Comparison of Tubeless Mini Percutaneous Nephrolithotomy with Conventional Technique in a Tertiary Care Center

Introduction: Mini Percutaneous Nephrolithotomy (mPCNL) is a safe and efficient method for management of nephrolithiasis. Post procedure nephrostomy tube drainage is considered as the standard practice. In recent years, tubeless mPCNL with the use of double J (DJ) stent alone has replaced the placement of the nephrostomy tube. Aims: This study intends to evaluate the safety and efficacy of tubeless Mini Percutaneous Nephrolithotomy. Methods: A total of 80 patients with Nephrolithiasis, admitted to Urology Unit of Nepalgunj Medical College, between September 2018 and September 2019 were enrolled in the study and divided into two groups: Tubeless group where tube was omitted and Standard Group where it was placed. The two groups were compared with respect to hemoglobin drop and blood transfusion requirement, hospital stay and analgesic requirement in the post-operative period. Results: Mean age of the patients was 34.30 ± 13.19 years. Mean stone size was 19.03 mm. The mean change in hemoglobin after standard mPCNL was 1.68 gm/dl and that in the tubeless group was 1.11 (p=0.018). The tubeless group had a significantly (p=0.001) shorter hospital stay (3.05 ± 1.23 days) compared to standard group (3.85 ± 0.86). The postoperative pain as assessed by visual analogue scale, was more in the standard group necessitating additional analgesia. It was significantly higher in the standard group at 12, 24, 48 hours, as compared to the tubeless group. Conclusion: Placement of nephrostomy tube can be omitted as a routine practice as Tubeless mini PCNL has an added advantage of significantly reduced postoperative pain, less analgesic requirement, shorter hospital stay, less postoperative blood loss.

Tubeless Percutaneous Nephrolithotomy with Hemostatic Plug Using Surgiflo® versus Standard Percutaneous Nephrolithotomy using a Nephrostomy Tube: A Prospective Randomized Controlled Study

Background Percutaneous Nephrolithotomy (PCNL) is the preferred technique for treating large renal stones (over 2cm in diameter). It involves keyhole surgery performed through a small skin incision overlying the kidney. Objectives Our study aimed at evaluating the safety and efficacy of local hemostatic sealant (surgiflo®) use in tubeless PCNL to enhance postoperative outcomes of PCNL. Patients and Methods We randomized our patients into two groups, Group A nephrostomy tube was used as standard PCNL, and at group B tubeless PCNL was done followed by injection of the local hemostatic flowable gelatin matrix (surgiflo®) under fluoroscopic guidance in the prone position Results There was no statistically significant difference between two groups regarding demographic data age, sex and BMI (P- value 0.280, 0.736 and 0.440 respectively), stone site and size (P- value 0.525 and 0.533 respectively), operative time (P- value 0.855), intraoperative complications as blood loss and pelvicalyceal perforation, (P- value 0.92 and P- value 0.83 respectively), postoperative complication as fever, haematuria and UTI (P- value 1.000, 0,113 and 1.000 respectivly), and Hb drop (P- value 0.735). Conclusion Tubeless PCNL with hemostatic sealant use is associated with less pain, no leakage from nephrostomy tract, less narcotic agent use, and a shorter hospital stay.

Visualization of the renal vein filled with contrast agent may indicate the renal vein injury during percutaneous nephrolithotomy: two case reports

Background Intravenous misplacement of a nephrostomy tube is a rare complication of percutaneous nephrolithotomy (PCNL) or percutaneous nephrostomy. The mechanism of misplacement of a nephrostomy tube into the vascular system is seldom investigated. One type of the possible mechanism is that the puncture needle penetrates a major intrarenal tributary of the renal vein and enters the collecting system. However, the guidewire is located outside the collecting system near the large branches of renal vein or perforates into the renal vein. The dilation is performed and causes a large torn injury. Subsequently, the nephrostomy tube is placed inside the vessel when radiological monitoring is not used. However, there is no imaging evidence and the scene of procedure is not demonstrated. This paper reports two cases of visualization of the renal vein filled with contrast agent during PCNL. The findings may be good evidence to support the step of renal vein injury in patients with intravenous nephrostomy tube misplacement. Case presentation We presented two cases with visualization of the renal vein filled with contrast agent during PCNL. In the process of injecting the contrast agent through the puncture needle, we could see the renal vein. Moreover, it was identified that the puncture needle tip was not on the optimal position. The position of puncture needle tip lay outside the collecting system, which was close to the calyceal infundibulum and branches of renal vein. Conclusions Visualization of the renal vein filled with contrast agent may be good evidence to verify the renal vein injury in patients with intravenous nephrostomy tube misplacement during PCNL or percutaneous nephrostomy. The suboptimal location of the puncture needle tip and visualization of the renal vein filled with contrast agent indicate the renal vein injury. One type of mechanism of intravenous nephrostomy tube misplacement is as following. Firstly, the guidewire stays outside the collecting system. Subsequently, dilatation directed by the guidewire results in the injury of the vein. Then, the nephrostomy tube migrates into the venous system due to prompt tube inserting and the direction of the sheath and/or the guidewire to the injured vein.

Retrograde endoscopic assisted percutaneous treatment of urinary fistulas after partial nephrectomy

Background. Urinary fistulas (UFs) are one of the most significant complications after partial nephrectomy. Placement of an ureteral stent eliminates urine extravasation in the majority of patients. However, some of them have persistent UFs despite upper urinary tract drainage. Such cases require retrograde injection of fibrin glue into the renal cavity through a ureteroscope or via the percutaneous approach. Some authors reported cases of simultaneous use of 2 stents and percutaneous cryoablation of the fistula, but these techniques are rare and, therefore, it is problematic to evaluate their efficacy.Objective: to evaluate the results of the new treatment method for the elimination of persistent UFs using the retrograde endoscopic percutaneous approach.Materials and methods. This study included 5 patients (3 males and 3 females) with UFs developed after kidney resection. Mean age of the patients was 55.8 years. The tumor size was 2.5 to 4.8 cm; mean R.E.N.A.L. score was 7.8. All patients had earlier undergone minimally invasive partial nephrectomy; the time between surgery and UF development varied between 3 and 10 days. Four out of 5 patients had a large amount of discharge from their paranephral drainage system, examination of which confirmed high creatinine level. Patients underwent flexible ureteropyelography in the lithotomy position. During this procedure, we identified the damaged calyx and then performed percutaneous puncture targeting the distal end of the endoscope at this calyx, ensuring that the tip of the needle appeared in the paranephral cavity in front of the injured calyx. Using the flexible ureteroscope, we inserted the needle into the pelvis, dilated the puncture opening along the string, and installed a nephrostomy drainage system (12 Fr). Then the endoscope was removed and the ureter was additionally drained with a stent. The stent was removed after 8-10 days with subsequent antegrade pyelography. If there was no extravasation, the nephrostomy tube was removed and the patient was discharged from hospital to continue treatment in outpatient settings.Results. All patients with UFs resulting from partial nephrectomy was successfully operated on. No complications were registered. The mean surgery time was 45.0 ± 20.5 min (range: 40-65 min). Only two patients had some discharge from the fistula within 1 day after nephrostomy tube removal and it stopped without any additional interventions. Three patients had their fistula healed immediately. The treatment efficacy during the whole follow-up period of 18 ± 4 months (range: 6-26 months) was 100 %.Conclusion. Ureteral stenting ensures elimination of UFs in the majority of patients after partial nephrectomy. In individuals with persistent UFs, retrograde endoscopic percutaneous drainage of the pelvicalyceal system is the method of choice, because it allows rapid and effective treatment of UFs.

Nephrostomy Tube Misplaced into the Right Atrium: An Extremely Rare Case and Review of the Literature

Although percutaneous nephrolithotomy is generally safe, it has various complications. We present an extremely rare case in which the nephrostomy tube pierced renal parenchyma, proceeded through the right renal vein and inferior vena cava, finally reaching the right atrium. Such a tube misplaced to atrium level was firstly reported, which was safely withdrawn using a 2-step process under fluoroscopic monitoring. We also recommend the tube be marked with different color lines to maintain awareness of the tube length that has passed the peel-away sheath. Such information might help to avoid such complication.

Case – Endoscopic management of severe ventral urine leak post-robot-assisted laparoscopic prostatectomy

Vesicourethral leakage following robot-assisted laparoscopic prostatectomy is an uncommon complication, and the majority of cases are managed conservatively. Persistent leakage, which is refractory to conservative measures, may require more invasive management. Herein, we describe a novel approach for managing urine leaks endoscopically, without the need for percutaneous nephrostomy tube insertion.