Precautions and complications in the use of the urolume wallstent

Recurrent Benign Urethral Strictures Treated with Covered Retrievable Self-Expandable Metallic Stents: Long-Term Outcomes over an 18-Year Period

PURPOSE

To assess the long-term outcomes of covered retrievable self-expandable metallic stent (REMS) placement for recurrent benign urethral stricture and to compare the outcomes associated with 3 types of covered REMSs.

MATERIALS AND METHODS

A retrospective study was performed in 54 male patients in whom 114 REMSs were placed between November 1998 and December 2016. These included 26 polyurethane-covered REMSs in 13 patients (group A), 47 internally polytetrafluoroethylene (PTFE)-covered REMSs in 21 patients (group B), and 41 externally PTFE-covered REMSs in 20 patients (group C). The outcomes were analyzed and compared between the groups.

RESULTS

Overall clinical success was achieved in 14 of the 54 patients (24%) at 5-year follow-up (group A, 12%; group B, 19%; group C, 40%). The overall complication rate was 60.5%, and the complication rate was significantly higher in group B than in groups A or C (group A vs B, P = .018; group B vs C, P = .002). The median stent indwelling time and maintained patency period were 3.1 months and 108 months, respectively. In multivariate analysis, stent indwelling time was the only significant factor associated with maintained patency.

CONCLUSIONS

The long-term outcome of covered REMSs has not achieved the desired success rate for the standard treatment of recurrent urethral stricture. However, externally PTFE-covered REMSs showed a better long-term outcome than the other studied types.

Long-term results of permanent memotherm urethral stent in the treatment of recurrent bulbar urethral strictures

PURPOSE

To evaluate the long term outcomes of permanent Memotherm urethral stent in the treatment of recurrent bulbar urethral stricture.

MATERIALS AND METHODS

Twenty patients who underwent permanent Memotherm urethral stent implantation due to recurrent bulbar urethral stricture following previous unsuccessful surgical procedure from 1996 to 2002 were included in the study. Long-term outcomes of the patients were evaluated.

RESULTS

The overall success rate was 87.5% at the end of the tenth year. There was discomfort in implantation area in eight patients about 1 month following the procedure. These patients were treated with alpha-blocker and anti-inflammatory drugs. Stone formation was observed at the urethral stent implantation area in two patients. Post-void dripping has been observed in 15 patients up to the postoperative 3rd month. Stress urinary incontinence was observed in a patient with a 1-year follow-up. Partial stent migration was observed in two patients. None of the patients experienced pain during erection.

CONCLUSION

Memotherm urethral stent is a minimal invasive surgical procedure which can be safely and effectively used in patients with recurrent urethral stricture.

Management for prostate cancer treatment related posterior urethral and bladder neck stenosis with stents

PURPOSE

Prostate cancer treatment has the potential to lead to posterior urethral stricture. These strictures are sometimes recalcitrant to dilation and urethrotomy alone. We present our experience with the Urolume® stent for prostate cancer treatment related stricture.

MATERIALS AND METHODS

A total of 38 men with posterior urethral stricture secondary to prostate cancer treatment were treated with Urolume stenting. Stents were placed in all men after aggressive urethrotomy over the entire stricture. A successfully managed stricture was defined as open and stable for greater than 6 months after any necessary secondary procedures.

RESULTS

The initial success rate was 47%. After a total of 31 secondary procedures in 19 men, including additional stent placement in 8 (18%), the final success rate was 89% at a mean ± SD followup of 2.3 ± 2.5 years. Four cases (11%) in which treatment failed ultimately requiring urinary diversion (3) or salvage prostatectomy (1). Incontinence was noted in 30 men (82%), of whom 19 (63%) received an artificial urinary sphincter a mean of 7.2 ± 2.4 months after the stent. Subanalysis revealed that irradiated men had longer strictures (3.6 vs 2.0 cm, p = 0.003) and a higher post-stent incontinence rate (96% vs 50%, p < 0.001) than men who underwent prostatectomy alone but the initial failure rate was similar (54% vs 50%, p = 0.4).

CONCLUSIONS

Urolume stenting is a reasonable option for severe post-prostate cancer treatment stricture when patients are unwilling or unable to undergo open reconstructive surgery. Incontinence should be expected. The need for additional procedures is common and in some men may be required periodically for the lifetime of the stent.

The Surgical Management of Obstructive Stents Used for Urethral Strictures

PURPOSE

We present our referral experience with patients who had extensive urethral obstruction following UroLume insertion and were treated with urethroplasty.

MATERIALS AND METHODS

We retrospectively analyzed the records of 13 men with urethral stricture who experienced recurrent obstruction following placement of a UroLume endoprosthesis. In all patients several attempts at urethral dilation and optical urethrotomy failed to overcome the obstruction. Complete excision of the obstructed urethra containing the stent with the surrounding periurethral fibrosis was done in all patients. In 12 patients a 1-stage bipedicled penile island tubularized flap was used to bridge the urethral defect. In 1 patient 1-stage urethroplasty was performed and he is awaiting stage 2. Followup assessment included urine flow, post-void residual urine measurement, retrograde urethrogram and urethroscopy at different intervals.

RESULTS

Of the 12 patients who underwent complete treatment 1 had a short segment stricture at the site of the distal anastomosis 3 months after catheter removal, which was successfully managed by internal urethrotomy. He was doing well at the 12-month followup. In 11 patients a successful outcome was noted immediately after catheter removal and it was maintained at a mean followup of 1.8 years (range 1 to 4).

CONCLUSIONS

Complete excision of the obstructed urethra containing the UroLume stent with the surrounding periurethral fibrosis is an important first step in reconstruction. Subsequent use of a 1-stage bipedicled penile island tubularized flap resulted in excellent long-term results. In a small subset of cases delayed stage 2 repair after skin inlay is a valuable option.

Long-term follow-up study of intraurethral stents in spinal cord injured patients with detrusor-sphincter dyssynergia

STUDY DESIGN

Retrospective study.

OBJECTIVES

To assess in the long-term clinical and urodynamic results of intraurethral stents in a group of patients with spinal cord injury.

SETTING

Spinal Cord Injury Unit, Juan Canalejo Hospital, A Coruña, Spain.

METHODS

Forty-seven consecutive male patients were studied from 1993 to 2002. All of them suffered from hyperreflexia with detrusor-sphincter dyssynergia (DSD) owing to spinal cord injury, and were treated by means of the placement of an intraurethral stent at the external sphincter.

RESULTS

After surgery, significant decreases in all the parameters studied were observed. The number of patients with symptoms of urinary tract infection decreased by 25% (P<0.031). Post-void residual urine volume experienced an average decrease of 224.3 cm(3) (P=0.001). Episodes of dysreflexia decreased from 35.1 to 16.2% (P=0.039). The urodynamic study showed an average reduction of 44.36 cm H(2)O in the maximum detrusor pressure (P<0.0001). Complications in the upper urinary tract descended from 46.8 to 23.4% after placing the stent (P=0.013). The most frequent stent complication was displacement, followed by stenosis, lithiasis and intraprosthetic calcification. In all, 8.5% required the stent removal.

CONCLUSIONS

Intraurethral stent is a good choice for the long-term management of DSD in spinal cord-injured patients, even in those who had been previously submitted to prior sphincterotomy. It has the advantage of being a potentially reversible procedure, so patients prefer it to more invasive therapies such as sphincterotomy.

Recurrent traumatic urethral strictures near the external sphincter: treatment with a covered, retrievable, expandable nitinol stent--initial results

PURPOSE

To investigate the clinical effectiveness of a covered, retrievable, expandable nitinol stent in treating traumatic urethral strictures near the external sphincter.

MATERIALS AND METHODS

The stent was 10 mm in diameter when fully expanded and 40-50 mm long. To make it removable, two nylon drawstrings were attached to its lower inner margin. Twelve consecutive men (19-67 years; mean age, 47 years) with traumatic urethral strictures near the external sphincter that were refractory to endoscopic urethrotomy were treated. With fluoroscopic guidance, a stent was placed to completely bridge the external sphincter. The stent was electively removed with a retrieval hook wire 2 months after placement. Stent placement and removal were successful in all patients, with no procedural complications.

RESULTS

Mean maximum urine flow rate was 5 mL/sec (range, 3-7 mL/sec) before stent placement and 27 mL/sec (range, 16-40 mL/sec) at 1 week after placement. During the mean follow-up of 20 months (range, 2-37 months) after the first stent removal, strictures recurred in eight of 12 patients. For the eight patients with recurrence, a second stent was placed and 4 months later was removed from seven of the eight patients. During the mean follow-up of 18 months (range, 4-32 months) after the second stent removal, strictures recurred in two patients, in whom a third stent was placed and then removed 4 months later, with good results. Four (33%) of 12 patients, five (62%) of eight patients, and two (100%) of two patients were successfully treated with placement of the first stent, the second stent, and the third stent, respectively. In the remaining patient, the second stent remains in place.

CONCLUSION

Placement of a covered, retrievable, expandable nitinol stent seems to be effective in treating urethral strictures near the external sphincter and warrants further investigation.

Are stents still a useful therapy for benign prostatic hyperplasia?

PURPOSE OF REVIEW

The use of an endoprosthesis to maintain lumenal patency is a well-established concept used in a variety of surgical settings, including cardiovascular and gastrointestinal pathologies. However, the utility of self-retaining endoprosthetics and their application in prostatic pathology and benign prostatic hyperplasia is not as clear. This report reviews recent developments in the management of symptomatic benign prostatic hyperplasia, particularly the current role of intraprostatic stenting in the advent of other minimally invasive therapies such as laser prostatectomy.

RECENT FINDINGS

Over the past 5 years, urology has witnessed the proliferation of minimally invasive surgical therapies for benign prostatic hyperplasia. These interventions have enabled the urologist to treat a problem whose management was once limited to medical therapy, transurethral resection of the prostate, or open, relatively morbid surgery. The role of stents as an intermediary in cases of treatment failure, or as definitive therapy for benign prostatic hyperplasia and its associated problems is still not clear, when compared with newer, minimally invasive options. Current literature on stents is relatively sparse. However recent studies demonstrate that permanent and temporary prostatic urethral stenting are effective in relieving obstruction and urinary retention. Nevertheless larger controlled clinical studies are needed to demonstrate the real value of this intervention.

SUMMARY

Prostatic stenting has a definite role in the management of benign prostatic hypertrophy, but stents must be used with caution because complications are still relatively common, and their true efficacy and utility in the urological setting has not been determined.

Removal of UroLume endoprosthesis: experience of the North American Study Group for detrusor-sphincter dyssynergia application

PURPOSE

We present the experience of the North American UroLume Multicenter Study Group with removal of the UroLume endoprosthesis.

MATERIALS AND METHODS

A total of 160 neurologically impaired patients were enrolled in the North American UroLume Multicenter Study Group for detrusor external sphincter dyssynergia application. Analysis was performed in 2 groups of patients in which the device was removed during insertion and after implantation, respectively.

RESULTS

Device retrieval was required during insertion in 21 patients (13%) mainly due to misplacement or migration in 17. Extraction was done with minimal complications and in all but 2 cases subsequent UroLume implantation was successful. Of 158 men with the device in place 31 (19.6%) required removal. In 34 procedures 44 devices were removed, mainly due to migration. Time from implantation to removal ranged from 4 days to 66 months (mean 22 months). The UroLume was removed en bloc in 20 cases and in parts or wire by wire in 19. The majority of patients had no or minimal complications after extraction. Only 2 patients had serious temporary complications, including bleeding and urethral injury, with no lasting consequences. No malignancy developed as a result of UroLume insertion.

CONCLUSIONS

While there is a potential for urethral injury and bleeding, UroLume endoprosthesis removal is largely a simple procedure with minimal complications and consequences.

Treatment of anastomotic strictures and urinary incontinence after radical prostatectomy with urolume wallstent and AMS 800 artificial sphincter

Anastomotic strictures and urinary incontinence are severe complications after a radical prostatectomy. We report on two patients suffering from both complications. We treated the anastomotic stricture with a Urolume Wallstent and inserted an AMS 800 artificial sphincter prosthesis 4 to 6 months later for treating urinary incontinence. Finally, the patients were fully continent with no evidence of recurrent strictures.

The combined implant of an endourethral prosthesis and artificial sphincter in post-operative urethral strictures involving the external sphincter

— Urethral strictures still represent one of the most difficult urological pathologies to treat. This report deals with two cases of post-operative urethral strictures involving the external sphincter treated with a combined implant of an endourethral prosthesis and an artificial sphincter AMS-800. Two years after the implant, the urodynamic equilibrium is satisfactory. The relatively high cost of the treatment requires really favourable results in particularly motivated subjects.

Prostatism: benign prostatic hyperplasia

This article is devoted to the most common cause of outlet obstruction in the male geriatric population, benign prostate hyperplasia (BPH). The prevalence, pathophysiology, and natural history of BPH is discussed, along with the work-up and indications for medical or surgical intervention. The authors also focus on medical and surgical options now available for management of BPH.