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Endourological management of uretero-ileal anastomosis stricture after cystectomy and Vescica Ileale Padovana (V.I.P.) orthotopic neobladder reconstruction
Urology Video Journal 4 (2019) 100014
Contents lists available at ScienceDirect
Urology Video Journal journal homepage: www.elsevier.com/locate/urolvj
Endourological management of uretero-ileal anastomosis stricture after cystectomy and Vescica Ileale Padovana (V.I.P.) orthotopic neobladder reconstruction Fabio Zattoni a, Gioacchino De Giorgi a, Afrovita Kungulli a, Giordana Ferraioli b, Claudio Valotto a, Fabrizio Dal Moro a,b a b
Urology Unit, Academical Medical Centre Hospital, 33100 Udine, Italy Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
a r t i c l e
i n f o
Keywords: Ureteric stricture Ureteral obstruction Neobladder Uretero-ileal anastomosis Laser Laser endoureterotomy Bladder cancer
a b s t r a c t Aim: To report an endourology management of uretero-ileal anastomosis stricture after cystectomy and orthotopic neobladder reconstruction (Vescica Ileale Padovana, VIP). Materials and methods: A nephrostomy was placed to provide a route of access for an anterograde canalization and a secure and working guide placement. These were than taken with a cystoscopy grasp and pulled out through the neobladder. Laser endoureterotomy of the stricture over a stiff working guide wire was than performed. A DJ stent was then placed in order to protect the urinary flow for the first month after surgery. Results: No immediate and late complications occurred during a follow up of 1 year according to the Clavien Dindo classification. The patient continued to be asymptomatic with a renal function stable over the years. Discussion: Endourological management of uretero-ileal anastomosis stricture after cystectomy and orthotopic neobladder (VIP) is safe and reproducible. It may avoid the difficulties and complications of invasive surgery and has durable results.
Introduction A ureteral stricture is a urological event defined as a narrowing of the ureter causing a functional obstruction and renal failure, if left untreated. The causative factor of uretero-ileal stricture after radical cystectomy and uretero-ileal anastomosis is the distal ureteral ischemia. The ischemia may be secondary to transposition of the left ureter under the sigmoid mesentery (in case of ureterocutaneostomy), periureteral urine leak, fibrosis and recurrence of tumor. All patients with a ureteral stricture require an extensive evaluation and planning before treatment, in particular with an orthotopic neobladder. The ureteroscopic approach to ureteral strictures has diminished morbidity because of smaller-caliber equipment, improved optics, Ho:YAG laser. Endoureterotomy with a retrograde approach is the route of choice for benign ureteric strictures, with a success rate ranging between 53% and 82% [1]. Direct visualization by means of retrograde ureteroscopy provides an effective approach to treat ureteral strictures. Furthermore, advantages of these are a fine and precise incision due to the small caliber and flexibility of fibers, the minimal peripheral damage and when needed a stone fragmentation [2]. Although described in the literature, aim of this video is to show the step-by-step techniques for an endourological treatment of uretero-enteric anastomosis stricture
status after radical cystectomy with orthotopic ileal neobladder urinary diversion. Materials and methods A 58 years old male patient developed a right hydronephrosis with slow excretion of contrast medium at CT scan after 18 months from radical cystectomy and an orthotopic neobladder reconstruction (Vescica Ileale Padovana, VIP [3]) for a muscle invasive bladder cancer. Since the right ureter orifice was not visible at the preliminary cystoscopy, a right nephrostomy was placed to heal the kidney, to study the length of the stricture and to provide a route of access for an anterograde canalization. A preoperative nephrostogram showed a ureteral stricture less than 2 cm. A secure and working guidewires were then placed in an anterograde fashion. These were than taken with a cystoscopy grasp and pulled out through the neobladder. Two wires (working and safety working guide) were used to improve the stricture dilatation, the passage of the ureteroscopy a to reduce movements of the anastomosis while working. Laser endouretherotomy (Ho:YAG) of the stricture over a stiff working guide wire was than performed. The laser setting was 15 Watt and 1.5 Joule.
E-mail address: [email protected] (F. Zattoni). https://doi.org/10.1016/j.urolvj.2019.100014 Received 14 July 2019; Received in revised form 17 September 2019; Accepted 20 November 2019 2590-0897/© 2019 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/)
F. Zattoni, G. De Giorgi and A. Kungulli et al.
A DJ stent was then placed in order to protect the urinary flow for 6 weeks after surgery. A CT urography was performed during the first years of follow up.
Urology Video Journal 4 (2019) 100014
Supplementary materials The video related to this article can be found online at: doi:10.1016/j.urolvj.2019.100014.
Results Declartion of Competing Interest The hospital stay was only 1 day. No immediate and late complications occurred during a follow up of over 1 year according to ClavienDindo classification. The patient continued to be asymptomatic with a renal function stable over the years. Discussion Technological advances have made endoscopic laser ureterotomy a good treatment option for selected patients with benign ureteral strictures providing good results and a short recovery time. In particular, the endourological management of uretero-ileal anastomosis stricture status after radical cystectomy with orthotopic ileal neobladder urinary diversion seems feasible and reproducible. Due to the neobladder reconfiguration, the internal ureteral orifices are often difficult to visualize with a cystoscopy. Thus, an anterograde guide placement seems necessary to find the right route for a retrograde approach, which may not be necessary in case of a Robot-assisted surgery. Further comparative studies with other mininvasive techniques (like the SP○R surgical system) [4] need to be done to assess the best treatment options for these selected patients.
The authors declare that they have no conflict of interest. Funding No funding was received. References [1] E. Emiliani, A. Breda, Laser endoureterotomy and endopyelotomy: an update, World J. Urol. 33 (2015) 583–587. [2] K.S. Hafez, J.S. Wolf Jr., Update on minimally invasive management of ureteral strictures, J. Endourol. 17 (2003) 453–464. [3] F. Pagano, W. Artibani, P. Ligato, R. Piazza, A. Garbeglio, G Passerini, Vescica ileale padovana: a technique for total bladder replacement, Eur. Urol. 17 (1990) 149–154. [4] J.H. Kaouk, J. Garisto, M. Eltemamy, R Bertolo, Robot-assisted surgery for benign distal ureteral strictures: step-by-step technique using the SP(R) surgical system, BJU Int. 123 (2019) 733–739.
Contents lists available at ScienceDirect
Urology Video Journal journal homepage: www.elsevier.com/locate/urolvj
Endourological management of uretero-ileal anastomosis stricture after cystectomy and Vescica Ileale Padovana (V.I.P.) orthotopic neobladder reconstruction Fabio Zattoni a, Gioacchino De Giorgi a, Afrovita Kungulli a, Giordana Ferraioli b, Claudio Valotto a, Fabrizio Dal Moro a,b a b
Urology Unit, Academical Medical Centre Hospital, 33100 Udine, Italy Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
a r t i c l e
i n f o
Keywords: Ureteric stricture Ureteral obstruction Neobladder Uretero-ileal anastomosis Laser Laser endoureterotomy Bladder cancer
a b s t r a c t Aim: To report an endourology management of uretero-ileal anastomosis stricture after cystectomy and orthotopic neobladder reconstruction (Vescica Ileale Padovana, VIP). Materials and methods: A nephrostomy was placed to provide a route of access for an anterograde canalization and a secure and working guide placement. These were than taken with a cystoscopy grasp and pulled out through the neobladder. Laser endoureterotomy of the stricture over a stiff working guide wire was than performed. A DJ stent was then placed in order to protect the urinary flow for the first month after surgery. Results: No immediate and late complications occurred during a follow up of 1 year according to the Clavien Dindo classification. The patient continued to be asymptomatic with a renal function stable over the years. Discussion: Endourological management of uretero-ileal anastomosis stricture after cystectomy and orthotopic neobladder (VIP) is safe and reproducible. It may avoid the difficulties and complications of invasive surgery and has durable results.
Introduction A ureteral stricture is a urological event defined as a narrowing of the ureter causing a functional obstruction and renal failure, if left untreated. The causative factor of uretero-ileal stricture after radical cystectomy and uretero-ileal anastomosis is the distal ureteral ischemia. The ischemia may be secondary to transposition of the left ureter under the sigmoid mesentery (in case of ureterocutaneostomy), periureteral urine leak, fibrosis and recurrence of tumor. All patients with a ureteral stricture require an extensive evaluation and planning before treatment, in particular with an orthotopic neobladder. The ureteroscopic approach to ureteral strictures has diminished morbidity because of smaller-caliber equipment, improved optics, Ho:YAG laser. Endoureterotomy with a retrograde approach is the route of choice for benign ureteric strictures, with a success rate ranging between 53% and 82% [1]. Direct visualization by means of retrograde ureteroscopy provides an effective approach to treat ureteral strictures. Furthermore, advantages of these are a fine and precise incision due to the small caliber and flexibility of fibers, the minimal peripheral damage and when needed a stone fragmentation [2]. Although described in the literature, aim of this video is to show the step-by-step techniques for an endourological treatment of uretero-enteric anastomosis stricture
status after radical cystectomy with orthotopic ileal neobladder urinary diversion. Materials and methods A 58 years old male patient developed a right hydronephrosis with slow excretion of contrast medium at CT scan after 18 months from radical cystectomy and an orthotopic neobladder reconstruction (Vescica Ileale Padovana, VIP [3]) for a muscle invasive bladder cancer. Since the right ureter orifice was not visible at the preliminary cystoscopy, a right nephrostomy was placed to heal the kidney, to study the length of the stricture and to provide a route of access for an anterograde canalization. A preoperative nephrostogram showed a ureteral stricture less than 2 cm. A secure and working guidewires were then placed in an anterograde fashion. These were than taken with a cystoscopy grasp and pulled out through the neobladder. Two wires (working and safety working guide) were used to improve the stricture dilatation, the passage of the ureteroscopy a to reduce movements of the anastomosis while working. Laser endouretherotomy (Ho:YAG) of the stricture over a stiff working guide wire was than performed. The laser setting was 15 Watt and 1.5 Joule.
E-mail address: [email protected] (F. Zattoni). https://doi.org/10.1016/j.urolvj.2019.100014 Received 14 July 2019; Received in revised form 17 September 2019; Accepted 20 November 2019 2590-0897/© 2019 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/)
F. Zattoni, G. De Giorgi and A. Kungulli et al.
A DJ stent was then placed in order to protect the urinary flow for 6 weeks after surgery. A CT urography was performed during the first years of follow up.
Urology Video Journal 4 (2019) 100014
Supplementary materials The video related to this article can be found online at: doi:10.1016/j.urolvj.2019.100014.
Results Declartion of Competing Interest The hospital stay was only 1 day. No immediate and late complications occurred during a follow up of over 1 year according to ClavienDindo classification. The patient continued to be asymptomatic with a renal function stable over the years. Discussion Technological advances have made endoscopic laser ureterotomy a good treatment option for selected patients with benign ureteral strictures providing good results and a short recovery time. In particular, the endourological management of uretero-ileal anastomosis stricture status after radical cystectomy with orthotopic ileal neobladder urinary diversion seems feasible and reproducible. Due to the neobladder reconfiguration, the internal ureteral orifices are often difficult to visualize with a cystoscopy. Thus, an anterograde guide placement seems necessary to find the right route for a retrograde approach, which may not be necessary in case of a Robot-assisted surgery. Further comparative studies with other mininvasive techniques (like the SP○R surgical system) [4] need to be done to assess the best treatment options for these selected patients.
The authors declare that they have no conflict of interest. Funding No funding was received. References [1] E. Emiliani, A. Breda, Laser endoureterotomy and endopyelotomy: an update, World J. Urol. 33 (2015) 583–587. [2] K.S. Hafez, J.S. Wolf Jr., Update on minimally invasive management of ureteral strictures, J. Endourol. 17 (2003) 453–464. [3] F. Pagano, W. Artibani, P. Ligato, R. Piazza, A. Garbeglio, G Passerini, Vescica ileale padovana: a technique for total bladder replacement, Eur. Urol. 17 (1990) 149–154. [4] J.H. Kaouk, J. Garisto, M. Eltemamy, R Bertolo, Robot-assisted surgery for benign distal ureteral strictures: step-by-step technique using the SP(R) surgical system, BJU Int. 123 (2019) 733–739.