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Agarwal S, Sharma D, Gupta A, Sankhwar S. Continent cutaneous diversion pouch calculi. BMJ Case Rep 2018; 2018:bcr-2018-226447. [PMID: 30219784 DOI: 10.1136/bcr-2018-226447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Samarth Agarwal
- Department of Urology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | | | - Akansha Gupta
- Department of Obstetrics and Gynaecology, Jolly Grant Medical College, New Delhi, India
| | - Satyanarayan Sankhwar
- Department of Urology, CSM Medical University (Upgraded KGMC), Lucknow, Uttar Pradesh, India
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Affiliation(s)
- D. Fontana
- Divisione Universitaria di Urologia 2, Ospedale San Giovanni Battista-Molinette, Università degli Studi di Torino
| | - P. Destefanis
- Divisione Universitaria di Urologia 2, Ospedale San Giovanni Battista-Molinette, Università degli Studi di Torino
| | - A. Cugiani
- Divisione Universitaria di Urologia 2, Ospedale San Giovanni Battista-Molinette, Università degli Studi di Torino
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Open Techniques and Extent (Including Pelvic Lymphadenectomy). Bladder Cancer 2018. [DOI: 10.1016/b978-0-12-809939-1.00024-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
We present a review on the current options for continent urinary diversion and their different indications on the basis of patient selection. In current clinical practice continent urinary diversion is being used world-wide in patients undergoing radical cystectomy and in severe cases of benign bladder pathologies. We also discuss the specific complications of continent urinary diversion and highlight the need to rigorously monitor these patients in the long- term specifically in terms of their renal function and cancer recurrence.
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Affiliation(s)
- Andrew Moon
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - Nikhil Vasdev
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - Andrew C. Thorpe
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
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6
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Muscle invasive bladder cancer: from diagnosis to survivorship. Adv Urol 2012; 2012:142135. [PMID: 22924038 PMCID: PMC3424737 DOI: 10.1155/2012/142135] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 05/16/2012] [Indexed: 11/17/2022] Open
Abstract
Bladder cancer is the fifth most commonly diagnosed cancer and the most expensive adult cancer in average healthcare costs incurred per patient in the USA. However, little is known about factors influencing patients' treatment decisions, quality of life, and responses to treatment impairments. The main focus of this paper is to better understand the impact of muscle invasive bladder cancer on patient quality of life and its added implications for primary caregivers and healthcare providers. In this paper, we discuss treatment options, side effects, and challenges that patients and family caregivers face in different phases along the disease trajectory and further identify crucial areas of needed research.
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Destefanis P, Fontana D. Proposta di Follow-Up del Paziente con Neovescica Ortotopica. Urologia 2010. [DOI: 10.1177/0391560310077016s07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Today, the most widely employed “solution” after radical cystectomy is bladder substitution through the creation of an othotopic neobladder. Many kind of othotopic neobladders have been proposed and employed and, during the last 20 years, we have observed a continuous improvement of such techniques. Nevertheless, notwithstanding these technical improvements, patients with orthotopic neobladder can still report many various complications. Thus, a specific “functional” follow-up is mandatory; “functional” follow-up should be associated and integrated to oncological follow-up that these patients usually undergo. Functional follow-up should be lifelong.
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Affiliation(s)
- P Destefanis
- Divisione Universitaria di Urologia 2 - Ospedale San Giovanni Battista “Molinette” - Torino
| | - D. Fontana
- Divisione Universitaria di Urologia 2 - Ospedale San Giovanni Battista “Molinette” - Torino
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Astroza Eulufi G, Velasco PA, Walton A, Guzmán KS. [Enterocystoplasty for interstitial cystitis. Deferred results]. Actas Urol Esp 2009; 32:1019-23. [PMID: 19143294 DOI: 10.1016/s0210-4806(08)73981-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Interstitial cystitis is clinically diagnosed entity, characterized by irritative bladder symptoms and suprapubic pain. It is reported that up to 10% of patients are refractory to conservative management. In these patients' supratrigonal cystectomy and bladder enlargement enterocystoplasty has been used. OBJECTIVE To evaluate the results of our series of patients that underwent this surgical technique due they were suffering interstitial cystitis refractory to conservative treatment. MATERIALS AND METHODS We reviewed the medical records of patients that underwent supratrigonal cystectomy and bladder enlargement enterocystoplasty in our hospital between 1999 and 2006. Mictional rhythm, pre and postoperative bladder capacity measured by cystodistention, postoperative bladder capacity measured as mictional volume, surgical complications and the degree of satisfaction of patients measured by means of application of a survey were recorded. Mictional rhythms and pre and postoperative bladder capacity were compared. RESULTS 15 interventions were performed. Mean preoperative bladder capacity was 125 cc, Mean preoperative mictional rhythm was 30.5 times a day. There were perioperative complications in 5 patients. The mean postoperative mictional volume was 355 cc and mean frequency was 8.26. When comparing pre and postoperative rythms and urinary volume there were statistically significant differences (p:0.0008 y p:0.0007 respectively). Regarding the survey, 13 patients were satisfied in terms of mictional frequency and 11 patients were satisfied in terms of suprapubic pain.
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Affiliation(s)
- G Astroza Eulufi
- Departamento de Urología, Hospital Clínico Pontificia Universidad Católica de Chile.
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KAMAT NAGESH, DASGUPTA RANAN, SHABBIR MAJID, NEULANDER ENDRZ, KLEIN JOSEPH, KANETI JACOB, JOSEPH JEANV, PATEL HITENDRAR, MCHUGH LYNSEYA, GRIFFITHS THOMASR, SHERGILL IQBALS, HAMID RIZWAN, GUPTA SUJOY, MAMMEN KIMJ, WALTON THOMASJ, MICELI PAULA. Dynamic three-dimensional spiral computed tomographic cysto-urethrography: a novel technique for evaluating post-traumatic posterior urethral defects. BJU Int 2008. [DOI: 10.1111/j.1464-410x.04949.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Arrowsmith SD. Urinary diversion in the vesico-vaginal fistula patient: general considerations regarding feasibility, safety, and follow-up. Int J Gynaecol Obstet 2007; 99 Suppl 1:S65-8. [PMID: 17878056 DOI: 10.1016/j.ijgo.2007.06.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Some women with vesico-vaginal fistulas (VVF) have injuries so severe that they cannot be repaired in a way that would restore continence. The management of these women has been a source of controversy among the providers of VVF care. It would seem logical that urinary diversion surgery could relieve the suffering endured by women with unrelenting urinary incontinence. However, there is little objective evidence on which to base determinations on the safety and practicality of performing urinary diversion in the desperately poor areas where fistulas occur. As in all other areas of VVF care, more data are required before good treatment choices can be made for patients with inoperable VVFs.
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Affiliation(s)
- S D Arrowsmith
- Rehoboth McKinley Christian Healthcare Services, Gallup, New Mexico 87301, USA.
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Stolzenburg JU, Schwalenberg T, Liatsikos EN, Sakelaropoulos G, Rödder K, Hohenfellner R, Fisch M. Colon pouch (Mainz III) for continent urinary diversion. BJU Int 2007; 99:1473-7. [PMID: 17346278 DOI: 10.1111/j.1464-410x.2007.06767.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the use of a continent cutaneous pouch made exclusively of colon (Mainz pouch III), as excellent results with the Mainz pouch III in irradiated patients suggested that the indication for this type of urinary diversion could be extended. PATIENTS AND METHODS The outcome of 24 patients with continent cutaneous urinary diversions using colon segments (Mainz pouch III) was investigated retrospectively. Overall, 22 of the patients had a malignant disease and two a benign disease; 16 had a hysterectomy and pelvic exenteration for gynaecological tumours; two men with a rhabdomyosarcoma of the prostate had a radical cystoprostatectomy; one woman had pelvic exenteration for bladder cancer; one man had a simultaneous rectum resection due to infiltrating rectal cancer, and another a left nephrectomy with cystectomy for concomitant kidney and bladder tumour. Benign indications were hyper-reflexive bladder after polytrauma and two cases of neurogenic bladder dysfunction. Eighteen patients had radiotherapy (32-48 Gy) before the urinary diversion. RESULTS The mean (range) follow-up was 35 (12-65) months. The mean pouch capacity was 293.8 mL. Three patients died during the follow-up (two from disease progression and one suicide); 20 patients were fully continent, four with reduced pouch capacity (<300 mL) had slight incontinence and are wearing a protective pad (band-aid at the umbilicus). All patients use intermittent self-catheterization (mean catheterization frequency 6.8/day, range 6-12). Complications related to the pouch were one outlet stenosis that required revision. Postoperative pouchograms showed asymptomatic reflux in four patients. None of the patients developed metabolic acidosis or diarrhoea. CONCLUSIONS The Mainz pouch III is an alternative to other types of continent urinary diversion.
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Koie T, Hatakeyama S, Yoneyama T, Ishimura H, Yamato T, Ohyama C. Experience and functional outcome of modified ileal neobladder in 95 patients. Int J Urol 2006; 13:1175-9. [PMID: 16984548 DOI: 10.1111/j.1442-2042.2006.01525.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS We took advantage of the Goodwin method to develop a modified ileal neobladder. We present the operation procedure and assessed the functional results. METHODS From April 1997 and May 2005, 95 patients (75 men and 20 women), mean age 64.6 years (range: 36-80 years) underwent orthotopic ileal neobladder replacement with application of the Goodwin method. The Le Duc technique was used for antireflux procedure. However, for the last 35 patients, antireflux procedure was not carried out. The median follow-up period was 37 months (range: 3-98 months). We reviewed the surgical outcome and complications. Continent status and urodynamic profile were also measured. RESULTS The mean operation time for the neobladder formation was 130 mins (range: 65-285 mins). There were no perioperative deaths. Leakage from the ileourethral anastomosis leak was found in four patients (4.2%), wound infection in nine patients (9.5%), ileal anastomosis leak in two patients (2.1%) and paralytic ileus in two patients. No hydronephrosis, neobladder-ureteral reflux or deterioration of renal function was seen. The maximum neobladder pressure was 21 +/- 13 cm (mean +/- SD) at 6 months and 12 +/- 11 cm at 12 months after surgery. The neobladder capacity was 293 +/- 118 mL at 6 months and 312 +/- 85 mL at 12 months after surgery. Of the 95 patients, 87 (91.6%) maintained complete dryness day and night. CONCLUSIONS These results suggest that the present orthotopic ileal neobladder is simple to be carried out and achieves acceptable voiding function. Longer observation for neobladder and upper urinary tract function is necessary.
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Affiliation(s)
- Takuya Koie
- Department of Urology, Hirosaki University School of Medicine, Hirosaki 036-8562, Japan
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Joniau S, Benijts J, Van Kampen M, De Waele M, Ooms J, Van Cleynenbreugel B, Van Poppel H. Clinical Experience with the N-shaped Ileal Neobladder: Assessment of Complications, Voiding Patterns, and Quality of Life in Our Series of 58 Patients. Eur Urol 2005; 47:666-72; discussion 672-3. [PMID: 15826760 DOI: 10.1016/j.eururo.2004.12.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2004] [Accepted: 12/15/2004] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- S Joniau
- Department of Urology, University Hospital Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Blaivas JG, Weiss JP, Desai P, Flisser AJ, Stember DS, Stahl PJ. LONG-TERM FOLLOWUP OF AUGMENTATION ENTEROCYSTOPLASTY AND CONTINENT DIVERSION IN PATIENTS WITH BENIGN DISEASE. J Urol 2005; 173:1631-4. [PMID: 15821519 DOI: 10.1097/01.ju.0000154891.40110.08] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We evaluated long-term outcomes in patients undergoing augmentation enterocystoplasty (AC) (with or without an abdominal stoma) or continent urinary diversion in patients with benign urological disorders. MATERIALS AND METHODS This was a retrospective study of 76 consecutive adults who underwent AC (with or without an abdominal stoma) or continent urinary diversion because of benign urological conditions. The outcomes assessed were a patient satisfaction questionnaire, continence status, catheterization status, bladder capacity, bladder compliance, detrusor instability, maximum detrusor pressure, upper tract status, significant postoperative morbidity, need for reoperation, persistent diarrhea and vitamin B12 deficiency. RESULTS The 76 patients (18 men and 58 women) were 19 to 80 years old (mean age 49). Followup was 1 to 19 years (mean 8.9). Preoperative diagnoses were neurogenic bladder in 41 patients, refractory detrusor overactivity in 9, interstitial cystitis in 7, end stage bladder disease in 7, radiation cystitis in 3, exstrophy in 3, postoperative urethral obstruction in 3 and low bladder compliance in 3. A total of 50 patients underwent simple AC, 15 underwent AC with an abdominal stoma and 11 underwent continent supravesical diversion. Of the 71 evaluable patients 49 (69%) considered themselves cured, 14 (20%) considered themselves improved and 8 (11%) considered treatment to have failed. All 7 patients with interstitial cystitis had failed treatment. Mean bladder capacity increased from 166 to 572 ml and mean maximum detrusor pressure decreased from 53 to 14 cm H2O. Serum creatinine improved or remained normal in all patients. Five patients experienced persistent diarrhea requiring intermittent antispasmodics but none had vitamin B12 deficiency, pernicious anemia or malabsorption syndrome. Long-term complications were stomal stenosis or incontinence in 11 of 26 patients (42%) with stomas, de novo bladder and renal stones in 2 of 71 (3%) and 1 of 71 (1%), respectively, and recurrent bladder stones in 6%. Small bowel obstruction occurred in 5 of 71 patients (7%), requiring surgical exploration in 4 (6%). CONCLUSIONS AC and urinary diversion provide a safe and effective long-term therapy in patients with refractory neurogenic bladder but stomal problems in patients with continent diversion continue to be a source of complications.
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Affiliation(s)
- Jerry G Blaivas
- Joan and Sanford I. Weill Medical College of Cornell University, Bronx, New York, USA
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Guimarães GC, Terabe F, Rossi BM, Aguiar Júnior S, Ferreira FDO, Nakagawa WT, Lopes A. The double-barreled wet ileostomy: an alternative method for simultaneous urinary and intestinal diversion without intestinal anastomosis after total colectomy and pelvic exenteration. Int J Colorectal Dis 2005; 20:190-3. [PMID: 15688101 DOI: 10.1007/s00384-004-0654-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2004] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although the number of cases of locally advanced colorectal cancer related to familial adenomatous polyposis (FAP) has decreased as a result of a better understanding of the disease, the condition still can offer therapeutic challenges. CASE PRESENTATION We report a case of a rectal tumor with prostate invasion associated with FAP, treated with neoadjuvant radiotherapy and total extended proctocolectomy with cystoprostatectomy. The reconstruction was undertaken with a double-barreled ileostomy with ureteral reimplantation on the distal segment of the ileostomy. Data including surgical aspects, post-operative complications, and outcome were evaluated. CONCLUSION The double-barreled wet ileostomy is a technically straightforward and safe procedure that is easily executed and may be an alternative to simultaneous diversion in extreme situations. To the best of our knowledge, this is the first description of this procedure in the literature.
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Affiliation(s)
- Gustavo Cardoso Guimarães
- Pelvic Surgery Department, Hospital do Câncer A. C. Camargo, Fundação Antônio Prudente, Sao Paulo, Brazil.
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Bochner BH, McCreath WA, Aubey JJ, Levine DA, Barakat RR, Abu-Rustum N, Poynor E, Wong D, Chi DS. Use of an ureteroileocecal appendicostomy urinary reservoir in patients with recurrent pelvic malignancies treated with radiation. Gynecol Oncol 2004; 94:140-6. [PMID: 15262132 DOI: 10.1016/j.ygyno.2004.03.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2003] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Evaluation of a modified right colon urinary reservoir in a heavily radiated patient population undergoing pelvic exenteration. METHODS A retrospective chart review was performed on all patients with recurrent gynecologic, colorectal, and urological tumors who underwent total pelvic or anterior exenteration and urinary diversion from 3/01 to 7/03 using an ureteroileocecal appendicostomy urinary reservoir. RESULTS Fourteen patients were identified over the study interval. The mean age of the patients was 53 years (range, 22-78 years). All patients received external beam, intracavitary, or a combination of both radiation treatment modalities to the pelvis preoperatively. Eight patients received intraoperative radiation therapy (IORT) at a mean dose of 16.25 Gy (range, 12.5-17.5 Gy). The primary sites of disease were as follows: cervix, five; prostate, three; uterus, two; colon/rectum two; and one each for vulva and bladder. Complete stomal continence was achieved in all patients after a median follow-up of 10 months (range, 2-31 months). Two patients experienced a traumatic disruption of the stomal-skin anastomosis in the early postoperative period (postoperative days 7 and 14). One late complication related to the ureterointestinal anastomosis was observed and consisted of an anastomotic stricture managed conservatively. One patient experienced an entero-pouch fistula following re-exploration for an acute postoperative hemorrhage. CONCLUSION The early outcomes using the ureteroileocecal appendicostomy urinary reservoir in heavily radiated patients demonstrate the technical feasibility of this design as both minimal early stoma and ureterointestinal complications may occur. Longer postoperative follow-up will be required to address the late outcomes of this procedure and its ultimate use in this population.
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Affiliation(s)
- Bernard H Bochner
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Shergill IS, Hamid R, Gupta S, Mammen KJ. Orthotopic ileal neobladder: the influence of reservoir volume and configuration on urinary continence and emptying properties. BJU Int 2004; 94:194. [PMID: 15217469 DOI: 10.1111/j.1464-410x.2004.4949g.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Fontana D, Bellina M, Fasolis G, Frea B, Scarpa RM, Mari M, Rolle L, Destefanis P. Y-neobladder: an easy, fast, and reliable procedure. Urology 2004; 63:699-703. [PMID: 15072884 DOI: 10.1016/j.urology.2003.11.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2003] [Accepted: 11/06/2003] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- D Fontana
- Divisione Universitaria di Urologia II, Ospedale Molinette (San Giovanni Battista), Dipartimento di Discipline Medico-Chirurgiche, Università degli Studi di Torino, Torino, Italy
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Abstract
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.
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Affiliation(s)
- Peter E Clark
- Department of Urology, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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Abstract
Radical cystectomy remains one of the mainstay treatments for organ-confined invasive bladder cancer. Components of this surgery including the extent of pelvic lymph node dissection, the assessment of ureteric margins and the indications for bladder reconstruction as opposed to the simpler ileal conduit urinary diversion continue to provoke debate. This review provides a broad overview of radical cystectomy and summarises the options for bladder reconstruction. Special emphasis is given to data concerning the role of pelvic lymphadenectomy in the patient staged pre-operatively as N0M0.
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Affiliation(s)
- Ashok G Bhojwani
- Division of Urology, University of Leicester, Clinical Sciences Unit, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
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McGee SM, Hulbert JC. Antegrade periurethral administration of Durasphere for management of a vesicoperineal fistula. Urology 2002; 59:773. [PMID: 11992924 DOI: 10.1016/s0090-4295(02)01538-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A patient who had developed a persistent fistula between the urethra and bladder neck after its surgical closure in the construction of a continent urinary pouch and Mitrofanoff nipple was successfully treated by antegrade periurethral injection of a newly approved injectable bulking agent for stress urinary incontinence (Durasphere) to occlude the bladder neck. We believe this to be the first reported use of Durasphere for such treatment.
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Affiliation(s)
- Shawn M McGee
- Department of Urologic Surgery, University of Minnesota Medical School and Fairview-University Medical Center, Minneapolis, Minnesota 55455, USA
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Ramirez PT, Modesitt SC, Morris M, Edwards CL, Bevers MW, Wharton JT, Wolf JK. Functional outcomes and complications of continent urinary diversions in patients with gynecologic malignancies. Gynecol Oncol 2002; 85:285-91. [PMID: 11972389 DOI: 10.1006/gyno.2002.6594] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to review our experience with continent urinary diversions in patients with gynecologic malignancies and evaluate the presentation and management of early and late complications. METHODS A retrospective chart review was performed of all patients who underwent a continent urinary diversion on the Gynecologic Oncology Service at The University of Texas M. D. Anderson Cancer Center during the period January 1988 to March 2001. We analyzed our data to evaluate potential risk factors for complications. Renal status, conduit integrity, and overall patient outcomes were also studied. RESULTS We identified 40 patients who underwent a continent urinary diversion using an ileocolonic segment (Miami pouch technique). All patients had a history of gynecologic malignancies. The median age at the time of the procedure was 50 years (range 24 to 76 years), and the median weight was 69.6 kg (range 47 to 125 kg). A total of 39 patients (98%) had a history of radiotherapy. Continent urinary diversion was performed as part of an anterior pelvic exenteration in 12 patients (30%), in conjunction with a total pelvic exenteration in 18 patients (45%), and as the main procedure in 10 patients (25%). The median estimated blood loss was 2100 ml (range 200 to 8500 ml). The median length of hospitalization was 19.5 days (range 7 to 56 days). A total of 24 patients (60.0%) had a postoperative complications unrelated to the reservoir. Complications directly related to the continent urinary diversion were seen in 26 (65.0%) of 40 patients. None of the patients in this study group developed chronic renal failure, and there were no perioperative deaths. At last evaluation, 36 (90%) of 40 patients reported normal continent conduit function. CONCLUSIONS Continent urinary diversion using an ileocolonic segment is a reasonable alternative to the ileal and transverse colon conduit in bladder reconstruction in patients undergoing radical pelvic surgery. The routine use of postoperative total parenteral nutrition, the chronic use of antibiotics after discharge from the hospital, and the routine use of imaging studies remain controversial. In this group of patients, the majority of complications may be successfully managed conservatively.
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Affiliation(s)
- Pedro T Ramirez
- Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Abstract
OBJECTIVES On behalf of the European Association of Urology (EAU) guidelines for diagnosis, therapy and follow-up of bladder cancer patients were established. Criteria for recommendations were evidence based, and included aspects of cost-effectiveness and clinical feasibility. METHOD A systematic literature research using Medline Services was conducted. References were weighted by a panel of experts. RESULTS TNM 1997 classification and WHO grading 1998 are recommended. Recommendations are developed for diagnosis for bladder cancer in general, treatment of superficial and infiltrative bladder cancer, and follow-up after different types of treatment modalities, such as intravesical instillations, radical cystectomy, urinary diversions, radiotherapy and chemotherapy.
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Soulié M, Seguin P, Mouly P, Thoulouzan M, Pontonnier F, Plante P. Assessment of morbidity and functional results in bladder replacement with Hautmann ileal neobladder after radical cystectomy: a clinical experience in 55 highly selected patients. Urology 2001; 58:707-11. [PMID: 11711346 DOI: 10.1016/s0090-4295(01)01354-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To analyze the morbidity and functional results of the ileal neobladder in a series of 55 highly selected patients. The ileal neobladder is a commonly used technique for orthotopic bladder reconstruction after radical cystectomy in both sexes. Good results have been published from Ulm University, where the technique was popularized. METHODS From February 1994 to June 2000, 55 patients (47 men and 8 women), 32 to 75 years old (mean age 58) with good performance status (American Society of Anesthesiologists score 1 and 2), underwent radical cystectomy for bladder cancer and Hautmann ileal neobladder reconstruction. Functional assessments were done at 3 months and every 6 months thereafter, with special attention to urinary continence and upper urinary tract status. RESULTS The median follow-up was 28.8 months (range 8 to 96). One perioperative death occurred. Early complications occurred in 23.6% without repeated surgery and late complications occurred in 25.4%, with three repeated operations for occlusive syndromes. The daytime and nighttime continence rates at 3, 6, and 12 months were 59.6%, 80.8%, and 88.5% and 38.5%, 61.5%, and 78.8%, respectively. The overall continence rate in patients younger than 70 years old was 80.8%. Three patients required self-catheterization to empty their neobladder. Eleven patients died of metastatic evolution of their bladder cancer or intercurrent disease at 6 to 36 months. CONCLUSIONS In highly selected patients, the ileal neobladder provides good functional results regarding continence with an acceptable complication rate. In this series, the results were comparable to those reported in the referent institution.
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Affiliation(s)
- M Soulié
- Department of Urologic Surgery and Andrology, Rangueil University Hospital, Toulouse, France
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La Fata V, Ramachandran A, Galt J, Keane TE, Halkar R. Diuretic renogram in a patient with a urinary diversion: avoiding a false-positive diagnosis of obstruction with an indwelling catheter. Clin Nucl Med 2001; 26:631-2. [PMID: 11416749 DOI: 10.1097/00003072-200107000-00014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- V La Fata
- Division of Nuclear Medicine, Department of Radiology, Emory University, Atlanta, Georgia, USA
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26
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Riedmiller H, Gerharz EW, Köhl U, Weingärtner K. Continent urinary diversion in preparation for renal transplantation: a staged approach. Transplantation 2000; 70:1713-7. [PMID: 11152102 DOI: 10.1097/00007890-200012270-00009] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We prospectively assessed the safety of kidney transplantation into continent urinary intestinal reservoirs as a planned two-stage procedure in patients with absent or dysfunctional lower urinary tract. METHODS Between November 1990 and June 1999, 12 patients have undergone renal transplantation into continent urinary reservoirs, and a further patient with a diversion is awaiting transplantation. This was part of a larger series of 356 patients who had undergone continent diversions during that period. A further 174 patients (33%) had diversions into ileal conduits. FINDINGS Within a mean follow-up of 26.1 months (5-72) after transplantation renal function was stable with serum creatinine values ranging from 0.9 to 1.8 mg/dl. There were 5 reoperations in the 12 patients (40%). Two patients needed their continence mechanism replaced. One had renal vein thrombosis with loss of the transplant. The cause for this was unknown but it had been speculated that it could have been caused by graft/body size disproportion. A second kidney was successfully transplanted after 12 months. Two further revisions were required for ureteric kinking and lymphocele. The patient with orthotopic substitution voids to completion. The other patients are continent day and night with easy catheterization. INTERPRETATION This is one of the largest single series reported to date of renal transplantation into continent urinary diversions, and we commend the approach in carefully selected patients, but the difficulties must not be underestimated and the specific problems of intestinal urinary reservoirs have to be reckoned with. These procedures should be confined to centers with considerable experience with this type of surgery and its complications. Lifelong close surveillance is critical for the success of this concept.
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Affiliation(s)
- H Riedmiller
- Department of Urology, Julius Maximilians University Medical School, Würzburg, Germany.
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27
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Hautmann RE. Which patients with transitional cell carcinoma of the bladder or prostatic urethra are candidates for an orthotopic neobladder? Curr Urol Rep 2000; 1:173-9. [PMID: 12084311 DOI: 10.1007/s11934-000-0016-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bladder replacement has become a standard method of urinary diversion in adults undergoing cystectomy. When faced with a treatment decision, the patient and urologist are most comfortable if information is available on short- and long-term possible outcomes of the proposed intervention and on the magnitude of the expected effect. This article presents and discusses absolute and relative contraindications for orthotopic neobladders that may help optimize the clinical results with these procedures. As our own series has progressed, so has our philosophy regarding patients who are candidates for an orthotopic reconstruction. All men who require radical cystectomy as treatment for bladder cancer are initially thought to be appropriate candidates for orthotopic lower urinary tract reconstruction. Given the criteria presented in this article approximately, 80% of men are considered acceptable candidates for a neobladder. By these criteria, 65% of women are adequate candidates for an orthotopic bladder.
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Affiliation(s)
- R E Hautmann
- Department of Urology, University of Ulm, Prittwitzstrasse 43, 89075 Ulm, Germany.
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28
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Abstract
The operative management of muscle invasive bladder cancer has been dramatically advanced by the advent of orthotopic reconstruction. Several studies reported during the past year have further demonstrated the utility of this form of urinary diversion. The long-term safety and efficacy of bladder replacement with respect to both surgical and metabolic complications has been demonstrated. As series include more patients with sufficient follow up, we are gaining a better appreciation of the results of treatment that patients and urologists can expect in terms of function and risk of complications. Taken together, published studies have made the following important points. Exenterative surgery as currently performed alters pelvic floor/urethral physiology. Early reports of complications in studies with short periods of follow up are not meaningful. When basic principles and complication rates are established for a procedure in the long term, sufficient follow up is required before it can be established that a modification to that procedure really is better. The occurrence of retention in a female patient with orthotopic bladder continues to be poorly understood.
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Affiliation(s)
- R E Hautmann
- Department of Urology, University of Ulm, Germany.
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