**2. Patient indications**

The main indication for insertion of an EAS is malignant ureteric obstruction that has failed management with internal ureteric stenting or nephrostomy (Fig 1a-b). Patients with benign ureteric obstruction that have either failed open reconstructive surgery or are unfit or unwilling to undergo open surgery can also be considered for EAS. Increasing experience with EAS has been paralleled by an expansion in it is indications. At our institution for example, we have successfully used EAS to treat intractable urinary incontinence due to ureteric fistulae in patients otherwise unfit for open surgical repair. In some patients, it has been used as a temporary measure for ureteric fistula before definitive repair is carried out. Lastly, EAS is increasingly being used in transplanted kidneys (Olsburgh , 2007) as well as in patients with ileal conduit (own series).

Fig. 1a. Bilateral Extra-anatomic stents of the Paterson Forrester type (short-term). There is also trans-ureteric ureterostomy stent seen in-situ to be removed. Patient had bilateral strictures and fistula after reconstruction in a post-irradiated abdomen and several attempts at corrective surgery without success.

The only absolute contraindications are uncorrected coagulopathies and active malignancy, either arising or invading the bladder. Tumour seeding along the track may occur if the stent is placed near a tumour (Fig. 2). Bowel stomas and multiple abdominal scars make stent placement more challenging but are not a contraindication. Likewise, patients with a small capacity bladder require appropriate counseling regarding potential increased urinary frequency especially if they have been managed with nephrostomy for a long time. Patients should be warned of the risk of subcutaneous infection that will usually respond to a course of appropriate antibiotic. Rarely, the infection may necessitate removal of the stent with a

The main indication for insertion of an EAS is malignant ureteric obstruction that has failed management with internal ureteric stenting or nephrostomy (Fig 1a-b). Patients with benign ureteric obstruction that have either failed open reconstructive surgery or are unfit or unwilling to undergo open surgery can also be considered for EAS. Increasing experience with EAS has been paralleled by an expansion in it is indications. At our institution for example, we have successfully used EAS to treat intractable urinary incontinence due to ureteric fistulae in patients otherwise unfit for open surgical repair. In some patients, it has been used as a temporary measure for ureteric fistula before definitive repair is carried out. Lastly, EAS is increasingly being used in transplanted kidneys (Olsburgh , 2007) as well as

Fig. 1a. Bilateral Extra-anatomic stents of the Paterson Forrester type (short-term). There is also trans-ureteric ureterostomy stent seen in-situ to be removed. Patient had bilateral strictures and fistula after reconstruction in a post-irradiated abdomen and several attempts

The only absolute contraindications are uncorrected coagulopathies and active malignancy, either arising or invading the bladder. Tumour seeding along the track may occur if the stent is placed near a tumour (Fig. 2). Bowel stomas and multiple abdominal scars make stent placement more challenging but are not a contraindication. Likewise, patients with a small capacity bladder require appropriate counseling regarding potential increased urinary frequency especially if they have been managed with nephrostomy for a long time. Patients should be warned of the risk of subcutaneous infection that will usually respond to a course of appropriate antibiotic. Rarely, the infection may necessitate removal of the stent with a

**2. Patient indications** 

in patients with ileal conduit (own series).

at corrective surgery without success.

Fig. 1b. Cystogram in a patient with a Detour extra-anatomic stent (permanent type) for ureteric obstruction after sarcoma excision.

temporary conversion of the proximal end to a nephrostomy. Rarely still, stent blockage may occur requiring change before 12 months. In our experience, storage bladder symptoms from the stent are exceptionally rare and no stent was ever removed at our institution due to this problem.
