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Introduction

Orthotopic bladder substitution using different bowel segments is the standard of care in selected patients after cystectomy [1]. The main goal is to create a neobladder with similar attributes as a normal bladder. It should store urine at low pressure and high capacity, empty volitionally and preserve the structural and functional integrity of the upper urinary tract [2].

The uretero-enteric anastomosis is an integral and very important part of the procedure. The ideal anastomosis should posses several attributes. It should be easy to perform in ureters with different lengths and calibres and in all types of bowel segments; it should be easily reproduced even by less experienced surgeons and should have a low risk of complications. Originally the protection of the upper urinary tract from the reflux was strictly recommended [3,4]. However based on long term experience, the anti-reflux techniques are connected with a high risk of stricture formation. Moreover, the question of whether an antireflux mechanism is important in large volume, low pressure neobladder has been widely discussed recently [2].

In our study we have evaluated the results of direct reflux ureteroenteric anastomosis in patients with orthotopic ileal neobladder.

Material and methods

Since 2001 orthotopic bladder substitution was performed in 12 female and in 39 male patients. A preterminal ileal segment of 50-60 cm was used to create the neobladder. The segment is opened antimesenterically except for the proximal 5-7 cm which serves as the iso-peristaltic limb. From the detubularized ileum the N or W shaped pouch is created using absorbable running suture. In the most caudal part of the neobladder the opening for anastomosis with urethral stump is created.

The ureters are mobilized and the left is pulled to the contralateral side through a wide aperture in the mesentery. They are implanted into the afferent segment using a direct anastomosis. In 45 patients the Wallace I modification was used [5]. In this technique the ureters are widely spatulated and a ureteric plate is created by suturing their edges with a running suture. This plate is anastomosed to the proximal end of the afferent segment in end-to-end fashion using a running absorbable suture. In the remaining 6 patients an end-to-side anastomosis into the afferent segment by direct Nesbit technique was performed [6].

The ureters are drained with 6 or 7 F ureteric stents which are removed 12-14 days postoperatively. The neobladder urethral catheter is removed after pouchogram on the 21st postoperative day. Postoperative care included thorough monitoring of catheter patency, its irrigation if necessary, parenteral antibiotics for 10-12 days and a regular follow up of serum electrolyte and renal function.

The upper urinary tract was imaged by ultrasound before discharge from the hospital (usually one day after the urethral catheter removal), one month thereafter and at 3 months interval subsequently. The IVU (the intravenous urogram) was performed routinely 6 months after the surgery and in cases of persistent or new dilatation of upper urinary tract on ultrasound. Serum electrolytes and creatinine were checked one month after discharge from hospital and in 3 months period thereafter.

Results

We have evaluated the results of 101 ureteric implantations in 51 patients. There was no death in early postoperative period but 12 patients (23.5%) had early complications requiring prolonged hospitalization or surgical revision. The list of the complications is given in table I. There were no early complications that could be attributed to the ureterointestinal anastomosis.

During the follow-up of 6-60 months, there were 12 late complications in 11 patients (table number II). Stricture of the ureteroileal anastomosis occurred in 5 patients (9.8%) in 5 ureteric units (4.95%). The stricture occurred during the first year after surgery in all cases.

The stenosis was situated on the left side in 4 patients and on the right side in one case only. The treatment was a reimplantation in 1 case and an antegrade endoscopic dilation of the anastomosis and insertion of stent in 2 cases. Two patients were managed conservatively with grade II dilation of the upper urinary tract without an increase of the serum creatinine level. No episode of acute pyelonephritis or deterioration of renal function was observed in patients without stricture in ureteroileal anastomosis.

Discussion

Orthotopic bladder substitution is currently accepted as a safe form of urinary diversion after cystectomy with an excellent quality of life [1]. This procedure is the treatment of choice in our institution in selected male and female patients with bladder cancer after cystectomy.

Ureterointestinal anastomosis is one of the key issues in patients with urinary diversion. Over the last two decades, antireflux anastomoses have been emphasised by many authors due to its upper urinary tract protection against the reflux.

As early as in 1951 Leadbetter and Clarke described a combined technique with a long, extracolonic, seromuscular tunnel used in ureterosigmoideostomy. Later, in 1953 Goodwin showed similar and sophisticated improvement with creating a tunnel within the bowel. This approach, widely known as the Goodwin submucosal tunnel enables safe creation of the tunnel and careful mucosal anastomosis under direct vision [7]. Because of difficult creation of a tunnel into the small bowel, Goodwin technique is not used in ileal neobladders. It can be, however, applied in all types of colonic continent diversions. When using Mainz pouch I upper urinary tract dilatation was reported in 8 out of 100 operated patients [4].

The most used form of anastomosis in ileal neobladders was Le Duc "mucosal-through" technique. In this method the ureter is placed in a sulcus created in the ileal mucosa. The sulcus is achieved by 3 cm long incision through the entire thickness of the mucosa as far as the submucosa. The ureter is introduced into the bowel lumen through a hole made at the proximal end of the sulcus. The ureter is fixed with absorbable sutures to the edges of the mucosa along the sulcus [3]. The initial experience showed a very low stricture rate of 1.5 %, but several further reports presented less optimistic results with stricture rates of 9.3 to 31.6% [2,8-10]. In our department the risk of stenosis with Le Duc anastomosis was approximately 15% (unpublished data).

The reason of stricture formation in Le Duc anastomosis is not completely understood. One possible explanation is direct contact of urine with ureteric adventitia which is not completely covered with ileal mucosa, which leads to an inflammatory reaction and scar formation (9). On the basis of this hypothesis, Muraishi described a modification of the technique which is based on complete covering of ureter with mucosal flaps and decreasing submucosal tunnel length [11]. His single institution results from 44 patients showed good experience and low stricture rate. There is, however, no other available report on this technique, which could confirm these promising results. Another modification was described by Schweibold with wide spatulation of terminal ureter. He reported low stricture rate, however, the results were not confirmed by any other authors too [12].

A very sophisticated method which could be used easily in practice in all bowel segments and in all types of continent diversions is a technique described by Hassan as seromuscular tunnel [13]. In this method two serosa lined troughs are created during the construction of the pouch by joining the seromuscularis of two lateral flaps. The ureter is laid down in the ipsilateral trough and mucosa-to-mucosa anastomosis between the spatulated end of the ureter and the intestinal mucosa of the distal end of the trough is performed. The mucosal edges on each side are approximated over the ureter, which makes the trough transformed into an extramural serous lined tunnel. Stricture rate of Hassan technique in orthotopic ileal neobladders was reported as low as 3.8%.

In the 80´s, Studer preferred direct ureterointestinal anastomosis, in which the tubular segment serves as the isoperistaltic limb and protect the upper urinary tract against the reflux [14]. For anastomosis of ureters with afferent segment the end-to-side anastomosis is used since 1949 when it was introduced by Nesbit. The operation consists of the spatulation of the ureter, longitudinal incision in the wall of the bowel and connection of the ureter and intestine by using a single layer running suture. The suture runs through the entire wall thickness of both structures with careful adaptation of mucosal edges [6].

The direct refluxing implantation of one or both widely spatulated ureters into the afferent limb of orthotopic neobladder can also be performed in direct end-to-end fashion. This technique was described by Wallace and originally used in ureteroileostomy [5].

Antireflux ureteric implantation is an integral part of continent urinary diversion. However the question is whether it is necessary in orthotopic neobladders where the leak point of the urethral resistance protects the reservoir from overfilling. Results of some studies have been presented recently which compare an antireflux anastomosis and a direct anastomosis into the afferent limb [15-17]. In all cases the direct refluxing anastomosis had significantly lower stricture rates. Moreover the deterioration of renal function was observed only in patients with obstruction but not in patients with reflux [16,17].

Our experience confirms low stricture rate of direct refluxing anastomosis into afferent limb of orthotopic ileal neobladder. With increasing experience we can even expect the decrease of risk of the stricture formation. Four out of five strictures were seen among first 30 patients.

According to the anatomical situation the end-to-end (Wallace) or end-to-side (Nesbit) anastomosis can be used [18]. There is no definition of optimal afferent limb length, but many authors have been using substantially shorter afferent segment contrary to Studer's suggestion [1,14,19]. We have gradually shortened the afferent segment to 5-7 cm without any postoperative deterioration. But it is important to be aware of the fact that a longer afferent segment enables more significant distal ureter shortening, which can be advantageous in case of insufficient vascular supply. This is the reason for our recommendation of different length according to the individual circumstances.

Apparently, there exists no technique of ureterointestinal anastomosis these days without a risk of stricture formation with subsequent obstruction of the upper urinary tract. Despite, majority of departments prefer the direct refluxing ureteroenteric anastomosis in orthotopic neobladders. And this also refers to authors who initially emphasised the need for antireflux anastomosis [16,17]. Regardless of this it is important that the creation of neobladder with large capacity and low intraluminal pressure is necessary for the upper urinary tract preservation [20]. The methods of antireflux ureteroenteric anastomosis, especially Goodwin and Hassan techniques, should be reserved for special situations and especially for heterotopic urinary diversions. Surgeon who is involved in urinary diversions should be familiar with these techniques [21].

Conclusions

The direct ureteroenteric anastomosis into the afferent limb of orthotopic ileal neobladder is a safe method with low stricture rate. It is currently considered as the method of choice in large capacity and low pressure orthotopic ileal neobladders.

The study was supported by the project MSM 0021620808.

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Marko Babjuk, MD
Urologická klinika VFN
Ke Karlovu 6
128 08 Praha 2
tel.: +420224967848
marko.babjuk@lf1.cuni.cz