Discussion:
The increase in the average life expectancy and aging population has
resulted in more renal stones being detected in geriatric patients. It
is important to determine the most appropriate method when treating
renal stones in elderly patients due to 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 renal stones, it can result in
major complications. Skolarikos and de la Rosette reported that the rate
of major complications after PCNL was 0.9-4.7% for septicemia,
0.6-1.4% for renal bleeding requiring an intervention, 2.3-3.1% for
pleural injury, and 0.2-0.8% for colonic injury (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 treatment 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 smaller than 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 complex 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 (stone-free status or fragments smaller
than 4 mm) was 89% for the elderly and 92% for the younger patients.
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,
there was no significant difference between the stone sizes of the
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 option for large renal 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 compared to younger 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, there is a need for
prospective studies with a larger series of geriatric patients with
staghorn stones, focusing specifically on complications, as well as
evaluating their medical complications.