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British Journal of Radiology (2007) 80, 103-106
© 2007 British Institute of Radiology
doi: 10.1259/bjr/72561092
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Full paper

The double wire technique: an improved method for treating challenging ureteroileal anastomotic strictures and occlusions

N Thiruchelvam, MRCS, MD1, M Harrison, FRCS1 and A C Page, FRCS2

Departments of 1 Urology and 2 Radiology, Royal Hampshire County Hospital, Winchester, Hampshire, UK

Correspondence: Nikesh Thiruchelvam, Department of Urology, Royal Hampshire County Hospital, Romsey Road, Winchester, Hampshire SO22 5DG, UK


   Abstract
Top
 Abstract
Introduction
 Methods and materials
 Results
 Discussion
 References
 
Up to 10% of patients who undergo ileal conduit urinary diversion may go on to develop ureteroileal anastomotic stenosis (UIAS); this can lead to recurrent urinary tract infections and deterioration in renal function. Classical management has been open revision of the anastomosis. We describe a novel technique that allows balloon dilatation and ureteral stent placement in a retrograde fashion. All patients in this study had undergone radical cystectomy and ileal conduit formation with Wallace type end-to-end refluxing uretero-intestinal anastomosis. After initial retrograde loopogram, a 6F MPA-1 catheter and an 0.035 inch extra stiff guide was passed to the distal ostium. Subsequently, a customised 8F bright tip MPA-1 guiding catheter was advanced over the guide wire which allowed effective splinting of the equipment to facilitate greater control of a second catheter and guide wire combination to access the stenotic or occluded anastomosis. Results show that a total of ten anastomoses were treated; nine anastomoses were successfully treated with a primary retrograde approach with no intra or post-procedural complications. After a mean follow-up of 19 months (5–33 months), as assessed by ascending loopograms, all anastomoses remained open. In conclusion, morbidity of open surgery has resulted in the popularization of endourological techniques in treating anastomotic stenoses. However, key to these endourological techniques is access to the anastomosis; typically, this has been via a percutaneously placed nephrostomy. The ideal route to the anastomosis is via a retrograde approach; we have illustrated a safe and successful novel technique that utilized two guidewires and a guiding catheter, allowing retrograde ureteral access.


   Introduction
Top
 Abstract
 Introduction
Methods and materials
 Results
 Discussion
 References
 
Of those patients who have undergone ileal conduit urinary diversion, often following radical cystectomy for invasive transitional cell carcinoma, 3–10% will develop uretero-intestinal anastomotic stenosis (UIAS) [1–3]. This is usually a result of ischaemic stricturing, more frequently on the left side due to increased advential stripping during dissection of the left ureter, and can be made worse by any prior radiotherapy. Rarely, stenosis can also occur as a result of tumour recurrence. Ultimately, this will lead to recurrent urinary infections, loin discomfort and, often silently, deterioration in renal function, a scenario to be avoided if any further oncological treatment is to be offered. Classical management of UIAS had been laparotomy and open revision of the anastomosis [4]. Over the past 15 years, there has been an increasing trend to manage these patients with endourological techniques. We describe a novel technique to allow balloon dilatation and ureteral stent placement in patients where retrograde access to an occluded anastamosis is not immediately achievable.


   Methods and materials
Top
 Abstract
 Introduction
 Methods and materials
Results
 Discussion
 References
 
The technique was used in four male patients with a mean age of 69 years (53–83 years); all had undergone radical cystectomy and ileal conduit formation for vesical transitional cell carcinoma with Wallace type end-to-end refluxing uretero-intestinal anastomosis [5]. UIAS was confirmed by hydronephrosis on ultrasound and subsequent conduit loopograms. All patients were consented for retrograde or antegrade ureteric procedures. Sedation and analgesia, by intravenous pethidine (50 mg), diazemuls (5–10 mg) or midazolam (1–2 mg), was offered to all patients and utilized in 60% of patients.

Stenting procedure
Initial retrograde loopogram was conducted using a 16F urinary catheter and contrast (Iohexol – 150: GE Medical Systems, Abingdon, Oxon, UK). Access for a 6F MPA-1 catheter (Cordis, Ascot, Berks, UK) and an 0.035 inch Amplatz extra stiff guide wire (Cook, IN) or a Storq 0.035 inch wire (Cordis) was achieved to the distal ostium with digital guidance. Further careful manipulation allowed positioning of the catheter and guide wire to the level of the anastomosis (see GoGoGoGoFigures 1–5Go).


Figure 1
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  		Figure 1. Schematic diagram of procedure.(a) Stenotic ureteroileal anastomosis, (b) guidewire insertion into patent anastomosis, (c) guidewire insertion into stenotic anastomosis and (d) balloon dilatation of UIAS. H, hydronephrotic kidney; K, normal kidney; S, stenotic ureteroileal anastomosis; P, patent ureteroileal anastomosis; I, ileal conduit; C6, 6F MPA catheter; Y, guidewire through P; C8, 8F MPA catheter; Z, guidewire through S; BD, balloon dilating catheter.

 

Figure 2
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  		Figure 2. Retrograde loopogram demonstrating critical stenosis of the right ureteroileal anastomosis.

 

Figure 3
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  		Figure 3. A guidewire has been inserted into the patent left anastomosis(arrow). This stabilises equipment position to allow crossing of the critical right anastomotic stricture.

 

Figure 4
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  		Figure 4. Balloon dilatation(6 mm diameter) of the right anastomosis.

 

Figure 5
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  		Figure 5. Completion image following J-J stent placement to right anastomosis.

 
Where primary cannulation of the occluded anastamosis was not possible, the less stenotic or non-occluded ureter was approached initially. The guidewire was advanced to the kidney where the 6F catheter was then removed. A customised 8F bright tip MPA-1 guiding catheter (Cordis) was advanced over the guide wire to the level of the anastomosis. This allowed effective splinting of the equipment, to facilitate greater control of a second catheter and guide wire combination to access the stenotic or occluded anastamosis via the guiding catheter. Once bilateral guide wires were in place, unilateral, bilateral and/or sequential anastomotic balloon dilatation (Cordis) and J-J stent placement (Cook) were undertaken.


   Results
Top
 Abstract
 Introduction
 Methods and materials
 Results
Discussion
 References
 
Seven procedures were undertaken in four patients, three were bilateral procedures; a total of ten anastomoses were treated. Nine anastomoses were successfully treated with a primary retrograde approach. In one UIAS, the distal occlusion was not crossed with a retrograde approach. Successful antegrade approach was performed via a percutaneous nephrostomy. There were no intra or post-procedural complications. After a mean follow-up of 19 months (5–33 months), one UIAS was dilated three times, another UIAS required two dilatations and the remaining seven UIAS were patent after one balloon dilatation. As assessed by ascending loopograms, all anastomoses remained open.


   Discussion
Top
 Abstract
 Introduction
 Methods and materials
 Results
 Discussion
References
 
Historical management of UIAS was by open repair of the stenosis, with reported success rates of up to 90% [5–7]. However, this type of procedure is a major undertaking; the operation is made difficult by any adhesions from previous surgery and fibrosis from any prior radiotherapy, together with significant risks of intraoperative iliac vein injury and post-operative urine leak [8].

Although open revision is likely to result in improved long-term success [6], the associated morbidity of open surgery has resulted in the popularisation of endourological techniques. Numerous studies have outlined these minimally invasive techniques to deal with UIAS. Poulakis et al described the use of cold-knife incision of the stricture in 2001 [9], although this can lengthen strictures and make secondary open repair difficult [8]. Investigators have described the use of ureteral expandable metal stents to hold open the UIAS [10, 11]; however, permanent stents run the risk of rapid obstruction with sepsis and death [12]. Clinicians have also tried using semi-rigid fascial dilators [13], but with limited success. Finally, the use of balloon dilators has been well described and appears to have remained popular with urologists and radiologist alike.

Crucially, the key to these endourological techniques is access to the anastomosis. Typically, the endourological management of the UIAS has been via a percutaneously placed nephrostomy. This is not without risk; studies suggest a 4% major complication rate of haemorrhage, infection, septicaemia, urine leak and inadvertent puncture of adjacent organs [14]. Furthermore, UIAS may not necessarily lead to upper tract dilatation, making nephrostomy insertion difficult. These problems have motivated others to try alternative approaches. Santoshi et al [15] have described the use of a video-duodenoscope to visualize the ureteroileal anastomosis; however, this side viewing scope would only be suitable for the Bricker-type end-to-side ureteroileal anastomosis. Furthermore, Costamagna et al [16] used a duodenoscope to gain access to the anastomosis but failed to do this in 20% of cases.

The ideal route to the anastomosis is via a retrograde approach, but this is also not without problems. Conduit tortuosity, mucus production, coiling guidewires in the conduit, maintenance of a conduit full of contrast and hand radiation exposure make retrograde catheterization a difficult technique. Nonetheless, we have described a novel technique utilizing two guidewires and a guiding catheter that allowed retrograde ureteral access with relative ease. Similar retrograde guidewire techniques have been described previously [17–19], but we believe the technique described here is more likely to lead to successful catheterization of the ureteroileal anastomosis and is less prone to complication. No patient suffered any peri-procedure complication, such as ureteroileal anastomosis disruption or ureteral perforation. Furthermore, on only one occasion did we have to revert to a percutaneous nephrostomy; this was when we were able to successfully catheterise the ueteral orifice, but could not pass the guidewire beyond the point of obstruction. Nonetheless, failure resulted in a procedure which would have been the alternate method in any case and with no compromise to nephrostomy placement.

In conclusion, we describe a novel method by which to access the ureters and allow balloon dilatation of a UIAS. This technique appears safe and painless, and is an improvement in obtaining access to the ureteroileal anastomosis.

Received for publication June 20, 2006. Accepted for publication August 15, 2006.


   References
Top
 Abstract
 Introduction
 Methods and materials
 Results
 Discussion
 References
 

  1. Sullivan JW, Grabstald H, Whitmore WF. Complications of ureteroileal conduit with radical cystectomy: review of 336 cases. J Urol 1980;124:797–801.[Medline]
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  4. Kramolowsky EV, Clayman RV, Weyman PJ. Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair. J Urol 1988;139:1195–8.[Medline]
  5. Clark PB. End-to-end ureteroileal anastomosis for ileal conduits. Br J Urol 1979;51:105–9.[Medline]
  6. Vandenbroucke F, Van Poppel H, Vandeursen H, Oyen R, Baert L. Surgical versus endoscopic treatment of non-malignant uretero-ileal anastomotic strictures. BJU 1993;71:408–12.[Medline]
  7. DiMarco DS, LeRoy AJ, Thieling S, Bergstralh EJ, Segura JW. Long-term results of treatment for ureteroenteric strictures. Urology 2001;58:909–13.[CrossRef][Medline]
  8. Laven BA, O'Connor RC, Gerber GS, Steinberg GD. Long-term results of endoureterotomy and open surgical revision for the management of ureteroenteric strictures after urinary diversion. J Urol 2003;170:1226–30.[CrossRef][Medline]
  9. Poulakis V, Witzsch U, de Vries R, Becht E. Antegrade percutaneous endoluminal treatment of non-malignant ureterointestinal anastomotic strictures following urinary diversion. Eur Urol 2001;39:308–15.[CrossRef][Medline]
  10. Palascak P, Bouchareb M, Zachoval R, Urban M, Sauvain JL, Palascak R. Treatment of benign ureterointestinal anastomotic strictures with permanent ureteral Wallstent after Camey and Wallace urinary diversion: long-term follow-up. J Endourol 2001;15:575–80.[CrossRef][Medline]
  11. Rapp DE, Laven BA, Steinberg GD, Gerber GS. Percutaneous placement of permanent metal stents for treatment of ureteroenteric anastomotic strictures. J Endourol 2004;18:677–81.[CrossRef][Medline]
  12. Walther PJ, Robertson CN, Paulson DF. Lethal complications of standard self-retaining ureteral stents in patients with ileal conduit urinary diversion. J Urol 1985;133:851–3.[Medline]
  13. Kramolowsky EV, Clayman RV, Weyman PJ. Endourological management of ureteroileal anastomotic strictures: is it effective? J Urol 1987;137:390–4.[Medline]
  14. Barbaric ZL. Percutaneous nephrostomy for urinary tract obstruction. Am J Roentgenol 1984;143:803–9.[Abstract/Free Full Text]
  15. Santoshi N, Nilesh P, Prakash S, Devendra D, Anand J, Srinivas V. A novel technique for ureteric access in ileal conduits. BJU Int 2003;91:423–4.[CrossRef][Medline]
  16. Costamagna G, Shah SK, Mutignani M, Tringali A, Alevrus PP, Vamvakousis V, et al. Use of a duodenoscope to manage complications at the ureteroileal anastomotic site after total urinary bladder resection and the Bricker procedure. Gastrointest Endosc 2002;55:242–8.[CrossRef][Medline]
  17. Applbaum YN, Diamond AB, Rappoport AS. Retrograde ureteral catheterization via the ileal conduit. Am J Roentgenol 1986;146:61–3.[Free Full Text]
  18. Banner MP, Amendola MA, Pollack HM. Anastomosed ureters: fluoroscopically guided transconduit retrograde catheterization. Radiology 1989;170:45–9.[Abstract/Free Full Text]
  19. 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.[CrossRef][Medline]



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This Article
Right arrow Abstract Freely available
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