Percutaneous Nephrostomy Tube Insertion Research Articles

Clinical profile and outcome of emphysematous pyelonephritis presenting to a tertiary care hospital

BackgroundEmphysematous pyelonephritis is a necrotizing infection of the renal parenchyma by gas-forming organisms. The diagnosis of emphysematous pyelonephritis is made by clinical features and the detection of air in the renal parenchyma. In the past, nephrectomy was considered the only treatment option with a high mortality rate, but with advances in minimally invasive conservative techniques and better antibiotic treatment, the rate of kidney salvage has increased.Case presentationFrom January 2019 to December 2022, eight cases of emphysematous pyelonephritis were diagnosed based on clinical features and documentation of gas in the renal parenchyma by a Computed tomography scan. The mean age was 61.75 ± 4.3 years. 62.5% were female and 75% were diabetics. E. coli was the most common pathogen (87.5%). All 8 patients underwent early interventions in the form of DJ stenting or percutaneous nephrostomy tube insertion with only one patient requiring nephrectomy without any immediate mortality.ConclusionEmphysematous pyelonephritis is more common in women and the elderly. Diabetes mellitus and nephrolithiasis are major risk factors. E. coli was the most frequently isolated pathogen. Early diagnosis and early minimally invasive intervention in the form of a DJ stenting or percutaneous nephrostomy reduced the rate of nephrectomy and mortality.

Surgical Management of Pediatric Urolithiasis: Descriptive Study from a Tertiary Care Center in Nepal

Introduction: Urolithiasis is common in the pediatric population in low-resource countries but appropriate management is not available in all parts of the country. This study aimed to identify demographic parameters, clinical characteristics, and surgical management of pediatric urolithiasis in a tertiary care center in Nepal. Methods: This was a retrospective and descriptive study of pediatric patients (≤18 years) who underwent surgical management of urolithiasis in the Department of Urology and Kidney Transplant Surgery, Tribhuvan University Teaching Hospital from January 2021 to December 2022. Results: Total 64 patients with Male: Female ratio 1.78:1 and mean age of 8.63±5.56 years presented mostly with pain abdomen (93.8%) followed by lower urinary tract symptoms (26.6%), hematuria (20.3%), and fever (14.1%). The mean number of calculi was 2.2±1.47 and the mean size was 13.97±8.30 mm. Most of the calculi (39.1%) were in the right system and 90.62% were in the upper tract. Only 15.62% of patients had calculi in the lower tract. Open surgeries were performed in only 10.93% and the rest were managed by minimally invasive procedures. Percutaneous nephrostomy tube insertion was done in 6 (9.37%) of patients and 1 (1.56%) underwent nephrectomy for nonfunctioning kidney. Conclusion: Pediatric urolithiasis patients presented with pain abdomen, lower urinary tract symptoms, or hematuria. Surgical management has shifted from open surgeries in the past to minimally invasive surgeries at present.

Case - Endoscopic management of severe ventral urine leak post-robot-assisted laparoscopic prostatectomy.

Vesicourethral leakage following robot-assisted laparoscopic prostatectomy is an uncommon complication, and the majority of cases are managed conservatively. Persistent leakage, which is refractory to conservative measures, may require more invasive management. Herein, we describe a novel approach for managing urine leaks endoscopically, without the need for percutaneous nephrostomy tube insertion.

Survival following palliative percutaneous nephrostomy tube insertion in patients with malignant ureteric obstruction: Validating a prognostic model

Background and Aims Malignant ureteric obstruction (MUO) is a life-threatening complication of advanced cancer associated with short survival. Percutaneous nephrostomy (PCN) is a commonly employed technique to decompress MUO. Prognostic models have been developed to identify patients with poor outcomes. This study aimed to validate and update the recent model by Alawneh et al. [Alawneh A, Tuqan W, Innabi A, et al. Clinical Factors Associated With a Short Survival Time After Percutaneous Nephrostomy for Ureteric Obstruction in Cancer Patients: An Updated Model. J Pain Symptom Manag 2016;51(2):255–261]. Methods A retrospective analysis was performed on patients who received PCN for MUO over a 10-year period. Clinical and demographic details were recorded. Patients were stratified into prognostic groups and survival was described using the Kaplan-Meier method. Association between prognostic group, individual variables and mortality was investigated. Results 29 patients had received PCN for MUO. When stratified by Alawneh prognostic group, survival was 0.9 months (0 risk factors), 8.4 months (1 factor), 3.4 months (2 factors) and 4.1 months (3 factors). No statistical association was identified between prognostic group and mortality risk (Hazard Ratio [HR] 0.92; p = 0.72). The only variable associated with increased mortality was pre-nephrostomy haemoglobin <100 g/L (HR 2.6; p = 0.037). Conclusion Survival with MUO remains short, despite advances in supportive care and PCN. This study was unable to either validate or update the prognostic model, due to limited numbers. Further research with prospective studies is recommended.

Tandem ureteral stents drainage lowers renal pelvis pressure in malignant ureteral obstruction: Experimental and computational models

Malignant ureteral obstruction may lead to impaired renal function and requires drainage by a percutaneous nephrostomy tube or an internal ureteric stent. Usage of stiff tandem ureteral stents may decrease stent failure rates. In this paper we combined computational and in vitro models to examine the flow in a malignant ureteral obstruction (MUO) managed by 4 methods of drainage: single soft stent, single stiff stent, soft tandem ureteral stents, and stiff tandem ureteral stents. Pressure at the renal pelvis was the primary outcome of the computational and in vitro models. Different drainage modalities were compared using ANCOVA. Results of computational and in vitro models agreed completely. Drainage by stiff tandem ureteral stents provides lower renal pelvis pressure levels compared with single and soft stents (p < 0.001), especially for high levels of external pressure. Usage of stiff tandem ureteral stents may decrease stent-failure rates and postpone the need for percutaneous nephrostomy tube insertion.

Urinary stone management during the COVID-19 pandemic: a suggested approach and review of literature.

COVID-19 is now the major health concern of the century in many countries. Prolonged homestay has various undesirable consequences for people, such as physical inactivity and weight gain, which potentially could put people at risk of urinary stone formation. With regard to the prevention and treatment strategy for urinary stones during this COVID-19 pandemic period, patients can be divided into two groups. The first group comprises those for whom urological intervention is not indicated and where general dietary and lifestyle recommendations are helpful. The second group comprises those patients where urological intervention is indicated. This group can be divided into emergent and nonemergent subgroups. Patients with urinary stones and concomitant uremia, sepsis, anuria, or refractory pain and vomiting make up the emergent group, where intervention is necessary. The preferred option during the novel coronavirus crisis for these patients is percutaneous nephrostomy tube insertion under local anesthesia. The second subgroup is made up of those patients with asymptomatic and noncomplicated renal and ureteral stones where urologic intervention is indicated in the usual time scale. However, we suggest conservative treatment for 3 months during the COVID-19 outbreak after which re-evaluation of the patient should be carried out. Thus the operation could be chosen carefully based on the patient’s and urologist’s preference and the rate of infection in that center.

Complications of percutaneous nephrostomy in a district general hospital.

Percutaneous nephrostomy (PCN) is one of the commonest procedures performed. There are currently no European recommendations on the accepted rate of complications. The aim of the present study is to report the complication rate of PCN with the specific emphasis on sepsis and septic shock, the causative organisms, sensitivities to antibiotics, and associated risk factors. Retrospectively collected data on patients undergoing acute or elective PCN at the Department of Radiology, Countess of Chester Hospital (COCH), in the UK between January 2014 and December 2016 were analyzed after the study was approved by Local Audit Department at COCH. A total of 66 patients underwent 90 acute or elective PCNs. Three patients developed major post-PCN complication (two patients developed septic shock and the third suffered a hemorrhagic episode requiring blood transfusion). Nephrostomy tube complications (blockage, leaking, fracturing and kinking of the catheter) occurred in 4 patients. Complications were more common when the PCN was performed out of working hours (71.4% [10/14], and 17.3% [9/52] for PCNs performed within, and out of working hours, respectively: p<0.001). The age of the patients did not seem to correlate with the development of complications (p<0.001). Of all 25 patients, in whom septicemia was diagnosed prior to PCN tube insertion, 12 developed septic shock and 13 had signs of sepsis for longer than 24 h. Fifteen patients had positive urine cultures. The most common organism isolated was Escherichia coli. Blood culture isolates included: Escherichia coli, Eggerthella lenta, Enterococcus, Proteus mirabilis, Pseudomonas aeruginosa and Streptococcus pneumonia. Our complication rates were within United States proposed target ranges. Our data may help to serve as a baseline for outcome targets in the European centres.

Predictors of Benign Ureteroenteric Anastomotic Strictures After Radical Cystectomy and Urinary Diversion

ObjectiveTo determine predictors of symptomatic ureteroenteric anastomotic strictures (UAS) formation following radical cystectomy (RC) and urinary diversion (UD). Materials and MethodsA total of 2,888 consecutive patients who underwent open RC at our institution from 1995 to 2014 were included for analysis. Data were collected from institutional databases and individual medical records. Symptomatic benign UAS was defined as percutaneous nephrostomy tube insertion for rising creatinine or unilateral hydronephrosis by comparing preoperative and postoperative imaging. Univariate and multivariable Cox proportional hazards models were utilized to identify features associated with UAS formation. ResultsUAS developed in 123 of 2888 patients following RC. There were 94 symptomatic and 29 asymptomatic strictures. Median follow-up was 32 months (IQR 12, 72) for patients without stricture. Higher BMI (P = 0.002), ASA score >2 (P < 0.0001), lymph node positive disease (P = 0.027), and 30-day postoperative grade 3I+ complications (P = 0.017) on univariate analysis and male gender on multivariable analysis were significantly associated with time to stricture development. However, history of prior abdominal surgery (PAS) had the strongest association with time to stricture formation (HR 3.25, 95% CI 1.78, 5.94, P = 0.0001). Risk of developing a stricture within 10 years was 1.9% for patients without PAS vs 9.3% with PAS. ConclusionAssociated factors with an increased risk of benign UAS include higher BMI, ASA score >2, lymph node involvement, grade 3/4 complications within 30 days, male sex, and a history of PAS. We conclude that while surveillance is important for patients who undergo cystectomy for malignancy, it may be beneficial for patients with history of PAS to undergo more intensive follow-up compared to those patients without history of PAS.

Treatment of Pyonephritis Complicated by Sepsis-Induced Disseminated Intravascular Coagulation Using Recombinant Human Soluble Thrombomodulin and Percutaneous Drainage

Pyonephritis is defined as infected hydronephrosis complicated by infectious destruction of the renal parenchyma or the presence of pus in the dilated pyelocaliceal. Pyonephritis is challenging to treat only using antibiotics; it sometimes requires immediate interventional treatment, including surgical intervention, percutaneous drainage, or retrograde ureteric stent insertion, because if left untreated, it may cause sepsis-related disseminated intravascular coagulation (DIC). Here we report three cases of pyonephritis complicated by sepsis-induced DIC using recombinant human soluble thrombomodulin (rhTM) and percutaneous drainage. An 87-year-old female presented with high-grade fever, vomiting, and diarrhea. Non-contrast computed tomography and ultrasonography revealed a dilated ureter and upper ureteral stone in the left kidney. Antibiotic treatment was initiated, and a percutaneous nephrostomy (PCN) tube was inserted into the patient; puncture fluid revealed the presence of Escherichia coli . During treatment, the patient’s DIC score was four points, indicating that rhTM administration was required. A 75-year-old female presented with nausea, diarrhea, and deterioration of consciousness. Laboratory analysis revealed remarkably elevated levels of WBC and CRP, and imaging modalities revealed left-sided hydronephrosis. The patient’s DIC score at admission was six points; rhTM and anti-biotics were administered. A PCN tube was inserted into the patient on the following day. With worsening renal function and oliguria, the patient needed hemodialysis (polymyxin-B direct hemoperfusion and continuous hemodiafiltration). A 62-year-old female presented with high-grade fever and deterioration of consciousness. The patient’s DIC score at admission was four points; rhTM and antibiotics were administered. Imaging modalities showed left-sided hydronephrosis and, the patient required PCN tube insertion. Temporal hemodialysis alleviated the patient’s renal malfunction and septicemia. All three cases recovered from sepsis-related DIC. Immediate and intensive treatments for pyonephritis, including interventional drainage, hemodialysis, administration of antibiotics, and the management of DIC, are necessary to save patients from fatal conditions. World J Nephrol Urol. 2016;5(4):85-90 doi: https://doi.org/10.14740/wjnu283w

Emphydematous pyelonephritis - Treat the patient, not the scan

Background: Emphysematous pyelonephritis (EPN) is a severe, necrotizing infection of the renal parenchyma. Until the late 1960s, these patients were treated with nephrectomies as EPN is associated with a high rate of mortality. It is a diagnosis based on computed tomography (CT) scan of the patient and based on the results, can be classified according to the severity of the disease. In our case report, we present a patient with seemingly extensive EPN on CT scan who was treated successfully with intravenous antibiotics (IV) and percutaneous drainage. Methods: Together with current literature, our case study adds to increasing evidence which supports how carefully selected patients can be treated with the above modalities. Results: We present a 75 year old diabetic Indian gentleman who came to us with right iliac fossa pain and was noted to have a positive right renal punch. CT scan revealed extensive gas in the right kidney. Considering that he was clinically stable amongst other factors, he was started on appropriate IV antibiotics and underwent a percutaneous nephrostomy tube insertion. Subsequent follow-up scans showed resolution of the EPN. Conclusions: EPN is a severe, necrotizing infection of the kidneys associated with high mortality rates. As such, physicians need to have a high index of suspicion in patients who are at risk. There is increasing evidence to show that patients with early EPN can and should be treated with appropriate IV antibiotics and percutaneous drainage procedures. We hope that this will help to increase awareness of the possible treatment modalities of this potentially life-threatening disease.

Clinical Factors Associated With a Short Survival Time After Percutaneous Nephrostomy for Ureteric Obstruction in Cancer Patients: An Updated Model

ContextPatients with advanced cancer can develop ureteric obstruction. Percutaneous nephrostomy (PCN) tube insertion can relieve this obstruction and prevent renal failure. PCN is associated with complications and can worsen quality of life. Prognostic models of survival after PCN in cancer patients can help identify the patients who will most likely benefit from this intervention. This work updates a prognostic model to predict overall survival in cancer patients after receiving PCN. ObjectivesThe primary objective was to assess survival of patients with malignant urinary obstruction after PCN tube insertion. The secondary objective was to identify factors associated with poor prognosis in this group of patients and externally validate an existing model. MethodsWe conducted a retrospective analysis of 211 patients who had malignant urinary obstruction and received PCN tube insertion. ResultsThe median survival was 5.05 months (95% CI = 3.87–7.11; range 2–963 days). On univariate analysis, the factors significantly associated with shorter survival were type of malignancy, bilateral hydronephrosis, serum albumin <3.5 mg/dL, presence of metastasis, ascites, and pleural effusion (P < 0.05). Multivariate analysis using a Cox proportional hazards regression model showed that type of malignancy, serum albumin <3.5 mg/dL, pleural effusion, and bilateral hydronephrosis were significantly associated with shorter survival (P < 0.05). Using the latter three factors, we stratified patients into four prognostic groups: zero risk factors (32 patients), one risk factor (85 patients), two risk factors (78 patients), and three risk factors (16 patients). Median survival for each group was 17.6 months, 7.7 months, 2.2 months, and 1.7 months, respectively (P < 0.0001). ConclusionSurvival in patients with malignant ureteric obstruction can range widely from a few days to a few years. The presented prognostic model is an updated model and can be used to identify patients with poor survival after PCN.

Retrograde ureteric stent insertion in the management of infected obstructed kidneys.

To quantify the outcomes of retrograde ureteric stenting in the setting of infected hydronephrosis secondary to ureteric calculi. Prospective analysis of all patients over a 15-month period admitted with infected obstructed kidneys secondary to ureteric calculi. Inclusion criteria were based on clinical evidence of systemic inflammatory response syndrome (SIRS) and radiological evidence of obstructing ureteric calculi. Outcome measures included success of procedure, admission to intensive care unit (ICU), length of hospital stay, morbidity, and all-cause mortality during hospital admission. In all, 52 patients were included. Success of retrograde ureteric stenting was 98%. In all, 17% of patients required an ICU admission, with a post ureteric instrumentation ICU admissions rate of 6%. The mean white cell count and serum creatinine improved significantly after the procedure. Major complication rate included septic shock 6%, but there were no episodes of major haemorrhage and no deaths. Retrograde ureteric stenting is safe and effective in infected obstructed kidneys with results comparable to percutaneous nephrostomy tube insertion. Post instrumentation ICU admissions occur in 6% of retrograde stentings.

Tubeless percutaneous nephrolithotomy: yes but when? A multicentre retrospective cohort study

The aim of our study is to determine the predictive factors for placement of percutaneous nephrostomy tube (PNT) in percutaneous nephrolithotomy (PCNL) procedure and to evaluate the optimal cutoff points of the predictive factors. 229 patients, who had undergone percutaneous nephrolithotomy operation between February 2009 and February 2013 were reviewed retrospectively. Five patients were excluded from the study because of solitary kidney. All characteristics of 224 patients, stones and operative data were investigated. Patient and stone-related factors, such as age, BMI, history of previous surgery or SWL, characteristics of the stone, renal parenchymal thickness (RPT), as well as procedural factors, such as percutaneous access number and location were analyzed by univariate and multivariate tests. The continuous variables were analyzed using Receiver operating characteristic curve analysis. There were no differences in sex, age, BMI and hemoglobin decrease between the groups. Previous operation status, RPT, stone size, multiplicity of the stone, stone localization, blood transfusion presence, access points, access number and operation time were found statistically different according to univariate analysis. Multivariate analysis showed that RPT, operation time and stone size were the independent factors that affected the PNT insertion. For RPT, operation time and stone size, the optimal cutoff points for insertion PNT were 13.75 mm, 75.5 min and 890 mm(2), respectively. Tubeless PCNL should be chosen in patients with stone area less than 890 mm(2), and parenchymal thickness thicker than 13.75 mm and procedure with operation period <75.5 min.

Comparison Between Double J (DJ) Ureteral Stenting and Percutaneous Nephrostomy (PCN) in Obstructive Uropathy

To compare the complications rate of percutaneous nephrostomy and double J ureteral stenting in the management of obstructive uropathy. Total number of 300 patients of age 20-80 years who underwent JJ stenting or percutaneous nephrostomy for obstructive uropathy were included in this study. Patients were divided in two groups i.e. A & B. In group A, 100 patients who underwent double J ureteral stenting while in group B, 200 patients who underwent percutaneous nephrostomy tube insertion were included. The stent was inserted retrograde by using cystoscope, under mild sedation or local anesthesia. While the percutaneous nephrostomy was done under ultrasound guidance by using local anesthetic agent. Complications were noted in immediate post-operative period and on follow up. Majority of the patients were between 36 to 50 years of age with male to female ratio was 2.6:1. The most common cause of obstructive uropathy was stone disease i.e. renal, ureteric or both. Post DJ stent, complications like painful trigon irritation, septicemia, haematuria and stent encrustation were seen in 12.0%, 7.0%, 10.0% and 5.0% patients respectively. On the other hand, post-PCN septicemia, bleeding and tube dislodgment or blockage was seen in 3.5%, 4.5% and 4.5% respectively. In this study, overall success rate for double J stenting was up to 83.0% and for percutaneous nephrostomy (PCN) was 92.0% (p<0.0001). Percutaneous nephrostomy is a safe and better method of temporary urinary diversion than double J stenting for management of obstructive uropathy with lower incidence of complications.

Ultrasound-guided percutaneous nephrostomy performed by urologists: 10-year experience

Objectives To assess the safety, feasibility, and effectiveness of percutaneous nephrostomy tube (PNT) insertion performed solely by a urologist on an outpatient basis. We present our relevant 10-year experience. Methods From 1996 to 2005, 650 PNT insertions were performed in 530 patients (356 men and 174 women), aged 39 to 94 years (mean 67.4). All patients were referred to our outpatient department. PNT placement was performed under local anesthesia by a consultant urologist or registrar during regular work hours or during on-call duty. Early complications within 30 days of PNT insertion were recorded. Results Primary successful PNT insertion was recorded in 615 (94.6%) of the 650 procedures. Follow-up data up to 30 days were available for 545 PNT placements (83.8%). Of the 650 PNT insertions, 22 (3.3%) major immediate complications were encountered. In 4 patients, laparotomy was performed for surgical exploration of hemorrhage (3 patients) or choleperitoneum, resulting in nephrectomy (1 patient). In 5 (0.8%) of 615 successful PNT procedures, we recorded septicemia, which resulted in 2 deaths. In 1 more case (0.1%), the nephrostomy tube was misplaced into the inferior vena cava. Minor complications within the follow-up period were recorded in 24 (4.5%) of 545 cases. The complication rate did not differ significantly between the consultants and registrars or whether PNT insertion was performed during regular work hours or during on-call duty. Conclusions Ultrasound-guided PNT insertion performed solely by a urologist is a safe, feasible, and efficient procedure, regardless of the operator’s experience.

ULTRASOUND-GUIDED PERCUTANEOUS NEPHROSTOMY PERFORMED BY AN UROLOGIST. TEN-YEARS' EXPERIENCE

To assess the safety, feasibility, and effectiveness of percutaneous nephrostomy tube (PNT) insertion performed solely by a urologist on an outpatient basis. We present our relevant 10-year experience.From 1996 to 2005, 650 PNT insertions were performed in 530 patients (356 men and 174 women), aged 39 to 94 years (mean 67.4). All patients were referred to our outpatient department. PNT placement was performed under local anesthesia by a consultant urologist or registrar during regular work hours or during on-call duty. Early complications within 30 days of PNT insertion were recorded.Primary successful PNT insertion was recorded in 615 (94.6%) of the 650 procedures. Follow-up data up to 30 days were available for 545 PNT placements (83.8%). Of the 650 PNT insertions, 22 (3.3%) major immediate complications were encountered. In 4 patients, laparotomy was performed for surgical exploration of hemorrhage (3 patients) or choleperitoneum, resulting in nephrectomy (1 patient). In 5 (0.8%) of 615 successful PNT procedures, we recorded septicemia, which resulted in 2 deaths. In 1 more case (0.1%), the nephrostomy tube was misplaced into the inferior vena cava. Minor complications within the follow-up period were recorded in 24 (4.5%) of 545 cases. The complication rate did not differ significantly between the consultants and registrars or whether PNT insertion was performed during regular work hours or during on-call duty.Ultrasound-guided PNT insertion performed solely by a urologist is a safe, feasible, and efficient procedure, regardless of the operator's experience.

Changing Trends in the Management of Iatrogenic Ureteral Injuries

Purpose We evaluated changing trends in the management of late diagnosed iatrogenic ureteral injuries before and after the introduction of percutaneous nephrostomy. Materials and Methods The study included 44 patients of whom 24 were treated primarily by immediate reconstructive surgery from 1979 to 1984 and 20 were treated primarily by percutaneous nephrostomy tube insertion beginning in 1985. Results Six of the 24 patients underwent ureteroneocystostomy and 18 underwent end-to-end uretero-ureteral anastomosis to repair the injury. Postoperatively 18 patients had a urinary tract infection. Hospital stay after reconstructive surgery ranged from 14 to 35 days (average 18). Long-term followup showed a normal upper urinary tract in 22 patients and mild to moderate hydroureteronephrosis in 2. Of the 20 patients who underwent percutaneous nephrostomy 16 (80 percent) had complete spontaneous recovery of the injured ureter after 14 to 66 days (average 32). Hospital stay after the insertion of the percutaneous nephrostomy tube ranged from 3 to 5 days. Urinary tract infection developed in 4 patients and mild hydronephrosis was noted in 1 on long-term followup. Conclusions The primary management of ureteral injury by percutaneous nephrostomy resulted in significantly decreased reoperation and morbidity rates, and enabled spontaneous recovery of the injured ureter in the majority of patients.