Postoperative Ureteral Stricture Research Articles

P026 - Retrograde holmium: YAG laser endoureterotomy in the treatment of postoperative ureteral strictures following endoscopic stone surgery

P026 - Retrograde holmium: YAG laser endoureterotomy in the treatment of postoperative ureteral strictures following endoscopic stone surgery

Thermal effect of holmium laser lithotripsy under ureteroscopy.

Thermal effect of holmium laser lithotripsy under ureteroscopy.

Ureteral stricture formation after removal of proximal ureteral stone: retroperitoneal laparoscopic ureterolithotomy versus ureteroscopy with holmium: YAG laser lithotripsy.

ObjectiveTo compare the risk of postoperative ureteral stricture formation following retroperitoneal laparoscopic ureterolithotomy (RPLU) and ureteroscopy with holmium: YAG laser lithotripsy (URSL) in patients with proximal ureteral stones.Materials and MethodsWe retrospectively reviewed the medical records of patients who underwent RPLU or URSL for proximal ureteral stones between April 2011 and May 2015. Patients were allocated into URSL group or RPLU group and the outcomes were compared.ResultsA total of 201 patients who underwent 209 procedures including 159 URSL and 50 RPLU with a median follow-up of 30 months were included. No significant difference was observed among the two groups in most baseline parameters, while the stone size was significantly larger in the RPLU group (11.37 ± 2.97 vs 14.04 ± 4.38 mm, p = 0.000). Patients in RPLU group had markedly longer operative time (p = 0.000) and longer postoperative hospital stay (p = 0.000). The initial and one-month stone-free rates were significantly higher in the RPLU group (78.6% vs 100%, p = 0.000 and 82.4% vs 100%, p = 0.001, respectively). Patients in the RPLU had a higher complication rate (18.0% vs 9.4%, p = 0.098) and lower ureteral stricture rate (2.5% vs 2.0%, p = 1.000), while the difference was not significant. Further logistic regression model identified RPLU and female sex as independent risk factors for postoperative complication (Odds Ratio[OR] = 3.57, p = 0.035 and OR = 3.57, p = 0.025, respectively); however, URSL was not an independent risk factor for the formation of postoperative ureteral stricture after adjusting confounding variables (OR = 0.90, p = 0.935).ConclusionRPLU and URSL have similar postoperative ureteral stricture formation risks. RPLU can provide significantly higher stone clearance rate, but relates with more postoperative complications.

Comparison of Holmium: YAG Laser and Pneumatic Lithotripsy in the Treatment of Ureteral Stones: An Update Meta-Analysis

Purpose: Holmium YAG laser lithotripsy (LL) and pneumatic lithotripsy (PL) are the most commonly used procedures in the treatment of ureteral calculi. In a previous meta-analysis examining the treatment effect of the 2 modalities, the authors highlighted the need for large sample size and high quality trials to provide more uncovered outcome. Recently, several randomized controlled trials (RCTs) evaluating the same issue with larger patient number and more complicated data have been published. Therefore, we conducted this meta-analysis to update and synthesize evidence on the efficacy and safety of the 2 procedures in the treatment of ureteral calculi. Methods: The relevant studies were identified by searching Medline, EMBASE and Cochrane Library Database from January 1990 to November 2015. RCTs assessing the efficacy and safety of Holmium YAG laser and PL for ureteral stones were included. Two reviewers independently screened studies and extracted data. Results: A total of 8 studies were identified including 1,555 patients. Compared with PL, Holmium YAG LL significantly reduced the mean operative time (weighted mean difference = -11.52, 95% CI -17.06 to -5.99, p < 0.0001) and increased the early stone-free rate (OR 2.69, 95% CI 1.91-3.78, p < 0.00001) and the delayed stone-free rate (OR 2.12, 95% CI 1.40-3.21, p = 0.0004). However, a higher postoperative ureteral stricture rate (OR 3.38, 95% CI 1.56-7.31, p = 0.002) was observed in LL group over PL group. There was no statistical significance in the ureteral perforation rate (OR 1.19, 95% CI 0.65-2.16, p = 0.58), the stone migration rate (OR 0.64, 95% CI 0.41-1.00, p = 0.05), the postoperative gross hematuria rate (OR 0.71, 95% CI 0.40-1.25, p = 0.23) and the postoperative fever rate (OR 0.73, 95% CI 0.50-1.09, p = 0.12). Conclusions: Our data reconfirmed that Holmium LL for ureteral stones can achieve shorter mean operative time, better early and delayed stone-free rate with larger sample size and more high quality studies. And further trials are unlikely to considerably alter this conclusion. In terms of higher risk of postoperative ureteral stricture in LL group over PL group observed in our review, more high quality, multicenter RCTs with long-term follow-up outcome are warranted to better assess this issue.

Retroperitoneal laparoscopic ureterolithotomy in comparison with ureteroscopic lithotripsy in the management of impacted upper ureteral stones larger than 12 mm.

To compare the results of ureteroscopic lithotripsy (URSL) with retroperitoneal laparoscopic ureterolithotomy (RPLU) as two minimally invasive techniques in the management of proximal ureteral stones larger than 12 mm. From January 2009 to October 2013, patients with impacted unilateral upper ureteral stones larger than 12 mm were enrolled including 182 males and 93 females with a medium age of 40 years (22-72 years). Patients were randomized to receive URSL (139 cases) with semirigid ureteroscope or RPLU (136 cases). Stone size was similar in RPLU and URSL groups (13.8 ± 1.9 vs 13.6 ± 1.4 mm, P = 0.312). Operating time and hospitalizing days in URSL group were significantly shorter than those in RPLU group (P < 0.001), whereas stone clearance rate was significantly higher in RPLU group (97.1 vs 89.9 %, P = 0.017). Ureteral strictures happened higher in URSL group (5 patients, 3.6 %) than RPLU group (2 patients, 1.5 %) with no statistical significance, while the strictures requiring surgical intervention were significantly higher in URSL group (4 cases) (2.9 vs 0 %, P = 0.046). RPLU could provide better stone clearance rate than semirigid URSL for upper ureteral impacted stones larger than 12 mm. It may also reduce the chance of surgical intervention for postoperative ureteral stricture.

Balloon Dilation of the Ureter: A Contemporary Review of Outcomes and Complications

During ureteroscopy ureteral balloon dilation may be necessary to allow for passage of endoscopic instruments or access sheaths. We assessed the efficacy and complications associated with ureteral balloon dilation. We retrospectively reviewed the records at 2 institutions from 2000 to 2012 to identify patients who underwent ureteral balloon dilation during ureteroscopic treatment of upper tract stones. An 18Fr balloon dilator was used in all cases. Patients with documented ureteral stricture, radiation therapy or urothelial cancer were excluded from analysis. Primary outcomes were the stone-free rate, operative complications, balloon dilation failure and the postoperative ureteral stricture rate. Complications were divided into intraoperative and postoperative groups according to the Satava and Clavien-Dindo classifications, respectively. A total of 151 patients fulfilled study criteria. Median followup was 12 months. The stone-free rate was 72% and median time to first postoperative imaging was 2.8 months. Balloon dilation failed in only 8 patients (5%). Eight intraoperative ureteral perforations (5%) were identified, which were managed by a ureteral stent in 7 patients and a percutaneous tube in 1. Endoscopic re-treatment was required in 4 patients with Satava 2b postoperative complications. The postoperative complication rate was 8% (11 cases). A single ureteral stricture was attributable to balloon dilation. In this contemporary review balloon dilation of the ureter before endoscopic treatment of stone disease was associated with a high success rate and few complications. Ureteral balloon dilation may decrease the need for a secondary procedure in patients undergoing ureteroscopy to manage proximal ureteral and intrarenal stones.

Antegrade Percutaneous Balloon Dilation of Ureteral Strictures After Failed Pelviureteric or Ureterovesical Reimplantation in Children

To assess the morbidity and success rate of percutaneous treatment of the postoperative ureteric strictures in children. Between January 1994 and December 2003, 12 children were treated by antegrade percutaneous balloon dilation for postoperative ureteric strictures. Stenosis occurred at the pelviureteric junction in 5 cases and ureterovesical junction in 7 cases. The 10 boys and 2 girls were between 3 months and 14 years old (mean, 5 years ± 4.7 years). General anesthesia was used in 10 cases for nephrostomy catheter placement. Five ureteral stents were used additionally for nephrostomy drainage with a 6-F catheter. Both nephrostomy and ureteric stents were in place for 28.5 ± 12 days, then removed after control antegrade pyelography. Dilation was technically successful in 9 of our patients. Two peroperative complications occurred. Postoperative results were evaluated by ultrasonography, intravenous urography, antegrade pyelography, and diethylene triamine pentaacetic acid renography that confirmed no obstacle in all 5 cases of pelviureteric stricture with a follow-up of 4 ± 2.9 years and in 4 cases of ureterovesical junction with a follow-up of 4.7 ± 2.8 years. Three unsuccessful results were reported: in 2 cases, the guide wire could not be advanced over the stenotic ureterovesical junction and in 1 case an early restenosis occurred that eventually required surgery. Although the main treatment of the postoperative ureteral strictures is surgical, the percutaneous antegrade balloon dilation seems to be an alternative to surgery with a low morbidity rate and short hospitalization period.

Emergency Ureteroscopic Treatment for Upper Urinary Tract Calculi Obstruction Associated with Acute Renal Failure: Feasible or Not?

To determine the efficacy and safety of emergency ureteroscopy (URS) and holmium:yttrium-aluminum-garnet (Ho:YAG) laser lithotripsy for ureteral calculi that are associated with acute renal failure (ARF). We retrospectively evaluated a cohort of 49 patients who underwent URS from November 2005 to November 2008 for ARF that was caused by calculi obstruction of the upper urinary tract. The mean (maximal diameter) stone size was 1.48 cm. Acute renal failure was demonstrated by oliguria or anuria and marked increase in serum creatinine and blood urea nitrogen levels. All the patients were treated with URS and Ho:YAG laser lithotripsy emergently. Ureteral stent placement was performed in all cases after lithotripsy. A plain film of the kidneys, ureters, and bladder and abdominal ultrasonography were performed to evaluate efficacy of treatment on the first day postoperatively. Serum creatinine and blood urea nitrogen levels and urine volume were successively monitored until they returned to normal. All patients had postoperative imaging, including ultrasonography and excretory urography, to confirm stone clearance and exclude late obstructive complications 3 months after URS. URS and laser lithotripsy were successfully performed in all patients. There were no major intraoperative complications, and no procedure was converted to open surgery. The mean operative time was 35 minutes. The successful fragmentation rate was 95.5%. The overall stone-free rate was 91.8%. Normal renal function returned in 46 (93.8%) patients within 7 days. No postoperative ureteral stricture occurred after 3 months. URS and Ho:YAG laser lithotripsy represent an effective and safe modality for treating patients with ARF that is caused by calculi obstruction of the upper urinary tract in strictly selected situations.

Selective Postoperative Imaging After Ureteroscopy

To evaluate the need of routine follow-up imaging after ureteroscopy. We performed a retrospective chart review of patients undergoing ureteroscopy for urolithiasis. Selective imaging was performed in the initial postoperative phase (1-3 weeks after removal of the ureteral stent) if the procedure was classified as complicated because of the presence of an impacted stone, the need for balloon dilation, intraoperative ureteral perforation, or postoperative pain after stent removal. Uncomplicated ureteroscopy was followed by repeat imaging if the patient developed recurrent renal colic or as surveillance for new stone growth at 6-12 months of follow-up. A total of 267 ureteroscopic procedures were performed on 253 patients. The data from 214 of 253 patients (84.6%) who had undergone noncontrast-enhanced computed tomography imaging > or = 1 month after surgery were analyzed. The mean follow-up was 14.5 months (range 1-66). The incidence of stricture was 1.4% (3/214). The incidence in the selective imaging (complicated ureteroscopy) group was 5.3% (3/56). In uncomplicated ureteroscopy group, it was 0% (0/158). Ureteral stricture developed in 3 of 11 patients with stone impaction (27.2%, P = .002), 2 of 14 patients undergoing ureteral balloon dilation (10.4%, P = .0052), and in 1 of 6 patients with an intraoperative mucosal perforation (16.6%, P = .0326). Persistent postoperative pain after stent removal was not predictive of stricture formation (3.6%, P = .139). The results of our study have shown that selective imaging as determined by the intraoperative findings of complicated ureteroscopy (eg, impacted stone, balloon dilation, mucosal perforation) will detect postoperative ureteral strictures. Routine follow-up imaging is not essential after uncomplicated ureteroscopy.

Ureteroscopy and Holmium: YAG Laser Lithotripsy as Emergency Treatment for Acute Renal Failure Caused by Impacted Ureteral Calculi

To present our clinical outcomes in managing acute renal failure caused by impacted ureteral calculi with ureteroscopy and holmium: yttrium-aluminum-garnet laser lithotripsy as emergency treatment. A series of 27 patients with acute postrenal failure were treated from November 2002 to December 2005. Impacted calculi were located in bilateral ureters in 22 patients and unilateral ureters in 5 patients with a solitary or single functioning kidney. Acute renal failure was demonstrated with oliguria or anuria and a significant increase in serum creatinine and blood urea nitrogen. Patients were treated emergently with ureteroscopy and holmium:yttrium-aluminum-garnet laser lithotripsy in the hospital within 24 hours. Ureteral stenting was performed in all cases. Postoperative renal function, electrolytes, and urine volume were monitored daily for 7 days. Radiography and/or ultrasonography were performed at a follow-up visit in 4 weeks. Ureteroscopy and laser lithotripsy were successfully performed in all patients. The mean operative time was 29.2 minutes (range 15-60). The successful fragmentation rate in the ureteroscopic procedure was 93.9% (46 of 49), and the overall stone-free rate was 88.9% (24 of 27). Shock wave lithotripsy was used in 3 patients after recovery of renal function. Of the 27 patients, 26 (96.3%) returned to normal renal function within 7 days. One patient (3.7%) had significant improvement of renal function, but it had not returned to normal at 12 weeks of follow-up. No intraoperative complications or postoperative ureteral stricture occurred. Emergency ureteroscopy and holmium: yttrium-aluminum-garnet laser lithotripsy can be safely and successfully performed by skilled endourologists for acute renal failure caused by impacted ureteral calculi.

Ureteroscopic Treatment of Ureteral Calculi with Holmium: YAG Laser Lithotripsy

We evaluated the effectiveness and safety of holmium: YAG laser lithotripsy with a semirigid ureteroscope for ureteral calculi in a prospective cohort of 697 patients. Holmium: YAG laser lithotripsy was performed with a semirigid ureteroscope in 697 inpatients between September 2002 and January 2006. Calculi were located in the distal ureter in 382 patients (54.8%), the midureter in 143 (20.5%), and the proximal ureter in 172 (24.7%). Patients were assessed 2 to 24 weeks postoperatively with repeat plain radiography, ultrasonography, intravenous urography, or some combination. The overall stone-free rate was 92.2%, the rate being 100% for calculi in the distal ureter (N = 382), 97.9% for calculi in the midureter (N = 140), and 70.3% for calculi in the proximal ureter (N = 121). Complications occurred in 13 patients (1.9%). Postoperative ureteral stricture developed in five patients (0.72%) and was managed surgically. Holmium: YAG laser lithotripsy with a semirigid ureteroscope is a highly effective and safe treatment for ureteral calculi, especially those in the distal ureter and midureter.

Treatment of Iatrogenic Postoperative Ureteral Strictures with Acucise Endoureterotomy

To determine factors influencing the outcome of Acucise endoureterotomy in patients with iatrogenic postoperative ureteral strictures after different open surgical procedures. Acucise endoureterotomy was performed in 18 patients with ureteral strictures after pyeloplasty (n = 5), renal transplantation (n = 5), ureteroenteric anastomosis (n = 3), calicoureterostomy (n = 1), ureterocystoneostomy (n = 1), hysterectomy (n = 1), ureterorenoscopy (n = 1) and transurethral resection of the ureteral orifice (n = 1). Success was determined as relief of clinical symptoms, improvement of renal function or improvement of radiographic findings. The overall success rate was 61% (mean follow-up: 21.5 months). Six out of 18 patients showed relevant side effects. Neither the localization of the stricture nor the duration of postoperative ureteral stenting but the length of the stricture had influence on the postoperative outcome. Decreased renal function to less than 25% of the total function was always associated with failure of the treatment. The time period between the ureteral injury and the appearance of the ureteral stricture had influence on the outcome of the treatment. Acucise endoureterotomy is effective in the treatment of postoperative ureteral strictures, but only in selected cases. The selection criteria are the time period from the primary operation to the appearance of the stricture (>6 months), the length of the stricture (<1.5 cm) and the renal function (>25% of the total function). In other cases, open surgical treatment of the ureteral stricture may provide better results.

Primary Endoscopic Treatment of Ureteric Calculi

Aim of the Study: In the post-ESWL period, ureteroscopy represented the solution giving a second choice in the treatment of ureteral calculi in case of failure of extracorporeal lithotripsy. The aim of this study is to review a wide series of ureteral stones in which ureteroscopy combined with endoscopic lithotripsy can be chosen as the first approach for the treatment of ureteral calculi. Methods: Between January 1994 and September 1997, 378 patients underwent ureteroscopy and endoscopic lithotripsy for ureteral stones with a miniscope associated with either a pneumatic or electropneumatic lithotriptor. Three different miniscopes were used: Olympus (8 Fr), Wolf (7 Fr) and Circon Acmi (7.7 Fr). 238 patients were male and 140 were female. The stones were localized in the upper tract of the ureter in 62 cases (16.4%), 96 (25.3%) in the mid ureter and 220 (58.3%) in the lower ureter. Results: A complete stone fragmentation with spontaneous expulsion of the fragments occurred in 354 patients (93.6%). In 22 patients (5.8%) the stones were accidentally pushed up and successfully underwent ESWL. In 38 patients (10%) the fragments were completely removed by basket. A single J polyethylene catheter was placed in 21 (5.5%) and a JJ stent in 147 patients (38.8%). The operative time ranged from 10 to 60 min, with an average time span of 32. In 22 cases (5.8%) an iterative ureteroscopy for stenosis or incomplete fragmentation was needed. Five cases (1.3%) of ureteral perforation were successfully treated by JJ stent, and only 1 case of ureteral avulsion (upper ureter) was treated by open surgery. In the attempt of overcoming an ureteral stenosis, we had 1 case (0.2%) of ureteral reimplantation. One patient (0.2%) underwent ureterolithotomy for an extremely narrow stenosis just before the ureteropelvic junction. No relevant complication was recorded in the postoperative period. Patients were dismissed after 1– 4 days (average 1.9). Up until now, no case of postoperative ureteral stricture has been observed, although we were not able to carry out a specific follow-up in all our patients. Conclusions: Ureteroscopy with miniscopes has a high success rate (93.6%) with low morbidity and can be given as a primary approach in the management of ureteral calculi. In the lumbar ureter (especially in women) this technique can represent a good alternative to ESWL in the treatment of obstructing stones (which need stenting) or when the patient asks for a ‘one-shot’ treatment.

Principles and applications of laser lithotripsy: experience with the holmium laser lithotrite.

The initial clinical experience with holmium laser energy applied for endoscopic lithotripsy was positive. The current study is presented as a contrast to the preliminary findings and as a means of defining the clinical usefulness of this specific laser lithotrite. Calculi were treated endoscopically with the holmium laser lithotriptor and data was gathered prospectively. The youngest patient in the series was a thirteen-month--old who underwent percutaneous therapy, while the youngest patient on whom a retrograde endoscopic procedure was performed was a six-year old male patient with a proximal ureteral calculus. Lower water density, quartz fibers delivery systems were developed and employed. Fiber diameters ranged from 200-1000 micrograms. The smaller fibers were employed most commonly through the actively deflectable, flexible endoscope to facilitate treatment with maximum deflection. Larger fibers, with their much larger vaporization bubbles, were used through rigid endoscopes to debulk large stone burdens. A total of 210 patients with 249 calculi were treated. All major stone compositions were treated with minimal variation in laser efficiency. All but three of 109 ureteral calculi were treated in a retrograde fashion to completion (i.e., "stone free") in one sitting (97%). One-hundred thirteen renal stone burdens were treated with the holmium laser; 99 of these were treated solely in a retrograde fashion. Of the latter, 79 (80%) required only a single session. The combination of the actively deflectable, flexible ureteroscope and the 200-micrograms fiber facilitated treatment to completion of 38 to 45 lower-pole caliceal calculi (85%). The success of ureteropyeloscopic lithotripsy with the holmium laser for all intrarenal calculi, including staged or second sitting for large complex stone burdens, was 90%. Sixteen percutaneous procedures (13 renal and 3 ureteral calculi) employed the holmium laser as an endoscopic lithotrite. All 28 patients with large bladder calculi with a mean diameter of 41.8 mm were treated to completion in one sitting. Complications from holmium laser energy, including postoperative ureteral stricture disease, were not encountered in this series. Holmium laser energy is uniquely suited to treat urinary calculi safely regardless of stone size, location, or metabolic composition, and has particular efficacy in complex clinical presentations.

Percutaneous Ureteroneocystotomy for Treatment of Postoperative Distal-Ureteral Stricture

We describe a technique for percutaneous ureteroneocystotomy in a patient with complete ureteral obstruction after reimplantation for correction of bladder exstrophy. Provided the obstruction is at the distal ureterovesical junction close to the bladder, this technique may be valuable in the treatment of some postoperative ureteral strictures.

Treatment of postoperative ureteral stricture by catheter dilation: A forgotten procedure

Some postoperative ureteral strictures can be managed successfully by simple catheter dilations as shown in the cases presented herein. It appears that only one or two dilations may be necessary for prolonged resolution of the obstructive process. Internal ureteral splints may be used with equally good results. Operative intervention should be reserved for those cases in which either ureteral catheterization cannot be accomplished or dense fibrosis renders adequate long-term management by catheter dilation impossible.

Treatment of postoperative ureteral stricture by catheter dilation: A forgotten procedure

Some postoperative ureteral strictures can be managed successfully by simple catheter dilations as shown in the cases presented herein. It appears that only one or two dilations may be necessary for prolonged resolution of the obstructive process. Internal ureteral splints may be used with equally good results. Operative intervention should be reserved for those cases in which either ureteral catheterization cannot be accomplished or dense fibrosis renders adequate long-term management by catheter dilation impossible.