DJS or PCN in acute pyelonephritis..which is better?

1. Dr.Gaurav Nahar
DNB Urology(Std),
M.M.H.R.C.,Madurai
Double J-Stent Vs.
Percutaneous
Nephrostomy in the m/m
of Acute Pyelonephritis

2. 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.

3. 2.c/o Fever.......since 7 days
-Moderate grade.
-a/w chills & rigors.
3.c/o Vomiting......since 7days
-Non-projectile;contains ingested food material
4.c/o Dysuria......since 7 days
5.c/o Increased frequency of urination....7days
6.c/o Chest pain.....since 2days
-Non-exertional; mild to moderate intensity.
No Hematuria,Nausea

4. 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.

5. 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- NAD
CNS- Conscious & Well-oriented.
CVS- NAD

6. INVESTIGATIONS:
Hb/PCV- 9.9gm%/30
TLC/DLC-8000/cu.mm(P-46,L-41,M-11,E-2,B-0)
Platelet count-3,29,000/cu.mm
BT-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

7. 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-nil
Urine Culture: E.coli(>1,00,000cfu/ml)

8. 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.

9. CT Urogram(12/07/14):
-
Lt.Kidney enlarged with Patchy nephrogram. Mild
perinephric fat stranding(Acute pyelonephritis);
Normal excretion, No PCS dilatation.
-Rt.Kidney LC-2mm calculus, Simple cortical cyst 1x1
cm.

11. MANAGEMENT
Pt.admitted and immediately started on
-Empirical antibiotic therapy for broad
spectrum 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.

12. 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)

13. -Symptoms(Fever,Pain,Vomiting) persist
despite Lt.DJ stenting.
-Persistent hypokalemia &
hypomagnesemia despite correction.

14. 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.

15. 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.

16. PARAMETERS 11-07-14 12-07-14 13-07-14 14-07-14 15-07-14
1. Temperature Spikes 99º F 100.5 99.5
3 spikes
(101, 100.5,
101
99.5
2. Symptoms(Vomiting,Pain) Present Persist Persist
Increased
vomiting &
Pain
Marked
Impovem
ent
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

17. 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.

18. 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.

19. 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.

22. 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.

23. 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.

25. 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.

26. 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.

27. 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.

28. 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

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

30. THANK YOU