Treatment of Iatrogenic Postoperative Ureteral Strictures with Acucise Endoureterotomy
Introduction
Endourological approaches to the treatment of ureteral strictures are supposed to be an effective alternative to open surgical procedures. Major experience exists in the treatment of obstruction of the ureteropelvic junction (UPJ) with different approaches like balloon dilatation, cold knife incision, electrocautery or laser incision. In contrast, there is less experience with the endourologic treatment of other forms of ureteral strictures [1], [2].
Since Chandhoke et al. presented their first clinical experience [3], the Acucise catheter system has become a very popular alternative for the endourologic treatment of UPJ-obstruction and also other ureteral strictures [4]. The attraction of this technique is its simplicity. The catheter system may be inserted via cystoscopy under fluoroscopic control. There is no need for ureteroscopy. The combination of electrocautery with balloon dilatation in one system increases the efficacy and shortens the procedure. Moreover, the minimal invasive character distinctly decreases the time of hospitalization.
In contrast to the mainly congenital etiology of UPJ-obstruction, most of the other forms of ureteral strictures are caused iatrogenic by affection of the ureter during endoscopic or open surgical procedures. A very special subgroup of these strictures is located at the enteroureteric junction in patients with supravesical urinary diversion by intestinal segments. Despite a greater perioperative morbidity and a longer time of hospitalization, the common treatment of all these forms of ureteral stricture is still open surgery [5]. Additionally, the so far presented studies suggest less efficacy of the endourologic treatment of benign ureteral strictures as well as ureteroenteric strictures compared to open surgical approaches [1], [2]. However, all of these studies investigated only small numbers of patients. Prospective studies have not yet been performed.
We report on our experience with Acucise endoureterotomy in a series of 18 patients with postoperative iatrogenic ureteral strictures resulting from heterogeneous open surgical procedures affecting the ureter. The analysis of our data compared to preceding reports may help to discover possible factors that influence the outcome of the treatment and to determine instructions for a better selection of ureteral strictures that are suitable for a endourologic approach.
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Patients
Between 1996 and 2001, we performed Acucise endoureterotomy in 18 patients with iatrogenic postoperative ureteral strictures preceded by surgery involving the ureter: 10 females, 8 males patients. All patients were adults. The mean age was 42.3 years (18–83 years). The ureteral stenosis occurred after renal transplantation (n=5), open surgical pyeloplasty (n=5), ureterenteric anastomosis after construction of an ileum neobladder (n=3), ureterocystoneostomy (n=1), ureterorenoscopy (n=1),
Results
A complete incision of the ureteric stricture was possible in all of the presented 18 patients. There were no intraoperative technical problems. The success rate was 11/18 (61%) during a mean follow-up of 21.5 months (6–61 months). All failures occurred within the first 3 months after endoureterotomy, except one patient (6 months). Only mild side effects or complications were observed in 6/18 (33%) patients. The effects were prolonged hematuria in four cases and short episodes of significant
Discussion
During the last years, advances in endourological techniques and instrumentation opened up new prospects for the management of benign ureteric strictures. Nevertheless, except UPJ-obstruction in adults, open surgery is still the prevalent treatment of benign ureteral strictures although, it is associated with a higher perioperative morbidity, a longer hospitalization time and, therefore, higher treatment costs. But following the promising results in the treatment of UPJ-obstruction,
Conclusion
Acucise endoureterotomy is an uncomplicated important alternative to open surgical revision in patients with ureteral strictures after different operations affecting the ureter, but only in selected cases. To improve long-term patency of the treated ureters we would recommend the following premises based on our reported series of patients: (i) The interval between the appearance of the stricture and the primary operative trauma should be at least 6 months. (ii) The length of the stricture
References (18)
- et al.
Long-term follow-up of Acucise incision of ureteropelvic junction obstruction and ureteral strictures
Urology
(1996) - et al.
Re: Complications of retrograde balloon cautery endopyelotomy
J. Urol.
(2001) Management of iatrogenic ureteral strictures after urologic procedures
J. Urol.
(1988)- et al.
Endourological treatment of ureteroenteric strictures: efficacy of Acucise endoureterotomy
J. Urol.
(1999) - et al.
Treatment of refractory kidney transplant ureteral strictures using balloon cautery endoureterotomy
Urology
(2001) Acucise endopyelotomy
Urology
(2000)- et al.
Holmium: YAG laser endoureterotomy for ureterointestinal strictures
J. Urol.
(2002) - et al.
Percutaneous endoscopic management of upper ureteral stricture: size of stent
J. Urol.
(1996) - et al.
Effect of stent duration on ureteral healing following endoureterotomy in an animal model
J. Urol.
(1993)
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