Chad R. Ritch, MD, MBA
David F. Penson, MD, MPH
BASICS
DESCRIPTION
• Ureteroenteric anastomotic stricture (UE) is typically a benign obstruction of the ureter at the level of the sutured anastomosis following an intestinal urinary diversion
– Typically benign process that develops 7–18 mo postoperatively (1)
most often performed in setting of radical cystectomy and ureteral/bowel anastomosis; therefore, recurrent malignancy must be ruled out (malignant stricture)
EPIDEMIOLOGY
Incidence
• Various series report range of 3–10% (1,2)
– More common on left (1,2)
Prevalence
N/A
RISK FACTORS
• Surgical technique is the main risk factor
– Aggressive handling of the ureter leads to stricture formation
Avoid stretching, grasping, skeletonization, and tension on the ureter
– A non-refluxing anastomosis may be more prone to stricture formation than a refluxing anastomosis
– Suture-line gaps lead to urine leak and predispose to stricture
Genetics
N/A
PATHOPHYSIOLOGY
• Aggressive handling, suboptimal technique devascularizes tissue causing poor blood flow and ischemia.
– Ischemia interferes with healing of ureteral tissue and causes scarring and stricture formation
Urine leakage causes inflammation around anastomotic site
Lack of mucosa to mucosa apposition impairs healing
ASSOCIATED CONDITIONS
• Any condition where urinary tract surgery requires urinary diversion using a bowel anastomosis
– Bladder carcinoma
– Neurogenic bladder
– Gynecologic malignancies
– Pelvic exenteration for rectal cancer
GENERAL PREVENTION
• Good surgical technique essential
– No grasping of ureter with instruments, may crush and devascularize tissue
– Maintain good blood supply—Avoid skeletonization
– Minimize stretching and tension
– Ensure mucosa to mucosa apposition
– Balance watertight anastomosis with excessively close/tightened suture line
– Ureteral stent may prevent urine leak
DIAGNOSIS
HISTORY
• Complaints of flank pain or fever and UTI suggestive of pyelonephritis
– Typically presents 6–18 mo after surgery
Chronic as opposed to acute process
PHYSICAL EXAM
• Dull achy pain on palpation of flank
– May be sharp if associated with infection
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• In the case of unilateral stricture with an unaffected contralateral kidney, often no significant abnormal laboratory findings.
– May have transient rise in serum Cr
– A urine analysis or dipstick evaluation may demonstrate elevated leukocyte esterase and white blood cells consistent with inflammation. Presence of urinary nitrites and bacteria may occur with concomitant UTI but should be interpreted with caution due to the presence of bowel in the urinary tract.
– If bilateral strictures are present or patient has poorly functioning or absent contralateral kidney, patient may present with markedly elevated serum creatinine and acute renal failure (hyperkalemia, marked acidosis)
Imaging
• Renal ultrasound or CT imaging are initial diagnostic modalities of choice
– Ultrasound cost-effective and highly sensitive for demonstrating obstruction
– CT imaging with pre- and post-IV contrast dye can provide further anatomic and functional information.
More costly than US and risk of radiation exposure and contrast-dye allergy in susceptible patients
Some patients may have compromised renal function that precludes the use of IV contrast
– MRI may also be considered if US unavailable and contraindications to CT imaging
– If kidney appears atrophic consider renal scan to assess function
Poorly functioning kidney (<15%) better served with nephrectomy than UE stricture repair
Diagnostic Procedures/Surgery
• If hydronephrosis found, consider percutaneous antegrade contrast instillation (nephrostogram) of affected side.
• If ileal conduit urinary diversion, instillation of contrast dye directly into the ileal loop (loopogram) may be considered as alternative to nephrostogram
– Ileal conduit has refluxing anastomosis so loopogram will demonstrate reflux of contrast up the ureter if hydronephrosis not due to obstruction.
If no reflux is demonstrated on loopogram, then cause of hydro is likely stricture
Loopogram is less costly and noninvasive compared to nephrostogram
Nephrostogram can be therapeutic by providing instant drainage via nephrostomy as well as provide access for endoscopic treatment (see “Treatment”)
– Retrograde pyelogram very difficult due to inability to locate and cannulate ureteroenteric orifice during loop endoscopy
Pathologic Findings
Inflammation and scarring identified on pathologic specimen following open surgical revision and excision
DIFFERENTIAL DIAGNOSIS
• Urine reflux
• Ureteral stone
• Extrinsic compression
• Ureteral kinking
• Recurrent malignancy
• Pyelonephritis
– Differential can be explored with CT or MR imaging which will provide anatomical detail
TREATMENT
GENERAL MEASURES
• Consider pain relief if obstruction causing hyrdonephrosis and flank pain
– Rule out and treat UTI if suspected
UTI, fever, and presence of obstruction is a medical emergency with increased mortality
Treat with urgent decompression via nephrostomy tube and systemic antibiotics
• If patient comfortable and no evidence of infection, then consider elective repair
MEDICATION
First Line
• No therapeutic medications
• Consider narcotics and anti-inflammatories for temporary relief of pain
• If infection noted and patient clinically stable, mildly symptomatic, treat with fluoroquinolone or culture specific antibiotics for 7–14 days
• Asymptomatic infection can be treated prior to elective repair
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Nephroureteral or antegrade ureteral stent placement for temporary relief of obstruction or in the setting of palliative care
• Definitive therapy: Open versus endoscopic repair
– Decision is based on surgeon experience, prior attempts at repair (primary vs. secondary) and length/complexity of stricture
– Retrospective series suggest higher success rates with open repair (see below)
– Indwelling stent for 2–3 wk after repair
• Open surgical repair
– Recommended for strictures >1 cm and failed endoscopic repairs
– Success rates of up to 71.4–100% reported for primary open revision (2,3)
– Difficult procedure with mean reported operative time of 240+ (145–450) min, EBL 300+ (150–500) cc (2,4)
• Endoscopic repair
– Recommended for stricture <1 cm and primary repairs
– Typically performed antegrade with Ho:Yag laser or Accucise device (2,5). Balloon dilation less commonly used and may be less efficacious.
– Success rates of 26–50% reported for primary repair (3 – 5).
– Secondary or redo endoscopic repair has low success rate (35%) (5)
– Left side strictures and those >1 cm in length appear more prone to failure after repair (2,5)
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• If ureteral stricture very long, ureter devascularized or insufficient length and renal unit still functional consider bowel interposition (ileal ureter)
• If renal scan demonstrates poorly functioning kidney (<15%) consider nephrectomy
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Mean time to failure after open and endoscopic repair are 12 and 5 mo, respectively (3)
– Left sided and redo repairs are at higher risk for failure
COMPLICATIONS
• Uretero enteric stricture
– Stone formation
– Hydronephrosis
– Renal insufficiency
– Pyelonephritis
• Open repair: complication rate of up to 40% (2,4)
– Complications include vascular injury, contralateral ureteral injury, urine leak, damage to diversion bowel segment, bowel injury (2,4).
• Endoscopic repair:
– Complications are rare, most common is infection (UTI/urosepsis) (2,3,5)
FOLLOW-UP
Patient Monitoring
• Consider renal U/S at 6 weeks following repair
– If hydronephrosis present consider waiting 2 wk (potential post-op anastomotic edema) and perform repeat imaging with contrast based study to rule out obstruction/failure
Reflux may occur following repair so should also rule out as possible cause of hydronephrosis
Patient Resources
N/A
REFERENCES
1. Anderson C, Morgan TM, Kappa S, et al. Ureteroenteric anastomotic stricture after radical cystectomy—Does operative approach matter? J Urol. 2013;189;541–547.
2. Laven B, O’Connor RC, Gerber GS, et al. Long-term results of endoureterotomy and open surgical revision for the management of ureteroenteric strictures after urinary diversion. J Urol. 2003;170:1226–1230.
3. Milhua P, Miller NL, Cookson MS, et al. Primary endoscopic repair versus open revision of ureteroenteric strictures after urinary diversion—single institution contemporary series. J Endourol. 2009;23;551–555.
4. Nassar O, Alsafa M. Experience with ureteroenteric strictures after radical cystectomy and diversion: Open surgical revision. Urology. 2011;78;459–465.
5. Schöndorf D, Meierhans-Ruf S, Kiss B, et al. Ureteroileal strictures following urinary diversion with an ileal segment: is there a place for endourological treatment at all? J Urol. 2013;190(2):585–590.
ADDITIONAL READING
Ureteroenteric Anastomotic Strictures after Radical Cystectomy: Does Operative Approach Matter? Download supplemental table. https://www.mc.vanderbilt.edu/root/vumc.php?site=urologicsurgery&doc=32446
See Also (Topic, Algorithm, Media)
• Hydronephrosis/Hydroureteronephrosis, (Dilated Ureter/Renal Pelvis), Adult
• Ureter, Obstruction
CODES
ICD9
• 593.3 Stricture or kinking of ureter
• 867.2 Injury to ureter, without mention of open wound into cavity
• 997.5 Urinary complications, not elsewhere classified
ICD10
• N13.5 Crossing vessel and stricture of ureter w/o hydronephrosis
• N99.89 Oth postprocedural complications and disorders of GU sys
• S37.10XA Unspecified injury of ureter, initial encounter
CLINICAL/SURGICAL PEARLS
• Avoid aggressive handling of the ureter to prevent devascularization and ischemia during urinary diversion operation.
• Ureteral obstruction, fever, and UTI in a patient with a urinary diversion requires emergent treatment with percutaneous drainage.
• Open primary repair of UE stricture has higher success rate than endoscopic repair.
• Open repair is complex procedure best performed in experienced hands.