SONUÇ VE ÖNERİLER

PNL’ nin açık böbrek taşı operasyonlarına olan üstünlüğü belirgindir. Artan endoürolojik gelişmelerle birlikte ürologlar tarafında PNL uygulanımı artmaktadır. PNL ile böbrek taşlarının tedavisinde taştan temizlenme oranları yüksektir. PNL üriner sistem taşlarının tedavisinde güvenle kullanılabilecek bir yöntemdir. Son zamanlarda tüpsüz PNL gittikçe artan oranlarda bazı kliniklerde güvenle uygulanmaktadır ve başarı oranları kliniğimizde olduğu gibi oldukça yüksektir.

Tüm bu bulgular değerlendirildiğinde tüpsüz PNL’nin belirgin hidronefrozu olmayan, karşı böbreğin sağlam olduğu, hafif-orta taş yükü olan basit böbrek taşlarının tedavisinde, taş temizliğini takiben işlemin sorunsuz olarak sonlandırılacağı olgularda uygulanabileceğini önermekteyiz.

VII. ÖZET

Amaç: Bu çalışmada, böbrek taşı hastalığının tedavisinde minimal invaziv

cerrahi bir yöntem olan Perkütan nefrolitotomi (PNL) ameliyatının Tüplü ve Tüpsüz olgularının biyokimyasal parametrelerin değişimleri, hemogram düşme oranları, ameliyat sonrası analjezik ihtiyaçları, hastanede kalış süreleri ve koplikasyonları bakımından karşılaştırılması.

Hastalar ve Metod: Tek taraflı PNL ameliyatı yapılan toplam 50 hasta

çalışmaya dahil edildi. Bunların 25’ine tüp takılmadı. Bütün hastaların ameliyat öncesi incelemeleri, ameliyat pozisyonu, ameliyat tekniği ve anestezi protokolü aynıydı. Ameliyat edilen tüplü ve tüpsüz hastaların hemogram düşme oranları, biyokimyasal parametrelerdeki değişiklikler postop analjezik ihtiyaçları, vizuel analog skorlar, hastanede kalış süreleri ve kopmlikasyonlar bakımında karşılaştırıldı.

Bulgular: Operasyon tarafı ve giriş polü açısından iki grup arasında istatistiksel

fark saptanmadı. Operasyon süresi, pnömotik litotriptör vuru sayısı, kullanılan irrigasyon sıvısı hacmi ve operasyon sonrası hastanede kalış süresi ortalamaları istatistiksel olarak tüplü grupta daha yüksektir. Ameliyat sonrası üreter kateterinin çekilme süresi ortalaması tüpsüz grupta daha düşük olmasına rağmen fark anlamsızdır. Taştan tam temizlenme oranları açısından iki grup arasında anlamlılık görülmedi. Ancak artık taşların boyutu tüpsüz grupta daha yüksektir.

İki gup arasında serum BUN, kreatinin ve elektrolit düzeylerinde ve hemogram parametrelerinde ameliyat öncesi ve sonrası ortalamalar arasında fark olmadığı tespit edildi. Operasyon sonrası ağrı kontrolü amacıyla uygulanan analjezik sayısı ve ayrı olarak NSAİD ve meperidine sayıları tüpsüz grupta daha düşük olmasına rağmen gruplar arası fark anlamsızdır. Yüzeyel ağrı skoru her iki grupta da 1. saatten 24. saate kadar istatistiksel olarak oldukça anlamlı biçimde azalmıştır. Ancak iki grup arasında ağrı skoru ortalamalarında hiçbir saatte istatistiksel fark bulunmamıştır. Her ne kadar

tüplü grupta ameliyat ve ameliyat sonrası komplikasyon gelişen hasta sayısı tüpsüz gruba göre daha yüksek olmasına rağmen iki grup arasındaki farkın anlamsız olduğu bulunmuştur. Her iki grup arasında hastanede kalış süreleri bakımında tüpsüz olguları 1,8 günde tüplü grupta ise 4.08 günde hastaneden taburcu edildikleri görüldü.

Sonuç: Çalışmamızda tüpsüz PNL’nin, belirgin hidronefrozu olmayan, karşı

böbreğin sağlam olduğu, hafif- orta taş yükü olan basit böbrek taşlarının tedavisinde, taş temizliğini takiben işlemin sorunsuz olarak sonlandırıldığı olgularda uygulanabileceğini düşünmekteyiz.

Anahtar kelimeler: Taş hastalığı, tüpsüz PNL, nefrostomi tüpü, analjezik,

VIII. SUMMARY

Aim of the study: In this study, we aimed to compare biochemical parameters,

haemogram falling levels, postoperative analgesic requirements, length of hospital stay, and the complications of tubeless and tubing percutaneous nephrolithotomy (PNL) as minimally invasive surgical procedure for the treatment of kidney stone disease.

Patients and Methods: The fifty patients who underwent one sided PNL

operations were included the study. Among of them tube was not applicated to the 25 patients. The preoperative examination, surgical position, tecnique and anaesthetic protocol of the patients were standardized. We analysed, biochemical parameters, haemogram falling levels, postoperative analgesic requirements, visual analog scales (VAS), length of hospital stay, and the complications of tubeless and tubing percutaneous nephrolithotomy (PNL) patients who were operated.

Results: There was no statistically significant results between groups for the

operation side and introducing pole. The operation time, pneumotic lithotriptor beat counts, the length of stay at hospital for the postoperative period and the volume irrigation solution were statistically higher than the tubeless group. Postoperative length of indwelling urether catheter time was lower than tubing group, but these difference was not statistically significant. Both groups were similar in stoneless success rate. The size of stones were bigger in the tubeless group.

The preoperative and postoperative levels of BUN, creatine and electrolytes and complete blood count parameters were similar in both groups. The postoperative analgesic requirements were lower than the tubing group according to NSAID and meperidine were given, but these difference was not statistically significant. The visual analog scale (VAS) levels were decreased statistically at 1-24th hours in both groups. But these VAS levels statistically similar between two groups in any hour. The overall complication rate at the perioperative session were higher than tubeless group, but these

difference was not statistically significant. The length of hospital stay 1,8 day and 4,08 days for the tubeless and tubing group, respectively.

Results: We think that tubeless PNL may be suitable for the patients with

nonsignificant hydronephrosis, with intact counter side kidney, with mild-moderate stone load and applicable for simple kidney stone disease treatment after full stoneless and problemless procedure.

Keywords: Stone disease, tubeless PNL, nephrostomy tube, analgesics,

IX. KAYNAKLAR

1) Fernstrom I, Johnson B. Percutaneus pyelolithotomy: A new extraction technique. Scand J Urol Nephrol 1976;10:257.

2) Matlaga BR, Assimos DG. Changing indications of open stone surgery. Urology 2002;59:490-4.

3) Kane JC, Bolton DM Stoller ML. Current indications of open stone surgery in an endourology center. Urology 1995;45:218-21.

4) Akıncı M, Esen T, Tellaloğlu S. Urinary stone disease in Turkey: An update epidemiologyical study. Eur Urol 1991;20:200-3.

5) Parsons JK, Jarret TW, Lancini V, Kavoussi LR. Infudidibular stenosis after percutaneous nephrolithotomy. J Urol 2002;167:35-8.

6) Balbay MD, Varoğlu E, Devrim H et al. Quantitative evaluation of renal parenchymal mass with 99mtechnetium dimercapto-succinic acid scintigraphy after nephrolithotomy. J Urol 1997;157:1226-8.

7) Tefekli A,. Altundere F, Tepeler K, Taş A, Aydın S, Müslümanoğlu AY. Tubeless percutaneous nephrolithotomy in sellected patients: a prospective randomized comparison. Endourology 2006;32:240-7.

8) Sahin A, Atsu N, Erdem E, Oner S, Bilen C, Bakkaloğlu M, Kendi S. Percutaneous nephrolithotomy in older children. J Ped Surg 2000;35:1336-8. 9) Coleman CC. Percutaneous nephrostomy: Renal anatomy. In Amplatz K,

Lange PH, eds. Atlas of endourology. Chiago: Year book, 1987;293-301. 10) Hopper KD, Yakes WF. The posterior intercostal approach for percutaneous

renal procedures: Risk of pucturing the lung, spleen and liver as determined by CT: AJR 1990;154:115-7.

11) Hopper KD, Sherman JL, Williams MD, Ghaed N. The variable antero- posterior position of the retroperitoneal colon to the kidneys. Invest Radio1987 22: 298-02.

12) Kılıç S,. Altınok MT, Ipek D, Beytur A, Baydinç YC, Güneş G. Color dopler sonography examinatıon of partially obstructed kineys associated with ureteropelvic junction stone before and after percutaneous nephrolithotripsy: Preliminary report. International Journal of Urology 2005;12: 429-35.

13) Kabalin JN. Surgical Anatomy of the retroperitoneum, kidneys, and ureters. In: Walsh RC, Retik AB, Vaughan AB, Kavoussi LR, Novick AC, Partin AW, Peters CA, Wein AJ Eds Campbell’s Urology, 8th ed. Philadelphia, Pennsylvania 2002:1-70.

14) Sampaio FJB. Anatomic classification of the pelviocaliceal system. Urologic and radiologic imlications. In Sampaio FJB, Uflacker R, eds. Renal Anatomy Applied to Urology, Endourology, and Interventional Radiology. New York:Thieme, 1993:1-6.

15) Sampaio FJB, Lacerda CAM Le systeme collecteur du rein chez I’ homme:systematisation et morphometrie d’apres 100 moulages en resine polyester. Bull Assoc Anat 1985;69:297-304.

16) Sampaio PJR. Basic anatomic features of the kidney collecting system. Three – dimensional and radiologic study. Sampaio FJB, Uflacker R, eds, Renal Anatomy Applied to Urology, Endourology, and Interventional Radiology. New York :Thieme, 1993:7-15.

17) Sampaio PJR, Aragao AHM. Anatomical relationship between the intrarenal arteries and the kidney collecting systm. J Urology 1990;143:679-81.

18) Özçelik R, Satar N, Doran Ş, Arıdoğan İ, Bayazıt Y, Zeren S, Anafarta K, Yaman Ö, Üriner Sistem Taş Hastalığı İn: Anafarta K, Gögüş O, Arıkan N, Bedük Y, Temel Üroloji, Ankara: 1998:561–603.

19) Randal A:The origin and growt of renal caculi. Ann Surg 1937;105:1009. 20) Finlasyon B: Renal lithiasis in review. Urol Clin North Am 1974;1:181-212. 21) Khan SR Shevock PN, Hackett RL: İn vitro precipitation of calcium oxalat in

the presence of whole matrix or lipid components of urinary stones. J Urol 1988;139:418-22.

22) Evan AP, Lingeman JE, Coe FL, Parks JH, Bledsoe SB:Randll’s plaque of paients with nephrolithiasis begins in the basement membranes of thin loops of Henle.J Clin Invest 2003;111:607-16.

23) Menon M, Resnick MI. Urinary lithiasis: etiology, diagnosis and medical management. In: Walsh RC, Retik AB, Vaughan AB, Kavoussi LR, Novick

AC, Partin AW, Peters CA, Wein AJ.(eds): Campbell’s Urology 8th edition. W.B. Saunders Company, Philadelphia, 2002:3229-304.

24) McDaugall EM, Liatsikos EN, Dinlenc CZ, Smith AD. Percutaneous approaches to the upper urinary track. In Walsh RC, Retik AB, Vaughan AB, Kavoussi LR, Novick AC, Partin AW, Peters CA, Wein AJ (eds): Campbell’s Urology 8th edition. W.B. Saunders Company, Philadelphia. 2002:3320–60. 25) Koursh A, Gordon M, Frank P, et al. Outcome of small rezidual stone

fragments folloving shock wave lithotripsy in childeren. J Urol 2004 172;1600-3.

26) Curham GC, Willett WC, Speizer FE, Stampfer MJ. Beverage use and risk for kidney stones in women.Ann Intern Med 1998;128:534-40.

27) Parivar F, Low RK, Stoller ML. The influence of diet on urinary stone disease. J Urol 1996;155:432-40.

28) Stoller LM, Bolton DM, Üriner Taş Hastalığı: Tanagho EA, McAninch JW, Smith Genel Üroloji, İstanbul:1999;15: 277-04.

29) Pak CYC, Sakhaee K, Fuller C. Successful management of uric acid nephrolithiasis with potassium citrate. Kidney Int 1986;30:422-8.

30) Cohen TD, Streem SB, Hall P. Clinical effect of captopril on the formation and growth of cystine calculi. J Urol 1995;154:164-6.

31) Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE, et al. Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. J Urol 1994;151:1648-51.

32) Laerum E, Larsen S. Thiazide prophylaxis of urolithiasis. Acta Med Scand 1984;215: 383–9.

33) Wickham JEA, et all. Extracorporeal shock wave treatment for kidney stones. Br J Urol 1985 ;290:188-9.

34) Eisenberger F, Miller K, Rassweiller J. Stone therapy in urology, New York, Thieme Medical Publishers Inc. 1991:29-82.

35) Marshall LS. Extracorporeal shock wave Lithotrpsy. In: Tanagho EA. Mc,Aninch JW. Ed.Smith’s General Urology, 13th ed. California, Lange Medical Book, 1992:299-07.

36) Chow GK. Steem SB. Extracorporeal shock wave Lithotrpsy. Update on technology. Urol Clin North Am. 2000:27:315-22.

37) Tailly G. Experience with the Dornier HM4 and MPL 9000 lithotriptors in urinary stone treatment.J Urol 1990;144:622-7.

38) Lingeman JE, Lifshitz DA. Surgical management of urinary lithiasis. In Walsh RC, Retik AB, Vaughan AB, Kavoussi LR, Novick AC, Partin AW, Peters CA, Wein AJ.Eds: Campbell’s Urology 8th edition. W.B. Saunders Company, 2002:3361-451.

39) Segura JW, Patterson DE, Le Roy, et al. Percutaneous stone removal of kidney stones: Preliminary report Mayo Clin Proc 1982;57:615.

40) Clayman RV: Techniques in percutaneous removal of renal calculi. Urol 1984;23:11-9.

41) Alken P. Hutschenreiter G, Günther R et al; Percutaneous stone manuplation. J Urol 1981;125:463.

42) Wickham JEA. Kellett MJ: Percutaneous nephrolithotomy.Br J Urol 1981;53- 297.

43) Lashley DB. Fuchs EF: Urologist-acquire renal access percutaneous renal surgery. Urology 1988;51:927.

44) Al-Shammari AM, Al-Otaibi K, Leonard MP, Hosking DH. Percutaneous nephrolithotomy in the pediatric population. J Urol 1999;162(5):1721-4.

45) Clayman VR, McDougall EM, Nakada YS. Endourology of the upper urinary tract: Percutaneous renal and ureteral procedures. In: Walsh RC, Retik AB, Vaughan AB, Wein AJ. Campbell’s Urology, 7th ed. London; WB Sounders Company,1998,2670-773.

46) Atici B, Zeren S, Aribogan A. Hormonal and hemodynamic chages during percutaneous nephrolithotomy. Int Urol Nephrol.2001;32(3):311-4

47) Menon M, Parulkar BG, Drach GW Urinary lithiasis: etiology, diagnosis and medical management, In Walsh PC, Retik AB, Vaughan ED JR, Wein AJ Eds: Campbell’s Urology 7th edition. W.B. Saunders Company, Philadelphia, 1998: 2661-70.

48) Şahin A, Tekgül S, Erdem E, et al. Percutaneous nephrolithotomy in older children. J Ped Surg 2002;35:1336-8.

49) Limb J, Bellman GC: Tubeless percutaneous renal surgery: Revew of first 112 cases. Urology 2002;59:527-31.

50) Desai MR, Kukreja RA, Desai MM et al: A prospective randomized comparison of type of nefrostomy drainage folloving percutaneous

nephrolithotomy. Large bore versus small bore versus tubeless. J. Urol 2004;172:565-7.

51) Segura JW. Percutaneous Nephrolithotomy: Technique, indications, and complications; AUA Guidelines 1993;12:154.

52) Candela J, Daidoff R, Gerspach J, Bellman GC: “Tubeless “surgery : A new advance in the technique of percutaneous renal surgery. Tech Uro1997;3:6-11. 53) Pietrow PK, Auge BK, Lallass CD, et al. Pain after percutaneous

nephrolithotomy:impact of nefrostomy tube size. J Endourol 2003;17:411-5. 54) Liatsikos EN, Hom D, Dinlenc CZ, et al. Tail stent versus re-entry tube: A

randomized comparison after percutaneous stone extraction. Urology 2002;59:15-21.

55) Bellman GC, Daidoff R, Candela J, et al. Tubeless percutaneous renal surgery.J Urol 1997;157:1578-82.

56) Feng MI, Tamaddon K, Mikhail A, et all. Prospective randomized study of various techniques of percutaneous nephrolithotomy.Urology 2001;58:345-50. 57) Karami H, Gholamrezaie HR. Totally tubeless percutaneous nephrolithotomy

in sellected cases. J Endourol 2004;18:475-6.

58) Bdesa AS, Jones CR, North EA,et al. Routine placement of nefrostomy tube is not necessary after percutaneous nephrolithotomy. Br J Uro 1997;79:1. 59) Winfield HN, Weyman P, Clayman RV: Percutaneous nephrolithotomy:

Complicationsof premature nephrostomy tube removal. J Uro1986;136:77-9. 60) Delnay KM, Wake RW: Safety and efficacy of tubeless percutaneous

nephrolithotomy.World J Urol 1998;16:375-7.

61) Lojanapiwat B, Soonthornphan S, Wudhikarn S: Tubeless percutaneous nephrolithotomy in selected cases. J Endourol 2001;15:711-3.

62) Gupta NK, Kesarwani P, Goel R, Aron M. Tubeless percutaneous nephrolithotomy. A comparative study with standard percutaneous nephrolithotomy. Urol int 2005;74:58-61.

63) Aghamir SMK, Hosseini SR, Gooran S: Totally tubeless percutaneous nephrolithotomy. J Endourol 2004;18:647-8.

64) Limb J, Bellman GC: Tubeless percutaneous renal surgery: Review of first 112 cases. Urology 2002;59:527-31.

65) Yew J, Bellman G : Modified ” tubeless percutaneous nephrolithotomy using a tail – stent. Urology 2003;62:346-9.

66) Aron M, Goel R, Kesarwani PK, Gupta NP; Hemostasis in tubeless PNL: Point of technique. Urol int 2004;73:244-7.

67) Jou YC, Cheng MC, Sheen JH, Lin CT, Chen PC: Electrocauterization of bleeding points of percutaneous nephrolithotomy. Urology 2004;64:443-7. 68) Gupta V, Sadasukhi TC, Sharma KK, Yadav RG, Mathur R: Tubeless and

stentless percutaneous nephrolithotomy. BJU İnt .2004;95:905-6.

69) Mikhail AA, Kaptein JS Bellman GC: Use of fibrin glue in percutaneous nephrolithotomy. Urology 2003;61:910-4.

70) Lee DI, Uribe C, Eichel L, et al. Sealing percutaneous nephrolithotomy tracts with gelatin matrix hemaostatic sealent: İnitial clinical use. J Urol. 2004 171;575-8.

71) Noller MW, Baughman SM, Morey AF, Auge BK. Fibrin sealent enables tubeless percutaneous stone surgery. J Urol 2004;172:166-9.

72) Uribe C, Eichel L, Khonsari S, et al. What hapens to hemostatic agents in contact with urine? An in vitro study. J Endourol 2005;9:312-7.

73) Yang RM, Bellman GC. Tubeless percutaneous renal surgery in obes patient. Urology 2005;66:500-4.

74) Menon M, Parulkar BG, Drach GW. Urinary lithiasis:Etiology,Diagnosis and Medical Treatment. In: Walsh RC, Retik AB, Vaughan AB, Wein AJ. Campbell’s Urology, 7th ed. London; WB Sounders Company 1998:2659-749. 75) Jou YC, Cheng MC, et al: Nephrostomy tube- free percutaneous

nephrolithotomy for patients with large stones and staghorn stones.Urology 2006;67:30-4.