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Keywords:

  • cutaneous ureterostomy;
  • mono-J catheter;
  • Seldinger technique;
  • ureter

Introduction

  1. Top of page
  2. Introduction
  3. References

Cutaneous ureterostomy as a therapeutic option in the setting of palliative cystectomy and in multi-morbid patients has gained renewed interest due to increasing life expectancy and to optimised perioperative critical care pathways [1].

A critical point of this procedure remains the high stricture rate at the ureter–skin implantation site, even with improved operative techniques [2, 3]. Thus, definitive mono-J catheter placement is usually required.

If during the perioperative period the mono-J catheter blocks and cannot be flushed through, it must be replaced. Occasionally, the ureteric stoma plate is oedematous and poorly visible at this point, making a simple exchange of tubes a difficult task. In one of our patients, a tube exchange over a coaxially placed wire was not possible due to complete obstruction (Fig. 1). Nor was the passage of a rigid wire parallel to the indwelling tube possible, as it repeatedly entered the wrong ureter.

figure

Figure 1. Mono-J exchange over guidewire not possible due to obstruction (insert).

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The indwelling blocked mono-J catheter was pulled back a few centimetres and cut open tangentially (Fig. 2a). The stiff wire was introduced through this opening and advanced until it reached the obstruction site (Fig. 2b). Now, both the mono-J catheter with the wire were advanced under fluoroscopy until it was clear that the wire was located inside the correct ureter (Fig 3a). At this point, the wire was held in place while the mono-J catheter was further advanced until the tip of the wire slipped out of the incision (Fig. 3b and c). The safety wire was now located within the correct ureter and could be advanced up to the renal pelvis parallel to the blocked tube, which was then removed. Afterwards, a new mono-J was introduced using the Seldinger technique.

figure

Figure 2. A. The indwelling mono-J catheter has been pulled back a few centimetres and cut open tangentially (brown arrow shows point of occlusion in mono-J catheter).

B. Introduction of stiff wire was through the catheter incision and advancement until it reaches the obstruction site.

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figure

Figure 3. A. Both, the mono-J catheter with the wire are simultaneously advanced under fluoroscopy in a ‘piggyback’ technique until it is clear that the wire is located inside the correct ureter (brown arrow shows point of occlusion in mono-J catheter).

B. Once it is clear that the wire is located in the correct ureter, the wire is held in place while the mono-J catheter is being further advanced.

C. The mono-J is advanced until the tip of the wire slips out of the incision.

Now, the correctly located stiff wire can be further advanced to the renal pelvis, the obstructed mono-J removed and a new mono-J inserted using the Seldinger technique.

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This technique can also be useful in the rare case of an ileal or colon conduit requiring a permanent mono-J tube placement due to inoperability (i.e. ureteroileal anastomosis stricture in an inoperable patient), and would possibly obviate the need of endoscopic retrograde or fluoroscopic antegrade mono-J catheter replacement. However, this would only be the case if the site of obstruction is close to the tip of the mono-J curl. Otherwise, even if the mono-J tube with indwelling wire is distinctly advanced, after the wire end springs out of the cut opening, it may still not be located in the ureter, but in the conduit.