Abstract
Introduction
To evaluate postoperative urinary complications and their management in patients undergoing Bricker urinary diversion for gynecologic cancers, with a focus on identifying risk factors, especially uretero‐ileal strictures.
Material and Methods
We conducted a retrospective single‐center study of 77 patients who underwent Bricker urinary diversion for gynecologic cancers between 2000 and 2020. All surgeries were performed by the same gynecologic oncologic team.
Results
Primary tumor sites included the cervix and uterine body in 87% of patients, with others involving the vagina, vulva, and adnexa. Preoperative pelvic radiotherapy was performed in 71%, and para‐aortic/pelvic radiotherapy in 10%. Over a median follow‐up of 21 months, uretero‐ileal strictures occurred in 30%, and fistulas in 6%. Preoperative nephrostomy was significantly associated with a higher rate of strictures (p = 0.001), while preoperative ureteral stenting was associated with a reduced risk (p = 0.005). All patients with strictures or fistulas were initially managed with ureteral stenting; nephrostomy was subsequently required in 56% of stricture and 80% of fistula cases. Surgical treatment was eventually needed in 17% and 60%, respectively. Additional risk factors for strictures included preoperative chemotherapy (p = 0.023) and intraoperative evidence of chronic enteritis (p = 0.013). No significant differences were observed in overall or recurrence‐free survival between patients with and without strictures (p > 0.05).
Conclusions
Uretero‐ileal strictures occurred in 30% and fistulas in 6% of patients undergoing Bricker urinary diversion. Preoperative ureteral stenting may help reduce stricture risk, and appropriate bowel segment selection is essential to minimize complications.
Keywords: complications, pelvic exenteration, recurrence, urinary diversion, urinary reconstruction
Uretero‐ileal stricture is a common complication of Bricker urinary diversion in gynecologic cancer, affecting 30% of 77 patients. Preoperative nephrostomy, chronic radiation enteritis, and prior chemotherapy increased the risk, while preoperative ureteral stenting was protective with no effect on overall survival.
Key message.
Uretero‐ileal strictures remain common after Bricker diversion in gynecologic oncology. Our findings highlight preoperative ureteral stenting and intraoperative bowel assessment as key strategies to lower complication risk. Preoperative nephrostomy was linked to higher complication risk.
1. INTRODUCTION
Pelvic exenteration is a complex, high‐morbidity surgical procedure primarily indicated for the management of recurrent pelvic malignancies, often in previously irradiated areas. Cervical and endometrial cancers represent the most frequent indications. 1 Five‐year survival rates after exenteration range from 25% to 60%, depending largely on disease stage and resection margin status. 2
To achieve complete cytoreduction, cystectomy is frequently required, necessitating urinary diversion. The Bricker procedure, a non‐continent cutaneous transileal urinary diversion, is widely adopted in gynecologic oncology. Uretero‐ileal anastomoses could be performed using either the Bricker or Wallace techniques. 3 Despite its widespread use, uretero‐ileal stricture remains a significant late complication, potentially impairing renal function and requiring timely intervention. Uretero‐ileal fistulas, while less common, are reported in approximately 5% to 10% of cases. Reported stricture rates for Bricker anastomosis vary considerably in the literature, ranging from 2.9% to 26.3%. Pelvic irradiation and prior pelvic surgery are known risk factors. 4 , 5 , 6
Systematic analyses focusing on the management strategies and outcomes of urologic complications in this specific gynecologic cancer patient population remain scarce. Despite advances in perioperative care and surgical technique, complication rates after pelvic exenteration remain high, with over 90% of patients experiencing at least one postoperative complication, and 20% to 50% experiencing major complications (Clavien‐Dindo Grade III–IV). 2 , 7 , 8 Improvements in surgical outcomes have been driven by enhanced perioperative protocols, such as optimized antibiotic prophylaxis, thromboprophylaxis, early rehabilitation, and advances in both radiotherapy and reconstructive surgery to fill the pelvic cavity and prevent the empty pelvis syndrome. 9 , 10 , 11 , 12 Additionally, rigorous preoperative assessment using validated scoring tools, positron emission tomography–computed tomography (PET‐CT) imaging, and multidisciplinary decision‐making are essential to optimize patient selection.
The primary objective of this study was to evaluate postoperative urinary complications and their management following Bricker urinary diversion in patients with gynecologic cancers. A secondary objective was to identify potential risk factors associated with the development of uretero‐ileal strictures.
2. MATERIAL AND METHODS
2.1. Patient selection
This retrospective study included all patients who underwent non‐continent trans‐intestinal urinary diversion using the Bricker technique for gynecologic malignancies at Gustave Roussy tertiary cancer center between January 2000 and December 2020. This period was selected to ensure consistency in surgical indications, therapeutic strategies, and surgical team composition, as well as reliable data availability from computerized medical records.
The intent of surgery was defined prospectively at the multidisciplinary tumor board. Surgery was considered curative when the procedure aimed at complete macroscopic tumor resection, and palliative when urinary diversion was undertaken to relieve symptoms such as an established pelvic cloaca, a symptomatic fistula, or refractory obstruction without an attempt at complete tumor clearance.
2.2. Data collection
Patient demographics, tumor characteristics, and treatment history were extracted from electronic health records. Preoperative renal insufficiency was defined as a glomerular filtration rate (GFR) <90 mL/min/1.73 m2. Preoperative information included prior surgeries, radiation therapy (pelvic or para‐aortic), chemotherapy, brachytherapy, preoperative ureteral stenting, nephrostomy placement, and staging laparoscopy.
Surgical variables included the surgical approach, operative time, type of pelvic exenteration (anterior or total), urinary diversion details (type of uretero‐ileal anastomosis: Bricker [separate, refluxive, end‐to‐side anastomosis] or Wallace [conjoined, refluxive, end‐to‐end anastomosis]), digestive segment used for the diversion, reconstruction procedures, and any associated planned or unplanned interventions. Additional intraoperative data collected included tumor size, margin status, estimated blood loss, transfusions, and intraoperative complications.
The intraoperative macroscopic appearance of the intestinal segment used for diversion was documented when suggestive of chronic enteritis (bowel wall thickening, induration, adhesions, strictures, white serosal discoloration, and mesenteric fibrosis). When available, this was correlated with histopathological examination of the resected ileal segment.
2.3. Postoperative outcomes and definitions
Postoperative complications were classified using the Clavien‐Dindo system and categorized as early (<30 days) or late (30–180 days). Uretero‐ileal strictures were defined as partial or complete obstruction of contrast passage on computed tomography (CT) imaging, intravenous urogram, or during an interventional procedure, necessitating urinary diversion. Fistulas were diagnosed by contrast‐enhanced CT imaging. Postoperative renal insufficiency was defined by persistent or new‐onset GFR <90 mL/min/1.73 m2.
We also recorded the duration of initial hospitalization, complication types and their management, ureteral catheter management, reasons for rehospitalization and hospital length of stay, adjuvant treatment modalities, follow‐up with a stoma care team, and survival outcomes (overall and recurrence‐free survival).
All urinary diversions were performed using the Bricker technique, with uretero‐ileal anastomoses conducted predominantly via the Bricker method and, in a minority of cases, the Wallace technique.
2.4. Statistical analysis
All statistical analyses were performed using R software (http://lib.stat.cmu.edu/R/CRAN/). Continuous variables were reported as medians with interquartile range (IQR); categorical variables as counts and percentages. The Student's t‐test was used for comparing continuous variables, and Chi‐squared or Fisher's exact tests for categorical variables. A two‐sided p‐value <0.05 was considered statistically significant. Kaplan–Meier curves were generated for overall and recurrence‐free survival, and comparisons between groups were made using the Cox proportional hazards model.
3. RESULTS
Between 2000 and 2020, a total of 6920 patients underwent oncologic gynecologic surgery at our institution. Of these, 77 patients met the inclusion criteria and were included in the analysis: 75 underwent anterior or total pelvic exenteration with urinary diversion (71 with Bricker and 6 with Wallace uretero‐intestinal anastomoses), and 2 underwent isolated cystectomies with Bricker diversion. Surgery was performed with curative intent in 75 patients (97%); the remaining 2 patients (3%) underwent palliative urinary diversion without resection of the pelvic tumor. The median follow‐up was 21 months.
3.1. Patient and tumor characteristics
Preoperative characteristics are summarized in Table 1. The most common histologic subtypes were squamous cell carcinoma (n = 44, 57%) and adenocarcinoma (n = 22, 29%). Preoperative urinary tract compromise necessitating diversion was documented in 28 patients (36%): 10 patients received ureteral stents, 10 had preoperative nephrostomy tubes, and 8 required both stents and nephrostomy due to urologic fistulas or severe hydronephrosis.
TABLE 1.
Baseline demographic, clinical, and oncological characteristics of the study population.
| N (%) or Median (IQR) | |
|---|---|
| Age at surgery (years) | 53 (46–63) |
| Body mass index–BMI (kg/m2) | 23.3 (20.3–29.3) |
| Obesity (BMI >30 kg/m2) | 15 (19) |
| Smoking | |
| Yes | 22 (28) |
| No | 52 (68) |
| N/A | 3 (4) |
| Preoperative renal failure | 13 (17) |
| Diabetes | 4 (5) |
| Previous thromboembolic events | 13 (17) |
| Previous abdominal surgery | 59 (77) |
| Other cancer a | 5 (7) |
| WHO score | |
| 0 | 1 (1) |
| 1 | 27 (35) |
| 2 | 47 (61) |
| 3 | 1 (1) |
| 4 | 0 (0) |
| N/A | 1 (1) |
| Median | 2 |
| Site of primary tumor | |
| Cervix | 56 (73) |
| Corpus uteri/Endometrium | 11 (14) |
| Vagina/Vulva | 7 (9) |
| Adnexa | 3 (4) |
| Initial FIGO stage | |
| 1 | 0 (0) |
| 2 | 13 (17) |
| 3 | 25 (32) |
| 4 | 39 (51) |
| Preoperative lymph node status | |
| N0 | 66 (86) |
| N+ | 8 (10) |
| N/A | 3 (4) |
| Preoperative radiotherapy (RT) | |
| Nb of patients | 63 (82) |
| Dose (Gy) | 45 (45–46) |
| Delay RT – Bricker (months) (1) | 20 (10–47) |
| Pelvic radiotherapy | 55 (71) |
| Pelvic and para‐aortic radiotherapy | 8 (10) |
| Preoperative brachytherapy | |
| Nb of patients | 52 (68) |
| Dose (Gy) | 15 (15–20) |
| Delay brachytherapy—Bricker (months) (2) | 20 (9–46) |
| Preoperative chemotherapy | |
| Nb of patients | 59 (77) |
| Number of cycles | 6 (5–6) |
| Delay chemotherapy—Bricker (months) (3) | 13 (6–30) |
| Surgery | |
| Primary surgery | 6 (8) |
| Primary chemotherapy treatment | 7 (9) |
| Chemoradiation | |
| –Persistence (<1 year after RT) | 17 (22) |
| –Recurrence (>1 year after RT) | 47 (61) |
| Tumor size: initial tumor (mm) | 39 (30–60) |
| Location of recurrence | |
| Vaginal fundus | 53 (69) |
| Cervix/Parametrium | 30 (39) |
| Rectovaginal septum | 31 (40) |
| Lower third vagina/trigone | 60 (78) |
| Other b | 2 (3) |
| Preoperative fistula | |
| Vesicovaginal | 10 (17) |
| Rectovaginal | 4 (9) |
| Both | 3 (4) |
| Preoperative ureteral stent (Mono J or double J) | |
| Unilateral | 5 (7) |
| Bilateral | 13 (13) |
| Preoperative Pyelostomy | |
| Unilateral | 4 (5) |
| Bilateral | 14 (18) |
Abbreviations: IQR, Interquartile Range; N/A, Not Applicable; Nb, Number; RT, Radiotherapy.
Other cancer: any previous or concurrent malignancy distinct from the one requiring urinary diversion.
Other location of recurrence: 2 cases of pulmonary recurrence. (1) Delay between radiotherapy and Bricker surgery. (2) Delay between brachytherapy and Bricker surgery. (3) Delay between chemotherapy and Bricker surgery.
3.2. Surgical data
Operative details are provided in Table S1. Intraoperative complications occurred in 7 patients (9%), including two vascular injuries (external and internal iliac veins), two bowel ischemias requiring resection, one technical Bricker revision, one massive stercoral peritonitis, and one case of terminal ureteral ischemia requiring iterative resection. At the end of surgery, all patients had bilateral single‐J stents exteriorized through the Bricker conduit.
3.3. Postoperative complications
Postoperative outcomes are detailed in Table S2. Overall, 32 patients (42%) experienced complications, with urinary complications being the most frequent. Uretero‐ileal strictures occurred in 23 patients (30%), and fistulas in 5 patients (6%). Combined, 34 patients (44%) required additional postoperative urinary diversion. Ureteral stents were used in 33 patients (43%), with a median of 4 stent placements per patient. Nephrostomies were placed in 19 patients (25%), with a median of 2 procedures. One patient required nephrostomy alone.
Among those requiring postoperative diversion, 22 patients (65%) no longer needed it after a median of 12 months. Five patients (6%) required home intravenous rehydration for dehydration. Renal complications occurred in 3 patients (4%): one underwent nephrectomy for a non‐functioning kidney, and two developed chronic renal failure requiring dialysis.
Surgical management for uretero‐ileal strictures was needed in 4 patients (5%): two had Bricker revisions, one had uretero‐intestinal reanastomosis, and one underwent nephrectomy due to a nonfunctional kidney. Fistula repair was required in 3 patients (4%): two underwent Bricker revisions and one reanastomosis. Two patients had both complications (fistulas and strictures), requiring combined surgery. All strictures were initially managed conservatively with ureteral stenting (median of 5 procedures per patient), and 16 (70%) also required nephrostomy placement (median of 2). After a median follow‐up of 13 months, 15 (65%) no longer needed diversion.
Digestive complications necessitated reoperation in 18 patients (23%) (see Table S2). Additionally, one patient (1%) required reoperation for a vascular complication and one (1%) for wound dehiscence. Morbidities are summarized in Figure 1.
FIGURE 1.
Bar chart of postoperative urological complications in the study population (n = 77). Bars show the number of patients affected by each complications, with the corresponding percentage of the cohort.
There were no intraoperative deaths. However, three patients (4%) died within 40 days postoperatively: one on day 17 from sepsis, one on day 20 from cachexia following isolated Bricker diversion in a pelvic cloaca without pelvic tumor excision, and one on day 40 from delayed hemorrhage after embolization failure in a patient with incomplete tumor resection. Within the first 6 months, 5 patients (7%) were lost to follow‐up, and 20 patients (26%) died.
3.4. Risk factors for uretero‐ileal stricture
Comparative analysis between patients with strictures (n = 23) and those without is presented in Table 2. Preoperative nephrostomy was significantly associated with stricture development (p = 0.001), whereas preoperative ureteral stenting was protective (p = 0.005). Although not statistically significant, no strictures occurred in patients who underwent Wallace anastomosis.
TABLE 2.
Comparative analysis of clinical and surgical characteristics between patients with and without uretero‐ileal strictures.
| No ureteral stricture | Ureteral stricture | p | |
|---|---|---|---|
|
N (%) or Median [range] N = 54 |
N (%) or Median [range] N = 23 |
||
| Age (years) | 53 [41.2–64.8] | 53.6 [40–67.2] | 0.859 |
| High blood pressure | 9 (17) | 9 (39) | 0.066 |
| Body mass index (BMI) (kg/m2) | 25.1 [18.9–31.3] | 24.1 [17.6–30.6] | 0.564 |
| Obesity (BMI >30 kg/m2) | 11 (20) | 4 (17) | 1.000 |
| Diabetes | 3 (5.6) | 0 (0) | 1.000 |
| Tumor size (mm) | 32 [0–74] | 64 [0–170] | 0.021 |
| Initial FIGO stage | |||
| 1 | 0 (0) | 0 (0) | 0.064 |
| 2 | 8 (15) | 5 (22) | |
| 3 | 15 (28) | 10 (43) | |
| 4 | 30 (56) | 9 (39) | |
| Preoperative radiotherapy | 42 (78) | 20 (87) | 0.278 |
| Dose (Gy) | 45 [0–100] | 45 [0–64] | 0.829 |
| No radiotherapy | 11 (20) | 3 (13) | 0.535 |
| Pelvic | 37 (65) | 18 (78) | |
| Pelvic and paraaortic | 6 (10) | 2 (9) | |
| Preoperative chemotherapy | 37 (69) | 22 (96) | 0.023 |
| Preoperative brachytherapy | 37 (69) | 16 (70) | 0.986 |
| No preoperative derivation | 36 (67) | 13 (56) | ‐ |
| Preoperative JJ stent or Mono‐J stent (unilateral or bilateral) | 14 (26) | 4 (17) | 0.005 |
| Preoperative Pyelostomy (unilateral or bilateral) | 10 (18) | 8 (37) | 0.001 |
| Surgical approach | |||
| Laparotomy | 50 (93) | 23 (100) | 0.436 |
| Laparotomy | 4 (7) | 0 (0) | |
| Pelvic exenteration | |||
| Total | 25 (46) | 11 (48) | 0.567 |
| Anterior | 29 (54) | 10 (43) | |
| Without Pelvic Exenteration | 0 (0) | 2 (9) | |
| Uretero‐ileal anastomosis technique | |||
| Bricker | 48 (89) | 23 (100) | 0.230 |
| Wallace | 6 (11) | 0 (0) | |
| Level of ureteral section | |||
| Pelvic | 40 (74) | 20 (87) | 0.849 |
| Iliac | 9 (16) | 2 (9) | |
| Lumbar | 1 (2) | 0 (0) | |
| Asymmetric | 3 (6) | 1 (4) | |
| N/A | 1 (2) | 0 (0) | |
| Distal ileum segment | 46 (85) | 16 (70) | 0.395 |
| Bowel segment length (cm) | 18.5 [9.8–27.2] | 19.2 [11.6–26.8] | |
| Chronic enteritis | 4 (7.4) | 6 (26.1) | 0.013 |
| Tumor margin status | |||
| R0 | 35 (64) | 21 (91) | 0.024 |
| R1‐R2 | 19 (36) | 2 (9) | |
| Blood loss (mL) | 1000 [0–4000] | 900 [200–5000] | 0.704 |
| Uretero‐ileal fistula | 1 (2) | 4 (17) | 0.043 |
| Postoperative hydronephrosis | 25 (46) | 22 (96) | <0.001 |
| Digestive complications (excluding cases of uretero‐ileal fistulas) | /53 | /19 | |
| None | 27 (50) | 12 (52) | 0.824 |
| At least one digestive complication | 23 (43) | 7 (30) | |
| Stomal disinsertion | 3 (6) | 0 (0) | |
| Peristomal cutaneous burn | 4 (7) | 1 (4) | |
| Stomal necrosis | 1 (2) | 0 (0) | |
| Stomal hernia | 4 (7) | 2 (9) | |
| Stomal stricture | 2 (4) | 0 (0) | |
| Intestinal anastomosis fistula | 7 (13) | 2 (9) | |
| Enterocutaneous fistula | 4 (7) | 2 (9) | |
| Rectovaginal fistula | 10 (18) | 4 (17) | |
| Collection/Hematoma | 8 (15) | 3 (13) | |
| Occlusion/ileus | 34 (63) | 11 (48) |
Abbreviation: N/A, Not Applicable.
Selection of the ileal segment was a significant factor, with signs of chronic enteritis associated with increased stricture risk (p = 0.013). The level of ureteral section was not significant (p = 0.85).
In the stricture group, the two‐year overall survival was 65.2%, and the one‐year recurrence‐free survival was 69.6%. No significant differences in overall survival (p = 0.15) or recurrence‐free survival (p = 0.28) were found when compared to patients without strictures.
4. DISCUSSION
In this retrospective, single‐center study of 77 patients undergoing pelvic exenteration or cystectomy with Bricker urinary diversion for gynecologic malignancies, uretero‐ileal strictures were observed in 30% of cases and uretero‐ileal fistulas in 6%. These urologic complications had a significant impact on postoperative morbidity, often necessitating repeated interventions such as ureteral stenting, nephrostomy placement, and, in certain cases, surgical revision.
Our findings suggest that preoperative nephrostomy is significantly associated with an increased risk of uretero‐ileal stricture, while preoperative ureteral stenting was associated with a protective effect. These results support a strategy that favors early planning of urinary diversion and careful selection of preoperative urinary decompression methods. When feasible, preoperative stenting performed by an experienced team may help reduce the risk of postoperative complications. The optimal timing for the Bricker procedure should therefore be determined strategically within the patient's treatment trajectory, ideally before the onset of advanced urologic deterioration requiring nephrostomy. It remains unclear, however, whether nephrostomy itself contributes to stricture formation or whether it simply identifies patients with more advanced ureteral damage (severe obstruction, major fistulas or cloacal defects) that already precludes safe stenting.
We also found a significant association between the presence of macroscopic signs of chronic enteritis in the ileal segment used for diversion and the development of strictures. This suggests that the quality of the bowel segment plays a role in anastomotic integrity and long‐term function. Although the level of ureteral sectioning was not statistically associated with complications in our series, preserving ureteral vascularization and avoiding ischemic segments may be beneficial. Intraoperative techniques such as near‐infrared fluorescence imaging with indocyanine green (ICG) could potentially guide optimal segment selection and enhance surgical safety.
From an anatomical and technical standpoint, the integrity of the uretero‐ileal anastomosis is highly dependent on adequate ureteral vascularization. The ureter has a segmental blood supply, and the distal pelvic segment, which was the most frequent level of transection in our cohort (78%), is particularly vulnerable because its perfusion relies on fine branches arising from the vesical and uterine vessels that are frequently sacrificed or compromised during radical pelvic resection and previous irradiation. Distal ureteral ischemia is therefore a central mechanism of stricture formation. Several technical principles may attenuate this risk: transecting the ureter back to healthy, well‐perfused, non‐irradiated tissue; preserving the periureteral adventitia and avoiding circumferential skeletonization that devascularizes the ureteral wall; and fashioning a tension‐free, widely spatulated and watertight anastomosis over a soft stent. The left ureter, which must be mobilized across the midline beneath the sigmoid mesentery to reach the conduit, is exposed to greater dissection and potential ischemia and therefore warrants particular attention. These considerations are especially relevant in the high‐risk settings encountered in this population: the heavily irradiated ureter, the chronically obstructed ureter managed by prolonged nephrostomy, and the ileal segment affected by chronic radiation enteritis. In such settings, intraoperative assessment of tissue perfusion, for example, with indocyanine green fluorescence, may help to secure a viable anastomosis. 3 , 5 , 6 , 13
Interestingly, preoperative chemotherapy emerged as a possible risk factor for stricture formation, whereas radiotherapy, regardless of its extent or field, did not. This observation is novel and underexplored in the literature. Further dedicated studies are needed to investigate the possible pathophysiological mechanisms linking systemic chemotherapy to uretero‐enteric anastomotic fibrosis or dysfunction. 14
A seemingly paradoxical finding in our series was the higher rate of complete (R0) resection among patients who developed strictures (91% vs. 64%, p = 0.024). Several non‐exclusive explanations may account for this. First, achieving an R0 resection in a previously irradiated and recurrent pelvic field often requires more extensive ureteral mobilization and peri‐anastomotic dissection, which may compromise distal ureteral vascularization. Second, and probably more importantly, strictures are a late complication: patients with incomplete resection (R1 to R2) have a markedly poorer prognosis, and a proportion of them died from disease progression before a late stricture could become clinically apparent. Given the small number of events and the retrospective design, this finding should be regarded as hypothesis‐generating rather than causal. 8
The observed 30% stricture rate in our series is higher than commonly reported estimates in the general uro‐oncologic population (typically around 15%). 13 Christoph et al. reported uretero‐ileal strictures in 25.3% of patients undergoing Bricker anastomosis for bladder cancer, with significantly fewer strictures (7.7%) in those treated with the Wallace technique. 15 Although our study was not powered to statistically compare Bricker and Wallace techniques, no strictures occurred in the Wallace subgroup, warranting further evaluation of its potential protective effect.
Alternative strategies, such as the Miami continent self‐catheterizable pouch, have been developed, particularly for younger patients. 16 However, these techniques carry significant risks, including self‐catheterization difficulties, pouchitis, pouch torsion, and increased surgical complications over time. 17 In a comparative study, ileal pouch patients experienced more diversion‐related complications than those with ileal conduits (48% vs. 31%, p = 0.03), despite a similar overall complication rate and quality of life. Patients with ileal pouch required more surgeries for stomal complications and bladder stone formation. 18 Furthermore, the use of the right colon or ileo‐colonic junction in Miami pouch construction may be suboptimal in patients with extensive irradiation, due to risks of diarrhea and impaired digestive function. In our view, continent diversions should be reserved for highly selected cases, while the Bricker conduit remains the reference option in irradiated patients and those undergoing curative procedures. 16
Globally, both nephrostomy and ureteral stenting are well‐established methods for treating ureteral obstruction, with nephrostomy being associated with a higher success rate and a lower complication rate compared to ureteral stenting, especially in patients with severe hydronephrosis or renal dysfunction. 19 Nonetheless, stenting is usually considered as a first‐line option, with nephrostomy being reserved for cases where stenting fails or is not feasible. 20 This decision should take into account patient factors such as the degree of ureteral obstruction, baseline renal function, and disease stage. 21
Because our cohort spans two decades (2000 to 2020), it inevitably reflects the evolution of care. Pelvic radiotherapy progressed from two‐dimensional and three‐dimensional conformal techniques toward intensity‐modulated and image‐guided radiotherapy; staging was refined by the routine use of PET‐CT; minimally invasive approaches; enhanced recovery pathways were introduced; and intraoperative tools such as indocyanine green fluorescence became available. These developments are likely to have modified both patient selection and the nature of complications, so that contemporary complication profiles may differ from those observed in the earlier years of the series. The same trend is apparent in perioperative mortality, which fell from up to 8% in older series 16 to 1.7% in the most recent multicenter experience. 8 The 4% early mortality observed across our 20‐year cohort (4% within 40 days) is consistent with this downward trend. Today, rigorous patient selection, relying on validated risk‐scoring tools, PET‐CT, multidisciplinary evaluation, and the centralization of these procedures in high‐volume referral centers, remains central to lowering morbidity and to identifying the patients most likely to benefit from this radical surgery. 2 , 3 , 8
However, several limitations must be acknowledged. The retrospective design limits control over data quality and introduces inherent bias. In addition, because the series spans a 20‐year period, it is subject to calendar‐period heterogeneity: surgical instruments, imaging, radiotherapy techniques, and perioperative care all evolved substantially over time, which may have introduced bias and limited the extrapolation of the earliest outcomes to current practice. The lack of a comparative cohort treated with alternative urinary diversion techniques (e.g., continent pouches) restricts our ability to evaluate the relative efficacy or safety of the Bricker approach. Additionally, quality‐of‐life outcomes, which are critically important in evaluating urinary diversion strategies, were not systematically assessed in this study. 22 Because quality of life is broadly comparable between continent and non‐continent diversions in several reports 13 , 18 yet differs by diversion type over longer follow‐up, 22 the prospective and standardized collection of patient‐reported outcomes should be a priority in future studies.
One of our study's strengths lies in the homogeneity of the patient population, exclusively composed of gynecologic oncology cases, with 82% having received pelvic or para‐aortic radiotherapy. All surgeries were performed by a consistent team of senior gynecologic oncologists using standardized techniques, which strengthens the reliability of our findings. Identifying modifiable risk factors, particularly related to preoperative urinary decompression and bowel segment selection, provides actionable insight that may improve surgical planning and reduce morbidity.
5. CONCLUSION
In conclusion, uretero‐ileal strictures and fistulas remain significant complications following Bricker urinary diversion in patients undergoing pelvic exenteration for gynecologic malignancies. When feasible, preoperative ureteral stenting may reduce the risk of postoperative anastomotic complications compared to percutaneous nephrostomy. In selected cases, proceeding directly to urinary diversion without prior nephrostomy could further limit morbidity, particularly when signs of progressive ureteral compromise are present. Surgical success also depends on meticulous intraoperative technique, including careful selection of a non‐inflamed, well‐vascularized bowel segment and an optimal ureteral transection level to ensure a viable uretero‐ileal anastomosis. Tailoring these factors to each patient's clinical context may help improve long‐term outcomes and preserve renal function.
AUTHOR CONTRIBUTIONS
Eya Jaafar: Data curation, investigation, methodology, formal analysis, visualization, writing – original draft, and writing – review and editing. Houssein El Hajj: Conceptualization, methodology, supervision, formal analysis, project administration, writing – original draft, and writing – review and editing. Amandine Maulard: Conceptualization, investigation, data curation, methodology, and writing – review and editing. Pierre André Mal, Stéphanie Scherier, Thomas Dabreteau, Kim Do, and François Zaccarini: Investigation, data curation, and writing – review and editing. Bastien Parier and Sophie Espenel: Methodology, investigation, and writing – review and editing. Alexandra Leary and Patricia Pautier: Methodology, interpretation of data, and writing – review and editing. Catherine Genestie: Investigation, pathology expertise, interpretation of data, and writing – review and editing. Philippe Morice and Sébastien Gouy: Conceptualization, methodology, supervision, project administration, interpretation of data, and writing – review and editing. All authors critically reviewed the manuscript, approved the final version, and agree to be accountable for the work.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
ETHICS STATEMENT
The study was approved by the Gustave Roussy Institutional Review Board (Commission Scientifique des Essais Thérapeutiques) on December 3, 2024 (registration no. 2024‐470). All patients provided written informed consent prior to surgery, including consent for the scientific use and publication of information related to their procedure, provided that their identity remained protected.
Supporting information
Table S1:Surgical Characteristics and Intraoperative Parameters of the Study Cohort.
Table S2:Postoperative Morbidity, Complication Profiles, and Clinical Outcomes of the Study Population.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1:Surgical Characteristics and Intraoperative Parameters of the Study Cohort.
Table S2:Postoperative Morbidity, Complication Profiles, and Clinical Outcomes of the Study Population.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.