- Email: [email protected]
Percutaneous Anterior Ureterostomy for Double J Ureteral Stent Placement in an 18-Month-Old Patient
EXTREME IR
Percutaneous Anterior Ureterostomy for Double J Ureteral Stent Placement in an 18-Month-Old Patient Christopher Yen, MD, Kamlesh Kukreja, MD, and Chester Koh, MD An 18-month-old boy presented with tachycardia and purulent drainage from a vesicostomy stoma. He had a prior history of obstructive uropathy from posterior urethral valves, with complications including end-stage renal disease and recent multidrug-resistant Escherichia coli bacteremia. Ultrasound demonstrated new layering debris in a severely dilated right ureter suggesting pyoureter and unchanged bilateral atrophic kidneys with nondilated pelves (Figs 1, 2). Urine culture was positive for Stenotrophomonas maltophilia. Right ureterovesical junction stenosis prevented cystoscopic stent placement, and percutaneous urinary decompression was required. Nephrostomy access was not possible because of the nondilated renal pelvis in an atrophic kidney. An anterior direct ureteral approach was chosen. With the patient in supine position and under general anesthesia, an 18-gauge needle was used to access the dilated distal right ureter with ultrasound guidance (Figs 3, 4). A 0.035-inch Glidewire (Terumo Medical Corp, Somerset, New Jersey) was maneuvered past the distal obstruction, into the bladder, and through the vesicostomy to obtain through-and-through access (Fig 5). A 4-F sheath (Cook, Inc, Bloomington,
Indiana) was advanced in retrograde fashion from the vesicostomy into the distal ureter. An 0.018-inch Cope wire (Cook, Inc) was advanced to the proximal ureter via the sheath. After a series of exchanges (Fig 6), a 6-F, 12-cm double J ureteral stent (Cook, Inc) was placed into the proximal ureter via the vesicostomy access (Fig 7). After successful decompression and intravenous antibiotics, tachycardia and pyuria resolved, and repeat urine culture was negative. Future bilateral nephroureterectomies are planned.
Figure 2. Dilated distal right ureter with layering debris (arrow).
Figure 1. Atrophic right kidney with nondilated pelvicalyceal system (arrow) and dilated right ureter inferior to kidney (star).
From the Department of Radiology, Texas Children’s Hospital, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030. Received December 1, 2016; final revision received January 4, 2017; accepted January 30, 2017. Address correspondence to K.K.; E-mail: [email protected] None of the authors have identified a conflict of interest. © SIR, 2017 J Vasc Interv Radiol 2017; 28:1034–1035 http://dx.doi.org/10.1016/j.jvir.2017.01.019
Figure 3. Needle (arrow) accessing dilated right ureter via anterior approach.
Volume 28 ▪ Number 7 ▪ July ▪ 2017
1035
Figure 6. Percutaneous ureterostomy wire (white arrow) and another wire placed from vesicostomy into proximal ureter (black arrow).
Figure 4. Needle in dilated right ureter without antegrade flow of contrast material into bladder due to ureterovesical junction stenosis (arrow).
Figure 5. Through-and-through access with 0.035-inch wire from percutaneous ureterostomy (white arrow) and out through vesicostomy site (black arrow).
Figure 7. Double J ureteral stent successfully placed in right ureter, cephalic end (black arrow) and caudal end (white arrow).
Percutaneous Anterior Ureterostomy for Double J Ureteral Stent Placement in an 18-Month-Old Patient Christopher Yen, MD, Kamlesh Kukreja, MD, and Chester Koh, MD An 18-month-old boy presented with tachycardia and purulent drainage from a vesicostomy stoma. He had a prior history of obstructive uropathy from posterior urethral valves, with complications including end-stage renal disease and recent multidrug-resistant Escherichia coli bacteremia. Ultrasound demonstrated new layering debris in a severely dilated right ureter suggesting pyoureter and unchanged bilateral atrophic kidneys with nondilated pelves (Figs 1, 2). Urine culture was positive for Stenotrophomonas maltophilia. Right ureterovesical junction stenosis prevented cystoscopic stent placement, and percutaneous urinary decompression was required. Nephrostomy access was not possible because of the nondilated renal pelvis in an atrophic kidney. An anterior direct ureteral approach was chosen. With the patient in supine position and under general anesthesia, an 18-gauge needle was used to access the dilated distal right ureter with ultrasound guidance (Figs 3, 4). A 0.035-inch Glidewire (Terumo Medical Corp, Somerset, New Jersey) was maneuvered past the distal obstruction, into the bladder, and through the vesicostomy to obtain through-and-through access (Fig 5). A 4-F sheath (Cook, Inc, Bloomington,
Indiana) was advanced in retrograde fashion from the vesicostomy into the distal ureter. An 0.018-inch Cope wire (Cook, Inc) was advanced to the proximal ureter via the sheath. After a series of exchanges (Fig 6), a 6-F, 12-cm double J ureteral stent (Cook, Inc) was placed into the proximal ureter via the vesicostomy access (Fig 7). After successful decompression and intravenous antibiotics, tachycardia and pyuria resolved, and repeat urine culture was negative. Future bilateral nephroureterectomies are planned.
Figure 2. Dilated distal right ureter with layering debris (arrow).
Figure 1. Atrophic right kidney with nondilated pelvicalyceal system (arrow) and dilated right ureter inferior to kidney (star).
From the Department of Radiology, Texas Children’s Hospital, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030. Received December 1, 2016; final revision received January 4, 2017; accepted January 30, 2017. Address correspondence to K.K.; E-mail: [email protected] None of the authors have identified a conflict of interest. © SIR, 2017 J Vasc Interv Radiol 2017; 28:1034–1035 http://dx.doi.org/10.1016/j.jvir.2017.01.019
Figure 3. Needle (arrow) accessing dilated right ureter via anterior approach.
Volume 28 ▪ Number 7 ▪ July ▪ 2017
1035
Figure 6. Percutaneous ureterostomy wire (white arrow) and another wire placed from vesicostomy into proximal ureter (black arrow).
Figure 4. Needle in dilated right ureter without antegrade flow of contrast material into bladder due to ureterovesical junction stenosis (arrow).
Figure 5. Through-and-through access with 0.035-inch wire from percutaneous ureterostomy (white arrow) and out through vesicostomy site (black arrow).
Figure 7. Double J ureteral stent successfully placed in right ureter, cephalic end (black arrow) and caudal end (white arrow).