Innovative Solution to Address Recurrent Anastomotic Strictures of Uretero-Intestinal Junctions After Radical Cystectomy Using DETOUR Prostheses.

Andrzej Jerzy Wrona, Dominik Chodor, lek Jarosław Zga­jew­s­ki, lek Michał Piotrows­ki

Żródło: „Przegląd Uro­log­iczny”, 2019, nr 118.

Cur­rent­ly, the gold stan­dard treat­ment for patients with mus­cle-inva­sive blad­der can­cer is rad­i­cal cys­tec­to­my. Patients under­go­ing rad­i­cal cys­tec­to­my require simul­ta­ne­ous recon­struc­tion of the uri­nary tract. Among the meth­ods of uri­nary diver­sion, we can men­tion uretero-cuta­neous con­duits, ortho­topic neoblad­der, inter­nal con­ti­nent intesti­nal reser­voirs, and non-con­ti­nent diver­sions, among which the ileal con­duit pre­dom­i­nates.

One of the most com­mon­ly per­formed meth­ods of uri­nary diver­sion is the ileal con­duit. There are two main types of uretero-ileal anas­to­moses: the Brick­er tech­nique and the Wal­lace tech­nique. The Brick­er tech­nique involves spat­u­lat­ing the ureters and indi­vid­u­al­ly sutur­ing each ureter to the side of the ileal con­duit. In the Wal­lace tech­nique, there are two types. In Type I, the ureters are incised, placed par­al­lel to each oth­er, and sutured along their inner edges. These joined ureters are then sutured to the prox­i­mal end of the ileal con­duit. In Type II, the incised ureters are sutured so that the dis­tal end of one ureter is sutured to the apex of the inci­sion of the sec­ond ureter, and then, as in Type I, joined to the prox­i­mal end of the ileal con­duit.

One of the com­pli­ca­tions of uri­nary diver­sion through an ileal con­duit is the nar­row­ing of the uretero-ileal anas­to­mo­sis. This nar­row­ing is usu­al­ly asymp­to­matic and can lead to hydronephro­sis, dete­ri­o­ra­tion of kid­ney func­tion, uri­nary tract infec­tions, and ulti­mate­ly kid­ney loss. Var­i­ous treat­ment meth­ods for uretero-ileal anas­to­mot­ic stric­tures are described. The most com­mon­ly per­formed pro­ce­dure is open surgery to excise the stric­ture and per­form a re-anas­to­mo­sis of the ureters to the ileal con­duit

The pro­ce­dure can also be per­formed laparo­scop­i­cal­ly or with robot assis­tance. Alter­na­tive treat­ments include endo­scop­ic tech­niques such as bal­loon dila­tion of the stric­ture, endo­scop­ic inci­sion of the stric­ture, or place­ment of a DJ stent. In cas­es where no treat­ment is fea­si­ble, patients may require per­ma­nent per­cu­ta­neous nephros­to­my to pre­serve kid­ney func­tion. The aim of this arti­cle is to present a new method for treat­ing uretero-ileal anas­to­mot­ic stric­tures using the Detour device (pyelovesi­cal bypass)

Fig­ure 1: The struc­ture of the Detour pros­the­sis (Used with per­mis­sion from Colo­plast, Inc.)

The pro­ce­dure is per­formed under gen­er­al anes­the­sia. The patient is posi­tioned on their side with the pelvis slight­ly rotat­ed to facil­i­tate easy access to both the lum­bar area and the urosto­my. Then, the table is par­tial­ly fold­ed to ele­vate the patien­t’s side. The punc­ture into the kid­ney is per­formed under ultra­sound and X‑ray guid­ance slight­ly to the side to avoid kink­ing of the Detour pros­the­sis where it exits the kid­ney and directs towards the urosto­my (Fig. 2).

 

Fig­ure 2: The nee­dle is intro­duced into the left kid­ney col­lect­ing sys­tem. Frontal view of the patient. The patient is lying on their right side, with the head turned towards the left side, the umbili­cus vis­i­ble at the bot­tom of the image (urosto­my not vis­i­ble).

 

The Detour pros­the­sis is intro­duced into the kid­ney through the Amplatz sheath under flu­o­ro­scop­ic guid­ance (Fig. 3).

 

Fig­ure 3: Access to the left kid­ney’s UPJ is cre­at­ed — the Amplatz sheath 30F is vis­i­ble, with the safe­ty wire to its right.

The radiopaque mark­er at the prox­i­mal end of the pros­the­sis helps sta­bi­lize its posi­tion so that the PTFE sheath is enveloped by the kid­ney parenchy­ma and does not intrude into the UPJ, pre­vent­ing encrus­ta­tions, while the kid­ney parenchy­ma sta­bi­lizes the pros­the­sis.

 

Fig­ure 4: Intra­op­er­a­tive X‑ray images dur­ing the pros­the­sis implan­ta­tion pro­ce­dure — on the left, the Detour pros­the­sis is vis­i­ble above the nephros­to­my drain. The radiopaque ring (arrow) mark­ing the posi­tion of the bound­ary point between the inter­nal and exter­nal parts of the renal end of the pros­the­sis is vis­i­ble. On the right, the moment of con­trast admin­is­tra­tion through the pros­the­sis — the con­trast­ed lumen of the pros­the­sis (17F) is vis­i­ble, marked by an arrow.

 

Once the pros­the­sis is cor­rect­ly posi­tioned, we remove the Amplatz sheath. The Detour pros­the­sis is then passed sub­cu­ta­neous­ly. To cre­ate a tun­nel for the pros­the­sis from the lum­bar region to the para-osto­my area, we use a plas­tic tube of appro­pri­ate width (see fig­ure 5).

 

Fig­ure 5: Detour pros­the­sis (27F) insert­ed into the right kid­ney. Cre­ation of a sub­cu­ta­neous chan­nel for the Detour pros­the­sis – a blue plas­tic tube is vis­i­ble pass­ing through the inci­sion pre­vi­ous­ly made in the left lum­bar region, sub­cu­ta­neous tis­sue, and exit­ing through an inci­sion a few cen­time­ters below and to the right of the umbili­cus.

 

In the case of insert­ing the pros­the­sis into the left kid­ney, due to the con­sid­er­able dis­tance between the left lum­bar region and the urosto­my locat­ed on the right side, as well as the sig­nif­i­cant cur­va­ture of the sub­cu­ta­neous tract, the inser­tion of the pros­the­sis under the skin is per­formed in two stages. First, the pros­the­sis is guid­ed to the ante­ri­or sur­face of the abdom­i­nal cav­i­ty, where a skin inci­sion is made and the pros­the­sis is brought out through this inci­sion (Fig. 6, Fig. 7).

 

Fig­ure 6::The Detour pros­the­sis (27F) passed through the sub­cu­ta­neous tis­sue.

 

Fig­ure 7: The image was tak­en from a dif­fer­ent angle from the front of the patient. The patien­t’s head is posi­tioned on the left side. At the top of the image, a dress­ing is vis­i­ble applied to the wound in the left lum­bar region. The Detour pros­the­sis can be seen emerg­ing from the inci­sion locat­ed below the navel. At the bot­tom, the urosto­my is vis­i­ble.

A sub­cu­ta­neous chan­nel is then cre­at­ed from the indi­rect inci­sion reach­ing the lat­er­al wall of the urosto­my in its suprafas­cial part (Fig.8).

 

Fig­ure 8: Cre­at­ing a sub­cu­ta­neous chan­nel for the Detour pros­the­sis blind­ly using a fin­ger. Next to the fin­ger, the pros­the­sis insert­ed into the left kid­ney, which is yet to be implant­ed into the urosto­my, is vis­i­ble. The dis­tal end of the Detour pros­the­sis, pre­vi­ous­ly insert­ed into the right kid­ney dur­ing anoth­er pro­ce­dure, is pro­trud­ing from the urosto­my..

 

Next, the wall of the intes­tine is incised from the inside, and a plas­tic tube is passed through the inci­sion, through which the Detour pros­the­sis will be con­duct­ed (Fig. 9).

 

Fig­ure 9: Moment of incis­ing the mucosa of the intesti­nal stoma.

 

Fig­ure 10:The moment of intro­duc­ing the plas­tic tube into the intesti­nal stoma.

 

The dis­tal part of the pros­the­sis is trimmed to the appro­pri­ate length, and the exter­nal PTFE coat­ing is sutured to the intesti­nal mucosa.

 

Fig­ure 11: Left Detour pros­the­sis (27F) intro­duced into the intesti­nal stoma requires fur­ther short­en­ing and stitch­ing to the wall of the stoma. Beside it, the dis­tal end of the right pros­the­sis is vis­i­ble.

After the pro­ce­dure, a Foley catheter is insert­ed into the intesti­nal stoma.

Case description.

The 72-year-old patient under­went rad­i­cal cysto­prosta­te­c­to­my with uri­nary diver­sion through an intesti­nal con­duit in April 2016. Fol­low­ing the pro­ce­dure, he was hos­pi­tal­ized twice due to severe sep­sis, once in May and once in June 2016. In July 2016, ultra­sonog­ra­phy revealed dilata­tion of the right-sided renal pelvis and calyces up to the third degree. In Sep­tem­ber 2016, the patient under­went per­cu­ta­neous nephros­to­my of the right kid­ney.

Descend­ing pyel­og­ra­phy was per­formed, reveal­ing no con­trast pen­e­tra­tion into the intesti­nal con­duit. In Octo­ber 2016, an endoscopy of the intesti­nal con­duit was per­formed in an attempt to relieve the stric­ture of the right-sided ureteroin­testi­nal anas­to­mo­sis. Due to the lack of improve­ment fol­low­ing the pro­ce­dure, the patient remained with a right-sided nephros­to­my. Sub­se­quent­ly, the patient was observed to have ane­mia, exac­er­bat­ed car­bo­hy­drate metab­o­lism dis­or­ders, and bio­chem­i­cal signs of renal insuf­fi­cien­cy.

In Novem­ber 2017, ultra­sound revealed dila­tion of the left renal pelvis. In March 2018, the patient was hos­pi­tal­ized due to a uri­nary tract infec­tion accom­pa­nied by fever. Sub­se­quent­ly, in April 2018, a left-sided per­cu­ta­neous nephros­to­my was per­formed. The patient was admit­ted to our depart­ment in Octo­ber 2018. He was sched­uled for implan­ta­tion of a Detour pros­the­sis into the right intesti­nal con­duit. The pre­op­er­a­tive cre­a­ti­nine lev­el was 151umol/L, with an eGFR of 43ml/min/1.73m^2. On Octo­ber 10, 2018, under gen­er­al anes­the­sia, the pro­ce­dure of implant­i­ng the Detour pros­the­sis into the right kid­ney and intesti­nal con­duit was per­formed. The dura­tion of the surgery was 60 min­utes. There were no intra­op­er­a­tive or ear­ly post­op­er­a­tive com­pli­ca­tions. Renal func­tion para­me­ters after the pro­ce­dure remained sim­i­lar to those before the surgery. Descend­ing pyel­og­ra­phy was per­formed, demon­strat­ing nor­mal con­trast flow through the pros­the­sis.

 

Fig­ure 12: Right-sided descend­ing pyel­og­ra­phy through the estab­lished nephros­to­my — vis­i­ble con­trast enhance­ment of the right renal pelvis and the Detour pros­the­sis.

W 7. dobie od zabiegu oper­a­cyjnego usunię­to nefros­tomię z ner­ki prawej. W 9. dobie poop­er­a­cyjnej chory został wyp­isany do domu. W sty­czniu 2019 roku chory był hos­pi­tal­i­zowany w innym ośrod­ku z powodu infekcji układu moc­zowego z towarzyszącą gorączką spowodowaną zag­ię­ciem się końców­ki pro­tezy Detour zna­j­du­jącej się we wstaw­ce jeli­towej i jej zatkaniem przez czop ślu­zowy. Po udrożnie­niu pro­tezy uzyskano praw­idłowy pasaż moczu z ner­ki prawej. 

In April 2019, the patient was again sched­uled for admis­sion to the Urol­o­gy Depart­ment of this hos­pi­tal. Dur­ing the pre­op­er­a­tive peri­od, the patient was treat­ed with antibi­otics due to uri­nary tract infec­tion (Ente­ro­coc­cus fae­calis). On April 2019, under gen­er­al anes­the­sia, the pro­ce­dure of implant­i­ng the Detour pros­the­sis into the left kid­ney and the intesti­nal stoma was per­formed. The dura­tion of the pro­ce­dure was 60 min­utes. There were no intra­op­er­a­tive or ear­ly post­op­er­a­tive com­pli­ca­tions. Due to lim­it­ed space with­in the intesti­nal stoma and the risk of pros­the­sis bend­ing and obstruc­tion by intesti­nal mucus, the tip of both Detour pros­the­ses was posi­tioned to slight­ly pro­trude through the urosto­my to the out­side (Fig­ure 13, Fig­ure 14).

 

Fig­ure 13: The Detour pros­the­ses pro­trud­ed out­side the stoma for bet­ter urine pas­sage. The image was tak­en before attach­ing the urosto­my bag plate.

 

Fig­ure 14: The Detour pros­the­ses pro­trud­ed out­side the stoma for bet­ter urine pas­sage. The view after attach­ing the plate.

 

After the pro­ce­dure, a descend­ing pyel­og­ra­phy was per­formed, reveal­ing the prop­er flow of con­trast through the pros­the­sis (Fig. 15).

 

Fig­ure 15: Descend­ing pyel­og­ra­phy on the left side through the placed nephros­to­my — vis­i­ble con­trast enhance­ment of the left kid­ney’s col­lect­ing sys­tem and the Detour pros­the­sis. In the pro­jec­tion of the right kid­ney, the radiopaque ring of the right Detour pros­the­sis is vis­i­ble.

 

On the 5th day after the surgery, the nephros­to­my from the left kid­ney was removed. On the 7th day post-surgery, the patient was dis­charged home. No com­pli­ca­tions were observed post­op­er­a­tive­ly. Cur­rent­ly, the patient feels well, and the pros­the­ses drain urine prop­er­ly.

 

Summary

Up to now, the implan­ta­tion of an arti­fi­cial ureter has been per­formed in cas­es of obstruc­tive uropa­thy with obstruc­tion occur­ring at the lev­el of the ureter. The Detour pros­the­sis has been used in patients with both malig­nant and benign caus­es of ureter­al obstruc­tion. There are also reports in the lit­er­a­ture of cas­es where this method was used in patients after kid­ney trans­plan­ta­tion. Con­stric­tion of the uretero-intesti­nal anas­to­mo­sis in patients under­go­ing rad­i­cal cys­tec­to­my with urine diver­sion through an intesti­nal con­duit may be anoth­er indi­ca­tion for the use of the Detour pros­the­sis.

In patients for whom oth­er meth­ods have failed or for whom oth­er treat­ment options are not fea­si­ble, per­cu­ta­neous nephros­to­my remains the method of urine diver­sion. How­ev­er, per­cu­ta­neous nephros­to­my is asso­ci­at­ed with a decreased qual­i­ty of life for patients and is not free from com­pli­ca­tions. The implan­ta­tion of the Detour pros­the­sis can be suc­cess­ful­ly used in these patients. The pro­ce­dure itself is not com­pli­cat­ed, and an addi­tion­al advan­tage is the min­i­mal­ly inva­sive nature of the surgery. Implan­ta­tion of an arti­fi­cial ureter car­ries the risk of both ear­ly and late com­pli­ca­tions, so patients require care­ful obser­va­tion in the post­op­er­a­tive peri­od and dur­ing sub­se­quent fol­low-up.

Ear­ly-diag­nosed com­pli­ca­tions can be ade­quate­ly man­aged [14, 21, 22]. Due to the exper­i­men­tal nature of this pro­ce­dure, more research and a longer obser­va­tion peri­od are need­ed to ful­ly assess its long-term effec­tive­ness. Nev­er­the­less, the implan­ta­tion of an arti­fi­cial ureter in the patient described in this arti­cle sig­nif­i­cant­ly improved his qual­i­ty of life and allowed for nor­mal func­tion­ing while main­tain­ing sat­is­fac­to­ry kid­ney func­tion. We hope that the use of kid­ney drainage with the Detour pros­the­sis will become an increas­ing­ly pre­ferred treat­ment method for patients with ureteroen­teric anas­to­mot­ic stric­tures fol­low­ing rad­i­cal cys­tec­to­my.

dr n med. Andrzej Jerzy Wrona

Szpi­tal Spec­jal­isty­czny im. Edmun­da Bier­nack­iego w Miel­cu

kierown­ik Odd­zi­ału Urologii: dr n. med. Andrzej Jerzy Wrona

lekarz Dominik Chodor

Szpi­tal Spec­jal­isty­czny im. Edmun­da Bier­nack­iego w Miel­cu

kierown­ik Odd­zi­ału Urologii: dr n. med. Andrzej Jerzy Wrona

lekarz Jarosław Zga­jew­s­ki

Szpi­tal Spec­jal­isty­czny im. Edmun­da Bier­nack­iego w Miel­cu

kierown­ik Odd­zi­ału Urologii: dr n. med. Andrzej Jerzy Wrona

lekarz Michał Piotrows­ki

Wojew­ódz­ki Spec­jal­isty­czny Szpi­tal im. M. Pirogowa w Łodzi. Pra­cow­n­ia RTG i TK.

 kierown­ik pra­cowni: dr n. med. Janusz Ścibór

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