UROLOGICAL SURVEY
Endourology & laparoscopy
Ureteropelvic junction obstruction: determining durability of endourological intervention
Albani JM, Yost AJ, Streem SB
From the Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
J Urol.; 171: 579-82
PURPOSE: We evaluated the durability of endourological intervention for ureteropelvic junction obstruction and established guidelines for postoperative surveillance.
MATERIALS AND METHODS: Since 1989, 150 patients have undergone endourological intervention for ureteropelvic junction obstruction, of whom 127 (53 men and 74 women) 13 to 79 years old (mean age 40.4) underwent postoperative evaluation at our center. These 127 patients are the study group reported. Endourological management consisted of hot wire balloon endopyelotomy in 25 patients, percutaneous endopyelotomy in 67 and ureteroscopic laser endopyelotomy in 35. Success in this study was strictly defined as symptomatic relief plus radiographic resolution on excretory urogram and/or diuretic renogram. Statistical analysis was performed to assess mean time to failure and develop Kaplan-Meier re-stenosis-free survival estimates.
RESULTS: Followup was 1 to 128 months (mean 22). Time to failure was 0.9 to 32.4 months (mean ± SD 10.3 ± 9.4). Kaplan-Meier estimates of time to re-stenosis (failure) were 6 months in 12% of patients, 12 in 22%, 18 in 24%, 24 in 27%, 30 in 32% and 36 in 37%. After 3 years no further failures were observed and Kaplan-Meier estimates remained unchanged.
CONCLUSIONS: The long-term probability of success, which is estimated to be 63.3% in this series, is somewhat lower than that reported in the literature. It likely is a result of longer followup and a more strict definition of success that includes functional and symptomatic relief. Our data suggest that while most failures become evident within the first 12 months, failure can develop as late as 3 years after intervention. As such, patients should be followed at least that long to ensure a durable result.
Editorial Comment
Data such as this has been presented at meetings for a few years, and many in the academic community have started to lose favor for endopyelotomy and move towards laparoscopic pyeloplasty because of these findings. Although the mean time to failure was 10 months in this study, patients continued to fail up to 3 years post-operatively. A procedure with a 63% success rate long-term is just not a good choice for a young, active patient. On the basis of data such as this, I continue to offer endopyelotomy but encourage my patients towards pyeloplasty (if they are medically fit) because of my perception (although there are few data) that pyeloplasty will have better durability.
Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA
A new technique for treating forgotten indwelling ureteral stents: silk loop assisted ureterorenoscopic lithotripsy
Yeh C-C, Chen C-H, Lin C-H, Chang C-H, Wu H-C
From the Department of Urology, China Medical University Hospital, China Medical University, Taichung City, Taiwan, Republic of China
J Urol. 2004; 171:719-21
PURPOSE: Treating forgotten indwelling ureteral stents is difficult because forgotten stents become encrusted and fragmented. Therefore, we developed a silk loop with which to loop the lower end of a forgotten ureteral stent during ureterorenoscopy to supply a counterforce, which fixed the stent while separating encrusted stones from the forgotten stent. We evaluated the success of the silk loop method.
MATERIALS AND METHODS: Nine patients were enrolled in this study from 1997 to 2003. Each patient had a forgotten ureteral stent with renal stones on the tip of the proximal end. All consented to the procedure of silk loop assisted ureterorenoscopic lithotripsy (URSL) with a Lithoclast (Microvasive, Natick, Massachusetts) lithotriptor.
RESULTS: We successfully removed the forgotten indwelling stent from all 9 patients with the silk loop assisted URSL method.
CONCLUSIONS: Silk loop assisted URSL makes the removal of forgotten stents easier. While percutaneous nephrostolithotomy and open surgery produce successful results, the silk loop method is less invasive and expensive, and it minimizes hospital recovery time.
Editorial Comment
Encrusted retained ureteral stents are a frustrating and difficult surgical challenge. Shock wave lithotripsy of the stent to loosen fragments, combined percutaneous and cystoscopic lithotripsy of the renal and bladder ends of the stent (which are usually the most encrusted), and open surgery have all been reported. The authors of this article demonstrate nicely that small caliber ureteroscopes can be used with great effectiveness to provide a less morbid, outpatient solution. The silk-loop retraction of the bladder end of the stent appears to be a great trick, as friction of the ureteroscope on the stent can sometimes be problematic as the ureteroscope is advanced up the ureter, and allowed use of a semi-rigid instrument with a pneumatic lithotrite. The next time you are faced with an encrusted ureteral stent, consider the ureteroscopic approach.
Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA
Publication Dates
-
Publication in this collection
02 June 2004 -
Date of issue
Apr 2004
