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Successful Percutaneous Management of Renal Abscess
0022-5347 /82/1273-0425$02.00/0 127 March
THE JOURNAL OF UROLOGY
7
Copyright© 1982 by The WilliarrlS
p;~inted
V/ilkins Co.
U.S.A.
SUCCESSFUL PERCUTANEOUS MANAGEMENT OF RENAL ABSCESS D. J. FINN, A. M. PALESTRANT
AND
W. C. DEWOLF*·t
From the Division of Urology and Department of Radiology, Beth Israel Hospital, Boston, Massachusetts
ABSTRACT
Six patients with intrarenal and perinephric abscesses underwent successful nonoperative management by percutaneous aspiration and systemic antibiotic therapy. The concept of percutaneous management is discussed with reference to its benefits, :risks and technical variations. The traditional management of renal abscess is either nephrectomy or open surgical drainage and appropriate systemic antibiotic therapy. 1• 2 Sporadic case reports have concerned successful nonsurgical management. 3- 9 We describe 6 patients successfully managed by a combination of antibiotic therapy and percutaneous drainage. PATIENTS AND METHODS
We reviewed 6 case histories from 3 hospitals, in which abscess aspirations were done under ultrasound guidance and local anesthesia (table 1). Several catheter/needle combinations were used, depending on the therapists' familiarity with the system chosen. RESULTS
Clinical sumincirv The 6 patients were women: 4 had infected renal cysts 2 had perinephric abscesses. All positive abscess cultures yielded Escherichia coli and this same organism was cultured from the urine in 4 patients. In patient A.O. the sterile purulent aspirate may have been due to pre-aspiration antibiotics. Ultrasonography delineated a cystic mass (some with internal echoes) in all cases. Five patients had an TABLE
Pt.-Age-Sex TL-21-F NR-19-F
JF-43-F A0-31-F MF-30-F EG-66-F
Abdominal Pain Yes Yes Yes No No No
Size of Abscess (cm.) 4.5* 9* 5* 2*
45t 12t
Abscess Organisms E.coli E.coli E. coli Sterile E.coli E.coli
1.
gently with l gm. ampicillin in 10 cc saline daily. All patients have remained free of symptoms at a minimum 6-month followup. DISCUSSION
The classical urological teaching for management of renal abscess is nephrectomy or open surgical drainage, This approach has been challenged recently by 2 major advances. First, the introduction of newer imaging modalities, such as ultrasound and computerized tomography (CT) scanning, has allowed the accurate diagnosis of renal abscesses. Moreover, the surrounding anatomy is defined clearly and a safe route may be chosen for the percutaneous introduction of a drainage catheter. In addition, newer catheter systems that facilitate the drainage of abscesses with minimal trauma have been developed. These techniques are being used with increasing frequency for the successful drainage of intra-abdominal abscesses, 10- 12 There are several advantages for managing renal abscesses percutaneously. After insertion of a drainage catheter into a renal abscess the fluid aspirated may be cultured and the appropriate antibiotic therapy can be chosen. The catheter also allows direct instillation of local antibiotics into the abscess
Clinical summary
Diagnosis
Urine Culture
IVP and ultrasound IVP and ultrasound Ultrasound IVP and ultrasound IVP and ultrasound IVP, ultrasound and angiogram
E.coli E.coli E.coli Not available No growth E.coli
Predisposing Factors None None Ureteropelvic junction obstruction Pregnant None
Urinary tract infection
* Intrarenal.
t Perinephric. excretory urogram (IVP) and l had a renal <>ncn,,,ms,n,, Predisposing factors were present in 3 pa.c,cus.~. l was pregnant, 1 had a ureteropelvic junction (which was corrected later) and 1 had symptoms of for 3 weeks before the onset of flank pain and fever. Management. AH 6 patients were treated initially with parenteral antibiotics (table 2). There was no uniformity in the type of antibiotic used nor in the duration of parenteral or oral use. All patients had ultrasonically guided percutaneous drainage of the abscess cavity, with no resulting complications. In 4 patients a small catheter was left indwelling in the abscess until the amount of drainage was minimal, at which time the catheter was removed. In 2 patients the abscess cavity was irrigated Accepted for publication June 17, 1981. Read at annual meeting of American Urological Association, Boston, Massachusetts, May 10-14, 1981. * Requests for reprints: Division of Urology, Beth Israel Hospital, 330 Brookline Ave., Boston, Massachusetts 02215. t Recipient of National Institutes of Health Research Career Development Award AI 00406. 425
which may be important because the concentration of systemic antibiotics within renal cysts is poor. The use of this approach in extremely patients (diabetes and severe cardiac disease) avoids the risks of an open operation. In addition, the risks, expense, discomfort and recovery time involved in an open surgical drainage procedrne may be avoided by percutaneous management. The possible disadvantages may be considered. When a less defined necrotic perirenal abscess is treated the expectation of success may be less but it does not preclude an attempt, as evidenced by the success in patients M.F. and E.G. The risk of inducing bacteremia by direct antibiotic instillation to the cavity relative to the advantage of high local antibiotic concentration will need to be determined by experience, although it was not a problem in patients T.L. and N.R. We recommend the following steps in the percutaneous management of renal abscesses: 1) use of ultrasound or CT to delineate the surrounding anatomy so that a safe percutaneous approach may be used for placement of a lOF pigtail catheter,
426
FINN, PALESTRANT AND DEWOLF TABLE
2. Treatment Drainage
Antibiotic Irrigation
TL
Ampicillin
lOF catheter
NR
Gentamicin and ampicillin
lOF catheter
JF AO MF EG
Gentamicin Yes, ?type Gentamicin Cefamandole nafate
8F catheter Aspiration only Aspiration only lOF catheter
1 gm. ampicillin daily 1 gm. ampicillin daily None None None None
Pt.
Antibiotics
Pt. Well (mos.) 6
6
6
6 10
6
2) aspiration of the abscess cavity and aspirate sent for Gram stain, culture and cytology, 3) continuous drainage and gentle instillation of antibiotic solution, 4) initial parenteral antibiotic followed by at least 2 weeks of oral antibiotic, 5) removal of the catheter when the clinical condition of the patient improves and ultrasound or CT examination demonstrates resolution of the abscess and 6) open surgical drainage if the condition of the patient does not improve or deteriorates. In summary, antibiotic therapy combined with ultrasound or CT guided percutaneous drainage of an infected renal cyst (and perhaps perinephric abscess) is a reasonable, safe and effective alternative to antibiotic therapy with open surgical drainage. Drs. L. A. Klein, F. Morse, S. Berg and V. A. Andalora allowed us to study their cases.
3. Pedersen, J. F., Haneke, S. and Kristensen, J. K.: Renal carbuncle: antibiotic therapy governed by ultrasonically guided aspiration. J. Ural., 109: 777, 1973. 4. Stables, D. P. and Jackson, R. S.: Management of an infected simple renal cyst by percutaneous aspiration. Brit. J. Rad., 47: 290, 1974. 5. Mindell, H. J.: Percutaneous renal cyst puncture: unusual results in 2 cases. J. Ural., 114: 332, 1975. 6. Goldman, S. M., Minkin, S. D., Naraval, D. C., Diamond, A. B., Pion, S. J., Meringoff, B. N., Sidh, S. M., Sanders, R. C. and Cohen, S. P.: Renal carbuncle: the use of ultrasound in its diagnosis and treatment. J. Ural., 118: 525, 1977. 7. Wright, F. W.: Percutaneous diagnosis and treatment of intra-renal abscess. Brit. J. Ural., 49: 22, 1977. 8. Caldamone, A. A. and Frank, I. N.: Percutaneous aspiration in the treatment of renal abscess. J. U rol., 123: 92, 1980. 9. Elyaderani, M. K., Subramanian, V. P. and Burgess, J.E.: Diagnosis and percutaneous drainage of a perinephric abscess by ultrasound and fluoroscopy. J. Ural., 125: 405, 1981. 10. Haaga, J. R., Alfidi, R. J., Havrila, T. R., Cooperman, A. M., Seidelmann, F. E., Reich, N. E., Weinstein, A. J. and Meaney, T. F.: CT detection and aspiration of abdominal abscesses. Amer. J. Roentgen., 128: 465, 1977. 11. Gronvall, J., Gronvall, S. and Hegedus, V.: Ultrasound-guided drainage of fluid-containing masses using angiographic catheterization techniques. Amer. J. Roentgen., 129: 997, 1977. 12. Haaga, J. R., George, C., Weinstein, A. J. and Cooperman, A. M.: New interventional techniques in the diagnosis and management of inflammatory disease within the abdomen. Rad. Clin. N. Amer., 17: 485, 1979.
REFERENCES 1. Limjoco, U. R. and Strauch, A. E.: Infected solitary cyst of the kidney: report of a case and review of the literature. J. Ural., 96: 625, 1966. 2. Mendez, G., Jr., Isikoff, M. B. and Morillo, G.: The role of computed tomography in the diagnosis of renal and perirenal abscesses. J. Ural., 122: 582, 1979.
EDITORIAL COMMENT This is a valuable contribution. The approach not only simplifies the management of this sometimes difficult problem but also facilitates the later management of a predisposing lesion, such as ureteropelvic junction obstruction, which undoubtedly would have been quite difficult if the abscess had been drained formerly by an open procedure. J.J.M.
THE JOURNAL OF UROLOGY
7
Copyright© 1982 by The WilliarrlS
p;~inted
V/ilkins Co.
U.S.A.
SUCCESSFUL PERCUTANEOUS MANAGEMENT OF RENAL ABSCESS D. J. FINN, A. M. PALESTRANT
AND
W. C. DEWOLF*·t
From the Division of Urology and Department of Radiology, Beth Israel Hospital, Boston, Massachusetts
ABSTRACT
Six patients with intrarenal and perinephric abscesses underwent successful nonoperative management by percutaneous aspiration and systemic antibiotic therapy. The concept of percutaneous management is discussed with reference to its benefits, :risks and technical variations. The traditional management of renal abscess is either nephrectomy or open surgical drainage and appropriate systemic antibiotic therapy. 1• 2 Sporadic case reports have concerned successful nonsurgical management. 3- 9 We describe 6 patients successfully managed by a combination of antibiotic therapy and percutaneous drainage. PATIENTS AND METHODS
We reviewed 6 case histories from 3 hospitals, in which abscess aspirations were done under ultrasound guidance and local anesthesia (table 1). Several catheter/needle combinations were used, depending on the therapists' familiarity with the system chosen. RESULTS
Clinical sumincirv The 6 patients were women: 4 had infected renal cysts 2 had perinephric abscesses. All positive abscess cultures yielded Escherichia coli and this same organism was cultured from the urine in 4 patients. In patient A.O. the sterile purulent aspirate may have been due to pre-aspiration antibiotics. Ultrasonography delineated a cystic mass (some with internal echoes) in all cases. Five patients had an TABLE
Pt.-Age-Sex TL-21-F NR-19-F
JF-43-F A0-31-F MF-30-F EG-66-F
Abdominal Pain Yes Yes Yes No No No
Size of Abscess (cm.) 4.5* 9* 5* 2*
45t 12t
Abscess Organisms E.coli E.coli E. coli Sterile E.coli E.coli
1.
gently with l gm. ampicillin in 10 cc saline daily. All patients have remained free of symptoms at a minimum 6-month followup. DISCUSSION
The classical urological teaching for management of renal abscess is nephrectomy or open surgical drainage, This approach has been challenged recently by 2 major advances. First, the introduction of newer imaging modalities, such as ultrasound and computerized tomography (CT) scanning, has allowed the accurate diagnosis of renal abscesses. Moreover, the surrounding anatomy is defined clearly and a safe route may be chosen for the percutaneous introduction of a drainage catheter. In addition, newer catheter systems that facilitate the drainage of abscesses with minimal trauma have been developed. These techniques are being used with increasing frequency for the successful drainage of intra-abdominal abscesses, 10- 12 There are several advantages for managing renal abscesses percutaneously. After insertion of a drainage catheter into a renal abscess the fluid aspirated may be cultured and the appropriate antibiotic therapy can be chosen. The catheter also allows direct instillation of local antibiotics into the abscess
Clinical summary
Diagnosis
Urine Culture
IVP and ultrasound IVP and ultrasound Ultrasound IVP and ultrasound IVP and ultrasound IVP, ultrasound and angiogram
E.coli E.coli E.coli Not available No growth E.coli
Predisposing Factors None None Ureteropelvic junction obstruction Pregnant None
Urinary tract infection
* Intrarenal.
t Perinephric. excretory urogram (IVP) and l had a renal <>ncn,,,ms,n,, Predisposing factors were present in 3 pa.c,cus.~. l was pregnant, 1 had a ureteropelvic junction (which was corrected later) and 1 had symptoms of for 3 weeks before the onset of flank pain and fever. Management. AH 6 patients were treated initially with parenteral antibiotics (table 2). There was no uniformity in the type of antibiotic used nor in the duration of parenteral or oral use. All patients had ultrasonically guided percutaneous drainage of the abscess cavity, with no resulting complications. In 4 patients a small catheter was left indwelling in the abscess until the amount of drainage was minimal, at which time the catheter was removed. In 2 patients the abscess cavity was irrigated Accepted for publication June 17, 1981. Read at annual meeting of American Urological Association, Boston, Massachusetts, May 10-14, 1981. * Requests for reprints: Division of Urology, Beth Israel Hospital, 330 Brookline Ave., Boston, Massachusetts 02215. t Recipient of National Institutes of Health Research Career Development Award AI 00406. 425
which may be important because the concentration of systemic antibiotics within renal cysts is poor. The use of this approach in extremely patients (diabetes and severe cardiac disease) avoids the risks of an open operation. In addition, the risks, expense, discomfort and recovery time involved in an open surgical drainage procedrne may be avoided by percutaneous management. The possible disadvantages may be considered. When a less defined necrotic perirenal abscess is treated the expectation of success may be less but it does not preclude an attempt, as evidenced by the success in patients M.F. and E.G. The risk of inducing bacteremia by direct antibiotic instillation to the cavity relative to the advantage of high local antibiotic concentration will need to be determined by experience, although it was not a problem in patients T.L. and N.R. We recommend the following steps in the percutaneous management of renal abscesses: 1) use of ultrasound or CT to delineate the surrounding anatomy so that a safe percutaneous approach may be used for placement of a lOF pigtail catheter,
426
FINN, PALESTRANT AND DEWOLF TABLE
2. Treatment Drainage
Antibiotic Irrigation
TL
Ampicillin
lOF catheter
NR
Gentamicin and ampicillin
lOF catheter
JF AO MF EG
Gentamicin Yes, ?type Gentamicin Cefamandole nafate
8F catheter Aspiration only Aspiration only lOF catheter
1 gm. ampicillin daily 1 gm. ampicillin daily None None None None
Pt.
Antibiotics
Pt. Well (mos.) 6
6
6
6 10
6
2) aspiration of the abscess cavity and aspirate sent for Gram stain, culture and cytology, 3) continuous drainage and gentle instillation of antibiotic solution, 4) initial parenteral antibiotic followed by at least 2 weeks of oral antibiotic, 5) removal of the catheter when the clinical condition of the patient improves and ultrasound or CT examination demonstrates resolution of the abscess and 6) open surgical drainage if the condition of the patient does not improve or deteriorates. In summary, antibiotic therapy combined with ultrasound or CT guided percutaneous drainage of an infected renal cyst (and perhaps perinephric abscess) is a reasonable, safe and effective alternative to antibiotic therapy with open surgical drainage. Drs. L. A. Klein, F. Morse, S. Berg and V. A. Andalora allowed us to study their cases.
3. Pedersen, J. F., Haneke, S. and Kristensen, J. K.: Renal carbuncle: antibiotic therapy governed by ultrasonically guided aspiration. J. Ural., 109: 777, 1973. 4. Stables, D. P. and Jackson, R. S.: Management of an infected simple renal cyst by percutaneous aspiration. Brit. J. Rad., 47: 290, 1974. 5. Mindell, H. J.: Percutaneous renal cyst puncture: unusual results in 2 cases. J. Ural., 114: 332, 1975. 6. Goldman, S. M., Minkin, S. D., Naraval, D. C., Diamond, A. B., Pion, S. J., Meringoff, B. N., Sidh, S. M., Sanders, R. C. and Cohen, S. P.: Renal carbuncle: the use of ultrasound in its diagnosis and treatment. J. Ural., 118: 525, 1977. 7. Wright, F. W.: Percutaneous diagnosis and treatment of intra-renal abscess. Brit. J. Ural., 49: 22, 1977. 8. Caldamone, A. A. and Frank, I. N.: Percutaneous aspiration in the treatment of renal abscess. J. U rol., 123: 92, 1980. 9. Elyaderani, M. K., Subramanian, V. P. and Burgess, J.E.: Diagnosis and percutaneous drainage of a perinephric abscess by ultrasound and fluoroscopy. J. Ural., 125: 405, 1981. 10. Haaga, J. R., Alfidi, R. J., Havrila, T. R., Cooperman, A. M., Seidelmann, F. E., Reich, N. E., Weinstein, A. J. and Meaney, T. F.: CT detection and aspiration of abdominal abscesses. Amer. J. Roentgen., 128: 465, 1977. 11. Gronvall, J., Gronvall, S. and Hegedus, V.: Ultrasound-guided drainage of fluid-containing masses using angiographic catheterization techniques. Amer. J. Roentgen., 129: 997, 1977. 12. Haaga, J. R., George, C., Weinstein, A. J. and Cooperman, A. M.: New interventional techniques in the diagnosis and management of inflammatory disease within the abdomen. Rad. Clin. N. Amer., 17: 485, 1979.
REFERENCES 1. Limjoco, U. R. and Strauch, A. E.: Infected solitary cyst of the kidney: report of a case and review of the literature. J. Ural., 96: 625, 1966. 2. Mendez, G., Jr., Isikoff, M. B. and Morillo, G.: The role of computed tomography in the diagnosis of renal and perirenal abscesses. J. Ural., 122: 582, 1979.
EDITORIAL COMMENT This is a valuable contribution. The approach not only simplifies the management of this sometimes difficult problem but also facilitates the later management of a predisposing lesion, such as ureteropelvic junction obstruction, which undoubtedly would have been quite difficult if the abscess had been drained formerly by an open procedure. J.J.M.