Combined antegrade and retrograde ureteral stenting: the rendezvous technique

Combined antegrade-retrograde cystourethroscopic rendezvous procedure for the management of a severe urethral stricture during kidney transplantation: A case report

INTRODUCTION

External bladder drainage with an indwelling transurethral catheter is standard during kidney transplant. Difficult Foley catheter placement is a frequent problem and one of the most common reasons for intraoperative urology consults. Suprapubic catheters are usually placed if retrograde urologic instrumentation options fail to cross the urethral obstruction. We report an alternative option with an antegrade-retrograde endoscopic approach.

PRESENTATION OF CASE

This case illustrates a urethral rendezvous procedure applied successfully to traverse an occult mid-urethral stricture for Foley catheter placement during kidney transplantation in a 69-year-old diabetic man with end-stage renal disease and anuria.

DISCUSSION

The combined antegrade-retrograde rendezvous techniques have largely been described in the treatment of complex ureteric strictures more so than urethral strictures. This technique has not been described in the setting of a complex urethral stricture encountered during kidney transplantation. After utilization of the urinary tract rendezvous technique during kidney transplantation, our patient experienced an uneventful post-operative course with excellent renal allograft function.

CONCLUSION

The combined antegrade-retrograde urinary tract rendezvous technique is a feasible and safe technique that can help manage occult severe urethral strictures found at the time of kidney transplantation instead of suprapubic catheter placement when retrograde urologic instrumentation options fail to cross the obstruction.

The "Cut-to-the-Light" Technique Laser Endoureterotomy for Complete Ureteral Obstruction Resurfaces! A New Application of an Old Technique

Objective

To describe our new endoscopic approach in treating iatrogenic ureteral stenosis using the “cut-to-The-light” technique.

Methods

Case of a 54 year-old female patient who underwent a right percutaneous nephrolithotomy to treat a staghorn calculus with two subsequent complimentary ureteroscopies complicated by a severe proximal ureteral obstruction. An antegrade flexible uretereroscope and a retrograde rigid ureteroscope were used to locate the stenosis. With the aid of a 365-µm Ho: YAG laser fiber (settings 0.4 J, 12 Hz), we managed to successfully create a small incision in the stenotic lesion, the rigid ureterscopy light was clearly seen by the antegrade flexible ureteroscope and a through-and-through guidewire was then placed, securing the ureter. Ureteral dilatation was then performed followed by a full thickness incision of the ureteral stenosis. A single 8Fr, 28 cm double J ureteral stent was finally placed after stone fragmentation.

Results

The operating time was 200 mins. No blood loss. No fever or signs of UTI were seen shortly after the operation. The Foley catheter was successfully removed at day one post-op. The hospital stay was short of only 2 days.

Conclusion

The “cut-to-the-light” technique is a new application in the arsenal of ureteral stricture treatment that has been scarcely described in the literature before. The use of this method seems to offer excellent outcomes thus demonstrating the importance of this minimally invasive technique as an alternative to conventional invasive methods used. We believe that studies with larger samples and longer follow up are needed in order to fully determine the benefits of this method and to assess and reveal its suitable application and its drawbacks.

Diagnostic and Interventional Radiology Management of Ureteral Iatrogenic Leakage after Gynecologic Surgery

OBJECTIVE

To report safety and efficacy of interventional radiology procedures in the treatment of gynecologic iatrogenic urinary leaks.

METHODS

A retrospective analysis of iatrogenic ureteral lesions treated between November 2009 to April 2019 was performed. Under ultrasound (US) and fluoroscopy guidance, an attempt to place a ureteral stent and nephrostomy was carried out in the same session using an anterograde percutaneous approach. At the end of any procedure, a fluoroscopic control and a cone-beam CT scan (CBCT) were performed to check the correct placement and functioning of the nephrostomy and DJ stent. In cases of difficult ureteral stent placement via the single anterograde approach, the collaboration of urologists was requested to perform a rendezvous technique, combined with the retrograde approach.

RESULTS

DJ stent placement was achieved using the anterograde approach in 12/15 (80.0%) patients and using the retrograde approach in 3/15 cases (20.0%). Moreover, in 3/15 (20.0%) patients, surgical treatment was needed: in one case because of the persistence of ureteral stenosis at 6 months, and in the other two cases due to ureter-vaginal fistula. No major complications were recorded; overall, minor complications occurred in 4/8 patients.

CONCLUSION

Percutaneous minimally invasive treatment of iatrogenic ureteral lesions after gynecological surgery is a safe and effective option.

Antegrade Double-J Stenting in Grossly Dilated and Tortuous Ureters

Failure of retrograde approach for ureteric stenting warrants percutaneous nephrostomy with antergrade stenting to relieve the pressure symptoms and prevent the need for external drainage. However, in some tight ureteric strictures with grossly dilated tortuous ureter it may not be possible to navigate a ureteric stent across. In such instances pull through or rendezvous techniques have been advocated. Here, we have illustrated simple and novel techniques for traversing tortuous ureters with tight strictures. In one instance, a guide wire was snared via the perurethral approach and the system stabilized from both ends; the flexometallic sheath was then advanced into the urinary bladder across the stricture and a ureteric stent was deployed. In the other situation where the ureter was very tortuous, plain twisting and turning maneuver with retraction of whole assembly was done to straighten the ureter followed by advancement of the flexometallic sheath and stationing of the ureteric stent. In both the cases no significant procedure-related complications were seen and patients were discharged in stable condition. Our experience has led us to believe that occasionally all facilities may not be accessible immediately or the desired armamentarium may be unavailable for interventional radiologists, especially when the patient is on the table; in such cases, simple improvisation and techniques can come in handy to place a ureteric stent across a dilated tortuous ureter.

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

PURPOSE

This study aimed to retrospectively evaluate the safety and efficacy of ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients.

MATERIALS AND METHODS

From January 2005 to April 2015, 19 patients (2 men and 17 women; median age, 59; range, 42-79 years old) with unilateral ureteral lesions (ureteral leakages in 6, strictures in 4, and both in 9) underwent ureteral stent placement using the rendezvous technique. Percutaneous nephrostomy was performed, and stent placement was attempted via antegrade and retrograde approaches. The technical success, procedure-related complications, and clinical success were retrospectively analyzed.

RESULTS

The median follow-up period was 29.8 months (range, 0.3-116.5 months). The ureteral stent placement was successful in 17 out of 19 patients (89.5%). Double J ureteral stent was used in 6 patients, and straight catheter as an internal-external nephro-ureteral stent was used in 11 patients. The rendezvous technique was used in the retroperitoneal space and urinary tract in 6 and 11 patients, respectively. No major complications related to the rendezvous technique occurred. Finally, 4 patients achieved stent-free condition (21.1%), and periodic stent exchange was continued in 9 (47.4%). However, permanent external drainage and surgical reconstruction were needed in 4 (21.1%) and 2 (10.5%) patients, respectively. The final clinical success rate was 68.4% (13 out of 19 patients).

CONCLUSION

Ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients is safe and may be alternative to permanent external drainage and invasive surgical reconstruction.

LEVEL OF EVIDENCE

Level 4, Case series.

Combined antegrade and retrograde access to difficult ureters: revisiting the rendezvous technique

INTRODUCTION

Complex ureteric strictures present a significant challenge to the endourologist and uro-radiologist. Multiple separate interventions to try to cross the stricture are often attempted. We describe our experience managing a heterogenous patient group using the 'rendezvous' procedure.

METHODS AND MATERIALS

16 patients and 18 ureters (one bilateral procedure, and two separate procedures in one patient) underwent rendezvous procedures. Seven patients had coexisting ureteric calculi treated. Each case was followed up for between 3 months and 5 years.

RESULTS

In 16/18 ureters there was technical success at time of surgery; successfully crossing the stricture, allowing ureteroscopic access to the ureter, dilating and/or stenting the ureter. 2/18 were unsuccessful; one secondary to advanced malignancy resulting in a uretero-vaginal fistula and the second a failure to remove a retained, displaced ureteric stent. Of the 18 ureteric procedures; 7/18 were stent free at 3 months, improving to 8/18 stent free at 6 months. 4/18 remained nephrostomy dependent (failure of drainage despite stent or failure to stent) at 3 months, increasing to 6/18 being nephrostomy dependent at 6 months. 1/16 remained dialysis dependent with a nephrostomy tube. For those procedures involving ureteric calculi, 6/7 were stone free and 1/5 had a persistent stone fragment requiring further intervention.

CONCLUSIONS

A combined approach may decrease the number of separate interventions required, with the aim of removing the need for a long-term nephrostomy, as well as providing opportunity to treat ureteric calculi in the context of stricture disease. Our experience has been that where the rendezvous has been required to treat strictures caused by malignant extrinsic compression, stenting has not been successful; this information is key to informed consent in a group of patients who may have a limited life expectancy.

Contemporary management of ureteral strictures

Ureteral stricture disease is a luminal narrowing of the ureter leading to functional obstruction of the kidney. Treatment of strictures is mandatory to preserve and protect renal function. In recent times, the surgical management of ureteral strictures has evolved from open repair to include laparoscopic, robotic and interventional techniques. Prompt diagnosis and early first line intervention to limit obstructive complications remains the cornerstone of successful treatment. In this article, we discuss minimally invasive, endo-urological and open approaches to the repair of ureteral strictures. Open surgical repair and endoscopic techniques have traditionally been employed with varying degrees of success. The advent of laparoscopic and robotic approaches has reduced morbidity, improved cosmesis and shortened recovery time, with results that are beginning to mirror and in some cases surpass more traditional approaches.

Level of evidence: Not applicable for this multicentre audit.

Interventional radiology in iatrogenic ureteral leaks: case series and literature review

Iatrogenic ureteral injuries are a dramatic complication in medical practice. Nowadays there are no universal guidelines for their management. The aim of our study was to evaluate the feasibility of the percutaneous treatment in restoring ureteral integrity in 19 patients that came to our attention. In each case retrograde stenting failed and patients were candidates for re-surgery. Our strategy consists of two phases. The first step is the nephrostomy that allows an external urinary diversion putting dry the damaged ureteral segment. The second step is the anterograde ureteral double-J stenting that keeps near the two stumps promoting the healing of the injured tract. In complete sections, when both retrograde and anterograde stenting singularly failed, we performed a rendez-vous technique with a combined radiological trans-nephrostomic access and urological cystoscopic approach to realign and catheterize the ureteral stumps. In patients with Bricker urinary diversion, peri-anastomotic leaks were treated by positioning a multi-hole pig-tail catheter with the inner end in the renal pelvis and the distal portion outgoing from the cutaneous stoma. Subsequent pyelographic controls demonstrated the resolution of the ureteral leak in all patients and none required a surgical re-intervention. Nephrostomies were removed and ureteral stents were regularly changed. We conclude that interventional uro-radiology may offer a valid conservative option in iatrogenic urinary injuries.

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.

Cutting-balloon angioplasty of resistant ureteral stenosis as bridge to stent insertion

Ureteral stenting is a routine, minimally invasive procedure performed for relief of benign or malignant obstruction. In case of ureteral stenosis, to allow a correct insertion of the stent, a predilatation of the ureter stenosis with a conventional balloon catheter can be necessary. In exceptional cases, it can be difficult to advance an 7-8 Fr JJ-catheter over a tight resistant ureter stenosis following unsuccessful high-pressure balloon dilatation. In the present report, we describe two cases of resistant ureter stenosis successfully dilated by a cutting-balloon following the failure of high-pressure balloon dilatation, allowing a correct and uncomplicated antegrade stent insertion.

Steerable antegrade stenting: a new trick of the trade

INTRODUCTION

Whereas a retrograde attempt to insert an indwelling stent is performed in lithotomy position, usually renal access is gained in a prone position. To overcome the time loss of patient repositioning, a renal puncture can be performed in a modified lithotomy position with torqued truncus and slightly elevated flank. There is a two-fold advantage of this position: transurethral and transrenal access can be obtained using a combined approach. In the present study, this simple technique is used to position a floppy guide wire through a modified needle directly through the renal pelvis into the ureter.

MATERIALS AND METHODS

The kidney is punctured in the modified lithotomy position under sonographic control using an initial three-part puncture needle. A floppy tip guide-wire is inserted into the collecting system via the needle after retrieving the stylet. The retracted needle is bent at the tip while the guide-wire is secured in the needle and the collecting system. The use of the floppy tip guide-wire helps to insert the curved needle back into the kidney pelvis, which becomes the precise guidance for the now steerable wire. The desired steerable stent is positioned under radiographic control in a retrograde fashion over the endoscopically harbored tip of the guide-wire. Two patient cohorts (newly described method and conventional method) were compared.

RESULTS

The presented steering procedure saves 16.5 mean minutes compared to the conventional antegrade stenting and 79.5 Euros compared to the control group.

CONCLUSION

The described combined antegrade-retrograde stent placement through a bent three-part puncture needle results in both clinical superiority (OR time, success rate) and financial benefits.