Bilateral Stenting Research Articles

Robotic-Assisted Laparoscopic Repair of Iatrogenic Vesico-Vaginal Fistula

<h3>Study Objective</h3> This video highlights the principles of robotic assisted laparoscopic repair of iatrogenic vesico-vaginal fistula <h3>Design</h3> Surgical video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> We present 2 cases of iatrogenic vesico-vaginal fistula repaired robotically. Case 1 is a 49-year-old patient with a vesico-vaginal fistula after an open supracervical hysterectomy with incidental cystotomy and repair. Case 2 is a 61-year-old patient who was referred for management of a supra-trigonal vesico-vaginal fistula as a complication of vaginal hysterectomy. <h3>Interventions</h3> Case 1 started with cystoscopy and placement of ureteral stents. The peritoneum above the vaginal cuff was incised and an anterior colpotomy was created. The bladder was dissected until the fistula was identified and the injured area was 4 cm away from the colpotomy. The fistulous margins where dissected. The bladder mucosa was repaired in 2 layers in a running fashion. The bladder was retrogradely filled, confirming the repair was watertight. The colpotomy was closed in 2 layers. The repair was reinforced with omental interposition. For case 2, a stent was placed through the vaginal fistulous opening. The stent was identified transvesically with cystoscopy. Bilateral ureteral stents were placed. Similar steps from case 1 were carried out. Cystoscopy was performed confirming an adequate repair. Bilateral ureteral stents were removed. A Foley catheter was inserted to remain in place for 3 weeks. <h3>Measurements and Main Results</h3> Both patients were discharged on post-operative day 1. The patient in case 1 had a voiding cystogram showing no evidence of residual or recurrent fistula on post-operative week 3, and urine leakage was resolved. The patient in case 2 is scheduled for follow up on post-operative week 3. <h3>Conclusion</h3> Robotic assisted repair offers optimal surgical exposure and is ideal for supra-trigonal and complex vesico-vaginal fistulas, affording good outcomes for patients.

Surgical Management of Endometriosis of the Bladder and Ureter

<h3>Study Objective</h3> To demonstrate a step-by-step approach for the surgical management of urinary tract endometriosis using conventional laparoscopy for partial cystectomy and robotic-assisted laparoscopy for ureteroneocystostomy. <h3>Design</h3> Surgical video. <h3>Setting</h3> Academic tertiary referral center for endometriosis. <h3>Patients or Participants</h3> The first patient was a 38-year-old G3P3 with a history of hysterectomy presenting with dysuria had an MRI which revealed a T2 hypointense bladder nodule consistent with endometriosis. The second patient was a 25-year-old nulliparous woman with history of stage IV endometriosis with DIE into the bowel and both ureters causing subsequent hydronephrosis requiring bilateral ureteral stents and subsequently bilateral percutaneous nephrostomy tubes. <h3>Interventions</h3> In the first case, a cystoscopy was performed to confirm MRI findings of bladder lesion and to delineate borders and depth of invasion. Conventional laparoscopy was utilized to perform bilateral ureterolysis, bladder mobilization, partial cystectomy for complete excision of the lesion, and two-layered bladder closure. Use of indigo carmine assisted with ureteral orifice identification. In the second case, cystoscopy was performed with injection of ICG to assist with ureteral identification. After ureterolysis, distal ureteric obstruction due to extensive disease was confirmed on laparoscopy and ureteroscopy. Bilateral ureteroneocystostomy with placement of Double-J ureteral stents was performed using a robotic-assisted approach. Each patient had indwelling foley catheter for bladder decompression during recovery. <h3>Measurements and Main Results</h3> Both patients had an uneventful postoperative course. A postoperative retrograde cystogram confirmed adequate repair prior to removal of each foley catheter. Patient two had office stent removal 6 weeks postoperative. <h3>Conclusion</h3> Endometriosis is an increasingly common condition. It is important for gynecological surgeons to have the proper understanding of anatomy, surgical technique, and multidisciplinary care needed with urology for safe and complete excision of bladder and ureter endometriosis.

Is Surgery the Only Fate of the Patient with Leriche Syndrome? Our Endovascular Therapy Results Early Follow-Up Outcomes.

In this research, we aimed to present early follow-up results of the endovascular treatment in patients with Leriche syndrome at our single center. Between October 2020 and January 2022, 14 patients with Leriche syndrome (12 men, two women) who underwent endovascular treatment at our center retrospectively were evaluated. Before the treatment, the ankle-brachial index (ABI) was found 0.50 ± 0.11 on the right leg and 0.45 ± 0.09 on the left leg. All of the patients with Leriche syndrome applied to our clinic for the first time. In five patients, the fully occluded lesion length was over 3 cm (ranging between 3.5-7.2 cm), hence they were treated with aortic and bilateral iliac bare metallic stents. Although in one patient, the aortic occluding lesion was below 3 cm; it was treated with a bare aortic and bilateral bare iliac stent application because the lesion in the aorta was too calcific. In eight patients, the lesion length was less than 3 cm, bilateral iliac metal bare stents were applied in a kissing stent way. Endovascular therapy for chronic aorto-iliac occlusive disease has an early high technical success with primary and secondary patency rates. Especially in patients with high risk factors, it may be considered as a good alternative to conventional surgery.

Endoscopic radiofrequency ablation for ingrowth occlusion after bilateral metal stent placement for malignant hilar biliary obstruction: a prospective pilot study

Endoscopic biliary radiofrequency ablation (RFA) may be an option for the treatment of ingrowth occlusion after self-expandable metal stent (SEMS) deployment; however, its utility remains uncertain. This study aimed to examine the feasibility of RFA for the palliation of ingrowth after bilateral SEMS placement in patients with malignant hilar biliary obstruction. This prospective, single-center, pilot study enrolled 30 patients who met the eligibility criteria between April 2020 and March 2022. Study outcomes were technical success, clinical success, recurrent biliary obstruction (RBO), and adverse events (AEs) besides RBO associated with RFA for ingrowth occlusion. Furthermore, factors predictive of clinical success were evaluated. Technical and clinical success rates were 93.3% (28/30) and 71.4% (20/28), respectively. The rates of early and late AEs were 6.7% (2/30) and 10.0% (2/20), respectively. The incidence rate of RBO after RFA was 45.0% (9/20), and the median time to RBO was 163 days. Multivariate analysis of the factors affecting clinical success revealed a positive association between the recanalization diameter on the ingrown part within the SEMS (odds ratio, 1.13; 95% confidence interval, 1.01-1.26; P= .038). The calculated optimal cutoff for the ratio of the recanalization diameter to the SEMS diameter for predicting clinical success was 51.1%. Endoscopic biliary RFA elicited promising results, with good long-term stent patency and without the requirement of any additional stent placement, for the palliation of ingrowth occlusion after bilateral SEMS placement. However, the clinical success rate was insufficient, necessitating improvements in the future. (Clinical trial registration number: UMIN000040154.).

RIGHT-SIDED CHYLOTHORAX DUE TO RECURRENT CERVICAL CANCER WITH PLEURAL METASTASIS

RIGHT-SIDED CHYLOTHORAX DUE TO RECURRENT CERVICAL CANCER WITH PLEURAL METASTASIS

Percutaneous insertion of a novel dedicated metal stent to treat malignant hilar biliary obstruction.

BACKGROUNDPercutaneous bilateral biliary stenting is an established method for the management of unresectable malignant hilar biliary obstruction.AIMTo evaluate the efficacy and safety of a novel uncovered biliary stent, specifically designed for hilar reconstruction.METHODSThis, single-center, retrospective study included 18 patients (mean age 71 ± 11 years; 61.1% male) undergoing percutaneous transhepatic Moving cell stent (MCS) placement for hilar reconstruction using the stent-in-stent technique for malignant biliary strictures, between November 2020 and July 2021. The Patients were diagnosed with cholangiocarcinoma (12/18; 66.6%), gallbladder cancer (5/18; 27.7%), and colorectal liver metastasis (1/18; 5.5%). Primary endpoints were technical (appropriate stent placement) and clinical (relief from jaundice) success. Secondary endpoints included stent patency, overall survival, complication rates and stent-related complications.RESULTSThe technical and clinical success rates were 100% (18/18 cases). According to Kaplan-Meier analysis, the estimated overall patient survival was 80.5% and 60.4% at 6 and 12 mo respectively, while stent patency was 90.9% and 68.2% at 6 mo and 12 mo respectively. The mean stent patency was 172.53 ± 56.20 d and median stent patency was 165 d (range 83-315). Laboratory tests for cholestasis significantly improved after procedure: mean total bilirubin decreased from 15.2 ± 6.0 mg/dL to 1.3 ± 0.4 mg/dL (P < 0.001); mean γGT decreased from 1389 ± 832 U/L to 114.6 ± 53.5 U/L (P < 0.001). One periprocedural complication was reported. Stent-related complications were observed in 5 patients (27.7%), including 1 occlusion (5.5%) and 1 stent migration (5.5 %).CONCLUSIONPercutaneous hilar bifurcation biliary stenting with the MCS resulted in excellent clinical and technical success rates, with acceptable complication rates. Further studies are needed to confirm these initial positive results.

A rare presentation of acute kidney failure due to retroperitoneal fibrosis as a result of gastric linitis plastica: a case-based review

This case study details the experience of a 52-year-old Dutch man, with a 4-month history of epigastric pain and weight loss, who was presented to a urology team and found to have rapidly deteriorating renal function with bilateral hydronephrosis. This prompted his admission to hospital for insertion of bilateral JJ ureteral stents. However, the patient's kidney function continued to worsen despite relief of the obstruction. He became increasingly oliguric and was referred to the renal service. Retroperitoneal fibrosis with acute kidney injury resulting from both obstruction and compression of the urinary system was suspected. Treatment with high-dose steroid was initiated. Shortly after, the patient's urine volume began to increase and his kidney function improved drastically. This avoided the need for dialysis. A month after discharge, the patient was diagnosed with poorly differentiated adenocarcinoma cells of the stomach, a diagnosis consistent with linitis plastica.

Novel J-tip guidewire for reintervention after stent-by-stent placement in patients with malignant hilar biliary obstruction

Reintervention (RI) after bilateral metal stent placement for malignant hilar biliary obstruction is a highly technically challenging procedure. This study aimed to examine the use of a novel J-tip guidewire (GW) for RI after stent-by-stent (SBS) placement. The study outcomes included technical success, procedure time, and procedure-related adverse events associated with RI after SBS placement. These parameters were compared between 20 patients who underwent RI using the J-tip GW (J-GW group) and a control cohort of 20 patients who underwent RI using a conventional GW (C-GW group). The technical success rate of GW placement without any advanced technique was significantly higher in the J-GW group than that in the C-GW group. The median procedure time was significantly shorter in the J-GW group. No significant differences on the procedure-related adverse event rate were observed between the groups. The novel J-tip GW yielded higher technical success rates with appropriate GW placement and shorter procedure time for RI after SBS placement, simplifying and streamlining the RI procedure.

Young Age Onset Multivascular Pathology in a Patient with Severe Dyslipidemia: an Incidental Case or a Particular Type of Familial Hypercholesterolemia?

Abstract Familial hypercholesterolemia (FH) is a genetic disorder that affects about 1 in 250 people and increases the likelihood of having coronary heart disease at a younger age. We present the case of a 55-year-old patient, known with inferior and anterior myocardial infarction treated by percutaneous coronary intervention and coronary artery bypass grafts, Leriche syndrome, aortic abdominal aneurysm, and bilateral renal stents—pathologies with onset at a young age—who was admitted for fast-paced palpitations, accompanied by increased fatigue. The coronarography did not reveal any acute lesions, but the presence of ventricular tachycardia at admission required the implantation of a cardiac defibrillator. Since the patient presented with early onset severe systemic atherosclerosis, with a lipid profile dominated by hypo-HDL, doubled by an apolipoprotein A1 deficiency, we considered the diagnosis of familial hypercholesterolemia. Due to the high-risk profile, the association between a statin and a PCSK9 inhibitor was initiated at discharge. At the 1-month follow-up control, a significant reduction of LDL-C has been achieved, with a simultaneous increase of HDL-C serum levels.

The influence of narrow aortic bifurcation on limb graft patency: a two-center retrospective study.

Narrow aortic bifurcation (NAB) has been considered as a potential risk factor for graft limb thrombosis after endovascular aortic repair (EVAR). The aim of this study was to compare mid- and long-term outcome of EVAR in patients with NAB and standard aortic bifurcation (SAB). Data from patients receiving EVAR were prospectively collected and retrospectively analyzed. In case of angiographic limb stenosis (>50%), additional stenting was performed. Patients with a NAB (≤20mm) were included in the NAB group, the remaining patients in the SAB group. Primary endpoints were limb thrombosis rate and technical success. A total of 902 patients were included; 18.3% (N.=165/902) in the NAB and 81.7% (N.=737/902) in the SAB group. Mean follow-up time was 43 months (range 0-198 months). Bilateral stenting of the aortic bifurcation was performed in 2.7% (N.=27/902), 8.5% (N.=14/165) in the NAB and 1.4% (N.=10/737) in the SAB group (P=0.001). Limb thrombosis was found in 2.8% (N.=25/902), 3.6% (N.=6/165) in the NAB and 2.6% (N.=19/737) in the SAB group (P=0.55). Technical success was 97.8%, 98.8% in the NAB and 97.6% in the SAB group (P=0.33). Device related reintervention rate was 16% (N.=144/902), 15.2% in the NAB and 16.1% in the SAB group (P=0.75). Standard EVAR could safely be performed in patients with NAB (≤20mm) when a low threshold for additional stenting was applied. This resulted in no significant higher incidence of limb thrombosis. Additional stent deployment did not increase the complication rate.

Successful Simultaneous Clearance of Bilateral Staghorn Stones with Flexible Uretero-Renoscopic Lasertripsy

A 50-year-old tetraplegic gentleman was referred with visible haematuria and recurrent urinary tract infections (UTI) presenting as behavioural difficulty. His past medical history includes diffuse brain injury following a motorbike accident, hypertension, BMI 41, performance status 4, and needing a hoist for transfer. CT showed bilateral staghorn complete calculi measuring the maximum length of 3 cm (left) and 4.2 cm (right) with 600 HU. Following best interest meetings, the patient communicated his unwillingness to proceed with PCNL or open surgery due to risks and opted for FURS. His bilateral staghorn stone was completely cleared simultaneously at his primary procedure after a total operative time of 190 min. He had no postoperative complications and was discharged with bilateral stents in situ. He had a second-look FURS 4 weeks later but only required washout of minimal dust and removal of bilateral ureteric stents. His stone analysis confirmed struvite stone. His haematuria, recurrent UTIs, and behavioural issues were resolved. His 6 months postoperative CTKUB showed a dust-free status. This report discusses the challenges of simultaneous bilateral staghorn clearance using FURS.

Gynecological malignancy with obstructive uropathy patient profile in Cipto Mangunkusumo Hospital: Our 2-year experience

Introduction: Gynecological malignancies are one of the most common causes of death from cancer in women. Hydronephrosis or obstructive uropathy is the most common finding in patients with gynecological malignancy. This study aimed to describe the profile of obstructive uropathy patients causes of gynecology malignancies treated in our center from 2019 to 2021. Method: From January 2019 to January 2021, obstructive uropathy patients with gynecological malignancies who underwent DJ stent or nephrostomy insertion procedures at Cipto Mangunkusumo Hospital were included in this prospective study. Patients with a history of urinary diversion or other diseases that may cause urinary tract obstruction were excluded. Result: One hundred and twenty-one patients with gynecological malignancies with obstructive uropathy were included. Cervical carcinoma was the most common cause, followed by ovarian carcinoma and endometrial carcinoma. The percentages of bilateral, right-, and left-sided stenting were 72%, 18%, and 10%, respectively. Most of them were grade 3 or grade 4 hydronephrosis. Percutaneous nephrostomy was mainly used for 69,4%, and only 17% of patients experienced a polyuria episode. Conclusion: Most cases of obstructive uropathy were caused by cervical malignancies, with bilateral obstruction due to cervical cancer occurring in most cases. Nephrostomy is the method of choice for urinary drainage in our center.

Acute bilateral ureteropelvic junction obstruction as a rare cause of hypertensive crisis: a case report

BackgroundBilateral ureteropelvic junction obstruction is a common cause of secondary hypertension in the pediatric population, often due to congenital malformation. On the other hand, it is less frequently encountered in the adult population and is usually due to an acquired condition, most commonly by a bilaterally obstructing nephrolithiasis causing hydronephrosis and subsequent hypertension. The aim of this study was to investigate and highlight the underlying mechanisms by which acute bilateral ureteropelvic junction obstruction causes hypertensive crisis and why early detection and prompt treatment are necessary to mitigate the effects of elevated blood pressure on target organs.Case presentationA 41-year-old African American man with hypertensive cardiomyopathy presented with anuria. He was found to have elevated blood pressure with evidence of target organ damage on laboratory examination, demonstrated by sudden elevation of his serum creatinine level. He was initially treated with oral and intravenous antihypertensives, with minimal improvement. The work-up was unremarkable apart from the imaging finding of acute bilateral ureteropelvic junction obstruction from obstructing nephrolithiasis causing hydronephrosis. Bilateral ureteral stents were placed for decompression, with resolution of the hypertensive crisis and improvement of renal function.ConclusionThis case highlights the importance of prompt diagnosis and treatment of underlying acute bilateral ureteropelvic junction obstruction to mitigate the deleterious effects of sudden blood pressure elevation on target organs.

Bilateral ductal stent in an andean newborn with discontinuous pulmonary arteries

Bilateral ductal stent in an andean newborn with discontinuous pulmonary arteries

Primary prostatic signet ring cell carcinoma in elderly with obstructive uropathy: a case report

BackgroundPrimary signet-ring cell carcinoma (SRCC) of the prostate is a rare and aggressive subtype of prostate adenocarcinoma with a poor prognosis, with only approximately 60 cases reported worldwide.Case presentationA 62-year-old man presented with acute urinary retention and hematuria, after a year’s history of lower urinary tract symptoms. Digital rectal examination revealed an irregular and hard prostate. Flexible cystoscopy showed bladder base infiltration by the enlarged prostate obscuring both ureteric orifices, necessitating nephrostomy and subsequent bilateral antegrade stenting to relieve the obstruction and improve his renal function. Transrectal ultrasonography biopsy of the prostate was performed revealing histological features of SRCC. Due to its rarity, there is currently no standardized treatment approach and it is often similarly treated according to the traditional management of prostate adenocarcinoma.ConclusionsSRCC of the prostate is a rare and aggressive subtype of acinar adenocarcinoma with no established guidelines. Histological criteria for SRCC of the prostate are highly variable in the available literature. It is important to differentiate between the primary and metastatic SRCC of the prostate as both are managed differently. However, the overall prognosis remains poor in general.

A Novel Suction-Irrigation Cannula-Guided Hydrophilic Tip Guidewire Technique of Intraoperative Ureteral Stent Placement During Robot-Assisted Radical Prostatectomy

Background: Patients with large median lobe, history of pelvic radiotherapy, or transurethral resection of the prostate are on the verge of ureteral orifice (UO) injury during robot-assisted radical prostatectomy (RARP). Not all aforementioned patients require ureteral stent placement. Intraoperative findings justify whether to proceed with ureteral stent placement or not. Previously described techniques of intraoperative stent placement involve use of transurethral cystoscopy or suprapubic skin incision, which makes procedure further difficult especially with robotic arms in place.1 Herein, we describe a simple and efficacious method Suction-Irrigation cannula-Guided Hydrophilic Tip guidewire (SIGHT) technique for intraoperative ureteral stent placement. Technique: The case shown here is a 64-year-old gentleman with Gleason 8 prostate cancer and opted for RARP. After division of bladder neck, the interior of the bladder was routinely inspected and the UOs were found too close to the bladder margins. The decision was made to proceed with bilateral ureteral stents placement. To facilitate stent placement, bladder margin is held up using 4th arm of the robot. The bedside assistant inserted laparoscopic suction irrigation cannula from 5 mm assistant trocar. Cannula tip was held a couple of centimeters away from respective UO. A 0.038 Inch diameter, 150 cm long hydrophilic straight tip guidewire is fed into the abdomen through shaft of the cannula. The surgeon on console (A.T.) places the wire into UO and feeds it proximally until the resistance is met. The bedside assistant (R.B.) then feeds the stent over the wire into the abdomen, and the surgeon threads the stent over the wire. The assistance held back-tension on the wire. A pusher is then guided over the wire in similar manner and stent is advanced until distal end of the stent is seen. The wire is pulled out by the bedside assistant, and the distal end of the stent is confirmed with use of robot and secure inside the bladder. Surgery proceeded as usual. Stent placement was verified postoperatively by plain kidney, ureter and bladder radiograph. Patient was discharged next day. Catheter removal was done at postoperative day 7. Ureteral stents were removed under local anesthesia in the office at 4 weeks postoperative visit without complication. Conclusions: Our SIGHT technique is safe, effective, and easily adaptable method for intraoperative ureteral stent placement during robotic procedures. It avoids intraoperative cystoscopy or suprapubic skin incision or use of additional guidewires thereby saving time during which patient is under anesthesia during surgery. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music Source:www.epidemicsound.com Copyright: Author owns copyright/license for the music used in the video. A.T. has served as a site-PI on pharma/industry-sponsored clinical trials from Kite Pharma, Lumicell Inc., Dendreon, and Oncovir Inc. He has received research funding (grants) to his institution from Department of Defence, National Institute of Health, Axogen, Intuitive Surgical, Arthur M. Blank Family Foundation, and other philanthropy. A.T. has served as an unpaid consultant to Roivant Biosciences and advisor to Promaxo. He owns equity in Promaxo. Rest of the authors do not have conflict of interests. Runtime of video: 3 mins 21 secs

TCTAP C-141 An Interesting Case of Bilateral Renal Artery Stenting in a Patient of Takayasu Arteritis With Uncontrolled Hypertension

TCTAP C-141 An Interesting Case of Bilateral Renal Artery Stenting in a Patient of Takayasu Arteritis With Uncontrolled Hypertension

Endoscopic re-intervention after stent-in-stent versus side-by-side bilateral self-expandable metallic stent deployment.

Endoscopic bilateral self-expandable metallic stent (SEMS) placement for unresectable malignant hilar biliary obstruction (MHBO) is widely performed; however, re-intervention after recurrent biliary obstruction (RBO) is often challenging. We compared stent-in-stent (SIS) and side-by-side (SBS) SEMS placement for MHBO considering re-intervention for RBO. One hundred five consecutive patients with MHBO who underwent endoscopic bilateral SEMS placement in our hospital and its affiliated institutions were enrolled in this study; 75 patients underwent partial SIS deployment between December 2005 and December 2012; and 30 underwent SBS deployment between January 2013 and March 2019. Initial treatments and re-interventions in each group were retrospectively evaluated. Technical success rate (92% vs 100%, P=0.179), procedure duration (46 vs 35min, P=0.382), functional success rate (97.1% vs 100%, P=1.00), complication rate (24.6% vs 20.0%, P=0.797), time to RBO (260 vs 312days; Gray test, P=0.815), and rate of RBO (59.4% vs 70.0%, P=0.371) were not significantly different between the SIS and SBS groups. However, bilateral re-stenting with plastic stents through SEMS was successful in 63.4% of patients in the SIS group compared with 100% of patients in the SBS group (P=0.0013). Median time to RBO upon first re-stenting with a plastic stent was 75days (range, 11-195days). Endoscopic re-stenting after RBO was significantly more successful in the SBS group than in the SIS group. SBS method is suitable for MHBO considering revisionary stent placement.

Simultaneous bilateral angioplasty and stenting for carotid stenosis - a single center experience.

Carotid artery stenosis is responsible for up to 12% of all ischemic strokes. The prevalence of bilateral carotid artery stenosis is nearly 8–39% among patients with stroke, and its management is still controversial. This study aimed to report the treatment results of bilateral carotid artery stenosis with simultaneous bilateral angioplasty and stenting (sbCAS) in a single institution during the last 10 years. 315 patients underwent carotid stenting in the Scientific-Practical Center of Endovascular Neuroradiology, NAMS of Ukraine during 2010–2020. 39 (12.4%) patients (mean age 57.9±2.1 – 28 men) underwent sbCAS. Primary clinical endpoints (stroke, myocardial infarction, or death) and secondary endpoints (hemodynamic depression (HD) – hypotension (<90 mmHg) or bradycardia (<60 bpm) and hyperperfusion syndrome (HPS) were evaluated. All sbCAS were technically successful, and a reduction of stenosis was noted in each case. There were two periprocedural neurological complications, one transient ischemic attack (TIA), and one minor stroke with the Modified Rankin Scale (mRS) – 3 at discharge. No myocardial infarction (MI) or death during hospitalization was noted. 28 patients (71.8%) had HD, and 2 (5.1%) had HPS. All patients except those with periprocedural stroke were discharged or transferred to another hospital without neurological deterioration. sbCAS is an effective and relatively safe procedure for carefully selected patients with bilateral carotid stenosis. Patients with bilateral carotid stenosis should be carefully examined, and the best treatment strategy should be assessed using a multidisciplinary approach taking into account the possibility of sbCAS.

Factors Associated with Ureteral Stent Failure in Patients with Malignant Ureteral Obstruction.

Introduction: Management of malignant ureteral obstruction (MUO) with ureteral stents remains a clinical challenge, often involving frequent stent exchanges attributable to stent failure or other urological complications. We report our institutional experience with ureteral stents for management of MUO, including analysis of clinical factors associated with stent failure. Methods: We performed a retrospective review of patients treated with indwelling ureteral stents for MUO in nonurothelial malignancies at our tertiary-care institution between 2008 and 2019. Univariate Cox proportional hazards analysis was performed to identify clinical variables associated with stent failure and stent-related complications. Stent failure was defined as need for unplanned stent exchange, placement of percutaneous nephrostomy (PCN), or tandem stents. Results: In our cohort of 78 patients, the median (range) number of stent exchanges was 2 (0-17) during a total stent dwell time of 4.3 (0.1-40.3) months. Thirty-four patients (43.6%) developed a culture-proven urinary tract infection (UTI) during stent dwell time. Thirty-five patients (44.8%) had stent failure. Twenty-two patients (28.2%) underwent unplanned stent exchanges, 23 (29.5%) required PCN after initial stent placement, and 6 (7.7%) required tandem stents. Ten (28.6%) patients with stent failure were treated with upsized stents, which led to resolution in seven patients. Stent failure occurred with 20/44 (45.4%) Percuflex™, 15/27 (55.6%) polyurethane, and 2/3 (66.7%) metal stents. In patients with ≥2 exchanges (N = 45), median time between exchanges was 4.1 (2.0-14.8) months. Bilateral stenting and history of radiation predicted UTI development. Median overall patient survival after initial stent placement was 19.9 months (95% CI 16.5-37.9 months). Conclusions: Ureteral stent failure poses a significant medical burden to patients with MUO. Better methods to minimize stent-related issues and improve patient quality of life are needed. Using a shared decision-making approach, clinicians and patients should consider PCN or tandem stents early in the management of MUO.