Orthotopic neobladder reconstruction

Role performance and factors affecting quality of life in bladder cancer survivors with ileal orthotopic neobladder

Objective

Bladder cancer survivors with neobladder experience changes in role performance and quality of life (QoL) due to various symptoms and problems, but related studies are limited. Therefore, this study attempted to explore the QoL and factors influencing it in bladder cancer survivors with neobladder.

Methods

A cross-sectional descriptive design was used. Data were collected from 100 bladder cancer survivors with a neobladder using the European Organisation for Research and Treatment of Cancer QLQ-C30 and Muscle-Invasive Bladder Cancer Module, the Patient Activation Measure 13, the Enforced Social Dependency Scale, and the Multidimensional Scale of Perceived Social Support. Factors affecting the QoL were identified using multiple regression analysis.

Results

QoL significantly differed by daily pad usage, need for clean intermittent catheterization, and role performance. QoL was correlated with urinary symptoms and problems, future perspective, abdominal bloating and flatulence, body image, role performance, and social support. Role performance, body image, and the need for clean intermittent catheterization were identified as the factors affecting QoL.

Conclusions

The study highlights the importance of bladder cancer survivors continuing their roles at home, at work, and in society after neobladder reconstruction. Specifically, continuing recreational and social activity positively affects QoL, even if the activity range is modified. To help with their role performance, institutional support and changes in social perception are needed. Additionally, education and interventions, including body image enhancement, symptom management, and self-care, should be developed and applied to improve their QoL.

Early and late post-procedural complications in different orthotopic neobladder surgical approaches: A systematic review

Bladder cancer (BCa) represents the second most common malignancy of the genitourinary tract. The major risk factors include age, gender, smoking attitude, and occupational exposure, while the exact etiopathogenesis is still uncertain. Patients diagnosed with a BCa showing invasion of the muscle layer below the submucosa must undergo radical cystectomy (RC) with urinary diversion (UD). Many different surgical approaches to UD have been developed. Packaging an orthotopic neobladder (ON) with a bowel tract represents the gold standard when certain patient selection criteria are satisfied. Using PRISMA guidelines, we performed a systematic review assessing early (within 90 days) and late (beyond 90 days) post-procedural complications of different ON surgical approaches. A comprehensive systematic search was conducted in PubMed, Scopus, and Google Scholar databases to identify papers starting from 2012 using dedicated keywords ("neobladder", "orthotopic neobladder", "complications'' and "outcomes"). A total of 27 articles were found to satisfy the inclusion criteria and selected. Although the ON is a safe procedure that guarantees the patient the best quality of life (QoL), it is not free from risks. Many complications could occur during and after the surgical time which imposes the necessity of strict follow-up and careful checks over time, which should be properly discussed with patients before.

Advances in Urinary Diversion: From Cutaneous Ureterostomy to Orthotopic Neobladder Reconstruction-A Comprehensive Review

Bladder cancer ranks as the 10th most prevalent cancer globally with an increasing incidence. Radical cystectomy combined with urinary diversion represents the standard treatment for muscle-invasive bladder cancer, offering a range of techniques tailored to patient factors. Overall, urinary diversions are divided into non-continent and continent. Among the first category, cutaneous ureterostomy and ileal conduit represent the most common procedures while in the second category, it could be possible to describe another subclassification which includes ureterosigmoidostomy, continent diversions requiring catheterization and orthotopic voiding pouches and neobladders. In this comprehensive review, urinary diversions are described in their technical aspects, providing a summary of almost all alternatives to urinary diversion post-radical cystectomy.

Robotic or laparoscopic pelvic exenteration for gynecological malignancies: feasible options to open surgery

OBJECTIVE

To acknowledge that minimally invasive pelvic exenteration is a feasible alternative to open surgery and potentially identify prediction factors for patient outcome.

METHODS

The study was designed as a retrospective single team analysis of 12 consecutive cases, set between January 2008 and January 2022.

RESULTS

Six anterior and 6 total pelvic exenterations were performed. A 75% of cases were treated using a robotic approach. In 4 cases, an ileal conduit was used for urinary reconstruction. Mean operative time was 360±30.7 minutes. for anterior pelvic exenterations and 440±40.7 minutes. for total pelvic exenterations and mean blood loss was 350±35 mL. An R0 resection was performed in 9 cases (75%) and peri-operative morbidity was 16.6%, with no deaths recorded. Median disease-free survival was 12 months (10-14) and overall survival (OS) was 20 months (1-127). In terms of OS, 50% of patients were still alive 24 months after surgery. Taking into consideration the follow up period,16.6% of females under 50 or above 70 years old did not reach the cut off and 4 out of 6 patients that failed to reach it were diagnosed with distant metastases or local recurrence (p=0.169).

CONCLUSION

Our experience is very much consistent with literature in regard to primary site of cancer, post-operative complications, R0 resection and survival rates. On the other hand, minimally invasive approach and urinary reconstruction type were in contrast with cited publications. Minimally invasive pelvic exenteration is indeed a safe and feasible procedure, providing patients selection is appropriately performed.

Outcome of small versus big capacity Hautmann neobladder reconstruction: A prospective randomized study - a 5-year follow up

BACKGROUND

Orthotopic urinary diversion is the preferred diversion after cystectomy. Neobladder reconstruction with a longer ileum segment (60 cm) is advantageous for obtaining a large capacity and continence at the beginning; however, the long-term risk of residual urine, chronic infection, and the need for intermittent catheterization is more pronounced with the neobladder constructed with a longer ileal segment compared to the neobladder tailored from the shorter ileal segment.

OBJECTIVE

To establish the differences in the functional outcome of a shorter (< 45 cm) and longer (⩾ 45 cm) ileal segment usage in the reconstruction of the Hautmann ileal neobladder following the radical cystectomy.

METHODS

Between July 2013 and September 2015, 121 patients with muscle-invasive bladder cancer underwent radical cystectomy and Hautmann ileal neobladder reconstruction. Patients were divided into two groups, depending on the length of the ileum used for the diversion creation: < 45 cm of the ileum was used in the first group and ⩾ 45 cm in the second group. Five-year follow-up was performed at 1, 3, 6, and 9 months and 1 and 5 years. The main measured outcomes were functional outcomes and the quality of life. The evaluation included clinical, laboratory, and QLQ-C30 questionnaires. Statistical analysis was performed using descriptive statistics, Mann-Whitney U test, Kolmogorov-Smirnov test, ANOVA, and chi-squared tests.

RESULTS

Patients with a smaller neobladder had a better quality of life, and higher global health status scale score. Thirteen early and 21 late complications developed in 10 and 17 patients, respectively. There were significant differences in the need for clean intermittent self-catheterization (CIC) between the two groups: smaller-volume pouch patients had statistically decreased need for CIC in 5 year follow-up compared to larger-volume pouch patients (χ2 test = 8.245; df = 1; P= 0.004). Eighteen percent of patients with smaller neobladders had urinary tract infections in 5 years, compared to 35% with larger neobladders (χ2 test = 4.447; df = 1; P= 0.034).

CONCLUSION

Minimizing the length of the ileal segment needed for Hautmann neobladder reconstruction is feasible and provides better long-term results than larger-volume neobladders.

[Urinary diversion with or without simple cystectomy as a salvage option for benign diseases of the lower urinary tract]

Benign diseases of the lower urinary tract can occur as a result of oncological or neurological diseases or their respective therapies (e.g., surgery or radiation treatment) and can significantly reduce the quality of life for affected patients. Urinary diversion serves as a salvage option when all other therapeutic regimens have been carried out and proven unsuccessful. When selecting the suitable urinary diversion, a comprehensive clinical assessment of the patients is required in order to ensure long-term success. In some cases, a cutaneous, catheterizable pouch offers the last and only option for a long-term and definitive treatment of a patient's condition. Overall, a decreasing trend in the establishment of a continent urinary diversion is observed in Germany. Current data on benign indications for urinary diversion are limited. Therefore, further data collection and research are needed.

Assessing utilities for muscle-invasive bladder cancer-related health states

OBJECTIVES

How patients value functional outcomes against oncologic outcomes during decision-making for muscular-invasive bladder cancer (MIBC) remains unclear. We sought to quantify individuals' preferences on a scale of 0 to 1, where 1 represents perfect health and 0 represents death.

METHODS

Descriptions of 6 hypothetical health states were developed. These included: Neoadjuvant chemotherapy followed by radical cystectomy with ileal conduit (IC) or with neobladder reconstruction (NB), Transurethral resection and chemotherapy/radiation (CRT), CRT requiring salvage cystectomy (SC), Recurrent/metastatic bladder cancer after local therapy (RMBC), and Metastatic bladder cancer (MBC). Descriptions consisted of diagnosis, treatments, adverse effects, follow-up protocol, and prognosis and were reviewed for accuracy by expert panel. Included individuals were asked to evaluate states using the visual analog scale (VAS) and standard gamble (SG) methods.

RESULTS

Fifty-four individuals were included for analysis. No score differences were observed between IC, NB, and CRT on VAS or SG. On VAS, SC (value = 0.429) was rated as significantly worse (P < 0.001) than NB (value = 0.582) and CRT (value = 0.565). However, this was not the case using the SG method. Both RMBC (VAS value = 0.178, SG value = 0.631) and MBC (VAS value = 0.169, SG value = 0.327) rated as significantly worse (P < 0.001) than the other states using both VAS and SG.

CONCLUSIONS

Within this sample of the general population, preferences for local treatments including IC, NB, and CRT were not found to be significantly different. These values can be used to calculate quality-adjusted life expectancy in future cost-effectiveness analyses.

Robot-assisted radical cystectomy: Where we are in 2023

Open radical cystectomy (ORC) is associated with high rates of perioperative morbidity and mortality, owing to its extensive surgical nature and the high frequency of multiple co-morbidities among patients. As an alternative, robot-assisted radical cystectomy (RARC) has been increasingly adopted worldwide, being a reliable treatment option that utilizes minimally invasive surgery. Seventeen years have passed since the advent of the RARC, and comprehensive long-term follow-up data are now becoming available. The present review focuses on the current knowledge of RARC in 2023, and analyzes various aspects, including oncological outcomes, peri/post-operative complications, post-operative quality of life (QoL) change, and cost-effectiveness. Oncologically, RARC showed comparable oncological outcomes to ORC. With regard to complications, RARC was associated with lower estimated blood loss, lower intraoperative transfusion rates, shorter length of stay, lower risk of Clavien-Dindo grade III-V complications, and lower 90-day rehospitalization rates than ORC. In particular, RARC with intracorporeal urinary diversion (ICUD) performed by high-volume centers significantly reduced the risk of post-operative major complications. In terms of post-operative QoL, RARC with extracorporeal urinary diversion (ECUD) showed comparable results to ORC, while RARC with ICUD was superior in some respects. As the RARC implementation rate increases and the learning curve is overcome, more prospective studies and randomized controlled trials with large-scale patients are expected to be conducted in the future. Accordingly, sub-group analysis in various groups such as ECUD, ICUD, continent and non-continent urinary diversion, etc. is considered to be possible.

Advances in Transversal Topics Applicable to the Care of Bladder Cancer Patients in the Real-World Setting

Simple Summary

There are a number of scientific questions that are novel or controversial, which are clinically relevant in the real-world setting for patients diagnosed with bladder cancer, independently of the stage of disease or the histological type and grade of the tumors. These transversal topics have been discussed by a panel of expert specialists who participated in the Genitourinary Alliance Project, aimed to develop actions focused on the integration of relevant information into clinical practice. Advances in radiological imaging techniques have the potential of improving accuracy of staging methods, resulting in a more personalized planning and therapeutic option. The use of liquid biopsy will undoubtedly contribute to an increase in the efficiency of the evaluation of the clinical response and outcome of the disease. It is important to consider specific conditions of elderly people with bladder cancer, as well as the implementation of appropriate measures to enhance safe drug administration.

Abstract

Recommendations regarding transversal topics applicable to bladder cancer patients independent of tumor grade and stage were established by members of the Spanish Oncology Genitourinary Multidisciplinary Working Group (SOGUG). Liquid biopsy in urine and blood samples is useful in the surveillance of non-muscle-invasive and muscle-invasive bladder cancer, respectively. Multiparametric MRI is an accurate, faster and non-invasive staging method overcoming the understaging risk of other procedures. The combination of FDG-PET/MRI could improve diagnostic reliability, but definite criteria for imaging interpretation are still unclear. Hospital oncology pharmacists as members of tumor committees improve the safety of drug use. Additionally, safety recommendations during BCG preparation should be strictly followed. The initial evaluation of patients with bladder cancer should include a multidimensional geriatric assessment. Orthotopic neobladder reconstruction should be offered to motivated patients with full information of self-care requirements. Bladder-sparing protocols, including chemoradiation therapy and immune checkpoints inhibitors (ICIs), should be implemented in centers with well-coordinated multidisciplinary teams and offered to selected patients. The optimal strategy of treatment with ICIs should be defined from the initial diagnostic phase with indications based on scientific evidence. Centralized protocols combined with the experience of professional groups are needed for the integral care of bladder cancer patients.

Neobladder "Function": Tips and Tricks for Surgery and Postoperative Management

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure increasingly used in patients with muscle-invasive bladder cancer following radical cystectomy (RC). It represents a valid alternative to the ileal duct in suitable patients who do not prefer a stoma and are motivated to undergo adequate training of the neobladder. Careful patient selection, taking into account the absolute and relative contraindications for ONB as well as an adequate recovery protocol after surgery are integral to the success of this procedure and the oncological and functional outcomes. The objective of this review is to summarize the current data on RC with ONB in terms of patient selection, preoperative preparation, surgical techniques and functional (continence and sexual activity) and oncological outcomes, with particular attention to the management of complications and the impact on quality of life (QoL).

Hydraulic Detrusor for Artificial Bladder Active Voiding

The gold standard treatment for bladder cancer is radical cystectomy that implies bladder removal coupled to urinary diversions. Despite the serious complications and the impossibility of controlled active voiding, bladder substitution with artificial systems is a challenge and cannot represent a real option, yet. In this article, we present hydraulic artificial detrusor prototypes to control and drive the voiding of an artificial bladder (AB). These prototypes rely on two actuator designs (origami and bellows) based either on negative or positive operating pressure, to be combined with an AB structure. Based on the bladder geometry and size, we optimized the actuators in terms of contraction/expansion performances, minimizing the liquid volume required for actuation and exploring different actuator arrangements to maximize the voiding efficiency. To operate the actuators, an ad hoc electrohydraulic circuit was developed for transferring liquid between the actuators and a reservoir, both of them intended to be implanted. The AB, actuators, and reservoir were fabricated with biocompatible flexible thermoplastic materials by a heat-sealing process. We assessed the voiding efficiency with benchtop experiments by varying the actuator type and arrangement at different simulated patient positions (horizontal, 45° tilted, and vertical) to identify the optimal configuration and actuation strategy. The most efficient solution relies on two bellows actuators anchored to the AB. This artificial detrusor design resulted in a voiding efficiency of about 99%, 99%, and 89%, in the vertical, 45° tilted, and horizontal positions, respectively. The relative voiding time was reduced by about 17, 24, and 55 s compared with the unactuated bladder.

Neurogenic Bladder Physiology, Pathogenesis, and Management after Spinal Cord Injury

Urinary incontinence is common after spinal cord injury (SCI) due to loss of supraspinal coordination and unabated reflexes in both autonomic and somatic nervous systems; if unchecked, these disturbances can become life-threatening. This manuscript will review normal anatomy and physiology of the urinary system and discuss pathophysiology secondary to SCI. This includes a discussion of autonomic dysreflexia, as well as its diagnosis and management. The kidneys and the ureters, representing the upper urinary tract system, can be at risk related to dyssynergy between the urethral sphincters and high pressures that lead to potential vesicoureteral reflux, urinary tract infections, and calculi associated with neurogenic lower urinary tract dysfunction (NLUTD). Recent guidelines for diagnosis, evaluation, treatment and follow up of the neurogenic bladder will be reviewed and options provided for risk stratification and management. Mechanical, pharmacological, neurolysis and surgical management will be discussed.

Current practice patterns in the perioperative management of patients undergoing radical cystectomy: Results from a global survey

OBJECTIVE

To determine current practice patterns and adherence to various components of enhanced recovery after surgery in cystectomy (ERAC) protocol for peri-operative management of radical cystectomy patients through a global survey.

METHODS

A survey containing 25 questions and addressing 15 of the 22 items of the ERAC protocol was developed and disseminated through Email to the urologists with recent bladder cancer publications. The mailing list was generated by retrieving Email-ids of corresponding authors of articles using the keyword "cystectomy" in Scopus from January 2018 to October 2020.

RESULTS

The survey was completed by 443 respondents across the globe. About 51.5% of respondents used some form of bowel preparation. A minority used carbohydrate loading (29.8%) and Alvimopan (13.3%). A short duration of nil by mouth was practised by 28.9%. For antibiotic prophylaxis, 51.7% used one, and 42% used two antibiotics. Duration of antibiotics was 24 hours, 48 hours, and >48 hours for 47.6%, 16.9%, and 35.4%, respectively. For peri-operative analgesia, 43.6% used non-steroidal anti-inflammatory drugs, 9.3% opioids and 40.6% combination of both. Pharmacological thrombo-prophylaxis was routinely used by 74.7% respondents. There was significant variability in ERAC and non-ERAC components according to region of practice; The open surgical approach was most commonly used in Africa (92%), whereas it was the robotic approach in North America (or America?) (41%). The use of bowel preparation was higher in Asia (58%) and Africa (65%). Alvimopan use was more common in North America (58%). Most used 1 or 2 prophylactic antibiotics but the duration was shorter (<24 hours) in the Americas and European (58%-83%) compared to Asia and Africa (15%-35%).

CONCLUSION

There is high variability in the use of different ERAC components. Other than the timely removal of the abdominal drain and the use of thromboprophylaxis, the overall adherence of ERAC components is low.

Neobladder creation in patients with chronic kidney disease: A viable diversion strategy

INTRODUCTION

Renal function impairment is often cited as a contraindication to continent diversion strategies. There is little evidence exploring renal function changes between continent and incontinent surgery in patients with preoperative chronic kidney disease (CKD), in particular CKD3B.

METHODS

This was a retrospective review of two high-volume centers performing robotic assisted radical cystectomy (RARC) with orthotopic neobladder (ONB) or ileal conduit (IC) between 2014 to 2020. Patients were stratified based on CKD estimated glomerular filtration (eGFR) stage, which was estimated via the CKD-EPI equation. Postoperative renal function was compared for up to 60 months postoperative. Surgical, post-surgical, complications, and readmission data were gathered and compared between all patients RESULTS: 522 cystectomy patients, 430 with IC and 125 with ONB, were included. eGFR decline was statistically significant in a matched cohort of IC and ONB patients only at 3 months. There were no statistically significant differences between readmission rates, time to readmission, or complications. 34.6% of stage 3B patients had hydronephrosis on imaging prior to surgery, compared to 11.4%, 22.1% and 21.8% of CKD stage 1, 2, and 3A patients. CKD stage 3B had statistically and clinically improved eGFR through 24 months.

CONCLUSION

ONB surgery may be a viable diversion strategy in patients previously thought to be contraindicated due to low renal function.

Ileal conduit versus neobladder: A propensity score-matched analysis of the effect on renal function

OBJECTIVES

To analyze the long-term effects of continent (neobladder) compared with incontinent (ileal conduit) urinary diversion.

METHODS

We carried out a retrospective review of our departmental database. Estimated glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Neobladder and ileal conduit patients were matched in a 1:2 ratio and a propensity score-matched analysis was carried out. Data were summarized using descriptive analysis. Trend plots were generated using baseline and follow-up creatinine values to compare estimated glomerular filtration rate at 3 months, then annually for 5 years. Variables associated with estimated glomerular filtration rate were assessed using multivariate linear analysis.

RESULTS

Our cohort consisted of 137 patients (neobladder n = 50 and ileal conduit n = 87) with a median follow-up time of 3 years (interquartile range 1-7 years). The ileal conduit group had shorter operative times (352 vs 444 min, P < 0.01), intracorporeal diversions were more common (66% vs 44%, P = 0.01), had prior abdominal surgery (66% vs 38%, P < 0.01) and had radiation (9% vs 0%, P = 0.03). The neobladder group more commonly had recurrent urinary tract infections (22% vs 3%, P < 0.01) and a steeper decrease in estimated glomerular filtration rate in the first year. On multivariate linear analysis, age/year (-0.59), body mass index per kg/m² (-0.52), preoperative estimated glomerular filtration rate per unit (0.51), recurrent urinary tract infections (-14.03) and time versus day 90 (year 1, -7.52; year 2, -9.06; year 3, -10.78) were significantly associated with estimated glomerular filtration rate.

CONCLUSION

Ileal conduits and neobladders showed a similar effect on the estimated glomerular filtration rate up to 5 years after robot-assisted radical cystectomy. Recurrent urinary tract infections were associated with a worse estimated glomerular filtration rate.

Surgical techniques, oncologic and functional outcomes of two types of modified ileal orthotopic neobladders

Background

In recent years, the construction of orthotopic neobladder has become the focus of research. Our study is aim to illustrate and evaluate surgical techniques, oncologic and functional outcomes of two types of modified ileal orthotopic neobladders (IONB).

Methods

We retrospectively reviewed of 64 patients who underwent laparoscopic radical cystectomy (LRC) + Xing’s neobladder (n=41), Institute of Urology Peking University neobladder (IUPUB) (n=23) at two tertiary referral centers. Then demographic characteristics, operation outcomes were analyzed. In addition, postoperative complication rates, oncologic outcomes, continence, and neobladders’ function were further evaluated.

Results

All LRC + IONB were carried out in 64 patients successfully. Pathological results show that 63 were urothelial carcinoma and 1 was adenocarcinoma. Time to flatus was 3 [1–6] d in Xing’s neobladder group while 3 [2–5] d in IUPUB group (P=0.049). In terms of overall survival (OS), cancer specific survival (CSS) and recurrence-free survival (RFS), there is no statistical difference between the two groups. Overall, grade 1–2 complications were 36%, grade 3–4 complications were 1.6% on the 30th day, and 15.6%, 1.6% respectively on the 90th day. On the whole, daytime and night continence were 96.4%, 83.6% respectively one year after operation.

Conclusions

The two types of modified IONB are safe and feasible. The technical improvements significantly simplify the procedure and decrease the difficulty of the surgery, probably shorten the operative time and reduce blood loss. Furthermore, they take the advantage of less late complications and comparative good functional outcomes without affecting the prognosis of oncology. In addition, Xing’s neobladder is more beneficial to the recovery of postoperative gastrointestinal function.

Functional outcomes after robot-assisted radical cystectomy: A review of literature

Robot-assisted radical cystectomy has steadily gained wider acceptance among urologists compared with open and laparoscopic approaches. Robot-assisted radical cystectomy has shown comparable perioperative and oncologic outcomes compared with open radical cystectomy. Nevertheless, data about the functional outcomes and quality of life after robot-assisted radical cystectomy remain limited. We sought to review the literature and describe urinary, sexual and bowel functions after robot-assisted radical cystectomy in addition to mental health and health-related quality of life. Despite limitations of the available literature, data suggests that functional outcomes after robot-assisted radical cystectomy are comparable to open radical cystectomy. However, more studies utilizing standardized definitions are required.

Longitudinal experience with Studer neobladders: Outcomes and complications

INTRODUCTION

This study aims to assess the longer-term functional, anatomical, and metabolic outcomes of patients who underwent Studer neobladder (SNB) urinary diversion.

METHODS

A retrospective review of patients who underwent SNB at a single center from 1995-2017 (n=116) was performed. Demographics, comorbidities, pathological data, and longer-term functional, anatomical, and metabolic outcomes were collected from hospital records. The primary outcome was voiding function of patients at most recent followup. Secondary outcomes included postoperative complications, renal function, nephrolithiasis, infections, and metabolic outcomes.

RESULTS

Excluding those with incomplete followup data, 72 patients with a minimum followup of one year were included for analysis. Median followup was 70±11 months, with 52.8% of patients having ≥5 years of followup. Clean intermittent catheterization (CIC) was used by 22.2% of patient at most recent followup, which was mostly necessitated by bladder overdistension, deteriorating renal function, or recurrent urosepsis despite timed voiding. Patients experienced more daytime and nighttime urinary incontinence in the early postoperative setting, which improved over time. Generally, renal function declined over time; poorer long-term renal function was predicted by hydronephrosis within one year (p=0.002).

CONCLUSIONS

Longer-term followup of SNB reveals significant but manageable complications. Gradual decline in renal function was common. Strict adherence to bladder emptying protocols (e.g., timed voiding or CIC) may reduce incidence of renal deterioration, metabolic disorders, and urinary dysfunction. Early onset (<1 year) of hydronephrosis may indicate a need for intervention to preserve long-term renal function.

Nursing Implication of People Treated by Radical Cystectomy Postsurgery and Rehabilitation

OBJECTIVE

The purpose of this paper is to summarize existing evidence about nursing interventions to selected symptoms experienced by patients undergoing radical cystectomy (RC) to maintain or return to their daily life activities.

DATA SOURCES

A non-systematic narrative review was conducted. A search in PubMed and CINAHL was conducted eliciting evidence about frequent symptoms experienced after RC. The following search terms were used: radical cystectomy and/or nursing interventions, pain, distress, fatigue, urinary dysfunction, sexual dysfunction, loss of appetite, sleep disturbance, and enhanced recovery after surgery (ERAS).

CONCLUSION

Evidence in the ERAS pathway is still lacking regarding the effect of preoperative education and counseling of the patient and the most difficult part to implement is related to preoperative optimization of the patient such as lifestyle changes. Most nursing interventions to alleviate symptoms in the rehabilitation period after RC are still practice based.

IMPLICATIONS FOR NURSING PRACTICE

Priority should be given to implementation of the ERAS protocol. To improve the management of symptoms experienced by patients in the RC rehabilitation period it is essential that validated screening tools to identify the symptoms be used. Accepted and effective strategies for treating the individual symptoms should be initiated and clear treatment outcomes should be defined. Urology nurse researchers should investigate the concept of symptom clusters to clarify whether there are more efficient methods to identify symptoms or symptom clusters and if so would the use of symptom clusters knowledge improve patient care.

Quality of life and functional outcomes after radical cystectomy with ileal orthotopic neobladder replacement for bladder cancer: a multicentre observational study

PURPOSE

Ileal orthotopic neobladder (IONB) reconstruction is the preferred urinary diversion among selected patients who have undergone radical cystectomy (RC) for bladder cancer (BCa). There is insufficient data regarding patients' quality of life (QoL), sexual and urinary outcomes. Our objectives were to assess QoL in a multicentre cohort study, and to identify related clinical, oncological and functional factors.

METHODS

Patients who underwent RC with IONB reconstruction for BCa from 2010 to 2017 at one of the three French hospitals completed the following self-reported questionnaires: European Organization for Research and Treatment of Cancer (EORTC) generic (QLQ-C30) and bladder cancer specific instruments (QLQ-BLM30). To assess urinary symptoms, patients completed the Urinary Symptom Profile questionnaire (USP) and a three-day voiding diary. Univariate and multivariate analyses were computed to identify clinical, pathological, and functional predictors of global QoL score.

RESULTS

Seventy-three patients completed questionnaires. The median age was 64 years and 86.3% were men. The median interval between surgery and responses to questionnaires was 36 months (range 12-96). Fifty-five percent of patients presented a high global QoL (EORTC-QLQC30, median score 75). A pre-RC American Society of Anesthesiologists score > 2, active neoplasia, sexual inactivity, and stress urinary incontinence were associated with a worse QoL. After a multivariate analysis, sexual inactivity was the only independent factor related to an altered QoL.

CONCLUSION

Patients with IONB reconstruction after RC have a high global QoL. Sexual activity could independently impact the global QoL, and it should be assessed pre- and post-operatively by urologists.

Feasibility and Outcomes of Orthotopic Ileal Neobladder Reconstruction Following Pelvic Irradiation

OBJECTIVES

To evaluate the complications and oncologic outcomes of orthotopic ileal neobladder reconstruction (ONB) following pelvic radiotherapy (RT) compared to patients with no prior pelvic RT.

METHODS

Our institutional database was queried for all patients with pT0-4bN0-3M0 urothelial carcinoma of the bladder who underwent radical cystectomy with curative intent and ONB between 1990 and 2018. We then queried this cohort for patients who had prior pelvic RT (>3900 cGy) and compared baseline characteristics, perioperative complications, and recurrence free survival between patients with and without prior pelvic RT.

RESULTS

One thousand eight hundred and forty-six patients matched our inclusion criteria; 34 had prior pelvic RT with a median dose of 6280 cGy. Prior RT targeted the bladder, prostate, and cervix in 27, 6, and 1 patient, respectively. Median time from RT to cystectomy was 15.5 months. Patients with prior RT had a longer time from diagnosis to cystectomy, more frequently had ≥5 TURBT and neoadjuvant chemo, and less frequently had multifocal disease. Perioperative complications including operative time, estimated blood loss, days hospitalized, as well as 30- and 90-day complication rates, were not statistically different. There was no statistical difference in recurrence free survival between the 2 groups (P = .48).

CONCLUSION

ONB in highly selected patients with prior pelvic RT is feasible with statistically similar perioperative complication rates compared to ONB without prior RT.

Smart Implantable Artificial Bladder: An Integrated Design for Organ Replacement

Substituting the natural bladder with an artificial solution, after cancer and other pathologies, is an ambitious challenge in biomedical engineering. In this work we propose a fully implantable smart artificial bladder system (ABS) that collects urinary fluids and provides the subject with real-time feedback on the implant status. To achieve long term duration, the ABS was designed to be unstretchable in order to be treated with urine resistant coatings and included built-in passive check valves preventing reflux to kidneys. To estimate the amount of fluid collected, the ABS was provided with four electromagnetic distance sensing units and a control unit. An algorithm implemented on an embedded controller enabled the reconstruction of the bladder volume through sensors readings. A wireless data transfer system allows for providing a real-time feedback to the subject. Bench tests validated volume reconstruction accuracy and ex-vivo experiments verified the implantability of the proposed device on a human cadaver, proving the reliability of a Bluetooth data transmission system and paving the way towards an in-body/out-body communication. The proposed solution has the potential to overcome the limitations of currently available replacement strategies towards a new generation of implantable devices for lost organ functions replacement.

The Role of Exenterative Surgery in Advanced Urological Neoplasms

Pelvic exenterative surgery is both complex and challenging, especially in the setting of locally recurrent disease. In recent decades, improved surgical techniques have facilitated more extensive resection of both locally advanced and recurrent pelvic malignancies, but its role in urological cancer surgery is highly selective. However, it remains an important part of the armamentarium for the management of bladder and prostate cancer cases where there is local invasion into adjacent organs or localized recurrence. Better diagnostics, reconstructive options and centralized care have reduced associated morbidity considerably, and it is still used rarely in palliative settings. Despite this, there is sparse prospective evidence reporting on long-term oncological or quality of life outcomes.

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.

Long-term evaluation of modified orthotopic Y-shaped ileal neobladder (Tanta pouch) with left retro-colic chimney

PURPOSE

In the present study, we evaluated the long-term results of modified Y-shaped orthotopic ileal neobladder (Tanta pouch) with trans-mesenteric left retro-colic chimney.

PATIENTS AND METHODS

A total of 70 patients with invasive bladder cancer underwent radical cystectomy and modified Y-shaped orthotopic ileal neobladder. (The left chimney elongated to pass to the left side through a window in the mesentery of the pelvic colon and the ureters were implanted directly end to side, in both chimneys after doing good spatulation.

RESULTS

The mean follow-up period ranged between 7 and 10 years (mean 7.8 years). 18 patients died during the period of follow-up. 6 months postoperatively, there was a spherical orientation of the pouch (The mean capacity was 542 ± 47 cm³) and the maximum intra-pouch pressure was 24 ± 3.2 cm H₂O. Daytime continence was achieved in 93% of the patients and nighttime continence was achieved in 87%. Stress incontinence occurred in 15% and total incontinence in 2%. Renal function was stable in 93% of renal units. Stricture ureter was not recorded of any case. Of 14 renal units with preoperative dilated ureters, 5 units had improved postoperatively and the others had persistent reflux. 13 renal units (3 unilateral and 5 bilateral) with normal preoperative ureters had persistent postoperative reflux. Persistent reflux showed no influence on renal function.

CONCLUSION

Modified Y-shaper pouch is suitable for short, dilated ureters. Longitudinal orientation of the pouch facilitates ileo-urethral anastomosis, especially with short mesentery. Long-term follow-up for direct uretero-ileal anastomosis did not show deterioration of the renal function.

Orthotopic neobladder after cystectomy for bladder cancer

More than 90% of bladder cancer is composed of transitional cell carcinoma (TCC), being characterized by the development of multiple tumors in the entire urinary tract over time. When cystectomy is conducted, the urinary tract must be reconstructed by various procedures, which can include an orthotopic neobladder using the patient's own intestine formed into a spherical shape anastomosed to the urethra. Using this procedure, patients can void urine from their own urethra even after cystectomy. The incidence of subsequent urethral cancer arising after cystectomy is known to be relatively high; however, if patients with a high risk of urethral recurrence are appropriately excluded, a neobladder can be safely provided for patients. Orthotopic neobladder use is reviewed from an oncological viewpoint and the patient's quality of life after cystectomy for bladder cancer.

Orthotopic Neobladder Reconstruction: Patient Selection And Perspectives

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure that may be performed in a patient with bladder cancer following a radical cystectomy. The selection of a patient for an ONB reconstruction is strict as not everyone may be suitable to undergo this complex surgery. Patients must be not only mentally competent but also physically dexterous enough to allow for appropriate neobladder training post-procedure, to achieve best urinary function. However, even with a carefully chosen patient population, various complications specific to ONB reconstruction may result. Metabolic acidosis may result from electrolyte shifts, resulting in secondary complications such as bone demineralization and urinary calculi. In addition, nutritional deficiencies may result from the use of a transposed intestinal segment for the fashioning of the reservoir. A widely used outcome measure when assessing for ONB reconstruction is continence. With a strict neobladder training regimen, daytime continence may be achieved in roughly 70% of patients post-ONB procedure. This number may increase over the course of several years, although may decrease in up to 20 years of follow-up. Similarly, quality of life (QoL) measures have been widely studied, and current literature suggests slightly better QoL achieved with ONB compared to other urinary diversion procedures. Of note, the tools used to assess continence and QoL vary between studies, limiting the interpretability of the summarized data. Nevertheless, ONB reconstruction is a procedure that is still evolving, with ongoing modifications that can reduce complications and improve patient urinary function.

Urinary function following radical cystectomy and orthotopic neobladder urinary reconstruction

INTRODUCTION

An orthotopic neobladder urinary diversion aims to minimize the physical and psychological effects of radical cystectomy through avoidance of a stoma and maintenance of urethral voiding. Neobladder function reported in the literature ranges widely due to differences in patient selection and method of assessment. The objective of the study was to characterize functional outcomes of consecutive patients treated at a tertiary care hospital.

METHODS

A historical cohort of patients who underwent radical cystectomy with a neobladder diversion performed at The Ottawa Hospital between January 2006 and December 2014 were reviewed. Outcomes of interest were urinary continence, use of clean intermittent catheterization (CIC), post-void residual volume, and uroflowmetry at three, six, and 12 months following cystectomy.

RESULTS

During the study period, 158 neobladder diversions were performed. The mean age of patients was 63.1 years (standard deviation [SD] 8.1), and 81.7% were male. Significant daytime incontinence (>1 pad) three months following surgery was common (65%), but decreased to 8.6% by 12 months. Nighttime incontinence was also common at three months (54%) and improved at 12 months (20%). While no appreciable differences between men and women were observed for continence, more women performed CIC at 12 months post-surgery (59% of women; 9% of men; relative risk [RR] 0.15; 95% confidence interval [CI] 0.07-0.30). Among patients who did not catheterize, uroflowmetry and post-void residual volume parameters were stable between three and 12 months postoperative.

CONCLUSIONS

Daytime and nighttime incontinence is common in neobladder patients following surgery, but improves considerably with time. Correspondingly, many female neobladder patients at our institution use CIC.

Renal Physiology and Robotic Urological Surgery

The use of robotic-assisted laparoscopic techniques has transformed the face of urological surgery in the last decade, with demonstrable benefits over both unassisted laparoscopic and traditional open approaches. For example, robotic-assisted partial nephrectomy is associated with lower morbidity, improved convalescence, reduced postoperative pain, shorter length of hospital stay, and a superior cosmetic result when compared to an open procedure. This review discusses the various perioperative influences on the renal physiology of patients undergoing robotic-assisted urological procedures.

Quality of Life in Elderly Bladder Cancer Patients Following a Cystectomy

INTRODUCTION

Bladder cancer is the ninth most common cancer worldwide. The most common treatment for invasive cancer is radical cystectomy and urinary diversion (ileal conduit, continent urinary reservoir, orthotopic neobladder). In elderly patients, the standards methods of urinary diversion have been the ileal conduit and ureterocutaneostomy. Quality of life is an important consideration for patients with urinary diversion.

PURPOSE

The purpose of the present study was to review the literature on quality of life in elderly patients with bladder cancer following a cystectomy and urinary diversion.

MATERIAL AND METHOD

A literature review was conducted using the electronic databases PubMed and Google scholar covering the period of time from 2006 to 2016. The following key words were entered: "quality of life", "bladder cancer", "elderly" "cystectomy" and a combination thereof. The exclusion criteria for the articles were languages other than English.

RESULTS

It was found that various questionnaires were used. Some instruments measure QoL in general, whereas others are more specific with respect to the unique ways in which urinary diversion can impact patients' lives. Furthermore, some findings are contradictory, with certain results indicating that there is no statistically significant difference between quality of life parameters when comparing patients with a neobladder to those with an ileal conduit. In another study, patients who underwent orthotopic neobladder reconstruction reported significantly better physical functioning, role functioning, social functioning and QoL in general throughout the first postoperative months compared to patients who had ileal conduit formation.

CONCLUSIONS

All types of treatment have a number of advantages and disadvantages, the details of which should be explained to elderly patients thoroughly. This calls for comprehensive counseling sessions during which the patient and health professional discuss all relevant considerations.

Current Concepts in the Management of Muscle Invasive Bladder Cancer

Bladder cancer is the ninth most common cancer in the world. Twenty to twenty-five percent of all newly diagnosed bladder cancers are muscle invasive in nature, and further, 20-25% of patients who are diagnosed with high-risk non-muscle invasive disease will eventually progress to muscle invasive disease in due course of time irrespective of adjuvant intravesical therapies. Availability of newer imaging modalities improves appropriate identification of patients with muscle invasive disease. Radical cystectomy remains the mainstay of treatment for management of muscle invasive disease. Availability of neoadjuvant chemotherapy has improved overall survival. Risk stratification systems are now in consideration to identify patients who benefit maximally from neoadjuvant chemotherapy. Urinary diversion is a major cause of morbidity in these patients, and several strategies are being employed to reduce morbidity. In this article, we review available literature on various aspects of management of muscle invasive disease.

Comparison of postoperative acute kidney injury between ileal conduit and neobladder urinary diversions after radical cystectomy: A propensity score matching analysis

Ileal conduit and neobladder urinary diversions are frequently performed after radical cystectomy. However, complications after radical cystectomy may be different according to the type of urinary diversion. Acute kidney injury (AKI) is a common complication after surgery and increases costs, morbidity, and mortality of hospitalized patients. This study was performed to compare the incidence of postoperative AKI between ileal conduit and neobladder urinary diversions after radical cystectomy.All consecutive patients who underwent radical cystectomy in 2004 to 2014 in a single tertiary care center were identified. The patients were divided into the ileal conduit and ileal neobladder groups. Preoperative variables, including demographics, cancer-related data and laboratory values, as well as intraoperative data and postoperative outcomes, including AKI, intensive care unit admission rate, and the duration of hospital stay, were evaluated between the groups. Postoperative AKI was defined according to the Kidney Disease: Improving Global Outcome criteria. Propensity score matching analysis was performed to reduce the influence of possible confounding variables and adjust for intergroup differences.After performing 1:1 propensity score matching, the ileal conduit and ileal neobladder groups each included 101 patients. The overall incidence of AKI after radical cystectomy was 30.7% (62 out of 202) and the incidences did not significantly differ between the groups (27 [26.7%], ileal conduit group vs 35 [34.7%], ileal neobladder group, P = 0.268). Intraoperative data, intensive care unit admission rate, and the duration of hospital stay were not significantly different between the groups.Postoperative AKI did not significantly differ between ileal conduit and neobladder urinary diversions after radical cystectomy. This finding provides additional information useful for appropriate selection of the urinary diversion type in conjunction with radical cystectomy.

Extended partial cystectomy with augmentation cystoplasty in urachal adenocarcinoma: An oncologically favorable but underutilized alternative to radical cystectomy

Partial/extended partial cystectomy (EPC) is the most common surgery done for localized urachal malignancies. However, sometimes, after EPC, patients may be left with small bladder remnant, reconstruction of which will result in very small capacity bladder with resultant severe storage voiding symptoms. We report a case of urachal adenocarcinoma, in which when a small bladder remnant was left post-EPC, instead of proceeding with radical cystectomy (RC) and neobladder (the standard alternative), bladder augmentation was done with good oncological and voiding outcome. Augmentation cystoplasty has many advantages over neobladder and we suggest it as an oncologically comparable alternative to RC with neobladder, which has been underutilized in urachal malignancies as we found on literature review.

A Systematic Review of Ileal Conduit and Neobladder Outcomes in Primary Bladder Cancer

Treatment for muscle invasive bladder cancer with curative intent includes radical cystectomy and urinary diversion. Using PRISMA guidelines, we conducted a systematic review assessing differences in patient selection, operative parameters, complications, and quality of life between ileal conduit and neobladder cohorts. Ileal conduit cohorts have more advanced age and disease, more comorbidities and complications, and poorer quality of life. Ileal conduit surgery is associated with adverse patient selection that inhibits reasonable comparison of outcomes with neobladder cohorts. Despite this, we observe longer operative times and hospital stays in neobladder cohorts, perhaps reflecting greater technical difficulty and the need for postoperative bladder training.

[Social medical/public health assessment of bladder cancer after curative and adjuvant therapy]

Radical cystectomy and urinary diversion are a challenge for patients. Requirements for the successful participation of the patient are sufficient urinary diversion management and recuperation/recovery as the result of urological rehabilitation. A social medical assessment reviews the individual oncological prognosis and the rehabilitation results to determine the return to work.

Is robotic-assisted radical cystectomy (RARC) with intracorporeal diversion becoming the new gold standard of care?

BACKGROUND

Totally intracorporeal robotic-assisted radical cystectomy (RARC) has perceived difficulties compared to open radical cystectomy (ORC). As the technique is increasingly adopted around the world, the benefits of RARC with intra- or extracorporeal urinary diversion or ORC for the patients are still unclear. In this article, we consider the current evidence for this issue.

METHODS

We assessed two questions through using expert opinion and the medical literature: (A) Is RARC better than ORC for removing the cancer surgery and outcome? (B) Is RARC better than ORC for the urinary diversion?

OUTCOMES

(A) RARC is better than ORC for shorter length of stay, blood loss and complication rates. (B) Intracorporeal orthotopic neobladder may have a significant physiological and surgical benefit to the patient recovery.

CONCLUSIONS

RARC with total intracorporeal reconstruction has potential benefits to the patient. We recommend that all surgeons document patient-related outcome measures, urodynamics and enhanced recovery protocols for cystectomy patients to help us understand the real improvements within bladder cancer surgery and reconstruction.

Potential in two types of collagen scaffolds for urological tissue engineering applications – Are there differences in growth behaviour of juvenile and adult vesical cells?

The aging society has a deep impact on patient care in urology. The number of patients in need of partial or whole bladder wall replacement is increasing simultaneously with the number of cancer incidents. Therefore, urological research requires a model of bladder wall replacement in adult and elderly people. Two types of porcine collagen I/III scaffolds were used in vitro for comparison of cell growth of two different pig breeds at different growth stages. Scaffolds were characterised with scanning electron and laser scanning microscopy. Urothelial and detrusor smooth muscle cells were isolated from 15 adult Göttingen minipigs and 15 juvenile German Landrace pigs. Growth behaviour was examined in cell culture and seeded onto the collagen scaffolds via immunohistochemistry, two-photon laser scanning microscopy and a viability assay. The collagen scaffolds showed different structured surfaces which are appropriate for seeding of the two different cell types. Moisturisation of the scaffolds resulted in a change of the structure. Cell growth of German Landrace urothelial cells and smooth muscle cells was significantly higher than cell growth of the Göttingen minipig cells. Seeding of scaffolds with both cell types from both pig races was possible which could be shown by immunohistochemistry and two-photon laser scanning microscopy. Growth behaviour on the scaffolds was significantly increased for the German Landrace compared to Göttingen minipig. Nevertheless, seeding with the adult Göttingen minipig cells resulted in a closed layer on the surface and urothelial cells and smooth muscle cells showed increasing growth until day 14. The results show that these collagen scaffolds are adequate for the seeding with vesical cells. Moreover, they seem appropriate for the use as an in vitro model for the adult or elderly as the cells of the adult Göttingen minipig too, show good growth behaviour.

Functional and Clinicopathologic Outcomes Using a Modified Vescica Ileale Padovana Technique

OBJECTIVE

To evaluate the clinicopathologic and functional outcomes of a modified Vescica ileale Padovana (VIP) neobladder technique.

METHODS

Data for 160 patients at a single institution who underwent radical cystectomy and orthotopic VIP neobladder creation between 1998 and 2013 were analyzed. Modified VIP technique involved longitudinal opening of the small bowel close to the anterior mesenteric border instead of along the true anti-mesentery. This allowed for creation of a dependent neourethral funnel and a large serosal surface for ureteral anastomosis, distant from any suture lines.

RESULTS

Mean age for the entire cohort was 59.5, with 9% female and 64% with muscle invasive disease prior to cystectomy. Within 30 days of surgery, 16 patients (10%) developed a Clavien grade 3-4 complication and there were no deaths. Ninety-six percent reported minor or no daytime urinary leakage at 12 months, and 70% reported minor or no nighttime urinary leakage. Two- and five-year overall survival rates were 84.2% and 72.6% , respectively. Seven patients developed a ureteral stricture (4%), three (2%) had bladder neck contractures, two (1%) experienced urethral recurrence, and there were no vesicovaginal fistulas.

CONCLUSIONS

This modified VIP neobladder technique achieves favorable functional, survival, and recurrence outcomes similar to other published orthotopic continent diversions. Its near spheroidal shape lowers internal pressure, allowing for improved continence at physiologic filling capacity, and its offset bowel opening helps prevent unnecessary stretch to the native urethra, even in large individuals. The widened uretero-enteric anastomosis site distant from bowel suture lines contributes to decreased stricture rates and its placement on the dome of the neobladder facilitates endoscopic access should strictures occur. Finally, lack of posterior overlapping suture lines also mitigates the risk of fistulae formation in females should anterior vaginal wall excision or entry be unavoidable.