Bechis Seth K, Han Daniel S, Abbott Joel E, Holst Daniel D, Alagh Amy, DiPina Thomas, Sur Roger L
1 Department of Urology, UC San Diego Health , La Jolla, California.
2 Chesapeake Urology Associates, University of Maryland , Baltimore, Baltimore, Maryland.
J Endourol. 2018 May;32(5):394-401. doi: 10.1089/end.2018.0056. Epub 2018 Apr 10.
Outpatient percutaneous nephrolithotomy (PCNL) has been described for highly selected patients. We sought to assess the safety and feasibility of outpatient PCNL in a tertiary referral stone center without strict patient selection criteria.
We reviewed all PCNLs performed at our institution from September 2015 to October 2016. Of the 97 eligible cases, 60 patients underwent planned outpatient PCNL. Primary outcome was complication rate, and secondary outcome determined predictor variables of inpatient admission.
Thirty-seven inpatient and 60 planned outpatient (one bilateral) PCNLs were performed with 65% and 44% American Society of Anesthesiologists (ASA) score ≥3, respectively. The 30-day overall complication rate for the inpatient and planned outpatient groups was 27% and 20%, respectively (p = 0.43) [70% and 92% Clavien grades I-II]. Emergency department presentation within 30 days was 19% and 18% (p = 0.94), and unplanned hospital readmission rate was 3% and 10% (p = 0.05). The 37 inpatient PCNL patients had larger total stone burden than outpatient cases (40.7 vs 25.8 mm, p = 0.0014); more often required two or more punctures into the kidney during the procedure (73% vs 45%, p = 0.025); and more often had supracostal access (20% vs 7%, p = 0.05). For the outpatient PCNL cohort, 72% patients were discharged same day, 28% were observed overnight for refractory symptoms or social reasons. Outpatient cohort radiographic stone-free rate by CT (no stones) was 67%.
Outpatient PCNL has been safely and effectively performed within our institution in moderate-sized stones almost regardless of comorbidity status. We suggest that this approach is a potential algorithmic change in centers with sufficient case volume.
门诊经皮肾镜取石术（PCNL）已应用于经过严格筛选的患者。我们旨在评估在一家三级转诊结石中心，在没有严格患者选择标准的情况下门诊PCNL的安全性和可行性。
我们回顾了2015年9月至2016年10月在我院进行的所有PCNL手术。在97例符合条件的病例中，60例患者接受了计划中的门诊PCNL。主要结局是并发症发生率，次要结局是确定住院的预测变量。
共进行了37例住院PCNL和60例计划中的门诊PCNL（1例双侧），美国麻醉医师协会（ASA）评分≥3的患者分别占65%和44%。住院组和计划门诊组的30天总体并发症发生率分别为27%和20%（p = 0.43）[Clavien分级I-II级分别为70%和92%]。30天内急诊就诊率分别为19%和18%（p = 0.94），非计划住院再入院率分别为3%和10%（p = 0.05）。37例住院PCNL患者的总结石负荷大于门诊患者（40.7 vs 25.8 mm，p = 0.0014）；手术过程中更常需要两次或更多次穿刺进入肾脏（73% vs 45%，p = 0.025）；更常采用肋上入路（20% vs 7%，p = 0.05）。对于门诊PCNL队列，72%的患者当天出院，28%的患者因难治性症状或社会原因留院观察一晚。门诊队列经CT检查的结石清除率（无结石）为67%。
在我们机构中，几乎无论合并症情况如何，门诊PCNL已安全有效地应用于中等大小结石患者。我们建议，在病例数量充足的中心，这种方法可能是一种潜在的算法改变。
