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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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History
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▶ Bladder Cancer Status post Cystectomy and Ileal Conduit Complicated by Bilateral Uretero-Enteric
Anastomotic Strictures. What catheters are shown in Figure 47.3?
Figure 47.1
Case 47
Figure 47.2
Figure 47.3
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Case 47 Retrograde Nephrostomy Catheters
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Figure 47.4 Figure 47.5
Figure 47.6
Findings
▶ Bilateral nephroureteral catheters have been placed with the distal pigtails in the ileal conduit (Fig. 47.4,
arrow).
▶ Each catheter has been advanced through the conduit and out of the stoma located in the le lower quadrant
(Fig. 47.5, arrow).
▶ Both catheters have been converted to retrograde nephrostomy catheters with the retention pigtails in
the renal pelvis. e catheters now drain into the stoma. e antegrade nephrostomy catheters have been
removed.
Teaching Points
▶ Retrograde catheters are ideal for patients with ureteral obstruction aer cystectomy and ileal conduit because
they drain into the stoma bag instead of antegrade nephrostomy catheters that require an additional bags for
drainage.
▶ Nephroureteral catheters in nonnative bladders (e.g., ileal conduits, neobladder, etc.) that are created from
bowel can neither be capped nor stented because the bowel secretes mucus that occludes the sideholes of the
catheter.
Management
▶ Aer obtaining “through-and-through” access from the site of antegrade access out of the stoma with
an angiographic catheter, a sti wire is advanced from the stoma side out of the antegrade nephrostomy
tract. Aretrograde nephrostomy can be placed over the wire and formed in the renal pelvis as the wire is
pulledback.
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▶ Routine exchange of all urinary drainage catheters (nephrostomy, nephroureteral catheter, ureteral stent,
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retrograde nephrostomy) is necessary to minimize the risk of catheter occlusion and resulting urosepsis.
Typical routine exchange intervals range from 3 to 6months.
▶ For patients who tend to have encrusted catheters, a sidehole may be made in the sha of the catheter prior to
placement. is functions as an “escape route” for the next exchange, allowing for a wire to be advanced out of
the catheter and up into the renal pelvis to preserve access if a wire cannot be advanced out of the end of the
catheter due to encrustation.
▶ e need for antibiotic prophylaxis prior to routine exchange is controvertial but widely practiced.
Further Reading
Adamo R, Saad WE, Brown DB. Management of nephrostomy drains and ureteral stents. Tech Vasc Interv Radiol.
2009;12(3):193–204.
Alago W Jr, Sofocleous CT, Covey AM, etal. Placement of transileal conduit retrograde nephroureteral stents in patients with
ureteral obstruction aer cystectomy:technique and outcome. Am J Roentgenol. 2008; 191(5):1536–1539.
140
Case 48
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History
▶ A68-Year-Old Female with Ovarian Cancer and Ureteral Obstruction
Both tubes have been capped for 2 weeks and she has not had pain, fever, or elevation in serum creatinine. What
is the best option for eliminating the external tubes?
Figure 48.1
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Case 48 Ureteral Stent
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Figure 48.2
Figure 48.3
Figure 48.4
Findings
▶ Contrast injection into the le nephroureteral catheter shows minimal hydronephrosis (Fig. 48.2). e
proximal pigtail is formed in the renal pelvis and the distal pigtail in the bladder. Aright-sided nephroureteral
catheter is also seen.
▶ Coronal computed tomography (CT) reformat (Fig. 48.3) shows the distal pigtails of the nephroureteral
catheters (hollow arrow) in the normal-appearing bladder (arrow).
▶ Both nephroureteral catheters have been exchanged over wire for double J stents. Contrast injection into a
catheter in the right renal pelvis (Fig.48.4) conrms there is good drainage across the stent into the bladder.
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Figure 48.5
Five minutes later, another image was obtained (Fig. 48.5) showing the contrast has drained across the stent
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into the bladder.
Teaching Points
▶ In patients who have normal bladders, cystoscopic stent placement is favored because drainage can be
achieved through a normal orice without the need for transparenchymal access.
▶ Patients with urinary obstruction who fail or are not candidates for cystoscopic stent placement may be
treated with percutaneous nephrostomy or nephroureterostomy placement. If a patients tolerates capping trial
of a nephroureterostomy, as in this case, stent placement should be considered.
▶ Over-the-wire exchange of a nephroureteral catheter for a stent is performed by “pushing” the stent into
position. is can be done with the prepackaged device or by using a standard nephrostomy tube. e latter
is preferred if ongoing external access is needed (e.g., if there is blood in the system aer stent placement, the
antegrade nephrostomy catheter can allow drainage until it resolves).
▶ If a primary stent is placed (i.e., stent placement at the time of rst antegrade access), a “covering”
nephrostomy may be le in place until function of the ureteral stent is conrmed. Because the pigtails of
the nephrostomy and stent can intertwine, removal of the nephrostomy over a wire and under uoroscopic
visualization is advisable.
▶ Primary stents should not be placed if there is signicant clot in the collecting system related to antegrade
access. Conversion could be attempted aer a short period, usually 1–2 weeks, aer hematuria has cleared.
Management
▶ Ureteral stents are generally exchanged every 3–6months to prevent encrustation or infection. In women this
can be done either uoroscopically or at cystoscopy. In men, the length of the penile urethra increases the
likelihood of losing access uoroscopically, and therefore cystoscopic exchange is preferred.
▶ Stents are available with dierent sidehole congurations. In the setting of a ureteral leak, a stent or catheter
with sideholes only in the proximal or distal pigtail (i.e., not along the ureteral portion) will help divert urine
from the site of leakage.
Further Reading
Hausegger KA, Portugaller HR. Percutaneous nephrostomy and antegrade ureteral stenting:technique-indications-complications.
Eur Radiol. 2006; 16(9):2016–2030.
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Case 49
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History
▶ Failed Cystoscopic Exchange of Occluded Ureteral Stent. What is the Best Alternative Option for Urinary
Drainage?
Figure 49.1
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Case 49 Routine Transurethral Exchange of Ureteral Stent
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Figure 49.2
Figure 49.3
Figure 49.4
Findings
▶ Indwelling ureteral stent is positioned with pigtails in the renal pelvis and bladder (Fig. 49.2).
▶ In Figure 49.3, a snare has been advanced through a sheath placed into the bladder via the urethra. e snare
has been used to capture the distal pigtail of the ureteral stent (Fig. 49.3). e stent is then pulled out through
the sheath (Fig. 49.4) and exchanged over a wire for new.
Teaching Points
▶ Stents are only indicated in the setting of a native bladder. Neobladders and conduits created from small bowel
secrete mucus, which quickly occludes the distal sideholes in stents placed in these nonnative bladders.
▶ Depending on the size of the cystoscope, larger stents may be dicult for urologists to exchange at cystoscopy.
▶ When using this technique of transurethral snare and exchange in men, care must be taken not to lose access
to the ureter when pulling the catheter through the penile urethra.
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Management
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▶ Ureteral stents require routine exchange every 3–6months. is may be performed cystoscopically by
urologists or uoroscopically by interventional radiologists.
▶ Results of self-expanding metallic stents placed for malignant ureteral obstruction have been disappointing
with early occlusion due to urothelial hyperplasia and encrustation.
▶ Tumor, chemotherapy, and radiation therapy all contribute to periureteric brosis. Once a stent is placed in
this setting, stent removal is unusual.
▶ In some tumors, for example, lymphoma, brosis may not occur and once the obstructing lesion has resolved
a trial of stent removal may be considered.
Further Reading
Park SW, Cha IH, Hong SJ, etal. Fluoroscopy-guided transurethral removal and exchange of ureteral stents in female
patients:technical notes. J Vasc Interv Radiol. 2007; 18(2):251–256.
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Case 50
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History
▶ Right Ureteral Stent Placed 2 Weeks Ago With Persistently Elevated Creatinine and Right Flank Pain. What
Procedure is Being Performed?
Figure 50.1
Figure 50.3
Figure 50.2
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