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Abdalla A, Cohn JA, Simhan J. Unraveling the Complexities of Uretero-Enteric Strictures: A Modern Review. Curr Urol Rep 2024; 25:287-297. [PMID: 39138815 DOI: 10.1007/s11934-024-01222-8] [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] [Accepted: 06/21/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review article is to provide a contemporary overview of benign uretero-enteric anastomotic stricture (UAS) management and outcomes. RECENT FINDINGS In this article, we will review the most recent studies investigating UAS and evaluate etiology, potential risk factors, presentation, diagnosis, and management options, along with personal insight gained from our experience with managing this challenging reconstructive complication. Benign UAS is a relatively common long-term complication of intestinal urinary diversion, affecting approximately 1 in 10 patients. It is thought to be caused by ureteral tissue ischemia and fibrosis at the anastomotic site. Risk factors appear to include any that increase the likelihood of leak or ischemia; it is not clear if anastomotic approach impacts risk for stricture as well. Management options are varied and include endourologic, open, and robotic approaches. Endoscopic approaches may be less morbid but are considerably less effective than reconstruction performed after a period of ureteral rest.
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Affiliation(s)
- A Abdalla
- Department of Urology, Albert Einstein Medical Center, Philadelphia, PA, 19141, USA
| | - Joshua A Cohn
- Department of Urology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - J Simhan
- Department of Urology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA.
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Kavaric P, Eldin S, Nenad R, Dragan P, Vukovic M. Modified wallace anastomotic technique reduces ureteroenteric stricture rates after ileal conduit urinary diversion. Int Braz J Urol 2020; 46:446-455. [PMID: 32167712 PMCID: PMC7088478 DOI: 10.1590/s1677-5538.ibju.2019.0417] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/15/2019] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To compare perioperative outcomes, complications and anastomotic stricture rate in a contemporary series of patients who underwent open radical cystectomy (RC) with modified Wallace anastomotic technique versus traditional ileal conduit. MATERIALS AND METHODS Study enrolled 180 patients, of whom 140 were randomized and underwent RC; seventy were randomized to group I and the seventy to the group II. For the primary objective, we hypothesized that the rate of ureteroenteric strictures would be at least 20 % lower in the second group. Secondary end points included rate of anastomotic leak, surgical time, deterioration of the upper tract, intraoperative blood loss and patient-reported quality of life (HRQOL). The modified Wallace 1 technique involved eversion of the ureteral plate and bowel mucosa edges, which were anastomosed together in running fashion, while the outher anastomotic wall was augmented with sero-serosal interrupted sutures. RESULTS The mean (SD) follow-up time was 26.1 (5.7) months in group I and 25.2 (4.8) months in group II, during which, anastomotic stricture was observed in 8 patients (12%) from the first and 2 patients (3%) from the second group (p < 0.05). The anastomotic leakage rate was significantly higher in first group (17% vs. 8.5%, p < 0.05), while patient-reported HRQOL outcomes were similar between groups after the 12 month follow-up period. CONCLUSIONS By using a modified Wallace technique, we were able to significantly lower anastomotic stricture and anastomotic leakage rates, which are major issues in minimizing both short- and long-term postoperative complications.
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Affiliation(s)
- Petar Kavaric
- Clinical Center of MontenegroDepartment of UrologyLjubljanskaPodgoricaMontenegroDepartment of Urology, Clinical Center of Montenegro, Ljubljanska, Podgorica, Montenegro
| | - Sabovic Eldin
- Clinical Center of MontenegroDepartment of UrologyLjubljanskaPodgoricaMontenegroDepartment of Urology, Clinical Center of Montenegro, Ljubljanska, Podgorica, Montenegro
| | - Radovic Nenad
- Clinical Center of MontenegroDepartment of UrologyLjubljanskaPodgoricaMontenegroDepartment of Urology, Clinical Center of Montenegro, Ljubljanska, Podgorica, Montenegro
| | - Pratljacic Dragan
- Clinical Center of MontenegroDepartment of UrologyLjubljanskaPodgoricaMontenegroDepartment of Urology, Clinical Center of Montenegro, Ljubljanska, Podgorica, Montenegro
| | - Marko Vukovic
- Clinical Center of MontenegroDepartment of UrologyLjubljanskaPodgoricaMontenegroDepartment of Urology, Clinical Center of Montenegro, Ljubljanska, Podgorica, Montenegro
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Abstract
Radical cystectomy and urinary diversion is the gold-standard treatment for muscle-invasive and high-risk non-muscle-invasive bladder cancer. Ureteroenteric anastomotic stricture is a well-known complication of urinary diversion and is associated with serious sequelae that lead to total or partial loss of kidney function, infectious complications, and the need for additional procedures. Although the exact aetiology of benign ureteroenteric anastomotic strictures is unclear, they most likely occur secondary to ischaemia at the anastomotic region. Diagnosis can be achieved using retrograde contrast studies, CT scan or MAG3 renography. Open revision remains the gold-standard treatment for ureteroenteric anastomotic strictures; however, endourological techniques are being increasingly used and, in select patients, might be the optimal approach.
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Campschroer T, Lock MT, Lo RT, Bosch JR. The Wallstent: long-term follow-up of metal stent placement for the treatment of benign ureteroileal anastomotic strictures after Bricker urinary diversion. BJU Int 2014; 114:910-5. [DOI: 10.1111/bju.12729] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Thijs Campschroer
- Department of Urology; University Medical Center Utrecht; Utrecht The Netherlands
| | - M.T.W. Tycho Lock
- Department of Urology; University Medical Center Utrecht; Utrecht The Netherlands
- Department of Urology; Central Military Hospital Dr. A. Mathijsen; Utrecht The Netherlands
| | - Rob T.H. Lo
- Department of Radiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - J.L.H. Ruud Bosch
- Department of Urology; University Medical Center Utrecht; Utrecht The Netherlands
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Liatsikos E, Kallidonis P, Stolzenburg JU, Karnabatidis D. Ureteral stents: past, present and future. Expert Rev Med Devices 2014; 6:313-24. [DOI: 10.1586/erd.09.5] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Stuurman RE, Al-Qahtani SM, Cornu JN, Traxer O. Antegrade percutaneous flexible endoscopic approach for the management of urinary diversion-associated complications. J Endourol 2013; 27:1330-4. [PMID: 23537189 DOI: 10.1089/end.2012.0371] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE We present our experience in the minimally invasive management of postoperative complications associated with urinary diversions using an ureteral access sheath (UAS) in an antegrade approach. PATIENTS AND METHODS From 2005 to 2011, 21 antegrade flexible ureteroscopies (F-URS) were performed in 17 patients with a urinary diversion. Urinary diversions in this population consisted of ileal conduits, orthotopic neobladders, catheterizable pouches, and an ureterosigmoidostomy in 9, 5, 2, and 1 patients, respectively. The most important reason for treatment was recurrent upper urinary tract infection. The indication for intervention was stone disease in 15 procedures and strictures in 6 cases. In two patients, "staged-therapy" was performed. Using UAS in an antegrade approach was the main concept. RESULTS A nephrostomy tube was already in place in 14 (66.6%) procedures, which was the access route used. Successful puncture was performed in all other patients. Eighty percent of patients were rendered stone free after the first antegrade session. Moreover, all strictures were successfully managed by dilation. In two sequential procedures in a patient, there was an inability to perform stone treatment because of abnormal position of the ureter (kinked), which did not allow the ureterorenoscope to pass. All other procedures were uneventful. Postoperative complications were reported in four procedures. There was significant urinary tract infection in two patients as well as an obstructed nephrostomy tube in two patients. CONCLUSION An antegrade endoscopic procedure using UAS in patients who present with stones or ureterointestinal stricture as late complications of urinary diversion is a feasible, well-tolerated technique, especially when using smaller access sheaths.
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Affiliation(s)
- Roos E Stuurman
- Urology Department, Tenon University Hospital, Pierre and Marie Curie University , Paris, France
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Endourological Treatment of Nonmalignant Upper Urinary Tract Complications After Urinary Diversion. Urology 2010; 76:1302-8. [DOI: 10.1016/j.urology.2010.03.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 02/19/2010] [Accepted: 03/01/2010] [Indexed: 11/19/2022]
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Tratamiento quirúrgico a cielo abierto y por vía endoscópica de las estenosis ureteroileales. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/s1761-3310(09)70019-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Thiruchelvam N, Harrison M, Page AC. The double wire technique: an improved method for treating challenging ureteroileal anastomotic strictures and occlusions. Br J Radiol 2007; 80:103-6. [PMID: 17495059 DOI: 10.1259/bjr/72561092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Up to 10% of patients who undergo ileal conduit urinary diversion may go on to develop ureteroileal anastomotic stenosis (UIAS); this can lead to recurrent urinary tract infections and deterioration in renal function. Classical management has been open revision of the anastomosis. We describe a novel technique that allows balloon dilatation and ureteral stent placement in a retrograde fashion. All patients in this study had undergone radical cystectomy and ileal conduit formation with Wallace type end-to-end refluxing uretero-intestinal anastomosis. After initial retrograde loopogram, a 6F MPA-1 catheter and an 0.035 inch extra stiff guide was passed to the distal ostium. Subsequently, a customised 8F bright tip MPA-1 guiding catheter was advanced over the guide wire which allowed effective splinting of the equipment to facilitate greater control of a second catheter and guide wire combination to access the stenotic or occluded anastomosis. Results show that a total of ten anastomoses were treated; nine anastomoses were successfully treated with a primary retrograde approach with no intra or post-procedural complications. After a mean follow-up of 19 months (5-33 months), as assessed by ascending loopograms, all anastomoses remained open. In conclusion, morbidity of open surgery has resulted in the popularization of endourological techniques in treating anastomotic stenoses. However, key to these endourological techniques is access to the anastomosis; typically, this has been via a percutaneously placed nephrostomy. The ideal route to the anastomosis is via a retrograde approach; we have illustrated a safe and successful novel technique that utilized two guidewires and a guiding catheter, allowing retrograde ureteral access.
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Affiliation(s)
- N Thiruchelvam
- Department of Urology, Royal Hampshire County Hospital, Winchester, Hampshire, UK
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Rapp DE, Orvieto MA, Lyon MB, Tolhurst SR, Gerber GS, Steinberg GD. Case Report: Urothelial Hyperplasia Causing Recurrent Obstruction after Ureteral Metal Stent Placement in Treatment of Ureteroenteric Anastomotic Stricture. J Endourol 2006; 20:910-2. [PMID: 17144861 DOI: 10.1089/end.2006.20.910] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Initial experience utilizing metal stents in the treatment of ureteroenteric anastomotic strictures has yielded promising results. However, the long-term efficacy of metal stent placement remains unknown. Further, there is a paucity of literature to describe the technical considerations associated with the surgical management of obstruction after metal stent failure. We report the case of a 67-year-old man undergoing bilateral ureteral metal stent removal and ileal conduit creation following stent failure and recurrent obstruction.
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Affiliation(s)
- David E Rapp
- Section of Urology, Department of Surgery, University of Chicago, Chicago, Illinois 60637, USA.
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Kurzer E, Leveillee RJ. Endoscopic Management of Ureterointestinal Strictures after Radical Cystectomy. J Endourol 2005; 19:677-82. [PMID: 16053356 DOI: 10.1089/end.2005.19.677] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To summarize the status of endoscopic treatment for ureterointestinal anastomotic strictures after radical cystectomy. MATERIALS AND METHODS We reviewed the English-language literature identified by PubMed and MEDLINE to evaluate the efficacy of various treatment options for these strictures. RESULTS Cumulative success rates from multiple studies analyzing patency after balloon dilation, endoureterotomy, and metal stenting specifically for ureteroenteric strictures were 18%, 63%, and 83%, respectively. Studies have not clearly shown any significant advantage over any specific cutting modality. The use of metal stents appears promising but is still fraught with complications of tissue ingrowth and recurrent obstruction. Clinical factors that appear to be associated with a poor prognosis are age >60 years, left-sided strictures, length >1 cm, stenting <4 weeks, and poor function in the affecting kidney. CONCLUSION Ureteroenteric strictures remain the most challenging and difficult of all ureteral strictures to treat. An evolution of technology has helped advance the therapeutic options available. Given the rarity of this condition, limited study designs, and small numbers of patients, conclusive statements regarding the optimal treatment for this condition are difficult. Given its patency rates and possible complications, endoureterotomy should be considered the initial treatment of choice in properly selected patients.
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Affiliation(s)
- Eliecer Kurzer
- Division of Endourology and Laparoscopy, Department of Urology, University of Miami School of Medicine, Miami, Florida 33136, USA
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Rapp DE, Laven BA, Steinberg GD, Gerber GS. Percutaneous Placement of Permanent Metal Stents for Treatment of Ureteroenteric Anastomotic Strictures. J Endourol 2004; 18:677-81. [PMID: 15597662 DOI: 10.1089/end.2004.18.677] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric anastomotic strictures following failed balloon dilation or laser endoureterotomy. PATIENTS AND METHODS Metal stents were placed in six ureteroenteric anastomotic strictures in four patients presenting with recurrent obstruction after balloon dilation or laser endoureteromy. Patients were evaluated at 1 week postoperatively with antegrade ureterography and at 3 to 6 months with renal ultrasound or CT scans. Serum creatinine assays and physical examination were performed at serial postoperative clinic visits. RESULTS At 1-week follow-up, antegrade studies demonstrated a patent anastomosis in all six strictures. With a mean follow-up of 10 months (range 7-12 months), no stricture recurrence has been seen. All patients have been clinically stable, without episodes of pyelonephritis, flank pain, or need for indwelling stents or nephrostomy tube placement. Serum creatinine concentrations have been stable in all patients. CONCLUSIONS Metal stents offer a useful treatment option in patients who develop ureteroenteric anastomotic strictures after urinary diversion. Further, such stents may be used in patients failing balloon dilation or laser endoureterotomy. Further study to assess the long-term durability of metal stent placement is needed.
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Affiliation(s)
- David E Rapp
- Section of Urology, Department of Surgery, University of Chicago, Chicago, Illinois 60637, USA
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