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Ureteric stent in severe hydronephrosis of pregnancy
European Journal of Obstetrics & Gynecology and Reproductive Biology 56 (1994) 79-81
ELSEVIER
Ureteric stent in severe hydronephrosis
of pregnancy
0. Sadana, M. Berara, R. Sagiv”, D. Drevala, G. Gewurtzc, D. Korczakb, H. Zakut*“, D. Bernstein” “Deparlment ofObsterrics and
Gynecology, bDeparrment of Urology , The Sackler Faculty of Medicine. Tel-Aviv University. Tel Aviv, Israel ‘Department of Radiology, The Edith Wolfson Medical Center, P. 0. Box 5. Holon (58100). Israel
Accepted 8 April 1994
Abstract
Eleven women (12 pregnancies) were included in the study. A double-pigtail ureteric stent was passed under cytoscopic vision in 8 patients. The mean gestational age on insertion of the stents was 29 weeks (range, 25-35 weeks). Delivery took place at a mean of 39 weeks (range, 35-41 weeks). Stents remained in situ for a mean of 9 weeks (range, 6-14 weeks) before delivery and were removed 4-5 weeks postpartum. Double pigtail ureteric stents did not expose the women to infection. Renal function tests remained within the normal limits. Ureteric stent is an effective method for internal drainage of severe hydronephrosis during pregnancy. Keywords:
Pregnancy; Hydronephrosis;
Ureteric stent
1. Introduction Hydronephrosis and hydroureter during pregnancy are termed physiological [ 11.They are seen in more than 80% of women, mainly primigravida [2]. Dilatation is unusual and slight until the 20th week of pregnancy.
Shortly thereafter dilatation develops abruptly and progresses slowly until labor. It disappears within a few weeks after the birth [2,3]. It is more marked on the right than the left side of the collecting system [4]. Dilatation is limited to above the pelvic brim [2]. Pressure of the uterus on the ureter where they cross the iliac vessels at the level of the linea terminally causes obstruction [5]. The unequal degree of dilatation may result from protection provided by the sigmoid colon and dextro rotation of the uterus [ 1,2]. The ovarian veins dilate during pregnancy and cause partial compression and stasis in the ureter [6]. Major support for the hormonal concept was provided by Van Wagenen and Jenkins [7] ~. l
Corresponding author.
0 1994 Elsevier Science Ireland 0028-2243/94/$07.00 SSDI 002%2243(94)01863-3
who described in the monkey further dilatation of the ureter after removal of the fetus, if the placenta remained in situ. The objective of the study was to describe the use of double pigtail ureteric stents in the treatment of severe hydronephrosis in pregnancy. 2. Material and methods Eleven women (12 pregnancies) complaining of loin pains and temperature, presented to the maternity unit, at the Edith Wolfson Medical Center. Diagnosis of severe hydronephrosis was confirmed by ultrasound. Patient details, gravidity, parity, side involved, size of the hydrouteter, severity of the hydronephrosis as well as the gestational age at insertion and delivery and mode of delivery are reported in Table 1. A double-pigtail ureteric stent was passed under cytoscopic vision in 8 patients. It is a polyurethane catheter which is used for internal drainage from the ureteropelvic junction to the bladder (Fig. 1).
Ltd. All rights reserved
80
et al. /Eur. J. Obsret. Gynecol. Reprod. Biol. 56 (1994)
0. Saah
79-81
Table 1 Patients’ details and clinical data Hydroureter
Age (years)
Gravidity/ parity
Side involved
2= 3b 4 5 6
21 25 24 26 21 20
GlPO G2PI GIPO GlPO GIPO GIPO
Right Right Right Right Left Bilateral
I 8 9d IO
29 29 38 22
GIPO G2Pl G6P3 GIPO
Left Left Left Left
Ild
25
GIPO
Bilateral
9 8
12
38
G4P2
Bilateral
13 I
Patient no.
I
Abbreviations: N.V.D., YSingle kidney.
normal
vaginal
10 5 10 I 6 6 12 II I2 I3 I2
Gestational at insertion (weeks)
Moderate-severe Moderate Moderate-severe Moderate Moderate Moderate (R) Severe (L) Severe Severe Moderate-severe Severe Moderate Moderate
31 30 35 31 29 25
39 31 35 38 35 36
N.V.D. N.V.D. N.V.D. (P.G.) N.V.D. N.V.D. N.V.D.
27 2oc 18c 15c 27
41 37 35 35 41
N.V.D. N.V.D. (P.G.) C.S. (P.G.) N.V.D. (P.G.) C.S.
32
38
N.V.D.
delivery;
C.S., caesarean
Severe (R) Moderate(L) section;
age
Mode of delivery
Hydronephrosis
(mm)
Gestational at delivery (weeks)
age
P.G., prostaglandins.
bFailed Insertion. ‘Nephrostomy tube. dCystein Stones.
3. Results Mean maternal age was 26.5 years (range, 20-38 years). Eight patients were in their first pregnancy (Table 1). The ureteric stent was passed under cystoscopic vision in 8 patients, (Table 1). Mean ureteral size was 9.4 mm (range, 5- 13 mm). Hydronephrosis was graded as moderate or severe [8]. An attempt to insert the stent in patient No. 3 failed. After confirmation of lung maturity labor was induced by prostaglandins. Nephrostomy tubes were inserted in 3 patients (Nos. 8-10). Because of recurrent episodes of infection, labor was induced by prostaglandins. Patient No. 2 had a single kidney. The stent was inserted at 30 weeks gestational age. She had a spontaneous labor 7 weeks later. The stent was removed shortly after delivery. Two women (Nos. 9 and 11) have had cystein stones. Before pregnancy they underwent extra corporel shock wave litothripsy (E.S.W.L.). One patient (No. 7 and 8) had 2 consecutive pregnancies while carrying a pig-tail stent. During the second gestation, the stent was obstructed and a nephrostomy tube was inserted. 4. Discussion
Fig. 1. Double pig-tail
ureteric
stent.
The most common cause of severe flank pain in pregnancy is acute hydronephrosis. Raised temperature is also often present. The clinical significance of hydro-
0. Sadan et al. /Eur. J. Obsret. Gynecol. Reprod. Biol. 56 (1994) 79-81
nephrosis and hydroureter lies in the association with ureteral obstruction and the high frequency of ascending infection and deterioration of renal function [6,9], The diagnosis was confirmed in the past by a single shot of intravenous pyelography (IVP). Now, it is done mainly by gray-scale ultrasound with a sensitivity of 98% [8]. Previously, the management of an obstructed ureter in pregnancy depended upon the gestational age of the fetus. Less advanced pregnancies were treated by percutaneous nephrostomy [IO], which was associated with recurrent episodes of obstruction and infection. When the fetus was considered mature enough to survive, the approach was to induce labor. Recently, the use of an indwelling uretetic stent was introduced [ 11,121. The introduction of ureteric catheter has been abandoned because of low patients compliance. A catheter or stent might rarely be associated with incrustation [5]. Patients carrying ureteric stents are expected to have spontaneous, normal labor. The mean gestational age on insertion of the stents was 29 weeks (range, 25-35 weeks). Patient complaints subsided within a short time after the procedure. Mean gestation age on delivery was 38 weeks (range, 35-41 weeks). Stents remained in situ for a mean of 9 weeks (range, 6-14 weeks) before delivery and were removed 4-5 weeks post partum when the physiological changes of pregnancies were considered to have resolved. Ten women had normal vaginal deliveries. The remaining two were delivered by cesarean section because of no progress of labor. No clinical or laboratory data of infection was noted. Antibiotics were not prescribed routinely. Renal function tests remained within normal limits. Double-pigtail ureteric stents are easy to place, to
81
remove, and are well tolerated. They provide a simple, safe and effective method of internal urinary tract drainage in severe hydronephrosis of pregnancy [ 121. References FG, MacDonald PC, Cant NF et al. Urinary system. In: Williams Obstetrics, 19th edition. Prentile-Hall, 1993; 230-232. 121Rasmussen PE, Nielsen FR. Hydronephrosis during pregnancy: a literature survey. Eur J Obstet Gynecol Reprod Biol 1988; 27:
111Cunningham
249-259. A, Newton JR. Serial qualitative maternal I31 Cietak nephrosonography in pregnancy. Br J Radio1 1985; 58: 399-404. H. Urinary tract dilatation in preg141 Schulman A, Herlinger nancy. Br J Radio1 1975; 48: 638-645. of acute [I Goldfarb RA, Neerhut GJ, Lederer E. Management hydronephrosis of pregnancy by ureteral stenting: risk of stone formation. J Urol 1989; 141: 921-922. dilatation 161 Bellina JH, Dougherty CM, Mickal A. Pyeloureteral and pregnancy. Am J Obstet Gynecol 1970: 108: 356-363. of 171 Van Wagenen G, Jenkins RH. An experimental examination factors causing ureteral dilatation of pregnancy. Urology 1939; 42: 1010-1020. Ellenbogen RH, Scheible FW, Tamer LB, Leopold CR. Sensitivity of gray scale ultrasound in detecting urinary tract obstruction. Am J Roentgen01 1978; 130: 731-733. 191 Eika B. Skajaa K. Acute renal failure due to bilateral ureteral obstruction by the pregnant uterus. Ural Int 1988; 43: 315-317. L, Amar AD, Das S. Percutaneous IlOl Quinn AD, Kusuda nephrostomy for treatment of hydronephrosis of pregnancy. J Urol 1988; 139: 1037-1038. 1111 Bali AJ, Gingell JC, Carter SS, Smith PJB. The indwelling ureteric stent. The Bristol experience. Br J Urol 1983; 55: 622-25. SD, [I21 Eckford ancy-diagnosis 98: I 137-40.
Gingell JC. Ureteric obstruction in pregnand management. Br J Obstet Gynaecol 1991:
ELSEVIER
Ureteric stent in severe hydronephrosis
of pregnancy
0. Sadana, M. Berara, R. Sagiv”, D. Drevala, G. Gewurtzc, D. Korczakb, H. Zakut*“, D. Bernstein” “Deparlment ofObsterrics and
Gynecology, bDeparrment of Urology , The Sackler Faculty of Medicine. Tel-Aviv University. Tel Aviv, Israel ‘Department of Radiology, The Edith Wolfson Medical Center, P. 0. Box 5. Holon (58100). Israel
Accepted 8 April 1994
Abstract
Eleven women (12 pregnancies) were included in the study. A double-pigtail ureteric stent was passed under cytoscopic vision in 8 patients. The mean gestational age on insertion of the stents was 29 weeks (range, 25-35 weeks). Delivery took place at a mean of 39 weeks (range, 35-41 weeks). Stents remained in situ for a mean of 9 weeks (range, 6-14 weeks) before delivery and were removed 4-5 weeks postpartum. Double pigtail ureteric stents did not expose the women to infection. Renal function tests remained within the normal limits. Ureteric stent is an effective method for internal drainage of severe hydronephrosis during pregnancy. Keywords:
Pregnancy; Hydronephrosis;
Ureteric stent
1. Introduction Hydronephrosis and hydroureter during pregnancy are termed physiological [ 11.They are seen in more than 80% of women, mainly primigravida [2]. Dilatation is unusual and slight until the 20th week of pregnancy.
Shortly thereafter dilatation develops abruptly and progresses slowly until labor. It disappears within a few weeks after the birth [2,3]. It is more marked on the right than the left side of the collecting system [4]. Dilatation is limited to above the pelvic brim [2]. Pressure of the uterus on the ureter where they cross the iliac vessels at the level of the linea terminally causes obstruction [5]. The unequal degree of dilatation may result from protection provided by the sigmoid colon and dextro rotation of the uterus [ 1,2]. The ovarian veins dilate during pregnancy and cause partial compression and stasis in the ureter [6]. Major support for the hormonal concept was provided by Van Wagenen and Jenkins [7] ~. l
Corresponding author.
0 1994 Elsevier Science Ireland 0028-2243/94/$07.00 SSDI 002%2243(94)01863-3
who described in the monkey further dilatation of the ureter after removal of the fetus, if the placenta remained in situ. The objective of the study was to describe the use of double pigtail ureteric stents in the treatment of severe hydronephrosis in pregnancy. 2. Material and methods Eleven women (12 pregnancies) complaining of loin pains and temperature, presented to the maternity unit, at the Edith Wolfson Medical Center. Diagnosis of severe hydronephrosis was confirmed by ultrasound. Patient details, gravidity, parity, side involved, size of the hydrouteter, severity of the hydronephrosis as well as the gestational age at insertion and delivery and mode of delivery are reported in Table 1. A double-pigtail ureteric stent was passed under cytoscopic vision in 8 patients. It is a polyurethane catheter which is used for internal drainage from the ureteropelvic junction to the bladder (Fig. 1).
Ltd. All rights reserved
80
et al. /Eur. J. Obsret. Gynecol. Reprod. Biol. 56 (1994)
0. Saah
79-81
Table 1 Patients’ details and clinical data Hydroureter
Age (years)
Gravidity/ parity
Side involved
2= 3b 4 5 6
21 25 24 26 21 20
GlPO G2PI GIPO GlPO GIPO GIPO
Right Right Right Right Left Bilateral
I 8 9d IO
29 29 38 22
GIPO G2Pl G6P3 GIPO
Left Left Left Left
Ild
25
GIPO
Bilateral
9 8
12
38
G4P2
Bilateral
13 I
Patient no.
I
Abbreviations: N.V.D., YSingle kidney.
normal
vaginal
10 5 10 I 6 6 12 II I2 I3 I2
Gestational at insertion (weeks)
Moderate-severe Moderate Moderate-severe Moderate Moderate Moderate (R) Severe (L) Severe Severe Moderate-severe Severe Moderate Moderate
31 30 35 31 29 25
39 31 35 38 35 36
N.V.D. N.V.D. N.V.D. (P.G.) N.V.D. N.V.D. N.V.D.
27 2oc 18c 15c 27
41 37 35 35 41
N.V.D. N.V.D. (P.G.) C.S. (P.G.) N.V.D. (P.G.) C.S.
32
38
N.V.D.
delivery;
C.S., caesarean
Severe (R) Moderate(L) section;
age
Mode of delivery
Hydronephrosis
(mm)
Gestational at delivery (weeks)
age
P.G., prostaglandins.
bFailed Insertion. ‘Nephrostomy tube. dCystein Stones.
3. Results Mean maternal age was 26.5 years (range, 20-38 years). Eight patients were in their first pregnancy (Table 1). The ureteric stent was passed under cystoscopic vision in 8 patients, (Table 1). Mean ureteral size was 9.4 mm (range, 5- 13 mm). Hydronephrosis was graded as moderate or severe [8]. An attempt to insert the stent in patient No. 3 failed. After confirmation of lung maturity labor was induced by prostaglandins. Nephrostomy tubes were inserted in 3 patients (Nos. 8-10). Because of recurrent episodes of infection, labor was induced by prostaglandins. Patient No. 2 had a single kidney. The stent was inserted at 30 weeks gestational age. She had a spontaneous labor 7 weeks later. The stent was removed shortly after delivery. Two women (Nos. 9 and 11) have had cystein stones. Before pregnancy they underwent extra corporel shock wave litothripsy (E.S.W.L.). One patient (No. 7 and 8) had 2 consecutive pregnancies while carrying a pig-tail stent. During the second gestation, the stent was obstructed and a nephrostomy tube was inserted. 4. Discussion
Fig. 1. Double pig-tail
ureteric
stent.
The most common cause of severe flank pain in pregnancy is acute hydronephrosis. Raised temperature is also often present. The clinical significance of hydro-
0. Sadan et al. /Eur. J. Obsret. Gynecol. Reprod. Biol. 56 (1994) 79-81
nephrosis and hydroureter lies in the association with ureteral obstruction and the high frequency of ascending infection and deterioration of renal function [6,9], The diagnosis was confirmed in the past by a single shot of intravenous pyelography (IVP). Now, it is done mainly by gray-scale ultrasound with a sensitivity of 98% [8]. Previously, the management of an obstructed ureter in pregnancy depended upon the gestational age of the fetus. Less advanced pregnancies were treated by percutaneous nephrostomy [IO], which was associated with recurrent episodes of obstruction and infection. When the fetus was considered mature enough to survive, the approach was to induce labor. Recently, the use of an indwelling uretetic stent was introduced [ 11,121. The introduction of ureteric catheter has been abandoned because of low patients compliance. A catheter or stent might rarely be associated with incrustation [5]. Patients carrying ureteric stents are expected to have spontaneous, normal labor. The mean gestational age on insertion of the stents was 29 weeks (range, 25-35 weeks). Patient complaints subsided within a short time after the procedure. Mean gestation age on delivery was 38 weeks (range, 35-41 weeks). Stents remained in situ for a mean of 9 weeks (range, 6-14 weeks) before delivery and were removed 4-5 weeks post partum when the physiological changes of pregnancies were considered to have resolved. Ten women had normal vaginal deliveries. The remaining two were delivered by cesarean section because of no progress of labor. No clinical or laboratory data of infection was noted. Antibiotics were not prescribed routinely. Renal function tests remained within normal limits. Double-pigtail ureteric stents are easy to place, to
81
remove, and are well tolerated. They provide a simple, safe and effective method of internal urinary tract drainage in severe hydronephrosis of pregnancy [ 121. References FG, MacDonald PC, Cant NF et al. Urinary system. In: Williams Obstetrics, 19th edition. Prentile-Hall, 1993; 230-232. 121Rasmussen PE, Nielsen FR. Hydronephrosis during pregnancy: a literature survey. Eur J Obstet Gynecol Reprod Biol 1988; 27:
111Cunningham
249-259. A, Newton JR. Serial qualitative maternal I31 Cietak nephrosonography in pregnancy. Br J Radio1 1985; 58: 399-404. H. Urinary tract dilatation in preg141 Schulman A, Herlinger nancy. Br J Radio1 1975; 48: 638-645. of acute [I Goldfarb RA, Neerhut GJ, Lederer E. Management hydronephrosis of pregnancy by ureteral stenting: risk of stone formation. J Urol 1989; 141: 921-922. dilatation 161 Bellina JH, Dougherty CM, Mickal A. Pyeloureteral and pregnancy. Am J Obstet Gynecol 1970: 108: 356-363. of 171 Van Wagenen G, Jenkins RH. An experimental examination factors causing ureteral dilatation of pregnancy. Urology 1939; 42: 1010-1020. Ellenbogen RH, Scheible FW, Tamer LB, Leopold CR. Sensitivity of gray scale ultrasound in detecting urinary tract obstruction. Am J Roentgen01 1978; 130: 731-733. 191 Eika B. Skajaa K. Acute renal failure due to bilateral ureteral obstruction by the pregnant uterus. Ural Int 1988; 43: 315-317. L, Amar AD, Das S. Percutaneous IlOl Quinn AD, Kusuda nephrostomy for treatment of hydronephrosis of pregnancy. J Urol 1988; 139: 1037-1038. 1111 Bali AJ, Gingell JC, Carter SS, Smith PJB. The indwelling ureteric stent. The Bristol experience. Br J Urol 1983; 55: 622-25. SD, [I21 Eckford ancy-diagnosis 98: I 137-40.
Gingell JC. Ureteric obstruction in pregnand management. Br J Obstet Gynaecol 1991: