Two Cases of Revisional Urinary Diversion from Ureterocutaneostomy to Ileal Conduit: A Staged Urinary Diversion Strategy for Patients with Bladder Cancer in the Targeted and Immunotherapy Era

Abstract

BACKGROUND Cutaneous ureterostomy (CU) is a commonly used urinary diversion procedure, particularly for patients with poor prognosis, such as those with advanced cancer, a single kidney, or older age. CU is technically easier and faster to perform than other procedures, such as ileal conduit and ileal neobladder, as it does not involve the intestines, thus reducing the risk of postoperative intestinal complications and metabolic abnormalities. However, CU has several drawbacks, including difficulty in achieving a catheter-free status, frequent urinary tract infections, and concerns about long-term renal function, which can negatively impact a patient's quality of life. Recent advancements in the treatment of advanced metastatic urothelial cancer, particularly with immune checkpoint inhibitors and antibody-drug conjugates, have significantly improved the prognosis of patients with urothelial carcinoma. As a result, some patients who underwent CU and were initially considered to have poor prognosis achieved long-term remission. For these patients, the next goal is to establish a stable urinary diversion method that minimizes management effort and reduces the risk of infection and renal dysfunction. CASE REPORT This report presents 2 cases of revisional urinary diversion from CU to ileal conduit in patients with locally advanced bladder cancer who initially underwent CU and achieved long-term remission with pembrolizumab. Both patients achieved catheter-free status and preserved renal function postoperatively. CONCLUSIONS These cases highlight the potential benefits of staged urinary diversion in improving the quality of life of bladder cancer survivors in an era of targeted immunotherapy.

Figure 1.

Imaging findings of case 1. Arrows indicate the tumor. (A, B) Plain computed tomography (CT) axial images of the pelvis and abdomen. Postrenal renal failure occurred immediately after 1 cycle of neoadjuvant therapy. The tumor invaded the extravesical and seminal vesicles, and bilateral hydronephrosis is observed. (C, D) Magnetic resonance imaging (MRI) T2-weighted axial and sagittal images of the pelvis. After 2 cycles of pembrolizumab treatment, the tumor appeared stable, and surgery was considered possible. (E) Positron emission tomography-CT maximum intensity projection image. No distant metastasis was observed preoperatively, and a left ureterocutaneostomy was performed. (F) Abdominal X-ray image before surgery. A left ureteral stent was placed. (G) CT image 3 months after surgery. Catheter-free condition.

Figure 2.

Operative findings of case 1, where the following steps are performed. (A) The adhesive left ureter is disconnected from the skin stoma, and the released distal ureter is trimmed. An ileal conduit (IC) is prepared from the terminal ileum. (B) The proximal end of the IC is connected to the shortened left ureter using Wallace anastomosis. A stoma is created in the right lower abdomen.

Figure 3.

99mTc-MAG3 scintigraphy image. The absence of right kidney function was confirmed.

Figure 4.

Imaging findings of case 2. Arrows indicate the tumors. (A, B) Magnetic resonance imaging (MRI) T2-weighted axial and sagittal images. The tumor is seen extending to the vaginal wall. (C–E) MRI T2-weighted axial image, diffusion-weighted axial image, and T2-weighted sagittal image. The tumor invaded the vagina. (F) Positron emission tomography-computed tomography (CT) maximum intensity projection image. Chemoradiotherapy followed by pembrolizumab resulted in complete remission of the recurrent tumor. No distant metastasis was observed, and a left ureterocutaneoustomy was performed. (G) CT image before surgery. (H) CT image 3 months after surgery. Catheter-free condition.

Figure 5.

Operative findings of case 2, where the following steps are performed. (A) The adhesive left ureter is disconnected from the skin stoma, and the released distal ureter is trimmed. An ileal conduit (IC) is prepared from the terminal ileum. (B) A small hole is made in the sigmoid mesocolon, and the IC is positioned on the left side of the pelvis. (C) The proximal end of the IC is connected to the shortened left ureter using Wallace anastomosis. A stoma is created in the left lower abdomen.