Endourological management of urolithiasis in hepatically compromised patients.

OBJECTIVE

Hepatic insufficiency is a medically debilitating disease state, resulting in coagulopathy, malnutrition and immunological suppression. Before and after liver transplantation patients are at increased risk for urolithiasis due to nutritional factors, acidosis and hyperoxaluria.

METHODS

We retrospectively reviewed our experience with endourological procedures for nephrolithiasis in hepatic compromised patients awaiting transplants and recipients. A total of 16 patients, including 13 males and 3 females, with a mean age of 52.8 years (range 46 to 59) underwent a total of 24 endoscopic stone procedures at 23 anesthesia sessions. Procedures included 18 ureteroscopies (extraction with or without lithotripsy), 5 percutaneous nephrolithotomies and 1 cystoscopic stone manipulation. Of the patients 12 patients had significant hepatic insufficiency and were evaluated for transplantation. Four patients had a prior orthotopic liver transplant at surgery. The most common causes of cirrhosis were hepatitis C and ethanol abuse. Of 22 sessions 12 were preceded by the use of fresh frozen plasma, platelets, vitamin K, desmopressin or recombinant factor VIIa for reversing severe coagulopathy. In 4 patients procedures were preceded by transfusion for anemia.

RESULTS

All 24 procedures were successfully accomplished. Average hospital stay was 2.8 days (range 0 to 8) with 5 patients treated on an outpatient basis. A total of 52 calculi with a mean size of 10.7 mm (range 2 to 40) were treated. Of the 17 evaluated stone analyses 15 revealed pure or mixed calcium oxalate calculi, while the remaining 2 were struvite. Morbidity included 2 postoperative transfusions and 1 rehospitalization for urinary tract infection. One death was due to multisystem organ failure in a pretransplant patient who underwent bilateral ureteroscopy.

CONCLUSIONS

Endourological procedures may be accomplished in this morbid group of patients. Mandatory preoperative medical evaluation, selective prehospitalization with supportive services and pre-stenting patients for passive ureteral dilation have led to successful endourological outcomes. Our experience has led us to adopt protocols and apply a team approach for the successful endoscopic management of urolithiasis in this complicated group of patients.