0022-534 7/79/1214-0587$02.00/0 Vol. 121, May
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
CONTROLLED URETERAL MEATOTOMY ARTHUR D. SMITH,* PAUL H. LANGE, ROBERT P. MILLER
AND
DONOVAN B. REINKE
From the Departments of Urology and Diagnostic Radiology, Veterans Administration Hospital and the Department of U rologic Surgery, University of Minnesota Hospitals, Minneapolis, Minnesota
!. I
ABSTRACT
An endourologic technique for a safe and adequate ureteral meatotomy has been devised. The ureter is catheterized anterograde through a percutaneous nephrostomy and a controlled ureteral meatotomy is done with a modified ureteral catheter. A silicone splint is then placed. The technique is safer than other techniques because repeated, more proximal incisions can be made and because the splint and proximal urinary division will prevent extravasation. Ureteral meatal stenosis may be caused by transurethral resection or fulguration of the orifice or in the vicinity of the orifice. 1 Scarring is more likely to occur if there is infection. 2 Severe stenosis may require operative correction, which often is accomplished by ureteral meatotomy. Although ureteral reflux often results3 • 4 it usually is well tolerated and, therefore, is an acceptable side effect in the majority of patients. 3 • 5 A problem common to all techniques for ureteral meatotomy is the occasional difficulty in intubating the ureter postoperatively. Our technique allows one to cut the ureteral orifice repeatedly and more proximally with the knowledge that the continuity of the urinary tract will not be lost. If the incision has been extended too far proximally, thus risking urinary extravasation, the situation can be controlled by intubating the ureterovesical junction and using proximal drainage. In our experience it often has been easier to traverse ureteral obstruction anterograde rather than retrograde 6 • 7 because the ureter above the obstruction supports the catheter. Attempts to catheterize and to dilate a stenotic ureteral orifice transcystoscopically may result in the catheter buckling or in a false passage. However, once a guide wire has been passed from the kidney into the bladder total control 01 the situation is achieved and the possibility of complications is reduced greatly. Our technique may be used in other situations involving ureteral stenosis. In ureteroileal stenosis it may be possible to position the modified ureteral catheter at the ureteroileal junction under fluoroscopic control and to divide the stricture. We have not tried this procedure yet but we have dilated ureteroileal strictures and inserted a Gibbons catheter to maintain the adequacy of the ureteral lumen. Transurethral fulguration or resection in the vicinity of the ureteral orifices may result in stricture formation, 1 vesicoureteral reflux3 • 4 or both. Once ureteral meatal stenosis is present it can be corrected either transurethrally or at open operation. The commonly used transcystoscopic methods include either a meatotomy with cystoscopic scissors, Calling's knife, cutting knife electrode or steel ureteral stylet, or a resection of the ureteral tunnel and stenotic orifice. Resection has a greater risk of postoperative vesicoureteral reflux than does meatotomy. Even if one succeeds in doing a difficult meatotomy, using any of the aforementioned methods, additional technical problems may be encountered. It may be impossible to catheterize the ureter or the endoscopist may be unable to tell whether the meatotomy was adequate to relieve the obstruction. Therefore, we developed a technique of ureteral meatotomy that overcomes some of the problems. This technique involves Accepted for publication August 11, 1978. * Requests for reprints: Department ofUrologic Surgery, Box 394 Mayo, University of Minnesota Hospitals, Minneapolis, Minnesota 55455.
percutaneous nephrostomy and anterograde catheterization of the ureter, after which a controlled meatotomy is performed transcystoscopically. TECHNIQUE
After percutaneous nephrostomy is done an angiogram catheter and guide wire are manipulated down the ureter to the area of stenosis as previously described. 6 • 7 Various combinations of guide wires and angiogram catheters are tried until the area of stenosis is traversed. A cystogram may be necessary to ascertain the direction in which to manipulate the guide wire through the lower ureter. The angiogram catheter, in which appropriately positioned side holes have been cut, is then manipulated into position to drain the upper tract. When the patient's condition is stable a cystoscopy is performed and the end of the angiogram catheter is withdrawn from the bladder with the Bumpus forceps. A modified ureteral catheter is constructed from a 5F whistle-tip ureteral catheter and a steel stylet (fig. 1, A). The stylet is inserted into the catheter so that it comes out through 1 side hole and re-enters the catheter through another side hole 1.5 cm. away. The tip of the stylet is bent over the end of the ureteral catheter. Traction on the steel stylet now causes angulation of the catheter. The end of the angiogram catheter at the urethral meatus is cut off and the modified ureteral catheter is sutured into its lumen so that the bent tip of the stylet is insulated by .the angiogram catheter (fig. 1, B). Traction on the angiogram catheter at the nephrostomy site together with cystoscopic manipulation allows correct positioning of the exposed portion of the stylet within the ureteral tunnel. Traction then is applied to the stylet at the end of the ureteral catheter so that the ureteral tunnel is stretched and the exposed part of the stylet abuts against the stenotic area. Finally, cutting current is applied to the stylet and the area of stricture is divided (fig. 1, C). This procedure can be repeated until the whole area of stenosis has been opened adequately. At this stage the modified ureteral catheter is removed and a silicone splint with appropriately positioned side holes is attached to the angiogram catheter and pulled into position. The end of the splint can be left in the bladder or extending out through the external urethral meatus. The splint is left in place for about 2 weeks and can then be removed if there is no extravasation on nephrostogram. CASE REPORT
An 82-year-old man who had undergone 5 resections of superficial bladder tumors in the region of the trigone was seen 3 months after the last resection for left renal pain and bilateral hydronephrosis caused by stenosis of the ureterovesical junction (fig. 2, A). A voiding cystourethrogram did not demonstrate reflux. The serum creatinine level was 2.1 mg./ 587
588
SMITH AND ASSOCIATES
~,~::1// ~A
/
\C,I
CA!~ETER OPEN
ANG IOGRAM CATHETER ANG IOGRAM CATHETER
~
~©
F
{)
MODIFIED URETERAL CATHETER
f
MODIFIED URETERAL CA1"ETER CLOSED
/
Fm. 1. A, modified ureteral catheter with steel stylet. Traction on stylet at urethral meatus opens catheter. B, end of modified ureteral catheter is sutured into lumen of angiogram catheter and apparatus is pulled into position. C, cutting current is applied to stylet after modified ureteral catheter is pulled into position. D, catheter opened.
Fm. 2. A, bilateral hydronephrosis caused by bilateral ureteral meatal stenosis. B, IVP 7 days after transcystoscopic ureteral meatotomy on right side and 3 days after ureteral meatotomy on left side with technique described.
100 ml. and the urine was sterile. The patient was a poor operative risk. A transcystoscopic ureteral meatotomy was performed on the right side with a ureteral steel stylet. However, on the left side this procedure was technically difficult because the orifice was so severely stenotic that it could not be intubated and the result of the meatotomy was not satisfactory. An excretory urogram (IVP) 72 hours later
showed some improvement on the right side but the obstruction on the left side was greater than previously. After percutaneous nephrostomy was done an angiogram catheter was manipulated down the ureter into the bladder. The angiogram catheter was retrieved from the bladder with the Bumpus forceps and a controlled left ureteral meatotomy was performed as described herein. After the meatotomy a
CONTROLLED URETERAL MEATOTOMY
silicone stent was inserted into the bladder from the percutaneous nephrostomy site. An IVP 4 days later showed significant improvement (fig. 2, B) and another IVP 3 weeks later revealed that the hydronephrosis had resolved to an even greater extent. REFERENCES
1. Amar, A. D.: Ureterovesical junction obstruction following transurethral resection. Brit. J. Urol., 37: 307, 1965. 2. Graham, J.B.: Electroresection injury of the ureteral orifice. J.
Urol., 86: 539, 1961. 3. McAdam, W. A. F. and James, W. B.: Vesico-ureteric reflux
589
after transurethral meatotomy. Brit. J. Surg., 54: 10, 1967. 4. Rees, R. W. M.: The effect of transurethral resection of the intravesical ureter during the removal of bladder tumours. Brit. J. Urol., 41: 2, 1969. 5. Lalli, A. F. and Lapides, J.: Long-term followup of ureteroneocystostomy without anti-reflux technique. J. Urol., 100: 441, 1968. 6. Smith, A. D., Lange, P.H., Miller, R. P. and Reinke, D. B.: Introduction of the Gibbons ureteral stent facilitated by antecedent percutaneous nephrostomy. J. Urol., 120: 543, 1978. 7. Smith, A. D., Lange, P. H., Reinke, D. B. and Miller, R. P.: Extraction of ureteral calculi from patients with ileal loops: a new technique. J. Urol., 120: 623, 1978.
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
CONTROLLED URETERAL MEATOTOMY ARTHUR D. SMITH,* PAUL H. LANGE, ROBERT P. MILLER
AND
DONOVAN B. REINKE
From the Departments of Urology and Diagnostic Radiology, Veterans Administration Hospital and the Department of U rologic Surgery, University of Minnesota Hospitals, Minneapolis, Minnesota
!. I
ABSTRACT
An endourologic technique for a safe and adequate ureteral meatotomy has been devised. The ureter is catheterized anterograde through a percutaneous nephrostomy and a controlled ureteral meatotomy is done with a modified ureteral catheter. A silicone splint is then placed. The technique is safer than other techniques because repeated, more proximal incisions can be made and because the splint and proximal urinary division will prevent extravasation. Ureteral meatal stenosis may be caused by transurethral resection or fulguration of the orifice or in the vicinity of the orifice. 1 Scarring is more likely to occur if there is infection. 2 Severe stenosis may require operative correction, which often is accomplished by ureteral meatotomy. Although ureteral reflux often results3 • 4 it usually is well tolerated and, therefore, is an acceptable side effect in the majority of patients. 3 • 5 A problem common to all techniques for ureteral meatotomy is the occasional difficulty in intubating the ureter postoperatively. Our technique allows one to cut the ureteral orifice repeatedly and more proximally with the knowledge that the continuity of the urinary tract will not be lost. If the incision has been extended too far proximally, thus risking urinary extravasation, the situation can be controlled by intubating the ureterovesical junction and using proximal drainage. In our experience it often has been easier to traverse ureteral obstruction anterograde rather than retrograde 6 • 7 because the ureter above the obstruction supports the catheter. Attempts to catheterize and to dilate a stenotic ureteral orifice transcystoscopically may result in the catheter buckling or in a false passage. However, once a guide wire has been passed from the kidney into the bladder total control 01 the situation is achieved and the possibility of complications is reduced greatly. Our technique may be used in other situations involving ureteral stenosis. In ureteroileal stenosis it may be possible to position the modified ureteral catheter at the ureteroileal junction under fluoroscopic control and to divide the stricture. We have not tried this procedure yet but we have dilated ureteroileal strictures and inserted a Gibbons catheter to maintain the adequacy of the ureteral lumen. Transurethral fulguration or resection in the vicinity of the ureteral orifices may result in stricture formation, 1 vesicoureteral reflux3 • 4 or both. Once ureteral meatal stenosis is present it can be corrected either transurethrally or at open operation. The commonly used transcystoscopic methods include either a meatotomy with cystoscopic scissors, Calling's knife, cutting knife electrode or steel ureteral stylet, or a resection of the ureteral tunnel and stenotic orifice. Resection has a greater risk of postoperative vesicoureteral reflux than does meatotomy. Even if one succeeds in doing a difficult meatotomy, using any of the aforementioned methods, additional technical problems may be encountered. It may be impossible to catheterize the ureter or the endoscopist may be unable to tell whether the meatotomy was adequate to relieve the obstruction. Therefore, we developed a technique of ureteral meatotomy that overcomes some of the problems. This technique involves Accepted for publication August 11, 1978. * Requests for reprints: Department ofUrologic Surgery, Box 394 Mayo, University of Minnesota Hospitals, Minneapolis, Minnesota 55455.
percutaneous nephrostomy and anterograde catheterization of the ureter, after which a controlled meatotomy is performed transcystoscopically. TECHNIQUE
After percutaneous nephrostomy is done an angiogram catheter and guide wire are manipulated down the ureter to the area of stenosis as previously described. 6 • 7 Various combinations of guide wires and angiogram catheters are tried until the area of stenosis is traversed. A cystogram may be necessary to ascertain the direction in which to manipulate the guide wire through the lower ureter. The angiogram catheter, in which appropriately positioned side holes have been cut, is then manipulated into position to drain the upper tract. When the patient's condition is stable a cystoscopy is performed and the end of the angiogram catheter is withdrawn from the bladder with the Bumpus forceps. A modified ureteral catheter is constructed from a 5F whistle-tip ureteral catheter and a steel stylet (fig. 1, A). The stylet is inserted into the catheter so that it comes out through 1 side hole and re-enters the catheter through another side hole 1.5 cm. away. The tip of the stylet is bent over the end of the ureteral catheter. Traction on the steel stylet now causes angulation of the catheter. The end of the angiogram catheter at the urethral meatus is cut off and the modified ureteral catheter is sutured into its lumen so that the bent tip of the stylet is insulated by .the angiogram catheter (fig. 1, B). Traction on the angiogram catheter at the nephrostomy site together with cystoscopic manipulation allows correct positioning of the exposed portion of the stylet within the ureteral tunnel. Traction then is applied to the stylet at the end of the ureteral catheter so that the ureteral tunnel is stretched and the exposed part of the stylet abuts against the stenotic area. Finally, cutting current is applied to the stylet and the area of stricture is divided (fig. 1, C). This procedure can be repeated until the whole area of stenosis has been opened adequately. At this stage the modified ureteral catheter is removed and a silicone splint with appropriately positioned side holes is attached to the angiogram catheter and pulled into position. The end of the splint can be left in the bladder or extending out through the external urethral meatus. The splint is left in place for about 2 weeks and can then be removed if there is no extravasation on nephrostogram. CASE REPORT
An 82-year-old man who had undergone 5 resections of superficial bladder tumors in the region of the trigone was seen 3 months after the last resection for left renal pain and bilateral hydronephrosis caused by stenosis of the ureterovesical junction (fig. 2, A). A voiding cystourethrogram did not demonstrate reflux. The serum creatinine level was 2.1 mg./ 587
588
SMITH AND ASSOCIATES
~,~::1// ~A
/
\C,I
CA!~ETER OPEN
ANG IOGRAM CATHETER ANG IOGRAM CATHETER
~
~©
F
{)
MODIFIED URETERAL CATHETER
f
MODIFIED URETERAL CA1"ETER CLOSED
/
Fm. 1. A, modified ureteral catheter with steel stylet. Traction on stylet at urethral meatus opens catheter. B, end of modified ureteral catheter is sutured into lumen of angiogram catheter and apparatus is pulled into position. C, cutting current is applied to stylet after modified ureteral catheter is pulled into position. D, catheter opened.
Fm. 2. A, bilateral hydronephrosis caused by bilateral ureteral meatal stenosis. B, IVP 7 days after transcystoscopic ureteral meatotomy on right side and 3 days after ureteral meatotomy on left side with technique described.
100 ml. and the urine was sterile. The patient was a poor operative risk. A transcystoscopic ureteral meatotomy was performed on the right side with a ureteral steel stylet. However, on the left side this procedure was technically difficult because the orifice was so severely stenotic that it could not be intubated and the result of the meatotomy was not satisfactory. An excretory urogram (IVP) 72 hours later
showed some improvement on the right side but the obstruction on the left side was greater than previously. After percutaneous nephrostomy was done an angiogram catheter was manipulated down the ureter into the bladder. The angiogram catheter was retrieved from the bladder with the Bumpus forceps and a controlled left ureteral meatotomy was performed as described herein. After the meatotomy a
CONTROLLED URETERAL MEATOTOMY
silicone stent was inserted into the bladder from the percutaneous nephrostomy site. An IVP 4 days later showed significant improvement (fig. 2, B) and another IVP 3 weeks later revealed that the hydronephrosis had resolved to an even greater extent. REFERENCES
1. Amar, A. D.: Ureterovesical junction obstruction following transurethral resection. Brit. J. Urol., 37: 307, 1965. 2. Graham, J.B.: Electroresection injury of the ureteral orifice. J.
Urol., 86: 539, 1961. 3. McAdam, W. A. F. and James, W. B.: Vesico-ureteric reflux
589
after transurethral meatotomy. Brit. J. Surg., 54: 10, 1967. 4. Rees, R. W. M.: The effect of transurethral resection of the intravesical ureter during the removal of bladder tumours. Brit. J. Urol., 41: 2, 1969. 5. Lalli, A. F. and Lapides, J.: Long-term followup of ureteroneocystostomy without anti-reflux technique. J. Urol., 100: 441, 1968. 6. Smith, A. D., Lange, P.H., Miller, R. P. and Reinke, D. B.: Introduction of the Gibbons ureteral stent facilitated by antecedent percutaneous nephrostomy. J. Urol., 120: 543, 1978. 7. Smith, A. D., Lange, P. H., Reinke, D. B. and Miller, R. P.: Extraction of ureteral calculi from patients with ileal loops: a new technique. J. Urol., 120: 623, 1978.
