A guidewire introducer as a ureteral foreign body: A case report

Abstract

A 63-year-old male, previously treated for a ureteral tumour by a right-sided segmental ureterectomy and end-to-end anastomosis of ureteral segments, was referred to our clinic for endoscopic follow-up. During his follow-up, he was diagnosed with partial right-sided ureteral stricture which eventually progressed to complete obstruction. During the ureteroscopy, as the stenotic segment did not allow passage of an hydrophilic guidewire, an antegrade-retrograde approach was decided. On the antegrade endoscopic view, a near-complete stenosis was diagnosed and a nephrostomy catheter (12 Fr) was placed. A second intervention was planned and from the nephrostomy tract, the ureteroscope was placed into the right pyelocaliceal system. The diagnostic ureteroscopy revealed a foreign object proximal to the stenotic area. Right-sided segmental ureterectomy of the stenotic segment with ureteroneocystostomy and removal of the foreign object was performed. This is the only case in literature to reveal a guidewire introducer as a ureteral foreign body. This case also highlights the importance of the fragility of the ureter, the importance of the equipment, of always being watchful during a surgery, and the importance of checking the integrity of the equipment at the end of each procedure.

Introduction

Foreign bodies in the urinary tract are very rare and mostly follow bodies.^1–7 The main problems with ureteral foreign bodies are infections and obstructions due to calcifications. We report an unusual case of ureteral foreign body along with ureteral stenosis.

Case report

A 63-year-old male was referred to our clinic for a 18-mm upper urinary tract tumour. In the past, he had a segmental right ureterectomy due to a right ureteral mass and right-sided end-to-end anastomosis of ureteral segments. During his routinely endoscopic follow-up in December 2011, right distal ureteral stenosis was discovered after the failure to insert a ureteral access sheath and a double J ureteral stent was placed in the right ureter.

In February 2012, an access sheath could not be introduced due to his right partial ureteral stenosis; therefore a double J ureteral stent was placed and left for 10 days. In June 2012, the right ureter could neither be catheterized with a stiff hydrophilic guidewire nor explored with flexible ureteroscope due to nearly-complete ureteral stenosis. The patient was then rescheduled 2 weeks later for a combined antegrade and retrograde approach. A stiff hydrophilic guidewire could not be introduced into the right ureteral orifice. Therefore, under ultrasonographic guidance, we punctured the right middle calyx and introduced a hydrophilic guidewire into the renal pelvis and then into the right ureter. The stenotic segment did not allow us to pass the guidewire into the bladder. The renal access tract was dilated up to 12 Fr with a Coloplast Retrace (Coloplast Inc.) ureteral access sheath 10/12 and flexible ureteroscope was introduced into the renal pelvis and ureter. The stenotic segment in the ureter did not allow passage of the ureteroscope, so a nephrostomy catheter (12 Fr) was placed.

In August 2012, the patient was re-hospitalized for the endoscopic re-evaluation and probable open segmental ureterectomy due to the intractable near-complete ureteral stenosis. A hydrophilic guidewire was placed from the nephrostomy tract into the right pyelocaliceal system and the tract was dilated up to 14 Fr via the Retrace ureteral access sheath 12/14. The URF-V Olympus flexible ureteroscope (Olympus Inc.) was introduced into the urinary tract, and the diagnostic ureteroscopy revealed a foreign object proximal to the stenotic area which was thought to be the introducer of the guidewire (Fig. 1). We decided to perform a right-sided segmental ureterectomy of the stenotic segment and to remove the foreign object. Through a right iliac incision, the right ureter was dissected and the stenotic ureteral segment and foreign object was excised. A ureteroneocystostomy was performed with a Lich-Gregoire anastomosis. A double J ureteral stent was placed in the right ureter and was removed 6 weeks later without complications.

Fig. 1.

The endoscopic view of the guidewire introducer.

Discussion

Ureteral foreign bodies are very rare cases and are usually due to suture materials inserted into the ureter mistakenly during other intraabdominal procedures. The symptoms are generally secondary to infections or obstruction due to calcification of the foreign material. The consequences may extend to renal infection with resulting pyonephrosis and sepsis.^1,2 Treatment consists of determining and removing the underlying cause and subsequent findings. The excision of the foreign body is necessary to establish a definive treatment. In our case, the foreign body was a guidewire introducer (Fig. 2), which was introduced inadvertently into the ureter during the first combined approach with the nephrostomy placement.

Fig. 2.

The guidewire introducer.

Guidewires are commonly used in various endoscopic interventions, and it is very rare to perform pathology treatment of the upper urinary tract without a guidewire (Fig. 3, Fig. 4). The importance depends on the easy manipulativity and fragility of the urinary tract. The precision and caution are key points in using this useful surgical equipment. As with inattentiveness, the redundancy of equipment interferes with good surgical outcomes. The guidewire introducer is an infrequently used element of the guidewire equipment and since this event, we have disregarded this unnecessary piece.

Fig. 3.

The guidewire sheath with and without the introducer.

Fig. 4.

The stabilization of the guidewire sheath to the drapes during ureteroscopy.

Ureteral integrity is one of the most important points in maintaining the blood flow of the ureter. When disrupted, due to ureteral ischemia, ureteral strictures may develop. Although rarely encountered, infectious pathologies, iatrogenic causes, ureteral stones, and their subsequent treatment via ureteroscopy and ureteral access sheaths are blamed for ureteral injury and subsequent ureteral strictures.^8–14 In this case, the ureteral strictrure was caused by segmental right ureterectomy and right-sided end-to-end anastomosis of ureteral segments. This procedure, although not the cause for the inadvertently foreign object insertion, was the starting point and also the consequent ureteral stricture was one of the main focuses of the surgical team.

With endourological advances, endoscopic management has become one of the most important treatment options for ureteral strictures. Corcoran and colleagues have demonstrated the success of endoscopic treatment via balloon dilatation and/or laser endoureterotomy in their series of 75 patients.^15–16 Also Emiliani and colleagues found that laser endoureterotomy was successful with minimal perioperative morbidity.¹⁶ Despite the reported success rates and low morbidities, endoscopic procedures require attention and a high level of expertise. As suggested by Traxer and colleagues, the ureteral integrity should be assessed at the end of each ureteroscopic procedure.¹⁷ Also, such as in open surgeries, at the end of the procedure, the integrity of all the equipment must be checked for any missing parts after endoscopic procedures.

Conclusion

This is the only case in literature to reveal a guidewire introducer as a ureteral foreign body. This case also highlights the importance of the fragility of the ureter, the importance of the equipment, of always being watchful during a surgery, and the importance of checking the integrity of the equipment at the end of each procedure.