**6. Post-operative management and follow-up**

A Foley catheter may be left in the bladder for a few hours to observe fluid balance but it is not essential following insertion of the short term EAS. Patients are usually discharged home on the day of surgery or the following day. The referring physician monitors the renal function. The patients are instructed to seek medical help immediately if they develop any signs of local or systemic sepsis. Following placement of the Detour stent, an indwelling catheter is left in situ for 1 week, and a cystogram is performed to check the integrity of the suture line before catheter removal (Fig. 10). Flexible cystoscopic view may show some mucosal oedema at the site of implantation (Fig. 11).

Extra-Anatomic Urinary Drainage for Urinary Obstruction 293

candidates for major reconstructive surgery. The remainder of the patients have either failed or declined reconstructive surgery, or are too frail for major surgery. The conventional practice of managing this group of patients is with external percutaneous nephrostomy drainage. Unfortunately long-term nephrostomy drainage presents significant compromises

In 1991, Ahmadzadeh reported short-term results in 8 patients with ureteric obstruction who underwent subcutaneous urinary diversion using a specially designed stent. The procedure had the advantage of being simple whilst at the same time avoided the complications and social effects of other methods of palliative treatment by urinary diversion (Ahmadzadeh 1991). Since this pioneering article, several authors have reported their experience with different types of EAS for urinary diversion. In 1994 Lingam and colleagues reported their series of 5 patients who had EASs inserted during a 15-month period. The diversion was created using a specially designed 7F double pigtail stent, which they routinely changed at 4-month intervals. They found it to be a safe, effective and an acceptable alternative to nephrostomy drainage that improved quality of life (Lingam et al., 1994). A year later, another small study reported a marked improvement in patients' overall comfort and quality of life following conversion of nephrostomies to EASs using a similar but slightly larger 8.5F stent (Nakada et al., 1995). In the same year, Desgrandchamps introduced another stent prototype, which was a one-piece, self-retaining expanded polytetrafluoroethylene-silicone tube that was successfully assembled as an EAS in 19 patients with a mean follow-up of 7.2 months. All patients expressed an improvement in the quality of life although in one case, a conversion to a conventional percutaneous

In 1999, our group published results of 13 patients treated with EAS. Urinary diversion was successful in all patients; two survived for more than 1 year, with changes at six monthly intervals. In three patients the stents were replaced by percutaneous nephrostomies because of problems with leakage or infection. The remaining patients died with functioning EAS in situ. For the first time long-term follow up was reported. This study showed that the mean (range) time from stent placement to death was 7.5 (3–18) months. It was also the first time in the literature that an EAS had been used in a patient with a benign stricture of a native ureter. The patient remained well and was alive to the end of the study at 24 months (Minhas et al., 1999). Since this original publication, we have implanted over one hundred EAS in candidate patients at our institution with equally excellent results (unpublished

One drawback of this one-piece stent was its long length of 70-cm, which some found to be complex to implant, time-consuming, and cumbersome for the patient (Schmidbauer et al., 2006). Nissenkorn and Gdor developed a two 14F 50-cm polyurethane J stents joined by a connector. After stent placement was confirmed by injecting a contrast agent through the tube, the stents were intra-operatively shortened as needed before linking them together. They used the stents successfully in eight patients with a mean follow up of mean 5.5 months (Nissenkorn & Gdor, 2000). In 2006, Schmidbauer et al. reported their successful results using a composite prosthesis set composed of two 12F polyurethane J-tubes, a 58-cm percutaneous nephrostomy part and a 56-cm percutaneous cystostomy part, malleable tunnelers, and a metal connector for joining the two tubes. In 27 patients followed up for 12 months (2 – 54 months) an improvement in mean quality of life score from 3.4+/-1.4 pre-operatively to 7.6+/-

to the patient's quality of life in addition to requiring regular changes.

nephrostomy was necessary (Desgrandchamps et al., 1995).

series).

Fig. 10. Cystogram used to check for suture line integrity.
