Subcutaneous pyelovesical bypass as replacement for standard percutaneous nephrostomy for palliative urinary diversion: prospective evaluation of patient's quality of life

Extra-anatomical stents in benign ureteric obstruction; experience and outcomes

Objectives To present our experience with the Patterson-Forester extra-anatomic stent (EAS, Cook Medical) in patients with benign ureteric obstruction. Utilising an EAS in complex ureteric obstruction can have a significant positive impact on quality of life as a result of removing external drainage devices. Materials and methods Between November 2012 and January 2021 10 patients underwent 33 EAS procedures. All patients had benign ureteric obstruction. Mean age at primary procedure was 58 years (range 43-63). Median follow-up was 27.5 months (range 11-100). Results Eight patients were successfully managed with EAS, with 6 patients continuing to have routine EAS exchanges. Two patients had the distal end exteriorised due to refractory bladder symptoms. There were three short-term failures; the distal end migrated out of the bladder requiring reinsertion one week later; one patient developed urosepsis requiring intravenous antibiotics and the stent removing within 30 days; one proximal stent migrated resulting in cutaneous erosion. The patient is now awaiting further EAS insertion. Conclusion The Patterson-Forester EAS is another tool in the endourologists' armamentarium when managing complex ureteric obstruction. In appropriately selected patients, it can improve their quality of life and is a durable long-term strategy in benign obstruction.

Morbidity and long-term results of subcutaneous pyelovesical bypass in chronic ureteral obstruction

BACKGROUND

We present the long-term results and complications of the DETOUR® prosthesis, a permanent subcutaneous pyelovesical bypass for the treatment of ureteral obstruction.

PATIENTS AND METHODS

Between 2006 et 2018, 34 prosthesis were implanted in 28 patients (mean age 65,8 years) with ureteral obstruction of malignant or benign etiologies. The prosthesis, composed to an inner tube of silicone and an outer tube of expanded polytetrafluoroethylene, is placed subcutaneously between the kidney and the bladder. We are performed infrared spectrophotometry and scanning electron microscopy on two removed prostheses to explore the prosthetic encrustation.

RESULTS

The average follow-up was 25,8 months (Maximum: 64 months). Stent revision was required for early bladder fistula in three patients. The major long-term complications were infection (46%), obstruction (3 patients) and bladder fistula (7 patients). The most frequently infection are non-severe, but two patients died from septic shock after fungic colonization of the prosthesis. The infrared spectrophotometry and scanning electron microscopy analysis showed that the obstruction was favored by urinary infection and an alkaline medium. The functional prosthesis rate at 1,2 and 3 years was 94%, 71% and 62%, respectively.

CONCLUSION

The DETOUR® subcutaneous extra-anatomical urinary bypass is an effective and minimally invasive alternative to permanent percutaneous nephrostomy, for both malignant and benign ureteral obstructions in selected patients.

LEVEL OF EVIDENCE

3.

Update of the ICUD-SIU International Consultation on Bladder Cancer 2018: urinary diversion

PURPOSE

To provide a comprehensive overview and update of the joint consultation of the International Consultation on Urological Diseases (ICUD) and Société Internationale d'Urologie on Bladder Cancer Urinary Diversion (UD).

METHODS

A detailed analysis of the literature was conducted reporting on the different modalities of UD. For this updated publication, an exhaustive search was conducted in PubMed for recent relevant papers published between October 2013 and August 2018. Via this search, a total of 438 references were identified and 52 of them were finally eligible for analysis. An international, multidisciplinary expert committee evaluated and graded the data according to the Oxford System of Evidence-based Medicine.

RESULTS

The incidence of early complications has been reported retrospectively in the range of 20-57%. Unfortunately, only a few randomized controlled studies exist within the field of UD. Consequently, almost all studies used in this report are of level 3-4 evidence including expert opinion based on "first principles" research.

CONCLUSIONS

Complications rates overall following RC and UD are significant, and when strict reporting criteria are incorporated, they are much higher than previously published. Complications can occur up to 20 years after surgery, emphasizing the need for lifelong follow-up. Progress has been made to prevent complications implementing robotic surgery and fast track protocols. Preoperative patient information, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good results.

Spotlight - Management of pyelovesical bypass device stones

Pyelovesical bypass devices or artificial ureters have been described as a last resort in patients with long ureteral strictures that fail traditional endoscopic and open repair. Herein, we describe a 52-year-old female who had a Detour (Coloplast, Humlebaek, Denmark) pyelovesical bypass device inserted after an iatrogenic ischemic injury to the distal two-thirds of the left ureter during pelvic surgery for recurrent endometrial stromal sarcoma. Six months after placement of the device, she presented with gross hematuria and recurrent urinary tract infections (UTIs) and was found to have encrustation of the distal silicone tip of the Detour device within the bladder. This was managed with resection of the distal silicone tip and flexible ureteroscopy with holmium laser lithotripsy. Despite suppressive antibiotic therapy and medical therapy for hypercalciuria, she presented four years later with intraluminal encrustations in the proximal end of the device. This was successfully managed with flexible ureteroscopy with holmium laser lithotripsy. Therefore, this case illustrates the feasibility of flexible ureteroscopy and holmium laser lithotripsy of Detour device encrustations as long as the device is not kinked and it allows the passage of the flexible ureteroscope up to the calcifications. In addition, patients contemplating insertion of such devices should be counselled regarding the risk of recurrent infections and encrustations.

Subcutaneous nephrovesical bypass: Treatment for ureteral obstruction in advanced metastatic disease

The aim of the present study was to explore the value of subcutaneous nephrovesical bypass (SNVB) for the treatment of ureteral obstruction due to pelvic metastatic disease. SNVB stents (n=30) were implanted in 24 patients with advanced metastatic disease between January 2008 and December 2012. Urinalysis, serum creatinine (SCr), glomerular filtration rate (GFR), quality of life (QoL) scores, and renal ultrasonography were evaluated at follow-up. The SNVB procedures were successful in all 24 patients. Patient follow-ups occurred at an average of 10.6 months. Preoperative hydronephrosis was eliminated in 16 cases (53.3%) and reduced in the remaining patients. Following surgery, SCr levels reduced significantly from 256±46 to 124±23 μmol/l (P<0.001). GFRs increased from 25±4.8 to 45±5.3 ml/min (P<0.01). The mean QoL scores were 3.4±1.4 preoperatively and 7.6±1.0 postoperatively (P<0.001). The results showed that SNVB is a minimally invasive, effective and safe procedure for patients with ureteral obstruction resulting from advanced malignant disease. As an alternative procedure to percutaneous nephrostomy, SNVB offers patients a better QoL.

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.

[Long-term results for subcutaneous Detour® prosthesis for ureteral obstruction: experiences of implantation, aftercare and management of complications]

BACKGROUND

We present the long-term results of implementation of the Detour® prosthesis as an alternative to established methods of surgical, percutaneous or internal urinary diversion.

PATIENTS AND METHODS

Between 2004 and 2012 a total of 40 prostheses were implanted in 31 patients (mean age 65 years) with ureteral strictures of various origins. In the follow-up the patients underwent examinations and completed questionnaires.

RESULTS

The average follow-up was 23 months (range 1-92 months). Sonographic examinations showed no urinary retention in 38 out of 40 implanted systems. The retention values were stable in 19 patients, improved in 7 and worse in 3. The quality of life (QoL) was high (EORTC QLQ-C30 90%). Intraoperative complications were 2 intestinal lesions and 3 bleeding of the renal-pelvic system. Postoperative urinary tract infections and wound complications were encountered. In the long-term course three infected hydronephroses occurred which were treated and cured with antibiotics and temporary nephrostomy and 4 systems were explanted, including 2 exchanges.

CONCLUSIONS

The system may be considered for patients with ureteral strictures with palliative and curative intent. There were no significant disadvantages in comparison with established methods. There were fewer risks in implantation and complications were manageable. The quality of life was significantly improved.

Use of a segmental thermoexpandable metal alloy stent in the management of malignant ureteric obstruction: a single centre experience in the UK

INTRODUCTION

The Memokath 051™ is a semipermanent inert metal alloy ureteric stent which can bridge strictures and, compared to double J stents, causes less bladder irritation and pain, is more resistant to external compression forces and may be more effective in patients with malignant ureteric obstruction. We present our experience with this novel stent in such cases.

METHODS

All suitable patients referred to us with malignancy-associated ureteric strictures over a 4-year period had ureteric Memokath 051™ stents inserted. Data on aetiology and position of the strictures as well as length of the Memokath stents used and their efficacy and complications were recorded prospectively.

RESULTS

42 ureteric Memokath 051™ stents were inserted in 37 patients (mean age 64 years). 40.5% of strictures were related to gynaecological cancer, 21% to bowel cancer, 14% were post radiation, 14% occurred in prostate cancer patients and 9.5% were found in other cancers. The mean follow-up was 22 months (range 5-60 months). The main complications were stent migrations in 5, urinary tract infections in 3 and blockage of stent due to progressive transitional cell carcinoma of the ureter in 2 cases.

CONCLUSION

Memokath 051™ ureteric stents are safe, effective and durable in the long-term treatment of malignant strictures.

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.

Pyelovesical bypass graft for palliative management of malignant ureteric obstruction: optimizing the technique by percutaneous access to the bladder using a split Amplatz sheath

OBJECTIVES

To introduce a simple modification to the original technique of pyelovesical bypass graft placement to make the procedure more minimally invasive.

METHODS

During the study period 2 patients with malignant ureteric obstruction underwent pyelovesical bypass graft placement using Detour stent (Mentor-Porges). The technique simply comprised tract dilatation of the previously placed percutaneous nephrostomy to place the proximal end of the graft in the renal collecting system, making a subcutaneous tunnel from a 1-cm suprapubic incision to the flank area, percutaneous access to the bladder under fluoroscopic guide and placement of the distal end of the stent into the bladder through a split Amplatz sheath. The operative outcome was analyzed prospectively.

RESULTS

Both patients tolerated the procedures well with no intra- and postoperative complications. Renal function remained stable during the follow-up period with acceptable urine output through the urethra. Abdominal wall complications such as fistula formation or pain along the subcutaneous tract as well as stent encrustation did not occur during the follow-up period.

CONCLUSIONS

Despite our small sample size and short follow-up period, percutaneous access to the bladder using a split Amplatz sheath during placement of the Detour stent, may be considered as a promising simple modification to optimize the technique by obviating the need for open cystostomy incision.

Management of ureteral obstruction due to advanced malignancy: optimizing therapeutic and palliative outcomes

PURPOSE

Treatment of ureteral obstruction due to advanced abdominal or pelvic malignancy is a clinical challenge. We discuss improvements and modern day outcomes in the palliative treatment of patients with ureteral obstruction by antegrade or retrograde ureteral decompression. Also, potential areas of clinical investigation involving ureteral stent improvement and pharmacological management of relief of symptoms resulting from ureteral obstruction are discussed.

MATERIALS AND METHODS

A literature search was performed using the Entrez-PubMed(R) database. All relevant literature on ureteral obstruction, advanced malignancy and nephrostomy, ureteral stent and associated topics concerning palliative care and quality of life were reviewed and analyzed.

RESULTS

Presenting symptoms are varied and depend on the acuity of the underlying problem. Mechanisms underlying the pain and symptoms of extrinsic ureteral compression have not fully been explored but they may include prostaglandin and renin-angiotensin pathways with medical interventions potentially directed at such therapeutic targets. Progressive obstructive uropathy may likely lead to clinical manifestations, such as uremia, electrolyte imbalances and persistent urinary tract infections, if obstruction is not bypassed. New approaches to antegrade and retrograde stenting, and the evaluation of new stent materials may help minimize the complications and side effects of such procedures. Unfortunately the finding of ureteral obstruction due to malignancy carries a poor prognosis with a resulting median survival of 3 to 7 months. This prognosis highlights the importance of maintaining quality of life in these patients.

CONCLUSIONS

Patients presenting with symptoms of ureteral obstruction due to advanced malignancy should be informed of the therapeutic options in the context of the poor prognosis. In the meantime research is needed to find methods of urinary diversion and pharmacological intervention for symptomatic relief without compromising quality of life in patients at the end of life.