Percutaneous Nephrostomy with Immediate Dilation

0022-534 7/81/1252-0169$02.00/0 Vol. 125, February Printed in U.S. A.

THE JOURNAL OF UROLOGY

Copyright© 1981 by The Williams & Wilkins Co.

PERCUTANEOUS NEPHROSTOMY WITH IMMEDIATE DILATION WALTER L. GERBER,* ROBERT C. BROWN

AND

DAVID A. CULP

From the Departments of Urology and Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa

ABSTRACT

Percutaneous nephrostomy may serve as an alternative to an open operation for urinary diversion. Difficulties with poor drainage and premature catheter dislodgement have prompted the development of a technique for dilation of the needle tract and placement of a large, self-retaining catheter at the time of the initial puncture. Ureteral obstruction often is treated by open surgical diversion, especially if a catheter cannot be passed in a retrograde fashion. In some situations, such as after a ureterosigmoid anastomosis, this procedure cannot or should not even be attempted. Percutaneous nephrostomy provides a viable alternative to the formal placement of a nephrostomy tube. With this technique a needle is passed directly through the skin, the soft tissue structures of the flank and the renal parenchyma into the collecting system. A more permanent drainage device then is exchanged over a guide wire for the needle. The concept was described first in 1955 by Goodwin and associates 1 but only now is it achieving acceptance. With the adaptation of sophisticated angiography skills this approach to urinary diversion is coming into more widespread usage and has decreased the indications for a major operation. The indications for percutaneous nephrostomy include 1) urinary tract obstruction (inability to pass a retrograde catheter, previous diversion, for example ureterosigmoidostomy, obstruction in a male newborn, patient, too ill to undergo an operation and delay to improve patient for an operation), 2) irrigation of the renal pelvis and 3) diagnosis (that is anterograde and/or pressure studies). Unfortunately, percutaneous drainage has had several drawbacks, including obstruction of the catheter, premature dislodgement, hemorrhage, extravasation and urinoma, and infection. The lumen of the typical BF angiography catheter is only 1 mm. Fluid may enter through multiple holes but each is <1.0 mm. in diameter. Pus and/or numerous small calculi are not the contraindications they once were believed to be 1 but they may plug the tube and have a role in limiting its functional life span. In addition, one of the most frequent complications of this approach is premature dislodgement of the catheter after an obstruction has been relieved. 2- 4 A urinoma around the kidney may result. This occurrence engendered the concept that only temporary diversion should be attempted. Modification of the nephrostomy tube to give a pigtail shape has decreased but by no means eliminated this difficulty since heavy reliance is made on a skin suture to keep the system in place. 5 To overcome these problems of small lumen and early dislodgement we have developed a procedure that allows for the insertion at the time of the initial percutaneous puncture of a retention catheter as large as I6F. This catheter is constructed of polyvinyl chloridet with an internal diameter of 3.9 mm., 3 elliptical side holes 2.2 X 5.0 mm. each and an end hole 2.5 mm. in diameter. There is a third lumen for irrigation purposes. A 12F size also is available if needed. MATERIALS AND METHODS

We have made several modifications of the usual percutaAccepted for publication June 17, 1980. * Requests for reprints: Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242. t Argyle Ingram Trocar Catheter, Sherwood Medical Industries, St. Louis, Missouri. 169

neous techniques. First, special dilators are needed to enlarge the passage through the fascia. These dilators extend to a size slightly greater than the external diameter of the catheter to be used. This is a standard practice for urologists performing urethral dilation. Initially, we fashioned our own dilators from woven-wax Philips followers. We have described their fabrication previously. 6 These dilators were effective but more tapered dilators presently are available commercially.* The use of these dilators for insertions of small balloon catheters has been reported previously.7· 8 However, these dilators are not sufficient by themselves to ensure an easy progression from a temporary percutaneous puncture to a more permanent one. The second innovation has been to stiffen the plastic catheter by immersion in ice water in much the same fashion that many practitioners stiffen nasogastric tubes before passing them. We obtain sterile ice from our operating suite, and immersion of the catheter for several minutes makes it sufficiently rigid to ease its passage through the flank. Of course, the catheter warms up and loses its stiffness rapidly. In some instances obstruction at the fascial level is not overcome by the use of dilators. It may be caused by the relatively blunt shape of the plastic catheter compared to the dilators. In these cases an additional modification is used. The stiffened catheter is pre-loaded onto a 60 cm. translumbar aortography arch needle* and the whole assembly is passed over the guide wire and into the kidney. The wire and needle can be withdrawn without difficulty. The translumbar aortography arch needle imparts sufficient stiffness to overcome even large amounts of resistance. Of course, care must be taken not to advance the sharp-pointed needle too far beyond the fascia; the guide wire makes injury unlikely but the extreme length of the needle always makes us apprehensive. Several precautions are in order. The catheter comes with a wide disk or plate to anchor it to the skin. In obese patients this disk must be removed to create sufficient length to reach the renal pelvis. The plate should be incised sharply with a scalpel from its lateral edge. If attempts are made to remove it merely by pulling it off an injury to the retention balloon may ensue. Also, the balloon is relatively rigid compared to that on the usual latex urethral catheter and it must not be overfilled. Two to 3 cc are the maximum that can be instilled safely, even though the balloon is labeled as 5 cc in capacity. A small gauge needle should be used for this purpose since a large one may damage the valve mechanism. PATIENT POPULATION

Between July 1977 and March 1980, 46 patients at our hospitals and clinics required nephrostomy drainage. There were 26 male and 20 female patients with an average age of 54.4 years (range 18 days to 79 years). The diversion was secondary to cancer in 24 patients (52 per cent) and stones in 13 (28 per cent), congenital in 5 (11 per cent) and miscellaneous

*Cook, Inc., Bloomington, Indiana.

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GERBER, BROWN AND CULP

in 4 (9 per cent) (tables 1 and 2). Most of the patients with calculi had the tubes placed at the time of the stone removal operation and not merely for relief of obstruction. The miscellaneous cases included 2 patients with neurogenic bladders, 1 with trauma to a solitary hydronephrotic kidney and 1 with ureteral obstruction after an aortoiliac bypass operation. As we would expect, malignancies of the prostate, cervix and bladder were the most common offenders (table 2). In 34 patients loop nephrostomies were placed at an open operation. Bilateral drainage was done in 5 patients. Silicone tubes were used: size 16F in adults and 12F in children. Percutaneous nephrostomies were inserted in 12 patients (bilateral in 1). In 4 patients only temporary drainage was planned and fascial dilation was done to the standard SF size. However, in 5 cases more permanent drainage was desired and the tract was dilated to allow insertion of our larger plastic retention catheters. In 3 additional cases our initial estimates about the projected length of diversion were incorrect and later dilation of the tract was done easily. CASE REPORTS

Case 1. S.S., a 27-year-old white woman with meningomyelocele and neurogenic bladder, and on chronic catheter drainage suffered the sudden onset of fever, right flank pain and gross, total, painless hematuria. Because of decreased renal function a blocking ureterogram was done, which showed filling defects consistent with clots along with ureteritis and pyelitis cystica severe enough to have caused obstruction at the ureteropelvic junction. A percutaneous nephrostomy was placed under fluoroscopic control. The patient did well with resolution of the pain, fever and hematuria. The nephrostomy tube was changed once without difficulty. The tube plugged 2 months later and attempts to replace it were unsuccessful. The patient underwent placement of a loop nephrostomy and has done well. This case illustrates several points. Hematuria, even with clots, is not a contraindication to the use of percutaneous nephrostomy. This patient had the nephrostomy done when we had not yet developed our techniques for immediate dilation. Perhaps this would have saved her from an open surgical procedure. Case 2. A. B., a 48-year-old white woman, had undergone total abdominal hysterectomy, bilateral salpingo-oophorectomy, and internal radium implantation for carcinoma of the cervix 13 years previously. The patient was followed for right hydronephrosis, which worsened progressively, but she did well until episodes of fever associated with right flank pain developed. She was treated with antibiotics several times but had prompt return of symptoms when the drugs were stopped. An excretory urogram (IVP) showed obstruction at the ureterovesical junction and a catheter could not be passed from below. A right percutaneous nephrostomy with immediate dilation was done, allowing the insertion of a 16F retention catheter. The symptoms resolved and the patient subsequently was explored. No evidence of tumor recurrence was found and a right-to-left transureteroureterostomy was done (frozen sections showed no evidence of radiation changes in the right ureteral end). The nephrostomy was clamped later when free flow through the anastomosis could be demonstrated. The tube was removed later when residuals in the renal pelvis were measured at 10 cc. This case illustrates the use of the percutaneous nephrostomy in allowing patients to improve their condition before an operation. Had tumor recurrence been proved an adequate method of drainage of the kidney would already have been provided. Case 3. J. H., a 42-year-old white woman with renovascular hypertension, underwent a saphenous vein graft. The patient returned 1 month postoperatively with right flank pain and fever. Blood pressure was normal. An IVP showed only a nephrogram on the right side with delayed films demonstrating an obstruction at the ureteropelvic junction. A double pigtail Cook catheter was passed up to the renal pelvis. The fever

TABLE

1. Reasons for diversion No.(%)

Ca Stones Congenital Miscellaneous

24 (52) 13 (28) 5 (11) 4 (9)

TABLE

2. Cancer obstruction No.

Prostate Cervix Bladder Colon Ovary Stomach

8 6 5 3

1 1

defervesced and the pain disappeared rapidly. Review of the preoperative IVP showed no evidence of a congenital ureteropelvic junction obstruction. The patient was rehospitalized several weeks later for a return of the symptoms and again was found to have an obstructed kidney despite good positioning of the indwelling ureteral stent. A right percutaneous nephrostomy was placed without difficulty using ultrasound guidance. Subsequent anterograde studies failed to show transport through the ureteropelvic junction. It originally was believed that the ureteral obstruction was secondary to edema from the original vascular operation and dilation was not done. However, no transport into the ureter was found even after 3 months. It was believed that repair of the ureteropelvic junction should not be undertaken immediately and the tube tract was dilated easily to allow the insertion of a 16F retention catheter. This catheter subsequently has been exchanged for an 18F Counciltip catheter without the need for further dilation. This case illustrates the main drawback with the use of the indwelling ureteral stents: retrograde studies cannot be done. A cystogram might have shown reflux through the catheter since it was found to be patent when removed 2 days after the percutaneous nephrostomy was placed. RESULTS

There were no failures of insertion or complications noted in any of the patients. Several patients had small amounts of hematuria, which cleared rapidly within a matter of hours. In 1 individual the retention balloon deflated spontaneously and the tube fell out, leaving a draining sinus. The patient did not return to the hospital for several days and he required an open nephrostomy, since the renal collecting system was no longer dilated sufficiently to allow for a safe percutaneous puncture. This case emphasizes the necessity for gentle handling of the argyle plastic catheter. We believe that our modifications of the standard percutaneous nephrostomy techniques allow for the insertion of a large, self-retaining catheter directly into a dilated renal collecting system without the need for an open operation. Limitations owing to obstruction or premature loss of the tube should no longer be a problem. Of our patients 25 per cent were spared an open operation by the percutaneous approach and 8 of these had more or less permanent drainage established in this fashion. REFERENCES 1. Goodwin, W. E., Casey, W. C. and Woolf, W.: Percutaneous trocar

(needle) nephrostomy in hydronephrosis. J.A.M.A., 157: 891, 1955. 2. Fowler, J. E., Meares, E. M., Jr. and Goldin, A. R.: Percutaneous nephrostomy: techniques, indications and results. Urology, 6: 428, 1975. 3. Barbaric, Z. L. and Wood, B. P.: Emergency percutaneous nephropyelostomy: experience with 34 patients and review of the literature. Amer. J. Roentgen., 128: 453, 1977. 4. Stables, D. P., Holt, S. A., Sheridan, H. M. and Donohue, R. E.:

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Permanent nephrostomy via percutaneous puncture. J. Urol., 114: 684, 1975. 5. Perinetti, E., Catalona, W. J., Manley, C. B., Geise, G. and Fair, W.: Percutaneous nephrostomy: indications, complications and clinical usefulness. J. Urol., 120: 156, 1978. 6. Gerber, W. L., Brown, R. C. and Barnhart, B.: Percutaneous ne-

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phrostomy. Letter to the Editor. J. Urol., 120: 387, 1978. 7. Burnett, L. L., Correa, R. J. and Bush, W. H.: A new method for percutaneous nephrostomy. Radiology, 120: 557, 1976. 8. 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.