Kidney Diseases

Nephrostomy tube-Ureteric obstruction

09/05/2006

Question:

My father had a radical cystectomy in Dec, 2005. He has an ideal conduit. As the result of the operation, one of his kidneys got dilated due to the obstruction in the ureter and the nephrostomy tube was inserted in the back to help and relieve the kidney. My father had 3 balloon procedures to attempt to expand the obstruction. None of them worked.

I have two questions: 1. He was offered to have the nephrostomy tube taken out from his back and put in internally through the conduit. What are the pros and cons of having this done? 2. If my Dad has an open surgery to remove the obstruction, what are the chances that the surgery will be successful?

Answer:

Prior to the mid-90's, open surgical procedures were the primary means of correcting obstruction in the urinary tract. However, in the last few years the use of endoscopic procedures has grown enormously. In these types of procedures, a flexible fiberoptic scope is inserted into the urinary tract (usually through the urethra, but in your dad's case, either through the opening of his ileal conduit or through the opening where the nephrostomy tube comes out of his back). The scope allows a direct look at what's going on inside the bladder, the ureters, and/or the central part of the kidneys. Biopsies can be taken under direct vision; and wires, catheters, or stents (expandable metal tubes) can often be inserted through or past areas that are obstructed with tumor or scar tissue. As you can imagine, this type of procedure is MUCH easier on the patient than the former "open" procedures, which required making an abdominal incision, dissecting through layers of muscle and tissue to reach the bladder/kidney, cutting into the bladder/kidney, and then putting everything back together and stitching it up afterwards.
In general, the insertion of an internal tube to correct or bypass an obstruction is preferable to having a nephrostomy tube (which protrudes outside the body, can be unsightly and annoying, and has a greater chance of becoming infected by bacteria from the skin and the environment). Patients generally tolerate the endoscopic placement of internal tubes well, although the tubes usually need to be changed every 3-6 months.
My reading indicates that the long-term results of endoscopic surgery used to correct obstruction are excellent at 5-10 years' follow-up (which is about all anyone has to report at this time in history). However, the results in your dad's case will depend on 1) the cause of obstruction (especially whether it's scar tissue or recurrent tumor); 2) the exact location of the obstruction, and the size or length of the obstructed area; and 3) the skill and experience of the surgeons who would be doing the operating, whether it's an endoscopic or an open procedure. In any case, when obstruction is present, it is very important to get it fixed as soon as possible, since persistent obstruction can cause permanent kidney damage. So do not hesitate to ask your dad's surgeon(s) for guidance in making the decision about the type of procedure: ask them for statistics, for their own recommendations, and perhaps even about the possibility of sending him to a center where there is lots of experience with endoscopic surgery. Best of luck to your dad, and I hope that he does well.
P.S. Note that his conduit is "ileal" (constructed from ileum, a segment of intestine), not "ideal" (although perhaps it will be that, too, after the surgery!).

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Response by:

Mildred Lam, MD
Associate Professor
Nephrology Division
MetroHealth Medical Center
School of Medicine
Case Western Reserve University