Double-J ureteral stents: an alternative to external urinary stents in orthotopic bladder substitution.

OBJECTIVE: The aim of this study was to compare advantages and disadvantages of using double-J or external stents to preserve the uretero-ileal anastomosis in patients receiving an orthotopic neobladder. METHODS: 77 consecutive patients with bladder cancer who underwent radical cystoprostatectomy and Studer neobladder were evaluated. All patients received a direct spatulated end-to-side uretero-ileal anastomosis in the afferent loop (Nesbit technique). In 45 patients (group A), the stents (Bracci ureteral splint) were brought our through the reservoir and anchored to the skin; in 32 patients (group B), an internal double-J stent was used. Median follow-up was 30 months. RESULTS: 9 (11.5%) uretero-ileal anastomosis strictures in group A and 7 (11.6%) in group B were observed. There was a significant difference in the side of stricture with a greater prevalence on the left side (p<0.004). Stricture formation and side were not related to the type of stent used. 14 (20%) neobladder-ureteral refluxes occurred, with a non-significant difference between the two groups (p = 0.37). 12 patients (86%) were asymptomatic; two patients developed pyelonephritis and needed antibiotic treatment. Neobladder catheter was removed after 17 days (range: 15-18 days) and 14 days (range: 12-15 days), respectively, in group A and group B with an earlier discharge of the patients in group B. There was a significant difference in mean hospital stay between the two groups (Mann-Whitney test p<0.0001). Discomfort related to the stent was mild for most of the patients of group B (84%). CONCLUSIONS: Internal stenting is an equally effective alternative to external stent in patients undergoing bladder replacement. The use of double-j stents appears to be associated with minimal discomfort, earlier mobilization and a shorter hospital stay.     

Improvement of ureteroileal anastomosis in orthotopic ileal neobladder with modified le duc procedure: short submucosal tunnel technique

PURPOSE: A modified Le Duc procedure with a short submucosal tunnel was applied for ureteroileal implantation in ileal orthotopic neobladder and bladder augmentation with the ileum. We assessed the rate of stenosis and ureteral reflux at the ureteroileal anastomosis after this procedure. MATERIALS AND METHODS: Two women and 22 men underwent radical cystectomy and creation of a Hautmann ileal neobladder for invasive bladder cancer. Another woman underwent ileal bladder augmentation with bilateral ureteral reimplantation into the ileal segment. Ureteroileal anastomosis was performed using the modified Le Duc technique in 48 renoureteral units. Followup in all patients included retrograde cystography done before discharge home and excretory urography, renal ultrasonography or abdominal computerized tomography every 4 to 6 months. Followup was 11 to 39 months in 23 of the 25 cases. RESULTS: Retrograde cystography before discharge home revealed no urinary reflux in any reimplanted ureter. There was no ureteral stenosis or reflux in 20 male and 3 female patients (44 renoureteral units) who voided successfully without catheterization. A unilateral ureteral stricture at the ureteroileal anastomotic site in 1 man who voided successfully was treated with endoscopic surgery. Bilateral slight upper urinary tract dilatation caused by ureteral reflux was present in another man who did not void successfully. CONCLUSIONS: The modified Le Duc technique is simple and safe for forming an ureteroileal anastomosis in ileal orthotopic neobladder creation. It appears to have a low ureteral stenosis and reflux complication rate in patients who successfully void postoperatively.     

Fluoroscopy guided retrograde ureteral stent insertion in patients with a ureteroileal urinary conduit: method and results

PURPOSE: We evaluated retrograde double pigtail stent placement in patients with ureteroileal anastomosis. MATERIALS AND METHODS: Procedures were performed under digital C-arm fluoroscopic guidance and the patient under sedation analgesia. Radiography of the conduit was done to delineate urinary diversion anatomy and identify ureteral reflux. A purpose designed, angled tip catheter was used to direct a straight glide wire across the ureteroileal anastomosis. The glide wire was exchanged for a stiff guide wire for stent placement. We retrospectively evaluated the clinical records of 7 men and 5 women with a mean age of 54.3 years in a 7-year period. In 11 patients a new stent was placed because of ureteroileal stricture in 5, anastomotic leakage in 3, ureterolithiasis in 2 and recurrent malignancy in 1. RESULTS: New stent placement was successful in 10 of the 11 patients (90.9%, 13 of 16 ureters or 81.3%). Stent placement was successful in the 8 ureters in which reflux was noted on radiography of the conduit and in 5 of the 9 (55.6%) in which no reflux was noted. Stent replacement was accomplished in all 22 ureters (6 patients) in which it was attempted. Mean radiological screening time for new stent placement was 13.3 minutes (range 4.7 to 19.7), while for exchange it was 6.4 minutes (range 0.8 to 15.1). There were no immediate complications. CONCLUSIONS: This technique represents a useful approach to the ureter and should be considered an alternative to percutaneous nephrostomy and surgical revision. The approach is also useful for other ureteral procedures, including stone or migrated stent retrieval.     

膀胱全切原位回肠新膀胱术后输尿管肠吻合口良性狭窄的处理

目的：探讨膀胱全切原位回肠新膀胱术后输尿管肠吻合口良性狭窄的处理方法。方法：我科自2003年1月～2012年6月采用膀胱全切原位回肠新膀胱术治疗395例膀胱癌患者。术后发生输尿管肠吻合口良性狭窄10例,采用输尿管镜扩张、内镜下逆行／经皮穿刺顺行球囊扩张、内镜下狭窄段内切开、开放输尿管膀胱再植术,并留置双J管3～6个月。结果：本组10例中,1例（1处）因导丝不能通过狭窄段而改行开放手术,术后随访36个月,肾积水明显改善。其余9例（11处）采用腔内技术处理,其中3例（4处）采用输尿管镜扩张,2例（3处）采用内镜下狭窄段内切开,4例（4处）采用内镜下逆行／经皮穿刺顺行球囊扩张。术后随访9～72个月（中位25个月）。5例（7处）肾积水明显改善,2例（2处）肾积水长期随访无加重,2例（2处,狭窄段长分别为1．2cm、1．5cm）再发狭窄,遂采用开放手术,分别随访16及24个月,肾积水改善。结论：腔内技术操作简单,创伤小,可作为输尿管肠吻合口良性狭窄的首选治疗方案。开放手术仍然是治疗输尿管肠吻合口狭窄的金标准。对于狭窄段〉1cm的患者,应首先考虑开放手术。     

Case report: Laparoscopy-assisted urinary undiversion: transforming an ileal conduit into an orthotopic continent neobladder

PURPOSE: To describe the technique of laparoscopy-assisted undiversion of an ileal conduit into a continent orthotopic ileal neobladder performed on a patient with a previous radical cystoprostatectomy and ileal conduit. CASE REPORT: A 57-year-old man presented with a prolapsed stoma and a history of a right radical nephroureterectomy for grade 3 ureteral transitional-cell carcinoma and a radical cystoprostatectomy and ileal conduit urinary diversion for in-situ bladder carcinoma, performed 12 and 8 years ago, respectively. After the ileal stoma was resected, five trocars were placed transperitoneally. Partial resection of the distal ileal conduit was performed, leaving in place the proximal segment with its left ureteroileal anastomosis. Flexible urethroscopy revealed a contracting external sphincter, and random urethral frozen-section biopsies ruled out tumor. A 45-cm segment of ileum was isolated and exteriorized through the stoma site, and an ileal neobladder was created extracorporeally, suturing the proximal ileal-conduit segment, with its ureteroileal anastomosis, to it. The ileal neobladder was reintroduced into the abdomen and anastomosed laparoscopically to the urethral stump with six 2-0 polyglactin sutures. The total operative time was 7 hours with a blood loss of 100 mL. There were no intraoperative complications. The hospital stay was 7 days. At a follow-up of 24 months, the patient had total daytime continence and normal renal function, and intravenous urography revealed an unobstructed urinary tract. CONCLUSION: Laparoscopy-assisted ileal-conduit undiversion into an orthotopic ileal neobladder is technically feasible. It can be considered an alternative to open surgery for patients who have undergone urinary diversion.     

Hammock nonrefluxing ureteroileal anastomosis]

Hammock nonrefluxing ureteroileal anastomosis was performed on 14 patients who had urinary tract reconstruction using ileal conduit (4), Kock pouch (3), modified Kock pouch with plicated efferent limb (1) and ileal neobladder (6). Radiographic examinations showed ureteral reflux of contrast medium in one patient (7.1%), ureteral stenosis in one patient (7.1%) and no urine leakage. Three patients had pyelonephritis (21.4%) and no one had any upper tract urolithiasis. This technique provides a simple and reliable antireflux mechanism into ileal segments without nonabsorbable material.     

A “bridge” technique to replace the obstructed single-J stent in the patient with ileal conduit urinary diversion: a case report

The ureteroileal anastomotic stricture is a complication of ileal conduit urinary diversion. To prevent the hydronephrosis and protect the renal function, a single-J ureteral stent may be needed. However, the most common complication of these patients is single-J stent obstruction. To solve this problem, we describe an easy, useful and low-cost technique to replace the obstructed ureteral stent under radiographic guidance without intervention by flexible cystoscopy or percutaneous nephrostomy. The key steps of our procedure are to identify the location of the stricture, to place the super smooth guide wire into pinhole of the obstructed single-J stent and to get the super smooth guide wire and 5-Fr ureteral catheter across the stricture. Our case was a 40-year-old male patient who was diagnosed as pelvic lipomatosis and received ileal conduit urinary diversion 3 years ago. The left-side ureteroileal anastomotic stricture occurred 1 year after surgery. He refused to repair the stricture by open or other minimal invasive surgery. He regularly changed his ureteral stent with intervals of three months. As the stent was obstructed by the stone, the guide wire couldn’t be inserted through the primary ureteral stent. We used our “bridge” technique to solve his problem successfully. No bleeding and no urinary tract infection were observed after intervention. The urine from the ureteral stent was fluent. We think that this “bridge” technique may be a good choice for the replacement of the obstructed single-J stent in the patients of ileal conduit urinary diversion.     

双J管在输尿管镜气压弹道碎石术中的临床应用

目的探讨双J管在输尿管镜气压弹道碎石术治疗泌尿系结石中的临床疗效。方法自1999年11月至2003年11月,采用输尿管镜下气压弹道碎石术治疗输尿管结石546例,术后16例未留置任何支架管引流,其他患者留置双J管或输尿管导管。结果留置双J管的451例患者术后无一例出现并发症,留置输尿管导管并发症发生率为22．7％（18／79）,未留置任何导管并发症发生率为56．2％（9／16）,主要是肾绞痛及急性肾盂肾炎、血尿。结论输尿管镜术后常规留置双J管可明显减少术后并发症的发生。     

Application of self-expandable metal stents for ureteroileal anastomotic strictures: long-term results

PURPOSE: We report our long-term experience with the management of benign ureteroileal anastomotic strictures using self-expandable metal stents. MATERIALS AND METHODS: A total of 16 male and 2 female patients with a mean+/-SD age of 72+/-7 years (range 66 to 78) with benign fibrotic strictures at the site of ureteroileal anastomosis underwent implantation of self-expandable metal stents with a nominal diameter of 6 to 8 mm. A total of 24 ureteroileal conduits were treated. The external nephrostomy tubes were removed after fluoroscopic validation of ureteral patency. Patients were followed with blood biochemistry, ultrasonography, urography and/or virtual endoscopy. Retrograde external-internal catheter insertion through the cutaneous stoma was performed in cases of recalcitrant stricture. RESULTS: The technical success rate of ureteroileal stricture crossing and stenting was 100% (24 of 24 cases). Mean followup was 21 months (range 7 to 50). The clinical success rate during the immediate post-stenting period was 70.8% (17 of 24 cases). The 1 and 4-year primary patency rates were 37.8% and 22.7%, respectively. Secondary interventions included repeat balloon dilation in 15 ureters, of which 8 also underwent subsequent coaxial stent placement. The 1 and 4-year secondary patency rates were 64.8% and 56.7%, respectively. Except in 2 patients who died external-internal Double-J catheters continued to be inserted retrograde in 6 ureteroileal conduits. They are periodically exchanged to prevent mucous inspissation and stent encrustation. CONCLUSIONS: Metal stents served as the definitive treatment for stricture in more than half of the cases, whereas in the remainder the stents allowed the uncomplicated and regular exchange of Double-J catheters in retrograde fashion. This combined, less invasive treatment for ureteroileal anastomotic strictures may help patients avoid surgical revision and preserve quality of life.     

腹腔镜下全膀胱切除原位回肠新膀胱重建术(附5例报告)

目的:介绍腹腔镜下全膀胱切除原位回肠新膀胱重建术的经验。方法:采用腹腔镜下全膀胱切除原位回肠新膀胱重建术治疗浸润性膀胱癌患者5例。方法是经腹壁小切口取出切除物,行回肠去管成形新膀胱,然后在腹腔镜下将新膀胱与尿道连续吻合。结果:5例患者手术成功,手术时间4.5~7.2h。腹腔镜手术中以超声刀及双极电凝行膀胱侧韧带、前列腺血管蒂及前列腺尖部切断止血,未使用钛夹、术中出血量180~550ml,平均输血400ml。术后4~5天恢复饮食,3周拔除输尿管支架管,4周拔除尿管。患者白天可完全控制排尿,2例夜间偶有尿失禁。1例术后尿漏,经引流治愈。结论:腹腔镜下全膀胱切除术具有创伤小、出血少、恢复快等优点;而回肠新膀胱和尿道连续吻合具有操作方便、省时、缝合紧密、可防止尿漏等优点。     

A deserosalized muscle layer covering method for antireflux ureteroileostomy: a preliminary clinical trial

PURPOSE: To achieve complete protection of the upper urinary tract in patients with a neobladder we designed and clinically applied the deserosalized muscle layer covering method, a new antireflux ureteroileal reimplantation technique in which the terminal ureter is implanted in the muscle layer of the ileum. We present the operative procedure and preliminary results. MATERIALS AND METHODS: We created an orthotopic ileal neobladder after radical cystectomy in 5 patients with invasive bladder cancer. The ureters were reimplanted into the reservoir using the deserosalized muscle layer covering method. The functional outcome of this procedure was evaluated by radiological studies. RESULTS: No patients died during the perioperative period and no reimplanted ureters showed ureteral reflux or ureteral stricture during the observation period. Video cystometrograms demonstrated the complete prevention of reflux during the voiding and storage phases. CONCLUSIONS: The deserosalized muscle layer covering method provided a nonobstructed unidirectional flow of urine in all renal units examined in this study. The efficacy of this method was proved during short-term followup.     

New serosal lined antireflux ureteroileal implantation technique on a gia stapler detubularised ileal neobladder: technical considerations and results

OBJECTIVES: To evaluate the adaptability and the possible advantages of the antireflux mechanism of the serous lined extramural tunnel for ureter re-implantation on a gastrointestinal anastomosis (GIA) Stapler detubularised ileal neobladder METHODS: From April 1998 to July 2002 43 male patients underwent radical cystectomy and the creation of a Camey II ileal neobladder using this antireflux technique. Follow-up in all cases included excretory urography or T.C. scan and a retrograde cystography at 6 months and a renal scintigraphy with DMSA at 1 year follow-up, besides serum creatinine, blood urea and serum electrolytes every three months and renal-neovesical ultrasound every six months. RESULTS: Early and late complications were low. At follow-up 1 case of neovesico-ureteral reflux and 2 cases of ureteroileal anastomotic strictures were found. DMSA scintigraphy showed no further renal scars. CONCLUSIONS: This preliminary experience was favourable due to overall reduced operating time (about 1 hour 45 minutes to create the orthotopic neobladder and the ureteroileal anastomosis), simplicity of execution and a low complication rate (6.9%) at a median follow-up of 38 months (range 12-52 months).     

Le Duc-Camey antireflux ureteroileal reimplantation for continent ileal reservoir]

Le Duc-Camey antireflux ureteroileal reimplantation was used on 15 patients with 30 ureters reimplanted into the ileum as part of a bladder substitution procedure (Kock pouch or ileal neobladder: U-bladder) or augmentation cystoplasty (Goodwin ileocystoplasty). In our experience, no reflux was observed, while hydronephrosis was identified in one ureter of ileal neobladder (4%). Le Duc-Camey antireflux ureteroileal reimplantation is suitable for reconstruction with the ileal reservoir.     

Results of chimney modification technique in ureterointestinal anastomosis of Hautmann ileal neobladder in bladder cancer

BACKGROUND: To evaluate the surgical technique and functional outcome of a new application of the chimney modification to the popular Hautmann ileal neobladder. This modification used 3-5 cm chimney tubularized ileal segment for the bilateral ureterointestinal anastomosis. METHODS: Between December 2000 and July 2004, 15 patients (14 men, 1 woman) with invasive bladder cancer underwent radical cystectomy and Hautmann neobladder with chimney modification at Siriraj Hospital, Bangkok. Mean age was 61.7 years (range, 43-72 years). Perioperative morbidity, early and late urinary diversion-related complications, other surgical complications, follow-up results of ureterointestinal anastomosis, renal function and metabolic disorders were evaluated. Patients were interviewed about their continence, voiding function and potency. RESULTS: At a mean follow-up of 29.5 months, two patients had died of cancer progression. Of the 15 patients, nine (60%) had 10 early complications. Eight complications were related to the neobladder and two were not. Three (20%) patients had three late complications. Two complications were neobladder-related and one was not. There was no perioperative mortality. There was no ureteroileal anastomosis stricture in this series. Neobladder-ureteral reflux was demonstrated in eight of 22 ureteral units in 11 patients in whom cystography was performed. All patients had normal upper urinary tract without evidence of urinary obstruction. All 14 men (93% of study sample) had spontaneous urination, normal renal function and no metabolic acidosis. Good and satisfactory continence in the day and night were 93% and 73%, respectively. All male patients experienced impotence postoperatively. Only one sought treatment and was successfully treated with sildenafil. The one woman in this study required intermittent catheterization to empty the neobladder completely. She also had renal insufficiency with serum creatinine of 2.2 mg/dL and hyperchloraemic metabolic acidosis. CONCLUSION: New chimney modification in Hautmann ileal neobladder is simple and safe. Complications are acceptable. Follow-up results of renal and voiding functions are satisfactory. This operation can maintain good quality of life for patients with bladder cancer undergoing radical cystectomy.     

经输尿管镜碎石术后留置支架管与否的探讨

目的 探讨不复杂性输尿管结石经输尿管镜碎石术后是否需要常规留置支架管。方法 回顾性分析2002年3月-2005年3月我院450例不复杂性输尿管结石行输尿管镜钬激光碎石术患者的资料。患者被分为三组：A组196例（放置双J管），B组185例（放置临时输尿管导管），C组69例（不放置支架管）。手术时间、术后无石率和并发症作为评价的指标。结果 三组患者手术时间比较，A、B两组显著长于C组；术后患者血尿的发生率和持续时间，A、B两组显著高于C组；术后患者肋腹区疼痛、尿频／尿急、排尿困难、尿路感染和输尿管狭窄的发生率，三组之间无显著差异；术后1个月输尿管无石率三组均为100％。结论 经输尿管镜钬激光治疗不复杂性输尿管结石术后放置支架管与否应视术中情况。所有病例均常规留置支架管是不必要的。     

The applicability of using straight ureteral stents for the treatment of ureteral stones in presumably non-compliant patients

There have been many reports describing the complications of retained ureteral stents following stone treatment. We wanted to evaluate the practicality of definitive treatment of poorly compliant patients who present with ureteral stones using a straight stent connected to a urethral catheter alone and compared these to patients treated with double-J stents alone. We treated 23 patients (12 in group I and 11 patients in group II) who had a ureteral stone of 6 mm or less, with an indwelling straight stent and a double-J stent, respectively, while on oral antibiotics. We followed these patients 1 week later with an abdominal X-ray prior to removing the stent. Eleven patients in group I and 9 patients in group II passed their stones spontaneously. Three patients required surgical intervention with a ureterscope and laser lithotripsy. There were no cases of infection or pyelonephritis. Although each of the straight-stent-treated patients returned to our clinic for follow-up, only 5 of the 11 double-J stent patients returned for follow-up. The remaining 6 patients had to be contacted to remind them that they still had an internal stent. Although technologic advances now allow many urologists to definitively treat ureteral stones, some urologists may lack the proper equipment and/or assistance to treat the stone at the time of presentation, or may deal with non-compliant patients. Therefore, in these certain circumstances, treatment of small ureteral stones in non-compliant patients using a straight stent connected to a leg bag, as either definitive or initial treatment, may be of practical use and avoid the risk of retained double-J ureteral stents.     

The ileal neobladder — updated experience with 306 patients

Summary From April 1986 through May 1995, 306 men with primary urothelial carcinoma underwent radical cystoprostatectomy and orthotopic bladder substitution via the ileal neobladder. Altogether, 7.5% of the patients suffered general early complications, including thrombosis, embolism, wound infection, and pneumonia. Specific early complications directly related to formation of the neobladder and requiring surgery included ileus (4%), abscess drainage (2%), and leakage of the ileal anastomosis (0.5%). The early reoperation rate was 6.5%. Early complications that required temporary percutaneous drainage were lymphocele formation (3%) or ureteral obstruction (6%). In all, 9% of our patients required prolonged catheter drainage for leakage of the ileouretheral anastomosis. Late complications requiring reoperation were ileus (2%), abscess drainage (1%), neobladder fistula to the colon (1,5%), ureteral reimplantation because of obstruction (3.6%), and nephrectomy for hydronephrosis (1%). A transurethral incision of the ileoureteral anastomosis was necessary in 7% of cases. Continence was separately addressed by sending each patient and his home physician a detailed questionnaire: Using our criteria (no diapers, no awakenings) the night and day continence rate increased from 67% at 6 months, to 72% at 1 year, to 85% at 2 years, finally reacting 90% after 4 years. In part II of this presentation we address the question as to whether the option of orthotopic bladder replacement has any impact on the patient's and physician's decision toward earlier cystectomy. We compared our ileal neobladder cohort with a group of 137 patients that had been operated on during the same time span by the same group of surgeons. There was no negative selection with regard of the tumor stage of our patients. However, as compared with the conduit group, the neobladder cohort had a significantly improved survival rate. This phenomenon is explainable by the significantly lower number of previous transurethral resections of the bladder (TUR-Bs) performed in the neobladder group. The time span between primary diagnosis and cystectomy was 10 months in the neobladder group as compared with 18 months in the conduit patients. These data reinforce our belief that orthotopic bladder replacement using the ileal neobladder yields an extraordinary functional result that can be accomplished with a high degree of patient satisfaction and minimal complication. The availability of orthotopic bladder replacement does indeed stimulate the physicians and patients decision toward earlier cystectomy.     

A simple technique to change an obstructed ureteral stent in patients with an ileal conduit

PURPOSE: We describe a simple technique to replace an obstructed ureteral stent in patients with an ileal conduit and ureteral stenosis. MATERIALS AND METHODS: Our study included 4 patients with an ileal conduit and ureteral stenosis. A total of 10 obstructed ureteral stents were replaced with a new stent using this simple technique under radiographic guidance. RESULTS: All obstructed ureteral stents were successfully replaced with a new stent without endoscopy, percutaneous nephrostomy or any special devices. CONCLUSIONS: Our technique is simple, easy and highly successful for changing an obstructed ureteral stent.     

Refluxing chimney versus nonrefluxing LeDuc ureteroileal anastomosis for orthotopic ileal neobladder: a comparative analysis for patients with bladder cancer

PURPOSE: Radical cystectomy and various techniques of urinary diversion are gold standard treatments for invasive bladder cancer. However, postoperative hydronephrosis is a common complication in these patients. A special focus was placed on the type of ureteroileal anastomosis used with 2 different techniques performed at 1 institution. MATERIALS AND METHODS: Between 1995 and 2003 a total of 106 consecutive patients with bladder cancer underwent cystectomy followed by construction of an ileal neobladder. The nonrefluxing technique of ureter tunneling described by LeDuc and the refluxing chimney technique used for ureter implantation into the ileum-neobladder were compared. Hydronephrosis due to ureteral strictures was studied immediately following surgery and up to 5 years after surgery. RESULTS: A total of 204 RU were included in the study. The LeDuc technique was used in 132 RU (64%) and the chimney technique was used in 72 RU (36%). Hydronephrosis rate of 2% were found in each of the 2 groups after 5 years of followup. CONCLUSIONS: Postoperative hydronephrosis due to ureteral strictures is observed at the same rate during long-term followup with the LeDuc and chimney techniques. We favor the chimney technique compared to the LeDuc tunnel due to easier technical preparation and a better chance to identify the ureters endoscopically at a later time. The chimney does give extra length to reach the ureteral stump, especially in cases of distal ureteral carcinoma in situ.