Management of Ureterointestinal Anastomotic Strictures: Comparison of Open Surgical and Endourological Repair

Abstract

The established treatment for ureterointestinal anastomotic strictures is open surgical revision. In an effort to evaluate the efficacy of endourological surgery for this problem, we compared 7 patients (9 strictures) who underwent open revision to 6 patients (7 strictures) who underwent endoscopic incision and balloon dilation of the stricture. The success rate (that is patent ureter and no stent) was 89 per cent for the open revision group and 71 per cent (5 of 7) for the endoscopic group. All open revisions required use of general anesthesia, while 3 of the endoscopic procedures were performed with the patient under assisted local anesthesia. The endoscopic group had markedly shorter hospitalization, decreased blood loss, diminished patient discomfort and no postoperative complications. While the endoscopic procedure for ureteroileal anastomotic strictures is less successful than open revision, the lower morbidity, decreased cost and shorter hospital stay associated with the endourological approach favor its use over open revision. For elderly patients who fail initial endoscopic revision and for patients with metastatic transitional cell cancer, placement of an indwelling stent is a reasonable alternative. Given these guidelines, less than 30 per cent of the patients who suffer a ureteroileal anastomotic stricture will require open surgical revision.

Antegrade Percutaneous Endoluminal Treatment of Non–Malignant Ureterointestinal Anastomotic Strictures following Urinary Diversion

“…In order to exclude a local cancer recurrence safely, the biopsy from the affected ureterointestinal area during the open surgical revision seems to be the most reliable method [4, 5]. However, in cases of endourological treatment, imaging methods (CT scans of the abdomen and pelvis) together with endoscopy of the conduit and urinary cytology should be part of the preoperative evaluation of patients with a history of pelvic cancer [11, 22].…”

“…In order to reduce the morbidity and mortality, the hydronephrosis must be managed preoperatively by a nephrostomy until renal function is restored or sufficiently improved and the infection should be treated efficiently [19]. Kramolowski et al [4]and Vandenbroucke et al [5]reported a high success rate of 89 and 91% with the open surgical revision, respectively. However, this success was related to considerable morbidity, longer hospital stay and therefore higher hospital costs.…”

“…Standard treatment consists of open surgery and re–anastomosis, which is technically challenging because of the fibrotic adhesions due to previous surgery or radiotherapy leading to significant morbidity, prolonged hospitalization and recovery periods [4, 5]. In the last decades, the percutaneous transrenal access to the ureter has been established as an alternative to re–laparotomy.…”

Percutaneous Ureteral Dilations for Management of Uretero-Intestinal Anastomosis Stricture following Bricker Urinary Diversion

“…Open surgical revision remains the treatment of choice with a success rate of around 80% [3]. However, the difficulty due to extensive intra-abdominal adhesions, the significant operative and post-operative morbidity (vascular injury, wound infection) [4,5] leads to look for less invasive procedure with shorter hospital stay, especially that the patients are generally old with concomitant morbidity. Alternative options include endoscopic techniques such as balloon dilatation, endoscopic incision, stricture stenting, and endoscopic stricture incision combined with balloon dilatation.…”

Percutaneous balloon dilatation for transplant ureteral strictures

“…If successful, these procedures can spare patients the nuisance of chronic indwelling stents which usua11y carry an increasing rate of complications (e.g., infection, stone formation, stent encrustation, etc.) or the risk of repeated operation which is often technically difficult (2).…”