Ureteroenteric Strictures Research Articles

V04-08 ROBOT-ASSISTED REPAIR OF BENIGN DISTAL URETEROENTERIC STRICTURES FOLLOWING RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 May 2022V04-08 ROBOT-ASSISTED REPAIR OF BENIGN DISTAL URETEROENTERIC STRICTURES FOLLOWING RADICAL CYSTECTOMY Victoria Maxon and Alvin Goh Victoria MaxonVictoria Maxon More articles by this author and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002560.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This video aims to provide a step-by-step approach for robot-assisted repair of benign distal ureteroenteric strictures (UES) following radical cystectomy (RC). METHODS: We demonstrate the feasibility and safety of robotic repair through three clinical scenarios after different forms of diversion and open primary surgery. UES repair is performed in the setting of an open RC and neobladder (NB), an open Indiana pouch and a repeat repair after RC and ileal conduit (IC). The RC/IC and Indiana pouch patients were placed in the modified lateral position with right side up. Port placement was directed at the right lower quadrant. The RC/NB patient was placed in the supine position and port placement was similar to that of RC. The operation consists of extensive lysis of adhesions, mobilization of the diversion and ureter, identification of the UES, excision of ureteral scar tissue and spatulation, assessment of ureteral perfusion using indocyanine green (ICG) fluorescence and the creation of a tension-free and watertight anastomosis. RESULTS: All cases were completed successfully without the need for open conversion. There were no intraoperative complications. Operative times ranged from 174-273 minutes. Estimated blood loss ranged from 10-50ml. Patients were discharged on postoperative day 1. No major complications occurred within 90 days of discharge. Renal function remained stable in all three patients at 6 weeks postoperatively. Patients were followed with functional renal imaging at 3 months postoperatively. CONCLUSIONS: Robot-assisted repair of UES is feasible and safe, even in the setting of extensive prior open abdominal surgery. This is the ideal approach for UES repair because it requires less mobilization of surrounding structures, allows for intraoperative ureteral assessment with ICG fluorescence and can successfully create a tension-free and watertight anastomosis. Our patients recovered quickly and without complications. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e369 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Victoria Maxon More articles by this author Alvin Goh More articles by this author Expand All Advertisement PDF downloadLoading ...

MP022 - Use of indocyanine green to minimise uretero-enteric strictures after robotic radical cystectomy.

MP022 - Use of indocyanine green to minimise uretero-enteric strictures after robotic radical cystectomy.

Robotic Repair of Ureteroenteric Stricture Following Radical Cystectomy: A Multi-Institutional Experience

ObjectiveTo examine the safety, feasibility and durability of robotic reimplantation of ureteroenteric stricture after radical cystectomy. Materials and MethodsA retrospective multi-institutional review was performed for all patients undergoing robotic repair of ureteroenteric stricture from January 2010 to January 2019. Functional outcomes and complications were followed and data were analyzed with SPSS statistical software. ResultsA total of 46 patients and 58 renal units were identified, of which 15 had right sided, 19 left sided and 12 patients had bilateral strictures. Presentation of stricture was asymptomatic in 14 (30.4%) patients. Symptomatic presentations included infection in 22 (47.8%), worsening renal function in 11 (23.9%) and pain in 3 (6.5%) patients. Median time from cystectomy to diagnosis of stricture was 5 months (1-40). Median stricture length was 1.5 cm (range 0.5-10). All strictures were of benign etiology except for 4 (6.9%), which were due to malignancy. Overall, 49 (84.5%) ureters underwent primary re-implantation, while 9 (15.5%) required Boari-like advancement flaps prior to re-implantation. Median operative time was 190 min (range 45-540) with median estimated blood loss of 50 mL (range 25-2000) and median length of stay of 2 days (range 1-33, IQR 2-4). Seven (15.2%) patients experienced complications; 3 (6.5%) were low grade and 4 (8.7%) high grade. With median follow up of 18 months (range 1-51) the stricture recurrence rate was 8.6%. ConclusionRobotic reimplantation of ureteroenteric strictures following radical cystectomy is safe and feasible in experienced centers with high success rates.

Perioperative and Functional Outcomes of Robot-assisted Ureteroenteric Reimplantation: A Multicenter Study of Seven Referral Institutions

BackgroundOpen revision of ureteroenteric strictures (UESs) is associated with considerable morbidity. There is a lack of data evaluating the feasibility of robotic revisions. ObjectiveTo analyze the perioperative and functional outcomes of robot-assisted ureteroenteric reimplantation (RUER) for the management of UESs after radical cystectomy (RC). Design, setting, and participantsA retrospective multicenter study of 61 patients, who underwent 63 RUERs at seven high-volume institutions between 2009 and 2020 for benign UESs after RC, was conducted. Outcome measurements and statistical analysisData were reviewed for demographics, stricture characteristics, and perioperative outcomes. Variables associated with being stricture free after an RUER were evaluated using a multivariate Cox regression analysis. Results and limitationsAmong 63 RUERs, 22 were right sided (35%), 34 left sided (54%), and seven bilateral (11%). Twenty-seven (44%) had prior abdominal/pelvic surgery and five (8%) radiotherapy (RT). Thirty-two patients had American Society of Anesthesiologists (ASA) scores I–II (52%) and 29 ASA III (48%). Forty-two (68%) RUERs were in ileal conduits, 18 (29%) in neobladders, and two (3%) in Indiana pouch. The median time to diagnosis of a UES from cystectomy was 5 (3–11) mo. Of the UESs, 28 (44%) failed an endourological attempt (balloon dilatation/endoureterotomy). The median RUER operative time was 195 (175–269) min. No intraoperative complications or conversions to open approach were reported. Twenty-three (37%) patients had postoperative complications (20 [32%] were minor and three [5%] major). The median length of hospital stay was 3 (1–6) d and readmissions were 5%. After a median follow-up of 19 (8–43) mo, 84% of cases were stricture free. Lack of prior RT was the only variable associated with better stricture-free survival after RUER (hazard ratio 6.8, 95% confidence interval 1.10–42.00, p = 0.037). The study limitations include its retrospective nature and the small number of patients. ConclusionsRUER is a feasible procedure for the management of UESs. Prospective and larger studies are warranted to prove the safety and efficacy of this technique. Patient summaryIn this study, we investigate the feasibility of a novel minimally invasive technique for the management of ureteroenteric strictures. We conclude that robotic reimplantation is a feasible and effective procedure.

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

PurposeUreteroenteric 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 methodsRetrospective, 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.ResultsOf 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).ConclusionThe 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.

Evaluating the impact of the learning curve on the perioperative outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion

IntroductionRobot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is a technically difficult procedure. Our aim was to evaluate the potential impact of the learning curve (LC) on perioperative and pathological outcomes of RARC with ICUD. Material and methodsRetrospective study of 62 consecutive patients who underwent RARC with ICUD for bladder cancer between 2015−2020. We compared 3 consecutive groups of 20 (G1), 20 (G2), and 22 (G3) patients to analyze the impact of the LC. G1 cases were performed by a senior surgeon experienced in robotic surgery, while G2–G3 were performed by 2 junior surgeons without experience under the mentorship of the senior surgeon. ResultsThe 3 groups had similar clinical and pathological characteristics. A total of 15 patients (24%) received a neobladder and 47 (75%) an ileal conduit. The mean operative time decreased 60 min between G1–G3 (p = 0.001). No conversions to open approach or intraoperative complications were reported. There were no differences between groups regarding positive margin rates (p = 0.6) or the number of lymph nodes removed (p = 0.061). The postoperative complication rate was 77% and did not change during the LC (p = 0.49). Uretero-enteric stricture rate decreased from 25% in G1 to 9% in G3 (p = 0.217). ConclusionsThe inclusion of junior surgeons to a RARC with ICUD program after the initial 20 cases does not have an impact on the perioperative and pathological outcomes of the procedure. The operative time and the uretero-enteric stricture rate could be reduced during the LC.

Incidence, Etiology, Prevention and Management of Ureteroenteric Strictures after Robot-Assisted Radical Cystectomy: A Review of Published Evidence and Personal Experience.

Benign ureteroenteric anastomosis strictures (UESs) are one of many critical complications that may cause irreversible disability following robot-assisted radical cystectomy (RARC). Previous studies have shown that the incidence rates of UES after RARC can reach 25.3%, with RARC having higher UES incidence rates compared to open radical cystectomy. Various known and unknown factors are involved in the occurrence of UES. To minimize the incidence of UES after RARC, our group has standardized the procedure and technique for intracorporeal urinary diversion by applying the following five strategies: (1) wide delicate dissection of the ureter and preservation of the periureteral tissues; (2) gentle handling of the ureter and security of periureteral tissues at the anastomotic site; (3) use of indocyanine green to confirm good blood supply; (4) standardization of the ample ureteral spatulation length for Wallace ureteroenteric anastomosis through objective measurements; and (5) development of an institutional standardized procedure manual. This review focused on the incidence, etiology, prevention, and management of UES after RARC to bring attention to the incidence of this complication while also proposing standardized surgical procedures to minimize its incidence after RARC.

Robotic Assisted Repair of Post-Ileal Conduit Parastomal Hernia: Technique and Outcomes

ObjectiveTo describe a novel method of robotic assisted laparoscopic parastomal hernia repair (RAL-PHR), including the evolving use of the Da Vinci Single Port (SP) robotic system. MethodsDemographic, intraoperative, and postoperative variables were collected for patients who underwent RAL-PHR. The technique for RAL-PHR utilizes a 3 cm incision in the contralateral upper quadrant for the robotic trocar and a 12 mm assistant port. The hernia sac is freed from the fascial defect. Dual Surface Mesh is approximated to the fascial edges with a portion excised to tailor the conduit. ResultsFour patients underwent RAL-PHR and three utilized the SP robot. Median age was 74.4 (range: 69.0-76.9) and median BMI 28.6 (26.5-43.2). All patients underwent cystectomy for bladder cancer and median time from index operation to parastomal hernia repair was 47.3 (40.4-11.48) months. Concurrent operations to hernia repair included ureteroenteric stricture repair, panniculectomy, abdominal wall reconstruction, stoma revision, and incisional hernia repair. Median operative time was 3.9 (2.6-8.7) hours including concurrent operations, median EBL was 50 (10-100) cc, mesh used in 3 cases, with no intraoperative complications reported. Median length of stay was 1 day and 1 post-operative complication greater than Clavien 2 reported. At median follow up of 18.3 (3.63-38.3) months, no recurrences were reported and 1 patient had undergone stoma dilation in the OR. ConclusionRAL-PHR using the SP system maximizes advantages of laparoscopic repair while allowing for flexibility to perform concurrent procedures and safer takedown of adhesions through just two incisions. RAL-PHR is a safe and effective alternative to open and laparoscopic parastomal hernia repair with several additional benefits.

PD35-04 THE EFFECT OF PELVIC RADIATION DOSE ON INCIDENCE OF URETEROENTERIC STRICTURE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion I (PD35)1 Sep 2021PD35-04 THE EFFECT OF PELVIC RADIATION DOSE ON INCIDENCE OF URETEROENTERIC STRICTURE Mei Tuong, Andrew Winkelman, Clinton Yeaman, Perri Nelson, Chandler Morris, Kara Romano, Tracey Krupski, and Sumit Isharwal Mei TuongMei Tuong More articles by this author , Andrew WinkelmanAndrew Winkelman More articles by this author , Clinton YeamanClinton Yeaman More articles by this author , Perri NelsonPerri Nelson More articles by this author , Chandler MorrisChandler Morris More articles by this author , Kara RomanoKara Romano More articles by this author , Tracey KrupskiTracey Krupski More articles by this author , and Sumit IsharwalSumit Isharwal More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002039.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior radiation therapy is a known risk factor for ureteroenteric stricture (UES) development following urinary diversion. We aimed to determine whether cancer radiation delivered dose impacts development of UES after urinary diversion. METHODS: An IRB approved cystectomy database was utilized to identify UES in patients treated with prior pelvic radiation who underwent radical cystectomy or pelvic exenteration and urinary diversion at a single academic center between 2016 and 2020. UES was confirmed by endoscopic diagnosis or imaging. Radiation dose delivered was extrapolated based upon current cancer guideline-based protocols. A Kaplan-Meier survival curve in addition to Cox Proportional-Hazards Model was used to compare UES rates between radiation treated cancers. RESULTS: 65 patients had a history of radiation prior to extirpative surgery in our cohort of 215 patients; 15 (23%) of these patients developed UES as compared to our institutional rate of 5.3%. The rate of UES development by cancer radiation dose is as follows: cervical cancer (target dose 85 Gy) 4/8 patients (50%), colorectal cancer (target dose 50 Gy) 3/11 patients (27%), urologic cancer (target dose 45-50 Gy) 7/39 patients (18%), and non-cervical gynecologic cancer (45-50 Gy) 1/7 patients (14%).Initial Kaplan-Meier estimation demonstrated radiation treated cervical cancer had a statistically significant higher probability of developing UES compared with other radiation treated cancers (p=0.046) (Figure 1). Cervical cancer also had a statistically significant UES hazard ratio (HR) of 3.6 (95% CI 1.04-12.2, p=0.04) compared to urologic cancers.Colorectal and non-cervical gynecologic cancers did not statistically significantly differ in UES HR when compared to urologic cancers (p=0.3, p>0.9). CONCLUSIONS: This contemporary series confirms that there is a high rate of UES, 23%, after urinary diversion in previously radiated patients in spite of our knowledge of this risk factor. The higher pelvic radiation dose given with cervical cancer appears to be associated with an increased risk of UES after urinary diversion compared with other radiation treated cancers. This knowledge of developing UES in radiation treated cancers is important for patient counseling. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e589-e589 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mei Tuong More articles by this author Andrew Winkelman More articles by this author Clinton Yeaman More articles by this author Perri Nelson More articles by this author Chandler Morris More articles by this author Kara Romano More articles by this author Tracey Krupski More articles by this author Sumit Isharwal More articles by this author Expand All Advertisement Loading ...

PD59-11 URETERO-ENTERIC STRICTURES AFTER ROBOT ASSISTED RADICAL CYSTECTOMY: PREVALENCE AND PREDICTORS

You have accessJournal of UrologyBladder Cancer: Invasive V (PD59)1 Sep 2021PD59-11 URETERO-ENTERIC STRICTURES AFTER ROBOT ASSISTED RADICAL CYSTECTOMY: PREVALENCE AND PREDICTORS Umar Iqbal, Holly Houenstein, Zhe Jing, Nighat Sofi, Gaybrielle James, Ahmed S. Elsayed, Qiang Li, Ahmed A. Hussein, and Khurshid A. Guru Umar Iqbal Umar Iqbal More articles by this author , Holly HouensteinHolly Houenstein More articles by this author , Zhe JingZhe Jing More articles by this author , Nighat SofiNighat Sofi More articles by this author , Gaybrielle JamesGaybrielle James More articles by this author , Ahmed S. ElsayedAhmed S. Elsayed More articles by this author , Qiang LiQiang Li More articles by this author , Ahmed A. HusseinAhmed A. Hussein More articles by this author , and Khurshid A. GuruKhurshid A. Guru More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002096.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteroenteric strictures (UES) are a common cause of reoperations after robot assisted radical cystectomy (RARC). We sought to evaluate the prevalence, predictors, management and trend over time for strictures after RARC. METHODS: We reviewed our departmental quality assurance database for RARC (2005-2020). Patients who developed UES were identified. Data was analyzed for demographics and perioperative variables. UES were described in terms of timing, laterality and management. Multivariable analysis was used to identify variables associated with UES. Kaplan Meir curves were used to depict time to UES. RESULTS: Out of 671 patients undergoing RARC, 101 (15%) developed UES. They occurred at a rate of 9%, 14% and 18% at 6 months, 1 year and 3 years after RARC, respectively (Figure). Strictures were on the right in 31%, on the left in 49 % and bilateral in 20%. Initial management was endoscopic in 65% and percutaneous in 35%. Eventually, reimplantation was performed in 44% of the patients (open 13% and robotic 31%). Patients with UES had higher body mass index (30±6 vs 29±6, p=0.03), lower eGFR (ml/min) at 90 days (61 vs 72, p=0.02), higher rate of acute kidney injury within 90 days (22% vs 12 %, p=0.01), higher rate of urinary tract infections (UTI) within 90 days (54% vs 36%, p=0.01) recurrent UTI within 90 days (13% vs 4 %, p <0.01) (Table). Congestive heart failure (OR 2.83, CI 1.12 -7.18, p=0.03) and neoadjuvant chemotherapy (OR 1.76, CI 1.12 – 2.77, p=0.01) were associated with stricture formation. CONCLUSIONS: UES occurred in 15% of patients after RARC and required reimplantation in almost half of cases. History of congestive heart failure and neoadjuvant chemotherapy were associated with UES. Source of Funding: Roswell Park Alliance Foundation © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1058-e1059 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Umar Iqbal More articles by this author Holly Houenstein More articles by this author Zhe Jing More articles by this author Nighat Sofi More articles by this author Gaybrielle James More articles by this author Ahmed S. Elsayed More articles by this author Qiang Li More articles by this author Ahmed A. Hussein More articles by this author Khurshid A. Guru More articles by this author Expand All Advertisement Loading ...

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 ...

Impact of radiation on the incidence and management of ureteroenteric strictures: a contemporary single center analysis

BackgroundUreteroenteric stricture incidence has been reported as high as 20% after urinary diversion. Many patients have undergone prior radiotherapy for prostate, urothelial, colorectal, or gynecologic malignancy. We sought to evaluate the differences between ureteroenteric stricture occurrence between patients who had radiation prior to urinary diversion and those who did not.MethodsAn IRB-approved cystectomy database was utilized to identify ureteroenteric strictures among 215 patients who underwent urinary diversion at a single academic center between 2016 and 2020. Chart abstraction was conducted to determine the presence of confirmed stricture in these patients, defined as endoscopic diagnosis or definitive imaging findings. Strictures due to malignant ureteral recurrence were excluded (3 patients). Statistical analysis was performed using chi squared test, t-test, and Wilcoxon Rank-Sum Test, logistic regression, and Kaplan–Meier analysis of stricture by cancer type.Results65 patients had radiation prior to urinary diversion; 150 patients did not have a history of radiation therapy. Benign ureteroenteric stricture rate was 5.3% (8/150) in the non-radiated cohort and 23% (15/65) in the radiated cohort (p = < 0.001). Initial management of stricture was percutaneous nephrostomy (PCN) in 78% (18/23) and the remaining 22% (5/23) were managed with primary retrograde ureteral stent placement. Long term management included ureteral reimplantation in 30.4% (7/23).ConclusionsOur study demonstrates a significant increase in rate of ureteroenteric strictures in radiated patients as compared to non-radiated patients. The insult of radiation on the ureteral microvascular supply is likely implicated in the cause of these strictures. Further study is needed to optimize surgical approach such as utilization of fluorescence angiography for open and robotic approaches.

Análisis del impacto de la curva de aprendizaje de la cistectomía radical asistida por robot con derivación urinaria intracorpórea sobre los resultados perioperatorios

IntroductionRobot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is a technically difficult procedure. Our aim was to evaluate the potential impact of the learning curve (LC) on perioperative and pathological outcomes of RARC with ICUD. Material and methodsRetrospective study of 62 consecutive patients who underwent RARC with ICUD for bladder cancer between 2015-2020. We compared 3 consecutive groups of 20 (G1), 20 (G2), and 22 (G3) patients to analyze the impact of the LC. G1 cases were performed by a senior surgeon experienced in robotic surgery, while G2-G3 were performed by 2 junior surgeons without experience under the mentorship of the senior surgeon. ResultsThe 3 groups had similar clinical and pathological characteristics. A total of 15 patients (24%) received a neobladder and 47 (75%) an ileal conduit. The mean operative time decreased 60minutes between G1-G3 (P=0.001). No conversions to open approach or intraoperative complications were reported. There were no differences between groups regarding positive margin rates (P=0.6) or the number of lymph nodes removed (P=0.061). The postoperative complication rate was 77% and did not change during the LC (P=0.49). Uretero-enteric stricture rate decreased from 25% in G1 to 9% in G3 (P=0.217). ConclusionsThe inclusion of júnior surgeons to a RARC with ICUD program after the initial 20 cases does not have an impact on the perioperative and pathological outcomes of the procedure. The operative time and the uretero-enteric stricture rate could be reduced during the LC.

Cumulative incidence of ureteroenteric strictures after radical cystectomy in a population-based Swedish cohort

Objective The incidence of benign ureteroenteric strictures following radical cystectomy (RC) for urinary bladder cancer (UBC) is investigated mainly in single-centre studies from high-volume centres. The aim of this study was to evaluate the cumulative incidence of strictures and risk factors in a population-based cohort. Patients and methods Data was collected from Bladder Cancer Data Base Sweden (BladderBaSe). The primary endpoint was stricture with intervention. Secondary endpoint included hydronephrosis both with/without intervention. Results In total, 5,816 patients were registered as having had RC due to UBC between 1997 and 2014. After a median follow-up of 23.5 months (IQR = 9.0–63.1 months; range = 0.0–214.0 months), we found that 515 (8.9%) patients underwent intervention for stricture. Seven hundred and sixty-one (13.1%) patients were diagnosed with hydronephrosis without intervention. The cumulative incidence of strictures with intervention was 19.7% (95% CI = 16.7–23.1%) during the 17 years of follow-up. In the first year, the cumulative incidence of strictures was 5.6% (95% CI = 5.0–6.2%), and in the first 2 years 8.4% (95% CI = 7.6–9.3%). For the secondary endpoint, the cumulative incidence was 30.4% (95% CI = 26.7–33.1%) after 17 years. Only the year of RC was associated with stricture incidence in Cox regression analysis, whereas hospital cystectomy volume, patient age and patient sex were not. Conclusion Ureteroenteric strictures requiring intervention may be more common than previously reported, affecting nearly one fifth of patients who have undergone RC for UBC. The annual incidence was highest in the first 2 years after surgery but the cumulative incidence increased continuously during 17 years of follow-up.

Contemporary management of benign uretero-enteric strictures after cystectomy: a systematic review.

Uretero-enteric stricture (UES) is a common postoperative complication after radical cystectomy with urinary diversion. The aim of this systematic review was to discuss the contemporary management of benign UES after cystectomy and to compare the different surgical approaches. A systematic review was performed from January 2000 to January 2021. Search engines used included PubMed, Embase and Medline databases. Search query were: (["ureteroileal" OR "uretero-ileal" OR "ureteroenteric" OR "uretero-enteric"] 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. Forty-one studies were finally included in this systematic review. No prospective studies were found; all included studies were retrospective. Open surgical repair had 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 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. Surgical management of UES remains challenging. Open surgery maintains a role given its high success rate, at the cost 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.

Management of upper urinary tract problems after radical cystectomy for urothelial carcinoma: tips and tricks.

After radical cystectomy (RC) patients are at risk for both benign and malignant problems regarding the upper urinary tract (UUT). This review summarizes the recent literature and provides tips on how to manage problems of the UUT after RC. Disease recurrence, kidney stones and ureteroenteric strictures (UES) are common after RC. Endourological techniques can be used to treat low-grade disease recurrence, either with a retrograde or antegrade approach. Treatment success depends on getting access to the UUT and on tumor characteristics; selecting the right approach is key. Kidney stones can be treated endourologically with good results. With use of minimal invasive techniques such as robot cystectomy, a higher incidence of UES is observed. The use of indocyanine green could help to prevent this complication. In case of a stricture, primary reconstruction should be the treatment strategy of choice. After RC, recurrence of the UUT remains a complicated problem. Choice of treatment method should be tailored to the patient and tumor characteristics. Kidney stones after cystectomy can be successfully managed endourological. Robot assisted RC introduced a higher rate of UES, which should be managed by primary revision.

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 ...

Functional results of hautmann neobladder with chimney modification and wallace ureteroileal anastomosis: initial experience with 22 patients.

ABSTRACTObjective:To assess the functional outcomes and complications of modified Hautmann neobladder with Wallace ureteroileal anastomosis on a 6-8 cm long isoperistaltic chimney, following radical cystectomy.Materials and Methods:Between January 2015 and October 2019, 22 patients (18 men and 4 women) underwent radical cystectomy and Hautmann neobladder reconstruction with chimney modification and Wallace I ureteroileal anastomosis. The mean age of patients was 61 years (45–74 years). All procedures were performed by the same surgeon and the mean follow-up was 29.4 months. Complications were registered as early (occurring within 3 months) or late (occurring after 3 months), with particular attention addressed to the ureteroileal anastomotic stricture and anastomotic leakage rate. Patient evaluation also included symptom analysis for daytime continence and voiding frequency.Results:Ureteroileal anastomotic stricture was not detected as a cause of hydronephrosis. Hovewer, the anastomotic leakage occurred in one patient during the early postoperative period. Early complications occurred in 9 patients and the most common was bilateral hydronephrosis, detected in 5 examinees. Late complications occurred in 4 patients. Complete daytime and nighttime continence achieved in 18 and 16 patients respectively, with two patients (9%) still required intermittent catheterization three months after surgery.Conclusions:The functional results with modified Hautmann neobladder, incorporating short afferent limb in Wallace I uretero-enteric anastomosis, were efficient. This technique is an effective way to minimize potential uretero-enteric stricture, anastomotic leakage and incidence of vesicoureteral reflux.

Effect of intracorporeal urinary diversion on the incidence of benign ureteroenteric stricture after cystectomy.

To compare ureteroenteric stricture rates after radical cystectomy in patients who undergo an intracorporeal urinary diversion versus other surgical approaches. We retrospectively reviewed health records of all patients who underwent cystectomy with urinary diversion at Mayo Clinic Hospital (Phoenix, AZ, USA) from 1 January 2007 through 1 January 2018. Ureteroenteric stricture was identified by surveillance imaging. Patients were stratified by surgical approach: open radical cystectomy, robot-assisted radical cystectomy with extracorporeal urinary diversion and robot-assisted radical cystectomy-intracorporeal urinary diversion. A Cox proportional hazards model was fitted that included independent predictors of stricture development. Of the 573 cystectomies assessed, 236 (41.2%) were carried out robotically. In the robot-assisted radical cystectomy cohort, 39 patients (16.5%) underwent intracorporeal urinary diversion. The median follow-up period was 55, 70 and 71months for the open radical cystectomy, robot-assisted radical cystectomy-extracorporeal urinary diversion and robot-assisted radical cystectomy-intracorporeal urinary diversion groups, respectively. Subgroup stricture rates were as follows: open radical cystectomy, 8.0%; robot-assisted radical cystectomy-extracorporeal urinary diversion, 9.6%; and robot-assisted radical cystectomy-intracorporeal urinary diversion, 2.6% (P=0.33). The median time to stricture was 5months (interquartile range 3.3-11.5months). In the bivariable analysis, factors that were associated with the development of ureteroenteric stricture were postoperative urinary leak (hazard ratio 3.177, 95% confidence interval 1.129-8.935; P=0.03) and body mass index (hazard ratio 1.078, 95% confidence interval 1.027-1.132; P=0.002). On multivariable logistic regression analysis, intracorporeal urinary diversion approach was not associated with the development of ureteroenteric stricture (hazard ratio 0.272, 95% confidence interval 0.036-2.066; P=0.21). Ureteroenteric stricture is a complication that typically occurs within the first postoperative year. Although our results did not support major differences in outcomes between intracorporeal urinary diversion and extracorporeal urinary diversion, the small sample size did not exclude the possibility of a type2 statistical error.

Urinary diversions for radical cystectomy: a review of complications and their management

Radical cystectomy involves a urinary diversion, the most used being the ileal conduit and the orthotopic neobladder. This review focuses on the complications associated with these procedures, dividing them into general and diversion related complications, as well as their management. We conducted a search on PubMed and Scopus to identify eligible articles on complications of urinary diversions. Randomized controlled trials and systematic reviews with meta-analysis were preferred when available. Early complications occur in the first 90 days after surgery. The most common is post-operative ileus, followed by urinary tract infections and urinary leakage. Most complications occur in the late post-operative setting, being related to the type of urinary diversion. Some of these complications are renal failure, metabolic abnormalities, infections, urolithiasis, and ureteroenteric strictures, each with particular management options. Specific ileal conduit complications are conduit deformities and parastomal hernias. Neobladder patients can have continence problems, like incontinence or urinary retention, but also fistulas and dehiscence. Standardization of complications’ definitions and time-dependent reporting are crucial to better understand and manage these complications. Complication rates are similar between open and robot-assisted procedures and between intracorporeal and extracorporeal diversion. Radical cystectomy with urinary diversion is the most difficult surgical procedure in urology with high early and late complication rates. There is an urgent need of standardizing complication reporting to better compare different procedures.