经皮肾穿刺经尿道双途径球囊扩张并双"J"支架置入治疗输尿管狭窄和梗阻

目的 评价输尿管良、恶性狭窄和梗阻通过经皮肾穿刺经尿道双途径球囊扩张并双“J”支架置入的治疗效果。方法 131例输尿管狭窄或梗阻患者，其中良性125例，恶性6例；采用经皮肾穿刺经尿道双途径球囊扩张并置入双“J”支架联合介入治疗方法，随访6个月至10年。结果 良性输尿管狭窄和梗阻125例，成功123例，失败2例。恶性输尿管狭窄和梗阻6例，均获成功。治愈95例，占72．5％；好转34例，占26．0％；无效2例，占1．5％，总有效率98．5％。结论 经皮肾穿刺经尿道双途径球囊扩张并双“J”支架置入联合介入治疗输尿管狭窄和梗阻，创伤小，并发症少，治疗效果显著。     

良性输尿管狭窄和梗阻的介入球囊扩张成形治疗

目的 :评价输尿管良性狭窄和梗阻的介入治疗效果。方法 :对 2 5例良性输尿管狭窄和梗阻患者 ,分别采用经皮肾盂穿刺顺行扩张法和经尿道逆行扩张法 ,并置入双“J”支架管进行内引流治疗。结果 :2 5例共对 2 7侧输尿管进行扩张治疗 ,成功 2 3例(2 5侧 ) ,失败 2例。随访 6～ 5 8个月 ,患者临床症状减轻或消失 ,感染得到控制 ,肾功能好转、尿流动力学、IVP、B超和放射性肾图检查不再出现梗阻现象。结论 :良性输尿管狭窄和梗阻的介入球囊扩张治疗 ,具有创伤小 ,操作简单 ,治疗效果显著     

金属支撑管:对恶性输尿管梗阻的一种新的治疗

作者对12例恶性输尿管梗阻的病人在输尿管腔内成功地放置Strecker球囊膨胀和Accullex金属的自膨胀支撑管(各6例)。男4例,女8例,年龄42～78岁。2例为双侧,共14根输尿管用29根支撑管。置管前均经尿道内腔镜下放置双J支撑管未成功,经US和CT确诊输尿管梗阻,梗阻段长4～9cm。完成经皮肾造瘘并注入对比剂后确定输尿管狭窄段的位置。用0.889mm(0.035时)导丝穿过狭     

经皮顺行球囊扩张及内引流术治疗输尿管狭窄

目的：评价经皮顺行球囊扩张及内引流术对良、恶性输尿管狭窄的疗效。材料和方法：良性输尿管狭窄11例，恶性狭窄3例。经皮肾盂穿刺后，行球囊导管扩张术，留置双猪尾多倒孔内引流导管3周至6个月，术后随访3至21个月。结果：14例中治愈50％、有效35．6％、无效14．4％，无重要并发症。结论：经皮顺行球囊扩张及内引流术治疗良、恶性输尿管狭窄成功率高，是一种安全可行的技术，具有较高的临床应用价值。     

球囊扩张治疗输尿管狭窄172例临床观察

目的评价逆行球囊导管扩张输尿管狭窄的治疗效果。方法采用球囊导管对172例输尿管狭窄患者进行扩张治疗,以上病例分为两组,原发性输尿管狭窄组与继发性狭窄组,均采用逆行法,扩张后均留置双J管。结果155例扩张成功,症状和肾积水缓解,肾功能改善,17例拔出双J管后发生再狭窄,其中6例患者严重再狭窄,肾积水加重需手术治疗。结论腔内球囊扩张治疗输尿管狭窄是一种安全有效、简便易行的方法。     

尿道狭窄的输尿管镜下治疗

目的 评估尿道狭窄的输尿管镜下的治疗效果。方法 对56例尿道狭窄（尿道探子扩张失败）的病例行输尿管镜直视下扩张或内切开术。结果 本组一次性手术治愈35例，21例复发需重复治疗，其中6例植入了形状记忆合金网状支架。结论 输尿管镜直视下尿道扩张或切开术是治疗尿道狭窄的一种较好的治疗方法，可以避免治疗过程中再次造成医源性损伤。     

输尿管狭窄支架置入术的临床应用

目的探讨塑料支架和金属内支架在输尿管狭窄中的应用价值,寻求支架的合理选用。方法对28例输尿管良恶性狭窄患者,采用经皮肾穿刺顺行法或经尿道逆行法插管,行球囊扩张后支架置入。10例置入金属内支架,18例置入塑料支架。结果手术成功率100%,随访2~48个月,患者尿路梗阻解除,临床症状减轻或消失,感染得到控制,肾功能好转。12例恶性狭窄患者,能耐受常规剂量动脉插管化疗。结论输尿管狭窄支架置入术,具有创伤小,操作简单,疗效显著,值得推广。金属内支架通畅性好,在良性输尿管狭窄中,疗效确切,两种支架可酌情选用。     

腔内球囊扩张治疗输尿管外科手术后狭窄

了解腔内球囊扩张治疗输尿管外科手术后狭窄的方法和临床价值。方法：用球囊导管对２４例输尿管外科手术后的狭窄进行扩张,其中２２侧用逆行法,２例用顺行法,扩后１４例放置了双Ｊ管。结果：９３％的狭窄扩张成功,术后患者症状和肾盂积水缓解。结论腔内球囊扩张对输尿管外科手术后狭窄是一种安全而有效的方法。     

经尿道钬激光内切开治疗尿道狭窄或闭锁

目的探讨钬激光治疗尿道狭窄或闭锁的治疗方法和经验。方法对28例尿道狭窄或闭锁的患者应用钬激光行尿道内切开术治疗。结果 28例患者手术均一次成功,顺利留置F20~22导尿管,留置4~6周,拔管后均排尿通畅,部分患者术后近期需定期尿道扩张。结论经尿道钬激光内切开治疗尿道狭窄或闭锁手术操作微创,安全,精确,疗效满意。     

输尿管镜下尿道会师术在尿道损伤中的应用体会（附21例报告）

目的探讨输尿管镜下尿道会师术在尿道损伤中的应用价值及疗效。方法对尿道损伤患者21例采用输尿管镜下置入导尿管行尿道会师术。结果21例尿道损伤患者手术均一次成功,术后14例排尿通畅,不需尿道扩张,7例尿道狭窄,行尿道扩张1～6个月。随访3～12个月,均排尿通畅,无性功能障碍。结论采用输尿管镜下尿道会师术治疗尿道损伤创伤小,疗效满意,值得临床推广。     

Primary Percutaneous Treatment of Transplant Ureteral Strictures Using Tandem Stents

PurposeTo evaluate outcomes of primary (first-occurrence) treatment of renal transplant ureteral strictures using tandem parallel internal double-pigtail stents.Materials and MethodsA retrospective electronic chart review, including demographics, medical history, stricture intervention, and outcomes, was performed of patients with renal transplants with first-occurrence ureteral obstructions or leaks reported in a transplant nephrology database over a 4-year period, with a focus on patients treated primarily with tandem stents.ResultsOf 27 patients with first-occurrence ureteral obstruction or ureteral leak, 18 (67%) were treated primarily using tandem internal stents, with 15 (83%) of 18 stent-free for a minimum 90 days of follow-up. There was no significant difference between outcomes for male versus female patients (P>.99) or early versus late strictures (P = .53). Urinary tract infections (UTIs) occurred in 14 (78%) of 18 patients with tandem stents in place. Four patients were hospitalized<48 hours with UTI and sepsis; there were no other major complications.ConclusionsPatients with renal transplants can be successfully managed nonsurgically using tandem ureteral stents for the primary treatment of first-occurrence ureteral stricture. These patients may require more intensive monitoring for UTIs.     

Intraureteral metallic endoprosthesis in the treatment of ureteral strictures

OBJECTIVE: We report our experience on intraureteral metallic stents placement for the treatment of malignant and benign ureteral strictures. METHODS: Eight patients (six men and two women) with inoperable malignant or benign ureteral strictures, underwent insertion of metallic stents through percutaneous tracts. Six lesions (three malignant, three benign) involved ureterointestinal anastomoses after cystectomy for bladder cancer and ureteroileal urinary diversion or bladder substitution, and two malignant lesions involved the midureter. Self-expandable stents were used in seven cases and a balloon-expandable stent in the remaining one case. One stent was sufficient in seven ureters, and in one ureter, two overlapping stents were placed. RESULTS: Metallic stents were inserted without technical difficulties in all obstructed ureters and patency was achieved in all patients. Ultrasonography revealed resolution of pre-existing hydronephrosis. The duration of follow-up was 6-17 months (mean, 9 months). One ureter was occluded 8 months after stent placement because of ingrowth of tumor and granulation tissue. The other ureters showed no signs of obstruction during follow-up. No major complications directly attributable to the metallic stent occurred. CONCLUSIONS: Our results suggest that insertion of a metallic stent in the ureter is feasible and safe for the treatment of benign or malignant ureteral strictures. However, more work needs to be done to establish the use of these stents for the treatment of ureteral obstruction.     

Whitaker test after pyeloplasty: establishment of normal ureteral perfusion pressures

Twenty-seven patients underwent percutaneous ureteral perfusion after successful surgical repair of ureteropelvic junction obstruction in order to determine the perfusion pressures in ureters without obstruction. In each patient, the postoperative ureteropelvic junction appeared widely patent and the rest of the ureter appeared entirely normal. Ureteral perfusion was performed via percutaneous puncture of the collecting system; the pressure in the pelvis was measured through this needle and bladder pressure was monitored through a urethral catheter. "Absolute" (renal pelvic) and "differential" (renal pelvic minus bladder) pressures were measured at 10, 15, and 20 ml/min perfusion rates. Absolute and differential pressures rose as the perfusion rates increased; absolute pressure rose but differential pressure fell as the bladder was filled. The upper limit of normal differential pressure encountered with the bladder empty was 13 cm of water during perfusion at 10 ml/min.     

Balloon dilatation and insertion of temporary coated stents using a retrograde approach in patients with irreversible strictures of the distal ureter

Purpose

Irreversible obstruction of urine flow due to stricture of the distal ureter is one of the most frequent reasons for uroradiological intervention. Using new technologies and with appropriate stents applied at the right time, it is possible to release the stricture and avoid external drainage of urine.

Materials and methods

Our case series consists of six patients (four women, two men) initially treated by percutaneous nephrostomy due to ureteral stricture. The authors used a combined approach (both percutaneous and retrograde) because the balloon catheter could not be inserted using only one approach owing to the morphology of the stricture. The metal guidewire was inserted through a residual tract after previous nephrostomy, and the balloon catheter and a stent were introduced using a retrograde approach through the urinary bladder (four cases) or through an ileostomy positioned at the anterior abdominal wall. In five of the six cases, coated temporary ureteral stents were used.

Results

In all six cases the therapeutic aim was achieved. Urine flow through the strictures was established, and the need for percutaneous nephrostomy was obviated. Neither early nor late complications (11 months after the procedure and 6 months after stent removal) associated with the procedure were recorded.

Conclusion

In patients with subtotal stricture of the distal ureter, which permits passage only of a hydrophyl guidewire, a combined percutaneous retrograde approach can achieve sustainable flow of urine through the stricture using a balloon catheter and coated stents.     

Percutaneous Therapy of Ureteral Obstructions and Leak After Renal Transplantation: Long-Term Results

The purpose of this study was to evaluate the long-term outcome of percutaneous therapy of ureteral complications after renal transplantation. Between January 2000 and June 2006 we percutaneously treated 26 renal transplant patients with ureteral obstruction (n=19) and leak (n=7). Obstructions were classified as early (<2 months after transplantation) or late (>2 months). Patients with leak were treated with nephro-ureteral catheter placement and subsequent double-J stenting. Balloon dilatation, stent placement, and basket extraction were used to treat ureteral obstructions. Patients were followed with ultrasonography. No major procedure-related complication occurred. The mean follow-up time was 34.3 months (range: 6 to 74 months). Initial clinical success was achieved in all 19 patients with obstruction and 6 of 7 patients with leak. Four of 9 early obstructions and 4 of 10 late obstructions recurred during the follow-up. All recurrences were initially managed again with percutaneous methods, including cutting balloon technique and metallic stent placement. Although there was no recurrence in patients with successfully treated leak, stricture was seen at the previous leak site in two patients. These strictures were also successfully managed percutaneously. We conclude that in the treatment of ureteral obstruction and leak following renal transplantation, percutaneous therapy is an effective alternative to surgery. However, further interventions are usually needed to maintain long-term patency.     

Assessment of ureteral obstruction in patients with compromised renal function: Value of Curved Planar Reformations in MDCT

Objective

To evaluate the usefulness of MDCT using a curved planar reformation technique for the noninvasive assessment of the causes and level of ureteral obstruction in patients with compromised renal function.

Patients and methods

Between January 2012 and February 2013, 50 patients with clinical and sonographic manifestations of ureteral obstruction underwent non-contrast multidetector CT (MDCT) using a 16-slice machine. A total of 65 ureters were examined. Curved planar reformation images were performed to display the entire course of ureters in the same image. All patients had renal impairment with serum creatinine greater than 2.0 mg/dl. The gold standard for diagnosis of the cause of obstruction was ureteroscopy and/or open surgery. The sensitivity, specificity and overall accuracy of MDCT using curved planar reformation in the diagnosis of ureteral obstruction were calculated in comparison with the gold standard.

Results

A total of 65 ureters were examined (35 unilateral, 15 bilateral). The most common cause of ureteric obstruction was ureteric stone representing 27/65 (41.5%), followed by ureteric stricture representing 23/65 (35.4%). The lower third was the most affected in our study, it was encountered in 38/65 ureters (58.46%). The total sensitivity, specificity and accuracy of CPR for the cause of the ureteric obstruction were 98.5%, 98.5% and 97.8%, respectively (P value >0.05). CPR also was more sensitive and accurate for the level of ureteral obstruction with a total sensitivity of 100% and accuracy of 100% (P value >0.001).

Conclusion

Curved planar reformation MDCT is a useful noninvasive technique which is accurate in diagnosing the cause and level of ureteral obstruction in patients with compromised renal functions and is helpful for planning the therapeutic management of such patients.     

Percutaneous antegrade removal of double J ureteral stents via a 9-F nephrostomy route

PURPOSE: To evaluate the safety and clinical efficacy of an antegrade approach in the removal of double J ureteral stents via preexisting nondilated nephrostomy routes under fluoroscopic guidance. MATERIALS AND METHODS: Under fluoroscopic guidance and local anesthesia, antegrade removal of 39 ureteral stents in 27 patients was attempted by using a snare or basket. Indications for percutaneous stent removal included the presence of a preexisting nephrostomy route (n = 8), a surgical history resulting in an inaccessible retrograde route (n = 8), urethral stricture (n = 5), upward stent migration (n = 2), inability to obtain a lithotomy position (n = 1), fragmentation of the proximal stent (n = 1), and inability to find the ureteral orifice with a cystoscope (n = 2). RESULTS: Thirty-seven of the 39 stents (95%) were successfully removed by using a snare or basket. Two stents (5.1%) could not be removed with a snare or basket because they were embedded against the renal calyx or pelvis. There were no major complications. Blood clot formation or laceration or tract leakage of the pelvicalyceal system occurred in six and two patients, respectively, all of which resolved spontaneously. CONCLUSIONS: Percutaneous antegrade removal of double J ureteral stents with a snare or basket via a nondilated nephrostomy route is effective without major complications in patients with an available nephrostomy route or an inaccessible retrograde option.     

Experience with a new ureteral stent made of a biocompatible copolymer

A double-pigtail ureteral stent made from a biocompatible copolymer was designed for antegrade insertion with a new coaxial system. Thirty-eight of these stents were successfully placed in 33 patients. Of eight stents used for benign temporary indications, two (two patients) occluded prematurely. One of these patients had retained stone fragments, which caused the 10-F stent to occlude 4 months after balloon dilation of a midureteral stricture. The second patient had a ureteroconduit stricture that was dilated and stented, but mucus occluded the 10-F stent 5 days after insertion. In 25 of the patients, 30 stents were placed for ureteral obstruction due to malignant neoplasms. Three patients died with patent stents, while surviving patients with malignancies continue to have functioning stents, for an overall mean patency of 5.1 months in these patients. No problems related to stent migration or brittleness have been encountered.     

Direct percutaneous ureteral approach for the treatment of ureteral stenosis or obstruction.

Two cases are presented in which conventional approaches did not permit dilation of and stent placement in obstructed ureters. In patients with iatrogenic ureteral laceration or rigid ureteral kinking, direct percutaneous translumbar puncture may provide a safe alternative. The authors' technique is described.