Urgent decompression of obstructed collecting systems due to a ureteral calculus is a daily practice in every urology department in cases of infection, renal failure or intractable pain. Despite the commonness of this situation, there are only a few studies comparing renal drainage methods, including clinical and QoL aspects [
1‐
3,
9,
10]. This study prospectively compared 45 DJS procedures to 30 PCN procedures. Selection criteria ensured that all patients were potential candidates for both procedures, and analysis revealed similar patients’ characteristics in both groups. QoL was evaluated with EuroQol EQ-5D and a ‘Tube symptoms’ questionnaire at two time points, in order to evaluate symptoms dynamics over time.
Clinical course
In face of opposing results in former studies [
1,
2], we found no distinct difference in post-procedural in-hospital pain, with patients in both groups reporting low VAS scores. The finding of higher post-operative pain for DJS in Mokhmalji et al. study [
2] might be explained by the fact that retrograde placement was achieved by using a rigid cystoscope with prior transurethral administration of local anesthetic sedation, and had a 80% success rate. Procedure complication rate was also comparable between the methods, and consistent with other reports [
11]. Ramsey at el. [
11] reported in their review that there appears little evidence to suggest that retrograde stent insertion leads to increased bacteremia or is significantly more hazardous in the setting of acute obstruction. In league with this report, few patients at each group developed post drainage sepsis, with no clear advantage for any method. Moreover, post procedural recuperation was equivalent in both groups, as supported by similar time to defeverence and time of leukocytosis returning to normal range. However, it should be mentioned that we excluded patients presenting with septic complications or shock, which may benefit from PCN drainage in comparison to DJS. Although time of eGFR return to baseline was found to be longer in the PCN group vs. the DJS group (2 days vs. 1 day respectively), this finding could be explained by the lower baseline eGFR of the PCN group, and is probably not clinically significant. The longer hospitalization is probably associated with a slower recovery to baseline GFR in the PCN group, as patients were kept under observation to assess the kidney recovery. The apparent difference in time to second procedure was also noted in other studies [
2]. DJS patients were summoned for their definitive treatment approximately twice as long as the nephrostomy patients. This substantial difference can be explained to some extent by a misguided perception that a patient with a DJS is less debilitated compared to a patient with a nephrostomy tube (an apparent external tube). Overall, our study supports similar clinical outcomes in both drainage methods.
Quality of life
QoL outcomes in our study corresponded well with the only other prospective study comparing QoL at two time points after urgent renal drainage [
2]. Both procedures caused pain or discomfort to a significant amount of patients. While the number of PCN patients complaining of pain remained similar over time, and analgesic use even lowered, more patients in the DJS group reported of pain, and analgesics use grew in prevalence and frequency as well. Clearly, the most troublesome symptoms in the DJS group are the urinary bother symptoms [
3,
12]. These symptoms inflicted 80% of the patients in our DJS study group, much more frequent compared to other symptoms. Furthermore, there was no alleviation over time, the prevalence and severity of these symptoms did not change, translating to a higher number of emergency room visits. In distinct opposition, PCN patients suffered at first mostly from discomfort involving “movement”, “self-care” and “personal hygiene”. However, over time, these patients adjusted to the nephrostomy tube. The number of patients experiencing symptoms in these domains dropped by half, or more, reaching similar discomfort level with the DJS group at time1. These trends are manifested in the overall health state results. At first, both groups suffered from bothering symptoms, albeit different, amounting to similar overall disturbance. This result is corroborated by the recent study of de Sousa Morais N. et al [
3]. Over time, PCN patients improved their symptoms, while DJS patients suffered similarly or worsened. This was reflected by significantly higher overall health state scores in the PCN group at time1. Of note, studies comparing PCN drainage vs DJS in other clinical scenarios [
4,
5], such as following PCNL, also found that patients with DJS suffered significantly from pain and irritative symptoms that decreased the overall QoL. Interestingly, in the DJS group women reported higher level of pain / discomfort at both time points, and higher use of pain medications post operatively. In the PCN group, higher use of pain medications post operatively in women was also noted.
Is there a preferred approach for urgent decompression of obstructed collecting systems?
The decision on the appropriate method of drainage is multifactorial, including factors such as stone parameters, patient’s characteristics, patient’s and urologist preferences, the expected definitive approach for stone treatment and procedure availability. In their summary of 15 years outcomes, Goldsmith et al. [
10] reported a tendency to prefer nephrostomy drainage in patients with larger stones and patients who are more acutely ill. Often, clinical judgment is exercised, and opinions may vary considerably [
13]. When both procedures are available, and the patient is a potential candidate for either procedure, the expected clinical benefit and the expected QoL are major determinants in the decision. It appears that both methods result in similar good clinical result, with no significant benefit for the one over the other. Thus, the implications of the drainage on patient’s QoL should not be overlooked or disregarded, but rather become a factor in the decision on the preferred rout. A thorough discussion with the patient is extremely important, explaining the pros and cons of each procedure, not only clinically, but of what is expected regarding tube symptoms and QoL. In general, for proximal ureteral stones the advantages of pre-stenting probably outweigh the discomfort associated with the stent. However, for patients with a distal ureteral stone requiring drainage, a nephrostomy tube may be the best choice as it would allow possible spontaneous passage and would avoid the stent discomfort.
There are several limitations to our study. The “tube symptoms” questionnaire was based on a validated DJS symptoms questionnaire, adjusted to be relevant for both DJS and PCN groups, but was not validated in itself or to local language, and might induce recall bias. As both hospitals are public, at no cost to the patient, procedural or hospitalization cost did not introduce bias. However, selection bias may have been introduced through choice of drainage procedure according to surgeon’s preference, recruitment rate, possibly influenced by severity of eGFR, hydronephrosis, or other unmeasured parameters. Therefore patients suspected of long standing impaction probably had a higher chance of receiving a PCN, thus explaining the lower GFR in this group. Furthermore, as different imaging modalities were used, we could not assess hydronephrosis severity as a possible confounder. Finally, we did not assess a third time point, after tube removal, to confirm symptoms resolution. Nevertheless, we believe our study, supported by other past reports, demonstrate an overlooked truth. To quote Dr. Louis R Kavoussi [
14], “Traditionally, urologists have placed stents because … that’s what we do”, but his experience is that “patients are more comfortable with a nephrostomy than a stent”. Interestingly, superior QoL of PCN over DJS placed after PCNL was also recently reported [
4,
5]. The results of this study support superior QoL of nephrostomy tube over time, and may cause some urologists to reconsider their choice of renal drainage, especially in health systems in which definitive treatment might be delayed. Undoubtedly, the specific tube symptoms, and their influence of the patient over time, should be given a serious consideration in the deliberation for the right drainage method for a specific patient.