Ureteroenteral Anastomotic Strictures in Continent Diversions

Rates of ureteral obstruction vary depending on the type of pouch and ureteral anastomosis, with a reported 3% incidence for Kock reservoirs (180) and a 10% incidence for the modified Indiana pouch (181). Wilson et al. (181) reported dismal results with combined therapy of balloon dilation and incision of strictures. The failure rate of percutaneous therapy was 83%, whereas subsequent ureteral reimplantation was successful in 91%. They also reported an increased risk for stricture complications in patients who received preoperative radiation therapy, whereas Frazier et al. (150) reported no increase in the risk of long-term complications with radiation therapy. Strictures that develop in patients with orthotopic neobladders appear to respond more favorably than do those in ileal conduits or cutaneous continent diversions (177).

A few technical points need to be emphasized at this juncture. The antegrade route is the safest and most practical approach for stricture dilation because there is no reported experience regarding the feasibility and safety of cannulating nonre-fluxing ureterocolonic anastomoses. After dilation, an 8 to 10 French stent is placed across the anastomosis, with its distal end in the colonic pouch and the proximal end obturated to prevent intrarenal reflux of mucus. In addition, a nephrostomy catheter is placed within the renal pelvis to facilitate drainage of the kidney. There are no reports regarding the effect of balloon dilation on the antireflux properties of the anastomosis, but our own experience indicates no significant ureteral reflux when the balloon dilation is successful. After a 6- to 8-week period of stenting, the ureteral stent is removed, and the effects of balloon dilation are assessed by a nephrostogram performed via the remaining nephrostomy catheter. When open surgical repair of the anastomotic stricture becomes necessary, the preoperative placement of a stent across the stricture (through a nephrostomy access) is helpful because it facilitates identification of the ureter (181).

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