V09-08 LAPAROSCOPIC BILATERAL URETERO-ILEAL RE-IMPLANTATION AFTER OPEN RADICAL CYSTECTOMY: STEP BY STEP

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You have accessJournal of UrologyCME1 Apr 2023V09-08 LAPAROSCOPIC BILATERAL URETERO-ILEAL RE-IMPLANTATION AFTER OPEN RADICAL CYSTECTOMY: STEP BY STEP Andreia Cardoso, Sara Anacleto, Catarina Laranjo Tinoco, Ricardo Matos Rodrigues, Ana Sofia Araújo, Mariana Capinha, Vera Marques, Carlos Oliveira, Mário Cerqueira-Alves, João Pimentel Torres, Miguel Mendes, and Emanuel Carvalho-Dias Andreia CardosoAndreia Cardoso More articles by this author , Sara AnacletoSara Anacleto More articles by this author , Catarina Laranjo TinocoCatarina Laranjo Tinoco More articles by this author , Ricardo Matos RodriguesRicardo Matos Rodrigues More articles by this author , Ana Sofia AraújoAna Sofia Araújo More articles by this author , Mariana CapinhaMariana Capinha More articles by this author , Vera MarquesVera Marques More articles by this author , Carlos OliveiraCarlos Oliveira More articles by this author , Mário Cerqueira-AlvesMário Cerqueira-Alves More articles by this author , João Pimentel TorresJoão Pimentel Torres More articles by this author , Miguel MendesMiguel Mendes More articles by this author , and Emanuel Carvalho-DiasEmanuel Carvalho-Dias More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) with urinary diversion (UD) is the gold-standard treatment for muscle-invasive bladder cancer. Ureteroenteric (UE) anastomotic stricture is a known complication, with sequelae such as kidney injury (KI) and urinary tract infection (UTI), requiring intervention. UE strictures present multifactorial etiology, yet, periureteral fibrosis and scarring secondary to ischemia or urine leakage at the anastomotic site are thought to be the main reasons. Classical open revision was the gold-standard for these strictures; however, minimally invasive approaches are arising. METHODS: An open RC (ORC) with Bricker UE anastomosis in ileal conduit (IC) complicated with bilateral stricture after 2 months (M). Patient presented recurrent UTI and KI, so, bilateral percutaneous nephrostomies (PN) were placed. Endoscopic balloon dilation was attempted, but impossible on the left. Thus, we performed a laparoscopic (lap) 5-port bilateral UE re-implantation due to uretero-ileal stenosis, 6.5M after ORC. RESULTS: Extensive peritoneal adhesions and fibrotic peri-ureteral tissue were found. Identification of anatomical landmarks, careful dissection and structures release was done. After IC release, we dissected the right ureter (the least fibrotic and with previous mono J stent) until the uretero-ileal junction. The left ureter revealead marked fibrosis and devascularization. After maximum fibrosis excision and ureteral spatulation, we performed an UE Bricker re-implantation over 7Ch mono J stents, using 4-0 Vicryl in 8 simple interrupted sutures, bilaterally. On the right, we used the previous site on the IC for re-implantation. On the left, due to fibrosis, we chose a different location. Operative time was 2 hours. Stents were removed after 4 weeks (right) and 2M (left). Patient had some UTI, but remains stents-free 9M after. CONCLUSIONS: Laparoscopy allows direct visualization of known UE anastomosis issues that contribute to strictures: ureteral skeletonization with blood supply compromise leading to ischemia; not tension-free and water-tight anastomosis, facilitating urine leak; tension and angled pathway of left ureter under the sigmoid mesocolon. In re-implantation surgery, correcting these problems is challenging, but essential for success. Careful dissection, using traction and counter-traction, anatomical planes and structures correct identification and preservation is mandatory. After maximum possible excision of fibrosis, suture with mucosa apposition rather than strangulation is required for a quality UE anastomosis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e839 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andreia Cardoso More articles by this author Sara Anacleto More articles by this author Catarina Laranjo Tinoco More articles by this author Ricardo Matos Rodrigues More articles by this author Ana Sofia Araújo More articles by this author Mariana Capinha More articles by this author Vera Marques More articles by this author Carlos Oliveira More articles by this author Mário Cerqueira-Alves More articles by this author João Pimentel Torres More articles by this author Miguel Mendes More articles by this author Emanuel Carvalho-Dias More articles by this author Expand All Advertisement PDF downloadLoading ...