Primary Report of Totally Tubeless Percutaneous Nephrolithotomy Despite Pelvi-calyceal Perforations

PURPOSE

Nephrostomy tube insertion and/or a ureteral stent placement is advised when pelvi-calyceal perforations are encountered during percutaneous nephrolithotomy (PNL) nevertheless totally tubeless PNL is a possible exit strategy in percutaneous renal surgery therefore case series on the short term clinical outcomes of noninvasive management of iatrogenic pelvicalyceal perforations encountered during PNL is presented.

PATIENTS AND METHODS

During retrospective analysis of 1271 PNL procedures, 25 incidents of accidental ureteral catheter/ jj stent dislodgement during first 24 post-operative hours were identified in patient who had pelvi calyceal perforations and had no nephrostomy tube (tubeless). Thirteen patients could not be re-stented nor a nephrostomytube could have been placed for them mainly due to patient refusal or comorbid conditions. The main outcome was rate of successful noninvasive management.

RESULTS

Eighteen Patients bearing mucosal tears (grade I trauma) or visible peri-pelvic fat (grade II) successfully recovered without need for ureteral stenting or nephrostomy (72.0%). In seven (28.0%) cases of extension of the perforation into the peri-pelvic fat (grade III), either nephrostomy insertion or JJ stenting was needed for resolution of fever and urinoma. The major limitation was the necessity to exclude patients and manage them in the standard fashion according to clinical guidelines.

CONCLUSION

Iatrogenic perforations of the collecting system are quite diverse in terms of severity that result in different natural histories and not all might need urinary diversion via nephrostomy or ureteral stenting.Low grade perforations may be successfully managed in totally tubeless fashion nevertheless further prospective investigations seem warranted.

Rupture of the maternal renal calyx secondary to fetal malpresentation: a case report

BACKGROUND

Rupture of the renal collecting system is a potentially life-threatening condition in pregnancy. Most cases are associated with obstruction from nephrolithiasis or diseased renal parenchyma.

CASE

A 24-year-old, nulliparous, African American woman at 38 weeks + 3 days' gestation presented with left flank pain refractory to conservative pain management. Computed tomography was negative for a stone but significant for infrarenal fluid and rupture of a left renal calyx. The fetal head was not flexed and appeared to be compressing the left ureter. A face presentation became apparent during her labor course, and she underwent a cesarean delivery when labor did not progress.

CONCLUSION

This represents the first reported case of a ruptured renal collecting system secondary to fetal malpresentation. A high index of suspicion is essential to diagnose collecting system rupture, and it may occur in the absence of parenchymal disease or stones.

Hand-assisted laparoscopic partial nephrectomy combined with caliceal ureterostomy for the treatment of post-traumatic ureteropelvic junction disruption

Ureteropelvic junction (UPJ) disruption seldom occurs in patients with blunt abdominal trauma. The diagnosis of UPJ disruption is delayed in more than 50% of patients, and it can lead to difficulty in further treatment or increase the risk of nephrectomy. We present a 25-year-old man who was found to have left UPJ disruption 2 months after blunt abdominal trauma and who was successfully treated by partial nephrectomy combined with caliceal ureterostomy under hand-assisted laparoscopy. We review the literature and discuss the possible images to help early diagnosis of UPJ disruption. As a reconstructive procedure, caliceal ureterostomy under hand-assisted laparoscopy can be an effective and facilitated option.

RENAL CRYOABLATION AND RADIO FREQUENCY ABLATION: AN EVALUATION OF WORST CASE SCENARIOS IN A PORCINE MODEL

PURPOSE

Although ablative technologies, including radio frequency (RF) ablation (RFA) and cryoablation (CA), are being used to treat renal masses, complications associated with injury to vital renal structures are not well understood. We investigated these worst case scenarios by deliberately targeting vital renal structures with CA or RFA in a porcine model.

MATERIALS AND METHODS

Following surgical exposure of the right kidney in female pigs a cryoneedle or an RF probe was deliberately placed under visual and ultrasound guidance in the renal pelvis (CA in 5 pigs and RFA in 7), major calix (CA and RFA in 5 each) or subsegmental renal vessels (CA in 5 pigs and RFA in 7). Cryo-energy or RF energy was then applied to create a 3 cm lesion. After 10 days the kidneys underwent gross and histological examination for urine and blood extravasation, cell death and injury. Ex vivo retrograde pyelography was performed to evaluate for urinary fistulas.

RESULTS

All pigs tolerated the treatment and no procedure related deaths occurred. No significant bleeding was noted. RFA and CA created reproducible lesions and areas of cell death and necrosis. Despite significant intentional injury to the collecting system no urinary fistulas were demonstrated in CA specimens (0 of 15). In contrast, damage to the renal pelvis (4 of 7) by dry (3 of 4) or wet (1 of 3) RFA was associated with a high likelihood of urinary extravasation.

CONCLUSIONS

This short-term study demonstrates that CA is safe, effective and not associated with urinary extravasation. In contrast, RFA to the renal pelvis is associated with urinary extravasation. Further studies are needed to support these findings.

Complete pyelo-calyceal avulsion as a result of blunt abdominal trauma

We present a rare case of complete avulsion of the kidney collecting system as a result of blunt abdominal trauma. Emergency celiotomy precluded radiographic studies. Perinephric hematoma was mild, the lesion was not detected and this later led to a nephrectomy. Pelvis disruption diagnosis is frequently delayed, and this compromises surgical reconstruction.

[Renal hematoma as a result of internal ureteral catheterization]

INTRODUCTION AND OBJECTIVE

Urinary catheterization by means of an internal ureteral catheter in an usual procedure that may present complications. In this article we presented a case of perforation and later renal subcapsular hematoma after the placement of a "double-J" catheter.

CONCLUSIONS

This complication, although rare, should be kept in mind. The manner of avoiding it is to maintain the tightness of the guidewire while inserting the ureteral catheter. Usually, the consequences are not life-threatening and are solved with conservative treatment. The administration of LFRE should be delayed until the resolution of the hematoma.

Lower pole calicostomy for the management of iatrogenic ureteropelvic junction obstruction

It is often possible to use endoscopic techniques for the management of iatrogenic upper ureteral or ureteropelvic junction obstruction. However, in some cases with severe stricture disease or significant ischemic injury open surgical reconstruction is necessary. We report our experience with ileal ureter-lower pole calicostomy for the management of these complex urological injuries. During the last 3 years we treated 3 patients with severe ureteral/ureteropelvic junction obstruction secondary to iatrogenic injuries, including ureteral avulsion during ureteroscopic stone extraction, ureteral laceration during dilation for diagnostic ureteropyeloscopy, and ureteral ligation with ureteropelvic junction disruption and large peri-pelvic urinoma. In all cases unsuccessful attempts at endoscopic management necessitated open repair. Lower pole heminephrectomy was performed in all patients to expose the lower pole calix and ileal ureter-lower pole calicostomy was created due to the injury of large segments of the ureter. Satisfactory results were demonstrated on postoperative excretory urography and by a lack of symptoms. Followup averaged 23 months (range 20 to 26) with stable renal function in all patients. We believe that ileal ureter-lower pole calicostomy represents an attractive alternative for the management of severe ischemic, iatrogenic upper ureteral or ureteropelvic junction obstruction when endoscopic maneuvers are not possible or ineffective.

Arteriocaliceal fistula from prolonged nephrostomy tube drainage

We report a case of an arteriocaliceal fistula that occurred after 21 months of continuous nephrostomy drainage. Hemorrhage was successfully controlled with selective angiography and embolization. Although unusual, arterial injury should be considered when patients with indwelling nephrostomy tubes present with new onset of bleeding.

Endourologic management of obstructed hydrocalyx after blunt renal trauma

Significant renal injuries caused by blunt trauma can produce early and delayed complications. We report a case of blunt trauma that resulted in what appeared to be a persistent encapsulated hematoma, but was in reality an obstructed hydrocalyx. Communication with the collecting system was re-established percutaneously by a method similar to that used in the management of caliceal diverticula.

Perirenal extravasation with blunt trauma from rupture of a calyceal fornix

Perirenal extravasation of urine with an intact renal parenchyma and with dye visualized in the ureter was seen on an excretory urogram (IVP) and computed tomographic (CT) scan in two patients (bilateral in one) with multiple injuries following blunt trauma. Expectant management with no invasive procedures resulted in disappearance of the extravasation within 3 to 5 days. Traumatic rupture of a calyceal fornix is thought to be the cause of the extravasation similar to the perirenal extravasation seen with renal colic from a ureteral calculus.

[Complications of percutaneous kidney surgery--prevention and control]

Possibilities and types of complications, how to avoid and deal with them, are outlined in our material of 43 exactly defined cases. Extravasation and perforation of the renal calyces, the leaving behind of small concrements, perforation of neighbouring organs, hemorrhage, infection and late complications are discussed. Other published series, are analyzed (about 4000 patients up to now). However, often no information about incidence and type of complications is given. One must assume that several complications are not mentioned depending upon the way each author judges the complications. In general mild complications like extravasation of irrigation water and/or contrast medium and even hemorrhage diminish with practise. Inspite of our small material of about 50 percutaneous operations on the renal calyces a critical view of the larger series in the literature concerning complications is necessary. The most important points are avoiding and dealing with the discussed complications. Since percutaneous surgery on the kidney does not utilize a natural channel like the other endoscopic procedures, but creates its own channel, one should call this method a "half-open" operation.

[Extravasation of contrast media in the excretory urogram]

Aetiology and diagnostic procedure of calyceal fornix rupture during intravenous urography are discussed. In the literature the fornix rupture is described as a spontaneous event--not so in the four cases presented. In two cases a sudden increase in intrapelvic pressure was due to an ureteric calculus, in the other cases an obstruction of the ureter was secondary to neoplasm. It is recommended to perform a CT as soon as a contrast medium extravasation in intravenous urography is diagnosed.

Traumatic rupture of renal cyst into the retroperitoneum and the pyelocalyceal system

Kidneys are involved in about 25% of abdominal traumas. Pathologically altered kidneys are mostly affected in the case of hydronephrosis, cysts and tumours.

[Spontaneous rupture of the kidney pelvis calix system--causes, diagnosis and therapy]

The symptoms, diagnosis and management of the spontaneous non-traumatic rupture of the urinary collecting system are described. It is important to distinguish this frank rupture of the diseased renal pelvis from extravasation due to pyelosinusal or fornical backflow. Most cases of the latter variety are caused by acute calculous ureteral obstruction and observed during intravenous pyelogram with abdominal compression. They can be managed conservatively. Frank rupture of the renal pelvis are caused by an acute obstruction in a collecting system affected by infection, chronic obstruction, calculous erosion or tumor and is usually of grave significance and requires early surgical intervention. If the therapy is adequate, the prognosis seems to be favourable and nephrectomy seldom necessary.

Ureterocalycostomy

Ureterocalycostomy, although infrequently indicated, can be a most useful aid to the urologist who is facing a difficult reconstruction problem. The use of this technique to provide internal urinary drainage in 2 patients with long-term nephrostomy tube drainage is described. One patient had a solitary functioning kidney. A third patient, facing nephrectomy from blunt renal trauma, had the kidney saved by this procedure. The technique of ureterocalycostomy is discussed.

[Urological complications of the infusion urogram (author's transl)]

Among the patients of a urological clinic, within 5 years 15 cases of spontaneous rupture of the renal calices with urinary extravasation were seen after infusion urograms. At 1.5% of the patients, they are rare. In two cases septicemia with endotoxin shock occurred as unusual complications and in two cases provocation or exacerbation of a pyelonephritis. The clinical picture is described in the case records. Pathophysiological problems, therapeutic possibilities and indications for infusion urography are discussed.

[Simple renal cyst open into the urinary tract]

The authors present the case of a three-year old girl in whose left kidney, they observed a cystic image communicating with a calyx. The authors class the said lesion as a simple, renal cyst open to ducts. They make a differential diagnosis with other entities (calicial diverticulum, hydrocalicosis, hydatidic cyst and kidney tumour) on the basis of histological, radiological and clinical findings. To reach the same, they assess the structure of the cyst epithelium which is at all times simple cuboid; the radiographic image and the intravenous urography by filling the cyst cavity retrogressively with contrast and the record of macroscopic hematuria which would correspond to the rupture of the cyst in the excretory duct. The suggest a traumatic origin in the mechanism which opened the cyst into the excretory duct.

[Long-term follow-up after spontaneous contrast extravasation during infusion urograms (author's transl)]

In 1978 we described 18 patients with acute spontaneous rupture of a pelvi-calycine system; these have now been followed up with the exception of four patients. The aim was to determine whether, and how frequently, long-term complications occur, such as chronic persistent rupture and particularly whether local retroperitoneal fibrosis develops. The clinical history, infusion urograms and cinematography provided no evidence of any abnormalities except in one case. In this patient changes interpreted as retroperitoneal fibrosis were found, but this was the only patient in whom surgery had been performed. It is thought that the operation played a significant part in the development of this complication. Our observations confirm that infusion urograms in acute urinary tract obstruction are an acceptable method of investigation and that extravasation should be treated conservatively. The exception to this rule is the presence of preexisting infection of the urinary tract.

Traumatic caliceal-parenchymal disruption

A unique case is described of traumatic disruption of an intact collecting system (calices, renal pelvis and ureter) from an intact kidney. Evidence is presented for a congenital weakness at the level of disruption.

Ureterocalycostomy in the management of renal and ureteric trauma: report of a case

The operation of ureterocalycostomy, although rarely indicated, may occasionally be most useful, and constitute a desirable alternative to removal of an injured kidney. A case of renal transection with avulsion at the pelvi-ureteric junction, managed successfully by carrying out this procedure, is now reported.