Transcript Day Care Percutanepus Nephrolithotomy (PCNL) in Rural Indian setup Mulawkar PM, Panpaliya GS, Bhat GR • • • • • Three patients OPD PCNL Mean op time 87 min Post-op Hospital stay.

Day Care Percutanepus
Nephrolithotomy (PCNL) in Rural
Indian setup
Mulawkar PM, Panpaliya GS, Bhat GR
•
•
•
•
•
Three patients
OPD PCNL
Mean op time 87 min
Post-op Hospital stay 175 minutes
Can Urol Assoc J 2010;4(4):E86-90
•
•
•
•
10 patients
Median op time 83 min
Median recovery room stay 240 min
UROLOGY 76: 1288–1292, 2010
Peculiarities of Rural setting
• Lack of transport
• Lack of medical care in villages
• Discharge in 24 hr
Selection Criterion : Pre-operative
•
•
•
•
ASA class 1 or 2
Age 16 or more
No active cardiac disease, solitary kidney
No h/o fever in recent past (3 months)
– Urine culture was not done if the patient did not
have H/o fever in last 3 months
• Serum creatinine < 2 mg/dl
• Stone size was not considered as a criterion
Selection Criterion: Family
• Patient has adequate
family support
• Patient and family must
be agreeable to
discharge planning
• Patient has handy
access to mobile phone
– at least one phone in the
family
Selection Criterion: Intra-op
•
•
•
•
•
•
Single tract
No intraoperative complications
No pelvicaliceal system perforation
No residual stones
Minimal intraoperative bleeding
No bleeding when removing sheath
Selection Criterion: Post-op
• No postoperative complications
• No bleeding from nephrostomy or after NT
removal
• Hemodynamically stable
• Able to ambulate without significant difficulty
• Normal KUB x ray findings
• Pain under control with oral analgesics
Anesthesia Protocol
• HS= Alprazolam, Ranitidine
• Pre-op= Clonidine 1.5mcg/Kg over 10 min
• Induction: Midazolam + Buterphenol +
Glycopyrolate + Propofol + Scoline
• Relaxant: Pavulon
• Maintainence : O2, N2O, Sevoflurane
• Reversal + Ondensetron
• Nasal O2 : 2 hr post-op
• Mobilization 3 hr post op
PONV
• Minimal Narcotics
• No Ketamine
• Midazolam instead of Diazepam
– Reduce duration of sedation
• Propofol instead of Pentothal
– Built in anti-emetic effect
– Clear headed recovery
– No hangover
– Propofol euphoria
Pain relief
• Pre puncture : Lignocaine + adrenaline
infiltration
• Post-procedure Bupivacaine infiltration
• Liberal use of Paracetamol
– Max dose 1 gm qid (1gm in 100 ml infusion)
Surgery
• Lignocaine + Adrenaline infiltration before
puncture
• Bupivacaine infiltration post-op
• Smallest possible tract
• Nephrostomy = 8 fr (when kept)
• Remove every fragment
• Lithotripsy: Pneumatic and Laser
Study Population
•
•
•
•
•
Jan 2011 to Aug 2014
Total PCNL = 441, Day care = 29
Age 16-70 (mean 40.2), F=12 M=17
Creatinine= 0.6 to 1.9 mg/dl (mean 1.15mg/dl)
Max stone diameter =8 to 43 mm (mean 17,
median 15)
• Op time 60-180 min (mean 92 min)
• Calyx of entry : Lower =26 Upper =2 Mid=1
Drainage of PCS Post-op
Tract Size
Stone Location
Results
•
•
•
•
•
•
All stone free (100%)
All except 1 discharged without nephrostomy
Significant pain = 3 (IV Paracetamol)
Fever = 1
Mild Hematuria = 1
Readmission = 2
– UTI 1
– Malarial fever 1
Yeh Hain India Meri Jaan!
• Administrative delay = 3
– No vehicle to transport =2
– Insurance physician did not come =1
Conclusion
• In highly selected patients, day care PCNL is
safe and feasible.
• In our setting same day discharge although
feasible, is not practical as most of the
patients are from remote places and medical
facilities in interior places are not adequate
for same day discharge.
Same day discharge is possible!!
Video Used with Consent of Patient
What Else is Possible
Thank You