(Radiology. 2000;214:358-362.)
© RSNA, 2000
Vascular and Interventional Radiology |
Percutaneous Incision of Stenotic Uroenteric Anastomoses with a Cutting Balloon Catheter: Long-term Results1
François Cornud, MD,
Yves Chrétien, MD,
Olivier Hélénon, MD,
Jean-Michel Casanova, MD,
Jean-Michel Correas, MD, PhD,
Didier Bonnel, MD,
Arnaud Méjean, MD and
Jean-François Moreau, MD
1 From the Departments of Radiology (F.C., O.H., J.M. Correas, J.M. Casanova, D.B., J.F.M.) and Urology (Y.C., A.M.), Hôpital Necker, Paris, France; and Collège Européen et Francophone d'Urologie Libérale, Paris (F.C., J.M. Casanova, D.B.). Received October 13, 1998; revision requested December 8; final revision received April 16, 1999; accepted July 27. Address reprint requests to F.C., 15 Avenue Robert Schuman, 75007 Paris, France (e-mail: frcornud@club-internet.fr).
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Abstract
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PURPOSE: To describe the technique and results of incision of strictures in anastomotic urinary diversions with a commercially available cutting balloon catheter.
MATERIALS AND METHODS: Thirty-seven stenoses were treated in 32 patients. Most (28 [88%]) of the patients had undergone surgery for bladder cancer 17.7 months ± 17.4 (SD) (range, 3–72 months) before incision. Thirteen patients had undergone ileal conduit diversion, and nineteen had undergone enterocystoplasty. All stenoses were shorter than 3 cm. The presence of adjacent ileal loops and/or iliac vessels was assessed with computed tomography before incision. The cutting wire was oriented anteriorly or anterolaterally, and the balloon was inflated with diluted contrast material during the incision. A Kaplan-Meier survival curve was constructed to illustrate the success rates over time.
RESULTS: No major complications occurred. Twelve (32%) stenoses recurred in nine patients 15 months ± 10 (range, 6–36 months) after stent removal; the failure rate was 53% (eight of 15 stenoses) for ileal conduits and 18% (four of 22 stenoses) for enterocystoplasties. Late failure (>12 months) was observed in four patients. The patency of the other 25 stenoses (23 patients) was checked 25 months ± 11 after stent removal (range, 5–43 months). The actuarial patency rate was 77% at 1 year, 68% at 2 years, and 62% at 3 years.
CONCLUSION: Cutting balloon incision is a safe and simple alternative to surgery, particularly when the urinary diversion is enterocystoplasty.
Index terms: Bladder, interventional procedures, 83.1267 • Bladder, neoplasms, 83.32 • Ureter, interventional procedures, 82.1267 • Ureter, stenosis or obstruction, 82.842, 82.843
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Introduction
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The onset of a stricture in a uroenteric anastomosis following urinary diversion is a serious problem that may lead to gradual loss of renal function (1). These stenoses occur in 5%–10% of cases (2,3). They are difficult to treat surgically because of fibrotic adhesions after previous surgery or impaired tissue healing due to radiation therapy or surgically induced ischemia; surgical revision carries a high risk of postoperative morbidity. This has stimulated the search for alternative approaches. Initially, percutaneous transrenal high-pressure balloon dilation was used by several investigators (4–8), but it had a long-term success rate of only 16%–37%.
Although metallic stents were used successfully in four patients (9), with a success rate of 75% (in three of four patients) at 12 months, and in two recent articles on balloon dilation more encouraging results were reported, with success rates of 61% (10) and 86% (11) after a mean follow-up of 16 and 17 months, respectively, it has been established that ureteroileal stenoses have a high potential for recurrence (8). This led several groups to try to incise rather than dilate these stenoses to obtain more consistent results. To the best of our knowledge, Meretyk et al (12) were the first to use incision in a clinical application, followed by Cornud et al (13,14). The major limitation of this technique is the need for specialized endoscopic equipment and for radiologists and endoscopists who have extensive experience in interventional uroradiologic techniques.
Because of the development of a cutting balloon catheter (Acucise; Applied Medical Technologies, Laguna Hills, Calif) (15), various types of ureteral stenoses, including uroenteric anastomoses, can now be incised with fluoroscopic guidance. Herein, we describe our long-term results with the cutting balloon catheter in 32 patients with 37 strictures of uroenteric anastomoses.
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MATERIALS AND METHODS
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Between July 1994 and July 1997, 32 patients with strictures of a uroenteric anastomosis were referred by 12 surgical centers to two separate institutions for interventional uroradiologic treatment. Thirty-seven stenoses were treated in the 32 patients (29 men, three women; mean age ± SD, 65 years ± 14; age range, 30–80 years). The reason for urinary diversion was bladder cancer in 28, uterine cervical carcinoma in one, and neurogenic bladder in three patients. Nineteen patients underwent enterocystoplasty (in every case, orthotopic continent ileal neobladder procedure was performed without crossed-over ureter), and 13 underwent ileal conduit diversion.
The mean interval between surgery and treatment of stenosis was 17.7 months ± 17.4 (SD) (range, 3–72 months). The stenoses became apparent because of either hydronephrosis or renal impairment in bilateral stenosis. Hydronephrosis was detected by using excretory urography performed during follow-up or by using ultrasonographic (US) examination; it was subsequently confirmed by using intravenous urography. One patient had poor renal function on the affected side, which manifested as poor excretion at urography and as thickness of the renal parenchyma at US. When the stenosis occurred within 3 months after surgery, a further interval of 4 months was allowed before performing incision. This interval was to ensure that the stenosis was not due to edema or poor peristaltic transmission at ureteral anastomoses, which can persist for several weeks postoperatively and produce transient substantial ureteral obstruction (1). One patient was treated 3 months after surgery for an infected hydronephrosis that required immediate percutaneous nephrostomy.
The stenoses were less than 3 cm long in every case, and the ureter was totally obstructed in two patients. The stenoses were on the right side in 20 cases and on the left side in 17. In every case, a CT scan was obtained 24 hours prior to incision. In four patients, the scan showed that the internal iliac artery lay close behind the anastomosis (Fig 1).
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Figure 1. Contiguous transverse CT scans obtained in a 68-year-old-man show the right internal iliac artery (arrows) just behind the anastomotic site (arrowheads). No vital structures are seen anteriorly, so the incision can be made safely.
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At each of the two institutions, all of the incisions were made by the same operator (F.C.). After providing informed consent, the patients were put under general anesthesia and placed in an oblique supine position to expose the lumbar fossa for percutaneous nephrostomy while allowing access to the cutaneous stoma, when it was present. A percutaneous nephrostomy tube was inserted with combined US and fluoroscopic guidance, and a preshaped angiographic catheter (Berenstein; Bard Urological, Covington, Ga) was inserted into the ureter. A nephrostogram was obtained to assess the length of the stenosis (Fig 2a), and a hydrophilically coated guide wire (Terumo, Tokyo, Japan) was used to traverse the stenosis. In the two patients with a totally obstructed ureter, a neotract between the ureter and the ileal bladder was created according to a technique previously described (15). The guide wire and catheter were then passed through the ileal conduit until both emerged from the stoma. In the cases of neobladder, the guide wire was coiled into the neobladder, and the Berenstein catheter was then removed.
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Figure 2a. Incision with the cutting balloon catheter in a 64-year-old man. (a) Nephrostogram (oblique view) shows a typical short (15-mm) right anastomotic stenosis through which a catheter (arrow) has been passed. (b) Photograph of the cutting balloon device with a 2.8-cm-long active cutting surface (arrows) on a 150-µm wire. (c) Nephrostogram (oblique view) shows the cutting balloon is in place and has been inflated with 1.5 mL of diluted contrast material. The waist (arrow) caused by the stenosis is visible, and the cutting current can be applied. (d) Nephrostogram (oblique view) shows the fully inflated balloon (arrowheads) after application of the cutting current. (e) Nephrostogram obtained after balloon removal shows a widely patent anastomosis. Although no extravasation of contrast material was seen at the site of the incision, the incision was not repeated. (f) Excretory urogram obtained 2 years later shows absence of hydronephrosis, which indicates a patent anastomosis on the right side.
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Figure 2b. Incision with the cutting balloon catheter in a 64-year-old man. (a) Nephrostogram (oblique view) shows a typical short (15-mm) right anastomotic stenosis through which a catheter (arrow) has been passed. (b) Photograph of the cutting balloon device with a 2.8-cm-long active cutting surface (arrows) on a 150-µm wire. (c) Nephrostogram (oblique view) shows the cutting balloon is in place and has been inflated with 1.5 mL of diluted contrast material. The waist (arrow) caused by the stenosis is visible, and the cutting current can be applied. (d) Nephrostogram (oblique view) shows the fully inflated balloon (arrowheads) after application of the cutting current. (e) Nephrostogram obtained after balloon removal shows a widely patent anastomosis. Although no extravasation of contrast material was seen at the site of the incision, the incision was not repeated. (f) Excretory urogram obtained 2 years later shows absence of hydronephrosis, which indicates a patent anastomosis on the right side.
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Figure 2c. Incision with the cutting balloon catheter in a 64-year-old man. (a) Nephrostogram (oblique view) shows a typical short (15-mm) right anastomotic stenosis through which a catheter (arrow) has been passed. (b) Photograph of the cutting balloon device with a 2.8-cm-long active cutting surface (arrows) on a 150-µm wire. (c) Nephrostogram (oblique view) shows the cutting balloon is in place and has been inflated with 1.5 mL of diluted contrast material. The waist (arrow) caused by the stenosis is visible, and the cutting current can be applied. (d) Nephrostogram (oblique view) shows the fully inflated balloon (arrowheads) after application of the cutting current. (e) Nephrostogram obtained after balloon removal shows a widely patent anastomosis. Although no extravasation of contrast material was seen at the site of the incision, the incision was not repeated. (f) Excretory urogram obtained 2 years later shows absence of hydronephrosis, which indicates a patent anastomosis on the right side.
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Figure 2d. Incision with the cutting balloon catheter in a 64-year-old man. (a) Nephrostogram (oblique view) shows a typical short (15-mm) right anastomotic stenosis through which a catheter (arrow) has been passed. (b) Photograph of the cutting balloon device with a 2.8-cm-long active cutting surface (arrows) on a 150-µm wire. (c) Nephrostogram (oblique view) shows the cutting balloon is in place and has been inflated with 1.5 mL of diluted contrast material. The waist (arrow) caused by the stenosis is visible, and the cutting current can be applied. (d) Nephrostogram (oblique view) shows the fully inflated balloon (arrowheads) after application of the cutting current. (e) Nephrostogram obtained after balloon removal shows a widely patent anastomosis. Although no extravasation of contrast material was seen at the site of the incision, the incision was not repeated. (f) Excretory urogram obtained 2 years later shows absence of hydronephrosis, which indicates a patent anastomosis on the right side.
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Figure 2e. Incision with the cutting balloon catheter in a 64-year-old man. (a) Nephrostogram (oblique view) shows a typical short (15-mm) right anastomotic stenosis through which a catheter (arrow) has been passed. (b) Photograph of the cutting balloon device with a 2.8-cm-long active cutting surface (arrows) on a 150-µm wire. (c) Nephrostogram (oblique view) shows the cutting balloon is in place and has been inflated with 1.5 mL of diluted contrast material. The waist (arrow) caused by the stenosis is visible, and the cutting current can be applied. (d) Nephrostogram (oblique view) shows the fully inflated balloon (arrowheads) after application of the cutting current. (e) Nephrostogram obtained after balloon removal shows a widely patent anastomosis. Although no extravasation of contrast material was seen at the site of the incision, the incision was not repeated. (f) Excretory urogram obtained 2 years later shows absence of hydronephrosis, which indicates a patent anastomosis on the right side.
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Figure 2f. Incision with the cutting balloon catheter in a 64-year-old man. (a) Nephrostogram (oblique view) shows a typical short (15-mm) right anastomotic stenosis through which a catheter (arrow) has been passed. (b) Photograph of the cutting balloon device with a 2.8-cm-long active cutting surface (arrows) on a 150-µm wire. (c) Nephrostogram (oblique view) shows the cutting balloon is in place and has been inflated with 1.5 mL of diluted contrast material. The waist (arrow) caused by the stenosis is visible, and the cutting current can be applied. (d) Nephrostogram (oblique view) shows the fully inflated balloon (arrowheads) after application of the cutting current. (e) Nephrostogram obtained after balloon removal shows a widely patent anastomosis. Although no extravasation of contrast material was seen at the site of the incision, the incision was not repeated. (f) Excretory urogram obtained 2 years later shows absence of hydronephrosis, which indicates a patent anastomosis on the right side.
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The cutting balloon device, which is a 5-F torque catheter in which both a monopolar electrocautery cutting wire and a low-pressure balloon are incorporated (Fig 2b), was inserted over the wire. The balloon was passed through the stenosis and oriented laterally or anterolaterally with fluoroscopic guidance. This positioning avoids the risk of injuring the adjacent iliac vessels. Our interest in the location of the adjacent ileal loops, as demonstrated at preoperative CT, was more limited, because the position of the bowel can change within 24 hours. However, if an ileal loop was present anteriorly on the CT scan, then we assumed that strictly lateral positioning of the balloon would reduce the risks of injuring the intestine. The balloon was then inflated with 1.5 mL of dilute contrast material (Meglumine 35; Laboratoire Guerbet, Aulnay-sous-bois, France) until a waist was visible on the balloon (Fig 2c). The cutting current (75–100 watts, pure cut) was then applied for 5 seconds while an additional 0.5 mL of contrast material was injected into the balloon (Fig 2d). One or two applications of current were sufficient to remove the waist. The balloon was then removed, and a 9-F catheter was inserted over the wire for ureterography. In 30 stenoses, the ureterogram showed extravasation of contrast material at the incision site, and a 12-F JJ stent with multiple side holes throughout its length was inserted anterogradely over the wire. In seven stenoses, no contrast material extravasation was visible and the ureterogram showed free flow of contrast material through a widely patent anastomosis; in these cases, the JJ stent was inserted without attempting further incision. A nephrostomy tube was always left in place for 24–48 hours. A repeat nephrostogram was then obtained to check for the absence of residual extravasation at the site of incision (Fig 2e), after which the nephrostomy catheter was removed.
A stent was kept in the anastomosis for 8 weeks. The total operating time was less than 1 hour and depended on how difficult it was to catheterize the stenosis. The postoperative stay did not exceed 4 days. No major complication occurred. The minor complications included four (11%) instances of bleeding, which occurred immediately after the incision but did not require transfusion. No ileal fistulas occurred. The follow-up after stent removal included excretory urography at 1, 3, 6, and 12 months, and then a yearly control urographic examination (Fig 2f). Four patients underwent repeat US after the 12-month excretory urographic examination. A Kaplan-Meier curve was constructed to illustrate the success rates over time. The actuarial data were applied to the patency of the anastomoses by using restenosis or, in the successful cases, the time to the last follow-up as the end point.
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RESULTS
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At the cutoff date, 12 (32%) stenoses, including those in the two patients with a totally obstructed ureter and in the patient with a poor functioning kidney, recurred in nine patients. The recurrences occurred in eight (53%) of the 15 stenoses treated with an ileal conduit procedure (four on the right side and four on the left side) and in four (18%) of the 22 stenoses treated with enterocystoplasty (three on the right side and one on the left side) an average of 15 months ± 10 (SD) (range, 6–36 months) after stent removal. In four cases, the stenosis recurred more than 12 months after stent removal (at 22, 23, 33, and 36 months). Four failures occurred in the seven patients who had no extravasation of contrast material at immediate postincision ureterography. However, three of these four cases (recurrence at 6, 6, and 11 months) had unfavorable predictors of outcome (ie, total ureteral obstruction and poor renal function [16]).
The remaining 25 stenoses (in 23 patients), including seven of the 15 treated with an ileal conduit procedure (47%) and 18 (82%) of the 22 treated with enterocystoplasty, remained patent after an average of 25 months ± 11 (range, 5–43 months). Patency was checked less than 12 months (5 and 6 months) after stent removal in two cases and more than 12, 24, and 36 months afterward in 10, nine, and four cases, respectively (average, 25 months ± 11; range, 5–43 months). Seven patients in this group (with seven stenoses) died with patent anastomoses during follow-up an average of 16.3 months ± 9 (range, 5–32 months) after stent removal; all of these deaths were caused by systemic metastases of bladder cancer. The remaining 18 stenoses, in 16 surviving patients, were patent at the cut-off date, with a mean follow-up of 28 months ± 10 (range, 6–43 months). The actuarial survival rate was 77% at 1 year, 68% at 2 years, and 62% at 3 years. The Table summarizes the clinical data on the patients with patent anastomoses and on those with recurrent stenoses.
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DISCUSSION
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Endoureterotomy of strictures in uroenteric anastomoses has evolved over the past decade. It was described by Kramolowsky et al (17), who incised the stenoses with a 5-F electrode introduced through the operating channel of a flexible nephroscope, which was inserted percutaneously in most cases. The incision was followed by balloon dilation to fully expand the stenosis. In 1991 and 1992, Cornud et al (13,14) described the use of a papillotome under fluoroscopic control for endoureterotomy of ureteroenteric anastomotic strictures. In an extended series (18), these authors preferred a combination of endoscopy and fluoroscopy to better assess the depth of the incision.
A cutting balloon catheter has been developed and become popular for incising ureteropelvic junction obstructions (19) and ureteral stenoses of various causes, including strictures of uroenteric anastomoses (19–21). Once the guide wire has been passed through the stenosis, the device is simple to use. Use of this device averts the difficulties inherent in flexible endoscopy, which is time-consuming (12), or obviates a second operator (18). However, regardless of the type of guidance, there is always a risk of injury to the vital surrounding structures, such as the nearby blood vessels or the intestines. A single case of a ureteroenteric fistula that healed over a ureteral stent without surgery was reported in the series of Meretyk et al (12). Damage to the internal iliac artery is a major potential problem. Cornud et al (18) encountered one such complication and attributed it to a technical fault: The incision was made entirely with fluoroscopic guidance. Theoretically, arterial pulsation should be detectable by using endoscopy; however, neither Cornud et al (18) nor Meretyk et al (12) reported seeing such pulsation prior to incision. Chandhoke et al (15) reported an internal iliac arterial injury with the cutting balloon, which led them to conclude that the device is unsuitable for treatment of strictures of uroenteric anastomoses that cross the aorta or iliac vessels.
We had no major complications in the present study and confirm that computed tomography (CT) is the examination of choice for detecting potentially risky neighboring vital structures, particularly major vessels (14). Fortunately, a posteriorly located internal iliac artery was found in only four (11%) of our 37 cases; it was on the left side in three of these four cases. Great care should be taken to ensure that the cutting wire is oriented anteriorly or anterolaterally in these circumstances. Such careful evaluation of the periureteral anatomy, as recommended by Kabalin (21), allows safe use of the cutting balloon, even in the management of left ureteroenteric strictures (18).
The long-term results of incision with a cutting balloon are available for series with a small number of patients. Preminger et al (20) treated six patients and reported a 50% patency rate with 9 months of follow-up, and Kabalin (21) treated four stenoses in three patients and reported a 75% patency rate with a follow-up of 11–28 months. Our results compare favorably with the long-term results of endoureterotomy with endoscopic or fluoroscopic guidance. Meretyk et al (12) achieved a long-term patency rate of 57% in a series of 19 stenoses after an average follow-up of 28.6 months, whereas Cornud et al (14), in a series of 33 stenoses, reported an actuarial 1-year patency rate of 71%, and Gutierrez et al (22) reported a 2-year patency rate of 73%. However, the present study results show that late failures are to be expected, because 33% of the failures in our series occurred after 12 months. Wolf et al (16) reported similar findings and noted that their 1-year success rate of 73% decreased to 51% and 32% at 2 and 3 years, respectively.
There are several unfavorable predictors of outcome after incision. Although stricture length was not a predictive factor in the study of Wolf et al (16), it is known that long (
3-cm) stenoses respond less favorably to endourologic management, regardless of the treatment option (8). Absence of contrast material extravasation on the immediate postincision ureterogram, which was observed in seven patients in our study, was associated with a high rate of recurrence (in four [57%] of seven patients). Among these seven patients, in the two with total ureteral obstruction, which is a known cause of recurrence (14,16), this radiologic appearance suggested that a full-thickness incision might not be accomplishable because of the large amount of thick fibrotic tissue around the anastomotic site. In the five patients without total ureteral obstruction, it was not possible to establish a link between absence of contrast material extravasation and failure, because three anastomoses remained patent, and among the two failures, one was in a patient who had poor ipsilateral renal function, which is, according to Wolf et al (16), a strong unfavorable predictor of outcome.
Finally, the type of urinary diversion might influence the long-term patency rate, and we found that the ureteroileal strictures in the patients who underwent a continent neobladder procedure responded more favorably to incision than did those in the patients who underwent an ileal conduit diversion, although this could not be statistically established owing to the small number of cases. This difference could not be determined in either the series of Wolf et al (16) or in series in which the results of balloon dilation (8) have been reported, because most of the incised stenoses involved ileal loop diversion. However, Ravery et al (10) reported a 61% long-term success rate in 13 dilated ureteroenteric strictures and found a 75% (six of eight strictures) success rate in patients who underwent an ileal conduit procedure and a 100% (five of five strictures) success rate in those who underwent an ileal neobladder procedure, with a mean follow-up of 16 months (range, 6–39 months). Although no definite explanation was given by the authors to explain the overall substantial improvement in the previously reported successes of balloon dilation, the article suggests that anastomotic strictures in patients who undergo an ileal continent neobladder procedure might respond more favorably to percutaneaous management than do those in patients who undergo ileal loop diversion. According to several authors (10,16,23), this might be explained by the surgical technique of ureteroileostomy, in which one of the two ureters (the left ureter in most cases) crosses the midline and therefore requires more extensive dissection, which entails a greater risk of devascularization. This would explain why failure of endourologic treatment is more frequent at the anastomotic site on the left.
This was not confirmed in our study, because half (four of eight) of the recurrences in the patients who had undergone an ileal conduit diversion occurred on the left ("crossed-over") ureter. Banner et al (24) reported similarly that three of the four failures (75%) in 11 patients who had undergone ureteroileostomy occurred on the right ("uncrossed") ureter. In our study, no patients who had a continent neobladder had such a crossed-over ureter; thus, further studies are necessary to better assess why a more favorable outcome can be expected in patients with a continent neobladder compared with that of those who have an ileal loop diversion.
In conclusion, incision of strictures in uroenteric anastomoses with a cutting balloon catheter yielded an actuarial 3-year patency rate of 62%, which confirms that these stenoses are difficult to treat; however, the outcome seems to be better in patients with a continent ileal neobladder. These results are no worse than those of endoscopic surgery and were achieved with a simpler technique that has a low morbidity rate when the necessary precautions are taken to detect the vital surrounding structures. Unless the reported improvements in the results of balloon dilation are confirmed in the future, endoureterotomy of strictures in uroenteric anastomoses remains a reasonable alternative to surgery, and, in our opinion, the cutting balloon technique is the simplest way of performing the incision.
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Footnotes
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Author contributions: Guarantor of integrity of entire study, F.C.; study concepts and design, F.C.; definition of intellectual content, F.C.; literature research, F.C.; clinical studies, Y.C.; data acquisition, D.B., J.M. Casanova; data analysis, F.C., Y.C., J.M. Casanova; statistical analysis, A.M., J.M. Correas; manuscript preparation and editing, F.C.; manuscript review, Y.C., J.F.M., O.H.
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Abstract
Introduction
