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Techniques for Bypassing and Stenting Ureteral Obstructions
0022-5347/94/1523-0917$03.00/0
THE JOURNAL OF UROLOGY
Copyright© 1994 by AMERICAN
Vol. 152, 917-919, September 1994 Printed in U.S.A.
UROLOGICAL AssoCIATION, INC.
Urologists At Work TECHNIQUES FOR BYPASSING AND STENTING URETERAL OBSTRUCTIONS JOHN A. MATA, DANIEL J. CULKIN AND DENNIS D. VENABLE From the Department of Urology, Louisiana State University Medical Center, Shreveport, Louisiana
ABSTRACT
The advent of current endourological equipment and combined cystoscopic fluoroscopy allows the urologist to divert and/or stent the majority of benign and malignant ureteral obstructions in either a retrograde or antegrade fashion. We report on our recent experience in managing 105 obstructed renal units to formulate a troubleshooting endourological algorithm for bypassing and stenting ureteral obstructions. The methods described allow for safe and successful stent diver sion in the majority of patients with ureteral obstruction requiring initial or primary endouro logical management. The algorithm presents alternative techniques for bypassing and stenting ureteral obstructions. KEY \VORDS: urinary catheterization, ureteral obstruction, urinary retention, endoscopy
Ureteral obstruction requiring surgical intervention is con sidered a urological urgency. The advent of current endouro logical equipment and fluoroscopically monitored transure thral manipulation has allowed the urologist to divert and/or stent the majority of benign and malignant renal obstruc tions in either a retrograde or antegrade fashion. When ap propriate, most stents can be positioned internally, thereby increasing patient comfort and shortening hospital stay. 1 However, tightly obstructed, kinked or tortuous ureters may require different instruments or maneuvers for successful bypass. Current open-ended catheters, diverse guide wire and stent designs, and fluoroscopy have paved the way for increasing endourological success. There are many "tricks of the trade" and a plethora of equipment that may be used.2 We describe our technique and algorithm for bypassing and stenting ureteral obstructions. MATERIALS AND METHODS
Since 1983, when fluoroscopy and the newer endourologi cal armamentarium became available at our university hos pital, we developed a systematic, although empiric, approach to stenting the ureter. The majority of patients required endourological diversion due to ureteral obstruction from calculi or malignancy. A cohort of the stone patients are involved in a study comparing the benefit and cost-effective ness of soft ureteral stent dilation (followed by outpatient ureteroscopic calculus removal) versus acute ureteral dila tion and immediate ureteroscopic extraction. 1 The tech niques detailed address 1 method to bypass and stent ure teral obstructions due to a variety of etiologies. As members of the urology department perform their own percutaneous access, all patients are informed and consent obtained for possible percutaneous nephrostomy at the same time should retrograde or antegrade bypass attempts fail. Intermittent fluoroscopy is used throughout the endourological procedures described. Routine initial attempts at bypassing a ureteral obstruc tion involve introduction of a 5F flexible-tipped, open-ended catheter into the ureteral meatus sufficiently far to inject
contrast medium to obtain a fluoroscopically monitored ret rograde ureteropyelogram. Once the obstructive (calculus, stricture, tumor, tortuousity and so forth) lesion and level are identified and carefully defined, a 0.038 double flexible tip guide wire is negotiated past the point(s) of obstruction into the renal pelvis. Many companies presently offer new smooth, lubricated, soft and safe guide wires for ease of insertion during endourological procedures. A lubricated in ternal Double-J* catheter is then passed over the guide wire into the appropriate position (see figure). We prefer an ante grade Double-J or Uro-Guidet stent, which has tapered tips to allow for easier placement. Occasionally, the obstructing area will require dilation with a balloon catheter or gradu ated sheaths before passage of the Double-J stent. A ureteral rneatotomy rarely is necessary to achieve intramural or dis tal ureteral intubation.3 A final plain abdominal film docu ments successful stent positioning. If our initial attempts at passing a guide wire to the renal pelvis fail, a change in guide wire design may be helpful. There currently are several hydrophilic coated slippery guide wire designs with different tip angles and directional capa bility available. Commonly used guide wires include a straight soft or curved tip, a polytetrafluoroethylene (Teflon) coated movable core, a smaller (0.035 inch) guide wire with less of a J shape or, rarely, a Lunderquist 0.032 inch 120 cm. guide wire. If passage is difficult secondary to angulation or tortuosity, the next step involves reintubating the distal ure ter below the obstruction with a different hollow catheter, such as various angiographic catheters. Such catheters pro vide more options in terms of stiffness, torque and curve. Angiographic catheters commonly used include renal access cobra catheters (6.5F, 65 cm.), straight angiographic cathe ters (6.5F, 70 cm.) and shepherd hook catheters (6.5F, 0.035 inch, 70 cm.). Often, passage of a guide wire can be facilitated by gentle lavage of the obstructing area with a 1:1 mixture of lidocaine jelly (2%) and water soluble contrast medium.4 Depending on the particular clinical situation, when retro grade access is still believed to be a reasonable option, a 3F or * Medical Engineering Corp., New York, New York.
t Cook Urological, Spencer, Indiana.
Accepted for publication December 22, 1993.
917
--918
---
BYPASSING AND STENTING URETERAL OBSTRUCTIONS !VP/US
I URETERAL OBSTRUCTION
----
CYSTO, 5 FR. tEN - RETROGRADE
Wire
(
asses
I
Wire cannot pass --------- Retrograde attempts fail
Insert DJStent I Appropriate therapy
L----
-Tortu s ureter _ r Flexible ureteroscope
Tight obs. or stricture with buck1 i ng
1
1 Sheath Pul1-down ureteral balloon I system L..... Wire passes _____J
a1
I
Stent
Appropriate therapy
Different guide wires
I I
I
Flexible ureteroscopy :(
Lidocaine lavage
Stent
. I
Wir
Angiographic catheters
Wire Passes
ol
False passage or kink
Wire Cannot Pass
asses
I I
Percutaneous Access Antegrade Bypass attempts Stent Passes
I
Appropriate therapy
I
Retrograde Ureteral Catheters Pass
I
Leave to Drainage Alongside Foley
Fails
I
Leave nephrostomy
I
Secondary Retrograde Attempt After Decompression
Techniques to bypass and stent ureteral obstructions. NP, excretory urography. US, ultrasound. DJ, Double-J. Cysto., cystoscopy. obs., obstruction.
4F flexible tip or pigtail spiral tip retrograde ureteral cathe ter will sometimes pass when a guide wire fails. At other times, a peel-away introducer sheath or a general ureteral dilator-sheathing system can be useful to prevent buckling or accomplish straightening of a tortuous ureter.5• 6 We often use a technique described by Fraser,7 and Clayman and Castafieda-Zufiiga2 to bypass a tortuous ureter by passing a hollow 4F to 7F ureteral balloon dilating catheter just distal to the problem point and gently filling the balloon with con trast medium until there is just enough traction to pull down and straighten the ureter, thereby allowing passage of a guide wire through the internal lumen of the catheter. The rigid or flexible ureteroscope is generally used as a diagnostic or therapeutic maneuver (for example acute dilation plus stone removal). However, it may be useful to bypass obstruc tions in the face of ureteral mucosal false passages.8 If the aforementioned maneuvers fail, the newer smaller flexible ureteroscopes may allow direct visualization of the narrowed lumen and bypass of the obstruction by passage of a guide wire under direct vision. When retrograde attempts fail, we proceed immediately to an antegrade approach. Previously placed retrograde contrast medium, when feasible, allows for direct renal needle placement. If retrograde contrast medium instilla tion is not possible and renal dysfunction or allergy pre vents intravenous contrast medium administration, ultra sound guidance allows for safe and accurate nephrostomy tube placement into a mid pole calix, which gives easy access to the proximal ureter. Similar attempts at bypass ing the obstructive point from above are made with guide wires, catheters and so forth. If all attempts fail, an 8.3F pigtail percutaneous nephrostomy tube is left to closed drainage and the system is allowed to decompress. Second ary antegrade or retrograde attempts at diversion follow ing several days of decompression are generally successful, even when initial attempts failed.
RESULTS
Between July 1983 and June 1986, 90 patients (105 renal units) required relief of renal obstruction secondary to calcu lous or malignant obstruction. Of the 75 obstructed renal units due to stone disease 62 had internal, 3 external and 5 antegrade stent placement, for a stent placement success rate of 93%. Five renal units (7%) required a percutaneous nephrostomy tube. Of the 30 ureters obstructed due to ma lignant disease 24 (80%) were successfully stented internally. The majority of malignant obstructions were secondary to carcinoma of the cervix, many after previous radiation ther apy and most before planned nephrotoxic chemotherapy. DISCUSSION
Continued refinements in endourological equipment and uroradiographic imaging have allowed urologists to continue to expand their expertise in diverting urinary obstructions.2 Using a transurethral approach, the majority of obstructions can be bypassed and stented internally (when appropriate), thereby avoiding external stents and tubes. Also, if the urol ogist is trained in percutaneous renal access, urine may be diverted from above the obstruction at 1 session with the patient under anesthesia.9 The figure outlines a troubleshooting scheme that may be used when a ureteral catheter or stent does not initially pass the level of the obstruction to the kidney. Initial options may include use of different sized and configured guide wires, a change of stent (that is various adaptable hollow angio graphic catheters) and gentle lavage of the affected area with a lidocaine jelly solution. Occasionally, retrograde flexible tipped catheters will pass when other attempts fail. Tortuous ureters may be negotiated with a hollow "pull down" ureteral balloon and guide wire or bypassed under direct vision with a sheath system and ureteroscope.5• 6 Smaller flexible ureteroscopes are useful to identify ureteral false passages, allowing the true ureteral lumen to be intu bated.
BYPASSING AND STENTING URETERAL OBSTRUCTIONS When all reasonable retrograde approaches fail, percuta neous access is then established. Antegrade bypass attempts may then be made or a percutaneous nephrostomy tube may be introduced and the urine drained from above the obstruc tion. Definitive therapy then may require a secondary ses sion following a brief period of upper tract decompression, with decrease in tortuosity and commonly associated ure teral edema.
REFERENCES 1. Humble, L. and Venable, D. D.: Perioperative use ofindwelling ureteral catheter as an adjunct to ureteroscopic stone manip ulation. J. Endourol., 1: 165, 1987. 2. Clayman, R. V. and Castafieda-Zufiiga, W. R.: Techniques in Endourology: A Guide to the Percutaneous Removal ofRenal
919
and Ureteral Calculi. Minneapolis, 1984. 3. Donovan, M. G., Hegarty, J., Fitzpatrick, J. M. and Butler, M.: Ureteral meatotomy by Sachse urethrotome in the manage ment oflower ureteral stones. J. Urol., 138: 566, 1987. 4. Steinbock, G. S. and Bezirdjian, L. B.: Technique for retrograde ureteral stone displacement. Urology, 31: 160, 1988. 5. Rich, M., Lee, W. J. and Smith, A. D.: Applications ofthe peel away introducer sheath. J. Urol., 137: 452, 1987. 6. Newman, R. C., Hunter, P. T., Hawkins, I. F. and Finlayson, B.: A general ureteral dilator-sheathing system. Urology, 25: 287, 1985. 7. Fraser, K. S.: A technique for stenting tortuous ureters. J. Urol., 138: 831, 1987. 8. Kraebber, D. M. and Torres, S. A.: Use ofureteroscope to avoid distal ureteral false passages. Urology, 31: 80, 1988. 9. Smith, A. D.: Percutaneous ureteral surgery and stenting. Urol ogy, special issue, 23: 37, 1984.
THE JOURNAL OF UROLOGY
Copyright© 1994 by AMERICAN
Vol. 152, 917-919, September 1994 Printed in U.S.A.
UROLOGICAL AssoCIATION, INC.
Urologists At Work TECHNIQUES FOR BYPASSING AND STENTING URETERAL OBSTRUCTIONS JOHN A. MATA, DANIEL J. CULKIN AND DENNIS D. VENABLE From the Department of Urology, Louisiana State University Medical Center, Shreveport, Louisiana
ABSTRACT
The advent of current endourological equipment and combined cystoscopic fluoroscopy allows the urologist to divert and/or stent the majority of benign and malignant ureteral obstructions in either a retrograde or antegrade fashion. We report on our recent experience in managing 105 obstructed renal units to formulate a troubleshooting endourological algorithm for bypassing and stenting ureteral obstructions. The methods described allow for safe and successful stent diver sion in the majority of patients with ureteral obstruction requiring initial or primary endouro logical management. The algorithm presents alternative techniques for bypassing and stenting ureteral obstructions. KEY \VORDS: urinary catheterization, ureteral obstruction, urinary retention, endoscopy
Ureteral obstruction requiring surgical intervention is con sidered a urological urgency. The advent of current endouro logical equipment and fluoroscopically monitored transure thral manipulation has allowed the urologist to divert and/or stent the majority of benign and malignant renal obstruc tions in either a retrograde or antegrade fashion. When ap propriate, most stents can be positioned internally, thereby increasing patient comfort and shortening hospital stay. 1 However, tightly obstructed, kinked or tortuous ureters may require different instruments or maneuvers for successful bypass. Current open-ended catheters, diverse guide wire and stent designs, and fluoroscopy have paved the way for increasing endourological success. There are many "tricks of the trade" and a plethora of equipment that may be used.2 We describe our technique and algorithm for bypassing and stenting ureteral obstructions. MATERIALS AND METHODS
Since 1983, when fluoroscopy and the newer endourologi cal armamentarium became available at our university hos pital, we developed a systematic, although empiric, approach to stenting the ureter. The majority of patients required endourological diversion due to ureteral obstruction from calculi or malignancy. A cohort of the stone patients are involved in a study comparing the benefit and cost-effective ness of soft ureteral stent dilation (followed by outpatient ureteroscopic calculus removal) versus acute ureteral dila tion and immediate ureteroscopic extraction. 1 The tech niques detailed address 1 method to bypass and stent ure teral obstructions due to a variety of etiologies. As members of the urology department perform their own percutaneous access, all patients are informed and consent obtained for possible percutaneous nephrostomy at the same time should retrograde or antegrade bypass attempts fail. Intermittent fluoroscopy is used throughout the endourological procedures described. Routine initial attempts at bypassing a ureteral obstruc tion involve introduction of a 5F flexible-tipped, open-ended catheter into the ureteral meatus sufficiently far to inject
contrast medium to obtain a fluoroscopically monitored ret rograde ureteropyelogram. Once the obstructive (calculus, stricture, tumor, tortuousity and so forth) lesion and level are identified and carefully defined, a 0.038 double flexible tip guide wire is negotiated past the point(s) of obstruction into the renal pelvis. Many companies presently offer new smooth, lubricated, soft and safe guide wires for ease of insertion during endourological procedures. A lubricated in ternal Double-J* catheter is then passed over the guide wire into the appropriate position (see figure). We prefer an ante grade Double-J or Uro-Guidet stent, which has tapered tips to allow for easier placement. Occasionally, the obstructing area will require dilation with a balloon catheter or gradu ated sheaths before passage of the Double-J stent. A ureteral rneatotomy rarely is necessary to achieve intramural or dis tal ureteral intubation.3 A final plain abdominal film docu ments successful stent positioning. If our initial attempts at passing a guide wire to the renal pelvis fail, a change in guide wire design may be helpful. There currently are several hydrophilic coated slippery guide wire designs with different tip angles and directional capa bility available. Commonly used guide wires include a straight soft or curved tip, a polytetrafluoroethylene (Teflon) coated movable core, a smaller (0.035 inch) guide wire with less of a J shape or, rarely, a Lunderquist 0.032 inch 120 cm. guide wire. If passage is difficult secondary to angulation or tortuosity, the next step involves reintubating the distal ure ter below the obstruction with a different hollow catheter, such as various angiographic catheters. Such catheters pro vide more options in terms of stiffness, torque and curve. Angiographic catheters commonly used include renal access cobra catheters (6.5F, 65 cm.), straight angiographic cathe ters (6.5F, 70 cm.) and shepherd hook catheters (6.5F, 0.035 inch, 70 cm.). Often, passage of a guide wire can be facilitated by gentle lavage of the obstructing area with a 1:1 mixture of lidocaine jelly (2%) and water soluble contrast medium.4 Depending on the particular clinical situation, when retro grade access is still believed to be a reasonable option, a 3F or * Medical Engineering Corp., New York, New York.
t Cook Urological, Spencer, Indiana.
Accepted for publication December 22, 1993.
917
--918
---
BYPASSING AND STENTING URETERAL OBSTRUCTIONS !VP/US
I URETERAL OBSTRUCTION
----
CYSTO, 5 FR. tEN - RETROGRADE
Wire
(
asses
I
Wire cannot pass --------- Retrograde attempts fail
Insert DJStent I Appropriate therapy
L----
-Tortu s ureter _ r Flexible ureteroscope
Tight obs. or stricture with buck1 i ng
1
1 Sheath Pul1-down ureteral balloon I system L..... Wire passes _____J
a1
I
Stent
Appropriate therapy
Different guide wires
I I
I
Flexible ureteroscopy :(
Lidocaine lavage
Stent
. I
Wir
Angiographic catheters
Wire Passes
ol
False passage or kink
Wire Cannot Pass
asses
I I
Percutaneous Access Antegrade Bypass attempts Stent Passes
I
Appropriate therapy
I
Retrograde Ureteral Catheters Pass
I
Leave to Drainage Alongside Foley
Fails
I
Leave nephrostomy
I
Secondary Retrograde Attempt After Decompression
Techniques to bypass and stent ureteral obstructions. NP, excretory urography. US, ultrasound. DJ, Double-J. Cysto., cystoscopy. obs., obstruction.
4F flexible tip or pigtail spiral tip retrograde ureteral cathe ter will sometimes pass when a guide wire fails. At other times, a peel-away introducer sheath or a general ureteral dilator-sheathing system can be useful to prevent buckling or accomplish straightening of a tortuous ureter.5• 6 We often use a technique described by Fraser,7 and Clayman and Castafieda-Zufiiga2 to bypass a tortuous ureter by passing a hollow 4F to 7F ureteral balloon dilating catheter just distal to the problem point and gently filling the balloon with con trast medium until there is just enough traction to pull down and straighten the ureter, thereby allowing passage of a guide wire through the internal lumen of the catheter. The rigid or flexible ureteroscope is generally used as a diagnostic or therapeutic maneuver (for example acute dilation plus stone removal). However, it may be useful to bypass obstruc tions in the face of ureteral mucosal false passages.8 If the aforementioned maneuvers fail, the newer smaller flexible ureteroscopes may allow direct visualization of the narrowed lumen and bypass of the obstruction by passage of a guide wire under direct vision. When retrograde attempts fail, we proceed immediately to an antegrade approach. Previously placed retrograde contrast medium, when feasible, allows for direct renal needle placement. If retrograde contrast medium instilla tion is not possible and renal dysfunction or allergy pre vents intravenous contrast medium administration, ultra sound guidance allows for safe and accurate nephrostomy tube placement into a mid pole calix, which gives easy access to the proximal ureter. Similar attempts at bypass ing the obstructive point from above are made with guide wires, catheters and so forth. If all attempts fail, an 8.3F pigtail percutaneous nephrostomy tube is left to closed drainage and the system is allowed to decompress. Second ary antegrade or retrograde attempts at diversion follow ing several days of decompression are generally successful, even when initial attempts failed.
RESULTS
Between July 1983 and June 1986, 90 patients (105 renal units) required relief of renal obstruction secondary to calcu lous or malignant obstruction. Of the 75 obstructed renal units due to stone disease 62 had internal, 3 external and 5 antegrade stent placement, for a stent placement success rate of 93%. Five renal units (7%) required a percutaneous nephrostomy tube. Of the 30 ureters obstructed due to ma lignant disease 24 (80%) were successfully stented internally. The majority of malignant obstructions were secondary to carcinoma of the cervix, many after previous radiation ther apy and most before planned nephrotoxic chemotherapy. DISCUSSION
Continued refinements in endourological equipment and uroradiographic imaging have allowed urologists to continue to expand their expertise in diverting urinary obstructions.2 Using a transurethral approach, the majority of obstructions can be bypassed and stented internally (when appropriate), thereby avoiding external stents and tubes. Also, if the urol ogist is trained in percutaneous renal access, urine may be diverted from above the obstruction at 1 session with the patient under anesthesia.9 The figure outlines a troubleshooting scheme that may be used when a ureteral catheter or stent does not initially pass the level of the obstruction to the kidney. Initial options may include use of different sized and configured guide wires, a change of stent (that is various adaptable hollow angio graphic catheters) and gentle lavage of the affected area with a lidocaine jelly solution. Occasionally, retrograde flexible tipped catheters will pass when other attempts fail. Tortuous ureters may be negotiated with a hollow "pull down" ureteral balloon and guide wire or bypassed under direct vision with a sheath system and ureteroscope.5• 6 Smaller flexible ureteroscopes are useful to identify ureteral false passages, allowing the true ureteral lumen to be intu bated.
BYPASSING AND STENTING URETERAL OBSTRUCTIONS When all reasonable retrograde approaches fail, percuta neous access is then established. Antegrade bypass attempts may then be made or a percutaneous nephrostomy tube may be introduced and the urine drained from above the obstruc tion. Definitive therapy then may require a secondary ses sion following a brief period of upper tract decompression, with decrease in tortuosity and commonly associated ure teral edema.
REFERENCES 1. Humble, L. and Venable, D. D.: Perioperative use ofindwelling ureteral catheter as an adjunct to ureteroscopic stone manip ulation. J. Endourol., 1: 165, 1987. 2. Clayman, R. V. and Castafieda-Zufiiga, W. R.: Techniques in Endourology: A Guide to the Percutaneous Removal ofRenal
919
and Ureteral Calculi. Minneapolis, 1984. 3. Donovan, M. G., Hegarty, J., Fitzpatrick, J. M. and Butler, M.: Ureteral meatotomy by Sachse urethrotome in the manage ment oflower ureteral stones. J. Urol., 138: 566, 1987. 4. Steinbock, G. S. and Bezirdjian, L. B.: Technique for retrograde ureteral stone displacement. Urology, 31: 160, 1988. 5. Rich, M., Lee, W. J. and Smith, A. D.: Applications ofthe peel away introducer sheath. J. Urol., 137: 452, 1987. 6. Newman, R. C., Hunter, P. T., Hawkins, I. F. and Finlayson, B.: A general ureteral dilator-sheathing system. Urology, 25: 287, 1985. 7. Fraser, K. S.: A technique for stenting tortuous ureters. J. Urol., 138: 831, 1987. 8. Kraebber, D. M. and Torres, S. A.: Use ofureteroscope to avoid distal ureteral false passages. Urology, 31: 80, 1988. 9. Smith, A. D.: Percutaneous ureteral surgery and stenting. Urol ogy, special issue, 23: 37, 1984.