Holmium laser endoureterotomy for benign ureteral stricture: a single center experience

Evaluation of risk factors, treatment options, and prognostic-related factors in patients with benign ureteral strictures: An 8-year single-center experience

OBJECTIVES

To investigate the etiology, therapeutic effect, and prognosis-related factors of benign ureteral strictures.

METHODS

We analyzed the date of 142 patients with benign ureteral strictures from 2013 to 2021. Ninety-five patients received endourological treatment and 47 patients underwent reconstruction. Preoperative, intraoperative, and postoperative information were compared and analyzed. Symptomatic improvement and radiographic blockage alleviation defined therapeutic success.

RESULTS

Stone-related factors caused 85.2% of cases. The overall success rate of endourological treatment was 51.6% versus 95.7% of reconstruction (p < 0.01). However, endourological treatment was better in terms of postoperative hospital stay time, operation time, and intraoperative blood loss (p < 0.001). In endourological group, patients with stricture length ≤2 cm, mild-to-moderate hydronephrosis, proximal or distal stricture had a higher success rate. Multivariate regression analysis showed that the surgical method was the only independent risk factor affecting success and recurrence. Reconstruction success rate was higher than endourological treatment (p = 0.001, OR 0.057, 95% CI (0.011-0.291)), and recurrence rate was also lower (p = 0.001, HR 0.074, 95% CI (0.016-0.338)). No obvious recurrence was seen in reconstruction, and the median recurrence time in endourological treatment was 51 months.

CONCLUSIONS

Stone-related factors are an important cause of benign ureteral strictures. Reconstruction is the gold standard treatment due to its high success rate and low recurrence rate. Endourological therapy is also preferred as the initial treatment in proximal or distal ureter with length ≤2 cm and mild-to-moderate hydronephrosis. Further close follow-up is required after treatment.

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.

Effects of hormone therapy on the clinical outcomes of endoscopic intervention in patients with endometriosis-related ureteral obstruction

PURPOSE

We investigated whether endoscopic interventions, including laser endoureterotomy and balloon dilatation following hormone therapy, are a good choice to treat ureteral obstruction due to ureteral endometriosis instead of laparoscopic or open surgery.

MATERIALS AND METHODS

Patients with ureteral obstruction due to endometriosis who underwent endoscopic intervention between 2004 and 2021 were reviewed. Patients with other causes of ureteral obstruction or previous ureteral surgery were excluded from the study. The primary endpoint was the 3-month success rate of endoscopic intervention with or without hormone therapy. Secondary endpoints were the success rate of endoscopic intervention between the hormone-treated and hormone-untreated groups at 6 months and the success rate according to the hormone therapy response of endometriosis at 3 and 6 months.

RESULTS

Eighteen patients with 19 ureter units were evaluated in this study, including 12 patients receiving hormone therapy and six patients not receiving hormone therapy. Among patients receiving hormone therapy, one patient had bilateral ureteral obstruction. The success rate of endoscopic intervention was higher in patients who received hormone therapy than in those who did not receive hormone therapy three months after endoscopic intervention (76.9% vs. 0.0%, p=0.003). The same result was also found 6 months after endoscopic intervention (75.0% vs. 0.0%, p=0.005). In addition, the success rates were higher in the hormone-responsive group than in the non-responsive group (100.0% vs. 57.1%), although the difference was not statistically significant (p=0.122).

CONCLUSIONS

Ureteral obstruction caused by endometriosis can be effectively treated by endoscopic intervention with hormone therapy in select patients.

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.

Ureterorenoscopic (URS) Lithotripsy and Balloon Dilation Cause Acute Kidney Injury and Distal Renal Tubule Damage: A Prospective Study

Ureterorenoscopy (URS) is believed to be a safe and effective procedure for treating ureteral stones or ureteral strictures. Rapidly increasing intrarenal pressure during URS may have a negative impact on the kidney, but its effect on renal function is not well known. The aim of this study was to evaluate whether URS balloon dilation or lithotripsy could cause acute kidney injury (AKI), which was evaluated using urine neutrophil gelatinase-associated lipocalin (NGAL), and renal tubular damage, which was evaluated using urine α-glutathione S-transferase (GST) and πGST. This prospective study included 207 patients with a mean age of 53.8 years between September 2012 and June 2013. Four groups were included: the ureteral stricture group (group 1), the ureteral stone group (group 2), and two control groups. URS increased urine NGAL (uNGAL) levels on days 1 and 14 in both groups, and only elevated uGST levels were noted on day 14 after URS lithotripsy (URS). On day 14, the difference between low-grade and high-grade hydronephrosis was significant in group 1 (p < 0.001) compared to that in group 2 (p = 0.150). Multivariate logistic regression analysis revealed that age, baseline estimated glomerular filtration rate (eGFR), and stone size > 1.0 cm were associated with the complete recovery of hydronephrosis after URS on day 14. Patients with ureteral stones with preserved renal function had more AKI than those with impaired renal function. However, there was no significant difference in URS-related AKI between the ≤1 cm and >1 cm subgroups. In addition, urine αGST and πGST levels were both significantly higher in the stone > 1 cm subgroup than in the ≤1 cm subgroup. In conclusion, URS laser lithotripsy and balloon dilatation resulted in AKI and renal tubular damage on day 14, although post-URS double-J (DBJ) stenting was performed in every patient.

Comprehensive endoscopic management of impacted ureteral stones: Literature review and expert opinions

Treatment of urolithiasis, a benign disease, requires high efficacy and safety. Endoscopic treatment of impacted ureteral stones remains a challenging procedure for urologists, despite recent remarkable advances in surgical technology in treatment of urolithiasis. The success rate of endoscopic treatment in patients with impacted stones is reported to be lower than that in patients with nonimpacted stones. Moreover, the presence of stone impaction is associated with high rates of intraoperative and postoperative complications. The best management for patients with impacted ureteral stones should therefore be devised based on the latest knowledge and techniques. The present review focuses on the preoperative prediction of stone impaction, the safest and most effective endoscopic surgical procedures, and the most appropriate management for postoperative ureteral strictures. We overview comprehensive endoscopic management for impacted ureteral stones based on literature review and expert opinions.

Analysis of long-term effect of ureteral balloon dilatation combined with internal and external drainage tube in the treatment of benign ureteral stricture

Purpose

There are few reports about balloon dilatation combined with internal and external drainage tube in the treatment of ureteral stricture under interventional therapy. The aim of the study is to explore the safety, effectiveness and long-term efficacy of this treatment strategy.

Materials and methods

It is a retrospective and observational study. From October 2013 to October 2016, 42 patients with benign lower ureteral stricture received interventional treatment. Balloon dilatation combined with internal and external drainage tube implantation were used. There were 25 male patients and 17 female patients. There were 7 cases (16.7%) with congenital ureteral stricture, 12 cases (28.6%) with inflammation, 15 cases (35.7%) with ureteral stricture after lithotomy or lithotripsy, and 8 cases (19.0%) with ureteral stricture after pelvic or abdominal surgery. After the drainage tube was removed, B ultrasound, enhanced CTU or IVP of urinary system were reexamined every six months. The follow-up time was 12–60 months.

Results

The age was 52.9 ± 11.6 years. The length of ureteral stricture was 1.1 ± 0.5 cm. 42 patients completed interventional treatment, the technical success rate was 100%, no ureteral perforation, rupture or other complications were identified. Preoperative urea nitrogen 9.2 ± 2.3 mmol/L and creatinine 175.8 ± 82.8umol/L. Urea nitrogen and creatinine were 3.8–9.1 mmol/L and 45.2–189.6 umol/L when removing the drainage tube. There were significant differences in the levels of urea nitrogen and creatinine before and after tube removal (P < 0.05). The ureteral patency rate was 100% at 6 months, 93% at 12 months, 83% at 18 months, 79% at 24 months, 76% at 30 months and 73% at 36–60 months. The overall success rate was 73%. Multivariate Cox regression analysis showed that stenosis length was a risk factor for postoperative patency (P < 0.05).

Conclusion

Balloon dilatation combined with internal and external drainage tube implantation in the treatment of benign lower ureteral stricture is safe and effective.

Endoureterotomy with the Lovaco technique for treatment of ureterointestinal strictures: outcomes in an experienced center and factors associated with procedural success or failure

INTRODUCTION

The study aimed to present the outcomes of an endoureterotomy series using the Lovaco technique for the treatment of ureterointestinal strictures. Factors influencing the success or failure of this technique were also determined.

MATERIALS AND METHODS

Data were collected from all endoureterotomies for ureterointestinal strictures performed in a single-center between 2017 and 2020. Clinical variables and characteristics of the stricture were recorded in each case, and success was defined as the complete resolution of ureterohydronephrosis. Univariate analysis was used to correlate the variables recorded with procedural success or failure.

RESULTS

A total of 25 patients were recruited: 16 with strictures on the left side, 5 on the right, and 4 bilateral. With the first endoureterotomy, 52% of the cases (13 patients) were resolved, and in patients undergoing a second intervention 64% success (16 patients) was achieved. Infectious complications occurred in 23.3% of surgeries. Stricture length, poor renal function, and left side involvement were associated with endoureterotomy failure.

CONCLUSIONS

Endoureterotomy with the Lovaco technique is a useful method in the setting of ureterointestinal strictures, achieving complete resolution of the obstruction in more than 60% of cases. Factors that can negatively affect the success of the procedure include stricture length, poor renal function, and left side involvement.

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.

Heparin coating in biodegradable ureteral stents does not decrease bacterial colonization-assessment in ureteral stricture endourological treatment in animal model

Background

We assessed an antireflux biodegradable heparin-coated ureteral stent (BraidStent^®-H) in an animal model comparative study after endoscopic treatment of ureteral strictures.

Methods

A total of 24 female pigs underwent initial endoscopic, nephrosonographic, and contrast fluoroscopy assessment of the urinary tract. Afterward, unilateral laparoscopic ureteral stricture model was performed. Three weeks later, the animals underwent laser endoureterotomy and were randomly assigned to Group-I, in which a double-pigtail stent was placed for 6 weeks, or Group-II, in which a BraidStent®-H was placed. Follow-up was carried out by ultrasonography, contrast fluoroscopy, ureteroscopy, urinalysis and bacteriuria assessment at 3, 6, 12 and 5 months. Finally, a pathological study of the urinary system was performed.

Results

There were no animals in Group-II with vesicoureteral reflux, with significance at 6 weeks with Group-I. Distal ureteral peristalsis was maintained in 50–75% in Group-II at 1–6 weeks. The 91.7% of stents in Group-II were degraded between 3–6 weeks, without obstructive fragments. Bacteriuria in Group II was 33.3–50% at 3 and 6 weeks. The global success rate by groups was 91.6% and 87.5% in groups I and II, respectively, with no statistical significance.

Conclusions

BraidStent^®-H has been shown to be as efficacious as current ureteral stents in the treatment of benign ureteral strictures following laser endoureterotomy. In addition, it reduces the morbidity associated with current stents and has a homogeneous and predictable degradation rate of about 6 weeks, with no obstructive fragments. Future studies are required to improve the antibacterial coating to reduce BraidStent^®-H contamination in view of the results obtained with the heparin coating.

Long-Term Outcomes of Two Ipsilateral vs Single Double-J Stent After Laser Endoureterotomy for Bilharzial Ureteral Strictures

Background: Laser endoureterotomy became a preferable choice for managing benign ureteral strictures. Ureteral stricture caused by bilharzias is characterized by focal destruction of ureteral musculature, ending by fibrosis, making it poor responder to endoureterotomy. There is no consensus about the ideal ureteral stent size after endoureterotomy. However, many researches recommend larger stents caliber (12-14F). We assess long-term efficacy of insertion of two ipsilateral Double-J stents vs single Double-J stent after laser endoureterotomy for bilharzial ureteral stricture. Materials and Methods: Within 4 years, 70 patients underwent retrograde laser endoureterotomy for bilharzial ureteral stricture (diagnosed by positive history of bilharziasis, positive serology test, and/or bilharzial cystoscopic finding). Patients with history of stone, urologic or pelvic surgery were excluded. Patients were randomized into two groups: the first group (35 patients) received ipsilateral two Double-J (7F each) postendoureterotomy, whereas the second group (35 patients) received one Double-J (7F). Double-Js were removed after 8 weeks. Follow-up was done regularly by clinical interpretation and imaging studies. Patients' characteristics, operative data, and postoperative outcomes (subjectively and objectively) were compared in both groups. Results: Sixty-three patients completed follow-up >18 months, mean follow-up 30 ± 4 months [19-41], and mean stricture length 1.4 ± 0.6 cm [0.5-3.0], with no statistical significance between both groups. Success proved by relief of symptoms and radiographic resolution of obstruction. The overall success rate was significantly better in 2-Double-J group than in 1-Double-J group (83.9% vs 53.1%) p = 0.009, and also for stricture >1.5 cm (85.7% vs 38.5%) p = 0.018, respectively. Conclusions: Insertion of two ipsilateral Double-J, after laser endoureterotomy for bilharzial ureteral stricture associated with long-term success rate better than insertion of 1-Double-J, especially for stricture segment >1.5 cm.

Factors affecting the effectiveness and success of retrograde holmium laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction in adults

PURPOSE

To evaluate the factors affecting the effectiveness, safety, and success of retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction in adults.

METHODS

Adult patients who underwent retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction between January 2012 and June 2016 at our clinic were retrospectively analyzed. Success was defined as the relief of symptoms and the resolution of obstruction, as assessed via radiography. Factors affecting success were analyzed, such as the clinical characteristics, procedural outcomes, complications, and the type of ureteroscopy used in the procedure.

RESULTS

Procedural success was achieved in 29 (74.4%) out of 39 patients, with a mean age of 38.3 ± 12.3 years during a median follow-up duration of 44 (33-65) months. Failure occurred at a median of 4.5 (3-22) months. It was detected that the presence of primary obstruction, ipsilateral kidney function being >30% of normal, and the length of obstruction being <1 cm positively affected procedural success (p = 0.009, p = 0.011, and p = 0.019, respectively). In the postoperative period, two Grade I and four Grade II complications were observed according to the Clavien-Dindo classification. There was a difference only in the operation time between semirigid (24) and flexible ureteroscopes (15), with the operation time being shorter with the use of a semirigid ureteroscope than with the use of a flexible uteroscope (p < 0.001).

CONCLUSION

Retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy is a minimally invasive method that can be used effectively and safely as the primary treatment of patients with ureteropelvic obstruction, when long-term results are also taken into consideration. The decision of performing laser endopyelotomy should be made after a detailed evaluation of the characteristics of the patient as well as of the obstruction.

Post ureteroscopic stone surgery ureteral strictures management: a retrospective study

PURPOSE

To share experience in managing ureteral strictures following ureteroscopic lithotripsy.

METHODS

Ninety five patients diagnosed as ureteral strictures after ureteroscopic lithotripsy between January 2013 and January 2018 were included. 53 received endourological treatment, 34 underwent reconstruction, 6 underwent nephrectomy for severe renal impairment, and 2 chose routine ureteral stent replacement. Therapeutic success was defined as absence of clinical symptoms and radiologic relief of obstruction.

RESULTS

The follow-up time ranged from 13 to 57 months, with a median time of 24. It lasted more than 13 months in all patients, exception for 2 nephrectomies. Two patient groups including 69 endourological procedures and 37 reconstructions were used to compare therapeutic effects and complications. The overall success rate was 60.9% (42/69) in endourological intervention vs. 97.3% (36/37) in reconstruction (p < 0.001), while 74.4% (29/39) patients with stricture less than 1 cm and 68.8% (33/48) patients with mild-to-moderate hydronephrosis achieved success in endourological group. All except 1 failure appeared within the first year postoperatively. Subgroup analyses for endourological procedures revealed significant differences in the success rate of different stricture lengths and hydronephrosis (p = 0.004 and p = 0.043). Multivariate Cox regression analysis indicated that reconstruction was significantly related to a more successful outcome, compared with endourological procedures (HR 0.052, 95% CI 0.007-0.394, p = 0.004).

CONCLUSION

Reconstruction performs better than endourological procedures in surgical outcome. Endourological procedure provides an acceptable success rate in patients with stricture shorter than 1 cm and slight hydronephrosis. Most stricture recurrence appeared within the first year postoperatively.

Minimally invasive management of ureteral strictures: a 5-year retrospective study

Introduction

Ureteric strictures are well-documented complications related to surgery or radiation therapy. Minimally invasive treatment using endoscopic dilatation or laser incision is the standard practice. There are no existing guidelines on which techniques to use in the treatment of different stricture types and a paucity of data regarding long-term results.

Purpose

Our study aimed to retrospectively assess the long-term efficacy of minimally invasive treatment in benign and malignant ureteric strictures.

Materials and methods

Over a 5-year period, 2007–2012, we analyzed the data of 59 consecutive patients undergoing minimally invasive treatment for symptomatic ureteric strictures. We excluded 16 patients from final analysis due to failed access or loss to follow-up. All patients but one were treated with antegrade, retrograde balloon or catheter dilatations. Successful outcome was defined as an asymptomatic, completely catheter free patient, with stable renal function.

Results

43 patients were eligible for retrospective final analysis. The largest proportion of strictures occurred following surgery combined with radiotherapy 8/43 (19%). Preoperative decompression was required in 30/43 (70%). We identified 32/43 (75%) balloon dilatations, 10/43 (23%) catheter dilatations and 1/43 (2%) laser incision. Overall success rate was 31/43 (72%). All 6 recurrences occurred within 36 months, 4 within the first 12 months. 3/6 patients were successfully re-dilated.

Conclusion

Minimally invasive treatment is a worthwhile alternative in strictures due to previous radiation and/or surgical treatment of malignancies. Most recurrences occurred within the first year. However, late recurrences arise; therefore, patients should be subject to long-term follow-up. Moreover, re-dilatation may be required.

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.

Endoscopic Management of Ureteral Strictures: an Update

PURPOSE OF REVIEW

This review focuses on the role of endoscopic treatment of ureteral stricture disease (USD) in the era of minimally invasive surgery.

RECENT FINDINGS

There is a relative paucity of recent literature regarding the endoscopic treatment of USD. Laser endopyelotomy and balloon dilation are associated with good outcomes in treatment-naïve patients with short (< 2 cm), non-ischemic, benign ureteral strictures with a functional renal unit. If stricture recurs, repetitive dilation and laser endopyleotomy is not recommended, as success rates are low in this scenario. Patients with low-complexity ureteroenteric strictures and transplant strictures may benefit from endoscopic treatment options, although formal reconstruction offers higher rates of success. Formal ureteral reconstruction remains the gold-standard treatment for ureteral stricture disease as it is associated with higher rates of complete resolution. However, in carefully selected patients, endoscopic treatment modalities provide a low-cost, low-morbidity alternative.

Simultaneous antegrade and retrograde endoscopic treatment of non-malignant ureterointestinal anastomotic strictures following urinary diversion

Background

The ureterointestinal anastomosis stricture (UAS) is a common complication of urinary diversion after radical cystectomy. For decades, open anastomotic revision remained the gold standard for the treatment of UAS. However, with the advancement in endoscopic technology, mini-invasive therapeutic approaches have been used in its management. Here, we report our experience with and long-term results of combined simultaneous antegrade and retrograde endoscopy (SARE) in the treatment of non-malignant UASs after urinary diversion in a consecutive series of patients.

Methods

From March 2012 to January 2015, there were 32 consecutive patients with 32 non-malignant UASs following radical cystectomy and urinary diversion. Twenty-nine patients were treated with SARE technique and comprised the study group. Using simultaneous antegrade flexible ureteroscope combined with retrograde semi-rigid ureteroscope or nephroscope, partial or complete strictures were managed with laser incision and balloon dilation under direct visualization. A 7/12 Fr graded endopyelotomy stent was left for 3–6 months after the procedure. Success was defined as symptomatic improvement and radiographic resolution of obstruction.

Results

With a median followup of 22 months (6–36), the overall success rate for SARE was 69.0%. Twenty patients with partial stricture had a success rate of 85%, and 9 patients with complete stricture had a success rate of 33.3%. Renal function, hydronephrosis grade, stricture type, and stricture length were significant influences on the outcome (P < 0.05). No complication was observed.

Conclusions

The SARE is a safe and effective treatment for UAS, and may be the only endoscopic treatment approach for complete UAS. While success rate for complete strictures is low compared to open revision, it should be considered as an initial approach given its low overall morbidity. For partial strictures, prudent patient selection results in higher success rates that are nearly comparable to open revision.

Ureteroscopy-Assisted Laparoscopic Segmental Resection of Ureteral Stricture with a Modified Flank Position: Clinical Experience

PURPOSE

To share the surgical technique that possesses the advantage of a perioperative ureteroscope without position change, which allows for a laparoscopic segmental resection of the ureteral stricture to be performed more precisely.

PATIENTS AND METHODS

Between 2006 January and 2015 December, 10 patients with a ureteral stricture received a laparoscopic segmental resection and ureteroureterostomy in our clinical institute. The etiology included stone, endometriosis, crossing vessel, and idiopathic benign ureteral polyp. With the advance of bilateral lower extremities extended and abducted, 1 assistant used a ureteroscope as a direct guide to the precise location of the stricture affected ureter. Thus, the surgeon was able to perform a more specific resection without an unnecessary excision, which may have compromised the blood supply or increased the tension at anastomosis.

RESULTS

Five patients received the traditional transperitoneal laparoscopic approach, whereas the other 5 patients received a ureteroscopy-assisted laparoscopic segmental resection and ureteroureterostomy. The operating time appears to be no different between the two groups (124 minutes versus 142 minutes, P = .351), and, thus, no additional time is consumed for the ureteroscope procedure. After at least 1 year of follow-up, only 1 patient in the traditional laparoscopic group suffered from recurrence. One patient had a right ureteral stricture due to stone impaction, where with the advantage of a ureteroscope guide without change position, the operator was able to make a limited excision at the affected location. No complications related to the decubitus and bilateral leg in the extended position were noted.

CONCLUSIONS

Ureteroscopy-assisted laparoscopic segmental resection of the ureter without a change in position is a feasible and safe procedure when dealing with a refractory ureter stricture. Although it is convenient, the surgeon should be aware of possible pressure sores at the dependent part.

Evaluation of risk factors and treatment options in patients with ureteral stricture disease at a single institution

INTRODUCTION

Ureteral strictures are a significant cause of morbidity and mortality, resulting in potential kidney damage requiring several surgical procedures. Non-malignant causes include radiation, trauma from calculi impaction, pelvic surgery, or ureteroscopy (URS). We identified risk factors in our patients with ureteral strictures and the success of their treatment outcomes.

METHODS

A retrospective chart review of 25 patients with 29 ureteral strictures was performed to determine the success of their treatment.

RESULTS

Twenty-five (25) patients with 29 benign ureteral strictures were identified. Most cases (60%) were caused by impacted stones where the median stone size was 1.15 cm (0.37-1.8 cm). Intervention for stones prior to stricture development included shockwave lithotripsy, URS, and percutaneous nephrolithotomy. Five patients with strictures from impacted stones had ureteric complications during stone treatment including perforation +/- urinoma (n=3), fractured guidewire left in situ (n=1), and ureteric orifice resection (n=1). Other stricture etiologies included radiation (28%) and endometriosis (4%). Treatment modalities used included ureteroureterostomy (n=2), ureteral re-implant (n=3), urinary diversion (n=3), autotrasplant (n=1), laser endoureterotomy +/- balloon dilation (n=8), nephrectomy (n=2), balloon dilation +/- stent (n=3), ureterovesical junction (UVJ) resection + stent (n=1), chronic stent changes (n=4), or surveillance (n=3).

CONCLUSIONS

Our evaluation highlights important principles. Patients with complicated ureteroscopies or severely impacted calculi warrant close followup with imaging after stone treatment due to possibility of rapid renal deterioration from stricture formation. Radiation-induced strictures are difficult to manage, possibly requiring subsequent urinary diversion. Finally, endoscopic management of benign ureteral strictures via balloon dilation and laser endoureterotomy is an excellent choice in properly selected patients, with opportunity for subsequent salvage treatments if needed.

Single Versus Double Ureteral Stent Placement After Laser Endoureterotomy for the Management of Benign Ureteral Strictures: A Randomized Clinical Trial

BACKGROUND AND PURPOSE

Endoureterotomy is a viable option for treating patients with benign ureteral stricture. We compared the efficacy and safety of double versus single ureteral stent placement after laser endoureterotomy.

PATIENTS AND METHODS

This study included 55 patients with benign ureteral strictures; all patients underwent retrograde laser endoureterotomy. Patients were randomized either to single or double ureteral stents. Single stents were placed in 27 ureters while double stents were placed in 28 ureters. The stent diameter used was 7 F, and stents were indwelling for 8 weeks. Imaging was performed 1 month after stent removal and repeated regularly every 3 months. Clinical characteristics, operative results, and functional outcomes were compared for strictures managed in both groups. Success was evaluated both subjectively and objectively.

RESULTS

Fifty-five patients with a mean age of 46 (16-75) years had benign ureteral strictures; the mean stricture length was 1.92 (1-3) cm. The mean follow-up was 25.7 (9-42) months. The overall success rate was 67.3% (37 patients) with no radiologic evidence of obstruction, 6 (10.9%) patients showed symptomatic improvement while 12 (21.8%) patients underwent surgical reconstruction. Success was significantly higher for ureteral strictures (>1.5 cm) managed with double stent placement (82.4%), compared with single stent placement (38.9%) with a P value of 0.009.

CONCLUSIONS

Double stent placement of the ureter after laser endoureterotomy achieved a higher success rate compared with single stent placement in cases of benign ureteral strictures. Although ureteral strictures (≤1.5 cm) achieved better outcome after laser endoureterotomy, strictures (>1.5 cm) favored better with double stent versus single stent placement.

[Management of ureteral strictures and hydronephrosis]

Patients who develop hydronephrosis due to an acute cause often have colic-like pain but hydronephrosis secondary to a chronic cause is often asymptomatic. Ureteral obstruction can be due to a variety of intrinsic and extrinsic causes, such as trauma, radiation, iatrogenic injury, urolithiasis, malignancies and congenital causes. Management planning is dictated by the underlying cause, patient comorbidity and life expectancy. Malignant ureteral obstructions can be managed with segmental metal stents with advantages in the quality of life and provide an alternative to long-term treatment with a DJ stent. Endoscopic balloon dilatation and endoureterotomy are options for benign ureteral strictures up to 2 cm in length. For longer benign strictures there are a number of reconstructive techniques, which can also be performed by laparoscopic or robot-assisted approaches at specialized centers.

Ureteral strictures revisited…trying to see the light at the end of the tunnel: a comprehensive review

A ureteral stricture is a rather rare urological event defined as a narrowing of the ureter causing a functional obstruction and renal failure, if left untreated. The aim of this review article is to summarize and discuss current knowledge on the incidence, pathogenesis, management, and follow up of proximal, mid, and distal ureteral strictures.

Laser endoureterotomy and endopyelotomy: an update

PURPOSE

Although minimally invasive approach is one of the first-line treatment choices for ureteral strictures, there are still controversies on the ideal method to treat this entity. The objective of this update was to define the level of evidence around endoscopic treatment of ureteropelvic junction (UPJ) and ureteral strictures.

METHODS

We reviewed the current available literature on the PubMed database from the last decade up to May 2014 on laser endoureterotomy and endopyelotomy.

RESULTS

The level of evidence for the endoscopic treatment of UPJ and ureteral strictures is low. Despite this, it appears that endoureterotomy and endopyelotomy performed mainly with Ho:YAG laser achieve good success rates with minimal perioperative morbidity.

CONCLUSIONS

Laser endoureterotomy and endopyelotomy should be considered a reasonable treatment option in selected patients.

Endoluminal release of ureteral ligature after hysterectomy

Iatrogenic ureteral injury is a well-recognized complication of abdominal total hysterectomy. We report a case of a 57-year-old female who underwent abdominal total hysterectomy for a uterine myoma and experienced severe right flank pain postoperatively. The imaging study displayed an obstruction of the right distal ureter. Under ureteroscopy, an extraluminal ligature was released with a holmium:yttrium-aluminum-garnet laser. The stenotic segment was immediately relieved. Two months later, the intravenous urogram illustrated patency of the distal ureter with regression of right hydronephrosis. There was no recurrent hydronephrosis during 1 year of follow-up.

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.

[European Association of Urology guidelines on laser technologies]

CONTEXT

The European Association of Urology (EAU) Guidelines Office has set up a guideline working panel to analyse the scientific evidence published in the world literature on lasers in urologic practice.

OBJECTIVE

Review the physical background and physiologic and technical aspects of the use of lasers in urology, as well as current clinical results from these new and evolving technologies, together with recommendations for the application of lasers in urology. The primary objective of this structured presentation of the current evidence base in this area is to assist clinicians in making informed choices regarding the use of lasers in their practice.

EVIDENCE ACQUISITION

Structured literature searches using an expert consultant were designed for each section of this document. Searches were carried out in the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Medline and Embase on the Dialog/DataStar platform. The controlled terminology of the respective databases was used, and both Medical Subject Headings and EMTREE were analysed for relevant entry terms. One Cochrane review was identified.

EVIDENCE SYNTHESIS

Depending on the date of publication, the evidence for different laser treatments is heterogeneous. The available evidence allows treatments to be classified as safe alternatives for the treatment of bladder outlet obstruction in different clinical scenarios, such as refractory urinary retention, anticoagulation, and antiplatelet medication. Laser treatment for bladder cancer should only be used in a clinical trial setting or for patients who are not suitable for conventional treatment due to comorbidities or other complications. For the treatment of urinary stones and retrograde endoureterotomy, lasers provide a standard tool to augment the endourologic procedure.

CONCLUSIONS

In benign prostatic obstruction (BPO), laser vaporisation, resection, or enucleation are alternative treatment options. The standard treatment for BPO remains transurethral resection of the prostate for small to moderate size prostates and open prostatectomy for large prostates. Laser energy is an optimal treatment method for disintegrating urinary stones. The use of lasers to treat bladder tumours and in laparoscopy remains investigational.

EAU guidelines on laser technologies

CONTEXT

The European Association of Urology (EAU) Guidelines Office has set up a guideline working panel to analyse the scientific evidence published in the world literature on lasers in urologic practice.

OBJECTIVE

Review the physical background and physiologic and technical aspects of the use of lasers in urology, as well as current clinical results from these new and evolving technologies, together with recommendations for the application of lasers in urology. The primary objective of this structured presentation of the current evidence base in this area is to assist clinicians in making informed choices regarding the use of lasers in their practice.

EVIDENCE ACQUISITION

Structured literature searches using an expert consultant were designed for each section of this document. Searches were carried out in the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Medline and Embase on the Dialog/DataStar platform. The controlled terminology of the respective databases was used, and both Medical Subject Headings and EMTREE were analysed for relevant entry terms. One Cochrane review was identified.

EVIDENCE SYNTHESIS

Depending on the date of publication, the evidence for different laser treatments is heterogeneous. The available evidence allows treatments to be classified as safe alternatives for the treatment of bladder outlet obstruction in different clinical scenarios, such as refractory urinary retention, anticoagulation, and antiplatelet medication. Laser treatment for bladder cancer should only be used in a clinical trial setting or for patients who are not suitable for conventional treatment due to comorbidities or other complications. For the treatment of urinary stones and retrograde endoureterotomy, lasers provide a standard tool to augment the endourologic procedure.

CONCLUSIONS

In benign prostatic obstruction (BPO), laser vaporisation, resection, or enucleation are alternative treatment options. The standard treatment for BPO remains transurethral resection of the prostate for small to moderate size prostates and open prostatectomy for large prostates. Laser energy is an optimal treatment method for disintegrating urinary stones. The use of lasers to treat bladder tumours and in laparoscopy remains investigational.