Perugia ileal neobladder: functional results and complications

Early and late post-procedural complications in different orthotopic neobladder surgical approaches: A systematic review

Bladder cancer (BCa) represents the second most common malignancy of the genitourinary tract. The major risk factors include age, gender, smoking attitude, and occupational exposure, while the exact etiopathogenesis is still uncertain. Patients diagnosed with a BCa showing invasion of the muscle layer below the submucosa must undergo radical cystectomy (RC) with urinary diversion (UD). Many different surgical approaches to UD have been developed. Packaging an orthotopic neobladder (ON) with a bowel tract represents the gold standard when certain patient selection criteria are satisfied. Using PRISMA guidelines, we performed a systematic review assessing early (within 90 days) and late (beyond 90 days) post-procedural complications of different ON surgical approaches. A comprehensive systematic search was conducted in PubMed, Scopus, and Google Scholar databases to identify papers starting from 2012 using dedicated keywords ("neobladder", "orthotopic neobladder", "complications'' and "outcomes"). A total of 27 articles were found to satisfy the inclusion criteria and selected. Although the ON is a safe procedure that guarantees the patient the best quality of life (QoL), it is not free from risks. Many complications could occur during and after the surgical time which imposes the necessity of strict follow-up and careful checks over time, which should be properly discussed with patients before.

Urodynamic Parameters and Continence Outcomes in Asymptomatic Patients with Ileal Orthotopic Neobladder: A Systematic Review and Metanalysis

INTRODUCTION

The orthotopic neobladder is the type of urinary diversion (UD) that most closely resembles the original bladder. However, in the literature the urodynamic aspects are scarcely analysed.

OBJECTIVE

To provide the first systematic review (SR) on the urodynamic (UDS) outcomes of the ileal orthotopic neobladders (ONB). Continence outcomes are also presented.

METHODS

A PubMed, Embase and Cochrane CENTRAL search for peer-reviewed studies on ONB published between January 2001-December 2022 was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement.

RESULTS AND CONCLUSION

Fifty-nine manuscripts were eligible for inclusion in this SR. A great heterogeneity of data was encountered. Concerning UDS parameters, the pooled mean was 406.2 mL (95% CI: 378.9-433.4 mL) for maximal (entero)cystometric capacity (MCC) and 21.4 cmH2O (95% CI: 17.5-25.4 cmH2O) for Pressure ONB at MCC. Postvoid-residual ranged between 4.9 and 101.6 mL. The 12-mo rates of day and night-time continence were 84.2% (95% CI: 78.7-89.1%) and 61.7% (95% CI: 51.9-71.1%), respectively.Despite data heterogeneity, the ileal ONB seems to guarantee UDS parameters that resemble those of the native bladder. Although acceptable rates of daytime continence are reported the issue of high rates of night-time incontinence remains unsolved. Adequately designed prospective trials adopting standardised postoperative care, terminology and methods of outcome evaluation as well as of conduction of the UDS in the setting of ONB are necessary to obtain homogeneous follow-up data and to establish UDS guidelines for this setting.

Robot-assisted radical cystectomy with intracorporeal reconstruction of urinary diversion by mechanical stapler: prospective evaluation of early and late complications

Introduction

Radical cystectomy with pelvic lymph node dissection is the gold standard treatment for non-metastatic muscle-invasive bladder cancer and high-risk non-muscle-invasive bladder cancer. For years, the traditional open surgery approach was the only viable option. The widespread of robotic surgery led to its employment also in radical cystectomy to reduce complication rates and improve functional outcomes. Regardless of the type of approach, radical cystectomy is a procedure with high morbidity and not negligible mortality. Data available in the literature show how the use of staplers can offer valid functional outcomes, with an acceptable rate of complications shortening the operative time. The aim of our study was to describe the perioperative outcomes and complications associated with robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) using a mechanical stapler.

Material and methods

From January 2015 to May 2021, we enrolled patients who underwent RARC with pelvic node dissection and stapled ICUD (ileal conduit or ileal Y-shaped neobladder according to the Perugia ileal neobladder) in our high-volume center. Demographic features, perioperative outcomes and early (≤30 days) and late (>90 days) post-operative complications according to the Clavien-Dindo classification, were recorded for each patient. We also analyzed the potential linear correlation between demographic, pre-operative as well as operative features and the risk of post-operative complications.

Results

Overall, 112 patients who underwent RARC with ICUD were included with a minimum follow-up of 12 months. Intracorporeal Perugia ileal neobladder was performed in 74.1% of cases while ileal conduit was performed in 25.9%. The mean operative time, estimated intraoperative blood loss, and LOS were 289.1 ± 59.7 min, 390.6 ± 186.2 ml, and 17.5 ± 9.8 days, respectively. Early minor and major complications accounted for 26.7% and 10.8%, respectively. Overall late complications were 40.2%. The late most common complications were hydronephrosis (11.6%) and urinary tract infections (20.5%). Stone reservoir formation occurred in 2.7% of patients. Major complications occurred in 5.4%. In the sub-analysis, the mean operative time and the estimated blood loss improved significantly from the first 56 procedures to the last ones.

Conclusion

RARC with ICUD performed by mechanical stapler is a safe and effective technique. Stapled Y-shaped neobladder did not increase the complication rate.

Bioabsorbable zinc alloys for use in urological surgery

PURPOSE

Non-absorbable clips are widely used in urologic surgery and they may come in contact with an open urinary tract intraoperatively. As a result, stray clips in the urinary tract and associated intractable infections have been reported. We developed a bioabsorbable metal and evaluated whether it would dissolve if it strayed into the urinary tract.

METHODS

We prepared four types of alloys mainly comprising zinc (Zn) with small amounts of magnesium (Mg) and strontium (Sr), and the biological effects, degradability, strength, and ductility were investigated. Each alloy was implanted in the bladder of five rats for 4, 8, and 12 weeks. The alloys were removed and evaluated for degradability, stone adhesion, and tissue changes. The Zn-Mg-Sr alloy had degradability and no stone adhesion in the rat experiments, and it was implanted in the bladders of five pigs for 24 weeks. The Mg and Zn levels in the blood were measured, and staple changes were confirmed by cystoscopy.

RESULTS

Zn-Mg-Sr alloys showed the best degradability of 6.51% at 12 weeks. In pig experiments, the degradation rate was 3.72% at 24 weeks. None of the pigs had changes in the Zn or Mg concentrations in the blood. Overall, the bladder incision was healed and the gross pathology showed wound healing.

CONCLUSIONS

The Zn-Mg-Sr alloys were safely used in animal experiments. Furthermore, the alloys are easy to process and can be formed into various shapes, such as staples, making them useful in robotic surgery.

Comparative study on the clinical effect of preparing neobladder with different lengths of ileum

OBJECTIVE

To investigate the relationship between orthotopic U-shaped ileal neobladder volume and bladder function. To investigate the correlation between the volume of the radical cystectomy and the U-shaped ileal neobladder in situ and the function of the bladder.

METHODS

The clinical data of patients undergoing in orthotopic U-shaped neobladder in our hospital were retrospectively analyzed. They were divided into two groups according to the length of the retained ileum. Group 1: The length of the ileum was 25-35cm (including 35cm), and the second group: the length of the ileum was 35-45cm. The basic information, cushion usage, urodynamic examination and complications of the two groups were obtained.

RESULTS

A total of 88 patients were included in the study, including 33 in the first group and 55 in the second group. There was no statistical difference in general data, lymph node collection, lymph node positive rate, positive margin rate, postoperative pathological stage, pathological grade, pathological type, intraoperative blood loss, blood transfusion, postoperative hospital stay, and complications between the two groups of patients. significance. Although the usage of urine pads in group 1 was more than that in group 2 in the short term after operation (P<0.05), it started from the third year after operation. Patients in group 1 used less cushion than group 2 (P<0.05). Urodynamic examination was performed on the patients, and the bladder function of group 1 maintained satisfactory time longer than that of group 2. The total number of deaths in the two groups was 12 and 23, respectively. The 5-year overall survival (OS) rate of group 1 was 53.60%, and the 5-year overall survival rate of group 2 was 52.9%.

CONCLUSIONS

A new bladder formed by cutting the ileum with a length of 25-35 cm (including 35cm) has a longer time to maintain good bladder function than cutting the ileum with a length of 35-45 cm to produce a new bladder.

Robot-Assisted Laparoscopic Radical Cystectomy and Modified Y-Shaped Ileal Orthotopic Neobladder Reconstruction

Background

Orthotopic neobladder reconstruction has become the preferred method of urinary diversion after radical cystectomy in major medical centers. We performed modified Y-shaped ileal orthotopic neobladder reconstruction and presented the functional results and postoperative complications of the modified surgery.

Methods

We included 21 patients with bladder cancer who underwent radical cystectomy at our center between February 2019 and December 2019. All patients underwent robotic-assisted laparoscopic radical cystectomy and lymph node dissection plus modified Y-shaped ileal orthotopic neobladder reconstruction. We collected the demographic and pathological history of the patients, and perioperative and postoperative functional outcomes and postoperative complications were recorded.

Results

All surgeries were successful and no serious postoperative complications occurred. The mean operative time was 321.43 ± 54.75 min, including 101.67 ± 10.88 min required for neobladder reconstruction. Liquid intake was encouraged about 5 days after surgery, stent and catheter were removed after 13.52 ± 3.28 days, and the patients were discharged 1–2 days after removing the catheter. No ureteral anastomotic and neobladder urethral anastomotic strictures occurred. The volume of the neobladder at 1-year post-surgery was 195.24 ± 16.07 mL and the maximum urinary flow rate was 20.64 ± 2.22 mL/s.

Conclusion

We describe the robotic-assisted modified Y-shaped ileal orthotopic neobladder reconstruction performed at our center, which requires a simple suture and short neobladder construction time, minimizes the occurrence of anastomotic stenosis, facilitates smooth patient emptying, and is clinically scalable and applicable.

Development of bioabsorbable zinc-magnesium alloy wire and validation of its application to urinary tract surgeries

PURPOSE

Metallic medical devices are typically constructed from non-bioabsorbable metals that remains in the body and causes considerable complications. Particularly in the urinary tract, calculus, intractable infection, and misdiagnosis as calculus are often caused by non-bioabsorbable metals. Here, we developed a zinc-magnesium alloy as a new bioabsorbable metal and sought to evaluate the bioabsorbable behavior of zinc and zinc-magnesium alloy in a rat bladder implantation model.

METHODS

We prepared zinc-magnesium alloy wires with various proportions of magnesium and investigated the strength, shape retention, formability, and absorbability of these novel materials. Then, we implanted zinc and zinc-magnesium alloy rings formed by the wires into rat bladder. Rats were euthanized at the end of the observation period, and the rings were removed for volume evaluation. Extracted bladder tissues were subjected to histological analysis.

RESULTS

The strength of the zinc wire was enhanced by more than fourfold upon the addition of magnesium, without loss of ductility. Linear reduction of ring volume in urine was observed based on the concentration of magnesium within the ring. Nearly all rings were covered with a thin layer of calculus. Histological findings of the transected urinary bladder tissues did not differ among groups.

CONCLUSIONS

Zinc-magnesium alloy is a promising candidate for use as a bioabsorbable medical device in the urinary tract.

Long-term outcome of spiral ileal neobladder with orthotopic ureteral reimplantation

PURPOSE

The purpose of this study was to analyze long-term complications, urodynamics, and quality of life (QoL) of patients after orthotopic ileal neobladder with orthotopic ureteral reimplantation to enrich clinical data and provide a basis for clinical use of this surgery.

METHODS

Between January 2007 and January 2013, 72 consecutive patients who underwent spiral ileal neobladder following radical cystectomy were enrolled. The neobladder was created using a modified Camey-II technique. Complications were reviewed and staged according to Clavien-Dindo classification and evaluated in long-term follow-up. Urodynamics were performed, and QoL was assessed by the Functional Assessment of Cancer Therapy for Bladder Cancer (FACT-BL) instrument.

RESULTS

The total follow-up time was 60 months, and the total survival rates at 3 and 5 years after surgery were 76.4% (55/72) and 65.3% (47/72), respectively. There were 34 (47.2%) early complications in 23 (31.9%) patients and 42 (58.3%) late complications in 35 (48.6%) patients. The total satisfactory control rates were 69.1% and 66.0% at 3 and 5 years after the surgery, respectively. Urodynamic studies were performed in some patients, and the receiver operating characteristic curve analysis showed that pressure at maximum capacity, compliance, and post void residual urine had predictive value for mortality (P < 0.05). The total FACT-BL scores of patients at 1, 3, and 5 years postoperation were 125.0 ± 15.2, 127.0 ± 16.2, and 120.6 ± 13.5, respectively, and it decreased at 5 years postoperation (P < 0.05).

CONCLUSION

Spiral ileal neobladder with orthotopic ureteral reimplantation offers satisfactory long-term results, and urodynamic monitoring might have prognostic value.

Comparison Between Ambulatory and Conventional Urodynamics of the Modified Orthotopic Hautmann Neobladder

PURPOSE

The aim of the present study was to determine the diagnostic accuracy of conventional and ambulatory urodynamic studies (UDS) in estimating neobladder function.

METHODS

We evaluated 32 patients who underwent radical cystectomy and orthotopic Hautmann W neobladder with Abol-Enein-Ghoneim uretero-intestinal anastomosis for bladder cancer. The patients were initially examined by using both conventional and ambulatory UDS.

RESULTS

Conventional UDS detected a very high mean intravesical pressure at maximum capacity (53.7±17.5 cm H2O). By contrast, the mean intravesical pressure detected by using ambulatory UDS (which reflects the dominant pattern of pressure variation during filling) was significantly lower (34.4±5.2 cm H2O, P<0.001). The comparison between intravesical pressure at half of maximum capacity in conventional UDS and the mean value in ambulatory UDS did not show significant difference (P=0.152). The mean voided volume in conventional UDS was greater than both the mean voided volume (P<0.001) and the mean maximum voided volume in ambulatory UDS (P=0.001). However, this difference did not affect the postvoid residual urine volume measured in both studies (P=0.207). Moreover, incontinence episodes recorded in ambulatory UDS were more frequent but not statistically significantly different from those recorded in conventional UDS (P=0.332).

CONCLUSIONS

The estimation of neobladder function by means of ambulatory UDS seems to provide interesting research data for the mode of lower urinary tract function in patients with orthotopic substitution after radical cystectomy. The great high value in ambulatory UDS, in cases in which conventional UDS had failed, is due to the exposure of daily and nocturnal incontinence episodes, confirming our patients' complaints.

Modified S-ileal neobladder for continent urinary diversion: functional and urodynamic results after 20 years of follow-up

OBJECTIVE

To report continence and urodynamic findings after radical cystectomy and urinary diversion with modified S-ileal neobladder between January 1993 and January 2013.

PATIENTS AND METHODS

181 patients were enrolled. Continence status, reservoir sensation, compliance, capacity and activity were assessed.

RESULTS

Daytime continence was reported by 88.0, 98.4 and 99.2%, while nighttime continence was reported by 70.2, 94.0 and 95.8% of our patients at 6 months, 5 years and 20 years, respectively. Enterocystometric capacity and maximum reservoir pressure were 366 vs. 405 ml and 502 ml, and 29 vs. 18 and 11 cm H2O, at 6 months, 5 years and 20 years, respectively. Median post-void residual urine volume was 32 ml at 6 months, 50 ml at 5 years and 120 ml at 20 years.

CONCLUSIONS

The modified S-ileal neobladder technique has a very good long-lasting functional outcome, with high day- and nighttime continence levels as well as high acceptability rates from our patients.