0022-5347 /90/1443-0631$02.00/0 THE JOURNAL OF UROLOGY

Copyright© 1990 by AMERICAN UROLOGICAL AsSOC!ATlON, !NC.

ENDOUROLOGICAL MANAGEMENT OF URETERAL STRICTURES NELSON RODRIGUES NETTO, JR.,* UBIRAJARA FERREIRA, GUSTAVO C. LEMOS JOAQUIM F. A. CLARO

AND

From the Division of Urology, University of Campinas Medical Center, UN/CAMP and Hospital Israelita Albert Einstein, Sao Paulo, Brazil

ABSTRACT

We reviewed the records of 20 patients (21 ureters) treated during the last 5 years for ureteral stricture disease. The causes of stricture formation included ureterolithotripsy in 47.7% of the patients, open ureterolithotomy in 9.5%, other urological procedures in 23.8%, general surgical and gynecological procedures in 9.5% and miscellaneous factors in 9.5%. A total of 20 patients (21 ureters) underwent endourological treatment with balloon dilation (19) or balloon dilation and internal ureterotomy (2), with good results in 57.1 % and a mean followup of 24 months. Of the 9 patients who failed endourological management 3 underwent successful open repair, 3 underwent nephrectomy, and 3 had a relatively large ureteral lumen and became asymptomatic, receiving no further treatment. The interval between injury and treatment was not a decisive factor. The length of ureteral stricture assumes the most significant parameter to predict success in the treatment of ureteral stricture. There were no intraoperative or postoperative complications. The association of balloon dilation and incision by special endoureterotomy scissors is a potentially useful technique. (J. Ural., 144: 631-634, 1990) Davis reported successful clinical results in the treatment of ureteral obstruction with incision and stenting of the ureter. 1 Nevertheless, ureteral strictures were managed by open repair up to the development and popularization of endourological procedures. Since 1926, when Dourmashkin introduced balloon dilation of ureteral strictures, 2 limited advances have been made in the endoscopic management of ureteral stricture. Later, Gruntzig and associates introduced balloon catheters for the treatment of coronary obstruction. 3 The use of the balloon dilation technique described for angioplasty was extended and popularized for ureteral strictures. Lately, endourological management of the ureteropelvic junction has associated balloon dilation with cold knife techniques. 4 · 5 However, endourological manipulation of ureteral strictures has limited use. We present the results in 20 patients (21 ureters) who underwent endoscopic manipulation of ureteral strictures. Ureteropelvic junction obstruction was not included in this study. PATIENTS AND METHODS

We reviewed the records of 20 patients (21 ureters) treated for ureteral stricture at our department from January 1984 through December 1988. There were 12 men and 8 women, with an average age of 55 years (range 23 to 76 years). The stricture involved the right ureter in 10 patients and the left ureter in 9, while 1 patient had bilateral involvement. The ureteral strictures were in the upper third of the ureter in 2 patients, middle third in 3 and lower third in 16. All patients presented with renal pain of long duration. A profile of each patient is presented in table 1. The causes of ureteral stricture are summarized in table 2. The etiology in 10 patients was related to ureteraltrauma after ureteroscopy with stone extraction and in 2 following ureterolithotomy. Three ureters in patients who underwent ureteroneocystostomy elsewhere and 1 patient with bilateral anastomosis of the ureter and transverse colon for urinary diversion to treat gynecological neoplasia were referred to our unit for treatment of the ureteral stricture. There were 2 other cases in which the stricture was due to transurethral resection of the ureteral orifice (1) and to obstructive megaureter (1). Stricture Accepted for publication March 28, 1990. * Current address: R. Augusta 2347, 3°, 01413 Sao Paulo, Brazil.

was not defined in 2 patients. Ureteropelvic junction strictures were excluded from review. Diagnosis of the stricture and followup evaluation included an excretory urogram (IVP) and ultrasound. Antegrade and/or retrograde ureterograms were performed when the stricture was not clearly delineated. Radionuclide study was performed in 5 patients with impaired renal excretion of contrast medium on the IVP. The length of the strictured ureter varied from 0.5 to 3 cm. as determined from radiographic studies. In 4 patients there was complete obstruction with no contrast medium traversing the strictured area on antegrade and retrograde studies. The stricture was up to 1 cm. long in 12 of the 21 ureters, 1 to 2 cm. in 5 and 3 cm. in 4. In the 21 ureters managed endoscopically an attempt was made to negotiate the stricture with a 0.035 angiographic guide wire in a retrograde fashion (fig. 1). Antegrade catheterization was attempted in case of unsuccessful retrograde catheterization. Percutaneous nephrostomy was performed in a standard fashion. The nephrostomy tube was exchanged over a guide wire for a 7F angiographic catheter. The guide wire and catheter were threaded under fluoroscopic vision through the stenotic segment. A second guide wire was introduced next to the catheter and maintained as a safety guide wire. A balloon catheter was advanced over the working guide wire up to the pathological area. The final position was controlled by fluoroscopy. The strictured segment was then dilated by inflation of the balloon for 10 minutes. The balloon catheters were of different diameters ranging from 5 to 7F, with a balloon size of 4 to 6 mm. wide and 4 cm. long. The balloon could be expanded with 5 to 10 atmospheres of pressure. A total of 3 strictures was approached in an antegrade endourological fashion and 18 ureters were managed transurethrally. The ureteroscope was introduced retrograde through a guide wire. The flexible guide wire was threaded under vision through the stenotic segment. The same maneuver as described for antegrade placement was repeated (fig. 2). In the last 2 patients whose ureteral dilation was considered not to be satisfactory internal ureterotomy with a cold knife was done. Special endoureterotomy scissors with an external side cutting edge were used (fig. 3). The scissors are a prototype instrument not commercially available to date. The 4F scissors are introduced through the ureteroscope, being long enough to

632

NETTO AND ASSOCIATES TABLE

Pt. No. 1

Etiology Calculi/ureteroscopy

Mos. to Diagnosis

Length (cm.)

2

3

Calculi/ureteroscopy

6

3

Trans urethral prostatectomy

8

4

Ureteroneocystostomy Calculi/ureteroscopy

12

Gynecological neoplasm

6

2

5

6

3

1. Patient profiles

Degree of Stricture

Primary Management

Outcome

Partial

Dilation

Failure

Complete

Dilation

Failure

Secondary Management

Final Outcome

Ureteral Site

Followup (mos.)

Ureteroneocystostomy

Success

Inferior

30

IVP, ultra-

30

grade ureterogram IVP, ultra-

Diagnosis

sound, ante-

Nephrectomy

Inferior

sound, radio-

1

5

Complete

Dilation

Success

Inferior

24

Partial

Dilation

Success

Inferior

18

nuclide study IVP, ultrasound, antegrade ureterogram, radionuclide study IVP, ultrasound

Partial

Dilation

Failure

Inferior

40

IVP, ultrasound, radio-

1 2

Partial (bilat.)

Dilation, anterior

Success Failure

Ureteroco-

Success

Inferior Inferior

60 60

Superior

18

nuclide study IVP, ultrasound

Ionic anas-

tomosis between ure-

ter and transverse

7

8 9

Calculi/meteroscopy

3

3

Complete

Dilation

Failure

colon Nephrectomy

IVP, ultrasound, ante-

Calculi/ureteroscopy Undetermined

12

2

Partial

Dilation

Success

24

3

Partial

Dilation

Failure

Nephrectomy

Mid

24

grade ureterogram, radionuclide study IVP, ultrasound

Mid

24

IVP, ultrasound, radio-

nuclide study, retrograde ureterogram

10

Calculi/meteroscopy

12

2

Complete

Dilation

Failure

24

IVP, ultrasound

Failure Success

Inferior Superior

24 24

IVP, ultrasound IVP, ultrasound

Success Success

Inferior Inferior

24 18

IVP, ultrasound IVP, ultra-

Dilation

Failure

12

Calculi/ureteroscopy Undetermined Calculi/ureterolithotomy Megaureter Calculi/ureteroscopy

10

1

Partial

Dilation

2 6

2 1

Partial Partial

Dilation Dilation an-

12 18

1 1

Partial Partial

Dilation Dilation an-

19 20

sound, ante-

Mid

Partial

18

IVP, ultra-

Success

2

U reteroneocystostomy Calculi/ureteroscopy Calculi/meterolithotomy U reteroneocystostomy

Success

24

24

18

17

Ureteroneocystostomy

Inferior

Inferior

Calculi/meteroscopy

15 16

Success

grade ureterogram IVP, ultrasound

11

13 14

Ureteroneocystostomy

terior

terior

Inferior

18

grade ureterogram IVP, ultrasound

Success

Inferior

24

IVP, ultrasound

10

1

Partial

Dilation plus incision Dilation

24

1

Partial

Dilation

Success

Inferior

20

IVP, ultrasound

10

1

Partial

Dilation plus incision

Success

Inferior

20

IVP, ultra-

6

1

Partial

sound, ante-

Failure

Dilation plus

Success

incision

sound, radio-

nuclide study

TABLE

2. Etiology of strictures No.

Calculi Megaureter Transurethral resection of prostate Urogynecological neoplasm Ureteroneocystostomy Undetermined

12 1 1 2 3 2

permit use with the long and short rigid instruments. With a safe guide wire in place the scissors are introduced through the ureteroscope. Under direct vision the scissors are threaded into the stenotic segment. When the open scissors are pulled out the external side cutting edge incises the ureteral stricture at 2

opposite sites (fig. 4). After completion of the procedure the ureteroscope is advanced past the treated segment and ureterography is done to examine the site of incision. When full thickness internal ureterotomy is performed extravasation of the contrast medium lS observed at the site of the lesion. Finally, the ureter is intubated with an 8.5F Double-J* catheter for 15 to 60 days (median 40 days). Followup ranged from 18 to 60 months (median 24 months). RESULTS

Treatment was considered successful when there was objective evidence of improvement of anatomical configuration, that is resolution of the stricture. * Medical Engineering Corp., New York, New York.

END8UROLOGICAL MANAGEMENT OF URETERAL STRICTURES

FIG, L Retrograde guide wire threaded through stenotic segment with balloon dilation.

The endoscopic approach was successful in 12 of the 21 ureters (5 7.1 %) . Of the 9 patients who failed endoscopic treatment 4 underwent successful open repair due to strictures longer than 1 cm. or that could not be cannulated with a guide wire (table 3). A total of 3 patients underwent nephrectomy in view of no improvement and poor renal function. All of these kidneys had impaired function demonstrated preoperatively on an IVP and renal scan. The last 2 failures were judged as static. Patients were asymptomatic with a relatively large ureteral lumen, without evidence of deterioration of renal function and therefore, they received no further treatment. ' Of the 4 completely obstructed ureters only 1 with a short stricture in the lower segment was negotiated successfully by the guide wire introduced in an antegrade direction. Good results were achieved in the 2 patients who underwent the special scissors approach despite the fact that 1 required another course of treatment. The strictured segments of ureter were examined pathologically in 6 patients. One specimen showed alterations suggestive of tuberculosis, and the others showed acute and chronic inflammation and fibrosis. DISCUSSION

If a guide wire can be passed endoscopic dilation and stenting should be used as initial treatment of ureteral strictures. Endoscopic ureteral dilation is safe, offering shorter hospitalization and more rapid rehabilitation. However, in case of failure open repair offers a good chance to restore adequate urinary drainage to the kidney. The endoscopic failures included stric-

633

tures of 2 cm. or longer that could not be cannulated with a guide wire. Strictures at the site of ureteroenterostomy are composed of a dense layer of fibrous tissue. It seems unlikely that dilation can improve drainage permanently across the mature stricture. The excessive scar might have been caused subclinical leakage of urine after the in_itial operation. Strictures following ureteroves1cal re1mplantation probably represent a special problem. Related to the oblique position of the reimplanted ureter in the bladder wall, secondary ischemia occurs and a relatively long segment of the lower ureter will be damaged. Therefore, it may be difficult to negotiate the guide wire across the ureterovesical junction either from above or below the stricture. 6 Our data correlate with those who admit that shorter strictures respond better to endoscopic manipulation. 7 In 2 patients with dense scar tissue the ureteral stricture was treated via a combined approach. After dilation, internal ureterotomy with the special scissors was performed. However, in 1 instance the obstruction recurred soon after the stent was removed and a second treatment was necessary. Apparent obliteration of the lumen on radiographic studies did not preclude endoscopic treatment if a guide wire could be positioned properly. 6 This was observed in the case of meatal stenosis following transurethral resection of benign prostatic hyperplasia, which was treated by percutaneous antegrade management of the stricture. There are controversies as to the interval between injury and treatment. 8- 10 In our experience there were 3 late failures treated 12 months after the initial operation and 6 early obstructions. The potential causes of ureteral strictures are many. 11- 13 In our series the length of the stricture was the most important parameter regarding the approach and the results obtained. We conclude that antegrade and retrograde endourological techniques are an alternative to additional operation and can produce favorable results in as many as 57.1 % of the patients with ureteral stenosis. The association of the cold knife incision and balloon dilation is a potentially useful technique, especially in ureteral strictures with intense scar tissue. REFERENCES 1. Davis, D. M.: Intubated ureterotomy. J. UroL, 66: 77, 1951.

2. Dourmashkin, R L.: Dilatation of ureter with rubber bags in the treatment of ureteral calculi. Presentation of a modified operating cystoscope: a preliminary report. J. Urol., 15: 449 1926, 3. Griintzig, A. R., Benning, A, and Siegenthaler, W. E.: No~operative dilation of coronary-artery stenosis: percutaneous transluminal coronary angioplasty. New Engl. J. Med., 301: 61, 1979,

FIG. 2. A, endoureterotomy with special scissors and Double-J catheter in place. B, balloon dilation of lower stenotic ureter

634

NETTO AND ASSOCIATES

B

A

FIG. 3. A, special scissors. B, ureteroscope and special scissors

FIG. 4. Endoureterotomy of lower stenotic ureter with special scissors TABLE 3.

Results

Type of treatment (No. pts.): Dilation Dilation plus ureterotomy Results: No. successes(%) No. failures(%) Median days ofureteral stenting (range) Median days of hospitalization (range) Median mos. of followup (range)

7.

19 2 12 9 40 2 24

(57.1) (42.9) (15-60) (1-4) (18-60)

8.

9. 10.

4. Schneider, A. W., Busch, R., Otto, U. and Klosterhalfen, H.: Endourological management of 41 stenosis in the upper urinary tract using the cold knife technique. J. Ural., part 2, 141: 208A, abstract 155, 1989. 5. Franco, I., Eshghi, M., Schwalb, D. and Addonizio, J. C.: Cold knife endoureterotomy of 28 ureteral strictures. J. Ural., part 2, 141: 209A, abstract 158, 1989. 6. Kramolowsky, E. V., Tucker, R. D. and Nelson, C. M. K.: Manage-

11. 12. 13.

ment of benign ureteral strictures: open surgical repair or endoscopic dilation? J. Ural., 141: 285, 1989. Chang, R., Marshall, F. F. and Mitchell, S.: Percutaneous management of benign ureteral strictures and fistulas. J. Urol., 137: 1126, 1987. King, L. R., Coughlin, P. W. F., Ford, K. K., Brown, M. W. and Van Moore, A.: Initial experiences with percutaneous and transurethral ablation of postoperative ureteral strictures in children. J. Ural., 131: 1167, 1984. O'Brien, W. M., Maxted, W. C. and Pahira, J. J.: Ureteral stricture: experience with 31 cases. J. Ural., 140: 737, 1988. Finnerty, D. P., Trulock, T. S., Berkman, W. and Walton, K. N.: Transluminal balloon dilation of ureteral strictures. J. Ural., 131: 1056, 1984. Ghoneim, M.A., Nabeeh, A. and El-Kappany, H.: Endouralogic treatment of ureteral strictures. J. Endourol., 2: 263, 1988. Smith, A. D.: Management of iatrogenic ureteral strictures after urological procedures. J. Urol., 140: 1372, 1988. Ikari, 0., Palma, P. C. R., D'Ancona, C. A. L. and Netto, N. R., Jr.: Abordagem endourol6gica nas lesoes ureterais. J. Bras. Ural., 12: 134, 1986.

Endourological management of ureteral strictures.

We reviewed the records of 20 patients (21 ureters) treated during the last 5 years for ureteral stricture disease. The causes of stricture formation ...
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