Category: Other, Miscellaneous

VS15-9 - Endoscopic incision for uretero-ileal anastomotic stricture: step by step technique

Sun, Sep 23
10:00 AM - 12:00 PM

Introduction & Objective :

Uretero-ileal anastomotic stricture (UAS) after urinary diversion represents a complication with a challenging management. A wide range of endourologic procedures have been described with controversial results. We present the step by step technique for endoscopic incision of uretero-ileal anastomotic stricture using Holmium laser.

Methods :

We present the case of a 63 years old male, who undergone laparoscopic radical cistoprostatectomy and Bricker urinary diversion in 2015. One year following the procedure, scheduled CT showed right UAS. After percutaneous nephrostomy insertion and an unsuccessful attempt of pneumatic dilation, not being able to pass a guidewire through the stricture, we decided to schedule endoscopic laser incision of UAS.

The procedure begins with an anterograde pielography, identification of the stricture and progression of guidewire until proximal level of stricture. Sequential dilation of the percutaneous tract till 14Fr is followed by insertion of a 11/13Fr ureteral sheath until mid ureter. Using both, flexible ureteroscope and flexible cystoscope, we negotiate the stricture until passing an hydrophilic guidewire through it. Combined direct vision through the conduit is performed, allowing us to grasp the distal end of the wire and effectively threading the urinary tract.

Retrograde sequential dilation of UAS is made allowing advance of a 6cm 18Fr high pressure dilation balloon catheter. Then, dilation of stricture applying 12atm is performed. Gentle traction of the catheter is applied in order to invaginate stricture into the ileal conduit, avoiding any intestinal loop damage during the subsequent procedure.

Section of the stenotic fibrotic tissue is achieved using a 360µm 50W Holmium laser fiber through a rigid cystoscope.

Finally, ureteral stent and right percutaneous nephrostomy are placed under fluoroscopic control.

Results : No surgical or postoperative complications occurred. Patient was discharged 48 hours after the procedure. Right percutaneous nephrostomy was removed after 24 hours and ureteral stent after 6 weeks. Control CT scan 3 months after surgery shows complete resolution of right ureterohydronephrosis.

Conclusions : In well selected cases and with proper training, endoscopic section with Holmium laser for uretero-ileal anastomotic strictures, can be an effective therapeutic option in order to provide a minimal invasive approach for this disease.

Manuel Carballo Quintá

Urology consultant
Complejo Hospitalario Universitario de Vigo
Vigo, Galicia, Spain

Miguel Pérez Schoch

Vigo, Galicia, Spain

Sheila Almuster Domínguez

Vigo, Galicia, Spain

Ángel Maximino Castro Iglesias

Vigo, Galicia, Spain

Jose María Díaz Álvarez

Vigo, Galicia, Spain

Jorge Sánchez Ramos

Vigo, Galicia, Spain

Adrián Martínez Vázquez

Vigo, Galicia, Spain

Rubén Montero Fabuena

Vigo, Galicia, Spain

López García Sabela

Vigo, Galicia, Spain

María Elena López Díez

Vigo, Galicia, Spain

Ignacio Martínez Sapiña-Llanas

Vigo, Galicia, Spain

Antonio Ojea Calvo

Vigo, Galicia, Spain