OBJECTIVES: To compare percutaneous nephrostomy (PCN) versus double J ureteric stent (JJ) as an initial urinary drainage in children with obstructive calcular anuria (OCA) and post-renal acute renal failure (ARF) due to bilateral ureteric calculi to identify the selection criteria for the initial urinary drainage method that will improve the urinary drainage, decrease the complications and facilitate the subsequent definitive clearance of stones.
As this comparison is lacking in literature.
PATIENTS AND METHODS: A series of 90 children ≤ 12 years old presenting with OCA and ARF due to bilateral ureteric calculi were included from March 2011 to September 2013 at Cairo University Pediatric hospital in this randomized comparative study. Patients with grade 0-1 hydronephrosis, fever or pyonephrosis were excluded. No patient had any contraindication to both methods of drainage. Stable patients (or patients stabilized by dialysis) were randomized (non-blinded, block randomization, closed envelope method) into PCN or bilateral JJ (45 patients for each group). Initial urinary drainage was performed under general anesthesia and fluoroscopic guidance. We used 4.8-6Fr JJ or 6-8Fr PCN. Primary outcome was the safety and efficacy of both groups in the recovery of renal functions. Both groups were compared in the operative and imaging times, complications, and period for return to normal serum creatinine. Secondary outcome included the number of subsequent interventions needed for clearance of stones. Additional analysis was done for factors affecting outcome inside each group.
RESULTS: All presented patients completed the study with intention-to-treat analysis. There was no significant difference between PCN and JJ in the operative and imaging times, period to return to normal creatinine and failure of insertion. The complications were significantly more with PCN group. The stone size (> 2cm) was the only factor affecting the rates of mucosal complications, operative time and failure of insertion in JJ group. The degree of hydronephrosis affected significantly the operative time for PCN insertion. Grade two hydronephrosis was associated with all cases of insertion failure in PCN group. The total number of the needed subsequent interventions to clear stones was significantly higher with PCN group especially in patients with bilateral stones prepared for chemolytic dissolution (alkalinization) or shockwave lithotripsy (ESWL).
CONCLUSION: We recommend the use of JJ as an initial urinary drainage in stones prepared for chemolytic dissolution or ESWL as this will lower the total number of the needed subsequent interventions to clear stones. This is also true for stones prepared for ureteroscopy, as JJ insertion will facilitate subsequent ureteroscopy due to previous ureteric stenting. Mild hydronephrosis will prolong the operative time for PCN insertion and may increase the incidence of insertion failure. We recommend the use of PCN if the stone size is > 2 cm as there was a more risk of possible iatrogenic ureteric injury during stenting alongside these large ureteric stones in addition to prolongation of operative time with increased incidence of failure.
Written by:
Elsheemy MS, Shouman AM, Shoukry AI, Elshenoufy A, Aboulel W, Daw K, Hussein AA, Morsi HA, Badawy H. Are you the author?
Division of Pediatric Urology, Aboul-Riche Children's Hospital, Cairo University, Cairo, Egypt.
Reference: BJU Int. 2014 Apr 4. Epub ahead of print.
doi: 10.1111/bju.12768
PubMed Abstract
PMID: 24698195
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