Ann Surg Oncol DOI 10.1245/s10434-014-3591-z
ORIGINAL ARTICLE – UROLOGIC ONCOLOGY
Technique Selection of Bricker or Wallace Ureteroileal Anastomosis in Ileal Conduit Urinary Diversion: A Strategy Based on Patient Characteristics Longfei Liu, MD, Minfeng Chen, MD, Yuan Li, MD, Long Wang, MD, Fan Qi, MD, Jingeng Dun, MD, Jinbo Chen, MD, Xiongbing Zu, MD, and Lin Qi, MD Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, China
ABSTRACT Objectives. This study was designed to establish an individualized selection strategy for the two most common types of ureteroenteric anastomotic techniques (Bricker and Wallace anastomosis) used in ileal conduit (IC) diversion. Methods. Patients who underwent IC diversion after radical cystectomy for transitional cell carcinoma between January 2009 and December 2011 were prospectively collected. The choice of anastomosis type (Bricker vs. Wallace) was successively based on tumor characteristics, ureteral anomalies, and ureteral length after retrosigmoidal tunneling. Results. Ninety-nine patients were enrolled in the final study. Fifty-three patients underwent Bricker anastomosis, and 46 underwent Wallace anastomosis. Ureteral stricture developed in 6 (6.1 %) patients and the overall stricture rate for all ureters was 3.1 % (6/196). Strictures occurred at an average of 13.3 months after surgery and were predominately located in the left ureter (66.7 %, 4/6). The difference in the ureter stricture rates between the two groups was not statistically significant: 3.8 % (4/104) and 2.2 % (2/92) for Bricker and Wallace, respectively (p = 0.686). There were no significant differences in age, sex, body mass index (BMI), prevalence of pelvic radiation therapy, length of stay, follow-up time, or time to stricture between the two techniques. Patients in whom stricture
Ó Society of Surgical Oncology 2014 First Received: 13 July 2013 X. Zu, MD e-mail: [email protected] L. Qi, MD e-mail: [email protected]
developed had a significantly higher mean BMI compared with those without stricture (25.2 vs. 23.3 kg/m2, respectively; p = 0.008). Conclusions. Our preliminary outcomes demonstrate that this selection strategy of Bricker vs. Wallace anastomosis seems to be clinically reliable, providing an acceptable low ureteral stricture rate of 3.1 %. However, the potential advantage for oncologic control of this strategy is needed to further confirm.
Although orthotopic neobladder reconstruction is becoming more popular for urinary diversion in patients undergoing radical cystectomy for invasive bladder carcinoma, the ileal conduit (IC) is still believed to be an appropriate form of urinary diversion after radical cystectomy in most patients because of its relative simplicity, acceptable complication rate, and satisfactory postoperative quality of life.1,2 The two most common forms of ureteroenteric anastomosis for IC diversion are the Bricker (separate, end-to-side, refluxing) and Wallace (conjoined, end-to-end, refluxing) techniques.3–5 However, the choice between these two forms of anastomosis has puzzled surgeons for the last few generations.6,7 Each of these two techniques has a perceived disadvantage.2,5–8 The Bricker approach has been criticized for an increased stricture rate. On the other hand, the Wallace technique has an increased potential for bilateral renal obstruction caused by recurrence at the ureteroenteric anastomosis or the possibility of stones. Despite the fact that a few previous studies have evaluated the success and complications of the two techniques, there are no clear answers to the question of which is the better technique.5–9 Clinical indications for each technique have not been systematically established, and the choice of the anastomosis type is mostly based on surgeon preference.5,7
L. Liu et al.
In this study, we established an optimal technique selection strategy for ureteroenteric anastomosis (Bricker vs. Wallace) based on patient characteristics and evaluated its preliminary clinical outcomes. MATERIAL AND METHODS Between January 2009 and December 2011, patients who underwent IC after radical cystectomy for transitional cell carcinoma were prospectively collected at a large urology center in South Central China. The study was approved by the Institutional Ethics Committee of Xiangya Hospital of Central South University, and written, informed consent was obtained from each patient. Indications for radical cystectomy included muscle-invasive cancer, recurrent superficial or early-stage invasive tumors, and refractory carcinoma in situ (CIS). Patients with complete clinical information and adequate follow-up (defined as [6 months) were enrolled in our study. We excluded patients who underwent radical cystectomy for nontransitional cell tumors or nonmalignant conditions. No patients in the series had a history of inflammatory bowel disease. The diagnosis of bladder transitional cell carcinoma was dependent upon cystoscopy and histologic evaluation of bladder biopsies or resected tissue. When prostatic urethral abnormalities were visible cystoscopically, biopsies of the prostatic urethra were performed. The diagnosis of CIS was made using the combination of cystoscopy, urine cytology, and histologic evaluation of multiple bladder biopsies. All patients underwent routine computed tomography urography (CTU) examination, which was used to evaluate the clinical stage of tumors and the upper urinary tract. Frozensection examination of the ureteral margins was performed in all patients during cystectomy. In our series, the decision of which anastomotic technique (Bricker or Wallace) to use was based on patient characteristics rather than surgeon preference. Patient characteristics included three aspects: tumor characteristics, ureteral anomalies, and ureteral length after retrosigmoidal tunneling. The first decision was based on tumor characteristics. Five risk factors for upper urinary tract recurrence (UUTR) following radical cystectomy for transitional cell carcinoma were identified according to the literature and included prostatic urethra involvement, CIS, superficial bladder tumor, ureteral involvement or positive ureteral margin, and recurrent tumor.10–16 For patients with one or more risk factors for UUTR, the Bricker technique was performed. The second decision was based on ureteral anomalies. For example, if the patient had a solitary kidney, a single Bricker anastomosis was performed. If the patient had a duplicated system on one side, both procedures were performed (Wallace on the duplicated system on one side and Bricker on the contralateral side). The third
decision was based on the ureteral length after retrosigmoidal tunneling. When the ureteral length was similar on both sides, Wallace was preferred; when disparate, Bricker was preferred.1,5 The majority of the Bricker and Wallace anastomoses were performed by two attending surgeons with two senior-level residents as first assistants. All anastomoses were performed using a no-touch technique with 4-0 polyglactin sutures in an interrupted (Bricker) or running (Wallace) fashion. Each ureter was stented with a 7F single-J ureteral stent for 1 month. The first follow-up was performed 4 weeks after surgery. The patients were then evaluated every 3 months for the first year and every 6 months thereafter. Ultrasonography was used to monitor the upper urinary tract at each evaluation. Intravenous urography and CTU were performed if the upper urinary tract was dilated or if there was any evidence of tumor recurrence. The follow-up deadline was December 31, 2012. Data collected in this study included age, sex, body mass index (BMI), type of anastomosis, length of stay (LOS), follow-up time, history of pelvic radiation therapy, time to stricture formation, diagnostic radiological imaging for stricture, and treatment of stricture. All statistical calculations were performed using SPSS 16.0 software. Univariate statistical analysis was performed using the two-tailed Student’s t test (continuous variables) and Fisher’s exact test (categorical variables). Tests with p \ 0.05 were considered statistically significant. RESULTS Ninety-nine patients were enrolled in the final study. Fifty-three patients underwent Bricker anastomosis
TABLE 1 Number of patients with different factors influencing the choice of anastomosis technique Variables
Bricker
Tumor characteristics Ureteral anomalies
a
b
Ureteral length of both sides after retrosigmoidal tunnelingc
Wallace
d
0
15f
46
36 2
e
0
a
With one or more risk factors for upper urinary tract recurrence (UUTR), Bricker was performed
b
With single ureter or duplex ureters, Bricker or Wallace was performed, respectively
c
When similar or disparate, Wallace or Bricker was respectively performed
d
All 36 patients had positive risk factors for UUTR and also had similar ureteral length of both sides after retrosigmoidal tunneling
e
Both patients had a solitary kidney, and one of the two patients had positive risk factors for UUTR
f
Ten of the 15 patients had positive risk factors for UUTR
Selection Strategy for Bricker and Wallace Anastomosis
(53.5 %), and 46 underwent Wallace anastomosis (46.5 %). The number of patients with different factors influencing the choice of anastomosis technique is shown in Table 1. The rate in patients with at least one of these risk factors for UUTR is 47.5 % (47/99). Of note, two patients had a solitary kidney and thus underwent a single Bricker anastomosis. Therefore, a total of 196 ureters were included in this study. The demographic characteristics and operative outcomes of each anastomotic group are provided in Table 2. Six of 99 (6.1 %) patients developed ureteral strictures, all of which were Clavien Grade IIIb complications.17 The overall stricture rate for all ureters was 3.1 % (6/196). Ureteral strictures developed in 4 of 53 (7.5 %) patients who underwent Bricker anastomosis, and the total stricture rate for all ureters with this technique was 3.8 % (4/104). With Wallace anastomosis, 2 of 46 patients developed ureteral strictures, and the total stricture rate for all ureters with this method was 2.2 % (2/92). The difference in the stricture rate for ureters between the two groups was not statistically significant (p = 0.686). The mean follow-up was 30.2 ± 9.5 months for all patients. There were no significant differences in age, sex, BMI, prevalence of pelvic radiation therapy, LOS, follow-up time, or time to stricture between the Bricker and Wallace groups. Although there were no significant differences in BMI between the two techniques, the 15 patients who underwent Bricker anastomosis due to disparate ureter lengths had a higher mean BMI (25.8 ± 0.7) than that of patients who underwent Wallace anastomosis (23.5 ± 1.4) because of similar ureter lengths (p = 0). Strictures occurred at an average of 13.3 months after surgery and were predominately located in the left ureter (66.7 %, 4/6). When comparing patients in whom stricture developed with those in whom stricture did not develop,
TABLE 2 Demographic characteristics and operative outcomes of each anastomotic group Parameter
Bricker (n = 53)
Wallace (n = 46)
p
Renal units (n) Mean age (years)
104 61.9 ± 9.0
92 62.7 ± 8.6
– 0.675
44
38
0.957
Males (n) 2
Mean BMI (kg/m )
23.3 ± 1.9
23.5 ± 1.3
0.534
History of pelvic radiation therapy (n)
5
6
0.325
Mean LOS (days)
8.8 ± 2
9±2
0.642
Mean follow-up (months)
26.4 ± 10.2
26.3 ± 10
0.95
Ureteral stricture (n)
4
2
0.686
Median months to stricture
14 ± 7.8
12 ± 8.5
0.787
BMI body mass index, LOS length of stay
TABLE 3 Comparison of patients with and without stricture Parameter
Stricture
No stricture
p
Mean age (years)
61.8 ± 7.1 62.3 ± 8.9 0.905
Males (n)
6
76
Mean BMI (kg/m2)
25.2 ± 1
23.3 ± 1.7 0.008
History of pelvic radiation therapy (n)
1
10
0.516
Mean follow-up (months)
21.8 ± 9
26.7 ± 10
0.257
0.586
BMI body mass index
there were no significant differences in age, sex, history of pelvic radiation therapy, or time of follow-up (Table 3). However, patients in whom stricture developed had a significantly higher mean BMI compared with those without stricture (25.2 vs. 23.3 kg/m2, respectively; p = 0.008). Of the six patients with strictures, two underwent successful open repair, two underwent successful endoscopic management (one with balloon dilation and the other one with endoureterotomy), and two were treated with nephrectomy because of poor renal function (including one after failed endoscopic incision). No patient in this series had evidence of UUTR. One patient in the Bricker group had an upper ureteral stone that was treated successfully using percutaneous nephrolithotomy. DISCUSSION The Bricker and Wallace techniques are the two most common forms of ureteroenteric anastomosis for urinary diversion.3–5 However, the choice between Bricker or Wallace anastomosis has puzzled surgeons for decades.6,7 Several previous studies have evaluated the success and complications of the two techniques.5,7–9 However, the results remain contradictory and conclusive statements regarding the optimal anastomosis techniques for IC diversion are difficult. To date, selection criteria for Bricker or Wallace anastomosis have not been developed, and the technique choice between these two techniques is mostly based on surgeon preference.5,7 Bricker and Wallace ureteroileal anastomoses have several perceived limitations. The Bricker technique potentially has a higher stricture rate, while the Wallace technique can lead to bilateral upper tract compromise with anastomotic recurrence.2,5–8 Therefore, we believe that the technique choice between Bricker or Wallace anastomosis should be based on the clinical features of an individual patient rather than surgeon preference. In the present study, several influencing factors, including tumor characteristics, ureteral anomalies, and ureteral length after retrosigmoidal tunneling, were taken into account in sequence when
L. Liu et al.
deciding upon the type of ureteroileal anastomosis for IC, and an individualized selection strategy based on patient characteristics was established. Oncologic factors were a prime consideration in our series. Although Wallace anastomosis is considered to have the lowest complication rate of any ureterointestinal anastomotic technique, it has been criticized that tumor recurrence at the anastomotic line in one ureter would block both ureters, causing uremia from bilateral obstruction.2,5,7 Anastomotic recurrence after radical cystectomy is relatively rarer, with an incidence of 1 %.16 However, UUTR after radical cystectomy is an uncommon event with a rate of 2.4–17 %, and a tendency toward a higher incidence can be seen in patients who undergo longer followup.10–15 Nephroureterectomy for UUTR involving Wallace anastomosis can be complex and requires reimplanting the contralateral ureter in a Bricker fashion.7 Thus, these perceived limitations of the Wallace technique appear clinically or oncologically significant. Several risk factors for UUTR have been reported, including prostatic urethra involvement, CIS, superficial bladder tumor, ureteral involvement or positive ureteral margin, and recurrent tumor, and the rate of UUTR increases with the number of positive risk factors.10–16 Therefore, the Wallace technique is not suitable for patients who have a high likelihood of UUTR. In our series, for patients who had any one of these risk factors, the Bricker technique was performed regardless of the ureteral length after retrosigmoidal tunneling. No patient in this series had evidence of UUTR, which was likely due to the limited mean follow-up period of 30.2 months. The median time from radical cystectomy to diagnosis of UUTR is approximately 43 months.13 Ureteral anomalies also have a role in the surgeon’s decision of the anastomosis type. For patients with a solitary kidney and ureter, a single Bricker anastomosis is suitable. In addition, one should be cautious in identifying ureter duplication during cystectomy, even though there were no patients with this in our series.2 Although duplex ureters are found in 2.5 % of autopsies and in 1.8 % of intravenous urograms, a failure to recognize ureter duplication when performing a cystectomy and IC diversion results in intraperitoneal urine leakage and can lead to considerable morbidity.2,18–20 Because duplex ureters are usually present within a common sheath and not easily separable, they should be spatulated, sewn together in a Wallace fashion, and then implanted into the IC as a single unit in an end-to-end (left duplex ureters) or end-to-side (right duplex ureters) fashion. Ureteral length after retrosigmoidal tunneling is a tertiary factor influencing the choice of anastomosis technique. When the ureteral length is similar on both sides, Wallace is preferred; when disparate, Bricker is preferred.1,5 In this study, although there were no
significant differences in BMI between the two technique groups, the 15 patients who underwent Bricker anastomosis because of disparate ureter lengths had a higher mean BMI than that of patients who underwent Wallace anastomosis because of similar ureter lengths. Obese patients may be more likely to have a shorter left ureteral length after tunneling, because they tend to have increased retroperitoneal adiposity.5 Accordingly, they are more likely to have disparate ureteral lengths and be selected to undergo Bricker anastomosis.5 For obese patients, the Bricker technique may have a role in reducing tension on the anastomosis compared with the Wallace technique. Our study demonstrated that BMI appeared to be a risk factor for stricture and strictures were predominately located in the left ureter (66.7 %), which is similar to findings in the literature.5,21 The impact of obesity on ureteroenteric stricture development remains uncertain. The extensive dissection of the distal left ureter to allow for a tension-free ureteroileal anastomosis after passage under the mesosigmoid often leads to a compromised blood supply to the left ureter and results in a higher incidence of delayed ischemic stricture, which is the most common cause of ureteroenteric stricture.5,21–23 Ureteroenteric strictures remain the most challenging and difficult of all ureteral strictures to treat.21,23 Thus, any technical modification that aims to decrease or prevent ileoureteral anastomosis-related stricture is commended. This analysis represents a prospective evaluation of a technique selection strategy for ureteroenteric anastomosis based on patient characteristics. According to our preliminary clinical outcomes, this individualized anastomosis technique selection strategy seems to be clinically reliable and safe, providing an acceptable ureteral stricture rate of 3.1 %, which is comparable with the rates of 1.9–2.92 % reported by Kouba et al.5 and Evangelidis et al.7 but significantly lower than the average rates of 7–14 % reported by others.1,23 In addition, similar to studies reported by Evangelidis et al.7 and Esho et al.,9 the stricture rates for the Bricker and Wallace techniques were not statistically different in our series. However, it did not mean that these two different techniques had the some indications. Obviously, the Wallace technique is not suitable for patients who have a high likelihood of UUTR and patients who have disparate ureteral length of both sides after retrosigmoidal tunneling. Our selection strategy provides a rational approach when choosing a particular technique for an individual patient. More importantly, this selection strategy may provide a potential advantage for oncologic control as follow-up prolonging, although this potential advantage is not revealed in our series because of the relatively short follow-up period. From this point of view, this selection strategy is clinically feasible.
Selection Strategy for Bricker and Wallace Anastomosis
Admittedly, there were several limitations of this study. First, the present study was an uncontrolled clinical study in a single center, and the patient sample was relatively small. Second, a potential advantage for oncologic control of this selection strategy was not revealed in our series, likely because of the relatively short follow-up period. Thus, long-term, multicenter, controlled, clinical trials with larger patient samples are needed to further confirm the advantages of this anastomosis technique selection system. CONCLUSIONS Our preliminary outcomes demonstrate that this patient characteristics-based selection strategy of ureteroileal anastomosis (Bricker vs. Wallace) in IC diversion after radical cystectomy for transitional cell carcinoma seems to be clinically reliable, providing an acceptable low ureteral stricture rate of 3.1 %. Long-term, multicenter, controlled, clinical trials with larger patient samples are needed to further confirm the advantages of this anastomosis technique selection strategy. ACKNOWLEDGMENT This study was supported by the National Natural Science Foundation of China (No. 81001137), and the Project (No. 2010sk3102) from China Hunan Provincial Science and Technology Department. CONFLICT OF INTEREST
None declared.
REFERENCES 1. Colombo R, Naspro R. Ileal conduit as the standard for urinary diversion after radical cystectomy for bladder cancer. Eur Urol Suppl. 2010;9(10):736–44. 2. Dahl DM, McDougal WS. Use of intestinal segments in urinary diversion. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell–Walsh urology. Vol 3, 9th edn. Philadelphia: Saunders Elsevier; 2007. P. 2534–78. 3. Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North Am. 1950;30(5):1511–21. 4. Wallace DM. Ureteric diversion using a conduit: a simplified technique. Br J Urol. 1966;38(5):522–7. 5. Kouba E, Sands M, Lentz A, Wallen E, Pruthi RS. A comparison of the Bricker versus Wallace ureteroileal anastomosis in patients undergoing urinary diversion for bladder cancer. J Urol. 2007;178(3 Pt 1):945–8; discussion 948–9.
6. Khurana N, Srivastava A. Which one is better, Wallace or Bricker? Indian J Urol. 2007;23(2):216–7. 7. Evangelidis A, Lee EK, Karellas ME, Thrasher JB, Holzbeierlein JM. Evaluation of ureterointestinal anastomosis: Wallace vs. Bricker. J Urol. 2006;175(5):1755–8; discussion 1758. 8. Wiederhorn AR, Roberts M. Ureteroileal anastomosis. Comparison of Wallace and Bricker techniques. Urology. 1974;3(2): 168–70. 9. Esho JO, Vitko RJ, Ireland GW, Cass AS. Comparison of Bricker and Wallace methods of ureteroileal anastomosis in urinary diversions. J Urol. 1974;111(5):600–2. 10. Picozzi S, Ricci C, Gaeta M, et al. Upper urinary tract recurrence following radical cystectomy for bladder cancer: a meta-analysis on 13,185 patients. J Urol. 2012;188(6):2046–54. 11. Volkmer BG, Schnoeller T, Kuefer R, Gust K, Finter F, Hautmann RE. Upper urinary tract recurrence after radical cystectomy for bladder cancer—who is at risk? J Urol. 2009;182(6):2632–7. 12. Tran W, Serio AM, Raj GV, et al. Longitudinal risk of upper tract recurrence following radical cystectomy for urothelial cancer and the potential implications for long-term surveillance. J Urol. 2008;179(1):96–100. 13. Sanderson KM, Roupret M. Upper urinary tract tumour after radical cystectomy for transitional cell carcinoma of the bladder: an update on the risk factors, surveillance regimens and treatments. BJU Int. 2007;100(1):11–6. 14. Huguet-Perez J, Palou J, Millan-Rodriguez F, Salvador-Bayarri J, Villavicencio-Mavrich H, Vicente-Rodriguez J. Upper tract transitional cell carcinoma following cystectomy for bladder cancer. Eur Urol. 2001;40(3):318–23. 15. Stenzl A, Bartsch G, Rogatsch H. The remnant urothelium after reconstructive bladder surgery. Eur Urol. 2002;41(2):124–31. 16. Raj GV, Tal R, Vickers A, et al. Significance of intraoperative ureteral evaluation at radical cystectomy for urothelial cancer. Cancer. 2006;107(9):2167–72. 17. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2): 205–13. 18. Phillips DI, Divall JM, Maskell RM, Barker DJ. A geographical focus of duplex ureter. Br J Urol. 1987;60(4):329–31. 19. Privett JT, Jeans WD, Roylance J. The incidence and importance of renal duplication. Clin Radiol. 1976;27(4):521–30. 20. Evans AJ, Manhire AR, Bishop MC. Duplex ureters: a pitfall during ileal conduit urinary diversion. Br J Urol. 1994;73(2):214–5. 21. Kurzer E, Leveillee RJ. Endoscopic management of ureterointestinal strictures after radical cystectomy. J Endourol. 2005;19(6):677–82. 22. Hautmann RE, Abol-Enein H, Hafez K, et al. Urinary diversion. Urology. 2007;69(1 Suppl):17–49. 23. Farnham SB, Cookson MS. Surgical complications of urinary diversion. World J Urol. 2004;22(3):157–67.
ORIGINAL ARTICLE – UROLOGIC ONCOLOGY
Technique Selection of Bricker or Wallace Ureteroileal Anastomosis in Ileal Conduit Urinary Diversion: A Strategy Based on Patient Characteristics Longfei Liu, MD, Minfeng Chen, MD, Yuan Li, MD, Long Wang, MD, Fan Qi, MD, Jingeng Dun, MD, Jinbo Chen, MD, Xiongbing Zu, MD, and Lin Qi, MD Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, China
ABSTRACT Objectives. This study was designed to establish an individualized selection strategy for the two most common types of ureteroenteric anastomotic techniques (Bricker and Wallace anastomosis) used in ileal conduit (IC) diversion. Methods. Patients who underwent IC diversion after radical cystectomy for transitional cell carcinoma between January 2009 and December 2011 were prospectively collected. The choice of anastomosis type (Bricker vs. Wallace) was successively based on tumor characteristics, ureteral anomalies, and ureteral length after retrosigmoidal tunneling. Results. Ninety-nine patients were enrolled in the final study. Fifty-three patients underwent Bricker anastomosis, and 46 underwent Wallace anastomosis. Ureteral stricture developed in 6 (6.1 %) patients and the overall stricture rate for all ureters was 3.1 % (6/196). Strictures occurred at an average of 13.3 months after surgery and were predominately located in the left ureter (66.7 %, 4/6). The difference in the ureter stricture rates between the two groups was not statistically significant: 3.8 % (4/104) and 2.2 % (2/92) for Bricker and Wallace, respectively (p = 0.686). There were no significant differences in age, sex, body mass index (BMI), prevalence of pelvic radiation therapy, length of stay, follow-up time, or time to stricture between the two techniques. Patients in whom stricture
Ó Society of Surgical Oncology 2014 First Received: 13 July 2013 X. Zu, MD e-mail: [email protected] L. Qi, MD e-mail: [email protected]
developed had a significantly higher mean BMI compared with those without stricture (25.2 vs. 23.3 kg/m2, respectively; p = 0.008). Conclusions. Our preliminary outcomes demonstrate that this selection strategy of Bricker vs. Wallace anastomosis seems to be clinically reliable, providing an acceptable low ureteral stricture rate of 3.1 %. However, the potential advantage for oncologic control of this strategy is needed to further confirm.
Although orthotopic neobladder reconstruction is becoming more popular for urinary diversion in patients undergoing radical cystectomy for invasive bladder carcinoma, the ileal conduit (IC) is still believed to be an appropriate form of urinary diversion after radical cystectomy in most patients because of its relative simplicity, acceptable complication rate, and satisfactory postoperative quality of life.1,2 The two most common forms of ureteroenteric anastomosis for IC diversion are the Bricker (separate, end-to-side, refluxing) and Wallace (conjoined, end-to-end, refluxing) techniques.3–5 However, the choice between these two forms of anastomosis has puzzled surgeons for the last few generations.6,7 Each of these two techniques has a perceived disadvantage.2,5–8 The Bricker approach has been criticized for an increased stricture rate. On the other hand, the Wallace technique has an increased potential for bilateral renal obstruction caused by recurrence at the ureteroenteric anastomosis or the possibility of stones. Despite the fact that a few previous studies have evaluated the success and complications of the two techniques, there are no clear answers to the question of which is the better technique.5–9 Clinical indications for each technique have not been systematically established, and the choice of the anastomosis type is mostly based on surgeon preference.5,7
L. Liu et al.
In this study, we established an optimal technique selection strategy for ureteroenteric anastomosis (Bricker vs. Wallace) based on patient characteristics and evaluated its preliminary clinical outcomes. MATERIAL AND METHODS Between January 2009 and December 2011, patients who underwent IC after radical cystectomy for transitional cell carcinoma were prospectively collected at a large urology center in South Central China. The study was approved by the Institutional Ethics Committee of Xiangya Hospital of Central South University, and written, informed consent was obtained from each patient. Indications for radical cystectomy included muscle-invasive cancer, recurrent superficial or early-stage invasive tumors, and refractory carcinoma in situ (CIS). Patients with complete clinical information and adequate follow-up (defined as [6 months) were enrolled in our study. We excluded patients who underwent radical cystectomy for nontransitional cell tumors or nonmalignant conditions. No patients in the series had a history of inflammatory bowel disease. The diagnosis of bladder transitional cell carcinoma was dependent upon cystoscopy and histologic evaluation of bladder biopsies or resected tissue. When prostatic urethral abnormalities were visible cystoscopically, biopsies of the prostatic urethra were performed. The diagnosis of CIS was made using the combination of cystoscopy, urine cytology, and histologic evaluation of multiple bladder biopsies. All patients underwent routine computed tomography urography (CTU) examination, which was used to evaluate the clinical stage of tumors and the upper urinary tract. Frozensection examination of the ureteral margins was performed in all patients during cystectomy. In our series, the decision of which anastomotic technique (Bricker or Wallace) to use was based on patient characteristics rather than surgeon preference. Patient characteristics included three aspects: tumor characteristics, ureteral anomalies, and ureteral length after retrosigmoidal tunneling. The first decision was based on tumor characteristics. Five risk factors for upper urinary tract recurrence (UUTR) following radical cystectomy for transitional cell carcinoma were identified according to the literature and included prostatic urethra involvement, CIS, superficial bladder tumor, ureteral involvement or positive ureteral margin, and recurrent tumor.10–16 For patients with one or more risk factors for UUTR, the Bricker technique was performed. The second decision was based on ureteral anomalies. For example, if the patient had a solitary kidney, a single Bricker anastomosis was performed. If the patient had a duplicated system on one side, both procedures were performed (Wallace on the duplicated system on one side and Bricker on the contralateral side). The third
decision was based on the ureteral length after retrosigmoidal tunneling. When the ureteral length was similar on both sides, Wallace was preferred; when disparate, Bricker was preferred.1,5 The majority of the Bricker and Wallace anastomoses were performed by two attending surgeons with two senior-level residents as first assistants. All anastomoses were performed using a no-touch technique with 4-0 polyglactin sutures in an interrupted (Bricker) or running (Wallace) fashion. Each ureter was stented with a 7F single-J ureteral stent for 1 month. The first follow-up was performed 4 weeks after surgery. The patients were then evaluated every 3 months for the first year and every 6 months thereafter. Ultrasonography was used to monitor the upper urinary tract at each evaluation. Intravenous urography and CTU were performed if the upper urinary tract was dilated or if there was any evidence of tumor recurrence. The follow-up deadline was December 31, 2012. Data collected in this study included age, sex, body mass index (BMI), type of anastomosis, length of stay (LOS), follow-up time, history of pelvic radiation therapy, time to stricture formation, diagnostic radiological imaging for stricture, and treatment of stricture. All statistical calculations were performed using SPSS 16.0 software. Univariate statistical analysis was performed using the two-tailed Student’s t test (continuous variables) and Fisher’s exact test (categorical variables). Tests with p \ 0.05 were considered statistically significant. RESULTS Ninety-nine patients were enrolled in the final study. Fifty-three patients underwent Bricker anastomosis
TABLE 1 Number of patients with different factors influencing the choice of anastomosis technique Variables
Bricker
Tumor characteristics Ureteral anomalies
a
b
Ureteral length of both sides after retrosigmoidal tunnelingc
Wallace
d
0
15f
46
36 2
e
0
a
With one or more risk factors for upper urinary tract recurrence (UUTR), Bricker was performed
b
With single ureter or duplex ureters, Bricker or Wallace was performed, respectively
c
When similar or disparate, Wallace or Bricker was respectively performed
d
All 36 patients had positive risk factors for UUTR and also had similar ureteral length of both sides after retrosigmoidal tunneling
e
Both patients had a solitary kidney, and one of the two patients had positive risk factors for UUTR
f
Ten of the 15 patients had positive risk factors for UUTR
Selection Strategy for Bricker and Wallace Anastomosis
(53.5 %), and 46 underwent Wallace anastomosis (46.5 %). The number of patients with different factors influencing the choice of anastomosis technique is shown in Table 1. The rate in patients with at least one of these risk factors for UUTR is 47.5 % (47/99). Of note, two patients had a solitary kidney and thus underwent a single Bricker anastomosis. Therefore, a total of 196 ureters were included in this study. The demographic characteristics and operative outcomes of each anastomotic group are provided in Table 2. Six of 99 (6.1 %) patients developed ureteral strictures, all of which were Clavien Grade IIIb complications.17 The overall stricture rate for all ureters was 3.1 % (6/196). Ureteral strictures developed in 4 of 53 (7.5 %) patients who underwent Bricker anastomosis, and the total stricture rate for all ureters with this technique was 3.8 % (4/104). With Wallace anastomosis, 2 of 46 patients developed ureteral strictures, and the total stricture rate for all ureters with this method was 2.2 % (2/92). The difference in the stricture rate for ureters between the two groups was not statistically significant (p = 0.686). The mean follow-up was 30.2 ± 9.5 months for all patients. There were no significant differences in age, sex, BMI, prevalence of pelvic radiation therapy, LOS, follow-up time, or time to stricture between the Bricker and Wallace groups. Although there were no significant differences in BMI between the two techniques, the 15 patients who underwent Bricker anastomosis due to disparate ureter lengths had a higher mean BMI (25.8 ± 0.7) than that of patients who underwent Wallace anastomosis (23.5 ± 1.4) because of similar ureter lengths (p = 0). Strictures occurred at an average of 13.3 months after surgery and were predominately located in the left ureter (66.7 %, 4/6). When comparing patients in whom stricture developed with those in whom stricture did not develop,
TABLE 2 Demographic characteristics and operative outcomes of each anastomotic group Parameter
Bricker (n = 53)
Wallace (n = 46)
p
Renal units (n) Mean age (years)
104 61.9 ± 9.0
92 62.7 ± 8.6
– 0.675
44
38
0.957
Males (n) 2
Mean BMI (kg/m )
23.3 ± 1.9
23.5 ± 1.3
0.534
History of pelvic radiation therapy (n)
5
6
0.325
Mean LOS (days)
8.8 ± 2
9±2
0.642
Mean follow-up (months)
26.4 ± 10.2
26.3 ± 10
0.95
Ureteral stricture (n)
4
2
0.686
Median months to stricture
14 ± 7.8
12 ± 8.5
0.787
BMI body mass index, LOS length of stay
TABLE 3 Comparison of patients with and without stricture Parameter
Stricture
No stricture
p
Mean age (years)
61.8 ± 7.1 62.3 ± 8.9 0.905
Males (n)
6
76
Mean BMI (kg/m2)
25.2 ± 1
23.3 ± 1.7 0.008
History of pelvic radiation therapy (n)
1
10
0.516
Mean follow-up (months)
21.8 ± 9
26.7 ± 10
0.257
0.586
BMI body mass index
there were no significant differences in age, sex, history of pelvic radiation therapy, or time of follow-up (Table 3). However, patients in whom stricture developed had a significantly higher mean BMI compared with those without stricture (25.2 vs. 23.3 kg/m2, respectively; p = 0.008). Of the six patients with strictures, two underwent successful open repair, two underwent successful endoscopic management (one with balloon dilation and the other one with endoureterotomy), and two were treated with nephrectomy because of poor renal function (including one after failed endoscopic incision). No patient in this series had evidence of UUTR. One patient in the Bricker group had an upper ureteral stone that was treated successfully using percutaneous nephrolithotomy. DISCUSSION The Bricker and Wallace techniques are the two most common forms of ureteroenteric anastomosis for urinary diversion.3–5 However, the choice between Bricker or Wallace anastomosis has puzzled surgeons for decades.6,7 Several previous studies have evaluated the success and complications of the two techniques.5,7–9 However, the results remain contradictory and conclusive statements regarding the optimal anastomosis techniques for IC diversion are difficult. To date, selection criteria for Bricker or Wallace anastomosis have not been developed, and the technique choice between these two techniques is mostly based on surgeon preference.5,7 Bricker and Wallace ureteroileal anastomoses have several perceived limitations. The Bricker technique potentially has a higher stricture rate, while the Wallace technique can lead to bilateral upper tract compromise with anastomotic recurrence.2,5–8 Therefore, we believe that the technique choice between Bricker or Wallace anastomosis should be based on the clinical features of an individual patient rather than surgeon preference. In the present study, several influencing factors, including tumor characteristics, ureteral anomalies, and ureteral length after retrosigmoidal tunneling, were taken into account in sequence when
L. Liu et al.
deciding upon the type of ureteroileal anastomosis for IC, and an individualized selection strategy based on patient characteristics was established. Oncologic factors were a prime consideration in our series. Although Wallace anastomosis is considered to have the lowest complication rate of any ureterointestinal anastomotic technique, it has been criticized that tumor recurrence at the anastomotic line in one ureter would block both ureters, causing uremia from bilateral obstruction.2,5,7 Anastomotic recurrence after radical cystectomy is relatively rarer, with an incidence of 1 %.16 However, UUTR after radical cystectomy is an uncommon event with a rate of 2.4–17 %, and a tendency toward a higher incidence can be seen in patients who undergo longer followup.10–15 Nephroureterectomy for UUTR involving Wallace anastomosis can be complex and requires reimplanting the contralateral ureter in a Bricker fashion.7 Thus, these perceived limitations of the Wallace technique appear clinically or oncologically significant. Several risk factors for UUTR have been reported, including prostatic urethra involvement, CIS, superficial bladder tumor, ureteral involvement or positive ureteral margin, and recurrent tumor, and the rate of UUTR increases with the number of positive risk factors.10–16 Therefore, the Wallace technique is not suitable for patients who have a high likelihood of UUTR. In our series, for patients who had any one of these risk factors, the Bricker technique was performed regardless of the ureteral length after retrosigmoidal tunneling. No patient in this series had evidence of UUTR, which was likely due to the limited mean follow-up period of 30.2 months. The median time from radical cystectomy to diagnosis of UUTR is approximately 43 months.13 Ureteral anomalies also have a role in the surgeon’s decision of the anastomosis type. For patients with a solitary kidney and ureter, a single Bricker anastomosis is suitable. In addition, one should be cautious in identifying ureter duplication during cystectomy, even though there were no patients with this in our series.2 Although duplex ureters are found in 2.5 % of autopsies and in 1.8 % of intravenous urograms, a failure to recognize ureter duplication when performing a cystectomy and IC diversion results in intraperitoneal urine leakage and can lead to considerable morbidity.2,18–20 Because duplex ureters are usually present within a common sheath and not easily separable, they should be spatulated, sewn together in a Wallace fashion, and then implanted into the IC as a single unit in an end-to-end (left duplex ureters) or end-to-side (right duplex ureters) fashion. Ureteral length after retrosigmoidal tunneling is a tertiary factor influencing the choice of anastomosis technique. When the ureteral length is similar on both sides, Wallace is preferred; when disparate, Bricker is preferred.1,5 In this study, although there were no
significant differences in BMI between the two technique groups, the 15 patients who underwent Bricker anastomosis because of disparate ureter lengths had a higher mean BMI than that of patients who underwent Wallace anastomosis because of similar ureter lengths. Obese patients may be more likely to have a shorter left ureteral length after tunneling, because they tend to have increased retroperitoneal adiposity.5 Accordingly, they are more likely to have disparate ureteral lengths and be selected to undergo Bricker anastomosis.5 For obese patients, the Bricker technique may have a role in reducing tension on the anastomosis compared with the Wallace technique. Our study demonstrated that BMI appeared to be a risk factor for stricture and strictures were predominately located in the left ureter (66.7 %), which is similar to findings in the literature.5,21 The impact of obesity on ureteroenteric stricture development remains uncertain. The extensive dissection of the distal left ureter to allow for a tension-free ureteroileal anastomosis after passage under the mesosigmoid often leads to a compromised blood supply to the left ureter and results in a higher incidence of delayed ischemic stricture, which is the most common cause of ureteroenteric stricture.5,21–23 Ureteroenteric strictures remain the most challenging and difficult of all ureteral strictures to treat.21,23 Thus, any technical modification that aims to decrease or prevent ileoureteral anastomosis-related stricture is commended. This analysis represents a prospective evaluation of a technique selection strategy for ureteroenteric anastomosis based on patient characteristics. According to our preliminary clinical outcomes, this individualized anastomosis technique selection strategy seems to be clinically reliable and safe, providing an acceptable ureteral stricture rate of 3.1 %, which is comparable with the rates of 1.9–2.92 % reported by Kouba et al.5 and Evangelidis et al.7 but significantly lower than the average rates of 7–14 % reported by others.1,23 In addition, similar to studies reported by Evangelidis et al.7 and Esho et al.,9 the stricture rates for the Bricker and Wallace techniques were not statistically different in our series. However, it did not mean that these two different techniques had the some indications. Obviously, the Wallace technique is not suitable for patients who have a high likelihood of UUTR and patients who have disparate ureteral length of both sides after retrosigmoidal tunneling. Our selection strategy provides a rational approach when choosing a particular technique for an individual patient. More importantly, this selection strategy may provide a potential advantage for oncologic control as follow-up prolonging, although this potential advantage is not revealed in our series because of the relatively short follow-up period. From this point of view, this selection strategy is clinically feasible.
Selection Strategy for Bricker and Wallace Anastomosis
Admittedly, there were several limitations of this study. First, the present study was an uncontrolled clinical study in a single center, and the patient sample was relatively small. Second, a potential advantage for oncologic control of this selection strategy was not revealed in our series, likely because of the relatively short follow-up period. Thus, long-term, multicenter, controlled, clinical trials with larger patient samples are needed to further confirm the advantages of this anastomosis technique selection system. CONCLUSIONS Our preliminary outcomes demonstrate that this patient characteristics-based selection strategy of ureteroileal anastomosis (Bricker vs. Wallace) in IC diversion after radical cystectomy for transitional cell carcinoma seems to be clinically reliable, providing an acceptable low ureteral stricture rate of 3.1 %. Long-term, multicenter, controlled, clinical trials with larger patient samples are needed to further confirm the advantages of this anastomosis technique selection strategy. ACKNOWLEDGMENT This study was supported by the National Natural Science Foundation of China (No. 81001137), and the Project (No. 2010sk3102) from China Hunan Provincial Science and Technology Department. CONFLICT OF INTEREST
None declared.
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