MANAGEMENT
OF POSTOPERATIVE
FISTULA OF
UPPER ,$JRINARY TRACT THOMAS HILDRETH, ALEXANDER
M.D.
S. CASS, M.B.B.S.
From the Department of Urology, St. Paul-Ramsey Hospital, St. Paul, Minnesota
ABSTRACT - The simple procedure of passage and withdrawal of a ureteral catheter hastens the closure of a urinary jistula after surgery of the ureter or renal pelvis.
During the past seven years the simple procedure of a one-time ureteral catheterization has been used to manage postoperative urinary fistula after ureterolithotomy and pyelolithotomy. This procedure has been described before in relation to managing urinary leakage after pyeloplasty.* Material Between July, 1968, and June, 1975, sixty-five straightforward nonstented ureterolithotomies, pyelolithotomies, and pyeloplasties were performed on 59 patients. Excluded were sixty-three ureterolithotomies, pyelolithotomies, and pyeloplasties in 36 patients who had associated procedures, stents or altered anatomy: nephrostomy, nephrotomy, excision of calyceal diverticulum, infundibulectomy of a horseshoe kidney, ureterostomy, ureteral reimplantation, or a previous ileac diversion. Another 2 patients died in the immediate postoperative period (myocardial infarction; acute pancreatitis) accounting for 97 consecutive patients (130 procedures) during these seven years. Interrupted 4-O or 5-O chromic sutures were used for closure of pyelolithotomies and ureterolithotomies. Continuous 4-O or 5-O chromic sutures were used with the Foley dis-
membered or Anderson-Hynes pyeloplasties. In all patients a Penrose drain to the closure site was left in place until approximately the seventh postoperative day when it was removed if no urinary drainage was present. There were eleven postoperative urinary fistulas (17 per cent) in the sixty-five procedures (Table I). A urinary fistula was defined as urine leakage beyond the seventh postoperative day and soaking of more than one 4 by 4 gauze pad per eight-hour period. Technique and Results In 9 of 11 patients with a postoperative urinary fistula a 4 or 5 F ureteral catheter was passed via cystoscope up to the renal pelvis and then withdrawn. Rapid cessation of urine leakage occurred one to four days after this simple procedure. Three of the 9 patients had a urinary tract infection with lo5 or greater colonies per milliliter at the time of passage of the ureteral catheter (Table I). The remaining 2 patients with a postoperative urinary fistula were managed conservatively, and their fistulas closed spontaneously in eleven days (urine infected) and fourteen days (urine sterile). Comment
*ANDERSON, J. C.: Hydronephrosis, Springfield, Illinois, Charles C Thomas Co., 1963, p. 63.
It is postulated that a functional and/or mechanical obstruction occurs at or below the closure site
264
UROLOGY
/ MARCH 1976 I
VOLUME
VII, NUMBER 3
TABLE
I. Urina y jistula
,-
Procedure Pyeloplasty Pyelolithotomy
Number
Urinary Fistula
9
0
31
6
Number
Passage and Withdrawal of Ureteral Catheter--, Duration of Fistula Duration of Fistula Before After Urinary Tract Infection (Days) (Days)
. . . 5
. . . 9
7
Ureterolithotomy
26
5
4
because of postoperative edema or cellular debris. This obstruction is sufficient to prevent the passage of urine down the ureter and results in urinary fistula. Passage and withdrawal of a ureteral catheter acts merely as an obturating force to
UROLOGY
/ MARCH1976
/ VOLUMEVII,
NUMBERS
14 9 18 7 9 7 13
. .
3 3 1 2 2 1 2 2 4
‘id Yes No Yes No No Yes No No
break the “log jam” allowing urine and accumulated debris to pass normally down the ureter. 640 Jackson St. Paul, Minnesota 55102 (DR. CASS)
265