Continent cutaneous diversion

Analysis of early perioperative outcomes of robot-assisted radical cystectomy and colonic diversion

Studies of right colon pouch urinary diversion have widely varying estimates of the risk of perioperative complications, reoperation, and readmission. We sought to describe the association between specific risk factors and complication, readmission, and reoperation rates following right colon pouch urinary diversion. Patients undergoing robot-assisted right colon pouch urinary diversion from July 2013 to December 2022 were analyzed. Outcome measures include high-grade (Clavien-Dindo grade ≥ 3) complications within 90 days, readmission within 90 days, and reoperation at any time during follow-up. Specific risk factors such as age, gender, body mass index (BMI), diabetes, Charlson comorbidity index (CCI), and prior radiation were analyzed to establish an association with these outcomes. During the study period, 77 patients underwent the procedure and were eligible to study. The average follow-up was 88.7 (SD 14) months. 90-day high-grade complications were 24.67%, and 90-day readmission was 33.76%. The cumulative rate of any reoperation was 40.2%, and major reoperation was 24.67%. Female gender (OR 3.3, p = 0.015), 1 kg/m2 increase in BMI (OR 3.77, p = 0.014), diabetes (OR 3.49, p = 0.021), higher CCI (OR 1.59, p = 0.034), prior radiation (OR 1.97, p = 0.026), lower eGFR (OR 0.99, p = 0.032) and BMI ≥ 25 kg/m2  (OR 3.9, p value 0.02) was associated with Clavien III-IV complications. Female gender (OR 3.3, p = 0.015), diabetes (OR 3.97, p = 0.029), higher Charlson Comorbidity Index (OR 1.73, p = 0.031), prior radiation (OR 1.45, p = 0.029), lower eGFR (OR 0.87, p = 0.037) and BMI ≥ 25 kg/m2 (OR 3.86, p = 0.031) were predictive of reoperation. Overall, the rate of postoperative complications, readmissions, and reoperation was high but consistent with other studies. This study helps further characterize surgical outcomes after right colon pouch urinary diversion and highlights patients who may benefit from enhanced preoperative management for minimising complications.

Stoma complications and quality of life in patients with Indiana pouch versus appendico/neo-appendico-umbilicostomy urinary diversions

OBJECTIVES

To evaluate three subtypes of continent-cutaneous urinary diversion (CCUD); Indiana pouch (IP), right colon pouch with appendico-umbilicostomy (AU), and right colon pouch with neo-appendico-umbilicostomy (NAU), by investigating diversion-specific complications and quality-of-life outcomes.

MATERIALS AND METHODS

A retrospective review of an IRB-approved database was conducted for perioperative and outcome data. The EORTC QLQ-C30 questionnaire was used to assess quality of life; all responses were obtained > 6 months after diversion.

RESULTS

Fifty-eight patients who underwent a CCUD at our institution from 2010 to 2016 (33 IP by two surgeons, 15 AU and ten NAU by third surgeon) were identified for this study. Higher age and Charlson Comorbidity Index (CCI) ≥ 3 were seen in the AU cohort when compared to the IP cohort (P = 0.02 and 0.02, respectively). NAU group were also older when compared to the IP group (P = 0.02). After a median follow-up of 21 months (range: 0.8-81.0), more high-grade diversion-related complications were reported for AU and NAU patients comparing to the IP group (P < 0.01 and P = 0.02, respectively). More stoma complications were also reported for the NAU cohort than the IP cohort (70% vs 30%, P = 0.03). In all groups, > 60% of stoma complications occurred at the skin or fascia level. In the 90-day postoperative period, a higher continence rate was reported for the IP cohort, and this difference was significant when compared to the NAU cohort (P = 0.04). Length of stay after surgery and revision rates were not significantly different. For all groups, the majority of patients reported little-to-no disturbance of daily functions and rated overall quality of life as good-to-excellent.

CONCLUSION

Urinary diversion using the Indiana pouch and right colon pouch with appendico/neo-appendico-umbilicostomy are all associated with high rates of continence and patient satisfaction. When compared to IP, AU and NAU patients had higher rates of high-grade diversion-related complications and NAU patients had a higher stoma complications with lower 90-day continence rate.

Long-term Outcomes of Cystectomy and Crossfolded Ileal Reservoir Combined with an Afferent Tubular Segment for Heterotopic Continent Urinary Diversion: A Longitudinal Single-centre Study

BACKGROUND

The crossfolded ileal reservoir combined with an afferent tubular isoperistaltic segment for heterotopic continent urinary diversion has been performed on a regular basis for over 20 years. Yet data on long-term-outcomes remain sparse.

OBJECTIVE

To report long-term functional and oncological outcomes, gastrointestinal and metabolic disturbances, urinary tract infections (UTIs), and quality of life.

DESIGN, SETTING, AND PARTICIPANTS

Long-term functional and oncological outcomes of a consecutive series of 118 patients undergoing cystectomy and construction of a continent cutaneous crossfolded ileal reservoir from 2000 to 2018 were evaluated.

INTERVENTION

Patients underwent cystectomy and construction of a continent cutaneous crossfolded ileal reservoir according to the Studer technique for bladder reconstruction.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Pre- and postoperative data until last follow-up appointment were entered prospectively in the departmental database. Self-reported questionnaires regarding quality of life, patient satisfaction, and difficulty in catheterisation were sent to patients preoperatively; after 3, 6, 12, and 24 mo; and at last follow-up, and were then manually entered in the departmental database.

RESULTS AND LIMITATIONS

The median follow-up was 7.8 (interquartile range 3-12.7) yr. Patient satisfaction was high in 77.4% and moderate in 16.9%. Serum creatinine and estimated glomerular filtration rate remained stable during follow-up. Of all patients, 81% (96/118) had at least one UTI during follow-up. Recurrent UTIs occurred in 67% (79/118) of patients. Urolithiasis was found in 12% (14/118), with 6% (7/118) having a single and 6% a recurrent event. Of all stone formers, 79% (11/14) had recurrent UTIs. In oncological patients, 12.5% (10/79) developed a local recurrence. Cancer-specific survival and overall survival were 90% and 88%, and 68% and 56% after 1 and 10 yr, respectively. A limitations is the retrospective analysis from prospectively assessed data.

CONCLUSIONS

A high satisfaction level, stability of kidney function, and low rates of urolithiasis in patients with a heterotopic continent ileal reservoir can be achieved, provided that close attention is paid to intra- and postoperative details. Regular lifelong follow-up is essential for timely detection and treatment of complications. Oncological outcome is not affected by the urinary diversion.

PATIENT SUMMARY

In patients with a continent cutaneous ileal reservoir, good quality of life and a high satisfaction rate are possible provided that patients adhere to regular lifelong follow-up.

Robotic intracorporeal urinary diversion: state of the art

PURPOSE OF REVIEW

We review historical aspects and current status of the emerging approach of robotic urinary diversion (rUD). Established surgical principles of constructing a low-pressure, large-capacity reservoir are described and the open surgical literature succinctly reviewed to establish the gold standard. Incontinent and continent rUD types [ileal conduit, orthotopic neobladder (all varieties), continent cutaneous diversion, cutaneous ureterostomy] and techniques (extra-corporeal, intra-corporeal) are discussed. Outcomes data (intra-operative, perioperative, intermediate-term, long-term), functional outcomes, complications and learning curve are presented. Outcomes data of open versus robotic urinary diversion are examined. Critiques, improvements, and pros-cons of rUD are discussed.

RECENT FINDINGS

Although the majority of centers performing rUD use the extracorporeal technique, use of intra-corporeal rUD is increasing. Although data are yet limited, intra-corporeal rUD may provide some benefits. For rUD, operative times are higher and complication rates comparable with open urinary diversion.

SUMMARY

The entire range of urinary diversion surgery has now been replicated robotically. At this writing, extracorporeal urinary diversion techniques still predominate following robotic cystectomy. However, all rUD options can now be performed intra-corporeally with success. As experience increases, the field of robotic urinary diversion is poised to grow.

Outcomes of right colon continent urinary pouch using standardized reporting methods

AIMS

Studies of right colon pouch urinary diversion estimate risk of perioperative complications, 1%-50%, and reoperation, 1%-69%. This wide range is due to variable outcome measurements and reporting methods; it is also unclear which factors increase the risk of complications and reoperation. We sought to characterize the impact of patient-specific factors on risk of complications, readmission, and reoperation after right colon pouch urinary diversion.

METHODS

Patients undergoing right colon pouch urinary diversion from January 2010 to April 2017 were analyzed. Outcomes included: high-grade complications within 90 days (Clavien-Dindo grade ≥3), readmission within 90 days, and reoperation at any time during follow-up. Patient-specific factors were analyzed to establish any associations with these outcomes.

RESULTS

During the study period, 53 patients underwent the procedure and the average follow-up was 30 (standard deviation [SD] 21.5) months; 90-day high-grade complications were 22% and readmission was 45%. The cumulative rate of any reoperation was 53% and major reoperation was 32%. Diabetes was associated with an increased risk of both postoperative complications and reoperation. Larger body mass index and prior abdominal surgery were associated with increased risk of readmission.

CONCLUSIONS

Overall the rate of postoperative complications, readmissions, and reoperation was high, but in agreement with other contemporary series. This study helps to further characterize surgical outcomes after right colon pouch urinary diversion, however, similar to other studies in the literature, the rarity of the procedure limits the power to establish a link between preoperative patient factors and outcomes.

Revisiting Ureterosigmoidostomy, a Useful Technique of Urinary Diversion in Functional Urology

Ureterosigmoidostomy has largely been disregarded in recent times but has now seen a resurgence of interest because of its potential applicability to newer, minimally invasive surgical techniques. The advantages of ureterosigmoidostomy over intestinal conduits are urinary continence (obviating the need for stoma and external appliances), ease, and rapidity of performance as well as acceptance by patients. Ureterosigmoidostomy has been characterized by good continence outcomes and it offers good quality of life. Possible complications are anastomosis stenosis, coloureteral reflux, electrolyte imbalance, hydronephrosis, pyelonephritis, chronic renal failure, colorectal cancer, and others. Ureterosigmoidostomy is therefore only advisable for patients ready to accept long-term follow-up.

Long-term third-party assessment of results after continent cutaneous diversion with Lundiana pouch

OBJECTIVES

To investigate the long-term functional outcomes and complications after continent cutaneous diversion with the Lundiana pouch.

PATIENTS AND METHODS

Complications, re-operations, renal function, and continence were ascertained from patient charts. Outcome variables were validated by a second and independent review of the patient files.

RESULTS

A complication of Clavien-Dindo grade ≥III, including unscheduled re-admissions, occurred in 45/193 patients (23%) at ≤90 days of surgery. At a median follow-up of 13 years, 105/193 patients (54%) had undergone at least one re-operation, with uretero-intestinal stricture being the most prevalent cause [28 patients (15%)]. Re-operations were more prevalent in patients operated during the first half of the study period than during the second half (2000-2007; 62% vs 47%; P = 0.03), and they were also more frequent in patients who underwent surgery for benign causes than in patients who underwent surgery for malignancy (60% vs 51%; P = 0.04). Continence was achieved in 172/188 patients (91%). In all, 16% of all patients required revisional surgery of the outlet to remain continent with an easily catheterisable pouch or to address stomal stenosis. The mean decrease in estimated glomerular filtration rate was more pronounced in patients with benign indications for urinary diversion than in those with malignancies, even after adjusting for younger age at surgery and longer follow-up in the former group (22 vs 11 mL/min/1.73 m² ; P < 0.006). A disinterested third-party assessment revealed 10 postoperative complications, 17 re-operations during follow-up, and seven occasions of hospitalisation due to pyelonephritis (included in data above) not recorded at the primary data review.

CONCLUSIONS

The Lundiana pouch is associated with a high risk of re-operation, although the functional results are good. Independent review by a third party increased the validity of the outcome data.

HETEROTOPIC CONTINENT OR INCONTINENT URINARY DIVERSION:MAKING THE OPTIMAL CHOICE

Introduction. Quality of life and survival rate of post-cystectomy patients depend on the urinary diversion methods [1,2].Purpose of the study. A comparison of morbidity, survival rate, and quality of life in patients after heterotopic continent or incontinent urinary diversions.Materials and methods. During the period from 1998 to 2016, 36 heterotopic intestinal diversions were performed using urine containment method according to the Kock pouch scheme in our modification, and 61 incontinent heterotopic intestinal Bricker diversions. We evaluated the comorbid conditions (Charlson comorbidity index), postoperative complications (acc. to Clavien-Dindo), survival rate (acc. to E.L. Kaplan, P. Meier), and the quality of life of patients (SF-36) using complex statistical analysis.Results. Early and late complications not related and related to urinary diversion prevailed in the group of patients after Bricker surgery without statistical significance. With longer postoperative monitoring periods the share of complications related to urinary diversion increases, while the frequency of delayed complications and survival rate show no statistical difference in both groups. No reliable differences were revealed in the quality of life in all cases of cutaneous urinary diversion.Discussion. 80% of patients after the Kock pouch surgery (mod.) throughout the medium follow-up period of over 5 years remain continent and enjoy high quality of life. It is necessary to develop and implement in clinical practice new and more advanced statistical tools for evaluation of the patients’ quality of life depending upon the type of urinary diversion after cystectomy.Conclusion. Heterotopic continent diversion (Kock pouch (mod.)) in comparison with the incontinent method (Bricker) does not increase morbidity or decrease the survival rate, and provides for higher quality of life.