BERKELEY, CA (UroToday.com) - The various urinary diversions existing today have been created to answer specific particularities. They either allow urine to exit in a simple manner (ileal conduit) or allow urine storage and continence (neobladders). However, their conception has not been thought to accommodate urologists in treating upper urinary tract complications associated with the post-cystectomy period.
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| Julien Letendre, MD, FRCSC |
Indeed, about 15% of patients will develop stones after urinary diversion, and 7 to 14% will develop anastomotic strictures.[1, 2] Managing these complications is always strenuous because of the new anatomy created. Retrograde access to the upper tract for the management of post-cystectomy complications is the most difficult step and is sometimes impossible. Finding the ureteric orifice in an ileal conduct or an orthotopic bladder can be a great challenge.
In a recent publication in the Journal of Endourology by our group (Stuurman et al.,[3] we propose a less invasive and more reliable way to access the upper tract. By placing a ureteral access sheath in percutaneous fashion, we obtained an easy and very small antegrade access. Kidney stones could then be treated easily using a flexible uretero-renoscope. Even more, the sheath could be brought down directly in the ureter allowing for easy entry and reentry through the ureteropelvic junction (UPJ). Treatment of ureteral stones or strictures could then proceed like a retrograde case using holmium laser lithotripsy. This access could be performed using the usually pre-inserted nephrostomy tube.
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From this initial feasibility study, we concluded that it was feasible, safe, and efficient, since the stone-free rate was excellent and the complications minimal.
However, we as urologists must reflect further on the way we build these urinary diversions. Stones, strictures, upper tract urothelial tumors and other complications involving the upper urinary tract will become more frequent as more patients undergo cystectomies, have orthotopic bladders performed, and also live longer after surgery. We must then find a way to allow easier access to the upper tract in a retrograde fashion through the ileal conduct or orthotopic diversion without having to struggle so much in order to treat these complications. Creating a ureteral anastomosis that is both easily visible and accessible is the cornerstone of the next surgical revolution for cystectomies.
Who will be the next Wallace or Studder?
References:
- Studer UE, Burkhard FC, Schumacher M, Kessler TM, Thoeny H, Fleischmann A, et al. Twenty years experience with an ileal orthotopic low pressure bladder substitute--lessons to be learned. Journal of Urology. 2006 Jul;176(1):161-6. PubMed PMID: 16753394.
- Gudjonsson S, Davidsson T, Mansson W. Incontinent urinary diversion. BJU International. 2008 Nov;102(9 Pt B):1320-5. PubMed PMID: 19035899.
- Stuurman RE, Al-Qahtani SM, Cornu JN, Traxer O. Antegrade percutaneous flexible endoscopic approach for the management of urinary diversion-associated complications. Journal of Endourology / Endourological Society. 2013 Nov;27(11):1330-4. PubMed PMID: 23537189.
Written by:
Julien Letendre, MD, FRCSC and Olivier Traxer, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Urology Department, Tenon University Hospital, Pierre and Marie Curie University, Paris, France
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