Editorial comment. The value of intensive medical management of distal ureteral calculi in an effort to facilitate spontaneous stone passage

Urolithiasis in the emergency department

Urolithiasis commonly presents to the emergency department with acute, severe, unilateral flank pain. Patients with a suspected first-time stone or atypical presentation should be evaluated with a noncontrast computed tomography scan to confirm the diagnosis and rule out alternative diagnoses. Narcotics remain the mainstay of pain management but in select patients, nonsteroidal anti-inflammatories alone or in combination with narcotics provide safe and effective analgesia in the emergency department. Whereas most kidney stones can be managed with pain control and expectant management, obstructing kidney stones with a suspected proximal urinary tract infection are urological emergencies requiring emergent decompression, antibiotics, and resuscitation.

Almost totally tubeless percutaneous nephrolithotomy: further evolution of the technique

BACKGROUND AND OBJECTIVES

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.

PATIENTS AND METHODS

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.

RESULTS

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).

CONCLUSION

Omission of PNT placement in selected patients may reduce morbidity without compromising efficacy and safety, but further study is needed.