1. A 35-year-old female presented with left loin pain, fever, vomiting, and dysuria for 7 days and was diagnosed with acute pyelonephritis of the left kidney based on investigations. 2. Initially, a left double J stent was placed but her symptoms persisted, so a left percutaneous nephrostomy was performed which led to significant improvement. 3. For acute pyelonephritis, a double J stent or percutaneous nephrostomy may be used for drainage but percutaneous nephrostomy is preferred if symptoms do not resolve with stenting due to more effective drainage of an obstructed system.

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