Presentation Authors: Ioannis Kartalas Goumas*, Michele Talso, Elena Tondelli, Vimercate, Italy
Introduction: Treatment of complex ureteral stenosis or lesions can be challenging. Ureteral bypass connects directly the renal cavities to the bladder with a specially designed subcutaneous tube. The main indication is in patients with an indwelling nephrostomy tube due to a ureteral obstruction related to malignancy. It has been previously reported that this option improves patientsâ€™ quality of life. We present a modified technique of ureteral bypass in the supine position that facilitates the procedure.
Methods: The Detourâ„¢ nephro-vesical subcutaneous bypass is a 30 Fr tube that is made of 2 components: an outer reinforced PTFE sheath with porous structure and a silicone inner sheath. We modified the position of the patient based on our experience with percutaneous nephrolithotomy in the supine position. If the patient has an indwelling nephrostomy catheter in a proper position then we proceed with a dilatation of the percutaneous access using fascial dilators or a balloon, and a 30 Fr Amplatz sheath is inserted. If the nephrostomy is not in an adequate position, an ultrasound guided percutaneous access is performed through an adequate calyx with a direct access to the renal pelvis. Dilatation then proceeds as described above. The Detourâ„¢ proximal end is positioned into the renal cavities through the Amplatz sheath. The bladder is then isolated through a minilaparotomy. A subcutaneous tract between the bladder and the percutaneous access is created with a tunneler and the Detourâ„¢ in passed through the tract in order to reach the bladder. A 1 cm cystotomy is performed on the bladder dome. The Detourâ„¢ distal end is then tailored to the proper length and it is anastomosed to the bladder. A bladder catheter is left in place for 5 days.
Results: 19 subcutaneous extra-anatomical urinary diversions were performed in 17 patients (2 bilateral) using the modified technique between 2016 and 2018. Mean operative time was 120â€™. In 12 cases an ex-novo percutaneous access was created. There were no intraoperative complications. In 4 cases an explant was performed: 1 due to displacement of the bypass distal end, 1 due to a multidrug-resistant infection and in 2 cases due to an enteric fistula.
Conclusions: The supine oblique position or the lithotomy oblique position allows a direct simultaneous access to the kidney and to the bladder simplifying the procedure. Still, the procedure may be complex due to high comorbidity patients with previous radiation or surgery and the high risk of infection. Patients must be appropriately informed about these risks.