Combined antegrade and retrograde endoscopic retroperitoneal bypass of ureteric strictures: a modification of the ‘rendezvous’ procedure

The Rendezvous Technique: A Minimally Invasive Non-Surgical Approach for the Management of Iatrogenic Ureteral Injuries

Background/Objectives: The aim of our study is to evaluate the feasibility and efficacy of the rendezvous technique for the treatment of iatrogenic ureteral injuries. Methods: From 2014 to 2019, 29 patients treated with the rendezvous technique for mono- or bilateral iatrogenic ureteral injuries were enrolled in this retrospective study. All the leaks were previously assessed by CT-urography and antegrade pyelography. Ureteral continuity was restored by performing the rendezvous technique, combining antegrade trans-nephrostomic access and a retrograde trans-cystostomic approach. A double J stent was antegradely inserted, and a nephrostomy tube was kept in place at the end of the procedure. A post-procedure CT-urography and a 30-day nephrostogram follow-up were performed. In the absence of a contrast leak, the nephrostomy tube was removed. Patient follow-up was set with CT-urography at 3, 6, and 12 months and stent substitution every 4 months. The CT-urography was performed to confirm the restored integrity of the ureter before stent removal. Results: The rendezvous technique was successful in all cases with the resolution of the ureteral leak. No major complications were observed. In all the patients, the nephrostomy tube was removed after 30 days. After performing CT-urography, the stent was removed permanently after 12 months. Only three cases showed local post-treatment stenosis treated with surgical ureteral reimplantation. Conclusions: The rendezvous technique is a safe and effective minimally invasive procedure that can be used to restore the continuity of the ureter, avoiding open surgery and providing valuable support for the management of complications after gynecological surgery.

Long-term Outcomes of Minimally Invasive Rendezvous Procedures to Treat Complex Ureteric Strictures and Injuries

Background

Complex ureteric strictures and injuries occurring during major abdominal and pelvic operations may cause significant morbidity and distress to patients. A rendezvous procedure is an endoscopic technique used in case of such injuries.

Objective

To evaluate perioperative and long-term outcomes of rendezvous procedures to treat complex ureteric strictures and injuries.

Design setting and participants

We retrospectively reviewed patients undergoing a rendezvous procedure for ureteric discontinuity including strictures and injuries, treated between 2003 and 2017 at our Institution and completing at least 12 mo of follow-up. We divided patients into two groups: early postsurgical obstruction, leakage, or detachment (group A) and late strictures (oncological/postsurgical; group B).

Outcome measurements and statistical analysis

If appropriate, we performed a retrograde study ± rigid ureteroscopy to assess the stricture 3 mo after the rendezvous procedure, followed by a MAG3 renogram at 6 wk, 6 mo, and 12 mo, and annually thereafter for 5 yr.

Results and limitations

Forty-three patients underwent a rendezvous procedure, 17 in group A (median age 50 yr, range 30-78) and 26 in group B (median age 60 yr, range: 28-83). Ureteric strictures and ureteric discontinuities were stented successfully in 15 out of 17 patients in group A (88.2%) and 22 out of 26 patients (84.6%) in group B. For both groups, the median follow-up was 6 yr. In group A, of 17 patients, 11 (64.7%) were stent free with no further interventions, two (11.7%) had a subsequent Memokath stent insertion (38%), and two (11.7%) required reconstruction. Of 26 patients in group B, eight (30.7%) required no further interventions and were stent free, ten (38.4%) were maintained with long-term stenting, and one was managed with a Memokath stent (3.8%). Of the 26 patients, only three (11.5%) required major reconstruction, while four patients with malignancy (15%) died during follow-up.

Conclusions

With a combined antegrade and retrograde approach, the majority of complex ureteric strictures/injuries can be bridged and stented with an overall immediate technical success rate of above 80%, avoiding major surgery in unfavourable circumstances and allowing time for stabilisation and recovery of the patient. Additionally, in case of technical success, further interventions may be unnecessary in up to 64% of patients with acute injury and about 31% of patients with late stricture.

Patient summary

The majority of complex ureteric strictures and injuries can be resolved using a rendezvous approach, avoiding major surgery in unfavourable circumstances. Moreover, this approach can help avoid further interventions in 64% of such patients.

Stenting Using the Rendezvous Technique for Postoperative Ureteral Complications in Cancer Patients

PURPOSE

This study aimed to retrospectively evaluate the safety and efficacy of ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients.

MATERIALS AND METHODS

From January 2005 to April 2015, 19 patients (2 men and 17 women; median age, 59; range, 42-79 years old) with unilateral ureteral lesions (ureteral leakages in 6, strictures in 4, and both in 9) underwent ureteral stent placement using the rendezvous technique. Percutaneous nephrostomy was performed, and stent placement was attempted via antegrade and retrograde approaches. The technical success, procedure-related complications, and clinical success were retrospectively analyzed.

RESULTS

The median follow-up period was 29.8 months (range, 0.3-116.5 months). The ureteral stent placement was successful in 17 out of 19 patients (89.5%). Double J ureteral stent was used in 6 patients, and straight catheter as an internal-external nephro-ureteral stent was used in 11 patients. The rendezvous technique was used in the retroperitoneal space and urinary tract in 6 and 11 patients, respectively. No major complications related to the rendezvous technique occurred. Finally, 4 patients achieved stent-free condition (21.1%), and periodic stent exchange was continued in 9 (47.4%). However, permanent external drainage and surgical reconstruction were needed in 4 (21.1%) and 2 (10.5%) patients, respectively. The final clinical success rate was 68.4% (13 out of 19 patients).

CONCLUSION

Ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients is safe and may be alternative to permanent external drainage and invasive surgical reconstruction.

LEVEL OF EVIDENCE

Level 4, Case series.

Long-segmental ureteral reconstruction using tubularization of ileal seromuscular fold: experimental canine study and preliminary clinical experience

Objective

This study was performed to investigate the feasibility of tubularization of the ileal seromuscular fold for long-segmental ureteral reconstruction in a canine model and assess the clinical application of this procedure.

Methods

The experimental study was conducted on six beagles. An ileal segment was chosen and folded along its longitudinal axis and thereafter sutured to tubularize the serous surface. The tubularization of the ileal seromuscular fold was designed to be 10 to 12 cm for ureteral substitution. The neo-ureters were pathologically examined. A patient in our hospital also underwent this reconstructive operation. Several blood parameters were assessed and urography was performed for postoperative evaluation.

Results

All animals and the patient tolerated the operation and recovered as planned. No severe postoperative complications occurred. Blood examination revealed that renal function was within the normal range. Urography indicated patency of urine excretion without leakage or stenosis. In the patient, antegrade urography showed rhythmic peristalsis of the neo-ureter. The pathologic examination revealed a healthy condition of the neo-ureter and an open lumen with a serous epithelial lining.

Conclusion

Ureteral reconstruction by tubularization of the ileal seromuscular fold is anatomically possible and was preliminarily validated in a patient in the clinical setting.

Minimally invasive surgical treatment on delayed uretero-vaginal fistula

Objective

To evaluate the procedure of endoscopic surgery for ureterovaginal fistula (UVF) and its clinical efficacy.

Materials and methods

A retrospective analysis of 46 patients needing treatment for UVF with endourology technology was conducted (all patients had unilateral ureteric injury, 27 left and 19 right). Transurethral retrograde ureteric stenting or realignment retrograde/antegrade approach stenting was used to treat the fistula, and the relation between treatment and prognosis was analyzed.

Results

One case failed, the patient undergoing percutaneous nephrostomy instead. Success was achieved in 45 cases, and urinary leakage was stopped 48 h after surgery. Of the 45 patients operated on, 16 had their double-J stents removed after 3–6 months, and 29 needed replacement every 6–12 months. In a postoperative follow-up of 6–36 months, 10 patients had recurrent stenosis needing ureteroscopic endoureterotomy or reexpansion with a balloon. No other complications occurred.

Conclusions

Endoscopic surgery is an effective technology in the treatment of UVF, with the advantages of being effective, reliable, less invasive, and readily accepted by patients.

Combined antegrade and retrograde access to difficult ureters: revisiting the rendezvous technique

INTRODUCTION

Complex ureteric strictures present a significant challenge to the endourologist and uro-radiologist. Multiple separate interventions to try to cross the stricture are often attempted. We describe our experience managing a heterogenous patient group using the 'rendezvous' procedure.

METHODS AND MATERIALS

16 patients and 18 ureters (one bilateral procedure, and two separate procedures in one patient) underwent rendezvous procedures. Seven patients had coexisting ureteric calculi treated. Each case was followed up for between 3 months and 5 years.

RESULTS

In 16/18 ureters there was technical success at time of surgery; successfully crossing the stricture, allowing ureteroscopic access to the ureter, dilating and/or stenting the ureter. 2/18 were unsuccessful; one secondary to advanced malignancy resulting in a uretero-vaginal fistula and the second a failure to remove a retained, displaced ureteric stent. Of the 18 ureteric procedures; 7/18 were stent free at 3 months, improving to 8/18 stent free at 6 months. 4/18 remained nephrostomy dependent (failure of drainage despite stent or failure to stent) at 3 months, increasing to 6/18 being nephrostomy dependent at 6 months. 1/16 remained dialysis dependent with a nephrostomy tube. For those procedures involving ureteric calculi, 6/7 were stone free and 1/5 had a persistent stone fragment requiring further intervention.

CONCLUSIONS

A combined approach may decrease the number of separate interventions required, with the aim of removing the need for a long-term nephrostomy, as well as providing opportunity to treat ureteric calculi in the context of stricture disease. Our experience has been that where the rendezvous has been required to treat strictures caused by malignant extrinsic compression, stenting has not been successful; this information is key to informed consent in a group of patients who may have a limited life expectancy.

Interventional radiology in iatrogenic ureteral leaks: case series and literature review

Iatrogenic ureteral injuries are a dramatic complication in medical practice. Nowadays there are no universal guidelines for their management. The aim of our study was to evaluate the feasibility of the percutaneous treatment in restoring ureteral integrity in 19 patients that came to our attention. In each case retrograde stenting failed and patients were candidates for re-surgery. Our strategy consists of two phases. The first step is the nephrostomy that allows an external urinary diversion putting dry the damaged ureteral segment. The second step is the anterograde ureteral double-J stenting that keeps near the two stumps promoting the healing of the injured tract. In complete sections, when both retrograde and anterograde stenting singularly failed, we performed a rendez-vous technique with a combined radiological trans-nephrostomic access and urological cystoscopic approach to realign and catheterize the ureteral stumps. In patients with Bricker urinary diversion, peri-anastomotic leaks were treated by positioning a multi-hole pig-tail catheter with the inner end in the renal pelvis and the distal portion outgoing from the cutaneous stoma. Subsequent pyelographic controls demonstrated the resolution of the ureteral leak in all patients and none required a surgical re-intervention. Nephrostomies were removed and ureteral stents were regularly changed. We conclude that interventional uro-radiology may offer a valid conservative option in iatrogenic urinary injuries.

Image-guided ureteral reconstruction using rendezvous technique for complex ureteric transection after gunshot injuries

Management of complex ureteric transection poses a significant clinical challenge, particularly after gunshot injuries due to marked distortion of anatomy and associated tissue loss. We report two cases of total ureteric transection due to gunshot injury successfully repaired using fluoroscopy-guided rendezvous procedure and double J stent placement. This minimally invasive approach may offer a safe and effective technique to repair complete ureteral transection and obviate the need for complex surgical procedures.

Partial substitution of the ureter using a double short segments of the ileum following the Monti procedure

The partial substitution of the ureter using a pediculated double short segments of the ileum is a technique used to re-establish ureteral transit and preserve the renal unit, following the resection of extensive ureteral lesions. Standard surgical procedure for an ileoureteroplasty consists of isolating an ileal duct of equal or greater length than the ureteral defect and interposing it in the urinary tract in an isoperistaltic direction. Monti described a surgical technique that allows for the creation of catheterizable stomas in continent urinary diversions, using the Mitrofanoff principle. These passageways were created from one or several 2.5 cm long ileal sections by means of their detubulization and transverse retubulization.

[Aetiology and management of iatrogenic injury of the ureter: a review]

OBJECTIVE

Ureteric injuries (IU) are common complications occurring during abdomino-pelvic surgical procedures. Our aim was to review risk factors, treatment and methods of prevention of these iatrogenic UI.

MATERIAL AND METHODS

A literature review in English and French by Medline(®) was performed using the keywords: ureter; iatrogenic; injury; ureteroscopy; morbidity and endoscopy.

RESULTS

The analysis of the epidemiology of IU shows that the first two causes are gynecological and urological surgery. In 80% of cases, the pelvic ureter was concerned. Mechanisms of injury were essentially ligation, section and ischemia by altering the ureteral vasculature. The main risk factors found were pelvic inflammation (endometriosis, radiation…) and the occurrence of bleeding during surgery. In the presence of risk factors, placing a double J stent or a CT may be useful preoperatively. The choice of reparation technique depended on the location of the PU, the circumstances of the occurrence and experience of the surgical team.

CONCLUSION

Pelvic surgery is a provider of iatrogenic PU. Knowledge of the management of PU once occurred must be mastered before carrying out any risk surgery.

Long-term functional outcomes after ileal ureter substitution: a single-center experience

OBJECTIVES

To assess the indications and outcomes of ileal ureter replacement for ureteral reconstruction, which remains a technique of choice in certain cases, notably when the ureter has been injured.

METHODS

A retrospective review of the data from patients treated with ureteroileoplasty from 1980 to 2010 was performed. The following data were analyzed: age, etiology of ureter injury, and pre- and postoperative creatinine levels. Follow-up visits occurred at 3 and 6 months postoperatively and at least annually thereafter.

RESULTS

A total of 17 patients with a median age of 43 years were included. The main etiology of the ureteral defect was an iatrogenic ureteral injury after a urologic procedure (n=6). The mean length of hospital stay was 12.4±8 days (range 7-26). Four major complications (grade 3) and 5 minor complications (grade 2) developed. The median follow-up time was 174 months. The mean creatinine level before surgery, at 1 month after surgery, and at the last follow-up visit was 1.3±0.3 mg/dL (range 0.6-3.4), 1.4±0.4 mg/dL (range 0.6-3.6), and 1.8±0.6 mg/dL (range 0.7-4.7), respectively. By the end of the follow-up period, 15 patients still had ileal ureters. Of these, 3 required dialysis.

CONCLUSIONS

The indications for an ileal ureter have evolved in recent years. The ileal ureter appears to remain a reasonable option for ureteral reconstruction to preserve long-term renal function.