The role of retrocolonic saline injection to obtain access for percutaneous nephrostomy in a pelvic kidney

Abstract

tests showed a random sugar level of 2.3 g/L and creatinine of 14 mg/L. Abdominal ultrasonography showed a malrotated pelvic left kidney and gross hydronephrosis with internal debris. A diagnosis of pyonephrosis of the malrotated left kidney was made, based on the presentation and the ultrasonography findings. The patient was referred for PCN drainage. CT showed a horizontally lying kidney in the midline at the level of the L4/5 vertebral body, with the renal pelvis directed antero-superiorly and to the right. There was a grossly distended pelvicalyceal system and thinning of renal parenchyma suggestive of PUJ obstruction (Fig. 1). There was no evidence of calculi. However, there was no suitable access to reach the left kidney because of the descending colon anteriorly and the left iliac bone posteriorly. It was planned to displace the descending colon anteriorly by a retrocolonic saline instillation and to obtain an access for PCN.The procedure was done under local anaesthesia and sedation, with the patient in the right lateral position. Axial CT sections were obtained and a suitable level (shortest distance, transrenal parenchymal, retroperitoneal approach) selected (Fig. 2). With strict aseptic precautions, a 7-cm, 21 G needle was placed horizontally from the left side behind the distal descending colon and in front of the left iliac bone (Fig. 3). Then a120 mL of normal saline was instilled in the retroperitoneal space after confirming the needle position by CT fluoroscopy. Check CT showed anterior displacement of the descending colon by > 2 cm (Fig. 4a,b). A 15-cm, 21 G needle was passed along this track into the renal pelvis through the upper pole calyceal region, and pus was aspirated. A 0.9 mm guidewire was initially passed and subsequently changed for a 0.9 mm Amplatz wire using an Accustick dilator system. A 10 F pigtail drainage catheter was placed and connected to a urine bag for dependent drainage (Fig. 5).Sample culture showed Gram-negative bacilli and the patient was kept on antibiotics with supportive therapy. She showed a significant clinical improvement within a few days and underwent elective left nephrectomy 2 months later.