Postoperative Nephrostomy Tube Research Articles

Meta-analysis of perioperative outcomes and safety of percutaneous nephrostomy versus retrograde ureteral stenting in the treatment of acute obstructive upper urinary tract infection.

The debate regarding the optimal drainage method for acute obstructive upper urinary tract infection persists, focusing on the choice between percutaneous nephrostomy (PCN) and retrograde ureteral stenting (RUS). This study aims to systematically examine the perioperative outcomes and safety associated with PCN and RUS in treating acute obstructive upper urinary tract infections. A comprehensive investigation was conducted using the Medline, Embase, Web of Science, and Cochrane databases up to December 2022, following the guidelines of the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. The utilized keywords included 'PCN', 'RUS', 'acute upper obstructive uropathy', and 'RCT'. Inclusion criteria encompassed studies providing accurate and analyzable data, which incorporated the total subject count, perioperative outcomes, and complication rates. The assessed perioperative outcomes included fluoroscopy time, normalization of temperature, normalization of serum creatinine, normalization of white blood cell (WBC) count, and operative time. Safety outcomes encompassed failure rate, intraoperative and postoperative hematuria, postoperative fever, postoperative pain, and postoperative nephrostomy tube or stent slippage rate. The study protocol was prospectively registered at PROSPERO (CRD42022352474). The meta-analysis encompassed 7 trials involving 727 patients, with 412 assigned to the PCN group and 315 to the RUS group. The outcome of the meta-analysis unveiled a reduced occurrence of postoperative hematuria in the PCN group [odds ratio (OR) = 0.54, 95% confidence interval (CI) 0.30-0.99, p = 0.04], along with a decreased frequency of insertion failure (OR = 0.42, 95% CI 0.21-0.81, p = 0.01). In addition, the RUS group exhibited a shorter fluoroscopy time than the PCN group (mean difference = 0.31, 95% CI 0.14-0.48, p = 0.0004). Given the significant impact of hematuria and catheterization failure on postoperative quality of life, the preference for PCN appears more advantageous than RUS.

Determinants of ureteral obstruction after percutaneous nephrolithotomy

BackgroundUreteral obstruction after percutaneous nephrolithotomy (PCNL) may require prolonged drainage with a nephrostomy tube (NT) or ureteral stent, but it is not well understood how and why this occurs. The goal of this study was to identify risk factors associated with postoperative ureteral obstruction to help guide drainage tube selection.MethodsProspective data from adult patients enrolled in the Registry for Stones of the Kidney and Ureter (ReSKU) who underwent PCNL from 2016 to 2020 were used. Patients who had postoperative NTs with antegrade imaging-based flow assessment on postoperative day one (POD1) were included. Patients with transplanted kidneys or those without appropriate preoperative imaging were excluded. We assessed the association between patient demographics, stone characteristics, and intraoperative factors using POD1 antegrade flow, a proxy for ureteral patency, as the primary outcome. Stepwise selection was used to develop a multivariate logistic regression model controlling for BMI, stone location, stone burden, ipsilateral ureteroscopy (URS), access location, estimated blood loss, and operative time.ResultsWe analyzed 241 cases for this study; 204 (84.6%) had a visual clearance of stone. Antegrade flow on POD1 was absent in 76 cases (31.5%). A multivariate logistic regression model found that stones located anywhere other than in the renal pelvis (OR 2.63, 95% CI 1.29–5.53; p = 0.01), non-lower pole access (OR 2.81, 95% CI 1.42–5.74; p < 0.01), and concurrent ipsilateral URS (OR 2.17, 95% CI 1.02–4.65; p = 0.05) increased the likelihood of obstruction. BMI, pre-operative stone burden, EBL, and operative time did not affect antegrade flow outcomes.ConclusionConcurrent ipsilateral URS, absence of stones in the renal pelvis, and non-lower pole access are associated with increased likelihood of ureteral obstruction after PCNL. Access location appears to be the strongest predictor. Recognizing these risk factors can be helpful in guiding postoperative tube management.

Trans-tract electrocoagulation can decrease the need for postoperative nephrostomy tube after endoscopic combined intrarenal surgery.

To assess the efficacy and safety of trans-tract electrocoagulation at the end of endoscopic combined intrarenal surgery for renal or ureteral stones. The present study included patients who underwent endoscopic combined intrarenal surgery from May 2010 to March 2018. After June 2013, the trans-tract electrocoagulation procedure, to coagulate bleeding from the access tract using a resectscope was carried out at the end of the operation. We compared the patients' background and surgical outcomes between patients with and without trans-tract electrocoagulation. Between the trans-tract electrocoagulation (n=225) and non-trans-tract electrocoagulation (n=72) groups, the stone number was significantly smaller (1:2:3or more, 126:72:27 vs 59:10:3, P=0.001) and the initial stone-free rates were significantly higher (80% vs 72%, P=0.006) in the trans-tract electrocoagulation group than in the non-trans-tract electrocoagulation group. Patients experienced a higher nephrostomy tube-free rate (67% vs 26%, P<0.0001), shorter postoperative catheterization time (2.8±3.8 vs 5.4±5.0days, P=0.002) and shorter hospital stay (6.5±3.6 vs 8.8±5.0days, P=0.0001) in the trans-tract electrocoagulation group than in the non-trans-tract electrocoagulation group. Trans-tract electrocoagulation in endoscopic combined intrarenal surgery is a safe and efficient procedure that decreases the need for nephrostomy tube placement after surgery.

Risk factors for fever and sepsis after percutaneous nephrolithotomy

ObjectivePercutaneous nephrolithotomy (PCNL) is commonly used in the management of large renal stones. Postoperative infections are one of the most common complications of this procedure. The present study is to determine and assess the factors that may increase the risk to develop fever and urinary sepsis after PCNL. MethodsA total of 60 patients (38 males and 22 females) with a mean age of 40.25 years enrolled in this study in Sulaimania Teaching Hospital. Patients had renal stone disease need operation with different socioeconomic status, body mass index and different type and size of stones were included in this study. Patients with preoperative positive urine culture and sensitivity were excluded. Preoperative investigations done for all patients. All Patients received prophylactic antibiotic gentamicin intravenously at the induction of anaesthesia. Renal pelvis urine sample were taken from all patients after puncturing the pelvicalyceal system and send for culture and sensitivity. Patients were monitored closely in the postoperative period for the development of fever and sepsis. ResultsMean duration of the operations was 77.08 min ranged 40–120 min. All patients had postoperative nephrostomy tube. Seventeen (28.33%) patients developed post PCNL fever and the statistically significant factors for post PCNL fever were diabetes mellitus (DM) (p = 0.001), stone burden (p = 0.001), number of the stones (p < 0.001), degree of hydronephrosis (p = 0.001), duration of the operation (p < 0.001), residual stones (p = 0.001) and number of tracts (p = 0.038). Three (5.00%) patients developed post PCNL sepsis, and the statistically significant risk factors for post PCNL sepsis were duration of the operation (p = 0.013) and intraoperative blood loss, postoperative drop in haemoglobin (HB) level (p = 0.046). ConclusionDM, staghorn stones, degree of hydronephrosis, duration of the operation and number of tracts are risk factors for post PCNL fever, while number of stones, intraoperative blood loss, duration of the operation and residual stones are risk factors for post PCNL sepsis.

Stone culture retrieved during percutaneous nephrolithotomy: is it clinically relevant?

Stone culture has been frequently investigated following percutaneous nephrolithotomy (PNL) in the last decade. We aimed to crucially define the clinical role of stone culture in modifying the treatment plan in patients with postoperative sepsis. Between June 2012 and April 2013, a total of 79 consecutive PNL procedures were included. Perioperative data were prospectively maintained. Preoperative urine sample, retrieved stone fragments and postoperative nephrostomy tube urine sample were cultured and antibiotic sensitivity tests were performed. The occurrence of at least two of the systemic inflammatory response syndrome (SIRS) events during their inpatient stay was diagnostic of SIRS. The antibiotic regimen utilized and its modifications were reported. The preoperative culture was positive in 26 patients (32.9%). The culture of stone fragments showed significant bacterial growth in 23 (29.1%) cases. Significant growth on stone culture was significantly associated with the presence of preoperative urinary catheters and positive preoperative urine culture (P=0.001, 0.006 respectively). Postoperative culture was positive in only six patients (7.6%). SIRS was diagnosed in the first postoperative day in 12 patients (15.2%). Leukocytosis was the only predictor of SIRS. Neither preoperative culture, stone culture nor postoperative culture was predictor of SIRS. Stone culture was positive in four patients with SIRS. Stone culture changed the treatment plan in only one patient. Our data do not support the routine implementation of stone culture in the PNL workup, as it did not indicate a change of antibiotic regimen in most of the cases.

Recent advancement or less invasive treatment of percutaneous nephrolithotomy.

Since its initial introduction in 1976, percutaneous nephrolithotomy (PCNL) has been widely performed for the management of large renal stones and currently is recommended for staghorn calculi, kidney stones larger than 2 cm, and shock wave lithotripsy-resistant lower pole stones greater than 1 cm. However, except for open and laparoscopic surgery, PCNL is the most invasive of the minimally invasive stone surgery techniques. Over the years, technical and instrumental advances have been made in PCNL to reduce morbidity and improve effectiveness. A thorough review of the recent literature identified five major areas of progress for the advancement of PCNL: patient positioning, method of percutaneous access, development of lithotriptors, miniaturized access tracts, and postoperative nephrostomy tube management. This review provides an overview of recent advancements in PCNL and the outcomes of each area of progress and notes how much we achieve with less invasive PCNL. This information may allow us to consider the future role and future developments of PCNL.

Categorisation of Complications and Validation of the Clavien Score for Percutaneous Nephrolithotomy

BackgroundAlthough widely used, the validity and reliability of the Clavien classification of postoperative complications have not been tested in urologic procedures, such as percutaneous nephrolithotomy (PCNL). ObjectiveTo validate the Clavien score and categorise complications of PCNL. Design, setting, and participantsData for 528 patients with complications after PCNL were used to create a set of 70 unique complication-management combinations. Clinical case summaries for each complication-management combination were compiled in a survey distributed to 98 urologists, who rated each combination using the Clavien classification. Outcome measurements and statistical analysisInterrater agreement for Clavien scores was estimated using Fleiss’ kappa (κ). The relationship between Clavien score and the duration of postoperative hospital stay was analysed using multivariate nonlinear regression models that adjusted for operating time, preoperative urine microbial culture, presence of staghorn stone, and use of postoperative nephrostomy tube. Results and limitationsOverall interrater agreement in grading postoperative complications was moderate (κ=0.457; p<0.001). Agreement was highest for Clavien score 5 and decreased with lower Clavien scores. Higher agreement was found for Clavien scores 3 and 4 than in subcategories of these scores. Postoperative stay increased with higher Clavien scores and was unaffected by inherent differences between study centres. A standard list of post-PCNL complications and their corresponding Clavien scores was created. ConclusionsAlthough the Clavien classification demonstrates high validity, interrater reliability is low for minor complications. To improve the reliability and consistency of reporting adverse outcomes of PCNL, we have assigned Clavien scores to complications of PCNL.

Supracostal access: does it affect tubeless percutaneous nephrolithotomy efficacy and safety?

Tubeless percutaneous nephrolithotomy (PCNL) in selected patients has been found to be safe and can reduce postoperative discomfort without increasing complications. The challenges of tubeless PCNL via supracostal access are inadequate drainage and postoperative bleeding, conditions that may increase pulmonary complications. We compare the efficacy and safety of the tubeless supracostal versus the standard supracostal PCNL. Supracostal PCNL with one percutaneous renal access, no significant bleeding, extravasation and residual stone was performed in 95 patients. Of these, 43 were tubeless PCNL (Group-I) and 52 were PCNL with standard routine postoperative nephrostomy tube (Group-II). In group-I, PCNL was done by the standard supracostal technique with the placement of a postoperative external ureteral catheter for 48 hours. The operative time, success rate, hospital stay and ensuing complications were compared between group-I and group-II. Patients in the tubeless PCNL group (Group-I) were 90.7% stone -free while those with standard routine postoperative nephrostomy tube(Group-II) were 84.6% stone -free. Additionally, stone fragments of less than 4 mm in diameter were found in 9.3% of patients in group-I and 25.4% in group-II. The success rate, hematocrit change and complication were not significantly different between both groups. The analgesic requirement, operative time and hospital stay were all significantly less in the tubeless supracostal group (Group-I). None of group I and only one patient of group II needed intercostal drainage. Tubeless supracostal percutaneous nephrolithotomy in selected patients is effective with acceptable complications. This technique offers the advantage of lower analgesic requirement, shorter operative time and hospital stay. The pulmonary complication is the same as the standard supracostal percutaneous nephrolithotomy.

Changing Practice to Stented Percutaneous Nephrolithotomy (PCNL): A 2 Year Experience

Introduction: Stented PCNL is an increasingly practiced technique in which PCNL is performed without leaving a post-operative nephrostomy tube. We present our results from one of the biggest UK series to assess the impact of this technique on the safety, efficacy, length of hospital stay and analgesic requirement, to guide our future practice in terms of patient selection. Patients and methods: Case notes of 56 stented PCNLs between October 2005 and 2007 were reviewed retrospectively and compared to a similar group of 50 conventional PCNLs (only a nephrostomy post-operatively) in terms of co-morbidities (ASA grade), stone burden, intra-operative details, complications, length of stay (LOS) and analgesic requirement. The stented technique was employed in complex stones and in anatomical abnormalities (e.g. horseshoe, solitary, and duplex systems). The use of a stent rather than a nephrostomy was decided at the time of surgery when satisfactory haemostasis and stone clearance were achieved at the end of the procedure. Results: Co-morbidities, anatomical abnormalities, stone burden, operative time, number of punctures, access and infection rates were comparable. The stented technique was employed in complex stones (staghorn n = 13, multiple stones n = 11) and in patients with anatomical abnormalities ( n = 9). Overall stone free rate was 92.8% and 82% for the stented and the conventional groups, respectively. No haemorrhage or ureteric obstruction was reported in the stented group. All stent removals were uneventful. Mean LOS and analgesic requirement of diclofenac were markedly less in stented group. The number of stented procedures tripled from year 1 ( n = 14) to year 2 ( n = 42). Mean LOS dropped steadily from 68.6h in the first 6 months ( n = 5) to 47.4h in the last 6 months ( n = 22) with increased experience. Twenty-four patients (42%) were fit for discharge within 35h. Conclusion: In our experience, the stented technique was well tolerated and has reduced the length of hospital stay with no evidence of loss of efficacy or increased morbidity even in complex stones or patients with anatomical abnormalities.

La néphrolithotomie percutanée “tubeless” : à propos de 37 cas

To assess the value and feasibility of "tubeless" percutaneous nephrolithotomy (without postoperative nephrostomy tube). Prospective study of 37 consecutive patients operated by "tubeless" percutaneous nephrolithotomy (PCNL) between 1998 and 2007 for renal stones. Inclusion criteria for this technique were: a single puncture tract, a procedure lasting less than 2 hours, <3 stones with a diameter <25 mm, complete extraction of all stones and no significant bleeding in the renal cavities at the end of the operation. A 7 Fr ureteric stent was inserted at the beginning of the operation in 33 patients and a double J stent was already present in the last four patients. All these stents were not remowed at the end of the procedure and the nephrostomy tract was electrocoagulated by a blunt electrocautery loop mounted on a 26 F resectoscope. No nephrostomy tube was left in place and no haemostatic product was used. Complications, length of hospital stay, operating time, blood loss, transfusions and intensity of pain were recorded. The mean stone diameter was 172 mm. The mean percutaneous operating time was 72 min. The mean length of hospital stay was 1.9 days (range: 1 to 7 days). The success rate was 95% and the complication rate was 13.5%. Complications were: two cases of pyelonephritis, one case of prolonged haematuria, one case of renal colic and one case of urinary extravasation. The mean decrease in haemoglobin was 0.95 g/dl (range: 0 to 2 g/dl). The mean intensity of pain evaluated by visual analogue scale (VAS) was 1.9. No blood transfusion was required. The ureteric stent was removed on postoperative D1 in 91% of patients with a stent. "Tubeless" percutaneous nephrolithotomy is an effective and reproducible procedure with low morbidity that provides satisfactory results in selected cases.

INFUNDIBULAR STENOSIS AFTER PERCUTANEOUS NEPHROLITHOTOMY

Acquired infundibular stenosis can develop after percutaneous nephrolithotomy. We review our experience with infundibular stenosis after this procedure. We evaluated the records of patients diagnosed with infundibular stenosis after percutaneous nephrolithotomy was performed at our institution between 1995 and 2000. Analysis included medical history, urinary stone type, stone removal procedure technique, length and number, postoperative course, stenosis time to development location, severity and treatment, and treatment outcome. Infundibular stenosis developed in 5 of 223 percutaneous nephrolithotomy cases (2%) performed during this period. Medical history in affected patients included previous ipsilateral open pyelolithotomy, diabetes and morbid obesity in 2 each. Percutaneous nephrolithotomy were done through a standard 30Fr nephrostomy tract and all cases were terminated before complete stone removal. Mean operative time was 258 minutes, which was significantly greater than the mean operative time of 207 minutes in all cases of unilateral percutaneous nephrolithotomy (p = 0.03). Postoperatively nephrostomy tube drainage was done for a mean of 33 days (range 16 to 51). All patients underwent at least 1 additional percutaneous stone removal procedure after primary percutaneous nephrolithotomy and before stenosis was detected. The mean time to stenosis detection was 9 months (range 2 to 24). Stenosis generally developed in areas corresponding to previous sites of percutaneous access and the degree of narrowing ranged from mild to severe. Mild and moderate stenosis was managed by observation and endoscopic dilation in 2 each. Severe stenosis in 1 patient was associated with significantly impaired ipsilateral renal function. Infundibular stenosis is a rare complication of percutaneous nephrolithotomy. In this series it was associated with prolonged operative time, a large stone burden requiring multiple removal procedures and extended postoperative nephrostomy tube drainage. In most cases stenosis developed at previous access sites within 1 year of initial percutaneous nephrolithotomy. Mild and moderate cases may be treated with observation and endoscopic dilation, respectively, while severe cases may result in renal impairment.

Almost totally tubeless percutaneous nephrolithotomy: further evolution of the technique.

There is renewed interest in the concept of foregoing placement of the postoperative nephrostomy tube (PNT) after percutaneous nephrolithotomy (PCNL) with the intent of reducing postoperative discomfort and hospital stay. We have omitted the PNT and placed an internal ureteral stent or externalized ureteral catheter after PCNL in selected patients. We reviewed our experience in order to assess the efficacy and safety of this practice. Primary PCNL was performed in 26 renal units in 21 patients (5 bilateral PCNL, 4 of which were simultaneous) by one surgeon at the University of Michigan and the Ann Arbor Veterans Affairs Medical Center. A postoperative nephrostomy tube was placed if the stone burden was >3 cm, more than one access site was used, the renal anatomy was obstructive, significant bleeding or perforation was noted, or a second look was required. No PNT was placed in 10 renal units in 8 patients (no-PNT group). In six no-PNT kidneys, internal ureteral stents were used, and in four, externalized ureteral stents were placed for 1 to 2 days. The mean stone size in the PNT and no-PNT patients was 3.0 and 1.8 cm, respectively. Of the 16 kidneys in the PNT group, 4 were initially eligible for omission of PNT, but a PNT was placed because of bleeding or other access-related problem. All patients were rendered stone free except for three (one PNT and two no-PNT) patients, who each had a fragment < or =4 mm. Omission of PNT placement resulted in decreased mean length of stay (2.3 days in the no-PNT group v 3.6 days in the PNT group). There were four complications, all managed with delayed stenting (one in a no-PNT patient and the remaining three in the PNT group). Omission of PNT placement in selected patients may reduce morbidity without compromising efficacy and safety, but further study is needed.

Percutaneous nephrolithotomy in infants and preschool age children: experience with a new technique

Objectives. To develop a less invasive method for performing percutaneous nephrolithotomy (PCNL) with the intent of decreasing the morbidity of the procedure in young children. Methods. A novel percutaneous renal access technique (“mini-perc”) was developed using an 11F peel-away vascular access sheath. Tract dilation and insertion of the sheath into the collecting system was performed with a single pass over an access wire. PCNL was performed using pediatric instruments and electrohydraulic lithotripsy. Sheath design improvements were implemented that make it specific for pediatric PCNL. Results. Eleven procedures have been performed with the 11F sheath. Patient age ranged from 2 to 6 years (mean 3.4) and weight from 5 to 24 kg (mean 12.5). The average stone burden was 1.2 cm 2. Mean procedure time, estimated blood loss, and length of hospitalization were 203 minutes, 25 mL, and 6 days, respectively. Six (85%) of 7 patients are currently stone free with an average follow-up of 12 weeks. No patient required transfusion, developed urosepsis, or had a procedure-related complication. One procedure was performed in an outpatient setting with no postoperative nephrostomy tube. Conclusions. The 11F “mini-perc” technique was successful in rendering 85% of patients stone free with minimal morbidity. Its advantages over obtaining access with standard 24 to 34F access sheaths include a smaller skin incision, single-step dilation and sheath placement, good working access for pediatric instruments, variable length, and lower cost. In addition, the hypothesized decrease in renal and body wall trauma may result in less pain, reduced severity or risk of complications, and shorter hospital stays including the possibility of performing “tubeless” outpatient PCNLs. Further study is needed to confirm these possibilities.

Percutaneous nephrostolithotomy and lithotripsy: a multi-institutional survey of complications.

A mail survey tabulating the results of some 8,595 percutaneous nephrostolithotomy and lithotripsy procedures (from 62 institutions) establishes an overall rate of failure, aborted procedure, and complications of 26% (2,262 cases). Data stratified as to the level of experience indicate a sharp improvement of the rate of failure and complications from 61% during the learning period to 18% thereafter. Inexperience and faulty technique rate highest as a cause for failure or complication. Underlying pathologic conditions and anatomic variants, while a relatively rare cause of failure or complication, can be diagnosed preoperatively and appropriate modification of technique instituted. The impact of technical factors such as the size of the postoperative nephrostomy tube is shown by statistical data.