0022-534 7/92/14 73-0578$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 147, 578-581, March 1992
Printed in U.S.A.
FLUOROSCOPICALLY GUIDED PERCUTANEOUS TRANSRENAL ELECTROINCISION OF URETEROINTESTINAL ANASTOMOTIC STRICTURES F. CORNUD,* M. MENDELSBERG, Y. CHRETIEN, 0. HELENON, D. BONNEL, B. DUFOUR J. F. MOREAU
From the Departments of Urology and Radiology, Necker Hospital, Paris, France
A new technique for electroincision of a strictured ureterointestinal anastomosis is described that uses a sphincterotome and high frequency current. After placement of a percutaneous nephrostomy tube a 7F "wire guided" sphincterotome was placed into the stenosis. The cutting wire was then deflected while cutting current was applied intermittently. Injection of contrast medium through the papillotome probe assessed the depth of the incision. A 10 mm. angioplasty balloon was inflated at low pressure to verify that the anastomosis had been incised to a depth of 1 cm. The anastomosis was then stented for 8 weeks with an I8F stent. The operative time did not exceed 45 minutes. A total of 9 stenoses was treated in 7 patients: 4 were ileal conduit diversions and 5 were enterocystoplasties. No immediate complication was observed. In 1 case a small urinoma was surgically drained at removal of the stent. Six stenoses are patent with 2, 3, 4, 4, 10 and 13 months of followup after removal of the stent. One patient died of bladder tumor metastases during the stenting period and 1 with bilateral incision still has a stent. The technique can be performed without major complication (bleeding or digestive fistula). Long-term results remain to be assessed. KEY WORDS:
urinary diversion, ureteral obstruction, electrosurgery
Standard treatment for stricture of a ureterointestinal anastomosis is an open operation and reanastomosis, which is considered a difficult procedure. The incidence of such stenoses ranges from 5 to 10% of the cases. 1 With recent advances in endourological techniques, access to the ureter can be achieved routinely through a nephrostomy tract. Initially, endourological techniques were confined to high pressure angioplasty balloon dilation of the strictured area but the reported success rates were only 13 to 37%.2- 5 More recently, Kramolowsky et al developed a technique that combines electroincision under endoscopic control and dilation with an angioplasty balloon. 6 In 7 strictured ureterointestinal anastomoses the long-term success rate of this technique was 71 %. We report our experience with percutaneous transrenal incision of ureterointestinal anastomotic strictures under fluoroscopic control. Incision is performed with a papillotome (fig. 1), which is used routinely for endoscopic retrograde sphincterotomy of the duodenal papilla. We present our preliminary results in 9 stenoses treated in 7 patients.
The procedure was performed with the patient under intravenous assisted local anesthesia. The patient was placed in an oblique supine position that exposed the lumbar fossa for the percutaneous nephrostomy and maintained access to the cutaneous stoma, when present. A percutaneous nephrostomy tube was placed under combined sonographic-fluoroscopic control
PATIENTS AND METHODS
From October 1988 to November 1990, 9 ureteroenteric stenoses were treated in 7 patients 49 to 63 years old (average age 56 years). The indication for urinary diversion, type of diversion, interval from diversion to stenosis, and signs and symptoms of the stenosis are listed in the table. Patient 6 was initially treated by radical prostatectomy for prostatic carcinoma and bilateral hydronephrosis developed during the immediate postoperative course. Bilateral cutaneous ureterostomy was done, followed a few weeks later by cystoplasty with an ileal segment and bilateral ureteroileal anastomosis. In all patients the antegrade pyelogram done before incision showed a short (less than 3 cm.) and tight stenosis. No patient had complete occlusion of the ureter. A percutaneous nephrostomy tube was placed to assess renal function before the incision was considered. Accepted for publication August 2, 1991. * Requests for reprints: Departments of Urology and Radiology, Necker Hospital, 149, rue de Sevres, 75015 Paris, France.
Fm. 1. Papillotome. A, sphincterotome is wire guided to facilitate insertion through stenosis. B and C, as handle is deflected and cutting current is applied, cutting wire incises stenosis. Distal tip of sphincterotome is available in several lengths.
TRANSRENAL ELECTROINCISWN OF URETEROINTESTINAL ANASTOMOTIC STRICTURES
Electroincision of strictured ureterointestinal anastomoses-methods and results Underlying Disease
N eurogenic bladder
Lt. ilea! conduit
Bladder Ca Bladder Ca
Bladder Ca Bladder Ca Prostatic Ca Bladder Ca
Yes Yes No Yes
Rt. ilea! conduit Bilat. enterocystoplasty Rt. ilea! conduit Rt. ilea! conduit Lt. enterocystoplasty Bilat. enterocystoplasty
Type of Ureterointestinal Anastomosis
Interval From Operation to Incision
Long-Term Result Patent 10 mos.
2 yrs. 2 yrs.
Urinoma (open drainage) None None
3 mos. 3 mos. 2 mos. 3 mos.
None None None None
Died of metastases Patent 3 mos. Patent 2 mos. Stented
Patent 13 mos. Patent 4 mos.
FIG. 2. Incision of ureterointestinal anastomosis using papillotome. A, antegrade pyelogram through stenosis shows contrast medium in ilea! conduit. B sphincterotome has been placed below stenosis. Handle has been deflected and cutting wire is in contact with ureteroileal anastomosis. C, immedi~te postoperative IVP shows 1 cm. wide anastomosis. No leak is observed around incision.
and an angiographic preshaped catheter was placed down into the ureter close to the lateral aspect of the stenosis. An Amplatz straight extra stiff guide wire was used to bypass the stenosis (fig. 2, A). The guide wire and catheter were then passed through the ilea! conduit until both emerged from the stoma. In case of a neobladder the guide wire was passed and coiled into the neobladder and the catheter was then removed. The wire guided 7F sphincterotome (Wilson Cook) was placed from below the stenosis in the ileal segment or neobladder. The handle of the sphincterotome was then deflected to half course and the sphincterotome was then withdrawn until a resistance was felt, indicating that the cutting wire was in contact with the stenosis (fig. 2, B). Under permanent fluoroscopic control, cutting current was then applied for a few seconds as the sphincterotome was withdrawn above the level of the stenosis. The stenosis was incised laterally in all cases. In case of an ilea! loop diversion the external side was incised relative to the position of the guide wire. In case of enterocytosplasty the cutting wire incised the internal aspect of the stenosis relative to the position of the guide wire, which was coiled into the bladder. After the incision contrast medium was injected to determine the patency of the anastomosis, which was 7 to 10 mm. wide (fig. 2, C). The depth of the incision was assessed by the degree of deflection of the sphincterotome before the incision. The sphincterotome was then removed and a 10 mm. angioplasty balloon was inflated at low pressure to ensure the absence of residual stenosis. If a persistent waist was observed on the balloon incision was repeated with a more marked deflection of the handle of the sphincterotome to increase the depth of the incision. The 10 mm. angioplasty balloon was then rein flated to ensure that the stenosis was completely incised without need for additional dilation. At the end of the procedure an 18F Neoplex* stent (fig. 3) was placed either from below the area (in case ofileal loop conduit) or from above it after dilation of the percutaneous tract up to 22F. The ileal loop end of the stent had no side holes to prevent early obstruction by mucus. 7 An antegrade excretory urogram (IVP) 2 days later showed patency of the stent and absence of extravasation at the site of * Porges SA, Palaiseau, France.
the incision. The nephrostomy tube was then removed and the anastomosis remained stented for 8 weeks. Total operative time was less than 45 minutes in all patients and postoperative hospital stay did not exceed 4 days. Followup protocol in 6 patients included an IVP 1, 3, 6 and 12 months after removal of the stent. One patient was followed by repeated ultrasonograms and loopograms (fig. 4). RESULTS
Incision was successful in all cases without immediate postoperative complication. We observed no extravasation of contrast medium around the incision on the immediate postoperative IVP. Only l late complication occurred in patient 1 when the stent was removed 8 weeks after the incision. This patient had a peritoneal syndrome that led to laparotomy for drainage of a small urinoma. The complication did not affect the good long-term result observed in this patient. Of the 9 stenoses 6 were patent on an IVP (5) or loopogram (1) with 2, 3, 4, 4, 10 and 13 months of followup after removal of the stent. One patient died of metastases of the bladder tumor during the stenting period and 1 patient with bilateral incision still has a stent. COMMENTS
Treatment of strictured ureteroenteric anastomoses by electroincision was reported initially by Kramolowsky et al, who used a combination of incision and dilation in 7 stenoses. 6 They used a 5F electrode introduced through the operating channel of a flexible nephroscope. The method of incision was either antegrade (4 patients) or retrograde (3). The incised stenoses were stented in all patients and 4 of them had an 18F silicone stent for 6 weeks. The procedure time averaged 151 minutes and the average postoperative hospital stay was 3.7 days. Followup showed patent anastomoses in 5 of the 7 patients, with 4 of them followed for more than 12 months. No postoperative complications were noted. The use of a sphincterotome under fluoroscopic control to incise benign inflammatory strictures was reported initially by Guenther et al. 8 The technique was applied in 5 cases of a stenotic hepaticojejunostomy. Access to the stenosis was
CORNUD AND ASSOCIATES
FIG. 4. Loopogram 10 months after removal of stent. Inferior ureter (arrow), opacified by reflux, has normal caliber.
FIG. 3. Stenting of incised stenosis with 18F silicone catheter. Intestinal portion of stent has no side holes.
through a percutaneous transhepatic approach and the incision was performed under fluoroscopic control. The technique was similar to ours and the incision could be achieved in all patients. without complication. To avoid injury to the portal vein and hepatic artery, the cutting wire was directed to the right side of the hilus of the liver. Long-term followup was not available in this study. The authors recommended incision for failed balloon dilation. Another study reported 2 cases of transhepatic antegrade sphincterotomy of the duodenal papilla under fluoroscopic control performed without complication after an endoscopic retrograde attempt had failed. 9 To our knowledge incision of a ureterointestinal anastomosis with a sphincterotome has been reported only once, in an isolated case of a strictured ureteroileal anastomosis incised under retrograde endoscopic control. 10 No complication was observed. The long-term result was not available in this case. Our study represents the first use of a sphincterotome to incise a strictured ureterointestinal anastomosis through a percutaneous approach and under fluoroscopic control. Our results show the feasibility of the method without immediate complication. We did not use endoscopy to make the incision but endoscopic control might be preferred to control the depth of the incision and to avoid the risk of ureteral or enteric perforation. The sphincterotome, if available in a SF diameter, could be inserted through the operating channel of the flexible nephroscope. Nevertheless, although I late complication occurred in our series we did not observe any extravasation of contrast medium on the immediate postoperative antegrade IVP. Incision is made into fibrotic tissue surrounding the strictured anastomosis, thus minimizing the risk of injury to vital structures, such as blood vessels or intestines adjacent to the stenosis. To assess the depth of the incision a 10 mm. balloon was inflated at low pressure to ensure the absence of residual
stenosis. Finally, our technique seems to be simpler than flexible endoscopic surgery, which is a difficult technique. The average procedure time, which does not exceed 45 minutes under fluoroscopic control, compares favorably with the average duration of the endoscopic method. We recommend that postoperative stenting be maintained for several weeks with a large caliber stent (18F). Such a large caliber was also used in the study of Kramolowsky et al and their results showed 2 recurrences in 2 patients who had a 7F catheter. 6 The followup in their study was 6 to 27 months, with an average of 16 months. The longest followup in our study is 13 months and 4 patients have been followed for less than 6 months. CONCLUSION
The most current effective treatment for stricture of a ureteroenteric anastomosis remains open revision of the anastomosis.6 Our new method had a low morbidity rate in our series, is based on the same principles as endoscopic surgery and seems to be a minimal time-consuming procedure. If long-term results prove to be similar, incision under fluoroscopic control may have a role in the management of ureteroenteric anastomoses. Placement of a large caliber stent at the end of the procedure is required, since it seems to represent an important criterion of success of the method. Only a longer followup and additional cases will help to determine long-term efficacy and potential applications to other ureteral stenoses. REFERENCES
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TRANSRENAL ELECTROINCISION OF URETEROINTESTINAL ANASTOMOTIC STRICTURES
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