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The use of percutaneous diversion during pregnancy
67
Znt. J. Gynecol. Obstet., 1990,32: 67-70 International Federation of Gynecology and Obstetrics
The use of percutaneous
diversion during pregnancy
A.K. Mandal, S.K. Sharma, A.K. Goswami, A.K. Hemal and R. Indudhara Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012 (Zndia) (Received December 13th, 1988) (Revised and accepted April 12th, 1989)
Abstract
Two patients with infected hydronephrosis and one patient with calculus anuria during pregnancy were managed initially by percutaneous nephrostomy. Maintenance of percutaneous diversion allowed continuation of pregnancy to term and effectivet’y preserved renal function. Definite surgical treatment for the obstructive pathology was done electively in the postpartum period. Keywords: Obstructive uropathy;
Percutaneous nephrostomy; gery in postpartum period.
Pregnancy; Definitive sur-
Introduction
To minimise the potential morbidity of the mother and fetus, early intervention with in an proximal diversion is imperative acutely obstructed kidney during pregnancy. Three such patients managed by our services at the Postgraduate Institute of Medical Education and Research, Chandigarh, during the last 3 years are presented.
showed numerous pus cells and grew E. coli on culture. Blood urea and serum creatinine were normal. She did not improve with systemic antibiotics. Renal ultrasound examination showed marked hydronephrosis on the left side. Percutaneous needle puncture under ultrasound guidance revealed frank pus necessitating placement of an 8F pigtail catheter as percutaneous nephrostomy (PCN) drainage. The patient made prompt recovery with percutaneous drainage and a short course of antimicrobial therapy. The PCN started draining clear urine by the third day following the procedure. The pregnancy continued uneventfully to term while PCN was maintained under close supervision. She delivered a healthy male newborn at 37 weeks. Six weeks later the patient returned with a slipped out PCN catheter. She was asymptomatic and there was no urine leak from the PCN site. So an IVU was obtained to evaluate the upper urinary tract. This showed persistent UPJ obstruction on the left side. An Anderson-Hynes pyeloplasty was done subsequently. The patient was well at 18 months follow-up. Case 2
Case 1
A 27-year-old woman, gravida 2, para 0 was seen by us at 24 weeks of gestation with acute left flank pain and fever with chills. Physical examination showed marked left costovertebral tenderness. Urine angle 0020-7292/90/$03.50 @ 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
A 20-year-old primigravida was seen at 22 weeks of gestation with a 6-day history of worsening right flank pain and anuria. Physical examination revealed a palpable and tender right kidney. Her blood urea and serum creatinine were raised to 128 mg% Case Report
68
Mandal et al.
Case 1: (A) 30 min IVU film done 6 weeks after delivery shows picture of left UPJ obstruction. (B) 30 min IVU film done at 6 months follow-up shows good function and drainage of left kidney.
Fig. 1.
and 7.2 mg%, respectively but serum electrolytes were normal. Ultrasonography revealed bilateral hydronephrosis, more on the right side. The cortical tissue was 9-10 mm thick on the right side but very thin on the left side. A right PCN was done under ultrasound guidance using a 7F pigtail catheter. The patient improved rapidly and her serum creatinine stabilised at 1.0 mgcrlo by the seventh day following PCN. The PCN was maintained and she delivered a healthy male newborn at 38 weeks. An IVU 6 weeks later revealed bilateral calculus ureteral obstruction with non-visualisation of the left renoureteral unit. Simultaneous bilateral lower third ureterolithotomy was carried out subsequently. At 6 months follow-up, an IVU showed good function on the right side and recovery of function on the left side. Int J Gynecol Obstet 32
Case 3 A 24-year-old nurse was referred to our Clinic with recurrent attacks of pyelonephritis and right-side abdominal pain. She had married 3 months prior to the onset of these complaints and taken multiple courses of antimicrobials without a lasting benefit. She missed her last menstruation 2 weeks previously. Physical examination revealed a tender and cystic mass measuring 15 x 12 cm in the right lumbar region extending onto the midline. An obstetric check-up confirmed her pregnancy. Her routine and renal function tests were normal and a urine culture was sterile. An IVU, done a month earlier showed a horse-shoe kidney with nonvisualisation of right moiety. Therefore an ultrasound guided right PCN was done. The
PCN duringpregnancy
69
Case 2: (A) IVU film 6 weeks after delivery shows bilateral calculus ureteral obstruction and non-visualisation of left Fig. 2. kidney. The PCN catheter is seen on the right side. (B) 10 min IVU film done at 3 months follow-up shows good function on the right side and recovery of function of the left kidney.
PCN initially drained pus but started draining clear urine within a week. The PCN was maintained and her pregnancy continued to term. At 38 weeks, she had to undergo a cesarian section, following a failed induction of labor, A healthy female baby was born. An antegrade pyelogram 6 weeks after delivery revealed persistent UPJ obstruction for which an Anderson-Hynes pyeloplasty was done subsequently. This patient is on followup and is doing well. Comments Traditional forms of diversion including retrograde passage of ureter-al catheters and operative nephrostomy require anesthesia in sick and uremic patients. An indwelling Foley catheter, which is needed to anchor the ureteral catheter, predisposes patients to an
increased risk of cystitis [5]. Long term catheterisation is uncomfortable and ureteral catheters can be dislodged easily. Use of internal double J-stents during pregnancy has been emphasised recently [4]. However, ureteral stents are not without complications. Pyelonephritis from severe encrustation [l] and clinically significant stone formation, requiring open removal of stent has been reported [7,9]. The stents also increase the risk of ascending pyelonephritis by causing reflux [5]. To minimise these potential risks in our patients, we chose to perform antegrade drainage of the obstructed kidney by PCN. PCN has been accepted as the procedure of choice in virtually all cases of urinary obstruction requiring temporary nephrostomy drainage [6]. It is useful for initial drainage of infected urine, for patient stabilCase Report
70
Mandal et al.
isation and for evaluation of residual kidney function prior to definitive surgery [lo]. In our patients, PCN was easily accomplished under local analgesia and ultrasound guidance, thus avoiding radiation exposure of PCN during pregnancy. Maintenance allowed uneventful continuation of pregnancy to full-term and effectively preserved and helped in recovery of renal function. Definite surgical correction was accomplished electively 6-8 weeks after delivery. Most problems with PCN tubes are mechanical, i.e. the tubes get dislodged or drainage is blocked by formation of sedment [3]. Use of wide-bore pigtail catheter, proper fixation of catheter to the skin and liberal fluid intake by the patient, can ensure minimum occurrence of these problems. Ureterorenoscopic extraction of obstructing stones during pregnancy has been reported [7]. However, potentially serious complications requiring operative intervenureteral tion (e.g. ureteral perforation, avulsion and ureteral stricture) have been reported with this procedure [2,8].
2 3 4
5
6 7 8
9
10
Chang R, Marshall PP: Management of ureteroscopic injuries. J Urol 137: 1132, 1987. Claes H, Vereecken RL. Oyen R: Use and maintenance of percutaneous nephrostomy. Urol Int 41: 434, 1986. Laughlin KR, Bailey RB: Internal ureteral stents for conservative management of ureteral calculi during pregnancy. N Engl J Med 315: 1647, 1986. Quinn AD, Kusuda L, Amar AD, Das S: Percutaneous nephrostomy for treatment of hydronephrosis of pregnancy. J Ural 139: 1037,1988. Renzek RH, Tahrer LB: Percutaneous nephrostomy. Radio1 Clin North Am 22: 393, 1984. Rodriguez PN, Klein AS: Management of urolithiasis during pregnancy. Surg Gynaecol Obstet 166: 103.1988. Schultz A, Kristensen JK, Bilde T, Eldrup J: Ureteroscopy: results and complications. J Urol 137: 865, 1987. Spimak JP, Resnick MI: Stone formation as a complication of indwelling ureteral stents: a report of 5 cases. J Ural 134: 349, 1985. Yoder IC, Lindfors KK, Pfister RC: Diagnosis and treatment of pyonephrosis. Radio1 Clin North Am 22: 407, 1984.
Address for repritns:
References 1 Abber JC, Kahn RJ: Pyelonephritis from severe encrustation on silicone ureteral stents: management. J Urol 130: 763, 1983.
Int .I Gynecol Obstet 32
S.K. Sharma Department of Urology Postgraduate Institute of Medical Education & Research Chandigarb 160012, Indii
Znt. J. Gynecol. Obstet., 1990,32: 67-70 International Federation of Gynecology and Obstetrics
The use of percutaneous
diversion during pregnancy
A.K. Mandal, S.K. Sharma, A.K. Goswami, A.K. Hemal and R. Indudhara Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012 (Zndia) (Received December 13th, 1988) (Revised and accepted April 12th, 1989)
Abstract
Two patients with infected hydronephrosis and one patient with calculus anuria during pregnancy were managed initially by percutaneous nephrostomy. Maintenance of percutaneous diversion allowed continuation of pregnancy to term and effectivet’y preserved renal function. Definite surgical treatment for the obstructive pathology was done electively in the postpartum period. Keywords: Obstructive uropathy;
Percutaneous nephrostomy; gery in postpartum period.
Pregnancy; Definitive sur-
Introduction
To minimise the potential morbidity of the mother and fetus, early intervention with in an proximal diversion is imperative acutely obstructed kidney during pregnancy. Three such patients managed by our services at the Postgraduate Institute of Medical Education and Research, Chandigarh, during the last 3 years are presented.
showed numerous pus cells and grew E. coli on culture. Blood urea and serum creatinine were normal. She did not improve with systemic antibiotics. Renal ultrasound examination showed marked hydronephrosis on the left side. Percutaneous needle puncture under ultrasound guidance revealed frank pus necessitating placement of an 8F pigtail catheter as percutaneous nephrostomy (PCN) drainage. The patient made prompt recovery with percutaneous drainage and a short course of antimicrobial therapy. The PCN started draining clear urine by the third day following the procedure. The pregnancy continued uneventfully to term while PCN was maintained under close supervision. She delivered a healthy male newborn at 37 weeks. Six weeks later the patient returned with a slipped out PCN catheter. She was asymptomatic and there was no urine leak from the PCN site. So an IVU was obtained to evaluate the upper urinary tract. This showed persistent UPJ obstruction on the left side. An Anderson-Hynes pyeloplasty was done subsequently. The patient was well at 18 months follow-up. Case 2
Case 1
A 27-year-old woman, gravida 2, para 0 was seen by us at 24 weeks of gestation with acute left flank pain and fever with chills. Physical examination showed marked left costovertebral tenderness. Urine angle 0020-7292/90/$03.50 @ 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
A 20-year-old primigravida was seen at 22 weeks of gestation with a 6-day history of worsening right flank pain and anuria. Physical examination revealed a palpable and tender right kidney. Her blood urea and serum creatinine were raised to 128 mg% Case Report
68
Mandal et al.
Case 1: (A) 30 min IVU film done 6 weeks after delivery shows picture of left UPJ obstruction. (B) 30 min IVU film done at 6 months follow-up shows good function and drainage of left kidney.
Fig. 1.
and 7.2 mg%, respectively but serum electrolytes were normal. Ultrasonography revealed bilateral hydronephrosis, more on the right side. The cortical tissue was 9-10 mm thick on the right side but very thin on the left side. A right PCN was done under ultrasound guidance using a 7F pigtail catheter. The patient improved rapidly and her serum creatinine stabilised at 1.0 mgcrlo by the seventh day following PCN. The PCN was maintained and she delivered a healthy male newborn at 38 weeks. An IVU 6 weeks later revealed bilateral calculus ureteral obstruction with non-visualisation of the left renoureteral unit. Simultaneous bilateral lower third ureterolithotomy was carried out subsequently. At 6 months follow-up, an IVU showed good function on the right side and recovery of function on the left side. Int J Gynecol Obstet 32
Case 3 A 24-year-old nurse was referred to our Clinic with recurrent attacks of pyelonephritis and right-side abdominal pain. She had married 3 months prior to the onset of these complaints and taken multiple courses of antimicrobials without a lasting benefit. She missed her last menstruation 2 weeks previously. Physical examination revealed a tender and cystic mass measuring 15 x 12 cm in the right lumbar region extending onto the midline. An obstetric check-up confirmed her pregnancy. Her routine and renal function tests were normal and a urine culture was sterile. An IVU, done a month earlier showed a horse-shoe kidney with nonvisualisation of right moiety. Therefore an ultrasound guided right PCN was done. The
PCN duringpregnancy
69
Case 2: (A) IVU film 6 weeks after delivery shows bilateral calculus ureteral obstruction and non-visualisation of left Fig. 2. kidney. The PCN catheter is seen on the right side. (B) 10 min IVU film done at 3 months follow-up shows good function on the right side and recovery of function of the left kidney.
PCN initially drained pus but started draining clear urine within a week. The PCN was maintained and her pregnancy continued to term. At 38 weeks, she had to undergo a cesarian section, following a failed induction of labor, A healthy female baby was born. An antegrade pyelogram 6 weeks after delivery revealed persistent UPJ obstruction for which an Anderson-Hynes pyeloplasty was done subsequently. This patient is on followup and is doing well. Comments Traditional forms of diversion including retrograde passage of ureter-al catheters and operative nephrostomy require anesthesia in sick and uremic patients. An indwelling Foley catheter, which is needed to anchor the ureteral catheter, predisposes patients to an
increased risk of cystitis [5]. Long term catheterisation is uncomfortable and ureteral catheters can be dislodged easily. Use of internal double J-stents during pregnancy has been emphasised recently [4]. However, ureteral stents are not without complications. Pyelonephritis from severe encrustation [l] and clinically significant stone formation, requiring open removal of stent has been reported [7,9]. The stents also increase the risk of ascending pyelonephritis by causing reflux [5]. To minimise these potential risks in our patients, we chose to perform antegrade drainage of the obstructed kidney by PCN. PCN has been accepted as the procedure of choice in virtually all cases of urinary obstruction requiring temporary nephrostomy drainage [6]. It is useful for initial drainage of infected urine, for patient stabilCase Report
70
Mandal et al.
isation and for evaluation of residual kidney function prior to definitive surgery [lo]. In our patients, PCN was easily accomplished under local analgesia and ultrasound guidance, thus avoiding radiation exposure of PCN during pregnancy. Maintenance allowed uneventful continuation of pregnancy to full-term and effectively preserved and helped in recovery of renal function. Definite surgical correction was accomplished electively 6-8 weeks after delivery. Most problems with PCN tubes are mechanical, i.e. the tubes get dislodged or drainage is blocked by formation of sedment [3]. Use of wide-bore pigtail catheter, proper fixation of catheter to the skin and liberal fluid intake by the patient, can ensure minimum occurrence of these problems. Ureterorenoscopic extraction of obstructing stones during pregnancy has been reported [7]. However, potentially serious complications requiring operative intervenureteral tion (e.g. ureteral perforation, avulsion and ureteral stricture) have been reported with this procedure [2,8].
2 3 4
5
6 7 8
9
10
Chang R, Marshall PP: Management of ureteroscopic injuries. J Urol 137: 1132, 1987. Claes H, Vereecken RL. Oyen R: Use and maintenance of percutaneous nephrostomy. Urol Int 41: 434, 1986. Laughlin KR, Bailey RB: Internal ureteral stents for conservative management of ureteral calculi during pregnancy. N Engl J Med 315: 1647, 1986. Quinn AD, Kusuda L, Amar AD, Das S: Percutaneous nephrostomy for treatment of hydronephrosis of pregnancy. J Ural 139: 1037,1988. Renzek RH, Tahrer LB: Percutaneous nephrostomy. Radio1 Clin North Am 22: 393, 1984. Rodriguez PN, Klein AS: Management of urolithiasis during pregnancy. Surg Gynaecol Obstet 166: 103.1988. Schultz A, Kristensen JK, Bilde T, Eldrup J: Ureteroscopy: results and complications. J Urol 137: 865, 1987. Spimak JP, Resnick MI: Stone formation as a complication of indwelling ureteral stents: a report of 5 cases. J Ural 134: 349, 1985. Yoder IC, Lindfors KK, Pfister RC: Diagnosis and treatment of pyonephrosis. Radio1 Clin North Am 22: 407, 1984.
Address for repritns:
References 1 Abber JC, Kahn RJ: Pyelonephritis from severe encrustation on silicone ureteral stents: management. J Urol 130: 763, 1983.
Int .I Gynecol Obstet 32
S.K. Sharma Department of Urology Postgraduate Institute of Medical Education & Research Chandigarb 160012, Indii