Background:

                    

Ureteral strictures are a recurrent chronic condition that leads to severe side effects and poor quality of life. Management of ureteral stricture is a great challenge for urologists and no specific guidelines exist. Retrograde Allium®ureteral stent (AUS) is a newly developed ureteral stent to treat either bulbar urethral or ureteral stenosis.

                        Case Presentation:

                    We describe a case of a 74-year-old Caucasian adult male presenting with a severe ureteral stricture secondary to an ureteroscopy for stone disease. Treatment with retrograde AUS placement produced a complete loss of renal function after 36 months, probably because of the development of a long achalasic stretch of the ureter.

                        Conclusions:

                    AUS is a new and promising device for the treatment of ureteral stenosis. However, a lack of standardization of the technique recommends a close instrumental follow-up after the procedure to decide the optimal time for stent removal

Alpi, Giorgio

Ciccariello, Mauro

D'Eramo, Giuseppe

Gentilucci, Alessandro

Lai, Silvia

Maggi, Martina

Polese, Milena

Ricciuti, Gian Piero

Salciccia, Stefano

Sciarra, Alessandro

Shahabadi, Houssain

English

Stefano Salciccia

Alessandro Sciarra

Milena Polese

Alpi Giorgio

Martina Maggi

Alessandro Gentilucci

Mauro Ciccariello

Giuseppe D'Eramo

Houssain Shahabadi

Silvia Lai

Gian Piero Ricciuti

Crossref

Journal of Endourology Case Reports

Loss of Renal Function After Retrograde Ureteral Placement of an Allium Stent for Severe Ureteral Stricture

Background:
                    
Ureteral strictures are a recurrent chronic condition that leads to severe side effects and poor quality of life. Management of ureteral stricture is a great challenge for urologists and no specific guidelines exist. Retrograde Allium®ureteral stent (AUS) is a newly developed ureteral stent to treat either bulbar urethral or ureteral stenosis.
                        Case Presentation:
                    We describe a case of a 74-year-old Caucasian adult male presenting with a severe ureteral stricture secondary to an ureteroscopy for stone disease. Treatment with retrograde AUS placement produced a complete loss of renal function after 36 months, probably because of the development of a long achalasic stretch of the ureter.
                        Conclusions:
                    AUS is a new and promising device for the treatment of ureteral stenosis. However, a lack of standardization of the technique recommends a close instrumental follow-up after the procedure to decide the optimal time for stent removal

Giorgio, Alpi

Archivio della ricerca- Università di Roma La Sapienza

Case ReportLoss of Renal Function After Retrograde Ureteral Placementof an Allium Stent for Severe Ureteral StrictureStefano Salciccia, MD,1 Alessandro Sciarra, MD,1 Milena Polese, PhD,1 Alpi Giorgio, MD,1Martina Maggi, MD,1 Alessandro Gentilucci, MD,1 Mauro Ciccariello, MD,1 Giuseppe D’Eramo,1Houssain Shahabadi, MD,1 Silvia Lai, MD,2 and Gian Piero Ricciuti, MD1AbstractBackground: Ureteral strictures are a recurrent chronic condition that leads to severe side effects and poorquality of life. Management of ureteral stricture is a great challenge for urologists and no specific guidelinesexist. Retrograde Allium ureteral stent (AUS) is a newly developed ureteral stent to treat either bulbarurethral or ureteral stenosis.Case Presentation: We describe a case of a 74-year-old Caucasian adult male presenting with a severe ureteralstricture secondary to an ureteroscopy for stone disease. Treatment with retrograde AUS placement produced acomplete loss of renal function after 36 months, probably because of the development of a long achalasic stretchof the ureter.Conclusions: AUS is a new and promising device for the treatment of ureteral stenosis. However, a lack ofstandardization of the technique recommends a close instrumental follow-up after the procedure to decide theoptimal time for stent removal.Keywords: ureteral stent, ureteral stricture, stone disease complicationsIntroduction and BackgroundUreteral stricture is a well-known complication af-ter endoscopic procedures in the upper urinary tract.1However, the exact mechanism for which stenosis developsis not well known. Some studies have revealed that in case ofimpacted calculi, ureteral perforation during the procedure isrelated to a high rate of stricture development (90% to 95%).2Damage to the ureteral mucosa can also trigger strictureformation. Fibrinous exudates produced by the mucosa pre-cipitate into the injured area, stimulating adherence and, fi-nally, stricture formation.3 Management of ureteral stricturesis a great challenge for urologists.To date, we have no specific recommendations on how totreat ureteral stenosis. Traditionally, the open surgical treatmentof ureteral strictures included ureteroureteral anastomosis,ileal substitution, autotransplant, or nephrectomy. With thetechnological evolution, endoscopic treatments such as balloondilatation, cold knife incision, and laser endoureterotomy aremore commonly used, including the insertion of new types ofureteral stent.4 The Allium ureteral stent (AUS) is a newlydeveloped ureteral stent, which can be inserted in structures ofsmall diameter and spontaneously expands and preserves alarge caliber. The stent is coated with a biochemical copolymerthat prevents tissue ingrowth and incrustation.5 The stent can beinserted endoscopically with an intraoperative X-ray guidanceafter dilatation of the stricture and then it can be removed in atime range from 6 to 12 months. We present the case of a manwith a complete loss of left kidney function after positioning ofthe AUS for an indwelling time of 36 months.Case PresentationOn March 2013, a 74-year-old Caucasian man witha history of stone disease was evaluated in our urologicdepartment for left side pain. Medical history includedonly hypertension under control with beta-blockers. Ultra-sonography (US) showed a severe left hydroureteronephrosisand an X-ray revealed an impacted stone of about 13mmdiameter at the level of the iliac tract of the ureter. Laboratorytests were unremarkable except for increased creatinine up to1.5mg/dL. There was no leukocytosis. Ureteroscopy (URS)Departments of 1Gynecology-Obstetrics and Urology and 2Clinical Medicine, Sapienza University of Rome, Rome, Italy.ª Stefano Salciccia et al. 2018; Published by Mary Ann Liebert, Inc. This is an Open Access article distributed under the terms of theCreative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the originalwork is properly cited.JOURNAL OF ENDOUROLOGY CASE REPORTSVolume 4.1, 2018Mary Ann Liebert, Inc.Pp. 9–11DOI: 10.1089/cren.2017.01179with holmium laser fragmentation was performed and aDouble-J stent was inserted for edema and inflammation ofthe ureteral walls in the side of the stone. Double-J stent wasremoved after 15 days. After 30 days from stent removal, thepatient referred a mild left flank pain and US showed amoderate hydroureteronephrosis. An X-Urography showed a4 cm stenosis of the iliac tract of the left ureter. A kidneyscintigraphy showed a normal renal function. In accordancewith the patient, it was decided to proceed endoscopically to aballoon dilatation of the stenosis followed by the positioningof an AUS (Fig. 1). At 1-month follow-up, US showed a slightdilation of left renal pelvis (Grade-I) and the same situationwas maintained at 3- and 6-month follow-ups. Subsequentlythe patient was lost in the follow-up for severe cardiovascularproblems. He came back again to our department after 2 yearsfrom the last control, without any sign or symptom. An USshowed a severe left hydroureteronephrosis with a markedthinning of the renal parenchyma and a secondary stone ofabout 15mm. An abdomen X-ray showed the AUS in theoriginal position. A kidney scintigraphy was planned and itshowed the complete loss of left kidney function. Consideringthe general conditions of the patient (ASA score IV) and thelack of symptoms, we decided to follow the patient at regularintervals and to be operated only in case of complications.DiscussionUreteral strictures are a recurrent chronic condition thatleads to severe side effects and poor quality of life. Man-agement of ureteral strictures is a great challenge for urolo-gists and no specific guidelines exist.There are several options, including repeated dilatations,stents, minimally invasive reconstructive surgery, and uri-nary diversion or nephrectomy. AUS is a new device recentlyintroduced to treat ureteral and urethral stenosis. Consideringthe recent introduction into the clinical practice, we haveonly few studies on AUS for ureteral strictures and mainlywe do not have specific indications on when to remove theAUS. Moreover, another open question is whether the AUScan be considered a permanent device, for example, in themanagement of ab-estrinseco compression of the ureter fromoncologic diseases. Since 2014, we have treated >50 casesof urethral stenosis with AUS, obtaining good functionalresults. We believe that the optimal time to remove the stentshould be between 6 and 12 months. We reported a case inwhom after 36 months of Allium positioning, it developed asevere hydronephrosis with a complete loss of left kidneyfunction probably because of the formation of a long acalasicstretch of the ureter in the side of the AUS. We can hypoth-esize that the presence of the stent in the wall of the ureter fora long period of time can trigger inflammation and a subse-quent fibrosis with loss of normal ureteral peristalsis. Anotherhypothesis is that in our case, the stenosis was very severe andthe marked dilation produced a stripping and tearing of thefibromuscular component of the ureter, resulting in fibrosisand loss of physiologic peristaltic function. Unfortunately,we did not have the possibility to perform an URS at a shorterfollow-up from the procedure to confirm this second hy-pothesis. Some studies5–7 have reported stent migration orinfection as complications of AUS. We believe that the de-velopment of ureteral achalasia should also be considered asa possible complication of AUS.ConclusionsAUS is a new and promising device for the treatment ofureteral stenosis. Some studies have reported promising re-sults for the treatment of ureteral stenosis. However, there is alack of standardization of the technique and predictive factorsof success or complications have not been determined. Forthese reasons, we recommend a close instrumental follow-upin the early months after the procedure so to decide the op-timal removal time of the stent or to identify a progressivehydronephrosis as a marker of possible failure.Disclosure StatementNo competing financial interests exist.References1. Legemate JD, Wijnstok NJ, Matsuda T, et al. Character-istics and outcomes of ureteroscopic treatment in 2650patients with impacted ureteral stones. World J Urol 2017;35:1497–1506.2. Robert WW, Caddedu JA, Fabrizio MD, et al. Ureteralstricture formation following removal of impacted calculi.J Urol 1999;161 Suppl:376.3. Fam XI, Singam P, Ho CC, et al. Ureteral stricture for-mation after ureteroscope treatment of impacted calculi: Aprospective study. Korean J Urol 2015;56:63–67.4. Tran H, Arsovska O, Paterson RF, et al. Evaluation of riskfactors and treatment options in patients with ureteral stric-ture disease at a single institution. Can Urol Assoc J 2015;9:E921–924.FIG. 1. Abdomen X-ray showing Allium ureteral stentpositioning in the iliac tract of the left ureter.Salciccia, et al.; Journal of Endourology Case Reports 2018, 4.1http://online.liebertpub.com/doi/10.1089/cren.2017.0117105. Bahouth Z, Meyer G, Halachmi S, et al. Multicenterexperience with allium ureteral stent for the treatment of ure-teral stricture and fistula. Harefuah 2015;154:753–756, 806.6. Guandalino M, Droupy S, Ruffion A, et al. The Allium ure-teral stent in the management of ureteral stenoses, a retro-spective, multicenter study. Prog Urol 2017;27:26–32.7. Papatsoris AG, Buchholz N. A novel thermo-expandableureteral metal stent for the minimally invasive managementof ureteral strictures. J Endourol 2010;24:487–491.Address correspondence to:Stefano Salciccia, MDDepartment of Gynecology-Obstetrics and UrologySapienza University of RomeRome 00161ItalyE-mail: stefano.salciccia@uniroma1.itAbbreviations UsedAUS ¼ Allium ureteral stentUS ¼ ultrasonographyURS ¼ ureteroscopyCite this article as: Salciccia S, Sciarra A, Polese M,Giorgio A, Maggi M, Gentilucci A, Ciccariello M,D’Eramo G, Shahabadi H, Lai S, Ricciuti GP (2018)Loss of renal function after retrograde ureteralplacement of an Allium stent for severe ureteralstricture, Journal of Endourology Case Reports 4:1,9–11, DOI: 10.1089/cren.2017.0117.Salciccia, et al.; Journal of Endourology Case Reports 2018, 4.1http://online.liebertpub.com/doi/10.1089/cren.2017.011711

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Loss of Renal Function After Retrograde Ureteral Placement of an Allium Stent for Severe Ureteral Stricture

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