Bilateral Ureteroenteric Strictures: A Case of the “Reverse 7”

Abstract

Anastomotic stricture is a well-known complication of the urinary diversion that accompanies radical cystectomy. Management options range from endoscopic procedures to open surgeries, with a subset of the latter employing bowel as the interposing segment. In this report, we describe a rare patient, who successfully underwent a “Reverse 7” procedure, bypassing strictures at both anastomotic junctions between ureters and neobladder.

A 66-year-old man with significant atherosclerosis underwent radical cystectomy with ileal neobladder for muscle-invasive high-grade urothelial carcinoma. Three months later, Lasix renogram displayed bilateral hydronephrosis due to long segment stricturing at both ureteroenteric anastomosis sites. His serum creatinine peaked at 1.56 mg/dL. Following upsizing of external nephroureteral catheters to facilitate drainage, as well as failed balloon dilation, we performed a bilateral ileal ureter diversion (“Reverse 7”). As shown in Figures 1 and 2, the ileal segment was anastomosed to the renal pelvis on each side and then directly anastomosed to the top of the neobladder adjacent to, but not at, the Studer limb. The strictured ureters were left in situ. The patient’s postoperative course was uncomplicated by pain, urine leak, or significant laboratory abnormalities. His serum creatinine normalized and he was discharged home on postoperative day 8.

Figure 1.

Artist illustration of “Reverse 7” procedure for bilateral ileal ureter diversion.

Figure 2.

(A) Multiplanar reformat coronal intravenous contrast-enhanced CT aligned to show bilateral collecting systems. No contrast is seen in the hydroureters due to lack of flow due to stricture of ureteroenteric anastomosis site (arrow). (B) Multiplanar volume rendered para axial reformat obliqued along renal collecting systems patent with ileal interposition anastomosis (arrows). (C) Interventional fluoroscopy saved image demonstrating the ileal interposition anastomosis (arrows). The percutaneous nephrostomy tubes were removed following confirmation of patency. CT, computed tomography.

Ureteroenteric anastomotic stricture represents a significant complication of radical cystectomy and urinary diversion.¹ Ureteral reconstruction in the form of ileal interposition has emerged as 1 option for surgical correction. Traditionally, it has been utilized when alternatives, such as endopyelotomy or segmental ureterectomy, have failed.^2,3 Here, we propose that the “Reverse 7” procedure may occupy a promising role in cases of bilateral ureteral stricture.