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865
Percutaneous Ureteral Stent Placement For Stricture Management and Internal Urinary Drainage
Lawrence
R.
Kyo Robert Winston
Bigongiari1 Rak Lee1 E. K.
Moffat1 Mebust2
John Foret2 John Weigel2
Percutaneous ureteral stent placement was attempted in nine patients with 14 ureteral lesions. Eight strictures in six patients were successfully stented. Three were subsequently converted to indwelling ureteral stents. The technique is described. No significant complications occurred. The procedure should be attempted as part of percutaneous nephrostomy for benign ureteral strictures, ureteral fistulae, or whenever long term nonoperative diversion can be useful.
Percutaneous collecting If a tube dilating
nephrostomy,
system, can be the
provides passed
strictured
the
translumbar
insertion
external drainage down the ureter
segment,
then
a percutaneous
can be performed. Internal urinary drainage side holes in the catheter above the obstructing in the literature about this procedure.
Subjects
and
Percutaneous ureteral with
ureteral
cystoscopy had
stent
and
Intramuscular
placement
in 1 978.
unsuccessful
Demerol
pyelography
was
All patients
an inflammatory
antegrade
February 26, 9, 1979. of Uroradiology,
1 979;
accepted
Department
after of
Di-
agnostic Radiology, Kansas University Medical Center, Kansas City, KS 66103. Address reprint requests to L. R. Bigongiari. 2 Section of Urology, Department of Surgery, Kansas University Medical Center, Kansas City,
KS 66103. AJR
133:86-868,
November
0361 -803X/79/ 1335-0865 © American Roentgen Ray
1979
$00.00 Society
junction
with
facilitated
multiple
protect level
the
had
attempted been
retrograde
stricture
and
and Phenergan in the
ureteral
side holes kidney
from
of obstruction,
A straight
stricture
oblique
ureteral
renal
kidney. lesion,
stent
in 1 4 ureters
evaluated
by the
pyelography
the
rest
placement
in nine
urology
and/or
malignant
stent
and
damage the
probed
with
by the
catheter
gentle
An 8 French, moving
heavy
duty
was
0.97
Teflon,
After
0.97
straight
Ind.) was passed wire.
advanced
mm guide
Then just
with usually
placement.
for analgesia.
a J-tipped
Inc., Bloomington,
patients
service,
One
encasement.
was administered position,
cannulation.
(Cook,
or movable-core
floppy
was
the
to the bladder can be provided by lesion. There is little information
was introduced into the collecting system and ureter via 1 8 gauge technique described by Stables et al [1 ]. Renal puncture directly opposite Received revision July 1 Section
into
Methods
obstruction
patient
of a tube
of urine from an obstructed and through the obstructing
the
proximal
preliminary
mm
guide
aortogram
catheter
over the guide
J-tip
was
to the
wire was substituted
wire
needle after the the ureteropelvic wire to
advanced
to the
obstructing
lesion.
for the J-tip
and the
pressure.
If the guide wire could not be easily passed, the catheter was advanced to engage the ureteral stricture, then held in place as the guide wire was pushed with steadily increasing force. If this maneuver was unsuccessful, larger stiffer dilators, such as a Dotter biliary dilating introduced.
set
(Cook)
or a Medi-Tech
Larger
guide
wires
steerable
catheter
up to 1 .31
mm were
(Medi-Tech, sometimes
Watertown, used
to probe
Mass.) the
were
stricture.
866
BIGONGIARI
TABLE
1 : Percutaneous
P aien 1.
Stent
(Success
Obstruction
1
Prostate
cancer
2
Cervix
3
Prostate
cancer
4
Prostate
cancer
5
Pancreatic noma
AJR:133,
Site of Obstruction of 5tent Placement)
carci-
Right ureterovesical junction left distal, at iliac level (+)
(-);
Right (+) and left (not tried) terovesical junctions Right and left ureterovesical junctions (-)
ure-
Right
(-)
ureteropelvic
junction
Became febrile when tubes closed proximally; used as nephrostomies Perforated at ureteropelvic junction on right; tumor eventually replaced bladder Converted to indwelling stent; nonfunctioning left kidney Both ureterovesical junctions 5shaped due to prostatic enlargement Perforated
6
Prostate
7
Inflammatory stricture
Left midureter
8
Bladder noma
carci-
Right
9
Prostate
cancer
Left midureter (not tried) Right and left ureterovesical junctions (+)
find
(+)
Ureteroileal
wire
as a ureteral
stent.
Urine
could
enter
the
catheter
above
the
obstruction and exit in the bladder. The percutaneous catheter was occluded proximally to prevent urine drainage out the flank and the patient observed for a few days. If no unosepsis intervened, the percutaneous stent was replaced with a uretenal indwelling pigtail stent (Vance Products, Inc. , Spencer, Ind.) cystoscopically over a guide wire introduced through the percutaneous stent.
our experience. was attempted lesions. Eight
Percutaneous in nine patients of the 1 4 lesions
successfully stented providing internal drainage the nine patients. In three ureters in two patients, neous ureteral stents were subsequently converted indwelling
stents
converted
(fig. for
1 ). In the
various
elicited
bladder
patients,
reasons.
became mildly febrile whenever were closed at the skin, but the were reopened. Also, the length bladder
other
spasms.
One
urewith were
for six of percutato pigtail stents
patient
were
(case
1)
the bilateral stent tubes fever resolved when they of Teflon catheter in his Therefore,
the
percuta-
neously placed ureteral stents were pulled back above the obstructed ureterovesical junctions to function as nephrostomies. In case 2, the bladder was soon replaced by tumor so
the
tube
functioned
case 6, a guide but a stent would and
an Ingram
as a nephrostomy.
wire passed through not follow. The guide catheter
(Sherwood
On
one
side
in
the tumoral stenosis wire was left in place
Medical
Industries,
Inc.,
in tumor
S-shaped M/3 with difficulty; to indwelling
St. Louis, retrograde
Mo.) placed placement
and
clot
the
wire
guide
on left negotiated both converted stents
over it. At the subsequent of a ureteral indwelling because
of the removed
urolithiasis, pyelolithotomy,
could
she
not
had she
ureter
be identified
attempt at pigtail stent,
bleeding prostatic tumor. The guide wire was the nephrostomy left in place. The single patient with inflammatory stricture a 52-year-old woman with ileal conduit created of the bladder (fig. 2). Because of repeated
in the Table 1 summarizes teral stent placement 1 4 obstructing ureteral
not
either
only one functioning developed a urine
urinoma was surgically sump tube would not
Results
junc-
Stone, lithotomy, leak and unnoma, stricture, stent; difficult reoperation avoided Ileal loop with recurrent bladder carcinoma at anastomosis and retropenitoneal metastases; 5shaped ureter blocked wire
(-)
If a guide wire could be passed into the bladder, either the straight, 8 French aortogram catheter or steerable catheter was used to dilate the stricture and an 8 French aortogram catheter with extra side holes in its midportion was advanced into place over the guide
at ureteropelvic
tion; left as percutaneous nephrostomy Stented on right; guide wire only on left; cystoscopist could not
Right (+) and left (guide only) ureterovesical junctions
cancer
1979
Comments
Right and left ureterovesical junctions (+)
Cancer
November
Placement
Cause of ureteral
1
0
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Ureteral
ET AL.
to splint
and
(case 7) was for extrophy infection and
kidney. After a left leak. A 1 ,500 ml
drained, but urine flow cease. A pigtail catheter the fistula,
large
a balloon
was
around the was placed placed
at the
ureteropelvic junction to divert flow, and a nephrostomy tube was placed in the renal pelvis to provide drainage. Splint tube injection 2 weeks later showed partial resolution of the urinoma, perinephric space
but the uninoma had to encase and obstruct
2A). This inflammatory neous ureteral stent The patient did No significant
(fig.
no manipulation the guide wire
or above
it, the
after all tubes were were encountered. if
left
procedure
In our experience, is maintained.
the (fig.
stricture was dilated and a percuta26) was left in place for 2 weeks.
well clinically complications
tempted Whenever
tracked down the midureter
was
perforations
pyonephrosis the ureteral
was channel,
abandoned do well
to await as long
removed. We atpresent. in tumor healing.
as drainage
Discussion Ureteral described
catheterization by Wiess
by the translumbar et al. [2]
in i976
route
as therapy
was
first
for urolith-
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AJR:133,
Fig.
November
1 -Case
ureteral
stent
9, 72-year-old
placed
8 French aortogram of percutaneously
Fig. with
2.-Case
ileal
bladder.
PERCUTANEOUS
1979
with
bilateral
on right
ureterovesical
over guide
catheter wedged in ureteral stricture. placed ureteral stent. Stent subsequently
7. 52-year-old
conduit
man
cystoscopically
created
URETERAL
junction
wire passed
obstruction
through
STENTS
from
previously
Ureteral tumor encasement. replaced cystoscopically
cancer
placed B, Left by pigtail
867
of prostate
percutaneous
with
painless
ureteral
stent passed through indwelling stent.
bone
stent.
stricture
metastases.
Indwelling
A, Left antegrade over
guide
C,
wire.
pigtail
pyelogram Final
via
position
woman
for extrophy
of
A, Contrast medium exits ureter arrow) and tracts up to sump tube
(open and down to ureteral stricture (c/osed arrows). Renal pelvis filled via nephrostomy and distal ureter by ileal loop injection. B, 8 French catheter in place as
percutaneous ureteral stent. Side holes above and below stricture. Former urine leak (arrow).
A iasis. Goldin [3] splinting to treat
successfully four cases
used percutaneous of urinary fistula and
of ureteroileal anastomosis stricture. scribed transluminal dilatation and whose ligature. described catheter
ureters In the
had been obstructed German literature,
percutaneous and
silastic
ureteral splint.
B ureteral one case
Barbaric et al. [4] destent placement in dogs by 3/0 chromic suture Gunther et al. [5] recently
splinting
Bigongiari
using
Smith
[7]
techniques
ureteral
stents
to spare
patients
principle,
this
is not et
reported
placed
from stent
a steerable
et al. [6] and
al.
the
of
to indwelling necessity
is the same
ureteral
converting
percutaneously
ureteral
stents
of an external stent
technique
below via cystoscopy. However, percutaneous placement can sometimes be applied when feasible
the orifice).
(e.g.,
ileal
conduit
or bladder
in order
appliance.
tumor
as applied ureteral the latter blocking
In
868
BIGONGIARI
The
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ment
basic
strategy
is to apply
of percutaneous
enough
forward
ureteral
force
wire to pass it through the stenotic is little resistance to advancing the narrowed tip cannot ureter
ureteral advance,
and
against which
most
foward. or coil
of
be
force
steerable Tortuous by using
applied
will
conduit
for them
catheter). dilated
proximal
a J-tipped
guide
force and/or
place-
If the in the
dissipated
(e.g. , stiffer ureters wire,
but
can be overcome a more rigid or catheter,
can if the
inside the peniureteric sheath, or grossly enlarged prostate, the guide wire and/or first
curve
so that
the
second
dilator,
so that the wire folded This loop then easily and carried the stiff
be passed
ureter
is fibrosed
deformed by an catheter may bind
cannot
when stent safe effective
management inflammatory
of
ureteral stricture
negotiated
the
placement
can
obstruction
first mafirst
tortuous
or ureteral
can
fistula.
percutaneous placement
sometimes
granulated until after
1.
be
used
tract has formed. therapy has been
In cancer applied
negotiation
of tortuous
S-shaped
ureter.
usually pigtail
attempt stent.
patients, we also to the obstructing
NJ, Johnson
and
review
of
ML: Percutaneous
the
literature.
AJR
nephros130:75-85,
1978
EQ. Leyva
forced
injection
translumbar Goldin 168,
4.
ZL, Gothlin
61
:419-422,
ureteral
of lithiasis
by the
catheterization
by
the
1976
splinting.
10:165-
Urology
JH, Davies
AS: Transluminal ureters
nephropyelostomy.
in dogs !nvest
dilation through
Radio!
the
and use
1 2 : 534-
1977
GUnther
A,
Alken
Altwein
conversion
an indwelling A,
P.
uretersplintung. LA, Lee KR,
Transureteral Smith
ureteral
in obstructed
percutaneous
transrenale 6. Bigongiani
7.
Surg
Int
A: Treatment
and
Percutaneous
placement
536, 5.
liquid
route.
AR:
Barbaric of
A, Hernandez of
1977
stent
to
stent If per-
DP, Ginsberg a series
2. Wiess
In supravesi-
ureteral has failed.
Stables tomy:
be
cutaneous ureteral stent placement cannot be accomplished, or if infection is present, we leave a percutaneous nephrostomy tube in place and try again in 2 weeks after a well wait
in successful
REFERENCES
seg-
via cystoscope has allows nonoperative and
3.-Steps
tumor. If successful in these patients, we will cystoscopic conversion to ureteral indwelling
3.
placement procedure
cal obstruction, we attempt placement if retrograde stent
Fig.
be maneuvered.
to present a loop to the second passed the second curve in the part of the wire into the distal
ureter (fig. 3). A catheter then ment over the guide wire. Percutaneous ureteral stent accomplished failed. This
or
usually
We were able to solve this problem in case 9 by maximally dilating the S-shaped segment with contrast terial, then engaging a J-tip with movable core in the
treat
1979
the ureteral wall. The wire and/or catheter through it is placed may coil in the renal pelvis or subcutane-
directable
curve curve. ureter
November
lumen. If there guide wire at the
segment, the tip will move the guide wire will bend the
AJR:133,
at the tip of the guide
ureteral straight
ously. Such loss of forward directed by using larger stiffer guide wires
in the
stent
ET AL.
stent. Lange
Gibbons ureteral neous nephrostomy.
P.
JE: Ureterobstruktion: perkutane Urol 9 : 1 95-1 99, 1978 Mebust WK, Foret J, Weigel JW: Aktuel
of
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AP,
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Reinke
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percuta-
to
of