Balloon dilatation of ureteric strictures.SV Punekar, SR Rao, G Swami, AB Soni, JS Kinne, SS Karhadkar
Department of Urology, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0010855073
Source of Support: None, Conflict of Interest: None
AIMS: Evaluation of dilatation as a minimally invasive technique for the treatment of ureteric strictures. MATERIAL AND METHODS: We evaluated this technique in 16 patients with ureteric and secondary pelviureteric junction strictures from June 1998. Of these, 7 were men and 9 were women. The age range was from 14 to 40 years. RESULTS: Balloon dilatation was successful in 69% of patients. Strictures secondary to previous surgery had nearly 100% success. Of the 8 cases diagnosed as genitourinary tuberculosis, success rate was 50%. CONCLUSIONS: Factors affecting success of balloon dilatation are: a) age of the stricture b) length of the stricture and c) etiology of the stricture. In a select group of patients with fresh post-operative or post-inflammatory strictures, balloon dilatation may be an attractive alternative to surgery.
Keywords: Adolescent, Adult, Balloon Dilatation, Female, Human, Male, Treatment Outcome, Ureteral Obstruction, etiology,therapy,
Balloon dilatation of ureteric strictures is only an extension of their use in angioplasty. Non-operative transluminal dilatation is being increasingly used for strictures of the blood vessels, urethra, gastrointestinal and hepatobiliary tracts and the mitral valve.
The aim of this study was to evaluate balloon dilatation as a modality of treatment in secondary pelvi-ureteral junction (PUJ) obstruction and in ureteric strictures. The study was performed in 16 patients. The clinical presentation, technique and results are presented in this paper.
From June 1995 to June 1998, balloon dilatation was performed on 16 adult patients who presented with stricture of the PUJ or ureter. Of these, seven were men and nine were women. The age range was from 14 to 40 years, the mean being 27 years.
All patients had symptoms suggestive of obstructive uropathy. In addition to a detailed clinical history and physical examination, a urinalysis, renal chemistry and sonography were part of the routine evaluation. The diagnosis of a significant stricture of the PUJ or ureter was made by an intravenous urogram1 (IVU) and/or retrograde pyelogram (RGP) and a 99m Tc DTPA renal scan.
Three patients had strictures following pyelolithotomy, three had strictures following a failed pyeloplasty, eight patients with strictures had a diagnosis of genito-urinary tuberculosis and in two patients, the strictures occurred following ureteric reimplantation (one in a renal transplant recipient, one in a patient with vesico-ureteric reflux) – [Table - 1].
Anatomically, the majority of strictures (62%) were in PUJ and upper ureter, four (31%) were in lower ureter and there were two patients (7%) with long strictures involving the mid and lower ureter.
They were arbitrarily classified as long i.e. >2 cm which accounted for only five of the cases and short i.e. <2 cm which accounted for the remaining 11 cases.
All cases were performed under sedoanalgesia. All except one patient underwent retrograde dilatation. The one exception was the renal transplant recipient whose stricture was dilated by percutaneous antegrade manner. An initial RGP was performed with a 6F open-ended ureteric catheter, which had been passed over a 0.035” guide wire. Once the number, site and extent of stricture was delineated, the catheter was exchanged for a 7F Uromax balloon catheter with a balloon 4 cm long and an outer diameter of 5 mm to 6 mm (15F - 18F). The balloon was centred over the stricture using the radiopaque markers. The balloon was inflated to its maximal volume (~2 ml) using dilute contrast till the “waisting” disappeared and a constant pressure was maintained for 3 minute. Immediately following dilatation, the catheter was withdrawn below the stricture and a retrograde gram performed to demonstrate widening of the strictured area. One or more than one dilatation was performed per procedure.
A double ‘J’ (DJ) stent was placed post procedure and removed six weeks later following which an IVU was performed after a gap of two weeks. Patients were followed up with three monthly scans in the first year and six monthly scans after that. The follow up period ranged from 15 months to 53 months after the procedure.
Success was defined as
i. symptomatic improvement
ii. morphological improvement on immediate ureterogram and on follow up IVU
iii. functional improvement on IVU and follow up renal scans
Failure was defined as any one or a combination of the following:
i. failure of improvement in clinical symptoms or
ii. a procedural failure due to inability to pass the guidewire across the stricture
iii. lack of appreciable widening of the stricture on IVU or antegrade studies
iv. deterioration in function on follow up scans or IVU.
Successful dilatation was possible in 11 of 16 cases (69%) – [Table - 2].
All three cases of PUJ strictures following pyeloplasty were successful dilated. Two of the three strictures following pyelolithotomy and both strictures following ureteric reimplantation were successfully dilated. Of the eight cases diagnosed as genito-urinary tuberculosis, there were four failures, while the other four responded satisfactorily.
Few complications were encountered. Early in our study two patients had fever and urinary tract infection (UTI), which we treated by double-J stenting and they responded satisfactorily. Subsequently we stented all our patients post procedure and we did not encounter this complication again. All of our patients now routinely undergo DJ stenting post balloon dilatation. Two patients had haematuria, which did not require transfusion. Minimal extravasation occurred in one patient at the site of dilatation. The patient was stented and recovered without any further complication.
Though non-operative dilatation of ureteric strictures has been described in the 1920s, more recently it was popularised by Kadir et al (1982). Since then, literature carries reports of a number of series of antegrade and retrograde balloon dilatation but most of these series describe balloon dilatation of primary PUJ obstruction in adults and/or children. In our series, cases selected were either ureteric strictures or secondary PUJ strictures. All patients were adults; we did not include any children in our study.
Balloon dilatation was successful in 11 of our 16 patients (69%), which is comparable to other reported series.
In our study, the three factors affecting response to dilatation were
i. Age of strictures: Of our five failures, one was following pyelolithotomy where the patient presented one year after surgery. The remaining four were in patients with genito-urinary tuberculosis who underwent dilatation after nine months of anti-tuberculous therapy. In subsequent cases we performed dilatation after only six weeks of anti-tuberculous therapy and found the response to be much better. This factor has been recognised in most series,,,. The best response to balloon dilatation occurs in those cases in which there is a short interval between the injury or lesion and the dilatation (preferably < 3-6 months). Older strictures become more dense and fibrotic and therefore difficult to dilate.
ii. Length of stricture: Four of our five failures were in strictures > 2 cm and only one failure in a stricture < 2 cm. Inevitably in longer strictures, there is more devascularisation and fibrosis and therefore more resistance to dilatation.
iii. Aetiology: 80% of our failures were in patients diagnosed as genito-urinary tuberculosis. It is possible that tuberculous endarteritis in these patient caused devitalisation of the ureter and ischaemia has been recognised as the most important adverse factor affecting response to dilatation .
Of our five failures, four cases had three adverse factors in common namely:
i. They were all tuberculous strictures
ii. They were > 2 cm long
iii. They were dilated > 9 months anti-tuberculous treatment.
It is possible that each of these factors contributed in some measure to the failure.
Our success rate of 69% is very encouraging especially in post-operative strictures. However, we had a limited number of patients in our series and follow up of only two and half years. It would therefore be premature to suggest that balloon dilatation is the answer to all ureteric strictures. What must be taken into consideration is the fact that it is non-invasive and safe, with a low complication rate. Moreover, it is a day care procedure and it is possible to subject the patient to multiple dilatations in cases of recurrence or re-stenosis.
Therefore, in a select group of patients with fresh post-operative or post-inflammatory strictures, balloon dilatation may be an attractive alternative to surgery.
[Table - 1], [Table - 2]