A multi-institutional study of orthotopic neobladders: functional results in men and women

Long-term complications of urinary diversion

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Urinary diversion after radical cystectomy for bladder cancer: options, patient selection, and outcomes

CONTEXT

The urinary reconstructive options available after radical cystectomy (RC) for bladder cancer are discussed, as are the criteria for selection of the most appropriate diversion, and the outcomes and complications associated with different diversion options.

OBJECTIVE

To critically review the peer-reviewed literature on the function and oncological outcomes, complications, and factors influencing choice of procedure with urinary diversion after RC for bladder carcinoma.

EVIDENCE ACQUISITION

A Medline search was conducted to identify original articles, review articles, and editorials on urinary diversion in patients treated with RC. Searches were limited to the English language. Keywords included: 'bladder cancer', 'cystectomy', 'diversion', 'neobladder', and 'conduit'. The articles with the highest level of evidence were selected and reviewed, with the consensus of all of the authors of this paper.

EVIDENCE SYNTHESIS

Both continent and incontinent diversions are available for urinary reconstruction after RC. In appropriately selected patients, an orthotopic neobladder permits the elimination of an external stoma and preservation of body image without compromising cancer control. However, the patient must be fully educated and committed to the labour-intensive rehabilitation process. He must also be able to perform self-catheterisation if necessary. When involvement of the urinary outflow tract by tumour prevents the use of an orthotopic neobladder, a continent cutaneous reservoir may still offer the opportunity for continence albeit one that requires obligate self-catheterisation. For patients who are not candidates for continent diversion, the ileal loop remains an acceptable and reliable option.

CONCLUSIONS

Both continent and incontinent diversions are available for urinary reconstruction after RC. Orthotopic neobladders optimally preserve body image, while continent cutaneous diversions represent a reasonable alternative. Ileal conduits represent the fastest, easiest, least complication-prone, and most commonly performed urinary diversion.

Functional results after orthotopic bladder substitution: a prospective multicentre study comparing four types of neobladder

OBJECTIVE

The aim of this study was to evaluate enterocystometry, voiding pattern and urine leakage of four types of orthotopic bladder substitute.

MATERIAL AND METHODS

At eight urological departments, 78 consecutive men were studied: 66 with an ileal neobladder [30 Studer pouches (S), 24 Hautmann pouches (H) and 12 T-pouches (T)] and 12 with a right colonic [Goldwasser type (G)] neobladder. Enterocystometry, determination of residual urine, micturition protocol and 24 h pad weight test were performed 6 and 12 months postoperatively.

RESULTS

Colonic neobladders had higher pouch pressure at first desire, normal desire and strong desire than ileal neobladders (except at first and normal desire at 12 months) (p < 0.02) and contraction was present more often at both 6 and 12 months (p < 0.01 and p < 0.01). Compliance was good in all types of pouch. Intermittent self-catheterization was more common in H patients at 6 months (p = 0.033). All patients with colonic neobladders used pads during the day and night. In patients with ileal pouches 32% used pads during the day and 70% during the night at 12 months. Urine leakage was higher in patients with colonic bladders at 6 and 12 months during the day (mean/median of 98/31 ml and 82/16 ml versus 10/0 ml and 4/0 ml, p < 0.001). T-pouches had excellent day-time continence, but nocturnal leakage was high.

CONCLUSIONS

The Hautmann pouch and the Studer pouch behaved similarly at enterocystometry and clinically, and continence was good in the majority of patients. The low number of patients with the other two types of pouch precludes definitive statements.

Stem cells for urinary tract regeneration

Regeneration of the urinary bladder is a complicated task, due to organ dimensions and diseases (cancer, interstitial cystitis) when autologous bladder cells cannot be used. Cancer is the most frequent indication for bladder removal (cystectomy). Stem cells can be used with the guarantee of the sufficient cell number for the in vitro construction of the urinary bladder wall. Tissue engineering techniques hold great promise for regeneration of dysfunctional urinary sphincter. Denervation following surgical procedures or injuries results in weakness of the urethral sphincter and stress urinary incontinence. Injectable therapies and the potential of stem cells for sphincter restoration was presented in this review. The aim of this review was to present possibilities of urinary bladder regeneration with the use of stem cells and tissue engineering techniques.

Orthotopic sigmoid vs. ileal neobladders in Japanese patients: a comparative assessment of complications, functional outcomes, and quality of life

OBJECTIVES

To compare the clinical outcomes of sigmoid and ileal neobladders (NBs) created following radical cystectomy.

MATERIALS AND METHODS

This study included 90 and 144 Japanese patients undergoing radical cystectomy and orthotopic NB reconstruction with a sigmoid and ileal segment, respectively. Postoperative clinical outcomes between the sigmoid and ileal NB groups (SNBG and INBG) were compared.

RESULTS

In this series, 110 early and 51 late complications occurred in 71 and 41 patients, respectively; however, there was no significant difference in the incidence of complications between SNBG and INBG. At 1 year postoperatively, there were no significant differences in the proportion of spontaneous voiders and the continence status between these 2 groups; however, despite the lack of significant differences in the maximal flow rate and voided volume, the post-void residual in SNBG was significantly smaller than that in INBG. Voiding functional outcomes at 5 years postoperatively were also obtained from 28 and 49 in SNBG and INBG, respectively. Although there were no significant changes in the functional outcomes in SNBG, the proportion of spontaneous voiders and post-void residual in INBG at 5 years postoperatively were significantly poorer than those at 1 year postoperatively. Furthermore, the postoperative health-related quality of life assessed by a Short-Form 36 survey did not show any significant differences in all 8 scores between these 2 groups.

CONCLUSIONS

Both types of NB reconstruction resulted in comparatively satisfactory outcomes; however, the voiding function, particularly that on long-term follow-up, in SNBG appeared to be more favorable than that in INBG.

Real-time MRI of Orthotopic Ileal Neobladder Voiding: Preliminary Findings

OBJECTIVES

The purpose of this preliminary study was to analyze the dynamic changes in the configuration of the neobladder and naïve bladder during voiding using real-time MRI.

METHODS

This study included 10 male patients who had a radical cystectomy and an ileal orthotopic neobladder due to organ-confined bladder cancer and had good urinary function, and 5 male control volunteers. With the subjects in the lateral decubitus position, real-time MRI was performed during micturition. A sagittal slice orientation was used to depict the bladder and the entire length of the urethra; individual movements along the X-axis and Y-axis of the bottom and top of the neobladder and the naïve bladder were recorded and analyzed. Urodynamic studies (UDS) and video voiding cystourethrography were performed in patients.

RESULTS

Five of the 10 neobladder patients could void in the lateral decubitus position. In normal controls and patients who could void, the bladder outlet bladder moved ventrocranially during micturition. The ileal bladder outlet moved a significantly longer distance than the naïve bladder during micturition (X-axis, -13.4+/-1.5 vs. -3.6+/-4.3 cm, p=0.0014; Y-axis, -10.6+/-0.5 vs. -2.0+/-6.5 cm, p=0.0187). The distance that the bladder top moved between the naïve bladders and the neobladder did not differ. UDS did not show a difference between patients who could and could not void at lateral position.

CONCLUSIONS

During micturition, the neobladder was found to rotate and move more dynamically than the naïve bladder. Real-time MRI is useful for assessing dynamic voiding function of orthotopic neobladders.

Long-term functional outcomes of ileal and sigmoid orthotopic neobladder procedures

OBJECTIVES

To retrospectively compare the long-term functional outcomes of ileal and sigmoid orthotopic bladder replacements after radical cystectomy.

METHODS

From 1990 to 2004, 123 male patients underwent orthotopic neobladder reconstruction after cystectomy; 75 underwent ileal neobladder (IN) and 48 sigmoid neobladder (SN) procedures. The observation period was 12.3 to 151.6 months (median 61.1). The voiding function of each patient was evaluated at three different observation periods: time 1, less than 5 years; time 2, 5 to 10 years; and time 3, more than 10 years after surgery.

RESULTS

Almost every SN patient could void without assistance throughout the observation period. In contrast, the rate of spontaneous voiders was significantly low for the IN patients. Daytime continence was significantly worse in the SN than in the IN patients at time 2 (P <0.01), and the difference in nighttime continence between the two groups was even larger during the first 10 years after surgery (P <0.01). The postvoid residual urinary volume at time 2 was significantly larger in the IN than in the SN patients (P <0.01). No significant change in neobladder capacity was observed for either procedure throughout the observation period. The mean serum creatinine level was stable for both groups throughout the follow-up period.

CONCLUSIONS

The IN and SN procedures result in different outcomes. The rate of spontaneous voiders was better in the SN group than in the IN group. The IN tends to provide better continence than the SN. In choosing a neobladder procedure, a proper understanding of the prospects of voiding functions is required.

Neobladder Emptying Failure in Males: Incidence, Etiology and Therapeutic Options

PURPOSE

Neobladder reconstruction is considered the best option for patients requiring cystectomy. Limited information is available about incidence, etiology and therapeutic options for neobladder emptying failure in males.

MATERIALS AND METHODS

In a retrospective study we analyzed the data of a consecutive series of 655 male patients (age range 23 to 82 years, median 63; followup range 0 to 208 months, median 36.5) who received an ileal neobladder following radical cystectomy at our institution. All patients had a complete followup until death or until December 2003. Data on all diagnostic and therapeutic procedures performed for neobladder emptying failure were collected.

RESULTS

Of 655 patients 75 (11.5%) had at least 1 episode of failure emptying the neobladder requiring some form of therapy during followup. Failure was due to dysfunctional voiding in 23 patients (3.5%) and mechanical obstruction in 52 patients (8%). Causes of mechanical obstruction were benign strictures of the neovesicourethral anastomosis (23 patients, 3.5%) or the anterior urethra (11 patients, 1.7%), neoplastic obstruction by local tumor recurrence (13 patients, 2.0%) or a nonurological malignancy (1 patient, 0.2%), and obstruction by mucosal valves (3 patients, 0.5%) or a foreign body (1 patient, 0.2%). In 38 of 52 patients with mechanical obstruction of the neobladder outlet emptying was fully restored with endourological procedures, while in 14 of 52 patients long-term catheterization was necessary. Catheterization was the therapy of choice for all patients with dysfunctional voiding.

CONCLUSIONS

Neobladder emptying failure is of major concern but is not an argument against orthotopic diversion. The overall rate of transient or permanent neobladder emptying failure in males is high but most of the mechanical causes can be managed endoscopically, while the rate of patients with long-term catheterization for dysfunctional voiding is relatively low.

5-year interval change in voiding function of orthotopic ileal neobladder

AIM

We report the 5-year interval change in voiding function of orthotopic ileal neobladder.

METHODS

Voiding function was evaluated at two points with an interval of 5 years in 49 patients with orthotopic ileal neobladder. The first and second surveys were performed in May, 1998 (1998 survey) and in April 2003 (2003 survey), respectively. Median age at operation was 67 years, ranging 47-77. Median follow-up times at the first and the second surveys were 19.5 months (range, 3-87) and 67.5 months (range, 62-145), respectively.

RESULTS

There was no significant change in daytime continence status between the 1998 and 2003 surveys. More than 95% never or only occasionally suffered daytime incontinence in the two surveys. On the other hand, 15 (34.1%) and 14 (31.8%), respectively, experienced night-time incontinence, despite regular voiding during the night. When voiding patterns were analysed, 11 patients (23.4%) sometimes or often performed catheterization because of difficulty in urinating or incomplete emptying of the neobladder in the 1998 survey. Three patients (6.4%) were unable to void and required regular catheterization. In the 2003 survey, however, such poor voiders increased to nine (19.1%), although the difference was not significant. During the study period of 5 years, there was no change in renal function.

CONCLUSIONS

Continence status, either at daytime or at nighttime, was stable during the study period. The number of the patients who needed regular catheterization tended to increase, suggesting deterioration of voiding function with time. Careful long-term follow up is warranted.