Usefulness of a long sheath in ureteral catheterization after failure of antegrade ureteral stent placement using a short sheath

Introduction

Antegrade ureteral intervention is a common procedure performed in interventional radiology (1). When performing antegrade ureteral interventions, such as balloon dilation or stent insertion, the use of a sheath via a percutaneous nephrostomy (PCN) tract is helpful. A sheath via the PCN tract prevents PCN tract loss during ureteral intervention, facilitates device exchange, and reduces bleeding by decreasing PCN tract and urothelial trauma. The sheath used for these purposes is mainly an angiographic short sheath (10 cm long and straight) (2). However, when the ureteral stricture or tortuosity is severe, the guidewire, balloon catheter, or stent cannot pass the lesion, and thus, failure of antegrade ureteral intervention can occur (2–4).

The use of a longer sheath to bypass the renal pelvis can solve these issues with ureteral stricture or tortuosity. However, reports on the use of long sheaths in antegrade ureteral stent placement are very limited. The aim of the present study was to evaluate the feasibility and effectiveness of the use of a long sheath in antegrade ureteral stent placement.

Material and Methods

Results

Causes of ureteral stricture and reasons for long sheath use are shown in Tables 1 and 2. Among the 57 ureters of 53 patients, the most common cause of ureteral stricture was malignant ureteral obstruction (Fig. 1). Kidney transplantation-related strictures and ureteral stones were common causes of benign ureteral strictures (Fig. 2). The most common reasons for the use of long sheaths were failure of balloon catheter advancement across the stricture (34/57, 59.6%; Fig. 1) and failure of guidewire advancement across the stricture (17/57, 29.8%, Fig. 2). In four patients, advancement of the double-J stent without prior balloon dilation failed. In the other two patients, advancement of the 0.035-inch guidewire failed, while advancement of the 0.025-inch guidewire was possible; however, advancement of the 4-Fr Cobra catheter over the 0.025-inch guidewire across the stricture failed.

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Table 1.

Causes of ureteral stricture (n = 57).

Causes of ureteral stricture	n
Malignant ureteral obstruction	44
Colorectal cancer	13
Bladder cancer	10
Cervical cancer	6
Stomach cancer	6
Prostate cancer	4
Ovary cancer	2
Endometrial cancer	1
Appendiceal cancer	1
Vulvar cancer	1
KT-related stricture	5
Ureter injury	3
Ureteral stone	2
Polyp	1
Ureteritis	1
Fibromatosis	1

KT, kidney transplantation.

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Table 2.

Reasons for the use of a long sheath (n = 57).

Reasons for use of a long sheath	n
Failed balloon catheter advance across the stricture	34
Failed guidewire advance across the stricture	17
Failed double-J stent advance across the stricture	4*
Failed 4-Fr catheter advance over a 0.025-inch guidewire	2

*In these two patients, the double-J stent was advanced without prior balloon dilation.

KT, kidney transplantation.

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Fig. 1.

A 73-year-old woman undergoing hysterectomy for cervical cancer. (a) The radiograph in the prone position shows that a 7-mm balloon catheter (white arrows) is inserted through the 9-Fr short sheath but does not pass the stricture at the right distal ureter (white arrowhead). Note the kinking of the 9-Fr short sheath (black arrows) and buckling of the balloon catheter (black arrowheads) within the renal pelvis (inset). In the left ureter, the guidewire was incorrectly passed to the vagina instead of the bladder (not shown), and the vagina was contrasted (asterisk). (b) After replacing the 9-Fr sheath with a Balkin sheath (arrows), the balloon catheter was able to pass through the stricture and balloon dilation was performed (arrowhead). Subsequently, a double-J stent could be inserted (not shown).

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Fig. 2.

A 69-year-old man undergoing radical cystectomy for bladder cancer. He underwent metal stent placement 14 months previously. (a) When the contrast agent is injected through the 5-Fr Kumpe catheter via the 9-Fr short sheath (arrow), a filling defect (arrowheads) considered as a stone in the upper part of the metal stent is noted. (b) A stiff guidewire (arrows) could not pass through the stricture at the upper part of the metal stent where the stone is present. (d) After replacing the 9-Fr sheath with a Balkin sheath (arrows), the stiff guidewire (arrowheads) could pass through the stricture. However, the 4-mm balloon catheter could not pass the stricture even after replacing the stiff guidewire with an Amplatzer guidewire (not shown). (d) Subsequently, after replacing the Balkin sheath with a TIPS sheath (arrows), 4-mm balloon dilation was possible at the upper part of the metal stent (arrowheads). Then, 8-mm balloon dilation and double-J stent placement could be performed (not shown).

The Balkin, Arrow, and TIPS sheaths were used in 52, three, and two ureters, respectively. The number of right, left, and transplanted ureters were 37, 15, and five, respectively. The stricture was most frequently at the distal ureter (n = 37). The attempted procedures were double-J (n = 48) and metal (n = 9) stent placements.

Technical success was achieved in 50 of 57 procedures (87.7%). In two out of seven failed procedures, the balloon catheter or stiff 0.035-inch guidewire could not be passed through the stricture using a Balkin sheath, and an additional TIPS sheath was used to achieve stricture negotiation; the balloon catheter was passed through the stricture after using the Balkin sheath inside the TIPS sheath, or the 0.035-inch guidewire was passed after replacing the Balkin sheath with the TIPS sheath (Fig. 2). When additional TIPS sheaths were used, the technical success rate improved to 91.2% (52/57). The technical success rate with long sheath was significantly higher in the patients who have failed balloon catheter advancement (97.1%, 33/34) than the patients who have failed guidewire advancement (64.7%, 11/17) (P = 0.004).

Hematoma was judged to have formed when filling defects in the renal pelvis were observed and hematuria was aspirated. Hematoma was observed in seven procedures, six of which developed hematoma before a long sheath was used, while one developed hematoma after the long sheath was used. Hematoma was resolved on follow-up pyelograms in all patients within one week and all were considered minor complications.

Discussion

In the present study, a long sheath was used in 4.4% of antegrade ureteral stent placement cases. However, it is estimated that more patients need longer sheaths in practice as long sheaths are not used in all cases of stricture negotiation failures. In reports of antegrade double-J stent placement in a total of 378 ureters, the mean technical failure rate was 7.1% (range = 3.8%–17.1%), and the most common reason for technical failure was impossible stricture negotiation (2–4,6).

Tight obstructions, tortuous dilated ureters, and poor angulation of the percutaneous tract are technical problems encountered during antegrade ureteral intervention (2–4,6). The most common cause of failure of stricture negotiation through a short sheath, in the present study, was balloon catheter or guidewire advancement failure owing to the tight ureteral stricture. The advantages of the placement of a long sheath that extends into the ureter through the PCN tract include straightening of a tortuous ureter, providing extra support while the catheter is advanced over the guidewire and prevention of buckling of the guidewire, balloon catheter, or stent by bypassing the renal pelvis and stabilizing the devices passing inside the sheath, resulting in easy passage through the stricture.

When using a long sheath, the technical success rate was higher when advancing the balloon catheter over the guidewire than when advancing the guidewire through tight stricture. Negotiating tight stricture with a guidewire depends more on the tightness of the stricture than providing extra support of the guidewire, while whether the balloon catheter is advanced over the guidewire is dependent on how strongly the balloon catheter is supported.

Several long sheaths can be used for ureteral intervention; in particular, a 40 cm or longer sheath with 7–8 Fr or larger inner diameter is recommended. Most sheaths used for vascular intervention can be used, with the sheath diameter based on the diameter of the devices to be used (usually 8 Fr). In the present study, a Balkin sheath was most commonly used and curved differently from other sheaths, allowing smoother entry into the ureter without resistance through the renal pelvis. Conversely, the TIPS sheath was the largest sheath (inner diameter = 10 Fr) and can facilitate stronger stabilization of devices in contrast to a 7–8-Fr long sheath. Therefore, the use of a larger TIPS sheath appears to be effective in cases of failure with a smaller diameter long sheath.

Only hematoma was noted as a complication in the present study, detected mostly before the use of a long sheath, indicating that the hematomas were caused by resistance and ureteral buckling as the devices could not pass the stricture. Long sheaths can help reduce injury by bypassing the renal pelvis and ureter and protect the ureter during repeated device exchanges; however, care must be taken during insertion to avoid traumatic injury caused by the sheath itself.

The present study is limited by its retrospective design. Further, no comparison was made with cases wherein a long sheath was not used. However, the clinical significance of a long sheath was evident because high success rate was achieved using a long sheath in cases of technical failure of ureteral catheterization with a short sheath in this study.

In conclusion, ureteral catheterization using a long sheath is feasible and effective when antegrade ureteral intervention using a short sheath fails. When using a long sheath, the technical success rate was higher when advancing the balloon catheter over the guidewire than when advancing the guidewire through tight stricture.