How to avoid and how to manage complications of radical cystectomy

Radical cystectomy is a morbid operation with a high rate of complications, with the 90-day complication rate approaching 65%, and over one-third being major complications. Long-term complications can significantly impact patients’ quality of life. Two of the most common long-term complications include ureteral strictures and parastomal hernias.

Ureteral strictures are usually related to ischemia. Prevention of strictures, therefore, centers on maintaining blood flow to the ureter, which includes dissection of the ureter, leaving healthy tissue around the ureter to carry the blood supply. However, mobilizing the ureter is required to prevent tension on the anastomosis; therefore, most perforating blood vessels from the iliacs, aorta, and gonads are divided. Therefore, antegrade blood flow is dependent on flow from the proximal ureter and branches of the renal artery. Because of this, the ureter after cystectomy is analogous to a transplant ureter, which has blood flow only from the renal artery. Thus, the ureter should be extensively spatulated to shorten the ureteral length. Often, the left ureter is spatulated back to where it crosses under the sigmoid mesentery, and the right ureter is spatulated back to the level of the psoas muscle. It has been shown that the length of the resected ureter, which serves as a surrogate for spatulation length, is associated with lower stricture rates.¹

Repair of ureteral strictures should follow the standard anastomotic principles, including a tension-free, water-tight anastomosis. A no-touch technique should be employed to prevent microvascular damage to the ureter. It should be noted that longer conduits make all reconstruction procedures easier, including stricture repair, hernia repair, and stoma relocation. For anastomotic stricture repair, the butt end of longer conduits can be mobilized to the left side of the colon in the event of a long segment left ureteral stricture without having to harvest another segment of bowel. Therefore, the use of a long segment to create the initial conduit can be very helpful in managing subsequent complications. Data on the management of proximal ureteral strictures indicate that indwelling ureteral stents at the time of reconstruction decrease the repair success rate.² Extrapolating from these data and applying it to ureteral anastomotic strictures, stents should be removed prior to repair, and nephrostomy tubes should be placed to allow for ureteral rest for a period of 4 to 6 weeks before repair. This will greatly reduce ureteral inflammation and improve the repair’s success rate.

Parastomal hernias are common, with some estimates suggesting that 50% of patients with ostomies will develop them. Several studies have looked at the prevention of parastomal hernias. One study used prophylactic intraperitoneal biologic mesh with a trephine, and the data showed no difference in hernia rate.³ However, findings from another study using retrorectus placement of synthetic mesh showed a decrease in the parastomal hernia rate.⁴ However, this retrorectus space is considered the golden plane in repair of ventral hernias, so violation of this space should be avoided if possible to allow for subsequent hernia repair.

Most patients with parastomal hernias do not require hernia repair. The absolute indications for repair include obstruction of the gastrointestinal tract or obstruction of the conduit itself. Relative indications for repair include decreased pouch wear time (usually less than 2 days or a significant decrease in time), skin breakdown, pain, or poor cosmesis. Patients who do require repair should be informed that they will develop a parastomal seroma 100% of the time due to the serosal-lined hernia sac in the defect. They should also be informed that their stomal will change shape and will often appear retracted, requiring a change in their appliances, often to a convex pouch.

Parastomal hernia repair can be performed either open or robotically, according to the surgeon’s preference. The 2 mainstays of repair are the keyhole and intraperitoneal Sugarbaker repairs. Synthetic, biologic, or slowly absorbent biosynthetic mesh can be used according to preference. Synthetic mesh carries an increased risk of infection and erosion. The standard Surgarbaker repair is described as lateralizing the bowel to the fascial defect. However, this can be difficult to achieve because it pulls the conduit in the opposite direction of the ureteroenteric anastomoses. The conduit typically runs from caudal to cranial under the abdominal wall as it courses from the ureteral anastomoses to the stoma. Therefore, a caudalizing Sugarbaker repair can be performed, taking advantage of the conduit’s natural lie beneath the abdominal wall. It should also be noted that a Sugarbaker repair may put undue tension on fresh ureteroenteric anastomoses and, therefore, may increase the leak rate in patients undergoing a concomitant stricture repair and parastomal hernia repair. Because of this increased complication rate, a keyhole technique is usually employed in this situation.

A retrorectus Sugarbaker repair (Pauli parastomal hernia repair) is a newer technique that lateralizes the insertion site through the posterior sheath. The bowel then runs in the retrorectus space from lateral to medial, and the mesh is placed in this retromuscular or retrorectus space. This type of repair violates the retrorectus space, which is vital to repairing ventral hernias. Therefore, this technique is usually not used for primary parastomal hernia repair but is an excellent option for concomitant ventral hernia repair. The Figure shows a useful algorithm for the repair of parastomal hernias.

Ureteral strictures and parastomal hernias are long-term complications of radical cystectomy. Therefore, understanding the prevention and management of these complications is vital to improving the quality of life of patients following surgery for bladder cancer.

References

1. Das A, Shapiro D, Risk M, Abel EJ, Jarrard D, Richards K. Length of ureter resected at time of urinary diversion is associated with ureteral stricture. Urol Oncol. 2024;42(suppl):S27. doi:10.1016/j.urolonc.2024.01.100

2. Lee Z, Lee M, Lee R, et al; Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS). Ureteral rest is associated with improved outcomes in patients undergoing robotic ureteral reconstruction of proximal and middle ureteral strictures. Urology. 2021;152:160-166. doi:10.1016/j.urology.2021.01.058

3. Djaladat H, Ghoreifi A, Tejura T, et al. Prophylactic use of biologic mesh in ileal conduit (PUBMIC): a randomized clinical trial. J Urol. 2024;211(6):743-753. doi:10.1097/JU.0000000000003902

4. Liedberg F, Kollberg P, Allerbo M, et al. Preventing parastomal hernia after ileal conduit by the use of a prophylactic mesh: a randomised study. Eur Urol. 2020;78(5):757-763. doi:10.1016/j.eururo.2020.07.033