Percutaneous Ureteral Occlusion with Use of Gianturco Coils and Gelatin Sponge. Part II. Clinical Experience! Kenneth T. Bing, MD Marshall E. Hicks, MD Daniel Picus, MD Michael D. Darcy, MD
Index terms: Fistula, urinary, 80.245 • Fistula, vesicovaginal, 85.2453 • Ureter, interventional procedure, 82.1299 JVIR 1992; 3:319-321
A previous report described the use of coils and gelatin sponge pledgets as a means of producing ureteral occlusion to achieve urinary diversion in patients with urinary fistulas. The authors have performed this procedure in nine ureters of six patients. Five of the patients had urinary leaks with extensive pelvic tumor, and one had severe chronic cystitis. Ureters were occluded with use of Gianturco coils and gelatin sponge pledgets placed via a sheath through a percutaneous nephrostomy tract. The procedure was successful in all patients as judged by means of antegrade nephrostogram or intravenous pyelogram and by marked improvement or complete resolution of symptoms.
NUMEROUS methods have been used to produce ureteral occlusion for the purpose of achieving urinary diversion primarily in patients with urinary fistulas. Glue (1), detachable balloons (2), occlusion balloon catheters (3), nylon occluding devices (4), percutaneous clips (5), and endoluminal radio-frequency electrocautery (6) have all been used with some success. The ideal method of ureteral occlusion would be minimally invasive, performed with inexpensive readily available materials, and produce immediate and long-term occlusion. None of the previously reported methods fulfill these criteria fully. Gaylord and Johnsrude (7) described a series of patients whose ureters were effectively occluded with a nest of spring coils and gelatin sponge pledgets (Gelfoam; Kalamazoo, Mich). We sought to reproduce their results using these agents. I From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110. Received July 8, 1991; revision requested August 21; revision received and accepted December 9. Address reprint requests to M.E.H.
" SCVIR, 1992 See also the article by Bing et al (pp 313317) in this issue.
PATIENTS AND METHODS This study is a retrospective review of six patients in whom ureteral occlusion was performed with use of Gianturco coils and Gelfoam to facilitate urinary diversion. All patients were referred over a 14-month period
by either the gynecologic oncology service or the urology service. Four patients had advanced cervical cancer and a vesicovaginal fistula. One patient had advanced prostatic cancer with bladder invasion and perforation. One patient had chronic cystitis from a Candida species and severe disabling dysuria. None of the six patients were considered surgical candidates. The procedure was performed after a trial of external drainage had failed to provide adequate diversion in five of the six patients. In one patient nephrostomy was followed immediately by ureteral occlusion. Three patients underwent bilateral ureteral occlusion, and three required only a unilateral procedure because the contralateral kidney was nonfunctional. A 9-F Peel-Away sheath (Cook, Bloomington, lnd) was placed in the ureter through a nephrostomy tract. A catheter was advanced into the distal ureter, and through this a nest of 5-mm x 5-cm, 8-mm x 5-cm, 10-mm x 5-cm, and 12-mm x 5-cm Gianturco coils (Cook) were placed. The longer coils were overlapped by 50%, and smaller coils were placed along the larger coils, forming an interlocking nest. Gelfoam pledgets measuring 2-3 mm in diameter and 1 cm in
319
320 • Journal of Vascular and Interventional Radiology May 1992
length were placed within the nest. The Gelfoam pledgets were usually positioned between sets of the smaller coils either by injecting the coils through a nontapered 6-F catheter or by using a smaller tapered catheter to push the Gelfoam through the nontapered catheter. Six to 18 coils were placed in each ureter. The occlusion procedure was considered complete when contrast material injected above the nest showed occlusion with no flow distally. A nephrostomy catheter (Cook) (8-12 F) was left in place for external drainage. Follow-up was obtained by means of chart review in all patients; the two patients still living at the time of this retrospective review were interviewed by phone.
RESULTS • Clinical Findings The results are shown in the Table. Two patients were alive at the time this article was prepared and had undergone follow-up at 4 and 14 months. One of these had no drainage. The other living patient (patient 5) had minimal drainage, which she tolerated well. Three patients died within 2 months after the procedure of unrelated causes. All three had undergone follow-up within 2 weeks of their death. The condition of one of "hese patients (patient 1) was markedly improved, with minimal persistent drainage. The fluid from his bladder was shown to have a creatinine level equal to that of plasma, and therefore the fluid was believed to be an exudate from a large bladder tumor. Patient 4 underwent the procedure because of severe cystitis, and he died at 13 months. He had undergone only a unilateral procedure because the contralateral kidney was small, scarred, and initially considered nonfunctional. Even though he produced a small amount of urine, his condition was improved to such a degree as to not require occlusion of the contralateral kidney.
Summary of Results
Clinical Follow-up Radiographic Follow-up Duration Findings Duration Findings 1 2 mo MI 2 mo Occ 1 8d Dry 4d Occ 2 7 wk Dry 8 wk Occ 1 13 mo MI 13 mo Occ 5/A 2 14 mo MI 12 mo Occ 6/A 2 4 mo Dry 4 mo Occ* Note.-A = alive, D = deceased, MI = markedly improved, Occ = occluded. * As determined with intravenous urography. Patient No.1 Status lID 2ID 3ID 4ID
No. of Ureters Treated
• Radiographic Findings All ureters were occluded at the end of the procedure. In five patients follow-up nephrostograms were obtained between 2 and 13 months. One patient who had undergone a bilateral ureteral occlusion procedure underwent intravenous urography at 4 months. At follow-up, all ureters remained occluded with no change in coil position (Fig). • Complications None of the patients experienced ureteral colic or abdominal discomfort as a result of the procedure. One patient was admitted 10 months after the occlusion procedure with pyelonephritis and hematuria. He responded to intravenous administration of antibiotics and tube exchange. He died 3 months later of pneumonia. This case constituted our only complication.
DISCUSSION Urinary leaks in patients with advanced pelvic malignancies can be quite disabling. For those patients who are not surgical candidates, permanent urinary diversion can be very helpful for the remainder of their often short life expectancy. We also report on a single patient in whom cystitis and dysuria were severe enough that he preferred permanent external diversion to surgical therapy. We placed the coil/Gelfoam nest as distal as possible in all ureters. This preserves the proximal ureter in the
unlikely event that subsequent surgical diversion is performed. This practice is supported by our animal data, which showed stricture formation at the level of the coils with a relatively unaffected proximal ureter (8). Placement of coils in the distal ureter also decreases the likelihood of the development of an iliac artery-to-ureter fistula, which occurs as a result of pressure necrosis from a foreign body in the ureter where the ureter crosses anterior to the iliac artery. Pelvic surgery and radiation therapy predispose patients to the development of such a complication, and certainly these risk factors will be present in many patients who are candidates for a urinary diversion procedure (9). The ureter crosses the artery at the junction of the middle third and distal third of the ureter, which corresponds anatomically to the level of the superior half of the sacroiliac joint. Here the ureter crosses anteriorly over the pelvic brim and iliac artery to enter the pelvis (10,11). The length of the pelvic ureter in adults is usually 15 cm, a length which should suffice for placement of an obstructing coil nest (12). Coils placed distal to the level of the inferior aspect of the sacroiliac joint should be sufficiently remote from the pelvic brim and iliac artery to minimize the risk of developing a -ureteral-iliac artery fistula. Coils were not placed in the proximal ureter, since this portion of the ureter was usually the most dilated segment and larger coils would have been nec-
Bing et al • 321 Volume 3 Number 2
Figure. At 1 year, the ureter remains occluded.
essary. Proximal coils would also tend to isolate stagnant urine in the middle and distal ureter and could be conducive to infection of the urinary tract. Gelfoam may not be necessary to produce a complete occlusion acutely in the compliant ureter. Use of this technique in our animal study sug-
gests that coils alone may suffice in providing total occlusion in the acute setting, however this experience was limited to one pig in the study. Since our clinical experience preceded our animal study, we did not have the benefit of this information, and all patients were treated with coils and Gelfoam (8). Altogether, three patients in the series had some mild persistent drainage of fluid. One patient had undergone a unilateral occlusion, and the other kidney was small and scarred but may have been the source of a small amount of urine. In one patient, the fluid was shown not to be urine. The third patient had such a small volume of persistent drainage that she was satisfied with the results. The last patient in our series was not given a trial of external drainage alone. We cannot be sure of the role of the occlusion procedure on this patient. Her ureter was effectively occluded radiographically, and she is therefore included. We found the coiliGelfoam method of ureteral occlusion to be highly effective. This method has a number of advantages over other methods previously reported. The materials are readily available, no additional puncture or tract dilation is necessary, the procedure is short, and the results are immediate and sustained. This is now our procedure of choice for producing permanent ureteral occlusion in patients in whom complete or near complete urinary diversion is desired. References 1. Gunther R, Marberger M, Klose KJ. Transrenal ureteral embolization. Radiology 1979; 132:317-319. 2. Gunther R, Klose KJ, Aiken P, Bohl J. Transrenal ureteral occlusion using a detachable balloon. Urol Radio11984; 6:210-214.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Papanicolaou N, Pfister R, Yodel 1. Percutaneous occlusion of ureteral leaks and fistula using nondetachable balloon. Urol Radio11985; 7:28-31. Sanchez R, Quinn S, Morrisseau P, et al. Urinary diversion by using a percutaneous ureteral occlusion device. AJR 1988; 150:1069-1070. Darcy MD, Lund G, Smith TP, et al. Percutaneously applied ureteral clips: treatment of vesicovaginal fistula. Radiology 1987; 163:819-821. Kopecky KK, Sutton GP, Bihrle R, Becker GJ. Percutaneous transrenal endoureteral radio-frequency electrocautery for occlusion: case report. Radiology 1989; 170:10471048. Gaylord GM, Johnsrude IS. Transrenal ureteral occlusion with Gianturco coils and gelatin sponge. Radiology 1989; 172:1047-1048. Bing KT, Hicks ME, Figenshau RS, et al. Percutaneous ureteral occlusion with use of Gianturco coils and gelatin sponge. 1. A swine model. JVIR 1992; 3:313-317. Keller FS, Barton RE, Routh WD, Gross GM. Gross hematuria in two patients with ureteral-ileal conduits and double-J stents. JVIR 1990; 1:69-79. Mellins HZ. Radiology of the urinary tract: urography and cystourethrography. In: Walsh PC, Gittes RF, Perlmutter AD, Stamey AT, eds. Campbell's urology. Philadelphia: Saunders, 1986;312-358. Witten DM, Myers GH, Utz DC. The normal urogram. In: Witten DM, Myers GH, Utz DC, eds. Emmett's clinical urography. Philadelphia: Saunders, 1977; 481-563. Olsson CA. Anatomy of the upper urinary tract. In: Walsh PC, Gittes RF, Perlmutter AD, Stamey TA, eds. Campbell's urology. Philadelphia: Saunders, 1986; 12-46.
Index terms: Fistula, urinary, 80.245 • Fistula, vesicovaginal, 85.2453 • Ureter, interventional procedure, 82.1299 JVIR 1992; 3:319-321
A previous report described the use of coils and gelatin sponge pledgets as a means of producing ureteral occlusion to achieve urinary diversion in patients with urinary fistulas. The authors have performed this procedure in nine ureters of six patients. Five of the patients had urinary leaks with extensive pelvic tumor, and one had severe chronic cystitis. Ureters were occluded with use of Gianturco coils and gelatin sponge pledgets placed via a sheath through a percutaneous nephrostomy tract. The procedure was successful in all patients as judged by means of antegrade nephrostogram or intravenous pyelogram and by marked improvement or complete resolution of symptoms.
NUMEROUS methods have been used to produce ureteral occlusion for the purpose of achieving urinary diversion primarily in patients with urinary fistulas. Glue (1), detachable balloons (2), occlusion balloon catheters (3), nylon occluding devices (4), percutaneous clips (5), and endoluminal radio-frequency electrocautery (6) have all been used with some success. The ideal method of ureteral occlusion would be minimally invasive, performed with inexpensive readily available materials, and produce immediate and long-term occlusion. None of the previously reported methods fulfill these criteria fully. Gaylord and Johnsrude (7) described a series of patients whose ureters were effectively occluded with a nest of spring coils and gelatin sponge pledgets (Gelfoam; Kalamazoo, Mich). We sought to reproduce their results using these agents. I From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110. Received July 8, 1991; revision requested August 21; revision received and accepted December 9. Address reprint requests to M.E.H.
" SCVIR, 1992 See also the article by Bing et al (pp 313317) in this issue.
PATIENTS AND METHODS This study is a retrospective review of six patients in whom ureteral occlusion was performed with use of Gianturco coils and Gelfoam to facilitate urinary diversion. All patients were referred over a 14-month period
by either the gynecologic oncology service or the urology service. Four patients had advanced cervical cancer and a vesicovaginal fistula. One patient had advanced prostatic cancer with bladder invasion and perforation. One patient had chronic cystitis from a Candida species and severe disabling dysuria. None of the six patients were considered surgical candidates. The procedure was performed after a trial of external drainage had failed to provide adequate diversion in five of the six patients. In one patient nephrostomy was followed immediately by ureteral occlusion. Three patients underwent bilateral ureteral occlusion, and three required only a unilateral procedure because the contralateral kidney was nonfunctional. A 9-F Peel-Away sheath (Cook, Bloomington, lnd) was placed in the ureter through a nephrostomy tract. A catheter was advanced into the distal ureter, and through this a nest of 5-mm x 5-cm, 8-mm x 5-cm, 10-mm x 5-cm, and 12-mm x 5-cm Gianturco coils (Cook) were placed. The longer coils were overlapped by 50%, and smaller coils were placed along the larger coils, forming an interlocking nest. Gelfoam pledgets measuring 2-3 mm in diameter and 1 cm in
319
320 • Journal of Vascular and Interventional Radiology May 1992
length were placed within the nest. The Gelfoam pledgets were usually positioned between sets of the smaller coils either by injecting the coils through a nontapered 6-F catheter or by using a smaller tapered catheter to push the Gelfoam through the nontapered catheter. Six to 18 coils were placed in each ureter. The occlusion procedure was considered complete when contrast material injected above the nest showed occlusion with no flow distally. A nephrostomy catheter (Cook) (8-12 F) was left in place for external drainage. Follow-up was obtained by means of chart review in all patients; the two patients still living at the time of this retrospective review were interviewed by phone.
RESULTS • Clinical Findings The results are shown in the Table. Two patients were alive at the time this article was prepared and had undergone follow-up at 4 and 14 months. One of these had no drainage. The other living patient (patient 5) had minimal drainage, which she tolerated well. Three patients died within 2 months after the procedure of unrelated causes. All three had undergone follow-up within 2 weeks of their death. The condition of one of "hese patients (patient 1) was markedly improved, with minimal persistent drainage. The fluid from his bladder was shown to have a creatinine level equal to that of plasma, and therefore the fluid was believed to be an exudate from a large bladder tumor. Patient 4 underwent the procedure because of severe cystitis, and he died at 13 months. He had undergone only a unilateral procedure because the contralateral kidney was small, scarred, and initially considered nonfunctional. Even though he produced a small amount of urine, his condition was improved to such a degree as to not require occlusion of the contralateral kidney.
Summary of Results
Clinical Follow-up Radiographic Follow-up Duration Findings Duration Findings 1 2 mo MI 2 mo Occ 1 8d Dry 4d Occ 2 7 wk Dry 8 wk Occ 1 13 mo MI 13 mo Occ 5/A 2 14 mo MI 12 mo Occ 6/A 2 4 mo Dry 4 mo Occ* Note.-A = alive, D = deceased, MI = markedly improved, Occ = occluded. * As determined with intravenous urography. Patient No.1 Status lID 2ID 3ID 4ID
No. of Ureters Treated
• Radiographic Findings All ureters were occluded at the end of the procedure. In five patients follow-up nephrostograms were obtained between 2 and 13 months. One patient who had undergone a bilateral ureteral occlusion procedure underwent intravenous urography at 4 months. At follow-up, all ureters remained occluded with no change in coil position (Fig). • Complications None of the patients experienced ureteral colic or abdominal discomfort as a result of the procedure. One patient was admitted 10 months after the occlusion procedure with pyelonephritis and hematuria. He responded to intravenous administration of antibiotics and tube exchange. He died 3 months later of pneumonia. This case constituted our only complication.
DISCUSSION Urinary leaks in patients with advanced pelvic malignancies can be quite disabling. For those patients who are not surgical candidates, permanent urinary diversion can be very helpful for the remainder of their often short life expectancy. We also report on a single patient in whom cystitis and dysuria were severe enough that he preferred permanent external diversion to surgical therapy. We placed the coil/Gelfoam nest as distal as possible in all ureters. This preserves the proximal ureter in the
unlikely event that subsequent surgical diversion is performed. This practice is supported by our animal data, which showed stricture formation at the level of the coils with a relatively unaffected proximal ureter (8). Placement of coils in the distal ureter also decreases the likelihood of the development of an iliac artery-to-ureter fistula, which occurs as a result of pressure necrosis from a foreign body in the ureter where the ureter crosses anterior to the iliac artery. Pelvic surgery and radiation therapy predispose patients to the development of such a complication, and certainly these risk factors will be present in many patients who are candidates for a urinary diversion procedure (9). The ureter crosses the artery at the junction of the middle third and distal third of the ureter, which corresponds anatomically to the level of the superior half of the sacroiliac joint. Here the ureter crosses anteriorly over the pelvic brim and iliac artery to enter the pelvis (10,11). The length of the pelvic ureter in adults is usually 15 cm, a length which should suffice for placement of an obstructing coil nest (12). Coils placed distal to the level of the inferior aspect of the sacroiliac joint should be sufficiently remote from the pelvic brim and iliac artery to minimize the risk of developing a -ureteral-iliac artery fistula. Coils were not placed in the proximal ureter, since this portion of the ureter was usually the most dilated segment and larger coils would have been nec-
Bing et al • 321 Volume 3 Number 2
Figure. At 1 year, the ureter remains occluded.
essary. Proximal coils would also tend to isolate stagnant urine in the middle and distal ureter and could be conducive to infection of the urinary tract. Gelfoam may not be necessary to produce a complete occlusion acutely in the compliant ureter. Use of this technique in our animal study sug-
gests that coils alone may suffice in providing total occlusion in the acute setting, however this experience was limited to one pig in the study. Since our clinical experience preceded our animal study, we did not have the benefit of this information, and all patients were treated with coils and Gelfoam (8). Altogether, three patients in the series had some mild persistent drainage of fluid. One patient had undergone a unilateral occlusion, and the other kidney was small and scarred but may have been the source of a small amount of urine. In one patient, the fluid was shown not to be urine. The third patient had such a small volume of persistent drainage that she was satisfied with the results. The last patient in our series was not given a trial of external drainage alone. We cannot be sure of the role of the occlusion procedure on this patient. Her ureter was effectively occluded radiographically, and she is therefore included. We found the coiliGelfoam method of ureteral occlusion to be highly effective. This method has a number of advantages over other methods previously reported. The materials are readily available, no additional puncture or tract dilation is necessary, the procedure is short, and the results are immediate and sustained. This is now our procedure of choice for producing permanent ureteral occlusion in patients in whom complete or near complete urinary diversion is desired. References 1. Gunther R, Marberger M, Klose KJ. Transrenal ureteral embolization. Radiology 1979; 132:317-319. 2. Gunther R, Klose KJ, Aiken P, Bohl J. Transrenal ureteral occlusion using a detachable balloon. Urol Radio11984; 6:210-214.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Papanicolaou N, Pfister R, Yodel 1. Percutaneous occlusion of ureteral leaks and fistula using nondetachable balloon. Urol Radio11985; 7:28-31. Sanchez R, Quinn S, Morrisseau P, et al. Urinary diversion by using a percutaneous ureteral occlusion device. AJR 1988; 150:1069-1070. Darcy MD, Lund G, Smith TP, et al. Percutaneously applied ureteral clips: treatment of vesicovaginal fistula. Radiology 1987; 163:819-821. Kopecky KK, Sutton GP, Bihrle R, Becker GJ. Percutaneous transrenal endoureteral radio-frequency electrocautery for occlusion: case report. Radiology 1989; 170:10471048. Gaylord GM, Johnsrude IS. Transrenal ureteral occlusion with Gianturco coils and gelatin sponge. Radiology 1989; 172:1047-1048. Bing KT, Hicks ME, Figenshau RS, et al. Percutaneous ureteral occlusion with use of Gianturco coils and gelatin sponge. 1. A swine model. JVIR 1992; 3:313-317. Keller FS, Barton RE, Routh WD, Gross GM. Gross hematuria in two patients with ureteral-ileal conduits and double-J stents. JVIR 1990; 1:69-79. Mellins HZ. Radiology of the urinary tract: urography and cystourethrography. In: Walsh PC, Gittes RF, Perlmutter AD, Stamey AT, eds. Campbell's urology. Philadelphia: Saunders, 1986;312-358. Witten DM, Myers GH, Utz DC. The normal urogram. In: Witten DM, Myers GH, Utz DC, eds. Emmett's clinical urography. Philadelphia: Saunders, 1977; 481-563. Olsson CA. Anatomy of the upper urinary tract. In: Walsh PC, Gittes RF, Perlmutter AD, Stamey TA, eds. Campbell's urology. Philadelphia: Saunders, 1986; 12-46.
