title: Confident intraoperative decision making during percutaneous nephrolithotomy: does this patient need a second look?
abstract: OBJECTIVE
  To evaluate intraoperative decision making regarding the necessity of second-look nephroscopy after percutaneous nephrolithotomy.
  
  
  METHODS
  Percutaneous nephrolithotomy was performed cooperatively by a urologist and radiologist equipped with a high-resolution C-arm. Ultrasonic lithotripsy was performed followed by thorough flexible nephroscopy and fluoroscopy. At conclusion patients were prospectively classified as radiologically and/or endoscopically stone free. If confident that complete stone clearance had been atraumatically achieved, a ureteral stent was placed. If there was suspicion of trauma or residual calculi, a nephrostomy tube was inserted. Postoperative CT was performed and allowed fragment classification as stone free, less than 2 mm, 2 to 4 mm, or 4 mm or greater.
  
  
  RESULTS
  Average stone dimensions were 640.2 +/- 412.5 mm2 in 39 consecutive renal units. Computed tomographic imaging demonstrated that 26 renal units (66.7%) were stone free after primary procedure, with 5 (12.8%), 5 (12.8%), and 3 (7.7%) having fragments less than 2 mm, 2 to 4 mm, and greater than 4 mm, respectively. Of the 34 renal units considered endoscopically and fluoroscopically stone free, postoperative CT demonstrated 9 with residual fragments, all less than 4 mm. Of the 5 renal units not considered radiologically and endoscopically stone free, 4 had fragments on CT. Nephrostomy tubes were avoided in 33 patients. This intraoperative decision was supported by negative predictive values of 100%, 88%, and 73% at postoperative CT fragment detection thresholds of 4 mm, 2 mm, and 0 mm, respectively.
  
  
  CONCLUSIONS
  Rigorous fragment detection allows confident intraoperative decision making regarding the necessity of second-look nephroscopy.
authors.affiliation: Metropolitan Urologic Specialists PA, St. Paul, Minnesota, USA. aportis@metro-urology.com
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Portis
authors.forename: Mark A
authors.initials: MA
authors.lastname: Laliberte
authors.forename: Cindy
authors.initials: C
authors.lastname: Holtz
authors.forename: Wenjun
authors.initials: W
authors.lastname: Ma
authors.forename: Michael S
authors.initials: MS
authors.lastname: Rosenberg
authors.forename: Carl A
authors.initials: CA
authors.lastname: Bretzke
mesh_terms: D004724:Endoscopy; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D007669:Kidney Calculi / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous; D024162:Second-Look Surgery / Q000706:statistics & numerical data*