Clinical application of fluoroscopic guided percutaneous antegrade ureteral stents placement for the treatment of malignant ureteral obstruction

Abstract

OBJECTIVE:

To investigate the clinical efficacy and safety of fluoroscopic guided percutaneous antegrade ureteral stents placement used for treatment of malignant ureteral obstruction.

METHODS:

Between April 2016 and March 2018, fluoroscopic guided percutaneous ureteral stents was performed in 25 patients, including 7 patients (28%) with bilateral obstruction. The most common cancer diagnoses were cervical cancer (28%), rectal cancer (24%) and colon cancer (16%) among these patients. Clinical data were retrospectively analyzed with respect to the efficacy, safety and outcome of this treatment method.

RESULTS:

Percutaneous antegrade placement of ureteral stents was performed in all cases, including 12 ureters that failed in the initial retrograde ureteral stents placement. The median stent patency time for the antegrade ureteral stents were 10.4 (95% CI: 8.3–12.6) months. The primary complications included mild flank pain and discomfort (44%), hematuria (44%), urinary tract infection (8%), bladder irritation symptoms (4%), and arterial bleeding (4%).

CONCLUSION:

Fluoroscopic guided percutaneous ureteral stents placement is a safe, efficient procedure and has a high success rate in patients with malignant ureteral obstruction.

Keywords

Malignant ureteral obstruction ureteral stent percutaneous antegrade fluoroscopic

Abbreviations

PCN

percutaneous nephrostomy

computerized tomography

MRI

magnetic resonance imaging

1. Introduction

Malignant ureteral obstruction is an ominous sign usually associated with locoregional primary tumors, remote metastatic disease or direct tumor infiltration [1]. Ureteral obstruction associated with renal failure, pain or fever is a urological emergency requiring prompt evaluation and treatment. Current treatment modalities involve decompression by a retrograde ureteral stenting or percutaneous nephrostomy (PCN) [2]. However, in many patients with pelvic, bladder, or prostate malignancy, the retrograde ureteral stenting success rate of stents in the setting of malignant extrinsic compression or infiltration is low, even 21% [3]. In addition, PCN may not be an optimal choice because of the need for an external appliance, such as routine care of the nephrostomy tube and infection, causing deteriorating quality of life [4, 5]. However, the antegrade approach has a very high technical success rate with low external appliance of nephrostomy. And what’s more, in most cases, local anaesthesia is the only requirement for these procedures, which can be well tolerated [6].

In order to maintain kidney function as well as quality of life, ureteral stents placement is now typically the first-line therapy to relieve malignant ureteral obstruction [7 –9]. Despite different materials of ureteral stents have been invented to achieve better drainage [8, 10], the ureteral stents placement technical success rate have not been satisfactory, especially in involvement of the ureteric orifices by tumor. The purpose of this study is to explore the clinical efficacy and safety of fluoroscopic guided percutaneous antegrade ureteral stents placement for the treatment of malignant ureteral obstruction.

2. Materials and methods

2.1. Study population and protocol

Between April 2016 and March 2018, 25 patients with unilateral or bilateral extrinsic malignant ureteral obstruction underwent percutaneous placement of ureteral stents. All patients were evaluated by a multidisciplinary team including senior urologists and interventional radiologists. The protocol was approved by the Institutional Ethics Review Board of our hospital, and all patients provided informed consent prior to percutaneous antegrade ureteral stents placement.

2.2. Indications or contraindications

They were selected according to the following criteria: ureteral obstruction was secondary to tumors associated with locoregional primary tumors, remote metastatic disease or direct tumor infiltration. Diagnostic imaging of obstruction was done by transabdominal ultrasound, computerized tomography (CT), magnetic resonance imaging (MRI) or intravenous urography.

The exclusion criteria included uncontrolled coagulopathy (platelet count <75×10⁹/L; international normalized ratio ≥1.5), confirmed bacteremia, multiple organ failure, severe electrolyte disturbance unable to be corrected in the short term and a life expectancy of more than 3 months.

2.3. Procedure techniques of ureteral stents placement

Percutaneous nephrostomy tube drainage was performed under ultrasound guidance in all cases. Ureteral stents were placed percutaneously under fluoroscopic guidance through the nephrostomy tract. Antibiotic prophylaxis was administered before operation if urinary tract infection happened. The operating procedure was performed with the patient under conscious and placed on the fluoroscopy table in a prone position (critical illness and weak advanced age in an oblique or supine position) with the respective lumbar fossa exposed for percutaneous nephrostomy.

Antegrade pyelography was done through the nephrostomy tract to identify the obstructed ureteral segment and to evaluate its morphology, site and length. Under fluoroscopic guidance, the nephrostomy tube was exchanged by a 0.035 inch guidewire and an 8-French sheath was placed into the renal pelvis. And then a 5-French DAV catheter and an 8-French Guiding catheter were coaxially inserted into the upper ureter. A hydrophilic guidewire and a 5-French DAV catheter were used to negotiate entrance into the involved ureter and bladder. For the patients with severe stricture or torture of ureter, microcatheter and microguide wire were also considered. And then the stent (Cook Medical) was slowly pushed along the hydrophilic guidewire until it crossed the malignant stricture with 1–2 cm length in the bladder from the ureteral orifice (Fig. 1).

Fig. 1.

Percutaneous antegrade placement of ureteral stent. Antegrade pyelography through the nephrostomy tract demonstrated the totally obstruction of terminal ureter (A). A guidewire was negotiated into the bladder through the obstruction (B). Stent was successfully placed along the hydrophilic guidewire and the self-contained sheath (C). An 8.5-French pigtail tube was left at the end of procedure (D).

At the end of procedure, an 8.5-French pigtail tube (Cook Medical) was left in the renal pelvis for the temporary drainage and was used to evaluate the ureteral stent patency or assess any periprocedural complications.

2.4. Follow-up and data analysis

After 2 to 7 days, the pigtail tube was blocked to allow complete internal drainage through the stent and was later removed after ureteral patency was confirmed by antegrade pyelography. Serum creatinine, blood urea nitrogen and transabdominal ultrasound or CT were performed to promptly evaluate of ureteral patency every 1 to 2 months until the end of follow-up. Internal drainage was achieved with percutaneous nephrostomy tube for restenosis after ureteral stents placed. Success was defined as a hydronephrosis subsided or remained stable and serum creatinine decreased or remained stable with nondeteriorating renal function. Additionally, the estimated progression free ureteral patency rate was evaluated using the Kaplan-Meier analysis with SPSS version 19.0 software (SPSS Inc, Armonk, NY).

3. Results

3.1. Clinical characteristics

Of all patients who underwent antegrade placement of internal ureteral stents for malignant obstruction, 25 (13 women, 12 men) were due to malignant ureteral obstruction. Mean age was 55 years (range 28 to 80 years). Seven patients (28%) had bilateral obstruction. Percutaneous nephrostomy tube was successfully placed in all cases. At presentation 23 patients (92%) had pathological diagnosis of malignant tumors, and the other 2 cases was confirmed by clinical symptoms, laboratory examination and imaging. The cancer type included cervical cancer (n = 7), rectal cancer (n = 6), colon cancer (n = 4), prostatic cancer (n = 2), stomach cancer (n = 1), recto-sigmoid cancer (n = 1), endometrial cancer (n = 1), liposarcoma (n = 1) and unidentified malignant tumors (n = 2). There were 7 obstruction sites in the upper ureter, 10 in the middle ureter and 15 in the lower ureter.

After antegrade ureteral stents placement, hydronephrosis subsided or remained stable in 93.75% (30/32) of the ureteral units. Serum creatinine decreased or remained stable in 92% (23/25) of the patients. The median serum creatinine of the preoperative and postoperative were 318.8 (95% CI: 196.7–440.9) and 122.4 (95% CI: 72.1–172.8)μmol/L.

3.2. Technique and clinical outcomes

The technical success rate of percutaneous antegrade placement of ureteral stents was 100% (32 ureteral stents in 25 patients), including 12 ureters in 12 patients that failed initial retrograde ureteral stents placement due to invasion of ureteral orifice by cancer or external compression from a cervical, rectal, colon or prostate malignancy (Fig. 2).

Fig. 2.

Percutaneous antegrade placement of ureteral stent. Antegrade pyelography displayed the obstructed ureteral segment (A). The lower segment obstructed ureteral with severe extensive strictures and multiple tortuous dilatations were coaxially passed by a microguide wire, microcatheter and DAV catheter (B). Stent was successfully placed along the hydrophilic guidewire and the self-contained sheath (C, D).

Procedure duration was between 30 and 60 minutes per ureter depending on obstruction length and severity. Average serum creatinine and blood urea nitrogen decreased to normal and hydronephrosis gradually resolved 1 to 2 weeks after stent insertion.

The complications in 32 ureteral stents placement were demonstrated in Table 1. A total of 11 patients appeared mild flank pain and discomfort a few days in duration after stent placed, probably because of the expanding force of the ureteral stents. Another 11 patients had gross hematuria, but after conservative treatment, the symptoms disappeared. One patient reported urinary frequency, dysuria and urgency may due to irritation symptoms of bladder by excessive protrusion of the distal stent end into the bladder. One patient reported arterial bleeding after PCN, which was controlled by transarterial embolization. Another 2 patients had urinary tract infection which needed antibiotic therapy.

Table 1

Complication and treatment of 32 ureteral stents in 25 patients

Complication	N (%)	Treatment
Mild flank pain and discomfort	11 (44 %)	Conservative
Gross hematuria	11 (44 %)	Hemostasis, absolute rest and drinking water
Urinary tract infection	2 (8 %)	Antibiotic therapy
Bladder irritation symptoms	1 (4 %)	Conservative
Arterial bleeding	1 (4 %)	Transarterial embolization

The primary stent patency rate at 3, 6, 9 and 12 months was 84.0%, 76.3%, 62.4%, and 45.4%, respectively. The median stent patency time for the antegrade ureteral stents were 10.4 (95% CI: 8.3–12.6) months (Fig. 3). And if ureteral patency was compromised by tumor progression, migration and hyperplastic reaction, internal drainage was achieved with percutaneous nephrostomy tube.

Fig. 3.

Kaplan-Meier curve of primary stent patency rate for 25 patients with 32 stents in the antegrade ureteral stents.

4. Discussion

Malignant ureteral obstruction is a severe event due to extrinsic tumor compression, retroperitoneal lymphadenopathy or direct tumor invasion. It can present with impaired renal function, hydronephrosis and/or urinary tract infection [11]. Initial management of obstructive uropathy due to malignancy may involve either percutaneous nephrostomy or retrograde ureteral stents [12].

Percutaneous nephrostomy or retrograde ureteral stent placement has matured in the last 30 years. PCN is the primary alternative to ureteral stenting with low morbidity and mortality for initial management of malignant obstruction or in patients who progress to stent failure [13 –15]. In addition, nephrostomy tubes in particular reports high technical success rates [16]. However, these patients with malignant ureteral obstruction often have short life expectancies, and the avoidance of pain, inconvenience, and psychosocial impairment may supersede the medical benefit of intervention [17]. Quality of life should be considered in deciding upon intervention for patients with malignant ureteral obstruction. The impact on the already aggregated quality of life of these patients is significant [12]. Retrospectively compared quality of life among patients with malignant obstruction managed with either stent or PCN, those who underwent nephrostomy tubes placement reported significantly higher incidence of minor complications as compared to ureteral stents placement, and required more frequent exchange [18, 19]. Despite these patterns, there was significant difference in responses to overall quality of life surveys between the two groups.

Retrograde ureteral stents has been the mainstay of palliative management with the majority of urologists favoring stent placement over percutaneous diversion as the primary treatment option [20]. The intervention approach avoids the potential complications of PCN, which is the prerequisite for antegrade ureteral stents insertion. In most institutions retrograde ureteral stents insertion through a cystoscope is attempted first, however retrograde stent insertion may be difficult, or even impossible. Especially in malignant obstructions, the success rate for antegrade stenting is higher than for retrograde. In a series of 92 patients Yossepowitch et al. [21] could successfully insert a ureteral stents via a retrograde route in 94% of their patients with benign intrinsic obstructions, but only in 73% of their patients with malignant ureteral obstruction. Another study reported a success rate of only 21% for retrograde ureteral stents in 65 patients with ureteral due to pelvic malignancy [3]. On the other hand, the use of percutaneous nephrostomy with placement of antegrade ureteric stent was a response rate of 96% [22], and Liatsikos EN et al reported antegrade ureter stent insertion is successful in 100% cases [23]. CT, MRI or intravenous urography was commonly done in patients with malignant ureteric obstruction. We can gain some insight into the degree of involvement of the bladder base and involvement of the ureteric orifices by tumor. If the bladder base or (and) ureteric orifices were invasive by tumor, antegrade ureteral stent placement often had low success rate.

In our cases, the technical success rate of percutaneous antegrade placement of ureteral stents was 100% (all 25 patients), and there were 12 ureters retrograde ureteral stents failed before antegrade ureteral stents were inserted, due to invasion of ureteral orifice by cancer or external compression from a cervical, rectal, colon or prostate malignancy. In addition, lumbar anesthesia was used in most retrograde ureteral stents insertion which a cystoscopy was attempted first. The patients associated with malignant upper urinary obstruction have a poor physical fitness, medical reason, may not was well tolerated in lumbar anesthesia. Our antegrade ureteral stents insertion was placed percutaneously under fluoroscopic guidance through the nephrostomy tract, only required local anaesthesia for PCN. Definitely, PCN was the prerequisite for antegrade ureteral stents, the potential complications of PCN should be considered. Actually, PCN is a standard procedure in interventional radiology, with a technical success rate well above 90% even in nonobstructed systems. In proficient hands the overall complication rate is 3–5% [18]. Therefore, antegrade ureter stent insertion is a safe procedure, minimal morbidity, high success rate and has a positive influence in patients with malignant ureteral obstruction. It should be considered as the primary route in cases of malignant ureteral obstruction.

The most challenging part of the procedure was passing the guidewire traversing the tight malignant stricture. The procedure can be difficult or impossible in patients with severe extensive strictures or occlusion, tortuous dilatational proximal ureteral or leak. Insertion of an appropriate angled 5Fr catheter could be used to through the stricture. A 5Fr DAV catheter is a good choice due to its ideal length, shaft stiffness and tapered tip. Put the 5Fr catheter on the upper, even into the strictures, its tapered tip and shaft stiffness provide optimal anchoring and stability needed to make the guidewire traversing the tight stricture. In addition, alternative appropriate combination such as microcatheter and microguidewire, have also been preferred for those patient population with severely stricture. To prevent ureteral rupture and contrast extravasation, which may promote periureteral fibrosis, gentle interventional was necessary. Furthermore, patient associated with malignant ureteral obstruction usually offered a congestive and (or) dropsical strictures and infection [24]. To alleviate these unfavorable conditions during ureteral stent placement, a two-stage procedure was performed. Percutaneous nephrostomy tube was placed through ultrasound guidance to relieve ureteral obstruction. After a few days of satisfactory external drainage, an antegrade stent was inserted in a second procedure.

Advancing the stent would have been an arduous task due to the tight strictures and tortuous dilatational proximal ureteral [25]. To avoid getting stuck in the stricture, theoretically, balloon dilatation should be used to advance the stent traversing [26]. However, we chose a rather unconventional device, a 5Fr DAV catheter. After the insertion of guidewire crossed the stricture, the 5Fr Kumpe catheter was slowly pushed along the hydrophilic guidewire until it traversed the malignant stricture. This 5Fr DAV catheter improved the stricture angle and dilated stricture, like balloon dilatation, allowing a straighter, commodious path for the stent to be advanced over the guidewire.

However, there are some limitations in our study. First, this study was a retrospective study and subject to the inherent limitations of retrospective studies. Second, because of the small sample size and no strict follow-up protocol, the result may be biased. Finally, this data was insufficient for cost and quality-of-life analyses compared to conventional retrograde ureteral stents treatment.

5. Conclusion

Malignant compression and infiltration is the most challenging part of ureteral obstruction. In our study, fluoroscopic guided antegrade ureter stent insertion is a safe, efficient procedure and has a high success rate in patients with malignant ureteral obstruction.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Footnotes

Acknowledgments

The authors gratefully acknowledge the National Natural Science Foundation of China (No. 81301978).

References

S.H.

Kim ,

Park ,

Joo , et al., Retrograde pyelography predicts retrograde ureteral stenting failure and reduces unnecessary stenting trials in patients with advanced non-urological malignant ureteral obstruction, PLoS One 12(9) (2017), e0184965.

J.L.

McDevitt ,

Acosta-Torres ,

Zhang , et al., Long-Term Percutaneous Nephrostomy Management of Malignant Urinary Obstruction: Estimation of Optimal Exchange Frequency and Estimation of the Financial Impact of Patient Compliance, J Vasc Interv Radiol 28(7) (2017), 1036–1042.e8.

S.V.

Chitale ,

Scott-Barrett ,

E.T.

Ho and

N.A.

Burgess , The management of ureteric obstruction secondary to malignant pelvic disease, Clin Radiol 57(12) (2002), 1118–1121.

P.M.

Chow ,

J.S.

Hsu ,

C.Y.

Huang , et al., Metallic ureteral stents in malignant ureteral obstruction: Clinical factors predicting stent failure, J Endourol 28(6) (2014), 729–734.

Keshavamurthy ,

Kumar ,

V.S.

Karthikeyan ,

Mallya and

G.G.

Nelivigi , Tubeless Pediatric Percutaneous Nephrolithotomy: Assessment of Feasibility and Safety, J Indian Assoc Pediatr Surg 23(1) (2018), 16–21.

M.C.

Uthappa and

N.C.

Cowan , Retrograde or antegrade double-pigtail stent placement for malignant ureteric obstruction? Clin Radiol 60(5) (2005), 608–612.

M.D.

Cordeiro ,

R.F.

Coelho ,

D.C.

Chade , et al., A prognostic model for survival after palliative urinary diversion for malignant ureteric obstruction: A prospective study of 208 patients, BJU Int 117(2) (2016), 266–271.

C.C.

Khoo ,

Abboudi ,

Cartwright ,

El-Husseiny and

Dasgupta , Metallic Ureteric Stents in Malignant Ureteric Obstruction: A Systematic Review, Urology 118 (2018), 12–20.

Prentice ,

Amer ,

Tasleem and

Aboumarzouk , Malignant ureteric obstruction decompression: How much gain for how much pain? A narrative review, J R Soc Med 111(4) (2018), 125–135.

10.

Wijayarathna ,

Suvendran ,

Ishak , et al., Outcome of retrograde ureteric stenting as a urinary drainage procedure in ureteric obstruction related to malignant lesions, Ceylon Med J 59(4) (2014), 124–127.

11.

Pavlovic ,

Lange and

B.H.

Chew , Stents for malignant ureteral obstruction, Asian J Urol 3(3) (2016), 142–149.

12.

A.D.

Benson ,

E.R.

Taylor and

B.F.

Schwartz , Metal ureteral stent for benign and malignant ureteral obstruction, J Urol 185(6) (2011), 2217–2222.

13.

Patel and

F.F.

Hussain , Percutaneous nephrostomy of nondilated renal collecting systems with fluoroscopic guidance: Technique and results, Radiology 233(1) (2004), 226–233.

14.

Radecka and

Magnusson , Complications associated with percutaneous nephrostomies. A retrospective study, Acta Radiol 45(2) (2004), 184–188.

15.

T.M.

Wah ,

M.J.

Weston and

H.C.

Irving , Percutaneous nephrostomy insertion: Outcome data from a prospective multi-operator study at a UK training center, Clin Radiol 9(3) (2004), 255–261.

16.

Barghouthy ,

Kourmpetis ,

Dekalo , et al., A Novel Method for Repositioning Suboptimally Preoperatively Placed Nephrostomy Tubes for Percutaneous Nephrolithotomy Without Renal Repuncture, J Endourol 2018. doi: 10.1089/end.2017.0725. [Epub ahead of print]

17.

I.S.

Kaskarelis ,

M.G.

Papadaki ,

N.E.

Malliaraki ,

E.D.

Robotis ,

K.S.

Malagari and

P.N.

Piperopoulos , Complications of percutaneous nephrostomy, percutaneous insertion of ureteral endoprosthesis, and replacement procedures, Cardiovasc Intervent Radiol 24(4) (2001), 224–228.

18.

K.A.

Hausegger and

H.R.

Portugaller , Percutaneous nephrostomy and antegrade ureteral stenting: Technique-indications-complications, Eur Radiol 16(9) (2006), 2016–2030.

19.

E.M.

O'Connor ,

G.J.

Nason and

E.A.

Kiely , Urological Management of Extramural Malignant Ureteric Obstruction: A Survey of Irish Urologists, Curr Urol 11(1) (2017), 21–25.

20.

M.J.

Aungst ,

C.L.

Sears and

J.R.

Fischer , Ureteral stents and retrograde studies: A primer for the gynecologist, Curr Opin Obstet Gynecol 21(5) (2009), 434–441.

21.

Yossepowitch ,

D.A.

Lifshitz ,

Dekel , et al., Predicting the success of retrograde stenting for managing ureteral obstruction, J Urol 166(5) (2001), 1746–1749.

22.

Punamiya , Percutaneous Nephrostomy and Antegrade Ureteric Stenting. In: Gervais D., Sabharwal T. (eds) Interventional Radiology Procedures in Biopsy and Drainage. Techniques in Interventional Radiology. Springer, London, 2010.

23.

E.N.

Liatsikos ,

Karnabatidis ,

Katsanos , et al., Ureteral metal stents: 10-year experience with malignant ureteral obstruction treatment, J Urol 182(6) (2009), 2613–2617.

24.

K.H.

Kim ,

K.S.

Cho ,

W.S.

Ham ,

S.J.

Hong and

K.S.

Han , Early Application of Permanent Metallic Mesh Stent in Substitution for Temporary Polymeric Ureteral Stent Reduces Unnecessary Ureteral Procedures in Patients With Malignant Ureteral Obstruction, Urology 86(3) (2015), 459–464.

25.

Iezzi ,

Di Stasi ,

Simeone and

Bonomo , Cutting-balloon angioplasty of resistant ureteral stenosis as bridge to stent insertion, Eur J Radiol 79(1) (2011), 12–14.

26.

K.L.

Ng ,

Nawawi ,

B.K.

Lim ,

T.H.

Htun ,

Dublin and

A.H.

Razack , Antegrade repositioning of Memokath stent in malignant ureteroileal anastomotic stricture, Asian J Surg 40(2) (2017), 171–174.