URETERAL STENT FOR NONREFLUXING,
CONTINENT URINARY DIVERSIONS Reduces Complications and Hospitalization for Patients NEIL H. BANDER, M.D. From the Department of Surgery (Urology), The New York Hospital-Cornei1 Medical Center, New York, New York
Herein is described a ureteral stent designed specifically for nonrefluxing, continent urinary diversions which resolves many potential pitfalls of these procedures. These pitfalls include (1) ureteral obstruction at the level of the antireflux mechanism (i.e., submucosal tunnel or afferent nipple valve). Ureteral obstruction not only compromises renal function, but in the case of resistance at the nipple valve, may lead to a leak or suture-line disruption at the level of the ureterointestinal anastomosis. (2) Virtually all continent diversions (except Carney procedure) have very long suture lines subject to leakage. (3) The use of long intestinal segments leads to copious mucus secretion which tends to obstruct the catheter draining the pouch. When this happens, there is increased stress on the suture lines c o m p o u n d i n g the likelihood of leakage, Lastly, even when the indwelling catheter is patent and functioning, some urine tends to pool in the pouch. The combination of an indwelling catheter, pooled urine, frequent irrigations, and multiple foreign bodies (catheters, stents, staples, suture material) combine to predispose patients to urosepsis and possible septicemia. The use of prophylactic antibiotics to attempt to avoid this problem can lead to growth of resistant organisms. In the construction of a nonrefluxing diversion, there is a consensus that ureteral stents are mandatory to protect and insure drainage of the upper tracts and, secondarily, to protect the ureterointestinal anastomoses. While virtually any stent will accomplish this, the use of appropriately designed stents can simultaneously help
04
resolve other problems. Features of such a ~l teral diversion stent (Fig. 1)* that has been:i signed and tested include: i 1. polyurethane composition !i 9.. a single blind-ending pigtail at the pr~ m al end : 3. drainage side holes in the pigtail and lX imai 10 cm of the stent 4. color coded (red-right; blue-left) 5. calibrated in centimeters 6. radiopaque i 7. guide wire for passage ~' 8. adjustable retaining devices at the end for securing the stent to the patie~ 9. Tuohy-Borst adaptor :: Polyurethane is intermediate in rigidity:~! tween silicone and "C-flex." This prevents:~ i lapsing of the stent, but is not so rigid a~i I cause erosion. The material is nonreact~veii i can be left in place for weeks memor) maintains the positio~ ter which is inserted over the Should the catheter become d blind end allows ready replac, guide wire "to the hilt" and subs tioning of the stent at the bedside for fluoroscopy. By restricting holes to the proximal 10 cm of t] holes remain in the ureter proxim rointestinal anastomosis and anti nism, As long as there is edema ance at the anastomosis or nipplc *Cook Urological, RO. Box 227, Spencer,
UROLOGY
/
JANUARY 1990
/
VOLUME
...............///G~, .......................................................... FLEXIBLE STYLET ,038 inch (0,97 ram) diameter Teflon® coated stainless steel 3 O0 cm long with 5 cm flexible tip
i!?:i¸ i, ¸:~¸
URO-SOFT" "STENT 7.0 French radiopaque soft poJyurethane
i!i~~;, '
~=~
CATHETER RETAINERS
STOMAL SITE
EXTERNAL J DRAINAGE POUCH
Fmu~aE 1. Drawing of urinary diversion stent. ia the stent directly into the external dnage bag. No urine drains into the ,'h remains empty. This is, perhaps, .portant feature of the stent. Bypasseh during the immediate postopera• obviates concern over a mucusinch catheter, protects an as yet lture line, and prevents pooling of •, pouch. One ean monitor the urine each kidney and, if desired or indiplit renal clearances. The retaining w the stents to be secured to the paut "choking" the stent. The Tuohytors provide a female luer adaptor 7¢ill aeeommodate the widest variety n devices, thus avoiding precarious :ed these ureterai stents in constructsuccessive (and successful) Koek ince their use, there have been no ,Ctions, whereas two pseudomonas .ct infections (one with septicemia) 'ed in both of 2 previous patients. Low- less dependenee on adequate ;ations by either the patient or the ft. The stents have been left in for ,seventeen days without any prob~y well be that these stents aid in al-
JANUARY 1990
/
lowing the suture lines to heat more rapidly as the author has found that pouchograms and pouchoseopy done as early as fourteen days post surgery, instead of the commonly recommended three weeks,* have demonstrated complete healing (Fig. 2)° All catheters are now removed on postoperative day 14 and patients begin intermittent catheterization. This is done every three hours for one week, then every four hours for another week, Patients may then adapt to their own schedule, including sleeping through the night. There are helpful hints in passing the stents. In a Kock pouch, this is done after fashioning the nipple valves but prior to closing the pouch. Two stents (one pink. one blue) are passed through the efferent nipple, then retrograde through the antireflux nipple and out the open afferent limb. The guide wires are w i t h d r a w n into their respective sheaths and the pigtail end of the stents clamped with Allis d a m p s to prevent the stents from being dislodged during or after closure of the pouch. The stents are fashioned into a gentle arc between the nipple *Skinner DG, Lieskovsky G. and Boyd SD: Technique of e~eation of a continent internal fleaI reservoir (Koek pouch) for urinary diversion, Urol Clin North Am 11:741 (1984b
VOLUME XXXV, NUMBER 1
65
(A) Portable abdominal x.ray film taken in recovery room of patient immediately after eoz tion of radical cystectomy and Kock pouch. (B-D) Films of Kock pouch on postoperative day 18. tt, graphic and endoscopic studies and extubation of pouch now routinely performed on postoperative da FIGURE 2.
86
UROLOGY
/
IANUARY 1990
/
VOI,UME xxxv
; pouch is closed in standard ~ce-type ureterointestinal anased. The guide wires are reintents are advanced up each urempleting the ureterointestinal ~.0-F multi-eve Robinson cathein the pouch and provide access :ing the remainder of the operaare secured to the patient using evices supplied. As previously 'ices avoid the problems of tight r" the stents or loose sutures alIts to dislodge. The retaining multiple-point fixation which ent dislodgement. No external luired, allowing ready inspeca. An x-ray film is taken in the :o confirm appropriate location lould their position be subopti-
[UARY 1990
/
real or should they become dislodged in the postoperative period, a guide wire can be reinserted "to the hilt" and the stent repositioned without a trip to the fluoroscopy suite. Repositioning has not been necessary in any of my cases.
In my experience, most patients are reluctant to be discharged from the hospital "until all the tubes are out." Initially this meant a hospital stay of at least three weeks until the pouch studies could be done. Since utilizing these ureteral catheters, I now routinely remove all catheters, and pouch studies are performed on the fourteenth postoperative day. Patients go home a day later after self-catheterization instruction. Hospital stay has, for all practical purposes, been shortened by seven days.
V O L U M E XXXV, N U M B E R 1
525 East 68th Street New York, New York 10021
67
CONTINENT URINARY DIVERSIONS Reduces Complications and Hospitalization for Patients NEIL H. BANDER, M.D. From the Department of Surgery (Urology), The New York Hospital-Cornei1 Medical Center, New York, New York
Herein is described a ureteral stent designed specifically for nonrefluxing, continent urinary diversions which resolves many potential pitfalls of these procedures. These pitfalls include (1) ureteral obstruction at the level of the antireflux mechanism (i.e., submucosal tunnel or afferent nipple valve). Ureteral obstruction not only compromises renal function, but in the case of resistance at the nipple valve, may lead to a leak or suture-line disruption at the level of the ureterointestinal anastomosis. (2) Virtually all continent diversions (except Carney procedure) have very long suture lines subject to leakage. (3) The use of long intestinal segments leads to copious mucus secretion which tends to obstruct the catheter draining the pouch. When this happens, there is increased stress on the suture lines c o m p o u n d i n g the likelihood of leakage, Lastly, even when the indwelling catheter is patent and functioning, some urine tends to pool in the pouch. The combination of an indwelling catheter, pooled urine, frequent irrigations, and multiple foreign bodies (catheters, stents, staples, suture material) combine to predispose patients to urosepsis and possible septicemia. The use of prophylactic antibiotics to attempt to avoid this problem can lead to growth of resistant organisms. In the construction of a nonrefluxing diversion, there is a consensus that ureteral stents are mandatory to protect and insure drainage of the upper tracts and, secondarily, to protect the ureterointestinal anastomoses. While virtually any stent will accomplish this, the use of appropriately designed stents can simultaneously help
04
resolve other problems. Features of such a ~l teral diversion stent (Fig. 1)* that has been:i signed and tested include: i 1. polyurethane composition !i 9.. a single blind-ending pigtail at the pr~ m al end : 3. drainage side holes in the pigtail and lX imai 10 cm of the stent 4. color coded (red-right; blue-left) 5. calibrated in centimeters 6. radiopaque i 7. guide wire for passage ~' 8. adjustable retaining devices at the end for securing the stent to the patie~ 9. Tuohy-Borst adaptor :: Polyurethane is intermediate in rigidity:~! tween silicone and "C-flex." This prevents:~ i lapsing of the stent, but is not so rigid a~i I cause erosion. The material is nonreact~veii i can be left in place for weeks memor) maintains the positio~ ter which is inserted over the Should the catheter become d blind end allows ready replac, guide wire "to the hilt" and subs tioning of the stent at the bedside for fluoroscopy. By restricting holes to the proximal 10 cm of t] holes remain in the ureter proxim rointestinal anastomosis and anti nism, As long as there is edema ance at the anastomosis or nipplc *Cook Urological, RO. Box 227, Spencer,
UROLOGY
/
JANUARY 1990
/
VOLUME
...............///G~, .......................................................... FLEXIBLE STYLET ,038 inch (0,97 ram) diameter Teflon® coated stainless steel 3 O0 cm long with 5 cm flexible tip
i!?:i¸ i, ¸:~¸
URO-SOFT" "STENT 7.0 French radiopaque soft poJyurethane
i!i~~;, '
~=~
CATHETER RETAINERS
STOMAL SITE
EXTERNAL J DRAINAGE POUCH
Fmu~aE 1. Drawing of urinary diversion stent. ia the stent directly into the external dnage bag. No urine drains into the ,'h remains empty. This is, perhaps, .portant feature of the stent. Bypasseh during the immediate postopera• obviates concern over a mucusinch catheter, protects an as yet lture line, and prevents pooling of •, pouch. One ean monitor the urine each kidney and, if desired or indiplit renal clearances. The retaining w the stents to be secured to the paut "choking" the stent. The Tuohytors provide a female luer adaptor 7¢ill aeeommodate the widest variety n devices, thus avoiding precarious :ed these ureterai stents in constructsuccessive (and successful) Koek ince their use, there have been no ,Ctions, whereas two pseudomonas .ct infections (one with septicemia) 'ed in both of 2 previous patients. Low- less dependenee on adequate ;ations by either the patient or the ft. The stents have been left in for ,seventeen days without any prob~y well be that these stents aid in al-
JANUARY 1990
/
lowing the suture lines to heat more rapidly as the author has found that pouchograms and pouchoseopy done as early as fourteen days post surgery, instead of the commonly recommended three weeks,* have demonstrated complete healing (Fig. 2)° All catheters are now removed on postoperative day 14 and patients begin intermittent catheterization. This is done every three hours for one week, then every four hours for another week, Patients may then adapt to their own schedule, including sleeping through the night. There are helpful hints in passing the stents. In a Kock pouch, this is done after fashioning the nipple valves but prior to closing the pouch. Two stents (one pink. one blue) are passed through the efferent nipple, then retrograde through the antireflux nipple and out the open afferent limb. The guide wires are w i t h d r a w n into their respective sheaths and the pigtail end of the stents clamped with Allis d a m p s to prevent the stents from being dislodged during or after closure of the pouch. The stents are fashioned into a gentle arc between the nipple *Skinner DG, Lieskovsky G. and Boyd SD: Technique of e~eation of a continent internal fleaI reservoir (Koek pouch) for urinary diversion, Urol Clin North Am 11:741 (1984b
VOLUME XXXV, NUMBER 1
65
(A) Portable abdominal x.ray film taken in recovery room of patient immediately after eoz tion of radical cystectomy and Kock pouch. (B-D) Films of Kock pouch on postoperative day 18. tt, graphic and endoscopic studies and extubation of pouch now routinely performed on postoperative da FIGURE 2.
86
UROLOGY
/
IANUARY 1990
/
VOI,UME xxxv
; pouch is closed in standard ~ce-type ureterointestinal anased. The guide wires are reintents are advanced up each urempleting the ureterointestinal ~.0-F multi-eve Robinson cathein the pouch and provide access :ing the remainder of the operaare secured to the patient using evices supplied. As previously 'ices avoid the problems of tight r" the stents or loose sutures alIts to dislodge. The retaining multiple-point fixation which ent dislodgement. No external luired, allowing ready inspeca. An x-ray film is taken in the :o confirm appropriate location lould their position be subopti-
[UARY 1990
/
real or should they become dislodged in the postoperative period, a guide wire can be reinserted "to the hilt" and the stent repositioned without a trip to the fluoroscopy suite. Repositioning has not been necessary in any of my cases.
In my experience, most patients are reluctant to be discharged from the hospital "until all the tubes are out." Initially this meant a hospital stay of at least three weeks until the pouch studies could be done. Since utilizing these ureteral catheters, I now routinely remove all catheters, and pouch studies are performed on the fourteenth postoperative day. Patients go home a day later after self-catheterization instruction. Hospital stay has, for all practical purposes, been shortened by seven days.
V O L U M E XXXV, N U M B E R 1
525 East 68th Street New York, New York 10021
67
