Changes in the upper urinary tract after radical cystectomy and urinary diversion: a comparison of antirefluxing and refluxing orthotopic bladder substitutes and the ileal conduit

Management of hydronephrosis after radical cystectomy and urinary diversion for bladder cancer: A single tertiary center experience

OBJECTIVES

To clarify the incidence of postoperative hydronephrosis and verify the validity of diagnostic and therapeutic approaches for hydronephrosis after cystectomy and urinary diversion for bladder cancer.

METHODS

Totally, 290 patients receiving urinary diversion from 2005 through 2017 with complete data were enrolled, including 258 (89.0%) with an ileal conduit and 32 (11.0%) with an ileal neobladder. Postoperative radiographic images were reviewed. In patients with postoperative hydronephrosis, antegrade pyelography and ureteroscopy were performed to exclude malignant etiology. Balloon dilation and open surgical revision were performed according to the conditions.

RESULTS

Forty-six patients (58 renal units) developed postoperative hydronephrosis. The cumulative incidence was 11.4% by a median follow-up of 59.5 months. Ureteral recurrence was detected by antegrade examinations in two patients, whereas malignant strictures were subsequently revealed in three patients. Thus, malignant etiology was found in hydronephrosis in five renal units (12.8%) of five patients (16.1%). The median times to diagnosis of hydronephrosis were 0 (interquartile range [IQR] 0-4) and 14 months (IQR 9-12) for benign and malignant strictures, respectively (p = 0.003). Of them, 31 patients (39 renal units) received interventions. Balloon dilation was performed in 13 renal units with benign strictures, and was successful in two (15.4%). Open surgical revision was performed in eight patients (11 renal units), including two with failed balloon dilation, all of which was successful.

CONCLUSIONS

Postoperative hydronephrosis is potentially associated with recurrent disease. Accurate differential diagnosis is challenging although antegrade procedures may be helpful in some cases. Open surgical revision is highly effective to treat benign strictures.

Evaluation of Upper Urinary Tract Integrity After Radical Cystectomy and Orthotopic Diversion with Ileal and Sigmoid Neobladder

The study aims to evaluate the effects of orthotopic urinary diversion using ileal and sigmoid segments after radical cystectomy on upper urinary tract function and morphology. A retrospective study included 60 patients divided into 2 equal groups (W-ileal pouch group and sigmoid pouch group). We assessed renal function and morphology post-operative after 6 months and after 1 year by serum creatinine, ultrasound, IVP, pouchogram, and renal scan study. After 6 months post-operatively, in the W-ileal group, there were 16 renal units (26.6%) deteriorated in morphology and 11 renal units (18.4%) deteriorated in function. After 1 year, further deterioration in morphology was noted in 17 renal units (28.3%) and in function in 16 renal units (26.7%). In the sigmoid group, after 6 months post-operatively, there were 14 renal units (23.3%) deteriorated in morphology and 14 renal units (23.4%) deteriorated in function. After 1 year, further deterioration in morphology was noted in 47 renal units (24.4%) and in function in 18 renal units (30%). Incorporating the bowel into the urinary tract is potentially dangerous to the upper urinary tract's integrity, and the leading cause of renal impairment is uretero-pouch obstruction.

External stent versus double J drainage in patients with radical cystectomy and orthotopic urinary diversion: A randomized controlled trial

OBJECTIVES

To compare treatment-related outcomes of ureteral stenting with an external versus double J stent in patients with orthotopic reservoirs after radical cystectomy.

METHODS

Patients undergoing radical cystectomy and orthotopic neobladder were randomized into two groups; group I patients received external stents, whereas group II received double J stents. In both groups, preoperative parameters were recorded, and patients were assessed regarding urinary tract infection, urinary leakage, upper tract deterioration, readmission and hospital stay.

RESULTS

A total of 48 and 45 patients were randomized in the external stent group and double J group, respectively. Both groups were comparable in terms of age, sex, associated comorbidity and oncological status. Early urinary leak was observed in two patients (4.2%) in the external stent group, and in two patients (4.4%) in the double J group (P = 0.95). None of our patients developed ureteral strictures in the external stent group, and one patient did in the double J group (P = 0.3). Positive urine culture (58.3%, 51.1%) as well as febrile urinary tract infections (2.1%, 6.7%) were comparable between both groups, respectively (P = 0.43, 0.28). Wound complications (12.5%, 8.9%) and stent-related complications (2.1%, 0%) were comparable between both groups, respectively (P = 0.57, 0.33). The mean hospital stay was 17.5 days (range 14-32 days) and 14.6 days (range 10-42 days) in both groups, respectively (P = 0.001), with comparable re-admission rates (P = 0.95).

CONCLUSIONS

Incorporation of double J stents in orthotopic urinary diversion is a safe alternative to the routinely used external stenting.

Renal function evaluation in patients undergoing orthotopic bladder substitution: a systematic review of literature

Renal function (RFn) after orthotopic bladder substitution (OBS) is a critical point to be assessed. We performed a systematic review of MEDLINE for full length peer reviewed English articles from the year 2000 till January 2013. We included only original articles and excluded reviews, editorials and replies and abstracts presented in conferences. The outcome is formulated in research questions; what is the status of RFn after OBS? Which is better, the direct free-refluxing or anti-refluxing ureteroileal anastomosis (UIA) techniques? Studies reporting RFn as secondary outcome were also reported. A total of 129 publications were reviewed for full text and only 41 were included in this review. All studies were of low level of evidence and grade of recommendations. Only 3 randomized controlled trials were included and were of poor quality. Renal function after OBS was poorly described in the literature with no universal definition about RFn deterioration or outcome with no consensus on the best evaluation method. Urinary obstruction, chemotherapy and pyelonephritis appeared significant factors but with insufficient evidence. There is a universal trend to use the free refluxing technique for UIA to avoid complications of anti-refluxing techniques. However, the anti-reflux technique proved acceptable outcome in experienced hands. There is marked heterogeneity and underestimation of RFn evaluation among reported outcomes after OBS with most publications reporting the incidence of UIA and pyelonephritis with paucity reporting absolute figures about RFn measurements. In conclusion, urinary tract obstruction remains the main factor of RFn deterioration after OBS. Methods evaluating RFn, definitions of RFn outcome and factors predicting it are poorly studied in the literature and the current evidence is relatively weak to draw solid conclusions. Further well-designed studies and consensus about method of assessment and definitions of RFn are warranted.

Radical cystectomy and orthotopic bladder substitution using ileum

Over the past decade, continent urinary diversion, especially orthotopic bladder substitutions, has become increasingly popular following radical cystectomy for bladder cancer. The ultimate goal of orthotopic bladder substitution is to offer patients the best quality of life, similar to that of patients with native bladders. To achieve that purpose, surgeons should be familiar with the characteristics of good candidates for neobladders, the possible intraoperative and postoperative problems related to the surgery, and the solutions to these problems. Postoperative surveillance and instructions given to the patients also contribute to successful, functional results. Here, we reviewed the indications, pitfalls, and solutions for orthotopic bladder substitutions and the patients' quality of life after surgery. When performed properly, orthotopic continent diversion offers good quality of life with few long-term complications. Therefore, we believe it is the best option for the majority of patients requiring cystectomy.

New Italian guidelines on bladder cancer, based on the World Health Organization 2004 classification

OBJECTIVE To provide evidence-based recommendations on bladder cancer management METHODS A multidisciplinary guideline panel composed of urologists, medical oncologists, radiotherapists, general practitioners, radiologists, epidemiologists and methodologists conducted a structured review of previous reports, searching the Medline database from 1 January 2004 to 31 December 2008. The milestone papers published before January 2004 were accepted for analysis. The level of evidence and the grade of the recommendations were established using the GRADE system. RESULTS In all, 15 806 references were identified, 1940 retrieved, 1712 eliminated (specifying the reason for their elimination) and 971 included in the analysis, as well as 241 milestone reports. A consensus conference held to discuss the discrepancies between the scientific evidence and the clinical practice was then attended by 122 delegates of various specialities. CONCLUSION Recommendations on bladder cancer management are provided.

Primary endoscopic management versus open revision of ureteroenteric anastomotic strictures after urinary diversion--single institution contemporary series

PURPOSE

To review our institutional experience in the management of ureteroenteric strictures by primary endoscopic intervention or primary open revision.

PATIENTS AND METHODS

Between January 2000 and December 2007, 28 patients with ureteroenteric strictures underwent endoscopic management (n = 21) or open revision (n = 7). Strictures were characterized with regard to length and side as well as time to failure between the two groups. Success was defined as symptomatic improvement and evidence of patency on follow-up radiologic imaging.

RESULTS

Of all study patients, 78.6% were symptomatic on presentation. Endoscopic intervention (balloon dilation, electroincision, or holmium endoureterotomy) was successful in six patients for an overall success rate of 27% with a median follow-up of 21 months. Open revision was successful in 87.5% (7 of 8) patients for whom initial endoscopic surgery had failed. The success rate of primary open revision was 71.4% (5 of 7 patients) with a mean follow-up of 18.1 months. For the entire series, left-sided strictures were more common than right sided strictures; however, side and stricture length were not found to be significant (P > 0.05) with regard to patency. Functional renal imaging studies were performed in 42.9% of all study patients postoperatively.

CONCLUSIONS

Endoscopic management continues to have success rates that remain lower than that of open revision. Left-sided strictures remain more common than right-sided strictures; however, side and stricture length were not found to be statistically significant in our series. The lack of consistent postoperative functional renal studies highlights the importance of diligent monitoring and warrants further study to develop a surveillance algorithm.

Upper urinary tract dilation due to conglutination of intraluminal distal ureters after orthotopic neobladder with split-cuff nipple ureteral reimplants: early results of 8 cases

OBJECTIVE

We reviewed our experience with dilation of the upper urinary tract caused by the conglutination of distal ureters after orthotopic neobladder reconstruction using the split-cuff nipple ureteral reimplant technique.

MATERIALS AND METHODS

From January 2000 to April 2007, 250 consecutive patients underwent radical cystectomy and orthotopic neobladder reconstruction. Ureterointestinal anastomosis was performed using the split-cuff nipple technique in 291 renoureteral units. The patients from a single center were followed up for a mean period of 8 months (range 1-22) after surgery. We incised the conglutination band using a transurethral endoscope. Patient characteristics, endoscopic technique, measurement of serum creatinine levels, and results of ultrasonography, cystoscopy, and excretory urography were collected.

RESULTS

Hydronephrosis was found in 8 patients (14 renoureteral units) due to the conglutination of the distal ureters to each other (n = 6) or to the neobladder wall (n = 2). After the incision procedure, seven patients had obvious improvement in renal function and hydronephrosis, and their symptoms disappeared. In 1 patient, hydronephrosis developed again because of ureteroenteric stenosis after 7 months and was resolved by open surgical revision. The hydronephrosis had improved greatly in this patient by 5 months after revision.

CONCLUSION

Conglutination of the distal ureters is a cause of hydronephrosis after orthotopic neobladder reconstruction using the reimplant technique with the split-cuff nipple. Cystoscopy is mandatory in following up patients who have hydronephrosis with the split-cuff nipple ureteral reimplant technique, not only to confirm the diagnosis but to treat the complication by incising the conglutination band. Continued follow-up is required to evaluate the long-term results of this treatment.

Does reflux in orthotopic diversion matter? A randomized prospective comparison of the Studer and T-pouch ileal neobladders

PURPOSE

Orthotopic neobladder reconstruction has become a standard form of urinary diversion in many centers for patients undergoing radical cystectomy for bladder cancer. There is still controversy about the best technique for construction of the neobladder, and especially whether it is necessary to include an antireflux mechanism.

METHODS

We designed a prospective randomized clinical trial comparing two forms of ileal neobladder: the Studer pouch and the T-pouch. The latter includes an extraserosal tunneled afferent limb which prevents reflux from the pouch to the kidneys. The primary endpoint of the study is renal function and anatomy at 3 years following surgery, with secondary endpoints including early and late postoperative complications, renal infections and need for secondary procedures.

RESULTS

To date we have randomized 462 patients over approximately 6 years, with a planned full enrollment of 550 patients. Ten percent of patients have been withdrawn because they did not undergo the planned orthotopic diversion due to a positive urethral margin on frozen section. We expect approximately 70% of patients to be alive and available for follow-up at 3 years, which will give us ample power to detect clinically meaningful differences in the outcome of these two diversions.

CONCLUSION

This trial has been feasible and randomization has been acceptable to most patients. Long-term follow-up of the patients on this trial should be able to definitively answer the question of the importance of an antireflux mechanism in the orthotopic neobladders construction.