Nephrostomy Tube Drainage Research Articles

Comparison of Tubeless Mini Percutaneous Nephrolithotomy with Conventional Technique in a Tertiary Care Center

Introduction: Mini Percutaneous Nephrolithotomy (mPCNL) is a safe and efficient method for management of nephrolithiasis. Post procedure nephrostomy tube drainage is considered as the standard practice. In recent years, tubeless mPCNL with the use of double J (DJ) stent alone has replaced the placement of the nephrostomy tube.
 Aims: This study intends to evaluate the safety and efficacy of tubeless Mini Percutaneous Nephrolithotomy.
 Methods: A total of 80 patients with Nephrolithiasis, admitted to Urology Unit of Nepalgunj Medical College, between September 2018 and September 2019 were enrolled in the study and divided into two groups: Tubeless group where tube was omitted and Standard Group where it was placed. The two groups were compared with respect to hemoglobin drop and blood transfusion requirement, hospital stay and analgesic requirement in the post-operative period.
 Results: Mean age of the patients was 34.30 ± 13.19 years. Mean stone size was 19.03 mm. The mean change in hemoglobin after standard mPCNL was 1.68 gm/dl and that in the tubeless group was 1.11 (p=0.018). The tubeless group had a significantly (p=0.001) shorter hospital stay (3.05 ± 1.23 days) compared to standard group (3.85 ± 0.86). The postoperative pain as assessed by visual analogue scale, was more in the standard group necessitating additional analgesia. It was significantly higher in the standard group at 12, 24, 48 hours, as compared to the tubeless group.
 Conclusion: Placement of nephrostomy tube can be omitted as a routine practice as Tubeless mini PCNL has an added advantage of significantly reduced postoperative pain, less analgesic requirement, shorter hospital stay, less postoperative blood loss.

Факторы риска осложнений контактной уретеролитотрипсии

to determine main risk factors for complications of ureterolithotripsy. a retrospective analysis of the results of 545 ureteroscopies performed in 506 patients with ureteral stones over the past 7 years at the urological clinic named after M.F. Vladimirsky was carried out. The relationship between preoperative and intraoperative factors and complications of ureterolithotripsy was analyzed. The overall complication rate was 22.4%. The risk of intraoperative complications was proved to increase (p<0.05) along with the stone size, location in proximal ureter, stone impaction for more than 3 weeks and the degree of hydronephrosis. No preoperative stenting or nephrostomy tube prior to ureteroscopy was associated to an increased risk of intraoperative complications (RR=2.88; p=0.03). Patients with preoperative drainage of upper urinary tract has lower probability of intraoperative complications (OR=0.35; p=0.03). The risk of developing stricture and ureteral obliteration in uncomplicated ureteroscopy was minimal (RR=0.008, p=0.0001). Small ureteral perforation and pronounced mucosal inflammation around the stone have the similar influence on the risk of complications, which was more than 7.5 times (p=0.0001) higher than in uncomplicated ureteroscopy. Large ureteral perforation was associated with the highest risk of stricture formation and ureteral obliteration, which was 64 times (p=0.0001) higher than in uncomplicated ureteroscopy. The rate of complications of ureterolithotripsy directly depends on the following factors: size and location of the stone, the stone impaction, pre- and intraoperative (nephrostomy tube) drainage of the upper urinary tract, the degree of hydronephrosis, level of bacteriuria and intraoperative trauma complications.

Does Ureteral Stent Drainage Prior to Cystectomy Increase the Risk of Subsequent Upper Tract Urothelial Carcinoma and Ureteral Complications?

OBJECTIVETo guide management of preoperative hydronephrosis prior to radical cystectomy (RC), we compared post-RC risks of upper tract urothelial carcinoma (UTUC) and ureteroenteric anastomotic complications between ureteral stent and percutaneous nephrostomy tube drainage. METHODSPatients who underwent RC for urothelial carcinoma without a prior diagnosis of UTUC at our institution between 2000 and 2015 were included and divided into 4 patient groups: (1) no hydronephrosis (75%, N = 787); (2) hydronephrosis without preoperative upper tract drainage (13%, N = 132); (3) hydronephrosis treated with nephrostomy tube (3%, N = 36); (4) hydronephrosis treated with ureteral stent (9%, N = 94). The incidence of post-RC UTUC and ureteral complications was compared using Kaplan-Meier analyses and multivariable Cox proportional hazard modeling. RESULTSWe identified a total of 1049 patients who underwent RC (median postoperative follow-up 4.3 years). Five-year post-RC UTUC incidence was 6.6%, 10.2%, 17%, 18.7% for groups 1-4, respectively (P= .13). On multivariable analysis, nephrostomy tube drainage (hazard ratio [HR] 4.10, P = .02) and preoperative ureteral stenting (HR 2.35, P = .04) were both associated with UTUC after RC, but ureteral stenting did not have a significantly higher association with UTUC than nephrostomy tube drainage. Severe hydronephrosis was also associated with development of UTUC (HR 4.03, P = .02). The incidence of ureteroenteric anastomotic complications did not vary by drainage modality. CONCLUSIONPreoperative hydronephrosis was associated with UTUC after RC, but ureteral stent placement did not increase the risk of UTUC or ureteral complications relative to nephrostomy tube placement. The choice of hydronephrosis drainage pre-RC should not be guided by concern for UTUC risk.

AUTHOR REPLY

We appreciate the thoughtful commentary and agree with the points that were raised. As mentioned in the editorial, early repair is often easier when significant inflammation has not been allowed to set in. Barriers to early repair are numerous. If a ureteral injury is identified intraoperatively, a urologist may not be available for repair, as may occur if the inciting surgery is performed at an ambulatory surgery center or institution without routine urologic coverage. If a urologist is available, they may not feel comfortable with repair. If the reason is due to lack of experience with minimally-invasive ureteral reconstruction, the patient would most benefit from conversion to an open approach with immediate repair after a discussion with the patient's family. Although this conversion increases the morbidity to the patient, it pales in comparison to the morbidity of temporary nephrostomy tube or catheter drainage with delayed repair. If the urologist has limited experience with performing a ureteral reimplantation, temporary drainage with immediate transfer to a center with experience in ureteral reconstruction for early repair allows the patient to avoid months of morbidity. We are often hopeful that placement of a ureteral stent will be sufficient in healing a ureteral injury. Although it has success with grade 1 injuries, those of higher grade will likely develop a stricture or persistent leak requiring reconstruction at a later date if not repaired immediately.

Success of Laparoscopic Robot-Assisted Approaches to Ureteropelvic Junction Obstruction Based on Preoperative Renal Function.

No literature exists examining the risk factors for failure after robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction (UPJO) in children. The goal of this study was to compare the success of robot-assisted pyeloplasty between UPJO kidneys with preoperative renal function <30% versus >30%. We performed a retrospective review of all patients who underwent a robot-assisted laparoscopic pyeloplasty for UPJO at a single institution from June 2009 to September 2013 by four surgeons. A failed procedure was defined as necessitating a second surgery for the UPJO, nonresolution of symptoms with no improvement of washout on postoperative mercaptoacetyltriglycine (MAG)-3 scan, and/or a reduction in renal function of the obstructed kidney to <10%. Success was compared between patients with <30% and >30% preoperative differential renal function via the Fisher exact test. There were 116 patients who were included. At a mean follow-up of 507 days after the surgical procedure, there were eight (8%) failures. The majority of the failures (5/8) were in kidneys whose preoperative function was <30%. There was a significant difference in the success of procedures performed on kidneys with >30% (86/89, 97%) versus <30% (7/12, 58%) preoperative renal function (P=0.0005). In this large cohort of patients, kidneys with preoperative function >30%, robot-assisted pyeloplasty had a 97% success rate. This was significantly different than the success of robot-assisted pyeloplasty (58%) in kidneys with preoperative function <30%. This information is useful for patient counseling as these patients may be at higher risk for a secondary procedure such as a subsequent nephrectomy or may benefit from a preoperative trial of nephrostomy tube drainage.

Determinants of nephrostomy tube dislodgment after percutaneous nephrolithotomy.

Percutaneous nephrolithotomy (PCNL) traditionally necessitates the placement of a nephrostomy tube at the conclusion of the surgical procedure. Although tubeless PCNL has become more popular, patients with complex problems still need traditional nephrostomy tube drainage. The goal of this study was to investigate whether patient body mass index (BMI) impacted inadvertent nephrostomy tube dislodgement. Furthermore, we hoped to determine whether nephrostomy tube type impacted tube dislodgement rates. A retrospective review between 2005 and 2012 of 475 consecutive PCNL cases was undertaken. Patients were categorized based on the type of nephrostomy tube placed. BMI was examined as a continuous variable. The primary outcome of nephrostomy tube dislodgment was determined based on imaging obtained at the time of PCNL and postoperative hospitalization. Logistic regression analysis was then used to adjust for nephrostomy tube type and BMI. Overall, 24 (5.5%) total patients experienced nephrostomy tube dislodgment postoperatively. The mean BMI for patients experiencing nephrostomy tube dislodgment was 39.7 vs 30.9 for those without tube dislodgment (P<0.0001; 95% confidence interval [CI] 4.6 to 12.9). Using logistic regression and adjusting for the use tube type, BMI was an independent predictor of tube dislodgement (P<0.001). For each unit of increase in BMI, the likelihood of tube dislodgment increased by 6% (1.06). After adjusting for BMI, however, nephrostomy tube type was not found to be an independent predictor of nephrostomy tube dislodgment. Nephrostomy tube type did not influence nephrostomy tube dislodgment rates. As a patient's BMI increased, the likelihood of tube dislodgment increased in a directly proportionate fashion. This is possibly because of the nephrostomy tube being fixed directly to the mobile skin associated with their fat pannus. Although the nephrostomy tube type itself did not affect tube dislodgment rates, a redesigned nephrostomy tube or fixation device should take into account the above findings related to obese patients to reduce the likelihood of nephrostomy tube dislodgment.

S99 Concurrent comparisons between results of antimicrobial susceptibility tests performed on percutaneous nephrostomy tube drainage fluids, and voided urine samples

S99 Concurrent comparisons between results of antimicrobial susceptibility tests performed on percutaneous nephrostomy tube drainage fluids, and voided urine samples

4:10 PM Abstract No. 50 - Pharmacomechanical pulverization of mycetoma in the renal collecting system

Purpose Renal mycetomas are rare manifestations of candidia infection in children, which if untreated may lead to urinary tract obstruction (UTO), renal failure and high mortality. We report successful use of an AngioJet device to pulverize an obstructing renal pelvis candida mycetoma resistent to conventional nephrostomy tube (NT) drainage in a small child with UTO and renal failure. Materials and Methods Case history : A 2.5 year old, 10.5 kg, former 26 wk premature girl was admitted with recurrent candida urinary tract infection and fungal balls within the right pelvicalyceal system leading to UTO, oliguria and renal failure (serum Cr 2.7 mg/dL). NT placement and administration of IV Amphotericin B (AmB) failed to improve urine output or renal failure. Ultrasound and antegrade pyelogram showed persistent dilatation of an obstructed right collecting system plugged with fungal balls. Technique : The in situ 8.5F NT catheter was exchanged for a vascular sheath through which a 6-French AngioJet Spiroflex catheter (AngioJet ® Ultra thrombectomy system, Medrad International ® ) with a 15-mm active tip was advanced into the renal pelvis and calyces under ultrasound and fluroscopic monitoring. Fungal balls were drawn into the catheter,fragmented by saline pressure jets from the active tip and aspirated simultaneously. The saline in the AngioJet system was replaced with AmB solution and pharmacomechanical pulverization of the fungal balls was performed followed by upsizing of the NT to 10F. Results After mycetoma pulverization, NT urine output improved from 0 to 490mL in the first 12 hr, and serum Cr decreased to 1.65 within 24 hr. The patient had no complications from the AngioJet therapy. She completed a 21 day course of systemic and transcatheter AmB and NT was removed. At 2 week follow-up, serum Cr was 0.6 mg/dL, and ultrasound and antegrade studies showed reduced hydronephrosis with no recurrence of fungal balls. At 12 month follow- up, patient had no recurrence of candida infection, no imaging recurrence of mycetoma and serum Cr 0.5 mg/dL. Conclusion Pharmacomechanical pulverization using an AngioJet thrombectomy system is an effective treatment option for refractory renal collecting system mycetoma.

U-shaped Bilateral Ileal Ureter Substitution for Failed Conservative Management of Retroperitoneal Fibrosis: A Case Report

Introduction: Retroperitoneal fibrosis (RPF) can cause bilateral chronic obstruction of the ureters. Definitive surgical management includes ureterolysis with omental wrapping or ileal ureter substitution. We present a case of bilateral ureteral obstruction from RPF in a patient with a large abdominal aortic aneurysm (AAA) managed with bilateral ileal ureter substitution in the U-configuration. Case presentation: A 65-year-old man had medically refractory RPF with bilateral ureteral obstruction that failed ureteral stenting. He required bilateral nephrostomy tubes. Initially bilateral ureterolysis was considered, but given his large AAA and the proximity of the ureters to the aneurysm, ileal substitution was recommended. We attempted a “7” shaped configuration at first, but the natural lie of the ileal segment led us to perform a “U”-shaped substitution with the ends sewn to both renal pelvises and the middle portion sewn to the bladder dome. Postoperatively, the patient recovered well, and at two months followup, the patient has a stable serum creatinine and no hydronephrosis. He no longer requires ureteral stenting or nephrostomy tube drainage. Conclusion: Bilateral ileal ureter substitution is a viable option for patients with RPF induced hydronephrosis who fail conservative management. The U-shape is a novel configuration that may facilitate this procedure.

The Effect of American Society of Anesthesiology Scores on Percutaneous Nephrolithotomy Outcomes

Introduction: To evaluate the effect of American Society of Anesthesiology (ASA) scores on percutaneous nephrolithotomy (PNL) outcomes. Materials and Methods: The records of 186 consecutive patients undergoing PNL procedures from 2006 to 2011 at a single institution were evaluated. Patients were divided into a low-risk group with a preoperative ASA of I or II and a high-risk group with ASA of III or IV. Postoperative complications were classified according to the modified Clavien classification system. Results and Conclusions: There were 140 cases in the low-risk and 46 cases in the high-risk groups. The mean operative time was 72 min (40–120 min) and 86 min (55–125 min) and the complication rates were 17.8 and 19.5% for the low- and high-risk groups, respectively. The average duration of nephrostomy tube drainage was 3.3 ± 1 and 4.2 ± 1.5 days for the low- and high-risk groups, respectively. Stone-free rates were 85 and 82% for the low- and high-risk groups, respectively. PNL can be safely performed in the ASA high-risk patient population.

Intractable Hemorrhagic Cystitis After Hematopoietic Stem Cell Tranplantation—Is There a Role for Early Urinary Diversion in Children?

Severe hemorrhagic cystitis is a major complication in the pediatric population undergoing hematopoietic stem cell transplantation. Percutaneous nephrostomy tube drainage as a treatment for severe hemorrhagic cystitis has rarely been investigated. We examined children undergoing hematopoietic stem cell transplantation for risk factors associated with severe hemorrhagic cystitis, as well as our experience with percutaneous nephrostomy tube placement as an adjunctive management strategy. Using prospectively collected data from the Blood and Marrow Transplant Database at the University of Minnesota, we reviewed 40 pediatric patients with severe hemorrhagic cystitis from 1996 to 2010. Specific treatment for each patient was administered at the discretion of the attending physician and generally included bladder irrigation before bladder fulguration or percutaneous nephrostomy tube placement. A percutaneous nephrostomy tube was placed in 11 patients due to the intractable nature of the hemorrhagic cystitis. Of the 11 patients who underwent percutaneous nephrostomy tube drainage 5 (45%) had improvement of the hemorrhagic cystitis within 30 days and the same number had long-term resolution. Among the patients with long-term resolution hemorrhagic cystitis resolved an average of 12.4 days after percutaneous nephrostomy tube placement, and the tubes were removed an average of 8.8 weeks after placement. Through September 2011 mortality among patients with percutaneous nephrostomy tubes was 55% (6 of 11 patients), which was identical to the overall mortality in the severe hemorrhagic cystitis group (22 of 40). No death could be directly attributed to hemorrhagic cystitis or percutaneous nephrostomy tube placement. Placement of percutaneous nephrostomy tubes for treatment of severe hemorrhagic cystitis results in long-term improvement in intractable hemorrhagic cystitis, and is a safe and viable option for the majority of patients.

The Impact of Surgical Approach and Urinary Diversion on Patient Outcomes in Pediatric Pyeloplasty

Recent comparisons of the impact of the surgical approach on pediatric pyeloplasty outcomes have generally incorporated a form of internal ureteral drainage. We hypothesized that the surgical approach does not affect outcomes in children who undergo unstented pyeloplasty and stenting offers no long-term benefit in those with pediatric pyeloplasty. After receiving institutional review board approval we examined the records of all children who underwent initial pyeloplasty from December 2001 to December 2009. We compared unstented and stented pyeloplasties, and each surgical approach in the unstented group. During the study period 367 pyeloplasties were performed, including 231 unstented and 136 stented procedures. When comparing unstented to stented pyeloplasties, there was no difference in the complication or failure rate. Of unstented pyeloplasties 71, 67 and 93 were done using a transperitoneal laparoscopic approach, a flank approach and dorsal lumbotomy, respectively. There were 5 failures, of which 2 were laparoscopic, 2 used a flank approach and 1 used dorsal lumbotomy (p = 0.51). A total of 31 patients, including 10 treated with a laparoscopic approach, 3 with a flank approach and 18 with dorsal lumbotomy (p = 0.02), required second procedures, of which 24 were temporary drainage for a urine leak. Univariate analysis of factors associated with secondary procedures in the unstented pyeloplasty group showed that only surgical approach was significant (p = 0.05). In pediatric pyeloplasty there is no significant difference in outcome between stented and unstented repairs. In unstented repairs complications may vary by surgical approach. Regardless of the approach unstented pyeloplasty is safe and effective in the pediatric population.

Emphysematous pyelitis, ureteritis and cystitis

A 36-year-old man with a history of gout and a congenital solitary right kidney with chronic hydronephrosis and non-obstructive megaureter of unknown etiology presented initially with a stone on KUB and flank pain. A computed tomography (CT) scan showed a right-sided calculus which was treated with extracorporeal shock wave lithotripsy and alkalinization therapy. Several weeks post-treatment, he presented to the emergency department with cloudy urine and dysuria. His urinalysis demonstrated pyruia and hematuria. He was empirically started on ciprofloxacin, but returned to the emergency department several days later with fevers, chills and rigors but no flank pain. His creatinine had risen from 109 mmol/L at baseline to 266 mmol/L, and his white blood cell count was 15.6 × 106/L. A CT scan failed to show any residual calculi; however, it demonstrated emphysematous pyelitis (Fig. 1, arrow) with concomitant emphysematous ureteritis and cystitis (Fig. 2, arrows). His urine culture revealed a multi-drug resistant E Coli and a percutaneous nephrostomy tube was arranged after a ureteric stent insertion was unsuccessful. His pre-nephrostogram scout x-ray showed a collecting system full of gas (Fig. 3, arrows demonstrating gas in ureter and renal pelvis). He was treated with nephrostomy tube drainage and intravenous ceftriaxone. Within 5 days, he had complete clinical and radiographical resolution of the gas in his collecting system, and his renal function returned to baseline. Subsequent pressure-flow studies of urinary drainage via the nephrostomy tube (Whittaker test) showed no evidence of ureteric obstruction. It is important to distinguish emphysematous pyelitis (gas in the collecting system) from emphysematous pyelonephritis (gas in the renal parenchyma), as the latter can be more severe. Fig. 1 The computed tomography scan with the arrow pointing to the emphysematous pyelitis. Fig. 2 The computed tomography scan with the arrows pointing to the emphysematous ureteritis and cystitis. Fig. 3 The patient’s pre-nephrostogram with the arrows demonstrating gas in the ureter and renal pelvis. Empysematous pyelitis is due to E. coli infection in 69% of cases and typically responds promptly to medical therapy.1

Percutaneous Management of Staghorn Calculi in Horseshoe Kidneys: A Multi-Institutional Experience

Percutaneous nephrolithotomy (PNL) is a first-line management technique for staghorn stones and stones located in a horseshoe kidney (HK). We present our multi-institutional experience on the management of staghorn calculi within HKs. The study included 15 patients with 17 staghorn calculi in HKs who were treated by PNL in six academic institutions. All PNL procedures were performed in a standard one-session technique with fluoroscopic guidance. The following information was assessed: Number of access dilations, renal access location, blood loss, blood transfusion, stone-free rate, length of hospitalization. Intraoperative and postoperative complications as well as secondary procedures (second-look PNL, ureteroscopy, and shockwave lithotripsy) were reviewed. Mean patient age was 50 years (range 24-72 y) years old. Subcostal (n = 16) or intercostal (n = 1) puncture was performed. The average anesthesia time was 126 minutes (93-200 min). The average blood loss was 450 mL, and transfusions were deemed necessary in 20% of the cases. Single skin incisions were made for the management of 11 renal units, and multiple incisions were made in 6. The average number of tract dilations per renal unit was 2.11 (range 1-4). The overall stone-free rate was 82%. The average length of hospital stay was 4.4 days (range 3-7). The average duration of nephrostomy tube drainage was 80 hours with a range of 72 to 96 hours. Major and minor complication rate was 20% and 46.6%, respectively. The performance of PNL is a safe and effective method to manage staghorn calculi in HKs.

Tubeless Vs Tubed PCNL in Children

Purpose The Objective of this study is to compare postoperative outcomes between tubeless and conventional large bore nephrostomy tube drainage following percutaneous nephrolithotomy (PCNL) in children. Material and Methods Between May 2005 and February 2006, 54 patients age 14 years and below undergoing percutaneous nephrolithomy (PCNL) in 60 renal units and meeting the inclusion criteria were randomized to placement of a 16F nephrostomy tube (Group A, 30 renal units) or no tube drainage (Group B, 30 renal units) at the end of the procedure. Patient's ages, number and position of stones, operating time, change in haemoglobin, postoperative analgesia requirement, length of hospital stay and post operative complications were compared between the two groups. Inclusion criteria included stone size larger than 1.5 cm, no perforation or tear in palvicalyceal system during procedure, absence of anatomical obstruction e.g. PUJO, single puncture for achieving access tract, no other procedure performed under same anesthesia and no previous surgery on ipsilateral kidney. Results Group A - tubed Group B - tubeless Number of patients 28 (2 simultaneous bilateral) 26 (4 simultaneous bilateral, 1 horse-shoe kidney) Number of renal units 30 30 Male:female 15:13 16:10 Mean age 7.4 years 6.7 years Age range 3-13 years 1-13 years Size of stone (mean) 28.3 mm 21.3 mm Mean change in Hb 0.81mg /dl(0-3.3) 0.63 mg/dl (0-2.1) Mean operating time (minutes) 54.2 66 Ureteric stent in situ 30 29 How long stent retained 1.5 days 1 day Post op abdominal tenderness nil nil Analgesic requirements postoperatively mg of pethidine (mean) 6.8 mg. 4.17mg (p 0.05) Duration of urinary leakage nil Nil Post op US done 0 17 Collection present 0 Nil Post op duration of hospital stay 66 hours 43 hours (p 0.05) Post op complications 5 (UTI 2, Fever 3) 9 (UTI 5, Fever 4) Stone clearance 26 28 Requiring ESWL postoperatively 4 2 Final complete clearance 30 30 Conclusions Tubeless PCNL in children is safe and effective. Post operative analgesia requirement is less and hospital stay is shortened as compared to conventional nephrostomy placement after PCNL.

Case Report: Percutaneous Catheter Management of Persistent Urine Leak due to Iatrogenic Infundibular Stenosis after Partial Nephrectomy

We describe two cases of persistent urine leak after partial nephrectomies that were both due to surgically induced isolated calices. We hypothesize that the isolated calices were created while suturing the collecting systems, with inadvertent closure of single infundibula. Both cases were managed by percutaneous nephrostomy tube drainage of the renal pelvises and the isolated calices, in addition to indwelling ureteral stents. This novel management technique has not been described in the literature and served as an effective management tool for this rare complication after partial nephrectomy.

Subcutaneous Bupivacaine Infiltration and Postoperative Pain Perception After Percutaneous Nephrolithotomy

Recent studies have shown a significant decrease in patient reported pain scores when the nephrostomy tube size is decreased from 22 to 10Fr. We hypothesize that patient reported pain and narcotic use could be further decreased for patients with post-percutaneous nephrolithotomy nephrostomy tubes if the incision is infiltrated with a local anesthetic. A randomized prospective trial was designed to assess the impact of Marcaine infiltration of the nephrostomy tract following percutaneous stone removal. Patients undergoing single access percutaneous nephrolithotomy were randomized to have a fixed volume of saline or weight based concentration of Marcaine infiltrated into the nephrostomy tube tract at the conclusion of the procedure. Postoperative narcotic use and patient reported pain scores were then obtained at 2, 4, 24 and 48 hours postoperatively. A total of 25 patients were enrolled in the study with 3 excluded from analysis due to incomplete data collection (2) or the development of hydrothorax (1). Of the 22 patients analyzed 10 were in the Marcaine cohort and 12 were in the saline cohort. Patient pain scores at 2, 4, 24 and 28 hours for the Marcaine group were 5, 4.2, 3.6 and 2.6, while for the saline group scores were 3.3, 3.1, 2.3 and 3.5. At all points differences between the groups were not statistically significant (p >0.05). Mean postoperative narcotic use was 24.7 mg morphine sulfate in the Marcaine group and 32.1 mg morphine sulfate in the control cohort (p >0.05). In this preliminary pilot study no significant differences in patient reported pain scores were observed. However, a trend toward decreased postoperative narcotic use was seen in patients receiving subcutaneous Marcaine administration around the nephrostomy tube tract. Further studies are warranted to define additional measures to reduce discomfort in those requiring nephrostomy tube drainage following percutaneous nephrolithotomy.

Treatment of renal transplant ureterovesical anastomotic strictures using antegrade balloon dilation with or without holmium:YAG laser endoureterotomy

Objectives To report our results after antegrade endoscopic treatment of ureteral stenosis with balloon dilation with or without holmium laser endoureterotomy. Ureteral stenosis is the most common long-term urologic complication of renal transplantation. Methods From July 2000 to October 2002, 9 renal transplant patients with ureteral obstruction diagnosed by an increase in serum creatinine and radiologic evidence presented for endoscopic treatment. All patients were treated with nephrostomy tube drainage followed by antegrade flexible nephroureteroscopy and balloon dilation of the stricture. Three patients required holmium laser endoureterotomy during the same procedure because of fluoroscopic and endoscopic evidence of persistent stricture. All patients were treated with ureteral stents and nephrostomy tubes postoperatively. The median follow-up was 24 months (range 6 to 32). Results The site of stenosis was at the ureterovesical anastomosis in all patients, and the mean stricture length was 0.28 cm. Two patients had previously undergone ureteroneocystostomy for prior ureteral stenosis. Six patients (66%) required only balloon dilation, and 3 patients (33%) also required holmium laser endoureterotomy. The median ureteral stent and nephrostomy tube duration was 40 and 62 days, respectively. The mean serum creatinine level was 2.3 mg/dL at presentation and 1.7 mg/dL at the last follow-up visit. After a median follow-up of 24 months, the ureteral patency and graft function rates were both 100%. No perioperative complications occurred. Conclusions Balloon dilation with or without holmium laser endoureterotomy was successful and safe in this group of renal transplant patients with short ureterovesical anastomotic strictures.

Modified “tubeless” percutaneous nephrolithotomy using a tail-stent

Introduction “Tubeless” percutaneous renal surgery has previously been described at our institution. Avoiding external nephrostomy tube drainage significantly decreases the pain and morbidity of percutaneous renal surgery. However, internal drainage with a double- J ureteral stent still results in bothersome bladder symptoms, especially in younger male patients. In addition, removal of the stent requires uncomfortable office cystoscopy. We report a technical enhancement of our “tubeless” technique that uses a novel tail-stent for internal drainage. Technical considerations A tubeless approach to any renal surgery should only be attempted in select uncomplicated cases. The exclusion criteria should include operative times longer than 2 hours, three or more percutaneous accesses, significant perforations or disruptions of the collecting system, significant residual stone burden, and significant bleeding. In these instances, and when second-look nephroscopy is desired, traditional external nephrostomy tube drainage should be used. In our select cases, in lieu of the standard double- J stent, we place a 7F/3F tail-stent with the string attached exiting the urethral meatus. Care is taken in correct placement to avoid having the tail of the stent exiting the meatus. Conclusions In our initial 4 patients, tail-stents were successfully placed. The pain scores were low and stent symptoms appeared minimal. All stents were easily removed without the use of cystoscopy. Fluoroscopic visualization of the 3F tail is poor, and positioning of the tail can be difficult. Nevertheless, this modification appears feasible and safe with excellent patient satisfaction.

Blunt renal trauma in children with previously undiagnosed pre-existing renal lesions and guidelines for effective initial management of kidney injury.

To record pre-existing renal lesions (PERL) found incidentally during evaluation for blunt renal trauma in children, determine their importance, suggest guidelines for the effective initial management of children with significant renal trauma and to evaluate the role of temporary percutaneous nephrostomy tube drainage (TPND) in these patients. We reviewed 338 children who were hospitalized with blunt abdominal trauma between 1992 and 2000. Thirty-one patients had significant renal injury, 17 before 1997 (reviewed retrospectively) and the others reviewed and followed prospectively. Eleven of the 31 children had a PERL, which had been undiagnosed before the injury. The mean (range) follow-up was 52 (15-104) months. There were 22 boys and nine girls (mean age 9.1 years, range 2-13). The mean age was lower in patients with a PERL than in children with isolated renal injury. The most common cause of blunt renal injuries was a fall (45%) followed by motor vehicle accidents. Renal stones were present in five children, pelvi-ureteric junction obstruction in four, megaureter in one and a renal cyst in one. The mean injury severity scores were 12 in the children with a PERL and 14 in patients without. TPND was used in seven (22%) children; four were associated with a PERL. The mean grade of injury score for the kidney was higher in patients with a PERL and in children who underwent TPND than in patients who previously had a normal kidney and in children who did not undergo TPND. Early surgical intervention was required in three children; all were associated with a PERL. Of the 13 children who underwent surgery 11 had previous disease. The frequency of PERL is high (36%) in children with blunt renal trauma. PERL can predispose minor trauma to cause kidney injury even with no evidence of hydronephrosis. When a minor trauma results in renal injury, it is important to seek a PERL. In selected patients, TPND may decrease the length of hospital stay and improve the outcome of the injured kidney, thereby decreasing the need for further surgery in those with isolated renal injury; however, it appears not to decrease the need for later operations in children with a PERL.