Should continent diversion be performed in patients with locally advanced bladder cancer?

[Urinary diversions: which one one is right for which patient?]

Standardized operating techniques and surgeons' experiences have contributed to the development of complex urinary diversion systems over the last two decades. Patients' desires and comorbidity risks, such as kidney or bowel dysfunction, as well as their mental and manual abilities need to be taken into account. Careful preoperative decision making is essential if patients are to accept the chosen urinary diversion system and improve their quality of life. Ileal and ileocecal orthotopic neobladders have proven to be effective and comfortable for long-time use, thus stimulating decisions for orthotopic bladder substitution despite the risk of incontinence episodes, especially during the night. Catheterization of continent reservoirs connected to the umbilicus (e.g., ileocecal reservoirs, Mainz pouch I) are widely accepted as an alternative diversion procedure if the urethra and/or sphincter region have to be removed. The patient's desire to avoid a wet stoma and achieve a cosmetically "unchanged" body image is met by these urinary diversion techniques. The surgeon's experience and the patient's mental and general health status must be considered in order to meet the increased complexity of these specific urinary diversions. Nevertheless, elderly patients often tend to prefer an ileal conduit as the easiest solution for urinary diversion. Therefore, even in experienced urological departments, the percentage of patients with orthotopic or self-catheterizable bladder substitution ranges between 30% and 66%, while the ileal conduit is selected in up to 64% of cases after cystectomy. The future of laparoscopic cystectomy has just begun and will affect future techniques of urinary diversion.

Terminal patients with urinary diversion: are there specific treatment or nursing care problems in the primary healthcare sector?

OBJECTIVE

To investigate the treatment and nursing care problems related to the type of urinary diversion in terminal patients experienced by the primary healthcare sector.

METHODS

A questionnaire about treatment and nursing care problems related to urinary diversion was sent to general practitioners (GPs) and district nurse units (DNUs) that had been in contact with 1 of 71 patients who died following cystectomy in a 5-year period. The patients had 1 of 3 types of urinary diversion: ileal conduit (IC), Indiana pouch (IP), or Hautmann orthotopic neobladder (NB).

RESULTS

Both GPs and DNUs reported significant difference in problems associated with the 3 types of urinary diversion favoring the IC (P = .049 and .025, respectively). However, clinical decisions about urinary diversion types are often based on incontinent versus continent diversions. When divided into continent versus incontinent diversions, the analysis revealed no differences in the number of problems (P = .31 and .052, respectively). Comparing IC and NB alone made the difference even less significant (P = .82 and .23, respectively).

CONCLUSIONS

It seems that there are no major disadvantages with one type of urinary diversion when compared to the other as perceived by primary healthcare providers. Relevant and thorough information should be provided to GPs and DNUs in order to minimize problems with all forms of urinary diversion.

Entérocystoplastie de substitution chez l'homme (Hautmann exclu) : principes et applications techniques

Orthotopic urinary reservoir using a bowel segment has become the most favoured form of diversion after radical cystectomy. Ideal neobladder has to (i) store the urine with a low pressure bladder substitute, (ii) protect the upper urinary tract and (iii) provide a better quality of life enabling volitional voiding. A lot of techniques have bee described to construct a reservoir, however, all of them are based on the principle of intestinal loop detubulation. Many intestinal segments have been used, but ileum seems to be preferred in Europe. The upper urinary tract is mainly protected by a low neobladder pressure, rather than an additional antireflux flap-valve-type implantation technique which may increase the risk of uretero-enteric stricture. No significant difference in functional outcome can be observed among the several techniques. In selected cases, orthotopic bladder replacement is well tolerated and feasible and appears to be the gold standard after cystectomy.

Lokalrezidiv nach radikaler Zystektomie bei Harnblasenkarzinom

The prognosis for patients with local recurrence following cystectomy for urothelial bladder cancer is poor. Only a small proportion of patients with good performance status are candidates for any form of therapy at all. Clinical experience shows that local recurrence is often accompanied or followed by systemic tumor spread. Therefore, palliative systemic chemotherapy is the cornerstone of treatment. Local radiotherapy or local tumor resection is reserved for subgroups of patients and to ease local symptoms or complications. Only a few patients are candidates for multimodal therapeutic approaches with curative intent. Despite such efforts, the survival of patients with local recurrence is limited in nearly all cases.

ORTHOTOPIC BLADDER SUBSTITUTION IN WOMEN: NONTRADITIONAL APPLICATIONS

PURPOSE

Orthotopic urinary diversion is a feasible and optimal technique for many women undergoing cystectomy. Although successful outcomes have been achieved, groups at most centers have strict selection criteria. We evaluated our experience with female orthotopic diversion in traditional and nontraditional candidates.

MATERIALS AND METHODS

From September 1, 1995 to February 6, 2003 53 females with a mean age of 62 years underwent orthotopic bladder substitution. Median followup was 24 months. Clinicopathological parameters were evaluated in traditional and nontraditional patients. The nontraditional subset comprised 22 women older than 70 years (12) or had a history of pelvic radiation (2), neoadjuvant chemotherapy (6) or stress incontinence (2).

RESULTS

The entire group had a mean operative time, blood loss and hospital stay of 6.2 hours, 1,135 ml and 8.2 days, respectively. Tumor was organ confined in 38 and extravesical in 14 patients with bladder cancer. Complications were detected in 20 patients, including 9 who were traditional (23%) and 11 who were nontraditional (50%). Daytime and nighttime continence was reported by 46 (87%) and 45 (85%) patients, respectively, of whom 11 (21%) required intermittent catheterization. Of the patients with cancer 42 were disease-free, 2 were alive with disease and 6 died of disease. The nontraditional subset was older (p <0.0003) and had shorter followup (p = 0.05), a higher American Society of Anesthesiologists score (p = 0.01) and a shorter overall survival (p = 0.001) than the traditional group. Continence was seen in 19 of 22 nontraditional patients (86%) and 4 (18%) required intermittent catheterization.

CONCLUSIONS

Orthotopic neobladder diversion offers excellent clinical and functional results, and should be the diversion of choice in most women following cystectomy. A subset of less favorable candidates can also successfully undergo orthotopic substitution with a tolerable toxicity profile.

Radical cystectomy for bladder cancer after definitive prostate cancer treatment

OBJECTIVES

To review our perioperative experience with patients presenting with high-risk bladder cancer who had undergone prior therapy for prostate cancer. With the increase in diagnosis and subsequent treatment of prostate cancer, more patients presenting with high-risk bladder cancer have undergone prior therapy for prostate cancer. Radical cystectomy in these patients can be technically challenging and may be associated with added morbidity.

METHODS

A retrospective review of 458 patients treated with radical cystectomy between January 1993 and January 2002 revealed 29 patients (mean age 72 years) who had received definitive treatment for prostate cancer prior to cystectomy for bladder carcinoma. The initial treatment in this cohort was radical prostatectomy or external beam radiotherapy in 12 (41%) and 17 (59%) men, respectively. Cystectomy was performed for transitional cell carcinoma in 25 (86%), small cell carcinoma in 2 (6%), and sarcoma in 2 (6%) patients.

RESULTS

At the time of cystectomy, the mean blood loss was 1175 mL (range 275 to 3500), and the median length of hospitalization was 8 days (range 4 to 23). No intraoperative or perioperative deaths occurred in this cohort. Twenty-seven early complications were identified in 16 (55%) of 29 patients; no rectal injuries occurred. Patients with prior radiotherapy had a higher rate of extravesical bladder carcinoma (60%) than those patients treated with prior prostatectomy (33%). An orthotopic neobladder diversion was created in 5 patients (17%).

CONCLUSIONS

Patients with bladder cancer previously treated for prostate cancer with external beam radiotherapy or radical prostatectomy have an increased risk of perioperative complications compared with patients undergoing cystectomy without prior therapy. This risk is not prohibitive, and radical cystectomy should remain the treatment of choice for high-risk bladder cancer in this population. Furthermore, orthotopic urinary diversion may be a reasonable option and should be considered in select patients.

Orthotopic urinary diversion after cystectomy for bladder cancer: implications for cancer control and patterns of disease recurrence

PURPOSE

The impact of orthotopic urinary diversion on the quality of cystectomy and ensuing cancer control has not been adequately studied. We analyzed our experience with this clinical problem.

MATERIALS AND METHODS

The records of 214 patients who underwent cystectomy and orthotopic diversion for bladder cancer were retrospectively evaluated and compared with those of 269 treated with an ileal conduit. Analyzed end points included overall and cancer specific survival. We specifically assessed the patterns of relapse and their association with pathological findings at cystectomy in the neobladder group.

RESULTS

No cancer specific survival difference was identified in the neobladder and ileal conduit cohorts when adjusting for pathological stage. Patterns of relapse in 62 of the 214 patients with a neobladder (29%) included local recurrence in 23 (11%), distant recurrence in 19 (9%), and combined local and distant recurrence in 18 (8%). Urethral recurrence was rare (2%). Of 10 patients (4.6%) diagnosed with upper tract recurrence 6 and 4 initially had relapse in the ureteroenteric anastomosis and renal pelvis, respectively. Five of the 6 patients with anastomotic relapse had evidence of disease in the intramural or juxtavesical ureter that was removed en bloc with the cystectomy specimen. Only 1 patient required neobladder takedown after such anastomotic recurrence.

CONCLUSIONS

These results indicate that neobladders do not compromise the quality of preceding cystectomy or interfere with management in the presence of local or distant disease relapse. Our data suggest that involvement of the intramural or juxtavesical ureteral segment at cystectomy irrespective of surgical margin status may identify patients at higher risk for anastomotic recurrence, which is associated with an ominous prognosis.

Urinary diversion after radical cystectomy

At most centers with experience in urinary diversion, an orthotopic urinary reservoir is the diversion of choice after radical cystectomy for bladder cancer. The paradigm has shifted in the past 10 years from actively looking for reasons to do an orthotopic diversion to carefully considering why a patient cannot undergo reconstruction to their native urethra. In our institution, any patient who is to undergo a radical cystectomy for bladder cancer is a potential candidate for orthotopic diversion provided they do not have chronic renal insufficiency. In addition, they must have a negative urethral margin on frozen section at the time of cystectomy, and have the mental and physical capacity to understand what is required to manage the reservoir after surgery. Proper patient selection is the key to success. Notably, chronologic age is not an absolute contraindication to orthotopic diversion. Instead, careful consideration of the patient's comorbid conditions should guide eligibility. In addition, locally advanced disease is not a contraindication to an orthotopic diversion. To have the flexibility to manage whatever situation presents itself intraoperatively, the surgeon performing a urinary diversion after radical cystectomy must be facile with several diversion techniques. At the very least, the surgeon must be comfortable with one type of each major form of urinary diversion, a conduit (incontinent) diversion, a continent cutaneous diversion, and an orthotopic diversion. As a result, radical cystectomy and urinary diversion should be performed at centers with significant experience in all three types of diversions.

[Recurrent urothelial tumor in orthotopic neobladder]

A case of an infiltrating bladder tumor is reported. The pathology was treated by radical cistectomy and orthotopic neo-bladder. After treatment we identified disease in the upper urinary tract and inside the ileal neo-bladder. This case show us the high relapse index of this kind of tumours.

Urinary diversion and bladder substitution in patients with bladder cancer

For the majority of patients with invasive bladder carcinoma, radical cystectomy remains the gold standard of care. As a result the twentieth century has seen the continuous development of methods for reconstructing the urinary tract. Two decades ago the ileal conduit was by far the most commonly used method, whereas today methods geared toward patient continence are first choices in most centers. Some of these methods are unquestionably more complex than the ileal conduit, yet whether they actually yield uniformly improved quality of life is the cause of much debate. Many different variables play a role in determining the best type of reconstruction for an individual bladder cancer patient. This review analyzes the different factors that must be considered to obtain an optimal match between patient and reconstructive method.

Ileal neobladder and local recurrence of bladder cancer: patterns of failure and impact on function in men

PURPOSE

Creation of an ileal neobladder has become a standard procedure in patients undergoing cystectomy for invasive bladder cancer. We evaluated the impact of local recurrence on ileal neobladder function and survival.

MATERIALS AND METHODS

Between April 1986 and February 1997, 357 men underwent radical cystectomy and ileal neobladder substitution at our institution. We retrospectively reviewed the records of these patients to determine patterns of local recurrence and survival rates.

RESULTS

Local recurrence developed in 43 of the 357 patients (12%), in whom median survival plus or minus standard deviation was 17 +/- 1.6 months and median time to recurrence was 10 months (range 2 to 41). Of the 43 patients with local recurrence at followup 36 had local advanced cancer on the final pathological evaluation (stage pT3a or node positive, or greater). A total of 17 patients (43%) had concomitant distant metastasis. Of the 43 patients 3 are alive at 36, 48 and 147 months, respectively. Death was due to disease in 36 cases, chemotherapy related complications in 3 and another cause in 1. Of the 43 patients 40 maintained good neobladder function. Local recurrence interfered with the upper urinary tract in 24 cases, neobladder in 10 and intestinal tract in 7. The neobladder was removed only in 1 patient due to a neovesical intestinal fistula.

CONCLUSIONS

The local recurrence rate after orthotopic urinary reconstruction is 12%. Survival after local recurrence is diagnosed is limited despite multimodality therapy. However, most patients may anticipate normal neobladder function even in the presence of recurrent disease or until death. Thus, creating orthotopic diversion after cystectomy in patients with locally advanced bladder cancer, including macroscopically or microscopically positive lymph nodes, is safe.

Surgery for invasive bladder tumors: technique and outcome

The operative management of invasive transitional cell carcinoma has advanced significantly in the past year, particularly with respect to continent urinary diversion. The long term safety and efficacy of this form of urinary reconstruction is being established in terms of both operative and metabolic complications. The availability of continent diversion can decrease the interval to cystectomy and therefore may impact positively on survival. It has also been shown that continent diversion can safely be offered to patients at high risk for local recurrence. The importance of urethral sensory threshold on postoperative continence is being established. These findings and others continue to enhance the survival and quality of life of patients undergoing cystectomy for invasive bladder cancer.

What is new in urinary diversion

There have been some suggestions for changes in technique and investigations of the quality of life. As experience has grown, there have been increasing numbers of reports of complications. Careful attention to technique, especially in nerve-sparing cystectomy and orthotopic cystoplasty may reduce the rate of incontinence. Increasing awareness of quality of life issues should improve preoperative counselling of patients, especially those whose underlying condition is not life-threatening.

Bladder substitution

Preliminary data have shown that composite reservoirs consisting of gastric segments in combination with ileum or colon may reduce metabolic problems. Orthotopic neobladders are the most natural way to reconstruct the urinary bladder and are a safe option in selected male and female patients. Experimental and preliminary clinical data about new methods using autologous muscle transfer and tissue engineering are promising.

Urinary diversion-related outcome in patients with pelvic recurrence after radical cystectomy for bladder cancer

OBJECTIVES

To evaluate the impact of urinary diversion on disease status, complications, and subsequent treatment in patients with pelvic tumor recurrence after radical cystectomy for bladder cancer.

METHODS

A retrospective review of 201 consecutive cases of radical cystectomy for bladder cancer, performed at our institution between March 1991 and March 1996, identified 33 patients (16.4%) with disease recurrence in the pelvis with or without systemic metastasis. Urinary diversion in patients with tumor recurrence was an ileal conduit, continent cutaneous diversion, or orthotopic neobladder in 19, 3, and 11 patients, respectively. The mean follow-up for all patients undergoing cystectomy was 25.9 months (range 8 to 75). The mean time to diagnosis of local disease recurrence after cystectomy was 13.9 months (range 5 to 50).

RESULTS

In 21 (63.6%) of 33 patients, pelvic recurrence and systemic metastasis were present simultaneously. Disease recurrence was associated with poor outcome: only 8 patients (24.2%) were alive and disease free, 7 of whom had isolated local recurrence without evidence of systemic metastasis. There was no difference in overall survival or type of therapy delivered once disease recurrence was diagnosed between patients with an orthotopic neobladder and those with a cutaneous (continent or incontinent) urinary diversion. The only diversion-related complication resulting from pelvic recurrence was 1 case of tumor invasion into an orthotopic neobladder, requiring conversion to an ileal conduit.

CONCLUSIONS

The type of urinary diversion did not impact a patient's risk of complications, the ability to receive salvage treatment, or overall survival once pelvic recurrence was diagnosed. Patients at high risk of pelvic recurrence should not be excluded from receiving an orthotopic urinary diversion.