Hybrid Ureteroenteric Anastomosis Is Associated with Lower Stricture Rates in Ileal Conduit Urinary Diversion

Abstract

BackgroundAnatomic complications of the ureteroenteric anastomosis in ileal conduit (IC) cause significant morbidity in patients post-cystectomy and cystoprostatectomy. The Bricker technique has a perceived disadvantage of increased risk for stricture, whereas the Wallace technique runs the risk for ureteral malignancy affecting both ureteric ends, and bilateral ureteric obstruction from a stone lodged at the anastomosis. We aimed to evaluate the safety, efficacy, and stricture rate of a novel hybrid ureteroenteric anastomosis technique. We compared these outcomes to the Bricker and Wallace anastomosis techniques for IC urinary diversion (ICUD). MethodsWe performed a retrospective chart review of patients who had undergone ICUD after cystectomy for bladder cancer from 2011 to 2016. Patients were categorized into groups undergoing the Bricker, Wallace, and hybrid ureteroanastomosic techniques. Strictures were identified during clinical follow-up or hospital presentations with complications. ResultsWe identified 68 patients suitable for inclusion. They were separated by Bricker, Wallace, and hybrid anastomosis techniques, with 19 (27.9%), 20 (29.4%), and 29 (42.6%) patients, respectively. Ureteroenteric anastomotic strictures occurred in 9 patients (5 Bricker, 3 Wallace, 1 hybrid). This difference in stricture rates for Bricker versus hybrid (26.3% vs. 3.4%; OR, 10 [95% CI, 1.1 to 121.1]; P = 0.02) was significant but was comparable for Wallace versus hybrid (15.0% vs. 3.4%; OR, 4.9 [0.7 to 66.0]; P = 0.15) and for Bricker versus Wallace (26.3% vs. 15.0%; OR, 2 [0.4 to 8.6]; P = 0.87). 15 patients (51%) in the hybrid group required oral antibiotics for a symptomatic urinary tract infection compared with 4 (21%) with Bricker and 8 (40%) with Wallace (P = 0.10). Median post-cystectomy follow-up and stricture formation time were 16 months (IQR, 4–36) and 9 months (7–32), respectively. ConclusionThe hybrid technique is a safe and efficacious alternative to the Bricker and Wallace anastomoses. It carries with it a risk for urinary tract infection that is eclipsed by substantially lowered rates of ureteric strictures requiring intervention while maintaining the advantage of separating the two ureters.

Keywords

• ileal conduit
• urinary diversion
• bricker
• wallace
• hybrid
• stricture
• retrospective