Renal diversion with silicone circle catheters

RENAL

DIVERSION

SILICONE

CIRCLE

N. K. BISSADA,

M.D.

A. T. COLE, F. A. FRIED,

WITH CATHETERS

M.D. M.D.

From the Department of Surgery, Division of Urology, University of North Carolina School of Medicine, Chapel Hill, North Carolina

ABSTRACT-At North Carolina Memorial Hospital, circle nephrostomy tubes in twenty-one patients. In jive major complications, two delayed hemorrhages included. Over-all, our experience with this form of and patient mobility and comfort are less frequent,

we have carried out renal diversion with silicone our series there was one postoperative death and and three catheter losses. A discussion of each is diversion has been gratifying. Tube changes are increased.

The institution of renal diversion is often a lifesaving procedure. Unfortunately, the conventional nephrostomy tube has proved unsatisfactory because of the frequency with which it becomes obstructed or pulled out. Satisfactory repositioning may be difficult or impossible if there is delay, and surgery may be required. We have found circle tube renal diversion superior to conventional nephrostomy because of the decreased frequency and ease of tube changes and the diminished chance of tube loss. The first use of this method is credited to Wenzel in 195O.l Since that time, it has been utilized by many urologists with good results.2-6 At North Carolina Memorial Hospital, we have carried out renal diversion in 21 patients utilizing silicone circle tubes. Although our results have also been favorable, there have been complications. The following is a report of our experience.

*Available as Silastic brand medical grade tubing, made by Dow Corning Corporation, Medical Products Division, Midland, Michigan 48640.

pairs of holes are punched in the center 3 cm. of the tube utilizing a leather punch. It is important that the holes be punched rather than cut with scissors, since with silicone tubing jagged edges are prone to tear. Polypropylene Yconnectors of suitable sizes are available to fit the various diameters of the silicone tubes. Recently we have been securing the tubes by sliding a silicone flange flush with the skin on each limb of the catheter. These flanges are easily made by cutting one-half inch segments of larger tubing (Fig. 1). Both silicone tubing and polypropylene connectors can be sterilized by autoclaving. The kidney and upper ureter are exposed through a standard flank incision, and the renal pelvis is opened. A stone forceps is passed through a convenient calyx, an incision is made in the capsule over the tip of the forceps, and the selected tube is grasped by the forceps and guided into the renal pelvis. It is then possible to bring the tube out through a second nephrotomy (Fig. 2A), the pyelotomy (Fig. 2B), or a more distal ureterotomy (Fig. 2C). On rare occasions, both openings may be in the renal pelvis (Fig. 2D). Acute angulation of the tube should be avoided by careful selection of the path through the collecting system. Complete diversion of urine can be obtained by ligating the ureter distal to the point of exit of the circle tube.

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Material

and Techniques

The material and techniques used are similar to those of other authors.5 Silicone tubing* has been used in all patients.7 This tubing is available in ten-foot coils in a variety of sizes. Sixtycm. lengths of tubing are cut, and three to four

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serum creatinine was 10.4 mg. - -per 100 ml. A drip infusion pyelogram demonstrated a left staghorn calculus and right hydronephrosis (Fig. 3A). A right retrograde pyelogram revealed obstruction at the ureteropelvic junction with pyonephrosis. A ureteral catheter was left indwelling. On July 10, 1972, the patient underwent right ureteropelvic Congenital flank exploration. junction obstruction was found with secondary pyonephrosis and perinephric abscess formation. A silastic nephropyelostomy tube was placed. Postoperatively the blood urea nitrogen fell to I4 mg. and the serum creatinine to I.2 mg. per 100 ml. A follow-up intravenous pyelogram showed the tube in good position (Fig. 3B). At a routine clinic visit after hospital discharge, the circleTtube was not functioning. Tube injection and retrograde pyelogram revealed an intact circle tube located in the subcutaneous tissues no longer in continuity with the renal collecting system (Fig. 4A and B). The patient recalled that she had a transient episode of gross hematuria from the tube and bladder associated with mild pain more than a week prior to her clinic appointment. We assume that during that episode, the catheter had eroded through the renal collecting system which then healed spontaneously. The patient, although asymptomatic, was admitted to the hospital for observaFIGURE

Appearance of circle tube. Arrows used to secure position of tube.

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cate jlanges

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Case

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In the last two years we have used this form of diversion for a variety of clinical situations (Table I). In our series five major complications have occurred and are briefly presented.

A sixty-seven-year-old woman was admitted to North Carolina Memorial Hospital on July 5, 1972, with a five-day history of nausea, vomiting, and abdominal pain on the right side. Physical examination demonstrated right flank tenderness. On admission her temperature was 102.4”F., and the white blood cell count was 13,000 (93 per cent polymorphonuclear leukocytes). Microscopic examination of the unspun urine showed 50 white blood cells per highpower field. Urine cultures were obtained growing Escherichia coli and Proteus mirabilis, and the patient was started on appropriate antibiotics. Blood urea nitrogen was 120 mg. and the

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/7

*;y ,

A

Case 1

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I

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Nephronephrostomy

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Nephropyelostomy

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Nephroureterostomy FIGURE

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Pyelopyelostomy

Types of diversion.

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FIGURE 3. Case 1. (A) Drip infusion p yelogram demonstrating left staghorn calculus and right hydronephrosis. (B) Postoperative intravenous pyelogram showing circle tube in position.

tion. Renal function studies were unchanged, and she was discharged to be followed in the clinic. Case 2 A one-month-old male infant was admitted to the hospital for evaluation of weight loss, anorexia, ascites, and azotemia. The blood urea nitrogen on admission was 85 mg. per 100 ml.; a urine culture grew Klebsiella and Proteus. An excretory pyelogram failed to visualize the collecting system. Attempts at passing a urethral catheter were unsuccessful. A voiding cystourethrogram, obtained after suprapubic tube insertion, showed posterior urethral valves and reflux up the right ureter. Following suprapubic tube diversion, hydronephrosis continued to

TABLE

1.

progress, and bilateral nephropyelostomies were done at one year of age at another hospital. He did well postoperatively and was referred for follow-up to our urology clinic. The blood urea nitrogen returned to normal. One year later the right circle tube was accidentally separated from the Y-connectors, and the catheter came out. Attempts at reinsertion of the circle tube under fluoroscopic control were unsuccessful. However, it was possible to establish simple nephrostomy drainage. Case 3 A forty-three-yrear-old renal disease underwent plantation on August 10, cedure, a branch of the

Indications

for operation

Indications

Number of Patients

Malignant diseases Carcinoma of the cervix Bilateral ureteral obstruction Vesicovaginal fistula Carcinoma of the prostate Bilateral ureteral obstruction Urinary extravasation after renal transplantation Stone disease Nonfunctioning contralateral kidney Staghorn calculus Multiple renal stones Ureteropelvic junction obstruction Ureteral calculus (following prior ureterosigmoidostomy) Functioning contralateral kidney Bilateral stone disease (circle tube on side with staghorn calculus) Recurrent multiple renal stones Congenital Posterior urethral valves (marked bilateral hydroureteronephrosis) Neurogenic bladder Post ileal loop diversion with stenosis at ureteroileal anastomosis with progressive hydronephrosis Post transureteroureterostomy with progressive hydronephrosis

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man with end-stage cadaveric renal trans1972. During the prorenal artery supplying

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FIGURE 4. Casel.(A) Tube injection showing sinus tract (black arrow) from circle tube (white arrow) to perinephric space. (B) Retrograde p yelogram demonstrating intact collecting system no longer in continuity with circle tube (white arrow).

the lower pole was found to be transected. An end-to-end repair of the lower pole artery was performed. Seven days after transplantation the urine output suddenly stopped. An intravenous pyelogram demonstrated extravasation. The incision was opened, and the lower pole of the kidney was found to be infarcted. The infarcted portion of the kidney was resected, and the calyceal system was carefully closed. The patient did well for the next ten days when extravasation again occurred. Because the transplant was functioning well, it was decided to divert the urine with a nephropyelostomy tube. Seventeen days after this procedure the tube tore at the site of the punched holes. Attempts at reinsertion of the circle tube were unsuccessful, and a simple nephrostomy tube was placed. The patient is now doing well eight months post transplantation. Case

4

Comment Procedures

A fifty-one-year-old woman with a past history of cancer of the cervix treated with radiotherapy was admitted to the urology service with a twoday history of anuria. In October, 1972, two months prior to admission, an intravenous pyelogram showed a nonfunctioning right kidney. A left nephroureterostomy was done. The postoperative course was uneventful, and she was discharged on the eighth postoperative day. One month later severe hematuria developed, and she was readmitted and managed with bed rest, blood transfusions, antibiotics, and epsilon aminocaproic acid. The bleeding subsided, and she was discharged on January 10, 1973, to be followed in the clinic, Case 5 A thirty-eight-year-old woman, with a past history of cancer of the cervix treated with radiotherapy, was admitted to a local hospital with hematuria and azotemia. A provisional diagnosis

UROLOGY

of radiation cystitis was made. Atteml?l’:; ar cystoscopy resulted in perforation of the damaged bladder wall, and a suprapubic cystostomy wa,~j performed. The patient continued to have severe hematuria and was transferred to North Carolina Memorial Hospital in November, 1970. Excretory pyelography demonstrated a nonfunctioning right kidney and left hydrometer and hydronephrosis. At operation a left nephroureterostomy tube was placed, and the distal ureter was ligated. Postoperatively she continued to bleed through the suprapubic cystostomy, but her course was further complicated by severe bleeding from the silicone circle tube on the third postoperative day. Despite attempts at fluid replacement and the use of epsilon aminocanroic acid, the patient went into shock and died.

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The silicone circle tube has proved useful for temporary and permanent diversion. Twentyfour procedures have been done at our hospital in twenty-one patients. Nine patients have had a nephropyelostomy. The advantages of this procedure include ease of performance and the need for only minimal renal and ureteral exposure. Its main disadvantage is increased drainage from the pyelostomy site in the immediate postoperative period. However, after the fistulous tract is well formed, the diversion functions satisfactorily. Nine patients have had nephroureterostomies. This procedure is preferable for permanent diversion because the ureter, after being divided distally, can be brought to the skin. This results in decreased postoperative drainage and facilitates tube changes. One disadvantage of nephroureterostomy is the limited tube size initially imposed by the ureteral caliber. However, it has proved possible to increase the diameter of

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FIGURE 5. {A)Preoperative retrograde pyelogram demonstrating obstruction from matrix stone. (B) Postoperative nephroureterostomy tube injection showing acute angulation (arrow) of ureter. (C) Intravenous pyelogram following circle tube removal showing adequate ureteral emptying.

the tube gradually at successive changes without problems. A theoretic tiisadvantage is the ureteral angulation occurring when using this procedure for temporary diversion (Fig. 5A and B). Fortunately, upon tube removal, it is our experience that the calyceal system empties adequately (Fig. 5C). Two patients have had nephronephrostomies. The second nephrotomy lengthens the operation and causes additional parer ichymal destruction and greater blood loss. However, the procedure provides more thorough cal? teal irrigation postoperatively in patients with 1ecurrent or residual nephrolithiasis. One patient underwent py elopyelostomy. This procedure proved unsatisfactory and has been abandoned. Tube drainage after initial pelvic decompression is prevented by the collapsed renal pelvis. Tube changes have been done every three to six months. The average period between changes in our experience is four nlonths. One patient, who was lost to follow-up for nine months, returned to our urology clinic with an adequately functioning circle tube. Mortality

incidence

One postoperative deatll occurred (Case 5), and 1 patient died later frolrn progressive carcinoma of the prostate with superimposed chronic renal disease.

operative course is not a reflection on the operative procedure. Rather it illustrates the poor general condition of the patient population. Several patients remained in the hospital for purposes of dissolving residual calculi which could not be entirely removed at the time of surgery. Others required further treatment of the underlying disease such as irradiation. In uncomplicated cases, patients were usually ready for discharge by the eighth postoperative day. Blood loss. The average estimated blood loss was 475 ml. This high figure is due to associated procedures such as pyelolithectomy and nephrolithectomy. Low-grade temperature elevations Feuer. were frequently observed during the immediate postoperative period. Although many of the patients had chronically infected urinary tracts, there were no incidents of septicemic shock. Dermatitis. Three patients had pro’blems with inflammatory skin lesions adjacent to the catheters. These responded promptly to local applications of zinc oxide ointment. It is interesting that this problem occurred in patients with pyelotomies (nephropyelostomies, 2, pyelopyelostomies, 1).

Complications-major

Prolonged hospitalization. In our group of patients the average post< Ipcrative hospitalization was thirty-one days. The lengthy post-

Hemorrhage. Significant episodes of delayed hemorrhage developed in 2 patients requiring transfusion and treatment with epsilon aminocaproic acid. One of these patients accounted for our sole postoperative death. We believe that this problem may result from erosion of the renal parenchyma by the tube. Prevention of this com-

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Complications-minor

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plication depends on avoidance of acute angulation by the catheter as it courses through the collecting system. The drainage holes must be smooth so as not to abrade the renal parenchyma. Movement of the silicone catheter can be minimized by using flanges (Fig. 1).

Catheter loss. In three instances the circle catheters inadvertently fell out of the patient. In 1 case this was due to tearing of the catheter at the site of a drainage hole. This flaw could have been detected by stretching the tube prior to use. In the 2 other cases, the tube slipped off the Y-connector. This is preventable by using tight-fitting connectors and the flanges. Although in our experience circle catheters are more secure than conventional nephrostomy tubes, discussion with both the patient and those responsible for him concerning tube care is important. Unfortunately, once the circle tube comes out of the collecting system, it has not been possible to replace it. This has been unsuccessfully attempted with image monitoring. Fortunately, it is usually a simple matter to introduce a latex catheter and obtain a conventional nephrostomy. Summary Our experience over the last two years with silicone circle nephrostomy tube drainage is presented. Twenty-one patients underwent twenty-four such diversions (nephronephrostomy, nephropyelostomy, nephroureterostomy, and pyelopyelostomy). A discussion of the operative techniques, the possible modifications, and over-all results is included. Two patients

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died, 1 of postoperative difficulties, and the other of the progressive nature of the underlying disease process. There were five major complications, two severe delayed renal hemorrhages, and three tube losses. A detailed discussion of each of these patients is presented. Over-all, our experience with circle tubes has been gratifying. Tube changes are much less frequent (averaging every four months) than with single-arm nephrostomies, and patient mobility and comfort are markedly increased. University of North Carolina School of Medicine Chapel Hill, North Carolina 27514 (DR. COLE)

Acknowledgment. We wish to thank Mr. W. Biddle, Miss M. Snyder, and Miss J. Wilson for their help in preparing this manuscript.

References 1. WEYRAUCH, H. M., and Rous, S. N.: U-tube nephrostomy, J, Ural. 97: 225 (1967). 2. TRESIDDER, G. C.: Nephrostomy, Br. J. Urol. 29: 130 (1957). 3. LUNGLMAYR, G., and PECHERSTORFER, M.: Long term drainage of the kidney by U-tube pyelonephrostomy, ibid. 41: 394 (1969). with the U-tube for renal 4. COMAR, A. E.: Experience drainage among patients with spinal cord injury, J. Ural. 95: 741 (1966). Favorable experience with silicone 5. LYON, E. S., et al.: circle ureterostomy tube diversion, ibid. 104: 821 (1970). 6. BINDER, C., GONICK, P., and CIAVARRA, V.: Experience with silastic U-tube nephrostomy, ibid. 106: 499 (1971). 7. DAVIS, D. M.: Use of silicone rubber in urology, ibid. 97: 845 (1967).

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