- Email: [email protected]
Antegrade Percutaneous Balloon Dilation of Ureteral Strictures After Failed Pelviureteric or Ureterovesical Reimplantation in Children
Pediatric Urology Antegrade Percutaneous Balloon Dilation of Ureteral Strictures After Failed Pelviureteric or Ureterovesical Reimplantation in Children Robert Anastasescu, Thierry Merrot, Kathia Chaumoître, Michel Panuel, and Pierre Alessandrini OBJECTIVES MATERIALS AND METHODS
RESULTS
CONCLUSIONS
To assess the morbidity and success rate of percutaneous treatment of the postoperative ureteric strictures in children. Between January 1994 and December 2003, 12 children were treated by antegrade percutaneous balloon dilation for postoperative ureteric strictures. Stenosis occurred at the pelviureteric junction in 5 cases and ureterovesical junction in 7 cases. The 10 boys and 2 girls were between 3 months and 14 years old (mean, 5 years ⫾ 4.7 years). General anesthesia was used in 10 cases for nephrostomy catheter placement. Five ureteral stents were used additionally for nephrostomy drainage with a 6-F catheter. Both nephrostomy and ureteric stents were in place for 28.5 ⫾ 12 days, then removed after control antegrade pyelography. Dilation was technically successful in 9 of our patients. Two peroperative complications occurred. Postoperative results were evaluated by ultrasonography, intravenous urography, antegrade pyelography, and diethylene triamine pentaacetic acid renography that confirmed no obstacle in all 5 cases of pelviureteric stricture with a follow-up of 4 ⫾ 2.9 years and in 4 cases of ureterovesical junction with a follow-up of 4.7 ⫾ 2.8 years. Three unsuccessful results were reported: in 2 cases, the guide wire could not be advanced over the stenotic ureterovesical junction and in 1 case an early restenosis occurred that eventually required surgery. Although the main treatment of the postoperative ureteral strictures is surgical, the percutaneous antegrade balloon dilation seems to be an alternative to surgery with a low morbidity rate and short hospitalization period. UROLOGY 77: 1444 –1449, 2011. © 2011 Elsevier Inc.
S
trictures of the pelviureteric and ureterovesical anastomosis are uncommon but well recognized complications of ureteral surgery. Traditional surgery is the usual treatment and reconstruction is successful in most cases. However, in some patients, open surgical repair fails and each subsequent attempt at surgery becomes more difficult and with higher risk of complications.1-3 Percutaneous nephrostomy in adults is a “routine” technique in uroradiology, with well-documented indications, technique, results, and complications.4 During the last decade, percutaneous endourological procedures were applied in pediatric population as well.5-7 Although this technique is considered as easy, safe, and efficient for some authors,5,6 its indications are still limited for others.8 We present in this article 12 cases of percutaneous antegrade balloon dilations of pelviureteric and ureterFrom the Service de Chirurgie Pédiatrique; and Service de Radiologie Pédiatrique, Université de la Méditerranée. Reprint requests: Robert Anastasescu, M.D., Hôpital Nord Marseille, chemin des Bourrelys 13015, Marseille CEDEX 20, the French Republic. E-mail: [email protected] Submitted: August 24, 2010, accepted (with revisions): October 29, 2010
1444
© 2011 Elsevier Inc. All Rights Reserved
ovesical postoperative strictures. The aim of this study was to assess the morbidity and success rate of the percutaneous procedures in treatment of ureteral postoperative strictures.
MATERIAL AND METHODS Between January 1994 and December 2003, 45 percutaneous nephrostomies were performed. Antegrade balloon dilations for postoperative ureteric strictures were performed in 12 of our patients. In 5 cases, the stenosis occurred after dismembered Hynes-Anderson pyeloplasty and in 7 cases ureterovesical junction was affected after Cohen re-implantation surgery. The 10 boys and 2 girls ranged from 3 months to 14 years (mean, 5 years ⫾ 4.7) at the moment of the procedure. Patients’ ages at the time of initial surgery ranged from 2 months to 13 years (mean, 52.6 months ⫾ 31). Routine preoperative evaluation of the ureteral obstruction consisted of ultrasonography and diethylene triamine pentaacetic acid (DTPA) or benzoylmercaptoacetyltriglycine (MAG3) renography. In some cases, intravenous pyelography, cystoscopy, and measurement of blood urea, serum creatinine, and serum electrolytes were performed. Antegrade pyelography performed after nephrostomy placement under fluoroscopic control demonstrated the site of ureteral obstruction. Follow-up 0090-4295/11/$36.00 doi:10.1016/j.urology.2010.10.052
Table 1. General table presenting the results in our personal series
Patient Age 5y 3y 6y 18 m 12 y 3m 14 y 5y 12 y 11 m 2y 2y
Stricture Location Ureterovesical junction Ureterovesical junction Pelviureteric junction Ureterovesical junction Pelviureteric junction Pelviureteric junction Pelviureteric junction Ureterovesical junction Ureterovesical junction Pelviureteric junction Ureterovesical junction Ureterovesical junction
Interval Between Initial Surgery and Balloon Stent Drainage Dilation Placement Period 4y 1y 6 mo 11 mo 11 mo 1 mo 14 mo 2y 10 mo 9 mo 18 mo 1y
after initial surgery was done at 6 months, by periodic assessment of urinary tract using ultrasonography, except 1 patient who presented with early symptoms (1 month after initial surgery). We have completed the follow-up studies by renal scans performed at different intervals postoperatively according to each case. Total follow-up period in successful cases ranged from 16 months to 9 years (mean, 87 months ⫾ 29.7) (Table 1). All patients received preoperative and postoperative antibiotics until the urinary drainage was removed, except 5 patients who presented with clinical features of urinary tract infection or bacteriuria. In these cases, the patients underwent percutaneous nephrostomy after a previous antibiotherapy using a thirdgeneration cephalosporin, ceftriaxone, 100 mg/kg, administrated 3 - 5 days preoperatively. Balloon dilation was performed at different intervals after nephrostomy tube placement. In all other cases, we used sulfamethoxazole and trimethoprim or cefaclor according to each case and to our institution protocol. During the procedure, all patients except infants received 1 intravenous injection of cefaclor (15 mg/kg). Urine control documentation was then performed weekly.
Procedure The nephrostomy was performed in all cases with general anesthesia, except 2 cases that required only sedation and local anesthesia, with the patient in prone position. Under real-time ultrasonographic and fluoroscopic guidance, the nephrostomy catheter was introduced in the collecting system by a direct technique with the catheter mounted on the trocar cannula. We used a “pig tale” Huysman 5-F or 6-F catheter with trocar. Urine was first collected, and then contrast medium type telebrix 12 was injected under fluoroscopic control to opacify the collecting system. The stricture area was dilated using a 5-F balloon catheter type haemaquet passed over a 0.35-mm Terumo guide wire (Terumo Medical Corporation, Tokyo, Japan) positioned in the stenotic segment and expanded up to 10 atm for 60 seconds. The balloons we used were 2 or 4 cm long and 6 or 8 mm of diameter, respectively, according to each case. The procedure was repeated until the ureteral lumen appeared to be sufficiently enlarged. The efficiency of the procedure was estimated by a preoperative and postoperative antegrade pyelography. A ureteral antegrade or retrograde stent was placed in 5 cases. Nephrostomy catheter drainage was preserved in all cases for 1– 6 weeks and then removed after antegrade opacification (Table 1). UROLOGY 77 (6), 2011
No No No No Yes Yes Yes No No Yes Yes No
4 wks 5 wks 3 wks 4 wks 4 wks 6 wks 6 wks 1 wk 3 wks 4 wks 5 wks 1 wk
Follow-up
Secondary Procedure
5.6 y — 18 mo — 8y — Relapse after 3 mo Open surgery 16 mo — 3y — Relapse after 3 mo Second dilation Failure Open surgery 3y — 6y — 9y — Failure None
RESULTS In all 12 cases, we attempted to perform an antegrade balloon dilation of postoperative stenosis at the pelviureteric or ureterovesical junction after ureteric reimplantation. Dilation was successful in 9 patients (Table 1). The procedure was performed in all cases under general anesthesia except in 2 children who required only sedation and local anesthesia according to their age. None of the procedures was performed on an outpatient basis according to our institution protocol. In most of the cases (8 patients), no other procedure was done before the nephrostomy and ureteral dilatation. However, we attempted 2 unsuccessful retrograde balloon dilations by cystoscopy in 1 case of ureterovesical reimplantation and 1 case of pelviureteric reimplantation, respectively. In 1 case of early pelviureteric stenosis, we performed a prolonged drainage by ureteral catheter and in 1 case, we performed a redo pyeloplasty, caused by a postoperative twisting effect of the pelviureteric junction, that eventually underwent balloon dilation. In 7 cases, the antegrade balloon dilation was performed for secondary stricture after ureterovesical reimplantation (Fig. 1). First, ultrasonographic study was performed 3 months after the dilation procedure. The patients who were successfully dilated were followed for 16 months to 9 years (mean follow-up period 87 ⫾ 29.7 months) after the procedure, and the diuresis renogram performed at 12 months showed no evidence of recurrent obstruction in 4 cases. In 1 case of ureterovesical stricture, the guide wire could not be advanced over the stricture and a new attempt using a 0.18 Terumo guide wire was also unsuccessful. In this case, the patient underwent subsequent open surgery. One child had stenosis of the ureterovesical junction corresponding to a nonrefluxing ureter in a double urinary system, whose function was low enough to not require secondary surgery. In 1 case, we attempted an unsuccessful retrograde balloon dilation of the ureterovesical stricture by cystoscopy, which finally required an antegrade balloon dilation that relieved the obstruction. The second procedure 1445
Figure 1. Five-year-old child. Postoperative stenosis at the left ureterovesical junction after reflux surgery drained by nephrostomy (A, B). Treatment by antegrade percutaneous balloon dilatation (C, D). Good result on intravenous urography (IVU) done 1 year after the endoscopic procedure (E, F).
Figure 2. Twelve-year-old child: Postoperative stenosis at the left pelviureteric junction (A, white arrow). Treatment by antegrade percutaneous balloon dilatation (B) was performed after percutaneous nephrostomy with a good result on opacification at day 3 (C).
was performed 1 month after the first attempt. Nevertheless, ultrasonographic study performed 3 months after dilation showed restenosis that eventually required open surgery. Dilation was successful in all 5 cases of postoperative stricture after dismembered Hynes-Anderson pyeloplasty (Fig. 2). However, in one of the cases, second antegrade balloon dilation was necessary when a residual stenotic 1446
ureter was revealed after antegrade pyelography (Fig. 3). The patient underwent second dilation 3 months after the first procedure. We preferred balloon dilation to redo surgery because of limited stenosis length of ⬍5 mm. In 1 case, postoperative stricture was revealed as soon as 10 days postoperatively by unexplained abdominal pain and hematuria. Ultrasonographic studies showed an important renal pelvic dilatation. A 5-F transanastomotic ureUROLOGY 77 (6), 2011
Figure 3. Twelve-year-old child. Two postoperative stenosis in the right pelviureteric junction and the middle part of the ureter after pelviureteric junction surgery with ureteral remodeling (A, white arrows). Treatment by antegrade percutaneous balloon dilatation was performed (B, C) after percutaneous nephrostomy with a good result on preoperative antegrade pyelography (D).
teral catheter was placed to resolve the postoperative swelling. The catheter clogged within 10 days and we chose to perform a percutaneous nephrostomy to drain the kidney. Antegrade pyelography performed 30 days postoperatively showed no passage and the patient underwent subsequent balloon dilation. In all cases, urine drainage was performed using a 5-F or 6-F nephrostomy catheter. In 2 cases, a pelviureteric stent was left in place to avoid the immediate recurrence of the stricture. In 3 other cases, the nephrostomy drainage was completed by external ureteric stent through the urethra. Routine stenting after balloon dilation was done in only 5 of our cases. The average period of urinary drainage was 28.5 days. The mean stenting period was 27.3 days. At the time of primary surgery, stenting was used in 4 cases of ureterovesical reimplantation and 1 case of pyeloplasty. In all cases, we used external drained stents. The mean stenting period in our series was 9.5 days. In 1 case of pelviureteric junction obstruction, we placed a transanastomotic ureteral catheter 48 hours after the initial surgery because of postoperative anastomotic leakage with secondary urinoma. The catheter was removed within 1 week after a ureteral opacification test. The mean hospital stay for patients undergoing percutaneous antegrade balloon dilation was 3 days. In all our cases, we preferred to perform the procedure on hospitalized patients for a better surveillance. Follow-up dilation procedures and percutaneous nephrostomy catheter removal were performed on an outpatient basis. We note 2 perioperative complications: a perirenal hemorrhage caused by the puncture of a blood vessel during nephrostomy that resolved spontaneously, and a urinary extravUROLOGY 77 (6), 2011
asation at the pelviureteric junction that occurred during the dilation procedure. Long-term results were evaluated by ultrasonography and diuretic renal flow scans that confirmed no obstacle in all 5 cases of pelviureteric stricture with a follow-up of 4 ⫾ 2.9 years and in 4 cases of ureterovesical junction with a follow-up of 4.7 ⫾ 2.8 years. These 9 successfully dilated patients were all asymptomatic. The overall success rate in our series is then 75%.
COMMENT Surgery remains the treatment of choice in cases of obstruction secondary to failed surgical pelviureteric or vesicoureteral reimplantation.2,3 However treatment of this uncommon but well-known complication is possible using a less invasive procedure, despite the high success rate of open surgery. Percutaneous nephrostomy was performed for the first time in 1955 by Goodwin for drainage of a distended kidney.9 This procedure has a lower morbidity than classic surgery, requiring only a short hospitalization period. The studies of Kramolowsky et al confirmed it.10 The use of balloon dilation of the ureter was described as early as 1926 by Dourmashkin to remove ureteral calculi.11 More recently, the development of percutaneous techniques12,13 has resulted in new applications of balloon catheters for relief of postoperative ureteral obstruction. In published series, the immediate success rate of percutaneous nephrostomy is almost always about 100%.10,14 In our study, successful dilations were achieved in 4 of 7 patients (57%) and 5 of 5 (100%) patients with ureterovesical postoperative strictures or ureteropelvic postoperative stricture, respectively. According to the litera1447
ture, the overall success rate of balloon dilation of the ureter using antegrade or retrograde approach is always ⬎50%.15-17 Few preoperative elements seem to be correlated with good long-term results. According to the literature, strictures ⬍2 cm are more accessible to balloon dilation and have a higher long-term success rate than those ⬎2 cm.18-20 Our study confirms these data, the best results obtained in stenoses of ⬍1 cm. In our series, stricture length ranged from 5 mm to 2 cm. Longest strictures were noted after failed vesicoureteric reimplantation rather then pelviureteric surgery. Thus, we can explain the lower success rate after balloon dilation of vesicoureteric strictures. We also have noticed in our patients that the best long-term results are obtained in recent stenosis. However all previous studies generally included few patients with brief follow-up intervals.21,22 Therefore, we suggest that best results are obtained in recent stenoses of ⬍1 cm. In our 12-case series of percutaneous endoluminal balloon dilation, the ureteral stricture was recognized after a variable period after the primary surgery (Table 1). In all cases except 2, the stenosis was revealed by imaging studies. In the other 2 cases, the stenosis was revealed by lumbar pain, hematuria, and urinary tract infection, respectively. An important issue in the endourological treatment of secondary ureteral strictures is the choice of antegrade or retrograde approach, but to our knowledge, no such comparative studies have been presented. However, longterm success rates appear to be similar.19 We consider that ureteropelvic strictures could be dilated both antegrade and retrograde, depending on the personal preferences and the associated pathology (normal or abnormal kidney, ureteral orifice presentation), although the antegrade approach appears to be the method of choice for dilation of ureterovesical strictures. Stenosis after ureterovesical re-implantation represents a real challenge for endoluminal balloon dilation. In this case, the stricture occurs at the penetration of the ureter into the bladder or at the ureteral meatus. In both situations, the metallic guide wire cannot always be advanced through the stenotic ureter as in 2 of our cases. In these situations, we consider that open surgery remains the gold standard. The interest of double-J drainage is discussed in the literature. Some authors consider that a double-J catheter should be left in place for at least 6 weeks.23 None of our patients had a double-J drainage. In our series, we preferred the retrograde ureteral stent drainage that allowed ureteral opacification and a well-controlled drainage without back pressure. Another advantage of retrograde external stent is its removal without anesthesia. The morbidity rate of this procedure is low.5,24,25 However, minor complications requiring no specific therapy, such as transient hematuria, urinary tract infection, catheter displacement, perirenal hematoma, and urine leak, may be seen in 15-25% of patients who undergo a ne1448
phrostomy procedure.26,27 Major complications like severe hemorrhage, vascular injury, septic shock, or kidney loss are quite rare (1-9%) according to different studies.28,29 Some other potentially catastrophic complications, including transfusion requiring hemorrhage, bowel perforation, and pleural complications have also been reported.30 In this study, we encountered one major complication (transfusion requiring hemorrhage) in a 12-year-old boy, which resolved spontaneously. Other complications were represented by minor hemorrhage (2 cases), urinary tract infection (1 case), dislodgement of the catheter (1 case), and urinary leak (1 case). Transient hematuria was noticed in almost all cases, but we did not consider it a complication. All major complications could be avoided by choosing a paucivascular punction area. Use of ultrasonography combined with real-time fluoroscopy reduces the morbidity rate.
CONCLUSIONS Treatment of postoperative ureteral strictures by open surgery was considered the gold standard. Percutaneous balloon dilation represents an interesting, less invasive alternative, with lower morbidity and a shorter hospitalization period. Although the long-term success of this procedure in children is not yet known, benefit has been documented for those 18 months to 9 years old. The mean follow-up in our series is up to 5 years. Overall, balloon dilation appears to be an appropriate initial approach to the treatment of most patients with ureteral strictures. The best results were obtained on short recent strictures. Acknowledgments. We acknowledge Publique-Hôpital Nord Marseille–Pavillon Mère Enfant. References 1. Aliabadi H, Reinberg Y, Gonzales R. Percutaneous balloon dilation of ureteral strictures after failed surgical repair in children. J Urol. 1990;144(2):486-488. 2. Glen JF, Anderson EE. Complications of ureteral reimplantation surgery. Urol Surv. 1973;23:243-247. 3. Hendren WH. Reoperation for failed ureteral reimplantation. J Urol. 1974;11:403-411. 4. Stables DP. Percutaneous nephrostomy: technique, indications and results. Urol Clin North Am. 1982;9(1):15-29. 5. Stanley P, Diament MJ. Pediatric percutaneous nephrostomy: experience with 50 patients. J Urol. 1986;135(6):1223-1226. 6. Winfield AC, Kirchner SG, Brun ME, et al. Percutaneous nephrostomy in neonates, infants and children. Radiology. 1984;151:617619. 7. Irving HC, Arthur RJ, Thomas DFM. Percutaneous nephrostomy in pediatrics. Clin Radiol. 1987;38:245-248. 8. Gordon I. Upper urinary tract dilatation in newborns and infants. In: Fotter R, editor. Pediatric Uroradiology. Berlin: Springer; 2001: 161-176. 9. Goodwin WE, Casey WC, Woolf W. Percutaneous trocar (needle) nephrostomy in hydronephrosis. JAMA. 1955;157:891-894. 10. Kramolowsky EV, Clayman RV, Weiman PJ. Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair. J Urol. 1988;139:1195-1198.
UROLOGY 77 (6), 2011
11. Dourmashkin RL. Dilatation of ureter with rubber bags in the treatment of ureteral calculi. Presentation of a modified uperating cystoscope: a preliminary report. J Urol. 1926;15:449-460. 12. Miller RP, Reinke DB, Clayman RV, et al. Percutaneous approach to the ureter. Urol Clin North Am. 1982;9:31-40. 13. Pollack HM, Banner MP. Percutaneous nephrostomy and related pyeloureteral manipulative techniques. Urol Radiol. 1981;2:147-154. 14. Lojanapiwat B, Mital D, Fallon L, et al. Management of ureteral stenosis after renal transplantation. J Am Coll Surg. 1994;179:21-24. 15. Dyer RB, Assimos DG, Reagan JD. Update on interventional uroradiology. Urol Clin North Am. 1997;24(3):623-652. 16. Lucey B, McGrath FP, Fotheringham T, et al. Miscellaneous visceral renal interventions. Semin Interv Radiol. 2000;17:367-372. 17. Tan HL, Roberts JP, Grattan-Smith D. Retrograde balloon dilatation of ureteropelvic obstructions in infants and children: early results. Urology. 1995;46:89-91. 18. Cormio L, Battaglia M, Traficante A, et al. Endourological treatment of ureteric injuries. Br J Urol. 1993;72:165-168. 19. Goldfischer ER, Gerber GS. Endoscopic management of the ureteral strictures. J Urol. 1997;157(3):770-775. 20. Lezin MA, Stoller ML. Surgical ureteral injuries. Urology. 1991;38: 497-506. 21. Glanz G, Gordon DH, Butt K, et al. Percutaneous transrenal balloon dilatation of the ureter. Radiology. 1983;149:101-104.
UROLOGY 77 (6), 2011
22. Finnerty DP, Trulock TS, Berkman W, et al. Transluminal balloon dilation of ureteral strictures. J Urol. 1984;131:1056-1060. 23. Kerbl K, Chandhoke PS, Figenshau RS, et al. Effect of stent duration on ureteral healing following endoureterotomy in an animal model. J Urol. 1993;150:1302-1305. 24. Dyer RB, Regan JD, Kavanagh PV, et al. Percutaneous nephrostomy with extension of the technique: step by step. RadioGraphics. 2002;22(3):503-525. 25. Agostini S, Dedola GL, Gabrielli S, et al. A new percutaneous technique in the treatment of obstructive uropathy. Radiol Med. 2003;105(5-6):454-461. 26. Bjarnason H, Ferral H, Stackhouse DJ, et al. Complications related to percutaneous nephrolithothomy. Semin Interv Radiol. 1994;11: 213-225. 27. Lee WJ, Smith AD, Cubelli V, et al. Complications of percutaneous nephrolithotomy. AJR Am J Roentgenol. 1987;148:177-180. 28. Ramchandani P, Cardella JF, Grassi CJ, et al. Quality improvement guidelines for percutaneous nephrostomy. J Vasc Interv Radiol. 2003; 14:277-281. 29. Rabii R, Joual A, Rais H, et al. Pyonephrosis: diagnosis and treatment. Report of 14 cases. Ann Urol. 2000;34:161-164. 30. Lewis S, Patel U. Major complications after percutaneous nephrostomy—lessons from a department audit. Clin Radiol. 2004;59:171179.
1449
RESULTS
CONCLUSIONS
To assess the morbidity and success rate of percutaneous treatment of the postoperative ureteric strictures in children. Between January 1994 and December 2003, 12 children were treated by antegrade percutaneous balloon dilation for postoperative ureteric strictures. Stenosis occurred at the pelviureteric junction in 5 cases and ureterovesical junction in 7 cases. The 10 boys and 2 girls were between 3 months and 14 years old (mean, 5 years ⫾ 4.7 years). General anesthesia was used in 10 cases for nephrostomy catheter placement. Five ureteral stents were used additionally for nephrostomy drainage with a 6-F catheter. Both nephrostomy and ureteric stents were in place for 28.5 ⫾ 12 days, then removed after control antegrade pyelography. Dilation was technically successful in 9 of our patients. Two peroperative complications occurred. Postoperative results were evaluated by ultrasonography, intravenous urography, antegrade pyelography, and diethylene triamine pentaacetic acid renography that confirmed no obstacle in all 5 cases of pelviureteric stricture with a follow-up of 4 ⫾ 2.9 years and in 4 cases of ureterovesical junction with a follow-up of 4.7 ⫾ 2.8 years. Three unsuccessful results were reported: in 2 cases, the guide wire could not be advanced over the stenotic ureterovesical junction and in 1 case an early restenosis occurred that eventually required surgery. Although the main treatment of the postoperative ureteral strictures is surgical, the percutaneous antegrade balloon dilation seems to be an alternative to surgery with a low morbidity rate and short hospitalization period. UROLOGY 77: 1444 –1449, 2011. © 2011 Elsevier Inc.
S
trictures of the pelviureteric and ureterovesical anastomosis are uncommon but well recognized complications of ureteral surgery. Traditional surgery is the usual treatment and reconstruction is successful in most cases. However, in some patients, open surgical repair fails and each subsequent attempt at surgery becomes more difficult and with higher risk of complications.1-3 Percutaneous nephrostomy in adults is a “routine” technique in uroradiology, with well-documented indications, technique, results, and complications.4 During the last decade, percutaneous endourological procedures were applied in pediatric population as well.5-7 Although this technique is considered as easy, safe, and efficient for some authors,5,6 its indications are still limited for others.8 We present in this article 12 cases of percutaneous antegrade balloon dilations of pelviureteric and ureterFrom the Service de Chirurgie Pédiatrique; and Service de Radiologie Pédiatrique, Université de la Méditerranée. Reprint requests: Robert Anastasescu, M.D., Hôpital Nord Marseille, chemin des Bourrelys 13015, Marseille CEDEX 20, the French Republic. E-mail: [email protected] Submitted: August 24, 2010, accepted (with revisions): October 29, 2010
1444
© 2011 Elsevier Inc. All Rights Reserved
ovesical postoperative strictures. The aim of this study was to assess the morbidity and success rate of the percutaneous procedures in treatment of ureteral postoperative strictures.
MATERIAL AND METHODS Between January 1994 and December 2003, 45 percutaneous nephrostomies were performed. Antegrade balloon dilations for postoperative ureteric strictures were performed in 12 of our patients. In 5 cases, the stenosis occurred after dismembered Hynes-Anderson pyeloplasty and in 7 cases ureterovesical junction was affected after Cohen re-implantation surgery. The 10 boys and 2 girls ranged from 3 months to 14 years (mean, 5 years ⫾ 4.7) at the moment of the procedure. Patients’ ages at the time of initial surgery ranged from 2 months to 13 years (mean, 52.6 months ⫾ 31). Routine preoperative evaluation of the ureteral obstruction consisted of ultrasonography and diethylene triamine pentaacetic acid (DTPA) or benzoylmercaptoacetyltriglycine (MAG3) renography. In some cases, intravenous pyelography, cystoscopy, and measurement of blood urea, serum creatinine, and serum electrolytes were performed. Antegrade pyelography performed after nephrostomy placement under fluoroscopic control demonstrated the site of ureteral obstruction. Follow-up 0090-4295/11/$36.00 doi:10.1016/j.urology.2010.10.052
Table 1. General table presenting the results in our personal series
Patient Age 5y 3y 6y 18 m 12 y 3m 14 y 5y 12 y 11 m 2y 2y
Stricture Location Ureterovesical junction Ureterovesical junction Pelviureteric junction Ureterovesical junction Pelviureteric junction Pelviureteric junction Pelviureteric junction Ureterovesical junction Ureterovesical junction Pelviureteric junction Ureterovesical junction Ureterovesical junction
Interval Between Initial Surgery and Balloon Stent Drainage Dilation Placement Period 4y 1y 6 mo 11 mo 11 mo 1 mo 14 mo 2y 10 mo 9 mo 18 mo 1y
after initial surgery was done at 6 months, by periodic assessment of urinary tract using ultrasonography, except 1 patient who presented with early symptoms (1 month after initial surgery). We have completed the follow-up studies by renal scans performed at different intervals postoperatively according to each case. Total follow-up period in successful cases ranged from 16 months to 9 years (mean, 87 months ⫾ 29.7) (Table 1). All patients received preoperative and postoperative antibiotics until the urinary drainage was removed, except 5 patients who presented with clinical features of urinary tract infection or bacteriuria. In these cases, the patients underwent percutaneous nephrostomy after a previous antibiotherapy using a thirdgeneration cephalosporin, ceftriaxone, 100 mg/kg, administrated 3 - 5 days preoperatively. Balloon dilation was performed at different intervals after nephrostomy tube placement. In all other cases, we used sulfamethoxazole and trimethoprim or cefaclor according to each case and to our institution protocol. During the procedure, all patients except infants received 1 intravenous injection of cefaclor (15 mg/kg). Urine control documentation was then performed weekly.
Procedure The nephrostomy was performed in all cases with general anesthesia, except 2 cases that required only sedation and local anesthesia, with the patient in prone position. Under real-time ultrasonographic and fluoroscopic guidance, the nephrostomy catheter was introduced in the collecting system by a direct technique with the catheter mounted on the trocar cannula. We used a “pig tale” Huysman 5-F or 6-F catheter with trocar. Urine was first collected, and then contrast medium type telebrix 12 was injected under fluoroscopic control to opacify the collecting system. The stricture area was dilated using a 5-F balloon catheter type haemaquet passed over a 0.35-mm Terumo guide wire (Terumo Medical Corporation, Tokyo, Japan) positioned in the stenotic segment and expanded up to 10 atm for 60 seconds. The balloons we used were 2 or 4 cm long and 6 or 8 mm of diameter, respectively, according to each case. The procedure was repeated until the ureteral lumen appeared to be sufficiently enlarged. The efficiency of the procedure was estimated by a preoperative and postoperative antegrade pyelography. A ureteral antegrade or retrograde stent was placed in 5 cases. Nephrostomy catheter drainage was preserved in all cases for 1– 6 weeks and then removed after antegrade opacification (Table 1). UROLOGY 77 (6), 2011
No No No No Yes Yes Yes No No Yes Yes No
4 wks 5 wks 3 wks 4 wks 4 wks 6 wks 6 wks 1 wk 3 wks 4 wks 5 wks 1 wk
Follow-up
Secondary Procedure
5.6 y — 18 mo — 8y — Relapse after 3 mo Open surgery 16 mo — 3y — Relapse after 3 mo Second dilation Failure Open surgery 3y — 6y — 9y — Failure None
RESULTS In all 12 cases, we attempted to perform an antegrade balloon dilation of postoperative stenosis at the pelviureteric or ureterovesical junction after ureteric reimplantation. Dilation was successful in 9 patients (Table 1). The procedure was performed in all cases under general anesthesia except in 2 children who required only sedation and local anesthesia according to their age. None of the procedures was performed on an outpatient basis according to our institution protocol. In most of the cases (8 patients), no other procedure was done before the nephrostomy and ureteral dilatation. However, we attempted 2 unsuccessful retrograde balloon dilations by cystoscopy in 1 case of ureterovesical reimplantation and 1 case of pelviureteric reimplantation, respectively. In 1 case of early pelviureteric stenosis, we performed a prolonged drainage by ureteral catheter and in 1 case, we performed a redo pyeloplasty, caused by a postoperative twisting effect of the pelviureteric junction, that eventually underwent balloon dilation. In 7 cases, the antegrade balloon dilation was performed for secondary stricture after ureterovesical reimplantation (Fig. 1). First, ultrasonographic study was performed 3 months after the dilation procedure. The patients who were successfully dilated were followed for 16 months to 9 years (mean follow-up period 87 ⫾ 29.7 months) after the procedure, and the diuresis renogram performed at 12 months showed no evidence of recurrent obstruction in 4 cases. In 1 case of ureterovesical stricture, the guide wire could not be advanced over the stricture and a new attempt using a 0.18 Terumo guide wire was also unsuccessful. In this case, the patient underwent subsequent open surgery. One child had stenosis of the ureterovesical junction corresponding to a nonrefluxing ureter in a double urinary system, whose function was low enough to not require secondary surgery. In 1 case, we attempted an unsuccessful retrograde balloon dilation of the ureterovesical stricture by cystoscopy, which finally required an antegrade balloon dilation that relieved the obstruction. The second procedure 1445
Figure 1. Five-year-old child. Postoperative stenosis at the left ureterovesical junction after reflux surgery drained by nephrostomy (A, B). Treatment by antegrade percutaneous balloon dilatation (C, D). Good result on intravenous urography (IVU) done 1 year after the endoscopic procedure (E, F).
Figure 2. Twelve-year-old child: Postoperative stenosis at the left pelviureteric junction (A, white arrow). Treatment by antegrade percutaneous balloon dilatation (B) was performed after percutaneous nephrostomy with a good result on opacification at day 3 (C).
was performed 1 month after the first attempt. Nevertheless, ultrasonographic study performed 3 months after dilation showed restenosis that eventually required open surgery. Dilation was successful in all 5 cases of postoperative stricture after dismembered Hynes-Anderson pyeloplasty (Fig. 2). However, in one of the cases, second antegrade balloon dilation was necessary when a residual stenotic 1446
ureter was revealed after antegrade pyelography (Fig. 3). The patient underwent second dilation 3 months after the first procedure. We preferred balloon dilation to redo surgery because of limited stenosis length of ⬍5 mm. In 1 case, postoperative stricture was revealed as soon as 10 days postoperatively by unexplained abdominal pain and hematuria. Ultrasonographic studies showed an important renal pelvic dilatation. A 5-F transanastomotic ureUROLOGY 77 (6), 2011
Figure 3. Twelve-year-old child. Two postoperative stenosis in the right pelviureteric junction and the middle part of the ureter after pelviureteric junction surgery with ureteral remodeling (A, white arrows). Treatment by antegrade percutaneous balloon dilatation was performed (B, C) after percutaneous nephrostomy with a good result on preoperative antegrade pyelography (D).
teral catheter was placed to resolve the postoperative swelling. The catheter clogged within 10 days and we chose to perform a percutaneous nephrostomy to drain the kidney. Antegrade pyelography performed 30 days postoperatively showed no passage and the patient underwent subsequent balloon dilation. In all cases, urine drainage was performed using a 5-F or 6-F nephrostomy catheter. In 2 cases, a pelviureteric stent was left in place to avoid the immediate recurrence of the stricture. In 3 other cases, the nephrostomy drainage was completed by external ureteric stent through the urethra. Routine stenting after balloon dilation was done in only 5 of our cases. The average period of urinary drainage was 28.5 days. The mean stenting period was 27.3 days. At the time of primary surgery, stenting was used in 4 cases of ureterovesical reimplantation and 1 case of pyeloplasty. In all cases, we used external drained stents. The mean stenting period in our series was 9.5 days. In 1 case of pelviureteric junction obstruction, we placed a transanastomotic ureteral catheter 48 hours after the initial surgery because of postoperative anastomotic leakage with secondary urinoma. The catheter was removed within 1 week after a ureteral opacification test. The mean hospital stay for patients undergoing percutaneous antegrade balloon dilation was 3 days. In all our cases, we preferred to perform the procedure on hospitalized patients for a better surveillance. Follow-up dilation procedures and percutaneous nephrostomy catheter removal were performed on an outpatient basis. We note 2 perioperative complications: a perirenal hemorrhage caused by the puncture of a blood vessel during nephrostomy that resolved spontaneously, and a urinary extravUROLOGY 77 (6), 2011
asation at the pelviureteric junction that occurred during the dilation procedure. Long-term results were evaluated by ultrasonography and diuretic renal flow scans that confirmed no obstacle in all 5 cases of pelviureteric stricture with a follow-up of 4 ⫾ 2.9 years and in 4 cases of ureterovesical junction with a follow-up of 4.7 ⫾ 2.8 years. These 9 successfully dilated patients were all asymptomatic. The overall success rate in our series is then 75%.
COMMENT Surgery remains the treatment of choice in cases of obstruction secondary to failed surgical pelviureteric or vesicoureteral reimplantation.2,3 However treatment of this uncommon but well-known complication is possible using a less invasive procedure, despite the high success rate of open surgery. Percutaneous nephrostomy was performed for the first time in 1955 by Goodwin for drainage of a distended kidney.9 This procedure has a lower morbidity than classic surgery, requiring only a short hospitalization period. The studies of Kramolowsky et al confirmed it.10 The use of balloon dilation of the ureter was described as early as 1926 by Dourmashkin to remove ureteral calculi.11 More recently, the development of percutaneous techniques12,13 has resulted in new applications of balloon catheters for relief of postoperative ureteral obstruction. In published series, the immediate success rate of percutaneous nephrostomy is almost always about 100%.10,14 In our study, successful dilations were achieved in 4 of 7 patients (57%) and 5 of 5 (100%) patients with ureterovesical postoperative strictures or ureteropelvic postoperative stricture, respectively. According to the litera1447
ture, the overall success rate of balloon dilation of the ureter using antegrade or retrograde approach is always ⬎50%.15-17 Few preoperative elements seem to be correlated with good long-term results. According to the literature, strictures ⬍2 cm are more accessible to balloon dilation and have a higher long-term success rate than those ⬎2 cm.18-20 Our study confirms these data, the best results obtained in stenoses of ⬍1 cm. In our series, stricture length ranged from 5 mm to 2 cm. Longest strictures were noted after failed vesicoureteric reimplantation rather then pelviureteric surgery. Thus, we can explain the lower success rate after balloon dilation of vesicoureteric strictures. We also have noticed in our patients that the best long-term results are obtained in recent stenosis. However all previous studies generally included few patients with brief follow-up intervals.21,22 Therefore, we suggest that best results are obtained in recent stenoses of ⬍1 cm. In our 12-case series of percutaneous endoluminal balloon dilation, the ureteral stricture was recognized after a variable period after the primary surgery (Table 1). In all cases except 2, the stenosis was revealed by imaging studies. In the other 2 cases, the stenosis was revealed by lumbar pain, hematuria, and urinary tract infection, respectively. An important issue in the endourological treatment of secondary ureteral strictures is the choice of antegrade or retrograde approach, but to our knowledge, no such comparative studies have been presented. However, longterm success rates appear to be similar.19 We consider that ureteropelvic strictures could be dilated both antegrade and retrograde, depending on the personal preferences and the associated pathology (normal or abnormal kidney, ureteral orifice presentation), although the antegrade approach appears to be the method of choice for dilation of ureterovesical strictures. Stenosis after ureterovesical re-implantation represents a real challenge for endoluminal balloon dilation. In this case, the stricture occurs at the penetration of the ureter into the bladder or at the ureteral meatus. In both situations, the metallic guide wire cannot always be advanced through the stenotic ureter as in 2 of our cases. In these situations, we consider that open surgery remains the gold standard. The interest of double-J drainage is discussed in the literature. Some authors consider that a double-J catheter should be left in place for at least 6 weeks.23 None of our patients had a double-J drainage. In our series, we preferred the retrograde ureteral stent drainage that allowed ureteral opacification and a well-controlled drainage without back pressure. Another advantage of retrograde external stent is its removal without anesthesia. The morbidity rate of this procedure is low.5,24,25 However, minor complications requiring no specific therapy, such as transient hematuria, urinary tract infection, catheter displacement, perirenal hematoma, and urine leak, may be seen in 15-25% of patients who undergo a ne1448
phrostomy procedure.26,27 Major complications like severe hemorrhage, vascular injury, septic shock, or kidney loss are quite rare (1-9%) according to different studies.28,29 Some other potentially catastrophic complications, including transfusion requiring hemorrhage, bowel perforation, and pleural complications have also been reported.30 In this study, we encountered one major complication (transfusion requiring hemorrhage) in a 12-year-old boy, which resolved spontaneously. Other complications were represented by minor hemorrhage (2 cases), urinary tract infection (1 case), dislodgement of the catheter (1 case), and urinary leak (1 case). Transient hematuria was noticed in almost all cases, but we did not consider it a complication. All major complications could be avoided by choosing a paucivascular punction area. Use of ultrasonography combined with real-time fluoroscopy reduces the morbidity rate.
CONCLUSIONS Treatment of postoperative ureteral strictures by open surgery was considered the gold standard. Percutaneous balloon dilation represents an interesting, less invasive alternative, with lower morbidity and a shorter hospitalization period. Although the long-term success of this procedure in children is not yet known, benefit has been documented for those 18 months to 9 years old. The mean follow-up in our series is up to 5 years. Overall, balloon dilation appears to be an appropriate initial approach to the treatment of most patients with ureteral strictures. The best results were obtained on short recent strictures. Acknowledgments. We acknowledge Publique-Hôpital Nord Marseille–Pavillon Mère Enfant. References 1. Aliabadi H, Reinberg Y, Gonzales R. Percutaneous balloon dilation of ureteral strictures after failed surgical repair in children. J Urol. 1990;144(2):486-488. 2. Glen JF, Anderson EE. Complications of ureteral reimplantation surgery. Urol Surv. 1973;23:243-247. 3. Hendren WH. Reoperation for failed ureteral reimplantation. J Urol. 1974;11:403-411. 4. Stables DP. Percutaneous nephrostomy: technique, indications and results. Urol Clin North Am. 1982;9(1):15-29. 5. Stanley P, Diament MJ. Pediatric percutaneous nephrostomy: experience with 50 patients. J Urol. 1986;135(6):1223-1226. 6. Winfield AC, Kirchner SG, Brun ME, et al. Percutaneous nephrostomy in neonates, infants and children. Radiology. 1984;151:617619. 7. Irving HC, Arthur RJ, Thomas DFM. Percutaneous nephrostomy in pediatrics. Clin Radiol. 1987;38:245-248. 8. Gordon I. Upper urinary tract dilatation in newborns and infants. In: Fotter R, editor. Pediatric Uroradiology. Berlin: Springer; 2001: 161-176. 9. Goodwin WE, Casey WC, Woolf W. Percutaneous trocar (needle) nephrostomy in hydronephrosis. JAMA. 1955;157:891-894. 10. Kramolowsky EV, Clayman RV, Weiman PJ. Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair. J Urol. 1988;139:1195-1198.
UROLOGY 77 (6), 2011
11. Dourmashkin RL. Dilatation of ureter with rubber bags in the treatment of ureteral calculi. Presentation of a modified uperating cystoscope: a preliminary report. J Urol. 1926;15:449-460. 12. Miller RP, Reinke DB, Clayman RV, et al. Percutaneous approach to the ureter. Urol Clin North Am. 1982;9:31-40. 13. Pollack HM, Banner MP. Percutaneous nephrostomy and related pyeloureteral manipulative techniques. Urol Radiol. 1981;2:147-154. 14. Lojanapiwat B, Mital D, Fallon L, et al. Management of ureteral stenosis after renal transplantation. J Am Coll Surg. 1994;179:21-24. 15. Dyer RB, Assimos DG, Reagan JD. Update on interventional uroradiology. Urol Clin North Am. 1997;24(3):623-652. 16. Lucey B, McGrath FP, Fotheringham T, et al. Miscellaneous visceral renal interventions. Semin Interv Radiol. 2000;17:367-372. 17. Tan HL, Roberts JP, Grattan-Smith D. Retrograde balloon dilatation of ureteropelvic obstructions in infants and children: early results. Urology. 1995;46:89-91. 18. Cormio L, Battaglia M, Traficante A, et al. Endourological treatment of ureteric injuries. Br J Urol. 1993;72:165-168. 19. Goldfischer ER, Gerber GS. Endoscopic management of the ureteral strictures. J Urol. 1997;157(3):770-775. 20. Lezin MA, Stoller ML. Surgical ureteral injuries. Urology. 1991;38: 497-506. 21. Glanz G, Gordon DH, Butt K, et al. Percutaneous transrenal balloon dilatation of the ureter. Radiology. 1983;149:101-104.
UROLOGY 77 (6), 2011
22. Finnerty DP, Trulock TS, Berkman W, et al. Transluminal balloon dilation of ureteral strictures. J Urol. 1984;131:1056-1060. 23. Kerbl K, Chandhoke PS, Figenshau RS, et al. Effect of stent duration on ureteral healing following endoureterotomy in an animal model. J Urol. 1993;150:1302-1305. 24. Dyer RB, Regan JD, Kavanagh PV, et al. Percutaneous nephrostomy with extension of the technique: step by step. RadioGraphics. 2002;22(3):503-525. 25. Agostini S, Dedola GL, Gabrielli S, et al. A new percutaneous technique in the treatment of obstructive uropathy. Radiol Med. 2003;105(5-6):454-461. 26. Bjarnason H, Ferral H, Stackhouse DJ, et al. Complications related to percutaneous nephrolithothomy. Semin Interv Radiol. 1994;11: 213-225. 27. Lee WJ, Smith AD, Cubelli V, et al. Complications of percutaneous nephrolithotomy. AJR Am J Roentgenol. 1987;148:177-180. 28. Ramchandani P, Cardella JF, Grassi CJ, et al. Quality improvement guidelines for percutaneous nephrostomy. J Vasc Interv Radiol. 2003; 14:277-281. 29. Rabii R, Joual A, Rais H, et al. Pyonephrosis: diagnosis and treatment. Report of 14 cases. Ann Urol. 2000;34:161-164. 30. Lewis S, Patel U. Major complications after percutaneous nephrostomy—lessons from a department audit. Clin Radiol. 2004;59:171179.
1449