Modified wallace anastomotic technique reduces ureteroenteric stricture rates after ileal conduit urinary diversion

Abstract

Purpose: To compare perioperative outcomes, complications and anastomotic stricture rate in a contemporary series of patients who underwent open radical cystectomy (RC) with modified Wallace anastomotic technique versus traditional ileal conduit.

Materials and methods: Study enrolled 180 patients, of whom 140 were randomized and underwent RC; seventy were randomized to group I and the seventy to the group II. For the primary objective, we hypothesized that the rate of ureteroenteric strictures would be at least 20 % lower in the second group. Secondary end points included rate of anastomotic leak, surgical time, deterioration of the upper tract, intraoperative blood loss and patient-reported quality of life (HRQOL). The modified Wallace 1 technique involved eversion of the ureteral plate and bowel mucosa edges, which were anastomosed together in running fashion, while the outher anastomotic wall was augmented with sero-serosal interrupted sutures.

Results: The mean (SD) follow-up time was 26.1 (5.7) months in group I and 25.2 (4.8) months in group II, during which, anastomotic stricture was observed in 8 patients (12%) from the first and 2 patients (3%) from the second group (p < 0.05). The anastomotic leakage rate was significantly higher in first group (17% vs. 8.5%, p < 0.05), while patient-reported HRQOL outcomes were similar between groups after the 12 month follow-up period.

Conclusions: By using a modified Wallace technique, we were able to significantly lower anastomotic stricture and anastomotic leakage rates, which are major issues in minimizing both short- and long-term postoperative complications.

Keywords: Cystectomy; Quality of Life; Urinary Diversion.

Figure 1. The mesentery window was closed with interrupted sutures, next, ureters were conjoined, with the left ureter transposed to the right side of the pelvis through a tunnel prepared at the base of the sigmoid mesentery in front of the common iliac vessels.

Figure 2. Ureters were spatulated and sutured together with continuous 4-0 Vicryl suture, while the lateral edges of the newly conjoined ureters were anastomosed to the proximal end of an open ileal conduit segment, using 4-0 PDS interrupted suture, according to the standard Wallace I technique.

Figure 3. After each ureter spatulation, initial 5-0 PDS suture was placed at the apex of both ureters through all layers with muco-mucosal running suture of everted posterior medial ureteral wall edges (4-0 Vicryl), over a 6 ch or 8 ch ureteric catheter.

Figure 4. The needle reverses posteriorly to facilitates further muco-mucosal running suture of postero-medial ureteral wall edges (4-0 Vicryl), while several anterior wall sutures complete ureteral plate anastomosis.

Figure 5. Lateral edges of the newly formed ureteral plate and the everted ileal mucosa (from the proximal end of conduit segment) were anastomosed in a running fashion.

Figure 6. Ureteroenteric anastomosis with retroperitone-alisation of anastomotic line: a) peritoneal flap; b) ureteroenteric anastomotic site; c) conduit segment.