Sp615 EUS-Guided Anterograde Ureteral Internal Drainage

Abstract

Retrograde ureteral stent placement by cystoscopy is the standard in patients with malignant ureteral obstruction due to advanced bladder cancer. When this attempt fails, the most common procedure used is percutaneous nephrostomy. EUS-Guided Anterograde Ureteral Internal Drainage is an alternative and it has been described before. We report a case of a 62-year old man that presented with flank pain and hematuria. After clinical and imaging evaluation, he was diagnosed with locally advanced bladder cancer. At the time of diagnosis, he presented bilateral hydronephrosis and renal failure. He was submitted to a retrograde approach by cystoscopy that succeeded in stent placement at right side ureteral obstruction, but failed at left side ureteral stent placement. In this presentation, we will demonstrate a EUS-Guided Anterograde Ureteral Internal Drainage in a patient with failure at retrograde approach by cystoscopy. By a single-step procedure, the EUS linear equipment was positioned at gastric greater curvature and it was possible to observe the dilated proximal ureter. Doppler analysis was obtained to confirm the fact that it had not any vessels nearby the working area. After that, it was performed a proximal ureteral puncture using a 19-Gauge needle. Contrast media was injected in proximal ureter and an urethrography was obtained. A 0.035-inch guidewire was passed in the left ureter. By progression of the guidewire, its distal part passed through the obstructed area and was positioned inside the bladder. Over the guidewire and under radioscopic view, an 8.5 Fr double-pigtail hydrophilic-coated stent was placed. The stent was positioned with the proximal part inside the ureter and the distal part inside the bladder. EUS-Guided Anterograde Ureteral Internal Drainage was a feasible technique and the patient presented with improvement in renal function. EUS-Guided Anterograde Ureteral Internal Drainage is an alternative to the Percutaneous Nephrostomy, which can be considered for palliation of ureteral obstruction patients with advanced bladder cancer. Larger multicenter studies are needed to further assess this novel technique.