Initial experience for treatment of refractory ureterovaginal fistula using self-expandable metal stent (Allium TM stent): a report of four cases and review of literatures

Initial experience for treatment of refractory ureterovaginal fistula using self-expandable metal stent (Allium TM stent): a report of four cases and review of literatures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Initial experience for treatment of refractory ureterovaginal fistula using self-expandable metal stent (Allium TM stent): a report of four cases and review of literatures Lizhe An, Mingrui Wang, Huanrui Wang, Qi Wang, Kexin Xu, Tao Xu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4069331/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To report our initial experience in the treatment of refractory ureterovaginal fistula (UVF) with Allium™ stent, and to review related literatures. Methods From May 2019 to June 2021, four patients with refractory UVF were treatment with Allium™ stent in our department. Refractory UVF was defined as failure of previous treatment and the patient was not suitable for open or laparoscopic surgery. The process was described as follows, the affected ureter was dilated with balloon followed by placement of Allium™ stent, the stent was finally removed and stent-free was achieved. The perioperative and follow-up data were reviewed. Results UVF of these four patients was developed after gynecological surgery. All patients had received previous treatment, including ureteral reimplantation in one patient and endoscopic treatment in three patients. The mean age of patients was 47 (35–54) years. The mean time from fistula diagnosis to Allium™ stent placement was 8 (4–16) months. The mean operative time was 36 (25–50) minutes. All of four patients was confirmed of ureteral stricture intraoperatively. Leakage of urine was disappeared within two days in all patients. No high grade (MCCS Ⅲ or Ⅳ) complications was occurred postoperatively. The mean indwelling time of Allium™ stent was 17 (12–23) months and the mean stent-free follow-up removal was 9 (1–22) months. No patients developed recurrence of leakage or ureteral stricture. Conclusions Our initial results and experience showed that it is safe and feasible to treat refractory UVF with Allium™ stent. The long-term follow-up results still need to be verified. Ureterovaginal fistula Refractory Endoscopic Allium™ stent Figures Figure 1 Figure 2 Introduction Ureterovaginal fistula (UVF) is a kind of urogenital fistula, which indicates an abnormal channel between ureter and vagina. The main manifestation of UVF is incontinent leakage of urine from vagina, thus the quality of patient’s life is greatly impaired. Almost all of the UVF cases result from iatrogenic injury, mainly secondary to hysterectomy, for which the incidence of postoperative UVF is about 2.43% [ 1 ]. The treatment of UVF includes endoscopic treatment and ureteral reconstruction surgery. Traditional endoscopic treatment is placement of ureteral stent, but the success rate is quite low, failure of stent insertion occurs in up to 63.1% of patients [ 2 ]. For ureteral reconstruction to treat UVF, the most prevalent surgery is ureteral implantation [ 3 , 4 ]. However, a special group of patients should be paid extra attention, they have received previous treatment for UVF or have undergone pelvic surgery. We define the UVF in these patients as refractory UVF. Therefore, the treatment may be challenging. On the one hand, traditional endoscopic treatment has been proven ineffective. On the other hand, adhesions and anatomical changes caused by previous treatment make it extremely difficult to perform ureteral reconstruction surgery. We applied a kind of self-expandable metal stent (Allium™ stent) to treat refractory UVF and all patients gained disappearance of urine leakage and stent-free. The initial experience and literature review were reported as follows. Methods Clinical data From May 2019 to June 2021, a total of 4 patients with refractory UVF were treated by endoscopic placement of Allium™ stent, which was performed by one surgeon. The four patients’ demographic and perioperative data were retrospectively reviewed, including history of present illness, previous treatment, operative time, postoperative complications and follow-up data. This study was approved by the Ethics Committee of Peking University People's Hospital, and informed consent was obtained from all patients. Presurgical evaluation The diagnosis of UVF was primarily established according to history of surgery and urine leakage from vagina, and was confirmed by intravenous pyelography, CTU and cystoscopy. Intravenous pyelography could find the extravasation of contrast from the lower ureter to projective area of vagina. CTU could show hydronephrosis caused by ureteral obstruction and extravasation of contrast from lower ureter into vagina. Cystoscopy was used to exclude the coexistence of vesicovaginal fistula. The indications for Allium™ stent placement were following: 1) Failure of previous ureteral reconstruction 2) History of abdominal and pelvic surgery, which made ureteral reconstruction surgery extremely difficult 3) Persistent urine leakage during indwelling of double-J stent 4) The patient rejected palliative treatment such as nephrostomy. Urine culture and urine analysis were conducted preoperatively to confirm whether urinary tract infection was existent. The infection should be controlled before surgery. Surgical techniques After spinal or general anesthesia, the patient was placed in lithotomy position. Ureteral lumen was explored by ureteroscope under guidance of a guide wire. Location of fistula, length of lesion, and presence of ureteral stricture were confirmed. No ureteral atresia was found in all patients, thus the guide wire could pass through the lesion and reach into renal pelvis, which was confirmed by X-ray. Ureteral catheter was inserted along the guide wire and retrograde pyelography was performed. The location and length of lesion was reconfirmed by X-ray, affected ureter lesion was dilated by 21F balloon under X-ray monitoring. Dilation of ureter was confirmed by ureteroscope. Then 10mm/12cm Allium™ stent was placed, the upper edge exceeded the lesion, and the lower edge was exposed in the bladder, about 1cm beyond the ureteral orifice. A double-J stent was placed within the lumen of Allium™ stent. Postoperative care and follow-up Infection and urine leakage were closely observed postoperatively. Complications were assessed by Modified Clavien-Dindo Classification System (MCCS). Double-J stent was removed 1 month after operation. Ultrasound, KUB, biochemical examination, urine analysis and urine culture were conducted in 1, 3, 6 months after removal of double-J stent and then every 6 months. Antibiotics should be given when urinary tract infection occurred, dislocation or encrustation of stent would also be treated timely. Removal of Allium™ stent and effect evaluation Allium™ stent indwelt for 1–2 years. Ureteroscopy was conducted after removal of Allium™ stent. Retrograde urography or methylene blue test was used to confirm closure of fistula if necessary. Then a double-J stent was placed and removed after one month. Nephrosis was evaluated by ultrasound. Success was defined as relief or stability of nephrosis and disappearance of urine leakage. Results Overall results The mean age of the patients was 47 years (35–54), and the mean BMI was 23.5kg/m2 (18.4–31.1). All patients developed UVF after gynecological surgery and had received previous treatment before admitting to our hospital. The primary diseases and corresponding gynecological surgeries were described detailly in Table 1 . All patients underwent CTU or IVU, extravasation of contrast from lower ureter to vagina was showed. The mean time from onset of UVF to placement of Allium™ stent was 8 month (4–16). Allium™ stent was retrogradely placed in all patients. The mean operative time was 36 minutes (26–50). No high grade (MCCS Ⅲ or Ⅳ) complications occurred postoperatively. No patients suffered infectious complications such as fever. Urine leakage disappeared within 1–2 days postoperatively. The mean postoperative hospital stay was 2 days (1–4). Allium™ stent was finally removed in all patients. The mean indwelling time was 17 months (12–23). One patient suffered repeated fever resulted from urinary tract infection with no sign of hydronephrosis in ultrasound. The symptoms were relieved after antibiotic treatment. The mean follow-up after Allium™ stent removal was 9 months (1–22). No relapse of urine leakage occurred and hydronephrosis was relived or stabilized. Table 1 . Table 2 Summary of literatures about endoscopic treatment of UVF Author, year Patients Mean age (range), years Sides Previous treatment Surgical manner Success rate of surgery, % Rate of urine leakage relief Long-term result Tsai, 2000 [ 13 ] 3 - - None Endoscopic ureteroureterostomy 100 (3/3) 100 (3/3) - Li, 2018 [ 12 ] 46 42.5 (34–53) 27 left, 19 right None Endoscopic stent placement or ureteral realignment 97.8 (45/46) 100 (45/45) 16 stent free, 29 regular stent replacement Kumar, 2009 [ 7 ] 8 - - None Cystoscopic stent placement 100 (8/8) 100 (8/8) 3 ureteric stricture Rabani, 2021 [ 9 ] 8 26.5 (21–42) 5 left, 3 right None Ureteroscopic stent placement 75 (6/8) 100 (6/6) 6 stent free, no ureteric stricture Shaw, 2014 [ 8 ] 13 - 7 left, 6 right None Endoscopic antegrade/retrograde stent placement 53.8 (7/13) 71.4 (5/7) 5 stent free, no ureteric stricture Rajamaheswari, 2013 [ 10 ] 17 36.5 (23–46) 14 left, 3 right None Endoscopic retrograde stent placement 76.5 (13/17) 100 (13/13) 13 stent free, no ureteric stricture Chen, 2019 [ 11 ] 12 - - None Endoscopic antegrade/retrograde stent placement 91.7 (11/12) 100 (11/11) 10 stent free, 1 ureteric stricture Mohammad, 2014 [ 15 ] 1 24 left Stent placement Memokath stent placement 100 (1/1) 100 (1/1) Regular stent replacement Present study 4 47 (35–54) 2 left, 2 right 1 ureteral reimplantation, 1 stent placement and nephrostomy, 1 stent placement, 1 ureteroscopic cauterization and stent placement AlliumTM stent placement 100 (4/4) 100 (4/4) 4 stent free, no ureteric stricture UVF, ureterovaginal fistula Case presentation A 35-year-old female with endometriosis referred to our hospital for development of UVF after laparoscopic abdominal and pelvic infiltrating endometriosis lesion resection + total hysterectomy, which was the third surgery she underwent for abdominal and pelvic infiltrative endometriosis. She received double-J stent placement initially and urine leakage didn’t disappear. Hydronephrosis and fever occurred afterwards, then nephrostomy was performed to control infection (Fig. 1 A). For her multiple abdominal and pelvic surgeries and residual lesion of infiltrating endometriosis, ureteral reconstruction surgery was extremely difficult to perform. The patient refused ureteral reconstruction surgery and agreed to receive Allium™ stent placement. Under spinal anesthesia, Allium™ stent (10mm/12cm) was retrogradely placed through ureteroscopy (Fig. 1 B). Urine leakage disappeared in two days after operation. During indwelling of Allium™ stent, she suffered fever related to urinary tract infection for several times. CT showed no aggravation of hydronephrosis, and symptoms relieved after antibiotic treatment (Fig. 1 C). Allium™ stent was removed after 16 months. Contemporary ureteroscopy showed no ureteral stricture or fistula (Fig. 2 A). Retrograde pyelography showed no extravasation of contrast (Fig. 2 B). Methylene blue saline solution was injected through ureteroscope, the gauze placed in vagina was not stained blue (Fig. 2 C). A double-J stent was indwelled sequentially and removed after 1 month. Two months after the removal of double-J stent, there was no relapse of urine leakage and ultrasound showed the hydronephrosis was stable (Fig. 2 D). Discussion Most of UVF is iatrogenic, about 53%-94.7% cases are due to due to gynecological surgery, especially hysterectomy [ 2 , 5 ]. And the incidence of UVF developed after gynecological surgery is about 0.5% -2.5% [ 6 ]. The treatment of UVF includes endoscopic treatment and ureteral reconstruction surgery. Endoscopic treatment mainly refers to placement of double-J stent. Due to its minimal invasiveness and fewer complications, indwelling double-J stent has been initial attempt to treat UVF. But the success rate was reported inconsistent, 71%-100% of the patients gained disappearance of urine leakage, but long-term follow-up showed that 9%-38% of the patients developed ureteral stricture, for whom permanent indwelling of double-J stent or ureteral reconstruction surgery was needed [ 7 – 11 ]. Li et al reported endoscopic treatment of UVF with a relatively large sample, a total of 46 patients were included, the results showed that double-J stent was successfully placed in 45 patients (97.8%) and all of them got free of urine leakage. But long-term follow-up showed that only 16 patients (35%) gained stent-free, the remaining 29 patients had to indwell double-J stent permanently [ 12 ]. The review of literatures about endoscopic treatment of UVF was shown in Table 2 [ 7 – 13 , 15 ]. Ureteral reconstruction surgery is the definitive treatment for UVF, the primary surgical manner is ureteral reimplantation, psoas hitch and boari flap could be used depends on situations. The surgery could be performed in minimally invasive pattern such as laparoscopic or robotic, with a success rate of almost 100% [ 3 – 5 , 14 ]. Although UVF is a non-fatal disease, it brings severe psychological and social disorders to women [ 2 ]. Psychological stress is much greater for patients who have experienced failed treatment in the past. All of the patients in this study had received unsuccessful treatment previously, including endoscopic treatment in 3 cases and ureteral reimplantation in 1 case. And some of them had history of abdominal or pelvic surgery. Therefore, the following treatment would be challenging for this “refractory” UVF. On the one hand, traditional endoscopic treatment with conventional stent has proven to be ineffective. On the other hand, due to adhesion caused by previous ureteral reimplantation or pelvic surgery, ureteral reconstruction surgery would be extremely difficult, and the result was uncertain. Some special stents were reported to treat refractory UVF. Mohammad et al reported a patient who underwent placement of Memokath™ stent to treat UVF after failed treatment by double-J stent, urine leakage disappeared soon after operation [ 15 ]. Allium™ stent is a covered self-expanding mental stent, whose unique structure is conducive to treat UVF. Specifically, unlike double-J stent whose main function is urine drainage, the membrane structure of Allium™ stent can seal the fistula, isolate the urine and wound surface, therefore promote the growth of fistula. Additionally, the large diameter of Allium™ stent enables adequate drain of urine as well as adequate sustain of ureteral wall, which can minimize the occurrence of ureteral stricture caused by inflammation. However, treatment of UVF with Allium™ stent was seldomly reported, and this study is the first report of treating refractory UVF with Allium™ stent. The primary results showed that this treatment was feasible and safe. Firstly, urine leakage disappeared soon postoperatively with no major complications (MCCS III Ⅳ) occurred. Secondly, long-term results showed that fistula healed well and no ureteral stricture developed after removal of Allium™ stent. For this study only enrolled patients with refractory UVF, traditional treatment was proven ineffective or would be severe difficult to perform, patients were “compelled” to try the treatment with Allium™ stent, thus the sample was quite small. Additionally, whether Allium™ stent is suitable for initial treatment of UVF remains unclear, further research is needed to clarify. Finally, due to relative short follow-up, long-term results are waiting to be verified. Conclusions Our initial experience demonstrates that it is feasible and safe to treat refractory UVF with Allium™ stent, and it will be an effective supplement to traditional treatment. However, further studies with larger sample and longer follow-up are required. Whether Allium™ stent is suitable for initial treatment of UVF is also needed to research. Declarations Disclosure of potential conflicts of interest The authors declare that they have no conflict of Interest. Research involving Human Participants and/or Animals None Informed content Informed consent was signed by the patients for the publication of related images and this report. Author Contribution LZ An: Data collection and Manuscript writingH Hu: Project development and manuscript editingMR Wang: Data collectionHR Wang: Data managementQ Wang: Data analysisKX Xu: Project developmentT Xu: Project development References Likic IS, Kadija S, Ladjevic NG, et al. Analysis of urologic complications after radical hysterectomy. Am J Obstet Gynecol 2008;199:641–44. Bahuguna G, Panwar VK, Mittal A, et al. Management strategies and outcome of ureterovaginal fistulae: A systematic review and meta-analysis. Neurourol Urodyn 2022;41:562–72. Ramalingam M, Senthil K, Venkatesh V. Laparoscopic repair of ureterovaginal fistula: successful outcome by laparoscopic ureteral reimplantation. J Endourol 2005;19:1174–76. Yuan C, Wang J, Cheng S, et al. Robotic ureteral reimplantation for the management of ureterovaginal fistula: four cases at a single center. Transl Androl Urol 2021;10:3705–13. Yu S, Wu H, Xu L, Li G, Zhang Z. Early surgical repair of iatrogenic ureterovaginal fistula secondary to gynecologic surgery. Int J Gynaecol Obstet 2013;123:135–38. Gilmour DT, Dwyer PL, Carey MP. Lower urinary tract injury during gynecologic surgery and its detection by intraoperative cystoscopy. Obstet Gynecol 1999;94:883–89. Kumar A, Goyal NK, Das SK, Trivedi S, Dwivedi US, Singh PB. Our experience with genitourinary fistulae. Urol Int 2009;82:404–10. Shaw J, Tunitsky-Bitton E, Barber MD, Jelovsek JE. Ureterovaginal fistula: a case series. Int Urogynecol J 2014;25:615–21. Rabani SM, Rabani S. Early detection and endoscopic management of post cesarean section ureterovaginal fistula: a case series study. Int Urogynecol J 2021;32:2537–41. Rajamaheswari N, Chhikara AB, Seethalakshmi K. Management of ureterovaginal fistulae: an audit. Int Urogynecol J 2013;24:959–62. Chen YB, Wolff BJ, Kenton KS, Mueller ER. Approach to Ureterovaginal Fistula: Examining 13 Years of Experience. Female Pelvic Med Reconstr Surg 2019;25:e7-11. Li X, Wang P, Liu Y, Liu C. Minimally invasive surgical treatment on delayed uretero-vaginal fistula. BMC Urol 2018;18:96. Tsai CK, Taylor FC, Beaghler MA. Endoscopic ureteroureterostomy: long-term followup using a new technique. J Urol 2000;164:332–35. Gellhaus PT, Bhandari A, Monn MF, et al. Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes. BJU Int 2015;115:430–36. Mohammad W, Fode MM, Azawi NH. Treatment of ureterovaginal fistula using a Memokath stent. BMJ Case Rep 2014;2014. Table 1 Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files table1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4069331","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":278315377,"identity":"61b9da94-e460-4c27-89a7-7794a0bc890b","order_by":0,"name":"Lizhe An","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAqUlEQVRIiWNgGAWjYFCCBMYDDBUScvykaGE4wHDGwliygSQtjG0ViRuI1sJ3PPnBwZ/zJBg3MDA/fHSDGC2SZ54ZHJDcJsFszsBmbJxDjBaDGwkGBwy3SbBZNvCwSROpJf3DgcQ5EjwGB4jXkmNw4GCDhATxWiTPvCk42HBMwkCymVi/8B1P3/jwR01dfT9788PHRGkBxiMUMBOlHEXLKBgFo2AUjAJcAAAETTTvvWvcxwAAAABJRU5ErkJggg==","orcid":"","institution":"Peking University People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Lizhe","middleName":"","lastName":"An","suffix":""},{"id":278315378,"identity":"a245efee-1563-4b94-9405-3fd92d8ed74b","order_by":1,"name":"Mingrui Wang","email":"","orcid":"","institution":"Peking University People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mingrui","middleName":"","lastName":"Wang","suffix":""},{"id":278315379,"identity":"6e3caf66-073f-47f6-b9b2-4585936b11d5","order_by":2,"name":"Huanrui Wang","email":"","orcid":"","institution":"Peking University People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Huanrui","middleName":"","lastName":"Wang","suffix":""},{"id":278315380,"identity":"0274a419-fab3-4621-a6a9-1b8f2ccd2b3a","order_by":3,"name":"Qi Wang","email":"","orcid":"","institution":"Peking University People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qi","middleName":"","lastName":"Wang","suffix":""},{"id":278315381,"identity":"57c763b6-56b4-43fe-83e1-9d19e33efa1b","order_by":4,"name":"Kexin Xu","email":"","orcid":"","institution":"Peking University People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kexin","middleName":"","lastName":"Xu","suffix":""},{"id":278315383,"identity":"4ca029a8-c288-4839-ac0e-2cc8f54576cd","order_by":5,"name":"Tao Xu","email":"","orcid":"","institution":"Peking University People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Xu","suffix":""},{"id":278315384,"identity":"1609538e-ad04-4914-9f26-4aad1da55714","order_by":6,"name":"Hao Hu","email":"","orcid":"","institution":"Peking University People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2024-03-11 03:37:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4069331/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4069331/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52624817,"identity":"d1e0028e-f801-4163-aeb5-107d00294c28","added_by":"auto","created_at":"2024-03-13 17:31:16","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":137303,"visible":true,"origin":"","legend":"\u003cp\u003eA: Ultrasound showed hydronephrosis developed, although double-J stent was placed. B: Postoperative KUB showed that Allium\u003csup\u003eTM\u003c/sup\u003e stent was located in lower left ureter. C: Hydronephrosis of left kidney was relieved after placement of Allium\u003csup\u003eTM\u003c/sup\u003e stent.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4069331/v1/6ea5a062ffcdc79f469d235e.jpeg"},{"id":52624818,"identity":"46b79fdf-8e4b-4e7e-8038-9e394a6d26bc","added_by":"auto","created_at":"2024-03-13 17:31:16","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":283635,"visible":true,"origin":"","legend":"\u003cp\u003eA: Contemporary ureteroscopy after removal of Allium\u003csup\u003eTM\u003c/sup\u003e stent showed that the fistula healed well and there was no ureteral stricture despite edema of mucusa. B: Contemporary retrograde ureterography after removal of Allium\u003csup\u003eTM\u003c/sup\u003e stent showed no obstruction of ureter and no extravasation of contrast (white arrow). C: Contemporary “methylene blue test” found no blue stain on gauze (yellow frame). D: Although ultrasound showed hydronephrosis of left kidney in 2 months after the removal of double-J stent, the hydronephrosis was stable and was relieved comparing to preoperative image.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4069331/v1/004206a0919814ab2b058d09.jpeg"},{"id":52789255,"identity":"2a4ca859-6174-4d1e-ad93-9206077bff6c","added_by":"auto","created_at":"2024-03-15 19:45:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":343027,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4069331/v1/ba775dc9-4038-447f-a367-0eb020ce567c.pdf"},{"id":52624816,"identity":"8d11ba1a-732e-4ad5-a24b-d93f85584b24","added_by":"auto","created_at":"2024-03-13 17:31:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":28830,"visible":true,"origin":"","legend":"","description":"","filename":"table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4069331/v1/28559a899e8e99b12f18b0b7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Initial experience for treatment of refractory ureterovaginal fistula using self-expandable metal stent (Allium TM stent): a report of four cases and review of literatures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUreterovaginal fistula (UVF) is a kind of urogenital fistula, which indicates an abnormal channel between ureter and vagina. The main manifestation of UVF is incontinent leakage of urine from vagina, thus the quality of patient\u0026rsquo;s life is greatly impaired. Almost all of the UVF cases result from iatrogenic injury, mainly secondary to hysterectomy, for which the incidence of postoperative UVF is about 2.43% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The treatment of UVF includes endoscopic treatment and ureteral reconstruction surgery. Traditional endoscopic treatment is placement of ureteral stent, but the success rate is quite low, failure of stent insertion occurs in up to 63.1% of patients [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. For ureteral reconstruction to treat UVF, the most prevalent surgery is ureteral implantation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, a special group of patients should be paid extra attention, they have received previous treatment for UVF or have undergone pelvic surgery. We define the UVF in these patients as refractory UVF. Therefore, the treatment may be challenging. On the one hand, traditional endoscopic treatment has been proven ineffective. On the other hand, adhesions and anatomical changes caused by previous treatment make it extremely difficult to perform ureteral reconstruction surgery. We applied a kind of self-expandable metal stent (Allium\u0026trade; stent) to treat refractory UVF and all patients gained disappearance of urine leakage and stent-free. The initial experience and literature review were reported as follows.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eClinical data\u003c/p\u003e \u003cp\u003eFrom May 2019 to June 2021, a total of 4 patients with refractory UVF were treated by endoscopic placement of Allium\u0026trade; stent, which was performed by one surgeon. The four patients\u0026rsquo; demographic and perioperative data were retrospectively reviewed, including history of present illness, previous treatment, operative time, postoperative complications and follow-up data. This study was approved by the Ethics Committee of Peking University People's Hospital, and informed consent was obtained from all patients.\u003c/p\u003e \u003cp\u003ePresurgical evaluation\u003c/p\u003e \u003cp\u003eThe diagnosis of UVF was primarily established according to history of surgery and urine leakage from vagina, and was confirmed by intravenous pyelography, CTU and cystoscopy. Intravenous pyelography could find the extravasation of contrast from the lower ureter to projective area of vagina. CTU could show hydronephrosis caused by ureteral obstruction and extravasation of contrast from lower ureter into vagina. Cystoscopy was used to exclude the coexistence of vesicovaginal fistula. The indications for Allium\u0026trade; stent placement were following: 1) Failure of previous ureteral reconstruction 2) History of abdominal and pelvic surgery, which made ureteral reconstruction surgery extremely difficult 3) Persistent urine leakage during indwelling of double-J stent 4) The patient rejected palliative treatment such as nephrostomy. Urine culture and urine analysis were conducted preoperatively to confirm whether urinary tract infection was existent. The infection should be controlled before surgery.\u003c/p\u003e \u003cp\u003eSurgical techniques\u003c/p\u003e \u003cp\u003eAfter spinal or general anesthesia, the patient was placed in lithotomy position. Ureteral lumen was explored by ureteroscope under guidance of a guide wire. Location of fistula, length of lesion, and presence of ureteral stricture were confirmed. No ureteral atresia was found in all patients, thus the guide wire could pass through the lesion and reach into renal pelvis, which was confirmed by X-ray. Ureteral catheter was inserted along the guide wire and retrograde pyelography was performed. The location and length of lesion was reconfirmed by X-ray, affected ureter lesion was dilated by 21F balloon under X-ray monitoring. Dilation of ureter was confirmed by ureteroscope. Then 10mm/12cm Allium\u0026trade; stent was placed, the upper edge exceeded the lesion, and the lower edge was exposed in the bladder, about 1cm beyond the ureteral orifice. A double-J stent was placed within the lumen of Allium\u0026trade; stent.\u003c/p\u003e \u003cp\u003ePostoperative care and follow-up\u003c/p\u003e \u003cp\u003eInfection and urine leakage were closely observed postoperatively. Complications were assessed by Modified Clavien-Dindo Classification System (MCCS). Double-J stent was removed 1 month after operation. Ultrasound, KUB, biochemical examination, urine analysis and urine culture were conducted in 1, 3, 6 months after removal of double-J stent and then every 6 months. Antibiotics should be given when urinary tract infection occurred, dislocation or encrustation of stent would also be treated timely.\u003c/p\u003e \u003cp\u003eRemoval of Allium\u0026trade; stent and effect evaluation\u003c/p\u003e \u003cp\u003eAllium\u0026trade; stent indwelt for 1\u0026ndash;2 years. Ureteroscopy was conducted after removal of Allium\u0026trade; stent. Retrograde urography or methylene blue test was used to confirm closure of fistula if necessary. Then a double-J stent was placed and removed after one month. Nephrosis was evaluated by ultrasound. Success was defined as relief or stability of nephrosis and disappearance of urine leakage.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOverall results\u003c/p\u003e \u003cp\u003eThe mean age of the patients was 47 years (35–54), and the mean BMI was 23.5kg/m2 (18.4–31.1). All patients developed UVF after gynecological surgery and had received previous treatment before admitting to our hospital. The primary diseases and corresponding gynecological surgeries were described detailly in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. All patients underwent CTU or IVU, extravasation of contrast from lower ureter to vagina was showed. The mean time from onset of UVF to placement of Allium™ stent was 8 month (4–16).\u003c/p\u003e \u003cp\u003eAllium™ stent was retrogradely placed in all patients. The mean operative time was 36 minutes (26–50). No high grade (MCCS Ⅲ or Ⅳ) complications occurred postoperatively. No patients suffered infectious complications such as fever. Urine leakage disappeared within 1–2 days postoperatively. The mean postoperative hospital stay was 2 days (1–4).\u003c/p\u003e \u003cp\u003eAllium™ stent was finally removed in all patients. The mean indwelling time was 17 months (12–23). One patient suffered repeated fever resulted from urinary tract infection with no sign of hydronephrosis in ultrasound. The symptoms were relieved after antibiotic treatment. The mean follow-up after Allium™ stent removal was 9 months (1–22). No relapse of urine leakage occurred and hydronephrosis was relived or stabilized. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of literatures about endoscopic treatment of UVF\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, year\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean age (range), years\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSides\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrevious treatment\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSurgical manner\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSuccess rate of surgery, %\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRate of urine leakage relief\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLong-term result\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTsai, 2000 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEndoscopic ureteroureterostomy\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100 (3/3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100 (3/3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLi, 2018 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.5 (34–53)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 left, 19 right\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEndoscopic stent placement or ureteral realignment\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e97.8 (45/46)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100 (45/45)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16 stent free, 29 regular stent replacement\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKumar, 2009 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCystoscopic stent placement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100 (8/8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100 (8/8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3 ureteric stricture\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRabani, 2021 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.5 (21–42)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 left, 3 right\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUreteroscopic stent placement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e75 (6/8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100 (6/6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6 stent free, no ureteric stricture\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShaw, 2014 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 left, 6 right\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEndoscopic antegrade/retrograde stent placement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e53.8 (7/13)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e71.4 (5/7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5 stent free, no ureteric stricture\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRajamaheswari, 2013 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.5 (23–46)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 left, 3 right\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEndoscopic retrograde stent placement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e76.5 (13/17)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100 (13/13)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13 stent free, no ureteric stricture\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChen, 2019 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEndoscopic antegrade/retrograde stent placement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e91.7 (11/12)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100 (11/11)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e10 stent free, 1 ureteric stricture\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMohammad, 2014 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eleft\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStent placement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMemokath stent placement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100 (1/1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100 (1/1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRegular stent replacement\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent study\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (35–54)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 left, 2 right\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 ureteral reimplantation, 1 stent placement and nephrostomy, 1 stent placement, 1 ureteroscopic cauterization and stent placement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAlliumTM stent placement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100 (4/4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100 (4/4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4 stent free, no ureteric stricture\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eUVF, ureterovaginal fistula\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 35-year-old female with endometriosis referred to our hospital for development of UVF after laparoscopic abdominal and pelvic infiltrating endometriosis lesion resection + total hysterectomy, which was the third surgery she underwent for abdominal and pelvic infiltrative endometriosis. She received double-J stent placement initially and urine leakage didn’t disappear. Hydronephrosis and fever occurred afterwards, then nephrostomy was performed to control infection (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). For her multiple abdominal and pelvic surgeries and residual lesion of infiltrating endometriosis, ureteral reconstruction surgery was extremely difficult to perform. The patient refused ureteral reconstruction surgery and agreed to receive Allium™ stent placement. Under spinal anesthesia, Allium™ stent (10mm/12cm) was retrogradely placed through ureteroscopy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Urine leakage disappeared in two days after operation. During indwelling of Allium™ stent, she suffered fever related to urinary tract infection for several times. CT showed no aggravation of hydronephrosis, and symptoms relieved after antibiotic treatment (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). Allium™ stent was removed after 16 months. Contemporary ureteroscopy showed no ureteral stricture or fistula (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Retrograde pyelography showed no extravasation of contrast (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Methylene blue saline solution was injected through ureteroscope, the gauze placed in vagina was not stained blue (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). A double-J stent was indwelled sequentially and removed after 1 month. Two months after the removal of double-J stent, there was no relapse of urine leakage and ultrasound showed the hydronephrosis was stable (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMost of UVF is iatrogenic, about 53%-94.7% cases are due to due to gynecological surgery, especially hysterectomy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. And the incidence of UVF developed after gynecological surgery is about 0.5% -2.5% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe treatment of UVF includes endoscopic treatment and ureteral reconstruction surgery. Endoscopic treatment mainly refers to placement of double-J stent. Due to its minimal invasiveness and fewer complications, indwelling double-J stent has been initial attempt to treat UVF. But the success rate was reported inconsistent, 71%-100% of the patients gained disappearance of urine leakage, but long-term follow-up showed that 9%-38% of the patients developed ureteral stricture, for whom permanent indwelling of double-J stent or ureteral reconstruction surgery was needed [\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Li et al reported endoscopic treatment of UVF with a relatively large sample, a total of 46 patients were included, the results showed that double-J stent was successfully placed in 45 patients (97.8%) and all of them got free of urine leakage. But long-term follow-up showed that only 16 patients (35%) gained stent-free, the remaining 29 patients had to indwell double-J stent permanently [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The review of literatures about endoscopic treatment of UVF was shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e[\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Ureteral reconstruction surgery is the definitive treatment for UVF, the primary surgical manner is ureteral reimplantation, psoas hitch and boari flap could be used depends on situations. The surgery could be performed in minimally invasive pattern such as laparoscopic or robotic, with a success rate of almost 100% [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough UVF is a non-fatal disease, it brings severe psychological and social disorders to women [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Psychological stress is much greater for patients who have experienced failed treatment in the past. All of the patients in this study had received unsuccessful treatment previously, including endoscopic treatment in 3 cases and ureteral reimplantation in 1 case. And some of them had history of abdominal or pelvic surgery. Therefore, the following treatment would be challenging for this \u0026ldquo;refractory\u0026rdquo; UVF. On the one hand, traditional endoscopic treatment with conventional stent has proven to be ineffective. On the other hand, due to adhesion caused by previous ureteral reimplantation or pelvic surgery, ureteral reconstruction surgery would be extremely difficult, and the result was uncertain.\u003c/p\u003e \u003cp\u003eSome special stents were reported to treat refractory UVF. Mohammad et al reported a patient who underwent placement of Memokath\u0026trade; stent to treat UVF after failed treatment by double-J stent, urine leakage disappeared soon after operation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAllium\u0026trade; stent is a covered self-expanding mental stent, whose unique structure is conducive to treat UVF. Specifically, unlike double-J stent whose main function is urine drainage, the membrane structure of Allium\u0026trade; stent can seal the fistula, isolate the urine and wound surface, therefore promote the growth of fistula. Additionally, the large diameter of Allium\u0026trade; stent enables adequate drain of urine as well as adequate sustain of ureteral wall, which can minimize the occurrence of ureteral stricture caused by inflammation.\u003c/p\u003e \u003cp\u003eHowever, treatment of UVF with Allium\u0026trade; stent was seldomly reported, and this study is the first report of treating refractory UVF with Allium\u0026trade; stent. The primary results showed that this treatment was feasible and safe. Firstly, urine leakage disappeared soon postoperatively with no major complications (MCCS III Ⅳ) occurred. Secondly, long-term results showed that fistula healed well and no ureteral stricture developed after removal of Allium\u0026trade; stent.\u003c/p\u003e \u003cp\u003eFor this study only enrolled patients with refractory UVF, traditional treatment was proven ineffective or would be severe difficult to perform, patients were \u0026ldquo;compelled\u0026rdquo; to try the treatment with Allium\u0026trade; stent, thus the sample was quite small. Additionally, whether Allium\u0026trade; stent is suitable for initial treatment of UVF remains unclear, further research is needed to clarify. Finally, due to relative short follow-up, long-term results are waiting to be verified.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur initial experience demonstrates that it is feasible and safe to treat refractory UVF with Allium\u0026trade; stent, and it will be an effective supplement to traditional treatment. However, further studies with larger sample and longer follow-up are required. Whether Allium\u0026trade; stent is suitable for initial treatment of UVF is also needed to research.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDisclosure of potential conflicts of interest\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflict of Interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eResearch involving Human Participants and/or Animals\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/p\u003e\u003ch2\u003e \u003cb\u003eInformed content\u003c/b\u003e \u003c/h2\u003e \u003cp\u003e Informed consent was signed by the patients for the publication of related images and this report.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLZ An: Data collection and Manuscript writingH Hu: Project development and manuscript editingMR Wang: Data collectionHR Wang: Data managementQ Wang: Data analysisKX Xu: Project developmentT Xu: Project development\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLikic IS, Kadija S, Ladjevic NG, et al. Analysis of urologic complications after radical hysterectomy. Am J Obstet Gynecol 2008;199:641\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahuguna G, Panwar VK, Mittal A, et al. Management strategies and outcome of ureterovaginal fistulae: A systematic review and meta-analysis. Neurourol Urodyn 2022;41:562\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamalingam M, Senthil K, Venkatesh V. Laparoscopic repair of ureterovaginal fistula: successful outcome by laparoscopic ureteral reimplantation. J Endourol 2005;19:1174\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan C, Wang J, Cheng S, et al. Robotic ureteral reimplantation for the management of ureterovaginal fistula: four cases at a single center. Transl Androl Urol 2021;10:3705\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu S, Wu H, Xu L, Li G, Zhang Z. Early surgical repair of iatrogenic ureterovaginal fistula secondary to gynecologic surgery. Int J Gynaecol Obstet 2013;123:135\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGilmour DT, Dwyer PL, Carey MP. Lower urinary tract injury during gynecologic surgery and its detection by intraoperative cystoscopy. Obstet Gynecol 1999;94:883\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar A, Goyal NK, Das SK, Trivedi S, Dwivedi US, Singh PB. Our experience with genitourinary fistulae. Urol Int 2009;82:404\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaw J, Tunitsky-Bitton E, Barber MD, Jelovsek JE. Ureterovaginal fistula: a case series. Int Urogynecol J 2014;25:615\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRabani SM, Rabani S. Early detection and endoscopic management of post cesarean section ureterovaginal fistula: a case series study. Int Urogynecol J 2021;32:2537\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajamaheswari N, Chhikara AB, Seethalakshmi K. Management of ureterovaginal fistulae: an audit. Int Urogynecol J 2013;24:959\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen YB, Wolff BJ, Kenton KS, Mueller ER. Approach to Ureterovaginal Fistula: Examining 13 Years of Experience. Female Pelvic Med Reconstr Surg 2019;25:e7-11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi X, Wang P, Liu Y, Liu C. Minimally invasive surgical treatment on delayed uretero-vaginal fistula. BMC Urol 2018;18:96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsai CK, Taylor FC, Beaghler MA. Endoscopic ureteroureterostomy: long-term followup using a new technique. J Urol 2000;164:332\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGellhaus PT, Bhandari A, Monn MF, et al. Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes. BJU Int 2015;115:430\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohammad W, Fode MM, Azawi NH. Treatment of ureterovaginal fistula using a Memokath stent. BMJ Case Rep 2014;2014.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ureterovaginal fistula, Refractory, Endoscopic, Allium™ stent","lastPublishedDoi":"10.21203/rs.3.rs-4069331/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4069331/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo report our initial experience in the treatment of refractory ureterovaginal fistula (UVF) with Allium\u0026trade; stent, and to review related literatures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFrom May 2019 to June 2021, four patients with refractory UVF were treatment with Allium\u0026trade; stent in our department. Refractory UVF was defined as failure of previous treatment and the patient was not suitable for open or laparoscopic surgery. The process was described as follows, the affected ureter was dilated with balloon followed by placement of Allium\u0026trade; stent, the stent was finally removed and stent-free was achieved. The perioperative and follow-up data were reviewed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eUVF of these four patients was developed after gynecological surgery. All patients had received previous treatment, including ureteral reimplantation in one patient and endoscopic treatment in three patients. The mean age of patients was 47 (35\u0026ndash;54) years. The mean time from fistula diagnosis to Allium\u0026trade; stent placement was 8 (4\u0026ndash;16) months. The mean operative time was 36 (25\u0026ndash;50) minutes. All of four patients was confirmed of ureteral stricture intraoperatively. Leakage of urine was disappeared within two days in all patients. No high grade (MCCS Ⅲ or Ⅳ) complications was occurred postoperatively. The mean indwelling time of Allium\u0026trade; stent was 17 (12\u0026ndash;23) months and the mean stent-free follow-up removal was 9 (1\u0026ndash;22) months. No patients developed recurrence of leakage or ureteral stricture.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur initial results and experience showed that it is safe and feasible to treat refractory UVF with Allium\u0026trade; stent. The long-term follow-up results still need to be verified.\u003c/p\u003e","manuscriptTitle":"Initial experience for treatment of refractory ureterovaginal fistula using self-expandable metal stent (Allium TM stent): a report of four cases and review of literatures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-13 17:31:11","doi":"10.21203/rs.3.rs-4069331/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"06e58bd1-bb38-41bd-bf14-7852b6aaed90","owner":[],"postedDate":"March 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-15T19:44:45+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-13 17:31:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4069331","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4069331","identity":"rs-4069331","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}