Temporary Interventions

Despite the multitude of diagnoses and associated problems contributing to the etiology of upper urinary tract obstruction, urgent temporary decompression, when warranted, is performed either with retrograde placement of ureteral stents or percutaneous nephro-stomy tube placement. The retrograde technique also provides the option that drainage be performed with an external ureteral catheter or an internal double pigtail stent. Both procedures have an established track record with high success rates and low complication rates. The following clinical scenarios would typically warrant a temporary drainage procedure (i.e., stenting or percutaneous nephrostomy):

1. Complete ureteral obstruction (unilateral or bilateral)

2. Obstruction with infection

3. Obstruction with acute renal failure

4. Obstruction in a solitary native kidney

5. Obstruction in a renal allograft

6. Obstruction in a pregnant female

Individualized clinical circumstances may also dictate use of temporizing interventions for other patient populations such as uncontrollable flank pain, fever, or uncontrollable gastrointestinal complaints. Indeed, when a decision is being made regarding the use of a temporary drainage procedure vs definitive therapy for initial relief of upper tract urinary obstruction, it is advisable to err on the side of conservative temporizing therapy rather than immediate definitive treatment. Not uncommonly, patients requiring an acute drainage procedure can have significant morbidity and can be acutely ill.

In a recent report by Yoshimura and co-workers, the need for temporizing interventions related to upper urinary tract obstruction appears to be increasing in older, more debilitated patients (Yoshimura et al. 2005). Among 424 patients with 473 upper tract stones treated in Japan, emergency drainage events in 59 renal units were performed for associated urosepsis by either ure-teral stenting (35/59 events, 59%) or percutaneous nephrostomy tube placement (24/59 events, 41%). In 24% of the emergency drainage cases, intensive care management with the use of vasopressors and anticoagulants was required. In addition, one death was reported related to sepsis. As would be expected, emergency drainage was associated with a significantly prolonged hospitalization in comparison to nonseptic patients (25.2 days vs 14.8 days, p< 0.001). In univariate and multivariate modeling, the need for a temporizing drainage procedure was related to age over 75 years (odds ratio, 2.1; p = 0.038), poor performance status (odds ratio, 2.9; p = 0.003), or female gender (odds ratio, 1.9; p = 0.046). Based on the increasing life span in developed countries, the authors suggested that the issue of emergency drainage procedures in the elderly patient population with significant comorbidity is likely to become more commonplace.

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