順行性輸尿管支架置放治療輸尿管迴腸吻合處狹窄 - 病例報告

王毓婷¹、陳冠州¹

¹台北醫學大學附設雙和醫院 泌尿科

Antegrade approach of intraureteral stent implantation for ureteroileal anastomosis stricture: case report

Yu-Ting Wang^1, Kuan-Chou Chen¹

¹Department of Urology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan

Introduction

Ureteroileal anastomotic stricture (UIAS) is a major complication following radical cystectomy and urinary diversion. Lesion excision and ureteral reimplantation remain challenging due to the potential adhesions and fibrosis caused by previous surgeries or radiation therapy. Along with the advances of endourological techniques, intraureteral stent implantation preceded by balloon dilation has offered a new treatment alternative for this condition. We described a case of bladder cancer patient with an ileal pouch who then developed UIAS and therefore underwent Allium intraureteral stent implantation in an antegrade approach. 

Case Report

A 71-year-old male patient with the history of bladder urothelial carcinoma received radical cystectomy and ileal pouch surgery about five years ago. He visited our emergency department with the symptoms of hematuria for three months; decreased urine output and turbid urine were also noted. Besides hematuria, laboratory data suggested urinary tract infection (UTI) and acute kidney injury (AKI) with creatinine level to be 2.71 mg/dl. Contrast A+P CT further revealed left UIAS and hydronephrosis, so left double J insertion was performed in an antegrade manner. To obviate the risks associated with repeated double J exchange, the patient decided to schedule readmission for Allium intraurethral stent implantation. During the surgery, the patient was placed in the right decubitus position under general anesthesia, and rigid cystoscopy was advanced through the stoma over the right lower quadrant of abdomen. We attempted to send the guidewire via the old double J stent but failed because of the inadequate length of the cystoscopy to reach the left ureteroileal orifice (UO). We therefore re-positioned the patient into prone position and created a percutaneous nephrostomy. Flexible ureterorenoscopy and guidewire accessed the tract antegradely, and we grasped the tip of the guidewire with forceps after it successfuly emerged from the UO. With fluroscopy, we pushed the catheter over the guidewire and then positioned the balloon across the stricture. Under the direct vision of cystoscopy, the balloon was inflated with contrast medium, and the intraureteral stent was further inserted and expanded. Final fluoroscopy showed patent ureteroileal anastomosis with intraureteral stent in place. As no postoperative complications were observed, the patient was discharged on postoperative day 2. At last, outpatient department follow-up found resolution of AKI (creatinine 1.26 mg/dl) and left hydronephrosis after the management.

Conclusion

This case highlighted the potential challenge when performing endourological techniques on patients who received urinary diversion. With careful strategizing, intraureteral stent implantation offered a minimally invasive treatment modality that allowed a well-controlled dilation of balloon and insertion of stent under direct vision for our patient who has an altered urinary tract anatomy.

Figure 1. (A) Left double J stent was initially inserted to manage the UIAS. (B) The UIAS was successfully corrected by the intraureteral stent and achieved a width of 0.68cm.