Uretero-Enteric Anastomosis Stricture after Urinary Diversion; Detailed Analysis of The Responsible Factors and Their Impact on The Management

1. Abstract
1.1. Objective: To report the lessons we have learned in the management of uretero-enteric anastomosis stricture (UEAS) in a tertiary urology center over a decade of experience.
1.2. Methods: This study included 52 patients (69 renal units) with UEAS (36 males and 16 females). Endoscopic treatment was utilized for short, passable and early strictures, while open surgical revision for impassable and failed endoscopic treatment. Complications of treatment were graded according to the modified Clavien system. Patients were followed up regularly for one year to assess the outcomes of treatment.
1.3. Results: Age range of the patients was 48-71 years. Median (Interquartile range [IQR]) of follow up was 20 (18-28) months. Hospital stay ranged from 2-3 days in patients subjected for endoscopic treatment and 3-15 days in case of open surgery. In patients who underwent open surgical revision, 2 (5.4%) patient had minor vascular injury (external iliac artery and vein, each in one patient) and 2 (5.4%) patients had enteric injuries which were primarily repaired. After treatment, abdominal US showed decompression of the pelvicalyceal system in 41 patients and mild residual pelvicalyceal dilation in 11. Recurrent strictures developed in 7 (13.5%) patients (4 after open treatment and 3 after endoscopic treatments) on follow up
1.4. Conclusions: Endoscopic treatment of UEAS is an appealing first choice that utilizes regional anesthesia, has minimal or no blood loss, results in minimal postoperative complications and shorter hospitalization. However, open surgical treatment is considered the suitable choice for long impassable strictures.
2. Introduction
Radical Cystectomy (RCX) and Urinary Diversion (UD) is the standard treatment for muscle invasive bladder cancer. It is a multistep surgery with high rate of complications even in highly experienced centers. One of its crucial steps is the Uretero-Enteric Anastomosis (UEA) [1].
Uretero-enteric anastomosis stricture (UEAS) management is the most frequent secondary surgical procedure after UD [2]. Its rate varies from 1.3‒13%. Its occurrence may be related to the preoperative state of ureters, how it were dissected and anastomosed to the future reservoir and the presence of prolonged leakage postoperatively [3].