RECONSTRUCTIVE UROLOGY

Open surgical repair of ureteral strictures and fistulas following radical cystectomy and urinary diversion
Msezane L, Reynolds WS, Mhapsekar R, Gerber G, Steinberg G
Chicago, Pritzker School of Medicine, Chicago, Illinois
J Urol. 2008; 179: 1428-31

• Purpose: Open surgery after cystectomy can be a challenge. We report the incidence of postoperative urinary diversion-enteric fistula and ureteral strictures in patients undergoing radical cystectomy, and discuss the diagnosis and management of these complications, including our surgical approach to these patients.
• Materials and Methods: We preformed a retrospective review of 553 patients undergoing radical cystectomy and urinary diversion for bladder cancer between April 1999 and January 2007. Patients in whom a ureteral stricture or fistula developed were identified by serial laboratory and imaging evaluations. A chart review was preformed to identify symptoms, time to stricture or fistula development, radiological findings, type of diversion, estimated blood loss and whether the original anastomosis was stented. Management and outcomes were assessed.
• Results: Of 553 patients reviewed ureteral stricture developed in 41 (7.4%) with a mean followup of 20.2 months (range 1 to 98). Strictures developed in 11% (31 of 272) of the orthotopic ileal neobladder, 2.5% (6 of 236) of ileal conduit and 8% (4 of 45) of Indiana pouch cases. Open repair led to an overall success rate of 87%. Urinary diversion-enteric fistula developed in 12 (2.2%) of the 553 patients with a mean followup of 28.4 months (range 3 to 94), all of whom had undergone orthotopic neobladder diversion. No patient had recurrence after surgical repair of the fistula.
• Conclusions: Open revision remains the gold standard management for ureteral strictures and urinary diversion-enteric fistulas occurring after radical cystectomy. The addition of the chimney modification to the orthotopic neobladder facilitates surgical repair.
  
  
• Editorial Comment
  Distal and anastomosis uretral strictures occurring after a cystectomy, following a myriad of diversion techniques, is not uncommon. Most likely these problems should be performed primarily in the old fashion way, that is open. In the hands of an experienced endoscopic surgeon the endoureterotomy using a laser can reach a 25% success rate in selected cases as Msezane et al. demonstrated in their retrospective analyzed data.
  Sometimes the blood parameters are less sensitive than the follow-up using ultrasound for the upper urinary tract; therefore, we perform both (1). Similar to the presented data we saw the incidence of strictures in ureters in different types of diversion. In addition to those who underwent previous radiation, the placing of an 8F double-J intra-operative might help to reduce the implantation stenoses further (2). Early surgery in our clinic usually involves the re-implantation of both ureters at the same time which we believe helps to avoid further complications. The occurrence of fistulas as reported is a rare case but might be handled with tissue glue if the fistula is small enough before an open surgery is performed (3). The possibilities are more extensive for the majority of cases, however, in the case of urinary diversions, we should be ready to perform open surgery for both cases - strictures and fistulas.

References
1. Nagele U, Kuczyk M, Anastasiadis AG, Sievert KD, Seibold J, Stenzl A: Radical cystectomy and orthotopic bladder replacement in females. Eur Urol. 2006; 50: 249-57.
2. Nagele U, Anastasiadis AG, Merseburger AS, Corvin S, Hennenlotter J, Adam M, et al.: The rationale for radical cystectomy as primary therapy for T4 bladder cancer. World J Urol. 2007; 25: 401-5.
3. Becker HP, Willms A, Schwab R: Small bowel fistulas and the open abdomen. Scand J Surg. 2007; 96: 263-71.

Dr. Karl-Dietrich Sievert &
Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany
E-mail: arnulf.stenzl@med.uni-tuebingen.de