A novel technique for ureteric access in ileal conduits


We were interested to read this article by Santoshi et al.[1] describing the use of a side-viewing duodenoscope to enable stenting of a ureteroileal anastomosis. The preliminary insertion of the guidewire by this means is ideal for the situation of a ureteroileal anastomosis of the Bricker type, and avoids the need for a preliminary renal puncture and antegrade stenting. However, as the Wallace technique involves an end-to-end type anastomosis, we feel that this might not allow sufficient room to steer the side-viewing duodenoscope [2]. Over the last 3 years, our department has managed five patients requiring regular stent changes of the ureteroileal anastomosis, using a different technique that involves the use of the flexible cystoscope, hydrophilic guidewire, Pollack ureteric catheter (6 F) and radiological screening. A hydrophilic guidewire is inserted into a ureteric neo-orifice under vision through the flexible cystoscope introduced via the urostomy. This enables placement of a Pollack ureteric catheter in the renal pelvis and the position is confirmed using radiological contrast medium [3]. After re-introducing the guidewire into the Pollack catheter, an infant feeding tube (10 F) is then introduced over the Pollack in a Seldinger fashion to the renal pelvis. The infant feeding tube is cut ≈ 6 cm longer than the stoma and secured by a polypropylene suture to the ileostomy spout. The procedure is very well tolerated and often conducted with no anaesthesia. Stent changes are simple after initially placing a guidewire through the old stent.

In all, five patients have been treated by this technique; one had a left-sided stent for 1 year and the hydronephrosis has not recurred a year after its removal. Two patients have long-term bilateral stents and have had improvement in their degree of chronic renal impairment, and their condition remains stable after 1 and 2 years of stenting, respectively. One patient had sloughing of his ileal spout after radiotherapy and could not maintain continence with his stomal appliance. The long-term protruding stents are well tolerated and allow him to use the stomal appliances effectively. The last patient had recurrent UTIs because of left hydronephrosis, which have significantly improved after stenting. After 2 years the patient is keen to keep the stent and has regular changes every 4 months.

The main indication for stenting is obstruction at the ureteroileal anastomosis [4]. However, as our method involves the use of externally draining stents, long-term stenting can also be considered in: (a) patients with a poor GFR, to minimize the contact of urine with bowel and reduce metabolic disturbances; and (b) in patients with stomal continence problems. Long-term stenting is well tolerated and stent changes are easy using the technique we describe.