Salvage cystectomy and ileal conduit urinary diversion as a last-line option for benign diseases-perioperative safety and postoperative health-related quality of life

Robotic simple cystectomy as a last resort for antibiotic-recalcitrant recurrent urinary tract infections in women

OBJECTIVE

To report a series of women with antibiotic-recalcitrant recurrent urinary tract infections (rUTI) managed with robotic simple cystectomy and ileal conduit urinary diversion.

METHODS

Following Institutional Review Board approval, all female patients who underwent robotic cystectomy for rUTI between 2011 and 2021 were identified from a prospectively-maintained internal database at a tertiary care center. Exclusion criteria included interstitial cystitis, neurogenic bladder, urinary tract neoplasm, or congenital abnormality. Electronic medical records were reviewed by an independent researcher. Patients were also administered the Quality of Life Questionnaire-C30.

RESULTS

Twenty-four patients met inclusion criteria. Median age was 75 years (range 53-87). Median rUTI duration was 6 (interquartile range [IQR] 2-10) years. Median urinary tract infections count in the 12-month preceding cystectomy was 5 (IQR 3-9). Infections with multidrug resistant organisms were found in 21 patients (88%). The 30-day postoperative complication rate was 79% (19/24), of which 11% were Clavien-Dindo grade ≥III. The main late complication was parastomal hernia, with 17% requiring repair or revision. At a median of 36 months (range 12-61) post-operatively, the median Quality of Life Questionnaire-C30 global health status score was 50 (range 33-83).

CONCLUSION

Cystectomy is a last-resort management option for women with severely symptomatic end-stage bladders in the setting of antibiotic-recalcitrant rUTI. Patients should be counseled thoroughly regarding possible acute and long-term postoperative complications. Select patients, managed in high-volume referral centers, can benefit from robotic simple cystectomy with ileal conduit urinary diversion.

The current use of the EORTC QLQ-NMIBC24 and QLQ-BLM30 questionnaires for the assessment of health-related quality of life in bladder cancer patients: a systematic review

PURPOSE

Investigating the use of the EORTC bladder cancer (BC) modules by evaluating: (a) study contexts/designs; (b) languages/countries in which the modules were administered; (c) their acceptance by patients/investigators; and (d) their psychometric properties.

METHODS

A systematic review was performed with studies from 1998 until 20/10/2021 in five databases. Articles/conference abstracts using the EORTC-QLQBLM30 (muscle invasive BC) and the EORTC-QLQNMIBC24 (previously referred to as QLQ-BLS24; non-muscle invasive BC) were included. Two authors independently screened titles/abstracts/full-texts and performed data extraction.

RESULTS

A total of 76 eligible studies were identified. Most studies included the BLM30 (n = 53), were in a urological surgery context (n = 41) and were cross-sectional (n = 35) or prospective (n = 30) in design. The BC modules were administered in 14 languages across 19 countries. Missing data were low-moderate for all non-sex related questions (< 1% to 15%). Sex-related questions had higher rates of missing data (ranging from 6.9% to 84%). Most investigators did not use all scales of the questionnaires. One validation study for the original BLS24 led to the development of the NMIBC24, which adopted a new scale structure for which good structural validity was confirmed (n = 3). Good reliability and validity was shown for the NMIBC24 module, except for malaise and bloating/flatulence scales. Psychometric evidence for BLM30 is lacking.

CONCLUSION

These results provide insight into how the EORTC BC quality of life modules could be further improved. Current work is ongoing to update the modules and to determine if the two modules can be combined into a single questionnaire that works well in both the NMIBC and MIBC settings.

Durable Treatment of Refractory Vesicourethral Anastomotic Stenosis via Robotic-assisted Reconstruction: A Trauma and Urologic Reconstructive Network of Surgeons Study

BACKGROUND

Refractory vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy poses challenges distinct from bladder neck contracture, due to close proximity to the sphincter mechanism. Open reconstruction is technically demanding, risking de novo stress urinary incontinence (SUI) or recurrence.

OBJECTIVE

To demonstrate patency and continence outcomes of robotic-assisted VUAS repair.

DESIGN, SETTING AND PARTICIPANTS

Patients with VUAS underwent robotic-assisted reconstruction from 2015 to 2020 in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) consortium of institutions. The minimum postoperative follow-up was 3 mo.

SURGICAL PROCEDURE

The space of Retzius is dissected and fibrotic tissue at the vesicourethral anastomosis is excised. Reconstruction is performed with either a primary anastomotic or an anterior bladder flap-based technique.

MEASUREMENTS

Patency was defined as either the passage of a 17 French flexible cystoscope or a peak flow on uroflowmetry of >15 ml/s. De novo SUI was defined as either more than one pad per day or need for operative intervention.

RESULTS AND LIMITATIONS

A total of 32 patients met the criteria, of whom 16 (50%) had a history of pelvic radiation. Intraoperatively, 15 (47%) patients had obliterative VUAS. The median length of hospital stay was 1 d. At a median follow-up of 12 mo, 24 (75%) patients had patent repairs and 26 (81%) were voiding per urethra. Of five men with 30-d complications, four were resolved conservatively (catheter obstruction and ileus). In eight patients, recurrent stenoses were managed with redo robotic reconstruction (in two), endoscopically (in four), or catheterization (in two). Of 13 patients without preexisting SUI, 11 (85%) remained continent at last follow-up. No patients underwent urinary diversion.

CONCLUSIONS

Robotic-assisted VUAS reconstruction is a viable and successful management option for refractory anastomotic stenosis following radical prostatectomy. The robotic transabdominal approach demonstrates high patency and continence rates.

PATIENT SUMMARY

We studied the outcomes of robotic-assisted repair for vesicourethral anastomotic stenosis. Most patients, after the procedure, were able to void per urethra and preserve existing continence.

Urinary diversions for benign and oncologic indications: what did we learn about short term complications in the last 24 months?

PURPOSE OF THE REVIEW

Urinary diversion (UD) with or without cystectomy is a procedure with high short term complication rates. In this review, we summarize the most relevant findings of the last 2 years.

RECENT FINDINGS

The use of a prophylactic mesh decreases the risk of parastomal hernia after ileal conduit (IC) surgery without adding mesh-related complications according to a recent randomized multicentre trial. Robot-assisted surgery is increasingly applied for UD and is evolving from extra- to intra-corporeal reconstruction in both continent and incontinent diversions, but there is still a need for appropriately designed studies assessing both short- and long-term complications. Promising techniques to decrease ureterointestinal stricture rates have been reported from small series, such as retrosigmoid placement of the proximal IC to avoid transpositioning of the left ureter, or in robot-assisted surgery the use of indocyanine green with near-infrared light to improve visualisation of distal ureteral viability.

SUMMARY

Most recent reports derive from observational data. Appropriate randomized studies are warranted for the evaluation of new techniques to be implemented in a surgical area that still is associated with high complication rates.