Evaluating Ultrasound-Guided Percutaneous Nephrostomy in Low-Resource Settings: Insights from Northern Nigeria

doi:10.21203/rs.3.rs-5304134/v1

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Evaluating Ultrasound-Guided Percutaneous Nephrostomy in Low-Resource Settings: Insights from Northern Nigeria

https://doi.org/10.21203/rs.3.rs-5304134/v1

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Objectives: Percutaneous Nephrostomy (PCN) is a procedure that decompresses or provides access to the renal collecting system. There is a dearth of data about the complications and outcomes of PCN in low and middle-income countries. Objectives: This audit will provide insight into the complications and outcomes of PCN in Nigeria.

Methods: This prospective study was on fifty-five patients who had PCN under ultrasound guidance. We obtained pre-PCN and serial serum creatinine on day one, one week, and one month post-PCN. The patients were monitored for two weeks. We also documented whether or not, the patient has continued to be on dialysis or died. The categorical data was expressed as proportions and percentages. The student’s t-test to compare means between groups for continuous variables. A p-value of <0.05 was considered statistically significant.

Results: Up to 32 (58.2%) were males. About 80% of patients had bilateral PCN. Some patients (27.2%) developed minor complications such as pain, wire impaction, bleeding, or vomiting. During the late post-procedure and follow-up periods, 72.7% had no complication, 12.7% had dislodged tube(s), 10.9% had unilateral tube blockage, and 1.8% had bilateral tube blockage.

The study also showed a significant reduction of serum creatinine in 80% of the subjects. 12.7% of the patients died with 5.5% of patients lost to follow-up, and 1.8% had fluctuating creatinine levels.

Conclusion: Ultrasound-guided PCN is a safe procedure to relieve obstructive uropathy in our setting. PCN significantly improves patient outcomes when performed judiciously and in inappropriate clinical contexts.

percutaneous nephrostomy

complications

serum creatinine

obstructive uropathy

Percutaneous Nephrostomy (PCN) is a minimally invasive procedure performed to divert urine from the renal pelvis or calyces, usually to bypass a distal obstruction causing marked hydronephrosis. Since its description in 1955 which was essentially meant for the aforementioned purpose[1], the procedure has been refined and quickly found relevance in a wide range of clinical indications in both dilated and non-dilated Calyceal systems. Despite advances in minimally invasive urological procedures, PCN continues to be a valuable therapeutic tool, particularly in settings where access to more advanced interventions may be limited. It offers benefits such as direct renal drainage, relief of urinary obstruction, and access to the upper urinary tract for other therapeutic interventions[2]. It has thus become a significant therapeutic modality, almost replacing surgical Nephrostomy as an obsolete procedure. While providing direct renal drainage and relief of urinary obstruction, it also gives convenient access to the upper urinary tract for ureteral stent insertions, dissolution or extraction of calculi, closure of fistulas, drugs administration, insertion of brush biopsy instruments and nephoscopes’ and performance of ureteral meatotomy among others[3–10].

In low-resource settings like Nigeria, the utility of PCN is particularly significant due to limited access to modern endo-urological technology and expertise. At Aminu Kano Teaching Hospital, PCN plays a pivotal role in the management of upper urinary tract obstructions, offering a cost-effective and accessible solution to many patients. However, despite its importance, data on the complications, outcomes, and overall effectiveness of PCN in such settings is limited, making it difficult for health policymakers to evaluate its full potential in improving healthcare outcomes.

This study seeks to address this gap by reviewing the outcomes of PCN procedures performed at Aminu Kano Teaching Hospital. The findings will provide valuable insights into the success rates, complications, and clinical improvements in patients with obstructive uropathy. Policymakers and public health practitioners will benefit from understanding how PCN can reduce the morbidity and financial burden associated with untreated urinary obstructions, thus promoting its integration into healthcare strategies at both local and national levels.

Moreover, documenting the outcomes of PCN in this setting will help justify investments in training, equipment procurement, and capacity building for minimally invasive urological procedures in Nigeria and other West African countries. The results of this audit will serve as baseline data for future studies and may influence policy decisions regarding resource allocation and the prioritization of PCN as a standard procedure for managing obstructive uropathy. By promoting the wider adoption of PCN, we can reduce the health and economic impacts of this condition, particularly in underserved populations.

This is a prospective cohort study of all consenting patients who had percutaneous nephrostomy at the Department of Radiology of Aminu Kano Teaching Hospital-Nigeria.

Approval was obtained from the Research Ethics Committee of Aminu Kano Teaching Hospital, Kano-Nigeria (AKTH/MAC/SUB/12A/P-3/V1/2220). Confidentiality and anonymity of patients were observed. Patients’ ages and sex including the clinical diagnosis were extracted from the records of the Radiology department and the individual patients’ case notes.

All fifty-five consenting patients had percutaneous nephrostomy tubes inserted under ultrasound guidance following routine pre-procedure baseline serum clotting profile (with emphasis on prothrombin time and international normalized ratio [INR]) and complete blood count. Any clothing abnormalities were corrected either by vitamin K supplements or fresh whole blood transfusion. In addition, they had pre-PCN imaging (ultrasound, abdominal computed tomography, or computed tomographic urography).

Patients were scanned in a prone position with a 3.5MHZ curvilinear transducer using NORTEK CS-50, Shenzhen China 2014 ultrasound machine, and transverse/longitudinal sections of the kidney where images were obtained to identify the degree of hydronephrosis. Afterwards, the ideal puncture site into the kidney was via a posterior calyx approach. As soon as the initial puncture site was chosen, it was cleaned and draped. Local anesthesia 5 ~ 10ml of 2% lidocaine was infiltrated subcutaneously at the puncture site.

Using the Seldinger technique under real-time ultrasound guidance, an 18G long access needle (Hakko Co. Ltd, Nagano-ken, Japan) was inserted into the target lower calyx; then a curved J tip 0.038-inch guide-wire (Cook, Bloomington, IN, USA) was passed through the needle sheath into collecting system with the help of an assistant (Fig. 1). Thereafter, the sheath was removed and the wire was retained. Further skin and fascia incision was widened, to allow for serial dilatation using plastic disposable percutaneous dilators. Over the guide wire, the drainage catheter set without inner metallic stylet was introduced into the collecting system after which the metallic trocar was removed. The drainage catheter was then advanced into the collecting system further following over the guide wire. Finally, after confirming the drainage catheter head curling in the collecting system, the guide wire was removed (Fig. 2). The safety string lock was tightened and the catheter was secured to the skin using silk 4 − 0 and connected to a drainage bag.

Urine samples were obtained and sent for Microbiological investigation and culture. All patients were placed on bed rest for two hours post-procedure before being discharged to the ward while the outpatients were usually observed/monitored for four hours before being discharged home on broad-spectrum antibiotics prophylaxis given for one day post-procedure.

We obtained pre-PCN and serial serum creatinine on day one, one week, and one month post-PCN. Furthermore, the patients were monitored for a minimum of two weeks for the presence of complications such as puncture site collections, intractable pain at the puncture site, lack of drainage of urine via PCN tubes, and Tube/catheter dislodgement or evidence of infection (urosepsis) and death were monitored and recorded. We also documented whether or not, the patient has continued to be on dialysis.

DATA ANALYSIS

The data collected was analyzed using the R programming software version 4.0. In the descriptive analyses, categorical data results were expressed as proportions and percentages.

Continuous data was assessed for normality. Those that are normally distributed were summarized using means and standard deviation. While those that are skewed were summarized using the median and interquartile range.

The student’s t-test to compare means between two groups for continuous variables was used. A confidence interval of 95% was used and a p-value of < 0.05 was considered statistically significant.

A total of fifty-five (55) patients had PCN during the study period. Out of which 32 (58.2%) were males and 23 (41.8%) were females.

Forty-four (80%) patients had their tubes inserted bilaterally while six (10.9%) and five (9.1%) had their tubes inserted only on the right and left sides respectively.

The most frequent indication for PCN in our study was advanced cervical cancer (30.9%) followed by advanced urinary bladder cancer (29.1%) and the least was prostate cancer (1.8%) and retroperitoneal tumors (1.8%).

A lot of the patients had no major complications (56.4%) except for procedure-related discomfort during the immediate (intra-procedure) periods. However, some patients developed minor complications including pain (21.8%) at puncture sites, impacted guide wire (1.8%), bleeding (1.8%), and vomiting (1.8%). During the late post-procedure and follow-up periods however, 72.7% had no complication, 12.7% had dislodged tube(s), 10.9% had unilateral tube blockage, and 1.8% had bilateral tube blockage. This is summarized in Table 1.

Table 1

Distribution of Intra and post-procedure complications among PCN patients
	Frequency (n)	Percentage (%)
Intra-procedure Complications
None	31	56.4
Pain	12	21.8
Several attempts	10	18.2
Vomiting	1	1.8
Bleeding	1	1.8
Total	55	100
Post-procedure Complications
None	40	72.7
Dislodged Tube	7	12.7
Blocked Tube (Unilateral)	6	10.9
Blocked Tube (Bilateral)	1	1.8
Impacted Guidewire	1	1.8
Total	55	100

The post-procedure clinical status and laboratory work-up of patients during the follow-up periods revealed that out of the fifty-five patients (80%) were clinically stable with significantly reduced creatinine levels, 12.7% of the patients died with 5.5% of patients lost to follow-up, and 1.8% had fluctuating creatinine levels but otherwise clinically stable. This is summarized in Table 2, Table 3, and Fig. 3.

Table 2

Distribution of post-procedure follow-up status among PCN Patients
Status	Frequency (n)
Stable with reduced serum creatinine levels	44	80.0
Died	7	12.7
Discontinued Follow-up	3	5.5
Stable with fluctuating creatinine levels	1	1.8
Total	55	100

Table 3

Comparison of mean serum creatinine levels between Pre and Post-procedure Period
	Means
	Pre-procedure	Post-procedure (One week)	t-test	P-value
Serum Creatinine Levels	834.79 ± 409.39	520.89 ± 414.45	6.175	*0.001
	Pre-procedure	Post-procedure (Four weeks)
	834.79 ± 409.39	416.39 ± 438.96	5.450	*0.001
Significant at p ≤ 0.05*

The graph shows a significant reduction in all the patients from the pre-procedure level to one-week post-procedure which tends to remain below 200 mmol/L for most of the patients at four (4) weeks post-procedure. Only a few of the patients had a slight rise in their creatinine levels from one week post-procedure with about slightly more than one-third of the baseline value at four weeks.

Obstructive uropathy leading to hydronephrosis /hydroureteronephrosis is among the common clinical presentations to urology emergency units requiring early and prompt interventions to avoid the damaging effect of high and sustained pelvi-calyceal pressure on renal tissues which may result in progressive fall in glomerular filtration rate (GFR), decline in renal excretory functions and eventually renal failure[11]. Percutaneous ultrasound-guided Nephrostomy tube insertion is a relatively simple and cheaper interventional radiological technique with fewer complications for the timely relief of obstructive effects of hydronephrosis on the urinary tract.

From our study, the majority (58.2%) of the patients who had ultrasound-guided PCN procedures were males. Though urinary tract obstructive diseases are generally commoner among males in our environment[12] which may have accounted for the predominance of males in our study. The patients in the present study were also preponderantly in their 5th, 6th, and 7th decades of life (65.4%). Previous researchers have reported that a large proportion of pelvic malignancies (Urologic and Gynecologic) that often cause upper urinary tract obstruction occur from 5th decade of life, hence the predominance of patients of this age group in our study.[13, 14] This is also consistent with the findings of Ahmed et’al in Zaria, Nigeria.[15]

Up to 80% of the patients had bilateral tube insertion; this is based on the fact that most of our patients in this study presented with bilateral obstruction and most often in renal failure. Bilateral ureteric obstruction is more commonly seen in pelvic malignancies as also reported by Ahmed et al in Zaria.[15] Our findings revealed advanced cervical cancer (30.9%) and bladder cancer (29.1%) to be the commonest malignant causes of urinary tract obstructions while obstructed ureteric stones (21.8%) were the commonest benign cause of obstructive uropathy. Previous reports[13,14] have indicated the presentation of these pelvic malignancies in this environment which mostly were in the advanced stages of their disease with high risk of local invasion of contiguous structures. The findings are also consistent with the study of Efesoy et al in Turkey.[16]

Most of the patients did not develop complications within both intra-procedure (56.4%) and post-procedure (72.7%) periods. Minor complications recorded were either related to the needle puncture site localized pain and tube blockage/dislodgement which may be from inappropriate tube handling post-procedure. The low complication rate in the majority of our patients resulted in significant patient clinical improvement and markedly reduced serum creatinine levels (80%) post-intervention. However, few deaths (12.7%) were recorded despite the intervention which may be attributable to primary disease progression. These findings are comparable with findings from other studies across the globe.[17, 18,19]

The Marked reduction in serum creatinine level one week post-intervention which continued up to the 4th week signified an immediate relief of the high intra-luminal pelvi-calyceal pressure with gradual recovery in renal function. These highlight the effectiveness of PCN as a viable and minimally invasive alternative to the existing treatment options in the overall management of patients with obstructive uropathy. Also, PCN helps secure adequate time for proper treatment planning of the primary cause of renal obstruction. However, some of the limitations of our study included the modest number of patient samples and the relatively short follow-up period of one-month post-procedure which didn’t permit monitoring of long-term complications.

This study offers valuable insights into the feasibility and outcomes of percutaneous nephrostomy (PCN) in low-resource settings, particularly where healthcare access and technology are limited. It addresses a critical gap in the literature by documenting PCN outcomes in Northern Nigeria, providing key information for clinicians and policymakers in managing obstructive uropathy. The study emphasizes PCN as a minimally invasive treatment option, especially for advanced pelvic malignancies, demonstrating its effectiveness in reducing complications and improving renal function. The use of serum creatinine levels as a clinical marker offers objective evidence of PCN’s positive impact. Additionally, the low complication rates affirm PCN’s safety and efficacy, supporting its broader use in resource-limited settings. The findings also have policy implications, encouraging investment in minimally invasive urological procedures and resource allocation for better healthcare outcomes.

The study’s modest sample size of 55 patients limits the generalizability of the findings to a broader population. The one-month follow-up period may not capture long-term complications such as tube dislodgement, infection, or disease progression. The absence of a control group prevents direct comparison with other interventions like ureteral stenting or surgery. Additionally, the 5.5% loss to follow-up could affect the assessment of long-term outcomes, potentially underestimating complication rates. Finally, while patient deaths were recorded, they were attributed to disease progression without investigating whether PCN or related complications played a role.

This study confirms that percutaneous ultrasound-guided nephrostomy (PCN) is an effective treatment for obstructive uropathy, particularly in patients with advanced pelvic malignancies. Most patients experienced clinical stability post-procedure, with marked improvements in renal function, evidenced by reduced serum creatinine levels. The procedure had a low complication rate, with only minor and manageable issues, highlighting its safety and practicality in low-resource settings. The observed deaths were likely due to disease progression rather than the procedure. Therefore, PCN provides critical time for planning definitive treatment, but further research with larger samples and extended follow-up is necessary to evaluate long-term outcomes.

PCN

Percutaneous Nephrostomy

INR

International Normalized Ratio

GFR

Glomerular Filtration Rate

Computed Tomography

AKTH

Aminu Kano Teaching Hospital

NIH

National Institutes of Health

FIC

Fogarty International Center

NIAAA

National Institute on Alcohol Abuse and Alcoholism

Ethics approval and consent to participate

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and approval for the study was obtained from the Health Research Ethics committee of Aminu Kano Teaching Hospital, Kano, Nigeria; with reference number (AKTH/MAC/SUB/12A/P-3/V1/2220). Furthermore, an informed Consent was obtained from each patient/research subject, to participate and to publish the findings in a scientific journal.

Consent for publication

All our subjects/patients are adults and have consented for the data, including images to be published and presented in scientific journals and gatherings of experts and relevant policymakers to improve the population's health.

Funding

The activities of this research in the form of design of the study and collection, analysis, and interpretation of data and in writing the manuscript were shouldered by the research team. In addition, the corresponding author has received partial funding for research methodology training and obtained some laboratory consumables from the Fogarty International Center (FIC) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the U.S. National Institutes of Health (NIH) award number 1D43TW011544. The findings and conclusions are those of the authors and do not necessarily represent the official position of the FIC, NIAAA, NIH, the Department of Health and Human Services, or the government of the United States of America.

Author Contribution

Author contributions: Data curation ARM, ABUFormal analysis: ABU, YL, MHG.Funding acquisition: AI,AMTInvestigation: MA,AI,AJ,AD.Methodology: AI, MAS,ARM.Project administration: ABU, MHGSoftware: ABUResources: MASupervision:AI,AMTValidation: AMTVisualization: All authorsWriting – original draft:ARM

Acknowledgement

: The corresponding author was partly supported by the Fogarty International Center (FIC) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the U.S. National Institutes of Health (NIH) award number 1D43TW011544. The findings and conclusions are those of the authors and do not necessarily represent the official position of the FIC, NIAAA, NIH, the Department of Health and Human Services, or the government of the United States of America.

Data Availability

The data is available with the corresponding author on request

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No competing interests reported.

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Evaluating Ultrasound-Guided Percutaneous Nephrostomy in Low-Resource Settings: Insights from Northern Nigeria

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INTRODUCTION

PATIENTS AND METHODS

DATA ANALYSIS

RESULTS

DISCUSSION

CONCLUSION

Abbreviations

Declarations

Funding

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

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