Objective: To compare the outcomes of supine percutaneous nephrolithotomy (PCNL) in elderly patients

with those of supine PCNL in healthy population.

Patients and Methods: A matched case–control study was performed from January 2007 through
December 2014 using our prospectively collected kidney stone database. Elderly patients were defined to
have age greater than 70 years. Control group included patients less than 70 years old. Patients were
randomly matched based on Guy’s score as a surrogate of case complexity.

Results: Fifty four patients were enrolled in this study, 18 cases and 36 controls. There were no significant
differences in age, gender, and body mass index between groups. Regarding PCNL technique, there were
no
differences in patient positioning, number of accesses, and operative time. There was no significant
difference in stone-free rate, nephrostomy tube time, complication rate, mean decrease in hemoglobin
level, and need of blood transfusion. There was a tendency of greater ASA score in the case group (22.2%
ASA 1 / 50.0% ASA 2 / 27.8% ASA 3 vs 55.6% ASA 1 / 41.7% ASA 2 / 2.8% ASA 3; p = 0.070). Hospital
stay time (days) was greater in the case group (4.0 ± 1.7 vs 2.4 ± 1.1; p = 0.002).

Conclusion: Elderly patients have similar complication rate than younger patients for the same Guy’s score
after supine PCNL.

Introduction
Percutaneous nephrolithotomy (PCNL) is the treatment of choice for patients with kidney stones >2.0 cm
and staghorn calculi due to its minimally invasive characteristics and high stone-free rate.1,2 Despite the
advantages in terms of stone removal compared with open surgery, extracorporeal shockwave lithotripsy
(SWL), and even with retrograde intrarenal surgery, the incidence of complications associated with PCNL is
reported as much as 50% and major complication rate is not negligible.

Patient positioning in PCNL is classically prone. In the last decade, supine positioning has been shown to
be equally effective in some patient groups, while it is also more desirable anesthesiologically.
Curr Opin Urol.​ 2016 Jan;26(1):81-7. doi: 10.1097/MOU.0000000000000239.

The purpose of this study was to evaluate supine PCNL success and complication rates in this particular
group of patients compared to younger patients with a similar condition (same stone complexity).
Patients and Methods

Study design
After Institutional Review Board approval, a retrospective case–control study was conducted from January
2007 through December 2014, using our prospectively collected kidney stone database. All elderly patients
who underwent supine PCNL were included.

Two controls were randomly selected for each elderly patient. The selector was blinded to the outcome;
patients were selected based on stone complexity. Patients were matched 2:1 based on Guy’s stone score,
which classifies stone disease according to its complexity and works as an independent predictive factor for
complications and stone-free rate.

Groups were compared for their demographic data, ASA Physical Status, comorbidities, number of
punctures, mean operative time, stone-free rate, overall and major complication rates, postoperative urinary
tract infection (UTI), drop in hemoglobin level, need for transfusion, tubeless rate, mean time with
nephrostomy tube, length of hospital stay, and stone-free rate. Stone-free rate was evaluated by a
noncontrast computed tomography (NCCT) scan routinely performed on the first postoperative day
following our institutional protocol. Stone-free status was defined as the complete absence of residual
fragments. Complications were stratified according to Clavien’s classification and classified as major if
greater than or equal to 3.

Surgical procedure
All procedures were performed under general anesthesia. The patients selected for this study were
positioned in supine position. A 6F ureteral catheter was placed through cystoscopy. After retrograde
pyelography, the selected calix was punctured under fluoroscopy guidance. A hydrophilic guidewire was
inserted and passed into the ureter. If this guidewire did not reach the ureter, a PTFE guidewire was used
to replace it. The tract was dilated with fascial dilators and then a 30F Amplatz sheath was placed.
Ultrasonic lithotripter was used for stone fragmentation and suction (Swiss LithoClast Master; EMD, Dallas,
TX). Irrigation was performed with saline at 25C and pressure of 30 to 40 cmH2O. An 18F nephrostomy
tube was
placed at the end of the procedure in cases of bleeding, residual stones, renal pelvis perforation, or multiple
accesses. The ureteral catheter was maintained for 12 hours or a Double-J stent (for 1 to 2 weeks) was left
in place at surgeon discretion.

Operative time was considered from the beginning of cystoscopy for ureteral catheter placement until the
end of nephrostomy tube placement. An NCCT scan and laboratory examinations were done on the first
postoperative day in all cases according to our institutional protocol. Patients with residual stones were
submitted to a second-look PCNL, flexible ureteroscopy, or SWL based on residual stone burden and
location.

Statistical analyses
Categorical variables were compared using chi-square and Fisher exact tests, whereas continuous
variables were compared using Student’s t test for independent groups. Odds ratio (OR) was calculated
when appropriate. All statistical analyses were performed using SPSS version 20.0 (SPSS, Inc., Chicago,
IL). Significance level was set at p < 0.05.
Results
Fifty four patients were included in this study, 18 cases and 36 controls. In the case group, average age
was 73.9 ± 3.6 years. The control group was 44.5 ± 11.8 years old. There was no significant difference in
BMI, sex or laterality between groups. ASA Physical Status was close to significantly different (p-value =
0.07) with a distribution of 22.2% ASA 1 / 50.0% ASA 2 / 27.8% ASA 3 in the case group and 55.6% ASA 1
/ 41.7% ASA 2 / 2.8% ASA 3 in the control group.

The number of punctures, number of supracostal punctures and operative time was also not significantly
different between groups.

The complication rate was the same in both groups, 16.7%. There was no significant difference in preop
and postop hemoglobin levels, hemoglobin level drop, blood transfusion rate, or time with nephrostomy
tube. Length of hospital stay was greater in the elderly patient group (4.0 ± 1.7 vs 2.4 ± 1.1, p-value =
0.002). Success rate was also not significantly different (83.30% case group vs 75% control group, p-value
= 0.487).