Percutaneous Nephrostomy Insertion Research Articles

Comparison one-step procedure with two-step procedure in percutaneous nephrolithotomy

The aim of this study was to compare the effects of one-step percutaneous nephrolithotomy (PCNL) by the urologist alone and two-step PCNL by cooperating with the radiologist. We included 168 patients who underwent surgery by the same surgeon, 83 who underwent two-step PCNL, in which percutaneous nephrostomy insertion was performed by the radiologists on the day before endo-surgery, and 85 who underwent one-step PCNL, which involved the creation of a nephrostomy tract and performing the PCNL at the same time in the operating room, by a urologist. We compared the perioperative and postoperative parameters between these two groups. The result revealed that there were no significant differences between one-step and two-step PCNL in the decreases in haemoglobin level and blood transfusion volume, and the hospital stay was shorter in the one-step PCNL group. In addition, the one-step PCNL group was associated with significantly lower visual analogue score (VAS), which were 2.3, 1.1, and 0.4 on the post-operative days 1, 2, and 3, respectively, compared with 3.2, 1.7, and 1.0 in the two-step PCNL group. The number of parenteral analgesic prescriptions was fewer in the one-step PCNL group (0.8 ± 1.1 amps/vials) than in the two-step PCNL group (4.1 ± 2.4 amps/vials). Furthermore, different stone locations barely affected VAS and analgesic administrations. The results indicate that the one-step PCNL by the urologist alone, compared to two-step PCNL with the radiologist, has better wound pain outcome and shorter hospital stay with comparable successful rate and complication grade.

Utilization of a Modified Clavien Classification System in Reporting Complications After Ultrasound-guided Percutaneous Nephrostomy Tube Placement: Comparison to Standard Society of Interventional Radiology Practice Guidelines

To report our results on percutaneous nephrostomy (PCN) and classify our complications with the Standard of Practice Committee of the Society of Interventional Radiology guidelines and the modified Clavien Classification System (CCS). Three hundred eighty-nine PCN insertions were performed in 322 patients (224 men and 98 women) at our institution. PCN insertion was performed under ultrasound for dilated pelvicalyceal system and ultrasound/fluoroscopy for nondilated system. PCN was considered successful if the catheter was drained urine spontaneously. Number of complications was registered. Primary successful PCN insertion was achieved in 368 of the 389 procedures (94.6%). The success rates for nondilated and dilated systems were 82.7% and 96.4%, respectively. Major complications occurred in 9.6% and minor complications in 9.9% according to the Society of Interventional Radiology. According to the modified CCS grades I, II, III, IV, and V was 9.9%, 1.2%, 6.8%, 1.2%, and 0.3%, respectively. Age, grade of the hydronephrosis, serum creatinine levels, and mean hemoglobin levels were statistically significant parameters for the occurrence of complications on univariate analysis. The nondilated system has statistically significant parameters affecting the complication rates on multivariate analysis (P= .001, odds ratio [OR]= 6.1, 95% confidence interval [CI]= 2-18.4). Percutaneous nephrostomy is a well-known procedure in the treatment of temporary or permanent drainage of an obstructed system. It is very important to define the complications related to interventions for interpretation of clinical comparisons more accurately. Modified CCS isa reproducible system to evaluate the complications.

Surgical Decompression is Associated with Decreased Mortality in Patients with Sepsis and Ureteral Calculi

The combination of sepsis and ureteral calculus is a urological emergency. Traditional teaching advocates urgent decompression with nephrostomy tube or ureteral stent placement, although published outcomes validating this treatment are lacking. National practice patterns for such scenarios are currently undefined. Using a retrospective study design, we defined the surgical decompression rate in patients admitted to the hospital with severe infection and ureteral calculi. We determined whether a mortality benefit is associated with this intervention. Patient demographics and hospital characteristics were extracted from the 2007 to 2009 Nationwide Inpatient Sample. We identified 1,712 patients with ureteral calculi and sepsis. Multivariate logistic regression was performed to determine the association between mortality and surgical decompression. Of the patients 78% underwent surgical decompression. Mortality was higher in those not treated with surgical decompression (19.2% vs 8.82%, p <0.001). Lack of surgical decompression was independently associated with an increased OR of mortality even when adjusting for patient demographics, comorbidities and geographic region of treatment (OR 2.6, 95% CI 1.9-3.7). Absent surgical decompression is associated with higher odds of mortality in patients with sepsis and ureteral calculi. Further research to determine predictors of surgical decompression is necessary to ensure that all patients have access to this life saving therapy.

A training simulator for ultrasound-guided percutaneous nephrostomy insertion

Increasing trainee numbers and changes to working patterns have resulted in a scarcity of training opportunities for training-grade doctors wishing to learn nephrostomy tube insertion techniques. A method of introducing trainees to the skills required to perform percutaneous nephrostomy in a safe, non-threatening environment, without risk to patients, is desirable. Commercial and biological nephrostomy phantoms are available, but they are expensive and not widely available, and a cheap, safe, valid alternative is desirable. We describe a simple technique for producing a gelatin-based phantom, which we suggest has face and content simulator validity. The use of this nephrostomy phantom could optimise existing clinical training opportunities through familiarisation with nephrostomy technique and equipment, and development of the psychomotor skills required for successful nephrostomy insertion prior to undertaking supervised procedures on patients.

Evidence-Based Drainage of Infected Hydronephrosis Secondary to Ureteric Calculi

The obstructed, infected kidney is a urological emergency. It has been accepted that the management of infected hydronephrosis secondary to ureteric stones is through prompt decompression of the collecting system. However, the optimal method of decompression has yet to be established. A PubMed and Medline search was performed of all English-language articles from 1960 using key words "sepsis," "urosepsis," "obstruction," "obstructive pyelonephritis," "pyonephrosis," "infection and hydronephrosis" "decompression," "stent," "nephrostomy," and "management." The Cochrane database and National Institute for Clinical Effectiveness guidelines were searched using the terms "sepsis," "urosepsis," "stent," "nephrostomy," or "obstruction." Scottish intercollegiate guidelines were reviewed and no relevant guidance was identified. Two randomised trials have compared retrograde stent insertion with percutaneous nephrostomy with one trial reporting specifically on patients with acute sepsis and obstruction. Neither trial showed one superior modality of decompression in effecting decompression and resolution of sepsis. A further literature search regarding the complications of percutaneous nephrostomy and stent insertion was carried out. An overall major complication rate from percutaneous nephrostomy insertion was found to be 4%, although the complication rates from stent insertion are less consistently reported. There appears little evidence to suggest that retrograde stent insertion leads to increased bacteraemia or is significantly more hazardous in the setting of acute obstruction. Further region-wide discussion between urologists and interventional radiologists is required to establish management protocols for these acutely unwell patients.

Erratum

Erratum

Artificial hydroureteronephrosis to facilitate MR urography during pregnancy

Insertion of a percutaneous nephrostomy (PCN) catheter decompresses the upper urinary tract, thereby removing the hydroureteronephrosis upon which magnetic resonance (MR) urography is dependent for diagnosing the precise level and cause of ureteric obstruction. We present the case of a young woman who required PCN insertion during pregnancy. Only when unenhanced T2-weighted MR urography was repeated after the creation of an artificial hydronephrosis by an injection of sterile saline via the PCN catheter was the diagnosis of stone in the mid-ureter later made possible. This case highlights an easy solution to a limitation with the use of MR urography during pregnancy, when a physiological hydroureteronephrosis has been relieved by the insertion of a PCN catheter.

Spontaneous Perinephric Urinoma in a Patient with Neurogenic Bladder

Spontaneous rupture of the renal pelvis or ureteropelvic juction area with extravasation of urine into the perinephric space is an uncommon pathologic condition (1). We report a case of 72-year -old woman who suffered 2 days of left loin pain. The patient has got residual urine sensation and weak urine stream since she has gone through a radical hysterectomy 17 years before. Because of these symptoms of voiding difficulty, the patient had abdominal straining during her urination. A CT scan exhibited renal pelvis rupture with perirenal extravasation of urine due to severe hydronephrosis, that was exacerbated by hidden neurogenic bladder disease. Moreover, the patient has detrusor underactivity and high intravesical pressure at voiding trial in the urodynamic study. One month after the percutaneous nephrostomy insertion into the left renal pelvis, the patient was successfully treated. The size of renal pelvis decreased. Moreover, urinoma disappeared in follow up CT scan image. (J Korean Continence Soc 2008;12:185-8)

Hypertensive Encephalopathy Treated by Percutaneous Nephrostomy

Although hypertension is a known complication of hydronephrosis, it is never severe enough to cause encephalopathy. Here we report a baby boy with unilateral hydronephrosis who presented with hypertensive encephalopathy and whose condition was cured by the insertion of percutaneous nephrostomy followed by pyeloplasty.

Antegrade Pyelography Versus Unenhanced Multidetector CT in the Assessment of Urinary-Tract Stones after Percutaneous Nephrostomy Insertion: A Prospective Blinded Study

In patients with a percutaneous nephrostomy tube (PCN) inserted for symptomatic stone disease, antegrade pyelography is an accepted modality to assess the collecting system and residual stone status prior to PCN removal. Recently, unenhanced multidetector CT (UMDCT) has shown its superiority for the assessment of urinary-tract stones. Comparison of UMDCT with antegrade pyelography has never been done; hence, our aim was to compare the two methods for the assessment of urinary stones in patients with a PCN. Between July 2004 and July 2005, we prospectively imaged 49 consecutive patients with known urinary-tract stone disease who had PCN (27 men and 22 women; average age 57 +/- 20 years; range 4-88 years). All patients underwent UMDCT and antegrade pyelography within 24 hours. Both examinations were prospectively and blindly evaluated by two attending radiologists for the presence, location, and size of urinary-tract stones. According to the findings of both imaging modalities, 18 patients were stone free, and 31 patients had urinary stones. In 20 of the latter 31 patients (64.5%), the urinary stones were diagnosed only by UMDCT. Antegrade pyelography missed renal as well as ureteral stones, with a significant mean size (5.1 x 6.2 mm, and 6 x 5.3 mm, respectively). Antegrade pyelography missed radiolucent (8/20) as well as radiopaque (12/20) stones. In 11 of the 31 patients (35.5%), urinary stones were diagnosed by both UMDCT and antegrade pyelography. The average size of these renal stones was 6 x 11 mm, and the mean ureteral stone size was 11 x 13 mm. In 64% (7/11), the stones were radiolucent and in 36% (4/11) radiopaque. There was no patient in whom urinary stones were diagnosed by antegrade pyelography but missed by UMDCT. Unenhanced multidetector CT is more accurate than antegrade pyelography via a PCN for the assessment of urinary-tract stones, with the advantage of reducing the risks of contrast injection side effects.

42 Percutaneous nephrostomy insertion for patients with bilateral ureteric obstruction caused by prostate cancer

Introduction: Ureteric obstruction is a severe complication of advanced prostate cancer. Percutaneous nephrostomy (PCN) can decompress the obstructed kidney(s) and treat renal failure. This study assessed whether PCN added any survival benefit and whether bilateral PCN were necessary when both ureters were obstructed.Methods: The notes of 20 patients, who underwent urinary diversion by PCN for ureteric obstruction, were retrospectively analysed. Data pertinent to the mode of presentation, survival times and urine output of respective nephrostomies were retrieved.Results: Seventeen of the 20 patients (85%) presented with acute renal failure. 18 of the 20 patients presented with bilateral hydronephrosis. Of these, 12 patients had bilateral PCN insertion and 6 patients had unilateral PCN insertion. In those 12 patients who had bilateral PCN, 8 (66%) had a greater urine output in one PCN than the other. In the six patients who had unilateral PCN insertion, five of them had their renal failure treated. The mean survival time following PCN was 6.5 months.Conclusion: Percutaneous nephrostomy insertion will prevent immediate death in patients. However, long term survival is limited to 6.5 months. The above results would suggest that acute renal failure requiring palliative decompression may be best treated by unilateral as opposed to bilateral nephrostomy. However, a larger randomised controlled prospective study would be helpful to further assess this observation.

Does the type of steinstrasse predict the outcome of expectant therapy?

<b>OBJECTIVES:</b> To determine the outcome of expectant therapy in steinstrasse according to its type.<br><b> MATERIALS AND METHODS:</b> A chart review was performed on patients who underwent extracorporeal shock wave lithotripsy (SWL) between 1995 and June 2004. Demographic profile, stone size, site, characteristics of steinstrasse (type 1; multiple small fragments, type 2; lead fragment of 5 mm or more with small fragments proximal to it and type 3; multiple fragments of 5 mm or more) and mode of treatment used, were noted. Patients of steinstrasse, diagnosed on X-Ray KUB were kept on expectant treatment for 4 weeks. Patients with high grade fever and infected hydronephrosis were treated with percutaneous nephrostomy (PCN) insertion. Non responders at 4 weeks, were treated with SWL and/or ureterorenoscopy (URS). <b> RESULTS:</b> 1000 patients of mean age 37.85 years, with urinary stones, received SWL (827 renal stones and 173 ureteric stones). Sixty patients (6%) developed steinstrasse. Mean stone size was 2.03 cm (0.6-4 cm). Type 1, 2 and 3 steinstrasse was present in 32 (53%), 20 (33%) and 8 (13%) patients, respectively. Conservative management was successful in 30 (50%) patients at 4 weeks. 3 patients who presented with infected hydronephrosis, required PCN. The remaining (27 patients) were subjected to repeat SWL. 24 of these 27 patients could be successfully treated with SWL, whereas the remaining 3 required URS. Of non- responders to conservative treatment i.e., 30 patients, 17 (56%) and 8 (26%) patients had type 2 and 3 steinstrasse respectively, whereas only 3 out of 30 (10%) responders had type 2 and none of the responders had type 3 steinstrasse, <i> P</i> value < 0.01. <b> CONCLUSION:</b> Type 2 and 3 steinstrasse have 90% (25 out of 28 failed) chance of not responding to the conservative treatment at 4 weeks. To avoid the risk of infected hydronephrosis (5%), active intervention should be done in patients with lead fragment of 5 mm or more (type 2 and 3 steinstrasse), as early as possible. SWL is successful in most of these patients and should be the primary modality of treatment.

The role of percutaneous nephrostomy in malignant ureteric obstruction

Uraemia as a result of malignant ureteric obstruction is a recognised event in those with advanced malignancy, usually of pelvic origin, which, if left untreated, is quickly a terminal event. Palliative decompression of the obstructed urinary system, either by percutaneous nephrostomy (PCN), ureteric stent or a combination of both is a recognised method of improving renal function, with presumed low morbidity. The aims of the study were to assess whether PCN placement in malignant ureteric obstruction provided any additional survival benefit or patient morbidity. The case notes of 32 patients with a mean age of 68.1 years (16 male, 16 female) who underwent PCN drainage for malignant ureteric obstruction were retrospectively analysed. Data on the site of primary malignancy, mode of presentation, improvement in renal function, median survival, conversion to internal ureteric stents and intervention-related complications were collected for analysis. The median survival following PCN insertion was 87 days and was unrelated to the patient's age and renal function. Those patients with primary underlying gynaecological malignancies appeared to survive almost 4 times as long as those with underlying primary bladder cancer. Renal function took a mean of 16.8 days to reach a nadir. Almost 79% of patients were able to be discharged from hospital--each patient, however, being re-admitted back to hospital on average 1.6 times prior to their death through PCN or internal ureteric stent related events. Retrospective "useful quality of life" was seen in less than half of the patient cohort. In the presence of malignant ureteric obstruction, palliative percutaneous urinary diversion may be performed and is effective in improving renal function. However, long-term survival is limited and should, therefore, be performed only when the views and wishes of the patient and carers are taken into account and if there is a definitive treatment plan available for the patient as quality of life can be suboptimal.

Percutaneous nephrostomy insertion: outcome data from a prospective multi-operator study at a UK training centre

The paper by Wah et al. 1. Wah TM, Weston MJ, Irving HC. Percutaneous nephrostomy insertion: outcome data from a prospective multi-operator study at a UK training centre. Clin Radiol 2004;59:255–61. Google Scholar is one of the few prospective studies of complications after percutaneous nephrostomy (PCN). With the contemporary concerns about service provision, it is timely. What are its messages? First, the performance figures broadly agree with the only existing guidelines: the American College of Radiology 2. ACR practice guidelines for the performance of percutaneous nephrostomy. In: ACR practice guidelines and technical standards. American College of Radiologists Reston, VA, 2003: 335–343 (www.acr.org, accessed September 2003). Google Scholar and the Society of Cardiovascular and Interventional Radiologists. 3. Ramchandani P. Cardella J.F. Grassi C.J. et al. Quality improvement guidelines for percutaneous nephrostomy. J Vasc Interv Radiol. 2001; 12: 1247-1251 Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar This was the primary aim of the study, and the safety of PCN performed by a well-staffed unit is proven. These are reassuring data. The secondary study aims are less convincingly answered, given the smaller numbers in the sub-groups. For example, the number of cases requiring more than one needle pass is not statistically different when the consultants are compared with the trainees; and neither are the complication rates in the four groups (Table 1), including major events. In fact, of the operator-dependent figures only the technical success rate is significantly better for consultants.

Percutaneous nephrostomy insertion: outcome data from a propspective multi-operator study at a UK training centre

AIM: To determine the success and complication rates of percutaneous nephrostomies (PCNs) performed at a UK training centre over a one-year period by different groups of operators. MATERIALS AND METHODS: During 2002, a total of 276 PCNs were performed in 190 patients by operators of varying experience. We employed two different techniques: (1) a “Seldinger” technique (ultrasound-guided puncture with a 19 G sheathed needle followed by guide-wire insertion and track dilatation to accommodate 8–12 F nephrostomy catheters), with or without fluoroscopic guidance, and (2) an ultrasound-guided “one-stab” technique using a 6 F Bonanno catheter. Selection of technique was according to configuration of the collecting system and whether the procedure was performed out of hours. RESULTS: There were 218 procedures using the Seldinger technique and 62 using the one-stab technique. The Seldinger technique and one-stab technique were compared: primary technical success rate was 98 versus 93%, the major complication rate was 4.1 versus 3.2%, the minor complication rate was 5 versus 13%, and tube complications, such as drainage catheter dislodgement and blockage, were 29.5 versus 17.7%, respectively. The 30-day mortality was 4.3%, none of which were procedure related. CONCLUSION: Based on data from the USA, proposed targets for primary technical success rates are 88–99%, major complications 4-8%, and minor complications 3–15%, and the results were within these target ranges. The ultrasound-guided one-stab technique is a quick and safe procedure in selected cases, and we recommend this method for temporary urinary diversion in cases with moderate to severe degrees of pelvicalyceal system dilatation. These data may help to form a baseline for outcome targets in the UK.

Major complications after percutaneous nephrostomy—lessons from a department audit

AIM: To audit the performance of our percutaneous nephrostomy service by comparing the major complication rate with the standards recommended by the Society of Cardiovascular and Interventional Radiology and the American College of Radiology: major haemorrhage in <4%, and septic shock in <4%. Secondary aims were to identify common sources of errors for quality improvement measures. METHODS: Major complications sustained between January 1997–December 2002 were identified. All cases had been carried out by the interventional radiology service of a large teaching hospital with the assistance of a nurse and radiographer, under fluoroscopic and ultrasound guidance using a Seldinger technique. Existing department protocols specified pre-procedure antibiotics for suspected infected cases and normal coagulation studies. From records and review of case notes pertinent clinical/procedural details and eventual outcome were assessed. The following were particularly noted: adherence to protocols, clinical status at time of procedure, delay in referral, complication sustained, signs of infection or coagulopathy, timing of procedure (in versus out of hours), level of operator and technical faults. RESULTS: Ten of 318 (3.1%) cases sustained a major complication: five had sepsis alone, two haemorrhage (one with sepsis as well) and three patients had a major pelvic injury (one with sepsis as well). Thus the major sepsis and haemorrhage rates were 2.2 and 0.6%, and were within the recommended threshold limits but proportionately more complications occurred out of hours: six of 105 (5.7%) versus four of 312 (1.8%; p=0.087). Sepsis was the most serious complication and may have contributed to the death of two patients. On individual case analysis, failed instrumentation with delay to definitive renal drainage was a common factor with sepsis; but the following were contributory factors in one or more cases: omitted antibiotics (in three of 10; two became septic), technical factors in four cases [medial renal puncture ( n=1), damage due to fascial dilator ( n=1) or peelaway sheath ( n=2)] and delay in diagnosis/therapy (of 1–8 days, in six of 10 cases of whom four out of six became septic). One pelvic injury required surgical correction (contributory factor—faulty use of peelaway sheath). Patients with haemorrhage settled with prolonged tube drainage alone. CONCLUSION: An adequately staffed percutaneous nephrostomy service can perform within published clinical standards. Best practice factors identified were: attention to agreed protocols and algorithms, pre-procedure antibiotics, careful renal puncture and care with use of dilators/peelaway sheaths, but the paramount finding was that sepsis was the most serious complication, contributing to death (two of 10 in this study) or a significant increase in the level of care required. The risk is greatest after failed instrumentation (retrograde ureteral stent or percutaneous nephrostomy insertion) and particularly if there is a further delay before establishment of renal drainage. A close working relationship between interventional radiologists and urologists is crucial.

A Survey of Current Practice in Out of Hours Percutaneous Nephrostomy Insertion in the United Kingdom

AIM: To establish the current out of hours service provided in the United Kingdom for nephrostomy insertion. MATERIALS AND METHODS: Using the Royal College of Radiologists' (RCR) database a questionnaire was sent to all the current clinical directors. RESULTS: Questionnaires were sent to 246 hospitals, with replies received from 178 (72.3%). The number of consultants doing nephrostomies as part of their routine work was 476; this increased to 625 including those who perform nephrostomies out of hours. Therefore 24% of consultants only perform nephrostomies out of hours. For the times when there was no formal out of hours nephrostomy service, the arrangements varied and included calling a consultant who was not on call (52%), or transferring the patient (37%). Only 19 hospitals (11%) had a separate interventional on call rota, the majority of these being teaching hospitals (68%). The availability of assistance was limited, with nursing staff available only 43% of the time. In institutions with specialist registrars, the registrars were involved with the nephrostomies 75% of the time. CONCLUSIONS: There is a wide variation in the out of hours service provided by radiology departments for nephrostomy insertion. A large percentage of out of hours nephrostomies are done by consultants who do not perform do the procedure as part of their routine clinical practice, which is contrary to the advice of the Royal College of Radiologists for out of hours working. In addition the provision of nursing assistance for the procedure is inadequate. Riddell A. M. and Charig M. J. (2002). Clinical Radiology57, 1067–1069.

Variations of the position of the colon as applied to percutaneous nephrostomy.

The widespread and increasing usage of percutaneous nephrostomy procedures makes an awareness of the anatomical variations of the colon in relation to the kidney essential. Injury to the colon during this procedure is associated with significant morbidity. The aim of this study was to determine the relation of the colon to the insertion line used during a percutaneous nephrostomy and therefore determine whether the colon is at risk of injury. 333 CT-scans taken in a supine position were studied in order to determine the position of both the ascending and descending colon to the percutaneous nephrostomy insertion line on the level of the superior pole, hilum and inferior pole of the kidneys. In the majority of cases, the ascending and descending colon lie anterior to the line of insertion, and were therefore not at risk. However the descending colon was found to be at risk in 16.1% of cases and the ascending colon in 9.0% of cases on the level of the inferior pole of the kidney. The risk was significantly lower on the level of the hilum and superior pole of the kidneys on both sides. Age distribution analysis showed that the colon is rarely at risk under twenty years of age and the highest risk being in the age range above 40 years. Adequate radiographic evaluation is essential before performance of percutaneous nephrostomy procedures, especially to evaluate the position of the colon as related to the inferior poles of the kidneys.