A randomized study comparing an antireflux system with a direct ureteric anastomosis in patients with orthotopic ileal neobladders

Abstract

Authors from Egypt conducted a randomized prospective study into the benefit of an anti‐reflux system in patients with orthotopic ileal neobladders. They found that anti‐reflux procedures were associated with a higher incidence of anastomotic structures. An editorial comment accompanies this paper, and together the two manuscripts make for interesting reading. OBJECTIVE To assess the benefit of an antireflux system in patients with orthotopic ileal neobladders, as there is controversy about whether reflux prevention offers any advantages. PATIENTS AND METHODS We conducted a randomized prospective study between January 2002 and March 2004, on 60 patients (53 men and seven women) with a mean (sd) age of 52.7 (7.3) years, who were candidates for orthotopic neobladders. Patients with comorbidities were excluded. Preoperative evaluation included intravenous urography (IVU), cystoscopic biopsy and radioisotope renography to evaluate the differential glomerular filtration rates (GFRs). Cases with normal kidneys and ureters, and with similar GFRs, were enrolled. Surgery comprised a standard radical cystectomy with pelvic lymphadenectomy. The ureters were randomized to either a direct anastomosis into a 5‐cm ileal chimney on one side, or to be implanted using the antireflux serous‐lined extramural tunnel on the contralateral side in the same patient. Regular follow‐up included IVU and renography every 6 months in cancer‐free patients. RESULTS The mean (sd) follow‐up was 23 (9.6) months. There was prolonged urinary leak from a refluxing ureter in one patient that was treated with a temporary percutaneous nephrostomy. Symptomatic pelvic collections required tube drainage in six cases. Six ureters developed early anastomotic strictures (one direct and five antirefluxing), and were treated with endoscopic ureterotomy in three and open revision in three. Serum creatinine levels were normal in all patients throughout the observation period. GFRs were similar in the two groups. The mean GFRs before surgery and at 6, 12, 18, and 24 months after cystectomy were: 55.1, 50.7, 49.4, 52.2 and 53.9 mL/min for the direct side; and 56.1, 53, 52.4, 53.2 and 50.4 mL/min for renal units with antirefluxing implantation. There was a significant deterioration of the GFRs due to anastomotic strictures, from 48.6 (6.7) mL/min before surgery to 31.8 (15.9) mL/min after the revision (P = 0.01). CONCLUSIONS The antireflux procedures were associated with a higher incidence of anastomotic strictures than the direct methods and there was a significant deterioration of renal function after obstruction. The long‐term follow‐up data are awaited.

605 Radical cystectomy with W-shaped orthotopic ileal neobladder constructed with non-absorbable titanium staples – long term follow-up

“…Anastomotic strictures occurred in two cases and were successfully treated with minimal endoscopic procedures. Although the stricture rate in our study was higher than that reported by Fontana et al, it is still comparable with the results of other studies (18). We also failed to find any sign of obstruction of the uretero-ileal anastomosis on the antiperistaltic site of neobladder.…”

Getting out of a tight spot: an overview of ureteroenteric anastomotic strictures

“…However, several studies have demonstrated a higher rate of strictures with this technique than with refluxing anastomoses 5,27-29 , which is most likely attributed to the mechanical compression of the distal ureter. By contrast, several prospective randomized studies have shown no significant difference between the techniques 27,28,30 . Thus, the choice between nonrefluxing and refluxing anastomosis should be based on the surgeon's preference and experience.…”

Orthotopic ileal neobladder creation according to the original surgical method “Belgrade pouch“ - a ten-years experience

“…Stenoses in the site of the ureter and the neobladder anastomosis most often occur in the first year after the operation and often result in asymptomatic ureterohydronephrosis due to its slow occurrence and course 15 . Stenosis in the site of anastomosis in direct methods of ureteral implantation is around 3.3% 16 . Our study reports a larger number of hydronephroses in the first six months due to reflux, however, after urinating, hydronephrosis completely spontaneously regressed in all patients except in two who were subjects to re-pouch-anastomosis.…”