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Al-Nader M, Krafft U, Hess J, Kesch C, AbdelRazek M, Abolyosr A, Alsagheer GA, Mohamed O, Fathi A, Tschirdewahn S, Hadaschik BA, Mahmoud O. Bricker versus Wallace ureteroileal anastomosis: A multi-institutional propensity score-matched analysis. Int J Urol 2024; 31:813-818. [PMID: 38644653 DOI: 10.1111/iju.15471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 04/03/2024] [Indexed: 04/23/2024]
Abstract
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.
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Affiliation(s)
- Mulham Al-Nader
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Ulrich Krafft
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Jochen Hess
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Claudia Kesch
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Mostafa AbdelRazek
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Ahmad Abolyosr
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Gamal A Alsagheer
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Omar Mohamed
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Atef Fathi
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | | | | | - Osama Mahmoud
- Department of Urology, University Hospital Essen, Essen, Germany
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
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Mahmoud O, Krafft U, Al-Nader M, Heß J, Kesch C, AbdelRazek M, Abolyosr A, Alsagheer GA, Mohamed O, Fathi A, Hadaschik BA, Tschirdewahn S. Risk factors for ureteroenteric stricture after radical cystectomy and urinary diversion: A systematic review. Arab J Urol 2023; 22:61-69. [PMID: 38205387 PMCID: PMC10776076 DOI: 10.1080/2090598x.2023.2239107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/17/2023] [Indexed: 01/12/2024] Open
Abstract
Introduction Ureteroenteric stricture (UES) is the leading cause of renal function deterioration after radical cystectomy (RC) and urinary diversion (UD). The aim of the present review is to summarize studies that discussed the risk factors associated with UES development. Identifying the responsible factors is of importance to help surgeons to modify their treatment or follow-up strategies to reduce this serious complication. Materials and Methods A comprehensive search of the literature using the PubMed database was conducted. The target of the search was only studies that primarily aimed to identify risk factors of UES after RC and UD. References of searched papers were also checked for potential inclusion. Results The search originally yielded a total of 1357 articles, of which only 15 met our inclusion criteria, comprising 13, 481 patients. All the studies were observational, and retrospective published between 2013 and 2022. The natural history of UES and the reported risk factors varied widely across the studies. In 13 studies, a significant association between some risk factors and UES development was demonstrated. High body mass index (BMI) was the most frequently reported stricture risk factor, followed by perioperative urinary tract infection (UTI), robotic-assisted radical cystectomy (RARC), occurrence of post-operative Clavian grade ≥ 3 complications and urinary leakage. Otherwise, many other risk factors were reported only once. Conclusion The literature is still lacking well-designed prospective studies investigating predisposing factors of UES. The available data suggest that the high BMI, RARC and complicated postoperative course are the main risk factors for stricture formation.
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Affiliation(s)
- Osama Mahmoud
- Department of Urology, University Hospital Essen, Essen, Germany
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Ulrich Krafft
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Mulham Al-Nader
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Jochen Heß
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Claudia Kesch
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Mostafa AbdelRazek
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Ahmad Abolyosr
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Gamal A Alsagheer
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Omar Mohamed
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Atef Fathi
- Department of Urology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
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Tanaka T, Shindo T, Hashimoto K, Kobayashi K, Masumori N. Management of hydronephrosis after radical cystectomy and urinary diversion for bladder cancer: A single tertiary center experience. Int J Urol 2022; 29:1046-1053. [PMID: 35772732 DOI: 10.1111/iju.14970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 06/15/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To clarify the incidence of postoperative hydronephrosis and verify the validity of diagnostic and therapeutic approaches for hydronephrosis after cystectomy and urinary diversion for bladder cancer. METHODS Totally, 290 patients receiving urinary diversion from 2005 through 2017 with complete data were enrolled, including 258 (89.0%) with an ileal conduit and 32 (11.0%) with an ileal neobladder. Postoperative radiographic images were reviewed. In patients with postoperative hydronephrosis, antegrade pyelography and ureteroscopy were performed to exclude malignant etiology. Balloon dilation and open surgical revision were performed according to the conditions. RESULTS Forty-six patients (58 renal units) developed postoperative hydronephrosis. The cumulative incidence was 11.4% by a median follow-up of 59.5 months. Ureteral recurrence was detected by antegrade examinations in two patients, whereas malignant strictures were subsequently revealed in three patients. Thus, malignant etiology was found in hydronephrosis in five renal units (12.8%) of five patients (16.1%). The median times to diagnosis of hydronephrosis were 0 (interquartile range [IQR] 0-4) and 14 months (IQR 9-12) for benign and malignant strictures, respectively (p = 0.003). Of them, 31 patients (39 renal units) received interventions. Balloon dilation was performed in 13 renal units with benign strictures, and was successful in two (15.4%). Open surgical revision was performed in eight patients (11 renal units), including two with failed balloon dilation, all of which was successful. CONCLUSIONS Postoperative hydronephrosis is potentially associated with recurrent disease. Accurate differential diagnosis is challenging although antegrade procedures may be helpful in some cases. Open surgical revision is highly effective to treat benign strictures.
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Affiliation(s)
- Toshiaki Tanaka
- Department of Urology, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Tetsuya Shindo
- Department of Urology, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Kohei Hashimoto
- Department of Urology, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Ko Kobayashi
- Department of Urology, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University, Sapporo, Hokkaido, Japan
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Management of upper urinary tract problems after radical cystectomy for urothelial carcinoma: tips and tricks. Curr Opin Urol 2021; 31:570-573. [PMID: 34138781 DOI: 10.1097/mou.0000000000000905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW After radical cystectomy (RC) patients are at risk for both benign and malignant problems regarding the upper urinary tract (UUT). This review summarizes the recent literature and provides tips on how to manage problems of the UUT after RC. RECENT FINDINGS Disease recurrence, kidney stones and ureteroenteric strictures (UES) are common after RC. Endourological techniques can be used to treat low-grade disease recurrence, either with a retrograde or antegrade approach. Treatment success depends on getting access to the UUT and on tumor characteristics; selecting the right approach is key. Kidney stones can be treated endourologically with good results. With use of minimal invasive techniques such as robot cystectomy, a higher incidence of UES is observed. The use of indocyanine green could help to prevent this complication. In case of a stricture, primary reconstruction should be the treatment strategy of choice. SUMMARY After RC, recurrence of the UUT remains a complicated problem. Choice of treatment method should be tailored to the patient and tumor characteristics. Kidney stones after cystectomy can be successfully managed endourological. Robot assisted RC introduced a higher rate of UES, which should be managed by primary revision.
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Benson CR, Ajay D, Barrett-Harlow BL, Cunningham KG, Bootwala Y, Pendleton C, Li H, Ayoub HI, Graber WJ, Westney OL. Ureteroenteric anastomosis in orthotopic neobladder creation: do urinary tract infections impact stricture rate? World J Urol 2020; 39:1171-1176. [PMID: 32468109 DOI: 10.1007/s00345-020-03266-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 05/16/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Radical cystectomy (RC) and urinary diversion in the treatment of muscle-invasive bladder cancer is associated with peri-operative complication rates as high as 60%. Ureteroenteric anastomotic stricture (UEAS) is a potential source significant morbidity often requiring secondary interventions. We sought to evaluate our experience with benign UEAS in our open ileal orthotopic neobladder (ON) population. METHODS After Internal Review Board (IRB) approval, we performed a retrospective review of patients who had RC and ON between 2000 and 2015 at MD Anderson Cancer Center and had at least 6 months of follow-up. Baseline demographics and treatment characteristics, peri-operative and post-operative outcomes, as well as information regarding anastomosis technique and suture types were evaluated. Patients with malignant ureteral obstruction were excluded from the analysis. RESULTS 418 patients had ON creation and the mean age was 59 years (SD 9.4 years) and 90% were males. The mean follow-up was 57 months (6-183 months). 37 patients (8.9%) developed UEAS in 42 renal units and the mean time to diagnosis was 15.8 months (0.85-90 months). Anastomosis and suture type were not predictive of UEAS (p = 0.594, p = 0.586). Perioperative UTI within 30 days of surgery, and recurrent UTI were predictive of UEAS, HR 2.4 p = 0.03, HR 5.1 p < 0.001, respectively. CONCLUSIONS UEAS are associated with potentially significant morbidity following ON creation. UEAS may occur early following ON, but may occur as late as 7 years following surgery. Indeed, technical factors and surgeon experience contribute to the rates of UEAS, but perioperative UTI appears to herald future stricture development.
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Affiliation(s)
- Cooper R Benson
- Division of Urology, University of Texas at Houston Health Science Center McGovern School of Medicine, Houston, USA.,Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Divya Ajay
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Brittani L Barrett-Harlow
- Division of Urology, University of Texas at Houston Health Science Center McGovern School of Medicine, Houston, USA.,Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Kathryn G Cunningham
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Yasmin Bootwala
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Clay Pendleton
- Division of Urology, University of Texas at Houston Health Science Center McGovern School of Medicine, Houston, USA.,Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Hanhan Li
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Hajar I Ayoub
- Division of Urology, University of Texas at Houston Health Science Center McGovern School of Medicine, Houston, USA
| | - William J Graber
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - O Lenaine Westney
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
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Yang DY, Boorjian SA, Westerman MB, Tarrell RF, Thapa P, Viers BR. Persistent, long-term risk for ureteroenteric anastomotic stricture formation: the case for long term follow-up. Transl Androl Urol 2020; 9:142-150. [PMID: 32055478 DOI: 10.21037/tau.2019.09.05] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- David Y Yang
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Prabin Thapa
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Boyd R Viers
- Department of Urology, Mayo Clinic, Rochester, MN, USA
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A Population-based Study of Ureteroenteric Strictures After Open and Robot-assisted Radical Cystectomy. Urology 2019; 135:57-65. [PMID: 31618656 DOI: 10.1016/j.urology.2019.07.054] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 06/25/2019] [Accepted: 07/18/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate differences in the incidence of benign ureteroenteric stricture, we compared stricture rates of robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC) using Surveillance, Epidemiology, and End Results-Medicare data. METHODS We identified 332 RARC and 1449 ORC performed between 2009 and 2014 to determine stricture rates at 6, 12, and 24 months following surgery. We defined ureteroenteric stricture as the need for procedural intervention. Additionally, we compared the incidence of stricture diagnosis. Multivariable proportional hazards regression was performed to determine factors associated with stricture development. RESULTS The incidence of ureteroenteric stricture at 6 and 12 months was higher for RARC vs ORC at 12.1% vs 7.0% (P < .01) and 15.0% vs 9.5% (P = .01), respectively. RARC vs ORC stricture incidence at 2 years did not differ significantly at 14.6% vs 11.4% (P = .29). Similarly, the stricture diagnosis rates were significantly lower following ORC at 6, 12, and 24 months (P < .05). In adjusted analysis, RARC (HR 1.64, 95%CI 1.23-2.19) and preoperative hydronephrosis (HR 1.51, 95% CI 1.17-1.94) were associated with the development of stricture. Higher hospital volume was associated with a lower risk of stricture (HR 0.40, 95%CI 0.26-0.63). CONCLUSION RARC is associated with a higher rate of ureteroenteric stricture diagnosis and intervention on a population-based level that is mitigated by higher hospital volume. A significant study limitation is inability to differentiate extracorporeal vs intracorporeal diversion. However, a stricture complication compounds the financial burden of care and efforts must be pursued to improve this surgical outcome.
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Scherzer ND, Greenberg JW, Shaw EJ, Silberstein JL, Thomas R, Krane LS. Robotic vs. open surgical management of ureteroenteric anastomotic strictures: technical modifications to enhance success. J Robot Surg 2019; 14:615-619. [PMID: 31586270 DOI: 10.1007/s11701-019-01027-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/16/2019] [Indexed: 11/28/2022]
Abstract
Development of ureteroanastamotic strictures (UAS) after urinary diversion is not uncommon, but is challenging to treat. Poor outcomes are likely with endoscopic and radiologic management, and definitive surgical treatment can cause significant morbidity. The comparative advantages of an operative approach have not yet been fully described in the literature. We retrospectively reviewed the prospectively maintained Tulane University Department of Urology quality assurance database of 12 patients who underwent operative UAS repair between 2012 and 2018. Data were reviewed for operative approach, demographics, baseline disease characteristics, operative variables, and perioperative and pathological outcomes. Of the 12 patients analyzed, 5 underwent open repair (OR) (2 bilateral, 2 right, 1 left) and 7 underwent robotic repair (RR) (3 right, 4 left). One robotic case required conversion to open due to significant intestinal and peri-ureteral adhesions. The median ages were 59 years in OR and 60 years in RR. Two patients in each group had failed previous endoscopic repair. Median time from cystectomy to treatment of enteroanastamotic stricture was 13 months for OR and 10 months for RR (p = 0.25). Median estimated blood loss was 80 mL in both OR and RR (p = 1.0), median operative time was 260 min in OR and 255 min in RR (p = 0.13), and median hospital stay was 8 and 4 days, respectively (p = 0.06). There were two intra-operative and one post-operative complication in the OR group, one of whom required further surgical intervention, and no complications in the robotic cohort. A minimally invasive, robotic approach offers a non-inferior alternative to OR with similar outcomes for appropriately selected patients with UAS. High success rates combined with minimal morbidity may provide definitive therapy at an earlier stage of the stricture state.
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Affiliation(s)
- Nickolas D Scherzer
- Department of Urology, Tulane University School of Medicine, 1430 Tulane Ave, 86-42, New Orleans, LA, 70112, USA
| | - Jacob W Greenberg
- Department of Urology, Tulane University School of Medicine, 1430 Tulane Ave, 86-42, New Orleans, LA, 70112, USA
| | - Eric J Shaw
- Department of Urology, Tulane University School of Medicine, 1430 Tulane Ave, 86-42, New Orleans, LA, 70112, USA
| | - Jonathan L Silberstein
- Department of Urology, Tulane University School of Medicine, 1430 Tulane Ave, 86-42, New Orleans, LA, 70112, USA
| | - Raju Thomas
- Department of Urology, Tulane University School of Medicine, 1430 Tulane Ave, 86-42, New Orleans, LA, 70112, USA
| | - L Spencer Krane
- Department of Urology, Tulane University School of Medicine, 1430 Tulane Ave, 86-42, New Orleans, LA, 70112, USA.
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