Endoureterotomy for treatment of ureteral strictures

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.

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.

Allium Ureteral Stent as a Treatment for Ureteral Stricture: Results and Concerns

INTRODUCTION

Ureteral strictures could be a chronic illness that leads to severe side effects and poor quality of life. A treatment with an Allium ureteral stent (URS), a self-expanding, large-caliber URS, was implemented in our department for ureteral stricture. Our study aim was to report the long-term results, including success rate, complications, and adverse effects.

METHODS

We retrospectively collected data on all patients who were treated with an Allium URS in our department between January 2017 and January 2021. Demographic, clinical, radiological, and perioperative parameters were retrieved and analyzed. The primary outcome was stricture resolution rates following stent removal.

RESULTS

Our cohort included 17 patients, 9 men and 8 women. The etiology of ureteral strictures was urolithiasis in 76.5% and pelvic procedure injury in 17.6%. The overall success rate was 35.29% in an average follow-up of 10.42 ± 2.39 months after stent removal. A higher failure rate was observed in the urolithiasis etiology group (90% vs. 66.7%, p = 0.38). The mean indwelling time of the Allium stent was 14.29 ± 1.29 months.

CONCLUSIONS

Although an Allium URS could be considered as a feasible and attractive treatment of ureteral strictures, due to its minimal invasiveness, the success rate of this treatment is relatively low. Therefore, this option should be carefully considered and should be discouraged in young and fit patients and reserved for older unfit patients who are unwilling to undergo surgical repair of ureteral strictures.

Dual ureteral stent placement after redo laser endoureterotomy to manage persistent ureteral stricture

INTRODUCTION

Endourological intervention is a minimally invasive approach for the management of ureteral strictures. Contraindications to this approach include active infection, strictures of sizes >2 cm, and failure of endoureterotomy. This report demonstrates a case of successful dual stent placement after redo endoureterotomy.

CASE PRESENTATION

A recurring ureteral stricture in a 69-year-old woman, who had undergone ureteroscopic lithotripsy for a right ureteral calculus 60 months earlier, was successfully managed by redo endoureterotomy. The procedure involved insertion of dual ureteral stents after endoluminal incision and balloon dilation. Ureteral stents were removed 8 weeks after the operation. No significant complications or signs of stricture were observed 42 months after endoscopic repair.

CONCLUSION

This minimally invasive and effective technique of dual ureteral stent placement following laser endoureterotomy successfully managed the recalcitrant ureteral stricture in a case with failed single stent placement following endoureterotomy.

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 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.

Percutaneous nephrolithotomy: complications and how to deal with them

Percutaneous nephrolithotomy is a common surgical treatment for large and complex stones within the intrarenal collecting system. A wide variety of complications can result from this procedure, including bleeding, injury to surrounding structures, infection, positioning-related injuries, thromboembolic disease, and even death. Knowledge of the different types of complications can be useful in order to prevent, diagnose, and treat these problems if they occur. This review describes the diversity of complications with the goal of improving their avoidance and treatment.

Endoureterotomy for Ureteral Stricture: A Retrospective Study of Holmium Versus Thulium Lasers

Background:

To compare the results of endoureterotomy for benign ureteral strictures by using holmium: yttrium-aluminum-garnet (Ho:YAG) and thulium lasers.

Methods:

A total of 25 patients (15 men and 10 women, mean age: 49.16 years) underwent endoureterotomy with either Ho:YAG or thulium lasers for benign ureteral strictures (13 proximal, 3 middle, and 9 distal), using semirigid ureteroscopy and a 365-μm fiber (Ho-YAG laser) at 1.2 J/pulse and 10 Hz, or a 300-μm fiber (thulium laser) at 8W to 15W. Following incision, a 7-Fr double-J ureteral stent was left for 4 to 6 weeks. Thereafter, patients were followed-up using ultrasonography and/or intravenous urography at 3- to 6-month intervals.

Results:

Success was defined as the absence of symptoms, plus radiographic resolution of obstructions, as assessed by diuretic renography and/or intravenous urography. With a mean follow-up of 43 months, success was achieved in 10 (52.6%) of 19 patients treated with Ho:YAG laser and in 5 (83.3%) of 6 patients treated with thulium laser. A total of 10 patients developed recurrent strictures and were considered to have treatment failures. Stricture length and the severity of hydronephrosis were correlated with successful outcome. Sex, etiology, side, and stricture location did not predict outcome.

Conclusions:

Although endoureterotomies using Ho:YAG and thulium lasers had equal efficacy, our analysis revealed that a patient with longer stricture length or severe hydronephrosis is more suitable to receive thulium laser. This general laser procedure is recommended as a safe therapeutic option for the initial management of patients presenting with benign ureteral strictures because it is less invasive.

Laparoscopic Reconstruction in Post-Tubercular Urinary Tract Strictures: Technical Challenges

BACKGROUND

Genitourinary tuberculosis still continues to plague developing countries and is a significant cause of morbidity as well as mortality in the developing world. At present, nearly 55% of the patients of genitourinary tuberculosis (GUTB) need surgical management. Owing to the presence of dense adhesions and loss of normal anatomical planes, GUTB was considered to be a contraindication to laparoscopic surgery. However, recent literature shows laparoscopy to be feasible in GUTB. Our study aimed at identifying the challenges in laparoscopic urinary tract reconstructive surgery in genitourinary tuberculosis-related urinary tract obstruction.

MATERIALS AND METHODS

The details of 6 patients who underwent different types of laparoscopic reconstructive surgery for genitourinary tuberculosis-related urinary tract obstruction from January 2014 to December 2015 were reviewed. Baseline characteristics, indications of surgery, type of surgery, operative duration, blood loss, and follow-up details were noted. All patients received antitubercular treatment before surgery as per the direct observed treatment short-course regimen followed in our country.

RESULTS

We performed one bilateral laparoscopic pyeloplasty, one unilateral laparoscopic pyeloplasty, two laparoscopic ureteroneocystostomies, and two ureteroureterostomies. Difficulty was encountered during dissection owing to the presence of adhesions, but conversion to open surgery was not done in five cases. Dense adhesions adjacent to the common iliac vessels necessitated conversion to open surgery in one of the ureteroureterostomies. Stenting was done in all the patients. All patients had uneventful postoperative recovery. Functional imaging following stent removal showed unobstructed tracer flow, showing successful operative outcome.

CONCLUSIONS

Our study showed that laparoscopic reconstructive surgery is feasible in genitourinary tuberculosis despite the presence of adhesions that may pose a challenge to dissection. This is in contrast to the previous studies which conclude that genitourinary tuberculosis is a relative contraindication to laparoscopic surgery.

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.

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.

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.

Endoscopic management and the role of double stenting for primary obstructive megaureters

PURPOSE

We determined the efficacy and potential complications of endoscopic incision and balloon dilation with double stenting for the treatment of primary obstructive megaureter in children.

MATERIALS AND METHODS

We prospectively reviewed cases of primary obstructive megaureter requiring repair due to pyelonephritis, renal calculi and/or loss of renal function. A total of 17 patients were identified as candidates for endoscopy. Infants were excluded from study. All patients underwent cystoscopy and retrograde ureteropyelography to start the procedure. In segments less than 2 cm balloon dilation was performed, and for those 2 to 3 cm laser incision was added. Two ureteral stents were placed within the ureter simultaneously and left indwelling for 8 weeks. Imaging was performed 3 months after stent removal and repeated 2 years following intervention.

RESULTS

Mean patient age was 7.0 years (range 3 to 12). Of the patients 12 had marked improvement of hydroureteronephrosis on renal and bladder ultrasound. The remaining 5 patients had some improvement on renal and bladder ultrasound, and underwent magnetic resonance urography revealing no evidence of obstruction. All patients were followed for at least 2 years postoperatively and were noted to be symptom-free with stable imaging during the observation period.

CONCLUSIONS

Endoscopic management appears to be an alternative to reimplantation for primary obstructive megaureter with a narrowed segment shorter than 3 cm. Double stenting seems to be effective in maintaining patency of the neo-orifice. Followup into adolescence is needed.

[Sacral hitch vesical pexy: a new ancillary technique for ureteroneocystostomy]

BACKGROUND

To describe the Sacral Hitch, vesical pexys to sacral promontory, an alternative technique to the Psoas Hitch when this is impossible to perform. We report intraoperative complications, and long-term functional results.

METHODS

From 1989 to date we performed 66 ureteroneocystostomies (UNCS) (transbladder technique and Politano-Leadbetter antireflux plasty): 51 with ancillary "Psoas Hitch" (11 Casati-Boari); 15 with "Sacral Hitch" because of the intraoperative finding of deficiency or lack of psoas tendon. Note of technique. Ureter and bladder are dissected as usual. Sacral Hitch: left lateralization of sigmoid and exposition of sacral promontory; longitudinal incision and divarication of peritoneum; smooth dissection of fat tissue, displacement of medium sacral vessels and visualization of neurovascular bundles. Direct fixation of the dome/posterior aspect of bladder to anterior longitudinal ligament above promontory.

RESULTS

Among the patients who underwent the Psoas Hitch technique, 3 (5.4%) showed hypoesthesia, acute pain and impossible flexion of the thigh on hip with EMG positive for femoral (1) and genito-femoral (2) neuropathy. The re-operation in 2 cases solved the symptoms. One case resolved conservatively with corticoids, tricyclic antidepressants (Amitriptyline) and antiepileptics (gabapentin). Mean follow-up was 115 months (8-252); two stenosis of anastomosis. Sacral Hitch: (15 pts), mean follow-up: 47 months (range 4-110), no stenosis of anastomosis 0%; transfusion rate 0%.

DISCUSSION

The psoas tendon deficiency or its congenital absence (children or women) requires the direct fixation to the muscle, an inadequate and weak target and housing of important sensitive-motor nerves (Genito-femoral, femoral and latero-cutaneous). A "Psoas-Syndrome" could be present in 5.1% and a re-operation could be necessary. The sacral promontory represents an affixation target already successfully adopted in other surgery specialties (Gynaecology, Orthopaedic and General Surgery) and gives to UNCS a stiffness plate and an effective bladder cranialization. CONCLUSIONS. Sacral Hitch Vesical Pexys represents an ancillary procedure to UNCS and surgeons should keep it in mind in cases of difficult finding of the psoas muscle tendon.

Options in the management of tuberculous ureteric stricture

Ureteric stricture is a feared manifestation of genitourinary tuberculosis (TB) with the commonest site being the lower ureter. The purpose of this review is to discuss the management options for this condition. Literature search was done using PubMed and all articles on TB and ureteric stricture were reviewed published between 1990 till September 2007. The exact site and length of stricture must be defined with radioimaging (intravenous urography, retrograde, or antegrade pyelography) and renal function be quantified. The treatment of stricture mostly requires some kind of intervention after a brief period of antituberculous medicines with or without steroids. For uncomplicated/simple strictures (short segment, passable, with renal function >25%, good bladder capacity) endourologic option should be used which usually means double-J stenting with or without balloon dilatation. For complicated/complex strictures (long segment, dense fibrosis, with renal function <20%, small bladder capacity) regular surgical options should be considered which usually means ureteroureterostomy or ureteropyelostomy for upper ureteric strictures, intubated ureterostomy, or transureteroureterostomy for midureteric strictures, psoas hitch/Boari flap for lower ureteric strictures or ileal ureter/autotransplantation for whole length/multiple strictures.

Ureterorenoscopy: avoiding and managing the complications

Retrograde exploration of the ureter and kidneys is currently a widely used and well-established procedure to deal with problems of a diagnostic and therapeutic nature with reduced invasiveness. The process of miniaturizing the instruments combined with the steady improvement in video quality has continuously amplified its potential applications, maintaining the procedure safe and rapid. During an operation, however, unexpected events may condition a change to the programme or determine the onset of even more serious complications. Our aim is to analyze such events and complications and recommend potential solutions to prevent and/or deal with such happenings.

Endourologic management of malignant ureteral obstruction: indications, results, and quality-of-life issues

Obstruction of the upper urinary tract is a problem commonly faced by practicing urologists. The constant evolution in endourology has effectively facilitated minimally invasive management of upper-tract obstruction. In a case in which malignancy is the cause of obstruction, however, the situation significantly changes. Questions arise regarding the need for relieving the obstruction, the means to accomplish this, and the benefits and drawbacks of each technique regarding both their efficacy and their impact on the patients well-being and the crucial issue of quality of life in the face of malignancy.

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.

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.

Long-term results of endoureterotomy using a holmium laser

The long-term results of endoureterotomy using a holmium laser in cases of benign ureteral stricture, uretero-pelvic junction obstruction (UPJ-O) and ureteroenteric stricture were evaluated. Twenty procedures were carried out in 18 patients. Strictures were incised with a holmium laser using a fiber passed through the ureteroscope. Sixteen of the 20 procedures (80%) were successful at average follow-up of 60.5 months (range, 46-74). Stricture recurred in four cases. All failures occurred within 18 months. Although stricture length was not correlated with recurrence, all failures, with the exception of a single UPJ-O, involved middle ureteral strictures. Endoureterotomy using a holmium laser affords favorable results with respect to long-term patency. This procedure is recommended as a satisfactory therapeutic option for the initial management of patients presenting with ureteral stricture.

Long-term efficacy of holmium laser endoureterotomy for benign ureteral strictures

OBJECTIVES

To determine the long-term clinical and radiographic success of holmium laser endoureterotomy for nonobliterative benign ureteral strictures.

METHODS

A total of 19 patients (12 women and 7 men, mean age 47.5 years) underwent holmium laser endoureterotomy for iatrogenic ureteral strictures (seven proximal, seven mid, and five distal) using semirigid ureteroscopy and a 360-microm fiber at 1 J and 10 Hz.

RESULTS

Success was strictly defined as both relief of symptoms and radiographic resolution of obstruction by intravenous pyelography or diuretic renography, or both. With a median follow-up of 3.0 years, success was achieved in 13 (68.4%) of 19 patients.

CONCLUSIONS

Our results have shown that holmium laser endoureterotomy is associated with a long-term success rate equivalent to, or better than, other currently available minimally invasive treatment options. Also, failure was uniformly evident within the first 3 months after treatment.

Handling and prevention of complications in stone basketing

OBJECTIVE

To review the incidence, risk factors, and treatment options of intraoperative and postoperative complications of stone basketing in urology with emphasis on certain principles that must be upheld to prevent those complications.

METHODS

A literature search was performed using the MEDLINE database on stone basketing between 1970 and 2005.

RESULTS

Iatrogenic trauma due to retrieval of a stone is well known but the exact incidence is difficult to ascertain. Rarely, stone basketing can cause major trauma to the ureter, such as avulsion or intussusception, requiring open or laparoscopic intervention for ureteral continuity restoration. Mucosal abrasion, ureteral perforation, and stricture formation have also been described as complications of stone basketing. Occasionally, the engaged or broken basket can provoke anxiety even for experienced urologists. Factors that increase the risk of complications, strategies for repair, and techniques for prevention are discussed extensively.

CONCLUSION

Infrequent, surgical misadventures during stone basketing can occur and must be treated appropriately. Careful attention to instrument selection and surgical techniques and awareness of risk factors and type and site of potential injury are essential to reduce these complications.

Result of endoscopic ureteroureterostomy with holmium:YAG laser for complete ureteral obstruction

BACKGROUND AND PURPOSE

Complete ureteral obstruction after pelvic surgery is traditionally managed by open repair. Recent advances in endoscopic instruments and techniques have improved the efficacy with which these conditions are treated. Here, we describe our experiences with a holmium:YAG laser in the endoscopic management of complete ureteral obstruction.

PATIENTS AND METHODS

Retrograde endoscopic ureteroureterostomy using a Ho:YAG laser was performed on five patients with complete ureteral obstruction having a mean length of 0.9 +/- 0.2 cm after gynecologic surgery. The obliterated segment was incised with a 550-microm fiber through a rigid ureteroscope and under fluoroscopic guidance. Afterward, balloon dilatation was performed. A 7F/14F endopyelotomy stent was maintained for a mean time of 7 weeks, and follow-up was conducted via radiologic imaging.

RESULTS

Recanalization was possible in all five patients immediately. One month after the initial operation, one patient exhibited a normal ureteral passage, and three other patients exhibited partial ureteral stricture. The remaining patient was lost to follow-up. Of the three patients with partial strictures, two evidenced no stricture after additional endoscopic treatment(s), and the remaining patient eventually underwent open repair. Overall, three of four (75%) patients exhibited normal excretory function without any open surgery and were symptom free with a mean follow-up time of 45 months (range 23-67 months).

CONCLUSIONS

Although the number of patients in this study was small, it appears that endoscopic ureteroureterostomy with a Ho:YAG laser may constitute a valuable option for the treatment of complete short ureteral obstructions.

Laparoscopic ureteral reimplantation: A simplified dome advancement technique

Laparoscopic Boari flap reimplantation has been used to treat long distal ureteral strictures. This technique requires extensive bladder mobilization and complex intracorporeal suturing. This demonstrates a novel laparoscopic bladder dome advancement approach for ureteral reimplantation. This technique obviates the need for bladder pedicle dissection and simplifies the required suturing.

Surgical technique to correct complex ureterointestinal stricture with defunctionalized limb of Turnbull stoma

We describe a novel technique to repair a long ischemic ureterointestinal stricture using the defunctionalized limb of a Turnbull stoma in a patient who had previously undergone two attempts at open surgical revision.

Endoscopic Treatment of Ureteric Strictures: Acucise, Cold-Knife Endoureterotomy and Wall Stents as a Salvage Approach

OBJECTIVE

To evaluate the factors influencing the results of endoureterotomy using cold-knife and cutting balloon dilatation, and permanent ureteral wall stents in patients with benign ureteral strictures after different operations affecting the ureter.

MATERIALS AND METHODS

Over a 4-year period, in 18 patients, endoscopic cold-knife and Acucise endoureterotomies were performed in 13 and 7 renal units, respectively. Eight Memoterm permanent ureteral wall stents were inserted into 7 patients when endoureterotomy failed. Successful outcome was defined by the absence of re-stricture assessed both clinically and radiologically.

RESULTS

The strictures were secondary to ureterolithotomy in 6, ureteroscopy in 3, gynecological procedures in 4, abdominal surgeries in 2, transplantation in 2 and continent urinary diversion in 1. The right and left ureters were unilaterally affected in 5 and 11 patients, respectively (5 of them had a solitary kidney), while the remaining 2 patients had bilateral ureteral strictures. We achieved total ureteral patency of 3 (43%) and 7 (54%) renal units with Acucise and cold-knife incision, respectively. Obstructive uropathy was resolved in 6 renal units (75%) of 8 using ureteral wall stents.

CONCLUSION

Endoureterotomy with cold-knife or Acucise cutting balloon dilatation is effective in the treatment of iatrogenic ureteral strictures, but only in a selected group. Based on our results, the favorable prognostic criteria for endoureterotomy are the length (< or =1.5 cm), the nonischemic nature of the stricture and adequate renal function. As a salvage approach, permanent self-expanding ureteral wall stents with a 75% success rate may provide a satisfactory outcome for decompression of an obstructed system.

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.

Transurethral incision of ureteroneocystostomy strictures in kidney transplant recipients

OBJECTIVES

To report the treatment of patients who presented with vesico-ureteric stricture after kidney transplantation, using a minimally invasive endourological approach.

PATIENTS AND METHODS

Patients (10 men and four women, mean age 34 years, range 22-55) were assessed at presentation by serum creatinine level, ultrasonography and intravenous pyelography when the serum creatinine level was < 200 micromol/L. When there was hydronephrosis of the allograft a percutaneous antegrade pyelogram was taken, followed by inserting a nephrostomy. After decompression a stent nephrostomy was passed into the bladder and the strictures at the vesico-ureteric junction incised along the stent during cystoscopy.

RESULTS

All 14 patients were treated endourologically by an endoscopic incision through the bladder; 13 fared well and one died from sepsis and transplantation problems. The mean follow-up was 8 months.

CONCLUSIONS

Simple incision of the stricture via cystoscopy was safe and effective, and succeeded in most patients. The endourological management of ureteric lesions is feasible and is currently our first-line management of ureteric complications after kidney transplantation.

Management of iatrogenic ureteric injuries associated with gynecological surgery

OBJECTIVE

This retrospective study defines the presentation and management of iatrogenic ureteric injuries consequent upon gynecological surgery in a teaching hospital in Punjab, Pakistan.

PATIENTS AND METHODS

18 patients with median age 35 years (range 18-80 years) with iatrogenic ureteric injuries associated with gynecological surgery were referred to the department of urology at Nishtar Hospital Multan Pakistan. Main presenting symptoms were urinary incontinence, loin pain and anuria. Median time since injury and presentation was 3 weeks (range 1 day to 7 years). In 16 (88%) patients injury resulted from abdominal hysterectomy. Other causes included ovarian cystectomy (one patient) and vaginal hysterectomy (one patient). 11 (61%) patients had ureterovaginal fistula, 5 (28%) patients had complete unilateral ureteric obstruction and 2 (11%) patients had bilateral ureteric obstruction and anuria. In 11 patients with ureterovaginal fistula ureteroneocystostomy was performed. In five patients with unilateral ureteric obstruction, one had end to end anastomosis of ureter, three had ureteroneocystostomy only and one had ureteroneocystostomy and psoas hitch done. Two had anuria secondary to bilateral ureteric obstruction. In one of these patients Boari flap and ureteroneocystostomy was carried out. The second patient had deligation of catgut sutures on ipsilateral side and ureteroneocystostomy on the contra-lateral side.

RESULTS

In 17 patients no major complication occurred. One patient who had deligation of catgut sutures, the distal ureter sloughed and re-exploration and ureteroneocystostomy was performed. Renal salvage was achieved in all cases.

CONCLUSION

Open surgical procedures for repair of iatrogenic ureteric injuries are associated with good outcome. Strategies to prevent these injuries include adequate surgical training and meticulous surgical techniques.

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 replacement using porcine small intestine submucosa in a porcine model

OBJECTIVES

To investigate an alternative technique using an onlay patch of porcine small intestine submucosa (SIS) allograft to bridge a ureteral defect. For ureteral strictures that fail endourologic management, few options are available for minimally invasive repair or reconstruction. Although laparoscopic interposition of a tubularized allograft of porcine SIS has great promise, animal studies have yielded mixed results.

METHODS

In 9 anesthetized female pigs, cystoscopy and retrograde pyelography were performed, and a ureteral stent was placed. Transperitoneal laparoscopic access was obtained, and a segment of ureter 2 cm long and encompassing one half the ureteral circumference was excised. An oval-shaped patch of SIS was sutured to the native ureter to cover the defect. In one control survival animal, the ureter was excised and a stent placed, but no SIS onlay was performed. Two pigs were killed immediately. In the survival group (6 pigs), the stents were removed at 1 week (n = 2), 2 weeks (n = 2), or 4 weeks (n = 2) and the corresponding animals were killed at 3 weeks (n = 2), 6 weeks (n = 2), and 9 weeks (n = 2). Intravenous urography was performed to evaluate renal function, and retrograde pyelography was performed after harvest to identify ureteral stricture or obstruction. The ureteral grafts were measured and examined histologically.

RESULTS

All 6 kidneys from the survival group were grossly normal, appeared promptly on intravenous urography, and were patent on retrograde pyelography. The control animal demonstrated complete ureteral obstruction. By 9 weeks, the SIS graft was replaced with ureteral tissue, including the muscle layers. The epithelium was primarily transitional epithelium, with focal intestinal metaplasia. The submucosa and ureteral musculature appeared histologically normal.

CONCLUSIONS

In the porcine model, a patch graft technique using SIS appears to induce ureteral regrowth. Renal function remained intact, and no evidence of stricture was demonstrated on radiographic imaging. Before clinical application of this technique, evaluation in a stricture model is required.

Endoscopic treatment of benign ureteral strictures

BACKGROUND

The traditional choice of procedure for treatment of ureteral stricture is open surgical repair. Advances in endourology have provided the urological surgeon with an alternative to open surgery for the treatment of benign ureteral stricture.

METHODS

Twenty-seven benign ureteral strictures in 24 patients were treated by the endourological method. Twelve endoureterotomies were performed using a cold knife via a 9.5Fr Storz ureteroscope and 15 high pressure balloon dilations were performed. The ureters were stented with 7 Fr double-J stents for 6 weeks.

RESULTS

The success rate was 9/12 (75%) in the endoureterotomy group and 9/15 (60%) in the balloon dilation group after follow-up for more than 6 months.

CONCLUSIONS

Endoscopic treatment of ureteral strictures appeared to be a safe and reasonably effective modality for the treatment of ureteral strictures, especially for the short type that are non-ischaemic in origin and not associated with radiation therapy. Endourological treatment of ureteral strictures is the procedure of choice for initial management of benign ureteral strictures and has high success rates and fewer complications.

Long-term results of antegrade endoureterotomy using the holmium laser in patients with ureterointestinal strictures

OBJECTIVES

To investigate the effectiveness and morbidity of percutaneous laser endoureterotomy in the management of ureterointestinal anastomotic strictures after radical cystectomy and urinary diversion.

METHODS

Between May 1997 and August 2000, 19 percutaneous endoureterotomy incisions, including 3 repeated incisions, were performed on 15 patients with a mean age of 61 years (range 41 to 80) to treat ureterointestinal strictures. A total of 16 renal units were treated (9 left, 7 right), including one bilateral procedure. All procedures were performed using a 200-micrometer holmium laser fiber in antegrade fashion with a 7.5F flexible ureteroscope. A nephroureteral stent was left in place for 4 to 6 weeks postoperatively. Success was defined as radiologic improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes.

RESULTS

With a median follow-up of 20.5 months (range 9 to 41), the overall success rate was 57% (8 of 14 renal units). Two patients were lost to follow-up. The mean operative time was 91 minutes, and no perioperative complications occurred. Three patients required repeated endoureterotomies, with two requiring open reimplantation. Overall, the endoureterotomy failed in 6 patients in the series, with five of the six failures involving left-sided strictures.

CONCLUSIONS

Percutaneous endoureterotomy is an effective, minimally invasive treatment option for patients with ureterointestinal strictures after urinary diversion. Better visualization and a more precise incision may make the holmium laser a safer cutting modality than alternative methods in patients with ureteroenteric strictures. Patients with left-sided ureterointestinal strictures should be cautioned that endourologic management might have a lower success rate.

Endoscopic ureteral incision using the holmium:YAG laser

BACKGROUND

We reviewed the results of endoscopic ureteral incision for benign ureteral stricture, ureteropelvic junction obstruction and ureteroenteroanastomotic stricture using the holmium laser.

METHODS

We carried out endoscopic ureteral incision using the holmium laser through an 8-Fr semirigid or 6.9-Fr flexible ureteroscope on 17 ureters in 15 patients. Balloon dilatation was not necessary before insertion of the ureteroscope. The stricture was incised with the holmium laser using a 200-365 microm fiber through the working channel of the ureteroscope. After completion of the incision, a 12-Fr double-J catheter was left for 6 weeks. Thereafter patients were followed by renal scan and/or ultrasound and excretory urography at 3-6 month intervals.

RESULTS

The mean operative time was 65 min (18-135 min). The stricture resolved completely in 86.7% of cases at an average follow up of 20.5 months (11-32 months).

CONCLUSIONS

The holmium laser endoscopic ureteral incision was associated with a good outcome in our series. We recommend this procedure to be employed initially because it is less invasive and has a favorable outcome.

Holmium:YAG laser endoureterotomy in the treatment of ureteroenteric stricture following Indiana urinary diversion

A 57-year-old man who had received radical urethrocystectomy and Indiana urinary diversion 6 months earlier was treated for ureteroenteric anastomosis stricture (left side) using a Holmium:YAG laser via antegrade approach. The availability of small (6.9 Fr) flexible ureteroscope, as well as the use of the Holmium:YAG laser has facilitated the ability to precisely incise the stricture under direct endoscopic visualization. The technique is described for laser endoureterotomy in a patient with ureteroenteric stricture following Indiana urinary diversion.

Long-term results of permanent indwelling wallstents for benign mid-ureteral strictures

BACKGROUND

Benign ureteral strictures are a potentially difficult problem that typically has been solved by open surgery. However, minimally invasive methods would be preferable.

PATIENTS AND METHODS

Three patients with benign ureteral strictures were treated with endoscopic placement of self-expanding permanent indwelling stents (Wallstents). The etiologies of the obstruction were multifactorial and included retroperitoneal fibrosis, stones, traumatic ureteroscopy, ureteral ischemia, and previous open surgery.

RESULTS

One patient died with a functioning stent 1 year, 7 months after placement. The other two patients are doing well 5 years, 2 months and 5 years, 11 months afterward (mean 51 months).

CONCLUSION

Insertion of a permanent indwelling self-expanding ureteral stent is relatively easy, and long-term successes are documented. Placement of Wallstents for benign ureteral strictures should be considered as a treatment alternative.

Endourologic management of malignant ureteral strictures

PURPOSE

This retrospective analysis assessed the efficacy of balloon dilatation, endoureterotomy, percutaneous ureteroneocystostomy with stenting, and insertion of Wallstents in the management of malignant ureteral strictures with an intact or compromised vascular supply.

PATIENTS AND METHODS

A series of 127 patients with ureteral strictures secondary to malignancies were assessed after at least 2-year follow-up (range 2-5 years; mean 3.5 years). Balloon dilation (antegrade approach) was applied in 46 patients, endoureterotomy with temporary stenting in 37, percutaneous ureteroneocystostomy with stenting in 34, bougie and stents in 13, and Wallstents in 31.

RESULTS

Balloon dilatation was successful in only two of four malignant midureteral stenoses with intact vascular supplies and was even less successful (10%) in midureteral strictures with a compromised vascular supply. Endoureterotomy failed in all cases to prevent ureteral obstruction. Percutaneous ureteroneocystostomy achieved patency in 11 of 34 patients (33%) having a compromised ureteral vascular supply. Wallstents were successful in 18 of 31 patients (58%) with stenoses of the pelvic ureter.

CONCLUSIONS

Percutaneous ureteroneocystostomy with stenting meets the requirement for palliation in patients with obstruction secondary to pelvic neoplasms. Wallstents proved to be most successful when used in the pelvic ureter.