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Treatment of Transplant Ureteral Stricture with Acucise Endoureterotomy: Case Report and Literature Review
TREATMENT OF TRANSPLANT URETERAL STRICTURE WITH ACUCISE ENDOURETEROTOMY: CASE REPORT AND LITERATURE REVIEW Hsi-Lin Hsiao,1 Ching-Chia Li,1 Tu-Hao Chang,1 Wen-Jeng Wu,1,3 Yii-Her Chou,1,3 Jung-Tsung Shen,2 Mei-Yu Jang,2 and Chun-Hsiung Huang1,3 1 Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 2Department of Urology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, and 3Department of Urology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
We report a patient who was diagnosed with end-stage renal disease and who received renal transplantation in her right iliac fossa in 2003. After transplantation, right hydronephrosis was noted on abdominal ultrasonography and right lower ureteral stricture was diagnosed by antegrade pyelography. She received ureter internal stent insertion three times, but hydronephrosis and urinary tract infection recurred after the stent was removed. Therefore, Acucise endoureterotomy was used to treat the recurrent ureteral stricture. The patient was discharged on the second postoperative day and abdominal ultrasonography revealed no hydronephrosis during regular follow-up.
Key Words: Acucise endoureterotomy, hydronephrosis, transplant kidney, ureteral stricture (Kaohsiung J Med Sci 2007;23:259–64)
Ureteral stenosis is the most frequent urologic complication of kidney transplantation. The incidence of stenosis has been reported as 2–10% of all renal transplant recipients [1–6]. Early recognition and treatment are critical for patients with ureteral stenosis because the complication can lead to deterioration in renal function and graft loss [7]. Despite greater perioperative morbidity and a longer period of hospitalization, the common treatment for all these forms of ureteral stricture remains open surgery [8]. Currently, minimally invasive endourologic techniques are being used more frequently, such as Acucise catheter endoureterotomy. Acucise ureteral catheter is a ureteral cutting balloon device that was first clinically reported in 1993
Received: September 21, 2006 Accepted: October 13, 2006 Address correspondence and reprint requests to: Dr ChingChia Li, Department of Urology, Kaohsiung Medical University Hospital, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan. E-mail: [email protected] Kaohsiung J Med Sci May 2007 • Vol 23 • No 5 © 2007 Elsevier. All rights reserved.
(Applied Medical, Laguna Hills, CA, USA). Favorable worldwide experience with endopyelotomy or endoureterotomy using Acucise has increased since then. The Acucise catheter system has become a very popular choice for endourologic treatment of ureteropelvic junction obstruction and also other ureteral strictures. However, there have only been a few cases treated with Acucise endoureterotomy following renal transplantation [9]. We report a case of ureteral stricture following renal transplantation successfully treated with Acucise endoureterotomy.
CASE PRESENTATION A 50-year-old female patient who was diagnosed with end-stage renal disease received renal transplantation in her right iliac fossa in 2003 in Mainland China. She received regular follow-up at our hospital after surgery. Unfortunately, right hydronephrosis was noted 259
H.L. Hsiao, C.C. Li, T.H. Chang, et al
Figure 1. Antegrade pyelography shows lower ureteral stricture.
on abdominal ultrasound (US) and right lower ureteral stricture was diagnosed by antegrade pyelography (Figure 1). She received ureter internal stent insertion three times, but hydronephrosis and right side flank pain recurred after the stent was removed. Urinalysis showed pyuria on and off since then. After discussion with the patient, we decided to use Acucise endoureterotomy to treat the ureteral stricture instead of traditional open procedures. With the patient in the dorsal lithotomy position, we introduced a 0.035-inch stiff guide wire through the cystoscope into the renal pelvis under fluoroscopic guidance. Unfortunately, the guide wire failed to enter the neoureter orifice due to severe stenosis of the lower ureter. So, US-guided antegrade percutaneous guide wire insertion was performed (Figure 2A–C). Next, the cystoscope was removed and the Acucise catheter was
A
B
C
D
Figure 2. (A) Stenotic region at the ureterovesical junction. (B, C) Ultrasound-guided antegrade percutaneous guide wire insertion was performed. (D) The Acucise catheter is advanced over the guide wire under fluoroscopic control until the balloon markers straddle the stenotic segment.
260
Kaohsiung J Med Sci May 2007 • Vol 23 • No 5
Acucise endoureterotomy for transplant ureteral stricture A
B
C
D
Figure 3. (A, B) Balloon is filled with 0.5 mL contrast medium under fluoroscopic guidance to confirm the correct placement of the balloon. (C, D) Insufflation of 2.2 mL of contrast medium into the balloon after cutting wire activation.
advanced over the guide wire under fluoroscopic control until the balloon markers straddled the stenotic segment (Figure 2D). The balloon was filled with 0.5 mL of contrast medium under fluoroscopic guidance to confirm correct placement of the balloon (Figure 3A and B). Then, the cutting wire was activated at 75 W pure cut for 5 seconds while the balloon was inflated to a total volume of 2.2 mL (Figure 3C and D). The generator was again placed on the “stand-by” mode and the Acucise balloon was left fully inflated for 10 minutes to tamponade the incised ureter (Figure 4A). We deflated the balloon (Figure 4B) and retrograde ureterography was performed through the Acucise catheter to confirm extravasation at the incision site. After the balloon catheter was removed, we placed a 7F/14F endopyelotomy stent with the 14F end positioned across the incised area. A Foley catheter was placed after the operation and was removed the following morning. Kaohsiung J Med Sci May 2007 • Vol 23 • No 5
The patient was discharged on the second postoperative day. The stent was removed 4 weeks later and abdominal US revealed no hydronephrosis. Renal function remained in the normal range after 5 months of regular follow-up at our outpatient department.
DISCUSSION Ureteral complications following renal transplant are uncommon [10–12]. The most common complications are ureteral obstruction, urine leakage, hematuria, and necrosis of the distal ureter [13]. Prompt diagnosis and effective therapy are mandatory if the risk of graft loss is to be reduced. Ureteral stenosis soon after transplantation commonly results from ischemia of the distal transplant ureter caused by restricted vascularization and this leads to fibrosis of the ureteral intima. Other reasons 261
H.L. Hsiao, C.C. Li, T.H. Chang, et al A
B
Figure 4. (A) Acucise balloon fully inflated for 10 minutes to tamponade the incised ureter. (B) The procedure is completed after deflating the balloon and removing the catheter.
are kinking of the ureter at the new muscular hiatus in the bladder, external compression for a variety of reasons, and intramural clot or calculus [14]. Standard therapy for stenosis of the transplant ureter is open surgical ureteroneocystostomy or pyeloureterostomy with the patient’s native ureter. These methods are associated with a high incidence of early perioperative complications, including wound infection and urinary tract infection leading to urosepsis. Recently, an innovative technique of endourologic therapy for stenosis of the ureter—Acucise endoureterotomy—was introduced. It was first introduced into clinical practice by Chandhoke et al [15]. Youssef et al [14] reported the first experience with this technique in three patients who had transplant ureteral obstruction. This minimally invasive procedure offers the following advantages over open surgery: (1) shorter operative time; (2) reduced postoperative analgesia requirements; and (3) faster recovery [16,17]. Bleeding is one of the most feared acute complications and usually results from injury to a crossing vessel and it can present as any combination of hemodynamic instability, flank mass/ecchymosis, hematuria or decreasing hematocrit [18]. Effective methods for managing postoperative bleeding are either a balloon passed over the guide wire and positioned to achieve tamponade or emergent angiography [19]. The treatment of renal transplant ureter stenosis with balloon cautery endoureterotomy has so far been investigated in only a small number of patients. To improve long-term patency of treated ureters, some authors suggest that patient selection is important 262
before operation, i.e. the interval between the appearance of the stricture and the primary operative trauma should be at least 6 months, the length of the stricture should not exceed 1.5 cm, and the function of the obstructed kidney should not be less than 25% of the total renal function [20]. We treated stenosis of the transplant ureter with the Acucise catheter technique and the patient was free of symptoms and re-stenosis during 5 months’ followup. Therefore, we believe that Acucise catheter is a significant addition to the available modalities for treating ureteric stenosis and this procedure should be considered an initial approach for distal ureteral stenosis in the transplant kidney because of the speed of the procedure, overall safety and short hospital stay. In conclusion, the Acucise technique is useful for treating ureteral stenosis following renal transplantation.
REFERENCES 1.
2.
3.
4.
Butterworth PC, Horsburgh T, Veith PS, et al. Urological complications in renal transplantation: impact of a change of technique. Br J Urol 1997;79:499–502. Conrad S, Schneider AW, Tenschert W, et al. Endourological cold knife incision for ureteral stenosis after renal transplantation. J Urol 1994;152:906–9. Peregrin J, Filipova H, Mati I, et al. Percutaneous treatment of early and late ureteral stenosis after renal transplantation. Transplant Proc 1997;29:140–1. Faenza A, Nardo B, Catena F, et al. Ureteral stenosis after kidney transplantation: a study on 869 consecutive transplants. Transplant Int 1999;12:334–40. Kaohsiung J Med Sci May 2007 • Vol 23 • No 5
Acucise endoureterotomy for transplant ureteral stricture 5.
Lojanapiwat B, Mital D, Fallon L, et al. Management of ureteral stenosis after renal transplantation. J Am Coll Surg 1994;179:21–4. 6. Kinnaert P, Hall M, Janssen F, et al. Ureteral stenosis after kidney transplantation: true incidence and longterm follow-up after surgical correction. J Urol 1985; 133:17–20. 7. Erdal E, Danil TB, David W. Treatment of transplant ureteral stenosis with endoureterotomy. J Urol 1999;161: 412–4. 8. Smith AD. Management of iatrogenic ureteral strictures after urologic procedures. J Urol 1988;140:1372–4. 9. Erturk E, Burzon DT, Waldman D. Treatment of transplant ureteral stenosis with Acucise incision. J Urol 1997; 157:1680. 10. Kashi SH, Lodge JP, Giles GR, et al. Ureteric complications of renal transplantation. Br J Urol 1992;70:139–43. 11. Hakim NS, Benedetti E, Pirenne J. Complications of ureterovesical anastomosis in kidney transplant patients: the Minnesota experience. Clin Transplant 1994; 8:504–7. 12. Jaskowski A, Jones RM, Murie JA, et al. Urological complications in 600 consecutive renal transplants. Br J Surg 1987;74:922–5.
Kaohsiung J Med Sci May 2007 • Vol 23 • No 5
13. Gross AJ, Seseke F, Lorf T, et al. Treatment of transplant ureteral stenosis with Acucise endoureterotomy. Transplant Int 1998;11:316–9. 14. Youssef NI, Jindal R, Babayan RJ, et al. The Acucise catheter: a new endourological method for correcting transplant ureteric stenosis. Transplantation 1994;57: 1398–400. 15. Chandhoke PS, Clayman RV, Stone AM. Endopyelotomy and endoureterotomy with Acucise ureteral cutting balloon device: preliminary results. J Endourol 1993;7:45–51. 16. Karlin GS, Baldani GH, Smith AD. Endopyelotomy versus open pyeloplasty: comparison in 88 patients. J Urol 1988;140:476–8. 17. Nadler RB, Pearle MS, Nakada SY, et al. Acucise endopyelotomy: assessment of long-term durability. J Urol 1996; 156:1094–8. 18. Kim FJ, Duke Herrell D, Jahoda AE, et al. Complications of Acucise endopyelotomy. J Endourol 1998;12:433–6. 19. Cohen TD, Gross MB, Preminger GM. Long-term followup of Acucise incision of ureteropelvic junction obstruction and ureteral strictures. Urology 1996;47:317–23. 20. Seseke F, Heuser M, Zöller G, et al. Treatment of iatrogenic postoperative ureteral strictures with Acucise endoureterotomy. Eur Urol 2001;42:370–5.
263
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!"VR= = V= = ON= !"VR= = NM= = NP= !"#$%&' !"!#$ %&'( UMT !"#$NMM Kaohsiung J Med Sci May 2007 • Vol 23 • No 5
We report a patient who was diagnosed with end-stage renal disease and who received renal transplantation in her right iliac fossa in 2003. After transplantation, right hydronephrosis was noted on abdominal ultrasonography and right lower ureteral stricture was diagnosed by antegrade pyelography. She received ureter internal stent insertion three times, but hydronephrosis and urinary tract infection recurred after the stent was removed. Therefore, Acucise endoureterotomy was used to treat the recurrent ureteral stricture. The patient was discharged on the second postoperative day and abdominal ultrasonography revealed no hydronephrosis during regular follow-up.
Key Words: Acucise endoureterotomy, hydronephrosis, transplant kidney, ureteral stricture (Kaohsiung J Med Sci 2007;23:259–64)
Ureteral stenosis is the most frequent urologic complication of kidney transplantation. The incidence of stenosis has been reported as 2–10% of all renal transplant recipients [1–6]. Early recognition and treatment are critical for patients with ureteral stenosis because the complication can lead to deterioration in renal function and graft loss [7]. Despite greater perioperative morbidity and a longer period of hospitalization, the common treatment for all these forms of ureteral stricture remains open surgery [8]. Currently, minimally invasive endourologic techniques are being used more frequently, such as Acucise catheter endoureterotomy. Acucise ureteral catheter is a ureteral cutting balloon device that was first clinically reported in 1993
Received: September 21, 2006 Accepted: October 13, 2006 Address correspondence and reprint requests to: Dr ChingChia Li, Department of Urology, Kaohsiung Medical University Hospital, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan. E-mail: [email protected] Kaohsiung J Med Sci May 2007 • Vol 23 • No 5 © 2007 Elsevier. All rights reserved.
(Applied Medical, Laguna Hills, CA, USA). Favorable worldwide experience with endopyelotomy or endoureterotomy using Acucise has increased since then. The Acucise catheter system has become a very popular choice for endourologic treatment of ureteropelvic junction obstruction and also other ureteral strictures. However, there have only been a few cases treated with Acucise endoureterotomy following renal transplantation [9]. We report a case of ureteral stricture following renal transplantation successfully treated with Acucise endoureterotomy.
CASE PRESENTATION A 50-year-old female patient who was diagnosed with end-stage renal disease received renal transplantation in her right iliac fossa in 2003 in Mainland China. She received regular follow-up at our hospital after surgery. Unfortunately, right hydronephrosis was noted 259
H.L. Hsiao, C.C. Li, T.H. Chang, et al
Figure 1. Antegrade pyelography shows lower ureteral stricture.
on abdominal ultrasound (US) and right lower ureteral stricture was diagnosed by antegrade pyelography (Figure 1). She received ureter internal stent insertion three times, but hydronephrosis and right side flank pain recurred after the stent was removed. Urinalysis showed pyuria on and off since then. After discussion with the patient, we decided to use Acucise endoureterotomy to treat the ureteral stricture instead of traditional open procedures. With the patient in the dorsal lithotomy position, we introduced a 0.035-inch stiff guide wire through the cystoscope into the renal pelvis under fluoroscopic guidance. Unfortunately, the guide wire failed to enter the neoureter orifice due to severe stenosis of the lower ureter. So, US-guided antegrade percutaneous guide wire insertion was performed (Figure 2A–C). Next, the cystoscope was removed and the Acucise catheter was
A
B
C
D
Figure 2. (A) Stenotic region at the ureterovesical junction. (B, C) Ultrasound-guided antegrade percutaneous guide wire insertion was performed. (D) The Acucise catheter is advanced over the guide wire under fluoroscopic control until the balloon markers straddle the stenotic segment.
260
Kaohsiung J Med Sci May 2007 • Vol 23 • No 5
Acucise endoureterotomy for transplant ureteral stricture A
B
C
D
Figure 3. (A, B) Balloon is filled with 0.5 mL contrast medium under fluoroscopic guidance to confirm the correct placement of the balloon. (C, D) Insufflation of 2.2 mL of contrast medium into the balloon after cutting wire activation.
advanced over the guide wire under fluoroscopic control until the balloon markers straddled the stenotic segment (Figure 2D). The balloon was filled with 0.5 mL of contrast medium under fluoroscopic guidance to confirm correct placement of the balloon (Figure 3A and B). Then, the cutting wire was activated at 75 W pure cut for 5 seconds while the balloon was inflated to a total volume of 2.2 mL (Figure 3C and D). The generator was again placed on the “stand-by” mode and the Acucise balloon was left fully inflated for 10 minutes to tamponade the incised ureter (Figure 4A). We deflated the balloon (Figure 4B) and retrograde ureterography was performed through the Acucise catheter to confirm extravasation at the incision site. After the balloon catheter was removed, we placed a 7F/14F endopyelotomy stent with the 14F end positioned across the incised area. A Foley catheter was placed after the operation and was removed the following morning. Kaohsiung J Med Sci May 2007 • Vol 23 • No 5
The patient was discharged on the second postoperative day. The stent was removed 4 weeks later and abdominal US revealed no hydronephrosis. Renal function remained in the normal range after 5 months of regular follow-up at our outpatient department.
DISCUSSION Ureteral complications following renal transplant are uncommon [10–12]. The most common complications are ureteral obstruction, urine leakage, hematuria, and necrosis of the distal ureter [13]. Prompt diagnosis and effective therapy are mandatory if the risk of graft loss is to be reduced. Ureteral stenosis soon after transplantation commonly results from ischemia of the distal transplant ureter caused by restricted vascularization and this leads to fibrosis of the ureteral intima. Other reasons 261
H.L. Hsiao, C.C. Li, T.H. Chang, et al A
B
Figure 4. (A) Acucise balloon fully inflated for 10 minutes to tamponade the incised ureter. (B) The procedure is completed after deflating the balloon and removing the catheter.
are kinking of the ureter at the new muscular hiatus in the bladder, external compression for a variety of reasons, and intramural clot or calculus [14]. Standard therapy for stenosis of the transplant ureter is open surgical ureteroneocystostomy or pyeloureterostomy with the patient’s native ureter. These methods are associated with a high incidence of early perioperative complications, including wound infection and urinary tract infection leading to urosepsis. Recently, an innovative technique of endourologic therapy for stenosis of the ureter—Acucise endoureterotomy—was introduced. It was first introduced into clinical practice by Chandhoke et al [15]. Youssef et al [14] reported the first experience with this technique in three patients who had transplant ureteral obstruction. This minimally invasive procedure offers the following advantages over open surgery: (1) shorter operative time; (2) reduced postoperative analgesia requirements; and (3) faster recovery [16,17]. Bleeding is one of the most feared acute complications and usually results from injury to a crossing vessel and it can present as any combination of hemodynamic instability, flank mass/ecchymosis, hematuria or decreasing hematocrit [18]. Effective methods for managing postoperative bleeding are either a balloon passed over the guide wire and positioned to achieve tamponade or emergent angiography [19]. The treatment of renal transplant ureter stenosis with balloon cautery endoureterotomy has so far been investigated in only a small number of patients. To improve long-term patency of treated ureters, some authors suggest that patient selection is important 262
before operation, i.e. the interval between the appearance of the stricture and the primary operative trauma should be at least 6 months, the length of the stricture should not exceed 1.5 cm, and the function of the obstructed kidney should not be less than 25% of the total renal function [20]. We treated stenosis of the transplant ureter with the Acucise catheter technique and the patient was free of symptoms and re-stenosis during 5 months’ followup. Therefore, we believe that Acucise catheter is a significant addition to the available modalities for treating ureteric stenosis and this procedure should be considered an initial approach for distal ureteral stenosis in the transplant kidney because of the speed of the procedure, overall safety and short hospital stay. In conclusion, the Acucise technique is useful for treating ureteral stenosis following renal transplantation.
REFERENCES 1.
2.
3.
4.
Butterworth PC, Horsburgh T, Veith PS, et al. Urological complications in renal transplantation: impact of a change of technique. Br J Urol 1997;79:499–502. Conrad S, Schneider AW, Tenschert W, et al. Endourological cold knife incision for ureteral stenosis after renal transplantation. J Urol 1994;152:906–9. Peregrin J, Filipova H, Mati I, et al. Percutaneous treatment of early and late ureteral stenosis after renal transplantation. Transplant Proc 1997;29:140–1. Faenza A, Nardo B, Catena F, et al. Ureteral stenosis after kidney transplantation: a study on 869 consecutive transplants. Transplant Int 1999;12:334–40. Kaohsiung J Med Sci May 2007 • Vol 23 • No 5
Acucise endoureterotomy for transplant ureteral stricture 5.
Lojanapiwat B, Mital D, Fallon L, et al. Management of ureteral stenosis after renal transplantation. J Am Coll Surg 1994;179:21–4. 6. Kinnaert P, Hall M, Janssen F, et al. Ureteral stenosis after kidney transplantation: true incidence and longterm follow-up after surgical correction. J Urol 1985; 133:17–20. 7. Erdal E, Danil TB, David W. Treatment of transplant ureteral stenosis with endoureterotomy. J Urol 1999;161: 412–4. 8. Smith AD. Management of iatrogenic ureteral strictures after urologic procedures. J Urol 1988;140:1372–4. 9. Erturk E, Burzon DT, Waldman D. Treatment of transplant ureteral stenosis with Acucise incision. J Urol 1997; 157:1680. 10. Kashi SH, Lodge JP, Giles GR, et al. Ureteric complications of renal transplantation. Br J Urol 1992;70:139–43. 11. Hakim NS, Benedetti E, Pirenne J. Complications of ureterovesical anastomosis in kidney transplant patients: the Minnesota experience. Clin Transplant 1994; 8:504–7. 12. Jaskowski A, Jones RM, Murie JA, et al. Urological complications in 600 consecutive renal transplants. Br J Surg 1987;74:922–5.
Kaohsiung J Med Sci May 2007 • Vol 23 • No 5
13. Gross AJ, Seseke F, Lorf T, et al. Treatment of transplant ureteral stenosis with Acucise endoureterotomy. Transplant Int 1998;11:316–9. 14. Youssef NI, Jindal R, Babayan RJ, et al. The Acucise catheter: a new endourological method for correcting transplant ureteric stenosis. Transplantation 1994;57: 1398–400. 15. Chandhoke PS, Clayman RV, Stone AM. Endopyelotomy and endoureterotomy with Acucise ureteral cutting balloon device: preliminary results. J Endourol 1993;7:45–51. 16. Karlin GS, Baldani GH, Smith AD. Endopyelotomy versus open pyeloplasty: comparison in 88 patients. J Urol 1988;140:476–8. 17. Nadler RB, Pearle MS, Nakada SY, et al. Acucise endopyelotomy: assessment of long-term durability. J Urol 1996; 156:1094–8. 18. Kim FJ, Duke Herrell D, Jahoda AE, et al. Complications of Acucise endopyelotomy. J Endourol 1998;12:433–6. 19. Cohen TD, Gross MB, Preminger GM. Long-term followup of Acucise incision of ureteropelvic junction obstruction and ureteral strictures. Urology 1996;47:317–23. 20. Seseke F, Heuser M, Zöller G, et al. Treatment of iatrogenic postoperative ureteral strictures with Acucise endoureterotomy. Eur Urol 2001;42:370–5.
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