Lethal complications of standard self-retaining ureteral stents in patients with ileal conduit urinary diversion

External stent versus double J drainage in patients with radical cystectomy and orthotopic urinary diversion: A randomized controlled trial

OBJECTIVES

To compare treatment-related outcomes of ureteral stenting with an external versus double J stent in patients with orthotopic reservoirs after radical cystectomy.

METHODS

Patients undergoing radical cystectomy and orthotopic neobladder were randomized into two groups; group I patients received external stents, whereas group II received double J stents. In both groups, preoperative parameters were recorded, and patients were assessed regarding urinary tract infection, urinary leakage, upper tract deterioration, readmission and hospital stay.

RESULTS

A total of 48 and 45 patients were randomized in the external stent group and double J group, respectively. Both groups were comparable in terms of age, sex, associated comorbidity and oncological status. Early urinary leak was observed in two patients (4.2%) in the external stent group, and in two patients (4.4%) in the double J group (P = 0.95). None of our patients developed ureteral strictures in the external stent group, and one patient did in the double J group (P = 0.3). Positive urine culture (58.3%, 51.1%) as well as febrile urinary tract infections (2.1%, 6.7%) were comparable between both groups, respectively (P = 0.43, 0.28). Wound complications (12.5%, 8.9%) and stent-related complications (2.1%, 0%) were comparable between both groups, respectively (P = 0.57, 0.33). The mean hospital stay was 17.5 days (range 14-32 days) and 14.6 days (range 10-42 days) in both groups, respectively (P = 0.001), with comparable re-admission rates (P = 0.95).

CONCLUSIONS

Incorporation of double J stents in orthotopic urinary diversion is a safe alternative to the routinely used external stenting.

The double wire technique: an improved method for treating challenging ureteroileal anastomotic strictures and occlusions

Up to 10% of patients who undergo ileal conduit urinary diversion may go on to develop ureteroileal anastomotic stenosis (UIAS); this can lead to recurrent urinary tract infections and deterioration in renal function. Classical management has been open revision of the anastomosis. We describe a novel technique that allows balloon dilatation and ureteral stent placement in a retrograde fashion. All patients in this study had undergone radical cystectomy and ileal conduit formation with Wallace type end-to-end refluxing uretero-intestinal anastomosis. After initial retrograde loopogram, a 6F MPA-1 catheter and an 0.035 inch extra stiff guide was passed to the distal ostium. Subsequently, a customised 8F bright tip MPA-1 guiding catheter was advanced over the guide wire which allowed effective splinting of the equipment to facilitate greater control of a second catheter and guide wire combination to access the stenotic or occluded anastomosis. Results show that a total of ten anastomoses were treated; nine anastomoses were successfully treated with a primary retrograde approach with no intra or post-procedural complications. After a mean follow-up of 19 months (5-33 months), as assessed by ascending loopograms, all anastomoses remained open. In conclusion, morbidity of open surgery has resulted in the popularization of endourological techniques in treating anastomotic stenoses. However, key to these endourological techniques is access to the anastomosis; typically, this has been via a percutaneously placed nephrostomy. The ideal route to the anastomosis is via a retrograde approach; we have illustrated a safe and successful novel technique that utilized two guidewires and a guiding catheter, allowing retrograde ureteral access.

Use of a duodenoscope to manage complications at the ureteroileal anastomotic site after total urinary bladder resection and the Bricker procedure

BACKGROUND

A novel flexible endoscopic technique is described for the treatment of ureteroileal strictures and leaks after the Bricker procedure.

METHODS

Seventeen patients with 24 ureteroileal complications (strictures, 22; leaks, 2) were treated under conscious sedation with a side-viewing duodenoscope. The ureter was cannulated and stent insertion, dilation, or both were performed.

RESULTS

Immediate technical success was achieved in 19 of the 24 (79.2%) ureteroileal complications. Treatment included stent placement alone in 12, dilation plus stent in 4, intraileal ureter resection plus stent with or without dilation in 3, and removal of ureteral calculi in 1. The procedure was unsuccessful in 5 (20.8%; failure to visualize ureteroileal anastomosis 4, unsuccessful cannulation 1). No major complications occurred. The 14 patients treated successfully were followed (mean 43 months, range 2-132 months) and a satisfactory outcome was observed in all. Partial stent displacement occurred in 2 patients and ureteral calculi developed in 2 patients. Three patients died with a stent in situ; no death was stent-related. Eleven patients are alive and asymptomatic, 5 with a stent in situ. In 6 patients, the stent was extracted after a mean of 36 months and all remained asymptomatic during a mean further follow-up of 41 months.

CONCLUSION

Treatment of ureteroileal anastomotic complications with a flexible duodenoscope and endoscopic techniques is safe, simple, and noninvasive with good success and excellent long-term results. This approach can be recommended as first-line therapy in patients with ureteroileal anastomotic complications.

Ureteroileal anastomotic strictures: an innovative approach with metallic stents

PURPOSE

We report our experience with the use of self-expandable metallic stents to bypass anastomotic strictures after ureteroileal urinary diversion.

MATERIALS AND METHODS

We evaluated 3 men and 1 woman with invasive bladder carcinoma who underwent radical cystectomy and ileal conduit urinary diversion. Ureteroenteric anastomotic strictures developed after a mean of 16 months. Self-expandable metallic stents were successfully placed (bilaterally in 2) comprising 6 stented ureters that bypassed strictures. Mean patient age was 64 years and mean followup was 12 months.

RESULTS

No restenosis was observed in 3 patients during followup. The stricture recurred 1 month after stent placement in the remaining patient and additional intervention was necessary, consisting of placement of a totally coaxial overlapping metal stent. No sepsis or other complication was observed. One patient died of metastatic disease 12 months after stent placement.

CONCLUSIONS

We propose the use of metal stents as an adequate, safe and effective alternative treatment for anastomotic strictures after ureteroileal diversion.

Problems with double-J stents and nephrostomy tubes

Double-J stents and nephrostomy tubes are used both to temporize prior to definitive treatment and for long-term relief of ureteral obstruction. Nephrostomy tubes that are correctly placed guarantee relief of obstruction and facilitate intrarenal manipulations but have a number of disadvantages, not least of which is the need for an external collecting bag. Double-J stents obviate the external bag but do not ensure relief of obstruction and have adverse functional and histopathologic effects on the ureter. Despite improvements in materials, no stent is totally resistant to encrustation, and frequent changes are required.

Routine stentograms are not necessary before stent removal following radical cystectomy

PURPOSE

Although ureteral stents have significantly reduced perioperative complications of urinary diversion, there is no universal agreement regarding their postoperative management. As part of an effort to eliminate unnecessary studies and hospital costs for radical cystectomy, we recently reviewed our experience with postoperative radiological stent studies to determine their clinical use and cost.

MATERIALS AND METHODS

A retrospective examination of medical records and radiographic studies was performed for 96 patients undergoing cystectomy and urinary reconstruction between 1989 and 1996. All patients were stented at the time of surgery. Of the patients 51 underwent bilateral retrograde "stentograms" performed under fluoroscopic guidance before stent removal to evaluate for obstruction or urine leak as dictated by the preference of the primary surgeon in each case. A total of 41 evaluable patients did not undergo stentograms.

RESULTS

In this study 102 stent injections were performed on 51 patients before stent removal. No patients were found to have ureteral obstruction at the ureterointestinal anastomosis, while 1 (0.98%) had a clinically silent anastomotic leak that healed with conservative measures. Complications directly attributable to the stent studies, including episodes of urosepsis, were noted in 9 patients (17.6%). Nine additional leaks were diagnosed in this cohort by other means. Half of all leaks were evident clinically and 60% of this group required further invasive procedures. All clinically silent leaks healed with conservative measures. Of 41 evaluable patients who did not undergo stentograms leak following stent removal developed in only 2 and both healed with conservative measures. The additional cost of detecting a single anastomotic leak with routine stentograms is estimated to be $58,000.

CONCLUSIONS

Routine evaluation of the ureterointestinal anastomosis with stentograms before stent removal is unnecessary, costly and may in fact increase patient morbidity.

Update on interventional uroradiology

From its humble beginnings as a method of expediently decompressing the obstructed kidney, the field of interventional uroradiology has evolved in the hands of urologists and interventional radiologists to a means of addressing myriad problems in the urinary tract and has changed the day-to-day practice of urology. The foundation of interventional uroradiology is the creation of an appropriate entry into the urinary system. After a review of this basic procedure, extensions of the technique and new applications of emerging technology are reviewed.

Endoscopic transurostomy diathermy anastomotomy. A combined approach to uretero-ileal stenoses

Uretero-ileal stenosis is a recognised complication of ileal conduit urinary diversion. Two patients are described in whom a combination of fibreoptic conduitoscopy with standard endoscopic "biliary" sphincterotomy was used to treat anastomotic strictures. The technique of endoscopic transurostomy diathermy anastomotomy allowed the salvage of 3 renal units without the need for laparotomy or long-term indwelling ureteric stents.

Fluoroscopically guided percutaneous transrenal electroincision of ureterointestinal anastomotic strictures

A new technique for electroincision of a strictured ureterointestinal anastomosis is described that uses a sphincterotome and high frequency current. After placement of a percutaneous nephrostomy tube a 7F "wire guided" sphincterotome was placed into the stenosis. The cutting wire was then deflected while cutting current was applied intermittently. Injection of contrast medium through the papillotome probe assessed the depth of the incision. A 10 mm. angioplasty balloon was inflated at low pressure to verify that the anastomosis had been incised to a depth of 1 cm. The anastomosis was then stented for 8 weeks with an 18F stent. The operative time did not exceed 45 minutes. A total of 9 stenoses was treated in 7 patients: 4 were ileal conduit diversions and 5 were enterocystoplasties. No immediate complication was observed. In 1 case a small urinoma was surgically drained at removal of the stent. Six stenoses are patent with 2, 3, 4, 4, 10 and 13 months of followup after removal of the stent. One patient died of bladder tumor metastases during the stenting period and 1 with bilateral incision still has a stent. The technique can be performed without major complication (bleeding or digestive fistula). Long-term results remain to be assessed.

Fistula between the common iliac artery and the left ureter

We report the history of a patient with ureteroileocutaneous-stomy who developed stenosis of both ureteroileal anastomoses after one year from cystectomy for urothelial cancer. The strictures were managed by percutaneous dilatation with an angioplasty baioon catheter. The double J catheters were left in place across the stenosis for three months, then the left stent was removed. Afterwards the patient presented a fistula between the common iliac artery and the left ureter, and he underwent conservative surgery. We discuss the possible etiopathogenesis and the management of this rare pathology.

Interventional procedures in the upper urinary tract

The introduction and acceptance of percutaneous nephrostomy as a safe and effective alternative to surgical nephrostomy served as the impetus for the development and expansion of an ever-increasing number of techniques that are encompassed by the term "interventional uroradiology." This article reviews many of the nonvascular interventional techniques that have proliferated during the past decade and that are currently used in the kidney, ureter, and perinephric space. The authors emphasize those procedures that are most frequently employed, as well as their own preferences and perspectives on these procedures.

Endourological treatment of ureteroenteric anastomotic strictures: long-term followup

In 1987 we reported our initial experience with an endosurgical incisional approach to ureteroenteric anastomotic strictures (that is endoureterotomy). We have extended that initial report to encompass 15 patients with 19 ureteroenteric strictures followed for an average of 2.5 years. In all cases an endosurgical approach was well tolerated, blood loss was less than 50 cc and hospital stay averaged 3.5 days. A 16 to 22F external stent was left in place for 4 to 6 weeks postoperatively in 14 strictures. A permanent external 12F catheter was left in 5 strictures due to the presence of metastatic disease (4) and a complete dense stricture (1). The only major complication was a ureteroenteric fistula that healed over a ureteral stent without any open surgical intervention. Among 14 ureteroenteric strictures in which the stent was removed, the ureteroenteric area has remained patent in 8 (57%) with an average followup of 28.6 months (range 9 to 57 months). Failures were associated with metastatic disease in 2 cases, generalized debility in 2 and unexplained in 2. In this series an endosurgical approach to ureteroenteric strictures provided long-term satisfactory management of the problem in the majority of patients with benign and malignant disease. By current standards, only 1 patient (7%) would have been considered a candidate for open surgical repair.

Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair

The established treatment for ureterointestinal anastomotic strictures is open surgical revision. In an effort to evaluate the efficacy of endourological surgery for this problem, we compared 7 patients (9 strictures) who underwent open revision to 6 patients (7 strictures) who underwent endoscopic incision and balloon dilation of the stricture. The success rate (that is patent ureter and no stent) was 89 per cent for the open revision group and 71 per cent (5 of 7) for the endoscopic group. All open revisions required use of general anesthesia, while 3 of the endoscopic procedures were performed with the patient under assisted local anesthesia. The endoscopic group had markedly shorter hospitalization, decreased blood loss, diminished patient discomfort and no postoperative complications. While the endoscopic procedure for ureteroileal anastomotic strictures is less successful than open revision, the lower morbidity, decreased cost and shorter hospital stay associated with the endourological approach favor its use over open revision. For elderly patients who fail initial endoscopic revision and for patients with metastatic transitional cell cancer, placement of an indwelling stent is a reasonable alternative. Given these guidelines, less than 30 per cent of the patients who suffer a ureteroileal anastomotic stricture will require open surgical revision.

Endourological management of ureteroileal anastomotic strictures: is it effective?

Ureteroileal stenosis represents a serious postoperative threat to the obstructed kidney and open revision in these patients often is difficult. We evaluated 9 patients with 10 ureteroileal strictures who were treated with semirigid fascial dilators (1), balloon dilation (4) or a combination of balloon dilation and percutaneous intraureteral surgery (4). All 5 patients who had semirigid fascial or balloon dilation alone had early recurrence of the strictures. However, in 4 patients dilation in conjunction with percutaneous intraureteral incision of the stricture through a flexible choledochonephroscope resulted in short-term resolution of each ureteroileal stricture. However, by 6 months these strictures had recurred in 50 per cent of the patients.

Endoscopic management of the obliterated ureteroileal anastomosis

Endoscopic restoration of a totally obstructed ureteroileal anastomosis was accomplished in 3 patients. The combined use of rigid endoscopy of the ileal conduit and flexible nephroureteroscopy provided full visualization of the blind-ending segments and allowed location of the shortest segment between the lumina. A guide wire was passed through intervening tissue with fluoroscopic monitoring to re-establish internal drainage. This technique offers an alternative to laparotomy and reimplantation in selected cases of ureteroileal stricture.

The management of the Kock continent ileal reservoir urinary diversion with single pigtail self-retaining ileal conduit stents

The use of single pigtail soft silicone self-retaining ileal conduit stents appears to have particular value in the perioperative management of patients with a Kock pouch continent urinary diversion. Stenting provides greater assurance of sustained internal urinary diversion, lessening concern regarding anastomotic leaks from the pouch itself. This technique also allows easy sequential radiographic confirmation of healing without losing the capability for continued internal drainage by these stents if necessary. A protocol for the use of such stents is described.