Transvaginal neobladder vaginal fistula repair after radical cystectomy with orthotopic urinary diversion in women

Othotopic ileal neobladder “Belgrade pouch” in females

Background/Aim. Orthotopic continent neobladder pro-vides adequate capacity, low pressure reservoir, acceptable rate of continence and satisfactory voiding frequency. Standard surgical techniques require the usage of an ileal segment in the length of 50?65 cm for neobladder creation with favorable results. However, the usage of a long intestinal segment is associated with high neobladder capacity, voiding problems, and metabolic complications. The aim of this study was to analyze clinical outcomes of the ?Belgrade pouch? orthotopic bladder replacement in female patients and to promote the usage of shorter ileal segment for neobladder creation. Methods. A prospective study conducted in our institution from 2009 to 2019 included 37 female patients who underwent orthotopic bladder replacement ac-cording to ?Belgrade pouch? technique with the usage of shorter ileal segment whose average length for neobladder creation was 28 cm. Inclusion criteria were: female continent patients older than 18, organ-confined muscle-invasive bladder carcinoma and, the American Society of Anestesiologists (ASA) score 1 or 2. Exclusion criteria were: diabetes mellitus, obstructive pulmonary diseases, systemic illnesses and metabolic diseases which may have some influence on results interpretation, renal deterioration and preoperative incontinence. We analyzed operative time, blood loss, histopathological findings, continence rate, metabolic disorders, immediate and delayed complications and survival rate in two-year periods of follow-up. Results. Average age of patients was 58 (32?67) years. Average time of surgical procedures was 199 (155?320) min. Blood transfusion was intraoperatively applied in 32.43% of the patients in average volume of 385 (300?640) mL. A total of 29.47% patients had anemia preoperatively. In the early postoperative period we reported one patient with paralytic ileus which was resolved conservatively and one patient with urinary fistula appearance; 56.75% of the patients were in pT2 stage. Two years following the surgery, day-time continence was achieved in 91.89% of the patients, neobladder capacity was 459 (345?592 ) mL, post-void residual urine volume was 27 (0?40) mL, 24 h voiding frequency 6, metabolic acidosis appeared in 2.7% of the patients. Survival rate in 2-year period was 86.48%. Conclusion. Orthotropic ileal neobladder created from the shorter ileal segment (?Belgrade pouch?) in females provides a high level of continence without a significant increase of voiding frequency, with adequate capacity, without urinary tract retention and with decrease of metabolic complications.

Surgical Outcomes of Transvaginal Neobladder-Vaginal Fistula Repair After Radical Cystectomy with Ileal Orthotopic Neobladder: A Case-Control Study

Purpose

To present surgical methods and outcomes in women with bladder cancer (BCa) requiring correction of neobladder-vaginal fistula (NVF) after radical cystectomy (RC) with ileal orthotopic neobladder (IONB).

Materials and Methods

The medical records of 163 women who underwent RC with IONB for BCa between January 2010 and December 2018 were retrospectively reviewed. The presence of NVF was confirmed by cystoscopy and/or voiding cystography. NVF repair was performed using a transvaginal approach, which included circumferential incision of the fistula tract, creation of a plane between the neobladder serosa and the vaginal epithelium, and multi-layered transvaginal closure.

Results

During a median follow-up of 47.9 months, NVF was identified in 12 (8.8%) of the 163 included women. Eight (66.7%) fistulas were located in the proximal anterior vaginal wall and four (33.3%) in the vaginal apex. Median time from RC to NVF repair was 3.4 months (range, 2.1-5.6 months), median NVF size was 6.0 mm (range, 4.0-22.0 mm), and median duration of urethral Foley catheter indwelling was 24.0 days (range, 15.0-43.0 days). Initial repair of NVF was successful in ten (83.3%) patients. Two (16.7%) patients who relapsed retained IONB through the subsequent operation. Two (16.7%) patients developed severe urinary incontinence after NVF repair, requiring anti-incontinence surgery with a synthetic transobturator mid-urethral sling.

Conclusion

The transvaginal approach for NVF repair is feasible, yielding successful surgical outcomes. However, women should be counseled about the risks of relapse and urinary incontinence.

Workup and conservative management of ileal conduit-vaginal fistulas: review of literature

Ileal conduit-vaginal fistulas are a rare but challenging complication of urinary diversion. Here we identify risk factors and summarize the workup and conservative management strategies for this complication. We present two cases of elderly women with remote history of cancer who presented with persistent urinary leakage from the vagina several years after ileal conduit creation. Fistulas may be identified using dye or imaging with a loopogram and looposcopy. Correction of obstruction such as stomal stenosis or urinary diversion should be pursued to relieve pressure off the conduit. Minimally invasive management such as fulguration can result temporary relief; however, the recurrence rate is high.

Management of Pelvic Organ Prolapse After Radical Cystectomy

PURPOSE OF REVIEW

This article explores the anatomy, management options, and outcomes of pelvic organ prolapse with a female cystectomy patient.

RECENT FINDINGS

There is a lack of data on surgical management outcomes for prolapse following radical cystectomy. However, most case series from tertiary referral centers show reasonable results irrespective of route of repair. As expected, the surgical planes and the reorientation of the bowel loop for urinary diversion makes any pelvic reconstruction a potential hazard and requires a high level of expertise and counseling to the patient in regard to the management of expectations. Pelvic organ prolapse following radical cystectomy is uncommon but presents a significant challenge to the reconstructive surgeon.

Neobladder-Vaginal Fistula: Surgical Management Techniques

PURPOSE OF REVIEW

To describe the complexities of diagnosis and management of neobladder-vaginal fistula (NVF) following orthotopic urinary diversion in women.

RECENT FINDINGS

Multiple recent single-institution series confirm the variability of outcomes for NVF repairs and caution regarding comorbid stress urinary incontinence which may necessitate further interventions including conversion to alternate diversions. Although both abdominal and transvaginal approaches have been advocated for surgical management of NVF, contemporary series from reconstructive surgeons favor a vaginal approach to decrease overall operative morbidity. Patients should be carefully counseled regarding neobladder and sphincter function following fistula repair along with the risks of secondary urinary diversion.

Neovagina construction and continent cutaneous urinary reservoir using a previous orthotopic ileal neobladder

Standard radical cystectomy (RC) in women involves removal of the distal ureters, bladder, proximal urethra, uterus, ovaries, and adjacent vagina. Furthermore, pelvic organ-preserving RC to treat selected women has become an accepted technique and may confer better postoperative sexual and urinary functions than standard RC, avoiding complications such as incontinence, prolapse, neobladder-vaginal fistula (NVF), and sexual dysfunction, without compromising oncological outcome. This article reports a different surgical approach: a patient who underwent a cutaneous continent reservoir and neovagina construction using a previous ileal orthotopic neobladder after RC. Patient presented no complications and she has no evidence of recurrent disease and is sexually active, with a satisfactory continent reservoir. This case is the first report of this procedure that was able to treat concomitant dyspareunia caused by short vagina and neobladder-vaginal fistula. In conclusion, standard radical cystectomy with no vaginal preservation can have a negative impact on quality of life. In the present case, we successfully treated neobladder fistula and short vagina by transforming a previous ileal orthotopic neobladder into two parts: a continent reservoir and a neovagina. However, to establish the best approach in such patients, more cases with long-term follow-up are needed.

Surgical Complications of Urinary Diversion

Urinary diversion (UD) with an intestinal segment has significant risks of short- and long-term complications. With modern reporting criteria, understanding of the true prevalence and spectrum of these complications has improved. Methods to minimize early postoperative complications include enhanced recovery pathways, restricted intraoperative fluid protocols, and referral to high-volume centers. With long-term follow-up after UD, the risk of complications steadily rises. Late surgical complications include ureterointestinal anastomotic strictures, urolithiasis, and stomal issues. Patients with UDs require close surveillance to monitor for anatomic, infectious, and metabolic complications and surgeons who perform UD should be aware of the risk and timing of postoperative complications.

How and why to take a Martius labial interposition flap in female urology

The Martius modified labial fat pad flap at nearly 90 years old is still very much part of the modern vaginal surgeon’s armamentarium. Here we describe this straightforward and adaptable technique, the avoidance of pitfalls, its advantages and uses in vaginal surgery, and outcomes both short and long term. Specifically patient reported outcomes related to scar perception and sexual function are explored.

Management of Voiding Dysfunction After Female Neobladder Creation

PURPOSE OF REVIEW

Functional complications after orthotopic neobladder urinary diversion (ONB), including urinary incontinence and urinary retention, present unique challenges. The purpose of this review is to outline contemporary treatment options for voiding dysfunction after ONB in females.

RECENT FINDINGS

Meticulous surgical technique in the form of urethral nerve-sparing has been shown to play an important role in maintaining continence, as has sparing the uterus when possible. Data supporting the effectiveness of lifestyle measures, urethral bulking, pubovaginal slings, and transobturator slings in the treatment of urinary incontinence are widely variable and limited to case reports. Urinary retention is still most effectively managed with self-catheterization. Voiding dysfunction after ONB can be devastating. Recent advances focus on improving surgical techniques to decrease the risk of incontinence and retention, as post-operative management options are limited.

Treatment of Pelvic Floor Disorders Following Neobladder

Radical cystectomy remains the gold standard treatment for organ-confined high-grade recurrent or muscle-invasive bladder cancer. Orthotopic neobladder urinary diversion following cystectomy represents an option for patients wishing for continent urinary diversion. Female patients who undergo radical cystectomy with orthotopic bladder substitution are at risk for developing both common and neobladder-specific disorders of the pelvic floor, including urinary incontinence, hypercontinence, vaginal prolapse, and neobladder-vaginal fistula. Each of these sequelae can have significant impact on the patient's quality of life. Due to the increased frequency of orthotopic neobladder creation in women, subspecialty urologists are more likely to confront such pelvic floor disorders in bladder cancer survivors. This review presents the most current information on the treatment of pelvic floor disorders after orthotopic bladder substitution.

Outcomes of Surgical Management in Patients with Stress Urinary Incontinence and/or Neovesicovaginal Fistula after Orthotopic Neobladder Diversion

PURPOSE

To our knowledge there are no guidelines for the evaluation and management of incontinence in women with an orthotopic neobladder. We propose a treatment algorithm based on our experience with treating this patient population.

MATERIALS AND METHODS

We identified women in whom orthotopic neobladder diversion and surgery for incontinence were performed from January 1, 1995 to January 1, 2014. Charts were reviewed for management, outcomes and complications within 30 days of surgery.

RESULTS

At this institution 12 women with orthotopic neobladder diversion were treated with surgery for incontinence between 1995 and 2014. Six women (50%) had an undiagnosed neovesicovaginal fistula, of whom 3 (50%) underwent successful fistula repair. A total of 12 bulking agent injections were performed in 6 women (50%). The outcomes were continued dryness after 1 injection (8%), transient improvement after 9 (75%), immediate failure after 1 (8%) and secondary fistula development after 1 (8%). Four transobturator slings and 4 pubovaginal slings were placed in a total of 6 patients (50%), of whom 1 (17%) was dry and 1 (17%) was improved. At a median followup of 22.9 months (IQR 11.1-46.4) 6 women (50%) were dry or improved and 6 (50%) had no improvement in leakage. Of the 6 (50%) women who were dry or improved 2 (17%) achieved planned intermittent catheterization after surgery and 2 (17%) underwent ileal conduit conversion.

CONCLUSIONS

Bulking agents have low long-term efficacy and carry the risk of fistula formation. The efficacy of tension-free sling placement is low and continence requires an obstructing sling. Counseling should include acceptance of multiple procedures, which may be necessary to achieve continence, and consideration of conduit diversion.