The PCN catheter was used for the first time in 1954 to decompress hydronephrosis [4]. Goodwin et al. first published the utility of PCN in their 15 patients with HUN [6]. Following USG-guided placement of PCN in 1974, the success rates have increased over the years from the initial 75%. Complicated urinary tract infections are those that generally require intravenous antibiotics due to the risk of urosepsis in patients with anatomical or other predisposing factors such as diabetes, pregnancy, nephrolithiasis, and malignancy [3]. Emergency PCN may be required in upper urinary tract infections to prevent sepsis [4]. Contraindications to the procedure would include severe hyperkalemia, uncorrected coagulopathy, and uncontrolled hypertension, all of which are seen in patients admitted in the medical departments [7].
Females are generally more prone to urosepsis [8], but it was more common among males in our study (29 vs 18), probably due to more diabetes (23 vs 15, p-value = 0.06), CKD (37 vs 22, p value = 0.007), nephrolithiasis (49 vs 21, p-value < 0.001) and prior pyelonephritis (12 vs 9, p-value = 0.32); interestingly, malignancies were commoner in females (30 vs 79, p-value < 0.001), but malignancies coexisting with pyelonephritis were seen only in 8(n = 101) patients with a p values of < 0.001. PCN is the first-line therapy in infected hydronephrosis and an early adjunctive therapy in patients with emphysematous pyelonephritis [5]. Thirty-three (33/47) of our patients with infection had an obstructed system that needed PCN.
Percutaneous nephrostomy is part of the initial treatment in patients with emphysematous pyelonephritis [9]. The PCN was used in most of our patients to relieve obstruction ( renal calculi, pregnancy-related hydronephrosis, and pyonephrosis) and obtain access to the renal system (removal of forgotten stents and percutaneous nephrolithotomy) [4]. Only three of our patients underwent the procedure for urinary diversion; none had diagnostic testing through the PCN [10]. Relief of urinary obstruction was the primary cause for placement of PCN; this was the case even in malignancy, where 65.2% of all malignancies needed PCN due to HUN. Overall, 82.5% of the total (n = 226) had an obstructed system necessitating PCN, which was similar to world literature [10]
. Complications arising out of PCNL and PCN range from 0.05 to 3% to 2–10%, respectively [10, 11]. Significant complications are seen in less than 1% [5]. Severe complications generally include new sepsis, hemorrhage needing transfusion, and trauma to adjacent structures. Major complications of PCN that have been described in the literature include organ or viscus puncture, hemorrhage requiring transfusion, sepsis; minor complications include tube blockage requiring further intervention, minor hemorrhage, and urinary extravasation [12].
The rate of complications (0.06% in the infectious group) was lower than the threshold of 4%, according to the Society of Interventional Radiology Standards of Practice Committee [2]. Displacement of catheters can range up to 30% over many months and low as 1% in the early post-operative period [10]. There was a 1.4% incidence of slippage of catheters in our study (n = 10). Bacteriuria is a risk factor for fever following PCN, possibly present in most cases, but none reported postoperative fever. Colonic perforation has been reported in left-sided procedures, elderly patients, and those with a distended colon [13] The lone patient with faecaluria had had bilateral PCN placement done.
In the study by Watson et al., 315 patients who underwent PCN, 187 (49.8%) had a calculus for the cause of obstruction and 37 without a determined obstructive cause [5]. Wah et al. had studied 218 PCN placements- half of them were due to malignancy and only 4% were due to renal stones [12]. The proportion of pyelonephritis and infective conditions was not known. Contrastingly, stones constituted 31% of our study, while infections contributed to 20.8%. Minor complications were 11% [12].
Successful PCN was placed in the first attempt in 214/218 of patients using the Seldinger technique in the study by Watson et al., while 81% (n = 183) was achieved in the first attempt in our study [5]. Overall, only 2.8% developed complications, both major and minor [5]. The only major complication in our study was faecaluria, which was conservatively managed. A 10-year Turkish study of 354 patients showed a major and minor complication rate of 11% and 7.7%, respectively [6]. They had 66 patients with pyonephroses, but whether they were initially pyelonephritis to begin with, is not clear [6].
Previously, a one-and-a-half-year prospective audit of PCN from our institution studied 368 PCN placements (344 patients) with infective conditions in 40 patients. Success rate and complications were studied.[14] A 4.2% major and 27.4% minor complication rate was found. A higher minor complication rate was attributed to a longer follow-up period of one month and inclusion of urinary tract infection and dislodgement [14]. Ours was retrospective with focus only on inpatients. We studied 262 PCN placements in 226 patients. Thirty-one of these were redo PCNs for complications such as blockage, urine leak, and slippage of the PCN catheter.