bệnh lý hẹp niệu quản là một bệnh lý khá thường gặp trong bệnh lý thận tiết niệu nói chung. có 2 nhóm nguyên nhân là mắc phải và nguyên phát. trong nguyên nhân mắc phải thì vấn đề do người thầy thuốc vẫn chiếm một tỷ lệ khá cao, điều này là do sự phát triển về các thiết bị nội soi và điều trị đường tiểu trên. vấn đề điều trị hiện nay rất phong phú và nhiều phương phát, điều này phụ thuộc vào vị trí hẹp, độ dài đoạn hẹp, mức độ hẹp, nguyên nhân hẹp cũng như trang thiết bị, trình độ của phẫu thuật viên.
Ureteral stricture Resident Minh Background A US is characterized by a narrowing of the ureteral lumen, causing upper tract obstruction The most common cause is UPJ obstruction, which is characterized by a congenital or acquired narrowing at the level of the UPJ The objective of this article is to discuss the incidence, etiology, diagnosis, therapy, and management outcomes of ureteral strictures Classification & Etiology Extrinsic or intrinsic, benign or malignant, and iatrogenic or noniatrogenic Extrinsic malignant strictures (primary or metastatic cancer): Primary pelvic malignancies (the cervix, prostate, bladder, and colon) → extrinsic compression of the distal ureter, Retroperitoneal lymphadenopathy (lymphoma, testicular carcinoma, breast cancer, or prostate cancer) → proximal to midureteral obstruction Classification & Etiology (cont) Extrinsic benign compression: idiopathic retroperitoneal fibrosis Intrinsic malignant strictures: TCC Intrinsic benign strictures: congenital (obstructing megaureter), iatrogenic, or noniatrogenic (passage of calculi or chronic inflammatory ureteral involvement (tuberculosis, schistosomiasis)) Classification & Etiology (cont) Iatrogenic benign strictures: Ureteroscopy Open or laparoscopic injury Radiation therapy Urinary diversions Renal transplantation Epidemiology ↑↑ upper tract endoscopy → ↑↑ iatrogenic ureteral stricture Factors by endoscopy: Large scope size Prolonged case duration Stone impaction Size Proximal location Perforation Use of intracorporeal lithotripsy Epidemiology (cont) Urinary diversion: 3-5% (ureterointestinal anastomotic strictures) Ureteral injuries (pelvic or retroperitoneal surgery, particularly abdominal hysterectomy and sigmoid colectomy) In: Gynecologic surgery (75% of iatrogenic) Vakili et al (a prospective analysis of 479 patients undergoing hysterectomy for benign disease): Iatrogenic ureteral injury: patients (1.7%) # the literature (0.02%-2.5%) Pathophysiology Ischemia → fibrosis: follows open, laparoscopic surgery or radiation therapy Nonischemic:caused by spontaneous stone passage or a congenital abnormality Mechanical (Less commonly): such as from a poorly placed permanent suture or surgical clip Pathophysiology (cont) Pathologic analysis: disordered collagen deposition, fibrosis, and varying levels of inflammation, depending on factors such as etiology and interval since the causative insult The resulting ureteral obstruction: mild (asymptomatic proximal ureteral dilation and hydronephrosis), to severe (complete obstruction and subsequent loss of renal function) Pathophysiology (cont) Patients: Asymptomatic Symptomatic only during periods of diuresis Severe renal colic The degree of symptoms correlates poorly with the degree of obstruction At times, severe obstruction is asymptomatic or silent Recovery depends on the duration of ureteral obstruction Laparoscopic and robot-assisted laparoscopic repair Simmons and colleagues (2007) Open (34) Laparoscopic (12) Average operative 258 86 The hospital stay (day) days Overall complication rate (%) 15 blood loss (ml) Laparoscopic and robot-assisted laparoscopic repair (cont) o Fugita and colleagues reported successful cases of distal ureteral stricture treated with laparoscopic Boari flap creation o Modi et al reported the successful use of laparoscopic ureteroneocystostomy with psoas hitch in patients with ureterovaginal fistula in whom endoscopic management initially failed o The first reported use of laparoscopic ureteroureterostomy was published in 1998 Laparoscopic and robot-assisted laparoscopic repair (cont) Seidemanet Al (2009) have largest series on Laparoscopic ureteral reimplantation: 45 patients with distal uretericstrictures Ureteroneocystostomyin 53% (n=24) and Boariflap in 47% (n=21) patients had undergone previous attempt at repair (balloon dilation, open repair, ureterolysis) Seidemanet al Success rate was 96% (no residual obstruction, no subsequent procedure, no renal deterioration, no symptoms) at 24.1 months patients had recurrent strictures with having nephrectomyfor chronic flank pain and pyelonephritis Mean intraoperativeblood loss = 150cc Mean LOS = days patients had high drain outputs post-op with documented leak but were managed conservatively Laparoscopic and robot-assisted laparoscopic repair (cont) With the increasing availability of the da Vinci robot system, this technology has been successfully applied to ureteral stricture disease It offers the advantage of easier intracorporal suturing and knot tying Multiple centers have reported small case series documenting successful treatment of distal ureteral stricture with robot-assisted laparoscopic reimplantation, with and without psoas hitch or Boari flap Robotic Assisted Reimplantation First described in 2004 following ureteric injury during radical prostatectomy UberoiJ et al 2007 described Robotic assisted laparoscopic ureteral reimplantationwith psoas hitch Patilet al 2008 performed multi-institutional evaluation of experience with Robotic assisted reimplantation with psoas hitch: 12 patients, 10 had distal uretericstrictures Conversion rate was 0% No complications w/ mean follow up of 15.5 months Follow-up 2-4 weeks after stent removal and include serum creatinine, urine culture, renal ultrasonography, IVP, or renal scintigraphy If the patient is asymptomatic, imaging is performed at months and then at 6month intervals for the first years Most stricture recurrences are identified within the first year after surgery Complications Balloon dilation: Infection Failure to successfully dilate Loss of renal access Subsequent need for percutaneous nephrostomy drainage Endoureterotomy: Infection Failure to successfully dilate Loss of renal access Subsequent need for percutaneous nephrostomy drainage Direct injury to adjacent structures (eg, bowel or vascular structures, urinoma formation) Vascular injury: Yamada et al reported that of 20 patients treated with a cold-knife ureterotomy had a major vascular injury that required an immediate laparotomy Complications (cont) Open surgical repair Prolonged ileus Urinoma Prolonged urine leak from repair Bowel injury Sepsis Late adhesion formation Small bowel obstruction Risks of major surgery (eg, deep venous thrombosis, myocardial infarction, surgical mortality) Impaired bladder function: Patients who undergo psoas hitch or Boari flap may develop impaired bladder function Future and Controversies Controversy: intralesional injection of steroids to inhibit stricture recurrence Wolf et al (77 endoureterotomies): the injection of intralesional triamcinolone → greater success in strictures longer than cm Future: extraurinary tissue (grafts or vascular pedicle flaps) Conclusions Variety of causes of distal uretericstrictures Important characteristics include: Extrinsic versus intrinsic Benign versus malignant Stricture length and location Renal Function (ie >25%) Strictures < 2cm consider endoscopic management Strictures >2 cm or complex strictures (long or obliterated) consider open or laparoscopic management Conclusions Balloon dilation effective for patients with short ([...]... For benign strictures > balloon dilation Hafez and Wolf (8 published series of endoureterotomy for benign stricture disease): success rates of 55-85% Goldfischer and Gerber: 62-100% Wolf et al: 82% Poor renal function (< 25%), long strictures (>1 cm), and tight stricture lumen (< 1 mm) → poorer Wolf et al: triamcinolone injection into the stricture bed + large stents (>12F) → long strictures... Depends primarily on the location of the ureteral stricture Open surgical management (cont) Distal strictures: ureteroneocystostomy or a psoas hitch, depending on the proximity to the ureteral orifice If more length is required, a Boari flap can bridge a 10- to 15-cm defect and may reach the mid ureter Midureteral strictures: short benign strictures with minimal tension → ureteroureterostomy... benign ureteral strictures is balloon dilation, followed by stent placement for 4-6 weeks Hafez and Wolf (8 published series): Success rates ranged from 48%-88% They found balloon dilation best suited for very short nonischemic strictures Goldfischer and Gerber (a large series): a success rate of 50%-76% Factors associated with a good outcome: short duration (< 3 mo) and short length of stricture ... Endoureterotomy (cont) Incisions should be of full thickness into periureteral fat and for 1-2 cm proximal and distal to the stricture At times, postincisional dilation may facilitate complete incision The orientation of the incision should vary depending on the location of the stricture in the ureter Endoluminal ultrasound may assist with the identification of the periureteral vessels Postoperative... Normal contralateralrenal function Medical Therapy No accepted medical treatment of ureteral strictures currently exists Surgical Therapy Indications Indications for intervention: Recurrent pyelonephritis Compromised renal function Pain Recurrent stone formation Need to rule out malignancy Stricture characteristics: Length Malignancy Location Renal Function Contraindications... functional study, not estimate the degree of obstruction or relative renal function The addition of intravenous contrast: The degree of obstruction A delayed nephrogram: anatomic relationship of the strictured ureter to the adjacent structures The best test for extrinsic obstruction Imaging Studies (cont) Intravenous pyelography: o CT → IVP is rarely used o Particularly valuable in patients who... periureteral vessels Postoperative stenting with a 7F-14F stent for 4-6 weeks is commonly performed Ureteral metal stents To treat end-stage malignant disease Sometimes: apply to benign ureteral strictures and UPJ obstruction and ureterovesical obstruction Innovations in the materials and design of ureteric stents will likely continue Stents coated with polymers that retard stone growth These... of diuresis Take note of any history of prior malignancy, surgery, or radiation therapy Physical examination: abdominal pain, fullness or tenderness, and costovertebral angle tenderness Ureteral strictures are often found during routine follow-up imaging after ureteroscopy or intestinal urinary diversion Less frequently, persistent urinary tract infection or pyelonephritis is associated with ... function (< 25%), long strictures (>1 cm), and tight stricture lumen (< mm) → poorer Wolf et al: triamcinolone injection into the stricture bed + large stents (>12F) → long strictures (>1 cm) Recent... benign compression: idiopathic retroperitoneal fibrosis Intrinsic malignant strictures: TCC Intrinsic benign strictures: congenital (obstructing megaureter), iatrogenic, or noniatrogenic... benign strictures: Ureteroscopy Open or laparoscopic injury Radiation therapy Urinary diversions Renal transplantation Epidemiology ↑↑ upper tract endoscopy → ↑↑ iatrogenic ureteral stricture