Urol Radiol 13:177-180 (1992)
Urologic Radiology © Springer-VedagNewYorkInc. 1992
Percutaneous Transrenal Ureteral Occlusion: Indication and Technique W. Hiibner, M. Knoll, and P. Porpaczy Department of Urology, Policlinic Hospital and Ludwig Boltzmann-Institute for the Research of Infections and Tumors of the Urinary Tract, Vienna, Austria
Abstract. Several techniques for achieving palliative ureteral occlusion in cases of underlying malignant diseases are known to exist. We performed nine ureteral occlusions on seven patients, using two different techniques (occlusion by detachable balloon and by "Harzmann 0live"). Initially, complete occlusion of all ureters was attained; in two cases a second occluding intervention had to be carried out after a period of 6 and 14 weeks. Six of seven patients enjoyed a marked improvement of their quality of life after occlusion. Complications were down to a minimum. In comparison with other techniques described in the literature, Harzmann's method seems to be the simplest, as well as the most fully developed one. It may also be recommended for patients in an advanced tumor stage. Key words: Ureteral occlusion -- Percutaneous nephrostomy -- Supravesical urine diversion.
there are a number of intrinsically different methods described in the literature. This paper will deal with these different procedures and describe our experience with two of the methods.
Materials and Methods During the period from February, 1985 to March, 1989 we performed nine palliative percutaneous ureteral occlusions on seven patients. Mean patient age was 62 years (range 45-73). Underlying diseases and indications for occlusion are illustrated in Table 1. The following methods were applied: 1. Occlusion with a detachable balloon filled with a contrast medium (balloon manufactured by Ingenor, Fig. 1) through a 14-Fr nephrostomy tract under x-ray control was performed four times. 2. Percutaneous ureteral occlusion by a device developed by Harzmann (manufactured by Angiomed Co., Fig. 2) was performed five times. We have coined the term "Harzmann Olive" for the above and will refer to this name henceforth.
Technique The problem of palliative supravesical urine diversion in cases of malignant underlying disease usually presents itself if there is a fistula in the lower urinary tract or extensive tumor invasion in the bladder. As far as therapeutic ureteral occlusion is concerned,
Address offprint requests to: Dr. W. Hiibner, Department of Urology, Policlinic Hospital, Mariannengasse 10, A-1090 Vienna, Austria
The "Harzmann Olive" is a surface-treated silicone cone with a silver wire labeled for radiological visualization. A nephrostomy tract of at least 18-Fr has to be established. The "Harzmann Olive" can then be easily inserted into the ureter over a flexible guidewire. The cone is released with the help of a pusher (Fig. 2A). The procedure is performed under x-ray control and takes about 20-30 rain [2, 3]. All interventions were performed under local anesthesia and parenteral sedation. The length of hospital stay was mainly determined by the conservative treatment of the underlying disease and was not influenced by the ureteral occlusion. The average period of postoperative observation was 12.3 months (2 weeks to 48 months).
W. Hiibner et al.: Percutaneous Transrenal Ureteral Occlusion
Table 1. Indications for percutaneous transrenal ureteral occlusions
O.J. S.M. F.I. E.H. S.M. Z.J.
Carcinoma of the bladder Rectal carcinoma, irr. Cervical carcinoma, irr. Cervical carcinoma, irr. Cervical carcinoma, irr. Cervical carcinoma, irr. Carcinoma of the prostate
Dysuria, hematuria reduced capacity Rectovesical vaginal fistula, incontinence Rectovesical vaginal fistula, incontinence Rectovesical vaginal fistula, incontinence Rectovesical vaginal fistula, incontinence Rectovesical vaginal fistula, incontinence Dysuria, reduced bladder capacity
Fig. 2. A Set for ureteral occlusion (Angiomed Co.). B "Harzmann Olive" in situ, nephrostomy. tralateral kidneys, three were completely and one partly nonfunctional.
Results Fig. 1. A Detachable balloon for occlusion (Ingenor Co.). B Detachable balloon in situ, nephrostomy.
Contralateral Kidneys In two cases the bladder was disabled by nephrostomy of the congested contralateral kidney; in one female patient the contralateral kidney had to be embolized. Of the remaining four con-
Complete radiological occlusion of all ureters was achieved immediately with the above techniques. All patients remained dry until death or last followup (Fig. 3). Six patients died from their underlying disease (average survival time, 6.3 months), with the remaining patient still alive 48 months after percutaneous occlusion of the ureter. This patient has experienced no leakage from the vesicovaginal
W. Hiibner et al.: Percutaneous Transrenal Ureteral Occlusion
Fig. 3. A Nephrostomogram of an occluded ureter ("Harzmann Olive"). B Nephrostomogram of an occluded ureter (detachable balloon).
fistula site. There was one case with advanced carcinoma of the prostate gland and distressing dysuria plus incontinence; it was possible to completely disable the bladder; however, the fact that the patient unexpectedly died 3 weeks after the intervention, the indication must be considered problematic. In six of the seven cases intervention resulted in an enormous improvement of the patient's quality of life. Complications
In two cases a second occlusion had to be performed 6 and 14 weeks after the first intervention. In the first case the balloon ruptured 16 weeks after having been released into the ureter. Successful management was achieved by the use of a "Harzmann Olive." In another female patient the Olive ascended into the renal pelvis, necessitating replacement 6 weeks after the initial intervention. The balloon ruptured twice during the intervention, and replacement was performed during the same session. Discussion
Back in 1979 G/inther et al. described transrenal ureter embolization with butyl-2-cyanocrylate and
adjuvant balloon catheter occlusion for the palliative treatment of inoperable vesicovaginal and vesicosacral fistulas performed on three patients . Initially, the results were good but after lengthy exposure to urine, the substance changed its surface properties, which resulted in a rechanneling of the ureter or an expulsion of the embolizing agent, making long-term results unsatisfactory . G/inther et al. also described transrenal ureter occlusion with a detachable balloon (filled with a low-viscosity silicone). This method constituted a considerable advancement and was successfully used in seven patients . These detachable balloons were prototypes. In 1985 K_inn et al. described a technique designed to release nylon plugs into the ureter. Although the plugs, which swelled on contact with urine, were kept in situ both proximally and distally by a sclerosing agent (polidocanol), they migrated in more than 50% of the 15 cases. In addition, this method presented some technical difficulties when applied . Reddy et al. in 1987 described ureteral fulguration, using a flexible nephroscope. In two patients it was possible to keep vesicoperineal and vesicovaginal fistulas dry for a period of six and 12 weeks, that is, until patients died. In a third case it was not
180 possible to achieve c o m p l e t e a n a t o m i c a l occlusion o f the ureteral lumen, with the patient still d a m p ening one or two sponges during a 24-h period at the fistula site . In 1987 Schmeller et al. introduced endoscopic percutaneous ureteral ligature. A n e p h r o s c o p e is brought into contact with the ureter which is subsequently exposed under CO2 insufflation, using lit h o t o m y forceps, at the level o f the lower kidney pole. With a special h o o k a ligature is tied a r o u n d the ureter a n d tightly knotted. This m e t h o d was used in three cases: tearing the ureter in two a n d m a k i n g the k n o t in one. C o m p a r e d with other techniques, this one seems rather c o m p l i c a t e d a n d also requires a special i n s t r u m e n t a t i o n . H a r z m a n n no d o u b t d e v e l o p e d the simplest a n d m o s t effective m e t h o d for ureteral occlusion [2, 3, 9, 10]. A cone m a d e o f silicone is reinforced by a silver wire that is available in different sizes. U n d e r x-ray control the cone is inserted into the ureter with the aid o f a guidewire. T r a u m a o f the ureter is m i n i m a l and, in principle, the procedure is reversible. H a r z m a n n reports a rising o f the occluding cone in two o f 16 cases but as far as o u r o w n experience is concerned, replacing the cone does not present a n y problems. In our d e p a r t m e n t we have tried detachable balloons filled with a 60% contrast m e d i u m . This technique has an edge o v e r the H a r z m a n n m e t h o d , since the balloon does not unfold until it reaches the ureter, implying that only a 12- to 14-Fr n e p h r o s t o m y tract has to be established . H o w e v e r , we were c o n f r o n t e d in two cases with a balloon rupture during the initial intervention, requiring the use o f another balloon. In one case, we o b s e r v e d a rupture after 4 m o n t h s . D i s a d v a n t a g e s o f this technique are the high rate o f rupture, as well as the high price o f the balloon. T o date we h a v e p e r f o r m e d five ureteral occlusions with the H a r z m a n n silicone cone . Application is simple and the results are good. Additionally, this m e t h o d is endoscopically reversible without d a m a g e to the ureter. In principle the question o f a palliative urine diversion in t u m o r patients has to be decided a m o n g the physician, patient, a n d family; therefore, it is i n o p p o r t u n e to set up general guidelines. H o w e v e r , particularly in changes o f the ureter due tO longstanding gynecological malignancies, prognosis seems to be favorable [11 ]. Percutaneous transrenal ureteral occlusion seems to greatly i m p r o v e the distressing s y m p t o m s caused by fistulas or contracted
W. Hiibner et al.: Percutaneous Transrenal Ureteral Occlusion bladders. T h e rate o f success o f reconstructive urological surgery in such cases does not exceed 50% due to t u m o r recurrence, radiation injuries, etc. , the palliative supravesical urine diversion by ile u m conduit, u r e t e r o p y e l o s t o m y , or uretercutan e o s t o m y has an intraoperative mortality o f 1-3% and a c o m p l i c a t i o n rate o f 7 - 1 4 % [12-14]. Ureteral occlusion according to H a r z m a n n constitutes a fully developed, standardized, a n d basically reversible procedure which m a y be r e c o m m e n d e d for percutaneous ureteral occlusion; its application is simple a n d invasiveness m i n i m a l . Thus, percutaneous ureteral occlusion is also indicated for patients in an a d v a n c e d t u m o r stage.
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