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Percutaneous Management of Benign Ureteral Strictures and Fistulas
0022-534 7/87 /1376-1126$02.00/0 Vol. 137, June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
PERCUTANEOUS MANAGEMENT OF BENIGN URETERAL STRICTURES AND FISTULAS RICHARD CHANG, FRAY F. MARSHALL AND SALLY MITCHELL From the Department of Radiology, The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital and The Johns Hopkins University School of Medicine, Baltimore, Maryland
ABSTRACT
The percutaneous methods of management of benign ureteral strictures or fistulas have developed as a natural evolution of percutaneous nephrostomy and angiographic techniques. We review our 5year experience, which includes 18 patients with 19 benign ureteral strictures and 12 patients with ureteral fistulas. In the majority of the patients the ureteral strictures occurred at sites of surgical reconstruction or endoscopic manipulation. All fistulas resulted from surgical injury. In 10 of the 12 patients (82 per cent) the fistulas healed without development of a stricture or need for further intervention. Patients with short ureteral strictures had a high incidence of success and they usually were the best candidates for percutaneous manipulation. The longer strictures usually were of longer duration and they were less likely to be managed successfully percutaneously. Failure of percutaneous dilation did not impede subsequent surgical management. Percutaneous management often is a reasonable initial step in the treatment of ureteral strictures and fistulas. Percutaneous methods of management of ureteral strictures or fistulas not associated with malignancy developed as a natural evolution of percutaneous nephrostomy and angiographic techniques for catheterization of strictures in the vascular and biliary systems. These procedures have been reported with success rates ranging from 60 to 100 per cent for benign ureteral fistulas 1 • 2 and from 48 to 100 per cent for benign ureteral strictures. 1• 3- 7 Our 5-year experience is reviewed with the use of percutaneous methods for the management of benign ureteral strictures and fistulas with emphasis on features that appear to affect the likelihood of success or failure with these methods. MATERIALS AND METHODS
During the last 5 years 18 patients with 19 benign ureteral strictures were treated (table 1). The strictures involved sites of surgical reconstruction in 11 cases, including ureteroileal anastomoses in 9, primary ureteroureterostomy in 1 and pyeloplasty in 1. One patient had a stricture at the ureteropelvic junction and another in the lower ureter following surgical procedures to removerenal calculi. Ureteral strictures
-
Accepted for publication January 9, 1987.
though 7 patients had malignant tumors (bladder carcinoma in 3, colon or rectal carcinoma in 2, pelvic tumor in 1 and retroperitoneal carcinoma in 1) all fistulas were owing to either injuries incurred during exploration or loss of integrity of ureteral anastomosis. In 4 patients the fistula resulted from complicated surgery for stone disease and in 1 patient a ureterovaginal fistula developed as a result of a hysterectomy. For ureteral strictures or ureteral fistulas an 8 to lOF percutaneous nephrostomy tube was placed to provide access to and diversion of the upper urinary tract. In cases of ureteral strictures, if the ureter distal to the stricture was visualized with injection of contrast material under fluoroscopy, the ureter was negotiated with a guide wire (fig. 2). The stricture was dilated using an Olbert balloon dilation catheter (diameter 5 to 8 mm.) followed by placement of an antegrade ureteral stent (8 to 16F). The larger ureteral stents were fashioned from feeding tubes with sideholes cut in appropriate positions to provide for drainage from the renal pelvis as well as the bladder. For ureteral fistulas the percutaneous management was similar. If the ureter distal to the fistula was not demonstrated by antegrade pyelography during initial nephrostomy placement, external urinary diversion for 3 to 4 days usuafly permitted sufficient resorption of previously extravasated urine to permit visualization of the distal ureter on repeat injection. Retrograde catheterization usually was unnecessary to demonstrate the distal ureter. When the distal ureter could be visualized it then could be negotiated with guide wire techniques. The nephrostomy tube was exchanged for an antegrade ureteral stent with an external access port for continued drainage for 4 to 6 weeks (fig. 3). In 1 patient an internal retrograde ureteral stent was passed while maintaining the nephrostomy tube for external drainage. While these procedures can be performed with intravenous sedation and local anesthesia, dilation of the stricture or the nephrostomy tract often produces significant pain. For this reason, these procedures usually were performed with the patient under general anesthesia using portable fluoroscopy. The external part of the ureteral stent was connected to external drainage to permit any hematuria to resolve (usually 1 to 2 days). If no extravasation was demonstrated on reinjection of contrast material the stent could be capped to permit internal drainage. All patients with ureteral fistulas were kept on external drainage. For ureteral fistulas and strictures the stent usually
1126
TABLE l
Pt.
Stricture Following
AW
U reteroileostomy U reteroileostomy U reteroi!eostomy U reteroileostomy Ureteroileostomy Ureteroileostomy Ureteroileostomy
LB WG SE JF IF AR MH
WB AM
RC WD SP SD
LA
RB PK EF
Pyeloplasty (ureteropelvic junction) Ureterolithotomy Pyelolithotomy U reteroureterostomy Basketing of calculus U reteroscopy Ureteroscopy / ureterolithotomy Ureteroscopy / ureterotomy Ureteroscopy Ureteral ligation, hysterectomy Chronic cystitis
Duration Since Initial Operation
Stricture Length (cm.)
3 mos. 2 mos.
13 mos. 3 ll10S. 19 yrs.
4.5 3.5*
13 yrs. 3 mos.
6
Rt. 1, lt.
Dilation Bailoon Size (mm.)
0
8
6
16 16
8 5
6 wks.
10
3 mos. 6 wks. 5 wks. 6 wks.
8 5
14 16 10
6 8
12 12
Duration of Stenting
6 wks. 8wks. 6 wks. 6 wks. 7 wks.
5
6t
Stent Size (F)
Follo'>mp (mos.) Successful (48) Successful (11) Successful (16):j: Failed:\: Failed:j: Failed+ Successful (4) :j: Failed (4)t Successful (8)
18 mos.
2*
5
8
8wks.
Successful (12)
2 mos.
0.7 2
5 5
10
9 yrs.
12
4 wks. 4wks.
Successful (14) Failed+
1 yr.
0.5
5
12
6wks.
Successful (18)
2 mos. 3 mos., 11 mos. later re-dilation 3½ mos.
0.6 occlusion 1 occlusion
5
5,8
12 10, 16
6 wks. 6 wks, 6 wks.
Successful (3):j: Partial success (11), successful
6 wks.
6 wks.
(10):f:
6
8
16
6 wks.
Failed:j:
lOt 0.5
6
5
12 12
6 wits. 6 wks.
Failed Successful (7)
5
10
6 wks,
Successful (3)
1-2 yrs.
* Multiple strictures, total length shown.
t Prior radiation therapy to area. :j: Followup evaluation included Whitaker test.
FIG. 1. Example of short stricture, A, nephrostogram reveals ureteral stricture 4 weeks after ureteral ligation at time of hysterectomy (arrow). B, excretory urogram 10 weeks after ureteral dilation shows patent unobstmcted distal left ureter (arrow indicates previously strictured area). TABLE
2. Urinary fi1Jtul,as
Causes
No. Pts./No. Success
Anastomotic leaks: Ureteroileal Ureteroureterostorny Surgical ureteral trauma Pyelolithotomy Ureterolithotomy U reterovaginal fistula Total Nos.(%)
3/3 2/2 2/2 2/2 2/1 1/0 12/10 (83)
was left in place for 4 to 6 weeks. In 1 patient with a ureteral fistula it was left for 3 months (fig. 4), The stent then is exchanged over a guide wire for a simple nephrostomy tube and an antegrade pyelogram is performed a few days later to evaluate the ureter for possible extravasation or stricture formation, If the appearance of the ureter remains satisfactory, the nephrostomy tube is clamped for 1 to 2 days as a final test. If the radiographic appearance of the ureter is equivocal the patient then is scheduled for a perfusion-pressure (Whitaker) test the following week. If low pressures are demonstrated the nephrostomy tube is removed, If high perfusion pressures are present
the nephrostomy tube is left in management is planned.
and alternative surgical
RESULTS
Of the 19 strictures 12 per cent) were dilated successfully as judged by radiographic, pressure-flow and functional criteria (table 1). Followup ranged from 3 months to 5 years, No patient had a significant ureternl injury as a result of the dilation procedure and there was no evidence that an unsuccessful dilation procedure compromised subsequent surgical management, In 10 of 11 cases in which obstruction was of a short duration (usually less than 3 months postoperatively) a successful result was obtained, whereas only 2 of 8 patients with chronic or insidious onset of obstruction had successful results. All 11 cases with a stricture of less than 1.5 cm. long had a successful result. Only 1 patient in the group with a long stricture (fig, 5) or multiple strictures (fig. 6) responded favorably to dilation. In 10 of 12 patients the ureteral fistula healed without development of a stricture or further intervention (table 2), No patient in whom percutaneous management of the fistula was successful required any additional treatment during followup
1128
CHANG, MARSHALL AND MITCHELL
FIG. 2. Example of short and long ureteral strictures in same patient. A, short stricture at right ureteroileal anastomosis (2 arrows) and longer distal left ureteral stricture (multiple arrows). B, 8 mm. Olbert balloon is used to dilate longer left ureteral stricture with SF catheter already in right ureter. C, 16F feeding tube stents left ureter and 14F catheter stents right ureter.
FIG. 3. A, nephrostogram demonstrates urinary extravasation following failed attempt at ureteral reconstruction after ureteral transection during removal of colonic carcinoma. B, followup injection of contrast material at 2 weeks shows continued extravasation at site of ureteral injury (arrows). C, nephrostogram at 4 weeks reveals no urinary extravasation.
from 6 months to 4 years. One patient continues to carry an internal ureteral stent as a precaution to prevent obstruction of the lower ureter by compression from a pelvic tumor. Of the 2 patients in whom percutaneous management failed 1 had a chronic ureterovaginal fistula following hysterectomy for 4 years before seeking medical attention. Subsequently, this patient underwent psoas hitch ureteral reimplantation. At operation it was remarkable that the ureter was adherent directly to the vaginal wall with little intervening tissue. The other patient survived with a large chronic urinoma for more than a year. This fistula developed after ureterolithotomy. The ureter was compromised further by continued periureteral infection
and passage of small calculi to the skin, since the urinoma occasionally would develop a spontaneous cutaneous communication. Antegrade pyelography at the time of nephrostomy tube placement demonstrated an extremely narrow section between the upper and lower ureter that could not be negotiated with guide wires primarily because of acute angulation. This was our only case that could not be stented. DISCUSSION
Percutaneous management of benign strictures or fistulas offers the patient a potentially simpler and perhaps safer approach to these problems. Such management is attractive par-
PERCUTANEOUS MANAGEMENT OF BENIGN URETERAL STRICTURES AND FISTULAS
l:i.29
FIG. 6. Patient with multiple strictures many years after ilea! conduit. Note stricture in conduit (large arrow) and stricture at ureteroileal anastomosis (small arrow). Another stricture higher in ureter had been dilated. Patient failed percutaneous management.
FIG. 4. A, nephrostogram 1 month after initial treatment in 87year-old woman demonstrates fistulous tract following abdominoperineal resection for colorectal carcinoma. B, nephrostogram 3 months later shows dilatation of ureter at site of previous fistula but no evidence of urinary extravasation or obstruction.
FIG. 5. Long tapered ureteral stricture 18 years after construction of ilea! conduit (arrows). Patient failed percutaneous dilation and management.
ticularly since many of these injuries arise as a complication of previous surgery. Subsequent operation for repair is more difficult and can result in loss of the renal unit. Our approach to urinary fistulas is based on the principle that the urine must be diverted from the site of extravasation, particularly if there is a communication to the skin since this provides low pressure drainage. Thus, there is a pressure gradient driving urine from the kidney and abdomen towards the skin. Simple nephrostomy drainage reduces renal pressure to 0 and diverts the urine away from the fistula. Many of these fistulas arise as a result of some injury to the ureter and there is a risk that the site of injury will heal with stricture formation following decompression with nephrostomy tube drainage. For this reason ureteral fistulas are stented with antegrade ureteral stents ranging from 8 to 12F in size. Appropriate sideholes are
made in the tube so that connection to the external port then permits drainage of the urine as well as provides support for the ureter while it heals. Those fistulas treated within the first 2 months have all responded to percutaneous urinary diversion and stenting. If management is delayed, the fistulous tract has a chance to epithelialize and it is unlikely to respond to urinary stenting and urinary diversion alone. This had occurred in the patient who suffered for 4 years with a ureterovaginal fistula before seeking medical attention. In the only technical failure the ureter had become angulated as a result of cicatrization and a chronic urinoma. There is no advantage to delay the management of a urinary fistula. In our experience fistulas that fail to exhibit a decrease in urinary extravasation within 1 to 2 weeks of onset generally will not heal spontaneously and require treatment. Further delay in treatment of these fistulas only decreases the likelihood of success. These principles of management of ureteral injuries are effective particularly in the treatment of acute ureteral perforations that can occur after percutaneous stone removal or basketing procedures. We have excluded such patients from this series of more extensive ureteral injuries but we take the precaution to leave a ureteral stent and to provide external drainage after any procedure when a significant ureteral injury has been recognized. To date all such injuries have healed with no evidence of subsequent stricture formation. Use of ureteral stenting during ureteral surgery or other procedures has been recommended by a number of authors, and the benefits of stenting have been documented recently in a large series of patients undergoing ureteroileal anastomosis. 8 •9 For benign ureteral strictures there are many variations in the percutaneous methods of management (table 3). Some authors have used dilation with successively larger angiographic or ureteral catheters (Dotter technique) ,1· 3• 4· 10- 12 while others have used only balloon dilation catheters. The choice of the size of the balloon dilation catheter varies from inflation diameters of 4 to 5 mm. 5 - 7 , 13- 15 up to 9 mm. 16- 18 There also is considerable variation in the manner in which balloon dilation is performed. Some recommend that the balloon catheter be inflated only 1 minute at a time, 3 • 5 - 7 • 1H 7 while others advise that the balloon be kept inflated continuously for extended periods ranging from 1 to 16 hours a session. 18• 19 In addition, there is great variation in the number of times the balloon dilation is repeated. Some authors believe that balloon dilation should be repeated from 2 to 6 sessions 5• 7• 15- 17 and others recommend only a single session. 3• 6 • 13• 14 Even the use of ureteral stents following balloon dilation is not a universal practice. The spectrum of management includes leaving the dilated stricture unstented14' 16• 19 or the use of ureteral stents ranging in size from 65 to 10 and 12F3 • 7• 18 left in place from 3 days 7 to 3 or 4 months. 3 • 18 Clearly, there is no consensus on the most effective method for dilation (table 3).
1130
CHANG, MARSHALL AND MITCHELL TABLE 3.
Reference
Nature of Stricture (No. pts.)
Lane, T. J. D.: Brit. J. Urol., 27: 27, 1955
Tuberculosis (15)
O'Flynn 12
Tuberculosis (72)
Witherington and Shelor4 Reimer and Oswalt 14
Post-hysterectomy short strictures (4) Surgical ligation of ureter, short stricture (1) Surgical ligation of ureter, short stricture (1) Ureteroileal (1) Ureteroenteric (3)
Kaplan and associates
10
Dixon and associates Martin and associates 16 17
Benign ureteral strictures: dilation methods* Balloon Size (mm.) or Tapered Dilator (F) Braasch bougies 2 parallel, 5F catheters Braasch bougies 2 parallel, 5F catheters 8F
No. Dilation Sessions
12 (80)
Multiple
Not used
59 (82)
8F (2 days-6 wks.)
4 (100)
4mm.
Multiple (up to 4) 1
Not used
1 (100)
14F
1
SF (1 wk.)
1 (100)
9mm. 8mm.
6 4
1 (100) 3 (100)
6mm.
1 (6 hrs.) and 3 (16 hrs.) inflation periods Up to 3, inflation period 10-15 mins. 1
6.7F (4 wks.) 6/4 (days not specified) Not used
Glanz and associates 7 • *
Ureteroileal (2), mid ureter (1)
Banner and associates3
Assorted (27)
Finnerty and associates• King and associates•· t
Assorted (5) Assorted (10)
Lang'·*
Assorted (28)
6mm.
1
Not specified, review article
8mm.
Multiple (1 hr. inflation periods until 10-12 hrs. dilation) 1
Present series§
Assorted (18)
(%)
Not used
Ureteropelvic junction post-pyeloplasty (1)
Coleman and associates
No. Success
Multiple
Kadir and associates 19
18
Stent Size (duration)
4to6mm. 4 mm. balloon in 22 pts. or 6 to lOF dilators in 5 pts. 4 and 5 mm. 5mm.
5-8 mm.
1 1
Technical early success, failed late (0)
9 and lOF (3-10 days)
1 (33)
7-lOF (4 days-3 mos.)
13 (48)
6F (1 wk.) Double-J (6-8 wks.):j: 8-9F (not specitied) 10-12F (12-16 wks.)
5 (100) 5 (50) 15 (54)
8-16F (4-6 wks.)
12 (63)
Not specified
* Excluded transplant cases. t Excluded 2 cases of endoscopic incision. :j: Medical Engineering Corp., New York, New York. § Excluded transplant cases and malignant strictures.
In this series the balloon dilation catheters ranged from 5 to 8 mm. (fig. 2, B) and dilation was performed only during 1 session. Frequently, dilation was initiated with a 5 mm. balloon catheter that was inflated gently to see if a "waist" was produced by the stricture. If the "waist" appeared to be effaced suddenly by vigorous inflation, the dilation was considered to be sufficient. If, however, such indentation was seen on more vigorous inflation, a larger dilation catheter was required. Larger balloon dilation catheters with inflation diameters of up to 8 mm. were used sometimes. Ureteral disruptions or evidence of gross extravasation did not occur with the use of these larger balloons. However, dilation must be assumed to cause direct ureteral injury so the ureter is stented routinely for 4 to 6 weeks to allow healing, which is the same rationale used for management of benign ureteral fistulas. Our series differs from most in that larger stents (up to 16F or 5.3 mm. in diameter) often were used (fig. 2, B). This preference is based on a number of considerations. In most normal adults the diameter of the ureteral lumen is approximately 5 mm. In patients with strictures the ureter proximal to the stricture usually is dilated and will accommodate easily stents of 16F or greater. In the management of ureteroileal anastomotic strictures the ileal loop accommodates easily large size stents. Even when 16F stents were used in normal distal ureteral segments no evidence of ureteral injury was detected. The stent size is determined by the size of the balloon used to dilate the stricture. A tight stricture may require use of larger balloon dilation catheters. Stenting such a stricture with a small catheter less than 3 mm. in size (9F) after dilation might permit the ureter to scar back to a small diameter. Whenever an 8 mm. balloon catheter is used, a 16F ureteral stent also is used on the supposition that this stent replaces the need for the repetitive dilation that other authors have recommended.
Whenever a 16F stent could not be passed easily the balloon dilation usually was inadequate or the ureter required a smaller 12F stent. It is difficult to determine whether larger dilation catheters and stents make a significant difference in the ultimate outcome of dilation. In our series as well as those reported in the literature many patients have had good results following dilation or with ureteral stents of only SF. 3• 4 In our series the larger stents and balloon catheters were used only for strictures or occlusions that appeared to resist dilation with sm_aller balloon catheters. Only 1 patient has undergone dilation and stenting procedures with small and large stents. This patient presented with complete obstruction of the right ureter following ureteroscopy and ureterolithotomy. After the first dilation with a 5 mm. balloon catheter and stenting with a lOF ureteral stent, patency of the ureter was re-established with satisfactory drainage. The patient returned 11 months later because of an episode of ureteral colic probably caused by passage of a small stone. A Whitaker test demonstrated elevated pressures. The patient underwent a second dilation with an 8 mm. Olbert balloon catheter followed by passage of a 16F ureteral stent that was left in place for 6 weeks. A subsequent Whitaker test showed a normal pressure of 4 cm. water at an infusion rate of 15 ml. per minute. Probably more important to the ultimate outcome is the nature of the stricture rather than the exact method of dilation. The 2 favorable prognostic signs include short stricture length and short duration. All of our short strictures also were of relatively short duration. The majority of long strictures were of long duration, although 2 of short duration also failed to heal after dilation. Therefore, the primary determinant seems to be the length of the stricture. These results also are borne out in the literature. One reason that the dog experimental models of
'":·,·,·,-,·•~·.;·=-~,s-,·=-·:·•."
PER.CUTAN-EOUS )_\!{Af"JAGEMENT OF BENIGl'J URETERAL STRICTURES AN[J FiSTlJLAS
strictures
to dilation be because strictures were created. Similarly, Witherington and Shelor reported 4 cases, all of which responded to dilation and stenting with 8F ureteral catheters. 4 Although their cases differed in duration, all were short focal strictures. An example of the importance of stricture length is demonstrated our patient who underwent bilateral dilation and stenting of the ureter for bilateral ureteral strictures (1 long and l short stricture) discovered 3½ months after ileal loop diversion (fig. Only the short stricture responded to treatment despite identical management of both sides. A short stricture is recognized not only by its length but by its appearance. The ureter proximal to the stricture dilates almost to the point of maximal narrowing on antegrade pyelography and the ureter distal to the stricture appears to be normal on retrograde injection to the level of the stricture. Long strictures often exhibit gradually tapering lumina to the point of maximum narrowing owing to limited distensibility of the ureteral segments immediately proximal and distal to the point of maximum narrowing (fig. 5)0 Previous infection, urinary extravasation and vascular compromise may be factors in the formation of long ureteral strictures and their resistance to dilation. Extensive cicatrix was present on pathological examination of those long strictures in patients who required an operation subsequent to unsuccessful dilation. Since all short strictures have responded to the percutaneous method of management, only 1 short stricture has been examined pathologically in a patient who died of an aortic dissection 3 months after successful balloon dilation. Autopsy revealed that the kidney and collecting system appeared to be normal without hydronephrosis. For this reason we believe that short strictures should be approached aggressively with percutaneous methods even if completely obstructed. Longer lesions can be treated with percutaneous dilation provided the patient understands that the rate of failure is much greater.
5.
60
7,
8.
9. 10.
lL 12.
13. 14.
15, 16. 17. 18.
REFERENCES L Lang, K K: Antegrade ureteral stenting for dehiscence, strictures, and fistu!ae. Amer. J. Roentgen., 143: 795, 1984. 2, Bettmann, M.A., Murray, P, D., Perlmutt, L. M., Whitmore, W. F., HI and Richie, Jo P.: Ureteroileal anastomotic leaks: percutaneous treatment. Radiology, 148: 95, 1983. 3. Banner, M, P., Pollack, H. Mo, Ring, E. J. and Wein, A J.: Catheter dilatation of benign ureteral strictures. Radiology, 14 7: 427, 1983, 4. Witherington, R and Shelor, W, C: Treatment of postoperative
19.
20.
2L
1131
ureteral stricture by catheter dilation: a forgotten procedure, Urology, 16: 592, 1980, Finnerty, D. P., Trulock, T. S., Berkman, W. and Walton, KN.: Transluminal balloon dilation of ureteral strictures. J. Urol., 131: 1056, 1984. King, L. R., Coughlin, P. W. F., Ford, K K, Brown, M. W. and Van Moore, A.: Initial experiences with percutaneous and transurethral ablation of postoperative ureteral strictures in children" J. UroL, 131: 1167, 1984. Glanz, S., Gordon, D. H., Butt, K., Rubin, B., Hong, J. and Sclafini, S. J. A.: Percutaneous transrenal balloon dilatation of the ureter. Radiology, 149: 101, 1983. Lang, E. K.: Diagnosis and management of ureteral fistulas by percutaneous nephrotomy and antegrade stent catheter. Radiology, 138: 311, 198L Regan, J. B. and Barrett, D. M.: Stented versus nonstented ureteroileal anastomoses: is there a difference with regard to leak and stricture? J. Urol., 134: 1101, 1985. Kaplan, J. 0., Winslow, 00 P., Sneider, S. E., Pryor, T. H., Caplan, L. H. and Messinger, N. H.: Dilatation of a surgically ligated ureter through a percutaneous nephrostomy. Amer. Jo Roentgen., 139: 188, 1982. Runner, G. L.: End results in one hundred cases of ureteral stricture. Jo Urol., 12: 295, 1924. O'Flynn, D.: Surgical treatment of genito-urinary tuberculosis. A report on 762 cases. Brit. J. Urol., 42: 667, 1970. List, A. R., Blohme, I., Brynger, H. and Nilson, A. E.: Balloon dilation for ureteral strictures in graft kidneys" A viable alternative to further surgery. Transplantation, 35: 105, 1983. Reimer, D. E. and Oswalt, G. C., Jr.: Iatrogenic ureteral obstruction treated with balloon dilation. J. Urol., 126: 689, 1981. Waller, R. Mo, III, Finnerty, Do Po and Casarella, W. J.: Transluminal balloon dilation of a tuberculosis ureteral stricture. J. Urol., 129: 1225, 1983. Martin, E. Co, Fankuchen, E. I. and Casarella, W. J.: Percutaneous dilatation of ureteroenteric strictures or occlusions in ilea! conduits" UroL Rad., 4: 19, 1982" Dixon, G.D., Moore, J. D. and Stockton, R.: Successful dilatation of ureteroileal anastomotic stenosis using Griintzig catheter. Urology, 19: 555, 1982. Coleman, C. C., Kimura, Y., Castaneda-Zuniga, W. R., Hunter, D. W., Castaneda, F., Young, A. and Amplatz, K.: Interventional techniques in the ureter. Sem. Inter. Rad., l: 24, 1984. Kadir, S., White, R. I., Jr. and Engel, R.; Balloon dilatation of a ureteropelvic junction obstruction. Radiology, 143: 263, 1982. Barbaric, Z. L,, Gothlin, J. H. and Davies, R. S.: Transluminal dilatation and stent placement in obstructed ureters in dogs through the use of percutaneous nephropyelostomy. Invest. Rado, 12: 534, 1977. El-Mahrouky, A., Ford, K. K., Van Moore, A., Jr., Shore, No and King, Lo R.: Balloon dilatation of ureteral strictures in dogs. J. Urol., 131: 582, 1984.
THE JOURNAL OF UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
PERCUTANEOUS MANAGEMENT OF BENIGN URETERAL STRICTURES AND FISTULAS RICHARD CHANG, FRAY F. MARSHALL AND SALLY MITCHELL From the Department of Radiology, The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital and The Johns Hopkins University School of Medicine, Baltimore, Maryland
ABSTRACT
The percutaneous methods of management of benign ureteral strictures or fistulas have developed as a natural evolution of percutaneous nephrostomy and angiographic techniques. We review our 5year experience, which includes 18 patients with 19 benign ureteral strictures and 12 patients with ureteral fistulas. In the majority of the patients the ureteral strictures occurred at sites of surgical reconstruction or endoscopic manipulation. All fistulas resulted from surgical injury. In 10 of the 12 patients (82 per cent) the fistulas healed without development of a stricture or need for further intervention. Patients with short ureteral strictures had a high incidence of success and they usually were the best candidates for percutaneous manipulation. The longer strictures usually were of longer duration and they were less likely to be managed successfully percutaneously. Failure of percutaneous dilation did not impede subsequent surgical management. Percutaneous management often is a reasonable initial step in the treatment of ureteral strictures and fistulas. Percutaneous methods of management of ureteral strictures or fistulas not associated with malignancy developed as a natural evolution of percutaneous nephrostomy and angiographic techniques for catheterization of strictures in the vascular and biliary systems. These procedures have been reported with success rates ranging from 60 to 100 per cent for benign ureteral fistulas 1 • 2 and from 48 to 100 per cent for benign ureteral strictures. 1• 3- 7 Our 5-year experience is reviewed with the use of percutaneous methods for the management of benign ureteral strictures and fistulas with emphasis on features that appear to affect the likelihood of success or failure with these methods. MATERIALS AND METHODS
During the last 5 years 18 patients with 19 benign ureteral strictures were treated (table 1). The strictures involved sites of surgical reconstruction in 11 cases, including ureteroileal anastomoses in 9, primary ureteroureterostomy in 1 and pyeloplasty in 1. One patient had a stricture at the ureteropelvic junction and another in the lower ureter following surgical procedures to removerenal calculi. Ureteral strictures
-
Accepted for publication January 9, 1987.
though 7 patients had malignant tumors (bladder carcinoma in 3, colon or rectal carcinoma in 2, pelvic tumor in 1 and retroperitoneal carcinoma in 1) all fistulas were owing to either injuries incurred during exploration or loss of integrity of ureteral anastomosis. In 4 patients the fistula resulted from complicated surgery for stone disease and in 1 patient a ureterovaginal fistula developed as a result of a hysterectomy. For ureteral strictures or ureteral fistulas an 8 to lOF percutaneous nephrostomy tube was placed to provide access to and diversion of the upper urinary tract. In cases of ureteral strictures, if the ureter distal to the stricture was visualized with injection of contrast material under fluoroscopy, the ureter was negotiated with a guide wire (fig. 2). The stricture was dilated using an Olbert balloon dilation catheter (diameter 5 to 8 mm.) followed by placement of an antegrade ureteral stent (8 to 16F). The larger ureteral stents were fashioned from feeding tubes with sideholes cut in appropriate positions to provide for drainage from the renal pelvis as well as the bladder. For ureteral fistulas the percutaneous management was similar. If the ureter distal to the fistula was not demonstrated by antegrade pyelography during initial nephrostomy placement, external urinary diversion for 3 to 4 days usuafly permitted sufficient resorption of previously extravasated urine to permit visualization of the distal ureter on repeat injection. Retrograde catheterization usually was unnecessary to demonstrate the distal ureter. When the distal ureter could be visualized it then could be negotiated with guide wire techniques. The nephrostomy tube was exchanged for an antegrade ureteral stent with an external access port for continued drainage for 4 to 6 weeks (fig. 3). In 1 patient an internal retrograde ureteral stent was passed while maintaining the nephrostomy tube for external drainage. While these procedures can be performed with intravenous sedation and local anesthesia, dilation of the stricture or the nephrostomy tract often produces significant pain. For this reason, these procedures usually were performed with the patient under general anesthesia using portable fluoroscopy. The external part of the ureteral stent was connected to external drainage to permit any hematuria to resolve (usually 1 to 2 days). If no extravasation was demonstrated on reinjection of contrast material the stent could be capped to permit internal drainage. All patients with ureteral fistulas were kept on external drainage. For ureteral fistulas and strictures the stent usually
1126
TABLE l
Pt.
Stricture Following
AW
U reteroileostomy U reteroileostomy U reteroi!eostomy U reteroileostomy Ureteroileostomy Ureteroileostomy Ureteroileostomy
LB WG SE JF IF AR MH
WB AM
RC WD SP SD
LA
RB PK EF
Pyeloplasty (ureteropelvic junction) Ureterolithotomy Pyelolithotomy U reteroureterostomy Basketing of calculus U reteroscopy Ureteroscopy / ureterolithotomy Ureteroscopy / ureterotomy Ureteroscopy Ureteral ligation, hysterectomy Chronic cystitis
Duration Since Initial Operation
Stricture Length (cm.)
3 mos. 2 mos.
13 mos. 3 ll10S. 19 yrs.
4.5 3.5*
13 yrs. 3 mos.
6
Rt. 1, lt.
Dilation Bailoon Size (mm.)
0
8
6
16 16
8 5
6 wks.
10
3 mos. 6 wks. 5 wks. 6 wks.
8 5
14 16 10
6 8
12 12
Duration of Stenting
6 wks. 8wks. 6 wks. 6 wks. 7 wks.
5
6t
Stent Size (F)
Follo'>mp (mos.) Successful (48) Successful (11) Successful (16):j: Failed:\: Failed:j: Failed+ Successful (4) :j: Failed (4)t Successful (8)
18 mos.
2*
5
8
8wks.
Successful (12)
2 mos.
0.7 2
5 5
10
9 yrs.
12
4 wks. 4wks.
Successful (14) Failed+
1 yr.
0.5
5
12
6wks.
Successful (18)
2 mos. 3 mos., 11 mos. later re-dilation 3½ mos.
0.6 occlusion 1 occlusion
5
5,8
12 10, 16
6 wks. 6 wks, 6 wks.
Successful (3):j: Partial success (11), successful
6 wks.
6 wks.
(10):f:
6
8
16
6 wks.
Failed:j:
lOt 0.5
6
5
12 12
6 wits. 6 wks.
Failed Successful (7)
5
10
6 wks,
Successful (3)
1-2 yrs.
* Multiple strictures, total length shown.
t Prior radiation therapy to area. :j: Followup evaluation included Whitaker test.
FIG. 1. Example of short stricture, A, nephrostogram reveals ureteral stricture 4 weeks after ureteral ligation at time of hysterectomy (arrow). B, excretory urogram 10 weeks after ureteral dilation shows patent unobstmcted distal left ureter (arrow indicates previously strictured area). TABLE
2. Urinary fi1Jtul,as
Causes
No. Pts./No. Success
Anastomotic leaks: Ureteroileal Ureteroureterostorny Surgical ureteral trauma Pyelolithotomy Ureterolithotomy U reterovaginal fistula Total Nos.(%)
3/3 2/2 2/2 2/2 2/1 1/0 12/10 (83)
was left in place for 4 to 6 weeks. In 1 patient with a ureteral fistula it was left for 3 months (fig. 4), The stent then is exchanged over a guide wire for a simple nephrostomy tube and an antegrade pyelogram is performed a few days later to evaluate the ureter for possible extravasation or stricture formation, If the appearance of the ureter remains satisfactory, the nephrostomy tube is clamped for 1 to 2 days as a final test. If the radiographic appearance of the ureter is equivocal the patient then is scheduled for a perfusion-pressure (Whitaker) test the following week. If low pressures are demonstrated the nephrostomy tube is removed, If high perfusion pressures are present
the nephrostomy tube is left in management is planned.
and alternative surgical
RESULTS
Of the 19 strictures 12 per cent) were dilated successfully as judged by radiographic, pressure-flow and functional criteria (table 1). Followup ranged from 3 months to 5 years, No patient had a significant ureternl injury as a result of the dilation procedure and there was no evidence that an unsuccessful dilation procedure compromised subsequent surgical management, In 10 of 11 cases in which obstruction was of a short duration (usually less than 3 months postoperatively) a successful result was obtained, whereas only 2 of 8 patients with chronic or insidious onset of obstruction had successful results. All 11 cases with a stricture of less than 1.5 cm. long had a successful result. Only 1 patient in the group with a long stricture (fig, 5) or multiple strictures (fig. 6) responded favorably to dilation. In 10 of 12 patients the ureteral fistula healed without development of a stricture or further intervention (table 2), No patient in whom percutaneous management of the fistula was successful required any additional treatment during followup
1128
CHANG, MARSHALL AND MITCHELL
FIG. 2. Example of short and long ureteral strictures in same patient. A, short stricture at right ureteroileal anastomosis (2 arrows) and longer distal left ureteral stricture (multiple arrows). B, 8 mm. Olbert balloon is used to dilate longer left ureteral stricture with SF catheter already in right ureter. C, 16F feeding tube stents left ureter and 14F catheter stents right ureter.
FIG. 3. A, nephrostogram demonstrates urinary extravasation following failed attempt at ureteral reconstruction after ureteral transection during removal of colonic carcinoma. B, followup injection of contrast material at 2 weeks shows continued extravasation at site of ureteral injury (arrows). C, nephrostogram at 4 weeks reveals no urinary extravasation.
from 6 months to 4 years. One patient continues to carry an internal ureteral stent as a precaution to prevent obstruction of the lower ureter by compression from a pelvic tumor. Of the 2 patients in whom percutaneous management failed 1 had a chronic ureterovaginal fistula following hysterectomy for 4 years before seeking medical attention. Subsequently, this patient underwent psoas hitch ureteral reimplantation. At operation it was remarkable that the ureter was adherent directly to the vaginal wall with little intervening tissue. The other patient survived with a large chronic urinoma for more than a year. This fistula developed after ureterolithotomy. The ureter was compromised further by continued periureteral infection
and passage of small calculi to the skin, since the urinoma occasionally would develop a spontaneous cutaneous communication. Antegrade pyelography at the time of nephrostomy tube placement demonstrated an extremely narrow section between the upper and lower ureter that could not be negotiated with guide wires primarily because of acute angulation. This was our only case that could not be stented. DISCUSSION
Percutaneous management of benign strictures or fistulas offers the patient a potentially simpler and perhaps safer approach to these problems. Such management is attractive par-
PERCUTANEOUS MANAGEMENT OF BENIGN URETERAL STRICTURES AND FISTULAS
l:i.29
FIG. 6. Patient with multiple strictures many years after ilea! conduit. Note stricture in conduit (large arrow) and stricture at ureteroileal anastomosis (small arrow). Another stricture higher in ureter had been dilated. Patient failed percutaneous management.
FIG. 4. A, nephrostogram 1 month after initial treatment in 87year-old woman demonstrates fistulous tract following abdominoperineal resection for colorectal carcinoma. B, nephrostogram 3 months later shows dilatation of ureter at site of previous fistula but no evidence of urinary extravasation or obstruction.
FIG. 5. Long tapered ureteral stricture 18 years after construction of ilea! conduit (arrows). Patient failed percutaneous dilation and management.
ticularly since many of these injuries arise as a complication of previous surgery. Subsequent operation for repair is more difficult and can result in loss of the renal unit. Our approach to urinary fistulas is based on the principle that the urine must be diverted from the site of extravasation, particularly if there is a communication to the skin since this provides low pressure drainage. Thus, there is a pressure gradient driving urine from the kidney and abdomen towards the skin. Simple nephrostomy drainage reduces renal pressure to 0 and diverts the urine away from the fistula. Many of these fistulas arise as a result of some injury to the ureter and there is a risk that the site of injury will heal with stricture formation following decompression with nephrostomy tube drainage. For this reason ureteral fistulas are stented with antegrade ureteral stents ranging from 8 to 12F in size. Appropriate sideholes are
made in the tube so that connection to the external port then permits drainage of the urine as well as provides support for the ureter while it heals. Those fistulas treated within the first 2 months have all responded to percutaneous urinary diversion and stenting. If management is delayed, the fistulous tract has a chance to epithelialize and it is unlikely to respond to urinary stenting and urinary diversion alone. This had occurred in the patient who suffered for 4 years with a ureterovaginal fistula before seeking medical attention. In the only technical failure the ureter had become angulated as a result of cicatrization and a chronic urinoma. There is no advantage to delay the management of a urinary fistula. In our experience fistulas that fail to exhibit a decrease in urinary extravasation within 1 to 2 weeks of onset generally will not heal spontaneously and require treatment. Further delay in treatment of these fistulas only decreases the likelihood of success. These principles of management of ureteral injuries are effective particularly in the treatment of acute ureteral perforations that can occur after percutaneous stone removal or basketing procedures. We have excluded such patients from this series of more extensive ureteral injuries but we take the precaution to leave a ureteral stent and to provide external drainage after any procedure when a significant ureteral injury has been recognized. To date all such injuries have healed with no evidence of subsequent stricture formation. Use of ureteral stenting during ureteral surgery or other procedures has been recommended by a number of authors, and the benefits of stenting have been documented recently in a large series of patients undergoing ureteroileal anastomosis. 8 •9 For benign ureteral strictures there are many variations in the percutaneous methods of management (table 3). Some authors have used dilation with successively larger angiographic or ureteral catheters (Dotter technique) ,1· 3• 4· 10- 12 while others have used only balloon dilation catheters. The choice of the size of the balloon dilation catheter varies from inflation diameters of 4 to 5 mm. 5 - 7 , 13- 15 up to 9 mm. 16- 18 There also is considerable variation in the manner in which balloon dilation is performed. Some recommend that the balloon catheter be inflated only 1 minute at a time, 3 • 5 - 7 • 1H 7 while others advise that the balloon be kept inflated continuously for extended periods ranging from 1 to 16 hours a session. 18• 19 In addition, there is great variation in the number of times the balloon dilation is repeated. Some authors believe that balloon dilation should be repeated from 2 to 6 sessions 5• 7• 15- 17 and others recommend only a single session. 3• 6 • 13• 14 Even the use of ureteral stents following balloon dilation is not a universal practice. The spectrum of management includes leaving the dilated stricture unstented14' 16• 19 or the use of ureteral stents ranging in size from 65 to 10 and 12F3 • 7• 18 left in place from 3 days 7 to 3 or 4 months. 3 • 18 Clearly, there is no consensus on the most effective method for dilation (table 3).
1130
CHANG, MARSHALL AND MITCHELL TABLE 3.
Reference
Nature of Stricture (No. pts.)
Lane, T. J. D.: Brit. J. Urol., 27: 27, 1955
Tuberculosis (15)
O'Flynn 12
Tuberculosis (72)
Witherington and Shelor4 Reimer and Oswalt 14
Post-hysterectomy short strictures (4) Surgical ligation of ureter, short stricture (1) Surgical ligation of ureter, short stricture (1) Ureteroileal (1) Ureteroenteric (3)
Kaplan and associates
10
Dixon and associates Martin and associates 16 17
Benign ureteral strictures: dilation methods* Balloon Size (mm.) or Tapered Dilator (F) Braasch bougies 2 parallel, 5F catheters Braasch bougies 2 parallel, 5F catheters 8F
No. Dilation Sessions
12 (80)
Multiple
Not used
59 (82)
8F (2 days-6 wks.)
4 (100)
4mm.
Multiple (up to 4) 1
Not used
1 (100)
14F
1
SF (1 wk.)
1 (100)
9mm. 8mm.
6 4
1 (100) 3 (100)
6mm.
1 (6 hrs.) and 3 (16 hrs.) inflation periods Up to 3, inflation period 10-15 mins. 1
6.7F (4 wks.) 6/4 (days not specified) Not used
Glanz and associates 7 • *
Ureteroileal (2), mid ureter (1)
Banner and associates3
Assorted (27)
Finnerty and associates• King and associates•· t
Assorted (5) Assorted (10)
Lang'·*
Assorted (28)
6mm.
1
Not specified, review article
8mm.
Multiple (1 hr. inflation periods until 10-12 hrs. dilation) 1
Present series§
Assorted (18)
(%)
Not used
Ureteropelvic junction post-pyeloplasty (1)
Coleman and associates
No. Success
Multiple
Kadir and associates 19
18
Stent Size (duration)
4to6mm. 4 mm. balloon in 22 pts. or 6 to lOF dilators in 5 pts. 4 and 5 mm. 5mm.
5-8 mm.
1 1
Technical early success, failed late (0)
9 and lOF (3-10 days)
1 (33)
7-lOF (4 days-3 mos.)
13 (48)
6F (1 wk.) Double-J (6-8 wks.):j: 8-9F (not specitied) 10-12F (12-16 wks.)
5 (100) 5 (50) 15 (54)
8-16F (4-6 wks.)
12 (63)
Not specified
* Excluded transplant cases. t Excluded 2 cases of endoscopic incision. :j: Medical Engineering Corp., New York, New York. § Excluded transplant cases and malignant strictures.
In this series the balloon dilation catheters ranged from 5 to 8 mm. (fig. 2, B) and dilation was performed only during 1 session. Frequently, dilation was initiated with a 5 mm. balloon catheter that was inflated gently to see if a "waist" was produced by the stricture. If the "waist" appeared to be effaced suddenly by vigorous inflation, the dilation was considered to be sufficient. If, however, such indentation was seen on more vigorous inflation, a larger dilation catheter was required. Larger balloon dilation catheters with inflation diameters of up to 8 mm. were used sometimes. Ureteral disruptions or evidence of gross extravasation did not occur with the use of these larger balloons. However, dilation must be assumed to cause direct ureteral injury so the ureter is stented routinely for 4 to 6 weeks to allow healing, which is the same rationale used for management of benign ureteral fistulas. Our series differs from most in that larger stents (up to 16F or 5.3 mm. in diameter) often were used (fig. 2, B). This preference is based on a number of considerations. In most normal adults the diameter of the ureteral lumen is approximately 5 mm. In patients with strictures the ureter proximal to the stricture usually is dilated and will accommodate easily stents of 16F or greater. In the management of ureteroileal anastomotic strictures the ileal loop accommodates easily large size stents. Even when 16F stents were used in normal distal ureteral segments no evidence of ureteral injury was detected. The stent size is determined by the size of the balloon used to dilate the stricture. A tight stricture may require use of larger balloon dilation catheters. Stenting such a stricture with a small catheter less than 3 mm. in size (9F) after dilation might permit the ureter to scar back to a small diameter. Whenever an 8 mm. balloon catheter is used, a 16F ureteral stent also is used on the supposition that this stent replaces the need for the repetitive dilation that other authors have recommended.
Whenever a 16F stent could not be passed easily the balloon dilation usually was inadequate or the ureter required a smaller 12F stent. It is difficult to determine whether larger dilation catheters and stents make a significant difference in the ultimate outcome of dilation. In our series as well as those reported in the literature many patients have had good results following dilation or with ureteral stents of only SF. 3• 4 In our series the larger stents and balloon catheters were used only for strictures or occlusions that appeared to resist dilation with sm_aller balloon catheters. Only 1 patient has undergone dilation and stenting procedures with small and large stents. This patient presented with complete obstruction of the right ureter following ureteroscopy and ureterolithotomy. After the first dilation with a 5 mm. balloon catheter and stenting with a lOF ureteral stent, patency of the ureter was re-established with satisfactory drainage. The patient returned 11 months later because of an episode of ureteral colic probably caused by passage of a small stone. A Whitaker test demonstrated elevated pressures. The patient underwent a second dilation with an 8 mm. Olbert balloon catheter followed by passage of a 16F ureteral stent that was left in place for 6 weeks. A subsequent Whitaker test showed a normal pressure of 4 cm. water at an infusion rate of 15 ml. per minute. Probably more important to the ultimate outcome is the nature of the stricture rather than the exact method of dilation. The 2 favorable prognostic signs include short stricture length and short duration. All of our short strictures also were of relatively short duration. The majority of long strictures were of long duration, although 2 of short duration also failed to heal after dilation. Therefore, the primary determinant seems to be the length of the stricture. These results also are borne out in the literature. One reason that the dog experimental models of
'":·,·,·,-,·•~·.;·=-~,s-,·=-·:·•."
PER.CUTAN-EOUS )_\!{Af"JAGEMENT OF BENIGl'J URETERAL STRICTURES AN[J FiSTlJLAS
strictures
to dilation be because strictures were created. Similarly, Witherington and Shelor reported 4 cases, all of which responded to dilation and stenting with 8F ureteral catheters. 4 Although their cases differed in duration, all were short focal strictures. An example of the importance of stricture length is demonstrated our patient who underwent bilateral dilation and stenting of the ureter for bilateral ureteral strictures (1 long and l short stricture) discovered 3½ months after ileal loop diversion (fig. Only the short stricture responded to treatment despite identical management of both sides. A short stricture is recognized not only by its length but by its appearance. The ureter proximal to the stricture dilates almost to the point of maximal narrowing on antegrade pyelography and the ureter distal to the stricture appears to be normal on retrograde injection to the level of the stricture. Long strictures often exhibit gradually tapering lumina to the point of maximum narrowing owing to limited distensibility of the ureteral segments immediately proximal and distal to the point of maximum narrowing (fig. 5)0 Previous infection, urinary extravasation and vascular compromise may be factors in the formation of long ureteral strictures and their resistance to dilation. Extensive cicatrix was present on pathological examination of those long strictures in patients who required an operation subsequent to unsuccessful dilation. Since all short strictures have responded to the percutaneous method of management, only 1 short stricture has been examined pathologically in a patient who died of an aortic dissection 3 months after successful balloon dilation. Autopsy revealed that the kidney and collecting system appeared to be normal without hydronephrosis. For this reason we believe that short strictures should be approached aggressively with percutaneous methods even if completely obstructed. Longer lesions can be treated with percutaneous dilation provided the patient understands that the rate of failure is much greater.
5.
60
7,
8.
9. 10.
lL 12.
13. 14.
15, 16. 17. 18.
REFERENCES L Lang, K K: Antegrade ureteral stenting for dehiscence, strictures, and fistu!ae. Amer. J. Roentgen., 143: 795, 1984. 2, Bettmann, M.A., Murray, P, D., Perlmutt, L. M., Whitmore, W. F., HI and Richie, Jo P.: Ureteroileal anastomotic leaks: percutaneous treatment. Radiology, 148: 95, 1983. 3. Banner, M, P., Pollack, H. Mo, Ring, E. J. and Wein, A J.: Catheter dilatation of benign ureteral strictures. Radiology, 14 7: 427, 1983, 4. Witherington, R and Shelor, W, C: Treatment of postoperative
19.
20.
2L
1131
ureteral stricture by catheter dilation: a forgotten procedure, Urology, 16: 592, 1980, Finnerty, D. P., Trulock, T. S., Berkman, W. and Walton, KN.: Transluminal balloon dilation of ureteral strictures. J. Urol., 131: 1056, 1984. King, L. R., Coughlin, P. W. F., Ford, K K, Brown, M. W. and Van Moore, A.: Initial experiences with percutaneous and transurethral ablation of postoperative ureteral strictures in children" J. UroL, 131: 1167, 1984. Glanz, S., Gordon, D. H., Butt, K., Rubin, B., Hong, J. and Sclafini, S. J. A.: Percutaneous transrenal balloon dilatation of the ureter. Radiology, 149: 101, 1983. Lang, E. K.: Diagnosis and management of ureteral fistulas by percutaneous nephrotomy and antegrade stent catheter. Radiology, 138: 311, 198L Regan, J. B. and Barrett, D. M.: Stented versus nonstented ureteroileal anastomoses: is there a difference with regard to leak and stricture? J. Urol., 134: 1101, 1985. Kaplan, J. 0., Winslow, 00 P., Sneider, S. E., Pryor, T. H., Caplan, L. H. and Messinger, N. H.: Dilatation of a surgically ligated ureter through a percutaneous nephrostomy. Amer. Jo Roentgen., 139: 188, 1982. Runner, G. L.: End results in one hundred cases of ureteral stricture. Jo Urol., 12: 295, 1924. O'Flynn, D.: Surgical treatment of genito-urinary tuberculosis. A report on 762 cases. Brit. J. Urol., 42: 667, 1970. List, A. R., Blohme, I., Brynger, H. and Nilson, A. E.: Balloon dilation for ureteral strictures in graft kidneys" A viable alternative to further surgery. Transplantation, 35: 105, 1983. Reimer, D. E. and Oswalt, G. C., Jr.: Iatrogenic ureteral obstruction treated with balloon dilation. J. Urol., 126: 689, 1981. Waller, R. Mo, III, Finnerty, Do Po and Casarella, W. J.: Transluminal balloon dilation of a tuberculosis ureteral stricture. J. Urol., 129: 1225, 1983. Martin, E. Co, Fankuchen, E. I. and Casarella, W. J.: Percutaneous dilatation of ureteroenteric strictures or occlusions in ilea! conduits" UroL Rad., 4: 19, 1982" Dixon, G.D., Moore, J. D. and Stockton, R.: Successful dilatation of ureteroileal anastomotic stenosis using Griintzig catheter. Urology, 19: 555, 1982. Coleman, C. C., Kimura, Y., Castaneda-Zuniga, W. R., Hunter, D. W., Castaneda, F., Young, A. and Amplatz, K.: Interventional techniques in the ureter. Sem. Inter. Rad., l: 24, 1984. Kadir, S., White, R. I., Jr. and Engel, R.; Balloon dilatation of a ureteropelvic junction obstruction. Radiology, 143: 263, 1982. Barbaric, Z. L,, Gothlin, J. H. and Davies, R. S.: Transluminal dilatation and stent placement in obstructed ureters in dogs through the use of percutaneous nephropyelostomy. Invest. Rado, 12: 534, 1977. El-Mahrouky, A., Ford, K. K., Van Moore, A., Jr., Shore, No and King, Lo R.: Balloon dilatation of ureteral strictures in dogs. J. Urol., 131: 582, 1984.