Vol. 115, June
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1976 by The Williams & Wilkins Co.
PERCUTANEOUS NEPHROSTOMY RONALD D. HARRIS, DAVID L. MCCULLOUGH*
AND
LEE B. TALNER
From the Departments of Radiology and Surgery, Division of Urology, University of California, San Diego School of Medicine and University Hospital, San Diego, California
ABSTRACT
A safe and effective method for long-term relief of renal obstruction is presented. This method has been successful in buying time for patients in situations in which other approaches are hazardous or more complex. Its use can be modified for short-term therapeutic drainage of the upper urinary tract. used for identifying and puncturing the collecting system. Once the appropriate puncture spot has been determined an 18 gauge teflon sheathed 4 or 6-inch needlet is directed toward an upper pole calix under either fluoroscopy or ultrasound guidance. Once the urine is obtained the inner metal needle portion is removed, leaving the teflon catheter in the collecting system. If ultrasound is used for the initial puncture contrast material can be injected directly through the catheter for fluoroscopic visualization of the collecting system during the remainder of
A safe and effective method for providing percutaneous therapeutic drainage of an obstructed kidney is described. The purpose of this technique is to provide long-term urinary diversion for patients who are not candidates for surgical intervention or temporary drainage for those who need to buy time for 1 reason or another. The technique is an extension of the antegrade pyelography technique and uses angiographic skills and instrumentation. 1 It has been performed successfully on 7 obstructed kidneys. The longest period during which this
FIG. 1. Longitudinal scan above left kidney with patient in prone position. Note echo pattern of dilated calices that closely resemble appearance on pyelography in figure 2, A.
technique has provided nephrostomy drainage has been 12 the procedure. A soft end 0.035 J-shape guide wire is then months (see table). Figures 1 to 4 indicate the technique and passed through the sheath into the renal pelvis, following findings in several different patients. which the catheter is exchanged for a 6F teflon angiographic dilator. The dilator has a tapered end to fit snugly above the TECHNIQUE guide wire and is used to establish a tract into the renal The patient is placed in the prone position on a fluoroscopic parenchyma. The dilator is then removed and a 7 or 8F tapered table. We have used diazepam for premedication. Lidocaine polyethylene angiographic catheter with multiple side holes for anesthesia is used locally after sterile preparation of the back. drainage is introduced above the guide wire into the renal Fluoroscopic localization of the dilated collecting system is pelvis. Its position is checked fluoroscopically and confirmed achieved either by an intravenous injection or retrograde with overhead radiograms in multiple projections. Once a administration of contrast material. Alternately an ultrasound satisfactory placement ft'as been obtained the guide wire is map with or without use of an aspiration transducer can be removed and the cathe,;er is sutured to the skin. The catheter is attached via a plastic connecting tubing to a bile bag or similar Accepted for publication October 31, 1975. Read at annual meeting of Southeastern Section, American Urologi- rei:eptacle for closed drainage. A bulky dressing is applied to prevent kinking or pulling of the catheter. cal Association, Atlanta, Georgia, April 13-16, 1975. * Current address: Department of Surgery/Urology, University of During the next few weeks catheter exchanges are done, South Alabama School of Medicine, Mobile General Hospital, Mobile, Alabama 36617.
628
tLongdwell, Becton-Dickinson, Rutherford, New Jersey.
PERCUTA.f',fE0US J.~EPHROSTOiviY
629
FIG. 2. A, left kidney being filled with contrast material via teflon sleeve catheter after percutaneous puncture of upper pole calix. B, antegrade pyelogram of kidney through teflon sleeve 2 days after nephrostomy. This shows marked decompression of size of collecting system. C, appearance of pelviocaliceal system after insertion of 7F teflon catheter. Note different size mucosa! irregularities (arrows) believed to be owing to mucosa! edema. D, final appearance of left kidney with SF polyethylene catheter in renal pelvis. This catheter drained well until patient's death.
Fm. 3. A, 20-minute film from excretory urogram demonstrates non-visualization of right kidney and hydronephrosis of left kidney. There is concentric narrowing of proximal ureter (arrow) owing to metastatic carcinoma in retroperitoneal area. B, antegrade pyelogram performed by indwelling teflon sleeve catheter of non-visualized right kidney. This was performed under ultrasound guidance. Marked hydronephrosis is seen. Actual site of obstruction is not visualized.
630
HARRIS, MCCULLOUGH AND TALNER
FIG. 4. A, hydronephrosis ofleft kidney demonstrated via retrograde ureteral catheter present in renal pelvis. B, 7F teflon angiographic catheter has been inserted into upper pole calix of left kidney. Marked decompression of collecting system is demonstrated. Note also mucosa! irregularities probably representing mucosa! edema (arrows). C, extravasation of contrast material is seen (arrows) in renal sinuses after perforation of lower pole calix by guide wire. Percutaneous catheter is lOF teflon catheter with multiple side holes. D, pyelogram shows final 18F soft polyethylene catheter in left renal pelvis. Dilatation of collecting system is artifact of overdistension during pyelogram.
Summary of percutaneous nephrostomies Clinical Presentation Pt. OSBCOSHSHNRWGM-
Age (yrs.)
Obstructive Etiology
60 31 61 67
Metastatic breast Ca Metastatic rectal Ca Metastatic breast Ca Bilat. calculi Calculus, solitary kidney Metastatic rectal Ca Bladder Ca
52
69 81
Sepsis
Uremia
Successful Results
Yes Yes Yes Yes Yes Yes No
Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes No Yes Yes Yes
Duration of Nephrostomy (wks.) 2
6 52
1 3 3
Other Therapy Rt. nephrectomy None Permanent nephrostomy Lt. ureterolithotomy Pyelolithotomy Lt. ureteral reimplantation Ilea! loop diversion
DISCUSSION using successively larger and softer catheters. Each time the There have been few reports concerning the feasibility of guide wire is inserted through the existing nephrostomy catheter into the renal pelvis and the catheter is withdrawn. The percutaneous nephrostomy for long-term drainage of an obnew, larger catheter with its tapered tip and multiple side holes structed kidney.2· 3 The technique was first reported by Goodis introduced above the guide wire, similar to catheter ex- win and associates, using radiologic demonstration of bony landmarks for localization. 2 Their major effort was to be able to change in a vascular procedure. Once a tract is established the tapered end is not required test unilateral renal function prior to nephrectomy for hydroneand the guide wire is used only to direct the new catheter. phrosis or as a temporizing measure until the patient was Eventually a large, soft 14 to 18F red rubber or silastic tube better fit for a nephrectomy. In their series they had 1 patient with a percutaneous nephrostomy for 2 months and another for should be placed easily for permanent drainage.
PERCUTAi"J20US NEPHROSTOM'.Y
a stiff catheter_ 10 n1anuacon to check the µuMc.,vu 5 r;:(onths before vvas undertaken. rrhis systen1 has been an of percutaneous antegrade of the catheter to ensure that the tip is not abutting pyelography, which was first described by Wickbom, 1 and the wall. Soft catheter material should be used as early as possible. Infection within the perirenal space and catheter tract is also nephrostomy technique, which was refined Saxton and associates.• A recent report from Sweden described an experi- a potential hazard. To date infection has not been a problem ence with a similar percutaneous nephrostomy technique. 5 despite infected urine being present on the initial puncture in However, this method was performed from a lateral approach, all of our cases. The organisms we have encountered have been which may produce a complication of placing the catheter in the Candida albicans, Proteus vulgaris, Klebsiella pneumoniae colon with the subsequent hazard of peritonitis. Also a recent and Pseudomonas. However, sterile technique and antibiotic rep'Ort by Bolich and Crummy described the use of angio- coverage are believed to be important to help prevent this complication. grnphic tools to catheterize an implanted ilea! loop ureter. 6 Contraindications to percutaneous nephrostomy are few and include a hemorrhagic diathesis, tuberculosis or neoplastic ADDENDUM involvement of the kidney itself or the presence of a perinephric Since submission of this manuscript we have performed an abscess. Previous statements have indicated that azotemia or additional 19 percutaneous nephrostomies in 13 patients. 2 acute infection are contraindications but we have not found this to be the case. On 3 occasions our patients were uremic Several patients underwent bilateral nephrostomy to relieve and infected when the percutaneous nephrostomy was done bilateral obstruction. Our technique remains essentially the and both conditions improved after proper drainage and same. The only additional complication has been brisk bleeding upon removal of 1 of the nephrostomy tubes a month after antibiotic therapy. We have encountered 4 complications, which so far have its insertion. The bleeding stopped spontaneously and did not been of minor significance. 1) Bleeding is self-limited and require an operation. The same technique can be used for related to the initial needle puncture. Occasionally, a minor pressure-flow studies on the upper urinary tract in patients amount of bleeding occurred after the use of a guide wire. The with dilated collecting systems or ureters. Anatomic or funcbleeding has cleared within an hour and catheter obstruction tional obstruction can then be diagnosed with certainty. by clot did not occur with sterile saline irrigation. 2) PerforaREFERENCES tion of a calix occurred once owing to a broken guide wire, producing a tear in the mucosa. Extravasation of contrast 1. Wickbom, I.: Pyelography after direct puncture of the renal pelvis. material was seen for a few minutes but ceased spontaneously. Acta Radio!., 41: 505, 1954. A soft J-shape guide wire should be used to help prevent this 2. Goodwin, W. E., Casey, W. C. and Woolf, W.: Percutaneous trocar (needle) nephrostomy in hydronephrosis. J.A.M.A., 157: 891, complication. 3) Mucosa! edema was seen in the renal pelvis 1955. for several days, which diminished during a short period and was believed to be owing to rigid catheter material irritating 3. Lilien, 0. M.: Percutaneous renal pelvic diversion. Urologists' Letter Club, p. 25, March 15, 1974. the mucosa. 4) Calculus encrustation in the catheter occurred 4. Saxton, H. M., Ogg, C. S. and Cameron, J. S.: Needle nephrostomy. once. A 0.5 cm. calculus was present in the tip hole of a Brit. Med. Bull., 28: 210, 1972. catheter, which was used for a I-month period. Especially for 5. Almgard, L. E. and Fernstrom, I.: Percutaneous nephropyelosthis reason a multiple side hole catheter must be used and the tomy. Acta Radio!., 15: 288, 1974. urine should be acidified to prevent blockage of the catheter. A 6. Bolich, P.R. and Crummy, A. B.: Extravascular use of angiogrnphic potential complication might be erosion of the collecting techniques to establish drainage. J.A.M.A., 227: 655, 1974.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1976 by The Williams & Wilkins Co.
PERCUTANEOUS NEPHROSTOMY RONALD D. HARRIS, DAVID L. MCCULLOUGH*
AND
LEE B. TALNER
From the Departments of Radiology and Surgery, Division of Urology, University of California, San Diego School of Medicine and University Hospital, San Diego, California
ABSTRACT
A safe and effective method for long-term relief of renal obstruction is presented. This method has been successful in buying time for patients in situations in which other approaches are hazardous or more complex. Its use can be modified for short-term therapeutic drainage of the upper urinary tract. used for identifying and puncturing the collecting system. Once the appropriate puncture spot has been determined an 18 gauge teflon sheathed 4 or 6-inch needlet is directed toward an upper pole calix under either fluoroscopy or ultrasound guidance. Once the urine is obtained the inner metal needle portion is removed, leaving the teflon catheter in the collecting system. If ultrasound is used for the initial puncture contrast material can be injected directly through the catheter for fluoroscopic visualization of the collecting system during the remainder of
A safe and effective method for providing percutaneous therapeutic drainage of an obstructed kidney is described. The purpose of this technique is to provide long-term urinary diversion for patients who are not candidates for surgical intervention or temporary drainage for those who need to buy time for 1 reason or another. The technique is an extension of the antegrade pyelography technique and uses angiographic skills and instrumentation. 1 It has been performed successfully on 7 obstructed kidneys. The longest period during which this
FIG. 1. Longitudinal scan above left kidney with patient in prone position. Note echo pattern of dilated calices that closely resemble appearance on pyelography in figure 2, A.
technique has provided nephrostomy drainage has been 12 the procedure. A soft end 0.035 J-shape guide wire is then months (see table). Figures 1 to 4 indicate the technique and passed through the sheath into the renal pelvis, following findings in several different patients. which the catheter is exchanged for a 6F teflon angiographic dilator. The dilator has a tapered end to fit snugly above the TECHNIQUE guide wire and is used to establish a tract into the renal The patient is placed in the prone position on a fluoroscopic parenchyma. The dilator is then removed and a 7 or 8F tapered table. We have used diazepam for premedication. Lidocaine polyethylene angiographic catheter with multiple side holes for anesthesia is used locally after sterile preparation of the back. drainage is introduced above the guide wire into the renal Fluoroscopic localization of the dilated collecting system is pelvis. Its position is checked fluoroscopically and confirmed achieved either by an intravenous injection or retrograde with overhead radiograms in multiple projections. Once a administration of contrast material. Alternately an ultrasound satisfactory placement ft'as been obtained the guide wire is map with or without use of an aspiration transducer can be removed and the cathe,;er is sutured to the skin. The catheter is attached via a plastic connecting tubing to a bile bag or similar Accepted for publication October 31, 1975. Read at annual meeting of Southeastern Section, American Urologi- rei:eptacle for closed drainage. A bulky dressing is applied to prevent kinking or pulling of the catheter. cal Association, Atlanta, Georgia, April 13-16, 1975. * Current address: Department of Surgery/Urology, University of During the next few weeks catheter exchanges are done, South Alabama School of Medicine, Mobile General Hospital, Mobile, Alabama 36617.
628
tLongdwell, Becton-Dickinson, Rutherford, New Jersey.
PERCUTA.f',fE0US J.~EPHROSTOiviY
629
FIG. 2. A, left kidney being filled with contrast material via teflon sleeve catheter after percutaneous puncture of upper pole calix. B, antegrade pyelogram of kidney through teflon sleeve 2 days after nephrostomy. This shows marked decompression of size of collecting system. C, appearance of pelviocaliceal system after insertion of 7F teflon catheter. Note different size mucosa! irregularities (arrows) believed to be owing to mucosa! edema. D, final appearance of left kidney with SF polyethylene catheter in renal pelvis. This catheter drained well until patient's death.
Fm. 3. A, 20-minute film from excretory urogram demonstrates non-visualization of right kidney and hydronephrosis of left kidney. There is concentric narrowing of proximal ureter (arrow) owing to metastatic carcinoma in retroperitoneal area. B, antegrade pyelogram performed by indwelling teflon sleeve catheter of non-visualized right kidney. This was performed under ultrasound guidance. Marked hydronephrosis is seen. Actual site of obstruction is not visualized.
630
HARRIS, MCCULLOUGH AND TALNER
FIG. 4. A, hydronephrosis ofleft kidney demonstrated via retrograde ureteral catheter present in renal pelvis. B, 7F teflon angiographic catheter has been inserted into upper pole calix of left kidney. Marked decompression of collecting system is demonstrated. Note also mucosa! irregularities probably representing mucosa! edema (arrows). C, extravasation of contrast material is seen (arrows) in renal sinuses after perforation of lower pole calix by guide wire. Percutaneous catheter is lOF teflon catheter with multiple side holes. D, pyelogram shows final 18F soft polyethylene catheter in left renal pelvis. Dilatation of collecting system is artifact of overdistension during pyelogram.
Summary of percutaneous nephrostomies Clinical Presentation Pt. OSBCOSHSHNRWGM-
Age (yrs.)
Obstructive Etiology
60 31 61 67
Metastatic breast Ca Metastatic rectal Ca Metastatic breast Ca Bilat. calculi Calculus, solitary kidney Metastatic rectal Ca Bladder Ca
52
69 81
Sepsis
Uremia
Successful Results
Yes Yes Yes Yes Yes Yes No
Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes No Yes Yes Yes
Duration of Nephrostomy (wks.) 2
6 52
1 3 3
Other Therapy Rt. nephrectomy None Permanent nephrostomy Lt. ureterolithotomy Pyelolithotomy Lt. ureteral reimplantation Ilea! loop diversion
DISCUSSION using successively larger and softer catheters. Each time the There have been few reports concerning the feasibility of guide wire is inserted through the existing nephrostomy catheter into the renal pelvis and the catheter is withdrawn. The percutaneous nephrostomy for long-term drainage of an obnew, larger catheter with its tapered tip and multiple side holes structed kidney.2· 3 The technique was first reported by Goodis introduced above the guide wire, similar to catheter ex- win and associates, using radiologic demonstration of bony landmarks for localization. 2 Their major effort was to be able to change in a vascular procedure. Once a tract is established the tapered end is not required test unilateral renal function prior to nephrectomy for hydroneand the guide wire is used only to direct the new catheter. phrosis or as a temporizing measure until the patient was Eventually a large, soft 14 to 18F red rubber or silastic tube better fit for a nephrectomy. In their series they had 1 patient with a percutaneous nephrostomy for 2 months and another for should be placed easily for permanent drainage.
PERCUTAi"J20US NEPHROSTOM'.Y
a stiff catheter_ 10 n1anuacon to check the µuMc.,vu 5 r;:(onths before vvas undertaken. rrhis systen1 has been an of percutaneous antegrade of the catheter to ensure that the tip is not abutting pyelography, which was first described by Wickbom, 1 and the wall. Soft catheter material should be used as early as possible. Infection within the perirenal space and catheter tract is also nephrostomy technique, which was refined Saxton and associates.• A recent report from Sweden described an experi- a potential hazard. To date infection has not been a problem ence with a similar percutaneous nephrostomy technique. 5 despite infected urine being present on the initial puncture in However, this method was performed from a lateral approach, all of our cases. The organisms we have encountered have been which may produce a complication of placing the catheter in the Candida albicans, Proteus vulgaris, Klebsiella pneumoniae colon with the subsequent hazard of peritonitis. Also a recent and Pseudomonas. However, sterile technique and antibiotic rep'Ort by Bolich and Crummy described the use of angio- coverage are believed to be important to help prevent this complication. grnphic tools to catheterize an implanted ilea! loop ureter. 6 Contraindications to percutaneous nephrostomy are few and include a hemorrhagic diathesis, tuberculosis or neoplastic ADDENDUM involvement of the kidney itself or the presence of a perinephric Since submission of this manuscript we have performed an abscess. Previous statements have indicated that azotemia or additional 19 percutaneous nephrostomies in 13 patients. 2 acute infection are contraindications but we have not found this to be the case. On 3 occasions our patients were uremic Several patients underwent bilateral nephrostomy to relieve and infected when the percutaneous nephrostomy was done bilateral obstruction. Our technique remains essentially the and both conditions improved after proper drainage and same. The only additional complication has been brisk bleeding upon removal of 1 of the nephrostomy tubes a month after antibiotic therapy. We have encountered 4 complications, which so far have its insertion. The bleeding stopped spontaneously and did not been of minor significance. 1) Bleeding is self-limited and require an operation. The same technique can be used for related to the initial needle puncture. Occasionally, a minor pressure-flow studies on the upper urinary tract in patients amount of bleeding occurred after the use of a guide wire. The with dilated collecting systems or ureters. Anatomic or funcbleeding has cleared within an hour and catheter obstruction tional obstruction can then be diagnosed with certainty. by clot did not occur with sterile saline irrigation. 2) PerforaREFERENCES tion of a calix occurred once owing to a broken guide wire, producing a tear in the mucosa. Extravasation of contrast 1. Wickbom, I.: Pyelography after direct puncture of the renal pelvis. material was seen for a few minutes but ceased spontaneously. Acta Radio!., 41: 505, 1954. A soft J-shape guide wire should be used to help prevent this 2. Goodwin, W. E., Casey, W. C. and Woolf, W.: Percutaneous trocar (needle) nephrostomy in hydronephrosis. J.A.M.A., 157: 891, complication. 3) Mucosa! edema was seen in the renal pelvis 1955. for several days, which diminished during a short period and was believed to be owing to rigid catheter material irritating 3. Lilien, 0. M.: Percutaneous renal pelvic diversion. Urologists' Letter Club, p. 25, March 15, 1974. the mucosa. 4) Calculus encrustation in the catheter occurred 4. Saxton, H. M., Ogg, C. S. and Cameron, J. S.: Needle nephrostomy. once. A 0.5 cm. calculus was present in the tip hole of a Brit. Med. Bull., 28: 210, 1972. catheter, which was used for a I-month period. Especially for 5. Almgard, L. E. and Fernstrom, I.: Percutaneous nephropyelosthis reason a multiple side hole catheter must be used and the tomy. Acta Radio!., 15: 288, 1974. urine should be acidified to prevent blockage of the catheter. A 6. Bolich, P.R. and Crummy, A. B.: Extravascular use of angiogrnphic potential complication might be erosion of the collecting techniques to establish drainage. J.A.M.A., 227: 655, 1974.
