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November 2017 -
Volume 15, Issue 9

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From the Editor

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Original contribution/Clinical Investigation
Diabetes Mellitus - Knowledge, Management and Complications: Survey report from Faisalabad-Pakistan
Ijaz Anwer, Ahmad Shahzad, Kashmira Nanji, Farah Haider, Muhammad Masood Ahmad

Alanine aminotransferase indicates excess weight and dyslipidemia
Mehmet Rami Helvaci, Orhan Ayyildiz* Mustafa Cem Algin, Yusuf Aydin, Abdulrazak Abyad, Lesley Pocock

Comparative Analysis of Antimicrobial Peptides Gene Expression in Susceptible/Resistant Mice Macrophages to Leishmania major Infection

Hamid Daneshvar, Iraj Sharifi, Alireza Kyhani, Amir Tavakoli Kareshk, Arash Asadi

Does socio-economic status of the patients have effect on clinical outcomes after coronary artery bypass grafting surgery?
Forough Razmjooei, Afshin Mansourian, Saeed Kouhpyma

Comparison of the uterine artery Doppler indices during pregnancy between gestational diabetes and diabetes mellitus and healthy pregnant women
Nazanin Farshchian, Farhad Naleini, Amir Masoud Jaafarnejhad,
Parisa Bahrami Kamangar

Survey single dose Gentamicin in treatment of UTI in children with range of 1 month to 13 years old in Jahrom during 2015
Ehsan Rahmanian, Farideh Mogharab,
Vahid Mogharab

Evaluation of control of bleeding by electro cauterization of bleeding points of amplatz sheath tract after percutaneous nephrolithotomy (PCNL) in Jahrom Peymanieh hospital during year 2015-2016
Ali Reza Yousefi , Reza Inaloo

Comparison of the three-finger tracheal palpation technique with triple ID formula to determine endotracheal tube depth in children 2-8 years in 2016-2017
Anahid Maleki, Alireza Ebrahim Soltani, Alireza Takzare, Ebrahim Espahbodi,
Mehrdad Goodarzi , Roya Noori

Effect of Sevoflurane and Propofol on pulmonary arterial pressure during cardiac catheterization in children with congenital heart diseases
Faranak Behnaz, Mahshid Ghasemi , Gholamreza Mohseni, Azim Zaraki
Population and Community Studies

Prevalence and risk factors of obesity in children aged 2-12 years in the Abu Dhabi Islands
Eideh Al-Shehhi, Hessa Al-Dhefairi, Kholoud Abuasi, Noora Al Ali, Mona Al Tunaiji, Ebtihal Darwish

Study and comparison of psychological disorders in normal students and students with multiple sclerosis in Shahrekord
Neda Ardestani-Samani, Mohammad Rabiei, Mohammad Ghasemi-Pirbalooti, Asghar Bayati, Saeid Heidari-Soureshjani

Comparative study of self-concept, physical self-concept, and time perspective between the students with multiple sclerosis and healthy students in Shahrekord
Neda Ardestani-Samani, Mohammad Rabiei, Mohammad Ghasemi-Pirbalooti, Asghar Bayati, Saeid Heidari-Soureshjani

Relationship between Coping Styles and Religious Orientation with Mental Health in the Students of the Nursing-Midwifery Faculty of Zabol
Nasim Dastras, Mohsen Heidari Mokarrar, Majid Dastras, Shirzad Arianmehr

Tuberculosis in Abadan, Iran (2012-2016): An Epidemiological Study
Ali-Asghar ValiPour, Azimeh Karimyan, Mahmood Banarimehr, Marzieh Ghassemi, Maryam Robeyhavi, Rahil Hojjati,
Parvin Gholizadeh

Family Stability and Conflict of Spiritual Beliefs and Superstitions among Yazdi People in Iran: A Qualitative Study
Zahra Pourmovahed , Seyed Saied Mazloomy Mahmoodabad ; Hassan Zareei Mahmoodabadi ; Hossein Tavangar ; Seyed Mojtaba Yassini Ardekani ; Ali Akbar Vaezi

A comparative study of the self-actualization in psychology and Islam
Simin Afrasibi, Zakieh Fattahi

The effectiveness of cognitive - behavioral therapy in reducing the post-traumatic stress symptoms in male students survivors of earthquake in the central district of Varzeghan
Sakineh Salamat, Dr.Ahad Ahangar, Robab Farajzadeh

Reviews

Effects and mechanisms of medicinal plants on stress hormone (cortisol): A systematic review
Kamal Solati, Saeid Heidari-Soureshjani, Lesley Pocock

Comparing Traditional and medical treatments for constipation : A Review Article
Mohammad Yaqub Rajput

A review of anti-measles and anti-rubella antibodies in 15- 25 year old women in Jahrom City in 2011
Ehsan Rahmania , Farideh Mogharab, Vahid Mogharab

Review of percutaneous nephrolithotomy in children below 12 years old in Jahrom hospital, during 2010-2014
Ali Reza Yousefi , Reza Inaloo

Physical and mental health in Islam
Bahador Mehraki, Abdollah Gholami

International Health Affairs

The Challenges of Implementation of Professional Ethics Standards in Clinical Care from the viewpoint of Nursing Students and Nurses
Saeedeh Elhami, Kambiz Saberi, Maryam Ban, Sajedeh Mousaviasl, Nasim Hatefi Moadab, Marzieh Ghassemi

Cognitive Determinants of Physical Activity Intention among Iranian Nurses: An Application of Integrative Model of Behavior Prediction
Arsalan Ghaderi, Firoozeh Mostafavi, Behzad Mahaki, Abdorrahim Afkhamzadeh,
Yadolah Zarezadeh , Erfan Sadeghi

Effect of resilience-based intervention on occupational stress among nurses
Hossein Jafarizadeh, Ebrahim Zhiyani, Nader Aghakhani, Vahid Alinejad, Yaser Moradi

Education and Training

Calculation of Salaries and Benefits of Faculty Members in the Ministry of Health and Medical Education of Iran
Abdolreza Gilavand

The effect of education on self-care behaviors of gastrointestinal side effects on patients undergoing chemotherapy
Shokoh Varaei, Ehsan Abadi Pishe, Shadan Pedram Razie, Lila Nezam Abadi Farahani

Creating and Validating the Faith Inventory for Students at Islamic Azad University of Ahvaz
Solmaz Choheili, Reza Pasha, Gholam Hossein Maktabi, Ehsan Moheb

Creating and Validating the Adjustment Inventory for the Students of Islamic Azad University of Ahvaz
Homa Choheili, Reza Pasha, Gholam Hossein Maktabi, Ehsan Moheb

Evaluating the Quality of Educational Services from the Viewpoints of Radiology Students of Ahvaz Jundishapur University of Medical Sciences
Abdolreza Gilavand, Jafar Fatahiasl

An Investigation of Psychosocial aspect of Iranian Nursing Students' Clinical Setting
Mahsa Boozaripour , Zanyar Karimi, Sima Zohari Anbohi, Amir Almasi-Hashiani, Fariba Borhani

Clinical Research and Methods

Comparison of the Antibacterial Effects of Chlorhexidine Mouth washes with Jaftex Mouth wash on Some Common Oral Microorganisms (An in Vitro Study)
Ebrahim Babadi, Zahra Bamzadeh, Fatemeh Babadi

Study of the effect of plasma jet on Fusarium isolates with ability to produce DON toxins
Elham Galin Abbasian, Mansour Bayat, Arash chaichi Nosrati, Seyed Jamal Hashemi, Mahmood Ghoranneviss

The comparison of anti-inflammatory effect in two methods of topical dexamethasone injection and topical application of ginger alcoholic extract after removing mandibular wisdom teeth
Sahar Zandi, Seyyed Muhammadreza Alavi, Kamran Mirzaie, Ramin Seyedian, Narges Aria, Saman Jokar

The effect of curcumin on growth and adherence of major microorganisms causing tooth decay
Leila Helalat, Ahmad Zarejavid, Alireza Ekrami, Mohammd Hosein Haghighizadeh, Mehdi Shiri Nasab


Middle East Quality Improvement Program
(MEQUIP QI&CPD)

Chief Editor -
Abdulrazak Abyad MD, MPH, MBA, AGSF, AFCHSE

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November 2017 - Volume 15, Issue 9

Evaluation of control of bleeding by electro cauterization of bleeding points of amplatz-sheath tract after percutaneous nephrolithotomy (PCNL) in Jahrom Peymanieh hospital during year 2015-2016


Ali Reza Yousefi
Reza Inaloo

Department of Urology, Jahrom University of Medical Sciences, Jahrom, Iran

Corresponding author:
Reza Inaloo,
Department of Urology,
Jahrom University of medical sciences,
Jahrom, Iran
Tel: +989173130056
Email: rezainaloo@yahoo.com

Abstract

Introduction:
Complications frequently related to percutaneous renal surgery include renal hemorrhage, perforation of the collecting system, urinary tract infection, and injury to adjacent organs. Renal hemorrhage is the most common and worrisome complication after PCNL. In an effort to reduce postoperative hemorrhage after completion of percutaneous renal surgery, we cauterized the bleeding points over the access tract.

Material & Methods: This cross sectional study was carried out on the 85 patients who underwent PCNL between March 2015 and March 2016 in Jahrom Peymanie hospital using census sampling method. Electro cauterization of bleeding points after operation was performed for the participants. Patient’s data was collected with a research made questionnaire including clinical and diagnosis characteristics. Data was recorded by Statistics Software (SPSS, Edition14) using chi-square test and Student’s t-test.

Results: From 85 patients 58 patients (68.2%) were male and 27 patients (31.8%) were female. The patients age ranged from 20 to 82 years old. The stone size range was from 10 to 35mm. 15 patients had stones located in upper pole, 20 patients had stones located in pelvis and midpole of the kidney, 13 patients had stones located in the lower pole and 37 patients had multiple staghorn stone. The mean hemoglobin (Hb) concentration before operation was 14±0.5 mg/dL while it was 14±0.2 mg/dL after operation. There was no statistically significant correlation between hemoglobin level before and after operation (P>0.05).

Conclusion: Electro cauterization of bleeding points with an electrode probe after percutaneous surgery decreased morbidity. It is an effective and safe procedure and should be considered an option in percutaneous renal surgery.

Key words: bleeding, electro cauterization, percutaneous nephrolithotomy


INTRODUCTION

Nephrolithiasis is a common clinical disorder affecting up to 5% of the general population in the USA (l). The prevalence of renal stone disease has been rising in both sexes, being estimated that about 5% of American women and l2% of men will develop a kidney stone at some time in their life (2). Nevertheless, in certain areas of the world, as in the Middle East, the lifetime risk appears to be even higher (3). There has been heightened awareness of renal stone disease in children as well (4). Recurrence rates of 50% after l0 years and 75% after 20 years have been reported (5, 6). Clinical manifestations are characterized by lumbar pain of sudden onset (the location of pain depends on the location of stone in the urinary tract) that may be accompanied by nausea and vomiting, gross or microscopic hematuria Diagnosis of renal stone in the acute setting is beyond the scope of the present update but in brief, is represented by urinalysis and imaging. Urinalysis often reveals hematuria but the latter is absent in approximately 9% of cases (7). Crystal Luria is occasional and the presence of leucocyturia may suggest associated urinary tract infection. Unenhanced helical computed tomography (CT) scan, the most sensitive and specific radiographic test (8, 9), is becoming the diagnostic procedure of choice to confirm the presence of kidney stone and especially of ureteral stones (10). However, high doses of radiation and elevated costs must be considered (11). Since renal ultrasound (US) provides information about obstruction (12) but may miss ureteral stones, the association of US with conventional abdominal X-ray may help (13). Renal colic must be differentiated from musculoskeletal pain, herpes zoster, pyelonephritis, appendicitis, diverticulitis, acute cholecystitis, gynecologic disease, ureteral stricture or obstruction due to blood clot, polycystic kidney disease. Stone formation usually results from an imbalance between factors that promote urinary crystallization, and those that inhibit crystal formation and growth (14). The main determinants of calcium oxalate (CaOx) super saturation are oxalate and calcium concentration, while the latter associated to urinary pH determines calcium phosphate super saturation. Urinary pH itself is the main determinant of uric acid super saturation (l4).

MATERIAL AND METHODS

Sampling & data collection & statistical analysis:
In a cross sectional study we reviewed the old charts of all patients in whom cauterization of bleeding points of access tract was performed after percutaneous nephrolithotomy (PCNL). We prepared a questionnaire including questions about age, sex, size and location of stone, mean hemoglobin level before and after operation, hemoglobin drop after operation, stone free rate, operating time, length of postoperative hospital stay, postoperative urinary tract infection rate, and blood transfusion rate, presence of per renal hematoma or urinoma. Per renal hematoma or urinoma was detected by KUB sonography the day after PCNL. Stone free patient was defined as those who had no stone or stone smaller than 4mm one week after PCNL. All patients who underwent PCNL between March 2015 and March 2016 in Jahrom Peymanie hospital and who had Electro cauterization of bleeding points after operation was performed participated in this study using census sampling method. Finally 85 patients were elected to participate in this study. Data was recorded by SPSS program using chi-square test and Student’s t-test. The most important difculty in this study especially in data collection is that sometimes the charts of the patients were not complete and we needed to call them.

Operation method:
All the patients underwent regional spinal anesthesia. Renal access was obtained under Fluoroscope guidance with an 18-guage needle and a 0.038 J-tip guide wire after retrograde placement of a SF or 6F ureteral occlusion balloon catheter cystoscopically. The access tract was dilated with metal coaxial dilators to allow for the passage of a 30F-working sheath. The pneumatic lithotripter was used for lithotripsy. After completion of stone extraction, a 6F double-J catheter was inserted in ante grade fashion after withdrawal of the occlusion balloon catheter. The bleeding points were cauterized with an elongated electrode probe connected to the hand piece of a conventional electric cauterizing device. The probe touched the bleeding points gently and cauterized them for a few seconds, as one would in transurethral surgery.

The bleeding points were usually located just beneath the collecting system torn by manipulation of instruments and beneath the urothelium where the access tract entered the collecting system. Most bleeding ceased after cauterization but some did not. To avoid adjacent organ or renal pedicle injury, we never cauterized the bleeding point for too long or too deep, especially for those located over the renal pelvis or ureter.

RESULTS

Totally 85 patients who underwent PCNL and Electro cauterization of bleeding points after their operation participated in this study. From 85 patients, 58 patients (68.2%) were male and 27 patients (31.8%) were female. The patients age ranged from 20 to 82 years old. The stone size ranged from 10 to 35mm.

All the patients underwent regional (spinal or epidural) anesthesia for the operation. From 85 patients; l5 patients (17.6%) had stones located in upper pole, 20 patients (23.5%) had stones located in pelvis of the kidney, l3 patients (15.2%) had stones located in lower pole and 37 patients (43.5%) had multiple staghorn stone.

The mean hemoglobin (Hb) concentration before operation was 14±0.5 mg/dL while it was 14± 0.2 mg/dL after operation. There was no statistically signicant correlation between hemoglobin level before and after operation (P>0.05).

Figure 1: Percentage of patients with renal stone in each sex

Figure 2: Stone location


Figure 3: Mean hemoglobin level before and after PCNL

DISCUSSION

Percutaneous renal surgery is a common urologic procedure. It has been widely used for the removal of renal and upper ureteral stones and also for the treatment of pelvi-ureteral stricture and management of tumor of the upper urinary tract. Improvements in instrumentation and technology in recent years have decreased the complication rate of percutaneous renal surgery dramatically. However, complications do occur. Renal hemorrhage after percutaneous renal surgery is one of the most common complications. Bleeding may occur during any point of theprocedure. Venous bleeding is the most common type and can be controlled by clamping the nephrostomy tube. Excessive bleeding during percutaneous renal surgery may result from renal vessel injury, such as to a segmental branch. For excessive bleeding during percutaneous renal surgery, in addition to nephrostomy tube clamping, several techniques can be used to minimize bleeding Intravenous administration of mannitol with hydration leads to forced diuresis, dilation of renal tubules, swelling of the renal capsule, and increased intra renal pressure, which may enhance the effect of tamponed. Application of the Kaye tamponade balloon catheter is an alternative to minimize postoperative hemorrhage, and the device can be placed and inated to control bleeding in the access tract (4). Angiography and embolization is required in persistent and active bleeding, in addition to the above-mentioned conservative treatment. Despite these efforts, percutaneous renal surgery still has a greater transfusion rate than other common urologic procedures. Because of the potential risks associated with blood transfusion, including transfusion reactions and transmission of the human immunodeciency virus, hepatitis, and other infectious diseases, it is important to develop a procedure to minimize renal hemorrhage after percutaneous renal surgery.

Serial reports about tubeless percutaneous renal surgery for selected patients have recently been published. After draining with a double-J catheter or externalized ureteral catheter on removal of the nephroscope with a Working sheath and completion of the percutaneous renal procedure, the guidewire over the nephrostomy site was still in place. The guidewire was removed, and the wound was closed if no bleeding was evident at the nephrostomy site. The advantages of tubeless percutaneous renal surgery include earlier discharge, lower analgesic requirement, faster recovery to resume normal activities, and greater cost benets. In literature and Medline there is only one article performed by Yeong-Chin J Ou et al in Chiayi Christian Hospital, Chiayi, Taiwan (1). In their study Electro cauterization of bleeding points with an elongated electrode probe was performed in 249 patients. The age, height, weight, preoperative hemoglobin level, stone burden, operating time, stone free rate, length of postoperative hospital stay, postoperative urinary tract infection rate, and blood transfusion rate were recorded by retrospective chart review. There was no statistically signicant differences in age, height, weight, stone burden, operating time, stone free rate, or length of postoperative hospital stay found between patients with or without Electro cauterization. No increase occurred in the postoperative urinary tract infection rate in patients who received Electro cauterization, and these patients had a statistically signicant decrease in the transfusion rate. No nephrostomy tube was inserted at the completion of surgery in 84 (33.7%) of the 249 operations in which Electro cauterization was performed. They nally concluded that Electro cauterization of the bleeding points at the end of percutaneous renal surgery decreases the blood transfusion rate without causing an increase in morbidity. This procedure is safe and effective and may make more patients suitable for tubeless modification (1). Encouraged by the positive results, many institutions have expanded the use of tubeless modication for percutaneous renal surgery. After cauterization of the bleeding points in percutaneous renal surgery, 84 (33.7%) of 249 PCNLs were performed with a tubeless modication without any sequelae. In 2002, Limb and Bellman (12) reported that of 398 patients undergoing percutaneous renal surgery, 112 (28.1%, 86 undergoing PCNL and undergoing ante grade endopyelotomy) underwent a tubeless modication. The stone burden of their patients who underwent tubeless PCNL was 330-279 mm2. In our study, after cauterization of bleeding points, the percentage of patients undergoing tubeless modication was greater (33.7% versus 28.1%), even though the stone burden was large in our patients.

CONCLUSION

Electro cauterization of bleeding points with an elongated electrode probe after percutaneous surgery decreased the transfusion rate without causing any increase in surgical morbidity. The procedure also made more patients undergoing percutaneous renal surgery suitable for a tubeless modication. It is an effective and safe procedure and should be considered an option in percutaneous renal surgery.

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