Percutaneous Nephrostomy in the Management of Ureteral and Renal Calculi 1 Arthur D. Smith, M.D., Donovan B. Reinke, M.D., Robert P. Miller, M.D., and Paul H. Lange, M.D.
A percutaneous nephrostomy tract can serve both to decompress the renal pelvis and as a route for dissolving renal stones and assisting in basket retrieval of ureteral stones. These techniques are especially valuable in patients who are poor operative risks. INDEX TERMS:
Kidneys, calculi, 8[ 11.811 • Kidneys, percutaneous nephrostomy, 8[ 1).454 • Ureters, calculi,
8(2).811 Radiology 133:49-54, October 1979
nephrostomy is now well established in the treatment of obstructive uropathy (15). In the past, it was used merely for temporary drainage, but now this tract should be regarded as a conduit to the ureters and kidneys (10). For example, angiographic catheters can be advanced down the ureter and retrieved from the bladder transcystoscopically, allowing dual access to a site of obstruction (13). In the past year, we have treated 5 patients for ureteral or renal calculi via a percutaneous nephrostomy. Their case histories demonstrate this use of the technique. ERCUTANEOUS
1, a). Randall forceps were inserted via the nephrostomy tract and directed toward the calculus under fluoroscopic control. The stone was very friable, and only a portion of it could be removed. We decided to irrigate the remaining portion with Suby's Solution G (Cutter Laboratories). The tip of an angiographic catheter was directed at the calculus, while another one was inserted down the ureter and retrieved from the bladder via the cystostomy. A Dermia stone basket was attached to the catheter and pulled up the ureter, and the stones were retrieved individually under fluoroscopic control. With the catheter and the stone basket forming a continuous line from the nephrostomy tract to the cystostomy, no difficulty was encountered in reinserting the stone basket into the ureter (Figs. 1, band 2, a). After the calculi had been dissolved, all catheters were removed. A few months later, radiographs showed no evidence of stones.
TECHNIQUE CASE II:
A 51-year-Old quadriplegic man was found to have a 4.5
X 1.5-cm obstructing calculus in his left kidney (Fig. 3, a and b). We
The patient is placed prone on the fluoroscopy table and prepared and draped in the usual manner. If renal function is adequate, intravenous contrast medium is used to opacify the renal pelvis; if not, a 23-gauge needle is used to find the pelvis, using backflow of urine as a sign of entry. Contrast material is then injected through the needle, Once the renal pelvis has been located, an 18-gauge needle with a Teflon sheath is advanced through the lateral margin of the kidney into the renal pelvis in a single pass, under biplane fluoroscopy and at approximately a 45 0 angle to the table. Once access to the kidney has been gained with a Teflon sheath and guide wire, various catheters can be inserted and dilatation, manipulation, and irrigation can be performed. All patients are given antibiotics beginning the day before the procedure and continuing for a few days afterward as indicated.
decided to dissolve the stone by irrigating the renal pelvis with Suby's Solution G via a percutaneous nephrostomy. In order to maintain ureteral patency and prevent ureteral colic, a Gibbons ureteral stent was inserted in the left ureter. After the irrigation was started, the stent became occluded and it was necessary to insert an additional catheter percutaneously to drain the renal pelvis. The calculus dissolved after five days of irrigation with Solution G. The patient had no untoward effects from the irrigation, and the various catheters were removed (Fig. 3, c). CASE III: A 52-year-old man presented with a 2-cm staghorn calculus in the upper calyx of a solitary right kidney. In 1967 he had had a cystectomy and ileal-loop diversion as well as radiation therapy for bladder carcinoma. A year later, he had undergone laparotomy for intestinal obstruction, and in 1973 he had had a left nephrectomy and revision of his ileal loop. In view of his obesity, many previous operations, a wide ureter, and obvious calcium magnesium ammonium phosphate (struvite) stones (Fig. 4, a), we decided to irrigate the calculus with Suby's Solution G. A percutaneous nephrostomy was performed, and a 7 French angled-tip angiographic catheter was inserted transparenchymally and positioned with the tip in the upper calyx, adjacent to the calculus (Fig. 2, c). After four days of irrigation, the calculus was significantly smaller, and after an additional five days no stone was visible. Nemoy and Stamey (8) advocate irrigation 24 to 48 hours longer, as small amounts of residual calcium may cause new stones to develop. We followed this procedure, but the additional irrigation caused the patient to become febrile. A nephrostogram showed linear folds in the ureter, indicating mucosal edema (Fig. 4, b). Irrigation was stopped, and the catheter was removed when the patient was afebrile. Throughout the irrigation period his serum magnesium level usually fluctuated be-
CASE REPORTS CASE I: A 62-year-old quadriplegic man presented with recurrent episodes of septicemia caused by gram-negative organisms as a result of intermittent occlusion or dislodgement of a right nephrostomy tube inserted in 1973 because of multiple large obstructing ureteral calculi and a right staghorn calculus. In addition, he had had a suprapubic cystostomy for management of a neurogenic bladder. Although he was a very poor operative risk, we wanted to remove all stones from the right kidney and ureter in order to remove the nephrostomy tube (Fig.
1 From the Departments of Urology (A.D.S., P.H.L.) and Diagnostic Radiology (D.B.R., R.P.M.) of Veterans Administration Hospital and the Department of Urologic Surgery, University of Minnesota College of Health Sciences (AD.S., P.HL), Minneapolis, Minn. Presented at the Sixty-fOtXth Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, III., Nov. 26-Dec. 1, 1978. Received Dec. 5, 1978; accepted and revision requested April 11, 1979; revision received May 2. sjh
SMITH AND OTHERS
Fig. 1. CASE I. a. Right staghorn calculus and multiple ureteral calculi (arrows). A nephrostomy tube is in place. b. Nephrostogram showing an angiographic catheter directed at the staghorn calculus, a nephrostomy tube draining the renal pelvis, and a silicone rubber tube extending from the nephrostomy site to the bladder.
tween 2.3 and 2.6 mEq/I. but on one occasion it was as high as 2.8 mEq/1. As it was unlikely that the wide ureter could be occluded by debris from the dissolving calculus. no ureteral splint was inserted. CASf IV: A 45-year-old man presented with renal colic caused by an obstructing 1.5-cm cystine calculus at the left ureteropelvic junction (Fig. 5, a), with nonfunction of the left kidney. He had had many operative procedures for cystine stones, and we wished to avoid another operation. A percutaneous nephrostomy was performed, and two angiographic catheters were inserted. One was inserted into the renal pelvis adjacent to the calculus and was used to infuse the irrigating solution. The other was advanced antegrade down the ureter into the bladder. This catheter had side holes at the level of the renal pelvis, allowing continuous drainage (Figs. 2. d and 5, b). After irrigation with a sodium
bicarbonate and saline solution had failed, 120 ml of a 20 % solution of acetylcysteine (Mucomyst, Mead Johnson) was added to the bicarbonate solution, dissolving the calculus (12). The catheters were removed, and the patient was stone-free for the first time in several years. CASE V: An emaciated 70-year-old man had a fever of 39.4°C (103° F) and obvious signs of sepsis. The patient had severe multiple sclerosis and poor pulmonary function and was bedridden with fixed contraction deformities. Three years earlier. he had had an ileal conduit operation for deteriorating renal function caused by a netKogenic bladder. An excretory urogram revealed hydronephrosis and a staghorn calculus on the left and a smaller obstructing calculus in the left midureter. He failed to respond to intravenous antibiotics and hydration.
NEPHROSTOMY IN THE MANAGEMENT OF RENAL CALCULI
ANGIOGRAM CATHETER ANGIOGRAM INFUSION ~ATHETER
SILICONE RUBBER SPLINT
Variations of the technique for irrigating renal calculi.
Fig. 3. CASE II. 8. Large struvite (calcium magnesium ammonium phosphate) calculus at the ureteropelvic junction. b. Excretory urogram showing obstruction and the shadow of the stone. c. Excretory urogram after irrigation shows that the kidney is free of stones and not obstructed.
ARTHUR D. SMITH AND OTHERS
Fig. 5. CASE IV. a. Cystine stone at the ureteropelvic junction. b. Nephrostogram showing a pigtail inflow catheter in the renal pelvis and an additional angiographic catheter extending to the bladder. The side holes of the latter catheter are situated in the renal pelvis
Fig. 4. CASE III. a. 2-cm staghorn calculus in the upper right calyx. b. Nephrostogram and ileostogram. Note the linear folds in the ureter. indicating mucosal edema.
A left percutaneous nephrostomy was performed under local anesthesia. and with drainage his fever abated. As the patient was a poor operative risk. we removed the uretero-ileal calculus by manipulating
a stone basket through both the percutaneous nephrostomy tract and the ileostomy without anesthesia as described elsewhere (14). A guide wire and polyethylene catheter were manipulated down the ureter past the stone and retrieved from the stoma; this wire was then withdrawn. and a Dormia stone basket was attached to the catheter and pulled up above the stone. After the calculus was extracted. a silicone rubber tube with appropriate side holes was placed so as to splint the uretero-ileal junction.
COMMENT: Splinting is worthwhile in any manipulation of large calculi or if excessive trauma has occurred. This
NEPHROSTOMY IN THE MANAGEMENT OF RENAL CALCULI
case illustrates the benefit of percutaneous nephrostomy not only for initial control of sepsis but as a means of access to the uretero-ileal calculus. DISCUSSION
Close cooperation between urologists and radiologists at our hospitals has resulted in new applications of percutaneous nephrostomy. We have used this nonoperative technique in the treatment of ureteral and renal calculi in 5 patients who were poor surgical risks and anticipate increased use as an alternative to operation, as there were no significant complications such as hemorrhage and urinary leakage. One patient had a fever and was treated with antibiotics without serious sequelae. Struvite, cystine, and urate stones can be dissolved by irrigation with appropriate solutions via a percutaneous nephrostomy (4, 7). We adhere to certain rules, whatever the type of stone. The patient must be free of urinary infection. We try to aim the solution directly at the stone, as this seems to make the stone dissolve faster, and perfuse at a rate of approximately 100 ml/hour. If the patient has pain or fever, irrigation is stopped immediately and antibiotics are given as indicated. Finally, we believe that a ureteral splint is advisable in nearly all cases to prevent ureteral colic caused by debris from the dissolving stone. Struvite stones can be dissolved with Suby's Solution G (16) or Renacidin (6). We have used the former exclusively, but Stamey et al. (2, 8) have used Renacidin extensively in postoperative patients without significant complications. It should be noted that at present Renacidin is considered an investigational drug for irrigation of the ureters and kidneys. When using either solution, it is vital to have adequate drainage of the solution, as stasis can lead to rapid absorption of the fluid and hypermagnesemia. The serum magnesium level should be monitored every 48 hours. We recently reported using acetylcysteine to dissolve cystine stones (12). Acetylcysteine is soluble in sodium bicarbonate solution and relatively nontoxic. Nonoperative treatment may be especially important with cystine stones because of their propensity to recur. Many patients can be treated with alkalinization of the urine, D-penicillamine, and systemic acetylcysteine; but if stones continue to form, irrigation with acetylcysteine through a percutaneous nephrostomy may be beneficial. Similarly, urate calculi usually dissolve with systemic alkalinization; but in patients who do not respond or who have severe pain or sepsis, percutaneous nephrostomy with decompression and irrigation may be performed. Calcium oxalate stones cannot be dissolved (6), but they can be manipulated via a percutaneous nephrostomy using Randall forceps (5), a Dormia stone basket (1, 3), or [under direct vision (9)] a resectoscope loop (1) or alligator forceps. Other, more sophisticated instruments may be developed. Percutaneous nephrostomy has many advantages over
a transcystoscopic approach alone for the manipulation of ureteral calculi, as illustrated in CASES I and V: 1. It is easier to bypass an obstruction from the upper ureter downward, as the ureter above the stone supports the catheter and guide wire, facilitating manipulation (10). On occasion it can be difficult to pass a stone basket transcystoscopically above the calculus. Similarly, it is easier to bypass an obstruction using primarily a 0.89-cm (0.035-in.) guide wire than with a 5 or 6 French stone basket (14). 2. The angiographic catheter is passed antegrade down the ureter, and the end is retrieved from the bladder with Bumpus forceps. We attach a stone basket to the end of the catheter and pull it up retrograde above the calculus. When pressure is applied to both the catheter and the basket, the basket opens wider than it does in a transcystoscopic procedure. 3. Fluoroscopic control and accurate manipulation of the basket reduce the risk of ureteral injury, and the increased support of the upper ureter may prevent avulsion of the ureter during the procedure. 4. Once the basket is attached to the catheter, several stones can be retrieved. In contrast, after transcystoscopic manipulation, it is frequently difficult to reintroduce the basket into the ureter. 5. If the ureteral orifice is too narrow to allow manipulation with a basket, a ureteral meatotomy can be performed by attaching a modified ureteral catheter with an exposed 1.5-cm steel stylet to the angiographic catheter (11). The stylet is placed in the ureteric orifice, and a cutting current is applied. After the meatotomy, the modified ureteral catheter is removed and a stone basket is attached in its place. 6. Antegrade passage of an angiographic catheter down the ureter is the only easily accessible route to ureteral calculi (14) in patients who have an ileal diversion. 7. After manipulation of the basket, it is simple to exchange it for a silicone rubber splint with appropriate side holes to intubate the ureter. CONCLUSION
Percutaneousnephrostomy is no longer an experimental procedure. Recently Stables et al. (15) reviewed 516 cases and found minimal complications. The percutaneous nephrostomy tract is the gateway to a combined urological and radiological attack on calculous disease, and every urologist and radiologist should be aware of these techniques for the benefit of their patients. Department of Urology Veterans Administration Hospital Minneapolis, Minn. 55417
REFERENCES t. Bissada NK. Meacham KR, Redman JF: Nephrostoscopy with removal of renal pelvic calculi. J UroI112:414-416. Oct 1974
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2. Cunningham JJ, Friedland GW, Stamey TA: Radiologic changes in the urothelium during Renacidin irrigations. J Urol 109: 556-558, Apr 1973 3. Fernstrom I, Johansson B: Percutaneous pyelolithotomy. A new extraction technique. Scand J Urol NephroI10:257-259, 1976 4. Fostvedt GA, Barnes RW: Complications dlJ"ing lavage therapy for renal calculi. J Urol 89:329-331, Mar 1963 5. Karamcheti A, O'Donnell WF: Percutaneous nephrolithotomy: an innovative extraction technique. J UroI118:671-672, Oct 1977 6. Mulvaney WP: The clinical use of Renacidin in urinary calcifications. J Urol 84:206-212, Aug 1960 7. Nataf R: Les nephrostomies per-cutanees. J Urol Nephrol (Paris) 19:271-277, Mar 1973 8. Nemoy NJ, Stamey TA: Use of Hemiaciclrin in management of infection stones. J UroI116:693-695, Dec 1976 9. Rupel E, Brown R: Nephroscopy with removal of stone following nephrostomy for obstructive calculous anurla. J Urol 46: 177-182, Aug 1941 10. Smith AD, Lange PH, Fraley EE: Applications of percutaneous
nephrostomy. New challenges and opportunities in endo-lJ"ology. Letter to the editor. J Urol 121:382, Mar 1979 11. Smith AD, Lange PH, Miller RP, et al: Controlled ureteral meatotomy. J UroI121:587-589, May 1979 12. Smith AD, Lange PH, Miller RP, et al: Dissolutions of cystine calculi by irrigation with acetylcysteine through percutaneous nephrostomy. Urology 13:422-423, Apr 1979 13. Smith AD, Lange PH, Miller RP, et al: Introduction of the Gibbons ureteral stent facilitated by antecedent percutaneous nephrostomy. J UroI120:543-544, Nov 1978 14. Smith AD, Lange PH, Reinke DB, et al: Extraction of ureteral calculi from patients with ileal loops: a new technique. J Urol 120: 623-625, Nov 1978 15. Stables DP, Ginsberg NJ. Johnson ML: Percutaneous nephrostomy: a series and review of the literature. Am J Roentgenol 130:75-82, Jan 1978 16. Suby HI, Albright F: Dissolution of phosphatic urinary calculi by the retrograde introduction of a citrate solution containing magnesium. N Engl J Med 228:81-91,21 Jan 1943