Vol. ll8, October Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
THE ADVANTAGES OF ROUTINE USE OF NEPHROSTOMY DRAINAGE WITH PYELOPLASTY PETER M. CANNON, RICHARD G. MIDDLETON
AND
DOUGLAS S. DAHL
From the Division of Urology, Department of Surgery, University of Utah College of Medicine, Salt Lake City, Utah
ABSTRACT
Pyeloplasty by a dismembered Y-V plasty technique to correct congenital ureteropelvicjunction obstruction has been used for 8 years with uniform success. The routine use of a nephrostomy and splinting catheter offers many advantages and no significant disadvantages. In the 1950s several reports were made on the theoretical advantages of a tubeless reconstructive urinary tract operation. 1• 2 It was suggested that nephrostomy tubes are foreign bodies and may result in a higher incidence of urinary tract obstruction, persistent infection and stone formation. Therefore, tubeless pyeloplasty was advocated in selected cases. 3 • 4 Other authors suggested that with these tubeless techniques
MATERIALS AND METHODS
Between 1967 and 1975, 52 pyeloplasties were done for congenital ureteropelvic junction obstruction. Pyeloplasty was done by a dismembered Y-V plasty technique based upon that originally described by Foley in 1937. 7 In each case a temporary nephrostomy tube and a small plastic splinting catheter were used through the area of repair.
FIG. 1. A, dependent V-shaped flap of renal pelvis is created, incision is made into upper ureter and redundant renal pelvis is excised. B, dependent pelvic flap is sutured to opened upper ureter.
early postoperative obstruction and urinary leakage sometimes complicate recovery. 5 • 6 Particularly when there is fever after a tubeless pyeloplasty the patient is often subjected to excretory urography (IVP), retrograde pyelography and cystoscopic passage of a ureteral catheter. These postoperative concerns can be avoided through the routine use of a nephrostomy tube and splinting catheter after pyeloplasty. An 8-year experience with the surgical correction ofureteropelvic junction obstruction with a nephrostomy and splint is reviewed. Accepted for publication February 18, 1977.
554
The study included 21 female and 31 male patients, with an average age of 33 years and a range of 1 to 73 years. In only 1 patient had a prior pyeloplasty been performed. The most common presenting symptom was flank pain, reported in 83 per cent of the patients, followed by urinary infection in 48 per cent and hematuria in 21 per cent. Each patient was evaluated preoperatively with an IVP, which was classified according to apparent renal function and degree of hydronephrosis. None was classified as mild, 45 were moderate (that is moderate hydronephrosis with mild decrease in amount of contrast medium visualization) and 7 were severe (marked hydronephrosis and minimal or non-visualization). Each patient un-
ADVANTAGES OF ROUTINE USE OF NEPHROSTOMY DRAINAGE WITH PYELOPLASTY
555
During the postoperative period in the hospital some of the patients had mild temperature elevation and 26 (50 per cent) received antibiotics. However, postoperative retrograde grams and ureteral catheterization were not necessary any case. Approximately 3 weeks postoperatively the splint was re· moved and a pyelogram was done via the nephrostomy tube, When this study demonstrated no extravasation and free drainage of contrast material to the bladder the nephrostomy tube was removed. The longest period of nephrostomy drainage was 34 days. Oral antibiotics were given at the time of nephrostomy removal. Urinary infection cleared promptly in all cases. RESULTS
Fm. 2. Pyeloplasty is completed, and nephrostomy tube and splinting catheter are in place.
derwent retrograde ureteropyelography, usually just before the pyeloplasty and during the same anesthetic period. Eleven of the 52 patients (21 per cent) had ipsilateral renal calculi. The goals of the surgical technique were to provide dependent drainage, good funneling and a ureteropelvic junction of good caliber with active peristalsis. 8 • 9 The kidney was exposed through a flank incision and, occasionally, a portion of the 12th rib was excised. The lower kidney, renal pelvis and upper ureter were dissected free. A V-shaped flap on the inferior aspect of the renal pelvis was formed (fig. 1, A). A longitudinal incision was then made along the lateral upper ureter. The dependent portion of the renal pelvic flap was secured to the edges of the opened upper ureter with interrupted 4-zero chromic catgut sutures (fig. 1, B). The redundant renal pelvis was excised with care to avoid cutting across an infundibulum. In each case temporary urinary diversion was accomplished with a nephrostomy tube placed through a lower calix. Also, a 5 or SF plastic catheter was used as a splint through the area of repair (fig. 2). The pyeloplasty was completed by approximating the edges of the renal pelvis with 4-zero chromic catgut sutures. Penrose drains were placed in the operative site. The surgical technique was similar to that described by Bredin and associates. 6 The patients were hospitalized for an average of 8 days.
Satisfactory initial postoperative nephrostomy tube grams were obtained in 48 cases (92 per cent). The remaining 4 patients (8 per cent) required repeat nephrostomy tube pyelo. grams to demonstrate good drainage through an adequate ureteropelvic junction. Eventually all patients had satisfac·· tory nephrostograms and all nephrostomy tubes were re· moved. The longest interval a nephrostomy tube was left indwelling was 34 days. Prolonged urinary drainage the nephrostomy tract was not a problem. Of the 52 patients 48 had followup IVPs and 42 of these (87 per cent) showed improvement in the radiographic appearance of the involved kidney. Six (13 per cent) did not show cant change when compared to the preoperative studies. noteworthy that none of the postoperative pyelograms showed progressive ureteropelvic junction obstruction and late nephrectomy has not been necessary in any case. Of the Li patients who had renal calculi associated with congenital ureteropelvic obstruction 2 (18 per cent) had retained stone ments. These are small calculi and further surgical treatment has not been necessary. No recurrent calculus formation has been noted. Chronic infection has not occurred. REFERENCES
1. Hamm, F. C. and Weinberg, S. R.: Renal and ureteral surgery
without intubation. J. Urol., 73: 475, 1955. 2. Henline, R. B.: Discussion of paper by Davis, D. M., Strong, G,
3. 4. 5. 6.
7. 8. 9.
H. and Drake, W. M.: Intubated ureterotomy: experimental work and clinical results. J. Urol., 59: 860, 1948. Persky, L. and Tynberg, P.: Unsplinted, unstinted, pyeloplasty. Urology, 1: 32, 1973. Smith, B. A., Jr., Webb, E. A. and Price, W. E.: Ureteroplastic procedures without diversion. J. Urol., 83: 116, 1960. Bard, R. H. and Kirk, R. M.: Caution used in unsplinted, u.nstented pyeloplasty. Urology, 3: 701, 1974. Bredin, H. C., Muecke, E. C., Georgsson, S. and Marshall, V. F.: The surgical correction of congenital ureteropelvic junction obstructions in normally rotated kidneys. J. Urol., 111: 460, 1974. Foley, F. E. B.: A new plastic operation for stricture at the uretero-pelvic junction. Report of 20 operations. J. Urol., 38: 643, 1937. Culp, 0. S.: Management of ureteropelvic obstruction. BuH. N. Y. Acad. Med., 43: 355, 1967. Kelalis, P. P., Culp, 0. S., Stickler, G. B. and Burke, E. C.· Ureteropelvic obstruction in children: experiences in 109 cases. J. Urol., 106: 418, 1971.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
THE ADVANTAGES OF ROUTINE USE OF NEPHROSTOMY DRAINAGE WITH PYELOPLASTY PETER M. CANNON, RICHARD G. MIDDLETON
AND
DOUGLAS S. DAHL
From the Division of Urology, Department of Surgery, University of Utah College of Medicine, Salt Lake City, Utah
ABSTRACT
Pyeloplasty by a dismembered Y-V plasty technique to correct congenital ureteropelvicjunction obstruction has been used for 8 years with uniform success. The routine use of a nephrostomy and splinting catheter offers many advantages and no significant disadvantages. In the 1950s several reports were made on the theoretical advantages of a tubeless reconstructive urinary tract operation. 1• 2 It was suggested that nephrostomy tubes are foreign bodies and may result in a higher incidence of urinary tract obstruction, persistent infection and stone formation. Therefore, tubeless pyeloplasty was advocated in selected cases. 3 • 4 Other authors suggested that with these tubeless techniques
MATERIALS AND METHODS
Between 1967 and 1975, 52 pyeloplasties were done for congenital ureteropelvic junction obstruction. Pyeloplasty was done by a dismembered Y-V plasty technique based upon that originally described by Foley in 1937. 7 In each case a temporary nephrostomy tube and a small plastic splinting catheter were used through the area of repair.
FIG. 1. A, dependent V-shaped flap of renal pelvis is created, incision is made into upper ureter and redundant renal pelvis is excised. B, dependent pelvic flap is sutured to opened upper ureter.
early postoperative obstruction and urinary leakage sometimes complicate recovery. 5 • 6 Particularly when there is fever after a tubeless pyeloplasty the patient is often subjected to excretory urography (IVP), retrograde pyelography and cystoscopic passage of a ureteral catheter. These postoperative concerns can be avoided through the routine use of a nephrostomy tube and splinting catheter after pyeloplasty. An 8-year experience with the surgical correction ofureteropelvic junction obstruction with a nephrostomy and splint is reviewed. Accepted for publication February 18, 1977.
554
The study included 21 female and 31 male patients, with an average age of 33 years and a range of 1 to 73 years. In only 1 patient had a prior pyeloplasty been performed. The most common presenting symptom was flank pain, reported in 83 per cent of the patients, followed by urinary infection in 48 per cent and hematuria in 21 per cent. Each patient was evaluated preoperatively with an IVP, which was classified according to apparent renal function and degree of hydronephrosis. None was classified as mild, 45 were moderate (that is moderate hydronephrosis with mild decrease in amount of contrast medium visualization) and 7 were severe (marked hydronephrosis and minimal or non-visualization). Each patient un-
ADVANTAGES OF ROUTINE USE OF NEPHROSTOMY DRAINAGE WITH PYELOPLASTY
555
During the postoperative period in the hospital some of the patients had mild temperature elevation and 26 (50 per cent) received antibiotics. However, postoperative retrograde grams and ureteral catheterization were not necessary any case. Approximately 3 weeks postoperatively the splint was re· moved and a pyelogram was done via the nephrostomy tube, When this study demonstrated no extravasation and free drainage of contrast material to the bladder the nephrostomy tube was removed. The longest period of nephrostomy drainage was 34 days. Oral antibiotics were given at the time of nephrostomy removal. Urinary infection cleared promptly in all cases. RESULTS
Fm. 2. Pyeloplasty is completed, and nephrostomy tube and splinting catheter are in place.
derwent retrograde ureteropyelography, usually just before the pyeloplasty and during the same anesthetic period. Eleven of the 52 patients (21 per cent) had ipsilateral renal calculi. The goals of the surgical technique were to provide dependent drainage, good funneling and a ureteropelvic junction of good caliber with active peristalsis. 8 • 9 The kidney was exposed through a flank incision and, occasionally, a portion of the 12th rib was excised. The lower kidney, renal pelvis and upper ureter were dissected free. A V-shaped flap on the inferior aspect of the renal pelvis was formed (fig. 1, A). A longitudinal incision was then made along the lateral upper ureter. The dependent portion of the renal pelvic flap was secured to the edges of the opened upper ureter with interrupted 4-zero chromic catgut sutures (fig. 1, B). The redundant renal pelvis was excised with care to avoid cutting across an infundibulum. In each case temporary urinary diversion was accomplished with a nephrostomy tube placed through a lower calix. Also, a 5 or SF plastic catheter was used as a splint through the area of repair (fig. 2). The pyeloplasty was completed by approximating the edges of the renal pelvis with 4-zero chromic catgut sutures. Penrose drains were placed in the operative site. The surgical technique was similar to that described by Bredin and associates. 6 The patients were hospitalized for an average of 8 days.
Satisfactory initial postoperative nephrostomy tube grams were obtained in 48 cases (92 per cent). The remaining 4 patients (8 per cent) required repeat nephrostomy tube pyelo. grams to demonstrate good drainage through an adequate ureteropelvic junction. Eventually all patients had satisfac·· tory nephrostograms and all nephrostomy tubes were re· moved. The longest interval a nephrostomy tube was left indwelling was 34 days. Prolonged urinary drainage the nephrostomy tract was not a problem. Of the 52 patients 48 had followup IVPs and 42 of these (87 per cent) showed improvement in the radiographic appearance of the involved kidney. Six (13 per cent) did not show cant change when compared to the preoperative studies. noteworthy that none of the postoperative pyelograms showed progressive ureteropelvic junction obstruction and late nephrectomy has not been necessary in any case. Of the Li patients who had renal calculi associated with congenital ureteropelvic obstruction 2 (18 per cent) had retained stone ments. These are small calculi and further surgical treatment has not been necessary. No recurrent calculus formation has been noted. Chronic infection has not occurred. REFERENCES
1. Hamm, F. C. and Weinberg, S. R.: Renal and ureteral surgery
without intubation. J. Urol., 73: 475, 1955. 2. Henline, R. B.: Discussion of paper by Davis, D. M., Strong, G,
3. 4. 5. 6.
7. 8. 9.
H. and Drake, W. M.: Intubated ureterotomy: experimental work and clinical results. J. Urol., 59: 860, 1948. Persky, L. and Tynberg, P.: Unsplinted, unstinted, pyeloplasty. Urology, 1: 32, 1973. Smith, B. A., Jr., Webb, E. A. and Price, W. E.: Ureteroplastic procedures without diversion. J. Urol., 83: 116, 1960. Bard, R. H. and Kirk, R. M.: Caution used in unsplinted, u.nstented pyeloplasty. Urology, 3: 701, 1974. Bredin, H. C., Muecke, E. C., Georgsson, S. and Marshall, V. F.: The surgical correction of congenital ureteropelvic junction obstructions in normally rotated kidneys. J. Urol., 111: 460, 1974. Foley, F. E. B.: A new plastic operation for stricture at the uretero-pelvic junction. Report of 20 operations. J. Urol., 38: 643, 1937. Culp, 0. S.: Management of ureteropelvic obstruction. BuH. N. Y. Acad. Med., 43: 355, 1967. Kelalis, P. P., Culp, 0. S., Stickler, G. B. and Burke, E. C.· Ureteropelvic obstruction in children: experiences in 109 cases. J. Urol., 106: 418, 1971.
