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ORIGINAL ARTICLE
Year : 2023 | Volume
: 34
| Issue : 4 | Page : 194-198
Outcomes of complete supine percutaneous nephrolithotomy: Comparison of elderly and young patients
Siavash Falahatkar1, Samaneh Esmaeili1, Mohammad Reza Javid1, Shahab Aali1, Habib Eslami-Kenarsari2
1 Urology Research Center, Razi Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
2 Department of Statistics, Vice-Chancellorship of Research and Technology, Guilan University of Medical Sciences, Rasht, Iran
Correspondence Address:
Mohammad Reza Javid
Urology Research Center, Razi Hospital, Sardar Jangle St., Rasht, Guilan
Iran
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_23_23
Purpose: Percutaneous nephrolithotomy (PCNL) in the elderly is challenging due to age-related decline in organ function and the general depletion of the physiological reserve. We aimed to compare the efficacy and safety of complete supine PCNL (csPCNL) between young and elderly patients with kidney stones. Materials and Methods: In this cross-sectional comparative study, a total of 656 patients aged 18–64 years (young group) and 83 patients aged ≥65 years (elderly group) who underwent csPCNL between April 2009 and September 2021 were studied. The two groups were compared in terms of clinical characteristics, stone-related parameters, perioperative parameters, and postoperative outcomes. Results: The mean age of elderly and young patients was 69.87 and 47.1 years, respectively. The female-to-male ratio was 1:1.21. The mean hemoglobin drop was significantly greater in the younger group (1.38 ± 1.08 vs. 1.01 ± 0.84 g/dL, P = 0.007). The stone-free rate was comparable in the two groups (96.8% vs. 91.5%), whereas hospitalization was significantly longer in the younger group (P = 0.014). There was no significant between-group difference regarding the postoperative complication rates (P = 0.36). On multivariate analysis, body mass index, stone burden, and presence of staghorn stone were identified as independent predictors of the success of the operation (P = 0.04, odds ratio [OR] = 1.091; P = 0.000, OR = 0.962; P = 0.045, OR = 0.404). None of these factors had an independent effect on the occurrence of postoperative complications (P > 0.05). Conclusion: CsPCNL in the elderly age group is an effective and safe procedure with high stone-free rates and similar complication rates compared to younger patients.
Keywords: Age, complete supine percutaneous nephrolithotomy, elderly, urolithiasis
The incidence of kidney stones among elderly patients has shown an increasing trend. Elderly patients with kidney stones are at risk of recurrent urinary tract infection and worsening of renal function with a decrease in the glomerular filtration rate.[1],[2] Therefore, endourologists prefer surgical treatment instead of conservative interventions in these patients.[1],[2] Moreover, the presence of comorbidities in elderly patients may increase the rate of complications and the length of hospital stay.[3],[4],[5],[6]
Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for large kidney stones in both elderly and young patients.[6] Studies have shown that the complication rates for PCNL are very different between elderly and young patients.[6],[7],[8],[9] Considering the compromised cardiovascular reserve and anesthesia-related risks in elderly patients, age seems to play a key role in perioperative and postoperative morbidity.[4],[10] Elderly patients are less tolerant to bleeding and septic complications owing to their overall poor organ reserve and the associated comorbidities.[3],[10]
Complete supine PCNL (csPCNL) has been shown to have a number of benefits for both surgeons and patients including shorter operative time, less patient handling, easier access to the urethra, and reduced risk of injury to peripheral nerves and cervical spine.[11],[12],[13],[14]
Due to the better tolerance of the supine position than the prone position in patients with cardiovascular and respiratory problems, the prevalence of which increases with age, this study aimed to evaluate whether there are significant differences between the outcomes of csPCNL in elderly and younger patients.
Materials and MethodsThis was a cross-sectional comparative study approved by the Ethics Committee of the Guilan University of Medical Sciences (IR.GUMS.REC.1400.468). A total of 739 adult patients who underwent csPCNL under general anesthesia between April 2009 and September 2021 were enrolled. All surgeries were performed by a single experienced surgeon in two medical centers (one educational medical center and one private hospital). Baseline demographic data (age, sex) and medical history were collected via a checklist. Other parameters such as the duration of surgery and the length of hospital stay were collected from the patient records extracted from a database at the Urology Research Center. Patients aged <18 years and patients with incomplete medical records were excluded from the study.
Informed consent of patients was not required because the study analyzed anonymized clinical data and the personal information of patients was kept confidential.
Success in surgery was assessed by requesting ultrasound and kidney, ureter and bladder (KUB) X-ray for patients 1 month after surgery. The surgery (csPCNL) was considered to be successful if there was either no residual lithiasis or the presence of residual stone sized <4 mm. Patients were divided into two age groups: 656 (88.8%) young adults (age: 18–64 years) and 83 (11.2%) elderly patients (age ≥65 years).
The preoperative evaluation included laboratory tests, ultrasonography, intravenous urogram, and/or computed tomography. In all patients, a ureteral catheter was inserted in a retrograde fashion for the injection of saline or contrast media. Then, PCNL was performed in the complete supine position under general anesthesia.
Collecting system puncture was done by an 18-gage needle under a fluoroscopic guide. We used one-shot technique (using 30 Fr Amplatz sheet) for dilatation in csPCNL involving two steps: step 1 was the insertion of guidewire and dilatation with 9F dilator; step 2 was dilatation with Amplatz dilator. Small stones were directly extracted by grasper or irrigation and large stones were first treated by pneumatic devices. In the presence of significant perforation, ureteral obstruction, large residual stone, or active bleeding, a nephrostomy tube was inserted.
The collected data were entered into the SPSS (IBM Corp., Chicago, IL, USA) software version 22. Chi-square test, Fisher's test, and Mann– Whitney tests were used to assess between-group differences. Logistic regression was used to identify predictors of postoperative complications and success rate. P < 0.05 was considered indicative of statistical significance.
ResultsThe mean age in our overall cohort was 50.4 ± 12.0 years. The mean age in the elderly and young groups was 69.8 years and 47.1 years, respectively. The overall female to male ratio was 1:1.21 (334 female versus 404 male).
The baseline characteristics and preoperative findings in the two groups are compared in [Table 1]. The prevalence of comorbid diseases (such as diabetes, hypertension, ischemic heart disease, metabolic syndrome, hepatic and pulmonary insufficiency) was significantly higher in the elderly group (76.8% vs. 46.9%, P < 0.001). Complete or partial staghorn stone was found in 11.9% of young patients and 16.2% of elderly patients (P = 0.288).
The prevalence of preoperative urinary tract infection was 18% in young patients and 24.7% in elderly patients (P = 0.16). The mean operative time was comparable in the two groups (45.3 ± 18.5 min and 45.8 ± 19.7 min, respectively; P = 0.830). The mean hemoglobin drop was significantly higher in the younger group (1.38 ± 1.08 vs. 1.01 ± 0.84 g/dL, respectively; P = 0.007). Stone-free rate (residual stones <4 mm) was higher in the elderly group (96.8% vs. 91.5%) with no statistical difference (P = 0.146). The length of hospital stay was significantly greater in the younger group (P = 0.014). A total of 153 (20.7%) patients developed complications. There was no significant between-group difference with respect to the incidence of postoperative complications (21.2% in the younger group versus 16. 9% in the elderly group; P = 0.36). Need for blood transfusion, fever, and hematuria were the most common postoperative complications [Table 2].
On multivariate analysis, body mass index (BMI) (P = 0.04, odds ratio [OR] = 1.091), stone burden P = 0.000, OR = 0.962), and presence of staghorn stone (P = 0.045, OR = 0.404) were identified as independent predictors of the success of the operation [Table 3]. None of these factors showed any independent effect on the occurrence of postoperative complications (P > 0.05).
DiscussionPCNL in the elderly is challenging due to aging, decreased function of all organs, and the general depletion of physiological reserve. Elderly patients are less tolerant of blood loss, infectious complications, and other complications caused by PCNL due to poor organ reserve.[15],[16],[17]
The skill and experience of the surgeon and the method used for performing PCNL play a major role in determining the success rate of surgery and the incidence of complications. Moreover, surgeons are typically more careful in selecting old patients for surgery due to the presence of underlying diseases and a higher risk of postoperative complications. Therefore, alternative therapies are often preferred over surgery in elderly patients. It seems that the selection of elderly patients is sometimes done so carefully that in some studies it has led to higher successful results in this group than in the young group.[18],[19]
A meta-analysis reported that performing PCNL in the supine method has a similar success rate, operative time, and length of hospital stay compared to the prone method, while having fewer complications (fever and the need for blood transfusions). It was also determined that the supine method may have advantages over the prone position, especially in patients with underlying diseases.[20] Another meta-analysis by Yuan et al. showed shorter mean operative time and lower incidence of blood transfusions in the supine position, while the stone-free rate was slightly higher in the prone position.[21] Therefore, we reviewed the results of csPCNL performed by a single surgeon over a period of 12 years in two age groups (>65 years and <65 years).
Despite the fact that the United Nations considers old age as ≥60 years, many studies have used 65 years as the threshold for old age.[22],[23] In general, it seems that a definite age cannot be declared as a gateway to old age. Indeed, various genetic and environmental factors affect the decline in organ function and depletion of body reserves, which may occur at a younger age and affect the outcomes of surgery. In general, due to the increase in average life expectancy in recent years, in this study, age >65 years was considered as the threshold for categorizing old age.
In the present study, 55.6% of the patients in the young group were men, while the elderly group contained relatively more women (51.8%). The sex distribution was not significantly different between the two groups (P = 0.203). Contrary to our study, in most previous studies,[18],[22],[24],[25] men accounted for a greater proportion of elderly patients with nephrolithiasis than women.
In our study, as expected and similar to what was reported in previous investigations,[9],[18],[26] a significant difference was observed between the comorbidity levels in the elderly group (76.8%) and the young group (46.9%) (P = 0.001). However, postoperative data analysis revealed no significant between-group difference with respect to the duration of surgery, duration of fluoroscopy, number of tracts, the occurrence of postoperative complications, or success rate of surgery.
In previous studies, the mean operative time in the elderly group varied widely from 52 to 131 min.[9],[18],[22],[24] In our study, the mean operative time was 45.8 min, which is significantly shorter than that in other studies. One of the reasons for the shorter duration of the operation is related to the position of the patients. Many previous studies have reported significantly shorter operative tine in the supine position than in the prone position.[11],[27],[28]
In our study, although the use of multiple tracts was more frequent in the young group (5.5% vs. 2.6%), the between-group difference in this respect was not statistically significant (P = 0.729). This finding is consistent with several previous studies.[9],[24],[25],[29] However, Haberal et al. reported a significantly higher number of multiple tracts in the elderly group (17.6% vs. 13.1%; P = 0.006).[18]
Moreover, in most of the studies, length of hospital stay was similar in the two groups[19],[24],[30] or longer in the elderly group.[7],[9],[29] However, in our study, the length of hospital stay was longer in the young group, owing to the difference in the discharge protocol for patients in the two participating centers. In private hospitals, patients tend to be discharged earlier to reduce costs. Furthermore, in private hospitals, the patient is discharged based on the opinion of the attending physician, while in educational hospitals, the residents tend to keep the patients longer. In our study, 48.2% of patients in the elderly group and 33.4% of patients in young group were admitted to a private hospital.
Most common postoperative complications reported in our study were fever, blood transfusions, and hematuria; 16.9% of patients in the elderly group developed at least one complication. The need for blood transfusions was 7.2% in the elderly group, which was not significantly different from that in the young group. However, the hemoglobin drop was significantly higher in the young group (P = 0.007). One of the important reasons for this difference is that elderly people have lower baseline hemoglobin, which increases the need for blood transfusions in this group with even less hemoglobin drop compared to young patients. A meta-analysis[26] showed that postoperative blood transfusion in elderly patients is significantly higher than in young patients. Also, Haberal et al.[18] reported that despite higher hemoglobin drop in the young group, the rate of blood transfusion was similar between the two groups. They attributed this discrepancy to the surgeons' braver approach in the younger group. A more cautious approach to surgery in the elderly group resulted in no difference between the two groups in the need for blood transfusions.
The previously reported success rates of PCNL surgery in the elderly group range from 60.7% to 94%.[6],[7],[8],[9],[24],[29],[30] In most of the studies, presence of residual stone with dimensions <4 mm is considered as surgical success.[6],[8],[19],[24],[30] Although many studies have found comparable stone-free rate between young and elderly age groups,[6],[22],[24],[29] several previous studies have revealed higher stone-free rates in the elderly group.[18],[25] In the present study, the success rates (stone-free patients and patients with residual calculi <4 mm) were 96.8% for the elderly patients and 91.5% for young patients (P = 0.146).
On multivariate analysis, BMI, stone size, and the presence of staghorn stones were identified as predictors of successful csPCNL. BMI and stone size, despite being significant in statistical calculations, do not seem to be clinically significant due to the very small OR (OR = 1.040 and OR = 1.090, respectively). None of the variables was identified as an independent predictor of postoperative complications. Very similar results were reported in previous studies. Stone size, number of stones, and the presence of complete or partial staghorn stones were identified as independent predictors of success rate, while only operative time was reported as a predictor of postoperative complications.[18],[24]
The main limitations of our study were the retrospective nature of data collection and the limited number of patients, especially in the elderly group. A larger study evaluating the effect of underlying and intervening variables in this patient population is required to obtain more definitive evidence.
ConclusionThe outcomes of csPCNL, stone-free rates, and the incidence of complications were similar in elderly and young groups. Despite the prevalence of underlying diseases in the elderly, csPCNL is effective and safe in the elderly age group with comparable results to younger patients.
Data Availability Statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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