Diagnosis and management of ureteral fistulas by percutaneous nephrostomy and antegrade stent catheter

Spontaneous Ureterocutaneous Fistula Secondary to Obstructed Ureteric Stone

We present a unique case of ureterocutaneous fistula secondary to an obstructed ureteric stone. A fistulagram confirmed a communication between right flank and the proximal ureter. Ureterocutanoues fistula in the absence of trauma, iatrogenic causes, granulomatous infection, or malignancy is highly unusual.

The Upper Urinary Tract

Pyelography is superior to all other imaging techniques for the demonstration of fine detail in the pelveocalyceal system and the ureter. For almost 90 years it has been performed through a retrogradely inserted catheter, but during the recent 30 years antegrade injection via a transparenchymally inserted needle or catheter has become an accepted alternative, especially in case of a dilated upper urinary tract. Both methods have their advantages and their disadvantages. This article presents a review of indications, techniques, and complications. Furthermore, interventional procedures on the upper urinary tract—such as stent placement and balloon dilatation—are now handled by the radiologist, mainly through an antegrade approach. These therapeutic procedures are also reviewed.

Endourologic management of obstetrical ureterouterine fistula: case report and review of literature

A 32-year-old woman presented to us with complaints of paradoxical incontinence for a period of 6 months following a cesarean section for obstructed labor performed elsewhere and subsequently treated elsewhere. Clinical and urographic assessment revealed an iatrogenic ureterouterine fistula, which was successfully treated endoscopically by dilatation of the ureteral stricture and ureteroscopic double-J stenting. It had been explained to the patient, and she had given consent for, ureteroneocystostomy in the event of failure. The literature regarding the management of this rare genitourinary fistula is reviewed and discussed.

US-guided nephrostomy with the aid of a magnetic field-based navigation device in the porcine pelvicaliceal system

PURPOSE

To assess the technique and feasibility of ultrasound (US)-guided nephrostomy performed with the aid of a magnetic field-based navigation device.

MATERIALS AND METHODS

Twelve percutaneous nephrostomy procedures were performed in seven domestic pigs under real-time US guidance employing a navigation system. Two magnetic field sensors registered the actual position of the puncture needle and the US transducer. The actual needle position and the aimed puncture tract were graphically projected into the real-time US images, allowing exact navigation of the needle. After placement of the needle into the renal pelvis, the nephrostomy tube was inserted by means of the Seldinger technique.

RESULTS

The puncture procedure was successfully performed in each case. The renal pelvis was punctured in a single attempt in 10 of 12 cases. In two cases, multiple attempts were necessary because bending of the puncture needle led to inaccuracies of the navigation system. With exception of two small perirenal urinomas, no complications were seen.

CONCLUSIONS

The magnetic field-based navigation device allows easy and accurate performance of nephrostomy guided solely by US.

The effects of acute and chronic JJ stent placement on upper urinary tract motility and calculus transit

OBJECTIVE

To determine the pathophysiological changes in upper urinary tract motility and calculus transit which may occur following JJ stent insertion.

MATERIALS AND METHODS

The acute and chronic effects of JJ stent placement were studied in 24 canine renal units. Intrarenal and intraureteric pressures and motility were measured, in addition to transit times for complete passage of synthetic calculi from the upper ureter into the bladder.

RESULTS

Acute effects included raised renal intrapelvic pressure, reduced pelvic and ureteric motility and delayed calculus transit time. Prolonged JJ stent placement was associated with return of intrapelvic pressure to normal but persistent changes in both renal and ureteric motility and also calculus transit time.

CONCLUSION

In situ JJ stents impair upper urinary tract motility and experimental calculus transit time and may delay passage of ureteric calculi or calculus fragments following extracorporeal shock wave lithotripsy.

Long-term effects of ureteric stent after ureteric dilation

Balloon dilation of the right ureterovesical junction (UVJ) and distal ureter to three times its normal caliber was performed in 12 pigs. A right double-J (D-J) stent was inserted after dilation in 6 pigs. Bilateral upper tract dynamics with different perfusion rates (0.5, 2 and 4 ml. per minute) were recorded before dilation, immediately after dilation, and then 4 and 7 weeks after dilation. Immediate and late antegrade nephrostograms as well as suprapubic cystograms were taken. Grade 3 reflux occurred in 100% of animals at 7 weeks on the dilated, stented ureter and no reflux on the dilated, nonstented ureter. At 7 weeks on the dilated, stented side, significant growth (> 100,000, colonies) of Pseudomonas species was noted in all animals. Creatinine clearance was significantly reduced on the dilated, stented side when compared to the dilated, nonstented side at 7 weeks. Histologic examination of the dilated, stented and dilated, nonstented ureters at 4 weeks revealed a segmental muscular defect with muscular regeneration starting from the edge of the defect, particularly in the innermost region. At 7 weeks, there was a more advanced, but similar, pattern of muscular regeneration in both groups. However, at 7 weeks, metaplastic changes of the ureter and chronic pyelonephritis were evident on the dilated, stented ureter. Electron microscopy showed that myofibroblasts played a major role in the healing process with new muscle formation. At 4 weeks, no significant morphologic difference was found between the dilated, stented and dilated, nonstented ureters. At 7 weeks, however, it appeared that the ureteric stent resulted in damage and deterioration of renal function without affecting muscular regeneration of the ureter. We conclude that the changes observed could be entirely due to the infection associated with the stent rather the stent itself.

Combined retrograde-antegrade ureteral stent passage: salvage procedure for a ureteral leak

The authors describe a stent placement procedure for treatment of an infected ureteral leak after failure of traditional antegrade and retrograde approaches. In this procedure, a guide wire was placed across the distal ureteral segment into a urinoma with use of cystoscopic guidance. Thereafter, an antegrade approach was used to pass a wire loop snare, capture the guide wire, and withdraw it through the proximal ureter for subsequent stent passage. This approach allowed percutaneous stabilization of a ureteral leak in a patient who would have otherwise required immediate surgical repair.

Use of the double pigtail stent in stone retrieval following unsuccessful ureteroscopy

Insertion of a double pigtail stent is known to cause ureteric dilatation. We analysed the effect of an indwelling double pigtail stent on the success rate of calculus extraction by second ureteroscopy when the initial ureteroscopy fails. Over a 12-month period, a first ureteroscopy failed in 42 patients; 30 were then treated by ureteroscopy combined with a ureteric stent and 12 were treated without a ureteric stent. The group with an indwelling stent had a successful second ureteroscopy or spontaneously passed the calculus in 24 cases (84%) compared with 5 unstented cases (45%). Ureterolithotomy was necessary in 2 patients with a stent and 3 with no stent. It was concluded that following failed ureteroscopic manipulation of calculi, insertion of a double pigtail stent was associated with a higher subsequent success rate for removal of stone by ureteroscopy and a consequent lower rate of ureterolithotomy.

The effects of double J stents on renal pelvic dynamics in the pig

Intra-pelvic pressure and peristaltic activity were measured before and during diuresis in 26 minipigs, immediately, one week and three weeks following ureteric intubation with 5 and 6F polyethylene double J stents. Changes in these dynamic parameters were seen which indicate that these stents caused renal outflow obstruction. The severity of this obstruction appears dependent upon the size of the catheter and the temporal length of intubation. This study indicates that double J stents provide sub-optimal drainage of the renal pelvis and damaged ureter.

Percutaneous management of benign ureteral strictures and fistulas

The percutaneous methods of management of benign ureteral strictures or fistulas have developed as a natural evolution of percutaneous nephrostomy and angiographic techniques. We review our 5-year experience, which includes 18 patients with 19 benign ureteral strictures and 12 patients with ureteral fistulas. In the majority of the patients the ureteral strictures occurred at sites of surgical reconstruction or endoscopic manipulation. All fistulas resulted from surgical injury. In 10 of the 12 patients (82 per cent) the fistulas healed without development of a stricture or need for further intervention. Patients with short ureteral strictures had a high incidence of success and they usually were the best candidates for percutaneous manipulation. The long strictures usually were of longer duration and they were less likely to be managed successfully percutaneously. Failure of percutaneous dilation did not impede subsequent surgical management. Percutaneous management often is a reasonable initial step in the treatment of ureteral strictures and fistulas.

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.

Iatrogenic ureteral injury

We treated 27 patients with iatrogenic ureteral injuries during a 6-year period. Gynecological operations were the most common antecedent surgical procedures (52 per cent). The diagnosis of ureteral injury was made immediately in 4 patients and was delayed 1 to 34 days in 23. Three of the 4 injuries recognized during an operation were repaired successfully at the time of injury; the primary repair in the remaining patient leaked and ultimately resulted in a nephrectomy. In the delayed diagnosis group retrograde ureteral catheterization was successful in only 1 of 20 attempts. Of the 23 patients with injuries recognized in the postoperative period 11 were managed successfully with percutaneous nephrostomy (with or without stenting) alone, 3 required surgical repair after temporary percutaneous nephrostomy drainage, 4 were treated surgically without prior nephrostomy drainage and 1 had spontaneous resolution of hydronephrosis. The remaining 3 patients required nephrectomy: 1 because of a urinary fistula in a previously irradiated field, 1 because of a concomitant (ipsilateral) renal cell carcinoma and 1 because of renal hypertension. Percutaneous nephrostomy or ureteral stenting was successful as primary therapy in 73 per cent of the patients in whom it was used.

Percutaneous occlusion of ureteral leaks and fistulae using nondetachable balloons

High-output ureteral fistulae were managed percutaneously in 3 patients with pelvic malignancies. Urine flow was diverted by combining percutaneous nephrostomy catheter drainage with transrenal balloon occlusion of the affected ureter proximal to the site of extravasation. This technique can be used either alone as the definitive method of treatment or as the initial procedure to preserve renal function and reverse the inflammatory reaction prior to subsequent surgical repair; its primary application is in patients in whom antegrade or retrograde ureteral stenting is not feasible or possible.

Interventional radiology in the treatment of retroperitoneal trauma

Interventional radiology is used most often in the management of the trauma patient to control hemorrhage and drain fluid collections. Transcatheter arterial embolization is an effective, expeditious, and safe technique for the nonoperative control of renal and other retroperitoneal bleeding, arteriovenous fistulas, and pseudoaneurysms. Transcatheter drainage of renal and other retroperitoneal collections of pus, urine, and blood is successful in more than 90% of trauma patients; such drainage should be attempted prior to any surgical intervention. Other procedures, such as antegrade nephrostomy, ureteral stenting and dilatation, angioplasty of traumatic renal artery stenosis, and suprapubic cystostomy, are infrequently indicated but provide alternatives to standard surgical intervention.

The transplanted kidney. Diagnostic and interventional radiology

Following kidney allotransplantation a great number of complications threaten the patient and his graft, e.g. acute tubular necrosis, acute and chronic rejection, urologic and vascular complications and complications due to the immunosuppressive treatment. During the last decade a number of technical developments in radionuclide, ultrasonographic and radiographic imaging and intervention has significantly improved the possibility of early recognition and handling of such complications. Knowledge of the capability and limitations of the various techniques is of vital importance for their rational use. The aim of this review article is to give a short description of the various imaging modalities, the rational monitoring of the posttransplant patient, and possible handling of complications by the aid of imaging techniques.

Renal artery embolization to control urinary cutaneous fistula after partial resection of a horseshoe kidney

We describe a patient with a chronic urinary cutaneous fistula following partial nephrectomy of a previously separated horseshoe kidney, who was treated successfully by stainless steel coil embolization of the renal artery. Thus, a major reoperation was avoided.

Transrenal ureteral occlusion using a detachable balloon

Percutaneous transrenal ureteral occlusion using a detachable balloon filled with silicone was performed in 20 patients. The main indications were palliation of large urinary fistulas and as a treatment of last resort for severe dysuria in patients with advanced pelvic malignancies. In 6 patients the contralateral kidney was rendered nonfunctional to obviate the need for bilateral nephrostomy. Due to frequent obstruction of the tube, ureteral blockage in 3 became insufficient. Two dislocated balloons were extracted percutaneously and replaced. In order to achieve effective interruption of urinary flow down the ureter, well-functioning external nephrostomy drainage is necessary.

Percutaneous nephrostomy and antegrade ureteral stent insertion

Sixty consecutive percutaneous nephrostomies were attempted in 37 patients with a 97-per cent success rate. The patients ranged in age from three to seventy-three years. Twenty-eight attempted nephrostomies were bilateral and 32 unilateral. When possible, the percutaneous nephrostomies were converted into internal ureteral stents by antegrade techniques. In each case of apparent complete ureteral obstruction, the area was successfully negotiated, and an indwelling ureteral stent was placed. In 2 patients, combined antegrade and retrograde techniques were required for successful internal stent placement. There was one failure because of a subcapsular hematoma resulting from multiple punctures with an 18-gauge needle. One major complication occurred when a segmental branch of the renal artery was injured by the nephrostomy catheter.

Dissolution of bilateral renal calculi via percutaneous nephrostomy. Report of a case

Both kidneys in a patient with multiple, bilateral renal calculi were treated consecutively by irrigation with a stone-dissolving solution through percutaneously placed nephrostomy catheters. Almost complete dissolution of the calculi was obtained. An intercurrent ureteral calculus necessitated introduction of a second catheter in one kidney, but was also successfully treated.