Retrograde Balloon Dilatation Research Articles

Refractory esophageal anastomotic stricture after esophageal atresia surgery improved with retrograde balloon dilatation through gastrostomy followed by laparoscopic fundoplication: a case report

BackgroundAn esophageal anastomotic stricture (EAS) after an esophageal atresia surgery occurs in approximately 4–60% of the cases, and its first-line therapy includes balloon dilatation. Oral balloon dilatation cannot be performed in some EAS cases; conversely, even if dilatation is possible, these strictures recur in some cases, necessitating a surgical procedure for repairing the stenosis. However, these procedures are invasive and have short- and long-term complications. If an EAS recurs repeatedly after multiple balloon dilations, gastroesophageal reflux disease (GERD) may be the underlying cause. A fundoplication procedure may be effective for treating a refractory EAS, as in the present case.Case presentationA neonatal patient with type D esophageal atresia underwent thoracoscopic esophago-esophageal anastomosis at the age of 1 day, and her postoperative course was uneventful. Thereafter, the patient underwent gastrostomy for poor oral intake at the age of 3 months. After gastrostomy, the patient presented with a complete obstructive EAS. Balloon dilatation via the oral route was attempted; however, a guidewire could not be inserted into the EAS site. Hence, retrograde balloon dilatation via gastrostomy was performed successfully. However, the EAS recurred easily thereafter, and laparoscopic anti-reflux surgery was performed to prevent GERD. The anti-reflux surgery cured the otherwise refractory EAS and prevented its recurrence.ConclusionsRetrograde balloon dilatation is another treatment option for an EAS. When an EAS recurs soon after dilatation, the patient must be evaluated for GERD; if severe GERD is observed, an appropriate anti-reflux surgery is required before dilating the EAS.

Endourological treatment of upper tract urinary disease in children

With advances in therapeutic interventions, endourology has become standard of care for the treatment of numerous diseases in the field of pediatric urology. However, there remains a lack of agreement and evidence on the optimal approaches and associated complications of endourological treatment of upper urinary tract conditions in children, namely ureteropelvic junction (UPJ) obstruction, primary obstructive megaureter, and nephrolithiasis. While pyeloplasty remains the first-line surgical treatment for pediatric UPJ obstruction, endoscopic retrograde balloon dilatation (ERBD) and endopyelotomy continue to gain traction as less invasive means of treating obstruction, particularly for failed repairs. Studies report success rates ranging from 76–100% although re-stenosis or need for revision surgery is not uncommon. Endourological options for the surgical management of primary obstructive megaureter include ERBD or endoureterotomy, rather than the open option of ureteroneocystotomy with or without tapering. Both have shown long-term success rates ranging from 70–90%, however, there is emerging evidence that these therapies may be associated with a risk of postoperative vesicoureteral reflux. Meanwhile, for stone disease, shock wave lithotripsy (SWL), flexible ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL) are mainstays in the pediatric urologist’s armamentarium. Studies have shown that URS and PCNL have comparable stone-free rates, although PCNL can be associated with increased morbidity. Advancements in technology have led to the use of smaller access sheaths without compromising stone-free rates or increasing long-term complications. The use of mini-PCNL in the adult population holds great potential for use in our pediatric patients. The rise of endourology expertise and improved technology makes it an attractive option that could even be considered as a first-line option for the treatment of various urinary tract conditions. Nevertheless, there is a paucity of evidence on outcomes and complications following its use for treatment of upper urinary tract diseases in children. This review aims to summarize and present results of endourological treatments for pediatric UPJ obstruction, primary obstructive megaureter, and nephrolithiasis, as well as highlight advancements in the field of endourology that may increase its utilization in pediatric urology in the future.

Long Term Outcome of 112 Pediatric Patients With Ureteroplevic Junction Obstruction Treated by Endourologic Retrograde Balloon Dilatation.

PurposeTo analyze the effectiveness, complications and long-term outcome of the patients with ureteropelvic junction obstruction (UPJO) treated by endoscopic retrograde balloon dilatation (ERBD) in the largest series reported.Materials and MethodsBetween years 2004 and 2018, 112 patients with primary unilateral UPJO were treated by ERBD. Endoscopic treatment consisted on a retrograde balloon dilatation of the ureteropelvic junction (UPJ), through cystoscopy and under fluoroscopic guidance, using high-pressure balloon catheters. In case of persistence in the balloon notch, a Cutting Balloon™ catheter was used. Double-J stent was placed after dilatation.ResultsMean age at surgery was 13.1 ± 21.3 months, 92 cases being younger than 18 months. Mean operative time was 24.4 ± 10.3 min; hospital stay was 1 day in 82% of patients. No intraoperative complications occurred. UPJ was calibrated at time of stent removal with cystoscopy 39.1 ± 13.7 days after dilatation. ERBD was not possible in 11 cases. An additional procedure was needed in 24 cases: second ERBD (n = 11, seven during the stent withdrawal), a third dilatation (n = 3) due to persistent hydronephrosis, and percutaneous endopyelotomy (n = 3) or open pyeloplasty (n = 7) in cases of technical failure. Significant improvement in postoperative ultrasound measures were observed (p < 0.05, T-test). Long-term success rate was 76.8% after one dilatation, and 86.6% in those who required up to 2 dilatations. Mean follow-up was 66.7 ± 37.5 months.ConclusionsERBD is a feasible and safe option for the minimally invasive treatment of UPJ obstruction in infants. Long-term outcome is acceptable with a very low complication rate.

Diagnosis and Management of Kock Afferent Nipple Valve Obstruction

ObjectiveTo characterize afferent nipple valve obstruction in Kock diversions presenting with hydronephrosis and discuss appropriate work-up and management. MethodsWe retrospectively reviewed 7 cases of afferent nipple valve obstruction. ResultsThe median time from diversion creation to afferent nipple valve intervention was 17-years. Presentations included febrile-UTIs, worsening renal function and hydronephrosis. All patients underwent upper tract imaging confirming bilateral hydronephrosis or hydronephrosis of a solitary kidney followed by nephrostomy tube insertion to drain the obstructed kidney(s). On nephrostogram assessment afferent nipple valve obstruction was confirmed by a lack of contrast passing through the valve. In 4 of these patients the afferent valve could not be cannulated while in one patient endoscopic retrograde balloon dilation was performed but failed after 12-months. One patient had successful antegrade balloon dilation (four-years follow-up). In five patients and the one patient who failed retrograde balloon dilation open surgical repair of the afferent nipple valve was successful (median follow-up time 5-years). ConclusionIt is essential to consider afferent nipple valve obstruction in a patient with a Kock diversion presenting with bilateral hydronephrosis/hydronephrosis of a solitary kidney, even after many years following the original diversion. Appropriate work-up consists of upper tract imaging, endoscopy and retrograde studies or nephrostomy insertion with nephrostogram. Management options include endoscopic retrograde or antegrade balloon dilation or valve incision. Failing that, surgical repair may be successful with long-term upper tract preservation.

Retrograde balloon dilation as a therapeutic option for post-gynecologic surgery ureteral stricture followed by ureteroureterostomy: a comparative study regarding stricture length.

BackgroundTo evaluate the success rate of balloon dilation and the factors possibly influencing the outcomes of balloon dilation for the ureteric strictured portion of ureteroureterostomy (UUS) site in patients with post-gynecologic surgeries.MethodsA single institution data base was screened for the patients who received balloon dilation for a treatment of ureteral stricture diagnosed after gynecologic surgery. Overall 114 patients underwent primary intra-operative UUS due to ureteral injury during gynecologic surgery. Among them, 102 patients received balloon dilation, and their medical records were retrospectively reviewed. Success of balloon dilation was defined as the condition that requires no further clinical interventions after 6 months from balloon dilation.ResultsThe ureter injury rate of women treated with open radical abdominal hysterectomy was highest (32 cases, 31.4%). 60 patients (60.8%) showed successful outcomes regarding dilation. All patients underwent technically successful dilation with a full expansion of balloon during the procedure, but 40 patients (39.2%) were clinically unsuccessful as they showed a recurrence of ureteral stricture on the previous balloon dilation site after the first dilation procedure. Univariate logistic regression analyses showed that stricture length >2 cm was a significant predictor of successful dilation (odds ratio, 0.751; 95% confidence interval, 0.634-0.901; p-value, 0.030), but it failed to achieve independent predictor status in multivariate analysis.ConclusionBalloon dilation can an effective alternative treatment option for strictured portion of the primary UUS in post-gynecologic surgery patients when its length is <2 cm.

Clinical observation of flexible ureteroscope combined with ultramini nephrostomy tract antegrade balloon dilatation on ureteral stricture

Objective To observe the clinical effect of flexible ureteroscope combined with ultramini nephrostomy tract antegrade balloon dilatation in the treatment of ureteral stricture. Methods A total of 24 patients with ureteral stricture in our hospital underwent flexible ureteroscope combined with ultramini nephrostomy tract under general anesthesia, and the guidewire and balloon dilatation catheters were used to expand urethral stricture, and F7 catheter was placed. Results All patients were successfully implemented flexible ureteroscope under direct vision narrow segment balloon dilatation and stent implantation, after the operation regular replacement of the stent, the stent was pulled out after six months. All patients were followed up for 1 year, and no long-term complications and recurrence occured. Conclusions Flexible ureteroscope combined with ultramini nephrostomy tract antegrade balloon dilatation is safe and effective method, especially for the patients under retrograde balloon dilation unsuccessful is a better alternative select. Key words: Ureteral Obstruction; Ureteroscopes; Balloon Dilatation

Retrograde balloon dilatation for the management of upper-pole ureteropelvic junction obstruction in an incomplete duplicated collecting system

Retrograde balloon dilatation for the management of upper-pole ureteropelvic junction obstruction in an incomplete duplicated collecting system

Endoscopic balloon catheter dilatation via retrograde or static technique is safe and effective for cricopharyngeal dysfunction.

AIMTo evaluate the safety and efficacy of upper esophageal sphincter (UES) dilatation for cricopharyngeal (CP) dysfunction. To determine if: (1) indication for dilatation; or (2) technique of dilatation correlated with symptom improvement.METHODSAll balloon dilatations performed at our institution from over a 3-year period were retrospectively analyzed for demographics, indication and dilatation site. All dilatations involving the UES underwent further review to determine efficacy, complications, and factors that predict success. Dilatation technique was separated into static (stationary balloon distention) and retrograde (brusque pull-back of a fully distended balloon across the UES).RESULTSFour hundred and eighty-eight dilatations were reviewed. Thirty-one patients were identified who underwent UES dilatation. Median age was 63 years (range 27-81) and 55% of patients were male. Indications included dysphagia (28 patients), globus sensation with evidence of UES dysfunction (2 patients) and obstruction to echocardiography probe with cricopharyngeal (CP) bar (1 patient). There was evidence of concurrent oropharyngeal dysfunction in 16 patients (52%) and a small Zenker’s diverticula (≤ 2 cm) in 7 patients (23%). Dilator size ranged from 15 mm to 20 mm. Of the 31 patients, 11 had dilatation of other esophageal segments concurrently with UES dilatation and 20 had UES dilatation alone. Follow-up was available for 24 patients for a median of 2.5 mo (interquartile range 1-10 mo), of whom 19 reported symptomatic improvement (79%). For patients undergoing UES dilatation alone, follow-up was available for 15 patients, 12 of whom reported improvement (80%). Nineteen patients underwent retrograde dilatation (84% response) while 5 patients had static dilatation (60% response); however, there was no significant difference in symptom improvement between the techniques (P = 0.5). Successful symptom resolution was also not significantly affected by dilator size, oropharyngeal dysfunction, Zenker’s diverticulum, age or gender (P > 0.05). The only complication noted was uvular edema and a shallow ulcer after static dilatation in one patient, which resolved spontaneously and did not require hospital admission.CONCLUSIONUES dilatation with a through-the-scope balloon by either static or retrograde technique is safe and effective for the treatment of dysphagia due to CP dysfunction. To our knowledge, this is the first study evaluating retrograde balloon dilatation of the UES.

Efficacy and safety of percutaneous renal access flexible ureteroscope plus balloon dilatation for patients with complex lower ureterostenosis

To explore the clinical efficacy and safety of percutaneous renal access anterograde flexible ureteroscope plus retrograde balloon dilation in the treatment of complex lower ureterostenosis. Under ultrasonic guidance, renal calices were successfully punctured for 78 patients with lower ureterostenosis. Then the tract was gradually expanded to 24 F with a metal dilator. Afterward upper ureter was expanded with a flexible ureteroscope sheath. Upon an insertion of guide wire into bladder, a 21 F balloon dilator was retrogradely placed in the narrow segment and maintained for 5 min. Then a D-J stent was antegradely deployed along the guide wire. And the clinical efficacy and safety were followed up. 6 F or 7/12 F D-J stent was successfully placed in 47 patients with unilateral ureterostenosis and 31 with bilateral ureterostenosis. The D-J stent was removed after 3 months. During a follow-up period of 3-9 months, 72 patients had gradually reduced hydronephrosis with an effective rate of 92.31%. Hydronephrosis remained unchanged or aggravated in 6 patients requiring regular replacement of D-J stent. For complex middle or lower ureterostenosis, percutaneous renal access anterograde flexible ureteroscope plus retrograde balloon dilatation can reverse infection, hydronephrosis, renal dysfunction and other complications. And it is safe, effective and mini-invasive.

Management of Ureteropelvic Junction Obstruction With High-pressure Balloon Dilatation: Long-term Outcome in 50 Children Under 18 Months of Age

To analyze the usefulness of dilatation in the treatment of ureteropelvic junction obstruction (UPJ) in children <18 months of age, including newborns and infants. Patients (n = 50; <18 months of age) were diagnosed using abdominal ultrasound, cystogram, and diuretic renography. Treatment was with endourologic retrograde balloon dilatation under fluoroscopic guidance. The balloons were, in all cases, semicompliant with a profile of 5 mm, 6 mm, or 7 mm. Follow-up was for 42.9 ± 23.2 months (mean ± SD). Double-J stents were inserted postdilatation, the caliber and length depending on the patient's body weight. Intervention duration was 22 ± 19 minutes. Dilatation was not possible in 5 patients, and pyeloplasty was the alternative treatment. Hospital stay was 24 hours in 44 patients. Analgesic needs were met exclusively by nonsteroidal anti-inflammatory drugs. The double-J stent was withdrawn using cystoscopy and the UPJ was calibrated.Residual stenosis was found in 7 patients. A second dilatation was required in 3 patients 6-18 months after surgery because of the lack of improvement of hydronephrosis. During follow-up, resolution of the hydronephrosis was observed in 45 cases (anterior-posterior diameter of the renal pelvis 7 ± 5 mm). The diuretic renography improved in 45 infants; the shape of the curve being normal in 44 cases and semi-obstructive in 1. We believe that high-pressure balloon dilatation could be a valid and safe option in the minimally invasive treatment of UPJ obstruction in infants. The outcome is acceptable with a low complication rate.

Papillary balloon dilation in patients with bile duct stones is not a cause of post-ERCP pancreatitis by itself; results of anterograde and retrograde papillary balloon dilation

s / Pancreatology 13 (2013) e1–e94 e20 metalloproteinases-1) genes. HPSC expressed all four EP (EP1-4) receptors. Only blocking the EP4 receptor resulted in abrogation of PGE2 mediated HPSC activation. Specificity of EP4 for the effects of PGE2 on stellate cells was confirmed using specific antagonists. Conclusion: Our data indicate that PGE2 regulates PSC profibrotic activities via EP4 receptor thus suggesting EP4 receptor as useful therapeutic target for pancreatic cancer to reduce desmoplasia.

Comparison of Seromuscular Tunnel and Split-cuff Nipple Antireflux Ureteroenteral Anastomosis Techniques in Orthotopic Taenia Myectomy Sigmoid Neobladder: A Prospective, Randomized Study

To compare the functional results and complications of seromuscular tunnel and split-cuff nipple antireflux ureteroenteral implantation techniques in orthotopic taenia myectomy sigmoid neobladder. A randomized prospective study was conducted from January 2004 to January 2009. A total of 62 patients (53 men and 9 women; all of Han ethnicity) with muscle-invasive urothelial carcinoma of the bladder and a normal upper urinary tract were enrolled in the present study. After pelvic lymphadenectomy and radical cystectomy, the ureters were randomized to implantation using seromuscular tunnel anastomosis or a split-cuff nipple technique. Regular follow-up visits included renogram intravenous urography and serum creatinine to evaluate renal function. The mean follow-up period was 52.0 ± 19.2 months (range 12-84). The serum creatinine levels remained normal in all patients throughout the study period. Stenosis occurred in 4 of 118 renoureteral units (4 patients), 2 with a seromuscular tunnel anastomosis and 2 with split-cuff nipple reimplantation. Only 1 stricture required treatment; the patient underwent retrograde balloon dilation after double-J stent insertion. The others received active surveillance, and the hydronephrosis did not worsen. No reflux was observed in any patient. One patient presented with bilateral hydronephrosis due to neovesicourethral stricture, which was treated successfully with transurethral urethrotomy. No difference in stricture formation was seen between the patients treated with the seromuscular tunnel or split-cuff nipple ureteroenteral anastomosis techniques in the orthotopic taenia myectomy sigmoid neobladder. No patients developed reflux. Our results suggest that both the seromuscular tunnel and the split-cuff nipple approach are reliable antireflux ureterointestinal anastomosis techniques, with low morbidity for orthotopic taenia myectomy sigmoid neobladder.

Laparoscopic-Assisted Vesicocalicostomy for Severe Pelvi-Ureteral Stricture Disease

A 39-year-old female previously treated with shock wave lithotripsy developed extensive ureteral stricture disease. After 2 unsuccessful attempts at retrograde balloon dilatation, she was evaluated at our center for further management. Successful reconstruction was performed with laparoscopic-assisted vesicocalicostomy.

Ureteral Injury in Gynecologic Surgery: A 5-Year Review in A Community Hospital

PurposeWe reviewed the cases of ureteral injury during gynecologic surgeries in a community hospital and attempted to find possible options for alleviating these distressing situations.Materials and MethodsA total of 2,927 patients underwent gynecologic surgeries in the last 5 years at our hospital. We retrospectively analyzed the cases, particularly the possible risk factors and management according to the time of detection of the injury. Thirty-five cases (1.2%) were identified with ureteral injury in a total of 2,927 gynecologic surgeries. Risk factors included endometriosis, pelvic inflammatory disease, previous pelvic surgery, history of pelvic radiation, and congenital anomalies. Among 2,927 patients, 522 had predisposing factors for ureteral injuries.ResultsThe incidence of ureteral injury in laparoscopic cases was 1.1%, similar to the cases of laparotomy (1.2%). The rate of ureteral injury was significantly higher in the group with risk factors (2.7%) than in the group without risk factors (0.9%; p=0.002). Prophylactic ureteral stenting was performed in 101 of 522 patients with risk factors according to the gynecologic surgeon's preference. The injury rate (1.0%) in the stenting group was lower than that in the non-stenting group (3.1%; p=0.324). Management of ureteral injuries was successful in all cases. Of the patients with postoperatively diagnosed injuries, two patients were managed with secondary procedures, such as retrograde balloon dilatation or ureteroneocystostomy.ConclusionsThe incidence of ureteral injury was significantly higher in cases having risk factors than in cases without risk factors. Surgeons should be cautious to avoid ureteral injury during gynecologic surgery, especially in patients with risk factors.

Retrograde balloon dilation >10 weeks after renal transplantation for transplant ureter stenosis – our experience and review of the literature

ObjectiveDespite many efforts to prevent ureteric stenosis in a transplanted kidney, this complication occurs in 3–5% of renal transplant recipients. Balloon dilatation (BD) is a possible minimally invasive approach for treatment, but reports to date refer only to the antegrade approach; we analysed our experience with retrograde BD (RBD) and reviewed previous reports. Patients and methodsFrom October 2008 to February 2011, eight patients after renal transplantation (RTX) underwent RBD for transplant ureteric stenosis at our hospital. We retrospectively analysed the outcome and reviewed previous reports. ResultsThe eight recipients (five men and three women; median age 55years, range 38–69) were treated with one or two RBDs for transplant ureteric stenosis. There were no complications. The median (range) time after RTX was 4.5 (2.5–11)months. Long-term success was only achieved in one recipient, while five patients were re-operated on (three with a new implant, two by replacement of transplanted ureter with ileum) after a median (range) of 2.8 (0.7–7.0)months after unsuccessful RBD(s). For two recipients the success remained unclear (one graft loss due to other reasons, one result pending). When the first RBD was unsuccessful there was no improvement with a second. ConclusionRBD is technically feasible, but our findings and the review of previous reports on antegrade ureteric dilatation suggest that the success rate is low when the ureter is dilated at ⩾10weeks after RTX. From our results we cannot recommend RBD for transplant ureteric stenosis at ⩾10weeks after RTX, while previous reports show favourable results of antegrade BD in the initial 3months after RTX.

Retrograde recanalization of chronic total coronary artery occlusion using a novel “reverse wire trapping” technique

Percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) remains a technical challenge for the interventional cardiologists. Recently, modified techniques based on the retrograde approach have demonstrated that this approach could increase the success rate for PCI of CTO. In the current report, we describe a novel "reverse wire trapping" technique that can help create an antegrade wire route to open CTO after the wire has passed through the CTO retrogradely, even though the retrograde balloon dilatation or antegrade wiring was unapproachable.

Resultados a medio plazo del tratamiento endourológico retrógrado con balón de la estenosis pieloureteral en niños menores de 1 año

AimIn the last years it has spread minimally invasive therapeutic for the treatment of pyeloureteral junction obstruction in children. Some of them have got poor outcomes in 4-year-old minor children. We show our experience in the retrograde dilatation with balloon of high pressure in infants. MethodsIt´s a retrospective study of 16 infants treated in our hospital. The average follow-up after the intervention is 27.4±10.0 months. The diagnostic protocol included abdominal ultrasound, cystogram and diuretic renography. The treatment was realized by endourology retrograde balloon dilatation under fluoroscopy. The balloons were in all the cases semicompliant, with a profile of 5 mm, 6 mm ó 7 mm. After the expansion there was placed stents type double J with profile and length depending on the weight of the patient. To obtain the results, we do ultrasound scans and diuretic renography at least 1 year after the intervention. ResultsThe mean duration of the intervention was 36.4±15.5 minutes. During the intervention, in 2 patients the placement of the stent was not possible. The time of revenue was 48 hours in all the patients except in 1 of them. The analgesic needs were exclusively non steroid antiinflammatorys. The double J stent was withdrawn with cystoscopy. In 3 patients there were postoperatory complications: a migration of the stent, a urinary infection and an urinoma. In 1 patient with worsening of hydronephrosis was needed of pyeloplasty. In the controls the disappearance of the hydronephrosis was observed in all the cases, eliminating likewise the expansion of the renal calyces. The diuretic renography improved in all babies, being the boss of the curve normal in 14 cases and semi obstructively in 2. The mean time of elimination was 9.8±2.8 minutes. ConclusionsWe think that the balloon dilatation of pyeloureteral junction obstruction is a minimally aggressive technique that is possible to realize in infants with good results and scanty complications.

Wire trapping technique combined with retrograde approach for recanalization of chronic total occlusion

Wire trapping technique combined with retrograde approach for recanalization of chronic total occlusion

Retrograde balloon dilatation of right coronary artery lesions through a venous graft

Percutaneous coronary intervention (PCI) using retrograde approach through venous grafts or collateral vessels is a promising option for chronic total occlusion (CTO) lesions in which antegrade crossing is not possible. We describe a successful retrograde balloon dilatation of right coronary artery lesions through a venous graft in a patient with a previous coronary bypass surgery.

POS-02.131: Efficacy of retrograde balloon dilation for the treatment of benign ureteral strictures

POS-02.131: Efficacy of retrograde balloon dilation for the treatment of benign ureteral strictures