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

Cumulative incidence of midline incisional hernia and its surgical treatment after radical cystectomy and urinary diversion for bladder cancer: A nation-wide population-based study

Background and objective

To study the cumulative incidence and surgical treatment of midline incisional hernia (MIH) after cystectomy for bladder cancer.

Methods

In the nationwide Bladder Cancer Data Base Sweden (BladderBaSe), cystectomy was performed in 5646 individuals. Cumulative incidence MIH and surgery for MIH were investigated in relation to age, gender, comorbidity, previous laparotomy and/or inguinal hernia repair, operative technique, primary/secondary cystectomy, postoperative wound dehiscence, year of surgery, and period-specific mean annual hospital cystectomy volume (PSMAV).

Results

Three years after cystectomy the cumulative incidence of MIH and surgery for MIH was 8% and 4%, respectively. The cumulative incidence MIH was 12%, 9% and 7% in patients having urinary diversion with continent cutaneous pouch, orthotopic neobladder and ileal conduit. Patients with postoperative wound dehiscence had a higher three-year cumulative incidence MIH (20%) compared to 8% without. The corresponding cumulative incidence surgery for MIH three years after cystectomy was 9%, 6%, and 4% for continent cutaneous, neobladder, and conduit diversion, respectively, and 11% for individuals with postoperative wound dehiscence (vs 4% without). Using multivariable Cox regression, secondary cystectomy (HR 1.3 (1.0–1.7)), continent cutaneous diversion (HR 1.9 (1.1–2.4)), robot-assisted cystectomy (HR 1.8 (1–3.2)), wound dehiscence (HR 3.0 (2.0–4.7)), cystectomy in hospitals with PSMAV 10–25 (HR 1.4 (1.0–1.9)), as well as cystectomy during later years (HRs 2.5–3.1) were all independently associated with increased risk of MIH.

Conclusions

The cumulative incidence of MIH was 8% three years postoperatively, and increase over time. Avoiding postoperative wound dehiscence after midline closure is important to decrease the risk of MIH.

A new ureteroileal anastomosis technique in modified ileal orthotopic bladder substitution after radical cystectomy

Background

The aim of this study is to describe a modified technique in ileal orthotopic bladder substitution with a new ureteroileal anastomosis.

Case presentation

After a classic open radical cystectomy with bilateral pelvic lymphadenectomy was performed extraperitoneally, a 56-cm ileal segment was used to construct the spheroidal shape bladder substitution. The 8-cm long proximal and distal ends of the ileal segment were used as afferent limbs. Two-centimeter ileal segments of afferent limbs were detubularized and transversally tubularized. The elongated ileal tube was anastomosed with the ureter in an end-to-end fashion. The pathway of the ureteroileal anastomosis was placed between the abdominal cutaneous fat and the anterior rectus muscular sheath. Perioperative data and long-term functional outcomes were assessed. Between December 2011 and December 2015, seven male patients underwent this procedure with a median 46 (30–77) months follow-up in our hospital. There was no difference between preoperative and postoperative estimated glomerular filtration rates (Z = − 1.693, P = 0.09). One of 14 sides had ureteroileal anastomotic stenosis; two of 14 sides in one patient had ureteroileal anastomotic stenosis caused by invasion of pelvic recurrence 15 months postoperatively. Reflux was completely prevented by placing pressure on the corresponding point on the abdominal surface when voiding urine in all patients.

Conclusions

We describe a feasible technique modification in detail, which provides some advantages for effective anti-reflux by mechanical finger pressing and abdominal contraction, a low incidence of stricture, and ease for a secondary operation in the long-term follow-up period.

Laparoscopic radical cystectomy with intracorporeal orthotopic ileal neobladder: technique and clinical outcomes

OBJECTIVE

To study the feasibility and safety of laparoscopic radical cystectomy with intracorporeal orthotopic ileal neobladder and to evaluate the role of endoscopic stapling in neobladder construction.

MATERIALS AND METHODS

Fifty-five patients with bladder cancer who underwent laparoscopic radical cystectomy were retrospectively examined. Extended pelvic lymph node dissection was performed before cystectomy. An ileal segment of 50 cm was harvested to construct a U-shaped reservoir. The bottom of the reservoir was anastomosed with the posterior urethra. Twenty-five patients underwent neobladder construction by manual suturing and 30 patients by endoscopic stapler suturing.

RESULTS

The mean operative time was 346 minutes, and mean neobladder construction time was 230 minutes. The median estimated blood loss was 500 mL, and 17 patients received intraoperative transfusion. Postoperative complications included 2 cases of urine leakage, 7 cases of pyelonephritis, 4 cases of incomplete bowel obstruction, 1 case of anastomotic stricture, and 1 case of death. Endoscopic stapler suturing for neobladder construction took significantly less time than manual suturing. However, neobladder stones were found in 2 patients who underwent operation using endoscopic suturing, and the stones were removed cystoscopically. The functional outcomes of the 2 constructive methods were comparable.

CONCLUSION

Laparoscopic radical cystectomy with intracorporeal orthotopic neobladder is safe and feasible for experienced laparoscopic surgeons. Application of endoscopic stapler simplifies the surgical procedure while increasing the risk of neobladder stone formation.