Early Application of Permanent Metallic Mesh Stent in Substitution for Temporary Polymeric Ureteral Stent Reduces Unnecessary Ureteral Procedures in Patients With Malignant Ureteral Obstruction

doi:10.1016/j.urology.2015.06.021

Urology

Volume 86, Issue 3, September 2015, Pages 459-464

https://doi.org/10.1016/j.urology.2015.06.021 Get rights and content

Objective

To identify risk factors for metal stent failure in patients who received polymeric double J (PDJ) ureteral stents for malignant ureteral obstructions (MUOs) and review our clinical experiences using a ureteral metallic stent.

Patients and Methods

Patients who underwent metallic stent placement to replace a double J ureteral stent for nonurological MUO between January 2011 and February 2014 were included. The collected data included gender, age, laterality, cause of obstruction, PDJ ureteral stenting duration, immediate success of the metal stent, and additional procedures to relieve obstruction after metal stenting (eg, additional metal stenting or percutaneous nephrostomy (PCN) indwelling catheter placement). Cox regression tests were used for the statistical analyses.

Results

In this analysis 40 ureteral units were included. There was no initial technical failure. However, 9 (22.5%) units required additional procedures due to de novo ureteral obstruction, including additional indwelling metal stents (7.5%), additional PDJ stenting (10%), or indwelling percutaneous nephrostomy (5%). Univariate and multivariate analyses revealed that the duration of previous PDJ ureteral stenting was an independent prognostic factor for predicting ureteral metal stent failure (hazard ratio = 1.063, 95% confidence interval = 1.004-1.125; P = .037).

Conclusion

Long-term indwelling of a PDJ ureteral stent increases the risk of additional management for de novo ureteral stricture after ureteral metal stent replacement for nonurological MUO. Our data suggest that careful patient selection and counseling for those at high risk are needed when metal stent replacement is considered for patients with long-term PDJ ureteral stents for MUO.

Section snippets

Patients and Methods

Patients who underwent ureteral metallic stent (UVENTA ureteral stent, TaeWoong Medical, South Korea) placement for a previously placed PDJ stent due to extrinsic MUO were included in the analysis. The UVENTA is a segmental ureteral stent made of double-layered, shape-memory strands of nickel-titanium alloy that are self-expandable, and a polytetrafluoroethylene cover between the two layers of metallic mesh is designed to prevent stent migration and urothelium anchoring. Replacement of the

Results

The median follow-up duration was 240 days after metallic mesh stent placement and 378 days after PDJ ureteral stent placement. The primary diseases that induced extrinsic MUO and the reasons for PDJ stent placement failure are shown in Figure 1. The patient baseline characteristics are outlined in Table 1.

The initial technical failure rate of metallic mesh stent placement was 0% (0/40). No procedure-related complications were reported, and no additional procedure was performed due to

Comments

PDJ ureteral stent placement is commonly performed during the early stage of extrinsic MUO for renal preservation and symptom relief; however, many studies have reported unsatisfactory success rates and various complications.16, 17, 18, 19, 20 Accordingly, various metal materials for ureteral stents have been described to achieve long-lasting ureteric patency and decrease the rate of complications due to PDJ ureteral stenting.

Wallstents (Schneider, Zürich, Switzerland) are made from a

Conclusion

The data presented here identified the duration of previous PDJ ureteral stenting as an independent prognostic factor for UVENTA stenting failure-free survival. Our findings indicate that UVENTA ureteral stenting can be a good option for patients who have had a PDJ ureteral stent for a relatively short time.

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Caution should be used with current-generation metal-mesh stents because their long-term consequences on ureteric physiology are not fully characterized. Changes reported to date include edema, fibrosis, and ureteric wall thickening.42 The Memokath 051 (PNN Medical, Kvistgaard, Denmark) is another expandable metallic stent designed specifically for the ureter.
Metallic Ureteric Stents in Malignant Ureteric Obstruction: A Systematic Review
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They report 100% stent patency at median follow-up of 8 months, although de novo ureteric obstruction developed in 9 cases to give an overall success rate of 77.5%. Cox regression analysis for predictors of failure demonstrated significance for duration of previous DJS placement (although the authors note this could possibly be explained by disease progression).30 Two included studies contained unextractable data.
The effectiveness of metallic stents in the management of malignant ureteric obstruction is unclear. This systematic review evaluates the use of 4 commercially available metallic stents (Resonance, Memokath 051, Uventa, and Allium URS). Twenty-one studies met eligibility criteria. Overall success rates ranged from 88% for the Allium stent to 65% for Memokath 051. Resonance demonstrated the lowest migration rate (1%). Uventa had the lowest obstruction rate (6%). Metallic ureteric stents offer a viable alternative in the management of malignant ureteric obstruction. Further high quality studies are required to assess cost effectiveness and refine specific indications based on etiology and level of the ureteric obstruction.
The effectiveness of ureteric metal stents in malignant ureteric obstructions: A systematic review
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Complications include haematuria, flank or abdominal pain, encrustation, UTIs, sepsis, and VUR. High rates of migration, decreased peristalsis of the ureter and relative obstruction, the possibility of loss of patency due to the extrinsic pressure, and the need for frequent replacements, are some of the disadvantages [1,2]. Patients with advanced malignant disease have a short life-expectancy and the quality of life should be taken into consideration when establishing a management plan.
To review the literature on the effectiveness, safety and long-term patency of ureteric metal mesh stents (MSs), as a variety of MSs have been used for managing malignant ureteric obstruction over the last three decades.
A systematic review using the search string; Ureter∗ AND (stent OR endoprosthesis) AND metal∗ was conducted on PubMed, Scopus, Web of science and Cochrane Library online databases in May 2016. Prospective, retrospective, and comparative studies including MSs were included. The primary endpoint was the patency rate and the secondary endpoint was complications.
In all, 324 publications were screened and 31 articles were included in the systematic review; 21 prospective and 10 retrospective studies. These studies reported the effectiveness of specific MSs in population studies, in comparative studies among different MSs, as well as among MSs and JJ stents. It should be noted that all comparative studies were retrospective.
The experiences with vascular MSs, such as the Wallstent™ (Boston Scientific/Microvasive, Natick, MA, USA), were related to high occlusion rates, due to endoluminal hyperplasia, and long-term disappointing patency. The use of covered MSs designed for the vascular system was also unfavourable. The Memokath 051™ (PNN Medical A/S, Kvistgaard, Denmark) had better patency rates, but also higher migration rates. The long-term results were acceptable and rendered the Memokath 051 as a viable option for the management of malignant ureteric obstruction. The Uventa™ (Taewoong Medical, Seoul, Korea) and Allium™ (Allium Medical Solutions Ltd, Caesarea, Israel) MSs, specifically designed for ureteric placement, provided promising results. Nevertheless, the wide acceptance of these MSs would require well-designed clinical studies and long-term follow-up.
In vitro and in vivo corrosion and histocompatibility of pure Mg and a Mg-6Zn alloy as urinary implants in rat model
2016, Materials Science and Engineering C
Pure Mg and a Mg-6 wt.% Zn alloy were investigated as potential candidates for biodegradable implants for the urinary system. The in vitro corrosion behavior was studied by potentiodynamic polarization and immersion tests in simulated body fluid (SBF) at 37 °C. The in vivo degradation and histocompatibility were examined through implantation into the bladders of Wistar rats. The alloying element Zn elevated the passivation potential and increased the cathodic current density. Both in vitro and in vivo degradation tests showed a faster corrosion rate for the Mg-6Zn alloy. Tissues stained with hematoxylin and eosin (HE) suggested that both pure Mg and Mg-6Zn alloy exhibited good histocompatibility in the bladder indwelling implantation and no differences between pure Mg and Mg-6Zn groups were found in bladder, liver and kidney tissues during the 2 weeks implantation. Overall, this work presented instructive information on the degradation properties and histocompatibility of pure Mg and the Mg-6Zn alloy in the urinary system.
Stents for malignant ureteral obstruction
2016, Asian Journal of Urology
Malignant ureteral obstruction can result in renal dysfunction or urosepsis and can limit the physician's ability to treat the underlying cancer. There are multiple methods to deal with ureteral obstruction including regular polymeric double J stents (DJS), tandem DJS, nephrostomy tubes, and then more specialized products such as solid metal stents (e.g., Resonance Stent, Cook Medical) and polyurethane stents reinforced with nickel-titanium (e.g., UVENTA stents, TaeWoong Medical). In patients who require long-term stenting, a nephrostomy tube could be transformed subcutaneously into an extra-anatomic stent that is then inserted into the bladder subcutaneously. We outline the most recent developments published since 2012 and report on identifiable risk factors that predict for failure of urinary drainage. These failures are typically a sign of cancer progression and the natural history of the disease rather than the individual type of drainage device. Factors that were identified to predict drainage failure included low serum albumin, bilateral hydronephrosis, elevated C-reactive protein, and the presence of pleural effusion. Head-to-head studies show that metal stents are superior to polymeric DJS in terms of maintaining patency. Discussions with the patient should take into consideration the frequency that exchanges will be needed, the need for externalized hardware (with nephrostomy tubes), or severe urinary symptoms in the case of internal DJS. This review will highlight the current state of diversions in the setting of malignant ureteral obstruction.
Management of single double-J stent failure in malignant ureteral obstruction: tandem ureteral stenting with less frequent stent exchange
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: Financial Disclosure: The authors declare that they have no relevant financial interests.

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Endourology and StonesEarly Application of Permanent Metallic Mesh Stent in Substitution for Temporary Polymeric Ureteral Stent Reduces Unnecessary Ureteral Procedures in Patients With Malignant Ureteral Obstruction

Objective

Patients and Methods

Results

Conclusion

Section snippets

Patients and Methods

Results

Comments

Conclusion

Urology

J Urol

Korean J Urol

Urology

J Urol

J Urol

J Urol

Urol Clin North Am

J Urol

J Urol

J Chin Med Assoc

Urology

Stent-change therapy in advanced malignancies with ureteral obstruction

J Endourol

Urologic emergencies in the cancer patient

Semin Oncol

Self-expanding metal stents for palliative treatment of malignant ureteral obstruction

AJR Am J Roentgenol

Endourology and Stones
Early Application of Permanent Metallic Mesh Stent in Substitution for Temporary Polymeric Ureteral Stent Reduces Unnecessary Ureteral Procedures in Patients With Malignant Ureteral Obstruction