Ureteroenteric Anastomotic Strictures Research Articles

Definition of Benign Ureteroenteric Anastomotic Strictures in Ileal Conduits After Radical Cystectomy: Experience From a Single Center and Previously Published Literature

To evaluate a cohort of patients diagnosed with benign ureteroenteric stricture (UES) after radical cystectomy with ileal conduits using a strict predefined definition of strictures. Additionally, we want to illustrate the UES debut, regarding symptoms and clinical findings. UES is a well-known long-term complication after radical cystectomy, affecting up to 20% of all patients. In the literature, different incidence rates are reported. However, these are based on various definitions of strictures. We used strict predefined criteria to evaluate UES incidence including symptoms, timing, diagnostic methods, treatment, and outcome in all patients who underwent radical cystectomy with an ileal conduit between 2012 and 2018 at a single high-volume center. Of a total of 693 patients who underwent radical cystectomy with ileal conduit, we found 109 patients with 135 UES in total, corresponding to 15.7% of patients (CI: 13.2-18.6) and 10% of all included ureteroenteric anastomosis (CI: 8.5-11.6) after radical cystectomy. Median follow-up was 24 months (IQR: 12 - 31), and postoperatively UES was diagnosed after a median of 6 months (IQR: 3 - 16). A total of 56% was diagnosed with elevated creatinine. Every UES underwent a median of two (IQR: 1-2) treatment attempts and 122 UES were treated successfully. Benign UES is a significant cause of morbidity following radical cystectomy. Our findings contribute to the knowledge of timing, incidence, and recommended treatment of strictures. We argue the importance of establishing a clear gold standard when defining UES to ensure accurate reporting in future research.

Robot-assisted uretero-enteric reimplantation for uretero-enteric anastomotic strictures following robot-assisted radical cystectomy: Surgical approach and outcomes over two decades

ObjectiveWe described the technique and outcomes of robot-assisted repair of uretero-enteric stricture (UES) following robot-assisted radical cystectomy (RARC) and urinary diversion. MethodsRetrospective review of our RARC database from November 2005 to August 2023 at Roswell Park Comprehensive Cancer center was performed. Patients who developed UES and ultimately underwent robot-assisted uretero-enteric reimplantation (RUER) were identified. Kaplan–Meier method was used to compute the cumulative incidence recurrence rate of UES after RUER. A multivariable regression model was used to identify variables associated with UES recurrence. ResultsA total of 123 (15%) out of 808 RARC patients developed UES, of whom 52 underwent reimplantation (45 patients underwent RUER [n=55 cases] and seven patients underwent OUER). The median time from RARC to UES was 4.4 (interquartile range 3.0–7.0) months, and the median time between UES and RUER was 5.2 (interquartile range 3.2–8.9) months. The 3-year recurrence rate after RUER is about 29%. On multivariable analysis, longer hospital stay (hazard ratio 1.37, 95% confidence interval 1.16–1.61, p<0.01) was associated with recurrent UES after RUER. ConclusionRUER for UES after RARC is feasible with durable outcomes although a notable subset of patients experienced postoperative complications and UES recurrence.

Shorter Ureters Lead to Fewer Strictures Following Cystectomy and Urinary Diversion

To identify the impact of length of distal ureteral resection on the risk of benign uretero-enteric anastomotic stricture (UEAS) formation following cystectomy and urinary diversion. A database of patients who underwent cystectomy and urinary diversion from 2015 to 2022 was analyzed. Distal ureteral resections were sent for final pathology. The length of resected ureter was collected from pathology reports. Benign UEAS were confirmed with renal scintigraphy, antegrade nephrostogram, or endoscopic evaluation. The relationship between stricture formation and clinical parameters were assessed using T-tests, Chi-square tests, and multivariable analysis. A total of 366 patients underwent cystectomy and urinary diversion. Of the cohort, 35 (9.5%) patients developed UEAS. Median time to stricture formation was 12.5 months (IQR 4-30). Of the 711 uretero-enteric anastomoses, 40 (5.6%) ultimately formed a UEAS. Median distal ureteral resection was significantly longer among ureteral anastomoses which did not form a UEAS (2.3 cm vs. 1.65 cm, p=0.028). Multivariable logistic regression adjusting for surgical approach, prior radiation, ureteral side, and urinary diversion type demonstrated that longer distal ureteral resections were inversely associated with odds of UEAS formation (OR 0.73, 95% CI 0.58-0.92). Multivariable Cox regression analysis similarly showed that length of distal ureteral resection was inversely associated with time to stricture formation (HR 0.78, 95% CI 0.62-0.98). The etiology of benign UIA strictures is multifactorial. Vascular compromise is a critical hypothesis. We found that longer distal ureteral resections (and thus shorter ureters) were associated with a significantly lower risk of stricture formation in cystectomy patients.

Robotic-Assisted Repair of Ureteroenteric Strictures after Cystectomy with Urinary Diversion: Technique Description and Outcomes from the ERUS Scientific Working Group.

Robotic-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. Between January 2013 and September 2022, 31 patients from 7 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. After robotic or open cystectomy, 31 patients had a total of 43 UAS at a median (IQR) follow-up of 21 (9-43) months. Median stricture length (cm) was 2.0 (1.0-3.25), operative duration (min) was 141 (121-232), estimated blood loss (mL) was 100 (50-150), and length of hospital stay (days) was five (3-9). 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. These results demonstrate that robotic repair of UAS is feasible and effective approach with outcomes in line with prior open series.

Hybrid Ureteroenteric Anastomosis Is Associated With Lower Stricture Rates in Ileal Conduit Urinary Diversion

BackgroundAnatomic complications of the ureteroenteric anastomosis in ileal conduit (IC) cause significant morbidity in patients post-cystectomy and cystoprostatectomy. The Bricker technique has a perceived disadvantage of increased risk for stricture, whereas the Wallace technique runs the risk for ureteral malignancy affecting both ureteric ends, and bilateral ureteric obstruction from a stone lodged at the anastomosis. We aimed to evaluate the safety, efficacy, and stricture rate of a novel hybrid ureteroenteric anastomosis technique. We compared these outcomes to the Bricker and Wallace anastomosis techniques for IC urinary diversion (ICUD).MethodsWe performed a retrospective chart review of patients who had undergone ICUD after cystectomy for bladder cancer from 2011 to 2016. Patients were categorized into groups undergoing the Bricker, Wallace, and hybrid ureteroanastomosic techniques. Strictures were identified during clinical follow-up or hospital presentations with complications.ResultsWe identified 68 patients suitable for inclusion. They were separated by Bricker, Wallace, and hybrid anastomosis techniques, with 19 (27.9%), 20 (29.4%), and 29 (42.6%) patients, respectively. Ureteroenteric anastomotic strictures occurred in 9 patients (5 Bricker, 3 Wallace, 1 hybrid). This difference in stricture rates for Bricker versus hybrid (26.3% vs. 3.4%; OR, 10 [95% CI, 1.1 to 121.1]; P = 0.02) was significant but was comparable for Wallace versus hybrid (15.0% vs. 3.4%; OR, 4.9 [0.7 to 66.0]; P = 0.15) and for Bricker versus Wallace (26.3% vs. 15.0%; OR, 2 [0.4 to 8.6]; P = 0.87). 15 patients (51%) in the hybrid group required oral antibiotics for a symptomatic urinary tract infection compared with 4 (21%) with Bricker and 8 (40%) with Wallace (P = 0.10). Median post-cystectomy follow-up and stricture formation time were 16 months (IQR, 4–36) and 9 months (7–32), respectively.ConclusionThe hybrid technique is a safe and efficacious alternative to the Bricker and Wallace anastomoses. It carries with it a risk for urinary tract infection that is eclipsed by substantially lowered rates of ureteric strictures requiring intervention while maintaining the advantage of separating the two ureters.

V01-08 ROBOTIC APPENDICEAL ONLAY FOR THE TREATMENT OF URETEROENTERIC STRICTURE

You have accessJournal of UrologyCME1 Apr 2023V01-08 ROBOTIC APPENDICEAL ONLAY FOR THE TREATMENT OF URETEROENTERIC STRICTURE Joseph J. Boyle, Ellen Cahill, Sai Krishnaraya Doppalapudi, and Sammy E. Elsamra Joseph J. BoyleJoseph J. Boyle More articles by this author , Ellen CahillEllen Cahill More articles by this author , Sai Krishnaraya DoppalapudiSai Krishnaraya Doppalapudi More articles by this author , and Sammy E. ElsamraSammy E. Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteroenteric anastomotic strictures (UES) are the most common complication requiring repeat surgery following radical cystectomy, occuring in up to 10% of patients. Untreated, they may result in loss of renal function and predispose patients to infection. Open revision of the stricture has been the gold standard, but is technically challenging. Minimally invasive surgical approaches (MIS) in stricture disease can afford greater visibility and maneuverability, while minimizing blood loss. Options for extended strictures or those located in the proximal or midureter have been historically limited to ileal ureter replacement or autologous kidney transplant, both having considerable morbidity. Onlay techniques utilizing buccal mucosa or appendix are options to repair rather than replace longer ureteral strictures. Appendiceal onlay flaps are an encouraging yet relatively under-described alternative for select patients in this group. In this video, we present a case of a 6 cm proximal right UES treated with robotic appendiceal onlay flap repair. METHODS: Procedure performed with Da Vinci Xi system. Patient placed in left lateral decubitus position. Veress needle technique used to insufflate the abdomen. Ports placed in standard position for robotic laparoscopic renal surgery, ensuring placement outside conduit margins. Right ureterolysis performed. 5-French ureteral catheter placed over a wire positioned through previously placed ureteral stent. Ureteroenteric anastomosis identified, with ureteral detubularization from anastomosis to just above stricture with a length of 6 cm. Increased ureteral caliber and vigorous saline efflux marked proximal stricture end. Appendix stapled at cecum and detubularized with preserving mesentery. Appendiceal flap sewn to detubularized segment of ureter. Intraoperative ureteroscopy demonstrated patent repair. JJ stent placed. RESULTS: No intraoperative complications. Case duration was 200 minutes. EBL was 25 mL. He was discharged POD 2 after an uncomplicated post-operative stay. Stent removed at 6 weeks. 3-month ultrasound and renal scan showed no obstruction. He was seen every 6 months with no signs or symptoms of UTI, flank pain, or hydronephrosis on ultrasound. Latest follow-up at 16 months. He reported resolution of chronic malodorous urine. CONCLUSIONS: UES remain a challenge following radical cystectomy. Robotic repair with appendiceal onlay is a safe, durable, and often overlooked treatment option. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e81 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph J. Boyle More articles by this author Ellen Cahill More articles by this author Sai Krishnaraya Doppalapudi More articles by this author Sammy E. Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...

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

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 ...

MP65-19 OPEN FIELD NEAR-INFRARED FLUORESCENCE ANGIOGRAPHY IS A USEFUL TOOL TO ASSESS TISSUE INTEGRITY IN COMPLEX, OPEN, GENITOURINARY RECONSTRUCTIVE SURGERY

You have accessJournal of UrologyCME1 Apr 2023MP65-19 OPEN FIELD NEAR-INFRARED FLUORESCENCE ANGIOGRAPHY IS A USEFUL TOOL TO ASSESS TISSUE INTEGRITY IN COMPLEX, OPEN, GENITOURINARY RECONSTRUCTIVE SURGERY Elizabeth Bearrick, Bridget Findlay, Paige Nichols, Kevin Hebert, Katherine Anderson, and Boyd Viers Elizabeth BearrickElizabeth Bearrick More articles by this author , Bridget FindlayBridget Findlay More articles by this author , Paige NicholsPaige Nichols More articles by this author , Kevin HebertKevin Hebert More articles by this author , Katherine AndersonKatherine Anderson More articles by this author , and Boyd ViersBoyd Viers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003323.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Genitourinary reconstructive surgery frequently involves high-risk patient populations with compromised tissue perfusion – a risk factor for poor reconstructive outcomes. Traditionally, intraoperative tissue viability characterization relies on direct and subjective surgeon assessment. Intravascular indocyanine green (ICG) combined with open field near-infrared fluorescence (NIRF) imaging enables objective quantification of tissue perfusion and viability. Herein, we sought to compare open subjective intraoperative surgeon and objective ICG angiography assessment in radiated patients undergoing complex urologic reconstruction. METHODS: A retrospective single surgeon review of 39 patients (40 surgeries) in which SPY-PHI (Stryker Kalamazoo, MI) was utilized during open, complex genitourinary reconstructive surgery between June 2018 and April 2022. Differences in altered surgical decision making, ureteral perfusion characteristics, complications, and reconstructive success were assessed. RESULTS: There were 39 patients with a median age of 66 who underwent 40 multimodality reconstructive surgeries during which open ICG angiograpy was utilized with median follow-up 23.4 months. Surgery was performed for radiation induced complications in 32 of 40 (80%). Among patients with documentation of ureteral length evaluation (N=16), median subjective vs objective assessment of poor distal perfusion was 1.8 cm vs 3.2 cm (p=0.001). In total, discordance in perfusion assessment was noted in 19(61%) of ureters. In 25 (63%) cases, use of ICG angiography influenced intraoperative surgical decision making. ICG angiography was significantly more likely to impact surgical decision making in radiated vs non-irradiated cases (23(72%) vs 1 (13%); p=0.007). There was 1 complication in the non-irradiated cohort and 12 complications in the radiated cohort. At a median follow-up of 23 months, 1 (3%) patient in the radiation cohort developed a ureteroenteric anastomotic stricture. CONCLUSIONS: Among patients with radiation injury undergoing complex open urinary reconstruction, utilization of ICG angiography revealed a high-level of operative discordance compared to subjective surgeon assessment and ultimately influenced surgical decision making. Reassuring reconstructive outcomes noted in this population would suggest that ICG angiography is a useful tool in complex open genitourinary reconstructive surgery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e899 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elizabeth Bearrick More articles by this author Bridget Findlay More articles by this author Paige Nichols More articles by this author Kevin Hebert More articles by this author Katherine Anderson More articles by this author Boyd Viers More articles by this author Expand All Advertisement PDF downloadLoading ...

India Ink Tattooing of Ureteroenteric Anastomoses

While upper tract access through the insensate conduit following urinary diversion takes less time and incurs fewer costs than percutaneous kidney access does for the treatment of ureter and kidney pathology, endoscopic ureteroenteric anastomoses (UEA) identification can be difficult. We injected India Ink into the bowel mucosa near the UEA during ileal conduit diversion (IC) to determine the safety and feasibility of ink tattooing. Patients undergoing IC were prospectively randomized to receive ink or normal saline (NS) injections. The injections were placed 1 cm from UEA in a triangular configuration, and loopogram exams and looposcopy were performed to identify reflux (UR), UEA, the tattooing site and strictures in 10 and 11 patients randomized with respect to ink and NS injections, respectively. Ink patients were older (72 vs. 61 years old, p = 0.04) and had a higher Charlson Comorbidity Index (5 vs. 2, p = 0.01). Looposcopy was performed in three ink and four NS patients. Visualization of UEA was achieved in 100% of the ink and 75% of the NS patients (p = 0.26). The ink ureteroenteric anastomotic stricture (UEAS) rate was higher (N = 3 vs. N = 1) and six patients vs. one patients underwent surgery, respectively, for UEAS (p = 0.31). The study was halted early due to safety concerns. Our pilot study demonstrates that ink can be well visualized following injection near UEA during IC. However, the ink cohort had more UEAS than previously cited in the literature and our prior institutional UEAS rate of 6%. While this study sample is small, the higher incidence of UEAS after ink injection led us to question the utility and safety of ink injection following IC.

Optimizing decision-making process of benign uretero-enteric anastomotic stricture treatment after radical cystectomy.

To identify preoperative predictors of endo-urological treatment (EUT) failure while promoting a new diagnostic and therapeutic pathway for benign uretero-enteric anastomosis stricture (UES) management after radical cystectomy (RC). We relied on a prospectively maintained database including 96 individuals (122 renal units) who developed a benign UES at our institution between 1990 and 2018. UES was classified into two different types according to morphology: FP1 (i.e., sharp or duckbill) and FP2 (i.e., flat or concave). EUT feasibility, success rate, as well as intra and postoperative complications were recorded. Uni- and multivariable logistic regression analysis (MVA) assessed for predictors of EUT failure. Overall, 78 (63.9%) and 32 (26.3%) cases were defined as FP1 and FP2, respectively. EUT was not feasible in 33 (27.1%) cases. After a median follow-up of 50 (IQR 5-240) months, successful treatment was reached only in 15/122 (12.3%) cases. EUT success rates raised when considering short (< 1cm) (16.8%), FP1 morphology (16.7%) strictures, or the combination of these characteristics (22.4%). Overall, 5 (5.2%) cases had CD ≥ III complications. FP2 (OR: 1.91, 95%CI 1.21-5.31, p = 0.03) and stricture length ≥ 1cm (OR: 9.08, 95%CI 2.09-65.71, p = 0.009) were associated with treatment failure at MVA. Endoscopic treatment for benign UES after RC is feasible but harbors a low success rate. Stricture length and radiological morphology of the stricture are related to endoscopic treatment failure. Surgeons should be aware of the stricture features during the preoperative decision-making process to choose the optimal candidate for endoscopic treatment.

Is Anti-Reflux Anastomosis an Advantage in an Orthotopic Ileal Neobladder? A Systematic Review and Meta-Analysis

Introduction: We conducted a systematic review and meta-analysis to assess the available literature regarding the postoperative effects of anti-reflux anastomosis and direct anastomosis in orthotopic ileal neobladder (ONB). Methods: We searched PubMed, Embase, and the Cochrane Library in October 2021. We included 11 studies of patients with bladder cancer who underwent radical cystectomy and ONB as urinary diversion. Outcomes evaluated in this review were ureteroenteric anastomotic stricture (UEAS), vesicoureteral reflux, renal function (RFn) impairment, and pyelonephritis. All data were analyzed using Review Manager 5.4.4 and subgroup analyses were applied. Results: A total of 11 studies were eligible for meta-analysis. The synthetic data suggested that anti-reflux anastomosis and direct anastomosis were comparable in terms of RFn impairment (odds ratio (OR) = 1.69; 95% confidence interval (CI): 0.18–15.6; p = 0.65, I² = 69%) and pyelonephritis (OR = 1.13; 95% CI: 0.65–1.99; p = 0.66, I² = 1%) without significant difference in each group statistically. The pooled study data showed a significantly higher incidence of UEAS (OR = 2.84; 95% CI: 1.75–4.61, p < 0.0001, I² = 50%) and a lower incidence of vesicoureteral reflux (OR = 0.24; 95% CI: 0.10–0.59; p = 0.002, I² = 75%) in anti-reflux anastomosis compared to direct anastomosis. In subgroup analysis, anti-reflux anastomosis was more likely to result in UEAS than direct anastomosis, especially when ureteral stent was removed within 14 days. Conclusion: Although meta-analysis showed that overall incidence of vesicoureteral reflux was higher with direct anastomosis than anti-reflux anastomosis, the rate of vesicoureteral reflux was not directly related to impairment of RFn. The anti-reflux mechanism of ONB was positively associated with a higher incidence of significant UEAS compared to the direct approach, which can lead to kidney damage and an increased risk of secondary surgical procedures.

MP23-03 INITIAL EXPERIENCE USING INDOCYANINE GREEN IN ROBOTIC-ASSISTED URETEROENTERIC ANASTOMOSIS

You have accessJournal of UrologyCME1 May 2022MP23-03 INITIAL EXPERIENCE USING INDOCYANINE GREEN IN ROBOTIC-ASSISTED URETEROENTERIC ANASTOMOSIS Monica Peradejordi Font, Alba Sierra del Rio, Claudia Mercader Barrull, Alberto Tello Delsors, Raul Martos Calvo, Jaime Durruti, Joan Sureda Riera, Antoni Vilaseca Cabo, Laura Izquierdo Reyes, Maria Jose Ribal Caparros, Antonio Alcaraz Asensio, and Mireia Musquera Felip Monica Peradejordi FontMonica Peradejordi Font More articles by this author , Alba Sierra del RioAlba Sierra del Rio More articles by this author , Claudia Mercader BarrullClaudia Mercader Barrull More articles by this author , Alberto Tello DelsorsAlberto Tello Delsors More articles by this author , Raul Martos CalvoRaul Martos Calvo More articles by this author , Jaime DurrutiJaime Durruti More articles by this author , Joan Sureda RieraJoan Sureda Riera More articles by this author , Antoni Vilaseca CaboAntoni Vilaseca Cabo More articles by this author , Laura Izquierdo ReyesLaura Izquierdo Reyes More articles by this author , Maria Jose Ribal CaparrosMaria Jose Ribal Caparros More articles by this author , Antonio Alcaraz AsensioAntonio Alcaraz Asensio More articles by this author , and Mireia Musquera FelipMireia Musquera Felip More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002562.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) has opened new horizons minimizing surgical aggressivity. Da Vinci surgical system® has an integrated fluorescence capability that uses near-infrared technology that permits to evaluate ureteral vascularity in a real time using indocyanine green (ICG). The objective of this study is to determine the possible benefit of using ICG to assess ureteral vascularity intraoperatively and consequently reduce uretero-ileal benign strictures. METHODS: Between January 2018 and December 2020, 109 RARC with ICUD were performed at our institution. In February 2019 we introduced ICG to assess ureteral vascularity intraoperatively. After discarding patients with cutaneous ureterostomies (8), 101 patients were retrospectively analyzed. Patients and tumor characteristics, surgical and histopathological reports were reviewed. The length of the ureteric segments excised, postoperative outcomes and complications were compared between the two groups. RESULTS: Patients were mostly male (87.13%), with a mean age of 68.5 (±6.5) years. ICG was administrated in 53 patients (52.4%). There were no differences in baseline patients and tumor characteristics between groups. Ureteroenteric anastomosis was mostly in a Bricker fashion. In 6 patients a Wallace anastomosis was performed, none of them received ICG. 3 patients presented a unique renal unit. There were no differences in the mean length of resected ureter between both groups (1.58 ± 0.99 cm in non-ICG group vs 1.77 ± 1.01 cm in ICG group, p: 0.32). Ureteral CIS positive margin was present in 9 ureters (4 in non-ICG and 5 ureters in the ICG group (p: 0.52). After a mean follow-up of 20.67 months (SD 10.34), 22 (11.05%) renal units presented with benign ureteroenteric anastomotic strictures (UES), 9 in ICG and 13 in non-ICG (p: 0.258). We did not find differences in terms of other complications between both groups except for urinary tract infection that was higher in the non-ICG group (p: 0.02). CONCLUSIONS: The use of intravenous indocyanine green with near-infrared fluorescence to assess distal ureteric vascularity during RARC does not reduce the incidence of ureteroenteric stenosis in our series. Larger studies with longer follow-up are needed to confirm our findings. Source of Funding: There is no source of funding to disclose © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e381 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Monica Peradejordi Font More articles by this author Alba Sierra del Rio More articles by this author Claudia Mercader Barrull More articles by this author Alberto Tello Delsors More articles by this author Raul Martos Calvo More articles by this author Jaime Durruti More articles by this author Joan Sureda Riera More articles by this author Antoni Vilaseca Cabo More articles by this author Laura Izquierdo Reyes More articles by this author Maria Jose Ribal Caparros More articles by this author Antonio Alcaraz Asensio More articles by this author Mireia Musquera Felip More articles by this author Expand All Advertisement PDF DownloadLoading ...

Survival outcomes following radical cystectomy in patients with prior pelvic radiation for prostate cancer: A matched cohort analysis.

To determine the impact of prior pelvic radiation therapy (XRT) on outcomes following radical cystectomy (RC) for bladder cancer. We performed a retrospective review comparing patients with bladder cancer requiring RC and prior history of XRT for prostate cancer to those undergoing RC without XRT history at our institution from 2011-2018. Propensity score matching was performed with the following variables: age, chronic kidney disease, nutritional deficiency, neoadjuvant chemotherapy use, Charlson comorbidity index, surgical approach, urinary diversion type, and pathologic T-stage. Perioperative, pathologic and oncologic outcomes were analyzed. Categorical variables were assessed utilizing the Pearson Chi Square Test, and continuous variables with the Wilcoxon rank-sum test. The Kaplan-Meier method with stratified-log rank was used to compare survival outcomes. Multivariable Cox proportional hazards models were utilized to identify predictors of overall and recurrence free survival. 227 patients were included, of which 47 had radiotherapy for prostate cancer. 47% of patients in the radiation cohort received external beam radiation therapy, 47% received brachytherapy and 7% received both. There were no differences in recurrence-free survival (P = 0.82) or overall survival (P = 0.25). Statistically significant differences in perioperative or postoperative outcomes such as 90-day complication, readmission, mortality rates, or ureteroenteric anastomotic stricture rates were not found. Rates of node-positive disease, median lymph node yield, positive surgical margin rates, lymphovascular invasion, or variant histology were not significantly different between cohorts. After matching for T-stage and other clinical variables, history of pelvic XRT for prostate cancer in patients who later required RC for bladder cancer, was not associated with an increased rate of perioperative complications or an independent predictor of RFS or OS.

V01-11 ROBOT-ASSISTED SURGICAL REPAIR OF URETERO-ILEAL ANASTOMOTIC STRICTURE AFTER CYSTECTOMY AND ILEAL CONDUIT IN NEUROLOGICAL PATIENT

You have accessJournal of UrologyIncontinence & Female Pelvic Medicine/Reconstructive Surgery (V01)1 Sep 2021V01-11 ROBOT-ASSISTED SURGICAL REPAIR OF URETERO-ILEAL ANASTOMOTIC STRICTURE AFTER CYSTECTOMY AND ILEAL CONDUIT IN NEUROLOGICAL PATIENT Gilles Dosin, Juliette Hascoet, Clement Mazouin, Zine-Eddine Khene, Gregory Verhoest, Romain Mathieu, Karim Bensalah, Lucas Freton, Emmanuel Voiry, Claire Richard, Camille Haudebert, Etienne Courboin, Andrea Manunta, and Benoit Peyronnet Gilles DosinGilles Dosin More articles by this author , Juliette HascoetJuliette Hascoet More articles by this author , Clement MazouinClement Mazouin More articles by this author , Zine-Eddine KheneZine-Eddine Khene More articles by this author , Gregory VerhoestGregory Verhoest More articles by this author , Romain MathieuRomain Mathieu More articles by this author , Karim BensalahKarim Bensalah More articles by this author , Lucas FretonLucas Freton More articles by this author , Emmanuel VoiryEmmanuel Voiry More articles by this author , Claire RichardClaire Richard More articles by this author , Camille HaudebertCamille Haudebert More articles by this author , Etienne CourboinEtienne Courboin More articles by this author , Andrea ManuntaAndrea Manunta More articles by this author , and Benoit PeyronnetBenoit Peyronnet More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001970.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cystectomy and ileal conduit (IC) are sometimes indicated for patient with a neurogenic bladder. However stricture of the uretero-enteric anastomosis are a common complication after this procedure. Robot-assisted uretero-enteric stricture repair may decrease the post operative morbidity and possibly increase the chance of success thanks to tools such as indocyanine green (ICG) and near infrared fluorescence (Firefly). The objective of this video is to assess the feasibility of this procedure. METHODS: We present the case of a 47 year-old patient with multiple sclerosis since 1987. She had a IC in 2018 with a Wallace 1 anastomosis for neurogenic detrusor overactivity refractory to conservative treatment with upper urinary tract deterioration and inability to self catheterize due to MS progression (cognitive dysfunction and upper limb impairment). She experienced multiple urosepsis with long hospital stays and eventually she needed bilateral nephrostomy tubes. Antegrade opacification revealed a stricture of the left uretero-enteric anastomosis. RESULTS: The patient is placed in 23° Trendelenburg position. Six ports are placed (4 robotic and 2 for the assistant) and the Da Vinci Xi robot is docked. We begin with adhesiolysis which allows to identify the ileal conduit. We carefully preserve the peri ureteral fat to ensure the best possible ureteral vascularization. We cut the ureters distally. The blood supply to the ureters end is checked using IV indocyanine green (ICG) injection and near infrared fluorescence (Firefly) and the ureters are cut as high as necessary and the ureter spatulation. A new uretero-enteric anastomosis is created according the Wallace 1 technique between the “ureteral plate” and the proximal stump of the ileal conduit. Two ureteral stents are placed for 10 days. CONCLUSIONS: Uretero-enteric anastomotic stricture in neurological patients can be treated using a robotic approach refection by robotic assisted procedure in a fully intracorporeal way is feasible. The magnified 3D vision, the precise dissection using the endowrist and the use of ICG may help preserve adequate blood supply to the ureter and minimize the risk of stricture recurrence The absence of large incision could also favored enhanced post operative recovery and minimize the risk of incisional hernias in this frail patient population. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e65-e65 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gilles Dosin More articles by this author Juliette Hascoet More articles by this author Clement Mazouin More articles by this author Zine-Eddine Khene More articles by this author Gregory Verhoest More articles by this author Romain Mathieu More articles by this author Karim Bensalah More articles by this author Lucas Freton More articles by this author Emmanuel Voiry More articles by this author Claire Richard More articles by this author Camille Haudebert More articles by this author Etienne Courboin More articles by this author Andrea Manunta More articles by this author Benoit Peyronnet More articles by this author Expand All Advertisement Loading ...

P0818 - Peak incidence of ureteroenteric anastomotic strictures after introduction of robot-assisted radical cystectomy with intracorporeal urinary diversion

P0818 - Peak incidence of ureteroenteric anastomotic strictures after introduction of robot-assisted radical cystectomy with intracorporeal urinary diversion

Editorial Comment.

No AccessJournal of UrologyAdult Urology1 Apr 2021Editorial CommentThis article comments on the following:Evaluation of Ureteroenteric Anastomotic Strictures after the Introduction of Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Results from a Large Tertiary Referral Center Rainjade Chung, and Christopher Anderson Rainjade ChungRainjade Chung Department of Urology, Columbia University Irving Medical Center, New York, New York More articles by this author , and Christopher AndersonChristopher Anderson Department of Urology, Columbia University Irving Medical Center, New York, New York More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001518.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 205(4), p. 1125 Reference 1. : Real-time indocyanine green angiography with the SPY fluorescence imaging platform decreases benign ureteroenteric strictures in urinary diversions performed during radical cystectomy. Ther Adv Urol 2019; 11: 175. Google Scholar © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of UrologyNov 30, 2020, 12:00:00 AMEvaluation of Ureteroenteric Anastomotic Strictures after the Introduction of Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Results from a Large Tertiary Referral Center Volume 205Issue 4April 2021Page: 1125-1125 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rainjade Chung Department of Urology, Columbia University Irving Medical Center, New York, New York More articles by this author Christopher Anderson Department of Urology, Columbia University Irving Medical Center, New York, New York More articles by this author Expand All Advertisement Loading ...

Evaluation of Ureteroenteric Anastomotic Strictures after the Introduction of Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Results from a Large Tertiary Referral Center. Reply.

No AccessJournal of UrologyLetters to the Editor1 Jan 2022Evaluation of Ureteroenteric Anastomotic Strictures after the Introduction of Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Results from a Large Tertiary Referral Center. Reply.is a reply to letterEvaluation of Ureteroenteric Anastomotic Strictures after the Introduction of Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Results from a Large Tertiary Referral Center. Letter. Daan J. Reesink, Sarah L. Gerritsen, Hans Kelder, Harm H.E. van Melick, and Pascal E.F. Stijns Daan J. ReesinkDaan J. Reesink Department of Urology, St. Antonius Hospital Nieuwegein/Utrecht, The Netherlands More articles by this author , Sarah L. GerritsenSarah L. Gerritsen Department of Urology, St. Antonius Hospital Nieuwegein/Utrecht, The Netherlands More articles by this author , Hans KelderHans Kelder Department of Statistics, St. Antonius Hospital Nieuwegein/Utrecht, The Netherlands More articles by this author , Harm H.E. van MelickHarm H.E. van Melick Department of Urology, St. Antonius Hospital Nieuwegein/Utrecht, The Netherlands More articles by this author , and Pascal E.F. StijnsPascal E.F. Stijns Department of Urology, St. Antonius Hospital Nieuwegein/Utrecht, The Netherlands More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001677AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Evaluation of Ureteroenteric Anastomotic Strictures after the Introduction of Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Results from a Large Tertiary Referral Center. Reply.." The Journal of Urology, 207(1), pp. 239–240

Evaluation of Ureteroenteric Anastomotic Strictures after the Introduction of Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Results from a Large Tertiary Referral Center.

Benign ureteroenteric anastomotic strictures following radical cystectomy are a critical complication. The incidence is highly dependent on study design, surgical technique and surgeon experience. We studied the incidence of ureteroenteric anastomotic strictures after open vs robot-assisted radical cystectomy with an intracorporeal urinary diversion, and determined the influence of the introduction of robot-assisted radical cystectomy in our clinic. A retrospective, single center, cohort study was performed between January 2012 and December 2017 in all patients undergoing radical cystectomy. Multivariate analysis was performed to determine which patient or disease-specific factors were associated with development of ureteroenteric anastomotic strictures. Of 279 patients, 192 (69%) underwent open radical cystectomy and 87 (31%) underwent robot-assisted radical cystectomy with intracorporeal urinary diversion. In total, 47/279 patients (17%) developed ureteroenteric anastomotic strictures after a median of 3.0 months (95% CI 2.4-3.7). The difference in incidence of ureteroenteric anastomotic strictures was statistically significant between open and robot-assisted radical cystectomy (13% vs 25%, p <0.001). On multivariate analysis, only surgical technique (open vs robot-assisted radical cystectomy) was independently associated with development of ureteroenteric anastomotic strictures (p=0.004). There was a peak incidence of ureteroenteric anastomotic strictures after robot-assisted radical cystectomy of 47% during the first year after introduction of the robot-assisted procedure. Introducing robot-assisted radical cystectomy with intracorporeal urinary diversion can result in an initial peak incidence of strictures, highlighting the importance of surgeon experience and the presence of a learning curve. Nonetheless, after experience has been gained, our results show that patients undergoing robot-assisted radical cystectomy with intracorporeal urinary diversion are still more likely to develop ureteroenteric anastomotic strictures compared to those undergoing open radical cystectomy.

Comparison of renal function after open radical cystectomy, extracorporeal robot assisted radical cystectomy, and intracorporeal robot assisted radical cystectomy

PurposeRenal function outcomes following robot-assisted radical cystectomy (RARC) have not been well established. We sought to compare long-term renal function outcomes between open radical cystectomy, RARC with extracorporeal urinary diversion and intracorporeal urinary diversion at a high volume institution. Materials and MethodsWe retrospectively reviewed our institutional bladder cancer database for patients who underwent RC from 2010 to 2019 with pre-operative estimated glomerular filtration rate (eGFR) > 45 ml/min/1.73m2. Changes in renal function were assessed through locally weighted scatter plot smoothing and comparison of median eGFR between surgical groups. Chronic Kidney Disease Stage 3B was defined as eGFR < 45 ml/min/1.73m2. Renal function decline was defined as a ≥10 ml/min/1.73m2 drop in eGFR. Kaplan Meier method with log-rank was used to compare CKD 3B-free survival and renal function decline. Cox Proportional Hazards model was used to identify predictors of CKD 3B. ResultsSix hundred and forty four patients were included with median follow-up of 32 months (IQR 12–56). Preoperative characteristics were similar among the groups with no differences in median pre-operative eGFR (ORC: 74.6, extracorporeal urinary diversion: 74.3, intracorporeal urinary diversion: 71.6 ml/min/1.73m2, P=0.15). Median postoperative eGFR on follow up was not different between groups (P=0.56). 33% of patients developed CKD 3B. There were no differences in CKD 3B-free survival by surgical approach (P = 0.23) or urinary diversion (P = 0.09). 64% of patients experienced renal function decline with a median time of 2.4 years (P 0.23). Predictors of CKD were pathologic T3 disease or greater (HR: 1.77, P = 0.01), ureteroenteric anastomotic stricture (HR: 2.80, P < 0.001), preoperative CKD Stage 2 (HR: 1.81, P =0.02), and preoperative CKD Stage 3A (HR: 5.56, P < 0.001). ConclusionRenal function decline is common after RC. Tumor stage, pre-operative eGFR, and ureteral stricture development, not surgical approach, influence renal function decline.

Long-Term Outcomes of Laser Incision and Triamcinolone Injection for the Management of Ureteroenteric Anastomotic Strictures

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.