Dr.Gaurav NaharDNB Urology(Std),M.M.H.R.C.,Madurai

Double J-Stent Vs. Percutaneous

Nephrostomy in the m/m of Acute Pyelonephritis

CASE PROFILE

PERSONAL DETAILS:-Mrs.Karupayee, 35y/F w/o Mr.Jeyakumar-Hindu, Married, Literate; Housewife.-Ettaiyapuram, Tuticorin

PRESENTING COMPLAINTS:1.C/o Lt. Loin pain........since 7days.-dull aching & continuous.-moderate to severe in intensity.

2.c/o Fever.......since 7 days-Moderate grade.-a/w chills & rigors.3.c/o Vomiting......since 7days-Non-projectile;contains ingested food

material4.c/o Dysuria......since 7 days5.c/o Increased frequency of

urination....7days6.c/o Chest pain.....since 2days-Non-exertional; mild to moderate intensity.No Hematuria,Nausea

PAST HISTORY: -DM-II since 3 years (on insulin);-Not a k/c/o TB,HT,IHD,BA.

No Surgical history; No h/o any drug allergy.

PERSONAL HISTORY: Normal appetite, sleep, bladder & bowel habits. No addiction.

EXAMINATION

GENERAL:-GC-fair; TPR-N/108/24/min; BP100/70mmHg;SYSTEMIC:P/A-Soft, Not distended, Tenderness+in

Lt.loin region, No organomegaly.R/S- NADCNS- Conscious & Well-oriented.CVS- NAD

INVESTIGATIONS:

Hb/PCV- 9.9gm%/30TLC/DLC-8000/cu.mm(P-46,L-41,M-11,E-

2,B-0)Platelet count-3,29,000/cu.mmBT-4'00" CT-10'00"RBS-165mg%; S.creatinine-1.3mg%,

B.Urea-10mg%;[Na+]-133, [K+]-2.3, [Cl-]-85, [HCO3-]-26.Viral markers(HBsAg,HCV,HIV)-Negative

CPK-67;CPK-MB- 0.7;Trop I-0.03(Normal)ECG, 2D Echo-Grossly WNL.Urine RE: Sugar-nil-Albumin-trace-Epi cells-1-2/hpf-Pus cells-4-6/hpf-RBC-nilUrine Culture: E.coli(>1,00,000cfu/ml)

USG Abdomen:(Outside 08/07/14)

-GB Calculi

-Lt.Kidney enlarged(14.1cm x 7.0cm); diffuse decreased echogenicity of renal parenchyma with compression of renal sinus-f/s/o Acute pyelonephritis of Left kidney.No PCS dilatation

-Rt.Kidney Normal(12cm x 4.7cm).No PCS dilatation.

CT Urogram(12/07/14):-Lt.Kidney enlarged with Patchy nephrogram. Mi

ld perinephric fat stranding(Acute pyelonephritis); Normal excretion, No PCS dilatation.

-Rt.Kidney LC-2mm calculus, Simple cortical cyst 1x1 cm.

MANAGEMENTPt.admitted and immediately started on-Empirical antibiotic therapy for broad spectru

m coverage(Imipenem Cilastatin 250mg iv 6hrly) & continued after Culture report.

-Analgesic-antipyretics(Inj.Paracetamol)

-Intensive Glucose control with Insulin.

-Electrolyte correction(Potassium replacement Inj.KCl iv infusion).

-Antiemetics(Inj.Ondansetron)to control vomiting.

Nephrology,Diabetelogy & Cardiology consultations

On Retrograde Uretero-pyelogram, No filling defects or contrast extravasation seen.

Lt.DJ Stenting done to control symptoms(13-07-14)

-Symptoms(Fever,Pain,Vomiting) persist despite Lt.DJ stenting.

-Persistent hypokalemia & hypomagnesemia despite correction.

Repeat USG Abdomen(14-07-14)

-Lt.Kidney enlarged, hypoechoic & edematous. Fullness of pelvicalyceal system with thickening of renal pelvis.DJ Stent in-situ. No e/o abscess or collection.

On account of non-resolution of symptoms & USG report, it was decided to consider external urinary drainage through Lt.PCN.

USG Guided Lt.PerCutaneous Nephrostomy(PCN) done on 15-07-14.

Drastic improvement in pts'.symptoms & clinical condition.(Pain,Vomiting & fever subsided.)

Diuresis ensued(s/o relief of obstruction); managed appropriately using fluid & electrolytes.

PARAMETERS 11-07-14 12-07-14 13-07-14 14-07-14 15-07-14

1. Temperature Spikes 99º F 100.5 99.53 spikes (101, 100.5, 101

99.5

2. Symptoms(Vomiting,Pain) Present Persist PersistIncreased vomiting & Pain

Marked Impovement

3. Urine output 1000ml 1800ml 1450ml 2000ml 2200+ 1000ml

4. S.Potassium 2.3 2.1 2.1 2.6/3.3

5. S.Creatinine 1.3 1.3 0.8 0.8

Condition of the patient Post-PCN: No pain, fever or vomiting, tolerated well orally.

All laboratory parameters within normal range.

Lt.PCN drainage continued until complete clinical & radiological resolution; then Lt.PCN tube removed, followed by Lt.DJ Stent removal later.

Long term antibiotics as per sensitivity report.

DISCUSSION

URETERAL STENTS:Ureteral stents are a mainstay in the urological

armamentarium.utilized in treatment of urolithiasis including postureteroscopy, preshockwave lithotripsy, to relieve symptomatic renal colic, to provide urinary drainage in nongenitourinary

causes of ureteral obstruction, such as pregnancy and malignant ureteral obstruction

To serve as a surgical landmark for ureteral identification in order to avoid iatrogenic ureteral injury in abdominal or pelvic surgery.

Mechanism:

Ureteral stents decrease the frequency and amplitude of ureteral contractions.

The ureter and ureteral orifice are theorized to passively dilate from the stent, thus facilitating drainage.

Available in various sizes, designs & materials.

PERCUTANEOUS NEPHROSTOMY

Primary indication- to relieve an obstructed and infected renal collecting system.

MERITS:A wide variety of catheter sizes can be placed (8

French to 18 French) depending on the characteristics of the fluid being drained.

Can be irrigated when the drainage is purulent or bloody, to avoid clogging.

UoP of the kidney can be measured.

Excessive ureteral manipulation can be avoided, decreasing the risk for sepsis or rupture.

Can also be done under LA & under conscious sedation, which eliminates the need for an anesthesiologist and risks a/w GA.

DJ STENT Vs. PCN

Whether urinary drainage is best accomplished via a ureteral stent or a nephrostomy tube is a subject of debate.

Both PCN catheters and retrograde internal stents have been shown to be equally effective in relieving an obstructed renal collecting system, with similar complication rates.

Percutaneous nephrostomy tube easily placed in significant hydronephrosis may be even more successful than retrograde ureteral stenting when urinary drainage is required as a result of obstruction of the distal ureter.

One theory of why nephrostomy tubes are more efficient at relieving obstruction is that because urine drains around a stent rather than through the lumen, extraluminal compression from cancer prevents ureteral peristalsis and precludes peristent urinary drainage.

Percutaneous nephrostomy tubes are advantageous over ureteral stents in relieving malignant ureteral obstruction and lowering serum creatinine.

The percentage of successful retrograde stent placements is lower than nephrostomy tube insertion which is nearly always successful in a dilated system.

M/M OF ACUTE PYELONEPHRITIS:Vast majority of patients respond to

conservative treatment(broad coverage for both gram-negative and gram-positive organisms).

Few will require ureteral stenting or nephrostomy tube insertion.

Indications for stenting include:rising creatinine,HUN (obstruction with febrile infection),

and intractable pain

Even though retrograde stenting by cystoscopy is attempted initially, if this procedure fails to alleviate symptoms, PCN insertion is typically pursued.

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