Ureteroileal Anastomosis Research Articles

Anti-reflux uretero-ileal anastomosis for orthotopic ileal neobladder using Wallace technique in a single trough.

To evaluate the modification of the subserous extramural tunnel for non-refluxing uretero-ileal anastomosis in U - shaped pouches using the Wallace technique with a single trough. This prospective study was conducted from 2017 to 2022 in a single tertiary center after approval from the research ethics committee of our institution (approval number: FWA 000017585). 45 patients' candidates for radical cystectomy and orthotopic urinary diversion were included in this study. The patients were diverted using a U-shaped pouch with uretero-ileal anastomosis, combining the extramural serous-lined tunnel and Wallace techniques in a single trough. Operative time and complications, including ureteric obstruction, reflux, and renal function, were recorded within one year. The modified uretero-ileal anastomosis combined with the extramural serous-lined tunnel and Wallace techniques had a relatively short operative time (mean 132.2 ± 18.3 min) and short bowel segment incorporation (30 cm). In 43 patients, vesicoureteral reflux (VUR) occurred in only two patients (4.7%). One case of anastomotic stricture was diagnosed (2.3%), which increased to two cases (4.7%) after one year. Three patients (7%) developed pyelonephritis during the year. The mean serum creatinine level of the patients before the operation was 1.2 mg/dl, which increased to 1.4 mg /dl 6 months postoperatively. A modification of the subserous extramural tunnel for non-refluxing uretero-ileal anastomosis in U-shaped pouch appears to be a good simple alternative that is less time consuming and using a shorter segment of bowel for orthotopic diversion with a comparable complication rate.

Intravenous indocyanine green to evaluate distal ureteral vascularity during robot-assisted radical cystectomy with intracorporeal urinary diversion.

The aim of the present study is to assess the role of indocyanine green (ICG) to evaluate distal ureteral vascularity during robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion and its impact on the incidence of benign ureteroenteric strictures (UES). The study included patients who underwent RARC for bladder cancer between 2018 and 2023. All patients included underwent intracorporeal urinary diversion with ileal conduit or neobladder. Bricker technique was performed in all ureteroenteric anastomosis. ICG was employed during the study period to evaluate ureteral vascularity. We divided patients into 2 groups depending on the utilization of ICG during surgery and compared demographic, clinicopathological and perioperative outcomes, including benign UES rates. We identified 221 patients that underwent RARC with intracorporeal urinary diversion. Ileal conduit was performed in 173 (78.3%) patients and neobladder in 48 (21.7%) cases. A total of 142 (64.3%) and 79 (35.7%) patients were in the non-ICG and ICG group, respectively. With a median follow-up of the entire cohort of 21.1 months, there were no differences in the rate of benign UES after RARC between the non-ICG and the ICG group (p = 0.901). In the non-ICG group, 26 (18.3%) patients developed benign UES and in the ICG group 15 (19.0%) patients. Most of the strictures appeared in the left ureter in both groups (80.8% non-ICG vs. 66.7% ICG, p = 0.599). Median time to stricture diagnosis was 4 months (IQR 3-7.25) for the non-ICG and 3 months (IQR 2-5) for the ICG group (p = 0.091). The ICG group had a slightly greater length of ureter resected compared with the non-ICG group (1.5 vs. 1.3cm, p = 0.007). In our experience, choosing to use ICG intraoperatively to evaluate distal ureteral vascularity may not reduce the rate of benign UES after robot-assisted radical cystectomy with intracorporeal urinary diversion and Bricker ureteroileal anastomosis.

Adjuvant Radiotherapy in Bladder Cancers: A dosimetric study focusing on ileal conduit sparing

PurposeTo compare ileal conduit (IC) and other organ at risk (OAR) dosimetry between treatment techniques in a prospective cohort of patients planned for adjuvant radiotherapy (RT) after radical cystectomy and IC reconstruction. Methods and materialsCT datasets of twenty patients who underwent adjuvant RT were obtained and used prospectively for delineation of target volumes (primary and nodal) and organs at risk, including IC, uretero-ileal anastomosis and ileal stoma using a specified protocol for simulation including a delayed CT to identify IC. Three RT plans were generated for each patient for a dose of 54 gray (Gy) in 27 fractions (PTV V95% >95%): 3-dimensional conformal radiotherapy (3DCRT) with (3DCRT_S) and without (3DCRT_N) stoma shielding, and volumetric modulated arc therapy (VMAT), with OAR constraints specified for VMAT plans (IC: Dmax<54Gy, V50Gy<20cc). Constraints were given for other pelvic OARs (bowel, rectum, femur heads as per published literature.Plans were evaluated for target coverage as well as OAR doses; in particular, IC and stoma). ANOVA test was used to compare medians of achieveddoses, and a p-value <0.05 was statistically significant. ResultsThe median IC volume was 63.34 (55.29-82.93) cc. The cranial end of IC was at L5 or L4 vertebral level in 95% of patients and caudal level at S2 or S3 in 80% of patients. In contrast, the ileal stoma spanned from L4 or L5 vertebral level cranially (100%) toL5 level caudally (80%). PTV V95% was similar for 3DCRT_N and VMAT plans while it was significantly lower in 3DCRT_S in areas of ileal stoma shielding (99.95% vs 99.01% vs 96.29%, p<0.01). Median IC V50 Gy was comparable in 3DCRT_N (38.81 cc) and 3DCRT_S (35.62 cc) while it was significantly lower in the VMAT plan (17.05 cc, p<0.01). IC Dmax did not differ significantly between the 3 plans. On the other hand, when 3DCRT_N, 3DCRT_S, and VMAT plans were compared for ileal stoma doses, Dmean was comparable (11.93 Gy vs 7.41 Gy vs 9.54 Gy, p=0.06) while Dmax was significantly higher for 3DCRT_N plan and least for VMAT plan (35.32 Gy vs 27.57 Gy vs 24.22 Gy, p<0.01). VMAT plans fared significantly better for uretero-ileal anastomosis, bowel, and rectal dosimetry. ConclusionIleal stoma shielding in 3DCRT compromises PTV coverage but does not spare IC effectively. Sparing IC with VMAT is feasiblewithout compromising PTV coverage. Dosimetric gains with VMAT are expected to benefit patients needing higher pelvic RT doses and nodalRT by reducing the risk of anastomotic and mucosal complications. Clinical benefits should be evaluated in a prospective protocol.

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

The aim of our study is to evaluate the difference in stricture rate between matched groups of Bricker and Wallace techniques for ureteroileal anastomosis. A retrospective analysis of patients undergoing urinary diversion (UD) with Bricker and Wallace ureteroileal anastomosis at two university hospitals. Two groups of Bricker and Wallace patients were matched in a 1:1 ratio based on the age, sex, body mass index (BMI), Charlson comorbidity index (CCI), preoperative hydronephrosis, prior radiation therapy or abdominal surgery, pathologic T and N stages and 30-days-Clavien grade complications≥III. A multivariable Cox regression analysis was conducted to identify predictors of ureteroenteric stricture (UES) in all patients. Overall, 740 patients met the inclusion criteria and 209 patients in each group were propensity matched. At a similar median follow-up of 25 months, UES was detected in 25 (12%) and 30 (14.4%) patients in Bricker and Wallace groups, respectively (p = 0.56). However, only one patient in the Bricker group developed a bilateral stricture compared to 15 patients in the Wallace group, resulting in a significantly higher number of affected renal units in the Wallace group: 45 (10.7%) versus only 26 (6.2%) in the Bricker group (p = 0.00). On multivariable extended Cox analysis, prior radiotherapy, presence of T4 pelvic malignancy and nodal positive disease were independent predictor of UES formation. The technique of ureteroileal anastomosis itself does not increase the rate of stricture; however, conversion of two renal units into one is associated with a higher incidence of bilateral upper tract involvement.

Migration of double-J ureteral stent in patients with ureteroileal anastomosis stricture undergoing radical cystectomy and orthotopic neobladder: Analysis risk factors of stent migration.

The objective was to evaluate the incidence and degree of double-J ureteral stent (DJUS) migration. Additionally, we aimed to investigate the risk factors associated with stent migration in the orthotopic neobladder group. In this retrospective study, 61 consecutive patients were included; 35 patients (45 DJUS placements) underwent radical cystectomy with orthotopic neobladder and 26 patients (35 DJUS placements) underwent urinary bladder without cystectomy between July 2021 and March 2023. All the patients were treated with a DJUS for ureteric strictures. The technical success rate was 100% in each group. The DJUS migration was significantly higher in the orthotopic neobladder group, with 22 of 45 cases (48.9%), compared to the urinary bladder group, which had 4 of 35 cases (11.4%) (P ≤ .001). Among the patients in the orthotopic neobladder group who experienced DJUS migration, stent dysfunction occurred in 18 cases (81.8%), which was statistically significant (P = .003). Multivariate logistic regression analysis revealed that only the size of the DJUS was significantly and positively associated with migration (odds ratio:10.214, P = .010). DJUS migration can easily occur in patients undergoing radical cystectomy and orthotopic neobladder, and smaller stent sizes are associated with a higher incidence of migration.

A modified ureteroileal anastomosis can reduce ureteroileal anastomotic stricture after ileal conduit.

Ileal conduit is commonly employed as a urinary diversion procedure for patients with bladder cancer after radical cystectomy. Studies have reported that ureteroileal anastomotic stricture remains a serious complication following ileal conduit diversion. The aim of this study was to introduce a novel modified technique for ureteroileal anastomosis and evaluate postoperative complications, with a specific focus on the incidence of ureteroileal anastomotic stricture. A prospective single-center, single-surgeon cohort study was conducted on 29 consecutive patients who underwent laparoscopic radical cystectomy with ileal conduit urinary diversion between February 2017 and April 2021. A descriptive statistical analysis was performed where intraoperative variables and postoperative complications were assessed. All 29 operations were successful with an average operation time of 372.9 ± 94.3min. The mean follow-up time was 39.62 ± 15.93months. No cases of UIAS occurred. Three patients (10.3%) had febrile urinary tract infection, three patients (10.3%) had a transient small bowel obstruction, one patient (3.4%) had ileal anastomotic fistula, one patient (3.4%) had ileal conduit leakage, and one patient (3.4%) died 2months after surgery due to multiple respiratory diseases. One patient (3.4%) had a mild left ureteral obstruction and CT indicated the obstruction site was in front of the iliac vessels where the left ureter had transposed to the right. The modified ureteroileal anastomosis can reduce the incidence of UIAS.

Percutaneous Ureteral Stent Insertion in Patients with Benign Uretero-Ileal Anastomosis Strictures Who Underwent Radical Cystectomy: Assessing Risk Factors for Stent Patency.

We aimed to investigate the risk factors of early double-J ureteral stent (DJUS) dysfunction rates and the long-term patency of DJUSs inserted via a percutaneous approach in patients with benign uretero-ileal anastomosis stricture (UIAS) who had undergone radical cystectomy. In this retrospective study, 63 DJUS placements were placed via a percutaneous nephrostomy tract in 42 consecutive patients between May 2020 and March 2023. The technical success rate was 100% in all patients without major complications. The early dysfunction rate and long-term patency rate were 38.1% (24/63) and 84.2% (32/38), respectively. The blood clot retention grade, balloon dilatation, and length of the ureteral stricture exhibited a significant correlation with early DJUS dysfunction (blood clot retention grade: odds ratio (OR) 6.922 in grade two, p = 0.009; balloon dilatation: OR 0.186, p = 0.017; length of ureteral stricture: OR 8.715, p = 0.035 in moderate stenosis, and 7.646, p = 0.028 in severe stenosis). A multivariate Cox's proportional hazard analysis revealed that blood clot retention grade and length of ureteral stricture were independent predictors of long-term DJUS patency. Percutaneous insertion of the DJUSs was safe and effective in patients with benign UIAS.

Clinical efficacy and safety of percutaneous drainage for post-operative fluid collection in patients with bladder cancer undergoing radical cystectomy and urinary diversion.

To evaluate the success rates of percutaneous drainage for fluid collection after radical cystectomy, with emphasis on factors affecting the clinical success, including lesion, patient, and procedure characteristics. In this retrospective study, 31 percutaneous drainage catheters were placed in 29 consecutive patients between January 2021 and September 2023. Most fluid collections formed near the uretero-ileal anastomosis site in the right pelvic cavity (80.6%). The technical success rate was 100%. The primary and final clinical success was 80.6% and 96.9%, respectively. Lymphoceles notably increased the primary clinical failure risk (odds ratio and 95% confidential interval: 22.667 (1.839-279.366), P = .015). Significant differences were observed between transabdominal and transgluteal approaches in terms of fluoroscopic time, dose, and location. Leakage indications on computed tomography prompted differing interventions, but all achieved final clinical success. Percutaneous drainage for post-operative fluid collection is safe and effective in patients with radical cystectomy and urinary diversion.

Intraoperative ICG-Fluorescence as a Method to Prevent Postoperative Strictures of Uretero-Ileal Anastomoses in Robot-Assisted Radical Cystectomy

Introduction. Radical cystectomy with urine diversion is recognized as the standard for the treatment of muscle-invasive bladder cancer. One of the dangerous complications in the postoperative period is the stricture of uretero-ileal anastomosis leading to hydroureteronephrosis, renal failure, and urosepsis. One of the factors in the development of the anastomotic stricture is ischemia. In order to reduce possible ischemic injury, the following manipulations are performed: careful treatment of tissues in the area of future anastomosis, preservation of periureteral adventitia, minimal mobilization of ureters before implantation into conduit. Intraoperative assessment of ureteral and intestinal tissue perfusion using ICG-fluorescence is a promising area. Materials and methods. The study enrolled 56 patients who underwent a robotic-assisted radical cystectomy with intracorporeal urine diversion from January 2021 to March 2022 at the Bashkir State Medical University Clinic. Patients were divided into two groups: group 1 (22 patients) underwent intraoperative ICG-imaging, and group 2 (34 patients) — imaging without fluorescence. The median follow-up period was 14 months for group 1 and 12 months for group 2. The comparison criteria between the groups were demographic indicators, perioperative outcomes (including 30- and 90-day complications), and the incidence of strictures of uretero-ileal anastomoses. The groups were compared using a test for equality of means and a test for sampling distributions. Results and discussion. No statistically significant differences between patients were reported during the time of surgery, estimated blood loss, and duration of hospital stay. No significant differences were also detected in the incidence of 30- and 90-day complications and the number of readmissions among patients in group 1 and group 2 (p = 0.477 and p = 0.089, respectively). The incidence of strictures of uretero-ileal anastomosis in group 1 demonstrated a statistically significant decrease, as compared with group 2 (0/34 [0 %] and 7/68 [10.3 %], p = 0.020). Conclusion. The ICG-fluorescence imaging to assess vascularization of the distal ureter during robotic-assisted radical cystectomy with intracorporeal urine diversion may reduce the risk of postoperative uretero-ileal anastomotic ischemic strictures.

Ureteroureteral Fistula as a Rare Complication of Ileal Conduit Urinary Diversion: a Case Report

Long-term studies on ileal conduit have shown a complication rate of up to 66%. Fistulas are a rare late complication of ileal conduit. To our knowledge, no data about ureteroureteral fistulas has been published yet. We present the case of a 73-year-old man with non-muscle invasive high-grade urothelial carcinoma of the bladder who failed to BCG due to intolerance and developed a cripple bladder. He underwent a cystoprostatectomy, pelvic lymphadenectomy, and an ileal conduit urinary diversion. Four months after the surgery, a raised creatinine level was discovered. Sonography revealed bilateral hydro-ureteronephrosis. Shortly after, the stomal urinary production became minimal, and a nephrostomy was introduced to the right kidney. As a result, the right- as well as the left-sided hydronephrosis diminished, as assessed by ultrasound. Through a loopogram and anterograde pyelography, a stenosis at the ureteroileal anastomosis as well as a connection between the two ureters was proven. As an endoscopic intervention to resolve the obstruction failed, a re-laparotomy to make a neo-anastomosis from the ureters to the ileal conduit was performed. We suspect that total obliteration of the oral end of the ileal conduit caused fistula formation of the ureters. We would like to address this rare phenomenon as a complication of ileal conduit to be mentioned in the differential diagnosis if the outcome of urine is in question. It is not a simple stenosis of the distal portion of the ureters and demands an adapted surgical reconstructing technique as well.

Early postoperative outcomes in stent vs stent-less ileal conduits after radical cystectomies.

e16612 Background: Placing stents at the ureteroileal anastomosis for radical cystectomy with ileal conduit (RCIC) diversion has been common practice for the vast majority of urologists. Recently, the practice has been called into question, as some institutions have shifted to not stenting their ileal conduits for patient comfort and convenience. In this study, we aim to investigate the difference in 30-day outcomes between patients who did and did not receive ureteroileal stents after RCIC. Methods: RCs performed between 2019-2020 were identified in NSQIP and the corresponding cystectomy-targeted database. Baseline demographics, comorbidities, and operative parameters were compared via Pearson’s chi-square and t-tests between stented and stent-less RCICs. Outcomes of interest included rates of urinary tract infections (UTIs), acute kidney injury (AKI), renal failure requiring dialysis, anastomotic leaks, ureteral obstruction, ureteral fistula formation, need for reoperation, and 30-day hospital readmissions. Outcomes were compared using Pearson’s chi-square. All statistical tests were two tailed, p&lt;0.05 considered significant. Results: 3,865 RCICs were identified, of which 446 (11.5%) were stent-less. There was no difference in baseline demographics, comorbidities, or operative parameters between the stented and stent-less group, with the notable exceptions that significantly more stent-less patients had robotic-assisted instead of open RCs compared to the stented group (33% vs 21%, p&lt;0.001), and significantly more stent-less patients were preoperatively on dialysis compared to the stented group (4.9% vs 0.5%, p&lt;0.001). There was no significant difference in 30-day rates of UTIs, AKIs, renal failure, anastomotic leaks, ureteral obstruction, ureteral fistula formation, need for reoperation, and readmissions between the stented and stent-less cohorts. Conclusions: Stent-less ileal conduits have recently emerged in popularity. This study represents the largest multi-institutional analysis comparing outcomes between traditionally stented and stent-less RCICs, and shows that there is no significant difference in outcomes. Given the added cost and patient discomfort of ureteroileal stents, this study may indicate that these stents may not play as significant of a role in preventing early complications as previously thought. These findings warrant further investigation.

V06-05 INTRACORPORPOREAL ROBOTIC CONVERSION OF A NEOBLADDER TO AN ILEAL CONDUIT

You have accessJournal of UrologyCME1 Apr 2023V06-05 INTRACORPORPOREAL ROBOTIC CONVERSION OF A NEOBLADDER TO AN ILEAL CONDUIT Mohamed Eltemamy, Rathika Ramkumar, Patrick Michael, and Georges-Pascal Haber Mohamed EltemamyMohamed Eltemamy More articles by this author , Rathika RamkumarRathika Ramkumar More articles by this author , Patrick MichaelPatrick Michael More articles by this author , and Georges-Pascal HaberGeorges-Pascal Haber More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003274.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In this video, we aim to describe the technique and feasibility of intracorporeal robotic conversion of a ileal neobladder to an ileal conduit. METHODS: This is a 68 years old male patient who had a robotic radical cystectomy and intracorporeal ileal neobladder for BCG refractory high risk non muscle invasive bladder cancer. He had his continent diversion for 7 years and was dependent on intermittent self-catheterization to empty his reservoir. After counselling the patient on his options, he elected to have a robotic conversion of his neobladder to an ileal conduit. RESULTS: The total operative time was 5 hours and 11 minutes. the estimated blood loss was minimal. No complications were noted and the patient was discharged on post operative day 1. We were able to reutilize the neobladder wall. This was done by partial resection of the pouch wall and reconfiguring the remaining wall in to a tube to reconstruct a new ileal conduit. In doing so, we avoided doing a new intestinal anastomosis and uretero-ileal anastomosis. CONCLUSIONS: We demonstrate the surgical steps for robotic conversion of a neobladder to an ileal conduit. This procedure is safe and technically feasible. Recycling the neobladder wall should always be favored over new construction of an ileal conduit as it avoids the need for intestinal anastomosis and redoing of an already patent uretero-ileal anastomosis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e510 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mohamed Eltemamy More articles by this author Rathika Ramkumar More articles by this author Patrick Michael More articles by this author Georges-Pascal Haber More articles by this author Expand All Advertisement PDF downloadLoading ...

Delineating and sparing the ileal conduit in adjuvant radiotherapy for bladder cancer with modulated radiotherapy.

We undertook a prospective planning study to describe the delineation of ileal conduit (IC) loop on radiotherapy planning computed tomography (RTP CT) scan as an organ at risk (OAR) and its sparing using volumetric modulated arc therapy (VMAT) during adjuvant irradiation of bladder malignancies. Fifteen patients with bladder malignancy needing adjuvant radiotherapy postoperatively and having normal renal function underwent delayed phase RTP CT from June 2020 to March 2021, with certain modifications (Foley's catheter through stoma, additional delayed scans). We identified the course of ureters, external stoma, IC, and uretero-ileal (right and left) anastomotic sites. VMAT plans were generated. A step-by-step description is given. Genitourinary OARs include kidneys, ureters, uretero-ileal anastomoses, and IC. The contrast on delayed scan opacifies ureters and IC. IC can be seen three-dimensionally as a structure with two fixed ends (blind proximal end anterior to the right sacroiliac joint and the open distal end over the right anterior abdominal wall in parasagittal location) and a 15-20 cm hanging intraabdominal loop that lies adjacent to the right iliac vessels. For prescription doses (PD) of 50.4 gray and 54 gray, respectively, VMAT plan achieved IC dose maximum to less than PD and V50 lower than 10 cc. Stoma sparing traditionally used as a surrogate for IC sparing is insufficient due to the variable intraabdominal location of IC loop. Delineation of IC as an OAR is feasible with slight modifications in the RTP protocols. VMAT (or other forms of intensity modulated radiation therapy) can help IC sparing and should be considered when it lies in close proximity to target volumes and the risk of additional morbidity is considerable.

MP46-13 ROBOT-ASSISTED RADICAL CYSTECTOMY WITH INTRACORPOREAL PADUA ILEAL NEOBLADDER: LONG-TERM FUNCTIONAL OUTCOMES AND CONTINENCE PREDICTORS ASSESSMENT FROM A HIGH-VOLUME CENTER LARGE CONSECUTIVE SERIES

You have accessJournal of UrologyCME1 Apr 2023MP46-13 ROBOT-ASSISTED RADICAL CYSTECTOMY WITH INTRACORPOREAL PADUA ILEAL NEOBLADDER: LONG-TERM FUNCTIONAL OUTCOMES AND CONTINENCE PREDICTORS ASSESSMENT FROM A HIGH-VOLUME CENTER LARGE CONSECUTIVE SERIES Gabriele Tuderti, Riccardo Mastroianni, Umberto Anceschi, Alfredo Maria Bove, Aldo Brassetti, Mariaconsiglia Ferriero, Leonardo Misuraca, Salvatore Guaglianone, Michele Gallucci, and Giuseppe Simone Gabriele TudertiGabriele Tuderti More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Umberto AnceschiUmberto Anceschi More articles by this author , Alfredo Maria BoveAlfredo Maria Bove More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Leonardo MisuracaLeonardo Misuraca More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Michele GallucciMichele Gallucci More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003292.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Daytime urinary continence recovery following robot assisted radical cystectomy with intracorporeal orthotopic neobladder (RARC-iON) has been poorly investigated. In this study we reported long-term functional outcomes of RARC-iON and assessed the predictors of daytime urinary continence recovery. METHODS: Our single center IRB approved bladder cancer database was queried for “RARC” and “iON”.All patients treated between January 2012 and September 2020, with a minimum 1-yr follow-up were included. Baseline demographic, clinical, perioperative and pathologic data were reported. Functional outcomes included: renal function modification over time, neobladder stone formation, development of uretero-ileal anastomosis strictures, need for self-catheterization and Trifecta achievement (defined as the coexistence of daytime continence, Clavien-Dindo ≥3 complication-free and recurrence-free status, all assessed at 1 year).Day- and night-time continence recovery probabilities were assessed with Kaplan-Meier method; univariable and multivariable analyses were performed to identify predictors of day-time continence. RESULTS: Overall, 192 patients were included, 146 were male (76%).Mean baseline eGFR was 83.5 ml/min (± 23.5). At a median follow- up of 41 months (IQR 21-60), mean last eGFR was 63.8 ml/min (± 22.1).The incidence of significant renal function deterioration (newly onset CKD stage ≥3b) was 16.1%. Neobladder stones were reported in 16 patients (8.3%), all of which successfully treated as outpatient endoscopic procedure. Incidence of ureteroileal anastomosis stricture was 22.4%. Trifecta was achieved in 64.1% of cases. One-yr day- and night-time continence rates were 78.6 % and 48.3 %, respectively. At multivariable analysis age, female gender and severe 30-d complications occurrence were identified as independent predictors of lower day-time continence recovery probabilities. CONCLUSIONS: We reported functional outcomes of a large single center consecutive series of RARC-iON. Male, young and those patients who did not experience severe perioperative complications had significantly higher likelihood of recovering daytime urinary continence. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e636 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gabriele Tuderti More articles by this author Riccardo Mastroianni More articles by this author Umberto Anceschi More articles by this author Alfredo Maria Bove More articles by this author Aldo Brassetti More articles by this author Mariaconsiglia Ferriero More articles by this author Leonardo Misuraca More articles by this author Salvatore Guaglianone More articles by this author Michele Gallucci More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement PDF downloadLoading ...

MP52-19 ROBOTIC VERSUS OPEN CYSTECTOMY WITH ILEAL CONDUIT FOR THE MANAGEMENT OF NEUROGENIC BLADDER: A COMPARATIVE STUDY

You have accessJournal of UrologyCME1 Apr 2023MP52-19 ROBOTIC VERSUS OPEN CYSTECTOMY WITH ILEAL CONDUIT FOR THE MANAGEMENT OF NEUROGENIC BLADDER: A COMPARATIVE STUDY Jeanne Beirnaert, Ugo Pinar, Davy Benarroche, Morgan Roupret, Véronique Phé, Christophe Vaessen, Jerome Parra, Emmanuel Chartier-Kastler, and Thomas Seisen Jeanne BeirnaertJeanne Beirnaert More articles by this author , Ugo PinarUgo Pinar More articles by this author , Davy BenarrocheDavy Benarroche More articles by this author , Morgan RoupretMorgan Roupret More articles by this author , Véronique PhéVéronique Phé More articles by this author , Christophe VaessenChristophe Vaessen More articles by this author , Jerome ParraJerome Parra More articles by this author , Emmanuel Chartier-KastlerEmmanuel Chartier-Kastler More articles by this author , and Thomas SeisenThomas Seisen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003300.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cystectomy associated with non-continent ileal diversion is a common surgery in patients with neurogenic bladder. Few data are available, especially for the robotic approach. Our purpose was to compare open cystectomy (OC) and robot-assisted radical cystectomy (RARC) with ileal conduit, regarding peri- and postoperative outcomes. METHODS: We included each patient who underwent cystectomy and ileal conduit for neurogenic bladder in a referral-center between January 2017 and November 2021. Datas were retrospectively analysed. Median follow-up was 16.6 months [IQR: 5; 41]. All patients had neurogenic bladder with failure of conservative treatment and/or impacted Quality of Life (QoL). Open cystectomy with non-continent ileal diversion and robot-assisted cystectomy with intra-corporeal non-continent ileal diversion were compared. Primary endpoint were postoperative complications. Secondary endpoints were length of hospital stay (LOS), surgery duration, blood loss and ureteral anastomosis stricture. RESULTS: A total of 123 patients were included, 85 (69.1%) undergoing OC and 38 (30.9%) RARC. Significant differences were observed for: operative time (OC: 266.9±64 vs. RARC: 205.8±55.5 min, p<0.001), blood loss (OC: 737.7±515.8 vs. RARC: 245.8±169.6 ml, p<0.001), delay until feeding resumption (OC: 7.1±4.7 vs. RARC: 5.5±2.9 days, p=0.05) and mean LOS (OC: 21.6±13.9 vs. RARC: 16.2±7.6 days, p=0.03). In RARC group, there were 10.5% complications Clavien-Dindo >2 whereas 23.8% complications underwent in the OC group (p=0.1). With regards to uretero-ileal anastomosis stenosis, 23 (18.7%) events occurred after a median follow-up of 16.6 months [IQR: 5; 41] including 20 (23.5%) and three (7.9%) in the ORC and RARC groups, respectively (p=0.07). Patients who underwent RARC had better ureteral stenosis-free survival rates than those who underwent ORC (log-rank test, p=0.05). CONCLUSIONS: RARC is a safe approach for management of neurological bladder showing significantly better perioperative outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e710 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeanne Beirnaert More articles by this author Ugo Pinar More articles by this author Davy Benarroche More articles by this author Morgan Roupret More articles by this author Véronique Phé More articles by this author Christophe Vaessen More articles by this author Jerome Parra More articles by this author Emmanuel Chartier-Kastler More articles by this author Thomas Seisen More articles by this author Expand All Advertisement PDF downloadLoading ...

Simultaneous Antegrade and Retrograde Endoscopic Management of Complete Short-Segment Ureteroileal Anastomotic Stricture: Technique and Early Outcome

Background: Ureteroileal anastomotic strictures have a prevalence of up to 10%. Although open surgical revision remains the gold standard treatment, endoscopic and robotic approaches are described to reduce morbidity.1 Patients with complete occlusive strictures are usually not considered candidates for endoscopic management. There are limited publications with small number of patients who employed endoscopic management for complete occlusive ureteroileal anastomotic stricture. Objective: The aim of this video is to describe surgical approach in a stepwise manner for endoscopic management of a complete short-segment (<1 cm) ureteroileal anastomotic stricture.2–6 Methods: A 51-year-old woman underwent an anterior pelvic exenteration and ileal conduit followed by adjuvant chemoradiotherapy for cervical cancer management. After 1 year, she underwent nephrostomy tube placement for pyelonephritis associated with a left hydroureteronephrosis. Subsequent antegrade nephrostogram demonstrated a complete ureteroileal anastomotic stricture. The patient was counseled regarding various management options, and she opted for endoscopic management. Under general anesthesia we initially performed a flexible cystoscopy through the ileal conduit and were unable to identify the left ureteroileal anastomotic site. We then dilated percutaneous renal access and placed 13F ultra-mini percutaneous nephrolithotomy sheath in kidney under fluoroscopic guidance. Antegrade simultaneous ureteroscopy and nephrostogram confirmed a short-segment complete stenosis of ureteroileal anastomosis. Using 200 micron holmium laser fiber at 1 J × 10 Hz, we incised the distal blind end of ureter near conduit allowing passage of the ureteroscope in periureteral tissue. We then incised the ileal conduit, allowing antegrade advancement of a guidewire into the conduit. This wire was retrieved cystoscopically through an ileal conduit and secured at the level of stoma. Finally, a 7F/14F endoureterotomy stent was placed followed by nephrostomy tube placement. Results: The patient had an uneventful postoperative recovery and was discharged home the next day with an open nephrostomy tube. After 10 days, we confirmed free drainage of contrast into the conduit without extravasation on antegrade nephrostogram and clamped the nephrostomy tube. We later removed nephrostomy tube at 2 weeks and endoureterotomy stent by office cystoscopy at 6 weeks. At 3-month and 1-year follow-up, the patient remained asymptomatic. A renal ultrasonography revealed residual mild left hydronephrosis and a renal scan showed stable split left renal function of 25% with adequate drainage. Conclusion: Our video provides detailed technical nuisances to novice endourologist for a safe and effective treatment of a complete short-segment ureteroileal anastomotic occlusion with simultaneous antegrade and retrograde endoscopic management. No competing financial interests exist. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 4 mins 58 secs

Robotic Radical Cystectomy with Intracorporeal Urinary Diversion - Tips and Tricks.

Radical cystectomy represents the standard surgical treatment in case of muscle invasive bladder cancer. During the last two decades a change in the surgical approach of the MIBC has been observed, from open surgery to minimal invasive surgery. Nowadays, in the majority of tertiary urologic centers, robotic radical cystectomy with intracorporeal urinary diversion represents the standard surgical approach. The aim of the current study is to describe in detail the surgical steps of the robotic radical cystectomy and the reconstruction of the urinary diversion and to present our experience. From the surgical point of view, the most important principles which should guide the surgeon when performing this procedure are: 1. Good working place and access both to the pelvis and abdomen and use of the "technique of spaces" 2. Respect the oncological principles of the surgery with attention to the margin resection and limitation of the risk of tumour spillage; 3. Attention to both the ureter and bowel manipulation in order to avoid grasping lesions; 4. High care in realisation of the uretero-ileal anastomosis so that good long term functional results are achieved. We analyzed our database of 213 patients diagnosed with muscle invasive bladder cancer who underwent minimally invasive radical cystectomy (laparoscopic and robotic approaches) between January 2010 and December 2022. We identified 25 patients for whom the robotic approach was used to perform the surgery. Despite being one of the most challenging urologic surgical procedures, with careful preparation and training, the surgeon is able to achieve the maximum oncological and functional results by performing robotic radical cystectomy with intracorporeal urinary.

The cause analysis of benign uretero-ileal anastomotic stricture after radical cystectomy and urinary diversion.

Benign uretero-ileal anastomotic stricture (UIAS) is a major complication following radical cystectomy (RC) and ileal orthotopic bladder substitution, and it can occur in combination with other complications. But risk factors for patients with UIAS have not been well described. We retrospectively reviewed 198 patients treated with RC for bladder cancer from 2014 to 2019 at the Zhejiang Provincial People's Hospital. Patient demographic and clinical variables were examined to determine the risk factors associated with UIAS by univariate and multivariate logistic regression analysis. A total of 180 patients into the group standards and in all 360 uretero-ileal anastomoses. Among the above cases, 22 patients developed UIAS, including 10 cases of left UIAS, nine cases of right UIAS, and three cases of bilateral UIAS. There was no difference in demographic, operative, or perioperative variables between patients with and without UIAS. In a multivariate analysis, after adjusting for gender, age, surgical methods, and underlying diseases, intraoperative or postoperative blood transfusion (HR = 0.144, P <0.01), postoperative urinary tract infection (HR = 3.624, P <0.01), and extracorporeal bladder anastomosis (HR = 3.395, P = 0.02) significantly increased the risk of UIAS. In our experience, intraoperative or postoperative blood transfusion, postoperative urinary tract infection, and extracorporeal neobladder anastomoses increased the risk of UIAS after radical cystectomy and ileal orthotopic bladder substitution surgery. Further studies with larger samples are necessary to validate this result.

Is it necessary to perform a retrosigmoid transposition of the left ureter in Bricker Ileal Conduit surgery?

BackgroundThe need for the left ureter to pass through the subsigmoid during ileal conduit diversion surgery has not been investigated in any studies. A modified technique is simply used in the ileal conduit with the left ureter straight over the sigmoid colon due to the possible damage and lack of scientifically validated advantages of this procedure. Our study aimed to investigate the feasibility of the suggested surgical technique, as well as to evaluate perioperative outcomes and postoperative complications with a focus on the prevalence of small bowel obstruction (SBO) and ureteroileal anastomotic stricture (UAS).MethodsA prospective single-center cohort of 84 consecutive patients undergoing laparoscopic radical cystectomy (LRC) and ileal conduit urinary diversion was conducted between January 2018 and April 2020. The incidence of SBO and UAS, perioperative outcomes, and postoperative complications were compared between a trial group of 30 patients receiving the modified procedure and a control group of 54 patients receiving the conventional Bricker ileal conduit.ResultsThe two groups were comparable concerning patient characteristics and clinicopathologic features. No differences were observed in terms of the operation time, perioperative outcomes, and short-term (< 90 days) postoperative complications between the two groups. There were no occurrences of UAS in the modified group, while there were two cases (3.70%) in the patients who received Bricker's ureteroileal anastomosis (p = 0.535).ConclusionIn the present study, a simple and feasible modified technique of ileal conduit is proposed. Compared with traditional techniques, our method has several advantages, including the ability to avoid compression of the left ureter from the mesentery without establishing a retrosigmoid tunnel, a low rate of UAS, and the ability to perform a secondary operation at long-term follow-up.

The effect of retroperitonealization of ureteroileal anastomosis on perioperative complications of radical cystectomy with ileal conduit urinary diversion.

Radical cystectomy (RC) has been considered the standard management of muscle-invasive bladder cancer. Despite the improvements in surgical techniques and perioperative care, RC is still associated with high perioperative morbidity and mortality. This study aims to evaluate the effect of retroperitonealization of ureteroileal anastomosis on perioperative complications of RC with ileal conduit urinary diversion. This is a retrospective cohort study. We reviewed medical charts of 876 patients who underwent RC between 2016 and 2021. Based on the inclusion and exclusion criteria, 748 patients entered the study. According to retroperitonealization of the ureteroileal anastomosis, patients were categorized into two groups (group I without retroperitonealization of the ureteroileal anastomosis and group II with retroperitonealization of the ureteroileal anastomosis). Patients' characteristics and occurrences of any complications and high-grade complications were compared between these groups. In comparing the complication categories between the two groups, fewer patients in group II suffered from gastrointestinal, urinary, and cardiac events (p values were 0.018, 0.021, and 0.013, respectively). Moreover, fewer patients in group II experienced any complications and high-grade complications (p values were < 0.001 and < 0.001, respectively). The length of hospital stay was also significantly shorter in group II (p < 0.001). RC is associated with comparatively high perioperative morbidity and mortality. In the present study, 61% of the patients experienced at least one complication postoperatively. Retroperitonealization of the ureterointestinal anastomosis may decrease perioperative adverse events of RC with ileal conduit urinary diversion.