Belastungsinkontinenz nach radikaler Zystektomie

Posterior reconstruction during robotic-assisted radical cystectomy with intracorporeal orthotopic ileal neobladder: description and outcomes of a simple step

A posterior reconstruction (PR) might improve the fluidity and delicacy of the maneuvers related to the neovesico-urethral anastomosis during robotic-assisted radical cystectomy (RARC). Our objective is to describe in detail the surgical steps of PR and to assess its feasibility and functional outcomes. The data regarding patients undergoing a totally intracorporeal RARC with neobladder and PR for high-grade and/or muscle-invasive urothelial cancer of the bladder at Karolinska University Hospital between October 2015 and November 2016 by a single surgeon (PW) were reviewed. Prior to the anastomosis, a modified posterior Rocco's repair involving the Denonvillier's fascia, the rhabdosphincter, and the posterior side of the ileal neobladder neck was performed. The steps are shown in a video at https://doi.org/10.1089/vid.2019.0029 . The primary outcome was urinary continence; the secondary outcomes were urinary leakage, intermittent catheterization, and complications related to the reconstructive steps. Eleven male patients with a median age and BMI of 67 years and 24, respectively, underwent RARC with PR associated to the neovesico-urethral anastomosis. Overall and posterior reconstruction time were 300' (195-320) and 6' (4-7), respectively. The daytime and nighttime continence rates were 100% and 44% at 12 months, respectively; the median pad weight was 3.5 g and 108 g at daytime and nighttime, respectively. One urinary leakage from the urethrovesical anastomosis was treated conservatively. Two patients perform intermittent catheterization. The posterior reconstruction during RARC is safe and feasible, providing good continence rates. It supported a careful suturing of the anastomosis as well as an uncomplicated catheter placement.

Transobturator vaginal tape (inside-out) for stress urinary incontinence after radical cystectomy and orthotopic reconstruction in women

Objectives

To evaluate the safety and clinical efficacy of the transobturator vaginal tape ‘inside-out’ (TVT-O) procedure for managing new-onset stress urinary incontinence (SUI) after radical cystectomy (RC) and orthotopic W-neobladder construction in women.

Patients and methods

Between January 2004 and June 2010, 57 women were treated with RC and orthotopic ileal neobladder reconstruction. Six of these patients (median age 44 years, range 39–62; grade 2 muscle-invasive squamous cell carcinoma in four and transitional cell carcinoma in two) developed de novo SUI that was moderate in four and severe in two. The median (range) duration of SUI was 11 (9–18) months. All six patients underwent TVT-O for control of their SUI.

Results

Four patients were completely dry day and night (three of them can initiate voiding and one cannot, and uses intermittent catheterization). One patient improved, as assessed by using fewer pads (from 5–7 pads to 1 pad/day and night). She can initiate voiding but has minimal leakage only on moderate exertion. One patient who had severe SUI showed no improvement. Patients were followed for a mean (range) of 18 (17–32) months, with no deterioration in the continence status.

Conclusion

These encouraging results confirm the safety and clinical efficacy of TVT-O for managing new-onset SUI after RC and ileal neobladder construction, although a larger survey and a longer follow-up are needed.

[Non-adjustable sling for treatment of male stress urinary incontinence]

Even though the artificial sphincter is still the treatment of choice in the surgical therapy of male stress urinary incontinence, recent developments have introduced numerous minimally invasive treatment options with acceptable clinical results. The male slings have been included into the EAU guidelines for treatment of male stress urinary incontinence. A distinct choice of patients and treatment options will lead to the highest chance of success. Besides the adjustable compressive slings, the non-adjustable and non-compressive AdVance Sling offers a possible option for a functional approach to treatmentratio. A critical assessment of all these methods remains essential and prospective randomized trials are still missing.

Complications of the AdVance transobturator male sling in the treatment of male stress urinary incontinence

OBJECTIVE

To evaluate prospectively the complication rate of the retrourethral transobturator sling (AdVance sling) for the functional treatment of male stress urinary incontinence (SUI).

METHODS

In 230 patients with SUI due to nonintrinsic sphincter deficiency (without direct sphincter lesion) after radical prostatectomy (n=213), radical cystoprostatectomy with ileal neobladder (n=2) and transurethral resection of the prostate (n=15) a retrourethral transobturator sling was implanted. Patients were followed up for a median of 17 months (range, 4-42 months) with regard to intraoperative, early postoperative, and midterm postoperative complications.

RESULTS

Overall complication rate of the AdVance sling was 23.9%. Despite one accidental sling misplacement, no intraoperative complication occurred. Forty-nine patients (21.3%) experienced urinary retention postsurgery. Two slings were explanted (0.9%), 1 due to initial wrong placement and the other due to a symphysitis, attributed to a Guillain-Barré syndrome and not to a sling infection. One sling was transected (0.4%) due to slippage of the sling with obstruction of the urethra. Further complications were local wound infection (0.4%), urinary infection with fever (0.4%), and persistent moderate perineal pain (0.4%). There was no correlation between postoperative acute urinary retention and age at sling implantation, time of incontinence before sling implantation, preoperative daily pad use, or prior invasive incontinence treatment, respectively.

CONCLUSIONS

The retrourethral transobturator AdVance sling is a safe treatment option for male nonintrinsic sphincter deficiency SUI, with the main postoperative complication being transient acute urinary retention. Severe intra- and postoperative complications are rare and sling explantation rate is very low.