Open surgical repair of ureteral strictures and fistulas following radical cystectomy and urinary diversion

Purpose: Open surgery after cystectomy can be a challenge. We report the incidence of postoperative urinary diversion-enteric fistula and ureteral strictures in patients undergoing radical cystectomy, and discuss the diagnosis and management of these complications, including our surgical approach to these patients. Materials and Methods: We preformed a retrospective review of 553 patients undergoing radical cystectomy and urinary diversion for bladder cancer between April 1999 and January 2007. Patients in whom a ureteral stricture or fistula developed were identified by serial laboratory and imaging evaluations. A chart review was preformed to identify symptoms, time to stricture or fistula development, radiological findings, type of diversion, estimated blood loss and whether the original anastomosis was stented. Management and outcomes were assessed. Results: Of 553 patients reviewed ureteral stricture developed in 41 (7.4%) with a mean followup of 20.2 months (range 1 to 98). Strictures developed in 11% (31 of 272) of the orthotopic ileal neobladder, 2.5% (6 of 236) of ileal conduit and 8% (4 of 45) of Indiana pouch cases. Open repair led to an overall success rate of 87%. Urinary diversion-enteric fistula developed in 12 (2.2%) of the 553 patients with a mean followup of 28.4 months (range 3 to 94), all of whom had undergone orthotopic neobladder diversion. No patient had recurrence after surgical repair of the fistula. Conclusions: Open revision remains the gold standard management for ureteral strictures and urinary diversion-enteric fistulas occurring after radical cystectomy. The addition of the chimney modification to the orthotopic neobladder facilitates surgical repair.