Editorial Comment

Abstract

How do you balance what is best for the patient, the physician, and the healthcare system? In this article, the authors describe their experience with active balloon dilation of impassable ureters and make a case for why this is better than simply stenting and coming back another day. There has long been concern about actively dilating ureters for fear of increasing the rate and progression of stricture formation. This article supports this practice and offers a good rationale for doing so. In the past years, when ureteroscopes were larger, it was a common practice to actively dilate the intramural ureter before introducing the ureteroscope. As our instruments decreased in size, most endourologists abandoned this practice because it was unnecessary, and we worried about the acute trauma to the ureter. This resurfaced with the introduction of ureteral access sheaths a decade ago, but despite renewed concerns, it has not resulted in an epidemic of new ureteral strictures. Now, when faced with a difficult or impassable ureter, it is all too easy to simply place a stent—which is safe and appropriate care—and allow the ureter to passively dilate over the course of a few weeks. A second procedure is almost always successful because of the transient increase in the ureteral caliber. This approach is safe for the patient, works well for the surgeon, but is costly for the healthcare system (a second surgical procedure) and drags out the time of the patient's treatment episode by weeks or months. The authors' more aggressive approach should be more cost effective for those 8%-10% of patients with a difficult ureter (6.5% in this series). We could quibble over the cost of a balloon dilator and access sheath vs sequential or reusable dilators, but all these are considerably less than the cost to the system of a second surgical procedure. In addition, the patients' needs are met in a timely fashion, achieving the end goal sooner. But is it really safe? In this experience of 20 patients, it seems to have worked out well, but there are cases for which this approach would still be inappropriate. Specifically, long strictured segments or intrinsically narrow ureters would be poor candidates for active dilation. Some ureters are just too small for even today's small instruments. So, although I am convinced that many more ureters can be actively dilated, there remain some patients who will still need a stent and a second procedure, and the less aggressive approach can never be completely condemned. The Difficult Ureter: Stent and Come Back or Balloon Dilate and Proceed With Ureteroscopy? What Does the Evidence Say?UrologyVol. 83Issue 1PreviewRecent technical advancements mean flexible ureteroscopy is emerging as a serious competitor to percutaneous approaches even for larger intrarenal calculi. Retrograde intrarenal surgery procedures are likely to increase for the treatment of not only calculi but also other therapeutic upper tract procedures. Full-Text PDF ReplyUrologyVol. 83Issue 1PreviewWhen coming across a ureter that is difficult to negotiate during ureterorenoscopy, in any of its segments, one should consider several factors, especially stricture length and possible etiology among others. In their review, Richter et al1 concluded that balloon dilatation is appropriate for short, benign ureteric strictures with an intact vascular supply. Indeed, malignant strictures do not respond well to balloon dilatation in the long term, but this modality is used routinely as a first stage for stenting procedures in such cases. Full-Text PDF