Ultrasound-guided percutaneous nephrostomy in the pediatric patient

Percutaneous nephrostomy in infants and children

RATIONALE AND OBJECTIVES

The purpose of this study was to review the authors' experience with percutaneous nephrostomy during an 11-year period, paying special attention to indications and outcomes.

MATERIAL AND METHODS

The records of 71 percutaneous nephrostomy procedures performed on 59 children at the authors' institution from January 1987 through December 1997 were retrospectively reviewed. In these children, ultrasonography was used for puncture and fluoroscopy for catheter insertion. Local anesthesia with sedation was used and later replaced by general anesthesia. Loop-end catheters were employed. The smallest patient weighed 1,200 g, and the mean patient age was 3.4 years.

RESULTS

The mean duration of drainage was 60 days, and the longest time was 11 months. Indications were mainly obstructions, with congenital obstruction (n = 28) and postoperative obstruction (n = 26) being the most common. Obstructive pyelitis, malignancy, stone, renal cystic disease, trauma, and neurogenic bladder disturbance were also indications. No complications such as loss of the kidney, serious infection, or hemorrhage of clinical importance were observed. Obstruction was successfully relieved in all patients, but 12 kidneys and five hemikidneys did not recover function and were eventually removed.

CONCLUSION

The percutaneous nephrostomy procedure is a safe technique that can be used successfully for short- and longterm drainage in all children, even in small infants and those with solitary kidneys, and is a valuable adjunct to surgery.

Percutaneous nephrostomy in infants

We reviewed our experience with percutaneous nephrostomy placement in children less than one year of age during a five-year period. Placement was successful in 8 of 9 cases. There were no complications. The procedure favorably altered the outcome for each patient and was useful for reversing azotemia prior to surgical intervention for repair of an obstructed system (2 renal units), for providing drainage of pyonephrotic kidneys (3 renal units), for demonstrating inadequate recovery of renal function after relief of obstruction (2 renal units), and for replacing a surgically placed nephrostomy that was dislodged (1 renal unit). Our experience has encouraged us to accept the technique, and we believe that it is a valuable nonsurgical alternative that should be available to urologists managing infants with urinary tract pathology.

Ultrasound guidance. For interventional and intraoperative techniques in infants and children

Since the advent of improved realtime ultrasound (US) imaging and the availability of the needle biopsy attachment, US-guided percutaneous biopsy and the drainage procedure can be performed safely in the pediatric patient. The authors review their experience over 3 years using US-guided interventional techniques in 96 children aged 5 days to 21 years. A wide variety of procedures were performed and included renal biopsy, nephrostomy tube placement, renal mass biopsy, puncture of bladder sinus tract and pancreatic pseudocyst, ventriculoperitoneal shunt placement and intraoperative localization of brain or renal tumor and renal calculi. No complication occurred. US can be safely and accurately used as guide for interventional procedures in children as long as the area of interest can be clearly demonstrated and the depth and necessary angle of needle insertion can be predetermined as feasible.

Octoson imaging in pediatric urology

Ultrasonic imaging of infants and children using an automated transducer water-path delay scanning system (Octoson) overcomes many of the technical difficulties of contact B mode ultrasound imaging and computed tomography. These disadvantages relate to small patient size, motion artifacts, hypothermia, and lack of patient cooperation. Sedation may be required for either conventional study. The automated water-path system is soothing to small children, maintains the body temperature of infants, and avoids direct transducer contact. Sedation is not necessary. Excellent resolution, shorter scan time than computed tomography, and greater flexibility of patient and transducer positioning allows much more complete imaging information. In addition, the panoramic view obtained using this modality serves to demonstrate the complete lesion and its relationship to surrounding structures.

Percutaneous nephrostomy in paediatrics

Percutaneous nephrostomy has been performed on 18 kidneys in 16 children with an age range of 1 day old to 14 years. The indications and techniques for percutaneous nephrostomy are described, the results are documented, and the effects of the procedure on the management of these patients are discussed. It is shown that percutaneous nephrostomy in paediatrics is a safe and reliable method for draining renal collecting systems in order to relieve obstruction, to assess renal function and to drain pyonephroses.

Pediatric percutaneous nephrostomy: experience with 50 patients

Percutaneous nephrostomy tube placement was performed on 50 children with obstructed urinary tracts. The youngest patient was 3 days old and the smallest weighed 1,400 gm. The most common indication was obstruction after ureteral reimplantation (17 cases) followed by preoperative placement for pelvioureteral junction obstruction (15 cases). Infection was the most common presenting feature (14 cases), followed by a mass (11 cases) and renal failure (11 cases). Catheter placement was performed with basal sedation and general anesthesia was not used. There were no failures. In 26 patients no further surgery was required, including 16 of the 17 patients who had obstruction secondary to ureteral reimplantation. The only 2 significant complications were sepsis after catheter exchange in 1 patient and brisk hematuria upon placement of the catheter in another patient. Percutaneous nephrostomy tube placement is the method of choice for temporary relief of obstruction of the upper urinary tracts in children, since the hazards of surgery and general anesthesia are avoided.

Therapeutic catheter procedures in pediatrics

There is a large spectrum of interventional catheter procedures being performed presently in children. The procedures that offer a greater advantage than surgical techniques and that will continue to be established procedures include percutaneous angioplasty of the pulmonary valve, peripheral pulmonary artery and caval stenosis, embolizations of pulmonary collaterals and pulmonary arteriovenous malformations, angioplasty of vascular access shunt, embolization of bronchial arteries for hemoptysis, and percutaneous nephrostomy and abscess drainage procedures. Others that have been successful but not yet routinely established in children include thrombolysis, renal artery angioplasty, embolization of peripheral arteriovenous malformations, dilatation of the urinary and gastrointestinal tract stenosis, and percutaneous biopsy.

Percutaneous nephrostomy in neonates and infants

A total of 8 patients between 2 days and 2 years old underwent 13 percutaneous nephrostomies for treatment of hydronephrosis. No significant complications were encountered.

Percutaneous nephrostomy in pelviureteric junction obstruction in children

Percutaneous nephrostomy using ultrasound guidance with the pigtail catheter is very useful in dealing with problems associated with pelvic hydronephrosis in children. It is safe, easy to perform and free of complications. Three cases are presented with a note on the technique. The role of percutaneous nephrostomy in pelviureteric junction obstruction in children is outlined.

Ultrasound diagnosis of liquid-filled lesions in children

The ultrasound studies and clinical records of 93 children with cystic lesions have been reviewed. Ultrasound is extremely accurate in identifying the cystic nature of the lesions. Where precise anatomical localisation is possible the prediction of pathology is most accurate. Where anatomical localisation (e.g., in soft tissues, some abdominal sites) is more difficult the ultrasound will generate a good differential diagnosis and aid in planning additional investigations. Review of other investigations done showed that CT in 16 cases rarely yielded new information.

Diagnosis and treatment of fluid-filled renal structures in children with ultrasonography and percutaneous puncture

The application of ultrasonographic and percutaneous needle puncture techniques in the diagnosis of various fluid-filled renal anomalies has permitted rapid delineation of anatomic detail, more definitive physiologic evaluation, and drainage, when necessary, in a safe and cost-effective manner. Its usefulness in children is emphasized in 6 illustrated cases of male infants with minimally or nonopacified renal anomalies, one of the more difficult diagnostic problems in pediatric urology.