Author(s): Srirangam S., Zelhof B., Neilson D.
Abstract: INTRODUCTION & OBJECTIVES: Patients with ileal conduits are at increased risk of long term complications, including urolithiasis, stricture formation and cancer recurrence in the upper tract. Despite advances in minimally invasive technology and expertise, retrograde ureteroscopic manipulation via the ileal conduit still poses a challenge for the endourologist. We describe our single centre experience in performing retrograde ureteroscopy in patients with ileal conduit urinary diversions. MATERIAL & METHODS: We retrospectively analysed all patients with previous urinary diversion who underwent a retrograde ureteroscopic procedure over a 5 year period. We evaluated the success rate in accessing the ureter, causes of failure, and identify technical aspects which have aided the procedure. RESULTS: Twenty five procedures were performed in 17 patients. Mean age was 59 (28-90) years. Median time from ileal conduit diversion to ureteroscopy was 19.5 (0.5-53) years. Stone disease was the primary indication for intervention in the majority (n=11, 44%). Other indications included ureteric/uretero-ileal anastomotic stricture (n=6, 24%), upper tract tumour (n=2, 8%), unexplained haematuria (n=3, 12%), calcified retained ureteric stents (n=2, 8%), and change of stents (n=1, 4%). Retrograde loopogram was performed in 17 cases to clarify the orientation/ anatomy of the ileal loop. Initial inspection was undertaken using a flexible cytoscope to examine the loop and cannulate the ureteral openings. Subsequent flexible ureteroscopic manipulation was aided by use of a highstiffness guide-wire and ureteral multiple access sheath. Access to the ureters was achieved in 76% (19/25) of cases. A long and tortuous ileal loop was the only cause of failure to access the ureter (n=6). Of these 6 patients, 2 cases underwent simultaneous PCNL to clear renal stones; 1 stent calcification was treated within the ileal loop; 2 patients with haematuria had normal retrograde studies and no tumour was found on subsequent follow up; 1 patient with stricture disease was followed up symptomatically. All stones were cleared using laser lithotripsy. Stone free rate was 72.7% (8/11). A retrograde approach was combined with a PCNL in 24% (6/25) of cases. Post operative renal drainage when required (n=18) was achieved using a double J stent (n=10), 6Ch ureteric catheter (n=3) or nephrostomy tube (n=5). Post operative complications including temporarily pyrexia (3 cases) and urosepsis (2 cases). Median length of stay was 2 days (ureteroscopy with simultaneous PCNL) and 1 day (ureteroscopy without PCNL) (range 1-10 days) with the majority only staying overnight (48%). CONCLUSIONS: Retrograde ureteroscopy via an ileal loop is technically challenging, but a high success rate is achievable in experienced centres, with access to standard endourology equipment. The main cause of failure is a long and tortuous ileal segment.
Publication Type: Journal: Conference Abstract