BERKELEY, CA (UroToday Inc.) - Percutaneous nephrostomy (PCN) is one of the most commonly performed interventional procedures. It is performed by many general and almost all interventional radiologists. The improvement of patients' overall medical condition is often significant after use of this method of relief of renal obstruction. Performance statistics for this common procedure can be used as a surrogate to assess interventional proficiency of a department. A recent standard of practice document by the American College of Radiologists recommended a department threshold level of morbidity at 4% for septic shock and 4% for major hemorrhage.

A retrospective review was performed of all PCN's placed over a five-year period at St. George's Hospital in London to audit the performance of their percutaneous nephrostomy service. The purpose of the audit was to attempt to identify areas for quality improvement, and to compare the major complication rate with the recent standards recommended by the American College of Radiology. The review was published in the February, 2004 issue of Clinical Radiology.

Over the study period, 318 PCN's were performed and 10 (3.1%) cases sustained a major complication: five had sepsis alone, two had hemorrhage (one with concurrent sepsis) and three patients had major renal pelvic injury. The major sepsis and hemorrhage rates were 2.2 and 0.6% respectively and were within the recommended threshold limits.

Further analysis showed that proportionately more complications occurred when the procedure was performed outside of normal working hours. Thirty-three percent, or 105 cases, were performed after hours, and the major complication rate rose from the 1.8% seen during regular business hours to 5.7%. A contributing factor to this finding may have been the higher proportion of procedures being performed during these hours by general radiologists and fellows rather than staff interventionalists.

As sepsis was the most common and serious major complication noted, departmental protocol for pre-procedural antibiotics was changed to include preparatory infusion of 500mg of gentamicin as a result of the audit. In comparison, major hemorrhage was a retrievable situation in all cases.

An additional striking finding was that a failed attempt to relieve renal obstruction by either the radiology service or by retrograde stenting by the urology service led to delays in establishing drainage. This dramatically augmented the risk of septicemia. Close cooperation between the urology, renal and radiology services was deemed to be vital in expediting any alternative and definitive drainage procedure.

Clin Radiol 2004;59:171-9