- Email: [email protected]
Ureterocutaneous Fistula: A Case Report of Treatment by Subtrigonal Injection of Polytetrafluoroethylene (Sting Procedure)
0022-5347 /89 /1425-1310$02.00 /0 THE JOURNAL OF UROLOGY Copyright© 1989 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 142, November
Printed in U.S.A.
URETEROCUTANEOUS FISTULA: A CASE REPORT OF TREATMENT BY SUBTRIGONAL INJECTION OF POLYTETRAFLUOROETHYLENE (STING PROCEDURE) M. SASLAWSKY, C. NIEDERBERGER, M. SCHACHT, L. PRINZ
AND
L. ROSS
From the Department of Urology, Michael Reese Hospital and Medical Center, Chicago, Illinois
ABSTRACT
A ureterocutaneous fistula developed in a patient after nephrectomy for pyohydronephrosis in a kidney with vesicoureteral reflux. Endoscopic injection of polytetrafluoroethylene (Teflon) paste at the ureteral orifice prevented further reflux and cured the ureterocutaneous fistula. (J. Urol., 142: 1310-1311, 1989) Subtrigonal injection of the ureteral orifice (the Sting procedure) has been developed as a method to treat vesicoureteral reflux in children. 1 • 2 The injection of small volumes of polytetrafluoroethylene paste (0.2 to 0.4 cc) in the submucosal tissues beneath the ureteral orifice can prevent reflux in 81 % of the children treated. 2 - 7 Knowledge of these data and experience with the technique led us to postulate that the Sting procedure could be adapted to obstruct intentionally a refluxive ureter. Closure of a ureterocutaneous fistula in this fashion obviated the need for an open procedure. Endoscopic polytetrafluoroethylene injection for deliberate total occlusion of a refluxive ureteral stump after nephrectomy has been described once previously, with similarly favorable results. 8 CASE REPORT
An 86-year-old black man who had been evaluated for recurrent gross hematuria had a nonfunctioning left kidney and a large staghorn calculus (fig. 1) on an excretory urogram (IVP). Cystoscopy revealed a nonobstructed prostatic urethra and bilateral patulous ureteral orifices. Purulent efflux emanated from the left ureteral orifice on 1 occasion and a blood clot eventually was seen at the same orifice at a later cystoscopic examination. Renal scan demonstrated no evidence of perfusion or function of the left kidney. Left simple nephrectomy was performed in May 1986 and an enlarged kidney with perinephric adhesions was removed. At operation the distal ureter was clamped and ligated with a 1zero chromic suture. A Penrose drain was left in the renal fossa and the bladder was catheterized. The Penrose drain was removed 3 days postoperatively, by which time the flank drainage had ceased. The Foley catheter was removed 2 days postoperatively but it was replaced 2 days later when urinary retention developed with a 600 cc residual urine volume. On postoperative day 5, a large amount of serous drainage appeared at the Penrose drain site. A cystogram demonstrated extraperitoneal extravasation from a patent, refluxive, left ureteral stump (fig. 2, A). Right ureteral reflux was present. Despite Foley catheter drainage for 8 days the reflux persisted. Daily flank drainage averaged 200 to 300 cc. On postoperative day 12, the patient underwent cystoscopy with general anesthesia through an 11.5F offset short ureteroscope. The left ureteral orifice was identified and a rigid injection needle was used to puncture the subtrigonal tissues at the 6 o'clock position. Then, 4 cc polytetrafluoroethylene were injected under direct vision with a piston syringe. After the ureteral orifice was visually obstructed the cystoscope was
Accepted for publication May 26, 1989.
Fm. 1. A, scout film of IVP shows large opaque left renal staghorn calculus. B, 5-minute film of same IVP demonstrates normal function of right kidney but obstruction of left renal unit by staghorn calculus.
removed and the bladder was drained with an 18F Foley catheter. Immediately after the procedure flank drainage decreased and 2 days after the procedure a cystogram revealed cessation of left ureteral reflux (fig. 2, B). Right ureteral reflux persisted. The patient was discharged from the hospital 9 days postoperatively after voiding to completion on bethanechol chloride therapy. Followup visits have confirmed a completely healed fistula. DISCUSSION
Ligation of the ureteral stump is traditional practice in simple nephrectomy. Vesicoureteral reflux in a stump inadequately ligated represents a possible complication of this procedure. 8 In most cases an unligated ureteral stump will fibrose rapidly and will not cause reflux. However, our case represents one in which conservative management was inadequate: 8 days of Foley catheter drainage were unsuccessful in reducing the amount of ureterocutaneous drainage, indicating persistent reflux in the ureteral stump. Traditional management would dictate open exploration and surgical correction. However, we opted to apply the relatively recent technique of subureteral polytetrafluoroethylene injection (Sting) to correct this surgical complication. 1• 2
1310
1311
URETEROCuTANEOUS FISTULA
Fm. 2. A, retrograde cystogram before Sting procedure shows extraperitoneal extravasation from refluxive left ureteral stump. B, retrograde cystogram after Sting procedure demonstrates cessation of left ureteral reflux. Right ureteral reflux persists.
Subureteral injection of polytetrafluoroethylene has been used for vesicoureteral reflux in children with excellent results. In 6 separate studies 261 patients with a wide range of severity and etiology of reflux were treated with this procedure, representing 383 ureters. 2- 7 Complete absence of reflux was noted in 295 of these ureters after 1 injection, an initial response rate of 77%. Many ureters required multiple injections to achieve correction of reflux. Followup of 2 to 25 months was described in 4 studies and 271 of these 335 ureters were free of reflux, a response rate of 81 % (at maximum fo!lowup of 25 months). Only 1 complication was noted in all 6 studies (slightly increased distension of a collection system in comparison with a previous IVP). 5 Thus, this procedure signifies a low risk, effective treatment of vesicoureteral reflux in children. The theoretical concern of adverse reactions has been raised in 1 study that documented the migration of polytetrafluoroethylene particles in laboratory animals. 9 In that study marked foreign body reactions were noted in the pelvic lymph nodes in 2 of 7 animals 10½ months after subureteral polytetrafluoroethylene injection. Although polytetrafluoroethylene particles were found in other organ systems, no other marked granulomatous reactions were noted. In the clinical domain, Vorstman and associates, who used polytetrafluoroethylene injection for urinary incontinence, found no instance of significant embolization in more than 300 cases since 1964. 10 Delayed carcinogenesis also has been cited as a possible concern. However, polytetrafluoroethylene injection has been used by our otolaryngological colleagues for 25 years (since 1963) for correction of displaced or deformed vocal cords with no untoward side effects reported to date. 5 • 11 We believe that subureteral polytetrafluoroethylene injection constitutes a safe procedure for treatment of vesicoureteral reflux. Endoscopic polytetrafluoroethylene injection for deliberate total occlusion of a ureter has been described previously for a refluxive ureteral stump after simple nephrectomy. 8 As in our case, 4 cc polytetrafluoroethylene paste were injected to occlude the refluxive ureteral orifice, which resulted in complete clinical
resolution of the ureterocutaneous fistula. Our results similarly are favorable. The problem of an inadequately ligated ureteral stump in simple nephrectorny causing persistent reflux is difficult. The subureteral injection of polytetrafluoroethylene (Sting procedure) represents a safe and effective alternative to conventional open exploration and correction in these cases. REFERENCES 1. Puri, P. and O'Donnell, B.: Correction of experimentally produced
2. 3. 4. 5.
6.
7. 8.
9.
10.
11.
vesicoureteric reflux in the piglet by intravesical injection of Teflon. B1·it. Med. J., 289: 5, 1984. O'Donnell, B. and Puri, P.: Treatment of vesicoureteric reflux by endoscopic injection of Teflon. Brit. Med. J., 289: 7, 1984. O'Donnell, B. and Puri, P.: Endoscopic correction of primary vesicoureteric reflux: results in 94 ureters. Brit. Med. J., 293: 1404, 1986. O'Donnell, B. and Puri, P.: Endoscopic correction of primary vesicoureteric reflux. Brit. J. Urol., 58: 601, 1986. Puri, P. and Guiney, E. J.: Endoscopic correction of vesicoureteral reflux secondary to neuropathic bladder. Brit. J. Urol., 58: 504, 1986. Schulman, C. C., Simon, J., Pamart, D. and Avni, F. E.: Endoscopic treatment ofvesicoureteral reflux in children. J. Urol., 138: 950, 1987. Kaplan, W. E., Dalton, D. P. and Firlit, C. F.: The endoscopic correction of reflux by polytetrafluoroethylene injection. J. UroL, 138: 953, 1987. Bullock, K. N., Deane, A. M. and Ashken, M. H.: Endoscopic teflon injection for a refluxing ureteric stump after simple nephrectomy. Brit. Med. J., 290: 1109, 1985. Malizia, A. Jr., Reiman, H. M., Myers, R. P., Sande, J. R., Barham, S. Benson, R. C., Jr., Dewanjee, l\/I. K. and Utz, W. J.: Migration and granulomatous reaction after periurethral injection of polytef (Teflon). J.A.MA, 251: 3277, 1984. Vorstman, B., Lockhart, J., Kaufman, M. R. and Politano, V.: Polytetrafluoroethylene injection for urinary incontinence in children. J. Urol., 133: 248, 1985. Arnold, G. E.: Alleviation of apho'lia or dysphonia through intrachordal injection of Teflon paste. Ann. Oto!. Rhinol. Laryngol., 72: 384, 1963.
Vol. 142, November
Printed in U.S.A.
URETEROCUTANEOUS FISTULA: A CASE REPORT OF TREATMENT BY SUBTRIGONAL INJECTION OF POLYTETRAFLUOROETHYLENE (STING PROCEDURE) M. SASLAWSKY, C. NIEDERBERGER, M. SCHACHT, L. PRINZ
AND
L. ROSS
From the Department of Urology, Michael Reese Hospital and Medical Center, Chicago, Illinois
ABSTRACT
A ureterocutaneous fistula developed in a patient after nephrectomy for pyohydronephrosis in a kidney with vesicoureteral reflux. Endoscopic injection of polytetrafluoroethylene (Teflon) paste at the ureteral orifice prevented further reflux and cured the ureterocutaneous fistula. (J. Urol., 142: 1310-1311, 1989) Subtrigonal injection of the ureteral orifice (the Sting procedure) has been developed as a method to treat vesicoureteral reflux in children. 1 • 2 The injection of small volumes of polytetrafluoroethylene paste (0.2 to 0.4 cc) in the submucosal tissues beneath the ureteral orifice can prevent reflux in 81 % of the children treated. 2 - 7 Knowledge of these data and experience with the technique led us to postulate that the Sting procedure could be adapted to obstruct intentionally a refluxive ureter. Closure of a ureterocutaneous fistula in this fashion obviated the need for an open procedure. Endoscopic polytetrafluoroethylene injection for deliberate total occlusion of a refluxive ureteral stump after nephrectomy has been described once previously, with similarly favorable results. 8 CASE REPORT
An 86-year-old black man who had been evaluated for recurrent gross hematuria had a nonfunctioning left kidney and a large staghorn calculus (fig. 1) on an excretory urogram (IVP). Cystoscopy revealed a nonobstructed prostatic urethra and bilateral patulous ureteral orifices. Purulent efflux emanated from the left ureteral orifice on 1 occasion and a blood clot eventually was seen at the same orifice at a later cystoscopic examination. Renal scan demonstrated no evidence of perfusion or function of the left kidney. Left simple nephrectomy was performed in May 1986 and an enlarged kidney with perinephric adhesions was removed. At operation the distal ureter was clamped and ligated with a 1zero chromic suture. A Penrose drain was left in the renal fossa and the bladder was catheterized. The Penrose drain was removed 3 days postoperatively, by which time the flank drainage had ceased. The Foley catheter was removed 2 days postoperatively but it was replaced 2 days later when urinary retention developed with a 600 cc residual urine volume. On postoperative day 5, a large amount of serous drainage appeared at the Penrose drain site. A cystogram demonstrated extraperitoneal extravasation from a patent, refluxive, left ureteral stump (fig. 2, A). Right ureteral reflux was present. Despite Foley catheter drainage for 8 days the reflux persisted. Daily flank drainage averaged 200 to 300 cc. On postoperative day 12, the patient underwent cystoscopy with general anesthesia through an 11.5F offset short ureteroscope. The left ureteral orifice was identified and a rigid injection needle was used to puncture the subtrigonal tissues at the 6 o'clock position. Then, 4 cc polytetrafluoroethylene were injected under direct vision with a piston syringe. After the ureteral orifice was visually obstructed the cystoscope was
Accepted for publication May 26, 1989.
Fm. 1. A, scout film of IVP shows large opaque left renal staghorn calculus. B, 5-minute film of same IVP demonstrates normal function of right kidney but obstruction of left renal unit by staghorn calculus.
removed and the bladder was drained with an 18F Foley catheter. Immediately after the procedure flank drainage decreased and 2 days after the procedure a cystogram revealed cessation of left ureteral reflux (fig. 2, B). Right ureteral reflux persisted. The patient was discharged from the hospital 9 days postoperatively after voiding to completion on bethanechol chloride therapy. Followup visits have confirmed a completely healed fistula. DISCUSSION
Ligation of the ureteral stump is traditional practice in simple nephrectomy. Vesicoureteral reflux in a stump inadequately ligated represents a possible complication of this procedure. 8 In most cases an unligated ureteral stump will fibrose rapidly and will not cause reflux. However, our case represents one in which conservative management was inadequate: 8 days of Foley catheter drainage were unsuccessful in reducing the amount of ureterocutaneous drainage, indicating persistent reflux in the ureteral stump. Traditional management would dictate open exploration and surgical correction. However, we opted to apply the relatively recent technique of subureteral polytetrafluoroethylene injection (Sting) to correct this surgical complication. 1• 2
1310
1311
URETEROCuTANEOUS FISTULA
Fm. 2. A, retrograde cystogram before Sting procedure shows extraperitoneal extravasation from refluxive left ureteral stump. B, retrograde cystogram after Sting procedure demonstrates cessation of left ureteral reflux. Right ureteral reflux persists.
Subureteral injection of polytetrafluoroethylene has been used for vesicoureteral reflux in children with excellent results. In 6 separate studies 261 patients with a wide range of severity and etiology of reflux were treated with this procedure, representing 383 ureters. 2- 7 Complete absence of reflux was noted in 295 of these ureters after 1 injection, an initial response rate of 77%. Many ureters required multiple injections to achieve correction of reflux. Followup of 2 to 25 months was described in 4 studies and 271 of these 335 ureters were free of reflux, a response rate of 81 % (at maximum fo!lowup of 25 months). Only 1 complication was noted in all 6 studies (slightly increased distension of a collection system in comparison with a previous IVP). 5 Thus, this procedure signifies a low risk, effective treatment of vesicoureteral reflux in children. The theoretical concern of adverse reactions has been raised in 1 study that documented the migration of polytetrafluoroethylene particles in laboratory animals. 9 In that study marked foreign body reactions were noted in the pelvic lymph nodes in 2 of 7 animals 10½ months after subureteral polytetrafluoroethylene injection. Although polytetrafluoroethylene particles were found in other organ systems, no other marked granulomatous reactions were noted. In the clinical domain, Vorstman and associates, who used polytetrafluoroethylene injection for urinary incontinence, found no instance of significant embolization in more than 300 cases since 1964. 10 Delayed carcinogenesis also has been cited as a possible concern. However, polytetrafluoroethylene injection has been used by our otolaryngological colleagues for 25 years (since 1963) for correction of displaced or deformed vocal cords with no untoward side effects reported to date. 5 • 11 We believe that subureteral polytetrafluoroethylene injection constitutes a safe procedure for treatment of vesicoureteral reflux. Endoscopic polytetrafluoroethylene injection for deliberate total occlusion of a ureter has been described previously for a refluxive ureteral stump after simple nephrectomy. 8 As in our case, 4 cc polytetrafluoroethylene paste were injected to occlude the refluxive ureteral orifice, which resulted in complete clinical
resolution of the ureterocutaneous fistula. Our results similarly are favorable. The problem of an inadequately ligated ureteral stump in simple nephrectorny causing persistent reflux is difficult. The subureteral injection of polytetrafluoroethylene (Sting procedure) represents a safe and effective alternative to conventional open exploration and correction in these cases. REFERENCES 1. Puri, P. and O'Donnell, B.: Correction of experimentally produced
2. 3. 4. 5.
6.
7. 8.
9.
10.
11.
vesicoureteric reflux in the piglet by intravesical injection of Teflon. B1·it. Med. J., 289: 5, 1984. O'Donnell, B. and Puri, P.: Treatment of vesicoureteric reflux by endoscopic injection of Teflon. Brit. Med. J., 289: 7, 1984. O'Donnell, B. and Puri, P.: Endoscopic correction of primary vesicoureteric reflux: results in 94 ureters. Brit. Med. J., 293: 1404, 1986. O'Donnell, B. and Puri, P.: Endoscopic correction of primary vesicoureteric reflux. Brit. J. Urol., 58: 601, 1986. Puri, P. and Guiney, E. J.: Endoscopic correction of vesicoureteral reflux secondary to neuropathic bladder. Brit. J. Urol., 58: 504, 1986. Schulman, C. C., Simon, J., Pamart, D. and Avni, F. E.: Endoscopic treatment ofvesicoureteral reflux in children. J. Urol., 138: 950, 1987. Kaplan, W. E., Dalton, D. P. and Firlit, C. F.: The endoscopic correction of reflux by polytetrafluoroethylene injection. J. UroL, 138: 953, 1987. Bullock, K. N., Deane, A. M. and Ashken, M. H.: Endoscopic teflon injection for a refluxing ureteric stump after simple nephrectomy. Brit. Med. J., 290: 1109, 1985. Malizia, A. Jr., Reiman, H. M., Myers, R. P., Sande, J. R., Barham, S. Benson, R. C., Jr., Dewanjee, l\/I. K. and Utz, W. J.: Migration and granulomatous reaction after periurethral injection of polytef (Teflon). J.A.MA, 251: 3277, 1984. Vorstman, B., Lockhart, J., Kaufman, M. R. and Politano, V.: Polytetrafluoroethylene injection for urinary incontinence in children. J. Urol., 133: 248, 1985. Arnold, G. E.: Alleviation of apho'lia or dysphonia through intrachordal injection of Teflon paste. Ann. Oto!. Rhinol. Laryngol., 72: 384, 1963.