Renal function up to 16 years after conduit (refluxing or anti-reflux anastomosis) or continent urinary diversion. 1. Glomerular filtration rate and patency of uretero-intestinal anastomosis

New clinical insights into the treatment of benign uretero-ileal anastomotic stricture following radical cystectomy and urinary diversion

BACKGROUND

Benign uretero-ileal anastomotic stricture (UIAS) is a potentially serious complication that can arise after radical cystectomy (RC) and subsequent urinary diversion. To preserve residual renal function and improve prognosis, it is crucial to derive insights from experience and tailor individualized treatment strategies for different patients.

PATIENTS AND METHODS

From October 2014 to June 2021, a total of 47 patients with benign UIAS underwent endoscopic management (n = 19) or reimplantation surgery (n = 28). The basic data, perioperative conditions, and postoperative outcomes of the two groups were compared and analyzed to evaluate efficacy.

RESULTS

Comparing preoperative and postoperative clinical efficacy within the same group, the endoscopic group showed no significant differences in creatinine and blood urea nitrogen (BUN) levels before surgery or after extubation (p > 0.05). However, significant differences were observed in glomerular filtration rate (GFR) levels on the affected side before surgery and after extubation (p < 0.05). In contrast, the laparoscopic reimplantation group did not exhibit significant differences in creatinine, BUN, or GFR levels of affected side before surgery and after extubation (p > 0.05). Postoperative clinical efficacy showed no significant difference in creatinine and BUN levels between the two groups (p > 0.05). However, GFR values of affected side in the endoscopic treatment group decreased more than those in the laparoscopic reimplantation group (p < 0.05). Additionally, the laparoscopic reimplantation group was able to remove the single-J tube earlier than the endoscopic treatment group (p < 0.05), had a lower recurrence rate of hydronephrosis after extubation (p < 0.05), and experienced a later onset of hydronephrosis compared to the endoscopic treatment group (p < 0.05).

CONCLUSIONS

Based on our experience in treating UIAS following RC combined with urinary diversion, laparoscopic reimplantation effectively addresses the issue of UIAS, allowing for the removal of the ureteral stent relatively soon after surgery. This approach maintains long-term ureteral patency, preserves residual renal function, reduces the risk of ureteral restenosis and hydronephrosis, and has demonstrated superior therapeutic outcomes in this study.

[Do's and Dont's for radical cystectomy and urinary diversion - how to minimise postoperative complications]

Radical cystectomy (RC) with urinary diversion is a challenging surgical intervention. There is significant risk of postoperative complications, particularly linked to urinary diversion and the patient's comorbidities. The surgeon and the multidisciplinary team need to be familiar with all potential complications. In order to achieve optimal oncological and functional outcomes, multiple factors have to be considered during perioperative management, including the adherence to evidence-based guidelines, standardised concepts of enhanced recovery and best surgical practice for RC and urinary diversion. All measures should aim to minimise complication rates after RC and to accelerate recovery. We summarise essential Dos and Don'ts when performing RC with different forms of urinary diversion.

The functioning and the complication rate of extreme long existing urinary diversions

PURPOSE OF REVIEW

This review is timely and relevant because many patients live many years with urinary diversions. Knowledge about the long term outcome with respect to function and complications are important for patient counseling and for the manner to follow-up patients. This study was performed to investigate the functioning of urinary diversions constructed > 25 years earlier.

RECENT FINDINGS

Most studies have a relatively shorter follow-up, mainly focussing on short term postoperative complications. Focussing on the long term, urinary tract infections (UTI) including pyelonephritis are common. Mild kidney function deterioration is described.

SUMMARY

Retrospective study (2018-2019); 43 patients with regular follow-up at the Radboud University Medical Centre Nijmegen the Netherlands. Ileal conduit (n = 19) and ureterosigmoidostomy (n = 11) are the most common diversion types for reasons such as: bladder exstrophy (n = 15), urinary incontinence (n = 9) and malignancy (n = 8). This series with a median follow-up of 40 years, shows it is possible to live and cope with a urinary diversion for a very long time. Ureterosigmoidostomies give relatively good results. Ileal conduits are functioning properly with acceptable complication rates. 95% suffers from chronic UTI's. Kidney function deterioration was mild. Diversions for benign reasons have more complex complications compared to diversion constructed for malignant reasons.Supplementary video abstracthttp://links.lww.com/COU/A32.

Congenital Bladder and Urethral Agenesis: Two Case Reports and Management

Background

Agenesis of the bladder and urethra is a rare congenital anomaly, with a very few living cases reported in the literature so far. Case Presentation. We are reporting two female patients (3 and 6 years old) with bladder and urethral agenesis who presented with urinary incontinence. In both patients, magnetic resonant imaging (MRI) revealed a case of bladder and urethral agenesis with normal ureters draining into the vagina. Patients underwent a neobladder and conduit creation surgery. The neobladder was constructed from the whole cecum and a part of the ascending colon, followed by an anastomose of the ureters into the neobladder in a nonrefluxing fashion; the appendix was used simultaneously as a continent catheterizable conduit. The two patients attained urinary continence postoperatively.

Conclusion

We reported two cases of bladder agenesis, and for the first time, we have performed neobladder creation surgery using the cecum and ascending colon. One-year follow-up did not reveal any complications.

Ureteroileal bypass: a new technic to treat ureteroenteric strictures in urinary diversion

Objective:

To present our technique of ureteroileal bypass to treat uretero-enteric stric- tures in urinary diversion.

Materials and Methods:

One hundred and forty-one medical records were reviewed from patients submitted to radical cystectomy to treat muscle-invasive bladder cancer between 2013 and 2015. Twelve (8.5%) patients developed uretero-enteric anastomotic stricture during follow-up. Five patients were treated with endoscopic dilatation and double J placement. Four were treated surgically with standard terminal-lateral im- plantation. Three patients with uretero-enteric anastomotic stricture were treated at our institution by “ureteroileal bypass”, one of them was treated with robotic surgery.

Results:

All patients had the diagnosis of uretero-enteric anastomotic stricture via computerized tomography and DTPA renal scan. Time between cystectomy and diag- nosis of uretero-enteric anastomotic stricture varied from five months to three years. Mean operative time was 120±17.9 minutes (98 to 142 min) and hospital stay was 3.3±0.62 days (3 to 4 days). Mean follow-up was 24±39.5 months (6 to 72 months). During follow-up, all patients were asymptomatic and presented improvement in ure-terohydronephrosis. Serum creatinine of all patients had been stable.

Conclusions:

Latero-lateral ureter re-implantation is feasible by open or even robotic surgery with positive results, reasonable operation time, and without complications.

Follow-up Management of Cystectomy Patients

Bladder cancer is the sixth leading cancer in the United States. Radical cystectomy is a lifesaving procedure for bladder cancer with or without muscle invasion. Radical cystectomy is performed on 39% of these patients, and 35% will have a life-threatening recurrence. Distant metastases are the most common; local, upper tract, and urethral recurrence can also occur. Surveillance after cystectomy is critical to diagnosing recurrence early. Functional complications after urinary diversion include bowel dysfunction, vitamin B12 deficiency, acidosis, electrolyte abnormalities, osteopenia, nephrolithiasis, urinary tract infections, renal functional decline, and urinary obstruction, which can be reversed when diagnosed early.

Acid-base disorders after orthotopic bladder replacement: comparison of an ileal neobladder and an ileal conduit

Objectives: For many years, creation of an orthotopic neobladder after cystectomy has been popular. In the present study, we measured the extent of metabolic acidosis in patients with ileal neobladders compared with ileal conduits and defined risk factors for development of metabolic acidosis.

Methods: We retrospectively studied 95 patients, who underwent radical cystectomy and urinary diversion to treat invasive bladder cancer from January 2001 to December 2014 at Hallym University Kangnam Sacred Heart Hospital, through investigation of acid-base balance, serum electrolyte levels and renal function one month and one year after operation.

Results: One month after the operation, metabolic acidosis was found from 18 patients (31.0%) in an ileal neobladder group and from 4 (14.8%) in an ileal conduits group. One year after the operation, the numbers became 11 (22.9%) and 2 (10.0%), respectively. However, there was not a statistical difference. The blood biochemical profiles of the two groups did not differ significantly after urinary diversion. Logistic analysis revealed that lower estimated glomerular filtration rate (eGFR) was associated with metabolic acidosis at one month (odds ratio, OR = 0.94 [0.91–0.97]; p < 0.001) and one year (OR = 0.94 [0.92–0.97]; P = 0.001) after urinary diversion. In multivariate analysis, lower eGFR is a significant risk factor for metabolic acidosis at one month.

Conclusions: Patients with ileal neobladders and conduits are at the similar risk of metabolic acidosis. A close association between renal function and development of metabolic acidosis was observed, especially stronger in an early period after operation.

Getting out of a tight spot: an overview of ureteroenteric anastomotic strictures

Radical cystectomy and urinary diversion is the gold-standard treatment for muscle-invasive and high-risk non-muscle-invasive bladder cancer. Ureteroenteric anastomotic stricture is a well-known complication of urinary diversion and is associated with serious sequelae that lead to total or partial loss of kidney function, infectious complications, and the need for additional procedures. Although the exact aetiology of benign ureteroenteric anastomotic strictures is unclear, they most likely occur secondary to ischaemia at the anastomotic region. Diagnosis can be achieved using retrograde contrast studies, CT scan or MAG3 renography. Open revision remains the gold-standard treatment for ureteroenteric anastomotic strictures; however, endourological techniques are being increasingly used and, in select patients, might be the optimal approach.

Techniques and Outcome of Surgery for Locally Advanced and Local Recurrent Rectal Cancer

Locally advanced primary rectal cancer is variably defined, but generally refers to T3 and T4 tumours. Radical surgery is the mainstay of treatment for these tumours but there is a high-risk for local recurrence. National Institute for Health and Care Excellence (2011) guidelines recommend that patients with these tumours be considered for preoperative chemoradiotherapy and this is the starting point for any discussion, as it is standard care. However, there are many refinements of this pathway and these are the subject of this overview. In surgical terms, there are two broad settings: (i) patients with tumours contained within the mesorectal envelope, or in the lower rectum, limited to invading the sphincter muscles (namely some T2 and most T3 tumours); and (ii) patients with tumours directly invading or adherent to pelvic organs or structures, mainly T4 tumours - here referred to as primary rectal cancer beyond total mesorectal excision (PRC-bTME). Major surgical resection using the principles of TME is the mainstay of treatment for the former. Where anal sphincter sacrifice is indicated for low rectal cancers, variations of abdominoperineal resection - referred to as tailored excision - including the extralevator abdominoperineal excision (ELAPE), are required. There is debate whether or not plastic reconstruction or mesh repair is required after these surgical procedures. To achieve cure in PRC-bTME tumours, most patients require extended multivisceral exenterative surgery, carried out within specialist multidisciplinary centres. The surgical principles governing the treatment of recurrent rectal cancer (RRC) parallel those for PRC-bTME, but typically only half of these patients are suitable for this type of major surgery. Peri-operative morbidity and mortality are considerable after surgery for PRC-bTME and RRC, but unacceptable levels of variation in clinical practice and outcome exist globally. To address this, there are now major efforts to standardise terminology and classifications, to allow appropriate comparisons in future studies.

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.

Long-term follow-up after ileocaecal continent cutaneous urinary diversion (Mainz I pouch): A retrospective study of a monocentric experience

OBJECTIVE

To assess the long-term follow-up after ileocaecal continent cutaneous reservoir (ICCR) and to review the late complications.

PATIENTS AND METHODS

In all, 756 patients underwent an ICCR in our department, with long-term follow-up data available in 50 patients. The inclusion criterion was ICCR regardless of the indication and the exclusion criteria were orthotopic neobladder or other continent urinary diversions not performed with the ileocaecum. Patients were followed to record primary outcomes and late complications. Complications were stratified according to the Clavien-Dindo classification.

RESULTS

The mean patient age was 44 years and pelvic malignancies were the first indication for urinary diversion. The mean (range) follow-up was 19 (9-36) years. A stoma stenosis was the most frequent outlet-related complication requiring re-intervention, followed by ischaemic outlet degeneration, and stoma incontinence. Six renal units (RUs) developed obstruction at the anastomotic site and were managed by open surgery. Three RUs had to be removed due to deterioration. A dederivation was necessary in three patients (6%).

CONCLUSION

The ICCR is a safe and established technique when an orthotopic pouch is impossible. The long-term follow-up shows acceptable complication rates and satisfactory continence conditions. However, large population studies are necessary to confirm this observation.

Acute Kidney Injury After Radical Cystectomy for Bladder Cancer is Associated with Chronic Kidney Disease and Mortality

PURPOSE

The aim of this study was to investigate the prevalence of acute kidney injury (AKI) after radical cystectomy, and evaluate its impact on chronic kidney disease (CKD) and mortality.

METHODS

The medical records of 866 patients who underwent radical cystectomy for bladder cancer were reviewed. AKI was assessed within 7 days after surgery according to the Acute Kidney Injury Network criteria. The prevalence of AKI after surgery was examined, and the significance of AKI for CKD and mortality was analyzed.

RESULTS

Of 866 patients, 269 (31.1 %) developed AKI in the first week after surgery. Of these, 231 (85.9 %) were at stage 1, 32 (11.9 %) at stage 2, and 6 (2.2 %) at stage 3. Of 722 patients with a preoperative Modification of Diet in Renal Disease estimated glomerular filtration rate (eGFR) of >60 ml/min/1.73 m(2), CKD developed in 23.0 % (118/513) of patients in the non-AKI group and 32.5 % (68/209) of patients in the AKI group. Independent factors predicting new-onset CKD were a preoperative eGFR (p < 0.001), age (p = 0.011), urinary tract complication (p < 0.001) and AKI (p = 0.015). In all, 297 patients died (191 in the non-AKI group and 106 in the AKI group). AKI also correlated significantly with overall survival (p = 0.001).

CONCLUSIONS

AKI is not only commonly encountered after radical cystectomy but is also associated with higher CKD rates and mortality. There is a critical need for strategies to increase the identification of patients at risk of postoperative AKI, and to improve the management of patients, with an aim toward preventing AKI and improving the treatment of AKI once it occurs.

Metabolic complications of urinary intestinal diversion

Patients with a urinary bladder malignancy or severe anatomical/functional bladder abnormalities may be candidates for urinary diversion at the time of cystectomy. Most urinary diversions are constructed from intestinal segments. Urological surgeons who perform urinary diversion surgery should be aware of the physiological and metabolic changes that can occur when intestinal segments are in direct contact with urine. The complications associated with urinary diversion are both acute and chronic. The most important factor associated with the development of metabolic complications following urinary diversion is the length of time that the urine is in contact with the bowel and the type of bowel segment used for urinary diversion. In this review, we describe the metabolic complications associated with urinary diversion, their characteristic clinical presentation, follow-up, and specific treatment.

Effect of ureterointestinal anastomosis on renal function and morbidity in intestinal urinary diversion

OBJECTIVE

The authors previously successfully applied the "flap-and-trough" (FT) method of antireflux ureterointestinal anastomosis (UIA) in a pilot set of 81 patients. This randomized prospective trial tested the effectiveness of this method in protecting the upper urinary tract from obstruction, reflux and infections.

MATERIAL AND METHODS

Forty-nine patients indicated for cystectomy and intestinal urinary diversion were randomly split into two groups, A and B. The FT antireflux UIA was applied in group A (n = 20), and refluxing direct elliptical UIA in group B (n = 29). Both groups were divided into two subcategories according to the type of diversion used: Ar (n = 10) and Br (n = 16) with low-pressure reservoirs and Ac (n = 10) and Bc (n = 13) with conduits. The follow-up evaluation compared the groups regarding perioperative complications, antireflux efficiency of FT, occurrence of obstruction and urinary infection, kidney morphology and glomerular filtration rate.

RESULTS

During the follow-up period (median 31 months), the obstruction occurred only in group Br (insignificant difference compared to Ar). A significant decrease in glomerular filtration rate and shortening of the left kidney occurred in group Br during the period and in comparison with Ar. There were no other considerable divergences in other studied parameters.

CONCLUSIONS

The antireflux FT anastomosis represents a low risk for stenosis. The reduced occurrence of obstructive complications in comparison with direct UIA was statistically insignificant. Its construction did not increase the frequency of complications; on the contrary, it guarantees a better protection of renal morphology and function.

[Symptomatic reflux and stenosis of ureteroenteric anastomosis. Diagnostics and therapy]

Stenosis of the ureteroenterostomy and symptomatic reflux are among the most dangerous complications of all forms of urinary diversion. Variations in ureter implantation techniques and different surgical expertises are responsible for the heterogeneity of the available prevalence data. Antirefluxive implantation techniques seem to be more vulnerable to stenosis and obstruction than refluxive techniques, although no difference in kidney function deterioration over time was shown according to the presence or absence of reflux protection. Despite frequent controls, approximately one quarter of all obstructed renal units show a complete loss of function. The reimplantation rate of stenotic ureters exceeds 30%.The development of an implantation stenosis may be silent and subtle. The loss of renal function often remains unnoticed if sonography and creatinine measurements are the only follow-up tools employed. Neither of these tests is reliable in estimating kidney function and may mislead both doctor and patient. DMSA scintigraphy and retrograde contrast studies (conduitogram, pouchogram) are the most sensitive tools available to evaluate a symptomatic reflux, whereas MAG-3 renal scans and antegrade function tests (nephrostogram, renal pelvic pressure measurement) are recommended for investigating ureteric obstruction. Stenosis of the ureteroenterostomy usually occurs within 2 years after urinary diversion; delayed occurrence of ureteric obstruction is indicative of malignant local recurrence or compressive metastases.There are various minimally invasive treatment options such as balloon dilatation, internal ureterotomy, stenting and nephrostomy placement. However, the technical challenge of a ureteroenterostomy should not be a deterrent. In fact, if surgically possible, the patient should be offered open revision, since this is the only way to durably cure the underlying pathology and re-establish the already impaired quality of life of patients with urinary diversion as much as possible.

Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy

BACKGROUND

Surgery performed to improve or replace the function of the diseased urinary bladder has been carried out for over a century. Main reasons for improving or replacing the function of the urinary bladder are bladder cancer, neurogenic bladder dysfunction, detrusor overactivity and chronic inflammatory diseases of the bladder (such as interstitial cystitis, tuberculosis and schistosomiasis). There is still much uncertainty about the best surgical approach. Options available at the present time include: (1) conduit diversion (the creation of various intestinal conduits to the skin) or continent diversion (which includes either a rectal reservoir or continent cutaneous diversion), (2) bladder reconstruction and (3) replacement of the bladder with various intestinal segments.

OBJECTIVES

To determine the best way of improving or replacing the function of the lower urinary tract using intestinal segments when the bladder has to be removed or when it has been rendered useless or dangerous by disease.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of surgery involving transposition of an intestinal segment into the urinary tract.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for appropriateness for inclusion and for risk of bias by the review authors. Three review authors were involved in the data extraction. Data were combined in a meta-analysis when appropriate.

MAIN RESULTS

Five trials met the inclusion criteria with a total of 355 participants. These trials addressed only five of the 14 comparisons pre-specified in the protocol. One trial reported no statistically significant differences in the incidence of upper urinary tract infection, uretero-intestinal stenosis and renal deterioration in the comparison of continent diversion with conduit diversion. The confidence intervals were all wide, however, and did not rule out important clinical differences. In a second trial, there was no reported difference in the incidence of upper urinary tract infection and uretero-intestinal stenosis when conduit diversions were fashioned from either ileum or colon. A meta-analysis of two trials showed no statistically significant difference in daytime or nocturnal incontinence amongst participants who were randomised to ileocolonic/ileocaecal segment bladder replacement compared to an ileal bladder replacement. However, one small trial suggested that bladder replacement using an ileal segment compared to using an ileocolonic segment may be better in terms of lower rates of nocturnal incontinence. There were no differences in the incidence of dilatation of upper tract, daytime urinary incontinence or wound infection using different intestinal segments for bladder replacement. However the data were reported for 'renal units', but not in a form that allowed appropriate patient-based paired analyses. No statistically significant difference was found in the incidence of renal scarring between anti-refluxing versus freely refluxing uretero-intestinal anastomotic techniques in conduit diversions and bladder replacement groups. Again, the outcome data were not reported as paired analysis or in form to carry out paired analysis.

AUTHORS' CONCLUSIONS

The evidence from the included trials was very limited. Only five studies met the inclusion criteria; these were small, of moderate or poor methodological quality, and reported few of the pre-selected outcome measures. This review did not find any evidence that bladder replacement (orthotopic or continent diversion) was better than conduit diversion following cystectomy for cancer. There was no evidence to suggest that bladder reconstruction was better than conduit diversion for benign disease. The clinical significance of data from one small trial suggesting that bladder replacement using an ileal segment compared to using an ileocolonic segment is better in terms of lower rates of nocturnal incontinence is uncertain. The small amount of usable evidence for this review suggests that collaborative multi centre studies should be organised, using random allocation where possible.

Orthotopic neobladder reconstruction after radical cystectomy in patients with a solitary functioning kidney: clinical outcome and evaluation

OBJECTIVE

To evaluate, in a prospective study, the clinical outcome of orthotopic neobladder reconstruction after radical cystectomy in patients with a solitary functioning kidney at the time of surgery.

PATIENTS AND METHODS

This study included a total of 28 patients (25 males and three females) with muscle invasive bladder cancer and a solitary functioning kidney at the time of surgery who underwent radical cystectomy (anterior pelvic excentration for females) and urinary reconstruction using orthotopic neobladder at The National Cancer Institute, Cairo University between February 2004 and April 2009. The surgical procedures included ileocaecal neobladder in 19 patients, ileal neobladder (Studer) in five and sigmoid neobladder in four. All perioperative and long-term complications were recorded. The renal functions were evaluated using mainly serum creatinine level, abdominal ultrasonography and intravenous urography (IVU).

RESULTS

The mean age of patients was 51.4years (range of 38-62years) while the mean follow-up period was 41.4months (range 18-62months). Early complications included wound infections in five patients, urine leakage in six, abdominal dehiscence with deep venous thrombosis in two, intestinal obstruction and prolonged ileus in three. During the follow-up period, 21 renal units (75%) remained stable with normal serum creatinine level and normal radiological configuration of the kidney. The remaining seven patients (25%) developed varying degrees of renal deterioration either due to uretero-intestinal stricture in three patients (10.7%), who were all treated by open surgical revision of the anastomotic sites or due to stricture at the vesico-urethral anastomosis in four patients (14.3%) that had been successfully managed by endoscopic dilatation and internal urethrotomy with stabilization of renal function. Severe metabolic acidosis occurred in one patient while mild forms occurred in three. These four patients required sodium bicarbonate therapy and their metabolic status was normalized thereafter.

CONCLUSION

Selecting the type of urinary diversion is important in patients with a solitary functioning kidney after radical cystectomy. Orthotopic neobladder reconstruction is a good choice in properly selected patients and could provide comparatively satisfactory results. Accordingly, a solitary functioning kidney should not be regarded as a contraindication for neobladder reconstruction after radical cystectomy.

Experience with ureteroenteric strictures after radical cystectomy and diversion: open surgical revision

OBJECTIVES

To evaluate the long term results of the treatment of benign ureteroenteric strictures as a serious complication after urinary diversion and to highlight on the precautions for the active intervention. The outcomes of endoureteral and open surgical revisions in our patients are described.

METHODS

Of 658 patients who had undergone radical cystectomy for bladder cancer from 1999 to 2009, 58 had developed benign stricture. The diversions used in this subgroup were orthotopic neobladder (53.4%), ileal conduit (27.6%), and ureterocolic (19%). The median interval to the diagnosis was 6 months, and 63.8% were on the left side. Endouretral interventions (dilation and stent or endoureterotomy) were the initial treatment in 37 patients. Thirty-two patients including patients who failed endoluminal interventions and patients with bilateral strictures underwent open surgery. Success was defined as radiologic improvement and the absence of flank pain, infection, or the need for a ureteral stent or nephrostomy tube.

RESULTS

Endoscopic intervention was successful in 19 (51.3%) of 37 patients, principally those with strictures <1 cm with no difference between side, diversion type, or implantation technique. A total of 32 patients underwent open stricture resection and repair by direct implantation or tissue interposition to bridge long defects (6 Boari flaps and 7 ileal segments). At a median follow-up of 47 months, 25 patients had long-term success (78%) and 36 (83.7%) of 43 repaired units had improvement. Improvement was superior for right-sided strictures compared with left-sided strictures (100% vs 75.8%) and for neobladder compared with other diversions (90% vs 69%). Both anastomotic and ureteral strictures were repaired with equivalent results (87.5% vs 82.8%).

CONCLUSIONS

Although endouretral procedures are viable treatment alternatives, open surgical revision is the preferred long-term definitive treatment. Bilateral and long left-sided strictures >1 cm long are indications for early open surgery.

Genomic characterization of asymptomatic Escherichia coli isolated from the neobladder

The replacement of the bladder with a neobladder made from ileal tissue is the prescribed treatment in some cases of bladder cancer or trauma. Studies have demonstrated that individuals with an ileal neobladder have recurrent colonization by Escherichia coli and other species that are commonly associated with urinary tract infections; however, pyelonephritis and complicated symptomatic infections with ileal neobladders are relatively rare. This study examines the genomic content of two E. coli isolates from individuals with neobladders using comparative genomic hybridization (CGH) with a pan-E. coli/Shigella microarray. Comparisons of the neobladder genome hybridization patterns with reference genomes demonstrate that the neobladder isolates are more similar to the commensal, laboratory-adapted E. coli and a subset of enteroaggregative E. coli than they are to uropathogenic E. coli isolates. Genes identified by CGH as exclusively present in the neobladder isolates among the 30 examined isolates were primarily from large enteric isolate plasmids. Isolations identified a large plasmid in each isolate, and sequencing confirmed similarity to previously identified plasmids of enteric species. Screening, via PCR, of more than 100 isolates of E. coli from environmental, diarrhoeagenic and urinary tract sources did not identify neobladder-specific genes that were widely distributed in these populations. These results taken together demonstrate that the neobladder isolates, while distinct, are genomically more similar to gastrointestinal or commensal E. coli, suggesting why they can colonize the transplanted intestinal tissue but rarely progress to acute pyelonephritis or more severe disease.

Renal and functional outcomes following cystectomy and neobladder reconstruction

BACKGROUND

Orthotopic reconstruction following cystectomy has evolved in an attempt to restore anatomy and function to as close as possible to the preoperative state. We review the renal and functional outcomes of patients who underwent cystectomy and neobladder reconstruction at our institution.

METHODS

Between December 2003 and October 2007, 31 patients underwent cystectomy with Studer neobladder reconstruction at the Ottawa Hospital, Ottawa, Ontario, Canada. Follow-up data were obtained regarding renal function (serum creatinine, μmol/L), continence, urinary flow rates and post-void residual (PVR) at 3, 6 and 12 months after surgery. Change in creatinine from preoperative baseline was calculated and analyzed by student t-test to determine if there was a significant rise in creatinine.

RESULTS

There was a statistically significant increase in creatinine from preoperative baseline, with an average increase of 17.3 μmol/L, 21.8 μmol/L and 26.3 μmol/L at 3, 6 and 12 months, respectively. Six patients developed hydronephrosis. Excluding patients with hydronephrosis, there continued to be a statistically significant rise in creatinine with an average increase of 11.9 μmol/L, 14.7 μmol/L and 19.4 μmol/L at 3, 6 and 12 months, respectively. At 1 year, daytime continence was achieved by 89% of patients; 70% were continent at night.

INTERPRETATION

Orthotopic neobladders have excellent functional outcomes with low rates of incontinence, which improved throughout follow-up. A significant proportion of patients developed hydronephrosis, highlighting the need for close follow-up to prevent reversible renal deterioration. Creatinine increased during follow-up irrespective of the development of hydronephrosis, but the clinical significance is unknown.

Clinical algorithms for the surgical management of locally recurrent rectal cancer

PURPOSE

Advances in surgical practice have helped expand the options for patients with locally recurrent rectal cancer through improvements in reconstructive options, management of operative complications, addition of intraoperative adjuvant therapies, and postoperative care. This review outlines the presentation and management of patients with locally recurrent rectal cancer, and it describes easy-to-apply clinical algorithms to aid management.

METHODS

The electronic literature was searched for studies reporting outcomes for locally recurrent rectal cancer limited to the English language.

RESULTS

Prospective and retrospective case series and single-center experiences were identified. A total of 106 articles were selected for full-text review of which 82 fulfilled the inclusion criteria. No randomized studies were identified. We found that multimodality treatment of locally recurrent rectal cancer can improve 5-year survival from 0% to over 40%, and selected patients may survive up to 10 years. A mixture of imaging modalities is used in patient selection for surgery. An R0 resection is consistently a favorable prognostic factor. R1 resection and surgery in the setting of oligometastases compare favorably with nonoperative palliation. Although mortality figures remain low, morbidity is significant and mostly wound related.

CONCLUSIONS

Improvements in radiological imaging modalities and technical improvements in surgical and reconstructive options have facilitated more accurate staging, better selection of patients for surgery, reduced morbidity and mortality, and higher R0 resections. Optimal management is in specialist units with a multidisciplinary approach with the use of multimodal therapy.

Surgery for recurrent rectal cancer: technical notes and management of complications

Local recurrence following surgery for rectal cancer remains a significant clinical problem and poses major therapeutic challenges. Radical surgical salvage is the only option with potential for curative treatment and is indicated in carefully selected patients. Surgery also provides acceptable palliation in certain cases. Nevertheless, such surgery is challenging, not commonly used, and historically associated with considerable morbidity and mortality. In more recent times, improvements in surgical techniques, reconstruction methods and management of perioperative complications have helped expand the options available for patients with recurrent rectal cancer. This review article highlights the techniques employed at our institution for the management of locally recurrent rectal cancer with particular emphasis on the surgical approaches, the methods used for reconstruction and the avoidance of complications.

Comparison between a serous-lined extramural tunnel and T-limb ileal procedure as an antireflux technique in orthotopic ileal substitutes: a prospective randomized trial

OBJECTIVE

To compare the functional results from a prospective randomized trial of two different reflux-prevention techniques for ileal bladder substitution.

PATIENTS AND METHODS

In all, 60 patients with invasive bladder cancer were randomized to receive either a serous-lined extramural tunnel (group 1) or T-limb ileal procedure (group 2) as an antireflux technique for the ileal substitute. The preoperative evaluation included intravenous urography, radioisotope renography to evaluate glomerular filtration rates (GFRs) and renal cortical imaging with 99mTc- dimercaptosuccinic acid to assess parenchymal scarring. Evaluable patients were re-assessed by the same imaging, and by ascending studies.

RESULTS

The follow-up included 27 patients (49 units) in group 1 and 23 (45 units) in group 2, with a mean (sd) follow-up of 6.3 (0.5) and 7.4 (1.9), respectively. Uretero-ileal strictures were diagnosed in one renal unit in each group (P = 0.5). Ascending studies showed no reflux in any patients in group 1, while 13 renal units (29%) in group 2 were refluxing (P < 0.01). There was progressive cortical scarring with or with no significant reduction in GFR (>25%) in three and four renal units in groups 1 and 2, respectively. Among the 13 refluxing units in group 2, three showed a significant deterioration in GFR and one renal unit was diagnosed with progressive cortical scarring.

CONCLUSION

Both procedures provided a low rate of anastomotic stricture, with acceptable preservation of renal function. The serous-lined extramural tunnel provided a more effective antireflux mechanism.

[Use of double J ureteral stent as an alternative to prevent ureteroileal anastomosis stricture in orthotopic bladder substitution]

OBJECTIVE

The aim of the study was to compare ureteroileal anastomosis strictures rates in patients receiving either double J stent or open-ended ureteral stent, after bladder replacement for cancer.

METHODS

Medical charts from 75 patients who underwent cystectomy and Z pouch bladder substitution for bladder cancer, between 2001 and 2005, were retrospectively reviewed. Ureteroileal anastomosis was direct, spatulated end-to-side fashioned in all patients. Double J stents were used in 39 patients (group A) and open-ended ureteral stent were used in 36 patients (group B). Mean hospital stay, early and late complications were also observed.

RESULTS

Seventeen anastomotic strictures have been documented during the follow-up: 5.2% in group A versus 18.3% in group B (p=0.012). Mean catheterization period was six weeks in group A and 12 days in group B. No significant differences were found in mean hospital stay, early and late complications.

CONCLUSION

The use of internal double J ureteral stent is now a feasible option and can decrease the rate of anastomotic stricture. The fact that the double J stent is removed after the anastomosis healing period may be a possible explanation.

Does reflux in orthotopic diversion matter? A randomized prospective comparison of the Studer and T-pouch ileal neobladders

PURPOSE

Orthotopic neobladder reconstruction has become a standard form of urinary diversion in many centers for patients undergoing radical cystectomy for bladder cancer. There is still controversy about the best technique for construction of the neobladder, and especially whether it is necessary to include an antireflux mechanism.

METHODS

We designed a prospective randomized clinical trial comparing two forms of ileal neobladder: the Studer pouch and the T-pouch. The latter includes an extraserosal tunneled afferent limb which prevents reflux from the pouch to the kidneys. The primary endpoint of the study is renal function and anatomy at 3 years following surgery, with secondary endpoints including early and late postoperative complications, renal infections and need for secondary procedures.

RESULTS

To date we have randomized 462 patients over approximately 6 years, with a planned full enrollment of 550 patients. Ten percent of patients have been withdrawn because they did not undergo the planned orthotopic diversion due to a positive urethral margin on frozen section. We expect approximately 70% of patients to be alive and available for follow-up at 3 years, which will give us ample power to detect clinically meaningful differences in the outcome of these two diversions.

CONCLUSION

This trial has been feasible and randomization has been acceptable to most patients. Long-term follow-up of the patients on this trial should be able to definitively answer the question of the importance of an antireflux mechanism in the orthotopic neobladders construction.

[Perspectives in urinary diversion]

"Perspectives in Urinary Diversion" was the title of a presentation held during the opening session of the 56th annual meeting of the German Urological Association in Hamburg on September 21, 2006. It focused on the balance between obstruction and reflux of ureters implanted in diverted intestinal segments, the choice of intestinal segments for orthotopic pouches, orthotopic diversion in the female, the status of rectal diversions, and alternatives to the use of intestinal segments.

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.

The natural history of postoperative renal function in patients undergoing ileal conduit diversion for cancer measured using serial isotopic glomerular filtration rate and 99m technetium-mercaptoacetyltriglycine renography

PURPOSE

There is little consensus regarding long-term followup of renal function in patients who undergo urinary diversion. We established the usefulness of combined serial isotopic glomerular filtration rate measurement and diuresis renography in the early identification of patients at risk for deterioration of renal function following ileal conduit diversion.

MATERIALS AND METHODS

A total of 340 patients with ileal conduit diversion who were followed between 1990 and 2000 were identified. We analyzed data on 178 patients who had more than 4 years of followup. Renal function was assessed by serial estimation of serum creatinine, isotopic glomerular filtration rate and diuresis renographic measurements.

RESULTS

Of the patients 52 (29%) demonstrated a worsening glomerular filtration rate. Mean followup +/- SEM was 8.2 +/- 0.4 years (range 4 to 30) and 67% of patients had more than 6 years of followup. In this group we found that hypertension, recurrent urinary sepsis and an initial post-diversion glomerular filtration rate of less than 50 ml per minute per 1.73 m were prevalent risk factors. Hypertension was an independent predictor of a decreased glomerular filtration rate in this group. Of 52 patients with a deteriorating glomerular filtration rate 19 had type II or IIIb curves on followup renography, of whom 13 underwent revision surgery. Renal function subsequently stabilized or improved in this group.

CONCLUSIONS

Of patients with an ileal conduit 29% have renal function deterioration in the long term. No surgical cause for glomerular filtration rate deterioration was found in 18%. Important predisposing factors in nonobstructed cases were hypertension, recurrent urinary sepsis and a glomerular filtration rate of less than 50 ml per minute per 1.73 m. Hypertension was an independent predictor of a decreased glomerular filtration rate in the group with worsening glomerular filtration rates. In 11% of patients deterioration was due to upper tract obstruction. This was identifiable using renography and the glomerular filtration rate. A type IIIb curve was an early indicator of obstruction.

Urinary Tract Infections in Patients With Urinary Diversion

Several surgical techniques have been used to provide urinary diversion after radical cystectomy. The noncontinent type of urinary diversion (using an intestinal conduit) and the continent urinary diversion (ureterosigmoidostomy or construction of an intestinal pouch that serves as a deposit of urine) were used commonly in the past, leading to a cumulative considerable number of patients encountered in clinical practice. The orthotopic urinary diversion (neobladder) has been used widely during the last years. The incidence and characteristics of urinary tract infection in patients with different types of urinary diversion are reviewed. Clinicians should be aware that urinary tract infection is a frequent cause of fever in patients with urinary diversion because it occurs in a significant proportion. In addition, symptoms from the lower urinary tract may not be prominent in this population.

IS ORTHOTOPIC BLADDER REPLACEMENT THE NEW GOLD STANDARD? EVIDENCE FROM A SYSTEMATIC REVIEW

PURPOSE

In this systematic review we determined whether the outcome of orthotopic bladder replacement is superior to that of continent and incontinent urinary diversion.

MATERIALS AND METHODS

We searched MEDLINE, PubMed, EMBASE, CINAHL and the Cochrane Library from January 1990 to January 2003. A total of 3,370 abstracts were reviewed, including all types of studies from prospective, randomized, controlled studies to small, retrospective series. All relevant articles with at least 10 patients and a mean followup of at least 1 year were retrieved. There were no language restrictions. NonEnglish articles were translated. Comparisons were made between the major surgery types, including ileal conduit, continent diversion, bladder reconstruction and bladder replacement. All studies were scored using a predetermined quality assessment checklist to assess internal validity (bias and confounding) and external validity.

RESULTS

A total of 405 studies met inclusion criteria. There were 32 prospective and 373 retrospective studies describing a total of 32,795 patients. The majority of studies were incompletely or poorly described and outcomes were often not defined. When they were defined, definitions varied. In clinical outcomes ileal conduit diversions had the lowest operative complications rate but highest reported postoperative morbidity. They also had a higher reported incidence of symptomatic urinary tract infections. The rates of postoperative morbidity, mortality and need for reoperation varied widely among studies even for the same procedure. Of physiological outcomes metabolic acidosis was the most commonly reported metabolic complication in patients with various urinary diversions. The quality of the reported literature was poor. There were no studies of the health economic implications of performing 1 type of surgery vs another type.

CONCLUSIONS

While enthusiasts regard orthotopic bladder replacement as the new gold standard when lower urinary tract function must be replaced, the level and quality of current evidence are poor. The immediate concern must be to rectify this paucity of evidence with well designed and well reported prospective studies, ideally in a randomized setting, comparing the various major forms of urinary diversion and bladder replacement surgery.

Renal function in the setting of urinary diversion

Incorporating bowel into the urinary tract sets the stage for a potentially dangerous situation for the upper part of this tract. Obstruction, reflux and chronic bacteriuria may develop, all of which can all be detrimental. Most reports on renal function have used IVP and serum creatinine only, methods which are inadequate for proper assessment. Long-term follow-up of patients with ileal conduit diversion reveals a high incidence of morphological and/or functional damage to the kidneys. Refluxing techniques for implanting the ureters have usually been employed. In patients with continent cutaneous diversion or orthotopic bladder substitution, some recent publications have shown rather well preserved glomerular filtration rates. Traditionally, antirefluxing ureteric implantation has been used in these patients. There is presently a trend towards refluxing anastomosis in this setting, providing a low pressure pouch has been constructed. However, pressure can be high in such pouches and bacteriuria is common. The consequences for the fate of the upper urinary tract is unknown and caution should be exercised in recommending such techniques. There is clearly a need for prospective randomized controlled studies on the issue of refluxing versus antirefluxing anastomosis in continent urinary reconstruction. Patients with continent or non-continent diversion should have lifelong follow-up with regard to the upper urinary tract.

Bladder, bowel and bugs--bacteriuria in patients with intestinal urinary diversion

The incorporation of intestinal segments into the urinary tract favors bacterial growth of the skin flora, anaerobic bacteria, and uropathogenic strains. The route of infection is ascending; bacteria enter the urethra or the abdominal stoma, which is followed by colonization of the reconstructed lower urinary tract. Bacteriuria is common in all kind of reconstructions; however, urine from neobladder patients with complete emptying is reported to carry bacteria to a lesser extent. Clean intermittent catheterization and residual urine seem to increase the bacterial burden. Patients with augmentation cystoplasties constitute a distinct subgroup in which the remaining part of the bladder tissue is an important determinant of urinary tract susceptibility to infection. The increased rate of bacteriuria in the reconstructed patients indicates a lack of "antibacterial defenses", and the symptom free state of the patients suggests that only a restricted host response is triggered. The role of the specific and inflammatory antibacterial defenses in the reconstructed lower urinary tract remains largely unknown.

Microbial flora in ileal and colonic neobladders

OBJECTIVE

To describe bacterial colonization in patients with ileal and colonic neobladders.

METHODS

Twenty-three patients with right colon neobladders, 30 with ileal neobladders, 11 who had undergone radical prostatectomy, and 6 healthy controls were included. Culture of clean-catch, midstream urine specimens was done weekly for 3 weeks, and this was repeated after 6 months. Residual urine was measured, and the patients were interviewed about leakage. All patients and controls were antibiotic free during the study except for 13 of the ileal neobladder patients, who were treated with trimethoprim 100mg daily.

RESULTS

Urine cultures from controls and prostatectomy patients were negative for bacteria, whereas 67% of the specimens from patients with neobladders, not on antibiotic therapy, were culture positive, and half of these contained uropathogenic species, such as Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Enterococcus faecalis. Bacterial colonization (including uropathogenic strains) was strongly correlated with residual urine (p<0.005), but not with leakage. Anaerobic strains were found more frequently (p=0.04) in urine from ileal neobladders than in urine from colonic neobladders. The 13 patients with ileal neobladders and on prophylactic antibiotic therapy carried bacteriuria in 80% of the samples, the majority being anaerobic strains. Uropathogenic strains, mainly Enterecoccus faecalis was revealed in 30% of the samples.

CONCLUSIONS

The lower urinary tract of patients with ileal or colonic neobladders is heavily colonized with potentially uropathogenic and anaerobic bacteria. Complete bladder emptying reduces the bacterial burden. Anaerobic colonization is increased in neobladders reconstructed from ileum. Prophylactic antibiotic therapy does not seem to reduce the bacterial burden, but interferes with the bacterial composition.

Y-neobladder: an easy, fast, and reliable procedure

OBJECTIVES

To describe the operative technique of a new, Y-shaped, ileal neobladder and report the clinical and functional outcomes to add a contribution to the most discussed issues about orthotopic neobladders, in particular related to the problem of the prevention of strictures of ureteral-neobladder anastomoses.

METHODS

Between January 1999 and June 2002, 50 patients (41 men and 9 women) underwent radical cystectomy and Y-shaped orthotopic neobladder reconstruction. The following parameters were considered: operative time, complications, and functional outcomes (evaluated with voiding chart and a questionnaire analyzing continence). Urodynamic studies were performed in the first 20 patients.

RESULTS

The operative time for neobladder reconstruction was 15 to 20 minutes. No severe complications or significant metabolic complications were recorded. Only 1 case of unilateral stricture of the ureteral-neobladder anastomosis was recorded (1% of renal units); the stricture was easily treated with a retrograde endoscopic approach. Daytime and nighttime continence was good or satisfactory in 90% and 85% of patients, respectively. One year after surgery, the average maximal neobladder capacity was 390 mL, and the average pressure at maximal capacity was 15 cm H2O.

CONCLUSIONS

The ileal Y-shaped orthotopic neobladder had good functional outcomes comparable to most popular orthotopic neobladders. Moreover, the surgical technique of the Y-neobladder is easy, rapid, and reliable. In particular, the Y-neobladder seemed to reduce, in our experience, the occurrence of strictures at the ureteral-neobladder anastomosis, because it permits a perfectly aligned anastomosis without mobilization of the ureters.