Tag Archive for: PCNL England

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Article of the week: Outcomes of PCNL in England

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Mr. Armitage and Mr. Withington discussing their article.

If you only have time to read one article this week, it should be this one

Percutaneous nephrolithotomy in England: practice and outcomes described in the Hospital Episode Statistics database

James N. Armitage, John Withington*, Jan van der Meulen*, David A. Cromwell*, Jonathan Glass, William G. Finch§, Stuart O. Irving§ and Neil A. Burgess§

Department of Urology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, *Clinical Effectiveness Unit, The Royal College of Surgeons of England, Department of Urology, Guy’s & St Thomas’ NHS Foundation Trust, London School of Hygiene and Tropical Medicine, London, and §Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK

OBJECTIVE

• To investigate the postoperative outcomes of percutaneous nephrolithotomy (PCNL) in English National Health Service (NHS) hospitals.

PATIENTS AND METHODS

• We extracted records from the Hospital Episode Statistics (HES) database for all patients undergoing PCNL between March 2006 and January 2011 in English NHS hospitals.

• Outcome measures were haemorrhage, infection within the index admission, and rates of emergency readmission and in-hospital mortality within 30 days of surgery.

RESULTS

• A total of 5750 index PCNL procedures were performed in 165 hospitals.

• During the index admission, haemorrhage was recorded in 81 patients (1.4%), 192 patients (3.8%) had a urinary tract infection (UTI), 95 patients (1.7%) had fever, and 41 patients (0.7%) had sepsis.

• There were 595 emergency readmissions in 518 patients (9.0%). Reasons for readmission were varied: 70 (1.2%) with UTI, 15 (0.3%) sepsis, 73 (1.3%) haematuria, 25 (0.4%) haemorrhage, and 25 (0.4%) acute urinary retention.

• There were 13 (0.2%) in-hospital deaths within 30 days of surgery.

CONCLUSIONS

• Haemorrhage and infection represent relatively common and potentially severe complications of PCNL.

• Mortality is extremely rare after PCNL (about one in 400 procedures overall) but almost one in 10 patients have an unplanned hospital readmission within 30 days of surgery.

• Complications of PCNL may be under-reported in the HES database and need to be corroborated using other data sources.

 

Editorial: How are we doing with percutaneous nephrolithotomy in England?

Over the past several years, with publications of studies evaluating multiple aspects of nephrolithiasis using large databases, our overview of kidney stone disease has vastly expanded. The most recent addition by Armitage et al. [1], published in this issue of BJUI, gives us a view of percutaneous nephrolithotomy (PCNL) outcomes in England that we otherwise would have difficulty seeing without tapping into a database study. Several salient features of this investigation are worth pointing out.

With any study comes the uncertainty of its validity. Evidence-based medicine (EBM) theory dictates we first ask ‘Are the results valid?’ rather than ‘What are the results?’. This study reports similar outcomes to a prior database study of the BAUS, giving us confidence that data from different sources still produce somewhat similar outcomes, hence adding validity to both studies [2]. Moreover, it is further reassuring that the type of epidemiological source of the information was derived from completely different origins, i.e. Armitage et al. [1] used an administrative database from Hospital Episode Statistics (HES) to create their outcomes while the BAUS used a voluntary online prospective database for British surgeons.

The second question that forms the basis of EBM is ‘What are the results?’. The HES data confirmed several findings of PCNL seen in other studies, including in both international series from the Clinical Research Office of the Endourological Society (CROES) as well as American administrative database studies using the Nationwide Inpatient Sample (NIS) [3-5]. Overall complications occur anywhere from 6% to 15% of the time, with the most common complications including infection and bleeding. Compared with these recent studies, the HES study reports lower bleeding, UTI and sepsis rates, which the authors admit could represents an under-reporting phenomenon. Mortality is an exceedingly rare event in all these studies. Overall, complication rates are comparable and give us assurance that they align approximately with other worldwide data. Another important finding with the HES database is the decreased length of stay for patients over time. Lastly, from a physician credentialing standpoint this study has relevant findings. It suggests that the HES administrative database may be a viable source of information to assist in the surgeon validating process.

Weaknesses of administrative database studies include the lack of detail that prospective clinical databases provide. Clinically pertinent PCNL endpoints are inherently absent for both patient and surgical domains. Missing patient information includes stone size, stone-free rates, and patient obesity, which are all reflections of clinical case difficulty. Missing critical surgical information includes where (upper, mid or lower calyx), who (urologist or radiologist) and how (balloon, serial dilators) access is obtained. As mentioned above, the uncertainty of under-coding clinical information always exists.

Why are large database studies, including this article, important? These studies are timely given the recent advocating of retrograde ureteroscopic treatment of large renal calculi [6]. Publication of low complication rates with equal efficacy in an outpatient setting has made ureteroscopic treatment of partial and staghorn renal calculi attractive. Even laparoscopic anatrophic nephrolithotomy has been advocated to further challenge the ‘gold standard’ treatment of PCNL [7]. It is therefore clinically important that British PCNL complication rates are low and that length of stay is decreasing to affirm the role that PCNL has with large renal calculi.

The role of PCNL surgery for renal calculi continues to develop but, more importantly, the value of these large epidemiological studies also continues to grow. They help us to look not only from the ground level but also give us perspective from a different, if not ‘higher’ level, which taken together helps shapes our interpretation of PCNL.

Roger L. Sur

Department of Urology, UC San Diego Health System, San Diego, CA, USA

References

  1. Armitage JN, Withington J, Van der Meulen J et al. Percutaneous nephrolithotomy in England: practice and outcomes described in the hospital episode statistics database. BJU Int 2014; 113: 777–782
  2. Armitage JN, Irving SO, Burgess NA, British Association of Urological Surgeons Section of Endourology. Percutaneous nephrolithotomy in the United Kingdom: results of a prospective data registry. Eur Urol 2012; 61: 1188–1193
  3. de la Rosette J, Assimos D, Desai M et al. The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: indications, complications, and outcomes in 5803 patients. J Endourol 2011; 25: 11–17
  4. Mirheydar HS, Palazzi KL, Derweesh IH, Chang DC, Sur RL. Percutaneous nephrolithotomy use is increasing in the United States: an analysis of trends and complications. J Endourol 2013; 27: 979–983
  5. Ghani KR, Sammon JD, Bhojani N et al. Trends in percutaneous nephrolithotomy use and outcomes in the United States. J Urol 2013; 190: 558–564
  6. Aboumarzouk OM, Monga M, Kata SG, Traxer O, Somani BK. Flexible ureteroscopy and laser lithotripsy for stones >2 cm: a systematic review and meta-analysis. J Endourol 2012; 26: 1257–1263
  7. Aminsharifi A, Hadian P, Boveiri K. Laparoscopic anatrophic nephrolithotomy for management of complete staghorn renal stone: clinical efficacy and intermediate-term functional outcome. J Endourol 2013; 27: 573–578

 

Video: PCNL practice and outcomes in England

Percutaneous nephrolithotomy in England: practice and outcomes described in the Hospital Episode Statistics database

James N. Armitage, John Withington*, Jan van der Meulen*, David A. Cromwell*, Jonathan Glass, William G. Finch§, Stuart O. Irving§ and Neil A. Burgess§

Department of Urology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, *Clinical Effectiveness Unit, The Royal College of Surgeons of England, Department of Urology, Guy’s & St Thomas’ NHS Foundation Trust, London School of Hygiene and Tropical Medicine, London, and §Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK

OBJECTIVE

• To investigate the postoperative outcomes of percutaneous nephrolithotomy (PCNL) in English National Health Service (NHS) hospitals.

PATIENTS AND METHODS

• We extracted records from the Hospital Episode Statistics (HES) database for all patients undergoing PCNL between March 2006 and January 2011 in English NHS hospitals.

• Outcome measures were haemorrhage, infection within the index admission, and rates of emergency readmission and in-hospital mortality within 30 days of surgery.

RESULTS

• A total of 5750 index PCNL procedures were performed in 165 hospitals.

• During the index admission, haemorrhage was recorded in 81 patients (1.4%), 192 patients (3.8%) had a urinary tract infection (UTI), 95 patients (1.7%) had fever, and 41 patients (0.7%) had sepsis.

• There were 595 emergency readmissions in 518 patients (9.0%). Reasons for readmission were varied: 70 (1.2%) with UTI, 15 (0.3%) sepsis, 73 (1.3%) haematuria, 25 (0.4%) haemorrhage, and 25 (0.4%) acute urinary retention.

• There were 13 (0.2%) in-hospital deaths within 30 days of surgery.

CONCLUSIONS

• Haemorrhage and infection represent relatively common and potentially severe complications of PCNL.

• Mortality is extremely rare after PCNL (about one in 400 procedures overall) but almost one in 10 patients have an unplanned hospital readmission within 30 days of surgery.

• Complications of PCNL may be under-reported in the HES database and need to be corroborated using other data sources.

 

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