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A New Catheter System for Permanent Percutaneous Nephrostomy
0022-534 7/79 / 1224-0442$02.00/0
THE
JOURNAL OF UROLOGY
Vol. 122, October
Copyright© 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
A NEW CATHETER SYSTEM FOR PERMANENT PERCUTANEOUS NEPHROSTOMY JONATHAN M. LEVY,* WILFRED M. POTTER
AND
CARY J. STEGMAN
From the Departments of Diagnostic Radiology and Urology, Scottsdale Memorial Hospital, Scottsdale, Arizona
ABSTRACT
A new catheter system is described for permanent percutaneous nephrostomy. The system allows the rapid, single stage placement of a large diameter drainage catheter. The technique avoids several problems associated with previous methods of percutaneous nephrostomy. Percutaneous nephrostomy can be used to relieve obstructive nephropathy. This procedure avoids the use of general anesthesia and produces minimal morbidity and postoperative discomfort. Temporary nephrostomy has been done by a variety of techniques but permanent drainage has been hampered by catheter displacement from the collecting system, as well as by obstruction of the small lumen catheters generally used. 1-• We report the use of a newly introduced suprapubic cystostomy catheter for percutaneous nephrostomy. This catheter avoids the problems encountered with previous methods.
DISCUSSION
Percutaneous nephrostomy was first described in 1955. 6 Since that time >500 such procedures have been published in the
TECHNIQUE
The catheter used is the Stamey suprapubic catheter set, consisting of a 10 or 14F polyethylene catheter with 4 wings (fig. l, A). t An 18 gauge needle is inserted into the lumen of the catheter and a flange on the needle straightens the catheter wings for insertion (fig. l, B). Once the catheter is in place the needle is withdrawn, opening the wings and preventing migration of the catheter tip. The patient is placed in the prone position and the renal pelvis is identified. Although this can be done with the use of fluoroscopy in kidneys that are not obstructed completely we prefer the use of ultrasound or computed tomography.4· 5 These latter modalities have the advantage of allowing the depth of the collecting system from the skin surface to be measured accurately (fig. 2). The skin is prepared and infiltrated with a local anesthetic. A needle stop is placed on a 20 gauge spinal needle at the proper depth and the needle is advanced into the renal pelvis in a single pass, during suspended respiration. Drainage of urine signifies that proper placement has been achieved. Iodinated contrast medium is instilled into the renal pelvis with a connecting tube and syringe. The needle is removed and the patient is moved from the computed tomography or ultrasound department to a fluoroscopy table. (Preliminary puncture and contrast medium instillation need not be done in patients having adequate visualization after intravenous contrast medium injection. We still use ultrasound or computed tomography for depth measurement in these cases.) Under fluoroscopy the Stamey catheter is advanced until the tip is in the opacified renal pelvis (fig. 3). The needle is removed and the catheter is connected to a urinary drainage bag by means of an adapter contained in the catheter set. The catheter is ligated with heavy silk to tapes in 4 quadrants, thus anchoring it to the skin. The needle is retained since it must be reinserted to straighten the catheter wings if removal of the catheter is desired. Accepted for publication January 5, 1979. * Requests for reprints: Department of Radiology, Scottsdale Memorial Hospital, 7400 E. Osborn Rd., Scottsdale, Arizona 85251. t Vance Products, Inc., 165 S. Main St., Spencer, Indiana 47460. 442
FIG. 1. A, catheter with wings extended. Note flange on needle. B, needle inserted in catheter, straightening wings for insertion.
FIG. 2. Computed tomography scan of patient with obstructed kidney. Electronic cursor (crosses on scan) measures distance between skin surface and renal collecting system.
NEW CATHETER SYSTEM FOR PERMANENT PERCUTANEOUS NEPHROSTOMY
443
catheter changes. The wings on the Stamey catheter prevent dislodgement. Therefore, patients can be discharged from the hospital without skin sutures and without worry as to maintenance of drainage. Percutaneous nephrostomy is not a totally benign procedure and has been associated with infection and/or hemorrhage in a small percentage of cases. 7 Permanent nephrostomy is not a replacement for operative nephrostomy but should be considered in patients who are not operative risks and in those in whom no definitive operative repair is contemplated. The Stamey catheter allows rapid establishment of drainage in these selected patients, avoiding the problems of catheter migration and blockage associated with other techniques for percutaneous nephrostomy. REFERENCES
1. Barbaric, Z. L. and Wood, B. P.: Emergency percutaneous nephro-
Fm. 3. Catheter in renal pelvis. Note extended wings, which prevent dislodgement.
2.
literature. 7 Although percutaneous nephrostomy generally has been successful the maintenance of permanent urinary drainage has been hampered because of blockage of the small lumen catheters used. Techniques have been devised to allow placement of larger catheters with multiple catheter changes or dilating instruments. 8' 9 These techniques require several days to 8 weeks to accomplish and there is the risk of loss of the nephrostomy at each catheter change. The Stamey catheter system allows placement of a 14F drainage catheter in a short, single procedure. The size of the catheter facilitates drainage and the system easily drains to the usual urine collection devices. The second major problem with percutaneous nephrostomy has been migration of the catheter. 1• 2 • 4 Balloon catheters have been used to maintain the catheter tip within the renal pelvis but these require creation of a tract and, therefore, multiple
3. 4. 5. 6. 7. 8. 9.
pyelostomy: experience with 34 patients and review of the literature. Amer. J. Roentgen., 128: 453, 1977. Perinetti, E., Catalona, W. J., Manley, C. B., Geise, G. and Fair, W. R.: Percutaneous nephrostomy: indications, complications and clinical usefulness. J. Urol., 120: 156, 1978. Saxton, H. M., Ogg, C. S. and Cameron, J. S.: Needle nephrostomy. Brit. Med. Bull., 28: 210, 1972. Pedersen, J. F.: Percutaneous nephrostomy guided by ultrasound. J. Urol., 112: 157, 1974. Haaga, J. R., Zelch, M. G., Alfidi, R. J., Stewart, B. H. and Daugherty, J. D.: CT-guided antegrade pyelography and percutaneous nephrostomy. Amer. J. Roentgen., 128: 621, 1977. Goodwin, W. E., Casey, W. C. and Woolf, W.: Percutaneous trocar (needle) nephrostomy in hydronephrosis. J.A.M.A., 157: 891, 1955. Stables, D. P., Ginsberg, N. J. and Johnson, M. L.: Percutaneous nephrostomy: a series and review of the literature. Amer. J. Roentgen., 130: 75, 1978. Almgard, L. E. and Fernstrom, I.: Percutaneous nephropyelostomy. Acta Rad., 15: 288, 1974. Stables, D. P., Holt, S. A., Sheridan, H. M. and Donohue, R. E.: Permanent nephrostomy via percutaneous puncture. J. Urol., 114: 684, 1975.
THE
JOURNAL OF UROLOGY
Vol. 122, October
Copyright© 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
A NEW CATHETER SYSTEM FOR PERMANENT PERCUTANEOUS NEPHROSTOMY JONATHAN M. LEVY,* WILFRED M. POTTER
AND
CARY J. STEGMAN
From the Departments of Diagnostic Radiology and Urology, Scottsdale Memorial Hospital, Scottsdale, Arizona
ABSTRACT
A new catheter system is described for permanent percutaneous nephrostomy. The system allows the rapid, single stage placement of a large diameter drainage catheter. The technique avoids several problems associated with previous methods of percutaneous nephrostomy. Percutaneous nephrostomy can be used to relieve obstructive nephropathy. This procedure avoids the use of general anesthesia and produces minimal morbidity and postoperative discomfort. Temporary nephrostomy has been done by a variety of techniques but permanent drainage has been hampered by catheter displacement from the collecting system, as well as by obstruction of the small lumen catheters generally used. 1-• We report the use of a newly introduced suprapubic cystostomy catheter for percutaneous nephrostomy. This catheter avoids the problems encountered with previous methods.
DISCUSSION
Percutaneous nephrostomy was first described in 1955. 6 Since that time >500 such procedures have been published in the
TECHNIQUE
The catheter used is the Stamey suprapubic catheter set, consisting of a 10 or 14F polyethylene catheter with 4 wings (fig. l, A). t An 18 gauge needle is inserted into the lumen of the catheter and a flange on the needle straightens the catheter wings for insertion (fig. l, B). Once the catheter is in place the needle is withdrawn, opening the wings and preventing migration of the catheter tip. The patient is placed in the prone position and the renal pelvis is identified. Although this can be done with the use of fluoroscopy in kidneys that are not obstructed completely we prefer the use of ultrasound or computed tomography.4· 5 These latter modalities have the advantage of allowing the depth of the collecting system from the skin surface to be measured accurately (fig. 2). The skin is prepared and infiltrated with a local anesthetic. A needle stop is placed on a 20 gauge spinal needle at the proper depth and the needle is advanced into the renal pelvis in a single pass, during suspended respiration. Drainage of urine signifies that proper placement has been achieved. Iodinated contrast medium is instilled into the renal pelvis with a connecting tube and syringe. The needle is removed and the patient is moved from the computed tomography or ultrasound department to a fluoroscopy table. (Preliminary puncture and contrast medium instillation need not be done in patients having adequate visualization after intravenous contrast medium injection. We still use ultrasound or computed tomography for depth measurement in these cases.) Under fluoroscopy the Stamey catheter is advanced until the tip is in the opacified renal pelvis (fig. 3). The needle is removed and the catheter is connected to a urinary drainage bag by means of an adapter contained in the catheter set. The catheter is ligated with heavy silk to tapes in 4 quadrants, thus anchoring it to the skin. The needle is retained since it must be reinserted to straighten the catheter wings if removal of the catheter is desired. Accepted for publication January 5, 1979. * Requests for reprints: Department of Radiology, Scottsdale Memorial Hospital, 7400 E. Osborn Rd., Scottsdale, Arizona 85251. t Vance Products, Inc., 165 S. Main St., Spencer, Indiana 47460. 442
FIG. 1. A, catheter with wings extended. Note flange on needle. B, needle inserted in catheter, straightening wings for insertion.
FIG. 2. Computed tomography scan of patient with obstructed kidney. Electronic cursor (crosses on scan) measures distance between skin surface and renal collecting system.
NEW CATHETER SYSTEM FOR PERMANENT PERCUTANEOUS NEPHROSTOMY
443
catheter changes. The wings on the Stamey catheter prevent dislodgement. Therefore, patients can be discharged from the hospital without skin sutures and without worry as to maintenance of drainage. Percutaneous nephrostomy is not a totally benign procedure and has been associated with infection and/or hemorrhage in a small percentage of cases. 7 Permanent nephrostomy is not a replacement for operative nephrostomy but should be considered in patients who are not operative risks and in those in whom no definitive operative repair is contemplated. The Stamey catheter allows rapid establishment of drainage in these selected patients, avoiding the problems of catheter migration and blockage associated with other techniques for percutaneous nephrostomy. REFERENCES
1. Barbaric, Z. L. and Wood, B. P.: Emergency percutaneous nephro-
Fm. 3. Catheter in renal pelvis. Note extended wings, which prevent dislodgement.
2.
literature. 7 Although percutaneous nephrostomy generally has been successful the maintenance of permanent urinary drainage has been hampered because of blockage of the small lumen catheters used. Techniques have been devised to allow placement of larger catheters with multiple catheter changes or dilating instruments. 8' 9 These techniques require several days to 8 weeks to accomplish and there is the risk of loss of the nephrostomy at each catheter change. The Stamey catheter system allows placement of a 14F drainage catheter in a short, single procedure. The size of the catheter facilitates drainage and the system easily drains to the usual urine collection devices. The second major problem with percutaneous nephrostomy has been migration of the catheter. 1• 2 • 4 Balloon catheters have been used to maintain the catheter tip within the renal pelvis but these require creation of a tract and, therefore, multiple
3. 4. 5. 6. 7. 8. 9.
pyelostomy: experience with 34 patients and review of the literature. Amer. J. Roentgen., 128: 453, 1977. Perinetti, E., Catalona, W. J., Manley, C. B., Geise, G. and Fair, W. R.: Percutaneous nephrostomy: indications, complications and clinical usefulness. J. Urol., 120: 156, 1978. Saxton, H. M., Ogg, C. S. and Cameron, J. S.: Needle nephrostomy. Brit. Med. Bull., 28: 210, 1972. Pedersen, J. F.: Percutaneous nephrostomy guided by ultrasound. J. Urol., 112: 157, 1974. Haaga, J. R., Zelch, M. G., Alfidi, R. J., Stewart, B. H. and Daugherty, J. D.: CT-guided antegrade pyelography and percutaneous nephrostomy. Amer. J. Roentgen., 128: 621, 1977. Goodwin, W. E., Casey, W. C. and Woolf, W.: Percutaneous trocar (needle) nephrostomy in hydronephrosis. J.A.M.A., 157: 891, 1955. Stables, D. P., Ginsberg, N. J. and Johnson, M. L.: Percutaneous nephrostomy: a series and review of the literature. Amer. J. Roentgen., 130: 75, 1978. Almgard, L. E. and Fernstrom, I.: Percutaneous nephropyelostomy. Acta Rad., 15: 288, 1974. Stables, D. P., Holt, S. A., Sheridan, H. M. and Donohue, R. E.: Permanent nephrostomy via percutaneous puncture. J. Urol., 114: 684, 1975.