Long-Term Results of Endoureterotomy for Benign Ureteral and Ureteroenteric Strictures

Open and Robotic Uretero-enteric Stricture Repair: Early Outcomes and Complications

Objective: To characterize our single institutional experience with robotic and open uretero-enteric stricture (UES) repair. Materials and Methods: We queried our ureteral reconstructive database for UES repair between 01/2017 and 10/2023. Patients with <3 months follow-up were excluded. Prior to surgery, patients underwent ureteral rest (4 weeks) with conversion to nephrostomy tube. Clinical characteristics, complications, reconstructive success (uretero-enteric patency), need for repeat intervention, and renal function were assessed in patients undergoing open and robotic UES reconstruction. Results: Of 50 patients undergoing UES repair during the study period, 45 were included for analysis due to complete follow-up (34 [76%] robotic and 11 [24%] open repair). UES repair was performed in 50 renal units a median of 13 months (interquartile range 7-30) from index surgery, and most often involved the left renal unit (34/50; 68%). Compared with robotic, open cases were significantly more likely to have undergone open cystectomy (100% vs 68%, p = 0.04), have longer strictures (median 4 vs 1 cm, p < 0.001), require tissue substitution (27% vs 3%, p = 0.04), and have lengthier postoperative hospitalization (5 vs 2 days, p < 0.001). There was no significant difference in total operative time (410 vs 322 minutes) or 30d major complications (18% vs 21%). At a follow-up of 13 months, per patient reconstructive success was 100% (11/11) for open and 97% (33/34) for robotic, respectively. Conclusion: In select patients with short UES unlikely to require advanced reconstructive techniques, a robotic-assisted approach can be considered. Careful patient selection is associated with limited morbidity and high reconstructive success.

Radiotherapy induced ureteric stenosis in locally advanced cervical cancer: A review of current evidence

BACKGROUND

Concurrent chemo-radiation followed by high dose rate brachytherapy is the standard of care for locally advanced cervical cancer. The proximity of the ureters to the tumor volume risks ureteric stenosis. Here we outline the current understanding of radiotherapy induced ureteric stenosis in patients treated for cervical cancer, focusing on the incidence, risk factors, clinical consequences, and management.

METHODS

Searches on EMBASE, PubMed, Science Direct, and Google Scholar were performed for publications reporting on radiotherapy, cervix cancer and ureteric stenosis. Multi and single center, prospective/retrospective, cohort, and cross-sectional studies were included.

RESULTS

This narrative review identified key issues relevant to radiation induced ureteric stenosis in cervical cancer in the literature. Thirteen studies were evaluated, identifying crude and actuarial rates of ureteric stenosis of 0.3-13.5% and 1.5-4.4% (at 5 years) respectively. The risk of ureteric stenosis is highest in the first 5 years after radiotherapy but continues to occur at a rate of 0.15% per year. Risk factors including advanced FIGO stage, tumor size >5 cm and baseline hydronephrosis increase the incidence of ureteric stenosis. EQD2 doses of ≥ 77Gy were significantly associated with ≥grade 3 ureteric morbidity. The majority of patients were managed with nephrostomy +/- ureteric stent insertion, with some requiring ureteral reimplantation, urinary diversion or nephrectomy.

CONCLUSIONS

This review has identified multiple considerations, highlighting the need to identify patients highest at risk of ureteric stenosis. There is also a need to recognize ureters as organs at risk, record dose exposure, and apply dose constraints, all of which set the landscape for allowing dose optimization.

Robot-assisted ureteric reconstructive surgeries for benign diseases: Initial single-center experience with point of technique

INTRODUCTION

We present our initial experience with robot-assisted reconstructive surgeries with the Da Vinci Xi robotic system for benign ureteric pathologies.

MATERIALS AND METHODS

This is a retrospective review of prospectively collected data of patients who underwent robot-assisted reconstructive procedures for benign diseases of the ureter at our department from April 2018 to November 2022. Demographic and perioperative details were recorded. Patients were followed up and surgical success was evaluated on the basis of symptomatic, functional, and radiological improvement.

RESULTS

A total of 34 patients underwent robot-assisted reconstructions for benign ureteric pathologies by various techniques. Mean age, body mass index (BMI), hospital stay and follow-up duration were 36 years, 24.1 kg/m2, 5.29 days, and 7.08 months respectively. Procedures included pyeloplasty in eight, primary ureteroneocystostomy (UNC) in seven, Psoas hitch UNC in five, Boari flap UNC in six, Ureteroureterostomy in four, ureterocalicostomy in two and ileal ureteral transposition in two patients. Mean docking time, total operative time, and estimated blood loss were 31.5 min, 178 min, and 64.3 ml, respectively. All patients had radiologic or functional improvement on follow-up after 6 months.

CONCLUSION

Robot-assisted reconstructive surgery for benign ureteric and bladder pathologies imparted excellent short-term outcomes without major complications with all the advantages of a minimally invasive approach.

Analysis of the Efficacy and Risk Factors for Failure of Balloon Dilation for Benign Ureteral Stricture

This study aimed to investigate the efficacy of balloon dilation in ureteral stricture and to analyze the risk factors for the failure of balloon dilation, which will hopefully provide some reference for clinicians to develop treatment plans. We retrospectively analyzed 196 patients who underwent balloon dilation between January 2012 and August 2022, 127 of whom had complete baseline and follow-up data. General clinical data, perioperative data, balloon parameters at the time of surgery, and follow-up results were collected from the patients. Univariate and multivariate logistic regression analyses were performed for the risk factors for surgical failure in patients undergoing balloon dilatation. The success rates of balloon dilatation (n = 30) and balloon dilatation combined with endoureterotomy (n = 37) for lower ureteral stricture at 3 months, 6 months, and 1 year were 81.08%, 78.38%, and 78.38% and 90%, 90%, and 86.67%, respectively. The success rates of balloon dilation at 3 months, 6 months, and 1 year in patients with recurrent upper ureteral stricture after pyeloplasty (n = 15) and primary treatment (n = 30) were 73.33%, 60%, and 53.33% and 80%, 80%, and 73.33%, respectively. The success rates of surgery at 3 months, 6 months, and 1 year for patients with recurrence of lower ureteral stricture after ureteral reimplantation or endoureterotomy (n = 4) and primary treatment with balloon dilatation (n = 34) were 75%, 75%, and 75% and 85.29%, 79.41%, and 79.41%, respectively. Multivariate analysis of the failure of balloon dilation showed that balloon circumference and multiple ureteral strictures were risk factors for balloon dilation failure (OR = 0.143, 95% CI: 0.023-0.895, p = 0.038; OR = 1.221, 95% CI: 1.002-1.491, p = 0.05). Balloon dilation combined with endoureterotomy in lower ureteral stricture had a higher success rate than balloon dilation alone. The success rate of balloon dilation in the primary treatment of the upper and lower ureter was higher than that of balloon dilation in the secondary treatment after failed repair surgery. Balloon circumference and multiple ureteral strictures are risk factors for balloon dilation failure.

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.

Renal Autotransplantation for the Treatment of Complete Ureteral Loss: A Case Report

We present an exceptional case of a patient with complete ureteral loss. The injury of the patient’s right ureter resulted as a complication of prior ureteroscopic and laparoscopic. For the treatment of complete ureteral loss, the right kidney was removed and placed into the left iliac fossa. Revascularization of the kidney was performed by anastomosis of the renal vasculatures to the external iliac vasculature. Ureteral reconstruction was performed through a Boari bladder flap. At the six-month follow-up visit, the resistive indices of the transplanted kidney proved to be in the normal range.

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.

Robotic Ureteral Reconstruction in Patients with Radiation-Induced Ureteral Strictures: Experience from the Collaborative of Reconstructive Robotic Ureteral Surgery

Objectives: Management of radiation-induced ureteral stricture (RIUS) is complex, requiring chronic drainage or morbid definitive open reconstruction. Herein, we report our multi-institutional comprehensive experience with robotic ureteral reconstruction (RUR) in patients with RIUSs. Patients and Methods: In a retrospective review of our multi-institutional RUR database between January 2013 and January 2020, we identified patients with RIUSs. Five major reconstruction techniques were utilized: end-to-end (anastomosing the bladder to the transected ureter) and side-to-side (anastomosing the bladder to an anterior ureterotomy proximal to the stricture without ureteral transection) ureteral reimplantation, buccal or appendiceal mucosa graft ureteroplasty, appendiceal bypass graft, and ileal ureter interposition. When necessary, adjunctive procedures were performed for mobility (i.e., psoas hitch) and improved vascularity (i.e., omental wrap). Outcomes of surgery were determined by the absence of flank pain (clinical success) and absence of obstruction on imaging (radiological success). Results: A total of 32 patients with 35 ureteral units underwent RUR with a median stricture length of 2.5 cm (interquartile range [IQR] 2-5.5). End-to-end and side-to-side reimplantation techniques were performed in 21 (60.0%) and 8 (22.9%) RUR cases, respectively, while 4 (11.4%) underwent an appendiceal procedure. One patient (2.9%) required buccal mucosa graft ureteroplasty, while another needed an ileal ureter interposition. The median operative time was 215 minutes (IQR 177-281), estimated blood loss was 100 mL (IQR 50-150), and length of stay was 2 days (IQR 1-3). One patient required repair of a small bowel leak. Another patient died from a major cardiac event and was excluded from follow-up calculations. At a median follow-up of 13 months (IQR 9-22), 30 ureteral units (88.2%) were clinically and radiologically effective. Conclusion: RUR can be performed in patients with RIUSs with excellent outcomes. Surgeons must be prepared to perform adjunctive procedures for mobility and improved vascularity due to poor tissue quality. Repeat procedures for RIUSs heighten the risk of necrosis and failure.

Long-Term Outcomes of Laser Incision and Triamcinolone Injection for the Management of Ureteroenteric Anastomotic Strictures

Purpose: Benign ureteroenteric anastomotic stricture (UEAS) is a common postoperative complication after urinary diversion with an incidence of 3%-10%. Our objective is to report long-term follow-up of our technique for endoscopically managing UEAS after cystectomy. Materials and Methods: Patients with endoscopically managed benign UEAS after cystectomy were included. Intervention entailed anetegrade flexible ureteroscopy with biopsy followed by laser incision of the stricture and of periureteral and peri-ileal tissues 1 cm below and 1 cm above the stricture into fat. Triamcinolone injection was then performed, followed by balloon dilation of the incised area to 24F. Parallel Double-J ureteral stents or upside down nephrostomy tubes were placed for 6 weeks. CT scans were obtained at 3 months and 1 year after surgery, and renal ultrasound at 6 and 9 months, and then annually. Results: Twenty-one patients, and a total of 24 UEAS were treated. Urinary diversion included ileal conduit (n = 12), neobladder (n = 7), and Indiana pouch (n = 2). Twenty out of 24 strictures had no recurrence, including three patients who had bilateral disease, yielding an overall success rate of 83.3%. The remaining three patients with recurrence had evidence of stricture within 3 months. Follow-up ranged from 8 to 102 months, with a median of 30 months. Conclusions: Patients treated endoscopically for UEAS have been shown to have acceptable immediate success with less morbidity when compared with ureteral reimplantation. Our technique of laser incision, triamcinolone injection, balloon dilation, and temporary stent placement has a success rate of over 80% and is unique in that long-term data confirms the durability of this endoscopic procedure.

Prospective evaluation and classification of endoscopic findings for ureteral calculi

Difficulty in performing ureteroscopic lithotripsy (URSL) depends on endoscopic findings surrounding calculi. In this multicentre prospective cohort study of 185 patients with a single ureteral stone who underwent ureteroscopic lithotripsy registered in the SMART study between January 2014 and February 2017, we established a classification of endoscopic findings and analysed risk factors for ureteral changes. We evaluated endoscopic findings (oedema, polyps, ureteral mucosa-stone adherence, and distal ureteric tightness) based on the SMART classification. Operative time and ureteral injuries were significantly correlated with endoscopic finding grades. Multivariate analyses revealed that mucosa-stone adherence (MSA) was strongly affected by hydronephrosis grade (odds ratio, 12.4; p = 0.022) and the interval before surgery (odds ratio, 1.10; p = 0.012). The cutoff value for MSA was 98 days, with a predictive accuracy of 0.78. Risk factors for distal ureteric tightness were age (odds ratio, 0.96; p = 0.004) and early intervention (odds ratio, 0.90; p = 0.023). The cutoff value was 34 days, with a predictive accuracy of 0.72. In conclusion, appropriate intervention around 34 days (limited to 98 days) after symptom onset is necessary for treating ureteral calculi. Even if intervention passed 98 days post-symptom onset, staged URSL, alternative procedures, and detailed informed consent should be planned in advance, assuming strong MSA.

Is there still a role of balloon dilatation of benign ureteric strictures in 2019?

Introduction and Objectives: Reconstructive surgery for benign ureteric strictures and long term nephrostomy are often invasive and lead to poor quality of life. Balloon dilatation has the potential to bridge this gap. We present the outcome of our series and examine the risk factors of stricture recurrence.Materials and Methods: There were 109 strictures in our series from August 2012 to July 2018 in our single center retrospective cohort analysis. All strictures were dilated retrogradely or antegradely and followed by stenting. Follow-up imaging was done to assess stricture recurrence.Results: Mean patient age was 57.7-years-old (SD ± 12.6). Mean follow-up was 20.2 months (SE ± 1.8). All strictures were successfully dilated and stented. Overall, mean patency rate was 63.7% at mean follow-up of 20.2 months (SE ± 1.8). Strictures caused by stone/inflammation had 28.0% (21/75) risk of recurrence compared to iatrogenic causes, 63.6% (7/11), and radiotherapy, 100.0% (5/5) (p = 0.001). Non-incidental strictures also had significantly higher risk of recurrence at 57.4% (27/47) vs. incidental strictures at 13.6% (6/44) (p = 0.000). The mean length of strictures was 12.5 mm (SE ± 1.7) in the recurrence group vs. 9.6 mm (SE ± 0.7) in those without recurrence (p = 0.001). The presence of ipsilateral atrophic kidney was associated with 72.2% (13/18) risk of recurrence vs. non-atrophic kidney 27.4% (20/73) (p = 0.000). The mean age of stricture was 14.5 months (SE ± 4.6) and 5.2 months (SE ± 2.1) in the recurrence and non-recurrence groups, respectively (p = 0.013).Conclusions: Balloon dilatation of benign ureteric stricture is a feasible option. Its effect can be long-lasting in selected patients, that is, non-irradiated, incidental, short strictures with normal kidneys. This will benefit patients unfit for reconstructive surgery.

The Morbidity of Ureteral Strictures in Patients with Prior Ureteroscopic Stone Surgery: Multi-Institutional Outcomes

PURPOSE

Nephrolithiasis is an increasingly common ailment in the United States. Ureteroscopic management has supplanted shockwave lithotripsy as the most common treatment of upper tract stone disease. Ureteral stricture is a rare but serious complication of stone disease and its management. The impact of new technologies and more widespread ureteroscopic management on stricture rates is unknown. We describe our experience in managing strictures incurred following ureteroscopy for upper tract stone disease.

MATERIALS AND METHODS

Records for patients managed at four tertiary care centers between December 2006 and October 2015 with the diagnosis of ureteral stricture following ureteroscopy for upper tract stone disease were retrospectively reviewed. Study outcomes included number and type (endoscopic, reconstructive, or nephrectomy) of procedures required to manage stricture.

RESULTS

Thirty-eight patients with 40 ureteral strictures following URS for upper tract stone disease were identified. Thirty-five percent of patients had hydronephrosis or known stone impaction at the time of initial URS, and 20% of cases had known ureteral perforation at the time of initial URS. After stricture diagnosis, the mean number of procedures requiring sedation or general anesthesia performed for stricture management was 3.3 ± 1.8 (range 1-10). Eleven strictures (27.5%) were successfully managed with endoscopic techniques alone, 37.5% underwent reconstruction, 10% had a chronic stent/nephrostomy, and 10 (25%) required nephrectomy.

CONCLUSIONS

The surgical morbidity of ureteral strictures incurred following ureteroscopy for stone disease can be severe, with a low success rate of endoscopic management and a high procedural burden that may lead to nephrectomy. Further studies that assess specific technical risk factors for ureteral stricture following URS are needed.

Endoscopic Balloon Dilatation in the Treatment of Benign Ureteral Strictures: A Meta-Analysis and Systematic Review

BACKGROUND AND PURPOSE

Although balloon dilatation is one of the main endoscopic procedures used to treat benign ureteral strictures, its precise efficacy remains controversial. We aimed to identify, combine, and analyze existing published data to ascertain the efficacy of endoscopic balloon dilatation for benign ureteral strictures.

METHODS

In December 2018, a literature search was performed using Medline, Embase, and Web of Science databases. We included reports in which the study population consisted of patients who underwent endoscopic balloon dilatation for the treatment of benign ureteral strictures. Technical, short-term, and long-term success rates (expressed as mean ± standard error) were adopted as the outcome measures.

RESULTS

Using our search strategy, a total of 19 studies (all series reports) were included for analysis. Using a random-effects model, the pooled technical success rate of endoscopic balloon dilatation for benign ureteral strictures was found to be 89% ± 4%. Furthermore, the short-term success rate (i.e., 3 months after surgery) was 60% ± 10%, and the long-term success rate (i.e., 6-12 months after surgery) was 54% ± 14%. In the subgroup analysis, the success rate of endoscopic balloon dilatation for ≤2-cm benign ureteral strictures was significantly higher than that for >2-cm ones (odds ratio [OR]: 0.13; 95% confidence interval [CI]: 0.05-0.35). In addition, the success rate in cases with strictures of onset timing ≤3 months was relatively higher than that in cases with strictures of onset timing >3 months (OR: 0.46; 95% CI: 0.15-1.43).

CONCLUSION

Our study indicates that endoscopic balloon dilatation has a high success rate in the treatment of benign ureteral strictures with length ≤2 cm and onset timing ≤3 months. However, there is still no consensus on balloon type, dilatation pressure, expansion number, postoperative ureteral stent type, and stent retention time for the balloon dilatation technique.

Treatment of congenital distal ureteral orifice stenosis by endoscopic laser ablation in dogs: 16 cases (2010-2014)

OBJECTIVE To determine characteristics of and outcomes for dogs with congenital distal ureteral orifice stenosis (CDUOS) treated by cystoscopic-guided laser ablation (CLA). DESIGN Retrospective case series. ANIMALS 16 client-owned dogs with CDUOS treated by CLA at 2 veterinary hospitals between 2010 and 2014. PROCEDURES Medical records were reviewed and data collected regarding clinical findings, imaging results, surgery characteristics, treatment, and outcome. Follow-up information was collected from dog owners and referring veterinarians via standardized interview. RESULTS Dogs included 10 males and 6 females; median age was 11.5 months (range, 4 to 112 months). Labrador Retriever (n = 6; 3 males) was the most common breed. Intramural ectopic ureteral openings were identified at the site of stenosis in 15 dogs (18/20 stenotic ureteral openings). Treatment with CLA to enlarge and relocate the stenotic opening was successful in all dogs. Median duration of anesthesia and hospitalization was 105 minutes and 24 hours, respectively. No complications were noted. Fourteen dogs remained alive (2 lost to follow-up) during a median follow-up period of 14.5 months. Owners of 11 of 13 dogs reported improvement in their dog's quality of life after CLA. The treated ureteral orifice remained patent in the 2 dogs that were reimaged. CONCLUSIONS AND CLINICAL RELEVANCE CDUOS should be considered as a differential diagnosis for dogs with idiopathic distal ureteral obstruction, particularly young male Labrador Retrievers, and was most often associated with an intramural ectopic ureter in this study. Treatment with CLA was safe and effective for opening the ureteral orifice.

Bone marrow mesenchymal stem cells reduce ureteral stricture formation in a rat model via the paracrine effect of extracellular vesicles

With no effective therapy to prevent or treat ureteral stricture (US), a multifactorial fibrotic disease after iatrogenic injury of the ureter, the need for new therapies is urgent. Mesenchymal stem cells (MSCs) have been widely studied for treating tissue defects and excessive fibrosis, and recent studies established that one of the main therapeutic vectors of MSCs is comprised in their secretome and represented by extracellular vesicles (EVs). Thus, we have determined to explore the specific role of MSCs‐derived EVs (MSC‐EVs) treatment in a pre‐clinical model of US. The results firstly showed that either a bolus dose of MSCs or a bolus dose of MSC‐EVs (administration via renal‐arterial) significantly ameliorated ureteral fibrosis and recuperated ureter morphological development in a US rat model. We confirmed our observations through MSCs or MSC‐EVs treatment alleviated hydronephrosis, less renal dysfunction and blunted transforming growth factor‐β1 induced fibration. Due to MSC‐EVs are the equivalent dose of MSCs, and similar curative effects of transplantation of MSCs and MSC‐EVs were observed, we speculated the curative effect of MSCs in treating US might on account of the release of EVs through paracrine mechanisms. Our study demonstrated an innovative strategy to counteract ureteral stricture formation in a rat model of US.

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.

Transplant Kidney Retrograde Ureteral Stent Placement and Exchange: Overcoming the Challenge

OBJECTIVE

To present a reliable technique for fluoroscopic controlled, large-bore, ureteral stent placement and exchange in transplant kidneys with persistent ureterovesical strictures.

MATERIALS AND METHODS

We reviewed the medical charts of all patients who underwent kidney transplant with persistent ureterovesical strictures who underwent ureteral stent placement or exchange at our institution between 2005 and 2015 using the new technique. Clinical characteristics and treatment outcomes of the study cohort were analyzed.

RESULTS

Ureteral stent insertion or stent exchange, using this technique, was performed in 32 renal transplant units. Median operating time was 24 minutes (interquartile range, 21-36.75 minutes). The overall success rate of the technique at first attempt was 96.9%. In 1 patient, drainage of the transplanted kidney with a nephrostomy tube was indicated after procedure failure. No other local or systemic complications were encountered, and no stent encrustation was noted in this cohort of patients. Renal function remained stable in all patients during a median follow-up of 59 months (interquartile range, 28-61 months).

CONCLUSION

Herein, we present in detail a step-by-step technique for the insertion and exchange of large-bore ureteral stents in transplanted kidneys. The technique was shown to be safe, effective, and highly successful.

Managing Mid and Lower Ureteral Benign Strictures: The Laparoscopic Way

OBJECTIVE

The aim of this study is to assess etiopathogenesis of ureteral mid/lower benign strictures and outcomes of various methods of laparoscopic reconstruction and repair.

MATERIALS AND METHODS

We retrospectively reviewed the data of patients who underwent laparoscopic repair for mid and lower ureteral benign strictures at our department from January 2013 to February 2016. The demographic, operative, complication, and outcome data were analyzed.

RESULTS

Twenty-two patients were treated by various methods of laparoscopic reconstruction in the department of urology for benign ureteral strictures. Ureteroneocystostomy was done by psoas hitch in 15 and Boari flap in 2. Ureteral tapering, followed by ureteral reimplantation, was done in 2 and ureteroureterostomy in 3 cases. The most common predisposing factor that leads to ureteral stricture was prior pelvic gynecological surgery. Other causes included endometriosis, tuberculosis, impacted ureteral calculus, and ureteroscopic removal of calculus. Seventeen patients had lower, 3 had mid, and 2 had mid/lower ureteral strictures. Ureteral patency was successfully reestablished in all 22 patients without significant complications during a mean follow-up of 25 months (range 12-48 months).

CONCLUSION

Laparoscopic treatment of benign ureteral strictures imparted excellent outcomes without major complications with the advantage of the minimally invasive technique.

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.

Ureteroenteric anastomotic revision as initial management of stricture after urinary diversion

OBJECTIVE

To report our experience with ureteroenteric anastomotic revision as initial treatment of stricture after urinary diversion.

METHODS

An institutional review board-approved retrospective study was carried out. A total of 41 patients who underwent primary ureteroenteric anastamotic revision were identified between 2007 and 2015. Data analyzed included patient characteristics, type of diversion, estimated blood loss, operative time, change in renal function, length of stay, postoperative complications and time with nephrostomy/stent. Success of revision was defined as an improvement in hydronephrosis on radiographic imaging and/or reflux during pouchogram. Predictors of length of stay and complications were analyzed using analysis of covariance.

RESULTS

A total of 50 renal units were revised with a success rate of 100%. The median length of stay was 6 days (2-16 days). There were a total of 15 complications (one major, 14 minor) in 14 patients (33% 30-day complication rate). The most common were wound infection (n = 4) and arrhythmia (n = 4). Robotic revision (n = 5) had a median length of stay of 3 days (2-4) with no complications.

CONCLUSIONS

Primary ureteroenteric anastomotic revisions have an excellent success rate at an experienced center and might obviate the need for multiple interventions. Open revision is associated with mostly minor complications. Robotic revision might reduce the morbidity of open revision in select cases.

Lessons from 151 ureteral reimplantations for postcystectomy ureteroenteric strictures: A single-center experience over a decade

OBJECTIVES

Ureteroenteric anastomotic strictures are common after cystectomy with urinary diversion. Endoscopic treatments have poor long-term success, although ureteral reimplantation is associated with morbidity. Predictors of successful open repair are poorly defined. Our objective was to characterize outcomes of ureteral reimplantation after cystectomy and identify risk factors for stricture recurrence.

PATIENTS AND METHODS

We performed a retrospective review of 124 consecutive patients with a total of 151 open ureteral reimplantations for postcystectomy ureteroenteric strictures between January 2006 and December 2015. Baseline clinicopathologic characteristics and perioperative outcomes were examined. Predictors for stricture recurrence were assessed by univariable testing and univariate Cox proportional hazards regression.

RESULTS

Most patients underwent preoperative drainage by percutaneous nephrostomy (PCN; 43%) or percutaneous nephroureterostomy (PCNU; 44%). Major iatrogenic injuries included enterotomies requiring bowel anastomosis (3.2%) and major vascular injuries (2.4%). Overall, 60 (48%) patients suffered 90-day complications, of which 15 (12%) patients had high-grade complications. Median length of stay was 6 days [interquartile range: 5, 8] and median follow-up was 21 months [interquartile range: 5, 43]. The overall success rate per ureter was 93.4%. On univariate analysis, the only significant predictor of stricture recurrence was preoperative PCNU placement compared with PCN placement or no drainage (success rates: 85.5% vs. 98.9%, respectively, P = 0.002). Cox proportional hazards regression demonstrated that preoperative PCNU placement yielded a hazard ratio of 10.2 (95% CI: 1.27-82.6) for stricture recurrence (P<0.005). Stricture recurrence was independent of previous endoscopic interventions (P = 0.42). Stricture length was unable to be assessed.

CONCLUSIONS

Postcystectomy ureteral reimplantation was associated with relatively low rates of major iatrogenic injuries and high-grade complications. Preoperative PCN placement rather than PCNU may yield better results.

Getting out of a tight spot: an overview of ureteroenteric anastomotic strictures

Radical cystectomy and urinary diversion is the gold-standard treatment for muscle-invasive and high-risk non-muscle-invasive bladder cancer. Ureteroenteric anastomotic stricture is a well-known complication of urinary diversion and is associated with serious sequelae that lead to total or partial loss of kidney function, infectious complications, and the need for additional procedures. Although the exact aetiology of benign ureteroenteric anastomotic strictures is unclear, they most likely occur secondary to ischaemia at the anastomotic region. Diagnosis can be achieved using retrograde contrast studies, CT scan or MAG3 renography. Open revision remains the gold-standard treatment for ureteroenteric anastomotic strictures; however, endourological techniques are being increasingly used and, in select patients, might be the optimal approach.

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.

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.

Double-Barreled Wet Colostomy versus Ileal Conduit and Terminal Colostomy for Urinary and Fecal Diversion: A Single Institution Experience

Background and Aims:

The aim of this study was to compare the feasibility and early postoperative outcomes between patients undergoing double-barreled wet colostomy and patients undergoing terminal colostomy and ileal conduit for simultaneous urinary and fecal diversion.

Material and Methods:

Between 1995 and 2012, we had 181 patients in whom it was necessary to make simultaneous urinary and fecal diversion. This is a retrospective study and patients were divided into two groups, depending on the technique applied for the fecal and urinary diversion. The first group consisted of patients undergoing ileal conduit and terminal colostomy and the second group consisted of patients undergoing  double-barreled wet colostomy.

Results:

Ileal conduit and terminal colostomy was performed in 77 (43%) cases, while wet colostomy was performed in 104 (57%) cases. Median length of stay was shorter for double-barreled wet colostomy (13.1 vs 18.1, p < 0.0001). Median operating times for urinary and fecal diversion were shorter for double-barreled wet colostomy (32 vs 64 min, p < 0.0001). The morbidity was lower for double-barreled wet colostomy (11.5% vs 23.4%, p = 0.0432), retrospectively. The mortality was 3.8% for double-barreled wet colostomy and 10.3% for ileal conduit and terminal colostomy group (p = 0.1282).

Conclusions:

Double-barreled wet colostomy is a safe, fast, and simple alternative to traditional ileal conduit and terminal colostomy diversion. The technique is relatively easy to learn, and it reduces the time for urinary and fecal diversion, length of stay, and morbidity rate.

Laparoendoscopic management of midureteral strictures

The incidence of ureteral strictures has increased worldwide owing to the widespread use of laparoscopic and endourologic procedures. Midureteral strictures can be managed by either an endoscopic approach or surgical reconstruction, including open or minimally invasive (laparoscopic/robotic) techniques. Minimally invasive surgical ureteral reconstruction is gaining in popularity in the management of midureteral strictures. However, only a few studies have been published so far regarding the safety and efficacy of laparoscopic and robotic ureteral reconstruction procedures. Nevertheless, most of the studies have reported at least equivalent outcomes with the open approach. In general, strictures more than 2 cm, injury strictures, and strictures associated either with radiation or with reduced renal function of less than 25% may be managed more appropriately by minimally invasive surgical reconstruction, although the evidence to establish these recommendations is not yet adequate. Defects of 2 to 3 cm in length may be treated with laparoscopic or robot-assisted uretero-ureterostomy, whereas defects of 12 to 15 cm may be managed either via ureteral reimplantation with a Boari flap or via transuretero-ureterostomy in case of low bladder capacity. Cases with more extended defects can be reconstructed with the incorporation of the ileum in ureteral repair.

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.

Ureteroileal strictures after urinary diversion with an ileal segment-is there a place for endourological treatment at all?

PURPOSE

We compared the long-term results of minimally invasive endourological intervention and open surgical revision in patients with a nonmalignant ureteroileal stricture.

MATERIALS AND METHODS

We retrospectively evaluated the records of 74 patients (85 renal units) treated for unilateral or bilateral nonmalignant ureteroileal strictures. Overall, 96 endourological and 35 open surgical procedures were performed. Balloon dilatation and Acucise® or Ho:YAG laser endoureterotomy were used as minimally invasive endourological interventions. Open surgical revision with stricture resection and open ureteroileal end-to-side-reanastomosis was the alternate therapy. Treatment success was defined as radiological normalization or improvement of upper urinary tract morphology combined with absent flank pain, infection, ureteral stents or percutaneous nephrostomies.

RESULTS

Median followup was 29 months (range 2 to 177). The overall success rate was 26% (25 of 96 cases) for endourological intervention vs 91% (32 of 35) for open surgical revision (p <0.001). Subgroup analysis showed a significant difference in the success rate of minimally invasive endourological interventions vs open surgical revision for strictures greater than 1 cm (3 of 52 cases or 6% vs 19 of 22 or 86%, p <0.001). The success rate of endourological and open surgical procedures for strictures 1 cm or less was 50% (22 of 44 cases) and 100% (13 of 13), respectively. After adjusting for multiple preoperative stricture characteristics, only stricture length was strongly and inversely associated with a successful outcome (p <0.001).

CONCLUSIONS

Open surgical revision produces better results than minimally invasive endourological intervention for ureteroileal strictures, particularly those greater than 1 cm. The success rate of endourological intervention is acceptable only for ureteroileal strictures 1 cm or less. Therefore, ureteroileal strictures greater than 1 cm should be primarily managed by open surgical revision.

Retroperitoneal robotic-assisted laparoscopic reimplantation of a ureter into an ileal conduit

A novel technique for managing ureteroenteric strictures is robotic-assisted retroperitoneal laparoscopic reimplantation. A 63-year-old morbidly obese male underwent a left nephroureterectomy and cystoprostatectomy after neoadjuvant chemotherapy for transitional cell carcinoma of both the bladder and left kidney. His single right ureter was anastomosed to the ileal conduit. Postoperatively, he developed acute renal failure and hydronephrosis. An antegrade pyelogram demonstrated a distal stricture that failed two attempts at endoscopic management. In an effort to avoid the morbidity of an open repair, we present a minimally invasive option that replicates the steps of an open reimplantation.

Ex vivo evaluation of femtosecond pulse laser incision of urinary tract tissue in a liquid environment: implications for endoscopic treatment of benign ureteral strictures

BACKGROUND

The femtosecond (FS) pulse laser incises soft tissues with minimal peripheral damage and is a promising cutting tool for ureteroscopic endoureterotomy of benign ureteral strictures.

OBJECTIVE

To evaluate the feasibility of applying the FS laser to ureteroscopic endoureterotomy.

MATERIALS AND METHODS

A commercial Ti:Sapphire regenerative amplifier system (Coherent, RegA 9050, USA) was used in this study. Normal saline, 5% glucose solution, 4% mannitol solution, distilled water, and a 1% (v/v) suspension of whole blood with each of these solutions were tested for their attenuation rate (AR) of the FS laser's power. Bladder specimens from Sprague-Dawley (SD) rats were used as a surrogate model. The laser incised slots of 2 mm in length at bladder samples using three power grades (5×, 10×, and 20× the threshold power) combined with five effective pulse rates (40, 20, 10, 5, and 2.5 kHz), both in air and in normal saline. After samples were processed with standard hematoxylin-eosin staining procedures, the incision depth and collateral damage range were determined microscopically.

RESULTS

The ARs of blood suspensions with each of the three isosmotic solutions were significantly higher than the other five solutions (P < 0.001). The FS laser's cutting depth and the collateral damage were increased with the laser power or power density but the collateral damages were less than 100 µm. Microbubble formation was detected in the liquid environments tested and influenced the effective laser power.

CONCLUSIONS

Endoscopic application of the FS laser is feasible. Microbubble formation with the laser incision, however, may influence cutting effects. Proposed methods to address these issues include increasing the irrigation rate, using distilled water as irrigation or using gas insufflation instead of irrigation. It is necessary to evaluate these methods, as well as the long-term biologic response to laser incision, on living animal models in endoscopic settings before use on humans.

Experience with ureteroenteric strictures after radical cystectomy and diversion: open surgical revision

OBJECTIVES

To evaluate the long term results of the treatment of benign ureteroenteric strictures as a serious complication after urinary diversion and to highlight on the precautions for the active intervention. The outcomes of endoureteral and open surgical revisions in our patients are described.

METHODS

Of 658 patients who had undergone radical cystectomy for bladder cancer from 1999 to 2009, 58 had developed benign stricture. The diversions used in this subgroup were orthotopic neobladder (53.4%), ileal conduit (27.6%), and ureterocolic (19%). The median interval to the diagnosis was 6 months, and 63.8% were on the left side. Endouretral interventions (dilation and stent or endoureterotomy) were the initial treatment in 37 patients. Thirty-two patients including patients who failed endoluminal interventions and patients with bilateral strictures underwent open surgery. Success was defined as radiologic improvement and the absence of flank pain, infection, or the need for a ureteral stent or nephrostomy tube.

RESULTS

Endoscopic intervention was successful in 19 (51.3%) of 37 patients, principally those with strictures <1 cm with no difference between side, diversion type, or implantation technique. A total of 32 patients underwent open stricture resection and repair by direct implantation or tissue interposition to bridge long defects (6 Boari flaps and 7 ileal segments). At a median follow-up of 47 months, 25 patients had long-term success (78%) and 36 (83.7%) of 43 repaired units had improvement. Improvement was superior for right-sided strictures compared with left-sided strictures (100% vs 75.8%) and for neobladder compared with other diversions (90% vs 69%). Both anastomotic and ureteral strictures were repaired with equivalent results (87.5% vs 82.8%).

CONCLUSIONS

Although endouretral procedures are viable treatment alternatives, open surgical revision is the preferred long-term definitive treatment. Bilateral and long left-sided strictures >1 cm long are indications for early open surgery.

New combined approach in metallic ureteral stenting to avoid urothelial hyperplasia: study in swine model

PURPOSE

We assessed the therapeutic value of a new treatment option for ureteral strictures that may avoid urothelial hyperplasia, which is the main cause of metallic stent failure.

MATERIALS AND METHODS

We used 24 pigs in this study. An experimental model of ureteral stricture was induced in all animals. Obstruction was confirmed by ultrasound and retrograde ureteropyelogram 6 weeks after model creation. The pigs were then randomly allocated to 2 experimental groups. Therapy involved placement of a 6 × 30 mm metallic ureteral covered stent in the ureteral stricture in group 1 and subsequent endoureterotomy at the ureteral segments adjacent to the 2 ends of the stent in group 2. A double pigtail stent was then deployed for 3 weeks. Completion studies 6 months after therapy included retrograde ureteropyelogram, endoluminal ultrasound and ureteroscopy to assess urothelial hyperplasia formation.

RESULTS

At the end of the study evidence of urothelial hyperplasia was seen in 50% of the pigs in group 1 and in 29% in group 2. Four and 2 cases of cranial stent migration in groups 1 and 2, respectively, were seen at 6 months. Hyperplasia and renal involvement were statistically significantly different between the groups with more damage in group 1 than in group 2.

CONCLUSIONS

Hyperplasia was markedly reduced when ureteral peristalsis was inhibited by endoureterotomy at the area of interaction between the stent and the ureter.

Ureteroenteric anastomotic stricture: novel use of a cutting balloon dilator

INTRODUCTION

Management of ureteroenteric strictures presents a significant challenge because of its intraabdominal location and morbidity associated with open surgical management. The peripheral cutting balloon microsurgical dilatation device (PCBD), approved by The United States Food and Drug Administration (USFDA) for use in coronary angioplasty, features a 2-cm noncompliant balloon with four microsurgical blades mounted longitudinally on its outer surface. We evaluated the feasibility and outcome of this cutting balloon dilator in the treatment of ureteroenteric anastomotic strictures.

MATERIALS AND METHODS

Three patients with a 1-cm or less ureteroenteric stricture underwent a transluminal incision under fluoroscopic guidance. Percutaneous access was obtained and a guidewire was introduced into the renal pelvis and ureter in antegrade fashion and passed through the stricture. The exact length of the strictured segment was measured. The PCBD was deployed over the guidewire and the balloon was inflated at the stricture site. The maximum diameter of the inflated balloon was 8 mm. Approximately 30 seconds later, the balloon was deflated and the enlarged passage from the ureter to the ileal loop was verified under fluoroscopy. A ureteral stent was placed and removed at 6 weeks after the procedure.

RESULTS

Postoperative computed tomography scans at 12 months revealed improved hydronephrosis. All patients were asymptomatic postoperatively. One patient had a solitary kidney and creatinine level decreased significantly following the procedure.

CONCLUSION

Dilatation and incision with PCBD is a novel approach for the treatment of the short ureteroenteric anastomotic strictures. Long-term data need to be obtained to establish the efficacy of this technique.

Management of benign ureteral strictures in the endoscopic era

BACKGROUND AND PURPOSE

During the past decade, endoscopic management has emerged as the first-line treatment of benign ureteral strictures. We reviewed our experience with the management of benign ureteral strictures to determine the success rate of endoscopic surgery in a contemporary series and assessed the viability of surgical reimplantation in the modern era.

PATIENTS AND METHODS

We identified 75 patients with a diagnosis of ureteral stricture between 2000 and 2005 via electronic medical records search and excluded those with completely obliterated, external compressive, malignant, or ureteroenteric strictures, ureteropelvic junction obstruction, and those with follow-up less than 2 months.

RESULTS

Thirty-four patients who were treated endoscopically (balloon dilation and/or holmium laser endoureterotomy) were identified. Mean stricture length in each patient was 1.6 +/- 1 cm (range 0.5-4 cm), and the mean number of procedures per patient was 1.7 +/- 0.8. Endoscopic success was achieved in 29 (85%), while 5 (15%) patients experienced endoscopic management failure and ultimately needed ureteral reimplantation. When comparing the endoscopically treated and reimplant groups, there was no significant difference in mean stricture length (1.38 +/- 1.13 vs 2 +/- 1.1 cm, P = 0.14), yet mean number of procedures performed (1.41 +/- 0.85 vs 3.6 +/- 1.5; P = 0.002) reached statistical significance. There were no clinical or radiographic signs of obstruction in 100% of patients who received endoscopic therapy only and 100% of patients who needed open surgical management at a mean follow-up of 25.2 +/- 19.3 and 7.7 +/- 3.2 months, respectively.

CONCLUSIONS

Endoscopic surgery is clearly a successful primary treatment modality in the management of benign ureteral strictures with minimal morbidity. In the modern era of endoscopic surgery, however, ureteral reimplantation remains a viable option in treating the small subset of patients with benign ureteral strictures for whom endoscopic management fails.

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

PURPOSE

We assessed the long-term outcome of laser endoureterotomy for benign ureteral stricture.

MATERIALS AND METHODS

From a database of 69 patients who underwent retrograde laser endoureterotomy from October 2001 to June 2007 we identified 35 with a benign ureteral stricture. Clinical characteristics, operative results and functional outcomes were investigated. Success was defined as symptomatic improvement and radiographic resolution of obstruction.

RESULTS

Median followup was 27 months (range 10 to 72). All except 1 patient were followed at least 16 months. All patients completed clinical followup and 33 completed imaging. Of 35 patients 29 (82%) were symptom-free during followup and 26 of 33 (78.7%) were free of radiographic evidence of obstruction. All except 1 failure occurred within less than 9 months postoperatively. The success rate was higher for nonischemic strictures (100% vs 64.7%, p = 0.027) and tended to be higher for strictures 1 cm or less (89.4% vs 64.2%, p = 0.109).

CONCLUSIONS

Holmium laser endoureterotomy is effective for benign ureteral stricture in well selected patients. Most failures occur within less than 9 months after surgery, which may indicate a need for closer followup during postoperative year 1. Factors that might may outcome are ischemia and stricture length.

Primary endoscopic management versus open revision of ureteroenteric anastomotic strictures after urinary diversion--single institution contemporary series

PURPOSE

To review our institutional experience in the management of ureteroenteric strictures by primary endoscopic intervention or primary open revision.

PATIENTS AND METHODS

Between January 2000 and December 2007, 28 patients with ureteroenteric strictures underwent endoscopic management (n = 21) or open revision (n = 7). Strictures were characterized with regard to length and side as well as time to failure between the two groups. Success was defined as symptomatic improvement and evidence of patency on follow-up radiologic imaging.

RESULTS

Of all study patients, 78.6% were symptomatic on presentation. Endoscopic intervention (balloon dilation, electroincision, or holmium endoureterotomy) was successful in six patients for an overall success rate of 27% with a median follow-up of 21 months. Open revision was successful in 87.5% (7 of 8) patients for whom initial endoscopic surgery had failed. The success rate of primary open revision was 71.4% (5 of 7 patients) with a mean follow-up of 18.1 months. For the entire series, left-sided strictures were more common than right sided strictures; however, side and stricture length were not found to be significant (P > 0.05) with regard to patency. Functional renal imaging studies were performed in 42.9% of all study patients postoperatively.

CONCLUSIONS

Endoscopic management continues to have success rates that remain lower than that of open revision. Left-sided strictures remain more common than right-sided strictures; however, side and stricture length were not found to be statistically significant in our series. The lack of consistent postoperative functional renal studies highlights the importance of diligent monitoring and warrants further study to develop a surveillance algorithm.

Cold cutting of ureteral stenosis with endoscopic scissors

OBJECTIVES

To study the procedure and results of cold cutting of ureteral stenosis with endoscopic scissors. Intrinsic or extrinsic ureteral stenosis can be congenital or acquired. Endoscopic dilation and incision is 1 potential option for ureteral intrinsic stenosis.

METHODS

During a 3-year period (2005-2007), a prospective study was performed of cold cutting of ureteral stenosis with endoscopic scissors in 17 consecutive patients (11 women and 6 men), aged 22-64 years. Of the 17 patients, 6 had been diagnosed with proximal ureteral stenosis, 3 with iliac ureteral stenosis, and 8 with pelvic ureteral stenosis. The procedure was performed with a semirigid 8.5Ch ureteroscope, catheterizing and dilation of the stenosis with a balloon catheter, cold cutting of the ureteral wall with scissors, including margins of healthy tissue at both ends of the stenosis, and a 6F double-J ureteral stent for 6 weeks.

RESULTS

The results were evaluated after 3 months with urography in 15 cases and diuretic renography in 2 cases. Analysis of the postoperative complications and urography was done at 12-24 months. Immediate success was obtained after the first endoscopic ureterotomy with scissors in 16 of 17 cases (94%). At 12-24 months, success was maintained in 88.5% of cases.

CONCLUSIONS

Cold cutting of ureteral stenosis with endoscopic scissors is a safe technique for the patient. This procedure could be a therapeutic option in cases of benign intrinsic ureteral stenosis of <15 mm.

Success of laser endoureterotomy of ureteral strictures associated with ureteral stones is related to stone impaction

PURPOSE

Since the holmium:yttrium-aluminum-garnet (Ho:YAG) laser is the flexible lithotrite of choice for ureteral stones, its application to ureteral strictures associated with ureteral calculi is convenient. The results of Ho:YAG laser endoureterotomy in this specific setting have not been defined. We report our experience with Ho:YAG laser endoureterotomy of ureteral strictures associated with ureteral stone treatment, with or without a history of stone impaction.

METHODS

We reviewed the medical records of 13 patients with ureteral stricture related to stone treatment, with (n = 9) or without (n = 4) a history of impacted ureteral stones, who were managed with Ho:YAG laser endoureterotomy. Follow-up was obtained with radiographic imaging and renal scans.

RESULTS

The overall success rate was 62%, with a mean follow-up of 21 months in successful cases and a mean recurrence time of 1.6 months in failures. Outcome was not associated with length or location of the stricture. Among the nine strictures associated with impacted stones, treatment was successful in only 5 (56%). Of the four strictures that occurred after stone removal but without history of impaction, the success rate was 75%. Success was also greater for strictures managed with post-procedure stents >or=8 Fr (75%), compared to stents <or=7 Fr. (56%).

CONCLUSIONS

Our results suggest that laser endoureterotomy of ureteral strictures due to ureteral stone treatment without a history of impaction is associated with a reasonable success rate (75%), but that laser endoureterotomy for strictures related to impacted stones is associated with a success rate of only 56%. Larger caliber stents might be preferred in this setting.