Longues sténoses urétérales: les alternatives à la sonde JJ au long cours

06 septembre 2021

Auteurs : S. Roux, C. Pettenati, C. Dariane, M. Sbizzera, I. Dominique, X. Matillon, T. Toinet, Y. Neuzillet, T. Bessède, C. Champy, M.O. Timsit, A. Méjean
Référence : Prog Urol, 2021, 10, 31, 598-604




 




Introduction


The widespread use of minimally invasive procedures has led to an increased number of iatrogenic ureteral injuries responsible for ureteral stenosis [1]. First-line treatment of ureteral stenosis consists in ureteral stent that allows urine derivation and acute symptoms relief. Patients with long ureteral stenosis (US) often remain with indwelling ureteral stents either because of patient's choice or characteristics, such as age, performans status, multiple abdominal surgeries, or because of US length that requires complex surgical repair. However, ureteral stents are associated with multiple general anesthesia, hospitalizations, infections and long-term discomfort [2, 3]. Alternatives exist, such as kidney autotransplantation (KAT) that was first performed in the United States in 1963, and ileal ureter substitution (IUS) described by Schoemaker in 1906 [4, 5]. These techniques are infrequently used, as shown by the published literature with mainly case reports and small series from expert centers [6, 7]. Without any available comparative data or high standard of proof to elaborate guidelines, the management of long US depends on surgeon's expertise. Understanding KAT and IUS surgical approaches and outcome is important in order to determine a surgical plan in US management and to give patients all available options regardless of surgeons' expertise [8].


The aim of our study was to evaluate KAT and IUS practice and functional outcome in the management of US in French university centers.


Materials and methods


Patients


We conducted a retrospective multicenter study including five French University centers (Hôpital Européen Georges Pompidou, Assitance Publique-Hopitaux de Paris (AP-HP), University of Paris Descartes; Hospices Civils de Lyon, HCL, University of Lyon 1; Hôpital Foch, University of Versailles-Saint-Quentin-en-Yvelines; Hôpital Kremlin-Bicêtre, AP-HP, University of Paris Sud; Hôpital Henri Mondor, AP-HP, University of Paris Est Créteil).


The five centers had kidney transplant expertise. The study was approved by our national urologic ethic committee (CERU n°CERU_2020/008) and by the French national commission of informatics and freedoms (CNIL n° 2217694v0).


All patients gave their informed consent for research and use of their medical data. We included patients (≥18 years-old) diagnosed with US and treated between 2010 and 2018 using KAT or IUS procedures. We excluded US due to urothelial carcinoma. Data on patient demographics and US characteristics at diagnosis were collected by chart review.


US management


US management choice between KAT or IUS was at the discretion of each centers. We collected peri-operative data including surgical difficulties as reported by surgeons, operating time, blood loss, length of hospital stay and post-operative serum creatinine. Complications were classified by the Clavien-Dindo classification system reported as short term (30 days or less) or long term (longer than 30 days).


Study analysis


The primary endpoint of our study was the preservation of the ipsilateral kidney to the US and of kidney function (Δcreat, defined as the difference between preoperative serum creatinine and serum creatinine level at last follow-up), without any urinary diversion.


Categorical variables were expressed in numbers (with percentage) and analyzed using Chi-square test. Continuous variables were expressed in means (± standard deviation, SD), or medians (with range) and analyzed using Wilcoxon-Mann-Whitney test. Statistical tests were performed as two-sided with a P- value<0.05 considered as significant. Statistics were performed using Prism® software.


Results


Between 2010 and 2018, 22 patients were included in our study. Overall patients' demographics and US characteristics are described in Table 1. Median age at US diagnosis was 55 years (range 33-69 years). Eight patients (36.4%) were treated by KAT, and 14 patients (63.6%) by IUS. Mean pre-operative renal clearance was 72.7ml/min with no difference between KAT and IUS groups (P =0.56).


The main US etiology was per-operative iatrogenic wound (n =11, 50%). All patients had prior treatment attempts including multiple procedures in one third of cases (n =7, 31.8%). US mean length was 5.5cm (±2.9). There was no significant difference in US length between KAT and IUS groups (4.6cm versus 5.9cm respectively, P = 0.52). US level varied, with pyelo-ureteral US mainly treated by KAT (n =4, 66.7%) and lumbar US by IUS (n =7, 87.5%). Surgical approaches differed according to KAT or IUS procedures, with laparoscopic or open surgeries as described in Table 2.


Peri-operative data are described in Table 3. Surgical difficulties were reported in 15 cases (68.2%) due to peritoneal adhesions or major renal hilar or retroperitoneal fibrosis. There was one surgical conversion from laparoscopic to open approach in KAT group due to complex adhesiolysis. There was no significant difference between the two groups as to operating time (336.3min versus 346.5min, in KAT and IUS groups respectively P =0.87). Length of hospital stay was 8.4 days versus 15 days in KAT and IUS groups respectively (P =0.001). Postoperative complications were reported in 20 patients (90.9%), mostly Clavien ≤2 (n =17, 77.3%) including ileus and urinary infection all medically treated. Revision surgery was required in the KAT group in 3 cases (37.5%), due to textiles, renal vein thrombosis and anastomotic leak. There was no revision surgery in the IUS group. The mean follow-up was 15.7 months. All but one ipsilateral kidneys were preserved. Nephrectomy was required in one case (KAT group) due to renal vein thrombosis. At the end of follow-up, there was no renal function impairment (Δcreat +2.1 vs. +2.4μmol/l in KAT and IUS groups respectively, P =0.67), and no need for urinary diversion.


Discussion


This retrospective and multicenter study reported 22 cases of ureteral stenosis managed by KAT or IUS. US were long (mean 5.5cm) and located at different levels. KAT and IUS were both safe procedures with mostly Clavien ≤2 complications (n =17, 77.3%). However, multiple prior treatments and per-operative difficulties highlighted the complexity of long and chronic US management. All ipsilateral kidneys were preserved, except one in KAT group. Kidney function remained unchanged at the end of follow-up, without any urinary diversion in both groups.


While gathering five French university centers experience, our study highlighted the relative scarcity of KAT and IUS practice in the management of US with only 22 cases. To our knowledge literature has so far mainly reported case reports or cohort studies without any available comparative data for KAT and IUS [9, 10, 11, 12]. As to KAT, most series included varied indications, such as ureteral stenosis or avulsion, vascular aneurysm, or loin pain-hematuria syndrome [6, 7, 13]. We only included KAT and IUS performed for US and detailed US etiologies. We excluded US from urothelial carcinoma because urothelial carcinoma would be at risk of recurrence leading to higher failure rate.


With one transplant loss in KAT group (12.5%), our results were similar to previous reports [6, 7, 13, 14]. Kidney transplant was removed in a female patient with multiple surgeries on the pyelo-ureteral junction. She had two pyeloplasty attempts, followed by indwelling ureteral stent before being addressed to a university center. Stent incrustation led to removal attempt by ureteroscopy and finally through a double access (ureteroscopy and per-cutaneous nephroscopy). KAT was extremely difficult due to severe renal hilar and peri-ureteral adhesions. Vein thrombosis led to transplant removal at day 1. It also was a rare case of KAT with a right kidney. KAT with a right kidney is more challenging because the vein is shorter than the left one, increasing the risk of thrombosis.


The five French centers of our study had transplantation expertise with more than 100 cases/year for four centers, and more than 200 cases/year for one center. Vein thrombosis is a known complication of kidney transplantation and explained by several factors, such as surgeon's expertise, graft placement, renal vein length or hemodynamic during and following surgery [15]. Nevertheless, satisfying KAT results were reported. In a 6 year-follow-up, Tran et al. reported 52 cases of KAT, including 40 cases for ureteral stricture. Three kidneys (7.5%) were removed due to thrombosis, pseudoaneurysm or pain, meaning a 92.5% success rate [13]. In two other studies, 15 cases of KAT for US were reported, with 2 transplant losses (13.4%) [6, 16].


Considering IUS, Wolff et al. reported 17 cases over 30 years (1980-2010), with an 88% success rate as 15 patients still had ileal ureter at the end of follow-up. However, 3 patients (20%) required dialysis [17]. In our cohort of 14 IUS cases, no ipsilateral kidney was lost. We did not observe electrolyte imbalance or kidney function impairment, as compared to previous reports [5, 8]. Our relative short 12-month follow-up in this group could explain this result.


Regardless of the procedure, success rate depends on several factors, such as patient's age and performans status, US characteristics and case selection, surgical difficulties and surgeon's expertise. In our study, patients were relatively young (mean age was 46 years in KAT group, 57 years in IUS group), as reported in other studies [5, 13, 18]. Mean pre-operative renal clearance was 72.7ml/min with no difference between KAT and IUS groups (P =0.56).


US management was complex. As in previous reports, all patients included in our study had prior treatments before KAT or IUS, including one third with multiple prior treatment attempts [3, 12, 16, 19, 20]. Post-operative complications were Clavien ≤2 in 17 cases (77.3%), with mainly ileus and urinary infection all medically treated. Clavien>2 complications (n =3, 13.6%) were only seen in KAT group despite surgical expertise in transplantation. Indeed, KAT practice presents specific difficulties as compared to kidney transplantation: first, prior treatments lead to renal hilar and ureteral fibrosis; second, KAT needs two distinct surgery times-nephrectomy and kidney transplantation. Both factors imply a long operating time (3 to 7hours in our study). Revision surgery was needed for textiles, arterial anastomotic leak and renal vein thrombosis, which could be explained by surgical difficulties and operating time.


We reported the surgical approaches used in KAT and IUS groups. We could not precisely describe procedures as they differed according to centers, since different surgical approaches exist for KAT and IUS. The first laparoscopic KAT was performed by Fabrizio et al. and the first laparoscopic IUS was reported in 2000 by Gill et al. [21, 22]. Literature reported benefits of laparoscopy over open surgeries with shorter length of hospital stay and recovery time. Minimally invasive approaches have been developed recently. The first totally intracorporeal robotic KAT was performed by Gordon et al. [23]. Decastecker et al. reported the largest published experience on robotic KAT and emphasized the safety and efficiency of this technique for selected patients [24]. The first robot-assisted approach for ileal interposition was described by Wagner et al. in 2008 [25]. The robotic approach is then feasible but needs long-term results and health care costs evaluation.


The key issue is: "how to choose between KAT and IUS?". Unfortunately, no clear guidelines or comparative studies help surgeons for procedure indication because of the lack of robust data. The choice between KAT and IUS relies on center expertise. Interestingly, in our study 6 of the KAT (75%) were performed in the center with the largest kidney transplantation activity (220 cases in 2017), and 9 of the IUS (64%) were performed in another center with the second largest kidney transplantation activity (195 cases in 2017). However, other factors come into play: location and length of US, stricture etiology, bowel availability, contralateral kidney status, renal function, the side of the kidney in KAT, patients' characteristics and preference are all factors that must be considered [9, 20, 26]. Knight et al. mentioned several contraindications for IUS such as inadequate length of usable bowel, inflammatory bowel disease, abdominopelvic radiation, kidney failure or untreated bladder outlet obstruction [8]. In KAT and IUS literature, US are typically long, mainly over 4cm [3, 7, 13, 17, 27]. We did not find significant difference in US length between KAT and IUS groups. Although both KAT and IUS can be performed regardless of US anatomic level, US was described as more often proximal for patients treated with IUS according to Stein et al. and Castillo et al. [16, 17, 19, 28, 29]. Indeed, according to Knight et al., IUS should be less complex for proximal stenosis [8].


Distal stenosis can be managed with vesicopsoas hitch as reported in EAU guidelines, but KAT and IUS stay an alternative for long distal stenosis [30].


In our study, we observed that pyelo-ureteral stenosis was mainly managed by KAT (4 cases out of 6 in overall cohort, 66.7%) and lumbar stenosis was mainly managed by IUS (7 cases out of 8 in overall cohort, 87.5%). Pyelo-ureteral anastomosis, uretero-ureteral or uretero-vesical reimplantation were used in KAT, depending on US location and length and on available downstream ureter of satisfying quality.


KAT has satisfying long-term results in selected patients and prevents the risk of bowel interposition with urinary tract infection, acidosis and mucous production [6, 13, 16]. Shekariz et al. mentioned two KAT limits: renal vessels length and severe fibrosis [12]. KAT could be chosen for young patients with complex, long, unilateral US or for patients with contraindication for IUS. IUS would be a better option for patients with proximal or lumbar stenosis with severe retroperitoneal fibrosis, and when renal vessels length is too short for transplantation or for patients with several kidney arteries. Patients' information on both techniques is mandatory, as well as referring them to expert centers.


This study has several limitations. The delta creat is shorter to be significant and could explain the low delta creat observed in our study in IUS group as compared to previous reports. The cohort was small with retrospective data collection. Twenty-two patients were included despite a multicenter analysis in university centers with kidney transplantation expertise, highlighting the scarcity of KAT and IUS practice for complex US management. Whenever possible, we suggest that expert centers opinion should be requested for US complex cases, in order to develop KAT and IUS practice and to give another chance to patients with indwelling ureteral stents. Our follow-up was short, prompting us to open a national register to record new cases and long-term data.


Conclusion


We reported satisfying results regarding KAT and IUS for complex and long ureteral stenosis. Renal function remained stable without any urinary diversion. Ipsilateral kidney was preserved in all cases except for one in KAT group.


In conclusion, KAT and IUS are safe alternatives to indwelling ureteral stent for the management of long ureteral stenosis in selected cases. However, all possible options with their advantages and known complications should be discussed with patients.


The major challenge is to preserve renal function, ipsilateral kidney and patients' quality of life. As such, we suggest to refer complex cases to expert centers. Regardless of expertise, guidelines would be helpful to select a procedure and its technical approach according to the various factors that can be involved in long US management.


Disclosure of interest


The authors declare that they have no competing interest.




Table 1 - Overall patients demographics and ureteral stenosis characteristics at diagnosis.
  Overall n =22  KAT n = IUS n =14 
Patients       
Mean age, years [min-max]  55 [33-69]  44 [33-61]  58 [39-69] 
Gender, n (%)       
Women  12 (54.5)  5 (62.5)  7(50.0) 
Men  10 (45.5)  3 (37.5)  7(50.0) 
Preoperative renal function       
creatinine in μmol/L, mean (± SD)  92.4 (± 34.8)  83.9 (± 19.5)  97.3 (± 41.0) 
GFR in ml/min, mean (± SD)  72.7 (± 24.8)  79.7 (± 19.5)  69.7 (± 19.2) 
Prior treatments, n (%)       
Ureteral stent alone  8 (36.4)  1 (12.5)  7 (50.0) 
Nephrostomy alone  4 (18.2)  2 (25.0)  2 (14.3) 
Balloon dilatation  3 (13.6)  3 (21.4) 
Multiple treatment attemptsa  7 (31.8)  5 (62.5)  2 (14.3) 
US characteristics       
Etiology, n (%)       
Scar lesionb  8 (36.4)  3 (37.5)  5 (35.7) 
Per-operative iatrogenic wound  11 (50.0)  4 (50.0)  7 (50.0) 
Retroperitoneal fibrosis
or extrinsic compression 
3 (13.6)  1 (12.5)  2 (14.3) 
Side, n (%)       
Right  8 (36.4)  2 (25.0)  6 (42.9) 
Left  14 (63.6)  6 (75.0)  8 (57.1) 
Length in cm, mean (± SD)  5.5 (± 2.9)  4.6 (± 1.5)  5.9 (± 3.4) 
Level, n (%)       
PUJ  6 (27.2)  4 (50.0)  2 (14.3) 
Lumbar  8 (36.4)  1 (12.5)  7 (50.0) 
Iliac  2 (9.1)  1 (12.5)  1 (7.1) 
Pelvic  4 (18.2)  1 (12.5)  3 (21.5) 
Multifocal  2 (9.1)  1 (12.5)  1 (7.1) 



Légende :
US: Ureteral stenosis, KAT: Kidney autotransplantation, IUS: Ileal ureter substitution, GFR: Glomerular Filtration Rate, PUJ: Pyelo-ureteral junction.

[a] 
Failures of dilatation, pyeloplasty, reimplantation, resection-anastomosis.
[b] 
Ureteroscopy, lithiasis migration, pyeloplasty.


Table 2 - Surgical approaches in KAT* and IUS** groups.
  Overall n =22  KAT n = IUS n =14 
Laparoscopy, n (%)  6 (27.3)  6 (75.0) 
Open surgery, n (%)  16 (72.7)  2 (25.0)  14 (100.0) 



Légende :
KAT: Kidney autotransplantation, IUS: Ileal ureter substitution.



Table 3 - Analysis of peri-operative data and functional outcome in KAT* and IUS** groups.
  Overall n =22  KAT n = IUS n =14  P  
Per-operative difficulties, n (%)  15 (68.2)  7 (87.5)  8 (57.1)  0.33 
Operating time,
in minutes, mean (± SD) 

342.6 (±86) 

336.3 (±83.7) 

346.5 (±90.5) 

0.87 
Blood loss,
in ml, mean (± SD) 

321.0 (±162.7) 

393.8 (±152.2) 

272.5 (±156.7) 

0.16 
Hospital stay,
in days, mean (± SD) 

12.5 (±5.2) 

8.4 (±2.8) 

15.0 (±4.8) 

0.001 
Complications ≤30 days, n (%)  20 (90.9)  7 (87.5)  13 (92.8)  0.91 
Complications >30 days, n (%)  2 (9.1)  1 (12.5)  1 (7.1)  0.91 
Δcreat
in μmol/L, mean (± SD) 

2.3 (±16.5) 

+2.1 (±14.7) 

+2.4 (±18.0) 

0.67 
Follow-up,
in months, mean (± SD) 

15.7 (±22.4) 

23.0 (±34.7) 

11.5 (±10.7) 

0.85 



Légende :
KAT: Kidney autotransplantation; IUS: Ileal ureter substitution.


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