Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction

Table 1 Percutaneous nephrostomy vs retrograde stent in malignant ureteral obstruction

Ref.	Study design	Cohort	Diagnosis	Stent	Complications	Nephrostomy	Complications	Mortality	Conclusions
Feng et al[1], 1999	Retrospective, 1984-1996	n = 37 (20 female) patients with ureteral obstruction due to pelvic malignancy	Diuretic renogram or abdominal CT scan	22/31 underwent successful stent placement, 13/31 (42%) remained successfully diverted with stents	Migration (1), encrustation requiring cystolitholapaxy (1), intractable pain requiring repositioning (2)	6 had primary PCN placement, 9/31 had PCN placed due to unsuccessful placement of stent, 6/22 had PCN placed due to failed internal stent, 3 failed stent but did not have PCN placement	Dislodgement requiring reinsertion (3)	NR	33% of patients with disease confined to primary organ or locally advanced disease were managed successfully by stents vs 36% of patients with distant metastases, 92% of cervical cancer patients required PCN (89% failed initial internal stents), 50% of prostate cancer patients required PCN but 100% of patients who initially had successful stent placement did not require PCN at average follow-up of 15 mo, 100% colon cancer patients required PCN due to failure of internal stents
Hyppolite et al[32], 1995	Retrospective, 1989-1994	n = 34 females with gynecologic malignancy	US and serum cr > 1.5 mg/dL	8 (3 had PCN as well)	6/7 (86%) developed urosepsis	17 (unilateral/bilateral)	7/17 (41%) (1 urosepsis, 3 bleeding, 3 urine leak)	2/34 died within 2 wk and declined intervention, 3/7 who underwent stent placement died from urosepsis from procedure	Stenting predisposes to urosepsis and should be avoided. Bilateral nephrostomy allows significant improvement of renal function
Kanou et al[48], 2007	Retrospective, 1990-2003	n = 75 (45 female) patients with pelvic malignancy, patients with normal excretion from 1 kidney excluded	NR, need for primary PCN reported to be based on CT, MRI, or cystoscopic evaluation	37/51 underwent successful stent placement, 29/37 (78%) remained successful	Earlier replacement (5), discomfort requiring no intervention (2)	24 had primary PCN placement, 14/51 had PCN due to inability to place stent, 8/37 had PCN placed after failed stent	Dislodgement (9), obstruction requiring exchange (4), difficulty in exchange (2), pain/dermatitis (3), minor hemorrhage (2)	66/75 with mean survival of 5.9 (PCN) and 5.6 mo (stent)	Higher percentage (78%) of success may be related to utilizing stents without shaft side holes
Ku et al[27], 2004	Retrospective, 2000-2002	n = 148 (80 female) patients with advanced malignancy causing ureteral obstruction	US, CT, or MRI with high grade obstruction, impaired renal function, clinical symptoms, or febrile UTI	68 (5 had antegrade stent placement), 60/68 (89%) remained successful	8 (11.8%)	80 (5 secondary PCN after failed stent placement), 1/80 failed PCN	7 (8.8%)	NR	Stenting and PCN placement have similar outcomes in terms of decreases in serum creatinine, complications, and incidence of pyelonephritis but significant differences in failure (11% stent vs 1.3% PCN) suggesting that patients with retrograde stenting may have ongoing obstruction requiring eventual PCN placement
Monsky et al[19], 2013	Prospective survey	n = 30 (16 female) patients with malignancy-related ureteral obstruction	Initially evaluated by symptoms of urinary obstruction such as pain, deterioration of renal function, or infection and confirmed by CT	15 patients (22 stents)	Dislodgement (1), Pain (1), Infection (1), Fistula (1)	15 patients (24 PCN)	Dislodgement (7), Pain (4), Infection (3) Obstruction (4), Leak (1)	2/30	Patients with PCN or stents have similar QOL. Patient with stents have more irritative symptoms while PCN may experience more minor complications requiring more frequent changes
Song et al[26], 2012	Retrospective, 2006-2010	n = 75 females with gynecologic malignancy	US, CT, or MRI with hydronephrosis, elevated cystanin(sic) c, or clinical symptoms	61/75 underwent stent placement, 50/61 (82%) were managed with stents successfully	16/25	14/75 underwent PCN after unsuccessful stenting, 11/61 required PCN after failure with stent management	24/50	61/75 with mean survival of 9 mo for stent and PCN cohort	Progression to PCN was noted in patients with bladder invasion and severe hydronephrosis. Multivariate analysis revealed that obstruction > 3 cm and elevated cystatin(sic) > 2.5 mg/L predicted stent failure. Stenting was less expensive and required less procedural time as compared to PCN

CT: Computed tomography; PCN: Percutaneous nephrostomy; MRI: Magnetic resonance imaging; NR: Not reported/studied; US: Ultrasonography.

Table 2 Percutaneous nephrostomy vs retrograde stent utilization in ureteral stone disease obstruction

Ref.	Study design	Cohort	Diagnosis	Stent	Complication	Nephrostomy	Complications	Conclusions
Ahmad et al[23], 2013	Retrospective, 2010-2011	n = 300 (20/100 (stent) and 36/200 (PCN) had malignant obstruction)	NR	97/100 had successful placement, 3 proceeded to have PCN	37/97 (38%) complication rate (7 fever/sepsis, 10 bleeding/hematuria, 12 pain/irritation, 1 ureteral perforation, 2 stent migration, 5 stone encrustation	195/200 had successful PCN placement	25/195 (12.8%) complication rate (7 fever/sepsis, 9 bleeding/hematuria, 9 dislodgement)	PCN had lower incidence of complications as compared to stenting
Goldsmith et al[36], 2013	Retrospective, 1995-2011	n = 130 patients with infected urolithiasis who underwent procedural decompression	CT and 2/4 SIRS criteria	69/71 successful stent placement, 2 proceeded to PCN	NR	58/59 successful PCN placement, 1 proceeded to retrograde stent	NR	Patients selected for PCN had larger stones and were more severely ill. Patients who underwent PCN had longer hospital stay on multivariable analysis. Time from septic event to definitive treatment, rates of spontaneous stone passage, and initiation of metabolic stone workup were the same between the two groups
Joshi et al[41], 2001	Prospective, non-randomized	n = 34 patients (22 male) with obstructing ureteral stones	X-ray, US, IV urography	21	NR	13	NR	Stent patients were more likely to report hematuria, dysuria, urgency as compared to PCN patients. Stent patients required analgesics more frequently than the PCN group. Patients in the PCN required more daily care as compared to stent patients. EuroQOL questionnaire revealed differences in mobility, self care, and problems with usual activity and pain between the two cohorts but no significant differences in overall QOL
Mokhmalji et al[38], 2001	Prospective randomized, 1996-1998	n = 40 patients with ureteral stone and evidence of infection	Imaging modality NR and 1 major (renal colic, fever, ston e > 15 mm, sepsis and elevated Cr > 1.7 mg/dL) or 2 minor criteria (lower UTI, wbc change, diminished patient compliance)	16/20 successfully underwent stent placement	Fluoroscopy exposure > 2 min (40%), IV analgesics (35%)	20/20 underwent initial PCN, 4/20 underwent subsequent PCN due to failed attempted stent	Fluoroscopy > 2 min (10%), IV analgesics (10%)	Time to definitive therapy was longer in stent group as compared to PCN group due to persistent signs of urinary tract infection. Unsuccessful stent placement occurred in older patients and with stones located in proximal ureter. No statistical differences in QOL but a trend to lower QOL was seen in stent patients who were male or < 40 yr
Pearle et al[40], 1998	Prospective randomized, 1995-1997	n = 42 patients with ureteral stone and evidence of infection	IV pyelography, US, X-ray, CT, or retrograde pyelography with WBC > 17000 mm or temperature > 38 °C	21 underwent successful stent placement		20/21 underwent successful PCN, 1 proceeded to undergo retrograde stent placement		Fluoroscopy and procedural times shorter in stent vs PCN cohort. Higher number of positive urine cultures post-PCN was noted as compared to post-stent placement. Length of stay, blood culture positivity, and time to WBC and temperature normalization were not statistically different. Costs associated with stent placement more than twice of that of PCN. Increased back pain noted in PCN group
Yoshimura et al[37], 2004	Retrospective, 1994-2003	n = 53 (59 events) patients underwent emergency drainage with ureteral stones and SIRS criteria	NR	35 stent events	NR	24 PCN events	NR	Patients who underwent stent had smaller stones but similar rates of ICU management as compared to PCN

SIRS: Systemic inflammatory response syndrome; QOL: Quality of life; US: Ultrasound; IV: Intravenous; WBC: White blood cell count; NR: Not reported/studied; ESWL: Extracorporeal shock-wave lithotripsy.