[Uretero-intestinal anastomosis: Achilles heel of urinary diversion using bowel segments]

A well-functioning uretero-intestinal anastomosis is essential for the preservation of kidney function following urinary diversion using bowel segments. In incontinent forms of urinary diversions, such as ileal conduits, the ureters are usually implanted in a refluxive manner, whereas there is still controversy about the ideal implantation technique in continent orthotopic or heterotopic reservoirs (i.e. refluxive versus anti-refluxive). Current techniques of refluxive and antirefluxive uretero-intestinal anastomosis, their indications, typical perioperative and postoperative complications and management are discussed. Irradiated or preoperatively dilated ureters show a higher complication rate in terms of postoperative dilatation and obstruction. Early revision of the implantation site and ureteral reimplantation yield more favorable outcomes and long-term results than a minor invasive endourological treatment. As ureteral stenosis may occur more than 15 years after urinary diversion, regular follow-up including sonographic evaluation of the upper urinary tract to detect hydronephrosis is mandatory. In this setting a diuretic renogram with MAG-III is a helpful tool to determine split renal function and to discriminate urodynamic relevant dilatation of the upper urinary tract from clinical situations requiring only observation, while dimercaptosuccinic acid (DMSA) scans provide valuable information about renal scarring.