Australas Radio1 1992.36: 174-175
Percutaneous Removal of Retained Suture Following Antegrade Ureteral Stenting W.M. JOHN HOE, M.B.B.S., D.M.R.D., F.R.C.R. Department of Diagnostic Radiology E.C.TAN, M.B.B.S.,F.R.C.S. Division of Urology, Department of Surgery National University Hospital, Singapore.
ABSTRACT A case is presented o f percutanmus removal of a foreign body, a silk suture, which was left in the kidney following antegrade placement of a multilength double J ureteral stent. I~~TRODUCITON Antegrade percutaneous placement of ureteral stents is. a well established p m d u r e . With the use of double pigtail or J stents, there can be difficulty in control of the final position of the proximal pigtail in the renal pelvis. A common method of simplifying placement of these stents is the use of a suture threaded through a side hole in the proximal end of the stent, and traction along the suture allows the stent to be pulled proximally into the renal pelvis if necessary. We describe a case in which following antegrade insertion of a multilength double pigtail stent, the silk suture could not be removed from the proximal end of the catheter following placement of the stent into a satisfactory position. Although the stent was removed at cystoscopy, the suture was retained in the renal pelvis and caused persistent haematuria. Following identification of its position by CT scan, it was percutaneously removed through a nephroscope following a repeat nephrostomy.
Ad&
for eomspocldeacc: h.John Hoe Department of Radiology MIElizebelhHospital 3 Mt E l i singapac 0922
174
Unenhanced CT scan of the kidneys. The foreign body in the R pelvicalyceal system is clearly demonstrated.
CASE REPORT A 25 year old man was hospitalized for percutaneous dilation of a secondary uretero-pelvic junction (UPJ) obstruction. He had a past history of Anderson Hynes pyeloplasty 6 years previously for obstruction of the right kidney secondary to a retrocaval ureter. Since then he had had recurrent episodes of urosepsis secondary to renal and ureteric calculi treated by nephrolithotomy 4 years and ureteroscopy 2 years previously. An excretory urogram 2 months prior to admission showed a non-functioning right kidney and a DTPA renogram confiied obstruction at the UPJ. On this admission, following percutaneous puncture of the R kidney, the nephrostomy tract was dilated to 12F and dilatation of the UPJ smcture performed using an angiographic balloon catheter. A nephrostomy catheter was left across the stricture and two days later, under local anaes-
thesia, a 7F multilength Cook C-flex (Bloomington, IN) stent was placed, using a guidewire. A 3-0 silk suture was placed through the proximal end of the stent but following removal of the guidewire, it was not possible to remove the stent in spite of persistent traction on one of the free ends of the suture. Part of the suture could be seen exiting through the nephrostomy wound. An externally drainage 7F nephrostomy catheter was left in the right kidney and following antegrade nephrostomy two days later which showed free flow of contrast down the ureter, this was removed and the patient discharged. On follow up the patient complained of occasional haematuria 4-5 times a day. The double J stem was removed at cystoscopy 8 weeks later but no suture
Submitted for publication on: 30th July, 1991 Accepted for publication on: 27th August, 1991 AustralasianRadiology. Vol.36. No.2. May. 1992
PERCUTANEOUS REMOVAL OF RETAINED SUTURE was found. Retrograde ureteroscopy was also performed all the way up to the renal pelvis but no suture was seen. On further review the patient complained of persistent haematuria associated with physical exertion. A renal angiogram was performed 6 months post operatively to exclude an arteriovenous fistula o r pseudoaneurysm and was normal. A CT scan of the kidney was then done and this revealed the foreign body in the renal pelvis. Retrograde ureteroscopy was again carried out, together with a retrograde pyelogram but again the suture could not be indentified. A repeat CT scan confirmed the foreign body was still present and under general anaesthesia the kidney was repunctured and the nephrostomy tract dilated to 30F. A nephroscope was inserted and a small area of granulation tissue with calcification was seen in the lower pole calyx. On removal of this tissue, the end of the silk suture was seen with the rest of the suture embedded in the renal parenchyma. Using alligator forceps the tip of the suture was held and pulled out in a medial direction towards the renal pelvis. Following removal of the foreign body the patient’s haematuria stopped and he has remained well and asymptomatic. Follow up isotope renogram shows no evidence of obstruction of the right kidney. DISCUSSION We describe a case of a previously unreported complication associated with percutaneous ureteral stent insertion, treated b y a percutaneous approach via a nephroscope. Although the placement of ureteral stents by an antegrade route is well established,
Australasian Radiolog?. Vol. 34. No. 2. Ma).. 1992
there can be technical difficulties, particularly related to poor visualization and localization of the proximal end of the stent and control of the final position of the stent. The use of a suture, nylon or silk, placed through a side hole of the proximal end of the stent is a common modification to aid placement of the stent (3). Once the suture has been placed, preferrably in the middle of the proximal portion of the pigtail stent, and the two free ends of the suture clamped together, the stent can b e inserted over the guidewire using a pusher. Once the stent has been positioned, the tip of the pusher is then withdrawn into the renal pelvis, and the guidewire and transrenal sheath, if used, are then removed. The proximal end of the stent is withdrawn to the renal pelvis if it was initially overadvanced by gentle traction on the suture. The suture is then removed from the stent by pulling on one of its free ends and pulled out of the kidney. Complications can result from insertion of indwelling stents. These include premature occlusion, stent migration, fracture or renal pelvic perforation. (1) Shearing off of a portion of a nephrostomy catheter during removal of a nylon suture placed through the proximal end of the stent has also been reported (3, but we believe this is to be the first report of a retained suture. Most previous authors have indicated that the guidewire should be removed from the stent prior to adjustment of its final position by traction on the suture (3,2,6). However, with multilength stents as used in this patient, it is probabIy advisable to only partly remove the guidewire, leaving the guidewire in the proximal end of the stent, prior to removal of the suture. In fact, the use of a safety suture may not be necessary with a multilength stent.
A percutaneous approach via a nephroscope can be used to remove not only calculi but other objects including fungus balls and broken stents or stone baskets (4). In this patient, a nephrostomy tract was dilated t o 3 0 F and a nephroscope used to remove the foreign body successfully.
REFERENCES 1. LeRoy AJ, Williams Jr H J, Segura JW, Patterson DE, Benson RC. Indwelling ureteral stents: percutaneous management of complications. Radiology 1986; 158: 219-222. 2. Liebeman RP. Percutaneous placement and removal of silicone rubber ureteral stents. Seminars inter. Radiology 1984; I: 19-23. 3. Salazer JE, Johnson JB, Scott R, Pinstein M. A simplified method for placement of internal ureteral stents. AJR 1983; 140: 611-612. 4. Smith AD. Retrieval of ureteral stents. Urol. Clinics North America 1982; 9: 109-112. 5. Sussman SK, Oke EJ, Perlmutt LM. Dunnick NR. Shearing of percutaneous nephrostomy catheter during indwelling ureteral stent placement. AJR 1986; 147: 832-833. 6. Tadavarthy SM, Coleman CC, Hunter DW er al. Percutaneous uroradiologic techniques in interventional radiology. Eds. Castaneda-Zuniga WR, Tadavarthy SM, Williams and Wilkins. Baltimore 1988; 517-521.
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Percutaneous Removal of Retained Suture Following Antegrade Ureteral Stenting W.M. JOHN HOE, M.B.B.S., D.M.R.D., F.R.C.R. Department of Diagnostic Radiology E.C.TAN, M.B.B.S.,F.R.C.S. Division of Urology, Department of Surgery National University Hospital, Singapore.
ABSTRACT A case is presented o f percutanmus removal of a foreign body, a silk suture, which was left in the kidney following antegrade placement of a multilength double J ureteral stent. I~~TRODUCITON Antegrade percutaneous placement of ureteral stents is. a well established p m d u r e . With the use of double pigtail or J stents, there can be difficulty in control of the final position of the proximal pigtail in the renal pelvis. A common method of simplifying placement of these stents is the use of a suture threaded through a side hole in the proximal end of the stent, and traction along the suture allows the stent to be pulled proximally into the renal pelvis if necessary. We describe a case in which following antegrade insertion of a multilength double pigtail stent, the silk suture could not be removed from the proximal end of the catheter following placement of the stent into a satisfactory position. Although the stent was removed at cystoscopy, the suture was retained in the renal pelvis and caused persistent haematuria. Following identification of its position by CT scan, it was percutaneously removed through a nephroscope following a repeat nephrostomy.
Ad&
for eomspocldeacc: h.John Hoe Department of Radiology MIElizebelhHospital 3 Mt E l i singapac 0922
174
Unenhanced CT scan of the kidneys. The foreign body in the R pelvicalyceal system is clearly demonstrated.
CASE REPORT A 25 year old man was hospitalized for percutaneous dilation of a secondary uretero-pelvic junction (UPJ) obstruction. He had a past history of Anderson Hynes pyeloplasty 6 years previously for obstruction of the right kidney secondary to a retrocaval ureter. Since then he had had recurrent episodes of urosepsis secondary to renal and ureteric calculi treated by nephrolithotomy 4 years and ureteroscopy 2 years previously. An excretory urogram 2 months prior to admission showed a non-functioning right kidney and a DTPA renogram confiied obstruction at the UPJ. On this admission, following percutaneous puncture of the R kidney, the nephrostomy tract was dilated to 12F and dilatation of the UPJ smcture performed using an angiographic balloon catheter. A nephrostomy catheter was left across the stricture and two days later, under local anaes-
thesia, a 7F multilength Cook C-flex (Bloomington, IN) stent was placed, using a guidewire. A 3-0 silk suture was placed through the proximal end of the stent but following removal of the guidewire, it was not possible to remove the stent in spite of persistent traction on one of the free ends of the suture. Part of the suture could be seen exiting through the nephrostomy wound. An externally drainage 7F nephrostomy catheter was left in the right kidney and following antegrade nephrostomy two days later which showed free flow of contrast down the ureter, this was removed and the patient discharged. On follow up the patient complained of occasional haematuria 4-5 times a day. The double J stem was removed at cystoscopy 8 weeks later but no suture
Submitted for publication on: 30th July, 1991 Accepted for publication on: 27th August, 1991 AustralasianRadiology. Vol.36. No.2. May. 1992
PERCUTANEOUS REMOVAL OF RETAINED SUTURE was found. Retrograde ureteroscopy was also performed all the way up to the renal pelvis but no suture was seen. On further review the patient complained of persistent haematuria associated with physical exertion. A renal angiogram was performed 6 months post operatively to exclude an arteriovenous fistula o r pseudoaneurysm and was normal. A CT scan of the kidney was then done and this revealed the foreign body in the renal pelvis. Retrograde ureteroscopy was again carried out, together with a retrograde pyelogram but again the suture could not be indentified. A repeat CT scan confirmed the foreign body was still present and under general anaesthesia the kidney was repunctured and the nephrostomy tract dilated to 30F. A nephroscope was inserted and a small area of granulation tissue with calcification was seen in the lower pole calyx. On removal of this tissue, the end of the silk suture was seen with the rest of the suture embedded in the renal parenchyma. Using alligator forceps the tip of the suture was held and pulled out in a medial direction towards the renal pelvis. Following removal of the foreign body the patient’s haematuria stopped and he has remained well and asymptomatic. Follow up isotope renogram shows no evidence of obstruction of the right kidney. DISCUSSION We describe a case of a previously unreported complication associated with percutaneous ureteral stent insertion, treated b y a percutaneous approach via a nephroscope. Although the placement of ureteral stents by an antegrade route is well established,
Australasian Radiolog?. Vol. 34. No. 2. Ma).. 1992
there can be technical difficulties, particularly related to poor visualization and localization of the proximal end of the stent and control of the final position of the stent. The use of a suture, nylon or silk, placed through a side hole of the proximal end of the stent is a common modification to aid placement of the stent (3). Once the suture has been placed, preferrably in the middle of the proximal portion of the pigtail stent, and the two free ends of the suture clamped together, the stent can b e inserted over the guidewire using a pusher. Once the stent has been positioned, the tip of the pusher is then withdrawn into the renal pelvis, and the guidewire and transrenal sheath, if used, are then removed. The proximal end of the stent is withdrawn to the renal pelvis if it was initially overadvanced by gentle traction on the suture. The suture is then removed from the stent by pulling on one of its free ends and pulled out of the kidney. Complications can result from insertion of indwelling stents. These include premature occlusion, stent migration, fracture or renal pelvic perforation. (1) Shearing off of a portion of a nephrostomy catheter during removal of a nylon suture placed through the proximal end of the stent has also been reported (3, but we believe this is to be the first report of a retained suture. Most previous authors have indicated that the guidewire should be removed from the stent prior to adjustment of its final position by traction on the suture (3,2,6). However, with multilength stents as used in this patient, it is probabIy advisable to only partly remove the guidewire, leaving the guidewire in the proximal end of the stent, prior to removal of the suture. In fact, the use of a safety suture may not be necessary with a multilength stent.
A percutaneous approach via a nephroscope can be used to remove not only calculi but other objects including fungus balls and broken stents or stone baskets (4). In this patient, a nephrostomy tract was dilated t o 3 0 F and a nephroscope used to remove the foreign body successfully.
REFERENCES 1. LeRoy AJ, Williams Jr H J, Segura JW, Patterson DE, Benson RC. Indwelling ureteral stents: percutaneous management of complications. Radiology 1986; 158: 219-222. 2. Liebeman RP. Percutaneous placement and removal of silicone rubber ureteral stents. Seminars inter. Radiology 1984; I: 19-23. 3. Salazer JE, Johnson JB, Scott R, Pinstein M. A simplified method for placement of internal ureteral stents. AJR 1983; 140: 611-612. 4. Smith AD. Retrieval of ureteral stents. Urol. Clinics North America 1982; 9: 109-112. 5. Sussman SK, Oke EJ, Perlmutt LM. Dunnick NR. Shearing of percutaneous nephrostomy catheter during indwelling ureteral stent placement. AJR 1986; 147: 832-833. 6. Tadavarthy SM, Coleman CC, Hunter DW er al. Percutaneous uroradiologic techniques in interventional radiology. Eds. Castaneda-Zuniga WR, Tadavarthy SM, Williams and Wilkins. Baltimore 1988; 517-521.
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