Introduction: An important complication of radical cystectomy and urinary diversion is benign uretero-enteric anastomosis (UEA) stricture, with reported rates of around 15-20%. In this study, we reported the impact on UEA stricture formation from the introduction of a multi-modal surgical technique combining the use of fluoroscence imaging visualization of ureteral blood flow, a wound-healing promoting wrap of decellularized umbilical tissue, and a retro-sigmoidal ileal conduit reconstruction to alleviate left ureteral tension.
Methods: We retrospectively reviewed patients with bladder cancer undergoing robotic-assisted radical cystectomy (RARC) and intracorporeal ileal conduit in our center by the same urologist (MMS) from December 2015 to June 2020. Patients were divided into two groups based on the ileal conduit reconstruction (multi-modal retro-sigmoidal conduit or standard conduit with optional use of fluoroscence imaging/wound-healing promoting wrap). Patients demographics, postoperative complications and UEA status were collected and compared between groups. KM curves were used to evaluate the UEA stricture between groups.
Results: 52 patients received RARC and intracorporeal ileal conduit and 45 had been followed up, with 25 in the standard group and 20 in the retro-sigmoidal group. Most variables were comparable between groups. With a median follow-up time of 19 months (IQR 6-36) in standard group vs 8 months (IQR 4.75-11.5) in retro-sigmoidal group, the global UEA stricture rates were 34.8% vs 0% in the retro-sigmoidal group (p=0.009, Figure 1). The left UEA stricture rate was 24% in standard group and the right UEA stricture rate was 16% in standard. Among the 10 benign UEA strictures (per ureter), the median time of stricture formation was 6months (IQR 3-8.5). The postoperative 30-day, 90-day complication rate, and 30-day readmission rate were comparable between groups.
Conclusions: The use of this multi-modal retro-sigmoidal ileal conduit technique in RARC may reduce the UEA stricture rate. Further studies with larger cohorts are needed to validate this finding as well as help elucidate if some components of the multi-modal intervention are most important.