EAU 2018: The Critically Ill Patient with Locally Advanced Bladder Cancer – Ureterocutaneostomy? YES

Copenhagen, Denmark (UroToday.com) Dr. Armin Pycha from Bolzano, Italy provided the “yes” argument for ureterocutaneostomy in critically ill patients with locally advanced bladder cancer. 

From 2000-2018, Dr. Pycha has performed 92 uretero-ureterocutaneostomies protected with omentum. Patients that are not candidates for Dr. Pycha are those that are extremely obese, previously irradiated patients, and those with short ureters due to previous surgery. The ideal candidates for a uretero-ureterocutaneostomy are those that are very old, high-risk, high metastatic tumor load (≥N2), have angina intestinalis, and those for which the radical cystectomy is a salvage procedure. 

For the operation, there are several steps that Dr. Pycha describes:
  1. Dissecting the ureters very high so that the right ureter can cross over to the left side
  2. Bringing the ureters well above the skin close to each other
  3. Anastamosing the ureters side-to-side and placing ureteral stents
  4. Omental wrap
  5. Eversion of the ureters to form a functional and wide ostomy
The most common complications of this operation reported in the literature are asymptomatic grade ≥ 2 hydronephrosis and stenting of the uretero-ureterocutaneostomy. In Dr. Pycha’s opinion, “one does not die of the cystectomy, but rather of the urinary diversion.” Historical series suggest that 85% of surgical related deaths were as a result of urinary diversion-related complications. The incidence rates of stomal stenosis in literature range from 4.5-19.2% and Dr. Pycha quotes his stomal stenosis rate at 19.2%. 

In summary, Dr. Pycha once again highlighted that the appropriate indications for uretero-ureterocutaneostomies is in the salvage/palliative setting, ASA ≥3, N2 (high tumor load), angina intestinalis and/or angiopathy III, and high biologic age. In his words “the simpler, the better.”

Presented by: Armin Pycha, Central Hospital of Bolzano, Bolzano, Italy 

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, twitter: @zklaassen_md at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark

Read More:

The Critically Ill Patient with Locally Advanced Bladder Cancer – Ureterocutaneostomy? NO