PEDIATRIC UROLOGY

USE OF KIDNEY INTERNAL SPLINT/STENT (KISS) CATHETER IN URINARY DIVERSION

AFTER PYELOPLASTY

ELIZABETH RITCHIE, M.D. DAVID A. HATCH, M.D. E. MICHAEL REISMAN, M.D. JEFFREY WACKSMAN, M.D. MARK R. ZAONTZ, M.D. MAX MAJZELS, M.D.

From the Division of Urology, Children’s Memorial Hospital, and the Department of Urology, Northwestern University School of Medicine, Chicago, Illinois, and

Children’s Hospital Medical Center, Cincinnati, Ohio

ABSTRACT-We report on the use of a new catheter, the kidney internal splint/stent (KISS), to facilitate renal urine drainage following pyeloplasty. The catheter combines the desirable qualities of nephrostomy tube diversion, anastomotic stent, and trocar place- ment in a single tube. The special construction of its lumen diminishes the likelihood of obstructed drainage. Our experience using the KISS catheter with 31 patients undergo- ing pyeloplasty shows it provides effective internal and external urinary diversion.

The method of renal drainage, if any, after pyelo- plasty is controversial. Nephrostomy and/or stent drainage is advocated by some and not others. Under special circumstances, tube drainage is rou- tine. For example, it is frequently employed in secondary operative procedures,’ when a difficult dissection has compromised the wall of the ureter in the solitary kidney,2 in newborns undergoing renal surgery3s4 and after ureterocalicostomy5

However, diversions using conventional tubes are prone to poor drainage, especially in small children, because the small-caliber tubes required for pediatric patients can lead to obstruction of side holes by blood or debris. In an effort to pro- vide more reliable drainage after pyeloplasty, we report on the use of a new catheter, the kidney in- ternal splint/stent (KISS) (Cook Urological, Spencer, IN). The catheter splints the anastomotic suture line internal to the surface of the ureter and also acts as a stent for the anastomosis. Herein, we describe the special construction of the catheter and present our experience with its use.

MATERIAL AND METHODS

The KISS catheter is made of radiopaque poly- ether-based polyurethane. The external surface of

Submitted: February 26, 1993, accepted (with revisions): March 15,1993

the catheter is marked at the midsection (junc- tion of the trough and tubular portions) with a broad stripe. Narrower stripes mark l-cm grada- tions to each end of the catheter. The segment of the tube which is a trough is positioned so as to drain the ureter and pelvis (Fig. 1). A malleable trocar tip, a modification of the Willscher tip catheter (Cook Urological, Spencer, IN), directs

TRCCARTIP !

EXTRA RENAL CONDUT

FIGURE 1. KISS catheter is designed with malleable trocar tip, tubular conduit portion, and trough-like portion for ready drainage of collecting system.

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FIGURE 3. Once tip is removed, hollow tubular por- tion is attached to urinary drainage bag. After one to two days postoperative, the end port is plugged and urine drains internally.

FIGURE 2. After malleable trocar is shaped as a “?“, the sharp tip is mounted on a right angle clamp and is passed through desired calix and renal parenchyma. Also, it can be more simply passed out the renal pelvis using right-angle clamp.

the KISS catheter in retrograde fashion into a lower pole or mid-renal calix (Fig. 2). The trough portion of the tube is positioned within the pelvis and upper ureter. After amputation of the trocar tip, the tubular portion of the catheter may be connected to a conventional urinary drainage bag (Fig. 3).

Between January 1987 and June 1988, at the Children’s Memorial Hospital, Chicago, Illinois, and Children’s Hospital Medical Center, Cincin- nati, Ohio, 31 children, 23 boys and 8 girls, have undergone repair of ureteropelvic junction ob- struction (UPJ) with use of the KISS catheter postoperatively. The children range in age from one month to fourteen years (mean 4.3 years). Ten of these children were less than six months of age and 6 more were six months to one year. Ureteropelvic junction obstruction was found on the left side in 19 children, on the right side in 6 children, and was bilateral in 6 children. This left-side preponderance for UPJ obstruction is recognized. 4,6 The most common presentation was hydronephrosis on antenatal ultrasonogra- Phy.

Most children had UPJ obstruction diagnosed by the findings of diuresis renography or excre- tory urography. The surgical approaches in- cluded: dorsal lumbotomy (7), flank incision (muscle splitting or muscle cutting) (23), or transperitoneal (1) in order to repair an ob- structed horseshoe kidney The repairs included dismembered pyeloplasty (28) or ureterocalicos- tomy (3). Ureterocalicostomy was performed for secondary repairs of UPJ obstruction or horse- shoe kidney In 15 cases, reduction pyeloplasty also was performed.

The KISS catheter was inserted prior to com- pleting the ureteropelvic anastomosis. The trocar is shaped as a “?” to facilitate creation of the nephrostomy. The KISS catheter is anchored at the renal capsule with 4-O chromic suture. The KISS catheter is brought out through the skin be- neath the incision. The sharp tip of the trocar of the catheter may aid this. The tubular section of the KISS catheter is attached to a leg bag and af- fords external drainage for about one to two days post pyeloplasty. At this time, the external port of the tube is capped. Since the KISS catheter pro- vides external renal drainage, a bladder catheter is not used postoperatively, rather the bladder is drained only by Crede maneuver after general anesthesia is induced. If aggressive reduction of the pelvis was performed, external drainage for a

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longer period may be opted. Flank drainage was minimal and serosanguineous.

Generally, the Penrose drain was removed one to three days postoperatively. In 1 case involving reduction of the pelvis the KISS catheter was left to external drainage for one week, and so the Penrose drain was removed after the KISS catheter was removed. Antibiotic prophylaxis was maintained until removal of the KISS catheter. The average postoperative stay was four days for patients living close to the institution. Children living several hours away, were hospitalized longer (average 6 days). In general, the KISS catheter is removed at a routine office visit about one week postoperatively.

RESULTS The children have been followed up to nine

months postoperatively and have had follow-up radiographic studies including excretory uro- gram, diuretic renogram, and/or ultrasonography. The postoperative studies of the children showed improved renal drainage by scintigraphy, im- proved visualization by urography, or improved hydronephrosis by sonography. One child with vesicoureteral reflux continues to have poor drainage, although renal function has improved; one child with a horseshoe kidney has stable function and drainage; and one child who pre- sented with hypertension is normotensive follow- ing pyeloplasty.

Two children have experienced complications related to the use of the KISS catheter. One child who previously had undergone two repairs as well as nephrostomy tube placement experienced bleeding on passage of the trocar. This bleeding was not severe enough to require transfusion, and stopped after five minutes of digital compression. After his stent was removed, clear urine drained from the site of the KISS catheter for about twenty-four hours. A second boy required contin- ued drainage through the KISS catheter due to unrecognized ureterovesical junction obstruction. His ureterocalicostomy has remained patent, and he has since undergone successful ureteroneocys- tostomy.

There were no incidences of obstruction of the KISS lumen. Wound infections were not encoun- tered. No child required transfusion.

COMMENT The use of a stent or nephrostomy tube after

pyeloplasty has been controversial. Hendren, Radhakrishnan, and Middleton preferred a nephrostomy tube in almost all cases, but did not

routinely use a stent. Johnson et ai.,7 Smart,8 and Snyder et aL3 advocated the use of both. Others preferred to use no stent or nephrostomy tube.9

Nephrostomy tube drainage diverts the urine, protecting the kidney from damage due to early obstruction and discouraging drainage through the anastomosis into the flank. It provides exter- nal access to visualize the reconstructed area radi- ographically, if desired.

A ureteral stent prevents synechiae across the walls of the repair. It can maintain proper align- ment of the anastomosis and normal ureteral cal- iber. It carries urine past the anastomotic site without leakage.

Smart8 stated that the use of pelvic urinary di- version and proper ureteral stenting decreased postoperative complications, and recommended that it be used routinely for secondary procedures. He also suggested their use in a primary repair might avoid creating the need for reoperation.

Historically, nephrostomy tubes had been avoided because bleeding and introduction of in- fection may complicate tube replacement. Also, the absence of a nephrostomy tube simplified postoperative care and reduced hospital stay.9 Furthermore, presence of the tube promoted tis- sue reaction which may compromise healing. Ureteral stents can cause iatrogenic ureteral in- jury during placement, and blood or tissue can block the lumen6 of the stent which would pro- mote urinary extravasation through the anasto- motic site.

A common procedure used by those who em- ploy both nephrostomy tube and ureteral stent is to place a retention catheter into a dependent calix, then using a clamp, the catheter is pulled through the renal parenchyma. The ureteral stent is brought out through the same or a different calix.8

These goals can be met by using only a KISS catheter as a modern alternative. The catheter is pliable, inert, acts as a ureteral stent and nephros- tomy by virtue of its trough construction and tubular portion, respectively. The sharp trocar al- lows the tube to be directed into a dependent calix with no parenchymal loss. Since 1991 the KISS catheter has routinely been brought out the renal pelvis, thereby entirely avoiding possible renal damage. It is available in several sizes (4F to 10F). This allows proper diameter selection for each ureter. In our experience, infection and tube blockage did not occur. Use of the KISS catheter did not prolong hospitalization. The KISS catheter has since become the routine nephros- tomy stent used by us. It has continued to provide

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reliable external and internal urinary drainage which has been trouble free.

From our experience, we believe that the trough lumen of the KISS catheter provides more effective, reliable internal and external drainage over conventional tubes which provide drainage via side holes.

Max Maizels, M.D. Childrenic Hospital

Chicago, Illinois

REFERENCES 1. Kelalis PP: Ureteropelvic junction, in Kelalis PP, King

LR, and Belman AB (Eds): Clinical Pediatric Urology, Philadelphia, WB Saunders Co, vol 1, chap 16, 1985, pp 450-486.

2. Schaeffer AJ, and Grayhack JT: Surgical management of ureteropelvic junction obstruction, in Walsh PC, Gittes RF, Perlmutter DA, and Stamey TA (Eds): Campbell’s Urology, Philadelphia, WB Saunders Co, ed 5, vol 3, chap 65, 1986, pp 2505-2533.

3. Snyder HM III, Lebowitz RL, Colodny AH, Bauer SB, and Retik AB: Ureteropelvic junction obstruction in chil- dren. Urol Clin North Am 7: 273-290, 1980.

4. Pfister RR: The difficult pyeloplasty. AUA Update Se- ries, Baltimore, Maryland, Vol 11, lesson 15, 1983.

5. Kay R: Ureterocalicostomy. Urol Clin North Am 15: 129-133,1988.

6. Hendren WI-I, Radhakrishnan J, and Middleton AW Jr: Pediatric pyeloplasty, J Pediatr Surg 15: 133-144, 1980.

7. Johnston JH, Evans JP, Glassberg KI, and Shapiro SR: Pelvic hydronephrosis in children: a review of 219 personal cases, J Urol 117: 97-101, 1977.

8. Smart WR: Surgical correction of hydronephrosis, in Harrison JH, Gittes RF, Perlmutter AD, Stamey TA, and Walsh PC (Eds): CampbellS Urology, ed 4, Philadelphia, WB Saunders Co, ~013, chap 66,1979, pp 2047.

9. Persky L, and Tynberg P: Unsplinted, unstented pyelo- plasty. Urology 1: 32-35, 1973.

EDITORIAL COMMENTS I have no personal experience with the KISS catheter. How-

ever, the authors have convinced me that it is an excellent addition to the urologic armamentarium, and I shall try it.

Although reported as preferring a nephrostomy tube in most cases6 today 1 use nephrostomy drainage selectively, not routinely The design of this catheter is so appealing that per- haps the indications for drainage should be extended. Cer- tainly drainage is a safety measure to avoid the occasional leak of a suture line which can be devastating by causing periureteral fibrosis even when a wide anastomosis has been achieved. Also a stent, which we almost never use, cannot do harm, provided it is very loose fitting. Thus, the KISS catheter should satisfy most surgeons: those who use nephrostomy tube and stent, those who use stent but no nephrostomy tube, and those who use nephrostomy tube alone. The option of using no tube remains, if the surgeon so chooses.

W Hardy Hendren, M.D. ChildtenS Hospital

Boston, Massachusetts

This is an interesting paper from several standpoints. The primary purpose is to promote the new nephrostomy which the authors have described. It does seem to be a very useful combination of nephrostomy tube and stent. Its design also enables a reasonably atraumatic placement of the tube. However, most of us in pediatric urology would not pass a Kelly clamp through the parenchyma of a pediatric kidney in any case. By using a silk suture passed with a probe, a standard nephrostomy tube may be passed quite atraumati- tally. Nonetheless, the authors have contributed a nice an- cillary piece of equipment to our armamentarium for deal- ing with difficult pyeloplasties. Indeed, in our practice these are the only ones in which we still entertain the use of a nephrostomy tube. Well over 90 percent of our pyeloplasties are done without either a nephrostomy tube or a stent. We would agree with the authors that the indications for the use of a nephrostomy tube with or without a stent are a re- do pyeloplasty or a ureterocalicostomy. Certainly, in any case which presents technical difficulties, the nephrostomy tube permits the minimization of urinary extravasation which probably, in the long run, will contribute to a better outcome.

To my mind, the most contentious points in the article were the indications for surgery. Eleven of 31 cases pre- sented by means of antenatally detected hydronephrosis. This is a group of patients where the indications for surgery are controversial. We base our indications for surgery pri- marily on functional considerations. The inaccuracy of the Lasix phase of the renogram in the immediate postnatal pe- riod has led us to abandon this as a useful parameter. It is somewhat surprising, therefore, to find the authors defining obstruction by this test. Additionally, we, as well as others, have found inaccuracies in defining obstruction by the pres- sure/perfusion Whitaker test. While we will occasionally do an antegrade contrast study, we have abandoned the pres- sure perfusion study Thus, I was surprised to find that the authors felt that equivocal renography could be sorted out in this fashion.

It is interesting to note that the authors’ one complication involved an unrecognized ureterovesical obstruction which led to a reimplant. One would wonder if the passage of a catheter distally in the ureter might have raised a mucosal flap that resulted in the subsequent obstruction. Years ago we saw that occur in our practice and subsequently have abandoned any form of “tube passage” distally. If the ureter below the UPJ obstruction is not dilated, we have never been surprised by a missed UVJ obstruction.

The authors are to be congratulated on their innovative contribution of a new tube for drainage in complicated pyeloplasties. This contribution should be useful to many. Unfortunately, I cannot agree with their indications for surgery However, this is a controversial area and much yet remains to be defined.

Howard M. Snyder III, M.D. ChiIdrenS Hospital OfPhiladelphia

Philadelphia, Pennsylvania

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