|Year : 2019 | Volume
| Issue : 3 | Page : 61-66
An alternative to DJ-stenting for ureteroneocystostomy: Experience at a tertiary health facility
Ngwobia Peter Agwu1, Abdullahi Khalid2
1 Department of Surgery, Institute of Urology and Nephrology, Usmanu Danfodiyo University and Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Surgery, Urology Unit, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
|Date of Submission||09-Feb-2020|
|Date of Acceptance||26-Mar-2020|
|Date of Web Publication||23-Sep-2020|
Dr. Abdullahi Khalid
Urology Unit, Department of Surgery, Usmanu Danfodiyo University and Teaching Hospital, Sokoto
Source of Support: None, Conflict of Interest: None
Background: Stenting of the ureters is an established principle of ureteral surgery. This can be achieved using conventional double-J (DJ) stents, ureteric catheter or improvised infant feeding tubes. In routine urological practice, our choice is influenced by availability, cost, and the availability of urethrocystoscopic equipment for device retrieval. We described an alternative surgical technique and review the outcomes of this procedure.
Patients and Method: This is a 10-year retrospective study from October 2007 to November 2017 of patients who had an alternative to DJ-stenting using infant feeding tube for ureteroneocystostomy following ureteric injury in the urology unit of a tertiary health facility. The records of socio-demographic, clinical and therapeutic characteristics and complications in patients who had alternative to DJ-Stenting inserted for ureteroneocystostomy following ureteric injury were extracted from patient's case notes. Data was analyzed using SPSS version 20.
Results: Out of a total of 26 female patients with ureteral injuries who had ureteroneocystostomy with alternative to DJ-stenting, complete records of 12 (46.2%) patients were available. Mean age of patients was 37.42 ± 13.69 years with a range of 20-58 years. Majority of the patients were between the ages of 30 to 39 years (33.3%). The alternative to DJ-stent specific complication was stent dislodgement noted in 12.5% of patients.
Conclusion: The alternative to DJ-stenting for ureteroneocystostomy is associated with low procedure-specific complications. It is a useful tool especially for patients from low socio-economic background presenting with ureteral complications after gynecological or obstetric surgeries.
Keywords: DJ-stenting, gynecological surgeries, ureteral injuries, ureteroneocystostomy
|How to cite this article:|
Agwu NP, Khalid A. An alternative to DJ-stenting for ureteroneocystostomy: Experience at a tertiary health facility. Arch Int Surg 2019;9:61-6
| Introduction|| |
Stenting of the ureters is an established procedure in urology. Indications for ureteral stent placement include relief of ureteral obstruction by calculi, urothelial carcinoma or extrinsic compression, to maintain upper tract patency in order to promote healing after upper tract reconstruction, endoscopy, trauma and post ureteroneocystostomy after renal transplant.,,,,,, The ideal ureteral stent should be characterized by the ease of placement and removal, lack of upper and lower urinary tract irritative and voiding symptoms, maintenance of excellent urine flow thus ensuring adequate drainage, resistance to infection, encrustation, biocompatibility and biodegradability if forgotten. However, the ideal ureteral stent does not exist.
Following open operations on the ureters including dismembered pyeloplasty, uretero-ureterostomy or ureteroneocystostomy, stenting may be accomplished using standard double J stent (D-J stent) which is the current gold-standard device, however, some recent modifications have been devised due to prevailing circumstances. Ureteric catheter or improvised infant feeding tubes are also used for ureteral stenting., In routine urological practice, the choice of stents is influenced by availability, cost, and the availability of urethrocystoscope for retrieval later.
Stenting the ureter with infant feeding tube following ureteroneocystostomy may require exteriorizing the tube through a separate incision and application of a device for urine collection. Placement of D-J stent may be associated with several complications such as loin pain, hematuria, recurrent urinary tract infection, stent encrustation, forgotten stent, but rarely retroperitoneal and intravascular migration and knotting.,,,,,,,,, In addition to the above complications, DJ stents are expensive, not easily available in our practice, and when inserted, their removal requires urethrocystoscopy which will require the use of a form of anesthesia. This places more burden on the patient and the urologist who is already with a long waiting list which is worsened by limited theatre spaces.
The alternative to DJ-stent is an internal ureteral stent involving the use of infant feeding tube (s) in place of conventional double-J stents. In our environment, health care bills are predominantly settled by out-of-pocket payment due to limited to near absence of health insurance coverage. Therefore, any technique that can reduce multi-staged surgical intervention in our practice among our patients is preferable. We describe the surgical technique and review the outcome of use of improvised infant feeding tubes as alternative to DJ stent.
| Patients and Method|| |
This is a retrospective cross-sectional review of female patients who presented with ureteric injury following various forms of obstetric and gynecologic surgeries. The operation register and case notes of patients who had alternative to DJ-stenting for ureteroneocystostomy case notes were retrievedto extract socio-demographic data including age, state of origin, ethnicity, educational level, occupation and family type. Other data included presenting symptoms, nature of surgery, type of previous gynecological surgery, place of surgery, cadre of surgeon, duration between initial surgery and presentation, attempt at repair before presentation, associated comorbidity, preoperative percutaneous nephrostomy, type of ureteroneocystostomy, side of ureteroneocystostomy, post-operative complication, outcome of intervention and follow-up duration. Our main outcome measures in this study are alternative to DJ-stent specific complications such as stent migration, urinary tract infection, bladder spasm, perivesical leakage and stent extrusion or dislodgement. Male patients who had ureteroneocystostomy and an alternative to DJ stents inserted over the same period were excluded in this review because the reason for ureteroneocystostomy was not as a result of iatrogenic ureteric injury.
The alternative to DJ-stenting for ureteroneocystostomy involves the use of one or two infant feeding tubes size 6 or 8 fr connected to indwelling urethral catheter. Initially, appropriately sized infant feeding tube is used to stent ureteroneocystostomy. The bladder end of the tube is anchored to indwelling urethral catheter with non-absorbable suture size 2/0 Nylon. The feeding tube is sutured to the bladder mucosa using chromic catgut 3/0 and catheter balloon tested before closure of cystostomy. The infant feeding tube connected to indwelling urethral catheter as a unit is removed 2-3 weeks post-operatively [Figure 1]. The open surgical options utilized in this study include direct ureteroneocystostomy, Psoas hitch and Boari's flap procedures [Figure 2]. All the patients had perioperative antibiotic administered starting at induction of anesthesia and continued post-operatively until the stents were removed. We routinely use antimuscarinics like tolterodine in the first post-operative week to minimize post-operative bladder spasm.
|Figure 1: Alternative to DJ-stent illustrating feeding tube anchored to urethral catheter|
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| Results|| |
A total of 26 female patients had ureteroneocystostomy over a 10-year period from October 2007 to November 2017 due to gynecological and obstetric surgical complications. Twelve (12) patients with complete record indicating use of alternative to DJ stents were reviewed. The mean age of patients was 37.42 ± 13.69 with a range of 20-58 years [Table 1]. The socio-demographic characteristics are shown in [Table 2]. Ureteroneocystostomy only was done in 4 (33.3%) while 8 (66.7%) patients had combined ureteroneocystostomy and gynecological intervention. Half of the patients reviewed in this series were complication free. The alternative to DJ-stent specific complication was stent dislodgement noted in 12.5% of patients. Half of the patients were regular on follow-up visit. Five 5 (41.7%) were lost to follow-up. Majority of the operations were performed at general hospitals (75%) while others were performed at teaching (8.3%), specialist (8.3%), and private (8.3) hospitals respectively. Eleven (91.7%) of the initial operations were performed by medical officers. Only 2 (16.7%) patients had attempt at repair before presentation. Six (50%) patients presented with leakage of urine per vaginam [Table 3]. Two patients had percutaneous nephrostomy. The side of ureteroneocystostomy was left in 50%, right in 25% and bilateral in 25%. Associated comorbidity are shown in [Figure 3], while post-operative complications in [Figure 4]. Overall, all the patients were satisfied with the outcome of surgery although one was discharged against medical advice due to financial constraints.
| Discussion|| |
All the subjects in this study were females and had undergone gynecologic or obstetric surgeries. Injuries to the ureters are common complications of these procedures.,,, The ages of the patients ranged from 20 to 58 years, and this is age of childbearing and common period of these surgeries.
Majority of the subjects reside in the rural areas of Niger or Sokoto states and the Nupe ethnic group form a significant size of the patients since our hospital serves as a referral center for the five states of former northwestern state of Nigeria. This may reflect the paucity of specialist urologic service in these states.
Majority of the patients who presented with ureteral injuries were housewives, in polygamous relationships with little western education, residing in the rural communities and these factors combine to affect their healthcare knowledge, economic status and access to specialist care.
The patients in this study presented mainly with urine leak per vaginam indicating the presence of uretero-vaginal fistula as similarly reported by Lawal et al. while others had symptoms ranging from anuria, recurrent flank pain to uraemia. Delayed presentation was very common as most presented more than six months after the initial injuries as previously reported., The delay in presentation is probably due to paucity of specialist urologists, poor access to healthcare as well as the non-specific symptoms of flank pain which is usually first managed by non-specialist medical officers in the rural and semi-urban centre prior to referral.
Surgical procedures that resulted in ureteral injuries in this review occurred following obstetric and gynecological surgeries such as caesarean section, cesarean hysterectomy as earlier noted., These procedures are usually carried out in the emergency settings, especially in the rural hospitals and at times in the specialist centers mainly by younger, inexperienced medical officers and residents.
Associated comorbid illnesses were low in these patients due to the fact that the indications for the initial surgeries were disease entities that present in young child-bearing female subjects and are devoid of associated chronic diseases such as hypertension, diabetes and cardiovascular diseases. Ureteral injuries occurred more on the left side as earlier documented., The predominance of left ureteric iatrogenic injuries is due to the fact that most surgeons are right-handed and the position of standing on the right of the patient during pelvic surgeries predisposes to errors that may result in injuries. Most of the patients were referred to the urology unit without prior attempts at repair and these were cases that had occurred in our hospital and nearby facilities while those that had attempts at repair of the fistulae were those that occurred in the peripheral hospitals and had earlier been managed at the regional fistula centers1.
Management of iatrogenic ureteral injuries depends on the time of presentation, mechanism of injury, patient clinical state, location of the injury, whether one-sided or bilateral as well as the training and equipment available to the surgeon. Surgical options in these patients range from endoscopic minimally invasive procedures including laparoscopic, robot-assisted laparoscopic ureteral reconstructions to open ureteral surgeries.,, The open surgical options utilized in this study include direct ureteroneocystostomy, psoas hitch and Boari flap procedures as have been similarly reported.,, The combined Ureteroneocystostomy and gynaecological intervention such as vesicovaginal fistula repair through abdominal approach was done in some patients as reported in other studies.
Our patients underwent ureteroneocystostomy and ureteral stenting using the technique described in this study. Stenting with double J stent is the standard that is routinely applied in ureteral procedures but not readily available in our environment and when available is costly. In addition, stenting with double J stent in open ureteroneocystostomy will require cystoscopic removal and administration of a form of anesthesia. Improved DJ stents which come with strings attached may be alternative device that can also obviate the need for cystoscopic removal, this type of DJ stents are still hard to come by in our practice and may even be more expensive.
The technique described in this study offers certain advantages to the standard double J stent such as easy availability, affordability, biocompatibility and easy removal of the stent without the requirement for cystoscopy or anesthesia. Removal of the improvised ureteral stent described here is carried out at the bedside therefore further reducing cost, the anxiety for the operating room as well as reducing the burden of theatre space. In addition, the dwelling time of our stent was three weeks after insertion thus further reducing the probability of occurrence of complications associated with ureteral stents. Our practice of connecting the urethral catheter to the infant feeding tube ureteral stent with 2/0 non absorbable suture helped to reduce incidence of stent migration although in two patients, the suture got loose thus leading to retention of the feeding tube which in each case was removed by cystoscopy. Also, the practice of connecting the feeding tube to the urethral catheter obviate the need of creating a stoma on the anterior abdominal wall and the need for a collecting device which we had earlier observed to be a source of discomfort to our patients.
There was low utilization of preoperative percutaneous nephrostomy in this review. This is because its use was reserved for patients with clear indications such as to provide symptomatic relief of pain and back pressure effect on the kidney and to aid control of upper tract infection. At the same time, it provides access for subsequent diagnostic antegrade pyelography. Also, we have found it useful in the crude assessment and monitoring of recovery of depress renal unit from the hourly urine output post nephrostomy tube insertion before definitive intervention due to non-availability of radioisotope renal scan for differential renal function in our setting.
Half of the patients reviewed in this series were complication free. The remaining half had complications of the Clavein-Dindo grade I and II, and this classification system has been reported to be reliable in identifying and ranking of post-operative complications of surgical procedures., These complications included superficial wound dehiscence, functional intestinal obstruction and deep venous thrombosis and these were mainly procedure non-specific and could have resulted from any major abdominal surgery. These complications were observed in patients who had ureteric injury repaired within the period of peuperium.
Procedure and stent-specific complication was present in only two patients and consisted of urethral catheter and stent dislodgement due to spontaneous rupture of self-retaining catheter balloon which occurred in the early postoperative period. Other specific complications such as stent migration, and perivesical leakage were not observed in these patients. The absence of urinary tract infection and bladder spasm may be because of our practice of ensuring pre-operative sterile urine, post-operative antibiotic use until stent removal and routine use of antimuscarinics like tolterodine in the first post-operative week, respectively. Also, most of the patients were noted to have relatively adequate bladder capacity intraoperatively, which may be another reason why bladder spasm was not observed.
All patients did well following treatment of the complications and no mortality was recorded. The long-term assessment of other complications related to this surgical intervention was not feasible due to the phenomenon of discharge against medical advice (DAMA), which is common in our practice. This phenomenon have been reported in other centres in our country and other parts of the world involving medical, psychiatric and surgical patients.,, Reasons for this practice among these patients include personal and family issues, prolonged hospital stay, desire to seek alternative treatment, feeling of wellness after surgical relief of the initial pressing complaints and most importantly financial difficulties in an environment of personal health financing by out-of-pocket payment due to non-availability of viable health insurance scheme.
Follow-up of patient post-surgical intervention has remained a huge challenge among our patients. A few of the patients did not return even for the first follow-up visit while a large proportion do not go beyond first month post intervention. This phenomenon has been observed by other urologists treating patients with urethral stricture. Factors responsible for the failure to attend follow up clinic in our subjects may include poverty, ignorance and the long distances from the centre of healthcare. Therefore, patients feeling well after discharge from the hospital do not feel it necessary to attend clinic visits in the absence of any clinical symptoms.
The limitations of this study include the small number of patients, single center experience, sample comprised of only females patients and there was no comparison with standard double J stent. Despite the above limitations, this technique can be very useful for use by surgeons working in poor resource environment where the standard double J stent is neither available nor affordable.
| Conclusion|| |
The alternative to DJ-stenting is a useful tool especially for patient from low socio-economic background presenting with ureteral injuries after gynecological or obstetric surgeries requiring ureteroneocystostomy where standard double-J stent is not available. This technique is associated with low procedure-specific complications and obviates the necessity for a second-stage endoscopic procedure for ureteric stent retrieval.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]