Abstract
BackgroundMalignant ureteric obstruction (MUO) due to pelvic malignancies is challenging for endourological management and carries high failure rates for retrograde cystoscopic ureteric stenting.MethodsWe adopted Galdakao-modified Valdivia (GMV) position in the management of MUO in an operating room equipped with a C-arm fluoroscopy unit and an ultrasound device. We prospectively studied the added value of this approach in 50 cases who failed retrograde ureteric stenting.ResultsThirty-seven (74%) cases were done under a high level of spinal anesthesia. Mean operative time was 62 min. Antegrade ureteric stenting succeeded in 45/50 (90%) patients who failed retrograde ureteric stenting. GMV position facilitated simultaneous retrograde and antegrade management of MUO. Eight patients (16%) underwent auxiliary cystoscopic procedures to reduce the mass over the ureteric orifice (UO) guided by antegrade methylene blue or over a probing antegrade guidewire. Nephrostomy tube was inserted in the same setting in 16/50 (32%) cases. Antegrade flow of contrast to the bladder (P < 0.001) and ureteric kinks rather than tight stenosis or infiltration of UO (P = 0.014) were significantly associated with the success of antegrade ureteric stenting. No major complications were encountered.ConclusionGMV position is an ideal choice for management of MUO as it allows simultaneous access to the lower and the upper urinary systems to accomplish ureteric stenting either in a retrograde or an antegrade fashion as well as the ability to insert a nephrostomy tube in the same setting, thus shortening the inpatient care and this should be the standard of care in cases with MUO.
Highlights
Hydronephrosis results from urinary tract obstruction that can be intrinsic or extrinsic and can result from both benign and malignant etiologies
After obtaining approval from the ethical committee at Ain shams University (No 344/2016), 50 patients with Malignant ureteric obstruction (MUO) whether urological or non-urological causes who failed retrograde ureteric stenting were included in this prospective study from 2016 until 2020, at the Department of Urology, Ain Shams University, Cairo, Egypt
Patients were positioned in Galdakao-modified Valdivia (GMV) position (Fig. 1) in an operating room equipped with a mobile C-arm fluoroscopy unit and a beside ultrasound device (3.5 MHz transducer) and received preoperative antibiotic prophylaxis
Summary
Hydronephrosis results from urinary tract obstruction that can be intrinsic or extrinsic and can result from both benign and malignant etiologies. It may fail in up to 50% in patients with distal and extra-ureteral obstruction caused by malignancies [4] In such cases, the only option left is the insertion of a PCN with or without an attempt of antegrade ureteric stenting [1]. Malignant ureteric obstruction (MUO) due to pelvic malignancies is challenging for endourological management and carries high failure rates for retrograde cystoscopic ureteric stenting. Conclusion GMV position is an ideal choice for management of MUO as it allows simultaneous access to the lower and the upper urinary systems to accomplish ureteric stenting either in a retrograde or an antegrade fashion as well as the ability to insert a nephrostomy tube in the same setting, shortening the inpatient care and this should be the standard of care in cases with MUO
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