Percutaneous implantation of subcutaneous prosthetic ureters: long-term outcome

Morbidity and long-term results of subcutaneous pyelovesical bypass in chronic ureteral obstruction

BACKGROUND

We present the long-term results and complications of the DETOUR® prosthesis, a permanent subcutaneous pyelovesical bypass for the treatment of ureteral obstruction.

PATIENTS AND METHODS

Between 2006 et 2018, 34 prosthesis were implanted in 28 patients (mean age 65,8 years) with ureteral obstruction of malignant or benign etiologies. The prosthesis, composed to an inner tube of silicone and an outer tube of expanded polytetrafluoroethylene, is placed subcutaneously between the kidney and the bladder. We are performed infrared spectrophotometry and scanning electron microscopy on two removed prostheses to explore the prosthetic encrustation.

RESULTS

The average follow-up was 25,8 months (Maximum: 64 months). Stent revision was required for early bladder fistula in three patients. The major long-term complications were infection (46%), obstruction (3 patients) and bladder fistula (7 patients). The most frequently infection are non-severe, but two patients died from septic shock after fungic colonization of the prosthesis. The infrared spectrophotometry and scanning electron microscopy analysis showed that the obstruction was favored by urinary infection and an alkaline medium. The functional prosthesis rate at 1,2 and 3 years was 94%, 71% and 62%, respectively.

CONCLUSION

The DETOUR® subcutaneous extra-anatomical urinary bypass is an effective and minimally invasive alternative to permanent percutaneous nephrostomy, for both malignant and benign ureteral obstructions in selected patients.

LEVEL OF EVIDENCE

3.

Long-term results of the treatment of complex ureteral stenosis with extra-anatomic ureteral bypasses

Introduction

Complex ureteral obstruction is a pathology that has always been a challenge for the urologist, especially in patients with high surgical risk or with a short life expectancy.

Material and methods

Between 2002 and 2017, 13 extra-anatomical bypasses were placed. A descriptive retrospective study was carried out. An analysis of the permeability time of the prosthesis was performed using Kaplan-Meyer curves. Demographic and etiological characteristics as well as early and late complications were analysed.

Results

Etiologies were benign in 39% (including 3 transplant recipients) and malignant in 69%. Permeability rates were 90.9% at each of 12, 24 and 48 months, respectively, and 75.8% at 60 months. There were no deaths in the early postoperative period, nor intraoperative complications. The most frequent complications were infections. Three of them were associated with bypass extrusion, which needed to be removed. A total of 5 prosthesis had to be removed. 40% of the patients did not present complications.

Conclusions

The extra-anatomical ureteral bypass is an alternative to permanent nephrostomy in the treatment of complex ureteral strictures. Their patency rates after long-term follow-up vary from 90% to 75% at 48 and 60 months, respectively. Their complication rates can be considered acceptable in the patients’ clinical contexts.

Subcutaneous nephrovesical bypass: Treatment for ureteral obstruction in advanced metastatic disease

The aim of the present study was to explore the value of subcutaneous nephrovesical bypass (SNVB) for the treatment of ureteral obstruction due to pelvic metastatic disease. SNVB stents (n=30) were implanted in 24 patients with advanced metastatic disease between January 2008 and December 2012. Urinalysis, serum creatinine (SCr), glomerular filtration rate (GFR), quality of life (QoL) scores, and renal ultrasonography were evaluated at follow-up. The SNVB procedures were successful in all 24 patients. Patient follow-ups occurred at an average of 10.6 months. Preoperative hydronephrosis was eliminated in 16 cases (53.3%) and reduced in the remaining patients. Following surgery, SCr levels reduced significantly from 256±46 to 124±23 μmol/l (P<0.001). GFRs increased from 25±4.8 to 45±5.3 ml/min (P<0.01). The mean QoL scores were 3.4±1.4 preoperatively and 7.6±1.0 postoperatively (P<0.001). The results showed that SNVB is a minimally invasive, effective and safe procedure for patients with ureteral obstruction resulting from advanced malignant disease. As an alternative procedure to percutaneous nephrostomy, SNVB offers patients a better QoL.

Current status of minimally invasive endoscopic management of ureteric strictures

Endourological techniques are used more often nowadays in the treatment of ureteric strictures of various etiologies. Advances in technology have provided new tools to the armamentarium of the endoscopic urological surgeon. Numerous studies exist that investigate the efficiency and safety of each of the therapeutic modalities available. In this review, we attempt to demonstrate the available and contemporary evidence supporting each minimally invasive modality in the management of ureteric strictures.

Simultaneous bilateral subcutaneous pyelovesical bypass as a salvage procedure in refractory retroperitoneal fibrosis

Ureteral obstruction causing renal failure is the most common complication associated with retroperitoneal fibrosis (RPF). Initial management includes steroid therapy together with ureteral stenting. When these fail, ureterolysis is the recommended surgical procedure. However, this could be challenging and recurrence is common. The aim of the present case series was to assess the feasibility of inserting simultaneous bilateral subcutaneous pyelovesical bypass grafts (SPBGs) in patients presenting with RPF who had failed initial endourologic/surgical management.

[Long-term results for subcutaneous Detour® prosthesis for ureteral obstruction: experiences of implantation, aftercare and management of complications]

BACKGROUND

We present the long-term results of implementation of the Detour® prosthesis as an alternative to established methods of surgical, percutaneous or internal urinary diversion.

PATIENTS AND METHODS

Between 2004 and 2012 a total of 40 prostheses were implanted in 31 patients (mean age 65 years) with ureteral strictures of various origins. In the follow-up the patients underwent examinations and completed questionnaires.

RESULTS

The average follow-up was 23 months (range 1-92 months). Sonographic examinations showed no urinary retention in 38 out of 40 implanted systems. The retention values were stable in 19 patients, improved in 7 and worse in 3. The quality of life (QoL) was high (EORTC QLQ-C30 90%). Intraoperative complications were 2 intestinal lesions and 3 bleeding of the renal-pelvic system. Postoperative urinary tract infections and wound complications were encountered. In the long-term course three infected hydronephroses occurred which were treated and cured with antibiotics and temporary nephrostomy and 4 systems were explanted, including 2 exchanges.

CONCLUSIONS

The system may be considered for patients with ureteral strictures with palliative and curative intent. There were no significant disadvantages in comparison with established methods. There were fewer risks in implantation and complications were manageable. The quality of life was significantly improved.

Joining the un-joinable: adhesion between low surface energy polymers using tetrapodal ZnO linkers

Tetrapodal ZnO crystals are used for mechanical interlocking of PTFE and cross-linked PDMS, classically non-adhesive polymers. This novel approach is straightforward and easily applicable and leads to a peel strength that is higher than 200 N m(-1) without chemical modification of the surfaces. The shape of these fillers emerged as a crucial aspect of the interlocking mechanism.

Successful salvage of kidney allografts threatened by ureteral stricture using pyelovesical bypass

Ureteral stricture is the most common urologic complication after renal transplantation. When endourologic management fails, open ureteral reconstruction remains the standard treatment. The complexity of some of these procedures makes it necessary to explore other means of repair. This study evaluated the intermediate-term outcome of subcutaneous pyelovesical bypass graft (SPBG) on renal transplant recipients. We reviewed 8 patients (6 male and 2 female; mean age 52 years) with refractory ureteral strictures postrenal transplantation, who received SPBG as salvage therapy. All patients failed endourologic management and half failed open management of their strictures. After a mean follow-up of 19.4 months, 7 out of 8 renal grafts have good function with mean GFR of 58.5 mL/min/1.73 m(2), without evidence of obstruction or infection. One patient lost his graft due to persistent infection of the SPBG and one patient developed a recurrent urinary tract infection managed with long-term antibiotics. SPBG offers a last resort in the treatment of ureteral stricture after renal transplantation refractory to conventional therapy.

Endourologic management of malignant ureteral obstruction: indications, results, and quality-of-life issues

Obstruction of the upper urinary tract is a problem commonly faced by practicing urologists. The constant evolution in endourology has effectively facilitated minimally invasive management of upper-tract obstruction. In a case in which malignancy is the cause of obstruction, however, the situation significantly changes. Questions arise regarding the need for relieving the obstruction, the means to accomplish this, and the benefits and drawbacks of each technique regarding both their efficacy and their impact on the patients well-being and the crucial issue of quality of life in the face of malignancy.

[Treatment of specific complications of locally advanced prostate cancer]

Despite improved screening methods and earlier detection of prostate carcinoma, the complications of locally advanced disease remain a challenge for urologists. The spectrum of possible complications includes subvesical obstruction, hydronephrosis, hematuria, pain, and local invasion of adjacent organs. Urinary diversion, palliative transurethral resection of the prostate, and endoscopic diathermy are classic procedures. Urethral stenting, laser evaporation, and selective arterial embolization are alternate approaches for treating these complex cases. Cystoprostatectomy and pelvic exenteration are ultimate options for patients with chronic pain and debilitating local symptoms.

The Detour Extra-Anatomic Stent—a Permanent Solution for Benign and Malignant Ureteric Obstruction?

OBJECTIVES

We describe our experience of the Detour extra-anatomic stent (EAS) (Mentor-Porgés, UK) for permanent bypass of complete upper urinary tract obstruction. The self-retaining expanded polytetrafluoroethylene-silicone tube, placed in the kidney using a percutaneous route, is tunnelled under the skin and sutured into the bladder to establish extra-anatomical urinary drainage.

METHODS

From April 2002 to November 2005, a total of nine Detour stents were inserted into eight patients; one patient needed bilateral stent insertions. The causes for ureteric obstruction were persistent malignant disease in three and complicated benign disease in five patients.

RESULTS

To date, four of five patients with benign disease are alive; one died unexpectedly of metastatic malignancy. The only stent-related complications were infection and haematuria. The two patients with malignancy have subsequently died, but there were no urinary drainage problems for their second and third years of life, respectively.

CONCLUSIONS

The preliminary data presented here suggest that the Detour EAS offers a permanent and minimally invasive method to establish internalisation of urinary drainage to bypass complete ureteric obstructions for which conventional stenting has failed, open surgery has been tried and failed or was not considered feasible, and long-term nephrostomy drainage was not favoured.

[Prospective study of the quality of life after palliative urinary diversion by subcutaneous pyelovesical bypass (Detour ureteric prosthesis)]

OBJECTIVE

To prospectively evaluate the quality of life of cancer patients at the palliative stage after implantation of an extra-anatomical ureteric prosthesis as an alternative to permanent percutaneous nephrostomy (PCN).

MATERIAL AND METHODS

A series of 27 prostheses in 19 patients with PCN was prospectively evaluated. The ureteric prosthesis (Detour) consists of two concentric tubes glued to each other. The inner tube is made of silicone and the outer tube is made of polyester. This prosthesis is introduced percutaneously into the renal pelvis as an alternative to nephrostomy. It is tunnelled subcutaneously and is introduced into the bladder via a short incision. Patients were reviewed every three months for 18 months or until death. The EORTC QLQ-C30 self-administered questionnaire was used to evaluate the patients' quality of life. The functioning and position of the prostheses were verified by ultrasound and/or intravenous urography (IVU).

RESULTS

There were no failures of prosthesis placement and no intraoperative or early postoperative complications. Injection of the suprapubic incision was observed in 3 cases, in patients with pre-existing bladder disease (radiation cystitis or bladder tumour). The mean follow-up was 7.8 months: 6.6 months for the group of patients who died (15) and 12 months for the 4 patients still alive at the end of the study. Functional scores improved due to elimination of the external nephrostomy tube. In parallel, physical score deteriorated due to disease progression. Overall quality of life and index of satisfaction were improved by elimination of the external diversion.

CONCLUSION

Subcutaneous pyelovesical diversion ensures a better quality of life than classical percutaneous nephrostomy in cancer patients at the palliative stage.

[Prospective study of the treatment of localised ureteric strictures by wire mesh stent]

AIMS

To assess efficacy of Mémotherm BARD ureteral metallic stent in the treatment of non-operable ureteral stenoses.

MATERIAL AND METHOD

Prospective evaluation of ureteral stenoses consecutively treated using Mémotherm BARD ureteral metallic stent. Assessment criteria (recurrence frequency, permeability, tolerance, complications) were measured by clinical examination, Intra Veinous Pyelography, renal sonography, urine culture at 1, and every 3 months.

RESULTS

Thirteen stents were inserted in 12 patients (mean age: 68 yrs) presenting with subsequent ureteral stenosis (9 neoplastic, 3 following radiotherapy) over a 3 year period. No technical difficulty was observed. Mean follow-up was 19 months. Stenosis recurrence was observed in 5 patients, due to tumoural progression, but with no tumour in-growth. There was non incrustation or migration, pain, hematuria, infection due to the stent. All stent remained permeable and functional in surviving patients.

CONCLUSIONS

In our experience, Mémotherm BARD ureteral metallic stent could be considered a useful cost-effective alternative to double J stent or traditional surgery in non-operable or end-of-life patients. The high ureteral stenosis recurrence rate was linked to the patient initial pathology. Considering these encouraging results, this study could represent the first stage of a multicenter tracker-study, which would permit to take into account further technological development of this type of material.

Subcutaneous pyelovesical bypass as replacement for standard percutaneous nephrostomy for palliative urinary diversion: prospective evaluation of patient's quality of life

PURPOSE

To improve the quality of life of patients with palliative definitive percutaneous nephrostomy, we prospectively evaluated a subcutaneous ureteral bypass using a newly designed ureteral prosthesis.

PATIENTS AND METHODS

A series of 19 patients receiving 27 subcutaneous tubes in replacement for percutaneous nephrostomy were evaluated. The ureteral prosthesis (Detour), a silicone tube glued inside a polyester tube, is inserted percutaneously into the renal pelvis to replace an established nephrostomy, tunneled subcutaneously, and introduced into the bladder through a small incision. All patients were followed every 3 months for 18 months or until death from tumor. Quality of life was assessed using the EORTC QLC-30 questionnaire; ultrasonography, intravenous urography, or both were used to assess the position and patency of the tubes.

RESULTS

There was no failure of insertion and no operative or immediate complication. The mean follow-up was 7.8 months, 6.6 months for the 15 patients who died from their tumors and 1 year for the 4 patients still alive at the end of the study. Suprapubic parietal infection occurred in three patients with altered bladders (radiation cystitis or tumor progression). There was an improvement of the function scale as a result of the elimination of the external percutaneous tube and a parallel worsening of the symptom scale secondary to the progression of disease. Patient ratings of the global quality of life and satisfaction with the urinary diversion were improved because of the absence of the percutaneous tube.

CONCLUSION

The subcutaneous pyelovesical bypass provides a better quality of life than a standard percutaneous nephrostomy tube in terminally ill patients by making them external-tube free.

Extraanatomic stents for transplant ureteric stenosis

Surgical and standard endourology options are limited in transplant patients with severe ureteric stenosis, particularly when access to the transplant renal pelvis is limited. The use of a silicone-polytetrafluoroethelene (PTFE)-bonded extraanatomic urinary tract stent for urinary tract drainage is described in two patients. This technique of ureteric reconstruction in renal transplantation may be considered when standard approaches have failed. It appears to be safe when performed by radiologists and urologists with expertise in percutaneous renal access.

Case report: relief of acute obstruction of the Detour subcutaneous pyelovesical bypass

A 36-year-old patient was admitted to the emergency department with complaints of severe flank pain, nausea, vomiting, anuria, and general illness. Five months earlier, we had placed a subcutaneous pyelovesical prosthesis (Detour; Porges) of the ureter for treatment of a chronically dilated upper urinary tract in a solitary right kidney previously treated by double-J stenting. Ultrasonography of the right kidney revealed severe hydronephrosis. A percutaneous nephrostomy catheter was placed, and antegrade pyelography showed complete obstruction of the prosthesis. Urinalysis and culture demonstrated a Candida infection. A systemic antimycotic was administered, and fluid management was started. On the third day, diuresis appeared, and antegrade nephrostomography confirmed patency of the bypass.

Nephrovesical subcutaneous ureteric bypass: long-term results in patients with advanced metastatic disease-improvement of renal function and quality of life

OBJECTIVE

Placing a percutaneous nephrostomy often is the only and final solution for patients with metastatic disease, where internal ureteral stenting proved to be impossible.

METHODS

Between August 1999 and June 2005, 31 nephrovesical ureteric bypasses were implanted in 28 patients with advanced metastatic disease. The ureteric bypass consists of two subcutaneously connected 12F polyurethane tubes, placed as a nephrostomy and cystostomy. Urinary culture, serum creatinine, quality of life score, and renal ultrasonography were evaluated at follow-up.

RESULTS

Mean follow-up was 11.9 mo (range, 2-54 mo). Preoperative hydronephrosis was eliminated in 27 cases (87.1%) and reduced in the remaining four kidneys (12.9%). Preoperative serum creatinine levels (5.9+/-3.2 mg%) decreased significantly postoperatively (1.4+/-0.9 mg%). Mean quality of life score was 3.4+/-1.4 preoperatively and 7.6+/-1.0 postoperatively. In five patients (17.9%) the system had to be replaced due to occlusion at a mean follow-up of 10.2 mo.

CONCLUSION

This nephrovesical ureteric bypass is a simple, minimally invasive, and highly effective treatment for patients with hydronephrosis resulting from advanced oncologic disease. Patients gain a better quality of life due to increased independence and mobility during their final stages of life.

Artificial ureters in renal transplantation

Ureteral strictures in transplanted renal units are initially managed by balloon dilation and indwelling stents. When endourologic management fails, ureteroneocystostomy or pyeloureteral anastomosis to the native ureter is the treatment of choice. Nevertheless, such procedures are not always successful. We present what we believe to be the first two North American cases of silicone-polyester artificial ureters (pyelovesical bypass graft) after failed endourologic or open management of ureteral strictures after renal transplantation. After 12 and 15 months of follow-up, the renal function was stable, with no evidence of obstruction. Long-term follow-up is needed to monitor the rate of late encrustation and obstruction.

Subcutaneous Nephrovesical and Nephrocutaneous Bypass

OBJECTIVE

We evaluated the effectiveness of the subcutaneous bypass for ureteral obstruction in patients with advanced malignancies. Two versions of the minimally invasive technique were performed: nephrovesical and nephrocutaneous bypass.

METHODS

A specially designed composite implant consisting of an inner smooth silicone-covered tube covered by a coiled e-PTFE-tube was used in 14 patients.

RESULTS

10 subcutaneous nephrovesical bypasses were inserted in 10 patients, 8 nephrocutaneous bypasses in 4 patients. During the mean follow-up period of 13.1 months complications were observed in 2 patients with nephrocutaneous bypass, one encrustation and one infection of the bypass system.

CONCLUSIONS

The subcutaneous nephrovesical and nephrocutaneous bypass is a safe alternative for palliative treatment of ureteral obstruction caused by pelvic malignancy.

[Prosthetic pyelovesical and pyelocutanous bypass. A palliative therapy concept in tumor-induced chronic hydronephprosis]

MATERIALS AND METHODS

Since 2/02 to 2/03 a total of 13 patients underwent either pyelovesical bypass (10 patients) or pyelocutaneous bypass (3 patients). A composite implant, consisting of two coaxial tubes internal pure smooth silicone covered by coiled e-PTFE has been designed to serve as the ureteral replacement. This prothesis in inserted percutaneously into the renal pelvis, tunnelled subcutaneously, and introduced through a small suprapubic incision in the bladder or out directly through a cutaneous orifice.

RESULTS

One encrustation of the subcutaneous pyelocutaneous bypass was observed, no angulation or dislocation during a mean follow up of 6.2 month. Improvement in the quality of life was stressed in all patients.

CONCLUSIONS

The subcutaneous urinary division using a silicone-PTFE prothesis is an efficient and minimal-invasive technique to attend malignant obstructions of the ureter.