Abdul Majid Rana

Purpose: To review the success rate and complications of radiologically guided percutaneous nephrostomies (PCNs) performed by urologists and compare the complication rates with the standards recommended by the Society of Interventional Radiology (SIR) and the American College of Radiology (ACR). Patients and Methods: From January 1996 to December 2005, 667 patients had 765 PCNs performed by three urologists, with 74 patients having simultaneous bilateral PCNs. The mean age of the patients was 29 years (range 8 months–95 years). The medical records were reviewed for underlying diseases, success rate, and complications of PCN; and the results were assessed in comparison with recommendations made by SIR and ACR. Results: The PCN was successful in 742 renal units (97%). A total of 26 of the 667 patients (3.89%) had major complications: 12 (1.79%) had sepsis, 10 (1.49%) had hemorrhage sufficient to necessitate transfusion, 1 (0.14%) had pleural injury that was managed conservatively, and another patient had a vascular complication necessitating nephrectomy. None of the patients had bowel transgression. Minor complications occurred in 61 patients (9.1%): urinary-tract infection in 17, PCN tube dislodgement in 11, catheter obstruction by clot or debris in 12, urine leakage around the PCN site in 8, and loss of the PCN catheter in 13. Conclusion: Percutaneous nephrostomy is a relatively safe, minimally invasive, and effective procedure with a low rate of morbidity. Our overall results in term of success rate and major complications are within the threshold limits set by the SIR and ACR. Hence, trained urologists can produce results similar to those of interventional radiologists. Learning of PCN should be mandatory in the training curriculum for all urology residents.

Purpose: To review the management approach to and results of severely encrusted retained ureteral stents and analyze predictive risk factors. Patients and Methods: Medical records from January 1996 to March 2006 were reviewed for Double-J stent complications and their final outcome. A total of 876 stents were inserted in 784 patients for treatment of renal calculi with extracorporeal shockwave lithotripsy, ureteral calculi, after percutaneous nephrolithotomy, pyeloplasty, or injury to the ureter and kidney. Of these stents, 95 (10.84%) were found to be encrusted, and 26 (2.96%) were not only encrusted but retained as well. These patients, 21 men and 5 women with a mean age of 34 years (range 18–69 years), underwent one or more of the following procedures: cystolitholapaxy, retrograde ureteroscopic manipulation, intracorporeal or extracorporeal lithotripsy, percutaneous nephrolithotomy, and open surgical removal to make them stent free. Results: The average duration of stent placement was 14 months (range 5 months–9 years). The encrustation was confined to the upper coil in 4 and the upper coil and body in 5. The lower coil and body in 8 and 9, respectively, were totally encrusted, of which 2 were fragmented as well. A total of 62 sessions of auxiliary procedures were required to render patients stent free. Four patients required percutaneous nephrolithotomy and one open removal. Conclusion: Encrustation and retention of a ureteral stent is a serious complication. Successful management of encrusted retained stents requires multimodality procedures along with proper record keeping of stent insertion and removal and patient counseling.

We challenge the routine placement of nephrostomy tube after percutaneous nephrolithotomy (PCNL) without taking into consideration the size, burden, and multiplicity of the stones; the degree of obstruction of the pelvicaliceal system, or any anatomic variations of the kidney in shape or position. Between January 2005 to March 2006, 110 patients underwent PCNL, 77% of whom had multiple stones. The mean size of the single stones was 4.3 cm (range 2.8-6.5 cm), and the mean single-stone burden was 7.2 cm2 (range 5.6-14.3 cm2). The mean burden of multiple stones was 11.4 cm2 (range 8-23 cm2). Among the patients, 18 had had previous renal surgery, 12 had renal insufficiency, and 7 had a solitary functioning kidney. One patient each had horseshoe kidney and malrotated kidney. In 106 patients, no nephrostomy drain was placed, only an externalized 5F ureteral catheter for 16 to 20 hours. Two patients had simultaneous bilateral tubeless PCNL. The outcome was evaluated prospectively. The frequency of complications, length of hospital stay, and stone-free status were assessed. A stone-free rate of 80% was achieved using PCNL as monotherapy. The mean postoperative hospital stay was 16 to 20 hours. Three patients required placement of a nephrostomy tube because of significant bleeding and one because of purulent renal discharge. In four patients, a ureteral catheter was replaced by a stent because of significant residual stone burdens. The initial 18 patients underwent ultrasound examination on the first postoperative day, and none demonstrated any extrarenal collection, so routine ultrasound examination was omitted in succeeding patients. One patient required exploration because of a retroperitoneal hematoma. Omission of a nephrostomy tube after PCNL while retaining an externalized ureteral catheter for 16 to 20 hours is sufficient and safe irrespective of the stone characteristics. Shape, position, and function of the kidneys are also irrelevant with regard to tubeless PCNL.