Percutaneous Nephrostomies : Planning for an Optimal Access, Complications, Follow-up and Outcome
Abstract: Percutaneous nephrostomy (PCN) is a well-established intervention performed to divert urine from the collecting system in ureteric obstruction or as a prelude to interventional procedures such as stent placement or percutaneous nephrolithotripsy (PCNL). The aim of this thesis is to enhance planning for an optimal insertion of PCN, investigate complications, long-term management, follow-up and outcome in patients with PCN treatment and to increase accuracy in CT-guided punctures.To enhance planning for an optimal insertion of PCN prior to PCNL, biomodels from CT data were performed. Eight patients with complex urinary calculi were selected. Multislice CT of the kidney was performed and the CT data were transformed into a biomodel. The biomodels visualised unique structures before surgery, which aided the planning of endourological procedures.PCNL is an essential procedure for treating complex urinary calculi. A subcostal approach is preferred to avoid laceration to the lung and pleura. However, a supracostal approach is often preferable, as it gives a better passage to the renal pelvis. The nature and frequency of complications after supra- versus subcostal punctures were studied in 85 patients treated with PCNL. In 63 patients, a subcostal track was established. In 22, a supracostal puncture was chosen. The main difference in preoperative complications was the higher number of patients in the supracostal group complaining of respiratory correlated pain (32%). In the subcostal group, this was (5%). 401 patients were reviewed retrospectively regarding underlying disease, subsequent management and complications of PCN treatment. The number of major complications was 4%. Minor complications were recorded in 38%, urinary tract infection being the most common. 151/401patients suffered from malignancy. 84/151 of the malignant patients died with the catheter. The median survival time of the patients with malignancies was 255 days and the median catheterisation time was 62 days. In order to increase accuracy when performing CT guided punctures, a new puncture guide was evaluated. In 15/17 patients the puncture was successful on the first attempt. The benefits of the puncture guide were the artefact from the needle guide pointing at the target indicating the puncture path and the needle support enhancing an accurate puncture.
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