TECHNIQUE OF HAUTMANN ILEAL NEOBLADDER WITH CHIMNEY MODIFICATION: INTERIM RESULTS IN 50 PATIENTS

Neobladder "Function": Tips and Tricks for Surgery and Postoperative Management

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure increasingly used in patients with muscle-invasive bladder cancer following radical cystectomy (RC). It represents a valid alternative to the ileal duct in suitable patients who do not prefer a stoma and are motivated to undergo adequate training of the neobladder. Careful patient selection, taking into account the absolute and relative contraindications for ONB as well as an adequate recovery protocol after surgery are integral to the success of this procedure and the oncological and functional outcomes. The objective of this review is to summarize the current data on RC with ONB in terms of patient selection, preoperative preparation, surgical techniques and functional (continence and sexual activity) and oncological outcomes, with particular attention to the management of complications and the impact on quality of life (QoL).

Technique selection of ureteroileal anastomosis in hautmann ileal neobladder with chimney modification: Reliability of patient-based selection strategy and its impact on ureteroentric stricture rate

OBJECTIVE

We aimed to establish the reliability of technique selection strategy for ureteroileal anastomosis (Bricker vs. Wallace) by comparing perioperative outcomes, complications, and anastomotic stricture rate in a contemporary series of patients who underwent open radical cystectomy followed by reconstruction of modified Hautmann neobladder.

MATERIALS AND METHODS

A total of 60 patients underwent radical cystectomy and modified Hautmann neobladder, of whom 30 patients (group I) with Bricker anastomotic technique were compared to 30 matched paired patients with end-to-end ureteroileal anastomosis (group II). Long-term results, including ureteroileal stricture (UIS) and postoperative complication rate at two year follow up were available. The choice of anastomosis type was successively based on chimney size, ureteral length after retro-sigmoidal tunneling and diameter of distal ureter. Postoperative complications were graded according to the Clavien-Dindo system.

RESULTS

Ureteroileal stricture rate was 6.6% in group I vs. 0% in group II, after three months (p < 0.05), while anastomotic leakage rate was 6.6% vs. 3.3% (group I vs group II) between the two groups for the same follow up period (p > 0.05). High-grade complications (Clavien III-V) were more in Bricker group as compared to Wallace group and the difference was significant (20% vs 10.3%, p = 0.03).

CONCLUSION

Our preliminary outcomes demonstrate that this selection strategy seems to be clinically reliable, with lower incidence of postoperative complications in Wallace group.

A new technique in the treatment of ureteroenteric anastomosis stricture: Repair of ureteroenteric anastomosis stricture with low lombotomy incision (retroperitoneal approach)

INTRODUCTION AND AIM

Ureteroenteric anastomosis stricture (UEAS) is one of the complications of urinary diversion and may lead to serious consequences. In this study, we evaluated our UEAS revision technique outcomes performed with a low lombotomy incision in the lateral decubitus position.

MATERIALS AND METHODS

Eleven patients who underwent surgical repair due to isolated right UEAS between January 2010 and June 2019 were included in the study. Anastomosis stricture was confirmed by ultrasonography, computed tomography or magnetic resonance urography techniques. Ultrasonography was used to detect hydronephrosis, which is a finding secondary to stricture. However, opaque urography imaging methods were used to confirm the definitive diagnosis of the stricture. Demographic and clinical data, preoperative and postoperative 3rd month serum creatinine, estimated glomerular filtration rate (eGFR) and dynamic renal scintigraphy data of patients were evaluated.

RESULTS

The mean operation time was 49.7 ± 9.3 minutes. No perioperative complications were observed. While the overall stricture rate was 11.4%, the isolated right-sided stricture rate was 5.7%. Preoperative and postoperative serum creatinine values were similar. Preoperative eGFR value was 58.8 ± 12.9 mL/min/1.73 m² and postoperative value was 53.5 ± 11.5 mL/min/1.73 m² . T½ level decreased in postoperative period (22.3 ± 8.2 min vs 15.1 ± 4.3 min).

CONCLUSIONS

Open revision of the UEAS with retroperitoneal approach provides lower morbidity rates and shorter hospitalisation time compared to other methods. The retroperitoneal approach is the main advantage of this technique and prevents morbidity caused by other techniques performed intraperitoneally and owing to it is an open technique, it can be easily applied in isolated right-sided UEAS.

Functional results of hautmann neobladder with chimney modification and wallace ureteroileal anastomosis: initial experience with 22 patients

OBJECTIVE

To assess the functional outcomes and complications of modified Hautmann neobladder with Wallace ureteroileal anastomosis on a 6-8 cm long isoperistaltic chimney, following radical cystectomy.

MATERIALS AND METHODS

Between January 2015 and October 2019, 22 patients (18 men and 4 women) underwent radical cystectomy and Hautmann neobladder reconstruction with chimney modification and Wallace I ureteroileal anastomosis. The mean age of patients was 61 years (45-74 years). All procedures were performed by the same surgeon and the mean follow-up was 29.4 months. Complications were registered as early (occurring within 3 months) or late (occurring after 3 months), with particular attention addressed to the ureteroileal anastomotic stricture and anastomotic leakage rate. Patient evaluation also included symptom analysis for daytime continence and voiding frequency.

RESULTS

Ureteroileal anastomotic stricture was not detected as a cause of hydronephrosis. Hovewer, the anastomotic leakage occurred in one patient during the early postoperative period. Early complications occurred in 9 patients and the most common was bilateral hydronephrosis, detected in 5 examinees. Late complications occurred in 4 patients. Complete daytime and nighttime continence achieved in 18 and 16 patients respectively, with two patients (9%) still required intermittent catheterization three months after surgery.

CONCLUSIONS

The functional results with modified Hautmann neobladder, incorporating short afferent limb in Wallace I uretero-enteric anastomosis, were efficient. This technique is an effective way to minimize potential uretero-enteric stricture, anastomotic leakage and incidence of vesicoureteral reflux.

Long-term evaluation of modified orthotopic Y-shaped ileal neobladder (Tanta pouch) with left retro-colic chimney

PURPOSE

In the present study, we evaluated the long-term results of modified Y-shaped orthotopic ileal neobladder (Tanta pouch) with trans-mesenteric left retro-colic chimney.

PATIENTS AND METHODS

A total of 70 patients with invasive bladder cancer underwent radical cystectomy and modified Y-shaped orthotopic ileal neobladder. (The left chimney elongated to pass to the left side through a window in the mesentery of the pelvic colon and the ureters were implanted directly end to side, in both chimneys after doing good spatulation.

RESULTS

The mean follow-up period ranged between 7 and 10 years (mean 7.8 years). 18 patients died during the period of follow-up. 6 months postoperatively, there was a spherical orientation of the pouch (The mean capacity was 542 ± 47 cm³) and the maximum intra-pouch pressure was 24 ± 3.2 cm H₂O. Daytime continence was achieved in 93% of the patients and nighttime continence was achieved in 87%. Stress incontinence occurred in 15% and total incontinence in 2%. Renal function was stable in 93% of renal units. Stricture ureter was not recorded of any case. Of 14 renal units with preoperative dilated ureters, 5 units had improved postoperatively and the others had persistent reflux. 13 renal units (3 unilateral and 5 bilateral) with normal preoperative ureters had persistent postoperative reflux. Persistent reflux showed no influence on renal function.

CONCLUSION

Modified Y-shaper pouch is suitable for short, dilated ureters. Longitudinal orientation of the pouch facilitates ileo-urethral anastomosis, especially with short mesentery. Long-term follow-up for direct uretero-ileal anastomosis did not show deterioration of the renal function.

Does the site of the orthotopic neobladder outlet matter? A prospective randomized comparative study

BACKGROUND

To compare the results of urethral anastomosis to a button hole and to the lowest part of the anterior suture line during orthotopic neobladder substitution.

METHODS

From January 2012 to December 2015, 87 consecutive male patients with invasive bladder cancer underwent radical cystectomy and Hautmann ileal neobladder. Patients were randomly divided into two groups; group I (44 patients), the outlet was created as a button-hole at the most dependent part of the pouch, group II (43 patients), the lowest 1 cm of the anterior suture line of the pouch was left open as an outlet. Patients were randomly assigned to either group using computer-generated random numbers (JMP, Version 12.0.1; SAS Institute, Cary, NC, USA) via a sealed envelope. The functional outcomes of both groups were compared especially at the urethro-enteric anastomosis.

RESULTS

There were no intraoperative complications. Early postoperative complications occurred in 9 patients (5 in group I and 4 in group II, p = 0.484). Prolonged urinary leakage persisted for 11 and 14 days in 2 patients in group I and 10 and 16 days in 2 patients in group II. Delayed postoperative complications occurred in 11 patients (5 [12.5%] in group I and 6 [15.6%] in group II) (p = 0.711). Three patients developed urethro-enteric strictures (2 in group I and 1 in group II) (p = 0.571).

CONCLUSION

The "non-hole" technique of urethral anastomosis was not associated with a significant increase in the complication rate when compared to the commonly performed "hole" technique.

Functional Assessment of the Hautmann Ileal Neobladder with Chimney Modification Using Uroflowmetry and a Questionnaire

Urinary diversion reconstruction is essential after radical cystectomy and neobladder reconstruction is accepted as a fine option. This study included 51 patients, who underwent radical cystectomy with orthotopic neobladder reconstruction by a Hautmann ileal neobladder with chimney modification from 2006 to 2014. Functional outcomes were evaluated using a questionnaire and uroflowmetry. Perioperative complications were analyzed retrospectively. The mean follow-up period was 36.1 months. Eighty-six percent of patients voided without clean intermittent catheterization (CIC) assistance. CIC was used 1-2x per day or every time they voided in 8% and 6% of patients, respectively, and 71% of patients were continent. The percentages of patients who used 1, 2, 3-4, and ≥5 pads per day were 15%, 6%, 2%, and 6%, respectively. Daytime and nighttime continence were achieved in 86% and 69% of patients, respectively. Daily mucus leakage was reported in 69% of patients. The mean maximum neobladder capacity, voided volume, postvoid residual volume, and maximum flow rate were 413.2 mL, 370.6 mL, 43.7 mL, and 20.8 mL/s, respectively. Eighteen early and 5 late complications developed in 13 and 5 patients, respectively. Reoperations were needed in 7 patients. The Hautmann ileal neobladder with chimney modification provided satisfactory results regarding functional outcomes.

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.

Benefits of laparoscopic prostate-sparing radical cystectomy

PURPOSE

Prostate-sparing radical cystectomy has been described in the literature and has proven to be a promising procedure owing to the continence and erectile function results without necessarily compromising the oncologic outcome in selected patients.

TECHNIQUE POINTS

A transperitoneal approach is used. Lymph node dissection is performed with frozen section, and then the ureters are ligated and biopsied. The seminal vesicles are dissected, followed by complete mobilization of the bladder. Incision of the bladder neck is performed, followed by simple prostatectomy. Finally, bowel reconstruction is carried out via a small infra-umbilical incision that also permits the extraction of the surgical specimen and the anastomosis of neobladder to the prostate capsule. A total of 25 patients have undergone this procedure, with average surgical times of 285 min and blood loss of 640 ml. The complications encountered included: one bowel incarceration, one urinary leak, one lymphocele and one port hernia. At median 9 months follow-up, no patient presented with daytime incontinence, although seven complained of nocturia. A total of 20 patients maintained their preoperative sexual potency, and four reported a postoperative decrease in their erectile function.

CONCLUSIONS

Laparoscopic prostate-sparing radical cystectomy appears to be oncologically safe, reproducible and has promising functional benefits. The authors believe this procedure presents a good option in very select patients.

Simple modification in Hautmann neobladder to carry out left ureteroileal anastmosis without mobilization of the ureter

We describe a simple modification in Hautmann neobladder that involves an elongation of its left chimney to advance it through the pelvic mesocolon in order to reach the left ureter in its original place. This technique was carried out on 27 patients who had Hautmann pouch after radical cystectomy, and we reported the outcome and complications that occurred at the site of urteteroileal anastomosis in the first 3 years after surgery. The modification was applied easily without any perioperative complications that were related to this step in particular. During follow up of these cases, we lost three patients who died before the end of the third postoperative year. At a mean follow up of 41.3 ± 10.2 months, we have not detected any cases of stricture formation or ureteral recurrence at the sites of the ureteroileal anastmosis. There was only one patient who developed acute pyelonephritis (3.7%) as a result of reflux.

The impact of mechanical bowel preparation on postoperative complications for patients undergoing cystectomy and urinary diversion

PURPOSE

The benefit of routine mechanical bowel preparation for patients undergoing radical cystectomy is not well established. We compared postoperative complications in patients who did or did not undergo mechanical bowel preparation before radical cystectomy.

MATERIALS AND METHODS

In 2008 a single surgeon (GDS) performed open radical cystectomy with an ileal conduit or orthotopic neobladder in 105 consecutive patients with preoperative mechanical bowel preparation consisting of 4 l GoLYTELY®. In 2009 radical cystectomy with an ileal conduit or orthotopic neobladder was performed in 75 consecutive patients without mechanical bowel preparation. A comprehensive database provided clinical, pathological and outcome data.

RESULTS

All patients had complete perioperative data available. The 2 groups were similar in age, Charlson comorbidity score, diversion type, receipt of neoadjuvant radiation or chemotherapy, blood loss, hospital stay, time to diet and pathological stage. Postoperative urinary tract infection, wound dehiscence and perioperative death rates were similar in the 2 groups. Clostridium difficile infection developed within 30 days of surgery in 11 of 105 vs 2 of 75 patients with vs without mechanical bowel preparation (p = 0.08). When adjusted for the annual hospital-wide C. difficile rate, the difference remained insignificant (p = 0.21). Clavien grade 3 or greater abdominal and gastrointestinal complications, including fascial dehiscence, abdominal abscess, small bowel obstruction, bowel leak and entero-diversion fistula, developed in 7 of 105 patients with (6.7%) vs 11 of 75 without (14.7%) mechanical bowel preparation (p = 0.08).

CONCLUSIONS

The use of mechanical bowel preparation for patients undergoing radical cystectomy with an ileal conduit or orthotopic neobladder does not seem to impact the rates of perioperative infectious, wound and bowel complications. Larger series with multiple surgeons are necessary to confirm these findings.

Modified orthotopic spiral ileal bladder substitution: surgical technique and long-term results

OBJECTIVES

The objectives of this study are to introduce the surgical technique of a modified spiral orthotopic ileal neobladder and to assess the long-term outcomes.

PATIENTS AND METHODS

Between January 1998 and January 2006, 44 male and 7 female patients with bladder cancer received radical cystectomy (RC) and pelvic lymphadenectomy. An ileal segment 40 cm to 45 cm long was isolated to create a spiral orthotopic ileal neobladder, and the ureters were implanted into the reservoir using a non-refluxing split-cuff nipple technique. Preoperative, perioperative, and postoperative data were collected. Complications were classified as early (less than 3 months after surgery) or late (more than 3 months after surgery). Continence incidence and urodynamic studies were evaluated 5 years after surgery. Duration of follow-up was an average of 95 months (range 60-156 months).

RESULTS

There were no perioperative deaths. The mean operative time was 315 ± 34 minutes. The mean blood loss was 783 ± 316 ml. There were 31 early complications in 21 patients (41%) and 42 late complications in 30 patients (59%). Urodynamic studies showed the maximum neobladder capacity to be 500 ± 71 ml, maximum flow rate to be 16 ± 5 ml/s and post-voiding residual (PVR) to be 50 ± 44 ml. Postoperative continence was excellent with a daytime continence rate of 90% and a nocturnal continence rate of 78% 5 years after surgery.

CONCLUSIONS

The modified spiral neobladder is easy to perform and allows for excellent long-term results with regard to complications and continence.

Factors associated with non-orthotopic urinary diversion after radical cystectomy

INTRODUCTION

Preoperative factors favoring the performance of non-orthotopic bladder substitution (OBS) after radical cystectomy for muscle-invasive bladder cancer were identified.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 730 patients who underwent radical cystectomy for urothelial carcinoma of the bladder. After excluding 75 patients who were unable to undergo OBS due to the tumor location or elevated serum creatinine level, we assessed the preoperative factors in the remaining 655 patients. Multivariate logistic regression analysis was performed to identify the independent preoperative predictors of type of urinary diversion.

RESULTS

Of the 655 patients, 171 (26.1%) underwent non-OBS. Patients who underwent non-OBS were more likely to be older and females, to have a lower educational status, non-organ confined disease, more comorbid medical conditions, more impaired performance status, lower body mass index, anemia, azotemia, and hypoalbuminemia, and to be treated by less-experienced surgeons (P < 0.05 each). After adjusting for provider-based factors, multivariate analysis showed that factors independently associated with non-OBS included advanced age (odds ratio [OR] 4.10, P < 0.001), female gender (OR 2.08, P = 0.027), ECOG performance status (≥ 1 vs 0, OR 5.20, P < 0.001), low educational status (OR 1.59, P = 0.042), clinically node-positive disease (OR 2.36, P = 0.003), anemia (OR 1.67, P = 0.041), azotemia (OR 3.97, P < 0.001), and hypoalbuminemia (OR 1.84, P = 0.046).

CONCLUSION

Several patient-based as well as provider-based factors were associated with the type of urinary diversion after radical cystectomy. Advanced age, female gender, low performance status, low education level, clinically node-positive disease, anemia, hypoalbuminemia, and azotemia were associated with non-OBS, as surgery was performed by relatively inexperienced surgeons.

A novel antireflux technique for orthotopic ileal bladder substitutes-flat-segment technique: preliminary results

Objective. Although a large debate exists regarding the need for reflux prevention in ileal orthotopic neobladders, it is our policy to continue performing nonrefluxing ureteroileal anastomoses for our patients. An ideal uretero-ileal anastomosis must be simple, nonrefluxing, as well as non-obstructive. Here, we present a new antireflux mechanism for orthotopic ileal neobladders. Methods. 12 radical cystectomy patients for muscle invasive bladder cancer were candidates for orthotopic urinary diversion and underwent a non-refluxing uretero-ileal anastomosis using the flat-segment technique with a follow up of 6 to 18 months. Results. Preliminary results after the short-term followup showed that the success rate in reflux prevention was 92% and no cases of obstruction. The upper tracts were preserved or improved in all 12 patients. Operative time for neobladder creation ranged between 120-240 minutes, with a mean of 165 minutes (±36 minutes). No diversion-related complications. Conclusions. Based on our early data, we believe that the flat-segment uretero-ileal anastomosis technique for reflux prevention in orthotopic ileal bladder substitutes is simple, easy to learn and carries no additional morbidity to a standard refluxing uretero-ileal anastomosis, but has the advantage of effective reflux prevention. A longer follow-up period study with more patient numbers is ongoing.

Orthotopic neobladder versus Indiana pouch in women: a comparison of health related quality of life outcomes

PURPOSE

Little is known about the health related quality of life of women who have undergone continent urinary diversion. We compared health related quality of life outcomes for women who underwent radical cystectomy with an orthotopic neobladder or Indiana pouch.

MATERIALS AND METHODS

From 1995 to June 2008 a single surgeon (GDS) performed radical cystectomy with an orthotopic neobladder in 47 women and radical cystectomy with an Indiana pouch in 45. A comprehensive database provided clinical, pathological and outcomes data. The validated Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index was mailed to 92 patients.

RESULTS

Complete data were available for 87% of patients treated with radical cystectomy with an orthotopic neobladder and 93% of those treated with radical cystectomy with an Indiana pouch, with a median followup of 34 and 24 months, respectively (p = 0.8). Median (IQR) age was 65 (58, 71) and 61.5 (51, 67) years for patients with an orthotopic neobladder and Indiana pouch, respectively (p = 0.03). No significant differences were found for pathological stage, nodal status, blood loss, Clavien grade III or greater complications, adjuvant therapy or hospital stay between the 2 treatment groups, or between respondents and nonrespondents. Five-year survival rates for patients with an orthotopic neobladder and Indiana pouch were 65% and 58%, respectively (p = 0.9). There were 21 (75%) living patients with an orthotopic neobladder and 19 (61%) with an Indiana pouch who completed the Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index, and physical (p = 0.53), social (p = 0.97), emotional (p = 0.61), functional (p = 0.55) and radical cystectomy specific (p = 0.54) health related quality of life domains were not significantly different between the groups.

CONCLUSIONS

Women undergoing radical cystectomy with an orthotopic neobladder vs an Indiana pouch have similar health related quality of life outcomes. Larger series with longer followup and multiple surgeons are necessary to confirm these findings.

Complications following radical cystectomy for bladder cancer in the elderly

CONTEXT

The incidence of bladder cancer increases with advancing age. Considering the increasing life expectancy and the increasing proportion of elderly people in the general population, radical cystectomy will be considered for a growing number of elderly patients who suffer from muscle-invasive or recurrent bladder cancer.

OBJECTIVE

This article reviews contemporary complication and mortality rates after radical cystectomy in elderly patients and the relationship between age and short-term outcome after this procedure.

EVIDENCE ACQUISITION

A literature review was performed using the PubMed database with combinations of the following keywords cystectomy, elderly, complications, and comorbidity. English-language articles published in the year 2000 or later were reviewed. Papers were included in this review if the authors investigated any relationship between age and complication rates with radical cystectomy for bladder cancer or if they reported complication rates stratified by age groups.

EVIDENCE SYNTHESIS

Perioperative morbidity and mortality are increased and continence rates after orthotopic urinary diversion are impaired in elderly patients undergoing radical cystectomy. Complications are frequent in this population, particularly when an extended postoperative period (90 d instead of 30 d) is considered.

CONCLUSIONS

Although age alone does not preclude radical cystectomy for muscle-invasive or recurrent bladder cancer or for certain types of urinary diversion, careful surveillance is required, even after the first 30 d after surgery. Excellent perioperative management may contribute to the prevention of morbidity and mortality of radical cystectomy, supplementary to the skills of the surgeon, and is probably a reason for the better perioperative results obtained in high-volume centers.

Open surgical repair of ureteral strictures and fistulas following radical cystectomy and urinary diversion

PURPOSE

Open surgery after cystectomy can be a challenge. We report the incidence of postoperative urinary diversion-enteric fistula and ureteral strictures in patients undergoing radical cystectomy, and discuss the diagnosis and management of these complications, including our surgical approach to these patients.

MATERIALS AND METHODS

We preformed a retrospective review of 553 patients undergoing radical cystectomy and urinary diversion for bladder cancer between April 1999 and January 2007. Patients in whom a ureteral stricture or fistula developed were identified by serial laboratory and imaging evaluations. A chart review was preformed to identify symptoms, time to stricture or fistula development, radiological findings, type of diversion, estimated blood loss and whether the original anastomosis was stented. Management and outcomes were assessed.

RESULTS

Of 553 patients reviewed ureteral stricture developed in 41 (7.4%) with a mean followup of 20.2 months (range 1 to 98). Strictures developed in 11% (31 of 272) of the orthotopic ileal neobladder, 2.5% (6 of 236) of ileal conduit and 8% (4 of 45) of Indiana pouch cases. Open repair led to an overall success rate of 87%. Urinary diversion-enteric fistula developed in 12 (2.2%) of the 553 patients with a mean followup of 28.4 months (range 3 to 94), all of whom had undergone orthotopic neobladder diversion. No patient had recurrence after surgical repair of the fistula.

CONCLUSIONS

Open revision remains the gold standard management for ureteral strictures and urinary diversion-enteric fistulas occurring after radical cystectomy. The addition of the chimney modification to the orthotopic neobladder facilitates surgical repair.

Real-time MRI of Orthotopic Ileal Neobladder Voiding: Preliminary Findings

OBJECTIVES

The purpose of this preliminary study was to analyze the dynamic changes in the configuration of the neobladder and naïve bladder during voiding using real-time MRI.

METHODS

This study included 10 male patients who had a radical cystectomy and an ileal orthotopic neobladder due to organ-confined bladder cancer and had good urinary function, and 5 male control volunteers. With the subjects in the lateral decubitus position, real-time MRI was performed during micturition. A sagittal slice orientation was used to depict the bladder and the entire length of the urethra; individual movements along the X-axis and Y-axis of the bottom and top of the neobladder and the naïve bladder were recorded and analyzed. Urodynamic studies (UDS) and video voiding cystourethrography were performed in patients.

RESULTS

Five of the 10 neobladder patients could void in the lateral decubitus position. In normal controls and patients who could void, the bladder outlet bladder moved ventrocranially during micturition. The ileal bladder outlet moved a significantly longer distance than the naïve bladder during micturition (X-axis, -13.4+/-1.5 vs. -3.6+/-4.3 cm, p=0.0014; Y-axis, -10.6+/-0.5 vs. -2.0+/-6.5 cm, p=0.0187). The distance that the bladder top moved between the naïve bladders and the neobladder did not differ. UDS did not show a difference between patients who could and could not void at lateral position.

CONCLUSIONS

During micturition, the neobladder was found to rotate and move more dynamically than the naïve bladder. Real-time MRI is useful for assessing dynamic voiding function of orthotopic neobladders.

A pilot study of the assessment of the quality of life, functional results, and complications in patients with an ileal neobladder for invasive bladder cancer

OBJECTIVE

To assess the functional results, health-related quality of life (QOL) outcomes, and complications in patients with an ileal neobladder in comparison to those with cutaneous diversion (ileal conduit and cutaneostomy).

METHODS

Between September 1992 and February 2003, we consecutively performed an ileal neobladder (the Studer method) in 30 patients and cutaneous diversion in 38 patients. In August 2004, questionnaires were mailed to 54 patients. The questionnaire included the validated health-related quality of life (QOL) questionnaire, SF-36 General Health Survey, and a urinary incontinence questionnaire. We also evaluated the functional results in patients with an ileal neobladder and the postoperative complications in patients with both urinary diversions.

RESULTS

The data from 41 patients (21 ileal neobladder procedures and 20 cutaneous diversions) were available for the analysis. No differences in the overall QOL were observed between the two groups. Complete daytime and night-time urinary continence was achieved in the 21 patients (100%) and 13 patients (61.9%), respectively. The mean value of the maximum flow rate was 15 +/- 12 mL/min in the 21 neobladder patients. There were 19 early complications in 18 patients (60.0%) and seven late complications in six patients (20.0%) with an ileal neobladder. However, there were 15 early complications in 14 patients (36.8%) and eight late complications in six patients (15.8%) with cutaneous diversions.

CONCLUSION

The findings regarding the health-related QOL and the frequency of complications in the neobladder group and those in the cutaneous diversion group were similar. However, the functional results and the status of urinary continence in the neobladder patients were satisfactory.

Does Body Mass Index Affect Outcome After Reconstruction of Orthotopic Neobladder?

OBJECTIVES

To evaluate the impact of body mass index (BMI) on outcome after orthotopic neobladder (NB) reconstruction.

METHODS

We performed a retrospective analysis of patients who underwent radical cystectomy and NB from 1992 to 2004. The patients were categorized according to BMI into group 1, BMI less than 25 kg/m2; group 2, BMI 25 to 29.9 kg/m2; and group 3, BMI greater than 30 kg/m2. The relationships among the BMI categories, the predominant complications (eg, urinary tract infection [UTI]; pyelonephritis; ureteral, bladder neck, and urethral stricture), other complications, and continence were analyzed.

RESULTS

Of the 343 patients who underwent radical cystectomy, 116 had an NB. The patient characteristics among the BMI groups were similar. Group 1 had fewer complications compared with the other groups (P <0.012). The principal complications observed were UTI, stricture, and pyelonephritis. The incidence of UTI, pyelonephritis, and wound infection were less in group 1 than in the other groups, with statistically significant differences (P = 0.001, P = 0.04, and P = 0.04, respectively). At the last follow-up visit, only 10% of the patients required clean intermittent catheterization to empty the NB, and no statistically significant differences were found in the continence status and voiding pattern among the groups.

CONCLUSIONS

An increased incidence of UTI, pyelonephritis, and wound infection was found in patients with increased BMI. However, they were transient and not life threatening. The continence and voiding patterns were relatively similar. Hence, an NB can be offered to patients with an increased BMI, and they should be formally counseled.

Urinary Diversion

A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) met to critically review reports of urinary diversion. The world literature on urinary diversion was identified through a Medline search. Evidence-based recommendations for urinary diversion were prepared with reference to a 4-point scale. Many level 3 and 4 citations, but very few level 2 and no level 1, were noted. This outcome supported the clinical practice pattern. Findings of >300 reviewed citations are summarized. Published reports on urinary diversion rely heavily on expert opinion and single-institution retrospective case series: (1) The frequency distribution of urinary diversions performed by the authors of this report in >7000 patients with cystectomy reflects the current status of urinary diversion after cystectomy for bladder cancer: neobladder, 47%; conduit, 33%; anal diversion, 10%; continent cutaneous diversion, 8%; incontinent cutaneous diversion, 2%; and others, 0.1%. (2) No randomized controlled studies have investigated quality of life (QOL) after radical cystectomy. Such studies are desirable but are probably difficult to conduct. Published evidence does not support an advantage of one type of reconstruction over the others with regard to QOL. An important proposed reason for this is that patients are subjected preoperatively to method-to-patient matching, and thus are prepared for disadvantages associated with different methods. (3) Simple end-to-side, freely refluxing ureterointestinal anastomosis to an afferent limb of a low-pressure orthotopic reconstruction, in combination with regular voiding and close follow-up, is the procedure that results in the lowest overall complication rate. The potential benefit of "conventional" antireflux procedures in combination with orthotopic reconstruction seems outweighed by the higher complication and reoperation rates. The need to prevent reflux in a continent cutaneous reservoir is not significantly debated, and this should be done. (4) Most reconstructive surgeons have abandoned the continent Kock ileal reservoir largely because of the significant complication rate associated with the intussuscepted nipple valve.

Results of Chimney Modification Technique in Ureterointestinal Anastomosis of Hautmann Ileal Neobladder in Bladder Cancer

BACKGROUND

To evaluate the surgical technique and functional outcome of a new application of the chimney modification to the popular Hautmann ileal neobladder. This modification used 3-5 cm chimney tubularized ileal segment for the bilateral ureterointestinal anastomosis.

METHODS

Between December 2000 and July 2004, 15 patients (14 men, 1 woman) with invasive bladder cancer underwent radical cystectomy and Hautmann neobladder with chimney modification at Siriraj Hospital, Bangkok. Mean age was 61.7 years (range, 43-72 years). Perioperative morbidity, early and late urinary diversion-related complications, other surgical complications, follow-up results of ureterointestinal anastomosis, renal function and metabolic disorders were evaluated. Patients were interviewed about their continence, voiding function and potency.

RESULTS

At a mean follow-up of 29.5 months, two patients had died of cancer progression. Of the 15 patients, nine (60%) had 10 early complications. Eight complications were related to the neobladder and two were not. Three (20%) patients had three late complications. Two complications were neobladder-related and one was not. There was no perioperative mortality. There was no ureteroileal anastomosis stricture in this series. Neobladder-ureteral reflux was demonstrated in eight of 22 ureteral units in 11 patients in whom cystography was performed. All patients had normal upper urinary tract without evidence of urinary obstruction. All 14 men (93% of study sample) had spontaneous urination, normal renal function and no metabolic acidosis. Good and satisfactory continence in the day and night were 93% and 73%, respectively. All male patients experienced impotence postoperatively. Only one sought treatment and was successfully treated with sildenafil. The one woman in this study required intermittent catheterization to empty the neobladder completely. She also had renal insufficiency with serum creatinine of 2.2 mg/dL and hyperchloraemic metabolic acidosis.

CONCLUSION

New chimney modification in Hautmann ileal neobladder is simple and safe. Complications are acceptable. Follow-up results of renal and voiding functions are satisfactory. This operation can maintain good quality of life for patients with bladder cancer undergoing radical cystectomy.

Complete urinary tract extirpation: the University of Maryland experience

OBJECTIVES

Complete urinary tract extirpation (CUTE) involves simultaneous bilateral nephroureterectomy, cystectomy or cystoprostatectomy, and the creation of a urinary diversion, if needed. Case reports of this operation have been published, but to our knowledge, this is the largest case series yet reported. We sought to evaluate the characteristics and outcomes of patients who underwent CUTE.

METHODS

From 1994 to 2005, 9 patients underwent CUTE at our institution. We performed a retrospective chart review of these patients. The data reviewed included demographics, operative time, length of stay, complications, recurrences, and overall survival.

RESULTS

Nine patients who underwent CUTE were identified. The mean patient age at the operation was 61 years. Five patients were men. The mean operative time was 356 minutes. Two patients required a blood transfusion. The length of stay averaged 10.8 days (range 6 to 47). Four patients had functioning renal allografts before and after surgery. Three patients needing dialysis received renal allografts postoperatively. The overall survival rate at a mean follow-up of 31 months was 86%.

CONCLUSIONS

Although this report presented a small number of patients, it has illustrated that CUTE can be performed safely and allow definitive surgical treatment of patients with complex genitourinary pathologic findings.

Refluxing Chimney Versus Nonrefluxing LeDuc Ureteroileal Anastomosis for Orthotopic Ileal Neobladder: A Comparative Analysis for Patients With Bladder Cancer

PURPOSE

Radical cystectomy and various techniques of urinary diversion are gold standard treatments for invasive bladder cancer. However, postoperative hydronephrosis is a common complication in these patients. A special focus was placed on the type of ureteroileal anastomosis used with 2 different techniques performed at 1 institution.

MATERIALS AND METHODS

Between 1995 and 2003 a total of 106 consecutive patients with bladder cancer underwent cystectomy followed by construction of an ileal neobladder. The nonrefluxing technique of ureter tunneling described by LeDuc and the refluxing chimney technique used for ureter implantation into the ileum-neobladder were compared. Hydronephrosis due to ureteral strictures was studied immediately following surgery and up to 5 years after surgery.

RESULTS

A total of 204 RU were included in the study. The LeDuc technique was used in 132 RU (64%) and the chimney technique was used in 72 RU (36%). Hydronephrosis rate of 2% were found in each of the 2 groups after 5 years of followup.

CONCLUSIONS

Postoperative hydronephrosis due to ureteral strictures is observed at the same rate during long-term followup with the LeDuc and chimney techniques. We favor the chimney technique compared to the LeDuc tunnel due to easier technical preparation and a better chance to identify the ureters endoscopically at a later time. The chimney does give extra length to reach the ureteral stump, especially in cases of distal ureteral carcinoma in situ.

Asymptomatic bacteriuria in men with orthotopic ileal neobladders: possible relationship to nocturnal enuresis

OBJECTIVE

To assess prospectively the incidence with time of asymptomatic bacteriuria in patients with orthotopic ileal neobladders, and the possible effect on neobladder function.

PATIENTS AND METHODS

In all, 47 patients (mean age 52.7 years, sd 8.7, range 31-68) with uncomplicated orthotopic ileal neobladders were prospectively evaluated. With no antibiotic manipulation, consecutive urine cultures were assessed monthly. Continence was assessed by direct information from the patients at each follow-up visit.

RESULTS

Overall, 797 samples were cultured from the 47 patients (mean 17.6, sd 7.1). There was a steady decrease in the incidence of positive cultures, from 74.5%, to 35.6% and 6.7% at 1, 6 and 18 months, respectively. While there was persistently sterile urine in only eight patients (17%), 32 had occasional and seven had persistent bacteriuria. Escherichia coli was the commonest organism (76.6%) followed by Klebsiella pneumonia (15.7%); 54% of E. coli and 38% of K. pneumonia infections were sensitive to nitrofurantoin. Diurnal continence was achieved in 98% of the patients at 6 months after surgery. There was a gradual decrease in the frequency of nocturnal enuresis (NE) with time, from 87%, to 42%, 28% and 27% at 1, 6, 12 and 18 months, respectively. There was a significant correlation between the presence of bacteriuria and NE during the first 6 months, but it was not sustained after that. The age of the patients was also related significantly to the incidence of NE; at 6 months, only one of 18 men aged < or = 50 years had NE, while 19 of 29 aged > 50 years had (P < 0.001). At 1 year all patients aged < or = 50 years were nocturnally continent, while half of those aged > 50 years had NE (P = 0.001).

CONCLUSIONS

Ileal neobladders are associated with a high incidence of asymptomatic bacteriuria during the first year after surgery. There was spontaneous clearance of bacteriuria with time, with no antimicrobial manipulation. Soon after surgery there was a significant association between bacteriuria and NE. The effect of antimicrobials on patients with NE should be evaluated.

[Ileal neobladder with double chimney. Ureterointestinal anastomosis]

Radical cystoprostatectomy is accepted as the standard treatment for muscle-invasive bladder cancer. During last years the indications for orthotopic neobladders have increased due to their advantages over other kind of diversions. Hautmann neobladder is one of the most commonly used. Several modifications have been later described. For example, after perform the W-shape pouch ureters can be anastomosed to a not-detubularized bowel segment (chimney modification). Here is described a modification of the Hautmann neobladder with two chimneys. Each ureter is spatulated in a golf club manner and anastomosed to the open end of each bowel loop. This kind of anastomosis provides several advantages. It is possible to use shorter ureteral segments by increasing the length of bowel used. It allows an anastomosis without tension, and less ischemia so the risk of stenosis and fistula is decreased. It is not necessary to perform additional enterothomies and in case of reintervention it is easier to access each anastomosis without damaging the other one.

Clinical Experience with the N-shaped Ileal Neobladder: Assessment of Complications, Voiding Patterns, and Quality of Life in Our Series of 58 Patients

PURPOSE

The purpose of this retrospective study was to assess complications, voiding patterns, and quality of life in patients with an orthotopic bladder substitution, using an N-shaped ileal neobladder.

MATERIALS AND METHODS

Between May 1996 and December 2002, 58 patients (52 men and 6 women) underwent an orthotopic ileal neobladder reconstruction after radical cystectomy. The mean age was 47 for the female and 60 for the male patients. In all patients an N-shaped ileal pouch was constructed. This pouch has not yet been described in the literature before. All procedures were performed by the same surgeon (HVP) and the mean follow-up was 38 months. Complications were registered as early (occurring within 3 months) or late (occurring after 3 months), and as pouch-related and non-pouch-related. The patients took part in a pelvic floor re-education programme for as long as they were incontinent. All patients completed a retrospective Quality of Life questionnaire, based on the QLQ-C30 questionnaire, which was validated by the EORTC's Study Group on Quality of Life.

RESULTS

In 38% of the patients, early complications occurred, whereas 48% had late complications. The most frequent early complications were diarrhea (24%) and pyelonephritis (9%). Diarrhea was again the most frequently mentioned non-pouch-related complication (19%). The most frequently observed pouch-related late complication was ileo-urethral stenosis. This occurred in five patients. All of these 5 patients were re-operated using a minimally invasive approach. Daytime continence was achieved in 95% of patients and nighttime continence in 66%. Hyper-continence with subsequent need for CISC was observed in 5 out of 6 women (83%) and 0 out of 52 men (0%). The retrospective QoL questionnaire learned that the impact of bladder removal and orthotopic bladder substitution has acceptable impact on patient's everyday life. Diarrhea was mentioned as being the most discomforting complication by most of the patients.

CONCLUSIONS

We describe a modified orthotopic ileal neobladder: the ileal N-pouch. The functional results with this pouch are good. Complication rates and QoL are comparable with the larger series published by other authors, using different ileal neobladder reconstructions.

Neobladder-vaginal fistula after cystectomy and orthotopic neobladder construction

OBJECTIVE

To determine the potential surgical and clinical factors that contribute to the development of neobladder-vaginal fistula (NVF) after cystectomy and orthotopic neobladder (ONB) construction in women.

PATIENTS AND METHODS

Of 37 patients who had vaginal-sparing cystectomy, the records of four who developed a NVF after radical cystectomy and ONB construction were reviewed. Retrospective clinical and surgical information was collected, including patient demographics, tumour pathology, surgical technique, presenting symptoms, and method and efficacy of surgical repair.

RESULTS

In two of the four patients who developed a NVF a small injury to the anterior vaginal wall was noted during surgery and closed primarily. All patients presented with severe urinary incontinence. The NVF was diagnosed after cystoscopy and/or speculum examination. Three of the four patients had an attempted surgical repair, including one obturator flap interposition, one rectus flap interposition, and one primary two-layer closure. To date, one patient is fistula-free and two were subsequently converted to an ileal conduit or continent cutaneous diversion because the fistula recurred. The fourth patient developed a NVF in association with local tumour recurrence and underwent conversion to an ileal conduit.

CONCLUSION

The development of a NVF is a significant complication after cystectomy. Inadvertent injury to the vaginal wall is an important predisposing factor to subsequent NVF development. The repair of a NVF is often difficult; upon diagnosis, conversion to a continent cutaneous urinary diversion may be considered.

Ileal orthotopic neobladder (modified Hautmann) via a shorter detubularized ileal segment: experience and results

OBJECTIVE

To evaluate the clinical, urodynamic, functional, radiological and metabolic results of the ileal (modified Hautmann) orthotopic neobladder over 10 years of experience.

PATIENTS AND METHODS

Between January 1992 and March 2002, 124 men (mean age 62.4 years, range 44-76) with advanced bladder cancer had a radical cystoprostatectomy and urinary diversion via an ileal orthotopic neobladder (modified Hautmann). Only 40 cm of small bowel (detubularized ileum) was used to construct the reservoir, as a modification of the method described by Hautmann. All patients were followed periodically and their data recorded.

RESULTS

While no patients died during surgery six died (mortality rate was 5%) in the first 30 days afterward (two of them from causes unrelated to the urinary diversion surgery). The early reoperation rate was 14%; there were early complications not requiring surgery in 40 (34%) and later reoperation rate was required in 20.6%. The mean (range) maximum neobladder capacity was 550 (310-720) mL, the maximum intravesical pressure at maximum capacity 26.4 (11-48) cmH(2)O, and the minimum and maximum flow rates 25.2 (16-64) and 17.5 (11-30) mL/s, respectively. Day- and night-time continence rates were 92% and 90% after 4 years. While there was no electrolyte imbalance, there was mild to moderate metabolic acidosis in 58% of patients. There was no urethral tumour recurrence in any patient.

CONCLUSION

Detubularization of ileum to form a neobladder gives a more favourable low-pressure and high-capacity reservoir. Therefore, a shorter ileal segment can be used for orthotopic urinary diversion, to avoid various metabolic dysfunctions when using detubularized bowel, but the surgery is not as free of complications as the original technique.

Y-neobladder: an easy, fast, and reliable procedure

OBJECTIVES

To describe the operative technique of a new, Y-shaped, ileal neobladder and report the clinical and functional outcomes to add a contribution to the most discussed issues about orthotopic neobladders, in particular related to the problem of the prevention of strictures of ureteral-neobladder anastomoses.

METHODS

Between January 1999 and June 2002, 50 patients (41 men and 9 women) underwent radical cystectomy and Y-shaped orthotopic neobladder reconstruction. The following parameters were considered: operative time, complications, and functional outcomes (evaluated with voiding chart and a questionnaire analyzing continence). Urodynamic studies were performed in the first 20 patients.

RESULTS

The operative time for neobladder reconstruction was 15 to 20 minutes. No severe complications or significant metabolic complications were recorded. Only 1 case of unilateral stricture of the ureteral-neobladder anastomosis was recorded (1% of renal units); the stricture was easily treated with a retrograde endoscopic approach. Daytime and nighttime continence was good or satisfactory in 90% and 85% of patients, respectively. One year after surgery, the average maximal neobladder capacity was 390 mL, and the average pressure at maximal capacity was 15 cm H2O.

CONCLUSIONS

The ileal Y-shaped orthotopic neobladder had good functional outcomes comparable to most popular orthotopic neobladders. Moreover, the surgical technique of the Y-neobladder is easy, rapid, and reliable. In particular, the Y-neobladder seemed to reduce, in our experience, the occurrence of strictures at the ureteral-neobladder anastomosis, because it permits a perfectly aligned anastomosis without mobilization of the ureters.

Routine pouchograms are not necessary after continent urinary diversion

OBJECTIVES

Pouchograms are routinely performed before catheter removal after continent urinary diversion at our institution. Our aim was to determine the necessity of pouchograms based on a review of our experience.

METHODS

A retrospective review of patient records and radiographic studies was done for patients undergoing radical cystectomy and continent urinary diversions between 1991 and 2001.

RESULTS

Seventy-two patients underwent continent urinary diversion (orthotopic, n = 59; cutaneous, n = 13) during the study period. All underwent pouchogram postoperatively (median 22 days; range 20 to 27). Six patients (8.3%) had a demonstrable radiographic leak; in 5 of the 6 patients, the urine leak was suspected on clinical grounds. Three patients (4.7%) developed urosepsis after pouchogram.

CONCLUSIONS

Our findings indicate that routine pouchograms before pouch activation after continent urinary diversion may not be necessary.

Outcome of patients with continent urinary reconstruction and a solitary functioning kidney

OBJECTIVE

To evaluate the outcome of patients with continent urinary diversions who had a solitary functioning kidney at the time of surgery.

PATIENTS AND METHODS

In all, 62 patients with continent urinary reservoirs and a solitary functioning kidney were reviewed (51 men and 11 women). The indications for surgery were bladder cancer in 54 and a contracted bladder in eight. The surgical procedures included an orthotopic ileal neobladder in 36 patients, a continent cutaneous ileal reservoir in 13 and rectal diversion in 13. Kidneys were evaluated using serum creatinine level, ultrasonography, intravenous urography and other radiological studies.

RESULTS

The follow-up was 6-173 months; 44 renal units (71%) remained stable during this period. Serum creatinine was increased in four patients with an orthotopic neobladder, with no evidence of obstruction or reflux, in one with preoperative renal impairment and one with voiding dysfunction, reflux and bacteriuria. Six renal units deteriorated because of uretero-intestinal strictures; of these patients, two were treated endoscopically, two with open ureteric reimplantation, one with conversion from a rectal reservoir to an ileal loop conduit, and one was maintained on JJ stenting. Six patients with a rectal diversion had renal deterioration because of chronic pyelonephritis.

CONCLUSIONS

A regular follow-up of renal function is mandatory in patients with a continent urinary diversion. Rectal diversion is associated with a higher risk of renal deterioration (54%) than are orthotopic (28%) and cutaneous reservoirs (8%).

Long-Term Results of Endoureterotomy and Open Surgical Revision for the Management of Ureteroenteric Strictures After Urinary Diversion

PURPOSE

Prior studies have demonstrated that while endoureterotomy offers a reasonable initial treatment option, open anastomotic revision should remain the gold standard for managing ureteroenteric strictures. However, to our knowledge the results of contemporary endoureterotomy series have not been compared with those of open anastomotic revision, and no study has assessed the morbidity or success rate of secondary open anastomotic revision after failed endoureterotomy.

MATERIALS AND METHODS

Between May 1997 and August 2002 a total of 31 renal units in 22 patients were treated for ureteroenteric strictures after radical cystectomy and urinary diversion. A total of 16 renal units were treated endoscopically, including 9 on the left and 7 on the right side, and open revision was performed in 15 renal units, including 9 on the left and 6 on the right side. Success was defined as radiological improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes.

RESULTS

At a median followup of 35 months (range 17 to 62) for endoureterotomy and 34 months (range 5 to 54) for open revision the success rate of endoureterotomy and open revision was 50% (8 of 16 renal units) and 80% (12 of 15), respectively. One of the 3 patients in whom open revision failed underwent prior pelvic external beam radiation and the other 2 underwent prior endoureterotomies. Overall interventions for right strictures were more successful 85% or 11 of 13 cases than those on the left side (50% or 9 of 18) (p = 0.037). Average operative time was longer and average estimated blood loss was higher in patients treated with open repair after failed endoureterotomy (p = 0.009 and 0.016, respectively). No complications developed in patients following endoureterotomy.

CONCLUSIONS

Open revision remains the gold standard for the management of ureteroenteric strictures. Left strictures are considerably more resistant to management. Patients with left anastomotic strictures should be cautioned that endoureterotomy might have a lower success rate, and failure may limit the success and increase the morbidity of subsequent open anastomotic revision.

The urethral Kock pouch: long-term functional and oncological results in men

OBJECTIVE

To evaluate our experience with men who underwent radical cystectomy and urethral Kock pouch construction between January 1986 and January 1996.

PATIENTS AND METHODS

Complications were classified as early (within the first 3 months after surgery) or late. Continence was assessed by interviewing the patient; they were considered continent if they were completely dry with no need of protection by pads, condom catheter or medication. The patients were followed oncologically and Kaplan-Meier survival curves constructed. Urodynamic studies were used to define the possible causes of enuresis.

RESULTS

Three patients died after surgery from pulmonary embolism. There were 67 early complications in 63 patients. The mean (SD) follow-up was 87.8 (49.1) months. There were 111 treatment failures from cancer; of these, four men only had an isolated local recurrence in the urethra. Late complications included 72 pouch stones in 55 patients, and 36 deteriorated renal units caused by reflux (17), uretero-ileal stricture (11), nipple valve eversion (four) or stenosis (four). Interestingly, 65 renal units that were dilated before surgery improved significantly afterward. Ileo-urethral strictures occurred in seven men and anterior urethral strictures in six. Nine patients were totally incontinent and two had chronic urinary retention. Daytime continence was complete in 94% of men, with nocturnal enuresis in 55; the latter had significantly more residual urine, and a higher amplitude and duration of phasic contractions.

CONCLUSIONS

Orthotopic bladder substitution after cystectomy for cancer is feasible, with good functional and oncological outcomes in properly selected patients. Nevertheless, the use of a hemi-Kock pouch is associated with many valve-related complications.

Urinary diversion: ileal conduit to neobladder

PURPOSE

The goals of urinary diversion have evolved from simply diverting the urine through a conduit to orthotopic reconstruction, which provides a safe and continent means to store and eliminate urine with efforts to provide an improved quality of life. We address meaningful points that may help optimize clinical results in patients with an orthotopic bladder substitute.

MATERIALS AND METHODS

The review involved an objective evaluation of the basic science literature of functional, structural and physiological characteristics of gastrointestinal tissue as a substitute for bladder. Potential problems that may be associated with particular parts of the gut for use in reconstruction are discussed. We also summarize the clinical results and complications of orthotopic reconstruction.

RESULTS

In the last 10 years the paradigm for choosing urinary diversion has changed substantially: In 2002 all patients undergoing cystectomy were neobladder candidates. It is critically important to understand the phenomenon of maturation. The motor and pharmacological response of the implanted gut changes dramatically toward that of the bladder. Structural and ultrastructural changes in the ileal mucosa lead to a primitive epithelium similar to urothelium. The need for reflux prevention is not the same as in ureterosigmoidostomy conduit or continent diversion. Reflux prevention in neobladders is even less important than in a normal bladder. When using nonrefluxing techniques, the risk of obstruction is at least twice that after direct anastomosis. Kidney function is not impaired by diversion if stenosis is recognized and managed. Patient health status is more influenced by underlying disease than by diversion. Complications of neobladders are actually similar to or lower than the true rates after conduit formation, in contrast to the popular view that conduits are simple and safe. Some degree of nocturnal leakage is a consistent finding in most reports despite a technically sound operation. The precise pathogenesis of urinary retention requiring clean intermittent catheterization remains uncertain. There are new complications, such as neobladder rupture and mucous tamponade.

CONCLUSIONS

Orthotopic reconstruction has passed the test of time. In these patients life is similar to that in individuals with a native lower urinary tract. Until a better solution is devised orthotopic bladder reconstruction remains the best option for patients requiring cystectomy.

Cystectomy with prostate sparing for bladder cancer in 100 patients: 10-year experience

PURPOSE

To minimize the risk of incontinence and impotence without compromising oncological outcome, we performed prostate sparing surgery during radical cystectomy for bladder cancer.

MATERIALS AND METHODS

Since 1992, 100 patients with a mean age of 64 years (range 48 to 82) underwent cystectomy for bladder transitional cell carcinoma with prostate sparing based on normal digital rectal examination of the prostate, normal prostate specific antigen (PSA), percent free PSA greater than 15 and normal transrectal ultrasound of the prostate. Prostate biopsies to exclude prostate cancer were performed on patients with an abnormal digital rectal examination, high PSA, percent free PSA less than 15 or hypoechoic lesions on ultrasound. Surgery consisted of transurethral resection of the prostate with analysis of frozen section of the prostatic urethra and transitional prostate and cystectomy with reconstruction by a Z ileal bladder anastomosed to the prostatic capsule after confirmation of the absence of prostate or bladder cancer on frozen sections of the surgical capsule specimens. Patients were followed closely with imaging and laboratory studies every 6 months and annually for 3 years thereafter.

RESULTS

Perioperative death occurred in 1 patient due to septicemia, 20 patients (20%) died of cancer and 6 (6%) died of nonrelated cancer causes. Mean followup 38 months (range 2 to 111). Postoperative pathological stage was PT0 in 2 cases, PtaT1 in 22, PT2 in 48, PT 3 in 28 and N+ in 13. The 5-year actuarial global survival according to pathological stage was pTaT1N0 in 96% of cases, pT2N0 in 83%, pT3N0 in 71% and N+ in 54% (p = 0.0001). The 5-year actuarial cancer specific survival was PT0, Ta T1 in 90% of cases, PT2 in 73%, PT3 in 63% and N- in 8%. The cancer specific survival according to pathological grade was 100% for well differentiated tumors (grade I), 76% for moderately differentiated tumors (grade II) and 47% for poorly differentiated tumors (grade III) (p = 0.003). Local recurrence was pTaT1N0 in 1 of 22 cases (4.5%), pT2N0 in 2 of 40 (5%), pT3N0 in 2 of 23 (8.5%) and N+ in 0 of 13 (0%). Prostate cancer was diagnosed in 3 patients (2 errors in the diagnosis and 1 cancer de novo within 5 years of followup). At 1-year followup 86 of 88 patients (97%) are fully continent (no pad) during the day, and 84 (95%) void 1 to 2 times a night to stay dry. Of 61 patients with previously adequate sexual function 50 (82%) maintained potency with retrograde ejaculation secondary to transurethral resection, 6 (10%) have partial potency and 5 (8.1%) are impotent.

CONCLUSIONS

Cystectomy with prostate sparing for bladder cancer is feasible and offers promising functional results with no additional oncological risk. Careful selection of patients is mandatory.