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Case R eport
REVISTA PAULISTA DE MEDICIN ADuode nal damage complicating
pe rcutane ous acce ss to kidne y
Discipline of Urology, Faculdade de Medicina do ABC, Santo André, Brazil
a b s t r a c t
CO N TEX T: Since the first percutaneo us nephro sto my perfo rmed by G o o dwin in 1 9 5 4 , technical advances in accessing the kidneys via percutaneo us puncture have increased the use o f this pro cedure and thus the co mplicatio ns to o . Amo ng these co mplicatio ns, dig estive tract damag e is no t co mmo n.
DESIGN : Case repo rt.
CASE REPO RT: W e repo rt a duo denal lesio n that was co rrected using surg ical explo ratio n and we to uch o n the therapeutic o ptio ns, which may be co nservative o r interventio nist. W e cho se co nserva-tive treatment, which has been appro ached in diverse manners in the literature.
KEY W O RDS: Pe rc uta ne o us N e p hro sto my. Duo d e na l Fistula e . Duo deno pathies.
• Anto nio Co rrêa Lo pes N eto • Marco s To bias-Machado • Ro berto Vaz Juliano • Marco Aurélio Lipay • Milto n Bo rrelli • Eric Ro g er W ro clawski
INTRODUCTION
Percutaneo us surgery o f the kidney is the go ld standard treatment fo r tempo rary urinary diversio n in ureteral o bstructio n due to gyneco lo gical cancer.
Kno wledge o f po ssible co mplicatio ns o f this sur-gery is very impo rtant. Duo denal damage is an un-co mmo n un-co mplicatio n described in the literature. The treatment o f this co nditio n has different appro aches, ranging fro m the co nservative (drainage, naso gastric tube and parenteral nutritio n) to the repair o f the le-sio n by laparo to my.
We describe a patient with duo denal damage due to an accident during kidney puncture, which was treated by suture o f the lesio n.
CASE REPORT
The patient was a 68-year-o ld wo man with stage IIB uterine cervical carcino ma who had undergo ne radio -therapy 1 year befo re and develo ped po st--therapy renal failure. An unsuccessful attempt to pass a do uble J cath-eter was first made, fo llo wed by right percutaneo us ultra-so und-guided nephro sto my. There was go o d urine drain-age fo r six ho urs, but then the catheter o utput ceased. An unsuccessful attempt to remove the obstruction was made, fo llo wed by a seco nd ultraso und-guided puncture, which was difficult due to insufficient renal pelvis dilatio n. Dur-ing the pro cedure, enteric fluid leaked thro ugh the Amplatz po lyethylene dilato r. Due to this intercurrence and to un-successful attempts to shunt the excretio n pathway, lap-aro to my was perfo rmed in the lo wer back to permit nephro sto my and explo re the perito neal cavity.
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Operatio n findings included clo ts in the excret-ing pathway, blo o d and sero us fluid in the cavity, and a 0.5-cm lesio n o n the 2nd duo denal po rtio n. Once the nephro sto my was perfo rmed, the duo denal wall was sutured o n two plans, and two drains, o ne periduo denal and o ne perirenal, were kept. The patient remained fast-ing until the 5th po sto perative day, when diet was rein-tro duced and the perirenal drain was remo ved. The periduo denal drain was remo ved o n the 6th po sto p-erative day, and the patient was discharged o n the 7th po st-o perative day with a functio ning nephro sto ma. Thirty days later she had no pyelo calyx dilatio n.
DISCUSSION
Recent repo rts o n large patient series have sho wn percutaneo us puncture o f the excretio n pathway to be a relatively safe pro cedure, with co mplicatio n rates rang-ing fro m 5 to 8 percent. Invo lvement o f o rgans adjacent to kidneys is no t co mmo n, but is repo rted in iso lated cases. Damage to the gastro intestinal (GI) tract is ex-tremely rare, mo st o ften invo lving the co lo n.1,2 Fifteen
cases o f duo denal damage asso ciated to percutaneo us pro cedures have been described so far.1-3
Timing o f diagno sis includes:
1) Early diagno sis by retro perito neal co llectio n with re no duo de nal fistula (using co ntrast-e nhance d
imaging o f the excretio n pathway and GI tract). 2) Diagno sis immediately after the pro cedure
(punc-ture o f enteric fluid and visualizatio n o f enteric muco us membrane fo lds).
Surgery is the classic appro ach fo r trauma-as-so ciated duo denal lesio ns. Co nservative management is re p o rte d in s o m e c as e s us ing p e rc utane o us intraduo denal catheterizatio n with peripheral drain-age, 10 to 14 days’ fasting, and parenteral feeding.1-3
Culkin also po ints o ut the fact that this co nditio n is benign, usually being reso lved via a naso gastric tube, nephro sto ma, and 14 days’ fasting with no parenteral feeding.4
In o ur patient, access via laparo to my o n the lo wer back allo wed us to clear the renal pelvis, to ad-equately place the nephro sto my catheter, to explo re and repair the duo denal lesio n, and to clear the cav-ity, with relative benefit and sho rter ho spital stay. Ac-cess to the perito neal cavity by lo wer back laparo to my enabled us to adequately explo re all po ssibly dam-aged abdo minal o rgans.
When access to the distal po rtio n o f the ureter is o btained, enabling ureteral catheterizatio n o r func-tio nal nephro sto my, and perio perative diagno sis o f duo denal damage, co nservative treatment by placing a duo denal tube fo r peripheral drainage o f the lesio n may be carried o ut with go o d results.
1. Ahmed M, Reeve R. Iatro genic duo deno -cutaneo us fistula at percutaneo us nephro litho to my managed co nservatively. Brit J Uro l 1995;75:416-8. 2. Kumar A, Banerjee GK, Temari A, Srivastava A. Iso lated duo denal injury
during percutaneo us nephro litho to my. Brit J Uro l 1994;74:382-3.
3. White EC, Smith AD. Percutaneo us sto ne extractio n fro m 200 patients. J Uro l 1984;132: 437-8.
4. Culkin DJ, Wheeler JS, Canning JR. Nephro duo denal fistula: a co mplicatio n o f percutaneo us nephro litho to my. J Uro l 1985;134:528-30.
REFERENCES
r e s u m o
CO N TEX TO : Desde a primeira nefro sto mia po r punção realiz ada po r G o o dwin em 1 9 5 4 , o s avanço s técnico s no acesso percutâneo ao rim aumentaram a freqüência destes pro cedimento s e, co mo co nseqüência, maio r número de co mplicaçõ es. Dentre essas, as lesõ es do trato dig estivo são raras.
TIPO DE ESTUDO : Relato de caso .
RELATO DE CASO : Relatamo s lesão duo denal que fo i co rrig ida co m explo ração cirúrg ica e abo rdamo s as o pçõ es terapêuticas que po de m se r c o nse rva do ra o u inte rve nc io nista . O pta ndo -se pe lo tra ta mento c o nserva do r, enc o ntra -se na s pub lic a ç õ es diferentes fo rmas de abo rdag em.
PALAV RAS-CH AV E: N efro sto mia perc utâ nea . Duo deno pa tia s. Fístula duo denal.
Antonio Corrê a Lope s Ne to. Precepto r o f Residents, Discipline o f Uro lo gy, Faculdade de Medicina do ABC, Santo André, SP, Brazil.
Marcos Tobias-Machado. Assistant Pro fesso r, Discipline o f Uro lo gy, Faculdade de Medicina do ABC, Santo André, SP, Brazil.
Robe rto Vaz Juliano. Assistant Pro fesso r, Discipline o f Uro lo gy, Faculdade de Medicina do ABC, Santo André, SP, Brazil.
Marco Auré lio Lipay. Assistant Pro fesso r, Discipline o f Uro lo gy, Faculdade de Medicina do ABC, Santo André, SP, Brazil.
Milton Borre lli. Department Head, Discipline o f Uro lo gy, Faculdade de Medicina do ABC, Santo André, SP, Brazil.
Eric Roge r Wroclawski. Adjunct Pro fesso r, Discipline o f Uro lo gy, Faculdade de Medicina do ABC, Santo André, SP, Brazil.
Source s of funding: No t declared
Conflict of inte re st: No t declared
Last re ce ive d: 31 March 1999
Acce pte d: 27 September 1999
Addre ss for corre sponde nce :
Anto nio Co rrêa Lo pes Neto Rua Peixo to Go mide, 1950 – Apto . 07 São Paulo /SP - Brasil - CEP 01409-002 E-mail: lo pes.neto @ ig.co m.br
p u b lis hin g in fo r m a t io n
