Double-J ureteric stenting in pregnancy: A single-centre experience from Iraq
Double-J ureteric stenting in pregnancy: A single-centre experience from Iraq
Ngai, Ho-Yin; Salih, Hawre Qadir; Albeer, Ayad; Aghaways, Ismaeel; Buchholz, Noor
2013-06-01 00:00:00
Arab Journal of Urology (2013) 11, 148–151 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com STONES/ENDOUROLOGY ORIGINAL ARTICLE Double-J ureteric stenting in pregnancy: A single-centre experience from Iraq a b c d Ho-Yin Ngai , Hawre Qadir Salih , Ayad Albeer , Ismaeel Aghaways , e, Noor Buchholz Department of Urology, Queen Elizabeth Hospital, Hong Kong, China Consultant Urologist, Shorsh Hospital, Sulaimani, Iraq Department of Urology, Medical City Hospital, Baghdad, Iraq Department of Surgery, University of Sulaimani, Sulaimani, Iraq Department of Urology, Bartshealth NHS Trust, The Royal London Hospital, London, UK Received 26 January 2013, Received in revised form 12 February 2013, Accepted 15 February 2013 Available online 25 March 2013 KEYWORDS Abstract Objectives: To evaluate the safety and effectiveness of ureteric stenting with a JJ stent in pregnant women, to relieve renal obstruction and intractable flank Hydronephrosis; pain. Pregnancy; Patients and methods: All pregnant patients presenting with intractable flank Stent pain, with or without complications, to a tertiary national teaching hospital in Kurd- istan/Iraq, and necessitating ureteric stenting with a JJ stent, were prospectively ABBREVIATION assessed for this study between March 2008 and March 2010. US, ultrasonography Results: In all, 30 pregnant patients presented with intractable flank pain necessi- tating JJ ureteric stenting during the 25 months. Intractable flank pain (23 patients, 77%) was the most common indication for ureteric stenting, followed by flank pain with clinical sepsis (six, 20%). All pregnant women had hydronephrosis on ultraso- nography (US), and 12 (40%) had evidence of coexisting renal stones on US. All ureteric stents were inserted successfully. The mean (range) indwelling time was 47.4 (3–224) days. Radiologically, 14 (47%) and 15 (50%) had complete resolution of the hydronephrosis on follow-up US in late pregnancy and in the early postnatal Corresponding author. Tel.: +44 2035942662. E-mail address: noor.buchholz@bartshealth.nhs.uk (N. Buchholz). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2013 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. http://dx.doi.org/10.1016/j.aju.2013.02.002 JJ in pregnancy 149 period, respectively. Two-thirds of patients had a clinical improvement immediately (15, 50%) and soon after (five, 17%) surgery. Stent encrustation (three, 10%), stent migration (three, 10%) and stent irritation (five, 17%) were reported as complica- tions. The post-natal evaluation confirmed that half the patients had urinary calcu- lus disease. Conclusion: Ureteric stenting during pregnancy can be safe, with no intraopera- tive imaging and even under local anaesthesia. It provides good symptom relief and has a low complication rate. We therefore advocate it as a first-line treatment in pregnant women with therapy-resistant flank pain. ª 2013 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. Introduction The ureter was stented either under local, spinal or general anaesthesia, using pregnancy-approved antibi- Pregnant women can have some degree of hydronephro- otic prophylaxis. The procedure was conducted using a sis, as a result of the physiological changes in pregnancy. 22-F rigid cystoscope. A 4.7-F 26-cm JJ ureteric stent It is not uncommon to have pregnant women with (Flexater ureteric stent, Gallini Medical Devices, Italy) intractable flank pain resulting from renal obstruction was inserted retrogradely over a guidewire. The posi- and who thus require hospital admission, and the condi- tioning of the ureteric stent was assumed to be correct tion is more complicated if associated with stone disease. after a smooth insertion, observation of stent markings The incidence of symptomatic urinary calculi in preg- and the adequate distal coiling of the stent inside the nancy is 1/244 to 1/3300 [1–4], and it is estimated that bladder. Immediate US was used for proximal coil posi- the incidence of urinary calculus disease in pregnant wo- tioning. No fluoroscopy was used during the procedure. men is similar to that in nonpregnant women of the The patient’s clinical signs and symptoms were clo- same age [5]. sely monitored after the procedure. Patients were dis- Managing flank pain during pregnancy can be chal- charged when the flank pain subsided, or when the lenging. Standard radiographic investigations and surgi- sepsis and the acute renal failure were resolved. Antibi- cal treatments, as used in nonpregnant women, cannot otic prophylaxis was maintained in all stented patients be applied easily due to concerns about ionising radia- to minimise bacteriuria and stent colonisation through- tion and the potential harm to the fetus. out the remaining course of pregnancy. A follow-up Thus we present data from a single institution in Iraq, with renal function tests and US was arranged weekly assessing the safety and effectiveness of ureteric stenting in the first month, then monthly throughout pregnancy. with a JJ stent in pregnant women to relieve renal After delivery, patients had a plain abdominal film, obstruction and intractable flank pain. US and/or IVU to assess the continued presence of renal obstruction and/or stone disease, and consequently the Patients and methods need for further treatment. Data were prospectively collected from the Department Results of Urology of a tertiary national teaching hospital in Iraq, from March 2008 to March 2010. All pregnant pa- In all, 30 patients were enrolled into the study during the tients presenting with intractable flank pain, with or 25-month period. Their baseline values are shown in Ta- without complications in the form of kidney infection ble 1. Intractable flank pain (23 patients, 77%) was the and deterioration of renal function, and necessitating most common indication for ureteric stenting, followed JJ ureteric stenting, were enrolled in the study. Intracta- by flank pain with clinical sepsis (six, 20%). Only one ble flank pain was defined as flank pain that could not case (3.3%) presented with anuria and acute renal fail- be relieved by conservative management comprising ure due to bilateral ureteric obstruction. bed rest, hydration and the use of paracetamol. All pregnant women had hydronephrosis on US, and Patients were assessed with a complete medical 12 (40%) had evidence of coexisting renal stones on US. history and comprehensive physical examination. A All ureteric stents were inserted successfully. Local mid-stream urine sample was collected for microscopy, anaesthesia (27, 90%) was the predominant form of culture and sensitivity testing. Blood tests included a anaesthesia. No percutaneous nephrostomy was needed. complete blood count and a renal function assessment. The mean (range) indwelling time was 47.4 (3–224) Trans-abdominal ultrasonography (US) provided evi- days. Radiologically, 14 (47%) and 15 (50%) of the wo- dence of hydronephrosis and, where possible, urinary men had complete resolution of the hydronephrosis on calculus disease. follow-up US in late pregnancy and the early postnatal 150 Ngai et al. one level, leading to ureteric dilatation [7]. Urinary sta- Table 1 The baseline demographic data of the 30 patients. sis, as a result, might have a role in urinary calculus Variable Mean (range) or n (%) formation and renal colic in these women. Age (years) 27.2 (18–38) Although pain from renal colic is the most common non-obstetric reason for hospital admission during preg- Trimester on presentation First 5(17) nancy [8], the timely diagnosis and subsequent manage- Second 15(50) ment in pregnant women can be challenging. It was Third 10(53) reported that 28% of pregnant women having obstruct- Parity ing stones were initially misdiagnosed as having other Primiparous 11(37) pathologies, such as appendicitis and placental abruption Multiparous 19(63) [2]. While flank pain (23, 77%) was the most common Positive history of urinary calculus 11(37) presenting symptom in this series, flank pain with sepsis Preoperative US findings (six, 20%) also features as an important presentation [2]. Presence of hydronephrosis 30(100) However, the clinical presentation might not always Left 11(37) be reliable in predicting stone disease in pregnant wo- Right 14(47) Bilateral 5(17) men with flank pain [9]. The role of radiographic inves- Presence of stones in kidneys 12(40) tigations in various trimesters of pregnancy has been the Left 6(20) subject of a long-standing and ongoing debate, in view Right 3(10) of the potential exposure to ionising radiation of the Bilateral 3(10) developing fetus. The potential sequelae of foetal radia- Indications for ureteric stenting tion exposure are teratogenesis, mutagenesis and carci- Intractable flank pain 23(77) nogenesis [7]. Limited IVU has been used in the past Flank pain with clinical sepsis 6(20) during later pregnancy, presuming the teratogenic effect Acute renal failure 1(3) was related to the high radiation sensitivity of the em- Presumed aetiologies bryo in the first trimester. However, mutagenic and car- Urinary calculus 12(40) Physiological 18(60) cinogenic effects in second and third trimesters cannot be neglected. As there is no well-defined safe radiation dose, it is deemed safer not to use radiographic investi- period, respectively. Two-thirds of patients had a clinical gations in pregnant women [7]. improvement in pain relief immediately (15, 50%) and Consequently, US becomes the first-line investigation soon after (five, 17%) surgery. Three patients (10%) re- to evaluate flank pain in pregnant women. While the ported no difference with ureteric stenting, and seven advantages of US are its non-invasiveness, lack of ionis- (23%) had a worsening of symptoms, with either an in- ing radiation and ready availability, it has a limited sen- creased analgesic requirement or the development of sitivity [9], and is further limited for accurately detecting new symptoms related to stent placement, i.e. frequency, stones, visualising the ureter, and differentiating be- urgency and haematuria. Three patients (10%) had a tween different causes of renal obstruction [7]. Neverthe- stent migration and required subsequent revision of the less, the accuracy of US in detecting stones can be ureteric stent. Stent encrustation was found in three improved significantly (up to 71.9%) by closely observ- (10%) patients on stent removal, and stent irritation ing the features of upper tract obstruction and interpret- (five, 17%) causing haematuria and LUTS were likewise ing them correctly, such as a hydroureter extending reported as complications (Table 2). below the pelvic brim, the asymmetric absence of ure- The postnatal evaluation confirmed that half the pa- teric jets, or an elevated resistive index [9]. tients had urinary calculus disease (Table 2). ESWL (in As renal colic in pregnant patients can be compli- eight of the 15) was used as the main treatment, while cated by severe upper-tract infection and premature la- percutaneous nephrolithotripsy (two), ureteroscopy bour [10], unrecognised pyonephrosis is potentially (one) and open ureterolithotomy (one) were also used life-threatening for both the mother and fetus. Given as definitive treatments. that most patients will recover with analgesia, antibiot- ics and hydration, the initial treatment should be conser- Discussion vative. However, some authors advocate early Physiological hydronephrosis and hydroureter begin in intervention after the analgesia has been shown to be the first trimester of pregnancy. By the third trimester, ineffective [11]. Drainage of the obstructed and infected system is indicated in patients who have symptoms up to 90% of pregnant women can have upper urinary refractory to conservative measures, i.e. ongoing sepsis tract dilatation [6]. It is known that these physiological despite antibiotics (>48 h) and the worsening of any changes are the result of mechanical obstruction of the of renal function, pain, obstruction or hydronephrosis ureters by an enlarged uterus at the pelvic brim, as well [12]. as the muscle-relaxing effect of an increased progester- JJ in pregnancy 151 most cases can be inserted under local anaesthesia. It Table 2 The complications of ureteric stenting with a JJ stent, provides good symptom relief and has a low complica- and the results of postnatal investigations. tion rate. We therefore advocate it as the first-line treat- Variable n (%) ment in pregnant women with therapy-resistant flank Complication pain. Stent migration 3 (10) Stent encrustation 3 (10) Bothersome LUTS 3 (10) Conflict of interest Gross haematuria 2 (7) None. Post-natal investigations No stone 12 (40) Renal stones 6 (20) Funding Ureteric stones 5 (17) Both ureteric stone and renal stones 4 (13) None. Not known 3 (10) References It was reported that JJ ureteric stenting can be diffi- cult in the third trimester due to the tortuosity of the [1] Butler EL, Cox SM, Eberts EG, Cunningham FG. Symptomatic nephrolithiasis complicating pregnancy. Obstet Gynecol ureter [13]. However, others did not confirm this [9– 2000;96:753–6. 12,14–16]. All patients in our series had successful [2] Stothers L, Lee LM. Renal colic in pregnancy. J Urol stenting. 1992;148:1383–7. The overall complication rate of JJ ureteric stenting, [3] Swartz MA, Lydon-Rochelle MT, Simon D, Wright JL, Porter MP. Admission for nephrolithiasis in pregnancy and risk of i.e. stent migration, stent encrustation, stent irritation adverse birth outcomes. Obstet Gynecol 2007;109:1099–104. and haematuria, was similar to that in other series of [4] Lewis DF, Robichaux AG, Jaekle RK, Marcum NG, Stedman pregnant women [14]. This might show that placing JJ CM. Urolithiasis in pregnancy – diagnosis, management and ureteric stents is a highly successful, safe and effective pregnancy outcome. J Reprod Med 2003;48:28–32. treatment option and should be considered for pregnant [5] Coe FL, Parks JH, Lindheimer MD. Nephrolithiasis during women with intractable flank pain. pregnancy. N Engl J Med 1978;298:324–6. [6] Boridy IC, Maklad N, Sandler CM. Suspected Urolithiasis in Although percutaneous nephrostomy and JJ ureteric pregnant women. Imaging algorithm and literature review. AJR stenting are equally effective in relieving upper tract Am J Roentgenol 1996;167:869–75. obstruction, JJ ureteric stenting is commonly regarded [7] Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. as the less invasive of the two, and has the additional Campbell-Walsh urology. Tenth ed. Saunders; 2011. advantage that pregnant women, mostly in the second [8] Rodriguez PN, Klein AS. Management of urolithiasis during pregnancy. Surg Gynecol Obstet 1988;166:103–6. and third trimesters, can undergo the procedure safely [9] Andreoiu M, MacMahon R. Renal colic in pregnancy: lithiasis or and comfortably in the supine lithotomy position. physiological hydronephrosis? Urology 2009;74:757–61. Further, especially if drainage is needed for many of [10] Paraukar BG, Hopkins TB, Wollin MR, Howard Jr PJ, Lal A. the remaining weeks of the pregnancy, a nephrostomy is Renal Colic during pregnancy: a case for conservative treatment. very uncomfortable for the patient and risks infection J Urol 1998;159:365–8. [11] Song G, Hao H, Wu X, Li X, Xiao YX, Wang G, et al. and displacement over time. Treatment of renal colic with double-J stent during pregnancy: a While ureteric stenting acts as an emergency interven- report of 25 cases. Zhonghua Yi Xue Za Zhi 2011;91:538–40. tion for intractable renal obstruction, some centres [12] Cheriachan D, Arianayagam M, Rashid P. Symptomatic urinary advocate the use of ureteroscopy under general anaes- stone disease in pregnancy. Aust NZ J Obstet Gynaecol 2008;48:34–9. thesia in pregnant women with obstructive ureteric cal- [13] Drago JR, Rohner Jr TJ, Chez RA. Management of urinary culi. High success rates can be achieved by calculi in pregnancy. Urology 1982;20:578–81. ureteroscopy, with no reported complications, making [14] Delakas D, Karyotis I, Loumbakis P, Daskalopoulos G, Kazanis ureteroscopy invaluable in both diagnosis and treatment A, Cranidis A. Ureteric drainage by double-J-catheters during [17,18]. However, if an infection proximal to the pregnancy. Clin Exp Obstet Gynecol 2000;27:200–2. obstruction cannot be excluded, ureteroscopy would [15] Velonda N, Giumelli P, Galdini R, Bennici S. Ureteral drainage with double-J catheters in obstructive uropathy during pregnancy. actually be contraindicated due to the irrigation pres- A report of 3 cases. Gynecol Obstet Invest 1995;40:274–5. sures needed and the mechanical manipulation, both [16] John H, Vondruska K, Sulser T, Lauper U, Huch A, Hauri D. of which can trigger urosepsis. Also, the infrastructure Ureteral stent placement in hydronephrosis during pregnancy. and expertise must be available, which might not always Urologe A 1999;38:486–9. be the case. In pregnant women it is preferable to err on [17] Polat F, Yesil S, Kirac¸ M, Biri H. Treatment outcomes of semirigid ureterorenoscopy and intracorporeal lithotripsy in the side of caution, and fast and smooth minimally inva- pregnant women with obstructive ureteric calculi. Urol Res sive JJ ureteric stent drainage remains our preferred and 2011;39:487–90. recommended first-line strategy. [18] Semins MJ, Trock BJ, Matlaga BR. The safety of ureteroscopy In conclusion, ureteric stenting during pregnancy can during pregnancy: a systematic review and meta-analysis. J Urol be safe, requiring no intraoperative imaging, and in 2009;181:139–43.
http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.pngArab Journal of UrologyTaylor & Francishttp://www.deepdyve.com/lp/taylor-francis/double-j-ureteric-stenting-in-pregnancy-a-single-centre-experience-aE6JzY7A6L
Double-J ureteric stenting in pregnancy: A single-centre experience from Iraq
Double-J ureteric stenting in pregnancy: A single-centre experience from Iraq
Abstract
AbstractObjectives:To evaluate the safety and effectiveness of ureteric stenting with a JJ stent in pregnant women, to relieve renal obstruction and intractable flank pain.Patients and methods:All pregnant patients presenting with intractable flank pain, with or without complications, to a tertiary national teaching hospital in Kurdistan/Iraq, and necessitating ureteric stenting with a JJ stent, were prospectively assessed for this study between March 2008 and March 2010.Results:In all, 30...
Arab Journal of Urology (2013) 11, 148–151 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com STONES/ENDOUROLOGY ORIGINAL ARTICLE Double-J ureteric stenting in pregnancy: A single-centre experience from Iraq a b c d Ho-Yin Ngai , Hawre Qadir Salih , Ayad Albeer , Ismaeel Aghaways , e, Noor Buchholz Department of Urology, Queen Elizabeth Hospital, Hong Kong, China Consultant Urologist, Shorsh Hospital, Sulaimani, Iraq Department of Urology, Medical City Hospital, Baghdad, Iraq Department of Surgery, University of Sulaimani, Sulaimani, Iraq Department of Urology, Bartshealth NHS Trust, The Royal London Hospital, London, UK Received 26 January 2013, Received in revised form 12 February 2013, Accepted 15 February 2013 Available online 25 March 2013 KEYWORDS Abstract Objectives: To evaluate the safety and effectiveness of ureteric stenting with a JJ stent in pregnant women, to relieve renal obstruction and intractable flank Hydronephrosis; pain. Pregnancy; Patients and methods: All pregnant patients presenting with intractable flank Stent pain, with or without complications, to a tertiary national teaching hospital in Kurd- istan/Iraq, and necessitating ureteric stenting with a JJ stent, were prospectively ABBREVIATION assessed for this study between March 2008 and March 2010. US, ultrasonography Results: In all, 30 pregnant patients presented with intractable flank pain necessi- tating JJ ureteric stenting during the 25 months. Intractable flank pain (23 patients, 77%) was the most common indication for ureteric stenting, followed by flank pain with clinical sepsis (six, 20%). All pregnant women had hydronephrosis on ultraso- nography (US), and 12 (40%) had evidence of coexisting renal stones on US. All ureteric stents were inserted successfully. The mean (range) indwelling time was 47.4 (3–224) days. Radiologically, 14 (47%) and 15 (50%) had complete resolution of the hydronephrosis on follow-up US in late pregnancy and in the early postnatal Corresponding author. Tel.: +44 2035942662. E-mail address: noor.buchholz@bartshealth.nhs.uk (N. Buchholz). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2013 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. http://dx.doi.org/10.1016/j.aju.2013.02.002 JJ in pregnancy 149 period, respectively. Two-thirds of patients had a clinical improvement immediately (15, 50%) and soon after (five, 17%) surgery. Stent encrustation (three, 10%), stent migration (three, 10%) and stent irritation (five, 17%) were reported as complica- tions. The post-natal evaluation confirmed that half the patients had urinary calcu- lus disease. Conclusion: Ureteric stenting during pregnancy can be safe, with no intraopera- tive imaging and even under local anaesthesia. It provides good symptom relief and has a low complication rate. We therefore advocate it as a first-line treatment in pregnant women with therapy-resistant flank pain. ª 2013 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. Introduction The ureter was stented either under local, spinal or general anaesthesia, using pregnancy-approved antibi- Pregnant women can have some degree of hydronephro- otic prophylaxis. The procedure was conducted using a sis, as a result of the physiological changes in pregnancy. 22-F rigid cystoscope. A 4.7-F 26-cm JJ ureteric stent It is not uncommon to have pregnant women with (Flexater ureteric stent, Gallini Medical Devices, Italy) intractable flank pain resulting from renal obstruction was inserted retrogradely over a guidewire. The posi- and who thus require hospital admission, and the condi- tioning of the ureteric stent was assumed to be correct tion is more complicated if associated with stone disease. after a smooth insertion, observation of stent markings The incidence of symptomatic urinary calculi in preg- and the adequate distal coiling of the stent inside the nancy is 1/244 to 1/3300 [1–4], and it is estimated that bladder. Immediate US was used for proximal coil posi- the incidence of urinary calculus disease in pregnant wo- tioning. No fluoroscopy was used during the procedure. men is similar to that in nonpregnant women of the The patient’s clinical signs and symptoms were clo- same age [5]. sely monitored after the procedure. Patients were dis- Managing flank pain during pregnancy can be chal- charged when the flank pain subsided, or when the lenging. Standard radiographic investigations and surgi- sepsis and the acute renal failure were resolved. Antibi- cal treatments, as used in nonpregnant women, cannot otic prophylaxis was maintained in all stented patients be applied easily due to concerns about ionising radia- to minimise bacteriuria and stent colonisation through- tion and the potential harm to the fetus. out the remaining course of pregnancy. A follow-up Thus we present data from a single institution in Iraq, with renal function tests and US was arranged weekly assessing the safety and effectiveness of ureteric stenting in the first month, then monthly throughout pregnancy. with a JJ stent in pregnant women to relieve renal After delivery, patients had a plain abdominal film, obstruction and intractable flank pain. US and/or IVU to assess the continued presence of renal obstruction and/or stone disease, and consequently the Patients and methods need for further treatment. Data were prospectively collected from the Department Results of Urology of a tertiary national teaching hospital in Iraq, from March 2008 to March 2010. All pregnant pa- In all, 30 patients were enrolled into the study during the tients presenting with intractable flank pain, with or 25-month period. Their baseline values are shown in Ta- without complications in the form of kidney infection ble 1. Intractable flank pain (23 patients, 77%) was the and deterioration of renal function, and necessitating most common indication for ureteric stenting, followed JJ ureteric stenting, were enrolled in the study. Intracta- by flank pain with clinical sepsis (six, 20%). Only one ble flank pain was defined as flank pain that could not case (3.3%) presented with anuria and acute renal fail- be relieved by conservative management comprising ure due to bilateral ureteric obstruction. bed rest, hydration and the use of paracetamol. All pregnant women had hydronephrosis on US, and Patients were assessed with a complete medical 12 (40%) had evidence of coexisting renal stones on US. history and comprehensive physical examination. A All ureteric stents were inserted successfully. Local mid-stream urine sample was collected for microscopy, anaesthesia (27, 90%) was the predominant form of culture and sensitivity testing. Blood tests included a anaesthesia. No percutaneous nephrostomy was needed. complete blood count and a renal function assessment. The mean (range) indwelling time was 47.4 (3–224) Trans-abdominal ultrasonography (US) provided evi- days. Radiologically, 14 (47%) and 15 (50%) of the wo- dence of hydronephrosis and, where possible, urinary men had complete resolution of the hydronephrosis on calculus disease. follow-up US in late pregnancy and the early postnatal 150 Ngai et al. one level, leading to ureteric dilatation [7]. Urinary sta- Table 1 The baseline demographic data of the 30 patients. sis, as a result, might have a role in urinary calculus Variable Mean (range) or n (%) formation and renal colic in these women. Age (years) 27.2 (18–38) Although pain from renal colic is the most common non-obstetric reason for hospital admission during preg- Trimester on presentation First 5(17) nancy [8], the timely diagnosis and subsequent manage- Second 15(50) ment in pregnant women can be challenging. It was Third 10(53) reported that 28% of pregnant women having obstruct- Parity ing stones were initially misdiagnosed as having other Primiparous 11(37) pathologies, such as appendicitis and placental abruption Multiparous 19(63) [2]. While flank pain (23, 77%) was the most common Positive history of urinary calculus 11(37) presenting symptom in this series, flank pain with sepsis Preoperative US findings (six, 20%) also features as an important presentation [2]. Presence of hydronephrosis 30(100) However, the clinical presentation might not always Left 11(37) be reliable in predicting stone disease in pregnant wo- Right 14(47) Bilateral 5(17) men with flank pain [9]. The role of radiographic inves- Presence of stones in kidneys 12(40) tigations in various trimesters of pregnancy has been the Left 6(20) subject of a long-standing and ongoing debate, in view Right 3(10) of the potential exposure to ionising radiation of the Bilateral 3(10) developing fetus. The potential sequelae of foetal radia- Indications for ureteric stenting tion exposure are teratogenesis, mutagenesis and carci- Intractable flank pain 23(77) nogenesis [7]. Limited IVU has been used in the past Flank pain with clinical sepsis 6(20) during later pregnancy, presuming the teratogenic effect Acute renal failure 1(3) was related to the high radiation sensitivity of the em- Presumed aetiologies bryo in the first trimester. However, mutagenic and car- Urinary calculus 12(40) Physiological 18(60) cinogenic effects in second and third trimesters cannot be neglected. As there is no well-defined safe radiation dose, it is deemed safer not to use radiographic investi- period, respectively. Two-thirds of patients had a clinical gations in pregnant women [7]. improvement in pain relief immediately (15, 50%) and Consequently, US becomes the first-line investigation soon after (five, 17%) surgery. Three patients (10%) re- to evaluate flank pain in pregnant women. While the ported no difference with ureteric stenting, and seven advantages of US are its non-invasiveness, lack of ionis- (23%) had a worsening of symptoms, with either an in- ing radiation and ready availability, it has a limited sen- creased analgesic requirement or the development of sitivity [9], and is further limited for accurately detecting new symptoms related to stent placement, i.e. frequency, stones, visualising the ureter, and differentiating be- urgency and haematuria. Three patients (10%) had a tween different causes of renal obstruction [7]. Neverthe- stent migration and required subsequent revision of the less, the accuracy of US in detecting stones can be ureteric stent. Stent encrustation was found in three improved significantly (up to 71.9%) by closely observ- (10%) patients on stent removal, and stent irritation ing the features of upper tract obstruction and interpret- (five, 17%) causing haematuria and LUTS were likewise ing them correctly, such as a hydroureter extending reported as complications (Table 2). below the pelvic brim, the asymmetric absence of ure- The postnatal evaluation confirmed that half the pa- teric jets, or an elevated resistive index [9]. tients had urinary calculus disease (Table 2). ESWL (in As renal colic in pregnant patients can be compli- eight of the 15) was used as the main treatment, while cated by severe upper-tract infection and premature la- percutaneous nephrolithotripsy (two), ureteroscopy bour [10], unrecognised pyonephrosis is potentially (one) and open ureterolithotomy (one) were also used life-threatening for both the mother and fetus. Given as definitive treatments. that most patients will recover with analgesia, antibiot- ics and hydration, the initial treatment should be conser- Discussion vative. However, some authors advocate early Physiological hydronephrosis and hydroureter begin in intervention after the analgesia has been shown to be the first trimester of pregnancy. By the third trimester, ineffective [11]. Drainage of the obstructed and infected system is indicated in patients who have symptoms up to 90% of pregnant women can have upper urinary refractory to conservative measures, i.e. ongoing sepsis tract dilatation [6]. It is known that these physiological despite antibiotics (>48 h) and the worsening of any changes are the result of mechanical obstruction of the of renal function, pain, obstruction or hydronephrosis ureters by an enlarged uterus at the pelvic brim, as well [12]. as the muscle-relaxing effect of an increased progester- JJ in pregnancy 151 most cases can be inserted under local anaesthesia. It Table 2 The complications of ureteric stenting with a JJ stent, provides good symptom relief and has a low complica- and the results of postnatal investigations. tion rate. We therefore advocate it as the first-line treat- Variable n (%) ment in pregnant women with therapy-resistant flank Complication pain. Stent migration 3 (10) Stent encrustation 3 (10) Bothersome LUTS 3 (10) Conflict of interest Gross haematuria 2 (7) None. Post-natal investigations No stone 12 (40) Renal stones 6 (20) Funding Ureteric stones 5 (17) Both ureteric stone and renal stones 4 (13) None. Not known 3 (10) References It was reported that JJ ureteric stenting can be diffi- cult in the third trimester due to the tortuosity of the [1] Butler EL, Cox SM, Eberts EG, Cunningham FG. Symptomatic nephrolithiasis complicating pregnancy. Obstet Gynecol ureter [13]. However, others did not confirm this [9– 2000;96:753–6. 12,14–16]. All patients in our series had successful [2] Stothers L, Lee LM. Renal colic in pregnancy. J Urol stenting. 1992;148:1383–7. The overall complication rate of JJ ureteric stenting, [3] Swartz MA, Lydon-Rochelle MT, Simon D, Wright JL, Porter MP. Admission for nephrolithiasis in pregnancy and risk of i.e. stent migration, stent encrustation, stent irritation adverse birth outcomes. Obstet Gynecol 2007;109:1099–104. and haematuria, was similar to that in other series of [4] Lewis DF, Robichaux AG, Jaekle RK, Marcum NG, Stedman pregnant women [14]. This might show that placing JJ CM. Urolithiasis in pregnancy – diagnosis, management and ureteric stents is a highly successful, safe and effective pregnancy outcome. J Reprod Med 2003;48:28–32. treatment option and should be considered for pregnant [5] Coe FL, Parks JH, Lindheimer MD. Nephrolithiasis during women with intractable flank pain. pregnancy. N Engl J Med 1978;298:324–6. [6] Boridy IC, Maklad N, Sandler CM. Suspected Urolithiasis in Although percutaneous nephrostomy and JJ ureteric pregnant women. Imaging algorithm and literature review. AJR stenting are equally effective in relieving upper tract Am J Roentgenol 1996;167:869–75. obstruction, JJ ureteric stenting is commonly regarded [7] Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. as the less invasive of the two, and has the additional Campbell-Walsh urology. Tenth ed. Saunders; 2011. advantage that pregnant women, mostly in the second [8] Rodriguez PN, Klein AS. Management of urolithiasis during pregnancy. Surg Gynecol Obstet 1988;166:103–6. and third trimesters, can undergo the procedure safely [9] Andreoiu M, MacMahon R. Renal colic in pregnancy: lithiasis or and comfortably in the supine lithotomy position. physiological hydronephrosis? Urology 2009;74:757–61. Further, especially if drainage is needed for many of [10] Paraukar BG, Hopkins TB, Wollin MR, Howard Jr PJ, Lal A. the remaining weeks of the pregnancy, a nephrostomy is Renal Colic during pregnancy: a case for conservative treatment. very uncomfortable for the patient and risks infection J Urol 1998;159:365–8. [11] Song G, Hao H, Wu X, Li X, Xiao YX, Wang G, et al. and displacement over time. Treatment of renal colic with double-J stent during pregnancy: a While ureteric stenting acts as an emergency interven- report of 25 cases. Zhonghua Yi Xue Za Zhi 2011;91:538–40. tion for intractable renal obstruction, some centres [12] Cheriachan D, Arianayagam M, Rashid P. Symptomatic urinary advocate the use of ureteroscopy under general anaes- stone disease in pregnancy. Aust NZ J Obstet Gynaecol 2008;48:34–9. thesia in pregnant women with obstructive ureteric cal- [13] Drago JR, Rohner Jr TJ, Chez RA. Management of urinary culi. High success rates can be achieved by calculi in pregnancy. Urology 1982;20:578–81. ureteroscopy, with no reported complications, making [14] Delakas D, Karyotis I, Loumbakis P, Daskalopoulos G, Kazanis ureteroscopy invaluable in both diagnosis and treatment A, Cranidis A. Ureteric drainage by double-J-catheters during [17,18]. However, if an infection proximal to the pregnancy. Clin Exp Obstet Gynecol 2000;27:200–2. obstruction cannot be excluded, ureteroscopy would [15] Velonda N, Giumelli P, Galdini R, Bennici S. Ureteral drainage with double-J catheters in obstructive uropathy during pregnancy. actually be contraindicated due to the irrigation pres- A report of 3 cases. Gynecol Obstet Invest 1995;40:274–5. sures needed and the mechanical manipulation, both [16] John H, Vondruska K, Sulser T, Lauper U, Huch A, Hauri D. of which can trigger urosepsis. Also, the infrastructure Ureteral stent placement in hydronephrosis during pregnancy. and expertise must be available, which might not always Urologe A 1999;38:486–9. be the case. In pregnant women it is preferable to err on [17] Polat F, Yesil S, Kirac¸ M, Biri H. Treatment outcomes of semirigid ureterorenoscopy and intracorporeal lithotripsy in the side of caution, and fast and smooth minimally inva- pregnant women with obstructive ureteric calculi. Urol Res sive JJ ureteric stent drainage remains our preferred and 2011;39:487–90. recommended first-line strategy. [18] Semins MJ, Trock BJ, Matlaga BR. The safety of ureteroscopy In conclusion, ureteric stenting during pregnancy can during pregnancy: a systematic review and meta-analysis. J Urol be safe, requiring no intraoperative imaging, and in 2009;181:139–43.
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