Bowel complications and anastomotic leak after ileocolic anastomosis in urinary diversion surgery: a comparative 12-year retrospective single-center study

Introduction

Over the years, various types of continent catheterizable urinary diversions have been described. One of the most common is the right colon pouch (RCP), which can be done by a variety of techniques but all utilize the colon and terminal ileum (1). The continence mechanism in RCPs often relies upon the ileocecal valve and a catheterizable channel created using some type of plication or staple reduction of the terminal ileum (2-4). Continent cutaneous ileocecocystoplasty (CCIC), utilizes the same construction as an RCP but a shorter segment of the colon. This technique allows bladder augmentation and creation of a continent catheterizable channel en bloc using a single bowel segment (5,6).

Urinary diversion and bladder augmentation are associated with significant perioperative and long-term complications. While these innovative approaches provide valuable therapeutic options, complications associated with the utilization of bowel segments in reconstructive urology pose significant risks and can lead to increased morbidity, re-interventions, and higher mortality (7-9). Bowel complications including anastomotic leak stand out as major contributors to morbidity and mortality following these surgeries (10,11).

There is limited data within the urologic literature regarding bowel complications and leak rates following surgery requiring ileocolic anastomoses such as RCP and CCIC (12). A recent literature review revealed that anastomotic leaks occur in approximately 1–6% of patients who undergo RCP leading to significant morbidities, the need for interventions, and an associated increase in mortality rates up to nearly 40% (12-15). The vast majority of the literature addressing ileocolic leak is in colorectal surgery or acute care surgery, where rates are 1.3% to 8.4%, however, patients often have colon cancer or other morbid conditions like toxic megacolon and traumatic injury (16).

In this study, we aimed to investigate patient characteristics, complications, and intervention needs among patients who underwent RCP and CCIC, specifically focusing on bowel-related complications. We hypothesized that patient factors could be associated with ileocolic bowel anastomotic complications and differences may exist between RCP and CCIC. We present this article in accordance with the SUPER reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-24-453/rc).

Methods

Study design

We conducted a comprehensive chart review on all adult patients who received RCP or CCIC at our institution from 2010 to 2022. The exclusion criteria included a follow-up period of less than 90 days, and those with a proximal diverting ileostomy.

Variables

Preoperative and demographic data and information regarding the index surgeries were documented for each patient. Comorbidities were recorded using the age-adjusted Charlson Comorbidity Index (CCI). Perioperative serum albumin levels, estimated glomerular filtration rate (eGFR), and the American Society of Anesthesiologists (ASA) physical status class were determined.

Operative variables including anastomosis type (hand-sewn or stapled, single or double-layered), concomitant procedures, operation time, estimated blood loss (EBL), and intraoperative blood transfusion were recorded for each patient. Post-operative complications, readmissions, and re-operations were evaluated within 90 days. Post-operative complications were classified using the Clavien-Dindo (CD) system (17). Urology follow-ups including the most recent (>90 days) visit were evaluated to determine long-term interventions, bowel-related complications, anastomotic leaks, and mortalities.

Surgeries

One surgeon performed all surgeries (J.B.M.) according to previously described methods for RCP (4) and CCIC (18). The surgical method utilized for creating RCP has been discussed in detail and is similar to the Indiana pouch with minor variations (4). This method includes staple reduction of the terminal ileum and detubularization of the colon to create a catheterizable channel and a continent pouch.

CCIC was performed according to the method first described by Sarosdy (5). In brief, 10–15 cm of the cecum and ascending colon and 10–13 cm of terminal ileum were harvested en bloc. The ileal segment was tapered via staple reduction over a 12Fr to 14Fr catheter to create the catheterizable channel and the ileocecal valve was reinforced with imbricating sutures to create the continence mechanism. This portion of the surgery is identical to the creation of an RCP or Indiana pouch. The cecum and ascending colon were then detubularized and anastomosed to the bivalved bladder with the channel brought through the abdominal wall usually at the umbilical level (18).

Statistical analysis

The outcomes were presented as frequencies for categorical variables and as mean [standard deviation (SD)] or median [interquartile range (IQR)] for continuous variables. Continuous variables were analyzed using independent T-tests, and chi-square tests were utilized for categorical variables. We used Cox Proportional Hazards analysis to compare bowel-related complications and anastomotic leaks. An unadjusted Kaplan-Meier curve was used to summarize the rate of bowel obstructions in the RCP versus CCIC group over time. All models were adjusted for age, gender, BMI, history of abdominopelvic radiotherapy, anastomosis type, and comorbidities using CCI. The statistical significance level was set at the <0.05 level, and all tests were two-tailed.

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional review board of the University of Utah (No. IRB_00101714), and individual consent for this retrospective analysis was waived.

Results

Study population

We identified 175 patients who underwent RCP and CCIC at our institution between 2010 and 2022. Thirteen patients were excluded due to inadequate postoperative follow-up periods (<90 days). Our final cohort comprised 162 patients, with 106 (65.4%) undergoing RCP and 56 (34.6%) undergoing CCIC.

Patient characteristics

There were 57 (53.8%) female patients in the RCP and 38 (67.9%) in the CCIC group (P=0.07). On average, patients who underwent RCP were older than those who underwent CCIC with a mean (SD) age of 55.5 (13.1) years in the RCP and 40.3 (14.6) years in the CCIC group (P<0.001). The mean (SD) BMI was 28.7 (8) in the RCP group and 27.9 (5.8) in the CCIC group (P=0.27).

The most common reasons for urinary diversion in the RCP group were bladder problems due to abdominopelvic radiation injury in 34 (32.1%) patients and 25 (23.6%) of the patients in the RCP group had bladder resection concurrently with diversion surgery for bladder cancer. The most common reasons for diversion in the CCIC group were bladder problems due to spinal cord injury in 32 (57.1%) patients, followed by congenital neurologic conditions in 12 (21.4%) patients including spina bifida in 6 (10.7%).

Overall, 38 (35.8%) patients in the RCP group had a history of abdominopelvic radiotherapy, mainly for primary treatment of prostate cancer in 13 (12.3%), adjuvant/salvage radiotherapy for prostate cancer in 12 (11.3%), and cervical cancer in 7 (6.6%) patients. Also, 17 (16%) patients in the RCP group had a history of neoadjuvant chemotherapy before the index surgery. No patients in the CCIC group had a history of abdominopelvic radiotherapy or chemotherapy.

Evaluating the comorbidities using CCI demonstrated that 49 (87.5%) patients in the CCIC group had a CCI of 3 or less. In comparison, only 51 (48.1%) patients in the RCP had a CCI of 3 or less (P<0.001), with 16 (15.1%) of them having a CCI of 7 or higher (versus no patients with CCI ≥7 in the CCIC group; P=0.002). The majority of the patients in the RCP group had a history of solid tumors [65 (61.3%)], which was significantly more prevalent compared to patients in the CCIC group [2 (3.6%)] (P<0.001). The prevalence of diabetes mellitus [RCP: 20 (18.9%), CCIC: 5 (8.9%); P=0.10] and cardiovascular diseases [RCP: 17 (16%), CCIC: 6 (10.7%); P=0.36] showed no statistical differences between the two groups.

Patients in the CCIC group had a significantly higher rate of prior suprapubic tube (SPT) placement [CCIC: 17 (30.4%), RCP: 16 (15.1%); P=0.02], bladder Botox injection [CCIC: 14 (25%), RCP: 7 (6.6%); P<0.001], bladder neck reconstruction [CCIC: 4 (7.1%), RCP: 1 (0.9%); P=0.03], and urethral slings [CCIC: 4 (7.1%), RCP: 1 (0.9%); P=0.03] compared to the RCP group. The RCP group had a significantly decreased preoperative eGFR compared to the CCIC group [RCP: 87.06 (39.81), CCIC: 122.33 (51.23); P<0.001]. Preoperative serum albumin levels and ASA class did not differ between the two groups (Table 1).

Operative variables

The RCP group had longer operative times compared to the CCIC group [RCP: 522.9 (127.4) minutes, CCIC: 361.4 (105.8) minutes; P<0.001]. Patients in the RCP group had higher mean EBL compared to the CCIC group [RCP: 494.5 (395.5), CCIC: 207.8 (118.9); P<0.001]. Moreover, 10 (9.4%) patients in the RCP group required intraoperative blood transfusion, whereas no patients in the CCIC group required such intervention (P=0.02). Omental flaps were more frequently utilized in the RCP group compared to the CCIC group [RCP: 76 (71.7%), CCIC: 31 (55.4%); P=0.04].

The ileocolic bowel anastomosis was performed in double-layers using stapling, with hand-sewn sutures reinforcing the staple lines in the majority of patients in both groups [RCP: 76 (71.7%), CCIC: 49 (87.5%), P=0.19]. Most patients in the RCP group [80 (75.5%)] received a concomitant cystectomy, and 8 (7.5%) received a prostatectomy with their RCP surgery. Moreover, 9 (8.5%) patients in the RCP groups received a protective ileostomy and were excluded from analysis for bowel-related complications. No patients in the CCIC group underwent prostatectomy or protective ileostomy. In addition, 14 (25%) patients in the CCIC group had a simultaneous bladder neck closure, and 4 (7.1%) received a urethral sling. The postoperative hospital stay was 9.9 (5.1) days for the RCP and 10.3 (5.9) days for the CCIC group (P=0.30).

Postoperative course

High-grade complications (CD ≥ grade 3) within 90 days from surgery occurred in 27 (25.5%) patients in the RCP group and 13 (23.2%) patients in the CCIC group (P=0.75). Patients in the RCP group experienced a higher readmission rate within the first 90 days [46 (43.4%)] compared to patients in the CCIC group [12 (20.7%)] (P=0.01). Particularly there was a higher rate of readmission rate for failure to thrive and poor nutrition [RCP: 11 (10.4%), CCIC: 0; P=0.01]. Other postoperative complications did not differ between the RCP and CCIC groups. There were no significant differences in interventions [RCP: 31 (29.2%), CCIC: 14 (25%); P=0.34] within 90 between the two groups.

Follow-up

The average follow-up period was 25.8 (9.4–54) months for the RCP group and 46 (10.9–89.9) months for the CCIC group (P=0.02). For the total follow-up period, the survival rates were 82.1% for the RCP group and 87.5% for the CCIC group (P=0.37). Importantly, there were no mortalities (CD grade 5) within 90 days after surgery in either group. Additionally, the 2-year survival rates were 94/106 (88.7%) for the RCP group and 49/56 (87.5%) for the CCIC group.

During the follow-up period (>90 days post-surgery), SPT placement was performed in 10 (9.4%) patients in the RCP group whereas no patients in the CCIC group underwent this procedure (P=0.02). Similarly, percutaneous nephrostomy tube placement was recorded in 7 (6.6%) patients in the RCP group, with no patients in the CCIC group (P=0.049). Out of these 7 cases, five had hydronephrosis and underwent revision of their catheterizable channel, and two cases had hydronephrosis due to kidney stones and received PCNL. On the contrary, long-term, 7 (12.5%) patients in the CCIC group required a bladder/reservoir stone removal compared to 3 (2.8%) in the RCP group (P=0.02).

Specific outcomes

Bowel complications were reported in 14 (13.2%) patients in the RCP group and 4 (7.1%) in the CCIC group (P=0.24) including bowel obstruction requiring intervention in 6 (5.7%) patients in the RCP group and 2 (3.6%) in the CCIC group (P=0.56). Anastomotic leaks occurred in 8 (7.5%) patients in the RCP and 2 (3.6%) patients in the CCIC group (P=0.32) (Table 2).

We excluded 10 patients with protective ileostomy for the final analysis including 9 patients who had undergone protective ileostomy at the time of the index surgery, and 1 patient who had an ileostomy before the index surgery. After adjusting for age and comorbidities, we found no significant difference in the occurrence of bowel complications in the CCIC group vs. RCP (HR: 0.6; 95% CI: 0.15–2.4). We also found no statistically significant difference in anastomotic leaks between RCP and CCIC groups (HR: 0.38; 95% CI: 0.06–2.21). Notably, we found that the type of anastomosis, stapled reinforced lines compared to single-layered (hand sewn or stapled), significantly influenced both bowel complications (HR: 0.1; 95% CI: 0.03–0.33) and anastomotic leaks (HR: 0.17; 95% CI: 0.04–0.75) (Table 3, Figure 1).

Figure 1 Unadjusted Kaplan-Meier curve showing bowel obstructions in the RCP (blue) versus CCIC (red) group over time. RCP, right colon pouch; CCIC, continent catheterizable ileocecal cystoplasty.

Discussion

Despite variations in patient characteristics and comorbidities between patients who received RCP and those who underwent CCIC, we found no significant differences in postoperative bowel complications and anastomotic leak rates between the two groups. Our findings underscore the critical role of the anastomosis technique, with stapled reinforced lines associated with significantly lower rates of bowel complications and anastomotic leaks. The rate of ileocolic anastomotic leak was 7.5% in RCP and 3.6% in CCIC. The higher anastomotic leak rate in the RCP cohort may be attributed to the greater complexity of cases and the increased comorbidity burden, both of which likely contributed to the elevated risk of postoperative complications. The variations in patient characteristics and comorbidities between the two groups in our study highlight the challenges in decision-making for diversion selection and patient optimization. These challenges arise from varying indications, patient characteristics, and postoperative expectations (12).

The longer operative times, increased EBL, and the need for intraoperative blood transfusions in the RCP group reflected the complexity of these cases, particularly as over 80% of patients in the RCP group underwent concomitant cystectomies or prostatectomies. The operative times for CCIC were consistent with findings from a multicenter study, revealing a median duration of 313 minutes for CCIC (18). Additionally, a prior series reported an average operative time of 510 minutes for RCPs (4). Prior studies reported that in comparison to ileal conduit and orthotopic neobladder surgeries, continent diversions are less commonly performed (19). Current literature supports the idea that the technical intricacies of RCP may contribute to these differences, emphasizing the need for experienced surgical teams when opting for this approach (4,20,21).

The higher readmission rate within the first 90 days among patients in the RCP group, compared to the CCIC group, particularly in cases attributed to failure to thrive and poor nutrition, indicates an association between the choice of diversion type and early postoperative complications. The readmission rates were consistent with earlier studies reporting a 90-day readmission rate of 45% for RCP and 21% for CCIC (4). Furthermore, the existing literature reports a wide range of 90-day complication rates and the associated occurrences of repeated procedures following RCP surgeries. Bazargani et al. identified a 64% complication rate, with 14% requiring a repeat procedure after receiving RCPs (22). Conversely, Liedberg’s study reported a lower 23% 90-day complication rate but a notably higher reoperation rate at 54%, possibly due to their extended follow-up period (23).

In terms of survival outcomes, there were no mortalities (CD grade 5) within 90 days after surgery for either group. The long-term survival rates were comparable between the two cohorts, despite the higher surgical complexity in the RCP group. The CCIC group had a higher incidence of bladder/reservoir stone removal during the follow-up period (>90 days post-surgery) compared to the RCP group. Urolithiasis is a common postoperative complication following urinary diversion surgery with a higher incidence in continent diversions due to prolonged urine dwell time (12). Interestingly, our findings indicate a lower rate of stone occurrence in RCP compared to previous reports. Stone disease rates after urinary conduit diversion range from 4.6% to 15.3% (12,24,25), and in continent diversions, stone formation rates range from 8.9% to 10.4%, with our observed rate aligning closely with these figures (12,24).

The higher rates of suprapubic tube placement and percutaneous nephrostomy tube placement in the RCP group compared to the CCIC group during the follow-up period (>90 days post-surgery) highlight the distinctive clinical trajectories of RCP and CCIC. Nephrostomy tubes were often required in RCP patients due to complications such as ureteral strictures or impaired drainage, particularly in patients with more complex urological histories and those who needed revision surgery for the catheterizable channel. SPTs were predominantly utilized during long-term follow-up in patients whose catheterizable channels had become stenotic above the fascia, requiring further revisions. Additionally, one patient who previously relied on catheterization opted for SPT placement for long-term management. These differences in complications further support the necessity for distinct approaches to managing patients undergoing RCP and CCIC.

The rate of bowel complications following RCP was slightly higher than the previously reported 8% bowel complication rate in a smaller cohort (4). Although not statistically significant, we observed a nearly two-fold higher rate of bowel complications in the RCP group compared to the CCIC group. This trend, while not conclusive, underscores the complexity of RCP procedures, which involve larger resections and are associated with increased perioperative risks.

Patients in the CCIC group had a lower rate of bowel obstruction (3.6%). A previous study on pediatric patients undergoing continent bladder augmentation cystoplasty reported a slightly higher rate of 5.6%, with no significant outcome variations observed among the different bowel segments utilized (26). However, a long-term follow-up study spanning over 20 years reported a higher rate of bowel obstruction in 10% of patients who underwent augmentation cystoplasty (11).

The anastomotic leak rates in both groups aligned with the ileocolic anastomotic leak rates reported in a recent literature review, ranging from 1% to 6% (1). These findings were also in line with outcomes of a previous RCP series which reported a 3.7% anastomotic leak rate and an additional 5.6% of patients experiencing postoperatively drained deep abscesses (4). Furthermore, the anastomotic leak rate in adult patients following CCIC has been documented as 3.5% in a recent multi-institutional investigation conducted over 10 years (18).

Anastomotic leaks after right hemicolectomy and ileocolic anastomoses were documented at 7.4% in a previous study, increasing the risk of death from 1.6% to over 10% when present (16). Moreover, the risk of bowel leaks post ileocolic anastomosis varied based on surgical variables such as the type of anastomosis (stapled vs. hand-sewn) and the approach (open vs. laparoscopic), with no evident association with patient-related factors (16,27). A Cochrane review reported lower rates of leaks with stapled ileocolic anastomoses (28), however, more recent population-based studies have favored a hand-sewn anastomosis due to their lower risk of anastomotic leaks (16,29). Our findings align with recent studies, demonstrating a protective role for double-layer ileocolic anastomosis using stapling reinforced with hand-sewn sutures in reducing the incidence of leaks, especially when compared to single-layer stapled anastomoses.

Although RCP is associated with significant perioperative and surgical risks, it is generally selected due to its ability to yield excellent continence and long-term functional outcomes, with only a few patients resorting to chronic indwelling catheters or converting their continent urinary diversions to incontinent diversions (1). An important aspect that the current study may not fully capture is the long-term impact on the quality of life for patients undergoing CCIC or RCP. Another notable limitation of our study is its retrospective design, making it challenging to precisely identify or associate the reasons behind intraoperative decision-making processes in hindsight.

Conclusions

Both RCP and CCIC demonstrated comparable outcomes regarding ileocolic anastomotic leaks, with rates of 7.5% for RCP and 3.6% for CCIC. The higher leak rate observed in RCP patients can likely be attributed to their increased surgical complexity and comorbidities. Importantly, our study highlights the role of anastomotic technique, as the type of anastomosis, particularly the use of double-layered hand-sewn methods, was associated with a reduced risk of leaks compared to single-layer stapled anastomoses.

Despite the procedural differences, we found no significant disparities in survival rates or bowel complications between RCP and CCIC during a follow-up period exceeding three years. These findings suggest that, with careful surgical technique, both procedures offer comparable long-term outcomes.

Acknowledgments

Part of this manuscript was presented as a podium presentation at the American Urological Association (AUA) 2024 Annual Meeting in San Antonio on May 4, 2024 (DOI: 10.1097/01.JU.0001008888.07102.14.03).

Funding: None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-24-453/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-24-453/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-24-453/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-24-453/coif). J.B.M. serves as an unpaid editorial board member of Translational Andrology and Urology from August 2024 to July 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional review board of the University of Utah (No. IRB_00101714), and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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