The response of strictures to balloon dilation is influenced by such factors as the etiology of the stricture, the length and location of the stricture, the duration of time that the stricture has been present, and the presence of ischemia or dense fibrosis (as in patients who have undergone radical extirpative surgery or have had radiation therapy). The relatively nonischemic strictures associated with endourologic surgery appear to respond better than do ischemic strictures.
Overall, 50% of all benign strictures respond favorably to one attempt at balloon dilation. Lang and Glorioso (160) reported that 91% of strictures less than three months old responded to dilation, compared to 53% of treated strictures that were of more than three months duration. In the presence of ischemia or fibrosis, only 21% of strictures were successfully dilated, whereas 70% of strictures not associated with vascular compromise responded. In a small series, Kim et al. (161) found that balloon dilation and stenting were successful in dilating tuberculous strictures in 75% of cases with good long-term results. Bilharzial strictures also respond to endourologic management, with the longer strictures requiring endoureterotomy (162). Chang et al. (143) reported 100% success in dilating strictures less than 1.5 cm in length, and O'Brien et al. (163) reported no difference in the outcomes whether the interval between ureteral injury and dilation was short or long. They reported a 65% overall success rate in dilating benign ureteral strictures. Kwak et al. (164) found that multiple dilations were of no benefit in prolonging or maintaining ureteral patency.
Strictures related to ureterolithotomy, ureteral endoscopy, and gynecologic surgery responded in 100%, 71%, and 62% of cases respectively, in one series (137). However, strictures associated with radical hysterectomy or retroperitoneal fibrosis responded poorly (33% and 0%, respectively).
Endoscopic incision has been used for treatment of many ureteral strictures that fail balloon dilation. An antegrade, retrograde, or combined approach can be used. Cutting devices in use are a cold knife, electrocautery, lasers, and the Acucise cutting balloon catheter (138). Endoureterotomy success rates range from 55% to 85% for benign ureteral strictures (141,146).
Balloon dilation and stenting have been used to treat UPJ obstruction (both primarily as an alternative to pyeloplasty and in secondary obstruction following
Figure 9 (Figure on facing page) Eighty-two-year-old man post-cystectomy for bladder cancer and urinary diversion to an ileal conduit. (A) A transconduit retrograde nephrostomy catheter was placed on the left side for a stricture at the left ureteroenteral anastomosis. The procedure was performed with a combination of an antegrade-retrograde approach, as described in the text. (B) A loopogram demonstrated the right ureteroenteral anastomosis to be patent, but a filling defect is present in the proximal ureter. (C) The right ureter was can-nulated in a retrograde manner. A patent anastomosis can usually be easily catheterized from the ileal conduit. A high-grade stricture in the proximal ureter was causing hydronephrosis of the right collecting system. (D) A brush biopsy of the abnormal area was performed through the retrograde transconduit route and demonstrated transitional cell carcinoma. (E) A transconduit retrograde nephrostomy catheter was placed on the right side, as well as on the left side, because the patient was not a surgical candidate.
pyeloplasty). The reported success rate varies from 64% to 86% (165,166). Balloon dilation has been nearly completely superseded by endopyelotomy, which may be more effective in treating UPJ obstruction. Reported success rates with endopyelotomy vary from 32% to 67% (167-169), with higher success rates in treating secondary UPJ obstructions (obstructions occurring after a pyeloplasty) than in treating primary UPJ obstructions (167).
The long-term results of balloon dilation of ureteroenteral anastomotic strictures are poor, indicating that the strictures are resistant to nonoperative therapy. Shapiro et al. (170) reported a patency rate of only 30% at six months and 16% at one year. Similarly, Chang et al. (143) and Kramolowsky et al. (171) reported patency rates of 20% to 38% at one year. Kwak et al. (164) reported a nine-month success rate of 18% for continuing patency of balloon-dilated anastomotic strictures. They found that multiple dilations were of no benefit in maintaining ureteral patency. Overall, the average success rate in many series is 29% at 14 months (138).
The addition of endoscopic electroincision of the stricture to balloon dilation may improve patency rates to 42% to 71% (137,172,173) (average follow-up 16-28 months). Wolf et al. (174) used electrocauteruy and the Acucise cutting balloon and reported success rates of 72%, 51%, and 32% at one, two, and three years respectively; right-sided strictures had a better outcome with 68% of strictures improved at three years versus 17% of left-sided strictures. They also found no correlation between successful treatment and stricture length or stricture diameter but did report a higher success rate with the use of stents that were 12 French or larger, stenting periods of longer than four weeks, and treating strictures less than 24 months after the inciting event. Holmium laser endoureterotomy (175) has a reported success rate of 57% to 83% for right-sided strictures and 38% for left-sided strictures. Injury to the iliac artery has been reported with endoureterotomy (176). Cornud et al. (177) reported that incision of strictures had an actuarial three-year patency rate of 62% and also found that strictures associated with a continent neobladder responded more favorably than did ureteroileal strictures.
Metal stents have also been used to treat anastomotic strictures. To date, the reported series are small. Pollak et al. (108) reported that metallic stents (Wallstent endoprostheses) are ineffective in keeping benign ureteroileal strictures patent. Only one of six stents remained patent at 11 months, with the remainder becoming occluded by hyperplastic tissue growth within the stent. Other series (178) reported 100% patency at 10 and 22 months (178,179). The ultimate role of metal stents in the management of these patients remains in evolution, and judgment has to be deferred till larger cohorts of patients have been studied.
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