Category: Other, Miscellaneous
Introduction & Objective : Treatment of complex ureteral stenosis or lesions can be challenging. When other options have failed or are not indicated, an extra-anatomical urinary diversion (ureteral bypass) can be an option.
Methods : The Detour™ is a 30 Fr tube that is made of 2 components: an outer reinforced PTFE sheath with porous structure and a silicone inner sheath. We modified the position of the patient based on our experience with percutaneous nephrolithotomy in the supine position. If the patient has an indwelling nephrostomy catheter in a proper position (subcostal, through the renal parenchyma and calyx with access to the pelvis) then we proceed with a dilatation of the percutaneous access using fascial dilators or a balloon, and a 30 Fr Amplatz sheath is inserted. If there is no nephrostomy, an ultrasound guided percutaneous access is performed through an adequate calyx with a direct access to the renal pelvis. Dilatation then proceeds as described above. The Detour™ proximal end is positioned into the renal cavities through the Amplatz sheath. The bladder is then isolated through a minilaparotomy. A subcutaneous tract between the bladder and the percutaneous access is created with a tunneler and the Detour™ in passed through the tract in order to reach the bladder. A 1 cm cystotomy is performed on the bladder dome. The Detour™ distal end is then tailored to the proper length and it is anastomosed to the bladder. A bladder catheter is left in place for 7 days.
Results : 17 subcutaneous ureteral bypasses were performed in 15 patients (2 bilateral) using the modified technique between 2016 and 2018. Mean operative time was 145’. In 12 cases an ex-novo percutaneous access was created. There were no intraoperative complications. In 3 cases an explant was performed: 1 due to displacement of the Detour™ distal end, 1 due to infection and in 1 case due to enteric fistula. 1 male patient refers LUTS.
Conclusions : The supine oblique position or the lithotomy oblique position allows a direct simultaneous access to the kidney and to the bladder simplifying the procedure. Still, the procedure may be complex due to high comorbidity patients with previous radiation or surgery and the high risk of infection.
Elena Tondelli– Urologist, Vimercate Hospital, Milano, Lombardia, Italy
Michele Talso– Consultant Urologist, ASST Vimercate Hospital, Italy, milano, Lombardia, Italy
Gianpaolo Zanetti– Chief, Vimercate Hospital, Vimercate, Lombardia, Italy
Ioannis Kartalas Goumas– Head Endourology, Vimercate Hospital, Milano, Lombardia, Italy
Milano, Lombardia, Italy
My name is Elena Tondelli and I was born in Milan on 20/03/1983. I enrolled in the Faculty of Medicine and Surgery at the University of Milan in 2003: from the third year I began to attend Urology Department as an internal student, and I started to love every aspect of this discipline. In 2009 I graduated with the thesis titled "Testicular sperm extraction in patients with testicular tumor: new surgical method of storage of fertility” and after obtaining the professional qualification, I entered the Urology School of the University of Studies from Milan. During the specialization I studied in particular the andrological field at San Giuseppe Hospital in Milan and I acquired the technique of urological specialist ultrasound; I also completed training periods at General Surgery Departments, at a Pediatric Urology Unit and at the European Institute of Oncology. I specialized in urology in 2015 with 70/70 with the thesis titled "Use of sacral neuromodulator in the treatment of detrusorial iperactivity after prostatic radical surgery". After a short period of work at San Donato Milanese Hospital, from 2016 I work at the Hospital of Vimercate (MB) where I perform urological activity at 360 degrees but in particolar I dedicate myself to the endoscopic treatment of urinary calculosis and to the bladder and renal oncological pathology. At the same time I continue to perform the private andrological outpatient activity and I also collaborate in holding lectures at the faculty of medicine and the urology school.
ASST Vimercate Hospital, Italy
milano, Lombardia, Italy
MD Urologist Consultant
ASST Vimercate Hospital MB