Use of single J urinary diversion stents in intestinal urinary diversion

Novel Endourological technique for a better navigation in incontinent urinary diversion (ileal conduit) during Double J stent removal

Introduction

Assessing ileal conduit for double J stents removal after radical cystectomy is not always a straightforward task as navigation inside the ileal loop can be challenging to manage due to the difficulty to maintain a waterfilled environment and its long and tortuous aspect.

Methods

We present a novel technique using a flexible ureteroscope that aims to ease this common demand with simple and readily available tools.

Results

This technique has been successfully utilized in 2 patients now. No complications were documented.

Conclusion

We propose a novel surgical technique to improve endoscopic navigation in incontinent ileal loop urinary diversion.

Feasibility and Safety of Stentless Uretero-Intestinal Anastomosis in Radical Cystectomy with Ileal Orthotopic Neobladder

Background: We evaluated the feasibility and safety of stentless uretero-intestinal anastomosis (UIA) during radical cystectomy (RC) with an ileal orthotopic neobladder. Methods: We retrospectively reviewed 403 patients who underwent RC for bladder cancer between August 2014 and December 2018. The primary objective was to study the effect of stentless UIA on uretero-intestinal anastomosis stricture (UIAS), and the secondary objective was to evaluate the association between stentless UIA and other complications, including paralytic ileus, febrile urinary tract infection (UTI), and urine leakage. Kaplan–Meier survival analysis was used to estimate UIAS-free survival, and Cox proportional hazard models were applied to identify factors associated with the risk of UIAS. Results: Among 403 patients with 790 renal units, UIAS was identified in 39 (9.7%) patients and 53 (6.7%) renal units. Forty-four (83.0%) patients with UIAS were diagnosed within 6 months. The 1- and 2-year overall UIAS-free rates were 93.9% and 92.7%, respectively. Paralytic ileus was identified in 105 (26.1%) patients and resolved with supportive treatment. Febrile UTI occurred in 57 patients (14.1%). However, there was no leak of the UIA. Conclusions: Stentless UIA during RC with an ileal orthotopic neobladder is a feasible and safe surgical option. Further prospective randomized trials are required to determine the clinical usefulness of stentless UIA during RC.

Ureteral stents cannot decrease the incidence of ureteroileal anastomotic stricture and leakage: A systematic review and meta-analysis

BACKGROUND

The ileal conduit and ileal orthotopic neobladder were the most popular methods for urinary diversion following radical cystectomy. Stenting the anastomosis of ileo-ureter or ureter-neobladder was a common practice. However, it is still controversial if ureteral stents could prevent complications such as ureteroileal anastomosis stricture (UIAS) and ureteroileal anastomosis leakage (UIAL) after ureteral anastomosis.

OBJECTIVES

This study aims to investigate the role of the ureteral stent in preventing UIAS and UIAL.

DATA SOURCES

We systematically searched the related studies in PubMed, Embase, and Cochrane Library up to June 2020.

STUDY ELIGIBILITY CRITERIA

Cohort studies that identified the use of stent and the incidence of UIAS or UIAL were recorded.

DATA SYNTHESIS

Comparative meta-analysis was conducted on four cohort studies for comparison of UIAS and UIAL between the stented and nonstented groups. Besides, eleven studies which reported the events of UIAS and UIAL were used for meta-analysis of single proportion.

RESULTS

A total of 11 studies were qualified for analysis. Comparative meta-analysis identified that the incidence of UIAS was higher in the stented group than that in the nonstented group, but this did not reach a significant difference (odds ratio [OR]: 1.64; 95% confidence interval [CI]: 0.88-3.05; P = 0.12). Besides, there was no difference in the incidences of UIAL between the stented and the nonstented groups. On meta-analysis of single proportion, the incidence of UIAS was 7% (95% CI: 3%-10%) in the stented group and 3% (95% CI: 1%-6%) in the nonstented group. The UIAL rate was 1% (95% CI, 0%-4%) in stented patients and 2% (95% CI, 1%-4%) in nonstented patients.

CONCLUSION

Stenting the ureteroileal anastomosis resulted in a higher incidence of UIAS. There is no evidence to support ureteral stents could prevent the occurrence of UIAL after urinary diversion.

Intraoperative Ureteral Stent Use at Radical Cystectomy is Associated with Higher 30-Day Complication Rates

PURPOSE

Radical cystectomy/urinary diversion is a high risk procedure. Intraoperative stents are commonly utilized to decrease ureteroenteric anastomosis related complications. Institutionally some surgeons routinely use intraoperative stents while others do not, providing an opportunity to compare complication differences.

MATERIALS AND METHODS

We queried a prospective database of 283 patients enrolled in a randomized controlled trial evaluating 30-day perioperative complications with goal directed fluid therapy following open radical cystectomy/urinary diversion between 2014 and 2018. Ureteroenteric anastomosis specific complications (ureteral obstruction, urinary leak, urinary infections/sepsis and intra-abdominal abscess) were compared between groups (intraoperative stent vs nonintraoperative stent group) using Fisher exact test and quantified using logistic regression.

RESULTS

The nonintraoperative stent group (77 of 283 patients, 27%) was older (median 72 vs 69 years) and was more likely to receive neoadjuvant chemotherapy (53% vs 40%), have baseline renal insufficiency (43% vs 30%) and undergo an ileal conduit (92% vs 53%). However, despite higher comorbidity, the nonintraoperative stent group had a significantly lower rate of ureteroenteric anastomosis complications (14% vs 32%, p=0.004). Since continent diversions may be associated with higher complications, the nonintraoperative stent group with ileal conduit was also compared to intraoperative stent cohorts with ileal conduit, and ureteroenteric anastomosis complications remained lower in the nonintraoperative stent group (14% vs 28%, p=0.043). Multivariable logistic regression showed significantly increased odds of urinary complications with intraoperative stent use (OR 3.55, 95% CI 2.93-4.31; p <0.0001). Importantly there was no obstruction and only 1 leak (1.3%) in the nonintraoperative stent group.

CONCLUSIONS

Contrary to conventional belief, we found intraoperative stent use in radical cystectomy/urinary diversion was associated with significantly higher infectious complications and urgent care visits, and significantly increased the odds of 30-day ureteroenteric anastomosis associated complications.

Routine postoperative urography after cystectomy and urinary diversion is not necessary

OBJECTIVE

It is routine procedure to obtain a urogram or retrograde stentogram 1-2 weeks after urinary diversion. The purpose of this is to diagnose silent urinary leakage and obstruction of the anastomosis. We registered the frequency of significant findings at routine postoperative urography in patients with bladder cancer treated with radical cystectomy and urinary diversion.

MATERIAL AND METHODS

We identified a total of 200 consecutive patients who were treated with radical cystectomy and urinary diversion between 1994 and 2002. Eight patients were never evaluated radiologically and another 14 were examined earlier than planned due to symptoms or signs from the urinary tract and abdomen. The remaining 178 patients underwent a routine radiological examination. The methods of deviation in these patients were Bricker conduit (n=119), continent abdominal reservoir (n=24) and orthotopic bladder reconstruction (n=35). A total of 170 patients underwent urography, seven underwent bilateral retrograde pyelographies and one was examined by means of antegrade pyelography.

RESULTS

Not a single significant finding was identified with urography in 170 patients. Minimal leakage was identified at retrograde pyelography in one patient with a Bricker conduit, which resulted in treatment for 2 weeks with a pyelostomy catheter.

CONCLUSION

Routine postoperative urography is not necessary in patients who have a normal postoperative course after cystectomy and urinary diversion.

Routine stentograms are not necessary before stent removal following radical cystectomy

PURPOSE

Although ureteral stents have significantly reduced perioperative complications of urinary diversion, there is no universal agreement regarding their postoperative management. As part of an effort to eliminate unnecessary studies and hospital costs for radical cystectomy, we recently reviewed our experience with postoperative radiological stent studies to determine their clinical use and cost.

MATERIALS AND METHODS

A retrospective examination of medical records and radiographic studies was performed for 96 patients undergoing cystectomy and urinary reconstruction between 1989 and 1996. All patients were stented at the time of surgery. Of the patients 51 underwent bilateral retrograde "stentograms" performed under fluoroscopic guidance before stent removal to evaluate for obstruction or urine leak as dictated by the preference of the primary surgeon in each case. A total of 41 evaluable patients did not undergo stentograms.

RESULTS

In this study 102 stent injections were performed on 51 patients before stent removal. No patients were found to have ureteral obstruction at the ureterointestinal anastomosis, while 1 (0.98%) had a clinically silent anastomotic leak that healed with conservative measures. Complications directly attributable to the stent studies, including episodes of urosepsis, were noted in 9 patients (17.6%). Nine additional leaks were diagnosed in this cohort by other means. Half of all leaks were evident clinically and 60% of this group required further invasive procedures. All clinically silent leaks healed with conservative measures. Of 41 evaluable patients who did not undergo stentograms leak following stent removal developed in only 2 and both healed with conservative measures. The additional cost of detecting a single anastomotic leak with routine stentograms is estimated to be $58,000.

CONCLUSIONS

Routine evaluation of the ureterointestinal anastomosis with stentograms before stent removal is unnecessary, costly and may in fact increase patient morbidity.

Role of stents in open ureteral surgery

Stents can be important adjuncts in open ureteral procedures. The authors provide guidelines to assist the surgeon in deciding whether to employ a stent.

Stented versus nonstented transverse colon conduits: a comparative report

Postoperative urinary tract complications were evaluated in 75 women who underwent urinary diversion with formation of a transverse colon conduit after radiation for gynecologic cancer. Urinary stents were placed at the ureterocolonic junction in 37 women, while no stents were used in 38 women. Leaks or fistulae developed in 18% of the nonstented group but in only 3% of the stented group (P less than 0.05). Ureteral strictures developed in 18% of the nonstented but in only 8% of the stented group. Pyelonephritis developed in 13% of the nonstented and in 8% of the stented patients. Overall, urinary tract complications developed in 50% of the nonstented and in 16% of the stented group (P less than 0.01). Leaks or strictures developed in 11% of the 75 renal units in the nonstented group but in only 1% of the 72 renal units in the stented group (P less than 0.02). Postoperative leaks or fistulae were associated with further serious complications. Results indicate a significant advantage in employing stents at the ureterocolonic junction in the formation of a transverse colon conduit.

The management of the Kock continent ileal reservoir urinary diversion with single pigtail self-retaining ileal conduit stents

The use of single pigtail soft silicone self-retaining ileal conduit stents appears to have particular value in the perioperative management of patients with a Kock pouch continent urinary diversion. Stenting provides greater assurance of sustained internal urinary diversion, lessening concern regarding anastomotic leaks from the pouch itself. This technique also allows easy sequential radiographic confirmation of healing without losing the capability for continued internal drainage by these stents if necessary. A protocol for the use of such stents is described.

Stented versus nonstented ureteroileal anastomoses: is there a difference with regard to leak and stricture?

We reviewed the clinical histories of 362 patients (711 renal units) who had undergone ileal conduit diversion. Stents were used in 126 patients (247 renal units) and were not used in 236 (464 renal units). The stented group was divided further into 95 patients (186 renal units) with silicone single J stents and 31 (61 renal units) with some other type of stent. The over-all incidence of urine leakage was 1.7 per cent (6 of 362 patients). The over-all incidence of stricture was 3.9 per cent (11 without and 3 with stents). No leak occurred among the 126 patients in whom a stent was used. None of the 95 patients in whom silicone single J stents were used had stricture. If stents are to be used, we recommend silicone single J stents because of their satisfactory performance to date.

Lethal complications of standard self-retaining ureteral stents in patients with ileal conduit urinary diversion

While standard commercially available pigtail ureteral stents are used commonly in the obstructed patient, particularly when metastatic disease has been identified, our recent experience suggests caution in the use of such stents for patients with ileal conduits. Rapid obstruction of these stents occurs with unacceptable frequency, which has resulted in urosepsis and death, and they do not appear to be cost-effective even for palliation. Although these standard pigtail stents have physical properties that allow easy placement by angiographic wire guidance, they are not to be recommended. Safe internal ureteral diversion in patients with an ileal conduit awaits further evolution in stent technology.