BERKELEY, CA (UroToday.com) - Radical cystectomy and urinary diversion with an ileal loop conduit represent the standard surgical technique for muscle invasive transitional cell carcinoma of the bladder. One of the most serious postoperative complications is late development of an ureteroileal anastomotic stricture which is seen in 4% to 11% of cases. Open surgical revision with intraoperative biopsy and ureteral reimplantation remains the definitive treatment but it may prove technically demanding due to the formation of fibrotic adhesions and ischemic effects of adjuvant radiotherapy.

The push toward minimally invasive strategies for this condition has led to the development of a self-expandable metal stent which attempts to improve upon the poor term-results of high-pressure balloon dilation. A prospective study by E. N. Liatsikos and colleagues from Patras Greece evaluated the long-term results of the treatment of benign ureteroileal anastomotic strictures with a self-expandable metal stent. The study is published in the July 2007 issue of the Journal of Urology.

A total of 16 males and 2 females with a mean age of 72 years and benign fibrotic strictures at the site of ureteroileal anastomosis underwent implantation of self-expandable metal stents with luminal diameter of 6 to 8mm. A total of 24 ureteroileal conduits were treated. Patients were followed with blood chemistry, ultrasonography, intravenous urography and/or virtual endoscopy to assess ureteral patency. Mean follow-up was 21 months. The stents were placed via existing percutaneous nephrostomy tubes in an interventional radiology suite. Antegrade nephrostomy was done to identify the stricture and the stricture was dilated to 6 to 7 mm with high-pressure angioplasty balloon dilators. A standard vascular self-expandable metal stent with a length of 4 to 10 cm was applied. In some cases of wasting, an additional balloon dilation was performed within the stent.

Analysis of the results revealed that all strictures were initially able to be treated with an initial technical success of 100%. The clinical success rate during the immediate post-stenting period was 70.8% (17 of 24 cases). The 1 and 4-year primary patency rates were 37.8% and 22.7% respectively. Secondary interventions included repeat balloon dilation in 15 ureters in which 8 also underwent coaxial stent placement. The 1 and 4-year secondary patency rates were 64.8% and 56.7%, respectively. Failures were treated with internal JJ catheters that were changed every 3 months. No patient underwent open revision.

In conclusion, metal stents served as the definitive treatment for stricture in more than one-half of cases where as the remainder of cases the stents allowed for uncomplicated and regular exchange of JJ catheters in a retrograde fashion. This procedure is an alternative for what may be a complicated and involved open surgical revision.

Liatsikos EN, Kagadis GC, Karnabatidis D, Katsanos K, Papathanassiou Z, Constantinides C, Perimenis P, Nikiforidis GC, Stolzenburg JU, Siablis D

J Urol. 178(1):169-173, July 2007
doi:10.1016/j.juro.2007.03.061

UroToday.com Urologic Trauma & Reconstruction Section

Written by Michael J. Metro, MD, a Contributing Editor with UroToday.

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