Radical cystectomy with pelvic lymphadenectomy is considered the standard of care
for nonmetastatic muscle-invasive bladder cancer.[[1]],[[2]] A variety of urinary reconstructions have been described during the urinary diversion.
Small intestine or large bowel are used to perform a continent or incontinent pouch
in state of bladder. But sometimes, ureters can be used directly for an ureterocutaneostomy.
Each technique has its advantages and disadvantages, but the main objective of a diversion
is the drainage of the kidneys, and after that, we must also see the appliance and
the patient's ability to perform self-catheterization, if necessary. Regardless, surgical
benefits should be balanced with possible complications, especially in the elderly.[[3]] One of the most feared complications is a fistula. In the use of intestinal in
urinary diversion, there is also the elimination of mucus which can disturb urine
drainage and promotes the formation of stones and metabolic disorder.[[4]],[[5]]
The other means of diversion is the ureterocutaneostomy. To avoid stenosis, it requires
the permanent placement of an endoureteric stent, which must be changed periodically,
and a bilateral ostomy appliance, which is not very comfortable for the patient. Hence,
Bricker transileal ureterocutaneostomy approach avoids this inside the permanent ureteral
stent and the bilateral appliance.[[6]] In our practice, we see advanced bladder cancer and uterine cervical tumors infiltrating
the bladder trigone, and we perform the Bricker most of the time. Disease extent and
anatomical considerations, therefore, limit reconstructive options. Ileal conduits
represent the fastest, easiest, least complication-prone, and most commonly performed
urinary diversion. The patient, in this Bricker's procedure, has one urinary diversion
and external stoma, and there is no risk of skin stenosis.
This article by Chiancone's et al.[[7]] describes a new surgical technique. This is another alternative when the length
of the ureter does not allow its use. The method of calculation, sampling, and tubulization
of this pedicled skin graft has been well described and illustrated with explanatory
figures. In their study, Chiancone emphasize that this patient already had an emergency
nephrostomy for obstructive uropathy. The question is, did the ureteric stricture
already exist at that time? Didn't this have an impact on the length of the ureter
remaining usable? With a 36 months' follow-up, the author puts forward a satisfactory
result with the absence of urinary leaks or fistula or anastomotic stenosis, while
leaving Bracci ureteral splints in place.
This new technique still requires bilateral appliances. In addition to follow-up the
bladder cancer, this urinary diversion would also require surveillance of the functionality
of the skin graft: what about the risk of skin degeneration, the risk of stone encrustation,
long-term stenosis, and the risk of infection related to commensal skin germ skin
flora such as Staphylococcus aureus and Streptococcus spp.[[8]]
Authors' contributions
Single author.
Compliance with ethical principles
Not applicable.
Reviewers:
Not Applicable (Invited Commentary)
Editors:
Elmahdi A Elkhammas (Columbus OH, USA)
