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Ureteric catheterization via an ileal conduit: technique and retrieval of a JJ stent
Clinical Radiology (2004) 59, 1041–1043
TECHNICAL REPORT
Ureteric catheterization via an ileal conduit: technique and retrieval of a JJ stent T.M. Wah, M.J. Kellett* Department of Uroradiology, University College London Hospitals and Institute of Urology and Nephrology U.C.L., London, UK Received 6 August 2003; received in revised form 4 February 2004; accepted 13 February 2004
KEYWORDS JJ stent; Ileal conduit; Retrograde ureteral catheterization
Retrograde ureteric catheterization of a patient with an ileal conduit is difficult, because guide wires and catheters coil in the conduit. A modified loopogram, using a Foley catheter as a fulcrum through which catheters can be advanced to the ureteric anastomosis, is described. This technique was used to remove a JJ stent, which had been inserted previously across a stricture in one ureter, the stent crossing from one kidney to the other. q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction
Case report
Percutaneous nephrostomy (PCN) has been traditionally used to provide access for temporary drainage or antegrade ureteric stenting in patients having an ileal conduit with an upper tract obstruction. Recently, some authors have achieved retrograde ureteral catheterization via an ileal conduit under fluoroscopic guidance.1 – 3 This obviates the need for PCN, which has a major complication rate of 4 –8%.4 It is not uncommon for patients to be referred to the radiology department after failed endoscopic retrieval and ureteric stent exchange by the urologist. We describe a modified method of retrograde ureteral catheterization via the ileal conduit under fluoroscopic guidance and use of the Amplatz gooseneck snare kit to retrieve an unusually positioned JJ stent after failed endoscopic ureteric stent retrieval from an ileal conduit.
A 82-year-old woman presented with worsening renal function and right loin pain. She had previously undergone a hysterectomy and bilateral oophorectomy followed by radiotherapy for locally advanced cervical cancer. After initial recurrence (2 years later) involving the bladder she had an ileo-caeco-cystoplasty with the two ureters attached together as a “Wallace 69” anastomosis. After a further recurrence 17 years later, she underwent cystectomy with fashioning of an ileal conduit. A few years later, her deteriorating renal function was investigated with a MAG3-renogram that confirmed right ureteric obstruction. A subsequent loopogram revealed a tight right mid-ureteric stricture with a markedly hydronephrotic collecting system. The stricture was treated with percutaneous balloon dilatation and antegrade right ureteric stent insertion. A JJ stent was deployed from right to left ureters as there were difficulties negotiating the very tortuous ileal conduit. Her renal function stabilized with the ureteric stent in-situ and her symptoms resolved. Recently she was admitted for elective retrograde right ureteric stent exchange. The urologist was unable to negotiate the flexible cystoscope through the tortuous ileal loop for ureteric stent retrieval and exchange. The patient was referred to the uroradiology department for stent exchange. A 16 F Foley catheter was modified by cutting off its tip just distal to the balloon catheter, to act as an end-hole catheter. A 6 F Cobra angiographic catheter (Cordis, Brentford, Middlesex, UK) over a 0.035 gauge 150 cm Teflon-coated straight-tip wire was inserted coaxially through the Foley catheter. The Foley was first advanced as far up the ileal conduit as possible. The inflated balloon of the Foley catheter gave a fixed point to allow the Cobra catheter to advance (Fig. 1). In addition, the Foley catheter enabled a loopogram to be performed (Fig. 2) and
*Guarantor and correspondent: M. J. Kellett, Department of Uroradiology, The Institute of Urology and Nephrology UCL, 48 Riding House St, London W1W 7EY, UK. Tel.: þ44-207-3172790; fax: þ 44-207-4367059. E-mail address: [email protected]
0009-9260/$ - see front matter q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2004.02.021
1042
T.M. Wah, M.J. Kellett
contrast refluxed up both ureters from the ileal conduit. The Cobra catheter was manoeuvred over a straight hydrophilic wire to the common ureteric anastomosis and an angled hydrophilic wire was advanced up the left ureter. The Foley catheter was then exchanged for a 12 F peel-away Teflon sheath through which an Amplatz gooseneck snare (Microvena, Vadnais Heights, MN, USA) 6 F 120 cm with a 15 mm loop could be introduced into the left ureter over the wire. The gooseneck snare deployment catheter was first advanced over the Terumo wire into the left ureter. The snare loop was then advanced beyond the catheter tip to allow the loop to grasp the top end of the JJ ureteric stent in the left renal pelvis (Fig. 3). This was withdrawn into the ileal conduit and retrieved out of the stoma, leaving the proximal end of the stent in the right ureter. The exteriorized stent tip was cannulated with an Amplatz super stiff wire 0.035 gauge 145 cm (Boston Scientific, Watertown, MA, USA) and this was exchanged for a new longer 8 F 24 cm JJ stent (Cook, Bloomington, IN, USA) with its distal J tip exteriorized within the stoma bag.
Discussion
Figure 1 Diagram of cut-end Foley catheter, which acts as a fulcrum together with a Cobra catheter for initial retrograde catheterization of the ileal conduit.
Figure 2 Loopogram via the cut-end Foley catheter to delineate the ileal conduit anatomy.
A proportion of patients with urinary diversion and ileal conduit encounter post-operative complications such as urinary leak, ureteric stricture and calculi.5 These complications, which that were once treated exclusively by surgery, are now amenable to management by interventional radiology.6 – 8 Access to the urinary tract may be achieved via the antegrade or retrograde route. Retrograde catheterization of the ureters via the ileal conduit carries less risk when compared with PCN, which has a major complication rate of 4 – 8%.4 Even during the immediate post-operative period, this method has proved to be a safe technique for treatment of urinary leak in anastomotic breakdown.3 Retrograde catheterization can be performed under direct vision using a flexible cystoscope9,10 or under fluoroscopic guidance with angiographic catheters and guide wires.1 – 3 However, retrograde catheterization of the implanted ureters in patient with an ileal conduit can sometimes be difficult for both the urologist and radiologist due to redundant loops and intestinal folds impeding the endoscope or the guide wires. The redundant loops may also cause a further complication because of excessive peristalsis causing catheters and guide wires to coil and be extruded. For successful retrograde catheterization, it is important to have a deep anchorage within the ileal conduit for stabilizing catheters and guide wires. Some authors had described the use of various catheters to facilitate retrograde cannulation of the uretero-ileal anatomosis such as purpose made angled tip catheters2 and a variety of angiographic catheters.1,3 As for deep anchorage within the ileal conduit, various techniques using a Teflon sheath1 or a blunt-ended Robinson catheter as a sleeve
Ureteric catheterization via an ileal conduit
1043
manipulations to be transmitted directly to the catheter tip for manoeuvring around the ileal conduit (Fig. 1). The unusually positioned JJ stent across the right and left ureters in this case is as a result of “Wallace 69” anastomosis. This posed a technical challenge for stent retrieval and exchange. The Amplatz gooseneck snare helped to solve this problem. A longer JJ stent was used on this occasion in order to exteriorize the lower end in the stoma bag. This enabled future retrograde catheter exchange as an out-patient in the radiology department. In conclusion, a simple coaxial catheter can be made from a Foley catheter with the advantages that a loopogram can be performed and the balloon can act as a fulcrum during retrograde ureteric catheterization via an ileal conduit.
References
Figure 3 The end of the JJ ureteric stent in the left renal pelvis is grasped by an Amplatz gooseneck snare loop.
device to deliver both catheters and guide wires have also been described.3 This helps to stabilize catheters and guide wires, preventing them from looping and buckling in the conduit. The modified Foley catheter with its balloon inflated provides a seal, in order to perform a loopogram to demonstrate anatomy, and it also acts as a fulcrum to allows the forward thrusts of the catheter
1. Banner MP, Amendola MA, Pollack HM. Anastomosed ureters: fluoroscopically guided transconduit retrograde catheterisation. Radiology 1989;170:45—9. 2. Drake MJ, Cowan NC. Fluoroscopy guided retrograde ureteral stent insertion in patients with a ureteroileal urinary conduit: method and results. J Urol 2002;167:2049—51. 3. Applbaum YN, Diamond AB. Rappoport retrograde ureteral catheterisation via the ileal conduit. AJR Am J Roentgenol 1986;146:61—3. 4. Barbaric ZL. Percutaneous nephrostomy for urinary tract obstruction. AJR Am J Roentgenol 1984;143:803—9. 5. Sullivan JW, Grabstald H, Whitmore Jr WJ. Complications of urteroileal conduit with radical cystectomy: review of 336 cases. J Urol 1980;124:797—801. 6. Bettman MA, Murray PD, Perlmutt LM, Whitmore III WF, Richie JP. Ureteroileal anastomotic leaks: percutaneous treatment. Radiology 1983;148:95—100. 7. Banner MP, Pollack HM, Ring EJ, Wein AJ. Catheter dilatation of benign ureteral strictures. Radiology 1983;147:427—33. 8. Smith AD, Lange PH, Reinke DB, Miller RP. Extraction of ureteral calculi from patients with ileal loops: a new technique. J Urol 1978;120:623—5. 9. Warner RS, Falkenstein DB, Golimbu MN, et al. Endoscopy of intestinal urinary conduit. Urology 1975;5:799—801. 10. Ramsburgh SR, Dent TL, Herwig KR. Flexible fibroscopy of urinary conduits. J Urol 1976;116:166—8.
TECHNICAL REPORT
Ureteric catheterization via an ileal conduit: technique and retrieval of a JJ stent T.M. Wah, M.J. Kellett* Department of Uroradiology, University College London Hospitals and Institute of Urology and Nephrology U.C.L., London, UK Received 6 August 2003; received in revised form 4 February 2004; accepted 13 February 2004
KEYWORDS JJ stent; Ileal conduit; Retrograde ureteral catheterization
Retrograde ureteric catheterization of a patient with an ileal conduit is difficult, because guide wires and catheters coil in the conduit. A modified loopogram, using a Foley catheter as a fulcrum through which catheters can be advanced to the ureteric anastomosis, is described. This technique was used to remove a JJ stent, which had been inserted previously across a stricture in one ureter, the stent crossing from one kidney to the other. q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction
Case report
Percutaneous nephrostomy (PCN) has been traditionally used to provide access for temporary drainage or antegrade ureteric stenting in patients having an ileal conduit with an upper tract obstruction. Recently, some authors have achieved retrograde ureteral catheterization via an ileal conduit under fluoroscopic guidance.1 – 3 This obviates the need for PCN, which has a major complication rate of 4 –8%.4 It is not uncommon for patients to be referred to the radiology department after failed endoscopic retrieval and ureteric stent exchange by the urologist. We describe a modified method of retrograde ureteral catheterization via the ileal conduit under fluoroscopic guidance and use of the Amplatz gooseneck snare kit to retrieve an unusually positioned JJ stent after failed endoscopic ureteric stent retrieval from an ileal conduit.
A 82-year-old woman presented with worsening renal function and right loin pain. She had previously undergone a hysterectomy and bilateral oophorectomy followed by radiotherapy for locally advanced cervical cancer. After initial recurrence (2 years later) involving the bladder she had an ileo-caeco-cystoplasty with the two ureters attached together as a “Wallace 69” anastomosis. After a further recurrence 17 years later, she underwent cystectomy with fashioning of an ileal conduit. A few years later, her deteriorating renal function was investigated with a MAG3-renogram that confirmed right ureteric obstruction. A subsequent loopogram revealed a tight right mid-ureteric stricture with a markedly hydronephrotic collecting system. The stricture was treated with percutaneous balloon dilatation and antegrade right ureteric stent insertion. A JJ stent was deployed from right to left ureters as there were difficulties negotiating the very tortuous ileal conduit. Her renal function stabilized with the ureteric stent in-situ and her symptoms resolved. Recently she was admitted for elective retrograde right ureteric stent exchange. The urologist was unable to negotiate the flexible cystoscope through the tortuous ileal loop for ureteric stent retrieval and exchange. The patient was referred to the uroradiology department for stent exchange. A 16 F Foley catheter was modified by cutting off its tip just distal to the balloon catheter, to act as an end-hole catheter. A 6 F Cobra angiographic catheter (Cordis, Brentford, Middlesex, UK) over a 0.035 gauge 150 cm Teflon-coated straight-tip wire was inserted coaxially through the Foley catheter. The Foley was first advanced as far up the ileal conduit as possible. The inflated balloon of the Foley catheter gave a fixed point to allow the Cobra catheter to advance (Fig. 1). In addition, the Foley catheter enabled a loopogram to be performed (Fig. 2) and
*Guarantor and correspondent: M. J. Kellett, Department of Uroradiology, The Institute of Urology and Nephrology UCL, 48 Riding House St, London W1W 7EY, UK. Tel.: þ44-207-3172790; fax: þ 44-207-4367059. E-mail address: [email protected]
0009-9260/$ - see front matter q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2004.02.021
1042
T.M. Wah, M.J. Kellett
contrast refluxed up both ureters from the ileal conduit. The Cobra catheter was manoeuvred over a straight hydrophilic wire to the common ureteric anastomosis and an angled hydrophilic wire was advanced up the left ureter. The Foley catheter was then exchanged for a 12 F peel-away Teflon sheath through which an Amplatz gooseneck snare (Microvena, Vadnais Heights, MN, USA) 6 F 120 cm with a 15 mm loop could be introduced into the left ureter over the wire. The gooseneck snare deployment catheter was first advanced over the Terumo wire into the left ureter. The snare loop was then advanced beyond the catheter tip to allow the loop to grasp the top end of the JJ ureteric stent in the left renal pelvis (Fig. 3). This was withdrawn into the ileal conduit and retrieved out of the stoma, leaving the proximal end of the stent in the right ureter. The exteriorized stent tip was cannulated with an Amplatz super stiff wire 0.035 gauge 145 cm (Boston Scientific, Watertown, MA, USA) and this was exchanged for a new longer 8 F 24 cm JJ stent (Cook, Bloomington, IN, USA) with its distal J tip exteriorized within the stoma bag.
Discussion
Figure 1 Diagram of cut-end Foley catheter, which acts as a fulcrum together with a Cobra catheter for initial retrograde catheterization of the ileal conduit.
Figure 2 Loopogram via the cut-end Foley catheter to delineate the ileal conduit anatomy.
A proportion of patients with urinary diversion and ileal conduit encounter post-operative complications such as urinary leak, ureteric stricture and calculi.5 These complications, which that were once treated exclusively by surgery, are now amenable to management by interventional radiology.6 – 8 Access to the urinary tract may be achieved via the antegrade or retrograde route. Retrograde catheterization of the ureters via the ileal conduit carries less risk when compared with PCN, which has a major complication rate of 4 – 8%.4 Even during the immediate post-operative period, this method has proved to be a safe technique for treatment of urinary leak in anastomotic breakdown.3 Retrograde catheterization can be performed under direct vision using a flexible cystoscope9,10 or under fluoroscopic guidance with angiographic catheters and guide wires.1 – 3 However, retrograde catheterization of the implanted ureters in patient with an ileal conduit can sometimes be difficult for both the urologist and radiologist due to redundant loops and intestinal folds impeding the endoscope or the guide wires. The redundant loops may also cause a further complication because of excessive peristalsis causing catheters and guide wires to coil and be extruded. For successful retrograde catheterization, it is important to have a deep anchorage within the ileal conduit for stabilizing catheters and guide wires. Some authors had described the use of various catheters to facilitate retrograde cannulation of the uretero-ileal anatomosis such as purpose made angled tip catheters2 and a variety of angiographic catheters.1,3 As for deep anchorage within the ileal conduit, various techniques using a Teflon sheath1 or a blunt-ended Robinson catheter as a sleeve
Ureteric catheterization via an ileal conduit
1043
manipulations to be transmitted directly to the catheter tip for manoeuvring around the ileal conduit (Fig. 1). The unusually positioned JJ stent across the right and left ureters in this case is as a result of “Wallace 69” anastomosis. This posed a technical challenge for stent retrieval and exchange. The Amplatz gooseneck snare helped to solve this problem. A longer JJ stent was used on this occasion in order to exteriorize the lower end in the stoma bag. This enabled future retrograde catheter exchange as an out-patient in the radiology department. In conclusion, a simple coaxial catheter can be made from a Foley catheter with the advantages that a loopogram can be performed and the balloon can act as a fulcrum during retrograde ureteric catheterization via an ileal conduit.
References
Figure 3 The end of the JJ ureteric stent in the left renal pelvis is grasped by an Amplatz gooseneck snare loop.
device to deliver both catheters and guide wires have also been described.3 This helps to stabilize catheters and guide wires, preventing them from looping and buckling in the conduit. The modified Foley catheter with its balloon inflated provides a seal, in order to perform a loopogram to demonstrate anatomy, and it also acts as a fulcrum to allows the forward thrusts of the catheter
1. Banner MP, Amendola MA, Pollack HM. Anastomosed ureters: fluoroscopically guided transconduit retrograde catheterisation. Radiology 1989;170:45—9. 2. Drake MJ, Cowan NC. Fluoroscopy guided retrograde ureteral stent insertion in patients with a ureteroileal urinary conduit: method and results. J Urol 2002;167:2049—51. 3. Applbaum YN, Diamond AB. Rappoport retrograde ureteral catheterisation via the ileal conduit. AJR Am J Roentgenol 1986;146:61—3. 4. Barbaric ZL. Percutaneous nephrostomy for urinary tract obstruction. AJR Am J Roentgenol 1984;143:803—9. 5. Sullivan JW, Grabstald H, Whitmore Jr WJ. Complications of urteroileal conduit with radical cystectomy: review of 336 cases. J Urol 1980;124:797—801. 6. Bettman MA, Murray PD, Perlmutt LM, Whitmore III WF, Richie JP. Ureteroileal anastomotic leaks: percutaneous treatment. Radiology 1983;148:95—100. 7. Banner MP, Pollack HM, Ring EJ, Wein AJ. Catheter dilatation of benign ureteral strictures. Radiology 1983;147:427—33. 8. Smith AD, Lange PH, Reinke DB, Miller RP. Extraction of ureteral calculi from patients with ileal loops: a new technique. J Urol 1978;120:623—5. 9. Warner RS, Falkenstein DB, Golimbu MN, et al. Endoscopy of intestinal urinary conduit. Urology 1975;5:799—801. 10. Ramsburgh SR, Dent TL, Herwig KR. Flexible fibroscopy of urinary conduits. J Urol 1976;116:166—8.