Lessons from Literature: Nephrostomy Versus Double J Ureteral Catheterization in Patients with Obstructive Urolithiasis

Abstract

Purpose:

To review the literature on optimal methods of drainage for obstructive urolithiasis in adult patients, comparing percutaneous nephrostomy (PCN) with retrograde ureteral catheterization (Double J [JJ]) regarding success of procedure, efficacy, complications, quality of life (QoL), and costs.

Methods:

Web of Science and the Medline, Embase, Emcare, and Cochrane controlled trial databases were searched for all relevant publications until November 2018. A review protocol was created, using the PRISMA statement. Two reviewers independently screened the titles and abstracts in Endnote X8, using criteria as stated in the research protocol. A total of 1108 abstracts were screened of which 9 were included in the qualitative synthesis. Level of evidence of the studied articles varies between 1b and 2c.

Results:

Both JJ and PCN have high success rates (80%–100% and 99%–100%, respectively). No major complications were reported in both groups. Procedural and fluoroscopy times are significantly shorter for JJ than for PCN (31–33 minutes vs 35–49 minutes and 5 minutes vs 7 minutes, respectively). Time to clinical improvement did not differ. In the JJ group, analgesics were used more frequently than in the PCN group. Data regarding procedural costs were contradictory, but overall the PCN group was associated with higher costs. In pregnant women, PCN placement appears to be significantly more effective than placement of JJ. A significant decrease between pre- and postintervention QoL was found with patients receiving a JJ. Back pain was reported more frequently in the PCN group, urinary symptoms were more common in the patients with a JJ.

Conclusions:

Both PCN and JJ have comparable success rates for patients with obstructive urolithiasis and procedure-related complications are rare. Overall, higher rates of sepsis, longer hospital stay, and higher costs were found in the PCN group, but that could be explained by patient selection. Patients with JJ experienced a lower QoL and experience more lower urinary tract symptoms.

Introduction

Drainage of the urinary tract is necessary when obstruction of the upper urinary tract causes infection, loss of renal function, or uncontrollable pain. Untreated obstruction in patients with infection may induce significant morbidity such as sepsis, pyonephrosis, and death.¹ Decompression of the urinary tract can be realized by retrograde or antegrade route. Most methods used are either percutaneous nephrostomy (PCN) or ureteral catheterization or stenting (Double J [JJ]).²

Both procedures have pros and cons concerning complications, costs, quality of life (QoL), and further treatment. However, for some patients, timing is essential and may influence the choice of treatment.³ European Association of Urology (EAU) guidelines recommend PCN as well as retrograde JJ insertion for adequate decompression.⁴ It is recommended that local expertise and resources should guide this choice.

The recommendation in the EAU guideline of 2018 is based on a review of data till 2010. More than 8 years later, the optimal method of decompressing the upper urinary tract is still a topic of discussion. High-quality data on this subject are rare. In this review, we aim to give a complete overview of available data on both drainage methods concerning success, efficacy, complications, costs, and QoL.

Methods

A review protocol was created, using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. A search was performed in November 2018 using PubMed, Embase, Web of Science, Wiley/Cochrane Library, and Emcare. The following search terms urolithiasis, nephrolithiasis, calculi, stones, drainage, nephrostomy, JJ, stent, decompression, obstruction, ureteral, hydronephrosis, dilatation, acute, and costs were used, and filters [human] and [English] were applied. No date restrictions were applied. Two reviewers (S.W. and B.S.) independently screened the titles and abstracts in Endnote (EndNote X8; Thomson Reuters, Philadelphia, PA) using the criteria as stated in the protocol.⁵ The full text of all potentially eligible publications was independently screened using a standardized screening form. Reasons to exclude articles were inclusions of patients with malignancy as a cause for obstruction, no comparison between PCN vs JJ, or describing only technical aspects and no outcomes. A third reviewer (R.P.) resolved any disagreements between the two reviewers.

The different types of interventions were insertion of PCN or that of a JJ. This review addresses drainage of obstruction by stones in the kidney or ureter. Excluded were children and patients with renal transplantation. Also, case series including <10 patients, case reports, and meeting abstracts were excluded. No date restrictions were applied. Duplicates were removed. Relevant reviews were screened for additional articles to be included. The Cochrane risk of bias assessment tool was used to perform a risk of bias analysis for included nonrandomized comparative studies. Studies were assessed according to risk of selection, performance, detection, attrition and reporting bias, and were graded as low, high, or unclear. The complete search string is shown (Supplementary Data). A PRISMA flow chart of our search is included (Supplementary Fig. S1). A total of nine articles were included in the final review. Level of evidence of the used articles varies between 1b and 2c.

Results

In all included articles, most patients experienced infection as the main cause for decompression of the urinary tract. An overview is given in the data table (Tables 1 –3).

Table 1.

Included Studies in Order of Clinical Relevance and Then Year of Publication. An Overview of Study Patients and Methods

Study	Study design (level of evidence)	Gender distribution (M:F)	Mean age in years (range or SD)	Procedure of PCN	Procedure of JJ	N total (PCN/JJ)	Reason for drainage	Inclusion criteria	Exclusion criteria	Primary outcome	Secondary outcome
Pearle et al. (1998)	Randomized controlled trial (1b) 1995 to 1997	PCN group: (8:13) JJ group: (10:11) p value not significant	PCN group: 41.3 (±13) JJ group: 41.3 (±14.5)	Angiography suite by interventional radiologist Local anesthesia supplemented with iv sedation	Operating room, under supervision of a urologist and under general anesthesia	42 (21/21)	Infection	Obstructing ureteral calculi+clinical signs of infection^a	Contraindication to either form of drainage	Time to normalization of WBC or temperature	Length of hospitalization
Mokhmalji et al. (2001)	Randomized prospective study (1b) 1996 to 1998	PCN group: (12:8) JJ group: (9:11) Comparable groups	PCN group: 55 (24–78) JJ group: 49 (24–76) Comparable groups	Sonographically guided renal puncture, facial dilatation over guidewire. Local anesthesia Placement under fluoroscopy of 12F drain	Rigid cystoscopy Prior local anesthetic using lidocaine instillation Fluoroscopic guidance, placement over guidewire	40 (20/20)	Infection Pain Loss of renal function	Hydronephrosis caused by urolithiasis and renal colic or T > 38 or stone >15 mm or urosepsis or creatinin increase or UTI and incipient sepsis in blood count	End-stage hydronephrosis, choice for one procedure to facilitate further diagnostic imaging. Anatomical: pouch, solitary kidney, poor coagulation, children	Course of procedure, subsequent progress and QoL	Use of analgesics, duration of X-ray exposure, success, iv antibiotics, duration of diversion
Rammohan et al. (2015)	Randomized prospective study (1b) 2012 to 2014	PCN group: (8:12) JJ group: (9:11) p value not significant	Overall 46.47 (±9.36)	In the operating room Local anesthesia 12F or 14F drain	In the operating room Local anesthesia 4.5F or 5Fstent	40 (20/20)	Infection	Obstructing ureteral or renal pelvic stones with clinical signs of infection^b	Calculus >15 mm, multiple calculi, pregnancy, urinary diversion, ureteral/urethral stricture, coagulopathy, solitary kidney	Time to normalization WBC, normalization of temperature, resolution of pyuria if seen	Procedural time, fluoroscopy time, complications, VAS. Time to definitive treatment and modality
Sammon et al. (2013)	Observational cohort (2b) 1999 to 2009	PCN group: (35:65) JJ group: (28:72) p < 0.001	PCN group: 53 (40–68) JJ group: 51 (37–65) p < 0.001	No information on procedure	No information on procedure	396,385 (13.967/99.492)	Infection	Adult patients hospitalized with infected urolithiasis	Patients undergoing URS or PCNL	Sepsis, organ failure, mortality rate, length of hospital stay, cost	Procedural time, fluoroscopy time, complications, VAS. Time to definitive treatment and modality
De Sousa Morais et al. (2018)	Prospective cohort (2b) 2017	PCN group: (6:12) JJ group: (19:13) p = 0.077	PCN group: 63.1 (±12.5) JJ group: 54.5 (±15.5) p = 0.048	No information on procedure	No information on procedure	50 (18/32) = 36% vs 64%	Infection Pain Loss of renal function	Adult patients with urinary tract obstruction caused by kidney stones, confirmed on NCCT	Not mentally capable, patients lost to follow-up after urinary diversion and pregnant women	Spontaneous stone passage (SSP) and QoL
Yoshimura et al. (2005)	Retrospective case study (2c)1994 to 2003	PCN group: (12:12)JJ group: (12:23) p = 0.034	PCN group:67.3 (±15.7)JJ group:59.5 (±17.4) p = 0.042	No information on procedure	No information on procedure	59 (24/35) = 41% vs 59%	Infection	Patients with urosepsis associated with upper urinary tract and requiring emergency drainage	Prior antibiotic, negative urine culture, other focus of sepsis	Course of procedure and subsequent progress	Blood tests for infection parameters (CRP/leukocytes/thrombocytes)Antibiotics
Song et al. (2013)	Retrospective comparative study (2c)2001 to 2012	All pregnant women	PCN group:26.9JJ group:27.2 p = 0.973	Local anesthesia with ultrasound guidance	Local anesthesia with flexible cystoscope	54 (16/17)	InfectionLoss of renal functionPain	Pregnant women who required medical intervention for urolithiasis, diagnosed by creatinine levels/urine analysis/ultrasonography or MRI	NR	Efficacy; success of procedure	Complicationsprocedure time, procedure cost, hospital stay
Goldsmith et al. (2013)	Retrospective case study (2c)1995 to 2011	NR	56 (19–88)	No information on procedure	No information on procedure	130 (59/71) = 45% vs 55%	Infection	CT diagnosis of obstructive urolithiasis and 2/4 SIRS criteria (T/HR/RR/WBC)	Noninfectious indication (pain/acute renal failure)	Stone related and clinical variables that predicted use of each treatment method APACHE/BMI/CCI/age, etc)	Length of hospital stay, risk of ICU admission, surgical approach for definitive stone management
Wang et al. (2014)	Retrospective comparative study (2c)2006 to 2012	Pregnant women	26 (17–39)	Under local anesthesia and ultrasound guidance, fascial dilatator from 8F to 14FIn patients with severe hydronephrosis, pyonephrosis, and/or sepsis	Using topical anesthesia and cystoscopic observation; 5F stent placed with guidewire	87 (4/19)Ureterolithotripsy (n = 64)	InfectionLoss of renal functionPain	Pregnant women who were treated with invasive procedures for proximal symptomatic ureteral stones between 2006 and 2012	NR	Success	Complications, operative time

T > 38C and/or WBC >17,000/mm.

Fever, WBC elevated.

APACHE = acute physiology, age = chronic health evaluation; CRP = C reactive protein; NCCT = noncontrast enhanced CT; NR = not reported; PCN = percutaneous nephrostomy; QoL = quality of life; SIRS = systemic inflammatory response syndrome; VAS = visual analog scale; URS = ureterorenoscopy; WBC = white blood cell.

Table 2.

Outcome Parameters of the Included Studies

Study	Technical aspects and outcome (success/complications)	Efficacy	QoL/pain	Length of stay and costs	Other results
Pearle et al. (1998)	+	+	+	+	Time to definitive drainage
Mokhmalji et al. (2001)	+	+	+	−	Time to definitive treatment
Rammohan et al. (2015)	+	+	+	−	Time to definitive treatment + modality
Sammon et al. (2013)	+	−	−	+	Difference men/women
De Sousa Morais et al. (2018)	+	−	+	−	Spontaneous stone passage
Yoshimura et al. (2005)	−	+	−	+	Stone size
Yoshimura et al. (2005)	−	+	−	+	Patient characteristics
Song et al. (2013)	+	+	−	+	Procedural time
Goldsmith et al. (2013)	−	+	−	+	Time from drainage to definitive treatment and correlation with treatment method
Wang et al. (2014)	+	−	+	−	Effective delivery

+Outcome has been described.

−Outcome has not been described.

Table 3.

Included Studies in Order of Clinical Relevance and then Year of Publication. An Overview of Results and Conflict of Interest

Study	Technical aspects and outcome (success/complications)	Efficacy	QoL	Length of stay and costs	Other results	Conflict of interest or sources of funding
Pearle et al. (1998)	Procedural and fluoroscopy times were significantly shorter for JJ than for PCNSuccess PCN: 95%Success JJ: 100%Complication; unsuccessful PCN requiring salvage ureteral stenting	No significant difference in normalization of clinical parameters (WBC/temperature)	More back pain in PCN group than in the stenting group (37.2 vs 6.5 on a scale of 0 to 100, p < 0.05).No difference in the use of analgesics	No difference in length of stay(4.5 days in PCNgroup vs 3.2 days in the JJ group).JJ under general anesthesia was twice costly at $2401 vs $1137 for PCN	No significant difference in time to definitive drainage	NR
Mokhmalji et al. (2001)	X-ray exposure shorter in PCN group (NS)Success PCN: 100%Success JJ: 80%(20% conversion to nephrostomy)Stent failure more frequently with proximal stones and age >60	Antibiotics >5 days 64% in stent group vs 0% in PCN group	Analgesics more frequently in stent group (NS)QoL reduction bigger in stent group. QoL improved in PCN group and deteriorated in stent group, especially in men and people <40	NR	PCN indwelling time significantly shorter because of persisting infection in JJ groupThis was more pronounced in patients with hydronephrosis and stones in the proximal ureter	Financial interest and/or other relationship with Storz America, Inc. and Storz Medical.
Rammohan et al. (2015)	Procedural and fluoroscopy time significantly shorter in stenting group1PCN-related complication (dislodgement of tube)	No significant difference in time to clinical improvement	Back pain significantly greater in PCN groupNo significant difference in duration of pain.	NR	NR	None
Sammon et al. (2013)	PCN showed higher rates of sepsis and mortality in matched analysis	NR	NR	PCN showed prolonged length of stay and elevated hospital charges in matched analysisProcedural costs and length of stay strongly favored JJ on propensity-score-matched analysis.	A total of 28.6% of hospitalized patients underwent immediate decompression (n = 113,459)Women >2 likely to have associated infection and more likely to experience sepsis when intervention is needed	None
De Sousa Morais et al. (2018)	No significant difference for need of antibiotics and urinary infections was found	NR	Decrease of QoL pre- and postinterventionIn JJ group (p < 0.001)In PCN group (p = 0.206)Patients in JJ group more urinary symptoms, mostly hematuria (p < 0.001) and dysuria (p < 0.001)More analgesics needed in JJ group (p = 0.004)	NR	Rate of spontaneous stone passage (SSP)25% in JJ group38.9% in PCN group(NS in univariate analysis)SSP influenced by stone size (NS)30.2% (n = 13) of stones in JJ group upward displacedStone size higher in PCN group vs JJ (p = 0.12)	None
Yoshimura et al. (2005)	NR	More rapid progression of inflammation and more severe thrombocytopenia in JJ group vs PCN groupPeak CRP and WBC did not differ	NR	Patients undergoing emergency drainage required more treatment interventions and a longer hospital stay than other patients with urolithiasis (10 days longer) p < 0.001	Stones larger in PCN group (9.7 mm vs 2.6 mm)Performance status, patient age, and gender were independent risk factors	NR
Song et al. (2013)	PCN success 100%Complications; 31.2%(5/16); skin infection and painJJ success in 71% (12/17)Complications;52.9% (encrusted stent, pain, and one preterm labor)	Symptoms disappeared after 12 hours, stent removed after 14 days.	NR	Cost in PCN group highest because of imported material and not covered by medical insurance	3 of 12 had spontaneous passage, 5 extracorporeal shockwave lithotripsy, 4 URSOf the five failed JJ insertions, three patients had stone sizes >2 cm.Of the five stent failures; four received PCN and one patient URS	None
Goldsmith et al. (2013)	Overall rate of failed procedure = 2.3% (3/130) with 1 hospital death (0.8%)2 JJ failures → PCN1 PCN failure → JJ(p = 0.571)	NR	NR	PCN group significant longer hospital stay on multivariable analysis and higher rate of ICU admission.No difference in stone location	More severely ill patients (higher APACHE scores) and larger stones (10 mm vs 7 mm) in PCN groupMethod of drainage correlated with later treatment methodTime from drainage to definitive treatment and rates of SSP equal in both groups	None
Wang et al. (2014)	PCN placement success 100% (4/4)Stent placement success 89% (17/19)Complications; one patient needed stent replacement	NR	21.1% urinary tract infection and 63.2% bladder irritation, 36.8% hematuria	NR	Two failed stent insertions received URS directlyAll underwent effective delivery	None

NS = nonsignificant.

The need for drainage and choice of procedure

Since patients in only three out of the nine articles included were randomized, a choice for either JJ or PCN was made in the other six studies (Tables 1 –3). When time from randomization to drainage procedure was reported, no significant difference was found between the PCN and JJ groups.⁶

Overall, patients in the PCN group had larger stones than those in the JJ group; in the study of Goldsmith et al.,⁷ stones had a median size of 10 mm in PCN vs 7 mm in the JJ group (p = 0.031); in the study of Yoshimura and colleagues,⁸ the mean stone size was 9.7 mm in the PCN vs 2.6 mm in the JJ group (p = 0.006). In the study of de Sousa Morais and colleagues,⁹ stone burden was significantly higher in the PCN group (median 92 mm²) than in the JJ group (median 47 mm², p = 0.012). Stone location did not differ.^7,8

Compared with patients receiving JJ, patients in the PCN group appeared to be more severely ill with higher APACHE scores.⁷ A large retrospective data analysis from the United States among 396,385 patients with urolithiasis and associated infection showed that with emergency decompression most of the time JJ was chosen (87.7%). A PCN was more likely to be placed at large urban teaching centers and men were significantly more often treated with PCN than women.¹⁰ When compared with patients requiring emergency drainage, more additional interventions and a longer hospital stay were necessary than patients with urolithiasis without need for emergency drainage.⁹

Technical aspects: Success and complications

Five studies described the type of anesthesia used when intervention took place. In four out of these, placement of both PCN and JJ was performed under local anesthesia. During procedures, analgesics were used more frequently in the JJ group than in the PCN group (p = 0.061).¹¹ Fluoroscopic guidance was used in most procedures. Most commonly 8F to 14F nephrostomy tubes and 4.5F to 7F JJ were used. Location to perform the procedures varied from operating theater (most frequent) to angiography suite or the urology outpatient department. Concerning procedural and fluoroscopy times, two randomized studies showed significantly shorter times for JJ than for PCN insertion (p < 0.05).^6,12 PCN insertion was effective in 95% to 100% and introduction of JJ was effective in 80% to 100% of the procedures. JJ failure occurred more frequently in patients with high ureteral stones and age >60 years.¹¹ When either of the procedures failed, the other procedure was performed in a second attempt.^6,7,11,13,14

Besides the failing procedure, complications were rare. Dislocation of nephrostomy occurred in one patient in the nephrostomy group.¹² One study reported that antibiotics were administered for >5 days in 64% of patients in the JJ vs 0% of patients in the PCN group.¹¹ However, a large epidemiologic study reported that in matched analysis the rates of sepsis and morbidity were significantly higher in the PCN group than in the JJ placement group.¹⁰ In the recent study of de Sousa Morais et al., no significant difference for need of antibiotics and urinary infections was found.⁹

Efficacy, length of stay, and costs

Two of the randomized studies showed that clinical improvement and normalization of index parameters such as white blood count and body temperature were not different between groups.^6,12 Another study stated that patients in the JJ group had more rapid progression of inflammation and more severe thrombocytopenia. Peak C reactive protein and white blood cell, however, did not differ between groups.⁸

Difference in length of hospital stay was not different in one of the randomized studies (4.5 days in PCN group vs 3.2 days in JJ group).⁶ But two other studies reported significant longer hospital stay (p = 0.001) and higher rates of ICU admission (p = 0.016) for the PCN group.⁷ When matched analysis was performed in a large demographic study from the United States, higher rates of sepsis, severe sepsis, prolonged length of hospital stay, elevated hospital charges, and mortality for patients in the PCN group were found. When comparing JJ and PCN within subsets (pyelonephritis vs cystitis, elective vs urgent), these differences were also found.¹⁰ Yoshimura and colleagues showed that hospital stay was 10 days longer in patients undergoing immediate drainage than other urolithiasis patients.⁸

In one of the randomized studies, costs of JJ insertion were twice as high ($2401) as PCN ($1137).⁶ Large demographic data analysis for elevated hospital charges (beyond the 75th percentile of $28 245) showed significant differences between groups, favoring the JJ group for lowest costs (26.5% vs 46.3%, p < 0.001).

Drainage during pregnancy

Two retrospective studies described the treatment of obstruction caused by urolithiasis during pregnancy. The indication for intervention varied from loss of renal function, infection, and pain to positive urine culture. PCN and JJ but also ureterorenoscopy were chosen as first treatment option. Both PCN placement and JJ insertion were carried out under local anesthesia. PCN was effective in 100% and complications were reported in 31.2%. Besides skin infection, pain was also accounted for as a complication. JJ placement was effective in 71% to 89%. Failure of JJ placement occurred more frequently in patients with stones larger than 2 cm. Complications were reported more frequently in the JJ group (52.9%), comprising pain, bladder irritation, but also an encrusted JJ and preterm labor. JJ replacement was needed twice for uncontrollable infection and stent migration. Procedural time, costs, and length of hospital stay were significantly different, favoring the JJ group (p < 0.001). Both PCN and JJ were reported to be uncomfortable. All patients underwent effective delivery.^13,14

Quality of life

Of our nine selected articles, five described QoL as study outcome. Anesthesia and analgesics did not only influence success of a procedure but also patients' QoL.^15,16

Back pain was frequently reported and was more present in the PCN group than in the JJ group (p < 0.05).^6,12 A difference in the use of analgesics was not reported and duration of pain was comparable. Another randomized study did report more frequent use of analgesics in the JJ group than the patients in the PCN group.¹¹ Urinary symptoms such as hematuria were more common in patients with a JJ (68.7%) than in patients with PCN (16.7%, p < 0.001). Also dysuria was reported significant more frequently in the JJ group vs the PCN group (78.3% vs 16.7%, p < 0.001).

A significant decrease was found between pre- and postintervention QoL in patients receiving JJ (p < 0.001), but not in patients receiving PCN (p = 0.206).⁹ QoL reduction was also found to be more prominent in the JJ group of a randomized study, especially in men and patients <40 years of age. However, these results were not significant.¹¹

Spontaneous stone passage and stone management

Spontaneous stone passage (SSP) was described in two studies and both presented no significant difference between the groups. One showed similar rates of passage between JJ and PCN groups (12%–14%, p = 0.786). The most recent article with SSP as a primary outcome reported spontaneous passage in 25% of JJ patients compared with 38.9% in PCN patients (p = 0.304).⁹ Evidence of impact of the type of intervention on stone passage was not found on univariate analysis in this last study, but after adjusting for predictors in multivariate analysis (stone size, previous surgery, medical expulsive therapy, and stone site), PCN was associated with significant increase of spontaneous passage (OR: 6.667, 95% CI: 1.1034–42.970).⁹ In 30.2% of patients (n = 13) in the JJ group, stones were displaced upward with retrograde endoscopy.⁹

Time to definitive treatment differed between studies and one of the randomized studies reported a significantly shorter indwelling time of PCN than of JJ. Another study reported an equal time to treatment of median 30 to 31 days.^7,11 Method of drainage correlated with the later treatment method in this last study. Patients receiving PCN were significantly more likely to be treated with a percutaneous approach and patients receiving JJ were significantly more often treated ureteroscopically.⁷

Discussion

With this systematic review, we aimed to identify the optimal drainage method in patients with obstructive urolithiasis, considering the technical aspects of the procedure, efficacy, complications, costs, patient comfort, and QoL.

There are few randomized studies on this subject limited by low inclusion rates. Most studies included focus on infection as the main cause for decompression and do not perform a subanalysis of the groups on indications for drainage: pain, loss of renal function, and infection. We aimed to give an overview of the present literature. Since the last review of Ramsey in 2010, six studies were published comparing JJ and PCN for drainage in obstructive urolithiasis.¹⁷ Evaluation of QoL and the use of patient-reported outcome measurements (PROMs) are introduced nowadays to assess outcome of procedures from a patient-centered view, a shift from a treatment-centered view. This is clearly visible in outcome parameters of the more recent studies.

Clinical practice

Preferences for JJ or PCN varied between specialties. A survey among radiologists and urologists in 2006 in the U.K. (response rate of 19.3%) showed that urologists significantly preferred PCN more often than JJ. Only in patients with uncomplicated benign disease and with coagulopathy, JJ was the first choice of urologists.³ Distinction in urgency also appeared to be an important factor in clinical decision-making. In contrast to infection, drainage for pain or loss of renal function may usually be safely delayed for a limited period of time, and logistics can be taken into account. Availability, logistics, and experience with PCN or JJ techniques vary during office hours vs on-call period, and result in local, regional, national, and international differences.

Symptoms and patient selection

Arguments for choosing PCN over JJ were monitoring of diuresis, less manipulation of the urinary tract, and the variety of tube sizes for irrigation in a patient with urosepsis. Urinary symptoms such as hematuria and dysuria are reported less frequently in patients with a nephrostomy tube.

Reasons to choose JJ over PCN was the belief of lower rate of complications and no use of external tubes or collecting bags.¹² An external tube and collecting bag are known to give back pain, which is reported more frequently in the nephrostomy group. Also the risk for congestion and luxation is higher when a nephrostomy tube is present than when an internal stent is present.

Patient-specific factors such as anatomic difficulties (benign prostate hyperplasia/altered lower tract anatomy) and expected definitive treatment may also play an important role in the individual decision-making process, which makes this process difficult to standardize.

A higher risk of bacteremia during retrograde manipulation was stated previously, but is doubted because of insufficient evidence. Demographic data, using the nationwide inpatient sample of the United States between 1999 and 2009, even support the opposite.¹⁰ One of our included randomized studies reported this as a secondary outcome and stated there was no significant difference in length of stay or normalizations of infectious parameters.^6,17

Success and complications

Success of procedure was reached in almost all patients in the JJ group and PCN group as well. Since most studies were nonrandomized, there has probably been patient selection for choosing either procedure, influencing outcome. In the few cases of either unsuccessful JJ placement or introduction of a nephrostomy, a second attempt crossover to the other procedure was sufficient. Sufficient use of analgesics or anesthesia could result in better procedural outcome. Most patients in the three randomized studies were treated under local anesthesia; only Pearle reported JJ placement under general anesthesia in some cases. Overall success rates in the literature for PCN and JJ in patients with obstructive urolithiasis ranged from 98% to 100% and from 96% to 100%, respectively,^18
–20 and are comparable with our review when compensating for low numbers.

Complications in our data were low compared with procedure-specific complications reported in the literature. Major complication rates for nephrostomy tube placement in urolithiasis patients reached up to 3% to 5% in the literature (colon puncture, sepsis, pneumothorax, and macroscopic hematuria requiring transfusion) and minor complications were reported up to 4% or 5% (urine extravasation, hematuria, and clot retention).^21

–24 In the randomized data included in this review, dislodgement of a nephrostomy tube occurred in one case, but no other complications were seen. Data on retrograde JJ placement in urolithiasis patients showed similar complication rates. The main difference is that these were mostly minor complications. Major hemorrhagic problems or death was not reported for patients receiving JJ.^18,25

Costs and length of hospital stay

A large variety in outcome was found when evaluating costs. Differences between financial systems of countries and other factors such as materials used, type of anesthesia, success rates, and outpatient vs inpatient procedure make comparison of costs difficult. Length of hospital stay and location of procedure (operating theater or outpatient department) or use of anesthesia are strong influencers of costs. As seen in the article of Pearle, general anesthesia was used often for JJ placement. Costs were twice as high compared with PCN procedures under local anesthesia, mainly because of additional costs for using the operating room, extra staff, anesthesia, and supplies. If a hospital provides possibilities for JJ insertion under local anesthesia in the outpatient department, the comparison would completely be different.

Length of hospital stay can be influenced by a selection bias introduced by the choice of PCN vs JJ. Sammon reported in his retrospective data analysis that patients in the JJ group significantly differed from those in the PCN group, both patient and hospital characteristics. Patients undergoing PCN experienced significantly higher rates of (severe) sepsis and inhospital mortality. Also, home health care after hospital discharge can take a longer time if PCN was performed and influences total length of stay.

A shorter time to definitive drainage could result in lower costs. A multicenter analysis in Romania among patients with hydronephrosis and infection showed that increased costs of hospital stay were in retrospect significantly related to a longer time to definitive drainage. The group that received drainage within 9 hours of first presentation associated with the lowest costs and drainage after 15 hours was associated with longer hospital stay and a significant increase in costs.²⁶

Pregnancy

For pregnant women, two studies were found and concluded that PCN seemed more effective than JJ insertion. Both JJ-induced bladder irritation and PCN carrying an external tube or collecting bag were described as uncomfortable. When choosing JJ placement in this group of patients, rapid encrustation needs to be taken into account. During pregnancy, hyperuricosuria, high calcium diet, hypercalciuria, and asymptomatic bacteriuria are common, enlarging the chance of complications.^27,28 With a higher chance of stent replacement, a JJ stent could be placed in the third trimester of pregnancy.²⁹ However, in the first and second trimesters, a PCN is preferred over a JJ.

Patient-reported outcome measurements in urolithiasis

Conclusions on pain and QoL are contradictory. Back pain was reported significantly more in PCN than in JJ. Where some opinions opt for a JJ as having greater patient comfort, this burden was considerable. Having a JJ may result in urinary tract symptoms such as dysuria, frequency, and hematuria, and influence QoL.^9,11,29 Hematuria in the literature ranged from 2% to 21% for patients with JJ and additional analgesia was required in up to 70% of patients in the first week after JJ placement.^31,32 A solution for this problem could be placement of an antireflux stent, which has proven to reach a higher acceptance rate with significantly less flank pain or pain in the bladder. However, costs of these types of stents are higher, which should be taken into account.³³

Age seems to influence QoL. One of our studies found that patients <40 years of age appeared to experience more complaints with a JJ than patients >40 years of age.¹¹ Also Borofsky reported in his PROMs study that patients <30 years and also between 30 and 65 years of age experienced more stent-related side effects than patients >65 years.³⁴ Thus burden of JJ may be greater for younger patients than for older patients.

In 2001, Joshi analyzed a group of 34 patients in a prospective study comparing PCN with JJ using the EuroQol EQ-5D. Patients in the JJ group had significantly more lower urinary tract symptoms (LUTSs) than those in the PCN group, but overall analysis showed no significant difference in impact on QoL.³⁵ However, intervention-specific PROMs regarding decompressing treatments comparing patients with indwelling JJ or nephrostomies have not been developed yet.

Conclusions

Both PCN and JJ have comparable success rates for patients with obstructive urolithiasis, and procedure-related complications are rare. Overall, higher rates of sepsis, longer hospital stay, and higher costs were found in the PCN group, but that could be explained by patient selection. Patients with JJ experienced a lower QoL and experience more LUTSs. Selection to date is made by local practice, patient characteristics, and expertise as well as facilities. Also reimbursement may influence preferences. Evaluations of QoL and PROMs in urolithiasis are gaining ground, but intervention-specific PROMs still have to be developed.

Footnotes

Acknowledgment

We thank Dr. N.F. Dabhoiwala for his corrections and advice on English writing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Data

Supplementary Figure S1

Abbreviations and Acronyms

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Supplementary Material

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Lessons from Literature: Nephrostomy Versus Double J Ureteral Catheterization in Patients with Obstructive Urolithiasis—Which Method Is Superior?

Abstract

Purpose:

Methods:

Results:

Conclusions:

Introduction

Methods

Results

The need for drainage and choice of procedure

Technical aspects: Success and complications

Efficacy, length of stay, and costs

Drainage during pregnancy

Quality of life

Spontaneous stone passage and stone management

Discussion

Clinical practice

Symptoms and patient selection

Success and complications

Costs and length of hospital stay

Pregnancy

Patient-reported outcome measurements in urolithiasis

Conclusions

Footnotes

Acknowledgment

Author Disclosure Statement

Funding Information

Supplementary Material

Abbreviations and Acronyms

References

Supplementary Material