Ureterointestinal Anastomotic Strictures Research Articles

MP65-17 LENGTH OF URETER RESECTED AT TIME OF URINARY DIVERSION IS ASSOCIATED WITH URETERAL STRICTURE RATE

You have accessJournal of UrologyCME1 Apr 2023MP65-17 LENGTH OF URETER RESECTED AT TIME OF URINARY DIVERSION IS ASSOCIATED WITH URETERAL STRICTURE RATE Arighno Das, Tudor Borza, Daniel Shapiro, E. Jason Abel, David Jarrard, and Kyle Richards Arighno DasArighno Das More articles by this author , Tudor BorzaTudor Borza More articles by this author , Daniel ShapiroDaniel Shapiro More articles by this author , E. Jason AbelE. Jason Abel More articles by this author , David JarrardDavid Jarrard More articles by this author , and Kyle RichardsKyle Richards More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003323.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Benign ureterointestinal anastomotic (UIA) strictures are a morbid complication following cystectomy with urinary diversion. Data from renal transplantation literature suggests that shorter ureters may result in fewer anastomotic strictures due to improved vascularization of the re-implanted segment. We evaluated whether length of distal ureteral resection may impact rates of UIA strictures in cystectomy patients. METHODS: A database of patients who underwent cystectomy with urinary diversion from 2015 to 2022 was analyzed. All cases were performed by a single surgeon to control for variations in surgical technique. Distal ureteral resections were routinely sent for final pathology. Length of this resection was collected from pathology reports. Benign UIA strictures were confirmed with renal scintigraphy, antegrade nephrostogram, or endoscopic evaluation. Relationship between stricture formation and clinical parameters were assessed using T-tests, Chi-squared tests, and multivariable analysis. RESULTS: A total of 362 patients underwent cystectomy with urinary diversion from 2015 to 2022. Of the cohort, 35 (9.6%) patients developed UIA strictures. Median time to stricture formation was 12.5 months (IQR 4-30). Of the 724 ureteral anastomoses among the 362 patients, 40 anastomoses developed benign strictures (6%). Median distal ureteral length resected was significantly longer among anastomosis that did not form a stricture (2.2 cm vs 1.65 cm, p=0.044, Table). Strictures more commonly formed on the left side, although this did not reach significance (65% vs 35%, p=0.051). Multivariable logistic regression adjusting for surgical approach, prior radiation, ureteral side, and urinary diversion type demonstrated longer distal ureteral resections were associated with a significantly lower risk of ipsilateral stricture formation (OR 0.74, 95% CI 0.58-0.94). CONCLUSIONS: 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, consistent with renal transplantation data. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e898 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arighno Das More articles by this author Tudor Borza More articles by this author Daniel Shapiro More articles by this author E. Jason Abel More articles by this author David Jarrard More articles by this author Kyle Richards More articles by this author Expand All Advertisement PDF downloadLoading ...

Surgical technique of uretero-ileal anastomosis in patients with bilateral duplex ureters undergoing radical cystectomy and ileal conduit urinary diversion: initial experience

Background We present a simple technique for construction of wide ureteral plate, consisting of four ureters, incorporated in ureteroileal anastomosis of ileal conduit urinary diversion. Methods We retrospectively reviewed the charts of six cases of ureteral duplication (five bilateral and one unilateral) and muscle-invasive bladder cancer, treated with radical cystectomy and ileal conduit diversion, at our institution from 2015 to 2020. Briefly, our technique includes construction of wide ureteral plate, consisting of four ureters from two separate ureteral units, after previous construction of right and left ureteral plates for each unit, according to the standard Wallace technique. Additionally, during construction of definite ureteral anastomotic plate, we used a modified Wallace I technique consisted of eversion of posteromedial ureteral walls of both ureteral units, with muco-mucosal running suture. Results Four males and two females underwent radical cystectomy with ileal conduit for muscle invasive bladder cancer. A total of 12 complications (CDC I–III) were registered in 4/6 (66.6%) patients, whereby ten of them (83.3%) occurred within 90 days post-surgery. High-grade (CDC III) complications were registered in 33.3% of patients. Within the first three months post-surgery, hydronephrosis and high-grade vesicoureteral reflux were associated with pyelonephritis and observed in two patients (33.3%), while uretero-intestinal anastomotic stricture or leakage were not detected during follow-up in any patients. Conclusion Modified Wallace uretero-ileal anastomosis after radical cystectomy and ileal conduit urinary diversion is functionally and cosmetically effective way to treat patients with bilateral duplex ureters harbouring muscle invasive bladder cancer.

Management of ureteric duplications identified during robotic cystectomy and intracorporeal urinary diversion.

Ureteral duplication is rarely seen malformation that could be diagnosed during radiological imaging. Herein, we present 5 patients with ureteral duplication who underwent robotic radical cystectomy with intracorporeal urinary diversion for bladder cancer. Preoperative computerized tomography did not show presence of a ureteral duplication in any patient and all were identified intraoperatively. A Wallace type uretero-ureteral anastomosis was performed in all patients. During the follow-up period, we did not detect any ureterointestinal anastomotic strictures or complication related to the presence of a ureteral duplication following robotic cystectomy. We conclude that ureteral duplication might be missed during preoperative radiological imaging, might be a surprising and challenging issue for the robotic surgeon that could be safely managed intraoperatively.

Simultaneous antegrade and retrograde endoscopic treatment of non-malignant ureterointestinal anastomotic strictures following urinary diversion

BackgroundThe ureterointestinal anastomosis stricture (UAS) is a common complication of urinary diversion after radical cystectomy. For decades, open anastomotic revision remained the gold standard for the treatment of UAS. However, with the advancement in endoscopic technology, mini-invasive therapeutic approaches have been used in its management. Here, we report our experience with and long-term results of combined simultaneous antegrade and retrograde endoscopy (SARE) in the treatment of non-malignant UASs after urinary diversion in a consecutive series of patients.MethodsFrom March 2012 to January 2015, there were 32 consecutive patients with 32 non-malignant UASs following radical cystectomy and urinary diversion. Twenty-nine patients were treated with SARE technique and comprised the study group. Using simultaneous antegrade flexible ureteroscope combined with retrograde semi-rigid ureteroscope or nephroscope, partial or complete strictures were managed with laser incision and balloon dilation under direct visualization. A 7/12 Fr graded endopyelotomy stent was left for 3–6 months after the procedure. Success was defined as symptomatic improvement and radiographic resolution of obstruction.ResultsWith a median followup of 22 months (6–36), the overall success rate for SARE was 69.0%. Twenty patients with partial stricture had a success rate of 85%, and 9 patients with complete stricture had a success rate of 33.3%. Renal function, hydronephrosis grade, stricture type, and stricture length were significant influences on the outcome (P < 0.05). No complication was observed.ConclusionsThe SARE is a safe and effective treatment for UAS, and may be the only endoscopic treatment approach for complete UAS. While success rate for complete strictures is low compared to open revision, it should be considered as an initial approach given its low overall morbidity. For partial strictures, prudent patient selection results in higher success rates that are nearly comparable to open revision.

Modified ureterosigmoidostomy (Mainz Pouch II) urinary diversion: 10 years experience and follow-up

Objective To report 10 years experience in modified ureterosigmoidostomy (Mainz Pouch Ⅱ) urinary diversion and evaluate its long-term outcome. Methods From October 2004 to December 2014, 248 patients , including 205 men and 43 women, had underwent Mainz Pouch Ⅱ urinary diversion at 26 institutions in Gansu Province, China.The median age at surgery was 61 years, ranged from 15 to 79 years, Among those patients, 239 patinets were diagnosed as bladder invasive urothelial carcinoma, including urothelial carcinoma in 230, squamous cell carcinoma in 6, adenocarcinoma in 2 and leiomyosarcoma in 1. 200 male patients underwent the radical vesico-prostsectomy. 39 female patients underwent the exenteration of total pelvis with bilateral pelvic lymadenectomy. For one paitent with urethral squamous cell carcinoma, exenteration of total pelvis, urethra resection and bilateral pelvic lymadenectomy were performed at the same time. Simple cystectomy were performed in 5 patients, including bladder retraction as a consequence of urinary tuberculosis, exstrophy bladder, interstitial cystitis, glandular cystitis and refractory vesicovaginal fistula. Bricker ileal conduit urinary diversion was transformed to Mainz Pouch Ⅱ in three patients. Clinical data and early complications were retrospective analysis. Data on long-term complications, continent status, urinary frequency and patient's quality of life were investigated by follow-up. Results The median operative time for urinary diversion is 120 minutes (ranging from 90 to 150 minutes). The median estimated blood loss was 800 ml (ranging from 400 to 2 500 ml). Seven patients (7/248, 2.8%) died in the perioperative period. Early complications were noticed in 66 patients (66/248, 26.6%), such as intestinal fistula(6/248, 2.4%), pulmonary infection(5/248, 2.0%), ileal obstruction (4/248, 1.6%), pyelonephritis(4/248, 1.6%), deep venous thrombosis(2/248, 0.8%), pelvic infection(2/248, 0.8%), wound dehiscence (10/248, 4.0%), superficial wound infections (30/248, 12.1%), hemorrhagic shock(1/248, 0.4%), myocardial infarction (1/248, 0.4%) and rectovaginal fistula (1/248, 0.4%). Thirty-seven patients (15.4%, 37/241) were lost during follow-up and eighty-five (41.7%, 85/204) passed away. 119 patients were followed from 7 to 126 months (mean 46 months). Late complications occurred in 29.4% of patients (60/204), including uretero-intestinal anastomotic stricture (20/204, 9.8%, 24 of 400 renoureteric units, 6.0%), recurrent pyelonephritis (12/204, 5.9%), delayed ileal obstruction (11/204, 5.4%), symptomatic metabolic acidosis (11/204, 5.4%), incisional hernia (5/204, 2.5%), pelvic infection (1/204, 0.5%). The overall quality of life was described as 'fully satisfied' by 20 patients (20/119, 16.8%), 'moderately satisfied' by 87 patients (87/119, 73.1%) and 'Poorly satisfied' by 12 patients (12/119, 10.1%). At the end of follow-up, three patients were excluded due to conversion to permanent nephrostomy. The other patients were continent at day time. Completely continence was achieved in 92 of 116 (79.3%) patients during the day and night. Conclusions Mainz Pouch Ⅱ is a simple and feasible procedure to achieve continent urinary diversion, with excellent continence rate and good quality of life. When the patient refused to have an incontinent urinary diversion, it may be used as a convenient and satisfactory alternative for cystectomized patients who are not suitable for orthotopic urinary diversion due to bladder cancer invasion into prostate or urethra. Key words: Ureterosigmoidostomy; Urinary diversion; Mainz Pouch Ⅱ; Surgical complications; Follow up

The effect of length of ureteral resection on benign ureterointestinal stricture rate in ileal conduit or ileal neobladder urinary diversion following radical cystectomy

ObjectivesTo assess the effect of the length of the ureter resected and other clinical variables on ureterointestinal anastomotic (UIA) stricture rate following radical cystectomy and ileal segment urinary diversion. Methods and materialsWe identified 519 consecutive patients who underwent cystectomy and ileal conduit or ileal orthotopic neobladder diversion from January 2007 to August 2012. The length of the ureter resected was defined as the length of the ureter in the cystectomy specimen plus the length of the distal ureter submitted for pathologic analysis. The primary end point was the risk of UIA stricture formation, assessed by Cox proportional hazards analysis. ResultsA total of 463 patients met the inclusion criteria with complete data. Median follow-up was 459 days (interquartile range [IQR]: 211–927). Median time to stricture formation was 235 (IQR: 134–352) and 232 days (IQR: 132–351) on the right and the left ureter, respectively. Overall stricture rate per ureter was 5.9% on the right vs. 10.0% on the left (P = 0.03). There was no difference in demographic, operative, or perioperative variables between patients with and without UIA strictures. On multivariate analysis adjusted for age, sex, anastomosis technique (running vs. interrupted), and length of ureter resected, only a Clavien complication≥III (hazard ratio = 2.11, 1.01–4.40) and urine leak (hazard ratio = 3.37, 1.08–10.46) significantly predicted for left- and right-sided stricture formation, respectively. The length of the ureter resected did not predict UIA stricture formation on either side. ConclusionsThe etiology of benign UIA strictures following ileal urinary diversion is likely multifactorial. Our data suggest that a complicated postoperative course and urine leak are risk factors for UIA stricture formation. The length of the distal ureter resected did not significantly affect stricture rate.

MP5-11 THE IMPACT OF LENGTH OF URETERAL RESECTION ON BENIGN URETERO-INTESTINAL STRICTURE RATE IN ILEAL CONDUIT OR ILEAL NEOBLADDER URINARY DIVERSION FOLLOWING CYSTECTOMY

Objectives: To assess the effect of the length of the ureter resected and other clinical variables on ureterointestinal anastomotic (UIA) stricture rate following radical cystectomy and ileal segment urinary diversion. Methods and materials: We identified 519 consecutive patients who underwent cystectomy and ileal conduit or ileal orthotopic neobladder diversion from January 2007 to August 2012. The length of the ureter resected was defined as the length of the ureter in the cystectomy specimen plus the length of the distal ureter submitted for pathologic analysis. The primary end point was the risk of UIA stricture formation, assessed by Cox proportional hazards analysis. Results: A total of 463 patients met the inclusion criteria with complete data. Median follow-up was 459 days (interquartile range [IQR]: 211–927). Median time to stricture formation was 235 (IQR: 134–352) and 232 days (IQR: 132–351) on the right and the left ureter, respectively. Overall stricture rate per ureter was 5.9% on the right vs. 10.0% on the left (P ¼ 0.03). There was no difference in demographic, operative, or perioperative variables between patients with and without UIA strictures. On multivariate analysis adjusted for age, sex, anastomosis technique (running vs. interrupted), and length of ureter resected, only a Clavien complication ZIII (hazard ratio ¼ 2.11, 1.01–4.40) and urine leak (hazard ratio ¼ 3.37, 1.08–10.46) significantly predicted for left- and right-sided stricture formation, respectively. The length of the ureter resected did not predict UIA stricture formation on either side. Conclusions: The etiology of benign UIA strictures following ileal urinary diversion is likely multifactorial. Our data suggest that a complicated postoperative course and urine leak are risk factors for UIA stricture formation. The length of the distal ureter resected did not

V10-03 USEFULNESS OF ENDOUROLOGY IN DIAGNOSIS AND TREATMENT OF URETEROINTESTINAL DIVERSION DISEASES

INTRODUCTION AND OBJECTIVES: Patients with ureterointestinal diversion after radical cystectomy are susceptible of developing different diseases in that location. Endourological techniques permit diagnosis and treatment of ureterointestinal diversion diseases as lithiasis, tumors and ureterointestinal anastomotic strictures. In these patients, we can also explore and treat upper urinary tract lesions. METHODS: In the context of ureterointestinal diversion lithiasis formation is unusual, but it is favored when urine drainage is slowed. Endoscopic examination permits direct visualization of the stones to complement imaging, evaluation of association with other lesions, intracorporeal lithotripsy if necessary and extraction for compositional analysis. In our experience we have noticed that lithiasis formation is more frequent specially around a foreign body such as metal suture used in elaboration of urinary diversion. Ureterointestinal nonmalignant anastomotic stricture is a late complication of difficult solution with conventional endourological techniques. In this cases we can perform endoureterotomy by intraluminal invagination adopting a combined percutaneous antegrade and endoscopic retrograde approach. Endoscopic approach also allows direct visualization and biopsy of suspicious lesions in the ureterointestinal diversion. Tumor recurrence in the urinary diversion is rare, it is more frequent in the anastomotic area and requires an individualized treatment. Endoscopical resection of de lesions is feasible, with the aim of establishing histological diagnosis prior to definitive treatment. In the same procedure we can also access the upper urinary tract in order to search for tumor or suspicious associated urothelial lessions, and it also permits the treatment of nonmalignant diseases such as lithiasis or ureteral strictures. RESULTS: Endourology permits the diagnosis and tratment of several diseases of ureteroileal diversion with good results and minimal invasion. CONCLUSIONS: In selected patients and with adequate training, endourology may offer a great spectrum of possibilities in diagnosis and treatment of patients with urinary diversion diseases.

The Impact of Running versus Interrupted Anastomosis on Ureterointestinal Stricture Rate after Radical Cystectomy

Benign ureterointestinal anastomotic stricture is not uncommon after radical cystectomy and urinary diversion. We studied the impact of the running vs the interrupted technique on the ureterointestinal anastomotic stricture rate. From July 2007 to December 2008 interrupted end-to-side anastomoses were created and from January 2009 to July 2010 running anastomoses were created. The primary study end point was time to ureterointestinal anastomotic stricture. Of 266 consecutive patients 258 were alive 30 days after radical cystectomy, including 149 and 109 with an interrupted and a running anastomosis, respectively. The groups did not differ in age, gender, body mass index, age adjusted Charlson comorbidity index, receipt of chemotherapy or radiation, blood loss, operative time, diversion type or postoperative pathological findings. The stricture rate per ureter was 8.5% (25 of 293) and 12.7% (27 of 213) in the interrupted and running groups, respectively (p = 0.14). Univariate analysis suggested that postoperative urinary tract infection (HR 2.1, 95% CI 1.1-4.1, p = 0.04) and Clavien grade 3 or greater complications (HR 2.6, 95% CI 1.4-4.9, p <0.01) were associated with ureterointestinal anastomotic stricture. On multivariate analysis postoperative urinary tract infection (HR 2.4, 95% CI 1.2-5.1, p = 0.02) and running technique (HR 1.9, 95% CI 1.0-3.7, p = 0.05) were associated with ureterointestinal anastomotic stricture. Median time to stricture and followup was 289 (IQR 120-352) and 351 days (IQR 132-719) in the running cohort vs 213 (IQR 123-417) and 497 days (IQR 174-1,289) in the interrupted cohort, respectively. Of the 52 strictures 33 (63%) developed within 1 year. Kaplan-Meier analysis controlling for differential followup showed a trend toward higher freedom from stricture for the interrupted ureterointestinal anastomosis (p = 0.06). A running anastomosis and postoperative urinary tract infection may be associated with ureterointestinal anastomotic stricture. Larger series with multiple surgeons are needed to confirm these findings.

Is the incidence of uretero‐intestinal anastomotic stricture increased in patients undergoing radical cystectomy with previous pelvic radiation?

Therapy (case series). 4. To present our long-term experience comparing uretero-intestinal anastomotic (UIA) stricture rates after radical cystectomy (RC) in patients with and without previous pelvic radiotherapy (pRT), as the risk of stricture is thought to be higher in patients undergoing RC and urinary diversion (UD) with a history of pRT. We retrospectively analysed patients who had RC and UD between 1992 and 2008 by one surgical team. Patients were divided into two groups, those with (group 1) and with no (group 2) previous pRT. Relevant clinical and pathological data were entered into a database. Patients who were symptomatic and required intervention for a UIA stricture were analysed; patients with malignant strictures were excluded. In all, 526 patients had RC by one surgical team during the study period; 65 had pRT before RC, 37 for prostate cancer, 23 for bladder cancer and the rest for other pelvic malignancies. All the patients in group 1 had an ileal conduit (IC) diversion. There were 250 IC and 211 neobladder diversions in group 2. There were 130 (12%) UIAs in group 1, vs 922 (88%) in group 2. There was no statistically significant difference between the groups in demographic profile and follow-up. The overall stricture rate for UIA was 1.3%; there were two (1.5%) UIA strictures in group 1 vs 12 (1.3%) in group 2. The mean (median, range) time to onset of the stricture was 10 (6, 2-39) months. There was no statistically significant difference in stricture rate between the groups (P > 0.05). In patients undergoing RC with UD there was no significant difference in UIA stricture rates between those with and without previous pRT.

UP-1.034: The Application of Flexible Ureteroscope in the Treatment of Ureterointestinal Anastomotic Stricture of Studer Neobladder

To investigate the feasibility and the efficacy of endoscopic management of ureterointestinal anastomotic stricture of the STUDER neobladder by the flexible ureteroscope.

Endoscopic treatment of benign ureterointestinal anastomotic strictures in patients with urinary diversion

Objective To evaluate the clinical efficacy of endourologic treatment of benign uret-erointestinal anastomotic strictures in patients with urinary diversion. Methods Nine cases of benign ureterointestinal anastomotic strictures with a length of 1-3 cm following radical cystectomy and uri-nary diversion accepted endourologic treatment. 8 cases were treated by antegrade percutaneous ap-proach, 1 case by retrograde ureteroscopic approach. The strictures received balloon dilation, and ure-teral stents indewelled. Results In a follow up of 0.5-5.0 years, 1 case received percutaneous ne-phrostomy for complete ureterointestinal anastomotic atresia and refused to open operation reconstruc-tion. 5 cases had no recurrence after 2-3 endoscopic sessions. 3 cases needed long time ureteral stents indwelled. Conclusion Endourological technique for ureterointestinal strictures following urinary di-version avoided the disadvantages of open operation. Key words: Urinary diversion; Stomas strictures; Endoscopic; Surgical procedures

IS ENDOSCOPIC BALLOON DILATATION OF URETERAL STRICTURES AN ALTERNATIVE TO OPEN SURGERY?

dilatation while opponents prefer surgical solutions due to better long term success rates. Therefore we evaluated the effect of balloon dilatation in the treatment of ureteral stenoses. METHODS: Between 2000 and 2007 a consecutive series of 40 patients with ureteral stenoses of benign and malignant etiology underwent endoscopic dilatation. We report on the median term outcome. RESULTS: 38 patients presented with 40 ureteric stenoses: iatrogenic strictures in 15 cases, 14 due to colorectal or uro-gynecological tumors and 11 because of ureterointestinal anastomotic strictures after urinary diversion. Two patients were not evaluable. A median of 4 dilatations was performed in monthly intervals. Success was reviewed by intravenous pyelogram, renal scan and ultrasound. Treatment was initially successful in 24 cases (60%). Of these 18 patients (75%) had no signs of ureteral obstruction after a median follow up of 16,6 months (range: 4,8-83). The remaining patients underwent additional open surgery or permanent ureteral stenting. Of these, nephrectomy was necessary in 3 cases due to preexisting renal deterioration. The worst outcome was noted in malign strictures. CONCLUSIONS: Endoscopic ureteral balloon dilatation may be an alternative to open surgery in patients with ureteral strictures, especially in older and morbid patients unable to undergo invasive surgery. Nevertheless long term success rates are disappointing particularly in malign stenoses. If possible open surgery should be preferred.

Treatment of Ureterointestinal Anastomotic Strictures by Diathermal or Cryoplastic Dilatation

Ureterointestinal anastomotic strictures (UAS) complicate 10-15% of surgeries for urinary diversion and are the main cause of deterioration in renal function. Treatments are surgical revision, management with autostatic stent, balloon dilatation, endoscopic incision, and percutaneous transrenal diathermy (Acucise). A new option is cryoplastic dilatation (Polar-Cath). To assess the feasibility, complications, and preliminary results of UAS treatment using the Acucise and Polar-Cath systems. Nineteen UAS, diagnosed by ultrasonography or computed tomography and sequential renal scintigraphy, occurred in 15 cancer patients after radical cystectomy and urinary diversion. Fifteen were managed with balloon diathermy and 4 by balloon cryoplasty in a three-stage procedure--percutaneous nephrostomy, diathermal or cryoplastic dilatation, and transnephrostomic control with nephrostomy removal--each separated by 15 days. All patients gave written informed consent. Dilatations were successful in all cases. The procedure is simple and rapid (about 45 min) under fluoroscopic control and sedation. Procedural complications occurred in 1 (5%) patient with UAS after Wallace II uretero-ileocutaneostomy: a common iliac artery lesion was induced by diathermal dilatation, evident subsequently, and required surgical repair. Patency with balloon diathermy was good, with two restenoses developing over 12 months (range 1-22) of follow-up. With balloon cryoplastic dilatation, one restenosis developed in the short term; follow-up is too brief to assess the long-term efficacy. Our short-term results with diathermal and cryoplastic dilatation to resolve UAS are good. If supported by longer follow-up, the techniques may be considered as first-choice approaches to UAS. Surgery should be reserved for cases in which this minimally invasive technique fails.

Clinical outcome of orthotopic neobladder replacement in patients with a solitary functioning kidney

To evaluate the outcome of orthotopic neobladder creation in patients with a solitary functioning renal unit at the time of surgery. This study included a total of 18 patients (15 men and three women) with a solitary functioning kidney who underwent radical cystectomy for invasive bladder cancer followed by orthotopic neobladder replacement. Of these, an ileal, ileocolic or sigmoid colon neobladder was constructed in 11, three or four patients, respectively. Clinical data from these patients were retrospectively reviewed to clarify the significance of neobladder creation in patients with a solitary functioning kidney. During the observation period of this series (mean, 44.2 months; range, 15-95 months), there were nine early complications in six patients (wound infection, ileus, urine leakage and pulmonary embolism in four, three, one and one, respectively) and 10 late complications in nine patients (severe metabolic acidosis, vesicourethral anastomotic stricture, ureterointestinal anastomotic stricture and neobladder calculi in six, two, one and one, respectively). Severe metabolic acidosis occurred in six (five ileal neobladders and one ileocolic neobladder); however, there were no significant differences in preoperative renal function and serum electrolytes as well as postoperative voiding function between patients with and without severe metabolic acidosis. These six patients required administration of sodium bicarbonate, and their metabolic status was normalized thereafter. Furthermore, there were no significant differences in renal function and serum electrolytes between these two groups throughout the observation period, and none of the patients demonstrated renal deterioration. These findings suggest, despite the analysis including a small number of patients with a short follow-up period, orthotopic neobladder replacement could provide comparatively satisfactory results in patients with a solitary functioning kidney; hence, a solitary kidney should not be regarded as a contraindicated factor for neobladder creation after radical cystectomy.

ENDOURETEROTOMY BY INTRALUMINAL INVAGINATION FOR NONMALIGNANT URETEROINTESTINAL ANASTOMOTIC STRICTURES: DESCRIPTION OF A NEW SURGICAL TECHNIQUE AND LONG-TERM FOLLOWUP

We describe a new surgical endoscopic technique for nonmalignant ureterointestinal anastomotic strictures. This procedure involving endoureterotomy by intraluminal invagination (the Lovaco technique) is performed by adopting a combined percutaneous antegrade and endoscopic retrograde approach. The results obtained by this technique are reviewed with long-term followup. A total of 25 ureterointestinal anastomotic strictures were subjected to endoureterotomy by intraluminal invagination, including 12 left, 7 right and 3 bilateral cases. Surgical success was defined by radiological improvement and/or the ability to recover normal activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes. At a median followup of 51 months (range 2 to 145) the success rate for endoureterotomy by intraluminal invagination was 80% (20 of 25 ureterointestinal anastomotic strictures). No complications were recorded in the patients following endoureterotomy. This new endoureterotomy technique for ureterointestinal strictures following urinary diversion can be applied to any type of urinary diversion. It allows direct visualization of the stricture and stricture tissue biopsy. Intraluminal invagination makes it possible to increase the distance between the stricture, and the retroperitoneal vessels and bowels. The technique provides the control required to ensure full-thickness and full-length stricture incision. The success rate is high and it persists after long-term followup.

Endoscopic Management of Ureterointestinal Strictures after Radical Cystectomy

To summarize the status of endoscopic treatment for ureterointestinal anastomotic strictures after radical cystectomy. We reviewed the English-language literature identified by PubMed and MEDLINE to evaluate the efficacy of various treatment options for these strictures. Cumulative success rates from multiple studies analyzing patency after balloon dilation, endoureterotomy, and metal stenting specifically for ureteroenteric strictures were 18%, 63%, and 83%, respectively. Studies have not clearly shown any significant advantage over any specific cutting modality. The use of metal stents appears promising but is still fraught with complications of tissue ingrowth and recurrent obstruction. Clinical factors that appear to be associated with a poor prognosis are age >60 years, left-sided strictures, length >1 cm, stenting <4 weeks, and poor function in the affecting kidney. Ureteroenteric strictures remain the most challenging and difficult of all ureteral strictures to treat. An evolution of technology has helped advance the therapeutic options available. Given the rarity of this condition, limited study designs, and small numbers of patients, conclusive statements regarding the optimal treatment for this condition are difficult. Given its patency rates and possible complications, endoureterotomy should be considered the initial treatment of choice in properly selected patients.

662: Uretero-Intestinal Anastomotic Strictures in Patients with Ileal Neobladder After Radical Cystectomy

662: Uretero-Intestinal Anastomotic Strictures in Patients with Ileal Neobladder After Radical Cystectomy

700 Uretero-intestinal anastomotic strictures in patients with ileal neobladder after radical cystectomy

700 Uretero-intestinal anastomotic strictures in patients with ileal neobladder after radical cystectomy

Holmium: Yag Laser Endoureterotomy For Ureterointestinal Strictures

The management of ureterointestinal stricture in patients who have undergone urinary diversion can be challenging. Endourological techniques have been increasingly used in recent years for ureteral stricture. While long-term results may not be as reliable or durable as those of traditional open reconstructive surgical techniques, associated morbidity is much less. The holmium (Ho):YAG laser, which has cutting and coagulating properties, has been demonstrated to have many applications in urology. We report our experience with and long-term results of Ho:YAG laser endoureterotomy for ureterointestinal strictures. We reviewed the charts and followup history of 23 patients in whom the Ho:YAG laser was used to treat ureterointestinal anastomotic stricture. Strictures were treated percutaneously via the antegrade approach with flexible endoscopes and the holmium laser. A reversed 12/6Fr endopyelotomy stent was left indwelling for 6 weeks postoperatively. Success was defined as symptomatic improvement and radiographic resolution of obstruction. Between 1993 and 2000, 23 patients with a mean age of 61 years underwent endo-ureterotomy using the Ho:YAG laser for 24 ureterointestinal stricture. An overall success rate of 71% (17 of 24 cases) was achieved at a mean followup of 22 months. The success rate of holmium laser endoureterotomy for ureterointestinal stricture at 1, 2 and 3 years was 85%, 72% and 56%, respectively. Seven patients had recurrent strictures of which 4 developed 16 months or more postoperatively. No complications were noted. Ho:YAG laser endoureterotomy for ureterointestinal stricture disease is a minimally invasive endourological procedure that may provide more durable results than other modalities used for endoureterotomy. The Ho:YAG laser with its ability to cut tissue precisely and provide hemostasis combined with its versatility and compatibility with flexible endoscopes is an ideal instrument for safely performing endoureterotomy.