Instrumentation of the ureters has an incidence of major complications and in a ser:es of 172 patients 3% had a major infection; 1% anuria and 2% perforation of the ureter. That this procedure should be considered selective and not routine is further reflected by a pronounced decrease in its use from 45% to 10% of all activities over an 8-year period in the urological theatre of Johannesburg Hospital. Indications for ureteric catheterization should be definite and contributory

Lissoos, Irving

van Blerk, P.J.P.

AJOL - African Journals Online

8 May 1971 S.A. MEDICAL JOURNAL 495examination is to be deplored. On the other hand, theradical procedures advised by some authors are unneces-sary as most of the tumours may be expected to bebenign. We have found that gentle traction applied to thefirm body of the tumour results in its extraction, intact.The point of attachment can be seen directly in thewidened nasal cavity, and excision of the base can thenbe accomplished. We have found the technique of intra-nasal spheno-ethmoidectomy to be adequate for this pur-pose. We have not hesitated to proceed to a Caldwell-Lucor lateral rhinotomy approach in those cases where theantrum was suspect. This allows direct inspection of theantrum and removal of infected mucosa or tumour. Thediscovery of malignant disease indicates telecobalt thera-py and radical surgery.I wish to thank the Superintendent, Baragwanath Hospital,for permission to publish these cases; Drs R. Sack, S. M. Maticand D. Haynes, for their advice in the management of the cases;Dr A. Schmamann of the South African Institute for MedicalResearch, for interpreting the histology; and the PhotographicUnit, Department of Medicine, University of the Witwatersrand,Johannesburg.REFERENCESI. Kramer, R. and Som, M. L. (1935): Arch. Otolaryng., 22, 22.2. Oshom, D. A. (1956): J. Laryng., 70, 547.3. Pfisterer, H. (1961): Pract. Oto-rhino-Iaryng. (Basel), 23, 217.4. Judge, A. F. (1952): Ann. Otol. (St Louis), 61, 625.5. Brown, B. (1964): J. Laryng., 78, 889.6. Gadre, K. C. and Lodaya, J. D. (196~): ibid., 78, 82.7. Ringertz, N. (1938): Acta oto-Iaryng. (Stockh.), 27, suppl., 31.8. Norris, H. 1. (1963): Laryngoscope (St Louis), 73, I.9. Vemer, J. L., Maguda, T. A. and Young, 1. M. (1959): Arch. Oto-laryng., 70, 574.10. Smith, A. T. and Decker, J. P. (1962): Ann. Otol. (St Louis), 71, 511.11. Marcel-Rojas, R. and De Leon, E. (1963): Arch. Otolaryng., 77, 634.12. Mabery, T. E., Devine, K. D. and Harrison, E. G. jnr (1965): ibid.,82, 296.13. Skolnik, E. M., Loewy, A. and Friedman, 1. E. (1966): ibid., 84, 61.RETROGRADE PYELOGRAPHY AND URETERIC CATHETERIZATION*IRVING LISSOOS AND P. J. P. VAN BLERK, Department of Urology, Johannesburg Hospital and the University of theWitwatersrand, Johannesburg...................-.-.- - _.. CASES UNDERGOING URETERIC CATHETERISATIONSUMMARYInstrumentation of the ureters has an incidence of majorcomplications and in a ser:es of 172 patients 3 % had amajor infection; 1 % anuria and 2 % perforation of theureter. That this procedure should be considered selectiveand not routine is further reflected by a pronounced de-crease in its use from 45% to 10% of all activities overan 8-year period in the urological theatre of JohannesburgHospital. Indications for ureteric catheterization should bedefinite and contributory.200018001600140012001000164317418161688TOTAL NO. OF CASES17911630181919061742With the advent of more sophisticated and better tech-niques of intravenous or secretory pyelography (IVP),the tenet that retrograde pyelography must form part ofa routine urological 'work-up' is no longer acceptable.Ureteric catheterization is not without its dangers; how-ever, catheterization of the ureters remains a valuabletool in the hands of the urologist, and is essential in thecorrect situation. As a method of investigation, it shouldbe considered as highly selective in specific circumstances.This is borne out by the reduced frequency with which thisprocedure is employed in this department (Fig. 1).MATERIALInvestigative procedures carried out in the departmentalurological theatre from 1963 to the end of October 1970are reviewed. This shows a steady decline of uretericcatheterization in the 8 years under study. The use ofureteric catheterization compared with all proceduresshowed a steady decline from 45% in 1964 to 10% in 1970.This decrease was not due to any decrease in the volumeof work done in the theatre (Fig. 1).The incidence of infection, anuria and perforation ofthe ureter in the 172 cases subjected to ureteric catheteri-zation from January 1970 to the end of October 1970 arereviewed and discussed.*Date received: 7 December 1970.7800 7S6...-~" 65'600 676.43.001722001963 1964 1965 1966 1967 1968 1969 ~97010c1.1Fig. 1. Cases treated 1963 - 1970.InfectionFive out of 172 cases developed severe and significantpostretrograde pyelography infection-an incidence of 3%.All 5 patients developed temperatures of over 101°F andwere considered seriously ill.Cases 1 - 4 were chronic renal failure patients with alow urinary output, in whom IVP was unsuccessful. Pseu-domonas aeruginosa was the causative organism, reaffirm-ing the experience that pseudomonas commonly is thecausative organism in infections following instrumentationof the urinary tract.'Case 5 was a female in whom the ureters were ob-structed due to an extension of cervical carcinoma. Thecausative organism in this case was E. coli.Vigorous and prolonged antibiotic therapy was re-quired in all these cases to avert a fatal outcome. Theincidence of mild infections following this type of instru-mentation is not known, ".s urinary cultures were not496 S.-A. MEDIESE TYDSKRIF 8 Mei 1971..';0-- __ ·-_._._._cc- 0Fig~~ 2. Radio-isotope renogram showing an obstructivepattern after ureteric catheterization.or some unknown substance in the catheters could betoxic or allergenic to the ureteral mucosa. Contrast mediacannot be invoked as a cause in case 2, as no contrastmedia was injected. This experience is confirmed byothers.'--Two cases of postretrograde pyelography anuria inwhich disposable ureteric catheters were used have beenbrought to our notice.]O This indicates that factors otherthan formaldehyde irritation are operative as well.The cause of the oedema is most likely trauma to theureteral mucosa.' Body tissues rapidly become oedematousas a result of trauma and only minimal circumferentialoedema within a closed tube would be necessary to createa complete obstruction.3In cases of postureteric catheterization anuria wherecatheters have been reinserted, urine has often passedfrom the catheters, thus confirming the fact that obstruc-tion was the operative factor.Hope and Michien demonstrated obstruction after retro-grade pyelography in 9 out of 14 children. Cohen et al.'"have shown that in only lout of 14 patients catheterizedwith 7F catheters was a postoperative renogram normal;the remaining renograms all showed an obstructive pat-tern. Further, it must be borne in mind that septicaemiaprecipitated by instrumentation can present as anuria,probably as a result of tubular necrosis. No such caseperformed as a routine after retrograde pyelography. Ure-thral instrumentaton, however, is known to be followedby bacteriuria in 4% of patients where the bladder isconsidered to be normal and in cases of bladder neckobstruction this increases to 30%.' Ureteric catheterizationcompounds the infection of urethral instrumentation bycarrying the bacteria into the pelvis of the kidney.In the 5 patients undergoing retrograde pyelography,the following significant contributory factors were pre-sent: (i) a low urinary output (cases 1 - 4); and (ii) anobstructed upper urinary tract (case 5). Wherever possible,retrograde pyelography should be avoided in these situa-tions. However, if retrograde pyelography is indicated as adiagnostic modality, the operator must be meticulous inits performance, with special care to drain off all radio-opaque material from the upper urinary tract before re-moving the ureteric catheters, thus removing a stasis factorand a cause of subsequent infection. Passage of uretericcatheters per se may cause obstruction (see below) and sopredispose to infection.AnuriaTwo patients developed postureteric catheterizationanuria, giving an incidence of 1 %.Case 1. A 78-year-old male had bilateral retrogradepyelography performed, under local anaesthesia, to betterdelineate the presence of a filling defect which was demon-strated on IVP in the right kidney. Subsequently, thepatient developed generalized abdominal pain and wastotally anuric for 12 hours. A urethral catheter was intro-duced into the bladder and the bladder was found to beempty of urine.Furosemide (Lasix), 40 mg, was given by intravenousinjection and 1 litre of 5% dextrose in water was adminis-tered intravenously over 1 hour. No response to thistherapy was obtained. Five hundred ml of half-normalsaline, with 160 mg furosemide, was then administeredrapidly with a good response. In the next 24 hours thepatient passed 3 500 ml of urine. His subsequent recoverywas uneventful.Case 2. A 72-year-old female underwent abdomino-perineal resection for a carcinoma of the rectum. Pre-operatively, both ureters were catheterized in order tofacilitate their identification during the operative proce-dure. The operation was uneventful and without anyepisodes of hypotension. Postoperatively the catheterswere removed, whereupon the patient became totally anu-ric for 24 hours. A radio-isotope renogram performed atthis stage showed only a secretory phase and no excretoryphase, this being compatible w:th obstruction (Fig. 2).After 24 hours of anuria, the patient proceeded to passblood-stained urine, having received intravenous fluids,mannitol and furosemide. Her blood urea rose from thepre-operative figure of 47 mg/lOO ml to 144 mg/lOO mlon the fourth postoperative day; subsequ::ntIy, her urinaryoutput improved and her blood urea level decreased,returning to normal by the twelfth postoperative day.Twenty-one cases of anuria, following retrograde pye-lography, were reported in the literature.3 This anuria isthought to be due to obstruction following oedema ofthe ureteral mucosa, after the passage of a uretericcatheter. It has been suggested that the contrast materiaV··the catheter sterilizing substance (usually formaldehyde):---8 May 1971 S.A. MEDICAL JOURNAL 497occurred in this series.In the 21 reported cases of anuria following retrogradeureteric catheterization' and in the 2 patients describedhere, both ureters were catheterized. This was necessaryin case 2 and only one of the reported cases. Anuriacould have been prevented if only one ureter had under-gone catheterization, emphasizing the fact that this bila-teral manoeuvre should be reserved for selected casesand not used as a routine. In addition, in order to mini-mize trauma to the mucosa, the calibre of ureteric cathe-ter used must be as fine as possible."The treatment of this complication consists of thejudicious use of intravenous fluids, electrolytes and diure-tic drugs, to overcome the obstructive oedema. The com-plication is usually responsive to this regimen and moreactive methods are rarely indicated.Perforation of the UreterA ureter was perforated in 4 of the 172 patients, anincidence of 2%. No. 5 French ureteric catheters withoutstylets were used in all cases. The perforations all occurredin the lower third of the ureter and were diagnosed by theextravasation of dye on the pyelogram (Figs. 3 and 4).Three of the ureters were considered to be normal beforeFig. 3. Perforation of a calculus containing ureter.9Fig. 4. Perforation of a normal ureter.perforation and the remaining one perforation occurredin a patient with a ureteric calculus, the site of perforationbeing just distal to the calculus (Fig. 3). This patientrequired a ureterolithotomy and the site of perforationwas visualized at operation. The remaining three patientswere treated conservatively with antibiotics and all madean uneventful recovery.Perforation of a normal ureter occurs most commonlynear the ureterovesical junction and rarely at the uretero-pelvic junction. The occurrence of perforation in theseareas is probably related to the angulation of the ureterat these points."A diseased ureter, however, is more prone to perfora-tion than the normal ureter. 13 Other factors which maypredispose to ureteral perforation are the use of sty letsand bougies, forceful and careless instrumentation, and theexertion of too much pressure on injecting the contrastmaterial.The majority of cases clear up uneventfully with con-servative therapy. However, several deaths from sepsisfollowing perforation of the ureter during attempts atretrograde pyelography have occurred."'" All patientswith perforations of the ureter must be admitted to hospi-tal and observed for complications which may develop.498 S.-A. MEDIESE TVDSKRIF 8 Mei 1971DISCUSSIONRetrograde pyelography and ureteric catheterization mustbe considered as a highly selective procedure with definiteindications and not used as a common routine procedure.Sophisticated intravenous secretory pyelography has re-placed retrograde pyelography as a diagnostic tool in themajority of instances. In addition to demonstrating theanatomy of the collecting system, intravenous pyelography(IVP) has the advantage of reflecting, to some extent,renal function, and also renal parenchymal morphology,which retrograde pyelography cannot do. The whole ure-ter can be demonstrated on IVP by taking X-ray filmswith the patient in the prone and supine positions andusing lower abdominal compression.The indications for retrograde pyelography and uretericcatheterization are:1. The demonstration of renal collecting system mor-phology.2. As a preliminary to ureteric calculus extraction witha stone basket.3. Differential renal function studies.4. To provide drainage to the obstructed ureter.5. To provide localization to the ureters in difficultabdominal and pelvic surgery.6. In patients with iodine sensitivity where IVP iscontraindicated.I. The Demonstration of Renal Collecting System Mor-phology.The decision as to when to perform retrograde pyelo-graphy should only be made after the performance ofpreliminary and thorough IVP and a considerationwhether retrograde pyelography will be contributory tothe diagnosis and management.Poor renal function is no indication per se for omittingintravenous secretory pyelography and performing retro-grade pyelography ab initio. With large dose contrastmaterial and tomography, it has even been possible todemonstrate renal tract morphology adequately in patientswith a serum creatinine level as high as 11·6 mg/lOO mland a creatinine clearance of 8 ml/min.In this department, retrograde pyelography is thus onlyreserved for those cases to demonstrate morphology whichis not adequately delineated on secretory pyelography.In these circumstances, only unilateral retrograde pyelo-graphy may be required.2. Ureteric Catheterization as a Preliminary to Stone Bas-ket Extraction of a U reteric Calculus.Extractions of a ureteric calculus necessitates uretericinstrumentation and as a preliminary manoeuvre it hasbeen found beneficial to pass a Fogarty catheter up to thecalculus, inflating the bulb and then dilating the ureterdistal to the ureteric calculus by extracting the inflatedbulb catheter.163. Differential Renal Function StudiesIn renovascular hypertension, the minute sequence intra-venous secretory pyelogram is a good screening and diag-nostic test. This and angiography will usually' confirmthe diagnosis. Differential renal function studies and thusureteric catheterization are only indicated in these andother cases of renal hypertension in which the diagnosisis doubtful. Where unilateral nephrectomy is contem-plated, split renal function studies will indicate the func-tional status of the unaffected kidney.4. Drainage of an Obstructed UreterDreteric catheterization is a useful temporary measureto relieve obstruction in an obstructed ureter or ureters.A ureteric catheter is introduced beyond the site ofobstruction and left in situ to allow drainage of theaffected kidney until more definitive measures can beundertaken.5. Localization of Ureters in Pelvic and Abdominal SurgeryWhere difficulty in localizing the ureters during pelvicor abdominal surgery is anticipated, preliminary uretericcatheterization will aid the surgeon in localizing the ure-ters. This enables the surgeon to avoid injuring the ureterand will reduce the morbidity associated with such acomplication.6. Iodine SensitivityIf intravenous secretory pyelography is contraindicatedbecause of iodine sensitivity, retrograde pyelography maybe used, in selected cases, to demonstrate renal morpho-logy. A serious systematic reaction to iodine is unlikelyduring retrograde pyelography.Lytton et al." have shown that, under normal condi-tions, less than 1% of the contrast material injectedduring retrograde pyelography appears in the systemiccirculation. However, if pyelorenal backflow is presentfrom excessive force used while injecting the contrastmaterial, this increases 12-fold;" also, if obstruction ispresent, there is a substantial increase in the systemicabsorption of the contrast material. This can result in asystemic reaction.We wish to thank the Director of Hospital Services, Trans-vaal, and the Medical Superintendent of Johannesburg Hospi-tal for permission to publish; the sisters and staff of thedepartmental urological theatre for their constant co-operationand effort; the Records Department for their efforts in pro-viding case notes; and Mr E. Wesselo for the illustrations.REFERENCES1. Harrison, A. R. (1970): Modern Trends in Urology-3, p. 5. London:Butterworth.2. Kerr, D. N. S. and Douglas, A P. (1968): A Short Textbook ofKidney Disease, p. 162. London: Pitman MedIcal PUblishmg Co.3. Conway, G. F. and Bicknell, F. B. (1966): J. Ural. (Baltimore), 96,805.4. Sirota, J. H. and Narins, L. (1957): New Engl. J. Med., 257, 1111.5. Burras, H. M .. Borromeo, V. H. J. and Seligson, D. (1958): Ann.Intern. Med., 48, 674.6. Quinby, W. C. and Austen, G. jnr (1939): New Engl. J. Med., 221.814.7. Stewart, B. H .. Schacht. R. A., Bishop. R. C. and Conway, J. (1965):J. Ural. (Baltimore). 94, 7.8. Harrow. B. R. and Sloane, J. A. (1962): J. Amer. Med. Assoc ..180, 415.9. Levant, B. and Yardumian, K. (1944): Ural. Cutan. Rev., 48, 554.10. Bleloch, J. (1970): Personal communication.11. Hope, J. W. and Michie, J. (1959): Radiology, 72, 844.12. Cohen. A. B.. Bourdneaux, J. L. and Schleoal, J. U. (1962): J. Urol.(Baltimore), 87, 662. ~13. GOldstein, A. G. and Conger, K. B. (1965): Ibid., 94, 658.14. Mdver, R. B. (1944): J. Amer. Med. Assoc., 124, 1116.15. Rusche, C. F. (1956): Neb. S1. Med. J., 41, 271.16. Gecelter, L. (1970): Personal communication.17. Lytton. B., Braoks, M. B. and Spencer, R. P. (1968): J. Urol.(Baltimore), lOO, 779.•

English

Retrograde pyelography and ureteric catherization

https://www.ajol.info/index.php/samj/article/download/170208/159644

Retrograde pyelography and ureteric catherization

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online