0022-534 7/94/1516-1619$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1994 by AMERICAN UROLOGICAL ASSOCIATION, !NC. Voi. 151, 1619-1622, June 1994 Printed in U.S.A. INTRAURETERAL METALLIC SELF-EXPANDING ENDOPROSTHESIS (WALLSTENT) IN THE TREATMENT OF DIFFICULT URETERAL STRICTURES YURI REINBERG, HECTOR FERRAL, RICARDO GONZALEZ, J. CARLOS MANIVEL, JOHN HULBERT, MANUEL MAYNAR,* J.M. PULIDO-DUQUE,* DAVID HUNTER AND WILFRIDO R CASTANEDA-ZUNIGAt From the Departments of Urology, Pathology and Radiology, University of Minnesota, Minneapolis, Minnesota ABSTRACT Intractable and recurrent ureteral stricture presents a continuous challenge to the urologist, We report on 5 patients with severe ureteral stricture who were successfully treated with self-expanding metallic stents, Ureteral stricture occurred at ureteroileal anastomotic sites after neoplasm resection in 2 cases, multiple upper ureteral strictures were related to multiple surgical procedures for correction of bladder exstrophy in 1 and a ureteral kink developed in 1. Treatment with transluminal balloon dilation provided poor results but self-expanding metallic stents were used successfully with no major complications. In the last patient the stent and the overlying ureter were removed due to recurrent reflux; the gross and histological ureteral changes are discussed in detail. The technical approach is described, alternative therapeutic options are considered and pertinent literature 1s reviewed. KEY WORDS: catheters, indwelling; balloon dilatation; ureter The management of ureteral stenosis or strictures can be- come a complex problem. The classical therapeutic approach has been retrograde balloon dilation with or without an inci- sion, or surgical correction if this is not successful. 1 ' 2 Some cases are managed by long-term ureteral plastic stent place- ment or external percutaneous drainage. However, current endourological percutaneous techniques make it possible to manage ureteral strictures secondary to fibrosis, trauma, pre- vious surgery, endourological manipulation and infection by transluminal balloon dilation therapy. Early results with this technique have been promising with reported success rates that range from 55 to 85%. 2 However, long-term followup results are poor, particularly after ureteroileal anastomosis. 3 • 4 The use of self-expanding metallic stents in the vascular and biliary systems has recently been reported and results have been encouraging. 5 ' 6 Although such stents are successfully used in the treatment of urethral strictures, use in the ureter has been minimal. We report 5 cases of ureteral strictures that were successfully treated by placing a metallic stent after balloon dilation therapy failed. We also discuss other therapeutic ap- proaches and technical difficulties. TECHNIQUE The ureteral stricture site is dilated with an angioplasty balloon 1 to 2 mm. smaller in diameter than the metallic stent to be placed. An injection of contrast medium allows the effects of balloon dilation to be assessed and helps to localize the stricture site for stent placement. Using fluoroscopy, the stent introducer catheter is advanced over the guide wire to the site of the stricture. The length of the stent should be longer than the length of the stricture. Stent deployment is begun by pulling back the rolling membrane that contains the stent. If the stent is adequately positioned after partial deployment its full length Accepted for publication October 22, 1993. Read at annual meeting of American Urological Association, Wash- ington, D. C., May 10-14, 1992. * Current address: Nuestra Senora del Pino Hospital, 35005 Las Palmas, Canary Islands, Spain. t Current address: Department of Radiology, Louisiana State Uni- versity Medical Center, New Orleans, Louisiana 70112-2822. can be deployed. If the position is inadequate the partially deployed stent can be locked in place in the introducer catheter and pulled back to a more suitable position. If the stent needs to be advanced it can be pulled back out of the abdomen, since a partially deployed stent cannot be advanced. Once the stent has been fully deployed the position cannot be changed. Balloon dilation of the stent might be necessary in some cases to accomplish full expansion. Normally, tensile force of the stent allows it to expand fully in time. Injection of contrast medium demonstrates flow through the stent. CASE REPORTS Case 1. A 44-year-old man underwent cystectomy and ileal loop diversion for the treatment of grade II stage B2 transitional carcinoma of the bladder. The patient was rehospitalized with left flank pain 3 months postoperatively and left hydrone- phrosis was found on ultrasound. Left percutaneous nephros- tomy was performed and the nephrostogram showed a long, severe area of stenosis at the level of the ureteroileal anasto- mosis (fig. 1, A). Repeated ureteral dilations with an angio- plasty balloon were performed in 3 months (fig. 1, B ). Because balloon dilation failed to resolve the condition, a self-expanding 8 mm. stent (W allstent:j:) was placed at the level of the stenotic segment (fig. 1, C). The nephrostomy tube was capped and 48 hours later a nephrostogram was performed to assess patency and adequate function of the stent. The percutaneous nephros- tomy tube was subsequently removed and the patient was discharged home. At followup 13 months later the patient was clinically asymptomatic and no abnormalities in renal function were noted. Followup ultrasound and an excretory urogram (IVP) showed good function of the left kidney. Case 2. A 53-year-old man underwent cystectomy and ileal diversion for transitional carcinoma of the bladder. The patient was rehospitalized 1 month postoperatively and right hydro- nephrosis was diagnosed on ultrasound. Right percutaneous nephrostomy was performed and the nephrostogram showed severe ureteroileal anastomotic stenosis (fig. 2, A). A total of 3 sessions of balloon dilation of the anastomotic stenosis was :j: Schneider, Inc., Plymouth, Minnesota. 1619