BERKELEY, CA (UroToday.com) - The incidence of ureterointestinal anastomotic stricture (UAS) after urinary diversion is reported to range from 3% to 14%. The apositioning of 2 types of mucosa (intestinal and ureteral) and technical defects that cause ureteral ischemia are considered the 2 main causes of such strictures. Standard, established management for these strictures involves exploratory laparotomy, excision of the stenotic segment, frozen section of the distal ureter if malignancy is suspected, followed by revision of the anastomosis. With the push toward minimally invasive techniques, a new surgical endoscopic technique of endoureterotomy by intraluminal invagination (the Lovaco technique) was developed. The procedure is described in detail and long-term results are reported in a review by F. Lovaco and colleagues from Madrid and Getafe, Spain. The paper is published in the November 2005 issue of the Journal of Urology.

In the review, a total of 25 ureterointestinal anastomotic strictures were subjected to the Lovaco technique of endoureterotomy over a 12 year period. The technique involves a combined percutaneous antegrade and endoscopic retrograde approach where the anastomosis is bridged by a balloon dilator over a guide wire and pulled into the conduit or pouch. This effectively brings the distal most ureter into the intestinal segment and out of the abdomen where any blind incision might harm surrounding tissue such as bowel segments, blood vessels or nerves. With the ureter pulled into the segment, a resectoscope with a hot Collins knife is introduced into the conduit or neobladder and employed to perform an incision at the 12 o'clock position until the wasting of the stricture seen in the balloon dilator under fluoroscopy disappears. A double-J catheter is then left for 6 weeks. Follow-up entailed excretory urography 6 weeks after stent removal followed by renal ultrasounds at 3 month intervals. Diuretic nuclear scintigraphy was employed when clinically indicated. Success was defined as radiographic improvement and/or the ability to recover normal activity in the absence of flank pain, infection, or the need for ureteral stents or percutaneous nephrostomy tubes.

Analysis of the long-term results with a mean follow-up 51 months revealed a success rate of 80%- 20 out of 25 anastomotic strictures. Endoureterotomy by UAS intraluminal invagination was performed in all patients without serious intraoperative or postoperative complications. The average time to stricture following urinary diversion was 39 months. There was no difference to time of stricture between successes and failures. There was a significant difference between the mean length of successfully treated strictures and failures (1.35 cm vs. 2.3 cm). Treatment failed within 2 to 6 months after the procedure in all failures.

This technique provides urologists with a minimally invasive option to fix a worrisome problem in a difficult patient population. More importantly, the technique has a high success rate with minimal complications.

J Urol. 2005 Nov; 174(5):1851-6