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Sam Chang: Hi. My name is Sam Chang. I'm a urologist in Nashville, Tennessee, at Vanderbilt University Medical Center. And we are quite fortunate to have Dr. Hadley Wyre from KU, from Kansas, who gave a wonderful talk actually focusing on an area that I struggle with quite commonly, which are complications associated with radical cystectomy.

This is a talk that actually generated quite a lot of interest at the SUO in 2024. So, Dr. Wyre, thank you so much for spending some time with us, and we look forward to the insights that you have on some of these common complications.

Hadley Wyre: Thank you, Dr. Chang, for having me. So, preventing and managing long-term complications of radical cystectomy. As we all know, radical cystectomy is a morbid operation. It unfortunately has a high rate of perioperative complications, and these long-term complications impact patients’ quality of life.

The two main complications that I'd like to talk about today are ureteroenteric anastomotic strictures, as well as hernias. Hernias come in two varieties: parastomal hernias and ventral hernias. I'll mainly be concentrating on parastomal hernias.

So when we talk about preventing ureteroenteric anastomotic strictures, we want to utilize standard anastomotic principles, which include a watertight closure, mucosa-to-mucosa apposition, and no tension. I also am a big proponent of the no-touch technique, which means not picking up the ureter with pickups. This is because it can create microvascular damage. So I teach the residents techniques on how to not handle the ureter specifically.

There's no data on this, but I like to just promote making long conduits. This is just from one oncologic reconstructionist to two other surgeons. Most repairs of any type are easier with long conduits, whether that's ureteroenteric anastomotic strictures or even parastomal hernia repairs or stomal stenosis. When the conduits are longer, it gives you more options to repair these complications. So I usually recommend making long conduits. We can then truncate the conduit if we need to. We can swing it to the opposite side of the contralateral side to reach a shorter left if we need to.

And then I like to extensively spatulate the ureter and discard the unused portion. There is some data showing that the longer the spatulate—meaning the shorter the remaining ureter that is in the body—will have a decreased stricture rate, and that's felt to be because you're getting closer to the remaining vascular supply of the ureter.

As far as managing ureteroenteric anastomotic strictures, I don't typically recommend proceeding with endoscopic treatments. They unfortunately have poor outcomes. These are ischemic strictures. So if you want a good long-term repair, I recommend proceeding with typically a redo ureteroenteric anastomosis.

The anastomosis does follow similar principles—again, watertight, tension-free, mucosa-to-mucosa apposition. I am a huge proponent of ureteral rest with a nephrostomy tube. I do not like to sew reconstructive ureteral anastomoses with a stent in place. One, ureteral stents will create a large amount of inflammation. We've all seen patients who are stented on one side and the difference between the ureter that's stented and the area that's not stented. There is also data from the reconstructive literature—this is looking at proximal ureteral strictures, but if we can extrapolate from that—when we look at this data, it shows that patients who have preoperative nephrostomy tubes and stents removed actually have a better success rate of their stricture repairs.

So all of my patients who I'm doing reconstruction in, they have the nephrostomy tube placed and the ureteral stent removed. They don't like this; they're frustrated by it. But I talk with them and tell them that there's hopefully an improved success rate and it's a short-term hassle for a long-term goal. So those are the main points when preventing and managing ureteroenteric anastomotic strictures.

Moving forward with parastomal hernias: in preventing parastomal hernias, I did spend a large amount of time talking about prophylactic mesh. So there are several studies regarding prophylactic mesh. There is an intraperitoneal biologic mesh placement, which unfortunately did not show any improvement in parastomal hernias.

The two studies that have shown to improve parastomal—excuse me, prevent parastomal—hernias would include the studies that show placement of mesh in the retrorectus space can help prevent parastomal hernias. Now, there's large controversy on what types of mesh, and this is certainly not the subject of this talk, because that could go on for days. But in these studies, it looked at placement of permanent mesh in the retrorectus space, which does show prevention of parastomal hernias. However, in looking at this data, it does cause you to violate the retrorectus space, which is considered a “golden plane” in hernia repairs. And so whether this is going to be something that I switch to, I haven't decided, because we really get one shot at using the retrorectus space for hernia repairs. And as I'll talk a little bit later, it is very important in the use of that space for treating ventral hernias, and so if that space had been violated, it may prevent us from being able to proceed with a retrorectus repair.

So in treating parastomal hernias, I actually talk most of my patients out of parastomal hernia repairs. We know that most hernias don't need to be fixed, and I go through the indications with them and allow them to decide. The absolute indications are obstruction of the GI tract—so small bowel obstruction related to the hernia—and obstruction of the urinary tract. So the hernia can actually obstruct the conduit, and then they have no urine output. The relative contraindications are pain, pouching problems (such that they typically would change their pouch every four to five days, and now they're down to one to two days), and then skin breakdown because the pouch is coming off so frequently or is being forced off—they can have skin breakdown and wounds that are poorly healing—and then cosmetic, so patients just don't like the bulge, which is significant and patients are unhappy with.

Again, I talk most patients out of parastomal hernia repairs. If they're not having any symptoms, I recommend we just watch it, and we can talk about hernia belts. But if they do end up wanting to proceed with hernia repairs, I talk to them about the different types of repair, and mostly it's an intraoperative decision. And so this is the algorithm that I use and I've developed. If we're doing a concomitant ventral hernia repair, then this is where I really like to use the retrorectus (retromuscular) repair. If you do a retromuscular parastomal hernia repair, it's called a Pauli repair, but this is a really good technique to fix the ventral hernia and has a very low recurrence rate with the ventral hernia. And you can also fix the parastomal hernia at the same time.

If they don't have concomitant ventral hernias, then I look to see if they've had multiple previous repairs. If they've had multiple previous repairs, I typically start talking about re-siting it. And I don't re-site many conduits—patients are really usually married to where their conduit is located. So if I have to re-site it, I'll talk with them about this. Now, I do ask everyone when I'm doing a parastomal hernia repair, “Do you want me to move it?” because it's much easier to just move it, and some patients are unhappy with it. So if they've had multiple previous repairs, I talk about re-siting. I may do that once every year—it's pretty uncommon.

And then if we're doing concomitant procedures, so these concomitant procedures may include ureteroenteric anastomotic strictures, and if I'm doing that, I typically like to do a keyhole repair. I did spend a significant amount of time talking about the different types of repair, but just for time's sake this morning, I won't. I'll do a keyhole repair; that's because it puts less pressure on the conduit and doesn't lateralize it or cauterize it, which can put some tension on the repair. So I do a keyhole repair. Now, I talk with them—that has a higher recurrence rate, but really our goal is also to fix the other problem, usually ureteroenteric anastomotic stricture. So we take the lower success rate with hopefully fixing the other problem.

If we're not doing concomitant procedures, then I look to see the conduit length. If it's a short conduit, you can't physically perform a Sugarbaker repair, which is the repair of choice, and that's when we have to keyhole it—again, going back to that “make long conduits,” it makes our reconstruction a little bit easier. And then if they have a good, long conduit, then I'll do an intraperitoneal Sugarbaker repair, which is really my preference if we're just doing standard parastomal hernia repairs.

So this is the algorithm that I've developed. Again, looking back at that retrorectus (retromuscular) repair, that is the ideal repair for ventral hernia. So that's why I'm a little bit hesitant to violate that space during the cystectomy for a preventative measure, because I want it to be available for future repairs. So I thank you for allowing me to talk, and I look forward to our discussion.

Sam Chang: Hadley, that was a wonderful overview. I'm going to start with a common issue that I think many of us have, that are probably under-reported: the parastomal hernias that occur. You talked a little bit about the prophylactic mesh placement unfortunately not showing a significant benefit in terms of prevention. So when you make an initial stoma, what do you try to do to prevent these hernias? Is there anything you really can do to try to prevent them?

Hadley Wyre: Unfortunately, probably not. I mean, I always like to tell patients a stoma is essentially a surgically created hernia. I mean, it's an opening in the fascia, so we're going to be prone to these hernias. We always talk about pulling it up through the rectus; there's minimal data on that. I think it can help in patients that I have done these repairs in who have had a previous vertical rectus abdominis muscle flap. So they have no rectus muscle—they get 100% hernia. So I think there is something to the rectus muscle.

We have started shifting our conduits up higher. And I don't have data on this, so this is purely anecdotal, but I think that may help not only in hernia prevention but size of hernias, because as the conduit’s higher, you have less of that abdominal pressure and abdominal girth. So I think that may assist. And then also there's a big controversy over how you incise the fascia—is it linear, is it cruciate? There was some data out of University of Washington looking at radial forces placed on the fascial opening, and that a cruciate may actually be weaker than a linear. And so their outcome was, maybe just make a linear, and truly if you want to, make it offset—so maybe make one transverse and one vertical. Again, that really was cadaveric data, so it hasn't been in vivo. But those are all the techniques that I try to do. And as I say, unfortunately, I just tell my patients 50% of people will get hernias. We don't need to fix the majority of them, and so hopefully we won't have to go forward with the repair.

Sam Chang: Some key takeaways—first of all, the fact that you say half, 50%. You see that in the literature, you'll see reported 10%, 12%. I'm so glad that those are reality because it makes me feel so much better, number one. Number two, I wasn't aware of the UW study, but for me, I've always tried to do different things. It just made sense—I made more of a linear incision as opposed to transverse, just because I thought the thought process behind hopefully weakening that. What about the technique that people have advocated regarding tacking to the fascia your actual conduit versus just the skin? To be honest, I don't tack my stomas to the fascia. I just do a rosebud to the skin and that type of thing. But has there been any benefit to that idea of fixing the stoma to the fascia?

Hadley Wyre: I am not aware of any data. A lot of our data does get extrapolated from the colorectal data, so I'd have to look at that. I was trained also to tack it to the fascia. And then I came to KU to do my fellowship and work with Dr. Holzbeierlein, and he said he didn't do it. And I said, “Why not?” He said, “I don't think it makes a difference and it saves time.” So I switched to doing that, so I don't tack either. Conceptually, it doesn't make sense how that would prevent a hernia.

Sam Chang: Good. That makes me feel better. I'm going to invite you again, Hadley, because you're reading my own biases. That's all important. Along the lines of a hernia belt, I think for the majority of my patients it's a combination of security and comfort and some cosmesis. There's no data showing that it prevents it from getting larger, correct?

Hadley Wyre: Yeah.

Sam Chang: And it serves basically to help fix the pouching system, et cetera. So that's great. With the ureteroenteric strictures, do you use ICG? You battle the combination of—it's easier to do an anastomosis when your ureteral length, honestly, is longer. Now, if you do it robotically, honestly, no difference. But doing it open, there's definitely a benefit. Do you use ICG, and where do you draw the line between tension-free versus, “I need to take more distal ureter because I'm worried about the vascular supply”?

Hadley Wyre: So I do all my repairs open. I don't do any robotic surgery anymore. Most of that's just because these are reoperative abdomens and all of my reconstructive training was open. So I do use ICG. This was actually a question that I got a lot after the talk—several people came up, which is a huge honor, to talk with people after the talk. And a lot of people asked about ICG. There is a handheld ICG device called the SPY-PHI, which I do utilize. I don't utilize it a lot in my ureteral work, because I feel like I spatulate back to really healthy, bleeding tissue. A lot of my patients are previously radiated, so I get out of the radiated field. I tend to spatulate the left side all the way down to where it comes under the sigmoid, so it's often an 8-centimeter, 10-centimeter spatulation. If you look at the transplant literature, there is some relatively weak data, but data saying spatulation length will improve your stricture outcomes. So I use SPY-PHI in other areas, mostly with evaluation of my bowel anastomosis. And yeah, if I get under the sigmoid and I'm really concerned at that point, I just say we have to sew it in.

Certainly, I have tunneled my conduit. Another trick that I like to use is I will tunnel the left ureter above the IMA in that there's that plane right above the IMA through the sigmoid mesentery, which is avascular, and I'll come through that. And that shortens the distance and also brings it closer to the right ureter. So if I'm real short, I also had to do a concomitant discectomy for cancer—I will tunnel it through that plane, or I'll tunnel the butt end of the conduit over.

Sam Chang: I know, those are great points regarding that space above the IMA in terms of basically making a small hole in the mesentery, moving the proximal butt end of the conduit closer. I've also actually personally laid the butt end on top and made a hole in the mesentery to bring my butt end almost to the left proximal ureter just to try to make things easier. And honestly, in those patients who are heavier, I've done certain maneuvers like that just so that I can get access. So those are all great, great points. And a takeaway for me, clearly, is the benefit—I haven't personally been a long spatulator, but since your presentation, honestly, I've actually started engaging in that longer spatulation, just like the transplant surgeons do, just as you said.

Hadley Wyre: Thank you.

Sam Chang: Wonderful overview on two areas of complication that we honestly face, that we under-report, and I think more discussions like this will only improve our ability to hopefully prevent but also manage these complications. So, Hadley, I look forward to hopefully having other discussions again in the future as we learn more and more ways to try to prevent these complications and how to treat them, and thanks for spending some time.

Hadley Wyre: I appreciate it. Thank you so much for talking with me, and thank you for having me this morning.