Percutaneous Nephrostomy Before Ureteral Reconstruction: Providing Ureteral Rest, But At What Cost?

doi:10.21203/rs.3.rs-5252729/v1

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Research Article

Percutaneous Nephrostomy Before Ureteral Reconstruction: Providing Ureteral Rest, But At What Cost?

https://doi.org/10.21203/rs.3.rs-5252729/v1

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Purpose

Ureteral stent removal with pre-operative placement of percutaneous nephrostomy (PCN) allows for a period of ureteral rest. To better understand the impact on pre-operative PCN placement on patient quality of life (QoL), we created a novel questionnaire to distribute to our patients with questions pertaining to pain, general health, work performance, sexual matters, ease of follow-up, and urinary symptoms.

Methods

We retrospectively surveyed 20 patients with pre-operative PCN before ureteral reconstruction. Questions ranged from strongly disagree (1) to strongly agree (5) on a 5-point Likert-scale.

Results

Conclusions

Pre-operative PCN placement did not significantly impact patient’s QoL in terms of overall satisfaction and should continue to be employed for ureteral rest prior to ureteral reconstruction. This tool can be further utilized to quantify the personal implications of a PCN on patients.

percutaneous nephrostomy

ureteral rest

quality of life

ureteral reconstruction

Ureteral rest refers to the absence of ureteral instrumentation for a period of time prior to a planned ureteral reconstruction. Ureteral rest plays a role in optimizing surgical outcomes in patients with ureteral obstruction prior to upper urinary tract reconstruction.^{1, 2} Avoidance of ureteral instrumentation through removal of ureteral stenting allows for ureteral tissue to stabilize and recover from peri-ureteral inflammation.^{3, 4} This grants a more precise characterization of ureteral stricture severity, location, and length at time of reconstructive repair.³ Implementation of ureteral rest prior to ureteral reconstruction has been associated with improved surgical outcomes, including increased success rates and lower estimated blood loss.³

In order to allow for ureteral rest, ureteral stents are removed, often with a pre-operative placement of a percutaneous nephrostomy (PCN) tube.^5–7 Complications and issues with patient satisfaction have been associated with PCN placement.^{8, 9} PCN placement has previously shown to significantly decrease mobility, personal care, daily activities, and cause anxiety/depression.^{10, 11} To this end, patient reported outcome measures allow for a structured assessment of patient health-related QoL that can be used to better understand the impact of pre-operative PCN placement in clinical practice.^{12, 13}

To our knowledge, a systematic and detailed assessment of symptoms associated with pre-operative PCN placement prior to ureteral reconstruction and its overall impact on patient QoL has not previously been performed. To better understand the impact of pre-operative PCN placement on patient’s QoL, we created a PCN symptom questionnaire (PCNSQ) to distribute to our patients with questions pertaining to pain, general health, work performance, sexual matters, ease of follow-up, urinary symptoms, and associated complications. We hypothesized that patient QoL would be negatively impacted by pre-operative PCN placement.

A symptom questionnaire was developed to retrospectively survey 20 patients managed pre-operatively with a PCN prior to surgery. Surgeries were performed at a single-institution from 2016 to 2023. Surveys were administered via a phone interview during July of 2023. The PCNSQ was comprised of 34 items covering areas relating to pain, general health, work performance, sexual matters, ease of follow-up, urinary symptoms, and associated complications. Additionally, patients were asked about their level of understanding of the purpose of pre-operative PCN placement in relation to a successful surgical outcome. Patients answered questions ranging from strongly disagree (1) to strongly agree (5) on a 5-point Likert-scale. The mean score and 95% confidence intervals were then individually calculated for each question item using DATA Tab (DATAtab team, Graz, Austria).

Of 20 total patients surveyed, 65% strongly agreed or agreed that PCN improved their pain prior to surgery with an average score of 3.9 (95% CI 3.31–4.49). Overall, 65% of patients strongly agreed or agreed that PCN made it challenging to enjoy everyday activities with an average score of 3.8 (95% CI 3.16–4.44). Additionally, 75% strongly agreed or agreed it made engaging in exercise difficult with an average score of 3.95 (95% CI 3.52–4.38). Regarding sexual health, 40% of patients felt neutral regarding PCN leading to a decreased desire to have sexual intercourse with an average score of 3.2 (95% CI 2.6–3.8). In terms of sexual health, 40% of patients were also neutral regarding PCN leading to feeling unattractive around partners with an average score of 3.3 (95% CI 2.7–3.9). Patients also felt neutral regarding finding sexual intercourse challenging with an average score of 3.2 (95% CI 2.6–3.8). For work performance, 70% of patients strongly disagreed or disagreed that the quality of their work was diminished with an average score of 2.05 (95% CI 1.44–2.66). Moreover, 85% of patients disagreed that their ability to concentrate at work was diminished with a PCN with an average score of 1.7 (95% CI 1.22–2.18). Regarding ease of follow-up care, 90% of patients strongly disagreed or disagreed that they had difficulty arranging for follow-up appointments with interventional radiology with an average score of 1.4 (95% CI 0.9–1.8). Also, 95% strongly disagreed or disagreed that they had difficulty arranging for dressing changes with the PCN in place with an average score of 1.5, (95% CI 1.0–2.0) (Fig. 1). In terms of urinary symptoms, 70% strongly disagreed or disagreed that they felt worried about leaking urine onto their surroundings or clothes with an average score of 2.1 (95% CI 1.4–2.8). Additionally, 95% of patients strongly agreed or agreed that they felt confident that they understood the reasoning for PCN placement with an average score of 4.8 (95% CI 4.4–5.1) (Fig. 1). In terms of overall satisfaction, 95% of patients strongly agreed or agreed that they were happy to have a PCN due to an increased likelihood of having a successful surgery with an average score of 4.8 (95% CI 4.6-5.0) (Fig. 1). Of 20 patients interviewed, 3 patients failed ureteral reconstruction and answered positively regarding overall satisfaction with an average score of 4.67 (95% CI 4.137–5.203).

Our survey instrument allowed for characterization of patient experiences with PCN and its impact on health-related quality of life. In our patient cohort, pre-operative PCN placement improved pain in a majority of patients and did not interfere with QoL in terms of work performance or urinary symptoms. However, patients found that PCN interfered most with daily activities and their ability to engage in exercise, and were neutral regarding changes in sexual health. Overall, patients felt satisfied in their understanding of the purposes of PCN placement and its role in improving their surgical outcome, showing how it may continue to be employed for ureteral rest prior to ureteral reconstruction.

The role of tissue rest was initially well-established in the context of urethral reconstruction in patients with urethral strictures prior to urethroplasty.^{3, 14–16} Terlecki et al. found that urethral rest from endoscopic manipulation allowed for enhanced detection of fibrotic stricture segments, as well as accurate radiographic identification of stricture length and location.¹⁵ Likewise, implementation of ureteral rest prior to definitive reconstruction has been associated with improved surgical outcomes for patients with ureteral stricture disease. Lee et al. retrospectively compared outcomes of robotic ureteral reconstruction in 234 patients who either underwent ureteral rest or did not undergo ureteral rest for management of proximal to mid-ureteral strictures³. Ureteral rest was defined as the absence of hardware, such as a ureteral stent or percutaneous nephroureterostomy tube, across a ureteral stricture for at least 4 weeks prior to robotic reconstruction. Patients who underwent ureteral rest were associated with a higher success rate (90.7% versus 77.5%, respectively; p = 0.027) and lower estimated blood loss − 50 mL versus 75 mL, respectively (p < 0.001) compared to those not undergoing ureteral rest³. Given ureteral rest prevents continuous microvascular injury which may be perpetuated with ureteral stenting, pre-operative PCN placement plays an integral role in allowing for healing of ureteral tissue and maturation of ureteral strictures prior to surgery.^{15, 17} Since there is an overall lack of evidence-based guidelines framing the indications for ureteral rest, understanding the nuances of patient QoL due to subsequent PCN placement is especially crucial.

External urinary drainage through urethral catheters, suprapubic tubes (SPTs) and PCNs has been shown to have a notable impact on quality of life, as demonstrated by several studies. In this present study, 65% strongly agreed or agreed that PCN improved their pain prior to surgery. A longitudinal descriptive study of 150 patients also found that patients had significant pain reduction following first-time PCN placement (p < 0.01).¹⁰ Using the European Quality of Life-5 Dimensions (EQ-5D) questionnaire, they found that PCN placement significantly diminished overall patient QoL in terms of mobility, personal care, daily activities, and anxiety (p < 0.05), with daily activities being the most altered QoL dimension.¹⁰ Similarly in our study, a majority of patients found it challenging to enjoy everyday activities and exercise with PCN in place. To assess the impact of other forms of external urinary drainage, the catheter-related quality of life tool is a validated instrument employed for long-term urinary catheter users who use indwelling urethral or suprapubic catheters permanently.¹⁸ Wiedemann et al. surveyed 357 patients with long-term SPTs or urethral catheters and found a negative impact on QoL related to fear of urine leakage, urine odor, painful catheter exchanges, and increased frequency of urinary infections.¹⁹ These patients also reported negative effects on their everyday life activities due to the catheter.¹⁹ Patient-reported outcomes play a crucial role in informing clinical indications for the utilization of urethral catheters, SPTs, and PCNs as these methods are variably tolerated and have a substantial impact on patient well-being.

Ureteral stenting is alternatively employed by urologists to relieve upper urinary tract obstruction in patients with ureteral stricture disease prior to reconstruction and has been shown to impact health-related QoL. The ureteral stent symptom questionnaire is a validated instrument that has been used in prior studies to measure the impact of ureteral stents. Using this tool, prior studies have found that indwelling ureteral stents have a significant impact on QoL in terms of pain, urinary symptoms, and general health.²⁰ Scarneciu et al. analyzed the prevalence of symptoms and complications of ureteral stents in 2200 patients through completion of questionnaires before stent placement, 7 days after placement, and 14 days after removal.²¹ It was found that frequency of uncomfortable symptoms was significantly higher 7 days after stent insertion in terms of urinary frequency, dysuria, urgency and macroscopic hematuria (p < 0.05).²¹ In patients with malignant ureteral obstruction, Shvero et al. studied changes in QoL in those managed with PCN and tandem ureteral stents using QoL and tube-symptom questionnaires.²² Among 107 patients with malignant ureteral obstruction, both methods had a negative impact on QoL and urinary symptoms without a significant difference between them.²² Joshi et al. compared changes in QoL in 34 patients managed with either PCN or ureteral stents using the EQ-5D questionnaire and intervention specific questions to assess for pain, urinary symptoms, and impact on daily activities.²³ Although there were no significant differences in overall physical and psychosocial function in terms of average EQ-5D score between both groups, patients who had a stent experienced significantly greater irritative urinary symptoms (p < 0.0001) than those with PCN.²³ In comparison, we found that a majority of patients with PCN did not report severe urinary symptoms, including leakage or blood in their nephrostomy bag. Notably, patients with PCNs required more help in the daily care of the nephrostomy tube than those with ureteral stents. In contrast, a majority of our patients did not find PCN challenging to care for. Both ureteral stents and PCNs have notable impacts on QoL- ureteral stents are associated with increased discomfort and urinary symptoms while PCN is generally better tolerated amongst patients, underscoring the significance of patient-reported outcomes in treatment selection.

Our study is not without limitations. Major limitations of this study are the small sample size and the retrospective nature of the patient interview process. This is also a single-institution, single-surgeon series and therefore may not be widely generalizable. Given we administered the PCNSQ to patients retrospectively, recall bias may have influenced patient answers. Since our survey instrument has not been previously validated as an objective symptom assessment tool, patient response bias based on subjective interpretation of certain questions during the interview process is possible. Further validation of our survey instrument in a larger patient population may increase its reliability in providing empirical evidence for the clinical decision-making process of PCN use for ureteral rest.

Health-related QoL is based on patient perception of their disease and how its management influences the physical, social, and emotional domains of everyday life.²⁴ Measuring QoL allows for an enhanced understanding of the confluence of these domains, thereby capturing the diversity of patient experiences in a standardized manner.²⁵ Considering underserved populations are more vulnerable to decreases in daily QoL through interventions such as PCN, achieving this understanding to investigate the effectiveness of health interventions is paramount.²⁶ Although patients may have a large apprehension to PCN placement, our patients’ experiences demonstrate that it is found not to limit their QoL in terms of pain, work performance, urinary symptoms, sexual health, and ease of follow-up care. This may stand an important finding to relay to patients who are posed with need for PCN placement ahead of surgery. Our PCNSQ tool can be further utilized to quantify the personal implications of PCN on patients, thereby influencing PCN utility prior to ureteral reconstruction.

Our survey instrument allowed for characterization of patient experiences with PCNs and their impact on health-related quality of life. In our patient cohort, pre-operative PCN placement interfered most with performing daily activities and their ability to engage in exercise. Notably a majority of patients reported an improvement of pain following PCN use, as well as little to no interruption in work performance, urinary symptoms, follow-up care, and sexual matters. Patients felt satisfied in their understanding of the purposes of PCN placement and its role in improving their surgical outcome, showing how it may continue to be employed for ureteral rest prior to ureteral reconstruction. This tool can be further utilized to quantify the personal implications of PCN on patients, thereby influencing PCN utility prior to ureteral reconstruction.

Funding- No funds, grants, or other support was received.

Conflict of interest- The authors have no relevant financial or non-financial interests to disclose.

Ethics approval- This study protocol was ethically approved by the Rutgers Institutional Review Board, approval reference number Pro2023000632. Research was conducted in accordance with the 1964 Helsinki Declaration or comparable standards.

Consent- Informed consent was obtained from all study patient participants.

Data availability-

The data that support the findings of this study are not openly available due to reasons of sensitivity and to protect the privacy of survey participants. Data are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Rutgers University.

Acknowledgements and Author Contributions- SEE and BL conceived the idea for the project. BL created the questionnaire. LK performed data collection, conducted phone interviews, and performed data analysis. LK performed the manuscript writing. SEE, BL, KC, AK, JP, KD, and RP provided review and editing of the manuscript. We would like to thank the reviewers for their time and consideration in reviewing this article.

S.E. Elsamra- Project development, manuscript editing

B. Lichtbroun- Project development, manuscript editing

L. Khizir - Protocol development, data collection, data analysis, manuscript writing, manuscript editing

A. Kaldany- Manuscript editing

J. Pfail- Manuscript editing

R. Passerelli- Manuscript editing

K. Doppalapudi- Manuscript editing

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No competing interests reported.

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Percutaneous Nephrostomy Before Ureteral Reconstruction: Providing Ureteral Rest, But At What Cost?

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Introduction

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