Novel technique for closure of percutaneous nephrostomy tract utilizing a hemostatic plug, "Beyond the Abstract," by Joel E. Abbott, DO and Julio G. Davalos, MD

BERKELEY, CA (UroToday.com) - Percutaneous nephrolithotomy (PCNL) is a procedure that was first introduced in 1976. In the 1980s it gained widespread acceptance as the procedure of choice for patients with large kidney stones.

During this early phase of adoption of the procedure, the standard-of-care became to have an interventional radiologist place a nephrostomy tube in advance of the stone procedure and also to leave a nephrostomy tube through the tract at the end of the stone procedure. So called tubeless PCNL refers to the procedure performed without placement of an external drainage tube (alternatively a ureteral stent is placed). Despite good evidence-based medicine with two large series published in the mid-1980s that demonstrated the safety of tubeless PCNL—routine practice became to always leave an external drainage tube.

bta abbott fig1
Figure 1: Pre and Post-Procedure Nephrograms Demonstrate the Tract Sealed After Plug Placement with No Contrast Extravasation from the Collecting System.

In the late 1990s multiple studies were published again demonstrating the safety and efficacy of tubeless PCNL. Totally tubeless PCNL—where no external drainage tube and also no ureteral stent are placed—was also demonstrated to be a viable option. Despite multiple studies in the 2000s that have demonstrated the safety of tubeless and totally tubeless PCNL, there has been limited adoption of these procedures by community urologists and even within academic centers.

Additional studies have also demonstrated improved surgical outcomes and preserved patient safety when the operative urologist establishes renal access or when multiple tracts are created during the stone procedure. Despite these findings, the routine practice continues to be the placement of a single nephrostomy tube by an interventional radiologist as a separate procedure. Few urologists routinely establish their own renal access or perform multiple access tract surgery.

There were an estimated 67 000 PCNLs performed in 2013 in the United States. A vast majority of these procedures were performed with a similar protocol as procedures performed in the 1980s. Hospital stays typically ranged from 1 – 3 days.

Patients with large kidney stones who need a PCNL often find it difficult to locate a urologist that is experienced in performing PCNLs—particularly one that offers more modern refinements with the procedure.

Ambulatory PCNL refers to PCNLs performed with same day discharge. In order to achieve ambulatory PCNL, several additional modifications are necessary. This video highlights one of the key enhancements that we routinely employ to achieve same day discharge ambulatory PCNL. Several studies have been published looking at ways to “seal” the percutaneous tract following PCNL—however challenges in precisely placing the plug and with proper plug material selection have been encountered. The video demonstrates a hemostatic plug that meets all of the criteria that are essential for proper tract closure:

  1. A plug that can be accurately placed through the tract but not into the collecting system.
  2. A plug that expands to fill the space of the tract—Gelfoam expands to 40 times its original weight and 300 – 400% its original size. Pre- and post-procedure radiographic images (Figure 1) in the video demonstrate how effectively the plug completely seals the tract.
  3. Ease of placement. The technique highlighted is easy to reproduce and master.
  4. A plug that helps to reduce the risk of bleeding—one of the major concerns with PCNL surgery—Gelfoam and Thrombin are well-established materials used during surgical procedures to aid with hemostasis. Additionally the plug acts to tamponade the tract due to its expansive properties.
  5. A plug that is bio-absorbable—thus eliminating the need for retrieval at a later time.
  6. Cost effective—the materials used for the plug are routinely available in an OR setting and are economical.

The hemostatic plug and the technique highlighted in the video are one of several innovations that we have made to achieve better outcomes and same day discharges for our patients with complex stones whom we deem are best managed with percutaneous surgery.

 

Written by:
Joel E. Abbott, DOa and Julio G. Davalos, MDb as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

aUrological Surgery, St. John Providence Health, Michigan State University
bDirector of Endourology and Kidney Stone Disease, University of Maryland Baltimore Washington Medical Center; Medical Director, Chesapeake Urology Kidney Stone Center; Clinical Associate Professor, University of Maryland School of Medicine

Hemostatic plug: Novel technique for closure of percutaneous nephrostomy tract - Abstract

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