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

Pelvic radiation-induced urinary strictures: etiology and management of a challenging disease

Radiation is a common treatment modality for pelvic malignancies. While it can be effective at cancer control, downstream effects can manifest months to years after treatment, leaving patients with significant morbidity. Within urology, a particularly difficult post-radiation consequence is urinary tract stricture, either of the urethra, bladder neck, or ureter. In this review, we will discuss the mechanism of radiation damage and treatment options for these potentially devastating urinary sequelae.

Verapamil inhibited the development of ureteral stricture by blocking CaMK II-mediated STAT3 and Smad3/JunD pathways

BACKGROUND

Ureteral stricture (US) is a fibrotic process that leads to urinary tract obstruction and even kidney damage, with the characteristic of reduced extracellular matrix (ECM) degradation and increased collagen synthesis. Verapamil, as a calcium channel blocker, was reported to prevent scar formation. Our work aimed to investigate the biological effects and mechanism of verapamil in US.

METHODS

Fibroblasts were subjected to transforming growth factor-beta 1 (TGF-β1) to stimulate collagen synthesis, and the messenger ribonucleic acid (mRNA) and protein expressions in fibroblasts were assessed using quantitative real-time polymerase chain reaction (qRT-PCR) and western blot. The location of phosphorylation-signal transducer and activator of transcription 3 (p-STAT3) and Jund proto-oncogene subunit (JunD) in fibroblasts were determined by immunofluorescence (IF). The binding relationship between signal transducer and activator of transcription 3 (STAT3) and collagen type I alpha1 (COL1A1)/collagen type III alpha 1 chain (COL3A1) and the binding relationship between JunD and tissue inhibitor of metalloproteinases-1 (TIMP-1) were verified by dual luciferase reporter gene and chromatin Immunoprecipitation (ChIP) assays.

RESULTS

Herein, we found that verapamil could inhibit TGF-β1/Ca2 + ⁄calmodulin-dependent protein kinase II (CaMK II)-mediated STAT3 activation in fibroblasts, and STAT3 inhibition repressed collagen production. In addition, verapamil could inhibit TGF-β1/CaMK II-mediated Mothers against DPP homolog 3 (Smad3)/JunD pathway activation in fibroblasts, and JunD silencing inhibited TIMP1 (a matrix metalloproteinase inhibitor) expression. Our subsequent experiments revealed that STAT3 bound with COL1A1 promoter and COL3A1 promoter and activated their transcription, and JunD bound with TIMP1 promoter and activated its transcription. Moreover, as expected, STAT3 activation could eliminate the inhibitory effect of verapamil treatment on TGF-β1-induced collagen production in fibroblasts, and JunD overexpression reversed the inhibitory effect of verapamil treatment on TGF-β1-induced TIMP1 expression in fibroblasts.

CONCLUSION

Verapamil inhibited collagen production and TIMP-1 expression in US by blocking CaMK II-mediated STAT3 and Smad3/JunD pathways.

Long-term outcomes of paclitaxel-coated balloons for non-malignant ureteral strictures

PURPOSE

To evaluate the clinical efficacy and safety of drug-coated balloon (DCB) ureteroplasty for the management of non-malignant ureteral strictures.

MATERIAL AND METHODS

A prospective "off-label" monocentric single-arm pilot study investigating the safety and efficacy of drug-coated balloon (DCB) (Lutonix^®; BD, USA) was performed. Twenty-five patients with benign ureteral strictures related to uretero-enteric anastomosis (n = 13); lithiasis (n = 5), post-surgical complications (iatrogenic n = 5), transplanted kidney (n = 1) and post-radiotherapy (n = 1) were included. Following lesion crossing, predilatation was performed using 4-7 mm high-pressure balloon catheter (5-6Fr) with a balloon pressure of 6-7 atm based on the manufacturer's recommendation. In the absence of rupture of the ureteral wall, the DCB was dilated for 4 min. across the lesion. The process was repeated if deemed necessary to a maximum of three stricture dilatations. We analysed both clinical and radiological primary patency (no signs of ipsilateral hydronephrosis or improvement of the existing residual dilatation at the follow-up examinations) and secondarily safety endpoints.

RESULTS

Mean lesion length was 40 ± 28.5 mm. Mean time follow up was 36 months ± 10.46 months. Strictures were located at upper ureteric (12%), lower ureteric (32%), ureterovesical anastomosis (4%) and uretero-enteric anastomosis (52%) levels. The overall radiological success at 1-year follow-up was 88% (22/25 patients). In 56% patients (14/25 patients with primary patency) the nephrostomy catheter was removed 21 days following a single DCB procedure. In 32% (8/25 patients) an additional dilatation sessions were required for maintaining the ureteral patency. The overall failure rate at 1-year follow-up was 12% (3/25 patients). Only one case of febrile urinary tract infection in a female patient (acute pyelonephritis) was encountered after the first dilatation.

CONCLUSIONS

Paclitaxel-coated balloon ureteroplasty proved to be safe and effective for the treatment of non-malignant ureteral strictures. Larger studies are warranted to validate these promising initial results.

Robotic Repair of Ureteroenteric Stricture Following Radical Cystectomy: A Multi-Institutional Experience

OBJECTIVE

To examine the safety, feasibility and durability of robotic reimplantation of ureteroenteric stricture after radical cystectomy.

MATERIALS AND METHODS

A retrospective multi-institutional review was performed for all patients undergoing robotic repair of ureteroenteric stricture from January 2010 to January 2019. Functional outcomes and complications were followed and data were analyzed with SPSS statistical software.

RESULTS

A total of 46 patients and 58 renal units were identified, of which 15 had right sided, 19 left sided and 12 patients had bilateral strictures. Presentation of stricture was asymptomatic in 14 (30.4%) patients. Symptomatic presentations included infection in 22 (47.8%), worsening renal function in 11 (23.9%) and pain in 3 (6.5%) patients. Median time from cystectomy to diagnosis of stricture was 5 months (1-40). Median stricture length was 1.5 cm (range 0.5-10). All strictures were of benign etiology except for 4 (6.9%), which were due to malignancy. Overall, 49 (84.5%) ureters underwent primary re-implantation, while 9 (15.5%) required Boari-like advancement flaps prior to re-implantation. Median operative time was 190 min (range 45-540) with median estimated blood loss of 50 mL (range 25-2000) and median length of stay of 2 days (range 1-33, IQR 2-4). Seven (15.2%) patients experienced complications; 3 (6.5%) were low grade and 4 (8.7%) high grade. With median follow up of 18 months (range 1-51) the stricture recurrence rate was 8.6%.

CONCLUSION

Robotic reimplantation of ureteroenteric strictures following radical cystectomy is safe and feasible in experienced centers with high success rates.

Endoureterotomy with the Lovaco technique for treatment of ureterointestinal strictures: outcomes in an experienced center and factors associated with procedural success or failure

INTRODUCTION

The study aimed to present the outcomes of an endoureterotomy series using the Lovaco technique for the treatment of ureterointestinal strictures. Factors influencing the success or failure of this technique were also determined.

MATERIALS AND METHODS

Data were collected from all endoureterotomies for ureterointestinal strictures performed in a single-center between 2017 and 2020. Clinical variables and characteristics of the stricture were recorded in each case, and success was defined as the complete resolution of ureterohydronephrosis. Univariate analysis was used to correlate the variables recorded with procedural success or failure.

RESULTS

A total of 25 patients were recruited: 16 with strictures on the left side, 5 on the right, and 4 bilateral. With the first endoureterotomy, 52% of the cases (13 patients) were resolved, and in patients undergoing a second intervention 64% success (16 patients) was achieved. Infectious complications occurred in 23.3% of surgeries. Stricture length, poor renal function, and left side involvement were associated with endoureterotomy failure.

CONCLUSIONS

Endoureterotomy with the Lovaco technique is a useful method in the setting of ureterointestinal strictures, achieving complete resolution of the obstruction in more than 60% of cases. Factors that can negatively affect the success of the procedure include stricture length, poor renal function, and left side involvement.

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

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

Endoscopic Procedures in the Treatment of Ureteroenteric Anastomotic Strictures: A Systematic Review and Meta-Analysis

Objective: To evaluate the safety and efficacy of endoscopic procedures for ureteroenteric anastomotic strictures (UESs) after radical cystectomy and urinary diversion. Methods: We performed a meta-analysis of relevant articles through March 2020 using PubMed, Embase, and Cochrane Central Register to assess the efficacy of endoscopic procedures in UES according to the PRISMA and PICOS criteria. The main endpoints were success rate and complications, and we also compared the efficacy of different methods and stricture length and side in UES. Cochrane Collaboration's Revman version 5.3 and Stata version 15.1 software were used for statistical analysis. Results: A total of 18 retrospective studies with 697 patients were included. The median follow-up ranges from 12 to 62.5 months. Patients treated with endoscopic procedures had an overall success rate of 46%. The pooled rate of Clavien-Dindo ≥ 3 complications was 3.8% among included studies. Laser vaporization and stent insertion (48 and 47%) had a relatively high success rate than balloon dilatation (35%). In subgroup analysis, the success rate of endoscopic procedures for ≤ 1-cm strictures was significantly higher than that for >1-cm ones [odds ratio (OR), 8.65; 95% confidence interval (CI), 3.53-21.21; P < 0.00001]. In addition, the success rate in cases with strictures of the right side was relatively higher than that in cases with strictures of the left side (OR, 1.72; 95% CI, 1.05-2.81; P = 0.03). Conclusion: Our pooled studies showed that endoscopic operation is feasible and associated with a moderate success rate along with a relatively low incidence of perioperative complications in the treatment of UES, especially with length ≤ 1 cm and right side. Although there is still no consensus on endoscopic technique for UES regarding balloon dilatation, stent insertion, and laser vaporization, we believe that endoscopic management is a safety and available approach for UES with close follow-up.

[Bladder cancer - complications related to urinary diversion]

Even today, radical cystectomy with urinary diversion is one of the most complicated procedures in uro-oncology. Particularly in the long-term course, but also perioperatively, problems caused by urinary diversion play a significant role.Perioperatively, gastrointestinal problems such as an ileus, but also infections and early complications of the different anastomoses are most important. While ileus and perioperative infections can usually be treated conservatively, failure of the intestinal or ureteroileal anastomoses require regular surgical revisions.In the long-term follow-up, scarring can lead to chronic obstruction of urinary flow and, in the case of continental urinary diversions, to stone formation. These complications, as well as parastomal hernias in patients with poor conduits, may require further therapy. Functional bowel disorders may impair patients' quality of life significantly.Improved preoperative preparation and accompanying measures during the inpatient stay can significantly reduce non-surgical complications.Cystectomy with therapy-associated morbidity is a classical example of when surgery must be performed at specialised centers to reduce complications perioperatively as well as in follow-up.

Ureterolysis with ureterotomy and omental sleeve wrap in patients with radiation induced pelvic retroperitoneal fibrosis

Introduction

Secondary retroperitoneal fibrosis (RPF) due to pelvic radiation alone or together with pelvic surgery is one of the causes of obstructive renal failure. Ureteral obstruction is caused by ischemic stricture and encasement by fibrotic tissue. Endo-ureterotomy alone, without vascular supply, is not successful in these cases.

Material and methods

We present eleven cases of ureteral obstruction due to radiation and surgery induced RPF. Seven patients had radiation therapy with or without radical hysterectomy and three patients had anterior resection of the rectum with pre-emptive radiation and one patient had anal cancer treated with local excision and radiation therapy. Nine of the eleven patients had bilateral ureteral obstruction. Open ('intubated') stented ureterotomy and omental sleeve wrap was performed. In one patient, Boari flap ureteroneocystostomy was necessary.

Results

Of the eleven patients (twenty renal units) we succeeded in nine patients (eighteen renal units). In two patients with bilateral ureteral obstruction, we were able to reestablish ureteral patency in only one renal unit each.

Conclusions

Ureterolysis with ureterotomy and omental sleeve wrap is a valid surgical approach for alleviation of ureteral ischemic obstruction due to secondary retroperitoneal fibrosis caused by radiation alone or together with pelvic surgery.

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

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

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.

Simultaneous antegrade and retrograde endoscopic treatment of non-malignant ureterointestinal anastomotic strictures following urinary diversion

Background

The ureterointestinal anastomosis stricture (UAS) is a common complication of urinary diversion after radical cystectomy. For decades, open anastomotic revision remained the gold standard for the treatment of UAS. However, with the advancement in endoscopic technology, mini-invasive therapeutic approaches have been used in its management. Here, we report our experience with and long-term results of combined simultaneous antegrade and retrograde endoscopy (SARE) in the treatment of non-malignant UASs after urinary diversion in a consecutive series of patients.

Methods

From March 2012 to January 2015, there were 32 consecutive patients with 32 non-malignant UASs following radical cystectomy and urinary diversion. Twenty-nine patients were treated with SARE technique and comprised the study group. Using simultaneous antegrade flexible ureteroscope combined with retrograde semi-rigid ureteroscope or nephroscope, partial or complete strictures were managed with laser incision and balloon dilation under direct visualization. A 7/12 Fr graded endopyelotomy stent was left for 3–6 months after the procedure. Success was defined as symptomatic improvement and radiographic resolution of obstruction.

Results

With a median followup of 22 months (6–36), the overall success rate for SARE was 69.0%. Twenty patients with partial stricture had a success rate of 85%, and 9 patients with complete stricture had a success rate of 33.3%. Renal function, hydronephrosis grade, stricture type, and stricture length were significant influences on the outcome (P < 0.05). No complication was observed.

Conclusions

The SARE is a safe and effective treatment for UAS, and may be the only endoscopic treatment approach for complete UAS. While success rate for complete strictures is low compared to open revision, it should be considered as an initial approach given its low overall morbidity. For partial strictures, prudent patient selection results in higher success rates that are nearly comparable to open revision.

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

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

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.

Experience with 45 Consecutive Patients with Neobladders Undergoing Retrograde Ureteroscopy for Upper Tract Abnormalities

Introduction

In this study we reviewed the feasibility, technique, complications and outcomes of retrograde ureteroscopy in patients with orthotopic neobladders.

Methods

We retrospectively reviewed our retrograde ureteroscopic experience in patients with orthotopic ileal neobladder diversions. Data were collected and analyzed regarding patient characteristics, indications, technique, success and complications of the procedure.

Results

Between 1995 and 2013, 45 patients with neobladders underwent 77 retrograde ureteroscopy sessions on 97 renal units for filling defects (47 cases), urothelial thickening (9), calculi (4), positive cytology (27) and/or positive fluorescence in situ hybridization (15) on followup. The ureter and renal pelvis were successfully instrumented in 78 of 97 units (80.4%), with 85.3% success in Hautmann-type neobladders (75 renal units attempted), 50% in Studer-type neobladders (8 renal units attempted) and 71.4% in unascertained-type neobladders (14 renal units attempted). Causes of failure involved the inability to locate the ureteral orifice (8 cases), to cannulate the orifice (6 cases) or to advance the ureteroscope due to tortuosity (5 cases). Among the successful attempts with appropriately documented findings 35.9% of cases with filling defects (39) were confirmed malignant and 61.5% were confirmed benign by ureteroscopy. All cases with a positive cytology (23) and 85.7% of cases with positive fluorescence in situ hybridization (14) were confirmed malignant by retrograde ureteroscopy, and 2 of the 4 cases of calculi were successfully managed retrogradely.

Conclusions

Retrograde ureteroscopic evaluation of upper tract abnormalities is feasible and practical in patients with orthotopic neobladders. Identification and cannulation of the ureteral orifice are challenging, particularly in tortuous situations, but difficulties can be overcome with fluoroscopic techniques. Retrograde ureteroscopy avoids the morbidity of percutaneous access with minimal complications.

Laser endoureterotomy and endopyelotomy: an update

PURPOSE

Although minimally invasive approach is one of the first-line treatment choices for ureteral strictures, there are still controversies on the ideal method to treat this entity. The objective of this update was to define the level of evidence around endoscopic treatment of ureteropelvic junction (UPJ) and ureteral strictures.

METHODS

We reviewed the current available literature on the PubMed database from the last decade up to May 2014 on laser endoureterotomy and endopyelotomy.

RESULTS

The level of evidence for the endoscopic treatment of UPJ and ureteral strictures is low. Despite this, it appears that endoureterotomy and endopyelotomy performed mainly with Ho:YAG laser achieve good success rates with minimal perioperative morbidity.

CONCLUSIONS

Laser endoureterotomy and endopyelotomy should be considered a reasonable treatment option in selected patients.

Laparoendoscopic management of midureteral strictures

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

Current status of minimally invasive endoscopic management of ureteric strictures

Endourological techniques are used more often nowadays in the treatment of ureteric strictures of various etiologies. Advances in technology have provided new tools to the armamentarium of the endoscopic urological surgeon. Numerous studies exist that investigate the efficiency and safety of each of the therapeutic modalities available. In this review, we attempt to demonstrate the available and contemporary evidence supporting each minimally invasive modality in the management of ureteric strictures.

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

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

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.

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.

Lasers in the upper urinary tract for non-stone disease

Though the most common use for lasers in the genitourinary tract is for urolithiasis, a number of other urologic conditions can be treated with lasers because of their unique ablative, destructive and hemostatic properties. This paper reviews the advantages and disadvantages of laser technology for a number of non-stone indications.

Endopyeloureterotomy using the holmium:YAG laser for the management of adult ureteral and ureteropelvic junction obstructions

AIM

To determine the efficacy of endopyeloureterotomy using a holmium:YAG laser for the management of adult benign ureteral and ureteropelvic junction obstructions.

PATIENTS AND METHODS

We reviewed the clinical outcomes of eight primary procedures performed in 5 patients. The causes of the strictures were idiopathic in five and stone impaction in three procedures. All strictures except one were approached in a retrograde fashion with either a rigid (8.0 Fr) or flexible (9.3 Fr) ureteroscope. The only energy source employed was the laser, and no balloon dilation was performed. In all cases, a 4.8-Fr ureteral stent was left indwelling, and retrograde ureteropyelography was performed within 6-8 weeks to remove the catheter.

RESULTS

Follow-up was performed in all patients for a mean period of 14.9 (minimum 10) months. Two strictures in 1 patient failed to be stent free, while six strictures were patent on postoperative radiographic imaging. There were no perioperative complications.

CONCLUSIONS

Endopyeloureterotomy using a holmium:YAG laser is safe and effective. Its relative noninvasiveness and its retrograde approach make it a first-line alternative for the management of benign upper urinary tract strictures in adults.

Endoscopic management of urologic disease with the holmium laser

The efficiency and safety profile of the holmium laser have made this tool a versatile multipurpose instrument for use in the endoscopic treatment of a wide variety of urologic disorders. Herein are reviewed holmium laser physics and current endourologic applications, as well as the performance of new low-power holmium lasers.