What is the role of nephrostomy (percutaneous catheter placement) in pyeloplasty (surgical reconstruction of the renal pelvis) as an intraoperative decision?

Role of Nephrostomy in Pyeloplasty Intraoperative Decision Making

Nephrostomy placement during pyeloplasty should be considered as a useful solution when complex urological reconstruction is needed, allowing for delayed definitive repair in an elective setting rather than during the initial procedure. 1

Indications for Nephrostomy During Pyeloplasty

• Nephrostomy placement combined with ureteral closure is valuable when complex urological reconstruction is needed, as it decreases morbidity and allows for delayed definitive repair in an elective setting 1
• In cases of damage to the renal pelvis not amenable to immediate repair or endoscopic/percutaneous techniques, delayed operative management with temporary nephrostomy diversion should be considered 1
• Nephrostomy tubes serve as an effective bridge to definitive treatment in cases of ureteral injuries identified during surgery 1
• When urological expertise is unavailable during emergency surgery, the "drain now, fix later" approach using nephrostomy can be adopted 1

Management of Complications with Nephrostomy

• For acute complications after minimally invasive pyeloplasty such as anastomotic leakage or obstruction, prompt placement of percutaneous nephrostomy preserves radiographic and symptomatic outcomes comparable to uncomplicated cases 2
• Percutaneous nephrostomy offers the possibility of temporary or permanent urinary diversion in the presence of obstruction and has largely replaced operative nephrostomy when supravesical drainage is necessary 3
• In cases of severe intraperitoneal bladder rupture during damage control procedures, urinary diversion via bladder and perivesical drainage or external ureteral stenting may be used 1

Selective vs. Routine Use of Nephrostomy

• Routine use of nephrostomy tubes after pyeloplasty is not necessary in all cases, as demonstrated by studies showing comparable success rates between stented and unstented pediatric pyeloplasties 4, 5
• Specific indications for nephrostomy use include: surgery on a solitary kidney, inflamed renal pelvis, or revision pyeloplasty 4
• Hospital stay is significantly longer for patients with nephrostomy tubes (12.1 days) compared to those without (5.4 days), suggesting selective rather than routine use 4

Technical Considerations

• When placing a nephrostomy during pyeloplasty, ensure adequate drainage to avoid urinoma and abscess formation 1
• If a nephrostomy tube becomes dislodged postoperatively, immediate medical attention is required with prompt replacement to prevent complications 6
• For nephrostomy tube management, timing of removal is critical - tubes typically remain in place for a median of 9.5 days (range 5 to 42 days) when used to manage complications 2

Role of Urologist in Decision Making

• The presence of a urologist during surgery is paramount when urinary tract injury is suspected or complex reconstruction is needed 1
• The old paradigm of having the primary surgeon manage urinary complications has shifted due to evolution of techniques and their complexities over the last 30 years 1
• In cases where urological expertise is unavailable and complex reconstruction is needed, temporary nephrostomy diversion with delayed definitive repair by a urologist is recommended 1

Outcomes and Follow-up

• Follow-up studies show that proper management with nephrostomy when indicated results in 85% of patients being cured (no symptoms and normal drainage from renal pelvis) 7
• Aggressive management of acute urinary complications with percutaneous nephrostomy placement preserves radiographic and symptomatic outcomes comparable to uncomplicated cases 2
• Monitor for signs of infection (fever, increased pain, purulent drainage) and bleeding after nephrostomy placement 6