RE: PERCUTANEOUS NEPHROLITHOTOMY WITH AND WITHOUT RETROGRADE PYELOGRAPHY: A RANDOMIZED CLINICAL TRIAL
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ALI TABIBI, HAMED AKHAVIZADEGAN, KIA NOURI-MAHDAVI, MOHAMMAD NAJAFI- SEMNANI, MOJGAN KARBAKHSH, ALI R. NIROOMAND

Section of Urology, Dr Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Section of Urology, Baharloo Hospital (HA) and Department of Community Medicine (MK), School of Medicine, University of Tehran, Tehran, Iran

Int Braz J Urol, 33: 19-24, 2007

To the Editor:

     This article by Tabibi et al. evaluates whether there is a benefit to performing cystoscopic ureteral catheter placement, for retrograde opacification of the renal pelvis and calyces, in order to obtain access prior to percutaneous nephrolithotomy (PCNL). The study was randomized to either no catheter placement (intervention group) or catheter placement (control group). No statistical differences were found when comparing demographic or intraoperative parameters (surgical duration, radiation exposure, hospital stay, postoperative fever) between the 2 groups. Interestingly, postoperative hemoglobin decrease was found to be significantly higher in the catheterized group (p<0.001). While no statistical difference was identified for outcome (p=0.136), a greater percentage of patients were found to be “stone free” on KUB in the catheterized group than the noncatheterized group, 93% vs. 79%, respectively. Based on these results, it would appear that while retrograde placement of a ureteral catheter does not influence the safety or duration of the procedure, it may facilitate the efficacy of PCNL in terms of achieving stone free status.
     The decision for selecting a noncatheterized versus a catheterized approach should take into account the experience of the individual obtaining access as well as the clinical scenario in terms of stone location and burden. In many institutions, initial access is obtained by an experienced interventional radiologist followed by PCNL that is performed by the urologist. Even in this circumstance, it is not uncommon for the interventionalist to request a ureteral catheter for retrograde opacification of the collecting system. Early in one’s experience, a catheterized approach may be beneficial for maximizing successful access with minimal complications. Once a level of comfort with percutaneous anatomy is achieved, a noncatheterized approach may be a natural evolution to performing percutaneous nephrolithotomy.
     A larger randomized study would assist in determining the value of pre-procedure catheter placement for obtaining optimal access to the collecting system. As there are a limited number of published randomized studies on access relating to percutaneous nephrolithotomy, the authors should be congratulated on their contribution.”

Dr. Ravi Munver
Chief, Minimally Invasive Urologic Surgery
Hackensack University Medical Center
Hackensack, New Jersey, USA
E-mail: rmunver@humed.com