Outpatient ureteric procedures: a new method for retrograde ureteropyelography and ureteric stent placement

Transcription

1 BJU International (2001), 87, 172±176 Outpatient ureteric procedures: a new method for retrograde ureteropyelography and ureteric stent placement J.P. MCFARLANE*, C. COWAN, S.J. HOLT and M.J. COWAN Departments of *Urology and Radiology, The Churchill Hospital, Oxford, UK Objective To evaluate a new method for retrograde ureteropyelography and retrograde ureteric stent placement. Patients and methods Procedures were undertaken using a exible cystoscope and digital C-arm uoroscopy in outpatients under sedoanalgesia. The exible cystoscope was used to identify the ureteric ori ce and a straight 0.9 mm hydrophilic guidewire inserted and passed into the renal pelvis under uoroscopic guidance. A 4 F general-purpose catheter was then passed over the wire and ureteropyelography performed. To place the stent the hydrophilic guidewire was exchanged for an ultra-stiff wire, over which the stent was passed directly. Results Over a 47-month period, 723 procedures were carried out in 472 patients. The clinical indications were ureteric obstruction in 229 (32%), stone disease in 165 (23%), unexplained hydronephrosis in 150 (21%), haematuria in 94 (13%) and others in 85 (12%). Of the 723 procedures, 643 (89%) were technically successful. Failure was most commonly caused by failure to cannulate the ureteric ori ce (51, 7%). Just over half the procedures (366, 51%) involved stent placement or replacement. Immediate complications occurred in 17 patients (3%). Of those who were questioned, 94% (282 of 300) reported the procedure to be acceptable. Conclusion Retrograde ureterography and ureteric stent placement may be satisfactorily undertaken with the patient under sedoanalgesia on an outpatient basis. This technique can reduce costs, hospital admissions, general anaesthetic use, demands on theatre time and complication rates. Keywords retrograde ureterography, ureteric stent, exible cystoscopy, local anaesthesia, sedoanalgesia Introduction Retrograde ureteropyelography was rst used almost 100 years ago. Since the development of IVU and other techniques such as ultrasonography, CT and MRI, it is now used less commonly. The technique still has an important role in selected cases for investigating hydronephrosis, haematuria and ureteric obstruction. Cystoscopic double-pigtail ureteric stents, rst introduced in 1967, are widely used to treat benign and malignant ureteric obstruction. The exible cystoscope was developed over 20 years ago, and is now in widespread use primarily for the diagnosis and follow-up of super cial bladder cancer. It is generally preferred by patients, and is quicker and cheaper than rigid cystoscopy. Other applications have been developed and include biopsy of suspicious urothelial lesions, diathermy of small super- cial bladder tumours [1], placement of retrograde ureteric catheters and removal of ureteric stents [2]. Modern exible cystoscopes are particularly well suited to the task of providing ureteric access. The 6 F working Accepted for publication 16 November 2000 channel allows the passage of guidewires, catheters and even stents. These operations may proceed with no general anaesthesia, saving time and money. We undertook a prospective, consecutive observational study over almost 4 years; ureteric procedures were carried out using a exible cystoscope on outpatients in the radiology department and we report our experience with this technique in over 700 patients. Patients and methods All procedures were carried out in the interventional radiology suite. Patients gave informed consent and were given antibiotic prophylaxis (cipro oxacin 250 mg orally). Lignocaine gel was used as a local anaesthetic and lubricant. For some procedures (e.g. stent removal) no other analgesia was used. However, for most ureteric procedures, sedoanalgesia, as diazemuls (2.5±10 mg intravenously) and pethidine (50±100 mg intravenously) was given as required. The patient's pulse, blood pressure and oxygen saturation were continuously monitored during the procedure. A exible cystoscope was passed into the bladder and 172 # 2001 BJU International

2 URETERIC PROCEDURES 173 rotated through 180u to allow greater deviation of the end of the scope and to facilitate identi cation of the ureteric ori ces. A 0.9 mm hydrophilic guidewire (Terumo Corp., Tokyo, Japan) was then passed into the ureteric ori ce under direct vision. The guidewire was then manipulated into the renal pelvis using C-arm digital uoroscopy. The cystoscope was placed close to the ureteric ori ce and its position relative to bony landmarks recorded by `frame grabbing' a uoroscopic image. This information was essential for nal stent positioning immediately before release. The exible cystoscope was removed and a 4 F general purpose ureteric catheter (Cordis Europa, Roden, The Netherlands) placed over the wire into the renal pelvis. Retrograde ureteropyelography was then undertaken using C-arm rotation and the table tilting facility. If a retrograde stent was to be placed, an ultra-stiff guidewire (Cook UK Ltd, Letchworth, UK) was passed up the ureteric catheter, which was subsequently removed. A double-pigtail stent (6±8 F, 20±26 cm, Boston Scienti c Ltd, St Albans, UK) was then placed over the wire and advanced to the renal pelvis, checking the position with uoroscopy. The stiff guidewire was then removed and the stent released into the bladder. A nal uoroscopic image was stored to document the stent position. The patients' details, clinical indications, immediate complications and a report of the procedure were prospectively entered into a database. The rst 300 patients undergoing outpatient ureteric procedures were asked to rate the procedure as acceptable, uncomfortable or painful. Results Between 26 February 1996 and 31 December 1999, 723 procedures were attempted in 472 patients, of which 643 (89%) were successful. The success rate of the technique improved slightly with increasing experience.(fig. 1). There were 252 male patients (53%) and 221 female (47%), with a mean (range) age of 60.6 (16±93) years. Failed procedures (%) Procedure number Fig. 1. The success rate with increasing experience. Number of procedures Cystoscopy Retrograde only ureterogram insertion Fig. 2. The number of procedures performed. change removal The procedures performed are detailed in.fig. 2; stents were placed or replaced in about half the patients. s were placed with no retrograde pyelography in a few patients, who were predominantly pregnant women with loin pain and associated hydronephrosis. The indications for stent placement or retrograde ureterography are listed in.table 1. The procedures were well tolerated, with 94% of respondents nding them acceptable, and only 4% and 2% reporting the experience as uncomfortable or painful, respectively. The most common reason for failing to complete a procedure was the inability to cannulate the ureteric ori ce (Table 1), usually because of tumour involving the bladder base. In 2.5% of patients it was not possible to pass either a wire or a stent past a ureteric stricture or stone causing obstruction. With planned stent replacement it was impossible to relocate the ureteric ori ce after removing the stent in four patients (0.6%). One patient had a panic attack just as a planned retrograde examination was about to start so the procedure was abandoned. The failure rate was higher in patients with malignant ureteric strictures (Table 1). Complications occurred in 21 patients (2.9%) and are listed in Table 1. One elderly patient died 4 days after stent placement; he had been admitted in renal failure with sepsis after a neglected stent had been left in situ for 4 years. The stent was removed and retrograde examination showed a complete ureteric occlusion, so a nephrostomy tube was placed and this drained pus. It is unlikely that the procedure contributed signi cantly to his death. One further patient with haematuria and a possible renal TCC developed severe bleeding after a retrograde examination. Positioning the retrograde catheter in the upper pole calyx provoked profuse arterial bleeding into the collecting system. The patient required resuscitation, blood transfusion and emergency selective embolization of the bleeding point. Four patients had severe pain during the procedure and two required admission overnight for analgesia. Four developed signs of sepsis and were treated with intravenous antibiotics;

3 174 J.P. MCFARLANE et al. Table 1 The clinical indications for the procedures, the reasons for their failure, the rate of failure by clinical indication, and the complications recorded Variable Number (%) Clinical indications Stone disease 165 (23) Malignant ureteric obstruction 157 (22) Unexplained hydronephrosis 150 (21) Haematuria 94 (13) Benign ureteric strictures 72 (10) Autosomal dominant polycystic kidney disease 20 (3) Filling defect on IVU 15 (2) Hydronephrosis of pregnancy 8 (1) Risk of contrast allergy 7 (1) Ureteric trauma 6 (1) Unexplained loin pain 6 (1) Other 23 (3) Reason for failure (% of total) Failure to cannulate ureteric ori ce 51 (7.0) Unable to: pass guidewire past stone/through stricture 13 (1.8) relocate ureteric ori ce after stent removal 4 (0.6) pass scope because of urethral stricture/urethritis 3 (0.4) push stent past stone/through stricture 5 (0.7) see stent because of bleeding 2 (0.3) change stent (distal end of stent in ureter) 1 (0.1) Panic attack 1 (0.1) Failure by clinical indication, n/group total (%) Malignant ureteric obstruction 44 (28) Filling defect on IVU 2 Stone disease 15 (9) Unexplained hydronephrosis 9 (6) Haematuria 6 (6) Autosomal dominant polycystic kidney disease 1 (5) Benign ureteric strictures 3 (4) Complication, n Unable to replace stent 4 Sepsis 4 Pain requiring admission 2 Severe pain 2 Torn collecting system 2 Perforated ureter 2 Misplacement of stent 2 Nausea and vomiting 1 Death 1 Severe haemorrhage 1 all made an uncomplicated recovery. Two patients had ureteric perforations from the guidewire and a further two had tears of the collecting system from over lling. The stent was misplaced in two cases, the proximal end lying in the proximal ureter in one patient and the distal end slipping into the distal ureter in the other. In four patients scheduled for stent changes, the stent was removed but the ureteric ori ce could not then be found to replace the stent. Discussion In 1906, Voelcher and von Lichtenberg [3] were the rst to successfully visualize the ureter and renal pelvis using a colloidal suspension of silver. There have been subsequent improvements in the procedure with the development of less toxic contrast agents, improvements in uoroscopic equipment, and developments in catheters, guidewires and cystoscopes. Although still a valuable technique, retrograde ureteropyelography is used less frequently, since the advent of IVU, ultrasonography, CT and MRI. Ureteric stents were rst used in open surgery in the 19th century but were popularized in the 1960s after endoscopic placement of a straight stent was reported by Zimskind et al. [4]. The modern `gold standard' is the double-pigtail stent which was rst described in 1978 [5]. Although there has been much work subsequently to try to improve biocompatibility, the basic design of the double-pigtail stent has remained the same. Antegrade ureteric stenting was rst described in 1978, and one of the advantages cited for this technique was the avoidance of general or regional anaesthesia [6]. Removal and replacement of stents has been described without anaesthetic, using snares under uoroscopic control [7±10], although dif culties can be encountered with stent removal using this technique in male patients because of the longer male urethra. s which have migrated can also be removed percutaneously using uoroscopy [11]. There are also reports of a few patients undergoing stent placement and retrograde ureterography using a exible cystoscope under local anaesthesia. Grasso and Bagley [12] reported the use of exible cystoscopy and sedoanalgesia to insert stents before ESWL in 27 patients. Mark et al. [13] reported on 34 patients who had stents placed before ESWL using a exible scope and local anaesthesia. Mark and Montgomery [14] used a similar technique successfully in 14 patients with stones. Adeyoju et al. [15] used a exible cystoscope with local anaesthesia and oral analgesia to insert a stent or ureteric catheter (before retrograde ureterography in the radiology department); they were successful in 14 of 17 patients when attempted in an outpatient setting. These reports principally used the exible cystoscope to position stents before ESWL, to avoid the need for general anaesthesia in the lithotripsy suite. The present study is the largest reported series of patients undergoing outpatient ureteric procedures, and the rst to show that the technique is safe and effective in all groups of patients, from uncomplicated retrograde studies to stenting of malignant strictures. General anaesthesia is unnecessary for these ureteric procedures; patients tolerated it well, with only 6% reporting signi cant discomfort.

4 URETERIC PROCEDURES 175 Performing ureteric procedures under local anaesthesia has several advantages over the conventional approach in the operating theatre. It is quicker and safer, as there is no need for general anaesthesia. A greater range of procedures can be undertaken (see below), on an outpatient basis, saving money, and freeing operating theatre time and inpatient/day-case beds. There is no need for an anaesthetist, and procedures can be carried out by either urologists or radiologists. When a stent is removed in the radiology department a retrograde study can be immediately performed if required, in contrast to the usual situation where stents are removed blindly using exible cystoscopy. The failure rate is low (11% in the present study). In almost two-thirds of patients this was because of failure to visualize the ureteric ori ce, usually when tumour involved the bladder base or through bleeding. This is one situation where general anaesthesia is advantageous, as the views inside the bladder can be improved by washing out blood/clots and the tumour can sometimes be resected to reveal the ureteric ori ce. The failure rate for retrograde treatment of malignant ureteric strictures was noticeably higher than average in this series (Table 1). Malignant strictures are dif cult to treat, and we now often use antegrade stenting as a rst-line treatment. In the study by Mark et al. [13] stent placement was unsuccessful in four of 34 patients because of buckling of the guidewire when resistance to the stent was encountered in the distal ureter. This may be because they used a standard guidewire. This problem was not encountered in the present series using a stiff wire or peelaway sheath acting as a support where necessary, and it was possible to pass stents through tight malignant strictures close to the vesico-ureteric junction. These strictures are the most dif cult to stent retrogradely. One advantage of carrying out ureteric procedures in the interventional radiology suite is that if a retrograde attempt at stenting fails, a nephrostomy can be placed immediately. Subsequent antegrade stenting is successful in < 96% of cases [16]. Another useful piece of equipment commonly used by the interventional radiologist is the purpose-designed 6 F `hockey stick' angiographic stent (Cordis Europa). These can be used to negotiate the tortuous ureter which can result from longstanding obstruction.(fig. 3). In our institution these procedures are usually undertaken by interventional radiologists, but the techniques are easily applicable by urologists with an interest in endourology. Urologists are familiar with exible cystoscopy, and interventional radiologists are used to techniques of crossing strictures, and the use of catheters and guidewires to optimum effect. The need for practice is inevitable, as shown by the present series in which the Fig. 3. An example of a tortuous ureter. success rate improved slightly with increasing experience. There is an advantage in having the combined experience of both the radiologist and urologist present for the rst 50 cases. In conclusion, ureteric stents can be placed and retrograde ureterography safely performed under local anaesthesia and sedoanalgesia in an outpatient setting. The success rate using this technique is high and there are few complications. The procedure is acceptable to patients and offers numerous advantages over the conventional approach using general or regional anaesthesia. References 1 Herr HW. Outpatient exible cystoscopy and fulguration of recurrent super cial bladder tumours. J Urol 1990; 144: 1365±6 2 Fowler CG. Removal of ureteric stents with the exible cystoscope. Br J Urol 1987; 62: Voelcher F, von Lichtenberg A. Pyelographie RoÈntgeno-

5 176 J.P. MCFARLANE et al. graphic des Niesenbechens nach KollargolfuÈ lling. MuÈnch Med Wschr 1905; 52: 1576±8 4 Zimskind PD, Fetter TR, Willierson JL. Clinical use of longterm indwelling silicone rubber ureteral splints inserted cystoscopically. J Urol 1967; 97: 840±4 5 Finney RP. Experience with a new double-j ureteral stent. J Urol 1978; 120: Smith AD, Lange PH, Miller RP, Reinke DB. Introduction of the Gibbons ureteral stent facilitated by antecedent percutaneous nephrostomy. J Urol 1978; 120: 543±4 7 Yedlicka JR, Aizpuru R, Hunter DW, Castaneda-Zuniga WR, Amplatz K. Retrograde replacement of internal double- J ureteral stents. Am J Roentgenol 1991; 156: 1007±9 8 Edwards RD, Robertson IR. Transureteral ureteric stent retrieval using the Amplatz `goose-neck' snare. J Intervent Radiol 1992; 7: 123±6 9 Breen DJ, Cowan NC. Fluoroscopically-guided retrieval of ureteric stents. Clin Radiol 1997; 50: 860±3 10 Wetton CWN, Gedroyc WMW. Retrograde radiological retrieval and replacement of double-j ureteric stents. Clin Radiol 1995; 50: 562±5 11 Boardman P, Cowan NC. Technical report: uoroscopically guided retrograde ureteric stent retrieval and replacement using a guide catheter directed snare. Clin Radiol 1997; 52: 308±9 12 Grasso M, Bagley DH. Flexible cystoscopic placement of ureteral stents before shock wave lithotripsy. J Endourol 1990; 4: 229±33 13 Mark SD, Gray JM, Wright WL. Flexible cystoscopy as an adjunct to extracorporeal shockwave lithotripsy. Br J Urol 1990; 66: 245±7 14 Mark IR, Montgomery BSI. Fibre-optic cystoscope-guided insertion of J-J ureteric stent. Br J Urol 1996; 77: 149±50 15 Adeyoju AB, Collins GN, Brooman P, O'Reilly PH. Outpatient exible cystoscope-assisted insertion of ureteric catheters and ureteric stents. BJU Int 1999; 83: 748±50 16 McCafferty IJ, Cowan NC, Holt SJ, Cooper G, Cowan MJ, Goodman TR. Can radiological parameters be used to predict outcome of antegrade ureteric stent placement for malignant obstruction? Radiology 1998; 209P: 377 Authors J.P. McFarlane, FRCS, Specialist Registrar in Urology. N.C. Cowan, FRCR, Consultant Uroradiologist. S.J. Holt, DCR, Interventional Radiographer. M.J. Cowan, SRN, Uroradiology Research Assistant. Correspondence: Dr N.C. Cowan, Oxford Urogenital Imaging, Department of Radiology, The Churchill Hospital, Oxford OX3 7LJ, UK. ncc@oui.org.uk