- Email: [email protected]
The Non-operative Re-establishment of a Broken Loop Nephrostomy
THE
,J OLRNAL
Vol. 112, August
OF UROLOGY
Printed in U.S.A.
Copyright © 1974 by The Williams & Wilkins Co.
Pediatric Urology THE NON-OPERATIVE RE-ESTABLISHMENT OF A BROKEN LOOP NEPHROSTOMY ROBERT C. BROWN, MARY C. WEBSTER
AND
CHARLES E. HAWTREY
From the Departments of Radiology and Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
In recent years silastic tube loop nephrostomy has gained acceptance as a method of upper urinary tract diversion. Hawtrey and associates reviewed 30 cases and noted that the indications for this type of diversion include: 1) small intrarenal pelvis, 2) hydronephrosis with anticipated prolonged urinary diversion, 3) loss of ureteropelvic continuity, 4) irrigation of calculus or infected debris, 5) severe inflammatory reaction at the
silastic tubing. In our patient it was necessary to replace the tube on 2 occasions after it broke and became dislodged. Loop nephrostomy replacement was accomplished by the non-operative technique herein described. CASE REPORT
K. 0., 62-125-58, was first seen on June 20, 1962 when she was 5 months old with multiple congeni-
FIG. 1. Selector catheter with metallic covering of handle removed. Arrow is directed at 1 of 4 nylon connectors which is attached to flat metal plate. Coiled springs can be seen leading from proximal end of catheter to nylon connectors. Reprinted with permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.'
ureteropelvic junction and 6) anomalous renal blood supply. 1 This type of urinary diversion has several advantages. The small silastic (14F) tube is more pliable and, thus, more comfortable to wear than the larger malecot or de Pezzer catheters. Urinary concretions do not precipitate in the tube as rapidly as in rubber catheters and, therefore, tube changes can be made at 3 to 6-month intervals. No systemic reactions such as chills and fever were noted with tube changes. Lastly, the tubes are easy to change and more easily secured. One complication of loop nephrostomy is fracture of the Accepted for publication February 22, 1974. 1 Hawtrey, C. E., Boatman, D. L., Brown, R. C. and Schmidt, J. D.: Clinical experience with loop nephrostomy for urinary diversion. J. Ural., 112: 36, 1974. 272
tal anomalies, including imperforate anus, a rectovaginal fistula and congenital absence of the sacrum. Excretory urograms (IVPs) at that time revealed prompt function from a normal left kidney and an indeterminate right kidney. The bladder was smooth and emptied completely. Bilateral reflux and hydronephrosis subsequently developed and necessitated a long sequence of diverting and corrective procedures, including bilateral nephrostomy, bilateral ureteral reimplantation with bladder neck plasty, ilea! conduit diversion and _stomal revision. Despite all of these procedures it was impossible to remove the nephrostomies because of infection. The patient was seen at 6-month intervals for nephrostomy tube changes until September 30,
NON-OPERATIVE RE-ESTABLISHMENT OF BROKEN LOOP NEPHROSTOMY
273
of the kidney. At the time of the exploration the communication between the intrarenal system and the ureter was totally necrotic. The loop nephrostomy functioned well until June 19, 1972 when the patient tugged on the silastic tube and it broke within the sinus tract. After the loop nephrostomy was re-established the clinical course was uneventful until 16 months later when the patient was seen in the clinic with both limbs of the loop nephrostomy having been
FIG. 3. Silastic tube has been passed over ureteral catheter and loop nephrostomy has been re-established.
FIG. 2. A, Foley catheters in each nephrostomy tract. Tips of catheters touch in renal pelvis. Note long stenotic segment in proximal ureter. B, Foley catheters have been removed and selector catheter has been directed through lower nephrostomy tract into upper renal pelvis. C, screw-tip ureteral catheter is passed into upper sinus tract and is entwined on selector catheter. D, screw-tip ureteral catheter has passed along selector catheter and distal end of ureteral catheter projects out lower nephrostomy tract. Selector catheter has been removed and silastic tube passed over proximal ureteral catheter.
1970. A loopogram at that time demonstrated bilateral ureteropelvic junction obstruction, while IVPs demonstrated non-function on the right side and poor function and calicectasis on the left side. A renal scan demonstrated asymmetrical radioactive mercury uptake, suggesting decreased concentration on the right side compared to the left. Blood urea nitrogen was 42, creatinine 2.7 and creatinine clearance 41 mm. per minute per 1.73 m 2 • On October 12 the child underwent right infundibulotomy and Davis intubation of the ureteropelvic junction. She responded well for 7 days and then spiked fevers to 104F. Extravasation of contrast material suggested a perinephric abscess and an emergency loop nephrostomy provided drainage 2 Rabinov, K. and Simon, M.: A new selective catheter with multidirectional controlled tip. Radiology, 92: 172, 1969.
FIG. 4. Lateral projection spot film with contrast medium in silastic tube taken at completion of first procedure. ·
274
BROWN, WEBSTER AND HA WTREY
removed. The following method was used on both of these occasions. PROCEDURE
Upon hospitalization Foley catheters were placed in both limbs of the nephrostomy to maintain urinary drainage and sinus tract patency. The sinus tracts should be dilated to 12 or 14F by changing the catheters to the progressively larger sizes. Large sinus tracts facilitate the procedure. It was decided to use a selector catheter* to re-establish the loop and thereby avoid an open operative procedure. A selector catheter is a special type of maneuverable catheter which was originally used to negotiate difficult to reach blood vessels or the smaller bronchi while performing a brush biopsy. 2 • 3 The selector catheter has wires running in its wall connecting the tip of the catheter to its proximal end. It is attached to the control handle by a Luer lock. Small coiled springs and nylon connectors attach the small wires from the catheter to a flat metal plate which rests at right angles to the catheter in the control handle. A joy stick is attached to the flat plate (fig. 1). Movement of the joy stick then directs the catheter tip. Under fluoroscopic control the catheter can be maneuvered by merely moving the joy stick and advancing the catheter. We had hoped to guide the catheter into one nephrostomy tract and out the other. A silastic catheter would then be passed over the selector catheter, re-establishing the loop. The patient was taken to the radiology suite and the radiopaque ureteral catheters were inserted into each Foley catheter for visualization of the sinus tracts. The patient was rotated until we could visualize the spacial relationships of the 2 Foley catheter tips. The tips were noted to be touching each other (fig. 2, A). Therefore, we removed the lower catheter and inserted the selec-
* Medi-Tech, Inc., 372 Main St., Watertown, Massachusetts 0217'2:. 'Brown, R. C., Hawtrey, C. E. and Pixley, E. E.: Brush biopsy of the renal pelvis: a preliminary report. Amer. J. Roentgen., 119: 779, 1973.
tor catheter in this tract. The selector catheter is radiopaque and we were unable to follow it into the upper portion of the renal pelvis. However, the angle of the exiting tract was too sharp to pass the catheter out the upper tract (fig. 2, B). The upper Foley catheter was removed and an attempt was made to visualize the relationship of the sinus tract to the selector catheter, using an opaque ureteral catheter. Fortunately, we chose a screw-tip ureteral catheter which engaged the selector catheter and became entwined about it (fig. 2, C). Gentle pressure on the ureteral catheter guided it along the selector catheter out through the lower opening (fig. 2, D). The selector catheter was removed, the silastic catheter was passed over the ureteral catheter and the loop nephrostomy was re-established (figs. 3 and 4). The patient was seen in the emergency room 16 months later with the loop nephrostomy tube removed. Foley type nephrostomy tubes (10 and 12F) were placed via the sinus tracts into the renal pelvis to maintain urinary drainage. The patient was taken to the radiology suite 2 days later and under fluoroscopic control the loop was re-established. Multiple attempts using various Foley and ureteral catheter combinations were unsuccessful in re-establishing the loop. However, on the first attempt using selector screw-tip catheter combination the loop was successfully re-established in a non-surgical manner. On both occasions the procedure was performed under general anesthesia because of the patient's age and her known inability to cooperate. With older, more stable patients general anesthesia is probably not necessary. SUMMARY
A method for the non-operative restoration of broken loop nephrostomy has been described. We have used this method successfully twice on the same patient. The procedure is recommended for the management of broken silastic catheters prior to doing an open surgical procedure.
,J OLRNAL
Vol. 112, August
OF UROLOGY
Printed in U.S.A.
Copyright © 1974 by The Williams & Wilkins Co.
Pediatric Urology THE NON-OPERATIVE RE-ESTABLISHMENT OF A BROKEN LOOP NEPHROSTOMY ROBERT C. BROWN, MARY C. WEBSTER
AND
CHARLES E. HAWTREY
From the Departments of Radiology and Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
In recent years silastic tube loop nephrostomy has gained acceptance as a method of upper urinary tract diversion. Hawtrey and associates reviewed 30 cases and noted that the indications for this type of diversion include: 1) small intrarenal pelvis, 2) hydronephrosis with anticipated prolonged urinary diversion, 3) loss of ureteropelvic continuity, 4) irrigation of calculus or infected debris, 5) severe inflammatory reaction at the
silastic tubing. In our patient it was necessary to replace the tube on 2 occasions after it broke and became dislodged. Loop nephrostomy replacement was accomplished by the non-operative technique herein described. CASE REPORT
K. 0., 62-125-58, was first seen on June 20, 1962 when she was 5 months old with multiple congeni-
FIG. 1. Selector catheter with metallic covering of handle removed. Arrow is directed at 1 of 4 nylon connectors which is attached to flat metal plate. Coiled springs can be seen leading from proximal end of catheter to nylon connectors. Reprinted with permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.'
ureteropelvic junction and 6) anomalous renal blood supply. 1 This type of urinary diversion has several advantages. The small silastic (14F) tube is more pliable and, thus, more comfortable to wear than the larger malecot or de Pezzer catheters. Urinary concretions do not precipitate in the tube as rapidly as in rubber catheters and, therefore, tube changes can be made at 3 to 6-month intervals. No systemic reactions such as chills and fever were noted with tube changes. Lastly, the tubes are easy to change and more easily secured. One complication of loop nephrostomy is fracture of the Accepted for publication February 22, 1974. 1 Hawtrey, C. E., Boatman, D. L., Brown, R. C. and Schmidt, J. D.: Clinical experience with loop nephrostomy for urinary diversion. J. Ural., 112: 36, 1974. 272
tal anomalies, including imperforate anus, a rectovaginal fistula and congenital absence of the sacrum. Excretory urograms (IVPs) at that time revealed prompt function from a normal left kidney and an indeterminate right kidney. The bladder was smooth and emptied completely. Bilateral reflux and hydronephrosis subsequently developed and necessitated a long sequence of diverting and corrective procedures, including bilateral nephrostomy, bilateral ureteral reimplantation with bladder neck plasty, ilea! conduit diversion and _stomal revision. Despite all of these procedures it was impossible to remove the nephrostomies because of infection. The patient was seen at 6-month intervals for nephrostomy tube changes until September 30,
NON-OPERATIVE RE-ESTABLISHMENT OF BROKEN LOOP NEPHROSTOMY
273
of the kidney. At the time of the exploration the communication between the intrarenal system and the ureter was totally necrotic. The loop nephrostomy functioned well until June 19, 1972 when the patient tugged on the silastic tube and it broke within the sinus tract. After the loop nephrostomy was re-established the clinical course was uneventful until 16 months later when the patient was seen in the clinic with both limbs of the loop nephrostomy having been
FIG. 3. Silastic tube has been passed over ureteral catheter and loop nephrostomy has been re-established.
FIG. 2. A, Foley catheters in each nephrostomy tract. Tips of catheters touch in renal pelvis. Note long stenotic segment in proximal ureter. B, Foley catheters have been removed and selector catheter has been directed through lower nephrostomy tract into upper renal pelvis. C, screw-tip ureteral catheter is passed into upper sinus tract and is entwined on selector catheter. D, screw-tip ureteral catheter has passed along selector catheter and distal end of ureteral catheter projects out lower nephrostomy tract. Selector catheter has been removed and silastic tube passed over proximal ureteral catheter.
1970. A loopogram at that time demonstrated bilateral ureteropelvic junction obstruction, while IVPs demonstrated non-function on the right side and poor function and calicectasis on the left side. A renal scan demonstrated asymmetrical radioactive mercury uptake, suggesting decreased concentration on the right side compared to the left. Blood urea nitrogen was 42, creatinine 2.7 and creatinine clearance 41 mm. per minute per 1.73 m 2 • On October 12 the child underwent right infundibulotomy and Davis intubation of the ureteropelvic junction. She responded well for 7 days and then spiked fevers to 104F. Extravasation of contrast material suggested a perinephric abscess and an emergency loop nephrostomy provided drainage 2 Rabinov, K. and Simon, M.: A new selective catheter with multidirectional controlled tip. Radiology, 92: 172, 1969.
FIG. 4. Lateral projection spot film with contrast medium in silastic tube taken at completion of first procedure. ·
274
BROWN, WEBSTER AND HA WTREY
removed. The following method was used on both of these occasions. PROCEDURE
Upon hospitalization Foley catheters were placed in both limbs of the nephrostomy to maintain urinary drainage and sinus tract patency. The sinus tracts should be dilated to 12 or 14F by changing the catheters to the progressively larger sizes. Large sinus tracts facilitate the procedure. It was decided to use a selector catheter* to re-establish the loop and thereby avoid an open operative procedure. A selector catheter is a special type of maneuverable catheter which was originally used to negotiate difficult to reach blood vessels or the smaller bronchi while performing a brush biopsy. 2 • 3 The selector catheter has wires running in its wall connecting the tip of the catheter to its proximal end. It is attached to the control handle by a Luer lock. Small coiled springs and nylon connectors attach the small wires from the catheter to a flat metal plate which rests at right angles to the catheter in the control handle. A joy stick is attached to the flat plate (fig. 1). Movement of the joy stick then directs the catheter tip. Under fluoroscopic control the catheter can be maneuvered by merely moving the joy stick and advancing the catheter. We had hoped to guide the catheter into one nephrostomy tract and out the other. A silastic catheter would then be passed over the selector catheter, re-establishing the loop. The patient was taken to the radiology suite and the radiopaque ureteral catheters were inserted into each Foley catheter for visualization of the sinus tracts. The patient was rotated until we could visualize the spacial relationships of the 2 Foley catheter tips. The tips were noted to be touching each other (fig. 2, A). Therefore, we removed the lower catheter and inserted the selec-
* Medi-Tech, Inc., 372 Main St., Watertown, Massachusetts 0217'2:. 'Brown, R. C., Hawtrey, C. E. and Pixley, E. E.: Brush biopsy of the renal pelvis: a preliminary report. Amer. J. Roentgen., 119: 779, 1973.
tor catheter in this tract. The selector catheter is radiopaque and we were unable to follow it into the upper portion of the renal pelvis. However, the angle of the exiting tract was too sharp to pass the catheter out the upper tract (fig. 2, B). The upper Foley catheter was removed and an attempt was made to visualize the relationship of the sinus tract to the selector catheter, using an opaque ureteral catheter. Fortunately, we chose a screw-tip ureteral catheter which engaged the selector catheter and became entwined about it (fig. 2, C). Gentle pressure on the ureteral catheter guided it along the selector catheter out through the lower opening (fig. 2, D). The selector catheter was removed, the silastic catheter was passed over the ureteral catheter and the loop nephrostomy was re-established (figs. 3 and 4). The patient was seen in the emergency room 16 months later with the loop nephrostomy tube removed. Foley type nephrostomy tubes (10 and 12F) were placed via the sinus tracts into the renal pelvis to maintain urinary drainage. The patient was taken to the radiology suite 2 days later and under fluoroscopic control the loop was re-established. Multiple attempts using various Foley and ureteral catheter combinations were unsuccessful in re-establishing the loop. However, on the first attempt using selector screw-tip catheter combination the loop was successfully re-established in a non-surgical manner. On both occasions the procedure was performed under general anesthesia because of the patient's age and her known inability to cooperate. With older, more stable patients general anesthesia is probably not necessary. SUMMARY
A method for the non-operative restoration of broken loop nephrostomy has been described. We have used this method successfully twice on the same patient. The procedure is recommended for the management of broken silastic catheters prior to doing an open surgical procedure.