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

Unraveling the Complexities of Uretero-Enteric Strictures: A Modern Review

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.

Tubeless ureteroenteric anastomosis in robot-assisted radical cystectomy with intracorporeal urinary diversion does not increase the risk of anastomotic stenosis or postoperative complications

The objective is to demonstrate that omitting ureteral stent placement in robotic intracorporeal urinary diversion does not lead to increased risk of perioperative complications, namely ureteral strictures or anastomotic leaks. We retrospectively reviewed the records of 68 consecutive patients who underwent robotic radical cystectomy with ileal conduit creation or orthotopic neobladder by a single surgeon between January 2020 and September 2023. Chronologically, the first cohort of patients had ureteral stents placed to bridge the ureteroenteric anastomosis, and in the second cohort, stenting was omitted. Cohort 1 consisted of 28 patients with surgeries performed between January 2020 and April 2021, while cohort 2 had 40 patients who underwent surgery from April 2021 to September 2023. The cohorts were well matched with regard to patient age, gender, ASA score and rate of neoadjuvant chemotherapy. The choice of urinary diversion was left to surgeon and patient preference, and there was no significant difference in the proportion of ileal conduits versus orthotopic neobladders within each cohort. Estimated blood loss, total operative time, inpatient length of stay and pathologic T and N staging did not statistically differ between the cohorts. Overall, there was no difference in the rates of postoperative ileus, ureteral stricture, anastomotic leak, infectious complications, and 30-day readmission rates between the groups. Tubeless ureteroenteric anastomosis in patients undergoing robotic radical cystectomy with intracorporeal diversion does not appear to increase the risk of anastomotic strictures or postoperative complications. Further prospective evaluation is warranted.

Trans Oblique Ileal Conduit Technique Has a Low Risk of Parastomal Hernias

OBJECTIVE

To outline our surgical technique and outcomes of a ipsilateral "transoblique" ileal conduit performed during pelvic exenteration with a Vertical Rectus Abdominis Myocutaneous flap. We report hernia rates in a transrectus group as reference.

METHODS

We identified patients from January 2007 to August 2020. The transoblique conduit is placed on the ipsilateral side as the VRAM, through the internal, external oblique, and transverse abdominis muscles. Stomal hernias were assessed radiologically. Transrectus patients were those undergoing radical cystectomy matched based on surgery date, age, and sex in a 3:1 ratio. We employed a Kaplan-Meier plot to visualize the duration between surgery and hernia. We calculated the hernia rate 2 years after surgery. Additionally, we present the 30-day postoperative complication rate.

RESULTS

Fifty underwent transoblique conduits and we matched them to 190 transrectus patients. Sixty-seven percent were men with a median age of 62. Exactly 10/50 patients in the transoblique and 44/190 in the transrectus group developed a hernia, with a median follow-up of 2.2 years (IQR 0.8, 4.0). The 2-year KM-estimated parastomal hernia rate was 14% (95% CI 1.6%, 25%) for the transoblique conduits, 21% (95% CI 15%, 28%) for the transrectus and 24% (95% CI 6.5%, 39%) for colostomies. Among the transoblique patients, 22 (44%) experienced at least 1 postoperative complication.

CONCLUSION

A transoblique ileal conduit is safe in patients undergoing a right VRAM flap during a pelvic exenteration with a low parastomal hernia and complication rates.

Risk Factors Analysis and Pathogen Distribution of Urinary Tract Infection in Patients Undergoing Cutaneous Ureterostomy After Radical Cystectomy for Bladder Cancer

BACKGROUND

Postoperative urinary tract infection is a common complication that not only significantly prolongs the hospital stay and amplifies the economic burden on patients, but also affects their quality of life and prognosis. This study aimed to investigate risk factors and distribution of pathogenic bacteria in urinary tract infections among bladder cancer patients who underwent cutaneous ureterostomy following radical cystectomy.

METHODS

A total of 137 bladder cancer patients, who underwent cutaneous ureterostomy after radical cystectomy at our hospital from November 2018 to October 2022, were enrolled in this retrospective study. Univariate and multivariate logistic regression analyses were employed to investigate the risk factors associated with postoperative urinary tract infection and the distribution of pathogenic bacteria among the infected patients.

RESULTS

The results of both univariate and multivariate analyses confirmed that age, proficiency in ostomy knowledge, frequency of ureteral stent tube replacement, ureteral stent tube dislodgement, urine immersion at the outer end of the ureteral stent tube, and the interval of ostomy bag replacement were independent risk factors for urinary tract infection after radical cystectomy and cutaneous ureterostomy in bladder cancer patients. A total of 55 pathogenic bacteria were isolated from 52 patients with infections. Predominantly, these were gram-negative bacteria (34 strains, 61.8%), with Proteus mirabilis having the highest proportion.

CONCLUSION

Urinary tract infections after radical cystectomy and cutaneous ureterostomy predominantly involve gram-negative bacteria. This is correlated with factors such as the age of bladder cancer patients, the level of nursing education, the duration of ureteral stent tubes and ostomy bag usage, as well as issues related to impaired urine drainage.

Ileal Conduit versus Cutaneous Ureterostomy after Open Radical Cystectomy: Comparison of 90-Day Morbidity and Tube Dependence at Intermediate Term Follow-Up

Background: This study aims to compare perioperative morbidity and drainage tube dependence following open radical cystectomy (ORC) with ileal conduit (IC) or cutaneous ureterostomy (CU) for bladder cancer. Methods: A single-center, retrospective cohort study of patients undergoing ORC with IC or CU urinary diversion between 2020 and 2023 was carried out. The 90-day perioperative morbidity, as per Clavien-Dindo (C.D.) complication rates (Minor C.D. I-II, Major C.D. III-V), and urinary drainage tube dependence (ureteral stent or nephrostomy tube) after tube-free trial were assessed. Results: The study included 56 patients (IC: 26, CU: 30) with a 14-month median follow-up. At 90 days after IC or CU, the frequencies of any, minor, and major C.D. complications were similar (any-69% vs. 77%; minor-61% vs. 73%; major-46% vs. 30%, respectively, p > 0.2). Tube-free trial was performed in 86% of patients with similar rates of tube replacement (19% IC vs. 32% CU, p = 0.34) and tube-free survival at 12 months was assessed (76% IC vs. 70% CU, p = 0.31). Conclusions: Compared to the ORC+IC, ORC+CU has similar rates of both 90-day perioperative complications and 12-month tube-free dependence. CU should be offered to select patients as an alternative to IC urinary diversion after RC.

Comparative study between the use of double J ureteric stents vs bander ureteric stents during robotic-assisted radical cystectomy with intra corporeal ileal conduit urinary diversion

Robotic-assisted radical cystectomy (RARC) is fast becoming the standard of care with comparable oncological outcomes to open surgery for patients with muscle-invasive bladder cancer. Ileal conduit is by far the most popular means of urinary diversion following a cystectomy. Use of stents is common practice to reduce uretero-enteric anastomosis-related complications. In the current study, practice was changed from the use of Double J (DJ) stents to bander stent intraoperatively. The potential advantages of using bander stent are avoiding second surgery for stent removal and easier change under local anaesthetic in the interventional radiology department. To compare the incidence of blocked, slipped stents and rate of ureteroileal anastomotic stricture after RARC with intracorporeal ileal conduit between practices of using DJ stents and bander stents. Retrospective analysis of all the patients undergoing Robotic radical cystectomy and intracorporeal ileal conduit between June 2014 and August 2023 was done. Initially, all intracorporeal anastomosis were covered with DJ stents. The practice was changed to cover the anastomosis with bander stent in November 2020. Number of patients needing re-surgery for blocked, slipped stents and ureteroileal anastomotic stricture were analyzed and compared using Chi-square analysis and Fisher's exact test (P < 0.05). A total of 168 patients underwent RARC with intracorporeal ileal conduit between June 2014 and August 2023 of which 128 patents were diverted with DJ stents and 40 with bander stent. The mean age and the patient demographics between the two groups were comparable. Of the 128 patients who were diverted with DJ stents, 6 (4.7%) had blocked stents, 3 (2.3%) had slipped stents, and 3 (2.3%) developed ureteroileal stricture needing readmission and urgent invasive intervention to exchange the stent or nephrostomy tube, whereas only 1 (2.5%) of the 40 patients with bander stent had blocked stent which was changed under local anaesthetic in the interventional radiology suite with no slipped stents reported and 2 (5%) had ureteroileal stricture who needed nephrostomies. Intraoperative ureteric stenting using bander stent has the potential to reduce the incidence of stent-related complications, such as blockage, slippage, and ureteroileal anastomotic stricture, following RARC with intracorporeal ileal conduit urinary diversion. Additionally, managing bander stent-related complications is less invasive with lower rate of readmission postoperatively compared to managing DJ stent-related ones.

Microbial Trends in Infection-related Readmissions Following Radical Cystectomy for Bladder Cancer

OBJECTIVE

To report microbial pathogens detected at infection-related readmissions, including their susceptibility to antimicrobials.

MATERIALS AND METHODS

A retrospective review of 785 patients who underwent radical cystectomy for bladder cancer at a tertiary center in Denmark between 2009 and 2019. All patients received prophylactic cefuroxime preoperatively and pivmecillinam at stent- or catheter removal. Data were collected through the national medical records and microbiology database. The primary outcome was readmission rate and pathogens detected at infection-related readmissions. Univariable and multivariable regression analyses were carried out to identify risk factors of readmission.

RESULTS

Within 90days of surgery, 225 (29%) patients experienced at least one infection-related readmission. The most common pathogen identified was Enterococcus spp (24% of all positive samples). In blood cultures, the most dominant species were Escherichia coli (29%) and Staphylococcus spp (26%). Due to the heterogeneity in microbial species identified, more than one-third of the bacteria where mecillinam was tested showed resistance. Most isolates were susceptible to piperacillin+tazobactam. Orthotopic neobladder and continent cutaneous reservoir were associated with the highest risk of infection-related readmission compared to ileal conduit (odds ratios 2.78 [95%CI 1.66;4.65] and 3.08 [95%CI 1.58;5.98], respectively). Patients with diabetes had an increased risk of infection-related readmission compared to patients without diabetes (odds ratio 1.67 [95%CI 1.02;2.73]).

CONCLUSION

Nearly one-third of all patients experienced at least one postoperative infection-related readmission with a wide range of microbial etiologies. Generalizability of our results is uncertain, but the data can be used to plan interventional trials of antibiotic prophylaxis.

A Multipronged Intervention to Reduce Readmissions and Readmission Intensity After Radical Cystectomy

OBJECTIVE

To develop a multipronged, evidence-based protocol to reduce readmission risk and readmission intensity, as represented by the duration of the index readmission, after radical cystectomy.

MATERIALS AND METHODS

A per-protocol study was performed. The protocol included preoperative nutritional supplementation, early stent removal, and a follow-up phone call within 4-5days of discharge. The preprotocol period was from February 1, 2020 to July 31, 2021 and the postprotocol period was from December 1, 2020 to November 31, 2021. Using multivariate regression models, we compared outcomes among patients treated with radical cystectomy before and after protocol initiation.

RESULTS

We identified 70 preprotocol patients and 126 postprotocol patients. After adjusting for age, sex, BMI, and frailty score, there was a significant reduction in 90-day readmission intensity (7 vs 5days; P = .048) among postprotocol patients.

CONCLUSION

After implementation of an evidence-based protocol for patients undergoing radical 90-day readmission intensity decreased significantly. This protocol may move the needle forward on reducing readmissions, but a larger randomized trial is needed.

Oncological and functional outcome of robotic-assisted radical cystectomy with total intracorporeal stentless J-pouch neobladder reconstruction

BACKGROUND

Robotic-assisted radical cystectomy (RARC) with neobladder reconstruction has gained popularity in recent years.

METHODS

We conducted a retrospective study of 17 consecutive patients who underwent RARC with totally intracorporeal J-pouch neobladder reconstruction without ureteral stent by a single experienced surgeon to evaluate perioperative, oncological and functional outcomes.

RESULTS

The median follow-up duration was 32.8 months (range: 17.4-59.0 months), and the 2-year disease-free survival rate was 88.2%. Five out of 12 patients were totally continent, and none required more than one pad per day. The overall complication rate was 41.2%, and hydronephrosis was the most common adverse event. The renal function remained stable, and no long-term renal function impairment was detected.

CONCLUSION

Our study suggests that RARC with totally intracorporeal J-pouch neobladder reconstruction without ureteral stent is a safe and feasible option for the treatment of muscle-invasive bladder cancer, with good oncological and functional outcomes.

Analysis of Complications After Robot-Assisted Radical Cystectomy Between 2002-2021

OBJECTIVE

To identify trends in complications following robot-assisted radical cystectomy (RARC) using a multi-institutional database, the International Robotic Cystectomy Consortium (IRCC).

METHODS

A retrospective review of the IRCC database was performed (2976 patients, 26 institutions from 11 countries). Postoperative complications were categorized as overall or high grade (≥ Clavien Dindo III) and were further categorized based on type/organ site. Descriptive statistics was used to summarize the data. Multivariate analysis (MVA) was used to identify variables associated with overall and high-grade complications.  Cochran-Armitage trend test was used to describe the trend of complications over time.

RESULTS

1777 (60%) patients developed postoperative complications following RARC, 51% of complications occurred within 30 days of RARC, 19% between 30-90 days, and 30% after 90 days. 835 patients (28%) experienced high-grade complications. Infectious complications (25%) were the most prevalent, while bleeding (1%) was the least. The incidence of complications was stable between 2002-2021. Gastrointestinal and neurologic postoperative complications increased significantly (P < .01, for both) between 2005 and 2020 while thromboembolic (P = .03) and wound complications (P < .01) decreased. On MVA, BMI (OR 1.03, 95%CI 1.01-1.05, P < .01), prior abdominal surgery (OR 1.26, 95%CI 1.03-1.56, P = .03), receipt of neobladder (OR 1.52, 95%CI 1.17-1.99, P < .01), positive nodal disease (OR 1.33, 95%CI 1.05-1.70, P = .02), length of inpatient stay (OR 1.04, 95%CI 1.02-1.05, P < .01) and ICU admission (OR 1.67, 95%CI 1.36-2.06, P < .01) were associated with high-grade complications.

CONCLUSION

Overall and high-grade complications after RARC remained stable between 2002-2021. GI and neurologic complications increased, while thromboembolic and wound complications decreased.

Development of a specific supportive care needs scale for radical cystectomy patients and its reliability and validity test

OBJECTIVE

To develop a specific supportive care needs scale for patients who have undergone radical cystectomy, and to assess its reliability and validity.

METHODS

The clinical test version of the scale was developed based on literature review, qualitative interviews, Delphi method, and a pretest. The reliability and validity of the scale were assessed in a cohort of 603 patients who had undergone radical cystectomy at 5 Grade A hospitals in Chongqing, China.

RESULTS

The final scale included 26 items across the following 7 dimensions: health information needs, social needs, family support needs, physiological needs, sexual needs, daily activities needs, and psychological needs. The content validity index was 0.991 and the content validity indices of each item ranged from 0.889 to 1.00. Seven factors were extracted by exploratory factor analysis and the cumulative contribution of variance accounted for 70.762%. Confirmatory factor analysis revealed a good fit of the model (X²/df = 1.595, GFI = 0.904, IFI = 0.943, TLI = 0.932, CFI = 0.942, RMSEA = 0.044, and RMR = 0.026). The Cronbach's ɑ coefficient and retest reliability were 0.807 and 0.810, respectively.

CONCLUSION

The specific supportive care needs scale for radical cystectomy patients developed in this study showed the good reliability and validity. The tool can be invaluable for comprehensive assessment of the specific supportive care needs of these patients.

Uretero-enteric stricture outcomes: secondary analysis of a randomised controlled trial comparing open versus robot-assisted radical cystectomy

OBJECTIVES

To analyse the risk of uretero-enteric anastomotic stricture in patients randomised to open (ORC) or robot-assisted radical cystectomy (RARC) with extracorporeal urinary diversion.

PATIENTS AND METHODS

We included 118 patients randomised to RARC (n = 60) or ORC (n = 58) at a single, high-volume institution from March 2010 to April 2013. Urinary diversion was performed by experienced open surgeons. Stricture was defined as non-malignant obstruction on imaging, corroborated by clinical status, and requiring procedural intervention. The risk of stricture within 1 year was compared between groups using Fisher's exact test.

RESULTS

In all, 58 and 60 patients were randomised to RARC and ORC, respectively. We identified five strictures, all in the ORC group. In patients with ≥1 year of follow-up, the increase in risk of stricture from open surgery was 9.3% (95% confidence interval 1.5%, 17%). Of the five strictures, three were managed endoscopically while two required open revision. There was no evidence that perioperative Grade 3-5 complications were associated with development of a stricture (P = 1) and no evidence of a difference in 24-month estimated glomerular filtration rate between arms (P = 0.15).

CONCLUSIONS

In this study at a high-volume centre, RARC with extracorporeal urinary diversion achieved excellent ureteric anastomotic outcomes. Purported increased risk of stricture is not a reason to avoid RARC. Future research should examine the impact of different surgical techniques and operator experience on the risk of stricture, especially as more intracorporeal diversions are performed.

Uretero-enteric Strictures after Robot Assisted Radical Cystectomy: Prevalence and Management Over Two Decades

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.

Reporting and grading of complications for intracorporeal robot-assisted radical cystectomy: an in-depth short-term morbidity assessment using the novel Comprehensive Complication Index®

OBJECTIVE

To assess suitability of Comprehensive Complication Index (CCI^®) vs. Clavien-Dindo classification (CDC) to capture 30-day morbidity after robot-assisted radical cystectomy (RARC).

MATERIALS AND METHODS

A total of 128 patients with bladder cancer (BCa) undergoing intracorporeal RARC with pelvic lymph node dissection between 2015 and 2021 were included in a retrospective bi-institutional study, which adhered to standardized reporting criteria. Thirty-day complications were captured according to a procedure-specific catalog. Each complication was graded by the CDC and the CCI^®. Multivariable linear regression (MVA) was used to identify predictors of higher morbidity.

RESULTS

381 complications were identified in 118 patients (92%). 55 (43%), 43 (34%), and 20 (16%) suffered from CDC grade I-II, IIIa, and ≥ IIIb complications, respectively. 16 (13%), 27 (21%), and 2 patients (1.6%) were reoperated, readmitted, and died within 30 days, respectively. 31 patients (24%) were upgraded to most severe complication (CCI^® ≥ 33.7) when calculating morbidity burden compared to corresponding CDC grade accounting only for the highest complication. In MVA, only age was a positive estimate (0.44; 95% CI = 0.03-0.86; p = 0.04) for increased cumulative morbidity.

CONCLUSION

The CCI^® estimates of 30-day morbidity after RARC were substantially higher compared to CDC alone. These measurements are a prerequisite to tailor patient counseling regarding surgical approach, urinary diversion, and comparability of results between institutions.

Feasibility and Safety of Stentless Uretero-Intestinal Anastomosis in Radical Cystectomy with Ileal Orthotopic Neobladder

Background: We evaluated the feasibility and safety of stentless uretero-intestinal anastomosis (UIA) during radical cystectomy (RC) with an ileal orthotopic neobladder. Methods: We retrospectively reviewed 403 patients who underwent RC for bladder cancer between August 2014 and December 2018. The primary objective was to study the effect of stentless UIA on uretero-intestinal anastomosis stricture (UIAS), and the secondary objective was to evaluate the association between stentless UIA and other complications, including paralytic ileus, febrile urinary tract infection (UTI), and urine leakage. Kaplan–Meier survival analysis was used to estimate UIAS-free survival, and Cox proportional hazard models were applied to identify factors associated with the risk of UIAS. Results: Among 403 patients with 790 renal units, UIAS was identified in 39 (9.7%) patients and 53 (6.7%) renal units. Forty-four (83.0%) patients with UIAS were diagnosed within 6 months. The 1- and 2-year overall UIAS-free rates were 93.9% and 92.7%, respectively. Paralytic ileus was identified in 105 (26.1%) patients and resolved with supportive treatment. Febrile UTI occurred in 57 patients (14.1%). However, there was no leak of the UIA. Conclusions: Stentless UIA during RC with an ileal orthotopic neobladder is a feasible and safe surgical option. Further prospective randomized trials are required to determine the clinical usefulness of stentless UIA during RC.

Urinary diversions for benign and oncologic indications: what did we learn about short term complications in the last 24 months?

PURPOSE OF THE REVIEW

Urinary diversion (UD) with or without cystectomy is a procedure with high short term complication rates. In this review, we summarize the most relevant findings of the last 2 years.

RECENT FINDINGS

The use of a prophylactic mesh decreases the risk of parastomal hernia after ileal conduit (IC) surgery without adding mesh-related complications according to a recent randomized multicentre trial. Robot-assisted surgery is increasingly applied for UD and is evolving from extra- to intra-corporeal reconstruction in both continent and incontinent diversions, but there is still a need for appropriately designed studies assessing both short- and long-term complications. Promising techniques to decrease ureterointestinal stricture rates have been reported from small series, such as retrosigmoid placement of the proximal IC to avoid transpositioning of the left ureter, or in robot-assisted surgery the use of indocyanine green with near-infrared light to improve visualisation of distal ureteral viability.

SUMMARY

Most recent reports derive from observational data. Appropriate randomized studies are warranted for the evaluation of new techniques to be implemented in a surgical area that still is associated with high complication rates.