Transluminal balloon dilation of ureteral strictures

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.

Ureteroileal bypass: a new technic to treat ureteroenteric strictures in urinary diversion

Objective:

To present our technique of ureteroileal bypass to treat uretero-enteric stric- tures in urinary diversion.

Materials and Methods:

One hundred and forty-one medical records were reviewed from patients submitted to radical cystectomy to treat muscle-invasive bladder cancer between 2013 and 2015. Twelve (8.5%) patients developed uretero-enteric anastomotic stricture during follow-up. Five patients were treated with endoscopic dilatation and double J placement. Four were treated surgically with standard terminal-lateral im- plantation. Three patients with uretero-enteric anastomotic stricture were treated at our institution by “ureteroileal bypass”, one of them was treated with robotic surgery.

Results:

All patients had the diagnosis of uretero-enteric anastomotic stricture via computerized tomography and DTPA renal scan. Time between cystectomy and diag- nosis of uretero-enteric anastomotic stricture varied from five months to three years. Mean operative time was 120±17.9 minutes (98 to 142 min) and hospital stay was 3.3±0.62 days (3 to 4 days). Mean follow-up was 24±39.5 months (6 to 72 months). During follow-up, all patients were asymptomatic and presented improvement in ure-terohydronephrosis. Serum creatinine of all patients had been stable.

Conclusions:

Latero-lateral ureter re-implantation is feasible by open or even robotic surgery with positive results, reasonable operation time, and without complications.

Robot-assisted repair of ureteroileal anastomosis strictures: initial cases and literature review

BACKGROUND AND PURPOSE

Ureteroileal anastomosis strictures are well-known complications of ileal conduit urinary diversion that occur in 4% to 8% of patients. Open surgical repair is the standard definitive treatment with minimally invasive, endoscopic approaches developed to prevent the need for major surgery when possible. Robot-assisted surgery has been applied to most primary urologic procedures, but the role of this surgery in the management of complications is undefined. We report our experience with two cases of robotic repair of ureteroileal anastomotic strictures after robot-assisted cystectomy, the first such cases to our knowledge, and review the literature regarding management of these strictures.

PATIENTS AND METHODS

Two patients underwent robot-assisted ureteroileal anastomosis revision for left-sided strictures of 1 and 6 cm in length after failed endoscopic management. Three ports were used in the first and four in the second procedure. The diseased segment was identified, and the healthy end of the ureter anastomosed to a new site on the conduit with a temporary stent. In the second case, the conduit was mobilized and brought to the end of the ureter for a tension-free anastomosis because of the length of the stricture.

RESULTS

Both patients were discharged on the first postoperative day without complications and are without recurrence after nearly 2 and 3 years since the robotic procedure.

CONCLUSION

Minimally invasive definitive revision of ureteroileal anastomotic strictures is feasible with a robotic surgical approach. The advantages of robotic instrumentation allowed successful repair in two patients after previous robot-assisted cystectomy and avoided major open surgery.

Severe primary obstructive megaureter in the first year of life: preliminary experience with endoscopic balloon dilation

BACKGROUND AND PURPOSE

Although conservative management is indicated in most cases of primary obstructed megaureter (POM), surgery is still indicated when POM is associated with increasing dilation, symptoms, or progressive renal damage. Surgery is associated with a significant rate of complications, however, especially in the case of very large ureter in the first year of life. A valid alternative could be endoscopic high pressure balloon dilation (EHPBD) of the vesicoureteral junction (VUJ). We report the first experience with EHPBD in patients under 1 year of age who were affected by severe POM.

PATIENTS AND METHODS

Five patients, aged between 6 and 12 months, were treated with EHPBD. In all patients, preoperative renal ultrasonography showed a distal ureteral dilation ≥15 mm that increased at later evaluations; an obstructive pattern was detected by preoperative diuretic renography. An 8-9,8 F cystoscope, and a 3F balloon catheter (balloon maximum diameter 4 mm) was used. The VUJ was dilated for 5 minutes at 12 to 14 atm. A 4.7F Double-J stent was then positioned and left in place for 6 to 8 weeks. Ultrasonography was performed every 3 months, and renography and voiding cystourethrography the fourth month after the EHPBD.

RESULTS

No operative complications were observed. All the patients showed an improvement at the ultrasonography postoperative follow-up, and there was no evidence of obstruction/reflux at the postoperative check up.

CONCLUSIONS

Our preliminary results seem to indicate that EHPBD is a feasible, safe, and successful procedure. It could play a role as a minimally invasive alternative to open surgery in cases of POM that necessitate intervention in the first year of life. Longer follow-up is necessary to verify the stability of these results.

Antegrade percutaneous balloon dilation of ureteral strictures after failed pelviureteric or ureterovesical reimplantation in children

OBJECTIVES

To assess the morbidity and success rate of percutaneous treatment of the postoperative ureteric strictures in children.

MATERIALS AND METHODS

Between January 1994 and December 2003, 12 children were treated by antegrade percutaneous balloon dilation for postoperative ureteric strictures. Stenosis occurred at the pelviureteric junction in 5 cases and ureterovesical junction in 7 cases. The 10 boys and 2 girls were between 3 months and 14 years old (mean, 5 years ± 4.7 years). General anesthesia was used in 10 cases for nephrostomy catheter placement. Five ureteral stents were used additionally for nephrostomy drainage with a 6-F catheter. Both nephrostomy and ureteric stents were in place for 28.5 ± 12 days, then removed after control antegrade pyelography.

RESULTS

Dilation was technically successful in 9 of our patients. Two peroperative complications occurred. Postoperative results were evaluated by ultrasonography, intravenous urography, antegrade pyelography, and diethylene triamine pentaacetic acid renography that confirmed no obstacle in all 5 cases of pelviureteric stricture with a follow-up of 4 ± 2.9 years and in 4 cases of ureterovesical junction with a follow-up of 4.7 ± 2.8 years. Three unsuccessful results were reported: in 2 cases, the guide wire could not be advanced over the stenotic ureterovesical junction and in 1 case an early restenosis occurred that eventually required surgery.

CONCLUSIONS

Although the main treatment of the postoperative ureteral strictures is surgical, the percutaneous antegrade balloon dilation seems to be an alternative to surgery with a low morbidity rate and short hospitalization period.

Balloon catheter dilatation in the treatment of ureteral and ureteroenteric stricture

Balloon catheter dilatation is a low-cost alternative to open surgery in patients with ureteral strictures, leading to low morbidity and short hospitalization. The goal of this study was to evaluate the results of this technique in patients with inflammatory ureteral strictures or ureteroenteric strictures after radical cystectomy. Twenty-five ureteral strictures in 20 (15 male, 5 female) patients were consecutively treated by high-pressure balloon dilatation: 14 cases of ureteroenteric stricture (9 after ileal cutaneous diversion, and 5 after orthotopic enterocystoplasty) and 11 of ureteral stricture from various inflammatory causes (tuberculosis, iatrogenic injury, radiation therapy, parasitosis). Dilatation was performed by an antegrade (ureteroenteric strictures) or retrograde (inflammatory strictures) approach using a balloon insufflated up to 10 to 20 atm for 5 to 15 minutes. The ureter was stented for a mean time of 2.1 months (range 1-5 months). Results were evaluated clinically and radiologically (intravenous urogram or CT scan). Immediate success was assessed by intraoperative radiologic monitoring. Long-term success was defined as the absence of recurrence of the stenosis after 6 months. Nineteen procedures were successful among the 23 evaluable cases. With a mean follow-up of 16 months (range 6-39 months), the long-term success rate was 52%: 40% in ureteral strictures and 61% in ureteroenteric strictures. Five strictures secondary to cutaneous diversion and six caused by radiation therapy recurred after dilatation. After cutaneous diversion, the failure occurred mostly at the anastomosis and involved the crossed-over ureter. This study shows that high-pressure balloon dilatation of ureteral strictures has a high early success rate and a long-term success rate of 52%. It can therefore be considered as an alternative to open surgery.

[Prosthetic replacement of the ureters]

STUDY AIM

The aim of this study is to demonstrate the reliability of silicone prosthesis for the replacement of ureters. This prosthesis derives from the biliary prosthesis developed after a personal experimental study continued by Triboulet.

PATIENTS AND METHODS

In 38 patients suffering from a malignant disease, a right silicone prosthesis was used for the replacement of an ureter during a 20-year period. There were 30 female and eight male patients. The mean age was 71 (range: 51-88 years). Forty one prostheses were used; one patient underwent two successive operations on the same side with a change of prosthesis, and two patients required a bilateral prosthesis. There were 12 gynaecological carcinomas (three with ureteral fistula), three prostatic carcinomas, 16 cancers of the rectum and recto-sigmoid junction, four cancers of the right colon with retroperitoneal carcinomatosis, and three ureteral fistulas after extended colonic resection.

RESULTS

Early complications were limited to ureteral fistulas (n = 6, 16%) in patients who had already a preoperative fistula (n = 3) and in patients with peritoneal metastases on the superior wall of the bladder. The secondary destruction of the kidney (four secondary nephrectomies) occurred when the function of the kidney was already impaired at the time of the procedure. There were no secondary fistulas, no secondary obstruction of the prosthesis. The longest follow-up was 69 months.

CONCLUSION

The silicone prostheses used for the replacement of ureters are reliable and still permeable beyond 5 years. The protection of the renal function in patients often submitted to chemotherapy improves the duration and quality of survival. These prostheses must be reserved to advanced malignant diseases with a rather long life expectancy.

Retrograde balloon dilation of ureteropelvic obstructions in infants and children: early results

OBJECTIVES

Although balloon dilation is a successful and widely accepted minimally invasive method of treating vascular, esophageal, and colonic strictures, it has not been reported in the management of ureteropelvic junction (UPJ) obstruction in infants. We investigated the role of retrograde balloon dilation as the primary treatment of UPJ obstruction in infants, and we report the technique and early results.

METHODS

Prospective study of infants and young children undergoing retrograde balloon dilation of primary UPJ obstruction using a 3.8 F, 8 atmosphere radial balloon dilator.

RESULTS

Ten infants and children with a median age of 16 months (range, 3 months to 9 years 6 months) underwent retrograde balloon dilation for proven UPJ obstruction with successful outcome in 7 patients following one dilation.

CONCLUSIONS

The minimally invasive nature of this technique and our encouraging early results lead us to conclude that this technique warrants further clinical evaluation.

Retrograde ureteroplasty using balloon dilatation in children with pelviureteric obstruction

Congenital and acquired pelviureteric junction obstruction (PUJ) were treated with balloon dilatation, using a Fogarty/Gruntzig catheter introduced through the cystoscope in 11 children (12 renal units). Stents were not used, and the hospitalization period was only 1 day for uncomplicated cases. Follow-up (maximum period, 4 1/2 years) has shown better drainage and function for all. In one child, who had solitary left kidney, acute obstruction developed; the patient underwent temporary percutaneous nephrostomy. Macroscopic hematuria was noted in one case, resulting in a 3-day hospital stay. Technical problems, advantages, and disadvantages are discussed. Retrograde ureteroplasty using balloon dilatation is a simple and effective procedure for children in whom the obstructed PUJ is in lower part of the pelvis.

Percutaneous antegrade dilation of ureteral strictures in kidney transplants

Transplant ureteral stricture can be treated by either incisional surgery or percutaneous endoluminal dilation. We present 17 cases of percutaneous antegrade endoluminal dilation. The results of this procedure were satisfactory, with a 70% success rate that seems to be maintained during long-term followup. The results were better if dilation was done on a short and recent juxta-anastomotic stricture stented with a 10F Double-J* catheter for 2 months.

Endourological management of ureteral strictures

We reviewed the records of 20 patients (21 ureters) treated during the last 5 years for ureteral stricture disease. The causes of stricture formation included ureterolithotripsy in 47.7% of the patients, open ureterolithotomy in 9.5%, other urological procedures in 23.8%, general surgical and gynecological procedures in 9.5% and miscellaneous factors in 9.5%. A total of 20 patients (21 ureters) underwent endourological treatment with balloon dilation (19) or balloon dilation and internal ureterotomy (2), with good results in 57.1% and a mean followup of 24 months. Of the 9 patients who failed endourological management 3 underwent successful open repair, 3 underwent nephrectomy, and 3 had a relatively large ureteral lumen and became asymptomatic, receiving no further treatment. The interval between injury and treatment was not a decisive factor. The length of ureteral stricture assumes the most significant parameter to predict success in the treatment of ureteral stricture. There were no intraoperative or postoperative complications. The association of balloon dilation and incision by special endoureterotomy scissors is a potentially useful technique.

Pelviureteric obstruction in children treated by retrograde ureteroplasty

Pelviureteric obstruction was treated by dilatation with a Fogarty balloon catheter in 2 children. The catheter was introduced through the cystoscope without any percutaneous procedure, ureteric stents or drainage. Follow-up for 18 months indicated improved drainage and renal function. The merits and demerits of this technique are discussed.

Management of ureteroscopic injuries

Ureteroscopy is an important technique in the management of calculous disease and ureteral lesions but it appears to have a greater potential for injury than percutaneous nephroscopy. In 2 years 4 patients with severe ureteroscopic injuries were treated. In 3 patients complete obstruction of the ureter occurred, and 1 had a major ureteral tear, prolonged urinary extravasation and infection. Even in the presence of total ureteral occlusion patients with short strictures were managed successfully percutaneously but the 2 patients with longer strictures were not. Previous surgery on the ureter or pelvic surgery and radiation therapy appear to be negative factors that affect adversely the ureteral blood supply, and potentiate poor healing and scarring. Nephrostomy tube drainage and ureteral stenting after ureteral dilation appear to be important steps in the percutaneous management of these patients.

Percutaneous management of benign ureteral strictures and fistulas

The percutaneous methods of management of benign ureteral strictures or fistulas have developed as a natural evolution of percutaneous nephrostomy and angiographic techniques. We review our 5-year experience, which includes 18 patients with 19 benign ureteral strictures and 12 patients with ureteral fistulas. In the majority of the patients the ureteral strictures occurred at sites of surgical reconstruction or endoscopic manipulation. All fistulas resulted from surgical injury. In 10 of the 12 patients (82 per cent) the fistulas healed without development of a stricture or need for further intervention. Patients with short ureteral strictures had a high incidence of success and they usually were the best candidates for percutaneous manipulation. The long strictures usually were of longer duration and they were less likely to be managed successfully percutaneously. Failure of percutaneous dilation did not impede subsequent surgical management. Percutaneous management often is a reasonable initial step in the treatment of ureteral strictures and fistulas.

Transplant ureteral obstruction masquerading as recurrent rejection episodes: management by percutaneous antegrade balloon dilatation

We report a 52-year-old male renal transplant recipient who had three "rejection episodes." The first of these responded to conventional antirejection therapy; however, the next two episodes showed incomplete responses to treatment for rejection. At subsequent presentation with deteriorating renal function, ureteral obstruction was evident and was relieved with percutaneous antegrade balloon dilatation with a return of his plasma creatinine to normal. Obstruction of the ureter was a major component in our patient's course given the lack of response to conventional antirejection therapy and the normalization of renal function with relief of the documented ureteral stenosis. This case illustrates that ureteral obstruction can mimic rejection in the renal transplant recipient. Management of ureteral stenosis in transplant patients with percutaneous antegrade balloon dilatation appears to be an effective procedure and can supplant the need for open surgical procedures.