Ileal Conduit as the Standard for Urinary Diversion After Radical Cystectomy for Bladder Cancer

Successful ureteral stent placement with rendezvous technique for ureteral obstruction after urinary diversion: A case report

Ureteral obstruction after urinary diversion is not a rare complication, and the treatment is generally the ureteral stent placement via antegrade approach via the nephrostomy. We present a case of 64-year-old man with history of total pelvic resection and urinary diversion for local recurrence of rectal cancer who presented bilateral ureteral obstruction due to postoperative adhesion. First, bilateral nephrostomies were performed. The antegrade approach via nephrostomy could not break through the obstruction in the left side. Therefore, antegrade and retrograde approaches were attempted, and the internal-external drainage catheter could be placed by the rendezvous technique using bilateral microcatheters and microguidewires. The patient was able to avoid a permanent nephrostomy and continues to undergo regular internal drainage catheter exchange. Permanent nephrostomy considerably reduces the patient's quality of life, and in cases of tight obstruction, rendezvous techniques can be used.

Long term outcomes and impact on renal function following radical cystectomy

INTRODUCTION

To assess clinical, oncological outcomes and impact on renal function in patients who underwent the radical cystectomy with pelvic lymphadenectomy for muscle invasive and high risk non-muscle invasive transitional cell carcinoma of urinary bladder without evidence of non-regional lymph nodes and distant metastasis.

MATERIALS AND METHODS

With curative intent total 156 patients underwent radical cystectomy with pelvic lymphadenectomy from January 2015 to December 2022. Total 132/156 patients had primary transitional cell carcinoma of bladder. Thirty patients, presented with obstructive nephropathy, operated after stabilization of renal function. Pre-operatively and post-operatively eGFR calculated using modified diet in renal disease formula.

RESULTS

In present study 114 (86.36%) patients had high grade TCC, 70 (53.02%) patients had organ confined disease. Nodal extension seen in 74 (56.06%) patients. Perioperative mortality noted in 36 (27.2%) patients. The overall survival and recurrence free survival (RFS) over 5 years was 66.67 and 45.45%. RFS was significantly related to pathological stage, nodal status, histological-grade, positivity of surgical margin and time of surgery from diagnosis. Total 92/132 (69.7%) patients had recurrence. Pelvic recurrence in 10/92 (10.87%) whereas 82/92 (89.13%) patients had distant recurrence. Pre-operatively mean creatinine was 2.6 mg/dl and mean eGFR was 38.9 ml/h in patients who presented with obstructive nephropathy after stabilization of renal function. Post-operatively in 46/132 (34.8%) patients had improvement in eGFR while 86/132 (65.2%) patients had deterioration of eGFR over 62 months of median follow up.

CONCLUSION

Radical cystectomy provides good overall survival outcomes. Pre-operative eGFR has significant impact on post-operative renal function in long term.

Migration of double-J ureteral stent in patients with ureteroileal anastomosis stricture undergoing radical cystectomy and orthotopic neobladder: Analysis risk factors of stent migration

The objective was to evaluate the incidence and degree of double-J ureteral stent (DJUS) migration. Additionally, we aimed to investigate the risk factors associated with stent migration in the orthotopic neobladder group. In this retrospective study, 61 consecutive patients were included; 35 patients (45 DJUS placements) underwent radical cystectomy with orthotopic neobladder and 26 patients (35 DJUS placements) underwent urinary bladder without cystectomy between July 2021 and March 2023. All the patients were treated with a DJUS for ureteric strictures. The technical success rate was 100% in each group. The DJUS migration was significantly higher in the orthotopic neobladder group, with 22 of 45 cases (48.9%), compared to the urinary bladder group, which had 4 of 35 cases (11.4%) (P ≤ .001). Among the patients in the orthotopic neobladder group who experienced DJUS migration, stent dysfunction occurred in 18 cases (81.8%), which was statistically significant (P = .003). Multivariate logistic regression analysis revealed that only the size of the DJUS was significantly and positively associated with migration (odds ratio:10.214, P = .010). DJUS migration can easily occur in patients undergoing radical cystectomy and orthotopic neobladder, and smaller stent sizes are associated with a higher incidence of migration.

Robot-assisted intracorporeal ileal conduit urinary diversion: A two-center comparative study of Bricker versus Wallace ureteroileal anastomosis

INTRODUCTION

This study was performed to evaluate the differences in the perioperative results, renal function, and incidence of hydronephrosis over time between the use of Bricker anastomosis and Wallace anastomosis for robot-assisted intracorporeal ileal conduit urinary diversion (RICIC).

METHODS

Fifty-five patients who underwent RICIC at two institutions were evaluated (Bricker, n = 23; Wallace, n = 32). We investigated changes in estimated glomerular filtration rate and hydronephrosis before surgery and at 3, 6, and 12 months after surgery.

RESULTS

The patients in the Bricker group were significantly older than those in the Wallace group. The urinary diversion time was significantly longer in the Bricker group. No significant difference in postoperative renal function was observed. Additionally, no significant difference was observed in the incidence of postoperative hydronephrosis. However, the incidence of right hydronephrosis tended to be high overall, especially in the Wallace group. No patients in either group required repair surgery or ureteral stent placement.

CONCLUSIONS

In patients undergoing RICIC, there was no difference in postoperative renal function or the incidence of hydronephrosis between Wallace and Bricker anastomosis. Symptomatic hydronephrosis was not observed in either group. The present study showed that each method was equally effective and safe.

Pitfalls in Urinary Tract Cytopathology

BACKGROUND

Urine cytopathology is a cost-effective method to diagnose and follow patients with high-grade urothelial carcinoma (UC). However, some benign, reactive, and metaplastic changes may mimic UC and pose a diagnostic challenge for cytopathologists.

SUMMARY

Our comprehensive review focuses on summarizing common pitfalls encountered in urine cytopathology, based on the 2nd edition of The Paris System (TPS) for reporting urinary tract cytopathology and other recent published literature. These pitfalls include urothelial tissue fragments, degenerative changes, treatment effects, viral cytopathic changes, iatrogenic and metaplastic changes. Our aim was to provide a clear understanding of these mimics in order to avoid diagnostic errors.

KEY MESSAGE

It is crucial for cytopathologists to recognize benign, reactive, or metaplastic lesions that sometimes resemble UC. An awareness of these cytological changes is essential to make an accurate diagnosis.

Ileal Conduit versus Cutaneous Ureterostomy after Open Radical Cystectomy: Comparison of 90-Day Morbidity and Tube Dependence at Intermediate Term Follow-Up

Background: This study aims to compare perioperative morbidity and drainage tube dependence following open radical cystectomy (ORC) with ileal conduit (IC) or cutaneous ureterostomy (CU) for bladder cancer. Methods: A single-center, retrospective cohort study of patients undergoing ORC with IC or CU urinary diversion between 2020 and 2023 was carried out. The 90-day perioperative morbidity, as per Clavien-Dindo (C.D.) complication rates (Minor C.D. I-II, Major C.D. III-V), and urinary drainage tube dependence (ureteral stent or nephrostomy tube) after tube-free trial were assessed. Results: The study included 56 patients (IC: 26, CU: 30) with a 14-month median follow-up. At 90 days after IC or CU, the frequencies of any, minor, and major C.D. complications were similar (any-69% vs. 77%; minor-61% vs. 73%; major-46% vs. 30%, respectively, p > 0.2). Tube-free trial was performed in 86% of patients with similar rates of tube replacement (19% IC vs. 32% CU, p = 0.34) and tube-free survival at 12 months was assessed (76% IC vs. 70% CU, p = 0.31). Conclusions: Compared to the ORC+IC, ORC+CU has similar rates of both 90-day perioperative complications and 12-month tube-free dependence. CU should be offered to select patients as an alternative to IC urinary diversion after RC.

Stent-free rates in cutaneous ureterostomy urinary diversion after radical cystectomy

PURPOSE

Cutaneous ureterostomy (CU) urinary diversion after radical cystectomy has been relegated to highly comorbid patients due to presumed rates of stenosis and drainage tube dependence. Rates of stricture as high as 70% have been reported. Though a variety of techniques have been developed to obviate the need for prolonged stenting, CU remains uncommonly performed. Herein, we present our experience with CU diversion after radical cystectomy and stent-free rates post-operatively.

MATERIALS AND METHODS

We retrospectively reviewed the records of consecutive patients undergoing radical cystectomy with single-stoma cutaneous ureterostomy from June 2020 to December 2022 at our institution. Demographic and clinical data were summarized. We recorded the presence of ureteral stent, nephrostomy, or nephroureteral catheter at the last follow-up. The primary outcome was "stent-free survival" incorporating all modalities of tube-dependent urinary drainage. Kaplan-Meier analysis was performed to determine stent-free survival at 12 months.

RESULTS AND CONCLUSIONS

We identified 28 patients meeting inclusion criteria with median age of 73 years (IQR: 66-78) and median body mass index of 25 (IQR: 22-28). Of patients that underwent stent-free trial (N = 23), the stent-free survival at 12 months was 74%. Five of 28 patients had continued tube dependence due to locally advanced disease with hydronephrosis rather than CU stenosis. These results suggest that single-stoma CU should be considered a viable option for patients undergoing radical cystectomy. Longer follow-up is needed to assess durability of stent-free rates.

Ileal conduit versus single stoma uretero-cutanoustomy after radical cystectomy in patients ≥ 75 years; which technique is better? a prospective randomized comparative study

PURPOSE

To compare the clinical results and patients' health-related quality of life (HR-QoL) of ileal conduit (IC) versus single stoma uretero-cutanoustomy (SSUC) after radical cystectomy in two groups of randomly selected patients ≥ 75 years.

METHODS

From January 2013 to March 2018, 100 patients ≥ 75 years with muscle invasive BCa underwent RCX and cutaneous diversion. Patients were divided in two groups; group I underwent IC (50 patients) and group II underwent SSUC (50 patients). Postoperative evaluation included clinical, laboratory, radiographic and HR-QoL. The latter was performed using the Functional Assessment of Cancer Therapy-Bladder Cancer (FACT-BL) after 12 months postoperatively.

RESULTS

Patients' characteristics were comparable between both groups. No intraoperative complications occurred. Early postoperative complications occurred in 27 patients [16 (35.5%) in group I and 11 (23.9%) in group II (p = 0.02)]. Delayed postoperative complications occurred in 26 patients [6 (13.3%) in group I and 20 (43.4%) in group II, (P = 0.002)]. No significant differences between both groups regarding the physical, social/family, emotional, functional and additional concerns scales of FACT-BL questionnaire were reported.

CONCLUSION

SSUC is a good alternative to IC in elderly frail patients  ≥ 75 years and those with multiple comorbidities who require rapid surgery in terms of perioperative complications and HR-QoL. However, the stomal complications and the possibility of a frequent stent exchange are considered its drawbacks.

Renal function outcome after selective bladder-preserving tetramodality therapy consisting of maximal transurethral resection, induction chemoradiotherapy and consolidative partial cystectomy in comparison with radical cystectomy for patients with muscle-invasive bladder cancer: a two-centre retrospective study

OBJECTIVE

To compare renal function (RF) outcomes after bladder-preserving tetramodal therapy against muscle-invasive bladder cancer (MIBC) to those after radical cystectomy (RC).

METHODS

This study included 95 patients treated with tetramodal therapy consisting of transurethral bladder tumour resection, chemoradiotherapy and partial cystectomy (PC) and 300 patients treated with RC. The annual change in the estimated glomerular filtration rate (eGFR) was compared using the linear mixed model. Renal impairment was defined as a >25% decrease from the pretreatment eGFR, and renal impairment-free survival (RIFS) was calculated. The association between treatment type and renal impairment was assessed.

RESULTS

The number of patients who received neoadjuvant chemotherapy was 8 (8.4%) in the tetramodal therapy group and 75 (25.0%) in the RC group. After the inverse probability of treatment weighting adjustments, the baseline characteristics were balanced between the treatment groups. The mean eGFR before treatment in tetramodal therapy and RC groups was 69.4 and 69.6 mL/min/1.73 m2 and declined with a slope of -0.7 and -1.5 mL/min/1.73 m2/year, respectively. The annual deterioration rate of post-treatment eGFR in the tetramodal therapy group was milder than in the RC group. The 5-year RIFS rate in the tetramodal therapy and the RC groups was 91.2 and 85.2%, respectively. Tetramodal therapy was an independent factor of better RIFS compared with RC.

CONCLUSIONS

RF was better preserved after tetramodal therapy than after radical therapy; however, even after tetramodal therapy, the eGFR decreased, and a non-negligible proportion of patients developed renal impairment.

Management of gastro-intestinal emergencies in patients with ileal conduit ureteral diversion

Radical cystectomy with urinary deviation is performed increasingly in France. Ileal conduit ureteral diversion (ICUD), described by Bricker and widely used after this type of radical resection, leads to substantial anatomic modifications that are potential danger zones during subsequent gastro-intestinal or urinary tract operations. Injury to the urinary diversion apparatus can lead to disastrous complications in these patients who are often elderly and frail. General surgeons are most often called upon to re-operate these patients, either for an ICUD-related gastro-intestinal complication, or for an unrelated abdominal emergency that arises later (bowel obstruction, infection, cancer). During such operations, certain anatomic structures are particularly exposed to injury that may be irreversible, particularly, the mesentery of the ileal conduit and the left ureter. Approaching the right lower quadrant, the dissection of the ileo-ileal anastomosis or of the left mesocolon are the procedures or maneuvers that pose the most risk. A number of simple but effective preventive measures are available and must be known, such as to operate the patient with an urologist or to insert ureteral stents before surgery. Preoperative contrast-enhanced computed tomography with late phase urinary imaging is essential to assess the anatomic modifications and anticipate the operative procedural steps. Finally, one should not hesitate to disinsert the stoma and proceed with retrograde dissection, thus facilitating the identification of the ileal conduit, the mesentery and the ureters.

Reduction of Perioperative Antibiotic Prophylaxis in Open Radical Cystectomy with Ileal Conduit Is Feasible: Results of a Prospective Clinical Trial

Introduction

The aim of this study is to perform a prospective clinical trial in antibiotic prophylaxis, infectious complication, and colonization of ileal conduit (IC) following radical cystectomy (RC) since urinary tract infections (UTIs) and surgical site infections (SSIs) contribute significantly to the morbidity associated with RC and IC. Moreover, an optimal regimen of antibiotic prophylaxis has not been established, yet.

Material and Methods

After a positive vote of ethical review committee and the registration at the German Clinical Trials Register (DKRS 00020406), we started a prospective clinical unicentric not interventional study. The urine samples were collected by sterile catheterization of the IC. All patients received an antibiotic prophylaxis with 3 × 500 mg metronidazole and 3 × 1.5 g cefuroxime intravenously for 3 days starting on the day before RC. Ureteral stents got removed on days 9 and 10 after surgery without prior antibiotic administration. The student t test and the χ² test or the Fisher exact test were used. For risk factor assessment, the univariate Cox regression method was applied.

Results

Nineteen male (63.3%) and 11 female patients (36.7%) with a median age of 70.5 years were included. Three patients developed complicated UTI (10%) on day 12 after RC with E. faecium and needed antibiotic treatment with meropenem (Clavien-Dindo II). Two patients (6.7%) developed SSI with E. faecium and needed surgery (Clavien-Dindo IIIb). Palliative RC (p < 0.0001), prior radiation therapy (p < 0.0001), and timeframe >3 months from diagnosis to RC (p = 0.036) are significantly associated with the development of complicated UTI. Interestingly, the IC got colonized with Staph. haemolyticus at day 12 after RC (n = 12; 40.0%). We must assume that our data have some limitations like a unicentric study population.

Conclusion

Further evaluation of reduction to single-shot antibiotic prophylaxis in nonpalliative RC with IC could be feasible.

Setting standards for cystectomy using the British Association of Urological Surgeons Complex Operations Reports, 2016–2018

Objective:

To produce comprehensive standards for cystectomy using contemporary data collected across a nation.

Patients and methods:

Surgical departments upload cystectomy data to the British Association of Urological Surgeons (BAUS) Complex Operations Database. Analysis of 2016–2018 data was performed for all recorded 5288 patients undergoing cystectomy in England. Logistic regression with general linear models was used to assess differences in patient selection between operative modalities. Analysis involved assessment of case selection, operative decisions and outcomes, case volume and pathological outcomes.

Results:

Using national Hospital Episode Statistics, the BAUS cystectomy dataset was estimated 93% complete. Median age was 70 years (interquartile range 63–75) and 75% were male. Charlson comorbidity index ⩽2 was reported in 87%. Primary treatment of muscle-invasive bladder cancer accounted for 46% of cases. Commonest preoperative disease stages were T2N0 and T1N0 (35% and 25% respectively). Robotic-assisted (RAC), laparoscopic (LC) and open cystectomy (OC) were performed in 41%, 5.5% and 54% of cases respectively. T-stage distribution differed by operative modality. Transfusion rates were 3.7% for RAC, 6.0% for LC and 18% for OC. Increasing positive surgical margin rates were observed with increasing T-stage, up to T3. The conversion-to-open rate for minimally-invasive surgery was 1.7%. Median annual centre and surgeon case volumes were highest for RAC. Median length of stay was 7, 10 and 10 days for RAC, LC and OC respectively. Postoperative histological upstaging was common (33% of cT1, 50% of cT2 cases). Lymph node positive rates were 28% for muscle-invasive bladder cancer.

Conclusion:

Analysis of this data provides understanding of ‘real-world’ cystectomy practice. Presentation of data specific to operative modality allows surgeons and centres to benchmark their respective practices. These findings offer to enhance patient and public understanding beyond that currently facilitated by publicly-facing information sources. They carry relevance by describing a near-complete and large volume of modern practice in a publicly funded healthcare system.

Level of evidence:

2b

A modified ileal conduit technique in patients undergoing radical cystectomy: Single-centre experience

Objective:

We aimed to evaluate perioperative outcomes and complications of a modified technique of ileal conduit diversion.

Methods:

Forty-seven cases of radical cystectomy with modified ileal conduit diversion were performed at our institution from January 2015 to January 2020. After radical cystectomy, a segment of ileum was used to pack the conduit and was placed below the digestive anastomosis. Then, the mesentery window of the ileo-ileal anastomosis was sutured. The ureters were anastomosed on their native side on single loop ureteral stents. All procedures were performed by a single surgical team. Intra- and postoperative complications were classified and reported according to the Satava and Clavien–Dindo grading systems.

Results:

The mean age of population was 66.40±10.14 years, and 76.6% were male. Concomitant diabetes was found in 31.9% of patients. About three quarters of patients had T2G3 bladder cancer. Mean blood loss was 449.36±246.50 ml, and hospitalization was 10.32±5 days. With a mean follow-up of 17.36±12.63 months, the recurrence rate was 17%, and 14.9% of patients died of bladder cancer. Out of the 47 patients, three (4.3%) experienced intraoperative complications, while 15 (31.9%) had postoperative complications. Of these, only three patients experienced Clavien–Dindo complications ⩾grade 3. Multivariate logistic regression model showed that diabetes ( p=0.023) and higher blood loss ( p=0.010) were significantly associated with an increased risk of postoperative complications. We reported one case of ureterointestinal anastomosis stenosis on the left side and none on the right side. Despite our results being promising, larger randomized trials with longer follow-up are needed to explore further the feasibility of this technique on a larger scale.

Conclusion:

We describe a safe and simple surgical technique with a similar postoperative complications rate and a lower incidence of ureteroileal anastomosis stenosis compared to the standard technique.

Level of evidence

4.

A tissue-engineered urinary conduit in a porcine urinary diversion model

The use of an ileal segment is a standard method for urinary diversion after radical cystectomy. Unfortunately, utilization of this method can lead to numerous surgical and metabolic complications. This study aimed to assess the tissue-engineered artificial conduit for urinary diversion in a porcine model. Tissue-engineered tubular polypropylene mesh scaffolds were used for the right ureter incontinent urostomy model. Eighteen male pigs were divided into three equal groups: Group 1 (control ureterocutaneostomy), Group 2 (the right ureter-artificial conduit-skin anastomoses), and Group 3 (4 weeks before urostomy reconstruction, the artificial conduit was implanted between abdomen muscles). Follow-up was 6 months. Computed tomography, ultrasound examination, and pyelogram were used to confirm the patency of created diversions. Morphological and histological analyses were used to evaluate the tissue-engineered urinary diversion. All animals survived the experimental procedures and follow-up. The longest average patency was observed in the 3rd Group (15.8 weeks) compared to the 2nd Group (10 weeks) and the 1st Group (5.8 weeks). The implant's remnants created a retroperitoneal post-inflammation tunnel confirmed by computed tomography and histological evaluation, which constitutes urostomy. The simultaneous urinary diversion using a tissue-engineered scaffold connected directly with the skin is inappropriate for clinical application.

The development of marine biomaterial derived from decellularized squid mantle for potential application as tissue engineered urinary conduit

Tissue engineering is focusing research effort on search for new biomaterials that might be applied to create artificial urinary conduit. Nevertheless, the demanding biomechanical characteristics necessary for proper conduit function is difficult to be replicated. In this study, we are introducing novel marine biomaterial obtained by decellularization of squid mantle derived from Loligo vulgaris. Squid mantles underwent decellularization according to developed dynamic flow two-staged procedure. Efficacy of the method was confirmed by computational dynamic flow analysis. Subsequently Decellularized Squid Mantle (DSM) underwent extensive histological analysis and mechanical evaluation. Based on gained biomechanical data the computational modelling using finite element method was utilized to simulate behavior of DSM used as a urinary conduit. Taking into account potential application in reconstructive urology, the DSM was then evaluated as a scaffold for urothelial and smooth muscle cells derived from porcine urinary bladder. Conducted analysis showed that DSM created favorable environment for cells growth. In addition, due to polarized structure and natural external polysaccharide layer, it protected seeded cells from urine.

Complications of Ileal Conduits after Radical Cystectomy: Interventional Radiologic Management

Since their introduction into clinical practice in the 1950s, ileal conduits have been the most common type of urinary diversion used after radical cystectomy worldwide. Although ileal conduits are technically simpler to construct than other forms of urinary diversion, a variety of complications can occur in the early and late postoperative periods. Early complications include urine leakage, urinary obstruction, postoperative fluid collection (eg, urinoma, hematoma, lymphocele, or abscess), and fistula formation. Late complications include ureteroileal anastomotic stricture, stomal stenosis, conduit stenosis, and urolithiasis. Although not directly related to ileal conduits, ureteroarterial fistula can occur in patients with an ileal conduit. Interventional radiologists can play a pivotal role in diagnosis and management of these complications by performing image-guided minimally invasive procedures. In this article, the authors review the surgical anatomy of an ileal conduit and the underlying pathophysiology of and diagnostic workup for complications related to ileal conduits. The authors also discuss and illustrate current approaches to interventional radiologic management of these complications, with emphasis on a collaborative approach with urologists or endourologists to best preserve patients' renal function and maintain their quality of life. ^©RSNA, 2020.

Intracorporeal versus extracorporeal urinary diversion following robot-assisted radical cystectomy: a meta-analysis, cumulative analysis, and systematic review

Over the last decade, the increased utilization of robot-assisted radical cystectomy (RARC) in the surgical treatment of muscle-invasive bladder cancer has led to an uptrend in intracorporeal urinary diversions (ICUD). However, the operative results comparing ICUD to extracorporeal urinary diversion (ECUD) have varied widely. We performed a meta-analysis to analyze perioperative outcomes and complications of ICUD compared to ECUD following RARC. This study is registered at International Prospective Register of Systematic Reviews (PROSPERO) CRD42020164074. A systematic literature review was conducted using PubMed, EMBASE, and Cochrane databases in August 2019. A total of six studies comparing ICUD vs ECUD were identified and meta-analysis was conducted on these studies. In addition, a cumulative analysis was also performed on 83 studies that reported perioperative outcomes after RARC and ICUD or ECUD. The Weighed Mean Difference of operative time and blood loss between ICUD and ECUD group was (16; 95% confidence interval - 34 to 66) and (- 86; 95% confidence interval - 124 to - 48), respectively. ICUD and ECUD had comparable early (30-day) and mid-term (30-90-day) complication rate (RR 1.19; 95% confidence interval 0.71-2.0; p = 0.5) and (RR 0.91; 95% confidence interval 0.71-1.15 p = 0.4) respectively. In the 83 studies that were included in the cumulative analysis, the mean operative time for ileal conduit and neobladders by ICUD were 307 and 428 min, respectively, compared to ECUD 428 and 426 min, respectively. ICUD and ECUD have comparable short- and mid-term complication rate. The ICUD group has lower blood loss and lower rate of blood transfusion compared to ECUD.

A perioperative management to reduce rate of urinary tract infection for patient underwent radical cystectomy with ileal conduit diversion

BACKGROUND

Although radical cystectomy, as the standard surgical treatment for muscle-invasive bladder cancer patients, prolongs survival remarkably, there are postoperative complications associated with urinary diversion. This study aimed to explore the antibiotic prophylaxis, according to culture of single J stent and urine from patients underwent urinary diversion (ileal conduit), its capacity to reduce the rate of urinary tract infection (UTI).

METHODS

A total of 179 patients at Renji Hospital were reviewed in the study between Jan 2016 and June 2019. All patients included in this study were underwent radical cystectomy and ileal conduit. In Jan 2018, we enacted a quality initiative of urologic department to create a modified management. Following this initiative, antibiotic prophylaxis began to be used according to postoperative urine culture and stub of J-stent culture, which were obtained in 3rd days and 7th days after surgery, respectively. All consecutive patients treated with this process were compared with a conventional group. The clinicopathologic features of the two groups were compared using the t test and Chi square test. Multivariable logistic regression analysis was performed to determine the odds of developing 30-day UTI in two groups.

RESULTS

112 and 67 patients underwent the modified and conventional postoperative management, respectively. Two groups were comparable with regard to all demographic, clinical variables. The most common organism in urine culture and stub of J-stent culture was Candida albicans (38.46% and 31.7%). The rate of UTI was significantly lower in the modified group than in the conventional group (4.5% vs 13.4%, P = 0.031). In multivariable analyses, the conventional management was significantly more likely to develop UTI (OR = 4.992, 95% confidence interval [CI] 1.432-17.398 P = 0.012) than modified management.

CONCLUSION

This procedure is associated with a significant decrease in UTI after surgery. During perioperative period, urine/single J stent culture with drug sensitivity test is necessary.

Modified wallace anastomotic technique reduces ureteroenteric stricture rates after ileal conduit urinary diversion

PURPOSE

To compare perioperative outcomes, complications and anastomotic stricture rate in a contemporary series of patients who underwent open radical cystectomy (RC) with modified Wallace anastomotic technique versus traditional ileal conduit.

MATERIALS AND METHODS

Study enrolled 180 patients, of whom 140 were randomized and underwent RC; seventy were randomized to group I and the seventy to the group II. For the primary objective, we hypothesized that the rate of ureteroenteric strictures would be at least 20 % lower in the second group. Secondary end points included rate of anastomotic leak, surgical time, deterioration of the upper tract, intraoperative blood loss and patient-reported quality of life (HRQOL). The modified Wallace 1 technique involved eversion of the ureteral plate and bowel mucosa edges, which were anastomosed together in running fashion, while the outher anastomotic wall was augmented with sero-serosal interrupted sutures.

RESULTS

The mean (SD) follow-up time was 26.1 (5.7) months in group I and 25.2 (4.8) months in group II, during which, anastomotic stricture was observed in 8 patients (12%) from the first and 2 patients (3%) from the second group (p < 0.05). The anastomotic leakage rate was significantly higher in first group (17% vs. 8.5%, p < 0.05), while patient-reported HRQOL outcomes were similar between groups after the 12 month follow-up period.

CONCLUSIONS

By using a modified Wallace technique, we were able to significantly lower anastomotic stricture and anastomotic leakage rates, which are major issues in minimizing both short- and long-term postoperative complications.

Ileal conduit volvulus: rare complication of urinary diversion

Ileal conduit volvulus is a rare complication of urinary diversion. It has been suggested that various factors including prolonged length of the ileal segment, lack of fixation of the conduit to the peritoneum and failure to close the incised mesentery predispose patients to this complication. We present the case of a 76-year-old man who presented to hospital with severe abdominal pain and oliguria secondary to a volvulus of his ileal conduit. Investigations revealed early acute kidney injury as a result of urinary obstruction which was evident on abdominal CT. The patient subsequently underwent operative repair of the volvulus. Symptoms resolved following the procedure, kidney function improved and the patient was discharged without complication.

Post-Operative Infections among Patients Undergoing Radical Cystectomy at a Tertiary Center

BACKGROUND

Post-operative infection after radical cystectomy is a common complication. It is essential to identify modifiable risk factors that can predict post-operative infection to reduce the incidence of infection after radical cystectomy. We investigated the incidence of post-operative infection, associated pathogens, and risk factors for post-operative infection after radical cystectomy.

PATIENTS AND METHODS

Patients who underwent radical cystectomy for bladder cancer in a single urologic department from 2014 to 2016 were included. Age, gender, length of stay, body mass index (BMI), diabetes mellitus, hypertension, pre-operative estimated glomerular filtration rate, hydronephrosis, smoking status, neoadjuvant chemotherapy, pathologic tumor stage, pathologic nodal stage, types of urinary diversion, laparoscopic approach, operative time, and receipt of peri-operative blood transfusion were assessed to determine the association of these factors with the risk of infection within 30 days of radical cystectomy. Risk factors were assessed for correlation with any kind of infection and separately for urinary tract infection (UTI), blood infection/septic shock (BI), and surgical site infection (SSI). Pathogens were identified in all cases of infection.

RESULTS

A total of 134 patients were included in the analysis. Post-operative infection was diagnosed in 10.45%. Urinary tract infection, BI, and SSI were diagnosed in 3.73%, 4.48%, and 7.46%, respectively. Co-infections and mixed infection were diagnosed in 50% of patients with infection. Enterococcus was the most common pathogen. On multivariable analysis, age, BMI ≥30 kg/m², and laparoscopic approach were associated with the risk of infection; odds ratios (ORs) were 1.27 (95% confidence interval [CI] 1.01-1.59), 13.07 (1.39-122.88), and 0.07 (0.01-0.78), respectively.

CONCLUSION

One-tenth of patients undergoing radical cystectomy developed an infection within 30 days of surgery. Fifty percent of patients had co-infection with UTI, SSI, and/or BI and 50% of infections were polymicrobial. Increased BMI is the strongest factor associated independently with all types of infection. Therefore, obese patients should be encouraged to lose weight pre-operatively.

Perioperative outcomes and complications of intracorporeal vs extracorporeal urinary diversion after robot-assisted radical cystectomy for bladder cancer: a real-life, multi-institutional french study

PURPOSE

To compare perioperative outcomes and complications of extracorporeal (ECUD) vs intracorporeal urinary diversion (ICUD) in patients after undergoing robot-assisted radical cystectomy (RARC) at five referral centers in France.

METHODS

We retrospectively reviewed our multi-institutional, prospectively-collected database to select patients undergoing RARC between 2010 and 2016 with at least 3 months of follow-up. At each center, the surgery was performed by one surgeon with extensive experience in robotic surgery and radical cystectomy but no prior experience in RARC.

RESULTS

Overall, 108 patients were included. ECUD and ICUD were performed in 34 (31.5%) and 74 (68.5%) patients, respectively. Patient characteristics were comparable among the two groups, except for a higher proportion of patients with high surgical risk (ASA score ≥ 3) in the ECUD group. Ileal conduit and ileal neobladder were performed in 63/108 (58%) and 45/108 (42%) cases, respectively. Ileal conduit was performed more often with an extracorporeal approach while ileal neobladder with an intracorporeal approach. Overall, operative time, length of hospital stay, positive margin rate, and number of lymph nodes removed did not significantly differ among the two cohorts. Estimated blood loss and transfusion rates were significantly higher in the ECUD group. Rate of early (38.2 vs 47.3%, p = 0.4) and late (29.4 vs 18.9%, p = 0.2) surgical complications did not significantly differ between the ECUD and ICUD groups. Results were comparable in the subgroup analysis in the ileal conduit subpopulation.

CONCLUSION

In our real-life, multi-institutional study, RARC with ICUD achieved perioperative outcomes and complication rates comparable to those of RARC with ECUD.

Urinary Tract Infections After Urinary Diversion-Different Occurrence Patterns in Patients With Ileal Conduit and Orthotopic Neobladder

OBJECTIVE

To compare the incidence rate of urinary tract infections (UTIs) and associated pathogens between patients with ileal conduit and patients with orthotopic neobladder urinary diversion.

PATIENTS AND METHODS

The medical records of 179 patients treated with radical cystectomy between 2006 and 2011 were reviewed and data pertaining to postoperative UTI were collected. UTI incidence was reported at 3 months' intervals and compared by diversion type. Preoperative predictors of UTI were evaluated with Cox regression analyses.

RESULTS

The study cohort included 130 patients with ileal conduit and 49 patients with orthotopic neobladder. Patients with a neobladder were younger (P <.001). Median follow-up was 38 months (IQR [interquartile range], 11-63). Median time from surgery to first infection was 1.5 months (IQR, 1-12.5) for patients with a neobladder and 11 months (IQR, 2.5-27) for patients with a conduit (P = .04). During the first 3 months after surgery, 29% of the patients with a neobladder and 8% of the patients with ileal conduit had a UTI episode (P = .001). Rates of UTI did not differ during subsequent follow-up. Diversion type was not associated with UTI on multivariable analysis. Escherichia coli was the most common pathogen in patients with a conduit (58%), and Klebsiella spp. in patients with a neobladder (29%).

CONCLUSION

The risk of UTI is significantly higher in patients with a neobladder during the first 3 months after surgery and comparable to patients with ileal conduit during subsequent follow-up. These findings may facilitate preoperative counseling regarding the expected risk of UTI after urinary diversion.

Quality of life among women in Bangladesh following ileal conduit urinary diversion operations for irreparable vesicovaginal fistula and bladder exstrophy: observational study

OBJECTIVE

To determine the quality of life (QOL) of fistula patients in Bangladesh who have undergone ileal conduit (IC) urinary diversion operations, and to assess whether the risks and ethical challenges involved, outweigh the reality of leaving a woman with urinary incontinence for the rest of her life.

DESIGN

Observational study.

SETTING

LAMB Hospital, Bangladesh.

POPULATION

Seventeen women who had undergone IC between February 2012 and March 2016: 14 women previously had irreparable obstetric fistulas and three had bladder exstrophy.

METHODS

Demographic, obstetric, IC-related, stigma and discrimination information were collected by questionnaire. Univariate analysis was done using the two-sided t-test for comparison of differences before and after IC surgery.

MAIN OUTCOME METHODS

Change in stigma and discrimination scores. Health-related QOL assessed using the 36-item Short Form Health Survey.

RESULTS

Of the 17 women, 14 (82.3%) felt they were cured of their fistula disease. Three complained of occasional leakage due to insufficient seal of the bag, mainly at night, and all but one experienced no limits to their daily activities. Stigma and discrimination scores were significantly lower after having the IC surgery. The mean difference from when the woman had a fistula to when she had an IC for stigma score was 3.17 (1.12-4.16, P < 0.001), and for discrimination score was 3 (1.9-4.1, P < 0.001).

CONCLUSION

Overall, there has been improved QOL following IC among the women in this study and all would recommend IC to women in the same situation. They remain chronic patients with some physical symptoms, but are well re-integrated back into their communities.

TWEETABLE ABSTRACT

Improved QOL following ileal conduit in women with persistent fistula related disorder in Bangladesh.

Evaluation of robot-assisted laparoscopic versus open cystectomy and effect of carbon dioxide-pneumoperitoneum on histopathological findings in ureteroenteric anastomoses: results from an experimental randomized porcine study

OBJECTIVE

The aim of this study was to investigate the histopathology of ureteroenteric anastomoses (UEAs) after radical cystectomy (RC) with an ileal conduit in a porcine model using different surgical techniques. The study also evaluated the potential anti-inflammatory effect of preoperative carbon dioxide-pneumoperitoneum (CO₂P).

MATERIALS AND METHODS

Forty female Danish Landrace pigs were randomized to four groups: three intervention groups [open surgery ± prior CO₂P and robot-assisted laparoscopic cystectomy (RALC)], all subjected to RC and an ileal conduit, and one control group. After euthanization, UEAs were harvested and histopathologically evaluated.

RESULTS

Five pigs were excluded from the study owing to postoperative complications. Operating room time and clamping of the right and left ureters were significantly longer in the robotic than in the open groups (p < .01). Inflammatory infiltration grade of the left ureter was significantly higher in RALC (p = .032). No statistically significant difference was observed between the open groups receiving prior CO₂P or not.

CONCLUSIONS

Results showed a statistically significant higher inflammatory infiltration grade of the left ureter in RALC, emphasizing the importance of using meticulous techniques when mobilizing the left ureter using the robot. It was not possible to conclude with certainty whether CO₂P could constitute an anti-inflammatory agent for local inflammation.

Evaluation of conservative approach in the management of ureteroenteric strictures following radical cystectomy with Bricker ileal conduit: a single-center experience

OBJECTIVE

The aim of this study was to evaluate the risk factors and treatment options for ureteroenteric strictures (UES) following radical cystectomy (RC) and ileal conduit (IC) formation, and specifically to comment on the conservative management of UES in asymptomatic patients.

MATERIALS AND METHODS

The datasheets were reviewed of 304 consecutive patients who were treated with an RC and IC between January 2001 and May 2011 in a Belgian tertiary center and who followed a strict follow-up protocol. Long-term treatment outcomes were retrospectively analyzed.

RESULTS

Twenty-two patients (7.2%) were diagnosed with UES (affecting 27 ureters in total), when a new-onset hydroureteronephrosis or increase of the pre-existing hydroureteronephrosis was detected by ultrasound or computed tomography. A retrograde loopogram was then performed to confirm the UES. The mean follow-up time was 33 months. A decline in renal function, the presence of flank pain and urinary tract infections were indications for interventional treatment. Six patients underwent double-J stent placement, two patients received percutaneous nephrostomies as a definitive treatment and two patients underwent ureterointestinal reimplantation. Asymptomatic patients with a UES and a favorable renal function were conservatively managed. They remained asymptomatic during follow-up and required no active treatment.

CONCLUSIONS

No clinical variable was independently associated with an increased risk of UES. These long-term data suggest that a selected patient population of asymptomatic patients with good renal function at the time of UES diagnosis can be safely managed conservatively.

Comparison of postoperative acute kidney injury between ileal conduit and neobladder urinary diversions after radical cystectomy: A propensity score matching analysis

Ileal conduit and neobladder urinary diversions are frequently performed after radical cystectomy. However, complications after radical cystectomy may be different according to the type of urinary diversion. Acute kidney injury (AKI) is a common complication after surgery and increases costs, morbidity, and mortality of hospitalized patients. This study was performed to compare the incidence of postoperative AKI between ileal conduit and neobladder urinary diversions after radical cystectomy.All consecutive patients who underwent radical cystectomy in 2004 to 2014 in a single tertiary care center were identified. The patients were divided into the ileal conduit and ileal neobladder groups. Preoperative variables, including demographics, cancer-related data and laboratory values, as well as intraoperative data and postoperative outcomes, including AKI, intensive care unit admission rate, and the duration of hospital stay, were evaluated between the groups. Postoperative AKI was defined according to the Kidney Disease: Improving Global Outcome criteria. Propensity score matching analysis was performed to reduce the influence of possible confounding variables and adjust for intergroup differences.After performing 1:1 propensity score matching, the ileal conduit and ileal neobladder groups each included 101 patients. The overall incidence of AKI after radical cystectomy was 30.7% (62 out of 202) and the incidences did not significantly differ between the groups (27 [26.7%], ileal conduit group vs 35 [34.7%], ileal neobladder group, P = 0.268). Intraoperative data, intensive care unit admission rate, and the duration of hospital stay were not significantly different between the groups.Postoperative AKI did not significantly differ between ileal conduit and neobladder urinary diversions after radical cystectomy. This finding provides additional information useful for appropriate selection of the urinary diversion type in conjunction with radical cystectomy.

Getting out of a tight spot: an overview of ureteroenteric anastomotic strictures

Radical cystectomy and urinary diversion is the gold-standard treatment for muscle-invasive and high-risk non-muscle-invasive bladder cancer. Ureteroenteric anastomotic stricture is a well-known complication of urinary diversion and is associated with serious sequelae that lead to total or partial loss of kidney function, infectious complications, and the need for additional procedures. Although the exact aetiology of benign ureteroenteric anastomotic strictures is unclear, they most likely occur secondary to ischaemia at the anastomotic region. Diagnosis can be achieved using retrograde contrast studies, CT scan or MAG3 renography. Open revision remains the gold-standard treatment for ureteroenteric anastomotic strictures; however, endourological techniques are being increasingly used and, in select patients, might be the optimal approach.

Tubular Constructs as Artificial Urinary Conduits

PURPOSE

A readily available artificial urinary conduit might be substituted for autologous bowel in standard urinary diversions and minimize bowel associated complications. However, the use of large constructs remains challenging as host cellular ingrowth and/or vascularization is limited. We investigated large, reinforced, collagen based tubular constructs in a urinary diversion porcine model and compared subcutaneously pre-implanted constructs to cell seeded and basic constructs.

MATERIALS AND METHODS

Reinforced tubular constructs were prepared from type I collagen and biodegradable Vicryl® meshes through standard freezing, lyophilization and cross-linking techniques. Artificial urinary conduits were created in 17 female Landrace pigs, including 7 with a basic untreated construct, 5 with a construct seeded with autologous urothelial and smooth muscle cells, and 5 with a free graft formed by subcutaneous pre-implantation of a basic construct. All pigs were evaluated after 1 month.

RESULTS

The survival rate was 94%. At evaluation 1 basic and 1 cell seeded conduit were occluded. Urinary flow was maintained in all conduits created with pre-implanted constructs. Pre-implantation of the basic construct resulted in a vascularized tissue tube, which could be used as a free graft to create an artificial conduit. The outcome was favorable compared to that of the other conduits. Urinary drainage was better, hydroureteronephrosis was limited and tissue regeneration was improved.

CONCLUSIONS

Subcutaneous pre-implantation of a basic reinforced tubular construct resulted in a vascularized autologous tube, which may potentially replace bowel in standard urinary diversions. To our knowledge we introduce a straightforward 2-step procedure to create artificial urinary conduits in a large animal model.

Use of the Memokath Urethral Stent in the management of ileal conduit stomal stenosis

INTODUCTION

Ileal conduit stomal stenosis is a difficult complication to manage. Definitive treatment usually requires refashioning or a reconstruction of the conduit. There remains a need for minimally invasive procedures that can restore function to the stoma while avoiding the risks associated with a significant surgical procedure. This case illustrates a novel approach to the management of this complication.

PRESENTATION OF CASE

An 84 year old female with muscle-invasive bladder cancer underwent cystectomy with formation of an ileal conduit urinary diversion system. Her recovery was complicated by stomal stenosis leading to recurrent urinary tract infections. The Memokath Stent 045 is a thermo-expandable nickel-titanium stent designed for treatment of urethral strictures. The stent was inserted into the stoma under direct vision without the need for general anaesthesia or intraoperative radiography. The conduit remains patent 12 months after insertion and the metal stent showed no evidence of migration, calcification, oxidation or degradation.

DISCUSSION

The use of a thermo-expandable nickel-titanium stent is able to provide the patency required to treat ileal conduit stomal stenosis. In this case, insertion of the stent was a simple procedure and no adverse events or degradation of the stent was identified at 12 months after insertion. The need for a significant surgical procedure such as a refashioning or reconstruction was avoided and general anaesthesia was not required to perform the procedure.

CONCLUSION

This case report highlights the possibility of using the thermo-expandable Memokath Stent 045 as an alternative to the long-term management of ileal conduit stomal stenosis.

Progressive ureteral dilations and retrograde placement of single-j stent guided by flexible cystoscope for management of ureteroenteral anastomotic stricture in patients after radical cystectomy and bricker urinary diversion

PURPOSE

To evaluate the safety and efficacy of retrograde placement of single-J stent guided by a flexible cystoscope for management of ureteroenteral anastomotic stricture in patients after radical cystectomy and Bricker urinary diversion.

PATIENTS AND METHODS

Between January 2008 and June 2012, 11 patients with ureteroenteral anastomotic stricture after open radical cystectomy and Bricker urinary diversion were enrolled in this study. All patients were treated with retrograde placement of single-J stent guided by a flexible cystoscope. A 7F single-J stent was placed for 6 weeks.

RESULTS

Of the 11 patients, seven strictures occurred on the left side, two on the right side, and two on both sides. The retrograde procedure was successfully performed in 10 cases, and the remaining 1 was successful on the right side but failed on the left side. Upper urinary tract infection was well controlled in all three patients with fever. After a follow-up of 12 to 66 months, eight patients had long-term symptom relief, one patient had open surgery to remove the stricture and re-implant the ureter, and one patient died because of tumor recurrence. The only failed case was that of a left side percutaneous nephrostomy, but the patient was lost to follow-up.

CONCLUSIONS

Retrograde placement of a single-J ureteral stent guided by a flexible cystoscope is safe and effective for ureteroenteral anastomotic stricture in patients with Bricker urinary diversion, and it brings fewer complications. The procedure is minimally invasive and could avoid immediate surgery for most patients.

Urinary diversion: tailored solutions for individual patients

PURPOSE OF REVIEW

Various urinary diversions are at disposition for reconstructive surgery after cystectomy. The chosen diversion has a strong impact on patients' life regarding complications and quality of life. The purpose of this review is to summarize the current tendency to adapt surgical solutions to individual needs of the patient.

RECENT FINDINGS

Tailored surgery requires that the surgeon has been trained in the handling of all gut segments. Only in this case can he react to anatomical variants, patient comorbidities and oncological circumstances, as well as to the prognosis and the social circumstances of the patient with a tailored diversion. Changing demography and ageing populations with increasing incidence of muscle invasive bladder cancer request new, less invasive methods of urinary diversions. There is little evidence as to which is the best urinary diversion due to a lack of well designed studies.

SUMMARY

The ileum conduit is still the most used urinary diversion worldwide. However, there are multiple techniques available to us, which guarantee the safest solution in combination with the highest quality of life for the construction of tailored urinary diversion.

Sclerotherapy for rare bleeding stomal varices after ileal conduit urinary diversion: an effective and noninvasive method

INTRODUCTION

Bleeding stomal varices after ileal conduit urinary diversion are rare, but they can develop in patients with portal venous hypertension caused by cirrhosis.

CASE PRESENTATION

We report the case of a 68-year-old man who developed stomal haemorrhage two months after radical cystectomy and ileal conduit urinary diversion to treat invasive bladder cancer. Alcoholic cirrhosis and portal venous hypertension were considered to be the causes of varices and bleeding. We chose to control the stomal varices using sclerotherapy. The stomal varices disappeared and no bleeding recurred during one year of follow up.

CONCLUSION

We believe that sclerotherapy is a suitable treatment for bleeding stomal varices.

Technique selection of bricker or wallace ureteroileal anastomosis in ileal conduit urinary diversion: a strategy based on patient characteristics

OBJECTIVES

This study was designed to establish an individualized selection strategy for the two most common types of ureteroenteric anastomotic techniques (Bricker and Wallace anastomosis) used in ileal conduit (IC) diversion.

METHODS

Patients who underwent IC diversion after radical cystectomy for transitional cell carcinoma between January 2009 and December 2011 were prospectively collected. The choice of anastomosis type (Bricker vs. Wallace) was successively based on tumor characteristics, ureteral anomalies, and ureteral length after retrosigmoidal tunneling.

RESULTS

Ninety-nine patients were enrolled in the final study. Fifty-three patients underwent Bricker anastomosis, and 46 underwent Wallace anastomosis. Ureteral stricture developed in 6 (6.1 %) patients and the overall stricture rate for all ureters was 3.1 % (6/196). Strictures occurred at an average of 13.3 months after surgery and were predominately located in the left ureter (66.7 %, 4/6). The difference in the ureter stricture rates between the two groups was not statistically significant: 3.8 % (4/104) and 2.2 % (2/92) for Bricker and Wallace, respectively (p = 0.686). There were no significant differences in age, sex, body mass index (BMI), prevalence of pelvic radiation therapy, length of stay, follow-up time, or time to stricture between the two techniques. Patients in whom stricture developed had a significantly higher mean BMI compared with those without stricture (25.2 vs. 23.3 kg/m(2), respectively; p = 0.008).

CONCLUSIONS

Our preliminary outcomes demonstrate that this selection strategy of Bricker vs. Wallace anastomosis seems to be clinically reliable, providing an acceptable low ureteral stricture rate of 3.1 %. However, the potential advantage for oncologic control of this strategy is needed to further confirm.

Robotic repair of post-cystectomy ureteroileal anastomotic strictures: techniques for success

INTRODUCTION

Post-cystectomy ureteroileal anastomotic strictures that fail percutaneous or endourologic management require operative repair. These cases can be challenging, and few reports of robotic repairs exist in the available literature. Here we describe our stepwise approach to robotic surgical repair of ureteroileal strictures.

TECHNIQUE

The da Vinci(®) Si Surgical System (Intuitive Surgical, Sunnyvale, CA) was used in all cases. The port configuration is similar to robotic cystectomy, although the ports are placed in a more cephalad location on the abdominal wall. The same port configuration was used for both right- and left-sided procedures. Principal surgical techniques used include dissection of the colonic mesentery, careful peeling of the ureter off of the common iliac vessels, and mobilization of the ureter on either side of the sigmoid colon.

RESULTS

Four patients with a mean age of 72 years underwent this procedure at our institution, including 2 with left-sided strictures and 2 with right-sided strictures. Three of the 4 patients had undergone prior abdominal surgery in addition to their cystectomy. All patients failed initial percutaneous and/or endourologic attempts to resolve their stricture. The ureteroileal strictures were successfully repaired robotically in all cases. With mean follow-up of 16 months no major complications were encountered, and all patients remain free of stricture recurrence to date.

CONCLUSIONS

Robotic ureteroileal anastomotic stricture repair is feasible for both right- and left-sided cases. A similar operative approach can be used regardless of stricture side.

Muscle invasive bladder cancer: from diagnosis to survivorship

Bladder cancer is the fifth most commonly diagnosed cancer and the most expensive adult cancer in average healthcare costs incurred per patient in the USA. However, little is known about factors influencing patients' treatment decisions, quality of life, and responses to treatment impairments. The main focus of this paper is to better understand the impact of muscle invasive bladder cancer on patient quality of life and its added implications for primary caregivers and healthcare providers. In this paper, we discuss treatment options, side effects, and challenges that patients and family caregivers face in different phases along the disease trajectory and further identify crucial areas of needed research.