IntroductionPercutaneous nephrolithotomy (PNL) is used to treat the large or complexcalculi (1). Following Fernstrom and Johansson has been reported the extractionof renal calculus through a nephrostomy tract (2), the operation techniques showeddevelopment with increasing success rate and decreasing complication andmortality (3).
There is a considerable debate about the anesthesia technique for PNL.Although regional anesthesia gradually gains popularity, the procedure isusually performed under general anesthesia which provides safety in patient’sairway during prone position and tidal volume control during the puncture tominimize pleural injury. It also maintains patient and surgeon comfort inprolonged anesthesia duration and facilitates the removal of large stones (4).Our hospital is a referral center for urinary stones and PNL operationshave been performed for a long time period with a high success rate. The primarygoal of this study was to document the PNL operations and evaluate theperioperative management of these patients in anesthesiologist perspective. Materials and MethodThe study group was composed of patients admitted to our hospital forurinary stones and scheduled for PNL between 2015 and 2017.
Routinepreoperative evaluation included total blood count, coagulation, renal andhepatic function tests, chest x-ray and electrocardiogram was performed byanesthesiologists and additional assessment was needed if any pathologicfinding was detected. A written informed consent was obtained from allpatients.After premedication with 0.
01-0.02 mg/kg midazolam and 1-2 µg/kg fentanyl,anesthesia was induced by 5-7 mg/kg thiopental sodium or 2-3 mg/kg propofol.Neuromuscular relaxation was provided by 0.
6 mg/kg rocuronium in all patientsand following endotracheal intubation, mechanical ventilation with tidal volumeof 8-10 ml/kg and a respiratory rate adjusted to normocapnia was conducted.Anesthesia maintenance was provided by sevoflurane or desflurane in 60% O2-airmixture. All patients were routed with 18-gauge peripheral venous line andinfused crystalloid solutions based on 4/2/1 rule. All procedures were carriedout in the prone position.Standard monitoring including continuous electrocardiogram, pulseoxymetry and end-tidal CO2 was applied to all patients. Right or left radialartery cannula was inserted for monitoring invasive blood pressure and bloodsampling during the intraoperative period. PNL was performed as a standard procedure. The kidney was punctured underfluoroscopic guidance………Data was collected in 3 steps and recorded to pre-prepared forms.
Firstlywe searched the hospital electronic database to find the patients having PNL operation.After that, we reviewed the patients’ anesthesia records to extract the dataincluding age, gender, ASA physical status, duration of operation, bloodtransfusion requirements and any adverse situation during the intraoperativeperiod. On the last step, patients’ hemoglobin levels, the total amount ofblood transfused, duration of hospitalization and stone characteristics wererecorded from the hospital electronic database.
The study protocol was by Scientific Research Ethics Committee of our hospitaland conducted according to ethical principles outlined in the Helsinki Declaration. Statistical analysis……. DISCUSSIONRecently, a large number of studies about the effect of anesthesia typeon the PNL were taken attention. Regional anesthesia was firstly reported byBallestrazzi et al (5) in 112 patients who underwent PNL with epiduralanesthesia in 88% satisfactory result. In a randomized controlled trialcomparing the efficacy of general and regional anesthesia intraoperative hemodynamicswas found comparable in both groups where as visual analog score (VAS) andanalgesic requirement were comparatively less in regional group (6). Kuzgunbayet al indicated that there was no significant difference regarding operationtime, amount of irrigation fluids, intraoperative complications, hemoglobinlevels and hospital stay between general and combined spinal-epiduralanesthesia (7). It’s also suggested that because of maintenance of betterhemodynamic state and disposing of the complications of general anesthesia,spinal anesthesia might be a better choice (8). In ourgeneral anesthesia series, no complication related with general anesthesia wasencountered_________________In literature, the most emphasized point of regional anesthesia is thedecreasing in analgesic requirements.
On the other hand, Mehrabi et alindicated that this advantageous was valid in a short time period and on the 2ndday of operation there was no significant difference between general andregional anesthesia(9). We used multimodal analgesiawith paracetamol and tramadol for postoperative pain.Predictable and unpredictable complications of PNL includes hemorrhage,injuries of collecting system, technical complications, hypothermia, fluidoverload, sepsis, stricture formation, nephrocutaneous fistula, renal damageand even death(10-12).
These complications are divided into two as major andminor complications. Pain (49%),fever (30%), urinary tract infections (11%) andrenal colic (4%) was reported as minor, septicemia (4.1%), and severehemorrhage (2.7%) was reported as major complications (13). Lee et al. reported12%of transfusion rate in 500 PNL patients as the most frequent complication(14). This rate was reported as high as 23.
8% (10). In case of excessivebleeding, clamping of nephrostomy tube,placement of larger nephrostomy tubes orballoon tamponade may be necessary (15). In some conditions, angiographicembolization may be a treatment of choice (16). In ourstudy transfusion rate was_________________In all comparative studies between general and regional anesthesia,mostly emphasized issue is the hazards of general anesthesia in the proneposition. These are accidental extubation, kinking of the endotracheal tube,torsion of the neck veins leading to fascial or ocular edema, ecchymosis andperipheral nerve injuries on pressure points (4). Prone position has beenwidely used in a variety of surgical procedures and possible complications werewell defined (17, 18). Due to abdominal muscle paralysis during general anesthesia,functional residual capacity and arterial partial pressure of oxygen areincreased, in contrast chest wall and lung compliance remain unchanged.
This physiologicalrespiratory change may be advantageous in many conditions (19-20). Allprocedures were conducted in prone position in our patients and no positionrelated complication was recorded.Anesthetics affect thermoregulation and this is an underestimated issue.During general anesthesia hypothermia develops in three phases. Rapid heat lossdevelops within first hour (Phase I). Heat loss exceeds the production in PhaseII after 2-4 hours. In third phase named thermal steady state occurs after 3-4hours and peripheral vasoconstriction is triggered (21, 22).
Thermoregulationis also affected during regional anesthesia. Because of the disruption ofthermal input in the blocked region, patient can’t distinguish warm or cold.Supplementation of sedatives or analgesics makes the hypothermic conditionworse (22). Due to large amount of irrigation fluid used during procedure bodycore temperature may decrease more than expected. Hypothermia is a limitationof our study. Because of the missing data statistical analysis could not be conducted.
Further studies about hypothermia during PNL mayprovide more definite data. There is predictable and unpredictable complications of PNL such ashemorrhage, collecting system injuries, contiguous organ injuries, technicalcomplications, hypothermia, fluid overload, sepsis, stricture formation,nephrocutaneous fistula, renal damage and even death (x,xx,xxx). Thesecomplications are divided as major or minor complications. Havel et alindicated pain (49%), fever (30%), urinary tract infections (11%), renal colic(4%) as minor complications. Most important major complication was reported asseprticemia (4.1%) and severe hemorrhage (2.7%) (xxxx). In literature, transfusionrate in PNL patient represents variability.
Lee et all reported 12% transfusionrate in 500 PNL patients as most frequent complication (5x). This ratio was ashigh as 23.8% (x). Excessive bleeding may require additional maneuvers such asplacement of larger nephrostomy tube, nephrostomy tube clamping, hydration andballoon tamponade (6x).
In some conditions, angiographic embolization may benecessary (7x).