Percutaneous Endoscopy-Assisted Laser Incision as Treatment for Ureteral Stricture Disease

Learning Objectives: 1. Discuss Ureteral Stricture Disease (USD) and the role of the Interventional Radiologist in disease management.

2. Describe percutaneous endoscopy-assisted laser incision treatment for severe benign USD.

3. Present preliminary results for a sample of patients with post-surgical anastomotic site stricture.

Background: USD is a common complication following kidney transplantation and uretero-intestinal anastomosis {1,2,3}. USD is defined as ureteral luminal obstruction due to primary fibrosis of the ureter without external compression, typically at the uretero-vesical anastomosis {1}.  Patients who are not candidates for conventional surgical, ureteroscopic or balloon ureteroplasty interventions may benefit from percutaneous endoscopy-assisted laser incision.

Clinical Findings/Procedure Details: Percutaneous access to the genitourinary (GU) system offers an antegrade approach with advantages over retrograde techniques, particularly in cases of altered anatomy, with better delineation of stricture length and severity {4}. Interventions can be performed via a 12 Fr sheath with endoscopy providing direct stricture visualization and precise application of the laser. The 365-μm bare holmium fiber laser makes longitudinal laser incisions of the stricture. Post laser incision balloon ureteroplasty enhances the effect of the laser incision providing better caliber results. A nephroureteral catheter is placed to maintain patency. Follow-up is necessary to confirm stricture resolution and for removal of the catheter after a capping trial.

We present five patients treated for severe benign USD. Treatment was successful in all patients, with no complications. Treatment was clinically successful in four patients, with one patient developing recurrent stricture four months after treatment. The average time to tube removal from laser incision of the stricture was 5.3 ± 2.2 months. Average follow up time post laser incision was 14.2 ± 9.2 months.

Conclusion and/or Teaching Points: Surgical ureteral reconstruction is the gold standard for patients with refractory USD. However, the Interventional Radiologist can play a key role providing endoscopy-assisted procedures for non-surgical candidates or patients who have failed conventional serial ureteral dilation. Particularly in benign, short segment (< 2 cm) USD, these endoscopy-assisted procedures can provide a low-cost, minimally invasive alternative to surgery