THE ,JO! !{~AL OF LIROLOC:\ Copvright © 197,', h,· The Williams & Wilk ins Co.
Vol. 114. '.\ovember
Printed in U.S .A.
PERMANENT NEPHROSTOMY VIA PERCUTANEOUS PUNCTURE DEREK P. STABLES,* STEVE A. HOLT. HOWARD M. SHER!DA\J
A'-ll
ROBERT E. DONOHUE
From the DiL·isions of Diainos t ic Radio/og, and Uro/ogv. Unit·ersity of Colorado Medirnl School , IJen uer. Colorado
Al:ISTHACT
A technique to convert a standard temporary percutaneous nephrostomy to prolonged or permanent nephrostom.v diversion with Foley catheters up to 16F in diameter is described herein. The method has been used for up to 22 months of drainage and is likely to be of principal benefit in the management of obstructive nephropathy in adults when the primar:,.· lesion is not readily amenable to repair. There have been no serious complications in our 4 cases. Percutaneous nephrostomy has been in use for 20 years. 1 The primary role of this procedure is the temporary alleviation of obstructive nephropat hy prior to definitive surgical correction.'· 3 The extension of this principle to provide prolonged or permanent supravesical diversion in selected cases is described herein. METHOD
The renal pelvis is opacified by excretor:,; urography (IVP) and then is punctured with a 6 or 8-inch, 18 gauge teflon cannula needle introduced perpendicularly through the locally anesthetized flank under fluoroscopic or ultrasonographic control. The cannula is exchanged over a 0.035-inch, Jtipped spring guide for a radiopaque , thick-walled angiographic catheter, either 6.5F polyethylene or 7F reinforced polyurethane, with at least 6 side holes arranged spirally around a coiled tip of l cm. radius (fig. 1). The introduction of the coiled tip is facilitated by dilatation of the puncture tract with a 6 or 7F teflon vessel dilator applied over the spring guide. The catheters are sutured to the skin and connected to urinary drainage bags. A large dressing is applied so that the patient can sit or lie supine without kinking the catheters. The patient could be discharged from the hospital on the following day, depending on the indication for the nephrostomy. Two weeks later the 6.5 or 7F catheter is exchanged for a 9F polyethylene catheter of similar design and this exchange is accomplished using in succession a O.o:3,5-inch spring guide, an 8F teflon dilator, a 0.045-inch spring guide, a 9F teflon dilator and a 0.052-inch spring guide. This exchange and all subsequent ones can be performed on an outpatient basis without anesthesia. After another 6 or 8 weeks the tract is suffiAccepted for publication June 20. 197.~. Read at annual meeting of Ameri ca n Urological Asso ciation, Miami Beach, Florida. Mav 11-15. l975. * Requests for reprints: Division ;Jf Diagnostic Radiology. University of Colorado Medical School. Denver. Colorado 80220.
684
ciently well formed that the 9F catheter can be removed and a closed-end, la tex Foley catheter is introduced. Ideally the lOF size is inserted but the flexibility of the catheter wall and the presence of the balloon may allow passage only of the SF size. des pite dilatation of the tract with a lOF teflon vessel dilator and the use of a firm wire to stiffen the catheter. The Foley catheter is replaced routinely at approximately monthly intervals to minimize crystal deposition and progressively larger catheters are inserted up to 12, 14 or 16F (fig. 2), after dilatation of the tract with teflon or Hegar dilators. The patients have been maintained on a urinary chemoprophylactic agent, usually nitrofurantoin . CASE !\IATEHlAI.. HESL'l,TS AND COMPLICATIOt\S
Of the 17 patients managed by percutaneous nephrostomy at our hospitals since 1972, 4 have been admitted to the program of prolonged (more than 6 months) or permanent nephrostomy (see table). Satisfactory drainage has been maintained in all 4 cases, except for the multiple episodes of catheter obstruction by phosphate crystals, necessitating catheter replacement more frequently than the planned monthly change in case 1 (fig. 3). The frequency of these episodes has diminished following the administration of a suitable diet and ascorbic acid to acidify the urine. Displacement of a Foley catheter occurred once, almost certainly because the catheter had not been advanced into the renal pelvis during a routine catheter change. Transient hematuria, usually less than l hour in duration, is common after any catheter change to a larger size. There has been no evidence of retroperitoneal hemorrhage, urinary extravasation or other serious complications. DISCUSSION
The relati\'e merits of the percutaneous approach to prolonged or permanent nephrostomy
PERMANENT NEPHROSTOMY VIA PER CUTANEOUS PUNCTURE
...
685
• ____________----
,........,
FIG. 1. Apparatu s for initial pun cture-18 gauge tet'lon cannula needle, 0.035-inch movable core ,)-tipped spring guide, 6F teflon vessel dilator and 6.5F polyethylene catheter with coi led tip.
FIG. 2. Case 2. Antegrade pyelography s hows left uret eropelvi c junction obstruction (arrow). A 16F Foley catheter balloon positioned in left renal pelvis 12 month s after initial puncture.
include the avoidance of general anesthesia, minimal postoperative discomfort, brief hospitalization (lower cost) and probably fewer nephrons are damaged. The relative merits of the surgica l approach to prolonged or permanent nephrostom y include a single manipulation ; early catheter displacement is rare, it is more readily available and a large size catheter is used . Most of the state ments are self-evident but it remains to be proved that fewer nephrons are damaged by the percutaneous technique. Surgical nephrostomy is available in every community served by a urologist, whereas permanent nephrostomy by the percutaneous route requires a radiologist prepared to maintain a level of expertise and a range of instrument s wider than those required for temporary percutaneous nephrostomy . The potential indications for the percutaneous methods of prolonged or permanent nephrostomy include obstructive nephropathy in the elderly or infirm , obstructive nephropathy or severe reflux in early infancy and large vesicovaginal fi stulas un suitable for primary repa ir. The potential indications for the surgical methods of prolonged or permanent nephrostomy include performance during another surgical procedure (such as laparotom y after mi ssile injury) , the majority of children and multiple small rena l calculi requiring a large catheter to maintain drainage. We certainly do not see the percutaneous technique rendering surgic a l nephrostomy obsolete. The once-and-forall surgical procedure will usually be prefera bl e for children because the manipulations described for the percutaneous approach would require hr.avy sedation , if not general anesthesia. The exception
686
STABLES AND ASSOCIATES
Case material Serum Pt.-Sex-Age Creatin ine (mg./lOOml.) HD-F- 5$
1.3
Indication for Nephrostomy
Rt. ureteral injur:, at radical hysterectomy, It. obstructive atro-
phy JA-M-69
:u
Cont ra ind icat i
Vol. 114. '.\ovember
Printed in U.S .A.
PERMANENT NEPHROSTOMY VIA PERCUTANEOUS PUNCTURE DEREK P. STABLES,* STEVE A. HOLT. HOWARD M. SHER!DA\J
A'-ll
ROBERT E. DONOHUE
From the DiL·isions of Diainos t ic Radio/og, and Uro/ogv. Unit·ersity of Colorado Medirnl School , IJen uer. Colorado
Al:ISTHACT
A technique to convert a standard temporary percutaneous nephrostomy to prolonged or permanent nephrostom.v diversion with Foley catheters up to 16F in diameter is described herein. The method has been used for up to 22 months of drainage and is likely to be of principal benefit in the management of obstructive nephropathy in adults when the primar:,.· lesion is not readily amenable to repair. There have been no serious complications in our 4 cases. Percutaneous nephrostomy has been in use for 20 years. 1 The primary role of this procedure is the temporary alleviation of obstructive nephropat hy prior to definitive surgical correction.'· 3 The extension of this principle to provide prolonged or permanent supravesical diversion in selected cases is described herein. METHOD
The renal pelvis is opacified by excretor:,; urography (IVP) and then is punctured with a 6 or 8-inch, 18 gauge teflon cannula needle introduced perpendicularly through the locally anesthetized flank under fluoroscopic or ultrasonographic control. The cannula is exchanged over a 0.035-inch, Jtipped spring guide for a radiopaque , thick-walled angiographic catheter, either 6.5F polyethylene or 7F reinforced polyurethane, with at least 6 side holes arranged spirally around a coiled tip of l cm. radius (fig. 1). The introduction of the coiled tip is facilitated by dilatation of the puncture tract with a 6 or 7F teflon vessel dilator applied over the spring guide. The catheters are sutured to the skin and connected to urinary drainage bags. A large dressing is applied so that the patient can sit or lie supine without kinking the catheters. The patient could be discharged from the hospital on the following day, depending on the indication for the nephrostomy. Two weeks later the 6.5 or 7F catheter is exchanged for a 9F polyethylene catheter of similar design and this exchange is accomplished using in succession a O.o:3,5-inch spring guide, an 8F teflon dilator, a 0.045-inch spring guide, a 9F teflon dilator and a 0.052-inch spring guide. This exchange and all subsequent ones can be performed on an outpatient basis without anesthesia. After another 6 or 8 weeks the tract is suffiAccepted for publication June 20. 197.~. Read at annual meeting of Ameri ca n Urological Asso ciation, Miami Beach, Florida. Mav 11-15. l975. * Requests for reprints: Division ;Jf Diagnostic Radiology. University of Colorado Medical School. Denver. Colorado 80220.
684
ciently well formed that the 9F catheter can be removed and a closed-end, la tex Foley catheter is introduced. Ideally the lOF size is inserted but the flexibility of the catheter wall and the presence of the balloon may allow passage only of the SF size. des pite dilatation of the tract with a lOF teflon vessel dilator and the use of a firm wire to stiffen the catheter. The Foley catheter is replaced routinely at approximately monthly intervals to minimize crystal deposition and progressively larger catheters are inserted up to 12, 14 or 16F (fig. 2), after dilatation of the tract with teflon or Hegar dilators. The patients have been maintained on a urinary chemoprophylactic agent, usually nitrofurantoin . CASE !\IATEHlAI.. HESL'l,TS AND COMPLICATIOt\S
Of the 17 patients managed by percutaneous nephrostomy at our hospitals since 1972, 4 have been admitted to the program of prolonged (more than 6 months) or permanent nephrostomy (see table). Satisfactory drainage has been maintained in all 4 cases, except for the multiple episodes of catheter obstruction by phosphate crystals, necessitating catheter replacement more frequently than the planned monthly change in case 1 (fig. 3). The frequency of these episodes has diminished following the administration of a suitable diet and ascorbic acid to acidify the urine. Displacement of a Foley catheter occurred once, almost certainly because the catheter had not been advanced into the renal pelvis during a routine catheter change. Transient hematuria, usually less than l hour in duration, is common after any catheter change to a larger size. There has been no evidence of retroperitoneal hemorrhage, urinary extravasation or other serious complications. DISCUSSION
The relati\'e merits of the percutaneous approach to prolonged or permanent nephrostomy
PERMANENT NEPHROSTOMY VIA PER CUTANEOUS PUNCTURE
...
685
• ____________----
,........,
FIG. 1. Apparatu s for initial pun cture-18 gauge tet'lon cannula needle, 0.035-inch movable core ,)-tipped spring guide, 6F teflon vessel dilator and 6.5F polyethylene catheter with coi led tip.
FIG. 2. Case 2. Antegrade pyelography s hows left uret eropelvi c junction obstruction (arrow). A 16F Foley catheter balloon positioned in left renal pelvis 12 month s after initial puncture.
include the avoidance of general anesthesia, minimal postoperative discomfort, brief hospitalization (lower cost) and probably fewer nephrons are damaged. The relative merits of the surgica l approach to prolonged or permanent nephrostom y include a single manipulation ; early catheter displacement is rare, it is more readily available and a large size catheter is used . Most of the state ments are self-evident but it remains to be proved that fewer nephrons are damaged by the percutaneous technique. Surgical nephrostomy is available in every community served by a urologist, whereas permanent nephrostomy by the percutaneous route requires a radiologist prepared to maintain a level of expertise and a range of instrument s wider than those required for temporary percutaneous nephrostomy . The potential indications for the percutaneous methods of prolonged or permanent nephrostomy include obstructive nephropathy in the elderly or infirm , obstructive nephropathy or severe reflux in early infancy and large vesicovaginal fi stulas un suitable for primary repa ir. The potential indications for the surgical methods of prolonged or permanent nephrostomy include performance during another surgical procedure (such as laparotom y after mi ssile injury) , the majority of children and multiple small rena l calculi requiring a large catheter to maintain drainage. We certainly do not see the percutaneous technique rendering surgic a l nephrostomy obsolete. The once-and-forall surgical procedure will usually be prefera bl e for children because the manipulations described for the percutaneous approach would require hr.avy sedation , if not general anesthesia. The exception
686
STABLES AND ASSOCIATES
Case material Serum Pt.-Sex-Age Creatin ine (mg./lOOml.) HD-F- 5$
1.3
Indication for Nephrostomy
Rt. ureteral injur:, at radical hysterectomy, It. obstructive atro-
phy JA-M-69
:u
Cont ra ind icat i
