Bricker versus Wallace ureteroileal anastomosis: A multi-institutional propensity score-matched analysis

AIM OF THE STUDY

The aim of our study is to evaluate the difference in stricture rate between matched groups of Bricker and Wallace techniques for ureteroileal anastomosis.

PATIENTS AND METHODS

A retrospective analysis of patients undergoing urinary diversion (UD) with Bricker and Wallace ureteroileal anastomosis at two university hospitals. Two groups of Bricker and Wallace patients were matched in a 1:1 ratio based on the age, sex, body mass index (BMI), Charlson comorbidity index (CCI), preoperative hydronephrosis, prior radiation therapy or abdominal surgery, pathologic T and N stages and 30-days-Clavien grade complications≥III. A multivariable Cox regression analysis was conducted to identify predictors of ureteroenteric stricture (UES) in all patients.

RESULTS

Overall, 740 patients met the inclusion criteria and 209 patients in each group were propensity matched. At a similar median follow-up of 25 months, UES was detected in 25 (12%) and 30 (14.4%) patients in Bricker and Wallace groups, respectively (p = 0.56). However, only one patient in the Bricker group developed a bilateral stricture compared to 15 patients in the Wallace group, resulting in a significantly higher number of affected renal units in the Wallace group: 45 (10.7%) versus only 26 (6.2%) in the Bricker group (p = 0.00). On multivariable extended Cox analysis, prior radiotherapy, presence of T4 pelvic malignancy and nodal positive disease were independent predictor of UES formation.

CONCLUSION

The technique of ureteroileal anastomosis itself does not increase the rate of stricture; however, conversion of two renal units into one is associated with a higher incidence of bilateral upper tract involvement.

Robot-assisted intracorporeal ileal conduit urinary diversion: A two-center comparative study of Bricker versus Wallace ureteroileal anastomosis

INTRODUCTION

This study was performed to evaluate the differences in the perioperative results, renal function, and incidence of hydronephrosis over time between the use of Bricker anastomosis and Wallace anastomosis for robot-assisted intracorporeal ileal conduit urinary diversion (RICIC).

METHODS

Fifty-five patients who underwent RICIC at two institutions were evaluated (Bricker, n = 23; Wallace, n = 32). We investigated changes in estimated glomerular filtration rate and hydronephrosis before surgery and at 3, 6, and 12 months after surgery.

RESULTS

The patients in the Bricker group were significantly older than those in the Wallace group. The urinary diversion time was significantly longer in the Bricker group. No significant difference in postoperative renal function was observed. Additionally, no significant difference was observed in the incidence of postoperative hydronephrosis. However, the incidence of right hydronephrosis tended to be high overall, especially in the Wallace group. No patients in either group required repair surgery or ureteral stent placement.

CONCLUSIONS

In patients undergoing RICIC, there was no difference in postoperative renal function or the incidence of hydronephrosis between Wallace and Bricker anastomosis. Symptomatic hydronephrosis was not observed in either group. The present study showed that each method was equally effective and safe.

Hybrid technique has lower stricture rates than Wallace and Bricker

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.

Surgical management of parastomal hernia following radical cystectomy and ileal conduit: A french multi-institutional experience

BACKGROUND

Parastomal incisional hernia (PH) is a frequent complication following the creation of an ileal conduit (IC), and it can be a significant detriment to quality of life. The aim of this study was to evaluate outcomes of PH repair following IC for urinary diversion.

METHOD

A multicenter retrospective study was conducted of 6 academic hospitals in France. The study's population included patients who underwent surgical treatment for parastomal hernia following IC creation from 2013 to 2021.

RESULTS

Fifty-one patients were included in the study. Median follow up was 15.3 months. Eighteen patients presented with a recurrence (35%), with a median time to recurrence of 11.1 months. The vast majority of PH repair was performed through an open approach (88%). With regard to technique, Keyhole was the most reported technique (46%) followed by Sugarbaker (22%) and suture only (20%). The Keyhole technique was associated with a higher risk of recurrence compared to the Sugarbaker technique (52% vs 10%, p = 0.046). Overall, there was a 7.8% rate of major complications without a statistical difference between PH repair techniques for major complications.

CONCLUSION

Surgical treatment of parastomal hernia following IC was associated with a high risk of recurrence. Novel surgical approaches to PH repair should be considered.

Late-onset enteric fistula following radical cystectomy for bladder cancer: A case report

Enteric fistula is a rare early onset complication following radical cystectomy with urinary diversion for bladder cancer. We present the case of a 55-year-old woman presenting with an insidious fistula between the ileum and the ileal conduit, diagnosed 20-months after the initial surgery. A single surgical intervention was sufficient for treating this rare etiology. We herein present the case and discuss the available literature on the diagnosis and treatment of such complication.

Comparation between the Bricker ileal conduit vs double-barrelled wet colostomy after pelvic exenteration for gynaecological malignancies

BACKGROUND

After exhausting other therapeutic options, pelvic exenteration is performed in patients who suffer from relapsed gynaecologic tumours, with most of them requiring some sort of urinary diversion.

MATERIAL AND METHODS

The main objective of this study was to assess the short- and medium/long-term urinary complications associated with the Bricker ileal conduit versus double-barrelled wet colostomy after performing a pelvic exenteration for gynaecologic malignancies.

RESULTS

A total of 61 pelvic exenterations were identified between November 2010 and April 2022; 29 Bricker ileal conduits and 20 double-barrelled wet colostomies were included in the urinary diversion analysis. Regarding the specific short-term urinary complications, no differences were found in the rate of urinary leakage (3 vs 0 %; p = 1), urostomy complications (7 vs 0 %; p = 0.51), acute renal failure (10 vs 20 %; p = 0.24) or urinary infection (0 vs 5 %; p = 0.41). Up to 69 % of patients with Bricker ileal conduits and 65 % of double-barrelled wet colostomies (p = 0.76) presented specific medium/long-term urinary complications. No differences in the rates of pyelonephritis (59 vs 53 %; p = 0.71), urinary fistula (0 vs 12 %; p = 0.13), ureteral stricture (10 vs 6 %; p = 1), conduit failure and reconstruction (7 vs 0 %; p = 0.53), renal failure (38 vs 29 %; p = 0.56) or electrolyte disorders (24 vs 18 %; p = 0.72) were found.

CONCLUSIONS

There are no significant differences in the rate of complications between double-barrelled wet colostomy and the Bricker ileal conduit. The long-term complications related to urinary diversion remained high regardless of the type of technique. In this context, the double-barrelled wet colostomy presents advantages such as the single stoma placement and the simplicity of the technique.

[Altered urinary pH as an aetiology of granulomas in urostomised patients.]

We present the case of a 72-year-oldman who underwent laparoscopic radical cystectomywith 8po Bricker urinary diversion in 2016 for muscle-invasive bladder cancer. During his follow-upswith our stomatotherapist, the patient started to developperistomal granulomas. Our aim is to eliminate the granulomas formed and prevent the appearanceof new lesions by controlling the urinary pH throughthe administration of Lit-Control® pH Down. The useof Lit-Control® pH Down in our patient has succeededin lowering urinary pH, eliminating part of the peristomalgranulomas, and improving urinary parameterssuch as urine odour and colour.

Bricker Intracorporeal Ileal Conduit Urinary Diversion

Background: Diversion after radical cystectomy (RC) is crucial when considering elderly subjects. Data on the quality of life (QoL) impact with different diversions is scarce. This study aims to compare complications and QoL in patients aged > 75 y.o., who underwent minimally invasive (MI) RC with Bricker intracorporeal urinary derivation and single stoma ureterocutaneostomy. Methods: We conducted a retrospective analysis of elderly patients who underwent MIRC and intracorporeal diversion. The 78 subjects were divided into two groups: group A, ileal conduit, and group B, single stoma ureterocutaneostomy. We evaluated the bowel’s recovery time and complications rate. We investigated QoL 3 and 6 months after surgery using the Stoma-QoL questionnaire. Results: Mean age was 77.2 in group A and 82.4 in group B. The mean ASA score and Charlson Comorbidity index were comparable between the two groups. Rates of complications were 57.6% and 37.4% in groups A and B, respectively. The mean postoperative Stoma-QoL score 3 months after surgery was 52.2 and 52.4 in groups A and B, respectively. At 6 months of follow-up the Stoma QoL mean score was 63.4, showing homogeneity between the groups. Conclusion: MIRC with single stoma ureterocutaneostomy represents an alternative to ileal conduit, with comparable QoL and ostomy management 6 months after surgery, reporting fewer complications.

Comparative analysis of Bricker versus Wallace ureteroenteric anastomosis and identification of predictors for postoperative ureteroenteric stricture

Purpose

Ureteroenteric anastomosis after cystectomy is usually performed using the Bricker or Wallace technique. Deterioration of renal function is the most common long-term complication of urinary diversion (UD).

To improve surgical care and optimize long-term renal function, we compared the Bricker and Wallace anastomotic techniques and identified risk factors for ureteroenteric strictures (UES) in patients after cystectomy.

Material and methods

Retrospective, monocentric analysis of 135 patients who underwent cystectomy with urinary diversion at the University Hospital Essen between January 2015 and June 2019. Pre- and postoperative renal function, relevant comorbidities, prior chemo- or radiotherapy, pathological findings, urinary diversion, postoperative complications, and ureteroenteric strictures (UES) were analyzed.

Results

Of all 135 patients, 69 (51.1%) underwent Bricker anastomosis and 66 (48.9%) Wallace anastomosis. Bricker and Wallace groups included 134 and 132 renal units, respectively. At a median follow-up of 14 (6–58) months, 21 (15.5%) patients and 30 (11.27%) renal units developed UES. We observed 22 (16.6%) affected renal units in Wallace versus 8 (5.9%) in Bricker group (p < 0.001). A bilateral stricture was most common in Wallace group (69.2%) (p < 0.001). Previous chemotherapy and 90-day Clavien-Dindo grade ≥ III complications were independently associated with stricture formation, respectively (OR 9.74, 95% CI 2–46.2, p = 0.004; OR 4.01, 95% CI 1.36–11.82, p = 0.013).

Conclusion

The results of this study show no significant difference in ureteroenteric anastomotic techniques with respect to UES development regarding individual patients but suggest a higher risk of bilateral UES formation in patients undergoing Wallace anastomosis. This is reflected in the increased UES rate under consideration of the individual renal units.

[Parastomal hernia in Bricker urinary diversion as a reversible cause of obstructive uropathy: An exceptional complication.]

Parastomal hernia in patientswith ileal urinary diversion is insufficiently described in theliterature, and among its complications, the presence ofurinary obstruction is not usually reported. METHODS: We present a 74-year-old male with a Brickertype urinary diversion. He presented urinary infections withCT scan showing hydronephrosis with obstruction of theileal conduit probably related to a parastomal hernia. Thehernia growth runs in parallel to the ureterohydronephrosis,so we performed a hernioplasty to solve the obstruction. CTat 6 months shows no urinary obstruction and no hernia recurrence.No hydronephrosis in the follow-up at 14 months. RESULTS: We reviewed the literature and we only foundthree articles that related parastomal hernia in Bricker toureterohydronephrosis, although none of them proved thisrelationship with the correction of the urinary obstructionafter hernia surgery. CONCLUSIONS: Parastomal hernia should be consideredin the differential diagnosis of obstructive uropathy in patientswith ileal urinary diversion.

[How do patients manage their urostomy in everyday life? A questionnaire survey]

INTRODUCTION

The complications of stoma and peristomal are encountered by nearly 80% of patients within two years of surgery. The objective of this study was to evaluate the practical modalities of daily management of stoma and possible skin complications in a series of patients with non-continent urinary stoma.

METHODS

Monocentric study by questionnaires including all patients with non-continent urinary stoma between 2007 and 2019 in a French university center. The STOMA-QOL and a self-report questionnaire with 15 specific questions were used.

RESULTS

Among the 87 patients included in the analysis whose median age was 71 years, 57.5% used a 2-piece system, 69% used leg or thigh pockets, 74.7% were self-sufficient in emptying their stoma pockets. Autonomy on cutaneous support change was 38%. 62.1% of patients reported a peristomal skin event and 74.7% reported leaking stoma. In multivariate analysis, BMI>30, the presence of leaks and physical activity were significantly associated with the onset of peristomal skin events.

CONCLUSION

This study sheds light on the practical modalities of management of urinary stoma and the occurrence of skin complications related to stoma in terms of frequency and predisposing factors. The results obtained are likely to guide practitioners in the information of future operations and in the management of complications of urinary stoma.

LEVEL OF EVIDENCE

III.

Cost-effectiveness analysis of two kinds of bladder cancer urinary diversion: Studer versus Bricker

Background

The purpose of our study was to evaluated the cost-effectiveness of two bladder cancer (BCa) urinary diversions: Studer and Bricker.

Methods

The study included 44 patients with Studer and 40 patients with Bricker. Collected and analyzed the patient's basic characteristics, health care costs, and prognosis survival. The quality-adjusted life-year (QALY) were calculated and verified by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30, Version 3, Chinese version). Cost-effectiveness depends on the incremental cost per QALY. The incremental cost-effectiveness ratio (ICER) was determined using the cost/QALY.

Results

We found the average total cost of the Studer group was $7,173.7±1,390.8, and the Bricker group was $6,545.2±1,458.4. There were significant differences in hospitalization time, total hospitalization expenses, bed cost, comprehensive medical service charge and drugs cost (all P<0.05). The hospitalization time, total hospitalization expenses, bed cost, comprehensive medical service charge, surgical treatment cost and drugs cost in Studer group were higher than those in Bricker group, while there was no significant difference in postoperative complications between the two groups (P=0.858). The ICER of Studer group and Bricker group were $8,535.6±2,027.6/QALY and $11,158.2±2,944.9/QALY, respectively. The ICER of Studer group over Bricker group was $2,514.0/QALY.

Conclusions

We found the Studer group had higher hospitalization time, total hospitalization expenses, bed cost, comprehensive medical service charge, surgical treatment cost, and drugs cost than the Bricker group, but the Studer group had a higher ICER than the Bricker group.

Ureteroenteric strictures: a single center experience comparing Bricker versus Wallace ureteroileal anastomosis in patients after urinary diversion for bladder cancer

Background

To evaluate the outcome and complication rate in a single institution experience using the two most commonly used techniques of ureteroenteric anastomosis, the Bricker and Wallace anastomosis.

Methods

A total of 137 patients underwent ileal conduit for bladder cancer. Ureters were anastomosed by two experienced surgeons, one performing a Bricker and the other, a Wallace anastomosis. Stricture was identified during clinical follow-up.

Results

Seventy-five patients underwent a Bricker anastomotic, and 65 received a Wallace anastomosis. The average age was 70 in both groups, males were predominant (66% Bricker, 70% Wallace). Follow up period was 36.5 months in Bricker group and 17 months in Wallace group. In both groups, the body mass index (BMI) was similar (26.1 kg/m² Bricker and 26.4 kg/m² Wallace). We observed that the stricture rate after performing the Bricker anastomosis technique was 25.3% (19/75) as compared to 7.7% (5/65) after Wallace anastomosis technique, which was statistically significant (p = 0.001). In the Bricker group, patients with strictures had higher BMI (28.3 vs. 25.7 kg/m², p = 0.05). On average it took 8.5 months in the Bricker group and three months in the Wallace group (p = 0.6) to develop stricture.

Conclusions

The stricture rate was significantly higher when Bricker technique was applied. Although the BMI was not different in both groups, patients with a higher BMI were more likely to develop stricture. We believe that the approach of the separate and refluxing technique of Bricker anastomosis especially in obese patients poses a higher risk for anastomotic stricture formation.