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Liang H, Sun H, Chen J. A modified ureteroileal anastomosis can reduce ureteroileal anastomotic stricture after ileal conduit. Int Urol Nephrol 2024; 56:2235-2241. [PMID: 38347248 DOI: 10.1007/s11255-024-03965-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/30/2024] [Indexed: 06/21/2024]
Abstract
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.
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Affiliation(s)
- Hao Liang
- Department of Urology, Qilu Hospital of Shandong University, 107 Wenhua West Road, Lixia District, Jinan City, Shandong Province, China
| | - Hui Sun
- Department of Urology, Qilu Hospital of Shandong University (Qingdao), Qingdao, Shandong, China
| | - Jun Chen
- Department of Urology, Qilu Hospital of Shandong University, 107 Wenhua West Road, Lixia District, Jinan City, Shandong Province, China.
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Das A, Zeng E, Risk M, Shapiro DD, Jason Abel E, Jarrard DF, Richards KA. Shorter Ureters Lead to Fewer Strictures Following Cystectomy and Urinary Diversion. Urology 2024; 184:272-277. [PMID: 38122989 DOI: 10.1016/j.urology.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To identify the impact of length of distal ureteral resection on the risk of benign uretero-enteric anastomotic stricture (UEAS) formation following cystectomy and urinary diversion. METHODS A database of patients who underwent cystectomy and urinary diversion from 2015 to 2022 was analyzed. Distal ureteral resections were sent for final pathology. The length of resected ureter was collected from pathology reports. Benign UEAS were confirmed with renal scintigraphy, antegrade nephrostogram, or endoscopic evaluation. The relationship between stricture formation and clinical parameters were assessed using T-tests, chi-square tests, and multivariable analysis. RESULTS A total of 366 patients underwent cystectomy and urinary diversion. Of the cohort, 35 (9.5%) patients developed UEAS. Median time to stricture formation was 12.5months (IQR 4-30). Of the 711 uretero-enteric anastomoses, 40 (5.6%) ultimately formed a UEAS. Median distal ureteral resection was significantly longer among ureteral anastomoses which did not form a UEAS (2.3 cm vs 1.65 cm, P = .028). Multivariable logistic regression adjusting for surgical approach, prior radiation, ureteral side, and urinary diversion type demonstrated that longer distal ureteral resections were inversely associated with odds of UEAS formation (OR 0.73, 95% CI 0.58-0.92). Multivariable Cox regression analysis similarly showed that length of distal ureteral resection was inversely associated with time to stricture formation (HR 0.78, 95% CI 0.62-0.98). CONCLUSION The etiology of benign UIA strictures is multifactorial. Vascular compromise is a critical hypothesis. We found that longer distal ureteral resections (and thus shorter ureters) were associated with a significantly lower risk of stricture formation in cystectomy patients.
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Affiliation(s)
- Arighno Das
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Erica Zeng
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Michael Risk
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Daniel D Shapiro
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Edwin Jason Abel
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - David F Jarrard
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Kyle A Richards
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI.
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Can O, Danış E, Kutlutürk EG, Polat EC, Ötünçtemur A. Hybrid technique has lower stricture rates than Wallace and Bricker. Surg Oncol 2024; 52:102036. [PMID: 38198985 DOI: 10.1016/j.suronc.2024.102036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/19/2023] [Accepted: 01/04/2024] [Indexed: 01/12/2024]
Abstract
INTRODUCTION A clear consensus has not yet been reached on the optimal ureteroenteric anastomosis technique for ileal conduit urinary diversion following radical cystectomy. This study aims to determine the incidence of strictures and their management associated with these anastomosis techniques. METHODS We conducted a retrospective, single-center study of patients who underwent radical cystectomy and urinary diversion between March 2014 and August 2022. Patients were categorized based on the ureteroenteric anastomosis technique used: Wallace, Bricker, or Hybrid. Strictures were identified through antegrade pyelography following nephrostomy placement. RESULTS A total of 141 patients were included in the study, with 60 patients in the Wallace group (42 %), 42 patients in the Bricker group (30 %), and 39 patients in the Hybrid group (28 %). The overall incidence of ureteroenteric strictures was 15 %, with 7 patients in the Wallace group, 11 patients in the Bricker group, and 3 patients in the Hybrid group experiencing strictures. There was no statistically significant difference in stricture rates between the Wallace and Bricker groups (11 % vs. 26 %, p = 0.09) or between the Wallace and Hybrid groups (11 % vs. 7 %, p = 0.73). However, a statistically significant difference was observed between the Bricker and Hybrid groups (26 % vs. 7 %, p = 0.03). The mean time to stricture development was 9.2 ± 3.3 months for the Wallace group, 9.5 ± 3.7 months for the Bricker group, and 12.6 ± 5 months for the Hybrid group (p = 0.407). CONCLUSION The Hybrid ureteroenteric anastomosis technique exhibits a lower stricture rate compared to the Bricker and Wallace techniques. It represents a safe and feasible alternative technique.
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Affiliation(s)
- Osman Can
- Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey.
| | - Eyyüp Danış
- Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey.
| | | | - Emre Can Polat
- Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey.
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Fu S, Shi H, Fan Z, Li J, Luan T, Dong H, Wang J, Chen S, Zhang J, Wang J, Ding M, Wang H. Robot-assisted radical cystectomy with intracorporeal urinary diversion: an updated systematic review and meta-analysis of its differential effect on effectiveness and safety. Int J Surg 2024; 110:01279778-990000000-00948. [PMID: 38260944 PMCID: PMC11020008 DOI: 10.1097/js9.0000000000001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/24/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion (iRARC) is increasingly being used in recent years. Whether iRARC offers advantages over open radical cystectomy (ORC) remains controversial. This study aimed to compare the difference of perioperative outcomes, oncological outcomes and complications between iRARC and ORC. METHODS The PubMed, Embase, Cochrane Library, Web of Science and CNKI databases were searched in July 2023 according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement. Studies were identified to be eligible if they compared perioperative outcomes, oncological outcomes and complications in patients who underwent iRARC with ORC. RESULTS Twenty-two studies involving 7,020 patients were included. Compared to ORC, iRARC was superior for estimated blood loss [EBL WMD: -555.52; 95% CI, -681.64 to -429.39; P<0.001], blood transfusion rate [OR: 0.16; 95% CI, 0.09 to 0.28; P<0.001], length of hospital stay [LOS WMD: -2.05; 95% CI, -2.93 to -1.17; P<0.001], Clavien-Dindo grades ≥III complication rate [30d: OR: 0.57; 95% CI 0.44 to 0.75; P<0.001; 90d: OR: 0.71; 95% CI 0.60 to 0.84; P<0.001], and positive surgical margin [PSM OR: 0.65; 95% CI 0.49 to 0.85; P=0.002]. However, iRARC had a longer operative time [OT WMD: 68.54; 95%CI 47.41 to 89.67; P<0.001] and a higher rate of ureteroenteric stricture [ UES OR: 1.56; 95% CI 1.16 to 2.11; P=0.003]. Time to flatus, time to bowel, time to regular diet, readmission rate, Clavien-Dindo grades CONCLUSION Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion appears to be superior to open radical cystectomy in terms of effectiveness and safety. However, attention should be paid to the occurrence of ureteroenteric stricture during follow-up.
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Affiliation(s)
- Shi Fu
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - HongJin Shi
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhinan Fan
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
- Department of Urology, Meishan People's Hospital, Meishan, China
| | - Jinze Li
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Luan
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Haonan Dong
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jincheng Wang
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shuwen Chen
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jinsong Zhang
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jiansong Wang
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Mingxia Ding
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Haifeng Wang
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
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Rich JM, Tillu N, Grauer R, Busby D, Auer R, Breda A, Buse S, D'Hondt F, Falagario U, Hosseini A, Mehrazin R, Minervini A, Mottrie A, Sfakianos J, Palou J, Wijburg C, Wiklund P, John H. Robot-Assisted Repair of Ureteroenteric Strictures After Cystectomy with Urinary Diversion: Technique Description and Outcomes from the European Robotic Urology Section Scientific Working Group. J Endourol 2023; 37:1209-1215. [PMID: 37694596 DOI: 10.1089/end.2023.0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
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.
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Affiliation(s)
- Jordan M Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Neeraja Tillu
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ralph Grauer
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dallin Busby
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rebecca Auer
- Department of Urology, Winterthur Kantonsspital, Winterthur, Switzerland
| | - Alberto Breda
- Department of Urology, Fundacio Puigvert, Barcelona, Spain
| | - Stephan Buse
- Department of Urology, Alfried Krupp Krankenhaus, Essen, Germany
| | | | - Ugo Falagario
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
- Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy
| | - Abolfazl Hosseini
- Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Urology, Basel University Hospital, Switzerland
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Alexandre Mottrie
- Department of Urology, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Urology, ORSI Academy, Melle, Belgium
| | - John Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joan Palou
- Department of Urology, Fundacio Puigvert, Barcelona, Spain
| | - Carl Wijburg
- Department of Urology, Rijnstate, Arnhem, Netherlands
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Hubert John
- Department of Urology, Winterthur Kantonsspital, Winterthur, Switzerland
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Ramahi YO, Shiekh M, Shah AA, Houenstein H, Ely HB, Shabir U, Jing Z, Li Q, Hussein AA, Guru KA. Uretero-enteric Strictures after Robot Assisted Radical Cystectomy: Prevalence and Management Over Two Decades. Clin Genitourin Cancer 2022; 21:e19-e26. [PMID: 36372690 DOI: 10.1016/j.clgc.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/04/2022] [Accepted: 10/09/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION To evaluate the prevalence, predictors, management, and trends for ureteroenteric strictures (UES) after robot-assisted radical cystectomy (RARC). METHODS Retrospective review of our RARC database was performed (2005-2022). UES was described in terms of timing, laterality, and management. Kaplan-Meier curves were used to depict time to UES. Local regression was used to assess trend of UES over time and multivariable regression to identify variables associated with UES. RESULTS UES occurred in 109 patients (15%). UES occurred in 13%, 17%, and 19% at 1, 3, and 5 years after RARC, respectively. Incidence of UES decreased in 2017, coinciding with stentless uretero-enteric anastomosis. UES occurred on the right in 33%, on the left in 46%, and bilaterally in 21%. All patients were initially managed by nephrostomy/stent. Surgical revision was required in 45% of patients, of which 13% developed recurrent UES after revision. On MVA, UES formation was associated with ureteral stents (OR 2.27, 95%CI 1.01-5.10, P = .05) and receipt of neoadjuvant chemotherapy (OR 2.01, 95%CI 1.24-3.25, P = .005). CONCLUSION UES occurred in 15% of patients after RARC, with 45% of patients requiring surgical reimplantation. Ureteral stents and the receipt of neoadjuvant chemotherapy were associated with UES formation.
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Flynn H, Davies S, Nielsen J, Navaratnam A. Robot-Assisted Reconstruction of Ureteroileal Anastomotic Stricture with Y-V Plasty. UROLOGY VIDEO JOURNAL 2022. [DOI: 10.1016/j.urolvj.2022.100166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Wang J, Tuo Z, Gao M, Min J, Wang Y, Zhang T, Yu D, Bi L. Is it necessary to perform a retrosigmoid transposition of the left ureter in Bricker Ileal Conduit surgery? BMC Urol 2022; 22:116. [PMID: 35897097 PMCID: PMC9330641 DOI: 10.1186/s12894-022-01073-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/21/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Jinyou Wang
- Department of Urology, Second Affiliated Hospital of Anhui Medical University, No. 678 Furong Road, Hefei, 200032, People's Republic of China
| | - Zhouting Tuo
- Department of Urology, Second Affiliated Hospital of Anhui Medical University, No. 678 Furong Road, Hefei, 200032, People's Republic of China
| | - Mingzhu Gao
- Department of Oncology, Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, People's Republic of China
| | - Jie Min
- Department of Urology, Second Affiliated Hospital of Anhui Medical University, No. 678 Furong Road, Hefei, 200032, People's Republic of China
| | - Yi Wang
- Department of Urology, Second Affiliated Hospital of Anhui Medical University, No. 678 Furong Road, Hefei, 200032, People's Republic of China
| | - Tao Zhang
- Department of Urology, Second Affiliated Hospital of Anhui Medical University, No. 678 Furong Road, Hefei, 200032, People's Republic of China
| | - Dexin Yu
- Department of Urology, Second Affiliated Hospital of Anhui Medical University, No. 678 Furong Road, Hefei, 200032, People's Republic of China
| | - Liangkuan Bi
- Department of Urology, Second Affiliated Hospital of Anhui Medical University, No. 678 Furong Road, Hefei, 200032, People's Republic of China.
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Mancini M, Nguyen AAL, Taverna A, Beltrami P, Zattoni F, Dal Moro F. Successful Multidisciplinary Repair of Severe Bilateral Uretero-Enteric Stricture with Inflammatory Reaction Extending to the Left Iliac Artery, after Robotic Radical Cystectomy and Intracorporeal Ileal Neobladder. Curr Oncol 2021; 29:155-162. [PMID: 35049688 PMCID: PMC8774511 DOI: 10.3390/curroncol29010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 11/26/2022] Open
Abstract
Uretero-enteric anastomotic strictures (UES) after robot-assisted radical cystectomy (RARC) represent the main cause of post-operative renal dysfunction. The gold standard for treatment of UES is open uretero-ileal reimplantation (UIR), which is often a challenging and complex procedure associated with significant morbidity. We report a challenging case of long severe bilateral UES (5 cm on the left side, 3 cm on the right side) after RARC in a 55 years old male patient who was previously treated in another institution and who came to our attention with kidney dysfunction and bilateral ureteral stents from the previous two years. Difficult multiple ureteral stent placement and substitutions had been previously performed in another hospital, with resulting urinary leakage. An open surgical procedure via an anterior transperitoneal approach was performed at our hospital, which took 10 h to complete, given the massive intestinal and periureteral adhesions, which required very meticulous dissection. A vascular surgeon was called to repair an accidental rupture that had occurred during the dissection of the external left iliac artery, involved in the extensive periureteral inflammatory process. Excision of a segment of the external iliac artery was accomplished, and an interposition graft using a reversed saphenous vein was performed. Bilateral ureteroneocystostomy followed, which required, on the left side, the interposition of a Casati-Boari flap harvested from the neobladder, and on the right side a neobladder-psoas-hitching procedure with intramucosal direct ureteral reimplantation. The patient recovered well and is currently in good health, as determined at his recent 24-month follow-up visit. No signs of relapse of the strictures or other complications were detected. Bilateral ureteral reimplantation after robotic radical cystectomy is a complex procedure that should be restricted to high-volume centers, where multidisciplinary teams are available, including urologists, endourologists, and general and vascular surgeons.
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Affiliation(s)
- Mariangela Mancini
- Urological Clinic, University Hospital of Padova, 35121 Padova, Italy; (A.A.L.N.); (A.T.); (P.B.); (F.Z.); (F.D.M.)
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, 35121 Padova, Italy
- Correspondence:
| | - Alex Anh Ly Nguyen
- Urological Clinic, University Hospital of Padova, 35121 Padova, Italy; (A.A.L.N.); (A.T.); (P.B.); (F.Z.); (F.D.M.)
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, 35121 Padova, Italy
| | - Alessandra Taverna
- Urological Clinic, University Hospital of Padova, 35121 Padova, Italy; (A.A.L.N.); (A.T.); (P.B.); (F.Z.); (F.D.M.)
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, 35121 Padova, Italy
| | - Paolo Beltrami
- Urological Clinic, University Hospital of Padova, 35121 Padova, Italy; (A.A.L.N.); (A.T.); (P.B.); (F.Z.); (F.D.M.)
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, 35121 Padova, Italy
| | - Filiberto Zattoni
- Urological Clinic, University Hospital of Padova, 35121 Padova, Italy; (A.A.L.N.); (A.T.); (P.B.); (F.Z.); (F.D.M.)
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, 35121 Padova, Italy
| | - Fabrizio Dal Moro
- Urological Clinic, University Hospital of Padova, 35121 Padova, Italy; (A.A.L.N.); (A.T.); (P.B.); (F.Z.); (F.D.M.)
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, 35121 Padova, Italy
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Bizzarri N, Foschi N, Loverro M, Tortorella L, Santullo F, Rosati A, Gueli Alletti S, Costantini B, Gallotta V, Ferrandina G, Fagotti A, Fanfani F, Ercoli A, Chiantera V, Scambia G, Vizzielli G. Indocyanine Green to Assess Vascularity of Ileal Conduit Anastomosis During Pelvic Exenteration for Recurrent/Persistent Gynecological Cancer: A Pilot Study. Front Oncol 2021; 11:727725. [PMID: 34950574 PMCID: PMC8691262 DOI: 10.3389/fonc.2021.727725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Pelvic exenteration performed for recurrent/persistent gynecological malignancies has been associated with urological short- and long-term morbidity due to altered vascularization of tissues for previous radiotherapy. The aims of the present study were to describe the use of intravenous indocyanine green (ICG) to assess vascularity of urinary diversion (UD) after pelvic exenteration for gynecologic cancers, to evaluate the feasibility and safety of this technique, and to assess the postoperative complications. Methods Prospective, observational, single-center, pilot study including consecutive patients undergoing anterior or total pelvic exenteration due to persistent/recurrent gynecologic cancers between August 2020 and March 2021 at Fondazione Policlinico Gemelli IRCCS, Rome, Italy. All patients underwent intravenous injection of 3–6 ml of ICG (1.25 mg/ml) once the UD was completed. A near-infrared camera was used to evaluate ICG perfusion of anastomoses (ileum–ileum, right and left ureter with small bowel, and colostomy or colorectal sides of anastomosis) a few seconds after ICG injection. Results Fifteen patients were included in the study. No patient reported adverse reactions to ICG injection. Only 3/15 patients (20.0%) had an optimal ICG perfusion in all anastomoses. The remaining 12 (80.0%) patients had at least one ICG deficit; the most common ICG deficit was on the left ureter: 3 (20.0%) vs. 1 (6.7%) patient had no ICG perfusion on the left vs. right ureter, respectively (p = 0.598). 8/15 (53.3%) and 6/15 (40.0%) patients experienced grade ≥3 30-day early and late postoperative complications, respectively. Of these, two patients had early and one had late postoperative complications directly related to poor perfusion of anastomosis (UD leak, ileum–ileum leak, and benign ureteric stricture); all these cases had a suboptimal intraoperative ICG perfusion. Conclusion The use of ICG to intraoperatively assess the anastomosis perfusion at time of pelvic exenteration for gynecologic malignancy is a feasible and safe technique. The different vascularization of anastomotic stumps may be related to anatomical sites and to previous radiation treatment. This approach could be in support of selecting patients at higher risk of complications who may need personalized follow-up.
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Affiliation(s)
- Nicolò Bizzarri
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Nazario Foschi
- UOC Clinica Urologica, Dipartimento Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Matteo Loverro
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Lucia Tortorella
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesco Santullo
- UOC Chirurgia Peritoneo e Retroperitoneo, Dipartimento Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Andrea Rosati
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Salvatore Gueli Alletti
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Barbara Costantini
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Valerio Gallotta
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Gabriella Ferrandina
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Fagotti
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Fanfani
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Ercoli
- Department of Gynecologic Oncology and Minimally-Invasive Gynecologic Surgery, Università Degli Studi di Messina, Policlinico G. Martino, Messina, Italy
| | - Vito Chiantera
- ARNAS Ospedali Civico Di Cristina Benfratelli, Department of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Giovanni Scambia
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Vizzielli
- Unità Operativa Complessa (UOC) Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Obstetrics and Gynecology Department, Academic Hospital of Udine, Department of Medicine, University of Udine, Udine, Italy
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11
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Impact of radiation on the incidence and management of ureteroenteric strictures: a contemporary single center analysis. BMC Urol 2021; 21:101. [PMID: 34348684 PMCID: PMC8336081 DOI: 10.1186/s12894-021-00869-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 07/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ureteroenteric stricture incidence has been reported as high as 20% after urinary diversion. Many patients have undergone prior radiotherapy for prostate, urothelial, colorectal, or gynecologic malignancy. We sought to evaluate the differences between ureteroenteric stricture occurrence between patients who had radiation prior to urinary diversion and those who did not. METHODS An IRB-approved cystectomy database was utilized to identify ureteroenteric strictures among 215 patients who underwent urinary diversion at a single academic center between 2016 and 2020. Chart abstraction was conducted to determine the presence of confirmed stricture in these patients, defined as endoscopic diagnosis or definitive imaging findings. Strictures due to malignant ureteral recurrence were excluded (3 patients). Statistical analysis was performed using chi squared test, t-test, and Wilcoxon Rank-Sum Test, logistic regression, and Kaplan-Meier analysis of stricture by cancer type. RESULTS 65 patients had radiation prior to urinary diversion; 150 patients did not have a history of radiation therapy. Benign ureteroenteric stricture rate was 5.3% (8/150) in the non-radiated cohort and 23% (15/65) in the radiated cohort (p = < 0.001). Initial management of stricture was percutaneous nephrostomy (PCN) in 78% (18/23) and the remaining 22% (5/23) were managed with primary retrograde ureteral stent placement. Long term management included ureteral reimplantation in 30.4% (7/23). CONCLUSIONS Our study demonstrates a significant increase in rate of ureteroenteric strictures in radiated patients as compared to non-radiated patients. The insult of radiation on the ureteral microvascular supply is likely implicated in the cause of these strictures. Further study is needed to optimize surgical approach such as utilization of fluorescence angiography for open and robotic approaches.
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12
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Does minimally invasive surgery for bladder cancer result in unusual sites of metastasis? Actas Urol Esp 2021; 45:512-519. [PMID: 34330694 DOI: 10.1016/j.acuroe.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/07/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND To compare sites of metastasis for the laparoscopic (LRC) and open (ORC) approaches in a cohort of patients at a district general hospital. Morbidity and mortality for the two approaches are assessed using secondary outcomes of length of stay and complication rate. Metastasis rate and site are compared. METHODS A retrospective case note review was carried out for all patients who underwent cystectomy for bladder malignancy at Pinderfields General Hospital, Wakefield between 2010 and 2016 (n = 219). There were 150 males and 69 females in 107 minimally invasive cases and 87 open (missing data on 25 cases). Data were analysed using Microsoft Excel XLSTAT. RESULTS Recurrence rate was 25.1% and did not differ significantly with approach (p = 0.89). Sites of recurrence did not differ with operative approach, the most frequent being pelvis, chest and bone. Unusual sites of recurrence included abdominal wall and sigmoid colon which both occurred in LRC. Length of stay was greater for the open approach (median LRC = 10, ORC = 13, p < 0.01). Five-year survival was 74.9%. Survival distribution did not significantly differ with operative approach (p = 0.43), and there was no significant association between operative approach and patient death within the follow-up period (p = 0.09). Stricture rate was 4.1% and was not significantly different between the 2 groups (p = 0.29). Median time to stricture was 130 days. Clavien-Dindo scores for complications did not differ with approach (p = 0.93), and there was no significant association between operative approach and whether complications developed (p = 0.19). CONCLUSIONS The adverse oncological outcomes in minimally invasive approaches suggested by some studies are not confirmed here. Those in the LRC group were discharged sooner, though this did not translate into differences in morbidity or survival. Analysis of the association between individual complications and length of stay may clarify this further. Shorter hospital stay is also likely to have significant financial implications. Despite no significant difference in outcomes, the findings demonstrate potential benefits of LRC. Extensions of this study could include: cost-benefit analysis, examination of individual complications' effect on length of stay; and analysis of approach-specific factors contributing to perioperative deaths.
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13
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Tartaglione G, Foschi N, Ragonese M, Recupero SM, Ieria FP, Tarantino G, Bassi P. A gravity-assisted approach to the management of urinary diversion: 99mTc-MAG3 diuresis renography with F + 10(sp) method. Ann Nucl Med 2021; 35:1127-1135. [PMID: 34236580 DOI: 10.1007/s12149-021-01648-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/20/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Radical cystectomy with permanent urinary diversion is the gold standard treatment for invasive muscle bladder cancer. Hydronephrosis is common in these patients, but Ultrasound (US) or Computed Tomography Urography (CTU) scan are unable to discriminate obstructive from non-obstructive hydronephrosis. We used Diuresis Renography (DR) with F + 10 in seated position (sp) method in the identification of patients with a Uretero-ileal Anastomosis Stricture (UAS) who would benefit from surgical therapy. METHODS We studied 39 asymptomatic patients, who underwent radical cystectomy and urinary diversion. Based on radiological findings (US, CTU) 44 kidneys were hydronephrotic. All patients underwent a 99mTc-MAG3 DR with F + 10(sp) method. We acquired a DR for 20 min with the patient in a seated position. Patient drank 400-500 mL of water at 5 min after tracer injection and received a 20 mg bolus of Furosemide at 10 min during dynamic acquisition. The indices Time to peak, diuretic half time, and 20 min/peak ratio have been evaluated. Retrograde pyelography confirmed UAS in all patients with DR obstructive findings. We repeated DR as follow-up in two subgroups of patients. RESULTS DR with F + 10(sp) method showed obstructive findings in 36 out of 44 hydronephrotic kidneys. 6 patients showed non-obstructive findings. 32 patients showed obstructive findings (20 out of 32 developed UAS within 12 months after surgery). Fifteen pts underwent a surgical treatment of UAS. In 1 patient with equivocal findings, we observed an ileo-ureteral reflux. CONCLUSIONS The DR with F + 10(sp) method in the seated position has a lower uncertain diagnostic rate, compared to the radiological findings of US or CTU, in management of bladder cancer patients with urinary diversion. The semiquantitative indices diuretic half time and 20 min/peak ratio evaluated in a condition of favorable gravity reduce uncertain responses improving interobserver concordance.
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Affiliation(s)
- Girolamo Tartaglione
- Department of Nuclear Medicine, Cristo Re Hospital, 25 Via delle, Calasanziane, 00167, Rome, Italy.
| | - Nazario Foschi
- Department of Urology, A. Gemelli Hospital IRCCS-Catholic University of Sacred Heart, Rome, Italy
| | - Mauro Ragonese
- Department of Urology, A. Gemelli Hospital IRCCS-Catholic University of Sacred Heart, Rome, Italy
| | - Salvatore M Recupero
- Department of Urology, Fatebenefratelli San Giovanni Calibita Hospital, Rome, Italy
| | - Francesco P Ieria
- Department of Nuclear Medicine, Cristo Re Hospital, 25 Via delle, Calasanziane, 00167, Rome, Italy
| | | | - Pierfrancesco Bassi
- Department of Urology, A. Gemelli Hospital IRCCS-Catholic University of Sacred Heart, Rome, Italy
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14
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Fonseca R, Santos JC, Lopes FA, Peyroteo I, Silva A, Gaspar FP, Mota RL. Endourological approach in patients with anatomical urinary tract challenges. JOURNAL OF CLINICAL UROLOGY 2021. [DOI: 10.1177/20514158211007733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: This article reports our experience managing neoplasms, stenosis and urolithiasis in patients with anatomical variations of the urinary system, using an endourological approach, either with an antegrade access or with combined access. Patients and methods: A retrospective review was performed using medical records of all patients who underwent percutaneous endourological treatment at our institution between 2014 and 2019. Those with such urinary anatomical variations were selected. Results: Out of 185 patients, 10 were identified. The study group included patients with urinary diversion, renal transplantation and congenital anomalies. Patients were divided into two sets, A and B, based on the presence or absence of urolithiasis, respectively. In set A, the median operative time was 213 minutes (standard deviation ( SD)=65.91 minutes). Only one patient had lithiasis in the first postoperative evaluation. Two patients had postoperative complications graded ⩾II in the Clavien–Dindo classification. Regarding set B, the median operation time was 75 minutes ( SD=66.89 minutes). Two patients had postoperative complications graded ⩾II in the Clavien–Dindo classification. Conclusions: Patients with anatomical tract challenges currently have a longer life expectancy and are therefore prone to urological complications in their unusual structures. Treatment of urological complications is essential, and minimal invasive procedures should be considered to resolve them and to reduce morbidity. Level of evidence: Not applicable.
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Affiliation(s)
- Rita Fonseca
- Department of Urology, Centro Hospitalar de Lisboa Ocidental EPE, Portugal
| | - José C Santos
- Department of Urology, Centro Hospitalar de Lisboa Ocidental EPE, Portugal
| | - Filipe A Lopes
- Department of Urology, Centro Hospitalar de Lisboa Ocidental EPE, Portugal
| | - Inês Peyroteo
- Department of Urology, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Portugal
| | - Andreia Silva
- Department of Urology, Centro Hospitalar de Lisboa Ocidental EPE, Portugal
| | - Frederico P Gaspar
- Department of Urology, Centro Hospitalar de Lisboa Ocidental EPE, Portugal
| | - Renato L Mota
- Department of Urology, Centro Hospitalar de Lisboa Ocidental EPE, Portugal
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15
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Does minimally invasive surgery for bladder cancer result in unusual sites of metastasis? Actas Urol Esp 2021. [PMID: 33744023 DOI: 10.1016/j.acuro.2020.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare sites of metastasis for the laparoscopic (LRC) and open (ORC) approaches in a cohort of patients at a district general hospital. Morbidity and mortality for the two approaches are assessed using secondary outcomes of length of stay and complication rate. Metastasis rate and site are compared. METHODS A retrospective case note review was carried out for all patients who underwent cystectomy for bladder malignancy at Pinderfields General Hospital, Wakefield between 2010 and 2016 (n=219). There were 150 males and 69 females in 107 minimally invasive cases and 87 open (missing data on 25 cases). Data were analysed using Microsoft Excel XLSTAT. RESULTS Recurrence rate was 25.1% and did not differ significantly with approach (p=0.89). Sites of recurrence did not differ with operative approach, the most frequent being pelvis, chest and bone. Unusual sites of recurrence included abdominal wall and sigmoid colon which both occurred in LRC. Length of stay was greater for the open approach (median LRC=10, ORC=13, p<0.01). Five-year survival was 74.9%. Survival distribution did not significantly differ with operative approach (p=0.43), and there was no significant association between operative approach and patient death within the follow-up period (p=0.09). Stricture rate was 4.1% and was not significantly different between the two groups (p=0.29). Median time to stricture was 130 days. Clavien-Dindo scores for complications did not differ with approach (p=0.93), and there was no significant association between operative approach and whether complications developed (p=0.19). CONCLUSIONS The adverse oncological outcomes in minimally invasive approaches suggested by some studies are not confirmed here. Those in the LRC group were discharged sooner, though this did not translate into differences in morbidity or survival. Analysis of the association between individual complications and length of stay may clarify this further. Shorter hospital stay is also likely to have significant financial implications. Despite no significant difference in outcomes, the findings demonstrate potential benefits of LRC. Extensions of this study could include: cost-benefit analysis, examination of individual complications' effect on length of stay; and analysis of approach-specific factors contributing to perioperative deaths.
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16
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Cool DW, Xu SS, Li KJ, Power NE, Kribs SW. Percutaneous Neoanastomosis Creation for an Ileal Conduit Ureteroenteric Occlusion using Radiofrequency Guidewire and Snare Target Technique. J Vasc Interv Radiol 2021; 32:778-781. [PMID: 33640218 DOI: 10.1016/j.jvir.2020.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/06/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Derek W Cool
- Division of Interventional Radiology, Department of Medical Imaging, Western University, 800 Commissioners Rd E, London, ON N6A 5W9, Canada
| | - Samuel S Xu
- Division of Interventional Radiology, Department of Medical Imaging, Western University, 800 Commissioners Rd E, London, ON N6A 5W9, Canada
| | - Katherine J Li
- Division of Interventional Radiology, Department of Medical Imaging, Western University, 800 Commissioners Rd E, London, ON N6A 5W9, Canada
| | - Nicholas E Power
- Division of Urology, Department of Surgery, Western University, 800 Commissioners Rd E, London, ON N6A 5W9, Canada
| | - Stewart W Kribs
- Division of Interventional Radiology, Department of Medical Imaging, Western University, 800 Commissioners Rd E, London, ON N6A 5W9, Canada
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17
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Incontinent Urinary Diversion. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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18
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Kobayashi K, Goel A, Coelho MP, Medina Perez M, Klumpp M, Tewari SO, Appleton-Figueira T, Pinter DJ, Shapiro O, Jawed M. Complications of Ileal Conduits after Radical Cystectomy: Interventional Radiologic Management. Radiographics 2020; 41:249-267. [PMID: 33306453 DOI: 10.1148/rg.2021200067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Katsuhiro Kobayashi
- From the Departments of Radiology (K.K., A.G., M.P.C., M.M.P., M.K., S.O.T., T.A.F., D.J.P., M.J.), and Urology (O.S.), SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210
| | - Atin Goel
- From the Departments of Radiology (K.K., A.G., M.P.C., M.M.P., M.K., S.O.T., T.A.F., D.J.P., M.J.), and Urology (O.S.), SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210
| | - Marlon P Coelho
- From the Departments of Radiology (K.K., A.G., M.P.C., M.M.P., M.K., S.O.T., T.A.F., D.J.P., M.J.), and Urology (O.S.), SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210
| | - Mariangeles Medina Perez
- From the Departments of Radiology (K.K., A.G., M.P.C., M.M.P., M.K., S.O.T., T.A.F., D.J.P., M.J.), and Urology (O.S.), SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210
| | - Matthew Klumpp
- From the Departments of Radiology (K.K., A.G., M.P.C., M.M.P., M.K., S.O.T., T.A.F., D.J.P., M.J.), and Urology (O.S.), SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210
| | - Sanjit O Tewari
- From the Departments of Radiology (K.K., A.G., M.P.C., M.M.P., M.K., S.O.T., T.A.F., D.J.P., M.J.), and Urology (O.S.), SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210
| | - Tomas Appleton-Figueira
- From the Departments of Radiology (K.K., A.G., M.P.C., M.M.P., M.K., S.O.T., T.A.F., D.J.P., M.J.), and Urology (O.S.), SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210
| | - David J Pinter
- From the Departments of Radiology (K.K., A.G., M.P.C., M.M.P., M.K., S.O.T., T.A.F., D.J.P., M.J.), and Urology (O.S.), SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210
| | - Oleg Shapiro
- From the Departments of Radiology (K.K., A.G., M.P.C., M.M.P., M.K., S.O.T., T.A.F., D.J.P., M.J.), and Urology (O.S.), SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210
| | - Mohammed Jawed
- From the Departments of Radiology (K.K., A.G., M.P.C., M.M.P., M.K., S.O.T., T.A.F., D.J.P., M.J.), and Urology (O.S.), SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210
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Near-infrared Fluorescence Imaging of Ureters With Intravenous Indocyanine Green During Radical Cystectomy to Prevent Ureteroenteric Anastomotic Strictures. Urology 2020; 144:220-224. [DOI: 10.1016/j.urology.2020.06.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 02/06/2023]
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Katims AB, Edelblute BT, Tam AW, Zampini AM, Mehrazin R, Gupta M. Long-Term Outcomes of Laser Incision and Triamcinolone Injection for the Management of Ureteroenteric Anastomotic Strictures. J Endourol 2020; 35:21-24. [PMID: 32689827 DOI: 10.1089/end.2020.0593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew B Katims
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Beth T Edelblute
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrew W Tam
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anna M Zampini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mantu Gupta
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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21
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董 文, 王 明, 胡 浩, 王 起, 许 克, 徐 涛. [Initial clinical experience and follow-up outcomes of treatment for ureteroileal anastomotic stricture with Allium coated metal ureteral stent]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2020; 52:637-641. [PMID: 32773792 PMCID: PMC7433639 DOI: 10.19723/j.issn.1671-167x.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To summarize the initial clinical experience and follow-up results of the treatment for ureteroileal anastomotic stricture after radical cystectomy with Allium coated metal ureteral stent. METHODS From September 2018 to September 2019, 8 patients with ureteroileal anastomotic stricture after radical cystectomy underwent Allium ureteral stent insertion in Peking University People's Hospital and People's Hospital of Daxing District. The preoperative renal pelvis width under ultrasound was collected to evaluate the postoperative hydronephrosis, creatinine and urea nitrogen (BUN) before and after surgery, perioperative infection, and stent-related complications. The serum creatinine and BUN, renal pelvis width under ultrasound, urography and abdominal plain film (KUB) were reviewed at the end of 1, 3, and 6 months and annually postoperatively to observe the stent position and morphology. The long-term stent patency rate, complication rate, renal function and hydronephrosis were followed up and analyzed. The t-test or rank-sum test was used to compare the measurement data of the matched sample from the preoperative to the last follow-up. RESULTS In the study, 6 cases (7 sides) were ureteral ileal conduit stricture, and 2 cases (3 sides) ureteral orthotopic neobladder stricture. Before surgery, 5 patients underwent long-term indwelling of a single J ureteral stent, with an average indwelling time of (20.6±8.8) months and an average replacement frequency of (3.6±1.3) months/time. The mean width of renal pelvis was (26.5±9.1) mm on preoperative renal ultrasonography. Among them, 6 patients were successfully indwelled with Allium coated metal ureteral stent by retrograde approach, and 2 patients by combination of double-endoscopy and ante-retrograde approach. No surgery-related complications during perioperative period were observed. The mean follow-up period was 9.8 months and Allium stent and ureter remained unobstructed in all the patients at the last follow-up without replacement or removal. Compared with preoperative data, the mean width of renal pelvis and mean blood urea nitrogen (BUN) in the last follow-up period were significantly reduced [(26.5±9.1) mm vs. (13.4±2.5) mm, P=0.008; (11.6±2.3) mmol/L vs. (10.2±2.2) mmol/L, P=0.017], however, there were no significant differences in the average serum creatinine or hemoglobin (P>0.05). Ureteroileal anastomotic re-stricture and other stent-related complications were not observed in all the patients by antegrade urography. CONCLUSION Allium coated metal ureteral stent could be used for the treatment for ureteroileal anastomotic stricture, which could maintain relatively long-term patency rate and protect renal function. The indwelling time was longer and it could improve quality of life of patients.
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Affiliation(s)
- 文敏 董
- 北京大学人民医院泌尿外科, 北京 100044Department of Urology, Peking University People's Hospital, Beijing 100044, China
- 北京大兴区人民医院泌尿外科, 北京 102600Department of Urology, People's Hospital of Daxing District, Beijing 102600, China
| | - 明瑞 王
- 北京大学人民医院泌尿外科, 北京 100044Department of Urology, Peking University People's Hospital, Beijing 100044, China
| | - 浩 胡
- 北京大学人民医院泌尿外科, 北京 100044Department of Urology, Peking University People's Hospital, Beijing 100044, China
| | - 起 王
- 北京大学人民医院泌尿外科, 北京 100044Department of Urology, Peking University People's Hospital, Beijing 100044, China
| | - 克新 许
- 北京大学人民医院泌尿外科, 北京 100044Department of Urology, Peking University People's Hospital, Beijing 100044, China
| | - 涛 徐
- 北京大学人民医院泌尿外科, 北京 100044Department of Urology, Peking University People's Hospital, Beijing 100044, China
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22
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Intraoperative Ureteral Stent Use at Radical Cystectomy is Associated with Higher 30-Day Complication Rates. J Urol 2020; 205:483-490. [PMID: 33238829 DOI: 10.1097/ju.0000000000001329] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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23
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Ericson KJ, Thomas LJ, Zhang JH, Knorr JM, Khanna A, Crane A, Zampini AM, Murthy PB, Berglund RK, Pascal-Haber G, Lee BHL. Uretero-Enteric Anastomotic Stricture Following Radical Cystectomy: A Comparison of Open, Robotic Extracorporeal, and Robotic Intracorporeal Approaches. Urology 2020; 144:130-135. [PMID: 32653565 DOI: 10.1016/j.urology.2020.06.047] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/21/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To compare the incidence of benign uretero-enteric anastomotic strictures between open cystectomy, robotic cystectomy with extracorporeal urinary diversion, and robotic cystectomy with intracorporeal urinary diversion. The effect of surgeon learning curve on stricture incidence following intracorporeal diversion was investigated as a secondary outcome. PATIENTS AND METHODS Patients who underwent radical cystectomy at an academic hospital between 2011 and 2018 were retrospectively reviewed. The primary outcome, incidence of anastomotic stricture over time, was assessed by a multivariable Cox proportional hazards regression. A Cox regression model adjusting for sequential case number in a surgeon's experience was used to assess intracorporeal learning curve. RESULTS Nine hundred sixty-eight patients were included: 279 open, 382 robotic extracorporeal, and 307 robotic intracorporeal. Benign stricture incidence was 11.3% overall: 26 (9.3%) after open, 43 (11.3%) after robotic extracorporeal, and 40 (13.0%) after robotic intracorporeal. An intracorporeal approach was associated with anastomotic stricture on multivariable analysis (HR 1.66; P = .05). After 75 intracorporeal cases, stricture incidence declined from 17.5% to 4.9%. Higher sequential case volume was independently associated with reduced stricture incidence (Hazard Ratio per 10 cases: 0.90; P = .02). CONCLUSION An intracorporeal approach to urinary reconstruction following robotic radical cystectomy was associated with an increased risk of benign uretero-enteric anastomotic stricture. In surgeons' early experience with intracorporeal diversion the difference in stricture incidence was more pronounced compared to alternative approaches; however, increased intracorporeal case volume was associated with a decline in stricture incidence leading to a modest difference between the 3 surgical approaches overall.
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Affiliation(s)
- Kyle J Ericson
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH.
| | - Lewis J Thomas
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Jj H Zhang
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Jacob M Knorr
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Abhinav Khanna
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Alice Crane
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Anna M Zampini
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Prithvi B Murthy
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Ryan K Berglund
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Georges Pascal-Haber
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
| | - Byron H L Lee
- Cleveland Clinic Foundation, Glickman Urological and Kidney Institute, Department of Urology, Cleveland, OH
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Beano H, He J, Hensel C, Worrilow W, Townsend W, Gaston K, Clark PE, Riggs S. Safety of decreasing ureteral stent duration following radical cystectomy. World J Urol 2020; 39:473-479. [PMID: 32303901 DOI: 10.1007/s00345-020-03191-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/30/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE We aim to assess the safety of decreasing ureteral stenting duration following Radical Cystectomy with Urinary Diversion (RCUD). MATERIALS AND METHODS We analyzed a prospectively and retrospectively collected dataset for cystectomy patients at our tertiary center. Adult patient who underwent RCUD for malignancy from January 2013 to February 2018 were included. Patients with a history of abdominal/pelvic radiation and continent diversions were excluded. The patient population was divided to late stent removal group (LSR-POD 14) and early stent removal group (ESR-POD5). Our endpoints were total stent duration, 90-day readmission, 90-day total-UTI, 90-day urinary-readmissions, complications and Ureteroenteric Stricture (UES) rates. Statistical methods included t test, Chi-squared test and multivariate logistic regression. RESULTS One hundred and seventy-eight patients were included in the final analysis after inclusion/exclusion criteria were applied. The LSR (n = 74) and ESR (n = 104) groups were similar in preoperative characteristics except higher intracorporeal ileal conduit formation in ESR. The duration of stenting decreased significantly from approximately 15.5-5 days (P < 0.001). The LSR had higher 90-day overall readmission rates (OR = 2.57, 95% CI 1.19-5.53, P = 0.016) and total-UTIs (OR = 2.36, 95%CI 1.11-5.04, P = 0.026). With a median follow-up of 9.8 months, UES was similar between the two groups. CONCLUSION Shorter ureteral stent duration is a safe and non-inferior option following RCUD. It allows for stent removal prior to discharge and less outpatient visits. In addition, decreasing stent duration was linked decreased readmissions and total-UTIs without increased risk of UES. However, future studies are needed to establish causality and promote stent duration change.
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Affiliation(s)
- Hamza Beano
- Department of Urology, Carolinas Medical Center/Atrium Health, 1000 Blythe Ave, Suite 163, Medical Education Building, Charlotte, NC, 28203, USA.
| | - Jiaxian He
- Department of Cancer Biostatistics, Levine Cancer Institute/Atrium Health, Charlotte, USA
| | - Caitlin Hensel
- Department of Cancer Biostatistics, Levine Cancer Institute/Atrium Health, Charlotte, USA
| | - William Worrilow
- Department of Urology, Carolinas Medical Center/Atrium Health, 1000 Blythe Ave, Suite 163, Medical Education Building, Charlotte, NC, 28203, USA
| | - William Townsend
- Department of Urology, Carolinas Medical Center/Atrium Health, 1000 Blythe Ave, Suite 163, Medical Education Building, Charlotte, NC, 28203, USA
| | - Kris Gaston
- Department of Urology, Carolinas Medical Center/Atrium Health, 1000 Blythe Ave, Suite 163, Medical Education Building, Charlotte, NC, 28203, USA
| | - Peter E Clark
- Department of Urology, Carolinas Medical Center/Atrium Health, 1000 Blythe Ave, Suite 163, Medical Education Building, Charlotte, NC, 28203, USA
| | - Stephen Riggs
- Department of Urology, Carolinas Medical Center/Atrium Health, 1000 Blythe Ave, Suite 163, Medical Education Building, Charlotte, NC, 28203, USA
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25
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Jimie J, Siraj M, Lyttle M, Alaaraj H. The mystery of the ureteric stent in the lumen of the terminal ileum. BMJ Case Rep 2020; 13:13/3/e233123. [PMID: 32234854 DOI: 10.1136/bcr-2019-233123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 65-year-old comorbid female patient presented to our urology department with a history of multiple interventions to treat severe overactive bladder symptoms. She had a history of clam ileocystoplasty, which was then converted to an ileal conduit due to failure to resolve her symptoms. She subsequently developed multiple complications, most significantly ureteroileal stenosis, managed with bilateral ureteric stents. She later decided on bilateral nephrostomies and subsequent antegrade stent insertion. At follow-up, the proximal end of the left stent remained within the kidney and the distal end was free within the abdominal cavity. There was further migration of the stent in its entirety into the lumen of the terminal ileum on subsequent imaging. She denied any significant gastrointestinal symptoms, signs or peritonitis. Consideration was made for the endoscopic removal of the stent by the gastrointestinal team; however, the patient refused any further procedures preferring to be monitored.
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Affiliation(s)
- Joachim Jimie
- Department of Urology, Mid Cheshire Hospitals NHS Foundation Trust, Crewe, Cheshire, UK
| | - Mamoon Siraj
- Department of Urology, Mid Cheshire Hospitals NHS Foundation Trust, Crewe, Cheshire, UK
| | - Margaret Lyttle
- Department of Urology, Mid Cheshire Hospitals NHS Foundation Trust, Crewe, Cheshire, UK
| | - Hazem Alaaraj
- Department of Radiology, Mid Cheshire Hospitals NHS Foundation Trust, Crewe, Cheshire, UK
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A Population-based Study of Ureteroenteric Strictures After Open and Robot-assisted Radical Cystectomy. Urology 2019; 135:57-65. [PMID: 31618656 DOI: 10.1016/j.urology.2019.07.054] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 06/25/2019] [Accepted: 07/18/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate differences in the incidence of benign ureteroenteric stricture, we compared stricture rates of robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC) using Surveillance, Epidemiology, and End Results-Medicare data. METHODS We identified 332 RARC and 1449 ORC performed between 2009 and 2014 to determine stricture rates at 6, 12, and 24 months following surgery. We defined ureteroenteric stricture as the need for procedural intervention. Additionally, we compared the incidence of stricture diagnosis. Multivariable proportional hazards regression was performed to determine factors associated with stricture development. RESULTS The incidence of ureteroenteric stricture at 6 and 12 months was higher for RARC vs ORC at 12.1% vs 7.0% (P < .01) and 15.0% vs 9.5% (P = .01), respectively. RARC vs ORC stricture incidence at 2 years did not differ significantly at 14.6% vs 11.4% (P = .29). Similarly, the stricture diagnosis rates were significantly lower following ORC at 6, 12, and 24 months (P < .05). In adjusted analysis, RARC (HR 1.64, 95%CI 1.23-2.19) and preoperative hydronephrosis (HR 1.51, 95% CI 1.17-1.94) were associated with the development of stricture. Higher hospital volume was associated with a lower risk of stricture (HR 0.40, 95%CI 0.26-0.63). CONCLUSION RARC is associated with a higher rate of ureteroenteric stricture diagnosis and intervention on a population-based level that is mitigated by higher hospital volume. A significant study limitation is inability to differentiate extracorporeal vs intracorporeal diversion. However, a stricture complication compounds the financial burden of care and efforts must be pursued to improve this surgical outcome.
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Tuderti G, Brassetti A, Minisola F, Anceschi U, Ferriero M, Leonardo C, Misuraca L, Vallati G, Guaglianone S, Gallucci M, Simone G. 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. J Endourol 2019; 33:823-828. [PMID: 31397180 DOI: 10.1089/end.2019.0376] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Gabriele Tuderti
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Aldo Brassetti
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Francesco Minisola
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Umberto Anceschi
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | | | | | - Leonardo Misuraca
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Giulio Vallati
- Department of Radiology, "Regina Elena" National Cancer Institute, Rome, Italy
| | | | - Michele Gallucci
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
- Department of Urology, Sapienza University, Rome, Italy
| | - Giuseppe Simone
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
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Shen JK, Jamnagerwalla J, Yuh BE, Bassett MR, Chenam A, Warner JN, Zhumkhawala A, Yamzon JL, Whelan C, Ruel NH, Lau CS, Chan KG. Real-time indocyanine green angiography with the SPY fluorescence imaging platform decreases benign ureteroenteric strictures in urinary diversions performed during radical cystectomy. Ther Adv Urol 2019; 11:1756287219839631. [PMID: 31057669 PMCID: PMC6452578 DOI: 10.1177/1756287219839631] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 03/04/2019] [Indexed: 01/09/2023] Open
Abstract
Background Ischemia is thought to contribute to benign ureteroenteric stricture (UES) after radical cystectomy with urinary diversion (RCUD). Our institution adopted the use of ureteral perfusion assessment during all RCUDs using real-time indocyanine green angiography using the SPY fluorescence imaging platform (Stryker Corp., Kalamazoo, MI, USA). This guides the location of ureteral transection prior to ureteroenteric anastomosis. We sought to compare UES rates before and after adoption of SPY. Methods A retrospective chart review was undertaken for the first 47 consecutive cases of RCUD using SPY as well as the previous 47 consecutive cases, which were performed without SPY. Fisher's exact and Wilcoxon rank-sum tests were used to compare benign UES rates and the length of ureter excised during anastomosis. A p < 0.05 indicated statistical significance. Results Median follow up was 12.0 months for SPY cases and 24.3 months for non-SPY cases. The UES rate for SPY RCUDs was 0% (0/93 ureters) compared with 7.5% (7/93 ureters) for non-SPY RCUDs (p = 0.01). Amongst SPY RCUDs, 86 ureters had no hydronephrosis and 7 had mild hydronephrosis with reflux on loopogram. A total of 34.4% of ureters (32/93) had poor distal perfusion, requiring a more proximal anastomosis. The median length excised for ureters with poor distal perfusion was 3.8 cm, compared with 2.2 cm for ureters with good distal perfusion (p < 0.0001). No complications attributable to the use of SPY were noted. Conclusion Use of SPY to assess ureteral perfusion was associated with a decrease in the UES rate after RCUD. A total of 34.4% of ureters demonstrated poor distal perfusion, requiring a significantly more proximal ureteroenteric anastomosis.
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Affiliation(s)
- Jim K Shen
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Juzar Jamnagerwalla
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Bertram E Yuh
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Mitchell R Bassett
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Avinash Chenam
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Jonathan N Warner
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Ali Zhumkhawala
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Jonathan L Yamzon
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Christopher Whelan
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Nora H Ruel
- Department of Biostatistics, City of Hope National Medical Center, Duarte, CA, USA
| | - Clayton S Lau
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Kevin G Chan
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, 1500 East Duarte Road, MOB L002H, Duarte, CA 91010, USA
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Omar K, Gan C, Rottenberg G, O’Brien TS, Thomas K, Thurairaja R, Khan MS. A prospective study of the utility of a routine ‘loopogram’ at three months for the early detection of anastomotic stricture post-cystectomy and conduit urinary diversion. JOURNAL OF CLINICAL UROLOGY 2018. [DOI: 10.1177/2051415817747475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objective: The objective of this study is to evaluate the utility of routine loopogram follow-up three months after cystectomy and urinary diversion in the early detection of benign ureteroileal anastomotic stricture (UAS). Materials and methods: A loopogram was incorporated into our standard follow-up three months after cystectomy and conduit urinary diversion in August 2010–December 2015. Data were maintained prospectively in a database. Results: A total of 250 patients (181 male; 69 female); median age of 70 years (range: 38–83) underwent cystectomy and conduit urinary diversion during this period. Of these, 167 (66.8%) had a routine loopogram at three months. Seven of 167 were confirmed to have a benign UAS. Twenty-three of 250 (9.2%) had an early loopogram prior to the planned three-month study in response to symptoms. Nine of 23 were diagnosed with benign UAS. Sixty of 250 (24%) did not have a routine loopogram for a variety of reasons. Five patients with normal three-month loopograms developed late strictures after a median time of 22 months (range 5–38). In total 21/250 (8.4%) patients developed UAS. Stricture rates for the open, robotic and laparoscopic modalities were 8/129 (6.2%), 12/111 (10.8%) and 1/10 (10%) respectively. Five of seven of patients with early, asymptomatic UAS diagnosed on routine loopogram received treatment; four of five had improvement in renal function. Conclusion: Overall stricture rate in this series was 8.4%. The majority of UAS occur early and are more likely to be symptomatic. A policy of routine loopogram benefitted only 4/250 (1.6%) patients. We advocate the use of loopograms in cases with a high index of suspicion rather than for routine screening. Level of evidence: Not applicable for this multicentre audit.
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Affiliation(s)
- Kawa Omar
- Guy’s and St Thomas’ NHS Foundation Trust, UK
| | | | | | | | - Kay Thomas
- Guy’s and St Thomas’ NHS Foundation Trust, UK
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Salem R, Hairston J, Hohlastos E, Riaz A, Kallini J, Gabr A, Ali R, Jenkins K, Karp J, Desai K, Thornburg B, Casalino D, Miller F, Hofer M, Hamoui N, Mouli S. Prostate Artery Embolization for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: Results From a Prospective FDA-Approved Investigational Device Exemption Study. Urology 2018; 120:205-210. [DOI: 10.1016/j.urology.2018.07.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/02/2018] [Accepted: 07/06/2018] [Indexed: 11/30/2022]
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Lee Z, Sterling ME, Keehn AY, Lee M, Metro MJ, Eun DD. The use of indocyanine green during robotic ureteroenteric reimplantation for the management of benign anastomotic strictures. World J Urol 2018; 37:1211-1216. [PMID: 30229414 DOI: 10.1007/s00345-018-2493-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/11/2018] [Indexed: 02/07/2023] Open
Abstract
PURPOSE We describe our technique for using intraureteral and intraurinary diversion indocyanine green (ICG) during robotic ureteroenteric reimplantation and report our outcomes. METHODS We retrospectively reviewed eight patients who underwent ten robotic ureteroenteric reimplantations between August 2013 and July 2017. ICG was injected antegrade and/or retrograde into the lumen of the ureter, and retrograde into the lumen of the urinary diversion. All patients consented to off-label use of ICG. Postoperatively, all patients were assessed for: clinical success: the absence of flank pain; and radiological success: the absence of obstruction on renal scan and/or loopogram. RESULTS Visualization of ICG under near-infrared fluorescence allowed for precise identification of the strictured ureter and urinary diversion, which fluoresced green; and localization the ureteroenteric stricture margins, which poorly fluoresced green. The median operative time was 208 min (IQR 191-299), estimated blood loss was 125 ml (IQR 69-150), and length of stay was 6 days (IQR 1-8). Three of eight (37.5%) patients suffered a minor (Clavien ≤ 2), and 2/8 (25.0%) patients suffered a major (Clavien > 2) post-operative complication. There were no complications related to ICG use. At a median follow-up of 29 months (IQR 21-38), 8/10 (80.0%) ureteroenteric reimplantations were clinically and radiologically successful. CONCLUSIONS Intraureteral and intraurinary diversion ICG may be utilized as a real-time contrast agent during robotic ureteroenteric reimplantation to assist with identification of the strictured ureter and urinary diversion, and delineation of the ureteroenteric stricture margins. Despite this, RUER remains a technically difficult and morbid procedure.
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Affiliation(s)
- Ziho Lee
- Department of Urology, Temple University School of Medicine, Parkinson Pavilion (Zone C), 3rd Floor, 3401 N. Broad Street, Philadelphia, PA, 19140, USA.
| | - Matthew E Sterling
- Department of Urology, Temple University School of Medicine, Parkinson Pavilion (Zone C), 3rd Floor, 3401 N. Broad Street, Philadelphia, PA, 19140, USA
| | - Aryeh Y Keehn
- Department of Urology, Temple University School of Medicine, Parkinson Pavilion (Zone C), 3rd Floor, 3401 N. Broad Street, Philadelphia, PA, 19140, USA
| | - Matthew Lee
- Department of Urology, Temple University School of Medicine, Parkinson Pavilion (Zone C), 3rd Floor, 3401 N. Broad Street, Philadelphia, PA, 19140, USA
| | - Michael J Metro
- Department of Urology, Temple University School of Medicine, Parkinson Pavilion (Zone C), 3rd Floor, 3401 N. Broad Street, Philadelphia, PA, 19140, USA
| | - Daniel D Eun
- Department of Urology, Temple University School of Medicine, Parkinson Pavilion (Zone C), 3rd Floor, 3401 N. Broad Street, Philadelphia, PA, 19140, USA
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Shergill AK, Wang DC, Thipphavong S, Zlotta AR, Jaffer N. Comprehensive Imaging and Surgical Review of Urinary Diversions: What the Radiologist Needs to Know. Curr Probl Diagn Radiol 2018; 48:161-171. [PMID: 29655890 DOI: 10.1067/j.cpradiol.2018.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 01/11/2023]
Abstract
Urinary diversions are surgical procedures that reconstruct the lower urinary tract following cystectomy. The 2 common surgical approaches are based on the continence status of the urinary tract. Incontinent diversions have continuous urine drainage through a cutaneous stoma, whereas continent diversions offer the patient the ability to self-void either via stoma catheterization or with the patient's own urethra. Given the large number of diversion procedures available, postsurgical anatomy may be complex. Multiple imaging modalities can be used to assess the postprocedural anatomy, potential complications, and for on-going oncologic monitoring. The purpose of this review is to describe the common surgical techniques and associated complications.
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Affiliation(s)
- Arvind K Shergill
- Joint Department of Medical Imaging, Mount Sinai Hospital, Toronto, ON
| | - David C Wang
- Joint Department of Medical Imaging, Mount Sinai Hospital, Toronto, ON
| | - Seng Thipphavong
- Joint Department of Medical Imaging, Mount Sinai Hospital, Toronto, ON
| | - Alexandre R Zlotta
- Division of Urology, Princess Margaret Hospital, University of Toronto, Toronto, ON
| | - Nasir Jaffer
- Joint Department of Medical Imaging, Mount Sinai Hospital, Toronto, ON.
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