Instrument to facilitate nephrostomy

Instrument to facilitate nephrostomy

INSTRUMENT JOHN F. REDMAN, TO FACILITATE NEPHROSTOMY M.D. From the Division of Urology, University of Arkansas Medical Center, Little Rock, Arkan...

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INSTRUMENT

JOHN F. REDMAN,

TO FACILITATE

NEPHROSTOMY

M.D.

From the Division of Urology, University of Arkansas Medical Center, Little Rock, Arkansas

ABSTRACT -An instrument to facilitate the placement of a nephrostomy techniques fm performing nephrostomies are historically reviewed.

Nephrostomy continues to be chosen as a means of proximal urinary diversion. X-3 The methods used to place the nephrostomy tube are still attended by bleeding and parenchymal damage.4’5 Dissatisfaction with the present methods of placing a nephrostomy tube led to the development of an instrument which is the basis of this report. Description The instrument consists of four parts: a malleable handle threaded at one end, a shoulder piece, a perforator tip, and a hollow cylinder in which a catheter may be held fast (Fig. 1). The latter three parts are of varying sizes depending on the size of the catheter to be placed, and all fit the same malleable handle (Fig. 2A). The catheter is drawn into the hollow cylinder by means of a silk suture (Fig. 2B). The suture is threaded by means of a straight needle. Stretching the catheter allows a catheter of larger diameter than the cylinder to be fitted into the cylinder (Fig. 2C). The reexpanded catheter is held fast, and the suture is removed by pulling on one end.

tube is described.

The

back into the pelvis of the kidney. The catheter follows without impediment. When the catheter is visible in the pyelotomy, it is grasped with a clamp and extracted from the cylinder (Fig. 3D). The catheter may then be drawn into the calyx (Fig. 3E). Comment The innovations described over the years to ease the task of performing a nephrostomy bear witness to the inherent problems of the procedure. Nephrostomies have been done for the past eighty years. 6 One of the first techniques formally described was that of Marion in 1917.’ Much like

Operative Technique The malleable handle with shoulder and perforator tip in place are inserted through a pyelotomy incision and threaded into a lower pole calyx (Fig. 3A). After piercing the capsule of the kidney, the perforator tip is unscrewed exposing a threaded post (Fig. 3B). The end aperture of the cylinder has threads. The handle and cylinder are screwed together much like attaching filiforms and followers (Fig. 3C). The handle is then drawn

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FIGURE 1. (A) Malleable handle; (B) detail of threaded tip; (C)shoulder piece in place with threaded tip exposed; (D) perfwator tip in place; and (E) hollow cylinder in place.

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B

I

FIGURE 2. (A)Handle is easily bent when cylinder is used to provide greater mechanical advantage. (B) Technique of placing Malecot catheter into cylinder. (C) Detail of position of Malecot catheter entrapped in hollow cylinder.

FIGURE 3. (A to E) Operative technique.

the techniques that preceded it involved the penetration of the collecting structures via the renal cortex with the subsequent introduction of a catheter through a speculum (Fig. 4A). In 1927 Papin described a technique which remains popular today.’ A curved clamp was introduced through a pyelotomy and then through the renal parenchyma. The jaws were spread. A catheter was grasped and drawn back into the collecting structures (Fig. 4B). Cabot and Holland in 1932’ described a technique which entailed passing a uterine sound into a lower pole calyx via pyelotomy. The parenchyma was penetrated. A

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silk suture was tied to the sound and was drawn back into the pelvis. A Malecot catheter with its end beveled was attached to the suture and drawn back through the renal parenchyma (Fig. 4C). In 1937 Wheeler8 reported an ingenious technique which returned to the route ofpenetration of the cortex. A hollow sound with a small metal sphere held to its tip by a long suture was introduced into the collecting structures via the cortex. When the ball was released, the suture followed. The catheter was then drawn back through the kidney after the technique of Cabot (Fig. 4D). In 1939 Herman9 described a trocar for

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A

1917 MARION

B

1927 PAPIN

JJ

1937 WHEELER

H

C

1931 CABOT

&HOLLAND

FIGURE

F MI 4.

1

1969GEAR C SMITH

(A to 1) Earlier techniques.

introduction through a pyelotomy with subsequent passage of a tube into the collecting structures through the trocar (Fig. 4E). Our initial efforts were directed toward devising such an instrument, but the outer diameter of a cannula which would accommodate a large Malecot catheter was prohibitive. Kimball in 194OiO described a barbed sound termed a hook. The instrument was made with three different curvatures and was introduced via pyelotomy. The catheter was impaled on the hook and drawn back into the collecting structures (Fig. 4F). In 1944 McMahan’l presented a nephrostomy hook which had a screw-on perforator tip and a tip with a groove surmounted by a small knob. After the perforator tip passed from the collecting structures through the cortex, it was unscrewed; and the knobbed tip was screwed in place. The nephrostomy tube was then tied to the knob with a length of suture and drawn into the collecting structures (Fig. 4G). In the 1960s McGovern” described the use of a sound with the tip drilled to receive a suture. A catheter was tied to the sound and drawn from the cortex into the collecting structures (Fig. 4H). In 1973 Tunner13 formalized the

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KIMBALL

1WOMcGOVERN

technique by describing a set of malleable nephrostomy sounds which were used in the manner described by McGovern. In 1969 Gear and Smith5 reported a technique of fitting a pointed catheter spigot into the distal end of a catheter and then pushing the spigot through the renal parenchyma working from within the renal pelvis as shown in Figure 41. Although most authors describe their particular innovations as atraumatic, subsequent reports by others frequently allude to damage resulting from their use.12 We would agree with McMahan” that the procedure of nephrostomy is often an unsatisfactory and clumsy one. The instrument described herein is considered unique in that no stretching of the catheter, particularly a winged catheter, is necessary which negates the dangers of excessive force applied to an easily fractured organ. Another unique feature is that the trauma-producing effects of spreading the jaws of a clamp to receive the catheter are absent. The catheter follows the shaft of the instrument without impediment because of the wedge effect produced. Using this technique a catheter larger in diameter than the cylinder used for its placement may be used which produces

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some hemostatic effect.7,8,10 To date we have experienced no difficulties with the use of this instrument. 4301 West Markham Street Little

Rock,

Arkansas

72201

ACKNOWLEDGMENT. Valuable assistance in the design of this instrument was provided by Mr. Calvin Jackson. References KING, L. R., and BELMAN, A. B.: A technique for nephrostomy in the absence of caliectasis, J. Urol. 108: 518 (1972). BARD, R. H., and KIRK, R. M.: Caution urged in unsplinted, unstented pyeloplasty, Urology 3: 701 (1974). RATTAZZI, L. C., et al. : Acute ureteric obstruction of kidney transplant. Management of late complications, ibid. 4: 385 (1974). BOONE, A. W.: “Atraumatic” nephrostomy, J. Urol. 68: 574 (1952).

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5. GEAR, M., and SMITH, J. C.:

Two techniques for nephrostomy, ibid. 103: 425 (1970). drainage, Urol. 6. KIMBROUGH, J. C.: Nephrostomy Cutan. Rev. 44: 296 (1940). 7. CABOT, H., and HOLLAND, W. W.: Nephrostomy: indications and technique, Surg. Gynecol. Obstet. 54: 817 (1932). 8. WHEELER, W. DE C.: Nephrostomy, Lancet 1: 440 (1937). 9. HERMAN, L. : Nephrostomy cannulae, J. Urol. 41: 282 (1939). 10. KIMBALL, F. N.: Indications and technique for a ibid. 44: 1 (1940). simplified method of nephrostomy, 11. MCMAHAN, S.: Three urological instruments: renal pedicle clamp; nephrostomy hook; renal calculus forceps, Br. J. Urol. 16: 146 (1944). 12. MCGOVERN, J. H.: Temporary supravesical diversion in children, in Scott, R., Gordon, H. L., Scott, F. B., Carlton, C. E., and Beach, P. D., Eds. : Current Controversies in Urologic Management, Philadelphia, W. B. Saunders Co., 1970, p. 223. 13. TUNNER, W. S.: A malleable nephrostomy sound and a technique for its use, J. Urol. 109: 775 (1973).

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