Modified Technique for Internal Ureteroileal Stenting in Orthotopic Neobladders

doi:10.4236/oju.2011.12005

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Open Journal of Urology, 2011, 1, 15-18

doi:10.4236/oju.2011.12005 Published Online May 2011 (http://www.SciRP.org/journal/oju)

Modified Technique for Internal Ureteroileal Stenting

in Orthotopic Neobladders

Guven Aslan

Dokuz Eylul University, School of Medic i ne Department of Urology, Izmi r, Turkey

E-mail:[email protected]

Received February 9, 2011; revised February 28, 2011; accepted Marc h 31, 2011

Abstract

We introduce a modified surgical technique for internal ureteroileal stenting to improve cosmesis in patients

undergoing ileal neobladder. Internal ureteric stents are secured to the tip of the urethral catheter with non-

absorbable suture facilitating removal of the stents postoperatively 2 - 3 weeks along with the urethral cathe-

ter. This surgical modification was applied to 21 patients of whom no significant surgical or infectious com-

plication due to single urethral catheter was observed. Internal ureteral stenting is simple, safe and inexpen-

sive alternative to conventional methods to support ureteroileal anastomosis in patients undergoing or-

thotopic bladder substitution.

Keywords: Bladder Cancer, Radical Cystectomy, Bladder Substitution, Ureteric Stent

1. Introduction

Radical cystectomy and urinary diversion represents the

standard treatment for muscle invasive and non muscle

invasive bladder cancer not controlled by conventional

treatment options. The use of the orthotopic bladder sub-

stitution has gained general acceptance within the past

decade and different types of surgical techniques have

been described in this regard. An orthotopic ileal

neobladder replacement is commonly used in both men

and women [1]. The tendency for orthotopic neobladder

is due to an increasing importance of providing patients

better quality of life and a favorable cosmetic effect [2].

Because cystectomy is a major surgery with complex

surgical procedures; the patients carry several bags for

drains, external catheters and cystostomy tube which

may cause restriction of patient postoperatively. Minor

surgical modifications have been reported including

omitting gastrostomy or cystostomy tube, and internaliz-

ing the ureteral stents as the experiences with any diver-

sion technique increased over the decades since they

have been first popularized [2-4]. We present our surgi-

cal experience with modification of internal stenting for

bladder substitution.

2. Technique

The indications and surgical techniques for open radical

cystectomy, including extended pelvic lymph node dis-

section, have been described previously [5]. Diversion

types performed were either T Pouch or Studer type uri-

nary diversion as described previously [6,7]. The or-

thotopic bladder substitute was performed by isolating 50

- 60 cm of ileum, 25 cm proximal to the ileocecal valve.

Both ureters were isolated. The left ureter was mobilised

up to the lower pole of the kidney with care to maintain

its surrounding blood supply. The left ureter was trans-

posed to the right side through a retrosigmoidal tunnel.

Once the pouch has been closed, each ureter was

spatulated and a standard, bilateral end-to-side uretero-

ileal anastomosis was made to the proximal portion of

the afferent limb using interrupted 4 - 0 polyglycolic acid

suture. Prior to completion of the anastomoses each

ureter was stented with a 8F feeding catheter (8F Levin’s

Tube 65 - 75 cm long) that is cut open-ended both side.

These anastomoses were stented with 8F infant-feeding

tubes, which are directed from the ipsilateral renal pelvis,

across the uretero-ileal anastomosis through the afferent

limb into the reservoir and out of the pouch (Figures 1 (a)

- (d)). A 22 - 24 F foley catheter was placed urethrally to

provide adequate drainage of the reservoir and the uret-

eric stents were secured to the tip of the urethral catheter

with nonabsorbable 0 Prolene sutures (Figures 2 (a) -

(d)). This facilities removal of the stents at postopera-

tively 3 weeks, along with the urethral catheter. A ten-

sion free mucosa-to-mucosa urethro-ileal anastomosis

as made at the end of procedure. w

G. ASLAN

Figure 1. (a) ureteral stent introduced to afferent limb of reservoir where ureter anostomosis is done; (b) ureteral stent

passed through the reservoir to the distal open end of neobladder and grasped by atraumatic Allis clamp; (c) Proximal 20 -

25 cm of catheter segment directed to the kidney through ureter; (d) both ureteric end-to-side anastomosis are completed.

We routinely do not use an additional suprapubic

cystostomy tube. Our irrigation protocol consisted of daily

irrigations every 4 h in order to keep the neobladder free

from accumulated mucus. The frequency of irrigations was

tapered down during the first postoperative week. All pa-

tients were trained by the nursing staff how to irrigate their

neobladder twice daily until the catheter was removed.

Patients were followed up at 2 weeks and 1, 3 months

postoperatively and continued every 6 months thereafter.

3. Results

From 2006 to 2010, 21 (19 males and 2 females) with a

median age of 59 (54 - 66) years underwent orthotopic

ileal neobladder operation. The median total operating

time was 330 (270 - 390) minutes. The median blood

loss was 500 mL (400 - 1000 mL). The median number

of lymph nodes removed was 19 (11 - 29). No intraop-

erative adverse event was observed in any patient.

Prolonged urinary leak from the ureteroilial anastomo-

sis (15 days postoperatively) was observed in one patient

which ceased after insertion of percutaneous nephrostomy

catheter and recovered with no further intervention. No

cystogram was performed before removing the Foley

catheter. The median hospital stay was 11 (7 - 21) days.

Postoperative ileus developed in 5 (23.8%) patients. No

patient needed surgical intervention for ileus and all

G. ASLAN

Figure 2. (a) both ureteric stents passed through the afferent limb into the reservoir and out of the neourethra; (b) Stents are

secured to the tip of the catheter with non absorbable suture; (c) tied; (d) Foley catheter and anchored stents directed to the

reservoir to create single urethral catheter drainage.

episodes of ileus resolved with standard treatments [8].

There was no bowel anastomosis leakage. No docu-

mented urinary tract infection determined in any patient.

Stent migration, premature dislodgement, stent occlusion

or incrustation was not observed in an y patient. We have

not determined any Foley catheter blockage due to plug

and Foley catheters were not changed in any patient.

Ureteral stents could be taken out easily by pulling out

the Foley catheter at 2 - 3 weeks.

Median follow-up time was 3 years (2 - 4 years). Stric-

tures of the ureteroileal anastomosis occurred in 2 of

patients in the first postoperative year and were treated

with open reimplantation.

4. Discussion

Stenting of the ureteroileal anastomosis has been shown

to have significant beneficial effect with decreased early

postoperative upper urinary tract dilatation, improved

recovery of bowel function and decreased metabolic

acidosis [9]. Conventionally both open-ended straight

ureteral catheters, brought out through a stab wound in

the reservoir and anchored to the skin are typically used

for ureteroileal stenting in orthotopic neobladders [2,6].

In addition to ureteric splints cystostomy tubes for

neobladder, urethral catheter, drains and gastrostomy

tube (some of centers) taken out externally through the

18 G. ASLAN

abdominal wall and therefore, the patients have to carry

several bags, with resultant of patient restriction and dis-

comfort. Apart from cosmesis and patient acceptability

suprapubic tubes may cause morbidity such as stent mi-

gration, urinary leak when they were taken out from the

neobladder or even persiste nt neobladder fistula [10] . Thus

several modifications of techniques have been proposed

those for tubes and ureteric stents [3,4]. Internal ureteral

stents anchored to foley catheter as we show here is de-

scribed elsewhere; however no published long term results

of this technique exist since then [11]. More recently dou-

ble J stents have been favored as internal splint acro ss the

ureteroilial anastomosis with good results [3,4]. However,

the disadvantages of this internal stenting are the need to

remove the stents with cystoscope and their expensiveness

compared to feeding tubes. More recently similar to the

technique we used double j stents are anchored to the

Foley catheter as urinary drainage with single urethral

catheter to be removed at 3 weeks [4].

The technique we used herein did not lead to any un-

toward events. We have not observed any significant

surgical or infectious complication or any catheter re-

lated problem due to single urethral catheter. There is

certain risk of catheters getting blocked. However with

frequent foley irrigation postoperatively this may be

avoided. We used infant feeding catheter as ureteral stent

with open en ded both sides. When anyway foley catheter

or ureter catheter need to be changed postoperatively;

Foley can be pulled slowly to level 1 - 2 cm distal to ex-

ternal meatus then a guidewire can be inserted through

the open end of ureteral stent and a catheter can be in-

serted over the gu idewire fluorosco pi ca ll y.

Internal ureteral stenting is simple, safe and inexpen-

sive alternative to conventional methods for supporting

of the ureteroileal anastomosis in patient undergoing

orthotopic bladder substitution.

5. References

[1] R. E. Hautmann, B. G. Volkmer, M. C. Schumacher, J. E.

Gschwend and U. E. Studer, “Long-Term Results of

Standard Procedures in Urology: The Ileal Neobladder,”

World Journal of Urology, Vol. 24, No. 3, 2006, pp.

305-314. doi:10.1007/s00345-006-0105-z

[2] R. Thurairaja, F. C. Burkhard and U. E. Studer, “The

Orthotopic Neobladder,” British Journal of Urology In-

ternational, Vol. 102, 2008, pp. 1307-1313.

[3] I. M. Varkarakis, A. Delis, A. Papatsoris and C. De-

liveliotis, “Use of External Ureteral Catheters and Inter-

nal Double J Stents in a Modified Ileal Neobladder for

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[4] A. Mandhani, A. Dharaskar and R. Kapoor, “Technical

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[6] U. E. Studer, C. Varol and H. Danuser, “Orthotopic Ileal

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[7] J. P. Stein and D. G. Skinner, “The Orthotopic T-Pouch

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[8] B. Pearson and S. D. Wexner, “The Management of Post-

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[9] A. Mattei, F. D. Birkhaeuser, C. Baermann, S. H.

Warncke and U. E. Studer, “To Stent or Not to Stent Pe-

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thotopic Bladder Substitutes and Ileal Conduits? Results

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[10] H. M. Abd Alla and A. A. Attia, “Lower Urinary Tract

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[11] S. D. Mark and G. D. Webster, “Simplified Urinary

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