Management of neobladder-vaginal fistula and stress incontinence following radical cystectomy in women: a review

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.

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.

Postoperative management of radical cystectomy. Review of the evidence on the prevention and treatment of urological complications

INTRODUCTION AND OBJECTIVES

This review article focuses on the prevention and management of the most common postoperative urological complications of radical cystectomy. We reviewed the current literature and conducted an analysis of frequency, prevention and treatment of complications.

ACQUISITION OF EVIDENCE

We conducted a search on Medline to identify original articles, literature reviews and editorials focusing on the urological complications of radical cystectomy during the first 90 days after surgery. We identified those series that included more than 100 patients.

SYNTHESIS OF THE EVIDENCE

The literature regarding the prevention and treatment of complications after cystectomy is in general retrospective and nonstandardised. The level of evidence is generally low, and it is difficult to make evidence-based recommendations.

CONCLUSIONS

Progress has been made in recent years in reducing mortality and preventing the complications of cystectomy. The most common complications are gastrointestinal, for which significant efforts have been made to implement ERAS and Fast Track protocols. The complications that can most significantly change patients' quality of life are urinary stoma.

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.

Functional and Clinicopathologic Outcomes Using a Modified Vescica Ileale Padovana Technique

OBJECTIVE

To evaluate the clinicopathologic and functional outcomes of a modified Vescica ileale Padovana (VIP) neobladder technique.

METHODS

Data for 160 patients at a single institution who underwent radical cystectomy and orthotopic VIP neobladder creation between 1998 and 2013 were analyzed. Modified VIP technique involved longitudinal opening of the small bowel close to the anterior mesenteric border instead of along the true anti-mesentery. This allowed for creation of a dependent neourethral funnel and a large serosal surface for ureteral anastomosis, distant from any suture lines.

RESULTS

Mean age for the entire cohort was 59.5, with 9% female and 64% with muscle invasive disease prior to cystectomy. Within 30 days of surgery, 16 patients (10%) developed a Clavien grade 3-4 complication and there were no deaths. Ninety-six percent reported minor or no daytime urinary leakage at 12 months, and 70% reported minor or no nighttime urinary leakage. Two- and five-year overall survival rates were 84.2% and 72.6% , respectively. Seven patients developed a ureteral stricture (4%), three (2%) had bladder neck contractures, two (1%) experienced urethral recurrence, and there were no vesicovaginal fistulas.

CONCLUSIONS

This modified VIP neobladder technique achieves favorable functional, survival, and recurrence outcomes similar to other published orthotopic continent diversions. Its near spheroidal shape lowers internal pressure, allowing for improved continence at physiologic filling capacity, and its offset bowel opening helps prevent unnecessary stretch to the native urethra, even in large individuals. The widened uretero-enteric anastomosis site distant from bowel suture lines contributes to decreased stricture rates and its placement on the dome of the neobladder facilitates endoscopic access should strictures occur. Finally, lack of posterior overlapping suture lines also mitigates the risk of fistulae formation in females should anterior vaginal wall excision or entry be unavoidable.

[Neobladder-rectal fistula as early postoperative complication of radical cystectomy and orthotopic neobaldder construction]

We report a case of neobladder-rectal fistula that developed as an early postoperative complication of radical cystectomy and orthotopic neobladder construction procedures. A 75-year-old man underwent a radical cystectomy and orthotopic neobladder construction using Studer's method for locally invasive bladder cancer (cT2N0M0). The patient had severe watery diarrhea on postoperative day 20, and was diagnosed with a neobladder-rectal fistula based on cystography findings. We inserted a Foley catheter into the neobladder, and performed conservative treatment. Four months after development of the fistula, cystography revealed that it had spontaneously closed. A neobladder-rectal fistula is an extremely rare complication, with no other known reports. Herein, we present this case of neobladder-rectal fistula and discuss its formation, diagnosis and treatment, along with reference to previous reports of neobladder-vaginal fistulas.

Vaginal repair of pouch-vaginal fistula after orthotopic bladder substitution in women

OBJECTIVE

To report the diagnosis, technique, and treatment outcome of pouch-vaginal fistula (PVF) with particular stress on the vaginal repair.

METHODS

Between January 1995 and March 2010, 298 women (mean age, 52 years) underwent orthotopic neobladder reconstruction after radical cystectomy. A standard radical cystectomy was conducted in 283 patients and genitalia-sparing cystectomy in 15. Certain modifications were adopted after 100 patients to prevent chronic urinary retention and PVF. Hautmann or hemi-Kock pouch was used. Patients were oncologically and functionally evaluated and asked about any sexual complaint. Eight PVF (2.7%) were diagnosed by voiding radiography of the pouch and preoperative endoscopy. Transabdominal repair was used in 2 patients(high, large, vaginal atrophy) and the other patients underwent a vaginal repair in nonopposing layers 3 to 6 months after cystectomy.

RESULTS

The incidence of PVF was 5 of 100 (5%) before and 3 of 198 (1.5%) after the technical modifications. In one patient, repair of the fistula was conducted in 2 stages. After repair (mean follow-up, 146 months), all repaired patients were continent during daytime and only one had nocturnal incontinence. The urodynamic parameters were comparable to these in other women undergoing orthotopic neobladder reconstruction and not having a fistula.

CONCLUSION

Transvaginal repair of PVF is feasible with good functional outcome. It is recommended in low, small fistula and if postmenopausal vaginal atrophy is absent. The repair does not compromise the external urethral sphincter. However, these conclusions need to be consolidated in future studies including a larger number of patients.