Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy

Analysis of early perioperative outcomes of robot-assisted radical cystectomy and colonic diversion

Studies of right colon pouch urinary diversion have widely varying estimates of the risk of perioperative complications, reoperation, and readmission. We sought to describe the association between specific risk factors and complication, readmission, and reoperation rates following right colon pouch urinary diversion. Patients undergoing robot-assisted right colon pouch urinary diversion from July 2013 to December 2022 were analyzed. Outcome measures include high-grade (Clavien-Dindo grade ≥ 3) complications within 90 days, readmission within 90 days, and reoperation at any time during follow-up. Specific risk factors such as age, gender, body mass index (BMI), diabetes, Charlson comorbidity index (CCI), and prior radiation were analyzed to establish an association with these outcomes. During the study period, 77 patients underwent the procedure and were eligible to study. The average follow-up was 88.7 (SD 14) months. 90-day high-grade complications were 24.67%, and 90-day readmission was 33.76%. The cumulative rate of any reoperation was 40.2%, and major reoperation was 24.67%. Female gender (OR 3.3, p = 0.015), 1 kg/m2 increase in BMI (OR 3.77, p = 0.014), diabetes (OR 3.49, p = 0.021), higher CCI (OR 1.59, p = 0.034), prior radiation (OR 1.97, p = 0.026), lower eGFR (OR 0.99, p = 0.032) and BMI ≥ 25 kg/m2  (OR 3.9, p value 0.02) was associated with Clavien III-IV complications. Female gender (OR 3.3, p = 0.015), diabetes (OR 3.97, p = 0.029), higher Charlson Comorbidity Index (OR 1.73, p = 0.031), prior radiation (OR 1.45, p = 0.029), lower eGFR (OR 0.87, p = 0.037) and BMI ≥ 25 kg/m2 (OR 3.86, p = 0.031) were predictive of reoperation. Overall, the rate of postoperative complications, readmissions, and reoperation was high but consistent with other studies. This study helps further characterize surgical outcomes after right colon pouch urinary diversion and highlights patients who may benefit from enhanced preoperative management for minimising complications.

Current evidence regarding alternative techniques for enterocystoplasty using regenerative medicine methods: a systematic review

Enterocystoplasty is the most commonly used treatment for bladder reconstruction. However, it has some major complications. In this study, we systematically reviewed the alternative techniques for enterocystoplasty using different scaffolds. A comprehensive search was conducted in PubMed, Embase, and Cochrane Library, and a total of 10 studies were included in this study. Five different scaffolds were evaluated, including small intestinal submucosa (SIS), biodegradable scaffolds seeded with autologous bladder muscle and urothelial cells, dura mater, human cadaveric bladder acellular matrix graft, and bovine pericardium. The overall results revealed that bladder reconstruction using regenerative medicine is an excellent alternative method to enterocystoplasty regarding the improvement of bladder capacity, bladder compliance, and maximum detrusor pressure; however, more large-scale studies are required.

The Role of Pelvic Exenteration in Cervical Cancer: A Review of the Literature

Pelvic exenteration represents a radical procedure aimed at achieving complete tumor resection with negative margins. Although it is the only therapeutic option for some cases of advanced tumors, it is associated with several perioperative complications. We believe that careful patient selection is related to better oncologic outcomes and lower complication rates. The objectives of this review are to identify the most current indications for this intervention, suggest criteria for case selection, evaluate recommendations for perioperative care, and review oncologic outcomes and potential associated complications. To this end, an analysis of English language articles in PubMed was performed, searching for topics such as the indication for pelvic exenteration for recurrent gynecologic neoplasms selection of oncologic cases, the impact of tumor size and extent on oncologic outcomes, preoperative and postoperative surgical management, surgical complications, and outcomes of overall survival and recurrence-free survival.

Outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction

OBJECTIVE

To evaluate the early and late outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction (LUTD).

MATERIALS AND METHODS

The charts of patients with refractory non-malignant LUTD who underwent continent or incontinent external urinary diversion at University of Cincinnati hospitals in the period between March 2012 and December 2019 were retrospectively reviewed. The demographic and baseline characteristics, surgery indications, operative data, early and late outcomes were collected, analyzed, and compared.

RESULTS

A total of 78 patients including 55 patients with neurogenic bladder (NGB) and 23 patients with non-neurogenic bladder (non-NGB) refractory non-malignant LUTD were included. Fifty-three patients underwent incontinent urinary diversions (IUD), while 25 patients underwent continent urinary diversions (CUD). During the first 4 postoperative weeks, 53.85% (n=42) of patients developed complications, and the incidence was nonsignificantly higher in patients with NGB than those with non- NGB (56.36% vs 47.83%, p-value=0.490). Fever was exclusively encountered in patients with NGB earlier, while stomal retraction occurred only in patients with non-NGB later. More non- NGB patients had early wound infection. There was an overall improvement of urological symptoms in 52 patients (66.67%), and the rate was non-significantly higher in non-NGB patients than NGB patients (78.26% vs 61.82%, p-value=0.160). Late complications were reported in 47 patients and were more encountered in those with non-NGB than those with NGB (65.22% vs 58.18%). Stomal leakage and stenosis occurred more with CUD than with IUD (52% vs 0% and 28% vs 3.77%, respectively).

CONCLUSIONS

External urinary diversion can achieve a reasonable level of urological symptoms control in patients with refractory non-malignant LUTD, but with associated adverse outcomes. Although non-significantly, these complications tend to be higher in patients with IUD and/or NGB during the early postoperative period and higher with CUD and/or non-NGB on the long-term.

[Do's and Dont's for radical cystectomy and urinary diversion - how to minimise postoperative complications]

Radical cystectomy (RC) with urinary diversion is a challenging surgical intervention. There is significant risk of postoperative complications, particularly linked to urinary diversion and the patient's comorbidities. The surgeon and the multidisciplinary team need to be familiar with all potential complications. In order to achieve optimal oncological and functional outcomes, multiple factors have to be considered during perioperative management, including the adherence to evidence-based guidelines, standardised concepts of enhanced recovery and best surgical practice for RC and urinary diversion. All measures should aim to minimise complication rates after RC and to accelerate recovery. We summarise essential Dos and Don'ts when performing RC with different forms of urinary diversion.

The impact of orthotopic reconstruction on female sexuality and quality of life after radical cystectomy for non-malignant bladder conditions

OBJECTIVE

To review the literature on the impact on female quality of life and sexual function of orthotopic reconstruction after radical cystectomy for non-malignant bladder conditions. Radical cystectomy is commonly required to treat malignant conditions but may also be considered for the treatment of non-malignant diseases. These heterogeneous group of disorders includes interstitial cystitis, painful bladder syndrome, neurogenic bladder, haemorrhagic/ radiation cystitis, endometriosis and refractory genitourinary fistula. Treatment begins with non-invasive medical therapies but, in non-responder cases, a surgical solution should be considered. Such invasive techniques include urinary diversion and reconstructive procedures that have an impact on healthrelated quality of life, physical, social, and mental status.

MATERIALS AND METHODS

This narrative review research was done using the PubMed database up until 2020, July. All papers referring to cystectomy for benign indication were considered.

RESULTS

In comparison to other reconstructive options, orthotopic neobladder allows the restoration of a normal self-image and consequently it is the most suitable procedure when a surgical reconstruction is necessary for non-malignant conditions. However, women can face many disorders that impact on everyday life, such as voiding dysfunction or sexual activity problems.

CONCLUSIONS

Scant data is available about quality of life, sexual life and self-perception in women treated by cystectomy for benign conditions and most literature is dedicated to those indicators in cancer patients. More research is needed to understand the tolerability and the quality of life results of the female population affected by benign conditions undergoing this kind of surgical approach.

Human adipose-derived mesenchymal stem cells accelerate decellularized neobladder regeneration

Decellularized natural bladder matrices (neobladders) represent an exciting means to regenerate the bladder following bladder cancer-associated cystectomy. In this study, we compare the evolution of decellularized matrices with recellularized matrices by seeding it with human adipose-derived mesenchymal stem cells (ADSC) after implantation following partial cystectomy in rats. We discovered significant anatomical differences since 10 days after neobladder implantation with the ADSC-containing matrices promoting a significant recovery of mature p63- and cytokeratin 7-positive urothelium. We also discovered significantly induced expression of the vimentin mesoderm marker in the submucosal layer in ADSC-seeded matrices. Interestingly, we found a higher expression of smooth muscle actin in transversal and longitudinal smooth muscle layers with ADSC-seeded matrices. Furthermore, ADSC also showed increased vascularization and nerve innervation of the neobladder as determined by the distribution of CD31 and S100β reactivity, respectively. We believe that ADSC and their paracrine-acting pro-regenerative secretome within decellularized matrices represent an efficient bladder substitution strategy; however, we require a fuller understanding of the mechanisms involved before clinical studies can begin.

Outcomes of right colon continent urinary pouch using standardized reporting methods

AIMS

Studies of right colon pouch urinary diversion estimate risk of perioperative complications, 1%-50%, and reoperation, 1%-69%. This wide range is due to variable outcome measurements and reporting methods; it is also unclear which factors increase the risk of complications and reoperation. We sought to characterize the impact of patient-specific factors on risk of complications, readmission, and reoperation after right colon pouch urinary diversion.

METHODS

Patients undergoing right colon pouch urinary diversion from January 2010 to April 2017 were analyzed. Outcomes included: high-grade complications within 90 days (Clavien-Dindo grade ≥3), readmission within 90 days, and reoperation at any time during follow-up. Patient-specific factors were analyzed to establish any associations with these outcomes.

RESULTS

During the study period, 53 patients underwent the procedure and the average follow-up was 30 (standard deviation [SD] 21.5) months; 90-day high-grade complications were 22% and readmission was 45%. The cumulative rate of any reoperation was 53% and major reoperation was 32%. Diabetes was associated with an increased risk of both postoperative complications and reoperation. Larger body mass index and prior abdominal surgery were associated with increased risk of readmission.

CONCLUSIONS

Overall the rate of postoperative complications, readmissions, and reoperation was high, but in agreement with other contemporary series. This study helps to further characterize surgical outcomes after right colon pouch urinary diversion, however, similar to other studies in the literature, the rarity of the procedure limits the power to establish a link between preoperative patient factors and outcomes.

Psychosocial Distress in Bladder Cancer Stratified by Gender, Age, Treatment, and Tumour Stage

OBJECTIVES

Cancer patients have to cope with anxieties -concerning their prognosis, potential recurrence/progression, and treatment-associated sequelae. Stress-related psychosocial factors influence survival and disease-related mortality in cancer patients. Despite improvements in diagnosis and treatment, bladder cancer (BC) remains characterized by high rates of recurrence and progression. We screened -pre-therapeutically the stress level of BC patients stratified by gender, disease state, treatment, and other factors by -self-administered validated questionnaires to integrate them into psychosocial support as needed.

METHODS

A cross-sectional analysis of distress and need of psychosocial care was done in 301 patients undergoing treatment for BC by 2 questionnaires (Distress Thermometer [DT] and Hornheider Screening Instrument).

RESULTS

Of the 301 patients, 230 patients underwent transurethral resection for a first -diagnosis, 63 for recurrent disease, 37 had progressive disease, and 25 had advanced metastatic disease and eventually died of BC. The mean stress level in all patients was 4.6. Twenty-eight percent of the patients expressed a need for psychosocial support. In patients with progressive disease, significantly higher stress scores were seen as well as a higher need of psychosocial care (5.4 and 41%).

CONCLUSIONS

The median DT-level of 4.6 indicates moderate psychosocial stress in BC patients. From a stress level of 5, the recommendations of a psycho-oncological supervision are pronounced, so that our study showed that early systematic evaluation of psychosocial needs in BC patients is important.

[Radical cystectomy and urinary diversion-what is important ?]

BACKGROUND

In Germany, radical cystectomy with urinary diversion is the primary therapeutic option for localized muscle invasive urothelial bladder cancer. Modifications in the pre-, peri-, and postoperative phase have significantly improved outcomes.

OBJECTIVES

Different factors and parameters are directly associated with patients' outcome. An overview on how to best approach this procedure is provided in this article.

MATERIALS AND METHODS

The data regarding preparation and the procedure for the radical cystectomy followed by urinary diversion are separately analyzed.

RESULTS

During the preoperative phase, Fast Track and ERAS (Enhanced Recovery after Surgery) concepts should be an integral part of therapeutic management. Different aspects of such models are presented and discussed. Comorbidities such as diabetes mellitus, hypertension, malnutrition or anemia should also be treated early. In the perioperative phase, optimized fluid management and close interaction with the anesthesiologist are needed. Use of vasopressors during surgery and controlled hypotension (about 80 mm Hg) help reduce perioperative blood loss. Blood product use should be minimized. The use of epidural anesthesia to improve the stress reaction of the body improves pain management and functional recovery. Radical cystectomy is associated with the best oncological outcome, preserving functional structures to maintain a good quality of life. Nerve-sparing procedures in men and women should be used where appropriate. The use of robotic assisted radical cystectomy (RARC) is also discussed.

CONCLUSION

The ileum conduit is still the most common urinary diversion worldwide. However, numerous other urinary diversions to provide patients with the highest quality of life are available. Centers with a high case load seem to be associated with an improved outcome.

Comparative Evaluation of Bladder-specific Health-related Quality of Life Instruments for Bladder Cancer

OBJECTIVE

To compare 2 bladder cancer-specific health-related quality of life instruments (HRQOL) in the same patient population. Previous HRQOL studies in cystectomy patients have yielded conflicting results. Using a cross-sectional study design, we examined the only 2 validated bladder cancer-specific (HRQOL) measures.

METHODS

Of the 256 patients who had undergone radical cystectomy from 2009 to 2014, 131 met both inclusion and exclusion criteria. The Functional Assessment Cancer Therapy-Vanderbilt Cystectomy Index (FACT-VCI) and Bladder Cancer Index (BCI) were mailed to these patients. Overall HRQOL and individual domain scores were compared between the 2 instruments with a Spearman correlation coefficient. HRQOL scores were compared by urinary diversion type as well using a non-parametric Wilcoxon rank sum test.

RESULTS

Our study had a response rate of 49% from 31 ileal conduit (IC) and 33 orthotopic neobladder patients. Overall, there was a moderate correlation between the FACT-VCI and BCI surveys (r = 0.57, P <.001). Responses on the BCI domains were strongly correlated with responses on the bladder cancer-specific domain of the FACT-VCI (r = 0.74, P <.001). The BCI scores for urinary function were significantly better in the IC group (P = .002). No significant difference was found between IC and orthotopic neobladder using the FACT-VCI.

CONCLUSION

The FACT-VCI and BCI instruments correlate well within the same patient cohort but capture different aspects of HRQOL. By focusing exclusively on bladder cancer treatment concerns, the BCI appears to be a better tool for assessing and counseling patients on expected treatment-specific changes after diversion type.

Biofabrication and biomaterials for urinary tract reconstruction

Reconstructive urologists are constantly facing diverse and complex pathologies that require structural and functional restoration of urinary organs. There is always a demand for a biocompatible material to repair or substitute the urinary tract instead of using patient's autologous tissues with its associated morbidity. Biomimetic approaches are tissue-engineering tactics aiming to tailor the material physical and biological properties to behave physiologically similar to the urinary system. This review highlights the different strategies to mimic urinary tissues including modifications in structure, surface chemistry, and cellular response of a range of biological and synthetic materials. The article also outlines the measures to minimize infectious complications, which might lead to graft failure. Relevant experimental and preclinical studies are discussed, as well as promising biomimetic approaches such as three-dimensional bioprinting.

Bladder Sparing Approaches for Muscle-Invasive Bladder Cancers

Organ preservation has been increasingly utilised in the management of muscle-invasive bladder cancer. Multiple bladder preservation options exist, although the approach of maximal TURBT performed along with chemoradiation is the most favoured. Phase III trials have shown superiority of chemoradiotherapy compared to radiotherapy alone. Concurrent chemoradiotherapy gives local control outcomes comparable to those of radical surgery, but seemingly more superior when considering quality of life. Bladder-preserving techniques represent an alternative for patients who are unfit for cystectomy or decline major surgical intervention; however, these patients will need lifelong rigorous surveillance. It is important to emphasise to the patients opting for organ preservation the need for lifelong bladder surveillance as risk of recurrence remains even years after radical chemoradiotherapy treatment. No randomised control trials have yet directly compared radical cystectomy with bladder-preserving chemoradiation, leaving the age-old question of superiority of one modality over another unanswered. Radical cystectomy and chemoradiation, however, must be seen as complimentary treatments rather than competing treatments. Meticulous patient selection is vital in treatment modality selection with the success of recent trials within the field of bladder preservation only being possible through this application of meticulous selection criteria compared to previous decades. A multidisciplinary approach with radiation oncologists, medical oncologists, and urologists is needed to closely monitor patients who undergo bladder preservation in order to optimise outcomes.

The Impact of Transtomal Rigid Endoscopy in Continent Cutaneous Urinary Diversions

OBJECTIVE

To determine if transtomal rigid endoscopy damages the continence mechanism of continent cutaneous reservoirs. We report the largest and longest series to date from a single institution demonstrating the safety of transtomal rigid endoscopy.

MATERIALS AND METHODS

We conducted an institutional review board-approved retrospective review of a prospectively accrued database of all patients with urinary diversions that underwent rigid endoscopic procedures for various reasons between 2000 and 2013. Pre- and postoperative continence, difficulty with catheterization, and need for surgical revision post procedure were evaluated.

RESULTS

From 2000 to 2013, 71 patients with continent cutaneous diversions underwent 191 endoscopic procedures by a single surgeon. Mean follow-up was 603 days. Mean age was 58.4 years. The mean number of procedures per patient was 2.7 (1-7). All procedures were performed by gaining access through the stoma with an offset rigid nephroscope and a 28-30Fr access sheath. Two patients reported incontinence postoperatively; 1 patient was treated conservatively by way of indwelling catheter for 1 week and full continence returned. The second patient had small-volume incontinence preoperatively that worsened postoperatively. The procedure uncovered an existing efferent limb-cutaneous fistula. Patients undergoing repeated procedures were not at any higher risk of incontinence. There were no patients that had difficulty with catheterization postoperatively. No surgical revisions were required for worsened continence postoperatively.

CONCLUSION

Transtomal rigid endoscopic procedures do not negatively affect the continence mechanism in continent cutaneous diversions. Transtomal rigid endoscopy allows for safe endoscopic access in these difficult to treat patients.

Bladder reconstruction: The past, present and future

Ileal conduit urinary diversion is the gold standard treatment for urinary tract reconstruction following cystectomy. This procedure uses gastrointestinal segments for bladder augmentation, a technique that is often associated with significant complications. The substantial progression in the fields of tissue engineering and regenerative medicine over the previous two decades has resulted in the development of techniques that may lead to the construction of functional de novo urinary bladder substitutes. The present review identifies and discusses the complications associated with current treatment options post-cystectomy. The current techniques, achievements and perspectives of the use of biomaterials and stem cells in the field of urinary bladder reconstruction are also reviewed.

[Continent urinary diversion following anterior exenteration]

BACKGROUND

Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir).

RESULTS

Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field.

CONCLUSION

Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).

Variation in performance of candidate surgical quality measures for muscle-invasive bladder cancer by hospital type

OBJECTIVE

To test the association between hospital type and performance of candidate quality measures for treatment of muscle-invasive bladder cancer (MIBC) using a large national tumour registry. Proposed quality measures include receipt of neoadjuvant chemotherapy, timely treatment, adequate lymph node dissection, and continent urinary diversion.

PATIENTS AND METHODS

Using the National Cancer Database, patients with stage ≥II urothelial carcinoma treated with radical cystectomy (RC) from 2003 to 2010 were identified. Hospitals were grouped by type and annual RC volume: community, comprehensive low volume (CLV), comprehensive high volume (CHV), academic low volume (ALV), and academic high volume (AHV) groups. Logistic regression models were used to test the association between hospital group and performance of quality measures, adjusting for year, demographic, and clinical/pathological characteristics; generalised estimating equations were fitted to the models to adjust for clustering at the hospital level.

RESULTS

In all, 23 279 patients underwent RC at community (12.4%), comprehensive (CLV 38%, CHV 5%), and academic (ALV 17%, AHV 28%) hospitals. While only 0.8% (175) of patients met all four quality criteria, 61% of patients treated at AHV hospitals met two or more quality metric indicators compared with ALV (45%), CHV (44%), CLV (38%), and community (37%) hospitals (P < 0.001). After adjustment, patients were more likely to receive two or more quality measures when treated at AHV (odds ratio [OR] 2.4, confidence interval [CI] 2.0-2.9), ALV (OR 1.3, CI 1.1-1.6), and CHV (OR 1.3, CI 1.03-1.7) hospitals compared with community hospitals.

CONCLUSIONS

Patients undergoing RC at AHV hospitals were more likely to meet quality criteria. However, performance remains low across hospital types, highlighting the opportunity to improve quality of care for MIBC.

A Review of Transplantation Practice of the Urologic Organs: Is It Only Achievable for the Kidney?

Transplantation is a viable treatment option for failure of most major organs. Within urology, transplantation of the kidney and ureter are well documented; however, evidence supporting transplantation of other urologic organs is limited. Failure of these organs carries significant morbidity, and transplantation may have a role in management. This article reviews the knowledge, research, and literature surrounding transplantation of each of the urologic organs. Transplantation of the penis, testicle, urethra, vas deferens, and bladder is discussed. Transplantation attempts have been made individually with each of these organs. Penile transplantation has only been performed once in a human. Testicular transplantation research was intertwined with unethical lucrative pursuits. Interest in urethra, bladder, and vas deferens transplantation has decreased as a result of successful surgical reconstructive techniques. Despite years of effort, transplantations of the penis, testicle, urethra, vas deferens, and bladder are not established in current practice. Recent research has shifted toward techniques of reconstruction, tissue engineering, and regenerative medicine.

Cystoprostatectomy versus prostatectomy alone for locally advanced or recurrent pelvic cancer

BACKGROUND

There is minimal published data evaluating the oncological outcome of rectal resection with prostatectomy alone versus rectal resection with cystoprostatectomy in patients undergoing pelvic exenteration for locally advanced or recurrent pelvic cancer. This study aims to evaluate the oncological and functional outcomes of performing rectal resection with prostatectomy alone compared with rectal resection with cystoprostatectomy in patients undergoing pelvic exenteration.

METHODS

Consecutive patients undergoing pelvic exenteration for locally advanced or recurrent pelvic cancer between 1998 and 2012 were identified from a prospectively maintained database. Patients undergoing rectal resection with prostatectomy alone were compared with a control group who underwent rectal resection with cystoprostatectomy and urostomy formation. The primary outcome was overall survival. Secondary outcomes analysed in the prostatectomy group included completeness of resection, continence and erectile function.

RESULTS

Eleven rectal resections with prostatectomy were compared with 20 rectal resections with cystoprostatectomy. R0 resection was achieved in 73 and 65% respectively. There was no difference in overall survival (P = 0.40). Urinary continence was achieved in 36% of prostatectomy alone patients, while 27% experienced mild incontinence. Erectile function was poor, with only one patient able to maintain normal erections.

CONCLUSION

In appropriately selected patients with invasive pelvic tumours, rectal resection with prostatectomy alone provides adequate oncological outcomes. The ability to achieve an R0 resection was not compromised and overall survival is comparable with cystoprostatectomy. Urinary function is reasonable in most patients, although sexual function is compromised in almost all.

Robot-assisted radical cystectomy with intracorporeal neobladder diversion: The Karolinska experience

Introduction:

The aim of this report is to describe our surgical technique of totally intracorporeal robotic assisted radical cystectomy (RARC) with neobladder formation.

Materials and Methods:

Between December 2003 and March 2013, a total of 147 patients (118 male, 29 female) underwent totally intracorporeal RARC for urinary bladder cancer. We also performed a systematic search of Medline, Embase and PubMed databases using the terms RARC, robotic cystectomy, robot-assisted, totally intracorporeal RARC, intracorporeal neobladder, intracorporeal urinary diversion, oncological outcomes, functional outcomes, and complication rates.

Results:

The mean age of our patients was 64 years (range 37-87). On surgical pathology 47% had pT1 or less disease, 27% had pT2, 16% had pT3 and 10% had pT4. The mean number of lymph nodes removed was 21 (range 0-60). 24% of patients had lymph node positive dAQ1isease. Positive surgical margins occurred in 6 cases (4%). Mean follow-up was 31 months (range 4-115 months). Two patients (1.4%) died within 90 days of their operation. Using Kaplan-Meier analysis, overall survival and cancer specific survival at 60 months was 68% and 69.6%, respectively. 80 patients (54%) received a continent diversion with totally intracorporeal neobladder formation. In the neobladder subgroup median total operating time was 420 minutes (range 265-760). Daytime continence and satisfactory sexual function or potency at 12 months ranged between 70-90% in both men and women.

Conclusions:

Our experience with totally intracorporeal RARC demonstrates acceptable oncological and functional outcomes that suggest this is a viable alternative to open radical cystectomy.

Laparoscopic radical cystectomy: neobladder or ileal conduit, debate still goes on

Objective

To compare the pre, intra, and post–operative data between ileal conduit and neobladder urinary diversions during laparoscopic radical cystectomy(LRC).

Material and methods

Between 2006 and 2011, 63 patients who underwent LRC and urinary diversion had their data input prospectively into a database and said data used for the analysis. The outcome comparators were the patient demographics, operative time, conversion rate, blood loss, transfusion rate, morphine analgesic requirement, length of hospital stay, complication rates, follow up, and quality of life assessments. A Mantel–Haenszel test was used for dichotomous data and an inverse variance method was used for continuous data. P values less than 0.5 were considered significant

Results

Thirty–nine patients (60 ±7.11 years) had ileal conduits and 24 patients (57 ±8.68 years) had neobladder urinary diversion. No difference was found (P >0.05) regarding age, BMI, smoking history, TURBT pathology result, blood loss, blood transfusion requirement, conversion rates, length of hospital stay, morphine requirement, complications, or follow–up and quality of life. The neobladder groups did have more previous abdominal operations and had significantly longer operative time.

Conclusions

We found no difference between either types of diversion in all comparative aspects except that the neobladder had longer operative times. This is the first comparative study between ileal conduit and neobladder urinary diversion after laparoscopic radical cystectomy and can pose as a bench mark for future comparisons.

Anticholinergic drugs versus non-drug active therapies for non-neurogenic overactive bladder syndrome in adults

BACKGROUND

Overactive bladder syndrome is defined as urgency with or without urgency incontinence, usually with frequency and nocturia. Pharmacotherapy with anticholinergic drugs is often the first line medical therapy, either alone or as an adjunct to various non-pharmacological therapies after conservative options such as reducing intake of caffeine drinks have been tried. Non-pharmacologic therapies consist of bladder training, pelvic floor muscle training with or without biofeedback, behavioural modification, electrical stimulation and surgical interventions.

OBJECTIVES

To compare the effects of anticholinergic drugs with various non-pharmacologic therapies for non-neurogenic overactive bladder syndrome in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 4 September 2012), which includes searches of the Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE, and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised, controlled trials of treatment with anticholinergic drugs for overactive bladder syndrome or urgency urinary incontinence in adults in which at least one management arm involved a non-drug therapy. Trials amongst patients with neurogenic bladder dysfunction were excluded.

DATA COLLECTION AND ANALYSIS

Two authors evaluated the trials for appropriateness for inclusion and risk of bias. Two authors were involved in the data extraction. Data extraction was based on predetermined criteria. Data analysis was based on standard statistical approaches used in Cochrane reviews.

MAIN RESULTS

Twenty three trials were included with a total of 3685 participants, one was a cross-over trial and the other 22 were parallel group trials. The duration of follow up varied from two to 52 weeks. The trials were generally small and of poor methodological quality. During treatment, symptomatic improvement was more common amongst those participants on anticholinergic drugs compared with bladder training in seven small trials (73/174, 42% versus 98/172, 57% not improved: risk ratio 0.74, 95% confidence interval 0.61 to 0.91). Augmentation of bladder training with anticholinergics was also associated with more improvements than bladder training alone in three small trials (23/85, 27% versus 37/79, 47% not improved: risk ratio 0.57, 95% confidence interval 0.38 to 0.88). However, it was less clear whether an anticholinergic combined with bladder training was better than the anticholinergic alone, in three trials (for example 74/296, 25% versus 95/306, 31% not improved: risk ratio 0.80, 95% confidence interval 0.62 to 1.04). The other information on whether combining behavioural modification strategies with an anticholinergic was better than the anticholinergic alone was scanty and inconclusive. Similarly, it was unclear whether these complex strategies alone were better than anticholinergics alone.In this review, seven small trials comparing an anticholinergic to various types of electrical stimulation modalities such as Intravaginal Electrical Stimulation (IES), transcutaneous electrical nerve stimulation (TENS), the Stoller Afferent Nerve Stimulation System (SANS) neuromodulation and percutaneous posterior tibial nerve stimulation (PTNS) were identified. Subjective improvement rates tended to favour the electrical stimulation group in three small trials (54% not improved with the anticholinergic versus 28/86, 33% with electrical stimulation: risk ratio 0.64, 95% confidence interval 1.15 to 2.34). However, this was statistically significant only for one type of stimulation, percutaneous posterior tibial nerve stimulation (risk ratio 2.21, 95% confidence interval 1.13 to 4.33), and was not supported by significant differences in improvement, urinary frequency, urgency, nocturia, incontinence episodes or quality of life.The most commonly reported adverse effect among anticholinergics was dry mouth, although this did not necessarily result in withdrawal from treatment. For all comparisons there were too few data to compare symptoms or side effects after treatment had ended. However, it is unlikely that the effects of anticholinergics persist after stopping treatment. 

AUTHORS' CONCLUSIONS

The use of anticholinergic drugs in the management of overactive bladder syndrome is well established when compared to placebo treatment. During initial treatment of overactive bladder syndrome there was more symptomatic improvement when (a) anticholinergics were compared with bladder training alone, and (b) anticholinergics combined with bladder training were compared with bladder training alone. Limited evidence from small trials might suggest electrical stimulation is a better option in patients who are refractory to anticholinergic therapy, but more evidence comparing individual types of electrostimulation to the most effective types of anticholinergics is required to establish this. These results should be viewed with caution in view of the different classes and varying doses of individual anticholinergics used in this review. Anticholinergics had well recognised side effects, such as dry mouth.