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Dislodged Nephrostomy Catheter: An Unusual Case of Idiopathic Transposition of Nephrostomy Catheter From Transplanted Kidney to Adjacent Small Bowel Loop: A Case Report
Dislodged Nephrostomy Catheter: An Unusual Case of Idiopathic Transposition of Nephrostomy Catheter From Transplanted Kidney to Adjacent Small Bowel Loop: A Case Report Shuo Lia, Giuseppe Serenab,c,e, Kritika Subramanianf,g, and Gaetano Ciancioc,d,e,* a
Department of Interventional Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA; Department of Surgery, Nassau University Medical Center, East Meadow, NY, USA; cDepartment of Surgery and dUrology; eMiami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA; fKU Leuven - University of Leuven, Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Virology, Leuven, Belgium; and gDepartment of Internal Medicine, The Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, NY, USA b
ABSTRACT A 72-year-old man with a past medical history notable for deceased renal transplant presented to the interventional radiology department for routine right lower quadrant renal transplant nephroureteral catheter exchange. The nephroureteral catheter was placed in 2016 because of the presence of a hematoma causing partial page kidney and hydronephrosis. An antegrade nephrostogram was notable for opacification of the small bowel instead of the renal collecting system. The patient then subsequently developed urinary retention and intractable abdominal pain. Because of the combination of events, it was deemed necessary for laparotomy and surgical repair of the small bowel. Intraoperative findings were notable for small bowel adhesion to the abdominal wall but otherwise no evidence of acute inflammatory changes. In this case report, we describe the first case of an idiopathically dislodged nephrostomy catheter to the small bowel from a transplanted kidney and its successful management.
T
HE placement of nephrostomy catheter is an accepted treatment modality in the management of hydronephrosis in both native and transplanted kidneys. Although safe, this procedure can have complications, such as bleeding or catheter dislodgement. We present an unusual case of catheter dislodgement, with the dislodged catheter idiopathically migrated to small bowel adjacent the transplanted kidney. To our knowledge, this is the first report of this nature.
After placing the patient on the angiosuite table, without any manipulation of the catheter (anchoring suture was already cut by the patient), an antegrade nephrostogram was performed with injection of dilute contrast through the patient’s nephroureteral catheter. The nephrostogram showed no contrast in renal collecting system. Instead, bowel loops were opacified with normal peristalsis (Fig 1A). At this point, the procedure was aborted, and the patient was transferred to the recovery area. The transplant surgery team was consulted for further evaluation. In the procedure recovery area, the patient developed progressive, severe pain that was not
CASE REPORT A 72-year-old male patient presented to our department for routine 3-month right lower quadrant transplant kidney nephrostomy catheter exchange. He has not had any prior issues with nephrostomy catheter exchanges. A review of his medical history showed diagnosis of hypertension, stroke, and end-stage renal failure status post deceased donor kidney transplant in 2013. The patient developed T-cell mediated rejection in 2016 along with a hematoma causing partial page kidney and hydronephrosis, which necessitated placement of a nephroureteral stent. 0041-1345/19 https://doi.org/10.1016/j.transproceed.2019.08.005
3084
Grant information: This work was supported by a grant of the Enrico ed Enrica Sovena Foundation (grant no. 20391 $), Rome, Italy. *Address correspondence to Gaetano Ciancio, MD, University of Miami Miller School of Medicine, Department of Surgery and Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami Transplant Institute, P.O. Box 012440, Miami, FL 33101. E-mail: [email protected] Published by Elsevier Inc. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 3084e3086 (2019)
DISLODGED NEPHROSTOMY CATHETER
3085
Fig 1. (A) Antegrade nephrostogram through the patient’s nephroureteral catheter. Note the contrast in small bowel loops, with typical small bowel folds. Normal peristalsis was seen in real time imaging. Transplanted renal pelvis and urinary bladder are not opacified. (B) Fluoroscopic image save from a routine nephroureteral catheter exchange 3 months prior to presentation. Contrast is seen in the renal pelvis and urinary bladder. No extravasation of contrast or small bowel loops were opacified. relieved by pain medication. He also started to experience progressively decreasing urine output. The surgical team evaluated the patient approximately 3 hours after the nephrostogram and placed a Foley catheter for urinary obstruction. Because of persistent pain and enterocutaneous fistulization by this nephrostomy catheter, the patient and surgical team elected for surgical excision and repair. Intraoperatively, the small bowel was found to adhere to the abdominal wall, but otherwise there were no signs of chronic inflammation or bleeding. The nephrostomy catheter was seen entering the direction from the anterior abdominal wall to the small bowel. The transplanted kidney did not interpose between the catheter or the small bowel. After disconnecting the catheter over the abdominal wall, the catheter was removed from the small bowel, followed by tract resection and bowel wall closure (Fig 2). The patient recovered well without immediate complications. A review of a most recent nephroureteral catheter exchange 3 months before this incident showed appropriate positioning of the nephroureteral catheter (Fig 1B). A computed tomography of the abdomen and pelvis obtained 6 months prior showed the nephroureteral catheter traversing through the kidney and into the urinary bladder. A loop of small bowel is noted adjacent to the nephroureteral catheter (Fig 3).
long-term nephrostomy is often preferred to definitive treatment of an obstruction because it is a less invasive treatment option and has a lower risk profile [3]. As is the case for any therapeutic radiologic procedures, there are adverse effects and complications that can result from the placement of a nephrostomy tube. Infection at the insertion site, retroperitoneal hemorrhage, pyelonephritis, a dislodged tube, and obstructed tubes are commonly recorded problems. One of the most common complications is dislodgement, which typically present with decreased nephrostomy output, flank pain, and hydronephrosis [2,4]. Raman et al described how frequently dislodgement occurs when the catheter breaks at the percutaneous site and migrates [2]. There are varying opinions regarding whether tube type influences dislodgement risk. Raman et al states that
DISCUSSION
There are many indications for the placement of a percutaneous nephrostomy tube in normal and transplanted kidneys: obstructions, ureteral leak, traumatic injury, and malignant neoplasm to name a few. The only absolute contraindication to percutaneous nephrostomy is severe, uncorrectable coagulopathy [1]. Nephrostomy placement allows the nephrons to filter and function normally while giving time for a calculus to pass, correction for electrolyte imbalance and/or renal failure, resolution of sepsis, or chemotherapy to take effect [2]. In the elderly population,
Fig 2. Dislodged nephrostomy tube included in the small bowel.
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LI, SERENA, SUBRAMANIAN ET AL
Fig 3. Computed tomography of the abdomen and pelvis obtained 6 months before presentation for unrelated indication. Two axial images (A) and (B) show the nephroureteral catheter entering the peritoneal cavity and into the renal parenchyma without traversing bowel. A coronal reformatted image shows the nephroureteral catheter in the renal pelvis and ureter. The distal tip is coiled in the urinary bladder (not shown).
dislodgement is less common with self-retaining catheter use because the loop at the end of the catheter is anchored to the renal pelvis. However, a retrospective study by Bayne et al indicated that the type of nephrostomy tube used does not influence the risk of dislodgement. What does increase the risk is an elevated body mass index due to fatty pannus increasing the mobility of the anchored skin [5]. According to Funaki et al, malpositioning of nephrostomies can occur to the colon during placement of the tubes. The colon often lies adjacent to the placement of the superficial kidney after transplant, making fistulas easy to form [6]. In the case that the colon is posterolateral, the nephrostomy procedure can penetrate through the colon [2]. Generally, this complication is reduced with the use of ultrasonography and computed tomography guidance for the needle. If penetration does occur, a double J stent can be placed to prevent the formation of a fistula, and the nephrostomy tube is pulled back over several days prior to complete removal [2]. In our case, the antegrade nephrostomy showed contrast opacification of small bowel loops prior to any manipulation of the catheter. The small bowel was found to be stuck to the abdominal wall intraoperatively, likely secondary to adhesions from the transplant, and the catheter had also penetrated through to the small bowel. More importantly to note is the lack of inflammatory changes during surgical intervention and repair, suggesting this finding to be a chronic event. Furthermore, the previous routine exchanged demonstrated no evidence of bowel perforation. One case of a nephro-jejunal fistula has been reported [7], secondary to acute and chronic pyelonephritis, and 3 cases of a pyelo-jejunal fistula have been reported [8]. Less data are available for patients developing fistula between the kidney and the ileum, although suggestions of ureteralenteric fistulas exist. All cases of published nephroenteric fistulas have been associated with inflammation and/or infection, something not found in our patient. We postulate that the nephrostomy catheter may have retracted outside the renal pelvis completely in the interim
between routine exchanges. As a result, it may have either inadvertently or purposely advanced forward into the small bowel by the patient or caretaker. Even more surprising was the lack of any report of pain and decreased urine output. However, we do not have any explanation for the sudden onset of urinary outlet obstruction after injection of contrast. CONCLUSION
To our knowledge, this is the first such case to be reported of a dislodged nephrostomy tube to the small intestine in the context of a transplanted kidney after an episode of T-cell rejection. In summary, we present a patient successfully managed with surgical removal of the stent and nephrostomy tube, with subsequent closure of the fistula. REFERENCES [1] Saad WE, Moorthy M, Ginat D. Percutaneous nephrostomy: native and transplanted kidneys. Tech Vasc Interv Radiol. 2009;12: 172e92. [2] Raman SS, Cochran ST. Complications of therapeutic radiologic procedures. In: Taneja SS, ed. Complications of Urologic Surgery. Fourth Edition. Philadelphia: W.B. Saunders; 2010. pp 143e53. [3] Sarkar D, Parr N. Dislodged nephrostomy: a top tip. BMJ Innov. 2018;4:113e4. [4] Collares FB, Faintuch S, Kim SK, Rabkin DJ. Reinsertion of accidentally dislodged catheters through the original track: what is the likelihood of success? J Vasc Interv Radiol. 2010;21:861e4. [5] Bayne D, Taylor ER, Hampson L, Chi T, Stoller ML. Determinants of nephrostomy tube dislodgment after percutaneous nephrolithotomy. J Endourol. 2015;29:289e92. [6] Hosmer J, Funaki B, eds. Management of transcecal renal transplant nephrostomy. Semin Intervent Radiol. 2013;30:87e90. [7] Bruni R, Bartolucci R, Biancari F, Santoro M. Nephro-jejunal fistula associated with nephro-cutaneous fistula. Minerva Chir. 1995;50:519e21 [in Italian]. [8] Evans PF. Spontaneous pyelo-jejunal fistula. Postgrad Med J. 1990;66:965e7.
Department of Interventional Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA; Department of Surgery, Nassau University Medical Center, East Meadow, NY, USA; cDepartment of Surgery and dUrology; eMiami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA; fKU Leuven - University of Leuven, Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Virology, Leuven, Belgium; and gDepartment of Internal Medicine, The Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, NY, USA b
ABSTRACT A 72-year-old man with a past medical history notable for deceased renal transplant presented to the interventional radiology department for routine right lower quadrant renal transplant nephroureteral catheter exchange. The nephroureteral catheter was placed in 2016 because of the presence of a hematoma causing partial page kidney and hydronephrosis. An antegrade nephrostogram was notable for opacification of the small bowel instead of the renal collecting system. The patient then subsequently developed urinary retention and intractable abdominal pain. Because of the combination of events, it was deemed necessary for laparotomy and surgical repair of the small bowel. Intraoperative findings were notable for small bowel adhesion to the abdominal wall but otherwise no evidence of acute inflammatory changes. In this case report, we describe the first case of an idiopathically dislodged nephrostomy catheter to the small bowel from a transplanted kidney and its successful management.
T
HE placement of nephrostomy catheter is an accepted treatment modality in the management of hydronephrosis in both native and transplanted kidneys. Although safe, this procedure can have complications, such as bleeding or catheter dislodgement. We present an unusual case of catheter dislodgement, with the dislodged catheter idiopathically migrated to small bowel adjacent the transplanted kidney. To our knowledge, this is the first report of this nature.
After placing the patient on the angiosuite table, without any manipulation of the catheter (anchoring suture was already cut by the patient), an antegrade nephrostogram was performed with injection of dilute contrast through the patient’s nephroureteral catheter. The nephrostogram showed no contrast in renal collecting system. Instead, bowel loops were opacified with normal peristalsis (Fig 1A). At this point, the procedure was aborted, and the patient was transferred to the recovery area. The transplant surgery team was consulted for further evaluation. In the procedure recovery area, the patient developed progressive, severe pain that was not
CASE REPORT A 72-year-old male patient presented to our department for routine 3-month right lower quadrant transplant kidney nephrostomy catheter exchange. He has not had any prior issues with nephrostomy catheter exchanges. A review of his medical history showed diagnosis of hypertension, stroke, and end-stage renal failure status post deceased donor kidney transplant in 2013. The patient developed T-cell mediated rejection in 2016 along with a hematoma causing partial page kidney and hydronephrosis, which necessitated placement of a nephroureteral stent. 0041-1345/19 https://doi.org/10.1016/j.transproceed.2019.08.005
3084
Grant information: This work was supported by a grant of the Enrico ed Enrica Sovena Foundation (grant no. 20391 $), Rome, Italy. *Address correspondence to Gaetano Ciancio, MD, University of Miami Miller School of Medicine, Department of Surgery and Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami Transplant Institute, P.O. Box 012440, Miami, FL 33101. E-mail: [email protected] Published by Elsevier Inc. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 3084e3086 (2019)
DISLODGED NEPHROSTOMY CATHETER
3085
Fig 1. (A) Antegrade nephrostogram through the patient’s nephroureteral catheter. Note the contrast in small bowel loops, with typical small bowel folds. Normal peristalsis was seen in real time imaging. Transplanted renal pelvis and urinary bladder are not opacified. (B) Fluoroscopic image save from a routine nephroureteral catheter exchange 3 months prior to presentation. Contrast is seen in the renal pelvis and urinary bladder. No extravasation of contrast or small bowel loops were opacified. relieved by pain medication. He also started to experience progressively decreasing urine output. The surgical team evaluated the patient approximately 3 hours after the nephrostogram and placed a Foley catheter for urinary obstruction. Because of persistent pain and enterocutaneous fistulization by this nephrostomy catheter, the patient and surgical team elected for surgical excision and repair. Intraoperatively, the small bowel was found to adhere to the abdominal wall, but otherwise there were no signs of chronic inflammation or bleeding. The nephrostomy catheter was seen entering the direction from the anterior abdominal wall to the small bowel. The transplanted kidney did not interpose between the catheter or the small bowel. After disconnecting the catheter over the abdominal wall, the catheter was removed from the small bowel, followed by tract resection and bowel wall closure (Fig 2). The patient recovered well without immediate complications. A review of a most recent nephroureteral catheter exchange 3 months before this incident showed appropriate positioning of the nephroureteral catheter (Fig 1B). A computed tomography of the abdomen and pelvis obtained 6 months prior showed the nephroureteral catheter traversing through the kidney and into the urinary bladder. A loop of small bowel is noted adjacent to the nephroureteral catheter (Fig 3).
long-term nephrostomy is often preferred to definitive treatment of an obstruction because it is a less invasive treatment option and has a lower risk profile [3]. As is the case for any therapeutic radiologic procedures, there are adverse effects and complications that can result from the placement of a nephrostomy tube. Infection at the insertion site, retroperitoneal hemorrhage, pyelonephritis, a dislodged tube, and obstructed tubes are commonly recorded problems. One of the most common complications is dislodgement, which typically present with decreased nephrostomy output, flank pain, and hydronephrosis [2,4]. Raman et al described how frequently dislodgement occurs when the catheter breaks at the percutaneous site and migrates [2]. There are varying opinions regarding whether tube type influences dislodgement risk. Raman et al states that
DISCUSSION
There are many indications for the placement of a percutaneous nephrostomy tube in normal and transplanted kidneys: obstructions, ureteral leak, traumatic injury, and malignant neoplasm to name a few. The only absolute contraindication to percutaneous nephrostomy is severe, uncorrectable coagulopathy [1]. Nephrostomy placement allows the nephrons to filter and function normally while giving time for a calculus to pass, correction for electrolyte imbalance and/or renal failure, resolution of sepsis, or chemotherapy to take effect [2]. In the elderly population,
Fig 2. Dislodged nephrostomy tube included in the small bowel.
3086
LI, SERENA, SUBRAMANIAN ET AL
Fig 3. Computed tomography of the abdomen and pelvis obtained 6 months before presentation for unrelated indication. Two axial images (A) and (B) show the nephroureteral catheter entering the peritoneal cavity and into the renal parenchyma without traversing bowel. A coronal reformatted image shows the nephroureteral catheter in the renal pelvis and ureter. The distal tip is coiled in the urinary bladder (not shown).
dislodgement is less common with self-retaining catheter use because the loop at the end of the catheter is anchored to the renal pelvis. However, a retrospective study by Bayne et al indicated that the type of nephrostomy tube used does not influence the risk of dislodgement. What does increase the risk is an elevated body mass index due to fatty pannus increasing the mobility of the anchored skin [5]. According to Funaki et al, malpositioning of nephrostomies can occur to the colon during placement of the tubes. The colon often lies adjacent to the placement of the superficial kidney after transplant, making fistulas easy to form [6]. In the case that the colon is posterolateral, the nephrostomy procedure can penetrate through the colon [2]. Generally, this complication is reduced with the use of ultrasonography and computed tomography guidance for the needle. If penetration does occur, a double J stent can be placed to prevent the formation of a fistula, and the nephrostomy tube is pulled back over several days prior to complete removal [2]. In our case, the antegrade nephrostomy showed contrast opacification of small bowel loops prior to any manipulation of the catheter. The small bowel was found to be stuck to the abdominal wall intraoperatively, likely secondary to adhesions from the transplant, and the catheter had also penetrated through to the small bowel. More importantly to note is the lack of inflammatory changes during surgical intervention and repair, suggesting this finding to be a chronic event. Furthermore, the previous routine exchanged demonstrated no evidence of bowel perforation. One case of a nephro-jejunal fistula has been reported [7], secondary to acute and chronic pyelonephritis, and 3 cases of a pyelo-jejunal fistula have been reported [8]. Less data are available for patients developing fistula between the kidney and the ileum, although suggestions of ureteralenteric fistulas exist. All cases of published nephroenteric fistulas have been associated with inflammation and/or infection, something not found in our patient. We postulate that the nephrostomy catheter may have retracted outside the renal pelvis completely in the interim
between routine exchanges. As a result, it may have either inadvertently or purposely advanced forward into the small bowel by the patient or caretaker. Even more surprising was the lack of any report of pain and decreased urine output. However, we do not have any explanation for the sudden onset of urinary outlet obstruction after injection of contrast. CONCLUSION
To our knowledge, this is the first such case to be reported of a dislodged nephrostomy tube to the small intestine in the context of a transplanted kidney after an episode of T-cell rejection. In summary, we present a patient successfully managed with surgical removal of the stent and nephrostomy tube, with subsequent closure of the fistula. REFERENCES [1] Saad WE, Moorthy M, Ginat D. Percutaneous nephrostomy: native and transplanted kidneys. Tech Vasc Interv Radiol. 2009;12: 172e92. [2] Raman SS, Cochran ST. Complications of therapeutic radiologic procedures. In: Taneja SS, ed. Complications of Urologic Surgery. Fourth Edition. Philadelphia: W.B. Saunders; 2010. pp 143e53. [3] Sarkar D, Parr N. Dislodged nephrostomy: a top tip. BMJ Innov. 2018;4:113e4. [4] Collares FB, Faintuch S, Kim SK, Rabkin DJ. Reinsertion of accidentally dislodged catheters through the original track: what is the likelihood of success? J Vasc Interv Radiol. 2010;21:861e4. [5] Bayne D, Taylor ER, Hampson L, Chi T, Stoller ML. Determinants of nephrostomy tube dislodgment after percutaneous nephrolithotomy. J Endourol. 2015;29:289e92. [6] Hosmer J, Funaki B, eds. Management of transcecal renal transplant nephrostomy. Semin Intervent Radiol. 2013;30:87e90. [7] Bruni R, Bartolucci R, Biancari F, Santoro M. Nephro-jejunal fistula associated with nephro-cutaneous fistula. Minerva Chir. 1995;50:519e21 [in Italian]. [8] Evans PF. Spontaneous pyelo-jejunal fistula. Postgrad Med J. 1990;66:965e7.