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© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

SIUJ.ORG SIUJ  •  Volume 4, Number 3  •  May 2023

Key Words Competing Interests Article Information

Ileal conduit, urinary diversion, Bricker, 
Wallace, hybrid, stricture, retrospective 

None declared. Received on June 6, 2022 
Accepted on January 22, 2023 
This article has been peer reviewed.

Soc Int Urol J. 2023;4(3):171–179

DOI: 10.48083/SZDP5651

171

ORIGINAL RESEARCH

Hybrid Ureteroenteric Anastomosis  
Is Associated With Lower Stricture Rates  
in Ileal Conduit Urinary Diversion
Zein Alhamdani,1 Kirby R. Qin,1 Vidyasagar Chinni,1 Scott Donellan,2 Damien Bolton,1  
Marlon Perera,1 Dixon Woon1

1 Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Victoria, Australia 2 Monash Health, Melbourne, Victoria, Australia 

Abstract

Background Anatomic complications of the ureteroenteric anastomosis in ileal conduit (IC) cause significant 
morbidity in patients post-cystectomy and cystoprostatectomy. The Bricker technique has a perceived disadvantage 
of increased risk for stricture, whereas the Wallace technique runs the risk for ureteral malignancy affecting both 
ureteric ends, and bilateral ureteric obstruction from a stone lodged at the anastomosis. We aimed to evaluate 
the safety, efficacy, and stricture rate of a novel hybrid ureteroenteric anastomosis technique. We compared these 
outcomes to the Bricker and Wallace anastomosis techniques for IC urinary diversion (ICUD).

Methods We performed a retrospective chart review of patients who had undergone ICUD after cystectomy for 
bladder cancer from 2011 to 2016. Patients were categorized into groups undergoing the Bricker, Wallace, and hybrid 
ureteroanastomosic techniques. Strictures were identified during clinical follow-up or hospital presentations with 
complications.

Results We identified 68 patients suitable for inclusion. They were separated by Bricker, Wallace, and hybrid 
anastomosis techniques, with 19 (27.9%), 20 (29.4%), and 29 (42.6%) patients, respectively. Ureteroenteric anastomotic 
strictures occurred in 9 patients (5 Bricker, 3 Wallace, 1 hybrid). This difference in stricture rates for Bricker versus 
hybrid (26.3% vs. 3.4%; OR, 10 [95% CI, 1.1 to 121.1]; P = 0.02) was significant but was comparable for Wallace 
versus hybrid (15.0% vs. 3.4%; OR, 4.9 [0.7 to 66.0]; P = 0.15) and for Bricker versus Wallace (26.3% vs. 15.0%;  
OR, 2 [0.4 to 8.6]; P = 0.87). 15 patients (51%) in the hybrid group required oral antibiotics for a symptomatic urinary 
tract infection compared with 4 (21%) with Bricker and 8 (40%) with Wallace (P = 0.10). Median post-cystectomy 
follow-up and stricture formation time were 16 months (IQR, 4–36) and 9 months (7–32), respectively.

Conclusion The hybrid technique is a safe and efficacious alternative to the Bricker and Wallace anastomoses.  
It carries with it a risk for urinary tract infection that is eclipsed by substantially lowered rates of ureteric strictures 
requiring intervention while maintaining the advantage of separating the two ureters.

Introduction

Ileal conduit is the commonest form of urinary diversion after radical cystectomy[1,2]. It has acceptable complication 
rates and reasonable postoperative quality of life, and the technique is relatively accessible by many urologists[3–7]. 
Despite the lower rates of morbidity compared to alternative types of urinary diversion, complications do occur. 

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A source of morbidity in ileal urinary diversion is 
associated with anatomical complications of the 
ureteroenteric anastomosis[8–10].

In general, there are three types of refluxing anasto-
moses of the ureter to the ileal conduit used in contem-
porary practice[11,12]. The Bricker anastomosis is 
categorized when the distal end of each ureter is anas-
tomosed to the anti-mesenteric side of the proximal 
ileal conduit[13]. Conversely, the Wallace anastomosis is 
performed by anastomosing both distal ureters together 
to form one ureteric plate, which is then anastomosed 
to the proximal luminal end of the ileal conduit[14]. The 
third is a hybrid technique, where the left ureter under-
goes an end-to-end anastomosis akin to the Wallace 
technique but with a single ureter, and the right ureter is 
anastomosed to the side of the ileal conduit in a fashion 
consistent with the Bricker technique. The Wallace tech-
nique is thought to have a lower stricture rate compared 
to the Bricker technique[15]; however, it is criticized to 
have a risk for bilateral renal obstruction with recurrence 
of disease or an obstruction stone with a theoretical risk 
of spreading the urothelial cancer to the contralateral 
side[16,17]. The hybrid technique may retain the benefits 
of the lower stricture rates in the left ureter while elimi-
nating the risks of joining the two ureters. 

The pathophysiology of benign strictures is thought 
to be due to periureteral fibrosis secondary to ischemia 
or urine leakage at the anastomotic site[18]. Ureteric 
stricture is more common in the left ureter, thought to 
be due to the additional mobilization and tension of the 
left ureter[16–18]. The incidence of strictures is quite 
variable, ranging from 1.9%[19] to as high as 25.3%[15], 
with the median time to diagnosis anywhere from 7 to 
25 months[18]. It is plausible that differences in rates for 
strictures exist between anastomotic techniques due to 
variation in distal ureteric vascular supply and anasto-
motic tension.

In this study, we aim to evaluate the safety, efficacy, 
and stricture rate for the hybrid method compared to the 
Bricker and Wallace methods performed at the institu-
tion. It is important to evaluate the incidence of stricture 
formation, as there is significant morbidity attached to 
the management of strictures. 

Materials and Methods
After institutional ethical approval, we performed a 
retrospective study where data was collected through a 

Abbreviations 
IV intravenous
UTI urinary tract infection

retrospective chart review. We identified patients who 
had undergone ileal conduit urinary diversion after 
radical cystectomy and radical cystoprostatectomy 
for bladder cancer from 2011 to 2016. By Australian 
standards, our institution is considered a moderate-
volume tertiary center, performing approximately 
15 radical cystectomies per year. At our institution, 
cystectomy is performed primarily by five consultant 
urological surgeons, with a fellow or a senior level 
resident as first assistant. Urinary diversion may be 
completed by a consultant, fellow, or senior registrar 
under supervision. In general, most of the ileal conduit 
formations are performed by fellows or senior registrars 
in training.

In our series, the decision of which anastomotic tech-
nique (Bricker, Wallace, or hybrid) to use was based 
on surgeon preference. A schematic highlighting the 
anatomic differences between the Bricker, Wallace, and 
hybrid techniques are highlighted in Figure 1. Prior to 
the formation of the ureteroenteric anastomosis, the 
segment of terminal ileum and ureteric mobilization 
techniques were standard irrespective of the anasto-
motic technique. The distal ureters were tension free, 
well vascularized, and generously spatulated at a mini-
mum of 1.5 cm. For the Bricker anastomosis, two small 
enterotomies were created on the proximal segment 
of the ileal conduit, free from the mesentery[13]. 
Anastomosis was performed with two continuous 
absorbable sutures, typically 5–0 Monocryl or 5–0 PDS 
(Ethicon, Raritan, New Jersey, USA). For the Wallace 
anastomoses, the medial borders of the left and right 
spatulated ureter were sutured adjacently with absorb-
able suture[14]. Anastomosis with the two ureters and 
the proximal lumen of the ileal conduit was performed 
with absorbable suture as above. Finally, for the hybrid 
technique, the ileum was selected and isolated the same 
way as for the other two methods. The proximal lumen 
of the ileal conduit was opened in its entire diameter. 
The left ureter was mobilized in the usual fashion and 
tunnelled through the retro-mesocolon space created. It 
was spatulated to match the diameter of the ileum and 
anastomosed end to end with the proximal lumen of the 
ileal conduit using continuous absorbable sutures. All 
anastomoses were performed using the reconstructive 
principals in addition to ureteral stents and peri-conduit 
surgical drains. If concern existed over excessive tension 
or the viability of the distal ureter or conduit—this was 
addressed intraoperatively based on surgeon discre-
tion. Postoperative management was based on surgeon 
discretion.

We collected data pertaining to age, gender, staging 
of the disease, and history of chemotherapy, radiother-
apy, and neoadjuvant chemotherapy. All of our cases 
were discussed at a multidisciplinary team meeting 
involving senior urologists, medical oncologists, and 

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radiation oncologists at our institution. Cisplatin-based 
neoadjuvant chemotherapy was the standard of prac-
tice; patients with contraindications or personal choices 
against this regimen could receive gemcitabine and 
carboplatin instead, or no neoadjuvant chemotherapy. 
Patients with a solitary kidney were excluded. All men 
had a radical cystoprostatectomy, and all women had a 
radical cystectomy.  

We recorded the following perioperative, intraopera-
tive, and postoperative factors: operative time, estimated 
blood loss (EBL), postoperative transfusion rate, length 
of stay (LOS), postoperative complications, and the char-
acteristic of ureteric strictures that required interven-
tion. Patients were monitored in the outpatient clinic or 
in hospital if they required readmission. Ureteroenteric 
stricture was diagnosed in routine follow-up in outpa-
tient clinics, which included a CT intravenous pyelo-
gram at 3 months, then every 6 months after that for the 
first 2 years and yearly until the fifth year or at hospi-
tal if requiring admission. Patients were excluded from 
subsequent analysis if key demographic information or 
outcome measures were missing, or if there was a history 
of or required postoperative salvage radiotherapy to the 
abdomen or pelvis. For missing data, the related data 
was removed. 

Statistical analysis 

Categorical variables were displayed as frequency 
(percentage) and compared using the chi-square test. 
When three-group chi-square yielded a P-value ≤ 0.10, 
a post-hoc Bonferroni correction was performed 
to compare individual subgroups using the Fisher 
exact test. Continuous variables were treated as non-
parametric (due to the small sample size), displayed as 
median (interquartile range [IQR]), and compared using 
the Kruskal-Wallis test. The Kaplan-Meier method was 
used to assess anastomotic stricture incidence after 

FIGURE 1. 

Schematic highlighting anatomic configurations of Bricker, Wallace, and hybrid anastomoses.

Hybrid anastomosis
End-to-end anastomosis of the left 
ureter, end-to-side anastomosis of  
the right ureter to the ileal conduit.

Wallace anastomosis
End-to-end anastomosis of a joint  
uretic plate to ileal conduit.

Bricker anastomosis
End-to-end anastomosis of each 
individual ureter to the ileal conduit.

surgery; time-to-event curves were compared using the 
log-rank test. Analysis was performed using GraphPad 
Prism v9.0 (La Jolla, California, USA) and StataBE v17.0 
(College Station, Texas, USA). P-values < 0.05 were 
considered statistically significant.

Results
Between 2011 and 2016, a total of 71 patients had 
radical cystectomy (or cystoprostatectomy) and ileal 
conduit diversion for bladder cancer. Three patients 
had a solitary kidney and, thus, underwent a single 
Bricker anastomosis, and therefore were excluded. Of 
the remaining 68 patients, 19 patients (28%) underwent 
a Bricker anastomosis, 20 (29%) underwent a Wallace 
anastomosis, and 29 (42%) underwent the hybrid 
anastomosis. The demographics of the 68 patients are 
shown in Table 1. Overall cohorts were comparable 
with respect to age, gender, and tumor staging 
between patients receiving Bricker, Wallace, or hybrid 
anastomosis. In the Wallace subgroup of 20 patients, 2 
(10%) had a history of radiotherapy to the head and neck 
and breast while the other subgroups had none.

Most early postoperative complications did not differ 
between the groups. There were no significant differ-
ences in EBL, LOS, transfusion rate, ileus, electrolyte 
disturbance, acute kidney injury, or readmission within 
30 days between the Bricker, Wallace, and hybrid tech-
niques (Table 2). The incidence of symptomatic urinary 
tract infection (UTI) requiring oral antibiotics was 
higher in the hybrid group compared to Bricker (52% vs. 
21%; OR, 4.0 [1.0 to 12.9]; P = 0.04) but similar compared 
to Wallace (52% vs. 40%; P = 0.56). In comparison,  
there was no statistically significant difference in the  
8 patients who developed urosepsis requiring intrave-
nous (IV) antibiotics, of whom 1/19 was in the Bricker 
group (5%), 4/20 in the Wallace group (20%), and 3/29 
in the hybrid group (10%) (P = 0.34) (Table 3).  

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The Clavien-Dindo classification demonstrated that the 
rate of grade 2 complications was higher in the hybrid 
group compared to Bricker and Wallace (62% vs. 31% 
vs. 50%, respectively); however, the hybrid group had 
less grade 3a and 3b complications (10% vs. 21% vs. 15%, 
respectively). Grade 4a complications were found only 
in the Bricker subgroup (10%). There were only grade 4a 
complications in the Bricker subgroup (10%)—there 
were no grade 4b or 5 complications. (Table 4) 

Overall, ureteral stricture needing intervention devel-
oped in 9 patients (13%). No patients developed bilateral 
ureteric stricture. In patients undergoing Bricker anas-
tomosis, ureteral stricture developed in 5/19 patients 
(28%); 3 strictures in the left and 2 in the right. With 
the Wallace anastomosis, 3/20 patients (15%) developed 
stricture; all in the left ureter. Of the 29 patients who had 
the hybrid anastomosis, 1 patient (3%) developed stric-
ture in the right ureter (chi square, P = 0.07). Median 
post-cystectomy follow-up and stricture formation time 
were 16 months (IQR, 4 to36) and 9 months (7 to 32), 
respectively. 

Using the Kaplan-Meier method, the estimated 
stricture-free survival in the hybrid group at 1, 3, and 5 

TABLE 1. 

Summary of patient demographics 

Characteristics Total Bricker Wallace Hybrid

Sample size (%) 68 (100) 19 (27.9) 20 (29.4) 29 (42.6)

Age (IQR)
68  

(62–73)
67 

(63–74)
67.5 

(61.5–71)
69  

(61–73)

Male 55 (80.9) 18 (94.7) 13 (65) 24 (82.8)

Staging, pT (%)

Tx 3 (4.4) 0 (0) 1 (5.0) 2 (6.9)

T0 9 (13.20 1 (5.3) 1 (5.0) 7 (24.1)

Tcis 5 (7) 1 (5.3) 1 (5.0) 3 (10.3)

T1 8 (11.8) 2 (10.5)  4 (20.0) 2 (6.9)

T2 17 (25) 8 (42.1) 3 (15.0) 6 (20.7)

T3 19 (27.9) 5 (26.3) 7 (35.0) 7 (24.1)

T4 7 (10.3) 2 (10.5) 3 (15.0) 2 (6.9)

History of 
radiotherapy not 
involving the 
abdomen and 
pelvis (%)

0 (0) 0 (0) 2 (10.0) 0 (0)

Neoadjuvant 
chemotherapy (%) 

7 (10.3) 1 (5.2) 2 (10.0) 4 (13.8)

years was 100%, 100%, and 80%, respectively (Figure 2).  
In the Bricker subgroup, the estimated 1-, 3-, and 5-year 
stricture-free survival rate was 100%, 75%, and 20%, 
respectively. For the Wallace subgroup, the estimated 1-, 
3-, and 5-year stricture-free survival rate was 92.5, 82%, 
and 65%, respectively. Estimated stricture-free survival 
differed significantly across anastomotic technique 
(log-rank test, P = 0.02). Strictures were predominantly 
located in the left ureter (66.7%; P = 0.32). All of the  
9 patients with strictures underwent successful endo-
scopic treatment, 7 as retrograde stent with dilation and 
2 as anterograde stent with dilation. None of the patients 
underwent open repair or conservative treatment.  

No significant differences in stricture rates were iden-
tified when stratified by patient age and T staging status. 
The difference in stricture rates for Bricker versus hybrid 
(26.3% vs. 3.4%; OR, 10 [95% CI 1.1 to 121.1]; P = 0.02) 
was significant but were comparable for Wallace versus 
hybrid (15.0% vs. 3.4%; OR, 4.9 [0.7 to 66.0]; P = 0.15) 
and for Bricker versus Wallace (26.3% vs. 15.0%; OR,  
2 [0.4 to8.6]; P = 0.87). The median time to diagnosis was 
15 (IQR, 8 to 37) months for the 5 patients in the Bricker 
subgroup, 7 (7 to 8) months in the Wallace group, and  
32 months for the 1 patient in the hybrid subgroup.

Discussion
The Bricker and Wallace techniques are the two 
most common forms of ureteroenteric anastomosis 
for urinary diversion post-radical cystectomy[19].  
The choice between these two techniques is based 
mostly on surgeon preference. Both have their perceived 
disadvantages, which are cumulatively listed as increased 

Log-Rank P = 0.21 

0%

25%

50%

75%

100%

St
ric

tu
re

 in
ci

de
nc

e 
(%

)

29 18 16 12 7 4 3 3 1 0Hybrid

20 11 8 7 4 3 3 2 0 0Wallace

19 14 11 9 2 1 0 0 0 0Bricker
Number at risk

0 10 20 30 40 50 60 70 80 90

Months after surgery

Bricker Wallace Hybrid

FIGURE 2. 

Anastomotic stricture formation

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stricture rates, chance for bilateral renal obstruction 
due to kidney stones or recurrence of disease, and 
theoretical risk for transfer of urothelial carcinoma to 
the contralateral side[11]. Here we report the rates of a 
hybrid technique that aims to eliminate some of the 
risks while retaining the benefits from both techniques. 
Our hybrid technique maintains distance between 
the ureteric orifice, eliminating the risk for bilateral 
renal obstruction due to kidney stones or disease, 
and theoretically retains the reduced risk in stricture 
formation. In addition, it is easier to discriminate the 
two ureters with retrograde conduitoscopy, as the 
right ureter is an end-to-side anastomosis and the 
left ureter is an end-to-end anastomosis, which also 
facilitates easier endoscopic access for surveillance. The 
practice of anastomosing a spatulated left ureter to the 
end of the conduit may have been performed in some 
institutions across the world; however, this is the first 
study to evaluate the safety and stricture rates of such an 
approach. 

TABLE 2. 

Reteroenteric stricture details 

Outcome Total Bricker Wallace Hybrid P-value

Sample size (%) 68 (100) 19 (27.9) 20 (29.4) 29 (42.6)

Number of ureteric strictures requiring 
intervention

9 5 (26.3) 3 (15.0) 1 (3.4)

0.07*
B vs. W: 0.87
B vs. H: 0.02
W vs. H: 0.15

Time from cystectomy to stricture formation 
(months), median (IQR)

9 (7–32) 15 (5.5–45.5) 7 (7–9) 32 0.46

Left:Right 6:3 3:2 3:0 0:1

Type of interventions  

Nephrostomy/Antegrade stent/Dilatation 2 1 1 0

Retrograde stent/dilatation 7 4 2 1

Indication

Infected obstructed kidney 1 1 0 0

AKI 1 0 1 0

Worsening hydronephrosis 4 2 2 0

Recurrent UTI 1 0 0 1

Ureteric stone 1 1 0 0

AKI; acute kidney disease; UTI, urinary tract infection. *Chi-square test P-value ≤ 0.10, Bonferroni correction performed with Fisher exact test. 

The overall stricture rate in our series was 13.2% and 
showed a propensity for the left ureter (66.7%; P = 0.32). 
This is comparable to the literature where the reported 
incidence of strictures ranges from 1.9% to 25.3%[15,19] 
and corroborates the tendency for strictures to form in 
the left ureter[12,16,18]. At our institution, there was a 
notable difference in stricture formation between all 
three techniques. Overall, it appeared that the hybrid 
anastomosis had substantially lower rates of stricture 
formation when compared to the Bricker and Wallace 
anastomoses performed at this site, with Bricker being 
the highest. The review only included four studies due 
to a paucity of studies in the literature, and as such, it is 
difficult to comment on the true rate of stricture forma-
tion with the Bricker or the Wallace anastomosis. This 
is illustrated by Cristoph et al.[15] in their analysis of 
137 patients, with reported stricture rates of 25.3% of 
patients (roughly 12.9% of ureters) with the Bricker tech-
nique and 7.7% of patients (roughly 3.9% of ureters) with 
the Wallace technique, highlighting the variability in 

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incidence of stricture formation. In a study by Large et 
al.[20], the stricture rate per ureter was 8.5% and 12.7% 
in the interrupted and running anastomosis groups, 
respectively. Perhaps our stricture rates can be further 
improved by switching from running to interrupted 
suturing. 

TABLE 3. 

Summary of perioperative outcomes 

Perioperative outcomes Total Bricker Wallace Hybrid P-value

Sample size (%) 68 (100) 19 (27.9) 20 (29.4) 29 (42.6)

Operative time (min), median (IQR)
317.5  

(270–390)
390  

(330–420)
315 

 (300–360)
300 

 (270–360)
0.01

Blood lost (mL), median (IQR)
700 

(500–1100)
500 

(375–950)
900

(725–1750)
700 

(400–1000)
0.55

Length of stay (days), median (IQR)
13.1  

(9.0–16.9)
13.9  

(10.2–15.75)
12.6  

(9.1–15.4)
13.1  

(7.4–19.1)
0.62

Postoperative complications (%)

Ileus 35 11 (57.9) 11 (55.0) 13 (44.8) 0.63

Electrolyte disturbance 25 6 (31.6) 8 (40.0) 11(37.9) 0.85

Acute kidney injury 18 7 (36.8) 4 (20.0) 7 (24.1) 0.46

UTI 27 4 (21.0) 8 (40.0) 15 (51.7)

0.10*
B vs. W: 0.30
B vs. H: 0.04
W vs. H: 0.56 

Urosepsis 8 1 (5.3) 4 (20.0) 3 (10.3) 0.34

Pelvic collection 9 1 (5.3) 5 (25.0) 3 (10.3) 0.16

Urine leak 5 0 (0) 3 (15.0) 2 (7.0) 0.20

Postoperative transfusion 36 (100) 8 (22.2) 12 (33.3) 16 (44.4) 0.51

Readmission within 30 days 13 (100) 4 (30.8) 4 (30.8) 5 (17.2) 0.94

Reoperation within 30 days 1 (100) 0 0 1 (100) 0.51

Post-cystectomy follow-up (months), 
median (IQR)

16 (4–36) 19 (4–33.8) 12 (6.3–36) 26 (3–41) 0.99 

*Chi-square test P-value ≤ 0.10, Bonferroni correction performed with Fisher exact test.

The left ureter has a higher risk of developing a stric-
ture in the Bricker and Wallace techniques, most likely 
due to ischemia from mobilizing it more than the right 
side in order to create a “tunnel” through the retrosig-
moid mesocolon. We believe that the hybrid technique 
has a lower risk of developing a stricture in the left ureter, 

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as there is less mobilization required to make an end-to-
end anastomosis as compared to the Bricker technique, 
and also with the Wallace technique a ureteric plate is 
required to be made between the two ureters. The right 
ureter undergoes a side-to-end anastomosis and is 
thought to be less susceptible to stricture formation, as it 
must travel less and undergoes less mechanical compres-
sion compared to the left ureter[18]. The anastomosis of 
the right ureter in our technique is essentially a Bricker 
end-to-side refluxing anastomosis, therefore the stric-
ture formation rates should be comparable to the rates 
found with Bricker anastomosis with the right ureter. 

Intraoperative and perioperative outcomes were a 
prime consideration in our study. We found that there 
was no statistically significant difference in periopera-
tive morbidity between the subgroups, excluding oper-
ation time and urinary tract infections not requiring 
IV antibiotics. The hybrid group had a lower operation 

TABLE 4. 

Outcomes classified by Clavien-Dindo classification 
and comprehensive complication index 

Clavien-Dindo 
Classification

Bricker Wallace Hybrid

Grade 1 3 1 3

Grade 2 6 10 18

Grade 3a 1 0 0

Grade 3b 3 3 3

Grade 4a 2 0 0

Grade 4b 0 0 0

Grade 5 0 0 0

Comprehensive complication index

0–20 3 1 3

20–40 10 12 19

40–60 2 1 1

60+ 0 0 1

time (P < 0.01); however, it posed an additional risk 
for urinary tract infections requiring only oral antibi-
otics in our cohort (P < 0.04). While lower operation 
times will inevitably have a positive effect on patient 
outcomes, it is hard to quantify this against recent stud-
ies in the literature, as only robotic studies comparing 
Bricker and Wallace anastomoses recorded their oper-
ating time, which were invariably longer than the open 
approach[21,22]. The increased incidence of urinary 
tract infection is of concern with the hybrid approach. 
The expected incidence is not reported in the litera-
ture, but when compared to the other two approaches 
at our institution, it was clear that more patients with 
the hybrid approach developed a urinary tract infection. 
We are unsure of the exact reason why there were more 
episodes of acute UTI in the hybrid group. One specula-
tion is that the proximal end of the ileal conduit poten-
tially can migrate through the retro-mesocolon space. 
As the retro-mesocolon space is usually narrow, it might 
cause urine trapping in the proximal ileal conduit and 
increase the risk for UTI due to urine stasis. If this is the 
culprit, making the retro-mesocolon space larger may 
prevent urine trapping. Fortunately, these urinary tract 
infections were treated with oral antibiotics only, and as 
such, it appears favorable to undergo the Hybrid tech-
nique despite the risk. This is further supported by other 
perioperative outcomes, as it is apparent that there are 
no statistically significant differences between each tech-
nique, including the incidence of urosepsis requiring IV 
antibiotics. Thereby, it can be said that the Hybrid tech-
nique appears to be as safe and efficacious as the other 
two techniques, with the benefit of lower stricture rates 
that required intervention.

Postoperative follow-up in this cohort is believed to 
be adequate to detect most events of strictures in our 
patients; however, patients were not followed up for a 
uniform length. The median time to stricture formation 
in our cohort was 9 months (IQR 7 to 32), with 2 cases 
who presented at 32 and 37 months, postoperatively. 
This is mostly in line with the current literature where 
most strictures are thought to present within the first 2 
years after surgery, though strictures have been reported 
at up to 40 months postoperatively[18]. Reporting the 
time to stricture formation is paramount in evaluating 
the extent of strictures in this cohort of patients, as the 
assumed stricture rate could be falsely lower than the 
actual rate. A criticism of Davis’ meta-analysis[19] is that 
3 of the 4 studies had a follow-up duration of less than  
2 years. Despite most of the strictures presenting before 
then, a more complete view of time to stricture duration 
is obtained from longer follow-up.  

Our study being retrospective and single center 
implies that it is susceptible to selection bias. As the 
operations were performed at a tertiary referring public 
teaching hospital, cases were performed by one of five 

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consultant surgeons supervising urology fellows and 
trainees. The decision on the choice of the three tech-
niques was based on individual surgeon or fellow pref-
erences. We were not able to ascertain the degree of 
involvement each consultant had intraoperatively based 
on chart review. Therefore, this study isn’t able to sepa-
rate surgeon technique from anastomotic technique, 
which could impact the results. It is worth mentioning 
that that the Hybrid technique was started by the most 
junior urologist on the team, hence it is unlikely, though 
possible, that lack of experience alone has contributed 
to the difference in outcomes including an increase in 
urinary tract infections. This study is also limited by 
the small sample size for all three techniques, which is a 
potential reflection of the findings being due to chance. 
A further larger prospective study would help address 
the limitations in this current study. There were no 
significant differences between patient demographics 
besides an obvious predilection for male patients across 
all subgroups that mirrors the incidence of bladder 
cancer in the population[23].  

Conclusion
In our single-center, retrospective, cohort study, it 
appears that the hybrid technique is a potentially safe 
and efficacious alternative to the Bricker and Wallace 
anastomoses. It carries with it a risk for urinary tract 
infection that is eclipsed by the substantially lowered 
rates of ureteric strictures requiring intervention 
while also maintaining the advantage of keeping the 
two ureters separate. This technique could lower the 
morbidity attached to stricture formation post–urinary 
diversion for many patients post-radical cystectomy; 
however, its role will need to be established by further 
prospective studies comparing the Bricker, Wallace, and 
hybrid anastomotic techniques.  

Acknowledgements
Funding: Marlon Perera is sponsored by the Australian-
America Fulbright Commission administered through a 
2021–2022 Fulbright Future Scholarship funded by The 
Kinghorn Foundation.

178 SIUJ  •  Volume 4, Number 3  •  May 2023 SIUJ.ORG

 ORIGINAL RESEARCH

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Hybrid Ureteroenteric Anastomosis Is Associated With Lower Stricture Rates in Ileal Conduit Urinary Diversion

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