Combined CT- and fluoroscopy-guided nephrostomy in patients with non-obstructive uropathy due to urine leaks in cases of failed ultrasound-guided procedures

Abstract

Aim

To report our experience of combined CT- and fluoroscopy-guided nephrostomy in patients with non-obstructive uropathy due to urine leaks in cases of failed ultrasound-guided procedures.

Patients and methods

Eighteen patients (23 kidneys) with non-obstructive uropathy due to urine leaks underwent combined CT- and fluoroscopy-guided nephrostomy. All procedures were indicated as second-line interventions after failed ultrasound-guided nephrostomy. Thirteen males and five females with an age of 62.3 ± 8.7 (40–84) years were treated. Urine leaks developed in majority after open surgery, e.g. postoperative insufficiency of ureteroneocystostomy (5 kidneys). The main reasons for failed ultrasound-guided nephrostomy included anatomic obstacles in the puncture tract (7 kidneys), and inability to identify pelvic structures (7 kidneys). CT-guided guidewire placement into the collecting system was followed by fluoroscopy-guided nephrostomy tube positioning. Procedural success rate, major and minor complication rates, CT-views and needle passes, duration of the procedure and radiation dose were analyzed.

Results

Procedural success was 91%. Major and minor complication rates were 9% (one septic shock and one perirenal abscess) and 9% (one perirenal haematoma and one urinoma), respectively. 30-day mortality rate was 6%. Number of CT-views and needle passes were 9.3 ± 6.1 and 3.6 ± 2.6, respectively. Duration of the complete procedure was 87 ± 32 min. Dose-length product and dose-area product were 1.8 ± 1.4 Gy cm and 3.9 ± 4.3 Gy cm², respectively.

Conclusions

Combined CT- and fluoroscopy-guided nephrostomy in patients with non-obstructive uropathy due to urine leaks in cases of failed ultrasound-guided procedures was feasible with high technical success and a tolerable complication rate.

Introduction

Percutaneous nephrostomy was first described more than 50 years ago as a blind puncture of the renal pelvis in hydronephrosis [1]. Since that time, the percutaneous approach has been performed routinely as a relief for obstructive uropathy with fluoroscopy, ultrasound, CT and MRI as guidance modalities [2], [3], [4], [5], [6]. It is used as direct urinary drainage for a variety of disorders. The most frequent are renal or ureteral calculi causing obstructive uropathy, trauma of bladder or ureter, urinary tract leaks due to infiltrating malignancies or after surgical complications [7], [8], [9]. In obstructive uropathy, blockage of the urinary drainage system can lead to severe functional defects of the kidney [10]. Non-obstructive uropathy associated with leaks bears the risk of localized and systemic infection such as infected urinoma, retroperitoneal abscess, pyelonephritis, peritonitis and urosepsis [11]. All these conditions can be treated effectively with percutaneous urinary drainage [12], [13]. Under fluoroscopy- and ultrasound-guidance, percutanoeus nephrostomy is technically feasible in up to 98% of cases with dilated systems [14]. In non-obstructive uropathy, fluoroscopy- and ultrasound-guided nephrostomy fail in 15% [15], [16]. CT-guided percutaneous nephrostomy is an alternative approach when routine procedures are difficult or infeasible. Especially in patients with complex anatomic situations as ectopic kidneys or retrorenal colon, obesity and postoperative patients with extensive laparotomy wounds, CT-guidance can be advantageous. For proper positioning of guidewire and catheter, fluoroscopy is mandatory after successful CT-guided access to the renal collecting system [17]. The purpose of the current study was to report our experience with combined CT- and fluoroscopy-guided nephrostomy in patients with non-obstructive uropathy due to urine leaks in cases of failed ultrasound-guided procedures.