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Ureteral and Renal Vein Perforation with Placement into the Renal Vein as a Complication of the Pigtail Ureteral Stent
0022-5347 /80/1242-0424$02.00/0 Vol. 124, September Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1980 by The Williams & Wilkins Co.
URETERAL AND RENAL VEIN PERFORATION WITH PLACEMENT INTO THE RENAL VEIN AS A COMPLICATION OF THE PIGTAIL URETERAL STENT R. VINCENT KIDD, III, DAVID J. CONFER*
AND
THOMAS P. BALL, JR.
From the Department of Urology, Division of Surgery, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, Texas
ABSTRACT
A 43-year-old woman with recurrent colon carcinoma presented with bilateral pelvioureteral obstruction_ After a 6F ureteral catheter had been in place for 4 days the left ureter was perforated near the ureteropelvic junction, while an attempt was made to insert a 7F Cook indwelling pigtail ureteral stent. The errant stent was allowed to remain in its extraureteral locale until urinary drainage was established_ To our surprise the stent had been placed into the renal vein, after exiting the ureter 2 cm_ inferiorly. There was excellent tamponade. When the large stent was removed severe bleeding ensued that was controlled by ligatures. Methods to prevent perforation are discussed. Should perforation of these stents occur in the proximal ureter or renal pelvis it would seem judicious to leave these in place rather than perform any further endoscopic manipulation before surgical inspection. The polyethylene ureteral stent is assuming a progressively greater role in the management of difficult urological problems, such as a ureteral fistula or obstruction. 1· 2 Its use has been lifesaving in many patients in whom prolonged urinary drainage is necessary for improvement of renal function. Presently, the 2 types of stents commercially available are the Gibbons ureteral stent and the pigtailed type of stent with a coil tip at 1 or both ends. The reported complications of Gibbons' stents have been described previously.'3 The reported complications of the coiltipped stents are similar but the experience with these is considerably less in most centers. 4 CASE REPORT
A 43-year-old white woman, who had known metastatic adenocarcinoma of the colon, Duke's class III, presented to our institution with a small bowel obstruction. Creatinine had increased from 1.3 to 4.3 during the previous 3 months. Retrograde ureterograms showed complete obstruction on the right side and partial obstruction on the left side at the pelvic brim. There was a kink in the left proximal ureter (fig. 1). A 6F Braasch bulb catheter was passed to the pelvis easily, followed by a decrease in creatinine to 2.7 during the next 4 days. A film of the kidneys, ureters and bladder 4 days later showed that the ureteral catheter had migrated to the distal third of the ureter. It was elected at this time to pass a Cook pigtail ureteral stent for permanent urinary drainage, since further operation and chemotherapy were contemplated. A 6F ureteral catheter was passed up to an apparent obstruction believed to be at the proximal third ureteral kink. Gentle pushing of the catheter seemed to maneuver it into the renal pelvis. The flexible softtipped wire guide was then positioned and a 7F stent was inserted into what appeared to be the renal pelvis (fig. 2). Because the catheter appeared to be high in the renal pelvis and there was no urinary efflux, an oblique film was obtained, Accepted for publication November 16, 1979. The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force. * Requests for reprints: Wilford Hall United States Air Force Medical Center/SGHSU, Lackland Air Force Base, Texas 78236. 424
FIG. 1. Retrograde pyelogram demonstrates kink or loop in proximal left ureter.
425
COMPLICATION OF PIGTAIL URETERAL STENT
control a perforation was closed with monofilament nylon sutures. A pyelotomy was made and a 4F ureteral catheter was passed down to the area of ureteral perforation. A small vertical incision was made in the ureter, extending the length of the perforation, and the 4F catheter was brought out through the ureterotomy. This catheter was then tied to the Cook stent and the stent was pulled into the renal pelvis. The inferior end of the stent was pushed back into the bladder. A nephrostomy tube was placed in the standard manner. The Cook wire guide was then passed the length of the Cook stent to remove blood clots or debris. The ureteral and pelvic incisions were then closed. Postoperatively, the creatinine has decreased to 1.3 and nephrostograms at 2 weeks and 3 months have shown no extravasation with the stent in good position. COMMENTS
FIG. 2. Radiography shows ureteral stent apparently residing on renal pelvis.
Our experience with the Cook indwelling ureteral stent has been favorable. We measure the ureter and select the appropriate length stent, as suggested by the manufacturer. If we err on the side of selecting one that might be slightly too long and > 1½ cm. extrudes from the orifice, we may change the stent if trigonal irritation occurs. In this case, when the pre-selected stent migrated proximally, an x-ray showed the coiled end of the stent high in the renal pelvis. Since there was no urinary efflux from the stent or ureteral orifice we suspected that the stent was extrapelvic in position. The bulb ureterogram (particularly the oblique film) confirmed the perforation and proximal extraureteral location of the stent. The small amount of blood exiting the orifice was
FLEXIBLE SOFT TIPPED WIRE GUIDE
FIG. 3. Retrograde bulb ureterogram reveals ureteral extravasation
which showed the catheter outside the renal pelvis. A bulb ureterogram around the stent confirmed this and demonstrated proximal ureteral extravasation of contrast material (fig. 3). The catheter was not retrieved endoscopically since it had fortuitously migrated proximally. At an emergency abdominal exploration the stent was seen perforating the ureter at the level of the kink. With extraction of the stent from the renal hilus, a brisk hemorrhage occurred. With appropriate vascular
FIG. 4. Drawing representing passage of flexible wire guide as initial step in pigtail ureteral stent placement.
426
KIDD, CONFER AND BALL
not surprising and it never occurred to us that the stent may have been residing in the renal vein. The brisk hemorrhage seen at the time of the operative procedure may well have caused death had the stent been removed endoscopically. Extending the traumatic ureterotomy about ½ cm. permitted the stent to be pulled into the renal pelvis as described previously. Closure of the pyelotomy and ureterotomy was modified for this terminal cancer patient. After an inner running musculomucosal 5-zero polygalactin suture was placed an external running musculoadventitial 6-zero polypropylene was used to ensure a watertight closure. The pyelotomy site also was modified and placed much higher than is customary to ensure that the stent would not reside against the closure. Based on our experience, when considering the pigtail ureteral stent as the permanent form of urinary drainage, several factors should be kept in mind. A bulb ureterogram should be obtained before insertion of a Cook stent to define better the anatomy of the ureter and renal pelvis. If a kink of the ureter is found it is probably best that a flexible soft-tipped wire guide be passed first under fluoroscopic control (we have used this technique of initially passing a flexible angiographic wire guide in about 80 patients for intrarenal manipulation of stones with-
out ureteral injury) (fig. 4). 5 Oblique films should be obtained to ensure that the catheter is in the renal pelvis if urinary efflux is less than optimal. If ureteral perforation is considered a possibility a bulb ureterogram around the stent should be obtained for confirmation. If the stent has perforated the proximal ureter or renal pelvis it is probably best to avoid any further manipulation until the injury can be defined clearly by surgical inspection. REFERENCES 1. Pais, V. M., Spellman, R. M., Stiles, R. E. and Mahony, S. A.:
Internal ureteral splints. Urology, 5: 32, 1975. 2. Gibbons, R. P., Correa, R. J., Jr., Cummings, K. B. and Mason, J. T.: Experience with indwelling ureteral stent catheters. J. Urol., 115: 22, 1976. 3. Schneider, R. D., Depauw, A. P., Montie, J. E. and Thompson, I. M.: Problems associated with Gibbons ureteral catheters. Urology, 8: 243, 1976. 4. Collier, M. D., Jerkins, G. R., Noe, H. N. and Soloway, M. S.: Proximal stent displacement as complication of pigtail ureteral stent. Urology, 13: 372, 1979. 5. Ball, T. P., Jr. and Bobroff, "L. M.: Selective caliceal catheterization for stone manipulation. J. Urol., 114: 172, 1975.
THE JOURNAL OF UROLOGY
Copyright© 1980 by The Williams & Wilkins Co.
URETERAL AND RENAL VEIN PERFORATION WITH PLACEMENT INTO THE RENAL VEIN AS A COMPLICATION OF THE PIGTAIL URETERAL STENT R. VINCENT KIDD, III, DAVID J. CONFER*
AND
THOMAS P. BALL, JR.
From the Department of Urology, Division of Surgery, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, Texas
ABSTRACT
A 43-year-old woman with recurrent colon carcinoma presented with bilateral pelvioureteral obstruction_ After a 6F ureteral catheter had been in place for 4 days the left ureter was perforated near the ureteropelvic junction, while an attempt was made to insert a 7F Cook indwelling pigtail ureteral stent. The errant stent was allowed to remain in its extraureteral locale until urinary drainage was established_ To our surprise the stent had been placed into the renal vein, after exiting the ureter 2 cm_ inferiorly. There was excellent tamponade. When the large stent was removed severe bleeding ensued that was controlled by ligatures. Methods to prevent perforation are discussed. Should perforation of these stents occur in the proximal ureter or renal pelvis it would seem judicious to leave these in place rather than perform any further endoscopic manipulation before surgical inspection. The polyethylene ureteral stent is assuming a progressively greater role in the management of difficult urological problems, such as a ureteral fistula or obstruction. 1· 2 Its use has been lifesaving in many patients in whom prolonged urinary drainage is necessary for improvement of renal function. Presently, the 2 types of stents commercially available are the Gibbons ureteral stent and the pigtailed type of stent with a coil tip at 1 or both ends. The reported complications of Gibbons' stents have been described previously.'3 The reported complications of the coiltipped stents are similar but the experience with these is considerably less in most centers. 4 CASE REPORT
A 43-year-old white woman, who had known metastatic adenocarcinoma of the colon, Duke's class III, presented to our institution with a small bowel obstruction. Creatinine had increased from 1.3 to 4.3 during the previous 3 months. Retrograde ureterograms showed complete obstruction on the right side and partial obstruction on the left side at the pelvic brim. There was a kink in the left proximal ureter (fig. 1). A 6F Braasch bulb catheter was passed to the pelvis easily, followed by a decrease in creatinine to 2.7 during the next 4 days. A film of the kidneys, ureters and bladder 4 days later showed that the ureteral catheter had migrated to the distal third of the ureter. It was elected at this time to pass a Cook pigtail ureteral stent for permanent urinary drainage, since further operation and chemotherapy were contemplated. A 6F ureteral catheter was passed up to an apparent obstruction believed to be at the proximal third ureteral kink. Gentle pushing of the catheter seemed to maneuver it into the renal pelvis. The flexible softtipped wire guide was then positioned and a 7F stent was inserted into what appeared to be the renal pelvis (fig. 2). Because the catheter appeared to be high in the renal pelvis and there was no urinary efflux, an oblique film was obtained, Accepted for publication November 16, 1979. The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force. * Requests for reprints: Wilford Hall United States Air Force Medical Center/SGHSU, Lackland Air Force Base, Texas 78236. 424
FIG. 1. Retrograde pyelogram demonstrates kink or loop in proximal left ureter.
425
COMPLICATION OF PIGTAIL URETERAL STENT
control a perforation was closed with monofilament nylon sutures. A pyelotomy was made and a 4F ureteral catheter was passed down to the area of ureteral perforation. A small vertical incision was made in the ureter, extending the length of the perforation, and the 4F catheter was brought out through the ureterotomy. This catheter was then tied to the Cook stent and the stent was pulled into the renal pelvis. The inferior end of the stent was pushed back into the bladder. A nephrostomy tube was placed in the standard manner. The Cook wire guide was then passed the length of the Cook stent to remove blood clots or debris. The ureteral and pelvic incisions were then closed. Postoperatively, the creatinine has decreased to 1.3 and nephrostograms at 2 weeks and 3 months have shown no extravasation with the stent in good position. COMMENTS
FIG. 2. Radiography shows ureteral stent apparently residing on renal pelvis.
Our experience with the Cook indwelling ureteral stent has been favorable. We measure the ureter and select the appropriate length stent, as suggested by the manufacturer. If we err on the side of selecting one that might be slightly too long and > 1½ cm. extrudes from the orifice, we may change the stent if trigonal irritation occurs. In this case, when the pre-selected stent migrated proximally, an x-ray showed the coiled end of the stent high in the renal pelvis. Since there was no urinary efflux from the stent or ureteral orifice we suspected that the stent was extrapelvic in position. The bulb ureterogram (particularly the oblique film) confirmed the perforation and proximal extraureteral location of the stent. The small amount of blood exiting the orifice was
FLEXIBLE SOFT TIPPED WIRE GUIDE
FIG. 3. Retrograde bulb ureterogram reveals ureteral extravasation
which showed the catheter outside the renal pelvis. A bulb ureterogram around the stent confirmed this and demonstrated proximal ureteral extravasation of contrast material (fig. 3). The catheter was not retrieved endoscopically since it had fortuitously migrated proximally. At an emergency abdominal exploration the stent was seen perforating the ureter at the level of the kink. With extraction of the stent from the renal hilus, a brisk hemorrhage occurred. With appropriate vascular
FIG. 4. Drawing representing passage of flexible wire guide as initial step in pigtail ureteral stent placement.
426
KIDD, CONFER AND BALL
not surprising and it never occurred to us that the stent may have been residing in the renal vein. The brisk hemorrhage seen at the time of the operative procedure may well have caused death had the stent been removed endoscopically. Extending the traumatic ureterotomy about ½ cm. permitted the stent to be pulled into the renal pelvis as described previously. Closure of the pyelotomy and ureterotomy was modified for this terminal cancer patient. After an inner running musculomucosal 5-zero polygalactin suture was placed an external running musculoadventitial 6-zero polypropylene was used to ensure a watertight closure. The pyelotomy site also was modified and placed much higher than is customary to ensure that the stent would not reside against the closure. Based on our experience, when considering the pigtail ureteral stent as the permanent form of urinary drainage, several factors should be kept in mind. A bulb ureterogram should be obtained before insertion of a Cook stent to define better the anatomy of the ureter and renal pelvis. If a kink of the ureter is found it is probably best that a flexible soft-tipped wire guide be passed first under fluoroscopic control (we have used this technique of initially passing a flexible angiographic wire guide in about 80 patients for intrarenal manipulation of stones with-
out ureteral injury) (fig. 4). 5 Oblique films should be obtained to ensure that the catheter is in the renal pelvis if urinary efflux is less than optimal. If ureteral perforation is considered a possibility a bulb ureterogram around the stent should be obtained for confirmation. If the stent has perforated the proximal ureter or renal pelvis it is probably best to avoid any further manipulation until the injury can be defined clearly by surgical inspection. REFERENCES 1. Pais, V. M., Spellman, R. M., Stiles, R. E. and Mahony, S. A.:
Internal ureteral splints. Urology, 5: 32, 1975. 2. Gibbons, R. P., Correa, R. J., Jr., Cummings, K. B. and Mason, J. T.: Experience with indwelling ureteral stent catheters. J. Urol., 115: 22, 1976. 3. Schneider, R. D., Depauw, A. P., Montie, J. E. and Thompson, I. M.: Problems associated with Gibbons ureteral catheters. Urology, 8: 243, 1976. 4. Collier, M. D., Jerkins, G. R., Noe, H. N. and Soloway, M. S.: Proximal stent displacement as complication of pigtail ureteral stent. Urology, 13: 372, 1979. 5. Ball, T. P., Jr. and Bobroff, "L. M.: Selective caliceal catheterization for stone manipulation. J. Urol., 114: 172, 1975.