Background
Radical cystectomy with urinary diversion is an established modality of curative treatment in patients diagnosed with muscle invasive or high grade bladder cancer.1 Acute kidney injury (AKI) is commonly encountered after major surgery which contributes to the overall morbidity and mortality.2 We describe a novel technique to maintain near normal physiology of the kidneys during the procedure by avoiding clamping of ureters.
Technique
The ureters are identified and dissected down to the bladder. Percutaneous extra corporeal cannulation of ureters with a single J stent is performed by passing a guidewire through a 14F cannula using the Seldinger technique. This is then connected to a collecting device to measure urine output. The diverted ureters with the stent in situ are snugly secured using an endoloop device (Figures 1 and 2).
Figure 1.
Technique of exteriorising the ureter
Figure 2.
Both ureters cannulated and exteriorised to a collection bag
Once urine is diverted, cystectomy, pelvic lymph node dissection is carried out. This is followed by isolation of the ileal loop and uretero-ileal anastomosis is then performed without obstructing the kidneys at any point during the procedure.
Discussion
Robotic radical cystectomy is a major procedure that is a known risk factor for deterioration in renal function.3 Patients who developed early postoperative AKI were almost six times more likely to develop chronic kidney disease (CKD) than those who did not.4 Unlike other factors such as prolonged pneumoperitoneum, blood loss, anaesthetic management, nephrotoxics and pre-existing comorbidities, intraoperative urinary obstruction can be avoided completely as a contributing factor for the development of AKI using this simple and quick to perform technique.
Acknowledgement
We’d like to thank Anh Parker, Senior Graphic Designer at Royal Surrey County Hospital, for the medical illustration in Figure 1.
References
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