Current management of severely encrusted ureteral stents with a large associated stone burden

PURPOSE

We review our recent experience with encrusted retained ureteral stents associated with a large stone burden as well as current endoscopic options available for management.

MATERIALS AND METHODS

One man and 3 women presented to our department between May 1998 and April 1999 for treatment of an encrusted retained ureteral stent. One patient had a history of 3 episodes of ureteral stent encrustation during the last 6 years. We reviewed the management of these stents and the associated stone burden.

RESULTS

Average patient age was 32.5 years (range 25 to 41). Average interval that the encrusted stent remained in place was 7 months (range 3 to 12). In the 3 women pregnancy was associated with the retained stent. All patients required 2 to 6 endourological approaches (average 4.2) performed at 1 or multiple sessions to render them stone-free and stent-free. Postoperatively sepsis in 1 case necessitated a prolonged intensive care unit stay with eventual recovery.

CONCLUSIONS

Successful management of a retained encrusted stent requires combined endourological approaches. Percutaneous nephrostolithotomy and ureteroscopy are often necessary for treating a severely encrusted stent and the associated stone burden.

Reassessing the efficacy of the Dornier MFL-5000 lithotriptor

PURPOSE

The Dornier MFL-5000* is a multifunctional lithotriptor unit that has been purported to be highly efficacious for treating stones. Our experience led us to believe that the actual success rates are not as high as those reported by others. We objectively reexamined the efficacy of this device and factors contributing to treatment success or failure.

MATERIALS AND METHODS

We retrospectively reviewed the records and x-rays of 105 consecutive patients treated with extracorporeal shock wave lithotripsy (ESWL*) using the MFL-5000 during an 18-month period from September 1997 to March 1999. One patient was excluded from study due to a stone within a caliceal diverticulum. Patients were divided evenly by gender and stone laterality. In 70% of cases a stent was placed preoperatively to relieve obstruction and/or facilitate the passage of calculous fragments. The majority of stones (70%) were 10 mm. or less. Treatment success was determined by examining x-rays done preoperatively and at a median of 4 weeks postoperatively.

RESULTS

ESWL was successful in only 47% of our patients, defined as residual stone fragments 2 mm. or less. A secondary procedure was required in 27% of the patients, including repeat ESWL in 6, ureteroscopic stone manipulation in 14, percutaneous tube placement in 1 and percutaneous nephrolithotripsy in 7. Factors contributing to secondary procedures and poor stone clearance were a stone burden of greater than 100 mm.2 and mid pole location (p = 0.0242 and 0.016, respectively). Poor stone fragmentation and clearance were noted despite significantly more shocks delivered (p = 0.0122). Only a small stone burden of 50 mm.2 or less responded well to ESWL (p = 0. 0142).

CONCLUSIONS

These results compel us to reconsider the effectiveness of the Dornier MFL-5000 lithotriptor. We encourage groups at other institutions to reexamine and report their success rates. We recommend the use of this lithotriptor only for a stone burden of 50 mm.2 or less.

[Stab wound to the left solitary kidney: report of a case]

A forty-four-years old man with a left solitary kidney presented a stab wound in the left lumbar region. Upon admission, the patient was hemodynamically stable, the abdominal ultrasonography showed a small perirenal hematoma and the intravenous pyelography was normal. Two days later, he had no hematuria and was discharged from the hospital, with a computed tomography scan control two weeks later. Unfortunately, seven days later, the patient was admitted to emergency for left lumbar pain, a 40 degrees C fever and pyuria. The creatinine level was 72 ng/mL, and the computed tomography scan showed a large urohematoma. The patient was operated and required partial upper polar nephrectomy for distorted upper pole with infected hematoma. A large hematoma was removed and a nephrostomy tube was introduced. The renal function returned to normal six days postoperatively and the nephrostomy tube was removed after nephrostogram at 12 days. Concerning this uncommon case, we emphasize the advantage of the computed tomography scan and the necessity of emergency management in a patient with solitary traumatic kidney.

Continuous antegrade infusion of adriamycin as adjuvant therapy for upper tract urothelial malignancies

OBJECTIVES

To evaluate the feasibility, efficacy, and toxicity of antegrade chemotherapy delivered continuously as adjuvant treatment for patients with upper tract transitional cell carcinoma.

METHODS

During a 6-year interval, 12 patients with upper tract transitional cell malignancies underwent continuous antegrade intraluminal infusion chemotherapy (CAIIC) with adriamycin. After placement of percutaneous access and surgical treatment of the primary lesion, patients received 5-day cycles of CAIIC. Patients received between two and four treatment cycles at 2-week intervals. After therapy, patients with no evidence of residual disease were then monitored long-term with retrograde pyelography and upper tract cytology.

RESULTS

Twelve patients underwent a total of 35 5-day cycles of CAIIC. No patient experienced hematologic and/or local/regional toxicity during or after drug infusion. Three patients were treated for upper tract carcinoma in situ, and 9 patients had discrete exophytic tumors. Two patients died (treatment unrelated) before a final assessment of therapeutic outcome, leaving 10 patients available for evaluation of the therapeutic response. One patient with carcinoma in situ and 5 of 7 patients with discrete upper tract tumors remained disease free after surgery and adjuvant therapy. Both patients with discrete tumors in whom therapy failed had residual gross disease after primary surgical treatment.

CONCLUSIONS

CAIIC using adriamycin was well tolerated for periods of up to 5 days over multiple cycles. Early data suggest a limited efficacy in treating patients with gross residual disease. The efficacy of this approach in preventing the recurrence of upper tract disease after surgical ablation awaits further assessment.

Percutaneous endopyelotomy

OBJECTIVES

During the past 10 years, numerous reports around the world have documented the safety and success rate of antegrade endopyelotomy. We describe the classic endopyelotomy in conjunction with some new alternatives for making the incision.

TECHNICAL CONSIDERATIONS

Antegrade endopyelotomy is performed through the 0.5-in. incision of the percutaneous nephrostomy created by way of an upper or middle calix. Using the hook-shaped cold knife, an endopyelotome is positioned, and the entire procedure can be performed under direct vision, which determines the exact position, depth, and extent of the incision. The ureteropelvic junction (UPJ) obstruction is incised in a posterolateral position, and the hook is withdrawn from the proximal ureter. Using nephroscopic scissors, a small full-thickness puncture is made into the renal pelvis and then the scissors is opened, under constant visual control, until it reaches the peripelvic space. The section of the pelvic wall is completed with the scissors running through the UPJ, without any interchange of the nephroscope. A holmium laser has been also used, with the 365-microm fiber introduced through a stent-pusher. Under direct vision, the UPJ is incised with fiber, permitting observation and coagulation of bleeding from small vessels. After the procedure, either a 14-8.2F endopyelotomy stent or a 14-7F tapered endoureterotomy stent is placed over the guidewire.

CONCLUSIONS

Percutaneous antegrade endopyelotomy is a safe and effective treatment of UPJ obstruction for most patients, regardless of the method used to perform the incision.

[Percutaneous nephrostomy as management technique of obstructive uropathy: review of 105 cases]

105 percutaneous nephrostomies in 73 patients. Indication for nephrostomy was obstruction in the drainage system in all cases. Nephrostomy was bilateral in 24 cases. Reasons for nephrostomy were: lithiasis in 35 cases, carcinoma of the bladder in 17, post-surgical iatrogenic stenosis in 13, prostate carcinoma in 9, cancer of the rectum in 9, infection in 5, neoplasia of the upper urinary tract in 5, retroperitoneal fibrosis in 3, glandular cystitis cystica in 3, ovarian cancer in 3, congenital in 2, lymphoma in 1. Six case were single-kidney patients. Renal puncture through the lower calyceal group was the preferred approach. Purulent urine was extracted in 10 cases. Complications of nephrostomy included haematuria in 34 cases, contrast extravasation in 8, fever in 6, 1 case of death due to septic shock, 2 perirenal haematoma (nephrectomy was required in 1 case), and catheter detachment in 5 cases. All patients showed improvement of both clinical signs and symptoms, and lab results.

Successful management of a large xanthine calculus by percutaneous nephrolithotomy after failed SWL in a 5-year-old boy

A 5-year-old child with a xanthine calculus resistant to SWL was made stone free by percutaneous ultrasonic lithotripsy.

Role of percutaneous urinary diversion in malignant and benign obstructive uropathy

OBJECTIVES

We evaluated the feasibility and effectiveness of percutaneous urinary diversion in patients with obstructive uropathy.

PATIENTS AND METHODS

A total of 206 percutaneous nephrostomies (PCNs) (right-sided in 54, left in 56, and bilateral in 48) were performed in 102 male and 57 female patients 18 to 94 years old. In 125 patients, malignancy was the underlying cause of the obstruction and in 30, benign disease. In four patients, the cause remained unknown. In most patients (N = 154), the access was guided with both ultrasound and fluoroscopy.

RESULTS

Percutaneous nephrostomy was successful in 158 patients (99%). Antegrade ureteral stenting was attempted in 48 patients with a success rate of 81%. Fifteen days postprocedure, the mean urea and creatinine concentrations had declined from 160.8 mg/mL to 63 mg/mL and from 6.9 mg/dL to 2.2 mg/dL, respectively. In 66% of the patients, renal function returned to normal. In 28%, it improved with no need for hemodialysis, while in 6%, there was no improvement. Advanced age and prostate cancer were negative predictive factors for the improvement of renal function, whereas the BUN and creatinine concentrations before the procedure and performance of unilateral v bilateral nephrostomies were not. We did not have severe complications. Three patients received transfusions, and in one patient, a urinoma was drained percutaneously. Patients with malignancy had a median survival of 227 days.

CONCLUSION

Percutaneous urinary diversion under radiologic guidance is a safe and effective procedure for patients with obstructive uropathy.

Sedation, analgesia and anesthesia for interventional radiological procedures in adults. Part I. Survey of interventional radiological practice in Belgium

A questionnaire was mailed to 217 interventional radiologists to evaluate current practice in analgesia and sedation in adults. Response rate was 15% (33/217). Diagnostic angiography was performed with local anesthesia in 94% to 99%; for PTA, local thrombolysis or stent placement, light sedation was added in 0.1%. Premedication was given in 43% of diagnostic angiographies and in 68% of therapeutic procedures. Radiologists consulted an anesthesiologist before administration of intravenous sedation, always in 54% of cases, occasionally in 19% and never in 27%. General anesthesia with artificial ventilation was applied in 56% of TIPS, in 70% of aortic stent grafting and in 82% of neuroradiological interventions. Intravenous sedation was applied given in 53% of percutaneous biliary drainage, in 42% of bile duct dilatation or stenting, in 40% of percutaneous nephrostomy and in 72% of ureteral balloon dilatation. Patient monitoring during an interventional procedure was always carried out by an anesthesiologist in 52% of cases. 21% of radiologists never visited the patient before a therapeutic procedure, and 36% never did so after completion of a procedure. This survey showed that high standard practice of sedation and analgesia, with the assistance of anesthesiologists, is underused by interventional radiologists in Belgium.

[A case of xanthogranulomatous pyelonephritis presenting with the flank subcutaneous mass]

A 51-year-old female exhibited fever, left flank pain and left flank mass in March, 1993. Drip infusion pyelography (DIP) revealed a non-functioning left kidney with shadows of calculi, and abdominal computerized tomography (CT) showed renal calculi and multilocular cystic lesions in the left kidney extending through the perinephric space into the mass on the left flank. Percutaneous nephrostomy and percutaneous drainage were performed, followed by left nephrectomy. Histopathological findings revealed xanthogranulomatous pyelonephritis. There have been a few case reports of xanthogranulomatous pyelonephritis forming nephrocutaneous fistula in the back.

[Clinical evaluation of spontaneous peripelvic extravasation]

We herein report 10 patients with spontaneous peripelvic extravasation. They were 7 males and 3 females, ranging in age from 39 to 78 years old. The spontaneous peripelvic extravasation were caused by ureteral stones in 6 patients, and by invasion of malignant tumors in 4 patients (2 gastric cancer, 1 prostatic cancer, 1 uterine cancer). In all patients with ureteral stones, the extravasation disappeared following conservative therapy or double J stent placement. In the cases of malignant tumors, nephrostomy or double J stent placement were needed for treatment of the extravasation and their prognosis were very poor.

[Two patients with emphysematous pyelonephritis]

A 55-year-old man with diabetes mellitus was sick with shivering, abdominal pain and Escherichia coli in blood and urine cultures; a 40-year-old woman with asthmatic bronchitis had abdominal pain and anaemia. Both had renal dysfunction and the CT scan showed hydronephrosis with a perirenal inflammatory infiltrate and gas in the right and left renal pelvis, respectively. The man had a difficult recovery after treatment with antibiotics and percutaneous drainage. In the woman, a calculus obstructed the pyelo-ureteral passage; the resected kidney contained a squamous cell carcinoma. She was operated, received chemotherapy and recovered. Emphysematous pyelonephritis is a rare, severe disease. Percutaneous drainage and, if necessary, nephrectomy are paramount in the treatment. The condition is observed mostly in patients with diabetes mellitus or obstruction of the urinary tract.

Percutaneous nephrolithotripsy in ectopic kidneys

BACKGROUND

Percutaneous nephrolithotomy (PCNL), although an accepted treatment modality in anatomically normal kidneys, is still not universally performed for calculi in pelvic ectopic kidneys. Fear of injury to abdominal viscera makes it a technically challenging procedure.

PATIENTS AND METHODS

We have performed PCNL in nine patients with calculi in pelvic ectopic kidneys. Technical factors which made this procedure safe include ultrasound-guided puncture, use of a mature tract or an Amplatz sheath, routine postoperative double-J stenting, and nephrostogram prior to nephrostomy tube removal.

RESULTS

Complete stone clearance was achieved in all cases. Six patients were treated in a single stage, while three patients required two stages. Seven patients needed only one tract, and two needed two tracts. No notable complications were encountered. The average hospital stay was 5.2 days.

CONCLUSION

With proper precautions and meticulous technique, PCNL is a safe and effective modality to treat calculi in pelvic ectopic kidney.

Ultrasound-guided drainage of perirenal and periureteral urine collections

Thirty patients with perirenal and periureteral collections were evaluated. The reasons for these collections were after open surgery on the kidney in 11, open surgery on the ureter in 10, percutaneous nephrostolithotomy in 2, after renal transplantation in 5, and after ureteroscopy in 2. The presenting symptoms and signs included flank pain in 12, urine leakage in 5, fever in 5, masses in the iliac fossa in 5, and flank mass in 3. Ultrasound-guided single-step drainage of these collections was done using 10-12 F catheters. Ultrasound-guided single-step percutaneous nephrostomy (PCN) was done prior to drainage of the collection in seven patients in whom ultrasound revealed back pressure changes in their renal units. Pigtail catheters (7-10 F) were used for PCN. The aspirated fluid was clear urine in 12 cases and turbid in 18. The amount of fluid drained ranged from 150-500 mL immediately after the procedure. We used color Doppler sonography to map the site of puncture. No complications were encountered after drainage. The period of drainage varied from 1 week to 37 days. Further intervention was needed in 12 cases due to development of ureteric stricture in 7, prolonged leakage in 3 (one after transplantation, one after ureterocolic anastomosis, and one after ureterolithotomy), and residual stones in 2. Double-J stenting was done in four cases. We conclude that ultrasound-guided drainage of perirenal and periureteral collections is a safe, rapid, and easy method of treatment and should eliminate the need for exploration to drain these collections. Whenever backpressure exists in the renal unit, ultrasound-guided PCN should be done prior to drainage of the collection.

[Anterograde insertion of ureteral catheter]

We report twenty-four patients with urinary obstruction, in which twenty-seven antegrade ureteral stent (double J) insertions were attempted (in six patients the obstruction was bilateral and in three other patients we failed). In all of them access to the urinary tract was through a nephrostomy catheter, in seventeen cases we proceeded to insert the antegrade catheter immediately after percutaneous nephrostomy and in ten remaining cases we achieved in a second try after carrying nephrostomy and failing a conventional retrograde approach to ureteral stent insertion. We got a 90-per cent success rate. A case of perirrenal hematoma occurred after applying a nephrostomy. It was the only relevant complication. In conclusion we consider that the antegrade ureteral stent insertion is a good alternative when, under several circumstances, the conventional retrograde insertion fails.

Augmentation ureterocystoplasty with ipsilateral renal preservation in the management of patients with compromised renal function secondary to dysfunctional voiding

We evaluated the role of ureterocystoplasty with ipsilateral renal preservation in the management of patients with neurovesical dysfunction and impaired renal function. The procedure was carried out on 6 patients with a mean age of 8.5 years. All patients had vesicoureteric reflux (VUR) secondary to neuropathic bladders, recurrent urinary tract infections, day time incontinence, impaired and deteriorating renal function. All patients were followed up with a mean of 22.5 months (range 6-30). Renal function stabilized in 4 patients and improved in 2 patients. Adequate urinary bladder capacity was achieved in all patients. Bladder volume increased from a mean of 210+/-71 to 382+/-66, this increase was statistically significant (p<0.001). All patients were dry by day including the children who at presentation were in diapers. We conclude that the results of this operative intervention are satisfactory and promising in the management of this difficult group of patients while avoiding the side effects of enterocystoplasty procedures.

Interventional uroradiologic procedures performed using gadodiamide as an alternative to iodinated contrast material

Three patients with either a history of severe allergic reactions to iodinated contrast or marked renal insufficiency underwent interventional uroradiologic procedures using full-strength gadodiamide (Gd) as a contrast agent in place of iodinated contrast material. The procedures were percutaneous access for nephrostolithotomy, antegrade pyelography with placement of a nephroureteral stent, and a diagnostic nephrostogram with exchange of a nephroureteral stent. Gd was visualized fluoroscopically and produced satisfactory digital radiographs without allergic reaction or worsening renal function. Gd can be useful in guiding interventional uroradiologic procedures when iodinated contrast material is contraindicated.