title: A randomized study comparing an antireflux system with a direct ureteric anastomosis in patients with orthotopic ileal neobladders.
abstract: OBJECTIVE
  To assess the benefit of an antireflux system in patients with orthotopic ileal neobladders, as there is controversy about whether reflux prevention offers any advantages.
  
  
  METHODS
  We conducted a randomized prospective study between January 2002 and March 2004, on 60 patients (53 men and seven women) with a mean (sd) age of 52.7 (7.3) years, who were candidates for orthotopic neobladders. Patients with comorbidities were excluded. Preoperative evaluation included intravenous urography (IVU), cystoscopic biopsy and radioisotope renography to evaluate the differential glomerular filtration rates (GFRs). Cases with normal kidneys and ureters, and with similar GFRs, were enrolled. Surgery comprised a standard radical cystectomy with pelvic lymphadenectomy. The ureters were randomized to either a direct anastomosis into a 5-cm ileal chimney on one side, or to be implanted using the antireflux serous-lined extramural tunnel on the contralateral side in the same patient. Regular follow-up included IVU and renography every 6 months in cancer-free patients.
  
  
  RESULTS
  The mean (sd) follow-up was 23 (9.6) months. There was prolonged urinary leak from a refluxing ureter in one patient that was treated with a temporary percutaneous nephrostomy. Symptomatic pelvic collections required tube drainage in six cases. Six ureters developed early anastomotic strictures (one direct and five antirefluxing), and were treated with endoscopic ureterotomy in three and open revision in three. Serum creatinine levels were normal in all patients throughout the observation period. GFRs were similar in the two groups. The mean GFRs before surgery and at 6, 12, 18, and 24 months after cystectomy were: 55.1, 50.7, 49.4, 52.2 and 53.9 mL/min for the direct side; and 56.1, 53, 52.4, 53.2 and 50.4 mL/min for renal units with antirefluxing implantation. There was a significant deterioration of the GFRs due to anastomotic strictures, from 48.6 (6.7) mL/min before surgery to 31.8 (15.9) mL/min after the revision (P = 0.01).
  
  
  CONCLUSIONS
  The antireflux procedures were associated with a higher incidence of anastomotic strictures than the direct methods and there was a significant deterioration of renal function after obstruction. The long-term follow-up data are awaited.
authors.affiliation: Department Of Urology, Urology and Nephrology Center, Mansoura, Egypt. shaaban1953@yahoo.com
authors.forename: Atallah A
authors.initials: AA
authors.lastname: Shaaban
authors.forename: Mohamed
authors.initials: M
authors.lastname: Abdel-Latif
authors.forename: Ahmed
authors.initials: A
authors.lastname: Mosbah
authors.forename: Hossam
authors.initials: H
authors.lastname: Gad
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Eraky
authors.forename: Bedeir
authors.initials: B
authors.lastname: Ali-El-Dein
authors.forename: Yasser
authors.initials: Y
authors.lastname: Osman
authors.forename: Mohsen
authors.initials: M
authors.lastname: El-Mekresh
authors.forename: El-Housseiny
authors.initials: el-H
authors.lastname: Ibrahim
authors.forename: Hamdy
authors.initials: H
authors.lastname: El-Kappany
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D015653:Cystectomy / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D011475:Prosthesis Failure; D011859:Radiography; D013536:Suture Techniques; D014521:Urethra / Q000601:surgery*; D016476:Urinary Reservoirs, Continent; D014718:Vesico-Ureteral Reflux / Q000000981:diagnostic imaging / Q000601:surgery*