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European Urology - Prosthetic Nephrovesical Bypass

Wednesday, 25 October 2006

Volume 50, Issue 5, Pages 879-883

Article Outline:

Patients with advanced malignant masses in the retroperitoneum often present with renal failure due to ureteral obstruction. If internal ureteral stenting fails in this situation, the usual outcome is a permanent nephrostomy, with all its sequelae in loss of quality of life and risk of tube dislocation, infection, and recurrent obstruction. In the 1960s and early 1970s, the first attempts were undertaken to solve the problem by bypassing the obstructed ureteral segments with silicone prostheses. Problems with extravasation, obstruction at the anastomotic sites, and incrustation were gradually overcome by changes in material, design, and surgical techniques, so that the systems were considered safe enough for clinical application in the mid 1970s. The case report from Schulman and colleagues is one of the first publications of prosthetic replacement of both ureters. The authors achieved this by severing the ureters just below the ureteropelvic junction through a transperitoneal approach and anastomosing the collecting systems to two silicone prostheses. The distal ends of these were then implanted into the posterior bladder wall with rhodergon cuffs and integrated antireflux valves. With the patient's normal renal function, good quality of life, and no major complications over a 2-yr period of follow-up, the authors proved the feasibility of the approach. More importantly, they, for the first time, demonstrated that peristaltic activity of the ureter was not needed for permanent normal function of the upper urinary tract—a dogma up until then. They had delivered the proof of principle.

The following two decades were dominated by a dramatic proliferation in technology and techniques of internal ureteric stenting. Nevertheless, internal stenting is still not universally applicable and prosthetic replacement of the ureter remains a challenge, with the main impetus directed towards lowering the invasiveness of the procedure. Lingam et al. [1] developed a nephrovesical 7F double-pigtail, extra-anatomic bypass system that was positioned in a subcutaneous tunnel. Initial clinical experiences were encouraging. In 1995, Desgrandchamps et al. [2] presented a self-retaining, one-piece expanded polytetrafluoroethylene-silicone tube for this purpose, which was successfully implanted in 19 patients with a mean follow-up of 7.2 mo. None of the tubes were dislodged or became obstructed due to incrustation or kinking. The major disadvantage of the system was its length of 70cm, which rendered surgical implantation complex and time consuming. Nakada et al. [3] worked on a similar subcutaneous nephrovesical bypass. Using the 8.5F prototype of Lingam's stent, they successfully placed prostheses in two patients with a marked and immediate improvement in quality of life. Nevertheless stent obstruction occurred within 6 and 9 wk, respectively. To avoid this, Nissenkorn and Yehoshua [4] used two 14F 50-cm polyurethane J-stents. After placing the proximal stent percutaneously into the renal collecting system and the distal stent into the bladder, both were shortened as needed and joined with a connector. In 2001, Jabbour et al. [5] developed a composite 27F prosthesis consisting of two coaxial tubes. Thirty-five ureters were bypassed in 27 patients including 5 patients with benign disease. They reported a success rate of 81% with a mean follow-up of 47 mo and late complications in only three patients. Other authors achieved similar results [6], [7]. Schmidbauer et al. [8] deployed a two-piece 12F polyurethane bypass system in 31 kidneys of 28 patients. Implantation of this system uses simple standard percutaneous nephrostomy and cystostomy techniques and is feasible with local anaesthesia. Permanent urinary drainage without an external device was established in 87% of the kidneys, with an over-all complication rate of 18% at a mean follow-up of 12 mo.

Today, an extra-anatomic, nephrovesical subcutaneous ureteric bypass represents a reliable and effective solution for patients with ureteral obstruction due to end-stage malignancies, in whom internal ureteral stenting proves to be impossible. Of course, a normal bladder function is an essential prerequisite. The bypass should be placed in a one-stage procedure to reduce the risk of urinary infection. This is achieved without the need for repositioning if the patient is placed in a 45° semioblique position for simultaneous percutaneous access to the kidney and bladder. The conclusion of the Schulman group 30 yr ago that ureteric peristalsis is not needed for drainage of the renal collecting system proved to be correct. What is not needed is an antireflux mechanism and positioning of the prostheses within the abdominal cavity.

References

1. Lingam K, Paterson PJ, Lingam MK, Buckley JF, Forrester A. Subcutaneous urinary diversion: an alternative to percutaneous nephrostomy. J Urol. 1994;152:70–72.

2. Desgrandchamps F, Cussenot O, Meria P, Cortesse A, Teillac P, Duc A. Subcutaneous urinary diversions for palliative treatment of pelvic malignancies. J Urol. 1995;154:367–370.

3. Nakada SY, Gerber AJ, Wolf JS, Hicks ME, Picus D, Clayman RV. Subcutaneous urinary diversion utilizing a nephrovesical stent: a superior alternative to long-term external drainage?. Urology. 1995;45:528–530.

4. Nissenkorn I, Yehoshua G. Nephrovesical subcutaneous stent: an alternative to permanent nephrostomy. J Urol. 2000;163:528–530.

5. Jabbour ME, Desgrandchamps F, Angelescu E, Teillac P, Le Duc A. Percutaneous implantation of subcutaneous prosthetic ureters: long-term outcome. J Endourol. 2001;15:611–614.

6. Loertzer H, Jurczok A, Wagner S, Fornara P. Der künstliche pyelovesikale and pyelokutane Bypass. Urologe [A]. 2003;42:1053–1059.

7. Jurczok A, Loertzer H, Wagner S, Fornara P. Subcutaneous nephrovesical and nephrocutaneous bypass. Gynecol Obstet Invest. 2005;59:144–148.

8. Schmidbauer J, Kratzik C, Klingler HC, Remzi M, Lackner J, Marberger M. Nephrovesical subcutaneous ureteric bypass: long-term results in patients with advanced metastatic disease—improvement of renal function and quality of life. Eur Urol. 2006;50:1073–1078.

Michael Marberger

University of Vienna, Department of Urology, Währinger Gürtel 18-20, A-1090 Vienna, Austria

published online 16 August 2006.

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