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Coated ureteral metallic stents: an unfavorable clinical experience
405 A N E W U R E T E R A L P R O S T H E S I S T O BYPASS O B S T R U C T I O N DUE TO ADVANCED MALIGNANCIES
URETERAL
Francois Desgandchamps ~, Philippe Ballanger 2, Vincent Ravery 3, Pierre Teillac ~, Alain Le Duc B ~Hospital Saint Louis, Paris, France 2Hospital, le Toudu, Bordeaux, France, 3Bichfit Hospital, Paris, France INTRODUCTION: in an attempt to improve the quality of life of patients with palliative definitive nephrostomy we prospectively evaluated a new ureteral prosthesis designed to bypass ureteral obstruction due to advanced malignancies with short life expectancy.
406 C O A T E D U R E T E R A L M E T A L L I C STENTS: AN UNFAVORABLE CLINICAL EXPERIENCE Liatsikos Evangelos ~, Siablis Dimitrios 2, Kalogeropoulou Christina 2, Karnabatidis Dimitrios'-, Athanasopoulos Anastasios ~, Perimenis Petros t, Barbalias George 1Urology, University of Patras, Patras, Greece, 2Radiology, University of Patras, Patras, Greece INTRODUCTION & OBJECTIVES: The purpose of the present study was to evaluate the use of externally coated stents in patients with malignant ureteral obstruction.
M A T E R I A L S & M E T H O D S : Twenty-two subcutaneous bypasses were performed in sixteen patients (7 bilateral and 8 unilateral). Double-J stenting was either impossible or ineffective in every case. A pre-existing nephrostomy was present in 14 renal units. The ureteral prosthesis (Detour R) is a composite prosthesis, consisting of two coaxial tubes, internal pure smooth silicone, covered by woven polyester. The tube is inserted percutaneously into the renal pelvis, tunnelled subcutaneously and introduced through a small suprapubic incision in the bladder. All patients were followed to date or until death from tumour using ultrasonography and/or IVP to assess tube position and patency, and quality of life questionnaire (question n°30 EORTC QLC-C30).
MATERIALS & M E T H O D S : We have prospectively evaluated sixteen patients, 10 men and 6 women, with malignant ureteral obstruction treated successfully by placement of Passager metal stents (Boston Scientific, Natick, MA, United States of America) bypassing the stricture. Mean patient age was 65.6 years (range 62-78 years). Ureteral patency was confirmed 24 and 48 hours by injection of contrast material through the nephrostomy tube, and after patency confirmation the nephrostomy catheter was removed.
RESULTS: No operative or immediate postoperative deaths were observed. Placement of the prosthesis was successful in all cases. With a mean follow-up of 6 months (2-12) there had been no dislodgment, incrustation or obstruction of the tubes. Chronic asymptomatic bacteriuria was only documented for patients with pre-existing nephrostomy. For patients with a follow-up longer than 6 months and a pre-existing nephrostomy (8/16) the mean improvement in quality of life reached 80%.
RESULTS: All stents were positioned successfully, and the postoperative course was uneventful. In 13 cases (81.2%) the prostheses finally migrated into the bladder hindering overall ureteral patency (mean time of migration: 1.5 months). Patency was achieved in the remaining ureters (n=3), during the follow-up period (mean: 8 months, range 6-16 months), without any need for further intervention.
CONCLUSION: The subcutaneous urinary diversion using a silicone-woven polyester prosthesis is an efficient and minimally invasive way to bypass malignant obstructions of the ureters that otherwise would require a permanent nephrostomy drainage.
CONCLUSION: The inappropriate anchorage and the increased ureteral peristalsis are the main causes of migration toward the bladder, thus minimising the usefulness of this stent for the treatment of ureteraI strictures.
407
408
THE
C O M P A R A T I V E STUDY OF T H E S U R G I C A L T E C H N I Q U E S IN PYELOPLASTY: SPIRAL-LOBE T E C H N I Q U E VERSUS ANDERSONHYNES
DOES FLEXIBLE URETERORENOSCOPY IMPROVE MANAGEMENT OF UPPER URINARY TRACT DISEASE?
Mayer Frank, Iselin Christophe, Schmidlin Franz Urology Clinic, Geneva University Hospital, Geneva, Switzerland INTRODUCTION: In recent years, several reports have shown the feasibility of flexible ureterorenoscopy suggesting that this technique may provide a major advantage in upper urinary tract endourology. We report on our initial experience with 40 patients focusing the analysis on our ability to perform flexible ureterorenoscopy over a 3 years period. METHODS: We reviewed the files of 40 patients who had had flexible ureterorenoscopy of the upper urinary tract at our institution (group A: 21 cases between October 1998 to July 2000, group B: 19 cases between august 2000 to July 2001). Mean age was 61 years (range 22-90). Indications were stone management in 30 (75%) cases (failure of ESWL or rigid endoscopy) with a mean stone size of 10 mm (6-27 mm), incomplete tumour staging in 8 (20%) cases and management of stricture disease in 2 (5%) patients. Flexible ureteroscopy was performed either with the Storz 7.5 Fr or the Olympus 6.9 Fr endoscope. RESULTS: Endoscopic stone management improved progressively from an initial success rate of 73% (11/15) in group A to 93% (14/15) in group B (p=ns). During this time period stone treatment changed from in situ laser fragmentation in our early cases to a combination of laser fragmentation with stone extraction using small tipless nitinol baskets. Of 8 (27%) lower calyx stones (mean size 9.2 mm) all 3 cases were treatment failures during the first time period whereas 4 out of 5 (80%) could be managed successfully during the second phase. Of the remaining 10 (25%) cases, tumour diagnosis or stricture management could be performed successfully in 8 (80%) patients. Overall complication rate was low with 2 (5%) patients presenting postoperative transient fever. CONCLUSIONS: This study confirms the safety and feasibility of flexible ureterorenoscopy in the management of complex upper urinary tract disease. Although technically more complex than rigid endoscopy, flexible ureterorenoscopy enabled us to improve our success rate with a relatively short learning curve (20 patients). We therefore consider this technique to be an effective tool that improves standard endoscopic procedures and that can be easily implemented within a teaching hospital.
European Urology Supplements 1 (2002) No. 1, pp. 104
Mueller Elisabeth Echtle Dieter, Frohneberg Detlef Urology, Klinikum Karlsruhe, Karlsruhe, Germany I N T R O D U C T I O N & OBJECTIVES: Standard procedure in the management of uretero-pelvic-junction (UPJ) obstruction is Anderson-Hynes pyeloplasty. By comparison a relatively uncommon method is Patel's coil flap technique, which was published in 1982. The aim of this retrospective study was to assess the value of this non-dismembered pyeloplasty that preserves the continuity of the ureter. MATERIALS & METHODS: Since 1986, 199 patients with UPJ obstruction have undergone operations in our clinic (74 before 1990 and 125 afterwards). Until 1990, the Anderson-Hynes technique was predominantly used (65/74); 8/74 patients underwent an antegrade ureterotomy and one a retrograde ureterotomy. Since 1990, the spectrum was expanded to include the previously little known Patel procedure (89/125). Additionally, 31/125 Anderson-Hynes procedures were performed, and 5/125 were endoscopic. The indication was decompensated obstruction with less than 40% washout after 20 minutes post diuretic renogram (isotope nephrogram). The patient distribution by sex and side was balanced. The average age was 39.5 (3-80) and average follow-up period 87.1 (3-166) months. RESULTS: Follow-up consisted of clinical evaluation, sonography, isotope nephrogram with diuretic renogram (99 Tc MAG 3) and urograph as needed. 96% of the follow-up patients showed no obstruction. Two patients post Anderson-Hynes and 5/14 post endoscopic operation required re-operation. One of the Anderson-Hynes patients is currently undergoing urinary diversion with a stent. CONCLUSION: Our results indicate that the alternative Patel procedure has as many merits as the standard Anderson-Hynes and even offers the advantage of not interrupting the continuity of the ureter. Furthermore, the procedure can even be used in longer subpelvic stenoses - usually up to 10 cm.
URETERAL
Francois Desgandchamps ~, Philippe Ballanger 2, Vincent Ravery 3, Pierre Teillac ~, Alain Le Duc B ~Hospital Saint Louis, Paris, France 2Hospital, le Toudu, Bordeaux, France, 3Bichfit Hospital, Paris, France INTRODUCTION: in an attempt to improve the quality of life of patients with palliative definitive nephrostomy we prospectively evaluated a new ureteral prosthesis designed to bypass ureteral obstruction due to advanced malignancies with short life expectancy.
406 C O A T E D U R E T E R A L M E T A L L I C STENTS: AN UNFAVORABLE CLINICAL EXPERIENCE Liatsikos Evangelos ~, Siablis Dimitrios 2, Kalogeropoulou Christina 2, Karnabatidis Dimitrios'-, Athanasopoulos Anastasios ~, Perimenis Petros t, Barbalias George 1Urology, University of Patras, Patras, Greece, 2Radiology, University of Patras, Patras, Greece INTRODUCTION & OBJECTIVES: The purpose of the present study was to evaluate the use of externally coated stents in patients with malignant ureteral obstruction.
M A T E R I A L S & M E T H O D S : Twenty-two subcutaneous bypasses were performed in sixteen patients (7 bilateral and 8 unilateral). Double-J stenting was either impossible or ineffective in every case. A pre-existing nephrostomy was present in 14 renal units. The ureteral prosthesis (Detour R) is a composite prosthesis, consisting of two coaxial tubes, internal pure smooth silicone, covered by woven polyester. The tube is inserted percutaneously into the renal pelvis, tunnelled subcutaneously and introduced through a small suprapubic incision in the bladder. All patients were followed to date or until death from tumour using ultrasonography and/or IVP to assess tube position and patency, and quality of life questionnaire (question n°30 EORTC QLC-C30).
MATERIALS & M E T H O D S : We have prospectively evaluated sixteen patients, 10 men and 6 women, with malignant ureteral obstruction treated successfully by placement of Passager metal stents (Boston Scientific, Natick, MA, United States of America) bypassing the stricture. Mean patient age was 65.6 years (range 62-78 years). Ureteral patency was confirmed 24 and 48 hours by injection of contrast material through the nephrostomy tube, and after patency confirmation the nephrostomy catheter was removed.
RESULTS: No operative or immediate postoperative deaths were observed. Placement of the prosthesis was successful in all cases. With a mean follow-up of 6 months (2-12) there had been no dislodgment, incrustation or obstruction of the tubes. Chronic asymptomatic bacteriuria was only documented for patients with pre-existing nephrostomy. For patients with a follow-up longer than 6 months and a pre-existing nephrostomy (8/16) the mean improvement in quality of life reached 80%.
RESULTS: All stents were positioned successfully, and the postoperative course was uneventful. In 13 cases (81.2%) the prostheses finally migrated into the bladder hindering overall ureteral patency (mean time of migration: 1.5 months). Patency was achieved in the remaining ureters (n=3), during the follow-up period (mean: 8 months, range 6-16 months), without any need for further intervention.
CONCLUSION: The subcutaneous urinary diversion using a silicone-woven polyester prosthesis is an efficient and minimally invasive way to bypass malignant obstructions of the ureters that otherwise would require a permanent nephrostomy drainage.
CONCLUSION: The inappropriate anchorage and the increased ureteral peristalsis are the main causes of migration toward the bladder, thus minimising the usefulness of this stent for the treatment of ureteraI strictures.
407
408
THE
C O M P A R A T I V E STUDY OF T H E S U R G I C A L T E C H N I Q U E S IN PYELOPLASTY: SPIRAL-LOBE T E C H N I Q U E VERSUS ANDERSONHYNES
DOES FLEXIBLE URETERORENOSCOPY IMPROVE MANAGEMENT OF UPPER URINARY TRACT DISEASE?
Mayer Frank, Iselin Christophe, Schmidlin Franz Urology Clinic, Geneva University Hospital, Geneva, Switzerland INTRODUCTION: In recent years, several reports have shown the feasibility of flexible ureterorenoscopy suggesting that this technique may provide a major advantage in upper urinary tract endourology. We report on our initial experience with 40 patients focusing the analysis on our ability to perform flexible ureterorenoscopy over a 3 years period. METHODS: We reviewed the files of 40 patients who had had flexible ureterorenoscopy of the upper urinary tract at our institution (group A: 21 cases between October 1998 to July 2000, group B: 19 cases between august 2000 to July 2001). Mean age was 61 years (range 22-90). Indications were stone management in 30 (75%) cases (failure of ESWL or rigid endoscopy) with a mean stone size of 10 mm (6-27 mm), incomplete tumour staging in 8 (20%) cases and management of stricture disease in 2 (5%) patients. Flexible ureteroscopy was performed either with the Storz 7.5 Fr or the Olympus 6.9 Fr endoscope. RESULTS: Endoscopic stone management improved progressively from an initial success rate of 73% (11/15) in group A to 93% (14/15) in group B (p=ns). During this time period stone treatment changed from in situ laser fragmentation in our early cases to a combination of laser fragmentation with stone extraction using small tipless nitinol baskets. Of 8 (27%) lower calyx stones (mean size 9.2 mm) all 3 cases were treatment failures during the first time period whereas 4 out of 5 (80%) could be managed successfully during the second phase. Of the remaining 10 (25%) cases, tumour diagnosis or stricture management could be performed successfully in 8 (80%) patients. Overall complication rate was low with 2 (5%) patients presenting postoperative transient fever. CONCLUSIONS: This study confirms the safety and feasibility of flexible ureterorenoscopy in the management of complex upper urinary tract disease. Although technically more complex than rigid endoscopy, flexible ureterorenoscopy enabled us to improve our success rate with a relatively short learning curve (20 patients). We therefore consider this technique to be an effective tool that improves standard endoscopic procedures and that can be easily implemented within a teaching hospital.
European Urology Supplements 1 (2002) No. 1, pp. 104
Mueller Elisabeth Echtle Dieter, Frohneberg Detlef Urology, Klinikum Karlsruhe, Karlsruhe, Germany I N T R O D U C T I O N & OBJECTIVES: Standard procedure in the management of uretero-pelvic-junction (UPJ) obstruction is Anderson-Hynes pyeloplasty. By comparison a relatively uncommon method is Patel's coil flap technique, which was published in 1982. The aim of this retrospective study was to assess the value of this non-dismembered pyeloplasty that preserves the continuity of the ureter. MATERIALS & METHODS: Since 1986, 199 patients with UPJ obstruction have undergone operations in our clinic (74 before 1990 and 125 afterwards). Until 1990, the Anderson-Hynes technique was predominantly used (65/74); 8/74 patients underwent an antegrade ureterotomy and one a retrograde ureterotomy. Since 1990, the spectrum was expanded to include the previously little known Patel procedure (89/125). Additionally, 31/125 Anderson-Hynes procedures were performed, and 5/125 were endoscopic. The indication was decompensated obstruction with less than 40% washout after 20 minutes post diuretic renogram (isotope nephrogram). The patient distribution by sex and side was balanced. The average age was 39.5 (3-80) and average follow-up period 87.1 (3-166) months. RESULTS: Follow-up consisted of clinical evaluation, sonography, isotope nephrogram with diuretic renogram (99 Tc MAG 3) and urograph as needed. 96% of the follow-up patients showed no obstruction. Two patients post Anderson-Hynes and 5/14 post endoscopic operation required re-operation. One of the Anderson-Hynes patients is currently undergoing urinary diversion with a stent. CONCLUSION: Our results indicate that the alternative Patel procedure has as many merits as the standard Anderson-Hynes and even offers the advantage of not interrupting the continuity of the ureter. Furthermore, the procedure can even be used in longer subpelvic stenoses - usually up to 10 cm.