Videoendoscopic cutaneous ureterostomy for palliative urinary diversion in advanced pelvic cancer

Retroperitoneal Laparoscopic Approach to Ureteral Primary and Reoperative Ureteral Reconstructive Surgery: A Case Series

Introduction: To improve the outcomes and extend the adaptation of salvage surgery for intractable urinary tract problems, this study retrospectively investigated indications and outcomes of retroperitoneal surgery based on retroperitoneal laparoscopic ureterolysis (RLU), in which the ureter is dissected with or without nephrolysis. Patients and Methods: Twenty-three salvage surgeries based on RLU were performed on 22 patients at our hospital between November 2002 and July 2017. Intractable urinary tract problems included lower urinary tract dysfunctions, refractory urinary fistulas, middle or lower ureter troubles, ureteroileal anastomotic strictures, and stomal stricture of cutaneous ureterostomy. After RLU, various urinary tract reconstructions were performed through minimal laparotomy under a retroperitoneal approach. Results: In all patients, RLU secured a sufficient length of ureter for subsequent urinary tract reconstructions, irrespective of intra-abdominal adhesions. Twelve cutaneous ureterostomies, one reconstruction of cutaneous ureterostomy, two ureteroileal reanastomoses, and five ureterovesicostomies were effectively performed after unilateral RLU. Three retroperitoneoscopic transureteroureterostomies with cutaneous ureterostomy were reconstructed after bilateral RLU. Over a median follow-up of 8 months (interquartile range, 2-80 months), two patients (8.7%) required additional procedures. Conclusions: Retroperitoneal salvage surgery based on RLU appears useful to salvage intractable urinary tract problems, avoiding intra-abdominal adhesions and securing a sufficient ureteral length for subsequent urinary tract reconstructions. This surgical procedure is minimally invasive and contributes to improving patient quality of life.

Determining the optimum way to maintain quality of life for very elderly patients with advanced bladder cancer and poor performance status: A case report

Locally advanced bladder cancer causes unpleasant symptoms such as irritative voiding symptoms, lower abdominal pain, gross hematuria and urinary retention, and lowers the quality of life. Treatment decisions in elderly patients may be difficult, as elderly patients are physically and psychologically different from younger patients. An 89-year-old male was referred to hospital for the treatment of an invasive bladder tumor with right hydronephrosis from tumor obstruction. The patient was elderly and did not have a good performance status; therefore curative radical cystectomy or chemotherapy was not indicated. Left retroperitoneoscopic ureterocutaneostomy was performed to alleviate gross hematuria and voiding difficulty. Intensity-modulated radiotherapy was administered 9 days after the surgery to control bleeding in the bladder tumor. After completing 8 days of radiotherapy, the patient was discharged from hospital. The patient exhibited no signs of either postrenal failure or gross hematuria for 7 months prior to mortality. Retroperitoneoscopic ureterocutaneostomy for very elderly patients with advanced bladder cancer with a poor performance status may be an important procedure for alleviating symptoms and improving quality of life.

A prognostic model for survival after palliative urinary diversion for malignant ureteric obstruction: a prospective study of 208 patients

OBJECTIVE

To identify factors associated with survival after palliative urinary diversion (UD) for patients with malignant ureteric obstruction (MUO) and create a risk-stratification model for treatment decisions.

PATIENTS AND METHODS

We prospectively collected clinical and laboratory data for patients who underwent palliative UD by ureteric stenting or percutaneous nephrostomy (PCN) between 1 January 2009 and 1 November 2011 in two tertiary care university hospitals, with a minimum 6-month follow-up. Inclusion criteria were age >18 years and MUO confirmed by computed tomography, ultrasonography or magnetic resonance imaging. Factors related to poor prognosis were identified by Cox univariable and multivariable regression analyses, and a risk stratification model was created by Kaplan-Meier survival estimates at 1, 6 and 12 months, and log-rank tests.

RESULTS

The median (range) survival was 144 (0-1084) days for the 208 patients included after UD (58 ureteric stenting, 150 PCN); 164 patients died, 44 (21.2%) during hospitalisation. Overall survival did not differ by UD type (P = 0.216). The number of events related to malignancy (≥4) and Eastern Cooperative Oncology Group (ECOG) index (≥2) were associated with short survival on multivariable analysis. These two risk factors were used to divide patients into three groups by survival type: favourable (no factors), intermediate (one factor) and unfavourable (two factors). The median survival at 1, 6, and 12 months was 94.4%, 57.3% and 44.9% in the favourable group; 78.0%, 36.3%, and 15.5% in the intermediate group; and 46.4%, 14.3%, and 7.1% in the unfavourable group (P < 0.001).

CONCLUSIONS

Our stratification model may be useful to determine whether UD is indicated for patients with MUO.

Long-term experience on laparoscopic incontinent urinary diversion unrelated to cystectomy in radiated or recurrent pelvic malignancies

BACKGROUND:

There are few reports describing series of cases about development on laparoscopic urinary diversions no related to cystectomy. The aim of this paper is to show the experience of our reference institutions for treatment of pelvic malignancies when laparoscopic techniques were applied to perform only urinary diversion without cystectomy or pelvic exenteration.

MATERIALS AND METHODS:

We included retrospectively 12 cases of cutaneous ureterostomy and 21 cases with a reservoir (16 ileal conduits, 2 colonic conduits and 3 wet colostomies) treated in our institute from 2004 to 2010. It was evaluated operative time, blood loss, intraoperative complications, conversion rate, length of large incision, post operative complications, analgesic consumption, time to food intake, hospital stay, time to recovery to normal activities. Mean time to follow-up was 3(2-7) years.

RESULTS:

All procedures were completed without conversions. In the cutaneous ureterostomy group the mean surgical time.

Retroperitoneoscopic ureterocutaneostomy as a method of urinary diversion in case of complicated urinary fistula after radiotherapy

The case of 71-year-old woman with massive vesicovaginal and recto-vaginal fistula after radiotherapy treated with bilateral laparoscopic ureterocutaneostomy is presented. A retroperitoneoscopic access was applied. The technical aspects of the procedure are described. The interdisciplinary character of this not so rare problem is underlined. In our opinion this kind of procedure may be considered as a valuable alternative for commonly used methods of urine deviation.

Bilateral ureterocutaneostomy with modified stoma: long-term follow-up

Ileal conduit and orthotopic bladder substitution have been the preferred options for urinary diversion after cystectomy. Self-catheterisation has revolutionised the management of neuropathic bladder. However, ureterocutaneostomy (cutaneous ureterostomy) described as a means of supravesical urinary diversion 40 years ago still has a definite role for both temporary and permanent diversion particularly in the developing countries. We present a small series of cutaneous ureterostomies performed in four children who have now grown up to become adults without being undiverted. We discuss the technique that we used to modify the stoma, which helped prevent stomal complications over the long term. Our results we believe will rekindle the interest in cutaneous ureterostomy as a viable option for permanent urinary diversion. Four children between ages 2 and 16 years had bilateral side-to-side single stoma tubeless end cutaneous ureterostomy as a primary procedure for permanent urinary diversion. The stoma was modified to prevent retraction and stenosis. Long-term follow-up is presented. All the children have grown up to become adults with their ureterocutaneostomies functioning very well. There have been no biochemical or mechanical complications. Only one out of four stomas had to be refashioned. A simple collection device has proved successful in maintaining a watertight drainage system without apparent problems. Bilateral side-to-side single stoma end cutaneous ureterostomy with modification of the stoma by a plastic surgical technique can help achieve a non-retracting stoma on which a collection device can snuggly fit. It is a viable option for permanent urinary diversion without any significant complications. It is simple, easy and highly practical way of managing urinary diversion especially in the developing countries.

Laparoscopic radical cystectomy and urinary diversion

Most of the publications regarding laparoscopic radical cystectomy (LRC) have reported the institutions' initial experience focusing on technique and perioperative results. Increasing experience from major medical centers worldwide indicates increasing interest and expertise with LRC. In this manuscript, initial laboratory experience, contemporary series, current controversies, and future directions of the procedure are discussed. Careful prospective evaluations of oncologic and functional outcomes are awaited to define the role of LRC as a viable alternative to open radical cystectomy.