NARUS 2018: Ureteroenteric Strictures

Las Vegas, NV (UroToday.com) Dr. Rene Sotelo provided a lecture discussing robotic reconstruction of ureteroenteric strictures. As Dr. Sotelo notes, a ureteroenteric stricture is well known complication of urinary diversion, resulting in loss of renal function, infectious complications, and additional procedures. The ureteroenteric stricture incidence is ~1.3-10% of all cases after open or robotic radical cystectomy with median time from surgery to diagnosis of 6-12 months.

These complications are likely underreported, with most occurring within two years, but occasionally up to 10 years after the cystectomy. Benign strictures are more common than malignant recurrence, thought to be secondary to periureteral fibrosis from ischemia and/or urine leakage. Furthermore, left ureteroenteric strictures are more common than right, secondary to additional mobilization of the left ureter and tension during mobilization under the sigmoid mesentery. 

A recent study assessing open radical cystectomy (ORC, n=375) vs robotic cystectomy (RARC, n=103) ureteroenteric stricture rates reported an overall ureteroenteric stricture occurrence in 9.4% of patients with no difference in incidence between ORC (8.5%) and RARC (12.6%, p=0.21) [1]. At USC, they assessed their experience with RARC and intracorporeal urinary diversion (ileal conduit, n=146; neobladder, n=68) with a ureteroenteric stricture rate of 6.8% for ileal conduits and 10% for a neobladder, with a median follow-up of 6-8 months. Further studies assessing type of anastomosis (Bricker vs Wallace) and interrupted vs continuous anastamotic suturing have failed to show any prediction for worse ureteroenteric stricture rate.

A recently published single surgeon analysis of 440 patients undergoing RARC between 2005-2016 found that ureteroenteric strictures developed in 12%, 16% and 19% of 51 patients (13%) at 1, 3 and 5 years after RARC, respectively [2]. The median time to ureteroenteric stricture in this group was 5 months (IQR 2-11). All patients were initially treated endoscopically or percutaneously, including 57% treated only endoscopically or percutaneously and 43% who required surgery, which was open repair in six and robot assisted repair in 16. At a median follow-up of 23 months, 33 patients (65%) were free of disease, including 13 after endoscopic or percutaneous treatment, 15 after robot assisted repair and five after open revision. Predictors of ureteroenteric anastomotic strictures were BMI (OR 1.07, 95%CI 1.01-1.13), intracorporeal urinary diversion (OR 3.28, 95%CI 1.41-7.61), length of the right resected ureter (OR 0.66, 95%CI 0.50-0.88), estimated GFR 30 days after RARC (OR 0.85, 95% CI 0.74-0.98), UTI (OR 2.68, 95% CI 1.31-5.49) and urine leak (OR 3.85, 95% CI 1.05-14.1). 

Dr. Sotelo highlighted several tips for preventing ureteroenteric stricture, including avoiding excessive mobilization and handling of the ureter, minimizing the use of thermal energy and utilization of indocyanine green (ICG) for identifying healthy bowel and ureteral segments. When encountering a ureteroenteric stricture, Dr. Sotelo favors a robotic approach for revision. Utilizing ICG, one is able to identify the ischemic segment of ureter and successfully reimplant healthy ureteral tissue into the bowel segment. This is particularly important considering that the majority of these cases will involve extensive lysis of adhesions.

In conclusion, Dr. Sotelo noted several take-home points, including (i) the ureteroenteric stricture rate is ~10% with a left > right predilection for stricture; (ii) prevention is possible with meticulous technique and the use of ICG; (iii) presentation of ureteroenteric strictures is typically asymptomatic, highlighting the importance of follow-up with imaging; (iv) surgical repair is the definitive treatment; (v) a robotic repair is feasible with comparable outcomes and avoiding major open surgery.

Speaker: Rene Sotelo, University of Southern California, Los Angeles, CA

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV

References: 

1. Anderson CB, Morgan TM, Kappa S, et al. Ureteroenteric anastomotic strictures after radical cystectomy – does operative approach matter? J Urol 2013;189(2):541-547.

2. Ahmed YE, Hussein AA, May PR, et al. Natural history, predictors and management of ureteroenteric strictures after robot assisted radical cystectomy. J Urol 2017;198(3):567-574.