The commonest indications and complications following percutaneous nephrostomy placement at Al-Ribat University Hospital, Khartoum State- Sudan

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1 The commonest indications and complications following percutaneous nephrostomy placement at Al-Ribat University Hospital, Khartoum State- Sudan Hassan M Eltigani, MD *, Tarig Hassan, MD, Amir Abbo, MD, Abdalazeem Hussein, MD ** Registrar, General Surgery, Faculty of Medicine, Sudan International University *, Consultant Urologists, Al-Ribat University ** ا ى د اعى فقش انكه اكثش ان ضاعفاخ ان صاحث ن ا ت ستشفى انشتاط اندايعى د. ؼغ ؽ ذ ا رعا ٠ د.غاسم ؼغ ؼاض ػ ٠ د.ػا ش ات ؼغ ات د.ػثذ ا ؼظ ٤ ؼغ ٤ خ ق هللا خهف : ػ ٤ ح كوش ا ٤ ػ غش ٣ ن ا ع ذ ػ ٤ كؼا ؤهر ال غ ٤ اب ا ث ػ ذ ا شظ ٠ ا صات ٤ تاػرال ا ٠ اال غذاد. ذعش ػادج تاعرخذا ا ظاخ ك م ا ص ذ ٤. ا ذاف االطش ح : ذكد ا ذساع ؼشكح ا د اػ ٠ ذش ٤ ة ا ث تح ا ٤ ػ غش ٣ ن ا ع ذ ا ٣ عا ؼشكح ا صش ا عاػلاخ ا صاؼث رش ٤ ث ا. طشق انذساس : ذؼرثش ا ذساع دساع ذؽ ٤ ٤ صل ٤ اظش ٣ د ك ٠ ا لرش 2011 ٤ ٣ ا ٠ 2012 ٤ ٣ ك ٠ غرشل ٠ ا شتاغ ا عا ؼ ٠. ش د ا ذساع 100 ش ٣ ط ٣ ؼا ا غذاد ػ تا غا ي ا ث ٤ ؼ ٤ س اظش ٣ د ػ ٤ ح كوش ا ٤ ػ غش ٣ ن ا ع ذ ذ د راتؼر. ان تائح : ذرشا غ اػ اس ا شظ ٠ ت ٤ ع ر عػ اػ اس 45 ع. ذؼرثش ا ؽصا ا غثثاخ ا غذاد ا غا ي ا ث ٤ ا ؼ ا صش ا ش ٤ ػا. ؼظد ك ٠ %90 ا شظ ٠ ٤ ا اال سا ك ٠ %5 ا شظ ٠ ش ذع ٤ ن ؼ ض ا ٤ ك ٠ %3 ا شظ ٠, اخ ٤ شا اصاتح ا ؽا ة اش اء ا رذخالخ ا طث ٤, ؼ ٤ س ؼع ك ٠ %2 ا شظ ٠. ذ كوش ا ٤ ؿ ٤ ش عاػلاخ ك ٠ %73.7 ا شظ ٠ ؼذشد عاػلاخ ك ٠ %26.3 ا شظ ٠. ا صش ا عاػلاخ ش ٤ ػا ذ ص د ك ٠ ؼذ ز ا ث ا ذ ك %10٠ ا شظ ٠ ش ا ضالم اال ث ب ك %6٠ ا شظ ٠ ش ؼذ ز اال ك ٠ ا ا ؼ ٤ ك %4٠ ا شظ ٠,ش اػرال ا ٠ ا صذ ٣ ذ ك ٠ %3 ا شظ ٠. ا غذاد اال ث ب ؼذز ك ٠ %3 ا شظ ٠. ا ي ش ٣ عا اؼراظا ؼ ٤ ح و د تؼذ كوش ا ٤ )2 %(. انخالصح : ػ ٤ ح كوش ا ٤ ػ غش ٣ ن ا ع ذ ػ ٤ ا ع ح ا رؼ ذ صؽ ت ت غثح عاغ ػا ٤ ػ ذ ذ ل ٤ ض ا تص س صؽ ٤ ؽ. Abstract Background Percutaneous nephrostomy (PCN) is an effective method for achieving temporary drainage of the obstructed urinary system or as a prelude to interventional procedures such as stent placement or percutaneous nephrolithotomy (PCNL). Usually it is performed under sonographic or fluoroscopic Corresponding author Hassan Mohammed Eltigani, hassantigaqni1@gmail.com guidance. The objective of this study is to study the commonest indications and complications following percutaneous nephrostomy placement. Patients & Methods This is an observational, analytical, crosssectional, prospective, hospital based-study done at Al-Ribat University Hospital for one year extended from June 2011 to June The study included 99 patients with upper urinary tract obstructions underwent PCN placement and followed up. The data was collected using a pre designed data sheet and 77

2 analysed using the software SPSS version 18. Results Ninety-nine patients were studied with a male to female ratio of 4:1. Patients age ranged between years; with a mean age of 45 years. Urinary tract stones was the commonest cause of obstruction seen in 89 patients (89.9%), followed by tumours in patients (5.1%), pelviureteric junction stenosis was reported in 3 patients (3%), and 2 patients (2%) had iatrogenic ureteric injury. The procedure was performed without complications in 73 patients (73.3%). The remaining 26 patients (26.7%) developed complications. The commonest complication was transient haematuria seen in 10 patients (10.1%), followed by slipping out of the tube in 6 patients (6.1%). Pain at the site of the nephrostomy required analgesics reported in 4 patients (4.1%). Pyonephrosis reported in 3 patients (3%), while blockage of the tube observed in 3 patients (3%). Only 2 patients (2%) developed massive bleeding requiring transfusion and was managed conservatively. Conclusion Percutaneous nephrostomy is a safe procedure, easily trainable, and associated with low major complications rate if done properly. Keywords: Indications, complications, PCN, Sudan Introduction Percutaneous nephrostomy (PCN) is an interventional procedure which is mainly used to decompress the renal collecting system. Since Goodwin and associates (1), published a report of the first series involving this procedure in Ten years later, Bartley described a technique for the application of a permanent drainage (2). He used a modified Seldinger technique and relieved the pressure on the renal pelvis using an angiography catheter. The procedure first became generally accepted when Almgard and Fernstrom (3) described a technique for the application of 78 nephrostomy using a Foley catheter. They used a dilatation technique in which the nephrostomy channel was dilated by gradually increasing the size of the catheter. The technique was time-consuming, and it could take a week from the first puncture until the Foley catheter was in place. The time required was reduced considerably when Lindgren and Hemmingsson introduced the coaxial dilatation technique (4). The first ultrasound-guided percutaneous nephrostomy was reported in 1974 (5). Cope introduced a loop catheter in 1980 which has a distal loop that is reformed in the renal pelvis with a loop shape (6). Since that, the percutaneous nephrostomy catheter placement has been the prime procedure for the temporary drainage of an obstructed collecting system (7,8). With proper training, technical success is achieved in more than 95% of cases. Images often demonstrate the level and cause of obstruction; however, at the time of tube placement, the cause of obstruction may not be known. Often, the ureteral obstruction is acute and is caused by ureteral calculi or traumatic ureteral injury. The obstruction may have a chronic cause, such as urothelial malignancy or extrinsic compression associated with bleeding or neoplasm. Frequently, the obstructed system becomes infected, and antibiotics are unable to penetrate the kidney when the purulent material cannot be drained. In these cases, percutaneous nephrostomy is an attractive treatment alternative because it allows decompression of the obstructed system, permits specimen collection, and creates a route for antibiotic instillation if needed. This procedure decreases the risk of urosepsis associated with acute surgical intervention. Often, patients may avoid surgery because the obstructing calculus spontaneously passes after the oedema within the ureter subsides. If the obstruction is the result of postsurgical oedema, percutaneous nephrostomy enables

3 the oedema to subside. The same is true with urinary fistulas. Methodology This is a prospective, analytical, crosssectional, hospital based-study that was conducted in Al-Ribat University Hospital in the period from June 2011 to June The study population was composed of 99 patients who fulfilled the criteria of adult patients during the defined study period. On the other hand, some patients were excluded because of severe bleeding disorders and renal congenital abnormalities. Informed consent was taken from the patients before performing the procedure. The procedure was performed by the authors. Data was collected by using pre-designed questionnaire covered with the following parameters: (1) Pre-procedure: Age, duration of symptoms, indication of nephrostomy tube placement, associated co-morbidity, Hb level, white blood cells count, renal profile and urine analysis. (2) Immediate complications following the procedure: pain, bleeding, haematuria, urinoma, injury to adjacent organ, pyonephrosis, sepsis and blood transfusions. Data was analyzed by computer using Statistical Package for the Social Science program (SPSS). Results During the study period, from June 2011 to June 2012, 104 patients were presented to Al- Ribat University Hospital diagnosed as having obstructive uropathy requiring nephrostomy placement. Five patients were excluded because of abnormal bleeding profile and solitary kidney. Ninety-nine patients fulfilled the criteria of the study and were included as a study group. Patients age ranged between years; two thirds of patients (65.7%) were between years, 27.3% (n=27) were above 60 years and 79 the remaining 7% (n=7) were between years Seventy-eight percent of patients were males (n=77) while the remaining 22 %( n=22) were females In 70.7% of patients (n=70), the duration of symptoms was more than one month. The remaining 29.3 %( n=29) presented with less than one month duration of symptoms Hypertension and diabetes were found to be the commonest associated co-morbidity; it represents 55.5% and 13.1% of patients respectively. All patients (n=99) underwent percutaneous nephrostomy to drain an obstructed system. Eighty-nine point nine percent of them (n=89) due to stones, 5.1% (n=5) due to tumors, 2% (n=2) iatrogenic and the remaining 3% (n=3) due to others (pelviureteric junction stenosis) The blood urea and serum creatinine levels were elevated preprocedurally in all patients. The total white blood cells count was elevated in 72.7% of patients (n=72) preprocedurally, and within the normal range in 27.3% of patients (n=27). The haemoglobin level prior to the procedure is more than 9.5g\dl in 94.9% of patients (n=94), while it is less than 9.5g\dl in 5.1% of patients (n=5). Preprocedural urine analysis showed RBCs more than 10\HPF in 92.9% of patients (n=92), and less than 10\HPF in 7.1% of patients (n=7). Pus cells content of the urine was more than 10\HPF in89.9% of patients (n=89), and less than 10\HPF in 10.1% of patients (n=10). The percutaneous nephrostomy tube was placed in the left kidney of 61.6% of patients (n=61), while in 36.4% of patients (n=36) placement was performed at the right side, with the remaining 2% of patients (n=2) bilaterally. The procedure performed without complications in 73.7% of patients, but complications occurred in 26.3% of patients. Ten point one percent of patients (n=10) developed haematuria, two of them developed massive bleeding requiring transfusion and

4 was managed conservatively. In 3% of patient (n=3) with pyonephrosis reported, the tube blocked in 3% of patients (n= 3), and the tube slipped out in 6.1% of patients (n= 6). Pain continuing for more than 24 hours and requiring analgesia was reported in 4.1% of patients (n= 4) (Table 1). Table 1: The type of complication following PCN placement in 99 patients presented to Al-Ribat University Hospital from June 2011 to June Complication Frequency Percent Bleeding % Slipping 6 6.1% Pain 4 4.1% Pyonephrosis 3 3% Blockage 3 3% No complication % Total % The urine culture result was positive in 3% of patients (n=3), and negative in 97% of patients (n=96). Post procedurally, 99% of patients had a marked improvement in their renal profile as determined by the blood urea and serum creatinine except in one patient with advanced uterine carcinoma. The total white cells count returned back to its normal range in 70.7% of patients (n=70), but remained high in 2% of patients post procedurally for more than 7 days. Only 2 patients had dropped in their hemoglobin count post procedurally and required blood transfusion. The output of the nephrostomy tube was more than 500ml\day in 94.9% of patients (n=94), and it is less than 500ml\day in 5.1% of patients (n=5). In all complicated cases, the duration of symptoms was more than one month, and they had either diabetes or hypertension. Discussion Percutaneous nephrostomy placement has been effective, both in the palliative care of obstructive uropathy of malignant etiology and in the initial management of benign diseases (9,10,11,12). Urinary tract stones were found to be the commonest cause of obstruction that required percutaneous nephrostomy placement reported in 89.9% of patients (n=89). Nearly similar results were achieved by Eva Radeca in 40.6% from a total number of patients 401 (13). In our study, only 26 patients developed complications. Ninety-two point three percent of it were minor complications. Only two patients (7.7%) developed major complication in the form of bleeding requiring transfusion. Carrafiello observed a major complication rate of 0% in massive hydronephrosis (14). Major complication rate of 0.29% was reported by Kaskarelis et al (15). Blockage of the catheter reported in 3% of patients which corresponds to the lowest rates reported by Kaskarelis Is and WahTM ( %) (15,16). The catheter slipped out in (6.1%) which is less than that reported by Stables D (17) and Von der Recke (18). According to the recent definition of sepsis (19,20), the most infectious complications could be reported as sepsis with different degrees of severity. In terms of major complications only severe sepsis and septic shock are interesting. Only one pyonephrotic patient who was a febrile preprocedurally, developed skin infection with fever after the procedure and managed with antipyretic and proper antibiotics. No severe sepsis or septic shock was observed in the remaining cases, this may be due to the use of prophylactic antibiotics and aseptic technique. Paulius Montvilas and associates reported similar results (21). Farrell TA (22), Agostini S (23) and Lewis (24) reported sepsis as a major complication in ( %). Ten patients developed transient macroscopic haematuria through PCN catheter and ceased within 24 hours in 8.1% of them. Nearly similar results obtained by Paulius Montvilas (21) in 13.1% (59 patients out of 448) in whom the macroscopic haematuria ceased within two days. 80

5 In our study none of the patients died during the interventional procedure, however, only one patient (1%) died during the first 30 days following the procedure, she had metastatic uterine carcinoma. Kaskarelis and associates had only 2 patients (total number 1036 patients) 0.19% died during the first 30 days as a result of metastatic urinary bladder carcinoma (15). In conclusion, all reported complications occurred during the first 50 procedures, the remaining procedures passed smoothly without complications. Major complications rate is very low and comparable with what is reported in the literature. References 1. Goodwin WE, Casey WC, Woolf W. Percutaneous trocar (needle) nephrostomy in hydronephrosis. JAMA 1955;157: Bartely O, Chidekel N. Percutaneous drainage of the renal pelvis for uraemia due to obstructed urinary outflow. Acta Chir Scand 1965;129: Almgard LE, Fernstrom I. Percutaneous nephrostomy. Acta Radiol (Diagn) 1974;15: Lindgren PG, Hemmingsson A. Percutaneous nephropyelostomy. A new technique. Acta Radiol Diagn (Stockh)1980; 21(6): Pedersen J. Percutaneous nephrostomy guided by ultrasound. J Urol 1974;112: Cope C. Improved anchoring of nephrostomy catheters: loop technique. Am J Roentgenol 1980;135: Dyer RB, Assimos DG, Regan JD. Update on interventional uroradiology. Urol Clin North Am 1997 Aug;24(3): Luo H, Liu X, Wu T, Zhang X. Clinical application of percutaneous nephrostomy in some urologic diseases. J Huazhong Univ Sci Technolog Med Sci 2008 Aug; 28(4): Saad WE, Moorthy M, Ginat D. Percutaneous nephrostomy placement: native and transplanted kidneys. Tech Vasc Interv Radiol 2009;12(3): Uppot RN. Emergent nephrostomy tube placement for acute urinary obstruction. Tech Vasc Interv Radiol 2009;12(2): Jalbani MH, Deenari RA. The role of percutaneous nephrostomy in malignant ureteral obstruction. J Pak Med Assoc 2010; 60(4): Hausegger KA, Portugaller HR. Percutaneous nephrostomy and antegrade ureteral stenting: technique-indications and complications. Euro Radiol 2006;16(9): Eva Radecka. Percutaneous nephrostomies-planning for an optimal access, complications, follow-up and outcome. ISBN Uppsala 2005;46: Carrafiello G, Lagana D, Mangini M. Complications of percutaneous nephrostomy in the treatment of malignant ureteral obstructions. Radiol Med 2006;111(4): Kaskarelis IS. Complications of percutaneous nephrostomy, percutaneous insertion of ureteral endoprothesis, and replacement procedures. Department of Radiology, Evangelismos Hospital, Athens, Greece. Cardiovasc Intervent Radiol 2001;24: WahTM, Weston MJ, Irving HC. Percutaneous nephrostomy insertion. Clin Radiol 2004;59(3): Stables D, Ginsberg N, Johnson M. Percutaneous nephrostomy: A series and review of the literature; AJR1978;130:

6 18. Von der Recke P, Nielsen MB, Pedersen JF. Complications of ultrasound-guided nephrostomy. Acta Radiol 1994;35: Bone RC, Balk RA, Cerra FB. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Society of Critical Care Medicine 1992;101(6): European Association of Urology. Definition and clinical manifestation of sepsis in urology [accessed September 2009]. 21. Pallius M, Jan S, Truls EBJ. Single center review of radiologically guided percutaneous nephrostomy mixed technique: success and complication rate. European Journal of Radiology 2011;80: Farrell TA, Hicks ME. A review of radiologically guided percutaneous nephrostomies. J Vasc Interv Radiol 1997; 8(5): Agostini S, Dedola GL, Gabbrielli S, Masi A. A new percutaneous nephrostomy technique in the treatment of obstructive uropathy. Radiol Med 2003;105(5 6): Lewis S, Patel U. Major complications after percutaneous nephrostomy. Clin Radiol 2004;59(2):