Lessons from 151 ureteral reimplantations for postcystectomy ureteroenteric strictures: A single-center experience over a decade.

OBJECTIVES: Ureteroenteric anastomotic strictures are common after cystectomy with urinary diversion. Endoscopic treatments have poor long-term success, although ureteral reimplantation is associated with morbidity. Predictors of successful open repair are poorly defined. Our objective was to characterize outcomes of ureteral reimplantation after cystectomy and identify risk factors for stricture recurrence. PATIENTS AND METHODS: We performed a retrospective review of 124 consecutive patients with a total of 151 open ureteral reimplantations for postcystectomy ureteroenteric strictures between January 2006 and December 2015. Baseline clinicopathologic characteristics and perioperative outcomes were examined. Predictors for stricture recurrence were assessed by univariable testing and univariate Cox proportional hazards regression. RESULTS: Most patients underwent preoperative drainage by percutaneous nephrostomy (PCN; 43%) or percutaneous nephroureterostomy (PCNU; 44%). Major iatrogenic injuries included enterotomies requiring bowel anastomosis (3.2%) and major vascular injuries (2.4%). Overall, 60 (48%) patients suffered 90-day complications, of which 15 (12%) patients had high-grade complications. Median length of stay was 6 days [interquartile range: 5, 8] and median follow-up was 21 months [interquartile range: 5, 43]. The overall success rate per ureter was 93.4%. On univariate analysis, the only significant predictor of stricture recurrence was preoperative PCNU placement compared with PCN placement or no drainage (success rates: 85.5% vs. 98.9%, respectively, P = 0.002). Cox proportional hazards regression demonstrated that preoperative PCNU placement yielded a hazard ratio of 10.2 (95% CI: 1.27-82.6) for stricture recurrence (P<0.005). Stricture recurrence was independent of previous endoscopic interventions (P = 0.42). Stricture length was unable to be assessed. CONCLUSIONS: Postcystectomy ureteral reimplantation was associated with relatively low rates of major iatrogenic injuries and high-grade complications. Preoperative PCN placement rather than PCNU may yield better results.

Redefining the implications of nasogastric tube placement following radical cystectomy in the alvimopan era.

PURPOSE: Alvimopan has decreased ileus and need for nasogastric tube (NGT) after radical cystectomy (RC). However, the natural history of ileus versus intestinal obstruction in patients receiving alvimopan is not well defined. We sought to examine the implications of NGT placement before and after the introduction of alvimopan for RC patients. METHODS: Retrospective review identified 278 and 293 consecutive patients who underwent RC before and after instituting alvimopan between June 2009 and May 2014. Baseline characteristics and postoperative outcomes were compared by alvimopan status. Multivariate logistic regression was performed to assess the impact of alvimopan on rates of NGT placement and reoperation for bowel complications. RESULTS: The cohorts had similar age, stage, approach, and BMI. Patients receiving alvimopan had decreased ileus (16 vs 32 %, p < 0.01) but similar rates of reoperation for bowel complications (2.8 vs 2.7 %). On multivariate analysis, alvimopan was associated with lower risk of NGT placement (OR 0.30, p < 0.01). For patients requiring NGT placement, there was an increased rate of reoperation among patients receiving alvimopan compared with those who did not (28 vs 11 %, p = 0.03). Patients receiving alvimopan who needed NGT had significantly increased median length of stay (22 vs 7 days), need for TPN (66 vs 5.3 %), and readmission for ileus (10.3 vs 2.3 %) compared with those who did not require NGT. CONCLUSIONS: Alvimopan significantly reduced the incidence of ileus and NGT placement following RC. NGT placement was associated with an increased need for reoperation for bowel complications in the setting of alvimopan.