Experience With Ureteroenteric Strictures After Radical Cystectomy and Diversion: Open Surgical Revision

Abstract

To evaluate the long term results of the treatment of benign ureteroenteric strictures as a serious complication after urinary diversion and to highlight on the precautions for the active intervention. The outcomes of endoureteral and open surgical revisions in our patients are described. Of 658 patients who had undergone radical cystectomy for bladder cancer from 1999 to 2009, 58 had developed benign stricture. The diversions used in this subgroup were orthotopic neobladder (53.4%), ileal conduit (27.6%), and ureterocolic (19%). The median interval to the diagnosis was 6 months, and 63.8% were on the left side. Endouretral interventions (dilation and stent or endoureterotomy) were the initial treatment in 37 patients. Thirty-two patients including patients who failed endoluminal interventions and patients with bilateral strictures underwent open surgery. Success was defined as radiologic improvement and the absence of flank pain, infection, or the need for a ureteral stent or nephrostomy tube. Endoscopic intervention was successful in 19 (51.3%) of 37 patients, principally those with strictures <1 cm with no difference between side, diversion type, or implantation technique. A total of 32 patients underwent open stricture resection and repair by direct implantation or tissue interposition to bridge long defects (6 Boari flaps and 7 ileal segments). At a median follow-up of 47 months, 25 patients had long-term success (78%) and 36 (83.7%) of 43 repaired units had improvement. Improvement was superior for right-sided strictures compared with left-sided strictures (100% vs 75.8%) and for neobladder compared with other diversions (90% vs 69%). Both anastomotic and ureteral strictures were repaired with equivalent results (87.5% vs 82.8%). Although endouretral procedures are viable treatment alternatives, open surgical revision is the preferred long-term definitive treatment. Bilateral and long left-sided strictures >1 cm long are indications for early open surgery.