Detection of residual stones after percutaneous nephrolithotomy Role of nonenhanced spiral computed tomography

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Slide 1 :

Detection of residual stones after percutaneous nephrolithotomy : Role of non-enhanced spiral computed tomography. Yasser Osman, Nasr El-Tabey, Hoda Refai, Ahmed Elnahas, Ahmed Shoma, Ibrahim Eraky, Mahmoud Kenawy, Hamdy El-Kapany. Urology & Nephrology Center, Mansoura University, Egypt

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Introduction Percutaneous nephrostolithotomy with minimally invasive techniques of stone disintegration had widely replaced the open stone surgery. (Downey & Tolley 2002)

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Introduction Evaluation of possible residual fragments after percutaneous nephrolithotomy is an essential aspect of the management of stone disease. (Pires et al., 2003)

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Introduction Post-operative unenhanced CT was suggested to be superior to plain renal tomography and is the best method to determine if a patient is stone-free after percutaneous ultrasonic lithotripsy. (Waldmann et al., 2003)

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Objectives To study the role of computed tomographuy in diagnosis of stones-free staus after percutaneous nephrolithotomy. The impact of the stone density as well as the clinically insignificant residuals upon this approach was addressed.

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Materials & Methods Between Nov. 2004 and Feb. 2005 prospective evaluation of 100 renal units (98 patients) who underwent percutanoues nephrolithotomy 54 male and 44 female patients Mean age of 49.1 ± 11.7

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Materials & Methods There were 20 staghorn 18 renal pelvis 12 calyceal renal stones 50 multiple renal stones The study included 55 opaque stones 45 lucent or faint.

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Materials & Methods The patients were examined within 48 hours after the procedure to detect residual stones by Plain radiography (KUB) Linear tomography (LT) Ultrasonography (US) Computed tomography (CT) Clinically insignificant residuals were defined as 1 or 2 calyceal stones < 5 mm.

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Results Stone-free status 38 units Clinically insignificant residuals 26 units Significant residuals 36 units (second look) 21 (ESWL) 10 (medical ttt) 5

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Results For faint and lucent stones: Sensitivity for overall stone detection was 100 % for CT (27 of 27) 11.1% for KUB (3 of 27) 22.2 % for LT (6 of 27) 22.2 % for US (6 of 27) (P < 0.05) Sensitivity for significant residuals detection was 100 % for CT (15 of 15) 20% for KUB (3 of 15) 33.3% for LT (5 of 15) 20% for US (3 of 15) (P < 0.05)

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Results For radio-opaque stones: Sensitivity for overall stone detection was 100 % for CT (35 of 35) 62.9% for KUB (22 of 35) 74.3 % for LT (26 of 35) 48.6 % for US (17 of 35) (P < 0.05) Sensitivity for significant residuals detection was 100 % for CT (21 of 21) 85.7% for KUB (18 of 21) 95.2% for LT (20 of 21) 57.1% for US (12 of 21) (P < 0.05 for US while P = N.S. for KUB & LT)

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Case I Fig.1a,b showing evidence of radio-opaque stone in the renal pelvis by KUB & IVP

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Case I Fig.2a,b,C showing no evidence of residual stones after PCNL by KUB & Tomogram or U/S

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Case I Fig.3 showing evidence of lower calyceal residual stone by un-enhanced spiral CT

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Case II Fig.1a,b,c showing evidence of a faint branched stone in the renal pelvis and lower calyces by IVP and un-enhanced spiral CT

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Case II Fig.2a,b,C showing no evidence of residual stones after PCNL by KUB & Tomogram or U/S

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Case I Fig.3 showing evidence of significant calyceal residual stone by un-enhanced spiral CT

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Conclusion I Spiral CT provides the most sensitive diagnostic tool for detection of residual stones after PCNL. Whereas, ultrasound provides the least sensitive mode.

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Conclusion II Un-enhanced spiral CT should not be routinely performed in patients with radio-opaque stones as it yields no significant increase in the diagnosis of clinically significant residuals compared with KUB and linear tomogram.

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Slide 21 :

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