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Antegrade approach for stoma revision

A 65-year-old man underwent bilateral ureterocutaneostomy several years ago because of bilateral multiple ureteral strictures after radiation therapy. He visited the emergency room one month ago due to flank pain, decreased urine output and high fever. CT scan images showed bilateral hydronephrosis and the stricture was found at the skin level next to the stoma. The distal tip of Rt ureter was completely obstructed and the tip of Lt ureter was incompletely obstructed.

Open revision for the distal tip of Rt ureter was planned after the antibiotic treatment and indwelling of percutaneous nephrostomy in the right kidney. However, open revision had a critical problem that blind dissection can be performed. I should consider the resultant risk of open surgery including distal ureter injury induced by blind ureter dissection, formation of neo-stoma and adhesiolysis. Finally I planned the antegrade approach to find the level and the length of stricture.

Percutaneous puncture and insertion of the flexible ureteroscope can be performed through the ultraminiperc metallic sheath and ureteral access sheath.

You can see the laser tip inside the ureter and the light can be found though the skin. The obstruction was just at the skin level.

Each guidewire from the right and the left ureters can be found and serial dilatation was performed. two DJ stents were placed for each kidney. The procedures were very clear and safe.

1 month f/up pictures

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