- Email: [email protected]
Combined antegrade and retrograde ureteral stenting: the rendezvous technique
Clinical Radiology (2005) 60, 257–260
TECHNICAL REPORT
Combined antegrade and retrograde ureteral stenting: the rendezvous technique A. Macrı`a,*, C. Magnoa, A. Certob, A. Basileb, G. Scuderia, F. Crescentia, C. Famularia Departments of aHuman Pathology, Emergency Surgery Unit, bRadiology, University of Messina, Messina, Italy Received 16 April 2003; received in revised form 28 February 2004; accepted 9 March 2004
KEYWORDS Combined antegrade/retrograde ureteral stenting; Rendezvous
Ureteral stenting is a routine procedure in endourology. To increase the success rate in difficult cases, it may be helpful to use the rendezvous technique, a combined antegrade and retrograde approach. We performed 16 urological rendezvous in 11 patients with ureteral strictures or urologic lesions. The combined approach was successful in all patients, without morbidity or mortality. In our experience the rendezvous technique increased the success rate of antegrade ureteral stenting from 78.6 to 88.09% ðp . 0:05Þ: This procedure is a valid option in case of failure of conventional ureteral stenting. q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction Ureteral stenting is a routine procedure in endourology. Retrograde or antegrade approaches are the conventional techniques used in the management of ureteral strictures. In case of failure of endosurgical intubation of ureteral strictures, percutaneous nephrostomy is the first line therapeutic option. This method of urinary diversion is not a reasonable long term option because of the poor compliance of patients.1 The rendezvous technique, a combined antegrade and retrograde approach, may increase the success rates of antegrade ureteral stenting in the more challenging cases of ureteral strictures or urinary leaks.
Material and methods In the period April 1997 – January 2001 we treated 11 patients (Table 1), 8 males and 3 females (M/ *Guarantor and correspondent: A. Macrı`, Cattedra di Chirurgia d’Urgenza, Policlinico Universitario “G. Martino”, Via Consolare Valeria, 98100 Messina, Italy. Tel.: þ 39-90-2212681; fax: þ 3990-2921929. E-mail address: [email protected]
F ¼ 2.6/1) with a mean age of 63 years (range 42 – 85) with the rendezvous technique for ureteral stenting. The lesions were localized in 11 (68.7%) cases in the left ureter and 5 (31.3%) in the right; 8 were unilateral (72.7%) and 4 bilateral (36.3%). The anatomic location was in the proximal ureter in 2 cases (12.5%) and in the distal portion in 14 (87.5%). The aetiology was related to urological pathology in 13 cases (81.2%), to gynaecologic surgery in 1 (6.3%) and to miscellaneous causes in 2 (12.5%). The urological group included 2 patients with a relapsing dehiscence of the cystostomy after a transvescical adenomyectomy, 1 patient with a bilateral stricture of the ureterostomy, 3 patients with a post-operative fibrosis of ureterovescical junction (1 after endoscopic meatotomy for a bilateral ureterocele, 1 post-endoscopic resection of a bladder lesion, 1 after partial cystectomy), 1 patient with the displacement, in the 2nd postoperative day, of the percutaneous catheter after a pyeloplasty, 1 patient with a stricture of the ureteropelvic junction and 1 patient with compression of the distal ureter by prostatic carcinoma. The others two groups included 1 patient with a fibrotic stricture of distal ureter following a total hysterectomy and 1 patient with extrinsic compression of the distal ureter by rectal carcinoma.
0009-9260/$ - see front matter q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2004.06.008
258
Table 1 Rendezvous series Patient no.
Initials
Sex
Age
Case no.
Indications
Notes
1
CA
M
65
1
Recurrent dehiscence of cystostomy
Patient with chronic lymphoid leukaemia, already submitted, without success, to a bilateral nephrostomies and a surgical correction of the dehiscence
2
PT
M
66
2 3
Recurrent dehiscence of cystostomy
Patient with diabetes mellitus, already submitted, without success, to bilateral nephrostomies and a surgical correction of the dehiscence
3
LG
M
61
4 5
Right obstructive uropathy by stricture of ureterocutaneostomy Left obstructive uropathy by stricture of ureterocutaneostomy Recurrent right obstructive uropathy in a patient submitted to an endoscopic treatment of ureterocele
The meati were not identifiable
6 4
DDMC
F
60
7
8 5
CM
F
77
9
6
MA
M
67
10
7
CP
M
49
11
8
SGA
M
85
12
9
PG
M
53
13
10
GG
M
68
14 15
11
DFL
F
42
16
The patient was submitted also to an endoscopic meatotomy Lack of pusher with radiopaque marker The approach used during surgery was too anterior to perform antegrade complex manoeuvres
A. Macrı` et al.
Recurrent left obstructive uropathy in a patient submitted to an endoscopic treatment of ureterocele Left obstructive uropathy by a post-TURP stricture of ureteral meatus Left obstructive uropathy by fibrotic post-partial cystectomy stricture of ureteral meatus Dislocation in left upper calyx, during II post-operative day, following pyeloplasty Failure of stenting in patient with left obstructive uropathy by prostatic neoplasm Failure of stenting in a patient with left obstructive uropathy by ureteropelvic junction obstruction Failure of stenting in a patient with left obstructive uropathy by rectal carcinoma Failure of cystoscopic substitution the malfunctioning antegrade stent Failure of stenting in a patient with post-hysterectomy right obstructive uropathy
The procedure was performed to position a guide wire in the ureterocele and perform endoscopic resection and retrograde stenting
Combined antegrade and retrograde ureteral stenting: the rendezvous technique
The first stage of the procedure is a percutaneous nephrostomy. After premedication with diazepam (10 mg i.v.) and atropine sulphate (0.5 mg i.v.) the ultrasonographic “window” for the percutaneous approach to renal cavities is localized. After local anaesthesia (ropivacaine 10%), a Chiba needle (18 G) is introduced, under ultrasound guidance (Fig. 1a), in the zone of the mid pole calyx of renal pelvis. After checking access to the renal pelvis by means of urine aspiration and introduction of a solution of 30% contrast medium, under fluoroscopic control, a 0.035 inches J-shaped guidewire is inserted and coiled in the pelvis (Fig. 1b). After progressive dilatation of the track (5-7-9 French), a 7 French peel-away sheath is positioned to introduce a second wire (0,035 inches glide wire). Removed the peel away introducer, a Berenestein catheter (5 French) is inserted on the glide wire to the ureteropelvic junction (Fig. 1c). We perform a pyelogram with the catheter positioned near the stricture (Fig. 1d) and attempt to pass through the stricture with wire (Fig. 1e). In case of success and, if necessary, after progressive or pneumatic dilatation of the stricture (Fig. 1f), we proceed to the
259
cystoscopic retrieval, with grasping forceps, of the end of the glide wire (Fig. 1 g). Applying bidirectional traction on the guide, an indwelling ureteral stent is passed through the stricture. A soft drain nephrostomy (8 French), is placed on the guide wire wrapped in the pelvis and left in situ for gravity drainage for 24 h to prevent, in case of haematuria, an obstruction of the stent. The nephrostomy stent therefore is clamped and, the next day, in absence of complications, is removed.
Results The combined antegrade and retrograde ureteral stenting was successful in all 16 cases that we attempted, without related morbidity and mortality. The rendezvous technique increased our success rates of antegrade ureteral stenting from 78.6 to 88.09% ðp . 0:05Þ: This combined technique was performed in 12 cases (75%) as first line approach and in 4 (25%) after the failure of ureteral stenting with conventional approaches.
Figure 1 The sequence demonstrates the ultrasound approach (a), the guide wire coiled in renal cavities (b), the Berenestein catheter (c), ureteral stenosis caused by uterine tumour (d), the passage of glide wire in the bladder (e), pneumatic dilatation of the stricture (f) and the recovery, in the bladder, of the guide wire with a cystoscope (g).
260
Discussion Ureteral stenting is a well established technique in endourology and retrograde or antegrade approaches are the conventional techniques used for the intubation of ureteral strictures or leaks. The success rates of these endourological approaches depend on the stricture characteristics in particular the aetiology, length and location. The strictures associated with radiation or ischaemic injury, those longer than 2 cm or in a middle ureteral location respond less favourably to endosurgical treatment. The more challenging problems associated with ureteral stricture disease occur when the retrograde ureterogram reveals complete ureteral obstruction. In difficult cases the ureteral stricture may be approached from a combined antegrade and retrograde approach,2 the rendezvous technique that is indicated also in the treatment of long ureteric defects.3 In accord with Lu et al.4 we think that it is technically important that the nephrostomy tract should be established in a middle or upper posterior calyx. This approach, even if with a potential increase of morbidity, provides a near straight line access to the affected middle or distal ureter. In cases with a tortuous ureter it is necessary to place a nephrostomy tube diverting some days before attempting the rendezvous technique. The combined approach permits application of a bidirectional traction on the guide wire at the kidney and bladder and so increases the success rates of antegrade ureteral stenting. In our experi-
A. Macrı` et al.
ence, the ureteral intubation success rate increased from 78.6 to 88.09% ðp . 0:05Þ: The rendezvous technique was used as first line treatment in 12 cases and after the failure of retrograde or antegrade approach in 4, avoiding the need for surgical intervention. We conclude that the rendezvous technique is particularly useful in ureteral leaks5 and to treat same difficult cases of obstructive uropathy,6 particularly in elderly patients.7
References 1. Wirth B, Loch T, Papadopoulos I, et al. Ureteral stenting used a combined antegrade/retrograde procedure. A technique for difficult cases. Scand J Urol Nephrol 1997;31:35—7. 2. Asch MR, Jaffer NM. Antegrade placement of a ureteric stent by a pull-through technique. Can Assoc Radiol J 1995;46: 465—7. 3. Muentener M, Egli J, Knoenagel H. The endourological management of long ureteric defects. BJU Int 2003;92: 647—9. 4. Lu DSK, Papanicolaou N, Girard M, et al. Percutaneous internal ureteral stent placement: review of thechnical issue and solution in 50 consecutive cases. Clin Radiol 1994; 49:256—61. 5. de Baere T, Roche A, Lagrange C, et al. Combined percutaneous antegrade and cystoscopic retrograde approach in the treatment of distal ureteric fistulae. Cardiovasc Intervent Radiol 1995;18:349—52. 6. Pappas P, Stravodimos KG, Mitropoulos D, et al. Role of percutaneous urinary diversion in malignant and benign obstructive uropathy. J Endourol 2000;14:401—5. 7 Watson JM, Dawkins GP, Whitfield HN, Philp T, Kellett MJ. The rendezvous procedure to cross complicated ureteric strictures. BJU Int 2002;89:317—9.
TECHNICAL REPORT
Combined antegrade and retrograde ureteral stenting: the rendezvous technique A. Macrı`a,*, C. Magnoa, A. Certob, A. Basileb, G. Scuderia, F. Crescentia, C. Famularia Departments of aHuman Pathology, Emergency Surgery Unit, bRadiology, University of Messina, Messina, Italy Received 16 April 2003; received in revised form 28 February 2004; accepted 9 March 2004
KEYWORDS Combined antegrade/retrograde ureteral stenting; Rendezvous
Ureteral stenting is a routine procedure in endourology. To increase the success rate in difficult cases, it may be helpful to use the rendezvous technique, a combined antegrade and retrograde approach. We performed 16 urological rendezvous in 11 patients with ureteral strictures or urologic lesions. The combined approach was successful in all patients, without morbidity or mortality. In our experience the rendezvous technique increased the success rate of antegrade ureteral stenting from 78.6 to 88.09% ðp . 0:05Þ: This procedure is a valid option in case of failure of conventional ureteral stenting. q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction Ureteral stenting is a routine procedure in endourology. Retrograde or antegrade approaches are the conventional techniques used in the management of ureteral strictures. In case of failure of endosurgical intubation of ureteral strictures, percutaneous nephrostomy is the first line therapeutic option. This method of urinary diversion is not a reasonable long term option because of the poor compliance of patients.1 The rendezvous technique, a combined antegrade and retrograde approach, may increase the success rates of antegrade ureteral stenting in the more challenging cases of ureteral strictures or urinary leaks.
Material and methods In the period April 1997 – January 2001 we treated 11 patients (Table 1), 8 males and 3 females (M/ *Guarantor and correspondent: A. Macrı`, Cattedra di Chirurgia d’Urgenza, Policlinico Universitario “G. Martino”, Via Consolare Valeria, 98100 Messina, Italy. Tel.: þ 39-90-2212681; fax: þ 3990-2921929. E-mail address: [email protected]
F ¼ 2.6/1) with a mean age of 63 years (range 42 – 85) with the rendezvous technique for ureteral stenting. The lesions were localized in 11 (68.7%) cases in the left ureter and 5 (31.3%) in the right; 8 were unilateral (72.7%) and 4 bilateral (36.3%). The anatomic location was in the proximal ureter in 2 cases (12.5%) and in the distal portion in 14 (87.5%). The aetiology was related to urological pathology in 13 cases (81.2%), to gynaecologic surgery in 1 (6.3%) and to miscellaneous causes in 2 (12.5%). The urological group included 2 patients with a relapsing dehiscence of the cystostomy after a transvescical adenomyectomy, 1 patient with a bilateral stricture of the ureterostomy, 3 patients with a post-operative fibrosis of ureterovescical junction (1 after endoscopic meatotomy for a bilateral ureterocele, 1 post-endoscopic resection of a bladder lesion, 1 after partial cystectomy), 1 patient with the displacement, in the 2nd postoperative day, of the percutaneous catheter after a pyeloplasty, 1 patient with a stricture of the ureteropelvic junction and 1 patient with compression of the distal ureter by prostatic carcinoma. The others two groups included 1 patient with a fibrotic stricture of distal ureter following a total hysterectomy and 1 patient with extrinsic compression of the distal ureter by rectal carcinoma.
0009-9260/$ - see front matter q 2005 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2004.06.008
258
Table 1 Rendezvous series Patient no.
Initials
Sex
Age
Case no.
Indications
Notes
1
CA
M
65
1
Recurrent dehiscence of cystostomy
Patient with chronic lymphoid leukaemia, already submitted, without success, to a bilateral nephrostomies and a surgical correction of the dehiscence
2
PT
M
66
2 3
Recurrent dehiscence of cystostomy
Patient with diabetes mellitus, already submitted, without success, to bilateral nephrostomies and a surgical correction of the dehiscence
3
LG
M
61
4 5
Right obstructive uropathy by stricture of ureterocutaneostomy Left obstructive uropathy by stricture of ureterocutaneostomy Recurrent right obstructive uropathy in a patient submitted to an endoscopic treatment of ureterocele
The meati were not identifiable
6 4
DDMC
F
60
7
8 5
CM
F
77
9
6
MA
M
67
10
7
CP
M
49
11
8
SGA
M
85
12
9
PG
M
53
13
10
GG
M
68
14 15
11
DFL
F
42
16
The patient was submitted also to an endoscopic meatotomy Lack of pusher with radiopaque marker The approach used during surgery was too anterior to perform antegrade complex manoeuvres
A. Macrı` et al.
Recurrent left obstructive uropathy in a patient submitted to an endoscopic treatment of ureterocele Left obstructive uropathy by a post-TURP stricture of ureteral meatus Left obstructive uropathy by fibrotic post-partial cystectomy stricture of ureteral meatus Dislocation in left upper calyx, during II post-operative day, following pyeloplasty Failure of stenting in patient with left obstructive uropathy by prostatic neoplasm Failure of stenting in a patient with left obstructive uropathy by ureteropelvic junction obstruction Failure of stenting in a patient with left obstructive uropathy by rectal carcinoma Failure of cystoscopic substitution the malfunctioning antegrade stent Failure of stenting in a patient with post-hysterectomy right obstructive uropathy
The procedure was performed to position a guide wire in the ureterocele and perform endoscopic resection and retrograde stenting
Combined antegrade and retrograde ureteral stenting: the rendezvous technique
The first stage of the procedure is a percutaneous nephrostomy. After premedication with diazepam (10 mg i.v.) and atropine sulphate (0.5 mg i.v.) the ultrasonographic “window” for the percutaneous approach to renal cavities is localized. After local anaesthesia (ropivacaine 10%), a Chiba needle (18 G) is introduced, under ultrasound guidance (Fig. 1a), in the zone of the mid pole calyx of renal pelvis. After checking access to the renal pelvis by means of urine aspiration and introduction of a solution of 30% contrast medium, under fluoroscopic control, a 0.035 inches J-shaped guidewire is inserted and coiled in the pelvis (Fig. 1b). After progressive dilatation of the track (5-7-9 French), a 7 French peel-away sheath is positioned to introduce a second wire (0,035 inches glide wire). Removed the peel away introducer, a Berenestein catheter (5 French) is inserted on the glide wire to the ureteropelvic junction (Fig. 1c). We perform a pyelogram with the catheter positioned near the stricture (Fig. 1d) and attempt to pass through the stricture with wire (Fig. 1e). In case of success and, if necessary, after progressive or pneumatic dilatation of the stricture (Fig. 1f), we proceed to the
259
cystoscopic retrieval, with grasping forceps, of the end of the glide wire (Fig. 1 g). Applying bidirectional traction on the guide, an indwelling ureteral stent is passed through the stricture. A soft drain nephrostomy (8 French), is placed on the guide wire wrapped in the pelvis and left in situ for gravity drainage for 24 h to prevent, in case of haematuria, an obstruction of the stent. The nephrostomy stent therefore is clamped and, the next day, in absence of complications, is removed.
Results The combined antegrade and retrograde ureteral stenting was successful in all 16 cases that we attempted, without related morbidity and mortality. The rendezvous technique increased our success rates of antegrade ureteral stenting from 78.6 to 88.09% ðp . 0:05Þ: This combined technique was performed in 12 cases (75%) as first line approach and in 4 (25%) after the failure of ureteral stenting with conventional approaches.
Figure 1 The sequence demonstrates the ultrasound approach (a), the guide wire coiled in renal cavities (b), the Berenestein catheter (c), ureteral stenosis caused by uterine tumour (d), the passage of glide wire in the bladder (e), pneumatic dilatation of the stricture (f) and the recovery, in the bladder, of the guide wire with a cystoscope (g).
260
Discussion Ureteral stenting is a well established technique in endourology and retrograde or antegrade approaches are the conventional techniques used for the intubation of ureteral strictures or leaks. The success rates of these endourological approaches depend on the stricture characteristics in particular the aetiology, length and location. The strictures associated with radiation or ischaemic injury, those longer than 2 cm or in a middle ureteral location respond less favourably to endosurgical treatment. The more challenging problems associated with ureteral stricture disease occur when the retrograde ureterogram reveals complete ureteral obstruction. In difficult cases the ureteral stricture may be approached from a combined antegrade and retrograde approach,2 the rendezvous technique that is indicated also in the treatment of long ureteric defects.3 In accord with Lu et al.4 we think that it is technically important that the nephrostomy tract should be established in a middle or upper posterior calyx. This approach, even if with a potential increase of morbidity, provides a near straight line access to the affected middle or distal ureter. In cases with a tortuous ureter it is necessary to place a nephrostomy tube diverting some days before attempting the rendezvous technique. The combined approach permits application of a bidirectional traction on the guide wire at the kidney and bladder and so increases the success rates of antegrade ureteral stenting. In our experi-
A. Macrı` et al.
ence, the ureteral intubation success rate increased from 78.6 to 88.09% ðp . 0:05Þ: The rendezvous technique was used as first line treatment in 12 cases and after the failure of retrograde or antegrade approach in 4, avoiding the need for surgical intervention. We conclude that the rendezvous technique is particularly useful in ureteral leaks5 and to treat same difficult cases of obstructive uropathy,6 particularly in elderly patients.7
References 1. Wirth B, Loch T, Papadopoulos I, et al. Ureteral stenting used a combined antegrade/retrograde procedure. A technique for difficult cases. Scand J Urol Nephrol 1997;31:35—7. 2. Asch MR, Jaffer NM. Antegrade placement of a ureteric stent by a pull-through technique. Can Assoc Radiol J 1995;46: 465—7. 3. Muentener M, Egli J, Knoenagel H. The endourological management of long ureteric defects. BJU Int 2003;92: 647—9. 4. Lu DSK, Papanicolaou N, Girard M, et al. Percutaneous internal ureteral stent placement: review of thechnical issue and solution in 50 consecutive cases. Clin Radiol 1994; 49:256—61. 5. de Baere T, Roche A, Lagrange C, et al. Combined percutaneous antegrade and cystoscopic retrograde approach in the treatment of distal ureteric fistulae. Cardiovasc Intervent Radiol 1995;18:349—52. 6. Pappas P, Stravodimos KG, Mitropoulos D, et al. Role of percutaneous urinary diversion in malignant and benign obstructive uropathy. J Endourol 2000;14:401—5. 7 Watson JM, Dawkins GP, Whitfield HN, Philp T, Kellett MJ. The rendezvous procedure to cross complicated ureteric strictures. BJU Int 2002;89:317—9.