Considerations for orthotopic diversions in women

Urinary function in female patients after traditional, organ-sparing and nerve-sparing radical cystectomy for bladder cancer: a systematic review and pooled analysis

OBJECTIVES

To determine and summarize the available data on urinary, sexual, and health-related quality-of-life (HRQOL) outcomes after traditional radical cystectomy (RC), reproductive organ-preserving RC (ROPRC) and nerve-sparing RC (NSRC) for bladder cancer (BCa) in female patients.

METHODS

The PubMed, SCOPUS and Web of Science databases were searched to identify studies reporting functional outcomes in female patients undergoing RC and urinary diversion for the treatment of BCa. The outcomes of interest were voiding function (for orthotopic neobladder [ONB]), sexual function and HRQOL. The following independent variables were derived and included in the meta-analysis: pooled rate of daytime and nighttime continence/incontinence, and intermittent self-catheterization (ISC) rates. Analyses were performed separately for traditional, organ- and/or nerve-sparing surgical approaches.

RESULTS

Fifty-three studies comprising 2740 female patients (1201 traditional RC and 1539 organ-/nerve-sparing RC, and 264 nerve-sparing-alone RC) were eligible for qualitative synthesis; 44 studies comprising 2418 female patients were included in the quantitative synthesis. In women with ONB diversion, the pooled rates of daytime continence after traditional RC, ROPRC and NSRC were 75.2%, 79.3% and 71.2%, respectively. The pooled rate of nighttime continence after traditional RC was 59.5%; this rate increased to 70.7% and 71.7% in women who underwent ROPRC and NSRC, respectively. The pooled rate of ISC after traditional RC with ONB diversion in female patients was 27.6% and decreased to 20.6% and 16.8% in patients undergoing ROPRC and NSRC, respectively. The use of different definitions and questionnaires in the assessment of postoperative sexual and HRQOL outcomes did not allow a systematic comparison.

CONCLUSIONS

Female organ- and nerve-sparing surgical approaches during RC seem to result in improved voiding function. There is a significant need for well-designed studies exploring sexual and HRQOL outcomes to establish evidence-based management strategies to support a shared decision-making process tailored towards patient expectations and satisfaction. Understanding expected functional, sexual and quality-of-life outcomes is necessary to allow individualized pre- and postoperative counselling and care delivery in female patients planned to undergo RC.

Initial Experience With Extraperitoneal Laparoscopic Radical Cystectomy With Pelvic Organ-Preserving and Orthotopic Neobladder Techniques for Bladder Cancer in Female Patients

OBJECTIVE

To present the extraperitoneal laparoscopic radical cystectomy (ELRC) technique, and initial outcomes of organ-preserving and orthotopic neobladder (ONB) techniques for bladder cancer in selected females.

MATERIALS AND METHODS

Data including patient characteristics, operative time, blood loss, transfusion rate, length of hospital stay, and pathologic outcomes, as well as 30- and 90-day complications were collected between April 2018 and May 2021 from females who underwent ONB after ELRC. Regular follow-up focused on patients' oncological and functional outcomes, and postoperative sexual function status was assessed using the Female Sexual Function Index (FSFI).

RESULTS

Eleven females with a mean age of 53 years who underwent ELRC with pelvic organ-preservation and ONB were analyzed retrospectively. All procedures were completed successfully. The mean operative time was 264.82 ± 33.81 min, and the average intraoperative blood loss was 128 ± 18.19 mL. All patients had negative pathological margins and no lymph node metastases. The average hospital stay was 10.72 days. The single J ureteral stent and catheter were usually removed 3-4 weeks after the procedure. The FIFS assessment of postoperative sexual function showed that the patients were relatively satisfied.

CONCLUSION

ELRC with pelvic organ preservation and ONB technology was a safe and feasible surgical strategy for the selected female patients. Preserving organs and vascular nerve bundles seemed to be safe in oncological and produced encouraging functional results. Further rigorous prospective studies with more patients and long-term follow-up data are needed to assess the oncologic and functional results.

Preliminary Functional Outcome Following Robotic Intracorporeal Orthotopic Ileal Neobladder Suspension with Round Ligaments in Women with Bladder Cancer

BACKGROUND

Chronic urinary retention (CUR) is a frequent complication after orthotopic neobladder (ONB) reconstruction in women. To decrease CUR, several open surgical modifications to provide back support to the ONB have been established on the basis of pelvic anatomical differences between females and males.

OBJECTIVE

To illustrate our technique for robotic intracorporeal reconfiguration of ONB as integrated into our open surgical approach to provide back support to the ONB with round ligaments in women.

DESIGN, SETTING, AND PARTICIPANTS

From November 2017 to April 2021, 28 patients underwent robotic intracorporeal ONB with a minimum of 6 mo of follow-up at a single centre.

SURGICAL PROCEDURE

We performed robotic radical cystectomy, pelvic lymphadenectomy, and a complete intracorporeal ONB suspended with round ligaments (rONB). Our surgical procedure is demonstrated in the accompanying video.

MEASUREMENTS

Demographics and clinical and pathological data were collected. Perioperative and 90-d complications and 6-mo functional outcomes were compared for the rONB group (n = 12) and the patients receiving a traditional ONB (tONB; n = 16).

RESULTS AND LIMITATIONS

The median total operative time was 305 min (interquartile range [IQR] 270-370) for tONB and 303 min (IQR 287-330) for rONB. The median estimated blood loss was 325 ml (IQR 200-700) for tONB and 350 ml (IQR 262-600) for rONB. Some 50% of the tONB group and 41.7% of the rONB group experienced low-grade complications. A total of 12.5% tONB and 8.3% rONB patients experienced high-grade complications with neobladder-vaginal fistula. The cumulative risk of CUR was 37.5% in the tONB group and 16.7% in the rONB group. This study is limited by the small sample size and the short follow-up period.

CONCLUSIONS

We established a feasible surgical technique for a robotic intracorporeal ONB configuration suspended with round ligaments. This may prevent the occurrence of emptying dysfunction in women.

PATIENT SUMMARY

We describe our stepwise technique for creating a new bladder within the body that is suspended with round ligaments. Patients undergoing removal of the bladder for bladder cancer may benefit from this technique in terms of better urinary function and the advantages of a robotic surgical approach.

Round ligament suspending treatment in orthotopic ileal-neobladder after radical cystectomy in women: a single-centre prospective randomised trial

OBJECTIVES

To compare the occurrence of emptying dysfunction between surgical techniques for orthotopic neobladder suspended with round ligament (rONB) and the standard procedure (sONB).

PATIENTS AND METHODS

A prospective randomised controlled trial was performed in a single centre of female patients undergoing creation of an ONB using rONB or sONB. Patients were followed for ≥24 months after ONB. The primary endpoints were significant post-void residual urine volume (sPVR) and need for clean intermittent catheterisation (CIC) at 24 months postoperatively. The secondary endpoints included early and late complications, urodynamic profile, and ONB continence.

RESULTS

Between January 2011 and October 2017, the trial enrolled 85 patients, of whom 82 were randomised. A total of 41 patients had a rONB and 41 a sONB. At 24 months, 17 of the 37 patients with a sONB and nine of the 39 patients with a rONB had a sPVR. The cumulative risk of a sPVR was significantly lower in the rONB group (23.1%) vs the sONB group (45.9%) (hazard ratio [HR] 0.43, 95% confidence interval [CI], 0.19-0.96; P = 0.040). In all, 15 of the 37 patients with a sONB and four of the 39 patients with a rONB needed CIC. The cumulative risk of requiring CIC was significantly lower in the rONB group (10.3%) vs the sONB group (40.5%) (HR 0.22, 95% CI 0.07-0.67; P = 0.008) at 24 months. Multivariable Cox regression analysis also showed that the rONB type was an independently protective factor for sPVR and CIC. The rates of early (0-90 days) and late complication (>90 days) were 54.1% and 13.5% in the sONB group, and 64.1% and 10.3% in the rONB group, respectively. There were no significant differences in complications, urodynamic profile or ONB continence. A major limitation is the small sample size at a single centre.

CONCLUSION

Posterior support with round ligament for an ONB significantly improved the emptying of the ONB and resulted in a reduced need for CIC. The surgical modification is a feasible and safe technique without additional complication-related surgeries.

Surgical Outcomes of Transvaginal Neobladder-Vaginal Fistula Repair After Radical Cystectomy with Ileal Orthotopic Neobladder: A Case-Control Study

Purpose

To present surgical methods and outcomes in women with bladder cancer (BCa) requiring correction of neobladder-vaginal fistula (NVF) after radical cystectomy (RC) with ileal orthotopic neobladder (IONB).

Materials and Methods

The medical records of 163 women who underwent RC with IONB for BCa between January 2010 and December 2018 were retrospectively reviewed. The presence of NVF was confirmed by cystoscopy and/or voiding cystography. NVF repair was performed using a transvaginal approach, which included circumferential incision of the fistula tract, creation of a plane between the neobladder serosa and the vaginal epithelium, and multi-layered transvaginal closure.

Results

During a median follow-up of 47.9 months, NVF was identified in 12 (8.8%) of the 163 included women. Eight (66.7%) fistulas were located in the proximal anterior vaginal wall and four (33.3%) in the vaginal apex. Median time from RC to NVF repair was 3.4 months (range, 2.1-5.6 months), median NVF size was 6.0 mm (range, 4.0-22.0 mm), and median duration of urethral Foley catheter indwelling was 24.0 days (range, 15.0-43.0 days). Initial repair of NVF was successful in ten (83.3%) patients. Two (16.7%) patients who relapsed retained IONB through the subsequent operation. Two (16.7%) patients developed severe urinary incontinence after NVF repair, requiring anti-incontinence surgery with a synthetic transobturator mid-urethral sling.

Conclusion

The transvaginal approach for NVF repair is feasible, yielding successful surgical outcomes. However, women should be counseled about the risks of relapse and urinary incontinence.

Risk Factors for Urethral Recurrence in Men After Radical Cystectomy with Orthotopic Urinary Diversion for Urothelial Carcinoma: A Retrospective Cohort Study

Purpose

To evaluate the risk factors affecting urethral recurrence (UR) in men after radical cystectomy (RC) with ileal orthotopic neobladder (IONB).

Materials and Methods

We retrospectively reviewed 348 men who underwent RC with IONB for bladder cancer between January 2010 and December 2017. Clinicopathologic characteristics, including tumor location (trigone and/or bladder neck), prostatic urethral and/or stromal involvement, presence of carcinoma in situ (CIS), pathologic T and N stage, and urethral resection margin status, were identified. Kaplan–Meier survival analysis was used to illustrate urethral recurrence-free survival (URFS), and Cox proportional hazard models were applied to identify factors predicting UR.

Results

Of the 348 patients, UR was identified in 7 (2.0%) patients during the mean follow-up of 33.3 months. The 2-, 3-, and 5-year URFS rates were 97.6%, 96.3%, and 93.8%, respectively. On multivariable analysis, prostatic urethral involvement (P = 0.033, hazard ratio: 6.25, 95% confidence interval: 1.06–36.96) was an independent predictor of UR. When patients were divided according to prostatic urethral involvement (negative vs positive), the 2- and 3-year URFS rates were significantly different (93.8% and 96.8%, respectively, vs 92.0% and 92.0%, respectively; P = 0.020). All 7 patients with UR underwent transurethral surgery and maintained their IONB.

Conclusion

In this series, UR occurred in approximately 2% of men after RC with IONB. Prostatic urethral involvement was the only significant prognostic factor for UR. Follow-up strategies considering UR risk should be adopted to facilitate early detection in those at high risk of UR.

Neobladder-Vaginal Fistula: Surgical Management Techniques

PURPOSE OF REVIEW

To describe the complexities of diagnosis and management of neobladder-vaginal fistula (NVF) following orthotopic urinary diversion in women.

RECENT FINDINGS

Multiple recent single-institution series confirm the variability of outcomes for NVF repairs and caution regarding comorbid stress urinary incontinence which may necessitate further interventions including conversion to alternate diversions. Although both abdominal and transvaginal approaches have been advocated for surgical management of NVF, contemporary series from reconstructive surgeons favor a vaginal approach to decrease overall operative morbidity. Patients should be carefully counseled regarding neobladder and sphincter function following fistula repair along with the risks of secondary urinary diversion.

Treatment of Pelvic Floor Disorders Following Neobladder

Radical cystectomy remains the gold standard treatment for organ-confined high-grade recurrent or muscle-invasive bladder cancer. Orthotopic neobladder urinary diversion following cystectomy represents an option for patients wishing for continent urinary diversion. Female patients who undergo radical cystectomy with orthotopic bladder substitution are at risk for developing both common and neobladder-specific disorders of the pelvic floor, including urinary incontinence, hypercontinence, vaginal prolapse, and neobladder-vaginal fistula. Each of these sequelae can have significant impact on the patient's quality of life. Due to the increased frequency of orthotopic neobladder creation in women, subspecialty urologists are more likely to confront such pelvic floor disorders in bladder cancer survivors. This review presents the most current information on the treatment of pelvic floor disorders after orthotopic bladder substitution.

Systematic Review on the Fate of the Remnant Urothelium after Radical Cystectomy

CONTEXT

Urothelial carcinoma is considered a pan-urothelial disease. As such, the remnant urothelium in the upper urinary tract and urethra following radical cystectomy (RC) remains at risk for secondary urothelial tumors (SUTs).

OBJECTIVE

To describe the incidence, diagnosis, treatment, and outcomes of patients with SUTs after RC.

EVIDENCE ACQUISITION

A systematic search was conducted using PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2016 reporting on malignant diseases of the urothelium after RC for bladder cancer. The search strategy separated between upper and lower tract urothelial tumors.

EVIDENCE SYNTHESIS

Of a total of 1069 studies, 57 were considered for evidence synthesis. SUTs occured in approximately 4-10% of patients after RC. Carcinoma in situ of the bladder, a history of nonmuscle invasive bladder cancer, and tumor involvement of the distal ureter are the strongest risk factors for secondary upper tract tumors. Risk factors for secondary urethral tumors represent urothelial malignancy in the prostatic urethra/prostate and bladder neck (in women), nonorthotopic diversions, and positive findings on permanent sections. The majority of patients (84%) with SUTs, presented with urothelial recurrence without evidence of metastasis. Of those, 84.0% were treated with surgery, 10.5% with systemic chemotherapy and/or radiotherapy, and 5.6% with topical chemotherapy and/or immunotherapy. After a median follow-up of 91 mo (range: 26-155), 65.9% of patients died of disease and 21.5% died of other causes. Detection and treatment of SUTs at an asymptomatic stage can reduce the risks of cancer-specfific and overall mortality by 30%. A limitation of the study is that the available data were retrospective.

CONCLUSIONS

SUTs are rare oncological events and most patients have an adverse prognosis despite absence of distant disease at diagnosis. Therefore, surveillance of the remnant urothelium should be implemented for patients with histological features of panurothelial disease as it may improve timely detection and treatment.

PATIENT SUMMARY

Secondary tumors of the renal pelvis, ureters, and urethra occur in approximately 4-10% of patients after radical removal of the bladder for bladder cancer. These patients' prognoses are reduced, likely due to delayed diagnosis. Therefore, routine surveillance might be important to detect tumors at an early stage.