Incidence and significance of positive urine cultures in patients with an orthotopic neobladder

The incidence and risk factor for febrile urinary tract infection after robot-assisted laparoscopic radical cystectomy in bladder cancer patients

INTRODUCTION

Febrile urinary tract infections are major complications of radical cystectomy; however, their characteristics after robot-assisted radical cystectomy remain unclear. Thus, we investigated the rate, severity, pathogens, and risk factors of febrile urinary tract infections after robot-assisted radical cystectomy.

PATIENTS AND METHODS

Patients who underwent robot-assisted radical cystectomy at three institutions between April 2018 and March 2022 were retrospectively analyzed. The febrile urinary tract infections occurring within 90 days of surgery were evaluated.

RESULTS

Overall, 191 patients were included. Of the 157 patients with ileal urinary diversions, 138 and 19 received ileal conduit and ileal neobladder, respectively; 42 febrile urinary tract infections were observed in 36 patients (22.9 %). Of the 32 patients who underwent cutaneous ureterostomy, four patients had febrile urinary tract infections (12.5 %). The incidence of postoperative febrile urinary tract infections was significantly higher in patients with ileal neobladder (52.9 %) than in those with an ileal conduit (18.8 %) (p < 0.05, log-rank test). Gram-positive strains were the dominant pathogen (60.0 %), followed by gram-negative strains (37.1 %) and fungi (2.9 %). The blood culture was positive in 28.6 % for febrile urinary tract infections. The primarily isolated strains were Enterococcus faecalis, Staphylococcus aureus, and Staphylococcus epidermidis, Escherichia coli and Pseudomonas aeruginosa. Female was the only risk factor for febrile urinary tract infections in those with an ileal conduit.

CONCLUSIONS

Gram-positive strains account for 60 % of pathogens causing febrile urinary tract infections after robot-assisted radical cystectomy, that may cause severe complications, rendering management of febrile urinary tract infections paramount.

Post-Operative Urinary Tract Infections After Radical Cystectomy: Incidence, Pathogens, and Risk Factors

Background: The incidence of urinary tract infections (UTIs) after radical cystectomy (RC) with urinary diversion (UD), the typical pathogens, and associated patient risk factors have not been well documented. In this study, we examined the incidence of post-op UTIs after RC to identify associated risk factors. Methods: Single-center, retrospective case series of 386 patients with bladder cancer who underwent RC with UD between 2012 and 2024. The primary objective was UTI incidence, defined by the frequency of patients with urine culture with >105 colony-forming units per high-powered field, spanning from post-op day 0 (POD0) to 90 days after discharge. Isolated pathogens were reported. Risk factors for UTIs were assessed. Results: The average age was 69 years old at surgery, and patients were predominantly male (80%). The cumulative incidence of post-op UTIs was 14%, among which 12 patients had more than one UTI. The UTI incidence was 2%, 8%, and 7% during the immediate post-op period, within 30 days, and within 31-90 days, respectively. Isolated pathogens included Escherichia coli (26%), Enterococcus faecalis (24%), Klebsiella pneumoniae (21%), and Pseudomonas species (21%). In the immediate post-op period, female sex was the only significant risk factor. At 31 to 90 days, cutaneous ureterostomy UD was the predominant risk factor for UTIs. For ileal conduit patients, those with a Wallace ureteral anastomosis were associated with UTI 31-90 days from discharge for RC. Conclusions: Our retrospective data suggests the incidence of UTIs and their causative pathogens after RC differ based on post-operative time points and vary according to different patient risk factors.

Development and validation of a parsimonious prediction model for positive urine cultures in outpatient visits

Urine culture is often considered the gold standard for detecting the presence of bacteria in the urine. Since culture is expensive and often requires 24-48 hours, clinicians often rely on urine dipstick test, which is considerably cheaper than culture and provides instant results. Despite its ease of use, urine dipstick test may lack sensitivity and specificity. In this paper, we use a real-world dataset consisting of 17,572 outpatient encounters who underwent urine cultures, collected between 2015 and 2021 at a large multi-specialty hospital in Abu Dhabi, United Arab Emirates. We develop and evaluate a simple parsimonious prediction model for positive urine cultures based on a minimal input set of ten features selected from the patient's presenting vital signs, history, and dipstick results. In a test set of 5,339 encounters, the parsimonious model achieves an area under the receiver operating characteristic curve (AUROC) of 0.828 (95% CI: 0.810-0.844) for predicting a bacterial count ≥ 105 CFU/ml, outperforming a model that uses dipstick features only that achieves an AUROC of 0.786 (95% CI: 0.769-0.806). Our proposed model can be easily deployed at point-of-care, highlighting its value in improving the efficiency of clinical workflows, especially in low-resource settings.

Impact of early self-clean intermittent catheterization in orthotopic ileal neobladder: prospective randomized study to evaluate functional outcomes, continence status and urinary tract infections

BACKGROUND

Urinary diversions after radical cystectomy (RC) have a significant impact on quality of life and body image. Particularly for orthotopic neobladder (ONB), the rate of continence, urinary retention and urinary tract infections can impact on patient's quality of life. The aim of this study was to investigate whether early clean intermittent catheterization (CIC) might improve functional outcomes, continence status, and reduce the incidence of UTIs in patients with ONB.

METHODS

In this prospective randomized study patients were divided in two groups. Patients were on a standard postoperative care (group A) or started CIC within the first postoperative month (group B). All patients were evaluated postoperatively at 1, 3, 6, and 9 months after ONB. The CIC was executed 4 times/daily after each voluntary micturition. The postoperative evaluation included: post-void residual volume (PVR), urine analysis and culture, number of pads/day and the self-administrated questionnaire International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF).

RESULTS

Thirty-nine male and 8 female patients underwent laparoscopic or robotic RC with intracorporeal ONB (37 U shaped and 10 Padua reconstructions). At the first follow up, mean PVR was in group A and B, 136.5 mL and 125.7 mL (P value: 0.105), respectively. The ICIQ-UI SF mean score was 16.2 and 17.1 (P value: 0.243) respectively and the mean no. of pads/day was 3 in both groups. 15 patients in group A and 10 in group B reported episodes of symptomatic UTIs. At 3, 6 and 9 months follow up after surgery the PVR and the ICIQ-UI SF scores were significantly improved (P value <0.0001). The number of pads decreased to 2 pads/day in group A and 1 in group B at 9 months. The episodes of UTIs significantly decreased over the time (P value <0.0001).

CONCLUSIONS

Our data support the early introduction of self CIC in patients with ONB after RC. The CIC was significantly associated a reduced risk of incontinence, urinary retention, and UTI with significant improvement in QoL. These encouraging data need to be confirmed by further investigations with a larger number of patients.

Comparative study on the clinical effect of preparing neobladder with different lengths of ileum

OBJECTIVE

To investigate the relationship between orthotopic U-shaped ileal neobladder volume and bladder function. To investigate the correlation between the volume of the radical cystectomy and the U-shaped ileal neobladder in situ and the function of the bladder.

METHODS

The clinical data of patients undergoing in orthotopic U-shaped neobladder in our hospital were retrospectively analyzed. They were divided into two groups according to the length of the retained ileum. Group 1: The length of the ileum was 25-35cm (including 35cm), and the second group: the length of the ileum was 35-45cm. The basic information, cushion usage, urodynamic examination and complications of the two groups were obtained.

RESULTS

A total of 88 patients were included in the study, including 33 in the first group and 55 in the second group. There was no statistical difference in general data, lymph node collection, lymph node positive rate, positive margin rate, postoperative pathological stage, pathological grade, pathological type, intraoperative blood loss, blood transfusion, postoperative hospital stay, and complications between the two groups of patients. significance. Although the usage of urine pads in group 1 was more than that in group 2 in the short term after operation (P<0.05), it started from the third year after operation. Patients in group 1 used less cushion than group 2 (P<0.05). Urodynamic examination was performed on the patients, and the bladder function of group 1 maintained satisfactory time longer than that of group 2. The total number of deaths in the two groups was 12 and 23, respectively. The 5-year overall survival (OS) rate of group 1 was 53.60%, and the 5-year overall survival rate of group 2 was 52.9%.

CONCLUSIONS

A new bladder formed by cutting the ileum with a length of 25-35 cm (including 35cm) has a longer time to maintain good bladder function than cutting the ileum with a length of 35-45 cm to produce a new bladder.

Early Warning Models to Predict the 90-Day Urinary Tract Infection Risk After Radical Cystectomy and Urinary Diversion for Patients With Bladder Cancer

Purpose

To develop and validate a nomogram of the 90-day urinary tract infection (UTI) risk for patients with bladder cancer undergoing radical cystectomy (RC) and urinary diversion.

Patients and Methods

The predictive nomogram was based on a retrospective study on the consecutive patients who underwent RC and urinary diversion for bladder cancer between January 2014 and March 2021. The incidence and microbiology of UTI were reported. The univariate and multivariate logistic analyses were conducted to determine independent risk factors associated with UTI. The predictive accuracy and discriminatory ability of the established nomogram were evaluated by the concordance index (C-index) and decision curve analysis (DCA). The performance of the model was validated internally.

Results

A total of 220 patients were included and the incidence of UTI within 90 days was 27.3%. The most commonly identified pathogens were Enterococcus (42.0%), Escherichia coli (21.70%), and Candida (13.0%). Urinary diversion type, Charlson comorbidities index (CCI), stricture, and prognostic nutritional index (PNI) were included in the nomogram. The C-index of the nomogram for predicting UTI was 0.858 (95% CI: 0.593–0.953). In the validation cohort, the nomogram also showed high-predictive accuracy. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) index indicated that PNI led to improvement in predictive ability.

Conclusion

The proposed early warning model shows great accuracy in predicting the incidence of 90-day UTI after RC and urinary diversion in patients with bladder cancer.

Late complications of robot-assisted radical cystectomy with totally intracorporeal urinary diversion

Introduction and objectives

To evaluate late complications in a large cohort of patients undergoing robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD).

Materials and methods

We prospectively enrolled patients who underwent RARC and ICUD between August 2012 and June 2019. We excluded patients with Ejection fraction < 36%, retinal vasculopathy, ventriculoperitoneal shunts, and those treated without curative intent. All complications and their onset date have been recorded, defined, and graded according to Clavien classification adapted for radical cystectomy.

Results

210 patients were included, 76% of whom were men, with a mean age of 62 years. Urinary diversions used were Padua Ileal Bladder (PIB) in 80% of cases, and ileal conduit (IC) in 20% of patients (generally older and with more comorbidity). The mean follow-up was 30 ± 22 months. The stenosis rate of uretero-ileal anastomosis was 14%, while a reduction in eGFR (≥ 20%) was observed in about half of the cases. UTIs occurred in 37% of the patients, especially in the first 12 months. Only 2% of patients had bowel occlusion, whereas incisional hernia, lymphocele, and systemic events (metabolic acidosis and major cardiovascular events) occurred respectively in 20%, 10%, and 1% of cases.

Conclusions

Our study evaluates first late complications in a cohort of patients who underwent RARC with ICUD. These data are encouraging and in line with findings from a historical series of open radical cystectomy (ORC). This study is a further step in supporting RARC as a safe and effective surgical option for the treatment of muscle-invasive bladder cancer (MIBC) in tertiary referral centers.

Electronic supplementary material

The online version of this article (10.1007/s00345-020-03378-7) contains supplementary material, which is available to authorized users.

Urinary tract infections following radical cystectomy with enhanced recovery protocol: A prospective study

OBJECTIVES

Urinary tract infection (UTI) following radical cystectomy (RC) is a common complication associated with significant morbidity and risk of readmission. Recent literature has assessed the effect of perioperative antibiotic regimens on the rate of postoperative infections but not yet yielded with significant changes in UTI rates. Our study focused on the effect of postoperative suppressive regimens on the rate of UTI following radical cystectomy with Enhanced Recovery After Surgery (ERAS) protocol.

METHODS

We retrospectively reviewed 427 patients who underwent RC with ERAS protocol between May 2012 and January 2017 at our institution. The ERAS protocol infection prevention measures included 24-hr perioperative antibiotic followed by suppressive antibiotic until removal of catheter/stents. A patient was found to have a UTI if they had a positive urine culture and documented symptoms, positive urine culture with treatment per practitioner discretion, or negative or unavailable urine culture but the clinical presumption of UTI that got treatment. Urosepsis was defined if any of UTI episodes were associated with positive blood culture. Patients' characteristics, UTI events, and urine culture sensitivities were reviewed for analysis.

RESULTS

The incidence of UTI and urosepsis was 36.1% and 7.13% within 90-days following RC, respectively. The median time to the first UTI was 13 days (IQR 8-35). Candida (25.57%) and Escherichia coli (22.16%) were the most commonly identified pathogens. UTI and urosepsis were significantly lower in patients who received suppressive fluoroquinolones compared to other antibiotic regimens (32.72% vs. 45.24%, P = 0.04 for UTI and 5.25% vs. 11.90%, P = 0.04 for urosepsis). In multivariable analysis, orthotopic neobladder and perioperative transfusion were significantly associated with increased UTI rate (OR = 2.3 and 1.71, p < 0.05, respectively).

CONCLUSIONS

UTI is common following RC and urinary diversion with ERAS protocol. The most common isolated pathogens are candida and Escherichia coli. Orthotopic neobladder and perioperative transfusion are independent risk factors for postoperative UTI. The use of suppressive fluoroquinolones is associated with a significant decrease in UTI rate.

Systematic review: bacterial colonisation of conduits and neobladders-when to test, watch, and treat

BACKGROUND

Urinary diversion procedures frequently result in bacterial colonisation. There is an increased incidence of developing urinary tract infections (UTIs) in this patient population. Current guidelines, however, recommend against treating this colonisation. This systematic review aimed to determine when and how to test, monitor, and treat bacteriuria in patients with urinary diversion.

METHODS

A systematic search strategy was conducted based on keywords "urinary diversion" and "bacteriuria", on MEDLINE, Embase, and Google Scholar. Articles were screened and included only if they reported on (i) testing methods for bacteriuria, (ii) surveillance of bacteriuria over time, or (iii) when and how to treat bacteriuria. Results were summarised and reported using a narrative synthesis.

RESULTS

Altogether, 26 studies were included in this review. Inconsistencies were noted in the definitions of bacteriuria, with most studies reporting bacteriuria as > 10⁴ cfu/mL (8/17 studies). Bacteriuria prevalence varied greatly (range 9.1-100%). Monitoring bacteriuria over time may help detect a reduction in bacteriuria, as demonstrated in three studies (follow-up range 5-18 months; sample size 18-56). The link between preceding bacteriuria and subsequent UTIs has not been fully explored yet. Short-term antimicrobial therapy may be useful in the immediate post-operative setting; however, long-term prophylactic treatment is ineffective in preventing bacteriuria.

CONCLUSIONS

We recommend consistent reporting of bacteriuria definitions, the benefits of monitoring bacteriuria over time, and use of short-term antimicrobial therapy; bacteriuria should not be treated with long-term therapy.

Use and duration of antibiotic prophylaxis and the rate of urinary tract infection after radical cystectomy for bladder cancer: Results of a multicentric series

OBJECTIVES

To assess the rate of urinary tract infection (UTI), the characteristics of the bacterial aetiological agents involved, the type and duration of antibiotics used, and the clinical risk factors of UTI in a multi-institutional cohort of patients who had undergone radical cystectomy (RC).

PATIENTS AND METHODS

The pre- and postoperative characteristics of patients who had undergone open RC at 1 of 3 institutions between 2009 and 2015 were analyzed by means of the patient charts. Patients were classified according to the presence or absence of UTI. Analysis of the severity of UTI was based on the EAU/EAU Section of Infections in Urology (ESIU) classification system. The bacterial aetiological agents and their antibiotic susceptibility were also assessed. Factors predicting postoperative UTI were identified using univariable and multivariable logistic regression analysis.

RESULTS

Of 217 patients, 42 (19.4%) had developed postoperative UTI, of whom 50% had urosepsis or uroseptic shock. Multivariable analysis showed continent urinary derivation as the only significant predictor of UTI with an odds ratio of 5.03 (95% confidence interval 2.12-11.9, P < 0.001). The duration of perioperative antibiotic prophylaxis was not associated with an increased risk of UTI. Enterococcus was the most commonly isolated bacteria (25.7%), but this species is not covered by the recommended antibiotic prophylaxis.

CONCLUSION

Patients with continent urinary diversion after RC have a significantly higher risk of developing UTI. Prolonged perioperative administration of antibiotics does not seem to reduce the risk of UTI. Enterococcus as the most commonly isolated bacteria is not covered by most recommended antibiotic prophylaxis regimens. Therefore different antibiotic regimens should be considered for high-risk patients.

Impact of a change in duration of prophylactic antibiotics on infectious complications after radical cystectomy with a neobladder

A profound number of prophylactic antibiotics are used after radical cystectomy with an ileal orthotopic neobladder (RCIONB) despite a negative effect of infection control. We investigated the impact of short-term prophylactic antibiotic use on infectious complications after RCIONB.We retrospectively reviewed data from 287 patients who underwent RCIONB for bladder cancer between 2012 and 2016 at a tertiary hospital. The patients were divided into 2 groups according to the pattern of prophylactic antibiotics (185 patients in a long-term group, 25-day use of 3-staged multiple antibiotics versus 102 patients in a short-term group, 24-hour use of cefotetan). The onset of complications, including bacteriuria, febrile urinary tract infection (FU), and bacteremia, and the microorganisms responsible for infections were compared between the groups. Of all 287 patients, bacteriuria, FU, and bacteremia were identified in 177 (61.7%), 85 (29.6%), and 18 (6.3%) patients, respectively. Bacteriuria was identified more frequently in the short-term group (49.2% vs 84.3%, P <.001). However, the rates of FU within 60 days of surgery were similar in both groups (28.6% vs 28.4%, P = .969). The rate of FU was not significantly different between the 2 groups. There was no significant difference in the rate of patients with bacteremia (5.4% vs 7.8%, P = .415). The most frequent microorganisms seen in bacteriuria were Enterococcus faecium and Enterococcus faecalis, in the long-term and short-term group, respectively. Antibiotic-resistant Enterococcus species were more frequently present in the long-term group.Short-term use of prophylactic antibiotics is effective for preventing urinary tract infections after RCIONB and decreasing colonization with multi-drug-resistant organisms.

Complications After Ileal Urinary Derivations

Introduction

The aim of the study was to determine the most frequent early and late complications in different types of ileal urinary diversions.

Patients and methods

The study was conducted in a five-year period, on 106 patients who were diagnosed with invasive urinary bladder cancer and who had indication for radical cystectomy with one of the investigated types of urine derivation. They were divided into 2 groups, based on the type of ileal urinary diversions.

Results

The colonization of bacteria was more prominently present in the ileal conduit urinary diversion group (97%) compared to Ghoneim (25%) and Hautmann (10%) group, Ureteral stenosis was slightly less represented in the conduit group (9.1%). Wound infections were significantly more represented in the conduit (21.2%) than in the Ghoneim group (5%) Nighttime incontinence was present in 20% of patients in both groups or 4 patients in each group. Daytime incontinence in the Ghoneim group was present in 3 patients (15%) and in the Hautmann group 2 patients (10%). Late complications correlate significantly negative with the type of surgery and slightly negative with the grade, and significantly positively with the examined group and T stage, and slightly correlate positively to the N and R stages. Early complications correlate slightly negative with the type of surgery, slightly negative with the grade, and significantly positively with T stage, and slightly positively correlates with the N and R stage.

Conclusion

The most commonly reported complications in ileal conduit are: prolonged ileus, stoma infection, wound dehiscence and bacterial colonization, followed by peristomal skin complications and complications related only to the stoma, such as stenosis and stoma retraction, and prolaps of ileostoma and ileointestinal stenosis. The ileus rate in orthotopic derivation was significantly lower than that of the ileal conduit group, which led to the conclusion that the neomybladder position does not disturb the anatomic abdominal structure.

Urinary tract infections following radical cystectomy and urinary diversion: a review of 1133 patients

OBJECTIVE

To investigate the incidence and microbiology of urinary tract infection (UTI) within 90 days following radical cystectomy (RC) and urinary diversion.

METHODS

We reviewed 1133 patients who underwent RC for bladder cancer at our institution between 2003 and 2013; 815 patients (72%) underwent orthotopic diversion, 274 (24%) ileal conduit, and 44 (4%) continent cutaneous diversion. 90-day postoperative UTI incidence, culture results, antibiotic sensitivity/resistance and treatment were recorded through retrospective review. Fisher's exact test, Kruskal-Wallis test, and multivariable analysis were performed.

RESULTS

A total of 151 urinary tract infections were recorded in 123 patients (11%) during the first 90 days postoperatively. 21/123 (17%) had multiple infections and 25 (20%) had urosepsis in this time span. Gram-negative rods were the most common etiology (54% of positive cultures). 52% of UTI episodes led to readmission. There was no significant difference in UTI rate, etiologic microbiology (Gram-negative rods, Gram-positive cocci, fungi), or antibiotic sensitivity and resistance patterns between diversion groups. Resistance to quinolones was evident in 87.5% of Gram-positive and 35% of Gram-negative bacteria. In multivariable analysis, Charlson Comorbidity Index > 2 was associated with higher 90-day UTI rate (OR = 1.8, 95% CI 1.1-2.9, p = 0.05) and Candida UTI (OR 5.6, 95% CI 1.6-26.5, p = 0.04).

CONCLUSIONS

UTI is a common complication and cause of readmission following radical cystectomy and urinary diversion. These infections are commonly caused by Gram-negative rods. High comorbidity index is an independent risk factor for postoperative UTI, but diversion type is not.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Asymptomatic Bacteriuria and Bacterial Interference

Asymptomatic bacteriuria is very common. In healthy women, asymptomatic bacteriuria increases with age, from <1% in newborns to 10% to 20% of women age 80 years, but is uncommon in men until after age 50 years. Individuals with underlying genitourinary abnormalities, including indwelling devices, may also have a high frequency of asymptomatic bacteriuria, irrespective of age or gender. The prevalence is very high in residents of long-term-care facilities, from 25% to 50% of women and 15% to 40% of men. Escherichia coli is the most frequent organism isolated, but a wide variety of other organisms may occur. Bacteriuria may be transient or persist for a prolonged period. Pregnant women with asymptomatic bacteriuria identified in early pregnancy and who are untreated have a risk of pyelonephritis later in pregnancy of 20% to 30%. Bacteremia is frequent in bacteriuric subjects following mucosal trauma with bleeding, with 5% to 10% of patients developing severe sepsis or septic shock. These two groups with clear evidence of negative outcomes should be screened for bacteriuria and appropriately treated. Asymptomatic bacteriuria in other populations is benign and screening and treatment are not indicated. Antimicrobial treatment has no benefits but is associated with negative outcomes including reinfection with antimicrobial resistant organisms and a short-term increased frequency of symptomatic infection post-treatment. The observation of increased symptomatic infection post-treatment, however, has led to active investigation of bacterial interference as a strategy to prevent symptomatic episodes in selected high risk patients.

Characterization of Standard Urine Properties in Noncomplicated Orthotopic Ileal Neobladders: A Prospective Controlled Study

OBJECTIVE

To characterize the standard physical, chemical, and microscopic characteristics of urine in patients with noncomplicated orthotopic ileal neobladders.

MATERIALS AND METHODS

This is a prospective study that included 100 male patients who underwent radical cystectomy and ileal neobladder between 1993 and 2013. All included patients were in a good health and having satisfactory function of the reservoirs with normal upper tract with a minimum 1-year postoperative follow-up. We excluded patients with oncological failure, those with diversion-related complications, those who were maintained on clean intermittent catheterization, or those who have symptoms of urinary tract infection. Patients with medical diseases that may affect urine properties (eg, diabetes mellitus) or receiving special medications (eg, diuretics, alkali therapy, or antibiotics) were also excluded. The patients were subjected to urine analysis, blood chemistry, pH, and blood gases; the results were compared to a control group of 40 normal male volunteers.

RESULTS

Urine analysis in diverted patients showed higher urine pH than in control group but it is still acidic. Pyuria, proteinuria, hematuria, and positive culture were significantly higher in diverted patients. The chemical analysis showed lower urinary calcium, phosphorus, and creatinine contents in diverted patients than in the control group. Serum creatinine was significantly higher in diverted patients, whereas blood pH and bicarbonate were lower, but these values are within normal.

CONCLUSION

Urine from uncomplicated orthotopic ileal reservoirs is acidic. Pyuria, proteinuria, minor degrees of microscopic hematuria, and positive nitrite reaction are normal findings. We also have normal findings for lower urinary calcium, phosphorus, and creatinine contents in patients.

Long-term complications of urinary diversion

PURPOSE OF REVIEW

Radical cystectomy and urinary diversion remains the cornerstone in surgical management of patients with muscle-invasive or high-risk nonmuscle-invasive bladder cancer. This approach has been associated with remarkable increase in patient survival and more patients are now living for years after surgery who may present with long-term complications. This review describes long-term complications associated with urinary diversion including renal function deterioration, voiding dysfunction, stoma and bowel-related complications, ureteroenteric stricture, metabolic disorders, and infectious complications.

RECENT FINDINGS

The overall complication rate reported in recent large studies assessing long-term complications of urinary diversion is as high as 60%. Stoma-related complications followed by urinary tract infections are among the most common complications. Some of these complications may occur years after surgery; therefore, long-term follow-up of patients with urinary diversion is of utmost importance.

SUMMARY

Long-term regular follow-up is imperative in patients with urinary diversion as nonfatal complications may occur years after surgery.

Febrile Urinary Tract Infection after Radical Cystectomy and Ileal Neobladder in Patients with Bladder Cancer

Urinary tract infection (UTI) is one of the most common complications after radical cystectomy and orthotopic neobladder reconstruction. This study investigated the incidence and implicated pathogen of febrile UTI after ileal neobladder reconstruction and identify clinical and urodynamic parameters associated with febrile UTI. From January 2001 to May 2015, 236 patients who underwent radical cystectomy and ileal neobladder were included in this study. Fifty-five episodes of febrile UTI were identified in 46 patients (19.4%). The probability of febrile UTI was 17.6% and 19.8% at 6 months and 24 months after surgery, respectively. While, Escherichia coli was the most common implicated pathogen (22/55, 40.0%), Enterococcus spp. were the most common pathogen during the first month after surgery (18/33, 54.5%). In multivariate logistic regression analysis, ureteral stricture was an independent risk factor associated with febrile UTI (OR 5.93, P = 0.023). However, ureteral stricture accounted for only 6 episodes (10.9%, 6/55) of febrile UTI. Most episodes of febrile UTI occurred within 6 months after surgery. Thus, to identify risk factors associated with febrile UTI in the initial postoperative period, we assessed videourodynamics within 6 months after surgery in 38 patients. On videourodyamic examination, vesicoureteral reflux (VUR) was identified in 16 patients (42.1%). The rate of VUR presence in patients who had febrile UTI was not significantly different from those in patients without febrile UTI (50% vs. 39.3%, P = 0.556). Patients with febrile UTI had significantly larger residual urine volume (212.0 ± 193.7 vs. 90.5 ± 148.2, P = 0.048) than those without. E. coli and Enterococcus spp. are common pathogens and ureteral stricture and residual urine are risk factors for UTI after ileal neobladder reconstruction.

Complications of Radical Cystectomy and Orthotopic Reconstruction

Radical cystectomy and orthotopic reconstruction significant morbidity and mortality despite advances in minimal invasive and robotic technology. In this review, we will discuss early and late complications, as well as describe efforts to minimize morbidity and mortality, with a focus on ileal orthotopic bladder substitute (OBS). We summarise efforts to minimize morbidity and mortality including enhanced recovery as well as early and late complications seen after radical cystectomy and OBS. Centralisation of complex cancer services in the UK has led to a fall in mortality and high volume institutions have a significantly lower rate of 30-day mortality compared to low volume institutions. Enhanced recovery pathways have resulted in shorter length of hospital stay and potentially a reduction in morbidity. Early complications of radical cystectomy occur as a direct result of the surgery itself while late complications, which can occur even after 10 years after surgery, are due to urinary diversion. OBS represents the ideal urinary diversion for patients without contraindications. However, all patients with OBS should have regular long term follow-up for oncological surveillance and to identify complications should they arise.

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.

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.

Does the afferent tubular segment in an orthotopic bladder substitution compromise ureteric antireflux properties? An experimental study in dogs

Objective

To study the effects of a short ureter on renal function and histology in an orthotopic bladder substitution model using a long afferent limb, in a canine model.

Materials and methods

The study included nine adult mongrel dogs. A 40-cm segment of ileum was isolated, the distal half detubularized, configured into a U-shape and sutured to form a flat plate; this was then used to augment the bladder. The proximal half of the isolated ileum remained in continuity with the enterocystoplasty to form an isoperistaltic ileal ‘chimney’. The left ureter was divided at its lumbar part and anastomosed to the chimney using a refluxing end-to-side Nesbit technique. The contralateral ureter was divided at its lower end and then anastomosed directly to the augmented segment of the bladder in a similarly refluxing manner to act as a control. The assessment after surgery included biochemical studies, ascending cystography, intravenous urography (IVU) and radioisotope renography at 6 weeks. The last two methods were repeated at intervals of 3 and 6 months after surgery. Urine culture was obtained and both kidneys were examined histopathologically at 6 months.

Results

The biochemical values assessed in all dogs were comparable to those before surgery. The urine culture obtained from the augmented bladders showed significant bacterial growth in all dogs. IVU at all follow-up sample times showed a normal configuration of both kidneys. Ascending cystography showed reflux in four of nine dogs on the right and six on the left side. There was a progressive decrease in the mean selective renographic clearance values of each of the right and left kidneys at intervals of 6 weeks, 3 and 6 months. The mean percentage reduction of renographic clearance was significantly higher in the left kidneys at 6 weeks and 3 months. Histopathological examination showed evidence of interstitial nephritis in all nine dogs and pyelonephritis in four of the left kidneys, while none of the right kidneys showed evidence of inflammation.

Conclusion

Adequate peristalsis in a healthy long ureter is superior to the ileal segment substitution for protecting the kidney tissue against inflammation in the absence of an anatomical antireflux mechanism.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Orthotopic diversion after cystectomy in women: A single-centre experience with a 10-year follow-up

Objective

To evaluate and update the clinical and surgical outcome of orthotopic diversion in an eligible cohort of women with bladder carcinoma.

Patients and methods

From 1999 to 2010, 78 women (mean age 42.4 years) had a radical cystectomy (RC) with orthotopic diversion using ileal neobladder reconstruction to treat invasive bladder carcinoma. The mean (SD) follow-up was 62 (25) months.

Results

The histopathological pattern was squamous cell carcinoma in 52 (67%) patients, transitional cell carcinoma in 17 (22%), mixed in four (5%) and undifferentiated carcinoma in five (6%). Three patients were completely incontinent day and night. Stress urinary incontinence after this surgery was reported in 11 (14%) patients, with daytime continence reported in 64 (82%); 59 (76%) patients were completely continent day and night. Chronic retention developed in nine (12%) patients. There was pouch prolapse through the vaginal stump in five (6%) patients, and a pouch-vaginal fistula in seven (9%). Sexual dysfunction was reported in 45 (69%) patients of 65 sexually active women. Stones formed in the pouch in five (6%) patients, while there were renal stones in four renal units. Oncological recurrence was reported in 15 (19%) patients, which was local in

11 (14%) and distant in four (5%).

Conclusion

The long-term results showed that orthotopic neobladder construction after RC in women provides oncological safety and is functionally effective with proper surgical technique. Removal of the gynaecological organs during RC in women might be unnecessary for low-grade, low-stage tumour.

25 years of experience with 1,000 neobladders: long-term complications

PURPOSE

We analyzed the long-term complications (greater than 90 days postoperatively) in a large, single center series of patients who underwent cystectomy and substitution with an ileal neobladder.

MATERIALS AND METHODS

A total of 1,540 radical cystectomies were performed at our center between January 1986 and September 2008. Of the patients 1,013 received an ileal neobladder. Only the 923 patients with followup longer than 90 days (median 72 months, range 3 to 267) were included in analysis. All long-term complications were identified. The complication rate was calculated using the Kaplan-Meier method.

RESULTS

The overall survival rate was 65.5%, 49.8% and 28.3% at 5, 10 and 20 years, respectively. The overall long-term complication rate was 40.8% with 3 neobladder related deaths. Hydronephrosis, incisional hernia, ileus or small bowel obstruction and feverish urinary tract infection were observed in 16.9%, 6.4%, 3.6% and 5.7% of patients, respectively, 20 years postoperatively. Subneovesical obstruction in 3.1% of cases was due to local tumor recurrence in 1.1%, neovesicourethral anastomotic stricture in 1.2% and urethral stricture in 0.9%. Chronic diarrhea was noted in 9 patients. Vitamin B12 was substituted in 2 patients. Episodes of severe metabolic acidosis occurred in 11 patients and 307 of 923 required long-term bicarbonate substitution. Rare complications included cutaneous neobladder fistulas in 2 cases, and intestinal neobladder fistulas, iatrogenic neobladder perforation, spontaneous perforation and necrotizing pyocystis in 1 each.

CONCLUSIONS

Even in experienced hands the long-term complication rate of radical cystectomy and neobladder formation are not negligible. Most complications are diversion related. The challenge of optimum care for these elderly patients with comorbidities is best mastered at high volume hospitals by high volume surgeons.

Radical cystectomy and orthotopic bladder substitution using ileum

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

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

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

Diagnosis and management of infectious complications in critically ill patients with cancer

Cancer and its treatments lead to profound suppression of innate and acquired immune function. In this population, bacterial infections are common and may rapidly lead to overwhelming sepsis and death. Furthermore, infections caused by viral and fungal pathogens should be considered in patients who have specific immune defects. As cancer therapies have become more aggressive the risk for infection has increased and many patients require intensive care support. Despite improvements in long-term survival, infections remain a common complication of cancer therapy and accounts for the majority of chemotherapy-associated deaths. By understanding the host defense impairments and likely pathogens clinicians will be better able to guide diagnosis and management of this unique population.

Effect of urinary tract infection on reservoir function in patients with ileal bladder substitute

PURPOSE

We determined the functional consequences of urinary tract infection in patients with an ileal bladder substitute in terms of urinary continence, post-void residual and urinary retention.

MATERIALS AND METHODS

A total of 48 patients with culture documented urinary tract infection (single organism, 10(5) or greater cfu) were retrospectively evaluated before, during and after the infection for changes in continence, post-void residual and urinary retention as well as for resolution of symptomatology after appropriate antibiotic therapy.

RESULTS

Of the 48 patients 40 had a single infection while the remaining 8 had multiple urinary tract infection episodes. During daytime 27 of the 44 patients with previously good daytime continence experienced deterioration in their baseline voiding status while infected. Of the 40 patients who were previously continent at night 20 had incontinence while infected. There were 15 patients with documented post-void residual and urinary retention developed in 4 during the urinary tract infection. All patients returned to baseline continence status and reservoir function after appropriate antibiotic treatment based on objective and subjective assessments.

CONCLUSIONS

Urinary tract infection may cause urinary incontinence in patients with ileal bladder substitutes. Therefore, when there are complaints of de novo urinary incontinence, a finding of post-void residual or an acute presentation of urinary retention, a urinary tract infection should be excluded. When the urinary tract infection is appropriately treated urinary continence and reservoir function return to their baseline status.

The impact of decreasing urinary IgA levels on decreased bacteriuria in a rat model of ileal augmented bladder

PURPOSE

Bacteriuria is frequently observed in patients with urinary tract reconstruction using intestinal segments. These patients have higher urinary IgA levels than those with a normal bladder. We examined the relationship between bacterial adherence and urinary IgA in a rat ileal augmented bladder model.

MATERIALS AND METHODS

Rat ileal augmented bladder models were divided into groups 3 months and 1 year after surgery. Experimental cystitis was induced in the 2 groups by transurethral inoculation of Escherichia coli. At 14 days after inoculation the rats were sacrificed, and cfu/mg tissue of the bladder and ileal patch was measured. Rats with negative urine culture in the 2 groups were sacrificed, and urine specimens and augmented bladder tissue were collected. Urinary IgA levels were determined and immunohistochemistry staining of the tissue was done with anti-rat IgA antibody.

RESULTS

In rats with experimental cystitis E. coli significantly adhered to the bladder and ileal patch in the 3-month group but not in the 1-year group. Urinary IgA levels in the 3-month group were significantly higher than in the 1-year group. On immunohistochemistry the number of IgA immunoreactive cells in the ileal patch decreased in the 1-year group compared to that in the 3-month group.

CONCLUSIONS

These results suggest that increased urinary IgA may be the cause of the higher incidence of bacteriuria in patients with urinary reconstruction using intestinal segments. Therefore, the decrease in IgA production in the inserted intestinal segments may contribute to a spontaneous decrease in of bacteriuria with time.

Risk factors for treatment failure in renal suppurative infections

There are conflicting results of published studies about prognostic value of various factors in purulent renal infections. The purpose of this study was to identify and quantify potential risk factors for early and late treatment failure in such infections. A retrospective review of 75 renal suppurative infections, at three tertiary Serbian Clinics of Urology, was conducted. We considered numerous potential risk factors in a multivariate analysis. This series was comprised of 49 women and 26 men, with mean age of 56.7 years. There were 38 and 37 patients who experienced successful and unfavorable early treatment outcome, respectively. Overall mortality rate was 9.3%. Comorbidity [odds ratio (OR) = 1.6], complex suppurative pathological findings (OR = 3.6), presence of Pseudomonas spp. (OR = 6.7), multiple bacterial strains (OR = 2.7), and positive culture itself (OR = 3.6) were the predictors of poor early prognosis. A urological intervention and presence of pyonephrosis significantly increased the chance for good initial outcome (OR = 0.32 and 0.37, respectively). In the late treatment failure analysis presence of comorbidities (OR = 5.8) and treatment complications (OR = 7.5) significantly increased chance for fatal outcome. Patients' baseline health status and complexity of suppuration itself were the most important predictors of clinical outcomes. Surgical drainage dominated over antimicrobial therapy.

Polymicrobial Infection in Patients with Cancer: An Underappreciated and Underreported Entity

Polymicrobial infections account for ~15% of infections in immunocompromised patients with cancer. However, limited information exists regarding the spectrum and microbiology of these infections, even in severely neutropenic patients. Most studies describe only monomicrobial bloodstream infections in detail, and information regarding polymicrobial infections and nonbacteremic infections is often incomplete or not provided at all. The current lack of well-established definitions for various infections in the immunocompromised host, including pneumonia, neutropenic enterocolitis, and polymicrobial infections, probably plays an important role in the paucity of published information. In this review, we briefly describe the limited information available regarding polymicrobial infections in patients with cancer and address the need for establishing consensus definitions for site-specific polymicrobial infections in neutropenic and nonneutropenic patients. We anticipate that, as factual information regarding such infections becomes available, a more comprehensive understanding of the true scope and impact of these infections will emerge, leading to appropriate modifications in the diagnostic work-up and in the therapeutic approaches used in treating these patients.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Elevated urinary cytokine levels in patients undergoing ileal neobladder replacement compared with sigmoid neobladder replacement

OBJECTIVES

The objective of this study was to examine the urinary cytokine levels for assessment of inflammatory conditions in patients with orthotopic neobladder.

MATERIALS AND METHODS

Urinary levels of IL-1beta, IL-6, and IL-8 were measured in 20 and 22 patients who underwent orthotopic neobladder replacement using ileum and sigmoid colon, respectively, and all cytokine levels greater than 5 pg/ml were defined as elevated. The outcomes were compared with respect to several parameters.

RESULTS

The proportions of patients positive for urinary culture, pyuria, and bacteriuria in the ileal neobladder group were higher than those in the sigmoid neobladder group, but these differences were not significant. Urinary levels of IL-1beta, IL-6, and IL-8 in the ileal neobladder group were significantly greater than those in the sigmoid neobladder group. Furthermore, the incidences of elevated urinary levels of IL-1beta, IL-6, and IL-8 in both groups were not affected by age, postoperative period, residual urine volume or pyuria; however, the incidences of elevated urinary IL-6 levels significantly differed between patients with and without bacteriuria in the ileal neobladder group, while there was a significant difference in the incidences of elevated urinary IL-8 levels between patients with and without bacteriuria in the sigmoid neobladder group.

CONCLUSIONS

These findings suggest that chronic inflammation was more frequently observed in patients with ileal neobladder than in those with sigmoid neobladder, and that IL-6 and IL-8 were involved in persistent bacteriuria in patients with ileal and sigmoid neobladder, respectively.

Urinary Diversion

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