
Relacionadas a Remocioacuten Litiaacutesica
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Nefrolitotomiacutea Percutaacutenea
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
El paso de mayor dificultad es la habilidad de obtener un acceso apropiado
Watterson JD Soon S Jana K Access related complications during percutaneous nephrolithotomy urology versus radiology at a single academic institution J Urol 2006176142ndash5
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Complicacioacuten maacutes comuacuten
Requerimiento de transfusioacuten 05-4 nefrostomiacutea vs 6-20 nefrolitotomiacutea
Fuente tracto Acceso litiaacutesico directo dilatacioacuten con baloacuten
Angulacioacuten miacutenima del sistema de dilatacioacuten y cubierta del nefroscopio Instrumentacioacuten flexible
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Factores de Sangrado del Pareacutenquima Renal
Caracteriacutesticas del pacientebull anemia preoperatoriabull diabetes
Muacuteltiples sitios de acceso
Acceso supracostal
Incremento del tamantildeo del tracto
Dilatacioacuten del tracto con otros meacutetodos que el baloacuten
Tiempo operatorio prolongado
Perforacioacuten de pelvis renal
Stoller ML Wolf JS Jr St Lezin MA Estimated blood loss and transfusion rates associated with percutaneousnephrolithotomy J Urol 1994 Dec152(6 Pt 1)1977-81Turna B Nazli O Demiryoguran S Mammadov R Cal C Percutaneous nephrolithotomy variables that influence hemorrhage Urology 2007 Apr69(4)603-7
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
A Yamaguchi A Skolarikos N Noor Buchholz G Chomoacuten M Grasso P Saba S Nakada J de la Rosette Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study JOURNAL OF ENDOUROLOGY Volume 25 Number 6 June 2011
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Peacuterdida de visioacuten por sangrado transoperatoriohellip
Mandatorio culminar procedimiento
Ocluir nefrostomiacutea por 30-60 min Mantener sistema colector libre de coaacutegulos
Persistencia del sangrado rarr angiografiacutea renal con embolizacioacuten selectiva
Re-intervencioacuten en 48 h
Sangrado del Pareacutenquima Renal
Patel RD Newland C Rees Y Major complications after percutaneous nephrostomymdashlessons from a department audit Clin Radiol 200459766ndash9
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Sangrado del Pareacutenquima Renal
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Hemostasis Transoperatorio rarr tamponamiento por camisa de acceso
Postoperatorio rarr colapso del pareacutenquima renal
Tubo de nefrostomiacutea no contribuye a hemostasis No diferencia entre dejarle tubo 8-18 Fr vs 20-28 Fr
No hay mayor sangrado si es omitido
Sangrado del Pareacutenquima Renal
Marcovich R Jacobson AI Singh J Shah D El-Hakim A Lee BR Smith AD No panacea for drainage after percutaneous nephrolithotomy J Endourol 2004 Oct18(8)743-7Istanbulluoglu MO CicekT Ozturk B Gonen M Ozkardes H Percutaneous nephrolithotomy nephrostomy or tubeless or totally tubeless Urology 2010 May75(5)1043-6 Epub 2009 Oct 24
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Baloacuten de tamponamiento de nefrostomiacutea Kaye
Sangrado del Pareacutenquima Renal
Kaye KW Clayman RV Tamponade nephrostomy catheter for percutaneous nephrostolithotomy Urology 1986 May27(5)441-5
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Empaque de gelatina absorbible en el tracto
Sangrado del Pareacutenquima Renal
Nagele U Anastasiadis AG Schilling DA Sievert KD Kuczyk MA Stenzl A Introducing a new sealant applicator for easy safe and quick closure of a mini-percutaneous nephrolitholapaxy access tract J Endourol 2007 Apr21(4)393-6Millard WW 2nd Jellison FC Tenggardjaja C Ebrahimi KY Baldwin DD Hemostatic sandwich to control percutaneousnephrolithotomy tract bleeding J Endourol 2010 Sep24(9)1415-9
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Sangrado del Pareacutenquima Renal
Shaw G WahTM Kellett MJ Choong SK Management of renal-vein perforation during a challenging percutaneousnephrolithotomy J Endourol 2005 Jul-Aug19(6)722-3
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Sangrado tardiacuteo 1
darr Hcto con orina clara 41 2-7 diacuteas y 35 gt 7 diacuteas postoperatorias
Por lesioacuten vascular Pseudoaneurisma arterial rarr sangrado intermitente
Fiacutestula arterio-venosa rarr sangrado continuo
Angiografiacutea diagnoacutestica 90 08 requieren tratamiento angioembolizacioacuten selectiva (tasa de eacutexito 94)
Sangrado del Pareacutenquima Renal
Kessaris DN Bellman GC Pardalidis NP Smith AG Management of hemorrhage after percutaneous renal surgery J Urol 1995 Mar153(3 Pt 1)604-8
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Sangrado del Pareacutenquima Renal
Srivastava A Singh KJ Suri A Vascular complications after percutaneous nephrolithotomy are there any predictive factors Urology 20056638ndash40Richstone L Reggio E Ost MC Seideman C Fossett LK Okeke Z Rastinehad AR Lobko I Siegel DN Smith AD Hemorrhage following percutaneous renal surgery characterization of angiographic findings J Endourol 2008 Jun22(6)1129-35
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Laceraciones del infundiacutebulo
Lesiones ureterales
Perforacioacuten pelvis renal Tubo de nefrostomiacutea + cateacuteter
ureteral interno
Nefrostograma y retiro de tubo de nefrostomiacutea 2-7 diacuteas
Lesioacuten del Sistema Colector
Ghai B Dureja GP Arvind P Massive intraabdominal extravasation of fluid a life threatening complicationfollowing percutaneous nephrolithotomy Int Urol Nephrol 200335(3)315-8
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Totalmente sin tubo vs tubo de nefrostomiacutea
Menor estadia hospitalaria
Menor uso de analgeacutesicos
No hay mayor tasa de complicaciones
No diferencia significativa de sangrado
Tubo de Nefrostomiacutea
Aghamir SM Modaresi SS Aloosh M Tajik A Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access J Endourol 201125583ndash6Istanbulluoglu MO Ozturk B Gonen M CicekT Ozkardes H Effectiveness of totally tubeless percutaneousnephrolithotomy in selected patients a prospective randomized study Int Urol Nephrol 200941541ndash5Zilberman DE Lipkin ME de la Rosette JJ et al Tubeless percutaneous nephrolithotomymdashthe new standard of care J Urol 20101841261ndash6
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
uarr riesgo 10 puncioacuten por arriba costilla 12ordf 05 abajo costilla 12ordf
46 arriba costilla 12ordf
246 arriba costilla 11ordf
Hidrotoacuterax pneumotoacuterax Tubo pleural si es grande yo compromiso
respiratorio presente
Rx toacuterax postoperatoria en acceso renal percutaacuteneo supracostal
Lesioacuten de Pleura
Lojanapiwat B Prasopsuk S Upper-pole access for percutaneous nephrolithotomy comparison of supracostal and infracostalapproaches J Endourol 2006 Jul20(7)491-4Yadav R Aron M Gupta NP Hemal AK Seth A Kolla SB Safety of supracostal punctures for percutaneous renal surgery Int J Urol 2006 Oct13(10)1267-70
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Incidencia 05 en decuacutebito prono similar al supino
Colon retrorenal 19 decuacutebito supino vs 10 decuacutebito prono
Manifestaciones postoperatorias Fiebre iacuteleo prolongado leucocitosis hematoquezia
fecalurianeumaturia (fiacutestula nefrocoloacutenica)
Lesioacuten de Colon
Wu P Wang L Wang K Supine versus prone position in percutaneous nephrolithotomy for kidney calculi a meta-analysis Int Urol Nephrol 20114367ndash77Liu L Zheng S XuY Wei Q Systematic review and meta-analysis of percutaneous nephrolithotomy for patients in the supine versus prone position J Endourol 2010241941ndash6
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
El-Nahas AR Shokeir AA El-Assmy AM et al Colonic perforation during percutaneous nephrolithotomy study of risk factors Urology 200667937ndash41
Factores de Lesioacuten del Colon
Acceso renal percutaacuteneo izquierdo a polo inferior
Rintildeoacuten en herradura
Edad avanzada
Colon dilatado
Pared abdominal delgada
Cirugiacutea abdominal previa
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Lesioacuten de Colon
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Tratamiento Extraperitoneal rarr Conservador
Drenaje pronto y separado del colon y sistema colector
Antibioacuteticos
NPO 3 diacuteas postoperatorias
Intraperitoneal o extraperitoneal con sepsisabdominalperitonitisrarr Quiruacutergico Rafia primaria
Gerspach JM Bellman GC Stoller ML Fugelso P Conservative management of colon injury following percutaneous renal surgery Urology 199749831ndash6Korkes F Lopes Neto AC Lucio J 2nd Bezerra CA Wroklawski ER Management of colon injury after percutaneous renal surgery J Endourol 2009 Apr23(4)569-73
Lesioacuten de Colon
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Nefrolitotomiacutea Percutaacutenea
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
15-30 cursan con fiebre postoperatoria Mayoriacutea no presentan infeccioacuten
Cursan con sepsis 1-2
Mandatorio Antibioacuteticos profilaacutecticos
Pionefrosis rarr suspender cirugiacutea y drenar con tubo de nefrostomiacutea Pus franca vs orina turbia
Sepsis Urinaria
Eisenberger F Miller K Rassweiler J editors Stone therapy in urology New York Thieme Medical Publishers 1991DoganHS SahinACetinkayaYAkdoganBOzdenEKendi S Antibiotic prophylaxis in percutaneous nephrolithotomy prospective study in 81 patients J Endourol 200216649ndash53Aron M Goel R Gupta NP Seth A Incidental detection of purulent fluid in kidney at percutaneous nephrolithotomyfor branched renal calculi J Endourol 2005 Mar19(2)136-9
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Takeuchi H Ueda M Nonomura M et al Fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy Hinyokika Kiyo 1987331357ndash63Rao PN Dube DA Weightman NC Oppenheim BA Morris J Prediction of septicemia following endourologicalmanipulation for stones in the upper urinary tract J Urol 1991 Oct146(4)955-60Troxel SA Low RK Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever J Urol 2002 Oct168(4 Pt 1)1348-51
Factores de Fiebre Postoperatoria
Tamantildeo ge 20 mm e infeccioacuten litiaacutesica
Infeccioacuten de viacuteas urinarias preoperatoria
Hidronefrosis
Cateacuteter ureteral interno o tubo de nefrostomiacutea
Tiempo quiruacutergico gt 90 min
Presioacuten gt 30 mmHg en sistema colector
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
POSITIVOS SIRS (+) SIRS (-) RROR
Urocultivopreoperatorio
661 104 495
Cultivo de orina de pelvis
464 35
Cultivo del lito 48-2 35 364
Lojanapiwat B Kitirattrakarn P Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy Urol Int 201186448ndash52Mariappan P Smith G Bariol SV Moussa SA Tolley DA Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy a prospective clinical study J Urol 20051731610ndash4
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Fuente maacutes comuacuten perforacioacuten del sistema colector
Prevencioacuten Manipulacioacuten bajo control fluroscoacutepico o endoscoacutepico
Sistema de irrigacioacuten abierta o continua 28 absorcioacuten gt 1 L
Solucioacuten salina normal como irrigante Agua rarr hemoacutelisis intravascular
Extravasacioacuten y Absorcioacuten de Fluidos
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Suspender procedimiento si entradasalida del fluido gt 500 ml Monitorizacioacuten de electrolitos
Dolor en flanco y signos de infeccioacuten a pesar de antibioacuteticos
Drenaje percutaacuteneo del urinoma y del sistema colector Colocacioacuten del cateacuteter ureteral interno JJ
Extravasacioacuten y Absorcioacuten de Fluidos
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
No significativo estimada 16 Menor dantildeo que litotripsia extracorpoacuterea con ondas de choque
Sin cambio en rintildeones solitarios
No desarrolla insuficiencia renal ni hipertensioacuten
Peacuterdida de funcioacuten renal
Kumar S Sandeep Ganesamoni R Mandal AK Efficacy and outcome of percutaneous nephrolithotomy in patients withcalculus nephropathy Urol Res 2011 Apr39(2)111-5Saxby MF SorahanT Slaney P Coppinger SW A case-control study of percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy Br J Urol 1997 Mar79(3)317-23Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease J Endourol 2008 May22(5)895-900Chatham JR DykesTE Kennon WG Schwartz BF Effect of percutaneous nephrolithotomy on differential renal functionas measured by mercaptoacetyl triglycine nuclear renography Urology 2002 Apr59(4)522-5
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
TFG lt 60 mlmin se evidencioacute beneficio postoperatorio
25 estadio III
50 estadio IV
Mayor incremento en estadio V
Peacuterdida renal aguda o progresioacuten a enfermedad renal terminal al antildeo es raro
Peacuterdida de funcioacuten renal
Bilen CY Inci K Kocak B Tan B Sarikaya S Sahin A Impact of percutaneous nephrolithotomy on estimated glomerularfiltration rate in patients with chronic kidney disease J Endourol 200822895ndash900Canes D Hegarty NJ Kamoi K et al Functional outcomes following percutaneous surgery in the solitary kidney J Urol2009181 154ndash60
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Importantes Factores de Prevencioacuten
Evaluacioacuten preoperatoria radioloacutegica y ultrasonograacutefica
Puncioacuten oacuteptima a traveacutes del caacuteliz
Control ultrasonograacutefico si es posible
Dilatacioacuten atraumaacutetica bajo control continuo fluoroscoacutepico
Miacutenima angulacioacuten del nefroscopio
Uso de nefroscopio flexible para litos en colectores superiores
Saber cuaacutendo detenerse y cuaacutendo reintervenir
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
Conocer los factores para prevenir complicaciones
Entrenamiento y experiencia Cada paso es importante
Cuidadosa seleccioacuten de pacientes posicioacuten precisa y uso de mejores instrumentos disponibles
1
2
3
4 Pronto reconocimiento y manejo de complicaciones para minimizar morbilidad
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