A comparison of the Bricker versus Wallace ureteroileal anastomosis in patients undergoing urinary diversion for bladder cancer

Unraveling the Complexities of Uretero-Enteric Strictures: A Modern Review

PURPOSE OF REVIEW

The purpose of this review article is to provide a contemporary overview of benign uretero-enteric anastomotic stricture (UAS) management and outcomes.

RECENT FINDINGS

In this article, we will review the most recent studies investigating UAS and evaluate etiology, potential risk factors, presentation, diagnosis, and management options, along with personal insight gained from our experience with managing this challenging reconstructive complication. Benign UAS is a relatively common long-term complication of intestinal urinary diversion, affecting approximately 1 in 10 patients. It is thought to be caused by ureteral tissue ischemia and fibrosis at the anastomotic site. Risk factors appear to include any that increase the likelihood of leak or ischemia; it is not clear if anastomotic approach impacts risk for stricture as well. Management options are varied and include endourologic, open, and robotic approaches. Endoscopic approaches may be less morbid but are considerably less effective than reconstruction performed after a period of ureteral rest.

New clinical insights into the treatment of benign uretero-ileal anastomotic stricture following radical cystectomy and urinary diversion

BACKGROUND

Benign uretero-ileal anastomotic stricture (UIAS) is a potentially serious complication that can arise after radical cystectomy (RC) and subsequent urinary diversion. To preserve residual renal function and improve prognosis, it is crucial to derive insights from experience and tailor individualized treatment strategies for different patients.

PATIENTS AND METHODS

From October 2014 to June 2021, a total of 47 patients with benign UIAS underwent endoscopic management (n = 19) or reimplantation surgery (n = 28). The basic data, perioperative conditions, and postoperative outcomes of the two groups were compared and analyzed to evaluate efficacy.

RESULTS

Comparing preoperative and postoperative clinical efficacy within the same group, the endoscopic group showed no significant differences in creatinine and blood urea nitrogen (BUN) levels before surgery or after extubation (p > 0.05). However, significant differences were observed in glomerular filtration rate (GFR) levels on the affected side before surgery and after extubation (p < 0.05). In contrast, the laparoscopic reimplantation group did not exhibit significant differences in creatinine, BUN, or GFR levels of affected side before surgery and after extubation (p > 0.05). Postoperative clinical efficacy showed no significant difference in creatinine and BUN levels between the two groups (p > 0.05). However, GFR values of affected side in the endoscopic treatment group decreased more than those in the laparoscopic reimplantation group (p < 0.05). Additionally, the laparoscopic reimplantation group was able to remove the single-J tube earlier than the endoscopic treatment group (p < 0.05), had a lower recurrence rate of hydronephrosis after extubation (p < 0.05), and experienced a later onset of hydronephrosis compared to the endoscopic treatment group (p < 0.05).

CONCLUSIONS

Based on our experience in treating UIAS following RC combined with urinary diversion, laparoscopic reimplantation effectively addresses the issue of UIAS, allowing for the removal of the ureteral stent relatively soon after surgery. This approach maintains long-term ureteral patency, preserves residual renal function, reduces the risk of ureteral restenosis and hydronephrosis, and has demonstrated superior therapeutic outcomes in this study.

Bricker versus Wallace ureteroileal anastomosis: A multi-institutional propensity score-matched analysis

AIM OF THE STUDY

The aim of our study is to evaluate the difference in stricture rate between matched groups of Bricker and Wallace techniques for ureteroileal anastomosis.

PATIENTS AND METHODS

A retrospective analysis of patients undergoing urinary diversion (UD) with Bricker and Wallace ureteroileal anastomosis at two university hospitals. Two groups of Bricker and Wallace patients were matched in a 1:1 ratio based on the age, sex, body mass index (BMI), Charlson comorbidity index (CCI), preoperative hydronephrosis, prior radiation therapy or abdominal surgery, pathologic T and N stages and 30-days-Clavien grade complications≥III. A multivariable Cox regression analysis was conducted to identify predictors of ureteroenteric stricture (UES) in all patients.

RESULTS

Overall, 740 patients met the inclusion criteria and 209 patients in each group were propensity matched. At a similar median follow-up of 25 months, UES was detected in 25 (12%) and 30 (14.4%) patients in Bricker and Wallace groups, respectively (p = 0.56). However, only one patient in the Bricker group developed a bilateral stricture compared to 15 patients in the Wallace group, resulting in a significantly higher number of affected renal units in the Wallace group: 45 (10.7%) versus only 26 (6.2%) in the Bricker group (p = 0.00). On multivariable extended Cox analysis, prior radiotherapy, presence of T4 pelvic malignancy and nodal positive disease were independent predictor of UES formation.

CONCLUSION

The technique of ureteroileal anastomosis itself does not increase the rate of stricture; however, conversion of two renal units into one is associated with a higher incidence of bilateral upper tract involvement.

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.

Comparison of long-term outcomes between ileal conduit and transuretero-cutaneostomy urinary diversion after radical cystectomy: a systematic review and meta-analysis

Background

Urinary diversion in bladder cancer treatment has been a distinguished topic of interest due to varying approaches available. Amongst them, ileal conduit (IC) and transuretero-ureterostomy (TUU) have been popular options in clinical practice. This study would like to compare the long-term outcomes of IC and TUU in patients undergoing RC procedures.

Materials and methods

Literature searches were conducted in MEDLINE, CENTRAL, and EMBASE. Duration of hospitalization, complication rate, quality of life, and survival rate were selected as outcomes. Risk of bias was assessed using the ROBINS-I tool. Outcome measure was pooled using forest plot in Review Manager V.5 for Macintosh. Heterogeneity was measured using the DerSimonian and Laird random-effects model.

Results

Eighteen matching interventional studies were included, 3 were prospective studies. The total number of included samples was 3,689; 1,172 patients of the TUU and 2,517 of IC group. The IC procedure associates with longer hospitalization [mean difference 3.80 [95% confidence interval (CI): 2.27-5.32), p < 0.001, I2 = 92%]. Duration of intensive care did not differ significantly. There were no differences in major complication rates [odds ratio (OR) = 1.45, 95% CI: 0.74-2.84, p = 0.27, I2 = 54%]: stone formation (OR = 1.07, 95% CI: 0.51-2.23, p = 0.48, I2 = 0%), and renal function deterioration (OR = 0.81, 95% CI: 0.39-1.68, p = 0.57, I2 = 0%) between the TUU and IC groups. Quality of life decreased in both groups, and only occurred in the early days after the stoma placement phase. Survival rates were not different among the groups.

Conclusion

TUU is a better UD option as it offers shorter time of hospitalization, with the similar major complications, quality of life, and survival rate compared to IC.

Systematic review comparing uretero-enteric stricture rates between open cystectomy with ileal conduit, robotic cystectomy with extra-corporeal ileal conduit and robotic cystectomy with intra corporeal ileal conduit formation

Cystectomy is the gold standard treatment for muscle invasive bladder cancer. Robotic cystectomy has become increasingly popular owing to quicker post- operative recovery, less blood loss and less post-operative pain. Urinary diversion is increasingly being performed with an intracorporeal technique. Uretero-enteric strictures (UES) cause significant morbidity for patients. UES for open cystectomy is 3-10%, but the range is much wider (0-25%) for robotic surgery. We aim to perform systematic review for studies comparing all 3 techniques, to assess for ureteric stricture rates. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (Page et al. in BMJ 29, 2021). PubMed, Scopus and Embase databases were searched for the period January 2003 to June 2023 inclusive for relevant publications.The primary outcome was to identify ureteric stricture rates for studies comparing open cystectomy and urinary diversion, robotic cystectomy with extracorporeal urinary diversion (ECUD) and robotic cystectomy with intracorporeal urinary diversion (ICUD). Three studies were identified and included 2185 patients in total. The open operation had the lowest stricture rate (9.6%), compared to ECUD (12.4%) and ICUD (15%). ICUD had the longest time to stricture (7.55 months), ECUD (4.85 months) and the open operation (4.75 months). Open operation had the shortest operating time. The Bricker anastomoses was the most popular technique. Open surgery has the lowest rates of UES compared to both robotic operations. There is a learning curve involved with performing robotic cystectomy and urinary diversion, this may need to be considered to decide whether the technique is comparable with open cystectomy UES rates. Further research, including Randomised Control Trials (RCT), needs to be undertaken to determine the best surgical option for patients to minimise risks of UES.

Hybrid technique has lower stricture rates than Wallace and Bricker

INTRODUCTION

A clear consensus has not yet been reached on the optimal ureteroenteric anastomosis technique for ileal conduit urinary diversion following radical cystectomy. This study aims to determine the incidence of strictures and their management associated with these anastomosis techniques.

METHODS

We conducted a retrospective, single-center study of patients who underwent radical cystectomy and urinary diversion between March 2014 and August 2022. Patients were categorized based on the ureteroenteric anastomosis technique used: Wallace, Bricker, or Hybrid. Strictures were identified through antegrade pyelography following nephrostomy placement.

RESULTS

A total of 141 patients were included in the study, with 60 patients in the Wallace group (42 %), 42 patients in the Bricker group (30 %), and 39 patients in the Hybrid group (28 %). The overall incidence of ureteroenteric strictures was 15 %, with 7 patients in the Wallace group, 11 patients in the Bricker group, and 3 patients in the Hybrid group experiencing strictures. There was no statistically significant difference in stricture rates between the Wallace and Bricker groups (11 % vs. 26 %, p = 0.09) or between the Wallace and Hybrid groups (11 % vs. 7 %, p = 0.73). However, a statistically significant difference was observed between the Bricker and Hybrid groups (26 % vs. 7 %, p = 0.03). The mean time to stricture development was 9.2 ± 3.3 months for the Wallace group, 9.5 ± 3.7 months for the Bricker group, and 12.6 ± 5 months for the Hybrid group (p = 0.407).

CONCLUSION

The Hybrid ureteroenteric anastomosis technique exhibits a lower stricture rate compared to the Bricker and Wallace techniques. It represents a safe and feasible alternative technique.

Pelvic Extirpative Surgery for the "End-Stage Irradiated Bladder"

Men with prostate cancer have the daunting task of selecting from multiple modalities of treatment. The long-term effects of radiation therapy are only now being recognized. For both patients and surgeons, the end-stage irradiated bladder poses numerous problems and challenges. Specifically, irradiated bladders with urosymphyseal fistula, radiation cystitis, and rectourethral fistula are challenging to manage and treat. This review outlines the presentation, workup, and management including cystectomy for these three devastating late complications of radiation therapy. There are special considerations when performing benign cystectomy that are not typically considered during oncologic cystectomy. We discuss an overview of the current literature regarding the "end-stage bladder" resulting from radiation therapy and the important considerations that must be acknowledged when managing these patients. It is shown that many of the less invasive and conservative options ultimately lead to cystectomy. Indeed, our review concludes that cystectomy with urinary diversion is a safe and viable option in select irradiated patients with the goal to improve quality of life.

India Ink Tattooing of Ureteroenteric Anastomoses

While upper tract access through the insensate conduit following urinary diversion takes less time and incurs fewer costs than percutaneous kidney access does for the treatment of ureter and kidney pathology, endoscopic ureteroenteric anastomoses (UEA) identification can be difficult. We injected India Ink into the bowel mucosa near the UEA during ileal conduit diversion (IC) to determine the safety and feasibility of ink tattooing. Patients undergoing IC were prospectively randomized to receive ink or normal saline (NS) injections. The injections were placed 1 cm from UEA in a triangular configuration, and loopogram exams and looposcopy were performed to identify reflux (UR), UEA, the tattooing site and strictures in 10 and 11 patients randomized with respect to ink and NS injections, respectively. Ink patients were older (72 vs. 61 years old, p = 0.04) and had a higher Charlson Comorbidity Index (5 vs. 2, p = 0.01). Looposcopy was performed in three ink and four NS patients. Visualization of UEA was achieved in 100% of the ink and 75% of the NS patients (p = 0.26). The ink ureteroenteric anastomotic stricture (UEAS) rate was higher (N = 3 vs. N = 1) and six patients vs. one patients underwent surgery, respectively, for UEAS (p = 0.31). The study was halted early due to safety concerns. Our pilot study demonstrates that ink can be well visualized following injection near UEA during IC. However, the ink cohort had more UEAS than previously cited in the literature and our prior institutional UEAS rate of 6%. While this study sample is small, the higher incidence of UEAS after ink injection led us to question the utility and safety of ink injection following IC.

The cause analysis of benign uretero-ileal anastomotic stricture after radical cystectomy and urinary diversion

Background

Benign uretero-ileal anastomotic stricture (UIAS) is a major complication following radical cystectomy (RC) and ileal orthotopic bladder substitution, and it can occur in combination with other complications. But risk factors for patients with UIAS have not been well described.

Material and methods

We retrospectively reviewed 198 patients treated with RC for bladder cancer from 2014 to 2019 at the Zhejiang Provincial People's Hospital. Patient demographic and clinical variables were examined to determine the risk factors associated with UIAS by univariate and multivariate logistic regression analysis.

Results

A total of 180 patients into the group standards and in all 360 uretero-ileal anastomoses. Among the above cases, 22 patients developed UIAS, including 10 cases of left UIAS, nine cases of right UIAS, and three cases of bilateral UIAS. There was no difference in demographic, operative, or perioperative variables between patients with and without UIAS. In a multivariate analysis, after adjusting for gender, age, surgical methods, and underlying diseases, intraoperative or postoperative blood transfusion (HR = 0.144, P <0.01), postoperative urinary tract infection (HR = 3.624, P <0.01), and extracorporeal bladder anastomosis (HR = 3.395, P = 0.02) significantly increased the risk of UIAS.

Conclusions

In our experience, intraoperative or postoperative blood transfusion, postoperative urinary tract infection, and extracorporeal neobladder anastomoses increased the risk of UIAS after radical cystectomy and ileal orthotopic bladder substitution surgery. Further studies with larger samples are necessary to validate this result.

Uretero-enteric stricture outcomes: secondary analysis of a randomised controlled trial comparing open versus robot-assisted radical cystectomy

OBJECTIVES

To analyse the risk of uretero-enteric anastomotic stricture in patients randomised to open (ORC) or robot-assisted radical cystectomy (RARC) with extracorporeal urinary diversion.

PATIENTS AND METHODS

We included 118 patients randomised to RARC (n = 60) or ORC (n = 58) at a single, high-volume institution from March 2010 to April 2013. Urinary diversion was performed by experienced open surgeons. Stricture was defined as non-malignant obstruction on imaging, corroborated by clinical status, and requiring procedural intervention. The risk of stricture within 1 year was compared between groups using Fisher's exact test.

RESULTS

In all, 58 and 60 patients were randomised to RARC and ORC, respectively. We identified five strictures, all in the ORC group. In patients with ≥1 year of follow-up, the increase in risk of stricture from open surgery was 9.3% (95% confidence interval 1.5%, 17%). Of the five strictures, three were managed endoscopically while two required open revision. There was no evidence that perioperative Grade 3-5 complications were associated with development of a stricture (P = 1) and no evidence of a difference in 24-month estimated glomerular filtration rate between arms (P = 0.15).

CONCLUSIONS

In this study at a high-volume centre, RARC with extracorporeal urinary diversion achieved excellent ureteric anastomotic outcomes. Purported increased risk of stricture is not a reason to avoid RARC. Future research should examine the impact of different surgical techniques and operator experience on the risk of stricture, especially as more intracorporeal diversions are performed.

Outcomes of Uretero-ileal Anastomosis in Bladder Cancer Cystectomies: Bricker vs. Wallace 1

Background

The two commonly used methods for uretero-ileal anastomosis (UIA) during radical cystectomy for muscle-invasive bladder cancer (MIBC) are the Bricker and Wallace 1 techniques. Published data on the incidence of strictures at anastomotic sites is limited. This study compares both anastomotic techniques in terms of uretero-ileal stricture (UIS) rates and the factors that govern it in the patient group.

Material and methods

Records of all patients presenting with bladder cancer who underwent radical cystectomy at the department of uro-oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) Lahore, Pakistan, from January 1, 2009, to December 31, 2018, were reviewed retrospectively, and all adult patients aged >18 years out of them were selected for the study.

Results

With a total of 116 patients, the mean age was 54.37 ± 11.16 and a male majority (83.6%). Urinary diversion using ileal conduit was performed in 70 (60.3%) patients and the rest of them i.e. 46 (39.7%) had neobladder formation. Amongst them, uretero-ileal anastomosis was constructed via Bricker and Wallace 1 in 73 (62.9%) patients and 43 (37.1%) patients respectively. Pelvic radiotherapy was received by 13 (11.2%) patients. Anastomotic stricture developed in 19 (16.4%) cases. A relatively similar proportion of stricture rate was found in Bricker and Wallace 1 technique (10% vs 13%). Body mass index (BMI) was found to be significantly higher in patients who developed UIS. Incidence of stricture formation was more on the left than right side i.e. 12 (63.2%) vs five (26.3%) while two (10.5%) patients developed bilateral strictures.

Conclusion

No significant difference in stricture formation was noted between Bricker and Wallace 1 technique. High BMI and anastomotic leaks were the contributory factors for this complication during our experience.

Robotic Repair of Ureteroenteric Stricture Following Radical Cystectomy: A Multi-Institutional Experience

OBJECTIVE

To examine the safety, feasibility and durability of robotic reimplantation of ureteroenteric stricture after radical cystectomy.

MATERIALS AND METHODS

A retrospective multi-institutional review was performed for all patients undergoing robotic repair of ureteroenteric stricture from January 2010 to January 2019. Functional outcomes and complications were followed and data were analyzed with SPSS statistical software.

RESULTS

A total of 46 patients and 58 renal units were identified, of which 15 had right sided, 19 left sided and 12 patients had bilateral strictures. Presentation of stricture was asymptomatic in 14 (30.4%) patients. Symptomatic presentations included infection in 22 (47.8%), worsening renal function in 11 (23.9%) and pain in 3 (6.5%) patients. Median time from cystectomy to diagnosis of stricture was 5 months (1-40). Median stricture length was 1.5 cm (range 0.5-10). All strictures were of benign etiology except for 4 (6.9%), which were due to malignancy. Overall, 49 (84.5%) ureters underwent primary re-implantation, while 9 (15.5%) required Boari-like advancement flaps prior to re-implantation. Median operative time was 190 min (range 45-540) with median estimated blood loss of 50 mL (range 25-2000) and median length of stay of 2 days (range 1-33, IQR 2-4). Seven (15.2%) patients experienced complications; 3 (6.5%) were low grade and 4 (8.7%) high grade. With median follow up of 18 months (range 1-51) the stricture recurrence rate was 8.6%.

CONCLUSION

Robotic reimplantation of ureteroenteric strictures following radical cystectomy is safe and feasible in experienced centers with high success rates.

Comparative analysis of Bricker versus Wallace ureteroenteric anastomosis and identification of predictors for postoperative ureteroenteric stricture

Purpose

Ureteroenteric anastomosis after cystectomy is usually performed using the Bricker or Wallace technique. Deterioration of renal function is the most common long-term complication of urinary diversion (UD).

To improve surgical care and optimize long-term renal function, we compared the Bricker and Wallace anastomotic techniques and identified risk factors for ureteroenteric strictures (UES) in patients after cystectomy.

Material and methods

Retrospective, monocentric analysis of 135 patients who underwent cystectomy with urinary diversion at the University Hospital Essen between January 2015 and June 2019. Pre- and postoperative renal function, relevant comorbidities, prior chemo- or radiotherapy, pathological findings, urinary diversion, postoperative complications, and ureteroenteric strictures (UES) were analyzed.

Results

Of all 135 patients, 69 (51.1%) underwent Bricker anastomosis and 66 (48.9%) Wallace anastomosis. Bricker and Wallace groups included 134 and 132 renal units, respectively. At a median follow-up of 14 (6–58) months, 21 (15.5%) patients and 30 (11.27%) renal units developed UES. We observed 22 (16.6%) affected renal units in Wallace versus 8 (5.9%) in Bricker group (p < 0.001). A bilateral stricture was most common in Wallace group (69.2%) (p < 0.001). Previous chemotherapy and 90-day Clavien-Dindo grade ≥ III complications were independently associated with stricture formation, respectively (OR 9.74, 95% CI 2–46.2, p = 0.004; OR 4.01, 95% CI 1.36–11.82, p = 0.013).

Conclusion

The results of this study show no significant difference in ureteroenteric anastomotic techniques with respect to UES development regarding individual patients but suggest a higher risk of bilateral UES formation in patients undergoing Wallace anastomosis. This is reflected in the increased UES rate under consideration of the individual renal units.

Feasibility and Safety of Stentless Uretero-Intestinal Anastomosis in Radical Cystectomy with Ileal Orthotopic Neobladder

Background: We evaluated the feasibility and safety of stentless uretero-intestinal anastomosis (UIA) during radical cystectomy (RC) with an ileal orthotopic neobladder. Methods: We retrospectively reviewed 403 patients who underwent RC for bladder cancer between August 2014 and December 2018. The primary objective was to study the effect of stentless UIA on uretero-intestinal anastomosis stricture (UIAS), and the secondary objective was to evaluate the association between stentless UIA and other complications, including paralytic ileus, febrile urinary tract infection (UTI), and urine leakage. Kaplan–Meier survival analysis was used to estimate UIAS-free survival, and Cox proportional hazard models were applied to identify factors associated with the risk of UIAS. Results: Among 403 patients with 790 renal units, UIAS was identified in 39 (9.7%) patients and 53 (6.7%) renal units. Forty-four (83.0%) patients with UIAS were diagnosed within 6 months. The 1- and 2-year overall UIAS-free rates were 93.9% and 92.7%, respectively. Paralytic ileus was identified in 105 (26.1%) patients and resolved with supportive treatment. Febrile UTI occurred in 57 patients (14.1%). However, there was no leak of the UIA. Conclusions: Stentless UIA during RC with an ileal orthotopic neobladder is a feasible and safe surgical option. Further prospective randomized trials are required to determine the clinical usefulness of stentless UIA during RC.

Technique selection of ureteroileal anastomosis in hautmann ileal neobladder with chimney modification: Reliability of patient-based selection strategy and its impact on ureteroentric stricture rate

OBJECTIVE

We aimed to establish the reliability of technique selection strategy for ureteroileal anastomosis (Bricker vs. Wallace) by comparing perioperative outcomes, complications, and anastomotic stricture rate in a contemporary series of patients who underwent open radical cystectomy followed by reconstruction of modified Hautmann neobladder.

MATERIALS AND METHODS

A total of 60 patients underwent radical cystectomy and modified Hautmann neobladder, of whom 30 patients (group I) with Bricker anastomotic technique were compared to 30 matched paired patients with end-to-end ureteroileal anastomosis (group II). Long-term results, including ureteroileal stricture (UIS) and postoperative complication rate at two year follow up were available. The choice of anastomosis type was successively based on chimney size, ureteral length after retro-sigmoidal tunneling and diameter of distal ureter. Postoperative complications were graded according to the Clavien-Dindo system.

RESULTS

Ureteroileal stricture rate was 6.6% in group I vs. 0% in group II, after three months (p < 0.05), while anastomotic leakage rate was 6.6% vs. 3.3% (group I vs group II) between the two groups for the same follow up period (p > 0.05). High-grade complications (Clavien III-V) were more in Bricker group as compared to Wallace group and the difference was significant (20% vs 10.3%, p = 0.03).

CONCLUSION

Our preliminary outcomes demonstrate that this selection strategy seems to be clinically reliable, with lower incidence of postoperative complications in Wallace group.

Ureteral stents cannot decrease the incidence of ureteroileal anastomotic stricture and leakage: A systematic review and meta-analysis

BACKGROUND

The ileal conduit and ileal orthotopic neobladder were the most popular methods for urinary diversion following radical cystectomy. Stenting the anastomosis of ileo-ureter or ureter-neobladder was a common practice. However, it is still controversial if ureteral stents could prevent complications such as ureteroileal anastomosis stricture (UIAS) and ureteroileal anastomosis leakage (UIAL) after ureteral anastomosis.

OBJECTIVES

This study aims to investigate the role of the ureteral stent in preventing UIAS and UIAL.

DATA SOURCES

We systematically searched the related studies in PubMed, Embase, and Cochrane Library up to June 2020.

STUDY ELIGIBILITY CRITERIA

Cohort studies that identified the use of stent and the incidence of UIAS or UIAL were recorded.

DATA SYNTHESIS

Comparative meta-analysis was conducted on four cohort studies for comparison of UIAS and UIAL between the stented and nonstented groups. Besides, eleven studies which reported the events of UIAS and UIAL were used for meta-analysis of single proportion.

RESULTS

A total of 11 studies were qualified for analysis. Comparative meta-analysis identified that the incidence of UIAS was higher in the stented group than that in the nonstented group, but this did not reach a significant difference (odds ratio [OR]: 1.64; 95% confidence interval [CI]: 0.88-3.05; P = 0.12). Besides, there was no difference in the incidences of UIAL between the stented and the nonstented groups. On meta-analysis of single proportion, the incidence of UIAS was 7% (95% CI: 3%-10%) in the stented group and 3% (95% CI: 1%-6%) in the nonstented group. The UIAL rate was 1% (95% CI, 0%-4%) in stented patients and 2% (95% CI, 1%-4%) in nonstented patients.

CONCLUSION

Stenting the ureteroileal anastomosis resulted in a higher incidence of UIAS. There is no evidence to support ureteral stents could prevent the occurrence of UIAL after urinary diversion.

The Pull-through Anastomosis of Ureter to Enteric Conduit (PAUTEC): A Novel Technique for Urinary Diversion

OBJECTIVE

To describe and illustrate a novel technique of uretero-ileal anastomosis for use in urinary diversion - the Pull-through Anastomosis of Ureter To Enteric Conduit (PAUTEC). A second objective was to evaluate the surgical outcomes of the PAUTEC anastomosis.

MATERIALS AND METHODS

Our novel anastomotic technique was described step-by-step and visually depicted with illustrations and the accompanying narrated video. Additionally, to evaluate safety and efficacy, a retrospective review of a prospectively maintained database was performed. Patients who underwent radical cystectomy alone or during pelvic exenteration, with ileal conduit diversion incorporating PAUTEC, 2016-2020 with ≥6 months follow-up were included. Surgical outcomes and renal function were analysed.

RESULTS

PAUTEC anastomosis was performed on 43 ureters in 23 patients. Mean age was 66 years [50-80] and 21 of 23 patients were male. One patient had a conservatively-managed small urine leak. No ureteric strictures have been identified to date. Mean serum creatinine was 1.15 mg/dL [0.69-2.08] (102umol/L, range 61-184 umol/L) preoperatively, and 1.09 mg/dL [0.61-2.59] (96.3 umol/L, range 54-229 umol/L) at follow-up, demonstrating no significant change (P= .26, paired t-test). Mean follow-up was 15 months [6-44].

CONCLUSION

A PAUTEC technique of uretero-ileal anastomosis is feasible and technically straightforward, with satisfactory outcomes observed to date.

Surgical management of urinary diversion and stomas in adults: multidisciplinary Italian panel guidelines

BACKGROUND

Urinary stomas represent a worldwide medical and social problem. Data from literature about stoma management are extensive, but inhomogeneous. No guidelines exist about this topic. So, clear and comprehensive clinical guidelines based on evidence-based data and best practice are needed. This article aims to elaborate guidelines for practice management of urinary stomas in adults.

METHODS

Experts guided review of the literature was performed in PubMed, National Guideline Clearing-house and other databases (updated March 31, 2018). The research included guidelines, systematic reviews, meta-analysis, randomized clinical trials, cohort studies and case reports. Five main topics were identified: "stoma preparation", "stoma creation", "stoma complications", "stoma care" and "stoma reversal". The systematic review was performed for each topic and studies were evaluated according to the GRADE system, AGREE II tool. Recommendations were elaborated in the form of statements with an established grade of recommendation for each statement. For low level of scientific evidence statements a consensus conference composed by expert members of the major Italian scientific societies in the field of stoma management and care was performed.

RESULTS

After discussing, correcting, validating, or eliminating the statements by the experts, the final version of the guidelines with definitive recommendations was elaborated and prepared for publication. This manuscript is focused on statements about surgical management of urinary stomas. These guidelines include recommendations for adult patients only, articles published in English or Italian and with complete text available.

CONCLUSIONS

These guidelines represent the first Italian guidelines about urinary stoma multidisciplinary management with the aim to assist urologists and stoma specialized nurses during the urinary stoma management and care.

A new technique in the treatment of ureteroenteric anastomosis stricture: Repair of ureteroenteric anastomosis stricture with low lombotomy incision (retroperitoneal approach)

INTRODUCTION AND AIM

Ureteroenteric anastomosis stricture (UEAS) is one of the complications of urinary diversion and may lead to serious consequences. In this study, we evaluated our UEAS revision technique outcomes performed with a low lombotomy incision in the lateral decubitus position.

MATERIALS AND METHODS

Eleven patients who underwent surgical repair due to isolated right UEAS between January 2010 and June 2019 were included in the study. Anastomosis stricture was confirmed by ultrasonography, computed tomography or magnetic resonance urography techniques. Ultrasonography was used to detect hydronephrosis, which is a finding secondary to stricture. However, opaque urography imaging methods were used to confirm the definitive diagnosis of the stricture. Demographic and clinical data, preoperative and postoperative 3rd month serum creatinine, estimated glomerular filtration rate (eGFR) and dynamic renal scintigraphy data of patients were evaluated.

RESULTS

The mean operation time was 49.7 ± 9.3 minutes. No perioperative complications were observed. While the overall stricture rate was 11.4%, the isolated right-sided stricture rate was 5.7%. Preoperative and postoperative serum creatinine values were similar. Preoperative eGFR value was 58.8 ± 12.9 mL/min/1.73 m² and postoperative value was 53.5 ± 11.5 mL/min/1.73 m² . T½ level decreased in postoperative period (22.3 ± 8.2 min vs 15.1 ± 4.3 min).

CONCLUSIONS

Open revision of the UEAS with retroperitoneal approach provides lower morbidity rates and shorter hospitalisation time compared to other methods. The retroperitoneal approach is the main advantage of this technique and prevents morbidity caused by other techniques performed intraperitoneally and owing to it is an open technique, it can be easily applied in isolated right-sided UEAS.

Contemporary techniques and outcomes of robotic assisted radical cystectomy with intracorporeal urinary diversion

The open approach to radical cystectomy continues to be accompanied by significant morbidity despite enhanced recovery protocols (ERP). Robotic assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) has become an increasingly popular technique for removal of aggressive bladder cancer and subsequent urinary diversion. Randomized clinical trials comparing the robotic and open techniques address the uncertainty surrounding oncological efficacy of the RARC and show that RARC is at least comparable to open radical cystectomy (ORC) in terms of oncologic adequacy and survival. Although RARC with ICUD is a technically challenging procedure, surgeons have noted ergonomic advantages while patients experience less blood loss and quicker time to recovery and to adjuvant chemotherapy (AC), if necessary. Even with these benefits, there is a paucity of data describing outcomes of ICUD. For those surgeons who have switched to ICUD, priority remains standardization of a protocol for the reconstructive component and for a safe transition from extracorporeal urinary diversion (ECUD) to ICUD. Additionally, there is a need for evidence of reduced financial toxicity for the patient, as well as more comprehensive cost-effectiveness analyses. The literature from this review represents 10 years of accumulating data on techniques and outcomes of RARC with ICUD.

Functional results of hautmann neobladder with chimney modification and wallace ureteroileal anastomosis: initial experience with 22 patients

OBJECTIVE

To assess the functional outcomes and complications of modified Hautmann neobladder with Wallace ureteroileal anastomosis on a 6-8 cm long isoperistaltic chimney, following radical cystectomy.

MATERIALS AND METHODS

Between January 2015 and October 2019, 22 patients (18 men and 4 women) underwent radical cystectomy and Hautmann neobladder reconstruction with chimney modification and Wallace I ureteroileal anastomosis. The mean age of patients was 61 years (45-74 years). All procedures were performed by the same surgeon and the mean follow-up was 29.4 months. Complications were registered as early (occurring within 3 months) or late (occurring after 3 months), with particular attention addressed to the ureteroileal anastomotic stricture and anastomotic leakage rate. Patient evaluation also included symptom analysis for daytime continence and voiding frequency.

RESULTS

Ureteroileal anastomotic stricture was not detected as a cause of hydronephrosis. Hovewer, the anastomotic leakage occurred in one patient during the early postoperative period. Early complications occurred in 9 patients and the most common was bilateral hydronephrosis, detected in 5 examinees. Late complications occurred in 4 patients. Complete daytime and nighttime continence achieved in 18 and 16 patients respectively, with two patients (9%) still required intermittent catheterization three months after surgery.

CONCLUSIONS

The functional results with modified Hautmann neobladder, incorporating short afferent limb in Wallace I uretero-enteric anastomosis, were efficient. This technique is an effective way to minimize potential uretero-enteric stricture, anastomotic leakage and incidence of vesicoureteral reflux.

Endoscopic Procedures in the Treatment of Ureteroenteric Anastomotic Strictures: A Systematic Review and Meta-Analysis

Objective: To evaluate the safety and efficacy of endoscopic procedures for ureteroenteric anastomotic strictures (UESs) after radical cystectomy and urinary diversion. Methods: We performed a meta-analysis of relevant articles through March 2020 using PubMed, Embase, and Cochrane Central Register to assess the efficacy of endoscopic procedures in UES according to the PRISMA and PICOS criteria. The main endpoints were success rate and complications, and we also compared the efficacy of different methods and stricture length and side in UES. Cochrane Collaboration's Revman version 5.3 and Stata version 15.1 software were used for statistical analysis. Results: A total of 18 retrospective studies with 697 patients were included. The median follow-up ranges from 12 to 62.5 months. Patients treated with endoscopic procedures had an overall success rate of 46%. The pooled rate of Clavien-Dindo ≥ 3 complications was 3.8% among included studies. Laser vaporization and stent insertion (48 and 47%) had a relatively high success rate than balloon dilatation (35%). In subgroup analysis, the success rate of endoscopic procedures for ≤ 1-cm strictures was significantly higher than that for >1-cm ones [odds ratio (OR), 8.65; 95% confidence interval (CI), 3.53-21.21; P < 0.00001]. In addition, the success rate in cases with strictures of the right side was relatively higher than that in cases with strictures of the left side (OR, 1.72; 95% CI, 1.05-2.81; P = 0.03). Conclusion: Our pooled studies showed that endoscopic operation is feasible and associated with a moderate success rate along with a relatively low incidence of perioperative complications in the treatment of UES, especially with length ≤ 1 cm and right side. Although there is still no consensus on endoscopic technique for UES regarding balloon dilatation, stent insertion, and laser vaporization, we believe that endoscopic management is a safety and available approach for UES with close follow-up.

Available active surveillance follow-up protocols for small renal mass: a systematic review

PURPOSE

To evaluate follow-up strategies for active surveillance of renal masses and to assess contemporary data.

METHODS

We performed a comprehensive search of electronic databases (Embase, Medline, and Cochrane). A systematic review of the follow-up protocols was carried out. A total of 20 studies were included.

RESULT

Our analysis highlights that most of the series used different protocols of follow-up without consistent differences in the outcomes. Most common protocol consisted in imaging and clinical evaluation at 3, 6, and 12 months and yearly thereafter. Median length of follow-up was 42 months (range 1-137). Mean age was 74 years (range 67-83). Of 2243 patients 223 (10%) died during the follow-up and 19 patients died of kidney cancer (0.8%). The growth rate was the most used parameter to evaluate disease progression eventually triggering delayed intervention. Maximal axial diameter was the most common method to evaluate growth rate. CT scan is the most used, probably because it is usually more precise than kidney ultrasound and more accessible than MRI. Performing chest X-ray at every check does not seem to alter the clinical outcome during AS.

CONCLUSION

The minimal cancer-specific mortality does not seem to correlate with the follow-up scheme. Outside of growth rate and initial size, imaging features to predict outcome of RCC during AS are limited. Active surveillance of SRM is a well-established treatment option. However, standardized follow-up protocols are lacking. Prospective, randomized, trials to evaluate the best follow-up strategies are pending.

Uretero-Enteric Anastomotic Stricture Following Radical Cystectomy: A Comparison of Open, Robotic Extracorporeal, and Robotic Intracorporeal Approaches

OBJECTIVES

To compare the incidence of benign uretero-enteric anastomotic strictures between open cystectomy, robotic cystectomy with extracorporeal urinary diversion, and robotic cystectomy with intracorporeal urinary diversion. The effect of surgeon learning curve on stricture incidence following intracorporeal diversion was investigated as a secondary outcome.

PATIENTS AND METHODS

Patients who underwent radical cystectomy at an academic hospital between 2011 and 2018 were retrospectively reviewed. The primary outcome, incidence of anastomotic stricture over time, was assessed by a multivariable Cox proportional hazards regression. A Cox regression model adjusting for sequential case number in a surgeon's experience was used to assess intracorporeal learning curve.

RESULTS

Nine hundred sixty-eight patients were included: 279 open, 382 robotic extracorporeal, and 307 robotic intracorporeal. Benign stricture incidence was 11.3% overall: 26 (9.3%) after open, 43 (11.3%) after robotic extracorporeal, and 40 (13.0%) after robotic intracorporeal. An intracorporeal approach was associated with anastomotic stricture on multivariable analysis (HR 1.66; P = .05). After 75 intracorporeal cases, stricture incidence declined from 17.5% to 4.9%. Higher sequential case volume was independently associated with reduced stricture incidence (Hazard Ratio per 10 cases: 0.90; P = .02).

CONCLUSION

An intracorporeal approach to urinary reconstruction following robotic radical cystectomy was associated with an increased risk of benign uretero-enteric anastomotic stricture. In surgeons' early experience with intracorporeal diversion the difference in stricture incidence was more pronounced compared to alternative approaches; however, increased intracorporeal case volume was associated with a decline in stricture incidence leading to a modest difference between the 3 surgical approaches overall.

Validation of the effectiveness of a modified Studer orthotopic neobladder in a single center after 3 years of its application

INTRODUCTION AND OBJECTIVE

In this study, we reported the 2 years outcomes of orthotopic neobladder diversion according to the Studer modified technique described by Bianchi G. et al. This technique improves the stability of the reservoir and the urine-storage capacity. After radical cystectomy, urinary diversion is created with a spheroidal-shaped reservoir with a conic distal-part, obtained with 40 cm detubulized ileal segment, and a 15 cm of tubular afferent limb, where a Wallace ureteral anastomoses is made. The conic distal part of the neobladder that is anastomized to the urethral stump. After the reconstructive part, the neobladder and the afferent limb are attached to the elevator ani and psoas muscles, respectively.

MATERIALS AND METHODS

In all, 18 patients underwent radical cystectomy with the reconstruction of urinary diversion with the Modified-Studer Orthotopic technique, at S. Giuseppe Hospital. We studied the post-operative years of follow-up, especially with anamnesis of lower urinary tract, axial computerized tomography, and blood tests, according to the EAU guidelines.

RESULTS

We discover with TC 2 cases of low-grade bilateral hydronephrosis, associated with a slight increase in creatinine levels (1.4-1.8 mg/dL). No stricture at the neobladder-urethral anastomosis was detected. Three patients complain daytime urinary incontinence; only two patients report nocturnal urinary incontinence. One patient underwent ureteroscopy for lithiasis and 1 patient died for non-onco-urological disease.

CONCLUSION

The modifications we applied to the Studer-Neobladder seems to improve urinary tract restoration, potentially decreasing long-term complications like hydronephrosis connected to ureteral anastomotic stenosis (11.1% vs 16.9% reported in literature) and urinary retention (0% vs 12% reported in literature). However, we discovered the same risk of diurnal and nocturnal incontinence reported in literature for the classic Studer Neobladder.

Persistent, long-term risk for ureteroenteric anastomotic stricture formation: the case for long term follow-up

Background

Up to one in ten patients undergoing cystectomy with urinary diversion develop a ureteroenteric stricture (UES). Despite unrecognized ureteral obstruction contributing to infection, nephrolithiasis, and/or progression of kidney disease, the long-term natural history and risk factors associated with UES remains understudied. Herein, we report our single institutional experience with the long-term incidence, clinical presentation, and risk factors associated with UES formation following urinary diversion.

Methods

We reviewed 2,285 patients who underwent RC with urinary diversion between 1980-2008. UES was defined as radiographic evidence of ureteral obstruction at the level of the ureteroenteric anastomosis. The diagnosis of benign UES was confirmed by pathology. UES-free survival was estimated using the Kaplan-Meier method. The association between clinicopathologic features and the development of a UES were assessed using multivariable models.

Results

A total of 192 (8%) patients developed a benign UES, at a median of 7 months (IQR 4-24) following RC, with 5% occurring after 10 years. Seventy seven percent of patients exhibited signs and/or symptoms of ureteral obstruction. Patients who developed a UES had a greater body mass index (BMI) (28 vs. 27), operative time (330 vs. 301 minutes) and were more likely to experience a <30-day Clavien ≥3 complication (all P<0.05). Receipt of abdominal radiation and smoking history were not significantly associated with UES stricture risk. On multivariable analysis, only greater BMI (per 1-unit increase) (OR 1.06, 95% CI: 1.02-1.09; P=0.0009) and <30-day Clavien ≥3 complication (OR 2.85, 95% CI: 1.90-4.28; P<0.0001) were associated with the development of a UES. Development of UES was associated with renal function deterioration.

Conclusions

UES was identified in 8% of patients following RC with urinary diversion, with the majority presenting with symptoms. While the majority of these occur in the first 2 years after surgery, a patients' risk for the development of this complication persists beyond 10 years. Due to the adverse sequelae of UES, long-term functional and imaging surveillance following urinary diversion is warranted, and early reconstruction should be considered.

Comparison of the Perioperative and Postoperative Outcomes of Ileal Conduit and Cutaneous Ureterostomy: A Propensity Score-Matched Analysis

INTRODUCTION

To compare perioperative and postoperative outcomes related to urinary diversion (UD) between ileal conduit and cutaneous ureterostomy following open radical cystectomy (ORC).

METHODS

This retrospective study included 232 patients with bladder cancer who underwent ORC and subsequent UD (ileal conduit, n = 123; cutaneous ureterostomy, n = 109) at Kobe University and related hospitals between January 2007 and December 2016. A propensity score method was used to adjust the preoperative status of the two groups, and the perioperative and postoperative outcomes were compared between matched cohorts. In addition, we evaluated several factors predicting renal deterioration.

RESULTS

In the matched cohorts, 87 patients were included in each group. While the operative time and postoperative fasting periods were significantly longer in patients with ileal conduit in comparison to those with cutaneous ureterostomy (both p < 0.001), there were no differences in blood loss or duration of hospitalization. Although the incidence of grade ≥III perioperative complications was similar between the two groups, the incidence of postoperative recurrent pyelonephritis in the cutaneous ureterostomy group was significantly higher than that in the ileal conduit group (25.3 and 11.4%, respectively; p = 0.030), and cutaneous ureterostomy was identified as a significant predictor of a decrease in the estimated glomerular filtration rate with an odds ratio of 2.13 (95% confidence interval, 1.19-3.85; p = 0.010).

CONCLUSIONS

The perioperative safety of ileal conduit was comparable to that of cutaneous ureterostomy, and cutaneous ureterostomy was a significant risk factor for pyelonephritis and subsequent renal deterioration, suggesting that ileal conduit may be preferable to cutaneous ureterostomy.

Internal double-J stent was associated with a lower incidence of ureteroileal anastomosis stricture than external ureteral catheter for patients undergoing radical cystectomy and orthotopic neobladder: A systematic review and meta-analysis

OBJECTIVE

Proper techniques used in procedures might play an important role in reducing ureteroileal anastomosis stricture (UIAS) for patients undergoing orthotopic neobladder. The present study was to evaluate the efficacy of internal double-J stent versus external ureteral catheter on UIAS for patients undergoing radical cystectomy and orthotopic neobladder.

METHODS

A comprehensive search of the literature referring to the topic was performed on 10th January 2019 in PubMed, EMBASE and Google Scholar, by using key words as radical cystectomy, orthotopic neobladder, stricture, stenosis. The Cochrane Collaboration's RevMan 5.3 software was employed for data analysis. The incidence of UIAS was evaluated as primary outcome.

RESULTS

Five studies were included eventually. The incidence of UIAS was lower in the group of internal double-J stent than that in the group of external ureteral catheter (odds ratio [OR], 0.49; 95% CI, 0.25-0.97; p = 0.04) with a low heterogeneity (I² = 0%). Besides, internal double-J stent group had a trend of a shorter length of stay than external ureteral catheter group.

CONCLUSIONS

Based on the present meta-analysis, internal double-J stent placement was associated with a lower incidence of UIAS than external ureteral catheter for patients undergoing orthotopic neobladder. In addition, a trend of a shorter hospital stay was also detected, thus, internal double-J stent placement may be favored in the view of the enhanced recovery after surgery (ERAS).

Ureteroenteric strictures: a single center experience comparing Bricker versus Wallace ureteroileal anastomosis in patients after urinary diversion for bladder cancer

Background

To evaluate the outcome and complication rate in a single institution experience using the two most commonly used techniques of ureteroenteric anastomosis, the Bricker and Wallace anastomosis.

Methods

A total of 137 patients underwent ileal conduit for bladder cancer. Ureters were anastomosed by two experienced surgeons, one performing a Bricker and the other, a Wallace anastomosis. Stricture was identified during clinical follow-up.

Results

Seventy-five patients underwent a Bricker anastomotic, and 65 received a Wallace anastomosis. The average age was 70 in both groups, males were predominant (66% Bricker, 70% Wallace). Follow up period was 36.5 months in Bricker group and 17 months in Wallace group. In both groups, the body mass index (BMI) was similar (26.1 kg/m² Bricker and 26.4 kg/m² Wallace). We observed that the stricture rate after performing the Bricker anastomosis technique was 25.3% (19/75) as compared to 7.7% (5/65) after Wallace anastomosis technique, which was statistically significant (p = 0.001). In the Bricker group, patients with strictures had higher BMI (28.3 vs. 25.7 kg/m², p = 0.05). On average it took 8.5 months in the Bricker group and three months in the Wallace group (p = 0.6) to develop stricture.

Conclusions

The stricture rate was significantly higher when Bricker technique was applied. Although the BMI was not different in both groups, patients with a higher BMI were more likely to develop stricture. We believe that the approach of the separate and refluxing technique of Bricker anastomosis especially in obese patients poses a higher risk for anastomotic stricture formation.

An improved ileal conduit surgery for bladder cancer with fewer complications

BACKGROUND

Radical cystectomy and urinary diversion remains the standard surgical treatment for patients with muscle-invasive or high-risk or recurrent non-muscle-invasive bladder cancer. Although this approach prolongs patient survival remarkably, there are postoperative complications associated with urinary diversion. This study aimed to assess the efficacy of modified ileal conduit surgery for reducing early and late stoma- and ureteroileal anastomosis-related complications, as compared with conventional ileal conduit urinary diversion.

METHODS

We retrospectively evaluated the clinical data of bladder cancer patients treated with radical cystectomy and ileal conduit urinary diversion at Sun Yat-sen University Cancer Center between January 1, 2000 and June 30, 2016. Ileal conduit was created by the conventional or a modified technique. The clinicopathologic features of the conventional and the modified ileal conduit groups were compared using the t test and the Chi square test. Multivariable logistic regression analysis and multivariable Cox regression analysis were performed to determine the odds of developing stoma- and ureteroileal anastomosis-related complications in the two groups.

RESULTS

145 and 100 patients underwent the modified and conventional ileal conduit surgery, respectively. The two groups were comparable with regard to clinicopathologic features. The rate of stoma-related complications was significantly lower in the modified ileal conduit group than in the conventional ileal conduit group (0.7% vs. 17.0%, P < 0.001). No late stoma-related complications were seen in the modified ileal conduit group, but were seen in 13 (13.0%) patients in the conventional ileal conduit group. The rate of ureteroileal anastomosis-related complications was significantly lower in the modified ileal conduit group than in the conventional ileal conduit group (4.8% vs. 15.0%, P = 0.001). In multivariable analyses, the modified ileal conduit group was significantly less likely to develop stoma- (odds ratio [OR] = 0.024, 95% confidence interval [CI] 0.003-0.235; P = 0.001) or ureteroileal anastomosis-related complications (OR = 0.141, 95% CI 0.042-0.476; P = 0.002) than the conventional ileal conduit group.

CONCLUSIONS

Our modified surgical technique for ileal conduit urinary diversion may be effective for reducing early and late complications related to the stoma and the ureteroileal anastomosis. Prospective randomized clinical trials are needed to confirm our results.

Use of indocyanine green to minimise uretero-enteric strictures after robotic radical cystectomy

OBJECTIVE

To evaluate the impact of indocyanine green (ICG) for assessing ureteric vascularity on the rate of uretero-enteric stricture formation after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD).

PATIENTS AND METHODS

We identified 179 patients undergoing RARC and ICUD between January 2014 and May 2017, and divided the patients into two groups based on the utilisation of ICG for the assessment of ureteric vascularity (non-ICG group and ICG group). We retrospectively reviewed the medical records to identify the length of ureter excised. Demographic, perioperative outcomes (including 90-day complications and readmissions), and the rate of uretero-enteric stricture were compared between the two groups. The two groups were compared using the t-test for continuous variables and the chi-squared test for categorical variables. A P < 0.05 was considered statistically significant.

RESULTS

A total of 132 and 47 patients were in the non-ICG group and the ICG group, respectively. There were no differences in baseline characteristics and perioperative outcomes including operating time, estimated blood loss, and length of stay. The ICG group was associated with a greater length of ureter being excised during the uretero-enteric anastomosis and a greater proportion of patients having long segment (>5 cm) ureteric resection. The median follow-up was 14 and 12 months in the non-ICG and ICG groups, respectively. The ICG group was associated with no uretero-enteric strictures compared to a per-patient stricture rate of 10.6% and a per-ureter stricture rate of 6.6% in the non-ICG group (P = 0.020 and P = 0.013, respectively).

CONCLUSION

The use of ICG fluorescence to assess distal ureteric vascularity during RARC and ICUD may reduce the risk of ischaemic uretero-enteric strictures. The technique is simple, safe, and reproducible. Larger studies with longer follow-up are needed to confirm our findings.

Laparoscopic Radical Cystectomy With Extracorporeal Neobladder: Our Initial Experience

OBJECTIVE

To illustrate our technique to construct the Institute of Urology Peking University (IUPU) orthotopic ileal bladder and present our initial experience.

METHODS

From August 2017 to April 2018, 12 patients with bladder cancer underwent radical cystectomy (RC), pelvic lymph node dissection and extracorporeal construction of an IUPU neobladder (IUPUB) by an experienced surgeon. We present the demographic, clinicopathologic, perioperative, and follow-up data. We also describe our step-by-step surgical technique for the IUPUB in this article.

RESULTS

Laparoscopic RC with an extracorporeal IUPUB was successfully accomplished in 11 patients, and 1 patient was converted to open RC with an IUPUB. The median total operative time and median time spent suturing the pouch were 248 minutes and 23 minutes, respectively. The median estimated blood loss was 150 mL. The median time to recovery of bowel function (tolerance of a liquid diet) was 3½ days. The urinary catheter was removed on post-operative day 21 in 10 patients. The ureteral stents and stoma catheter were removed on day 7 after cystography. At a median followup of 7½ months, 2 patients had early complications (<30 days), and no major complications (grade ≥ 3) occurred. The follow-up outcomes were satisfactory. The limitations included the small sample size and short-term outcomes.

CONCLUSION

Our technique of constructing the IUPUB is feasible and safe. The operative time and early complication rates are acceptable.

A prospective study of the utility of a routine ‘loopogram’ at three months for the early detection of anastomotic stricture post-cystectomy and conduit urinary diversion

Objective:

The objective of this study is to evaluate the utility of routine loopogram follow-up three months after cystectomy and urinary diversion in the early detection of benign ureteroileal anastomotic stricture (UAS).

Materials and methods:

A loopogram was incorporated into our standard follow-up three months after cystectomy and conduit urinary diversion in August 2010–December 2015. Data were maintained prospectively in a database.

Results:

A total of 250 patients (181 male; 69 female); median age of 70 years (range: 38–83) underwent cystectomy and conduit urinary diversion during this period. Of these, 167 (66.8%) had a routine loopogram at three months. Seven of 167 were confirmed to have a benign UAS. Twenty-three of 250 (9.2%) had an early loopogram prior to the planned three-month study in response to symptoms. Nine of 23 were diagnosed with benign UAS. Sixty of 250 (24%) did not have a routine loopogram for a variety of reasons. Five patients with normal three-month loopograms developed late strictures after a median time of 22 months (range 5–38). In total 21/250 (8.4%) patients developed UAS. Stricture rates for the open, robotic and laparoscopic modalities were 8/129 (6.2%), 12/111 (10.8%) and 1/10 (10%) respectively. Five of seven of patients with early, asymptomatic UAS diagnosed on routine loopogram received treatment; four of five had improvement in renal function.

Conclusion:

Overall stricture rate in this series was 8.4%. The majority of UAS occur early and are more likely to be symptomatic. A policy of routine loopogram benefitted only 4/250 (1.6%) patients. We advocate the use of loopograms in cases with a high index of suspicion rather than for routine screening.

Level of evidence:

Not applicable for this multicentre audit.

Robotics and urologic reconstructive surgery

Minimally invasive surgery has made a profound impact on how urologists approach the challenges in reconstruction of the urinary tract. The advent of laparoscopic approaches to reconstructive urology have demonstrated comparable outcomes to open surgery with improved morbidity. The recent adoption of robotic surgery has seen further advancements such as improved visibility and, freedom of movement, and an easier technical learning curve. With these advantages, more reconstructive urology procedures are being performed robotically. Herein, we review reconstructive urology procedures for which robotics have been applied.

Diabetes and elevated urea level predict for uretero-ileal stricture after radical cystectomy and ileal conduit formation

INTRODUCTION

Benign uretero-ileal anastomotic stricture is a significant complication following radical cystectomy and ileal conduit urinary diversion after radical cystectomy. We examined risk factors for stricture formation to predict those at greatest stricture risk.

METHODS

A retrospective chart review was conducted for patients undergoing radical cystectomy and ileal conduit diversion between 2002 and 2012. Demographic data and patient variables were analyzed to determine risk factors for uretero-ileal stricture using multivariate logistic regression.

RESULTS

Over the study period, 133 patients underwent cystectomy and ileal conduit formation, with 14 (10.5%) developing uretero-ileal anastomotic stricture. Diabetes and elevated serum urea level (defined as >7.1 mmol/L) were associated with increased risk for development of uretero-ileal stricture (odds ratio 4.31 and 4.28, respectively; p<0.05 for each).

CONCLUSIONS

In this patient cohort, diabetes and elevated serum urea level were predictive for the development of uretero-ileal anastomotic stricture. Further prospective study with larger patient samples is required.

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.

Lessons from 151 ureteral reimplantations for postcystectomy ureteroenteric strictures: A single-center experience over a decade

OBJECTIVES

Ureteroenteric anastomotic strictures are common after cystectomy with urinary diversion. Endoscopic treatments have poor long-term success, although ureteral reimplantation is associated with morbidity. Predictors of successful open repair are poorly defined. Our objective was to characterize outcomes of ureteral reimplantation after cystectomy and identify risk factors for stricture recurrence.

PATIENTS AND METHODS

We performed a retrospective review of 124 consecutive patients with a total of 151 open ureteral reimplantations for postcystectomy ureteroenteric strictures between January 2006 and December 2015. Baseline clinicopathologic characteristics and perioperative outcomes were examined. Predictors for stricture recurrence were assessed by univariable testing and univariate Cox proportional hazards regression.

RESULTS

Most patients underwent preoperative drainage by percutaneous nephrostomy (PCN; 43%) or percutaneous nephroureterostomy (PCNU; 44%). Major iatrogenic injuries included enterotomies requiring bowel anastomosis (3.2%) and major vascular injuries (2.4%). Overall, 60 (48%) patients suffered 90-day complications, of which 15 (12%) patients had high-grade complications. Median length of stay was 6 days [interquartile range: 5, 8] and median follow-up was 21 months [interquartile range: 5, 43]. The overall success rate per ureter was 93.4%. On univariate analysis, the only significant predictor of stricture recurrence was preoperative PCNU placement compared with PCN placement or no drainage (success rates: 85.5% vs. 98.9%, respectively, P = 0.002). Cox proportional hazards regression demonstrated that preoperative PCNU placement yielded a hazard ratio of 10.2 (95% CI: 1.27-82.6) for stricture recurrence (P<0.005). Stricture recurrence was independent of previous endoscopic interventions (P = 0.42). Stricture length was unable to be assessed.

CONCLUSIONS

Postcystectomy ureteral reimplantation was associated with relatively low rates of major iatrogenic injuries and high-grade complications. Preoperative PCN placement rather than PCNU may yield better results.

Biphasic decline in renal function after radical cystectomy with urinary diversion

BACKGROUND

We evaluated short- and long-term renal function in patients after radical cystectomy with urinary diversion and identified risk factors for the deterioration of renal function.

METHODS

This retrospective study comprised 91 patients who underwent radical cystectomy and urinary diversion for bladder cancer and survived ≥3 years after surgery. The estimated glomerular filtration rate (eGFR) was calculated, and longitudinal changes of eGFR were assessed. Deterioration in renal function in early and late postoperative years was defined as a ≥25 % decrease in the eGFR from preoperative to postoperative year one, and a reduction in the eGFR of >1 mL/min/1.73 m² annually in subsequent years, respectively. Univariate and multivariate logistic regression analyses were used to evaluate its association with clinicopathologic features.

RESULTS

The median follow-up period after surgery was 7 years (range 3-26). The mean eGFR decreased from preoperative 65.1 to 58.9 mL/min/1.73 m² 1 year after the surgery, followed by a continuous decline of ~1.0 mL/min/1.73 m² per year thereafter. Multivariate analyses identified ureteroenteric stricture as the sole risk factor associated with early renal function deterioration [odds ratio (OR) 4.22, p = 0.037]. Diabetes mellitus (OR 8.24, p = 0.015) and episodes of pyelonephritis (OR 4.89, p = 0.038) were independently associated with the gradual decline in the late postoperative period.

CONCLUSION

In cystectomy patients with urinary diversion, the rapid deterioration of renal function observed during the first year after surgery and the gradual but continuous decline in function thereafter were found to be associated with different risk factors.

Outcomes Following First-line Endourologic Management of Ureteroenteric Anastomotic Strictures After Urinary Diversion: A Single-center Study

OBJECTIVE

To assess the outcomes of patients following a first-line systematic endourologic procedure used to treat ureteroenteric anastomotic strictures (UEAS).

MATERIALS AND METHODS

All data from patients treated using a first-line endourologic approach for UEAS between 2010 and 2015 were reviewed retrospectively. The following data were analyzed: age, type of urinary diversion, initial symptoms, surgical endoscopic approach (antegrade or retrograde), pre- and postoperative creatinine levels, and postoperative complications and outcomes. Follow-up visits occurred at 6 weeks, 3 months, and 6 months postoperatively, and at least annually thereafter.

RESULTS

A total of 27 patients (median age: 62.5 years) were included. Overall, 28 UEAS were treated endoscopically (ileal conduit: n = 25; neobladder: n = 3). Most UEAS developed following radical cystectomy for bladder cancer (n = 19). Overall, the endoscopic approach was successful in 20 cases (71.4%). The UEAS length was >1 cm in 21 cases (75%). All UEAS of <1 cm were treated successfully (n = 7). There were three grade II and five grade III complications. The median follow-up period was 25 months. The median creatinine levels before surgery and at last follow-up were 1.3 mg/dL and 0.9 mg/dL, respectively.

CONCLUSION

An endourologic procedure is a reasonable option for first-line treatment for UEAS and has promising functional outcomes and limited morbidity.