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Lumbar Ureteral Shunt: An Absolute Contraindication for Retrograde Pyelography
oozw347W1556202S.00/0 "HE JOUUNAL OF UROLOCY Capyright 0 1996 by AMERICAN UROLOGICAL AS~OCUTION,INC.
Vol. 155,2026-2027, June 1% Pnnted in U . S A
LUMBAR URETERAL SHUNT: AN ABSOLUTE CONTRAINDICATION FOR RETROGRADE PYELOGRAPHY EDWARD J. PIENKOS From the Department of Urology, Carbondale Clinic, Carbondale, Illinois KEY WORDS:contraindications; ureter; urography; lumbosacral region; anastomosis, surgical
The patient required hospitalization and respiratory support for several days, Recovery was complicated by the development of the adult respiratory distress syndrome but after 2 weeks of hospitalization there was no permanent further disability beyond the original condition.
Although the indications for retrograde pyelography have decreased in recent years due to advances in imaging technology, certain conditions (for example the need to visualize the ureteral stump a h r nephrectomy) require its use. Contraindications to retrograde pyelography are generally relative, involving the potential for sepsis or allergic reactions to contrast material. In fact, this evaluation is commonly performed in patients with a reported allergy to contrast media. To our knowledge no absolute contraindication to retrograde pyelography has been reported previously. We describe an unusual condition, which urologists should recognize to prevent a serious complication.
DISCUSSION
CASE REPORT
A 35-year-old totally disabled woman presented in 1991 with lower urinary symptoms of urge incontinence and microscopic hematuria. The mother provided history of left donor nephrectomy and multiple neurosurgical procedures relating to a malignant brain tumor when the patient was 4 years old, which resulted in severe physical and mental retardation, and convulsions. However, a review of the medical records included the terms "ureterothecal shuntn and "ureterofecal fistula" as the reasons for left nephrectomy. A history of allergy to intravenous contrast media was also obtained. A review of the literature provided no reference to the term ureterothecal shunt. Cystoscopy and bilateral retrograde pyelography were performed using ionic contrast medium. Preliminary x-ray of the kidneys, ureters and bladder demonstrated only a ventriculoperitoneal shunt. However, injection with contrast medium revealed a radiolucent shunt connecting the superior aspect of the left ureter with the lumbar subarachnoid space (see figure). For several hours after injection lower extremity twitching gradually developed, progressing to convulsions. Accepted for publication December 1, 1995.
Lumbar ureteral shunt was first described to effect decompression in cases of communicating hydrocephalus. The left kidney was removed, and L2 and L3 laminectomy was performed with the insertion of a polyethylene plastic tube intrathecally to connect with the ureteral stump. Spinal fluid passed into the bladder and only the ureterovesical junction prevented reflux and meningitis during bladder infections. In 1969 Matson reported 172 cases in which f U ldisclosure was required to parents and referring physicians.l Variations of this procedure include performing the operation without nephrectomy;2 shunting cerebrospinal fluid from the lateral ventricle to the ureter, as for a ventriculoureteral shunt with or without nephrectomy,3 and direct anastomosis of the ureteral stump to the dura, as in subarachnoid ureterostomy.4 Any combination of anatomical terminology relating to the central nervous and urinary systems could be used to describe this shunt. The dangers of using ionic contrast material during cystography in myelodysplastic patients with ventriculoperitoneal shunts were subsequently reported by Dalkin et a1.5 Nonionic media (iohexol and iopamidol) are used in various concentrations, doses and routes of administration by neuroradiologists in the performance of myelography with acceptable complication rates. However, to our knowledge no additional information exists in the urological literature cautioning against the use of such media in retrograde pyelography due to the rarity of central nervous and urinary system communication. Furthermore, there is no guarantee that nonionic contrast media will not cause seizures, especially in patients with a history of convulsions. Although Kelly et a1 performed a retrograde pyelogram using ionic contrast material in a patient with a lumbar ureteral shunt without complications, the shunt was completely obstructed at the time.2 CONCLUSIONS
We report an absolute contraindication to retrograde pyelography. A high index of suspicion is required to penetrate inaccuracies in patient histories. Virtually any accepted or idiosyncratic terminology can be used to describe the existence of such a communication between the central nervous and urinary systems. Nephrectomy may or may not have been performed. Ionic contrast media are toxic to the central nervous system but nonionic media are also a risk. In addition, breaching the ureterovesical junction may introduce bacterial contamination. While voiding cystography is also A. plain abdominal x-ray shows only ventriculoperitoneal shunt. B, contraindicated, the patient would be seriously ill if reflux retrograde pyelogram reveals leR lumbar ureteral shunt previously were present. Neurosurgeons who have performed this pronot visible. cedure in the past should locate long-term survivors and 2026
LUMBAR URETERAL SHUNT provide t h e m accurate medical warnings regarding the presence of such a shunt. REFERENCES
1. Matson, D. D.: Neurosurgery of Infancy and Childhood, 2nd ed. Springfield, Illinois: C. C. Thomas, pp. 242-247, 1969. 2. Kelly, J. H., McCullough, D. L. and Harrison, L. H.: Lumbar ureteral shunt-an unusual cause of ureteral obstruction. Urology, 33: 309, 1989. 3. Smith, J. A., Jr., Lee, R. E. and Middleton, R. G.: Ventricu-
2027
loureteral shunt for hydrocephalus without nephrectomy. J. Urol., 123: 224, 1980. 4. Schoenberg, H., Smith, H. St. J. and Murphy, J. J.: Vesicoureterd reflux &r subarachnoid ureterostomy. J. Urol., 8 2 474, 1959. 5. Dalkin, B., Franco, I., Reda, E. F., McLone, D., Godine, L. and Kaplan, W. E.: Contrast-induced central nervous system toxicity &r radiographic evaluation of the lower urinary tract in myelodysplastic patients with ventriculoperitoneal shunts. J. Urol., 148. 120, 1992.
Vol. 155,2026-2027, June 1% Pnnted in U . S A
LUMBAR URETERAL SHUNT: AN ABSOLUTE CONTRAINDICATION FOR RETROGRADE PYELOGRAPHY EDWARD J. PIENKOS From the Department of Urology, Carbondale Clinic, Carbondale, Illinois KEY WORDS:contraindications; ureter; urography; lumbosacral region; anastomosis, surgical
The patient required hospitalization and respiratory support for several days, Recovery was complicated by the development of the adult respiratory distress syndrome but after 2 weeks of hospitalization there was no permanent further disability beyond the original condition.
Although the indications for retrograde pyelography have decreased in recent years due to advances in imaging technology, certain conditions (for example the need to visualize the ureteral stump a h r nephrectomy) require its use. Contraindications to retrograde pyelography are generally relative, involving the potential for sepsis or allergic reactions to contrast material. In fact, this evaluation is commonly performed in patients with a reported allergy to contrast media. To our knowledge no absolute contraindication to retrograde pyelography has been reported previously. We describe an unusual condition, which urologists should recognize to prevent a serious complication.
DISCUSSION
CASE REPORT
A 35-year-old totally disabled woman presented in 1991 with lower urinary symptoms of urge incontinence and microscopic hematuria. The mother provided history of left donor nephrectomy and multiple neurosurgical procedures relating to a malignant brain tumor when the patient was 4 years old, which resulted in severe physical and mental retardation, and convulsions. However, a review of the medical records included the terms "ureterothecal shuntn and "ureterofecal fistula" as the reasons for left nephrectomy. A history of allergy to intravenous contrast media was also obtained. A review of the literature provided no reference to the term ureterothecal shunt. Cystoscopy and bilateral retrograde pyelography were performed using ionic contrast medium. Preliminary x-ray of the kidneys, ureters and bladder demonstrated only a ventriculoperitoneal shunt. However, injection with contrast medium revealed a radiolucent shunt connecting the superior aspect of the left ureter with the lumbar subarachnoid space (see figure). For several hours after injection lower extremity twitching gradually developed, progressing to convulsions. Accepted for publication December 1, 1995.
Lumbar ureteral shunt was first described to effect decompression in cases of communicating hydrocephalus. The left kidney was removed, and L2 and L3 laminectomy was performed with the insertion of a polyethylene plastic tube intrathecally to connect with the ureteral stump. Spinal fluid passed into the bladder and only the ureterovesical junction prevented reflux and meningitis during bladder infections. In 1969 Matson reported 172 cases in which f U ldisclosure was required to parents and referring physicians.l Variations of this procedure include performing the operation without nephrectomy;2 shunting cerebrospinal fluid from the lateral ventricle to the ureter, as for a ventriculoureteral shunt with or without nephrectomy,3 and direct anastomosis of the ureteral stump to the dura, as in subarachnoid ureterostomy.4 Any combination of anatomical terminology relating to the central nervous and urinary systems could be used to describe this shunt. The dangers of using ionic contrast material during cystography in myelodysplastic patients with ventriculoperitoneal shunts were subsequently reported by Dalkin et a1.5 Nonionic media (iohexol and iopamidol) are used in various concentrations, doses and routes of administration by neuroradiologists in the performance of myelography with acceptable complication rates. However, to our knowledge no additional information exists in the urological literature cautioning against the use of such media in retrograde pyelography due to the rarity of central nervous and urinary system communication. Furthermore, there is no guarantee that nonionic contrast media will not cause seizures, especially in patients with a history of convulsions. Although Kelly et a1 performed a retrograde pyelogram using ionic contrast material in a patient with a lumbar ureteral shunt without complications, the shunt was completely obstructed at the time.2 CONCLUSIONS
We report an absolute contraindication to retrograde pyelography. A high index of suspicion is required to penetrate inaccuracies in patient histories. Virtually any accepted or idiosyncratic terminology can be used to describe the existence of such a communication between the central nervous and urinary systems. Nephrectomy may or may not have been performed. Ionic contrast media are toxic to the central nervous system but nonionic media are also a risk. In addition, breaching the ureterovesical junction may introduce bacterial contamination. While voiding cystography is also A. plain abdominal x-ray shows only ventriculoperitoneal shunt. B, contraindicated, the patient would be seriously ill if reflux retrograde pyelogram reveals leR lumbar ureteral shunt previously were present. Neurosurgeons who have performed this pronot visible. cedure in the past should locate long-term survivors and 2026
LUMBAR URETERAL SHUNT provide t h e m accurate medical warnings regarding the presence of such a shunt. REFERENCES
1. Matson, D. D.: Neurosurgery of Infancy and Childhood, 2nd ed. Springfield, Illinois: C. C. Thomas, pp. 242-247, 1969. 2. Kelly, J. H., McCullough, D. L. and Harrison, L. H.: Lumbar ureteral shunt-an unusual cause of ureteral obstruction. Urology, 33: 309, 1989. 3. Smith, J. A., Jr., Lee, R. E. and Middleton, R. G.: Ventricu-
2027
loureteral shunt for hydrocephalus without nephrectomy. J. Urol., 123: 224, 1980. 4. Schoenberg, H., Smith, H. St. J. and Murphy, J. J.: Vesicoureterd reflux &r subarachnoid ureterostomy. J. Urol., 8 2 474, 1959. 5. Dalkin, B., Franco, I., Reda, E. F., McLone, D., Godine, L. and Kaplan, W. E.: Contrast-induced central nervous system toxicity &r radiographic evaluation of the lower urinary tract in myelodysplastic patients with ventriculoperitoneal shunts. J. Urol., 148. 120, 1992.