Day Care Percutanepus Nephrolithotomy (PCNL) in Rural Indian setup Mulawkar PM, Panpaliya GS, Bhat...

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 1

• 10 patients• Median op time 83 min• Median recovery room stay 240 min• UROLOGY 76: 1288–1292, 2010 2

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 U

sed with Consent of Patient

What Else is Possible

Thank You