Air vs contrast pyelogram for initial puncture access in percutaneous nephrolithotomy: a randomized controlled trial
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ORIGINAL PAPER
Air vs contrast pyelogram for initial puncture access in percutaneous nephrolithotomy: a randomized controlled trial Prateek Gupta1 · Gautam Ram Choudhary1 · Himanshu Pandey1 · Vijay Kumar Sarma Madduri1 · Mahendra Singh1 · Likhiteswer Pallagani1 Received: 26 July 2020 / Accepted: 15 October 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Percutaneous nephrolithotomy (PCNL) is a standard procedure for large renal stones. Contrast (traditionally) as well as air is being used to delineate pelvi-calyceal system (PCS) to perform initial puncture. Contrast, when used has certain disadvantages including poor differentiation of anterior and posterior calyces. In this interim analysis of 122 patients of a prospective study subjects were stratified in two groups: in group 1, contrast was used while in group 2, air was used to delineate PCS. Out of 122,103 patients underwent puncture by contrast or air exclusively while 19 patients required mix of contrast and air (14 patients failed puncture using contrast while 5 using air). Mean dosage of radiation exposure (8.43 vs. 14.26 mGy), duration of radiation exposure (0.66 vs. 1.02 min), access time (3.72 vs. 5.84 min), were less in group 2 as compared to group 1. 84.5% of patients underwent puncture in single attempt in group 2 as compared to 56.25% in group 1. Five patients had post-operative fever and one had trans-pleural tract dilation. Complete stone clearance was seen in 94.8% of patients using air to only 75% of patients using contrast. Conclusion: Air pyelogram is a feasible, safe, cost effective and efficient access alternative to contrast pyelogram and in difficult situation a mixture of both is better than using one. Keywords Air pyelogram · Contrast pyelogram · Pcnl · Urolithiasis · Initial puncture · Percutaneous · Nephrolithotomy
Introduction Percutaneous nephrolithotomy (PCNL) is the treatment of choice for renal calculi (> 2 cm) especially in lower pole, staghorn calculi and diverticular stone [1, 2]. Safety has been studied even in chronic kidney disease (CKD) patients without compromising renal function in these patients [3]. PCNL has evolved remarkably since its first description in 1980’s [4]. Obtaining access to the collecting system is the first and most critical step in percutaneous interventions, [5] which is followed by placement of guidewire into the pelvi-calyceal system (PCS) of the kidney, tract dilation, placement of a nephrostomy sheath and finally, lithotripsy and stone fragment and retrieval using a nephroscope. Fluoroscopy, ultrasonography (US) and computed tomography (CT) or a combination of these can be used to obtain initial access to the collecting system, fluoroscopy being the most common * Gautam Ram Choudhary [email protected] 1
[6–8]. A posterior calyceal puncture is deemed most suitable for entry into the collecting system in prone PCNL because of favorable path and angle characteristics. A retrograde pyelogram (RGP) using iodinated contrast, injected via a ureteric catheter, is per
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