title: Using and choosing a nephrostomy tube after percutaneous nephrolithotomy for large or complex stone disease: a treatment strategy.
abstract: OBJECTIVE
  Percutaneous nephrolithotomy (PCNL) is a well-accepted technique for removal of large or complex renal calculi. However, little attention has been paid to strategies for nephrostomy tube (NT) selection. We reviewed the reasons for selecting three types of NT after PCNL for large or complex stone disease.
  
  
  METHODS
  A series of 106 consecutive renal units undergoing PCNL for stone burdens >2 cm by a single surgeon (JEL) were reviewed. Noncontrast CT (NCCT) was carried out on postoperative day 1, and secondary procedures were performed if fragments remained. The NTs studied were 8.5F and 10F Cope loops (CP), 20F reentry Malecot catheters (REM), and 20F circle loops (CL). Patient demographics, access site and number, complications, and stone type were examined. "Stone free" was defined as a negative NCCT or negative second-look PCNL.
  
  
  RESULTS
  A total of 134 accesses were created in 106 renal units: 35 upper, 7 mid, and 92 lower; however, only 111 NTs were placed: 85 CP (76.6%), 19 REM (17.1%), and 7 CL (6.3%). Sixteen accesses were performed tubeless; all but two were in the upper pole. All 16 of these renal units had a concomitant NT placed in the lower pole. Multiple sites were accessed in 21 patients; 7 of these patients had CL placed. Five of ten patients with spinal-cord injury had REM/CL placed. Nineteen REM were placed: 10 for drainage of infection, and 9 for difficult anatomy. All renal units were rendered stone free: 31.1% with a single procedure and 95.6% with one or two procedures. There were no difficulties with drainage or access for secondary PCNL regardless of the NT employed. Complications included two hydrothoraces, one arteriovenous fistula, and one ureteral perforation. Three of four renal units in patients requiring transfusions underwent bilateral PCNL, and at least one renal unit required multiple accesses. Of kidneys with infection stones, 57.1% required REM or CL; only 12.0% of nonstruvite stones necessitated REM or CL.
  
  
  CONCLUSIONS
  All patients having PCNL done for complex stone disease should have an NT placed; however, small (8.5F-10F) CP suffice in most cases and can provide greater patient comfort. To minimize pleural morbidity, tubeless upper-pole access should be considered if the kidney is judged to be stone free at the conclusion of PCNL. Circle loops are useful when multiple accesses are necessary, whereas REM are appropriate if access is difficult, gross residual stone remains, or pain is not an issue (i.e., spinal-cord injury).
authors.affiliation: Methodist Hospital Institute for Kidney Stone Disease, Indiana University School of Medicine, 1801 N. Senate Boulevard #220, Indianapolis, IN 46202, USA. samckim@iupui.edu
authors.forename: Samuel C
authors.initials: SC
authors.lastname: Kim
authors.forename: William W
authors.initials: WW
authors.lastname: Tinmouth
authors.forename: Ramsay L
authors.initials: RL
authors.lastname: Kuo
authors.forename: Ryan F
authors.initials: RF
authors.lastname: Paterson
authors.forename: James E
authors.initials: JE
authors.lastname: Lingeman
mesh_terms: D000328:Adult; D000368:Aged; D004867:Equipment Design; D004869:Equipment Safety; D005260:Female; D006801:Humans; D007669:Kidney Calculi / Q000175:diagnosis* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation / Q000379:methods; D009403:Nephrostomy, Percutaneous / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D018579:Patient Selection; D011183:Postoperative Complications; D011336:Probability; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013523:Surgical Equipment