Endoscopic Management of Ureterointestinal Strictures after Radical Cystectomy

Outcomes of Uretero-ileal Anastomosis in Bladder Cancer Cystectomies: Bricker vs. Wallace 1

Background

The two commonly used methods for uretero-ileal anastomosis (UIA) during radical cystectomy for muscle-invasive bladder cancer (MIBC) are the Bricker and Wallace 1 techniques. Published data on the incidence of strictures at anastomotic sites is limited. This study compares both anastomotic techniques in terms of uretero-ileal stricture (UIS) rates and the factors that govern it in the patient group.

Material and methods

Records of all patients presenting with bladder cancer who underwent radical cystectomy at the department of uro-oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) Lahore, Pakistan, from January 1, 2009, to December 31, 2018, were reviewed retrospectively, and all adult patients aged >18 years out of them were selected for the study.

Results

With a total of 116 patients, the mean age was 54.37 ± 11.16 and a male majority (83.6%). Urinary diversion using ileal conduit was performed in 70 (60.3%) patients and the rest of them i.e. 46 (39.7%) had neobladder formation. Amongst them, uretero-ileal anastomosis was constructed via Bricker and Wallace 1 in 73 (62.9%) patients and 43 (37.1%) patients respectively. Pelvic radiotherapy was received by 13 (11.2%) patients. Anastomotic stricture developed in 19 (16.4%) cases. A relatively similar proportion of stricture rate was found in Bricker and Wallace 1 technique (10% vs 13%). Body mass index (BMI) was found to be significantly higher in patients who developed UIS. Incidence of stricture formation was more on the left than right side i.e. 12 (63.2%) vs five (26.3%) while two (10.5%) patients developed bilateral strictures.

Conclusion

No significant difference in stricture formation was noted between Bricker and Wallace 1 technique. High BMI and anastomotic leaks were the contributory factors for this complication during our experience.

Technique selection of ureteroileal anastomosis in hautmann ileal neobladder with chimney modification: Reliability of patient-based selection strategy and its impact on ureteroentric stricture rate

OBJECTIVE

We aimed to establish the reliability of technique selection strategy for ureteroileal anastomosis (Bricker vs. Wallace) by comparing perioperative outcomes, complications, and anastomotic stricture rate in a contemporary series of patients who underwent open radical cystectomy followed by reconstruction of modified Hautmann neobladder.

MATERIALS AND METHODS

A total of 60 patients underwent radical cystectomy and modified Hautmann neobladder, of whom 30 patients (group I) with Bricker anastomotic technique were compared to 30 matched paired patients with end-to-end ureteroileal anastomosis (group II). Long-term results, including ureteroileal stricture (UIS) and postoperative complication rate at two year follow up were available. The choice of anastomosis type was successively based on chimney size, ureteral length after retro-sigmoidal tunneling and diameter of distal ureter. Postoperative complications were graded according to the Clavien-Dindo system.

RESULTS

Ureteroileal stricture rate was 6.6% in group I vs. 0% in group II, after three months (p < 0.05), while anastomotic leakage rate was 6.6% vs. 3.3% (group I vs group II) between the two groups for the same follow up period (p > 0.05). High-grade complications (Clavien III-V) were more in Bricker group as compared to Wallace group and the difference was significant (20% vs 10.3%, p = 0.03).

CONCLUSION

Our preliminary outcomes demonstrate that this selection strategy seems to be clinically reliable, with lower incidence of postoperative complications in Wallace group.

Complications of Ileal Conduits after Radical Cystectomy: Interventional Radiologic Management

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

Endoscopic Treatment of Complete Ureterointestinal Stenosis Without Antegrade Ureteroscopy

Background: Ureterointestinal stenosis is a frequent complication after radical cystectomy, occurring in up to 10%-12% of cases. Endoscopic treatment of complete stenosis has been described through double access, with antegrade flexible ureteroscopy and simultaneous retrograde endoscopy through the intestinal diversion. We present a case of endoscopic treatment without use of antegrade ureteroscopy. Case Presentation: A 52-year-old man underwent surgery for peritoneal carcinomatosis secondary to mucinous adenocarcinoma. Ileocecal resection, omentectomy, sigmoidectomy, rectal resection, cystoprostatectomy, and ileal duct were performed. He had a complicated postoperative period because of enterocutaneous fistulas, peritonitis, and secondary intention wall closure, needing multiple surgeries. Four months later, he was diagnosed with left ureteroinestinal stenosis, for which endoscopic management was the chosen treatment. Intraoperative diagnosis was complete stenosis. To locate the stenosis, methylene blue was instilled using a percutaneous ureteral catheter. With a resectoscope inserted through the ileal duct, the stenosis was observed and opened using cold knife and Collins knife. The stenosis was resolved satisfactorily. Conclusion: Endoscopic management of complete ureterointestinal stenosis is a viable treatment option. Although stenosis localization has previously been described with two endoscopes using transillumination, we demonstrate another localization technique using methylene blue.

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

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

Ureteroileal bypass: a new technic to treat ureteroenteric strictures in urinary diversion

Objective:

To present our technique of ureteroileal bypass to treat uretero-enteric stric- tures in urinary diversion.

Materials and Methods:

One hundred and forty-one medical records were reviewed from patients submitted to radical cystectomy to treat muscle-invasive bladder cancer between 2013 and 2015. Twelve (8.5%) patients developed uretero-enteric anastomotic stricture during follow-up. Five patients were treated with endoscopic dilatation and double J placement. Four were treated surgically with standard terminal-lateral im- plantation. Three patients with uretero-enteric anastomotic stricture were treated at our institution by “ureteroileal bypass”, one of them was treated with robotic surgery.

Results:

All patients had the diagnosis of uretero-enteric anastomotic stricture via computerized tomography and DTPA renal scan. Time between cystectomy and diag- nosis of uretero-enteric anastomotic stricture varied from five months to three years. Mean operative time was 120±17.9 minutes (98 to 142 min) and hospital stay was 3.3±0.62 days (3 to 4 days). Mean follow-up was 24±39.5 months (6 to 72 months). During follow-up, all patients were asymptomatic and presented improvement in ure-terohydronephrosis. Serum creatinine of all patients had been stable.

Conclusions:

Latero-lateral ureter re-implantation is feasible by open or even robotic surgery with positive results, reasonable operation time, and without complications.

Natural History, Predictors and Management of Ureteroenteric Strictures after Robot Assisted Radical Cystectomy

PURPOSE

Ureteroenteric strictures represent the most common complication requiring reoperation after radical cystectomy. We investigated the prevalence, outcomes, predictors and management of ureteroenteric strictures.

MATERIALS AND METHODS

We retrospectively reviewed our quality assurance, robot assisted radical cystectomy database to identify patients in whom ureteroenteric strictures developed. Data were reviewed for demographics, perioperative outcomes and ureteroenteric stricture characteristics. The Kaplan-Meier method was used to calculate time to ureteroenteric stricture and multivariable stepwise regression was done to evaluate predictors of ureteroenteric strictures.

RESULTS

Ureteroenteric strictures developed in 12%, 16% and 19% of 51 patients (13%) at 1, 3 and 5 years after robot assisted radical cystectomy, respectively. All patients were initially treated endoscopically or percutaneously, including 57% treated only endoscopically or percutaneously and 43% who required surgery, which was open repair in 6 and robot assisted repair in 16. At a median followup of 23 months 33 patients (65%) were free of disease, including 13 after endoscopic or percutaneous treatment, 15 after robot assisted repair and 5 after open revision. Open and robot assisted revisions showed comparable perioperative outcomes. On multivariable analysis the predictors of ureteroenteric anastomotic strictures were body mass index (OR 1.07, 95% CI 1.01-1.13, p = 0.02), intracorporeal urinary diversion (OR 3.28, 95% CI 1.41-7.61, p = 0.006), length of the right resected ureter (OR 0.66, 95% CI 0.50-0.88, p = 0.004), estimated glomerular filtration rate 30 days after assisted radical cystectomy (OR 0.85, 95% CI 0.74-0.98, p = 0.03), urinary tract infection (OR 2.68, 95% CI 1.31-5.49, p = 0.007) and leakage (OR 3.85, 95% CI 1.05-14.1, p = 0.04). Male gender (OR 0.19, 95% CI 0.04-0.96, p = 0.04) and higher body mass index (OR 0.85, 95% CI 0.72-0.996, p = 0.05) were associated with lower odds of successful endoscopic management.

CONCLUSIONS

Multiple modifiable factors were associated with ureteroenteric anastomotic strictures following robot assisted radical cystectomy. Surgical revision can provide a definitive management with comparable outcomes for open and robotic repairs.

Outcomes Following First-line Endourologic Management of Ureteroenteric Anastomotic Strictures After Urinary Diversion: A Single-center Study

OBJECTIVE

To assess the outcomes of patients following a first-line systematic endourologic procedure used to treat ureteroenteric anastomotic strictures (UEAS).

MATERIALS AND METHODS

All data from patients treated using a first-line endourologic approach for UEAS between 2010 and 2015 were reviewed retrospectively. The following data were analyzed: age, type of urinary diversion, initial symptoms, surgical endoscopic approach (antegrade or retrograde), pre- and postoperative creatinine levels, and postoperative complications and outcomes. Follow-up visits occurred at 6 weeks, 3 months, and 6 months postoperatively, and at least annually thereafter.

RESULTS

A total of 27 patients (median age: 62.5 years) were included. Overall, 28 UEAS were treated endoscopically (ileal conduit: n = 25; neobladder: n = 3). Most UEAS developed following radical cystectomy for bladder cancer (n = 19). Overall, the endoscopic approach was successful in 20 cases (71.4%). The UEAS length was >1 cm in 21 cases (75%). All UEAS of <1 cm were treated successfully (n = 7). There were three grade II and five grade III complications. The median follow-up period was 25 months. The median creatinine levels before surgery and at last follow-up were 1.3 mg/dL and 0.9 mg/dL, respectively.

CONCLUSION

An endourologic procedure is a reasonable option for first-line treatment for UEAS and has promising functional outcomes and limited morbidity.

Minimal invasive treatment of benign anastomotic uretero-ileal stricture in Hautmann neobladder with thermoexpandable ureteral metal stent

Technical challenges and increased morbidity of open reconstruction for uretero-ileal strictures have led to a search for minimal invasive treatments as an alternative solution. The insertion of a thermo-expandable ureteral Memokath 051^® metal stent across benign uretero-ileal anastomotic stricture in orthotopic neobladder has not been described in the English literature. Herein, we describe a case of a woman with a Hautmann neobladder and a 3.5 cm benign stricture of the right uretero-ileal anastomosis that was treated with insertion of a thermo-expandable ureteral Memokath 051^® metal stent.

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

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

Technique selection of bricker or wallace ureteroileal anastomosis in ileal conduit urinary diversion: a strategy based on patient characteristics

OBJECTIVES

This study was designed to establish an individualized selection strategy for the two most common types of ureteroenteric anastomotic techniques (Bricker and Wallace anastomosis) used in ileal conduit (IC) diversion.

METHODS

Patients who underwent IC diversion after radical cystectomy for transitional cell carcinoma between January 2009 and December 2011 were prospectively collected. The choice of anastomosis type (Bricker vs. Wallace) was successively based on tumor characteristics, ureteral anomalies, and ureteral length after retrosigmoidal tunneling.

RESULTS

Ninety-nine patients were enrolled in the final study. Fifty-three patients underwent Bricker anastomosis, and 46 underwent Wallace anastomosis. Ureteral stricture developed in 6 (6.1 %) patients and the overall stricture rate for all ureters was 3.1 % (6/196). Strictures occurred at an average of 13.3 months after surgery and were predominately located in the left ureter (66.7 %, 4/6). The difference in the ureter stricture rates between the two groups was not statistically significant: 3.8 % (4/104) and 2.2 % (2/92) for Bricker and Wallace, respectively (p = 0.686). There were no significant differences in age, sex, body mass index (BMI), prevalence of pelvic radiation therapy, length of stay, follow-up time, or time to stricture between the two techniques. Patients in whom stricture developed had a significantly higher mean BMI compared with those without stricture (25.2 vs. 23.3 kg/m(2), respectively; p = 0.008).

CONCLUSIONS

Our preliminary outcomes demonstrate that this selection strategy of Bricker vs. Wallace anastomosis seems to be clinically reliable, providing an acceptable low ureteral stricture rate of 3.1 %. However, the potential advantage for oncologic control of this strategy is needed to further confirm.

Primary endoscopic management versus open revision of ureteroenteric anastomotic strictures after urinary diversion--single institution contemporary series

PURPOSE

To review our institutional experience in the management of ureteroenteric strictures by primary endoscopic intervention or primary open revision.

PATIENTS AND METHODS

Between January 2000 and December 2007, 28 patients with ureteroenteric strictures underwent endoscopic management (n = 21) or open revision (n = 7). Strictures were characterized with regard to length and side as well as time to failure between the two groups. Success was defined as symptomatic improvement and evidence of patency on follow-up radiologic imaging.

RESULTS

Of all study patients, 78.6% were symptomatic on presentation. Endoscopic intervention (balloon dilation, electroincision, or holmium endoureterotomy) was successful in six patients for an overall success rate of 27% with a median follow-up of 21 months. Open revision was successful in 87.5% (7 of 8) patients for whom initial endoscopic surgery had failed. The success rate of primary open revision was 71.4% (5 of 7 patients) with a mean follow-up of 18.1 months. For the entire series, left-sided strictures were more common than right sided strictures; however, side and stricture length were not found to be significant (P > 0.05) with regard to patency. Functional renal imaging studies were performed in 42.9% of all study patients postoperatively.

CONCLUSIONS

Endoscopic management continues to have success rates that remain lower than that of open revision. Left-sided strictures remain more common than right-sided strictures; however, side and stricture length were not found to be statistically significant in our series. The lack of consistent postoperative functional renal studies highlights the importance of diligent monitoring and warrants further study to develop a surveillance algorithm.

Management of Benign Ureteral Strictures Following Radical Cystectomy and Urinary Diversion for Bladder Cancer

PURPOSE

Ureteral obstruction due to benign strictures is a significant complication of radical cystectomy and urinary diversion for bladder cancer that can lead to renal function loss and infection related morbidity. Treatment may be performed surgically or with minimally invasive techniques. We describe the 10-year experience at our department with various treatment modalities for post-cystectomy benign strictures.

MATERIALS AND METHODS

The study group consisted of 28 patients treated for benign ureteral strictures following radical cystectomy for bladder cancer. Their medical records were reviewed for clinical presentation, diagnostic procedures, treatment and long-term outcome.

RESULTS

The study group represented 12.7% of all 221 patients treated at our department with radical cystectomy for bladder cancer in 1994 to 2004. Ureteral strictures were asymptomatic in 71.4% of cases. Median time to diagnosis was 7.0 months and 75% of the patients were diagnosed within year 1 after cystectomy. Treatment consisted of stenting, dilation and open surgical revision with removal of the strictured segment and reanastomosis. Median followup was 62.5 months. The stenting procedures served as the long-term definitive treatment in 45% of cases, whereas balloon dilation uniformly failed. Although open surgical revision was technically challenging, it had a long-term success rate of 93%.

CONCLUSIONS

Benign ureteral strictures commonly occur during postoperative year 1 and they are usually asymptomatic. Early diagnosis and prompt drainage are required to prevent consequent renal parenchymal loss and infectious complications. Although minimally invasive procedures are viable treatment alternatives, open surgical revision is still the preferred long-term definitive treatment.

A comparison of the Bricker versus Wallace ureteroileal anastomosis in patients undergoing urinary diversion for bladder cancer

PURPOSE

In recent years few studies have evaluated the success and complications of the 2 most common types of ureteroenteric anastomotic techniques, the Bricker and the Wallace anastomosis. We evaluated the complications of the Bricker and Wallace techniques of ureteroenteric anastomosis in a single surgeon, single institution series.

MATERIALS AND METHODS

From 2001 to 2005 a total of 186 patients underwent ileal conduit or ileal neobladder after cystectomy for bladder cancer. All patients were followed for a minimum of 12 months after surgery with complete clinical information. In all cases the ureters were anastomosed to a segment of ileum in a separate (Bricker) or conjoined (Wallace) fashion.

RESULTS

Of the 186 patients 94 underwent a Bricker (51%), 90 underwent a Wallace (48%) and 2 patients underwent both procedures (Wallace on duplicated system on 1 side, Bricker on contralateral side). Ureteral stricture developed in 5 of 186 (2.6%) patients and the overall stricture rate for all ureters was 7 of 371 (1.9%). In patients undergoing Bricker anastomosis the total stricture rate for all ureters was 3.7% (7 of 187). With the Wallace anastomosis the total stricture rate for all ureters was 0% (0 of 184). This difference in stricture rate in the Bricker vs Wallace subgroups was significant (p = 0.015). There was no difference in age, gender, creatinine, prior radiation, complications or mode of diversion between the groups. Body mass index was higher in the Bricker vs the Wallace group (29.0 vs 25.9 kg/m(2)). Of the 5 patients with strictures 1 underwent successful open repair, 1 had successful interventional radiological repair and 3 were treated with chronic ureteral stents (1 after failed open repair and 2 after failed radiological repair).

CONCLUSIONS

Both the Bricker and the Wallace anastomoses provide acceptably low stricture rates in a single surgeon case series. Indeed, the Wallace anastomosis had no strictures in this series. The Bricker group had a higher body mass index which was likely due to the often disparate ureteral lengths in obese patients after retrosigmoidal tunneling, which would have affected the choice of technique.