Cystoscope assisted trans-conduit removal of fragmented percutaneous nephrostomy catheter

Abstract

Percutaneous nephrostomy catheter fragmentation is an uncommon complication that is managed through different approaches. In this report we describe an iatrogenicly fragmented nephrostomy catheter in a patient with an ileal conduit, that was removed by using combined cystoscope and fluoroscopy guidance through a retrograde trans conduit approach.

1. Introduction

Percutaneous Nephrostomy (PCN) stands out for its acknowledged effectiveness as a minimally invasive image-guided procedure performed for various indications, including obstructive uropathy, urinary diversion and providing access for percutaneous interventions, such as stone removal. PCN is generally a safe procedure with a major complication rate less than 5 %.¹ Notably, PCN fragmentation is seldom reported in literature. Herein, we present our firsthand experience in extracting an iatrogenically fragmented PCN.

2. Case presentation

A gentleman in his 70's, diagnosed with stage T2a prostate cancer, underwent bilateral nephrostomy catheters placement for obstructive uropathy. The patient received chemotherapy, and six months later he underwent total pelvic exenteration, uretero-ileal anastomosis and ileal conduit creation. The nephrostomy catheters were removed during surgery. Follow up CT scan after 1 week revealed a retained fragment of the PCN catheter in the left kidney. Interventional radiology was consulted, and following a multidisciplinary discussion, the decision was made to proceed with cystoscope-assisted foreign body retrieval in collaboration with urology.

3. Procedure

The patient's ileal conduit was prepped and draped in the standard sterile fashion. A flexible cystoscope, operated by a urologist with at least 7 years of experience, was advanced through the ileal conduit. The left ureteral anastomosis was identified and a 5 French open-ended ureteral catheter was advanced over a guidewire. After the guidewire was removed, a retrograde pyelogram revealed the fragmented catheter in the left renal pelvis.

A 0.035-inch stiff Amplatz wire was advanced to the left renal pelvis, over which, a 12 French sheath was placed up to the proximal ureter. Using coaxial technique, a 35 mm snare was pushed through the 12 French sheath into the left renal pelvis. The tip of the retained nephrostomy was successfully snared and retrieved through the sheath, to minimize trauma to the newly created ureteral anastomosis. Follow up retrograde pyelogram showed no contrast extravasation from the left renal collecting system, left ureteral anastomosis or the ileal conduit. The procedure was completed uneventfully (Fig. 1, Fig. 2).

Fig. 1.

(A) Still fluoroscopy image showing a fragmented and retained pigtail nephrostomy tube in the left kidney. Through the ileal conduit a 5 French open-ended ureteral catheter was advanced into the renal pelvis. (B) Over a guidewire a 12 French sheath was placed in the proximal ureter. A loop snare is used to grab the retained nephrostomy tube. (C) After removal of the nephrostomy fragment, a retrograde pyelogram showed no contrast extravasation from the left renal pelvis, left ureteral anastomosis or ileal conduit.

Fig. 2.

(A) Picture of the snare grabbing the tip of the PCN fragment. (B) Picture of the retrieved pigtail nephrostomy tube fragment.

4. Discussion

PCN fragmentation is not a common complication; however, management of these cases may represent a dilemma. We are sharing our experience in managing patients with a retained PCN fragment in the renal pelvis.

While PCN fragmentation in our case was iatrogenic, it's important to note that fragmentation of PCN or ureteral stents can occur spontaneously.^2,3 This can be attributed to various factors, including the insertion technique, such as bending or excessive torsion of the tissue planes,² the duration of indwelling catheter, metabolic abnormalities, infection, and the biomaterial composition of the catheter.¹

The technique of retrieval varies from case to case. Kuma et al.⁴ has shared their experience in 7 patients using different techniques and instruments in each case; 26 Fr nephoscope, 15 Fr cystoscope, 7.5 Fr semi-rigid ureteroscope. In our case, we used a flexible cystoscope through the ileal conduit to identify the left ureteral anastomosis, through which a 5 French open-ended ureteral catheter was advanced into the renal pelvis and the fragment was successfully snared. This case illustrates that a multidisciplinary approach in management of complicated cases is in the patient's best interest. The collaboration of the interventional radiology and urology teams resulted in the best outcome with the least invasive approach.

Generally Percutaneous trans-renal catheter retrieval is the employed technique for retrieval of foreign bodies within the collecting system including ureteral stents and fractured nephrostomy catheters5, 6, 7 when a retrograde approach is deemed non feasible. Our method of using the trans-conduit approach might be an alternative useful technique to access the renal pelvis using a less invasive route, and subsequently removing PCN or stent fragments, making it a potentially valuable tool in selected cases.

Learning points

• •Percutaneous nephrostomy catheter fragmentation is a rare but important complication that requires careful management.
• •Trans-conduit approach offers a safe and effective method for retrieving fragmented catheters in selected patients, minimizing the need for more invasive procedures.
• •Multidisciplinary collaboration between interventional radiology and urology plays a crucial role in ensuring successful retrieval while reducing patient morbidity.

CRediT authorship contribution statement

Ahmed Awad: Writing – review & editing, Writing – original draft, Visualization, Validation, Resources, Formal analysis, Data curation, Conceptualization. Judy Ahrar: Writing – review & editing, Visualization, Supervision. Mohamed E. Abdelsalam: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Formal analysis, Data curation, Conceptualization.

Informed consent

Informed consent for patient information to be published in this article was not obtained because the patient passed away and the next of kin is not reachable for consent. The patient's information is fully anonymized.

Ethics approval

Our institution does not require ethical approval for reporting individual cases or case series.