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.     

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。     

Does the Success of Ureterointestinal Implantation in Orthotopic Bladder Substitution Depend More on Surgeon Level of Experience or Choice of Technique?

Purpose

We attempted to determine the relative risk of ureterointestinal anastomosis using 2 antireflux techniques of orthotopic bladder substitution, and we assessed the degree to which success is determined by surgeon experience.

Materials and Methods

A total of 120 patients underwent surgery, including 74 with the Hautmann (Le Duc) technique and 46 with a somewhat modified Studer (Nesbit/Studer) technique. The urologists who performed the operations were classified as expert, skilled and learner. Evaluation was done retrospectively. All patients in the Studer group, except 3 who died and 1 who was lost to followup, were monitored a minimum of 12 months.

Results

There was a 20.4% rate of nonneoplastic obstructions in the 142 ureters reimplanted with the Le Duc technique (Hautmann group). The variation in obstruction rates of 16.7, 18.2 and 25%, respectively, for expert, skilled and learning surgeons was statistically insignificant. Only 3 nonneoplastic obstructions (3.6%) developed in the 83 ureters reimplanted with the Nesbit/Studer technique (Studer group). The variation in obstruction rates of 5.1, 0 and 3.6%, respectively, for expert, skilled and learner surgeons was statistically insignificant.

Conclusions

The Nesbit/Studer technique results in a generally lower rate of ureterointestinal anastomotic stricture than the Le Duc technique. Using the Le Duc technique there was no statistically significant correlation between incidence of obstruction and surgeon level of experience, indicating that obstruction with this technique probably arises from other factors.     

Evaluation of direct versus non-refluxing technique and functional results in orthotopic Y-ileal neobladder after 12 years of follow up

OBJECTIVES: We report on the long-term functional results of the orthotopic Y-ileal neobladder and compare the outcome of the antireflux technique for ureteral implantation versus direct anastomosis. PATIENTS AND METHODS: Between 1990 and 2002, 120 patients underwent cystoprostatectomy and orthotopic Y-shaped ileal neobladder for invasive bladder carcinoma. The direct Nesbit technique for ureteral reimplantation was applied in 58 patients (group 1) and in 62 patients the ureters were reimplanted using the Le Duc antirefluxing technique (group 2). The mean follow-up period was 72 months (range, 36-144 months). RESULTS: Of 62 patients who underwent the Le Duc technique, six (9.7%) had unilateral uretero-ileal anastomotic stricture and four (6.5%) had reflux. Of 58 patients who underwent direct anastomosis, six (10.3%) patients had unilateral reflux, four of them had dilated ureters preoperatively and no patient had uretero-ileal anastomotic stricture. The incidence of stricture formation in the Le Duc technique is significantly higher than direct anastomosis (P = 0.04). There was no significant difference in the overall incidence of reflux in both groups. However, the incidence of reflux in preoperatively dilated ureters was significantly higher in direct ureteral anastomosis than Le Duc technique (40% in group 1 vs 16.7% in group 2; P = 0.045). The incidence of stone formation, azotemia, pyelonephritis and bacteriuria was comparable in both groups. The urodynamic findings showed a mean increase in the neobladder capacity at 6 and 18 months after surgery by 340 and 560 mL, respectively. The mean of the maximum pressure was 22 +/- 10 cm H2O, 18 months after surgery. Daytime and nighttime continence was good or satisfactory in 93.3% and 85.5% of the patients, respectively, after 3 years of follow-up. CONCLUSIONS: The functional and voiding results of a Y-shaped neobladder pouch using 40 cm of ileum are similar to the more sophisticated larger pouches. Direct uretero-ileal anastomosis in orthotopic bladder replacement is more reasonable than the Le Duc antireflux technique in non-dilated ureters. The benefit of the antireflux technique has been overestimated despite of the frequency of stricture formation.     

肠代膀胱术中输尿管吻合方法的改进

目的：探讨肠代膀胱输尿管吻合的理想方法。方法：对60例肠代膀胱术后118侧作肠代膀胱输尿管吻合的患者进行随访．对不同吻合方法的效果作对比分析。采用黏膜下隧道法吻合6例11侧，黏膜沟法吻合10例19侧，改良黏膜沟法吻合42例84侧．改良乳头种植法吻合2例4侧。结果：吻合一侧所需时间．黏膜下隧道法和黏膜沟法为25min，改良黏膜沟法8min，改良乳头种植法5min。无吻合口漏及输尿管反流并发症，吻合口狭窄均见于黏膜下隧道法。结论：改良黏膜沟法和直接种植法是肠代膀胱输尿管吻合的理想方法。     

改良Sigma直肠膀胱术中输尿管单腔、并腔肠吻合的疗效分析

目的 评价改良Sigma直肠膀胱术中输尿管单并腔肠吻合的疗效.方法 对14例膀胱多发移行细胞癌、1例膀胱腺癌根治性膀胱全切术后患者行改良Sigma直肠膀胱术.折叠25 cm直肠乙状结肠缝合成U形储尿囊,其中输尿管分别单腔与储尿囊吻合5例、双输尿管末端1.5～2.0cm并腔缝合后与储尿囊吻合10例.结果 15例患者控尿良好,无明显水电解质酸碱紊乱,术后15～22 d痊愈出院.13例随访8～24个月,其中输尿管单腔肠吻合4例出现吻合口狭窄、轻～重度肾积水,并腔肠吻合9例未出现肾积水.结论 改良Sigma直肠膀胱术创伤小、并发症少,患者可通过肛门括约肌自控排尿,无需配带尿袋或间断导尿,符合生理要求,提高了患者的生活质量;输尿管并腔后吻合口径大,不易发生狭窄等严重并发症.

Abstract：

Objective To make a comparison of curative effect of 1 and 2 ureters anastomosis in modified sigma operation. Methods Modified sigma operation was used after radical cystectomy in 14 cases of bladder transitional cell carcinoma and 1 case of adenocarcinoma of the bladder.We used a folded suture of 25 cm from the sigmoid colon to make the U-shaped urinary reservoirs to anastomose with the ureters in study group.Among study group,1 ureter was anastomosed with urinary reservoir in 5 cases.In the other 10 cases,1.5-2 cm of the terminal parts of 2 ureters were sutured tI am not sure what the authors mean by "big diamogether and then anastomosed with the urinary reservoir.Results 15 cases obtained good voiding control and no obvious water-electrolyte disturbance occurred.All the patients were cured and discharged within 15 to 22 days.Thirteen cases were followed-up in 8 to 24 month time period.Anastonmtic stenosis and moderate-severe hydronephrosis occurred in 4 cases with 1 ureter anastomosis.No hydronephrosis occurred in the 9 cases with 2 ureters anastomosis.Conclusions Modified sigma operation has the advantages of less injury and fewer complications.The patients can obtain self-control urination by anal sphincter without urine bags or intermittent catheterization,so the life quality of the patients is improved.Modified sigma operation with 2 ureters anastomosis has big diameter and there was a lower incidence of serious complications such as anastomotic stenosis.     

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.     

Ureterointestinal anastomosis in orthotopic neobladders

OBJECTIVE: This study reports our experience with a ureteroileal reimplantation technique based on the Leadbetter-Clarke method, which is used for orthotopic neo-bladders, constructed preferably with the Camey II technique. METHODS: We carried out 114 ureteroileal reimplantations using this technique in 58 patients undergoing radical cystectomy and orthotopic neobladder reconstruction. The incidence of neobladder-ureteral stenosis and reflux were analyzed during the follow-up. RESULTS: During the mean follow-up of 31 months, the incidence of stenosis was 2.6% (3 ureteroileal implants, including 1 case of neoplastic stenosis). The incidence of slight-to-moderate reflux was 9.6% but did not cause any deterioration in renal function or an increased incidence of reflux-related pyelonephritis. CONCLUSION: This technique provided good functional results and a low incidence of complications, and may be recommended as a valid alternative to standard methods of creating ureterovesical anastomosis.     

A continent colonic urinary reservoir: the Florida pouch

A total of 92 patients underwent continent urinary diversion with an extended, detubularized right colonic segment as the urinary reservoir and the distal ileum as a continent catheterizable efferent system. In this series 65 patients were followed for 6 to 46 months (average 17 months). Our reservoir allows the accommodation of a large volume of urine; urodynamic studies in 28 patients demonstrated a maximum reservoir capacity varying between 550 and 1,200 cc (average 747 cc). Maximal reservoir pressures ranged from 10 to 58 cm. water (average 35 cm. water). Of the 127 ureterocolonic reimplantations 4 ureters were initially reimplanted with a modified Le Duc procedure, 26 ureters were managed subsequently with the Goodwin transcolonic approach and 91 reimplantations were done with a direct (nontunneled) mucosa-to-mucosa anastomosis. The overall success rates with each of the 3 techniques (absence of reflux and obstruction) were 75, 88.6 and 90.1%, respectively. Six megaureters underwent imbrication and direct reimplantation, and 3 of these (50%) became obstructed. Two converted ileal conduits were opened at the antimesenteric edge and were patched to the reservoir while the ureteroileal anastomosis was left undisturbed. One patient (1.5%) died of pulmonary embolism. Medical and surgical complications occurred only in the group who underwent simultaneous cystectomy and the over-all rate of complication was comparable to previous series with ileal conduits. The double row plication of the distal ileum and ileocecal valve allows for easy catheterization every 4 to 6 hours and 63 patients (97%) remain continent between catheterization. Four patients (6%) required reoperation for correction of incontinence or other complications. Our satisfactory experience with these patients makes this technique an excellent approach to achieving continent urinary diversion.     

输尿管末端粘连:原位新膀胱术后上尿路积水原因之一

目的:总结原位新膀胱术后输尿管末端粘连致上尿路积水的诊断和处理经验。方法:2000年1月~2007年4月共施行全膀胱切除加原位新膀胱术250例,发现8例原位新膀胱术后患者上尿路积水是由输尿管末端互相粘连或与新膀胱壁粘连引起,在内镜下经尿道切断粘连带予以处理。结果:术后中位随访8个月(1~22个月),7例肾功能和积水程度明显改善,1例稳定,并在密切随访观察中。1例在积水缓解后7个月再次复发,发现输尿管肠吻合口狭窄,行开放手术作输尿管新膀胱再植,随访5个月,积水程度明显改善。结论:输尿管末端粘连是使用输尿管直接种植法的原位新膀胱术后上尿路积水的原因之一。膀胱镜检查既可明确诊断又能同时作粘连带切断而达到治疗的目的,因此,对原位新膀胱术后上尿路积水患者应常规作膀胱镜检查。     

Upper urinary tract dilation due to conglutination of intraluminal distal ureters after orthotopic neobladder with split-cuff nipple ureteral reimplants: Early results of 8 cases

ObjectiveWe reviewed our experience with dilation of the upper urinary tract caused by the conglutination of distal ureters after orthotopic neobladder reconstruction using the split-cuff nipple ureteral reimplant technique.Materials and methodsFrom January 2000 to April 2007, 250 consecutive patients underwent radical cystectomy and orthotopic neobladder reconstruction. Ureterointestinal anastomosis was performed using the split-cuff nipple technique in 291 renoureteral units. The patients from a single center were followed up for a mean period of 8 months (range 1–22) after surgery. We incised the conglutination band using a transurethral endoscope. Patient characteristics, endoscopic technique, measurement of serum creatinine levels, and results of ultrasonography, cystoscopy, and excretory urography were collected.ResultsHydronephrosis was found in 8 patients (14 renoureteral units) due to the conglutination of the distal ureters to each other (n = 6) or to the neobladder wall (n = 2). After the incision procedure, seven patients had obvious improvement in renal function and hydronephrosis, and their symptoms disappeared. In 1 patient, hydronephrosis developed again because of ureteroenteric stenosis after 7 months and was resolved by open surgical revision. The hydronephrosis had improved greatly in this patient by 5 months after revision.ConclusionConglutination of the distal ureters is a cause of hydronephrosis after orthotopic neobladder reconstruction using the reimplant technique with the split-cuff nipple. Cystoscopy is mandatory in following up patients who have hydronephrosis with the split-cuff nipple ureteral reimplant technique, not only to confirm the diagnosis but to treat the complication by incising the conglutination band. Continued follow-up is required to evaluate the long-term results of this treatment.     

Long-term functional outcomes in patients with various types of orthotopic intestinal neobladder

Objectives:   To evaluate the long-term functional outcomes of various types of orthotopic neobladder (NB).
Methods:   Eighty-nine patients who underwent orthotopic NB reconstruction after radical cystectomy and were followed for at least 60 months after surgery were included in this retrospective study. The types of NB in this series were: modified Studer type, Hautmann type, Mainz type, Goldwasser type and modified Reddy type in 36, 9, 15, 10 and 19 patients, respectively.
Results:   Sixty-seven (75.3%) patients could void spontaneously, 15 (16.8%) voided with clean intermittent catheterization (CIC) assistance and seven (7.9%) with CIC alone. After excluding the seven voiding with CIC alone, daytime and night-time continence was achieved in 63 and 50 of the remaining 82 patients, respectively. In addition, the proportion of daytime continence in the modified Studer group was significantly greater than that in the Mainz group, whereas there was no significant difference in the proportion of night-time continence among these groups. Uroflow examination indicated that despite the lack of significant differences in the maximal flow rates and the voided volumes, the post-void residual in the modified Reddy group was significantly smaller than that in the modified Studer group. Blood gas analysis in the 82 patients showed that there were no significant differences in the pH, bicarbonate, chloride and base excess among these groups.
Conclusions:   Orthotopic NB created with intestinal segments generally has acceptable functional outcomes on long term follow up. These outcomes differ according to the type of NB. To define the optimal procedure for NB reconstruction, it is necessary to understand the long-term functional prospects, on which the subjective success of NB creation is based.     

Management of vesicoureteral reflux in patients with neurogenic bladder dysfunction

We studied 20 cases of neurogenic bladder with vesico-ureteral reflux retrospectively. Seven patients voided with Valsalva's maneuver and 12 patients were managed with clean intermittent catheterization, but one patient required permanent urinary diversion because of uncontrollable urinary tract infection. The patients were followed by intravenous pyelography, radioisotope renogram, voiding cystourethrography, determination of serum creatinine level and urodynamic study. Anti-reflux surgery was performed in 22 ureters and reflux resolved in 19 ureters. Among 12 ureters not treated by anti-reflux surgery, reflux disappeared in 5 ureters and improved in 2 ureters. Of 5 ureters, reflux resolved after clean intermittent catheterization in 2 ureters, and remained stable without recurrent infection or renal deterioration in the remaining 5 ureters. Regardless whether antireflux surgery was done or not, most of the patients who had high grade reflux and obstructive renal damage on radioisotope examinations had marked low compliance bladders. Our experience suggested the necessity of a suitable treatment to improve bladder compliance before considering anti-reflux surgery.     

Management of reflux in the myelodysplastic child

More than 75 per cent of the patients with spinal dysrhaphisms followed at our hospital are on intermittent catheterization. A previous report indicated that 62 per cent of 200 children with reflux and a neurogenic bladder either ceased to have reflux or reflux was downgraded while on intermittent catheterization and chronic antibiotics. We report on those children in whom either reflux did not stop while on the program, or who presented with high grades of reflux not amenable to cure by intermittent catheterization. During the last 4 years 25 children (40 ureters) required antireflux surgery. The criterion of repair was persistent reflux of at least grade IIB, associated with recurrent episodes of infection. A modified Leadbetter-Politano technique was used in 5 children (7 ureters) and the Cohen cross-trigonal technique was used in 20 children (33 ureters). A successful result, that is cessation of reflux and no obstruction, was achieved in 96 per cent of the patients. During the last 2 years the Cohen cross-trigonal technique has been used exclusively and there have been no failures. This successful result in 96 per cent of the children with neurogenic bladder indicates that while clean intermittent catheterization should be used primarily to relieve reflux, in a select group of children antireflux surgery should be done and clean intermittent catheterization should be continued.     

Endoscopic Treatment of Vesicoureteral Reflux in Patients With Myelodysplasia

Purpose

We assessed the usefulness of and indications for endoscopic treatment of vesicoureteral reflux in myelodysplasia patients.

Materials and Methods

A total of 26 patients treated with intermittent catheterization was divided into 11 (16 ureters) with and 15 without vesicoureteral reflux. In 9 patients (13 ureters) endoscopic correction was performed with 3 percent atelo-collagen and without anesthesia at the outpatient clinic. In each ureter we obtained the sum of scores for 4 risk factors for upper urinary tract deterioration: bladder compliance less than 10 ml./cm. water, grade 2 to 3 bladder deformity, detrusor-sphincter dyssynergia and urethral closure pressure 50 cm. water or greater.

Results

No reflux was demonstrated immediately after the initial collagen injection but cystography 3 to 6 months later showed recurrent reflux in 5 ureters (38 percent). Repeat injection cured the reflux, with results persisting for an average of 17 months. Mean risk factor score for patients without vesicoureteral reflux was significantly lower than that for patients with reflux. In patients treated with intermittent catheterization and anticholinergic agents the mean score for ureters with an increased or unchanged reflux grade was significantly greater than for those with a decreased grade.

Conclusions

Endoscopic treatment of reflux appears to be safe and useful in patients with myelodysplasia. This treatment is preferable in those with high risk factor scores due to the possibility of increased reflux grade in such patients.     

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.     

Ureteric duplication is not a contraindication for robot-assisted laparoscopic radical cystoprostatectomy and intracorporeal Studer pouch formation

Objectives:

Ureteric duplication is a rarely seen malformation of the urinary tract more commonly seen in females.

Materials and Methods:

We report 2 cases of robot-assisted laparoscopic radical cystoprostatectomy (RALRCP) with bilateral extended pelvic lymph node dissection and intracorporeal Studer pouch formation in patients with duplicated right ureters.

Results:

Two male patients (53 and 68 years old) underwent transurethral resection of a bladder tumor that revealed high-grade muscle invasive transitional cell carcinoma, with no metastases. We performed RALRCP and intracorporeal Studer pouch formation. A duplicated right ureter was observed during the procedures in both patients. Left ureter distal segment was spatulated 2cm long and anastomosed using running 4/0 Vicryl to the right ureter at its bifurcation where it forms a single lumen without spatulation. All 3 ureters were catheterized individually. A Wallace type uretero-ileal anastomosis was performed between the ureters and the proximal part of the Studer pouch chimney. Although ureteric frozen section analysis suggested ureteric carcinoma in situ in patient 1, postoperative pathologic evaluation was normal. Frozen section and final postoperative pathologic evaluations were normal in patient 2.

Conclusions:

Duplicated ureters might be underdiagnosed on CT. The presence of a duplicated ureter is not a contraindication to RALRCP and intracorporeal Studer pouch formation. The da Vinci-S surgical robot is very safe for performing this complicated procedure. Frozen section analysis of ureters during radical cystectomy for bladder cancer might not reliably diagnose the pathologic condition and might overestimate the disease in the ureters.     

原位新膀胱术后输尿管末端粘连的内镜治疗

目的探讨内镜治疗原位新膀胱术后输尿管末端粘连的临床应用。方法采用改良的全膀胱切除和原位新膀胱术治疗157例浸润性膀胱癌患者，男性144例，女性13例。术后发现11例患者因输尿管末端互相粘连或与新膀胱壁粘连而导致上尿路积水，遂行经尿道内镜下切断粘连带。结果内镜治疗术中术后均无明显并发症，随访9～36个月（中位14个月），10例肾功能和积水程度明显改善，1例稳定。1例在积水缓解后7个月再次复发，发现输尿管肠吻合口狭窄，行开放手术作输尿管新膀胱再植，随访18个月，积水改善。结论原位新膀胱术后输尿管末端粘连是上尿路积水的原因之一，常规膀胱镜检有利于诊断，经尿道内镜下切断粘连带是较为简单有效地治疗方法。     

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.     

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.