A prospective study on 77 patients with 80 kidneys diagnosed staghorn calculi that were treated by combination of PCNL and ESWL at Military Central Hospital 108 from September 2014 to September 2017. Among these 80 cases, UIV with iobitridol was carried out in 53 cases and DRS - Tc99m - DTPA was performed in 54 cases. All these tests were done before and after combination of PCNL and ESWL.
Journal of military pharmaco-medicine no5-2020 RENAL FUNCTION VARIATION IN TREATMENT OF STAGHORN CALCULI BY COMBINATION OF PERCUTANEOUS NEPHROLITHOTOMY AND EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY Kieu Duc Vinh1,2, Tran Cac1, Nguyen Phu Viet2 SUMMARY Objectives: To evaluate renal function after treatment of staghorn calculi using combination of percutaneous nephrolithotomy (PCNL) and extracoporeal shock wave lithotripsy (ESWL) by dynamic renal scintigraphy with Tc99m - DTPA (DRS - Tc99m - DTPA) and urographie intraveineuse (UIV) Subjects and methods: A prospective study on 77 patients with 80 kidneys diagnosed staghorn calculi that were treated by combination of PCNL and ESWL at Military Central Hospital 108 from September 2014 to September 2017 Among these 80 cases, UIV with iobitridol was carried out in 53 cases and DRS - Tc99m - DTPA was performed in 54 cases All these tests were done before and after combination of PCNL and ESWL Results: After intervention, the secretory fuction and flowability of urinary tract were significantly th improved Iobitridol was found in renal collecting system at 15 minute in 100% of the cases and 56.6% (30/53 cases) had no hydronephrosis pre-treatment as compared to 100% had hydronephrosis post-treatment (p = 0.008) On the radioisotope renography of the staghorn kidney after treatment, there was a slight decrease in relative renal uptake with a statistic decrease (50 ± 14% and 49 ± 14%, p = 0.020) Conclusion: Treatment of staghorn calculi by combination of PCNL and ESWL had a positive effect on the renal function but glomerula filtration rate (GLR) was not changed before and after treatment and also the flowability of urinary tract was remarkably improved after treatment * Keywords: Renal scintigraphy; Tc99m - DTPA; Staghorn calculi; Renal function; Percutaneous nephrolithotripsy; Extracorporeal shock wave lithotripsy INTRODUCTION Minimally invasive kidney stones treatments are now being optimally applied to minimize the impact on kidney function Currently, PCNL and ESWL are two of these approaches Combined treatment of staghorn calculi by PCNLESWL has also been applied to improve the efficiency of stones clearance and reduce the kidney parenchyma trauma Department of Urology, Military Central Hospital 108 Department of Urology, Military Hospital 103, Vietnam Military Medical University Corresponding author: Kieu Duc Vinh (kieuvinh2006@gmail.com) Date received: 02/6/2020 Date accepted: 18/6/2020 153 Journal of military pharmaco-medicine no5-2020 To assess the improvement of kidney function before and after intervention of the combination of these two techniques, we conducted a study based on the results of kidney function tests pre- and post-treatment such as: functional renal radiography with Tc99m - DTPA (Technetium - 99m - Diethylene - triamine - pentaacetate) and urinary intravenous radiography (UIV): To evaluate renal function after treatment of staghorn calculi using combination of PCNL and ESWL - Step 1: Percutaneous nephrolithotomy - Step 2: Extracorporeal shock wave lithotripsy * Criteria for study: + Urea and creatinine serum at the time before treatment, 24 hours after PCNL + Functional renal radiography with Tc99m - DTPA pre- and post-treatment (n = 54): GLR; GLRs for renal that are treated, relative uptake of kidneys that are SUBJECTS AND METHODS Subjects 80 kidneys of 77 patients with staghorn calculi were treated by a combination of PCNL and ESWL at Military Central Hospital 108 from September 2014 to September 2017 treated + Computer tomography or intravenous renal X-ray (n = 53): Grade of hydronephrosis before and after treatment more than one month * Data processing: Comparative analysis of pairs of indicators pre- and post-treatment Instruments Devices for PCNL: Alken's percutaneous nephrolithic and stone collection devices with Amplatz plastic tube; endoscopic lithotripsy Swiss lithoclast master with ultrasonic and steam pulse mechanism (can be used separately or simultaneously with ultrasonic and steam pulse to shatter kidney stones) Devices for ESWL: Modulith SLX F2 external lithotripsy instrument with electromagnetic stone breaking mechanism Methods Prospective, cross-sectional, non-controlled study All patients underwent the two following steps: 154 to draw results by using medical statistic SPSS 25.0 RESULTS Some characteristics of the patient group - Aged 27 - 78, average 54 ± 11 years old - Males had a higher proportion of SSH disease (57.5%) than females (42.5%) - Staghorn calculi size ranged from 25 - 84 mm, average size 46 ± 13 mm - Mean hospitalization time after intervention was 7.3 ± 2.2 days Journal of military pharmaco-medicine no5-2020 Hydronephrosis variation after treatment Table 1: The morphology of calyceal dilation before and after treatment on UIV Number of cases n (%) Before treatment After treatment Hydronephrosis n (%) n (%) Grade 0 (0.0) (0.0) 30 (56.6) Grade I 55 (68.8) 34 (64.2) 21 (39.6) Grade II 25 (31.2) 19 (35.8) (3.8) Total 80 (100.0) 53 (100.0) 53 (100.0) 53/80 cases agreed to take UIV after treatment The renal excretion function of the treated kidneys was maintained, the level of circulating urine excretion after treatment achieved good results with 56.6% (30/53 cases) of the renal calyces without dilation after treatment, the difference was significant (p = 0.008, Fischer's exact test) Table 2: Hydronephrosis rate variation before and after treatment on UIV After treatment (n, %) Hydronephrosis Before treatment Total Grade Grade I Grade II Grade 0 (0.0) (0.0) (0.0) (0.0) Grade I 24 (70.6) 10 (29.4) 34 (100.0) Grade II (31.6) 11 (57.9) (10.2) 19 (100.0) 70.6% of patients (24/34 cases) with hydronephrosis in grade I turned back grade 31.6% of patients (6/19 cases) with grade II hydronephrosis turned back grade and 57.9% (11/19 cases) turned back grade I Glomerula filtration rate variation before and after treatment Table 3: Early change in urea and creatinine indices 24 hours after PCNL Index n Before treatment After PCNL p Urea (mmol/L) 78 5.8 ± 1.6 5.4 ± 1.7 0.064 Creatinine (µmol/L) 78 85 ± 26 86 ± 33 0.773 There were cases without or loosen of urea and creatinine test results after 24 hours PCNL so the samples were evaluated n = 78 There was no significant change in serum urea and creatinine before and after PCNL (paired samples test) 155 Journal of military pharmaco-medicine no5-2020 Table 4: Early change in urea and creatinine index after 24 hours ESWL Index n Before ESWL After ESWL p Urea (mmol/L) 41 5.3 ± 1.7 6.2 ± 1.7 0.000 Creatinine (µmol/L) 41 85 ± 28 85 ± 27 0.902 Serum urea concentration increased significantly after 24 hours of ESWL (p = 0.000), creatinine index was not changed significantly (paired samples test) There were 39 cases without urea and creatinine test results after 24 hours of ESWL due to patient’s discharge on the day after ESWL Table 5: Urea and creatinine index before and after PCNL and ESWL Index n Before treatment After treatment p Urea (mmol/L) 42 5.8 ± 1.7 6.0 ± 1.5 0.311 Creatinine (µmol/L) 42 86 ± 28 87 ± 25 0.513 The results showed that there was no significant change in urea and creatinine index before and after combination of PCNL and ESWL, kidney function based on urea and creatinin index was not changed (paired samples test) There were 42 cases tested for urea and creatinine before and after the treatment, the rest did not agree to test Table 6: Renography pre- and post-PCNL and ESWL combination treatment Radioisotope renography n Before treatment After treatment (mean) (mean) p Relative renal uptake (%) 54 50 ± 14 49 ± 14 0.02 Overall GFR (mL/min) 54 92 ± 24 88 ± 24 0.284 GFR of treated kidney (mL/min) 54 45 ± 13 43 ± 16 0.232 Mean value of treated renal function on radioisotope renography decreased from 50% to 49% after treatment, the difference was statistically significant (p = 0.02) The overall and separate GLR of the intervened kidney decreased after treatment, the difference was not statistically significant (p = 0.284 and p = 0.232) Table 7: Variation in rate of renal failure before and after treatment Index Before treatment (n, %) After treatment (n, %) GFR ≥ 60 mL/min 50 (92.6) 44 (81.5) GFR < 60 mL/min (7.4) (1.9) p 0.436 Among 50 patients of non-renal failure before treatment, patients (12%) developed renal impairment after treatment whereas 3/4 cases (75%) experienced the recovery of renal function after treatment 156 Journal of military pharmaco-medicine no5-2020 DISCUSSION Hydronephrosis Results of UIV before and after treatment in table showed that iobitridol absorbed in the kidneys in the first 15 minute in all 53 cases (100%), the urine excretion improved markedly There was no hydronephrosis in 56.6% (30/53 cases) post-treatment compared to 100% had calyceal dilation prior to treatment Hydronephrosis grade I decreased from 34 cases (34/53 accounting for 64.2%) to 21 cases (21/53 accounting for 39.6%) and calyceal dilation grade II decreased from 19 cases (19/53; 35.8%) to cases (2/53; 3.8%) The difference was significant (p = 0.008, Fischer’s exact test) Specifically, up to 70.6% of patients (24/34) with hydronephrosis in grade I turned back grade (table 2) Of 19 cases of dilated renal calyces, cases (31.6%) had no hydronephrosis (grade 0) and 11 cases (57.9%) turned into grade I This difference was statistically significant, p < 0.05 Regarding the morphological form of renal pelvis and calyces on UIV film, compared with UIV or CT scans with contrast agent injection before surgery, it was not clear which case of change or deformation or loss of local excretion function at the intervention site (the location of the tunnel into the kidneys, the location of the lithotripsy outside the body) including cases where bleeding complications require blood transfusions (none of severe bleeding complication required selective renal vascular intervention) Renal function variation before, during and after treatment The average serum urea in 24 hours before treatment (5.8 ± 1.6 mmol/L) was slightly reduced after PCNL (5.4 ± 1.7 mmol/L) (p = 0.064), this index in 24 hours increased after ESWL (from 5.3 ± 1.7 mmol/L to 6.2 ± 1.7 mmol/L), with statistically significant difference (p = 0.000) Mean serum urea level pre- and posttreatment increased from 5.8 ± 1.7 mmol/L to 6.0 ± 1.5 mmol/L, the difference was not significant, p = 0.311 The mean serum creatinine index was assessed at each stage before treatment (85 ± 26 µmol/L) and after PCNL (86 ± 33 µmol/L) with no difference (p = 0.773) After ESWL, mean creatinine index did not change (85 ± 28 µmol/L and 85 ± 27 µmol/L, p = 0.982) Serum creatinine index before and after month’s treatment increased, but not statistically significant, p = 0.513 (before and after intervention, these indices were 86 ± 28 µmol/L and 87 ± 25 µmol/L) In the study samples, there were only cases of solitary kidney caused by the nephrectomy due to benign dysfunction kidney disease, in cases renal function of the opposite kidney was severely impaired (radiographical renal function was less than 20%) As a result, renal function did not decrease in these cases after treatment In fact, in this study urea and creatinine indices could not fully evaluate kidney function because of the compensation of contralateral kidney functions However, when intervention interferes with one kidney (kidney with stones), there is an acute vasoconstriction response in the first 157 Journal of military pharmaco-medicine no5-2020 hours in both kidneys (Handa [3]) The urea and creatinine indices, therefore, somewhat revealed that the changes in kidney function was due to technical interventions at this time These indicators are of great value in cases of renal solitary or functional solitary In our study, the above cases showed no change in renal function before and after intervention According to Handa et al (2009) [3], in an experimental study on pig kidney and PCNL retrospective study on human with tunnel and tunnels, function of the separate intervened kidney and both kidneys were assessed The author concluded that at the acute time (first hours) after PCNL, there was a phenomenon of renal vasoconstriction response leading to a decrease in renal plasma flow, a decrease in GLR in the first hours after PCNL and this vasoconstriction response occurs in both kidneys (the kidney with PCNL and the normal kidney on the opposite side) However, in our study, the tests in our study were performed in 24 hours (> 12 - 24 hours), the time when the kidneys were affected by the PCNL interventions during the first hours has passed and the renal function is restored and functioned normally As a result, there was no significant change in urea and creatinine indices in PCNL The evaluation of the functional renography with 99mTc - DTPA before and after treatment showed that (table 6): the relative renal uptake after treatment was 49 ± 14%, slightly decreased compared to before intervention being 50 ± 14%, the difference was statistically significant (p = 0.020) The overall and individual 158 GLRs after treatment were also significantly reduced compared to before treatment, 92 ± 24 mL/min and 45 ± 15 mL/min compared to 88 ± 24 mL/min and 43 ± 16 mL/min, respectively, however, the difference was not statistically significant with p = 0.284 and p = 0.232 (> 0.05) 6/50 cases (12%) with non-renal failure turned into renal failure assessed by GLR (table 7) Besides, renal failure was improved in 3/4 cases (75%) after treatment Thus, patients with renal insufficiency increased by 4/54 cases to 7/54 cases However, this result is statistically non-significant (p = 0.436, Fischer’s exact test) Therefore, there is no sufficient evidence to confirm that intervention by PCNL and TESWL can increase the risk of renal failure There have been a number of published studies on renal function evaluation by renal scanning before and after treatment with PCNL and ESWL and impact of PCNL on renal function, Fentes P (2014) [4] reported 30 cases of kidney stones treated with PCNL based on creatinine indices and functional renal imaging with 99mTc - DMSA, and also gave an evaluation of treated renal function before and after months of PCNL The results showed little impact of PCNL on kidney function, mainly at the site of tunneling into the kidney, in which, bleeding complication was a factor that increase the risk of decreased renal function Moskovitz et al (2006) [5] announced the findings of renal function with 99mTc - DMSA (n = 76) pre- and post PCNL from 1.5 to 24 months The results showed that there was a significant reduced drug uptake in Journal of military pharmaco-medicine no5-2020 the tunnel parenchyma region, but no change in total drug absorption of treated kidneys pre- and post-PCNL Compared to our study, renal function was significantly reduced after intervention (50 ± 14% vs 49 ± 14%, p = 0.020) However, the total and seperate GLR before and after treatment were not different Markovic et al (2001) [6] conducted a study on functional renal radiography with 99m Tc - DTPA, aiming to evaluate the effects of ESWL Pre- and post-ESWL result was evaulated by timepoints: before ESWL, days and months after ESWL As a result, there was no difference in filtration function of the treated kidney before and after days and months after treatment, the time to reach the peak of absorption of active substance (T-max) decreased significantly (p < 0.05), the author concluded that GLR improved after months of ESWL Naito et al (1995) [7] also studied the effect of ESWL (MPL9000 lithotripsy instrument) on the function of treated kidney pre- and posttreatment, results showed that there were no significant changes in filtration and excretion activity of the treated kidney before and after ESWL day and month However, 30 minute-chart analysis in the first 24 hours after ESWL showed that urine was stagnant in the collecting system and especially the kidney area was directly affected by shockwave even though there was no obstruction of the urinary tract As a result, patients had no abnormal symptoms after month From this result, the author concluded that the ESWL treatment on MPL9000 reduces localized temporary urine excretion function of the treated kidney with little or no impact on renal excretion activity of the kidneys This result was similar to Nguyen Khoa Hung's findings [1] in the treatment of lower calyx stone with ESWL Compared to our results, this result was compatible: although the urea and creatinine index changed in the first 24 hours of individual PCNL and ESWL method, but there was no change of these indices pre- and post-treatment including urea, blood creatinine and GLR on renal radiography in combination of the two methods In this study, we have not determined the local distribution of radioisotope capture on each position of each kidney on the scan results, especially the location of tunneling into the kidneys in PCNL and bleeding complication or calyx stone location treated with ESWL Therefore, the risk of localized renal parenchymal injury due to the impact of tunnel in PCNL and shock wave in ESWL at the intervened site were not evaluated CONCLUSION Through the study of variation in renal function before and after the treatment of staghorn calculi by combination of PCNL and ESWL, we draw some following conclusions: - After treatment, the proportion of patients with hydronephrosis decreased significantly compared with before treatment, p < 0.05 - After treatment of staghorn calculi, renal function decreases when estimating the level of radiation absorption on renal scintigraphy with Tc99m - DTPA, but GLR does not change significantly 159 Journal of military pharmaco-medicine no5-2020 REFERENCES Nguyễn Khoa Hùng Nghiên cứu điều trị sỏi đài thận tán sỏi thể ảnh hưởng sóng xung kích lên thận Luận án Tiến sĩ Y học Học viện Quân y 2011 Preminger GM Chapter 1: AUA guideline on management of staghorn calculi: Diagnosis and treatment recommendations J Urol 2005; 173(6) Handa K, Evan P, Willis R, et al Renal functional effects of multiple-tract percutaneous access Journal of Endourology 2009; 23:1951-1956 Pérez-Fentes D, Cortés J, Gude F, et al Does percutaneous nephrolithotomy and its outcomes have an impact on renal function? 160 Quantitative analysis using SPECT-CT DMSA Urolithiasis 2014; 42(5):461-467 Moskovitz B, Halachmi S, Sopov V, et al Effect of percutaneous nephrolithotripsy on renal function: Assessment with quantitative SPECT of 99mTc-DMSA renal scintigraphy Journal of Endourology 2006; 20(2):102-106 Marković S, Butorajac J, Ajdinović B, et al Dynamic scintigraphy of the kidney using 99m-Tc-DTPA before and after extracorporeal shock wave lithotripsy Vojnosanitetski pregled 2001; 58(3):259-261 Naito S, Yoshida T, Ogata N, et al Effect of MPL 9000 extracorporeal shock wave lithotripsy on renal hemodynamics and urine flow: Assessment by 99mTc-DTPA renal scintigraphy Urologia internationalis 1995; 54(2):85-88 ... tunnel in PCNL and shock wave in ESWL at the intervened site were not evaluated CONCLUSION Through the study of variation in renal function before and after the treatment of staghorn calculi by combination. .. urea and creatinine index changed in the first 24 hours of individual PCNL and ESWL method, but there was no change of these indices pre- and post -treatment including urea, blood creatinine and. .. (UIV): To evaluate renal function after treatment of staghorn calculi using combination of PCNL and ESWL - Step 1: Percutaneous nephrolithotomy - Step 2: Extracorporeal shock wave lithotripsy * Criteria