Ileal orthotopic bladder substitutes. What we have learned from 12 years' experience with 200 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).

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Contemporary techniques and outcomes of robotic assisted radical cystectomy with intracorporeal urinary diversion

The open approach to radical cystectomy continues to be accompanied by significant morbidity despite enhanced recovery protocols (ERP). Robotic assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) has become an increasingly popular technique for removal of aggressive bladder cancer and subsequent urinary diversion. Randomized clinical trials comparing the robotic and open techniques address the uncertainty surrounding oncological efficacy of the RARC and show that RARC is at least comparable to open radical cystectomy (ORC) in terms of oncologic adequacy and survival. Although RARC with ICUD is a technically challenging procedure, surgeons have noted ergonomic advantages while patients experience less blood loss and quicker time to recovery and to adjuvant chemotherapy (AC), if necessary. Even with these benefits, there is a paucity of data describing outcomes of ICUD. For those surgeons who have switched to ICUD, priority remains standardization of a protocol for the reconstructive component and for a safe transition from extracorporeal urinary diversion (ECUD) to ICUD. Additionally, there is a need for evidence of reduced financial toxicity for the patient, as well as more comprehensive cost-effectiveness analyses. The literature from this review represents 10 years of accumulating data on techniques and outcomes of RARC with ICUD.

Robot-assisted radical cystectomy with totally intracorporeal neobladder diversion: perioperative, oncologic, and functional outcomes

Background

The use of robot-assisted radical cystectomy (RARC) has increased rapidly in the past decade. However, reports of intracorporeal neobladder diversion remain limited. This article aimed to provide the surgical steps for RARC with totally intracorporeal neobladder diversion and the present perioperative, oncologic, and functional outcomes.

Methods

Between June 2017 and January 2020, RARC with intracorporeal neobladder diversion was performed in 12 male patients. Perioperative variables, pathologic data, early and late complications, urinary continence, potency, and recurrence-free survival were evaluated as outcome measures.

Results

The surgery was successful in all cases without open conversion. The median operative time, estimated blood loss, and postoperative hospital stay were 419 min (range, 315–640 min), 400 mL (range, 250–1,200 mL), and 14.5 days (range, 9–25 days), respectively. No positive surgical margins nor lymph nodes were observed. Eleven minor (grades 1 and 2) and one major (grades 3–5) complications were found in the early (0–30 days) period and six minor and one major complications in the late (>30 days) period. The median follow-up time was 13.1 months (range, 5.4–32.0 months), and two patients died due to metastatic disease. At 6 months after surgery, the daytime continence rate was 90.0%, while the nighttime continence rate was 80.0%. Only two patients (16.7%) reported capability of potency. The study was limited by a small sample size and short follow-up.

Conclusions

RARC with intracorporeal neobladder is a complex procedure but technically feasible with acceptable oncologic and functional outcomes. Studies with long-term follow ups and increased number of cases and randomized trials are indispensable to assess the potential of this technique.

Cost-effectiveness analysis of two kinds of bladder cancer urinary diversion: Studer versus Bricker

Background

The purpose of our study was to evaluated the cost-effectiveness of two bladder cancer (BCa) urinary diversions: Studer and Bricker.

Methods

The study included 44 patients with Studer and 40 patients with Bricker. Collected and analyzed the patient's basic characteristics, health care costs, and prognosis survival. The quality-adjusted life-year (QALY) were calculated and verified by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30, Version 3, Chinese version). Cost-effectiveness depends on the incremental cost per QALY. The incremental cost-effectiveness ratio (ICER) was determined using the cost/QALY.

Results

We found the average total cost of the Studer group was $7,173.7±1,390.8, and the Bricker group was $6,545.2±1,458.4. There were significant differences in hospitalization time, total hospitalization expenses, bed cost, comprehensive medical service charge and drugs cost (all P<0.05). The hospitalization time, total hospitalization expenses, bed cost, comprehensive medical service charge, surgical treatment cost and drugs cost in Studer group were higher than those in Bricker group, while there was no significant difference in postoperative complications between the two groups (P=0.858). The ICER of Studer group and Bricker group were $8,535.6±2,027.6/QALY and $11,158.2±2,944.9/QALY, respectively. The ICER of Studer group over Bricker group was $2,514.0/QALY.

Conclusions

We found the Studer group had higher hospitalization time, total hospitalization expenses, bed cost, comprehensive medical service charge, surgical treatment cost, and drugs cost than the Bricker group, but the Studer group had a higher ICER than the Bricker group.

Comparison of a Significant Decline in the Glomerular Filtration Rate between Ileal Conduit and Ileal Neobladder Urinary Diversions after Radical Cystectomy: A Propensity Score-Matched Analysis

Urinary diversion after radical cystectomy is associated with a risk of renal function impairment. A significant decline in the glomerular filtration rate (GFR) (i.e., a ≥30% decline in baseline GFR after 12 months) is associated with long-term renal function impairment. We compared the significant GFR decline between ileal conduit and ileal neobladder urinary diversions 12 months after radical cystectomy. We retrospectively included radical cystectomy patients. Propensity score-matched analysis was performed. The primary outcome was the incidence of a significant GFR decline in ileal conduit urinary diversion (ileal conduit group) and ileal neobladder urinary diversion (ileal neobladder group) 12 months after radical cystectomy. The secondary outcomes were the change of GFR and the incidence of end-stage renal disease (ESRD) in the two groups. After propensity score matching, the ileal conduit and neobladder groups had 117 patients each. The incidence of a significant GFR decline was not significantly different between ileal conduit and ileal neobladder groups (12.0% vs. 13.7%, p = 0.845). The change of GFR and ESRD incidence were not significantly different between the two groups (−8.4% vs. −9.7%, p = 0.480; 4.3% vs. 5.1%, p > 0.999, respectively). These results can provide important information on appropriate selection of the urinary diversion type in radical cystectomy.

Multimodality Imaging Findings Postcystectomy: Postoperative Anatomy, Surgical Complications, and Surveillance Imaging

Various surgical techniques exist for urinary diversion post cystectomy and each have different imaging features. This diverse range of surgical procedures can make imaging interpretation difficult and so familiarity with the postoperative anatomy is essential. Multiple imaging modalities and techniques are available for the radiologist's assessment including fluoroscopic studies, computed tomography, magnetic resonance, and radionuclide imaging. Knowledge of when each of these modalities is indicated and the typical imaging appearances is essential for early identification of postoperative complications and detection of tumor recurrence. This information enables the radiologist to make an accurate and early diagnosis and subsequently guide the management pathway for these patients.

Long-term functional recovery after orthotopic spiral ileal bladder substitution

Background

To explore the value of orthotopic spiral ileal bladder substitution (OSIBS) following radical cystectomy in treating bladder cancer patients by investigating the short- and long-term postoperative complications and assessing the quality of life in patients who had undergone OSIBS.

Methods

The post-operative complications were retrospectively analyzed among bladder cancer patients who had undergone radical cystectomy + OSIBS in our center from January 2001 to January 2017. The quality of life was assessed by using the Function Assessment of Cancer Therapy-Bladder Cancer Form (FACT-BL). Patients were followed up by mails, telephone, and outpatient visits.

Results

A total of 68 subjects were included in this study. All patients undergoing radical cystectomy + OSIBS were followed up for an extended period. The patients aged 39–68 years (mean: 60.34±9.43 years). The surgeries were completed, and all the patients were smoothly discharged after good postoperative recovery. Of the 68 patients who had completed the follow-up visits, 10 had early complications (14.71%), and 11 (17.64%) developed late complications. The blood urea nitrogen (BUN) (t=0.358, P=0.764) and serum creatinine (Cr) (t=1.305, P=0.196) levels showed no significant difference before and after surgery. The serum potassium (t=1.347, P=0.169), sodium (t=−1.748, P=0.144), and calcium (t=1.097, P=0.319) levels also showed no significant changes before and after surgery. However, the change in serum chlorine level was statistically significant (t=−4.701, P=0.000). To support urinary function, the patients were encouraged to take exercises During the 10-year follow-up period, the daytime urinary continence rate reached 94.1% (n=64) in the daytime, and the nighttime incontinence rate was 13.2% (n=9). Six months after the surgery, the neobladder capacity was (365.02±45.11) mL, the maximum flow rate was (14.36±1.41) mL/s, and the post-voiding residual (PVR) was (26.01±8.10) mL. The total FACT-BL score was (124.8±13.4) during the 10-year follow-up.

Conclusions

After 10 years of follow-up, the early and late complications in patients who had undergone radical cystectomy + OSIBS were within acceptable range and the daily and nightly continence levels allowed normal daily life. OSIBS not only preserves the physical integrity of the body but also has normal physiological characteristics of the bladder. It remarkably improves the postoperative quality of life and can be easily accepted by patients. Therefore, it is an ideal surgical procedure.

Contemporary techniques and outcomes of robotic cystectomy and intracorporeal urinary diversions

PURPOSE OF REVIEW

Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is being increasingly performed worldwide. This review summarizes recent technical developments and outcome data for RARC with ICUD.

RECENT FINDINGS

With the recent description of intracorporeal continent cutaneous diversion, all classes of urinary diversion can presently be performed totally intracorporeally. The summary of our seven cases of intracorporeal continent cutaneous diversion in this article brings the number of reported cases in the literature to 17. Additional recent advancements in ICUD focus on novel technical descriptions and outcome data. Several intracorporeal orthotopic ileal neobladder techniques have been described with intermediate perioperative outcomes. There is some rationale for reduced overall, wound, gastrointestinal and genitourinary complications with ICUD.

SUMMARY

RARC with intracorporeal diversion is a feasible option for patients with bladder cancer. Prospective and randomized outcome data are needed to better characterize the benefit of ICUD in patients following radical cystectomy.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Nontraumatic posterior urethral stenosis

INTRODUCTION

Posterior urethral stenoses and contractures are complications after treatment of benign prostatic hyperplasia (BPH), localised prostate cancer (PCa), and orthotopic neobladder formation, compromising prognosis and functional outcomes.

OBJECTIVES

To identify factors related to aetiology, prevention and treatment of non-traumatic posterior urethral stenosis and contractures.

ACQUISITION OF EVIDENCE

Review of the published evidence related to posterior urethral stenosis and contractures after PCa treatment, BPH therapies and orthotopic neobladder formation. PubMed database search with English and Spanish papers considered. Cohort studies, case series, prospective and retrospective studies and review papers were included.

SYNTHESIS OF EVIDENCE

Posterior urethral stenoses and contractures are common, leading to significant morbidity. A worsening on voiding quality should rise some concerns. Careful surgical and/or radiotherapic techniques prevent their development. Endoscopic therapies are the initial approach, with complex urethroplasties often required. Subsequent urinary incontinence, the most important sequelae, may need artificial sphincters.

CONCLUSIONS

Non-traumatic posterior urethral stenoses could be important complications, potentially compromising the outcomes of initial therapy. They could require complex surgeries leading to urinary incontinence.

Santosh PGI pouch: A new innovation in urinary diversion

Introduction

To know the feasibility and outcome of the Santosh PGI pouch as a new innovative technique of continent cutaneous diversion (CCD) following cystectomy.

Material and methods

Twelve patients (eleven with carcinoma of the bladder and one with an exstrophy of the bladder) underwent CCD using the Santosh PGI pouch after cystectomy. A 50-cm segment of terminal ileum was isolated 15-20 cm proximal to the ileocecal junction. The ileal segment was folded into the form of an ‘S’ configuration. On the antimesenteric border three longitudinal incisions were performed of about 7 cm in length. The terminal 8 cm portion of the distal part of the pouch was used for creating the intussuscepted nipple valve. Demucosalization of the interior of the nipple, fixing the nipple valve with the serosa of the pouch wall and wrapping of the catheterizable channel with a pouch wall for providing continence was done. The uretero-pouch anastomosis was done using the serosal lined tunnel technique. The catheterizable channel was brought out through the right rectus muscle.

Results

Median follow-up of the patients was 13.5 months. No significant complications were noted in the pouch reconstruction. Duration of the pouch reconstruction was around 75-110 min. Postoperatively, one patient had a UTI and another had paralytic ileus on the follow-up. All patients were doing regular CIC with acceptable continence of up to 400 ml. No ureteroileal anastomotic stricture or difficulty in catheterizing the pouch was seen.

Conclusions

The Santosh PGI pouch, which is a type of CCD, is technically feasible, easy to reconstruct with acceptable continence and offers minimal morbidity.

Robot-assisted intracorporeal pyramid neobladder

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Urinary diversion after radical cystectomy for bladder cancer: options, patient selection, and outcomes

CONTEXT

The urinary reconstructive options available after radical cystectomy (RC) for bladder cancer are discussed, as are the criteria for selection of the most appropriate diversion, and the outcomes and complications associated with different diversion options.

OBJECTIVE

To critically review the peer-reviewed literature on the function and oncological outcomes, complications, and factors influencing choice of procedure with urinary diversion after RC for bladder carcinoma.

EVIDENCE ACQUISITION

A Medline search was conducted to identify original articles, review articles, and editorials on urinary diversion in patients treated with RC. Searches were limited to the English language. Keywords included: 'bladder cancer', 'cystectomy', 'diversion', 'neobladder', and 'conduit'. The articles with the highest level of evidence were selected and reviewed, with the consensus of all of the authors of this paper.

EVIDENCE SYNTHESIS

Both continent and incontinent diversions are available for urinary reconstruction after RC. In appropriately selected patients, an orthotopic neobladder permits the elimination of an external stoma and preservation of body image without compromising cancer control. However, the patient must be fully educated and committed to the labour-intensive rehabilitation process. He must also be able to perform self-catheterisation if necessary. When involvement of the urinary outflow tract by tumour prevents the use of an orthotopic neobladder, a continent cutaneous reservoir may still offer the opportunity for continence albeit one that requires obligate self-catheterisation. For patients who are not candidates for continent diversion, the ileal loop remains an acceptable and reliable option.

CONCLUSIONS

Both continent and incontinent diversions are available for urinary reconstruction after RC. Orthotopic neobladders optimally preserve body image, while continent cutaneous diversions represent a reasonable alternative. Ileal conduits represent the fastest, easiest, least complication-prone, and most commonly performed urinary diversion.

Early and late urodynamic assessment of the orthotopic N-shaped neobladder

The present study aimed to report the urodynamic data from 46 male patients who underwent an orthotopic N-shaped neobladder replacement following a radical cystectomy during a 12-month period and to provide urodynamic evidence for the improvement of this technique. A total of 46 consecutive male patients underwent a radical cystectomy and orthotopic N-shaped neobladder substitution due to muscle-invasive bladder cancer. Uroflowmetry, cystometry and urethral pressure profilometry were analyzed at 3-12 months following the surgery. The mean pressure of the neobladders was <15 cm H₂O at volumes of <400 ml and 22.4 cm H₂O at 100% capacity at 6 months. The mean pressure of the contractions was <40 cm H₂O at 6 months. The mean filling pressure following the surgery at 3 months was higher compared with that at 6 months. No difference was observed at the other time-points. When comparing the 9- and 12-month urodynamic characteristics, no significant changes were observed in the cystometric capacity. The mean post-void residual (PVR) urine volume was 58 ml. A mean voiding peak of 16.2 ml/sec was obtained using the Valsalva maneuver. The daytime continence rate was 90% at 12 months while the night-time continence rate was 60%.

The Studer orthotopic neobladder: long-term (more than 10 years) functional outcomes, urodynamic features, and complications

PURPOSE

Radical cystectomy and urinary diversion are the standard treatment for invasive bladder cancer. We analyzed the long-term (>10 years postoperatively) functional outcomes, complications, and urodynamic findings in a single center series of patients who underwent cystectomy and a Studer ileal neobladder substitution.

MATERIALS AND METHODS

A retrospective chart review of 108 Studer pouches constructed during 1990 and 2011 was performed. Data were analyzed in terms of long-term (>10 years) outcomes. Complications, incontinence, voiding difficulties, upper urinary tract changes, overall satisfaction, and urodynamic findings of the reservoir were obtained.

RESULTS

We evaluated 19 out of 50 patients who had lived for over 10 years postoperatively. Another 31 patients were not traced: 7 patients died following recurrence, 15 died due to exacerbation of a comorbidity, and 9 patients were lost to follow-up. Concerning complications, 6 patients had an atrophied kidney, 5 patients had moderate hydronephrosis, 5 patients had chronic recurrence of pylelonephritis, and 2 patients had voiding difficulty because of bladder neck stricture due to clean intermittent catheterization. One patient underwent an operation due to intestinal obstruction. Seven patients had incontinence; all 7 patients showed intermittently at night and 2 patients even in waking hours. Maximum bladder capacity was 484.1±119.2 mL, maximum flow rate was 13.6±9.7 mL/sec, and post-void residual urine volume was 146.8±82.7 mL.

CONCLUSION

Long-term outcomes with the Studer orthotopic ileal neobladder have an acceptable complication rate and good functional results. However, potential adverse outcomes such as renal deterioration, dysfunctional voiding should also be considered.

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.

Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy

BACKGROUND

Surgery performed to improve or replace the function of the diseased urinary bladder has been carried out for over a century. Main reasons for improving or replacing the function of the urinary bladder are bladder cancer, neurogenic bladder dysfunction, detrusor overactivity and chronic inflammatory diseases of the bladder (such as interstitial cystitis, tuberculosis and schistosomiasis). There is still much uncertainty about the best surgical approach. Options available at the present time include: (1) conduit diversion (the creation of various intestinal conduits to the skin) or continent diversion (which includes either a rectal reservoir or continent cutaneous diversion), (2) bladder reconstruction and (3) replacement of the bladder with various intestinal segments.

OBJECTIVES

To determine the best way of improving or replacing the function of the lower urinary tract using intestinal segments when the bladder has to be removed or when it has been rendered useless or dangerous by disease.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of surgery involving transposition of an intestinal segment into the urinary tract.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for appropriateness for inclusion and for risk of bias by the review authors. Three review authors were involved in the data extraction. Data were combined in a meta-analysis when appropriate.

MAIN RESULTS

Five trials met the inclusion criteria with a total of 355 participants. These trials addressed only five of the 14 comparisons pre-specified in the protocol. One trial reported no statistically significant differences in the incidence of upper urinary tract infection, uretero-intestinal stenosis and renal deterioration in the comparison of continent diversion with conduit diversion. The confidence intervals were all wide, however, and did not rule out important clinical differences. In a second trial, there was no reported difference in the incidence of upper urinary tract infection and uretero-intestinal stenosis when conduit diversions were fashioned from either ileum or colon. A meta-analysis of two trials showed no statistically significant difference in daytime or nocturnal incontinence amongst participants who were randomised to ileocolonic/ileocaecal segment bladder replacement compared to an ileal bladder replacement. However, one small trial suggested that bladder replacement using an ileal segment compared to using an ileocolonic segment may be better in terms of lower rates of nocturnal incontinence. There were no differences in the incidence of dilatation of upper tract, daytime urinary incontinence or wound infection using different intestinal segments for bladder replacement. However the data were reported for 'renal units', but not in a form that allowed appropriate patient-based paired analyses. No statistically significant difference was found in the incidence of renal scarring between anti-refluxing versus freely refluxing uretero-intestinal anastomotic techniques in conduit diversions and bladder replacement groups. Again, the outcome data were not reported as paired analysis or in form to carry out paired analysis.

AUTHORS' CONCLUSIONS

The evidence from the included trials was very limited. Only five studies met the inclusion criteria; these were small, of moderate or poor methodological quality, and reported few of the pre-selected outcome measures. This review did not find any evidence that bladder replacement (orthotopic or continent diversion) was better than conduit diversion following cystectomy for cancer. There was no evidence to suggest that bladder reconstruction was better than conduit diversion for benign disease. The clinical significance of data from one small trial suggesting that bladder replacement using an ileal segment compared to using an ileocolonic segment is better in terms of lower rates of nocturnal incontinence is uncertain. The small amount of usable evidence for this review suggests that collaborative multi centre studies should be organised, using random allocation where possible.

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.

Oncological and functional outcomes of radical cystectomy and orthotopic bladder replacement in women

OBJECTIVE

To report oncological and functional results in women undergoing radical cystectomy and orthotopic bladder replacement.

MATERIALS AND METHODS

The charts of all women undergoing bladder replacement after radical cystectomy at UCSF through April 2008 were reviewed. Pathologic characteristics, survival (overall and disease-specific), and urinary functional outcomes are reported. Survival was estimated using Kaplan-Meier methods, and Cox proportional hazards regression analyses were performed to determine factors associated with incontinence, retention, and mortality.

RESULTS

Fifty-six women with a mean follow-up of 35 months were analyzed. The cancer recurrence rate was 32%. Kaplan-Meier estimated 5-year recurrence-free, cancer-specific, and overall survival were 54%, 57%, and 47%, respectively. Pathologic lymph node status (HR 14.2, P <.001) and age at diagnosis (HR 1.7, P = .04) were the only clinical or pathologic characteristics significantly associated with survival. The overall continence rate (no pads) was 57%. Hypercontinence occurred in 24% of patients.

CONCLUSIONS

With careful patient selection and usage of urethral frozen section, rates of local recurrence are low. Overall rates of incontinence (43%) and hypercontinence (24%) are similar to those previously reported. When pathologically organ-confined, women have an excellent disease-specific survival. Orthotopic bladder replacement is a safe and effective form of urinary diversion after radical cystectomy in women.

Renal and functional outcomes following cystectomy and neobladder reconstruction

BACKGROUND

Orthotopic reconstruction following cystectomy has evolved in an attempt to restore anatomy and function to as close as possible to the preoperative state. We review the renal and functional outcomes of patients who underwent cystectomy and neobladder reconstruction at our institution.

METHODS

Between December 2003 and October 2007, 31 patients underwent cystectomy with Studer neobladder reconstruction at the Ottawa Hospital, Ottawa, Ontario, Canada. Follow-up data were obtained regarding renal function (serum creatinine, μmol/L), continence, urinary flow rates and post-void residual (PVR) at 3, 6 and 12 months after surgery. Change in creatinine from preoperative baseline was calculated and analyzed by student t-test to determine if there was a significant rise in creatinine.

RESULTS

There was a statistically significant increase in creatinine from preoperative baseline, with an average increase of 17.3 μmol/L, 21.8 μmol/L and 26.3 μmol/L at 3, 6 and 12 months, respectively. Six patients developed hydronephrosis. Excluding patients with hydronephrosis, there continued to be a statistically significant rise in creatinine with an average increase of 11.9 μmol/L, 14.7 μmol/L and 19.4 μmol/L at 3, 6 and 12 months, respectively. At 1 year, daytime continence was achieved by 89% of patients; 70% were continent at night.

INTERPRETATION

Orthotopic neobladders have excellent functional outcomes with low rates of incontinence, which improved throughout follow-up. A significant proportion of patients developed hydronephrosis, highlighting the need for close follow-up to prevent reversible renal deterioration. Creatinine increased during follow-up irrespective of the development of hydronephrosis, but the clinical significance is unknown.

Neovesical-urethral anastomotic stricture successfully treated by ureteral dilation balloon catheter

Neovesical-urethral anastomotic stricture is a complication of orthotopic neobladder, with a reported incidence of 2.7% to 8.8%. Strictures of the neovesico-urethral anastomotic site can be treated with regular self-dilation, but high-grade strictures require a surgical procedure involving incision by electrocautery or cold knife. Here we describe a grade III neovesical-urethral anastomotic stricture after an orthotopic bladder substitution that was successfully treated by use of a ureteral dilation balloon catheter.

Urinary diversion trends at a high volume, single American tertiary care center

PURPOSE

We analyzed patient characteristics and practice patterns at our institution with time, and identified current patterns and factors contributing to the choice of urinary diversion.

MATERIALS AND METHODS

We reviewed the records of 553 consecutive radical cystectomy and urinary diversions performed from January 2000 to July 2005. Multivariate analysis was done to determine significant differences in diversion choice.

RESULTS

We analyzed the records of 539 patients, including 338 with an ileal conduit and 201 with a neobladder. Patients with a neobladder were younger (mean age 62 vs 71 years) and had fewer comorbidities (American Society of Anesthesiologists class greater than 2 in 31% vs 69%) than those with an ileal conduit. Mean age and the percent of American Society of Anesthesiologists class 3 or 4 cases increased during the study. Neobladder represented 47% of urinary diversions in 2000 and 21% in 2005. On multivariate analysis age (p <0.001), gender (p = 0.004), surgery year (p = 0.002), American Society of Anesthesiologists class greater than 2 (p = 0.004), organ confined disease (p = 0.01) and surgeon (p <0.001) independently predicted diversion choice. Patients were dichotomized into young (younger than 65 years) and old (65 years old or older) groups. Overall 59% of younger and 26% of older patients received a neobladder (p <0.001).

CONCLUSIONS

There was a significant trend toward the more liberal use of ileal conduit urinary diversion. Patients with female gender, advanced age, significant medical comorbidity or locally advanced disease were less likely to undergo neobladder urinary diversion. This trend is partly explained by surgeon preference combined with an aging, more comorbid patient population. Neobladder continues to be the most commonly performed urinary diversion in patients younger than 65 years.

The impact of prior prostatic surgery on urinary continence in patients undergoing orthotopic ileal neobladder

OBJECTIVE

To establish if previous surgery for benign prostatic hyperplasia (transurethral resection of the prostate or open prostatectomy), age, and preservation of prostatic apex can influence postoperative urinary continence in patients submitted to radical cystectomy and orthotopic ileal neobladder.

PATIENTS AND METHODS

We analyzed 62 patients with bladder cancer who were treated with radical cystectomy and orthotopic ileal neobladder between 1987 and 1998 and had been followed for at least 24 months. The average age and median follow up were 61 years and 53 months, respectively. Postoperative urinary continence was correlated with 3 factors: patient age, preservation of prostatic apex during surgical excision and prior prostatic surgery for benign disease. Patients were defined as incontinent when they had to use more than 1 protective pad at the daytime.

RESULTS

The overall incidence of urinary incontinence was 12.9%(8 out of 62 patients). The only statistically significant factor that impacted upon urinary continence was previous prostatic surgery, with respectively 33% versus 7% rate of incontinence for patients previously operated on and for those without previous operation (p = 0.023 odds ratio = 6.5, 95% confidence interval). Preservation of prostatic apex did not reach difference, 12% versus 13%, for those with and without preservation, and age also did not influence the postoperative continence rate.

CONCLUSIONS

Prior prostatic surgery for benign prostatic hyperplasia probably can increases the risk for postcystectomy incontinence and preservation of prostate apex did not affect the continence rate. This issue deserves to be considered by the surgeon and must be discussed previously with the patients when planning an orthotopic bladder replacement.

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.

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

Aims and background

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

Methods

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

Results

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

Conclusions

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

Urinary diversion: 30 years experience of a single centre in Republic of Macedonia

OBJECTIVES

The aim of this report is to present our 30 years experience with various types of urinary diversions, in particular the Bricker and Studer techniques for the management of muscle invasive bladder cancer at our institution. Perioperative, early and late complications are also evaluated.

MATERIAL AND METHODS

Between 1977 and 2007, 186 male and 15 female patients underwent combined radical cystectomy, pelvic lymphadenectomy and urinary diversion. In two subgroups of patients we evaluated the complications, divided as early and late, and subdivided as those related or unrelated to the neobladder. Mean follow up time was 28 months (range 12-60 months).

RESULTS

Two main types of urinary diversion were performed: the ileal conduit diversion using a technique previously described by Bricker and the ileal neobladder diversion using a technique previously described by a Studer. The ages at surgery ranged from 40 to 82 years with a mean age of 60 years. Histopathologically, transitional cell carcinoma was the most common tumor cell type (93,7%), followed by difuse papilomatosis (5.5%) and adenocarcinoma (0.7%). The pathological tumor stage was pT1 (4.7%), pT2 (31.4%), pT3 (50.3 %) and pT4a (13,3%). Histological evidence of regional lymph node involvement was seen in 25% of the cases. From 52 patients from the Studer subgroup perioperative complications were found in 16 patients (30.7%). Specific early complications directly related to the neobladder occurred in 14 (26.9%) patients. Prolonged ileus in 2 patient (3.8%), ureteral leakage in 9 patients (17.3%), mucous buildup within the diversion in 3 patients (5.7%). Late complications occurred in 10 patients (19.2%): retention of the urine in 4 patients (7.6%) (stricture of the urethra-pouch anastomosis in one 1 patient) and to big reservoir in 3 patients. One patient (1.9%) developed prolonged metabolic acidosis. Stone formation was observed in one patient, two years postoperatively. Unilateral hydroureteronephrosis was observed in 2 patients whereas bilateral hydroureteronephrosis was observed in one patients at one year postoperatively. Perioperative and late complications were similar in the 32 patients from the Bricker subgroup.

CONCLUSION

We show that our results with urinary diversion are promising in patients requiring radical cystoprostatectomy. The two methods preferred in our institution offer a sufficient protection of the upper urinary tract with a low complication rate, good voiding function and continence.