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Page 6 of 11 Tinoco et al. Mini-invasive Surg 2021;5:28 https://dx.doi.org/10.20517/2574-1225.2021.35

After development of a stricture, the patients can complain of flank pain or present with recurrent UTIs or
urinary stones. If they develop an acute obstruction, decompression with a percutaneous nephrostomy is
required. Nevertheless, a significant proportion will be asymptomatic, with diagnosis of ureteroenteric
stenosis after imaging exams incidentally revealing hydronephrosis or blood tests hinting a deterioration of
renal function.

The open repair of the stenosis with excision of the affected segment and reimplantation of the ureter is the
gold-standard treatment, with the greatest rates of long-term success (up to 80%), but it involves high
technical expertise as these patients frequently have adhesions from the previous surgery. Therefore,
minimally invasive options are being increasingly used.

Endourological access to the stenosis can be retrograde or anterograde through a percutaneous
nephrostomy. Treatment may involve stenting, balloon dilation, or endoureterotomy (using cold knife,
laser, or other devices); balloon dilation is the less effective method. These techniques have reported success
rates of 4%-50%.

Although achieving less long-term patency when compared to open revision, endourological techniques
have less morbidity, shorter operative times and post-operative recovery and reduced costs, what makes
them an attractive option. In general, endoscopic techniques are recommended as a first-line treatment for
short strictures (≤ 1 cm) and for patients who cannot stand open repair [21,23] .

Minimally invasive alternatives to open revision, such as laparoscopic and robot-assisted repair, seem to
achieve similar results with less morbidity [24,25] . All these techniques are useful in managing this frequent
complication, when carefully selected.

DIVERSION SPECIFIC COMPLICATIONS
Each diversion type has its own specific complication, related not only to the construction of the diversion
but also to the chosen intestinal segment. The surgical approach (open vs. robot-assisted and extracorporeal
[6,7]
vs. intracorporeal) is not related to specific complications .

Ileal conduit
Parastomal hernia
Parastomal hernia (PSH) definition can be clinical or radiographic, with substantial heterogeneity across
studies. The largest systematic review to date, which included only retrospective observational studies, used
a clinical definition of a palpable bulge at the base of stoma and a radiographic definition of a cross-
sectional image evidencing protrusion of intraabdominal contents through the abdominal wall defect
created to fixate the conduit. Of the total of 3170 patients submitted to radical cystectomy with ileal conduit,
529 (17.1%) developed a PSH based on those criteria. The authors point that a substantial number of PSH
[26]
remains asymptomatic and are only detected in the oncologic follow-up imaging studies .

Treatment of PSH may be needed to alleviate symptoms such as pain or poor fit of ostomy bags or because
of more serious complications like bowel obstruction or strangulation. Conservative treatment with the use
of a hernia belt is a possibility, but no studies reported outcomes related to this modality. Surgical correction
for PSH is frequently avoided due to the difficulty of the technique, high morbidity, and frequent hernia
recurrence. Common procedures include local repair, the use of a synthetic or biological mesh, or relocating
the stoma, mainly based on general surgery literature. A technique of local repair of PSH after ileal conduit
was described by Rodriguez Faba et al. : a ipsilateral relocation of stoma without the need of midline
[27]