Nephrostomy in pyelonephritis

NEPHROSTOMY

IN PYELONEPHRITIS*

IRA R. SISK, M.D., JOHN B. WEAR, M.D., AND EARL F. CUMMINGS, M.D MADISON, WIS.

T

HOUGH nephrostomy has been advocated for many renaI Iesions, references to its use in pyeIonephritis are infrequent and usuaIIy brief. Crosbie’ states : “ DoubIe nephrostomy gives more rehef than anything eIse I have found for the cases of doubIe chronic pyeIonephritis with megaioureters.” Chute2 in discussing non-tuberculous renaI suppurations states that drainage through the Ioin is indicated in the more advanced cases. Mathe in discussing modern treatment of pyeIonephritis dismisses the subject with the statement that in particuIarIy resistant and recurrent types of pyeIonephritis, it is sometimes necessary to resort to surgica1 drainage empIoying the method of Marion. Among other indications for nephrostomy Cabot and HoIIand” cite “a group of cases of renaI infection without high grade obstruction in which the nephrostomy is done as a method of avoiding recurrent renaI infection and aIIowing some amount of renaI recovery.” In considering the treatment of pyeIonephritis one must keep in mind the fact that the mechanics of the passage of urine from the renaI cortex to the bIadder incIudes more than the flow of a fIuid from a higher to a Iower IeveI. MuscuIar and neurogenic eIements are predominating factors with the diameter and reIations of the various hoIIow structures playing an important pa rt. Adequate drainage is a fundamenta1 surgical principIe of treatment of disease when pus or infected fluid of any kind is present. Tissue reaction to infection resuIts in sweIIing and edema. SweIIing and edema in the caIyces, peIves and ureters occur to a marked degree in very acute pyeIone-

phritis. In the cases which we shaI1 report the kidneys were not onIy seen to be highIy inflamed and congested but the pelves thickened and edematous, the ureters severa times normal size with thick, edematous waIIs. Much peripeIvic and periureteral inff ammation was present in a11 cases. This inflammatory reaction interferes with renaI drainage by actuaI diminution in the caIiber of the ureter from sweIIing in the waI1 and by interfering with True inff ammator;v strictures peristaIsis. do not occur until Iate in the disease. UreteraI buIbs if passed by the orihces, which are usuaIIg spastic, pass freeI?; up these ureters without evidence of obstruction, and yet in one of our cases an opaque medium introduced into the kidney pelvis was found to be there one hour and fifteen minutes Iater. This interference with drainage brings about an increased intrarena1 pressure which forces the infection into the cortex of the kidney. A smaI1 intrarena1 peIvis wiI1 aggravate this condition of back pressure on the caIyces more than an extrarena peIvis as pointed out by Rose, et aL5 Rose has aIso caIIed attention to the fact that a11 components of the kidney do not drain with equal ease. The advantage of nephrostomv over the use of indweIIing catheters arises from the constant and satisfactory drainage which can be obtained. To accompIish this in a11 cases for any considerabIe period of time with catheters is impossibIe. Even when the catheter tip is pIaced at the most advantageous point a portion of the peIvis and Iower major caIyx Iies beIow its IeveI in many kidneys. As a result the entire content of the peIvis is not- drained.

* Presented before the North Central Branch of the American 451

Urological

Association;

Chicag,

Ill.

FIG. I. Case I. BiIateral pyeloureterogram, ApriI IO, 1928, showing IittIe change in peIves and caIyces but moderate diIatation in mid-portion of both ureters.

May 6, 1928, FIG. 2. Case I. Left pyeloureterogram, showing diIatation in peIvis and caIyces.

FIG. 3. Case I. Right

FIG. 4. Case I. BiIateraI pyeloureterogram, October x928. Right side incompktely filled. Dilatation Ieft pelvis, calyces and ureter increased.

pyeloureterogram,

August

13,

x928.

U4PB

I I,

in

FIG. 5. Case

I. Right

pyeloureterogram,

October

16,

FIG. 7. Case

I. Left

pyeloureterogram,

FIG. 6. Case

I. Right

pyeloureterogram,

Jnnuaq

10.

1930.

tc)ztl.

February

IO,

1930.

u4531

FIG. 8. Case 1. Left pyeloureterogram taken seventy -five minutes after injection with opaque medium. Du (ring interval patient was permitted to be up and albout and void.

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Furthermore, it is difEcuIt and oftentimes impossibIe to keep the catheter at the proper IeveI to maintain the most satis-

neurogenic factors for drainage into an open system depending entirely upon a Iarge opening properIy pIaced for purely

FIG. g. Case I. Left pyeloureterogram,

FIG. IO. Case I. Intravenous urograrn with nephrostomy tubes cIamped, August 20, 1931.Picture taken thirty minutes after injection of dye. Note absence of dye in ureters and bladder.

June

II, 1930.

factory drainage. The fine Iine dividing conservative and radica1 measures in the treatment of uroIogica1 Iesions is nowhere better exempIified than in the care of patients with pyeIonephritis. In order to pointedIy state our position with regard to the vaIue of nephrostomy in acute pyeIonephritis we must cite those cases in which we do not think it indicated. When the response to any form of interna medication, dietary treatment or indweIIing catheters is satisfactory, operation is obviousIy unnecessary. When cortica1 abscesses have developed we do not expect any great benefit from nephrostomy. The clinica entities on which we base this discussion are the acute fuIminati?g infections which do not improve under conservative management, and the Iow-grade chronic processes existing for a long period of time with progressive renaI damage. A nephrostomy tube judiciousIy used at a cIosed the right time, thus converting depending upon muscuIar and system

mechanica drainage, wiI1 in most cases arrest the infection without further danger to the kidney and the patient’s Iife. The muscuIar and neurogenic eIements are put at rest, as no other method wiI1 do, and the factor of back pressure on the renaI cortex is satisfactoriIy interrupted. Recovery from the infection can then proceed by the usua1 process and if recovery is not compIete further pressure destruction and to a large degree inff ammatory destruction of renaI function is arrested. Four case reports wiI1 be given brieffy: CASE I. A man, first seen on March 17, 1928, at the age of twenty-four and whose course was followed cIosely unti1 his death more than four years Iater on May I, 1932. This case was reported to this Society- in rg28, as one of a series of cases of gonococca1 pyelonephritis. When first seen he had a gonorrhea of five months’ duration and complained of dysuria and termina1 hematuria. frequency, The urine from both kidneys showed numerous

I I. Case I. Retrograde urcterogram, October I, rc,sr. nledium could not be forced beyond lcvel of fourth lumbar vertebra. No evidence of ureteral orifice was seen on Ieft side.

FIG.

Frc. 14. Frc. rj. FIG. r3. Case I. Photograph of patient showing beIt to support bottles for collection of urine. Flc;. 14. Case 1. Photograph showing receptacles for urine.

FIG. 15. Case I. Photograph of kidnqs, urctcrs bladder after remova at aut~~ps>.

and

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organisms identified as gonococci. In about four weeks’ time these organisms had disappeared but many staphyIococci were present.

FIG. 16. Case II. Right and left pyeIoureterograms, August, 1932. Right kidney and ureter practicaIIy normaI. Left peIvis, calyces and ureter somewhat diIated.

These in turn gave way to colon bacilli and streptococci. As this patient spent between two and three years in the hospital it is unnecessary and obviously impossible to report his record in detaiI. It wiI1 suffice to say that a11 forms of treatment in general use at that time were tried. These included intravenous injections of various dyes and neo-arsephamine. Seventy cystoscopic examinations were performed. In many instances the ureters were dilated and indweIIing catheters inserted. In spite of a11 forms of treatment progressive destruction of the kidneys with dilatation of the pelves, calyces and ureters and gradual diminution in function occurred. These changes are very well shown in the pyeIograms. (Figs. 1-15.) In January, 1929 doubIe temporary nephrostomies were performed. FoIIowing this rapid improvement occurred and more than 25 Ib. in weight were gained in two months. UnfortunateIy, these tubes were removed by the patient when asIeep and couId not be repIaced.

In December, rg3o a permanent right nephrostomy was performed and in February, I 93 I the operation was performed on the Ieft kidney.

FIG.

17. Case II. Intravenous urogram, May 3, 1933. Note increase in size of right renal pelvis.

FoIIowing these operations great genera1 improvement again occurred. Furthermore, the urine from both kidneys, which at the time of operation and previousIy had been very puruIent, improved rapidIy and four months Iater onIy an occasiona pus cel1 was found in the urine from each kidney. The excretion of phthaIein which had been as Iow as 15 per cent in two hours from both kidneys returned to an output of 40 per cent; 20 per cent from each kidney in two hours. The genera1 condition improved and the patient returned home and went to work. He was seen from time to time and his genera1 heaIth remained good for about a year after introduction of the nephrostomy tubes. In March, rg3z the patient returned with evidence of nephritis. There was a genera1 arasarca. The non-protein nitrogen was 60 and creatinine 2. I. Phthalein excretion was 30 per cent in two hours. Under treatment the patient again improved and was discharged from the hospital to return in ApriI, 1932, withsymptoms which led to a diagnosis of intestina1 obstruc-

tion, for which he was operated on and from which he expired on May I, 1932. At autopsy both kidneys appeared norma in size, the pehes were dilated, the capsuIes thickened, the surface of the kidneys mottled and studded with smaI1 abscesses and many scars. The lumen in the lower portion of the Jcft ureter was compIeteIy obliterated. CASE II. A man, aged fifty-six, with a history of urinary tract infection of seven years’ duration. His compIaints were extreme frequency, urgency and intermittent hematuria. At intervals he had attacks of chiIIs and fever of many clays’ duration. The bIadder capacity \vas Go C.C. The Jeft kidney pelvis, caIyces and ureter \yere dilated; the right kidney peIvis was norma but there was some dilatation in the right Iower ureter. Life was intolerable because of the extreme frequency and urgency and the attacks of chiIIs and fever. The kidneys were infected with &on baciIIi and staphyIococci. Conservative treatment including bIadder Ia\.age and hydrostatic dilatation of the bladder over a period of more than three months gave no reIief. Nephrostomy was performed on the Jeft side on November 29, 1932. The temperature dropped to normal and the patient was discharged from the hospita1. About six months Iater, May I, 1933, he returned to the hospital. During the interva1 his general condition has improved and he had worn the nephrostomy tube confortably. He still had a very marked urgency and frequency of every haIf hour during the day and night.

FIG.

19. Case

III.

Temperature

chart

from

The urine coIIected through the Ieft nephrostomy tube showed onIy seven pus ceIIs to the microscopic fieId in the centrifuged specimen.

The differential phenolsulphonephthalein test gave a return of 20 per cent from the right kidney and 30 per cent from the nephrostomy

FIG. 18. Case III. Right and left pyelour~tcrograms, hlay, 1933. Right is practically normal. Left shows great dibtation in pelvis, calyccs and uret cr.

tube in two hours. The capacity of the bladder was now about 40 C.C. A pyelogram shelved a

day

of admission to hospital to day of death.

rather marked diIatation in the pelvis of the right kidney, whereas it had previously been normal. In view of the extreme frequency and

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evidence of deveIoping hydronephrosis on the right, right nephrostomy was performed on May 16, 1933. At the time of operation the

FIG. 20. Case IV. X-ray

of caIcuIus in Ieft kidney.

FIG. 22. Case IV. Bilateral pyeloureterograms, September 9, 1933, three days before nephrostomy was performed on right kidney.

upper ureter was found to be three times norma size, acuteIy inflamed and very tortuous. The Delvis was diIated and contained about 2 oz.

of very turbid urine. The patient was greatly reIieved by the operation and was discharged from the hospita1 on June 21, 1933.

FIG. ZI. Case IV. BilateraI pyeIoureterograms showing normal kidney and ureter on right side. Left shows deformity resuIting from caIcuIus in pelvis.

He has subsequently been seen in the outpatient department as recentIy as September 9, 1933 and reports great genera1 improvement, a gain of IO Ib. in weight, a reduction in the frequency to three times per day and one time at night and the abiIity to do Iight work. CASE III. A woman, aged forty, had a left nephrectomy for hydronephrosis and hydroureter on May g, 1933 (Fig. IS). FoIIowing operation she ran a septic course, had some drainage from the wound, became anemic, and was given several bIood transfusions. Cystoscopic studies reveaIed infection in the remaining kidney which had been uninfected before operation. CuItures showed coIon baciIIi and streptococci. Continuous uretera catheter drainage and other conservative measures were tried without benefit. A right nephrostomy was performed on JuIy 22, 1933. Upon opening the kidney pelvis a great deaI of pus was evacuated. Following operation the white bIood count to 14,000 and genera1 dropped from 30,000 improvement was noted. However, pneumonia developed in the Ieft Iung and she expired on JuIy 30, 1933. (Fig. 19.) CASE IV. A woman, aged forty-five, had a Ieft DeIvioneDhrolithotomv on August I, 1933.

Following

operation

sepsis deveIoped. age through

a

gradualIy

increasing

There was satisfactory

the flank

from the kidney

drainwhich

ureter

may

occur

without

demonstrabIe

evidence of stricture formation. 4. Great stasis of urine ma!-

occur

as

U-m&

FIG. 23.

Case IV. Temperature

chart showing rapid drop in temperature to normal folIowing nephrostomy kidney.

had been operated on. Cystoscopic studies revealed infection (colon bacilIus) in the right kidney which had been uninfected before operation (Figs. 20 to 23). Conservative measures incIuding indwelIing catheters did not benefit. A right nephrostomy was performed on September 12, 1933. Improvement foIIowing operation was rapid. The nephrostomy tube was removed on the seventeenth postoperative day and the wound was heaIed on the twentyfirst postoperative day without an erevation of temperature above 99.8” F. CONCLUSIONS I. Acute pyelonephritis may cause great destruction of kidney cortex with reduction in function. 2. The inflammatory process in the waI1 of the peIvis and ureter and in the peripeIvic and periuretera1 tissues may interfere with drainage earIy in the course of the disease by diminution in the caIiber of the Iumen, and by Iessening peristaIsis. 3. Marked diIatation in the pelvis and

on right

shown bv an emptying time of se\-enty-five minutesin one case reported. This increases the intrarena1 pressure and increases the tendency of the infection to in\,ade the cortex. 3. Nephrostomy offers a means of giving constant and compIete drainage and should be carried out before great renal damage has occurred. 6. Drainage may be temporaq or permanent, depending upon the progress of the case. 7. In many cases nephrostomy wilI conserve renaI function and in some cases it wiI1 sa\re human Iife. REFERENCES

A. If. J. Ural., 14: 249, 1925. CHUTE, A. L. J. urol., 14: 231-237, 1925. 3. MATHE, C. P. J. Ural., 24: 119-140, 1930. 4. CABOT, H., and HOLLAND, W. \V. Surg. Gynec. Ok., 54: 817-825 (May) 1932. 5. ROSE, D. K., HAMM, W. F., MOORE, S., and WILSON, H. 9. Surg. Gynec., Ok., 57: r-14 [Aug.1 1933. I. CROSBIE,

2.