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A New Technique for Percutaneous Nephropyelostomy
0022-,5347 /81/1254-04 75$02.0C /CJ
Vol. i25,
TrtE JOUR)>Ti':,_L OF UROLOGY
Printed in
Copyright© 1981 by The \1/illiams & VVilkins Co.
TECHNIQUE FOR PERCUTAI'~EOUS NEPHROPYELOSTOIVIY A SCHILLING,* H. GOETTINGER, F. J. MARX, J. SCHUELLER
AND
H. W. BAUER
From the Department of Urology, Klinikum Grosshadern, University of Munich, Munich, West Germany
ABSTRACT
Prima:ry insertion of a large caliber catheter into the renal pelvis would provide the most favorable drainage in all cases in which urinary diversion by nephropyelostomy is indicated. Therefore, the puncture technique of Guenther and associates was modified. A specially designed balloon catheter was used to prevent dislocation. In 1955 Goodwin and associates performed the first percutaneous nephropyelostomy. 1 However, the common use of this method was delayed because of inadequate technology. The development of improved x-ray screening techniques with an image intensifier and of ultrasonically guided puncture equipment provided a new impulse for this procedure. In almost all cases in which urinary diversion by nephropyelostomy is indicated it would be best if the first catheter inserted was of a large caliber. Furthermore, dislocation of the catheter must be prevented. MATERIALS AND METHODS
Percutaneous nephropyelostomy was done on 128 patients during the last 18 months. With the aforementioned consideration the method of Guenther and associates was modified by inserting a large-bore balloon catheter at the end of the first procedure. 2 The puncture set consists of a hollow puncture needle, a fine needle, a wire guide, bougies, a metal tube and a specially designed balloon catheter with a central terminal opening and a side opening proximal to the balloon. Usually, the percutaneous nephropyelostomy is done with the patient in the prone position. After local anesthesia and excretory urography are done the puncture needle is inserted from the posterior axillary line just below the 12th rib to the renal capsule. Through this needle a fine needle is advanced into the renal pelvis. The exact positioning is assured by aspiration of urine (fig. 1, A). If the renal pelvis shows no sufficient radiopaque contrast material a blind puncture can be tried. Final injection of radiopaque contrast medium through the fine needle then reveals the position of the renal pelvis for all further manipulations. However, an ultrasonic puncture is more secure than a blind puncture. Moreover, the exposure to x-:rays is reduced. After the is located the puncture needle then is advanced into using the fine needle as a guide (fig. 1, Ji and B). The fine needle then is withdrawn and a wire guide is passed down the ureter through the puncture needle, which is then removed. The puncture channel is dilated up to 12 or even 16F polytetrafluoroethylene bougies passed over the wire guide (fig. 1, C and D). Finally, the balloon catheter of the same size is inserted through the puncture channel. To prevent bending the balloon catheter it is splinted internally with a flexible metal tube (fig. 2). After exact positioning is confirmed the metal tube and the wire guide are withdrawn and the balloon is filled with 3 cc saline. Then, the balloon duct is ligated (fig. 3). The most frequent indications for urinary diversion by percutaneous nephropyelostomy were ureteral obstruction and the Accepted for publication June 27, 1980. Read at annual meeting of American Urological Association, San Francisco, California, May 18-22, 1980. * Requests for reprints: Department of Urology, Klinikum Grosshadern, University of Munich, 8000 Munich, West Germany.
FIG. 1. A, advancement of puncture needle guided by fine needle into renal pelvis. µLU1n,u1e needle placed in pelvis. C and D, dilation of puncture
drainage of ureteral fistulas, followed extractions of calculi and transrenal occlusion of the ureter (see table). DISCUSSION
Excellent drainage is guaranteed by large caliber catheters since in most cases in which urinary diversion is indicated urinary infection with fibrinous inflammation must be considered. Dislocation of the catheter must be prevented because this is the most frequent reason for repuncture. Dislocation of the catheter is mostly owing to the extreme mobility of the unoperated kidney sinking with changes in body position and after the excursion of the diaphragm. The immediate insertion of a large-bore balloon catheter in the first session using a flexible metal tube as a splint is the most important advantage of this method. Thus, fibrinous blockade of the catheter did not occur. Reinsertion of the wire guide permits dilation of the channel and insertion of even larger catheters in short intervals if needed. Since the introduction of the balloon catheter dislocation is
475
476
SCHILLING AND ASSOCIATES
Indications for percutaneous nephropyelostomy in 128 patients No. Pts.
FIG. 2. Introduction of 12F balloon catheter splinted with metal tube following wire guide.
FIG. 3. A withdrawal of metal tube and wire guide. Balloon is filled with 3 cc saline. B, nephrostomy catheter in situ with ligated balloon duct.
no longer possible. In 128 cases dislocation has been seen only once owing to a ruptured balloon. In 53 of the 128 cases the obstruction was caused mostly by tumors (see table). However, percutaneous nephropyelostomy should be reserved for patients in relatively good condition. This procedure is contraindicated in patients with terminal states of cancer who would, thus, be denied the mercy of uremia. In 21 cases the ureteral obstruction was caused by calculi necessitating temporary drainage. As acute management for ureteral obstruction after various operative procedures, percutaneous nephropyelostomy spares the patient a further open operative procedure during the postoperative period. Urinary diversion through percutaneous nephropyelostomy has provided excellent results for treatment of ureteral fistulas. Most patients are dry immediately after a successful puncture. In 5 of 8 cases the ureterovaginal fistulas closed spontaneously. After adequate dilation (up to 22 or even 24F) during an interval it was possible to extract a renal calculus successfully through the catheter in some cases. In 2 cases with a functional solitary kidney and incontinence owing to invasion of the bladder tumor into the sphincter with
Ureteral obstruction: Malignant tumors: Gynecologic, 21 Bladder, 12 Prostate, 11 Retroperitoneal lymph node metastases, 9 Calculi Strictures after radiotherapy Postop. stenosis after urinary diversion Ureteral stenosis in urotuberculosis Decompensation owing to stenosis of the ureteropelvic junction Stenosis after ureteral reimplantation Urinary congestion in adenoma of the prostate Retroperitoneal fibrosis Ligature of the ureter in gynecologic operation Ureteral obstruction after shock wave procedure for renal calculi Total Ureteral fistulas (draining): Ureterovaginal fistulas after gynecologic operation Lesion of the ureter after abdominal operation Fistula of the ureter after ilea! conduit Fistula of the ureter after ureteral anastomosis in a double kidney Stoma-small bowel fistula after ilea! conduit Total Extraction of a pelvic calculus Transrenal occlusion of the ureter
53
21 10 5 3 2
2 2 1
2 1
102 8 5
1 1 1 16 8
2
extreme dysuria transrenal occlusion of the ureter with a tissue glue was done. Percutaneous nephropyelostomy is the least stressful procedure for temporary and permanent urinary diversion (see table). Drainage can be done even in septic high risk patients with cardiac and pulmonary problems until their condition improves for a definite operation. The incidence of complications is small. Hemorrhage occurred frequently and most episodes subsided spontaneously. At the worst this complication could be followed by a tamponade of the renal pelvis requiring open revision, which occurred in 3 cases. A retroperitoneal hematoma, which also is possible, was not seen in our series. Other complications included perforation of the renal pelvis during the dilation procedure requiring open revision in 1 case, delayed hemorrhage (after 8 days) requiring open revision in 1 and dislocation of the catheter owing to a ruptured balloon requiring a new puncture in 1. As long as the percutaneous nephropyelostomy catheter remains indwelling for even a short interval urinary infection cannot be avoided. There even is the risk of a perirenal abscess. Local severe pain and loss of renal function after the puncture have been reported but they did not occur in our series. Transperitoneal puncture may be avoided by exact location of the puncture entrance. REFERENCES 1. Goodwin, W. E., Casey, W. C. and Woolf, W.: Percutaneous trocar
(needle) nephrostomy in hydronephrosis. J.A.M.A., 157: 891, 1955. 2. Guenther, R., Altwein, J.E. and Georgi, M.: Feinnadelpunktion zur antegraden Pyelographie und perkutanen Nephropyelostomie. Fortschr. Rontgenstr., 127: 439, 1977.
Vol. i25,
TrtE JOUR)>Ti':,_L OF UROLOGY
Printed in
Copyright© 1981 by The \1/illiams & VVilkins Co.
TECHNIQUE FOR PERCUTAI'~EOUS NEPHROPYELOSTOIVIY A SCHILLING,* H. GOETTINGER, F. J. MARX, J. SCHUELLER
AND
H. W. BAUER
From the Department of Urology, Klinikum Grosshadern, University of Munich, Munich, West Germany
ABSTRACT
Prima:ry insertion of a large caliber catheter into the renal pelvis would provide the most favorable drainage in all cases in which urinary diversion by nephropyelostomy is indicated. Therefore, the puncture technique of Guenther and associates was modified. A specially designed balloon catheter was used to prevent dislocation. In 1955 Goodwin and associates performed the first percutaneous nephropyelostomy. 1 However, the common use of this method was delayed because of inadequate technology. The development of improved x-ray screening techniques with an image intensifier and of ultrasonically guided puncture equipment provided a new impulse for this procedure. In almost all cases in which urinary diversion by nephropyelostomy is indicated it would be best if the first catheter inserted was of a large caliber. Furthermore, dislocation of the catheter must be prevented. MATERIALS AND METHODS
Percutaneous nephropyelostomy was done on 128 patients during the last 18 months. With the aforementioned consideration the method of Guenther and associates was modified by inserting a large-bore balloon catheter at the end of the first procedure. 2 The puncture set consists of a hollow puncture needle, a fine needle, a wire guide, bougies, a metal tube and a specially designed balloon catheter with a central terminal opening and a side opening proximal to the balloon. Usually, the percutaneous nephropyelostomy is done with the patient in the prone position. After local anesthesia and excretory urography are done the puncture needle is inserted from the posterior axillary line just below the 12th rib to the renal capsule. Through this needle a fine needle is advanced into the renal pelvis. The exact positioning is assured by aspiration of urine (fig. 1, A). If the renal pelvis shows no sufficient radiopaque contrast material a blind puncture can be tried. Final injection of radiopaque contrast medium through the fine needle then reveals the position of the renal pelvis for all further manipulations. However, an ultrasonic puncture is more secure than a blind puncture. Moreover, the exposure to x-:rays is reduced. After the is located the puncture needle then is advanced into using the fine needle as a guide (fig. 1, Ji and B). The fine needle then is withdrawn and a wire guide is passed down the ureter through the puncture needle, which is then removed. The puncture channel is dilated up to 12 or even 16F polytetrafluoroethylene bougies passed over the wire guide (fig. 1, C and D). Finally, the balloon catheter of the same size is inserted through the puncture channel. To prevent bending the balloon catheter it is splinted internally with a flexible metal tube (fig. 2). After exact positioning is confirmed the metal tube and the wire guide are withdrawn and the balloon is filled with 3 cc saline. Then, the balloon duct is ligated (fig. 3). The most frequent indications for urinary diversion by percutaneous nephropyelostomy were ureteral obstruction and the Accepted for publication June 27, 1980. Read at annual meeting of American Urological Association, San Francisco, California, May 18-22, 1980. * Requests for reprints: Department of Urology, Klinikum Grosshadern, University of Munich, 8000 Munich, West Germany.
FIG. 1. A, advancement of puncture needle guided by fine needle into renal pelvis. µLU1n,u1e needle placed in pelvis. C and D, dilation of puncture
drainage of ureteral fistulas, followed extractions of calculi and transrenal occlusion of the ureter (see table). DISCUSSION
Excellent drainage is guaranteed by large caliber catheters since in most cases in which urinary diversion is indicated urinary infection with fibrinous inflammation must be considered. Dislocation of the catheter must be prevented because this is the most frequent reason for repuncture. Dislocation of the catheter is mostly owing to the extreme mobility of the unoperated kidney sinking with changes in body position and after the excursion of the diaphragm. The immediate insertion of a large-bore balloon catheter in the first session using a flexible metal tube as a splint is the most important advantage of this method. Thus, fibrinous blockade of the catheter did not occur. Reinsertion of the wire guide permits dilation of the channel and insertion of even larger catheters in short intervals if needed. Since the introduction of the balloon catheter dislocation is
475
476
SCHILLING AND ASSOCIATES
Indications for percutaneous nephropyelostomy in 128 patients No. Pts.
FIG. 2. Introduction of 12F balloon catheter splinted with metal tube following wire guide.
FIG. 3. A withdrawal of metal tube and wire guide. Balloon is filled with 3 cc saline. B, nephrostomy catheter in situ with ligated balloon duct.
no longer possible. In 128 cases dislocation has been seen only once owing to a ruptured balloon. In 53 of the 128 cases the obstruction was caused mostly by tumors (see table). However, percutaneous nephropyelostomy should be reserved for patients in relatively good condition. This procedure is contraindicated in patients with terminal states of cancer who would, thus, be denied the mercy of uremia. In 21 cases the ureteral obstruction was caused by calculi necessitating temporary drainage. As acute management for ureteral obstruction after various operative procedures, percutaneous nephropyelostomy spares the patient a further open operative procedure during the postoperative period. Urinary diversion through percutaneous nephropyelostomy has provided excellent results for treatment of ureteral fistulas. Most patients are dry immediately after a successful puncture. In 5 of 8 cases the ureterovaginal fistulas closed spontaneously. After adequate dilation (up to 22 or even 24F) during an interval it was possible to extract a renal calculus successfully through the catheter in some cases. In 2 cases with a functional solitary kidney and incontinence owing to invasion of the bladder tumor into the sphincter with
Ureteral obstruction: Malignant tumors: Gynecologic, 21 Bladder, 12 Prostate, 11 Retroperitoneal lymph node metastases, 9 Calculi Strictures after radiotherapy Postop. stenosis after urinary diversion Ureteral stenosis in urotuberculosis Decompensation owing to stenosis of the ureteropelvic junction Stenosis after ureteral reimplantation Urinary congestion in adenoma of the prostate Retroperitoneal fibrosis Ligature of the ureter in gynecologic operation Ureteral obstruction after shock wave procedure for renal calculi Total Ureteral fistulas (draining): Ureterovaginal fistulas after gynecologic operation Lesion of the ureter after abdominal operation Fistula of the ureter after ilea! conduit Fistula of the ureter after ureteral anastomosis in a double kidney Stoma-small bowel fistula after ilea! conduit Total Extraction of a pelvic calculus Transrenal occlusion of the ureter
53
21 10 5 3 2
2 2 1
2 1
102 8 5
1 1 1 16 8
2
extreme dysuria transrenal occlusion of the ureter with a tissue glue was done. Percutaneous nephropyelostomy is the least stressful procedure for temporary and permanent urinary diversion (see table). Drainage can be done even in septic high risk patients with cardiac and pulmonary problems until their condition improves for a definite operation. The incidence of complications is small. Hemorrhage occurred frequently and most episodes subsided spontaneously. At the worst this complication could be followed by a tamponade of the renal pelvis requiring open revision, which occurred in 3 cases. A retroperitoneal hematoma, which also is possible, was not seen in our series. Other complications included perforation of the renal pelvis during the dilation procedure requiring open revision in 1 case, delayed hemorrhage (after 8 days) requiring open revision in 1 and dislocation of the catheter owing to a ruptured balloon requiring a new puncture in 1. As long as the percutaneous nephropyelostomy catheter remains indwelling for even a short interval urinary infection cannot be avoided. There even is the risk of a perirenal abscess. Local severe pain and loss of renal function after the puncture have been reported but they did not occur in our series. Transperitoneal puncture may be avoided by exact location of the puncture entrance. REFERENCES 1. Goodwin, W. E., Casey, W. C. and Woolf, W.: Percutaneous trocar
(needle) nephrostomy in hydronephrosis. J.A.M.A., 157: 891, 1955. 2. Guenther, R., Altwein, J.E. and Georgi, M.: Feinnadelpunktion zur antegraden Pyelographie und perkutanen Nephropyelostomie. Fortschr. Rontgenstr., 127: 439, 1977.