Comparison of tandem ureteral stents,cryoplasty, and cutting balloon ureteroplasty in treatment of refractory transplant ureteral strictures

The objective of study was to compare clinical outcome of cryoplasty, tandem stents, and cutting balloon ureteroplasty as “bailout procedures” to prevent surgical intervention or stent dependency in renal transplant patients with refractory ureteral stricture. All patients who underwent a bailout procedure from June 11, 2003, to August 8, 2015, at a single institution were reviewed retrospectively. Refractory ureteral stricture was defined as ureteral stenosis not responding to at least two prior percutaneous plain balloon ureteroplasties. Primary patency was defined as stable allograft function following the procedure with unobstructed urine outflow, not requiring indwelling ureteral stent, repeat ureteroplasty, or surgical revision. Sixty-one procedures were performed on 51 patients. Patients were followed up for a median of 286 days. Overall primary patency rate was 26.1%. Primary patency rate by method was 38.1%, 23.1%, and 14.3% after cryoplasty, tandem stent placement, and cutting balloon dilatation, respectively (P = .260). Primary patency rate was higher in early (<3 months post-transplant) ureteral strictures (35.7% vs 13.3%; P = .047). More complications identified in patients who had tandem ureteral stents (P = .00754). As some renal transplant patients may not be good operative candidates for ureteral revision, it would be reasonable to attempt one of these “bailout” interventions as long as the clinical team and patient are aware of overall low potential for achieving primary patency.     

Outcomes of indwelling metallic stents for malignant extrinsic ureteral obstruction

Objectives

To report the treatment outcomes of patients with extrinsic ureteral obstruction treated with metallic stents and to identify the factors predicting stent failure.

Methods

A total of 52 patients with extrinsic ureteral obstruction as a result of malignancy (66 ureters) were treated with metallic stents (Resonance^®) and included in the study. The median observation period was 118 days.

Results

The median survival time of these patients was 210 days, and the stent patency rate was 86.0% at 6 months and 60.0% at 1 year. Eight (15.4%) patients underwent nephrostomy as a result of stent failure. The occlusion rate of bilateral ureteral obstructed cases was significantly higher than that of unilateral cases. There was no correlation between the preoperative serum creatinine level, causes of ureteral occlusions (compression by tumor, lymph node metastasis, peritoneal dissemination), obstructed site (upper, middle, lower ureter) and stent failure.

Conclusions

Metallic stents are excellent in maintaining patency compared with the conventional stents. Therefore, they can be used as first‐line treatment of malignant ureteral obstructions.     

Ureteral Obstruction: Is the Full Metallic Double-Pigtail Stent the Way to Go?

Background

The Resonance metallic ureteral stent (Cook Medical, Bloomington, Indiana, USA) has been introduced for the management of extrinsic-etiology ureteral obstruction for time periods up to 12 mo.

Objective

The current study aims to determine short- and medium-term effectiveness of the Resonance stent in malignant and benign ureteral obstruction.

Design, setting, and participants

In total, 50 patients with extrinsic malignant obstruction (n = 25), benign ureteral obstruction (n = 18), and previously obstructed mesh metal stents (n = 7) were prospectively evaluated.

Intervention

All patients were treated by Resonance stent insertion. Twenty stents were inserted in antegrade fashion, and the remaining stents were inserted in a retrograde approach. No patient dropped out of the study. The follow-up evaluation included biochemical and imaging modalities.

Measurements

We evaluated the technical success rate, stricture patency rate, complications, and the presence and type of encrustation.

Results and limitations

The technical success rate of transversal and stenting of the strictures was 100%. In 19 patients, balloon dilatation was performed prior to stenting. The mean follow-up period was 8.5 mo. The stricture patency rate in patients with extrinsic malignant ureteral obstruction was 100% and in patients with benign ureteral obstruction 44%. Failure of Resonance stents in all cases of obstructed metal stents was observed shortly after the procedure (2–12 d). In nine cases, stent exchange was demanding. Encrustation was present in 12 out of 54 stents.

Conclusions

The Resonance stent provides safe and sufficient management of malignant extrinsic ureteral obstruction. Resonance stent use in benign disease needs further evaluation, considering the untoward results of the present study.     

Comparison between the use of percutaneous nephrostomy and internal ureteral stenting in the management of long-term ureteral obstructions

ObjectivesIn this study, we compared between the efficacy and complications of percutaneous nephrostomy (PCN) tubes and those of internal ureteral stents (e.g., double-J stents) used for relieving ureteral obstructions.Materials and methodsA retrospective chart review was performed. Between 2003 and 2009, 110 patients (63 females and 47 males, with a mean age of 63.6 years, range 19–89 years) who had an extrinsic ureteral obstruction, and subsequently underwent either PCN tube placement (n = 44) or internal ureteral stent placement (n = 66), were enrolled. Clinical data on patients with duration of diversion/drainage for more than 6 months were collected. Statistical analyses were performed with respect to a patient's age, etiology of the obstruction, outcome of residual hydronephrosis, and renal function tests.ResultsPatient ages and procedure-related complications were comparable between these two groups. The mean duration of diversion was 16.8 ± 8.6 months in the stent group versus 14.1 ± 6.7 months in the PCN group (p = 0.067). A smaller elevation in serum creatinine was noted in the PCN group (0.21 vs. 0.78 mg/dL, p = 0.03). Nine of 86 (10.4%) double-J stents were converted to PCN tubes during the study period. Residual hydronephrosis after decompression was more common in the stent group than in the PCN group (65.2% vs. 27.2%, p = 0.01). These findings suggest better preservation of renal function by a PCN tube.ConclusionsResults of this study suggest that, to better preserve renal function, PCN is the choice of treatment, irrespective of the etiology. While patients who have a PCN tube may have to carry an additional external drainage device, the complications did not seem to differ significantly from those who used internal drainage with a ureteral stent. Because young cancer patients may especially need aggressive chemotherapy to prolong their survival, PCN urinary drainage may become a better choice from the standpoint of cancer control.     

Application of resonance metallic stents for ureteral obstruction

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To determine the effectiveness of the Resonance ureteral stent and clarify the risk factors that lead to stent failure. In the present study, we review our clinical experiences using Resonance stent in treating malignant and benign ureteral obstruction.

PATIENTS AND METHODS

• ? Nineteen patients with extrinsic malignant ureteral obstruction (n= 15) and benign stricture (n= 4) were retrospectively evaluated.
• ? All patients had received Resonance stent insertion through antegrade or cystoscopic retrograde approaches. The pre‐insertion and follow‐up interventions included image studies and biochemical tests. The insertion success rate, obstruction patency rate and complications were reviewed.
• ? For categorical variables, the chi‐square test and Fisher’s exact test were carried out to determine associations between variables.

RESULTS

• ? The technical success rate of stent insertion was 84.6%. The mean follow‐up was 5 months (range 1–10.5 months).
• ? Five stents failed to alleviate the obstruction, and the patency rate was 77.3% (17/22).
• ? Patients who had had previous radiation therapy had a lower ureter patency rate in comparison with non‐radiation patients (50% vs 92.3% respectively, P= 0.039).
• ? The 6‐ and 9‐month patency rates were 81.0% with 11 stents and 27.0% with 3 stents, respectively.

CONCLUSIONS

• ? The results of the present study demonstrated that malignant or benign ureteral obstruction could be treated safely and sufficiently with the Resonance metallic stent.
• ? Careful patient selection is critical to achieve successful results.
• ? For malignant ureteral obstruction, previous radiation therapy is a risk factor for stent failure.

     

Retrospective analysis of the long-term indwelling ureteral stent

An indwelling ureteral stent is commonly used for relief of ureteral obstruction. However, few reports have documented the frequency of febrile urinary tract infection and changes in renal function in patients with long-term ureteral stent placement. Here we report our experience with patients who had undergone long-term placement of ureteral stents. Between January 2005 and March 2011, we performed exchange of ureteral stents in 25 patients for more than one year. The mean serum creatinine level at the baseline, after stent placement, and 1 year later was 2.10, 1.24, and 1.39 mg/dl, respectively. In 14 of the patients, 39 episodes of febrile urinary tract infection occurred. Among a total of 1,055 stent exchanges, 39 episodes (3.7%) of stent encrustation occurred. Two patients in whom stents had been forgotten suffered septic shock. The serum creatinine level following a long placement period did not change significantly, and of the patients whose hydronephrosis remained after stent placement, the risk of febrile urinary tract infection rises. Our results suggest that ureteral stents could be indwelt for a fairly long period of time without major complications as long as they were carefully followed up and regularly exchanged.     

Stenting for malignant ureteral obstruction: Tandem,metal or metal‐mesh stents

Extrinsic malignant compression of the ureter is not uncommon, often refractory to decompression with conventional polymeric ureteral stents, and frequently associated with limited survival. Alternative options for decompression include tandem ureteral stents, metallic stents and metal‐mesh stents, though the preferred method remains controversial. We reviewed and updated our outcomes with tandem ureteral stents for malignant ureteral obstruction, and carried out a PubMed search using the terms “malignant ureteral obstruction,” “tandem ureteral stents,” “ipsilateral ureteral stents,” “metal ureteral stent,” “resonance stent,” “silhouette stent” and “metal mesh stent.” A comprehensive review of the literature and summary of outcomes is provided. The majority of studies encountered were retrospective with small sample sizes. The evidence is most robust for metal stents, whereas only limited data exists for tandem or metal‐mesh stents. Metal and metal‐mesh stents are considerably more expensive than tandem stenting, but the potential for less frequent stent exchanges makes them possibly cost‐effective over time. Urinary tract infections have been associated with all stent types. A wide range of failure rates has been published for all types of stents, limiting direct comparison. Metal and metal‐mesh stents show a high incidence of stent colic, migration and encrustation, whereas tandem stents appear to produce symptoms equivalent to single stents. Comparison is difficult given the limited evidence and heterogeneity of patients with malignant ureteral obstruction. It is clear that prospective, randomized studies are necessary to effectively scrutinize conventional, tandem, metallic ureteral and metal‐mesh stents for their use in malignant ureteral obstruction.     

Heparin coating in biodegradable ureteral stents does not decrease bacterial colonization—assessment in ureteral stricture endourological treatment in animal model

BackgroundWe assessed an antireflux biodegradable heparin-coated ureteral stent (BraidStent^®-H) in an animal model comparative study after endoscopic treatment of ureteral strictures.MethodsA total of 24 female pigs underwent initial endoscopic, nephrosonographic, and contrast fluoroscopy assessment of the urinary tract. Afterward, unilateral laparoscopic ureteral stricture model was performed. Three weeks later, the animals underwent laser endoureterotomy and were randomly assigned to Group-I, in which a double-pigtail stent was placed for 6 weeks, or Group-II, in which a BraidStent®-H was placed. Follow-up was carried out by ultrasonography, contrast fluoroscopy, ureteroscopy, urinalysis and bacteriuria assessment at 3, 6, 12 and 5 months. Finally, a pathological study of the urinary system was performed.ResultsThere were no animals in Group-II with vesicoureteral reflux, with significance at 6 weeks with Group-I. Distal ureteral peristalsis was maintained in 50–75% in Group-II at 1–6 weeks. The 91.7% of stents in Group-II were degraded between 3–6 weeks, without obstructive fragments. Bacteriuria in Group II was 33.3–50% at 3 and 6 weeks. The global success rate by groups was 91.6% and 87.5% in groups I and II, respectively, with no statistical significance.ConclusionsBraidStent^®-H has been shown to be as efficacious as current ureteral stents in the treatment of benign ureteral strictures following laser endoureterotomy. In addition, it reduces the morbidity associated with current stents and has a homogeneous and predictable degradation rate of about 6 weeks, with no obstructive fragments. Future studies are required to improve the antibacterial coating to reduce BraidStent^®-H contamination in view of the results obtained with the heparin coating.     

Metallic ureteral stents in malignant ureteral obstruction: short-term results and radiological features predicting stent failure in patients with non-urological malignancies

Purpose

To provide short-term result of the metallic ureteral stent in patients with malignant ureteral obstruction and identify radiological findings predicting stent failure.

Materials and methods

The records of all patients with non-urological malignant diseases who have received metallic ureteral stents from July 2009 to March 2012 for ureteral obstruction were reviewed. Stent failure was detected by clinical symptoms and imaging studies. Survival analysis was used to estimate patency rates and factors predicting stent failure.

Results

A total of 74 patients with 130 attempts of stent insertion were included. A total of 113 (86.9 %) stents were inserted successfully and 103 (91.2 %) achieved primary patency. After excluding cases without sufficient imaging data, 94 stents were included in the survival analysis. The median functional duration of the 94 stents was 6.2 months (range 3–476 days). Obstruction in abdominal ureter (p = 0.0279) and lymphatic metastasis around ureter (p = 0.0398) were risk factors for stent failure. The median functional durations of the stents for abdominal and pelvic obstructions were 4.5 months (range 3–263 days) and 6.5 months (range 4–476 days), respectively. The median durations of the stents with and without lymphatic metastasis were 5.3 months (range 4–398 days) and 7.8 months (range 31–476 days), respectively.

Conclusion

Metallic ureteral stents are effective and safe in relieving ureteral obstructions resulting from non-urological malignancies, and abdominal ureteral obstruction and lymphatic metastasis around ureter were associated with shorter functional duration.     

金属输尿管支架管在肿瘤源性输尿管中下段梗阻中的应用(附15例报告)

目的 探讨金属输尿管支架管在肿瘤源性输尿管中下段梗阻中的临床应用价值.方法 15例肿瘤源性输尿管中下段梗阻患者均放置了金属输尿管支架管17根(其中2例放置双侧).12例经输尿管镜技术逆行放置,3例经皮肾穿刺技术顺行放置.结果 通过逆行及顺行方式放置成功率100%.均随访6个月至18个月,平均13个月.全组肾积水均不同程...     

Application of self-expandable metal stents for ureteroileal anastomotic strictures: long-term results

PURPOSE: We report our long-term experience with the management of benign ureteroileal anastomotic strictures using self-expandable metal stents. MATERIALS AND METHODS: A total of 16 male and 2 female patients with a mean+/-SD age of 72+/-7 years (range 66 to 78) with benign fibrotic strictures at the site of ureteroileal anastomosis underwent implantation of self-expandable metal stents with a nominal diameter of 6 to 8 mm. A total of 24 ureteroileal conduits were treated. The external nephrostomy tubes were removed after fluoroscopic validation of ureteral patency. Patients were followed with blood biochemistry, ultrasonography, urography and/or virtual endoscopy. Retrograde external-internal catheter insertion through the cutaneous stoma was performed in cases of recalcitrant stricture. RESULTS: The technical success rate of ureteroileal stricture crossing and stenting was 100% (24 of 24 cases). Mean followup was 21 months (range 7 to 50). The clinical success rate during the immediate post-stenting period was 70.8% (17 of 24 cases). The 1 and 4-year primary patency rates were 37.8% and 22.7%, respectively. Secondary interventions included repeat balloon dilation in 15 ureters, of which 8 also underwent subsequent coaxial stent placement. The 1 and 4-year secondary patency rates were 64.8% and 56.7%, respectively. Except in 2 patients who died external-internal Double-J catheters continued to be inserted retrograde in 6 ureteroileal conduits. They are periodically exchanged to prevent mucous inspissation and stent encrustation. CONCLUSIONS: Metal stents served as the definitive treatment for stricture in more than half of the cases, whereas in the remainder the stents allowed the uncomplicated and regular exchange of Double-J catheters in retrograde fashion. This combined, less invasive treatment for ureteroileal anastomotic strictures may help patients avoid surgical revision and preserve quality of life.     

Management of encrusted ureteral stents

ObjectivesTo present our experience in managing encrusted ureteral stents and to review the literature on the subject.MethodsA total of 22 patients with encrusted ureteral stent were treated in our department. Encrustation of the stent and associated stone burden were evaluated using plain radiography, sometimes supplemented by intravenous urography or ultrasonography. The treatment method was determined by the site of encrustation, the size of the stone burden and the availability of endourologic equipment.ResultsStents were inserted for stone disease in 17 patients, for congenital abnormality in 3 and for ureteric obstruction by malignancy in 2. Stents were left in place for a mean of 10.8 months (range 5–34 months). The site of encrustation was in the bladder in 15 (68.2%), ureter in 13 (59%) and kidney in 8 patients (36.4%); more than one site was involved in 11 (50%) cases. For upper coil encrustations, retrograde ureterorenoscopy was performed in 9 cases, percutaneous nephrolithotomy in 4 and open pyelolithotomy in 2. For lower coil encrustation, fragmentation by grasper and/or transurethral cystolithotripsy was attempted in 11 cases, and suprapubic cystolithotomy was required for failure in 7 cases. Sixteen patients (72.7%) were rendered stone-free and 5 (22.7%) had clinically insignificant residual stones (3 mm or less).ConclusionsEncrustation is one of the most difficult complications of ureteral stents and its management is a complex clinical scenario for the treating surgeon. The combination of several surgical techniques is often necessary but the best treatment remains the prevention of this problem by providing patient education.     

Reconstruction of late‐onset transplant ureteral stricture disease

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Most of the published literature reporting on ureteral obstruction after renal transplantation details the outcomes of management when performed within a few months post‐transplantation. The present study attempts to document the management and outcomes of patients who develop delayed ureteral strictures after renal transplant.

OBJECTIVE

? To describe our experience with surgical management of transplant ureteral strictures over a 6‐year period.

PATIENTS AND METHODS

? The present study identified patients who underwent open reconstruction for transplant ureteral strictures between March 2002 and May 2008 after kidney or kidney–pancreas transplantation. ? Baseline clinical characteristics were documented, including age at transplantation and reconstruction, serum creatinine levels, immunosuppressive drug regimen, and comorbidities. ? Postoperative complications were noted, including urinary tract infections, stricture recurrence and graft failure. ? Successful reconstructions were defined as stable allograft function with unobstructed outflow not requiring repeat dilation, ureterotomy or stent placement.

RESULTS

? Median age at the time of reconstruction was 51 years and the mean time from transplantation was 62 months. ? Seven of the 13 patients had failed previous balloon dilation. ? The patients were followed for a median of 41 months and a successful repair was achieved in 10 of 13 patients. ? Ureteral strictures recurred in two patients who received ureteroneocystostomies, which were subsequently managed with chronic stent exchanges. ? Another recurrence involved a 1.5‐cm anastomotic stricture 6 months postoperatively, which was balloon‐dilated and has remained recurrence‐free for 16 months.

CONCLUSIONS

? Patients who present >6 months after renal transplantation with ureteral strictures that are recalcitrant to endoscopic management can safely undergo open surgical ureteral reconstruction without subsequent renal or graft failure. ? Further investigation involving a larger patient cohort is required to confirm these initial results.     

Ureteral stenting after ureteroscopy for distal ureteral calculi: a multi-institutional prospective randomized controlled study assessing pain, outcomes and complications

PURPOSE: We compare postoperative pain, stone-free rates and complications after ureteroscopic treatment of distal ureteral calculi with or without the use of ureteral stents. MATERIALS AND METHODS: A total of 113 patients with distal ureteral calculi amenable to ureteroscopic treatment were prospectively randomized into stented (53) and unstented (60) groups. Stones were managed with semirigid ureteroscopes with or without distal ureteral dilation and/or intracorporeal lithotripsy. Preoperative and postoperative pain questionnaires were obtained from each patient. Patients with stents had them removed 3 to 10 days postoperatively. Radiographic followup was performed postoperatively to assess stone-free rates and evidence of obstruction. RESULTS: Six patients randomized to the unstented group were withdrawn from the study after significant intraoperative ureteral trauma was recognized, including 3 ureteral perforations, that required ureteral stent placement, leaving 53 with stents and 54 without for analysis. Patients with stents had statistically significantly more postoperative flank pain (p = 0.005), bladder pain (p <0.001), urinary symptoms (p = 0.002), overall pain (p <0.001) and total narcotic use (p <0.001) compared to the unstented group. Intraoperative ureteral dilation or intracorporeal lithotripsy did not statistically significantly affect postoperative pain or narcotic use in either group (p >0.05 in all cases). Overall mean stone size in our study was 6.6 mm. There were 4 (7.4%) patients without stents who required postoperative readmission to the hospital secondary to flank pain. All patients (85%) who underwent imaging postoperatively were without evidence of obstruction or ureteral stricture on followup imaging (mean followup plus or minus standard deviation 1.8 +/- 1.5 months), and the stone-free rate was 99.1%. CONCLUSIONS: Uncomplicated ureteroscopy for distal ureteral calculi with or without intraoperative ureteral dilation can safely be performed without placement of a ureteral stent. Patients without stents had significantly less pain, fewer urinary symptoms and decreased narcotic use postoperatively.     

Externally coated ureteral metallic stents: an unfavorable clinical experience

OBJECTIVE: The purpose of the present study was to evaluate the use of externally coated stents in patients with malignant ureteral obstruction. MATERIALS AND METHODS: We have prospectively evaluated 16 patients, 10 men and 6 women, with malignant ureteral obstruction treated successfully by placement of Passager metal stents (Boston Scientific, Natick, MA, USA) bypassing the stricture. Mean patient age was 65.6 years (range 62-78 years). Ureteral patency was confirmed 24 and 48 hours by injection of contrast material through the nephrostomy tube, and after patency confirmation the nephrostomy catheter was removed. RESULTS: All stents were positioned successfully, and the postoperative course was uneventful. In 13 cases (81.2%) the prostheses finally migrated into the bladder hindering overall ureteral patency (mean time of migration: 1.5 months). Patency was achieved in the remaining ureters (n=3), during the follow-up period (mean: 8 months, range 6-16 months), without any need for further intervention. CONCLUSION: The inappropriate anchorage and the increased ureteral peristalsis are the main causes of migration towards the bladder, thus, minimizing the usefulness of this stent for the treatment of ureteral strictures.     

Migration of biliary plastic stents: experience of a tertiary center

Background and study aims  Stent migration occurs in about 5–10% of patients undergoing biliary stenting. The aim of this study was to analyze the risk factors for stent migration in patients with benign and malignant strictures. Patients and methods  We retrospectively analyzed records of 524 biliary plastic stent placement procedures. Details noted included the cause and localization of stricture, characteristics and number of stents, direction of stent migration, presentation of patient with migrated stent, and the methods used for retrieval of migrated stents. Results  Two hundred and four (38.9%) of the procedures were performed for benign biliary strictures (BBS) and 320 (61.1%) for malignant biliary strictures (MBS). Thirty-four patients had 45 migrated biliary stents. The rate of migration was 8.58% (proximal 4.58% and distal 4.00%). Migration frequency was higher in BBS compared with MBS (13.7% versus 5.3%, p = 0.001). In BBS, the rate of stent migration was higher in cases with one (19.3%) and two stents (20.9%) when compared with cases with multiple stents (2.7%) (p = 0.001; p = 0.001, respectively). Migration occurred more frequently (10.9%) in cases with two stents when compared both to cases with one stent (3.0%) and those with multiple stents (0%) in MBS (p = 0.008; p = 0.020, respectively). In BBS, short stents migrated more frequently proximally (77%) and long stents more frequently distally (73%) (p = 0.008). In BBS, migration in cases with proximal stricture occurred more frequently distally (76.9%), while in those with distal stricture, migration was more frequently proximal (73.3%) (p = 0.008). All of the proximally migrated stents could be successfully retrieved endoscopically. Conclusions  The risk of stent migration is higher in BBS compared with in MBS. The cases with multiple stents had significantly lower stent migration. In BBS, long stent, proximal and postcholecystectomy strictures were associated with distal migration, while short stent, distal and non-postcholecystectomy strictures were associated with proximal migration.     

The use of triclosan eluting stents effectively reduces ureteral stent symptoms: a prospective randomized trial

Study Type – Therapy (RCT) Level of Evidence 1b What's known on the subject? and What does the study add? Infection, encrustation and ureteral‐stent‐related symptoms (USRS) including pain, urgency and frequency are all major problems associated with stent use. No current ureteral stent or exogenously applied therapy adequately deals with these problems and antibiotic use is ineffective once a bacterial biofilm forms on the device. Triclosan is a broad spectrum antibacterial agent widely used in numerous healthcare products and has been previously shown to reduce inflammation on the skin and in the oral cavity. This study tested a triclosan‐impregnated ureteral stent for its ability to reduce infection, encrustation and USRS. This study shows that while a triclosan‐impregnated ureteral stent cannot reduce infection rates alone compared with antibiotic use, the stent can reduce several USRS including pain during indwelling. This study suggests that the triclosan eluting stent may have a role in treating patients, perhaps in combination with standard antibiotic therapy.

OBJECTIVE

• ? To evaluate the capacity of triclosan‐loaded ureteral stents to reduce stent‐associated bacterial attachment, biofilm formation and encrustation, thereby potentially reducing infection development and other device‐related sequelae.

PATIENTS AND METHODS

• ? Twenty subjects requiring short‐term stenting (7–15 days) were randomized to receive either a Percuflex Plus® non‐eluting stent (control) or a Triumph® triclosan eluting stent.
• ? Control‐stented subjects received 3 days of levofloxacin prophylaxis (500 mg once daily) while Triumph®‐stented subjects did not.
• ? All subjects were assessed for positive urine and stent cultures, stent biofilm development and encrustation.
• ? Following device removal, each subject completed an analogue‐scale symptom assessment questionnaire.

RESULTS

• ? Ureteral stenting was performed after nine ureteroscopic and one extracorporeal shock wave lithotripsy procedure in the control group and eight ureteroscopic and two shock wave lithotripsy procedures in the triclosan group.
• ? No significant differences were observed for culture, biofilm and encrustation between the two groups.
• ? Subjects in the triclosan group reported significant reductions in lower flank pain scores during activity (58.1% reduction, P= 0.017) and urination (42.6%, P= 0.041), abdominal pain during activity (42.1%, P= 0.042) and urethral pain during urination (31.7%, P= 0.049).

CONCLUSIONS

• ? In this study, the use of the Triumph® triclosan eluting stent had no marked impact on biofilm formation, encrustation or infection development in short‐term stented patients.
• ? The Triumph® device led to significant reductions in several common ureteral‐stent‐related symptoms, supporting its use in this patient population.

     

Central venous occlusion in hemodialysis access: Comparison between percutaneous transluminal angioplasty alone and nitinol or stainless-steel stent placement

PurposeThe purpose of this study was to compare the primary and secondary patency rates of percutaneous transluminal angioplasty (PTA) alone with those of metallic stent placement in patients with hemodialysis access and central venous occlusion (CVO) and to compare the respective effects of nitinol and stainless-steel stents on patency.Materıals and methodsA total of 150 consecutive patients with hemodialysis access who underwent endovascular treatment for symptomatic CVO with ipsilateral functioning hemodialysis access were evaluated. There were 67 men and 83 women with a mean age of 56.2 ± 15.2 (SD) years (range: 15–86 years). The primary endovascular treatment of CVO was PTA alone. Stent placement either with nitinol or stainless-steel stents was performed as a bailout procedure. The results were analyzed on a per patient basis.ResultsTechnical success was achieved in 141/150 patients (94%). Of the 141 patients, 109 (77%) underwent PTA alone and 32 (23%) underwent stent placement. The mean number of interventions in the stent group [4.3 ± 2.5 (SD)] was significantly higher than that in the PTA alone group [2.6 ± 2.8 (SD)] (P = 0.002). The primary patency rates at 12, 24, and 60 months for the stent group (58.7%, 41.9%, and 27.9%, respectively) were significantly higher than those in the PTA alone group (42.4%, 36.3%, and 20.2%, respectively) (P = 0.036). Secondary patency rates at 12, 24, and 60 months for the stent group (87.6%, 80.7%, and 50.3%, respectively) were significantly greater than those in the PTA alone group (68.4%, 56%, and 38.6%, respectively) (P = 0.046). Furthermore, the primary patency rates at 6 and 12 months in the nitinol stent group (89% and 80.9%, respectively) were significantly greater than those in the stainless-steel stent group (78.8% and 38.4%, respectively) (P = 0.007). The secondary patency rates at 6, 12 and 24 months for the nitinol stent group (92.8%, 87.7% and 65.8%, respectively) were significantly greater than those in the stainless-steel stent group (85.7%, 76.2% and 65.3%, respectively) (P = 0.011).ConclusıonAlthough PTA alone is an effective interventional treatment strategy of CVO in short term, stent placement yields greater primary and secondary patency rates in the long-term. But the mean number of interventions per vein after stenting is significantly higher. Close follow-up and multiple re-interventions are necessary to ensure long-term patency.     

Treatment of benign ureterointestinal anastomotic strictures with permanent ureteral Wallstent after Camey and Wallace urinary diversion: long-term follow-up

BACKGROUND AND PURPOSE: Ureterointestinal anastomotic stricture follows urinary diversion in 4% to 8% of patients and may lead to a progressive deterioration of renal function. There are problems with all current management techniques: surgical revision, endourologic incision, nephrostomy drainage, external ureteral stents, and dilation with a high-pressure angioplasty balloon. The authors present their long-term results with permanent ureteral Wallstents for the treatment of benign ureterointestinal stricture. PATIENTS AND METHODS: Eight patients with 10 strictures were treated by placement of self-expanding permanent indwelling stents via percutaneous nephrostomy between September 1993 and January 1998. The mean age of the group was 59.2 years. Development of strictures occurred a mean of 20.9 months after urinary diversion. There were seven complete and three partial strictures. Of 49 patients treated by the Camey procedure, 7 patients (14%) developed 9 (18%) strictures. Of 28 patients having the Wallace procedure, 1 patient (3.5%) developed one stricture. After recanalization of the distal ureter by a Terumo guidewire and dilation with a high-pressure angioplasty balloon, a Wallstent was placed across the stricture via a percutaneous approach. RESULTS: The endourologic placement of the Wallstent was well tolerated by all patients. The hospital stay averaged 2 days. Seven patients with nine strictures after the Camey procedure are doing well with a follow-up of 7 to 68 months (mean 22.4 months). One major complication was observed in one patient necessitating an additional procedure (lithotripsy) because of stone formation at the lower part of the stent extending into the neobladder in order to maintain patency after 68 months. The other patient, who had a Wallace procedure, is doing well 1 year 8 months afterward. CONCLUSION: An endourologic ureteral Wallstent approach to ureterointestinal stricture is a successful alternative, providing satisfactory management of the problem in most patients. No complication such as stent migration, hematuria, pain, or recurrent stricture was observed.     

Antibiotic prophylaxis for ureteral stent removal after kidney transplantation

There are no guidelines for antibiotic prophylaxis for ureteral stent removal after kidney transplantation. We reviewed the charts of 277 adult kidney transplant recipients with ureteral stents transplanted at our center between September 2014 and December 2015 and investigated whether antibiotic prophylaxis for stent removal was associated with reduced incidence of urinary tract infections (UTI). We defined UTI as a urine culture ≥10⁴ CFU/mL of bacterial isolates irrespective of symptoms. Primary outcome was the incidence of UTI within four weeks of stent removal. Among the 277 recipients, 199 (72%) were on sulfamethoxazole/trimethoprim (SMZ/TMP) as Pneumocystis jirovecii prophylaxis. At the time of ureteral stent removal, 56 recipients (20%) received additional antibiotic prophylaxis (ABX+) and 221 (80%) did not (ABX‐). The difference in the incidence of UTI in the ABX(+) group (16%) and ABX(?) group (19%) was not statistically significant (P = 0.85). Variables independently associated with the development of UTI were recipient age (odds ratio [OR] 1.04, [95% confidence interval 1.01‐1.07]) and UTI while stents were in situ (OR 3.9 [2.00‐7.62]). Use of SMZ/TMP was protective (OR 0.35 [0.18‐0.7]). Our study does not show a statistically significant benefit for additional antibiotic prophylaxis for ureteral stent removal. Antibiotic prophylaxis may be beneficial for recipients not on SMZ/TMP at the time of stent removal.