title: Percutaneous nephrolithotomy in super obese patients (body mass index ≥ 50 kg/m²): overcoming the challenges.
abstract: OBJECTIVE
  To analyse our experience with and the outcomes and lessons learned from percutaneous nephrolithotomy (PCNL) in the super obese (body mass index [BMI] ≥50 kg/m(2) ).
  
  
  METHODS
  In this institutional review board approved study we retrospectively reviewed our PCNL database between July 2011 and September 2014 and identified all patients with a BMI ≥ 50 kg/m(2) . Patient demographics, peri-operative outcomes and complications were determined. Additionally, we identified a number of special PCNL considerations in the super obese that can maximize safe outcomes.
  
  
  RESULTS
  A total of 21 PCNL procedures performed on 17 super obese patients were identified. The mean patient age was 54.8 years, the mean BMI was 57.2 kg/m(2) and the mean stone area was 1 037 mm(2) . Full staghorn stones were observed in six patients and partial staghorns in four patients. The mean operating time was 106 min and the mean haemoglobin decrease was 1.2 g/dL. The overall stone-free rate was 87%. There were four total complications: two Clavien grade II, one Clavien IIIb and one Clavien IVb. We identified several special considerations for safely preforming PCNL in the suber obese, including using extra-long nephroscopes and graspers, using custom-cut extra long access sheaths with suture 'tails' secured to easily retrieve the sheath, choosing the shortest possible access tract, readily employing flexible nephroscopes, placing nephroureteral tubes rather than nephrostomy tubes postoperatively, and meticulous patient positioning and padding.
  
  
  CONCLUSIONS
  With appropriate peri-operative considerations and planning, PCNL is feasible and safe in the super obese. Stone clearance was similar to that reported in previous PCNL series in the morbidly obese, and is achievable with few complications.
authors.affiliation: Smith Institute for Urology, Hofstra North Shore Long Island Jewish School of Medicine, New Hyde Park, NY, USA.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Keheila
authors.affiliation: Smith Institute for Urology, Hofstra North Shore Long Island Jewish School of Medicine, New Hyde Park, NY, USA.
authors.forename: David
authors.initials: D
authors.lastname: Leavitt
authors.affiliation: Smith Institute for Urology, Hofstra North Shore Long Island Jewish School of Medicine, New Hyde Park, NY, USA.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Galli
authors.affiliation: Smith Institute for Urology, Hofstra North Shore Long Island Jewish School of Medicine, New Hyde Park, NY, USA.
authors.forename: Piruz
authors.initials: P
authors.lastname: Motamedinia
authors.affiliation: Smith Institute for Urology, Hofstra North Shore Long Island Jewish School of Medicine, New Hyde Park, NY, USA.
authors.forename: Nithin
authors.initials: N
authors.lastname: Theckumparampil
authors.affiliation: Smith Institute for Urology, Hofstra North Shore Long Island Jewish School of Medicine, New Hyde Park, NY, USA.
authors.forename: Micheal
authors.initials: M
authors.lastname: Siev
authors.affiliation: Smith Institute for Urology, Hofstra North Shore Long Island Jewish School of Medicine, New Hyde Park, NY, USA.
authors.forename: David
authors.initials: D
authors.lastname: Hoenig
authors.affiliation: Smith Institute for Urology, Hofstra North Shore Long Island Jewish School of Medicine, New Hyde Park, NY, USA.
authors.forename: Arthur
authors.initials: A
authors.lastname: Smith
authors.affiliation: Smith Institute for Urology, Hofstra North Shore Long Island Jewish School of Medicine, New Hyde Park, NY, USA.
authors.forename: Zeph
authors.initials: Z
authors.lastname: Okeke
mesh_terms: D015992:Body Mass Index; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007669:Kidney Calculi / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous / Q000379:methods*; D009767:Obesity, Morbid / Q000150:complications / Q000601:surgery*; D061646:Operative Time; D056888:Patient Positioning; D017410:Practice Guidelines as Topic; D015995:Prevalence; D011379:Prognosis; D012189:Retrospective Studies
keywords: obesity; percutaneous nephrolithotomy; renal stones