Erich
K. Lang,
MD
Percutaneous Management and Infundibular
Infundibuloplasty: ofCalyceal Diverticula Stenosis’
T
Calculi in calyceal diverticula or behind stenotic renal infundibula are generally managed with percutaneous extraction. Percutaneous infundibuloplasty, a relatively noninvasive technique, is advocated to drain and eradicate the potentially infected space and can be performed at the same time as stone extraction. A communication between the diverticulum
and
renal
pelvis
is created
by
passing a transjugular cholangiographic needle under fluoroscopic or visual guidance, dilating the tract with a balloon catheter, and placing a stent until uroepithelial coverage has occurred. Stenotic infundibula are dilated in a like fashion. During 7 years, six (60%) of 10 patients with such “neoinfundibula” draining calyceal diverticula remained patent for at least 2 years. In two more patients (20%), both the calyceal diverticular cavity and neoinfundibulum were obliterated; in only one patient (10%) was there a residual cavity after the neoinfundibulum became obstructed. One patient was lost to follow-up. Long-term
correction
of infundibular
stenoses was achieved with this technique in four (67%) of six patients, and there were no renal or perirenal abscesses. Index terms: Kidney, calculi, 813.811 #{149} Kidney, diverticuta, ney, infection, 81.20 #{149}Kidney, procedure, 81.1299 . Kidney, Radiology
1991;
812.811, 812.3115 #{149} Kidinterventional stone extraction
181:871-877
From the Department of Radiology, Louisiana State University Medical Center, 1542 Tulane Ave. New Orleans, LA 70112-2822; and Charity Hospital of Louisiana at New Orleans. From the 1990 RSNA scientific assembly. Received January 22, 1991; revision requested March 4; final revision received July ii; accepted July 19. Address reprint requests to the author. © RSNA, 1991 I
is controversy as to the cause of pyebocalyceal diventicula; they are thought by some to be congenital in origin and by others to be the end stage of an intranenal abscess. It is generally agreed that about 40% contam calculi and may be associated with persistent infection (1,2). For these persistent infections to be eradicated, the calculi must be removed (3). These stones are formed secondary to colonization by unease-producing microorganisms, and their infective natune mandates adequate drainage or excision of diverticula harboring such stones. A number of surgical procedunes have been advocated for that purpose. Open surgery with either marsupialization and fulguration or excision of the diverticulum and closure of the narrow neck by means of nephnotomy are techniques with a proved high success rate (4). Internal drainage by means of operative infundibuboplasty, that is, either developing a flap from the pelvis or combining sevenal infundibula by spatulation (Y-V type of anastomosis) to create a more spacious infundibubum, is another option (5). With the increasing popularity of percutaneous stone removal, placement and retention of a nephrosHERE
tomy tube for 2 weeks has been advocated to drain and eventually oblitenate the diverticulan space (6-8).
Fulguration neck another
of the
diverticulum
and
vision is obliterate the diventicubum. Should the presumed calyceal diverticulum be a hydrocalyx, however, fulguration and obstruction of the tract might cause redevelopment of the cavity and, in the presence of infection, abscess formation. Dilation of the neck of the
its
diventiculum
by means of direct option to speedily
by using
a 24-F
tele-
scopic dilator (Olympus-Winters & the, Hamburg, Germany) is another technique useful for establishing drainage from the infected space (9). To minimize surgical intervention
and facilitate complete and drainage at one developed a technique ous infundibuboplasty formed immediately
stone removal sitting, we have for percutanethat can be perafter percutaneous stone removal from a calyceal diventicubum or hydnocalyx behind a stenotic infundibubum.
PATIENTS
AND
METHODS
Patients Since plasties tients 23-60 boring
1983, have
percutaneous been performed
infundibuboin 10 pa-
(six men, four women; age range, years) with catyceal diverticula hama calculus. Criteria for inclusion in
this study were as follows: (a) known and demonstrated calyceal diverticulum contaming a calculus or calculi, (b) evidence of repeated urinary tract infections, (c) clinicab symptoms, or (d) delayed filling and emptying of the calyceal diverticulum seen
on
intravenous
compromise debris.
Repeated
Proteus, had
urograms,
of drainage
urinary
tract
Pseudoinonas,
been
or
demonstrated
infections appeared by the same species
suggesting
by
the
calculus
infections
infection Phage carried
coating patients,
was documented indicating that
with
Klebsiella
species in all patients.
to have been of organism
original recurrence. not been
of the
Re-
caused of the
and therefore suggested typing, however, had out. Positive antibiotic in eight of the 10 the bacteria origi-
nated from an infection in the upper nary tract. Septicemia had been documented in two (Table 1). Temporary control
or
urinary
tract
infection
un-
and
septicemia was achieved in all patients with aminoglycoside and 13-tactamaseresistant cephatosponins and in two patients
with
A history from eight
clindamycin
and
cefoxitin.
of persistent pain patients, hematunia
was elicited from four,
and recurrent urinary infections from all 10. The presence of diverticula harboring calculi was known in all patients for at least 6 months and had been followed in
Abbreviation: wave tithotripsy.
ESWL
=
extracorporeal
shock-
871
Table
1 Management
of Calyceal
Diverticula
with
in 10 Patients
Stones
Findings
Management Preoperative
Urine Stone Stone
1
2
Early-filling Interventional
(d) Complications Size of stent (F) Time stent retained
=
septicemia, WU RU = radionuclide did not fill early.
P
PS
P
K
P
P
K
P
+
+
-
+
+
+
+
S
S
CA
S
S
S
S
0
0
0
0
0
0
0
0
0
0
+
+
-
+
+
+
+
-
+
MgAP
MgAP
E
E
E
75
60
45
2
4 +B
-
(wk)
and
of the calculus of a new
of patent
8
8
8
8
6
6
4
6
drainage,
calculus
Radiology
#{149}
E
E
60
60
2
2
3
4 +B,gr-
-
(+)-
2 -
6
5
(+)-
-
E 75
7 gr-
4
8 8
10 6
8 6
l
6
E 105
-
(+)-
-
-
+
+
LTF
+
-
-
+
ND
ND
ND
-
-
LTF
-
-
-
-
Table 2 Management
and failure
communication on evidence
in the
Preoperative Unineculture Stoneculture
with
2
SE +
=
in Six Patients
Stones
1
0
by Patient
No.
3*
4
M
P
+
+
S(D) ND
S(D) ND
S ND
+
+
+
+
+
E 75 2
E 90 1
-
-
Hem
8 8
8 8
20/12 1/6
-
-
-
+
+
-
+
-
-
+
+
5
6
K
P
C
-
-
diagnosis
Stone composition Early-filling
NU
Late-retention IVU RU with furosemide washout, ERPF Interventional procedure Removal of stone Procedure time (mm) Length of hospitalization (d) Complications Size of stent (F) Time stent retained (wk) Follow-up Urine culture IVU-patency of neoinfundibulum RU with Lasix washout, ERPF
of
+
MgAP
CP
S(D)
ND
ND
ND
+
+
+
+
+
+
-I-
E 181) 5
US + E 75 1
E 45 2
E 50 1
+B iO
-
-
8
8
6
6
6
-
-
-
+
+
-
(+)-
Note.-+B = positive blood culture, C = Escherichia coli, CP = calicified papilla, D = debris, E = extraction, ERPF = estimated renat plasma flow rate, Hem = hemorrhage, IVU = intravenous urogram, K = K!ebsiella, M = Mycoplasma, MgAP = magnesium amnionium phosphate, ND = no data, P = Proteus, RU = radionudlide urogram, S = struvite, SE = Staphylococcus epidermidis, US = ultrasound lithotnipsy, (+)= positive at first, then negative. *Two stents of diffenrent sizes were used in this patient.
of the
sat-
of com-
hydrocalyx.
Stenosis
Management
(b) demonsystem,
of Infundibular
Findings
tom-
criteria had to be met for patients to be included in this series: (a) suggestion of a stenotic infundibulum on an intravenous urogram (n = 6) or retrograde urogram (n = 1); (b) confirmation
872
E
60
+
plete obliteration and disappearance of the diverticulum; (c) lack of recurrent unnary tract infections; and (d) resolution and disappearance of clinical symptoms such as pain and hematuna. Six patients (five men, one woman; age range, 34-47 years) underwent treatment for an infundibular stenosis with a catcu-
The following
US+E 80
+
computed
calculus;
to the collecting
or debris
-
positive blood culture, CA = carbonate apatite, ND = no data, E = extraction, ERPF = estimated renal plasma flow rate, gr- = gram-negative = intravenous urography, K = Klebsiella, LiT = tost to follow-up, MgAP = magnesium animonium phosphate, P = Proteus, PS = Pseudomas, urogram, S = struvite(magnesium ammonium calcium phosphate), US = ultrasound lithotnipsy, (+)= positive at first, then negative,
radiogmaphs
diverticulum
US4-E 120
2
(CT) scans is consistent with the commonly seen radiographic appearance of struvite (magnesium ammonium calcium phosphate) and cambonate-apatite calculi. After removal, all calculi were analyzed chemically, ground up, and cultuned. To ascertain success of treatment, the following parameters were assessed:
lus
10
+
ographic
isfactory
9
P
some for up to 3 years. None of the 10 patients showed a demonstrable communication between diverticula and the collectmg system on the early-phase intravenous (3-, 5-, and 10-minute) urograms (Fig ib). On delayed 30-, 45-, and 60-minute urograms, however, contrast medium-laden urine was retained in the diverticubum in eight of the 10 patients. This delayed filling and emptying of the calyceal diverticula suggested calculi in an occluding tocation that were probably responsible for the recurrent bouts of urinary tract infections (Table 1). A granular appearance of the
stration
8
+
-
IVU-patency of neoinfundibutum RU with furosemide washout, ERPF
reformation
7
P
Follow-up Urine culture
(a) removal
6
procedure
Removal of stone Procedure time (mm) Length of hospitalization
on
5
No.
-
S
IVU IVU
Late-retention
calculi
4
by Patient
diagnosis
culture culture composition
Note.-+B
3
Parameters
and
of the diagnosis by
means
(u
=
of functional
of a radionucide
6), abnormal
furosemide
Hoechst-Rousseb,
clide
Somerville,
urogram
segmental
(n renal
=
(e) clinical
flow
pain
(Lasix; NJ)
4), and/or
plasma
obstruction urogram
On
radionu-
of the
reduced rate
(ii
and
=
4)
(Table 2); (c) demonstration of a calculus or debris calculus in the compromised calyceal group; (d) documented evidence of repeated urinary tract infections; and/or
symptoms
such
as persistent
hematunia.
the basis calculi
of the granular on
radiographs,
thought
to be struvite
calculus
had
a characteristic
calculi;
appearance two
were
the
third
crescent
shape suggesting a sloughed papila with secondary catcifications. Three calculi were debris stones with elements of struvite (Table 2).
December
1991
All six patients
had
evidence
of three
to
12 documented occurrences of urinary tract infections with Proteus, Mycoplasma, or Klebsiella species, Staphylococcus epider-
midis, on Escherichia patients,
the
tuned
from urine of infection;
sodes ferent patients,
g. Figure 1. (a-c) as target for the
Intravenous probing
urograms 18-thin-walled
of the diverticulum. needle. Contrast
the catyceal diverticulum is conspicuously opacified from prior intravenous injection lyceal
tion
diverticulum
from
to the collecting
(Cook,
with
Bloomington,
from
(d) After
is wrapped
reference
removal
advanced under (Cook) is advanced
obscures
the
(c) Flexible around
of the
calculus,
control
into
calculus,
element
a calculus
6.) (d, e) Craphic
fluoroscopic
calculus serves the calculus in
tacking. (b) Collecting system of the left kidney is of contrast material. Much opacification of the ca-
injection
is lacking.
Ind)
permission,
toplasty.
direct
system
(a) Readily visible medium enveloping
and
in a calyceal
representation
a transjugulan
the kidney
demonstrable
of a Bentson
guide
diverticulum.
and
infundibu-
needle
a Lundenquist
wire
(Reprinted,
of percutaneous
cholangiographic
pelvis,
communica-
0.038-inch
(Cook)
guide
is
wire
through the transjugular sheath into the renal pelvis, the ureter, and, ultibladder. (e) Six-millimeter Blue Max balloon catheter (Medi-tech/Boston Scientific, Watertown, Mass) bridges the space from the calyceal diverticulum to the infundibulum and dilates the tract. (f) Radiograph demonstrates the location of the 6-mm balloon catheter seated across the space from the calyceal diverticulum to the infundibulum. A nephnostomy tube has mately,
the
been introduced into the posterior division of the midcatyceal group for the purpose of lavage and provision of additional egress should bleeding from the juxtainfundibular plexus be brisk. (g) Craphic representation of, first, an externalized and, later, an internalized stent placed and retained for 8 weeks (Fig I continues).
the
patients,
of appropriate
antibi-
of infections
of the
bouts
urinary
tract, period
however,
developed
of observation.
bacteriunia
use of multiple with proved
cul-
epiwere dif-
In four of the was temporarily
by means
during
was
during repeated in two, there
Recurrent
upper
of the
microorganism
microorganisms. the infection
controlled otics.
coli. In four
same
In two
persisted
despite
broad-spectrum efficacy in eradication
the
antibiotics of the
cultured bacteria. Three of the patients had positive results of the tuberculin skin test; there was no evidence, however, of urinary tract tuberculosis. Success was gauged with the following criteria: (a) documentation of a patent infundibulum infundibuloplasty,
of adequate
normalization
in the
segment
drocabyx
on a radionuctide
furosemide
radionuctide
obstructed
current urinary (e) disappearance able
to an
after or
of the
hy-
and (c) tack of a calculus in the previcalyx, (d) absence of metract infections, and/or of symptoms attmibut-
of re-formation ously
caliber
(b) improvement urogram
umogram,
obstructed
and
infected
calyx.
Methods A tract into
the
for routine calyceal
percutaneous
diventiculum
byx was established. had been attained,
needle
(Bard
erica,
After local anesthesia a 6-inch 18-thin-walled
Candiosurgery
Mass)
was
posterotaterat
introduced
approach
the calculus
with
and
fluoroscopic
readily visible calculus (Fig ia). Crepitation,
h. Figure
(h)
1 (continued).
patency travenous (arrowheads)
Follow-up
of the neoinfundibulum urogram and
obtained opacification
i
years later demonstrates continued cation of the calyceal diverticutum.
Volume
181
Number
#{149}
3
study
and
prompt
years of the
obtained
later shows diverticulum.
patency
after
drainage
removal
from
of the
the catyceal
continued patency (j) Intravenous
of the neoinfundibulum
stent
demonstrates
diverticulum.
of the urogram
(i) In-
neoinfundibulum obtained 3/2
(arrowhead)
and
Division,
Bill-
by means
of a
advanced
to
control.
served elicited
The
as the target when the
needle engaged the calculus, indicated attainment of the goal. Injection of 1-2.5 mL of air distended and demonstrated the
j.
i.
access on hydroca-
opacifi-
diverticulum.
wire
was
ulum, and the calculus verticulum
A 0.038-inch
then
advanced
its floppy (Fig Ic). with
air
end
Bentson
guide
into the diverticcoiled around
Distention facilitated
of the
di-
advance-
Radiology
#{149} 873
li_A a.
C.
b.
ment of the guide wire around the calculus. The guide wire was advanced until the stiff component extended from the point of entry to the calyceal diverticutum.
The tract was then fashion a 28-F seated.
second was
dilated
in a
with Amplatz dilators Amplatz sheath (Cook) No attempt was made safety
then
scopic
guide
retrieved
control
mentation ble2).
The
calculus
by means
either
with
Removal
wire. in toto
of endoor after
an ultrasound
of calculi
from
customary
(Cook) until could be to place a
frag-
probe
(Ta-
hydrocatyces
behind a stenotic infundibulum was carried out in a like fashion. In five patients, a single guide wire was coiled in the dilated calyx harboring the calculus; in the sixth patient, the guide wire and the safety guide wire could be passed through the stenotic infundibutum into the pelvis, ureten, and bladder. Unlike the situation in our patients with calyceal diverticula, a communication strated
to the
in alt patients
pelvis with
was
demon-
stenotic
in-
fundibuta by injection first of air and then diluted contrast medium. Infundibuloplasty was performed unden either endoscopic or fluonoscopic controt. In nine patients with calyceat diverticula, communication to the renal pelvis or major catyx was established with fluoroscopic guidance; in the other, endoscopy was used. The collecting system was opacified by prior intravenous administra-
tion of contrast lum,
into
been
advanced,
medium.
phy
curved needle
through
874
the
transjugular
the instrument
Radiology
#{149}
Amplatz
was outlined
(Cook)
was
e.
Figure 2. (a-il) Intravenous unograms. (a) Infundibulan stenosis compromises the superior calyceal group of the left kidney. (b) Under visual control, a guide wine and safety wine are advanced through the strictuned infundibulum into the renal pelvis, ureter, and bladder. (c) Four-millimeter high-pressure Blue Max balloon catheter (Medi-tech/Boston Scientific) is seated and fully distended in an attempt to dilate the stricture. (d) Twenty-four-French Foley catheter is used as a temporary stent to control bleeding. Later, an internalized stent with the
upper
coil in the superior
calyx
and
the lower
one
placed
in the bladder
is seated
and
retained
in position for 8 weeks. Hemorrhage occurring immediately after transtuminal dilation was believed to be secondary to bleeding from the periinfundibular venous plexus. (e) Antegrade urogram obtained 2 years later demonstrates a widely patent infundibulum of the superior calyceal group. Obstruction of the uneteropetvic junction was caused by a stoughed papilla.
The diverticu-
sheath had by an injection of air. The patient was placed in a prone 45#{176} anterior oblique position, with the affected side elevated. Two right-angle madiographs on right-angle C-arm fluoroscopy established the projected path from the diverticulum to the renal pelvis. A mildly
which
d.
cholangiograthen
advanced
channel
of the
and along the predetermined tract into the pelvis or a major calyx (Fig id). A C- or U-arm fluoroscopic unit facilitated monitoring of the advancement of the needle. Once the renal pelvis or major cabyx cystoscope
projected
was sheath the
entered, was needle
or Lundenquist
the
transjugulan
needle
advanced
over
the
exchanged
for
a stiff
guide
wine
needle Ampbatz
or Clidewine
and
(Cook). These were advanced with fluonoscopic guidance through the ureter into the bladder (Figs if, 2b). A high-pressure balloon (Medi-tech/Boston Scientific) of appropriate
length
and
a 4- or 6-mm
ameter was then seated, which the space from the diventicubum pelvis
(Figs
le,
if,
2c).
The
di-
bridged to the
balloon
flated with diluted contrast solution kept inflated for at least 2 minutes.
December
was
in-
and
1991
Follow-up
of patients
fundibular culus
stenosis,
consisted
furosemide
treated
for in-
hydrocalyx,
and
cab-
of madionuclide urograms; radionucide urograms ob-
tamed
at 6 months
i-year
and
and,
2-year
thereafter,
intervals;
at
urine
cultures
at 2 weeks, 1, 3, and 6 months and, thereafter, at yearly intervals if negative or at more frequent intervals as necessary for clinical management if positive; and intravenous urograms obtained 2-3 months after the procedure and, thereafter, at i-year
and
2-year
intervals.
RESULTS Fifteen
(94%)
of 16 patients
treated
by means of percutaneous infundibubopbasty and stone removal for cabyceal diverticula (n = 10 [62%]) on a.
infundibuban (n = 6 [38%])
b.
Figure
3.
(a) Intravenous
unogram
shows
externalized
stent
being
seated
under
visual
con-
beast
up
treated with calculus The calculi
this
intravenous
cessfulby
been
seated;
urogram.
The
from
calyceal
diverticulum
the catyceat
After the balloon was fully distended and collapse without re-formation of a documentabbe deformity was achieved, a 10-F on 8-F pigtail catheter was placed as a stent
(Fig
ig).
The
pigtail
vanced into the renal tional side holes were catheter to be situated cabyceal diventiculum. secures
the
catheter
vis, the distance diverticulum appropriate holes, despite
catheter
was
ad-
pelvis, and addicut into the 10-F at the level of the Since the pigtail in position
from
pelvis
in the
peb-
to cabyceab
was constant, which location of the added respiratory motion
is collapsing.
diverticulum
assured side of the
into
An
externalized
stent
has
ble-J polyethylene stent (Medi-tech/Boston Scientific) of appropriate length was then seated by means of fluomoscopy with the upper coil in the calyceal diverticulum or hydrocatyx and the lower coil in the bladder. On the basis of sensitivity studies of voided urine, all patients underwent a regimen of broad-spectrum antibiotics for 2-3
days
before
and
procedure. Doxycycline Morris
7-10
hyclate
Plains,
NY),
was lost to follow-up. in diverticula were suc-
removed
in all 10 patients. of these calculi
Chemical analysis vealed that seven calculi; one (10%)
the bladder.
days
after
(Warner
100
mg
(80%)
were
of the
phosphate
cultured
10 calculi
from (Table
1).
In seven patients (70%), urine cubtunes were negative at the follow-up examinations performed 2 weeks after the procedure and remained negative thereafter. In three patients (30%), positive
the
urine
cultures
were
reported
in the first 3 postoperative months. The bacteria proved sensitive to anti-
Chibcott,
twice
eight
Bacteria
me-
(70%) were struvite was a carbonate and two (20%) were
apatite calculus, magnesium ammonium
calculi.
calculi
up for at to 7 years. One patient for a cabyceal diverticubum
2 and
trol. The coil of the 8-F pigtail catheter is in the renal pelvis. Side holes have been cut into the catheter at an appropriate location to drain the calyceal diverticulum. The coil in the pelvis retains the catheter in an unchanged position to the calyceal diverticulum. (b) Injection of contrast medium through the externalized stent shows patency of the neoinfundibulum on it extends
stenoses with were followed
daily,
biotics,
however,
and
subsequent
the medication most often administered to asymptomatic patients. The negimen was started 2 days before and continued for 7 days after the procedure. Cephapinn sodium (Cefaton; Stuart, Wilmington, Del), 2 g administered intma-
urine and blood cultures tive. In one of these three
Infundibular stenosis was first characterized on intravenous urograms and antegrade urograms performed by injecting diluted contrast medium into the accessed calyx (Fig 2a). A guide wine was then advanced with endoscopic control in five of the patients, and with fluoroscopic control
muscularly
cemia developed within ‘/2 hour after completion of the procedure in one patient, who had previously experienced septic episodes despite appropriate antibiotic coverage. This patient recovered with standard
into
intervals, intervals
The
externalized component of the stent permits drainage from the catyceal diverticulum to the outside and via the internalized segment to the renal petkidney.
vis
(Fig
3).
the
pelvis
and,
subsequently,
the
ure-
ten and bladder in one patient (Fig 2b). Dilation was carried out in an identical manner (Fig 2c). The externalized stent was generally maintained in position for 4 weeks. Thereafter, stent.
it was converted to an internalized One of our patients with a calyceal
diverticulum and another with an infundibular stenosis, however, underwent treatment with an externalized stent only. To exchange the externalized stent for an internalized
(Glidewire, introduced advanced
Volume
stent,
a stiff
guide
wire
Lundenquist, or Ampbatz) was with fluoroscopic control and into the bladder. An 8-F dou-
181
#{149} Number
3
was
and
1 g every
6 hours,
was
also
used.
Follow-up stone removal
of patients who and percutaneous
ulopbasty
for
calculi
consisted
of urine
2-week,
in calyceal cultures
1-, 2-, 3-, and if negative, as necessary
of urine
and
diventicuba
obtained
6-month,
at
and
on at more for clinical
ment. Antibiotic treatment according to culture and ies
underwent infundib-
yearly
frequent manage-
was modified sensitivity stud-
ground
calculi
retrieved
from the caliceal diverticulum. Intravenous unograms were obtained 2 and 6 months or 1 year after the procedune (Table 1). Three tomographic sections at the appropriate level obtained immediateby
after
complemented In addition, at 6-month, vals
with
sessment
infusion
of the
contrast
the intravenous all patients were 1-year, and then madionuclide
of renal
unography
function.
medium
urogram. followed up 2-year interfor
as-
were
only one negative postoperative culture was obtained before to follow-up. A gram-negative
treatment
consisting
nega-
patients, urine being lost septi-
of corticostem-
oids, vasopressons, antibiotics, and volume expansion. In three (30%) other of the 10 patients, positive blood cultures were recorded during the first two postoperative days (Tabbe 2). With appropriate antibiotic treatment, the blood cultures became negative on the third day; a positive urine culture, however, persisted in one of these patients for 3 months. A patent neoinfundibubum was demonstrated on follow-up intravenous unograms in six (60%) of the 10 patients
(Fig
ic,
lh-lj).
In three
Radiology
pa#{149} 875
tients (30%), the communication to the pelvis or major calyx appeared to have been obliterated. Nephrotomograms demonstrated that in two of the three, there was no evidence of a residual cavity at the site of the prior cabyceab patients
smaller cavity
diverticubum. Only one of the showed evidence of a much
but on
still identifiable
residual
nephnotomograms
(Table
i).
Ten-French externalized stents were used in four patients, and 8-F externalized stents were used in six. All internalized stents were 8-F. The
bum;
an unusually however,
calyx, strated
on
prominent
had
the
initial
infundibubum. Techniques for percutaneous entry into such structures have been refined during the past 10
hydno-
been
demon-
pnepmocedurab
intravenous urogram. Significant loss of functioning parenchyma of the involved segment was preexistent. The operative time for infundibuboplasty
and
stone
extraction
from 45 to 180 (average, There was no substantial operative time whether uboplasty was performed scopic
or endoscopic
varied
85) minutes. difference in the infundibwith fluorocontrol.
of hospitalization
was
Length
1-5 (mean,
2)
2). hemorrhage
be no correlation between obliteration of the tract and length of time of use or size of the stent. The operative times for the intervention were 45-120 (average, 74) minutes. The patients were hospitalized for 2-8 days (Table 1). The calculi harbored in hydrocaby-
one patient. nated from nous plexus,
It appeared to have origithe periinfundibulam yewhich may have been
ces
charged
were
and
retained weeks.
in position variThere appeared to
behind an infundibubar stenosis successfully removed in all six patients. Two of these, which were
solid calculi, were found to be struvite at chemical analysis, a third was a calcified sboughed papibla, and three were debris stones containing struvite (Table 2). Bacteria were cultured from four of the six stones. In five (83%) of the six patients, fobbow-up urine cultures were negative over periods of 2-7 years. In the sixth patient (17%), positive urine cultures persisted
for
i month
despite
appro-
pniate therapy with antibiotics that were proved effective against the cubtuned bacteria. Thereafter, however, urine cultures became and remained negative for a follow-up period of 2 years.
The
same
patient
also
had
posi-
tive results of blood culture 2 weeks after the intervention, which then became negative during treatment with appropriate antibiotics (Table 2). Follow-up intravenous unograms demonstrated unabated patency of the dilated infundibubar stenosis in four (67%) of the patients over a foblow-up period of 2-7 years (Fig 2e). In two patients (33%), there was significant restenosis 6 months and i year after the initial infundibuboplasty. One of these patients showed progressive loss of renal panenchyma of the afflicted segment (Table 2). Follow-up radionuclide furosemide washout unograms showed normalization in three (50%) of the patients but deterioration in the other three (50%).
Two
riomating nificant urograms. showed 876
of the
patients
with
dete-
function demonstrated sigrestenosis on intravenous The third patient, however, a widely patent infundibu-
#{149} Radiology
ruptured
during
occurred
balloon
ble 2). Bleeding was controlled tamponade of the region with Foley
catheter
(Fig
complication,
the on
had
the
2d).
(Ta-
by a 24-F
Despite
patient
6th
in
dilation
this
was
dis-
postoperative
an uneventful
day
recovery.
DISCUSSION Although extracorporeab wave lithotripsy (ESWL) cessfully 85%
notable use
in the
shockis used suc-
management
technique
(iO,il).
ments
passage of fragthe effective use
is
of
ESWL. of infected cabculi in a confined space such as a diverticulum possibly might provoke septicemia and abscess formation (13i5). Heminephmectomy
as advocated
in
the urology literature (3,5) would memove both the calculus and a space harboring potentially infected debris. Open surgery for stone removal and subsequent
drainage of the diverticuaccomplishes the goals
bum likewise of removal of the stone and proper drainage of the potentially infected space.
The
surgical
interventions,
however, are attended by a prolonged hospitalization and recovery period and loss of pamenchyma if heminephnectomy is performed. Percutaneous stone removal is an excellent alternative in the management of calculi in calyceab diverticula or calyces
compromised
by
stenotic
widely
used
(6-9).
of this space formation
is mandaof an intra-
renal means
abscess. As documented of surgical experience,
space
can
be drained
sive
by the
to the
outside
instances will eventually (2,4). Since the offen-
organisms
are
usually
known
from findings of cultures of the stone and debris, effective antibiotic thenapy
can
be maintained
during
the
initial period of drainage. Fulguration of the diventicubum after removal of the calculus has been advocated as a way to obliterate the diverticubar space and discharge the patient tube-free (7). This procedure, however, is fraught with potential risks. Should the presumed cabyceal diventiculum be a hydnocabyx, fulguration of the cavity would obstruct the collecting ducts draining into the
cavity,
obstruction, in formation
which,
to an
in turn, of a sec-
if infected,
can
abscess.
To shorten the time of external drainage and to address the urobogic dictum of establishing internal drain-
Calculi
(6,8,i2). The mere of the calculi, which ESWL, does not solve
to permit precludes Fragmentation
now
Drainage to prevent
progress
the problem. Lack of communication to the collecting system, pelvis, ureter, and bladder or a communication too narrow
bris. tony
ondamy
in calyceab diventicula and calculi behind stenotic infundibuba are two such exceptions fragmentation possible with
are
hydnocalyx. This is likely to result
of about
of renal calculi, theme are some exceptions that preclude the
of this
and
There remains, however, the problem of a confined space with inadequate or absent drainage that may contain residual fragments and infected de-
and in many be obliterated
days (Table A massive
stents were ably for 4-8
years
age whenever possible, surgical infundibuboplasty has been performed (3,8). This procedure effectively estab-
bishes permanent drainage of the
or at beast long-term potentially infected
space and, in essence, eliminates the risk of abscess in a confined space.
While effective, it is a major surgical procedure with attendant high cost and prolonged hospitalization and convalescence. Percutaneous infundibuboplasty is a relatively noninvasive and inexpensive goal
procedure that as fulguration.
attains It can
the same be per-
at the same
sitting
as percuta-
formed neous
stone
In our
experience,
ous
procedure
tive
to open
surgical
extraction. is an
surgical
infundibuboplasty.
the
percutane-
excellent
altemna-
intervention The
and exter-
nab and later internalized drainage routes provided with this technique, in conjunction with appropriate antibiotic therapy, can eradicate the existing infectious process. Our experience shows long-term patency of the newly established drainage route from such cabyceal diverticuba to the pelvis in six of 10 patients (Figs ih-ij, 3b). In two other patients, the cavity
December
1991
was obliterated, suggesting that the drainage provided by the externalized and internalized stent had evacuated the infected debris and permitted collapse and obliteration of the infected cavity. Only one of the 10 patients showed premature oblitemation of the newly established drainage tract and perseverance of the diverticular space, even though the patient was clinically asymptomatic. With respect to complications, we suspect that our protocol of repetitive urine and blood cultures after the procedure unmasked a problem that
posing balloon
may be prevalent in all patients dengoing percutaneous extraction
cations,
infected calculi. of positive blood
The
high
and even intenven-
tion is more likely caused by the ponent of the procedure dealing fragmentation and extraction of calculus than by the subsequent tablishment of a communication the pelvis. Intermittently increased pressure
within
bum attendant of fragments bly
are
the
calyceal
to bavage of infected
responsible
of
prevalence
cultures occurring after
septicemia
un-
comwith the es-
to
diventicu-
and presence stones pnoba-
for
entry
of bacte-
ria into the bloodstream. Meticulous attention to ensure unimpeded efflux of lavage fluid should reduce the number of complications. A tight-fitting Amplatz sheath should eliminate the risk of displacing infected stone fragments on debris into the perirenab space and potentially setting the stage for a perinenal abscess (16). Hemorrhage may be rebated to injuries of the periinfundibulan venous plexus occurring during balloon dilation of a stenotic infundibulum. Im-
Volume
181
#{149} Number
3
such
limits used injury.
on the diameter of the might reduce the risk of That
the
resulting
hemor-
rhage appears to be readily controlbable by tamponade of the tract with a large catheter suggests a venous cause of the hemorrhage. Although heminephrectomy and open surgical lithotomy and surgical
infundibuboplasty
are accepted for these removal
fundibuboplasty
offer the advantages
and
entities, and in-
pen-
procedure, rate of compli-
comparable
success
Wulfsohn
5.
Unol 1980; 123:1-8. Clenn J. Nephnolithotomy.
6.
7.
8.
9.
10.
11.
AW, Pfister
ing pyelocatyceal genic, anatomic, 2.
3.
RC.
Stone
12.
13.
In: Clenn J, 3rd ed. Philadelphia:
surgery.
Lippincott 1983; 181-193. Lang EK, Clonioso LW. Multiple percutaaccess routes to multiple calculi, calculi in caticeat diventicuti, and staghorn calculi. Radiology 1986; 158:211-214. Hulpent JC, Reddy PK, Hunter DW, et al. Percutaneous techniques for management calyceat diverticula containing calculi. Urol 1986; 135:225-227. Janetschek C. Intranenale perkutane chirurgie bei kelchsteinen, ketchhalsstenosen, kelchdivertikeln und unetenabgangsstenosen. Urologe [A] 1988; 27:256-262. Clanz 5, Laungani CB, Cordon DH, Macchia RJ, Sclafani SJ. Percutaneous nemovat of renal caticeal calculi: an altennative approach. Unol Radiol 1986; 8:40-43. Psihramis KE, Dretlen SP. Extracorporeal shock wave lithotripsy of caliceal diverticula calculi. J Urol 1987; 138:707-711. Schulze H, Hertle L, Craff Y, et at. Combined treatment of branched calculi by pennephnolithotomy and extra-conporeal shock wave tithotripsy. Radiology 1986; 161:860-867. Leroy AJ, Seguna JW, Williams MJ Jr, et al. Percutaneous renal calculus removal in an extracorponeal shock wave lithotripsy practice. J Urol 1987; 138:703-706. Karamalegos AZ, Diokuo AC, Moylan DF.
neous
Formation
14.
contain-
diventiculum: embryonadiologic and clinical characteristics. J Unot 1974; 111:2-6. Abeshouse BS, Abeshouse CA. Calyceal diverticulum: a report of 16 cases and review of the literature. Unol tnt 1963; 15: 329-357. Hedelin H, Ceterud L, Crenabo L, Henniksson C, Pettensson 5, Zachrisson BF. Pencutaneous surgery for stones in pyelocalyceal diverticuta. BrJ Urol 1988; 62:206-208.
diverticula.
cutaneous
15.
References 1. Middleton
Pyelocalyceal
of
in
the eradication of the underlying condition. The significantly reduced length of hospitalization after the percutaneous procedure (2.75 days) vis#{224}-visthat after a surgical intervention (8 days) (17) and reduced time of convabescence translate into a significant reduction of cost. Moreover, unlike heminephnectomy, the percutaneous intervention causes no loss of renal parenchyma. This technique should be considered first in the management of all cabyceab diverticuba contaming potentially infected calculi on calculi retained in hydnocabyces behind a stenotic infundibubum. U
MA.
ed. Urotogic
cuna-
tive procedures cutaneous stone
of a minimally invasive bow cost, an acceptable
4.
16.
of perinephric
abscess
following
extracorporeal shock wave tithotnipsy. Urology 1989; 34:277-280. Lang EK. Renal, perirenal, and panarenal abscesses: percutaneous drainage. Radiology 1990; 174:109-113. Maligieni JJ, Kursh ED, Pensley L. The changing clinical pathologic pattern of abscesses in or adjacent to the kidney. J Urol 1977; 118:230-235.
Lang EK.
Percutaneous
omy and lithotripsy: survey of complications.
nephrostotithota multi-institutional Radiology
1987;
162:25-30.
17.
Timmons
JW Jr. Malek
RS, Hattery
DeWeend
J.
diverticulum.
1975;
Calyceal
RR,
J Urol
114:6-10.
Radiology
#{149} 877
J
K. Lang,
MD
Percutaneous Management and Infundibular
Infundibuloplasty: ofCalyceal Diverticula Stenosis’
T
Calculi in calyceal diverticula or behind stenotic renal infundibula are generally managed with percutaneous extraction. Percutaneous infundibuloplasty, a relatively noninvasive technique, is advocated to drain and eradicate the potentially infected space and can be performed at the same time as stone extraction. A communication between the diverticulum
and
renal
pelvis
is created
by
passing a transjugular cholangiographic needle under fluoroscopic or visual guidance, dilating the tract with a balloon catheter, and placing a stent until uroepithelial coverage has occurred. Stenotic infundibula are dilated in a like fashion. During 7 years, six (60%) of 10 patients with such “neoinfundibula” draining calyceal diverticula remained patent for at least 2 years. In two more patients (20%), both the calyceal diverticular cavity and neoinfundibulum were obliterated; in only one patient (10%) was there a residual cavity after the neoinfundibulum became obstructed. One patient was lost to follow-up. Long-term
correction
of infundibular
stenoses was achieved with this technique in four (67%) of six patients, and there were no renal or perirenal abscesses. Index terms: Kidney, calculi, 813.811 #{149} Kidney, diverticuta, ney, infection, 81.20 #{149}Kidney, procedure, 81.1299 . Kidney, Radiology
1991;
812.811, 812.3115 #{149} Kidinterventional stone extraction
181:871-877
From the Department of Radiology, Louisiana State University Medical Center, 1542 Tulane Ave. New Orleans, LA 70112-2822; and Charity Hospital of Louisiana at New Orleans. From the 1990 RSNA scientific assembly. Received January 22, 1991; revision requested March 4; final revision received July ii; accepted July 19. Address reprint requests to the author. © RSNA, 1991 I
is controversy as to the cause of pyebocalyceal diventicula; they are thought by some to be congenital in origin and by others to be the end stage of an intranenal abscess. It is generally agreed that about 40% contam calculi and may be associated with persistent infection (1,2). For these persistent infections to be eradicated, the calculi must be removed (3). These stones are formed secondary to colonization by unease-producing microorganisms, and their infective natune mandates adequate drainage or excision of diverticula harboring such stones. A number of surgical procedunes have been advocated for that purpose. Open surgery with either marsupialization and fulguration or excision of the diverticulum and closure of the narrow neck by means of nephnotomy are techniques with a proved high success rate (4). Internal drainage by means of operative infundibuboplasty, that is, either developing a flap from the pelvis or combining sevenal infundibula by spatulation (Y-V type of anastomosis) to create a more spacious infundibubum, is another option (5). With the increasing popularity of percutaneous stone removal, placement and retention of a nephrosHERE
tomy tube for 2 weeks has been advocated to drain and eventually oblitenate the diverticulan space (6-8).
Fulguration neck another
of the
diverticulum
and
vision is obliterate the diventicubum. Should the presumed calyceal diverticulum be a hydrocalyx, however, fulguration and obstruction of the tract might cause redevelopment of the cavity and, in the presence of infection, abscess formation. Dilation of the neck of the
its
diventiculum
by means of direct option to speedily
by using
a 24-F
tele-
scopic dilator (Olympus-Winters & the, Hamburg, Germany) is another technique useful for establishing drainage from the infected space (9). To minimize surgical intervention
and facilitate complete and drainage at one developed a technique ous infundibuboplasty formed immediately
stone removal sitting, we have for percutanethat can be perafter percutaneous stone removal from a calyceal diventicubum or hydnocalyx behind a stenotic infundibubum.
PATIENTS
AND
METHODS
Patients Since plasties tients 23-60 boring
1983, have
percutaneous been performed
infundibuboin 10 pa-
(six men, four women; age range, years) with catyceal diverticula hama calculus. Criteria for inclusion in
this study were as follows: (a) known and demonstrated calyceal diverticulum contaming a calculus or calculi, (b) evidence of repeated urinary tract infections, (c) clinicab symptoms, or (d) delayed filling and emptying of the calyceal diverticulum seen
on
intravenous
compromise debris.
Repeated
Proteus, had
urograms,
of drainage
urinary
tract
Pseudoinonas,
been
or
demonstrated
infections appeared by the same species
suggesting
by
the
calculus
infections
infection Phage carried
coating patients,
was documented indicating that
with
Klebsiella
species in all patients.
to have been of organism
original recurrence. not been
of the
Re-
caused of the
and therefore suggested typing, however, had out. Positive antibiotic in eight of the 10 the bacteria origi-
nated from an infection in the upper nary tract. Septicemia had been documented in two (Table 1). Temporary control
or
urinary
tract
infection
un-
and
septicemia was achieved in all patients with aminoglycoside and 13-tactamaseresistant cephatosponins and in two patients
with
A history from eight
clindamycin
and
cefoxitin.
of persistent pain patients, hematunia
was elicited from four,
and recurrent urinary infections from all 10. The presence of diverticula harboring calculi was known in all patients for at least 6 months and had been followed in
Abbreviation: wave tithotripsy.
ESWL
=
extracorporeal
shock-
871
Table
1 Management
of Calyceal
Diverticula
with
in 10 Patients
Stones
Findings
Management Preoperative
Urine Stone Stone
1
2
Early-filling Interventional
(d) Complications Size of stent (F) Time stent retained
=
septicemia, WU RU = radionuclide did not fill early.
P
PS
P
K
P
P
K
P
+
+
-
+
+
+
+
S
S
CA
S
S
S
S
0
0
0
0
0
0
0
0
0
0
+
+
-
+
+
+
+
-
+
MgAP
MgAP
E
E
E
75
60
45
2
4 +B
-
(wk)
and
of the calculus of a new
of patent
8
8
8
8
6
6
4
6
drainage,
calculus
Radiology
#{149}
E
E
60
60
2
2
3
4 +B,gr-
-
(+)-
2 -
6
5
(+)-
-
E 75
7 gr-
4
8 8
10 6
8 6
l
6
E 105
-
(+)-
-
-
+
+
LTF
+
-
-
+
ND
ND
ND
-
-
LTF
-
-
-
-
Table 2 Management
and failure
communication on evidence
in the
Preoperative Unineculture Stoneculture
with
2
SE +
=
in Six Patients
Stones
1
0
by Patient
No.
3*
4
M
P
+
+
S(D) ND
S(D) ND
S ND
+
+
+
+
+
E 75 2
E 90 1
-
-
Hem
8 8
8 8
20/12 1/6
-
-
-
+
+
-
+
-
-
+
+
5
6
K
P
C
-
-
diagnosis
Stone composition Early-filling
NU
Late-retention IVU RU with furosemide washout, ERPF Interventional procedure Removal of stone Procedure time (mm) Length of hospitalization (d) Complications Size of stent (F) Time stent retained (wk) Follow-up Urine culture IVU-patency of neoinfundibulum RU with Lasix washout, ERPF
of
+
MgAP
CP
S(D)
ND
ND
ND
+
+
+
+
+
+
-I-
E 181) 5
US + E 75 1
E 45 2
E 50 1
+B iO
-
-
8
8
6
6
6
-
-
-
+
+
-
(+)-
Note.-+B = positive blood culture, C = Escherichia coli, CP = calicified papilla, D = debris, E = extraction, ERPF = estimated renat plasma flow rate, Hem = hemorrhage, IVU = intravenous urogram, K = K!ebsiella, M = Mycoplasma, MgAP = magnesium amnionium phosphate, ND = no data, P = Proteus, RU = radionudlide urogram, S = struvite, SE = Staphylococcus epidermidis, US = ultrasound lithotnipsy, (+)= positive at first, then negative. *Two stents of diffenrent sizes were used in this patient.
of the
sat-
of com-
hydrocalyx.
Stenosis
Management
(b) demonsystem,
of Infundibular
Findings
tom-
criteria had to be met for patients to be included in this series: (a) suggestion of a stenotic infundibulum on an intravenous urogram (n = 6) or retrograde urogram (n = 1); (b) confirmation
872
E
60
+
plete obliteration and disappearance of the diverticulum; (c) lack of recurrent unnary tract infections; and (d) resolution and disappearance of clinical symptoms such as pain and hematuna. Six patients (five men, one woman; age range, 34-47 years) underwent treatment for an infundibular stenosis with a catcu-
The following
US+E 80
+
computed
calculus;
to the collecting
or debris
-
positive blood culture, CA = carbonate apatite, ND = no data, E = extraction, ERPF = estimated renal plasma flow rate, gr- = gram-negative = intravenous urography, K = Klebsiella, LiT = tost to follow-up, MgAP = magnesium animonium phosphate, P = Proteus, PS = Pseudomas, urogram, S = struvite(magnesium ammonium calcium phosphate), US = ultrasound lithotnipsy, (+)= positive at first, then negative,
radiogmaphs
diverticulum
US4-E 120
2
(CT) scans is consistent with the commonly seen radiographic appearance of struvite (magnesium ammonium calcium phosphate) and cambonate-apatite calculi. After removal, all calculi were analyzed chemically, ground up, and cultuned. To ascertain success of treatment, the following parameters were assessed:
lus
10
+
ographic
isfactory
9
P
some for up to 3 years. None of the 10 patients showed a demonstrable communication between diverticula and the collectmg system on the early-phase intravenous (3-, 5-, and 10-minute) urograms (Fig ib). On delayed 30-, 45-, and 60-minute urograms, however, contrast medium-laden urine was retained in the diverticubum in eight of the 10 patients. This delayed filling and emptying of the calyceal diverticula suggested calculi in an occluding tocation that were probably responsible for the recurrent bouts of urinary tract infections (Table 1). A granular appearance of the
stration
8
+
-
IVU-patency of neoinfundibutum RU with furosemide washout, ERPF
reformation
7
P
Follow-up Urine culture
(a) removal
6
procedure
Removal of stone Procedure time (mm) Length of hospitalization
on
5
No.
-
S
IVU IVU
Late-retention
calculi
4
by Patient
diagnosis
culture culture composition
Note.-+B
3
Parameters
and
of the diagnosis by
means
(u
=
of functional
of a radionucide
6), abnormal
furosemide
Hoechst-Rousseb,
clide
Somerville,
urogram
segmental
(n renal
=
(e) clinical
flow
pain
(Lasix; NJ)
4), and/or
plasma
obstruction urogram
On
radionu-
of the
reduced rate
(ii
and
=
4)
(Table 2); (c) demonstration of a calculus or debris calculus in the compromised calyceal group; (d) documented evidence of repeated urinary tract infections; and/or
symptoms
such
as persistent
hematunia.
the basis calculi
of the granular on
radiographs,
thought
to be struvite
calculus
had
a characteristic
calculi;
appearance two
were
the
third
crescent
shape suggesting a sloughed papila with secondary catcifications. Three calculi were debris stones with elements of struvite (Table 2).
December
1991
All six patients
had
evidence
of three
to
12 documented occurrences of urinary tract infections with Proteus, Mycoplasma, or Klebsiella species, Staphylococcus epider-
midis, on Escherichia patients,
the
tuned
from urine of infection;
sodes ferent patients,
g. Figure 1. (a-c) as target for the
Intravenous probing
urograms 18-thin-walled
of the diverticulum. needle. Contrast
the catyceal diverticulum is conspicuously opacified from prior intravenous injection lyceal
tion
diverticulum
from
to the collecting
(Cook,
with
Bloomington,
from
(d) After
is wrapped
reference
removal
advanced under (Cook) is advanced
obscures
the
(c) Flexible around
of the
calculus,
control
into
calculus,
element
a calculus
6.) (d, e) Craphic
fluoroscopic
calculus serves the calculus in
tacking. (b) Collecting system of the left kidney is of contrast material. Much opacification of the ca-
injection
is lacking.
Ind)
permission,
toplasty.
direct
system
(a) Readily visible medium enveloping
and
in a calyceal
representation
a transjugulan
the kidney
demonstrable
of a Bentson
guide
diverticulum.
and
infundibu-
needle
a Lundenquist
wire
(Reprinted,
of percutaneous
cholangiographic
pelvis,
communica-
0.038-inch
(Cook)
guide
is
wire
through the transjugular sheath into the renal pelvis, the ureter, and, ultibladder. (e) Six-millimeter Blue Max balloon catheter (Medi-tech/Boston Scientific, Watertown, Mass) bridges the space from the calyceal diverticulum to the infundibulum and dilates the tract. (f) Radiograph demonstrates the location of the 6-mm balloon catheter seated across the space from the calyceal diverticulum to the infundibulum. A nephnostomy tube has mately,
the
been introduced into the posterior division of the midcatyceal group for the purpose of lavage and provision of additional egress should bleeding from the juxtainfundibular plexus be brisk. (g) Craphic representation of, first, an externalized and, later, an internalized stent placed and retained for 8 weeks (Fig I continues).
the
patients,
of appropriate
antibi-
of infections
of the
bouts
urinary
tract, period
however,
developed
of observation.
bacteriunia
use of multiple with proved
cul-
epiwere dif-
In four of the was temporarily
by means
during
was
during repeated in two, there
Recurrent
upper
of the
microorganism
microorganisms. the infection
controlled otics.
coli. In four
same
In two
persisted
despite
broad-spectrum efficacy in eradication
the
antibiotics of the
cultured bacteria. Three of the patients had positive results of the tuberculin skin test; there was no evidence, however, of urinary tract tuberculosis. Success was gauged with the following criteria: (a) documentation of a patent infundibulum infundibuloplasty,
of adequate
normalization
in the
segment
drocabyx
on a radionuctide
furosemide
radionuctide
obstructed
current urinary (e) disappearance able
to an
after or
of the
hy-
and (c) tack of a calculus in the previcalyx, (d) absence of metract infections, and/or of symptoms attmibut-
of re-formation ously
caliber
(b) improvement urogram
umogram,
obstructed
and
infected
calyx.
Methods A tract into
the
for routine calyceal
percutaneous
diventiculum
byx was established. had been attained,
needle
(Bard
erica,
After local anesthesia a 6-inch 18-thin-walled
Candiosurgery
Mass)
was
posterotaterat
introduced
approach
the calculus
with
and
fluoroscopic
readily visible calculus (Fig ia). Crepitation,
h. Figure
(h)
1 (continued).
patency travenous (arrowheads)
Follow-up
of the neoinfundibulum urogram and
obtained opacification
i
years later demonstrates continued cation of the calyceal diverticutum.
Volume
181
Number
#{149}
3
study
and
prompt
years of the
obtained
later shows diverticulum.
patency
after
drainage
removal
from
of the
the catyceal
continued patency (j) Intravenous
of the neoinfundibulum
stent
demonstrates
diverticulum.
of the urogram
(i) In-
neoinfundibulum obtained 3/2
(arrowhead)
and
Division,
Bill-
by means
of a
advanced
to
control.
served elicited
The
as the target when the
needle engaged the calculus, indicated attainment of the goal. Injection of 1-2.5 mL of air distended and demonstrated the
j.
i.
access on hydroca-
opacifi-
diverticulum.
wire
was
ulum, and the calculus verticulum
A 0.038-inch
then
advanced
its floppy (Fig Ic). with
air
end
Bentson
guide
into the diverticcoiled around
Distention facilitated
of the
di-
advance-
Radiology
#{149} 873
li_A a.
C.
b.
ment of the guide wire around the calculus. The guide wire was advanced until the stiff component extended from the point of entry to the calyceal diverticutum.
The tract was then fashion a 28-F seated.
second was
dilated
in a
with Amplatz dilators Amplatz sheath (Cook) No attempt was made safety
then
scopic
guide
retrieved
control
mentation ble2).
The
calculus
by means
either
with
Removal
wire. in toto
of endoor after
an ultrasound
of calculi
from
customary
(Cook) until could be to place a
frag-
probe
(Ta-
hydrocatyces
behind a stenotic infundibulum was carried out in a like fashion. In five patients, a single guide wire was coiled in the dilated calyx harboring the calculus; in the sixth patient, the guide wire and the safety guide wire could be passed through the stenotic infundibutum into the pelvis, ureten, and bladder. Unlike the situation in our patients with calyceal diverticula, a communication strated
to the
in alt patients
pelvis with
was
demon-
stenotic
in-
fundibuta by injection first of air and then diluted contrast medium. Infundibuloplasty was performed unden either endoscopic or fluonoscopic controt. In nine patients with calyceat diverticula, communication to the renal pelvis or major catyx was established with fluoroscopic guidance; in the other, endoscopy was used. The collecting system was opacified by prior intravenous administra-
tion of contrast lum,
into
been
advanced,
medium.
phy
curved needle
through
874
the
transjugular
the instrument
Radiology
#{149}
Amplatz
was outlined
(Cook)
was
e.
Figure 2. (a-il) Intravenous unograms. (a) Infundibulan stenosis compromises the superior calyceal group of the left kidney. (b) Under visual control, a guide wine and safety wine are advanced through the strictuned infundibulum into the renal pelvis, ureter, and bladder. (c) Four-millimeter high-pressure Blue Max balloon catheter (Medi-tech/Boston Scientific) is seated and fully distended in an attempt to dilate the stricture. (d) Twenty-four-French Foley catheter is used as a temporary stent to control bleeding. Later, an internalized stent with the
upper
coil in the superior
calyx
and
the lower
one
placed
in the bladder
is seated
and
retained
in position for 8 weeks. Hemorrhage occurring immediately after transtuminal dilation was believed to be secondary to bleeding from the periinfundibular venous plexus. (e) Antegrade urogram obtained 2 years later demonstrates a widely patent infundibulum of the superior calyceal group. Obstruction of the uneteropetvic junction was caused by a stoughed papilla.
The diverticu-
sheath had by an injection of air. The patient was placed in a prone 45#{176} anterior oblique position, with the affected side elevated. Two right-angle madiographs on right-angle C-arm fluoroscopy established the projected path from the diverticulum to the renal pelvis. A mildly
which
d.
cholangiograthen
advanced
channel
of the
and along the predetermined tract into the pelvis or a major calyx (Fig id). A C- or U-arm fluoroscopic unit facilitated monitoring of the advancement of the needle. Once the renal pelvis or major cabyx cystoscope
projected
was sheath the
entered, was needle
or Lundenquist
the
transjugulan
needle
advanced
over
the
exchanged
for
a stiff
guide
wine
needle Ampbatz
or Clidewine
and
(Cook). These were advanced with fluonoscopic guidance through the ureter into the bladder (Figs if, 2b). A high-pressure balloon (Medi-tech/Boston Scientific) of appropriate
length
and
a 4- or 6-mm
ameter was then seated, which the space from the diventicubum pelvis
(Figs
le,
if,
2c).
The
di-
bridged to the
balloon
flated with diluted contrast solution kept inflated for at least 2 minutes.
December
was
in-
and
1991
Follow-up
of patients
fundibular culus
stenosis,
consisted
furosemide
treated
for in-
hydrocalyx,
and
cab-
of madionuclide urograms; radionucide urograms ob-
tamed
at 6 months
i-year
and
and,
2-year
thereafter,
intervals;
at
urine
cultures
at 2 weeks, 1, 3, and 6 months and, thereafter, at yearly intervals if negative or at more frequent intervals as necessary for clinical management if positive; and intravenous urograms obtained 2-3 months after the procedure and, thereafter, at i-year
and
2-year
intervals.
RESULTS Fifteen
(94%)
of 16 patients
treated
by means of percutaneous infundibubopbasty and stone removal for cabyceal diverticula (n = 10 [62%]) on a.
infundibuban (n = 6 [38%])
b.
Figure
3.
(a) Intravenous
unogram
shows
externalized
stent
being
seated
under
visual
con-
beast
up
treated with calculus The calculi
this
intravenous
cessfulby
been
seated;
urogram.
The
from
calyceal
diverticulum
the catyceat
After the balloon was fully distended and collapse without re-formation of a documentabbe deformity was achieved, a 10-F on 8-F pigtail catheter was placed as a stent
(Fig
ig).
The
pigtail
vanced into the renal tional side holes were catheter to be situated cabyceal diventiculum. secures
the
catheter
vis, the distance diverticulum appropriate holes, despite
catheter
was
ad-
pelvis, and addicut into the 10-F at the level of the Since the pigtail in position
from
pelvis
in the
peb-
to cabyceab
was constant, which location of the added respiratory motion
is collapsing.
diverticulum
assured side of the
into
An
externalized
stent
has
ble-J polyethylene stent (Medi-tech/Boston Scientific) of appropriate length was then seated by means of fluomoscopy with the upper coil in the calyceal diverticulum or hydrocatyx and the lower coil in the bladder. On the basis of sensitivity studies of voided urine, all patients underwent a regimen of broad-spectrum antibiotics for 2-3
days
before
and
procedure. Doxycycline Morris
7-10
hyclate
Plains,
NY),
was lost to follow-up. in diverticula were suc-
removed
in all 10 patients. of these calculi
Chemical analysis vealed that seven calculi; one (10%)
the bladder.
days
after
(Warner
100
mg
(80%)
were
of the
phosphate
cultured
10 calculi
from (Table
1).
In seven patients (70%), urine cubtunes were negative at the follow-up examinations performed 2 weeks after the procedure and remained negative thereafter. In three patients (30%), positive
the
urine
cultures
were
reported
in the first 3 postoperative months. The bacteria proved sensitive to anti-
Chibcott,
twice
eight
Bacteria
me-
(70%) were struvite was a carbonate and two (20%) were
apatite calculus, magnesium ammonium
calculi.
calculi
up for at to 7 years. One patient for a cabyceal diverticubum
2 and
trol. The coil of the 8-F pigtail catheter is in the renal pelvis. Side holes have been cut into the catheter at an appropriate location to drain the calyceal diverticulum. The coil in the pelvis retains the catheter in an unchanged position to the calyceal diverticulum. (b) Injection of contrast medium through the externalized stent shows patency of the neoinfundibulum on it extends
stenoses with were followed
daily,
biotics,
however,
and
subsequent
the medication most often administered to asymptomatic patients. The negimen was started 2 days before and continued for 7 days after the procedure. Cephapinn sodium (Cefaton; Stuart, Wilmington, Del), 2 g administered intma-
urine and blood cultures tive. In one of these three
Infundibular stenosis was first characterized on intravenous urograms and antegrade urograms performed by injecting diluted contrast medium into the accessed calyx (Fig 2a). A guide wine was then advanced with endoscopic control in five of the patients, and with fluoroscopic control
muscularly
cemia developed within ‘/2 hour after completion of the procedure in one patient, who had previously experienced septic episodes despite appropriate antibiotic coverage. This patient recovered with standard
into
intervals, intervals
The
externalized component of the stent permits drainage from the catyceal diverticulum to the outside and via the internalized segment to the renal petkidney.
vis
(Fig
3).
the
pelvis
and,
subsequently,
the
ure-
ten and bladder in one patient (Fig 2b). Dilation was carried out in an identical manner (Fig 2c). The externalized stent was generally maintained in position for 4 weeks. Thereafter, stent.
it was converted to an internalized One of our patients with a calyceal
diverticulum and another with an infundibular stenosis, however, underwent treatment with an externalized stent only. To exchange the externalized stent for an internalized
(Glidewire, introduced advanced
Volume
stent,
a stiff
guide
wire
Lundenquist, or Ampbatz) was with fluoroscopic control and into the bladder. An 8-F dou-
181
#{149} Number
3
was
and
1 g every
6 hours,
was
also
used.
Follow-up stone removal
of patients who and percutaneous
ulopbasty
for
calculi
consisted
of urine
2-week,
in calyceal cultures
1-, 2-, 3-, and if negative, as necessary
of urine
and
diventicuba
obtained
6-month,
at
and
on at more for clinical
ment. Antibiotic treatment according to culture and ies
underwent infundib-
yearly
frequent manage-
was modified sensitivity stud-
ground
calculi
retrieved
from the caliceal diverticulum. Intravenous unograms were obtained 2 and 6 months or 1 year after the procedune (Table 1). Three tomographic sections at the appropriate level obtained immediateby
after
complemented In addition, at 6-month, vals
with
sessment
infusion
of the
contrast
the intravenous all patients were 1-year, and then madionuclide
of renal
unography
function.
medium
urogram. followed up 2-year interfor
as-
were
only one negative postoperative culture was obtained before to follow-up. A gram-negative
treatment
consisting
nega-
patients, urine being lost septi-
of corticostem-
oids, vasopressons, antibiotics, and volume expansion. In three (30%) other of the 10 patients, positive blood cultures were recorded during the first two postoperative days (Tabbe 2). With appropriate antibiotic treatment, the blood cultures became negative on the third day; a positive urine culture, however, persisted in one of these patients for 3 months. A patent neoinfundibubum was demonstrated on follow-up intravenous unograms in six (60%) of the 10 patients
(Fig
ic,
lh-lj).
In three
Radiology
pa#{149} 875
tients (30%), the communication to the pelvis or major calyx appeared to have been obliterated. Nephrotomograms demonstrated that in two of the three, there was no evidence of a residual cavity at the site of the prior cabyceab patients
smaller cavity
diverticubum. Only one of the showed evidence of a much
but on
still identifiable
residual
nephnotomograms
(Table
i).
Ten-French externalized stents were used in four patients, and 8-F externalized stents were used in six. All internalized stents were 8-F. The
bum;
an unusually however,
calyx, strated
on
prominent
had
the
initial
infundibubum. Techniques for percutaneous entry into such structures have been refined during the past 10
hydno-
been
demon-
pnepmocedurab
intravenous urogram. Significant loss of functioning parenchyma of the involved segment was preexistent. The operative time for infundibuboplasty
and
stone
extraction
from 45 to 180 (average, There was no substantial operative time whether uboplasty was performed scopic
or endoscopic
varied
85) minutes. difference in the infundibwith fluorocontrol.
of hospitalization
was
Length
1-5 (mean,
2)
2). hemorrhage
be no correlation between obliteration of the tract and length of time of use or size of the stent. The operative times for the intervention were 45-120 (average, 74) minutes. The patients were hospitalized for 2-8 days (Table 1). The calculi harbored in hydrocaby-
one patient. nated from nous plexus,
It appeared to have origithe periinfundibulam yewhich may have been
ces
charged
were
and
retained weeks.
in position variThere appeared to
behind an infundibubar stenosis successfully removed in all six patients. Two of these, which were
solid calculi, were found to be struvite at chemical analysis, a third was a calcified sboughed papibla, and three were debris stones containing struvite (Table 2). Bacteria were cultured from four of the six stones. In five (83%) of the six patients, fobbow-up urine cultures were negative over periods of 2-7 years. In the sixth patient (17%), positive urine cultures persisted
for
i month
despite
appro-
pniate therapy with antibiotics that were proved effective against the cubtuned bacteria. Thereafter, however, urine cultures became and remained negative for a follow-up period of 2 years.
The
same
patient
also
had
posi-
tive results of blood culture 2 weeks after the intervention, which then became negative during treatment with appropriate antibiotics (Table 2). Follow-up intravenous unograms demonstrated unabated patency of the dilated infundibubar stenosis in four (67%) of the patients over a foblow-up period of 2-7 years (Fig 2e). In two patients (33%), there was significant restenosis 6 months and i year after the initial infundibuboplasty. One of these patients showed progressive loss of renal panenchyma of the afflicted segment (Table 2). Follow-up radionuclide furosemide washout unograms showed normalization in three (50%) of the patients but deterioration in the other three (50%).
Two
riomating nificant urograms. showed 876
of the
patients
with
dete-
function demonstrated sigrestenosis on intravenous The third patient, however, a widely patent infundibu-
#{149} Radiology
ruptured
during
occurred
balloon
ble 2). Bleeding was controlled tamponade of the region with Foley
catheter
(Fig
complication,
the on
had
the
2d).
(Ta-
by a 24-F
Despite
patient
6th
in
dilation
this
was
dis-
postoperative
an uneventful
day
recovery.
DISCUSSION Although extracorporeab wave lithotripsy (ESWL) cessfully 85%
notable use
in the
shockis used suc-
management
technique
(iO,il).
ments
passage of fragthe effective use
is
of
ESWL. of infected cabculi in a confined space such as a diverticulum possibly might provoke septicemia and abscess formation (13i5). Heminephmectomy
as advocated
in
the urology literature (3,5) would memove both the calculus and a space harboring potentially infected debris. Open surgery for stone removal and subsequent
drainage of the diverticuaccomplishes the goals
bum likewise of removal of the stone and proper drainage of the potentially infected space.
The
surgical
interventions,
however, are attended by a prolonged hospitalization and recovery period and loss of pamenchyma if heminephnectomy is performed. Percutaneous stone removal is an excellent alternative in the management of calculi in calyceab diverticula or calyces
compromised
by
stenotic
widely
used
(6-9).
of this space formation
is mandaof an intra-
renal means
abscess. As documented of surgical experience,
space
can
be drained
sive
by the
to the
outside
instances will eventually (2,4). Since the offen-
organisms
are
usually
known
from findings of cultures of the stone and debris, effective antibiotic thenapy
can
be maintained
during
the
initial period of drainage. Fulguration of the diventicubum after removal of the calculus has been advocated as a way to obliterate the diverticubar space and discharge the patient tube-free (7). This procedure, however, is fraught with potential risks. Should the presumed cabyceal diventiculum be a hydnocabyx, fulguration of the cavity would obstruct the collecting ducts draining into the
cavity,
obstruction, in formation
which,
to an
in turn, of a sec-
if infected,
can
abscess.
To shorten the time of external drainage and to address the urobogic dictum of establishing internal drain-
Calculi
(6,8,i2). The mere of the calculi, which ESWL, does not solve
to permit precludes Fragmentation
now
Drainage to prevent
progress
the problem. Lack of communication to the collecting system, pelvis, ureter, and bladder or a communication too narrow
bris. tony
ondamy
in calyceab diventicula and calculi behind stenotic infundibuba are two such exceptions fragmentation possible with
are
hydnocalyx. This is likely to result
of about
of renal calculi, theme are some exceptions that preclude the
of this
and
There remains, however, the problem of a confined space with inadequate or absent drainage that may contain residual fragments and infected de-
and in many be obliterated
days (Table A massive
stents were ably for 4-8
years
age whenever possible, surgical infundibuboplasty has been performed (3,8). This procedure effectively estab-
bishes permanent drainage of the
or at beast long-term potentially infected
space and, in essence, eliminates the risk of abscess in a confined space.
While effective, it is a major surgical procedure with attendant high cost and prolonged hospitalization and convalescence. Percutaneous infundibuboplasty is a relatively noninvasive and inexpensive goal
procedure that as fulguration.
attains It can
the same be per-
at the same
sitting
as percuta-
formed neous
stone
In our
experience,
ous
procedure
tive
to open
surgical
extraction. is an
surgical
infundibuboplasty.
the
percutane-
excellent
altemna-
intervention The
and exter-
nab and later internalized drainage routes provided with this technique, in conjunction with appropriate antibiotic therapy, can eradicate the existing infectious process. Our experience shows long-term patency of the newly established drainage route from such cabyceal diverticuba to the pelvis in six of 10 patients (Figs ih-ij, 3b). In two other patients, the cavity
December
1991
was obliterated, suggesting that the drainage provided by the externalized and internalized stent had evacuated the infected debris and permitted collapse and obliteration of the infected cavity. Only one of the 10 patients showed premature oblitemation of the newly established drainage tract and perseverance of the diverticular space, even though the patient was clinically asymptomatic. With respect to complications, we suspect that our protocol of repetitive urine and blood cultures after the procedure unmasked a problem that
posing balloon
may be prevalent in all patients dengoing percutaneous extraction
cations,
infected calculi. of positive blood
The
high
and even intenven-
tion is more likely caused by the ponent of the procedure dealing fragmentation and extraction of calculus than by the subsequent tablishment of a communication the pelvis. Intermittently increased pressure
within
bum attendant of fragments bly
are
the
calyceal
to bavage of infected
responsible
of
prevalence
cultures occurring after
septicemia
un-
comwith the es-
to
diventicu-
and presence stones pnoba-
for
entry
of bacte-
ria into the bloodstream. Meticulous attention to ensure unimpeded efflux of lavage fluid should reduce the number of complications. A tight-fitting Amplatz sheath should eliminate the risk of displacing infected stone fragments on debris into the perirenab space and potentially setting the stage for a perinenal abscess (16). Hemorrhage may be rebated to injuries of the periinfundibulan venous plexus occurring during balloon dilation of a stenotic infundibulum. Im-
Volume
181
#{149} Number
3
such
limits used injury.
on the diameter of the might reduce the risk of That
the
resulting
hemor-
rhage appears to be readily controlbable by tamponade of the tract with a large catheter suggests a venous cause of the hemorrhage. Although heminephrectomy and open surgical lithotomy and surgical
infundibuboplasty
are accepted for these removal
fundibuboplasty
offer the advantages
and
entities, and in-
pen-
procedure, rate of compli-
comparable
success
Wulfsohn
5.
Unol 1980; 123:1-8. Clenn J. Nephnolithotomy.
6.
7.
8.
9.
10.
11.
AW, Pfister
ing pyelocatyceal genic, anatomic, 2.
3.
RC.
Stone
12.
13.
In: Clenn J, 3rd ed. Philadelphia:
surgery.
Lippincott 1983; 181-193. Lang EK, Clonioso LW. Multiple percutaaccess routes to multiple calculi, calculi in caticeat diventicuti, and staghorn calculi. Radiology 1986; 158:211-214. Hulpent JC, Reddy PK, Hunter DW, et al. Percutaneous techniques for management calyceat diverticula containing calculi. Urol 1986; 135:225-227. Janetschek C. Intranenale perkutane chirurgie bei kelchsteinen, ketchhalsstenosen, kelchdivertikeln und unetenabgangsstenosen. Urologe [A] 1988; 27:256-262. Clanz 5, Laungani CB, Cordon DH, Macchia RJ, Sclafani SJ. Percutaneous nemovat of renal caticeal calculi: an altennative approach. Unol Radiol 1986; 8:40-43. Psihramis KE, Dretlen SP. Extracorporeal shock wave lithotripsy of caliceal diverticula calculi. J Urol 1987; 138:707-711. Schulze H, Hertle L, Craff Y, et at. Combined treatment of branched calculi by pennephnolithotomy and extra-conporeal shock wave tithotripsy. Radiology 1986; 161:860-867. Leroy AJ, Seguna JW, Williams MJ Jr, et al. Percutaneous renal calculus removal in an extracorponeal shock wave lithotripsy practice. J Urol 1987; 138:703-706. Karamalegos AZ, Diokuo AC, Moylan DF.
neous
Formation
14.
contain-
diventiculum: embryonadiologic and clinical characteristics. J Unot 1974; 111:2-6. Abeshouse BS, Abeshouse CA. Calyceal diverticulum: a report of 16 cases and review of the literature. Unol tnt 1963; 15: 329-357. Hedelin H, Ceterud L, Crenabo L, Henniksson C, Pettensson 5, Zachrisson BF. Pencutaneous surgery for stones in pyelocalyceal diverticuta. BrJ Urol 1988; 62:206-208.
diverticula.
cutaneous
15.
References 1. Middleton
Pyelocalyceal
of
in
the eradication of the underlying condition. The significantly reduced length of hospitalization after the percutaneous procedure (2.75 days) vis#{224}-visthat after a surgical intervention (8 days) (17) and reduced time of convabescence translate into a significant reduction of cost. Moreover, unlike heminephnectomy, the percutaneous intervention causes no loss of renal parenchyma. This technique should be considered first in the management of all cabyceab diverticuba contaming potentially infected calculi on calculi retained in hydnocabyces behind a stenotic infundibubum. U
MA.
ed. Urotogic
cuna-
tive procedures cutaneous stone
of a minimally invasive bow cost, an acceptable
4.
16.
of perinephric
abscess
following
extracorporeal shock wave tithotnipsy. Urology 1989; 34:277-280. Lang EK. Renal, perirenal, and panarenal abscesses: percutaneous drainage. Radiology 1990; 174:109-113. Maligieni JJ, Kursh ED, Pensley L. The changing clinical pathologic pattern of abscesses in or adjacent to the kidney. J Urol 1977; 118:230-235.
Lang EK.
Percutaneous
omy and lithotripsy: survey of complications.
nephrostotithota multi-institutional Radiology
1987;
162:25-30.
17.
Timmons
JW Jr. Malek
RS, Hattery
DeWeend
J.
diverticulum.
1975;
Calyceal
RR,
J Urol
114:6-10.
Radiology
#{149} 877
J
