Experience with ureteroenteric strictures after radical cystectomy and diversion: open surgical revision

Open and Robotic Uretero-enteric Stricture Repair: Early Outcomes and Complications

Objective: To characterize our single institutional experience with robotic and open uretero-enteric stricture (UES) repair. Materials and Methods: We queried our ureteral reconstructive database for UES repair between 01/2017 and 10/2023. Patients with <3 months follow-up were excluded. Prior to surgery, patients underwent ureteral rest (4 weeks) with conversion to nephrostomy tube. Clinical characteristics, complications, reconstructive success (uretero-enteric patency), need for repeat intervention, and renal function were assessed in patients undergoing open and robotic UES reconstruction. Results: Of 50 patients undergoing UES repair during the study period, 45 were included for analysis due to complete follow-up (34 [76%] robotic and 11 [24%] open repair). UES repair was performed in 50 renal units a median of 13 months (interquartile range 7-30) from index surgery, and most often involved the left renal unit (34/50; 68%). Compared with robotic, open cases were significantly more likely to have undergone open cystectomy (100% vs 68%, p = 0.04), have longer strictures (median 4 vs 1 cm, p < 0.001), require tissue substitution (27% vs 3%, p = 0.04), and have lengthier postoperative hospitalization (5 vs 2 days, p < 0.001). There was no significant difference in total operative time (410 vs 322 minutes) or 30d major complications (18% vs 21%). At a follow-up of 13 months, per patient reconstructive success was 100% (11/11) for open and 97% (33/34) for robotic, respectively. Conclusion: In select patients with short UES unlikely to require advanced reconstructive techniques, a robotic-assisted approach can be considered. Careful patient selection is associated with limited morbidity and high reconstructive success.

A modified ureteroileal anastomosis can reduce ureteroileal anastomotic stricture after ileal conduit

PURPOSE

Ileal conduit is commonly employed as a urinary diversion procedure for patients with bladder cancer after radical cystectomy. Studies have reported that ureteroileal anastomotic stricture remains a serious complication following ileal conduit diversion. The aim of this study was to introduce a novel modified technique for ureteroileal anastomosis and evaluate postoperative complications, with a specific focus on the incidence of ureteroileal anastomotic stricture.

METHODS

A prospective single-center, single-surgeon cohort study was conducted on 29 consecutive patients who underwent laparoscopic radical cystectomy with ileal conduit urinary diversion between February 2017 and April 2021. A descriptive statistical analysis was performed where intraoperative variables and postoperative complications were assessed.

RESULTS

All 29 operations were successful with an average operation time of 372.9 ± 94.3 min. The mean follow-up time was 39.62 ± 15.93 months. No cases of UIAS occurred. Three patients (10.3%) had febrile urinary tract infection, three patients (10.3%) had a transient small bowel obstruction, one patient (3.4%) had ileal anastomotic fistula, one patient (3.4%) had ileal conduit leakage, and one patient (3.4%) died 2 months after surgery due to multiple respiratory diseases. One patient (3.4%) had a mild left ureteral obstruction and CT indicated the obstruction site was in front of the iliac vessels where the left ureter had transposed to the right.

CONCLUSION

The modified ureteroileal anastomosis can reduce the incidence of UIAS.

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

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

Percutaneous Ureteral Stent Insertion in Patients with Benign Uretero-Ileal Anastomosis Strictures Who Underwent Radical Cystectomy: Assessing Risk Factors for Stent Patency

We aimed to investigate the risk factors of early double-J ureteral stent (DJUS) dysfunction rates and the long-term patency of DJUSs inserted via a percutaneous approach in patients with benign uretero-ileal anastomosis stricture (UIAS) who had undergone radical cystectomy. In this retrospective study, 63 DJUS placements were placed via a percutaneous nephrostomy tract in 42 consecutive patients between May 2020 and March 2023. The technical success rate was 100% in all patients without major complications. The early dysfunction rate and long-term patency rate were 38.1% (24/63) and 84.2% (32/38), respectively. The blood clot retention grade, balloon dilatation, and length of the ureteral stricture exhibited a significant correlation with early DJUS dysfunction (blood clot retention grade: odds ratio (OR) 6.922 in grade two, p = 0.009; balloon dilatation: OR 0.186, p = 0.017; length of ureteral stricture: OR 8.715, p = 0.035 in moderate stenosis, and 7.646, p = 0.028 in severe stenosis). A multivariate Cox's proportional hazard analysis revealed that blood clot retention grade and length of ureteral stricture were independent predictors of long-term DJUS patency. Percutaneous insertion of the DJUSs was safe and effective in patients with benign UIAS.

Robot-Assisted Repair of Ureteroenteric Strictures After Cystectomy with Urinary Diversion: Technique Description and Outcomes from the European Robotic Urology Section Scientific Working Group

Background: Robot-assisted repair of benign ureteroenteric anastomotic strictures (UAS) provides an alternative to the open approach. We aimed to report short-, medium-, and long-term outcomes for robotic repair of benign UAS, and to provide a detailed video demonstration of critical operative techniques in performing this procedure robotically. Materials and Methods: Between January 2013 and September 2022, 31 patients from seven institutions who previously underwent radical cystectomy and subsequently developed UAS underwent robotic repair of UAS. Perioperative variables were prospectively collected, and postoperative outcomes were assessed. The surgery starts with a lysis of adhesions after previous surgery. Ureters are dissected, and the level of the stricture is identified. The ureter is then divided, and the stricture is resected. Finally, the ureter is spatulated and reimplanted with Nesbit technique after stenting with Double-J stents. In cases where both ureters show strictures, Wallace technique for reimplantation can be applied. Results: After robotic or open cystectomy, 31 patients had a total of 43 UAS at a median (interquartile range) follow-up of 21 (9-43) months. Median stricture length was 2.0 (1.0-3.25) cm, operative duration was 141 (121-232) minutes, estimated blood loss was 100 (50-150) mL, and length of hospital stay was 5 (3-9) days. One (3.2%) case was converted to open and one (3.2%) intraoperative complication occurred. Seven (22.6%) patients experienced postoperative complications, including four (12.9%) Clavien-Dindo grade 3 complications. No Clavien-Dindo grade 4 or 5 complications occurred. Stricture recurrence occurred in 2 (6.5%) patients. Conclusions: These results demonstrate that robotic repair of UAS is feasible and effective approach with outcomes in line with prior open series. Patient Consent Statement: Authors have received and archived patient consent for video recording and publication in advance of video recording of procedure.

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.

Is it necessary to perform a retrosigmoid transposition of the left ureter in Bricker Ileal Conduit surgery?

BACKGROUND

The need for the left ureter to pass through the subsigmoid during ileal conduit diversion surgery has not been investigated in any studies. A modified technique is simply used in the ileal conduit with the left ureter straight over the sigmoid colon due to the possible damage and lack of scientifically validated advantages of this procedure. Our study aimed to investigate the feasibility of the suggested surgical technique, as well as to evaluate perioperative outcomes and postoperative complications with a focus on the prevalence of small bowel obstruction (SBO) and ureteroileal anastomotic stricture (UAS).

METHODS

A prospective single-center cohort of 84 consecutive patients undergoing laparoscopic radical cystectomy (LRC) and ileal conduit urinary diversion was conducted between January 2018 and April 2020. The incidence of SBO and UAS, perioperative outcomes, and postoperative complications were compared between a trial group of 30 patients receiving the modified procedure and a control group of 54 patients receiving the conventional Bricker ileal conduit.

RESULTS

The two groups were comparable concerning patient characteristics and clinicopathologic features. No differences were observed in terms of the operation time, perioperative outcomes, and short-term (< 90 days) postoperative complications between the two groups. There were no occurrences of UAS in the modified group, while there were two cases (3.70%) in the patients who received Bricker's ureteroileal anastomosis (p = 0.535).

CONCLUSION

In the present study, a simple and feasible modified technique of ileal conduit is proposed. Compared with traditional techniques, our method has several advantages, including the ability to avoid compression of the left ureter from the mesentery without establishing a retrosigmoid tunnel, a low rate of UAS, and the ability to perform a secondary operation at long-term follow-up.

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.

Early Warning Models to Predict the 90-Day Urinary Tract Infection Risk After Radical Cystectomy and Urinary Diversion for Patients With Bladder Cancer

Purpose

To develop and validate a nomogram of the 90-day urinary tract infection (UTI) risk for patients with bladder cancer undergoing radical cystectomy (RC) and urinary diversion.

Patients and Methods

The predictive nomogram was based on a retrospective study on the consecutive patients who underwent RC and urinary diversion for bladder cancer between January 2014 and March 2021. The incidence and microbiology of UTI were reported. The univariate and multivariate logistic analyses were conducted to determine independent risk factors associated with UTI. The predictive accuracy and discriminatory ability of the established nomogram were evaluated by the concordance index (C-index) and decision curve analysis (DCA). The performance of the model was validated internally.

Results

A total of 220 patients were included and the incidence of UTI within 90 days was 27.3%. The most commonly identified pathogens were Enterococcus (42.0%), Escherichia coli (21.70%), and Candida (13.0%). Urinary diversion type, Charlson comorbidities index (CCI), stricture, and prognostic nutritional index (PNI) were included in the nomogram. The C-index of the nomogram for predicting UTI was 0.858 (95% CI: 0.593–0.953). In the validation cohort, the nomogram also showed high-predictive accuracy. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) index indicated that PNI led to improvement in predictive ability.

Conclusion

The proposed early warning model shows great accuracy in predicting the incidence of 90-day UTI after RC and urinary diversion in patients with bladder cancer.

Perioperative and Functional Outcomes of Robot-assisted Ureteroenteric Reimplantation: A Multicenter Study of Seven Referral Institutions

Background

Open revision of ureteroenteric strictures (UESs) is associated with considerable morbidity. There is a lack of data evaluating the feasibility of robotic revisions.

Objective

To analyze the perioperative and functional outcomes of robot-assisted ureteroenteric reimplantation (RUER) for the management of UESs after radical cystectomy (RC).

Design, setting, and participants

A retrospective multicenter study of 61 patients, who underwent 63 RUERs at seven high-volume institutions between 2009 and 2020 for benign UESs after RC, was conducted.

Outcome measurements and statistical analysis

Data were reviewed for demographics, stricture characteristics, and perioperative outcomes. Variables associated with being stricture free after an RUER were evaluated using a multivariate Cox regression analysis.

Results and limitations

Among 63 RUERs, 22 were right sided (35%), 34 left sided (54%), and seven bilateral (11%). Twenty-seven (44%) had prior abdominal/pelvic surgery and five (8%) radiotherapy (RT). Thirty-two patients had American Society of Anesthesiologists (ASA) scores I–II (52%) and 29 ASA III (48%). Forty-two (68%) RUERs were in ileal conduits, 18 (29%) in neobladders, and two (3%) in Indiana pouch. The median time to diagnosis of a UES from cystectomy was 5 (3–11) mo. Of the UESs, 28 (44%) failed an endourological attempt (balloon dilatation/endoureterotomy). The median RUER operative time was 195 (175–269) min. No intraoperative complications or conversions to open approach were reported. Twenty-three (37%) patients had postoperative complications (20 [32%] were minor and three [5%] major). The median length of hospital stay was 3 (1–6) d and readmissions were 5%. After a median follow-up of 19 (8–43) mo, 84% of cases were stricture free. Lack of prior RT was the only variable associated with better stricture-free survival after RUER (hazard ratio 6.8, 95% confidence interval 1.10–42.00, p = 0.037). The study limitations include its retrospective nature and the small number of patients.

Conclusions

RUER is a feasible procedure for the management of UESs. Prospective and larger studies are warranted to prove the safety and efficacy of this technique.

Patient summary

In this study, we investigate the feasibility of a novel minimally invasive technique for the management of ureteroenteric strictures. We conclude that robotic reimplantation is a feasible and effective procedure.

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.

Incidence, Etiology, Prevention and Management of Ureteroenteric Strictures after Robot-Assisted Radical Cystectomy: A Review of Published Evidence and Personal Experience

Benign ureteroenteric anastomosis strictures (UESs) are one of many critical complications that may cause irreversible disability following robot-assisted radical cystectomy (RARC). Previous studies have shown that the incidence rates of UES after RARC can reach 25.3%, with RARC having higher UES incidence rates compared to open radical cystectomy. Various known and unknown factors are involved in the occurrence of UES. To minimize the incidence of UES after RARC, our group has standardized the procedure and technique for intracorporeal urinary diversion by applying the following five strategies: (1) wide delicate dissection of the ureter and preservation of the periureteral tissues; (2) gentle handling of the ureter and security of periureteral tissues at the anastomotic site; (3) use of indocyanine green to confirm good blood supply; (4) standardization of the ample ureteral spatulation length for Wallace ureteroenteric anastomosis through objective measurements; and (5) development of an institutional standardized procedure manual. This review focused on the incidence, etiology, prevention, and management of UES after RARC to bring attention to the incidence of this complication while also proposing standardized surgical procedures to minimize its incidence after RARC.

Cumulative incidence of ureteroenteric strictures after radical cystectomy in a population-based Swedish cohort

OBJECTIVE

The incidence of benign ureteroenteric strictures following radical cystectomy (RC) for urinary bladder cancer (UBC) is investigated mainly in single-centre studies from high-volume centres. The aim of this study was to evaluate the cumulative incidence of strictures and risk factors in a population-based cohort.

PATIENTS AND METHODS

Data was collected from Bladder Cancer Data Base Sweden (BladderBaSe). The primary endpoint was stricture with intervention. Secondary endpoint included hydronephrosis both with/without intervention.

RESULTS

In total, 5,816 patients were registered as having had RC due to UBC between 1997 and 2014. After a median follow-up of 23.5 months (IQR = 9.0-63.1 months; range = 0.0-214.0 months), we found that 515 (8.9%) patients underwent intervention for stricture. Seven hundred and sixty-one (13.1%) patients were diagnosed with hydronephrosis without intervention. The cumulative incidence of strictures with intervention was 19.7% (95% CI = 16.7-23.1%) during the 17 years of follow-up. In the first year, the cumulative incidence of strictures was 5.6% (95% CI = 5.0-6.2%), and in the first 2 years 8.4% (95% CI = 7.6-9.3%). For the secondary endpoint, the cumulative incidence was 30.4% (95% CI = 26.7-33.1%) after 17 years. Only the year of RC was associated with stricture incidence in Cox regression analysis, whereas hospital cystectomy volume, patient age and patient sex were not.

CONCLUSION

Ureteroenteric strictures requiring intervention may be more common than previously reported, affecting nearly one fifth of patients who have undergone RC for UBC. The annual incidence was highest in the first 2 years after surgery but the cumulative incidence increased continuously during 17 years of follow-up.

Contemporary management of benign uretero-enteric strictures after cystectomy: a systematic review

INTRODUCTION

Uretero-enteric stricture (UES) is a common post-operative complication after radical cystectomy with urinary diversion. The aim of this systematic review is to discuss the contemporary management of benign UES after cystectomy and to compare the different surgical approaches.

EVIDENCE ACQUISITION

A systematic review was performed from January 2000 through January 2021. Search engines used included PubMed, Embase and Medline databases. Search query was: ((ureteroileal OR uretero-ileal OR ureteroenteric OR ureteroenteric) AND (stricture OR stenosis)) AND (management OR treatment). Study selection followed the PRISMA statement. Studies tackling management of UES, either through open, endoscopic, laparoscopic or robot-assisted approaches, were included in our systematic review.

EVIDENCE SYNTHESIS

Forty-one studies were finally included in this systematic review. No prospective studies were found; all included studies were retrospective. Open surgical repair had a 78-100% success rate, a significant rate of complications, and a low recurrence rate (6-8%). Endourological management decreased complication rate, length-of-stay, and blood loss, with however lower success (15-50%) and higher recurrence rates (62%-91%) compared to open surgery. Robotic assisted surgery showed comparable success rates to open surgery (80-100%), while limiting the number of major complications and hospital length-of-stay.

CONCLUSIONS

Surgical management of UES remains challenging. Open surgery maintains a role given its high success rate, at the cost however of a significant morbidity. On the other hand, endourological procedures offer a favorable and low complication risk, but a low long-term success rate. Robotic-assisted surgery is emerging with a valid resolution of UES as it offers comparable success rates to an open approach, while reducing surgical morbidity. Head-to-head comparisons are awaited to confirm these findings.

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.

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.

A "bridge" technique to replace the obstructed single-J stent in the patient with ileal conduit urinary diversion: a case report

The ureteroileal anastomotic stricture is a complication of ileal conduit urinary diversion. To prevent the hydronephrosis and protect the renal function, a single-J ureteral stent may be needed. However, the most common complication of these patients is single-J stent obstruction. To solve this problem, we describe an easy, useful and low-cost technique to replace the obstructed ureteral stent under radiographic guidance without intervention by flexible cystoscopy or percutaneous nephrostomy. The key steps of our procedure are to identify the location of the stricture, to place the super smooth guide wire into pinhole of the obstructed single-J stent and to get the super smooth guide wire and 5-Fr ureteral catheter across the stricture. Our case was a 40-year-old male patient who was diagnosed as pelvic lipomatosis and received ileal conduit urinary diversion 3 years ago. The left-side ureteroileal anastomotic stricture occurred 1 year after surgery. He refused to repair the stricture by open or other minimal invasive surgery. He regularly changed his ureteral stent with intervals of three months. As the stent was obstructed by the stone, the guide wire couldn’t be inserted through the primary ureteral stent. We used our “bridge” technique to solve his problem successfully. No bleeding and no urinary tract infection were observed after intervention. The urine from the ureteral stent was fluent. We think that this “bridge” technique may be a good choice for the replacement of the obstructed single-J stent in the patients of ileal conduit urinary diversion.

Complications of Ileal Conduits after Radical Cystectomy: Interventional Radiologic Management

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

Long-Term Outcomes of Laser Incision and Triamcinolone Injection for the Management of Ureteroenteric Anastomotic Strictures

Purpose: Benign ureteroenteric anastomotic stricture (UEAS) is a common postoperative complication after urinary diversion with an incidence of 3%-10%. Our objective is to report long-term follow-up of our technique for endoscopically managing UEAS after cystectomy. Materials and Methods: Patients with endoscopically managed benign UEAS after cystectomy were included. Intervention entailed anetegrade flexible ureteroscopy with biopsy followed by laser incision of the stricture and of periureteral and peri-ileal tissues 1 cm below and 1 cm above the stricture into fat. Triamcinolone injection was then performed, followed by balloon dilation of the incised area to 24F. Parallel Double-J ureteral stents or upside down nephrostomy tubes were placed for 6 weeks. CT scans were obtained at 3 months and 1 year after surgery, and renal ultrasound at 6 and 9 months, and then annually. Results: Twenty-one patients, and a total of 24 UEAS were treated. Urinary diversion included ileal conduit (n = 12), neobladder (n = 7), and Indiana pouch (n = 2). Twenty out of 24 strictures had no recurrence, including three patients who had bilateral disease, yielding an overall success rate of 83.3%. The remaining three patients with recurrence had evidence of stricture within 3 months. Follow-up ranged from 8 to 102 months, with a median of 30 months. Conclusions: Patients treated endoscopically for UEAS have been shown to have acceptable immediate success with less morbidity when compared with ureteral reimplantation. Our technique of laser incision, triamcinolone injection, balloon dilation, and temporary stent placement has a success rate of over 80% and is unique in that long-term data confirms the durability of this endoscopic procedure.

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).

Transnephrostomic Indocyanine Green-Guided Robotic Ureteral Reimplantation for Benign Ureteroileal Strictures After Robotic Cystectomy and Intracorporeal Neobladder: Step-By-Step Surgical Technique, Perioperative and Functional Outcomes

Objectives: To describe our surgical technique of robotic ureteroileal reimplantation (RUIR) for ureteroileal anastomosis strictures with the use of near-infrared fluorescence imaging (NIFI) after transnephrostomic antegrade injection of indocyanine green in patients previously treated with robot-assisted radical cystectomy and intracorporeal orthotopic neobladder. Materials and Methods: From March 2015 to December 2017, 10 consecutive patients underwent RUIR in our tertiary referral center. All patients previously underwent percutaneous nephrostomy and at least one antegrade stenting and stricture dilatation attempt. Clinical data were prospectively collected into our institutional dataset. Both perioperative and functional outcomes were assessed. Results: Median time from robotic cystectomy to ureteroileal anastomosis strictures diagnosis was 5 months (interquartile range [IQR] 2-6). Median stricture length was 1.5 cm (IQR 1-2). Median operative time was 140 minutes (IQR 81-155), and median length of stay was 5 days (IQR 3-9). Two patients experienced Clavien grade 2 complications (urinary tract infection requiring antibiotics and blood transfusion, respectively). One patient underwent ileum resection and anastomosis due to bowel perforation (Clavien IIIb). At a median follow-up of 19 months (IQR 14-39), one patient developed a stricture recurrence. No patient developed worsening of renal function (newly onset chronic kidney disease stage 3b-4). Conclusions: Robotic reimplantation for ureteroileal anastomosis strictures is a safe and highly effective procedure, with a high success rate and excellent perioperative and functional outcomes. NIFI provides an easy guide to identify and progressively dissect the ureter.

Comparison of perioperative outcomes and complications of robot assisted radical cystectomy with extracorporeal vs intracorporeal urinary diversion

OBJECTIVES

To compare perioperative outcomes and complications of robot assisted radical cystectomy (RARC) with extracorporeal (ECUD) vs. intracorporeal urinary diversion (ICUD) for bladder cancer.

MATERIAL AND METHODS

Retrospective revision of 43 patients who underwent RARC for bladder cancer between 2015-2018 with at least 3 months of follow-up. The analysis included the initial series of RARC performed by one surgeon with extensive experience in open radical cystectomy.

RESULTS

Forty-three patients, 40 men (93%) and 3 women (7%), with a median age of 65 years (44-83) and mean follow-up of 27.7 months (±20.1) underwent RARC. A ECUD was performed in 22 cases (51%), of whom 10 were ileal conduits (45.5%) and 12 neobladders (54.5), and ICUD in 21 cases (49%), of whom 14 were ileal conduits (66.7%) and 7 neobladders (33.3%). Clinical and preoperative characteristics were similar in both groups. The median operative time was 360 minutes (240-540) and length of hospital stay was 12 days (7-73). Thirty-five patients (81%) had postoperative complications, of whom 10 (23%) were major. Operative time, peroperative complications, pathological stage, positive margins, and number of lymph nodes removed did not significantly differ among groups. Patients who underwent ECUD had a higher rate of uretero-ileal strictures than those with ICUD (45.5% vs. 14.3%, P=.026). Among the neobladders, the ECUD developed a higher rate of urethro-neobladder stricture than the ICUD (33% vs. 0%, P=.044).

CONCLUSIONS

RARC with ICUD achieved peroperative outcomes and complication rates comparable than those with ECUD. The ICUD could reduce the risk of developing uretero-ileal and urethro-neobladder strictures.

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.

Treating benign ureteroenteric strictures: 27-year experience comparing endourological techniques with open surgical approach

PURPOSE

To compare open surgical anastomotic revision with endourological techniques for the treatment of ureteroenteric strictures in patients with urinary diversions.

METHODS

All records of patients treated for ureteroenteric strictures in our clinic between 1989 and 2016 were retrospectively reviewed. In 76 patients, 161 completed procedures were analyzed: 26 open revisions vs. 135 endourological treatments, including balloon dilation, Wallstent and/or laser vaporization.

RESULTS

Median follow-up was 34 months. At 60 months, patency rates were 69% (95% CI 52-92%) after open vs. 27% (95% CI 19-39%) after endo-treatment (p = 0.003); median patency duration was 15.5 vs. 5 months, respectively (p = 0.014). Eventually, 15% of patients required open surgery after primary endo-treatment and 21% received endoscopic re-treatment after primary open surgery. Cox regression analysis revealed no confounding factors among the risk factors added to the model. Complication rates were higher after open surgery (27% Clavien 2, 12% Clavien 3-4 vs. 5% Clavien 1-2, 3% Clavien 3, p = 0.528). Median postoperative hospital stay was 14 days (open) vs. 2 days (endo), p < 0.001. Mean estimated glomerular filtration rate improved with + 17 (open) vs. + 8.1 (endo), p = 0.024. Renal function was compromised in 8% of patients in the open surgery group vs. 6% in the endo-treatment group.

CONCLUSIONS

In these patients, in terms of patency and patency duration, open surgery was superior to endourology. Nevertheless, endourological treatments offer a safe and less-invasive alternative to delay or avoid open surgery, especially in patients who are unfit for open surgery.

Bilateral Ureteroenteric Strictures: A Case of the "Reverse 7"

Anastomotic stricture is a well-known complication of the urinary diversion that accompanies radical cystectomy. Management options range from endoscopic procedures to open surgeries, with a subset of the latter employing bowel as the interposing segment. In this report, we describe a rare patient, who successfully underwent a "Reverse 7" procedure, bypassing strictures at both anastomotic junctions between ureters and neobladder.

Follow-up Management of Cystectomy Patients

Bladder cancer is the sixth leading cancer in the United States. Radical cystectomy is a lifesaving procedure for bladder cancer with or without muscle invasion. Radical cystectomy is performed on 39% of these patients, and 35% will have a life-threatening recurrence. Distant metastases are the most common; local, upper tract, and urethral recurrence can also occur. Surveillance after cystectomy is critical to diagnosing recurrence early. Functional complications after urinary diversion include bowel dysfunction, vitamin B12 deficiency, acidosis, electrolyte abnormalities, osteopenia, nephrolithiasis, urinary tract infections, renal functional decline, and urinary obstruction, which can be reversed when diagnosed early.

Feasibility of expert and crowd-sourced review of intraoperative video for quality improvement of intracorporeal urinary diversion during robotic radical cystectomy

INTRODUCTION

Development of uretero-ileal stricture (UIS) after robotic-assisted radical cystectomy (RARC) may be dependent on surgical technique. Video review of intraoperative technique is an emerging paradigm for surgical quality improvement. We examined whether surgeon-perceived risk of UIS or crowd-sourced assessment of robotic skill are associated with the development of UIS.

METHODS

We conducted a case-control study comparing the operative technique of uretero-ileal anastomoses resulting in clinically significant UIS with the contralateral anastomosis for the same patient. De-identified videos were analyzed by 1) five high-volume surgeons; and 2) crowd workers (Crowd-Sourced Assessment of Technical Skill, C-SATS) to determine Global Evaluative Assessment of Robotic Skill (GEARS) score. Mantel-Haenszel common odds ratio (OR) estimates were calculated to assess the association between surgeon performance and the development of UIS. Logistic regression models were used to examine the association between GEARS scores and the development of UIS.

RESULTS

A total of 10 UIS videos were compared to eight control videos by five surgeons and 2142 crowd workers. Expert surgeons systematically evaluated intraoperative footage, however, no association between the expert mode response and UIS (OR 0.42; 95% confidence interval [CI] 0.05-3.45; p=0.91) was identified. Crowd-sourced assessment was not predictive of UIS (p=0.62).

CONCLUSIONS

We used video review to systematically analyze procedure-specific content and technique. The inability of surgeons to predict UIS may reflect the questionnaire, uncontrolled patient factors, or a lack of power. Crowd-sourced GEARS score was unsuccessful in predicting UIS after RARC.

Simultaneous antegrade and retrograde endoscopic treatment of non-malignant ureterointestinal anastomotic strictures following urinary diversion

Background

The ureterointestinal anastomosis stricture (UAS) is a common complication of urinary diversion after radical cystectomy. For decades, open anastomotic revision remained the gold standard for the treatment of UAS. However, with the advancement in endoscopic technology, mini-invasive therapeutic approaches have been used in its management. Here, we report our experience with and long-term results of combined simultaneous antegrade and retrograde endoscopy (SARE) in the treatment of non-malignant UASs after urinary diversion in a consecutive series of patients.

Methods

From March 2012 to January 2015, there were 32 consecutive patients with 32 non-malignant UASs following radical cystectomy and urinary diversion. Twenty-nine patients were treated with SARE technique and comprised the study group. Using simultaneous antegrade flexible ureteroscope combined with retrograde semi-rigid ureteroscope or nephroscope, partial or complete strictures were managed with laser incision and balloon dilation under direct visualization. A 7/12 Fr graded endopyelotomy stent was left for 3–6 months after the procedure. Success was defined as symptomatic improvement and radiographic resolution of obstruction.

Results

With a median followup of 22 months (6–36), the overall success rate for SARE was 69.0%. Twenty patients with partial stricture had a success rate of 85%, and 9 patients with complete stricture had a success rate of 33.3%. Renal function, hydronephrosis grade, stricture type, and stricture length were significant influences on the outcome (P < 0.05). No complication was observed.

Conclusions

The SARE is a safe and effective treatment for UAS, and may be the only endoscopic treatment approach for complete UAS. While success rate for complete strictures is low compared to open revision, it should be considered as an initial approach given its low overall morbidity. For partial strictures, prudent patient selection results in higher success rates that are nearly comparable to open revision.

Ureteroenteric anastomotic revision as initial management of stricture after urinary diversion

OBJECTIVE

To report our experience with ureteroenteric anastomotic revision as initial treatment of stricture after urinary diversion.

METHODS

An institutional review board-approved retrospective study was carried out. A total of 41 patients who underwent primary ureteroenteric anastamotic revision were identified between 2007 and 2015. Data analyzed included patient characteristics, type of diversion, estimated blood loss, operative time, change in renal function, length of stay, postoperative complications and time with nephrostomy/stent. Success of revision was defined as an improvement in hydronephrosis on radiographic imaging and/or reflux during pouchogram. Predictors of length of stay and complications were analyzed using analysis of covariance.

RESULTS

A total of 50 renal units were revised with a success rate of 100%. The median length of stay was 6 days (2-16 days). There were a total of 15 complications (one major, 14 minor) in 14 patients (33% 30-day complication rate). The most common were wound infection (n = 4) and arrhythmia (n = 4). Robotic revision (n = 5) had a median length of stay of 3 days (2-4) with no complications.

CONCLUSIONS

Primary ureteroenteric anastomotic revisions have an excellent success rate at an experienced center and might obviate the need for multiple interventions. Open revision is associated with mostly minor complications. Robotic revision might reduce the morbidity of open revision in select cases.

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.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Internal versus external ureteric stents for uretero-ileal anastomosis after laparoscopic radical cystectomy with orthotopic neobladder: A prospective comparative study

OBJECTIVE

To prospectively compare the use of external ureteric stents with internal JJ stenting of the uretero-ileal anastomosis in patients undergoing laparoscopic radical cystectomy (LRC) with a Y-shaped ileal orthotopic neobladder (ON).

PATIENTS AND METHODS

The study included 69 patients undergoing LRC with ON. Patients were grouped according to the type of uretero-ileal stents used. An external ureteric stent was used in Group A (33 patients) and a JJ stent was used in Group B (36). We prospectively compared the duration of hospital stay, the incidence of short- and intermediate-term complications in the two study groups.

RESULTS

The mean (SD) follow-up periods were 29.18 (3.94) and 28.19 (3.37) months for patients in Groups A and B, respectively. Perioperative patient characteristics were comparable in the two study groups. The use of JJ stenting was associated with a shorter hospital stay compared with external stenting, at a mean (SD) of 14.63 (3.74) and 6.8 (3.03) days in Groups A and B, respectively (P < 0.001). The incidence of urinary leakage was comparable in the two study groups, at 6.1% in Group A vs 8.3% in Group B (P = 1.0). Strictures of the uretero-ileal anastomosis occurred in two patients (6%) in Group A and confirmed by intravenous urography. All strictures were treated with antegrade JJ fixation.

CONCLUSION

JJ stents could be used as an effective alternative to external ureteric stents to support the uretero-ileal anastomosis. JJ stenting is associated with a shorter hospital stay and similar complication rates compared with external stenting in patients undergoing LRC with ON.

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

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

Detour technique, Dipping technique, or Ileal bladder flap technique for surgical correction of uretero-ileal anastomotic stricture in orthotopic ileal neobladder

Background:

Uretero-ileal anastomotic stricture (UIAS) is a urological complication after ileal neobladder, the initial management being endourological intervention. If this fails or stricture recurs, surgical intervention will be indicated.

Design and Participants:

From 1994 to 2013, 129 patients were treated for UIAS after unsuccessful endourological intervention. Unilateral UIAS was present in 101 patients, and bilateral in 28 patients; total procedures were 157. The previous ileal neobladder techniques were Hautmann neobladder, detubularized U shape, or spherical shape neobladder.

Surgical procedures:

Dipping technique was performed in 74 UIAS. Detour technique was done in 60 renal units. Ileal Bladder flap was indicated in 23 renal units. Each procedure ended with insertion of double J, abdominal drain, and indwelling catheter.

Results:

Follow-up was done for 12 to 36 months. Patency of the anastomosis was found in 91.7 % of cases. Thirteen patients (8.3%) underwent antegrade dilatation and insertion of double J.

Conclusion:

After endourological treatment for uretero-ileal anastomotic failure, basically three techniques may be indicated: dipping technique, detour technique, and ileal bladder flap. The indications are dependent on the length of the stenotic/dilated ureteral segment. Better results for long length of stenotic ureter are obtained with detour technique; for short length stenotic ureter dipping technique; when the stenotic segment is 5 cm or more with a short ureter, the ileal tube flap is indicated. The use of double J stent is mandatory in the majority of cases. Early intervention is the rule for protecting renal units from progressive loss of function.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Ureteral strictures revisited…trying to see the light at the end of the tunnel: a comprehensive review

A ureteral stricture is a rather rare urological event defined as a narrowing of the ureter causing a functional obstruction and renal failure, if left untreated. The aim of this review article is to summarize and discuss current knowledge on the incidence, pathogenesis, management, and follow up of proximal, mid, and distal ureteral strictures.