Upper Urinary Tract
The Wallstent: long-term follow-up of metal stent placement for the treatment of benign ureteroileal anastomotic strictures after Bricker urinary diversion Thijs Campschroer*, M.T.W. Tycho Lock*‡, Rob T.H. Lo† and J.L.H. Ruud Bosch* Departments of *Urology and †Radiology, University Medical Center Utrecht, and ‡Department of Urology, Central Military Hospital Dr. A. Mathijsen, Utrecht, The Netherlands T.C and M.T.W.T.L. contributed equally to this manuscript.
Objective To evaluate the long-term follow-up (primary and secondary patency) of metal stent placement in benign ureteroileal anastomotic strictures after Bricker urinary diversion and to compare the failed treatment group with the group of successfully treated patients to search for predisposing factors of stent failure.
Patients and Methods For patients treated since 1989 for benign ureteroileal strictures after Bricker urinary diversion with end-to-side anastomosis, we retrospectively collected data on clinical history, stent placement, auxiliary measures and patency rates from a prospectively kept database.
Results In all, 49 patients (mean age 64 years) underwent 56 metal stent procedures. Placement of the stent was possible in all patients. Stent patency without auxiliary treatment remained
Introduction Stenosis of the ureteroileal anastomosis after Bricker urinary diversion occurs in 4–14% of all cases [1–3]. These stenoses can cause obstructive nephropathy and can eventually lead to end-stage renal disease. These lesions are generally caused by ischaemia, radiotherapy, temporary urine leak directly after surgery, chronic infection or a combination of these. Management of these strictures is challenging. Endourological incision or dilatation often provides temporary patency and recurrences are frequently seen [4,5]. Bierkens et al. [4] performed ureteric incision with success rates of only 53% after 8 months. High-pressure balloon dilatation alone has produced success rates of only 16% after 12 months [5]. Permanent drainage by nephrostomy tube or JJ catheter causes
BJU Int 2014; 114: 910–915 wileyonlinelibrary.com
adequate in 23 cases (primary patency of 41.1%, mean follow-up 37.7 months). A secondary treatment was successfully performed in 11 patients who had stent obstruction, mostly caused by hyperplastic reaction, encrustation, or migration of the stent. The secondary patency rate was 60.7% (mean follow-up 55.8 months), comparable with patency rates of 36–100% described in literature with mostly small patient groups and much shorter follow-up periods.
Conclusion To the best of our knowledge we report the largest series of metal stenting in benign ureteroileal anastomotic strictures with the longest follow-up. We show that placement of a metal stent can lead to a permanent de-obstruction in approximately six out of 10 patients with preservation of renal function.
Keywords benign, metal stent, Bricker, ureteroileal stricture, anastomosis
an increased risk of infection, migration and encrustation, and requires periodic renewal of the drain. In the literature, exact figures on the risk of pyelonephritis in patients with permanent percutaneous nephrostomy are scarce [6–8]. Recently, Bahu et al. [6] reported a 19% risk of pyelonephritis at ≤90 days after placement in a selected group of 200 patients with cancer with a permanent nephrostomy. Open surgical revision is often technically challenging due to previous operations or radiotherapy and carries a significant risk of postoperative morbidity and even mortality [9]. The successful use of metal stents in the vascular and biliary systems has led to the implementation of these stents in the management of urological diseases. In 1988, Milroy et al. [10] implanted the first eight metal stents in patients with a © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12729 Published by John Wiley & Sons Ltd. www.bjui.org
Metal stent placement in benign ureteroileal anastomotic strictures
urethral stricture. Subsequently, these stents have been widely used in other urological diseases: BPH, detrusor sphincter dyssynergia and ureteric strictures, both of malignant or benign origin [11–14].
Fig. 1 Ureteroileal anastomotic stricture on the left side on antegrade pyeloureterography before metal stent placement.
The successful use of a self-expandable metal stent in a ureteroileal anastomotic stricture was first described in our institution by Gort et al. [15] in 1990. Various retrospective studies have been performed to show the value of metal stents in ureteroileal anastomosis of benign origin, in series containing one to 18 patients [16–20]. Since 1989, we have treated patients with ureteroileal anastomotic strictures of benign origin with the placement of a self-expandable metal stent under local anaesthesia. These patients were not eligible for open surgical repair due to advanced age or high American Society of Anesthesiologists (ASA) score. The objectives of the present study were: (i) to evaluate stent patency over time, both as a primary treatment (primary patency) as well as combined with supplementary endourological treatments to open an obstructed stent (secondary patency) and (ii) to compare the failed treatment group with the group of successfully treated patients to search for predisposing factors of stent failure.
Patients and Methods We retrospectively collected data on patient clinical history, procedures of stent placement, auxiliary measures and patency rates during follow-up from a prospectively kept database. In all, 49 patients were treated for ureteroileal anastomotic strictures by placement of a self-expandable metal stent between April 1989 and July 2013. The patient population consisted of 33 men and 16 women; the mean (range) age was 64 (28–84) years. In all, 56 metal stents were placed in these patients and there was left-side predominance in cases where the stricture was not bilateral (34 strictures on the left side vs 22 strictures on the right side). Most of the patients treated in this group showed significant comorbidity and could be classified as ASA score III or IV (32/49 patients, 65%).
Procedure Patients received a single dose of a third-generation cephalosporin, unless urine culture before the intervention showed bacteria resistant to these antibiotics. In such cases, antibiotic choice was guided by urine culture. With the patient under local anaesthesia and in an oblique supine position a 7 F percutaneous nephrostomy tube was placed under ultrasound (US) guidance, if the patient did not already have one prior to the procedure. Under fluoroscopic control, the stricture was passed antegradely by a 0.1 cm (0.035 inch) straight or angled hydrophilic guidewire (inserted through the nephrostomy tube), all the way down to the ileal conduit. The initially floppy guidewire was then exchanged for a rigid 0.1 cm Amplatz guidewire through a 4 F ureteric catheter. Then antegrade dilatation of the stricture was carried out using a high-pressure balloon catheter (4–7 mm diameter) and a self-expanding metal stent (8 mm diameter and 3–10 cm in length) fixed on an insertion instrument was deployed at the site of the stricture, protruding about 0.5–1.0 cm within the conduit. Self-expandable metal stents were used in all patients (1. Wallstent, Schneider, Zurich, Switzerland, 2. Protégé, EV3, California, USA).
After development of a stricture some patients presented with symptoms of flank pain or UTI. Most patients did not have any complaints, but hydronephrosis on diagnostic imaging or deterioration of renal function were indicators for ureteric obstruction. In most patients renal scintigraphy was used to show functional obstruction. If a stricture was suspected, a percutaneous nephrostomy tube was placed and the length of the stricture was defined by antegrade pyeloureterography (Fig. 1).
After the intervention the nephrostomy tube was left in situ for 48 h to several days. Antegrade pyeloureterography was used to show adequate patency of the stent, because in some cases reactive oedema of the urothelium can occur due to stent placement. If patency was adequate on pyeloureterography, the nephrostomy tube was removed. The median (mean, range) hospital stay was 2 (3.7, 1–13) days.
A secondary treatment was performed, if obstruction was suggested by diagnostic imaging or if renal function deteriorated without other explainable renal causes.
Follow-up consisted of a standardised follow-up schedule with retrograde contrast studies at 3 months after stent placement. Retrograde studies were performed by catheterisation of the
Follow-up
© 2014 The Authors BJU International © 2014 BJU International
911
Campschroer et al.
ureteroileal conduit and slowly injecting fluid with diluted contrast to visualise the conduit, ureter(s) and pyelocalyceal system(s). Furthermore, at 3, 6 and 9 months US was performed and at 12-month US was combined with retrograde flexible endoscopy to evaluate the hyperplastic reaction within the lumen of the stent. Blood biochemistry for renal function was carried out at all follow-up appointments. If there was any indication of a possible recurrent ureteroileal anastomotic stricture (e.g. new complaints, or loss of kidney function) diagnostic imaging was performed earlier. Time to last follow-up was defined as the time between the stent placement and last known imaging study. Outcomes Placement of the stent was considered successful if pyeloureterography after the procedure showed adequate patency all the way to the ureteroileal conduit combined with stabilised or improved renal function on diagnostic follow-up. A Kaplan–Meier curve was constructed to show the success of the procedure over time. Primary patency was defined as successful dilatation of the stricture after placement of the stent without any auxiliary interventions. Secondary patency included all concomitant therapies to open the stent, e.g. repeat ballooning, laser vaporisation or even a stent-in-stent placement. All statistical analyses were performed using SPSS Statistics version 20. The Mann-Whitney U-test was used to analyse predisposing factors of stent failure.
Table 1 Baseline characteristics and results of metal stent placement. Variable
Value
Number of patients (number of stents): Male Female Reasons for urinary diversion: TCC Gynaecological malignancy Neurogenic bladder disorders Bladder exstrophy Severe urinary incontinence Interstitial cystitis Side of stricture, n: Left Right Mean (median) follow-up in months Primary patency, % Mean (median) follow-up, months Median time to stent failure, months Secondary patency, % Mean (median) follow-up, months Number of restenosed ureters/stents (number of patients) Type and number of successful secondary treatments (number of patients) Laser vaporisation Balloon dilatation Second stent placement due to migration Endourological stone removal Type and number of failed secondary treatments (number of patients) Laser vaporisation Open surgical revision Balloon dilatation Second stent placement due to breaking of stent
33 (37) 16 (19) 34 6 4 3 2 1 34 22 39.2 (14.0) 41.1 37.7 (18) 34 60.7 55.8 (21) 34 (27)
14 (7) 1 (1) 1 (1) 2 (2)
14 (10) 7 (7) 1 (1) 1 (1)
Fig. 2 Kaplan–Meier curve of time-to-event analysis in entire cohort, both primary and combined primary and secondary patency. Observed
Table 1 summarises the baseline characteristics and treatment results of the patients in this study. In all, 56 metal stents were placed in 49 patients (33 men and 16 women). Four patients were treated for bilateral strictures. Stent placement was successful in all patients. No major complications occurred. Minor complications included transient febrile temperature indicative of a UTI for which i.v. antibiotics were given. The median (mean, range) interval between the initial surgery resulting in a urinary diversion and the diagnosis of ureteroileal anastomotic stricture (often called Bricker patency) was 42 (96, 1.5–444) months. The mean (range) follow-up of the study group (49 patients) was 39 (0–245) months. After the first stent placement, 19 patients (23 stents) showed no signs of obstruction at last follow-up (38.8% of patients, mean follow-up 37.7 months). This yielded a primary patency rate of 41.1% (23/56 stents; Fig. 2). Obstruction recurred in 30 patients (61.2%). The mean interval between stent placement and diagnosis of recurrent stricture and/or stent obstruction was 21.4 months. In 11 patients, a secondary obstruction due to encrustation, stone
912
© 2014 The Authors BJU International © 2014 BJU International
events were stent failures.
Patency in time
Stent patency
Results
1.0
Primary patency
0.8
Combined primary and secondary patency
0.6 0.4 0.2 0.0 0
50 100 150 200 250 Time to obstruction, months
300
formation in the stent or migration of the stent was successfully treated. The secondary patency rate was 60.7% at last follow-up (34/56 stents, mean follow-up 55.8 months; Fig. 2).
Metal stent placement in benign ureteroileal anastomotic strictures
Table 2 Comparison of baseline characteristics in ‘treatment-failure’ group compared to ‘successful treatment’ group. Possible predisposing factors
Successful treatment
Failed treatment
P
58.8 61.8 57.1 6.0 17.6
77 66.7 63.6 8.6 13.6
0.158 0.168 0.568 0.204 0.692
Gender, % male Age, years Side of stricture (% left) Duration of Bricker patency, years History of radiotherapy, % yes
Table 3 Results of case-series of metal stent placement in ureteroileal anastomotic strictures of benign origin. Reference Gort et al. [15] Sanders et al. [16] Barbalias et al. [17] Rapp et al. [19] Liatsikos et al. [20] Present series
Number of patients
Stent placements, n
Primary patency, %
Secondary patency, %
Mean follow-up, months
1 1 4 4 18 49
1 2 6 6 24 56
100 100 83.3 100 22.7 41.1
NA NA 100 NA 56.7 60.7
6 7 12 12 21 39
NA, not applicable.
Laser vaporisation was the most used technique to reopen the lumen of the stent. Until 2005 patients were treated with neodymium-doped yttrium aluminium garnet laser (Nd:YAG). After 2005 the thulium laser was introduced in our hospital to treat localised penile carcinoma and its use was extended to the field of the metal stents with similar results. The objective for any laser treatment is to vaporise tissue only in a parallel angle to the stent to avoid perforation of the stent or the ureteric wall. Seven patients underwent an open revision of the urinary diversion because obstruction of the stent was suggested. During surgery two stents appeared to be patent. Nevertheless, a revision of the ileal conduit was performed in both patients. In the other cases, the part of the ureter in which the metal stent was placed was removed and reimplantation of the vital, unaffected proximal part of the ureter was performed. In all, 10 patients died during follow-up because of intercurrent disease. Four patients died from metastatic disease, six patients died from cardiovascular and pulmonary causes. These patients were censored in the Kaplan–Meier analysis. Stent placement was performed in 15 patients (30.6%) with only a single functional kidney, mostly due to nephrectomy or nephroureterectomy for TCC in the past or deterioration of kidney function due to silent obstruction on one side. We evaluated baseline characteristics in both the group with treatment failure and the group with successful treatment. Gender, age, side of stricture, history of radiotherapy and Bricker patency were factors included in the analysis. We found no significant differences between the groups (Table 2).
Discussion Stricture of the ureteroileal anastomosis is perhaps one of the most difficult complications to manage and may lead to a silent deterioration of renal function. We have shown that metal stent placement in benign ureteroileal strictures is a suitable treatment option in selected patients with an overall primary patency rate of 41.1% and with minor additional treatments a combined primary and secondary patency rate of 60.7%. Furthermore, placement of the metal stent was successful in all patients and no major complications occurred. We found no predisposing factors that could predict stent patency failure. Kramolowsky et al. [21] compared open revision with endourological management in small patient groups and found a 89% (eight of nine strictures) success rate in the open revision group compared with a 71% (five of seven strictures) success rate in the those treated by endourological procedures. They concluded that the high morbidity associated with open revision, concomitant need of general anaesthesia and long hospital stay did not compensate for the slightly better success rate. The use of metal stents is one of the suitable endourological treatment methods. A few studies describe the promising results of metal stents in patients with benign ureteroileal anastomotic strictures, but the follow-ups were very short and all patient groups were small (≤18 patients, Table 3). Metal stents in ureteroileal anastomotic strictures provide a reasonable success rate compared with studies investigating other minimally invasive procedures, e.g. balloon dilatation and endoureterotomy [5,22]. In the present study, the success rate was 40–60% taking in account the primary and secondary patency rates. © 2014 The Authors BJU International © 2014 BJU International
913
Campschroer et al.
Although patients need an additional treatment in the last scenario these interventions are minimally invasive, mostly under local anaesthesia and above all come with short hospital stays and low morbidity risks. Different studies suggest that strictures after ureteroileal anastomoses occur at a mean interval of 5–17 months [23,24]. In the present study, the median time to development of a ureteroileal stricture was 42 months with a wide range of 1.5–444 months. The mean interval between surgery and first stricture was even longer (almost 96 months). In all, 41 stent placements (72%) took place ≥2 years after ileal conduit construction. Despite the high incidence of early-onset ureteroileal anastomotic strictures in the literature, we conclude according to our present results that a long follow-up is essential to evaluate the late-onset development of ureteroileal anastomotic strictures. Because most patients were referred to our tertiary healthcare centre for metal stent placement, we were not able to compare surgical techniques in order to find an explanation for this unexpected late onset occurrence of strictures. A possible explanation could be the fact that in the Netherlands patients with Bricker urinary diversion are seen on a regular basis for kidney function screening for years after the surgery and when oncological follow-up is no longer necessary. Particularly asymptomatic patients with deterioration of kidney function were found in this way. In the Netherlands, people live close to a hospital and this screening is therefore easier to accomplish compared with bigger countries where patients have to travel long distances for regular follow-ups. As stated in earlier studies, most recurrent strictures develop within 6 months to 1 year after first stent placement [20,25]. However, in the present study recurrent strictures after stent placements were seen after a mean interval of 21.4 months and 24% of all strictures (eight of 34) recurred at >2 years. Therefore, long-term follow-up, even after 2 years, is essential after stent placement to diagnose silent recurrent strictures and to prevent renal insufficiency. Sometimes migration of the metal stent or obstruction of the stent (encrustation, stone formation or severe urothelial hyperplasia) necessitates a second intervention. In the present study, one stent migration occurred for which a successful second stent placement was performed (1.8% migration rate). Migration has been described in several studies with rates of 11–81% and depends on several factors, e.g. the biocompatibility of the stent and extent of tissue ingrowth [26,27]. Urothelial hyperplasia is one of the most common causes of stent obstruction in the first months after stent placement. According to Soria et al. [28], urothelial hyperplasia leads to progressive loss of luminal stent diameter and is caused by pressure of the stent on the ureteric wall and concomitant irritative effects due to peristalsis of the ureter in relation to the rigid stent. Moreover, Thijssen et al. [29] found the same hyperplastic effects of the metal stent on the ureteric
914
© 2014 The Authors BJU International © 2014 BJU International
wall in an animal model. Most ureteric hyperplasia occurs just after stent insertion and regresses within the first 6 weeks after placement [30]. Therefore, early onset obstruction after stent placement does not always necessitate a revision of the stent and sometimes a nephrostomy tube or preferably a JJ catheter can be placed temporarily to maintain stent patency. We acknowledge the limitations of the present report: its retrospective nature restricts the ability to compare the group with treatment failure and the successful treatment group. Furthermore, 10 patients were lost to follow-up due to intercurrent disease. In conclusion, metal stents in benign ureteroileal anastomotic strictures following ureteroileal urinary diversion is a successful alternative compared with open surgical revision and provides satisfactory results in the long-term in almost 40% of patients. With additional minimal invasive procedures success rates increase to >60%. In selected patients, for example high-risk surgical patients or patients with a history of extensive abdominal surgery or radiotherapy, placement of a metal stent is a suitable, effective and minimal invasive treatment with low associated morbidity and a short hospitalisation period. Furthermore, the present study shows that long-term follow-up is essential to diagnose both new ureteroileal anastomotic strictures and recurrent strictures after metal stent placement.
Conflict of Interest The authors do not have any conflicts of interest.
References 1
2
3 4
5
6
7
8 9
Frazier HA, Robertson JE, Paulson DF. Complications of radical cystectomy and urinary diversion: a retrospective review of 675 cases in 2 decades. J Urol 1992; 148: 1401–5 Anderson CB, Morgan TM, Kappa S et al. Ureteroenteric anastomotic strictures after radical cystectomy-does operative approach matter? J Urol 2013; 189: 541–7 Gudjónsson S, Davidsson T, Månsson W. Incontinent urinary diversion. BJU Int 2008; 102: 1320–5 Bierkens AF, Oosterhof GO, Meuleman EJ, Debruyne FM. Anterograde percutaneous treatment of ureterointestinal strictures following urinary diversion. Eur Urol 1996; 30: 363–8 Shapiro MJ, Banner MP, Amendola MA, Gordon RL, Pollack HM, Wein AJ. Balloon catheter dilation of ureteroenteric strictures: long-term results. Radiology 1988; 168: 385–7 Bahu R, Chaftari AM, Hachem RY et al. Nephrostomy tube related pyelonephritis in patients with cancer: epidemiology, infection rate and risk factors. J Urol 2013; 189: 130–5 Chung SY, Stein RJ, Landsittel D et al. 15-year experience with the management of extrinsic ureteral obstruction with indwelling ureteral stents. J Urol 2004; 172: 592–5 Ganatra AM, Loughling KM. The management of malignant ureteral obstruction treated with ureteral stents. J Urol 2005; 174: 2125–8 Vandenbroucke F, van Poppel H, Vandeursen H, Oyen R, Baert L. Surgical versus endoscopic treatment of non-malignant uretero-ileal anastomotic strictures. Br J Urol 1993; 71: 408–12
Metal stent placement in benign ureteroileal anastomotic strictures
10 Milroy EJ, Chapple CR, Cooper JE et al. A new treatment for urethral strictures. Lancet 1988; 1: 1424–7 11 Kirby RS, Heard SR, Miller P et al. Use of the ASI titanium stent in the management of bladder outflow obstruction due to benign prostatic hyperplasia. J Urol 1992; 148: 1195–7 12 McInerney PD, Vanner TF, Harris SA, Stephenson TP. Permanent urethral stents for detrusor sphincter dyssynergia. Br J Urol 1991; 67: 291–4 13 Barbalias GA, Siablis D, Liatsikos EN et al. Metal stents: a new treatment of malignant ureteral obstruction. J Urol 1997; 158: 54–8 14 Erdogru T, Kutlu O, Koksal T et al. Endoscopic treatment of ureteric strictures: acucise, cold-knife endoureterotomy and wall stents as a salvage approach. Urol Int 2005; 74: 140–6 15 Gort HB, Mali WP, van Waes PF, Kloet AG. Metallic self-expandable stenting of a ureteroelial stricture. AJR Am J Roentgenol 1990; 152: 422–3 16 Sanders R, Bissada NK, Bielsky S. Ureteroenteric anastomotic strictures: treatment with Palmaz permanent indwelling stents. J Urol 1993; 150: 469–70 17 Barbalias GA, Liatsikos EN, Karnabatidis D, Yarmenitis S, Siablis D. Ureteroileal anastomotic strictures: an innovative approach with metallic stents. J Urol 1998; 160: 1270–3 18 Palascak P, Bouchareb M, Zachoval R, Urban M, Sauvain JL, Palascak R. Treatment of benign ureterointestinal anastomotic strictures with permanent ureteral Wallstent after Camey and Wallace urinary diversion: long-term follow-up. J Endourol 2001; 15: 575–80 19 Rapp DE, Laven BA, Steinberg GD, Percutaneous GGS. placement of permanent metal stents for treatment of ureteroenteric anastomotic strictures. J Endourol 2004; 18: 677–81 20 Liatsikos EN, Kagadis GC, Karnabatidis D et al. Application of self-expandable metal stents for ureteroileal anastomotic strictures: long-term results. J Urol 2007; 178: 169–73 21 Kramolowsky EV, Clayman RV, Weyman PJ. Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair. J Urol 1988; 139: 1195–8
22 Wolf JS Jr, Elashry OM, Clayman RV. Long-term results of endoureterotomy for benign ureteral and ureteroenteric strictures. J Urol 1997; 158: 759–64 23 Tsuji Y, Nakamura H, Ariyoshi A. Upper urinary tract involvement after cystectomy and ileal conduit diversion for primary bladder carcinoma. Eur Urol 1996; 29: 216–20 24 Cornud F, Chrétien Y, Hélénon O et al. Percutaneous incision of stenotic ureteroenteric anastomoses with a cutting balloon catheter: long-term results. Radiology 2000; 214: 358–62 25 Pollak JS, Rosenblatt MM, Egglin TK, Dickey KW, Glickman M. Treatment of ureteral obstructions with the Wallstent endoprosthesis: preliminary results. J Vasc Interv Radiol 1995; 6: 417–25 26 Barbalias GA, Liatsikos EN, Kalogeropoulou C et al. Externally coated ureteral metallic stents: an unfavorable clinical experience. Eur Urol 2002; 42: 276–80 27 Liatsikos EN, Karnabatidis D, Katsanos K et al. Ureteral metal stents: 10-year experience with malignant ureteral obstruction treatment. J Urol 2009; 182: 2613–7 28 Soria F, Sun F, Durán E, Sánchez FM, Usón J. Metallic ureteral stents versus endoureterotomy as a therapeutic approach for experimental ureteral stricture. J Vasc Interv Radiol 2005; 16: 521–9 29 Thijssen AM, Millward SF, Mai KT. Ureteral response to the placement of metallic stents: an animal model. J Urol 1994; 151: 268–70 30 Wakui M, Takeuchi S, Isioa J, Iwabuchi K, Morimoto S. Metallic stents for malignant and benign ureteric obstruction. BJU Int 2000; 85: 227–32
Correspondence: Thijs Campschroer, Department of Urology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. e-mail: [email protected] Abbreviations: ASA, American Society of Anesthesiologists; US, ultrasound/ultrasonography.
© 2014 The Authors BJU International © 2014 BJU International
915
The Wallstent: long-term follow-up of metal stent placement for the treatment of benign ureteroileal anastomotic strictures after Bricker urinary diversion Thijs Campschroer*, M.T.W. Tycho Lock*‡, Rob T.H. Lo† and J.L.H. Ruud Bosch* Departments of *Urology and †Radiology, University Medical Center Utrecht, and ‡Department of Urology, Central Military Hospital Dr. A. Mathijsen, Utrecht, The Netherlands T.C and M.T.W.T.L. contributed equally to this manuscript.
Objective To evaluate the long-term follow-up (primary and secondary patency) of metal stent placement in benign ureteroileal anastomotic strictures after Bricker urinary diversion and to compare the failed treatment group with the group of successfully treated patients to search for predisposing factors of stent failure.
Patients and Methods For patients treated since 1989 for benign ureteroileal strictures after Bricker urinary diversion with end-to-side anastomosis, we retrospectively collected data on clinical history, stent placement, auxiliary measures and patency rates from a prospectively kept database.
Results In all, 49 patients (mean age 64 years) underwent 56 metal stent procedures. Placement of the stent was possible in all patients. Stent patency without auxiliary treatment remained
Introduction Stenosis of the ureteroileal anastomosis after Bricker urinary diversion occurs in 4–14% of all cases [1–3]. These stenoses can cause obstructive nephropathy and can eventually lead to end-stage renal disease. These lesions are generally caused by ischaemia, radiotherapy, temporary urine leak directly after surgery, chronic infection or a combination of these. Management of these strictures is challenging. Endourological incision or dilatation often provides temporary patency and recurrences are frequently seen [4,5]. Bierkens et al. [4] performed ureteric incision with success rates of only 53% after 8 months. High-pressure balloon dilatation alone has produced success rates of only 16% after 12 months [5]. Permanent drainage by nephrostomy tube or JJ catheter causes
BJU Int 2014; 114: 910–915 wileyonlinelibrary.com
adequate in 23 cases (primary patency of 41.1%, mean follow-up 37.7 months). A secondary treatment was successfully performed in 11 patients who had stent obstruction, mostly caused by hyperplastic reaction, encrustation, or migration of the stent. The secondary patency rate was 60.7% (mean follow-up 55.8 months), comparable with patency rates of 36–100% described in literature with mostly small patient groups and much shorter follow-up periods.
Conclusion To the best of our knowledge we report the largest series of metal stenting in benign ureteroileal anastomotic strictures with the longest follow-up. We show that placement of a metal stent can lead to a permanent de-obstruction in approximately six out of 10 patients with preservation of renal function.
Keywords benign, metal stent, Bricker, ureteroileal stricture, anastomosis
an increased risk of infection, migration and encrustation, and requires periodic renewal of the drain. In the literature, exact figures on the risk of pyelonephritis in patients with permanent percutaneous nephrostomy are scarce [6–8]. Recently, Bahu et al. [6] reported a 19% risk of pyelonephritis at ≤90 days after placement in a selected group of 200 patients with cancer with a permanent nephrostomy. Open surgical revision is often technically challenging due to previous operations or radiotherapy and carries a significant risk of postoperative morbidity and even mortality [9]. The successful use of metal stents in the vascular and biliary systems has led to the implementation of these stents in the management of urological diseases. In 1988, Milroy et al. [10] implanted the first eight metal stents in patients with a © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12729 Published by John Wiley & Sons Ltd. www.bjui.org
Metal stent placement in benign ureteroileal anastomotic strictures
urethral stricture. Subsequently, these stents have been widely used in other urological diseases: BPH, detrusor sphincter dyssynergia and ureteric strictures, both of malignant or benign origin [11–14].
Fig. 1 Ureteroileal anastomotic stricture on the left side on antegrade pyeloureterography before metal stent placement.
The successful use of a self-expandable metal stent in a ureteroileal anastomotic stricture was first described in our institution by Gort et al. [15] in 1990. Various retrospective studies have been performed to show the value of metal stents in ureteroileal anastomosis of benign origin, in series containing one to 18 patients [16–20]. Since 1989, we have treated patients with ureteroileal anastomotic strictures of benign origin with the placement of a self-expandable metal stent under local anaesthesia. These patients were not eligible for open surgical repair due to advanced age or high American Society of Anesthesiologists (ASA) score. The objectives of the present study were: (i) to evaluate stent patency over time, both as a primary treatment (primary patency) as well as combined with supplementary endourological treatments to open an obstructed stent (secondary patency) and (ii) to compare the failed treatment group with the group of successfully treated patients to search for predisposing factors of stent failure.
Patients and Methods We retrospectively collected data on patient clinical history, procedures of stent placement, auxiliary measures and patency rates during follow-up from a prospectively kept database. In all, 49 patients were treated for ureteroileal anastomotic strictures by placement of a self-expandable metal stent between April 1989 and July 2013. The patient population consisted of 33 men and 16 women; the mean (range) age was 64 (28–84) years. In all, 56 metal stents were placed in these patients and there was left-side predominance in cases where the stricture was not bilateral (34 strictures on the left side vs 22 strictures on the right side). Most of the patients treated in this group showed significant comorbidity and could be classified as ASA score III or IV (32/49 patients, 65%).
Procedure Patients received a single dose of a third-generation cephalosporin, unless urine culture before the intervention showed bacteria resistant to these antibiotics. In such cases, antibiotic choice was guided by urine culture. With the patient under local anaesthesia and in an oblique supine position a 7 F percutaneous nephrostomy tube was placed under ultrasound (US) guidance, if the patient did not already have one prior to the procedure. Under fluoroscopic control, the stricture was passed antegradely by a 0.1 cm (0.035 inch) straight or angled hydrophilic guidewire (inserted through the nephrostomy tube), all the way down to the ileal conduit. The initially floppy guidewire was then exchanged for a rigid 0.1 cm Amplatz guidewire through a 4 F ureteric catheter. Then antegrade dilatation of the stricture was carried out using a high-pressure balloon catheter (4–7 mm diameter) and a self-expanding metal stent (8 mm diameter and 3–10 cm in length) fixed on an insertion instrument was deployed at the site of the stricture, protruding about 0.5–1.0 cm within the conduit. Self-expandable metal stents were used in all patients (1. Wallstent, Schneider, Zurich, Switzerland, 2. Protégé, EV3, California, USA).
After development of a stricture some patients presented with symptoms of flank pain or UTI. Most patients did not have any complaints, but hydronephrosis on diagnostic imaging or deterioration of renal function were indicators for ureteric obstruction. In most patients renal scintigraphy was used to show functional obstruction. If a stricture was suspected, a percutaneous nephrostomy tube was placed and the length of the stricture was defined by antegrade pyeloureterography (Fig. 1).
After the intervention the nephrostomy tube was left in situ for 48 h to several days. Antegrade pyeloureterography was used to show adequate patency of the stent, because in some cases reactive oedema of the urothelium can occur due to stent placement. If patency was adequate on pyeloureterography, the nephrostomy tube was removed. The median (mean, range) hospital stay was 2 (3.7, 1–13) days.
A secondary treatment was performed, if obstruction was suggested by diagnostic imaging or if renal function deteriorated without other explainable renal causes.
Follow-up consisted of a standardised follow-up schedule with retrograde contrast studies at 3 months after stent placement. Retrograde studies were performed by catheterisation of the
Follow-up
© 2014 The Authors BJU International © 2014 BJU International
911
Campschroer et al.
ureteroileal conduit and slowly injecting fluid with diluted contrast to visualise the conduit, ureter(s) and pyelocalyceal system(s). Furthermore, at 3, 6 and 9 months US was performed and at 12-month US was combined with retrograde flexible endoscopy to evaluate the hyperplastic reaction within the lumen of the stent. Blood biochemistry for renal function was carried out at all follow-up appointments. If there was any indication of a possible recurrent ureteroileal anastomotic stricture (e.g. new complaints, or loss of kidney function) diagnostic imaging was performed earlier. Time to last follow-up was defined as the time between the stent placement and last known imaging study. Outcomes Placement of the stent was considered successful if pyeloureterography after the procedure showed adequate patency all the way to the ureteroileal conduit combined with stabilised or improved renal function on diagnostic follow-up. A Kaplan–Meier curve was constructed to show the success of the procedure over time. Primary patency was defined as successful dilatation of the stricture after placement of the stent without any auxiliary interventions. Secondary patency included all concomitant therapies to open the stent, e.g. repeat ballooning, laser vaporisation or even a stent-in-stent placement. All statistical analyses were performed using SPSS Statistics version 20. The Mann-Whitney U-test was used to analyse predisposing factors of stent failure.
Table 1 Baseline characteristics and results of metal stent placement. Variable
Value
Number of patients (number of stents): Male Female Reasons for urinary diversion: TCC Gynaecological malignancy Neurogenic bladder disorders Bladder exstrophy Severe urinary incontinence Interstitial cystitis Side of stricture, n: Left Right Mean (median) follow-up in months Primary patency, % Mean (median) follow-up, months Median time to stent failure, months Secondary patency, % Mean (median) follow-up, months Number of restenosed ureters/stents (number of patients) Type and number of successful secondary treatments (number of patients) Laser vaporisation Balloon dilatation Second stent placement due to migration Endourological stone removal Type and number of failed secondary treatments (number of patients) Laser vaporisation Open surgical revision Balloon dilatation Second stent placement due to breaking of stent
33 (37) 16 (19) 34 6 4 3 2 1 34 22 39.2 (14.0) 41.1 37.7 (18) 34 60.7 55.8 (21) 34 (27)
14 (7) 1 (1) 1 (1) 2 (2)
14 (10) 7 (7) 1 (1) 1 (1)
Fig. 2 Kaplan–Meier curve of time-to-event analysis in entire cohort, both primary and combined primary and secondary patency. Observed
Table 1 summarises the baseline characteristics and treatment results of the patients in this study. In all, 56 metal stents were placed in 49 patients (33 men and 16 women). Four patients were treated for bilateral strictures. Stent placement was successful in all patients. No major complications occurred. Minor complications included transient febrile temperature indicative of a UTI for which i.v. antibiotics were given. The median (mean, range) interval between the initial surgery resulting in a urinary diversion and the diagnosis of ureteroileal anastomotic stricture (often called Bricker patency) was 42 (96, 1.5–444) months. The mean (range) follow-up of the study group (49 patients) was 39 (0–245) months. After the first stent placement, 19 patients (23 stents) showed no signs of obstruction at last follow-up (38.8% of patients, mean follow-up 37.7 months). This yielded a primary patency rate of 41.1% (23/56 stents; Fig. 2). Obstruction recurred in 30 patients (61.2%). The mean interval between stent placement and diagnosis of recurrent stricture and/or stent obstruction was 21.4 months. In 11 patients, a secondary obstruction due to encrustation, stone
912
© 2014 The Authors BJU International © 2014 BJU International
events were stent failures.
Patency in time
Stent patency
Results
1.0
Primary patency
0.8
Combined primary and secondary patency
0.6 0.4 0.2 0.0 0
50 100 150 200 250 Time to obstruction, months
300
formation in the stent or migration of the stent was successfully treated. The secondary patency rate was 60.7% at last follow-up (34/56 stents, mean follow-up 55.8 months; Fig. 2).
Metal stent placement in benign ureteroileal anastomotic strictures
Table 2 Comparison of baseline characteristics in ‘treatment-failure’ group compared to ‘successful treatment’ group. Possible predisposing factors
Successful treatment
Failed treatment
P
58.8 61.8 57.1 6.0 17.6
77 66.7 63.6 8.6 13.6
0.158 0.168 0.568 0.204 0.692
Gender, % male Age, years Side of stricture (% left) Duration of Bricker patency, years History of radiotherapy, % yes
Table 3 Results of case-series of metal stent placement in ureteroileal anastomotic strictures of benign origin. Reference Gort et al. [15] Sanders et al. [16] Barbalias et al. [17] Rapp et al. [19] Liatsikos et al. [20] Present series
Number of patients
Stent placements, n
Primary patency, %
Secondary patency, %
Mean follow-up, months
1 1 4 4 18 49
1 2 6 6 24 56
100 100 83.3 100 22.7 41.1
NA NA 100 NA 56.7 60.7
6 7 12 12 21 39
NA, not applicable.
Laser vaporisation was the most used technique to reopen the lumen of the stent. Until 2005 patients were treated with neodymium-doped yttrium aluminium garnet laser (Nd:YAG). After 2005 the thulium laser was introduced in our hospital to treat localised penile carcinoma and its use was extended to the field of the metal stents with similar results. The objective for any laser treatment is to vaporise tissue only in a parallel angle to the stent to avoid perforation of the stent or the ureteric wall. Seven patients underwent an open revision of the urinary diversion because obstruction of the stent was suggested. During surgery two stents appeared to be patent. Nevertheless, a revision of the ileal conduit was performed in both patients. In the other cases, the part of the ureter in which the metal stent was placed was removed and reimplantation of the vital, unaffected proximal part of the ureter was performed. In all, 10 patients died during follow-up because of intercurrent disease. Four patients died from metastatic disease, six patients died from cardiovascular and pulmonary causes. These patients were censored in the Kaplan–Meier analysis. Stent placement was performed in 15 patients (30.6%) with only a single functional kidney, mostly due to nephrectomy or nephroureterectomy for TCC in the past or deterioration of kidney function due to silent obstruction on one side. We evaluated baseline characteristics in both the group with treatment failure and the group with successful treatment. Gender, age, side of stricture, history of radiotherapy and Bricker patency were factors included in the analysis. We found no significant differences between the groups (Table 2).
Discussion Stricture of the ureteroileal anastomosis is perhaps one of the most difficult complications to manage and may lead to a silent deterioration of renal function. We have shown that metal stent placement in benign ureteroileal strictures is a suitable treatment option in selected patients with an overall primary patency rate of 41.1% and with minor additional treatments a combined primary and secondary patency rate of 60.7%. Furthermore, placement of the metal stent was successful in all patients and no major complications occurred. We found no predisposing factors that could predict stent patency failure. Kramolowsky et al. [21] compared open revision with endourological management in small patient groups and found a 89% (eight of nine strictures) success rate in the open revision group compared with a 71% (five of seven strictures) success rate in the those treated by endourological procedures. They concluded that the high morbidity associated with open revision, concomitant need of general anaesthesia and long hospital stay did not compensate for the slightly better success rate. The use of metal stents is one of the suitable endourological treatment methods. A few studies describe the promising results of metal stents in patients with benign ureteroileal anastomotic strictures, but the follow-ups were very short and all patient groups were small (≤18 patients, Table 3). Metal stents in ureteroileal anastomotic strictures provide a reasonable success rate compared with studies investigating other minimally invasive procedures, e.g. balloon dilatation and endoureterotomy [5,22]. In the present study, the success rate was 40–60% taking in account the primary and secondary patency rates. © 2014 The Authors BJU International © 2014 BJU International
913
Campschroer et al.
Although patients need an additional treatment in the last scenario these interventions are minimally invasive, mostly under local anaesthesia and above all come with short hospital stays and low morbidity risks. Different studies suggest that strictures after ureteroileal anastomoses occur at a mean interval of 5–17 months [23,24]. In the present study, the median time to development of a ureteroileal stricture was 42 months with a wide range of 1.5–444 months. The mean interval between surgery and first stricture was even longer (almost 96 months). In all, 41 stent placements (72%) took place ≥2 years after ileal conduit construction. Despite the high incidence of early-onset ureteroileal anastomotic strictures in the literature, we conclude according to our present results that a long follow-up is essential to evaluate the late-onset development of ureteroileal anastomotic strictures. Because most patients were referred to our tertiary healthcare centre for metal stent placement, we were not able to compare surgical techniques in order to find an explanation for this unexpected late onset occurrence of strictures. A possible explanation could be the fact that in the Netherlands patients with Bricker urinary diversion are seen on a regular basis for kidney function screening for years after the surgery and when oncological follow-up is no longer necessary. Particularly asymptomatic patients with deterioration of kidney function were found in this way. In the Netherlands, people live close to a hospital and this screening is therefore easier to accomplish compared with bigger countries where patients have to travel long distances for regular follow-ups. As stated in earlier studies, most recurrent strictures develop within 6 months to 1 year after first stent placement [20,25]. However, in the present study recurrent strictures after stent placements were seen after a mean interval of 21.4 months and 24% of all strictures (eight of 34) recurred at >2 years. Therefore, long-term follow-up, even after 2 years, is essential after stent placement to diagnose silent recurrent strictures and to prevent renal insufficiency. Sometimes migration of the metal stent or obstruction of the stent (encrustation, stone formation or severe urothelial hyperplasia) necessitates a second intervention. In the present study, one stent migration occurred for which a successful second stent placement was performed (1.8% migration rate). Migration has been described in several studies with rates of 11–81% and depends on several factors, e.g. the biocompatibility of the stent and extent of tissue ingrowth [26,27]. Urothelial hyperplasia is one of the most common causes of stent obstruction in the first months after stent placement. According to Soria et al. [28], urothelial hyperplasia leads to progressive loss of luminal stent diameter and is caused by pressure of the stent on the ureteric wall and concomitant irritative effects due to peristalsis of the ureter in relation to the rigid stent. Moreover, Thijssen et al. [29] found the same hyperplastic effects of the metal stent on the ureteric
914
© 2014 The Authors BJU International © 2014 BJU International
wall in an animal model. Most ureteric hyperplasia occurs just after stent insertion and regresses within the first 6 weeks after placement [30]. Therefore, early onset obstruction after stent placement does not always necessitate a revision of the stent and sometimes a nephrostomy tube or preferably a JJ catheter can be placed temporarily to maintain stent patency. We acknowledge the limitations of the present report: its retrospective nature restricts the ability to compare the group with treatment failure and the successful treatment group. Furthermore, 10 patients were lost to follow-up due to intercurrent disease. In conclusion, metal stents in benign ureteroileal anastomotic strictures following ureteroileal urinary diversion is a successful alternative compared with open surgical revision and provides satisfactory results in the long-term in almost 40% of patients. With additional minimal invasive procedures success rates increase to >60%. In selected patients, for example high-risk surgical patients or patients with a history of extensive abdominal surgery or radiotherapy, placement of a metal stent is a suitable, effective and minimal invasive treatment with low associated morbidity and a short hospitalisation period. Furthermore, the present study shows that long-term follow-up is essential to diagnose both new ureteroileal anastomotic strictures and recurrent strictures after metal stent placement.
Conflict of Interest The authors do not have any conflicts of interest.
References 1
2
3 4
5
6
7
8 9
Frazier HA, Robertson JE, Paulson DF. Complications of radical cystectomy and urinary diversion: a retrospective review of 675 cases in 2 decades. J Urol 1992; 148: 1401–5 Anderson CB, Morgan TM, Kappa S et al. Ureteroenteric anastomotic strictures after radical cystectomy-does operative approach matter? J Urol 2013; 189: 541–7 Gudjónsson S, Davidsson T, Månsson W. Incontinent urinary diversion. BJU Int 2008; 102: 1320–5 Bierkens AF, Oosterhof GO, Meuleman EJ, Debruyne FM. Anterograde percutaneous treatment of ureterointestinal strictures following urinary diversion. Eur Urol 1996; 30: 363–8 Shapiro MJ, Banner MP, Amendola MA, Gordon RL, Pollack HM, Wein AJ. Balloon catheter dilation of ureteroenteric strictures: long-term results. Radiology 1988; 168: 385–7 Bahu R, Chaftari AM, Hachem RY et al. Nephrostomy tube related pyelonephritis in patients with cancer: epidemiology, infection rate and risk factors. J Urol 2013; 189: 130–5 Chung SY, Stein RJ, Landsittel D et al. 15-year experience with the management of extrinsic ureteral obstruction with indwelling ureteral stents. J Urol 2004; 172: 592–5 Ganatra AM, Loughling KM. The management of malignant ureteral obstruction treated with ureteral stents. J Urol 2005; 174: 2125–8 Vandenbroucke F, van Poppel H, Vandeursen H, Oyen R, Baert L. Surgical versus endoscopic treatment of non-malignant uretero-ileal anastomotic strictures. Br J Urol 1993; 71: 408–12
Metal stent placement in benign ureteroileal anastomotic strictures
10 Milroy EJ, Chapple CR, Cooper JE et al. A new treatment for urethral strictures. Lancet 1988; 1: 1424–7 11 Kirby RS, Heard SR, Miller P et al. Use of the ASI titanium stent in the management of bladder outflow obstruction due to benign prostatic hyperplasia. J Urol 1992; 148: 1195–7 12 McInerney PD, Vanner TF, Harris SA, Stephenson TP. Permanent urethral stents for detrusor sphincter dyssynergia. Br J Urol 1991; 67: 291–4 13 Barbalias GA, Siablis D, Liatsikos EN et al. Metal stents: a new treatment of malignant ureteral obstruction. J Urol 1997; 158: 54–8 14 Erdogru T, Kutlu O, Koksal T et al. Endoscopic treatment of ureteric strictures: acucise, cold-knife endoureterotomy and wall stents as a salvage approach. Urol Int 2005; 74: 140–6 15 Gort HB, Mali WP, van Waes PF, Kloet AG. Metallic self-expandable stenting of a ureteroelial stricture. AJR Am J Roentgenol 1990; 152: 422–3 16 Sanders R, Bissada NK, Bielsky S. Ureteroenteric anastomotic strictures: treatment with Palmaz permanent indwelling stents. J Urol 1993; 150: 469–70 17 Barbalias GA, Liatsikos EN, Karnabatidis D, Yarmenitis S, Siablis D. Ureteroileal anastomotic strictures: an innovative approach with metallic stents. J Urol 1998; 160: 1270–3 18 Palascak P, Bouchareb M, Zachoval R, Urban M, Sauvain JL, Palascak R. Treatment of benign ureterointestinal anastomotic strictures with permanent ureteral Wallstent after Camey and Wallace urinary diversion: long-term follow-up. J Endourol 2001; 15: 575–80 19 Rapp DE, Laven BA, Steinberg GD, Percutaneous GGS. placement of permanent metal stents for treatment of ureteroenteric anastomotic strictures. J Endourol 2004; 18: 677–81 20 Liatsikos EN, Kagadis GC, Karnabatidis D et al. Application of self-expandable metal stents for ureteroileal anastomotic strictures: long-term results. J Urol 2007; 178: 169–73 21 Kramolowsky EV, Clayman RV, Weyman PJ. Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair. J Urol 1988; 139: 1195–8
22 Wolf JS Jr, Elashry OM, Clayman RV. Long-term results of endoureterotomy for benign ureteral and ureteroenteric strictures. J Urol 1997; 158: 759–64 23 Tsuji Y, Nakamura H, Ariyoshi A. Upper urinary tract involvement after cystectomy and ileal conduit diversion for primary bladder carcinoma. Eur Urol 1996; 29: 216–20 24 Cornud F, Chrétien Y, Hélénon O et al. Percutaneous incision of stenotic ureteroenteric anastomoses with a cutting balloon catheter: long-term results. Radiology 2000; 214: 358–62 25 Pollak JS, Rosenblatt MM, Egglin TK, Dickey KW, Glickman M. Treatment of ureteral obstructions with the Wallstent endoprosthesis: preliminary results. J Vasc Interv Radiol 1995; 6: 417–25 26 Barbalias GA, Liatsikos EN, Kalogeropoulou C et al. Externally coated ureteral metallic stents: an unfavorable clinical experience. Eur Urol 2002; 42: 276–80 27 Liatsikos EN, Karnabatidis D, Katsanos K et al. Ureteral metal stents: 10-year experience with malignant ureteral obstruction treatment. J Urol 2009; 182: 2613–7 28 Soria F, Sun F, Durán E, Sánchez FM, Usón J. Metallic ureteral stents versus endoureterotomy as a therapeutic approach for experimental ureteral stricture. J Vasc Interv Radiol 2005; 16: 521–9 29 Thijssen AM, Millward SF, Mai KT. Ureteral response to the placement of metallic stents: an animal model. J Urol 1994; 151: 268–70 30 Wakui M, Takeuchi S, Isioa J, Iwabuchi K, Morimoto S. Metallic stents for malignant and benign ureteric obstruction. BJU Int 2000; 85: 227–32
Correspondence: Thijs Campschroer, Department of Urology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. e-mail: [email protected] Abbreviations: ASA, American Society of Anesthesiologists; US, ultrasound/ultrasonography.
© 2014 The Authors BJU International © 2014 BJU International
915
![[Percutaneous management of benign ureteroileal anastomotic strictures after ileal conduit urinary diversion].](/assets/img/hold.png)
