External-internal nephro-uretero-ileal stents in patients with an ileal conduit: long-term results

Primary retrograde urinary drainage using image and endoscopy guidance via urostomies

AIM

To report the technical success of image and endoscopy-guided retrograde trans-urostomy urinary drainage as a primary catheter placement method performed by interventional radiology (IR).

MATERIALS AND METHODS

Nine patients (15 attempted drain placements) with ureteric obstruction following radical cystectomy and urostomy creation were included. The patients were referred to IR for urinary drainage. All patients underwent primary image and endoscopy-guided retrograde trans-urostomy urinary drainage.

RESULTS

Primary image and endoscopy-guided retrograde trans-urostomy urinary drainage was successful in 13/15 (86.6%) attempts. The proposed technique had a limited complication rate omitting the percutaneous nephrostomy access step.

CONCLUSION

Primary image and endoscopy guided retrograde trans-urostomy urinary drainage should be considered before percutaneous nephrostomy in all patients with a urostomy.

Analysis of long-term effect of ureteral balloon dilatation combined with internal and external drainage tube in the treatment of benign ureteral stricture

PURPOSE

There are few reports about balloon dilatation combined with internal and external drainage tube in the treatment of ureteral stricture under interventional therapy. The aim of the study is to explore the safety, effectiveness and long-term efficacy of this treatment strategy.

MATERIALS AND METHODS

It is a retrospective and observational study. From October 2013 to October 2016, 42 patients with benign lower ureteral stricture received interventional treatment. Balloon dilatation combined with internal and external drainage tube implantation were used. There were 25 male patients and 17 female patients. There were 7 cases (16.7%) with congenital ureteral stricture, 12 cases (28.6%) with inflammation, 15 cases (35.7%) with ureteral stricture after lithotomy or lithotripsy, and 8 cases (19.0%) with ureteral stricture after pelvic or abdominal surgery. After the drainage tube was removed, B ultrasound, enhanced CTU or IVP of urinary system were reexamined every six months. The follow-up time was 12-60 months.

RESULTS

The age was 52.9 ± 11.6 years. The length of ureteral stricture was 1.1 ± 0.5 cm. 42 patients completed interventional treatment, the technical success rate was 100%, no ureteral perforation, rupture or other complications were identified. Preoperative urea nitrogen 9.2 ± 2.3 mmol/L and creatinine 175.8 ± 82.8umol/L. Urea nitrogen and creatinine were 3.8-9.1 mmol/L and 45.2-189.6 umol/L when removing the drainage tube. There were significant differences in the levels of urea nitrogen and creatinine before and after tube removal (P < 0.05). The ureteral patency rate was 100% at 6 months, 93% at 12 months, 83% at 18 months, 79% at 24 months, 76% at 30 months and 73% at 36-60 months. The overall success rate was 73%. Multivariate Cox regression analysis showed that stenosis length was a risk factor for postoperative patency (P < 0.05).

CONCLUSION

Balloon dilatation combined with internal and external drainage tube implantation in the treatment of benign lower ureteral stricture is safe and effective.

Nephroureterostomy as a treatment of obstructive uropathy: A single center experience

OBJECTIVE

To report the outcomes of percutaneous nephroureterostomies performed in a single center a period of ten years.

MATERIALS AND METHODS

We retrospectively collected and analyzed data for 52 nephroureterostomy procedures that were performed from September 2008 to August 2018. We present patient's demographics, indications for the procedure, type of anesthesia, technical difficulties, length of stay in hospital and complications.

RESULTS

A total of 52 procedures including 13 bilateral nephroureterostomies were performed on 39 patients. Taking into account the need for replacement of nephroureterostomy procedures during the study period, total number of procedures was 168. Out of a total 39 patients, 32 (84%) of patients had advanced cancer. All procedures were performed as day cases using sedation and had no immediate or early complications. Ten patients or 16% (27 nephroureterostomies out of total 168 procedures) had minor complications.

CONCLUSIONS

To the best of author's knowledge, this is the largest case series reporting the outcome of percutaneous nephroureterostomies. We can therefore conclude that percutaneous nephroureterostomy is a useful palliative procedure to relieve ureteric obstruction, when other measures are not possible, and it has low incidence of complications. However, further studies are warranted to compare different procedures used to relieve ureteric obstruction.

The thermoexpandable nitinol stent: a long-term alternative in patients without nephropathy or malignancy

OBJECTIVE

The aim of this study was to investigate the long-term outcome of a thermoexpandable nickel-titanium nitinol ureteral stent (Memokath 051™) and to identify individual risk factors for failure.

MATERIALS AND METHODS

This retrospective single-centre study included 125 patients who underwent implantation of the self-expandable Memokath 051 stent. Complications, indwelling time and reason for explantation were recorded. Analyses were stratified by gender, age, body mass index, American Society of Anesthesiologists score, estimated glomerular filtration rate (eGFR), side, localization and cause of the stricture.

RESULTS

In total, 91 out of 125 patients (73%) were available for analysis. Median indwelling time was 355 days (range 7-2125 days). Most stents were removed because of dislocation (42%) or occlusion (40%). Stent removal was rarely performed because of infection (3%). Patients with sufficient renal function (eGFR ≥60 ml/min/1.73 m²) showed increased indwelling times compared with those with nephropathy (386 vs 317 days; p < 0.01). Patients with active malignant disease showed reduced patency time compared with strictures of benign origin (455 vs 190 days; p < 0.01).

CONCLUSIONS

This thermoexpandable nitinol stent offers safe mid-term treatment of ureteric strictures, especially in patients without active malignancy and with good renal function.

Internal versus external ureteric stents for uretero-ileal anastomosis after laparoscopic radical cystectomy with orthotopic neobladder: A prospective comparative study

OBJECTIVE

To prospectively compare the use of external ureteric stents with internal JJ stenting of the uretero-ileal anastomosis in patients undergoing laparoscopic radical cystectomy (LRC) with a Y-shaped ileal orthotopic neobladder (ON).

PATIENTS AND METHODS

The study included 69 patients undergoing LRC with ON. Patients were grouped according to the type of uretero-ileal stents used. An external ureteric stent was used in Group A (33 patients) and a JJ stent was used in Group B (36). We prospectively compared the duration of hospital stay, the incidence of short- and intermediate-term complications in the two study groups.

RESULTS

The mean (SD) follow-up periods were 29.18 (3.94) and 28.19 (3.37) months for patients in Groups A and B, respectively. Perioperative patient characteristics were comparable in the two study groups. The use of JJ stenting was associated with a shorter hospital stay compared with external stenting, at a mean (SD) of 14.63 (3.74) and 6.8 (3.03) days in Groups A and B, respectively (P < 0.001). The incidence of urinary leakage was comparable in the two study groups, at 6.1% in Group A vs 8.3% in Group B (P = 1.0). Strictures of the uretero-ileal anastomosis occurred in two patients (6%) in Group A and confirmed by intravenous urography. All strictures were treated with antegrade JJ fixation.

CONCLUSION

JJ stents could be used as an effective alternative to external ureteric stents to support the uretero-ileal anastomosis. JJ stenting is associated with a shorter hospital stay and similar complication rates compared with external stenting in patients undergoing LRC with ON.

Nephroureteral stents: principles and techniques

Nephroureteral stents including antegrade, retrograde, or internal (double-J) stents are routinely placed by interventional radiologists. The purpose of this review is to provide a detailed and comprehensive description of indications, contraindications, technique, and various technical challenges of these procedures. Also pre- and postprocedure management of patients will be discussed including routine follow-up and dealing with potential complications.

Percutaneous nephrostomy: technical aspects and indications

First described in 1955 by Goodwin et al as a minimally invasive treatment for urinary obstruction causing marked hydronephrosis, percutaneous nephrostomy (PCN) placement quickly found use in a wide variety of clinical indications in both dilated and nondilated systems. Although the advancement of modern endourological techniques has led to a decline in the indications for primary nephrostomy placement, PCNs still play an important role in the treatment of multiple urologic conditions. In this article, the indications, placement, and postprocedure management of percutaneous nephrostomy drainage are described.

Two thermoformable spiral metallic ureteral stents in a patient with ileal conduit and distal stenosis of the ureters

The insertion of two thermoformable ureteral titanium spiral stents (Memokath® 051) through ileal conduit due to bilateral ureteral stenosis distally has not been described in the English literature so far. We present the case of a young female patient with a history of ileal conduit urinary diversion due to congenital urinary bladder exstrophy, who had multiple previous surgeries and the insertion of two Memokath® ureteral stents in both ureters due to distal ureteral stenosis.

Management of Benign Ureteral Strictures Following Radical Cystectomy and Urinary Diversion for Bladder Cancer

PURPOSE

Ureteral obstruction due to benign strictures is a significant complication of radical cystectomy and urinary diversion for bladder cancer that can lead to renal function loss and infection related morbidity. Treatment may be performed surgically or with minimally invasive techniques. We describe the 10-year experience at our department with various treatment modalities for post-cystectomy benign strictures.

MATERIALS AND METHODS

The study group consisted of 28 patients treated for benign ureteral strictures following radical cystectomy for bladder cancer. Their medical records were reviewed for clinical presentation, diagnostic procedures, treatment and long-term outcome.

RESULTS

The study group represented 12.7% of all 221 patients treated at our department with radical cystectomy for bladder cancer in 1994 to 2004. Ureteral strictures were asymptomatic in 71.4% of cases. Median time to diagnosis was 7.0 months and 75% of the patients were diagnosed within year 1 after cystectomy. Treatment consisted of stenting, dilation and open surgical revision with removal of the strictured segment and reanastomosis. Median followup was 62.5 months. The stenting procedures served as the long-term definitive treatment in 45% of cases, whereas balloon dilation uniformly failed. Although open surgical revision was technically challenging, it had a long-term success rate of 93%.

CONCLUSIONS

Benign ureteral strictures commonly occur during postoperative year 1 and they are usually asymptomatic. Early diagnosis and prompt drainage are required to prevent consequent renal parenchymal loss and infectious complications. Although minimally invasive procedures are viable treatment alternatives, open surgical revision is still the preferred long-term definitive treatment.

Application of self-expandable metal stents for ureteroileal anastomotic strictures: long-term results

PURPOSE

We report our long-term experience with the management of benign ureteroileal anastomotic strictures using self-expandable metal stents.

MATERIALS AND METHODS

A total of 16 male and 2 female patients with a mean+/-SD age of 72+/-7 years (range 66 to 78) with benign fibrotic strictures at the site of ureteroileal anastomosis underwent implantation of self-expandable metal stents with a nominal diameter of 6 to 8 mm. A total of 24 ureteroileal conduits were treated. The external nephrostomy tubes were removed after fluoroscopic validation of ureteral patency. Patients were followed with blood biochemistry, ultrasonography, urography and/or virtual endoscopy. Retrograde external-internal catheter insertion through the cutaneous stoma was performed in cases of recalcitrant stricture.

RESULTS

The technical success rate of ureteroileal stricture crossing and stenting was 100% (24 of 24 cases). Mean followup was 21 months (range 7 to 50). The clinical success rate during the immediate post-stenting period was 70.8% (17 of 24 cases). The 1 and 4-year primary patency rates were 37.8% and 22.7%, respectively. Secondary interventions included repeat balloon dilation in 15 ureters, of which 8 also underwent subsequent coaxial stent placement. The 1 and 4-year secondary patency rates were 64.8% and 56.7%, respectively. Except in 2 patients who died external-internal Double-J catheters continued to be inserted retrograde in 6 ureteroileal conduits. They are periodically exchanged to prevent mucous inspissation and stent encrustation.

CONCLUSIONS

Metal stents served as the definitive treatment for stricture in more than half of the cases, whereas in the remainder the stents allowed the uncomplicated and regular exchange of Double-J catheters in retrograde fashion. This combined, less invasive treatment for ureteroileal anastomotic strictures may help patients avoid surgical revision and preserve quality of life.