الفهرس 
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Abstract
R
enal stones remain one of the most common urologic problems. Percutaneous Nephrolithotomy is the optimal treatment for complex renal stone. The goal of percutaneous nephrolithotomy (PCNL) is to ensure complete stone clearance with minimal morbidity. The technique of PCNL has developed over several years. The access tract can be dilated using a balloon dilator (BD) or a single-step Amplatz dilator.
In the current trial we aimed to evaluate the efficacy of Percutaneous Nephrolithotomy as a primary modality of treatment for complex renal stones, moreover the feasibility and safety of single step dilatation using Amplatz dilator versus Balloon dilatation in the Percutaneous Nephrolithotomy access.
100 patients were enrolled in our study and were randomized into 2 groups; 50 subjected to percutaneous nephrolithotomy (PNCL) by single step 30-Fr Amplatz dilatation and 50 subjected to percutaneous nephrolithotomy by Balloon dilatation.
Both groups were subjected to the same preoperative, operative and postoperative investigations, evaluation and management. Apart from the tract access dilation was by single step 30-Fr Amplatz dilatation in 50 patients (group SSAD) and by Balloon dilatation in 50 patients (group BD).
The results of our study were as follows:
In our study, age of the patients ranged from 20 to 60 years with mean ± SD age (40.84 ± 8.53), of whom 75 (75.0%) males and 25 (25.0%) females.
The main presenting symptom was loin pain in 88 patients (88.0%). The loin pain was associated with other symptoms. These symptoms were in the form of dysuria 76 patients (76.0%), hematuria 39 patients (39.0%), fever 6 patients (6.0%), and nausea & vomiting 20 patients (20.0%). Urine analysis showed slightly turbid urine in 86 patients (86%) and turbid in 14 patients (14%), with pus cells median (IQR) 3 (3-4) range 2-10, and RBCs median (IQR) 15 (9-38) range 3-80. The serum creatinine of the studied patients range was 0.4-1.4 mg/dl.
Regarding stone characteristics, Stones were Mid-lower in 62 patients (62.0%), Mid-upper in 38 patients (38.0%), in 27 patients (27.0%) pelvicalyceal system was with mild HN, in 12 patients (12.0%) pelvicalyceal system was with moderate HN, and 61 patients (61.0%) pelvicalyceal system was with NAD.
The patients were performed under general anesthesis, were placed in the prone position. Ureteral catheter was fixed in all 100 patients (100%), it was removed at the day of discharge with the urethral catheter.
The most used puncture access was single puncture which was done in 83 patients (83%). In 17 patients (17%) two punctures were used.
The mean operative time in our study was 102.98 ± 9.46 minutes (Mean ± SD) with range of 90-120 minutes. Mean operative time for group SSAD was (mean±SD 103.62 ± 9.73) and (mean±SD 102.34 ± 9.24) for group BD. The difference in the mean operative time between both groups was not statistically significant. Mean time of establishing puncture access, tract creation and dilation was 1.70 ± 0.30 minutes in group SSAD. While it was 1.60 ± 0.28 minutes in group BD. The difference in the mean time for tract creation and dilation between both groups was statistically insignificant.
Mean hemoglobin level (Hb g/dl) Mean±SD preoperative was 12.51±1.07, while postoperative was 11.83 ± 1.10, so mean Hb g/dl level DROP was -0.68 ± 0.17. group SSAD mean Hb g/dl preoperative was 12.18±0.98, while postoperative was 11.53±1.07, and mean difference was -0.65 ± 0.21. group BD mean Hb g/dl preoperative was 12.83 ± 1.06, while postoperative was 12.13 ± 1.06, and mean difference was -0.70 ± 0.11. Mean difference in hemoglobin level (Hb g/dl) in group SSAD was -0.65 ± 0.21, while was -0.70 ± 0.11 in group BD, this mean difference in hemoglobin level between both groups was not statistically significant in difference.
The stone free rate was insignificant in 45 patients (90%) for group SSAD and residual in 5 patients (10%). While, for group BD stone free rate was insignificant in 44 patients (88%) and residual in 6 patients (12%). This difference is not statistically significant (p>0.05).
There were no major complications occur in our study such as bowel injury, renal pelvic perforation, hydro or pneumothorax, hepatic or splenic injury in both groups.
Our study proved that there was no statistical significant difference between the two methods of dilatation (BD and SSAD) in Operative Time, access tract dilation time, Hemoglobin decrease level pre-postoperative, Early Postoperative Complications, Stone-free rate after PCNL, Except for the economic issue the Single Step Amplatz 30-Fr dilator is much more economic & many times cheaper than the single used balloon dilator which is a very important factor for any financial issue considering the patient, the surgeon, the hospital and even the whole country economical supply for the health industries as there is no clear scientific or statistical benefit for the usage of balloon dilator instead of the Single Step Amplatz 30-Fr dilator. In addition, the Single Step Amplatz 30-Fr dilator is safe, efficient, time saving technique and economic as well.
CONCLUSION
from the results of our study we concluded that:
• Percutaneous Nephrolithotomy is the mainstay in treatment of complex renal stones. It must be done by experienced endourologist in an operative theater with all facilities for stone management.
• Balloon dilatation and single step Amplatz 30-Fr dilatation are all effective and safe in Percutaneous Nephrolithotomy renal tract access. Compared with balloon dilatation, single step Amplatz 30-Fr dilation is a better choice, as it is more feasible and has no statistical significant difference with balloon dilation in renal access creation time, stone free rate and blood loss.
• The use of single step Amplatz dilator 30-Fr for dilating renal access tract in PCNL is a time saving procedure, being safe, subjectively economical and an effective technique to gain renal access. We found no specific complication with this technique, and the morbidity rated were comparable with other modalities.
• We recommend its use for patients undergoing PCNL.