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Percutaneous Nephrostomy and Ureteral Injury
0022-5347 /81/1253-0298$02.00/0 Vol. 125, March
THE JOURNAL OF UROLOGY
Copyright © 1981 by The Williams & Wilkins Co.
Printed in U.S.A.
PERCUTANEOUS NEPHROSTOMY AND URETERAL INJURY LESTER PERSKY, NEHEMIA HAMPEL
AND
KAILASH KEDIA
From the Department of Surgery, Division of Urology, Case Western Reserve University School of Medicine and University Hospitals of Cleveland, Cleveland, Ohio
ABSTRACT
The courses of 6 patients with various forms of ureteral injury and disruption herein illustrate the value and worth of percutaneous nephrostomy drainage and study. The nature and degree of injury are ascertained, and sepsis and obstruction are managed without formal anesthesia or surgical intervention, leading to ultimate repair in a planned and orderly fashion. eter was 7 days and the longest was 18 days. Nephrostomy drainage was maintained from 7 days to 6 weeks.
Ureteral injury, although seen in increasing numbers in civilian practice as a consequence of external violence, still is most often a sequela to an operative misadventure. The retroperitoneal position of the ureter, the diminutive size of the tubular structure, and the adjacent and overlying vascular and visceral elements make such iatrogenic trauma overlooked easily. Therefore, the often late recognition of such mishaps at times sparked differences of opinion concerning management. One school of observers believed that, in the interest of avoiding troublesome edema, secondary hemorrhage, sepsis or failure of repair, a preliminary nephrostomy should be done when the ureteral obstruction or fistula was not found until the patient was well into the postoperative period. 1• 2 On the other hand, along with others, we have advocated immediate intervention as soon as the trouble was discerned with a direct approach to the operative site and an immediate attempt at reimplantation, primary anastomosis or whatever surgical therapeutic measure was necessary to assure continuity and renal salvage. 3 Recently, with the advent of ultrasound, fluoroscopy and computerized tomography scans, and with skillful, readily available percutaneous manipulation4 ' 5 we have modified this stance. Recently, 6 patients have been handled initially by such percutaneous passage of a catheter and preliminary temporary drainage with a subsequent direct attack on the primary probPt.-Age-Sex
Antecedent Operation
Clinical Manifestation
MS-78-F
Vaginal hysterectomy
Constant vaginal wetness
GF-33-F
Hysterectomy
Vaginal leakage of urine
RM-63-M
Cystectomy, ilea! loop
JW-58-F
Vaginal repair
SW-43-F
Pelvic laparotomy, endometriosis Pelvic laparotomy, Ca of colon with resection
Extravasation of urine, penile drainage of urine Postop. fever and flank pain Flank pain, fever, nonvisualization Urine leak from perineum
GG-61-M
DISCUSSION
The use of this technique has had several advantages. The exploitation of anterograde pyelography has permitted an exact localization of the site of injury as in case 2. This 33-year-old woman had vaginal leakage 1 week after a vaginal hysterectomy. Cystoscopic study failed to determine the exact site of urinary loss of control. However, a percutaneous anterograde study through the slightly dilated left collecting system showed filling of the vagina (fig. 1). Relief of obstruction and control of constant wetness also were afforded in cases 1, 3 and 6. In cases 4 and 5 sepsis was managed comfortably and readily with relief of spiking fever and subsidence of pain. Therefore, a deliberate, safe corrective procedure was afforded without need to perform a formal nephrostomy or use an anesthetic agent or other invasive techniques. Although cystoscopic study ultimately was accomplished in these patients it could be done at a leisurely time when fever and the clinical condition permitted a more deliberate, planned approach. The illustrative courses cited herein are only a small sample of the advantages afforded the urologist. The patient-physician relationship is strained less by hurried explanations, evasive
Percutaneous Value
Ultimate Course
Time of Delay
Length of Percutaneous Nephrostomy
Temporary control of wetness, demonstration of site of leak Demonstration of site of leak Demonstration of site, cessation of leakage
Reimplantation of ureter, dryness
2wks.
Reimplantation, dryness
7 days
Spontaneous correction of leakage
3 wks.
6wks.
Cessation of fever, relief of pain Relief of pain, fever
Reimplantation of ureter of kidney Reimplantation
17 days
10 days
10 days
7 days
Cessation of leakage, convalescence from operation
Transureteroureterostomy
18 days
12 days
lem and eventual repair. The courses of these patients are reviewed and the ultimate outcomes are summarized. MATERIALS AND METHODS
The o patients were seen at our hospitals and associated institutions. There were 4 women and 2 men (see table). Of the patients 2 had ureteral ligations, 3 had fistulas and 1 had an anastomotic failure. Patient age ranged from 33 to 78 years. The shortest interval before insertion of the percutaneous cathAccepted for publication July 18, 1980.
298
3wks.
Study only
platitudes and the affording of a more definitive intervention. Greater -dfagnostic acumen permits a more positive, secure relationship with the family and should afford less apprehension on all parts. The great value and benefits of the simple insertion of the percutaneous catheter are illustrated by case 5. This 78year-old woman had had an operation for procidentia and incontinence. Urine began to drain from the vagina in the immediate postoperative period. Excretory urography (IVP) revealed moderate hydronephrosis on the left side (fig. 2, A). A voiding cystourethrogram showed no extravasation (fig. 2, B). Attempts at cystoscopy were unsuccessful when obstruction··
PERCTJTA~TE'OD"S J>TEPHR,OSTOIVEY AND 1JRETE~RAL I1'-TJU"l:tY
299
FIG. 1. A, dilated left collecting system in 33-year-old woman with vaginal leakage of urine after vaginal hysterectomy. B, lateral view shows vaginal filling with contrast material after left anterograde pyelog:raphy.
FIG. 2. A, IVP shows hyd:ronephrosis on left side after vaginal repair to correct incontinence. B, cystogram shows no extravasation from bladder despite vaginal urinary leakage.
300
PERSKY, HAMPEL AND KEDIA
was met on the left side. However, left percutaneous nephrostomy demonstrated vaginal leakage with concomitant filling of the bladder (fig. 3). The placement of the tube afforded immediate relief from constant wetness. Finally, after several weeks without spontaneous healing reimplantation of the left ureter was done. Expert percutaneous efforts may help in other areas of ureteral injury, such as angulation and distortion owing to reperitonealization efforts. Continued decompression also may afford complete relief from the need for a further operation. The technique has helped us also in that we are now more secure in delaying an operation until we can be sure of the site, nature and extent of the offending injury. Previously, we advocated an early direct approach to the site of suspected harm. We now believe that, although such non-delay still is proper, we can use the percutaneous catheter with benefit to facilitate a more deliberate and accurate repair. REFERENCES 1. Kohler, F. P., Uhle, C. A. and MacKinney, C. C.: Urinary tract
2. 3. 4. 5. FIG. 3. Anterograde pyelogram through left kidney shows vaginal filling through left ureter.
injuries incidental to gynecologic procedures. Obst. Gynec., 28: 867, 1966. Everett, H. S. and Mattingley, R. F.: Urinary tract injuries resulting from pelvic surgery. Amer. J. Obst. Gynec., 71: 502, 1956. Herman, G., Guerrier, K. and Persky, L.: Delayed ureteral deligation. J. Urol., 107: 723, 1972. Pedersen, J. F.: Percutaneous nephrostomy guided by ultrasound. J. Urol., 112: 157, 1976. Stables, D. P., Ginsberg, N. J. and Johnson, M. L.: Percutaneous nephrostomy: a series and review of the literature. Amer. J. Roentgen., 130: 75, 1978.
THE JOURNAL OF UROLOGY
Copyright © 1981 by The Williams & Wilkins Co.
Printed in U.S.A.
PERCUTANEOUS NEPHROSTOMY AND URETERAL INJURY LESTER PERSKY, NEHEMIA HAMPEL
AND
KAILASH KEDIA
From the Department of Surgery, Division of Urology, Case Western Reserve University School of Medicine and University Hospitals of Cleveland, Cleveland, Ohio
ABSTRACT
The courses of 6 patients with various forms of ureteral injury and disruption herein illustrate the value and worth of percutaneous nephrostomy drainage and study. The nature and degree of injury are ascertained, and sepsis and obstruction are managed without formal anesthesia or surgical intervention, leading to ultimate repair in a planned and orderly fashion. eter was 7 days and the longest was 18 days. Nephrostomy drainage was maintained from 7 days to 6 weeks.
Ureteral injury, although seen in increasing numbers in civilian practice as a consequence of external violence, still is most often a sequela to an operative misadventure. The retroperitoneal position of the ureter, the diminutive size of the tubular structure, and the adjacent and overlying vascular and visceral elements make such iatrogenic trauma overlooked easily. Therefore, the often late recognition of such mishaps at times sparked differences of opinion concerning management. One school of observers believed that, in the interest of avoiding troublesome edema, secondary hemorrhage, sepsis or failure of repair, a preliminary nephrostomy should be done when the ureteral obstruction or fistula was not found until the patient was well into the postoperative period. 1• 2 On the other hand, along with others, we have advocated immediate intervention as soon as the trouble was discerned with a direct approach to the operative site and an immediate attempt at reimplantation, primary anastomosis or whatever surgical therapeutic measure was necessary to assure continuity and renal salvage. 3 Recently, with the advent of ultrasound, fluoroscopy and computerized tomography scans, and with skillful, readily available percutaneous manipulation4 ' 5 we have modified this stance. Recently, 6 patients have been handled initially by such percutaneous passage of a catheter and preliminary temporary drainage with a subsequent direct attack on the primary probPt.-Age-Sex
Antecedent Operation
Clinical Manifestation
MS-78-F
Vaginal hysterectomy
Constant vaginal wetness
GF-33-F
Hysterectomy
Vaginal leakage of urine
RM-63-M
Cystectomy, ilea! loop
JW-58-F
Vaginal repair
SW-43-F
Pelvic laparotomy, endometriosis Pelvic laparotomy, Ca of colon with resection
Extravasation of urine, penile drainage of urine Postop. fever and flank pain Flank pain, fever, nonvisualization Urine leak from perineum
GG-61-M
DISCUSSION
The use of this technique has had several advantages. The exploitation of anterograde pyelography has permitted an exact localization of the site of injury as in case 2. This 33-year-old woman had vaginal leakage 1 week after a vaginal hysterectomy. Cystoscopic study failed to determine the exact site of urinary loss of control. However, a percutaneous anterograde study through the slightly dilated left collecting system showed filling of the vagina (fig. 1). Relief of obstruction and control of constant wetness also were afforded in cases 1, 3 and 6. In cases 4 and 5 sepsis was managed comfortably and readily with relief of spiking fever and subsidence of pain. Therefore, a deliberate, safe corrective procedure was afforded without need to perform a formal nephrostomy or use an anesthetic agent or other invasive techniques. Although cystoscopic study ultimately was accomplished in these patients it could be done at a leisurely time when fever and the clinical condition permitted a more deliberate, planned approach. The illustrative courses cited herein are only a small sample of the advantages afforded the urologist. The patient-physician relationship is strained less by hurried explanations, evasive
Percutaneous Value
Ultimate Course
Time of Delay
Length of Percutaneous Nephrostomy
Temporary control of wetness, demonstration of site of leak Demonstration of site of leak Demonstration of site, cessation of leakage
Reimplantation of ureter, dryness
2wks.
Reimplantation, dryness
7 days
Spontaneous correction of leakage
3 wks.
6wks.
Cessation of fever, relief of pain Relief of pain, fever
Reimplantation of ureter of kidney Reimplantation
17 days
10 days
10 days
7 days
Cessation of leakage, convalescence from operation
Transureteroureterostomy
18 days
12 days
lem and eventual repair. The courses of these patients are reviewed and the ultimate outcomes are summarized. MATERIALS AND METHODS
The o patients were seen at our hospitals and associated institutions. There were 4 women and 2 men (see table). Of the patients 2 had ureteral ligations, 3 had fistulas and 1 had an anastomotic failure. Patient age ranged from 33 to 78 years. The shortest interval before insertion of the percutaneous cathAccepted for publication July 18, 1980.
298
3wks.
Study only
platitudes and the affording of a more definitive intervention. Greater -dfagnostic acumen permits a more positive, secure relationship with the family and should afford less apprehension on all parts. The great value and benefits of the simple insertion of the percutaneous catheter are illustrated by case 5. This 78year-old woman had had an operation for procidentia and incontinence. Urine began to drain from the vagina in the immediate postoperative period. Excretory urography (IVP) revealed moderate hydronephrosis on the left side (fig. 2, A). A voiding cystourethrogram showed no extravasation (fig. 2, B). Attempts at cystoscopy were unsuccessful when obstruction··
PERCTJTA~TE'OD"S J>TEPHR,OSTOIVEY AND 1JRETE~RAL I1'-TJU"l:tY
299
FIG. 1. A, dilated left collecting system in 33-year-old woman with vaginal leakage of urine after vaginal hysterectomy. B, lateral view shows vaginal filling with contrast material after left anterograde pyelog:raphy.
FIG. 2. A, IVP shows hyd:ronephrosis on left side after vaginal repair to correct incontinence. B, cystogram shows no extravasation from bladder despite vaginal urinary leakage.
300
PERSKY, HAMPEL AND KEDIA
was met on the left side. However, left percutaneous nephrostomy demonstrated vaginal leakage with concomitant filling of the bladder (fig. 3). The placement of the tube afforded immediate relief from constant wetness. Finally, after several weeks without spontaneous healing reimplantation of the left ureter was done. Expert percutaneous efforts may help in other areas of ureteral injury, such as angulation and distortion owing to reperitonealization efforts. Continued decompression also may afford complete relief from the need for a further operation. The technique has helped us also in that we are now more secure in delaying an operation until we can be sure of the site, nature and extent of the offending injury. Previously, we advocated an early direct approach to the site of suspected harm. We now believe that, although such non-delay still is proper, we can use the percutaneous catheter with benefit to facilitate a more deliberate and accurate repair. REFERENCES 1. Kohler, F. P., Uhle, C. A. and MacKinney, C. C.: Urinary tract
2. 3. 4. 5. FIG. 3. Anterograde pyelogram through left kidney shows vaginal filling through left ureter.
injuries incidental to gynecologic procedures. Obst. Gynec., 28: 867, 1966. Everett, H. S. and Mattingley, R. F.: Urinary tract injuries resulting from pelvic surgery. Amer. J. Obst. Gynec., 71: 502, 1956. Herman, G., Guerrier, K. and Persky, L.: Delayed ureteral deligation. J. Urol., 107: 723, 1972. Pedersen, J. F.: Percutaneous nephrostomy guided by ultrasound. J. Urol., 112: 157, 1976. Stables, D. P., Ginsberg, N. J. and Johnson, M. L.: Percutaneous nephrostomy: a series and review of the literature. Amer. J. Roentgen., 130: 75, 1978.