Percutaneous Nephroureteral Tube: A Useful Tool for Management of Intractable Hematuria

Surgeon's Workshop

Percutaneous Nephroureteral Tube:

A Useful Tool for Management

of Intractable Hematuria

D1X XKyle SpradlingD2X X, D3X XChristopher S ElliottD4X X, D5X XHong VoD6X X, and D7X XJeffrey ReeseD8X X

OBJECTIVE To describe our experience using percutaneous nephroureteral (PCNU) tube placeme nt for the

management of intractable gross hematuria.

METHODS We identiﬁed patients at our institution who underwent PCNU tube placement from August

2011 to October 2017 for management of gross hematuria who had previously failed management

with manual irrigation, continuous bladder irrigation, and cystoscopy with clot evacuation. The

primary outcome measured was cessation of bleeding obviating the need for further blood transfu-

sion in a 30 day follow-up period.

RESULTS Six patients were treated with PCNU tube placement for intractable hematuria from either malig-

nant or nonmalignant etiologies. In all patients after PCNU tube placement, hematocrit value

remained stable, there were no further transfusions requirements within 30 days, and no immedi-

ate or periprocedural compl ications were encountered. In no instance did a PCNU become

obstructed by blood clots and in all cases the bladder and both kidneys were adequately drained.

CONCLUSION In patients with hematuria refractory to conventional management techniques, the placement of a

PCNU tube allows for cessation of bleeding, successfully diverts urine with no immediate compl i-

cations and is not subsequent to clot obstruction of the tube. The use of PCNU tube is a viable

treatment in the algorithm of intractable hematuria, speciﬁcally before resorting to more morbid

ross hematuria is a common presenting symptom

in urology. Clo t urinary retention secondary to

gross hematuria is routinely managed conserva-

tively with mechanical irrigation and continuous bladder

irrigation using a 3-way urethral catheter, though occa-

sionally cystoscopy is required for clot evacuation and ful-

guration of bleeding areas.

1-3

In rare cases intractable

hematuria is encountered which may necessitate blood

transfusions and multiple procedures to remove obstruct-

ing clots.

Current management of intractable hematuria includes

intravesical formalin instillation, vessel embolization,

bilateral nephrostomy tubes, and even cystectomy in rare

cases.

5-8

These methods, however, are often associated

with signiﬁcant morbidity, including catheter obstruction

and compromise of future bladder function. Having an

additional step in the algorithm for the management of

intractable hematuria prior to undergoing potentially

irreversible therapies is invaluable. Herein, we describe

our experience using percutaneous nephroureteral

(PCNU) tube placement for the management of intracta-

ble gross hematuria. Unlike bilateral nephrostomy tubes

which partially divert a patient's urine and require some

additional form of bladder drainage, a PCNU tube works

by initially allowing an organized clot to form within the

bladder (which tamponades further bleeding), and addi-

tionally works to drain urine from the co ntralateral kidney

and bladder in a retrograde fashion via capil lary action.

METHODS

We conducted a single institutional retrospective review of all

patients who underwent placement of PCNU tubes from August

2011−October 2017 for the management of gross hematuria.

Only patients whose indication for placement was macroscopic

hematuria with failed conservative management with manual

irrigation through a 6-eye urethral catheter followed by continu-

ous bladder irrigation and an escalation to cystoscopy with trans-

urethral evacuation of clot in the operating room, were

included. All patients were trialed with a PCNU tube prior to

considering more invasive treatments such as intravesical forma-

lin instillation, vascular embolization, or cystectomy. All

patients received Cook Cope-Nephroureterostomy stents (Cook

Medical, Bloomington, IN 47402). The primary outcome mea-

sured was the cessation of bleeding obviating the need for further

Conﬂict of Interest Disclosure: There is no direct or indirect commercial ﬁnancial

incentive associated with the publication of this article, and no commercial support was

involved in the writing or publication of this manuscript.

From the Stanford University School of Medicine, Department of Urology, Stanford,

CA; and the Santa Clara Valley Medical Center, Division of Urology, San Jose, CA

Address correspondence to: Kyle Spradling, M.D., Stanford University School of

Medicine, Department of Urology, 300 Pasteur Drive, Palo Alto, CA 94304. E-mail:

[email protected]

Submitted: August 28, 2018, accepted (with revisions): January 8, 2019

1https://doi.org/10.1016/j.urology.2019.01.003

0090-4295

ARTICLE IN PRESS

blood transfusion in a 30-day follow-up period. The secondary

outcome measured was the interval change in serum creatinine

after placement of PCNU.

RESULTS

Between August 2011 and October 2017, a total of 6 patients were

treated by way of a single PCNU tube for intractable hematuria

with urinary retention. All patients had been unresponsive to con-

servative therapies and subsequent cystoscopy with clot evacua-

tion. Five of the 6 patients were male, and the mean age of the

cohort was 72 years. No patient underwent intravesical instillation,

hyperbaric oxygen, or vessel embolization prior to PCNU tube

placement. In 4 patients, the etiology of bleeding was secondary to

malignancy, either from primary bladder cancer, direct invasion of

a local malignancy, or malignancy metastatic to the bladder. The

other etiologies include postradiation hemorrhagic cystitis and

upper tract bleeding of an unclear nature.

PCNU tube placement was on the left side in 4 patients and

right side in the other two. Sizes of the PCNU used were 8.5 Fr

in 4 patients and 10.2 Fr in 2 patients and lengths of stents

ranged from 24 cm to 28 cm. In all patients, urethral catheters

were removed after PCNU tube placement to allow for forma-

tion of an organized blood clot in the bladder. All patients had

required blood transfusion prior to PCNU tube placement for a

hematocrit less than 21. In all patients, the hematocrit level

remained stable after PCNU tube placement, and no further

blood transfusions were required. No patient required intravesi-

cal formalin instillation, vessel embolization, or cystectomy after

PCNU tube placement. Serum creatinine levels remained stable

or decreased in all patients with recorded postprocedure labora-

tory values following PCNU tube placement (Table 1).

There were no immediate or periprocedural complications

from PCNU tube placement. Several patients did experience

bladder spasms in the initial days due to bladder clot formation

after removal of the urethral catheters, but all were successfully

treated with anticholinergic medication and/or beta-3 agonists.

No patient had obstruction of the PCNU tubes by blood clots or

required replacement or manipulation of the PCNU tubes due

to poor drainage. Two patients, after being stabilized and dis-

charged home, were re-admitted for accidental dislodgment of

their PCNU tube requiring replacement. In 2 patients whose

intractable hematuria was secondary to terminal, nonoperative

cancer, the PCNU tube provided hemostasis and diverted urine

without the need for an additional urethral catheter. Both

patients expired from their primary terminal disease within 1

month of PCNU tube placement. In an additional patient with

a severely contracted bladder after radiation treatment, the

PCNU tube was preferred for long-term bladder drainage. In our

3 patients who had PCNU tubes removed, all were able to

resume normal voiding per urethra without need for additional

instrumentation.

DISCUSSION

Gross hematuria is a common urologic problem often

managed by conservative approaches alone. Hematuria

refractory to these conservative measures is uncommon,

but can be challenging to manage. Previous studies have

shown that bilateral percutaneous nephrostomy (PCN)

placement is an effective management strategy for intrac-

table hematuria.

9,10

However, this method increases

Table 1. Patient characteristics

Patient Age Gender Etiology of Hematuria

Duration of

PCNU (months)

Serum Cr

pre-PCNU

Serum Cr

post-PCNU Complications 30-Day Follow-Up

1 55 M Urothelial carcinoma of the bladder 4 0.6 0.6 None Hematuria resolved, PCNU

tube removed

2 92 M Idiopathic right upper urinary tract

bleeding

1 3.6 2.2 PCNU tube dislodged PCNU tube not replaced,

hematuria resolved

3 86 M Hemorrhagic cystitis after external

radiation therapy

28 0.9 0.9 None Patient chose to continue

PCNU with regular 3 month

exchanges

4 63 M Renal cell cancer metastatic to the

bladder

3 1.2 1.2 PCNU tube dislodged PCNU tube replaced,

hematuria resolved, PCNU

tube removed

5 67 F Endometrial cancer metastatic to the

bladder

1 3.1 1.2 None Patient expired in hospice care

6 75 M Urothelial carcinoma of the bladder 1 1.1 n/a None Patient expired in hospice care

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2 UROLOGY 00 (00), 2019

the risk of patient morbidity by requiring both renal units

be manipulated and further does not drain urine from the

bladder. To our knowledge, our study is the ﬁrst series to

describe the use of unilateral PCNU tube placement

for management of intractable hematuria in patients

with both malignant and nonmalignant etiologies of

hematuria.

In our experience, PCNU tube placement is a safe and

effective method for managing intractable hematuria in

the acute setting when more conservative treatment

approaches have failed. Further, PCNU tube is a valuable

palliative treatment option in end-of-life care. A single

PCNU tube can effectively divert urine from both kid-

neys, requires only one procedure site and subsequently

only one drain to manage. Compared to urethral cathe-

ters, which are susceptible to clot obstruction in the set-

ting of ongoing severe hematuria, PCNU tube allows for

adequate urine drainage without obvious obstructive com-

plications though no postprocedure imaging was obtained.

As such, contralateral hydronephrosis may have persisted,

however these concerns are tempered by the fact that no

patient in our cohort developed contralateral ﬂank pain,

infection, or increasing serum creatinine after PCNU

placement. No patient in our series required tube

exchange for obstruction or poor urinary drainage. We

believe the mechanism behind a lack of obstruction is

likely related to a smaller tube diameter, allowing for uri-

nary drainage in a retrograde fashion, as similarly

described for vascular catheters.

11,12

Speciﬁcally, the

8.5 Fr and 10.2 Fr PCNU tubes used in this study drain

via capillary action thereby propelling ﬂuid out the blad-

der with continuous ﬂow within the lumen of the PCNU

tube which simultaneously prevents luminal obstruction

by larger blood clots (Fig. 1).

Placement of a PCNU tube for intractable hematuria

can obviate the need for more invasive and possibly irre-

versible surgical procedures. No patient in our series had

immediate or periprocedural complications related to the

placement o f a PCNU tube, though 2 out of 6 patients

required readmission for tube dislodgement. A few

patients did experience bladder spasms, this was easily

managed with anticholinergic medication and/or beta-3

agonists. In our experience, patients were able to resume

spontaneous voidi ng after PCNU removal without need

for additional irrigation or instrumentation. The quick

resolution of bladder clot after PCNU removal may be

due to presence of urokinase which facilitates the break-

down of clot after tamponade of bleeding has occurred. It

should also be noted that management of intractable

hematuria with a single PCNU tube is only intended for

venous bleeding and would not be expected to work in

cases of arterial bleeding, which is unlikely to tamponade.

Furthermore, PCNU tube placement may not be feasible

in the setting of advanced bladder cancer which inﬁltrates

the trigone or obstructs the ureteral oriﬁces.

CONCLUSION

In patients with hematuria refractory to conventional

management techniques, placement of a single PCNU

tube allows for tamponade of bleedi ng and successfully

diverts urine with no immediate complications or subse-

quent obstruction of the PCNU tube. The use of PCNU

tube is a viable treatment in the algorithm of intractable

hematuria, speciﬁcally before resorting to more morbid

and potentially irreversi ble treatments.

References

1. Davis TM. A simple method for removing blood clots from the uri-

nary bladder. JAMA. 1929;92:2168.

2. Goel A, Sengottayan VK, Dwivedi AK. Mechanical suction: a safe

and effective method to remove large and tenacious clots from the

urinary bladder. Urology. 2011;7:494–496.

3. Onishi T, Sugino Y, Shibahara T, et al. Randomized controlled

study of the efﬁcacy and safety of continuous saline bladder irrigation

after transurethral resection for the treatment of non-muscle-

invasive bladder cancer. BJU Int. 2017;119:276–282.

4. Avellino GJ, Bose S, Wang DS. Diagnosis and management of

hematuria. Surg Clin North Am. 2016;96:503–515.

5. Fair WR. Formalin in the treatment of massive bladder hemorrhage.

Techniques, results, and complications. Urology. 1974;3:573–576.

6. Kumar S, Rosen P, Grabstald H. Intravesical formalin for the control

of intractable bladder hemorrhage secondary to cystitis or cancer. J

Urol. 1975;144:540–543.

7. Liguori G, Amodeo A, Mucelli FP, et al. Intractable haematuria:

long-term results after selective embolization of the internal iliac

arteries. BJU Int. 2010;106:500–503.

8. Linder BJ, Tarrell RF, Boorjian SA. Cystectomy for refractory hem-

orrhagic cystitis: contemporary etiology, presentation, and outcomes.

J Urol. 2014;192:1687–1692.

9. Sneiders A, Pryor JL. Percutaneous nephrostomy drainage in

the treatment of severe hemorrhagic cystitis. JUrol. 1993;150:966–967.

10. Zagoria RJ, Hodge RG, Dyer RB, et al. Percutaneous nephrostomy

for treatment of intractable hemorrhagic cystitis. J Urol. 1993;149:

1449–1451.

Figure 1. Percutaneous nephroureterostomy (PCNU) tube

allows for adequate urine drainage from both kidneys in

patients with intractable hematuria while allowing bladder

bleeding to tamponade. (Color version available online).

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11. Cooper GL, Schiller AL, Hopkins. Possible role of capillary action

in pathogenesis of experimental catheter-associated dermal tunnel

infections. J Clin Microbiol. 1988;26:8–12.

12. Harris GJ, Rosenquist MD, Kealey GP. An in vitro model for study-

ing the effect of the subcutaneous tunnel and the skin exit site on

the accuracy of central venous catheter tip cultures. J Burn Care

Rehabil. 1992;13:628–631.

13. Lau HL, Lawrence KW, King TM. Further experience with

a capillary tube pregnancy test. Int J Gynaecol Obstet. 1978;17:

68–72.

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