Open Journal of Urology, 2011, 1, 15-18
doi:10.4236/oju.2011.12005 Published Online May 2011 (
Copyright © 2011 SciRes. OJU
Modified Technique for Internal Ureteroileal Stenting
in Orthotopic Neobladders
Guven Aslan
Dokuz Eylul University, School of Medic i ne Department of Urology, Izmi r, Turkey
Received February 9, 2011; revised February 28, 2011; accepted Marc h 31, 2011
We introduce a modified surgical technique for internal ureteroileal stenting to improve cosmesis in patients
undergoing ileal neobladder. Internal ureteric stents are secured to the tip of the urethral catheter with non-
absorbable suture facilitating removal of the stents postoperatively 2 - 3 weeks along with the urethral cathe-
ter. This surgical modification was applied to 21 patients of whom no significant surgical or infectious com-
plication due to single urethral catheter was observed. Internal ureteral stenting is simple, safe and inexpen-
sive alternative to conventional methods to support ureteroileal anastomosis in patients undergoing or-
thotopic bladder substitution.
Keywords: Bladder Cancer, Radical Cystectomy, Bladder Substitution, Ureteric Stent
1. Introduction
Radical cystectomy and urinary diversion represents the
standard treatment for muscle invasive and non muscle
invasive bladder cancer not controlled by conventional
treatment options. The use of the orthotopic bladder sub-
stitution has gained general acceptance within the past
decade and different types of surgical techniques have
been described in this regard. An orthotopic ileal
neobladder replacement is commonly used in both men
and women [1]. The tendency for orthotopic neobladder
is due to an increasing importance of providing patients
better quality of life and a favorable cosmetic effect [2].
Because cystectomy is a major surgery with complex
surgical procedures; the patients carry several bags for
drains, external catheters and cystostomy tube which
may cause restriction of patient postoperatively. Minor
surgical modifications have been reported including
omitting gastrostomy or cystostomy tube, and internaliz-
ing the ureteral stents as the experiences with any diver-
sion technique increased over the decades since they
have been first popularized [2-4]. We present our surgi-
cal experience with modification of internal stenting for
bladder substitution.
2. Technique
The indications and surgical techniques for open radical
cystectomy, including extended pelvic lymph node dis-
section, have been described previously [5]. Diversion
types performed were either T Pouch or Studer type uri-
nary diversion as described previously [6,7]. The or-
thotopic bladder substitute was performed by isolating 50
- 60 cm of ileum, 25 cm proximal to the ileocecal valve.
Both ureters were isolated. The left ureter was mobilised
up to the lower pole of the kidney with care to maintain
its surrounding blood supply. The left ureter was trans-
posed to the right side through a retrosigmoidal tunnel.
Once the pouch has been closed, each ureter was
spatulated and a standard, bilateral end-to-side uretero-
ileal anastomosis was made to the proximal portion of
the afferent limb using interrupted 4 - 0 polyglycolic acid
suture. Prior to completion of the anastomoses each
ureter was stented with a 8F feeding catheter (8F Levin’s
Tube 65 - 75 cm long) that is cut open-ended both side.
These anastomoses were stented with 8F infant-feeding
tubes, which are directed from the ipsilateral renal pelvis,
across the uretero-ileal anastomosis through the afferent
limb into the reservoir and out of the pouch (Figures 1 (a)
- (d)). A 22 - 24 F foley catheter was placed urethrally to
provide adequate drainage of the reservoir and the uret-
eric stents were secured to the tip of the urethral catheter
with nonabsorbable 0 Prolene sutures (Figures 2 (a) -
(d)). This facilities removal of the stents at postopera-
tively 3 weeks, along with the urethral catheter. A ten-
sion free mucosa-to-mucosa urethro-ileal anastomosis
as made at the end of procedure. w
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Figure 1. (a) ureteral stent introduced to afferent limb of reservoir where ureter anostomosis is done; (b) ureteral stent
passed through the reservoir to the distal open end of neobladder and grasped by atraumatic Allis clamp; (c) Proximal 20 -
25 cm of catheter segment directed to the kidney through ureter; (d) both ureteric end-to-side anastomosis are completed.
We routinely do not use an additional suprapubic
cystostomy tube. Our irrigation protocol consisted of daily
irrigations every 4 h in order to keep the neobladder free
from accumulated mucus. The frequency of irrigations was
tapered down during the first postoperative week. All pa-
tients were trained by the nursing staff how to irrigate their
neobladder twice daily until the catheter was removed.
Patients were followed up at 2 weeks and 1, 3 months
postoperatively and continued every 6 months thereafter.
3. Results
From 2006 to 2010, 21 (19 males and 2 females) with a
median age of 59 (54 - 66) years underwent orthotopic
ileal neobladder operation. The median total operating
time was 330 (270 - 390) minutes. The median blood
loss was 500 mL (400 - 1000 mL). The median number
of lymph nodes removed was 19 (11 - 29). No intraop-
erative adverse event was observed in any patient.
Prolonged urinary leak from the ureteroilial anastomo-
sis (15 days postoperatively) was observed in one patient
which ceased after insertion of percutaneous nephrostomy
catheter and recovered with no further intervention. No
cystogram was performed before removing the Foley
catheter. The median hospital stay was 11 (7 - 21) days.
Postoperative ileus developed in 5 (23.8%) patients. No
patient needed surgical intervention for ileus and all
Figure 2. (a) both ureteric stents passed through the afferent limb into the reservoir and out of the neourethra; (b) Stents are
secured to the tip of the catheter with non absorbable suture; (c) tied; (d) Foley catheter and anchored stents directed to the
reservoir to create single urethral catheter drainage.
episodes of ileus resolved with standard treatments [8].
There was no bowel anastomosis leakage. No docu-
mented urinary tract infection determined in any patient.
Stent migration, premature dislodgement, stent occlusion
or incrustation was not observed in an y patient. We have
not determined any Foley catheter blockage due to plug
and Foley catheters were not changed in any patient.
Ureteral stents could be taken out easily by pulling out
the Foley catheter at 2 - 3 weeks.
Median follow-up time was 3 years (2 - 4 years). Stric-
tures of the ureteroileal anastomosis occurred in 2 of
patients in the first postoperative year and were treated
with open reimplantation.
4. Discussion
Stenting of the ureteroileal anastomosis has been shown
to have significant beneficial effect with decreased early
postoperative upper urinary tract dilatation, improved
recovery of bowel function and decreased metabolic
acidosis [9]. Conventionally both open-ended straight
ureteral catheters, brought out through a stab wound in
the reservoir and anchored to the skin are typically used
for ureteroileal stenting in orthotopic neobladders [2,6].
In addition to ureteric splints cystostomy tubes for
neobladder, urethral catheter, drains and gastrostomy
tube (some of centers) taken out externally through the
Copyright © 2011 SciRes. OJU
abdominal wall and therefore, the patients have to carry
several bags, with resultant of patient restriction and dis-
comfort. Apart from cosmesis and patient acceptability
suprapubic tubes may cause morbidity such as stent mi-
gration, urinary leak when they were taken out from the
neobladder or even persiste nt neobladder fistula [10] . Thus
several modifications of techniques have been proposed
those for tubes and ureteric stents [3,4]. Internal ureteral
stents anchored to foley catheter as we show here is de-
scribed elsewhere; however no published long term results
of this technique exist since then [11]. More recently dou-
ble J stents have been favored as internal splint acro ss the
ureteroilial anastomosis with good results [3,4]. However,
the disadvantages of this internal stenting are the need to
remove the stents with cystoscope and their expensiveness
compared to feeding tubes. More recently similar to the
technique we used double j stents are anchored to the
Foley catheter as urinary drainage with single urethral
catheter to be removed at 3 weeks [4].
The technique we used herein did not lead to any un-
toward events. We have not observed any significant
surgical or infectious complication or any catheter re-
lated problem due to single urethral catheter. There is
certain risk of catheters getting blocked. However with
frequent foley irrigation postoperatively this may be
avoided. We used infant feeding catheter as ureteral stent
with open en ded both sides. When anyway foley catheter
or ureter catheter need to be changed postoperatively;
Foley can be pulled slowly to level 1 - 2 cm distal to ex-
ternal meatus then a guidewire can be inserted through
the open end of ureteral stent and a catheter can be in-
serted over the gu idewire fluorosco pi ca ll y.
Internal ureteral stenting is simple, safe and inexpen-
sive alternative to conventional methods for supporting
of the ureteroileal anastomosis in patient undergoing
orthotopic bladder substitution.
5. References
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