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Percutaneous Antegrade Pyelography and Hydronephrosis
THE JOURNAL OF UROLOGY
Vol. 74, No. 1, July 1955
Printed in U.S.A.
PERCUTANEOUS ANTEGRADE PYELOGRAPHY AND HYDRONEPHROSIS DIRECT, INTRAPELVIC INJECTION OF UROGRAPHIC CONTRAST MATERIAL TO SECURE A PYELOURETEROGRAM AFTER PERCUTANEOUS NEEDLE PUNCTURE AND ASPIRATION OF HYDRONEPHROSIS
WILLIAM C. CASEY
AND
WILLARD E. GOODWIN
From the Division of Urology, the Los Angeles Coimty Harbor General Hospital, the Veterans Administration Center, and the University of California Medical Center, Los Angeles
Pyelograms can be made by needle puncture of the renal pelvis and injection of urographic material after aspiration of urine. This simple procedure, antegrade pyelography, * is a useful adjunct to usual methods of diagnosis in selected cases of hydronephrosis. Our use of this technique was an accidental discovery during needle biopsy of a "nonfunctioning" kidney in August 1953. Resulting roentgenograms provided a clear picture of the extent of hydronephrosis. The procedure seemed so easy and informative that it was tried in a series of hydronephroses. We found this procedure mentioned three times in the literature. However, it might easily be missed, as there is no standard name for it and others have used it occasionally without reporting it in detail. t Kapandji (1949) first reported planned puncture of the renal pelvis associated with pyelography. Ainsworth and Vest (1951) described it as a diagnostic method. Braasch and Emmett (1951) state: "The possibility of making urograms in selected cases by the introduction of a needle through the lumbar area has not been fully explored or evaluated .... " TECHNIQUE
Needle puncture of the renal pelvis is not difficult in large hydronephroses, but it becomes harder in smaller hydronephroses. It probably should be reserved for cases of known or suspected hydronephrosis, exceeding 20 cc in volume, in which diagnosis is incomplete or cannot be definitely made by conventional means of pyelography. Figures 1 and 2 illustrate anatomic relations. Scout films and excretory and retrograde urograms should all be done or attempted, before undertaking antegrade pyelography. Evaluation of preliminary films as to renal size, shape, and Presentation of this work was supported by The Fund for the Advancement of Urology, and a grant from the Schering Corporation. Read at annual meeting, American Urological Association, New York, N. Y., June 2, 1954. Note by editor. The paper by Drs. Casey and Goodwin was awarded first prize in the essay competition sponsored annually by the American Urological Association under the Committee on Scientific Research, Dr. Miley B. Wesson, chairman. * This term was selected as an appropriate opposite of the already established "retrograde". D. M. Davis (1953) used it to describe urograms obtained after injection of a nephrostomy tube. t e.g. Urologists Correspondence Club letter Feb. 5, 1954. Earl Floyd describes the usefulness of the method in an interesting single case under the title "Renal Tapping." Since this paper was originally written, two papers on the subject have appeared in the literature: Wickbom, June 19.54; and Weens and Florence, October 1954. 164
Pl<~HCO'rA:-.r:E:OuS AN'TEGRADE PY8LOGRAPHY
Fm. 1 Technique: Schemu.tic drawing of right hydronephrosis vi:ewed from behiml toshow relationship of dilated renal pelvis to bony landmarks. Optimum point of tJSLtally lies four or five fingc-rbreadths lateral to the midline m the lcvd 11·hern a rib would be.
FJG. 2. Anatomy. A
cross section of right retroperitoneal space ut a.pproxirrrn.te a.nd L+2 (a.fter Brode], 1914). Relationships of muscles, renal pelvis, hydronephrotic kidney and its great vessels are Safe path of aspirating needle is diagrammatically represented. B, paramedian, sagittid section of right side of body at approximatPly the Brode!, 1914). Relationships of contiguous intra.peritoneal orgmis, as they fa; the kidney, are demonsf-.rated of interspace between
µosition J8 essential. A. skin marker may be used to locate the renal m relation to the tip of the twelfth rib and the lumbar vertebrae. The patient nm.v sit bent forward over chair or may lie prone on an x-rny table. A 6 inch. HJ gauge spinal needle is introduced way of the lumbar area into the renal vis after local anesthesia. If no urine is ohtai1wcl, another 61rn with
166
WILLIAM C. CASEY AND WILLARD E. GOODWIN TABLE
Group Group Group Group
A: B: C: D:
1
Diagnosis could be made no other way ... Diagnosis made clear ..... Antegrade pyelography seemed method of choice .. Procedure of no help. Total.
21 22 1 11
patients patients patient patients
55 patients
needle in place may guide the operator. Urine, usually aspirated at a depth of 4--5 inches, is cultured and studied microscopically. Intravenous indigo carmine, given before the procedure, may establish aspirated fluid as urine if renal function is still present. After pelvic puncture, 15 cc of urine are aspirated, and 10 cc of neoiopax injected. If a large hydronephrosis is present, more contrast material* may be necessary. Barbotage near the end of injection aids diffusion of the material. It is important not to overdistend the renal pelvis, and the amount of dye injected should ALWAYS be less than the quantity of v,rine aspirated. Early in the series this was not recognized, and some "cystoscopic-like" reactions occurred. When concentrated organic iodides are used, less volume is required to produce satisfactory roentgenograms; and their heavy weight enhances gravitation to the obstruction, which is often sharply delineated (e.g. fig. 4). Occasionally delayed films show dye in the perirenal space, but transient local pain is the only complaint associated with this. The site of puncture requires no attention after the needle is withdrawn. Films are exposed with the patient in different positions following injection. Emptying is determined by films exposed at hourly intervals. In some instances absorption of neoiopax. by the hydronephrotic kidney and excretion by the contralateral kidney occurred This may provide a clue to function of the hydronephrotic kidney. There are no vital structures between the lumbar skin and the renal pelvis (fig. 2, A). Damage could follow trauma to large renal vessels, however this is not yet recognized after antegrade pyelography. If a needle passes completely through the kidney, intraperitoneal organs may be entered (fig. 2, B). Probably this has happened, but there have been no recognized complications as small needles were used. Probably hazards are no greater than those of aortography or sympathetic blockade. RESULTS
Early in the study antegrade pyelography was tried on several moribund patients and on others in whom it was not necessary to make a diagnosis or in whom pyelography failed technically because of a small renal pelvis. From August 1953 to May 1954, it was used in 55 patients. It is now an accepted procedure with us and our associates, when indicated, and has been used frequently since this work was presented. Cases in this study are divided into four groups. Illustrative examples are briefly presented. * Neoiopax (50 or 75%), supplied by the Schering Corporation, and urokon (70%) furnished by the Mallinckrodt Chemical Works, were used in this study.
Ui7
l<'rn. 3. Case 1. Right hydronephrosis due t.o postoperative meteropelvie junctiou oL,. struction. A, retrograde ureterogram. Complete obstruct.ion at right Ul'8ternpelvic iww·· tion. B, ,rntegrade pyelograrn, A-P.
Group A, Exact roentgenoqraphic diagnosis could be made ·in no other 11.1ay
53
cases). Case 1 (S. J. H. x-ray Ko. 25809). A 12-year-old boy* had an unsuc(;es'3ful operation elsewhere for suspected right renal tumor (probably congenital hy.
dronephrosis ·with obiltruetion at the ureteropelvic junction. When we first ..~aw him, he had a dra.iniug right flank sinus, daily spiking fever, and excrct.ory urngraphic evidence of a uormal left kidney and nonfunctioning right kidtH\\'. Infected hydronephrosi:,, wail suspected. Passage of a uret.eral catheter was obiltructed in the upper third of the right ureter, and dye injected under prer,sure did not pass beyond the olmtruction (fig. :3, A). Injeetion of the flank sinus did not outline the renal pelvjs. After these unsuccessful preliminary studies, an Legrade pyelography was done while the boy sat on the edge of aux-ray table and talked t,o a nurse. After 20 cc of urine were aspirated for culture and micrm;cnpic study, IO cc of urographic material were slowly illjected ,Yit.h barbotage. X-ray film8 were made after the needle was removed (fig. :3, B). He had Leen gi'ven indigo carmine at cystoscopy about six hours before the antegrade pyelograrn. Blne dye appeared in faint concentration in urine recovered from the hydronephrotic kidney. Temporary drainage of the hydronephrosis wa8 eiltablished by trocar nephrostomy which drained well while the patient went home in an at· Lempt to revive function of the kidney before surgery. As soon as drainage wa,s established, fever subsided, and the sinus closed. Renal function wail poor. Later· surgical exploration rnrealed that, scar at the ureteropelvic junction was adlwrent to the vena cava. Right nephrectomy was done. Case 2 (I-I. H. No. 86-124). A 4A-year-old woman who had hysterecr.omy, hilateral nophorectomy, and appendeetorny in 1948 eomplained of left [lank pain and nocturia. In 195;-3 an excretory urogram demonstrated a normal right kid. * Thi8 patient included through comtesy of Dr. Robert C. Walter.
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I
•!
168
WILLIAM C. CASEY AND WILLARD E. GOODWIN
Fm. 4. Case 2. Left hydronephrosis, secondary to pelvic surgery 5 years previously. A, right retrograde pyelogram, unsuccessful attempt to catheterize left ureter. B, antegrade pyelogram, P-A film. Good visualization of cause of hydronephrosis; ureterovesical junction obstruction.
ney but no dye on the left in a 1½ hour delayed film. The left flank was tender. The left ureter could not be catheterized because of obstruction 3 cm. from the orifice (fig. 4, A). Antegrade pyelography (done on an out-patient basis) showed left hydroureter and hydronephrosis with obstruction of the terminal ureter (fig. 4, B). A culture of purulent urine aspirated from the left kidney showed Escherichia coli, the same organism found in her bladder urine. On the basis of this information, left nephroureterectomy was performed. In a film made 45 minutes after figure 4, B, there was no extravasation, but an excretory urogram appeared on the right (opposite) side. This is considered visual evidence of reabsorption from the hydronephrotic left renal pelvis. It may indicate incomplete left ureteral obstruction and continued tubular reabsorptive activity of the partially obstructed kidney, or it could be due to pyelovenous circulation (cf. Hinman and Vecki, 1926). This observation opens many vistas of intriguing physiological study in cases of hydronephrosis. In this case, although the diagnosis of infected hydronephrosis might have been guessed, it was not clear until the simple and informative procedure of antegrade pyelography was performed. This is a good example of usefulness of this procedure in patients with gynecological surgical accidents involving the ureter. Group B. Diagnosis suspected or fairly well demonstrated by other methods, but antedgrade pyelography made clear the true situation and site of obstruction (22/55 patients). Case 3 (H. H. 84-820). A 54-year-old woman had a radical operation for carcinoma of the uterus; later a vesicovaginal fistula and right ureterovaginal fistula developed. Right hydronephrosis was progressive, and the right ureter
l'lcHC1:T.J,;\'J~OCS .\.XTEGHADE PYELOGHAPHY.
I
.!
F1u 5. Carn ;:L VeHicovaginal fistula; right nreterovaginal fistula; rigb( hydro1rnphrosis, progressive. A, antegrade pyelogram (P-A film). ;\;ot.e urel,eral tortnosi1y and suggest.inn of ureternl fistula in right iliac n.rea. B, antegrade urogram made by injcctiou Lhrouglt nephrostorny tubing after segment of ileum ,ms substituted for damaged urP1Pr.
,,ould not be cathet<,rizecl. Sine"' the exact level of obstruction ,vas uncer1.ai11, n.n antegrade pyelogram was made 2;,1 mouths aft.er hysterectorny (fig. ii, A). ln delayed films, dye was new,r observed below the brim of the pelvis. This sug-· gested surgical trauma to [he right ureter in the iliac region. Simultaneously with antegrade pyelogrnpby, indigo carmine was injected into the right renal pelvis. Following this, c:ystoscopy \\'as carried out 1,o see where the right- nrcteral orifice emptied, in the bladder or the vagina. Hmvever, even after 40 mi1111tes, none of tho blue color wa:s Reen. :Next da,v a larger needle 1Yas inLrouueed into the nght renal pelviR, and a polyethylene catheter ,vas passed through j1, for temporary urinary diversion.* After drainage from the right, had been establisl1ed for 2 weeks, the vesicovaginal fistula was closed surgic~dly. Three months later, a segment of .ileum was successfully s11bstituted for the damaged right uretPr (fig. 5, B). Case .4 (V.A.C. No. 20:356). A. 65-year-old man (mtered the hospital because of hematuria of 2 days' dmation. Cystoscopy disclosed blood trickling frmn the right urei,er. .An excretory urogrnm showed right renal duplication 1Yith modera /.<', hydronephrosis. Beeause the exact point of obstruction was 110t identifa,d and retrograde pyelogeaphy failed, an antegrade pyelogram ,vas attempted Liur. failed ..A few days later the procedure was n~peat.ed with success (fig. h, A) Roenlgenogrnphic diagno:Sis of primary urnteral tumor was eoufirmed ·ffhe11 segmental ureterectomy showed squamous cell carcinoma of the ureter (fig. G, H). The dilated ureter ,vas reimplanted in the dome of the bladder. Case /j (H. H. No. 10-:39[J) In 1952, a M,-year-o[d man had eyRtectomy and * This t.opic is the subject of a .~eparnte communication: Pereutaueous troear (nr,ed1',) nephrostomy in byclro,wphrosis, Ly Goodwin, W. E., Cn,e.v, vY. C. nnd Woolf vY, J A.M .. \ 1.57': 891-894, 1955.
l
!
170
WILLIAM C. CASEY AND WILLARD E. GOOffWIN
Fm. 6. Case 4. Ureteral tumor with hydronephrosis. A, right antegrade pyelogram. Convex filling defect with sharp superior margin seen in lower ureter. Diagnosis, carcinoma, of the ureter. B, surgical specimen, terminal portion of right ureter. Histologic diagnosis: squamous cell carcinoma.
ureterosigmoidostomy for carcinoma of the bladder. A Coffey 1 procedure was performed on the right, and a combination of direct elliptical anastomosis plus tunneling -was done on the left. Subsequent excretory urograms showed gradually progressive right hydronephrosis presumably due to obstruction where the ureter entered the bowel (fig. 7, A). Since this was not certain, antegrade pyelography was performed with injection of 8 cc of contrast medium after withdrawal of 6 cc of urine. (In this instance more contrast medium was injected than urine withdrawn. The patient suffered chills and fever one hour later, which may be
Fm. 7. Case 5. Hydronephrosis, right, after ureterosigmoidostomy. A, excretory urogram, A-P. One year after ureterosigmoidostomy (Coffey 1, right; "Leadbetter-Weyrauch", left). Right hydronephrosis and hydroureter; exact point of obstruction not demonstrated. B, right ante grade pyelogram, P-A. Note point of obstruction at ureterosigmoid junction.
PERCUTANEOUS ANTEGRADE PYELOGRAPHY
171
attributed to overdistention. See Complications.) Hydronephrosis and hydroureter were demonstrated with sharp obstruction at the ureterosigmoid junction (fig. 7, B). On the basis of these films it was decided to revise the ureteral stoma (Henderson, 1952) by exploration of the area through anterior colotomy. The right ureteral orifice, which was constricted and scarred with a warty projection where the granulating ureteral stump projected into the bowel, was identified and amputated; and intubated ureteral meatotomy was performed. Excretory urograms a year later showed return to normal. It may be that antegrade pyelography will find further use in cases of ureterosigmoidostomy to demonstrate a poorly functioning hydronephrosis and secure cultures when the surgeon desires to assess extent of damage and point of obstruction before planning definitive surgery. COMPLICATIONS
No serious complications have been recognized. Antegrade pyelography was attempted in 55 patients. In 7 there was failure due to inability to puncture the renal pelvis. In 4 others resulting roentgenograms were of no help. These were small hydronephroses or nearly normal kidneys and should not have been subjected to the procedure. Unfavorable reactions, observed in 7 of 55 patients, were usually like "cystoscopic reactions" (Stevens, 1938), and were probably due to the same factors that cause reactions after retrograde pyelography. Most complications were due to unfamiliarity with the procedure. They were associated with: overdistention of the pelvis in 4 patients, with resultant extravasation in 2; injection of excessive quantities of organic iodides in 2; multiple puncture of both kidneys in 1; and unexplained in l. One patient had a combination of overdistention and injection of an excessive quantity of radiopaque medium. There should be few complications when antegrade pyelography is properly employed. The following rules should be followed: 1) The renal pelvis should not be over distended. Increased intrapelvic pressure produces pyelovenous, pyelolymphatic, pyelotubular, and interstitial reflux. With infected hydronephrosis overdistention can produce bacteremia. The quantity of contrast medium should never exceed, and preferably be less than, the amount of urine aspirated. Direct injection of iodides into renal parenchyma is not desirable. If urine is freely aspirated before and during injection, such a complication is remote. 2) Excessive quantities of contrast media should not be injected, particularly into a completely closed hydronephrosis. In two instances where over 40 cc of concentrated iodides were injected into large hydronephroses, chills, fever, and vomiting occurred. Both patients had completely obstructed ureters, and in one contrast medium was demonstrated in the kidney by x-ray 27 hours after injection. The total quantity of dye injected should not exceed 10 or 15 cc which produces excellent pyelograms in most hydronephroses. 3) Until more is known about antegrade pyelography, it is probably best not to perform it bilaterally on the same day. One experience with multiple needle punctures of both kidneys and resultant temporary reflex ileus led to this conclusion.
172
WILLIAM C. CASEY AND WILLARD E. GOODWIN
Complications could include reactions to iodides, shock from emptying an overdistended viscus, urinary fistulas, and hemorrhage. These have not yet been encountered. OTHER POSSIBLE USES
As familiarity with the simplicity of needle puncture of hydronephroses led to boldness, other uses of this technique were considered. These are listed, without discussion, for completeness. Some have been tried. 1) Direct aspiration of urine for culture and microscopic or chemical study. 2) Direct injection of appropriate antibiotics in high concentration in pyonephrosis. 3) Direct air or oxygen antegrade pyelograms for contrast. 4) Continuous irrigation of the renal pelvis with "solution G" introduced through a polyethylene tube and allowed to drain out the ureter in an attempt to dissolve calculi. 5) Introduction of dyes to identify an ectopic ureteral orifice or fistula. 6) Introduction of enzymes (streptokinase, streptodornase) to dissolve pus or blood. 7) Direct injection of local anesthetics into the renal pelvis to relieve colic or anesthetize the ureter and possibly help in the passage of a stone. 8) Direct aspiration of material from the renal pelvis for Papanicolaou smears. 9) Dilation of a ureter from above. 10) Combination of antegrade pyelography with other diagnostic procedures. Nearly all these could more readily be done by ureteral catheterization. If any are to be useful, it would usually be when catheterization is impossible. Several interesting questions concerning the dynamics of hydronephrosis should be mentioned: l) Why is organic iodide absorbed from a hydronephrotic kidney pelvis giving a contralateral excretory urogram in some cases and not in others? 2) How much do secretory pressures in various hydronephroses vary? What would be the effect of drugs? 3) Could action potentials within the renal pelvis be measured by appropriately placed electrodes? Would they vary? SUMMARY
A method of direct, percutaneous, needle puncture of a hydronephrotic renal pelvis is described. Urine is aspirated for culture and microscopic study, and a urographic medium is injected into the pelvis to secure good pyeloureterograms from above. This has been called "antegrade pyelography"; the technique is described and illustrated in detail. Illustrative cases, selected from 55 patients in whom this procedure has been used, are presented. Advantages and complications are discussed. Limitations of and indications for antegrade pyelography are mentioned. Translumbar needle nephrostomy, with insertion of polyethylene tubing through a large needle is briefly mentioned as a natural outgrowth of this techmque. CONCLUSIONS
In selected cases of hydronephrosis, antegrade pyelography is a safe and useful adjunct to other accepted methods of urography.
PERCUTANEOUS ANTEGRADE PYJi!LOGHAPHY
173
Ih, use should be re8erved for patients with large hydronephro8es in ,vhorn accurate rnentgenographic diagnosis cannot be made by excretory or retrograde pyelography, It may have special application in children and adults with poorly functioning uninfected hydroncphroses when the urologist wishes to minimize chances of infection and still secure good radiographic studies before surgery. It does not supplant but rather augments conventional methods . Antegrade pyelograpby warrants further evaluation. We expect to ,:ontinue to usP it when it is indicated. Acknmvledgment: vVe wish to express appreciation for encouragement and help received from many sources during this study. We are particularly indebted to Dr. Elmer Belt and Dr. Milo Ellik on whose service the project was initiated at the Harbor General Hospital. The study would have been impossible without the aid and interest of the resident, staff: Drs. Wilford \~T oolf and .John A.rconti at Harbor Hospital; and Drs. Carl Dahlen, John Watkins, Donald Burke, Jame,s Nelson, Chester ViTinter, Hobert Parker, and Stanley Ross at Wadsworth Veterans Hospital. Drawings by i\1ary P. Goodwin and photographs by Mr. William J'vlartinsen and the Photographic Laboratory at vVadsworth Hospital. made pos sibie a graphic presentation of the work. Technical help was provided by Mr Roy Beltran. 2411 Torrance Blocl., Torrance, Cal~f (W. C. C,) The Um.vrrsit:i; of California Mcchcal Center, Los Angeles :?J4, Cal1j'. (W, K U,) REFERENCES \IV L. A:S- D VEST, S. A.: The differenti,tl diagnosis between renal tumors nnd cysts. J. lTroL, 66: 740 749, l95L BRAASCH, W. F, AND EMMF:TT, .J. L.· Clinical Urogra.phy. Philadelphia.: W. R S.1.unclm·l' Co., HJ51, pp. 71271:l. CA.vlPBBLL, 1\L · Hyclronephrosis in infants and children . J UroL, 65: 734--7 117, 1951. DEAN, A. L .. Treatment of solitary cyst of the kidney by a,pirntiotL Tr, Arn. A. GemtoUri1L Surg,, 32: Pl--!-l5, 1939. DE:,\RING, R.: A study of the reirnl trnct in ctucinonrn of the cervix, J Obst, Gyn, Brit. Empire, 60: 165 174, 19fr:3. IL,.RLUL lVL S. S.: Gi,111t. hyclronephrosis. J. lTroL, 63: 19.5-202, 1950. FISH, G. W.: Large solitary serous eysts of the kidney . .J.A.M.A., 112: 514-517 . Hi3H. HENDERSO!':, D, S. · Operative procedures for stenosis following nreterosigmordostomy, J. llroL, 6'7: 479-483. HJ52 H1NMAN, F. AND V1<~cKr, :\L. Pyelovenous backfiow; the. fate of phenosulpbonephtJ1,dein in a normal renal pelvis with the ureter tied. J, Urol., 15: 267-271, 192t\. KAPAND.rr, M.: Ponction de Bassinel, et RadiomenometriP IVfeato-ureu,rn-pyelocalicidle, Rev . C. Par. 68: 270-W0, Sept..-Oct. 1949, (Abstracted in. Internat_ Abstr. Surg., 90: 577-:578, fone 19.50), LANDES, IL H. AND RooKER, J. W. · Sclerosing Jipogranuloma and peri-urnteraI fibrosis foJ!owing extravasation of mographic contrnst media. ,J, 1JroL, 68: 403-4{16, 1952 7\/lcLAUGHLIN, VV, L. ANO BowLER, J.P.: Excretory nrograpby in the diagnosis of ureteropelvic obstruction. J, Urol., 67: 1012-1018, 1952. l\fumcK, A. W., I'A'l'EY, D. H. AND \VmTESIDE, C. G.: Percutaneous tnmshepatic cholangiog .. raphy in the diagnosis of obstructive jaundice. Brit. J. Surg., 41: 27-31, 1953. SMAH.1', W. IC: Giant hydronepbrosis eausing eontrnlnteral hydronephrosis and obstrucfrve jaundice . .J. UroL, 67; 605..610, 1052. STEVENS, W. E, · Roentgenological examination of the kidney with special reference. to lrnckflm.v and injuries a.ssociated with retrogra.de pyelogrn.phy. J. (JroL, 39: 598-610. l[J:38. WEE.>1s, H. S. AND FL0RE:-1c1,;, T. J : The diagnosis of hydronephrosis by percutaneous renal rmueture, J, UroL, 72: 58\)-595, 1954. WrcKBmr, L: Pyelogrnphy a.her di reel puncture of the renal pelvis, Act,, Radiologica. 41: 505-512, H/54, AINSWORTH,
Vol. 74, No. 1, July 1955
Printed in U.S.A.
PERCUTANEOUS ANTEGRADE PYELOGRAPHY AND HYDRONEPHROSIS DIRECT, INTRAPELVIC INJECTION OF UROGRAPHIC CONTRAST MATERIAL TO SECURE A PYELOURETEROGRAM AFTER PERCUTANEOUS NEEDLE PUNCTURE AND ASPIRATION OF HYDRONEPHROSIS
WILLIAM C. CASEY
AND
WILLARD E. GOODWIN
From the Division of Urology, the Los Angeles Coimty Harbor General Hospital, the Veterans Administration Center, and the University of California Medical Center, Los Angeles
Pyelograms can be made by needle puncture of the renal pelvis and injection of urographic material after aspiration of urine. This simple procedure, antegrade pyelography, * is a useful adjunct to usual methods of diagnosis in selected cases of hydronephrosis. Our use of this technique was an accidental discovery during needle biopsy of a "nonfunctioning" kidney in August 1953. Resulting roentgenograms provided a clear picture of the extent of hydronephrosis. The procedure seemed so easy and informative that it was tried in a series of hydronephroses. We found this procedure mentioned three times in the literature. However, it might easily be missed, as there is no standard name for it and others have used it occasionally without reporting it in detail. t Kapandji (1949) first reported planned puncture of the renal pelvis associated with pyelography. Ainsworth and Vest (1951) described it as a diagnostic method. Braasch and Emmett (1951) state: "The possibility of making urograms in selected cases by the introduction of a needle through the lumbar area has not been fully explored or evaluated .... " TECHNIQUE
Needle puncture of the renal pelvis is not difficult in large hydronephroses, but it becomes harder in smaller hydronephroses. It probably should be reserved for cases of known or suspected hydronephrosis, exceeding 20 cc in volume, in which diagnosis is incomplete or cannot be definitely made by conventional means of pyelography. Figures 1 and 2 illustrate anatomic relations. Scout films and excretory and retrograde urograms should all be done or attempted, before undertaking antegrade pyelography. Evaluation of preliminary films as to renal size, shape, and Presentation of this work was supported by The Fund for the Advancement of Urology, and a grant from the Schering Corporation. Read at annual meeting, American Urological Association, New York, N. Y., June 2, 1954. Note by editor. The paper by Drs. Casey and Goodwin was awarded first prize in the essay competition sponsored annually by the American Urological Association under the Committee on Scientific Research, Dr. Miley B. Wesson, chairman. * This term was selected as an appropriate opposite of the already established "retrograde". D. M. Davis (1953) used it to describe urograms obtained after injection of a nephrostomy tube. t e.g. Urologists Correspondence Club letter Feb. 5, 1954. Earl Floyd describes the usefulness of the method in an interesting single case under the title "Renal Tapping." Since this paper was originally written, two papers on the subject have appeared in the literature: Wickbom, June 19.54; and Weens and Florence, October 1954. 164
Pl<~HCO'rA:-.r:E:OuS AN'TEGRADE PY8LOGRAPHY
Fm. 1 Technique: Schemu.tic drawing of right hydronephrosis vi:ewed from behiml toshow relationship of dilated renal pelvis to bony landmarks. Optimum point of tJSLtally lies four or five fingc-rbreadths lateral to the midline m the lcvd 11·hern a rib would be.
FJG. 2. Anatomy. A
cross section of right retroperitoneal space ut a.pproxirrrn.te a.nd L+2 (a.fter Brode], 1914). Relationships of muscles, renal pelvis, hydronephrotic kidney and its great vessels are Safe path of aspirating needle is diagrammatically represented. B, paramedian, sagittid section of right side of body at approximatPly the Brode!, 1914). Relationships of contiguous intra.peritoneal orgmis, as they fa; the kidney, are demonsf-.rated of interspace between
µosition J8 essential. A. skin marker may be used to locate the renal m relation to the tip of the twelfth rib and the lumbar vertebrae. The patient nm.v sit bent forward over chair or may lie prone on an x-rny table. A 6 inch. HJ gauge spinal needle is introduced way of the lumbar area into the renal vis after local anesthesia. If no urine is ohtai1wcl, another 61rn with
166
WILLIAM C. CASEY AND WILLARD E. GOODWIN TABLE
Group Group Group Group
A: B: C: D:
1
Diagnosis could be made no other way ... Diagnosis made clear ..... Antegrade pyelography seemed method of choice .. Procedure of no help. Total.
21 22 1 11
patients patients patient patients
55 patients
needle in place may guide the operator. Urine, usually aspirated at a depth of 4--5 inches, is cultured and studied microscopically. Intravenous indigo carmine, given before the procedure, may establish aspirated fluid as urine if renal function is still present. After pelvic puncture, 15 cc of urine are aspirated, and 10 cc of neoiopax injected. If a large hydronephrosis is present, more contrast material* may be necessary. Barbotage near the end of injection aids diffusion of the material. It is important not to overdistend the renal pelvis, and the amount of dye injected should ALWAYS be less than the quantity of v,rine aspirated. Early in the series this was not recognized, and some "cystoscopic-like" reactions occurred. When concentrated organic iodides are used, less volume is required to produce satisfactory roentgenograms; and their heavy weight enhances gravitation to the obstruction, which is often sharply delineated (e.g. fig. 4). Occasionally delayed films show dye in the perirenal space, but transient local pain is the only complaint associated with this. The site of puncture requires no attention after the needle is withdrawn. Films are exposed with the patient in different positions following injection. Emptying is determined by films exposed at hourly intervals. In some instances absorption of neoiopax. by the hydronephrotic kidney and excretion by the contralateral kidney occurred This may provide a clue to function of the hydronephrotic kidney. There are no vital structures between the lumbar skin and the renal pelvis (fig. 2, A). Damage could follow trauma to large renal vessels, however this is not yet recognized after antegrade pyelography. If a needle passes completely through the kidney, intraperitoneal organs may be entered (fig. 2, B). Probably this has happened, but there have been no recognized complications as small needles were used. Probably hazards are no greater than those of aortography or sympathetic blockade. RESULTS
Early in the study antegrade pyelography was tried on several moribund patients and on others in whom it was not necessary to make a diagnosis or in whom pyelography failed technically because of a small renal pelvis. From August 1953 to May 1954, it was used in 55 patients. It is now an accepted procedure with us and our associates, when indicated, and has been used frequently since this work was presented. Cases in this study are divided into four groups. Illustrative examples are briefly presented. * Neoiopax (50 or 75%), supplied by the Schering Corporation, and urokon (70%) furnished by the Mallinckrodt Chemical Works, were used in this study.
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l<'rn. 3. Case 1. Right hydronephrosis due t.o postoperative meteropelvie junctiou oL,. struction. A, retrograde ureterogram. Complete obstruct.ion at right Ul'8ternpelvic iww·· tion. B, ,rntegrade pyelograrn, A-P.
Group A, Exact roentgenoqraphic diagnosis could be made ·in no other 11.1ay
53
cases). Case 1 (S. J. H. x-ray Ko. 25809). A 12-year-old boy* had an unsuc(;es'3ful operation elsewhere for suspected right renal tumor (probably congenital hy.
dronephrosis ·with obiltruetion at the ureteropelvic junction. When we first ..~aw him, he had a dra.iniug right flank sinus, daily spiking fever, and excrct.ory urngraphic evidence of a uormal left kidney and nonfunctioning right kidtH\\'. Infected hydronephrosi:,, wail suspected. Passage of a uret.eral catheter was obiltructed in the upper third of the right ureter, and dye injected under prer,sure did not pass beyond the olmtruction (fig. :3, A). Injeetion of the flank sinus did not outline the renal pelvjs. After these unsuccessful preliminary studies, an Legrade pyelography was done while the boy sat on the edge of aux-ray table and talked t,o a nurse. After 20 cc of urine were aspirated for culture and micrm;cnpic study, IO cc of urographic material were slowly illjected ,Yit.h barbotage. X-ray film8 were made after the needle was removed (fig. :3, B). He had Leen gi'ven indigo carmine at cystoscopy about six hours before the antegrade pyelograrn. Blne dye appeared in faint concentration in urine recovered from the hydronephrotic kidney. Temporary drainage of the hydronephrosis wa8 eiltablished by trocar nephrostomy which drained well while the patient went home in an at· Lempt to revive function of the kidney before surgery. As soon as drainage wa,s established, fever subsided, and the sinus closed. Renal function wail poor. Later· surgical exploration rnrealed that, scar at the ureteropelvic junction was adlwrent to the vena cava. Right nephrectomy was done. Case 2 (I-I. H. No. 86-124). A 4A-year-old woman who had hysterecr.omy, hilateral nophorectomy, and appendeetorny in 1948 eomplained of left [lank pain and nocturia. In 195;-3 an excretory urogram demonstrated a normal right kid. * Thi8 patient included through comtesy of Dr. Robert C. Walter.
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WILLIAM C. CASEY AND WILLARD E. GOODWIN
Fm. 4. Case 2. Left hydronephrosis, secondary to pelvic surgery 5 years previously. A, right retrograde pyelogram, unsuccessful attempt to catheterize left ureter. B, antegrade pyelogram, P-A film. Good visualization of cause of hydronephrosis; ureterovesical junction obstruction.
ney but no dye on the left in a 1½ hour delayed film. The left flank was tender. The left ureter could not be catheterized because of obstruction 3 cm. from the orifice (fig. 4, A). Antegrade pyelography (done on an out-patient basis) showed left hydroureter and hydronephrosis with obstruction of the terminal ureter (fig. 4, B). A culture of purulent urine aspirated from the left kidney showed Escherichia coli, the same organism found in her bladder urine. On the basis of this information, left nephroureterectomy was performed. In a film made 45 minutes after figure 4, B, there was no extravasation, but an excretory urogram appeared on the right (opposite) side. This is considered visual evidence of reabsorption from the hydronephrotic left renal pelvis. It may indicate incomplete left ureteral obstruction and continued tubular reabsorptive activity of the partially obstructed kidney, or it could be due to pyelovenous circulation (cf. Hinman and Vecki, 1926). This observation opens many vistas of intriguing physiological study in cases of hydronephrosis. In this case, although the diagnosis of infected hydronephrosis might have been guessed, it was not clear until the simple and informative procedure of antegrade pyelography was performed. This is a good example of usefulness of this procedure in patients with gynecological surgical accidents involving the ureter. Group B. Diagnosis suspected or fairly well demonstrated by other methods, but antedgrade pyelography made clear the true situation and site of obstruction (22/55 patients). Case 3 (H. H. 84-820). A 54-year-old woman had a radical operation for carcinoma of the uterus; later a vesicovaginal fistula and right ureterovaginal fistula developed. Right hydronephrosis was progressive, and the right ureter
l'lcHC1:T.J,;\'J~OCS .\.XTEGHADE PYELOGHAPHY.
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F1u 5. Carn ;:L VeHicovaginal fistula; right nreterovaginal fistula; rigb( hydro1rnphrosis, progressive. A, antegrade pyelogram (P-A film). ;\;ot.e urel,eral tortnosi1y and suggest.inn of ureternl fistula in right iliac n.rea. B, antegrade urogram made by injcctiou Lhrouglt nephrostorny tubing after segment of ileum ,ms substituted for damaged urP1Pr.
,,ould not be cathet<,rizecl. Sine"' the exact level of obstruction ,vas uncer1.ai11, n.n antegrade pyelogram was made 2;,1 mouths aft.er hysterectorny (fig. ii, A). ln delayed films, dye was new,r observed below the brim of the pelvis. This sug-· gested surgical trauma to [he right ureter in the iliac region. Simultaneously with antegrade pyelogrnpby, indigo carmine was injected into the right renal pelvis. Following this, c:ystoscopy \\'as carried out 1,o see where the right- nrcteral orifice emptied, in the bladder or the vagina. Hmvever, even after 40 mi1111tes, none of tho blue color wa:s Reen. :Next da,v a larger needle 1Yas inLrouueed into the nght renal pelviR, and a polyethylene catheter ,vas passed through j1, for temporary urinary diversion.* After drainage from the right, had been establisl1ed for 2 weeks, the vesicovaginal fistula was closed surgic~dly. Three months later, a segment of .ileum was successfully s11bstituted for the damaged right uretPr (fig. 5, B). Case .4 (V.A.C. No. 20:356). A. 65-year-old man (mtered the hospital because of hematuria of 2 days' dmation. Cystoscopy disclosed blood trickling frmn the right urei,er. .An excretory urogrnm showed right renal duplication 1Yith modera /.<', hydronephrosis. Beeause the exact point of obstruction was 110t identifa,d and retrograde pyelogeaphy failed, an antegrade pyelogram ,vas attempted Liur. failed ..A few days later the procedure was n~peat.ed with success (fig. h, A) Roenlgenogrnphic diagno:Sis of primary urnteral tumor was eoufirmed ·ffhe11 segmental ureterectomy showed squamous cell carcinoma of the ureter (fig. G, H). The dilated ureter ,vas reimplanted in the dome of the bladder. Case /j (H. H. No. 10-:39[J) In 1952, a M,-year-o[d man had eyRtectomy and * This t.opic is the subject of a .~eparnte communication: Pereutaueous troear (nr,ed1',) nephrostomy in byclro,wphrosis, Ly Goodwin, W. E., Cn,e.v, vY. C. nnd Woolf vY, J A.M .. \ 1.57': 891-894, 1955.
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WILLIAM C. CASEY AND WILLARD E. GOOffWIN
Fm. 6. Case 4. Ureteral tumor with hydronephrosis. A, right antegrade pyelogram. Convex filling defect with sharp superior margin seen in lower ureter. Diagnosis, carcinoma, of the ureter. B, surgical specimen, terminal portion of right ureter. Histologic diagnosis: squamous cell carcinoma.
ureterosigmoidostomy for carcinoma of the bladder. A Coffey 1 procedure was performed on the right, and a combination of direct elliptical anastomosis plus tunneling -was done on the left. Subsequent excretory urograms showed gradually progressive right hydronephrosis presumably due to obstruction where the ureter entered the bowel (fig. 7, A). Since this was not certain, antegrade pyelography was performed with injection of 8 cc of contrast medium after withdrawal of 6 cc of urine. (In this instance more contrast medium was injected than urine withdrawn. The patient suffered chills and fever one hour later, which may be
Fm. 7. Case 5. Hydronephrosis, right, after ureterosigmoidostomy. A, excretory urogram, A-P. One year after ureterosigmoidostomy (Coffey 1, right; "Leadbetter-Weyrauch", left). Right hydronephrosis and hydroureter; exact point of obstruction not demonstrated. B, right ante grade pyelogram, P-A. Note point of obstruction at ureterosigmoid junction.
PERCUTANEOUS ANTEGRADE PYELOGRAPHY
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attributed to overdistention. See Complications.) Hydronephrosis and hydroureter were demonstrated with sharp obstruction at the ureterosigmoid junction (fig. 7, B). On the basis of these films it was decided to revise the ureteral stoma (Henderson, 1952) by exploration of the area through anterior colotomy. The right ureteral orifice, which was constricted and scarred with a warty projection where the granulating ureteral stump projected into the bowel, was identified and amputated; and intubated ureteral meatotomy was performed. Excretory urograms a year later showed return to normal. It may be that antegrade pyelography will find further use in cases of ureterosigmoidostomy to demonstrate a poorly functioning hydronephrosis and secure cultures when the surgeon desires to assess extent of damage and point of obstruction before planning definitive surgery. COMPLICATIONS
No serious complications have been recognized. Antegrade pyelography was attempted in 55 patients. In 7 there was failure due to inability to puncture the renal pelvis. In 4 others resulting roentgenograms were of no help. These were small hydronephroses or nearly normal kidneys and should not have been subjected to the procedure. Unfavorable reactions, observed in 7 of 55 patients, were usually like "cystoscopic reactions" (Stevens, 1938), and were probably due to the same factors that cause reactions after retrograde pyelography. Most complications were due to unfamiliarity with the procedure. They were associated with: overdistention of the pelvis in 4 patients, with resultant extravasation in 2; injection of excessive quantities of organic iodides in 2; multiple puncture of both kidneys in 1; and unexplained in l. One patient had a combination of overdistention and injection of an excessive quantity of radiopaque medium. There should be few complications when antegrade pyelography is properly employed. The following rules should be followed: 1) The renal pelvis should not be over distended. Increased intrapelvic pressure produces pyelovenous, pyelolymphatic, pyelotubular, and interstitial reflux. With infected hydronephrosis overdistention can produce bacteremia. The quantity of contrast medium should never exceed, and preferably be less than, the amount of urine aspirated. Direct injection of iodides into renal parenchyma is not desirable. If urine is freely aspirated before and during injection, such a complication is remote. 2) Excessive quantities of contrast media should not be injected, particularly into a completely closed hydronephrosis. In two instances where over 40 cc of concentrated iodides were injected into large hydronephroses, chills, fever, and vomiting occurred. Both patients had completely obstructed ureters, and in one contrast medium was demonstrated in the kidney by x-ray 27 hours after injection. The total quantity of dye injected should not exceed 10 or 15 cc which produces excellent pyelograms in most hydronephroses. 3) Until more is known about antegrade pyelography, it is probably best not to perform it bilaterally on the same day. One experience with multiple needle punctures of both kidneys and resultant temporary reflex ileus led to this conclusion.
172
WILLIAM C. CASEY AND WILLARD E. GOODWIN
Complications could include reactions to iodides, shock from emptying an overdistended viscus, urinary fistulas, and hemorrhage. These have not yet been encountered. OTHER POSSIBLE USES
As familiarity with the simplicity of needle puncture of hydronephroses led to boldness, other uses of this technique were considered. These are listed, without discussion, for completeness. Some have been tried. 1) Direct aspiration of urine for culture and microscopic or chemical study. 2) Direct injection of appropriate antibiotics in high concentration in pyonephrosis. 3) Direct air or oxygen antegrade pyelograms for contrast. 4) Continuous irrigation of the renal pelvis with "solution G" introduced through a polyethylene tube and allowed to drain out the ureter in an attempt to dissolve calculi. 5) Introduction of dyes to identify an ectopic ureteral orifice or fistula. 6) Introduction of enzymes (streptokinase, streptodornase) to dissolve pus or blood. 7) Direct injection of local anesthetics into the renal pelvis to relieve colic or anesthetize the ureter and possibly help in the passage of a stone. 8) Direct aspiration of material from the renal pelvis for Papanicolaou smears. 9) Dilation of a ureter from above. 10) Combination of antegrade pyelography with other diagnostic procedures. Nearly all these could more readily be done by ureteral catheterization. If any are to be useful, it would usually be when catheterization is impossible. Several interesting questions concerning the dynamics of hydronephrosis should be mentioned: l) Why is organic iodide absorbed from a hydronephrotic kidney pelvis giving a contralateral excretory urogram in some cases and not in others? 2) How much do secretory pressures in various hydronephroses vary? What would be the effect of drugs? 3) Could action potentials within the renal pelvis be measured by appropriately placed electrodes? Would they vary? SUMMARY
A method of direct, percutaneous, needle puncture of a hydronephrotic renal pelvis is described. Urine is aspirated for culture and microscopic study, and a urographic medium is injected into the pelvis to secure good pyeloureterograms from above. This has been called "antegrade pyelography"; the technique is described and illustrated in detail. Illustrative cases, selected from 55 patients in whom this procedure has been used, are presented. Advantages and complications are discussed. Limitations of and indications for antegrade pyelography are mentioned. Translumbar needle nephrostomy, with insertion of polyethylene tubing through a large needle is briefly mentioned as a natural outgrowth of this techmque. CONCLUSIONS
In selected cases of hydronephrosis, antegrade pyelography is a safe and useful adjunct to other accepted methods of urography.
PERCUTANEOUS ANTEGRADE PYJi!LOGHAPHY
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Ih, use should be re8erved for patients with large hydronephro8es in ,vhorn accurate rnentgenographic diagnosis cannot be made by excretory or retrograde pyelography, It may have special application in children and adults with poorly functioning uninfected hydroncphroses when the urologist wishes to minimize chances of infection and still secure good radiographic studies before surgery. It does not supplant but rather augments conventional methods . Antegrade pyelograpby warrants further evaluation. We expect to ,:ontinue to usP it when it is indicated. Acknmvledgment: vVe wish to express appreciation for encouragement and help received from many sources during this study. We are particularly indebted to Dr. Elmer Belt and Dr. Milo Ellik on whose service the project was initiated at the Harbor General Hospital. The study would have been impossible without the aid and interest of the resident, staff: Drs. Wilford \~T oolf and .John A.rconti at Harbor Hospital; and Drs. Carl Dahlen, John Watkins, Donald Burke, Jame,s Nelson, Chester ViTinter, Hobert Parker, and Stanley Ross at Wadsworth Veterans Hospital. Drawings by i\1ary P. Goodwin and photographs by Mr. William J'vlartinsen and the Photographic Laboratory at vVadsworth Hospital. made pos sibie a graphic presentation of the work. Technical help was provided by Mr Roy Beltran. 2411 Torrance Blocl., Torrance, Cal~f (W. C. C,) The Um.vrrsit:i; of California Mcchcal Center, Los Angeles :?J4, Cal1j'. (W, K U,) REFERENCES \IV L. A:S- D VEST, S. A.: The differenti,tl diagnosis between renal tumors nnd cysts. J. lTroL, 66: 740 749, l95L BRAASCH, W. F, AND EMMF:TT, .J. L.· Clinical Urogra.phy. Philadelphia.: W. R S.1.unclm·l' Co., HJ51, pp. 71271:l. CA.vlPBBLL, 1\L · Hyclronephrosis in infants and children . J UroL, 65: 734--7 117, 1951. DEAN, A. L .. Treatment of solitary cyst of the kidney by a,pirntiotL Tr, Arn. A. GemtoUri1L Surg,, 32: Pl--!-l5, 1939. DE:,\RING, R.: A study of the reirnl trnct in ctucinonrn of the cervix, J Obst, Gyn, Brit. Empire, 60: 165 174, 19fr:3. IL,.RLUL lVL S. S.: Gi,111t. hyclronephrosis. J. lTroL, 63: 19.5-202, 1950. FISH, G. W.: Large solitary serous eysts of the kidney . .J.A.M.A., 112: 514-517 . Hi3H. HENDERSO!':, D, S. · Operative procedures for stenosis following nreterosigmordostomy, J. llroL, 6'7: 479-483. HJ52 H1NMAN, F. AND V1<~cKr, :\L. Pyelovenous backfiow; the. fate of phenosulpbonephtJ1,dein in a normal renal pelvis with the ureter tied. J, Urol., 15: 267-271, 192t\. KAPAND.rr, M.: Ponction de Bassinel, et RadiomenometriP IVfeato-ureu,rn-pyelocalicidle, Rev . C. Par. 68: 270-W0, Sept..-Oct. 1949, (Abstracted in. Internat_ Abstr. Surg., 90: 577-:578, fone 19.50), LANDES, IL H. AND RooKER, J. W. · Sclerosing Jipogranuloma and peri-urnteraI fibrosis foJ!owing extravasation of mographic contrnst media. ,J, 1JroL, 68: 403-4{16, 1952 7\/lcLAUGHLIN, VV, L. ANO BowLER, J.P.: Excretory nrograpby in the diagnosis of ureteropelvic obstruction. J, Urol., 67: 1012-1018, 1952. l\fumcK, A. W., I'A'l'EY, D. H. AND \VmTESIDE, C. G.: Percutaneous tnmshepatic cholangiog .. raphy in the diagnosis of obstructive jaundice. Brit. J. Surg., 41: 27-31, 1953. SMAH.1', W. IC: Giant hydronepbrosis eausing eontrnlnteral hydronephrosis and obstrucfrve jaundice . .J. UroL, 67; 605..610, 1052. STEVENS, W. E, · Roentgenological examination of the kidney with special reference. to lrnckflm.v and injuries a.ssociated with retrogra.de pyelogrn.phy. J. (JroL, 39: 598-610. l[J:38. WEE.>1s, H. S. AND FL0RE:-1c1,;, T. J : The diagnosis of hydronephrosis by percutaneous renal rmueture, J, UroL, 72: 58\)-595, 1954. WrcKBmr, L: Pyelogrnphy a.her di reel puncture of the renal pelvis, Act,, Radiologica. 41: 505-512, H/54, AINSWORTH,