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.

     

15-year experience with the management of extrinsic ureteral obstruction with indwelling ureteral stents

PURPOSE: We assessed the success of retrograde placement of indwelling ureteral stents in the management of ureteral obstruction due to extrinsic compression. MATERIALS AND METHODS: Between July 1987 and December 2002 adequate followup was available for 101 patients who underwent primary retrograde ureteral stenting for extrinsic ureteral obstruction. Mean age at presentation was 61.4 years (range 33 to 90). Chart review was performed on all patients for primary diagnosis, symptomatology, degree of hydronephrosis, creatinine levels (baseline, treatment and posttreatment), location of compression, size and number of stents used, progression to percutaneous nephrostomy tube (PNT), stent failure, days to stent failure, post-stent therapy and status at last followup. RESULTS: Mean length of followup was 11 months (range 1 to 127). In 101 patients 138 ureteral units (UU) were stented. Total stent failure occurred in 41 (40.6%) patients and 58 (42.0%) UU. A total of 40 (29.0%) UU required PNTs at a mean of 40.3 days (range 0 to 330) with 18 PNTs placed in less than 1 week. Cases of stent failure that did not undergo PNT placement included 18 (13.0%) UU at a mean of 52.4 days (range 3 to 128). A total of 90 (89.1%) patients had metastatic cancer at stenting with 32.2% dead at 5.8 months (range 1 to 32). Univariate and multivariate analyses identified cancer diagnosis, baseline creatinine greater than 1.3 mg/dl and post-stent systemic treatment as predictors of stent failure. Proximal location of compression and treatment creatinine greater than 3.11 mg/dl were marginal predictors of failure on univariate analysis, while proximal location of obstruction was also marginally significant on multivariate analysis. No predictors were identified for early stent failure (less than 1 week). CONCLUSIONS: At almost 1 year followup stent failure due to extrinsic compression occurred in nearly half of treated patients. Analysis of data revealed a diagnosis of cancer, baseline mild renal insufficiency and metastatic disease requiring chemotherapy or radiation as predictors of stent failure. Managing extrinsic compression by retrograde stenting continues to be a practical but guarded decision and should be tailored to each patient.     

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.     

Stent failure in the management of malignant extrinsic ureteral obstruction: Risk factors

There is still controversy surrounding the indications for performing either a retrograde ureteral stent or percutaneous nephrostomy to manage malignant extrinsic ureteral obstruction (MEUO). We retrospectively analyzed 53 patients who underwent a decompression of MEUO using retrograde ureteral stent. Ureteral stent failure occurred in 18 of 53 patients (34%). Multivariate analysis showed that gastrointestinal cancer as the primary disease, poor preoperative performance status and severe preoperative hydronephrosis were independent predictors of stent failure. Based on the present data, we propose an algorithm for the management of MEUO.     

Management of extrinsic malignant ureteral obstruction with urinary diversion

OBJECTIVE: The effectiveness of urinary diversion for patients with renal insufficiency due to extrinsic ureteral obstruction was assessed. METHODS: Between 1990 and 2003, 30 males and 45 females, ranging 36-90 years of age (average, 62.7) who had secondary ureteral obstruction due to either a retroperitoneal or pelvic invasion of malignant disease, underwent nephrostomy or ureteral stenting using a double-J stent without side holes. RESULTS: Ureteral stenting was attempted as an initial procedure in 51 of the 75 cases. The remaining 24 cases had a nephrostomy at the first step. Of 51, 37 cases were successfully stented, while internal stenting was unsuccessful in the remaining 14 cases. These 14 cases were treated with nephrostomy at the second step following the unsuccessful internal stenting. Eight cases of the 37 successfully stented cases were eventually changed to a nephrostomy because of catheter trouble. As a result, 29 cases could be managed by internal ureteral stenting up until the end of their life. The follow-up period for the 75 cases who underwent urinary diversion ranged from 5 days to 19 months, averaging 5.7 months. The average period from diversion to death was 5.6 months in the internally stented group and 5.9 months in the nephrostomy group. CONCLUSION: The high patency rate of the internal ureteral stent in our cases might be due to our use of a stent without shaft vent holes.     

The management of malignant ureteral obstruction treated with ureteral stents

PURPOSE: We developed an algorithm for the management of ureteral obstruction due to malignant extrinsic compression. MATERIALS AND METHODS: We retrospectively reviewed all ureteral stents placed for noncalculous reasons at our institution from January 1, 1990 to January 1, 2004. Further clinical information was gathered from 157 patients with malignant extrinsic ureteral compression. Failure was defined as recurrent ureteral obstruction or an inability to place stents cystoscopically. RESULTS: A total of 157 patients underwent retrograde ureteral stent attempt for malignant extrinsic ureteral obstruction. Mean patient age was 54.7 years (range 23 to 83) and average followup was 13.6 months. Of our patients 61% were women, and the most common cancer diagnoses were ovarian cancer (in 26), lymphoma (17) and cervical cancer (16). A total of 24 patients required immediate percutaneous nephrostomy (PCN) referral. There were 32 patients who experienced a late failure and required PCN (average 180 days after initial stent), and 83 patients in our series (52.9%) who experienced 110 major complications. Type of cancer did not predict need for PCN. However, when invasion into the bladder was noted on cystoscopy, 55.9% (19 of 34, p = 0.008) progressed to PCN referral. A total of 77 patients underwent stent replacement on average 2.8 times and with an interval of 95 days. CONCLUSIONS: In our series patients with malignant extrinsic ureteral compression presenting for ureteral stent(s) experienced a failure rate of 35.7% (56 of 157). Invasion at cystoscopy had a significant predictive value for progression to PCN. We present an algorithm on the management of extrinsic malignant ureteral obstruction.     

恶性肿瘤致输尿管梗阻治疗方法的选择及疗效观察

目的 探讨恶性肿瘤引起的输尿管梗阻治疗方法的选择并观察其疗效.方法 回顾性分析2011年6月至2013年12月中山大学附属第六医院泌尿外科收治的因恶性肿瘤引起的输尿管梗阻患者32例,行逆/顺行输尿管金属支架置入术或经皮肾穿刺造瘘术,分析治疗过程的临床资料.结果 32例患者均先行逆行输尿管金属支架置入手术,成功17例（53.1％）,失败15例（46.9％）,失败15例患者再行顺行输尿管金属支架置入手术,成功10例（66.7％）,失败5例（33.3％）,失败5例患者最后行经皮肾穿刺造瘘术,全部成功.所有患者治疗后临床症状明显改善,肌酐（Cr）,血尿素氮（BUN）及肾盂分离值三种指标均较治疗前有显著性改善（P＜0.05）.经皮肾穿刺造瘘术患者慢性疼痛发生率显著高于输尿管金属支架置入术患者（P＜0.05）.所有患者均无严重并发症.结论 输尿管金属支架逆/顺行置入术或经皮肾穿刺造瘘术治疗恶性肿瘤引起的输尿管梗阻临床疗效满意,可根据不同情况灵活选择术式.     

金属内支架治疗消化道恶性梗阻的方法探讨

目的探讨不能手术治疗的消化道恶性梗阻患者，使用金属内支架治疗的方法和疗效。方法回顾分析63例食管癌、6例胰头癌和6例直肠癌所致75例消化道梗阻患者行金属内支架植入术的资料，分析不同部位梗阻行内支架植入的手术操作相似点和不同点及影响术后疗效的因素。结果①各种支架植入术的难度由低到高为食管支架、直肠支架和十二指肠支架植入术；②消化道各部位支架植入术在操作步骤、导管导丝的运用手法、支架直径与长度的选择标准和释放支架的原理方面具有明显的相似性；③十二指肠支架植入在患者术中体位、所用导管型号、医生所受辐射剂量和交换超长超硬导丝的手法方面具有一定特点；④直肠支架植入在患者术中体位、释放支架后1／3时的手法方面具有一定特点；⑤影响术后疗效的主要因素为病变位置特点、患者饮食习惯及疾病发展转归，患者的死亡原因主要为转移和全身衰竭。结论消化道不同部位的金属内支架植入术的操作过程具有高度的相似性，术后并发症的防治亦十分相近；有条件的医疗单位可通过练习依次开展食管支架、直肠支架和十二指肠支架植入术。     

Systemic chemotherapy in patients with indwelling ureteral stenting

BACKGROUND: We investigated whether systemic chemotherapy increased episodes of acute pyelonephritis (APN) in patients with an indwelling double-J stent due to non-urological malignant ureteral obstruction. METHODS: A retrospective study was performed on a total of 74 patients (16 men and 58 women; median age, 53.0; range, 34-84 years) with non-urological malignant ureteral obstruction, who were managed by double-J stenting between October 1997 and December 2001. The patients were divided into those who received (33 patients, group I) and those who did not receive systemic chemotherapy (41 patients, group II) during the stent indwelling period (median, 7.0; range, 1-44 month). Routine antibiotic prophylaxis was not administered to any patient. Median follow-up was 10.5 (range, 1-45) months. Clinical features, including the incidence of febrility and APN, were compared between the two groups. RESULTS: Of the 74 patients, 18 patients (24.3%) experienced acute febrile episodes during ureteral stenting, but only five (6.8%) patients were diagnosed as having APN. No significant difference in the incidence of fever or APN was found between the two groups (P = 1.000 and P = 0.651, respectively). Univariate logistic analysis indicated that only the duration of follow-up was a risk factor for an episode of fever. Other parameters had no clinical significance. CONCLUSION: Our findings suggest that systemic chemotherapy may not predispose the risk of acute pyelonephritis in patients with an indwelling ureteral stent due to non-urological malignant ureteral obstruction.     

肠道支架减压在左侧大肠癌梗阻一期切除吻合中的应用

目的 探讨术前肠道支架减压在左侧大肠癌梗阻一期切除吻合中运用的安全性和有效性.方法 回顾性分析2005年5月至2008年9月浙江中医药大学附属第一医院收治的97例左侧大肠癌患者临床资料.支架联合手术组46例,为左侧大肠癌合并肠梗阻的患者,成功放置肠道支架减压后行手术一期切除吻合治疗.单纯手术组51例,为无梗阻的左侧大肠癌而限期手术治疗的患者.观察两组患者术后胃肠功能恢复、术后住院时间、并发症发生情况.采用t检验、χ~2检验对数据进行分析.结果 支架联合手术组46例中,1例乙状结肠癌患者于肠道支架植入术后第4天出现肠道穿孔致弥漫性腹膜炎,急诊行乙状结肠癌根治术.45例均顺利完成一期手术治疗,术后11～16 d痊愈出院,1例患者术后10 d死于呼吸道感染及心功能衰竭.术后随访4～48个月.两组患者在术后肛门排气时间、住院时间、围手术期并发症发生率、复发转移率、随访期内生存率方面比较差异无统计学意义(t=0.164,1.358,χ~2=0.252,1.200,0.580,P>0.05).结论 术前肠道支架减压是治疗左侧大肠癌梗阻患者安全、有效的方法.     

Percutaneous nephrostomy versus indwelling ureteral stents in patients with bilateral nongenitourinary malignant extrinsic obstruction

We present five cases of bilateral extrinsic ureteral obstruction in advanced nongenitourinary abdominal malignancy. They show the superiority of percutaneous nephrostomy to indwelling ureteral stents in providing diversion. We suggest that percutaneous nephrostomy drainage should be the management of choice in extrinsic obstruction by advanced abdominal malignancies.     

Resonance金属输尿管双J管在恶性疾病相关性输尿管梗阻中的应用

目的比较Resonance金属输尿管双J管和传统聚合物双J管在解除恶性疾病相关性输尿管梗阻中的应用。 方法回顾性分析中山大学附属第六医院2013年1月至2016年1月收治的69例晚期恶性肿瘤侵犯或压迫输尿管引起上尿路积液的病例资料,均由我科同一治疗组医师逆行置入Resonance金属输尿管双J管（RMU组）或传统聚合物双J管（T组）解除梗阻,RMU组肾盂分离（31±10）mm,上段梗阻15条,中下段梗阻53条,术前肌酐115.5（85.7）μmol/L;T组肾盂分离（29±7）mm,上段梗阻7条,中下段梗阻16条,术前肌酐104（101）μmol/L,两组一般资料比较差异无统计学意义（P>0.05）,评估两组置管成功率、支架引流通畅率、支架引流持续时间及并发症发生情况。 结果（1）共收集69例患者（91条输尿管单位）临床资料,进入Resonance金属双J管组并进行后续研究者50例（68条输尿管单位）,平均随访250 d;进入传统聚合物双J管组并进行后续研究者19例（23条输尿管单位）,平均随访203 d。（2）Resonance金属双J管组和传统聚合物双J管组置管成功率的差异无统计学意义（89.7% vs 87.0%,P>0.05）,在30 d、60 d、90 d各时间点,Resonance金属双J管组引流通畅率均明显高于传统聚合物双J管组,且平均引流持续时间明显长于传统聚合物双J管组,差异有统计学意义（P<0.05）。（3）Resonance金属双J管组总的并发症发生率明显低于传统聚合物双J管组（46.0% vs 73.7%）,差异有统计学意义（P<0.05）。 结论Resonance金属双J管用于解除恶性疾病相关性输尿管梗阻时,置管成功率与传统聚合物双J管相当,引流效果优于传统聚合物双J管,且并发症较少。     

坦索罗辛改善留置双J管患者相关临床症状及生活质量的疗效观察

目的:观察坦索罗辛改善留置双J管患者相关临床症状及生活质量的疗效。方法:将90例上尿路手术后并留置双J管患者随机分为两组,治疗组(组1)45例,给予坦索罗辛0.4mg,每天1次,口服1个月;空白对照组(组2)45例,未给予干预性治疗。所有患者在置管4周后均随访,并完成输尿管支架管相关症状问卷(Ureteral stent symptom questionnaire,USSQ)调查。结果:置管4周,两组平均尿路症状指数评分为22.1∶33.3,平均疼痛指数评分为12.5∶18.9,平均健康指数评分为8.1∶12.9,性指数评分为3.2∶5.8,治疗组相对于安慰剂组置管相关临床症状及生活质量均有明显改善(P0.01)。结论:坦索罗辛能明显改善留置输尿管支架管患者尿路症状及生活质量。     

Self-expandable metallic stents for malignant biliary obstruction with an anomalous pancreaticobiliary junction

Background Anomalous pancreaticobiliary junction (APBJ) is associated with pancreaticobiliary cancer. Limited data are available on endoscopic biliary drainage for unresectable malignant biliary obstruction with APBJ. This study evaluated the efficacy and safety of self-expandable metallic stents (EMSs) for the management of malignant biliary obstruction with APBJ. Methods Between 1993 and 2005, 324 patients with unresectable malignant biliary obstruction underwent insertion of an EMS. Six of these patients with concomitant APBJ constituted the subjects of this study. Early (≤30 days after EMS insertion) and late (>30 days after EMS insertion) stent-related complications and stent patency were evaluated in these six patients. Results The cause of biliary obstruction was gallbladder cancer in four patients and pancreatic cancer in two patients. Uncovered EMSs were inserted across the common channel without performance of a biliary sphincterotomy. The diameter of the uncovered EMS used was based on the diameter of the common channel. For all six patients, endoscopic biliary drainage was successful, and their jaundice subsided steadily. None of the six patients experienced early complications, including acute pancreatitis. The mean stent-related complication-free period was 163 days. Stent occlusion caused by tumor ingrowth occurred in two patients. Acute cholangitis and cholecystitis were observed in one patient each. Conclusions Uncovered EMSs are effective for palliation of unresectable malignant biliary obstruction in patients who have APBJ without increasing the risk of stent-related early complications.     

经皮下置管输尿管旁路肾膀胱分流术在输尿管梗阻中的临床应用

目的:探讨经皮下置管输尿管旁路肾膀胱分流术(EAS)在治疗因晚期腹腔、盆腔及腹膜后恶性肿瘤所导致的输尿管梗阻中的临床应用价值及预后效果。方法:回顾性分析14例15侧EAS患者的临床资料及随访情况。结果:14例手术分流置管均成功,未出现任何并发症,术后72小时KUB及B超均显示导管位置良好;15侧肾积水明显减轻或消失,术后血肌酐水平较术前明显降低。其中1例术后1周内出现严重泌尿系感染,高烧寒战,应用抗生素效果不好,取出皮下旁路置管,改为经皮肾造瘘,病情得到控制。其余13例术后随访3~13个月,1~3个月疗效满意,仅有一过性镜下和肉眼血尿;置管6~13个月患者中有5例存在一过性肉眼血尿和不同程度的泌尿系统感染,予以更换导管处理,其中3例患者反复出现感染症状,药物治疗未能有效控制,最终改为经皮肾造瘘外引流。本组带管生存最长13个月。结论:EAS是一种尿流改道手段和方法,操作简单、微创,较之传统的经皮肾造瘘术为优,避免了繁琐的生活护理,提高了生活质量,适用于晚期肿瘤引起的输尿管梗阻。     

输尿管支架管在腔内泌尿外科的应用(附230例报告)

目的 探讨输尿管支架管在腔内泌尿外科手术中的适应证及并发症。方法 对230例复杂肾结石、输尿管结石、输尿管狭窄、肾盂输尿管连接部梗阻患者在腔内泌尿外科手术中应用输尿管支架管作内支架和内引流，置管时间1-12个月（一般小于5周）。结果 体外冲击波震波碎石术后肾结石排出顺利，未形成石街；输尿管结石、输尿管狭窄、肾盂输尿管连接部梗阻经输尿管镜腔内手术后梗阻均被解除，肾积水改善或消失；腔内插管延长了盆腔肿瘤晚期致输尿管梗阻患者的生存时间。结论 留置输尿管内支架管治疗效果肯定，操作简便，并发症少，在腔内泌尿外科手术中有良好的应用价值。     

The efficacy and safety of ureteral dilation and long-term type ureteral stent for patients with ureteral obstruction

ObjectiveThis study was conducted to investigate the efficacy and safety of ureteral dilation and placement of a long-term ureteral stent for patients with various types of ureteral obstructions.MethodsWe retrospectively reviewed the records of 39 patients presenting with ureteral obstruction secondary to malignant strictures (n = 9) or nonmalignant strictures (n = 30). The mean age of these patients was 55.8 ± 16.1 years (range, 13–87 years). All patients underwent retrograde ureteral balloon dilation and placement of one to three ureteral stents. Stent patency rate and complications including febrile urinary tract infection, stent encrustation, and stent fragmentation were recorded.ResultsA total of 117 ureteral stents were implanted during the 83 procedures. Three stents were placed in seven patients and two stents in 20 patients. The patency rate was 95.2% with a mean 75-day follow-up. There was no encrustation in 104 stents and Grade 1 in 13 stents. The patency rate was similar between the patients with malignant strictures and those with nonmalignant strictures (100% vs. 94.7%, p = 0.57). However, three episodes of febrile urinary tract infection were noted only in patients with malignant strictures. The improvement of hydronephrosis and complications were also comparable between those patients with ureteral stents indwelling for >90 days and those for <90 days. No stent fragmentation was found in any of the patients.ConclusionWe demonstrated that ureteral dilation and placement of a single or multiple ureteral stents was effective and safe for patients with ureteral obstruction.