The Detour Extra-Anatomic Stent a Permanent Solution for Benign and Malignant Ureteric Obstruction?

Transcription

1 european urology 52 (2007) available at journal homepage: Endo-urology The Detour Extra-Anatomic Stent a Permanent Solution for Benign and Malignant Ureteric Obstruction? Stuart N. Lloyd a, *, Prasanda Tirukonda b, Chandra Shekhar Biyani c, Tze M. Wah b, Henry C. Irving b a Department of Urology, St James s University Hospital, Leeds, England, UK b Department of Radiology, St James s University Hospital, Leeds, England, UK c Department of Urology, Pinderfields General Hospital, Wakefield, UK Article info Article history: Accepted November 3, 2006 Published online ahead of print on November 13, 2006 Keywords: Subcutaneous urinary diversion Ureteric obstruction Extra-anatomic stent Abstract Objectives: We describe our experience of the Detour extra-anatomic stent (EAS) (Mentor-Porgés, UK) for permanent bypass of complete upper urinary tract obstruction. The self-retaining expanded polytetrafluoroethylene silicone tube, placed in the kidney using a percutaneous route, is tunnelled under the skin and sutured into the bladder to establish extra-anatomical urinary drainage. Methods: From April 2002 to November 2005, a total of nine Detour stents were inserted into eight patients; one patient needed bilateral stent insertions. The causes for ureteric obstruction were persistent malignant disease in three and complicated benign disease in five patients. Results: To date, four of five patients with benign disease are alive; one died unexpectedly of metastatic malignancy. The only stent-related complications were infection and haematuria. The two patients with malignancy have subsequently died, but there were no urinary drainage problems for their second and third years of life, respectively. Conclusions: The preliminary data presented here suggest that the Detour EAS offers a permanent and minimally invasive method to establish internalisation of urinary drainage to bypass complete ureteric obstructions for which conventional stenting has failed, open surgery has been tried and failed or was not considered feasible, and long-term nephrostomy drainage was not favoured. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. 1. Introduction Percutaneous nephrostomy has been traditionally used to provide temporary or long-term urinary * Corresponding author. Department of Urology, St James s University Hospital, Beckett Street, Leeds LS9 7TF, England, UK. Tel address: slloyd140@btinternet.com (S.N. Lloyd). drainage for patients with impassable ureteric strictures. This procedure has major disadvantages for long-term use because there is the need for regular changes, the catheters often get dislodged /$ see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 194 european urology 52 (2007) and/or blocked, and the external drainage with catheter and bag often contributes to an impaired quality of life for the patients [1]. Subcutaneous urinary diversion using extraanatomic stents (EASs) reestablishes the connection between the renal pelvis and urinary bladder, and has broadened the choices available for patients requiring long-term urinary diversion [2,3]. The indications for EAS insertion is an impassable ureteric stricture (benign and malignant) or complete disruption of the ureter. There are essentially two types of EAS that are available: temporary and permanent. The temporary extra-anatomic stent is an 8F, 65-cm long, double-pigtail urinary stent without any side holes along the shaft (Paterson-Forrester stent; Cook Ireland Ltd, Limerick, Ireland). This stent requires changing at 6- to 12-mo intervals. Problems include encrustation and luminal blockage [4] The Detour stent (Mentor-Porgés, a subsidiary of Coloplast, Lancing, West Sussex, UK) offers a permanent solution for long-term urinary diversion in patients with benign or malignant disease in whom reconstruction is not considered or not possible [5 8]. We present our experience with this stent. 2. Methods Between April 2002 and December 2005, a total of eight patients (six male, two female) with complete complicated urinary obstruction underwent extra-anatomic stent insertion using the Detour stent (seven unilateral and one bilateral stent insertions. The mean age of the patients was 53 yr, (range: 20 69). The mean follow-up was 17 mo (range: 5 36). Three patients had previously been managed with temporary EAS, four had percutaneous nephrostomies in place, and one had a primary procedure Construction of the Detour system The Detour stent is a self-retaining coaxial (polytetrafluoroethylene [PTFE] silicone) tube. Its construction consists of a porous, 27F PTFE outer tube, which is reinforced by plastic rings to prevent kinking, and an inner 17F silicone tube, which extends beyond the PTFE at either end, with perforations in the protruding segments. There is a radio-opaque ring that marks the junction between the inner silicone and outer PTFE layer proximally to aid accurate deployment of the proximal end of the stent. The kit also includes a 30F renal amplatz (Cook Ireland Ltd) sheath and a large-bore plastic subcutaneous tunneling device Insertion technique The procedure is performed under general anaesthesia. The patient is positioned in a supine position with the side for EAS elevated from the table using a 3-l fluid bag. The nephrostomy Fig. 1 (a) A new lateral percutaneous track is created for the proximal insertion of the Detour stent because the patient s existing track is too posteriorly located. (b) The proximal end of the stent is inserted through the 30F amplatz sheath. track is laterally placed to avoid tube kinking. A new track is required if the existing track is too posteriorly located (Fig. 1a). The puncture is ideally made with the aid of ultrasound guidance to avoid colonic injury; then the track is serially dilated with either metal dilators or a balloon dilator so that a 30F amplatz sheath can be introduced under fluoroscopic guidance. The Detour stent is then introduced through the amplatz sheath (Fig. 1b). Contrast agent is injected retrogradely through the stent with the use of a bladder syringe to ensure accurate stent positioning and deployment. A radioopaque ring marker on the proximal end marks the aspect of the stent to be positioned at the junction of the calyx and renal parenchyma (Fig. 2). Stent retention is ensured by tissue fixation around the PTFE outer covering. A subcutaneous tunnel is created from the loin to the subrapubic region with the use of the large-bore, plastic hollow tube (Fig. 3). The distal end of the stent is fed into the lumen of the hollow tunelling tube, and the large-bore tunelling tube is then gently pulled out of the subcutaneous tissue, bringing out the distal end of the stent to the suprapubic region. The bladder is accessed through a

3 european urology 52 (2007) Fig. 4 The bladder is accessed through a Pfannensteil rectus splitting incision, and a small open cystotomy is performed following retrograde bladder distension. The inner silicone tube, with a few small perforations, is inserted into the bladder, and the outer polytetrafluoroethylene tube is secured onto the blader wall with 4-0 Vicryl sutures. Fig. 2 The radio-opaque ring marker is sited at the junction of the calyx with renal parenchyma. Pfannensteil incision, and a 1-cm open cystotomy is performed, aided by retrograde bladder distension via a threeway catheter. The catheter enables the operator to control bladder distension at exactly the right time in the procedure and can be used to check for a watertight seal around the lower end of the stent and to permit gentle irrigation in case of haematuria postoperatively. The irrigation port is sealed after the early postoperative period. The stent length needs to be tailor-made for the individual patient by cutting the distal end of the stent to the required length, peeling off the outer PTFE to expose the inner silicone tube for 2 cm, and then making a few small perforations in the exposed area. The perforated area is then inserted into the bladder, and the outer PTFE is secured with 4-0 Vicryl sutures to the bladder serosa (Fig. 4). Finally, the wound is closed with absorbable sutures (Fig. 5). An indwelling catheter is left in situ for 1 wk, and a cystogram is performed to check the integrity of the suture line before catheter removal (Fig. 6). 3. Results 3.1. Maligant case study A 42-year-old male had developed right-sided ureteric obstruction following local resection of metastatic retroperitoneal sarcoma. He had been successfully managed with a temporary EAS and had undergone one stent change at 6 mo. He suffered with chronic prostatitis and severe lower urinary tract symptoms. A Detour stent was inserted at the time of the scheduled stent change. He survived for a further 2 yr completely trouble-free with the Detour stent Benign ureteric injury case study Fig. 3 The large-bore plastic hollow tube is used to create a subcutaneous tunnel from the loin to the subrapubic region. A 58-year-old female had left renal obstruction as a result of iatrogenic ureteric damage following an aortic aneurysm repair. Her respiratory function was severely compromised. She was initially managed with a temporary EAS and had undergone one stent change 6 mo later. A Detour stent was inserted at the scheduled stent change. She remains well and symptom-free 3 yr later.

4 196 european urology 52 (2007) Fig. 5 All incisions are sutured at the end of the procedure in a patient following insertion of the stent, which has rendered the patient tubeless and bagless Other cases Three patients (cases 1, 2, and 5) have subsequently died as a result of malignancy, but none of these patients had complications attributable to the stent (Table 1). Case 5 had a missed diagnosis of transitional cell carcinoma of the upper ureter. He presented with hydronephrosis suspected to be due to aortic aneurysm. Retrograde ureteroscopy was attempted but failed. At open aortic surgery the ureter was traumatised and explored, but again a Fig. 6 This cystogram confirms the patency of the stent with free reflux of contrast from the bladder into the collecting system with no leaks. lesion was not indentified. He presented 9 mo later with haematuria and metastic disease from highgrade transitional cell cancer of urothelial origin as well as locally advanced prostatic cancer. A postmortem was not requested because histologic proof was available. Table 1 Summary of all cases treated with the Detour extra-anatomic stent Case Age (yr) Sex Etiology Side Follow-up (mo) Outcome 1 62 F Metastatic breast cancer Bilateral 36 Died from disease 2 42 M Retroperitoneal sarcoma Right 24 Died from disease 3 58 F Ureteric injury after aortic aneurysm, Left 42 Alive severe pulmonary disease 4 50 M Ureteric injury during partial nephrectomy, Left 18 Alive failed exploration 5 58 M Ureteric injury after aortic aneurysm Left 12 Died, prostatic and urotheleial cancer 6 67 M Retroperitoneal fibrosis and previous Right 14 Alive thermoexpandable metal ureteric stent 7 20 M Single kidney, PUJ failed open and Right 12 Alive endoscopic surgery; refused ileal interposition 8 69 M Carcinoid tumour of the colon, unilateral ureteric obstruction due to fibrosis Right 12 Alive

5 european urology 52 (2007) Discussion Complete ureteric obstruction caused by malignant or benign disease poses a challenging clinical management dilemma. Traditionally, percutaneous nephrostomy is used to provide urinary drainage when internal ureteric stenting has failed. However, long-term urinary drainage with percutaneous nephrostomy offers a reduced quality of life and leaves the patient needing regular catheter changes along with the stent-related problems of encrustation, infection, blockage, and dislodgement. In a selected group of patients, reconstructive surgery may be applicable, but this may be inappropriate for patients with extensive pelvic disease and either not possible or too dangerous in others. The sobering outcome of case 5 reminds us that a detailed search should be made for a cause of new onset hydronephrosis in case occult malignancy exists masquerading as a benign obstruction. The introduction of the subcutaneous EAS has offered patients the opportunity to be free of external drainage devices with an improved quality of life. Extra-anatomic urinary diversion with an 8F double-pigtail stent (Paterson-Forrester stent, Cook Ireland Ltd) offers an acceptable solution for many of these patients, especially those with extensive malignant disease and limited life expectancy [2 4]. The 8F stent has the disadvantage that it requires regular changing involving a general anaesthetic, although we have successfully changed one under local anaesthesia. Pelvic dissection is not required in this type of stent placement. The Detour EAS is a safe and effective permanent solution for complete ureteric obstruction in both benign and malignant disease. We do not advocate this approach with extensive pelvic tumour because the short-term Cook EAS is our preferred option because of the poor outlook. If there is bladder invasion, neither option is considered, and long-term nephrostomy drainage is continued. Open bladder surgery may lead to local tumour extension and fistula formation. If a patient survives the short-term stent, we consider placement of the Detour EAS. We have not encountered any major complications in our series such as stent obstruction or encrustation. Complications of the stent with encrustation has been reported by Jurczok et al [7]; they have managed to clear the stent successfully using a flexible ureteroscope. This group has also reported use of this stent as a nephrocutaneous diversion. To date there is no reports of complete stent obstruction with this stent. In our series, all the patients have reported an improved quality of life compared with previous external drainage systems or the experience of failed surgical repair. Case 2 had significant improvement in quality of life with this stent compared with the shorter-term Cook EAS, which led to recurrent prostatitis. The short-term Cook stent is not sutured into the bladder; thus, excess stent is required to ensure safe positioning. The distal end of the stent is coiled in the bladder just above the prostate and predisposes to urinary infection. At present no long-term outcome data of more than 3 yr is available for the primary patency of the Detour stent. It is therefore important to select patients carefully. Patients with advanced malignant disease with limited life expectancy are clearly the ideal group, but in our practice patients with benign disease with good life expectancy have presented. In these patients either open repair had been tried, except in the youngest patient (case 7) who had refused ileal interposition and in whom a long-term ureteric stent could no longer be passed. This patient has been reviewed 1 yr after surgery; he remains symptom-free and has started university study. Flexible cystoscopy and cystogram have shown the stent to be free from encrustation and in perfect position. We hope that this option will give the patient at least 10 yr benefit, by which time tissue engineering may offer him an alternative solution other than ileal interposition. The unique construction of the Detour stent offers certain advantages. The tube is designed to be self-retaining; the inner silicone coating minimises direct contact between the outer expanded PTFE tube and urine, thus minimising encrustation; and the large bore of the tube also allows for the passage of a flexible ureteroscope to deal with potential encrustation. However, these advantages are offset by the need for an invasive procedure to insert the device; in contrast, the short-term stent is placed mainly as a radiologic procedure. This technique has been reported in patients with ureteric obstruction following renal transplantation [8]. It could be considered if reconstruction has failed or thought to be too hazardous. The Detour stent costs approximately 2200 Euro and usually involves a 3-d hospital stay. Mentor- Porgés has identified a limited number of national centres for referral. The experience to date in the United Kingdom numbers less than 20 procedures including this series. Longer-term data exist on the continent, with nine experienced operators in France dating back to The authors feel that in selected cases the Detour extra-anatomic stent offers a permanent solution for benign and malignant

6 198 european urology 52 (2007) ureteric obstruction. The technique does involve manoeuvres best observed before attempted; thus designated sites in the United Kingdom have been set up to offer this service. Conflicts of interest There is no conflict of interest declared here, nor is there now or has there ever been any funding stream. Acknowledgements The authors made the following contributions to this study: guarantor of integrity of entire study: S.N. Lloyd, T.M. Wah, H.C. Irving; literature search: S.N. Lloyd, P. Tirukonda, T.M. Wah, H.C. Irving; data acquisition and analysis: S.N. Lloyd, P. Tirukonda, T.M. Wah, H.C. Irving; manuscript preparation and editing: S.N. Lloyd, P. Tirukonda, T.M. Wah, H.C. Irving, C.S. Biyani; and manuscript review: S.N. Lloyd, T.M. Wah, H.C. Irving. Clinical studies, and study concepts and designs are based on those for a case series, descriptive study. References [1] Hepperlen TW, Mardis HK, Kammandel H. The pigtail ureteral stent in the cancer patient. J Urol 1979;148:17 8. [2] Ahmadzadeh M. Clinical experience with subcutaneous urinary diversion: new approach using a double pigtail stent. Br J Urol 1991;67: [3] Lingam K, Peterson PJ, Lingam MK, et al. Subcutaneous urinary diversion: an alternative to percutaneous nephrostomy. J Urol 1994;152:70 2. [4] Minhas S, Irving HC, Lloyd SN, et al. Extra-anatomic stents in ureteric obstruction: experience and complications. BJU Int 1999;84: [5] Degrachamps F, Cussenot O, Meria P, et al. Subcutaneous urinary diversions for palliative treatment of pelvic malignancies. J Urol 1995;154: [6] Jabbour ME, Degrachamps F, Angelescu E, et al. Percutaneous implantation of subcutaneous prosthetic ureter: long term outcome. J Endourol 2001;15: [7] Jurczok A, Loertzer H, Wagner S, et al. Subcutaneous nephrovescical and nephrocutaneous bypass: palliative approach to ureteral obstruction caused by pelvic malignancy. Gynae Obstet Invest 2005;59: [8] Degrachamps F, Paulhac P, Fornairon S, et al. Artificial ureteral replacement for ureteral necrosis after renal transplantation. J Urol 1998;159: