Discussion:
The increase in the aging population has resulted in more renal stones
being detected in geriatric patients. It is important to determine the
most appropriate approach when managing renal stones in geriatric
patients because of age-related cardiovascular and pulmonary system
deterioration and presence of multiple comorbidities. In elderly
patients with multiple comorbidities, observation may be an option for
asymptomatic small stones. However, in elderly patients, stone growth is
observed to occur over a shorter time, and urinary tract infection
causes pain that requires obstruction and analgesics (10), adversely
affecting their kidney functions. Although PCNL is accepted as an
effective and safe method in large kidney stones, it can result in major
complications. One of the review by Skolarikos et al. stated that the
rate of major complications after PCNL were septicemia (0.9-4.7%),
bleeding requiring an intervention (0.6-1.4%), pleural injury
(2.3-3.1%), and colonic injury (0.2-0.8%) (11). Changes in the
cardiorespiratory reserve of elderly patients make them less tolerant to
bleeding or septic complications (12). Therefore, a detailed evaluation
and a careful approach are required in the management of renal stones in
elderly patients.
Despite advances in instrumentation and technology, staghorn stones are
difficult to manage. In a study retrospectively reviewing 42 PCNL
procedures performed on 33 patients aged 65 years and older compared
with younger patients (47% of the stones were staghorn), 82% (27/33)
of the patients were determined to achieve stone-free status or have
fragments <5 mm at three months after surgery. In this study,
PCNL was shown to be a safe and effective treatment for elderly
patients, even in the presence of renal stones; however, a higher rate
of transfusion was required in this group (13). Şahin et al. reported
the PCNL results of 27 patients aged over 60 years and compared them to
178 PCNL procedures performed in 166 younger patients at the same time
interval (14). Only 25% of the patients had staghorn renal stones, and
the success rate was 89% and 92% for elderly and younger patients,
respectively. In contrast to previous studies reporting higher
stone-free rates (78-93%) after PCNL in staghorn renal stones (5,15),
the success rates obtained from the current study including only
complete staghorn stones were found to be 67.4% and 54.7%, for the
elderly and younger groups, respectively. This lower rate of success can
be explained by technical limitations, such as the exclusion of partial
staghorn stones, use of only one access point for each patient,
lithotripsy being performed only with a pneumatic lithotripter, and not
using a flexible nephroscope. Similar to our study, Kuzgunbay et al.,
who performed 47 PCNL procedures in 45 patients aged 65 years with
complete staghorn stones and compared their data to 37 younger patients,
found the success rate after the first procedure as 53% in the elderly
group and 37.8% in the control group (16).
In our study, in which only complete staghorn stones were included, the
stone sizes were similar between elderly and younger patients, which
shows the comparability of the two groups in terms of stone burden.
Furthermore, length of hospital stay, operation and fluoroscopy
durations, and success rate were found to be similar in the elderly and
younger groups. Therefore, we consider that advanced age does not have a
negative effect on intraoperative parameters and postoperative outcomes
in complex stones. However, in our study, while the decrease in
hemoglobin was significantly higher in younger people (1.9 ± 1.3 g/dl
versus 1.3 ± 1.2 g/dl, p = 0.001), the rate of transfusion requirement
was moderately higher in the elderly (7.2% versus 18.6 %). This
suggests that the rate of transfusion was higher in the elderly relative
to the decrease in hemoglobin. The higher transfusion rate in the
elderly indicates that they have lower tolerance to hemoglobin drop.
Stoller et al. found higher blood transfusion rates after PCNL in
elderly patients with complex renal stones (13). Şahin et al. reported
the transfusion rates after PCNL as 21% in elderly patients and 18% in
younger patients (14). In another study, the transfusion rate after PCNL
in staghorn renal stones was detected as 10.6% in the elderly and
13.5% in the younger group, while the hemoglobin change was 1.46 ± 1.29
g/dl and 1.70 ± 1.33 g/dl, respectively (16).
Percutaneous nephrolithotomy is recognized as an effective and safe
treatment modality for large kidney stones. Although the efficacy of the
procedure has been proven, complication rates of up to 83% have been
reported in the literature, including bleeding requiring transfusion
(7%), organ damage (0.4%), and infectious events (up to 33%) (17,18).
Elderly patients tend to have more comorbidities, making them more
vulnerable to fatal bleeding and septic complications (19). In a study
by Okeke et al., the overall complication rate after PCNL was
significantly higher in elderly patients (20). However, Karami et al.
reported that age alone was not a predictive factor for high
complication rates (21). In another study, no major complications were
observed after PCNL in staghorn renal stones in the elderly and younger
population, and their minor complication rates were similar (16). In
contrast, in our study, there was a higher rate of minor complications,
such as bleeding requiring transfusion in eight and postoperative fever
requiring antibiotic change in seven of the 43 patients in the elderly
group, while sepsis, pneumothorax and bowel injury were not observed in
either group. This suggests that elderly patients are less tolerant of
bleeding and less resistant to infectious events because they are more
prone to having comorbidities. To our knowledge, this is the first study
to separately evaluate post-PCNL complications in elderly patients with
staghorn renal stones according to the Clavien-Dindo classification.
There are some limitations to our study. First, it had a retrospective
design and a limited number of patients. Second, there was no long-term
comparison of surgical complications. Finally, further prospective
studies are needed with a larger series of geriatric patients with
staghorn stones, focusing specifically on complications, as well as
evaluating their medical complications.