Hemostatic plug: novel technique for closure of percutaneous nephrostomy tract

Abstract

Percutaneous nephrolithotomy (PCNL) is a standard treatment for patients with large or complex kidney stones. The procedure has traditionally included postoperative placement of a nephrostomy tube to allow for drainage and possible reentry. This practice was first implemented after complications incurred after tubeless PCNL in a small patient population. Recently, tubeless PCNL has reemerged as a viable option for selected patients, resulting in decreased pain and analgesic use, shorter hospitalization, quicker return to normal activity, and decreased urine extravasation. Gelatin matrix sealants are occasionally used in nephrostomy tract closure. Techniques for delivery of these agents have been ill described, and placement may be performed with varying results. We present a literature review comparing tubeless PCNL to its traditional variant with indications for use of each, as well as a comparison of agents used in closure. Finally, we outline a novel, reproducible technique for closure of the dilated percutaneous renal access tract.

FIG. 1.

Preoperative CT evaluated in surgical planning determining the zone of safe access and to obtain measurements of skin to renal calix for determining plug length.

FIG. 2.

Identification of the calices-parenchymal junction as the clear renal sheath is withdrawn positioning the leading edge of the sheath at this junction.

FIG. 3.

Measurement taken of the external portion of the clear renal sheath. This measurement is then subtracted from the total sheath length (17 cm), determining the exact length needed to create the Gelfoam plug.

FIG. 4.

After cut to precise length, Gelfoam is rolled in “cigar” fashion to create the plug.

FIG. 5.

Injection of thrombin into the Gelfoam plug followed by advancement of the plug to the skin edge using the cylindrical packaging insert as a plunger. The plug is deployed by backing out the clear renal sheath in a modified Seldinger technique.

FIG. 6.

Pre- and postprocedure images of four tubeless PCNL cases. The plug is identified in the postprocedure images. Minimal extravasation is seen with high-pressure contrast injected nephrostogram.

FIG. 7.

Postoperative day 1 CT scan demonstrates the appearance of the hemostatic plug placed within the tract of the left kidney after percutaneous nephrolithotomy.