Objective To evaluate the impact of indocyanine green (ICG) for assessing ureteric vascularity on the rate of uretero‐enteric stricture formation after robot‐assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD). Patients and methods We identified 179 patients undergoing RARC and ICUD between January 2014 and May 2017, and divided the patients into two groups based on the utilisation of ICG for the assessment of ureteric vascularity (non‐ICG group and ICG group). We retrospectively reviewed the medical records to identify the length of ureter excised. Demographic, perioperative outcomes (including 90‐day complications and readmissions), and the rate of uretero‐enteric stricture were compared between the two groups. The two groups were compared using the t‐test for continuous variables and the chi‐squared test for categorical variables. A P < 0.05 was considered statistically significant. Results A total of 132 and 47 patients were in the non‐ICG group and the ICG group, respectively. There were no differences in baseline characteristics and perioperative outcomes including operating time, estimated blood loss, and length of stay. The ICG group was associated with a greater length of ureter being excised during the uretero‐enteric anastomosis and a greater proportion of patients having long segment (>5 cm) ureteric resection. The median follow‐up was 14 and 12 months in the non‐ICG and ICG groups, respectively. The ICG group was associated with no uretero‐enteric strictures compared to a per‐patient stricture rate of 10.6% and a per‐ureter stricture rate of 6.6% in the non‐ICG group (P = 0.020 and P = 0.013, respectively). Conclusion The use of ICG fluorescence to assess distal ureteric vascularity during RARC and ICUD may reduce the risk of ischaemic uretero‐enteric strictures. The technique is simple, safe, and reproducible. Larger studies with longer follow‐up are needed to confirm our findings.
Aim: We report the rates of artificial urinary sphincter (AUS) mechanical failure in a contemporary cohort of patients stratified by component type and size to determine if the 3.5-cm cuff is at higher risk of failure. Methods: From 2005-2016, a total of 486 male patients with stress incontinence underwent implantation or revision of an AUS. 993 individual cases were retrospectively reviewed (465 primary placements and 528 revisions). Components were separately tallied and cases of mechanical failure were identified. Multiple variables including duration until failure and follow-up interval were collected and analyzed for each malfunction. Results: After median follow-up of 31.5 months, there were 48 distinct cases of mechanical failure. The urethral cuff was the most common component to fail (n = 27, 56.3%), followed by the pressure regulating balloon (PRB) (n = 6, 12.5%), tubing (n = 6, 12.5%), and the control pump, (n = 5, 10.4%). Four (8.3%) cases did not have the source of malfunction identifiable in available records though fluid loss was evident at the time of device interrogation. Sub-analyses of cuff failure events showed that the 3.5-cm cuff had a statistically significant higher risk of failure (HR: 7.313, (P < .0001) compared to larger cuff sizes. Conclusions: While each component is prone to malfunction, our study suggests that the 3.5-cm urethral cuff is more susceptible to failure and failure events occur earlier after placement than larger cuff sizes. K E Y W O R D S artificial, cuff leak, device malfunction, prosthesis and implants, stress, urinary incontinence, urinary Body mass index (kg/m2), median (range) 27.45 (18.3-55.5) DM, n (%) 100 (20.6) HTN, n (%) 257 (52.9) CAD, n (%) 60 (12.3) Smoking history, n (%) 131 (27.0) Etiology of incontinence Prostate cancer, n (%) 386 (79.4) Prostatectomy 340 (69.9) Salvage prostatectomy 31 (6.37) Bladder cancer, n (%) 83 (17.1) Benign etiology, n (%) 33 (6.79) BPH procedure, n (%) 19 (3.90) Neurogenic bladder, n (%) 11 (22.6) Urethral stricture disease/pelvic trauma, n (%) 3 (6.17) History of pelvic radiation, n (%) 176 (36.2) Orthotopic Ileal neobladder, n (%) 79 (16.2)
cystectomy for muscle-invasive bladder cancer and in 1 case after radical cystectomy for locally advanced prostate cancer. In 4 cases the new pouch procedure was performed after total exenteration of the pelvis due to locally advanced colorectal cancers invading the bladder. Ureteral anastomotic strictures were only experienced in 2 of 30 patients (6.7%). Concerning renal units the ureteral anastomotic stricture rate was 2 of 59 (3.4 % of renal units). In one case ureteral anastomotic stricture had to be revised by open surgery 57 months after the pouch procedure. CONCLUSIONS: After a more than 10-year experience with our new modification of the Indiana-Pouch continent urinary diversion we can report that the technique of ureteral anastomosis to a tubular segment of the pouch is easy to perform and effective in reducing the rate of ureteral anastomotic strictures. By lengthening the afferent tubular ileal segment it additionally allows easy ureteral replacement if necessary. In young patients our new technique also effectively prevents the development of secondary carcinomas at the anastomic site.
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