**1. Introduction**

280 Chronic Kidney Disease

scan. The ideal nephrostomy tract should course through renal parenchyma into the tip of posterolateral calix then into the middle portion of renal pelvis. The complication following

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simple nephrostomy tube drainage is minor.

**8. References** 

Long-term drainage of the urinary tracts of patients with impassable ureteric strictures remains a major challenge to the urologist. Until the mid 1970's the only viable, minimally invasive treatment was a permanent nephrostomy with all its sequelae, loss of quality of life, risk of tube dislocation, infection, and recurrent obstruction (Marberger, 2006). For decades, researchers experimented with different prosthetic ureteric replacements with minimal success. with minimal success. The breakthrough came in 1976 with a case report of the first successful prosthetic replacement of both ureters in a patient with malignant obstruction. The authors proved that not only were prosthetic materials possible replacements for ureters, peristaltic activity was not needed for permanent normal function of the upper urinary tract (Schulman, et al., 1976). This landmark study resulted in rapid progress in the investigation for potential materials for ureteric replacement that could be used without need for major reconstructive surgery. However, it was not until 1994 that the first viable 7F double-pigtail prosthetic extra-anatomic bypass system was developed (Lingam et al., 1994). Despite several series reporting excellent outcomes during the last two decades, extraanatomic stenting is not yet universally offered to candidate patients.

Conventionally, such patients are offered a minimally invasive procedure in the form of a percutaneous nephrostomy or alternatively reconstructive surgery. Percutaneous nephrostomy, though minimally invasive, is far from ideal for long-term use. Reconstructive surgery overcomes some of the problems related to long-term nephrostomy use; however, it requires patients to undergo major surgery. Unfortunately, the majority of impassable ureteric strictures are due to malignant disease, which has been reported to carry a poor prognosis with a resulting median survival of 3 to 7 months (Kouba et al., 2008). This prognosis highlights the importance of maintaining quality of life in this group of patients and major reconstructive surgery with all its potential sequelae, should ideally be avoided.

An ideal urinary diversion should provide symptomatic relief for the required duration without requiring multiple changes and should be associated with minimal or no morbidity. Several authors have reported their experience of using extra-anatomical stents (EAS) for temporary or permanent drainage of obstructed urinary tracts (Ahmadzadeh, 1991; Lingam et al., 1994; Nakada et al., 1995; Desgrandchamps et al., 1998a 1998b; Minhas et al., 1999; Lloyd et al., 2007). In this chapter, we describe the indications for and the technique of inserting the EAS, and a review of the results from the major series.

Extra-Anatomic Urinary Drainage for Urinary Obstruction 283

Fig. 1b. Cystogram in a patient with a Detour extra-anatomic stent (permanent type) for

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

Different types of EAS have been developed and used successfully by different authors (Lingam, 1994; Minhas, 1999; Desgrandchamps, 1998a;, Lloyd, 2007). The designs have varied with the materials used, length of stent, diameter of stent and on whether one or composite stent/s are utilized. They however, all have a common objective of establishing a

ureteric obstruction after sarcoma excision.

this problem.

**3. Stents** 
