Journal of Medical Imaging and Radiation Oncology 58 (2014) 75–78 bs_bs_banner
R ADIOLO GY—TE C H N I C A L A RT I C L E
Retrograde exchange of heavily encrusted ureteric stents via the ileal conduit: A technical report Charles Ross Tapping1,2 and Phil Boardman2 1 Department of Radiology, Oxford University Hospitals, John Radcliffe Hospital, and 2Department of Radiology, Oxford University Hospitals, Churchill Hospital, Oxford, UK
Correspondence Dr CR Tapping, Oxford University Hospitals, Department of Radiology, Churchill Hospital, Headington, Oxon, OX3 7HE, UK. Email: [email protected] Conflict of interest: Dr Charles Ross Tapping and Dr Phil Boardman have no potential conflicts of interest. Submitted 4 June 2013; accepted 10 August 2013.
Summary We describe two cases of retrograde ureteric stent exchange of heavily encrusted ureteric stents (JJ) via tortuous ileal conduits. The blocked ureteric stents were snared from inside the conduit so they could be accessed and a wire inserted. The lumens of the stents were unblocked with a wire but the stents could not be withdrawn due to heavy encrustation of the ureteric stent in the renal pelvis. A stiff wire was inserted to provide support and a 9 French peel away sheath was used to remove the encrustations allowing the stents to be withdrawn and exchanged. This is a safe and successful technique allowing ureteric stents to be removed when heavily encrusted. Key words: encrusted; ileal conduit; ureteric stent.
doi:10.1111/1754-9485.12110
Introduction Ureteroileal anastomosis strictures are a well-known complication of ileal conduits following radial cystectomy occurring in up to 16% of cases.1 Open surgical revision of these strictures is technically challenging due to scar tissue surrounding the operative site. Interventional radiological techniques involving either retrograde or antegrade stent insertions are an excellent alternative to open surgery. Antegrade stents enter the patient via the back and traverse the kidney and terminate preferably outside the ileal conduit. Retrograde stent placement enters the ileal conduit and the stent terminates in the renal collecting system. Placement of antegrade stents is technically easier however, patients are usually more comfortable with retrograde placement via the conduit and this approach minimises potential complications from puncturing the kidney (bleeding) and infection. The long-term management of patients with stents placed across ureteroileal strictures requires regular stent exchange. This prevents the stents from becoming encrusted and blocked which would require emergency stent exchange or nephrostomy to prevent infection and urinary sepsis.2 © 2013 The Royal Australian and New Zealand College of Radiologists
We present a technique for retrograde exchange of heavily encrusted ureteroileal stents using a sheath and stiff wire. In both cases the stent exchange was required due to the existing stents being blocked and the presence of hydronephrosis, deranged renal function tests and high inflammatory markers. The stents were exchanged without the need for nephrostomy and remained patent until their scheduled exchange 4 months later.
Technical report Case 1: A 71 year old man had an ileal conduit formed in 2004 due to bladder dysfunction, recurrent bladder stones and episodes of cystitis. In 2006 he had an initial retrograde stent placed via the conduit for obstruction and stenosis at the ureteroileal anastomosis. Initially he attended for 6 monthly stent exchanges but this was increased to 4 monthly exchanges over the past 12 months due to recurrent stent blockages in the 4–6 month period. In total he had received 15 ureteroileal stent exchanges. On this occasion a chest infection requiring antibiotics meant he missed his 4 monthly stent exchange and attended via emergency clinic 6 75
CR Tapping and P Boardman
months post stent exchange. CT revealed a heavily encrusted proximal ureteric stent and retrograde conduitogram showed the stent was obstructed. Case 2: A 66 year old woman had an ileal conduit formed in 1980 for interstitial cystitis. In 2000 a stenosis occurred at the ileal anastomosis and she had her initial retrograde ureteroileal stent placed. She had 6 monthly stent exchanges for 10 years and then had recurrent admissions with urosepsis secondary to stent obstruction. She then stared to have 4 monthly stent exchanges. She presented to our department after 7 months since previous stent exchange with an obstructed stent. A recent illness abroad had meant the regular 4 monthly stent exchanges had lapsed. CT revealed a heavily encrusted proximal ureteric stent and retrograde conduitogram showed the stent was obstructed. In both cases the heavily encrusted stents were exchanged as described below. Technique: Pre procedure the patients received coamoxiclav 2 g i.v and conscious sedation with 3 mg midazolam i.v and 50 micrograms of fentanyl i.v. A 12 French Foley catheter (C.R. Bard Inc, Covington, GA, USA) was initially introduced into the ileal conduit and the 10 mL balloon inflated. Contrast was then injected and delineated the tract providing a ‘road map’ of the conduit. The ileal conduit was then accessed with a hydrophilic wire (Terumo, Tokyo, Japan) and 4 French Berenstein II catheter (Cordis, Miami Lakes, Florida, USA). The wire and catheter were navigated through the tortuous ileal conduit to the distal end of the ureteral stent. The distal end of the 28 cm 8 French Flexima ureteral stent (Boston Scientific, Natick, MA, USA) was then snared with a 10 mm Amplatz goose neck snare (EV3, Plymouth, MN, USA) (Fig. 1). Under fluoroscopic guidance the distal end of the ureteral stent was withdrawn out of the conduit and grasped with a forceps. A hydrophilic wire (Terumo, Tokyo, Japan) was inserted into the stent but would not advance due to calcific deposits within the stent. An attempt was made to pass a stiff wire (Amplatz Ultra stiff wire, Bjaeverskov, Denmark) and a stiff hydrophilic wire (Terumo, Tokyo, Japan) through the stent but again this was not possible. The reverse end of the stiff hydrophilic wire (Terumo, Tokyo, Japan) was carefully inserted into the stent and advanced under fluoroscopic guidance. This was passed through the blocked stent and advanced to the proximal ‘J’ tip. The hydrophilic wire was then exchanged for a stiff wire (Amplatz Ultra stiff wire, Bjaeverskov, Denmark) and an attempt was made to with draw the stent. This was not possible due to the heavy encrustation at the upper end of the ‘JJ’ stent. Therefore, using the stiff wire as a ‘scaffold’ a 9 French peel away sheath (Peel-Away Introducer set, Cook, Bloomington, USA) was advanced over the wire until its introducer abutted the distal end of the stent then the peel away sheath, without its introducer, was advanced over the wire stent complex. Resistance was encountered but with gentle rotation of 76
Fig. 1. The distal end of the stent was snared.
the peel away sheath it was advanced over the encrusted stent The peel away sheath was then split to allow more of the stent to be grasped allowing it to be more easily retracted (Fig. 2). The previously encrusted stent was then withdrawn through the sheath over the stiff wire (Fig. 2). A catheter was advanced over the stiff wire and contrast injected to confirm position of the renal pelvis. A new ureteral stent was inserted via the conduit (28 cm 8 French Flexima ureteric stent) over the stiff wire through the sheath (Fig. 3). There were no immediate complications and the patients both left hospital within 48 hours. There were no further blockages, infection or pain and the stents were routinely exchanged over a wire 4 months following the procedure without complication.
Discussion This procedure is safe and effective and maintains urinary drainage via the ileal conduit in the case of obstructed encrusted transileal stents. The procedure can be performed under conscious sedation with antibiotic prophylaxis. It negates the need for percutaneous nephrostomy and antegrade stent insertion and also more invasive techniques to retrieve the encrusted stent. It permits continued urine drainage via the ileal © 2013 The Royal Australian and New Zealand College of Radiologists
Retrograde ileal conduit exchange
patients to the department with blocked stents and urosepsis. However, occasionally the 4 month time period lapses and stents block requiring urgent exchange. In the event of uro-sepsis, in most cases,2 we would advocate percutaneous nephrostomy to decompress the system and antibiotic treatment with retrograde exchange of ureteroileal stent change via the ileal conduit at a later date. However, in the event of an obstructed stent without signs or symptoms of uro-sepsis then urgent retrograde stent exchange via the conduit would be our treatment of choice. This obviously reduces the risk from performing percutaneous nephrostomy and allows rapid restoration of renal function. Moreover, patients prefer retrograde exchange via the conduit as they can lie supine rather than prone which is an important consideration for comfort in patients with ileal conduits. If it had not been possible to pass the wire all the way through the stent then another option would have been to advance the sheath over the wire/stent complex to its hub. Then attempt to withdraw the stent and wire leaving the peel away sheath as the form of access to the ureter. Following wire/stent removal the ureter could be navigated with a hydrophilic wire and catheter and tranileal retrograde stent deployment could be performed in a traditional way. In conclusion we believe this is a useful technique in maintaining urinary drainage via ileal conduits. It is an adjunctive procedure to the well-established technique
Fig. 2. The peel away sheath was split to allow more of the stent to be grasped, and the stent was removed over the wire from within the sheath.
conduit and allows successful retrograde stent exchange in the future maintaining the high durability of transileal stents.3,4 Placement and exchange of trans ileal ureteral stents is an attractive and successful option for managing postoperative ureteroileal anastomotic strictures in the long term. It reduces the need for external forms of drainage which patients dislike and also reduces the need for complex difficult surgical intervention. Repeated exchanges are safe and can be performed under conscious sedation. In our practice we attempt to insert all de novo ileal stents via a retrograde approach via the ileal conduit. If this fails we then perform a nephrostomy and insert an antegrade stent in a single stage procedure leaving the distal end of the ‘JJ’ stent outside of the ileal conduit to allow easy exchange in the future. In our practice stents are exchanged every 6 months however, in certain circumstances we increase the frequency to every 4 months (repeated infections/ encrustations/lithiasis/blockages prior to 6 monthly exchanges and discussed in a multidisciplinary team setting). This frequency reduces the presentation of © 2013 The Royal Australian and New Zealand College of Radiologists
Fig. 3. Following contrast injection to confirm the location of the renal pelvis a new 28-cm ureteric stent was inserted over the wire.
77
CR Tapping and P Boardman
of retrograde transileal stent exchange via an ileal conduit. It is successful and, in our small number of cases safe, allowing subsequent stent exchange at an appropriate time interval.
Author contributions CRT: guarantor of integrity of the entire study, study concepts and design, literature research, manuscript preparation, manuscript editing. PB: study concepts and design, literature research, manuscript preparation, manuscript editing.
2. Tapping CR, Boardman P. Post laparotomy retrograde navigation of an obstructed ileal conduit to relieve urinary sepsis. J Vasc Interv Radiol 2013. doi: 10.1016/j.jvir.2013.05.069. 3. Tal R, Bachar GN, Baniel J et al. External–internal nephro-uretero-ileal stents in patientswith an ileal conduit: long-term results. Urology 2004; 63: 438–41. 4. Alago W Jr, Sofocleous CT, Covey AM et al. Placement of transileal conduit retrograde nephroureteral stents in patients with ureteral obstruction after cystectomy: technique and outcome. AJR Am J Roentgenol 2008; 191: 1536–9.
References 1. Gilbert SM, Lai J, Saigal CS et al. Downstream complications following urinary diversion. J Urol 2013; 190: 916–22.
78
© 2013 The Royal Australian and New Zealand College of Radiologists
R ADIOLO GY—TE C H N I C A L A RT I C L E
Retrograde exchange of heavily encrusted ureteric stents via the ileal conduit: A technical report Charles Ross Tapping1,2 and Phil Boardman2 1 Department of Radiology, Oxford University Hospitals, John Radcliffe Hospital, and 2Department of Radiology, Oxford University Hospitals, Churchill Hospital, Oxford, UK
Correspondence Dr CR Tapping, Oxford University Hospitals, Department of Radiology, Churchill Hospital, Headington, Oxon, OX3 7HE, UK. Email: [email protected] Conflict of interest: Dr Charles Ross Tapping and Dr Phil Boardman have no potential conflicts of interest. Submitted 4 June 2013; accepted 10 August 2013.
Summary We describe two cases of retrograde ureteric stent exchange of heavily encrusted ureteric stents (JJ) via tortuous ileal conduits. The blocked ureteric stents were snared from inside the conduit so they could be accessed and a wire inserted. The lumens of the stents were unblocked with a wire but the stents could not be withdrawn due to heavy encrustation of the ureteric stent in the renal pelvis. A stiff wire was inserted to provide support and a 9 French peel away sheath was used to remove the encrustations allowing the stents to be withdrawn and exchanged. This is a safe and successful technique allowing ureteric stents to be removed when heavily encrusted. Key words: encrusted; ileal conduit; ureteric stent.
doi:10.1111/1754-9485.12110
Introduction Ureteroileal anastomosis strictures are a well-known complication of ileal conduits following radial cystectomy occurring in up to 16% of cases.1 Open surgical revision of these strictures is technically challenging due to scar tissue surrounding the operative site. Interventional radiological techniques involving either retrograde or antegrade stent insertions are an excellent alternative to open surgery. Antegrade stents enter the patient via the back and traverse the kidney and terminate preferably outside the ileal conduit. Retrograde stent placement enters the ileal conduit and the stent terminates in the renal collecting system. Placement of antegrade stents is technically easier however, patients are usually more comfortable with retrograde placement via the conduit and this approach minimises potential complications from puncturing the kidney (bleeding) and infection. The long-term management of patients with stents placed across ureteroileal strictures requires regular stent exchange. This prevents the stents from becoming encrusted and blocked which would require emergency stent exchange or nephrostomy to prevent infection and urinary sepsis.2 © 2013 The Royal Australian and New Zealand College of Radiologists
We present a technique for retrograde exchange of heavily encrusted ureteroileal stents using a sheath and stiff wire. In both cases the stent exchange was required due to the existing stents being blocked and the presence of hydronephrosis, deranged renal function tests and high inflammatory markers. The stents were exchanged without the need for nephrostomy and remained patent until their scheduled exchange 4 months later.
Technical report Case 1: A 71 year old man had an ileal conduit formed in 2004 due to bladder dysfunction, recurrent bladder stones and episodes of cystitis. In 2006 he had an initial retrograde stent placed via the conduit for obstruction and stenosis at the ureteroileal anastomosis. Initially he attended for 6 monthly stent exchanges but this was increased to 4 monthly exchanges over the past 12 months due to recurrent stent blockages in the 4–6 month period. In total he had received 15 ureteroileal stent exchanges. On this occasion a chest infection requiring antibiotics meant he missed his 4 monthly stent exchange and attended via emergency clinic 6 75
CR Tapping and P Boardman
months post stent exchange. CT revealed a heavily encrusted proximal ureteric stent and retrograde conduitogram showed the stent was obstructed. Case 2: A 66 year old woman had an ileal conduit formed in 1980 for interstitial cystitis. In 2000 a stenosis occurred at the ileal anastomosis and she had her initial retrograde ureteroileal stent placed. She had 6 monthly stent exchanges for 10 years and then had recurrent admissions with urosepsis secondary to stent obstruction. She then stared to have 4 monthly stent exchanges. She presented to our department after 7 months since previous stent exchange with an obstructed stent. A recent illness abroad had meant the regular 4 monthly stent exchanges had lapsed. CT revealed a heavily encrusted proximal ureteric stent and retrograde conduitogram showed the stent was obstructed. In both cases the heavily encrusted stents were exchanged as described below. Technique: Pre procedure the patients received coamoxiclav 2 g i.v and conscious sedation with 3 mg midazolam i.v and 50 micrograms of fentanyl i.v. A 12 French Foley catheter (C.R. Bard Inc, Covington, GA, USA) was initially introduced into the ileal conduit and the 10 mL balloon inflated. Contrast was then injected and delineated the tract providing a ‘road map’ of the conduit. The ileal conduit was then accessed with a hydrophilic wire (Terumo, Tokyo, Japan) and 4 French Berenstein II catheter (Cordis, Miami Lakes, Florida, USA). The wire and catheter were navigated through the tortuous ileal conduit to the distal end of the ureteral stent. The distal end of the 28 cm 8 French Flexima ureteral stent (Boston Scientific, Natick, MA, USA) was then snared with a 10 mm Amplatz goose neck snare (EV3, Plymouth, MN, USA) (Fig. 1). Under fluoroscopic guidance the distal end of the ureteral stent was withdrawn out of the conduit and grasped with a forceps. A hydrophilic wire (Terumo, Tokyo, Japan) was inserted into the stent but would not advance due to calcific deposits within the stent. An attempt was made to pass a stiff wire (Amplatz Ultra stiff wire, Bjaeverskov, Denmark) and a stiff hydrophilic wire (Terumo, Tokyo, Japan) through the stent but again this was not possible. The reverse end of the stiff hydrophilic wire (Terumo, Tokyo, Japan) was carefully inserted into the stent and advanced under fluoroscopic guidance. This was passed through the blocked stent and advanced to the proximal ‘J’ tip. The hydrophilic wire was then exchanged for a stiff wire (Amplatz Ultra stiff wire, Bjaeverskov, Denmark) and an attempt was made to with draw the stent. This was not possible due to the heavy encrustation at the upper end of the ‘JJ’ stent. Therefore, using the stiff wire as a ‘scaffold’ a 9 French peel away sheath (Peel-Away Introducer set, Cook, Bloomington, USA) was advanced over the wire until its introducer abutted the distal end of the stent then the peel away sheath, without its introducer, was advanced over the wire stent complex. Resistance was encountered but with gentle rotation of 76
Fig. 1. The distal end of the stent was snared.
the peel away sheath it was advanced over the encrusted stent The peel away sheath was then split to allow more of the stent to be grasped allowing it to be more easily retracted (Fig. 2). The previously encrusted stent was then withdrawn through the sheath over the stiff wire (Fig. 2). A catheter was advanced over the stiff wire and contrast injected to confirm position of the renal pelvis. A new ureteral stent was inserted via the conduit (28 cm 8 French Flexima ureteric stent) over the stiff wire through the sheath (Fig. 3). There were no immediate complications and the patients both left hospital within 48 hours. There were no further blockages, infection or pain and the stents were routinely exchanged over a wire 4 months following the procedure without complication.
Discussion This procedure is safe and effective and maintains urinary drainage via the ileal conduit in the case of obstructed encrusted transileal stents. The procedure can be performed under conscious sedation with antibiotic prophylaxis. It negates the need for percutaneous nephrostomy and antegrade stent insertion and also more invasive techniques to retrieve the encrusted stent. It permits continued urine drainage via the ileal © 2013 The Royal Australian and New Zealand College of Radiologists
Retrograde ileal conduit exchange
patients to the department with blocked stents and urosepsis. However, occasionally the 4 month time period lapses and stents block requiring urgent exchange. In the event of uro-sepsis, in most cases,2 we would advocate percutaneous nephrostomy to decompress the system and antibiotic treatment with retrograde exchange of ureteroileal stent change via the ileal conduit at a later date. However, in the event of an obstructed stent without signs or symptoms of uro-sepsis then urgent retrograde stent exchange via the conduit would be our treatment of choice. This obviously reduces the risk from performing percutaneous nephrostomy and allows rapid restoration of renal function. Moreover, patients prefer retrograde exchange via the conduit as they can lie supine rather than prone which is an important consideration for comfort in patients with ileal conduits. If it had not been possible to pass the wire all the way through the stent then another option would have been to advance the sheath over the wire/stent complex to its hub. Then attempt to withdraw the stent and wire leaving the peel away sheath as the form of access to the ureter. Following wire/stent removal the ureter could be navigated with a hydrophilic wire and catheter and tranileal retrograde stent deployment could be performed in a traditional way. In conclusion we believe this is a useful technique in maintaining urinary drainage via ileal conduits. It is an adjunctive procedure to the well-established technique
Fig. 2. The peel away sheath was split to allow more of the stent to be grasped, and the stent was removed over the wire from within the sheath.
conduit and allows successful retrograde stent exchange in the future maintaining the high durability of transileal stents.3,4 Placement and exchange of trans ileal ureteral stents is an attractive and successful option for managing postoperative ureteroileal anastomotic strictures in the long term. It reduces the need for external forms of drainage which patients dislike and also reduces the need for complex difficult surgical intervention. Repeated exchanges are safe and can be performed under conscious sedation. In our practice we attempt to insert all de novo ileal stents via a retrograde approach via the ileal conduit. If this fails we then perform a nephrostomy and insert an antegrade stent in a single stage procedure leaving the distal end of the ‘JJ’ stent outside of the ileal conduit to allow easy exchange in the future. In our practice stents are exchanged every 6 months however, in certain circumstances we increase the frequency to every 4 months (repeated infections/ encrustations/lithiasis/blockages prior to 6 monthly exchanges and discussed in a multidisciplinary team setting). This frequency reduces the presentation of © 2013 The Royal Australian and New Zealand College of Radiologists
Fig. 3. Following contrast injection to confirm the location of the renal pelvis a new 28-cm ureteric stent was inserted over the wire.
77
CR Tapping and P Boardman
of retrograde transileal stent exchange via an ileal conduit. It is successful and, in our small number of cases safe, allowing subsequent stent exchange at an appropriate time interval.
Author contributions CRT: guarantor of integrity of the entire study, study concepts and design, literature research, manuscript preparation, manuscript editing. PB: study concepts and design, literature research, manuscript preparation, manuscript editing.
2. Tapping CR, Boardman P. Post laparotomy retrograde navigation of an obstructed ileal conduit to relieve urinary sepsis. J Vasc Interv Radiol 2013. doi: 10.1016/j.jvir.2013.05.069. 3. Tal R, Bachar GN, Baniel J et al. External–internal nephro-uretero-ileal stents in patientswith an ileal conduit: long-term results. Urology 2004; 63: 438–41. 4. Alago W Jr, Sofocleous CT, Covey AM et al. Placement of transileal conduit retrograde nephroureteral stents in patients with ureteral obstruction after cystectomy: technique and outcome. AJR Am J Roentgenol 2008; 191: 1536–9.
References 1. Gilbert SM, Lai J, Saigal CS et al. Downstream complications following urinary diversion. J Urol 2013; 190: 916–22.
78
© 2013 The Royal Australian and New Zealand College of Radiologists
