Teaching Case

55-year old female patient presented with hydronephrosis caused by iatrogenic benign ureteral stricture;management with percutaneous balloon dilatation and stent placement

A 55-year old asymptomatic female patient with a 2-month history of radical hysterectomy and pelvic external beam irradiation for stage IIb cervical cancer had an abdominal CT (not shown) that depicted left hydronephrosis. There was no evidence of residual pelvic tumor or lymphadenopathy. Tumor markers (CEA, Ca 125, SCC) were normal. Attempts to place an indwelling ureteral stent in a retrograde fashion failed twice because "the stricture was very tight". The patient was referred to our interventional radiology service for percutaneous nephrostomy and stenting. Percutaneous nephrostomy was performed under local anesthesia and conscious sedation, using the Acustic percutaneous access set (Meditech, Boston Scientific Corporation, Watertown, MA, USA). The needle was inserted in an upper pole calyx under ultrasonographic guidance (Fig. 1). A platimun-tip 0.018-inch guide wire was introduced and subsequently exchanged for a 0.038-inch guide wire. A 5-F cobra catheter (Terumo, Leuven, Belgium) was placed in the pyeloureteric junction and an antegrade pyelography depicted an obstruction at the pelvic portion of the ureter (Fig.2). The obstructing lesion was transversed with a 0.038-inch stiff hydrophilic guidewire (Terumo, Leuven, Belgium), and a 6-F biliary manipulation catheter (William Cook Europe, A/S). An Amplatz stiff guidewire (William Cook Europe, A/S) was inserted with its floppy end coiled into the bladder.The stricture was dilated with a 6-mm high pressure balloon (Blue Max, Meditech, Boston Scientific Corporation, Watertown, MA, US) for 2 minutes (Fig. 3 a&b). After successful dilatation, a 10-F,30-cm long peel away sheath was introduced into the ureter(William Cook Europe, A/S) A 8-F double pig-tail ureteral stent (Meditech, Boston Scientific Corporation, Watertown, MA, USA) was inserted and a 8-F nephrostomy catheter was finally placed. Immediate nephrostogramm showed good stent patency (Fig.4). The patency was checked 3-days later, and the external catheter was removed. The patient was afebrile and was discharged home.Abdominal ultrasonography performed 3 months after the procedure depicted abscence of hydronephrosis. The patient's urologist plans to remove the double pig-tail stent after a total 6-month-period.

The patient's ureteral stricture was short and very tight, therefore it was most likely an iatrogenic stricture.Abdominal CT , and tumor markers were normal at the time of patient's presentation in our department. Our patient's initially tumor staging most likely precludes pelvic dissemination within a two-months time. Therefore the ureteral stricture was attributed to a benign process. Since post radiation strictures require a few months to develop, the patient's stricture should be attributed to a surgical trauma. Tradionally benign ureteral strictures were managed surgically. Non-operative treatment includes retrograde or antegrade dilatation with serial dilators or preferrably with balloon-catheters, followed by long-term stenting (1). Ureteral catheterization and negotiation of an ureteric stricture is easier from the percutaneous route, than via the retrograde approach (2). Regardless of this technical advantage, the response to dilatation is unpredictable; dilatation time ranges from 30 seconds up to many hours (3). Some researchers believe that postoperative strictures, especially new ones, respond favorably to dilatation, while dense fibrotic strictures, such as from fistulas, do not (4). Our patient's stricture responded well to dilatation, thereby considered a technical success. Nevertheless long-term stenting was considered necessary to allow for prompt endothelization of the diseased segment. Ultrasonography at 3-months showed good stent patency. The mid-term result of the dilatation itsself could not be assessed with the stent in place. Nevertheles the patient's physician preferred a longer stenting period . Long-term patency is reported in 70%, when there was no vascular compromise of the affected segment, but only in 20% when there was vascular damage (1). Recently the use of metallic stents, such the Wallstent, is reported for the management of malignant and benign ureteric strictures (5,6). The results are not uniformly satisfactory, with good technical success, but with long patency rates from few days to years. We refrained from using metallic stent in our patient, because our previous experience in malignant strictures was not satisfactory.