Introduction and Objectives
Intestinal neobladder with low pressure is method of choice for urinary diversion after radical cystectomy. Ureterointestinal anastamosis is a critical element of any surgical procedure employing intestinal segment for urine derivation. It should be technically easily execute, applicable for normally and dilated ureter, with minimum of stenosisrisk occurrence, accessible for endoscopy. Main complications in region of ureterointestinal anastomosis (UIA) are strictures (8–17%), urinary reflux (2–15%) and pyelonephritis (11–13%). To achieve protection of the upper urinary tract in patients with neobladder we designed and clinically applied the subserosal invagination (SSI) method, a new antireflux ureterointestinal reimplantation technique. We present the operative procedure and comparative results.
Material and Methods
After ureteras mobilization spatulation and intubation with soft ureteral catheter are performed. Ureter and neobladder are anastamosed with “anchor” sutures by “back to side” type. The neobladder wall is sutured over the ureter by sero-serosal sutures. We created an orthotopic ileal neobladder after radical cystectomy in 99 patients for bladder cancer with 4 different types of uretero-intestinal anastomosis. The comparative study included 4 groups according to these types: 1 – UIA without antireflux protection, 2 – UIA with antireflux protection by SSI, 3 – UIA by subserosal extramural tunnel type, 4 – UIA by submucosal implantation type (LeDuc). Evaluation included clinical, radiological, laboratory, urodynamic and endoscopic evaluations. Mean follow-up was 34 months.
Results
Reflux was reported in 11/23 cases (23.9%) for 1 group, 1/32 (1.6%) for 2 group, 1/17 (2.9%) for 3 group and 5/27 (9.3%) for 4 group. Strictures were reported in 6/23 cases (13.0%) for 1 group, 1/32 (1.6%) for 2 group, 5/17 (14.7%) for 3 group and 8/27 (14.8%) for 4 group. Accessible for endoscopy of the ureteras orifices after 3 months of surgery was possible in 34.8% for 1 group, 88.5% for 2, 75.0% for 3, and 23.5% for 4.
Conclusions
The ureterointestinal anastomosis by subserosal invagination type has the optimal antireflux protection. It is associated with low risk of stricture occurrence and ensure high endoscopic visualization.
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Copyright
© 2009 European Association of Urology. Published by Elsevier Inc. All rights reserved.
