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Tinoco et al. Mini-invasive Surg 2021;5:28 https://dx.doi.org/10.20517/2574-1225.2021.35 Page 5 of 11

Acidosis may be managed with alkalinizing treatment with sodium bicarbonate and vitamin deficiency with
oral or parenteral supplementation [15-17] .

UTI
Risk factors for UTIs are incomplete emptying of urinary pouch (as residual urine is an infectious focus),
intermittent catheterization or stenosis of the stoma or ureterointestinal anastomosis. Bacteriuria is
common in these patients, but UTIs and urosepsis are not, so there is no need for prolonged suppressive
antibiotic therapy. Although less frequent than in the early post-operative period, UTI in this setting should
[16]
also be treated with a short course of antibiotics .
Urolithiasis
The bowel epithelium, incomplete emptying of reservoirs with urinary stasis, foreign materials like staples,
and chronic bacterial colonization or UTIs all contribute to stone formation, not uncommon in these
patients . These stones are mostly infectious and mixed, with metabolic stones being less frequent,
[17]
particularly if only reservoir stones are considered .
[18]
Regarding the role of staples in stone formation, Muto et al. reviewed their series of stapled neobladders
[19]
and report a global stone rate of 4.6%, with a risk of stone formation of 4.5%, 6.5%, 8.5%, and 10% at 5, 10,
15, and 20 years, respectively. They highlight the role of synchronous risk factors such as outlet obstruction
and UTI in these patients and note that when they treated the stones endoscopically, the stapled lines were
usually completely covered by mucosa .
[19]

A study on conduit recipients reported a stone rate of 15.3% at a median of 2.5 years, more frequently in the
[15]
upper urinary tract than in the conduit; less than 20% required treatment . Marien et al. studied 99
[18]
patients with urolithiasis after urinary diversion (not exclusively oncologic patients) and report an equal
rate of upper and lower urinary tract stones, including 15 patients with both. The rates of urolithiasis in a
recent meta-analysis were 3.5% for ileal conduits and 6.4% for neobladders, with a statistically significant
difference . Treatment options include all classical options for urolithiasis treatment, but endourological
[20]
procedures and external lithotripsy are preferred .
[15]
Ureteroenteric stricture
All but the cutaneous ureterostomy diversion involve uretero-enteric anastomoses. There are multiple
techniques for anastomosing the ureters to the bowel, either refluxing or nonrefluxing.

The stricture of this anastomosis is a well-recognized complication with its serious consequences being the
deterioration of the glomerular filtration rate with loss of kidney function. The rates of stenosis described in
the literature range from 1.3% to 10%, occurring predominantly on the first 2 years after surgery [2,21] .

Ureteroenteric stricture can have malignant causes, but most are benign. The pathophysiology of the benign
stricture formation is not fully understood but it is likely secondary to ischemia or urine leakage leading to
periureteral fibrosis. Preserving the ureteral blood supply, with careful handling and minimization of
electrocautery around the ureters, and the creation of tension-free anastomoses may reduce the stenosis
risk. Excision of redundant ureteric length, wider anastomosis, using stents for protection and testing with
saline for leaks are other recommendations that can reduce the rate of this complication . The use of
[21]
intraoperative indocyanine green (ICG) fluorescence to evaluate ureteric vascularity and choose the site of
ureteric division may reduce the risk of stricture; this is specially used in RARC, using the camera’s
capabilities .
[22]