Endoscopic closure of a fistula between an ileal conduit and an ileal handle localized between two uretero-ileal anastomoses
22 March 2017 (online)
Cystectomy is the gold standard treatment for patients with bladder cancer. Urinary diversion with ileal conduit and uretero-ileal anastomoses, as described by Bricker, is the most widely used surgical therapy because of the lower risk of postoperative complications in elderly patients and in those with co-morbidities. The Bricker technique involves the use of a segment of the ileum as a conduit to the skin, with a successive uretero-ileal-cutaneous anastomosis for each ureter . The endoscopic approach to construction of the ileal conduit for urological obstruction is rarely reported . We present the case of a patient who underwent cystectomy with a Bricker uretero-ileal-cutaneous anastomosis, who developed a fistula between the ileal conduit and an ileal handle.
In May 2015, the patient underwent cystectomy with a Bricker uretero-ileal-cutaneous anastomosis because of bladder transitional cell carcinoma. In October 2016, stool appeared in the drainage. The patient underwent radiological examination with contrast medium at another hospital, which revealed a fistula between the ileal conduit and an ileal handle. The patient was referred to our unit and an ileal conduit endoscopy ([Fig. 1]) was performed using a gastroscope, which showed stool leakage from an orifice between the two ureteral anastomoses ([Fig. 2]). An 11/6 traumatic-teeth over-the-scope clip (OTSC), 9 mm in diameter, was placed to close the leak ([Video 1]), using an OTSC anchor to grasp the fistula ([Fig. 3]). Stool no longer appeared in the drainage 24 hours after OTSC placement. No adverse events occurred, and the patient was discharged 3 days after the procedure.Video 1: Placement of an over-the-scope clip to seal the fistula between the ileal conduit and an ileal handle, which was located between the two ureteral anastomoses.
There are no reports in the literature of the endoscopic closure of a fistula between the ileal conduit and an ileal handle. The current case demonstrates successful closure using an OTSC, which avoided damage to the uretero-ileal anastomoses. The OTSC is an excellent endoscopic therapeutic and conservative option in this particular and rare adverse event.
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