Complications of ureteroileal conduit with radical cystectomy: review of 336 cases

Bladder cancer with urinary diversion by a sigmoid colon conduit after transverse colon stoma

Introduction

Sigmoid conduit is one of the methods for achieving urinary diversion, but it is performed less frequently than ileal conduit and ureterostomy. Herein, we report a case in which a sigmoid colon conduit was performed after nephrostomy and transverse colostomy.

Case presentation

A 70-year-old man was referred to our hospital because of a bladder tumor. Computed tomography and transurethral biopsy revealed advanced bladder cancer with ureteral and rectal invasion. Despite drug therapy, the tumor progressed. Thus, nephrostomy and transverse colostomy were performed for urinary and fecal diversion, respectively. Subsequently, chemotherapy was administered for 8 months. As nephrostomy-related complications occurred frequently during chemotherapy, a sigmoid colon conduit was performed instead of nephrostomy for urinary diversion to improve the patient's quality of life.

Conclusion

In patients with advanced bladder cancer requiring a double stoma of the urinary and fecal tracts, sigmoid colon conduit may be selected as a urinary diversion method.

Endoureterotomy with the Lovaco technique for treatment of ureterointestinal strictures: outcomes in an experienced center and factors associated with procedural success or failure

INTRODUCTION

The study aimed to present the outcomes of an endoureterotomy series using the Lovaco technique for the treatment of ureterointestinal strictures. Factors influencing the success or failure of this technique were also determined.

MATERIALS AND METHODS

Data were collected from all endoureterotomies for ureterointestinal strictures performed in a single-center between 2017 and 2020. Clinical variables and characteristics of the stricture were recorded in each case, and success was defined as the complete resolution of ureterohydronephrosis. Univariate analysis was used to correlate the variables recorded with procedural success or failure.

RESULTS

A total of 25 patients were recruited: 16 with strictures on the left side, 5 on the right, and 4 bilateral. With the first endoureterotomy, 52% of the cases (13 patients) were resolved, and in patients undergoing a second intervention 64% success (16 patients) was achieved. Infectious complications occurred in 23.3% of surgeries. Stricture length, poor renal function, and left side involvement were associated with endoureterotomy failure.

CONCLUSIONS

Endoureterotomy with the Lovaco technique is a useful method in the setting of ureterointestinal strictures, achieving complete resolution of the obstruction in more than 60% of cases. Factors that can negatively affect the success of the procedure include stricture length, poor renal function, and left side involvement.

Robot-Assisted Cystectomy and Ileal Conduit for Neurogenic Bladder: Comparison of Extracorporeal vs Intracorporeal Urinary Diversion

Objectives: The aim of the present study was to compare the perioperative outcomes of extracorporeal (EXTRA) vs intracorporeal (INTRA) urinary diversion in patients undergoing robotic cystectomy and ileal conduit for neurogenic bladder. Methods: All consecutive patients who underwent robot-assisted cystectomy and ileal conduit for neurogenic bladder in six centers between 2011 and 2020 were included in a retrospective study. Four centers performed exclusively INTRA urinary diversion all over the study period, one center performed exclusively EXTRA urinary diversion, and the last center performed EXTRA urinary diversion during a first period and INTRA during the subsequent period. Results: Ninety-seven patients were included: 66 in the EXTRA group and 31 in the INTRA group. There were 11 major (Clavien grade ≥3) postoperative complications in the overall population (11.3%) with no statistically significant difference between both groups (EXTRA = 12.1% vs INTRA = 9.7%; p = 0.99). The mean length of stay did not differ significantly between INTRA and EXTRA (13.1 vs 14.1 days; p = 0.44). The mean times to oral feeding and to return of bowel function were similar in the two groups (3.9 vs 3.5 days; p = 0.28 and 4.1 vs 4.1 days; p = 0.51, respectively). There was no incisional hernia in the INTRA group vs five in the EXTRA group (0% vs 7.6%; p = 0.17). Conclusion: The perioperative morbidity of robotic cystectomy and ileal conduit for neurogenic bladder appears to be relatively limited compared with the historical open series. Possibly due to the relatively small sample size, no difference was found between INTRA and EXTRA urinary diversion in terms of perioperative outcomes.

Intraoperative Ureteral Stent Use at Radical Cystectomy is Associated with Higher 30-Day Complication Rates

PURPOSE

Radical cystectomy/urinary diversion is a high risk procedure. Intraoperative stents are commonly utilized to decrease ureteroenteric anastomosis related complications. Institutionally some surgeons routinely use intraoperative stents while others do not, providing an opportunity to compare complication differences.

MATERIALS AND METHODS

We queried a prospective database of 283 patients enrolled in a randomized controlled trial evaluating 30-day perioperative complications with goal directed fluid therapy following open radical cystectomy/urinary diversion between 2014 and 2018. Ureteroenteric anastomosis specific complications (ureteral obstruction, urinary leak, urinary infections/sepsis and intra-abdominal abscess) were compared between groups (intraoperative stent vs nonintraoperative stent group) using Fisher exact test and quantified using logistic regression.

RESULTS

The nonintraoperative stent group (77 of 283 patients, 27%) was older (median 72 vs 69 years) and was more likely to receive neoadjuvant chemotherapy (53% vs 40%), have baseline renal insufficiency (43% vs 30%) and undergo an ileal conduit (92% vs 53%). However, despite higher comorbidity, the nonintraoperative stent group had a significantly lower rate of ureteroenteric anastomosis complications (14% vs 32%, p=0.004). Since continent diversions may be associated with higher complications, the nonintraoperative stent group with ileal conduit was also compared to intraoperative stent cohorts with ileal conduit, and ureteroenteric anastomosis complications remained lower in the nonintraoperative stent group (14% vs 28%, p=0.043). Multivariable logistic regression showed significantly increased odds of urinary complications with intraoperative stent use (OR 3.55, 95% CI 2.93-4.31; p <0.0001). Importantly there was no obstruction and only 1 leak (1.3%) in the nonintraoperative stent group.

CONCLUSIONS

Contrary to conventional belief, we found intraoperative stent use in radical cystectomy/urinary diversion was associated with significantly higher infectious complications and urgent care visits, and significantly increased the odds of 30-day ureteroenteric anastomosis associated complications.

Evaluation of the residual prostate cancer rate on cystoprostatectomy specimen in patients treated with radiotherapy for prostate cancer

PURPOSE

To evaluate the residual cancer rate after cystoprostatectomy (CPT) in patients with a history of radiation therapy for prostate cancer and the postoperative complication rates.

MATERIAL AND METHODS

We conducted a retrospective study involving 21 patients who had a CPT over 7 years and who had a history of radiotherapy for prostate cancer. To compare results, two additional groups were created: a group of patients without a history of radiotherapy in whom a CPT was performed, and a group without a history of radiotherapy and in whom was accidentally discovered a prostate cancer after CPT on histology specimens.

RESULTS

The median age at the time of radiotherapy was 69 years. The median age at the time of cystoprostatectomy was 78 years. The median PSA at the time of the intervention was 0.6 ng/ml in the group with a history of radiotherapy. The residual cancer rate was 24%. No patients had criteria for biological recurrence. There were no additional surgical complications in the radiotherapy group (p = 0.2). The rate of cutaneous ureterostomy was higher (p = 0.0006) due to increased surgical difficulties (p = 0.0009).

CONCLUSION

The residual cancer rate was 24% after radiotherapy for prostate cancer. PSA alone does not appear to be sufficient to detect the persistence of residual prostate cancer after radiotherapy. There were no more surgical complications after prostate radiotherapy.

Revisiting Ureterosigmoidostomy, a Useful Technique of Urinary Diversion in Functional Urology

Ureterosigmoidostomy has largely been disregarded in recent times but has now seen a resurgence of interest because of its potential applicability to newer, minimally invasive surgical techniques. The advantages of ureterosigmoidostomy over intestinal conduits are urinary continence (obviating the need for stoma and external appliances), ease, and rapidity of performance as well as acceptance by patients. Ureterosigmoidostomy has been characterized by good continence outcomes and it offers good quality of life. Possible complications are anastomosis stenosis, coloureteral reflux, electrolyte imbalance, hydronephrosis, pyelonephritis, chronic renal failure, colorectal cancer, and others. Ureterosigmoidostomy is therefore only advisable for patients ready to accept long-term follow-up.

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.

Ureteroileal strictures after urinary diversion with an ileal segment-is there a place for endourological treatment at all?

PURPOSE

We compared the long-term results of minimally invasive endourological intervention and open surgical revision in patients with a nonmalignant ureteroileal stricture.

MATERIALS AND METHODS

We retrospectively evaluated the records of 74 patients (85 renal units) treated for unilateral or bilateral nonmalignant ureteroileal strictures. Overall, 96 endourological and 35 open surgical procedures were performed. Balloon dilatation and Acucise® or Ho:YAG laser endoureterotomy were used as minimally invasive endourological interventions. Open surgical revision with stricture resection and open ureteroileal end-to-side-reanastomosis was the alternate therapy. Treatment success was defined as radiological normalization or improvement of upper urinary tract morphology combined with absent flank pain, infection, ureteral stents or percutaneous nephrostomies.

RESULTS

Median followup was 29 months (range 2 to 177). The overall success rate was 26% (25 of 96 cases) for endourological intervention vs 91% (32 of 35) for open surgical revision (p <0.001). Subgroup analysis showed a significant difference in the success rate of minimally invasive endourological interventions vs open surgical revision for strictures greater than 1 cm (3 of 52 cases or 6% vs 19 of 22 or 86%, p <0.001). The success rate of endourological and open surgical procedures for strictures 1 cm or less was 50% (22 of 44 cases) and 100% (13 of 13), respectively. After adjusting for multiple preoperative stricture characteristics, only stricture length was strongly and inversely associated with a successful outcome (p <0.001).

CONCLUSIONS

Open surgical revision produces better results than minimally invasive endourological intervention for ureteroileal strictures, particularly those greater than 1 cm. The success rate of endourological intervention is acceptable only for ureteroileal strictures 1 cm or less. Therefore, ureteroileal strictures greater than 1 cm should be primarily managed by open surgical revision.

Chronic kidney disease in patients with ileal conduit urinary diversion

While renal dysfunction is often observed in patients following urinary diversion due to bladder cancer, there have been few studies on this subject. A cross-sectional study was performed on the renal function of ileal conduit urinary diversion patients and the prevalence and risk factors for chronic kidney disease (CKD) were examined. Patients with ileal conduit urinary diversion (n=102), who were being followed-up as outpatients and who were in stable condition, as well as age- and gender-matched healthy control subjects (n=63) were selected for this study. The prevalence of CKD was compared between the patients and healthy subjects. Next, the clinical factors associated with the presence of CKD were investigated in the patients with ileal conduit diversion using logistic regression analysis. The prevalence of CKD was significantly higher in the patients with ileal conduit diversion compared with the healthy subjects [60 patients (58.8%) vs. 11 healthy subjects (17.5%), P<0.0001]. The mean decrease in the estimated glomerular filtration rate per year of the patients with urinary diversion was 0.95±2.0 ml/min/1.73 m². Multiple logistic regression analysis revealed that the independent and significant factors associated with the presence of CKD were older age and the presence of hypertension, urolithiasis and a past history of hydronephrosis. In conclusion, an increased prevalence of CKD was revealed in the patients with ileal conduit urinary diversion, suggesting the need for better management of hypertension, urolithiasis and hydronephrosis following surgery.

Robot-assisted repair of ureteroileal anastomosis strictures: initial cases and literature review

BACKGROUND AND PURPOSE

Ureteroileal anastomosis strictures are well-known complications of ileal conduit urinary diversion that occur in 4% to 8% of patients. Open surgical repair is the standard definitive treatment with minimally invasive, endoscopic approaches developed to prevent the need for major surgery when possible. Robot-assisted surgery has been applied to most primary urologic procedures, but the role of this surgery in the management of complications is undefined. We report our experience with two cases of robotic repair of ureteroileal anastomotic strictures after robot-assisted cystectomy, the first such cases to our knowledge, and review the literature regarding management of these strictures.

PATIENTS AND METHODS

Two patients underwent robot-assisted ureteroileal anastomosis revision for left-sided strictures of 1 and 6 cm in length after failed endoscopic management. Three ports were used in the first and four in the second procedure. The diseased segment was identified, and the healthy end of the ureter anastomosed to a new site on the conduit with a temporary stent. In the second case, the conduit was mobilized and brought to the end of the ureter for a tension-free anastomosis because of the length of the stricture.

RESULTS

Both patients were discharged on the first postoperative day without complications and are without recurrence after nearly 2 and 3 years since the robotic procedure.

CONCLUSION

Minimally invasive definitive revision of ureteroileal anastomotic strictures is feasible with a robotic surgical approach. The advantages of robotic instrumentation allowed successful repair in two patients after previous robot-assisted cystectomy and avoided major open surgery.

Perioperative morbidity of radical cystectomy: A review

A systematic review of the literature on perioperative morbidity (POM) was done using Medline software with a combination of keywords like mortality, morbidity, and complications. In addition, we review the analysis of our hospital data of 261 Radical cystectomies (RCs) performed in an 11-year period and our latest clinical pathway for RC. Age range in our series was 50 to 81 years with 240 males and 21 females. RCs were performed by intraperitoneal method in 172 patients and by our extraperitoneal (EP) method in 89 patients. Urinary diversion was ileal conduit in 159 patients and neobladder in 102 patients. Blood loss ranged between 500 and 1500 ccs. Postoperative mortality occurred in eight patients (3%). Among the other early post-op complications, major urinary leak was seen in nine and minor in 11, requiring PCN in five patients and reoperation in four patients. Bowel leak or obstruction was seen in six and four patients, respectively, requiring reoperation in six patients. EP RC in our series showed some benefit in reduction of POM. The mortality of RC has declined but the POM still ranges from 11 to 68%, as reported in 23 series (1999-2008) comprising of 14 076 patients. Various risk factors leading to POM and some corrective measures are discussed in detail. However, most of these series are retrospective and lack standard complication reporting, which limits the comparison of outcomes. Various modifications in open surgical technique and laparoscopic and Robotic approaches are aimed at reduction in mortality and POM of RC.

Long-term outcome of ureterosigmoidostomy: an analysis of patients with >10 years of follow-up

STUDY TYPE

Therapy (case series).

LEVEL OF EVIDENCE

4.

OBJECTIVE

To examine our long-term experience with ureterosigmoidostomy (USS) to evaluate its potential applicability in the treatment of benign and malignant conditions of the urinary bladder, as USS has been largely disregarded recently, secondary to concerns of long-term complications, but has had a resurgence of interest due to its potential applicability to newer minimally invasive surgical techniques.

PATIENTS AND METHODS

We identified 51 patients who had USS from 1956 to 2006 at our institution and with >10 years of follow-up. The patients were followed retrospectively by a chart review. Patient data were analysed in a multifaceted fashion, paying particular attention to metabolic abnormalities, early (< or =30 days) and late (>30 days) complication rates, continence rates, imaging changes, and the rate of repeat surgical intervention.

RESULTS

The median (range) follow-up was 15.7 (10.0-45.4) years and the median age at surgery was 58.8 (0.4-79.0) years; 40 (79%) patients had the procedure for malignancy and 11 (22%) for benign disease. Six patients (12%) had at least one early complication, including one wound dehiscence and one pulmonary embolus. In all, 22 patients (43%) had at least one late complication, with anastomotic stricture being the most common (11/51, 22%). This was followed by recurrent pyelonephritis in eight patients (16%), stones in five (10%), chronic renal insufficiency in three (6%) and severe intractable acidosis in two (4%). A repeat surgical intervention was required in 19 (37%) patients. In all, 94% (48) reported complete continence. No patient developed colonic malignancy during the course of this study.

CONCLUSIONS

USS is associated with long-term complications. While this complication rate might not be acceptable for all patients, some might be willing to undergo the procedure as the primary method of urinary diversion. When designing newer minimally invasive techniques for the treatment of benign and malignant conditions of the bladder, consideration could be given to USS as a form of urinary diversion in highly selected patients.

Application of Self-Expandable Metal Stents for Ureteroileal Anastomotic Strictures: Long-Term Results

PURPOSE

We report our long-term experience with the management of benign ureteroileal anastomotic strictures using self-expandable metal stents.

MATERIALS AND METHODS

A total of 16 male and 2 female patients with a mean+/-SD age of 72+/-7 years (range 66 to 78) with benign fibrotic strictures at the site of ureteroileal anastomosis underwent implantation of self-expandable metal stents with a nominal diameter of 6 to 8 mm. A total of 24 ureteroileal conduits were treated. The external nephrostomy tubes were removed after fluoroscopic validation of ureteral patency. Patients were followed with blood biochemistry, ultrasonography, urography and/or virtual endoscopy. Retrograde external-internal catheter insertion through the cutaneous stoma was performed in cases of recalcitrant stricture.

RESULTS

The technical success rate of ureteroileal stricture crossing and stenting was 100% (24 of 24 cases). Mean followup was 21 months (range 7 to 50). The clinical success rate during the immediate post-stenting period was 70.8% (17 of 24 cases). The 1 and 4-year primary patency rates were 37.8% and 22.7%, respectively. Secondary interventions included repeat balloon dilation in 15 ureters, of which 8 also underwent subsequent coaxial stent placement. The 1 and 4-year secondary patency rates were 64.8% and 56.7%, respectively. Except in 2 patients who died external-internal Double-J catheters continued to be inserted retrograde in 6 ureteroileal conduits. They are periodically exchanged to prevent mucous inspissation and stent encrustation.

CONCLUSIONS

Metal stents served as the definitive treatment for stricture in more than half of the cases, whereas in the remainder the stents allowed the uncomplicated and regular exchange of Double-J catheters in retrograde fashion. This combined, less invasive treatment for ureteroileal anastomotic strictures may help patients avoid surgical revision and preserve quality of life.

Lasers in the upper urinary tract for non-stone disease

Though the most common use for lasers in the genitourinary tract is for urolithiasis, a number of other urologic conditions can be treated with lasers because of their unique ablative, destructive and hemostatic properties. This paper reviews the advantages and disadvantages of laser technology for a number of non-stone indications.

Evaluation of findings during re-exploration for obstructive ileus after radical cystectomy and ileal-loop urinary diversion: insight into potential technical improvements

OBJECTIVE

To retrospectively evaluate the findings during re-exploration for obstructive ileus after radical cystectomy (RC) and ileal conduit diversion.

PATIENTS AND METHODS

During a 12-year period, 434 patients who had RC and ileal conduit diversion were retrospectively evaluated for the diagnosis of early (</=30 days after RC) or late abdominal re-exploration. The operative reports of patients requiring a second abdominal procedure were reviewed, evaluating in particular the reason for small bowel obstruction (SBO). In addition, the type of entero-enteric anastomosis and the retroperitonealization of the uretero-enteric anastomosis were compared between patients who required abdominal re-exploration for SBO and those who did not.

RESULTS

Abdominal re-exploration for SBO was necessary for 14 (3.2%) and 32 (7.3%) patients in the early and late postoperative period, respectively. The most common reasons for SBO were anastomotic malfunction (1.4%) and malignant recurrence (2.8%). Adhesions were the second most common cause leading to ileus in both periods (1.1% and 2.3%, respectively). When there was no retroperitonealization of the uretero-enteric anastomosis, SBO occurred more often both early and late (P = 0.06). Early anastomotic malfunction leading to SBO was more common (but not statistically significant, P = 0.06) when the entero-enteric anastomosis was hand-sutured end-to-end.

CONCLUSIONS

Anastomotic malfunction, bowel adhesions and internal hernias are responsible for SBO early after surgery. The above reasons, in addition to malignant recurrence, are the most common reasons for SBO in the late postoperative period.

The double wire technique: an improved method for treating challenging ureteroileal anastomotic strictures and occlusions

Up to 10% of patients who undergo ileal conduit urinary diversion may go on to develop ureteroileal anastomotic stenosis (UIAS); this can lead to recurrent urinary tract infections and deterioration in renal function. Classical management has been open revision of the anastomosis. We describe a novel technique that allows balloon dilatation and ureteral stent placement in a retrograde fashion. All patients in this study had undergone radical cystectomy and ileal conduit formation with Wallace type end-to-end refluxing uretero-intestinal anastomosis. After initial retrograde loopogram, a 6F MPA-1 catheter and an 0.035 inch extra stiff guide was passed to the distal ostium. Subsequently, a customised 8F bright tip MPA-1 guiding catheter was advanced over the guide wire which allowed effective splinting of the equipment to facilitate greater control of a second catheter and guide wire combination to access the stenotic or occluded anastomosis. Results show that a total of ten anastomoses were treated; nine anastomoses were successfully treated with a primary retrograde approach with no intra or post-procedural complications. After a mean follow-up of 19 months (5-33 months), as assessed by ascending loopograms, all anastomoses remained open. In conclusion, morbidity of open surgery has resulted in the popularization of endourological techniques in treating anastomotic stenoses. However, key to these endourological techniques is access to the anastomosis; typically, this has been via a percutaneously placed nephrostomy. The ideal route to the anastomosis is via a retrograde approach; we have illustrated a safe and successful novel technique that utilized two guidewires and a guiding catheter, allowing retrograde ureteral access.

Laparoscopic Cystectomy with Extracorporeal-Assisted Urinary Diversion: Experience with 34 Patients

OBJECTIVES

Open radical cystectomy remains the gold standard for nonmetastatic muscle invasive bladder cancer. Laparoscopic cystectomy has been described as a feasible procedure and is still being evaluated. We describe our initial experience with this laparoscopic surgical approach in 34 patients.

METHODS

From February 2002 to October 2004, 18 men and 16 women underwent laparoscopic cystectomy with extracorporeal-assisted urinary diversion for transitional cell carcinoma of the bladder (n=27), invasive cervical carcinoma (n=4), and atrophic bladder (n=3). We report here on specific technical details and present initial results of our series.

RESULTS

The mean operating time was 244 min, the mean blood loss 325 ml, and the transfusion rate 5.9%. All procedures were completed laparascopically without conversion to open techniques. No major complications occurred during or after the operation. In case of urothelial malignancy (n=27), the histopathologic analysis of the removed specimen revealed organ-confined transitional cell carcinoma of the bladder in 66.7% (pT1:14.8%; pT2: 51.9%) and locally advanced disease in 33.3% (pT3: 25.9%; pT4: 7.4%). In two cases final histology proved positive surgical margins. Extended lymphadenectomy detected lymph node metastasis in two patients.

CONCLUSIONS

We demonstrate that the combination of laparoscopic cystectomy and extracorporeal urinary diversion is possible and remains a safe, feasible, and repeatable surgical technique. To determine the oncologic outcome long-time follow-up will be necessary.

Comparison of Ileal Conduit and Transureteroureterostomy with Ureterocutaneostomy Urinary Diversion

INTRODUCTION

We compare the postoperative early and late complications of patients who had undergone ileal conduit (IC) urinary diversion and transureteroureterostomy (TUU) with ureterocutaneostomy (UC) urinary diversion during the same interval and by the same surgeons.

MATERIALS AND METHODS

Between 1992 and 2004, we performed TUU with UC urinary diversion in 27 men and 7 women (group I) and ileal conduit urinary diversion in 57 men and 10 women (group II). The mean age of the TUU with UC diversion and the ileal conduit patients was 57+/-11.2 (range 51-76) and 64+/-12.6 (range 54-76) years, and the mean follow-up was 37 (range 14-52) and 56 (range 14-72) months, respectively. The 6F or 8F stents were used routinely.

RESULTS

Of 34 TUU with UC cases 8 (23.52%) had early postoperative complications and 2 (5.88%) had early reoperation rates, whereas 11 (16.42%) of 67 ileal conduit cases had early postoperative complications and 4 (5.97%) had early reoperation. The mean hospital stay was 7 (range 5-25 day) and 11 (range 7-34 day) days for each group, respectively. Of the TUU and UC cases, 6 (17.64%) had late complications and 3 had (8.82%) late reoperation, whereas 14 conduit cases (20.89%) had late complications and 6 had (8.9%) late reoperation. Early postoperative complications were defined as those that occurred before hospital discharge or within 30 days from the date of surgery and late complications were defined as those occurring greater than 30 days from the date of surgery as previously described. In group I, the mean operative time was 170 min (range 120-325) compared with 260 min (range 170-473) in group II. The mean blood loss in group I was 474 ml (range 250-1,400) and 589 ml (range 300-1,700) in group II (p>0.05).

CONCLUSIONS

Our results suggest that patients undergoing a TUU and UC diversion have no additional risk of reoperation and the TUU with UC urinary diversion is a safe procedure with postoperative early and late complications.

Urinary Tract Infections in Patients With Urinary Diversion

Several surgical techniques have been used to provide urinary diversion after radical cystectomy. The noncontinent type of urinary diversion (using an intestinal conduit) and the continent urinary diversion (ureterosigmoidostomy or construction of an intestinal pouch that serves as a deposit of urine) were used commonly in the past, leading to a cumulative considerable number of patients encountered in clinical practice. The orthotopic urinary diversion (neobladder) has been used widely during the last years. The incidence and characteristics of urinary tract infection in patients with different types of urinary diversion are reviewed. Clinicians should be aware that urinary tract infection is a frequent cause of fever in patients with urinary diversion because it occurs in a significant proportion. In addition, symptoms from the lower urinary tract may not be prominent in this population.

ENDOURETEROTOMY BY INTRALUMINAL INVAGINATION FOR NONMALIGNANT URETEROINTESTINAL ANASTOMOTIC STRICTURES: DESCRIPTION OF A NEW SURGICAL TECHNIQUE AND LONG-TERM FOLLOWUP

PURPOSE

We describe a new surgical endoscopic technique for nonmalignant ureterointestinal anastomotic strictures. This procedure involving endoureterotomy by intraluminal invagination (the Lovaco technique) is performed by adopting a combined percutaneous antegrade and endoscopic retrograde approach. The results obtained by this technique are reviewed with long-term followup.

MATERIALS AND METHODS

A total of 25 ureterointestinal anastomotic strictures were subjected to endoureterotomy by intraluminal invagination, including 12 left, 7 right and 3 bilateral cases. Surgical success was defined by radiological improvement and/or the ability to recover normal activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes.

RESULTS

At a median followup of 51 months (range 2 to 145) the success rate for endoureterotomy by intraluminal invagination was 80% (20 of 25 ureterointestinal anastomotic strictures). No complications were recorded in the patients following endoureterotomy.

CONCLUSIONS

This new endoureterotomy technique for ureterointestinal strictures following urinary diversion can be applied to any type of urinary diversion. It allows direct visualization of the stricture and stricture tissue biopsy. Intraluminal invagination makes it possible to increase the distance between the stricture, and the retroperitoneal vessels and bowels. The technique provides the control required to ensure full-thickness and full-length stricture incision. The success rate is high and it persists after long-term followup.

Hemiresective reconstruction of a redundant ileal conduit with severe bilateral ileal conduit-ureteral reflux

A 58-year-old man was referred to our hospital with high fever and anuria. Since undergoing a total pelvic exenteration due to bladder-invasive sigmoid colon cancer, urinary tract infections had frequently occurred. We treated with the construction of a bilateral percutaneous nephrostomy (PCN), and chemotherapy. Although we replaced the PCN with a single J ureteral catheter after an improvement of infection, urinary infection recurred because of an obstruction of the catheter. Urological examinations showed that an ileal conduit-ureteral reflux caused by kinking of the ileal loop was the reason why frequent pyelonephritis occurred. We decided to resect the proximal segment to improve conduit-ureteral reflux for the resistant pyelonephritis. After the surgery, the excretory urogram showed improvement and the urinary retention at the ileal conduit disappeared. Three years after the operation, renal function has been stable without episodes of pyelonephritis. Here we report a case of open repair surgery of an ileal conduit in a patient with severe urinary infection.

Extracorporeal shock wave lithotripsy of upper urinary tract calculi in patients with cystectomy and urinary diversion

OBJECTIVES

To present our experience with extracorporeal shock wave lithotripsy (ESWL) in the management of upper urinary tract calculi in patients with urinary diversion.

METHODS

Between March 1989 and June 2004, 27 patients with radical cystectomy and urinary diversion were treated using ESWL for upper urinary tract calculi using the Dornier MFL 5000 lithotripter. The mean length of the stones was 11 +/- 3.1 mm and the mean width was 8.8 +/- 3.5 mm. The follow-up protocol included plain abdominal x-ray and renal ultrasonography every 2 weeks until complete stone clearance. All follow-up data were collected and analyzed after 3 months. Success was defined as the absence of residual stones or the presence of insignificant gravel less than 4 mm.

RESULTS

Retreatment was required in 12 patients (44.4%). Failure to disintegrate the stones was recorded in 2 cases (7.4%) and significant residual stones were recorded in 1 (3.7%). Post-ESWL renal obstruction was observed in 2 cases (7.4%). Secondary procedures were needed in 5 cases (18.5%). Two percutaneous nephrolithotomy and one antegrade ureteroscopy were performed for treatment of ESWL failure. One open ureterolithotomy and one antegrade ureteroscopy were performed for treatment of post-ESWL renal obstruction. Thus, the overall success rate of ESWL monotherapy in the treatment of upper urinary tract stones was 81.5% (22 of 27).

CONCLUSIONS

ESWL monotherapy proved to be a valuable option in the treatment of upper tract lithiasis in patients with urinary diversion. However, it may cause renal obstruction, and antegrade endoscopic maneuvers should be available.

Surgical technique to correct complex ureterointestinal stricture with defunctionalized limb of Turnbull stoma

We describe a novel technique to repair a long ischemic ureterointestinal stricture using the defunctionalized limb of a Turnbull stoma in a patient who had previously undergone two attempts at open surgical revision.

Endoscopic Management of Ureterointestinal Strictures after Radical Cystectomy

PURPOSE

To summarize the status of endoscopic treatment for ureterointestinal anastomotic strictures after radical cystectomy.

MATERIALS AND METHODS

We reviewed the English-language literature identified by PubMed and MEDLINE to evaluate the efficacy of various treatment options for these strictures.

RESULTS

Cumulative success rates from multiple studies analyzing patency after balloon dilation, endoureterotomy, and metal stenting specifically for ureteroenteric strictures were 18%, 63%, and 83%, respectively. Studies have not clearly shown any significant advantage over any specific cutting modality. The use of metal stents appears promising but is still fraught with complications of tissue ingrowth and recurrent obstruction. Clinical factors that appear to be associated with a poor prognosis are age >60 years, left-sided strictures, length >1 cm, stenting <4 weeks, and poor function in the affecting kidney.

CONCLUSION

Ureteroenteric strictures remain the most challenging and difficult of all ureteral strictures to treat. An evolution of technology has helped advance the therapeutic options available. Given the rarity of this condition, limited study designs, and small numbers of patients, conclusive statements regarding the optimal treatment for this condition are difficult. Given its patency rates and possible complications, endoureterotomy should be considered the initial treatment of choice in properly selected patients.

Urinary conduit formation using retubularized bowel from continent urinary diversion or intestinal augmentations: I. A multi-institutional experience

OBJECTIVES

To present our multi-institutional experience with retubularized bowel conduits. Some patients with augmentation cystoplasty, augmented rectal bladder, or continent urinary reservoirs require conversion to an ileal conduit for various reasons. This is generally accomplished by construction of a de novo ileal conduit. We retubularized the bowel segment used in the augmented bladder or the urinary reservoir to form the intestinal urinary conduit.

METHODS

A total of 29 patients (mean age 42 years) underwent conduit formation using the augmentation patch of enterocystoplasty, the segment of cutaneous urinary diversion reservoir or orthotopic neobladder, or the augmentation patch of an augmented rectal bladder. Patients were followed up with history, physical examination, laboratory tests, and imaging studies.

RESULTS

The follow-up ranged from 12 to 130 months (mean 42). One patient developed small bowel obstruction requiring laparotomy with lysis of adhesions. None of the other patients had bowel complications. Two patients developed ureteral obstruction with hydronephrosis. One had pyocystitis requiring simple cystectomy. One patient was lost to follow-up.

CONCLUSIONS

Retubularization of previously used bowel segments to construct a urinary conduit is feasible and has several advantages. It is possible to perform this procedure after several types of reconstructive procedures in which bowel was incorporated into the urinary tract.

Ureteroscopic endoureterotomy

OBJECTIVE

To highlight the current status of ureteroscopic endoureterotomy (UE) by reporting extensive experience with the endoscopic management of ureteric strictures, with special emphasis on factors determining success, and by reviewing publications on the minimally invasive management of ureteric strictures.

PATIENTS AND METHODS

The study comprised 50 patients (mean age 53 years, range 18-85, equal sex distribution) with ureteric strictures of varying causes; all had their stricture treated endoscopically. The follow-up was 0.5-9 years; 10 patients with recurrent strictures had two ipsilateral stents placed to try to improve the outcome, and eight patients with completely obliterating strictures were treated by ureteroscopic re-canalization.

RESULTS

The site of stricture had no bearing on the eventual outcome. Patients with uretero-enteric and malignant strictures did not fare so well. The most important predictor of failure was the length of the stricture, with failure in all seven patients with strictures of > 2 cm. In the 10 patients treated with two ipsilateral stents, eight were successful, which was very promising considering that these patients had recalcitrant strictures and placing one stent had previously failed. The overall success rate was 74%.

CONCLUSION

UE has become the procedure of choice for the initial management of ureteric strictures. Simple balloon dilatation is also effective in certain situations. The characteristics of the stricture often govern the eventual outcome. In properly selected cases success rates of approximately 75% can be expected.

Antireflux Uretero-Intestinal Anastomosis—Flap-and-Trough Technique—Applicable to Ileum: Early Clinical Experience

OBJECTIVE

To report our functional results of the "flap-and-trough" (FT) antireflux uretero-intestinal anastomosis (UIA) applied to various forms of urinary diversions.

PATIENTS AND METHODS

From April 1998 through March 2003, a total of 49 ureters were implanted in 28 patients into various types of urinary diversions. Forty-six ureters were implanted transluminally (32 separately, 14 conjointly by the double-barrelled method), 3 ureters extraluminally into preformed reservoirs during kidney transplantation. Forty-one ureters were implanted primarily, 8 ureters secondarily due to stricture of former UIA.

RESULTS

Median observation time was 26 months. The healing was uneventful in all cases. Late complications were not related to the UIA. Twenty-four patients could be evaluated. The upper urinary tract remained stable, no reflux and no stenosis at the site of UIA were detected. FT anastomoses were clearly seen and easily accessible at endoscopy.

CONCLUSION

In our hands the FT anastomosis has proved to be simple, safe and highly effective in terms of protecting the upper urinary tract against obstruction and reflux. Creation of antireflux UIA need not mean increased risk of obstruction in comparison with direct (reflux) ones. The FT technique could represent another alternative of nonrefluxing implantation of normal as well as dilated ureters into various types of urinary diversion.

Ureteric catheterization via an ileal conduit: technique and retrieval of a JJ stent

Retrograde ureteric catheterization of a patient with an ileal conduit is difficult, because guide wires and catheters coil in the conduit. A modified loopogram, using a Foley catheter as a fulcrum through which catheters can be advanced to the ureteric anastomosis, is described. This technique was used to remove a JJ stent, which had been inserted previously across a stricture in one ureter, the stent crossing from one kidney to the other.

External-internal nephro-uretero-ileal stents in patients with an ileal conduit: long-term results

OBJECTIVES

To describe an improved technique for upper urinary tract drainage in patients with ureteroileal anastomotic stricture after radical cystectomy and urinary diversion to an ileal conduit, and to review our experience and long-term results.

METHODS

From 1995 to 2002, 16 patients (18 renal units) with ureteroileal anastomotic stricture after radical cystectomy and urinary diversion to an ileal conduit underwent external-internal nephro-uretero-ileal stent placement. The procedure consisted of three stages: insertion of a percutaneous nephrostomy tube; retrograde external-internal stent placement with the help of an antegrade-inserted wire, leaving the stent's port in the stoma bag; and periodic retrograde stent exchange. The median duration of follow-up was 26.6 months.

RESULTS

The overall success rate was 94.7%. No serious complications occurred during the procedure or during follow-up. Patient compliance was fairly good. In 75% of the patients, the stent served as the definitive treatment, avoiding the need for surgical revision.

CONCLUSIONS

External-internal nephro-uretero-ileal stent placement can be used successfully and safely as a definitive treatment for anastomosis-related complications in patients after radical cystectomy and urinary diversion to an ileal conduit.

Ureteroscopic management of ureteral and ureteroenteral strictures

The ureteroscopic approach to ureteral strictures has diminished morbidity because of smaller-caliber equipment, improved optics, Ho:YAG laser, and a better understanding of the risk factors for ureteral strictures. Direct visualization by means of retrograde ureteroscopy provides a safe and effective approach to treat ureteral strictures without the need for an open incision or percutaneous nephrostomy access. All patients with a ureteral stricture require an extensive evaluation and planning before treatment. Generally, patients with ureteral strictures and a history of carcinoma should undergo biopsy of the area of stricture. With recurrent cancer, patients may present with pain, nausea, vomiting, pyelonephritis, or loss of the ipsilateral renal unit. Malignant strictures tend to not respond well to balloon dilation alone. Open or laparoscopic resection and reconstruction may be indicated if there is a chance for cure. In patients who are not good surgical candidates or in those who have advanced disease, the urologist is left with the option of an indwelling stent or nephrostomy tube.

Litotricia extracorpórea en litiasis en pacientes con derivación urinaria

We evaluate the efficacy of ESWL in the management of calculi in patients with urinary diversion. We treated 5 patients who suffered from urinary lithiasis after urinary diversion post cistectomy. We managed the patients with extracorporeal shock wave lithotripsy in monotherapy with a Siemens Lithostar Modularis device. Mean stone size (long axis) was 1.95 cm (range 1 to 3.5 cm). The mean shockwave number per session was 2.6 per patient. Stone free result was 100%. We conclude that ESWL technique can provide acceptable results in patients with urinary diversion and can be used as first choice treatment in these type of patients due to its minimal morbidity and excellent results, equivalent to those achieved in patients without urinary diversion.

Long-Term Results of Endoureterotomy and Open Surgical Revision for the Management of Ureteroenteric Strictures After Urinary Diversion

PURPOSE

Prior studies have demonstrated that while endoureterotomy offers a reasonable initial treatment option, open anastomotic revision should remain the gold standard for managing ureteroenteric strictures. However, to our knowledge the results of contemporary endoureterotomy series have not been compared with those of open anastomotic revision, and no study has assessed the morbidity or success rate of secondary open anastomotic revision after failed endoureterotomy.

MATERIALS AND METHODS

Between May 1997 and August 2002 a total of 31 renal units in 22 patients were treated for ureteroenteric strictures after radical cystectomy and urinary diversion. A total of 16 renal units were treated endoscopically, including 9 on the left and 7 on the right side, and open revision was performed in 15 renal units, including 9 on the left and 6 on the right side. Success was defined as radiological improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes.

RESULTS

At a median followup of 35 months (range 17 to 62) for endoureterotomy and 34 months (range 5 to 54) for open revision the success rate of endoureterotomy and open revision was 50% (8 of 16 renal units) and 80% (12 of 15), respectively. One of the 3 patients in whom open revision failed underwent prior pelvic external beam radiation and the other 2 underwent prior endoureterotomies. Overall interventions for right strictures were more successful 85% or 11 of 13 cases than those on the left side (50% or 9 of 18) (p = 0.037). Average operative time was longer and average estimated blood loss was higher in patients treated with open repair after failed endoureterotomy (p = 0.009 and 0.016, respectively). No complications developed in patients following endoureterotomy.

CONCLUSIONS

Open revision remains the gold standard for the management of ureteroenteric strictures. Left strictures are considerably more resistant to management. Patients with left anastomotic strictures should be cautioned that endoureterotomy might have a lower success rate, and failure may limit the success and increase the morbidity of subsequent open anastomotic revision.

Incontinent ileovesicostomy in the management of neurogenic bladder dysfunction

AIMS

To report outcome and urodynamic follow-up of incontinent ileovesicostomy in quadriplegic patients with neurogenic bladder.

METHODS

Seven patients (five male, two female; mean age, 33.7 yr) with neurogenic bladder underwent ileovesicostomy for management of leakage or complications of chronic catheter drainage. Five had chronic indwelling catheters: three suprapubic and two urethral. Preoperatively, all had upper tract evaluation and videourodynamics. All seven patients had detrusor hyperreflexia. Preoperative detrusor leak point pressures averaged 42.7 cm H(2)O. Two females had intrinsic sphincteric deficiency from prolonged Foley catheter drainage. Ileovesicostomy involves isolation of a 15-20-cm segment of terminal ileum. The proximal 6-8 cm of this segment is opened on the antimesenteric border. The dome of the bladder is opened widely in a transverse manner and the proximal portion of the bowel is sutured onto the bladder. The distal portion of the ileum remains tubularized and becomes the stoma.

RESULTS

There were no intraoperative complications. Operative time averaged 159 minutes. Associated procedures included removal of bladder calculus (n = 1), pubovaginal sling (n = 2), and Marshall Marchetti Krantz suspension (n = 1). Mean blood loss was <200 cc in six patients. Mean hospital stay was 8 days. Complications in two patients included: fascial stenosis requiring stoma revision (n = 1), wound infection (n = 1), and postoperative ileus (n = 1). Mean follow-up was 37.4 months. Postoperatively, mean detrusor leak point pressures were 16.7 cm H(2)O (P = 0.0061). Patient satisfaction is high with only one complaint of occasional difficulty fitting the appliance.

CONCLUSIONS

Ileovesicostomy is an effective method of urinary drainage in quadriplegic patients. Detrusor leak point pressures were lowered, and upper tracts were preserved. No long-term complications were encountered.

Long-term outcome of ileal conduit diversion

PURPOSE

Ileal conduit is considered a safe procedure and the gold standard to which newer forms of urinary diversion should be compared, although few long-term results are known. We analyzed a consecutive series of patients who lived a minimum of 5 years after ileal conduit diversion.

MATERIALS AND METHODS

A total of 412 patients underwent ileal conduit diversion between 1971 and 1995 at our institution. We analyzed all conduit related complications occurring later than 3 months after surgery in 131 long-term survivors (survival 5 years or greater).

RESULTS

Median followup was 98 months (range 60 to 354). Overall 192 conduit related complications developed in 87 of 131 (66%) patients. The most frequent complications were related to kidney function/morphology in 35 patients (27%), stoma in 32 (24%), bowel in 32 (24%), symptomatic urinary tract infection (including pyelonephritis) in 30 (23%), conduit/ureteral anastomosis in 18 (14%) and urolithiasis in 12 (9%). Within the first 5 years complications developed in 45% of patients. This percentage increased to 50%, 54% and 94% in those surviving 10, 15 and longer than 15 years, respectively. In this last group 50% had upper urinary tract changes and 38% had urolithiasis, for which the respective numbers after 5 years were 12% and 17%.

CONCLUSIONS

This study demonstrates a high conduit related complication rate in long-term survivors and underlines the need for vigorous long-term followup. Only studies lasting more than 1 decade cover the entire morbidity spectrum.

Shockwave lithotripsy for urinary stones in patients with urinary diversion after radical cystectomy

BACKGROUND AND PURPOSE

During recent years, survival of patients with invasive bladder cancer has been improved by early diagnosis and radical treatment. Urinary lithiasis is not rare in patients who have been submitted to radical cystectomy and urinary diversion. We have demonstrated the effectiveness and safety of SWL for these patients.

PATIENTS AND METHODS

We studied 11 patients who presented to our lithotripsy department suffering from urinary lithiasis after radical cystectomy. They were all cancer free at the time of treatment, and all underwent SWL on the Dornier HM-3 lithotripter as a first-line treatment. The mean stone burden was 1.85 cm(2), and the stone-to-patient ratio was 1:1.

RESULTS

The stone-free rate 1 month after SWL was 63.7%. Patients who were not stone free underwent a second SWL, and the stone-free rate after the second SWL session was 81.8%. We performed percutaneous nephrolithotripsy in one patient after the second SWL session because of the large stone burden remaining (3.2 cm(2)). The remaining patient was submitted to ureterolithotomy.

CONCLUSION

Application of SWL gives very good results in the treatment of urinary lithiasis in patients with a urinary diversion. Indeed, the results are equivalent to those achieved in patients without urinary diversion.

Endoluminal ureteroileal anastomosis

PURPOSE

We present an alternative technique used to complete the ureteroileal anastomosis during the formation of an ileal conduit or neobladder.

MATERIALS AND METHODS

Using an intraoperative camera to produce digital images and with the aid of computer graphics a visual and descriptive method was used to illustrate the technique. It involves eversion of the proximal ileal segment with exteriorization of the ileal mucosa.

RESULTS

This technique allows for direct visualization of the mucosa-to-mucosa ureteroileal anastomosis. With normal tissues it does not require ureteral stents postoperatively. We have been performing this technique for the last 20 years and have never observed symptomatic urinary leakage.

CONCLUSIONS

We present an alternative technique for completing the ureteroileal anastomosis with direct visualization and minimal morbidity.

Long-term results of antegrade endoureterotomy using the holmium laser in patients with ureterointestinal strictures

OBJECTIVES

To investigate the effectiveness and morbidity of percutaneous laser endoureterotomy in the management of ureterointestinal anastomotic strictures after radical cystectomy and urinary diversion.

METHODS

Between May 1997 and August 2000, 19 percutaneous endoureterotomy incisions, including 3 repeated incisions, were performed on 15 patients with a mean age of 61 years (range 41 to 80) to treat ureterointestinal strictures. A total of 16 renal units were treated (9 left, 7 right), including one bilateral procedure. All procedures were performed using a 200-micrometer holmium laser fiber in antegrade fashion with a 7.5F flexible ureteroscope. A nephroureteral stent was left in place for 4 to 6 weeks postoperatively. Success was defined as radiologic improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes.

RESULTS

With a median follow-up of 20.5 months (range 9 to 41), the overall success rate was 57% (8 of 14 renal units). Two patients were lost to follow-up. The mean operative time was 91 minutes, and no perioperative complications occurred. Three patients required repeated endoureterotomies, with two requiring open reimplantation. Overall, the endoureterotomy failed in 6 patients in the series, with five of the six failures involving left-sided strictures.

CONCLUSIONS

Percutaneous endoureterotomy is an effective, minimally invasive treatment option for patients with ureterointestinal strictures after urinary diversion. Better visualization and a more precise incision may make the holmium laser a safer cutting modality than alternative methods in patients with ureteroenteric strictures. Patients with left-sided ureterointestinal strictures should be cautioned that endourologic management might have a lower success rate.

Long-term results of treatment for ureteroenteric strictures

OBJECTIVES

To review the long-term outcome for ureteroenteric stricture treatment.

METHODS

The ileal conduit diversions that formed ureteroenteric strictures from 1966 to 1999 were reviewed. The strictures were diagnosed radiographically, and malignancy was excluded. The treatment, location, length, diameter, and timing of stricture development after conduit creation was evaluated and compared regarding the time until stricture recurrence (failure). Success was defined as symptomatic improvement and radiologic evidence of patency.

RESULTS

Forty patients, after exclusions, returned for ureteroenteric stricture repair, comprising 79 procedures (27 open repairs and 52 balloon dilations). The open repair had a success rate at 1, 2, and 3 years of 92%, 87%, and 76%, respectively. Seven of the open cases were preceded by failed dilations. Balloon dilation had a success rate at 1, 2, and 3 years of 15%, 15%, and 5%, respectively (P = 0.0001 versus open). Similar patency results for open versus balloon (P = 0.0001) were noted with analysis restricted to each patient's first stricture repair. Strictures greater than 1.0 cm were more likely to recur (P = 0.03). All strictures forming within 6 months of the conduit creation were treated with dilation and failed within 1 year. Of note, 11 of the 40 patients were found to have less than 25% renal function on the strictured side.

CONCLUSIONS

Open repair for ureteroenteric strictures offers excellent long-term patency (76% at 3 years, P = 0.0001). On review, balloon dilation appeared to have less successful patency rates and was often followed by open repair after failure. Patients with a history of anastomotic strictures should be closely monitored to avoid renal damage and failure.

Urinary diversion in gynecologic oncology

Urinary diversion in gynecology is performed primarily in conjunction with cancer surgery, but at times, it is required for women with intractable urinary fistulas or other urologic disorders. After 1950, ileal conduits replaced ureterosigmoidostomies as the most widely used form of urinary diversion. Transverse colon conduits have gained popularity because these nonirradiated bowel segments offer less risk for postoperative urinary leaks and small bowel complications associated with bowel and ureteral anastomoses. In 1978, Kock et al described the use of detubularized segments of ileum and the intussuscepted nipple valves to create a continent pouch that is still advocated by urologists in some centers. Ileocolonic continent pouches, originally suggested in 1908, have received considerable attention in the past 10 to 15 years because of ease of construction, lower revision rates, and higher continence rates compared with the Kock ileal pouches. At the Division of Gynecologic Oncology at the University of Miami, the authors have been using the Miami pouch as the preferred form of continent urinary diversion since 1988, with acceptable results. Women who need urinary diversion can be offered at least two major choices: (1) the traditional bowel (ileum or colon) conduit, which requires an external ostomy appliance, or (2) a continent pouch, such as the Miami ileocolonic reservoir. In choosing between non-continent and continent conduits, the patients must be made aware that the continent pouches are available in only a few centers in the United States and carry a slightly higher risk for complications because of the relatively higher complexity. Nonetheless, data strongly suggest that most of these complications can be managed noninvasively and that these patients retain a closer to normal quality of life. The age, disease status, and general health of the woman and the likelihood of her long-term survival after diversion weigh heavily in the final decision.

Holmium:YAG laser endoureterotomy in the treatment of ureteroenteric stricture following Indiana urinary diversion

A 57-year-old man who had received radical urethrocystectomy and Indiana urinary diversion 6 months earlier was treated for ureteroenteric anastomosis stricture (left side) using a Holmium:YAG laser via antegrade approach. The availability of small (6.9 Fr) flexible ureteroscope, as well as the use of the Holmium:YAG laser has facilitated the ability to precisely incise the stricture under direct endoscopic visualization. The technique is described for laser endoureterotomy in a patient with ureteroenteric stricture following Indiana urinary diversion.