For Refractory Strictures, A Better Option

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SEATTLE—Cutting balloon ureteroplasty may be a safe and effective treatment option for anastomotic strictures resistant to conventional high-pressure balloon dilation, according to findings presented here at the Society of Interventional Radiology's 31st Annual Scientific Meeting.

This alternative approach may prevent morbidity associated with long-term catheter drainage as well as the risks associated with surgical revision.

“This is a fairly new approach and an off-label use of the device. However, this is the largest case series that has been presented for the treatment of this problem,” said lead investigator Todd Schirmang, MD, a second-year radiology resident at Brown Medical School in Providence, R.I.

“By using the cutting balloon device we found that at about one year of follow-up we had almost an 80% success rate, with patients not needing drainage catheters for long-term management of the strictures.”

The investigators retrospectively reviewed data on eight men and four women (13 ureters) with benign ureteroenteric anastomotic strictures refractory to conventional balloon ureteroplasty. The patients, who underwent cutting balloon dilation between November 2004 and September 2006, had a mean age of 71 years (range 38-88 years). Technical success was defined as residual stenosis of less than 30% of luminal diameter. Clinical success was defined as tube-free existence at time of review.

Nine of the patients had a prior cystectomy with a neobladder created for transitional cell carcinoma, and one patient had ureteroileal diversion for trauma. Another patient had ureteroileal diversion for neurogenic bladder and one patient developed a stricture post renal transplant.

Over-the-wire dilations using cutting balloons were employed, ranging in size from 5-8 mm. During each dilation session, internal/external nephroureteral stents were placed, with plans to convert to nephrostomy at subsequent visits.

Follow-up consisted of routine nephrostogram and catheter change at six-week intervals with repeat dilation, catheter replacement, or removal as determined by angiographic and clinical findings. The immediate technical success was deemed to be 100% and clinical success was achieved in 10 of 13 strictures (77%). The median follow-up was 10.5 months (range: 5-15 months).

The average number of sessions per ureter was 1.6. The average number of sessions between the clinically successful group (1.6) and the clinically unsuccessful group (1.7) was not statistically significant. No deaths occurred, and there were no ureteral ruptures or bleeding requiring transfusion or surgery.

“It appears dilation using a cutting balloon may be a better option for these patients. There is no risk of general anesthesia and it is an outpatient procedure. We found no complications of bleeding, infection or urine leak in our study.”The most common side effect was pain for a day or two at the site of treatment, but it was transient. All the patients received conscious sedation.

“Traditionally, these patients have been difficult to treat surgically, so we are trying to find a treatment that is effective without high morbidity and mortality. The conventional balloon has had disappointing long-term success. Patients must therefore live with a catheter or stent and require these to be exchanged every six weeks for the rest of their lives. However, this new technique shows that these patients can be treated successfully and live catheter-free.”

He cautioned that the new data have limitations because the study was retrospective and the follow-up relatively short.
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