The Utility of Intraluminal Therapies in Upper Tract Urothelial Carcinoma: A Narrative Review

Nephron sparing surgery (NSS) is considered for selected cases of upper tract urothelial carcinoma (UTUC) as it maintains renal function and avoids morbidity associated with radical nephroureterectomy (RNU). The appropriate selection of patients suitable for NSS without compromising oncological outcomes can sometimes be difficult, given the limitations of diagnostic modalities. Recurrence rates for UTUC can be as high as 36 to 54% after NSS. Intraluminal adjuvant therapy can be attempted following NSS to reduce recurrence, but delivery to the upper tract is more challenging than into the bladder. Bacillus Calmette-Guerin (BCG) and chemotherapy such as Mitomycin (MMC) have been administered via nephrostomy or ureteric catheter, which requires invasive/repeated instrumentation of the upper urinary tract. Drug delivery by reflux from bladder instillation along indwelling stents has also been tried but can potentially be unreliable. Recently, a gel formulation of mitomycin has been developed for the controlled exposure of the upper urinary tract to treatment over a number of hours. Drug-eluting stents to deliver chemotherapy to the upper urinary tract have been developed but have not yet entered clinical practice. Endoluminal phototherapy utilising an intravenous photosensitising agent is another novel approach that has recently been described. Intraluminal therapies may be beneficial in decreasing recurrence rates in UTUC, but currently have some limitations in their usage.

Malignant upper urinary tract obstruction in cancer patients: A systematic review

Objective

To systematically summarise the current clinical evidence for de novo malignant upper urinary tract obstruction treatment with a focus on standards of reporting, patient outcomes and future research needs.

Methods

This review protocol was published via PROSPERO (CRD42022341588). OVID MEDLINE (R), EMBASE, Cochrane Central Register of Controlled Trials-CENTRAL were searched up to June 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Prospective and retrospective studies were included.

Results

Of 941 articles identified, 82 with 8796 patients were eligible for inclusion.Most studies in the published literature are retrospective and investigate heterogenous malignancies. Percutaneous nephrostomy and ureteric stenting are the most studied interventions. Few studies describe the outcomes from no intervention or investigate patient perspectives. Overall reported median survival after intervention was around 11.7 months. A lack of standardised reporting of outcomes was evident.

Conclusions

Malignant upper urinary tract obstruction is an important clinical condition affecting patients globally. Overall survival after intervention appears poor however the current evidence base has significant limitations due to studies of low methodological quality and the lack of a standardised framework for reporting outcomes.We have provided a pragmatic framework for future studies based on the review to ensure a uniform methodology is utilised moving forward.

Not-so-simple nephrectomy: Comparative analysis of radical and simple nephrectomy in a high-volume tertiary referral center

OBJECTIVES

Simple nephrectomies can be challenging with significant morbidity. To prove the hypothesis of "not-so-simple" nephrectomy, we compared demographics, perioperative outcomes, and complications between simple and radical nephrectomy in a tertiary referral center.

METHODS

We analyzed 473 consecutive radical nephrectomies (January 2018-October 2020) and simple nephrectomies (January 2016-October 2020). Univariate and multivariate analysis of perioperative outcomes utilized the Mann-Whitney U test, Chi-squared test, Mantel-Haenszel test of trend, and multiple linear regression. Radical nephrectomies were classified in cT1, cT2a, and cT2b-T3 subgroups and compared to simple nephrectomies. Minimally invasive and open techniques were compared between the two groups. Infected versus non-infected simple nephrectomies were compared.

RESULTS

A total of 344 radical and 129 simple nephrectomies were included. Simple nephrectomy was an independent predictor of increased operative time (p = 0.001), length of stay (p = 0.049), and postoperative complications (p < 0.001). Simple nephrectomies had higher operative time (p < 0.001), length of stay (p = 0.014), and postoperative morbidity (p < 0.001) than cT1 radical nephrectomies and significantly more Clavien 1-2 complications than cT2a radical nephrectomies (p = 0.001). The trend was similar in minimally invasive operations. However, conversion to open rates was not significantly different. Infected simple nephrectomies had increased operative time (p < 0.001), length of stay (p = 0.005), blood loss (p = 0.016), and intensive care stay (p = 0.019).

CONCLUSIONS

Patients undergoing simple nephrectomy experienced increased operative time and morbidity. Simple nephrectomy carries higher morbidity than radical nephrectomy in tumors ≤10 cm. Robotic simple nephrectomies may reduce open conversion rates. Postoperative intensive care and enhanced recovery may be essential in simple nephrectomy planning with infected pathology.

Application of Bipolar Cauterization During Standard Percutaneous Nephrolithotomy

Introduction: We aimed to evaluate the efficacy of bipolar cauterization for tract site bleeding during standard percutaneous nephrolithotomy (PCNL). Methods and Materials: We defined tract site bleeding as when the visual field across the parenchymal tract starts to bleed while the sheath of a balloon dilator is being withdrawn just before the operation is completed. Among 181 patients, 90 patients showed no significant bleeding, and 91 patients required further procedures to resolve tract site bleeding. In cases of unresolved tract site bleeding, either nephrostomy placement (n = 60) or cauterization (n = 31) was performed. The outcomes of three groups (no procedure group, nephrostomy group and cauterization group) were compared. Results: The median decrease in hemoglobin at 2-hour intervals postoperatively was -1.75, -1.0, and -0.2 in the nephrostomy, cauterization, and no procedure groups, respectively (P < .001). There were 25 patients (41.7%) who received transfusions in the nephrostomy group, whereas only 1 patient (3.2%) received a transfusion in the cauterization group (P < .001). Conclusion: The bipolar cauterization of bleeding points at the end of PCNL could efficiently decrease tract site bleeding and reduce the need for transfusion. Clinical Research Information Service (https://cris.nih.go.kr/cris; No. KCT0008303).

Factors predicting infective complications following percutaneous nephrolithotomy and retrograde intrarenal surgery according to systemic inflammatory response syndrome and quick sequential organ failure assessment: A prospective study

Purpose

Myriad operative factors and characteristics of patients may influence the risk of infection in a patient undergoing stone surgery. We prospectively determined the risk factors for systemic inflammatory response syndrome (SIRS) and quick sequential organ failure assessment (qSOFA) in patients undergoing percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS).

Materials and Methods

Patients who underwent PCNL and RIRS from March 2018 to January 2020 satisfying our selection criteria were enrolled. Samples of urine from the renal pelvis, bladder, and retrieved stones were sent for culture testing. Postoperatively patients were keenly supervised for any indications of SIRS and qSOFA. The association between stone and urine cultures across various sites was examined. Regression analysis was performed to ascertain clinical variables affiliated with SIRS and qSOFA.

Results

The study included a total of 150 patients including both PCNL and RIRS, of which 23% post-PCNL and 20% post-RIRS met the criteria of SIRS and qSOFA. On univariate analysis in PCNL-Dilated pelvicalyceal system (PCS), renal pelvic urine culture (RPUC), stone culture (SC), and operative time >124 min among others were identified as risk factors whereas, in RIRS-residual calculus, RPUC, SC and operative time >62 min were risk factors. Multivariate analysis identified dilated PCS and SC for PCNL and only intraoperative RPUC for RIRS as independent risk factors. Only a significantly strong correlation among culture analysis was found between RPUC and SC in both the procedures.

Conclusion

Intraoperative RPUC and SCs are better predictors of post-PCNL SIRS while Intraoperative RPUC and duration of surgery are better predictors of post-RIRS sepsis. We, therefore, recommend that both these cultures must routinely be obtained in the above procedures to identify the offending organisms and amend antibiotic therapy during treatment and surgical duration should be kept <62 min in RIRS. SIRS serves as a sensitive review tool which is specifically useful for initial care and on the contrary qSOFA is well suited for patients at greater risk of demise, thereby guiding clinicians to decide future care and course of treatment of patients.

Multiple Percutaneous Drainage of a Giant Pyonephrosis Caused by Urolithiasis: A Case Report

The prevalence of kidney stones continues to rise in modern times. Undiagnosed and/or mistreated, it can result in suppurative kidney damage and, in rare instances, death from systemic infection. We present the case of a 40-year-old woman who presented to the county hospital for sleight left lumbar pain, fever, and pyuria for about two weeks. Ultrasound and CT scan revealed a giant hydronephrosis with no visible parenchyma, secondary to a stone in the pelvic-ureteral junction. Although a nephrostomy stent was placed, 48 hours later the purulent content was not evacuated completely. She was referred to a tertiary center, where two more nephrostomy tubes were placed to completely evacuate approximately 3 L of purulent urine. Three weeks later, after the inflammation parameters normalized, a nephrectomy was performed with good outcomes. A pyonephrosis urologic emergency can develop into septic shock, demanding rapid medical attention to prevent potentially fatal outcomes. In some circumstances, percutaneous draining of a purulent collection may not be sufficient to remove the whole purulent mass. Before nephrectomy, all collections must be removed with further percutaneous procedures.

Antegrade administration of mitomycin gel for upper tract urothelial carcinoma via percutaneous nephrostomy tube: a multi-institutional retrospective cohort study

OBJECTIVES

To assess the safety profile of antegrade mitomycin gel instillation through a percutaneous nephrostomy tube (PCNT) for upper tract urothelial carcinoma (UTUC) with the aim of decreasing morbidity associated with therapy.

PATIENTS AND METHODS

Patients undergoing antegrade administration of mitomycin gel via PCNT were retrospectively included for analysis from four tertiary referral centres between 2020 and 2022. The primary outcome was safety profile, as graded by Common Terminology Criteria for Adverse Events (v5.0). Post-therapy disease burden was assessed by primary disease evaluation (PDE) via ureteroscopy.

RESULTS

Thirty-two patients received at least one dose of mitomycin gel via PCNT for UTUC, 29 of whom completed induction and underwent PDE. Thirteen patients (41%) had residual tumour present prior to induction therapy. At a median of 15.0 months following first dose of induction therapy, ureteric stenosis occurred in three patients (9%), all of whom were treated without later recurrence or chronic stenosis. Other adverse events included fatigue (27%), flank pain (19%), urinary tract infection (12%), sepsis (8%) and haematuria (8%). No patients had impaired renal function during follow-up and there were no treatment-related deaths. Seventeen patients (59%) had no evidence of disease at PDE and have not experienced recurrence at a median follow-up of 13.0 months post induction.

CONCLUSIONS

Administration of mitomycin gel via a PCNT offers a low rate of ureteric stenosis, demonstrates a favourable safety profile, and is administered without general anaesthesia.

Early pyeloplasty and excision of a multicystic kidney in a neonate with a complicated nephrostomy: A case report

The association of multicystic renal dysplasia with ureteropelvic junction obstruction is noteworthy in newborn. However, the possibility of conservative management is still a primary requirement, unless there are complications that suggest surgery. The authors are studying a case of a newborn in which an incorrect nephrostomy led to complications that required emergency surgery.

Case Presentation

A newborn girl with left-side ureteropelvic junction obstruction and an enlarged and multicystic right kidney was operated on at an early age by unexpert hands, leading to complications. Was monitored daily, and an emergency procedure was done. Following up shows the success of the emergency operation.

Clinical Discussion

The age and the precise timing of intervention are controversial. In this case, several postnatal diagnostic tests were made due to the severity of the hydronephrosis in the antenatal period, which resulted in the implementation of percutaneous nephrostomy.

Conclusion

Authors suggest that it is better to not operate as long as the patient's condition is stable.

The implications when offering percutaneous nephrostomy for the management of malignant obstructive uropathy secondary to urological malignancy: can we be more selective?

Background & Objectives

Percutaneous nephrostomy (PN) for malignant ureteric obstruction (MUO) is increasingly accessible with high success rates. However, it is not without associated risks and morbidity, impacting quality of life, while not improving overall survival. In two UK hospitals, we investigated the outcomes of undergoing PN for MUO, to inform future patient counselling and selection for this intervention.

Methods

A retrospective audit of electronic records identified patients that received PN for bladder, and prostate cancer (PCa) between January 2015 and December 2018. Hospital 1 had a 24-h nephrostomy service, while Hospital 2 had a limited service; Group A: recurrent or treatment-resistant PCa, Group B: primary PCa, Group C: Bladder cancer.

Results

A total of 261 patients (Hospital 1 = 186, Hospital 2 = 75), had PN insertion. Seventy-eight had prostate or bladder cancer. Group A n = 30, Group B n = 12, Group C n = 36. Median age = 79 [interquartile range (IQR) = 72-86]. Following PN insertion, 12-month mortality was significantly greater in Hospital 1 at 82%, versus 52% in Hospital 2 (p = 0.015). Median survival: Group A: 177 days (IQR = 80-266), Group B: 209 days (IQR = 77-352), Group C: 145 days (IQR = 97-362). There was no significant difference in same-admission mortality, although group A had the greatest same-admission mortality at 17%. A total of 69% of all patients received bilateral nephrostomies. Patients with bilateral versus unilateral PN had no difference in mortality or nadir creatinine.

Conclusion

Most patients with malignant obstruction secondary to prostate or bladder cancer lived less than 12 months after PN insertion. When offering PN, careful consideration of disease prognosis should be made, and frank discussion of the implications of a life-long nephrostomy with patients and relatives.

Interventions for obstructive uropathy in advanced prostate cancer: a population-based study

OBJECTIVES

To develop and validate a coding framework to identify interventions for upper tract obstructive uropathy (UTOU) in men with locally advanced and metastatic prostate cancer (PCa) using administrative hospital data to assess clinical outcomes. There are no population-based studies on the incidence, treatment, and outcomes of this complication.

PATIENTS AND METHODS

Patients newly diagnosed with PCa between April 2014 and March 2019 were identified in the English cancer registry. A coding framework based on procedure (Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures fourth edition) and diagnostic (International Classification of Diseases, 10th edition) codes was developed and validated. Subsequent clinical outcomes were determined using Hospital Episodes Statistics to determine the utility of the intervention.

RESULTS

A total of 77 010 patients newly diagnosed with locally advanced, and 30 083 patients with metastatic PCa were identified. Of these, 1951 (1.8%) patients underwent an intervention for UTOU according to our coding framework: 830 (42.5%) had locally advanced disease and 1121 (57.5%) had metastatic disease. In all, 844 (43.3%) had a percutaneous nephrostomy (PCN), 473 (24.2%) had a PCN with antegrade stent, and 634 (32.5%) had a retrograde stent. The mean follow-up was 43.2 months. The cumulative incidence of the use of these interventions at 1, 3, and 5 years was 2.5%, 3.6% and 4.2% in men with metastases compared to 0.5%, 0.9% and 1.4% in men with locally advanced disease.

CONCLUSION

A new coding framework, developed to identify procedures for UTOU was applied in the largest study to date of UTOU in men with primary locally advanced and metastatic PCa. Results demonstrated that 2% of men with locally advanced PCa and 4% of men with metastatic PCa require an intervention to resolve UTOU within 5 years of their PCa diagnosis.

Percutaneous Nephrostomy in the Treatment of Hydronephrosis in Renal Transplant Patients - Case Report

Percutaneous nephrostomy is a first-line minimal invasive treatment option for ureteral obstruction following kidney transplantation, with high effectiveness and a low complication rate. Percutaneous nephrostomy might be used as a temporary salvage therapy, providing acute decompression of the kidney collecting system and preventing graft loss. It can also function as a permanent and sometimes only possible option in transplant patients with frequent recurrences of ureteral stenosis who either fail an open surgical reconstruction or who are not good candidates for these procedures. We present two patients with acute decline in urine output after renal transplantation with radiologically verified hydroureteronephrosis of the transplanted kidney (graft) caused by stenosis of distal ureter. In both cases, nephrostomy was placed within 48 hours as a temporary salvage treatment that ameliorates renal function and prevents graft loss. The permanent nephrostomy was the only possible solution for the preservation of the graft's function in the first case because of the recurrences of ureteral stenosis after several percutaneous interventions and open-surgery ureteral reconstruction. A few episodes of nephrostomy tube-related infections were resolved with antibiotics in the first case. The second case was treated with open ureteroneocystostomy with resection of stenotic segment and reinsertion of the ureter into the bladder (ureterocystoneostomy) because of the length of the involved ureteral segment. Both patients had stable graft function in the follow-up period.

Urinary tract obstruction: Ultrasound-guided intervention

Introduction

Urinary tract obstruction (UTO) is a common clinical problem of which there are many potential causes. The aim of this feature article is to explore the role of ultrasound in diagnosing UTO, during guided interventional procedures and the potential procedural complications.Topic description and discussion: Ultrasound is an integral imaging modality throughout the management pathway of a patient with UTO and is often utilised as a first-line test in diagnosis and treatment. Percutaneous nephrostomy is an interventional technique, usually performed by radiologists or interventional sonographers, as either a short- or long-term management strategy. It can either be used in isolation or to gain access to the renal collecting system prior to more complex interventional or surgical techniques. Ultrasound-guided interventional techniques to relieve UTO can be employed in a number of clinical scenarios each with their own indications, contraindications and complications.

Conclusion

Ultrasound plays a unique role in the planning and active stages of intervention with the provision of dynamic imaging which is crucial for providing safe and effective patient management.

Impact of COVID-19 on the management and outcomes of ureteric stones in the UK: a multicentre retrospective study

OBJECTIVES

To determine if management of ureteric stones in the UK changed during the coronavirus disease 2019 (COVID-19) pandemic and whether this affected patient outcomes.

PATIENTS AND METHODS

We conducted a multicentre retrospective study of adults with computed tomography-confirmed ureteric stone disease at 39 UK hospitals during a pre-pandemic period (23/3/2019-22/6/2019) and a period during the pandemic (the 3-month period after the first severe acute respiratory syndrome coronavirus-2 case at individual sites). The primary outcome was success of primary treatment modality, defined as no further treatment required for the index ureteric stone. Our study protocol was published prior to data collection.

RESULTS

A total of 3735 patients were included (pre-pandemic 1956 patients; pandemic 1779 patients). Stone size was similar between groups (P > 0.05). During the pandemic, patients had lower hospital admission rates (pre-pandemic 54.0% vs pandemic 46.5%, P < 0.001), shorter mean length of stay (4.1 vs 3.3 days, P = 0.02), and higher rates of use of medical expulsive therapy (17.4% vs 25.4%, P < 0.001). In patients who received interventional management (pre-pandemic 787 vs pandemic 685), rates of extracorporeal shockwave lithotripsy (22.7% vs 34.1%, P < 0.001) and nephrostomy were higher (7.1% vs 10.5%, P = 0.03); and rates of ureteroscopy (57.2% vs 47.5%, P < 0.001), stent insertion (68.4% vs 54.6%, P < 0.001), and general anaesthetic (92.2% vs 76.2%, P < 0.001) were lower. There was no difference in success of primary treatment modality between patient cohorts (pre-pandemic 73.8% vs pandemic 76.1%, P = 0.11), nor when patients were stratified by treatment modality or stone size. Rates of operative complications, 30-day mortality, and re-admission and renal function at 6 months did not differ between the data collection periods.

CONCLUSIONS

During the COVID-19 pandemic, there were lower admission rates and fewer invasive procedures performed. Despite this, there were no differences in treatment success or outcomes. Our findings indicate that clinicians can safely adopt management strategies developed during the pandemic to treat more patients conservatively and in the community.

Comparison of Percutaneous Nephrostomy and Ureteral DJ Stent in Patients with Obstructive Pyelonephritis: A Retrospective Cohort Study

PURPOSE

Comparing the two different drainage methods of percutaneous nephrostomy (PCN) versus retrograde ureteral double - J (DJ) stent insertion in patients with obstructive pyelonephritis cases.

MATERIAL AND METHODS

In this retrospective study, patients with obstructive pyelonephritis secondary to urolithiasis who underwent PCN or DJ insertion were included in the study. Patients were divided into two groups according to drainage method. After exclusion criteria, the study included 105 patients. The groups were compared for intraoperative outcomes, duration of fluoroscopy usage, the time needed for normalization of infection parameters (white blood cells (WBC), C - reactive protein (CRP), procalcitonin), and complications were observed.

RESULTS

From 105 patients, 56 patients were in DJ stent group and 49 patients were in PCN group. According to intraoperative data, operative time and fluoroscopy duration were significantly shorter in the DJ ureteral stent group (P < .001). WBC returned to normal range in mean 3.5 ± 1.3 days in the DJ stent group and 3.2 ± 1.1 days in the PCN group (95% CI: -0.76-0.21, P = .268). There were no statistically significant differences identified for the duration for CRP, PCT and fever to return to normal range between the drainage methods. The complication rates was 51.8% for DJ stent group and, 30.6% in PCN group (P = .028).

CONCLUSION

Both methods are effective and safe in obstructive pyelonephritis. Despite the higher complication rate in DJ stent group, these complications were minor.

Intermittent peri-tubal instillation of dexamethasone and ropivacaine on postoperative analgesia after percutaneous nephrolithotomy: A prospective randomized controlled trial

OBJECTIVES

Percutaneous nephrolithotomy and placement of nephrostomy tube are performed for renal stones >2 cm in diameter. Attempts have been made to infiltrate local anesthetics with or without adjuvants into the surgical site to reduce pain. We hypothesized that there would be a significant prolongation of the analgesic effect of local anesthetic instillation along the nephrostomy tube due to the adjuvant dexamethasone.

METHODS

After ethical approval and Clinical Trials Registry - India registration (CTRI/2020/03/024332), 64 American Society of Anesthesiologists classification 1 and 2 adult patients were enrolled in this randomized double-blinded prospective study divided into Group R-received 20 mL 0.2% Ropivacaine and Group R + D-received 20 mL 0.2% Ropivacaine with dexamethasone 8 mg, injected through a multi-lumen wound infiltration catheter.

RESULTS

The demographic profile of patients was similar in both groups. The mean duration of analgesia was longer in Group R + D (21.3 ± 2.1 hrs) versus Group R (10 ± 1.9 hrs, P = 0.001). The mean numeric rating scale scores of Group R + D were significantly lower at all time intervals (P = 0.001). Also, the cumulative dose of ropivacaine and the total use of fentanyl postoperatively in Group R was much higher (70 ± 10.4 vs 56 ± 8.9 μg, P = 0.02). The C-reactive protein levels were significantly lower in Group R + D (13.8 ± 1.5 vs 23.1 ± 1.2 mg/L, P = 0.001 and 16.5 ± 1.3 vs 28.5 ± 1.7 mg/L, P = 0.001, at 24 and 48 hrs, respectively).

CONCLUSION

We conclude that dexamethasone can be used as a suitable adjuvant to intermittent local anesthetic infiltration after percutaneous nephrolithotomy with a nephrostomy tube for the prolongation of analgesia.

[Surgical treatment of traumatic kidney laceration in children]

A clinical observation of a 12-year-old patient with a traumatic right kidney laceration is described in the article. The child underwent an organ-preserving procedure, namely diagnostic laparoscopy, laparotomy, revision of the abdominal cavity and right retroperitoneal space, suturing of the right kidney, nephrostomy. Irrigation and drainage of the abdominal cavity and retroperitoneal space. The satisfactory result was seen.

Percutaneous nephrostomy in Ureteropelvic junction obstruction with poorly functioning kidney: Is it still pertinent in adults?

OBJECTIVE

To determine the pertinence of percutaneous nephrostomy drainage in adult patients of primary ureteropelvic junction obstruction with poorly functioning kidneys (<20% split renal function).

MATERIAL AND METHODS

Clinical records of all patients with primary ureteropelvic junction obstruction with poorly functioning kidneys who underwent percutaneous nephrostomy drainage in our institute between February 2015 and January 2020 were retrospectively reviewed. The patients were divided into 4 groups according to their split renal function obtained from the Tc-99m ethylenedicysteine diuretic renogram. Group I consisted of all patients having split renal function ≤5%, group II with split renal function 6-10%, groupIII with split renal function 11-15%, and finally group IV with split renal function 16-20%. Those patients inwhom split renal function was improved by >10% and had daily percutaneous nephrostomy output >400 mL, underwent pyeloplasty and the rest underwent nephrectomy.

RESULTS

Seventy-two patients were studied, out of which 5 were in group I, 20 in groups II and III each, and27 in group IV. The mean age of presentation was 34.4 ± 14 years. The split renal function improvement of>10% was seen in 55 patients (76.4%) after percutaneous nephrostomy drainage (P < .05). Pyeloplasty wasdone in 40 patients (55.6%) and nephrectomy was done in 32 patients (44.4%).

CONCLUSION

In conclusion, we recommend the use of a Tc-99m ethylenedicysteine scan for estimation of split renal function during the initial presentation in every patient followed by reconstructive surgery if split renal function is above 15% and nephrectomy if it is below 5%. The trial of percutaneous nephrostomy is pertinent if split renal function is between 6% and 15%.

Myiasis (maggots) around nephrostomy tube

Myiasis is caused by the presence of dipterous larvae in humans and animals. It is usually associated with poor hygienic conditions. A urologist rarely comes across myiasis. We report a case of myiasis around a recently placed nephrostomy tube. A 55-year-old male farmer from a rural area underwent right percutaneous nephrolithotomy. The procedure was terminated because of bradycardia and arrhythmia. There were residual calculi. A nephrostomy was kept. His relook nephroscopy was planned, but he was not willing. Hence, he was discharged with an indwelling nephrostomy tube. Two weeks later, he presented with severe pain around the right nephrostomy tube with surrounding pruritus. The wound hygiene was poor. He was found to have maggots around the nephrostomy tube. These were treated by local instillation of turpentine oil and oral and topical ivermectin, followed by manual removal of the maggots.

Percutaneous nephrolithotomy - the puncture

OBJECTIVE

To determine what importance is given to the puncture and assistive technologies in percutaneous nephrolithotomy (PNL) in the current urological literature.

METHODS

PubMed was searched for English publications and reviews for the keywords: 'percutaneous nephrolithotomy', 'percutaneous nephrostomy', 'puncture'. The search was limited to the last 5 years, January 2016 until February 2021. Based on 183 abstracts, 121 publications were selected, read, and reviewed. References, older or seminal papers were read and cited if they contributed to a better understanding. A total of 198 references form the basis of this narrative review.

RESULTS

The puncture is frequently referred to as the most crucial part of PNL. In contrast, the influence of the puncture on the failure rate of PNL and the specific puncture-related complications seems to be low in the single-digit percentage range. However, there are no universally accepted definitions and standards measuring the quality of puncture. Consequently, the impact of the puncture on general PNL complications, on stone scores predicting success rates and on learning curves evaluating surgeons' performance have not been systematically studied. Assistive technologies rely on fluoroscopy and ultrasonography, the latter of which is becoming the preferred imaging modality for monitoring the entire procedure. Needle bending, a problem relevant to all puncture techniques, is not addressed in the urological literature.

CONCLUSIONS

The importance attached to puncture in PNL in the current urological literature is subjectively high but objectively low. Some basics of puncture are not well understood in urology. Disciplines other than urology are more actively involved in the development of puncture techniques.

Outcomes Related to Percutaneous Nephrostomies (PCN) in Malignancy-Associated Ureteric Obstruction: A Systematic Review of the Literature

Background: Malignant ureteric obstruction occurs in a variety of cancers and has been typically associated with a poor prognosis. Percutaneous nephrostomy (PCN) can potentially help increase patient longevity by establishing urinary drainage and treating renal failure. Our aim was to look at the outcomes of PCN in patients with advanced cancer and the impact on the patients’ lifespan and quality of life. Materials and Methods: A literature review was carried out for articles from 2000 to 2020 on PCN in patients with advanced malignancies, using MEDLINE, EMBASE, Scopus, CINAHL, Cochrane Library, clinicaltrials.gov, and Google Scholar. All English-language articles reporting on a minimum of 20 patients who underwent PCN for malignancy-associated ureteric obstruction were included. Results: A total of 21 articles (1674 patients) met the inclusion criteria with a mean of 60.2 years (range: 21–102 years). PCN was performed for ureteric obstruction secondary to urological malignancies (n = −633, 37.8%), gynaecological malignancies (n = 437, 26.1%), colorectal and GI malignancies (n = 216, 12.9%), and other specified malignancies (n = 205, 12.2%). The reported mean survival times varied from 2 to 8.5 months post PCN insertion, with an average survival time of 5.6 months, which depended on the cancer type, stage, and previous treatment. Conclusions: Patients with advanced malignancies who need PCN tend to have a survival rate under 12 months and spend a large proportion of this time in the hospital. Although the advent of newer chemotherapy and immunotherapy options has changed the landscape of managing advanced cancer, decisions on nephrostomy must be balanced with their survival and quality of life, which must be discussed with the patient.

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.

A perfect storm: Open surgical approach to iatrogenic abdominal aortic injury developed during percutaneous nephrostomy

Percutaneous nephrostomy catheter insertion allows the diagnosis and treatment of many pathologies from kidney failure to infection and obstruction. Vascular injuries are considered one of the complications of percutaneous interventions and are rarely seen after percutaneous nephrostomy catheter insertion. Herein, we report the first case of the successful surgical treatment of iatrogenic abdominal aortic injury after percutaneous nephrostomy catheter insertion in a 78-year-old female patient who developed hydroureteronephrosis and acute renal failure due to obstructive ureteral stone in the right proximal ureter.

Factors Affecting Survival Outcome After Percutaneous Nephrostomy as Palliative Urinary Diversion in Obstructive Uropathy due to Advance Cervical Cancer Patients

Introduction:

Cervical cancer is the 3^rd most common cancer in women. In late stages, obstructive uropathy due to mass infiltration is common and the mainstay of treatment for this condition is palliative urinary diversion through percutaneous nephrostomy. Nevertheless, complications due to nephrostomy may have adverse effects on some patients. Further study is necessary to determine whether nephrostomy is suitable for all cervical cancer patients with obstructive uropathy. This study aims to identify the determinants of survival rate of cervical cancer patients undergoing nephrostomy for obstructive uropathy and determine the group of cervical cancer patients that would benefit the most from nephrostomy.

Methods:

Data were obtained from medical records of cervical cancer patients in Hasan Sadikin Central Public Hospital from January 2018 to December 2019. Log-rank analysis was performed to assess the survival rate of patients based on clinical conditions (age, metastasis, and ECOG performance status) and initial laboratory results (hemoglobin, leukocyte, thrombocyte and blood acidity).

Results:

A total of 163 cases were identified from the medical records, with a median survival of 5(1-17) months. The results of the analysis showed that the survival rates of cervical cancer patients undergoing nephrostomy were significantly affected by age (p = 0.0001), metastasis (p = 0.0001), and ECOG performance status (p = 0.0001), while laboratory findings were not significant factors affecting survival (pHb=0.501; pLeu=0.634; pTr=0.077; pBGA=0.687).

Conclusion:

The survival after nephrostomy in advanced cervical cancer patients is largely affected by age, metastasis, and performance status. The choices of doing nephrostomy in those patients should be considering those factors to maximize the benefit over the risk of complications.

Efficacy of contrast-enhanced percutaneous nephrosonography to evaluate urinary tract patency in children

A novel method known as contrast-enhanced percutaneous nephrosonography (cePNS), using an ultrasound contrast agent administered through the nephrostomy catheter, has been used to evaluate the urinary tract patency in children. Nine cePNS examinations were performed in seven children to evaluate the urinary tract patency prior to further management. The cePNS results were compared with the clinical evaluation of patent urinary tract cases or with surgery results. Both, the technical success rate and accuracy of cePNS examinations were 100%. CePNS is a radiation-free method and can be performed as a continuation of an ultrasound examination.

Emergent Percutaneous Nephrostomy for Pyonephrosis: A Primer for the On-Call Interventional Radiologist

Pyonephrosis is gross accumulation of pus within an obstructed renal collecting system that, if left untreated, can lead to potentially fatal septic shock. Treatment requires urgent decompression coupled with systemic antibiotics. Percutaneous nephrostomy (PCN) placement, first described in 1976 for the treatment of pyonephrosis, is now widely utilized for emergent decompression in these patients. When performed by an experienced interventional radiologist, PCN is a safe procedure with technical success rates of over 96 to 99%. This article will address the clinical presentation of pyonephrosis, and will discuss the indications, technique, complications, and outcomes of emergent PCN placement. Additionally, the expanded indications for PCN placement in nonemergent scenarios will also be described.

Outcome of Palliative Urinary Diversion and Observation for Malignant Extrinsic Ureteral Obstruction

Background: Urologists are often referred to manage the extrinsic malignant ureteral obstruction (MUO) caused by nonurological malignancies. Usually palliative urinary diversion (ureteral stent or nephrostomy) will be performed; however, in the cases of no symptom or poor prognosis, observation (OBS) without any intervention will be selected. There are few reports about outcome of the OBS policy for MUO. Objective: To evaluate the outcome of palliative urinary diversion or OBS for MUO. Design: We retrospectively reviewed the selection of treatment and the prognosis. Setting/Subjects: A total of 151 cases were introduced to our department as MUO between April 2011 and December 2016. Measurements: The patients were divided to immediate palliative urinary diversion (immediate-DIV) or OBS. The latter patients were subdivided to OBS followed by deferred palliative urinary diversion (deferred-DIV), and observation only (OBS-only). Results: There was no significant difference between immediate-DIV and OBS about overall survival (OS) from the consultation. In OBS group, deferred-DIV did not prolong prognosis from the consultation more than OBS-only. In the same way, there was no significant difference between immediate-DIV and deferred-DIV in OS from the intervention. Unfavorable prognostic factors for OS were lack of anticancer treatment after consultation, symptoms of MUO, and gastrointestinal cancer. When we classified the patients by these factors, the group with three factors showed significantly poorer prognosis than the others. Conclusion: Immediate-DIV or OBS did not influence the prognosis in the whole patients. Three prognostic factors that will be judged by urologists easily might be useful for the indication and timing of palliative urinary diversion.

Retrospective Analysis of the Role of Antibiotic Prophylaxis in the Placement and Replacement of Percutaneous Nephrostomy Catheters in Patients with Malignant Ureteral Obstruction

Background: Antibiotic prophylaxis is usually adopted to prevent urinary tract infection (UTI) after nephrostomy catheter placement and replacement. This prophylaxis has been little studied in cancer patients, and its efficacy is uncertain. Objective: To determine the rate of UTI associated with percutaneous nephrostomy catheters placement and replacement and associated risk factors. Methods: This retrospective study collected data from the available medical records. Catheter-related UTI was defined as any diagnosis of UTI based on clinical symptoms recorded in antibiotic prescription charts, and on the results of urine culture collected up to 7 days after percutaneous nephrostomy catheter. The associations between categorical variables were analyzed using Fisher's exact test. The risk factors for UTI were assessed using logistic regression. Results: In the univariate analyses, there was no significant difference in the rate of urinary infection between patients receiving and not receiving antibiotic prophylaxis before percutaneous nephrostomy and after replacement. Conclusion: The results of the present study suggest that the use of antibiotic prophylaxis for managing urinary tract obstruction by percutaneous nephrostomy is not recommended in cancer patients. In contrast, for catheter replacement, antibiotic prophylaxis appears to have a protective effect for UTI.

Failure of initial superselective renal arterial embolization in the treatment of renal hemorrhage after percutaneous nephrolithotomy: A respective analysis of risk factors

Superselective renal arterial embolization (SRAE) is a well-established method for the treatment of severe hemorrhage following percutaneous nephrolithotomy (PCNL). However, there remains a significant rate of failures requiring repeat SRAE or nephrectomy. To identify risk factors for initial treatment failure of SRAE, the data of patients who had undergone SRAE for severe bleeding due to PCNL between August 2005 and June 2016 were retrospectively analyzed. A total of 98 patients required SRAE for bleeding control following PCNL. Renal arteriography revealed pseudoaneurysm in 65 patients, arteriovenous fistula in 6 patients, and a combination of both in 11 patients. Free extravasation was observed in 11 patients; 8 of these patients exhibited coexisting pseudoaneurysm. Vascular aberration/tortuosity was identified in 10 patients. A total of 17 patients (17.3%) experienced initial treatment failure and underwent repeat SRAE. Multivariate analysis identified percutaneous tract size, number of bleeding sites and vascular aberration/tortuosity as significant predictors of initial treatment failure. The results from the present study suggested that repeated SRAE is preferred for patients who have experienced initial treatment failure with recurrent hemorrhage following PCNL. Large tract size, multiple bleeding sites and renal vascular aberration/tortuosity were significantly associated with increased risk of initial treatment failure of SRAE. These data may assist interventional radiologists in the planning and execution of SRAE in the treatment of PCNL.

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

AIM

To assess the efficacy and safety of trans-tract electrocoagulation at the end of endoscopic combined intrarenal surgery for renal or ureteral stones.

METHODS

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.

RESULTS

Between the trans-tract electrocoagulation (n = 225) and non-trans-tract electrocoagulation (n = 72) groups, the stone number was significantly smaller (1:2:3 or 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 ± 5.0 days, P = 0.002) and shorter hospital stay (6.5 ± 3.6 vs 8.8 ± 5.0 days, P = 0.0001) in the trans-tract electrocoagulation group than in the non-trans-tract electrocoagulation group.

CONCLUSIONS

Trans-tract electrocoagulation in endoscopic combined intrarenal surgery is a safe and efficient procedure that decreases the need for nephrostomy tube placement after surgery.

Percutaneous Nephrolithotomy (PCNL): Standard Technique Versus Tubeless - 125 Procedures

Introduction: Tubeless percutaneous nephrolithotomy (PCNL) is the non-placement of a nephrostomy tube at the end of the procedure. The benefits of a nephrostomy tube placement are numerous as it provides adequate renal drainage. It may also tamponade bleeding and allow for an easier second-look nephroscopy. However, these advantages are mostly theoretical, and the majority of authors consider the nephrostomy tube as a source of morbidity.

Objectives: The aim of this report was to study the efficiency, safety, and morbidity of tubeless PCNL by comparing it to the standard technique.

Methods: This is a unicentric retrospective study of 125 patients who had undergone PCNL for renal lithiasis. We divided the patients into two groups: the standard PCNL group (n = 74) and the tubeless PCNL group (n = 51). The rates of good outcomes, complications, duration of hospitalization, and the degree of postoperative pain were compared between these two groups.

Results: There were no statistically significant differences between the two groups in age, gender, history, and the number of stones treated. There were more staghorn stones in the PCNL group with nephrostomy (p = 0.007) and more pelvicalyceal stones in the tubeless group (p = 0.037). Patients who had the standard PCNL had larger stones (p = 0.008). Patients who had a tubeless PCNL had more postoperative infectious complications than the standard PCNL group (p = 0.042). No statistically significant differences were noted for other complications, good outcomes (p = 0.13), postoperative pain (p = 0.51), and duration of hospitalization (p = 0.16).

Conclusion: According to the majority of authors, tubeless PCNL is considered a safe and efficient technique. It also provides advantages with less postoperative pain and duration of hospitalization. We believe that a selection bias may exist in most published work concerning routine nephrostomy tube placement.

Ureteral Catheter Versus Nephrostomy Tube for Patients Undergoing Percutaneous Nephrolithotomy Under Spinal Anesthesia: A Prospectively Randomized Trial

PURPOSE

The aim of this study is to evaluate overnight ureteral catheterization vs nephrostomy tube for urinary diversion in patients undergoing percutaneous nephrolithotomy (PNL) under spinal anesthesia.

MATERIALS AND METHODS

Patients were enrolled using block randomization between February 2016 and July 2016. Patients with renal stones >2 cm confirmed via noncontrast-enhanced CT were included. All patients underwent PNL under spinal anesthesia. Group 1 refers to patients who had a nephrostomy tube following PNL, whereas group 2 refers to overnight ureteral catheterization. Those who refuse spinal anesthesia, <18 years of age, >70 years of age, and anomalous kidneys (ectopic pelvic kidney, horseshoe kidney, etc.) were excluded. In group 1, nephrostomy tube (14F) was removed 48 hours after surgery, whereas the ureteral catheter (6F) was removed at postoperative 12th hour in group 2. Visual analogue scores (VASs) at 24th hour and mean narcotic analgesic (tramadol) amounts were compared.

RESULTS

There were 30 patients in both groups. Mean age, mean body mass index, and stone area were not significant between groups (p > 0.05, for all). With regard to operative measures, mean duration of surgery, mean number of accesses, and mean drop in Hb levels were comparable. Besides, mean hospitalization period in group 1 was 68.8 ± 12 hours, whereas it was 54.5 ± 10 hours in group 2 (p < 0.001). No patients in either group needed transfusion. Stone-free rates were similar in both groups (83% vs 90%, p = 0.391). Mean 24th hour VAS was 6.17 ± 1.4 in group 1 and 3.37 ± 1.4 in group 2 (p < 0.001). Also, there was a statistically significant difference in mean tramadol requirements between groups (181.67 ± 56.45 vs 86.67 ± 57.13, groups 1 and 2, respectively).

CONCLUSION

In patients undergoing PNL under spinal anesthesia, using an open-ended ureteral catheter to be removed at early postoperative period reduces analgesic requirement and duration of hospital stay without compromising surgical outcomes and complication rates.

Role of percutaneous nephrostomy in end of life prostate cancer patients: a systematic review of the literature

Introduction

Prostate cancer is the most common cancer amongst men in the UK. Treatments for malignant ureteric obstruction consist of percutaneous nephrostomy, ureteric stent insertion, or occasionally other forms of urinary diversion. Our aim was to look at the outcomes of percutaneous nephrostomy (PCN) in patients with advanced prostate cancer and to look at the impact on patient's general health, quality of life, life expectancy and complications after PCN insertion.

Material and methods

A systematic review of the literature was done for all prospective English language articles on PCN in patients with prostate cancer using PubMed, MEDLINE, EMBASE, Scopus, CINAHL, Cochrane library, Clinicaltrials.gov, Google Scholar and individual urological journals from inception to August 2017. While studies involving prostate cancer patients were included, studies on all other mixed pelvic malignancies were excluded.

Results

Seven articles met the inclusion criteria. There were 184 patients, with a mean age of 70 years (range: 51–94 years). PCN was performed for ureteric obstruction due to advanced prostate cancer, patients underwent unilateral (n = 66) or bilateral PCN (n = 118) with conversion to an antegrade stent in 25 patients. Their post-PCN survival varied between 4–31 months and this was longer if they were hormone naïve or showed a good recovery in their renal function. Although the complication rates were low (1–3%), patients spend a high proportion of their lives in the hospital.

Conclusions

PCNs should only be pursued after thoughtful counselling regarding further treatment options and prognosis as these patients with advanced malignancies seem to have reduced survival duration and spend a significant amount of time in hospital.

Pyonephrosis as the first symptom of congenital hydronephrosis in a 6-year old girl

Pyonephrosis in the course of hydronephrosis usually provides to total or near-total loss of renal function. In adults pyonephrosis usually results from urolithiasis. In children usually congenital urinary tract anomalies are present as contributing factors.

CASE REPORT

6-year old girl was admitted to the hospital because of 2-day history of high fever, abdominal pain, progressive deterioration of general condition and ultrasonographically (US) detected left hydronephrosis. US on admission showed grossly dilated left renal collecting system together with extensive echogenic debris and laboratory tests highly elevated inflammatory markers. Once diagnosis of pyonephrosis was established on the basis of clinical picture and US as well as laboratory tests results, nephrostomy tube was placed percutaneously. Pus culture obtained during placement of nephrostomy showed E.Coli ESBL (-) growth. Intensive antibiotic treatment (Meropenem) was continued for 3 weeks, nephrostomy was removed after 12 days after receiving normal urine. Further evaluation of urinary tract (US and computed tomography urography) showed large hydronephrosis due to ureteropelvic junction obstruction, while dynamic scintigraphy obstructive renogram with grossly diminished left kidney function to 20% of differential renal function. The girl was referred for operative treatment on urgent basis. Intraoperatively long distance utreteropelvic junction stenosis was found and dismembered Anderson- Hynes pyeloplasty was performed. During 2-years follow-up postoperatively US showed gradually decrease of dilatation of left renal collecting system, while dynamic scintigraphy revealed permanent improvement of drainage together with almost normal renal function (up to 45%). No urinary tract infections were noted.

CONCLUSIONS

Proper management of pyonephrosis in hydronephrotic kidney due to congenital ureteropelvic junction obstruction enables good final result of treatment.

Clinical profile and successful outcomes of conservative and minimally invasive treatment of emphysematous pyelonephritis

INTRODUCTION

Emphysematous pyelonephritis (EPN) is a rare clinical entity, characterized by gas in the renal system, due to an acute, fulminant and potentially fatal necrotizing process with varying clinical presentations. It is much more aggressive than uncomplicated pyelonephritis, with the mortality of 20-40% in the contemporary meta-analysis.

MATERIAL AND METHODS

A retrospective record review of inpatients at the Institute of Nephro Urology, Bangalore, India (2007-2014), who were treated after EPN was diagnosed with the aid of a CT (computed tomography) scan.

RESULTS

Sixty-six patients (M:F 27:39) treated for EPN over the past seven years with the mean (±SD) age of 52.32 (±12.48) years were analyzed. Median (interquartile range) duration of hospital stay was 8 (11.25) days with 4 (6%) patients requiring intensive care unit admission (median, IQR = 5.5, 1.5 days) of whom two passed away due to septicemia. Fifty-six (84.85%) patients were diabetics, forty (60.6%) patients had estimated glomerular filtration rate (eGFR) <60 ml/min/1.7 3 m2, 6 (9.1%) patients had eGFR <30 ml/min/1.73 m2 including 3 (4.5%) with eGFR <15 ml/min/1.73 m2 requiring hemodialysis and twenty-two (33%) had thrombocytopenia. Fifty (75.76%) patients were classified as Huang and Tseng Class 2, 7 (10%) as Class 3 with perinephric abscess requiring open drainage and 9 (13.64%) had bilateral EPN (Class 4). Majority (43; 65%) responded to piperacillin-tazobactam treatment. Double J stenting was done in 17 (25.76%) patients, percutaneous drainage in 5 (7.58%) patients and nephrectomy in 2 (3%) patients.

CONCLUSIONS

Although EPN historically carries high morbidity and mortality, modern day medical management with timely intervention in the form of urinary drainage is effective and curative in most patients resulting in a low mortality rate.

CT-guided nephrostomy: Re-inventing the wheel for the occasional interventionalist

Percutaneous nephrostomy insertion has, in recent times, become a subspecialised skill performed by an interventional trained Radiologist. However, this creates access issues, particularly in remote and regional medical centres. In this article, we describe a simple and effective method for computed tomography (CT)-guided percutaneous nephrostomy insertion, utilising the CT interventional skills of the general radiologist.

Choosing the appropriate size of Amplatz sheath during percutaneous nephrolithotomy-a novel method

Objective

To choose appropriate size Amplatz sheath during percutaneous nephrolithotomy (PCNL) based on retrograde pyelogram.

Material and methods

We performed standard PCNL in prone position in 20 patients. All these patients had placement of appropriate size of Amplatz sheath based on retrograde pyelogram images. All patients had nephrostomy tubes postoperatively. The preoperative and postoperative renal parameters, hemoglobin, mean operating time and mean hospitalisation stay were measured.

Results

There was no significant difference between the pre-operative and postoperative hemoglobin and creatinine levels. Median operating time was 60.5 mins (45 to 98 mins). The median hospitalisation stay was 4.6 days (3 to 7 days). There was no intraoperative pelvic wall or infundibular injury.

Conclusion

Choosing correct size of Amplatz sheath lowers the incidence of kidney hemorrhage and renal function impairment.

Systematic review and meta-analysis to compare success rates of retrograde intrarenal surgery versus percutaneous nephrolithotomy for renal stones >2 cm: An update

BACKGROUND

We performed a systematic review and meta-analysis comparing stone-free rates between retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL), using updated, more reliable evidence.

MATERIALS AND METHODS

Randomized controlled trials comparing RIRS and PCNL for >2 cm stones were identified from electronic databases. Stone-free rates for the procedures were compared by qualitative and quantitative syntheses (meta-analyses). Outcome variables are shown as risk ratios (RRs) with 95% confidence intervals (CIs).

RESULTS

Eleven articles were included in this study. Most recently published studies exhibited relatively low quality during quality assessment. For the meta-analysis comparing success (stone-free) rates between PCNL and RIRS, the forest plot using the random-effects model showed an RR of 1.11 (95% CI 1.02-1.21, P < .014) favoring PCNL. After determining the among-study heterogeneity, subgroup analysis was performed of 9 studies with less heterogeneity: the stone-free rate of PCNL was superior to that of RIRS using a fixed-effect model (RR 1.07, 95% CI 1.01-1.14, P < .019) for these studies.

CONCLUSIONS

RIRS can be a safe and effective procedure for selected patients with large renal stones. However, in this meta-analysis, the postoperative stone-free rate of PCNL was higher than that of RIRS in patients with >2 cm renal stones.

Elevated Renal Pelvic Pressures during Percutaneous Nephrolithotomy Risk Higher Postoperative Pain and Longer Hospital Stay

PURPOSE

Renal pelvic pressure may vary during percutaneous nephrolithotomy. We sought to determine the relationship of postoperative pain to endoscope caliber, renal pelvic pressure and hospital stay.

MATERIALS AND METHODS

We reviewed the records of 20 percutaneous nephrolithotomies done under ureteroscopic guidance with renal pelvic pressure monitoring. The ureteroscope working channel was connected to a pressure transducer and used to determine renal pelvic pressure at baseline, when irrigating with a 26Fr rigid nephroscope and a 16Fr flexible nephroscope, and during suction. Patient demographics, operative characteristics, Likert pain scores and length of hospital stay were compared as stratified by average renal pelvic pressure. The Mann-Whitney U and Fisher exact tests were used with p <0.05 considered significant.

RESULTS

A total of 220 measurements were recorded in 20 patients undergoing single access percutaneous nephrolithotomy. Mean patient age was 55.2 years (range 20 to 77) and mean body mass index was 32.4 kg/m² (range 18 to 53.3). Rigid nephroscopy resulted in significantly higher average renal pelvic pressure than flexible nephroscopy (30.3 vs 12.9 mm Hg, p = 0.007). Average renal pelvic pressure was 30 mm Hg or greater in 7 patients (35%) undergoing rigid nephroscopy and in none (0%) undergoing flexible nephroscopy (p <0.01). Patients exposed to an average renal pelvic pressure of 30 mm Hg or greater during rigid nephroscopy had significantly higher average pain scores (p = 0.004) and longer hospital stays (p = 0.04) than patients with renal pelvic pressure less than 30 mm Hg. Average renal pelvic pressure 30 mm Hg or greater during rigid nephroscopy was also associated with a longer skin to calyx distance (105.5 vs 79.7 mm, p = 0.03).

CONCLUSIONS

Knowledge of the factors that influence renal pelvic pressure and methods to control pressure extremes may improve patient outcomes during percutaneous nephrolithotomy.

A Randomized Controlled Comparison of Nephrostomy Drainage vs Ureteral Stent Following Percutaneous Nephrolithotomy Using the Wisconsin StoneQOL

OBJECTIVE

We compared postoperative outcomes and quality of life (QoL) between patients who received a nephrostomy tube vs a ureteral stent following percutaneous nephrolithotomy (PCNL) in a prospective, double-blind, randomized manner.

MATERIALS AND METHODS

Between September 2015 and March 2016, we randomized 30 patients undergoing PCNL to receive nephrostomy drainage (Group 1: 8F or 10F) or Double-J ureteral stent (Group 2) at conclusion of surgery. Nephrostomy tubes were removed within 48 hours (before discharge) and ureteral stents were removed at least 2 weeks after surgery. Patients' QoL was assessed with the Wisconsin StoneQOL questionnaire preoperatively and then 7 to 10 days and 30 days following surgery. Inclusion criteria included an uncomplicated procedure, normal preoperative renal function, and clinically insignificant residual stone fragments on postoperative imaging. We calculated the preoperative and postoperative QoL score difference between the two groups. We also evaluated perioperative characteristics, inpatient analgesic requirements, length of stay (LOS), and postsurgical complications.

OUTCOME

Patient characteristics between Groups 1 and 2 were comparable with similar age (58.3 vs 54.7, p = 0.534), gender ratio, and stone burden (276.6 mm² vs 259 mm², p = 0.84) and composition. There was no significant difference between perioperative outcomes, including stone-free rate (93.3% vs 86.7%), operative times (125.7 minutes vs 115 minutes, p = 0.29), estimated blood loss (103.3 mL vs 100.7 mL, p = 0.9), LOS (3.2 days vs 1.9 days, p = 0.1), and complications (2 in each group). Inpatient analgesic requirements were also the same (both 21.1 mg, p = 1.0). Assessment of QoL using the Wisconsin StoneQOL questionnaire showed significant differences between preoperative and postoperative health-related QoL in 18 of the 28-question instrument at 7 to 10 days. Patients in Group 2 had significantly worse QoL change and a multitude of negative responses on the StoneQOL assessment, not only those commonly associated with stent irritation. Eighty percent of participants in Group 2 also attributed their complaints to having a stent placed. Both groups had similar QoL status at 30 days after surgery.

CONCLUSION

Despite the literature advocating "tubeless" PCNL with ureteral stent placement at conclusion of surgery, our randomized prospective study shows that QoL is significantly worse with stent placement than with temporary nephrostomy drainage in the immediate aftermath following PCNL, using a validated QoL assessment instrument specific for nephrolithiasis.

Stenting Prior to Cystectomy is an Independent Risk Factor for Upper Urinary Tract Recurrence

PURPOSE

Patients with bladder cancer who present with hydronephrosis may require drainage of the affected kidney before receiving further cancer treatment. Drainage can be done by retrograde stenting or percutaneously. However, retrograde stenting carries the risk of tumor cell spillage to the upper urinary tract. The aim of this study was to evaluate whether patients with bladder cancer are at higher risk for upper urinary tract recurrence if retrograde stenting has been performed prior to radical cystectomy.

MATERIALS AND METHODS

We retrospectively analyzed the records of 1,005 consecutive patients with bladder cancer who underwent radical cystectomy at our department between January 2000 and June 2016. Negative intraoperative ureteral margins were mandatory for study inclusion. Patients received regular followup according to our institutional protocol, including imaging of the upper urinary tract and urine cytology.

RESULTS

Preoperative drainage of the upper urinary tract was performed in 114 of the 1,005 patients (11%), including in 53 (46%) by Double-J® stenting and in 61 (54%) by percutaneous nephrostomy. Recurrence developed in the upper urinary tract in 31 patients (3%) at a median of 17 months after cystectomy, including 7 of 53 (13%) in the Double-J group, 0% in the nephrostomy group and 24 of 891 (3%) in the no drainage group. Multivariate regression analysis revealed a higher risk of upper urinary tract recurrence if patients underwent Double-J stenting (HR 4.54, 95% CI 1.43-14.38, p = 0.01) and preoperative intravesical instillations (HR 2.94, 95% CI 1.40-6.16, p = 0.004).

CONCLUSIONS

Patients who undergo Double-J stenting prior to radical cystectomy are at higher risk for upper urinary tract recurrence. If preoperative upper urinary tract drainage is required, percutaneous drainage might be recommended.

In Vitro Study of Antimicrobial Percutaneous Nephrostomy Catheters for Prevention of Renal Infections

Percutaneous nephrostomy (PCN) catheters are the primary method for draining ureters obstructed by malignancy and preventing a decline of renal function. However, PCN catheter-related infections, such as pyelonephritis and urosepsis, remain a significant concern. Currently, no antimicrobial PCN catheters are available for preventing infection complications. Vascular catheters impregnated with minocycline-rifampin (M/R) and M/R with chlorhexidine coating (M/R plus CHD) have previously demonstrated antimicrobial activity. Therefore, in this study, we examined whether these combinations could be applied to PCN catheters and effectively inhibit biofilm formation by common uropathogens. An in vitro biofilm colonization model was used to assess the antimicrobial efficacy of M/R and M/R-plus-CHD PCN catheters against nine common multidrug-resistant Gram-positive and Gram-negative uropathogens as well as Candida glabrata and Candida albicans Experimental catheters were also assessed for durability of antimicrobial activity for up 3 weeks. PCN catheters coated with M/R plus CHD completely inhibited biofilm formation for up to 3 weeks for all the organisms tested. The reduction in colonization compared to uncoated PCN catheters was significant for all Gram-positive, Gram-negative, and fungal organisms (P < 0.05). M/R-plus-CHD PCN catheters also produced significant reductions in biofilm colonization relative to M/R PCN catheters for Enterobacter spp., Escherichia coli, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, C. glabrata, and C. albicans (P < 0.05). M/R-plus-CHD PCN catheters proved to be highly efficacious in preventing biofilm colonization when exposed to multidrug-resistant pathogens common in PCN catheter-associated pyelonephritis. M/R-plus-CHD PCN catheters warrant evaluation in a clinical setting to assess their ability to prevent clinically relevant nephrostomy infections.

Percutaneous Management of Stone Containing Calyceal Diverticula: Associated Factors and Outcomes

PURPOSE

We evaluated the outcomes of percutaneous treatment and metabolic evaluation of calyceal diverticula with associated stones.

MATERIALS AND METHODS

We retrospectively identified 51 patients with a calyceal diverticulum in our prospectively maintained percutaneous nephrolithotomy database. Patients with complete data were separated into 14 with stones isolated to the diverticulum and 15 with renal stones in and outside the diverticulum. A total of 571 patients with renal stones but no diverticulum were used for comparison. Statistical differences were assessed using the chi-square test and the t-test.

RESULTS

Patients with stones isolated to the diverticulum were younger (44 vs 54 years, p = 0.024), had a lower body mass index (23.2 vs 27 kg/m², p = 0.032) and were more often female (71% vs 44%, p = 0.046) compared to patients with renal stones but no diverticulum. Calyceal diverticula were anterior in 19 of 29 cases and in the upper pole in 15. Average diverticular size was 2.5 cm with a 1.5 cm stone burden. Percutaneous treatment was successful in 96% of patients with a 4% complication rate. The diverticular neck was dilated in 22 of 51 patients (43%). During 5-year followup in the 51 patients there was 1 stone recurrence, which was managed by ureteroscopy, while 46 and 5 patients showed complete absence and reduction of the diverticulum, respectively. Of the calyceal diverticular stones 82% contained calcium phosphate compared to only 33% in patients with renal stones but no diverticulum. All patients with a diverticulum had at least 1 metabolic derangement.

CONCLUSIONS

Percutaneous treatment of calyceal diverticula is safe and effective regardless of size or location, including anterior diverticula. Infundibular neck dilation does not appear to be necessary. There are metabolic abnormalities in a significant proportion of patients with a calyceal diverticulum.

Prediction of Pediatric Percutaneous Nephrolithotomy Outcomes Using Contemporary Scoring Systems

PURPOSE

We evaluate the applicability of contemporary percutaneous nephrolithotomy scoring systems in pediatric patients and compare their predictive power regarding postoperative outcomes.

MATERIALS AND METHODS

We retrospectively analyzed the records of 125 children who were diagnosed with renal calculi and underwent percutaneous nephrolithotomy between March 2011 and April 2016. Predictive scores, which consisted of Guy's Stone Score, S.T.O.N.E. (stone size, tract length, obstruction, number of involved calyces and essence/stone density) nephrolithometry and CROES (Clinical Research Office of the Endourological Society) nomogram, were calculated for all patients included in the study. Patient demographics, stone-free rate and complications were all analyzed and are reported.

RESULTS

Median Guy's Stone Score was 2 (IQR 2 to 3) in patients with residual stones (group 1) and 2 (1 to 2) in those who were stone-free (group 2). Median respective CROES nomogram scores were 215 (IQR 210 to 235) and 257 (240 to 264), and S.T.O.N.E. nephrolithometry scores were 8 (7 to 9) and 5 (5 to 6, all p <0.0001). S.T.O.N.E. score demonstrated the greatest accuracy in predicting stone-free rate. Guy's Stone Score was significantly correlated with complications but the CROES and S.T.O.N.E. scores were not significantly correlated with complications.

CONCLUSIONS

The scoring systems analyzed could be used to predict success of percutaneous nephrolithotomy in the pediatric setting. However, further studies are needed to formulate modifications for use in children. The main variables in the scoring systems, ie stone burden, tract length and case volume, were measured using records from adult patients. Besides these variables, the relatively small pelvicalyceal system and higher incidence of anatomical malformations in children could potentially affect percutaneous nephrolithotomy outcomes.

Patient Preference for Management of an Asymptomatic 15 mm Renal Calculus-Avoid Risk or Maximize Success?

INTRODUCTION

We evaluate patient preferences and the underlying factors determining decision making in the management of the asymptomatic 15 mm renal stone.

METHODS

A survey was randomly distributed to 106 patients at our multidisciplinary stone clinic. Patients were given a hypothetical scenario of a 15 mm renal stone, and were asked to choose among the 3 treatment options of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy. The success rate, risk and morbidity associated with each treatment were provided to patients. Statistical analysis involved the Fisher exact and Wilcoxon signed rank tests. Analysis was performed using standard computer software with p <0.05 considered statistically significant.

RESULTS

A total of 103 patients completed our survey, and 58 (56%) chose ureteroscopy, 26 (25%) chose percutaneous nephrolithotomy and 19 (19%) preferred shock wave lithotripsy as the treatment option. Patients who selected shock wave lithotripsy were increasingly concerned with risk rather than success rate (74% vs 16%, respectively). In contrast, patients who selected percutaneous nephrolithotomy were more concerned with the success rate rather than risk (81% vs 7.5%, respectively). Rates of success and risk were given approximately equal importance by patients selecting ureteroscopy (40% vs 48%, respectively).

CONCLUSIONS

Patients who choose percutaneous nephrolithotomy are primarily motivated by a desire to maximize success while the choice of shock wave lithotripsy is primarily motivated by a desire to minimize risks. The majority of patients selected ureteroscopy as a procedure with a balance of moderate risk and moderate success. Understanding the factors driving patient decision making would allow urologists to more effectively manage expectations and provide counseling.

[Subcutaneous ureteral bypass devices as a treatment option for bilateral ureteral obstruction in a cat with ureterolithiasis]

A 6-year-old female spayed Domestic Shorthair cat was presented with acute lethargy, dehydration, marked azotemia, metabolic acidosis, left-sided renomegaly, and bilateral hydronephrosis. Ureterolithiasis and ureteral obstruction were suspected based on further diagnostics including abdominal sonography. Medical treatment was not successful. Fluoroscopically guided antegrade pyelography confirmed the diagnosis of bilateral ureteral obstruction due to ureterolithiasis. Subcutaneous ureteral bypass (SUB) devices were placed bilaterally, followed by close patient monitoring. Frequent reassessment of patient parameters and blood work served to adjust the fluid needs of the patient and to ensure proper hydration, correction of azotemia at an appropriate rate, and cardiovascular stability. After significant improvement of all patient parameters within 5 days, the patient was discharged from the hospital. Treatment included a dietary change to reduce the risk of stone formation as well as a phosphorus binder. Clinical and clinicopathologic parameters were unchanged at the 1- and 4- and 7-month rechecks (consistent with IRIS CKD stage II-NP-AP0), and both SUB devices continued to provide unobstructed urine flow. Bilateral placement of subcutaneous ureteral bypass devices may be a safe and potentially effective treatment option for acute bilateral ureteral obstruction in cats with ureterolithiasis. Strict patient monitoring and patient-centered postoperative treatment decisions are crucial to successful treatment outcomes.

Outcome and complications of percutaneous nephrolithotomy as primary versus secondary procedure for renal calculi

PURPOSE

To compare the efficacy of percutaneous nephrolithotomy (PCNL) as a primary procedure of patients following previous open surgery or post percutaneous nephrolithotomy (PCNL) for renal calculi.

MATERIALS AND METHODS

The medical records of 367 patients who underwent PCNL by a single surgeon from January 2008 to December 2013 were reviewed retrospectively. All patients were divided into 3 Groups. Group-1 (n=232) included patients with no history of ipsilateral open stone surgery. Group 2 (n=86) patients had undergone one or more open stone surgeries before PCNL, patients with failed or recurrence following PCNL were placed in Group-3 (n=49). The demographic data, operation duration, stone free rate (SFR), number of attempts to access the collecting system and intra operative and postoperative complications between the three Groups were compared.

RESULTS

There was no difference in sex, Body Mass Index (BMI), stone burden and laterality among the three Groups. Operation time was significantly less in first Group, while there was a statistically significant difference in operation duration between second and third Groups (p<0.05). The number of attempts to enter the collecting system was lower in the first Group in comparison to other two Groups (p<0.5). There was no significant differences among three groups in stone free rate. Intra operative and postoperative complications were slightly more frequent in Groups 2 and 3. Mortality occurred in 1 patient with colon perforation in Group-2.

CONCLUSION

Our study demonstrated that PCNL can be performed in patients even as secondary procedure without further complications.

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

CONTEXT

Patients 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.

OBJECTIVES

The 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.

METHODS

We conducted a retrospective analysis of 211 patients who had malignant urinary obstruction and received PCN tube insertion.

RESULTS

The 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).

CONCLUSION

Survival 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.

Lymphocytopenia may be a new indicator for infected obstructed kidneys secondary to urinary stone disease

Objective:

Infected obstructed kidney (IOK) is a urological emergency. We wanted to look at the role of serum inflammatory markers in these patients.

Materials and Methods:

Patients with IOK requiring percutaneous nephrostomy (PCN) at our university hospital were identified, and data were collected on lymphocyte count, C-reactive protein (CRP) and microbiology results.

Results:

Thirty-nine patients had PCN for IOK. Lymphocytopenia was seen in two-thirds of these patients. Severe lymphocytopenia was associated with a significant rise in CRP in all cases and following PCN, lymphocytopenia improved in the majority of cases.

Conclusions:

Lymphocytopenia seems to be associated with the severity of infection and could be a surrogate marker on its own or in conjunction with CRP for initial diagnosis and monitoring response to treatment in patients with IOKs.

Prospective Outcomes of Ultra Mini Percutaneous Nephrolithotomy: A Consecutive Cohort Study

PURPOSE

Ultra mini percutaneous nephrolithotomy is a less invasive technique of percutaneous nephrolithotomy to treat small to medium sized calculi.

MATERIALS AND METHODS

We prospectively evaluated the outcomes of ultra mini percutaneous nephrolithotomy in a single surgeon, consecutive cohort study. Data on 94 patients who underwent ultra mini percutaneous nephrolithotomy were collected.

RESULTS

Mean ± SD calculus size was 15.9 ± 4.5 mm and mean density was 1,106 ± 167 HU. Access was achieved via the upper pole in 8 cases, interpolar in 33 and lower pole in 54. Mean operative time was 54 minutes (range 28 to 120). Mean hemoglobin loss was 0.81 gm/dl and the mean creatinine increase was 0.05 mg/dl. There were no transfusions or kidney injuries. Grade I and IIIb complications were observed in 4 and 1 patients, respectively. The most serious complication was a perinephric collection. Postoperatively oral analgesia was sufficient in 86 patients (91%). Mean length of stay was 38.2 ± 15.9 hours. Nephrostomy drainage was used in 13 patients while 7 (7%) required a stent for 1 week. Intraoperatively 99% of renal units were stone free (absence of detectable calculi) on fluoroscopy, and 74% and 81% were stone free on day 1 postoperative ultrasound and 1-month computerized tomography, respectively. The 10 to 20 mm stones showed less bleeding, shorter operative time and a significantly lower requirement for nephrostomy or a Double-J(®) stent.

CONCLUSIONS

Ultra mini percutaneous nephrolithotomy appears to be effective and safe with a short length of stay. It may be a valuable addition to the armamentarium to treat 10 to 20 mm calculi in patients who wish to avoid routine nephrostomy or stents. Randomized, controlled trials are required.

A rare case of unusual migrated foreign bodies in kidney and their successful extraction using retrograde percutaneous nephrostomy

Foreign body ingestion is a common presentation in the emergency room and most cases are without any major symptoms, or go unnoticed and later cause severe complications that can potentially threaten patient life. We report a case of multiple migrated metallic foreign bodies in the right kidney presenting as right renal colic and gross haematuria one year after its accidental ingestion, treated successfully with retrograde percutaneous nephrostomy.