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Research article

PCNL, Clotting Status and Bleeding Risk: Is Pre-operative Clotting Status Justified?

Goonewardene SS*1, Dickinson A2

1Guys and St Thomas Hospitals, London
2Plymouth Hospitals NHS Trust

*Corresponding author:   Dr. Goonewardene SS, Great Western Hospitals, Marlborough Road, Swindon SN3 5NB, Email: ssg7727@yahoo.co.uk

Submitted: 09-01-2015 Accepted: 13-02-2016 Published: 16-02-2016

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Article

 

Abstract

Introduction
Percutaneous nephrolithotomy (PCNL) demonstrates better results of stone clearance compared to ESWL or open stone surgery. Intraoperative and postoperative haemorrhage is a frequent complication. Transfusion rates of up to 34% have been reported. We aim to review this cohort to see if clotting status pre-procedure is required.

Patients and Methods

We conducted a retrospective analysis of 100 patients undergoing PCNL over the past year under a single surgeon (AD). We recorded pre-operative clotting status, post-operative haemorrhage, blood transfusion rate and complications. In addition, stent/ nephrostomy insertion, bleeding risk and length of stay was recorded.

Results

32% of procedures were done on the right, 68% on the left. 62% had a nephrostomy inserted post procedure, 6% had antegrade stents. Complete stone clearance was achieved in 72%. Bleeding risk was high in 2 %. The mean length of stay was days 3.0 (range 1 - 9). Average pre-operative APTT ratio was 1.0 (range 0.9 – 1.2), the average INR was 0.9 (range 0.9 – 1.5). Average post-operative haemoglobin drop was 0.8. Post-operative haemorrhage requiring transfusion occurred in no patients. Complications included: blood clots/ minimal bleeding 6.0 %, sepsis in 6%. None of these patients were re-admitted with haemorrhage.

Conclusions

We demonstrate that patients have no significant complications related to pre-operative clotting status. We concluded pre-operative clotting status is not required as routine before this procedure. Results are compared with other published data.

Keywords: Percutaneous Nephrolithotomy; Clotting Status Pre-Operatively

Introduction

Percutaneous nephrolithotomy (PCNL) monotherapy shows superior results in terms of stone clearance, cost-effectiveness, and also early postoperative convalescence when compared with shockwave lithotripsy (SWL) or open stone surgery [1-3].

PCNL monotherapy as the most effective approach to large volume renal stone disease with a superior overall stone-free rate  of 78% [1].Complication rates as high as 83% have been reported [4-6]. Intraoperative and postoperative hemorrhage is one of the most frequent complications associated with PCNL. Transfusion rates of up to 34% have been reported [8]. About 1% of all PCNL patients complain of delayed postoperative bleeding [7].

Both intraoperative and postoperative bleeding are a matter of concern for any patient undergoing PCNL. Kukreja et al [8] reported an 8% blood transfusion rate in 301 PCNL procedures in patients with normal clotting parameters, and Kessaris et al. reported a 0.8% incidence of post-PCNL bleeding requiring embolization [9]. We aim To investigate the intra- and postoperative hemorrhage of percutaneous nephrolithotomy via the standard nephrostomy tract.

Prior papers have demonstrated stone burden was the most influencing predictive factors for PCNL blood loss [10]. Amount of blood requested and cross-matched was found to be much greater than actual blood loss [10]. Even in patients with pre-operative clotting problems, with careful perioperative regulation of anticoagulation therapy and clotting parameters, percutaneous nephrostolithotomy can be performed safely and efficiently in properly selected patients requiring long-term anticoagulation [11].

Methods

A retrospective analysis was conducted among 100 patients undergoing percutaneous nephrolithotomy under a single surgeon (AD). During the operations, all the nephrostomy tracts were dilated with Amplatz to F24 size after successful puncture . The stones were shattered and removed by EMS lithotrity system. We recorded pre-operative clotting status, post-operative haemorrhage, blood transfusion rate and complications. In addition, stent/ nephrostomy insertion, bleeding risk and length of stay was recorded.

Results

32% of procedures (16) were done on the right, 68% (34) on the left. 62% (31) had a nephrostomy inserted post procedure, 6% (3) had antegrade stents Complete stone clearance was achieved in (36) 72. All patients were stratified as normal clotting status. The mean length of stay was 3.0 days (range 1 - 9). Average pre-operative APTT ratio was 1.0 (range 0.9 – 1.2), the average INR was 0.9 (range 0.9 – 1.5)- all has normal pre-operative clotting status. Average post operative haemoglobin drop was 0.8. Post operative haemorrhage requiring transfusion occurred in no patients. Complications included: blood clots/ minimal bleeding (3) 6.0 %, sepsis in (3) 6% Clavien-Dindo grade 2 [12]. None of these patients were re-admitted with haemorrhage. No patients required a return to theatre.

Discussion

In addition to clotting status, adequate access is a key factor [13]. Whilst USS input has been shown to be part of this,  surgeon experience is the core component to lack of complications [13]. Clinically significant bleeding can be treated conservatively in a majority of cases with tamponade nephrostomy tubes with or without transfusions [13]. Arterial hemorrhage, pseudoaneurysms, and arterial-venous fistulas, however, require prompt intervention with angiographic embolization [13].

Conclusions

We conclude according to risk stratification, patients have no significant complications related to pre-operative clotting status. Percutaneous nephrolithotomy through standard nephrostomy tract is safe and does not increase the risk of bleeding with careful operation.

References

 References

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10. Rasyid N, Birowo P, Syahputra FA, Matondang FA, Noviandrini E et al. Blood loss predictive factors and transfusion practice during percutaneous nephrolithotomy of kidney stone: A prospective study. Journal of Endourology. 2014, 28: A194.

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13. Lee KL, Stoller ML. Minimizing and managing bleeding after percutaneous nephrolithotomy. Curr Opin Urol. 2007,17(2):120-124.

Cite this article: Goonewardene. PCNL, Clotting Status and Bleeding Risk: Is Pre-operative Clotting Status Justified?. J J Nephro Urol. 2016, 3(1): 024.

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