Comparison of Orthotopic Sigmoid and Ileal Neobladders: Continence and Urodynamic Parameters

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.

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.

Management of tuberculous-contracted bladder with bilateral duplex collecting system: a case report with modified robotic urinary tract reconstructive surgery

Tuberculous bladder contracture with a bilateral duplicated collecting system is rare. According to anatomic variation, the surgical treatment strategy is highly individualized. We illustrate our robotic technique of urinary tract reconstruction. A 19-year-old girl with a history of pulmonary tuberculosis (TB) as a young child presented with a complaint of increasing frequency of micturition, nocturia, urgency, and urge incontinence starting at the age of 17. Clinical and imaging examinations demonstrated tuberculous contracted bladder with a bilateral duplex collecting system. The patient underwent a robot-assisted Institute of Urology Peking University (IUPU) orthotopic ileal neobladder reconstruction. This is a modified urinary tract reconstructive method, including resection of the end of the duplex ureters and diseased contracted bladder with preservation of the proximal urethra and bladder neck, ileal harvesting and IUPU strategy to reconstruct an ileal neobladder, uretero-ileal anastomosis and neobladder-bladder neck anastomosis. The patient remained symptom-free without recurrence of TB and had improved renal function during the one-year follow-up after surgery. Thus, our robot-assisted IUPU orthotopic ileal neobladder reconstruction method is an effective approach for this benign case. It can effectively increase bladder capacity, reduce intravesical pressure, and improve symptoms such as urination frequency and urgency.

Clinical efficacy of mebeverine for persistent nocturnal enuresis after orthotopic W-neobladder

OBJECTIVES

To investigate the efficacy of mebeverine for nocturnal incontinence in male patients with an ileal orthotopic bladder substitute (OBS).

PATIENTS AND METHODS

A randomised controlled trial was carried out for adult male patients who were nocturnal incontinent. Patients were allocated to receive mebeverine 200 mg or placebo once a day in the evening for 3 months. The primary outcome was to compare the continence status between groups, assessed by the urinary domain of the Bladder Cancer Index (BCI) and pad usage. The secondary outcomes were to assess the safety of mebeverine.

RESULTS

There were 55 patients in the placebo group and 58 in mebeverine group who completed the follow-up. The median (interquartile range) interval between OBS surgery and starting treatment was 9 (4-13) years in the placebo group and 9 (6-13) years in the mebeverine group. The mean (SD) 3-month urinary domain score of the BCI was 70.8 (5.6) and 86.4 (14.2) in the placebo and mebeverine groups, respectively (P < 0.001). At 3 months, 54 (98.2%) and 26 (44.8%) patients required the use of a night-time pad in the placebo and mebeverine groups, respectively. Mebeverine reduced the risk of pad use by 53.4% (95% confidence interval 40.1-66.6; P < 0.001). Constipation occurred in one (2.1%) and three (5.8%) patients in the placebo and mebeverine groups, respectively; abdominal distention occurred in two (3.8%) of the patients in the mebeverine group (P = 0.25).

CONCLUSION

Mebeverine decreases night-time pad use and improves the quality of life in male patients with an ileal OBS and is associated with minimal adverse events.

Clam augmentation enterocystoplasty as management of urge urinary incontinence and reduced bladder capacity

Objectives: Third line treatment of urge urinary incontinence (UUI) and/or reduced bladder capacity is bladder augmentation. The aim of this study was to investigate whether clam enterocystoplasty (CECP) was an efficient treatment for patients who were refractory to conservative treatments of UUI and small functional bladder capacity and secondly if there was a difference in outcome in patients with neurogenic and non-neurogenic bladders.Methods: We evaluated 118 patients retrospectively treated in the period 2006-2018 at a single university hospital. Data were collected retrospectively. Patient groups were compared with Wilcoxon signed-rank test and Fisher's exact test.Results: Overall, 76% became continent with 92% using clean intermittent self-catherization (CISC) of patients with neurogenic bladder, 82% became continent and 100% were using CISC, whereas of patients with non-neurogenic bladder 64% became continence and 77% were using CISC. The median overall improvement of capacity was 296.5 mL (IQR: 142-440), 310 mL (186-467) in the neurogenic group and 214 mL (IQR: 126.8-361.5) in non-neurogenic (p = 0.01).Conclusion: CECP is an efficient treatment in UUI and reduced bladder capacity. Difference in outcome was seen with neurogenic patients having a bigger functional capacity and a higher rate of continence compared to the non-neurogenic.

Current Indications and Techniques for the Use of Bowel Segments in Pediatric Urinary Tract Reconstruction

Today, there are few indications for the use of bowel in pediatric urology. This is in large extent due to the successful conservative therapy in patients with neurogenic bladder and the improved success of primary reconstruction in patients with the bladder exstrophy-epispadias complex. Only after the failure of the maximum of conservative therapy or after failure of primary reconstruction, bladder augmentation, or urinary diversion should be considered. Malignant tumors of the lower urinary tract (e.g., rhabdomyosarcomas of the bladder/prostate) are other rare indications for urinary diversion. Replacement or reconstruction of the ureter with a bowel segment is also a quite rarely performed procedure. In this review, the advantages and disadvantages of the different options for the use of bowel segments for bladder augmentation, bladder substitution, urinary diversion, or ureter replacement during childhood and adolescence are discussed.

Laparoscopic Radical Cystectomy With Extracorporeal Neobladder: Our Initial Experience

OBJECTIVE

To illustrate our technique to construct the Institute of Urology Peking University (IUPU) orthotopic ileal bladder and present our initial experience.

METHODS

From August 2017 to April 2018, 12 patients with bladder cancer underwent radical cystectomy (RC), pelvic lymph node dissection and extracorporeal construction of an IUPU neobladder (IUPUB) by an experienced surgeon. We present the demographic, clinicopathologic, perioperative, and follow-up data. We also describe our step-by-step surgical technique for the IUPUB in this article.

RESULTS

Laparoscopic RC with an extracorporeal IUPUB was successfully accomplished in 11 patients, and 1 patient was converted to open RC with an IUPUB. The median total operative time and median time spent suturing the pouch were 248 minutes and 23 minutes, respectively. The median estimated blood loss was 150 mL. The median time to recovery of bowel function (tolerance of a liquid diet) was 3½ days. The urinary catheter was removed on post-operative day 21 in 10 patients. The ureteral stents and stoma catheter were removed on day 7 after cystography. At a median followup of 7½ months, 2 patients had early complications (<30 days), and no major complications (grade ≥ 3) occurred. The follow-up outcomes were satisfactory. The limitations included the small sample size and short-term outcomes.

CONCLUSION

Our technique of constructing the IUPUB is feasible and safe. The operative time and early complication rates are acceptable.

A Simple Neobladder Using a Porcine Model: The Double Limb U-Pouch

OBJECTIVE

To create a simple neobladder and determine whether the double-limb U-Pouch (D-LUP) has the same capacity and compliance as a Studer or Camey I neobladder. To develop an orthotopic diversion that can be applied to robotic surgery with laboratory data supporting the concept.

MATERIALS AND METHODS

Kidneys, ureters, bladders, and small intestine were obtained from pigs at the time of scheduled autopsy after completion of institutionally approved investigational trauma protocols. A Camey I neobladder, spherical neobladder, and D-LUP, were constructed from 40-cm segments of small intestine. They were compared for capacity, compliance, and pouch-to-urethra anastomotic distance.

RESULTS

The cystometric capacity at 30 cm H2O for the Camey I, Studer, and D-LUP neobladders were 250 mL, 350 mL, and 430 mL, respectively. The pouch-to-urethra anastomotic distance was 0 cm for the Camey I, 10 cm for the spherical reservoir, and 0 cm for the D-LUP. Compliance was 10 mL/cm H20 for the Camey 1, 15 mL/cm H2O for the sphere, and 16 mL/cm H20 for the D-LUP.

CONCLUSION

The D-LUP neobladder was simple to construct, had a more dependent ileo-urethrostomy site, larger capacity, and similar compliance when compared with a spherical neobladder.

Perioperative morbidity, bowel function and oncologic outcome after radical cystectomy and ileal orthotopic neobladder reconstruction: Studer-pouch versus I-pouch

OBJECTIVE

To investigate whether the length of ileum used for ileal orthotopic neobladder (ONB) reconstruction (60 cm vs. 40 cm) after radical cystectomy (RC) for bladder cancer (BC) impacts on bowel function, postoperative complications or survival outcome.

MATERIAL AND METHODS

In this retrospective study, we included 56 patients who received an ONB (Studer (S)-Pouch: 23 patients; I-Pouch: 33 patients) after RC for BC between 2003 and 2011. Preoperative comorbidities were assessed by the Charlson Comorbidity Index (CCI) and surgical complications as graded by the Clavien-Dindo classification. Changes of perioperative bowel habits were retrospectively evaluated by the validated Gastrointestinal Quality of Life Index (GIQLI). Kaplan-Meier analyses calculated survival outcomes between both ONB types.

RESULTS

Preoperative CCI was comparable between S- and I-pouch patients. No significant differences were observed for 30-day major- (p = 0.33) and minor (p = 0.96) complication rates between both neobladder types. S-Pouch patients reported higher preoperative stool frequencies (S-pouch: mean 2.7; I-pouch: mean 3.4; p = 0.049) and tended to suffer from urgency (S: mean 2.9; I: mean 3.4; p = 0.059). No significant differences in postoperative bowel disorders were found between both neobladder types (S-Pouch: 15.9, IQR; I-Pouch: 16.6 IQR; p = 0.84). Furthermore, we observed no overall-, cancer specific- or recurrence free survival advantage for either of both ONB variants (p = 0.81; 0.65 and 0.78), respectively.

CONCLUSION

Comorbidities, perioperative complication rates and bowel habits were similar between both ONB substitutes and did not influence survival outcomes. These stratified data suggest that the length of ileum used for ONB reconstruction (60- vs. 40 cm) does not impact per se on postoperative bowel function.

Cluster analysis identifies three urodynamic patterns in patients with orthotopic neobladder reconstruction

PURPOSE

To classify patients with orthotopic neobladder based on urodynamic parameters using cluster analysis and to characterize the voiding function of each group.

MATERIALS AND METHODS

From January 2012 to November 2015, 142 patients with bladder cancer underwent radical cystectomy and Studer neobladder reconstruction at our institute. Of the 142 patients, 103 with complete urodynamic data and information on urinary functional outcomes were included in this study. K-means clustering was performed with urodynamic parameters which included maximal cystometric capacity, residual volume, maximal flow rate, compliance, and detrusor pressure at maximum flow rate. Three groups emerged by cluster analysis. Urodynamic parameters and urinary function outcomes were compared between three groups.

RESULTS

Group 1 (n = 44) had ideal urodynamic parameters with a mean maximal bladder capacity of 513.3 ml and mean residual urine volume of 33.1 ml. Group 2 (n = 42) was characterized by small bladder capacity with low compliance. Patients in group 2 had higher rates of daytime incontinence and nighttime incontinence than patients in group 1. Group 3 (n = 17) was characterized by large residual urine volume with high compliance. When we examined gender differences in urodynamics and functional outcomes, residual urine volume and the rate of daytime incontinence were only marginally significant. However, females were significantly more likely to belong to group 2 or 3 (P = 0.003). In multivariate analysis to identify factors associated with group 1 which has the most ideal urodynamic pattern, age (OR 0.95, P = 0.017) and male gender (OR 7.57, P = 0.003) were identified as significant factors.

CONCLUSIONS

While patients with ileal neobladder present with various voiding symptoms, three urodynamic patterns were identified by cluster analysis. Approximately half of patients had ideal urodynamic parameters. The other two groups were characterized by large residual urine and small capacity bladder with low compliance. Young age and male gender appear to have a favorable impact on urodynamic and voiding outcomes in patients undergoing orthotopic neobladder reconstruction.

Ileal versus sigmoid neobladder as bladder substitute after radical cystectomy for bladder cancer: A meta-analysis

PURPOSE

To evaluate and compare the functional outcomes of ileal and sigmoid neobladders in patients underwent radical cystectomy.

METHODS

Relevant studies were identified by searching PubMed, Embase, and Cochrane Library. The studies comparing the functional outcomes of sigmoid neobladder (SN) and ileal neobladder (IN) in patients underwent radical cystectomy were included.

RESULTS

A total of 12 cohort studies were included in this meta-analysis. From our analysis, more early complications were observed in SN group than in IN group (RR = 1.37, 95% CI: 1.03-1.81). Both daytime and nighttime continence rates were significantly better in IN group than in SN group (RR = 0.87, 95%CI: 0.81-0.94) (RR = 0.73, 95%CI: 0.60-0.90). More patients could spontaneous voiding in SN group than in IN group (RR = 1.12, 95%CI: 1.00-1.26). According to the urodynamic study, ileal neobladder exhibited bigger capacity (WMD = -84.93, 95%CI: -160.36 to -9.50), lower pressure at capacity (WMD = 11.18, 95%CI: 4.29-18.06), better compliance (WMD = -25.55, 95%CI: -32.45 to -18.64), and greater post-void residual volume(WMD = -23.48, 95%CI: -36.75 to -10.21); There was no significant difference in the max voiding flow rate or void volume between the two groups (WMD = -1.00, 95%CI: -3.73-1.73) (WMD = -27.00, 95%CI: 70.05-16.06). No significant difference was found in the serum creatinine between the two groups (WMD = -0.05, 95%CI: -0.12-0.03).

CONCLUSIONS

Ileal neobladder seems able to provide more favorable patient's satisfaction, while sigmoid neobladder may provide a better chance of spontaneous voiding. This meta-analysis may provide some useful evidences for urological surgeons to choose the ideal bladder substitute for patients underwent radical cystectomy.

Robot-assisted intracorporeal pyramid neobladder

OBJECTIVE

To describe a robot-assisted intracorporeal pyramid neobladder reconstruction technique and report operative and perioperative metrics, postoperative upper tract imaging, neobladder functional outcomes, and oncological outcomes.

PATIENTS AND METHODS

In all, 20 patients (19 male and one female) with a mean (sd; range) age of 57.2 (12.4; 31.0-78.2) years underwent robot-assisted radical cystectomy (RARC). Most cases were ≤pT1 (17 patients) and the remaining three patients had muscle-invasive bladder cancer (MIBC) at RARC histopathology. Although half of the patients (10) actually had MIBC at transurethral resection histopathology. All patients underwent RARC, bilateral pelvic lymphadenectomy, and intracorporeal neobladder formation using a pyramid detubularised folding pouch configuration.

RESULTS

The median estimated blood loss was 250 mL and operating time was 5.5 h. The mean (sd) number of lymph nodes removed was 16.5 (7.8) and median hospital stay was 10 days. Early postoperative complications included urinary tract infection (UTI) (four patients), ileus (four), diarrhoea and vomiting (three), postoperative collection (two), and blocked stent (one). Late postoperative complications included UTI (seven patients), neobladder stone (two), voiding Hem-o-Loc (two), neobladder leak (two), diarrhoea and vomiting (one), uretero-ileal stricture (one), vitamin B12 deficiency (one), and port-site hernia (one). There was no evidence of hydronephrosis in 18 patients with a median follow-up of 21.5 months. At 24 months, recurrence-free survival was 86% and overall survival was 100%. In all, 19 patients and 13 patients reported 6-month day time and night time continence, respectively.

CONCLUSIONS

The pyramid neobladder is technically feasible using a robotic platform and provides satisfactory functional outcomes at median of 21.5 months.

Morphological and functional analysis of a cohort of patients undergoing orthotopic ileal neobladder

INTRODUCTION

This study was conducted between January 2001 and December 2013 to evaluate patient's outcomes after radical cystectomy and orthotopic ileal neobladder from a morphological and functional point of view at a median follow-up of 2 years.

MATERIALS AND METHODS

A total of 48 eligible patents were included. We first report our technical modifications to Studer's neobladder. Sequently, after a medium follow-up of two years, we assessed morphology of the reservoir and voiding functionality of this patients cohort, submitting them to specific questionnaires and to uroflowmetry.

RESULTS

Early and late postoperative data are available for 36 patients. From the morphological follow-up, 2 years after surgery, six patients had hydroureteronephrosis for vescico-ureteral reflux in four cases (11% of total) and uretero-neobladder anastomosis stenosis in the other two (5.6% of total). Neobladder shape always remained spherical, with a relative right lateralization in eight cases (22.2%). Regarding the nine patients subjected to uroflowmetry, seven (77.7%) highlighted the lack of postvoid residual urine, with a maximum urinary flow rate within the normal range in six of them.

DISCUSSION

Improvements in surgical technique may help to reduce complications rate. From uroflowmetry analysis, we can observe that the mean filling pressure following surgery was relatively stable and urinary flow rate was mostly satisfactory. In patients without postvoid residual urine, all referred absence of daily incontinence and good quality of life.

CONCLUSION

From this morpho-functional evaluation, our orthotopic Studer-modified ileal neobladder seems an ideal solution for urinary diversion, presenting functional features similar to native bladder and assuming a well-defined morphology, not changing in time.

Sacrocolpopexy with polypropylene tape as valuable surgical modification during cystectomy with orthotopic ileal bladder: functional results

Introduction. Urinary diversion is very often associated with urinary retention and urinary incontinence. In this study, a surgical modification during cystectomy with orthotopic ileal neobladder is presented. Material and Methods. Female patients enrolled in the study (n-24) were subjected to sacrocolpopexy during the operation. Apart from oncological control, the follow-up consisted of 1-hour inlay test and questionnaires (UDI-6 and IIQ-7) in the 3rd, 6th, and 12th month after the operation. In the 12th month after the surgery, the urodynamic pressure-flow test was performed. Outcomes were compared with the control group (n-18) in which sacrocolpopexy was not implemented. Results. The study group was characterised by reduced urinary retention and improved continence. Conclusion. Sacrocolpopexy during cystectomy with orthotopic ileal bladder is a valuable surgical method which provides patients with a better quality of life.

Total bladder and posterior urethral reconstruction: salvage technique for defunctionalized bladder with recalcitrant posterior urethral stenosis

PURPOSE

Recalcitrant posterior urethral stenosis is a challenging disease. When combined with a defunctionalized bladder, cutaneous urinary diversion is the most common surgical option. We present a novel technique of total lower urinary tract reconstruction, combining salvage cystectomy, ileal neobladder formation and urethral pull-through, as an orthotopic alternative in patients with a defunctionalized bladder and recalcitrant posterior urethral stenosis.

MATERIALS AND METHODS

We completed a retrospective review of 8 patients who underwent salvage cystectomy, orthotopic ileal neobladder formation and urethral pull-through. Artificial urinary sphincter placement was performed in a staged fashion. Six patients received prostate cancer treatment including radiation therapy, 1 had urethral disruption after robotic radical prostatectomy, and 1 experienced bladder rupture and urethral distraction injury during a motorcycle accident. Patient demographics, operative variables and postoperative outcomes were examined.

RESULTS

No high grade complications were observed after salvage cystectomy, orthotopic neobladder formation and urethral pull-through. After staged artificial urinary sphincter placement, a median of 2 revision surgeries (range 0 to 4) was required to establish social continence. All patients maintained functional urinary storage, urethral patency and social continence at a median followup of 58 months. No patient had complications related to orthotopic neobladder formation, including ureteroileal anastomotic stricture or pyelonephritis, and no patient required cutaneous diversion.

CONCLUSIONS

Total lower urinary tract reconstruction with cystectomy, ileal neobladder formation and urethral pull-through offers an orthotopic alternative for patients with recalcitrant posterior urethral stenosis and defunctionalized bladders. Although it requires staged placement of an artificial urinary sphincter, this approach can offer functional urinary storage, durable urethral patency and avoidance of cutaneous urinary diversion.

Urodynamic and continence assessment of orthotropic neobladder reconstruction following radical cystectomy in bladder cancer; a prospective, blinded North Indian tertiary care experience

Aim:

The aim of this study is to compare urodynamic and continence parameters among patients undergoing orthotropic neo-bladder substitution with sigmoid or ileal segments. Variations in the Urodynamic parameter between the continent and incontinent patients were also evaluated.

Patients and Methods:

From January 2008 to March 2012, 44 patients underwent ileal neobladder (IN) reconstruction and 36 patients underwent sigmoid neobladder (SN) reconstruction. Evaluation of Urodynamic and Continence parameters was performed at 12 months after surgery.

Results:

The average capacity of IN and SN was 510 ml and 532 ml respectively. The voiding pressure, mean peak flow rates and post void residual urine (PVRU) for IN and SN were 27.5 cm H₂O versus 37 cm H₂O, 15ml/s versus 17ml/s and 36 ml versus 25 ml respectively. Daytime continence for IN and SN was 93% (41/44) and 89% (32/36), and night-time continence was 91% (40/44) and 78% (28/36) respectively. The compliance, maximum cystometric capacity and PVRU in the daytime continent (versus incontinent) were 61 (versus 41), 471 (versus 651) and 22 (versus 124) and in the night-time continent (versus incontinent) were 57 (versus 43), 437 (versus 654) and 18 (versus 105) respectively.

Conclusion:

A neobladder constructed from detubularized ileum or sigmoid achieves urodynamically proven adequate capacity and compliance with 89-93% daytime and 78-91% night time continence. Continent men when compared with incontinent (both daytime and night time) were more likely to have comparatively higher compliance, lower maximum cystometric capacity and lower PVRU. Urodynamic study could predict which incontinent men would improve with pelvic floor exercises and clean intermittent catheterization (CIC).

Long-term follow-up of sigmoid bladder augmentation for low-compliance neurogenic bladder

OBJECTIVE

To assess the clinical and urodynamic outcomes of patients with low-compliance neurogenic bladder who were treated with sigmoid bladder augmentation (SBA) over a long-term follow-up.

MATERIALS AND METHODS

We retrospectively reviewed 52 patients with low-compliance neurogenic bladder who underwent SBA alone or with antireflux techniques in our hospital from 2006 to 2014. Clinical outcomes regarding bladder function, incontinence, medications, catheterization schedules, subsequent interventions, bowel function, and patient satisfaction were addressed.

RESULTS

The mean follow-up was 49 months. All patients experienced significant increases in safe cystometric capacity from 113.8 ± 65.9 mL to 373.1 ± 66.7 mL (P <.001), bladder compliance from 2.96 ± 1.55 mL/cm H2O to 14.07 ± 5.45 mL/cm H2O (P <.001), and decreases in creatinine from 88.1 ± 38.6 μmol/L to 77.1 ± 30.4 μmol/L (P <.001) compared with those before surgery. Six patients (11.5%) required anticholinergic medicine to control neurogenic detrusor overactivity, and 11 (21.1%) had recurrent febrile urinary tract infections after SBA. Among 47 prehydronephrosis patients (grade I-II in 10 and III-V in 37), 16 still had minor hydronephrosis after SBA, but the hydronephrosis had been improved significantly (all posthydronephroses were grade I-II instead). All patients reported significant improvements in constipation, and no patient had obvious metabolic acidosis or bladder perforation after SBA. All patients expressed extreme satisfaction with the operation.

CONCLUSION

SBA provided durable clinical and urodynamic improvement for patients with low-compliance neurogenic bladder and constipation. SBA alone, without ureteral reimplantation, seemed sufficient for neurogenic bladder. Furthermore, there was a high level of patient satisfaction with SBA.

Long-term urodynamic evaluation of laparoscopic radical cystectomy with orthotopic ileal neobladder for bladder cancer

The long-term urodynamics of laparoscopic radical cystectomy with orthotopic ileal neobladder for bladder cancer remain unclear in the clinical setting. The present prospective observational study was conducted between January 2010 and December 2012 to evaluate the 6-month and 12-month follow-up data of urodynamic changes of bladder cancer patients who were initially treated by laparoscopic radical cystectomy with orthotopic ileal neobladder. A total of 53 eligible patients were included, and all patients were followed up for at least 12 months, with a median time of 18 months. During the follow-up period, no patients reported difficulty urinating, and the daily frequency of urination and the urine output were gradually improved with time. Dynamic urodynamic examinations showed that the maximum flow rate (11.4±1.1 vs. 7.3±1.4 ml/sec; P<0.001), residual urine content (22.8±10.5 vs. 40.7±12.7 ml; P<0.001), maximum bladder capacity (373.8±62.2 vs. 229.7±56.3 ml; P<0.001) and maximum bladder pressure during filling (35.8±6.7 vs. 26.4±7.0 cm H₂O; P<0.001) at 12 months were all improved significantly compared with that at 6 months after the initial surgical treatment. However, there were no significant differences in maximum bladder pressure during voiding (75.7±24.7 vs. 73.1±24.7 cm H₂O; P=0.618) and bladder compliance (26.9±13 vs. 27.4±13.1 cm H₂O; P=0.848) at 12 and 6 months after initial surgical treatment. In conclusion, the urodynamics of this orthotopic ileal neobladder gradually improve, and its long-term urine storage and voiding functions are acceptable.

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.

Short-Term Functional and Urodynamic Outcome of W-ileal Orthotopic Neobladder with Serosa-Lined Tunneled Uretero-Ileal Anastomosis

OBJECTIVES

Functional and urodynamic (UDS) outcomes of W-configured ileal orthotopic neobladder (ONB) with extramural serosa-lined tunnel uretero-ileal anastomosis are presented

METHODS

Consecutive 17 patients undergoing ONB during December 2009 to March 2011 were enrolled. Of these 15 men (bladder cancer 14, tuberculosis 1) with mean age 52.7 ± 11.3 years completed the follow-up. Pouch-related quality of life (PQOL) was assessed using a published questionnaire. Uroflowmetry, cystometry/cystography and urethral-pressure profilometry were done at two follow-up visits at least 3 months apart. Mean follow up 10 ± 5 months. Mean length of harvested ileum 48 ± 6 cm.

RESULTS

Overall PQOL were similar at both evaluations (55 ± 11 and 54 ± 15, respectively). During first and second follow-up, maximum flow-rate, voided-volume and post-void residual urine were 11 ± 4 mL/sec, 246 ± 99 mL and 68 ± 74.9 mL and 10.4 ± 4.6 mL/sec, 234 ± 138 mL and 86 ± 146 mL, respectively. Mean neobladder capacity, compliance, maximum urethral closure-pressure (MUCP) and functional urethral length were 484 ± 244 mL, 50.5 ± 49.1 mL/cmH2 O, 42 ±20 cmH2 O and 22 ± 12 mm, and 468 ± 250 mL, 46.4 ± 47.5 mL/cmH2 O, 52 ± 27cmH2 O and 23 ± 12 mm, respectively. Patients with smaller pouch (r = 0.828; P = 0.0001), longer urethral length (r = -0.392; P = 0.023) and lesser incontinence (r = 0.429; P = 0.011) had significantly better PQOL. With continued supervised pelvic-floor rehabilitation, a trend in improvement in hesitancy (P = 0.058), MUCP (P = 0.05) and bothersome incontinence (P = NS) was observed. None of the patients had any obstruction or reflux of the upper tracts.

CONCLUSION

The index ONB has reasonable storage and voiding characteristics but with a rider of nocturnal urinary incontinence.

Preliminary short-term outcomes of a modified double-T ileal continent cutaneous urinary diversion using Yang-Monti tube implantation through serosa-lined extramural tunnel: the PGIMER pouch

OBJECTIVE

To present our simplified technical modification of double-T continent cutaneous diversion (CCD) using Yang-Monti tubes.

METHODS

During 2008-2011, 8 adult patients underwent CCD; 4 had classical exstrophy, 2 bladder cancer, 1 recurrent vaginal cancer post-radiotherapy, and 1 prostate cancer with post-simple retropubic prostatectomy urethral stricture with incontinence. For reconstruction, a 45- to 50-cm segment of terminal ileum sparing 25 cm of terminal ileum was harvested. Its distal 3- to 6-cm and proximal 3-cm segments were separated on vascular pedicle and fashioned into Yang-Monti tubes (1 proximally and 1 or 2 distally). The middle 40- to 45-cm detubularized segment was fashioned into a "W" shape, and serosal aspects of adjacent loops were sutured together close to the mesentery. The tubes were implanted into the W pouch via extramural serosa-lined tunnel (Abol-Enein and Ghoneim). The pouch was closed transversely over an 18-Fr pouchostomy and 16-Fr stomal catheter. The ureters were implanted into the proximal tube using the Wallace principle, over 6- to 8-Fr infant feeding tubes exteriorized through the pouch. The distal end of the distal tube was made into a flush stoma.

RESULTS

In the early postoperative period, intestinal obstruction (2 cases), ureteroileal anastomotic leakage (3 cases) and vesico-ileocutaneous fistula (1 case) were encountered. No ureteroileal anastomotic obstruction or catherization-related difficulty was observed until the last follow-up (2 months to 3 years). Of 15 anastomoses, 14 were nonrefluxing.

CONCLUSION

Ileal double-T CCD using the Yang-Monti principle is technically feasible and relatively simple, particularly in nonirradiated ileum. However, early complications indicate a learning curve, and long-term follow-up and larger data are needed.

Orthotopic sigmoid vs. ileal neobladders in Japanese patients: a comparative assessment of complications, functional outcomes, and quality of life

OBJECTIVES

To compare the clinical outcomes of sigmoid and ileal neobladders (NBs) created following radical cystectomy.

MATERIALS AND METHODS

This study included 90 and 144 Japanese patients undergoing radical cystectomy and orthotopic NB reconstruction with a sigmoid and ileal segment, respectively. Postoperative clinical outcomes between the sigmoid and ileal NB groups (SNBG and INBG) were compared.

RESULTS

In this series, 110 early and 51 late complications occurred in 71 and 41 patients, respectively; however, there was no significant difference in the incidence of complications between SNBG and INBG. At 1 year postoperatively, there were no significant differences in the proportion of spontaneous voiders and the continence status between these 2 groups; however, despite the lack of significant differences in the maximal flow rate and voided volume, the post-void residual in SNBG was significantly smaller than that in INBG. Voiding functional outcomes at 5 years postoperatively were also obtained from 28 and 49 in SNBG and INBG, respectively. Although there were no significant changes in the functional outcomes in SNBG, the proportion of spontaneous voiders and post-void residual in INBG at 5 years postoperatively were significantly poorer than those at 1 year postoperatively. Furthermore, the postoperative health-related quality of life assessed by a Short-Form 36 survey did not show any significant differences in all 8 scores between these 2 groups.

CONCLUSIONS

Both types of NB reconstruction resulted in comparatively satisfactory outcomes; however, the voiding function, particularly that on long-term follow-up, in SNBG appeared to be more favorable than that in INBG.

Real-time MRI of continent and stress incontinent male patients after orthotopic ileal neobladder

INTRODUCTION

The aim of this study was to correlate anatomic differences with continence status in male patients after cystoprostatectomy and ileal neobladder using real-time magnetic resonance imaging.

PATIENTS AND METHODS

Anatomic differences of 14 male patients (7 daytime continent and 7 stress incontinent) with ileal neobladder were determined by measuring the orthogonal distance of the bladder neck to the pubococcygeal line (PCL) to correlate anatomic differences with continence status.

RESULTS

The median distance of the bladder neck to PCL was +5.4 mm in continent patients before voiding whereas in incontinent patients it was +2 mm (p = 0.012). During the Valsalva maneuver, the median distance in continent patients was +4 and in incontinent patients -3 mm (p = 0.003). At the end of micturition, the median distance was +2.3 mm in continent patients and -12 mm in incontinent patients (p = 0.002).

CONCLUSIONS

The bladder neck in incontinent patients showed more pronounced mobility in relation to the PCL during micturition and the Valsalva maneuver as compared to continent patients. In addition, the ileal neobladder was positioned significantly lower in the pelvis of incontinent patients. These preliminary results suggest that a stable bladder neck may be an important factor to reach full continence in patients with ileal neobladder.

Ultrastructural changes in colorectal mucosa after chronic contact with urine

Ultrastructural changes in the colorectal mucosa in response to chronic contact with the urine were demonstrated in outbred albino rat experiments. Oral correction with slightly alkaline sodium hydrocarbonate solution reduced the destructive effect of the urine on rat colorectal mucosa.

Voiding symptoms and urodynamic findings in patients with modified ileal neobladde

The aim of our study was to find the cause of urinary incontinence and voiding dysfunction in patients undergoing radical cystectomy and orthotopic bladder replacement with modified ileal neobladder (Reddy). Twenty-eight incontinent patients (operated on between 1988 and 2004) were involved in our examination. Based on the complaints of the patients, continence status was evaluated and divided into two groups: group I: partially incontinent (only night-time incontinence) n = 11 (39.3%) and group II: totally incontinent (night-time and daytime incontinence) n = 17 (60.7%). Detailed urodynamic examination (enterocystometry and urethral pressure profile) in addition to involuntary neobladder contractions and capacity detection were carried out on all patients. Furthermore resting pressure and maximal voluntary contraction ability of the sphincter were determined and statistically analyzed in both groups. Significant difference was noticed in resting pressure and maximal voluntary contraction ability of the sphincter among the partially incontinent and totally incontinent patients. Frequency, intensity and duration of involuntary neobladder contractions also showed significant differences between the two groups. Incontinence of neobladder depends not only on the destruction of resting and contraction capability of the urethral sphincter, but also on the presence or absence of involuntary contractions in the wall of the neobladder and decreased capacity of the neobladder.

Insight into long-term histological, proliferative and apoptotic modifications in ileal orthotopic neobladder and conduit mucosa

Aims and background

To assess the long-term histological, apoptotic and proliferating alterations of the intestinal mucosa of ileal conduits and orthotopic neobladders.

Methods

Fifty patients (46 males, 4 females), aged 52–78 years, who underwent urinary diversion with either ileal orthotopic neobladder (group ON, 20 patients) or conduit (group IC, 30 patients) from 2001 to 2005, were included in this prospective study Ileal samples were collected during surgery (controls) and by random mucosal biopsies 6, 12, 24, 36 and 48 months later. Histological (villi height, crypt depth, eosinophil cell count), proliferation (Ki67 immunochemistry), and apoptotic (Bcl-2 immunochemistry TUNEL) parameters were assessed.

Results

During the 4-year follow-up, we recorded progressive villi area, height and crypt depth reduction, mucosa flattening, and inflammatory and eosinophilic infiltration. Villi height: crypt depth ratio showed a statistically significant difference ( P <0.05) between the two groups from the 6th month. Dysplasia, metaplasia, and neoplasia were not observed. Bcl-2 values showed a progressive increase until 24 months in group ON and 12 months in group IC, followed by a decline thereafter. Ki-67 values showed a progressive increase after 6 months in group ON and an increase until 24 months followed by a decline thereafter in group IC. TUNEL showed two peaks, at 24 and 48 months.

Conclusions

Histological adaptation was revealed in both groups, with statistically significant differences in favor of orthotopic substitution. Proliferative and apoptotic pathways are implicated as demonstrated by relevant modifications of Bcl-2, Ki-67 and TUNEL, in accord with the histological adaptation.

Long-term functional outcomes in patients with various types of orthotopic intestinal neobladder

OBJECTIVES

To evaluate the long-term functional outcomes of various types of orthotopic neobladder (NB).

METHODS

Eighty-nine patients who underwent orthotopic NB reconstruction after radical cystectomy and were followed for at least 60 months after surgery were included in this retrospective study. The types of NB in this series were: modified Studer type, Hautmann type, Mainz type, Goldwasser type and modified Reddy type in 36, 9, 15, 10 and 19 patients, respectively.

RESULTS

Sixty-seven (75.3%) patients could void spontaneously, 15 (16.8%) voided with clean intermittent catheterization (CIC) assistance and seven (7.9%) with CIC alone. After excluding the seven voiding with CIC alone, daytime and night-time continence was achieved in 63 and 50 of the remaining 82 patients, respectively. In addition, the proportion of daytime continence in the modified Studer group was significantly greater than that in the Mainz group, whereas there was no significant difference in the proportion of night-time continence among these groups. Uroflow examination indicated that despite the lack of significant differences in the maximal flow rates and the voided volumes, the post-void residual in the modified Reddy group was significantly smaller than that in the modified Studer group. Blood gas analysis in the 82 patients showed that there were no significant differences in the pH, bicarbonate, chloride and base excess among these groups.

CONCLUSIONS

Orthotopic NB created with intestinal segments generally has acceptable functional outcomes on long term follow up. These outcomes differ according to the type of NB. To define the optimal procedure for NB reconstruction, it is necessary to understand the long-term functional prospects, on which the subjective success of NB creation is based.