|Year : 2014 | Volume
| Issue : 1 | Page : 29-32
Role of perinephric drain in the era of internal drainage (DJ stent) in open renal surgery
Kailash Banale, Karan Vir Singh Rana, Sunil V Panchabhai, S Srihari, Murtuza Calcuttawallah, Ketak Nagare
Department of General Surgery, Padmashree Dr. D Y Patil Medical College, Hospital & Research Centre, Dr. D Y Patil Vidyapeeth, Pimpri, Pune, Maharastra, India
|Date of Web Publication||10-Dec-2013|
Department of General Surgery, Dr. D. Y. Patil Medical College, Pimpri, Pune - 411 018, Maharastra
Source of Support: None, Conflict of Interest: None
Objective: The purpose of the study was to evaluate the effect of internal drainage on the perinephric drain after open renal surgeries. Materials and Methods: 68 patients who had undergone open renal surgeries were prospectively studied. Patients were divided in two groups randomly: Group A (n = 33) without double J stent and group B (n = 35) with Double J stent. In both groups, perinephric drain was placed. Results: The average drain output and duration of perinephric drain kept in group A and B were 36 ml and 29 ml and 4.63 days and 3.35 days, respectively. The commonest surgical complication was wound infection (9.72%). Complaints like frequency, dysuria, and hematuria during follow-up were less in group A than in group B. Conclusion: With the use of double J stent, there is considerable decrease in drain volume and early removal of perinephric drain. Late irritative urinary complaints were seen more in the group with double J stent.
Keywords: Double J stent, drain output, open renal surgery, peri-nephric drains
|How to cite this article:|
Banale K, Rana KS, Panchabhai SV, Srihari S, Calcuttawallah M, Nagare K. Role of perinephric drain in the era of internal drainage (DJ stent) in open renal surgery. Med J DY Patil Univ 2014;7:29-32
| Introduction|| |
Drain is defined as a channel by which exit of fluids or purulent material from a cavity, wound, or infected area is established. Drains inserted after surgery are perceived to help in wound healing and assist in preventing infection. Unfortunately, this misconception is ingrained in the minds of many surgeons.  Though perinephric drains are routinely used after all type of renal surgeries, there is a lack of evidence of their role in actually preventing complications like urinoma formation and infections. Internal drainage in the form of internal stents (ureteric stents) has been in use since 1967.  Broadly speaking, the indications for ureteral stenting are adjunct to ureteral surgery (pre and/or postoperative) and for managing ureteral obstruction (extrinsic and/or intrinsic).  In the present evidence-based medicine era, literature evidence in the form of randomized blind and unbiased clinical trials are the need of time to prove the role of practice of surgical drains and drainage in renal surgeries. To drain or not to and for how long are unanswered questions.
| Materials and Methods|| |
Sixty eight patients who underwent renal surgery for different renal diseases in our institute from April 2007 to May 2009 were included in this study. Exclusion criteria included patients <15 years, previous renal surgery on the same side, treatment by extracorporeal lithotripsy, endoscopic stone removal and laparoscopic surgery, and lower ureteric and vesical pathology. Written consent for the study was obtained from the patients, and the study protocol was approved by the ethics committee of the hospital.
Preoperative investigations of patients included hemogram, blood sugar levels, renal function tests, liver function tests, cardiovascular assessment in form of ECG and 2D-Echo (where appropriate), urine microscopy, and culture. Chest X-ray, X-ray of kidney, uretus, and bladder (KUB), abdominal and pelvic ultrasound (USG), and intravenous urograms (IVU) were done in all cases. All patients received intravenous (I.V) injection of cefotaxim (1 gm) at the time of induction and continued for 5 days bid postoperatively. Surgeries were performed by senior faculty and assisted by surgery residents from Department of Surgery in our Institute.
The total 68 patients were divided in two groups: Group A (n = 33) patients without double J stent and group B (n = 35) with double J stent. In all the patients, perinephric tube drain was placed. The patients were randomly selected. The size of perinephric drain used was 28 Fr and double J stent was 5 Fr. 26 cm. All intraoperative complication and postoperative morbidities were recorded by single research assistant. Postoperatively, intramuscular (I.M) injection of diclofenac (1 ampoule) bid was given for 2 days and then shifted to tablet diclofenac (50 mg) bid for 3 days. Respiratory physiotherapy and early ambulation was done from the first postoperative day (POD).
Drain output and its nature were assessed daily at 8:00 AM. Drain output <20 ml in 24 hours was the criteria for the removal of drain. Postoperative time and the number of days the perinephric drain was kept were noted. Skin sutures removed on PODs 8 to 10 as per the wound site, and the patients were discharged. Patients' complaints like fever, inability to walk, and drain site pain were noted on PODs 1, 3, and 8 at 10.00 AM. Complications like urinoma, drain site haematoma, wound infection, and abscess formation were noted. Pain was assessed by Visual Analogue Score (VAS) on respective PODs. Patients with double J stent were called after 1 month for cystoscopic removal of stent.
The patients were called for follow-up on POD 15, and the first, third, and sixth month. All patients attended follow-up for 15 th day and 1 month. On the third month, 2 patients of group A and 1 of group B and, during sixth month follow-up, 4 patients of group A and 2 patients from group B were lost to follow-up. At every follow-up, condition of the wound was noted and they were evaluated for irritative urinary symptoms.
| Results|| |
Among the 68 patients included in study, there were 45 men and 23 women with a mean age of 39 years (range 15-65 years). The common pathology seen was renal stones (n = 66) and pelviureteric (PUJ) obstruction (n = 2). The diagnosis was confirmed by preoperative IVU and USG of abdomen. The procedure performed in group A and group B were pyelolithotomy in 38 (18 and 20), upper ureterolithotomy in 15 (8 and 7), pyelonephrolithotomy in 13 (6 and 7), and pyeloplasty in 2 (1 and 1) patients, respectively. The clinic pathological parameters were compared in both the groups of patient [Table 1]. The mean duration of operative procedure in group A and B was 120.9 min and 130.5 min, respectively [Table 2]. The average drain output per day in all procedures was seen more in group A than in group B [Table 3]. The perinephric drain was kept averagely for 4.91 days (range 4.37-5.2 days) and 3.35 days (range 3-3.57 days) in group A and B, respectively [Table 4]. Postoperatively, drain site pain was the common complain seen in both groups with similar complaints of fever and inability to walk [Table 5]. The commonest surgical complication was wound infection (10.29%) in 15.15% patients of group A and 5.7% of group B. One patient from group B developed urinoma formation after drain removal, which resulted in discharging sinus and the patient was managed conservatively [Table 6]. All patients in our study were assessed by VAS for postoperative loin pain. Postoperative pain was observed more in group B (6.29%) than in group A (4.42%) [Table 7]. Patients were followed-up on POD 15, and first, third, and sixth months. The wound status was healthy in all patients. Patients from group B had more complaints regarding frequency, dysuria, and hematuria as compared to group A patients [Table 8].
| Discussion|| |
Based on the best available evidences, the routine drainage is not recommended in colorectal surgeries, appendicectomy, cholecystectomy, and hepatic resections.  However, its role in renal surgery is not studied. Drains must not be considered as a substitute for hemostasis or a replacement for meticulous technique. For either prophylactic or therapeutic indications, the surgeon should select the form of drainage, either passive or active, that is best suited for the purpose intended.  The drain should be inspected daily and particular attention should be paid to the following features:
- Is the drain secured?
- Are there signs of infection, excoriation, or peritubal leakage at the skin exit site?
- Is the tube kinked or damaged?
- Is the drain connected properly?
- What is draining? - Volume, color, nature, smell
- Is the vacuum for suction drains working?
Time to remove a drain varies with the fluid to be drained and volume. Appropriate time is when the drain output is <30 ml in the last 8 hours. 
An ideal stent is expected to stay up and drain well. With such high expectations, tremendous improvements have taken place in the field of stent biomaterials, design, and texture; however, the ideal stent continues to elude us. , The goal of ureteral stenting is to have a stent that slides up, stays in place, drains well, is comfortable to the patient, is easily visible on fluoroscopy, and provides cost benefit to the patient and hospital.
In this study, the average duration of operative procedure in group A was 120.9 min, where as it was 130.5 min in group B. This observation of increased operative time in group B patients was expected because of the extra time required for placement of double J stent. Byrne et al.,  in his study, mentioned an average operative time of 54 min and 42 min in stented versus non-stented procedures.
The drain volume on POD 1, was found to be 20% less in group B than in group A. Subsequently, drain volume was reduced faster in group B than in group A in further postoperative periods; this was expected because the presence of functional double J stent reduces the urinary leak.
In our study, the common postoperative complaints seen in groups A and B were fever (24.24% and 20%), drain site pain (35.13% and 31.42%), inability to walk (21.62% and 22.85%) on POD 1, and complications like wound infection found in 7 (9.72%) cases, out of which 5 were from group A and 2 from group B. Urinoma formation that progressed to urinary cutaneous fistula was seen in group B, in which external drain was kept for 10 days. The morbidity of open surgery has been reported extensively by Rassweiler et al.,  who reported fever (26-29%), pain (16%), urinoma (1%), wound infection (4%), and abscess (2%) in his study of 250 cases of renal calculus.
Loin pain was assessed according to VAS. In our study, on POD 1, mean VAS was 6.62 in group A patient and 7 in group B patients. On PODs 3 and 8, there was significant decrease in VAS in group A (4.32 and 2.32, respectively) than in gGroup B (6.74 and 5.14, respectively). Overall mean VAS was 4.42 in group A and 6.29 in group B. This observation can be attributed to the presence of double J stent. Denstedt et al.,  concluded that there is an increase in loin pain in stented group (4.1) versus non-stented group (1.7).
Symptoms like frequency, dysuria, and hematuria were assessed during follow-up period in our study. On first follow-up on 15th day frequency, dysuria, hematuria were observed in 12.5%, 15.6%, and 28.12% in group A, respectively. In group B, it was 60%, 37.14%, and 51.42%, respectively. Till the end of 1 month, there was a significant decrease in these symptoms in group A as compared to that in group B. Denstedt et al.,  in his study concluded that patients with double J stent have significantly greater voiding symptoms like frequency (5.5/10), dysuria (5.1/10), and hematuria than those without a stent (frequency 1.6/10 and dysuria 1.0/10) in the early postoperative period.
| Conclusion|| |
The use of double J stent is associated with reduction in drain volume, number of days with drain, and chances of drain site infection. Early removal of double J stent during the first hospital admission may avoid complaints like frequency, dysuria, hematuria, and loin pain.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]