The use of percutaneous diversion during pregnancy

ACR Appropriateness Criteria® Radiologic Management of Urinary Tract Obstruction

Acute obstructive uropathy is a medical emergency, which often is accompanied by acute renal failure or sepsis. Treatment options to resolve the acute obstructive process include conservative medical management, retrograde ureteral stenting, or placement of percutaneous nephrostomy or nephroureteral catheters. It is important to understand the various treatment options in differing clinical scenarios in order to guide appropriate consultation. Prompt attention to the underlying obstructive process is often imperative to avoid further deterioration of the patient's clinical status. A summary of the data and most up-to-date clinical trials regarding treatment options for urinary tract obstruction is outlined in this publication. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Conservative/surgical treatment predictors of maternal hydronephrosis: results of a single-center retrospective non-randomized non-controlled observational study

PURPOSE

To determine the parameters that may help the clinicians decide the best suitable treatment method for the pregnant women with symptomatic hydronephrosis which will be based on the easily accessible laboratory tests, monitoring methods and clinical symptoms.

METHODS

Digital data and documents of 246 pregnant women with symptomatic hydronephrosis who were hospitalized in our clinic between the dates of January 2011 and January 2016 were retrospectively evaluated. All patients were statistically evaluated in terms of age, symptomatic maximal anterior-posterior diameter of the renal pelvis (MADP), parity, C-reactive protein (CRP) level, white blood cell count (WBC), presence of pyuria, growth of urine culture, fever, serum urine and creatinine levels, visual analog scale (VAS) score of pre- and post-therapy and threatened preterm labor.

RESULTS

The study includes a total of 211 pregnant women with symptomatic hydronephrosis. In the second and third trimester groups, the surgical treatment group statistically provided higher levels of CRP, WBC and VAS. Mean MADP in the second trimester of the conservative and surgical groups where symptomatic hydronephrosis was on the right side was 16.67 ± 4.67 and 28.68 ± 7.70 mm, respectively. Mean MADP in the third trimester group of the conservative and surgical groups where symptomatic hydronephrosis was on the right side was 16.96 ± 5.96 and 28.85 ± 7.64 mm, respectively.

CONCLUSIONS

In patients with symptomatic pregnancy hydronephrosis, the likelihood of surgical treatment for CRP levels, WBC counts and VAS is high.

Success and Short-term Complication Rates of Percutaneous Nephrostomy during Pregnancy

Outcome of percutaneous nephrostomy creation during pregnancy was retrospectively studied. Catheter insertion was successful in all cases (N = 8; 3% of all nephrostomies over a 5-year period), with one major complication (sepsis) and three minor complications. Catheters remained in situ for a mean of 9.4 days until the stone passed (n = 1) or was removed on ureteroscopy (n = 2) or a ureteral stent was inserted (n = 5). Maternal outcome was normal in all cases, but there were two premature deliveries. Nephrostomy during pregnancy has acceptable technical and clinical results, but the possibility of an increased risk of septic complications (12.5% in this series) necessitates further study.

A radiation perspective for treating loin pain in pregnancy by double-pigtail stents

OBJECTIVE

To review the risks of placing double-pigtail stents during pregnancy in women presenting with loin pain associated with hydronephrosis.

PATIENTS AND METHODS

A consecutive series of women presenting with loin pain and hydronephrosis in pregnancy were treated with double-pigtail ureteric stents. A flexible cystoscope was used to identify the ureteric orifice and to pass a guidewire into the renal pelvis under fluoroscopic guidance. Stents were placed using the exchange technique over a stiff guidewire. Procedures were carried out under none or limited sedoanalgesia. Screening times and radiation dose were recorded. Data were collected for the average uterine radiation dose from a variety of radiological procedures. Previous publications were reviewed to determine the lethal, teratogenic and carcinogenic risk to the developing fetus from radiation exposure.

RESULTS

Seven patients referred with symptomatic hydronephrosis during pregnancy were treated. The screening time during placement was minimized. The mean (range) uterus (i.e. fetal) dose was 0.40 (0.03-0.79) mGy. Most radiological procedures involve uterine doses of < 20 mGy, far below the 100 mGy that may result in fetal damage during periods of maximum radiosensitivity.

CONCLUSION

Minimized radiation exposure from a range of uroradiological procedures in pregnant women has limited fetal risk. The use of fluoroscopy for symptomatic hydronephrosis during pregnancy allows ureteric stents to be placed safely and reliably. The average excess risk to the fetus from this procedure is 1 in 43 000 of cancer induction and 1 in 100 000 of heritable disease, i.e. very small when compared with the natural incidence. Pregnancy should not exclude the use of appropriate diagnostic radiation exposure and urologists may conduct appropriate diagnostic and therapeutic procedures, taking care to limit X-ray exposure without fear of risk to the developing fetus.

Percutaneous nephrostomy in the treatment of hydronephrosis during pregnancy: Our experience

Hydronephrosis during pregnancy is commonly considered physiological due to compression of the ureters by the gravid uterus and by dilated ovarian veins. Only in symptomatic cases or secondary to obstruction is a urinary diversion required. Six cases of symptomatic hydronephrosis treated with percutaneous nephrostomy are reported. Tocolytic therapy was practised in order to avoid the risk of abortion.

Infected Hydronephrosis of Pregnancy with Renal Abscess Formation: Role of the Percutaneous Nephrostomy

Hydronephrosis of pregnancy is a physiological phenomenon and usually asymptomatic. When it becomes associated with intractable or prolonged pain, infection refractory to antibiotics or extreme dilatation damaging the obstructed kidney, invasive intervention is necessary. Percutaneous nephrostomy is the procedure of choice for draining the acutely obstructed kidney early, rapidly and continuously. We present two cases of unusual severity, one of them being the first report of renal abscess formation complicating hydronephrosis of pregnancy. The role, advantages and some technical points of percutaneous nephrostomy are discussed.

Use of percutaneous nephrostomy in hydronephrosis of pregnancy

Traditional methods of urinary diversion in pregnancy include retrograde passage of ureteral catheter or stents and operative nephrostomy. These techniques are, however, associated with the use of anesthesia, are technically difficult to perform, and may induce labor. We report the use of percutaneous nephrostomy in four pregnant patients, two with obstruction due to ureteral calculi and two with infected hydronephrosis. The procedure provided rapid relief from pain and pyosepsis, and allowed uneventful continuation of the pregnancy to full-term, with preservation of renal function.

Percutaneous management of urolithiasis during pregnancy

A total of 6 pregnant women with obstructing urinary calculi was managed by percutaneous nephrostomy drainage placed under ultrasound guidance with the patient under local anesthesia. All patients initially had relief of acute obstruction. However, occlusion of the percutaneous nephrostomy tubes with debris necessitated tube changes in 5 of 6 patients. In 2 patients recurrent nephrostomy tube obstruction, fever and pain led to percutaneous stone removal during pregnancy. In the remaining 4 patients the nephrostomy tubes were left indwelling through delivery. During the postpartum period 3 patients successfully underwent ureteroscopic stone extraction and 1 passed the stone spontaneously. Bacteriuria developed in each patient despite the use of preventive antibiotics. All 6 women had uncomplicated vaginal deliveries of healthy newborns and are currently asymptomatic with no evidence of obstruction. Percutaneous drainage of an acutely obstructed kidney in a pregnant woman is an effective temporizing alternative to ureteral stent placement until definitive treatment can be performed.