Full text of DOI:10.1089/end.2000.14.735

OF ENDOUROLOGY
JOURNAL
Volume
14,
Number
November 2000
9,
Inc.
Ann
Liebert,
Mary
after
Tube
Percutaneous
Nephrostomy
Large-Bore
Nephrolithotomy:
or
Catheter?
Pigtail
PANKAJ N.
MUKUND G.
M.Ch.
M.Ch.
and MANISH
MAHESHWARI,
(Urology),
ANDANKAR,
(Urology),
MBBS
BANSAL,
ABSTRACT
and
A
tube
is
tube
3F
of
renal
used
Com¬
an
Background
nephrostomy
Purpose:
any
surgery.
after
integral part
percutaneous
that
our
to
is 2F
tract
is
a
smaller than the
percutaneous
have
percutaneous
tube and
monly, nephrostomy
nephrolithotomy
In
of
the
few
a
at
(PCNL).
site,
nephrostomy
experience,
quite
patients
pain
removal when
tube
after
leak
tube
is
a
a
many
used.
large nephrostomy
complain
urinary
prolonged
patients
document whether these
could be
the
to
to
This
attributed
was
study
planned
whether
symptoms
prospective
the
tube and
small
catheter could reduce
these
size of
without in¬
a
nephrostomy
creasing complications.
Patients and Methods:
pigtail
in
problems
well-matched
Alternate
whom
PCNL
for
dis¬
calculus
a
was done
one-stage
nephrostomy
for
the duration of
Forty
patients
studied
28F
ease were
had
a
tube or 9F
catheter
of
a
prospectively.
patients
pigtail
number
placed
in¬
at
of
Patients
the end
the
were observed
after
hematuria,
procedure.
analgesic
the
tube
and
and the
duration of
and
leak
removal.
needed,
urinary
jections
Results: The
in
amount
duration of
hematuria after PCNL. There
were
the
was
a
groups
comparable
the
leak
tube
difference in
need
catheter.
after PCNL
is
increase in
duration of
after
removal,
statistically significant
analgesic
a
urinary
of which
in
both
Conclusions:
less
were
patients having pigtail
A
tube
course
reduces the
the du¬
catheter
by
stay
pain
pigtail
nephrostomy
postoperative
hospital
reducing
The
the
leak.
has less
and needs less anal¬
ration of
as
smooth,
the
urinary
patient
is
to
use
There
of a
no
secondary
nephrostomy
pigtail
support.
statistically significant
gesic
pigtail
postoperative bleeding
in
catheter.
the
Second-look
procedure.
with
was
one
a
catheter
nephroscopy
easy
patient
who needed the
INTRODUCTION
With so
integral
a
tube is considered
Most
many advantages, nephrostomy
an
of
percutaneous
renal
part
surgery.
urologists
tract1
nephrostomy
is 2F
NEPHROLITHOTOMY
has
a
a
tube that
of
to 3F smaller than the
a few
(PCNL)
place
definite
in
of
PERCUTANEOUSthe
calculus dis¬
at the end
PCNL. We noticed
with the
place
urinary
management
problems
place¬
for
of
of
a
Some
tube.
the removal
A
stay.
the tube.
the treatment
the
and
re¬
ment
ease,
patients
especially
large
complex
large nephrostomy
after
develop pro¬
of
few
nal calculi.
of
there are individual variations in the tech¬
this tube. This leak
urinary
usually lengthens
Although
most
longed
leakage
the
a
of
tube. This
them
PCNL,
urologists
hospital
patients complain
nique
place nephrostomy
site of
tube serves
The most
at the
among
of the
significant pain
This
many purposes.1
important
was
determine
is to drain the
at the end
to
whether
size of the
pelvicaliceal system
serves as an access
the
to
procedure.
study
prospective
planned
tube
if these
could be attributed to the
The
a
also
system
pelvicaliceal
problems
large
small tube could be substi¬
tube without
second-look
the
is needed for the residual calculi.
tube and whether
a
nephroscopy
tube is considered
nephrostomy
for
a
to
tuted
related
the
Also,
the
large-bore
complications.
nephrostomy
way
tamponade
increasing nephrostomy-
tract to control
bleeding.
percutaneous
India.
Institute, Mumbai,
Research
R.G. Stone
Urological
735

736
MAHESHWARI
ET AL.
the
at
and duration of leak after
PATIENTS AND METHODS
nephrostomy site,
nephrostomy
tube removal. Hematuria
red color in
was defined as the
of
presence
any
Patient
the
urine. Pain was
Selection
ac¬
nephrostomy
quantified
the
of
A
the
to
amount
hours after PCNL.
was
needed in the 48
cording
analgesic injections
non-narcotic
From
were
1998
to
PCNL
1999,40
groups.
tube,
All these
July
February
in
patients needing
Twenty patients
(diclofenac
analgesic
two
a
had
alternately placed
to
on demand. To
the
hours until
sodium)
given
patients
was
quantify
28F catheter as
a
whereas in the
a
others,
nephrostomy
duration of
the
2
leak,
dressing
changed every
9F catheter was inserted.
had
a
one-
pigtail
patients
guided
two consecutive
were
dry.
dressings
PCNL
done
a
30F
tract
stage
using
by making fluoroscopy
done
was
in all
these
dis¬
to
Ultrasonography
from the
patients prior
in either
Aiken's
dilators.
telescopic
of
None
the
charge
hospital.
patients
group
for
We selected
this
(20-40
thickness
study young patients
years age).
cm on
showed
renal or
hematoma or urine
any significant
perirenal
with
a
renal cortical
Only
(>2
patients
ultrasonography)
were
good
good
collection.
and
renal function on
intravenous
urog¬
need¬
selected for this
We excluded
These exclusion criteria
raphy
study.
patients
Statistical
Analysis
tracts or
Y
tracts.
ing
to
multiple
helped
Statistical
and
was
done
with
the
for
rule
Mest
out other causes of
or
leak after
analysis
prolonged
using
unpaired
error
bleeding
a
5%
level.
Mean,
tube removal. It is
leak after
a common
have
unequal variances,
t
to
alpha
equal
nephrostomy
experience
standard
and values were
P
calculated to de¬
a
deviation,
tube removal in el¬
value,
prolonged urinary
nephrostomy
termine
statistical
the
of all the variables.
and
with thin renal
significance
(based
derly patients
patients
parenchyma
on our as
yet
or
Y
tracts
unreported study). Similarly, multiple
cause an increase
in the tract
These
exclusions
may
also
bleeding.
in the
have
were done
to
All
two
PCNL
RESULTS
helped
uniformity
a
groups.
author
single
(PNM).
operations
by
An
observer was
look for
The
tients
to
the
two
were
their
in the distribution of
independent
engaged
groups
to
proper
comparable
(Table 1).
age
pa¬
the two
of the
and to exclude selection bias. It was
groups
the
The mean
in
matching
according
age
role of the
were
observer to see to it that the
was around 34
36
to
years.
two
The difference in
in
the
age
independent
in
groups
length
groups
the
the
stone size and
to
of two
was
not
(P 0.393).
statistically significant
comparable
regard
groups
The difference in
the
duration of
(P
the
hematuria after PCNL was
procedure.
of
The aim
this
was
on
to
the
also
not
In both the
0.135).
study
compare
postoperative
nephrostomy
statistically significant
groups,
of
course
the two
of
the basis their
had red urine for an
of
24 hours. As the dura¬
groups
those
patients
average
tubes.
in
PCNL
was done
calculus were in¬
whom
tion of hematuria was found
to be
in these
two well-
Hence,
only
patients
equal
one subcostal
clear
a
<3 cm
tract to
matched
it was concluded that
of
the
through
groups,
had no
type
nephrostomy
cluded.
tube
on the duration of hematuria.
None of the
bearing
in either
needed
blood transfusion.
patients
group
postoperative
Placement
Catheter
Large-Bore
of
the end of
an
At
end-hole 28F catheter was
PCNL,
sheath in the
placed
Results
Table 1.
Type
According to
Nephrostomy Tube
the
under flu¬
tube with
system
through
Amplatz
collecting
of
control. We used
drainage
marker. The catheter was fixed skin
a
Teflon
a ra¬
oroscopic
diopaque
to
a
suture.
by
Mean
SD
t
value3
value3
0.393
p
Catheter
Placement
The
of Pigtail
Age
LBCb
36
34
7.78
6.84
of the
done
catheter was
over
a
placement
pigtail
0.864
the end of
a
At
was
ad¬
PCNL,
guidewire.
J-tipped guidewire
PTC
vanced into the
The
sheath
was
system.
pelvicaliceal
Amplatz
Duration of
hematuria
LBC
the
in
Under
removed,
keeping
fluoroscopic
guidewire
place.
(h)
the
catheter was
in
the
24
8.13
10.38
1.43
guidance,
pigtail
collecting
positioned
-1.526
9.215
0.135
over this
wire and fixed
was done at the end of the
the skin
a
to
suture.
A
system
by
procedure
PTC
28.5
6.4
2.8
to docu¬
nephrostogram
needc
Analgesic
the
of
the catheter.
ment
correct
position
LBC
<0.0001
<0.0001
Postoperative
All
Follow-Up
PTC
1.01
Duration of leakd
LBC
had
a
to document
patients
postoperative radiograph
25.5
6.2
11.64
2.48
stone clearance.
tubes were
had their
once
removed
the
tubes for
Nephrostomy
7.254
hematuria
an
cleared. The
nephrostomy
patients
PTC
of 36
to
42 hours.
A
was done in
all
average
nephrostogram
to document that there was no
extravasation of urine
patients
with
f-tests
variances.
PTC
aUnpaired
bLBC
cNumber of
dUnpaired
equal
from
free.
the
and that the
was
stone
pain
system
patient
pelvicaliceal
catheter.
in 48 hours after PCNL.
large-bore
catheter;
pigtail
injections
Patients were observed for
the duration of
t-tests with
variances.
hematuria,
unequal

737
BEST NEPHROSTOMY TUBE
AFTER PCNL
Patients who had
in the
a
needed more
This indicated
noticed
that
anal¬
We
had
a
large nephrostomy
patients
at the
prolonged post-tube-removal
that
a
leak and
tube site. This
nephrostomy
gesic
support
tube
postoperative period.
significant
pain
more
than the
catheter. This
was done
evaluate the use of
catheter as
a
to
study
large
produced
pain
pigtail
pigtail
tube. This is one of the
post-
studies we
difference
was found
be
<
to
PCNL
(P
statistically significant
nephrostomy
only
have come across
PCNL
where
tube.
a
catheter is used as
a
0.0001).
One of
catheter
post-
useful, safe,
pigtail
the
the
noticed in
short
found this
tube
We have
significant advantages
pigtail
nephrostomy
was that
was a
there
and well tolerated.
group
very
leakage period
after
tract
This
tube removal.
around the
could be because the
nephrostomy
collapsed
whereas
the
large
time.
As the leak
catheter,
longer
pigtail
for
could be
catheter
the
a
tract
CONCLUSION
kept
open
from the
patients
stopped early,
discharged
hospital
and
sooner.
Early
of leak led
reduced
After this
to
we revised our indications for the
In most
the end of PCNL.
stoppage
morbidity
experience,
convalescence.
can be
of
the
choice
tail
tube.
of our
a
prompt
Although patients
once the
tube is
discharged
our
nephrostomy
patients, pig¬
from
the
catheter is
have
We reserved
at
removed,
hospital
nephrostomy
placed
nephrostomy
to
in the
until the leak reduces or
tubes for
patient
who suffer mucosal
who have
stay
large-bore
or
prefer
patients
hospital
renal trauma
tract dilatation or
stops completely.
during
patients
py-
pelvi¬
pa¬
The two
groups
were not
was
for the
that the functional
of renal
nephron
extent
or
a
dilated
compared
onephrosis,
poorly functioning kidney,
large
functional
loss. It
caliceal
We also still
catheters in
system.
presumed
prefer
large-bore
loss would
on the
of
dilata¬
tients in
whom
extent
tract
or
Y
tracts have been made.
depend predominantly
multiple
of
tion and not on the size
the
tube.
for
tubes
nephrostomy
All the
had their
hours. None
an
patients
42
nephrostomy
average
of 36
of
these
to
had
of
ACKNOWLEDGMENTS
patients
any episode
tube
nephrostomy
blockage postoperatively.
also
ease of
second-look
We
the
in
for
Sincere thanks
S.T.
Gandhi,
Medicine,
in the statistical
to Dr.
&
Lecturer in the
Grant Medical
of this
compared
nephroscopy
Depart¬
the
needed
a
second
two
Four
of Preventive
for
Mumbai,
Social
ment
groups.
patients
nephroscopy
a
College,
residual calculi. In the three
who
had
and
large catheter,
A
study
patients
helping
independent
analysis
the
rod was
sheath was
and
as an
observer.
placing
Amplatz
easy
straightforward.
serving
under
over
the
guide
placed
fluoroscopic guidance
an
through
tube, and
dilator and sheath
catheter needed
that,
who had
nephrostomy
Amplatz
were inserted. One
a
a
REFERENCES
patient
pigtail
second-look
an
to
a
Here,
through
Amplatz sheath,
nephroscopy.
place
1. Hunter DW. Percutaneous
moval. In:
after
re¬
stone
Endourology. Chicago:
227-233.
was threaded
the catheter. Over
guidewire
of
that,
nephrolithotomy: Drainage
of
place¬
PH: Atlas
K,
Lange
a
Amplatz
ment
rod and
smooth. In all
dilatation
30F
the
to
guide
one-step
by Amplatz
Year Book Medical
Publishers, 1986,
pp.
Bellman GC. "Tubeless"
four
dilator was
very
not
patients,
nephrostomy
2. Candela
Davidoff
J,
cutaneous
R,
new
J,
per¬
Gerspach
was
of
the
tube
the end
The
was
at
replaced
procedure.
Amplatz
A
advance in the
of
surgery:
Techn
technique
percutaneous
was
sheath
The
and
a
removed,
were
compression dressing
under
applied.
renal
surgery.
3. Wickham
Urol
1997;3:6-11.
intravenous
sedation.
procedures
accomplished
Miller
Kellet
or
SR. Percutaneous
1984;56:582-585.
JE,
RA,
stage
MJ,
Payne
One
two? Br J Urol
nephrolithotomy:
4. Winfield
RV. Percutaneous
HN,
P,
Clayman
Wayman
nephrolitho¬
DISCUSSION
of
tube removal.
J
Urol
tomy: Complications premature nephrostomy
1986;136:77-79.
Percutaneous
is
for
this
the choice
done
large
nephrolithotomy
frequently
the
Address
to:
of
and
cedure is
the
lines
renal calculi.
reprint requests
complex
Although
technique
pro¬
N.
M.Ch.
Research Institute
there are
variations in
Pankaj
R.G. Stone
Maheshwari,
standardized,
many
of
tube. With no definite
Urological
postprocedure
nephrostomy
guide¬
about the
Khar
14-A
are individual
to be used.
about the
tube,
there
type
Road, (W)
Mumba: 400 India
052,
perceptions
the
and
need,
safety,
There are
in the literature of
of
"tube-less"
In
reports
selected
case
percutaneous
there have
E-mail:
in
a
contrast,
calrgse@bom5.vsnl.net.in
surgery
been
group
patients.23
and
with
severe
the
com¬
ample
reports4
experiences
when PCNL is
and
without
a
removed.
tube is an
plications
morbidity
performed
prematurely
nephrostomy
tube or when the tube is
EDITORIAL COMMENT
nephrostomy
of
of a
and size of
The
feel that
renal
percutaneous
a
majority
urologists
This is
a
evaluation of
40
integral
part
undergoing
procedure.1,2
prospective
patients
The
after
is
the
tube used
PCNL
tube that is 2F
sheath. He believes this
with
type
nephrostomy
(PCNL),
tube or
percutaneous nephrolithotomy
alternating
place¬
standardized. Hunter1 has advised the use of
a
of
a
not
ment
standard 28F
a
9F
catheter
nephrostomy
pigtail
to 4F smaller than the
if
the
of
the
at
end
The authors demonstrate that the
Amplatz
helps
procedure.
no different
is
or
a
there
when second-look
is
For duration of hematuria
was
in the two
How¬
leak
On
bleeding
procedure planned.
groups.
urinary
group.
a
similar
we
28F
at our
have been
a
less
duration of
catheter
was needed and the
reason,
center,
done
using
30F
tract.
ever,
after
nephros¬
analgesia
tube removal was shorter in
tube after PCNL
a
the
tomy
through
pigtail

738
MAHESHWARI
ET AL.
the basis of these
the authors
and well-tolerated" alternative
concluded that the 9F
of
a
smaller
ment
is also effective.
tube,
findings,
nephrostomy
Despite
catheter is
a
to
a
initial enthusiasm for the "tubeless" PCNL
at our in¬
"useful, safe,
technique
after PCNL. Since
tube
this
of
the
we
most
have been
tube
the
stitution,
tive
choosing
postopera¬
similar to the
large nephrostomy
performing
now choose
the
recently,
the authors
study,
that
report
percutaneous
indicated
selectively,
they
type
patients,
nephrostomy
tube
In most of their
Dr. Maheshwari and associates. If
the tract is
by
bloody,
system complicated,
nephrostomy
nephrostomy
selectively.
plan
smaller
catheter is
who have
of
at the end
the
if
is
accesses have been
then we
or if
used,
pigtail
patients
placed
suffered
mucosal or renal
procedure,
particularly
multiple
in
but
or the
di¬
trauma
or
a
24F
collecting
place
per¬
10F
with the
who have
lated
used.
a
a
cutaneous
tube.
we use an 8F
to
Otherwise,
pyonephrosis, poorly functioning kidney,
a
standard
tube is
tube. have been
I
the comfort of
system,
collecting
large nephrostomy
impressed
by
patients
greater
not
which
smaller
be
than
that
to
tube,
experienced by patients
subjectively appears
the
of
the
to two
alternate
was
with
a
24F tube and
the
Although
assignment
patients
groups
significantly
the
of
not
the
for different from that
in whom we had
not
randomized,
by
technique
selecting
patients
experienced
tube.
patients
different
of tubes minimizes
two
bias. The ex¬
are not
no
we have
studied this
However,
types
likely
operative
placed
nephrostomy
size and duration of
act stone
the
as was
done in the
report.
adopted
procedures
approach systematically,
preceding
have
but we are told that an
verified
observer
Other
to
a
have indicated
with
me
to
that
they
reported,
their
independent
this
was limited
urologists
similar
to
results.
comparability. Additionally,
study
per¬
sin¬
technique,
generally satisfactory
us with some
cutaneous
in
a
The
dence to
evi¬
nephrostolithotomies
subcostal tract and for
stone <3 cm. With 20
young patients, using
preceding study provides
support
objective
a
in
well
the
of
the
of PCNL
gle
patients
practice reducing
morbidity
each
it is
that the
are
a
smaller
tube. The entire
of
by
group,
likely
demographics
fairly
placing
nephrostomy
purpose
matched.
extraction rather than
stone
percutaneous
surgi¬
offering
cal
open
With
studies
recent
on the limitations of ex-
is
to reduce
it is
a
natural
pro¬
shedding light
nephrolithotomy
morbidity;
for
Shockwave
those in the lower
some renal
calculi,
par¬
we
further
that
should
reduce the morbid¬
to
tracorporeal
lithotripsy
gression
attempt
inter¬
and
there has been renewed
of the
ity
percutaneous
ticularly
pole,
procedure.
in
PCNL. The flexible
and
est
small lithotrites that are
almost in the
ureteroscopy
ureteroscopes
available
allow treatment of
J. Stuart
Jr., M.D.
Michigan
Michigan
currently
collecting
Wolf,
University
stone
occasion¬
although
system,
any
of
calculi can be
for
Ann Arbor,
ally, lower-pole
problematic. Additionally,
quite
here.
can be
suited
and
the
Efforts
have thus been
laborious,
stones, ureteroscopy
larger
per¬
is
cutaneous
well
the
technique
directed
of PCNL.
the
to
Because
minimizing
morbidity
suffered
is in
many
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