Yang David Y, Boorjian Stephen A, Westerman Mary Beth, Tarrell Robert F, Thapa Prabin, Viers Boyd R
Department of Urology, Mayo Clinic, Rochester, MN, USA.
Transl Androl Urol. 2020 Feb;9(1):142-150. doi: 10.21037/tau.2019.09.05.
Up to one in ten patients undergoing cystectomy with urinary diversion develop a ureteroenteric stricture (UES). Despite unrecognized ureteral obstruction contributing to infection, nephrolithiasis, and/or progression of kidney disease, the long-term natural history and risk factors associated with UES remains understudied. Herein, we report our single institutional experience with the long-term incidence, clinical presentation, and risk factors associated with UES formation following urinary diversion.
We reviewed 2,285 patients who underwent RC with urinary diversion between 1980-2008. UES was defined as radiographic evidence of ureteral obstruction at the level of the ureteroenteric anastomosis. The diagnosis of benign UES was confirmed by pathology. UES-free survival was estimated using the Kaplan-Meier method. The association between clinicopathologic features and the development of a UES were assessed using multivariable models.
A total of 192 (8%) patients developed a benign UES, at a median of 7 months (IQR 4-24) following RC, with 5% occurring after 10 years. Seventy seven percent of patients exhibited signs and/or symptoms of ureteral obstruction. Patients who developed a UES had a greater body mass index (BMI) (28 27), operative time (330 301 minutes) and were more likely to experience a <30-day Clavien ≥3 complication (all P<0.05). Receipt of abdominal radiation and smoking history were not significantly associated with UES stricture risk. On multivariable analysis, only greater BMI (per 1-unit increase) (OR 1.06, 95% CI: 1.02-1.09; P=0.0009) and <30-day Clavien ≥3 complication (OR 2.85, 95% CI: 1.90-4.28; P<0.0001) were associated with the development of a UES. Development of UES was associated with renal function deterioration.
UES was identified in 8% of patients following RC with urinary diversion, with the majority presenting with symptoms. While the majority of these occur in the first 2 years after surgery, a patients' risk for the development of this complication persists beyond 10 years. Due to the adverse sequelae of UES, long-term functional and imaging surveillance following urinary diversion is warranted, and early reconstruction should be considered.
接受膀胱切除术并行尿流改道的患者中，高达十分之一会发生输尿管肠吻合口狭窄（UES）。尽管未被识别的输尿管梗阻会导致感染、肾结石和/或肾脏疾病进展，但UES的长期自然史及相关危险因素仍未得到充分研究。在此，我们报告我们单一机构关于尿流改道后UES形成的长期发病率、临床表现及危险因素的经验。
我们回顾了1980年至2008年间接受根治性膀胱切除术并行尿流改道的2285例患者。UES定义为输尿管肠吻合口处输尿管梗阻的影像学证据。良性UES的诊断经病理证实。采用Kaplan-Meier法估计无UES生存期。使用多变量模型评估临床病理特征与UES发生之间的关联。
共有192例（8%）患者发生良性UES，中位时间为根治性膀胱切除术后7个月（四分位间距4 - 24个月），5%发生在10年后。77%的患者出现输尿管梗阻的体征和/或症状。发生UES的患者体重指数（BMI）更高（28对27），手术时间更长（330对301分钟），且更有可能发生30天内Clavien≥3级并发症（所有P<0.05）。接受腹部放疗和吸烟史与UES狭窄风险无显著关联。多变量分析显示，只有更高的BMI（每增加1个单位）（比值比1.06，95%置信区间：1.02 - 1.09；P = 0.0009）和30天内Clavien≥3级并发症（比值比2.85，95%置信区间：1.90 - 4.28；P<0.0001）与UES的发生相关。UES的发生与肾功能恶化相关。
在接受根治性膀胱切除术并行尿流改道的患者中，8%被发现有UES，大多数有症状。虽然这些情况大多发生在术后头2年，但患者发生这种并发症 的风险在10年后仍然存在。由于UES的不良后果，尿流改道后进行长期功能和影像学监测是必要的，应考虑早期重建。
