**7. Discussion of results**

End-stage ureteric obstruction, which has failed ureteric stenting, presents a significant challenge the urologist. Most of our patients have terminal cancer and are therefore not ideal

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

Fig. 11. Cystoscopic appearance of the silicone part of the Detour stent.

End-stage ureteric obstruction, which has failed ureteric stenting, presents a significant challenge the urologist. Most of our patients have terminal cancer and are therefore not ideal

**7. Discussion of results** 

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

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

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 series).

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+/-

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1.0 post-operatively was reported. In five patients (17.9%) the system had to be replaced due to occlusion at a mean follow-up of 10.2 months. In three out of these five patients only the distal part of the two-piece bypass was exchanged (Schmidbauer et al., 2006).

Desgrandchamps et al. were the first authors to report use of a permanent PTFE-silicone EAS (Detour). They reported 3 patients who underwent successful EAS for ureteric necrosis, a rare complication of renal transplantation (Desgrandchamps et al., 1998). In 2001, the same group, reported use of the PTFE-silicone EAS in 27 patients with neoplastic (22) or benign (5) ureteric strictures. The mean follow-up was 6.3 months for the deceased patients and 47 months for the surviving ones, the longest follow-up being 84 months. In 3 cases, the EAS had to be removed due skin erosion in one and local tumour progression with bladder fistulae in two patients. Otherwise, five patients survived with the prosthesis in situ and a follow-up as long as 84 months without encrustation, infection, obstruction, or skin problems and with normally functioning kidneys (Jabbour et al., 2001). A prospective evaluation of their patients' quality using the EORTC QLC-30 questionnaire following insertion of the Detour EAS demonstrated an improvement of the function scale as a result of the elimination of the external percutaneous tube and a parallel worsening of the symptom scale secondary to the progression of disease (http://groups.eortc.be/qol/ questionnaires\_qlqc30.htm). Patient ratings of the global quality of life and satisfaction with the urinary diversion were high because of the absence of the percutaneous tube (Desgrandchamps et al., 2007). Other authors have since reported equally excellent results with the Detour EAS (Lloyd et al., 2007; Olsburgh et al., 2007; Burgos et al., 2009).

Aminsharifi A et al. recently described a promising simple modification of using percutaneous access to the bladder utilizing a split Amplatz sheath, and thus obviating the need for open cystostomy incision (Aminsharifi et al., 2010).

The main long-term complication reported is tumour invasion along the stent and active bladder cancer is the main contraindication to EAS insertion. One case report reported a patient presenting with acute obstruction of the Detour system secondary to a Candida infection that was managed successfully with short term nephrostomy and systemic antimycotic therapy without removing the stent (Bynens et al., 2006).
