PCNL IN A STAGHORN CALCULUS: ANTIBIOTIC CONSIDERATIONS

The patient was admitted 12 hours prior to the procedure.As a protocol we start them on oral antibiotics 2 weeks prior to the surgery ( after ascertaining the culture negativity).

A broad spectrum antibiotic is administered prior to the start of the procedure.With this antibiotic prophylaxis protocol we can reduce the post PCNL sepsis and thus the postoperative morbidity and stay.

In-spite of urine culture negativity and prophylaxis antibiotic administration around 10%  of the patients develop post PCNL fever and SIRS.The postoperative fever is common in staghorn calculi, diabetic patients,previous culture positive cases,patients on indwelling stents/ PCN, long duration of the surgery.

We involve Critical Care Specialist in all such cases where we anticipate postoperative complications especially sepsis. 

In all cases we send urine culture from the urine aspirated from the first puncture( as the bladder urine culture and pelvicalyceal urine culture can be different).In cases where the aspirate is turbid we postpone the surgery and rather go for the definitive PCNL after 48 hours with indwelling  PCN.

 We attempt to clear the pelvicalyceal system of all the residual fragments because in some cases the residual stones can be a cause of the persistent sepsis.Preplanned punctures( preoperative CT urography helps in determining the punctures and plan the PCNL properly),placing punctures simultaneously with guide wires in situ, precise and meticulous dilatation are keys to a successful PCNL in a staghorn calculus.these measures ensure a blood less( or minimal bloody  ) field and the necessity of high pressure irrigation can be obviated.The high pressure irrigation in cases of bleeding leads to endotoxemia and bacterimia.

Use of flexible nephroscopy for clearing calculi in remote/inaccessible calyces gives stone clearance rate higher.With advent of routine use of penams/ third generation cephalosporins the MDR bacteria strain is on the rise.

PREPLANNED PUNCTURES WITH GUIDEWIRES IN SITU RESULTS IN QUICK CLEARANCE

To eradicate MDR bacteria in cases of stagorn calculi we have resorted to colistin and sulbactum therapy with meropenam combination and PCNL ( with the aim of giving a complete stone free outcome).As any residual fragments can harbour the MDR bacteria and can lead to refractory sepsis in the evnt the fragment causes ureteric obstrution.