Quality improvement guidelines for percutaneous nephrostomy

Percutaneous Nephrostomy as a Procedure in the Treatment of Urinary Tract Obstruction - Experiences in the University Clinic of Urology in Skopje

INTRODUCTION

Obstructive uropathy encompasses various urinary tract obstructions, leading to changes in urine flow, kidney pressure, and impaired kidney function. Predicting renal recovery from obstructive uropathy, can be challenging and necessitates treatment, as in percutaneous nephrostomy (PNS) drainage. The choice of drainage method depends on patient-specific factors and local expertise. According to the data for the Republic of North Macedonia, in the register of the European Renal Association, in the last few years, there has been an increase in the percentage of patients with obstructive nephropathy from 7.6% to 8.9% who end up on a chronic hemodialysis program. Prompt relief from urinary tract obstruction is essential to preserve renal function and prevent complications. The aim of this study is to present our initial data analysis of recent experience in the use of nephrostomies as a method for temporary or long-term resolution of obstructive nephropathy, in terms of safety and success in preserving kidney function and reducing the number of patients on hemodialysis.

MATERIALS AND METHODS

This study analyzed the medical records of 24 patients with obstructive uropathy who underwent PNS placement. Data were collected for the type and degree of obstruction from the ultrasonographic examination. A pig tail nephrostomy was used, with a dilator, guided under ultrasound and controlled with contrast and fluoroscope. Obstructive nephropathy was defined as an elevation of the serum creatinine > 109 µmol/L, before the intervention. Glomerular filtration rate (GFR) was calculated according to the formula CKD epi in ml/min. Each placement of the PNS was considered as an individual procedure and the data of 38 placed nephrostomies were analyzed. We compared the laboratory analyses from the day before (D0) PNS placement and on the seventh day (D7) after PNS placement. The reduction of values for red blood cells (RBC) and hemoglobin (Hb) baseline values from D0 to D7 and the need for transfusion after the procedure were defined as a complication-bleeding. The increase in total counts of the white blood cells (WBC) and C-reactive protein (CRP) from the baseline values from D0 to D7 were defined as a complication-infection. Standard statistical methods were used for data processing.

RESULTS

Most patients, 17 (70%), had malignant disease as the cause of obstruction. Unilateral obstruction was more common, detected in 24 (63%) of procedures, with a high degree of hydronephrosis. Obstructive nephropathy, marked by elevated serum creatinine, was observed in 23 (60%) cases before PNS placement. Complications included bleeding and infection but did not result in any fatalities. When comparing the laboratory analysis before PNS placement (D0) and seven days later (D7), a statistically significant decrease in serum creatinine (225±161 vs. 162±145, p=0.005) and an increase in GFR (47±39 vs.59±34, p= 0.005) were observed.

CONCLUSION

Percutaneous nephrostomy is a safe and effective treatment option for urinary tract obstruction, especially in patients with malignancies. Continuous monitoring is essential to assess long-term complications and the longevity of PNS functionality. This procedure offers a significant benefit in preserving renal function and minimizing the need for hemodialysis in these patients.

Is it a complication or a consequence - a new perspective on adverse outcomes in Interventional Radiology

The aim of the article is to introduce a new term in post-procedural events related to the procedure itself. All the Societies and Councils report these events as complications and they are divided in mild, moderate and severe or immediate and delayed.On the other hand the term error is known as the application of a wrong plan, or strategy to achieve a goal.For the first time, we are trying to introduce the term "consequence"; assuming that the procedure is the only available and the best fit to clinical indication, a consequence should be seen as an expected and unavoidable occurrence of an "adverse event" despite correct technical execution.

Nephrostomy catheter entering the right renal vein during an exchange procedure: A case report and literature review

INTRODUCTION

We encountered an extremely rare case of a nephrostomy catheter entering the right renal vein during an exchange procedure.

CASE PRESENTATION

An 80-year-old man underwent radical cystectomy. Urinary diversion was achieved through right percutaneous nephrostomy. After the 15th nephrostomy catheter exchange, the patient bled heavily from the catheter. We clamped the catheter immediately, and the patient became hemodynamically stable. Emergency angiography showed the nephrostomy catheter entering the renal vein from outside the renal pelvis. Under fluoroscopy, we pulled the catheter until its tip was located in the previous penetration site of the renal pelvic wall and inserted the catheter over the guidewire into the renal pelvis.

CONCLUSIONS

Herein, we report an extremely rare case of a nephrostomy catheter inserted into the right renal vein during an exchange procedure. Inserting a nephrostomy catheter in the appropriate position and performing exchange under imaging guidance techniques could help clinicians avoid severe complications.

Percutaneous Nephrostomy Catheter Misplacement into Inferior Vena Cava in a Patient with a Horseshoe Kidney

Background: Percutaneous nephrostomy (PCN) is commonly indicated for upper urinary tract drainage in case of obstruction or fistula. Only a few cases of PCN catheter misplacement into the inferior vena cava (IVC) have been published. Case Presentation: We report a case of a PCN catheter misplaced into the IVC through a fistula between the urinary tract and an ipsilateral renal vein in a patient with horseshoe kidney, after bedside urgent replacement for hemorrhage and hemorrhagic shock. Conclusion: Although a nephrostomy Foley catheter can be used for adequate urinary drainage and hemostatic purposes after percutaneous nephrolithotomy, its placement should be always verified through antegrade pyelography and particular care should be used for horseshoe kidneys. In case of massive hemorrhage, after temporary closure of the PCN catheter, the cause of bleeding should be investigated with urgent angiography or contrast-enhanced CT scan and promptly treated.

Complications of percutaneous nephrostomy in a district general hospital

OBJECTIVE

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.

MATERIAL AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

Use of cone-beam CT and live 3-D needle guidance to facilitate percutaneous nephrostomy and nephrolithotripsy access in children and adolescents

BACKGROUND

Gaining access into non-dilated renal collecting systems for percutaneous nephrolithotripsy, particularly in patients with prohibitive body habitus and/or scoliosis, is often challenging using conventional techniques.

OBJECTIVE

To evaluate the feasibility of cone-beam CT for percutaneous nephrostomy placement for subsequent percutaneous nephrolithotripsy in children and adolescents.

MATERIALS AND METHODS

A retrospective review of percutaneous nephrostomy revealed use of cone-beam CT and 3-D guidance in 12 percutaneous nephrostomy procedures for 9 patients between 2006 and 2015. All cone-beam CT-guided percutaneous nephrostomies were for pre-lithotripsy access and all 12 were placed in non-dilated collecting systems.

RESULTS

Technical success was 100%. There were no complications.

CONCLUSION

Cone-beam CT with 3-D guidance is a technically feasible technique for percutaneous nephrostomy in children and adolescents, specifically for nephrolithotripsy access in non-dilated collecting systems.

Interventional radiology: a half century of innovation

The evolution of modern interventional radiology began over half century ago with a simple question. Was it possible to use the same diagnostic imaging tools that had revolutionized the practice of medicine to guide the real-time treatment of disease? This disruptive concept led to rapid treatment advances in every organ system of the body. It became clear that by utilizing imaging some patients could undergo targeted procedures, eliminating the need for major surgery, while others could undergo procedures for previously unsolvable problems. The breadth of these changes now encompasses all of medicine and has forever changed the way we think about disease. In this brief review article, major advances in the field, as chronicled in the pages of Radiology, will be described.

Percutaneous silicon catheter insertion into the inferior vena cava, following percutaneous nephrostomy exchange

Percutaneous nephrostomy (PCN) has been widely used to drain an infected, obstructed kidney. Few major complications have been associated with it. Few publications have reported the misplacement of nephrostomy tube into the inferior vena cava (IVC), following percutaneous nephrolithotomy. We report a case of a misplaced silicon catheter, through the left renal vein, extending into the IVC, following nephrostomy tube exchange. Our case was safely managed, and we concluded that although PCN and nephrostomy tube exchange are relatively simple procedures, they should be done cautiously, by a well-trained urologist, and preferably under ultrasound or fluoroscopic guidance.

Migrated embolization coil: A rare cause of urinary tract obstruction

Refractory bleeding following percutaneous nephrolithotomy (PCNL) is mainly due to formation of pseudoaneurysm. Transarterial embolization is required to control the bleeding in such cases. We report a case of post-PCNL hematuria in whom angioembolization was done. An early erosion of the embolization coil from the renal vasculature into the urinary collecting system occurred, causing urinary tract obstruction and urinary tract infection (UTI). The coil was retrieved ureteroscopically after control of UTI with antibiotics. Migration of embolization coil into urinary collecting system is a rare but important cause of urinary tract obstruction. The treating physician as well as the patient should be aware of this complication.

Percutaneous nephrostomy: technical aspects and indications

First described in 1955 by Goodwin et al as a minimally invasive treatment for urinary obstruction causing marked hydronephrosis, percutaneous nephrostomy (PCN) placement quickly found use in a wide variety of clinical indications in both dilated and nondilated systems. Although the advancement of modern endourological techniques has led to a decline in the indications for primary nephrostomy placement, PCNs still play an important role in the treatment of multiple urologic conditions. In this article, the indications, placement, and postprocedure management of percutaneous nephrostomy drainage are described.

Temporal trends, practice patterns, and treatment outcomes for infected upper urinary tract stones in the United States

BACKGROUND

The incidence of infected urolithiasis is unknown, and evidence describing the optimal management strategy for obstruction is equivocal.

OBJECTIVE

To examine the trends of infected urolithiasis in the United States, the practice patterns of competing treatment modalities, and to compare adverse outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A weighted estimate of 396385 adult patients hospitalized with infected urolithiasis was extracted from the Nationwide Inpatient Sample, 1999-2009.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Time trend analysis examined the incidence of infected urolithiasis and associated sepsis, as well as rates of retrograde ureteral catheterization and percutaneous nephrostomy (PCN) for urgent/emergent decompression. Propensity-score matching compared the rates of adverse outcomes between approaches.

RESULTS AND LIMITATIONS

Between 1999 and 2009, the incidence of infected urolithiasis in women increased from 15.5 (95% confidence interval [CI], 15.3-15.6) to 27.6 (27.4-27.8)/100 000); men increased from 7.8 (7.7-7.9) to 12.1 (12.0-12.3)/100000. Rates of associated sepsis increased from 6.9% to 8.5% (p=0.013), and severe sepsis increased from 1.7% to 3.2% (p<0.001); mortality rates remained stable at 0.25-0.20% (p=0.150). Among those undergoing immediate decompression, 113 459 (28.6%), PCN utilization decreased from 16.1% to 11.2% (p=0.001), with significant regional variability. In matched analysis, PCN showed higher rates of sepsis (odds ratio [OR]: 1.63; 95% CI, 1.52-1.74), severe sepsis (OR: 2.28; 95% CI, 2.06-2.52), prolonged length of stay (OR: 3.18; 95% CI, 3.01-3.34), elevated hospital charges (OR: 2.71; 95%CI, 2.57-2.85), and mortality (OR: 3.14; 95%CI, 13-4.63). However, observational data preclude the assessment of timing between outcome and intervention, and disease severity.

CONCLUSIONS

Between 1999 and 2009, women were twice as likely to have infected urolithiasis. Rates of associated sepsis and severe sepsis increased, but mortality rates remained stable. Analysis of competing treatment strategies for immediate decompression demonstrates decreasing utilization of PCN, which showed higher rates of adverse outcomes. These findings should be viewed as preliminary and hypothesis generating, demonstrating the pressing need for further study.

Non-elective percutaneous nephrostomy (PCN) service in a tertiary uroradiology centre: can radiologists and urologists agree on timing?

AIM

To assess agreement between uroradiologists and urologists with regards to the timing of non-elective percutaneous nephrostomy (PCN) catheter insertion, and whether any delay produced unacceptable complications.

MATERIALS AND METHODS

Standardized data collection forms detailing patient demographics, indications for PCN catheter insertion, blood results, procedural details, and immediate complications were completed by uroradiologists. At the time of referral, patients were stratified by both radiologists and urologists into three groups as follows: group 1 = PCN within 6 h; group 2 = PCN between 6 and 24 h; and group 3 = PCN between 24 and 48 h.

RESULTS

One hundred and eighteen non-elective PCN catheter insertions were performed over 2 years. Radiologists stratified 12 patients (10.2%) into group 1, 65 (55.1%) patients into group 2, and 41 (34.7%) patients into group 3. Urologists stratified 14 (11.9%) patients into group 1, 68 (57.6%) patients into group 2, and 36 (30.5%) patients into group 3. There was good agreement between radiologist and urologists (κ = 0.865) on stratification in all but nine (7.6%) cases. Ninety-four point one percent of PCN catheters were inserted within the timeframe stratified by radiologists and urologists, or sooner. Sepsis was associated with a shortened timeframe. Elevated international normalized ratio (INR; >1.5) resulted in an increased timeframe. A major complication rate of 3% is within recommended limits. Fourteen percent of PCN catheter insertions were inserted outside normal working hours. Urgency stratification has decreased the number of cases performed out of hours.

CONCLUSION

Radiologists and urologists had good agreement on stratification with an acceptable major complication rate of 3%.

Diuretic agent and normal saline infusion technique for ultrasound-guided percutaneous nephrostomies in nondilated pelvicaliceal systems

PURPOSE

Percutaneous nephrostomy (PCN) in a nondilated pelvicaliceal system is technically challenging. We describe an effective method to achieve transient dilatation of the pelvicaliceal system via induction of diuresis using infusion of a diuretic agent in normal saline, therefore allowing easier access to the pelvicaliceal system.

METHODS

Under real-time ultrasound guidance, the technique had been tested in 22 nephrostomies with nondilated system (a total of 20 patients with 2 patients having bilateral nephrostomies) during a 5-year period. Patients were given 40 mg of furosemide in 250 ml of normal saline solution intravenously by rapid infusion. As soon as maximum calyceal dilatation of more than 5 mm was observed, which is usually 15 min later after the end of rapid infusion, patients were positioned obliquely, and PCN procedure under ultrasound guidance was performed.

RESULTS

The procedure was successful in 19 of the nephrostomies in 17 patients with a success rate of 86.36 % per procedure and 85 % per patient in nondilated pelvicaliceal systems. No major nephrostomy-, drug-, or technique-related complications were encountered. The technique failed to work in three patients due to the presence of double J catheters and preexisting calyceal perforation which avoided transient dilation of the pelvicaliceal system with diuresis.

CONCLUSIONS

Diuretic infusion in saline is a feasible and effective method for PCN in nondilated pelvicaliceal systems.

Safe and effective obtainment of access for percutaneous nephrolithotomy by urologists: the Louisiana State University experience

BACKGROUND AND PURPOSE

Access for percutaneous nephrolithotomy (PCNL) is critical to successful removal of stone burden and is often performed by a specialist other than a urologist. In many regions, however, there is limited availability of such personnel. We reviewed the complication rates that were related to PCNL access when performed at a teaching hospital to establish that access for PCNL may be safely taught to and performed by urology residents. Chief urology residents across the nation were also anonymously surveyed to better understand the current trends and dynamics regarding PCNL access in teaching institutions.

PATIENTS AND METHODS

A retrospective chart review was performed of all PCNLs performed at our institution from 1995 to 2009 for any complications that were related to surgery. Patients with access gained at outside institutions or not attempted at the time of surgery by residents were excluded. The complication rate was compared with those of the American College of Radiology. An eight-question survey was also sent by e-mail to all current urology chief residents regarding their experience with PCNL access during residency.

RESULTS

A total of 290 patients underwent PCNL with 338 separate access sites gained at the time of surgery under the supervision of nine teaching staff. Access was gained in all cases at the time of surgery. Major complications included: Transfusion in 20 (5.9%) patients, sepsis in 2 (0.6%) patients, pseudoaneurysm necessitating intervention in 2 (0.6%) patients, hydrothorax in 2 (0.6%) patients, pneuomothorax in 1 (0.3%) patient, ureteropelvic junction disruption in 1 (0.3%) patient, and one death (0.3%) after surgery. Minor complications included: Urinary tract infection in five (1.5%) patients, and collecting system injuries in 6 (1.8%) patients necessitating placement of a ureteral stent. Our survey of residents demonstrated that 53% did not routinely gain access for PCNL at their institution. The 94% who did not get instruction on PCNL access, however, thought it would be a valuable addition to their training.

CONCLUSION

Our results show that access for PCNL surgery can be safely and successfully obtained by genitourinary residents under the supervision of trained staff at the time of surgery. We think that access for PCNL is a valuable tool that should be in the armamentarium of all urologic surgeons on leaving an accredited urology training program.

Passage of embolization coil through urinary collecting system one year after embolization

Vascular injury is an uncommon, but serious, complication of percutaneous nephrolithotomy. Hyperselective angioembolization is an effective means of managing this complication with few reported adverse sequelae. We report a case in which an embolization coil placed after renal hemorrhage subsequently eroded into the collecting system more than 1 year postoperatively and was passed through the patient's urinary tract.

Single-Center Review of Fluoroscopy-Guided Percutaneous Nephrostomy Performed by Urologic Surgeons

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.

Minimally invasive percutaneous nephrolithotomy for staghorn calculi: a novel single session approach via multiple 14-18Fr tracts

OBJECTIVE

To report our experience with minimally invasive percutaneous nephrolithotomy (MPCNL) (14-18Fr percutaneous tract) to treat staghorn calculi via multiple percutaneous tracts in a single session procedure, and evaluate the feasibility and efficiency of this technique.

PATIENTS AND METHODS

From March 2001 to November 2005, 100 patients with staghorn calculi were treated by MPCNL via multiple percutaneous tracts. The size and location of the stone, operative parameters, number of tracts, stone-free rate, operating time, hospital stay, and complications were analyzed retrospectively.

RESULTS

A total of 209 percutaneous tracts were established in 100 renal units during 128 operations including 28 second-look procedures. The mean operating time was 107 minutes (range 43 to 130 min) and the mean hospital stay was 9.4 days (range 6 to 13 d). The initial stone clearance rate of 72% after the first session was improved to 93% after a second-look procedure in 28 patients. The mean blood loss was 112 mL (range 64 to 483 mL), 3 patients required blood transfusion and 1 patient with branched renal arterial injury during puncture received a highly elective embolism. Seven patients had a postoperative fever of 38.5 degrees C or greater, whereas 4 patients had mild hydropneumothorax.

CONCLUSIONS

With the development of instrument and increased experience, judiciously made multiple percutaneous tracts in a single session MPCNL for treating staghorn calculi in selected cases is safe, feasible, and efficient with an acceptable morbidity.

Risk of injury to adjacent organs with lower-pole fluoroscopically guided percutaneous nephrostomy: evaluation with prone, supine, and multiplanar reformatted CT

PURPOSE

To assess the risk of injury to organs near the kidney during lower-pole fluoroscopically guided percutaneous nephrostomy by evaluation of prone, supine, and multiplanar reformatted computed tomography (CT).

MATERIALS AND METHODS

Eighty-three patients who underwent prone and supine CT examinations were identified retrospectively. The expected path of nephrostomy tube placement to the lower-pole calyx was simulated on prone and supine axial images and multiplanar CT reformations. Intervening organs along this path were considered at risk for injury and were recorded for each kidney (N = 166).

RESULTS

The risk of organ injury as determined on multiplanar reformatted prone images (n = 5) and supine images (n = 0) was significantly less (P < .05) than determined on axial prone images (n = 25) or supine images (n = 10). The colon was the only organ identified to be at risk for injury during the simulated lower-pole percutaneous nephrostomy placement; spleen and liver were not seen along the nephrostomy path on axial or multiplanar reformatted images.

CONCLUSION

Lower-pole fluoroscopically guided percutaneous nephrostomy carries a low risk of visceral injury, and the risk of injury is overestimated by evaluation of axial CT images alone compared with oblique parasagittal reformations.

Percutaneous Treatment of the Obstructive Uropathy

Purpose

to analyse the technical aspects, the patient's selection criteria, and some useful tactics to reduce the complications of percutaneous nephrostomy and of other interventional procedures to temporarily treat obstructive uropathy (OU), such as double J stent insertion, dilatation of the stricture using high-pressure balloon catheters, removal of renal or ureteral calculi, fistulas treatment.

Materials and Methods

a fluoroscopy table and an ultrasonographic guidance are key elements. Two techniques are employed, either the Seldinger type (wire-guided catheters) or the trocar needle type. Sole contraindication: uncorrectable severe coagulopathy. Most important risk factors are: dendritic calculus, non corrected high blood pressure, obesity, small size kidney, severe scoliosis.

Results

high technical success of the procedure in case of dilated collecting systems (98%); it is minor without dilatation (85%).

Conclusion

percutaneous nephrostomy is indicated in 87% of obstructive uropathy cases. It represents the basic technique allowing other interventional procedures to treat obstructive uropathy; it should be performed by most radiologists following an adequate training with technique and materials.

Percutaneous nephrostomy in children: diagnostic and therapeutic importance

The aim of this study was to evaluate the effectiveness and safety of percutaneous nephrostomy (PN) in terms of diagnostic and therapeutic approach in children with urological problems. PN was performed on 39 kidneys in 28 patients (12 girls, 16 boys) aged 4.5 months to 13 years (average 5.38+/-3.41 years) during the period from January 1996 to December 2003. Underlying abnormalities were ureteropelvic junction obstruction (UPJO) in 14 patients (17 kidneys), ureterovesical junction obstruction (UVJO) in six patients (eight kidneys), supravesical obstruction due to tumour or hydatid cyst or ureteral stone in three patients (five kidneys), and severe vesicoureteral reflux (VUR) with/without neurogenic bladder associated with pyonephrotic kidneys in five patients (nine kidneys). The duration of catheter insertion was between 2 and 160 days (average 80+/-65.01 days). The complications were haematuria (six cases), infection (five cases) and displacement of catheter (four cases). Radical surgical management was performed in 25 patients (33 kidneys): pyeloplasty in eight cases (ten kidneys), UVJO correction in six cases (eight kidneys), nephrectomy in five cases (five kidneys), ureteroneocystostomy in four cases (seven kidneys), hydatid cyst operation in one case (two kidneys) and stone extraction in one case (one kidney). PN is an easy, safe and efficient diagnostic and therapeutic procedure with few complications in childhood.

Success and Short-term Complication Rates of Percutaneous Nephrostomy during Pregnancy

Outcome of percutaneous nephrostomy creation during pregnancy was retrospectively studied. Catheter insertion was successful in all cases (N = 8; 3% of all nephrostomies over a 5-year period), with one major complication (sepsis) and three minor complications. Catheters remained in situ for a mean of 9.4 days until the stone passed (n = 1) or was removed on ureteroscopy (n = 2) or a ureteral stent was inserted (n = 5). Maternal outcome was normal in all cases, but there were two premature deliveries. Nephrostomy during pregnancy has acceptable technical and clinical results, but the possibility of an increased risk of septic complications (12.5% in this series) necessitates further study.

Percutaneous nephrostomy of nondilated renal collecting systems with fluoroscopic guidance: technique and results

PURPOSE

To retrospectively review experience with a double-puncture technique for percutaneous nephrostomy of nondilated renal collecting systems.

MATERIALS AND METHODS

Over a 5-year period, 15 patients (26 kidneys) without calyceal dilatation at ultrasonography (US) who required nephrostomy drainage were studied. Eleven patients (21 kidneys) had ureteral leaks or fistulas, one patient (one kidney) had a renal pelvic stone, one patient (one kidney) was suspected of having a ureteral tumor, and the final two patients (three kidneys) had acute nondilated renal failure. Mean age was 62 years (range, 20-78 years); 13 patients were men and two were women. A double-puncture technique was used with fluoroscopic guidance (supplemented with US in some patients who had renal failure). After intravenous administration of iodinated contrast material, a 22-gauge needle was inserted into the opacified renal pelvis, and double-contrast pyelography was performed by using air or carbon dioxide to allow visualization and distention of the nondependent calyces for definitive renal access with an 18-gauge 5-F sheath-needle set and a hydrophilic wire. After serial dilation, a nephrostomy or nephroureteral catheter was inserted. Success and major complication rates were studied by reviewing radiologic and clinical case notes.

RESULTS

Catheter placement was successful in 25 (96%) of 26 kidneys after one, two, or three passes with the sheath-needle set. In all successful cases, the calyx was accurately punctured. There were two major complications. One patient developed hematuria that required transfusion but no further intervention; another sustained a renal pelvic injury, but this was believed to be due to excessive dilation of the pelviureteral junction, not faulty renal puncture. There were no cases of septicemia.

CONCLUSION

With a double-puncture technique and air or carbon dioxide distention, nephrostomy was achieved in 25 (96%) of all nondilated renal collecting systems. There were two major complications (two [8%] of 25 kidneys, two [13%] of 15 patients), but only one was secondary to the renal puncture.

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.

Ureteral stent placement without postprocedural nephrostomy tube: experience in 41 patients

PURPOSE

To evaluate one-stage antegrade ureteral stent placement without postprocedural nephrostomy tube.

MATERIALS AND METHODS

Tubeless ureteral stent insertion was attempted in 41 (30 men, 11 women; eight, benign obstruction; nine outpatients) of 97 adults (56 excluded). Patients were clinically stable with known ureteral obstruction and had been referred for antegrade ureteral stent insertion. Exclusion criteria were infection, coagulopathy, or emergency cases. After renal access was achieved, ureteral stents were inserted. If drainage was satisfactory and there was no marked procedural bleeding, all access was removed without leaving a nephrostomy tube behind. Technical and clinical success rates and complications were assessed with review of radiologic and clinical notes. If one-stage stent insertion was unsuccessful, a nephrostomy tube was inserted and two-stage stent placement was performed. All 56 patients excluded from this study underwent two-stage stent placement. Major complication rate was assessed (Fisher test).

RESULTS

One-stage stent insertion was technically successful in 36 (88%) patients; two with an identifiable risk factor (recent bladder operation, retrograde ureteral instrumentation) developed septicemia that required repeat nephrostomy tube insertion and 2-8 extra days of hospitalization. Clinical success rate was 83% (34 of 41). No major bleeding occurred. In 13 (36%) of 36 patients, hematuria lasted longer than 24 hours but resolved without further intervention or blood transfusion. In those who underwent two-stage stent placement (n = 61), technical success rate was 100%, but clinical success rate was 98%; one patient developed septicemia, and no major hemorrhage occurred. Difference in major complication rate between groups was not significant (6% [two of 36] vs 2% [one of 61]; P =.55).

CONCLUSION

One-stage tubeless antegrade ureteral stent insertion in selected cases showed 88% technical success rate and 83% clinical success rate, with no major hemorrhage.

Imaging of renal tuberculosis in eastern Taiwan: correlation with clinical course and different communities

Hualien, located in eastern Taiwan, is a relatively isolated district. The population is composed of different ethnic communities. Our hospital is the only medical center in eastern Taiwan, so is the most important referral hospital for epidemic diseases. After reviewing our collected cases of renal tuberculosis (TB), we observed a great diversity in staging and outcomes. The aim of this study was to classify different imaging presentations and clinical outcomes in the ethnic communities represented by these cases (non-aboriginal and aboriginal). We retrospectively reviewed 22 cases from 1991 to 2001. We reviewed laboratory data, radiologic reports, and clinical outcomes. Before TB was proved by biopsy or culture, patients were not treated with an anti-TB regimen. Roentgenography showed that 68% of patients had renal calcification, 59% had dilated calyces, 55% had lung involvement, and 41% had auto-nephrectomy. The proportion of mild and severe forms was significantly different between aboriginal and non-aboriginal groups (0.05 > p > or = 0.00409). From this series, we recommend routine plain film roentgenography, including chest roentgenography and kidney, ureter, and bladder or abdominal roentgenography, followed by intravenous urography or computerized tomography as investigative tools for renal TB. Based on the significantly different outcomes of the disease between aboriginal and non-aboriginal groups, a stronger health education program for the isolated district in eastern Taiwan is necessary.