Stenting Using the Rendezvous Technique for Postoperative Ureteral Complications in Cancer Patients

The Rendezvous Technique: A Minimally Invasive Non-Surgical Approach for the Management of Iatrogenic Ureteral Injuries

Background/Objectives: The aim of our study is to evaluate the feasibility and efficacy of the rendezvous technique for the treatment of iatrogenic ureteral injuries. Methods: From 2014 to 2019, 29 patients treated with the rendezvous technique for mono- or bilateral iatrogenic ureteral injuries were enrolled in this retrospective study. All the leaks were previously assessed by CT-urography and antegrade pyelography. Ureteral continuity was restored by performing the rendezvous technique, combining antegrade trans-nephrostomic access and a retrograde trans-cystostomic approach. A double J stent was antegradely inserted, and a nephrostomy tube was kept in place at the end of the procedure. A post-procedure CT-urography and a 30-day nephrostogram follow-up were performed. In the absence of a contrast leak, the nephrostomy tube was removed. Patient follow-up was set with CT-urography at 3, 6, and 12 months and stent substitution every 4 months. The CT-urography was performed to confirm the restored integrity of the ureter before stent removal. Results: The rendezvous technique was successful in all cases with the resolution of the ureteral leak. No major complications were observed. In all the patients, the nephrostomy tube was removed after 30 days. After performing CT-urography, the stent was removed permanently after 12 months. Only three cases showed local post-treatment stenosis treated with surgical ureteral reimplantation. Conclusions: The rendezvous technique is a safe and effective minimally invasive procedure that can be used to restore the continuity of the ureter, avoiding open surgery and providing valuable support for the management of complications after gynecological surgery.

Magnetic Compression Anastomosis of Benign Short-Segment Ureteral Obstruction

PURPOSE

To investigate the feasibility, safety, and effectiveness of magnetic compression anastomosis of benign short-segment ureteral obstruction.

MATERIALS AND METHODS

Patients referred for failure of ureteral double-J stent placement because of impassable benign ureteral obstruction were included. Eleven patients (11 ureters) with a mean age of 57.5 years (range, 19-85 years; 8 women) underwent ureteral magnetic compression anastomosis. All patients had indwelling nephrostomy catheters. In all patients, anterograde and retrograde ureteral stent placements were unsuccessful using either interventional or cystoscopic access. Ureteral magnetic compression anastomosis was performed as a 2-step procedure. In the first step, magnets were placed. In the second step, the stricture was traversed via magnetic compression anastomosis. Successful establishment of anastomosis and ureteral double-J stent placement were considered technical success. The mean time for complete magnetic adherence and fluoroscopy time for each procedure were recorded.

RESULTS

Five patients (45%) had an ileal conduit. The technical success rate was 91% (n = 10/11). The mean time for magnetic adherence was 5.7 days (SD ± 1.3). The mean single-rotation fluoroscopy times during the first and second steps of the procedure were 9.45 minutes (SD ± 2.09) and 15.70 minutes (SD ± 2.62), respectively. Magnets were removed with the support of either balloon catheters (n = 9) or biopsy forceps (n = 2). No procedure-related adverse events occurred.

CONCLUSIONS

Magnetic compression anastomosis of benign ureteral obstruction is feasible and safe and can be performed in an interventional radiology (IR) suite without the need for endoscopy.

Two methodologies of the rendezvous procedure to establish ureteral continuity from a delayed ureteral leak following pelvic surgery

BACKGROUND

Ureteral trauma recognized in the operating theater is managed, for the most part, at the same surgical procedure oftentimes with urologic consultation. A delayed urine leak presents unique problems in that direct access to the site of the leak is not possible except by a reoperative procedure.

METHODS

In patients who develop delayed urine leakage following cancer surgery, the leakage may be controlled by the collaborative efforts of a urologist and interventional radiologist. Success depends on placement of a nephroureteral stent by the rendezvous procedure.

RESULTS

The sequence of procedures to reestablish ureteral continuity following a delayed leak are important in the successful placement of a nephroureteral stent. In the first methodology, through a percutaneous nephrostomy, a guidewire is placed in the ureter and down to the ureteral defect. The guidewire is then recovered and advanced into the bladder using a ureteroscope and grasping forceps. A nephroureteral stent is placed over the guidewire to bridge the gap and stent the ureteral defect. In the second methodology, the urologist passed a guidewire into the distal ureter, out of the ureteral defect, and into the free peritoneal space. Under fluoroscopic control, the wire loop must snare the ureteral guidewire and pull it out at the percutaneous nephrostomy. The nephroureteral stent is passed over the ureteral wire into the bladder.

CONCLUSIONS

Two different methodologies were described to complete the rendezvous procedure. It can be successful a large percentage of the time with a delayed ureteral leakage. Success requires a combined interventional radiology and urologic procedure.

Therapeutic Ureteral Occlusion with Use of Occlusion Stents for Urinary Leakage or Fistula: A Bicentric Study

PURPOSE

To evaluate the safety and efficacy of ureteral occlusion stents for urinary diversion in patients with inoperable urinary leakage or fistula or intractable bladder bleeding.

MATERIALS AND METHODS

A total of 13 ureters in 12 patients (M:F = 4:8) who underwent ureteral occlusion stenting were included in this study. The internally silicone membrane-coated occlusion stent was a self-expanding stent with constriction at the middle (M-type) or distal end (D-type) of the stent.

RESULTS

The reasons for ureteral occlusion were surgery infeasibility for urinary leakage (n = 6), temporary ureteral occlusion for urinary leakage before surgical reconstruction (n = 2), urinary fistula (n = 3), or control of bleeding from bladder cancer (n = 1). Technical success defined as successful deployment of the occlusion stent with no contrast agent passing beyond the occlusion stent was achieved in 92.3% (12/13 ureters); in one ureter with contrast passage beyond the occlusion stent, additional n-butyl cyanoacrylate (NBCA) embolization was performed immediately so that there was no further leakage. There were no procedure-related complications. During the mean follow-up of 11.6 months, recurrence of urinary leakage was observed in two ureters (15.4%, 2/13) where a D-type occlusion stent was used on the 3-day follow-up antegrade ureterogram; the contrast agent passed through the widened constricted portion of the occlusion stent and repeat occlusion with microcoils, and NBCA was subsequently performed inside the occlusion stent and with no further urinary leakage until the last follow-up.

CONCLUSION

The ureteral occlusion stent is safe and effective for ureteral occlusion. Recurrence of leakage can be managed with additional microcoil and NBCA embolization.