91

Downloaded from www.ajronline.org by 175.106.37.116 on 11/07/15 from IP address 175.106.37.116. Copyright ARRS. For personal use only; all rights reserved

Symptomatic Renal Obstruction Urosepsis During Pregnancy: Treatment by Sonographicafly Percutaneous Nephrostomy

Eric

2

Giovanna Casola1 Lee B. Talner1 Gerhard R. WittiCh1’3 Robert R. Varney1’4 HoraCio B. D’Agostino1

or

Guided

Seven pregnant women with symptomatic hydronephrosis had sonographically guided percutaneous nephrostomy for pyosepsis (five patients) or for pain with azotemia (two patients with renal transplants). Antibiotics had been ineffective in controlling pyosepsis in each patient; retrograde ureteral catheterization via cystoscopy was unsuccessful in one patient. After percutaneous nephrostomy, prompt clinical improvement was observed in all patients (i.e., sepsis was relieved and pain abated). Labor was not induced in any of the patients, and no adverse effects occurred to any fetus or mother. Eleven (eight percutaneous nephrostomy, three catheter exchanges) of the 12 procedures were done without conventional radiography and with sonographic guidance alone. After percutaneous nephrostomy, maneuvers to obtain a diagnosis and to treat the obstruction (if necessary)

were

delayed

until

after

delivery.

The

causes

of ureteral

obstruction

were

calculi (four patients) and a gravid uterus (three patients). After delivery, stones were removed either percutaneously (one patient) or cystoscopically (two patients) or passed spontaneously (one patient); resolution of obstruction by the gravid uterus was proved by Whitaker test after delivery. Sonographically guided percutaneous nephrostomy is an effective and safe method to treat pregnant women who have symptomatic obstructive hydronephrosis associated with either pyosepsis or azotemia. The procedure is rapid, requires minimal anesthesia, has no radiation, and is safe for the fetus. The technique is a useful and perhaps preferable alternative to more invasive surgical therapy or retrograde stenting. AJR

158:91-94,

January

The diagnosis and formidable challenges. during

Received June 27, 1 991 ; accepted after revision August 26, 1991. I Department of Radiology, University of California, San Diego, Medical Center, 225 Dickinson St., San Diego, CA 921 03. Address reprint requests to E. vanSonnenberg. 2 Department of Medicine, University of California,

San

Diego,

Medical

Center,

San

Diego,

CA

92103. 3 Present address: Department Stanford University Medical Center, 94305.

of Radiology, Palo Alto, CA

4 Present address: Department Scripps Memorial Hospital, La Jolla,

of Radiology, CA 92037.

pregnancy

the treatment of urinary Recent reports focusing

recommend

retrograde

obstruction during pregnancy are on noninfected ureteral obstruction

passage

of

stents

or

fluoroscopically

guided percutaneous nephrostomy [1 -6]. These techniques have been effective, but each has disadvantages. Cystoscopic passage of stents may require spinal or general anesthesia and may induce labor. Ureteral catheterization via cystoscopy is technically more difficult with a gravid uterus than it is usually, and it may predispose to ascending pyelonephritis [3, 7]. The inherent drawback to fluoroscopically guided percutaneous nephrostomy is exposure to radiation during pregnancy. We present a series of sonographically guided percutaneous nephrostomies in seven pregnant women. Pyosepsis and pain associated with dilatation of the urinary tract were treated successfully. Avoidance of the aforementioned disadvantages and the lack of complications suggest the usefulness of sonographically guided

percutaneous

ment

in five patients

Materials 0361 -803x/92/1 581-0091 cc American Roentgen Ray Society

1992

Nine

nephrostomy

who

were

in this

ill from

clinical

pyosepsis

setting.

The

was particularly

immediate

improve-

dramatic.

and Methods

percutaneous

nephrostomies

and

three

tube

exchanges

were

performed

in seven

vANSONNENBERG

92

pregnant

women. The

neous

nephrostomy)

main

patients,

women

weeks’

tomy. five

Downloaded from www.ajronline.org by 175.106.37.116 on 11/07/15 from IP address 175.106.37.116. Copyright ARRS. For personal use only; all rights reserved

The

of 8-34

nancies

were

duration

presenting

pain

1 9-31

problems

included in six

years

old

and

had

at the time of percutaneous (and

fever

patients,

indications

for

(temperature,

and

creatinine

percuta-

neous

#{176}C) in level

(3.1

By sonography, all patients had moderate or severe hydronephrosis (2 to 4+) on the symptomatic side that was out of proportion to the

patients

side. The causes of obstruction (three patients) calculi (stones and

compression side).

The

on

the

left

in

by the gravid kidneys

were

two

patients)

uterus

native

were renal (one patient) on the right side in two and

extrinsic

(three patients,

in five

women

and

ureteral

all on the right were

transplants

in two. Antibiotics

were

administered

before

percutaneous

in the five patients with fever and were percutaneous nephrostomy, depending

reports. sporins, ampicillin

for

a urinary

tract

infection

caused

by

Proteus

mirabilis

before percutaneous nephrostomy. In one patient, an attempt at retrograde passage of a stent under fluoroscopy had been unsuccessful; there was associated extravasation of contrast material from the retrograde injection. Spontaneous uterine contractions and threatened

labor

resulted,

but

were

controlled

by tocolytic

agents.

Sonography was used to guide the percutaneous nephrostomy in each patient. It was the sole guidance method in six women having eight units

nephrostomies. were

A variety

used.

nephrostomies

Biopsy

and freehand

neous nephrostomy assist

one

and limited

excretory

guided

available

attachments

real-time

procedures.

sonographically

vious radiographic

of commercially

guide

were

monitoring

Limited

studies included abdominal urograms

(four patients).

for

four

for five percuta-

fluoroscopy

percutaneous

sonographic used

was used to

nephrostomy.

Pre-

plain films (six patients) The procedures

nephrostomy

(five percutaneous

nephrostomies)

phrostomy.

technique

With Seldinger

in each

nephrostomies) was

technique,

January

patient.

1992

Standard

or trocar (four percuta-

used

for

percutaneous

either the 22-gauge

ne-

removable

hub needle system (Cook Inc., Bloomington, IN) (three cases) or an 1 8-gauge needle (two cases) was placed initially, depending on the operator’s preference. Pigtail catheters (7- or 8-French) (four nonlocking,

five

technique

locking)

(four

were

cases),

inserted

by these

7- or 8-French

were placed directly into the renal collecting with

a 22-gauge

needle.

Standard

methods.

single-lumen 0.038-in.

With

the trocar

pigtail

catheters

system after localization (0.096-cm)

guidewires

were used for the Seldinger procedures; no guidewires were used for trocar insertion. Medications were tailored for each patient and included, either alone or in combination, diazepam (2.5-5 mg), mid-

azolam (1 -2 mg), meperidine hydrochloride (50 mg), fentanyl (25-50 lAg), and local anesthesia with xylocaine (1 %) Patients with infection were treated with antibiotics throughout the duration of catheterization.

nephrostomy

continued or changed after on culture and sensitivity

Antibiotics that were used included a variety of cephaloampicillin, and sulfa compounds in standard dosages. One with persistent sepsis had been treated for 1 0 days with

patient

AJA:158,

percutaneous

Seldinger

and 4.0 mg/dl [270 and 350 pmol/I]) in two patients; several patients had more than one indication. All patients with sepsis had ureteral obstruction. Both patients with renal transplants had azotemia and pain. WBC counts were 1 1 ,400-2i 800/Ml in the five febrile women.

contralateral or ureteral

preceded

nephros-

38.9-40.1

elevated

preg-

ET AL.

were

performed by various staff members. Patients undergoing percutaneous nephrostomy in a native kidney were placed in a prone oblique position with the affected side elevated. The two women with a transplant kidney had percutaneous nephrostomy via an anterior approach while supine. Insertion of a fine needle into the renal collecting system to aspirate urine for culture

Results Percutaneous nephrostomy was successful in each patient, and signs and symptoms were relieved uniformly. Defervescence occurred on the first day after the procedure in all five women who had sepsis (Fig. 1). In the two patients with renal transplants who were not infected, sonography showed prompt resolution of hydronephrosis, and pain was relieved; the creatinine levels improved only modestly (4 to 2.2 and 3.1 to 2.5 mg/dl [350 to 1 90 and 270 to 220 ,mol/I]). Undesirable uterine contractions or premature labor did not occur in any patient after percutaneous nephrostomy. In the one woman who had cystoscopy before percutaneous nephrostomy, threatened labor ceased promptly after percutaneous nephrostomy. Six women delivered healthy neonates, and one woman elected therapeutic abortion. Gross pus was recovered from the obstructed collecting system in two patients. Cultures were positive in five patients: Escherichia co/i (four patients), K/ebsie//a (one patient), and Proteus (one patient); one patient had two organisms. The original percutaneous nephrostomy catheter remained in place for the remainder of the pregnancy (1 0-1 8 weeks) in five women. The catheters became dislodged in two women

Fig. 1.-Successful sonographically guided percutaneous nephrostomy for acute pyosepsis (body temperature to 40#{176}C) during pregnancy. A, 7-French catheter (cursors) is being in-

serted by trocar technique into dilated collecting system. Fluoroscopy was not used. B, Collecting system is decompressed after removal of 30 ml of pus through catheter. Pregnancy

proceeded

uneventfully,

extracted postpartum.

and a stone

was

Downloaded from www.ajronline.org by 175.106.37.116 on 11/07/15 from IP address 175.106.37.116. Copyright ARRS. For personal use only; all rights reserved

AJA:158,

January

SONOGRAPHICALLY

1992

GUIDED

(2 and 7 weeks after placement) and were replaced by new percutaneous nephrostomies after unsuccessful attempts at tract recannulation. These cases occurred before the routine use of self-retaining catheters. One catheter was removed 3 weeks after insertion, after a stone passed into the patient’s urine spontaneously. No urinoma, hematoma, or sepsis occurred as a complication of either percutaneous nephrostomy or tube dislodgment. After delivery, one patient with persistent stones had percutaneous tract dilatation with stone removal, and two patients had ureteroscopic stone removal. Spontaneous passage of a stone occurred in one patient 1 1 days after percutaneous nephrostomy. Three patients with presumed uterine compression of the ureter had postpartum Whitaker testing to ensure that no residual obstruction existed; these studies were performed between 2 and 4 weeks after delivery and the results were normal (Fig. 2).

Discussion The success, safety, and ease of sonographically guided percutaneous nephrostomy suggest its usefulness as primary treatment of infected or noninfected symptomatic renal obstruction during pregnancy. The procedure relieves the symptoms and signs of obstruction and infection by allowing rapid drainage of obstructed urine and evacuation of pus from the collecting system. Relief of the acute problems and drainage of the collecting system allow the fetus to mature until term. Sonographically guided percutaneous nephrostomy does not require general or spinal anesthesia and does not expose the fetus or mother to radiation. The procedure usually lasts 1020 mm, with only minimal discomfort to the patient. Selfretention catheters are preferred to avoid catheter dislodgment when long-term drainage is anticipated. Although the causes of ureteral obstruction in pregnancy are relatively few, the uncertainties are several and are prob-

Fig. 2.-sonographically A, Fine needle has been B, 7-French catheter was C, Follow-up antegrade

PERCUTANEOUS

NEPHROSTOMY

93

lematic. Is the hydronephrosis attributable to the well-known physiologic dilatation of pregnancy or is the obstruction potentially dangerous? Are the symptoms and signs caused by acute pyelonephritis or by another acute abdominal process unrelated to the pregnancy? Should a plain abdominal radiograph and/or an excretory urogram be obtained? If obstruction is present, is it due to a renal or ureteral stone, or is it due to an enlarged uterus? What should be the extent of treatment prepartum vs postpartum? Should therapy be conservative or invasive; if invasive, how aggressive should the treatment be? In the face of these uncertainties and with the constraints imposed by pregnancy, guidelines for clinical management are unclear, as is the optimal radiologic approach to these patients. Renal obstruction during pregnancy is potentially deleterious to both the mother and fetus. The major risks are infection, renal failure, urinary extravasation, urinoma formation, premature labor, renal rupture, and fetal death [5-12]. The causes of obstruction during pregnancy include stones, gravid uterus, ureteral stricture, pelvic tumor, congenital anomalies such as obstruction of the ureteropelvic junction, horseshoe kidney, pelvic kidney, and intraabdominal infection. Infected hydronephrosis may cause serious consequences. Women with calculi during pregnancy are more likely to have urinary tract infection, septicemia, and premature labor, especially if spontaneous passage of stones does not occur [12-14]. When the obstruction is caused by an enlarged uterus, the right kidney is affected more commonly than the left; with calculi, neither side predominates [5, 7, 9, 12]. Sonographically guided percutaneous nephrostomy for pyonephrosis with urosepsis in pregnancy is particularly useful

because

it avoids

the

disadvantages

of other

treatment

options. Anesthesia administered for surgery or cystoscopy can induce premature labor and may result in abortion. Both surgery and cystoscopy are more difficult in the presence of an enlarged gravid uterus [3, 7, 1 4], so the operative and

guided

percutaneous nephrostomy for pain and worsening renal failure in a pregnant woman with into markedly hydronephrotic renal transplant. Note fetal parts adjacent to transplant. inserted without fluoroscopy by trocar technique. Catheter is coiled in dilated collecting system.

a renal

transplant.

inserted

pyelogram and Whitaker test several weeks after delivery of a healthy neonate revealed pressure, or pain on infusion. Obstruction presumably was due to enlarged uterus.

no obstructing

lesion, elevation

of

Downloaded from www.ajronline.org by 175.106.37.116 on 11/07/15 from IP address 175.106.37.116. Copyright ARRS. For personal use only; all rights reserved

94

VANSONNENBERG

cystoscopic risks may not be trivial. Indeed, in one patient in our series, an attempt to place a stent cystoscopically induced uterine contractions; these eventually subsided after treatment with tocolytic agents. This complication notwithstanding, a report [2] of 12 patients treated successfully by cystoscopic insertion of double J stents showed that retrograde catheterization can be an effective alternative to percutaneous nephrostomy [2]. However, several authors [1 5, 1 6] recommend that before any invasive percutaneous or retrograde maneuver be performed, if the uterus is the sole cause of obstruction, the position of the patient should be changed to move the enlarged uterus away from the ureters [1 6]. This approach seems prudent for the patient with pain. However, urgent decompression is indicated for pyosepsis. Regardless of the cause of the obstruction, it may be beneficial to delay definitive treatment until after delivery. A recent report [1 7] of three patients described the effectiveness of this two-stage strategy. Manipulation to remove stones or to dilate strictures during the pregnancy may endanger the fetus and might require fluoroscopy. In patients with obstructing calculi, stone removal may be postponed until after delivery as long as the percutaneous nephrostomy continues to decompress the collecting system effectively. If the stone passes spontaneously, the catheter can be removed. Spontaneous passage of obstructing urinary calculi in pregnancy

occurs

in 54-78%

of cases;

passage

of upper

ureteral stones is less likely to occur as the pregnancy matures, because the enlarging uterus tends to obstruct more with time [1 2, 1 6, 1 8, 1 9]. When extrinsic uterine compression is the cause of obstruction, percutaneous nephrostomy should provide definitive therapy. Once the gravid uterus has resumed its normal postpartum size, antegrade pyelography with Whitaker testing via the percutaneous nephrostomy is a simple method to prove absence of residual or unsuspected causes of obstruction. Because the combination of drainage and antibiotics successfully treats the pregnant woman with pyonephrosis whatever the cause, it might be argued that no imaging study that uses radiation (plain abdominal radiography, excretory urography) is necessary during the pregnancy. In a pregnant woman with the telltale clinical picture of pyonephrosis (flank pain, ipsilateral hydronephrosis by sonography, fever, pyuria, and a failed response to antibiotics), immediate decompression by sonographically guided percutaneous nephrostomy or retrograde stent placement is mandatory. A plain abdominal radiograph and one-shot urogram should be done only if the results will influence treatment. For example, the urologist might be less enthusiastic about retrograde placement of a stent if obstruction is due to a proximal ureteral stone, as stent placement is technically more difficult and might require

ET AL.

AJR:158,

January

1992

considerable fluoroscopy under these circumstances. Sonographically guided percutaneous nephrostomy effectively and safely solves the immediate clinical problem, and sets the stage for deferred and definitive postpartum therapy if that proves to be necessary.

ACKNOWLEDGMENT We thank

Peggy

Chambers

for manuscript

preparation.

REFERENCES 1 . Lowes JJ, MacKenzie JC, Abrams PH, Gingell JC. Acute renal failure and acute hydronephrosis in pregnancy: use of the double-J stent. J R Soc Med 1987:80:524-525 2. Loughtin KR, Bailey RB Jr. Internal ureterat stents for conservative management of ureteral calculi during pregnancy. N Eng! J Med 1986; 315:1647-1649 3. Quinn AD, Kusuda L, Amar AD, Das S. Percutaneous nephrostomy for treatment of hydronephrosis of pregnancy. J Urol 1988; 1 39 : 1 037-i 038 4. Maggiolo LF, Lackhart JL, Wasmer JM. Palliative treatment of obstructing stone during pregnancy. Urology 1987;29 :402-403 5. Laverson PL, Hankins GDV, Quirk JG Jr. Ureteral obstruction during pregnancy. J Urol 1984; 1 31 : 327-329 6. Bennett AH, Adler S. Bilateral ureteral obstruction causing anuria secondary to pregnancy. Urology 1982:20:631-633 7. Horowitz E, Schmidt JD. Renal calculi in pregnancy. Clin Obstet Gynecol 1985:28:324-338 8. Aaro LA, Juergens JL. Thrombophlebitis associated with pregnancy. Am J Obstet Gynecol 1971:1 09: 1 1 28-i 136 9. Novell HA, Maclurm JG, Liebman N, Salt W. Spontaneous peripelvic and periureteral extravasation associated with pregnancy. J Urol 1967;97: 64-67 1 0. Noe HN, Aaghavaiah NV. Spontaneous peripelvic extravasation of urine during pregnancy. South Med J i980;73:809-81 0 1 1 . Homans DC, Blake GD, Harrington JT, Cetrulo CL. Acute renal failure caused by ureteral obstruction by a gravid uterus. JAMA 1981;246: 12301231 1 2. Cass AS, Smith CS, Gleich P. Management of urinary calculi in pregnancy. Urology 1986:28:370-372 1 3. Biswas M, Perloff D. Cardiac, hematologic, pulmonary, renal and urinary tract disorders in pregnancy. In: Pemoll ML, Benson AG, eds. Current obstetric and gynecologic diagnosis and treatment 1987, 6th ed. Norwalk, CT: Appleton & Lange, 1987:353-385 14. Cunningham FG, MacDonald PC, Gant NF. Complications of pregnancy. In: Williams obstetrics, 18th ed. Norwalk, CT: Appleton & Lange,

1989:489-778 15. Talner LB. Obstructive uropathy. In: Pollack HM, ed. Clinical urography, vol. 2. Philadelphia: Saunders, 1989:1535-1752 16. DElia FL, Brennan RE, Brownstein PK. Acute renal failure secondary to ureteral obstruction by a gravid uterus. J Uro! 1982;1 28: 803-804 17. Mandal AK, Sharma 5K, Goswami AK, Hemat AK, Indudhara A. The use of percutaneous diversion during pregnancy. Int J Gynaecol Obstet 1990;32:67-70 18. Harris RE, Dunnihoo DR. The incidence and significance of urinary calculi in pregnancy. Am J Obstet Gynecol 1967:99:237-241 1 9. Strong DW, Murchison RJ, Lynch DF. The management of ureteral calculi during pregnancy. Surg Gynecol Obstet 1978;146:604-608

Symptomatic renal obstruction or urosepsis during pregnancy: treatment by sonographically guided percutaneous nephrostomy.

Seven pregnant women with symptomatic hydronephrosis had sonographically guided percutaneous nephrostomy for pyosepsis (five patients) or for pain wit...
772KB Sizes 0 Downloads 0 Views