Detour – An Alternative to Chronic Nephrostomy

lek. Michał Piotrows­ki

Skamex Sp. z o.o.

What is Detour?

Detour is an arti­fi­cial ureter used when no oth­er solu­tion is pos­si­ble, and the patient must have a nephros­to­my, which means liv­ing with a “hole in the back” where a catheter is placed. This catheter can become a gate­way for infec­tion, poten­tial­ly lead­ing to kid­ney loss. Liv­ing with a nephros­to­my – a catheter in the back – impos­es many lim­i­ta­tions on dai­ly life. Patients are unable to engage in pre­vi­ous activ­i­ties such as swim­ming, run­ning, or dri­ving a car. Even dai­ly tasks like bathing and sleep­ing become sig­nif­i­cant­ly more chal­leng­ing.

A nephros­to­my can also lim­it career devel­op­ment oppor­tu­ni­ties, as patients may strug­gle with per­form­ing cer­tain tasks. Addi­tion­al­ly, the patient must vis­it a doc­tor approx­i­mate­ly every three months to have the nephros­to­my replaced.

If you or some­one you know has a nephros­to­my, there is a solu­tion that allows for a return to an active life. After the implan­ta­tion of the Detour arti­fi­cial ureter, the patient can once again go swim­ming, sleep nor­mal­ly on their back, dri­ve a car, and work. The nephros­to­my, mean­ing the catheter pro­trud­ing from the back, is no longer nec­es­sary – the Detour arti­fi­cial ureter is hid­den under the skin.

Detour Artificial Ureter

Sztuczny moczowód Detour, Detour – czyli alternatywa dla przewlekłej nefrostomii, nefrostomia

Detour Kit

The solu­tion is Detour – an arti­fi­cial ureter. The Detour Kit includes an arti­fi­cial ureter, a tun­nel­er, and an Amplatz sheath. The arti­fi­cial ureter is a sil­i­cone tube with a length of 840 mm and an inter­nal lumen of 17Fr/CH (5.8 mm), sur­round­ed by a poly­ester sheath along 660 mm of its length. It has an X‑ray ring at the renal end to facil­i­tate local­iza­tion in the kid­ney dur­ing implan­ta­tion.

Indications for the procedure

Detour, or the arti­fi­cial ureter, is typ­i­cal­ly implant­ed for var­i­ous rea­sons, most com­mon­ly:

  • Obstruc­tion of the ureters in the course of onco­log­i­cal dis­eases (gyne­co­log­i­cal dis­eases, col­orec­tal can­cer, radio­ther­a­py).
  • Obstruc­tion of the ureters in the course of Ormond’s dis­ease.
  • Necro­sis of the ureters in a trans­plant­ed kid­ney.
  • Absence or injury of the ureter.

Preparation for the procedure

The patient should per­form a urine cul­ture from the nephros­to­my about 10 days before the pro­ce­dure (if the patient has a nephros­to­my). Then, at least 3 days before the pro­ce­dure, the patient should start tak­ing a tar­get­ed antibi­ot­ic if the cul­ture is pos­i­tive or a broad-spec­trum antibi­ot­ic if the cul­ture is ster­ile.

Course of the procedure

The pro­ce­dure is usu­al­ly per­formed under gen­er­al anes­the­sia, with the patient posi­tioned to allow access to the kid­ney and uri­nary blad­der. The first part of the pro­ce­dure involves access­ing the renal pelvis and plac­ing the Detour stent at the bor­der of the renal parenchy­ma and calyx, with the renal end posi­tioned so that the X‑ray ring is vis­i­ble at the bor­der of the calyx and parenchy­ma. This place­ment ensures that the calyx con­tains sil­i­cone, while the parenchy­ma con­tains the poly­ester sleeve of the arti­fi­cial ureter. Next, the sur­geons make a supra­pu­bic inci­sion and iso­late the uri­nary blad­der, which is filled by a Foley catheter at this stage to facil­i­tate the local­iza­tion of the blad­der.

The blad­der is secured with two sutures, known as “bri­dles.” Next, a tun­nel is cre­at­ed in the adi­pose tis­sue using a spe­cial tool includ­ed in the arti­fi­cial ureter set. The Detour stent is then passed through this tun­nel, fit­ted, short­ened, and sub­se­quent­ly sewn into the blad­der.

After the procedure

The patient receives antibi­ot­ic ther­a­py for a min­i­mum of 10 days, and the Foley catheter is main­tained dur­ing this peri­od.

Patients should mas­sage the arti­fi­cial ureter at least 3–4 times a week to pre­vent encrus­ta­tion; the man­u­fac­tur­er rec­om­mends doing this once a day. The patient should gen­tly mas­sage along the path of the arti­fi­cial ureter under the skin with their fin­gers. The arti­fi­cial ureter is eas­i­ly pal­pa­ble under the skin.

The average duration of the procedure is approximately 2 hours, and the average hospitalization time is 5 days.

Most common adverse symptoms

  • For a peri­od of 2–3 weeks after the pro­ce­dure, post­op­er­a­tive pain may occur. In the lat­er peri­od, patients typ­i­cal­ly do not feel the arti­fi­cial ureter.
  • The Detour arti­fi­cial ureter is intend­ed to last for a life­time, though in excep­tion­al sit­u­a­tions it may require replace­ment.
  • Leak­age and seep­age from the blad­der side can occur, most com­mon­ly due to the Foley catheter being main­tained for too short a peri­od after the pro­ce­dure.
  • The Detour, like any for­eign body implant­ed into the human body, can become infect­ed. There­fore, all asep­tic and anti­sep­tic prin­ci­ples must be strict­ly fol­lowed before and dur­ing the pro­ce­dure.
  • If the patient has a nephros­to­my and no alter­na­tive is avail­able, they should ask their doc­tor about the arti­fi­cial ureter, also known as the Detour.
  • The first pro­ce­dure was per­formed in May 2013 at the PSK2 Hos­pi­tal in Szczecin on a pal­lia­tive care patient, and the sec­ond in Sep­tem­ber 2013 at the Dis­trict Hos­pi­tal in Mielec.
  • The patient oper­at­ed on in Mielec is still alive today, with a func­tion­ing ureter for the past 4 years.
  • Since 2013, near­ly 40 pro­ce­dures have been per­formed in Poland*.
  • There is already over 14 years of expe­ri­ence world­wide with the Colo­plast Porges arti­fi­cial ureter.

Recommended centers for Detour implantation
Szpital Powiatowy Mielec – Oddział Urologii Ogólnej i Onkologicznej 
https://www.szpital.mielec.pl/jednostki/oddzialy/oddzial-urologii-ogolnej-i-onkologicznej 

Dol­nośląs­ki Szpi­tal Spec­jal­isty­czny im. T. Marcini­a­ka Wrocław – Odd­zi­ał Urologii i Onkologii Uro­log­icznej
http://www.szpital-marciniak.wroclaw.pl/p,169,oddzial-urologii-i-onkologii-urologicznej

PSK2 Szczecin – Klini­ka Urologii i Onkologii Uro­log­icznej 
http://www.uroinfo.pl​Świę­tokrzyskie Cen­trum Onkologii Kielce – Klini­ka Urologii
https://www.onkol.kielce.pl/pl/centrum/klinika-urologii-im-dr-n-med-stefana-olszewskiego

Detour set – pro­ce­dure

The pro­ce­dure is usu­al­ly per­formed under gen­er­al anes­the­sia, and patients must have a func­tion­al blad­der; it can­not be a shrunk­en blad­der. In Europe, the Detour has also been implant­ed in cas­es of intesti­nal blad­ders.

In 2016, a film was made for patients about liv­ing with a nephros­to­my and how their lives changed after the implan­ta­tion of an arti­fi­cial ureter. The film fea­tures real patients from across Europe who share their sto­ries. We man­aged to include 3 patients from Poland in the film. The film will be avail­able in 2017.

In 2017, Dr. Andrzej Wrona, the head of the Depart­ment of Urol­o­gy and Onco­log­i­cal Urol­o­gy at the Dis­trict Hos­pi­tal in Mielec, was invit­ed to a con­fer­ence in Milan. There, he shared his expe­ri­ences with implant­i­ng the arti­fi­cial ureter dur­ing his lec­ture for Ital­ian urol­o­gists.

Dr. Andrzej Wrona has the most exten­sive expe­ri­ence in Poland, hav­ing implant­ed arti­fi­cial ureters in over 25 patients.

*as of July 2017

 

Con­tact us: urologia@skamex.com.p