Experience with 45 Consecutive Patients with Neobladders Undergoing Retrograde Ureteroscopy for Upper Tract Abnormalities

Abstract

Introduction: In this study we reviewed the feasibility, technique, complications and outcomes of retrograde ureteroscopy in patients with orthotopic neobladders. Methods: We retrospectively reviewed our retrograde ureteroscopic experience in patients with orthotopic ileal neobladder diversions. Data were collected and analyzed regarding patient characteristics, indications, technique, success and complications of the procedure. Results: Between 1995 and 2013, 45 patients with neobladders underwent 77 retrograde ureteroscopy sessions on 97 renal units for filling defects (47 cases), urothelial thickening (9), calculi (4), positive cytology (27) and/or positive fluorescence in situ hybridization (15) on followup. The ureter and renal pelvis were successfully instrumented in 78 of 97 units (80.4%), with 85.3% success in Hautmann-type neobladders (75 renal units attempted), 50% in Studer-type neobladders (8 renal units attempted) and 71.4% in unascertained-type neobladders (14 renal units attempted). Causes of failure involved the inability to locate the ureteral orifice (8 cases), to cannulate the orifice (6 cases) or to advance the ureteroscope due to tortuosity (5 cases). Among the successful attempts with appropriately documented findings 35.9% of cases with filling defects (39) were confirmed malignant and 61.5% were confirmed benign by ureteroscopy. All cases with a positive cytology (23) and 85.7% of cases with positive fluorescence in situ hybridization (14) were confirmed malignant by retrograde ureteroscopy, and 2 of the 4 cases of calculi were successfully managed retrogradely. Conclusions: Retrograde ureteroscopic evaluation of upper tract abnormalities is feasible and practical in patients with orthotopic neobladders. Identification and cannulation of the ureteral orifice are challenging, particularly in tortuous situations, but difficulties can be overcome with fluoroscopic techniques. Retrograde ureteroscopy avoids the morbidity of percutaneous access with minimal complications.

Challenges of Retrograde Ureteroscopy in Patients with Urinary Diversion: Outcomes and Lessons Learnt from a Systematic Review of Literature

“…The lowest success rate in retrograde URS was 56% reported by Hertzig et al [13] and the highest was Singla et al [14] at 80.4%. All these articles were retrospective studies from large tertiary referral units.…”

“…Of the studies reporting on complication rates, [1,2,[13][14][15][16][17] in 113 sessions of retrograde URS, the overall complication rate was 10.6% (n = 12), with 11 Clavien I and 1 Clavien IIIa complication. The Clavien I complication included hematuria, post-op pyrexia, acute renal insufficiency, obstruction, and ureteral perforation; and none of them needed active intervention.…”

“…Similarly, a single unit study by Gomez et al [16] had a low threshold to convert to antegrade approach when the retrograde URS was not feasible. A further 10-year data from the same unit showed Review a modest improvement in retrograde evaluation of upper tract abnormalities [14]. Sub-analysis highlighted the difference in success rates between NB subtypes (Hautmann pouch vs. Studer pouch) within the study population.…”

“…URS is the least invasive surgical approach to the upper tract lesion and is associated with reduced morbidity when compared to percutaneous access [19]. Studies with high number of patients have reported stone-free rate of over 70% when undergoing retrograde URS [1,2,14,17]. Rivera and Krambeck [16] reported modest results of 59% success rate in 2014.…”

Ureteroscopy for stone disease: expanding roles in the modern era

“…In patients with previous urinary diversion, identification and cannulation of the ureteric orifice might be difficult with a learning curve associated with it [ 24 ]; however, success rates of 80% have been described in patients with a neobladder [ 25 ].…”