INTERNAL VERNON ROBERT
URETERAL
M. PAIS,
SPLINTS
M.D.
M. SPELLMAN,
M.D.
RICHARD
E. STILES,
M.D.
STEPHEN
A. MAHONEY,
M.D.
From the Departments of Urology, St. Elizabeth’s Hospita1 and New England Medical Center Hospital, and Tufts University School of Medicine, Boston, Massachusetts
ABSTRACT - lndwelling silicone rubber ureteral splints introduced endoscopically provide a useful method in the management of patients with ureteral obstruction or injuries. These splints have been used in 19 patients with ureteral obstruction and in 1 patient with ureteraljstula. Results of ureteral in 17 patients, with minima1 number of complications. The splints splinting have been encouraging have remained indwelling for more than one year in 9 patients and more than two years in 2 patients. This relatively conservative therapeutic measure is simple and effective.
Indwelling silicone rubber ureteral splints introduced endoscopically provide a useful method in the management of patients with ureteral obstruction or injuries. These splints provide prompt decompression of obstructed ureters and adequate intemal urinary diversion in ureteral injuries with extravasation of urine. The method we describe is not a new one. Zimskind, Felter, and Wilkerson’ reported the use of silicone rubber ureteral splints in patients with ureteral obstruction in 1967, and Marmar’ modified the technique to simplify the method of placement of the splints. Orikasa et al. 3 have recently reported on a technique for insertion of splints endoscopically . The method we employ was described by Marmar in 19702; we advocate its use because of its simplicity and long-standing benefits.
mature for twenty-four hours and then autoclaved before use. Three or four holes are cut near the sealed end, the first hole being at least 1 cm. from the plugged end. A no. 5 whistle-tipped
Technique Silastic” tubing comes in several sizes; the two sizes that we commonly use have an inner diameter of 0.062 inch (9 F) and 0.059 inch (7 F), respectively. One end of a 30 cm. length tubing is cut on a bias and sealed with a plug of silicone adhesive (Fig. 1A). The splint is allowed to
*Dow
32
Coming
Corporation,
Midland,
Michigan.
FIGURE 1. (A) One end of silicone tubing is cut on u bias and sealed with plug of silicone adhesive. (B) Splint with ureteral catheter and stylet is fed through catheterizing elecenter nipple of a Brown-Buerger ment. (C) DefEector hotds splint in place while ureteral catheter is being withdrawn.
UROLOGY
i
JANUARY 1975 / VOLUME V, NUMBER 1
ureteral catheter wil1 fit inside the larger splint and a no. 4 ureteral catheter inside the smaller splint. A well-lubricated ureteral catheter with a stylet is introduced inside the splint; this is fed through the center nipple of the Brown-Buerger catheterizing element (Fig. 1B). After the entire splint, except for the last centimeter, has been introduced up the ureter, the splint is held firmly in place by the deflector, and the ureteral catheter with the stylet is removed (Fig. 1C). Final adjustments of the splint can be achieved by using a foreign body grasping forceps or an acorntipped ureteral catheter. Results The silicone rubber splints have been used in 19 patients with ureteral obstruction and in 1 patient with ureteral injury. Causes of obstruction were as follows: carcinoma of cervix (1 case), carcinoma of prostate (l), carcinoma of rectum (l), retroperitoneal lymphoma (2), retroperitoneal fibrosis (2), urolithiasis with stricture (3), ureteropelvic obstruction (3), postsurgical obstruction (4), and undetermined (2). Metastatic malignant tumors accounted for obstruction in 5 patients. The majority of splints were placed endoscopically. However, in 6 patients the splints were placed during abdominal exploration by performing a smal1 ureterotomy. Of the 20 patients 7 had excellent results, 10 good, and 3 poor. Results were considered excellent when the renal function returned to normal and there were no significant complications; good when renal function improved considerably with or without complications; and poor when there was no improvement in renal function. Complications included: hematuria in 2 patients, spontaneous passage in 4, upward migration in 3, and calcification in 1 patient. In 1 patient with hematuria, the splints were too long and the hematuria subsided after splints of correct length were substituted. Spontaneous passage occurred when splints of smal1 caliber were used and in those patients who had a nonmalignant cause for obstruction. Upward migration of splints was seen in only those cases in which the splints were placed transabdominally through a ureterotomy. The splints were retrieved with a Dormia basket in 2 patients. In 1 patient basket extraction was unsuccessful, and the splint has remained indwelling for thirty-two months without any evidente of obstruction, infection, or calcification. There has been no
UROLOGY
/ JANUARY1975
/ VOLUMEV,NUMBERl
FIGURE
2.
Roentgenogram
showing splints which
have calci$ed. evidente of calcification in the splints that were removed or passed spontaneously except in 1 patient with lymphoma on long-term therapy with cyclophosphamide (Cytoxan), chlorambucil (Leukeran), and prednisone who was noted to have Proteus urinary tract infection. Figure 2 shows calcification of both ureteral splints which have since been removed. The splints have remained indwelling for more than six months in 11 patients, more than one year in 9, and more than two years in 2 patients. At present, a total of five splints remain indwelling in 4 patients, four of these splints having remained in for more than one year. Case Reports Case 1 A seventy-six-year-old woman underwent abdominal exploration and had resection of recurrent and metastatic carcinoma of the vagina. Two weeks postoperatively urinary leakage was suspected at the drain site, and extravasation of urine was noted on an intravenous pyelogram
33
FICURE 3. Cuse 1. (A) Excretory urogram revealing extr« vasution of urine. (B) Retrograde ureterograrn localixing leak to right uretcr. (C) Excretory urogram sir months after insertion of splint showing kidneys without extraausation. (0) E.scretor!y nwmally functioning urogram two years ufter removal of splint showing normul urinaq tract.
Case 2
(Fig. 3A). The site of the leak was localized to the right ureter by a retrograde ureterogram (Fig. 3B). A size 7 Silastic splint was introduced up the right ureter endoscopically. The urinary extravasation subsided promptly, the wound healed well, and the patient was discharged in good condition for outpatient radiotherapy. Six months after insertion of the splint excretory urography revealed the right kidney to be functioning wel1 (Fig. 3C). The splint was removed electively one year following the injury, and two years later an excretory urogram showed a normal collecting system (Fig. 3D).
34
This patient had a known carcinoma of the prostate. Serum creatinine was 12 mg. per 100 ml. An excretory urogram revealed poor function bilaterally (Fig. 4A). Bilateral retrograde urography revealed hydronephrosis (Fig. 4B). Only the left ureter could be catheterized, there being an impassable stricture in the right ureter at the pelvic brim. With subsequent brisk diuresis and a course of diethylstilbestrol (Stilphostrol) therapy, the serum creatinine stabilized at 3.5 mg. per 100 ml., and the excretory urogram was repeated (Fig. 4C). Intubation of both ureters was done through a midline lower abdominal incision. The right ureter was occluded by metastatic tumor invasion. Following intubation, the serum creatinine fel1 to 1.8 mg. per 100 ml., and excretory urogram showed considerable improvement (Fig. 4D). The splints were too long and had to be removed two months later because of hematuria. There was deterioration in renal function, and the splints were reinserted endoscopically with ease. Hematuria subsided, serum creatinine remained stable at 1.5 mg. per 100 ml., but the patient died of metastatic disease nine months after insertion of the silicone splints.
CKOLOGC
/
JANUARY 1975 i VOLL’MEV,
NUMBEW i
FIGURE4. Case 2. (A) Excretory urogram showing poor function bilaterally; serum creatinine 12 mg. per 100 ml. (B) Bilateral retrograde urograph y revealing h ydroureteronephrosis. (C and D) Excretory urogram following drainage with lefì ureteral catheter, (C) diethylstilbestrol therapy and insertion of bilateral Silastic ureteral splints (DJ.
Comment The results of ureteral splinting in our 20 patients are most encouraging and demonstrate the feasibility of long-term internal drainage with minima1 number of complications. Silicone rubber is wel1 tolerated by the urinary tract, and no significant encrustation of the tube was noted in those splints which were removed or extruded spontaneously, except in 1 patient with lymphoma.
UROLOGY
/ JANUARY 1975 / VOLUME V, NUMBER 1
Free reflux is usually present, and many patients have microscopic hematuria and pyuria. Most patients were maintained on prophylactic chemotherapy. In situations of metastatic disease, if the obstruction is above the leve1 of the intramural ureter, the splint can be pushed inside the intramural ureter with an acorn-tipped ureteral catheter. This was performed in 1 patient on one side, and no reflux was demonstrated on that side (Fig. 5).
35
In cases of ureteral obstruction from intraabdominal malignant conditions, this relatively conservative therapeutic measure provides adequate relief of obstruction and obviates the need for unnecessary and comphcated methods of urinary diversion and use of extemal collecting devices. An indwelling splint has been used successfully in treating a patient with ureteral fistula, and its use in the management of ureterovagina1 fistulas is worthy of consideration. Internal urinary diversion is a simple and effective method for managing difficult situations and is a useful tool for urologists. 697 Cambridge Street Boston, Massachusetts 02135 (DR. PAIS)
References
FIGURE 5. Cystogram shows no rejlur on lejî side; splint had been pushed inside intramural ureter with acwn-tipped ureteral catheter.
36
ZIMSKIND, P. D., FELTER, T. R., and WILKERSON, J. I,.: Clinical use of long term indwelling silicone rubber ureteral splints inserted cystoscopically, J. Urol. 97: 840 (1967). MARMAR, J. L.: The management of ureteral obstruction with silicone rubber splint catheters, ibid. 104: 386 (1970). ORIKASA, S., TSJJI, 1.. SIBA, T., and PHASHI, A.. A new technique for transurethral insertion of a silicone rubber tube into an obstructed ureter, ibid. 110: 184 (1973).
UROLOCY / JrlhUARY 1973 / VOLUMEV, NUMBER 1
URETERAL
M. PAIS,
SPLINTS
M.D.
M. SPELLMAN,
M.D.
RICHARD
E. STILES,
M.D.
STEPHEN
A. MAHONEY,
M.D.
From the Departments of Urology, St. Elizabeth’s Hospita1 and New England Medical Center Hospital, and Tufts University School of Medicine, Boston, Massachusetts
ABSTRACT - lndwelling silicone rubber ureteral splints introduced endoscopically provide a useful method in the management of patients with ureteral obstruction or injuries. These splints have been used in 19 patients with ureteral obstruction and in 1 patient with ureteraljstula. Results of ureteral in 17 patients, with minima1 number of complications. The splints splinting have been encouraging have remained indwelling for more than one year in 9 patients and more than two years in 2 patients. This relatively conservative therapeutic measure is simple and effective.
Indwelling silicone rubber ureteral splints introduced endoscopically provide a useful method in the management of patients with ureteral obstruction or injuries. These splints provide prompt decompression of obstructed ureters and adequate intemal urinary diversion in ureteral injuries with extravasation of urine. The method we describe is not a new one. Zimskind, Felter, and Wilkerson’ reported the use of silicone rubber ureteral splints in patients with ureteral obstruction in 1967, and Marmar’ modified the technique to simplify the method of placement of the splints. Orikasa et al. 3 have recently reported on a technique for insertion of splints endoscopically . The method we employ was described by Marmar in 19702; we advocate its use because of its simplicity and long-standing benefits.
mature for twenty-four hours and then autoclaved before use. Three or four holes are cut near the sealed end, the first hole being at least 1 cm. from the plugged end. A no. 5 whistle-tipped
Technique Silastic” tubing comes in several sizes; the two sizes that we commonly use have an inner diameter of 0.062 inch (9 F) and 0.059 inch (7 F), respectively. One end of a 30 cm. length tubing is cut on a bias and sealed with a plug of silicone adhesive (Fig. 1A). The splint is allowed to
*Dow
32
Coming
Corporation,
Midland,
Michigan.
FIGURE 1. (A) One end of silicone tubing is cut on u bias and sealed with plug of silicone adhesive. (B) Splint with ureteral catheter and stylet is fed through catheterizing elecenter nipple of a Brown-Buerger ment. (C) DefEector hotds splint in place while ureteral catheter is being withdrawn.
UROLOGY
i
JANUARY 1975 / VOLUME V, NUMBER 1
ureteral catheter wil1 fit inside the larger splint and a no. 4 ureteral catheter inside the smaller splint. A well-lubricated ureteral catheter with a stylet is introduced inside the splint; this is fed through the center nipple of the Brown-Buerger catheterizing element (Fig. 1B). After the entire splint, except for the last centimeter, has been introduced up the ureter, the splint is held firmly in place by the deflector, and the ureteral catheter with the stylet is removed (Fig. 1C). Final adjustments of the splint can be achieved by using a foreign body grasping forceps or an acorntipped ureteral catheter. Results The silicone rubber splints have been used in 19 patients with ureteral obstruction and in 1 patient with ureteral injury. Causes of obstruction were as follows: carcinoma of cervix (1 case), carcinoma of prostate (l), carcinoma of rectum (l), retroperitoneal lymphoma (2), retroperitoneal fibrosis (2), urolithiasis with stricture (3), ureteropelvic obstruction (3), postsurgical obstruction (4), and undetermined (2). Metastatic malignant tumors accounted for obstruction in 5 patients. The majority of splints were placed endoscopically. However, in 6 patients the splints were placed during abdominal exploration by performing a smal1 ureterotomy. Of the 20 patients 7 had excellent results, 10 good, and 3 poor. Results were considered excellent when the renal function returned to normal and there were no significant complications; good when renal function improved considerably with or without complications; and poor when there was no improvement in renal function. Complications included: hematuria in 2 patients, spontaneous passage in 4, upward migration in 3, and calcification in 1 patient. In 1 patient with hematuria, the splints were too long and the hematuria subsided after splints of correct length were substituted. Spontaneous passage occurred when splints of smal1 caliber were used and in those patients who had a nonmalignant cause for obstruction. Upward migration of splints was seen in only those cases in which the splints were placed transabdominally through a ureterotomy. The splints were retrieved with a Dormia basket in 2 patients. In 1 patient basket extraction was unsuccessful, and the splint has remained indwelling for thirty-two months without any evidente of obstruction, infection, or calcification. There has been no
UROLOGY
/ JANUARY1975
/ VOLUMEV,NUMBERl
FIGURE
2.
Roentgenogram
showing splints which
have calci$ed. evidente of calcification in the splints that were removed or passed spontaneously except in 1 patient with lymphoma on long-term therapy with cyclophosphamide (Cytoxan), chlorambucil (Leukeran), and prednisone who was noted to have Proteus urinary tract infection. Figure 2 shows calcification of both ureteral splints which have since been removed. The splints have remained indwelling for more than six months in 11 patients, more than one year in 9, and more than two years in 2 patients. At present, a total of five splints remain indwelling in 4 patients, four of these splints having remained in for more than one year. Case Reports Case 1 A seventy-six-year-old woman underwent abdominal exploration and had resection of recurrent and metastatic carcinoma of the vagina. Two weeks postoperatively urinary leakage was suspected at the drain site, and extravasation of urine was noted on an intravenous pyelogram
33
FICURE 3. Cuse 1. (A) Excretory urogram revealing extr« vasution of urine. (B) Retrograde ureterograrn localixing leak to right uretcr. (C) Excretory urogram sir months after insertion of splint showing kidneys without extraausation. (0) E.scretor!y nwmally functioning urogram two years ufter removal of splint showing normul urinaq tract.
Case 2
(Fig. 3A). The site of the leak was localized to the right ureter by a retrograde ureterogram (Fig. 3B). A size 7 Silastic splint was introduced up the right ureter endoscopically. The urinary extravasation subsided promptly, the wound healed well, and the patient was discharged in good condition for outpatient radiotherapy. Six months after insertion of the splint excretory urography revealed the right kidney to be functioning wel1 (Fig. 3C). The splint was removed electively one year following the injury, and two years later an excretory urogram showed a normal collecting system (Fig. 3D).
34
This patient had a known carcinoma of the prostate. Serum creatinine was 12 mg. per 100 ml. An excretory urogram revealed poor function bilaterally (Fig. 4A). Bilateral retrograde urography revealed hydronephrosis (Fig. 4B). Only the left ureter could be catheterized, there being an impassable stricture in the right ureter at the pelvic brim. With subsequent brisk diuresis and a course of diethylstilbestrol (Stilphostrol) therapy, the serum creatinine stabilized at 3.5 mg. per 100 ml., and the excretory urogram was repeated (Fig. 4C). Intubation of both ureters was done through a midline lower abdominal incision. The right ureter was occluded by metastatic tumor invasion. Following intubation, the serum creatinine fel1 to 1.8 mg. per 100 ml., and excretory urogram showed considerable improvement (Fig. 4D). The splints were too long and had to be removed two months later because of hematuria. There was deterioration in renal function, and the splints were reinserted endoscopically with ease. Hematuria subsided, serum creatinine remained stable at 1.5 mg. per 100 ml., but the patient died of metastatic disease nine months after insertion of the silicone splints.
CKOLOGC
/
JANUARY 1975 i VOLL’MEV,
NUMBEW i
FIGURE4. Case 2. (A) Excretory urogram showing poor function bilaterally; serum creatinine 12 mg. per 100 ml. (B) Bilateral retrograde urograph y revealing h ydroureteronephrosis. (C and D) Excretory urogram following drainage with lefì ureteral catheter, (C) diethylstilbestrol therapy and insertion of bilateral Silastic ureteral splints (DJ.
Comment The results of ureteral splinting in our 20 patients are most encouraging and demonstrate the feasibility of long-term internal drainage with minima1 number of complications. Silicone rubber is wel1 tolerated by the urinary tract, and no significant encrustation of the tube was noted in those splints which were removed or extruded spontaneously, except in 1 patient with lymphoma.
UROLOGY
/ JANUARY 1975 / VOLUME V, NUMBER 1
Free reflux is usually present, and many patients have microscopic hematuria and pyuria. Most patients were maintained on prophylactic chemotherapy. In situations of metastatic disease, if the obstruction is above the leve1 of the intramural ureter, the splint can be pushed inside the intramural ureter with an acorn-tipped ureteral catheter. This was performed in 1 patient on one side, and no reflux was demonstrated on that side (Fig. 5).
35
In cases of ureteral obstruction from intraabdominal malignant conditions, this relatively conservative therapeutic measure provides adequate relief of obstruction and obviates the need for unnecessary and comphcated methods of urinary diversion and use of extemal collecting devices. An indwelling splint has been used successfully in treating a patient with ureteral fistula, and its use in the management of ureterovagina1 fistulas is worthy of consideration. Internal urinary diversion is a simple and effective method for managing difficult situations and is a useful tool for urologists. 697 Cambridge Street Boston, Massachusetts 02135 (DR. PAIS)
References
FIGURE 5. Cystogram shows no rejlur on lejî side; splint had been pushed inside intramural ureter with acwn-tipped ureteral catheter.
36
ZIMSKIND, P. D., FELTER, T. R., and WILKERSON, J. I,.: Clinical use of long term indwelling silicone rubber ureteral splints inserted cystoscopically, J. Urol. 97: 840 (1967). MARMAR, J. L.: The management of ureteral obstruction with silicone rubber splint catheters, ibid. 104: 386 (1970). ORIKASA, S., TSJJI, 1.. SIBA, T., and PHASHI, A.. A new technique for transurethral insertion of a silicone rubber tube into an obstructed ureter, ibid. 110: 184 (1973).
UROLOCY / JrlhUARY 1973 / VOLUMEV, NUMBER 1
