Simultaneous bilateral subcutaneous pyelovesical bypass as a salvage procedure in refractory retroperitoneal fibrosis

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.

Long-term results of the treatment of complex ureteral stenosis with extra-anatomic ureteral bypasses

Introduction

Complex ureteral obstruction is a pathology that has always been a challenge for the urologist, especially in patients with high surgical risk or with a short life expectancy.

Material and methods

Between 2002 and 2017, 13 extra-anatomical bypasses were placed. A descriptive retrospective study was carried out. An analysis of the permeability time of the prosthesis was performed using Kaplan-Meyer curves. Demographic and etiological characteristics as well as early and late complications were analysed.

Results

Etiologies were benign in 39% (including 3 transplant recipients) and malignant in 69%. Permeability rates were 90.9% at each of 12, 24 and 48 months, respectively, and 75.8% at 60 months. There were no deaths in the early postoperative period, nor intraoperative complications. The most frequent complications were infections. Three of them were associated with bypass extrusion, which needed to be removed. A total of 5 prosthesis had to be removed. 40% of the patients did not present complications.

Conclusions

The extra-anatomical ureteral bypass is an alternative to permanent nephrostomy in the treatment of complex ureteral strictures. Their patency rates after long-term follow-up vary from 90% to 75% at 48 and 60 months, respectively. Their complication rates can be considered acceptable in the patients’ clinical contexts.

Subcutaneous pyelovesical bypass - Detour bypass - as a solution for ureteric obstruction

Introduction

Many patients suffer from unilateral or bilateral hydronephroses caused by pelvic tumors, retroperitoneal fibrosis, occlusion due to radiation therapy or iatrogenic damage to the ureter. Currently, percutaneous nephrostomy or double J stents are primarily used. Nephrostomy deteriorates a patient’s quality of life and leads to frequent infections, blockage of tubes, or bleeding, while uretral stents are associated with septicemia and irritative bladder symptoms. Thus, a useful solution is a Detour stent.

Material and methods

A Detour stent consists of an outer layer made of polytetrafluoroethylene and an inner layer that is a silicone tube 17 F wide, with perforations on both ends and a radio-opaque ring on the proximal end. The ring allows for the insertion of the Detour to the kidney in the correct way. The Detour is placed subcutaneously to the kidney and to the bladder. The route is then tunneled by the large plastic hollow tube for inserting the Detour, and its distal end is sutured to the bladder.

Results

Twelve patients were operated using this method, one of which received a Detour stent bilaterally. The mean follow-up was 10 months. All patients were operated previously by different methods. The average time of surgery was 78 minutes. The following complications occurred: urinary tract infections, haematoma, obstructed flow of urine through the Detour stent, prolonged urinary leakage, and pyelonephritis.

Conclusions

Subcutaneous nephrovesical bypass – Detour System – is a minimally invasive, safe and effective procedure that improves quality of life with no serious complications. The Detour System allows urine to be drained in those cases where many other treatments had failed or were not feasible.

Retroperitoneal fibrosis: a retrospective clinical data analysis of 30 patients in a 10-year period

Background:

Retroperitoneal fibrosis (RPF) is an uncommon disease that is characterized by development of fibrosclerotic tissues involving retroperitoneal structures. This study aimed to investigate the clinical features of 30 patients with RPF in a single center in Beijing in a 10-year period.

Methods:

We retrospectively analyzed clinical data on demographic characteristics, clinical manifestations, laboratory findings, radiological findings, modalities of treatments, outcomes and prognosis of 30 patients with RPF. Patients were treated in Beijing Chao-Yang Hospital between January 2003 and December 2013.

Results:

The mean age of patients with RPF was 56.7 ± 14.4 years. Twenty-three patients were men and seven patients were women. Acute phase reactants were elevated in most patients. Rheumatic factor was positive in 4/25 (16.0%) patients, and antinuclear antibody was positive in 6/22 (27.3%) patients. Elevation of IgG4 was observed in 9/22 (40.9%) patients. The most common type was I + III (n = 13), followed by I + II + III (n = 12). Five patients undertook an ¹⁸F-fluoro-deoxy-D-glucose positron emission tomography examination and increased uptake was detected in four patients. Eight patients received combination therapy with glucocorticoids and tamoxifen. Surgical intervention treatments included intraureteral double-J stent implantation (n = 26), percutaneous nephrostomy (n = 2), open ureterolysis and intraperitonealization of the ureters (n = 5) and laparoscopic ureterolysis and intraperitonealization of the ureters (n = 5). Three patients underwent hemodialysis because of renal failure.

Conclusions:

Clinical characteristics of RPF patients in our study are similar to those previously reported. Steroids and immunosuppressive therapy combined with ureterolysis could be a viable choice of treatment for RPF. More prospective, multi-center studies with a longer follow-up are warranted.