Fran#{231}ois E. Cornud,
Sameh
M. Hanna,
MD MD
Jean-Michel P. Casanova, MD Yves R. Chretien, MD #{149}Bertrand
#{149} #{149}
Impassable Ureteral with Percutaneous Sixteen of 227 patients referred for percutaneous placement of a ureteral stent had impassable stenoses. Stenoses were benign (n = 8) or attributed to malignant retroperitoneal neoplasm (n = 8). Electrocautery was used to create a neotract between the stenosed ureter and the bladder or ileal loop. A double-J stent was placed after dilation of the tract by use of angioplasty. Neofracts were established and stents were placed in all patients. Complications (digestive tract fistulas) developed in two patients. This technique is safe if the electrode is placed close to the bladder or ileal loop The procedure can be used as an alternative to surgery or permanent nephrostomy or in initial treatment of benign anastomotic stenosis. Index terms: Ureter, interventional procedure, 82.129 #{149}Ureter, stenosis or obstruction, 82.84 Radiology
1991;
180:451-454
F. Dufour,
H. Bonnel, MD
MD
#{149} Olivier
#{149} Jean-Fran#{231}ois
R. Helenon, M. Moreau,
MD MD
Strictures: Management Ureteroneocystostomy’
P
placement of a doustent is a well-established method of managing certain benign or malignant ureteral stenoses. Occasionally, however, if the ureter is totally obstructed or otherwise not negotiable by a guide wire, stent placement by use of the usual techniques is preduded. Endourologic management, by using electrocautery (cutting current) has been reported in only a few cases of ureteroenteric anastomosis (1) or malignant ureteral stenosis (2). We evaluated a technique for treatment of impassable ureteral stenosis, whereby a neotract between the ureter and the bladder or ileal loop is established by use of electrocautery, thus permitting a percutaneous transrenal ureteroneocystostomy or ureteroileostomy. The technique was developed as an alternative to neERCUTANEOUS
ble-J
phrectomy, nephrostomy,
ureterovesical tomosis.
PATIENTS
permanent
percutaneous
or open revision or ureteroenteric
AND
of a anas-
METHODS
From October 1987 to December 1989, patients were referred to our institulion to undergo stent placement for treatment of ureteral stenosis. In 16 patients (age range, 52-76 years), the stenosis was dedared impassable after multiple attempts to create a passage with various guide wires and catheters had failed. Eight cases involved postoperative anastomotic stenosis; in seven of these, strictures occurred at the ureteroenteric junction 6-18 months after ileal loop diversion. The eighth patient underwent surgical ureteroneocystostomy after removal of a large impacted stone from the left pelvic ureter, but total stenosis of the tract was evident by 6 weeks after surgery. Percutaneous ureteroneocystostomy was therefore performed. The other eight stenoses resulted from malignancies of various types. Three cases were the result of a gynecologic carcinoma and involved the distal pelvic portion of the ureter. Five cases were related to ma227
I From the Departments of Radiology (F.E.C., D.H.B., O.R.H., S.M.H.,J.F.M.M.) and Urology O.M.P.C., Y.R.C., B.F.D.), H#{244}pital Necker, 146, rue de S#{232}vres, 75015 Paris, France. Received January 23, 1991; revision requested February 18; revision received April 4; accepted April 8. Address reprint requests to F.E.C. C RSNA, 1991
#{149} Didier
lignant retroperitoneal fibrosis. Underlying malignancies were carcinoma of the breast (n = 1) ovary (n = 1), stomach (n = 2), and prostate (n = 1). Four of these five stenoses involved the iliac portion of the ureter (two right, two left), and the fifth case involved the lumbar portion of the left ureter. In all patients that did not have ileal loop diversions, cystoscopically guided retrograde catheterization of the stenosis had been attempted prior to percutaneous manipulations, but had failed.
Stenosis
of the
Pelvic
Ureter
In the three
patients with stenosis of the (Fig 1), percutaneous nephrostomy was performed, and a 7-F proshaped Berenstein catheter (USC!, Billerica, Mass) was inserted into the ureter; the catheter tip was positioned just proximal to the stenosis. If necessary, a coaxial 12-F Amplatz dilator (Cook, Bloomington, md) was used as a sheath (Fig 1) to make the maneuver easier. The flexible tip of a Lunderquist-Ring torque guide wire (Cook) protruding a few millimeters beyond the distal tip of the catheter was used as an electrode. Intermittent cutting current was then applied (intensity level 5) with a high-frequency current source (Erbotom 400; Erbe, Tubingen, Germany), and the Berenstein catheter and tip of the wire, under continuous fluoroscopic guidance, were gently advanced until they entered the fully distended bladder. To control the degree of distention, dilute contrast medium (Telebrix 38; Guerbet, Paris) was injected through a Foley catheter kept in the bladder during the procedure. After the neotract was created, it was subsequently dilated with a 9-mm-diameter angioplasty balloon of appropriate length, and a 10- or 12-F double-J stent was inserted in the usual way, that is, without the use of a sheath (Fig 1). Radiographs of the nephrostomy area were obtained 2 days later, to check for leakage and to assess patency of the stent. The nephrostomy tube was then removed. pelvic
Benign
ureter
Anastomotic
In the patients enteric
anastomoses
ter was placed
Stenosis
with
stenosis of uretero(n = 8), a Foley cathein retrograde fashion 451
through
the cutaneous
raphy
of the
Particular
ileal
stoma,
loop
attention
the catheter
was
was
balloon
adequate
filling
and
given
to keeping
inflated,
of the
teroneoileostomy
to ensure
ileal
was
radiog-
performed.
loop.
then
The
ure-
performed
in
the same tal ureter. changed
fashion as for stenoses of the disThe torque guide wire was exfor an Amplatz straight wire (Cook), to catheterize the loop until it exited the stoma. After antegrade balloon dilation, an 18-F Silastic indwelling ure-
teral stent placed
(Porges,
Palaiseau,
in retrograde
fashion.
Stenoses Ureter
of the
Iliac
In the five cases
France)
was
or Lumbar
in which
a stenosis
was
located in a more proximal (iliac or lumbar) portion of the ureter (Fig 2), the technique was modified (Fig 3). The ureteral wall was first perforated with the rigid
end of an extra-stiff Amplatz guide wire (Cook), and an 8-F straight Teflon catheter was inserted. Use of the rigid end of the wire did not allow perforation of the ureter in any specific direction. The Teflon catheter was then pushed down into the retroperitoneum
until
of the
posterior
it was
exchanged
wall for
To minimize loops,
it reached
the
level
of the bladder,
where
a Berenstein
catheter.
the risk of interposing
the
Berenstein
catheter
bowel
was
posi-
tioned as close as possible to the bladder wall, by use of C-arm biplane fluoroscopy. Cutting current was then applied through the Lunderquist-Ring torque guide wire, until the catheter and guide wire could be passed through the bladder wall. In two of these patients, however, the guide-wirecatheter combination would not pass through the dense retroperitoneal tissues to the bladder. In these two cases, cutting current
was
used
to make
from the ureteral into the bladder
stenosis (Fig 3a).
the
entire
-
b.
C.
Figure 1. Urograms of ureteroneocystostomy procedure used to bypass a complete stenosis, related to a gynecologic carcinoma, of the distal portion of the right pelvic ureter. (a) The tip of the wire is close to the bladder wall. A coaxial 12-F Amplatz dilator passed over the 7-F catheter facilitates forward pressure when cutting current is applied. The bladder is fully distended
with
the degree cutting
without
contrast
medium
of distention.
current.
leakage
(c) Two
injected
through
(b) The 7-F catheter days
of contrast
later,
antegrade
a Foley
is coiled urogram
catheter
into
kept
the bladder,
shows
patency
in the
after of the
bladder
to control
application double-J
of stent,
medium.
tract
through
and
RESULTS In all cases, a neotract was established by placement of a double-J stent after the electrocautery procedune.
In the
two
patients
whole
tract
was
established
ting
current,
due
to interposition
and
left
In the
terocolic the
first
loops
procedure.
In both
was malignant portion of the
case
(Fig
3), a left
appeared The
cut-
occurred,
respectively.
fistula
the
with
of bowel
cases, the stenosis involved the iliac ten.
in whom
complications
colon,
I
3 days
double-J
and ureure-
after
stent
was
removed under cystoscopic guidance. Percutaneous occlusion of the fistula was
not
attempted,
tion
was
treated
phrectomy.
The
and
by means second
the
complica-
of left nepatient
had
malignant netroperitoneal fibrosis due to the recurrence of an ovarian carcinoma, and she had been previously
452
Radiology
#{149}
b.
Figure 2. (a) Antegrade urogram in a case of stenosis shows total obstruction of the left iliac ureter. This obstruction was related to a breast carcinoma. (b) The ureteral wall has been perforated with the rigid end of an extra-stiff Amplatz guide wire and a straight Teflon catheter (not shown). The Berenstein catheter and Lunderquist-Ring torque guide wire are close to the bladder. The guide wire can now be used as an electrode.
August
1991
if
b.
a. Figure
3.
stricture bypass
the
shows
the double-J
stent
completely
also
treated
C.
Left ureterocolic fistula after ureteroneocystostomy. (a) Antegrade urogram through the 12-F Amplatz dilator shows of the left iliac ureter, caused by a malignancy. The pelvic ureter has been opacified by reflux from the fully distended occluded
stent
and
ureter,
cutting
a ureterocolic
current
fistula.
used
to perforate
the
of the bladder
ureteral
and
wall
with
external
established
high-dose
nadia-
only
after
numerous
ap-
current. Four of the double-J stent, intestinal ileus developed. An intraperitoneal leak of contrast medium from the terminal ileum was radiagraphically evident after administration (into the colon) of an enema of water-soluble contrast material with retrograde opacification of the ileum. During the surgery, several small perforations of the ileum, as well as chronic ischemic ileal changes, were noted. No ureteral fistula was present. A proximal ileocolic anastomosis was created, but the patient died of dehiscence of the anastomosis during the postoperative course.
If fluoroscopy was used (four cases), a smooth grasping forceps was inserted into the bladder, and the distal end of the double-J stent was pulled back to the urethral meatus. The stent was then exchanged over an extra-stiff Amplatz guide wire. The first change
plicalions
of cutting
was
days
placement
were
after
Long-term available
follow-up information for the 14 remaining In the six remaining malig-
done
then
after
2 months;
performed
changes
at longer
to make
a neotract.
are superimposed.
(c) Antegrade
urogram
A contralateral
double-J
inter-
of the
would
result
in loss
neotract.
In male patients, the changed endoscopically ring urologist. The risk neotract doscopist pigtail gently
stent was by the referof losing the
was higher in males; the enhad to grasp the distalmost end of the stent and pull it to the urethral meatus.
Ileal loop diversion had been performed in seven of the eight patients with benign stricture. Permanent indwelling stents were preferred in six of these because of poor prognosis associated
with
open
revision
of the
with
was done by grasping the of the stent and exchanging
distal the
over wire.
guide the stent
either
fluoroscopic
or endo-
180
Number
#{149}
2
(stenosis
an extra-stiff Amplatz In the seventh case,
were to Periodic guidance, end stent
siderably
been
the
changed
months
stenosis
ev-
after
recurred,
an open revision of the In the eighth case
of a left surgical
removal however,
stent
had Three
necessitating anastomosis.
lion
anastomosis if the stenosis recur after stent removal. change, under fluoroscopic
scopic guidance. In female patients, the stent was changed with either endoscopic or fluoroscopic guidance.
The 18-F stent ery 2 months. stent removal,
cystostomy), stenosis was
of the
after estabin the hope remain open.
was removed 6 months lishment of the neotract, that the stricture would
vals, depending on the degree of incrustation of the stent. Total incrusta-
patients. nant cases, the stent was periodically changed through the retrograde route
Volume
and
of the rectum
is in place.
lion therapy; the stenosis involved the iliac portion of the right ureter. Because the tip of the wire could not be pushed downward close to the bladder wall, the neotract could be
was
was
Opacification
a complete bladder. (b) To
a moderate observed
of the renal
ureteroneoresidual 3 months
after
stent. Two years later, function was not con-
decreased.
DISCUSSION In 1988, Lang (3) reported a technique of ureteroneocystostomy in a series of 21 patients with fistulas of the distal portion of either ureter. A preshaped catheter was advanced into the distal portion of the ureter, as close as possible to the bladder wall. The bladder wall was then perforated with a transseptal needle pushed through the preshaped catheter. The technique was successful in all cases, without immediate complication, but long-term follow-up information was slight. Lang’s technique might be considered a less aggressive attack of the
Radiology
453
#{149}
ureter and our patients,
thus preferred for use in but it was applied in a different clinical setting, that is, in patients without retroperitoneal neoplasm or fibrotic changes occurring in strictured ureteroenteric anastomoses. Such conditions could preclude the efficacy of the transseptal needle to establish the neotract. The use of electrocautery to bypass an impassable ureteral stricture has been reported only in a few cases. One case report (2) described the successful use of cutting current applied to a guide wire as an aid in bypassing a strictured pelvic ureter that was ocduded by prostatic carcinoma. In another case (1), a completely obstructed ureteroileal
with
anastomosis
an electrode,
guidance, nephroscope
by
means placed
was
under
incised
endoscopic
of a flexible percutaneously
into the distal ureter. Use of electrocautery to circumvent impassable ureteral stenoses was feasible in this series of cases. If the distance between the ureter and the bladder exceeds 2 cm, however, as it can in stenoses caused by malignancy, the risk of perforating interposed bowel loops or colon increases. In
454
#{149} Radiology
these cases, perforation of the ureteral wall and placement of the electrode adjacent to the bladder should be done by manipulating wires and catheters through the retroperitoneum. If the electrode cannot be passed adjacent to the bladder wall, establishment of the neotract should not be attempted. If the electrode can be placed dose to the bladder wall, cutting current can be used, but knowledge of factors predisposing to ileal fistula, such as ischemic enteritis secondary to irradiation, mandates still more care when establishing the neotract. Ureteroneocystosotomy should be contemplated when a hydronephrotic kidney cannot be allowed to atrophy progressively, either because the contralateral kidney cannot maintain sufficient renal function or because hydronephrosis is complicated with pain or fever. This is particularly applicable in patients with retroperitoneal malignancies and short life expectancy. In the case of benign ureteroenteric stenosis, the technique can be used in initial treatment, as suggested by Kramolowsky et al (4). In patients without metastatic disease, the stent can be removed after 6-8 weeks, as it was in two of our cases. if
the stenosis recurs, the choice of surgery or permanent stent placement can be made according to patient age and general condition. In conclusion, percutaneous transrenal ureteroneocystostomy or ureteroileostomy by using cutting current can be performed without complication if the electrode is placed dose to the bladder or the ileal loop. if this principle is strictly respected, the technique is safe and can be an alternative to surgery or permanent percutaneous nephrostomy in selected
cases.
#{149}
References 1.
Kramolowsky EV, Clayman RV, Weyman PJ. Endourological management of tireteroileal anastomotic strictures: is it effecfive? J Urol 1987; 134:390-394. Horowitz MI, Feigenbaum A. Transcatheter electrocautery as an aid in the percutaneous insertion of a ureteral stent. J Urol
2.
1984; 132:111-112. Lang EK. Percutaneous
3.
and ureteroneocystostomy.
ureterocystostomy AJR 1988; 150:
1065-1068.
4.
5
Kramolowsky PJ.
Management
EV, Clayman RV, Weyman of ureterointestinal anas-
tomotic strictures: comparison of open stirgical and endourological repair. J Urol 1988; 139:1195-1198.
August
1991
Sameh
M. Hanna,
MD MD
Jean-Michel P. Casanova, MD Yves R. Chretien, MD #{149}Bertrand
#{149} #{149}
Impassable Ureteral with Percutaneous Sixteen of 227 patients referred for percutaneous placement of a ureteral stent had impassable stenoses. Stenoses were benign (n = 8) or attributed to malignant retroperitoneal neoplasm (n = 8). Electrocautery was used to create a neotract between the stenosed ureter and the bladder or ileal loop. A double-J stent was placed after dilation of the tract by use of angioplasty. Neofracts were established and stents were placed in all patients. Complications (digestive tract fistulas) developed in two patients. This technique is safe if the electrode is placed close to the bladder or ileal loop The procedure can be used as an alternative to surgery or permanent nephrostomy or in initial treatment of benign anastomotic stenosis. Index terms: Ureter, interventional procedure, 82.129 #{149}Ureter, stenosis or obstruction, 82.84 Radiology
1991;
180:451-454
F. Dufour,
H. Bonnel, MD
MD
#{149} Olivier
#{149} Jean-Fran#{231}ois
R. Helenon, M. Moreau,
MD MD
Strictures: Management Ureteroneocystostomy’
P
placement of a doustent is a well-established method of managing certain benign or malignant ureteral stenoses. Occasionally, however, if the ureter is totally obstructed or otherwise not negotiable by a guide wire, stent placement by use of the usual techniques is preduded. Endourologic management, by using electrocautery (cutting current) has been reported in only a few cases of ureteroenteric anastomosis (1) or malignant ureteral stenosis (2). We evaluated a technique for treatment of impassable ureteral stenosis, whereby a neotract between the ureter and the bladder or ileal loop is established by use of electrocautery, thus permitting a percutaneous transrenal ureteroneocystostomy or ureteroileostomy. The technique was developed as an alternative to neERCUTANEOUS
ble-J
phrectomy, nephrostomy,
ureterovesical tomosis.
PATIENTS
permanent
percutaneous
or open revision or ureteroenteric
AND
of a anas-
METHODS
From October 1987 to December 1989, patients were referred to our institulion to undergo stent placement for treatment of ureteral stenosis. In 16 patients (age range, 52-76 years), the stenosis was dedared impassable after multiple attempts to create a passage with various guide wires and catheters had failed. Eight cases involved postoperative anastomotic stenosis; in seven of these, strictures occurred at the ureteroenteric junction 6-18 months after ileal loop diversion. The eighth patient underwent surgical ureteroneocystostomy after removal of a large impacted stone from the left pelvic ureter, but total stenosis of the tract was evident by 6 weeks after surgery. Percutaneous ureteroneocystostomy was therefore performed. The other eight stenoses resulted from malignancies of various types. Three cases were the result of a gynecologic carcinoma and involved the distal pelvic portion of the ureter. Five cases were related to ma227
I From the Departments of Radiology (F.E.C., D.H.B., O.R.H., S.M.H.,J.F.M.M.) and Urology O.M.P.C., Y.R.C., B.F.D.), H#{244}pital Necker, 146, rue de S#{232}vres, 75015 Paris, France. Received January 23, 1991; revision requested February 18; revision received April 4; accepted April 8. Address reprint requests to F.E.C. C RSNA, 1991
#{149} Didier
lignant retroperitoneal fibrosis. Underlying malignancies were carcinoma of the breast (n = 1) ovary (n = 1), stomach (n = 2), and prostate (n = 1). Four of these five stenoses involved the iliac portion of the ureter (two right, two left), and the fifth case involved the lumbar portion of the left ureter. In all patients that did not have ileal loop diversions, cystoscopically guided retrograde catheterization of the stenosis had been attempted prior to percutaneous manipulations, but had failed.
Stenosis
of the
Pelvic
Ureter
In the three
patients with stenosis of the (Fig 1), percutaneous nephrostomy was performed, and a 7-F proshaped Berenstein catheter (USC!, Billerica, Mass) was inserted into the ureter; the catheter tip was positioned just proximal to the stenosis. If necessary, a coaxial 12-F Amplatz dilator (Cook, Bloomington, md) was used as a sheath (Fig 1) to make the maneuver easier. The flexible tip of a Lunderquist-Ring torque guide wire (Cook) protruding a few millimeters beyond the distal tip of the catheter was used as an electrode. Intermittent cutting current was then applied (intensity level 5) with a high-frequency current source (Erbotom 400; Erbe, Tubingen, Germany), and the Berenstein catheter and tip of the wire, under continuous fluoroscopic guidance, were gently advanced until they entered the fully distended bladder. To control the degree of distention, dilute contrast medium (Telebrix 38; Guerbet, Paris) was injected through a Foley catheter kept in the bladder during the procedure. After the neotract was created, it was subsequently dilated with a 9-mm-diameter angioplasty balloon of appropriate length, and a 10- or 12-F double-J stent was inserted in the usual way, that is, without the use of a sheath (Fig 1). Radiographs of the nephrostomy area were obtained 2 days later, to check for leakage and to assess patency of the stent. The nephrostomy tube was then removed. pelvic
Benign
ureter
Anastomotic
In the patients enteric
anastomoses
ter was placed
Stenosis
with
stenosis of uretero(n = 8), a Foley cathein retrograde fashion 451
through
the cutaneous
raphy
of the
Particular
ileal
stoma,
loop
attention
the catheter
was
was
balloon
adequate
filling
and
given
to keeping
inflated,
of the
teroneoileostomy
to ensure
ileal
was
radiog-
performed.
loop.
then
The
ure-
performed
in
the same tal ureter. changed
fashion as for stenoses of the disThe torque guide wire was exfor an Amplatz straight wire (Cook), to catheterize the loop until it exited the stoma. After antegrade balloon dilation, an 18-F Silastic indwelling ure-
teral stent placed
(Porges,
Palaiseau,
in retrograde
fashion.
Stenoses Ureter
of the
Iliac
In the five cases
France)
was
or Lumbar
in which
a stenosis
was
located in a more proximal (iliac or lumbar) portion of the ureter (Fig 2), the technique was modified (Fig 3). The ureteral wall was first perforated with the rigid
end of an extra-stiff Amplatz guide wire (Cook), and an 8-F straight Teflon catheter was inserted. Use of the rigid end of the wire did not allow perforation of the ureter in any specific direction. The Teflon catheter was then pushed down into the retroperitoneum
until
of the
posterior
it was
exchanged
wall for
To minimize loops,
it reached
the
level
of the bladder,
where
a Berenstein
catheter.
the risk of interposing
the
Berenstein
catheter
bowel
was
posi-
tioned as close as possible to the bladder wall, by use of C-arm biplane fluoroscopy. Cutting current was then applied through the Lunderquist-Ring torque guide wire, until the catheter and guide wire could be passed through the bladder wall. In two of these patients, however, the guide-wirecatheter combination would not pass through the dense retroperitoneal tissues to the bladder. In these two cases, cutting current
was
used
to make
from the ureteral into the bladder
stenosis (Fig 3a).
the
entire
-
b.
C.
Figure 1. Urograms of ureteroneocystostomy procedure used to bypass a complete stenosis, related to a gynecologic carcinoma, of the distal portion of the right pelvic ureter. (a) The tip of the wire is close to the bladder wall. A coaxial 12-F Amplatz dilator passed over the 7-F catheter facilitates forward pressure when cutting current is applied. The bladder is fully distended
with
the degree cutting
without
contrast
medium
of distention.
current.
leakage
(c) Two
injected
through
(b) The 7-F catheter days
of contrast
later,
antegrade
a Foley
is coiled urogram
catheter
into
kept
the bladder,
shows
patency
in the
after of the
bladder
to control
application double-J
of stent,
medium.
tract
through
and
RESULTS In all cases, a neotract was established by placement of a double-J stent after the electrocautery procedune.
In the
two
patients
whole
tract
was
established
ting
current,
due
to interposition
and
left
In the
terocolic the
first
loops
procedure.
In both
was malignant portion of the
case
(Fig
3), a left
appeared The
cut-
occurred,
respectively.
fistula
the
with
of bowel
cases, the stenosis involved the iliac ten.
in whom
complications
colon,
I
3 days
double-J
and ureure-
after
stent
was
removed under cystoscopic guidance. Percutaneous occlusion of the fistula was
not
attempted,
tion
was
treated
phrectomy.
The
and
by means second
the
complica-
of left nepatient
had
malignant netroperitoneal fibrosis due to the recurrence of an ovarian carcinoma, and she had been previously
452
Radiology
#{149}
b.
Figure 2. (a) Antegrade urogram in a case of stenosis shows total obstruction of the left iliac ureter. This obstruction was related to a breast carcinoma. (b) The ureteral wall has been perforated with the rigid end of an extra-stiff Amplatz guide wire and a straight Teflon catheter (not shown). The Berenstein catheter and Lunderquist-Ring torque guide wire are close to the bladder. The guide wire can now be used as an electrode.
August
1991
if
b.
a. Figure
3.
stricture bypass
the
shows
the double-J
stent
completely
also
treated
C.
Left ureterocolic fistula after ureteroneocystostomy. (a) Antegrade urogram through the 12-F Amplatz dilator shows of the left iliac ureter, caused by a malignancy. The pelvic ureter has been opacified by reflux from the fully distended occluded
stent
and
ureter,
cutting
a ureterocolic
current
fistula.
used
to perforate
the
of the bladder
ureteral
and
wall
with
external
established
high-dose
nadia-
only
after
numerous
ap-
current. Four of the double-J stent, intestinal ileus developed. An intraperitoneal leak of contrast medium from the terminal ileum was radiagraphically evident after administration (into the colon) of an enema of water-soluble contrast material with retrograde opacification of the ileum. During the surgery, several small perforations of the ileum, as well as chronic ischemic ileal changes, were noted. No ureteral fistula was present. A proximal ileocolic anastomosis was created, but the patient died of dehiscence of the anastomosis during the postoperative course.
If fluoroscopy was used (four cases), a smooth grasping forceps was inserted into the bladder, and the distal end of the double-J stent was pulled back to the urethral meatus. The stent was then exchanged over an extra-stiff Amplatz guide wire. The first change
plicalions
of cutting
was
days
placement
were
after
Long-term available
follow-up information for the 14 remaining In the six remaining malig-
done
then
after
2 months;
performed
changes
at longer
to make
a neotract.
are superimposed.
(c) Antegrade
urogram
A contralateral
double-J
inter-
of the
would
result
in loss
neotract.
In male patients, the changed endoscopically ring urologist. The risk neotract doscopist pigtail gently
stent was by the referof losing the
was higher in males; the enhad to grasp the distalmost end of the stent and pull it to the urethral meatus.
Ileal loop diversion had been performed in seven of the eight patients with benign stricture. Permanent indwelling stents were preferred in six of these because of poor prognosis associated
with
open
revision
of the
with
was done by grasping the of the stent and exchanging
distal the
over wire.
guide the stent
either
fluoroscopic
or endo-
180
Number
#{149}
2
(stenosis
an extra-stiff Amplatz In the seventh case,
were to Periodic guidance, end stent
siderably
been
the
changed
months
stenosis
ev-
after
recurred,
an open revision of the In the eighth case
of a left surgical
removal however,
stent
had Three
necessitating anastomosis.
lion
anastomosis if the stenosis recur after stent removal. change, under fluoroscopic
scopic guidance. In female patients, the stent was changed with either endoscopic or fluoroscopic guidance.
The 18-F stent ery 2 months. stent removal,
cystostomy), stenosis was
of the
after estabin the hope remain open.
was removed 6 months lishment of the neotract, that the stricture would
vals, depending on the degree of incrustation of the stent. Total incrusta-
patients. nant cases, the stent was periodically changed through the retrograde route
Volume
and
of the rectum
is in place.
lion therapy; the stenosis involved the iliac portion of the right ureter. Because the tip of the wire could not be pushed downward close to the bladder wall, the neotract could be
was
was
Opacification
a complete bladder. (b) To
a moderate observed
of the renal
ureteroneoresidual 3 months
after
stent. Two years later, function was not con-
decreased.
DISCUSSION In 1988, Lang (3) reported a technique of ureteroneocystostomy in a series of 21 patients with fistulas of the distal portion of either ureter. A preshaped catheter was advanced into the distal portion of the ureter, as close as possible to the bladder wall. The bladder wall was then perforated with a transseptal needle pushed through the preshaped catheter. The technique was successful in all cases, without immediate complication, but long-term follow-up information was slight. Lang’s technique might be considered a less aggressive attack of the
Radiology
453
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ureter and our patients,
thus preferred for use in but it was applied in a different clinical setting, that is, in patients without retroperitoneal neoplasm or fibrotic changes occurring in strictured ureteroenteric anastomoses. Such conditions could preclude the efficacy of the transseptal needle to establish the neotract. The use of electrocautery to bypass an impassable ureteral stricture has been reported only in a few cases. One case report (2) described the successful use of cutting current applied to a guide wire as an aid in bypassing a strictured pelvic ureter that was ocduded by prostatic carcinoma. In another case (1), a completely obstructed ureteroileal
with
anastomosis
an electrode,
guidance, nephroscope
by
means placed
was
under
incised
endoscopic
of a flexible percutaneously
into the distal ureter. Use of electrocautery to circumvent impassable ureteral stenoses was feasible in this series of cases. If the distance between the ureter and the bladder exceeds 2 cm, however, as it can in stenoses caused by malignancy, the risk of perforating interposed bowel loops or colon increases. In
454
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these cases, perforation of the ureteral wall and placement of the electrode adjacent to the bladder should be done by manipulating wires and catheters through the retroperitoneum. If the electrode cannot be passed adjacent to the bladder wall, establishment of the neotract should not be attempted. If the electrode can be placed dose to the bladder wall, cutting current can be used, but knowledge of factors predisposing to ileal fistula, such as ischemic enteritis secondary to irradiation, mandates still more care when establishing the neotract. Ureteroneocystosotomy should be contemplated when a hydronephrotic kidney cannot be allowed to atrophy progressively, either because the contralateral kidney cannot maintain sufficient renal function or because hydronephrosis is complicated with pain or fever. This is particularly applicable in patients with retroperitoneal malignancies and short life expectancy. In the case of benign ureteroenteric stenosis, the technique can be used in initial treatment, as suggested by Kramolowsky et al (4). In patients without metastatic disease, the stent can be removed after 6-8 weeks, as it was in two of our cases. if
the stenosis recurs, the choice of surgery or permanent stent placement can be made according to patient age and general condition. In conclusion, percutaneous transrenal ureteroneocystostomy or ureteroileostomy by using cutting current can be performed without complication if the electrode is placed dose to the bladder or the ileal loop. if this principle is strictly respected, the technique is safe and can be an alternative to surgery or permanent percutaneous nephrostomy in selected
cases.
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References 1.
Kramolowsky EV, Clayman RV, Weyman PJ. Endourological management of tireteroileal anastomotic strictures: is it effecfive? J Urol 1987; 134:390-394. Horowitz MI, Feigenbaum A. Transcatheter electrocautery as an aid in the percutaneous insertion of a ureteral stent. J Urol
2.
1984; 132:111-112. Lang EK. Percutaneous
3.
and ureteroneocystostomy.
ureterocystostomy AJR 1988; 150:
1065-1068.
4.
5
Kramolowsky PJ.
Management
EV, Clayman RV, Weyman of ureterointestinal anas-
tomotic strictures: comparison of open stirgical and endourological repair. J Urol 1988; 139:1195-1198.
August
1991
