Editing Intestinal Segments and Urinary Diversion (section)

== Ureterointestinal Anastomoses ==

* '''The ureter may be anastomosed to the small bowel or colon or in a refluxing or non-refluxing anastomosis. There is controversy as to whether there is a benefit for either approach'''
* '''Methods of ureterocolonic anastomoses'''
*# Leadbetter-Clarke technique
*# Strickler technique
*# Pagano technique
*# Transcolonic Technique of Goodwin
*# Cordonnier and Nesbit Techniques
* '''<span style="color:#ff0000">Small bowel anastomoses</span>'''
** '''<span style="color:#ff0000">Bricker Technique</span>'''
*** '''See [https://www.researchgate.net/profile/Rustom-Manecksha/publication/277559810/figure/fig1/AS:613858561503250@1523366694970/Bricker-ureteroenteric-anastomosis-Ureters-are-spatulated-and-anastomosed-independently.png Figure]'''
*** '''<span style="color:#ff0000">A refluxing end-to-side ureter–small bowel anastomosis</span>'''
*** Relatively simple to perform
*** Low complication rate
**** Stricture rate is ≈6%
**** Leak rate is ≈3% in the absence of stents, negligible with stents
*** Summary of Steps:
**** Excise a small button of seromuscular tissue and mucosa, spatulate the ureter for 0.5 cm, and suture the full thickness of the ureter to the full thickness of the bowel (i.e., mucosa and seromuscular layer to ureteral wall) with either interrupted or running 5-0 PDS. The anastomosis is stented with a soft Silastic catheter.
** '''<span style="color:#ff0000">Wallace technique</span>'''
*** '''See Figure'''
*** '''<span style="color:#ff0000">A refluxing end-to-end ureter-small bowel anastomosis</span>'''
*** '''Lowest complication rate of any of the ureterointestinal anastomotic techniques.'''
*** '''Not recommended for patients who have extensive carcinoma in situ or who have a high likelihood of recurrent tumor in the ureter.'''
**** A recurrence of tumor at the anastomotic line in one ureter would block both ureters, causing uremia from bilateral obstruction.
** '''Other techniques described in Campbell’s: Le Duc technique (non-refluxing, laid down on ileal track),''' tunneled Small Bowel Anastomosis, Split-Nipple technique, Hammock anastomosis, Ureteral dipping technique, Ureter–Small Bowel Anastomosis Using Serosal Compression of the Extramural Ureter as an Antireflux Mechanism
* Intestinal Antireflux Valves
** The ureter is sutured by the technique of either Bricker or Wallace (as described earlier) to the end of the bowel, and the bowel is used to make a one-way valve.
** '''Three basic types of antireflux mechanisms commonly used with the bowel:'''
**# '''Ileocecal intussusception'''
**# '''Ileoileal intussusception'''
**# '''Ileal nipple valve placed into colon.'''
* '''Complications of ureteroinstestinal anastamoses (5):'''
*# '''Leakage (fistula)'''
*#* '''Typically occur within the first 7-10 days postoperatively'''
*#* '''May cause''' periureteral fibrosis and scarring with '''subsequent stricture''' formation.
*#* Incidence of 3-9%; can be reduced nearly to 0 if soft Silastic stents are used.
*#** Soft Silastic stents are effective in reducing the leak rate, subsequent stricture formation, and postoperative complications.
*# '''Stricture'''
*#* One of the most difficult complications of ureterointestinal anastomoses
*#* In general, strictures are caused by ischemia, a urine leak, radiation, or infection. '''Anti-refluxing techniques have a higher incidence of stricture'''.
*#* '''Ureteral strictures can also occur away from the ureterointestinal anastomosis. This stricture is most common in the left ureter''' '''and is usually found as the ureter crosses over the aorta beneath the inferior mesenteric artery.'''
*#** This may occur because of overly aggressive stripping of adventitia and angulation of the ureter at the inferior mesenteric artery.
*#* Treatment options include endoscopic, interventional radiology, open surgery techniques
*#** See Management of Upper Urinary Tract Obstruction Chapter Notes
*#** The most successful technique is re-exploration, with removal of the stenotic segment and reanastomosis of the ureter to the bowel.
*#** '''Strictures with less favorable outcomes with endourologic methods:'''
*#**# '''Occurring < 1 year from the original procedure'''
*#**# '''Strictures ≥1.5 cm (Chapter 49 describes 1.0 and 2.0cm cut-offs)'''
*#**# '''Left-sided strictures'''
*# '''Renal function deterioration'''
*#* Usually a consequence of lack of ureteral motility, infection, or stones but can be caused by obstruction at the ureteral-intestinal anastomosis.
*# '''Acute pyelonephritis'''
*#* Occurs both in the early postoperative period and during the long term
*#* Incidence 10-20% with ileal conduits and 9% with antirefluxing colon conduits
*# '''Reflux in those anastomoses that were performed to prevent reflux'''