Tubeless Percutaneous Renal Surgery

0022-5347/97/1575-1578$03.ooM)

v01.157,1578-1582,May 1997

THEJOLXNAL OF UROLIJGV Copyright 0 1997 by AMERICAN UROUMXAL Assocmnox, I w

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TUBELESS PERCUTANEOUS RENAL SURGERY GARY C. BELLMAN, RAMIN DAVIDOFF, JOSEPH CANDELA, JILL GERSPACH, STEVEN KURTZ AND LISA STOUT From the Department of Urology, Kaiser Permanente, Los Angeles, California

ABSTRACT

Purpose: W e challenge the requirement for routine placement of a nephrostomy tube following percutaneous renal surgery. Materials and Methods: A total of 50 patients underwent tubeless percutaneous renal proced u r e s consisting of nephrolithotripsy, endopyelotomy, and stone extraction plus endopyelotomy performed d u r i n g the same setting. In the initial 30 patients a Double-J* stent and a Councill nephrostomy tube were placed at the end of the procedure. The Councill catheter w a s removed 2 t o 3 h o u r s postoperatively. The subsequent 20 patients received only a Double-J stent with n o Councill catheter. This s t u d y group w a s compared t o a control group of 50 age, sex and procedure matched p a t i e n t s who had previously undergone s t a n d a r d percutaneous renal procedures w i t h routine placement of postoperative nephrostomy tubes. The incidence of complications, analgesia requirements, length of hospitalization, interval to return t o normal activities a n d cost of t r e a t m e n t were compared between the 2 groups. Results: All 50 tubeless percutaneous procedures were performed successfully without signifi c a n t complications. In the initial 15 patients postoperative renal ultrasound demonstrated n o urinoma. Hospitalization w a s 0.6 d a y s for the s t u d y group and 4.6 days for the controls ( p = 0.0001). Average parenteral o r intramuscular analgesia requirements were 11.58 and 36.06 mg. morphine sulfate, respectively ( p = 0.0001), w i t h patients requiring oral analgesia for 5.9 and 11.7 days, respectively (p = 0.0001). Patients in the s t u d y group returned t o normal activities within 17.85 d a y s versus 26.6 d a y s for the controls (p = 0.0004). The costs of the procedures w e r e $1,638 and $3,750 (129%greater), respectively, for a cost saving of $2,112 per case. Conclusions: Tubeless percutaneous renal surgery is a safe procedure a n d offers n u m e r o u s advantages over routine placement of a nephrostomy tube. The hospitalization, analgesia requirements, r e t u r n to normal activities as well as cost are significantly less w i t h this new technique. KEY WORDS:kidney; urinary catheterization; nephrostomy, percutaneous

Placement of a nephrostomy tube after completing a per- the study was to learn whether not leaving a nephrostomy cutaneous renal procedure is considered standard practice. tube would hasten recovery and decrease postoperative pain. The purpose of the tube is to allow for renal healing, avoid All patients referred to our tertiary kidney stone center were urinary extravasation, aid in hemostasis, provide for access considered candidates for this study. Indications for a percuwhen future endoscopic procedures are anticipated and pro- taneous renal procedure at our medical center included a vide a means of instilling intracavitary chemotherapy or large stone burden (complete or partial staghorn calculi), agents for chemolysis. Oflen bleeding is minimal and no stones in the presence of obstruction (ureteropelvic junction further antegrade procedures are planned. In such cases obstruction, caliceal diverticula with narrowed infundibuplacement of a Double4 stent alone may suffice, which would lum), extracorporeal shock wave lithotripsy (ESWLI) failures potentially lead to less postoperative pain and a more rapid (lower pole or cystine stones), ureteropelvic junction obstrucrecovery. To our knowledge this question has not been stud- tion and transitional cell carcinoma in solitary kidneys or in ied previously. Our objective is to challenge the requirement patients with renal insufficiency. Our referral center serves a for routine placement of nephrostomy tubes following percu- large population of 2.2 million members, which is reflected in taneous renal surgery. We present our experience with tube- the wide variety of complex cases referred for management. less percutaneous renal surgery. The patients in the control and study groups were typical of those undergoing percutaneous treatment referred to a large tertiary medical center. MATERIALS A N D METHODS Exclusion criteria for this study were a case lasting longer Between December 1,1995 and March 1,1996,35 patients than 2 hours, more than 2 percutaneous accesses necessary were referred to our regional kidney stone center for a per- (the main exclusion criterion), significant perforation of the cutaneous renal procedure, including stone extraction or an- collecting system, significant residual stone burden, signifitegrade endopyelotomy performed alone or during the same cant postoperative bleeding and resection of transitional cell setting. Informed consent was obtained from all patients carcinoma when instillation of chemotherapy may be indibefore considering them for this study. Patients were told cated. Of 60 patients initially considered for the study only 50 that nephrostomy tubes are generally left in place for 1 to 3 qualified. Therefore 10 of 60 patients fulfilled a t least 1 of the days after a percutaneous renal procedure. The purpose of exclusion criteria. Surgical technique. A 6 cm. x 24F Double-J stent and a Accepted for publication October 25, 1996. * Medical Engineering Corp., New York, New York.

+ Dornier Medical Systems, Inc., Marietta, Georgia. 1578

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20F Councill catheter nephrostomy tube were placed at the conclusion of the operation. When endopyelotomy was performed an internal 147F endopyelotomy stent was placed. A Double-J stent was passed over a safety guide wire under direct vision (fig. 1,A) and its position was adjusted with the grasping forceps (fig. 1, B). An adequate proximal coil was confirmed endoscopically (fig. 1 C). The working sheath was removed and an avascular nephrostomy tract was noted (fig. 1, D).A 20F Councill catheter was then passed over the second guide wire into the renal pelvis. The nephrostomy site was closed with a No. 1 silk suture, which was also used to secure the Councill catheter. At approximately 3 hours postoperatively the patient was evaluated in the recovery room or outpatient area. The Councill catheter was removed and a pressure dressing was applied. The tube was removed leaving the hemostatic sutures in place by simply cutting the portion that secured the tube. This technique was used for the initial 30 patients in the study group. The subsequent 20 patients received no Councill catheter. The nephrostomy site was inspected after the working sheath was removed with the guide wire still in place (fig. 2, A). The guide wire was left in place until there was no evidence of active bleeding. Superficial vessels seen at the nephrostomy site were suture ligated with No. 1 silk (fig. 2, B). The nephrostomy site was closed with an additional suture and the guide wire was removed. The nephrostomy site was visualized at the end of the procedure (fig. 2, C and D). The patients were considered suitable for hospital discharge 2 to 3 hours thereafter and they were given the option of same day discharge. Hematocrit was verified before hospital discharge and a Foley catheter was leR in place for 24 hours. Patients who were discharged home the same day were instructed to present to a local clinic or our institution the next day for removal of the Foley catheter and verification of the hematocrit. They were also instructed to return

FIG. 1. A,

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immediately to our emergency room if they experienced any difficulties. Patients returned to the clinic after 1 week for renal ultrasound to rule out a urinoma, stent removal and removal of flank sutures. The study group of 50 patients was compared to a control group of 50 age, sex and procedure matched patients who had undergone standard percutaneous renal surgery at our institution before this new technique. All procedures in both groups were performed by the same surgeon (G. C. B.) in conjunction with a resident in a 1-stage fashion with the urologist performing the percutaneous access. All tracts were dilated to 30F to allow for passage of the 34F working sheath. The standard technique used in the control group involved 2 to 3 days of postoperative nephrostomy drainage. Both groups were compared with regard to length of hospitalization, operative time, cost of treatment, postoperative analgesia requirements (defined as milligrams of morphine or morphine equivalent plus the number of days oral analgesia was necessary), return to normal activities and complications. All p values were obtained from the log-rank test. Calculation ofcosts. The cost of the procedure was calculated as the cost of hospitalization, as well as operating and recovery room costs. At our institution the per night cost of hospitalization is $500 plus $90 for an outpatient procedure. The operating room costs are an all-inclusive (including all instruments and equipment) $490 per hour with a standard $152 for recovery room costs. We did not include the cost of the Double-J catheter, since it was placed instead of the nephrostomy tube, which is of similar cost. The cost of postoperative renal ultrasound was not included because it was deemed unnecessary, since all of the initial studies were negative. These calculations were based on marginal costs and fixed overhead costs were not considered, which may vary greatly depending on the age of the medical center. Professional costs were likewise not considered in this study.

endoscopic view of Double4 stent passed in antegrade fashion. B , position of proximal coil of Double-J stent is adjusted. C, position of Doub1e-J stent is confirmed. D,avascular appearance of nephrostomy tract at removal of working sheath.

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FIG. 2. A and B , nephrostomy site with safety wire in place after placement of suture. C and D,nephrostomy site at end of procedure

While professional costs are generally greater for a percutaneous procedure compared to ESWL an increasing number of physicians today are salaried, making the issue of professional costs less significant. The cost of the procedure was calculated as the sum of the costs of hospitalization, recovery room and operating room. Analgesia requirements. The analgesia requirements were tabulated initially by a chart review of all oral and parenteral or intramuscular medication given while in the hospital. Patients were contacted by telephone to tabulate the remaining amount of oral analgesia taken while a t home. The parenteral or intramuscular medication was converted to morphine equivalent and presented as milligrams of morphine per patient, and the oral analgesia was presented as number of days of oral analgesia required. With the use of a telephone questionnaire patients were asked the interval from surgery to the time they were able to return to work if employed or to normal activities if not working.

groups. Study patients required a n average of 11.5 mg. morphine compared to 35.9 mg. for the controls (p = 0.0001, fig. 3, A), stayed in the hospital for a n average of 0.6 compared to 4.6 days, respectively (p = 0.0001, fig. 3, B) and returned to normal activities after an average of 18.3 compared to 31.4 days, respectively (p = 0.0004, fig. 3, C ) .The average cost of the procedure in the study group was $1,638 compared to $3,750 for the control group (fig. 3, D).The cost of the standard procedure was 129%or $2,112 greater than that of the tubeless procedure. DISCUSSION

The technique of percutaneous renal surgery has revolutionized the way renal stones are treated, as well as other renal pathological conditions, such as ureteropelvic junction obstruction, caliceal diverticula and select patients with transitional cell carcinoma in a solitary functioning kidney. With the advent of ESWL the interest in percutaneous renal surgery diminished with the hope that the lithotriptor would be RESULTS the panacea for all stones. It has become increasingly clear The 2 groups were similar with regard to age, sex, height, during the last several years that the pendulum has swung weight and type of percutaneous procedure. Average age, back with the realization that a percutaneous approach is height and weight were 48.69 years, 194.37 pounds and 5.61 optimal for many patients. Lingeman et a1 examined lower feet, respectively, for the controls and 51.50 years, 186.31 pole stones in a randomized prospective fashion.' A low pounds and 5.66 feet, respectively, for the patients. Opera- stone-free rate has been found with many lower pole calculi tive time did not differ significantly between the groups treated with ESWL. The optimal choice for lower pole stones (average 158 compared to 142 minutes, respectively). There is often a percutaneous approach. Residual stones initially were no significant complications in either group and, there- believed to be insignificant have currently been shown t o be fore, no difference in incidence of complications. Because important and impact directly on the incidence of stone repostoperative abdominal ultrasound, performed to rule out a currence.2 The American Urological Association guidelines perirenal urinoma, was negative in the initial 15 patients in demonstrated the important role of percutaneous treatment the study group no further scans were performed. There was for staghorn stones.3 The reality of economics has impacted no significant difference in transfusions rates between the 2 the way we treat stone patients as well. Some insurance

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FIG.3. A, analgesia requirements for study and control groups. B , hospitalization. C , time to return to normal activities. D,cost of

procedure.

carriers will not reimburse physicians for repeat ESWL procedures, making a percutaneous approach to many stones the most direct cost-effective choice. Thus, multiple important indications remain for percutaneous renal surgery. The morbidity of a percutaneous procedure has decreased dramatically with improvements in technique. The use of the balloon dilator compared to the sequential Amplatz dilators has been associated with significantly less postoperative hemorrhage and a lower rate of transfusion.4 Limiting the length of the procedure to no more than 2 to 3 hours has significantly decreased the incidence of postoperative sepsis, hypothermia and hyponatremia. Nonetheless, there exists room to decrease the morbidity of a percutaneous renal procedure further. The challenge is to make a percutaneous renal operation a truly outpatient procedure, which would make it more palatable to patients as well as more costeffective. h m i n g e r et a1 reported on 5 patients who underwent outpatient percutaneous surgery for stones smaller than 1 Fm. and all were discharged home with the nephrostomy tube 1n place." A significant cost advantage was demonstrated. However, patients are often reluctant to be discharged home with a nephrostomy tube, since it pulls at the flank and ofken contributes significantly to pain. The question is whether

a postoperative nephrostomy tube is necessary. In 1984 Wickham et a1 reported on their experience with percutaneous stone extraction and stated that in select cases it is not unreasonable to avoid leaving a nephrostomy tube.6 Winfield et a1 then reported on 2 cases of percutaneous stone removal when nephrostomy tubes were not left in place, and significant morbidity occurred resulting in prolonged hospitalization and pain.7 In these patients the nephrostomy tubes were removed and no drainage was provided. A nephrostomy tube following a percutaneous renal procedure is believed to serve several purposes, including allowing the renal puncture t o heal, providing for proper hemostasis and allowing for access for future procedures or the delivery of desired agents into the collecting system. It is known that controlled trauma to the urinary tract will heal spontaneously when proper drainage is provided. Major ureteral perforations are often invisible after several days of stenting. Extraperitoneal bladder injuries heal rapidly with catheter drainage and renal trauma rarely requires intervention. Creation of a nephrostomy tract is a n example of controlled renal trauma. A nephrostomy tube provides adequate drainage for urine and blood clots. A Double-J stent alone should provide similar internal drainage and any blood clots should lyse

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spontaneously in t h e urinary tract. A Foley catheter is left for 24 hours to prevent or minimize reflux. Bleeding following percutaneous renal surgery can arise from a variety of sources a n d may occur from the mucosa of the collecting system, renal parenchyma, a n arteriovenous fistula or pseudoaneurysm, or t h e intercostal or subcutaneous vessels. When tract hemorrhage occurs a Kay tamponade balloon is believed to provide direct pressure limiting bleeding. When venous bleeding occurs and the nephrostomy tube is clamped i t is believed that the collecting system fills with clots, which in t u r n occludes the venous channels and limits further bleeding. Our experience with the balloon nephrostomy dilators is that there is little tract bleeding. Bleeding often occurs from superficial vessels that can be seen at the skin puncture site and easily controlled with suture ligation. Often a second procedure is scheduled, particularly when treating patients with a large stone burden such as staghorn calculi. Some surgeons routinely perform second look procedures after every percutaneous operation or at nephrostomy tube removal. More often, however, no further antegrade procedure is planned and leaving a nephrostomy tube is not necessary. When transitional cell carcinoma is resected percutaneously in a solitary kidney a chemotherapeutic agent is often instilled and, thus, i t is important to leave a nephrostomy tube in this case a n d in t h e rare instance when instillation of an agent for chemolysis of residual stones is necessary. When a tubeless percutaneous renal procedure is performed patients experience minimal flank pain. The nephrostomy site heals rapidly and t h e main complaint relates to the presence of t h e Double-J stent. Consequently, analgesia requirements are dramatically less t h a n with the standard percutaneous technique. This difference is apparent immediately postoperatively as well as during convalescence. Following a standard percutaneous procedure the patients often complain of soreness or a sensation of pulling in t h e side, which may persist for weeks to months. These complaints are not observed with the tubeless technique. When a nephrostomy tube is left in place t h e nephrostomy tract will mature, which presumably creates a local inflammatory response that may explain these symptoms not seen with the tubeless technique. Not only was there a significant decrease in the analgesia requirements but patients experienced a more rapid return to normal activities. Cost is a n important issue when comparing different treatment modalities. Tubeless percutaneous renal surgery at our institution costs $1,638 compared to $3,750 for t h e standard technique, which translates into a savings of $2,112 per case and makes t h e cost of a percutaneous stone extraction comparable with t h a t of a single ESWL. Jewett et a1 compared the cost of a percutaneous stone extraction with ESWL and found the percutaneous procedure to be considerably more expensive.HThe cost in Canadian dollars was $4,087 for the percutaneous approach versus $2,226 for ESWL. When retreatments were considered the cost of ESWL increased to $2,746. However, other studies have shown similar costs for a percutancous procedure and ESWL." Our modifications to the technique of a percutaneous procedure makes it considerably less expensive and less morbid. With the cost of a percutaneous procedure virtually the same as that of ESWL, the treatment of patients with stones may change significantly. The high success and low morbidity rates with a percutaneous procedure make treating a patient with 2 or 3 ESWL sessions unacceptable from a cost viewpoint. Additionally one must consider the extended period off work when several ESWL procedures are performed consecutively, since the patients often have a stent throughout this period and cannot return to normal activities. Our study adds another

argument for making a percutaneous approach t h e optimal choice in an increasing number of stone cases. CONCLUSIONS

I n t h e majority of our patients we believed t h a t a nephrostomy tube was not necessary and a Double-J stent would provide adequate drainage. Additionally t h e Double-J stent passively dilates the ureter allowing for passage of a n y small unnoticed fragments. No patient who underwent renal sonography had a urinary collection. There w a s high patient satisfaction, with a significant decrease in postoperative analgesia requirement a s well as a more rapid return to work or normal activities compared to the control group. Additionally hospitalization decreased dramatically leading to savings of greater than $2,000 per case. At our tertiary referral center we perform approximately 100 percutaneous renal procedures a year. Institution of this technique translates into an annual dollar savings of $200,000. The cost benefit of decreased analgesia requirements, and earlier return to work and normal activities may be equally significant but more difficult to quantify. Additionally many patients who initially refused a percutaneous procedure because of the need for a nephrostomy tube and hospitalization have since reconsidered surgery due to our modifications in technique. While this is a preliminary study, we a r e encouraged by the results and a r e using this technique for t h e majority of our cases. REFERENCES

1. Lingeman, J. E.and Lower Pole Study Group: Prospective randomized trial of extracorporeal shock wave lithotripsy and

percutaneous nephrostolithotomy for lower pole nephrolithiasis. J. Urol., part 2,155 330A,abstract 79,1996. 2. Streem, S.B., Yost, A. and Mascha, E.: Clinical implications of clinically insignificant stone fragments after extracorporeal shock wave lithotripsy. J. Urol., 155 1186,1996. 3. Segura, J. W., Preminger, G . M., Assimos, D. G., Dretler, S. P., Kahn, R. I., Lingeman, J. E., Macaluso, J. N.. Jr. and McCullough, D. L.: Nephrolithiasis clinical guidelines panel summary report on management of staghorn calculi. J. Urol., 151: 1648,1994. 4. Davidoff, R. and Bellman, G. C.: Influence of technique of percutaneous tract creation on incidence of renal hemorrhage. J. Urol., 157: 1229,1997. 5. Preminger, G.M., Clayman, R. V., Curry, T., Redman, H. C. and Peters, P. C.: Outpatient percutaneous nephrostolithotomy. J. Urol., 136 355, 1986. 6. Wickham, J.E. A., Miller, R. A,, Kellett, M. J. and Payne, S. R.:

Percutaneous nephrolithotomy: one stage or two? Brit. J. Urol., 56: 582,1984. 7. Winfield, H.N., Weyman, P. and Clayman, R. V.: Percutaneous nephrostolithotomy: complications of premature nephrostomy tube removal. J. Urol., 136: 77, 1986. 8. Jewett, M. A. S., Bombardier, C. and Menchions, C. W. B.: Comparative costs of the various strategies of urinary stone disease management. Urology, 46: 15, 1995. 9. Mays, N., Challah, S., Patel, S., Palfrey, E., Creeser, R., Vadera, P. and Burney, P.: Clinical comparison of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy in treating renal calculi. Brit. Med. J., 297: 253. 1988. 10. Carlsson, P., Naucler, J., Petterson, S. and Tiselius. H. G.: A cost-effective analysis of extracorporc~:11shuck wave lithotripsy and percutaneous nephrolithotoniv. Scand. J. Urol. Nrphrol., suppl., 122: 44. 1989. 1 1 . Charig, C. R., Webb, I). It., Pziyne, S. R . a n d Wickham. .I. E. A.: Comparison of treatment of renal c:ilculi hy open surgery, percutantwus nephr(,lithotr,m?.. : i n d <%tI'nCtJrp(Jl-c';il shock wave lithotripsy. Brit. h l r d . .I.. 292: ST!), l%%. 12. IJinjicman, .J. E., S:iy\rell. I< 51.. .Ir , \ V ( J I ) ~ S .I, K ;inti N w m a n . D. M.: Cost. analysis I J ~ 'i,ut1.;1c.r,l.l),,r.c.;11s h o c k \v:i\-c I~thotripsy relativc to otI1t.r S U I . ~ I ~ , I I : i n d n ~ ~ i > . ~ l i I ~ g ] ttr(.;itrnc,nt .,11 ;IltcrnaLives for u r ~ ~ l ~ t h i ~\ ~l ,sdi . -( .' , ~ I . , K 24: I

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