Urology Casablanca

Urinary tract stones Percutaneous nephrolithotomy Some concepts of urinary anatomy This will allow you to better understand the explanations of the surgeon who indicated this treatment. In your tummy (belly) there is an entire system for making and storing urine and passages for its emptying. The corresponding chart will help you identify the different parts of the urinary system. The kidneys (R) are located above and behind the abdomen. There is usually one kidney on the right and one on the left. The kidney is about 12 cm high and contains cavities (cups) to collect urine. These calyces come together to form the renal pelvis (b). From there is a thin channel that delivers urine from the kidney to the bladder (V): this is the ureter (U). It is about 20 cm long. The ureters (left and right) carry urine to the bladder. The bladder is the reservoir of urine. Urine exits the bladder (urination) through a channel called the urethra

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Support options at this point The stone(s) located in your kidney (or the beginning of the ureter below the kidney) warrant treatment because they are the cause of some problems (or symptoms) such as pain, bleeding and infection and on the other hand, there is a risk of blocking the flow of urine with at most a stoppage of the functioning of the kidney and then destruction of the kidney. The absence of treatment exposes you to the persistence or recurrence of these disorders and to complications. There are several treatment methods:- Extracorporeal lithotripsy: fragmentation of the stones by shock waves- Endoscopy: a device equipped with a camera is introduced into your body, either by natural means going up towards the kidney (ureteroscopy) , either directly towards the kidney by crossing the skin and the wall of the back by a single orifice (this is percutaneous nephrolithotomy), or several orifices (laparoscopy). - Conventional surgery: the operation requires a wide opening of the skin and the wall of the abdomen to approach the entire kidney and remove very large stones. The choice of technique depends mainly on the size, situation and hardness of the calculation. Your urologist has explained the advantages and disadvantages of each method to you and why he is suggesting a percutaneous nephrolithotomy (acronym: NLPC) procedure. The choice was guided by the recommendations drawn up by the French Association of Urology

Principle of percutaneous nephrolithomy Your stone is located in the kidney cavities. Percutaneous nephrolithotomy consists in introducing directly into the kidney through the skin and the wall of the back a device which makes it possible to see, fragment and remove the stone(s). In some cases, if stones remain, additional treatment may be necessary. Stone fragments are collected for analysis. This procedure usually requires general anesthesia and hospitalization for a total of 4 to 5 days. Preparation for the intervention As with any surgery, a pre-operative anesthesia consultation is required a few days before the operation. The urine must be sterile (absence of infection). A urine analysis (ECBU) is therefore carried out before the intervention in order to treat a possible infection. In some cases the calculation is obviously related to a urine infection. Antibiotic therapy is then prescribed 3 to 5 days before the operation. It is important for this technique to know if you are taking a treatment to thin the blood (aspirin, anticoagulant or others) and to ensure that there is no blood clotting disorder. An evaluation of renal function and blood count is also required. The prevention of phlebitis may justify the wearing of compression stockings from the day of the operation until discharge. Given the complexity of the PCNL technique, a CT scan is generally performed before the therapeutic choice. This examination specifies as best as possible the size of the stone(s), the shape of the kidney and the organs located around the kidney.

Modalities of nephrolithomy The operation usually takes place under general anesthesia and antibiotics. The intervention begins in principle with the establishment of a probe in the kidney by natural means to ensure the drainage of urine from the kidney. It exits through the bladder and out the urethra. The patient is then placed either on his stomach or on his back, depending on the operating possibilities and the surgeon's habits. The kidney cavities are punctured through the skin of the back under X-ray or ultrasound guidance. Then a path (tunnel) of about 1 centimeter in diameter is created between the skin and the kidney in order to be able to introduce the endoscopy material. The calculation is then extracted in its entirety or fragmented then removed in several pieces if it is too large. In some cases multiple trips may be required. The intervention generally ends with the placement of a probe in the kidney exiting through the skin of the back. However, several drainage methods are possible at the end of the operation. Your surgeon will explain them to you. In some cases, a second exploration of the kidney, by the same route, can be carried out in the days following the operation. This makes it possible to extract remaining fragments or calculations. This prolongs the hospitalization for a few days. The calculus (or its fragments) is sent for analysis to define the risks of recurrence and guide medium and long-term management. Risks and Complications Any intervention carries a risk of complications, which can sometimes be serious, due not only to the disease with which you are affected, but also to individual variations which are not always predictable. Despite systematic checks, sophisticated equipment may break down, which may cause the gesture to be interrupted or postponed. Failures and complications directly related to percutaneous nephrolithotomy may occur.

During the operation - Failures: rare (< 2%) - Complications: Each of these complications can lead the surgeon to interrupt the operation and modify the operating technique or even perform a surgical opening. Exceptionally, removal of the kidney may be necessary in the event of vital risk. In the postoperative - Complications are rare and can prolong hospitalization: - Renal colic with obstruction of the ureter by a remaining stone, sometimes justifying drainage of the kidney by a catheter through natural channels (double J catheter) or directly to through the wall of the back (nephrostomy). - Urinary and/or kidney infection requiring antibiotic therapy. - Bleeding which may require the extension of the drainage. In very rare cases bleeding can occur in the days following the procedure. Stopping the bleeding then requires an emergency radiological procedure to obstruct the bleeding vessel, or even surgery. - Urinary fistula: a flow may persist or appear at the level of the orifice of the skin in the back. The urine then leaves the kidney directly to the outside. A new drainage by internal probe, double J type, under general anesthesia is necessary. The home visit is postponed.

After discharge from hospital - Haemorrhage: it can occur in the month following the operation. While the urine was clear, it becomes frankly red. It is then necessary to return urgently to the urology department. - Infection: an infection can occur secondarily with possible fever. You will need to contact your doctor and/or your urologist. - Residual calculation: it is possible that fragments or calculations could not be extracted. These residual elements justify the follow-up by your urologist and possibly the realization of an additional treatment. - Dilation of the renal cavities: this can be observed on follow-up examinations and justify additional actions. Postoperative follow-up A few weeks later, you will see your surgeon again in consultation with the prescribed assessment to evaluate the result. Additional treatment may be offered to you. The result of the calculus analysis will be communicated to you and additional examinations will be prescribed to you to identify the cause of the calculus and prevent a recurrence. An annual consultation with biological and radiological controls is often recommended. Your urologist is at your disposal for any information