Routine Stentograms are not Necessary Before Stent Removal Following Radical Cystectomy

Drain fluid creatinine-to-serum creatinine ratio as an initial test to detect urine leakage following cystectomy: A retrospective study

Introduction:

Urine leak following radical cystectomy is a known complication. Among the various methods to diagnose this, assessment of drain fluid creatinine is a relatively easy procedure. We aimed to ascertain the validity of the drain fluid creatinine-to-serum creatinine ratio (DCSCR) as an initial indicator of urinary leak in patients undergoing radical cystectomy.

Methods:

We retrospectively identified consecutive patients with documentation of drain fluid creatinine in the postoperative period following cystectomy and urinary diversion at our institution between January 2009 and December 2018. All continent diversions and any patient with a DCSCR >1.5:1 underwent contrast study postoperatively. A diagnosis of urine leak was made following confirmatory imaging. Receiver operative characteristic curves were created, and Youden's index was used to determine the strength and clinical utility of DCSCR as a diagnostic test.

Results:

Two hundred forty-four of the 340 patients included in the study underwent cystectomy with conduit and 81 underwent neobladder creation. Sixteen out of 340 (4.7%) patients had radiologically confirmed urinary leak. DCSCR was elevated in all ureteric anastomotic leaks and in 1 out of the 7 neobladder-urethral anastomotic (NUA) leaks. The sensitivity and specificity of DCSCR to predict all urinary leaks were 68.8% and 80.9% at 1.12 (area under the curve [AUC] = 0.838), whereas at a value of 1.18 (AUC = 0.876) and with the exclusion of NUA leaks, the sensitivity was 77.8% and specificity was 87.6%.

Conclusions:

DCSCR is a good preliminary test for identifying patients who need prompt confirmatory testing for localizing urinary leaks. A drain creatinine level just 18% higher than the serum creatinine level can signify a urine leak. This is different from general assumptions of a higher DCSCR.

[Current practice patterns of perioperative cystectomy management in Germany: a questionnaire survey]

OBJECTIVE

 Radical cystectomy (RCX) is the standard treatment for muscle-invasive and treatment-refractory non-invasive bladder cancer, but that is associated with high morbidity. We now survey current practice patterns on perioperative management among German urological departments of all sizes METHODS:  Members of the German Association of Urology and the German Society of Residents in Urology (GeSRU) were contacted by email and asked to answer a 24-item online questionnaire covering clinically relevant aspects of current guidelines and controversies.

RESULTS

 Responses were obtained from at least 19 % of all German urological centers. About 60 % performed preoperative staging using CT urography and chest CT. The most common perioperative antibiotic prophylaxis was a third generation cephalosporin combined with metronidazole (46 %), administered for a median of 5 days. Stentograms for ileal conduit and neobladder are routinely performed in 38 % and 55 % of patients, respectively. Ureteral stents were usually removed 11 - 12 days after the procedure (ileal conduit and neobladder). Based on the surrogate parameters of preoperative bowel preparation, postoperative start of oral nutrition and use of nasogastric tube, fast-track concepts such as ERAS were not generally established (< 50 %). Robot-assisted cystectomy appears to be performed in 15 % of German urological centers and was associated with the number of performed cystectomies (p < 0.001).

CONCLUSIONS

 Most aspects of perioperative management in cystectomy patients - staging diagnostics, use of antibiotics, stent removal - are performed in accordance with current guidelines. Other clinical questions such as stent imaging before removal and fast track concepts are handled heterogeneously. Guideline-adherence was not associated with hospital size or number of procedures performed.

Ureteric stent removal post cystectomy

AIM

The aim of this study was to develop a step-by-step guide to aid nurses in the safe removal of ureteric stents. Examination of the literature related to at what timespan after the operation the stents should be removed and whether antibiotic cover and/or precautionary investigations such as stentogram are necessary prior to stent removal.

METHOD

A purpose-designed questionnaire was sent to consultants and stoma nurses to assess current practice regarding the removal of stents.

RESULTS

Findings show that opinion was divided on how long the stents should remain in situ postoperatively, whether or not a stentogram is necessary prior to stent removal to check for healing and evidence of anastomosis leak, and whether or not patients require prophylactic antibiotic cover.

CONCLUSION

It is not currently possible to formulate a standard policy for the procedure of ureteric stent removal because consultants have varying ideas on their management. Therefore, further research on ureteric stent removal is required to ensure evidence-based practice.

[Uretero-intestinal anastomosis: Achilles heel of urinary diversion using bowel segments]

A well-functioning uretero-intestinal anastomosis is essential for the preservation of kidney function following urinary diversion using bowel segments. In incontinent forms of urinary diversions, such as ileal conduits, the ureters are usually implanted in a refluxive manner, whereas there is still controversy about the ideal implantation technique in continent orthotopic or heterotopic reservoirs (i.e. refluxive versus anti-refluxive). Current techniques of refluxive and antirefluxive uretero-intestinal anastomosis, their indications, typical perioperative and postoperative complications and management are discussed. Irradiated or preoperatively dilated ureters show a higher complication rate in terms of postoperative dilatation and obstruction. Early revision of the implantation site and ureteral reimplantation yield more favorable outcomes and long-term results than a minor invasive endourological treatment. As ureteral stenosis may occur more than 15 years after urinary diversion, regular follow-up including sonographic evaluation of the upper urinary tract to detect hydronephrosis is mandatory. In this setting a diuretic renogram with MAG-III is a helpful tool to determine split renal function and to discriminate urodynamic relevant dilatation of the upper urinary tract from clinical situations requiring only observation, while dimercaptosuccinic acid (DMSA) scans provide valuable information about renal scarring.

The role of routine postoperative stentograms in the pediatric patient undergoing excisional tapered ureteral reimplantation

OBJECTIVE

To determine the usefulness of routine stentograms in postoperative management of pediatric patients undergoing excisional tapered ureteral reimplantation.

MATERIALS AND METHODS

A retrospective review of all pediatric patients undergoing excisional tapered ureteral reimplantation from March 2003 to March 2008 at one center was performed. One hundred patients were identified. Seventeen had stentograms performed approximately 2 weeks (1-5 weeks) after surgery. The 83 without stentograms composed the control group.

RESULTS

Of the 17 pediatric patients with postoperative stentograms, 10 (59%) had no contrast observed in the bladder. Ureteral stents were removed despite this finding. No anastamotic leaks were observed. In this group, not one had a postoperative complication at time of follow up (mean 25 months; range 4-52). Of the 83 patients without stentograms, not one had clinical signs of anastamotic leakage or obstruction at discharge. The stents were removed routinely 2 weeks (range 1-8) after surgery. Nine patients (10.8%) developed ureteral obstruction (mean 7 weeks; range 1-24) requiring intervention. Three of these patients required a second operation.

CONCLUSIONS

Since routine stentograms rarely identify ureteral leak, and poor drainage on postoperative stentogram does not indicate a risk of obstruction, these studies are not required following routine excisional tapered ureteral reimplant.

Use of External Ureteral Catheters and Internal Double J Stents in a Modified Ileal Neobladder for Continent Diversion: A Comparative Analysis

INTRODUCTION

Open-ended straight ureteral stents are typically used for the support of the ureteroileal anastomosis during the creation of an orthotopic 'S-pouch' ileal neobladder. The use of double J stents as an alternative in this setting is evaluated.

MATERIALS AND METHODS

Medical charts from 43 patients undergoing radical cystectomy with formation of an ileal 'S-pouch' neobladder were retrospectively evaluated. In 30 patients (group A), a 6-Fr open-ended straight ureteral catheter was used to stent the ureteroileal anastomosis, while a double J stent was used for the same reason in 13 patients (group B). The ureteral catheter was removed 15 days after the procedure while the double J stent 3 weeks postoperatively. Hospital stay, early and late complications were evaluated for both groups during a mean follow-up period of 22.5 and 19.6 months respectively.

RESULTS

Stricture of the ureteroileal anastomosis was observed in 2 (6.6%) and 1 (7.6%) patient of groups A and B respectively. All complications presented with similar rates, except for an increased but not statistically significant incidence of urethrovesical anastomotic leakage and early urinary tract infections in group B. Hospital stay was significantly (p<0.005) shorter for patients of group B (9.9 vs. 15.2 days).

CONCLUSIONS

The use of double J stents to support the ureteroileal anastomosis can be used as an alternative to open-ended ureteral stents. With double J stents a shorter hospital stay was achieved with similar complication rates but a higher incidence of upper urinary tract infections.

Routine pouchograms are not necessary after continent urinary diversion

OBJECTIVES

Pouchograms are routinely performed before catheter removal after continent urinary diversion at our institution. Our aim was to determine the necessity of pouchograms based on a review of our experience.

METHODS

A retrospective review of patient records and radiographic studies was done for patients undergoing radical cystectomy and continent urinary diversions between 1991 and 2001.

RESULTS

Seventy-two patients underwent continent urinary diversion (orthotopic, n = 59; cutaneous, n = 13) during the study period. All underwent pouchogram postoperatively (median 22 days; range 20 to 27). Six patients (8.3%) had a demonstrable radiographic leak; in 5 of the 6 patients, the urine leak was suspected on clinical grounds. Three patients (4.7%) developed urosepsis after pouchogram.

CONCLUSIONS

Our findings indicate that routine pouchograms before pouch activation after continent urinary diversion may not be necessary.

Orthotopic bladder substitution after radical cystectomy: 5 years of experience with a novel personal modification of the ileal s pouch

PURPOSE

We report a 5-year experience with 52 patients who underwent radical cystoprostatectomy for bladder cancer and orthotopic bladder substitution using a novel personal modification of the S pouch.

MATERIALS AND METHODS

From September 1995 to December 1999, 52 men 36 to 72 years old (mean age 63) underwent bladder substitution with an S pouch. They were followed until September 2000. The pouch was constructed with a 36 cm. segment of ileum with the whole length used for the reservoir. The ureters were directly anastomosed with one above the other in the mid segment of the pouch without any antireflux procedure. Complications were documented and classified as early or up to 3 months postoperatively and late, and further subdivided by the relationship to neobladder construction. Continence and voiding pattern were evaluated by personal interview and neobladder function was urodynamically assessed. Mean followup in our patients was 30 months.

RESULTS

The most common of the 5 early and 9 late neobladder related complications were persistent urine leakage and reflux, respectively. There was no reflux greater than grade III in the 4 patients with reflux (5 refluxing ureters) and no functional disorders. We observed 12 early and 5 late complications unrelated to the neobladder. Open reoperation was required in 5 cases. Good or satisfactory daytime and nighttime continence was reported by 95% and 88% of our patients, respectively. By year 1 postoperatively 91% of our patients voided at an interval of 3 to 5 hours during the day. Mean maximum neobladder capacity was 672 ml. and mean post-void residual was 30 ml. by year 3 postoperatively. Two patients required self-catheterization once daily and mild hyperchloremia without acidosis developed in 2.

CONCLUSIONS

The advantages of our modified S pouch are technical simplicity, substantially shorter operative time and decreased bowel length required. It is associated with an acceptable complication rate and functional parameters with subsequent patient satisfaction and good quality of life.

Ureteroenteric anastomosis in continent urinary diversion: long-term results and complications of direct versus nonrefluxing techniques

PURPOSE

Controversy exists over the importance of antireflux mechanisms in large volume, low pressure intestinal bladder substitutions. Despite the theoretical benefits of reflux prevention, antirefluxing ureteral reimplantations may have a greater risk of anastomotic stricture. We hypothesize that this inherent stricture rate may outweigh the potential benefits associated with reflux prevention. To assess this question critically we compare our results to those of direct and nonrefluxing techniques of ureterointestinal anastomosis during continent diversion.

MATERIALS AND METHODS

Between 1990 and 1998, 58 patients underwent continent urinary diversion using an Indiana pouch or ileal orthotopic neobladder following cystectomy for muscle invasive bladder cancer. A total of 56 renal units were implanted using an end-to-side Nesbit direct anastomosis and 60 were implanted in a nonrefluxing manner. Clinical end points included anastomotic stricture formation, hydronephrosis, pyelonephritis, upper tract stone formation and renal deterioration, and were assessed with a mean followup of 41 months.

RESULTS

Of 60 nonrefluxing ureteroenteric anastomoses 8 (13%) resulted in nonneoplastic stricture formation compared to 1 of 56 (1.7%) direct anastomoses, which was statistically significant (Fisher's exact test p <0.05). Strictures occurred up to 6 years following the original surgery. There was no significant difference between the 2 groups in regard to hydronephrosis, pyelonephritis, upper tract stone formation or azotemia.

CONCLUSIONS

Nonrefluxing methods of ureterointestinal reimplantation resulted in a statistically significant higher rate of anastomotic stricture than the end-to-side direct anastomosis. This finding appears to outweigh any theoretical benefits of preventing pyelonephritis, stones or azotemia. For patients undergoing large volume, low pressure continent diversion the refluxing ureterointestinal anastomosis may be the technique of choice since it preserves renal function as well as the nonrefluxing method, is technically easier to perform and poses less risk of stricture. Delayed stricture formation years after surgery underscores the necessity for long-term radiological followup in patients following continent diversion.