Ureteral stones, the most common etiology causing acute upper urinary obstruction and they are a frequent reason for emergency department visits. Most cases can be managed conservatively (10).
In cases of persistent colic pain or recurrent colic attacks where medical analgesia fails to provide relief, surgical intervention via stenting, percutaneous nephrostomy, or stone removal becomes necessary (11). Indeed, a study by Eaton H. et al. revealed that refractory colic attacks lead to repeated admissions, increasing costs and causing loss of work productivity (12).
In cases accompanied by infection, decompression must be performed due to the risk of developing urosepsis, which may progress to septic shock—a condition with a current mortality rate of 30–40% (13).
Acute kidney injury due to obstructive uropathy, which can arise from acute upper urinary obstruction, has the potential to progress to end-stage renal disease. Untreated or inadequately managed cases can result in tubular damage, inflammation, and interstitial renal fibrosis, leading to permanent kidney damage (14). In our clinical practice, given the emphasis on nephron preservation, surgical decompression is generally preferred over conservative management in cases with elevated creatinine levels suggestive of acute kidney injury.
Placement of ureteral stents was unsuccessful in 9 patients, while percutaneous nephrostomy failed in 1 patient. These rates did not show a significant technical difference. Similarly, the literature reports technical success rates of up to 99% for percutaneous nephrostomy and approximately 98% for ureteral stents (15,16).
In patients undergoing PNC, a significantly faster reduction in creatinine levels was observed at 12 hours post-procedure. However, by the 48th hour, creatinine levels had returned to normal ranges in both groups, and no significant difference was detected. Similarly, Yang S. et al. reported that 1–5% of acute upper urinary obstruction cases presented to the emergency department with acute kidney injury, with renal function recovery primarily depending on the severity and duration of the obstruction and infection (17).
The length of hospital stay was significantly longer in the PNC group. We attribute this to the tendency to use PNC in patients with higher grades of dilation and the prolonged antibiotic therapy necessitated by concomitant urinary infections in this group.
Although there was a tendency to use RUS in distal stones, stone location did not significantly influence the choice of procedure. Similarly, Sivalingam et al. reported that the use of percutaneous nephrostomy and stents was comparable for proximal stones (18% and 16%, respectively), while stents were preferred for mid and distal stones (18).
At our clinic, RUS procedures are performed in the operating room under optimal sterilization conditions to minimize complication rates. In contrast, PNC placement is conducted in the interventional radiology clinic under local anesthesia. The mean operation time for JJ stent insertion was significantly longer than the mean time for nephrostomy application (17.9±4.6 min and 13.7±3.7 min). Both procedures utilized fluoroscopy, and no significant difference in fluoroscopy times was observed between the groups.
Intraoperative complications are shown in Table 3. As expected, complications such as stone migration and ureteral mucosal damage were observed in the RUS group due to intraluminal manipulation, while bleeding occurred in both groups. However, no significant difference in complication rates was detected between the groups. This finding aligns with the study by Pearle M.S. et al., which also found no significant difference in overall complication rates between RUS and PNC (19).
The time from surgical decompression to final treatment was significantly longer in the PNC group. This may be attributed to the extended duration of antibiotic therapy and the need to wait for sterile urine cultures before the final treatment, particularly in patients with infection or sepsis, which were more prevalent in the PNC group. However, the difference between the groups was not statistically significant.
The limitations of our study include its retrospective design and the absence of randomization in case selection. Additionally, performing both procedures by the same surgical team might have provided more definitive insights. Besides the study was conducted at a single center, limiting it’s generalizability. The sample size of the nephrostomy group was relatively small, which may have affected statistical power. Long-term follow-up data on renal function and stone recurrence were not included, which could provide a more comprehensive assessment. Nevertheless, given the lack of sufficient evidence regarding procedure selection in emergency upper urinary obstruction cases, we believe the findings of this study will contribute valuable information to the literature regarding disease management.
DISCUSSION
Ureteral stones, the most common etiology causing acute upper urinary obstruction and they are a frequent reason for emergency department visits. Most cases can be managed conservatively (10).
In cases of persistent colic pain or recurrent colic attacks where medical analgesia fails to provide relief, surgical intervention via stenting, percutaneous nephrostomy, or stone removal becomes necessary (11). Indeed, a study by Eaton H. et al. revealed that refractory colic attacks lead to repeated admissions, increasing costs and causing loss of work productivity (12).
In cases accompanied by infection, decompression must be performed due to the risk of developing urosepsis, which may progress to septic shock—a condition with a current mortality rate of 30–40% (13).
Acute kidney injury due to obstructive uropathy, which can arise from acute upper urinary obstruction, has the potential to progress to end-stage renal disease. Untreated or inadequately managed cases can result in tubular damage, inflammation, and interstitial renal fibrosis, leading to permanent kidney damage (14). In our clinical practice, given the emphasis on nephron preservation, surgical decompression is generally preferred over conservative management in cases with elevated creatinine levels suggestive of acute kidney injury.
Placement of ureteral stents was unsuccessful in 9 patients, while percutaneous nephrostomy failed in 1 patient. These rates did not show a significant technical difference. Similarly, the literature reports technical success rates of up to 99% for percutaneous nephrostomy and approximately 98% for ureteral stents (15,16).
In patients undergoing PNC, a significantly faster reduction in creatinine levels was observed at 12 hours post-procedure. However, by the 48th hour, creatinine levels had returned to normal ranges in both groups, and no significant difference was detected. Similarly, Yang S. et al. reported that 1–5% of acute upper urinary obstruction cases presented to the emergency department with acute kidney injury, with renal function recovery primarily depending on the severity and duration of the obstruction and infection (17).
The length of hospital stay was significantly longer in the PNC group. We attribute this to the tendency to use PNC in patients with higher grades of dilation and the prolonged antibiotic therapy necessitated by concomitant urinary infections in this group.
Although there was a tendency to use RUS in distal stones, stone location did not significantly influence the choice of procedure. Similarly, Sivalingam et al. reported that the use of percutaneous nephrostomy and stents was comparable for proximal stones (18% and 16%, respectively), while stents were preferred for mid and distal stones (18).
At our clinic, RUS procedures are performed in the operating room under optimal sterilization conditions to minimize complication rates. In contrast, PNC placement is conducted in the interventional radiology clinic under local anesthesia. The mean operation time for JJ stent insertion was significantly longer than the mean time for nephrostomy application (17.9±4.6 min and 13.7±3.7 min). Both procedures utilized fluoroscopy, and no significant difference in fluoroscopy times was observed between the groups.
Intraoperative complications are shown in Table 3. As expected, complications such as stone migration and ureteral mucosal damage were observed in the RUS group due to intraluminal manipulation, while bleeding occurred in both groups. However, no significant difference in complication rates was detected between the groups. This finding aligns with the study by Pearle M.S. et al., which also found no significant difference in overall complication rates between RUS and PNC (19).
The time from surgical decompression to final treatment was significantly longer in the PNC group. This may be attributed to the extended duration of antibiotic therapy and the need to wait for sterile urine cultures before the final treatment, particularly in patients with infection or sepsis, which were more prevalent in the PNC group. However, the difference between the groups was not statistically significant.
The limitations of our study include its retrospective design and the absence of randomization in case selection. Additionally, performing both procedures by the same surgical team might have provided more definitive insights. Besides the study was conducted at a single center, limiting it’s generalizability. The sample size of the nephrostomy group was relatively small, which may have affected statistical power. Long-term follow-up data on renal function and stone recurrence were not included, which could provide a more comprehensive assessment. Nevertheless, given the lack of sufficient evidence regarding procedure selection in emergency upper urinary obstruction cases, we believe the findings of this study will contribute valuable information to the literature regarding disease management.