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

[Palliative surgery for metastatic prostate cancer]

Androgen deprivation in combination with novel hormonal agents, docetaxel, or in combination with abiraterone/prednisone plus docetaxel or darolutamid plus docetaxel represent the standard therapeutic approach in metastatic hormone-sensitive prostate cancer (mHSPC). Patients with low-risk prostate cancer also benefit from additional radiation therapy or radical prostatectomy in terms of progression-free and overall survival. Despite favorable response rates, basically all patients will develop castration resistant prostate cancer (CRPC) within 2.5 to 4 years. In addition to systemic chemotherapy, second-line hormonal treatment of systemic application of radionuclides such as radium223 or 177Lu-PSMA represent salvage management options. However, nowadays about 50-65% of patients will develop symptoms due to local progression of prostate cancer which is the result of improved oncological outcomes with significantly prolonged survival times due to the new medical treatment options. Management of such symptomatic local progression will become more important in upcoming years so that all uro-oncologists need to be aware of the various surgical management options. Complications of the lower urogenital tract such as recurrent gross hematuria ± bladder clotting and with the necessity for red blood cell transfusions, subvesical obstruction and acute urinary retention, rectourethral or rectovesical fistulas might be managed by palliative surgery such as palliative transurethral resection of the prostate (TURP), radical cystectomy, radical cystoprostatectomy with urinary diversion, and pelvic exenteration. Symptomatic or asymptomatic obstruction of the upper urinary tract might be managed by endoluminal or percutaneous urinary diversion, ureteral reimplantation, ileal ureter replacement, or implantation of the Detour® system (Coloplast GmbH, Hamburg, Germany).

[Palliative urologic surgery for metastatic prostate cancer: what needs to be considered in the future?]

Androgen deprivation in combination with novel hormonal agents, docetaxel or the combination of abiraterone/prednisone plus docetaxel or darolutamide plus docetaxel represent the standard therapeutic approach in metastatic hormone-sensitive prostate cancer (mHSPC). Patients with low-risk prostate cancer also benefit from additional radiation therapy or radical prostatectomy in terms of progression-free and overall survival. Despite favourable response rates, basically all patients will develop castration-resistant prostate cancer (CRPC) within 2.5 to 4 years. Systemic chemotherapy, second-line hormonal treatment or systemic application of radionuclides such as Radium-223 or 177Lu-PSMA represent salvage management options. As the new medical treatment options have led to an improved oncological outcome with significantly prolonged survival times, about 50% to 65% of patients will develop symptoms due to local progression of prostate cancer. The management of such symptomatic local progression will become more important in upcoming years, which means that all uro-oncologists need to be aware of the various surgical management options. If complications of the lower urogenital tract occur, for example repetitive gross haematuria with or without bladder clotting and with the necessity for red blood cell transfusions, subvesical obstruction, acute urinary retention or rectourethral or rectovesical fistulas, these may be managed by palliative surgery such as palliative TURP, radical cystectomy, radical cystoprostatectomy with urinary diversion, and pelvic exenteration. Symptomatic or asymptomatic obstruction of the upper urinary tract can be managed by endoluminal or percutaneous urinary diversion, ureteral reimplantation, ileal ureter replacement, or implantation of a Detour system. However, an individualised and risk-adapted treatment strategy needs to be developed for each single patient to achieve an optimal therapeutic outcome with improvement of both symptoms and quality of life. In specific clinical situations, best supportive care may be an adequate option.

Unveiling the Challenges in Tandem Ureteral Stent Management for Malignant Ureteral Obstruction: Failure Rate, Risk Factors, and Durability of Their Replacement

BACKGROUND

Malignant ureteral obstruction (MUO) is a sequela of advanced malignant disease that requires renal drainage, with tandem ureteral stents (TUSs) being a viable option. This study aimed to evaluate the TUS failure rate, associated risk factors, and the feasibility of replacing failed TUSs with a new pair of stents.

METHODS

A retrospective analysis of MUO patients treated with TUS insertion from 2014 to 2022 was conducted. TUS failure was defined as urosepsis, recurrent urinary tract infections, acute kidney failure, or new hydronephrosis on imaging. Cox proportional hazard regression analysis identified the independent predictors of TUS failure.

RESULTS

A total of 240 procedures were performed on 186 patients, with TUS drainage failing in 67 patients (36%). The median time to failure was 7 months. Multivariate analysis revealed female gender (OR = 3.46, p = 0.002), pelvic mass (OR = 1.75, p = 0.001), and distal ureteral obstruction (OR = 2.27, p = 0.04) as significant risk factors for TUS failure. Of the failure group, 42 patients (22.6%) underwent TUS replacement for a new pair. Yet, 24 (57.2%) experienced a second failure, with a median time of 4.5 months. The risk factors for TUS second failure included a stricture longer than 30 mm (OR = 11.8, p = 0.04), replacement with TUSs of the same diameter (OR = 43, p = 0.003), and initial TUS failure within 6 months (OR = 19.2, p = 0.006).

CONCLUSIONS

TUS insertion for the treatment of MUO is feasible and has good outcomes with a relatively low failure rate. Primary pelvic mass and distal ureteral obstruction pose higher risks for TUS failure. Replacing failed TUSs with a new pair has a success rate of 42.8%. Consideration should be given to placing larger diameter stents when replacing failed TUS.

Post-Transplant Ureteric Stricture Managed By Extra-Anatomical Stenting With Modification on the Originally Described Stent Location: A Case Report

Ureteric strictures are a relatively uncommon complication following renal transplant, which may be managed endoscopically or surgically by repairing the stricture. Extra-anatomical bypass is a useful procedure in complex cases that bypasses the ureter by creating a subcutaneous route, although it is uncommonly used given its rare indication. We report a case of renal transplant ureteric stricture, in which we utilized a modified extra-anatomical stenting technique with a Detour® stent to avoid the fibrotic planes surrounding the lateral aspect of the kidney graft.

Urinary tract obstruction: Ultrasound-guided intervention

Introduction

Urinary tract obstruction (UTO) is a common clinical problem of which there are many potential causes. The aim of this feature article is to explore the role of ultrasound in diagnosing UTO, during guided interventional procedures and the potential procedural complications.Topic description and discussion: Ultrasound is an integral imaging modality throughout the management pathway of a patient with UTO and is often utilised as a first-line test in diagnosis and treatment. Percutaneous nephrostomy is an interventional technique, usually performed by radiologists or interventional sonographers, as either a short- or long-term management strategy. It can either be used in isolation or to gain access to the renal collecting system prior to more complex interventional or surgical techniques. Ultrasound-guided interventional techniques to relieve UTO can be employed in a number of clinical scenarios each with their own indications, contraindications and complications.

Conclusion

Ultrasound plays a unique role in the planning and active stages of intervention with the provision of dynamic imaging which is crucial for providing safe and effective patient management.

Extra-anatomical stents in benign ureteric obstruction; experience and outcomes

Objectives To present our experience with the Patterson-Forester extra-anatomic stent (EAS, Cook Medical) in patients with benign ureteric obstruction. Utilising an EAS in complex ureteric obstruction can have a significant positive impact on quality of life as a result of removing external drainage devices. Materials and methods Between November 2012 and January 2021 10 patients underwent 33 EAS procedures. All patients had benign ureteric obstruction. Mean age at primary procedure was 58 years (range 43-63). Median follow-up was 27.5 months (range 11-100). Results Eight patients were successfully managed with EAS, with 6 patients continuing to have routine EAS exchanges. Two patients had the distal end exteriorised due to refractory bladder symptoms. There were three short-term failures; the distal end migrated out of the bladder requiring reinsertion one week later; one patient developed urosepsis requiring intravenous antibiotics and the stent removing within 30 days; one proximal stent migrated resulting in cutaneous erosion. The patient is now awaiting further EAS insertion. Conclusion The Patterson-Forester EAS is another tool in the endourologists' armamentarium when managing complex ureteric obstruction. In appropriately selected patients, it can improve their quality of life and is a durable long-term strategy in benign obstruction.

Step-by-step technique for the endoscopic treatment of ureteric stricture

OBJECTIVE

To outline our step-by-step technique for the endoscopic treatment of ureteric stricture.

MATERIALS AND METHODS

Between January 2019 and June 2020, 25 patients with ureteric strictures underwent ureteric bypass and were included in this study. The ureteric bypass surgery included three key steps. First, holmium laser endoureterotomy was used to establish a small channel. Then, balloon dilatation was performed to create a large channel. Finally, an Allium stent was inserted.

RESULTS

Over a median follow-up time of 12 months, the success rate of ureteric bypass surgery was 92.0% (23/25). The median operating time was 78 min. The incidence of pain was 16% (4/25), and the incidence of fever was 4.0% (1/25). The preoperative hydronephrosis volume and urea nitrogen levels decreased significantly after surgery.

CONCLUSIONS

We performed ureteric bypass for patients with ureteric strictures. This technique was found to be safe and effective over a short follow-up time. For patients who are not suitable for surgical reconstruction, the ureteric bypass technique is a good choice.

Modern surgical strategies in the management of complex ureteral strictures

PURPOSE OF REVIEW

The purpose of this article is to outline the various therapeutic options of ureteral strictures.

RECENT FINDINGS

Ureteral strictures with consecutive hydronephrosis can be due to endourological and surgical procedures, inflammatory processes, radiation therapy as well as spontaneous passage of ureteral calculi. When planning surgical correction, stricture length, anatomical location as well as patients' characteristics like age, comorbidities and previous treatment in the peritoneal cavity, retroperitoneum or pelvis should be taken into consideration. Treatment options include not only surgical reconstruction techniques like simple stricture excision, end-to-end anastomosis, ureterolysis with omental wrapping, ureteroneoimplantation, renal autotransplantation and ureter-ileum replacement, but also minimally invasive procedures such as self-expandable thermostents and pyelovesical bypass prosthesis.

SUMMARY

Various therapeutic options can be offered in the treatment of ureteral strictures, potentially leading to long-term success rate of more than 90% and a rate of significant complications < 5%.

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.

Management and treatment options when facing malignant ureteral obstruction

Malignant ureteral obstruction is an unfortunate finding that can be caused by a wide-ranging number of malignancies with a prognosis of limited survival. Given its presentation and progression, it can be refractory to treatment by traditional single polymeric ureteral stents. With a higher failure rate than causes of benign ureteral obstruction, a number of other options are available for initial management, as well as in cases of first-line therapy failure, including tandem stents, metallic stents, percutaneous nephrostomies and extra-anatomic stents. We reviewed the literature and carried out a PubMed search including the following keywords and phrases: "malignant ureteral obstruction," "tandem ureteral stents," "metallic ureteral stents," "resonance stent," "metal mesh ureteral stents" and "extra-anatomic stents." The vast majority of studies were small and retrospective, with a large number of studies related to metallic stents. Given the heterogenous patient population and diversity of practice, it is difficult to truly assess the efficacy of each method. As there are no guidelines or major head-to-head prospective trials involving these techniques, it makes practicing up to the specific provider. However, this article attempts to provide a framework with which the urologist who is presented with malignant ureteral obstruction can plan in order to provide the individualized care on a case-by-case basis. What is clear is that prospective, randomized clinical trials are necessary to help bring evidence-based medicine and guidelines for patients with malignant ureteral obstruction.

Quarter Century Management of Chronic Ureteropelvic Junction Obstruction in a Solitary Kidney with a Ureteral Stent

Background: The ureteral stent provides a conduit for urinary drainage from the kidney to the bladder and is integral to contemporary urologic practice. A ureteral stent is often utilized in acute conditions to prevent or overcome obstruction; however, in nonsurgical patients, because of disease or preference, a ureteral stent may be used as a last resort for long-term management of a stricture in lieu of a nephrostomy tube. This case highlights a patient whose chronic ureteral obstruction has been managed with an indwelling ureteral stent for 25 years; remarkably, stent exchanges are currently required only every 2 years.

Case Presentation: A 33-year-old man initially presented with a solitary left kidney and a ureteropelvic junction obstruction. The patient's right kidney was nonfunctioning since childhood because of a presumed ureteropelvic junction obstruction with grade IV hydronephrosis. The patient underwent two failed open repairs of the left kidney in the 1980s, resulting in a totally intrarenal, constricted renal pelvis; an endopyelotomy in 1992 also failed and required angioembolizaton of a segmental renal vessel. The patient refused any further surgical procedures and thus has been managed exclusively with a 7/14F × 28 cm endopyelotomy stent (Boston Scientific^®) for 25 years; the interval between stent changes was slowly expanded until they are now being done at 2-year intervals. The patient has not developed recurrent urinary tract infections, stent colic, or stent encrustation.

Conclusion: Patients who require chronic indwelling ureteral stents are rare. In this situation, with careful monitoring, the interval between stent exchanges was extended to 2 years, thereby precluding a chronic nephrostomy tube.

Subcutaneous pyelovesical bypass - Detour bypass - as a solution for ureteric obstruction

Introduction

Many patients suffer from unilateral or bilateral hydronephroses caused by pelvic tumors, retroperitoneal fibrosis, occlusion due to radiation therapy or iatrogenic damage to the ureter. Currently, percutaneous nephrostomy or double J stents are primarily used. Nephrostomy deteriorates a patient’s quality of life and leads to frequent infections, blockage of tubes, or bleeding, while uretral stents are associated with septicemia and irritative bladder symptoms. Thus, a useful solution is a Detour stent.

Material and methods

A Detour stent consists of an outer layer made of polytetrafluoroethylene and an inner layer that is a silicone tube 17 F wide, with perforations on both ends and a radio-opaque ring on the proximal end. The ring allows for the insertion of the Detour to the kidney in the correct way. The Detour is placed subcutaneously to the kidney and to the bladder. The route is then tunneled by the large plastic hollow tube for inserting the Detour, and its distal end is sutured to the bladder.

Results

Twelve patients were operated using this method, one of which received a Detour stent bilaterally. The mean follow-up was 10 months. All patients were operated previously by different methods. The average time of surgery was 78 minutes. The following complications occurred: urinary tract infections, haematoma, obstructed flow of urine through the Detour stent, prolonged urinary leakage, and pyelonephritis.

Conclusions

Subcutaneous nephrovesical bypass – Detour System – is a minimally invasive, safe and effective procedure that improves quality of life with no serious complications. The Detour System allows urine to be drained in those cases where many other treatments had failed or were not feasible.

[Ureteral stricture as a late complication of radiotherapy : Possible treatment options]

Ureteral strictures are uncommon complications of radiotherapy which are often recognized late. Their consequences range from harmless dilatation of the ureter to loss of renal function and potential life-threatening urosepsis.Therapy of radiogenic ureteral stricture is a challenging task for every urologist. Several surgical strategies including minimally invasive procedures, reconstruction and partial or complete replacement of the ureter are available.This article provides an overview of the various options in the treatment of radiogenic stricture of the ureter, focusing on the use of ileum and colon segments for ureteral substitution.

Stenting for malignant ureteral obstruction: Tandem, metal or metal-mesh stents

Extrinsic malignant compression of the ureter is not uncommon, often refractory to decompression with conventional polymeric ureteral stents, and frequently associated with limited survival. Alternative options for decompression include tandem ureteral stents, metallic stents and metal-mesh stents, though the preferred method remains controversial. We reviewed and updated our outcomes with tandem ureteral stents for malignant ureteral obstruction, and carried out a PubMed search using the terms "malignant ureteral obstruction," "tandem ureteral stents," "ipsilateral ureteral stents," "metal ureteral stent," "resonance stent," "silhouette stent" and "metal mesh stent." A comprehensive review of the literature and summary of outcomes is provided. The majority of studies encountered were retrospective with small sample sizes. The evidence is most robust for metal stents, whereas only limited data exists for tandem or metal-mesh stents. Metal and metal-mesh stents are considerably more expensive than tandem stenting, but the potential for less frequent stent exchanges makes them possibly cost-effective over time. Urinary tract infections have been associated with all stent types. A wide range of failure rates has been published for all types of stents, limiting direct comparison. Metal and metal-mesh stents show a high incidence of stent colic, migration and encrustation, whereas tandem stents appear to produce symptoms equivalent to single stents. Comparison is difficult given the limited evidence and heterogeneity of patients with malignant ureteral obstruction. It is clear that prospective, randomized studies are necessary to effectively scrutinize conventional, tandem, metallic ureteral and metal-mesh stents for their use in malignant ureteral obstruction.

The use of internal stents in chronic ureteral obstruction

PURPOSE

Despite the lack of a well delineated definition, chronic ureteral obstruction imposes significant quality of life loss, increased pathological morbidity and risk of mortality as well as substantial economic burden. Ureteral stenting serves as an important therapeutic option to alleviate obstruction. Thus, we assessed the recently published literature on chronic ureteral obstruction; treatment options; types, benefits and shortcomings of current ureteral stents; as well as outcomes and complications of chronic ureteral stenting, with the goal of providing concise management guidelines.

MATERIALS AND METHODS

A systemic literature review was performed on Embase™, PubMed®, Cochrane Controlled Trials Register and Google Scholar™ on ureteral obstruction and internal ureteral stents. Relevant reviews, original research articles and their cited references were examined, and a synopsis of original data was generated on a clinically oriented basis.

RESULTS

Chronic ureteral obstruction can be classified into compression that is either intrinsic or extrinsic to the ureteral wall, or obstruction that is of a benign or malignant origin. Patients with malignant ureteral obstruction generally have a poor prognosis and are often difficult to treat. The aim of stenting is to adequately drain the upper urinary tracts while minimizing hospitalization and the negative impact on quality of life. Facing the challenge of chronic ureteral obstruction, novel stents with new compositions, materials, coatings and designs have been developed. Metallic stents are emerging as efficacious and financially viable alternatives. Early stent related complications include iatrogenic injury, stent migration or patient discomfort, while late complications include infection, difficulties with stent exchange, hardware malfunction, infection and stent encrustation.

CONCLUSIONS

Stenting in chronic ureteral obstruction is a complex and challenging problem. Much work is being done in this area and many options are being explored.

Extra-anatomic stent (EAS) as a salvage procedure for transplant ureteric stricture

Ureteric stricture is the most common urological complication following renal transplantation. Management often involves endo-urological interventions and open surgery. The definitive treatment is surgical reconstruction to restore continuity. Where this is not possible or contra-indicated and a stent cannot be placed in the ureter, an extra-anatomic stent (EAS) could be used to bypass a complete ureteric obstruction. Using an existing nephrostomy tract, a percutaneous stent is placed in the kidney and is tunneled under the skin into the bladder establishing extra-anatomical urinary drainage. We report the use of a novel EAS system in a patient with transplant ureteric stricture when antegrade stent placement or surgical reconstruction was not possible.

[Avoidance and management of complications in open surgical ureter reconstruction]

Open surgical reconstruction of the ureter is a urological procedure with a potentially high risk of complications. The correct selection of patients and time of operation are important aspects regarding the treatment strategy. Position and length of the affected ureter segment to be reconstructed determine the surgical intervention possibilities. The psoas hitch procedure is a well-established technique for distal reconstruction of the ureter where most iatrogenic injuries occur. In more proximal or complex defects, several procedures are available. Partial or complete replacement of the ureter with bowel is still considered the standard for bridging long ureteral defects but is accompanied with higher intra- and postoperative complication rates. In specific patients and situations, autotransplantation of the kidney and subcutaneous pyelovesical bypasses are clinical options. Using mucosal grafts or tissue engineering may be new therapeutic prospects to cover ureteral defects but the clinical impact still needs to be clarified. All therapeutic strategies share the fact that great surgical expertise and experience are necessary as the operative technique must be mastered to avoid severe complications.

Management of secondary pelviureteric junction obstruction

Pelviureteric junction obstruction (PUJO) of the kidney can lead to a number of different clinical manifestations, which often require surgical intervention. Although the success of pyeloplasty and endopyelotomy are good, there are still a number of patients who fail primary treatment and develop secondary PUJO. These treatment failures can be a challenging cohort to manage. This article aims to provide a comprehensive overview on the surgical options available to the urologist for managing secondary PUJO as well as providing some guidance on assessing factors that will influence management decisions.

Metallic ureteral stents in malignant ureteral obstruction: short-term results and radiological features predicting stent failure in patients with non-urological malignancies

PURPOSE

To provide short-term result of the metallic ureteral stent in patients with malignant ureteral obstruction and identify radiological findings predicting stent failure.

MATERIALS AND METHODS

The records of all patients with non-urological malignant diseases who have received metallic ureteral stents from July 2009 to March 2012 for ureteral obstruction were reviewed. Stent failure was detected by clinical symptoms and imaging studies. Survival analysis was used to estimate patency rates and factors predicting stent failure.

RESULTS

A total of 74 patients with 130 attempts of stent insertion were included. A total of 113 (86.9 %) stents were inserted successfully and 103 (91.2 %) achieved primary patency. After excluding cases without sufficient imaging data, 94 stents were included in the survival analysis. The median functional duration of the 94 stents was 6.2 months (range 3-476 days). Obstruction in abdominal ureter (p = 0.0279) and lymphatic metastasis around ureter (p = 0.0398) were risk factors for stent failure. The median functional durations of the stents for abdominal and pelvic obstructions were 4.5 months (range 3-263 days) and 6.5 months (range 4-476 days), respectively. The median durations of the stents with and without lymphatic metastasis were 5.3 months (range 4-398 days) and 7.8 months (range 31-476 days), respectively.

CONCLUSION

Metallic ureteral stents are effective and safe in relieving ureteral obstructions resulting from non-urological malignancies, and abdominal ureteral obstruction and lymphatic metastasis around ureter were associated with shorter functional duration.

[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.

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.

Pyelovesical bypass graft for palliative management of malignant ureteric obstruction: optimizing the technique by percutaneous access to the bladder using a split Amplatz sheath

OBJECTIVES

To introduce a simple modification to the original technique of pyelovesical bypass graft placement to make the procedure more minimally invasive.

METHODS

During the study period 2 patients with malignant ureteric obstruction underwent pyelovesical bypass graft placement using Detour stent (Mentor-Porges). The technique simply comprised tract dilatation of the previously placed percutaneous nephrostomy to place the proximal end of the graft in the renal collecting system, making a subcutaneous tunnel from a 1-cm suprapubic incision to the flank area, percutaneous access to the bladder under fluoroscopic guide and placement of the distal end of the stent into the bladder through a split Amplatz sheath. The operative outcome was analyzed prospectively.

RESULTS

Both patients tolerated the procedures well with no intra- and postoperative complications. Renal function remained stable during the follow-up period with acceptable urine output through the urethra. Abdominal wall complications such as fistula formation or pain along the subcutaneous tract as well as stent encrustation did not occur during the follow-up period.

CONCLUSIONS

Despite our small sample size and short follow-up period, percutaneous access to the bladder using a split Amplatz sheath during placement of the Detour stent, may be considered as a promising simple modification to optimize the technique by obviating the need for open cystostomy incision.

Long-term nephrostomy in an adult male spinal cord injury patient who had normal upper urinary tracts but developed bilateral hydronephrosis following penile sheath drainage: pyeloplasty and balloon dilatation of ureteropelvic junction proved futile: a case report

Introduction

The consequences of spinal cord injury upon urinary bladder are readily recognised by patients and health care professionals, since neuropathic bladder manifests itself as urinary incontinence, or retention of urine. But health care professionals and persons with spinal cord injury may not be conversant with neuropathic dysmotility affecting the ureter and renal pelvis. We report an adult male patient with spinal cord injury, who developed bilateral hydronephrosis after he started managing neuropathic bladder by penile sheath drainage.

Case presentation

A male patient, born in 1971, sustained spinal cord injury following a motorbike accident in September 1988. In November 1988, intravenous urography showed normal upper tracts. He was advised spontaneous voiding with 2-3 catheterisations a day. In February 1995, this patient developed fever, chills and vomiting. Blood urea: 23.7 mmol/L; creatinine: 334 umol/L. Ultrasound revealed marked hydronephrosis of right kidney and mild hydronephrosis of left kidney. Bilateral nephrostomy was performed in March 1995. Right pyeloplasty was performed in May 1998. In July 2005, this patient developed urine infection and was admitted to a local hospital with fever and rigors. He developed septicaemia and required ventilation. Ultrasound examination of abdomen revealed bilateral hydronephrosis and multiple stones in left kidney. Percutaneous nephrostomy was performed on both sides. Subsequently, extracorporeal shock wave lithotripsy of left renal calculi was carried out. Right nephrostomy tube slipped out in January 2006; percutaneous nephrostomy was performed again. In June 2006, left ureteric antegrade stenting was performed and nephrostomy tube was removed. Currently, right kidney is drained by percutaneous nephrostomy and left kidney is drained by ureteric stent. This patient has indwelling urethral catheter.

Conclusion

It is possible that regular intermittent catheterisations along with anticholinergic medication right from the time of rehabilitation after this patient sustained paraplegia might have prevented the series of urological complications. Key components to successful management of external drainage of kidney in this patient are: [1] use of size 14 French pigtail catheter for long-term nephrostomy, [2] anchoring the catheter to skin to with Percufix catheter cuff to prevent accidental tug [3], replacing the nephrostomy dressing once a week by the same team in order to provide continuity of care, and [4] changing nephrostomy catheter every six months by a senior radiologist.

Updates in endourology

Rapid urologic innovations in minimally invasive treatment are creating exciting new horizons in endourology. However, these new concepts are blurring the traditional boundary between endourology and oncology. Organ-sparing surgery, laparoscopy, robotics systems, and image-guided ablation techniques enable surgeons to develop specifically tailored treatments for patients. We examine recent developments and future prospects for how new technology will continue to advance the field of endourology.