First published online November 8, 2006
British Journal of Radiology (2007) 80, 216-218
© 2007 British Institute of Radiology
doi: 10.1259/bjr/89175992
Extraanatomic stents for transplant ureteric stenosis
J Olsburgh, PhD, FRCS(Urol)
1
A Dorling, PhD, FRCP
2
P Tait, FRCR
3 and
G Williams, FRCS
1
Departments of 1 Urology, 2 Renal Medicine and 3 Radiology, Hammersmith Hospitals NHS Trust, London, UK
Correspondence: Mr Jonathon Olsburgh, Urology, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK. E-mail: jonnyolsburgh{at}hotmail.com.
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Abstract
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Surgical and standard endourology options are limited in transplant patients with severe ureteric stenosis, particularly when access to the transplant renal pelvis is limited. The use of a silicone-polytetrafluoroethelene (PTFE)-bonded extraanatomic urinary tract stent for urinary tract drainage is described in two patients. This technique of ureteric reconstruction in renal transplantation may be considered when standard approaches have failed. It appears to be safe when performed by radiologists and urologists with expertise in percutaneous renal access.
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Introduction
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The incidence of transplant ureteric stenosis (TUS) ranges from 1.5% to 9% [1]. Most commonly TUS is due to ureteric ischaemia but can also be secondary to rejection or fibrosis encapsulating the ureter.
TUS can be difficult to manage. Initial management usually includes a percutaneous nephrostomy and antegrade stent with or without balloon dilatation of the stenotic segment [2]. Traditionally open definitive surgery, for example ureteric re-implantation, has provided excellent long-term results [3, 4].
However, circumstances can prevent either successful standard minimally invasive or open surgical interventions. We have used an extraanatomic ureteric stent to reconstruct urinary drainage in two patients with inoperable ureteric stenosis of transplanted kidneys and we wish to bring this useful technique to peoples' attention.
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Patients and methods
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A 55-year-old female with end stage renal failure of uncertain aetiology received a cadaveric renal transplant in November 2003. A 41-year-old man with end-stage renal failure secondary to reflux nephropathy received a cadaveric renal transplant in July 2003. In both cases the ureteroneocystotomy was performed using a direct mucosal anastomosis technique over a 6/16F double J ureteric stent (Cook, UK). The stents were removed 3 months post-operatively and shortly afterwards each patient developed transplant hydronephrosis, raised creatinine and required percutaneous nephrostomy and antegrade stent. Subsequent endoscopic management, including balloon dilation, for distal ureteric stenoses failed and open exploration and attempted re-implantation were unsuccessful due to the position of the transplant renal pelvis being adjacent to the iliac vessels. In the second case the proximal ureter was encased in fibrotic tissue, having had a previous exploration, and the distal ureter could not be located due to distal ureteric necrosis. Nephrostomies were left in situ.
In both cases elective extraanatomic stenting was performed under general anaesthetic after antibiotic prophylaxis and with fluoroscopic guidance. A guidewire was placed through the pre-existing nephrostomy tube and exchanged for a balloon dilator catheter (Amplatz TractMaster; Boston Scientific, UK). This was used to dilate the perirenal tissues to permit an Amplatz sheath to be placed into the transplant renal pelvis (Figure 1a
).
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Figure 1. (a,b) Radiographs demonstrating exchange of a percutaneous nephrostomy tube with a guidewire and balloon dilation technique to permit placement of an Amplatz sheath. This facilitates percutaneous placement of the extraanatomic urinary tract stent into the transplant kidney.
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A silicone-PTFE-bonded DETOUR extraanatomic stent (Mentor Medical Systems, West Sussex, UK) was used. This is a composite prosthesis, consisting of two coaxial tubes: an internal pure smooth silicone tube covered by coiled PTFE. The proximal end of the DETOUR stent was placed through the Amplatz sheath into position within the renal pelvis (Figure 1b
). An open cystotomy was performed. A subcutaneous tunnel was formed anterior to the rectus abdominis and the DETOUR stent was then passed through from renal pelvis to bladder (Figure 2). The stent was cut to size removing the distal 4 cm of PTFE fortified outer sheath and the silicone distal end placed into the bladder. The bladder was closed incorporating the PTFE cuff and bladder mucosa to secure the DETOUR catheter in position. The rectus was apposed around the DETOUR (Figure 3). A urinary catheter was left on free drainage for 5 days prior to removal with antibiotic prophylaxis.
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Figure 2. Creation of a subcutaneous tunnel in the lower abdomen to pass the extraanatomic urinary tract stent from the transplant kidney to the urinary bladder.
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Figure 3. Placement of the extraanatomic urinary tract stent through the rectus abdominis to the bladder via an open cystotomy.
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Results
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There were no post-operative complications. Post-operative follow up for the two patients is 12 months and 6 months, respectively. Both have freely draining renal transplant pelvicalyceal systems. Renal function has remained at the patients' baseline levels. The first patient has had two Escherichia coli urinary tract infections. The second patient, who had methicillin-resistant Staphylococcus aureus (MRSA) at the nephrostomy site pre-operatively, now has sterile urine.
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Discussion
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Obstruction of the transplant ureter is most commonly due to distal ureteric stenosis. The majority can be treated with antegrade balloon dilation and endourological stenting or by open surgical ureteric re-implantation. The advantage of these techniques over long-term stents is the decreased risk of infection and morbidity of stent changes and stent symptoms.
The surgical challenge is greater when there is complete necrosis of the distal ureter, which precludes endourological stenting. In order to preserve graft function alternatives in these difficult circumstances include use of the native ureter such as ureteroureterostomy or pyeloureterostomy [3]. If there had been previous native nephroureterectomy or ureteric stricture, an alternative conduit such as bowel interposition [5] may be required or a Boari flap re-implantation can be used [6].
However, these options are dependent on surgical access to the transplant renal pelvis. The lie of the transplant renal pelvis can be inaccessibly deep adjacent or adherent to the iliac vessels precluding access to the renal pelvis. Options are more limited, but if the lower pole calyces are favourably positioned may include calycoureterostomy or calycovesicostomy [7, 8].
Extraanatomic stenting (EAS) was developed for extrinsic malignant native ureteric obstruction [9]. At an early point in the development of the EAS, DETOUR stents were used for TUS [10–12]. There have been few recent reports of EAS use in TUS [13]. However, EAS should feature in the armamentarium for the urologist managing the obstructed transplant ureter. The first advantage of the EAS is that access to the transplant renal pelvis is from "within" the kidney via an existing percutaneous nephrostomy track. Second, any length of ureteric stenosis can be dealt with by varying the length of EAS used.
Long-term EAS follow up for TUS is limited but includes patients up to 5 years post procedure [14]. The potential risks of stent encrustation and migration of the proximal end of the stent have not been documented. The proximal end is not sutured in place but tissue fibrosis to the PTFE is hoped to maintain its intrarenal position.
To our knowledge we present the first reported use of EAS for ureteric stenosis of transplant kidneys in the UK. EAS appears to be a safe technique of ureteral reconstruction in renal transplantation. It may be considered when standard approaches have failed and can be performed by radiologists and urologists with expertise in percutaneous renal access.
Received for publication July 14, 2006.
Revision received September 7, 2006.
Accepted for publication September 12, 2006.
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References
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BJR review of the year -- 2007
Br. J. Radiol.,
April 1, 2008;
81(964):
265 - 269.
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Abstract
Introduction
