Ureteroenteric anastomosis in continent urinary diversion: Long-term results and complications of direct versus nonrefluxing techniques

Purpose: Controversy exists over the importance of antireflux mechanisms in large volume, low pressure intestinal bladder substitutions. Despite the t heoretical benefits of reflux prevention, antirefluxing ureteral reimplanta tions may have a greater risk of anastomotic stricture. We hypothesize that this inherent stricture rate may outweigh the potential benefits associate d with reflux prevention. To assess this question critically we compare our results to those of direct and nonrefluxing techniques of ureterointestina l anastomosis during continent diversion. Materials and Methods: Between 1990 and 1998, 58 patients underwent contine nt urinary diversion using an Indiana pouch or ileal orthotopic neobladder following cystectomy for muscle invasive bladder cancer. A total of 56 rena l units were implanted using an end-to-side Nesbit direct anastomosis and 6 0 were implanted in a nonrefluxing manner. Clinical end points included ana stomotic stricture formation, hydronephrosis, pyelonephritis, upper tract s tone formation and renal deterioration, and were assessed with a mean follo wup of 41 months. Results: Of 60 nonrefluxing ureteroenteric anastomoses 8 (13%) resulted in nonneoplastic stricture formation compared to 1 of 56 (1.7%) direct anastom oses, which was statistically significant (Fisher's exact test p <0.05). St rictures occurred up to 6 years following the original surgery. There was n o significant difference between the 2 groups in regard to hydronephrosis, pyelonephritis, upper tract stone formation or azotemia. Conclusions: Nonrefluxing methods of ureterointestinal reimplantation resul ted in a statistically significant higher rate of anastomotic stricture tha n the end-to-side direct anastomosis. This finding appears to outweigh any theoretical benefits of preventing pyelonephritis, stones or azotemia. For patients undergoing large volume, low pressure continent diversion the refl uxing ureterointestinal anastomosis may be the technique of choice since it preserves renal function as well as the nonrefluxing method, is technicall y easier to perform and poses less risk of stricture. Delayed stricture for mation years after surgery underscores the necessity for long-term radiolog ical followup in patients following continent diversion.