Overview
Nephrocutaneous fistula is an abnormal communication between the renal collecting system and the skin, often occurring as a complication of percutaneous renal procedures 24. Management focuses on optimizing surgical technique, ensuring tract stability, and employing effective closure methods to prevent persistent drainage 34.Diagnosis
Imaging: Postoperative CT scans are used to evaluate the percutaneous access tract and identify complications such as perirenal hematomas 3.
Procedural Monitoring: Fluoroscopy is utilized during tract creation and stone removal to ensure proper positioning and tract integrity 14.Management
Surgical Positioning: The split-leg oblique supine/flank position (SLP) is associated with the highest stone-free rates and significantly reduced operative time and hospital stay compared to prone or traditional supine positions 2.
Tract Stability: Use of a screwed Amplatz sheath provides superior tract stability compared to conventional sheaths, significantly reducing the risk of tract loss during the procedure 4.
Access Tract Sealing: In tubeless percutaneous nephrolithotomy (PCNL), the access tract may be managed with hemostatic agents (e.g., fibrin glue or Tachosil) or standard suturing and compressive dressing 3.
Hemostatic Agents: While fibrin glue and Tachosil are options for tract control, they do not significantly improve postoperative hemoglobin drop, stone-free rates, or hospital stay compared to suturing 3.
Positioning for Novices: For urologists in training, the supine position may offer a shorter learning curve for mastering percutaneous access compared to the prone position 1.
Complication Reduction: The prone position is more likely to result in complications than supine, flank, or oblique supine positions 2.Special Populations
Morbid Obesity: Patients with morbid obesity are typically excluded from standard trials evaluating new access tools like screwed Amplatz sheaths 4.Key Recommendations
Utilize the split-leg oblique supine/flank position (SLP) as the optimal surgical position to minimize operative time and maximize safety during percutaneous access 2. (Evidence: Strong)
Employ a screwed Amplatz sheath to maintain a stable percutaneous tract and reduce the risk of tract loss 4. (Evidence: Strong)
For novice urologists, prioritize the supine position to potentially shorten the learning curve for percutaneous renal procedures 1. (Evidence: Strong)
Standard suturing and compressive dressing may be used for access tract control in tubeless procedures, as hemostatic agents do not offer superior clinical outcomes in selective cases 3. (Evidence: Strong)References
1 Zoeir A, Mamdoh H, Moussa A, Abdel-Raheem A, Gameel T, Elsherbeny A et al.. Which is easier for beginners: supine or prone position percutaneous nephrolithotomy? Assessment of the learning curve in novice urologists through a randomized clinical trial. Minerva urology and nephrology 2024. link
2 Li P, Ma Y, Liao B, Jin X, Xiang L, Li H et al.. Comparison of safety and efficacy of different positions in percutaneous nephrolithotomy: a network meta-analysis. International journal of surgery (London, England) 2024. link
3 Choi YS, Sorkhi SR, Choi SW, Kim KS, Cho HJ. Are hemostatic agents for selective cases of tubeless percutaneous nephrolithotomy necessary for access tract control? A randomized control trial. International urology and nephrology 2023. link
4 Abdelwahab K, El-Babouly IM, Mahmoud MM, Elderey MS. Comparative study between a new screwed Amplatz sheath and the ordinary one in percutaneous nephrolithotomy. World journal of urology 2022. link