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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

AJR

1 31

Miller

AP,

a percutaneous : 1 098-1

Reinke

ureteral

stent

099, 1978 DB: The introduction

stents facilitated by J Uro! 120:543-544,

antecedant 1979

percuta-

to

of

Percutaneous ureteral stent placement for stricture management and internal urinary drainage.

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