A modified ileo conduit tecnique to avoid ureteroenteric stricture
Despite the popularity of continent urinary diversion and neobladder recostruction, radical cistectomy with ileal conduit urinary diversion remains the most commonly performed curative surgical treatment option for invasive bladder cancer. Commonly, the ileal conduit is created using a 15-20 cm ileum length. The distal left ureter passage under mesosigmoid previous its extensive dissection, in order to allow a tension-free ureteroileal anastomosis, often leads to a compromised blood supply to the left ureter, resulting in a higher incidence of delayed ischemic damage of the distal ureter, wich is the most common cause of ureteroenteric stricture. In literature, ileoureteral stricture rate reported is 1,7-14%, being more common on the left side. Of some interest is the fact that no significant diferrence is been reported in strictures occurrance rate between Bricker anastomosis type and Wallace type. The strictures resulting from urinary diversion are difficult to treat, have a high risk of recurrence and may lead to renal function deterioration. We presented our results with a modified ileal conduit tecnique (MICT) and left ileoureteral anastomosis aimed to prevent uretero-ileal anastomosis stricture.
Materials and Methods
We prepared an ileal tract of 20 cm medium lenght. The proximal end of the ileal conduit tract was brought on the left side through the mesosigmoid and was fixed to the parietal peritoneum, to avoid an extensive dissection and mobilization of the left ureter and to perform a tension free anastomosis. On the right side, we performed a classical Bricker ureteroileal anastomosis, while on the left side the ureter was sutured directly to the end of ileal conduit, according to our modified ureteroileal anastomosis in Y shape ileal neobladder. Between 2001 and 2010, 98 consecutive patients underwent to radical cistectomy with ileal conduit diversion with Bricker anastomotic tecnique; from 2011 to 2015, 46 consecutine patients underwent to new tecnique.
The MICT was easily performed in all cases, leading to neither intraoperative nor postoperative complications, without increasing intraoperative time. The ileoureteral stricture rate was 9.1% (8/98 patients, 1/8 patients with bilateral stricture) in the traditional tecnique; no patient had ureteral stricture with the modified tecnique.
There are several potential etiologies for ureteroileal stricture formation. Ischemia of the distal ureter due to prior radiation therapy, during surgical dissection. Tension caused by tunneling the left ureter below the sigmoid mesocolon has also been implicated as left sided strictures have been observed more comonly. The latter etiology may be of additional relevance in an increasingly obese population. No significant diferrence is been reported in strictures occurrance rate between Bricker anastomosis type and Wallace type.
Our preliminary experience with the MICT are very encouraging; further randomized studies with a larger series are needed to confirm our results.
– A.Evangelidis, E. K. Lee, M. E. Karellas, J. B. Thrasher and J. M. Holzbeierlein. Evaluation of Ureterointestinal Anastomosis: Wallace vs Bricker. J Urol Vol. 175, 1755-1758, May 2006
– N. F. Davis, MD; J P. Burke, MD; T McDermott, MD; R. Flynn, MD; R. P. Manecksha, MD; J. A. Thornhill, MD. Bricker versus Wallace anastomosis: A meta-analysis of ureteroenteric stricture rates after ileal conduit urinary diversion. CUAJ, Volume 9, Issues 5-6, May-June 2015
– M. Cheng MD, S. W. Looney MD, J. A. Brown MD. Ureteroileal anastomotic strictures after a Bricker ileal conduit 50 case assestment of the impact of conversion from a slit incision to a “shield shaped” ileotomy. The Canadian Journal of Urology; 18 (2); April 2011