Choosing the ideal nephrostomy tube

Comparative analysis of re-entry malecot and nelaton catheters after standard percutaneous nephrolithotomy in adult patients: a cross-sectional study

Drainage catheters are used almost routinely to provide urinary drainage, prevent extravasation of urine, and create tamponade against bleeding after percutaneous nephrolithotomy (PNL). In the literature, there is no standardized approach to determining which type of catheter is superior. In this context, we aimed to comparatively analyze two different types of catheters (re-entry malecot catheter and nelaton catheter) in terms of success and complications, which we use for drainage after a PNL operation and which have very different costs. Patients who underwent PNL for kidney stones between January 2018 and October 2022 were included in the study. The data of a total of 148 patients who had a 16-F reentry malecot nephrostomy catheter or a 16-F nelaton catheter were analyzed. In addition to the demographic characteristics of the patients, stone characteristics, operative data, hospitalization time, analgesia requirement, hemoglobin exchange, amount of blood transfusion, and postoperative data (success and complications) were comparatively evaluated. The current unit price for a reentry malecot and a nelaton catheter is 4.7 United States dollars (USD) and 0.11 USD, respectively. There were a total of 148 patients in the study, 63 of whom were nelaton catheters and 85 were reentry malecots, and the mean age was 39.95 ± 13.28 years. There was no statistically significant difference between preoperative stone sizes and residual stone rates according to the groups. In addition, there was no statistically significant difference between the groups in terms of access site and stone localization. There was no significant difference between the groups in terms of complication rates according to the Clavien-Dindo classification, Hb levels, blood transfusion rates, operation times, or hospitalization times. In conclusion, if a second procedure is planned, a reentry malecot catheter may be preferred. Apart from this situation, nelaton catheters should be preferred because they are similar to reentry catheters in terms of effectiveness, and side effects and are more economical than reentry catheters in terms of cost.

Reasons and risk factors for delayed discharge after day-surgery percutaneous nephrolithotomy

BACKGROUND

Day-surgery percutaneous nephrolithotomy (PCNL) is being developed quickly but some potential factors are affecting the recovery process. This study is aim to analyze the reasons and risk factors for delayed discharge after day-surgery PCNL.

METHODS

The data of 205 patients who accepted day-surgery PCNL in our institution between January 2018 and February 2020 were analyzed, retrospectively. Univariate and multivariate logistic regression analysis were used to analyze the risk factors for delayed discharge. Besides, the nomogram prediction model was established by the multivariable logistic regression analysis.

RESULTS

The rate of delayed discharge was 14.6%. Independent risk factors for delayed discharge were larger stone burden (odds ratio [OR] = 3.814, P = 0.046), positive urine nitrite (OR = 1.001, P = 0.030), longer duration of surgery (OR = 1.020, P = 0.044), multiple nephrostomy tubes (OR = 4.282, P = 0.008). The five main reasons that caused delayed discharge included psychological reasons, pain, bleeding, urosepsis, and urine leakage.

CONCLUSIONS

This study identified some independent risk factors for a hospital length of stay longer than 24 h. Patients with larger renal stones or positive urine nitrite may be at increased risk of delayed discharge after day-surgery PCNL. Reducing surgery time and nephrostomy tubes will help to facilitate recovery.

Factors Predicting Outcomes of Supine Percutaneous Nephrolithotomy: Large Single-Centre Experience

Objective: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large renal calculi. The prone position has been considered the preferred position to obtain renal access. However, the supine position has recently gained popularity, which confers several potential advantages. The current study analyses the prognostic factors for successful supine PCNL procedures in a larger tertiary centre. Subjects: Prospective data were collected from all patients undergoing PCNL in the Galdako modified Valdivia position at our institution between February-2007 and September-2020. Surgical outcomes variables collected included: the rate of Endoscopic-combined intra-renal surgery (ECIRS), operative times, surgical effectiveness (no residuals <2 mm stone fragments) and complications. Results: A total of 592 patients underwent PCNL with a median age of 56 years (IQR: 42−67). The median stone size was 17 mm (IQR: 13−23). Of those, 79% of patients had an effective procedure. Stone size (p < 0.001), location (p < 0.001) and Guys-Stone Score (GSS) (p < 0.001) were associated with effectiveness. A Percutaneous nephrostomy tube was sited at the completion of the procedure in 97.3% of patients and a simultaneous double-J stent in 45.3%. Stent insertion was associated with larger stones (p < 0.001), the performance of ECIRS (p < 0.001) and higher GSS (p < 0.001). The overall complication rate was 21.7%. The main type of complication was an infection in 26.2 of the cases followed by the need for repeated nephrostogram in 12.7%. Conclusions: We demonstrate that PCNL in a high-volume centre is safe and efficacious in the Galdalko modified Valdivia position. Patients with smaller stones in the renal pelvis and a low GSS have the highest chance of a successful procedure.

A prospective, single-centered, cohort study comparing the treatment of renal stones by following PCNL types: Standard, tubeless & totally tubeless

Introduction

Renal stones are a frequent cause of morbidity globally. The number of lumbotomies performed for benign lithiasis has been greatly decreased with the usage of Percutaneous Nephrolithotomy (PCNL). Further development is aimed at reducing tract size, leading to numerous advanced minimally invasive PCNL procedures like mini-PERC, ultra-mini-PERC, and micro-PERC. The aim of this study was to evaluate whether tubeless or totally tubeless PCNL is the safest and most efficient, less morbid management technique for renal stones compared to the standard PCNL with a nephrostomy tube.

Methodology

This is a comparative, prospective, single-centered, cohort study that took place between August 2015 and January 2018 in the Urology department of Benazir Bhutto Hospital in Rawalpindi, Pakistan. 218 patients having single/multiple stones of variable sizes were enrolled in the study. Participants were stratified into three groups; Group A: Standard PCNL treatment; Group B: Tubeless PCNL treatment; Group C Totally Tubeless treatment. Mean operation time (±SD) and stone-free rates were our primary outcomes. The rate of complications during and post-operative complications were our secondary outcomes.

Results

A total of 181 patients were included in our study. A decreasing trend can be seen in mean operation time as we move from Group A to Group C (p = 0.000). The rate of problems during operation in each group was highest (45.8%) in Group A, much lesser problems in Group C (13.3%), and least problems in Group B (8.1%) (p = 0.000). The postoperative complication rate was again the highest in Group A (30.5%), low in Group C (8.3%), and extremely low in Group B (1.6%)

Conclusion

Tubeless PCNL proved to be the safest and most effective when compared to standard and totally tubeless PCNL procedures. It also showed the highest stone-free rates and least ‘unsatisfactory’ results amongst all the groups. Conclusively, it should be performed in routine preferably.

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In terms of safety and efficacy, tubeless PCNL outperformed both regular and completely tubeless PCNL.

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The Tubeless PCNL is much superior than other techniques of PCNL.

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Aftercare and difficulties during surgery are virtually nonexistent with tubeless PCNL.

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Stone-free rates were also the highest and the least “unsatisfactory” across all groups. Finally, it's best if it's done on a regular basis.

An insight into predominance of pulmonary complications on right side in supracostal percutaneous nephrolithotomy

PURPOSE

To analyse pulmonary complications following supracostal percutaneous nephrolithotomy especially after right sided supracostal punctures, both in initial and relook PCNL.

MATERIAL AND METHODS

From February 2016 till date, 90 patients underwent PCNL in Government Medical College, Jammu through supracostal puncture - 53 on right side and 37 on left side. All supracostal punctures were made about 7-8.5 cm from midline. Tract dilatation was done using metal dilators and calculi were fragmented using pneumatic lithotripsy. Patients with supracostal superior calyceal punctures were evaluated for chest complications intraoperatively by fluoroscopy, X-ray chest on evening of postoperative day 0 and repeated thereafter on third and seventh postoperative days.

RESULTS

Stone configuration included complete staghorn in 16, partial staghorn in 23, multiple stones in 16 and pelvic stone in 35 cases. Age range of patients was 07-76 years. There was 14.4% (13 out of 90) incidence of early or delayed chest complications - 20.8% (11 out of 53) on right side and 5.4% (2 out of 37) on left side.

CONCLUSION

Pulmonary complications in supracostal punctures; especially on right side should not be underestimated. There are always chances of delayed hydrothorax after supracostal puncture. A chest X-ray should be repeated after 1 week in patients with supracostal PCNL punctures.

Intrauterine adhesion prevention with Malecot catheter after hysteroscopic myomectomy: A novel approach

OBJECTIVE

Intrauterine adhesion after hysteroscopic myomectomy contributes to infertility, recurrent miscarriages, menstrual irregularities, and hinders pregnancy outcomes. The aim of this study was to apply the indwelling Malecot catheter in prevention of intrauterine adhesion after hysteroscopic myomectomy and to further evaluate the effectiveness of this approach with reported live birth rates in infertile patients who underwent subsequent infertility treatment.

MATERIALS AND METHODS

Seventeen patients with FIGO Classification System PALM-COIEN Type 0 or 1 submucous myoma that received hysteroscopic myomectomy were recruited in this retrospective analysis. Post-operative insertion of the Malecot catheter via the aid of the uterine sound was performed and the catheter was left in place for seven days.

RESULTS

The mean duration of TTP (time to pregnancy) was 15.6 months after hysteroscopy. Within three years after the operation, 10 out of 17 infertility patients achieved ongoing pregnancy over 12 weeks. Ongoing pregnancy rate was 58.8% (10/17). Eight patients achieved live birth (seven singletons, one twin pregnancy) with mean gestational age of 38 weeks. Live birth rate was 47.1% (8/17).

CONCLUSION

The Malecot catheter is an inexpensive, easy-to-operate, and effective physical barrier method for preventing IUA in infertile patients undergoing hysteroscopic myomectomy with high live birth rate and no obvious visible post-operative adhesions.

Tubeless PNL can safely be applied to selected patients in pediatric stone disease

OBJECTIVE

The purpose of this study was to compare the results of tubeless percutaneous nephrolithotomy (TPNL) and standard percutaneous nephrolithotomy (SPNL) for the management of nephrolithiasis in children.

MATERIAL AND METHODS

The data for 48 patients aged lesser than 18 years who underwent percutaneous nephrolithotomy (PNL) between January 2010 and June 2018 were reviewed retrospectively. The patients were classified into 2 categories depending on tube placement. A total of 21 patients were treated with TPNL and 27 with SPNL technique. The surgical method employed was selected depending on intraoperative complications. The size of the endoscopic instrument (mini/standard) to be used was decided according to the stone burden and surgeon preference.

RESULTS

A complete stone-free rate (SFR) was achieved in 85.7% (n=18) of the TPNL group and 85.2% (n=23) of the SPNL group (p=0.959). In the TPNL group, two patients with clinically significant stones underwent retrograde intrarenal surgery, and one patient with clinically insignificant residual stone remained under follow-up. In the SPNL group, two patients with clinically significant stones underwent repeat mini-PNL surgery, the stones being fragmented with shock wave lithotripsy in one patient, and 1 one patient with insignificant residual stone remained under follow-up. No significant differences were observed in terms of intraoperative and postoperative complications, mean SFRs, or operative and fluoroscopy times. However, a statistically significant difference was observed in lengths of hospital stay (p<0.001).

CONCLUSION

TPNL is a safe and effective procedure in children. No significant difference was found between TPNL and SPNL in terms of stone clearance; however, patients undergoing TPNL had significantly shorter hospital stays.

Dislodgement in Long-Term Patients with Nephrostomy Tube: Risk Factors and Comparative Analysis Between Two Catheter Designs

Objective: To determine possible risk factors for accidental nephrostomy tube dislodgement and compare two different tube types in this context in patients with chronic catheters. Materials and Methods: We conducted a retrospective study of long-term patients with nephrostomy tube. We performed a comparative analysis, studying the possible variables that were related to catheter dislodgement. In addition, a subanalysis was also carried out comparing different catheter designs (Pigtail and Foley) in case this could be related to the dislodgement. Results: Two hundred five cases were collected. A total of 51.2% of cases had a pigtail nephrostomy and 48.8% Foley type, and accidental dislodgement occurred in 26.3% of cases. In multivariate analysis, we observed that first time nephrostomy tube placement entailed higher risk of accidental dislodgement than successive placements (odds ratio [OR] 1.95, confidence interval [CI] 1.01-3.74, p = 0.04). In the pigtail-type catheter patient subgroup, tubes placed by a resident were more prone to accidental dislodgement than those placed by an attending physician (OR 3.39, CI 1.29-8.91, p = 0.01), while first episode cases were more likely to have become dislodged than in a subsequent event (OR 3.17, CI 1.17-8.57, p = 0.02). In addition, the mean (in days) until nephrostomy tube dislodgement in cases where this occurred was 20.32 ± 3.52 for pigtail and 60.92 ± 5.15 for Foley (p < 0.01 in Kaplan-Meier's test). Conclusion: Nephrostomy tube displacement in long-term patients is a common problem. Some factors associated with the catheter could increase the risk of involuntary displacement, such as being a first event or being inserted by less experienced resident doctors. In addition, pigtail type nephrostomies tend toward accidental dislodgement earlier than Foley ones.

Tubeless supra-costal percutaneous nephrolithotomy is associated with significantly less hydrothorax: a prospective randomized clinical study

OBJECTIVES

To evaluate prospectively whether a tubeless (JJ stent-only) percutaneous nephrolithotomy (PCNL) might reduce the risk of hydrothorax, compared to an approach where a nephrostomy tube is left.

MATERIALS AND METHODS

We conducted a two-arm open-label prospective randomized study (NCT02036398) comparing tubeless supra-costal PCNL (with a JJ stent only) to standard PCNL (with nephrostomy tube and JJ stent) using intention-to-treat (ITT) and per-protocol (PP) analyses. All patients underwent a standard single-stage prone supra-costal procedure with single-tract access. Complication data were collected according to the Clavien-Dindo grading system. The primary endpoint was the rate of hydrothorax, and secondary endpoints included stone-free rate (SFR) and complication rate. Multivariable logistic regression analysis identified factors associated with hydrothorax formation.

RESULTS

Out of 101 patients approached, 75 were finally analysed. No differences were observed between the two arms with regard to baseline demographic and stone characteristics. The mean largest stone size ranged between 23 and 24.2 mm. No significant difference was seen in the mean operating time and length of hospital stay. The incidence of hydrothorax was significantly higher in the nephrostomy group in comparison to the tubeless group (37.8% vs 15.8%, P = 0.031, and 38.4% vs 13.8%, P = 0.016, in the ITT and PP analyses, respectively). The SFR and complication rate were similar in both groups using the ITT and PP analyses. Multivariable logistic regression analysis showed that nephrostomy tube placement was the only covariate associated in a statistically significant manner to hydrothorax (odds ratio 3.628, 95% confidence interval 1.073-12.265; P = 0.038).

CONCLUSION

The rate of hydrothorax in supra-costal PCNL is associated with the type of postoperative drainage left. When possible, a tubeless approach should be applied as it may confer a lower risk of hydrothorax.

Comparison of outcomes of tubed versus tubeless percutaneous nephrolithotomy in children: A single center study

Objective

To evaluate and compare the effectiveness of tubeless percutaneous nephrolithotomy (PCNL) and tubed PCNL by using small bore nephrostomy tube (12Fr) in children for the management of nephrolithiasis.

Material and methods

This study was a retrospective analysis of 35 children where tubed PCNL (Group 1) was done in 18, and tubeless PCNL (group 2) in 17 patients from January 2010 to December 2016. Charts were reviewed for age, mass, stone size, operative time, hospital stay and stone-free rates. These variables were compared between the two groups. SPSS version 21 was used for data analysis. The data were shown as mean±standard deviation for continuous variables. Categorical variables were presented in percentages.

Results

There is no difference in terms of age, stone sizes, operative times, hospital stays, stone-free rates and post-PCNL complications between the two groups (p>0.05). The mean drop in hemoglobin level was 0.7±0.1 g/dL and 1.3±0.2 g/dL in Groups 1 and 2, respectively (p=0.01).

Conclusion

Tubeless PCNL in children is a safe option in well selected cases.

Intraoperative and postoperative feasibility and safety of total tubeless, tubeless, small-bore tube, and standard percutaneous nephrolithotomy: a systematic review and network meta-analysis of 16 randomized controlled trials

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is performed to treat relatively large renal stones. Recent publications indicate that tubeless and total tubeless (stentless) PCNL is safe in selected patients. We performed a systematic review and network meta-analysis to evaluate the feasibility and safety of different PCNL procedures, including total tubeless, tubeless with stent, small-bore tube, and large-bore tube PCNLs.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, and EMBASE™ databases were searched to identify randomized controlled trials published before December 30, 2013. One researcher examined all titles and abstracts found by the searches. Two investigators independently evaluated the full-text articles to determine whether those met the inclusion criteria. Qualities of included studies were rated with Cochrane's risk-of-bias assessment tool.

RESULTS

Sixteen studies were included in the final syntheses including pairwise and network meta-analyses. Operation time, pain scores, and transfusion rates were not significantly different between PCNL procedures. Network meta-analyses demonstrated that for hemoglobin changes, total tubeless PCNL may be superior to standard PCNL (mean difference [MD] 0.65, 95% CI 0.14-1.13) and tubeless PCNLs with stent (MD -1.14, 95% CI -1.65--0.62), and small-bore PCNL may be superior to tubeless PCNL with stent (MD 1.30, 95% CI 0.27-2.26). Network meta-analyses also showed that for length of hospital stay, total tubeless (MD 1.33, 95% CI 0.23-2.43) and tubeless PCNLs with stent (MD 0.99, 95% CI 0.19-1.79) may be superior to standard PCNL. In rank probability tests, small-bore tube and total tubeless PCNLs were superior for operation time, pain scores, and hemoglobin changes.

CONCLUSIONS

For hemoglobin changes, total tubeless and small-bore PCNLs may be superior to other methods. For hospital stay, total tubeless and tubeless PCNLs with stent may be superior to other procedures.

Intraoperative and postoperative feasibility and safety of total tubeless, tubeless, small-bore tube, and standard percutaneous nephrolithotomy: a systematic review and network meta-analysis of 16 randomized controlled trials

Background

Percutaneous nephrolithotomy (PCNL) is performed to treat relatively large renal stones. Recent publications indicate that tubeless and total tubeless (stentless) PCNL is safe in selected patients. We performed a systematic review and network meta-analysis to evaluate the feasibility and safety of different PCNL procedures, including total tubeless, tubeless with stent, small-bore tube, and large-bore tube PCNLs.

Methods

PubMed, Cochrane Central Register of Controlled Trials, and EMBASE™ databases were searched to identify randomized controlled trials published before December 30, 2013. One researcher examined all titles and abstracts found by the searches. Two investigators independently evaluated the full-text articles to determine whether those met the inclusion criteria. Qualities of included studies were rated with Cochrane’s risk-of-bias assessment tool.

Results

Sixteen studies were included in the final syntheses including pairwise and network meta-analyses. Operation time, pain scores, and transfusion rates were not significantly different between PCNL procedures. Network meta-analyses demonstrated that for hemoglobin changes, total tubeless PCNL may be superior to standard PCNL (mean difference [MD] 0.65, 95% CI 0.14–1.13) and tubeless PCNLs with stent (MD -1.14, 95% CI -1.65–-0.62), and small-bore PCNL may be superior to tubeless PCNL with stent (MD 1.30, 95% CI 0.27–2.26). Network meta-analyses also showed that for length of hospital stay, total tubeless (MD 1.33, 95% CI 0.23–2.43) and tubeless PCNLs with stent (MD 0.99, 95% CI 0.19–1.79) may be superior to standard PCNL. In rank probability tests, small-bore tube and total tubeless PCNLs were superior for operation time, pain scores, and hemoglobin changes.

Conclusions

For hemoglobin changes, total tubeless and small-bore PCNLs may be superior to other methods. For hospital stay, total tubeless and tubeless PCNLs with stent may be superior to other procedures.

Is it Necessary to Perform Nephrostography before Tube Removal after Percutaneous Nephrolithotomy

BACKGROUND

The aim of this study is the caparison of the complications rate among the patients which underwent nephrostomy removal with and without performing nephrostography.

MATERIALS AND METHODS

Between October 2010 and November 2011, 200 patients who underwent standard percutaneous nephrolithotomy (PCNL) procedures were included in this study. The patients were randomly assigned into two groups, Group A (n = 100) did not undergo the antegrade nephrostography on postoperative day 2 and the patients were discharged keeping the nephrostomy until postoperative day 3, while in Group B (n = 100) the nephrostomy tube was removed on postoperative day 3 after antegrade nephrostography demonstrating ureteral drainage down to the bladder. Postoperative complications in both groups were recorded and compared between two groups.

RESULTS

A total of 200 patients were treated with standard PCNL. The persistent leakage of urine after removal of the nephrostomy tube was encountered in 5 (5.0%) and 3 (3%) of patients in Groups 1 and 2, respectively. Urinary leakage was resolved with conservative management in 3 and 2 patients of Groups 1 and 2, respectively, but a double-J stent was inserted in 2 and 1 patients in each group because of persistent leakage of urine more than 1-week. The two groups show comparable complications such as prolonged urinary leakage which managed in a similar manner, however, postoperative hospital stay was lesser in Group 1.

CONCLUSION

Our results revealed postoperative performing nephrostogramy before tube removal changed the planning of complications such as prolonged urinary leakage and could be omitted in cases.

The Circle Nephrostomy Tube: An Attractive Nephrostomy Drainage System Following Complex Percutaneous Nephrolithotomy

OBJECTIVE

To describe our experience with the circle nephrostomy tube (NT) (Cook Medical), a drainage system uniquely designed for use after multiple-access percutaneous nephrolithotomy (PNL).

METHODS

A retrospective review of 1317 consecutive patients undergoing 1599 PNLs at IU Health Methodist Hospital was performed. All multiple access cases utilizing circle NTs were reviewed and analyzed. The method of insertion of circle NT was demonstrated.

RESULTS

A total of 1843 accesses were obtained in 1599 renal units (RUs): 380 upper pole, 129 interpolar, and 1334 lower pole. Multiple accesses in this series were required in 282 RUs (17.6%). Following multiple-access PNL, circle NTs, Cope loop, and reentry Malecot NTs were inserted in 91 RUs (32.3%), 208 RUs (73.8%), and 31 RUs (11%), respectively. None of the patients who had circle NT experienced clogging, dislodgement, or obstruction of the tube. The cost of circle, Cope loop, and Malecot NTs are 121.73 USD, 95.20 USD, and 81 USD, respectively.

CONCLUSION

Circle NTs are easy to insert, secure, cost-effective compared with inserting two NTs. Circle NTs provide excellent drainage and facilitate secondary procedures.

A randomized controlled study comparing the standard, tubeless, and totally tubeless percutaneous nephrolithotomy procedures for renal stones from a tertiary care hospital

Introduction:

Percutaneous nephrolithotomy (PCNL) is an effective treatment for renal stones. Due to the significant pain and morbidity after standard PCNL because of nephrostomy tubes, various modifications of PCNL are being performed. We report a randomized trial comparing these modalities.

Materials and Methods:

A total of 75 patients were randomized into three groups of 25 each: standard PCNL with nephrostomy tubes (Group 1), tubeless PCNL with ureteric stent and no nephrostomy (Group 2), and totally tubeless PCNL without ureteric catheter or nephrostomy (Group 3). Randomization was done at the end of the procedure for those patients satisfying the inclusion criteria based on duration of surgery, single puncture tract, intraoperative bleeding, stone burden, intact pelvicalyceal system, and no residual stones at the end of procedure. The outcomes measured were hemoglobin (Hb) drop, hemorrhage, need for blood transfusion, pyrexia, urine leak, pain score, analgesic requirement, and duration of hospital stay.

Results:

There was no significant difference in hemorrhage, Hb drop, need for blood transfusion, and postoperative pyrexia among the groups. All patients except one in the standard group only had variable amount of urinary leak. The analgesic requirement and duration of hospital stay attained statistical significance in favor of tubeless and totally tubeless groups compared to the standard.

Conclusions:

Tubeless and totally tubeless PCNL are safe and effective method of renal stone management. Totally tubeless PCNL significantly reduced postoperative pain and morbidity compared to the tubeless method.

Management of dysfunctional catheters and tubes inserted by interventional radiology

Minimally invasive percutaneous interventions are often used for enteral nutrition, biliary and urinary diversion, intra-abdominal fluid collection drainage, and central venous access. In most cases, radiologic and endoscopic placement of catheters and tubes has replaced the comparable surgical alternative. As experience with catheters and tubes grows, it becomes increasingly evident that the interventional radiologist needs to be an expert not only on device placement but also on device management. Tube dysfunction represents the most common complication requiring repeat intervention, which can be distressing for patients and other health care professionals. This manuscript addresses the etiologies and solutions to leaking and obstructed feeding tubes, percutaneous biliary drains, percutaneous catheter nephrostomies, and drainage catheters, including abscess drains. In addition, we will address the obstructed central venous catheter.

Determinants of nephrostomy tube dislodgment after percutaneous nephrolithotomy

BACKGROUND AND PURPOSE

Percutaneous nephrolithotomy (PCNL) traditionally necessitates the placement of a nephrostomy tube at the conclusion of the surgical procedure. Although tubeless PCNL has become more popular, patients with complex problems still need traditional nephrostomy tube drainage. The goal of this study was to investigate whether patient body mass index (BMI) impacted inadvertent nephrostomy tube dislodgement. Furthermore, we hoped to determine whether nephrostomy tube type impacted tube dislodgement rates.

METHODS

A retrospective review between 2005 and 2012 of 475 consecutive PCNL cases was undertaken. Patients were categorized based on the type of nephrostomy tube placed. BMI was examined as a continuous variable. The primary outcome of nephrostomy tube dislodgment was determined based on imaging obtained at the time of PCNL and postoperative hospitalization. Logistic regression analysis was then used to adjust for nephrostomy tube type and BMI.

RESULTS

Overall, 24 (5.5%) total patients experienced nephrostomy tube dislodgment postoperatively. The mean BMI for patients experiencing nephrostomy tube dislodgment was 39.7 vs 30.9 for those without tube dislodgment (P<0.0001; 95% confidence interval [CI] 4.6 to 12.9). Using logistic regression and adjusting for the use tube type, BMI was an independent predictor of tube dislodgement (P<0.001). For each unit of increase in BMI, the likelihood of tube dislodgment increased by 6% (1.06). After adjusting for BMI, however, nephrostomy tube type was not found to be an independent predictor of nephrostomy tube dislodgment.

CONCLUSIONS

Nephrostomy tube type did not influence nephrostomy tube dislodgment rates. As a patient's BMI increased, the likelihood of tube dislodgment increased in a directly proportionate fashion. This is possibly because of the nephrostomy tube being fixed directly to the mobile skin associated with their fat pannus. Although the nephrostomy tube type itself did not affect tube dislodgment rates, a redesigned nephrostomy tube or fixation device should take into account the above findings related to obese patients to reduce the likelihood of nephrostomy tube dislodgment.

Intraoperative patient selection for tubeless percutaneous nephrolithotomy

This study was conducted to report our experience of intraoperative patient selection for tubeless percutaneous nephrolithotomy (PCNL) based on a tentative decision-making algorithm. Thirty-four consecutive patients who were scheduled to undergo tubeless PCNL were included and medical records were obtained from a prospectively maintained database for these patients. After completion of PCNL, the nephrostomy site was observed with a safety guidewire in place. If there was no significant bleeding through the tract, tubeless PCNL was performed, and in cases with significant bleeding or other complications, nephrostomy catheter insertion was performed as usual. In 29 cases (85.3%), tubeless PCNL was performed according to our decision-making protocol. Mean stone size was 7.33 ± 9.35 cm(2). Mean hospital stay was 2.61 ± 1.01 days. The difference between preoperative and postoperative hemoglobin was 0.68 ± 1.22 g/dL (p > 0.05). Visual analog pain scale scores immediately post-operation, on postoperative day one and on the day of discharge were 4.62 ± 1.80, 3.25 ± 1.68 (postoperative day one vs. operative day; p = 0.001), and 1.87 ± 0.83 (the day of discharge vs. operative day; p = 0.001), respectively. The success rate with insignificant remnant stones was 85.2% and complete stone-free rate was 76.5%. In conclusion, tubeless PCNL was performed successfully with low complication rate and reduced pain score through our decision-making algorithm.

Feasibility and efficacy of intermediate-supine percutaneous nephrolithotomy: initial experience

We evaluated the feasibility and efficacy of intermediate-supine percutaneous nephrolithotomy (PCNL) in patients with renal calculi. Fifteen patients were included in this study. The intermediate-supine operative position was modified by using a 1-L saline bag below the ipsilateral upper flank. A nephrostomy and stone extraction were performed as usual. After completion of the stone removal, a nephrostomy tube was used when necessary according to the surgeon's decision. If there was no significant bleeding or renal pelvic injury, tubeless PCNL was performed. The mean stone size was 5.48±5.69 cm(2), the mean operative time was 78.93±38.72 minutes, and the mean hospital stay was 2.60±1.29 days. Tubeless PCNL was performed in 13 cases (86.7%), and retrograde procedures were simultaneously performed without a change of position in 2 patients (ureteroscopic ureterolithotomy in one patient and transurethral placement of an occlusion catheter in one patient). There were two complications according to the Clavien-Dindo classification (Grade I in one patient and Grade II in one patient). The success rate was 80.0% and the complete stone-free rate was 73.3%. Three patients with a significant remnant stone were also successfully managed with additional procedures (one patient underwent a second-look operation, and the remaining two patients were treated with shock wave lithotripsy). In the treatment of renal calculi, intermediate-supine PCNL may be a safe and effective choice that offers several advantages with excellent outcomes. Thus, a prospective study with a larger population is needed to verify our outcomes.

Tubeless percutaneous nephrolithotomy using antegrade tether: a randomized study

BACKGROUND AND PURPOSE

Tubeless percutaneous nephrolithotoomy (PCNL), although an accepted technique by now, continues to suffer from two major limitations: The need for postoperative cystoscopy for ureteral stent removal and inability to perform a "second-look" procedure for any residual fragments. We share our experience with a modification of the standard tubeless PCNL technique that allows us to overcome these shortcomings.

PATIENTS AND METHODS

A total of 166 patients selected to have PCNL were randomized into two groups of 83 each. In group A (control group), the patients underwent standard PCNL with the insertion of a nephrostomy tube at completion; in group B (intervention group), modified tubeless PCNL was performed with a Double-J (DJ) stent inserted with a tether attached to its proximal end, taken out through the percutaneous tract. The nephrostomy tube in group A was removed postoperatively on the second or third day, whereas those in group B had the stent removed directly by pulling the attached tether within the office setting 10 to 14 days postoperatively.

RESULTS

The need for postoperative analgesia was significantly higher in group A compared with group B (mean dose of tramadol needed, 128 mg vs 81.3 mg) (P<0.001). Four patients in group A had postoperative urinary leakage from the nephrostomy site, whereas there were no leaks in patients in group B. Group B patients spent significantly shorter average time in hospital (21.6 hours) compared with group A (54 hours) (P<0.001). Two of the patients in group B needed a second-look procedure, performed by the insertion of a guidewire down the stent, which was pulled out partially by its tether. Presence of the tether in the flank or the process of subsequent removal did not cause any discomfort to any patient.

CONCLUSION

The present study demonstrates that tubeless PCNL with a tethered DJ stent overcomes its main drawback, namely, the need for cystoscopy for stent removal, and also allows access to the pelvicaliceal system for second-look nephroscopy.

Percutaneous nephrolithotomy: Large tube, small tube, tubeless, or totally tubeless?

The role of percutaneous nephrostomy tube for drainage after percutaneous nephrolithotomy (PCNL) procedure has come under scrutiny in recent years. The procedure has been modified to use of small diameter tubes, ‘tubeless’ PCNL, and even ‘totally tubeless’ PCNL. A review of the available literature confirms that the chosen method of drainage after PCNL has a bearing upon the post-operative course. It is generally recognized now that small tubes offer benefit in terms of reduced post-operative pain and morbidity. Similarly, nephrostomy-free or ‘tubeless’ PCNL, using a double-J stent or ureteric catheter as alternative form of drainage, can be used with a favorable outcome in selected patients with the advantage of decreased postoperative pain, analgesia requirement, and hospital stay. Although the tubeless technique has been applied for extended indications as well, the available evidence is insufficient, and needs to be substantiated by prospective randomized trials. In addition, ‘totally tubeless’ approach has also been shown to be feasible in selected patients.

Infectious Complications Associated with Percutaneous Nephrostomy Catheters: Do we know Enough?

The percutaneous nephrostomy catheter (PCNC) has evolved since its inception. Over more than half a century, it has gone from a temporary maneuver to a permanent fixture in a large proportion of patients who have incurable illnesses with obstructed renal drainage systems. Unfortunately, the research looking specifically at infectious complications associated with PCNCs suffers from oversimplification as studies predominantly assess sepsis alone. There are no standardized definitions or criteria to define the various infectious complications described in this paper. Although the PCNC has a relative paucity of infectious complications, which represents an excellent marker for patient care, the low rate of infection dictates a large sample size for sufficiently-powered research studies to be able to find a significant impact of interventional measures. In this review article, we discuss various aspects of pathogenesis and treatment of the different subtypes of PCNC-associated infections.

Tubeless percutaneous nephrolithotomy

Introduction and Objective:

Placement of a percutaneous nephrostomy tube for drainage has been an integral part of the standard percutaneous nephrolithotomy (PCNL) procedure. However, in recent years, the procedure has been modified to what has been called ‘tubeless’ PCNL, in which nephrostomy tube is replaced with internal drainage provided by a double-J stent or a ureteral catheter. The objective of this article is to review the evidence-based literature on ‘nephrostomy-free’ or ‘tubeless’ PCNL to compare the safety, effectiveness, feasibility, and advantages of tubeless PCNL over standard PCNL.

Materials and Methods:

We performed a MEDLINE database search to retrieve all published articles relating to ‘tubeless’ PCNL. Cross-references from retrieved articles as well as articles from urology journals not indexed in MEDLINE, were also retrieved.

Results:

The majority of the studies have shown ‘tubeless’ PCNL to be a safe and economical procedure, with reduced postoperative pain and morbidity and shorter hospital stay. tubeless PCNL has been found to be safe and effective even in patients with multiple stones, complex staghorn stones, concurrent ureteropelvic junction obstruction, and various degrees of hydronephrosis. The technique has been successful in obese patients, children, and in patients with recurrent stones after open surgery.

Conclusion:

Tubeless PCNL can be used with a favorable outcome in selected patients (stone burden <3 cm, single tract access, no significant residual stones, no significant perforation, minimal bleeding, and no requirement for a secondary procedure), with the potential advantages of decreased postoperative pain, analgesia requirement, and hospital stay. However, for extended indications, like supine PCNL, multiple, complex and staghorn stones, and concurrent PUJ obstruction, the evidence is insufficient and should come from prospective randomized trials.

Are multiple nephrostomy tubes necessary after multitract percutaneous nephrolithotomy? A randomized comparison of single versus multiple nephrostomy tubes

PURPOSE

Placement of multiple nephrostomy tubes is the standard practice after completion of multitract percutaneous nephrolithotomy (PCNL) for complex/staghorn calculi. We conducted a study to see whether use of a single nephrostomy tube in comparison with multiple tubes reduces postoperative discomfort without compromising safety of the procedure.

PATIENTS AND METHODS

One hundred and ninety-two patients with complex/staghorn renal calculi who were treated with PCNL requiring multiple tracts were included in the study. The inclusion criteria included normal renal function, complete clearance of calculi, and no significant intraoperative complication. Patients were randomized into two groups on operation table at completion of procedure-group A, single nephrostomy tube placement after multitract PCNL; group B, one nephrostomy tube for each tract.

RESULTS

Postoperative analgesia requirement in group A was significantly less than that in group B (111.9 +/- 27.4 mg meperidine in group A; 165.8 +/- 34.4 mg in group B) (p < 0.001). The difference in average blood loss for two groups was not statistically significant (drop in hemoglobin: group A, 0.48 gm%; group B, 0.51 gm%) (p = 0.55). Three patients in group A and four in group B required blood transfusion (p = 0.65). The average hospital stay in group A (42.4 +/- 8.6 hours) was significantly shorter than that in group B (68.1 +/- 6 hours) (p < 0.001). No long-term squealae were noticed in the median follow-up of 18 months in any patient.

CONCLUSION

The present study demonstrates that use of a single nephrostomy tube in multitract PCNL is safe and as effective as the conventional practice of placing multiple tubes. In addition, a single tube minimizes postoperative morbidity related to the drainage tubes.

The use of adjunctive hemostatic agents for tubeless percutaneous nephrolithotomy

Tubeless percutaneous nephrolithotomy (PCNL) is a viable option for selected patients, particularly those with solitary calculi, multiple stones located in a single location, or those that can be accessed using one access tract. Benefits over the standard PCNL include reduced hospital stay, decreased pain, and decreased urine leak from the access site that would typically occur from around the nephrostomy tube. Hemostatic agents in the form of fibrin "glue" or gelatin matrix substances have been demonstrated to be safe and effective to augment the tubeless procedure. The most appropriate sealant agent available is yet to be determined. We present a review of the contemporary literature on the use of hemostatic agents for tubeless PCNL.

Renal drainage after percutaneous nephrolithotomy

Exit strategy after percutaneous nephrolithotomy (PCNL) is an area of continuing innovation to improve postoperative morbidity and operative outcomes for patients. The two important components of an exit strategy after PCNL are hemostasis and renal drainage. We review the different techniques of renal drainage after PCNL-ie, nephrostomy tube, ureteral stents, and totally tubeless strategy with critical discussion of available evidence for and against each of these techniques. We conclude that the optimal renal drainage method depends on patient characteristics and the operative course; hence, it should be individualized. To simplify this, we group patients undergoing PCNL as routine, problematic, and complicated, based on increasing complexity of the procedure and procedural complications. In routine PCNLs, we favor placement of an ureteral stent or a small-bore nephrostomy tube. In problematic and complicated PCNLs, we think the evidence directs toward placement of a nephrostomy tube, small bore being an option in problematic PCNLs.

Endovascular coil embolization in a postnephrostomy renal vein to renal pelvis fistula

We report the case of a 74-year-old man with post-percutaneous-nephrostomy venous hemorrhage from an iatrogenic fistula between the renal pelvis and a large tributary of the renal vein. Conservative management failed to contain the hemorrhage. Hence the fistula was occluded by coil embolization through the renal vein. This endovascular approach enabled rapid and effective stoppage of the venous bleed.There was no recurrence of the bleed or any pertinent complication at 3-month follow-up.

A randomized comparison of tubeless and standard percutaneous nephrolithotomy

PURPOSE

We present a randomized study of tubeless or nephrostomy-free percutaneous nephrolithotomy (PCNL), a modification of the standard technique, compared with standard PCNL to evaluate the role of tubeless PCNL in minimizing postoperative discomfort and reducing duration of hospital stay.

PATIENTS AND METHODS

Two hundred and two patients undergoing PCNL were randomized to two groups: Group A (standard PCNL) with nephrostomy tube placement postoperatively, and group B (tubeless PCNL) with antegrade placement of a Double-J stent without nephrostomy. Inclusion criteria were: normal renal functions, single tract procedure with complete clearance, and minimal bleeding at completion. The two groups were comparable in age and sex and in metabolic and anatomic features. Factors evaluated included postoperative pain, analgesia requirement, blood loss, postoperative morbidity, hospital stay, and time to recovery.

RESULTS

All patients had an uneventful postoperative recovery. The average visual analogue scale pain score on postoperative day 1 for group A patients was 59 +/- 5.1 compared with 31 +/- 4.8 in group B (P < 0.01). The mean analgesia requirement for group A (meperidine 126.5 +/- 33.3 mg) was significantly more compared with group B (meperidine 81.7 +/- 24.5 mg) (P < 0.01). The difference in average blood loss and urinary infection for the two groups was not statistically significant. The incidence of urinary leakage from the nephrostomy site was significantly less for the tubeless group (0/101), compared with the standard PNL group (7/101). The average hospital stay in the tubeless group (21.8 +/- 3.9 hours) was significantly shorter than that of the standard PCNL group (54.2 +/- 5 hours) (P < 0.01). Tubeless group patients took 5 to 7 days for complete convalescence whereas standard PCNL patients recovered in 8 to 10 days. No long-term sequelae were noticed in the median follow-up period of 18 months in any patient.

CONCLUSION

Nephrostomy-free or tubeless PCNL reduces postoperative urinary leakage and local pain related to the drainage tube. It also minimizes hospital stay; the majority of patients were discharged from the hospital in fewer than 24 hours.

Percutaneous nephrostomy catheters: Drainage flow and retention strength

OBJECTIVES

To evaluate the impact of percutaneous nephrostomy catheter configuration on drainage flow and retention strength.

METHODS

The Cook nephrostomy 16F (symmetric balloon), Bardex Council 16F (eccentric balloon), Microvasive Flexima 14F (pigtail), and Bardex Malecot 16F (flange) nephrostomy catheters were attached to an artificial renal pelvis (12-in.-round latex balloon). The balloon was subsequently filled with either 60 mL of water or orange juice with pulp, and gravity drainage of this fluid was recorded as flow into a flowmeter. Using a Force Five Model FDV-100 force gauge, the retention strength was tested by measuring the force required to pull the nephrostomy catheter through an 8-mm hole in a 35-mm-thick biologic tissue specimen (bologna).

RESULTS

The maximal flow rate using both orange juice and saline was significantly greater for the Cook nephrostomy than for the Microvasive Flexima, Bardex Malecot, and Bardex Council catheters (P < or = 0.016). The average flow rate using saline for the Cook nephrostomy catheter was significantly greater than for all other catheters (P < or = 0.02) and was significantly greater than for the Microvasive Flexima and the Bardex Council catheters (P < or = 0.036) using orange juice. The retention strength was strongest for the Cook nephrostomy catheter (3.41 +/- 0.14 lb) compared with the Bardex Council (1.75 +/- 0.1), Microvasive Flexima (1.35 +/- 0.3), and Bardex Malecot (0.29 +/- 0.03) catheters. In addition, the Microvasive Flexima catheter resulted in greater maceration of the biologic tissue after forceful dislodgement.

CONCLUSIONS

The results of this study have demonstrated that the Cook nephrostomy catheter combines strong drainage flow and strong retention strength during in vitro testing. Clinical evaluations of the ease of use and patient comfort are warranted.

Using and Choosing a Nephrostomy Tube after Percutaneous Nephrolithotomy for Large or Complex Stone Disease: A Treatment Strategy

BACKGROUND AND PURPOSE

Percutaneous nephrolithotomy (PCNL) is a well-accepted technique for removal of large or complex renal calculi. However, little attention has been paid to strategies for nephrostomy tube (NT) selection. We reviewed the reasons for selecting three types of NT after PCNL for large or complex stone disease.

PATIENTS AND METHODS

A series of 106 consecutive renal units undergoing PCNL for stone burdens >2 cm by a single surgeon (JEL) were reviewed. Noncontrast CT (NCCT) was carried out on postoperative day 1, and secondary procedures were performed if fragments remained. The NTs studied were 8.5F and 10F Cope loops (CP), 20F reentry Malecot catheters (REM), and 20F circle loops (CL). Patient demographics, access site and number, complications, and stone type were examined. "Stone free" was defined as a negative NCCT or negative second-look PCNL.

RESULTS

A total of 134 accesses were created in 106 renal units: 35 upper, 7 mid, and 92 lower; however, only 111 NTs were placed: 85 CP (76.6%), 19 REM (17.1%), and 7 CL (6.3%). Sixteen accesses were performed tubeless; all but two were in the upper pole. All 16 of these renal units had a concomitant NT placed in the lower pole. Multiple sites were accessed in 21 patients; 7 of these patients had CL placed. Five of ten patients with spinal-cord injury had REM/CL placed. Nineteen REM were placed: 10 for drainage of infection, and 9 for difficult anatomy. All renal units were rendered stone free: 31.1% with a single procedure and 95.6% with one or two procedures. There were no difficulties with drainage or access for secondary PCNL regardless of the NT employed. Complications included two hydrothoraces, one arteriovenous fistula, and one ureteral perforation. Three of four renal units in patients requiring transfusions underwent bilateral PCNL, and at least one renal unit required multiple accesses. Of kidneys with infection stones, 57.1% required REM or CL; only 12.0% of nonstruvite stones necessitated REM or CL.

CONCLUSIONS

All patients having PCNL done for complex stone disease should have an NT placed; however, small (8.5F-10F) CP suffice in most cases and can provide greater patient comfort. To minimize pleural morbidity, tubeless upper-pole access should be considered if the kidney is judged to be stone free at the conclusion of PCNL. Circle loops are useful when multiple accesses are necessary, whereas REM are appropriate if access is difficult, gross residual stone remains, or pain is not an issue (i.e., spinal-cord injury).