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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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Albisinni S, Aoun F, Mjaess G, Abou Zahr R, Diamand R, Porpiglia F, Esperto F, Autorino R, Fiori C, Tubaro A, Roumeguère T, DE Nunzio C. Contemporary management of benign uretero-enteric strictures after cystectomy: a systematic review. Minerva Urol Nephrol 2021; 73:724-730. [PMID: 34308609 DOI: 10.23736/s2724-6051.21.04463-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Uretero-enteric stricture (UES) is a common post-operative complication after radical cystectomy with urinary diversion. The aim of this systematic review is to discuss the contemporary management of benign UES after cystectomy and to compare the different surgical approaches. EVIDENCE ACQUISITION A systematic review was performed from January 2000 through January 2021. Search engines used included PubMed, Embase and Medline databases. Search query was: ((ureteroileal OR uretero-ileal OR ureteroenteric OR ureteroenteric) AND (stricture OR stenosis)) AND (management OR treatment). Study selection followed the PRISMA statement. Studies tackling management of UES, either through open, endoscopic, laparoscopic or robot-assisted approaches, were included in our systematic review. EVIDENCE SYNTHESIS Forty-one studies were finally included in this systematic review. No prospective studies were found; all included studies were retrospective. Open surgical repair had a 78-100% success rate, a significant rate of complications, and a low recurrence rate (6-8%). Endourological management decreased complication rate, length-of-stay, and blood loss, with however lower success (15-50%) and higher recurrence rates (62%-91%) compared to open surgery. Robotic assisted surgery showed comparable success rates to open surgery (80-100%), while limiting the number of major complications and hospital length-of-stay. CONCLUSIONS Surgical management of UES remains challenging. Open surgery maintains a role given its high success rate, at the cost however of a significant morbidity. On the other hand, endourological procedures offer a favorable and low complication risk, but a low long-term success rate. Robotic-assisted surgery is emerging with a valid resolution of UES as it offers comparable success rates to an open approach, while reducing surgical morbidity. Head-to-head comparisons are awaited to confirm these findings.
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Affiliation(s)
- Simone Albisinni
- Urology Department, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium -
| | - Fouad Aoun
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beyrouth, Liban
| | - Georges Mjaess
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beyrouth, Liban
| | - Rawad Abou Zahr
- Urology Department, University Clinics of Brussels, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Romain Diamand
- Urology Department, University Clinics of Brussels, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Francesco Porpiglia
- Department of Urology, Ospedale San Luigi Gonzaga, University of Turin, Orbassano, Turin, Italy
| | | | | | - Cristian Fiori
- Department of Urology, Ospedale San Luigi Gonzaga, University of Turin, Orbassano, Turin, Italy
| | - Andrea Tubaro
- Urology Department, Sant'Andrea Hospital, Università degli Studi di Roma La Sapienza, Rome, Italy
| | - Thierry Roumeguère
- Urology Department, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Cosimo DE Nunzio
- Urology Department, Sant'Andrea Hospital, Università degli Studi di Roma La Sapienza, Rome, Italy
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Lu X, Wang Y, Chen Q, Xia D, Zhang H, Chen M. Endoscopic Procedures in the Treatment of Ureteroenteric Anastomotic Strictures: A Systematic Review and Meta-Analysis. Front Surg 2021; 8:626939. [PMID: 33937315 PMCID: PMC8079934 DOI: 10.3389/fsurg.2021.626939] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/11/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the safety and efficacy of endoscopic procedures for ureteroenteric anastomotic strictures (UESs) after radical cystectomy and urinary diversion. Methods: We performed a meta-analysis of relevant articles through March 2020 using PubMed, Embase, and Cochrane Central Register to assess the efficacy of endoscopic procedures in UES according to the PRISMA and PICOS criteria. The main endpoints were success rate and complications, and we also compared the efficacy of different methods and stricture length and side in UES. Cochrane Collaboration's Revman version 5.3 and Stata version 15.1 software were used for statistical analysis. Results: A total of 18 retrospective studies with 697 patients were included. The median follow-up ranges from 12 to 62.5 months. Patients treated with endoscopic procedures had an overall success rate of 46%. The pooled rate of Clavien-Dindo ≥ 3 complications was 3.8% among included studies. Laser vaporization and stent insertion (48 and 47%) had a relatively high success rate than balloon dilatation (35%). In subgroup analysis, the success rate of endoscopic procedures for ≤ 1-cm strictures was significantly higher than that for >1-cm ones [odds ratio (OR), 8.65; 95% confidence interval (CI), 3.53-21.21; P < 0.00001]. In addition, the success rate in cases with strictures of the right side was relatively higher than that in cases with strictures of the left side (OR, 1.72; 95% CI, 1.05-2.81; P = 0.03). Conclusion: Our pooled studies showed that endoscopic operation is feasible and associated with a moderate success rate along with a relatively low incidence of perioperative complications in the treatment of UES, especially with length ≤ 1 cm and right side. Although there is still no consensus on endoscopic technique for UES regarding balloon dilatation, stent insertion, and laser vaporization, we believe that endoscopic management is a safety and available approach for UES with close follow-up.
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Affiliation(s)
- Xun Lu
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Yiduo Wang
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Qi Chen
- Department of Interventional Radiology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Di Xia
- Reproductive Medicine Center, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Hanyu Zhang
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Ming Chen
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
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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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Sali GM, Joshi HB. Ureteric stents: Overview of current clinical applications and economic implications. Int J Urol 2019; 27:7-15. [PMID: 31549458 DOI: 10.1111/iju.14119] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 09/01/2019] [Indexed: 12/16/2022]
Abstract
Ureteric stents are one of the most crucial tools used for various clinical conditions in the urological field. Placement of a ureteric stent, for short- or long-term use, remains one of the commonest urological interventional procedures. In the past few decades, ureteral stents have undergone notable technological advancements. However, an ideal stent without significant side-effects is yet to be engineered. Indwelling ureteric stents are often accompanied by physical distress to the patient and clinical complications, such as bacterial adhesion, encrustation, malpositioning, stent fracture and forgotten stent syndrome, that influence patients' health-related quality of life. In the market, different stent types are available, designed to reduce infections, and improve patient symptoms and tolerance. In this review, we have emphasized the recent developments that have taken place in stent design, size, materials and coating. This overview looks at current practices and problems related to stents, along with clinical and economic considerations. Few trial studies have been enumerated in the context of utilization of a ureteral stent symptom questionnaire and various stent models to compare their effects in patients.
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Treating benign ureteroenteric strictures: 27-year experience comparing endourological techniques with open surgical approach. World J Urol 2018; 37:1217-1223. [PMID: 30232554 PMCID: PMC6533231 DOI: 10.1007/s00345-018-2475-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/03/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE To compare open surgical anastomotic revision with endourological techniques for the treatment of ureteroenteric strictures in patients with urinary diversions. METHODS All records of patients treated for ureteroenteric strictures in our clinic between 1989 and 2016 were retrospectively reviewed. In 76 patients, 161 completed procedures were analyzed: 26 open revisions vs. 135 endourological treatments, including balloon dilation, Wallstent and/or laser vaporization. RESULTS Median follow-up was 34 months. At 60 months, patency rates were 69% (95% CI 52-92%) after open vs. 27% (95% CI 19-39%) after endo-treatment (p = 0.003); median patency duration was 15.5 vs. 5 months, respectively (p = 0.014). Eventually, 15% of patients required open surgery after primary endo-treatment and 21% received endoscopic re-treatment after primary open surgery. Cox regression analysis revealed no confounding factors among the risk factors added to the model. Complication rates were higher after open surgery (27% Clavien 2, 12% Clavien 3-4 vs. 5% Clavien 1-2, 3% Clavien 3, p = 0.528). Median postoperative hospital stay was 14 days (open) vs. 2 days (endo), p < 0.001. Mean estimated glomerular filtration rate improved with + 17 (open) vs. + 8.1 (endo), p = 0.024. Renal function was compromised in 8% of patients in the open surgery group vs. 6% in the endo-treatment group. CONCLUSIONS In these patients, in terms of patency and patency duration, open surgery was superior to endourology. Nevertheless, endourological treatments offer a safe and less-invasive alternative to delay or avoid open surgery, especially in patients who are unfit for open surgery.
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Hautmann RE, de Petriconi R, Kahlmeyer A, Enders M, Volkmer B. Preoperatively Dilated Ureters are a Specific Risk Factor for the Development of Ureteroenteric Strictures after Open Radical Cystectomy and Ileal Neobladder. J Urol 2017; 198:1098-1106. [DOI: 10.1016/j.juro.2017.05.069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2017] [Indexed: 10/19/2022]
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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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