1. Day Care Percutanepus Nephrolithotomy (PCNL) in Rural Indian setup Mulawkar PM, Panpaliya GS, Bhat GR

2. Three patients OPD PCNL Mean op time 87 min Post-op Hospital stay 175 minutes Can Urol Assoc J 2010;4(4):E86-90 1

3. 10 patients Median op time 83 min Median recovery room stay 240 min UROLOGY 76: 1288–1292, 2010 2

4. Peculiarities of Rural setting Lack of transport Lack of medical care in villages Discharge in 24 hr

5. Selection Criterion : Pre-operative ASA class 1 or 2 Age 16 or more No active cardiac disease, solitary kidney No h/o fever in recent past (3 months) – Urine culture was not done if the patient did not have H/o fever in last 3 months Serum creatinine < 2 mg/dl Stone size was not considered as a criterion

6. Selection Criterion: Family Patient has adequate family support Patient and family must be agreeable to discharge planning Patient has handy access to mobile phone – at least one phone in the family

7. Selection Criterion: Intra-op Single tract No intraoperative complications No pelvicaliceal system perforation No residual stones Minimal intraoperative bleeding No bleeding when removing sheath

8. Selection Criterion: Post-op No postoperative complications No bleeding from nephrostomy or after NT removal Hemodynamically stable Able to ambulate without significant difficulty Normal KUB x ray findings Pain under control with oral analgesics

9. Anesthesia Protocol HS= Alprazolam, Ranitidine Pre-op= Clonidine 1.5mcg/Kg over 10 min Induction: Midazolam + Buterphenol + Glycopyrolate + Propofol + Scoline Relaxant: Pavulon Maintainence : O2, N2O, Sevoflurane Reversal + Ondensetron Nasal O2 : 2 hr post-op Mobilization 3 hr post op

10. PONV Minimal Narcotics No Ketamine Midazolam instead of Diazepam – Reduce duration of sedation Propofol instead of Pentothal – Built in anti-emetic effect – Clear headed recovery – No hangover – Propofol euphoria

11. Pain relief Pre puncture : Lignocaine + adrenaline infiltration Post-procedure Bupivacaine infiltration Liberal use of Paracetamol – Max dose 1 gm qid (1gm in 100 ml infusion)

12. Surgery Lignocaine + Adrenaline infiltration before puncture Bupivacaine infiltration post-op Smallest possible tract Nephrostomy = 8 fr (when kept) Remove every fragment Lithotripsy: Pneumatic and Laser

13. Study Population Jan 2011 to Aug 2014 Total PCNL = 441, Day care = 29 Age 16-70 (mean 40.2), F=12 M=17 Creatinine= 0.6 to 1.9 mg/dl (mean 1.15mg/dl) Max stone diameter =8 to 43 mm (mean 17, median 15) Op time 60-180 min (mean 92 min) Calyx of entry : Lower =26 Upper =2 Mid=1

14. Drainage of PCS Post-op

15. Tract Size

16. Stone Location

17. Results All stone free (100%) All except 1 discharged without nephrostomy Significant pain = 3 (IV Paracetamol) Fever = 1 Mild Hematuria = 1 Readmission = 2 – UTI 1 – Malarial fever 1

18. Yeh Hain India Meri Jaan! Administrative delay = 3 – No vehicle to transport =2 – Insurance physician did not come =1

19. Conclusion In highly selected patients, day care PCNL is safe and feasible. In our setting same day discharge although feasible, is not practical as most of the patients are from remote places and medical facilities in interior places are not adequate for same day discharge.

20. Same day discharge is possible!! Video Used with Consent of Patient

21. What Else is Possible

22. Thank You