Conservative Management of the Duodenal Injury during Percutaneous Nephrostomy Placement: A Few and Far between Complications of the Urological Literature

Herein, we reported a duodenal perforation case as an intestinal injury during a percutaneous nephrostomy procedure. A 73-year-old woman with bilateral nephrostomy catheters was applied to the emergency service with right flank pain. Early in the day, her bilateral nephrostomy catheters had been changed. On physical examination, she had a defense and rebound at her right quadrant, and costovertebral angle tenderness was also positive. In the contrast-enhanced abdominal computed tomography scan, the right nephrostomy catheter was located in the second part of the duodenum, and the contrast agent did not leak into the peritoneum from the injury area. We decided on conservative management of the case with active surveillance using daily blood tests and physical examinations. The nephrostomy catheter in the duodenum was left to prevent fistula between the duodenum and the skin, and a new one was placed in the right kidney. The broad spectrum antibiotherapy regime was applied, and the patient was followed up closely. The catheter in the duodenum was removed on the 20th day, uneventfully, and the patient was discharged successfully on the 24th day with her permanent bilateral nephrostomy tubes. On the first follow-up, one month later, the patient had no active medical complaint.

Primary adenocarcinoma of renal pelvis or ureter: an uncommon histopathological entity seen in three cases

Background Primary adenocarcinoma of renal pelvis or ureter is rarest (< 1%) among all urothelial tumors. Regrettably, no characteristic symptoms, radiological features and treatment for this tumor are reported. We report three cases of adenocarcinoma of renal pelvis and ureter. Case presentation Case 1 had grossly hydronephrotic non-functional right kidney and underwent percutaneous nephrostomy followed by laparoscopic simple nephrectomy. Incidentally, histopathological examination reported adenocarcinoma of renal pelvis. Whole-body positron emission tomography-CT (PET-CT) ruled out malignancy at other sites. Patient refused adjuvant chemotherapy. Case 2 presented with previous history of right pyelolithotomy, right ureteroscopic lithotripsy and right flank pain with intermittent discharge via previous percutaneous site. On biochemical and radiological investigations, right poorly functioning pyonephrotic kidney was confirmed. Patient underwent right open nephrectomy which incidentally reported adenocarcinoma of renal pelvis. Patient is disease-free at 18 months of follow-up. Case 3 had left ureteric wall thickening on CT scan when evaluated for hematuria. Ureteroscopic-guided biopsy showed villous adenoma. Laparoscopic left nephroureterectomy with bladder cuff excision specimen showed well-differentiated adenocarcinoma in ureter with extension into periureteric fat. Patient died 32 months after surgery. Conclusion Primary adenocarcinoma of renal pelvis or ureter is very rare and urologists should suspect it in patients with mucinous material in nephrostomy tube. We should have a low threshold for performing radical nephrectomy with complete ureterectomy in these unusual cases to improve the prognosis.

Is JJ Ureteral Stenting Inferior to Percutaneous Nephrostomy as a Drainage Method in Emphysematous Pyelonephritis?

<b><i>Introduction:</i></b> The aim of the study was to examine the efficacy of JJ stenting in comparison with percutaneous nephrostomy (PCN) as a drainage method in patients with emphysematous pyelonephritis (EPN). <b><i>Methods:</i></b> We retrospectively identified patients with EPN between January 2000 and January 2021. Platelet-to-leukocytic ratio (PLR) at the time of hospital admission and discharge, time taken to clear air locules and to normalize leukocytic count, and air locule volume in mm³ were identified. Renal drainage by either PCN or JJ stent was required if symptoms persist for ≥3 days or in obstructed renal units. Failure of drainage method was defined as conversion to another method of drainage, need for intensive care unit admission, salvage nephrectomy, and mortality. <b><i>Results:</i></b> Twenty-nine patients were managed by JJ stent. Treatment success was identified in 20 patients and 19 patients who were managed by PCN and JJ stent, respectively. Higher air locule volume ≥16.7 mm³ and lower PLR ≤18.4 increased the risk of drainage failure (<i>p</i> = 0.009 and 0.001, respectively). <b><i>Conclusion:</i></b> Ureteral JJ stenting is an effective method for EPN drainage with a comparable overall success to the PCN use. Higher air locule volume and lower PLR increased the risk of drainage failure.

Ultrasound guided direct puncture percutaneous nephrostomy: a single tertiary centre observational study

Background: Percutaneous nephrostomy (PCN) is indicated to drain the upper urinary tract collecting system in cases of obstruction. Objective of our study is to evaluate the safety and efficacy of Ultrasound guided direct puncture PCN in our populations.Methods: This observational study was conducted from May 2020 to April 2021in department of urology and renal transplant. The total 65 patients with upper urinary tract obstruction requiring PCN were enrolled. All parameters were recorded and statistical analysis was performed using the Statistical package for the social sciences (SPSS 16.0) for windows.Results: In our study Ca Cervix with ureteric infiltration (35%) was the most common indication for PCN tube placement. Majority of patients (83%) had Grade IV and Grade III hydroneprosis. Single attempt for tube placement was sufficient most of the time in (86% cases). Direct Puncture PCN tube placement was successful in 62 (95.4%) cases. The mean duration of procedure was 12.4 minutes. Loin pain was the most common procedure related complication observed in 58 patients. There was no evidence of visceral injury, no need of blood transfusion in post procedural duration in our study.Conclusions: USG guided direct puncture PCN technique is simple, low cost, less time consuming, less chance of loss of tract and effective procedure for drainage of urine in case of upper urinary tract obstruction. We recommended this procedure in grade III and IV hydronephrosis and this procedure suitable for developing countries like India because of procedure related low cost.

Polymyxin B and low-dose hydrocortisone treatment in a patient with uroseptic shock in a rural health unit

ABSTRACT Sepsis has a high mortality rate; thus, in the intensive care unit, early diagnosis and adjunctive treatments are crucial. However, generally, most patients with sepsis from rural area initially visit the emergency department at a rural hospital and are managed in general medical wards in Japan. Here we report on an 81-year-old Japanese female manifesting septic shock caused by the upper urinary tract infection of extended-spectrum beta-lactamase-producing Escherichia coli secondary to the left ureter obstruction by the urothelial carcinoma. Broad-spectrum antibiotics were administered. Although critical for the source control of infection, drainage of the ureteropelvic junction could not be performed immediately because of catecholamine-resistant hypotension. Hence, we administered polymyxin B-immobilized fiber column direct hemoperfusion, followed by low-dose hydrocortisone administration. After 8 hours of infusion, she recovered from the septic shock and successfully underwent emergency percutaneous nephrostomy. This presented strategy may provide a new resolution of catecholamine-resistant patients in urosepsis.

Urinary tract obstruction: Ultrasound-guided intervention

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

Optimizing the lithotripsy timing after drainage of the upper urinary tract in patients with urolithiasis and obstructive uropathy

Introduction. Timely unresolved upper urinary tract (UUT) obstruction in patients with infection can cause severe complications, such as sepsis, pyonephrosis and even death. There are no clear recommendations regarding the methods and timing of drainage. At the same time, this issue is still the subject of discussion in publications of recent years.Purpose of the study. To optimize the timing of lithotripsy after drainage of the UUT in patients with urolithiasis and obstructive uropathy (OU).Materials and methods. At the first stage, 90 patients with OU caused by the stone of the ureteropelvic junction underwent drainage of the UUT using a percutaneous nephrostomy. Subsequently, percutaneous nephrolithotripsy (PNLT) was performed at various times after drainage. The level of inflammatory markers (IL-8) and profibrotic factor (MCP-1) in the urine was determined. The calculated concentrations of urinary biomarkers were normalized by the level of urinary creatinine. Urine sampling for the analysis was carried out during and after the PCN placement (nephrostomy urine) 7 days later, and then once weekly before surgery. The coefficient K was calculated using a patented formula to evaluate the process of kidney remodeling. Urine sampling was performed for culture to determine the bacterial spectrum and antibiotic sensitivity.Results. The values of K ≤ 1.85 were observed in 11 patients of the group with OU (12.2%), K > 1.85 in 79 (87.8%) by day 21. The values of K ≤ 1.85 were achieved in 70 patients (88.6%) by day 28 and 4 patients (80.0%) by day 35. PNLT was performed on 21 days in patients with K ≤ 1.85 (11 patients), no complications were noted in the postoperative period., PNLT was performed in patients with K ≤ 1.85 (70 patients) by day 28, exacerbation of pyelonephritis and the development of chronic kidney disease were not noted. Six patients with values of K ˃ 1.85 underwent PNLT by day 28. In the postoperative period, all patients had an exacerbation of calculous pyelonephritis, 50% had a decrease in glomerular filtration rate within 3 months after surgery. The bacteria in urine were detected in 55 (61.0%) patients. Escherichia coli (63.0%), Proteus mirabilis (18.0%), Enterococcus faecalis (14.5%), Streptococcus haemolyticus (2.5%) were identified most often.Conclusion. The use of the developed remodeling index allows optimizing the surgery timing and minimizing the development of complications during the postoperative period. The presence of bacteria is associated with a long process of renal parenchymal remodeling.