Journal of Urology and Renal Diseases (ISSN: 2575-7903)

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The Dilemma of Ureteroileal Anastomosis Stricture

Usama Nihad Rifat*

Emeritus Professor of Urology, Iraqi Board for Medical Specializations

*Corresponding author: Usama Nihad Rifat, Emeritus Professor of Urology, Iraqi Board for Medical Specializations, POB: 954410, Amman, Jordan

Received Date: 19 September, 2022

Accepted Date: 19 September, 2022

Published Date: 22 September 2022

Citation: Rifat UN (2022) The Dilemma of Ureteroileal Anastomosis Stricture. J Urol Ren Dis 07: 1286. DOI: https://doi.org/10.29011/2575-7903.001286

Editorial

Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. The incidence was studied based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Surgical method in cystectomy does not influence future development of ureteroileal strictures; however, laparoscopic and robot-assisted ureteroileal reimplantation achieved high success rates [1].

Uretero-enteric anastomotic strictures after robot-assisted radical cystectomy represent the main cause of post-operative renal dysfunction. The standard for treatment is open uretero-ileal reimplantation, which is a complex procedure associated with considerable morbidity. It requires multidisciplinary teams including urologists, endourologists, general and vascular surgeons [2].

Other authors found in cases of ureteroileal anastomosis strictures, that robotic reimplantation is a safe and highly effective procedure, with a high success rate and excellent perioperative and functional outcomes. Near-Infrared Fluorescence Imaging (NIFI) provides an easy guide to identify and progressively dissect the ureter [3].

In general, the incidence of ureteric strictures is low in patients undergoing Robot-Assisted Radical Cystectomy (RARC) with totally intracorporeal urinary diversion. Strictures were more common on the left side, which has been described in open series and is probably related to the increased mobilization on the left side required to cross the ureter to the right side [4].

Minimally invasive definitive revision of ureteroileal anastomotic strictures is feasible with a robotic surgical approach. The advantages of robotic instrumentation allows successful repair and avoids major open surgery [5].

A laparoscopic approach for patients with a ureteroileal anastomosis stricture after radical cystectomy was described to avoid the complications associated with open surgery. This was found to be practical and safe with good long-term results [6].

Before that, it was known that ureteroenteric anastomotic strictures are common after cystectomy with urinary diversion postcystectomy ureteral reimplantation and was associated with relatively low rates of major iatrogenic injuries and high-grade complications. Preoperative percutaneous nephrostomy PCN placement rather than percutaneous nephroureterostomy PCNU was suggested to give better results [7].

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. To minimize the incidence of UES after RARC, groups has standardized the procedure and technique for intracorporeal urinary diversion by applying certain strategies and proposing standardized surgical procedures to minimize its incidence after RARC [8]. Surgical experience affects perioperative and oncological outcomes after Robot-Assisted Radical Cystectomy (RARC) with Intracorporeal Urinary Diversion (ICUD) in a linear fashion, and its beneficial effect does not reach a plateau. Conversely, no further improvement was observed for Operative Time (OT). Robot-assisted radical cystectomy with intracorporeal urinary diversion is a complex surgical procedure with a relatively long learning curve [9].

A recent study showed again that robotic reimplantation of ureteroenteric strictures following radical cystectomy is safe and feasible in experienced centers with high success rates. In a nine-year study, the majority of strictures were benign. Overall, 49 (84.5%) ureters underwent primary re-implantation, while 9 (15.5%) required Boari-like advancement flaps prior to re-implantation [10].

Uretero-ileal anastomosis strictures occur in 3 to 11% of patients who undergo ileal conduit urinary diversion after cystectomy. Technically preoperative placement of a ureteral stent is required for guidance and urinary diversion. Port placement should be tailored according to the previous surgical site; in addition to maximal ureteral dissection facilitates , and frozen section from the stricture which is mandatory to rule out malignancy. Repair is feasible and reproducible using a minimally invasive robotic approach [11].

Florence Robotic Intracorporeal Neobladder (FloRIN) reconfiguration technique was introduced in 2016 according to the IDEAL Collaboration Guidelines, with the attempt to conjugate the advantages of both intracorporeal neobladder and robotic assistance. The technique involves many surgical steps including isolation of 50 cm of ileum; bowel anastomosis; urethro-ileal anastomosis creating an asymmetrical 'U'-shape (30 cm distally and 20 cm proximally to anastomosis), ileum detubularisation; posterior wall reconfiguration as an 'L'; bladder neck reconstruction; anterior folding of the posterior plate to reach the 12 o'clock position; and uretero-enteral 'orthotopic' bilateral anastomosis [12].

In conclusion, Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. Robotic correction is safe and feasible in experienced centers with high success rates

Referrences

  1. E Alonso Mediavilla, F Campos-Juanatey, G Azcárraga Aranegui, R Varea Malo, et al. (2021) Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center. Actas Urol Esp 2021.
  2. Mariangela Mancini, Alex Anh Ly Nguyen, Alessandra Taverna, Paolo Beltrami, et al. (2022) Successful Multidisciplinary Repair of Severe Bilateral Uretero-Enteric Stricture with Inflammatory Reaction Extending to the Left Iliac Artery, after Robotic Radical Cystectomy and Intracorporeal Ileal Neobladder. Curr. Oncol 29: 155-162.
  3. Gabriele Tuderti, Aldo Brassetti, Francesco Minisola, Umberto Anceschi (2019) Transnephrostomic Indocyanine Green-Guided Robotic Ureteral Reimplantation for Benign Ureteroileal Strictures after Robotic Cystectomy and Intracorporeal Neobladder: Step-By-Step Surgical Technique, Perioperative and Functional Outcomes . JOURNAL OF ENDOUROLOGY 33: 823-828.
  4. Abolfazl Hosseinia, Linda Deya, Oscar Laurina, Cristofer Addinga, et al. (2018) Ureteric stricture rates and management after robot-assisted radical cystectomy: a single-centre observational study. SCANDINAVIAN JOURNAL OF UROLOGY 52: 244-248.
  5. Pankaj P. Dangle, Ronney Abaza (2012) Robot-Assisted Repair of Ureteroileal Anastomosis Strictures: Initial Cases and Literature Review. JOURNAL OF ENDOUROLOGY 26: 372-376.
  6. Antonio Rosales, Esteban Emiliani, Josep T. Salvador, Juan Antonio Pen˜a, et al. (2016) Laparoscopic Management of Ureteroileal Anastomosis Strictures: Initial Experience. European Association of Urology 2016.
  7. Vignesh T. Packiam, Vijay A. Agrawal, Andrew J. Cohen, Joseph J. Pariser, et al. (2017) Lessons from 151 ureteral reimplantations for postcystectomy ureteroenteric strictures: A single-center experience over a decade. Urologic Oncology: Seminars and Original Investigations 35: 112.e19-112.e25.
  8. Shintaro Narita, Mitsuru Saito, Kazuyuki Numakura, Tomonori Habuchi (2021) Incidence, Etiology, Prevention and Management of Ureteroenteric Strictures after Robot-Assisted Radical Cystectomy: A Review of Published Evidence and Personal Experience. Curr. Oncol 28: 4109-4117.
  9. Paolo Dell’Oglio, Elio Mazzone, Edward Lambert, Jonathan Vollemaere, et al. (2021) The Effect of Surgical Experience on Perioperative and Oncological Outcomes After Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Evidence from a Referral Centre with Extensive Experience in Robotic Surgery . Eur Urol Focus 7: 352- 358.
  10. Saum Ghodoussipour, Nariman Ahmadi, Alvin Goh, Mehrdad Alemozaffar, et al. (2022) Robotic Repair of Ureteroenteric Stricture Following Radical Cystectomy: A Multi-Institutional Experience. UROLOGY 161: 125-130.
  11. Juan Garisto, Riccardo Bertolo, Mohamed Eltemamy, Rebecca Campbell, et al. (2019) Robot-assisted repair for ureteroileal anastomosis stricture after cystectomy: technical points. Int Braz J Urol 45: 1275-1276.
  12. Fabrizio Di Maida, Antonio Andrea Grosso, Giovanni Tasso, Luca Gemma, et al. (2022) Robot assisted radical cystectomy with Florence Robotic Intracorporeal Neobladder (FloRIN): Functional and urodynamic features compared with a contemporary series of open Vescica Ileale Padovana (VIP), European Journal of Surgical Oncology 48: 1854e1861.

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