Elsevier

European Urology

Volume 61, Issue 6, June 2012, Pages 1188-1193
European Urology

Platinum Priority – Stone Disease
Editorial by Jean de la Rosette on pp. 1194–1195 of this issue
Percutaneous Nephrolithotomy in the United Kingdom: Results of a Prospective Data Registry

https://doi.org/10.1016/j.eururo.2012.01.003Get rights and content

Abstract

Background

Percutaneous nephrolithotomy (PCNL) is commonly used in the management of large upper renal tract stones. It is highly effective but carries a greater risk of significant morbidity than less invasive treatment options such as ureteroscopy or extracorporeal shock wave lithotripsy.

Objective

Evaluate the current practice and outcomes of PCNL using a national prospective data registry.

Design, setting, and participants

All surgeons undertaking PCNL in the United Kingdom were invited to submit data to an online registry.

Measurements

Effectiveness was assessed by stone-free rates and safety according to complications including blood transfusion, fever, and sepsis rates.

Results and limitations

Since January 2010, data on 987 patients who had 1028 PCNL procedures were collected. A total of 299 of 1012 procedures (30%) were for staghorn calculi, 299 (30%) for stones >2 cm, 329 (33%) for stones 1–2 cm, and 89 (9%) for stones <1 cm. There were no significant differences in rates of failed access or complications according to whether a urologist or radiologist obtained renal access. There was a nonsignificant trend to a higher transfusion rate with balloon dilatation (7 of 222 [3.2%]) compared with serial dilatation (2 of 245 [0.8%]) of the renal tract (p = 0.093). Totally tubeless procedures were not associated with higher complication rates but did lead to a significant reduction in median length of stay (3 d vs 1.5 d; p < 0.0001). Intraoperatively, 78% of patients were believed to be stone free, which was confirmed in 68% with postoperative imaging. Blood transfusion was required in 24 of 968 patients (2.5%). The incidence of postoperative fever was 16% and of sepsis was 2.4%.

Conclusions

The PCNL data registry is a unique resource providing vital information on current practice and critical outcome data. Using the registry, endourologists can audit their practice against national outcome data for this benchmark procedure. It will help surgeons counsel patients during consent for this complex endourologic procedure about the possible outcome in their hands.

Introduction

The management of large upper renal tract stones is evolving. Open stone surgery is now almost never used, given the progress that has been made in extracorporeal shock wave lithotripsy (SWL), flexible ureterorenoscopy, and percutaneous nephrolithotomy (PCNL). Each has a role depending on factors such as stone features, renal anatomy, and patient characteristics and preferences. PCNL is often considered to be the most effective treatment but carries the highest risk of morbidity. It is recommended for the treatment of renal pelvic and upper calyceal stones >2 cm and lower pole stones >1.5 cm [1].

Since PCNL was first described in 1973 [2], many technological developments have made the procedure safer and more effective. For example, several imaging modalities are now available to guide percutaneous access, and three-dimensional computed tomography reconstruction can be used to plan the surgical approach [3]. The availability of flexible instruments and the practice of secondary nephroscopy may also improve stone-free rates [4]. A wide array of available energy sources for intracorporeal lithotripsy allows large, hard, and inaccessible stones to be effectively fragmented and removed from the kidney [5].

In recognition of the value of audit in the revalidation of surgeons, the British Association of Urological Surgeons (BAUS) has developed an online facility for the collection of data sets representing several benchmark urologic procedures. Following a retrospective national audit of PCNL in the United Kingdom [6], the BAUS Section of Endourology in January 2010 established a prospective data registry for this procedure. We present an evaluation of the data that have so far been submitted to the BAUS PCNL data registry that includes >1000 procedures.

Section snippets

Materials and methods

Through advertisement at national urologic meetings, all surgeons undertaking PCNL in the United Kingdom were invited to submit data to the registry using an online interface. An individual record that contained both a unique patient identifier and National Health Service (NHS) number was created for each PCNL procedure. Demographic and procedural data were collected for each case. Effectiveness was evaluated according to stone-free rates defined as “no visible stone on imaging.” Stone-free

Results

Between January 1, 2010, and September 16, 2011, 57 consultant urologic surgeons from 50 centres contributed 987 patients who had 1028 PCNL procedures. Because of incomplete data in some records, percentages were calculated from the total number for which these data were available. Mean age was 54 yr, and 526 of 980 patients (54%) were men (Table 1). A total of 577 of 1000 procedures (58%) were undertaken on the left side. Of 1009 procedures for which data on stone size were available, 295

Discussion

The BAUS PCNL data registry is a unique resource providing important information on current practice as well as essential outcome data for PCNL in the United Kingdom. It facilitates personal audit against national outcomes and may be used by surgeons when counselling patients about the treatment options for their renal stone. As the registry matures and surgeons become increasingly familiar with submitting data, it will be possible in the future to derive national standards for this benchmark

Conclusions

We envisage an increasing requirement for individual surgeons to maintain complete and accurate records of their procedures and outcome data in the future. We hope that the success of the BAUS PCNL data registry will encourage the development of prospective registries of other urologic procedures.

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