UroToday- Managing extrinsic compression of the ureter by retrograde stenting is first-line therapy but involves a guarded decision because stent failure occurs in nearly half of treated patients. Failure is especially high when ureteral obstruction is due to malignant ureteral compression. The placement of a percutaneous nephrostomy tube is indicated in cases of stent failure which results in a decreased quality of life due to complications such as tube dislocation, infection, or obstruction.

A recent article by J. Schmidbauer and colleagues from Vienna Austria examines the use of a nephrovesical subcutaneous stent for ureteric bypass in patients with ureteric obstruction from advanced metastatic disease. All patients had failed previous internal ureteral stenting. The paper is published in the November 2006 issue of European Urology.

The study group included 31 nephrovesical bypasses implanted in 28 patients with advanced metastatic disease. The ureteric bypass consists of two subcutaneously connected 12 Fr polyurethane tubes placed as nephrostomy and cystotomy tubes. The bypass was placed in the OR using ultrasonographic or fluoroscopic guidance with the patient in a 45 degree flank position. Urinary culture, serum creatinine, quality of life score, and renal ultrasonography were evaluated over a mean follow-up of 11.9 months.

Analysis of the results showed a complete resolution of hydronephrosis in 27 kidneys (87.1%) and reduced hydronephrosis in the remaining 4. Serum creatinine fell from a mean of 5.9 pre-op to 1.4 post-operatively. Mean quality-of-life scores increased from 3.4 to 7.6 post-procedure. In five patients (17.9%), the system had to be replaced at a mean follow-up of 10.2 months due to inclusion and incrustation. Only 4 of the patients were still alive at the time of publication- the others had died from progression of their malignancies.

The nephrovesical subcutaneous bypass is a minimally invasive, safe, and highly effective option for malignant ureteral obstruction. It is a good option for patients that would otherwise be committed to external percutaneous nephrostomy tube placement. This option has the potential to improve quality-of-life due to increased independence, flexibility, and mobility during the final phase of life.

Schmidbauer J, Kratzik C, Klingler HC, Remzi M, Lackner J, Marberger M, Méria P
Eur Urol :50(5):1073-78

Reviewed by UroToday Contributing Editor Michael J. Metro, M.D.

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