Hybrid Ureteroenteric Anastomosis Is Associated with Lower Stricture Rates in lleal Conduit Urinary Diversion

To the Editor:

The study by Alhamdani et al. in the May issue of SIUJ [1] perfectly illustrates how variations in surgical technique, guided by the principles of reconstructive surgery, can improve clinical outcomes for patients. The authors evaluated a hybrid ureteroenteric anastomosis technique in ileal conduit construction in which the right ureter is implanted using the standard end-to-side Bricker anastomosis, while the left ureter, susceptible to a higher rate of anastomotic complications (66.7% in this study) compared with the right ureter, is implanted via an end-to-end anastomosis. At a median follow-up of 9 months, there were 9 patients with anastomotic strictures, including 5 in the Bricker only group, 3 in the Wallace only group, and one in the hybrid group. It is worth noting that the single case of stricture occurred in the right ureter indicating no cases of left-sided ureteroenteric stricture at 32 months, which is very encouraging [1].

As the authors state, the end-to-end anastomosis is no new innovation, and we have performed this approach in reoperative cases in our center but rarely at the initial construction. Given the results here, perhaps the end-to-end anastomosis should be performed in all instances of left-sided ureteroenteric anastomosis including neobladder construction. However, it does lead one to wonder what features of this technique contribute to a lower rate of stricture. As the authors state, less mobilization is required for this anastomosis and there is a lower degree of angulation of the ureter. Another factor may be that the anastomosis is inherently wider than if performed with the end-to-side technique given the requirement to perform adequate spatulation of the left ureter to match the diameter of the distal ileum which has been reported as 1.89 cm on average [2]. Therefore, the anastomosis in this case is almost half a centimeter wider than the end-to-side anastomosis (1.5 cm of spatulation).