A Novel Method for Repositioning Suboptimally Preoperatively Placed Nephrostomy Tubes for Percutaneous Nephrolithotomy Without Renal Repuncture

Nephrostomy tubes (NTs) inserted in emergency settings by interventional radiologists are frequently unsuitable for subsequent percutaneous nephrolithotomy (PCNL). We report a novel method of adjusting these NTs to be used as PCNL tracts and avoid renal repuncture. A retrospective search of 981 consecutive PCNLs performed in our institution between 2002 and 2017 identified all patients with preoperatively inserted NTs. The NTs unsuitable for PCNL were adjusted by a novel approach in which a 5-mm incision was made at the ideal puncture location (IPL) as indicated under fluoroscopic guidance. The preinserted NT was removed after passing a guidewire into the kidney. A dissector clamp was introduced through the entry wound of the removed NTs to bluntly dissect a retroperitoneal tunnel and pull out the distal tip of guidewire through the IPL, while its proximal segment was maintained in the kidney. The newly positioned guidewire was used for PCNL tract preparation without repuncturing the kidney. The NTs were located in the mid calix, lower calix, and renal pelvis in 6 (26%), 13 (57%), and 4 (17%) cases, respectively. The NT was suitable for PCNL in 5 (22%) cases, a new renal access was performed in 3 (13%), and the novel adjustment approach was used in 15 (65%), all successfully. The place of entry was moved an average of 6 cm (range 47) and the angle between the tract axis and the calix axis was reduced by 65° in average. The procedure was done uneventfully in an average of 4 minutes. The novel method of adjusting preoperatively inserted NTs for PCNL by repositioning their original entry location to the IPL offers the possibility of avoiding kidney repuncture. It is feasible, safe, and easy to implement, and it spares potential morbidity related to additional puncturing of the kidney.