Long-term nephrostomy in an adult male spinal cord injury patient who had normal upper urinary tracts but developed bilateral hydronephrosis following penile sheath drainage: pyeloplasty and balloon dilatation of ureteropelvic junction proved futile: a case report

Abstract

Introduction: The consequences of spinal cord injury upon urinary bladder are readily recognised by patients and health care professionals, since neuropathic bladder manifests itself as urinary incontinence, or retention of urine. But health care professionals and persons with spinal cord injury may not be conversant with neuropathic dysmotility affecting the ureter and renal pelvis. We report an adult male patient with spinal cord injury, who developed bilateral hydronephrosis after he started managing neuropathic bladder by penile sheath drainage.

Case presentation: A male patient, born in 1971, sustained spinal cord injury following a motorbike accident in September 1988. In November 1988, intravenous urography showed normal upper tracts. He was advised spontaneous voiding with 2-3 catheterisations a day. In February 1995, this patient developed fever, chills and vomiting. Blood urea: 23.7 mmol/L; creatinine: 334 umol/L. Ultrasound revealed marked hydronephrosis of right kidney and mild hydronephrosis of left kidney. Bilateral nephrostomy was performed in March 1995. Right pyeloplasty was performed in May 1998. In July 2005, this patient developed urine infection and was admitted to a local hospital with fever and rigors. He developed septicaemia and required ventilation. Ultrasound examination of abdomen revealed bilateral hydronephrosis and multiple stones in left kidney. Percutaneous nephrostomy was performed on both sides. Subsequently, extracorporeal shock wave lithotripsy of left renal calculi was carried out. Right nephrostomy tube slipped out in January 2006; percutaneous nephrostomy was performed again. In June 2006, left ureteric antegrade stenting was performed and nephrostomy tube was removed. Currently, right kidney is drained by percutaneous nephrostomy and left kidney is drained by ureteric stent. This patient has indwelling urethral catheter.

Conclusion: It is possible that regular intermittent catheterisations along with anticholinergic medication right from the time of rehabilitation after this patient sustained paraplegia might have prevented the series of urological complications. Key components to successful management of external drainage of kidney in this patient are: [1] use of size 14 French pigtail catheter for long-term nephrostomy, [2] anchoring the catheter to skin to with Percufix catheter cuff to prevent accidental tug [3], replacing the nephrostomy dressing once a week by the same team in order to provide continuity of care, and [4] changing nephrostomy catheter every six months by a senior radiologist.

Figure 1

X-ray of kidneys (13 July 2005) showed nephrostomy catheters in both kidneys. Calculi were present in left renal pelvis and inferior calyx.

Figure 2

X-ray of abdomen (31 July 2006) showed stents in both ureters. Nephrostomy catheter was seen in right kidney. Left nephrostomy had been removed.

Figure 3

Intravenous urography (14 May 2007) - 90 minutes film showed bilateral hydronephrosis.

Figure 4

Intravenous urography (18 February 2008) - 30 minutes film showed dilated left renal pelvis and clubbing of calyces. Left ureteric stent and right nephrostomy catheter were present. Right nephrostomy catheter had not been clamped; therefore, urographic contrast drained straightaway from right kidney.

Figure 5

Intravenous urography (06 March 2009) - 90 minutes film showed marked hydronephrosis on left side. Left ureteric stent and right nephrostomy catheter were present. Right nephrostomy catheter had not been clamped; therefore, urographic contrast drained straightaway from right kidney.

Figure 6

Cytology of urine from nephrostomy, shows three benign squamous cells (large cells with abundant, pink-orange cytoplasm), with numerous inflammatory cells and inflammatory debris in the background.