PCNL Nephrostomy Tube Placement For Kidney Stones

[Dr. Aditya Bagrodia]
If [PCNL patients] are coming in with a preexisting nephrostomy tube or a stent, do you ever prophylactically treat them with the antifungals?

[Dr. Margaret Pearle]
Yeah, that's a really good question and comment because fungal sepsis, I think we all would agree, is really one of the probably worst forms of sepsis that we deal with and those patients get incredibly sick. So, sometimes I'll just think about it and think this patient's been on a lot of antibiotics preoperatively, let's just give a dose of an antifungal at the time of surgery, not necessarily preoperatively.

Sometimes I look in the kidney and I see something that looks a little fluffier than I like to see, and I'll start it then. But it is absolutely something to keep in mind preoperatively. And I know Dr. Nicole Miller has always been a proponent of being pretty liberal about placing nephrostomy tubes preoperatively if they don't have tubes in, but they have a high grade obstruction. She will often put in a nephrostomy tube so she can sample the urine preoperatively and know what she’s actually treating, which might reveal fungus. But certainly with tubes in place, they're at higher risk of that.

So, in patients with longer term indwelling tubes, I'm definitely thinking about antifungals. I may not do it routinely every time if cultures from the tube are negative. But sometimes the cultures are negative for yeast and yet intraoperatively, there'll be the appearance that maybe there's yeast. Then, I'll add it at the time.

[Dr. Aditya Bagrodia]
If they're coming in with a preexisting nephrostomy tube or a stent, do you ever prophylactically treat them with the antifungals?

[Dr. Margaret Pearle]
Yeah, that's a really good question and comment because fungal sepsis, I think we all would agree, is really one of the probably worst forms of sepsis that we deal with and those patients get incredibly sick. So, sometimes I'll just think about it and think this patient's been on a lot of antibiotics preoperatively, let's just give a dose of an antifungal at the time of surgery, not necessarily preoperatively.

[Dr. Aditya Bagrodia]
...Before we jump into some of those considerations, I want to ask you a quick question. Patients coming in with partial stags or full stags, positive UTIs, not clinically sick, are those patients routinely getting decompressed? Or do you think it's safe to manage them with antibiotics, try to sterilize them and then treat them as you typically would down the way?

[Dr. Margaret Pearle]
Yeah, I don't typically decompress them. Patients will often come to me with a standard nephrostomy tube in place. But if I encounter them, if they're referred to me and they don't have drainage or I'm seeing for the first time and they don't have drainage, I don't routinely place a drainage tube--unless sometimes they'll have sort of the appearance of an XGP type kidney. That might worry me more that I might want to sample that urine and save a trip to the operating room. Because if you get in there and you find pus, then you're going to put a nephrostomy tube in and get out. But I don't typically.

Now, there are times I've been burned by that and found pus at the time of obtaining access. But more often than not, I'd say usually I don't. And again, this is where Dr. Nicole Miller probably is more aggressive about putting tubes in and sampling the urine. I just obtain my routine urine cultures and treat appropriately and aggressively with antibiotics preoperatively and intraoperatively. But I don't necessarily prophylactically place nephrostomy tubes, even in a patient with a staghorn stone and a hydronephrosis.

[Dr. Jose Silva]
...And in those cases, you will leave like a big Foley instead of just an 18 French or a smaller caliber nephrostomy tube?

[Dr. Margaret Pearle]
Yeah, and I don't know if that's really necessary or not. But generally, if I've been in there and I went ahead and dilated the track to 24 French or 30 French, I may leave a 16 or 18 French tube in place that is going to achieve good drainage and also leave a way for me to come back the second time. And I don't go through that procedure with the intent of finishing it. I go through with the intent of getting enough stone out to achieve better drainage.

[Dr. Aditya Bagrodia]
Okay, okay. So, hopefully, as to be the case, stone free, tubes coming out, tube comes out and you encounter bleeding. Can you walk us through kind of the management of your preferred way to deal with an early or even a delayed post-operative bleed?

[Dr. Margaret Pearle]
So, outside the operating room, typically, if we have, for instance, a council catheter in the kidney, which we advance over like a 5 French angiographic catheter into the bladder, we typically remove the council catheter first, leaving the angiographic catheter in place. So, if there's bleeding encountered immediately, you can just slip the council catheter back over the angiographic catheter into the collecting system. And that will almost always stop the bleeding until you can get interventional radiology.

So, we sort of give it just a little time before burning that angiographic catheter. In rare cases, and I've certainly had them through my career, we had to take them straight to interventional radiology because of a significant bleed. We've done so. But we've almost always been able to get a tube back in. So, we've had very few real sort of dire emergency, big bleeds that were critical in terms of wheeling pretty much down to IR right away.

But if you can get a nephrostomy tube back in, it'll generally stop and then we would subsequently take them to interventional radiology. And I think the key, in terms of arteriograms, is that you sometimes have to deflate the balloon to find the bleeder or find the pseudoaneurysm, or you have to back the nephrostomy tube out. So, again, we'll put a wire down our angiographic catheter.

And then if they do an arteriogram on a first run and don't see a bleed, then we deflate the balloon and then we back the nephrostomy tube out. And sometimes, there's significant bleeding as you back it out, but you're not going to be able to find the pseudoaneurysm sometimes until you get the tube out of the way. So, we're always kind of prepared to do that. And our interventional radiologists are aware that they may need to contact us to come and move the tube if need be.