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Hemiacidrin Renal Irrigation: Complications and Successful Management
THE ,JCURL'JAL OF
Copy-_cight © 1982 ~ii rChe \7Villimns & Vhlkins Co.
HEMIACIDRIN RENAL IHRIGATIOI'-.J: SUCCESSFUL MANAGEIVl:ENT ROBERT S. KLEIN, EUGENE V. CATTOLICA
AND
KENNETH N. RANKIN
From the Departments of Urology, Kaiser-Permanente Jvfedical Center, Oakland and University of California Medical Center, San Francisco, California
ABSTRACT
The complications of hemiacidrin irrigation of the kidneys for postoperative residual stmvite calculi can test the ingenuity and perseverance of the clinician. The the irrigation of 9 in 8 patients included Candida tract extravasation, ureteral obstruction and chemical"""".,."' Some causes and the management of these probl.emS are diSCUlSSed. su·~~s,u the Of and the H~,;:,~JlLcU.ll,i:1 these ~~-u'+""~~ hemiacidrin an effective agent for the dissolution of struvite can be used safely are taken to 1naintain sterile urine and to irrigating systemil. 4 However, complications can occur even with a meticulous approach. We report the problems encountered during irrigation of 9 kidneys in 8 patients with postoperative residual infected stmvite calculi and discuss their management. MATERIALS AND METHODS
Between 1976 and 1980, 22 removalofbranchedm,tgr1es,1u1:n 9 kidneys in 8 PWCLC''""
on
in each renal unit at the had a Penrose drain, which
ureteral calculus was removed vvhile the second had 2 ureternl calculi that vvere dissolved after the insertion of a ureteral catheter and with hemi&cidrin into the PnhrnQtrn'TI,r tube. Th.ree female ~,,~'°""·'"v., In 2
be continued. sterile urine cultures.
v,,ras the same as that outlined The instillations were .,~HH""''W were cultured from the .,,,k=u"'~ from the drains or if the 5
reRESULTS -,,,,,,,,c,~,-v,,-,,- occurred only in those patients with residual calculi (table 2). Urine from 4 of the 9 kidneys a Candida species while the patients v,ere In each case the infection was treated stopping .. and starting irrigation with a solution of 50 mg. amphotericin B in 500 ml. sterile water at a rate of 125 mL per hour. Hemiacidrin perfusion was reinstituted after the urine was sterile for 24 hours. In no instance was amphotericin B irrigation required for >72 hours. In 2 patients the yeast infection recurred and once again responded to the same treatment. No patient had signs of systemic candidiasis. Irrigation fluid leaked from the
the "'"'1'>''"""" tional 72 hours of herniacidrin treatment. DISCUSSION
~u.,.>~V•>-HU
Accepted for publication November 20, 1981. Read at annual meeting of Western Section, American Urological Association, Salt Lake City, Utah, June 28-July 2, 1981. 241
Although rarely mentioned in the literature a Candida urinary tract infection associated with hemiacidrin renal irrigation is not unexpected.'i, 6 Patients undergoing this therapy receive long-term broad-spectrum antibiotics, which predispose the urinary tract to colonization yeast. Although usually of low virulence in nonimmunosuppressed patients Candida can cause morbidity and even renal loss in patients having renal irrigation.7 Treatment of these Candida infections has proved to be simple and safe. The same precautions used during hemiacidrin
242
KLEIN, CATTOLICA AND RANKIN TABLE
1. Summary of clinical data in 8 patients requiring
postoperative hemiacidrin irrigation Pt. Age S No. - (yrs.) - ex 1-56-F 2-52-M 3-46-F 4-59-F 5-44-M 6-37-F 7-61-F 8-26-F* 8-26-Ft
Operation Extended pyelolithotomy Extended pyelolithotomy Extended pyelolithotomy Extended pyelolithotomy Anatrophic nephrolithotomy Lower pole heminephrectomy Anatrophic nephrolithotomy Anatrophic nephrolithotomy Anatrophic nephrolithotomy
Days Hospitalized
Days oflrrigation
33 50 45 21 29 17 36 60 45
14 15 25 8 19 4 21
26 34
* Right kidney.
t Left kidney. TABLE
2. Complications during hemiacidrin irrigation No. Occurrences
Complication Yeast infection Delayed leakage Obstructing ureteral calculus Chemical cystitis Fever
TABLE
4 kidneys 4 kidneys
2 kidneys 3 pts. 3 pts.
3. Day of occurrence of hemiacidrin irrigant extravasation Pt. No.
Postop. Day
Irrigation Day
1
14
5
4 8 8
11
2
25
16
22
6
with the nephrostomy providing drainage of the effluent. Two of our patients who had extravasation of irrigant also had chemical cystitis. No patient in our series exhibited hypermagnesemia or deteriorated renal function. Because hypermagnesemia has been reported in a uremic patient 10 the serum magnesium of patients with impaired renal function must be monitored closely. None of the complications listed herein proved to be lifethreatening. However, they did prolong the hospitalization of these patients and this can be a heavy burden for an otherwise healthy patient and can test the patience and dedication of the professional staff. To obviate the need for lengthy irrigation every effort must be made to extract all stone fragments at the operation. Despite the best efforts, however, total stone removal is not always possible. Preoperatively, the patient and family should be fully counseled concerning the possibility of postoperative renal irrigation and the substantial investment of time that may be required. CONCLUSION
Postoperative hemiacidrin renal irrigation for retained struvite stone fragments can be accomplished effectively and safely provided sterile urine and a low pressure perfusion system are maintained. The complications that do occur can be managed safely. Such safe management requires considerable time, effort and determination on the part of the patient, the physician and the nursing staff. REFERENCES 1. Fa~, B., Rossier, A. B., Yalla, S. and Berg, S.: The role of hemia-
perfusion should be used with amphotericin B. Sterile water is used to avoid the precipitation of the fungicide that occurs with sodium chloride. The chills, fever, vomiting and headache frequently encountered with the intravenous administration of amphotericin B have not occurred with renal perfusion of the drug. Renal function has remained unchanged. The extravasation of irrigant encountered in these cases probably results from the changes that the uroepithelium undergoes when exposed to hemiacidrin. Ulceration may occur8 • 9 and impaired healing of suture lines also is likely. Such weakened areas may leak when exposed to even modest increases in pressure caused by edema of the proximal ureter or by the passage of sandy calculous debris. Attenuated areas that easily rupture explain why the leakage can occur at any time during the course of the irrigation and why 3 of our patients did not have pain before the leakage. Whatever the cause it is unwise to remove the drains placed at the operation until the irrigation has been completed. Chemical cystitis commonly is associated with hemiacidrin renal irrigation and occurs in men and women. Treatment includes insertion of a Foley urethral catheter, cessation of the irrigation until the symptoms have subsided or irrigation with saline until the patient is asymptomatic. Particularly severe cases may necessitate irrigation through a ureteral catheter
2. 3. 4. 5.
6.
7.
8.
9. 10.
cidrin in the management of renal stones in spinal cord injury patients. J. Urol., 116: 696, 1976. Blaivas, J. G., Pais, V. M. and Spellman, R. M.: Chemolysis of residual stone fragments after extensive surgery for staghorn calculi. Urology, 6: 680, 1975. Jacobs, S. C. and Gittes, R. F.: Dissolution of residual renal calculi with hemiacidrin. J. Urol., 115: 2, 1976. Nemoy, N. J. and Stamey, T. A.: Use ofhemiacidrin in management of infection stones. J. Urol., 116: 693, 1976. Nemoy, N. J. and Stamey, T. A.: Surgical, bacteriological, and biochemical management of "infection stones". J.A.M.A., 215: 1470, 1971. Bueschen, A. J., Zahm, M. J. and Lloyd, L. K.: Adjuvant surgical techniques in the removal of staghorn calculi. J. Urol., 123: 342, 1980. Griffin, D.: Urolithiasis: update 1981. Postgraduate Seminar, American Urological Association, March 5-6, 1981, San Diego, California. Auerbach, S., Mainwaring, R. and Schwarz, F.: Renal and ureteral damage following clinical use of renacidin. J.A.M.A., 183: 61, 1963. Cunningham, J. J., Friedland, G. W. and Stamey, T. A.: Radiologic changes in the urothelium during renacidin irrigations. J. Urol., 109: 556, 1973. Cato, A. R. and Tulloch, A. G. S.: Hypermagnesemia in a uremic patient during renal pelvis irrigation with renacidin. J. Urol., 111: 313, 1974.
Copy-_cight © 1982 ~ii rChe \7Villimns & Vhlkins Co.
HEMIACIDRIN RENAL IHRIGATIOI'-.J: SUCCESSFUL MANAGEIVl:ENT ROBERT S. KLEIN, EUGENE V. CATTOLICA
AND
KENNETH N. RANKIN
From the Departments of Urology, Kaiser-Permanente Jvfedical Center, Oakland and University of California Medical Center, San Francisco, California
ABSTRACT
The complications of hemiacidrin irrigation of the kidneys for postoperative residual stmvite calculi can test the ingenuity and perseverance of the clinician. The the irrigation of 9 in 8 patients included Candida tract extravasation, ureteral obstruction and chemical"""".,."' Some causes and the management of these probl.emS are diSCUlSSed. su·~~s,u the Of and the H~,;:,~JlLcU.ll,i:1 these ~~-u'+""~~ hemiacidrin an effective agent for the dissolution of struvite can be used safely are taken to 1naintain sterile urine and to irrigating systemil. 4 However, complications can occur even with a meticulous approach. We report the problems encountered during irrigation of 9 kidneys in 8 patients with postoperative residual infected stmvite calculi and discuss their management. MATERIALS AND METHODS
Between 1976 and 1980, 22 removalofbranchedm,tgr1es,1u1:n 9 kidneys in 8 PWCLC''""
on
in each renal unit at the had a Penrose drain, which
ureteral calculus was removed vvhile the second had 2 ureternl calculi that vvere dissolved after the insertion of a ureteral catheter and with hemi&cidrin into the PnhrnQtrn'TI,r tube. Th.ree female ~,,~'°""·'"v., In 2
be continued. sterile urine cultures.
v,,ras the same as that outlined The instillations were .,~HH""''W were cultured from the .,,,k=u"'~ from the drains or if the 5
reRESULTS -,,,,,,,,c,~,-v,,-,,- occurred only in those patients with residual calculi (table 2). Urine from 4 of the 9 kidneys a Candida species while the patients v,ere In each case the infection was treated stopping .. and starting irrigation with a solution of 50 mg. amphotericin B in 500 ml. sterile water at a rate of 125 mL per hour. Hemiacidrin perfusion was reinstituted after the urine was sterile for 24 hours. In no instance was amphotericin B irrigation required for >72 hours. In 2 patients the yeast infection recurred and once again responded to the same treatment. No patient had signs of systemic candidiasis. Irrigation fluid leaked from the
the "'"'1'>''"""" tional 72 hours of herniacidrin treatment. DISCUSSION
~u.,.>~V•>-HU
Accepted for publication November 20, 1981. Read at annual meeting of Western Section, American Urological Association, Salt Lake City, Utah, June 28-July 2, 1981. 241
Although rarely mentioned in the literature a Candida urinary tract infection associated with hemiacidrin renal irrigation is not unexpected.'i, 6 Patients undergoing this therapy receive long-term broad-spectrum antibiotics, which predispose the urinary tract to colonization yeast. Although usually of low virulence in nonimmunosuppressed patients Candida can cause morbidity and even renal loss in patients having renal irrigation.7 Treatment of these Candida infections has proved to be simple and safe. The same precautions used during hemiacidrin
242
KLEIN, CATTOLICA AND RANKIN TABLE
1. Summary of clinical data in 8 patients requiring
postoperative hemiacidrin irrigation Pt. Age S No. - (yrs.) - ex 1-56-F 2-52-M 3-46-F 4-59-F 5-44-M 6-37-F 7-61-F 8-26-F* 8-26-Ft
Operation Extended pyelolithotomy Extended pyelolithotomy Extended pyelolithotomy Extended pyelolithotomy Anatrophic nephrolithotomy Lower pole heminephrectomy Anatrophic nephrolithotomy Anatrophic nephrolithotomy Anatrophic nephrolithotomy
Days Hospitalized
Days oflrrigation
33 50 45 21 29 17 36 60 45
14 15 25 8 19 4 21
26 34
* Right kidney.
t Left kidney. TABLE
2. Complications during hemiacidrin irrigation No. Occurrences
Complication Yeast infection Delayed leakage Obstructing ureteral calculus Chemical cystitis Fever
TABLE
4 kidneys 4 kidneys
2 kidneys 3 pts. 3 pts.
3. Day of occurrence of hemiacidrin irrigant extravasation Pt. No.
Postop. Day
Irrigation Day
1
14
5
4 8 8
11
2
25
16
22
6
with the nephrostomy providing drainage of the effluent. Two of our patients who had extravasation of irrigant also had chemical cystitis. No patient in our series exhibited hypermagnesemia or deteriorated renal function. Because hypermagnesemia has been reported in a uremic patient 10 the serum magnesium of patients with impaired renal function must be monitored closely. None of the complications listed herein proved to be lifethreatening. However, they did prolong the hospitalization of these patients and this can be a heavy burden for an otherwise healthy patient and can test the patience and dedication of the professional staff. To obviate the need for lengthy irrigation every effort must be made to extract all stone fragments at the operation. Despite the best efforts, however, total stone removal is not always possible. Preoperatively, the patient and family should be fully counseled concerning the possibility of postoperative renal irrigation and the substantial investment of time that may be required. CONCLUSION
Postoperative hemiacidrin renal irrigation for retained struvite stone fragments can be accomplished effectively and safely provided sterile urine and a low pressure perfusion system are maintained. The complications that do occur can be managed safely. Such safe management requires considerable time, effort and determination on the part of the patient, the physician and the nursing staff. REFERENCES 1. Fa~, B., Rossier, A. B., Yalla, S. and Berg, S.: The role of hemia-
perfusion should be used with amphotericin B. Sterile water is used to avoid the precipitation of the fungicide that occurs with sodium chloride. The chills, fever, vomiting and headache frequently encountered with the intravenous administration of amphotericin B have not occurred with renal perfusion of the drug. Renal function has remained unchanged. The extravasation of irrigant encountered in these cases probably results from the changes that the uroepithelium undergoes when exposed to hemiacidrin. Ulceration may occur8 • 9 and impaired healing of suture lines also is likely. Such weakened areas may leak when exposed to even modest increases in pressure caused by edema of the proximal ureter or by the passage of sandy calculous debris. Attenuated areas that easily rupture explain why the leakage can occur at any time during the course of the irrigation and why 3 of our patients did not have pain before the leakage. Whatever the cause it is unwise to remove the drains placed at the operation until the irrigation has been completed. Chemical cystitis commonly is associated with hemiacidrin renal irrigation and occurs in men and women. Treatment includes insertion of a Foley urethral catheter, cessation of the irrigation until the symptoms have subsided or irrigation with saline until the patient is asymptomatic. Particularly severe cases may necessitate irrigation through a ureteral catheter
2. 3. 4. 5.
6.
7.
8.
9. 10.
cidrin in the management of renal stones in spinal cord injury patients. J. Urol., 116: 696, 1976. Blaivas, J. G., Pais, V. M. and Spellman, R. M.: Chemolysis of residual stone fragments after extensive surgery for staghorn calculi. Urology, 6: 680, 1975. Jacobs, S. C. and Gittes, R. F.: Dissolution of residual renal calculi with hemiacidrin. J. Urol., 115: 2, 1976. Nemoy, N. J. and Stamey, T. A.: Use ofhemiacidrin in management of infection stones. J. Urol., 116: 693, 1976. Nemoy, N. J. and Stamey, T. A.: Surgical, bacteriological, and biochemical management of "infection stones". J.A.M.A., 215: 1470, 1971. Bueschen, A. J., Zahm, M. J. and Lloyd, L. K.: Adjuvant surgical techniques in the removal of staghorn calculi. J. Urol., 123: 342, 1980. Griffin, D.: Urolithiasis: update 1981. Postgraduate Seminar, American Urological Association, March 5-6, 1981, San Diego, California. Auerbach, S., Mainwaring, R. and Schwarz, F.: Renal and ureteral damage following clinical use of renacidin. J.A.M.A., 183: 61, 1963. Cunningham, J. J., Friedland, G. W. and Stamey, T. A.: Radiologic changes in the urothelium during renacidin irrigations. J. Urol., 109: 556, 1973. Cato, A. R. and Tulloch, A. G. S.: Hypermagnesemia in a uremic patient during renal pelvis irrigation with renacidin. J. Urol., 111: 313, 1974.