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Self-Retaining Loop Nephrostomy
THE JOURNAL OF UROLOGY Copyright © 1977 by The Williams & Wilkins Co.
Vol. 117, May Printed in U.S.A.
SELF-RETAINING LOOP NEPHROSTOMY ROY P. FINNEY
AND
JOHN R. SHARPE
From the Section of Urology, University of South Florida and Veterans Administration Hospital, Tampa, Florida
ABSTRACT
A self-retaining loop nephrostomy with an inflated balloon in the renal pelvis to prevent accidental extraction or displacement is described. An additional feature of this tube is a plug that may be positioned to promote maximal irrigation of the kidney with a stone solvent or to allow urine to flow from 1 or both ends of the loop. Nephrostomy drainage with a silicone U-tube has become increasingly popular and this device is now available commercially.* Described by Tresidder in 19571 and, subsequently, by Comarr2--5 and others, 6--£ its inherent advantages over the traditional nephrostomy tube are well documented. The superiority of silicone elastomer drainage devices needs no additional comment. 9 The standard loop nephrostomy can be changed at any time beginning with the immediate postoperative period, and one can be assured that the new catheter can be brought into the same position occupied by the previous catheter. Innumerable reoperations have had to be performed when a Foley or malecot nephrostomy tube needed to be changed or was displaced accidently before a fibrous sheath was developed sufficiently in the perirenal tissues to allow passage of a new tube into the collecting system. Even after months or years of nephrostomy changes the catheter tip may break through the fibrous tract and pass outside of the kidney, necessitating surgical replacement. However, the standard loop nephrostomy tube currently in use has several significant disadvantages. If 1 end of the tube becomes detached from the Y-connection it can be extracted accidently with little or no awareness on the part of the patient, especially during the hours of sleep. The development of this new catheter was prompted by just such an occurrence. Various external retaining devices have been tried but none is entirely satisfactory and they make cleaning of the skin difficult. Replacement of the loop nephrostomy tube once it has been extracted completely is difficult, time consuming, requires xray control and is sometimes impossible. In addition, the loop nephrostomy can shift in position so that the drainage holes are outside of the collecting system, causing obstruction, leakage and abscess formation. This fact is particularly true in obese patients whose skin and fat covering the flank change position considerably from the standing to the recumbent position. A new stabilized silicone loop nephrostomy tube has been developed that overcomes these disadvantages. MATERIALS AND TECHNIQUES
The new loop nephrostomy catheter is essentially an allsilicone Foley catheter, t with an extension tube of the same size to complete the loop and with drainage holes on either side of the balloon (fig. 1). It combines the Foley nephrostomy, the most common type in use today, with the advantages of the continuous loop nephrostomy. Although there is interest this catheter is not yet available commercially. In its simplest form, ·.vithout a removable plug, the nephrostomy tube may be constructed in less than 5 minutes by Accepted for publication September 24, 1976. Read at annual meeting of Southeastern Section, American Urological Association, Hollywood, Florida, April 4-8, 1976. * Heyer-Schulte Corp., Goleta, California. t Travenol LaboratoFies, Inc., Deerfield, Illinois 60015.
cutting off the tip of an all-silicone Foley catheter and removing the balloon and inflation cuff from another silicone Foley catheter to supply the second part of the loop (fig. 2, A). The second part of the loop also may be constructed of medical grade tubing of the same diameter.t The 2 ends are cemented together with Medical Adhesive Type At over a 6 mm. length of medical grade silicone tubing, which fits snugly in the catheter lumen (fig. 2, B). Depending on its intended use, a more versatile nephrostomy loop may be had by filling a short segment of the loop at point A or B (fig. 1) with silicone cement just before cementing the 2 tubes together. The cement requires 24 hours to cure and the loop may then be autoclaved for an operation. Several holes are placed close to the balloon on either side with a cork borer (fig. 2, C) but care must be taken to avoid cutting into the balloon inflation tube on that side of the loop. The loop nephrostomy tube is inserted in the same manner as are other loop nephrostomy tubes and the balloon is inflated in the renal pelvis with 2 or 3 ml. saline to prevent accidental removal and to keep the drainage holes placed properly. When there is a small intrarenal pelvis sufficient space for the balloon may not be present and the simple U-tube nephrostomy is indicated. In the majority of cases requiring a nephrostomy there is some degree of hydronephrosis and ample room for a balloon. With a plug in the A position the center of the nephrostomy is blocked and this mode is used for continuous post-nephrolithotomy irrigation of the kidney with stone solvents, when stone fragments or concretions remain. Irrigation fluid flowing into 1 limb passes out of the lumen into the renal collection system, around the inflated balloon and back into the second limb, where it drains into a bedside closed sterile container. We believe this is the best method yet devised for renal lavage. All the irrigation fluid reaches the kidney with minimal chance of outflow obstruction. Furthermore, the patient is not required to void the excess fluid and the output of the contralateral kidney still may be monitored. Reports by Nemoy and Stamey10 and Blaivas and associates 11 have shown that with the proper criteria and technique, hemiacidrin may be used with reasonable safety and it is hoped that the use of this stone solvent will be permitted once again. Currently, a buffered acid solution, such as Suby's, may be used for acid soluble stones or 0.1 per cent solution of sodium bicarbonate7 may be used for uric acid stones. The loop may be plugged at pointB, which permits the urine to drain through only 1 limb of the nephrostomy and is the method that we use most commonly for long-term drainage. Patients find this single-tube drainage more convenient than drainage with a Y-tube and there is no need for double-tube drainage since most tubes must be changed at only 3-month intervals. If the surgeon desires the loop may be left unplugged initially and Y-tube drainage may be instituted.
*Dow Corning Co., Midland, Michigan. 638
3ELF- RETA.Il..J"Il¾J G· LOOP :t"•fEPI-IRO§'l'O:tV.P{
V/ith a properly finned plug attached to a monofilament pull cord (fig. 1) the drainage mode may be changed from A to B position or removed altogether at any time postoperatively. Thus, a patient who has undergone lavage for residual stones may be converted to single-limb drainage. This
Skin
,
,. ;
'
'
!
' , '-
',
/
Pull Cord
Fm. 1. Diagram of self-retaining loop nephrostomy shows A, plug position for continuous renal irrigation and B, position for single limb drainage.
firmed plug is not made the average urologist. cylindrical plugs unreasonable force to remove while in the patient. The drainage mode now is changed by inserting a different nephrostomy loop. The old and new loops are joined with a connector or by suturing and then push-pulled through either stoma, depending on the desired placement of the single drainage limb. RESULTS AND DISCUSSION
Permanent nephrostomy tube drainage with any method is less than ideal but when this was the diversion of choice we have had excellent results. When the nephrostomy is to be permanent the tube may be inserted quickly through a ureterostomy at the level of the lower pole of the kidney and out through a middle calix (fig. 3). An aluminum knitting needle with a small hole in its tip for a suture is used to draw the tube into the kidney and may be bent to the desired curve. When this technique is used the kidney need not be mobilized nor the pelvis identified, a significant time saver when there is considerable scarring from previous infection and operations. Otherwise, the loop is placed as a pyelonephrostomy or nephronephrostomy. At first, all loop changes were done under x-ray control but with careful measurement of the length of the loop remaining outside of the skin the U-tube can be positioned accurately. Ideally, the loop could be marked in centimeters. Our only complications occurred early when large diameter drainage holes were used and there was kinking of the loop at this point. This problem has been overcome by using smaller holes, approximately two-thirds the diameter of the lumen of the catheter. Finally, there is a tendency for the loop to be self-retaining, even with the balloon deflated. The deflated balloon remains slightly larger than the loop and it passes quite snugly
Fm. 2. A, method of cutting 2 catheters. B, catheters are cemented over sleeve. C, holes are cut with cork borer after cement has cured
----640
~-
FINNEY AND SHARPE
through a well formed fibrous tract, making accidental removal unlikely even if the balloon deflates. If desired, a short sleeve of silicone tubing may be cemented to the end of the loop for additional safety. Most patients wearing this device have minimal drainage around the tubes and do not require a dressing but are advised to apply povidone-iodine to the skin once or twice daily. REFERENCES
Fm. 3. Permanent ureteronephrostomy plugged for single tube drainage.
1. Tresidder, G. C.: Nephrostomy. Brit. J. Urol., 29: 130, 1957. 2. Comarr, A. E.: The U-tube pyelonephrostomy. J. Indian Med. Prof., 10: 4626, 1963. 3. Comarr, A. E.: An improved U-tube catheter. J. Urol., 92: 78, 1964. 4. Comarr, A. E.: A new tapered U-tube catheter. J. Urol., 95: 436, 1966. 5. Comarr, A. E.: Experience with the U-tube for renal drainage among patients with spinal cord injury. J. Urol., 95: 741, 1966. 6. Weyrauch, H. M. and Rous, S. N.: U-tube nephrostomy. J. Urol., 97: 225, 1967. 7. Binder, C., Gonick, P. and Ciavarra, V.: Experience with silastic U-tube nephrostomy. J. Urol., 106: 499, 1971. 8. Hawtrey, C. E., Boatman, D. L., Brown, R. G. and Schmidt, J. D.: Clinical experience with loop nephrostomy for urinary diversion. J. Urol., 112: 36, 1974. 9. Speirs, A. C. and Blocksma, R.: New implantable silicone rubbers. An experimental evaluation of tissue response. Plast. Reconstr. Surg., 31: 166, 1963. 10. Nemoy, N. J. and Stamey, T. A.: Surgical, bacteriological, and biochemical management of "infection stones". J .A.M.A., 215: 1470, 1971. 11. Blaivas, J. G., Pais, V. M. and Spellman, R. M.: Chemolysis of residual stone fragments after extensive surgery for staghorn calculi. Urology, 6: 680, 1975.
Vol. 117, May Printed in U.S.A.
SELF-RETAINING LOOP NEPHROSTOMY ROY P. FINNEY
AND
JOHN R. SHARPE
From the Section of Urology, University of South Florida and Veterans Administration Hospital, Tampa, Florida
ABSTRACT
A self-retaining loop nephrostomy with an inflated balloon in the renal pelvis to prevent accidental extraction or displacement is described. An additional feature of this tube is a plug that may be positioned to promote maximal irrigation of the kidney with a stone solvent or to allow urine to flow from 1 or both ends of the loop. Nephrostomy drainage with a silicone U-tube has become increasingly popular and this device is now available commercially.* Described by Tresidder in 19571 and, subsequently, by Comarr2--5 and others, 6--£ its inherent advantages over the traditional nephrostomy tube are well documented. The superiority of silicone elastomer drainage devices needs no additional comment. 9 The standard loop nephrostomy can be changed at any time beginning with the immediate postoperative period, and one can be assured that the new catheter can be brought into the same position occupied by the previous catheter. Innumerable reoperations have had to be performed when a Foley or malecot nephrostomy tube needed to be changed or was displaced accidently before a fibrous sheath was developed sufficiently in the perirenal tissues to allow passage of a new tube into the collecting system. Even after months or years of nephrostomy changes the catheter tip may break through the fibrous tract and pass outside of the kidney, necessitating surgical replacement. However, the standard loop nephrostomy tube currently in use has several significant disadvantages. If 1 end of the tube becomes detached from the Y-connection it can be extracted accidently with little or no awareness on the part of the patient, especially during the hours of sleep. The development of this new catheter was prompted by just such an occurrence. Various external retaining devices have been tried but none is entirely satisfactory and they make cleaning of the skin difficult. Replacement of the loop nephrostomy tube once it has been extracted completely is difficult, time consuming, requires xray control and is sometimes impossible. In addition, the loop nephrostomy can shift in position so that the drainage holes are outside of the collecting system, causing obstruction, leakage and abscess formation. This fact is particularly true in obese patients whose skin and fat covering the flank change position considerably from the standing to the recumbent position. A new stabilized silicone loop nephrostomy tube has been developed that overcomes these disadvantages. MATERIALS AND TECHNIQUES
The new loop nephrostomy catheter is essentially an allsilicone Foley catheter, t with an extension tube of the same size to complete the loop and with drainage holes on either side of the balloon (fig. 1). It combines the Foley nephrostomy, the most common type in use today, with the advantages of the continuous loop nephrostomy. Although there is interest this catheter is not yet available commercially. In its simplest form, ·.vithout a removable plug, the nephrostomy tube may be constructed in less than 5 minutes by Accepted for publication September 24, 1976. Read at annual meeting of Southeastern Section, American Urological Association, Hollywood, Florida, April 4-8, 1976. * Heyer-Schulte Corp., Goleta, California. t Travenol LaboratoFies, Inc., Deerfield, Illinois 60015.
cutting off the tip of an all-silicone Foley catheter and removing the balloon and inflation cuff from another silicone Foley catheter to supply the second part of the loop (fig. 2, A). The second part of the loop also may be constructed of medical grade tubing of the same diameter.t The 2 ends are cemented together with Medical Adhesive Type At over a 6 mm. length of medical grade silicone tubing, which fits snugly in the catheter lumen (fig. 2, B). Depending on its intended use, a more versatile nephrostomy loop may be had by filling a short segment of the loop at point A or B (fig. 1) with silicone cement just before cementing the 2 tubes together. The cement requires 24 hours to cure and the loop may then be autoclaved for an operation. Several holes are placed close to the balloon on either side with a cork borer (fig. 2, C) but care must be taken to avoid cutting into the balloon inflation tube on that side of the loop. The loop nephrostomy tube is inserted in the same manner as are other loop nephrostomy tubes and the balloon is inflated in the renal pelvis with 2 or 3 ml. saline to prevent accidental removal and to keep the drainage holes placed properly. When there is a small intrarenal pelvis sufficient space for the balloon may not be present and the simple U-tube nephrostomy is indicated. In the majority of cases requiring a nephrostomy there is some degree of hydronephrosis and ample room for a balloon. With a plug in the A position the center of the nephrostomy is blocked and this mode is used for continuous post-nephrolithotomy irrigation of the kidney with stone solvents, when stone fragments or concretions remain. Irrigation fluid flowing into 1 limb passes out of the lumen into the renal collection system, around the inflated balloon and back into the second limb, where it drains into a bedside closed sterile container. We believe this is the best method yet devised for renal lavage. All the irrigation fluid reaches the kidney with minimal chance of outflow obstruction. Furthermore, the patient is not required to void the excess fluid and the output of the contralateral kidney still may be monitored. Reports by Nemoy and Stamey10 and Blaivas and associates 11 have shown that with the proper criteria and technique, hemiacidrin may be used with reasonable safety and it is hoped that the use of this stone solvent will be permitted once again. Currently, a buffered acid solution, such as Suby's, may be used for acid soluble stones or 0.1 per cent solution of sodium bicarbonate7 may be used for uric acid stones. The loop may be plugged at pointB, which permits the urine to drain through only 1 limb of the nephrostomy and is the method that we use most commonly for long-term drainage. Patients find this single-tube drainage more convenient than drainage with a Y-tube and there is no need for double-tube drainage since most tubes must be changed at only 3-month intervals. If the surgeon desires the loop may be left unplugged initially and Y-tube drainage may be instituted.
*Dow Corning Co., Midland, Michigan. 638
3ELF- RETA.Il..J"Il¾J G· LOOP :t"•fEPI-IRO§'l'O:tV.P{
V/ith a properly finned plug attached to a monofilament pull cord (fig. 1) the drainage mode may be changed from A to B position or removed altogether at any time postoperatively. Thus, a patient who has undergone lavage for residual stones may be converted to single-limb drainage. This
Skin
,
,. ;
'
'
!
' , '-
',
/
Pull Cord
Fm. 1. Diagram of self-retaining loop nephrostomy shows A, plug position for continuous renal irrigation and B, position for single limb drainage.
firmed plug is not made the average urologist. cylindrical plugs unreasonable force to remove while in the patient. The drainage mode now is changed by inserting a different nephrostomy loop. The old and new loops are joined with a connector or by suturing and then push-pulled through either stoma, depending on the desired placement of the single drainage limb. RESULTS AND DISCUSSION
Permanent nephrostomy tube drainage with any method is less than ideal but when this was the diversion of choice we have had excellent results. When the nephrostomy is to be permanent the tube may be inserted quickly through a ureterostomy at the level of the lower pole of the kidney and out through a middle calix (fig. 3). An aluminum knitting needle with a small hole in its tip for a suture is used to draw the tube into the kidney and may be bent to the desired curve. When this technique is used the kidney need not be mobilized nor the pelvis identified, a significant time saver when there is considerable scarring from previous infection and operations. Otherwise, the loop is placed as a pyelonephrostomy or nephronephrostomy. At first, all loop changes were done under x-ray control but with careful measurement of the length of the loop remaining outside of the skin the U-tube can be positioned accurately. Ideally, the loop could be marked in centimeters. Our only complications occurred early when large diameter drainage holes were used and there was kinking of the loop at this point. This problem has been overcome by using smaller holes, approximately two-thirds the diameter of the lumen of the catheter. Finally, there is a tendency for the loop to be self-retaining, even with the balloon deflated. The deflated balloon remains slightly larger than the loop and it passes quite snugly
Fm. 2. A, method of cutting 2 catheters. B, catheters are cemented over sleeve. C, holes are cut with cork borer after cement has cured
----640
~-
FINNEY AND SHARPE
through a well formed fibrous tract, making accidental removal unlikely even if the balloon deflates. If desired, a short sleeve of silicone tubing may be cemented to the end of the loop for additional safety. Most patients wearing this device have minimal drainage around the tubes and do not require a dressing but are advised to apply povidone-iodine to the skin once or twice daily. REFERENCES
Fm. 3. Permanent ureteronephrostomy plugged for single tube drainage.
1. Tresidder, G. C.: Nephrostomy. Brit. J. Urol., 29: 130, 1957. 2. Comarr, A. E.: The U-tube pyelonephrostomy. J. Indian Med. Prof., 10: 4626, 1963. 3. Comarr, A. E.: An improved U-tube catheter. J. Urol., 92: 78, 1964. 4. Comarr, A. E.: A new tapered U-tube catheter. J. Urol., 95: 436, 1966. 5. Comarr, A. E.: Experience with the U-tube for renal drainage among patients with spinal cord injury. J. Urol., 95: 741, 1966. 6. Weyrauch, H. M. and Rous, S. N.: U-tube nephrostomy. J. Urol., 97: 225, 1967. 7. Binder, C., Gonick, P. and Ciavarra, V.: Experience with silastic U-tube nephrostomy. J. Urol., 106: 499, 1971. 8. Hawtrey, C. E., Boatman, D. L., Brown, R. G. and Schmidt, J. D.: Clinical experience with loop nephrostomy for urinary diversion. J. Urol., 112: 36, 1974. 9. Speirs, A. C. and Blocksma, R.: New implantable silicone rubbers. An experimental evaluation of tissue response. Plast. Reconstr. Surg., 31: 166, 1963. 10. Nemoy, N. J. and Stamey, T. A.: Surgical, bacteriological, and biochemical management of "infection stones". J .A.M.A., 215: 1470, 1971. 11. Blaivas, J. G., Pais, V. M. and Spellman, R. M.: Chemolysis of residual stone fragments after extensive surgery for staghorn calculi. Urology, 6: 680, 1975.