A novel technique for ureteric access in ileal conduits

Authors


Dr V. Srinivas, Consultant Uro-oncosurgeon, Room No – 009, P D Hinduja National Hospital, V S Marg, Mahim, Mumbai 400 016, India.
e-mail: dr_vsrinivas@hotmail.com

INDICATIONS

A few patients have complications associated with their ileal conduit after radical cystectomy. Soon after surgery 2.2% of such patients develop a ureteroileal anastomotic leak and 1.7% develop obstruction [1]. There can be delayed stenosis of the anastomotic site in 4–9% of patients [1,2]. Endoscopic retrograde techniques to access the lower ureter have been tried through the stoma, with limited success. The main problems are related to poor visualization, water spillage and tortuous angulation for catheterizing the ureters. A recent report suggested the use of fluoroscopically guided guidewires to overcome the last problem [3]. In most instances antegrade stenting is easier, as there is a longer section of ureter for stent manipulation. However, the major drawback with the latter is that a patient who already has an ileal conduit will require an additional temporary nephrostomy tube, and if stent placement is unsuccessful, this may become a permanent nephrostomy. Herein, we describe a technique using a video-duodenoscope for accessing the ureteroileal anastomosis which appears to overcome some of these problems.

METHODS

The procedure is carried out fluoroscopically with the patient sedated. A side-viewing duodenoscope (TJF 160/R, Olympus, Tokyo, Japan) is negotiated through the stoma of the conduit. The distal tip of the duodenoscope can be easily manoeuvred, and a clear view of the conduit mucosa and ureteric orifice obtained (Fig. 1). Through the 4.2 mm side channel a cannula is inserted and negotiated through the desired ureteric orifice. With the help of a 0.9 mm guidewire through the cannula, using the Seldinger technique, a JJ stent can be passed (Fig. 2). Because the tip of the duodenoscope has a wide range of movement the ureteric orifices can be viewed from different angles and catheterized with guidewires. The duodenoscope also has an elevator proximal to the distal end which functions like Albarran's lever (Fig. 3). We have successfully used this technique of stenting in three patients; two had a urinary leak from the ureteroileal anastomosis and one had an obstruction (stenosis).

Figure 1.

The video-duodenoscopic internal view of the ileal conduit, with ureteric orifice and urine jet.

Figure 2.

Figure 2.

a, The cannula in the ureteric orifice; and b, negotiating the JJ stent through the ureteric orifice.

Figure 2.

Figure 2.

a, The cannula in the ureteric orifice; and b, negotiating the JJ stent through the ureteric orifice.

Figure 3.

A schematic figure of the tip of the duodenoscope showing the Albarran lever-like mechanism.

ADVANTAGES AND DISADVANTAGES

The limitations of accessing the ureteroileal anastomosis using a conventional cystoscope or flexible cystoscope are overcome by using the video-duodenoscope. As normal saline or sterile water is not used during gastro-enteroscopy, there is no problem of water spillage, which invariably soaks the patient and the procedure field. The duodenoscope also has a built-in suction-irrigation channel, which can be used to dislodge and aspirate mucus, to improve vision. The vision remains excellent throughout the procedure, as there is no dependency on water or saline to distend the bowel, as with conventional cystoscopes. The deflecting tip of the duodenoscope can be placed against any wall of the conduit, to easily identify the ureteric orifices and facilitate stenting. Overall, the superior optics of the videoscope allows excellent vision, and as irrigation fluid is not required the cost is marginally reduced. The other advantage of this procedure is the easy use of the video-endoscope, which is easily available in all multi-speciality hospitals. In the initial stages the expertise of a gastroenterologist is required, familiar with the technical details of these instruments. Thus the present technique eliminates the two main disadvantages of water spillage and difficulty in accessing the ureteroileal anastomosis.

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