Radical cystectomy and ileocaecal bladder reconstruction for carcinoma of the urinary bladder. A study of 130 patients

[Continent urinary diversion following anterior exenteration]

BACKGROUND

Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir).

RESULTS

Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field.

CONCLUSION

Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).

Neobladder long term follow-up

One of the commonest forms of orthotopic bladder substitution for bladder cancer survivors, used in our institute, is the use of ileocecal segment. Sometimes, the need for Indiana pouch heterotropic continent diversion arises.

AIM

To compare the long-term effect of orthotopic ileocecal bladder and heterotropic Indiana pouch following radical cystectomy in bladder cancer patients.

PATIENTS AND METHODS

Between January 2008 and December 2011, 91 patients underwent radical cystectomy/anterior pelvic exentration and orthotopic ileocecal bladder reconstruction (61 patients) and Indiana pouch (30 patients), when orthotopic diversion could not be technically or oncologically feasible.

RESULTS

Convalescence was uneventful in most patients. All minor and major urinary leakage cases, in both diversions groups, where successfully conservatively treated. Only one patient in the ileocecal group with major urinary leak required re-exploration with successful revision of uretro-colonic anastomosis. Only one patient in the Indiana pouch group had accidentally discovered sub-centimetric stone, which was simply expelled. The overall survival proportion of ileocecal group was 100% compared to 80% in the Indiana pouch group (p<0.001). The disease free survival proportion of ileocecal group was 90.8% compared to 80% in the Indiana pouch group (p=0.076). Effective comparative daytime and nighttime urinary continence as well as renal function deterioration were not statistically significant between both reconstruction types.

CONCLUSION

Both ileocecal bladder and Indiana pouch are safe procedures in regard to long-term effects over kidney function following radical cystectomy.

Ileocaecal vs ileal neobladder after radical cystectomy in patients with bladder cancer: a comparative study

OBJECTIVE

To compare an ileocaecal orthotopic bladder, (which has been the standard procedure in Egypt for >30 years) with the ileal neobladder, as there is no ideal continent orthotopic bladder replacement for patients after cystectomy for bladder cancer.

PATIENTS AND METHODS

Between June 1999 and December 2001, 60 patients with invasive bladder cancer were randomized into two groups. Group A comprised 29 patients who had radical cystectomy and reconstruction with an ileal neobladder (median age 50 years, 27 men and two women) and group B included 31 who had an ileocaecal bladder substitution after radical cystectomy (median age 51 years, 28 men and three women).

RESULTS

The complication rate after surgery in group A was 17%, with two deaths, one from acute myocardial infarction and the other from haematemesis. In group B, the complication rate was 13%, with two deaths, one from a massive pulmonary embolism and the other from liver cell failure. Daytime continence was achieved in 93% of patients in group A and 90% in group B. The mean (sd) postvoid residual urine volume was larger in group A than group B, at 90 (72) vs 12 (20) mL. Acidosis and hyponatraemia were evident in the patients in group A but in none in group B (P < 0.05). The pelvicalyceal systems were preserved in 85% of patients in group A and 93% in group B during the 2-year follow-up. The mean (sd) renal cortical thickness was less in group A than in group B, at 1.8 (0.5) and 1.9 (0.2) cm, respectively. Although the cystometric capacity was greater and the basal pressure less in group A than B, these were not reflected in the degree of diurnal and nocturnal continence or back pressure on the renal units.

CONCLUSION

Continence in both pouches was similar but the renal units were preserved better in the ileocaecal than in the ileal neobladder. Residual urine volume was greater in the ileal neobladder, with its potential complications of infection and stone formation, and acidosis was more evident.

Replacement of the bladder by the urethral Kock pouch: functional results, urodynamics and radiological features

After cystoprostatectomy for cancer of the bladder 43 men were provided with a detubularized, low pressure ileal reservoir (Kock pouch) connected to the urethra. Reflux was prevented by an intussusception valve. There was no operative mortality and few early complications. At followup the mean postoperative observation time was 13 months, with a range of 5 to 20 months. Late complications included manifestations of local tumor recurrence or distant metastases in 9 patients within 6 months postoperatively, which made adequate functional evaluation impossible. In 18 patients reflux to the upper urinary tract due to eversion or sliding of the antireflux valve occurred at various postoperative intervals. In 16 of these patients incontinence developed as a consequence of the reflux. Surgical correction of the failing antireflux valve restored reflux prevention and continence. Within 3 to 6 months the capacity of the reservoirs had reached an ultimate volume of approximately 600 ml. Pressure waves exceeding 40 cm. water seldom occurred in the mature reservoirs and then only at high filling volumes. The mean urethral resting resistance to flow was 64 cm. water. The configuration and function of the upper urinary tract improved or stabilized postoperatively. Of 34 evaluable patients 30 were continent during the day with a voiding frequency of 3 to 5 times and dry at night with a frequency of 0 to 2.