Transurethral Ureteroscopic Ureterotomy Assisted by a Prior Balloon Dilation for Relieving Ureteral Strictures

Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility

BACKGROUND

The ureter is the second most common site affected by urinary tract endometriosis, after the bladder. Optimal strategies in the diagnosis and treatment of ureteral endometriosis (UE) are not yet well defined.

OBJECTIVE AND RATIONALE

The aim of this study was to systematically review evidence regarding the epidemiology, pathophysiology, diagnosis, medical and surgical treatment, impact on fertility and risk of malignant transformation of UE.

SEARCH METHODS

A systematic literature review, by searching the MEDLINE and PUBMED database until April 2018, was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/PROSPERO CRD42017060065). A total of 67 articles were selected to be included in this review.

OUTCOMES

The involvement of the ureter by endometriosis is often asymptomatic or leads to non-specific symptoms. When the diagnosis is delayed, UE may lead to persistent hydronephrosis and eventually loss of renal function. Ultrasonography is the first-line technique for the assessment of UE; alternatively, magnetic resonance imaging provides an evaluation of ureteral type involvement. The surgical treatment of UE aims to relieve ureteral obstruction and avoid disease recurrence. It includes conservative ureterolysis or radical approaches, such as ureterectomy with end-to-end anastomosis or ureteroneocystostomy performed in relation to the type of ureteral involvement. Fertility and pregnancy outcomes are in line with those observed after surgical treatment of deep infiltrating endometriosis (DIE). Current evidence does not support the potential risk of malignant transformation of UE.

WIDER IMPLICATIONS

In this article, we review available evidence on ureteral endometriosis, providing a useful tool to guide physicians in the management of this disease. Diagnosis and management of UE remain a challenge. In relation to the degree of ureteral involvement and the association with other DIE implants, the surgical approach should be planned and carried out in an interdisciplinary collaboration between gynecologist and urologist.

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.

Optimal management of distal ureteric strictures following renal transplantation: a systematic review

Our objective was to define optimal management of distal ureteric strictures following renal transplantation. A systematic review on PubMed identified 34 articles (385 patients). Primary endpoints were success rates and complications of specific primary and secondary treatments (following failure of primary treatment). Among primary treatments (n = 303), the open approach had 85.4% success (95% CI 72.5-93.1) and the endourological approach had 64.3% success (95% CI 58.3-69.9). Among secondary treatments (n = 82), the open approach had 93.1% success (95% CI 77.0-99.2) and the endourological approach had 75.5% success (95% CI 62.3-85.2). The most common primary open treatment was ureteric reimplantation (n = 33, 81.8% success, 95% CI 65.2-91.8). The most common primary endourological treatment was dilation (n = 133, 58.6% success, 95% CI 50.1-66.7). Fourteen complications, including death (4 weeks post-op) and graft loss (12 days post-op), followed endourological treatment. One complication followed open treatment. This is the first systematic review to examine the success rates and complications of specific treatments for distal ureteric strictures following renal transplantation. Our review indicates that open management has higher success rates and fewer complications than endourological management as a primary and secondary treatment for post-transplant distal ureteric strictures. We also outline a post-transplant ureteric stricture evaluation and treatment algorithm.

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.

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.

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.

Treatment of Ureterointestinal Anastomotic Strictures by Diathermal or Cryoplastic Dilatation

BACKGROUND

Ureterointestinal anastomotic strictures (UAS) complicate 10-15% of surgeries for urinary diversion and are the main cause of deterioration in renal function. Treatments are surgical revision, management with autostatic stent, balloon dilatation, endoscopic incision, and percutaneous transrenal diathermy (Acucise). A new option is cryoplastic dilatation (Polar-Cath).

PURPOSE

To assess the feasibility, complications, and preliminary results of UAS treatment using the Acucise and Polar-Cath systems.

METHODS

Nineteen UAS, diagnosed by ultrasonography or computed tomography and sequential renal scintigraphy, occurred in 15 cancer patients after radical cystectomy and urinary diversion. Fifteen were managed with balloon diathermy and 4 by balloon cryoplasty in a three-stage procedure--percutaneous nephrostomy, diathermal or cryoplastic dilatation, and transnephrostomic control with nephrostomy removal--each separated by 15 days. All patients gave written informed consent.

RESULTS

Dilatations were successful in all cases. The procedure is simple and rapid (about 45 min) under fluoroscopic control and sedation. Procedural complications occurred in 1 (5%) patient with UAS after Wallace II uretero-ileocutaneostomy: a common iliac artery lesion was induced by diathermal dilatation, evident subsequently, and required surgical repair. Patency with balloon diathermy was good, with two restenoses developing over 12 months (range 1-22) of follow-up. With balloon cryoplastic dilatation, one restenosis developed in the short term; follow-up is too brief to assess the long-term efficacy.

CONCLUSION

Our short-term results with diathermal and cryoplastic dilatation to resolve UAS are good. If supported by longer follow-up, the techniques may be considered as first-choice approaches to UAS. Surgery should be reserved for cases in which this minimally invasive technique fails.

Prise en charge de l'endométriose urinaire

Endometriosis of the urinary tract (bladder and/or ureter) is rare and concerns 1-2% of cases of endometriosis. Surgical management is usually mandatory. Rate of peri operative morbidity is low. There is a risk of functional (dysuria, chronic hypogastric pains, imperiosity) and anatomical recurrences (0-15 and 0-10% respectively). Surgical treatment of bladder and/or ureteral endometriosis requires informed consent of patients and multidisciplinary management.

Ureteroscopic endoureterotomy

OBJECTIVE

To highlight the current status of ureteroscopic endoureterotomy (UE) by reporting extensive experience with the endoscopic management of ureteric strictures, with special emphasis on factors determining success, and by reviewing publications on the minimally invasive management of ureteric strictures.

PATIENTS AND METHODS

The study comprised 50 patients (mean age 53 years, range 18-85, equal sex distribution) with ureteric strictures of varying causes; all had their stricture treated endoscopically. The follow-up was 0.5-9 years; 10 patients with recurrent strictures had two ipsilateral stents placed to try to improve the outcome, and eight patients with completely obliterating strictures were treated by ureteroscopic re-canalization.

RESULTS

The site of stricture had no bearing on the eventual outcome. Patients with uretero-enteric and malignant strictures did not fare so well. The most important predictor of failure was the length of the stricture, with failure in all seven patients with strictures of > 2 cm. In the 10 patients treated with two ipsilateral stents, eight were successful, which was very promising considering that these patients had recalcitrant strictures and placing one stent had previously failed. The overall success rate was 74%.

CONCLUSION

UE has become the procedure of choice for the initial management of ureteric strictures. Simple balloon dilatation is also effective in certain situations. The characteristics of the stricture often govern the eventual outcome. In properly selected cases success rates of approximately 75% can be expected.

Update On Minimally Invasive Management of Ureteral Strictures

PURPOSE

To review the role of minimally invasive management in ureteral stricture disease.

MATERIALS AND METHODS

A literature search was performed on the MEDLINE database through 2002 concerning endoscopic treatment of patients with ureteral strictures.

RESULTS

Many endourologic methods are available for ureteral strictures. Ureteral dilation may be accomplished in most cases, with various rates of success depending on stricture etiology, location, and length. Endoureterotomy also leads to long-term patency in properly selected cases and appears to be superior to dilation alone.

CONCLUSIONS

Significant advances in technique and technology have improved our ability to treat ureteral strictures without the need for open surgery in most patients.

Ureteral endometriosis

PURPOSE

This review discusses the pathophysiology, presentation, and different minimally invasive medical and surgical treatment options for ureteral endometriosis.

MATERIALS AND METHODS

A comprehensive literature review of reports on the diagnosis and management of ureteral endometriosis was performed using MEDLINE.

RESULTS

Ureteral endometriosis is a rare disease. Most cases present with silent obstruction, as opposed to cyclical hematuria. The diagnosis of ureteral endometriosis requires a high index of suspicion. A variety of diagnostic tests can help identify the extent of disease and the degree of renal function on the side of ureteral involvement.

CONCLUSIONS

Ureteral endometriosis can be treated with hormones or surgical intervention. While surgery is reserved for hormone refractory cases and obstruction associated with extensive scarring, the majority of cases can be managed with hormones only. A combination of hormones and surgery is also effective. Surveillance for obstructive uropathy with periodic noninvasive monitoring of kidney function is currently recommended for all patients with endometriosis.

Treatment of uretero-intestinal and ureterovesical strictures by Acucise balloon catheter

OBJECTIVE

Acucise balloon catheter has been proposed as an alternative to open surgery for the treatment of strictures of the ureteropelvic junction because of its low morbidity and the short hospital stay following the endoscopic procedure. The objective of this study was to evaluate the results of this technique applied to patients developing strictures after surgical reimplantation of the ureterovesical (UV) or uretero-intestinal (UI) junction.

MATERIAL AND METHODS

Between March 1997 and January 2000, 12 strictures (11 patients) were treated by Acucise balloon catheter via an antegrade and/or retrograde approach with double J stenting for an average of 6 weeks (range: 4-12 weeks): six uretero-ileal strictures (three Bricker, one uretero-ileoplasty, one enterocystoplasty and one Kock pouch) and six ureterovesical strictures (Lich-Grégoir or Paquin UV reimplantations after gynaecological, vascular or endoscopic surgery). The median postoperative follow-up was 16 months (range: 10-36 months). A good result was defined by the absence of recurrence of the stricture evaluated both clinically and radiologically (regression of stasis measured by IVU and/or ultrasonography).

RESULTS

The mean operating time was 70 minutes and the mean hospital stay was 4.8 days (range: 3-14 days). Only one intraoperative complication was observed (migration of the double J stent to the kidney). The operation was successful in eight patients (75%). The success rate was 83% for ureterovesical strictures and 50% for uretero-ileal strictures. A history of previous irradiation appeared to be a factor of failure.

CONCLUSION

The Acucise procedure is a minimally invasive and effective (75% success rate) treatment option for the treatment of postoperative stricture after ureteric reimplantations. In our department, this option is considered to be first-line treatment, as surgical reimplantation is reserved for failures of the endoscopic technique.

[Treatment of stenosis in uretero-intestinal anastomosis]

We report our experience in the treatment of uretero-enteric anastomotic strictures. Our incidence in this complication is 3.8% in orthotopic bladder substitution and 8.3% in ileal conduict.

MATERIAL AND METHODS

We have treated this complication in 6 patients with orthotopic bladder substitution and 4 with ileal conduict. We tried to perform a dilatation with a high pressure balloon and to place a Double-J catheter.

RESULTS

In 4 cases we could not introduce the guidewire through the stricture because there was a total stop. In the others 6 cases, one is doing well without Double-J, another one did not tolerate the catheter and we performed an open surgical reanastomosis, 2 kept the catheters until their death due to metastases and the other two continue alive with their catheter periodically replaced.

CONCLUSIONS

The direct uretero-enteric anastomoses present less stenoses risk. Endourological techniques should be the first option in treatment of these patients.

Endourologic management of benign ureteral strictures with and without compromised vascular supply

OBJECTIVES

To retrospectively assess the efficacy of balloon dilation, endopyelotomy/ureterotomy, and stenting alone in the management of benign ureteral strictures with intact or compromised vascular supply.

METHODS

One hundred fourteen patients with benign ureteral strictures were assessed after at least a 2-year follow-up (range 2 to 16 years, mean 6.3). Balloon dilation was performed in 81, endopyelotomy/ureterotomy with temporary stenting in 27, and ureteral stenting alone in 6 patients. Ureteral strictures were divided into strictures with intact or with compromised vascular supply.

RESULTS

Balloon dilation was successful in short ureteral strictures with intact vascular supply in 33 of 37 (89.2%), but only in 3 of 8 (37.5%) long ureteral strictures and in 1 of 2 (50%) recurrent ureteropelvic junction strictures. Balloon dilation was less successful when the vascular supply was compromised in 2 (40%) of 5 short strictures, 1 (16.7%) of 6 long strictures, and 2 (33.3%) of 6 recurrent ureteropelvic junction strictures. Endopyelotomy/ureterotomy was successful in 17 (89.5%) of 19 strictures with compromised vascular supply.

CONCLUSIONS

Balloon dilation is recommended for management of short strictures with intact vascular supply. Endoureterotomy with stenting is recommended for all long ureteral strictures, for ureteropelvic junction stenoses, and for short ureteral strictures with compromised vascular supply and benign underlying etiology.

Long-term results of endoureterotomy for benign ureteral and ureteroenteric strictures

PURPOSE

We reviewed the results of endoureterotomy for benign ureteral and ureteroenteric strictures to determine efficacy and factors associated with a successful outcome.

MATERIALS AND METHODS

Followup was available for 69 patients undergoing 77 endoureterotomies. Success was defined as symptomatic improvement and radiographic resolution of obstruction. Kaplan-Meier survival curves were constructed and data were analyzed with a Cox proportional hazards model.

RESULTS

None of 9 procedures in patients with the ipsilateral kidney contributing less than 25% of total renal function was successful. Among the 38 remaining benign ureteral stricture treatments with ipsilateral function 25% or greater with a median followup of 28.4 months among successful cases the 3-year success rate was 80%. No procedure failed beyond 11 months and there were 25 patients at risk beyond this point. Among the 30 remaining ureteroenteric stricture treatments with ipsilateral function 25% or greater the success rates at 1, 2 and 3 years were 73, 51 and 32%, respectively. Failures were noted during the first 36 months but none occurred later and 5 patients were at risk beyond this point. Overall, complete or tight strictures were less successfully treated. A nonischemic etiology, a stent 12F or greater and injection of triamcinolone into the bed of the incised stricture were associated with better outcome for strictures longer than 1 cm.

CONCLUSIONS

Endoureterotomy of benign ureteral strictures is associated with an excellent outcome (80% success at 3 years). Endoscopic treatment of ureteroenteric strictures is less successful but still offers a reasonable first step (32% 3-year success rate). For all strictures failure is likely if ipsilateral renal function is poor. For strictures longer than 1 cm. use of a stent 12F or greater and injection of triamcinolone appear to be beneficial.