Author's Accepted Manuscript Risk factors for postoperative complications after percutaneous nephrolithotomy (PCNL) in a tertiary referral centre Daniel Olvera-Posada , Thomas Tailly , Husain Alenezi , Philippe D. Violette , Linda Nott , John D. Denstedt , Hassan Razvi

PII: DOI: Reference:

S0022-5347(15)04310-4 10.1016/j.juro.2015.06.095 JURO 12736

To appear in: The Journal of Urology Accepted Date: 25 June 2015 Please cite this article as: Olvera-Posada D, Tailly T, Alenezi H, Violette PD, Nott L, Denstedt JD, Razvi H, Risk factors for postoperative complications after percutaneous nephrolithotomy (PCNL) in a tertiary referral centre, The Journal of Urology® (2015), doi: 10.1016/j.juro.2015.06.095. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to The Journal pertain.

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ACCEPTED MANUSCRIPT

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Risk factors for postoperative complications after percutaneous nephrolithotomy (PCNL) in a tertiary referral centre

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Daniel Olvera-Posada MD, Thomas Tailly MD, MSc, Husain Alenezi MD, Philippe D. Violette MDCM FRCSC, Linda Nott RN, John D. Denstedt MD FRCSC FACS FCAHS, Hassan Razvi MD FRCSC

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Division of Urology, Department of Surgery, Schulich School of Medicine & Dentistry, Western University

London, Ontario, Canada

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Running head: Risk factors for PCNL complications

Correspondence: Hassan Razvi, MD, FRCSC Urology, St. Joseph´s Hospital 268 Grosvenor Street, London, Ontario, Canada. N6A 4V2 519 646-6259 [email protected]

Keywords: risk factors, postoperative complications, kidney calculi, percutaneous, nephrolithiasis Abstract count: 249 Total world count: 2500

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Abstract Purpose: To describe and evaluate the complications related to percutaneous nephrolithotomy (PCNL) and to identify risk factors of morbidity according to the modified Clavien scoring system.

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We also wished to specify which perioperative factors are associated with minor and major complications.

Materials and Methods: A retrospective analysis was performed using data from patients who

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underwent PCNL from 1990 to 2013. Descriptive statistics were used to analyze patients’ characteristics, medical comorbidities and perioperative features. Complications were categorized

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according the Clavien Score for PCNL. Mann-Whitney and Fisher’s exact tests were used as appropriate. Logistic regression analysis was performed to look for prognostic factors associated with major complications.

Results: A total of 2318 surgeries were evaluated. Mean age of the population was 53.7 years.

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Stone-free rate at hospital discharge was 81.6%. Overall complication rate was 18.3%. Two deaths occurred. Patients with any postoperative complications were older, with more comorbidities, were more likely to have staghorn calculi and had longer operative time and hospital stay on univariate

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analysis (p3a). Previous analyses of prognostic factors have determined that age,3 horseshoe kidney,3 medial and multiple punctures,16 supracostal access,17 multiple tracts, staghorn calculi, diabetes,18 type of intracorporeal lithotripter15, and prolonged operative time19,20 are independent risk factors for postoperative complications.

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We have previously reported our overall experience21 with PCNL, but had not evaluated potential risk factors for postoperative complications. The purpose of this study was to determine which factors were related to PCNL complications in our practice. The primary objective was to identify

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and analyze the rate of postoperative complications after PCNL according to the modified Clavien score. We examined perioperative factors that were associated with any type of complication,

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particularly major postoperative complications.

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Material and Methods

A retrospective review approved by the Ethics Review Board of Western University, of PCNL cases performed in a single tertiary referral centre from July 1990 to December 2013 by one of two fellowship trained endourologists (JDD, HR) was conducted.

During the first years of the study, patients had a preoperative IVP (intravenous pyelogram) and

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after 1999 a CT scan (Computed Tomography) was routinely used. PCNL was performed in the prone position using a 3-5 day course of preoperative broad-spectrum antibiotic. The surgical technique has been previously described.21,22 We used an upper pole access selectively, for patients

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with staghorn stones, upper pole calyceal diverticular stones or a large upper pole stone burden. Stone free status (SFS) was determined before hospital discharge by postoperative imaging chosen

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by the treating urologist based on intraoperative findings, location of the tract and complexity of the stone burden, and included non-contrast CT, nephrotomography, nephrostography, KUB (Kidney Ureter Bladder plain X-ray) and renal ultrasound (US). The information collected included: demographics, clinical symptoms (history of recurrent urinary tract infections (UTI), hematuria and pain), presence of complete staghorn calculi (stone in more than 2 calices and 2 or more kidney regions) or partial staghorn calculi (stone in pelvis, branching into one or 2 calices in one region of kidney). Medical comorbidities included hypertension,

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diabetes, cardiac and pulmonary diseases, and chronic renal failure. Patients were binary categorized depending on their comorbidity, and also grouped depending on the number of any of the five analyzed comorbidities. Perioperative characteristics included operative time (OT), number

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and location (upper, mid, and/or lower pole) of tracts, dilation device, use of nephrostomy tube/double J stent at the end of the procedure, length of hospital stay and presence of urinary tract abnormalities, as previously defined by Violette et al.23

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Postoperative information such as stone composition, the need for a second look procedure, and the SFS at discharge (stones < 5mm) were included. Postoperative complications were collected during

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follow-up and classified by the modified Clavien Score for PCNL.14 Complications classified as Clavien 3a, 3b, 4a, 4b and 5 were categorized as major complications. In cases where patients had more than one complication, only the highest Clavien score was included for final analysis. Patients with incomplete perioperative information were excluded from the analysis.

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We compared perioperative characteristics between patients with an uneventful surgery and those with postoperative complications. Perioperative, clinical and radiological data were analyzed using Fisher’s exact test for categorical variables and Mann-Whitney for continuous variables. Univariate and multivariate logistic regression testing was used to evaluate the influence of the studied

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variables for minor and major postoperative complications. ROC (Receiver Operating Characteristic) curve analysis was used to find the best cut-off point to analyze the impact of age on

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major complications. All p-values were from 2-tailed tests and p

Risk Factors for Postoperative Complications of Percutaneous Nephrolithotomy at a Tertiary Referral Center.

We sought to describe and evaluate the complications related to percutaneous nephrolithotomy and identify risk factors of morbidity according to the m...
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