Introduction

Due to its increasing frequency, lithiasis is a major health problem. The

treatment of this pathology is explored in detail in most countries of the world.
Managing complicated forms of lithiasis is a particular difficulty due to its negative
influence on kidney function. Percutaneous nephrolithotomy has been shown to be
the most rational method in their treatment, thanks to multiple benefits.

Actuality of the research topic

Statistical information indicates that urinary lithiasis is second in the top of

urologica disases. Globally, is observet at 1-5% of the population, occupying 3-22%
of all kidney-related diseases. In our country urolithiasis is the first in the top of
urological pathologies, with an increase of 0.1-0.5% and prevails to about 10% of the
total population.

Aim of study

The research of contemporary strategies in the treatment of urolithiasis, with a

detailed study of the method of percutaneous nephrolithotomy (NLP), as well as the
evaluation of the advantages of the given method compared to the use of open
surgery.

Materials and research methods

This paper was created at the Department of Urology and Surgical Nephrology.
116 bibliographic sources relevant for the given topic were selected for the study and
the purpose of the given paper.
The theoretical form of the work was done in accordance with the provisions of
the National Clinical Protocol "Urolithiasis of adult", and also based on the
guidelines: AUA (American Urological Association) and EAU (European
Association of Urology). Articles from the HINARI, EMBASE, PubMed data
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networks have been studied. Also abstracts from the international conferences on the
subject.
Keywords: lithiasis, percutaneous nephrolithotomy, urolithiasis

Background

General information about urolithiasis

Urolithiasis is a urological disease, which is described by the presence of

stones in different compartments of the uropoetic system. The disease occurs as a
consequence of the action of some exogenous, endogenous factors in certain genetic
disorders that cause metabolic changes at the tissue level along with the increase of a
series of litogenic substances in the blood. These in turn lead to an excessive
excretion of the substances in the urine, altering its physicochemical and biological
characteristics, facilitating stonegenesis.

Lithiasis in complicated form includes: massive stones (larger than 2 cm);

coraliform stones, calicidal stones; ugly lithiasis; single or anomalous kidney stones.
Coraliform lithiasis, as defined, are branched stones that occupy a significant part of
the renal collector system. The given type of stones is more common to females.

General information on the treatment of lithiasis

Contemporary intervention therapy for urolithiasis consists of the following

therapeutic alternatives: non-invasive methods (extracorporeal shock wave lithotripsy
- ESLW); minimal invasive methods, endoscopic (NLP) and open surgery.

Choosing the correct method is very important and must take into account the
following: ensuring non-invasiveness or minimal invasiveness, complete elimination
of calculus (free stone rate); few complications; etc. to ensure maximum functional
rehabilitation of the diseased kidney.

The use of NLP methodology is favored because it has a much higher rate of
stone removal, and it has a reduced invasiveness compared to "classic" surgery.

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 Using the endoscope the whole stones can be extracted or after an in situ
fragmentation by a series of disintegration methods: laser, electrohydraulic,
electromechanical, ultrasound, ballistic.

Patient preparation

Patient preparation determines postoperative evolution. Urological researches

are conducted with the aim of receiving detailed information about renal stones and
of observing their actions on the urinary system; the presence or absence of infection
associated with lithiasis. Investigation of patients is performed using the whole
diagnostic imaging arsenal, which includes: simple reno-bladder radiography,
ultrasound, computed tomography, intravenous urography. They show the presence
and location of the stones; determines the shape, structure and spatial orientation of
the pyelocaliceal system. Ultrasound allows to highlight the morphological changes
occurring in organ architecture, caused by chronic renal failure or acute renal failure.

The intervention is performed under the peridural or spinal conduction

anesthesia with a duration of about one hour. In order to avoid the occurrence of
infectious complications, with premedication, a broad spectrum antibiotic is
administered and a diuretic. On the operating table, the patient is positioned in the
precut position because the kidney approach is performed in the posterior lumbar
spine in order to prevent abdominal organ damage .

Concrete steps of the intervention

1. Assembling the ureteral catheter for the purpose of the opacification of the pelvic-
limb complex and the formation of the percutaneous nephrostomy tract, as well as
the purpose of stopping the migration of the primitive fragments as a consequence
of the lithotrisis and finally the retrograde lavage with saline to eliminate the clots
potential.

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2. Percutaneous puncture of a posterior calicillus with a needle for puncture on the
posterior axillary line under the top of the XIIth rib.
3. Achieve a 1 cm incision in the skin at the point where the needle was inserted.
4. Pre-dilatation with Teflon dilators on the percutaneous nephrostomy tract,
followed by gentle, telescopic metal dilator (Alken) or dilatator type (Amplatz)
up to 24 hours.
5. The insertion of the external cord of the nephroscope on the last dilator and then
the extraction of the telescopic dilators together with the guide, while maintaining
the outer nephroscope sheath and inserting the inner sheath with the telescope 0.
The external sheath together with the inner one separates a space, making it
possible to make the liquid circuit washing.
6. Nephroscopy of orientation followed by lithotripsy and extraction of resulting
fragments of calculation.

NLP guidelines
 large volume of stone in the basin (over 2.5-3 cm) / multiple lithiasis located in
the basin;
 coraliform stone, treatment alone or in combination with ESWL;
 old anclavic stone in the ureteral pituitary-ureteral junction with urographic
kidney;
 unique single kidney lithiasis or multiple kidney ligation secondary to congenital
or acquired stenosis of the pielo-ureteral junction, impossible to address with
ESWL;
 kidney like horseshoe, unique kidneys;
 extraction of outstanding stones after open surgery or ESWL;
 stones of patients with certain professions (sailors, cosmonauts, pilots).

Contraindications of NLP
 Absolute - excessive obesity; clotting disorders; sick comatose; pregnancy.

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 Relative - kidney abnormalities or skeleton (which complicate or even make
intervention impossible); decompensated diabetes mellitus; active duodenal ulcer;
cardiovascular or hepatic disorders that make anticoagulant treatment impossible;
uncontrolled HTA; specific and non-specific urinary infections.
Potential complications of NLP
 Intraoperative: perforation of the renal collector system, loss of the
nephrostomy tract, pneumothorax / hydrotorax, adjacent organ lesions,
haemorrhage, infectious complications, perineal fluid collections, hematuria.
 Postoperative: infection of the wound; urinary fistula; bleeding; urethral
obstruction through migrated fragments that cause the progression of renal
insufficiency; lithiasis recurrence; febrile syndrome.

Indicators on the effectiveness of NLP treatment of urolithiasis

To evaluate the efficacy of treatment, AUA has proposed a set of indicators:

 the average of the number of procedures that the patient is under the given
treatment method;
 proportion of patients with stone-free rate;
 the proportion of patients who develop acute complications following the
application of the complication rate. The worst indicator in the complication
group is lethality.
 Blood transfusions are also concomitantly counted;
 the main indicator in evaluating the effectiveness of the method is the "stone free"
index.

Research and results

The effectiveness of NLP does not depend on the number of nephrostomy tracts

Rana A. M. et al. reported 48 cases of urolithiasis treated with NLP. Complete

clearance was performed to 39 patients after one session of NLP. Three patients had
several nephrostomic tracts. 7 patients were treated later with ESWL due to the
presence of residual stones.
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 Treatment of kidney lithiasis with the horseshoe form

Raj G.V. et al., on a sample of 37 cases of lithiasis with the horseshoe form
with treated by percutaneous nephrolithotomy, reported a "stone-free" rate of 87.5%
of cases.

Treatment of polycystosis with renal lithiasis

Zhang J. et al. analyzed 11 cases of renal lymphocytosis, all treated by NLP.

Statistical data noted that NLP had no impact on perioperative renal function (p>
0.05).

Treatment of coraliform lithiasis

Blandy J.P. et al. presents the results of the treatment of two groups of patients
with coraliform lithiasis. The first group was treated to the conservative method. The
second group underwent surgical removal of renal calculus. At 10 years of active
surveillance in the first group, the mortality rate was 28%, compared with 7.2% in the
second group. At the same time, 27% of the first group of patients developed
complications, life-threatening.

Treatment of single kidney lithiasis

Akman T. et al. reported treatment of 47 single kidney patients with

percutaneous nephrolithotomy. NLP efficiency in one session was 84.5%, and 97.7%
after several sessions. Different complications occurred in only 5 of the cases.
The Wang Y et al. study is based on 18 cases with single kidney lithiasis. In 12
cases, percutaneous nephrolithotomy resulting after the first session, a total
elimination rate of 91.7%, and the other 6 being 83.3%.

Treatment of coraliform lithiasis on the unique kidney

Resorlu B. et al. presents the results of the treatment of 16 cases of coraliform

lithiasis of uniques kidneys by NLP. 81.3% of the stones were completely eliminated
from the first intervention, and for the remainder due to residual fragments, it was
necessary to perform repeated interventions of NLP combined with ESWL.
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 Treatment of transplanted kidney lithiasis

Mahdavi R. et al. analyzed 1800 cases of transplanted kidney, 21 of which had

lithiasis disease. Percutaneous nephrolithotomy benefited 2 patients, transurethral
lithotripsy - 9 patients and ESWL - 10 patients. Treatment outcomes were "stone
free" in 7 out of 10 patients treated with ESWL (70%), 8 out of 9 patients treated with
transurethral lithotripsy (89%) and 2 out of 2 patients who were treated with NLP
(100% rate).

Patients with diabetes

Duvdevani M. et al. analyzed 1338 cases of NLP, of which 183 patients were
diabetic. The results of the research showed that: the duration of the intervention
(90.8 minutes) and the complications (major 2.2%), the intervention interval (90.8
minutes) and the complications (major 2.2%) and the "stone free" (94,5%).

Patients with spine deformities

Following the treatment of 16 patients with deformities of the spine, lithiasis

patients, Izol V. et al. reported 13 (81.2%) cases stones were completely eliminated.

Positioning the patient on the abdomen

Lucarelli G. et al. compared NLP results of coraliform lithiasis patients,

correlated with the patient's position during surgery: lying on the back or abdomen.
From the research, the authors concluded that both positions are described by the
similar success of surgery, but patient positioning on the back during operative
procedure provides retrograde and anterograde access to the urinary tract with lower
anesthetic risk.
La Rosa P. and Di Grazia E. came to the same conclusion.

The success rate of NLP is independent of the body weight of the patient

Torrecilla Ortiz, C., et al., Analyzed 255 cases to evaluate the influence of
obesity on the outcome of NLP treatment. Statistically significant differences were
not observed between the four groups in terms of the rate of postoperative

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complications and the complete elimination rate of the calculation. The complication
rate was 31.4% and the average elimination rate of stones was 76.3%.

Treatment of coraliform lithiasis of children

Veeratterapillay R. et al., on a 32-case study, demonstrated that the disease can

be completely treated through a single percutaneous nephrectomy tract of 75% of
patients.
Wang F. et al. reported the results of mini-PCNL extraction, of 247 units of
stones in 234 cases of kidney lithiasis of children.

Treatment of elderly patients

Okeke Z. et al. compared patients aged below 70 years and above 70 years
treated by percutaneous nephrolithotomy, and observed that on older patients, intra
and postoperative complications were more frequent, and the hospitalization interval
was prolonged.
Nakamon T. et al. analyzed 446 cases of NLP-treated kidney lithiasis of the
patients sorted by age. The success rate was 85.24% and 86.24% in groups I and II,
respectively.

NLP provides results of complete elimination of stones better than using

classical surgical operations

Bryniarski P. et al. studied two groups of patients with large stones treated in
the first group by percutaneous nephrolithotomy and in the second group with
retrorenal intrarenal intervention. The severity of postoperative pain was significantly
lower in NLP interventions.
Al-Kohlany K.M. et al. conducted a randomized study to compare the results
obtained from percutaneous nephrolithotomy treatment to open surgery treatment.
Intraoperative complications were recorded in 7 cases treated with NLP and 17 in the
open-surgery group. Major postoperative complications were seen in 14 in the open
surgery group and 68 in the group (PCNL).

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 Long-term results

In several publications, the percentage of relapse after NLP was 1.24%, with a
follow-up average of 1 year. In other studies - the probability of recurrence of
coraliform stones in the first 12 months is 10%, and in 5 years - 50%. Most authors
recommend that a complex of preventive measures be taken after the intervention to
prevent the reappearance of renal stones.

Effectiveness of NLP treatment

Percutaneous nephrolithotomy allows direct visualization of the stones, making

it almost always possible for complete removal or possible lice fragments. Similarly,
the short period of hospitalization is up to 5 days. The use of the NLP method in the
treatment of complex forms of lithiasis reaches 80.5%, according to a survey
conducted by US urologists. This is due, in addition to complete elimination of the
stones and a fairly high indicator of renal function rehabilitation.
By practicing NLP, complete elimination of stones in one stage is possible up
to 70-75%, and after secondary nephroscopy or in combination with ESWL, up to 95-
99%, but with minimal trauma to classical surgery.
In order to minimize risk factors and achieve better results, systemic and
anatomical preoperative assessments are required. Anesthetic and surgical planning is
crucial to achieving intervention with low morbidity and high success rates.

Conclusions

 In the active surgical treatment of multiple complex forms of lithiasis NLP is

the basic method, by: reducing the duration of hospitalization and morbidity;
minimal trauma and a low rate of complications.
 In order for the intervention to be successful, preoperatively, an imaging,
clinical and complex laboratory of the patient is performed.
 Both AUA recommendations and EAU have identified 3 main methods of
treatment of renal lithiasis: percutaneous nephrolithotomy; extracorporeal
shock wave lithotripsy and open classical surgery. They recommend the NLP
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 method as the first choice surgical method for complex kidney lithiasis.
Combined treatments are also useful.
The NLP method is appreciated due to its extensive use in lithiasis: in the case
of multiple kidney abnormalities; for coraliform stones or bulky stones; in
compensated diabetes; in the case of spine deformities; including elders and children.
Percutaneous nephrolithiasis provides an elimination of urinary lithiasis,
similar to open surgery, but with a much lower incidence of complications.
Performing preoperative urological investigations, prudent patient selection
based on the NLP method's indications and contraindications, as well as observing
the methodology of applying the method, are key factors in the success of the
intervention.

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