**5. Insertion of the detour stent**

The equipment required are provided as a kit and include the 29F PTFE-silicone stent and the dilator (Coloplast, UK). In addition, a surgical set suitable for a lower abdominal

Fig. 6. Supra-pubic puncture and peel-away sheath used to deliver stent into the bladder

Fig. 7. Wounds closed with subcutaneous absorbable sutures and skin glue.

The equipment required are provided as a kit and include the 29F PTFE-silicone stent and the dilator (Coloplast, UK). In addition, a surgical set suitable for a lower abdominal

under cystoscopic control.

**5. Insertion of the detour stent** 

transverse incision is required. Insertion of the permanent Detour stent follows the same principals described above but because it is a bigger stent (29F), it requires the tract to be dilated to 30F (Lloyd et al., 2007). This is achieved with a 30F renal Amplatz sheath and a large-bore plastic subcutaneous tunneling device, which are included in the kit (Fig. 8a-f). A lower abdominal transverse incision is undertaken before a 1cm open cystostomy is performed via which the stent is placed into the bladder and secured with 4-0 Vicryl sutures to the bladder serosa. The large bore subcutaneous stent can be easily palpated and seen in the thin patient (Fig. 9).

Fig. 8a. Lateral percutaneous track using the existing nephrostomy to inject contrast to outline and dilate the pelvi-calyceal system

Fig. 8b. Insertion of the proximal end of the Detour stent through the Amplatz sheath into the kidney (note yellow radiolucent ring to aid positioning).

Extra-Anatomic Urinary Drainage for Urinary Obstruction 291

Fig. 9. Wide bore Detour stent may be palpable in thin patients. Healed incisions are visible.

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

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

mucosal oedema at the site of implantation (Fig. 11).

Fig. 8c. Opaque contrast medium injected through the stent to ensure correct positioning.

Fig. 8d. Subcutaneous tunneling device (blue) and Detour stent being positioned from renal puncture site to supra-pubic region prior to bladder suture

Fig. 8e,f. Sutured cystostomy after shortening the stent, skin glue is applied to wounds after subcutaneouse sutures and glue.

Fig. 8c. Opaque contrast medium injected through the stent to ensure correct positioning.

Fig. 8d. Subcutaneous tunneling device (blue) and Detour stent being positioned from renal

Fig. 8e,f. Sutured cystostomy after shortening the stent, skin glue is applied to wounds

puncture site to supra-pubic region prior to bladder suture

after subcutaneouse sutures and glue.

Fig. 9. Wide bore Detour stent may be palpable in thin patients. Healed incisions are visible.
