Endoscopic Management of Ureteral Stricture
NYU Case of the Month, August 2018
Case of the Month Endoscopic Management of Ureteral Stricture NYU Case of the Month, August 2018 Philip Zhao, MD Department of Urology, NYU Langone Medical Center, New York, NY [Rev Urol. 2018;20(3):140–142 doi: 10.3909/riu0819] ® © 2018 MedReviews, LLC A 70-year-old man presented with right flank pain of 2 weeks’ duration. The pain was intermittent but sharp and radiated to the right lower quadrant. There were no precipitating factors. He had mild concurrent nausea without vomiting and denied any fevers or chills. Of note, he underwent brachytherapy for prostate cancer 8 years prior. His prostate-specific antigen (PSA) level was undetectable. He had a workup for gross hematuria 6 months earlier with negative computed tomography (CT) urogram, cytology, and cystoscopy. He had no prior history or family history of stone disease. An upper tract ultrasound (US) showed mild right hydroureteronephrosis to the ureterovesical junction without a discernible stone. Urinalysis was negative for leukocyte esterase or blood. Creatinine was normal (0.77 mg/dL). The patient was sent home with return precautions, and he scheduled another office visit a week later. He had worsening pain, and a repeat US showed persistent hydroureteronephrosis (Figure 1). A ureteral jet was present on the right side but was asymmetrically less than on the left side. The patient followed recommendations to undergo ureteroscopic evaluation of the right ureter. Management Cystoscopy performed under general anesthesia in the operating room showed a normal bladder. Right Figure 1. Ultrasound showing persistent hydroureteronephrosis. retrograde pyelogram revealed a 1.5-cm area of narrowing in the distal ureter, with mild hydroureteronephrosis proximal to this segment (Figure 2). No filling defects were identified. Ureteroscopic evaluation showed diffuse fib rotic changes of the ureteral wall. There was no evidence of suspicious lesions or tumors. The ureteroscope did not pass beyond the area of narrowing. The ureteral stricture was dilated with a 15F balloon dilator (Figure 3), enabling passage of the semirigid ureteroscope and inspection of the right upper tract. Full-thickness incision of the 140 • Vol. 20 No. 3 • 2018 • Reviews in Urology 4170018_00_RIU0819_V3_rev02.indd 140 10/25/18 3:58 PM Endoscopic Management of Ureteral Stricture Figure 2. Right retrograde pyelogram revealing a 1.5-cm area of narrowing in the distal ureter, with mild hydroureteronephrosis proximal to this segment. Figure 3. The ureteral stricture was dilated with a 15F balloon dilator, enabling passage of the semirigid ureteroscope and inspection of the right upper tract. stricture segment was confirmed into the periureteral fat; otherwise, additional incision would have been made with a laser. There were no additional findings. A 7F/14F endopyelotomy stent (Retromax™ Plus Endopyelotomy Stent; Boston Scientific, Marlborough, MA) was inserted with the 14F segment across the dilated stricture site. The stent was removed 3 weeks later and 1-, 3-, and 6-month postoperative US studies showed no hydroureteronephrosis. The patient has remained asymptomatic. Discussion Ureteral strictures are becoming an increasingly common problem. Etiologies include ureteroscopic trauma, stone impaction, radiation, and obstructing ureteral anastomosis. Patients generally present with flank pain concurrent with nausea. They may have elements of urinary tract infection or pyelonephritis. Not all ureteral strictures are symptomatic, though, so it is important to make the appropriate diagnosis based on history, physical examination, and imaging studies, including CT scan or upper tract US. MAG3 renal scan can also be used to determine renal function and degree of urinary obstruction. The treatment of ureteral stricture disease is based on several factors, including the location, etiology, and length of the strictured segment and the function of the associated renal moiety. The most common endoscopic treatments for managing ureteral stricture disease are balloon dilation and endoureterotomy (generally with laser energy). The goal of both balloon dilation and endoureterotomy is to make a full-thickness incision in the ureteral wall and into the periureteral fat both proximal and distal to the segment of stricture. This can be accomplished with any of several energy sources, including cold knife, electrocautery, or laser. Laser has become the gold standard for endoureterotomy because the laser fiber can be inserted into both rigid and flexible ureteroscopes. The laser has improved precision of energy delivery and offers the ability to perform lithotripsy on concurrent ureteral calculi. Some prefer balloon dilation over laser incision of the stricture because the balloon technique dilates the stricture uniformly and circumferentially. Balloon dilation is faster to accomplish under fluoroscopy, and if the stricture is cut through its entire thickness and periureteral fat is seen, the success rate is similar to endoureterotomy. A few large studies, including the 151 cases reviewed by Kuntz and associates,1 show no long-term sequelae or clinically significant complications from ureteral balloon dilation up to 18F. Much of the literature describes a multimodality approach—using balloon dilation initially to open the stricture and then evaluating the area of effect under ureteroscopic vision and completing the full-thickness cut with a laser if necessary.2,3 The literature supports a success rate of 33% to 83% at 36 months for treatment of benign stricture disease using an endoscopic approach. Generally, stricture location has huge implications for postoperative success rates: proximal, 33% to 69%; mid, 50% to 67%; distal, 53% to 83%.4 Distal strictures or strictures in the intramural portion of the bladder are more favorably managed endoscopically. It is thought that distal ureteral reflux after stricture dilation provides additional distention of the incised ureter and that this contributes to the better success rates. In the current case, the stricture was secondary to post-radiation changes and ischemic in nature. The etiology of the stricture formation is not as important as the length of the stricture but is also an important parameter in addition to location, for surgical outcome following endoscopic management. For distal strictures with intact blood supply, success rates were noted to be as high as 89% for strictures less than 2 cm long and only 38% for strictures 2 cm or longer. For distal ischemic strictures with compromised vascularity, success rates were up to 83% for strictures less than 2 cm long but only 17% for strictures 2 cm or longer.5 A few studies have demonstrated a 0% success rate at 12 months for endoscopic management of strictures of more than 2 cm at any location. Endoscopic management of ureteral strictures with either balloon dilation or endoureterotomy can be Vol. 20 No. 3 • 2018 • Reviews in Urology • 141 4170018_00_RIU0819_V3_rev02.indd 141 10/25/18 3:58 PM Endoscopic Management of Ureteral Stricture continued highly successful as the initial treatment option for strictures that are benign and nonischemic, in proximal or distal locations, shorter than 2 cm. This approach offers a less invasive alternative to open or laparoscopic/robotic ureteral recon structive repair. References 1. 2. 3. Kuntz NJ, Neisius A, Tsivian M, et al. Balloon dilation of the ureter: a contemporary review of outcomes and complications. J Urol. 2015;194:413-417. Tyritzis SI, Wiklund NP. Ureteral strictures revisited... trying to see the light at the end of the tunnel: a comprehensive review. J Endourol. 2015;29:124-136. Hafez KS, Wolf JS Jr. Update on minimally invasive management of ureteral strictures. J Endourol. 2003;17:453-464. 4. 5. Lucas JW, Ghiraldi E, Ellis J, Friedlander JI. Endoscopic management of ureteral strictures: an update. Curr Urol Rep. 2018;19:24. Byun SS, Kim JH, Oh SJ, Kim HH. Simple retrograde balloon dilation for treatment of ureteral strictures: etiology-based analysis. Yonsei Med J. 2003;44:273-278. 142 • Vol. 20 No. 3 • 2018 • Reviews in Urology 4170018_00_RIU0819_V3_rev02.indd 142 10/25/18 3:58 PM