Subcutaneous Pyelovesical Bypass Research Articles

Morbidity and long-term results of subcutaneous pyelovesical bypass in chronic ureteral obstruction

We present the long-term results and complications of the DETOUR® prosthesis, a permanent subcutaneous pyelovesical bypass for the treatment of ureteral obstruction. Between 2006 et 2018, 34 prosthesis were implanted in 28 patients (mean age 65,8 years) with ureteral obstruction of malignant or benign etiologies. The prosthesis, composed to an inner tube of silicone and an outer tube of expanded polytetrafluoroethylene, is placed subcutaneously between the kidney and the bladder. We are performed infrared spectrophotometry and scanning electron microscopy on two removed prostheses to explore the prosthetic encrustation. The average follow-up was 25,8 months (Maximum: 64 months). Stent revision was required for early bladder fistula in three patients. The major long-term complications were infection (46%), obstruction (3 patients) and bladder fistula (7 patients). The most frequently infection are non-severe, but two patients died from septic shock after fungic colonization of the prosthesis. The infrared spectrophotometry and scanning electron microscopy analysis showed that the obstruction was favored by urinary infection and an alkaline medium. The functional prosthesis rate at 1,2 and 3 years was 94%, 71% and 62%, respectively. The DETOUR® subcutaneous extra-anatomical urinary bypass is an effective and minimally invasive alternative to permanent percutaneous nephrostomy, for both malignant and benign ureteral obstructions in selected patients. 3.

The significance of palliative surgery in castration-resistant prostate cancer

If prostate cancer recurs after primary treatment, deprivation therapy with LHRH analogues or antagonists is the treatment of choice in men with metastatic prostate cancer. However, this treatment only achieves palliative results. Median time to progression ranges between 11 and 78 months. After the introduction of Docetaxel as a first-line treatment in castration-resistant prostate cancer (CRPCA) and cabazitaxel as a second-line chemotherapy, several new drugs containing abiraterone, enzalutamide, radium 223 and sipuleucel-T have become available, which can lead to complete or partial remissions in metastasis, but do not have an effect on the prostate itself as has been shown recently. As a result of local progression of CRPCA, local complications of the urinary tract such as subvesical obstruction, recurrent gross haematuria with or without clotting, upper urinary tract dilatation, rectourethral or rectovesical fistulae and rectal obstruction will occur in about one third of all patients. Several surgical treatment options are available to manage the aforementioned complications. In patients with local progressive CRPCA and lower urinary tract symptoms, palliative TUR-P, radical prostatectomy or radical cystoprostatectomy with urinary diversion and even anterior and posterior exenteration can be performed in selected patients, requiring a preoperative multiparametric MRI of the prostate and the pelvic floor along with a laboratory examination to optimise surgical techniques and perioperative outcomes. In case of symptomatic involvement of the upper urinary tract system, the placement of endoluminal DJ stents or percutaneous nephrostomy in men with a poor performance status and a short life expectancy is the treatment of choice. In men with an ECOG performance status of 0 to 1, reconstructive surgery such as ureteral reimplantation, ileal ureteral replacement or placement of a subcutaneous pyelovesical bypass is an appropriate treatment option. To summarise, the aforementioned palliative surgical treatment options should be provided for selected patients and performed by well-experienced urologists.

Subcutaneous pyelovesical bypass - Detour bypass - as a solution for ureteric obstruction.

IntroductionMany patients suffer from unilateral or bilateral hydronephroses caused by pelvic tumors, retroperitoneal fibrosis, occlusion due to radiation therapy or iatrogenic damage to the ureter. Currently, percutaneous nephrostomy or double J stents are primarily used. Nephrostomy deteriorates a patient’s quality of life and leads to frequent infections, blockage of tubes, or bleeding, while uretral stents are associated with septicemia and irritative bladder symptoms. Thus, a useful solution is a Detour stent.Material and methodsA Detour stent consists of an outer layer made of polytetrafluoroethylene and an inner layer that is a silicone tube 17 F wide, with perforations on both ends and a radio-opaque ring on the proximal end. The ring allows for the insertion of the Detour to the kidney in the correct way. The Detour is placed subcutaneously to the kidney and to the bladder. The route is then tunneled by the large plastic hollow tube for inserting the Detour, and its distal end is sutured to the bladder.ResultsTwelve patients were operated using this method, one of which received a Detour stent bilaterally. The mean follow-up was 10 months. All patients were operated previously by different methods. The average time of surgery was 78 minutes. The following complications occurred: urinary tract infections, haematoma, obstructed flow of urine through the Detour stent, prolonged urinary leakage, and pyelonephritis.ConclusionsSubcutaneous nephrovesical bypass – Detour System – is a minimally invasive, safe and effective procedure that improves quality of life with no serious complications. The Detour System allows urine to be drained in those cases where many other treatments had failed or were not feasible.

The role of palliative surgery in castration-resistant prostate cancer.

Androgen deprivation therapy with luteinising hormone releasing hormone (LHRH) analogues or antagonists represents the treatment of choice in men metastatic prostate cancer (PCA). Depending on the serum concentration of the prostate-specific antigen (PSA) nadir, the survival might vary between 11 and 78 months. About one-third of all patients without local treatment of the primary will develop significant complications of the lower and upper urinary tract because of local progression of PCA. It is the purpose of the review to inform the treating physician about palliative surgical options in men with castration-resistant prostate cancer (CRPC). In men with CRPC and lower urinary tract symptoms, palliative transurethral resection of the prostate (TUR-P) can be performed with a 60-70% success rate. Infiltration of the pelvic floor, the bladder neck and trigone and the external urethral sphincter can make palliative radical surgery necessary. Bladder neck closure with continent vesicostomy, radical cystoprostatectomy with an incontinent urinary diversion, and anterior and posterior exenteration are individual therapeutic options in men with a good performance status and a considerable life expectancy. Symptomatic involvement of the upper urinary tract can be managed by placement of endoluminal stents or a percutaneous nephrostomy in men with a poor performance. In men with a good response to androgen deprivation therapy (ADT) and a good performance status reconstructive ureteral surgery might be considered and the options of ureteral reimplantation, ureter ileal replacement and a subcutaneous pyelovesical bypass have to be discussed. There are various palliative surgical treatment options in the management of men with CRPC and symptomatic deterioration of the lower or the upper urinary tract, which should be considered in well selected patients. The indication to perform one of the above-mentioned surgical approaches needs to be discussed in a multidisciplinary tumour board.

Simultaneous bilateral subcutaneous pyelovesical bypass as a salvage procedure in refractory retroperitoneal fibrosis

Ureteral obstruction causing renal failure is the most common complication associated with retroperitoneal fibrosis (RPF). Initial management includes steroid therapy together with ureteral stenting. When these fail, ureterolysis is the recommended surgical procedure. However, this could be challenging and recurrence is common. The aim of the present case series was to assess the feasibility of inserting simultaneous bilateral subcutaneous pyelovesical bypass grafts (SPBGs) in patients presenting with RPF who had failed initial endourologic/surgical management.

Long-Term Outcome of Subcutaneous Pyelovesical Bypass in Extended Ureteral Stricture After Renal Transplantation

Extended ureteral stricture is a rare complication of renal transplantation. Its management remains challenging. The aim of our study was to report our 15 years of experience with subcutaneous pyelovesical bypass graft (SPBG) in selected renal transplant patients who presented with extended ureteral stricture and who were not eligible for open ureteral reconstruction. Seven patients were operated on between 1992 and 2007-six men and one woman-with a mean age at surgery of 47 years (range 30-67 y). We report no encrustation or dislodgment with a mean follow-up of 6 years (range 1-14 y). Postoperative mortality was null. During the follow-up, three patients died: Two from an extrarenal cause with a functional SPBG and a stable renal function; one from septic shock after fungic colonization of the prosthesis. Asymptomatic urinary tract infection developed in two other patients, with no renal function impairment. Despite a 47% rate of infection (3/7), SPBG can be a safe and efficient alternative to open surgery to save many years of graft function in renal transplant patients who present with extended ureteral stricture.

Successful Salvage of Kidney Allografts Threatened by Ureteral Stricture Using Pyelovesical Bypass

Ureteral stricture is the most common urologic complication after renal transplantation. When endourologic management fails, open ureteral reconstruction remains the standard treatment. The complexity of some of these procedures makes it necessary to explore other means of repair. This study evaluated the intermediate-term outcome of subcutaneous pyelovesical bypass graft (SPBG) on renal transplant recipients. We reviewed 8 patients (6 male and 2 female; mean age 52 years) with refractory ureteral strictures postrenal transplantation, who received SPBG as salvage therapy. All patients failed endourologic management and half failed open management of their strictures. After a mean follow-up of 19.4 months, 7 out of 8 renal grafts have good function with mean GFR of 58.5 mL/min/1.73 m(2), without evidence of obstruction or infection. One patient lost his graft due to persistent infection of the SPBG and one patient developed a recurrent urinary tract infection managed with long-term antibiotics. SPBG offers a last resort in the treatment of ureteral stricture after renal transplantation refractory to conventional therapy.

2068 ARTIFICIAL URETERS IN RENAL TRANSPLANTATION: A RETROSPECTIVE CASE SERIES

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery I1 Apr 20102068 ARTIFICIAL URETERS IN RENAL TRANSPLANTATION: A RETROSPECTIVE CASE SERIES Raed A. Azhar, Saad Aldousari, Mazen Hassanain, Murad Aljiffry, Sero Andonian, Steven Paraskevas, and Maurice Anidjar Raed A. AzharRaed A. Azhar More articles by this author , Saad AldousariSaad Aldousari More articles by this author , Mazen HassanainMazen Hassanain More articles by this author , Murad AljiffryMurad Aljiffry More articles by this author , Sero AndonianSero Andonian More articles by this author , Steven ParaskevasSteven Paraskevas More articles by this author , and Maurice AnidjarMaurice Anidjar More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.2128AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteral stricture is the most common urologic complication after renal transplantation and is seldom cured by endoscopic management alone. When endourologic management fails, open ureteral reconstruction remains the standard treatment. The complexity of some of these procedures added to the additional risk of graft loss made it necessary to provide other means of bypass procedures. Subcutaneous pyelovesical bypass graft, otherwise known as the artificial ureter (AU), was used as an alternative method to treat ureteral strictures in selected patients as a last resort to prevent renal graft loss. The aim of the present study was to evaluate the intermediate-term outcome of AU. METHODS A retrospective review of 8 patients (6 men and 2 woman; median age 49 years) who received AU was performed. Four patients had failed endourologic and open management of ureteral strictures, and in the other 4 we elected to proceed with AU primarily due to the complexity of their lesions. RESULTS After a median follow-up of 19 months, 7 out of 8 renal grafts have good late function without evidence of encrustation or obstruction of their AUs. AU was dislodged in 2 patients; this was easily revised in the immediate post-operative period. One patient developed recurrent urinary tract infections which were managed with long-term antibiotic prophylaxis. Finally, one patient had graft loss secondary to persistent infection of the AU. CONCLUSIONS AU offers a last resort option in the management of ureteral strictures after renal transplantation refractory to conventional therapy, which would otherwise necessitate permanent nephrostomy drainage or nephrectomy. In this intermediate-term analysis, there was stable graft function without evidence of obstruction. Long-term follow-up of these patients is planned to better evaluate the ability of AU in salvaging renal graft function in these high risk patients. Montreal, Canada© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e804 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Raed A. Azhar More articles by this author Saad Aldousari More articles by this author Mazen Hassanain More articles by this author Murad Aljiffry More articles by this author Sero Andonian More articles by this author Steven Paraskevas More articles by this author Maurice Anidjar More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Nephrocutaneous Bypass in Ureteral Obstruction

To describe our experiences with nephrocutaneous bypass and to assess the role of this procedure as a mean of urinary diversion in patients with incurable ureteral obstruction who are not appropriate candidates for subcutaneous pyelovesical bypass. Nephrocutaneous bypass was performed on 15 (12 male, 3 female) patients with incurable ureteral obstruction of malignant (n = 13; 87%) or benign (n = 2; 13%) etiology. Only patients with a significant disturbance of the bladder/sphincter-system were eligible for the procedure. In total, 29 stents were applied using this technique. No major complications were observed perioperatively. The operating time for bilateral nephrocutaneous bypass was 74 (46-102) minutes and for unilateral bypass (1 patient) 38 minutes. Time of indwelling percutaneous nephrostomy before application of nephrocutaneous bypass was 190 (40-870) days. The patients who survived have a mean follow-up of 27 months, whereas for those patients who died the mean follow-up was 7.8 months. Nephrocutaneous bypass resulted in an improved renal function in all patients. Quality of life improvement was reported by all patients, and the objective criteria of "useful life" were met by 13 patients (87%). Nephrocutaneous bypass is a safe and feasible method to provide effective pyelovesical drainage of urine in patients who have a short-term life expectancy, who are in poor general conditions, or otherwise would need a permanent nephrostomy drainage. The technique offers patients a higher mobility, increased independence resulting in higher quality of life during their final period of life, and may also be applied in nonmalignant patients after careful consideration of alternative urinary diversions.

Subcutaneous Pyelovesical Bypass As Replacement for Standard Percutaneous Nephrostomy for Palliative Urinary Diversion: Prospective Evaluation of Patient's Quality of Life

To improve the quality of life of patients with palliative definitive percutaneous nephrostomy, we prospectively evaluated a subcutaneous ureteral bypass using a newly designed ureteral prosthesis. A series of 19 patients receiving 27 subcutaneous tubes in replacement for percutaneous nephrostomy were evaluated. The ureteral prosthesis (Detour), a silicone tube glued inside a polyester tube, is inserted percutaneously into the renal pelvis to replace an established nephrostomy, tunneled subcutaneously, and introduced into the bladder through a small incision. All patients were followed every 3 months for 18 months or until death from tumor. Quality of life was assessed using the EORTC QLC-30 questionnaire; ultrasonography, intravenous urography, or both were used to assess the position and patency of the tubes. There was no failure of insertion and no operative or immediate complication. The mean follow-up was 7.8 months, 6.6 months for the 15 patients who died from their tumors and 1 year for the 4 patients still alive at the end of the study. Suprapubic parietal infection occurred in three patients with altered bladders (radiation cystitis or tumor progression). There was an improvement of the function scale as a result of the elimination of the external percutaneous tube and a parallel worsening of the symptom scale secondary to the progression of disease. Patient ratings of the global quality of life and satisfaction with the urinary diversion were improved because of the absence of the percutaneous tube. The subcutaneous pyelovesical bypass provides a better quality of life than a standard percutaneous nephrostomy tube in terminally ill patients by making them external-tube free.

Total ureteral replacement by subcutaneous pyelovesical bypass in ureteral necrosis after renal transplantation

Abstract Objectives: Ureteral necrosis is a rare complication of renal transplantation, and is seldom cured by endoscopic management alone. To avoid the potential hazard to the graft created by an open ureteral reconstruction in cases of renal transplant ureteral necrosis, we have appiled a new minimally invasive technique of total ureteral replacement, initially described for the palliative treatment of ureteral obstructions. The subcutaneous bypass technique is based on the use of a silicone-PTFE-bonded tube tunnelled underneath the skin. Methods: Total ureteral replacement by subcutaneous pyelovesical bypass was performed in three renal transplant patients (two men and one woman; mean age 41 years, (range 23–58) years with ureteral necrosis after failure of primary endoscopic treatment. The ureteral lesion was distal necrosis in two patients, and a total necrosis in the other. Under general anaesthesia and fluoroscopic guidance, a percutaneous tract was created and progressively dilated. The ureteral prosthesis was introduced into the pyelocaliceal cavities through a 30 F Amplatz sheet, then subcutaneously tracked down to the suprapubic area, and introduced into the bladder via a short incision. Results: There was no operative or postoperative morbidity. There was no obstruction, dislodgement or encrustation of the prosthesis. There were no bladder-related symptoms, or clinical reflux, and no abdominal wall complications. An asymptomatic episode of lower urinary tract infection (Staphylococcus epidermidis) was observed in the female patient. All the grafts were functioning with fine pyelocaliceal cavities, with a mean follow-up of 32 months (13–69 months). Conclusion: Total ureteral replacement by subcutaneous pyelovesical bypass is a simple and safe technique of ureteral reconstruction in renal transplantation. Late encrustation of the prosthesis may occur, and the prosthesis may need to be changed in such cases. Subcutaneous pyelovesical bypass can be regarded as an alternative to an open procedure to treat ureteral necrosis after renal transplantation.

ARTIFICIAL URETERAL REPLACEMENT FOR URETERAL NECROSIS AFTER RENAL TRANSPLANTATION: REPORT OF 3 CASES

Purpose We applied a new minimally invasive technique of artificial ureteral replacement for renal transplant ureteral necrosis. Materials and Methods Artificial ureteral replacement was performed in 3 renal transplant recipients with ureteral necrosis (complete in 1 and distal in 2) after failure of primary endoscopic treatment. Under fluoroscopic guidance a percutaneous tract is created and progressively dilated. The ureteral silicone polytetrafluoroethylene bonded tube is introduced into the pyelocaliceal renal graft cavities, tracked subcutaneously down to the suprapubic area and introduced into the bladder via a short incision. Results There were no immediate postoperative complications except for transient postoperative acute prostatitis in 1 patient. No secondary complications were observed with a mean followup of 2.5 years. All grafts have good late function and all tubes are patent with no evidence of encrustation or obstruction. The tubes are well tolerated underneath the skin. Reflux was present in all 3 cases with no clinical manifestation. An asymptomatic episode of lower urinary tract infection was observed in the female patient. Conclusions In select cases of ureteral necrosis after renal transplantation artificial ureteral replacement by subcutaneous pyelovesical bypass offers a possible alternative to open ureteral reconstruction.