Antegrade perkutane endoluminale Therapie der nichtmalignen Strikturen von ureterointestinalen Anastomosen nach Harnableitung

We report our experience on the use of antegrade percutaneous incision of ureterointestinal anastomosis strictures after urinary diversion. Since 1994, we evaluated 9 patients with 12 ureterointestinal anastomosis (UAS) strictures who were treated with a cold-knife incision. After placement of an 8-Fr nephrostomy tube, a 0.035-in guide wire was passed through the stricture under guidance of a central opened ureter catheter (5 Fr). A wire-mounted cold-knife was pulled through the strictured area in the retrograde way under fluoroscopic control. Routinely, following the incision, an 8-Fr external stent was left in place for 6-8 weeks. After removal of the stent, the ureteroenteric area remained patent in 7 UAS (58%) cases versus 7 of 9 (78%) patients, with average follow-up of 18 months (range 13-25 months). Failures were associated with radiogenic injury of the ureter in three UAS cases and unexplained in two. No complication was observed. Percutaneous endourological management of ureterointestinal anastomotic strictures with the cold-knife incision is a safe and effective alternative to open surgical repair and should be tried as an initial approach.     

Antegrade percutaneous endoluminal treatment of non-malignant ureterointestinal anastomotic strictures following urinary diversion

OBJECTIVE: We report our experience on antegrade percutaneous incision of ureterointestinal anastomosis strictures after urinary diversion. MATERIALS AND METHODS: Since 1994, we have evaluated retrospectively 18 patients with 22 ureterointestinal anastomosis strictures (UAS), who were treated with cold-knife incision. After placement of an 8-french nephrostomy tube, a 0.035-inch guide wire bypassed the stricture under guidance of a centrally opened (5-french) ureter catheter. A wire-mounted cold-knife was pulled through the strictured area retrogradely under fluoroscopic control. Routinely, following the incision, an 8-french external stent was left in place for 6-8 weeks. RESULTS: After stent removal as a primary procedure, the ureteroenteric area has remained patent in 14 of 19 (74%) UAS. In 3 cases undergoing a secondary or repeated procedure, treatment failed. The average follow-up was 23.5 (range 12-39) months. Failures were associated with radiogenic injury of the ureter in 5 UAS and unexplained in 2. No complication was observed. CONCLUSION: Percutaneous endourological management of UAS with the cold-knife incision, when used as a primary treatment, is a safe and effective alternative to open surgical repair and should be considered as an initial approach.     

Long-term results of antegrade endoureterotomy using the holmium laser in patients with ureterointestinal strictures

Objectives. To investigate the effectiveness and morbidity of percutaneous laser endoureterotomy in the management of ureterointestinal anastomotic strictures after radical cystectomy and urinary diversion.Methods. Between May 1997 and August 2000, 19 percutaneous endoureterotomy incisions, including 3 repeated incisions, were performed on 15 patients with a mean age of 61 years (range 41 to 80) to treat ureterointestinal strictures. A total of 16 renal units were treated (9 left, 7 right), including one bilateral procedure. All procedures were performed using a 200-μm holmium laser fiber in antegrade fashion with a 7.5F flexible ureteroscope. A nephroureteral stent was left in place for 4 to 6 weeks postoperatively. Success was defined as radiologic improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes.Results. With a median follow-up of 20.5 months (range 9 to 41), the overall success rate was 57% (8 of 14 renal units). Two patients were lost to follow-up. The mean operative time was 91 minutes, and no perioperative complications occurred. Three patients required repeated endoureterotomies, with two requiring open reimplantation. Overall, the endoureterotomy failed in 6 patients in the series, with five of the six failures involving left-sided strictures.Conclusions. Percutaneous endoureterotomy is an effective, minimally invasive treatment option for patients with ureterointestinal strictures after urinary diversion. Better visualization and a more precise incision may make the holmium laser a safer cutting modality than alternative methods in patients with ureteroenteric strictures. Patients with left-sided ureterointestinal strictures should be cautioned that endourologic management might have a lower success rate.     

Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair

The established treatment for ureterointestinal anastomotic strictures is open surgical revision. In an effort to evaluate the efficacy of endourological surgery for this problem, we compared 7 patients (9 strictures) who underwent open revision to 6 patients (7 strictures) who underwent endoscopic incision and balloon dilation of the stricture. The success rate (that is patent ureter and no stent) was 89 per cent for the open revision group and 71 per cent (5 of 7) for the endoscopic group. All open revisions required use of general anesthesia, while 3 of the endoscopic procedures were performed with the patient under assisted local anesthesia. The endoscopic group had markedly shorter hospitalization, decreased blood loss, diminished patient discomfort and no postoperative complications. While the endoscopic procedure for ureteroileal anastomotic strictures is less successful than open revision, the lower morbidity, decreased cost and shorter hospital stay associated with the endourological approach favor its use over open revision. For elderly patients who fail initial endoscopic revision and for patients with metastatic transitional cell cancer, placement of an indwelling stent is a reasonable alternative. Given these guidelines, less than 30 per cent of the patients who suffer a ureteroileal anastomotic stricture will require open surgical revision.     

Holmium: YAG laser endoureterotomy for treatment of ureteral stricture

Objectives

Endourologic techniques ranging from balloon dilation to endoincision with electrocautery, cold knife, and lasers have been increasingly used in recent years for the treatment of ureteral strictures. While the long-term results may not be as reliable or as durable as traditional reconstructive surgical techniques, they can be accomplished with much less morbidity. Recently, the holmium:yttrium-aluminum-garnet (YAG) laser, which possesses both cutting and coagulating properties, has been demonstrated to have many applications in urology. We report our experience with this laser in the endoscopic treatment of ureteral strictures.

Methods

We reviewed the charts and follow-up history of 22 patients in whom the holmium:YAG laser was used to treat ureteral strictures from a variety of causes and including those in ureteroenteric anastomoses. Strictures were either approached in a retrograde fashion with a 6.9F ureteroscope or antegrade with flexible instruments in the cases involving ureteroenteric strictures. The only energy source employed was the laser, followed by balloon dilation. Indwelling stents were left in place for at least 4 weeks postoperatively and follow-up was obtained with radiographic imaging.

Results

A minimum 9-month follow-up was available for 18 patients. There were 5 patients who had developed recurrent strictures and were therefore considered treatment failures. Each of these patients failed in less than 3 months and all had either lengthy or complex strictures noted at the time of surgery. One patient was lost to follow-up and three recent patients have follow-up of 3 to 6 months showing no evidence of recurrent stricture formation. Overall, 16 of 21 (76%) patients are clinically well with no evidence of stricture recurrence.

Conclusions

Endoureterotomy for ureteral stricture disease is a minimally invasive, less morbid, but ultimately less successful, alternative to open surgical reconstruction. Stricture length and etiology remain the most important determinants of success. The holmium:YAG laser, with its ability to precisely cut tissue and provide hemostasis and its multiuse potential and compatibility with small rigid and flexible endoscopic instruments, is an ideal tool for performing endoureterotomy.     

Percutaneous placement of permanent metal stents for treatment of ureteroenteric anastomotic strictures

PURPOSE: To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric anastomotic strictures following failed balloon dilation or laser endoureterotomy. PATIENTS AND METHODS: Metal stents were placed in six ureteroenteric anastomotic strictures in four patients presenting with recurrent obstruction after balloon dilation or laser endoureteromy. Patients were evaluated at 1 week postoperatively with antegrade ureterography and at 3 to 6 months with renal ultrasound or CT scans. Serum creatinine assays and physical examination were performed at serial postoperative clinic visits. RESULTS: At 1-week follow-up, antegrade studies demonstrated a patent anastomosis in all six strictures. With a mean follow-up of 10 months (range 7-12 months), no stricture recurrence has been seen. All patients have been clinically stable, without episodes of pyelonephritis, flank pain, or need for indwelling stents or nephrostomy tube placement. Serum creatinine concentrations have been stable in all patients. CONCLUSIONS: Metal stents offer a useful treatment option in patients who develop ureteroenteric anastomotic strictures after urinary diversion. Further, such stents may be used in patients failing balloon dilation or laser endoureterotomy. Further study to assess the long-term durability of metal stent placement is needed.     

Endoureterotomy for treatment of ureteral strictures.

Advances in endosurgical technology have provided the urological surgeon with an alternative to open surgery for the treatment of ureteral strictures. We report the use of an endoscopic intraureteral incision (endoureterotomy) followed by balloon calibration to treat benign ureteral strictures in 13 patients. With an average subjective and objective followup among successful endoureterotomies of 20 months (all cases 12 months or greater), the overall success rate for this procedure is 62%. Of these patients 5 also received triamcinolone injections into the stricture bed following incision and dilation. This method appeared to influence favorably subsequent ureteral patency. The only operative complication was a urinoma, which resolved without intervention. Endoureterotomy appears to be a safe and reasonably effective modality for the treatment of ureteral stricture disease.     

Implantation of the urethral stent for treatment of complex urethral strictures. Evaluation of the functional and radiological results

We describe the results after implantation of a urethral stent in 6 patients with recurrent urethral strictures. Four patients had strictures located in close vicinity to the external sphincter. In 3 of these 4 patients open urethroplasty procedures had failed. The treatment was successful in 5 of the 6 patients with a follow-up of 6-10 months. However, in 1 patient who had a complex stricture close to the sphincter, dense fibrotic strictures recurred at the proximal end of the stent where a short segment of the stricture was left uncovered in order to preserve continence. We conclude that implantation of the stent is a valuable treatment for complex strictures in the vicinity of the sphincter on condition that the stent covers the whole stricture.     

Long-term results of treatment for ureteroenteric strictures

Objectives. To review the long-term outcome for ureteroenteric stricture treatment.Methods. The ileal conduit diversions that formed ureteroenteric strictures from 1966 to 1999 were reviewed. The strictures were diagnosed radiographically, and malignancy was excluded. The treatment, location, length, diameter, and timing of stricture development after conduit creation was evaluated and compared regarding the time until stricture recurrence (failure). Success was defined as symptomatic improvement and radiologic evidence of patency.Results. Forty patients, after exclusions, returned for ureteroenteric stricture repair, comprising 79 procedures (27 open repairs and 52 balloon dilations). The open repair had a success rate at 1, 2, and 3 years of 92%, 87%, and 76%, respectively. Seven of the open cases were preceded by failed dilations. Balloon dilation had a success rate at 1, 2, and 3 years of 15%, 15%, and 5%, respectively (P = 0.0001 versus open). Similar patency results for open versus balloon (P = 0.0001) were noted with analysis restricted to each patient’s first stricture repair. Strictures greater than 1.0 cm were more likely to recur (P = 0.03). All strictures forming within 6 months of the conduit creation were treated with dilation and failed within 1 year. Of note, 11 of the 40 patients were found to have less than 25% renal function on the strictured side.Conclusions. Open repair for ureteroenteric strictures offers excellent long-term patency (76% at 3 years, P = 0.0001). On review, balloon dilation appeared to have less successful patency rates and was often followed by open repair after failure. Patients with a history of anastomotic strictures should be closely monitored to avoid renal damage and failure.     

Treatment of uretero-intestinal and ureterovesical strictures by Acucise balloon catheter

OBJECTIVE: Acucise balloon catheter has been proposed as an alternative to open surgery for the treatment of strictures of the ureteropelvic junction because of its low morbidity and the short hospital stay following the endoscopic procedure. The objective of this study was to evaluate the results of this technique applied to patients developing strictures after surgical reimplantation of the ureterovesical (UV) or uretero-intestinal (UI) junction. MATERIAL AND METHODS: Between March 1997 and January 2000, 12 strictures (11 patients) were treated by Acucise balloon catheter via an antegrade and/or retrograde approach with double J stenting for an average of 6 weeks (range: 4-12 weeks): six uretero-ileal strictures (three Bricker, one uretero-ileoplasty, one enterocystoplasty and one Kock pouch) and six ureterovesical strictures (Lich-Grégoir or Paquin UV reimplantations after gynaecological, vascular or endoscopic surgery). The median postoperative follow-up was 16 months (range: 10-36 months). A good result was defined by the absence of recurrence of the stricture evaluated both clinically and radiologically (regression of stasis measured by IVU and/or ultrasonography). RESULTS: The mean operating time was 70 minutes and the mean hospital stay was 4.8 days (range: 3-14 days). Only one intraoperative complication was observed (migration of the double J stent to the kidney). The operation was successful in eight patients (75%). The success rate was 83% for ureterovesical strictures and 50% for uretero-ileal strictures. A history of previous irradiation appeared to be a factor of failure. CONCLUSION: The Acucise procedure is a minimally invasive and effective (75% success rate) treatment option for the treatment of postoperative stricture after ureteric reimplantations. In our department, this option is considered to be first-line treatment, as surgical reimplantation is reserved for failures of the endoscopic technique.     

Temporarily implanted urethral coil stent for the treatment of recurrent urethral strictures: a preliminary report

A new urethral stent developed for use in recurrent urethral strictures is presented. This metallic coil is self-expanding when released from its introducing catheter. The stent was used in 18 patients with recurrent strictures necessitating frequent dilation or urethrotomy. The stent is introduced under fluoroscopic guidance after internal urethrotomy or simple dilation. Strictures of 5 to 60 mm. were treated successfully with this device. All strictures were distal to the external sphincter. No serious complications attributed to the device were recorded. When necessary, the stent could be repositioned either under fluoroscopic control or endoscopically. This device can hold the stenotic area of the urethra open for long intervals allowing for complete healing. Even after 6 months the stent is not covered with urethral epithelium and does not become incorporated into the urethral wall. It can be removed easily without an operation by simple manipulation. The large internal caliber permits passage of endoscopes up to 17F in patients who require cystoscopy. The device can be removed before transurethral resections and then a new stent can be inserted at the end of the procedure. Mean followup of our patients with the stent indwelling was 8 months (range 4 to 11 months). Followup after removal of the stent (6 patients) was 3 to 8 months (mean 5 months). The patients voided well during followup and were fully continent. No incrustations were noted in the removed stents even after 6 months and no stent became obstructed due to tissue proliferation or incrustation. In 1 patient the stricture recurred after 3 months and a new stent was inserted. Urine sterilization was obtained in 7 patients with infected urine after relatively short courses of antibiotics. This stent seems to be a promising tool for the nonoperative treatment of recurrent urethral strictures.     

An endourologic approach to complete ureteropelvic junction and ureteral strictures

BACKGROUND AND PURPOSE: Complete stricture of the ureteropelvic junction (UPJ), ureter, or both represents a secondary upper tract obstruction and is a challenge for surgical management. The endourologic repair of these complete strictures remains controversial because of the many unsatisfactory results in the literature. The aim of this study was to achieve recanalization of the ureter or the UPJ using endourologic techniques to prove durable success of this technique. PATIENTS AND METHODS: We present data on the 21 patients with complete UPJ or ureteral strictures treated over 5-year period. The length of the obliterated portion of the ureter or UPJ ranged from 0.3 to 1.7 cm. The stricture was at the UPJ level in 12 patients (57%), in the upper ureter in 3, and in the lower ureter in 4. The technique was a combined approach, with antegrade introduction of the guidewire and retrograde cold-knife incision in the majority of the cases. In five cases, the incision was carried out in the reverse direction with a guidewire introduced retrograde up to the stricture level. An originally designed 6F to 7F polyethylene double-J stent with a movable 12F to 16F silicon sheath or percutaneous tube was placed at the completion of the procedure. RESULTS: The follow-up period ranged from 6 to 48 months. Recanalization was achieved in 17 patients (81%), of whom 14 became symptom free. Other surgical outcomes necessitated open surgical intervention (pyeloplasty, nephrectomy) in two patients. One patient developed a clinically significant recurrent urinary tract infection and deterioration of kidney function. Thus, the overall success rate of the endourologic management of the complete UPJ and ureteral strictures was 67% in our series. CONCLUSION: Endourologic management with retrograde or antegrade pyeloureterotomy can be successful in patients with short (up to 1.0-cm) obliterative strictures who are without extensive hydronephrosis and with preserved renal function.     

Combined antegrade and retrograde endoscopic approach for the management of urinary diversion-associated pathology

BACKGROUND: Endourologic management of stones and strictures in patients with a urinary diversion is often cumbersome because of the absence of standard anatomic landmarks. We report on our technique of minimally invasive management of urinary diversion-associated pathology by means of a combined antegrade and retrograde approach. PATIENTS AND METHODS: Five patients with urinary diversion-associated pathology were treated at our institution between May 1997 and October 1998. Their problems were: an obstructing ureteral stone in a man with ureterosigmoidostomy performed for bladder extrophy; two men with a valve stricture in their hemiKock urinary diversions; an anastomotic stricture in a man with an ileal loop diversion; and a long left ureteroenteric stricture in a man with a right colon pouch diversion. After percutaneous placement of an guidewire across the area of interest, the targeted pathology was accessed via a retrograde approach using standard semirigid or flexible fiberoptic endoscopes. Postoperative follow-up with intravenous urography, differential renal scan, or both was performed at 3 to 24 months (mean 12 months). RESULTS: The combined antegrade and retrograde approach allowed successful access to pathologic areas in all patients. Holmium laser/Acucise incision of stenotic segments or ballistic fragmentation of stones was achieved in all cases without perioperative complications. None of the strictures with an initially successful outcome has recurred; however, in one patient, the procedure failed as soon as the internal stent was removed. The patient with the ureteral calculus remains stone free, and his ureterosigmoidostomy is patent without evidence of obstruction on his last imaging study, 24 months postoperatively. CONCLUSIONS: Combined antegrade and retrograde endoscopic access to the area of interest is our preferred method of approaching pathologic problems in patients with a urinary diversion. An antegrade nephrostogram provides better delineation of anatomy, while through-and-through access enables rapid and easier identification of stenotic segments that may be hidden by mucosal folds. Furthermore, this approach allows the use of larger semirigid or flexible endoscopes in conjunction with more efficient fragmentation devices, resulting in enhanced vision from better irrigation. Finally, an initial endoscopic approach may be preferred because its failure does not compromise the success of future open surgery.     

Case report: Urothelial hyperplasia causing recurrent obstruction after ureteral metal stent placement in treatment of ureteroenteric anastomotic stricture

Initial experience utilizing metal stents in the treatment of ureteroenteric anastomotic strictures has yielded promising results. However, the long-term efficacy of metal stent placement remains unknown. Further, there is a paucity of literature to describe the technical considerations associated with the surgical management of obstruction after metal stent failure. We report the case of a 67-year-old man undergoing bilateral ureteral metal stent removal and ileal conduit creation following stent failure and recurrent obstruction.     

Ureteroscopic management of ureteral and ureteroenteral strictures

The ureteroscopic approach to ureteral strictures has diminished morbidity because of smaller-caliber equipment, improved optics, Ho:YAG laser, and a better understanding of the risk factors for ureteral strictures. Direct visualization by means of retrograde ureteroscopy provides a safe and effective approach to treat ureteral strictures without the need for an open incision or percutaneous nephrostomy access. All patients with a ureteral stricture require an extensive evaluation and planning before treatment. Generally, patients with ureteral strictures and a history of carcinoma should undergo biopsy of the area of stricture. With recurrent cancer, patients may present with pain, nausea, vomiting, pyelonephritis, or loss of the ipsilateral renal unit. Malignant strictures tend to not respond well to balloon dilation alone. Open or laparoscopic resection and reconstruction may be indicated if there is a chance for cure. In patients who are not good surgical candidates or in those who have advanced disease, the urologist is left with the option of an indwelling stent or nephrostomy tube.     

A new thermo-expandable shape-memory nickel-titanium alloy stent for the management of ureteric strictures.

OBJECTIVE: To assess the ease on insertion, patient tolerance, undesirable side-effects, degree of encrustation and duration of upper tract decompression with a new thermo-expandable shape memory alloy ureteric stent. PATIENTS AND METHODS: From November 1996 to October 1998, 15 patients with ureteric strictures were treated with a new nickel-titanium shape-memory alloy stent, the Memokath 051 (Engineers & Doctors A/S, Hornbaek, Denmark). A total of 22 insertions were carried out. Ureteric obstruction was caused by recurrent colorectal carcinoma in four patients; two patients each with transitional cell carcinoma of the bladder, iatrogenic injury or ischaemia at the uretero-ileal anastomosis; and one patient each with metastatic lymph nodes from prostatic carcinoma, radiation-induced fibrosis, pelvi-ureteric junction obstruction, metastatic carcinoma of the vagina and extra-luminal endometriosis. The stent has a shaft diameter of 9 F and its proximal end expands to 17 F. The first three patients were treated with the original version, which expanded to 14 F. The unexpanded stent is inserted into the ureter after initial dilatation of the stricture to 12 F. The stent is expanded by injection with sterile water preheated to 50 degrees C. The procedures were carried out under a general anaesthetic and patients were allowed home the next day. The follow-up protocol included initial intravenous urography (IVU) at 6 weeks, with assessment of a mid-stream urine sample and renal function tests. These were repeated at 3-monthly intervals. Isotopic renography was performed when indicated. RESULTS: The mean (range) follow-up was 10.6 (2-21) months; there was complete relief of upper tract obstruction in all patients. No stent-related symptoms, e.g. pain, sepsis, haematuria or frequency, were noted and no encrustation has occurred so far. The stent migrated in the first three patients with the original smaller diameter of stent but decompression of the upper tracts was maintained. None of the modified wider stents have migrated. The return of peristalsis in the proximal ureter was detected during IVU. There was no apparent endothelial growth through the stent material and no re-admissions for stent-related complications. CONCLUSION: Early experience with this new stent is very encouraging. All patients have maintained satisfactory decompression of their upper tracts with no need for repeated hospitalization for stent changes. There have been no untoward side-effects so far. This stent appears to have a valuable place in the long-term management of ureteric strictures; it is probably most suited for malignant ureteric obstruction. It should be considered in the management of selected benign strictures that require long-term JJ stenting.     

Ureterointestinal strictures following Bricker ileal conduit: management via a percutaneous approach

OBJECTIVE: Urinary diversion after radical cystectomy is commonly performed via an ileal conduit using the Bricker method. However, 4-8% of these cases are complicated with stricture formation at the ureterointestinal junction. Thus, this could eventually lead to hydronephrosis and kidney loss in neglected patients. Few data exist concerning the outcomes of patients with ureterointestinal junction strictures managed via a percutaneous approach and balloon dilatation of the stricture. The potential of managing these strictures, using a stent replacement strategy, was evaluated. PATIENTS AND METHODS: A total of 14 patients (10 male, 4 female; age range 24-72 years) were enrolled in the study. Mean follow-up time was 30.9 months. Invasive bladder cancer was diagnosed in 11, neurogenic bladder in 2 and shrunk bladder after external beam radiation for prostate cancer in 1 patient. They were all managed by radical cystectomy followed by Bricker ileal conduit. In 6 cases, ureterointestinal strictures bilaterally were discovered, whereas unilateral (left-sided) strictures were noted to the remaining 8 patients. All strictures were managed via a percutaneous approach and balloon dilatation. A double J stent was placed at the end of the procedure and was regularly replaced after an interval of 3-6 months. RESULTS: A percutaneous nephrostomy was successfully placed in all patients. Double J stent insertion was possible in 18 of a total of 20 (90%) obstructed ureters. No major complications were observed in any of the cases while adequate renal function was preserved in all patients. Quality of life is not reported to be significantly compromised in any patient. Double J ureteral stent replacement is performed every 3-6 months in a retrograde fashion. One patient died in the follow-up period due to disease progression. CONCLUSION: Placement of a double J stent via a percutaneous approach seems to have offered a viable option in the management of ureterointestinal strictures in this patient population. In addition, periodical retrograde replacement of the stent probably does not constitute a factor compromising quality of life. However, further studies are required to justify these primary clinical data.     

Holmium:YAG laser endoureterotomy in the treatment of ureteroenteric stricture following Indiana urinary diversion

A 57-year-old man who had received radical urethrocystectomy and Indiana urinary diversion 6 months earlier was treated for ureteroenteric anastomosis stricture (left side) using a Holmium:YAG laser via antegrade approach. The availability of small (6.9 Fr) flexible ureteroscope, as well as the use of the Holmium:YAG laser has facilitated the ability to precisely incise the stricture under direct endoscopic visualization. The technique is described for laser endoureterotomy in a patient with ureteroenteric stricture following Indiana urinary diversion.     

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.     

Evolving treatment of biliary strictures following liver transplantation.

BACKGROUND: The optimal endoscopic treatment for anastomotic biliary strictures after deceased donor liver transplantation is undefined. Endoscopic therapy with conventional methods of biliary dilation and stent placement has been successful but often requires prolonged therapy. OBJECTIVE: To determine the outcomes of an aggressive endoscopic approach that uses endoscopic dilation followed by maximal stent placement. SETTING: Tertiary-care academic medical center. PATIENTS: Of 176 patients who underwent deceased donor liver transplantation between June 1999 and July 2004, 25 were diagnosed with anastomotic biliary strictures. INTERVENTIONS: Patients were treated endoscopically with a combined technique of balloon dilation and maximal stent placement. MAIN OUTCOME MEASUREMENTS: Treatment outcomes, including bileduct patency, a need for surgical intervention, morbidity, and mortality, were evaluated retrospectively. RESULTS: Endoscopic dilation followed by maximal stent placement was performed until resolution of strictures in 22 or 25 patients (88% immediate success on intent-to-treat analysis). Persistent resolution of strictures was achieved in 18 of these 22 patients. Re-treatment was successful in 2 of 4 patients with recurrent strictures. Overall, 20 or 22 patients who completed endoscopic therapy (91%) avoided surgical intervention. Medical duration of endoscopic treatment was 4.6 months. Patients with early onset strictures required a significantly shorter duration of endoscopic therapy (3 vs 9 months; P < .01). Multiple stent placement was not technically difficult, and no major complications were encountered. CONCLUSIONS: Aggressive endoscopic therapy with combined biliary dilation and maximal stent placement allows resolution of anastomotic biliary strictures after deceased donor liver transplantation in a relatively short period, with sustained success and minimal complications.