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Urgent ureteral stent or nephrostomy tube placement for obstructing stone; a 10-year experience
Michael Kurtz, MD, Ronald S. Arellano, MD, Avinash Kambadakone, MD, Deborah A. Gervais, MD, Dianne E. Sacco, MD.
Massachusetts General Hospital, Boston, MA, USA.

BACKGROUND:Ureteral obstruction from stone with proximal infected hydronephrosis represents a urologic emergency; to date only three studies have addressed the question of optimal drainage with internalized ureteral stents versus nephrostomy tube drainage for this condition.
METHODS:The case records of a single hospital were reviewed from January 2000 to September 2010. 97 ureteral stent cases and 15 percutaneous cases were booked as urgent or emergent with the indication of infected hydronephrosis from stone. Demographic, hemodynamic, laboratory, historical, and microbiologic data were recorded. Drainage modality was selected by clinician at presentation.
RESULTS:Ureteral stent drainage was effective in 95 of 97 patients, with a mean operative time of 19.3 minutes vs 55.2 for nephrostomy placement (p<0.001). Stones were larger in the PCN group, with a mean of 9.4 mm vs 5.5 mm (p<0.001). Stent placement was associated with an ICU admission rate of 13.4% versus 66% for nephrostomy placement (p<0.001); mean length of stay was 4.05 days versus 8.5 days with nephrostomy tube placement (p=0.01). Charlson comorobidity index was similar between the two groups, with 51.5% of those in the stented group having an index of ≥1, compared with 60% in the PCN group (p=0.37). There was a higher incidence of both lower (Grade 1-3) and higher (Grade 4-5) Clavien grade complications in the PCN group at 60% and 13.3% versus 18.6% and 1% (p < 0.001),. Rates of bacteremia differed, with 26% of the stented group becoming bacteremic, versus 66% of the nephrostomy tube group (p=0.03). Positive bladder cultures strongly correlated with positive blood cultures (LR=9.4, p=0.002).
CONCLUSIONS:For the majority of patients presenting to a single center over 10 years with infected pyonephrosis from stone disease, internalized ureteral stent drainage proved rapid and successful. Lower urinary tract cultures were useful predictors of bacteremia..


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