Long-term results of standard procedures in urology: the ileal neobladder

Ileal Neobladder With Mucous Plugs as a Cause of Obstructive Acute Kidney Injury Requiring Emergent Hemodialysis

Ileal neobladder is the preferred technique in the management of urinary diversion postradical cystectomy for bladder malignancy. The common complications associated with this procedure are atrophied kidney, chronic pyelonephritis, decreased renal function, ureteroileal or urethral anastomotic site stricture, urinary tract stones, incontinence, and hyperchloremic metabolic acidosis. Mucous plugs are also seen in 2%-3% patients. We present a rare presentation of a patient who required hemodialysis for severe hyperkalemia and acute kidney injury caused by mucous plugging of ileal neobladder.

Trends in renal function after radical cystectomy and ileal conduit diversion: new insights regarding estimated glomerular filtration rate variations

INTRODUCTION

Our objectives were to evaluate the long-term renal function after radical cystectomy (RC) and ileal conduit diversion (ICD) and to analyze year-by-year the estimated glomerular filtration rate (eGFR) and morphologic upper urinary tract changes.

PATIENTS AND METHODS

We retrospectively identified 226 patients who had undergone RC and ICD from 1980 to 2008, with regular postoperative follow-up visits. The eGFR was calculated using the Modification of Diet in Renal Disease equation at baseline and during follow-up. A decrease in renal function was defined as > 1 mL/min/1.73 m(2) annually.

RESULTS

The median follow-up period after RC was 91 months (range, 61-235 months). The median eGFR decreased from 66 mL/min/1.73 m(2) (range, 17-139 mL/min/1.73 m(2)) to 59 mL/min/1.73 m(2) (range, 33-102 mL/min/1.73 m(2)). A rapid decline in renal function occurred during the first 2 postoperative years (-9 mL/min/1.73 m(2) and -4 mL/min/1.73 m(2) in the first and second year, respectively), with a moderate to slight decrease in the subsequent years. Urinary obstruction was diagnosed in 51 patients (23%). Among the patients who underwent prompt surgical treatment, we did not find any association with the eGFR decline (P = .8).

CONCLUSION

Patients with urinary ICD have a lifelong risk of chronic kidney disease. Regular monitoring of renal function and the morphologic upper urinary tract will permit early diagnosis and treatment of modifiable factors, avoiding irreversible kidney damage.

Summary of the 8th Annual Bladder Cancer Think Tank: Collaborating to move research forward

OBJECTIVES

The 8th Annual Bladder Cancer Think Tank (BCAN-TT) brought together a multidisciplinary group of clinicians, researchers, and patient advocates in an effort to advance bladder cancer research.

METHODS AND MATERIALS

With the theme of "Collaborating to Move Research Forward," the meeting included three panel presentations and seven small working groups.

RESULTS

The panel presentations and interactive discussions focused on three main areas: gender disparities, sexual dysfunction, and targeting novel pathways in bladder cancer. Small working groups also met to identify projects for the upcoming year, including: (1) improving enrollment and quality of clinical trials; (2) collecting data from multiple institutions for future research; (3) evaluating patterns of care for non-muscle-invasive bladder cancer; (4) improving delivery of care for muscle-invasive disease; (5) improving quality of life for survivors; (6) addressing upper tract disease; and (7) examining the impact of health policy changes on research and treatment of bladder cancer.

CONCLUSIONS

The goal of the BCAN-TT is to advance the care of patients with bladder cancer and to promote collaborative research throughout the year. The meeting provided ample opportunities for collaboration among clinicians from multiple disciplines, patients and patient advocates, and industry representatives.

[Complications and their management after urinary diversion]

BACKGROUND

Bladder cancer is a common disease. It is predicted that 11,900 men and 4,500 women in Germany will be diagnosed with invasive bladder cancer in 2014. The cystectomy, which is standard treatment in muscle-invasive bladder cancer, requires urinary diversion.

PURPOSE

The goal of this article is to present the complications associated with urinary diversions and their management.

METHODS

Based on a selective literature search in PubMed and our own clinical experience, the options for urinary diversion and their management are discussed.

RESULTS

In patients treated with curative intent, orthotopic bladder replacement is preferred. In patients with palliative intent, incontinent cutaneous urinary diversion is commonly used. The present work shows the variety of early and late complications, peri-/postoperative mortality, and the management of these patients.

CONCLUSION

After cystectomy, various methods for urinary diversion are available, which can be used in curative and/or palliative intent. Crucial to the success and the long-term satisfaction of the patients is selection of the right urinary diversion method.

Urinary diversion: long-term functional aspects

Functional aspects and quality of life (QOL) of patients with a urinary diversion (UD) represent important issues in Urology. Any form of UD has its specific problems. In experienced hands and with regular long-term follow-up, serious complications can be avoided and excellent long-term results can be achieved. Thus, the selection of an appropriate UD is critical to patient's long-term satisfaction. Patients must be fully counseled in all types of UD and should have ready access to all options. There are 3 kinds of factors to be considered in the selection of UD: patient, physician, and general factors. In the pre-operative counseling, it is mandatory to explain all factors that over time may contribute to affect the patient's urinary tract function and QOL, mainly linked to long-term complications of UD. One of the most important requirements for any bladder substitution is that it should not jeopardize the renal function. There are many urological and non-urological potential reasons for deterioration in renal function following UD. Continence results after neobladder (NB) are difficult to compare between series published in the literature because of a lack of consensus of definitions, varied follow-up periods, and different mechanisms of data collection. In up to 22% of patients with NB, significant residual urine volumes were observed. The overall patients' QOL reported in most articles was good, irrespective of the type of UD. QOL of patients with a well functioning NB seems to be significantly better than other forms of diversion. Well-designed randomized prospective trials are warranted to render definitive conclusions.

Long-term efficacy of polydimethylsiloxane (Macroplastique) injection for Mitrofanoff leakage after continent urinary diversion surgery

OBJECTIVE

To assess the long-term efficacy of polydimethylsiloxane (Macroplastique) injection (MPI) in the treatment of Mitrofanoff leakage secondary to valve incompetence.

PATIENTS AND METHODS

Between 1995 and 2012, the records of 24 consecutive patients who underwent MPI for Mitrofanoff urinary leakage after continent cutaneous urinary diversion (CCUD) surgery were examined. All patients had a valve deemed of sufficient length (>2 cm) to attempt Macroplastique coaptation. Treatment outcomes were divided into three categories based on physician assessment: success (dry), partial success (>50% reduction in incontinence pads) and failure. Success rates were assessed according to the type of reservoir and conduit channel.

RESULTS

The mean (range) follow-up was 30 (6-96) months. One patient had initial difficulty catheterising, and subsequently required major revision surgery. In all, 12 patients (50%) failed the treatment and subsequently underwent operative revision to the channel. Three patients (12.5%) achieved complete success; one patient had an appendix channel through native bladder and the remaining two had Monti channels through colon. Nine patients (37.5%) had partial success; success rates were higher with appendix channels (four of six) and colonic reservoirs (six of seven) when compared with Monti channels (eight of 18, 44%) and ileal reservoirs (zero of two). Five of the nine patients with partial success eventually required further surgical revision for deteriorating continence at a mean (range) of 41 (14-96) months, whilst the other four have maintained sufficient continence with MPI alone.

CONCLUSION

Macroplastique bulking cured only 12.5% patients, but leakage was substantially improved in a further 37.5% allowing major surgery to be avoided or postponed in one half of the cohort. Appendix Mitrofanoffs do better than the Monti Mitrofanoff, with channels through colonic segments generally doing better than those through ileal bladders. MPI should be considered as a less invasive alternative to avoid or delay major reconstructive surgery.

Laparoscopic versus open radical cystectomy in bladder cancer: a systematic review and meta-analysis of comparative studies

Background and Objective

More recently laparoscopic radical cystectomy (LRC) has increasingly been an attractive alternative to open radical cystectomy (ORC) and many centers have reported their early experiences in the treatment of bladder cancer. Evaluate the safety and efficacy of LRC compared with ORC in the treatment of bladder cancer.

Methods

A systematic search of Medline, Scopus, and the Cochrane Library was performed up to Mar 1, 2013. Outcomes of interest assessing the two techniques included demographic and clinical baseline characteristics, perioperative, pathologic and oncological variables, and post-op neobladder function and complications.

Results

Sixteen eligible trials evaluating LRC vs ORC were identified including seven prospective and nine retrospective studies. Although LRC was associated with longer operative time (p<0.001), patients might benefit from significantly fewer overall complications (p<0.001), less blood loss (p<0.001), shorter length of hospital stay (p<0.001), less need of blood transfusion (p<0.001), less narcotic analgesic requirement (p<0.001), shorter time to ambulation (p = 0.03), shorter time to regular diet (p<0.001), fewer positive surgical margins (p = 0.006), fewer positive lymph node (p = 0.05), lower distant metastasis rate (p = 0.05) and fewer death (p = 0.004). There was no significant difference in other demographic parameters except for a lower ASA score (p = 0.01) in LRC while post-op neobladder function were similar between the two groups.

Conclusions

Our data suggest that LRC appears to be a safe, feasible and minimally invasive alternative to ORC with reliable perioperative safety, pathologic & oncologic efficacy, comparable post-op neobladder function and fewer complications. Because of the inherent limitations of the included studies, further large sample prospective, multi-centric, long-term follow-up studies and randomized control trials should be undertaken to confirm our findings.

Current status of minimally invasive radical cystectomy: an outcome-based comparison

Minimally invasive approaches to radical cystectomy are 20 years old. Available data suggest that minimally invasive radical cystectomy can provide comparable outcomes to open radical cystectomy despite the scarcity of level 1-2 evidence. Perioperative, functional and early oncologic outcomes seem comparable between the two surgical approaches. Robotic technology has allowed more surgeons to perform minimally invasive radical cystectomy and has simplified technically demanding steps that posed problems in conventional laparoscopy. This is evident by the rapid dissemination of robotics in many bladder cancer centers worldwide and by the numerous emerging series of robot-assisted intracorporeal urinary diversion. Until more data are available regarding the oncologic performance of minimally invasive radical cystectomy, open radical cystectomy remains the gold standard procedure for now.

Orthotopic bladder substitution (Neobladder): part II: postoperative complications, management, and long-term follow-up

Bladder replacement following radical cystectomy is widely practiced and in some centers has become the standard method of urinary diversion when possible, rather than the traditional ileal conduit. To minimize the impact of cystectomy and bladder replacement on quality of life and to obtain optimal functional results, postoperative care must be comprehensive and multidisciplinary. Critical team members include the surgeon, urologic nurses, WOC nurses, and allied health care providers such as physiotherapists. This article highlights postoperative considerations for patients undergoing radical cystectomy with orthotopic neobladder construction. The common issues and complications that arise are discussed with a focus on strategies to optimize outcomes.

Short-Term Functional and Urodynamic Outcome of W-ileal Orthotopic Neobladder with Serosa-Lined Tunneled Uretero-Ileal Anastomosis

OBJECTIVES

Functional and urodynamic (UDS) outcomes of W-configured ileal orthotopic neobladder (ONB) with extramural serosa-lined tunnel uretero-ileal anastomosis are presented

METHODS

Consecutive 17 patients undergoing ONB during December 2009 to March 2011 were enrolled. Of these 15 men (bladder cancer 14, tuberculosis 1) with mean age 52.7 ± 11.3 years completed the follow-up. Pouch-related quality of life (PQOL) was assessed using a published questionnaire. Uroflowmetry, cystometry/cystography and urethral-pressure profilometry were done at two follow-up visits at least 3 months apart. Mean follow up 10 ± 5 months. Mean length of harvested ileum 48 ± 6 cm.

RESULTS

Overall PQOL were similar at both evaluations (55 ± 11 and 54 ± 15, respectively). During first and second follow-up, maximum flow-rate, voided-volume and post-void residual urine were 11 ± 4 mL/sec, 246 ± 99 mL and 68 ± 74.9 mL and 10.4 ± 4.6 mL/sec, 234 ± 138 mL and 86 ± 146 mL, respectively. Mean neobladder capacity, compliance, maximum urethral closure-pressure (MUCP) and functional urethral length were 484 ± 244 mL, 50.5 ± 49.1 mL/cmH2 O, 42 ±20 cmH2 O and 22 ± 12 mm, and 468 ± 250 mL, 46.4 ± 47.5 mL/cmH2 O, 52 ± 27cmH2 O and 23 ± 12 mm, respectively. Patients with smaller pouch (r = 0.828; P = 0.0001), longer urethral length (r = -0.392; P = 0.023) and lesser incontinence (r = 0.429; P = 0.011) had significantly better PQOL. With continued supervised pelvic-floor rehabilitation, a trend in improvement in hesitancy (P = 0.058), MUCP (P = 0.05) and bothersome incontinence (P = NS) was observed. None of the patients had any obstruction or reflux of the upper tracts.

CONCLUSION

The index ONB has reasonable storage and voiding characteristics but with a rider of nocturnal urinary incontinence.

EAU guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2013 guidelines

CONTEXT

The European Association of Urology (EAU) guidelines panel on Muscle-invasive and Metastatic bladder cancer (BCa) updates its guidelines yearly. This updated summary provides a synthesis of the 2013 guidelines document, with emphasis on the latest developments.

OBJECTIVE

To provide graded recommendations on the diagnosis and treatment of patients with muscle-invasive BCa (MIBC), linked to a level of evidence.

EVIDENCE ACQUISITION

For each section of the guidelines, comprehensive literature searches covering the past 10 yr in several databases were conducted, scanned, reviewed, and discussed both within the panel and with external experts. The final results are reflected in the recommendations provided.

EVIDENCE SYNTHESIS

Smoking and work-related carcinogens remain the most important risk factors for BCa. Computed tomography (CT) and magnetic resonance imaging can be used for staging, although CT is preferred for pulmonary evaluation. Open radical cystectomy with an extended lymph node dissection (LND) remains the treatment of choice for treatment failures in non-MIBC and T2-T4aN0M0 BCa. For well-informed, well-selected, and compliant patients, however, multimodality treatment could be offered as an alternative, especially if cystectomy is not an option. Comorbidity, not age, should be used when deciding on radical cystectomy. Patients should be encouraged to actively participate in the decision-making process, and a continent urinary diversion should be offered to all patients unless there are specific contraindications. For fit patients, cisplatinum-based neoadjuvant chemotherapy should always be discussed, since it improves overall survival. For patients with metastatic disease, cisplatin-containing combination chemotherapy is recommended. For unfit patients, carboplatin combination chemotherapy or single agents can be used.

CONCLUSIONS

This 2013 EAU Muscle-invasive and Metastatic BCa guidelines updated summary aims to increase the quality of care and outcome for patients with muscle-invasive or metastatic BCa.

PATIENT SUMMARY

In this paper we update the EAU guidelines on Muscle-invasive and Metastatic bladder cancer. We recommend that chemotherapy be administered before radical treatment and that bladder removal be the standard of care for disease confined to the bladder.

Orthotopic bladder substitution (neobladder): part I: indications, patient selection, preoperative education, and counseling

Bladder substitution following radical cystectomy for urothelial cancer (transitional cell carcinoma) has become increasingly common and in many centers has evolved to become the standard method of urinary diversion. In determining the best type of urinary diversion for a specific patient, consideration must be given to both the morbidity associated with surgery and the potential positive impact on the patient's quality of life. Decision-making and perioperative care is ideally multidisciplinary, involving physicians and nurse specialists in urology, continence, and ostomy therapy. Physiotherapists may also be involved for pelvic floor muscle retraining. This article highlights preoperative considerations for patients undergoing radical cystectomy with a focus on issues specific to orthotopic bladder substitution as the method of urinary diversion. The second article in this 2-part series will outline postoperative strategies to manage these patients.

Early and late urodynamic assessment of the orthotopic N-shaped neobladder

The present study aimed to report the urodynamic data from 46 male patients who underwent an orthotopic N-shaped neobladder replacement following a radical cystectomy during a 12-month period and to provide urodynamic evidence for the improvement of this technique. A total of 46 consecutive male patients underwent a radical cystectomy and orthotopic N-shaped neobladder substitution due to muscle-invasive bladder cancer. Uroflowmetry, cystometry and urethral pressure profilometry were analyzed at 3-12 months following the surgery. The mean pressure of the neobladders was <15 cm H2O at volumes of <400 ml and 22.4 cm H2O at 100% capacity at 6 months. The mean pressure of the contractions was <40 cm H2O at 6 months. The mean filling pressure following the surgery at 3 months was higher compared with that at 6 months. No difference was observed at the other time-points. When comparing the 9- and 12-month urodynamic characteristics, no significant changes were observed in the cystometric capacity. The mean post-void residual (PVR) urine volume was 58 ml. A mean voiding peak of 16.2 ml/sec was obtained using the Valsalva maneuver. The daytime continence rate was 90% at 12 months while the night-time continence rate was 60%.

Long-term renal function outcomes after radical cystectomy

PURPOSE

We evaluated the long-term natural history of renal function after radical cystectomy with urinary diversion and determined factors associated with decreased renal function.

MATERIALS AND METHODS

We reviewed the records of 1,631 patients who underwent radical cystectomy between 1980 and 2006. The estimated glomerular filtration rate was calculated preoperatively and at various intervals after surgery. A renal function decrease was defined as a greater than 10 ml per minute/1.73 m(2) reduction in the estimated glomerular filtration rate. Multivariate analysis was done to evaluate the association of clinicopathological features, incontinent vs continent diversion type and postoperative complications with decreased renal function.

RESULTS

A total of 1,241 patients (76%) underwent incontinent diversion and 390 (24%) underwent continent diversion. Median followup after radical cystectomy in patients alive at last followup was 10.5 years (IQR 7.1, 15.3). The median preoperative estimated glomerular filtration rate was higher in the continent diversion cohort (67 vs 59 ml per minute/1.73 m(2), p <0.0001). This difference was maintained until 7 years postoperatively, after which no difference was noted in renal function by diversion type. By 10 years after radical cystectomy the risk of a renal function decrease was similar for incontinent and continent diversion (71% and 74%, respectively, p = 0.13). On multivariate analysis risk factors associated with decreased renal function included age (HR 1.03, p <0.0001), preoperative estimated glomerular filtration rate (HR 1.05, p <0.0001), chronic hypertension (HR 1.2, p = 0.01), postoperative hydronephrosis (HR 1.2, p = 0.03), pyelonephritis (HR 1.3, p = 0.01) and ureteroenteric stricture (HR 1.6, p <0.0001).

CONCLUSIONS

Decreased renal function is noted in most patients during long-term followup after radical cystectomy. Postoperative hydronephrosis, pyelonephritis and ureteroenteric stricture represent potentially modifiable factors associated with a decrease. Choice of urinary diversion was not independently associated with decreased renal function.

Ureterocutaneostomy: for whom and when?

OBJECTIVE

To discuss the indications and the results of the patients treated with ureterocutaneostomy (UCN) for urinary diversion in our center.

MATERIAL AND METHODS

Between March 2008 and November 2012, 27 patients (19 males and 8 females) were treated with UCN in our clinic. Patients' ages ranged between 56-78 years. Radical cystectomy was performed on 21 of these patients. The patients underwent transureteroureterostomy and UCN or unilateral or bilateral side-by-side UCN on the abdominal wall. Double-J stents were placed inside the ureters and changed every 12 weeks. Comorbidities and American Society of Anesthesiologists (ASA) scores were noted.

RESULTS

The patients had invasive bladder cancer (n=24), multiple tumors within and outside of a diverticulum and intractable recurrent bleeding (n=1), recurrent hemorrhage (n=1), and bladder contracture (n=1). As comorbidities, hypertension (n=14), chronic obstructive pulmonary disease (n=11), diabetes mellitus (n=10), coronary artery disease (n=8), chronic renal failure (n=1), and Crohn's disease (n=1) were detected. The ASA score was 3 or greater in 14 patients. During follow-up period, 3 patients experienced pyelonephritis, and one of them had a strictured ureteral orifice.

CONCLUSION

UCN can be used as a method of urinary diversion in selected patients.

The Studer orthotopic neobladder: long-term (more than 10 years) functional outcomes, urodynamic features, and complications

PURPOSE

Radical cystectomy and urinary diversion are the standard treatment for invasive bladder cancer. We analyzed the long-term (>10 years postoperatively) functional outcomes, complications, and urodynamic findings in a single center series of patients who underwent cystectomy and a Studer ileal neobladder substitution.

MATERIALS AND METHODS

A retrospective chart review of 108 Studer pouches constructed during 1990 and 2011 was performed. Data were analyzed in terms of long-term (>10 years) outcomes. Complications, incontinence, voiding difficulties, upper urinary tract changes, overall satisfaction, and urodynamic findings of the reservoir were obtained.

RESULTS

We evaluated 19 out of 50 patients who had lived for over 10 years postoperatively. Another 31 patients were not traced: 7 patients died following recurrence, 15 died due to exacerbation of a comorbidity, and 9 patients were lost to follow-up. Concerning complications, 6 patients had an atrophied kidney, 5 patients had moderate hydronephrosis, 5 patients had chronic recurrence of pylelonephritis, and 2 patients had voiding difficulty because of bladder neck stricture due to clean intermittent catheterization. One patient underwent an operation due to intestinal obstruction. Seven patients had incontinence; all 7 patients showed intermittently at night and 2 patients even in waking hours. Maximum bladder capacity was 484.1±119.2 mL, maximum flow rate was 13.6±9.7 mL/sec, and post-void residual urine volume was 146.8±82.7 mL.

CONCLUSION

Long-term outcomes with the Studer orthotopic ileal neobladder have an acceptable complication rate and good functional results. However, potential adverse outcomes such as renal deterioration, dysfunctional voiding should also be considered.

Neobladder long term follow-up

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

AIM

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

[Urinary diversions and bladder replacement surgery: evolution, current situation and long-term outcomes]

Nowadays, radical cystectomy represents the first choice of therapy for muscle invasive bladder cancer. The first choice after radical cystectomy, both in male and in female patients, is no more urinary diversion, but bladder replacement surgery through orthotopic reconstruction. The ileal conduit is considered a safe procedure and the gold standard to which newer forms of urinary diversion should be compared, although few long-term results are known. Currently, neobladder is the most important urinary diversion in the world, followed by Bricker's ileal conduit. We evaluated the long-term results of the most important forms of urinary diversions, analyzing some data available in the Literature. Then, we focused our attention on long-term outcomes of our "Y Neobladder": functional outcome and long-term complications. At last, we critically examined the widely accepted notion that patients undergoing "Y Neobladder" experience superior quality of life outcomes than patients receiving an ileal conduit.

Quality of life in patients with muscle invasive and non-muscle invasive bladder cancer

PURPOSE

Compared to the literature on other malignancies, data on quality of life (QoL) in bladder cancer are sparse. This study sought answers to the following questions: In what QoL domains do patients with bladder cancer differ from the general population? Do patients with radical cystectomy differ in QoL compared to those who received conservative treatment? Do patients with neobladder generally have better QoL compared to patients with other diversion methods?

METHODS

At the beginning of inpatient rehabilitation, N = 823 patients with bladder cancer were assessed. Data of a representative community sample (N = 2037) were used for comparison. The questionnaire EORTC QLQ-C30 was used to measure QoL. Multivariate linear regression models were computed to investigate differences between groups.

RESULTS

Patients with both non-muscle invasive and muscle invasive bladder cancer reported significantly more problems and worse functioning than the general population. Radiotherapy is associated with clinically relevant more pain, dyspnoea, constipation, appetite loss and decreased social functioning while chemotherapy is associated more with dyspnoea. Cystectomy patients reported more fatigue, appetite loss and decreased role functioning. Male patients ≥70 years with conduit experienced more sleep and emotional problems. These effects of urinary diversion were not observed in women and younger patients.

CONCLUSIONS

Patients with bladder cancer experience various QoL concerns at the beginning of inpatient rehabilitation. These problems can partly be explained by the type of treatment the patients receive. Type of urinary diversion is relevant for QoL in subgroups of patients.

Tissue-engineered tubular graft for urinary diversion after radical cystectomy in rabbits

BACKGROUND

Clinically, using ileal conduit for urinary diversion often caused many serious complications. Tissue engineering technology may offer an alternative method for urinary diversion after radical cystectomy. In this study, we aimed to make a tissue-engineered tubular graft (TETG) using bladder epithelial cells and bladder acellular matrix (BAM) for urinary diversion in rabbits.

METHODS

Bladder epithelial cells of rabbit were cultivated and expanded in vitro, which were then seeded on BAM and cultured for 7 d. Then, cell-seeded grafts of 4 cm length and 0.8 cm diameter were used to make TETGs and transferred into the omentum for 2 wk before urinary diversion. In the experimental group, bladders of the rabbits were removed. The proximal ends of TETGs were anastomosed with ureters, and the distal ends were anastomosed with the abdominal stomas. In the control group, TETGs were constructed using unseeded BAM. Newly formed tissue structures were functionally and microscopically evaluated using urography and immunohistochemistry at 1, 2, 4, and 8 wk after operation, respectively. Histologic examination with hematoxylin and eosin staining was conducted to assess tissue regeneration. Immunohistochemistry was performed with AE1/AE3, uroplakin Ⅲa, and zonula occludens 1 (ZO-1) antibodies.

RESULTS

All animals were alive in the experimental group. Hematoxylin and eosin staining showed epithelial coverage in TETG. Immunohistochemistry showed positive stain with AE1/AE3, uroplakin Ⅲa, and ZO-1, which indicated mature and functional epithelial cells on the lumen of TETG. Intravenous urography showed that there were no obstructions in TETGs. In the control group, four rabbits were dead within 2 wk, and scar formation, atresia, and severe hydronephrosis were found.

CONCLUSIONS

It was feasible that TETG constructed using bladder epithelial cells and BAM for urinary diversion after radical cystectomy in rabbits.

[Treatment of muscle-invasive and metastatic bladder cancer: update of the EAU guidelines]

CONTEXT

New data regarding treatment of muscle-invasive and metastatic bladder cancer (MiM-BC) has emerged and led to an update of the European Association of Urology (EAU) guidelines for MiM-BC.

OBJECTIVE

To review the new EAU guidelines for MiM-BC with a specific focus on treatment.

EVIDENCE ACQUISITION

New literature published since the last update of the EAU guidelines in 2008 was obtained from Medline, the Cochrane Database of Systematic Reviews, and reference lists in publications and review articles and comprehensively screened by a group of urologists, oncologists, and a radiologist appointed by the EAU Guidelines Office. Previous recommendations based on the older literature on this subject were also taken into account. Levels of evidence (LEs) and grades of recommendations (GRs) were added based on a system modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence.

EVIDENCE SYNTHESIS

Current data demonstrate that neoadjuvant chemotherapy in conjunction with radical cystectomy (RC) is recommended in certain constellations of MiM-BC. RC remains the basic treatment of choice in localised invasive disease for both sexes. An attempt has been made to define the extent of surgery under standard conditions in both sexes. An orthotopic bladder substitute should be offered to both male and female patients lacking any contraindications, such as no tumour at the level of urethral dissection. In contrast to neoadjuvant chemotherapy, current advice recommends the use of adjuvant chemotherapy only within clinical trials. Multimodality bladder-preserving treatment in localised disease is currently regarded only as an alternative in selected, well-informed, and compliant patients for whom cystectomy is not considered for medical or personal reasons. In metastatic disease, the first-line treatment for patients fit enough to sustain cisplatin remains cisplatin-containing combination chemotherapy. With the advent of vinflunine, second-line chemotherapy has become available.

CONCLUSIONS

In the treatment of localised invasive bladder cancer (BCa), the standard treatment remains radical surgical removal of the bladder within standard limits, including as-yet-unspecified regional lymph nodes. However, the addition of neoadjuvant chemotherapy must be considered for certain specific patient groups. A new drug for second-line chemotherapy (vinflunine) in metastatic disease has been approved and is recommended.

Robotic intracorporeal orthotopic ileal neobladder: replicating open surgical principles

BACKGROUND

Robotic radical cystectomy (RC) for cancer is beginning to gain wider acceptance. Yet, the concomitant urinary diversion is typically performed extracorporeally at most centers, primarily because intracorporeal diversion is perceived as technically complex and arduous. Previous reports on robotic, intracorporeal, orthotopic neobladder may not have fully replicated established open principles of reservoir configuration, leading to concerns about long-term functional outcomes.

OBJECTIVE

To illustrate step-by-step our technique for robotic, intracorporeal, orthotopic, ileal neobladder, urinary diversion with strict adherence to open surgical tenets.

DESIGN, SETTING, AND PARTICIPANTS

From July 2010 to May 2012, 24 patients underwent robotic intracorporeal neobladder at a single tertiary cancer center. This report presents data on patients with a minimum of 3-mo follow-up (n=8).

SURGICAL PROCEDURE

We performed robotic RC, extended lymphadenectomy to the inferior mesenteric artery, and complete intracorporeal diversion. Our surgical technique is demonstrated in the accompanying video.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Baseline demographics, pathology data, 90-d complications, and functional outcomes were assessed and compared with patients undergoing intracorporeal ileal conduit diversion (n=7).

RESULTS AND LIMITATIONS

Robotic intracorporeal urinary diversion was successfully performed in 15 patients (neobladder: 8 patients, ileal conduit: 7 patients) with a minimum 90-d follow-up. Median age and body mass index were 68 yr and 27 kg/m2, respectively. In the neobladder cohort, median estimated blood loss was 225 ml (range: 100-700 ml), median time to regular diet was 5 d (range: 4-10 d), median hospital stay was 8 d (range: 5-27 d), and 30- and 90-d complications were Clavien grade 1-2 (n=5 and 0), Clavien grade 3-5 (n=2 and 1), respectively. This study is limited by small sample size and short follow-up period.

CONCLUSIONS

An intracorporeal technique of robot-assisted orthotopic neobladder and ileal conduit is presented, wherein established open principles are diligently preserved. This step-wise approach is demonstrated to help shorten the learning curve of other surgeons contemplating robotic intracorporeal urinary diversion.

[Management of urinary incontinence after orthotopic urinary diversion]

Orthotopic urinary diversion (OUD) is performed in almost half of all radical cystectomies. This review presents an overview of the incidence, pathophysiology, and management of urinary incontinence (UI) after OUD. Daytime and nighttime UI are reported in up to 15% and 45% of cases after OUD, respectively. UI after OUD is more frequent in women. Stress incontinence is the most common reason for daytime urinary leakage, while an absent vesicourethral reflex with reduced external sphincter muscle tone is associated with nighttime UI. Conservative management has limited therapeutic value in UI after OUD. Surgical approaches include adjustable and nonadjustable slings as well as the ProACT® system in mild stress UI. Implantation of the artificial urinary sphincter system AMS 800® is the standard treatment for stress UI after OUD. Very limited data exist regarding results after implantation of newer artificial urinary sphincter systems such as the FlowSecure® and the Zephyr® ZSI 375 after OUD.

[Uretero-intestinal anastomosis: Achilles heel of urinary diversion using bowel segments]

A well-functioning uretero-intestinal anastomosis is essential for the preservation of kidney function following urinary diversion using bowel segments. In incontinent forms of urinary diversions, such as ileal conduits, the ureters are usually implanted in a refluxive manner, whereas there is still controversy about the ideal implantation technique in continent orthotopic or heterotopic reservoirs (i.e. refluxive versus anti-refluxive). Current techniques of refluxive and antirefluxive uretero-intestinal anastomosis, their indications, typical perioperative and postoperative complications and management are discussed. Irradiated or preoperatively dilated ureters show a higher complication rate in terms of postoperative dilatation and obstruction. Early revision of the implantation site and ureteral reimplantation yield more favorable outcomes and long-term results than a minor invasive endourological treatment. As ureteral stenosis may occur more than 15 years after urinary diversion, regular follow-up including sonographic evaluation of the upper urinary tract to detect hydronephrosis is mandatory. In this setting a diuretic renogram with MAG-III is a helpful tool to determine split renal function and to discriminate urodynamic relevant dilatation of the upper urinary tract from clinical situations requiring only observation, while dimercaptosuccinic acid (DMSA) scans provide valuable information about renal scarring.

A new prognostic model for cancer-specific survival after radical cystectomy including pretreatment thrombocytosis and standard pathological risk factors

Study Type - Prognosis (cohort series) Level of Evidence 2a What's known on the subject? and What does the study add? Preoperative thrombocytosis has been identified as a predictor of poor outcome in various cancer types. However, the prognostic role of platelet count in patients with invasive bladder cancer undergoing radical cystectomy is unknown. The present study demonstrates that preoperative thrombocytosis is an independent risk factor for decreased cancer-specific survival after radical treatment of invasive bladder cancer. We developed a new prognostic scoring model for cancer-specific outcomes after radical cystectomy including platelet count and established pathological risk factors. Consideration of platelet count in the final model increased its predictive accuracy significantly. Thrombocytosis may be a useful parameter to include within established international bladder cancer nomograms.

OBJECTIVE

•  To investigate the oncological significance of preoperative thrombocytosis in patients with invasive bladder cancer undergoing radical cystectomy, as it has been reported as a marker for aggressive tumour biology in a variety of solid tumours.

PATIENTS AND METHODS

•  The series comprised 258 patients undergoing radical cystectomy between 1999 and 2010 in whom different clinical and histopathological parameters were assessed. •  Elevated platelet count was defined as >450 × 10(9) /L. •  Based on regression estimates of significant parameters in multivariable analysis a new weighted scoring model was developed to predict cancer-specific outcomes.

RESULTS

•  The median follow-up was 30 months (6-116). •  Of the 258 patients, 26 (10.1%) had elevated and 232 (89.9%) had normal platelet count. The 3-year cancer-specific survival in patients with normal and elevated platelet count was 61.5% and 32.7%, respectively (P < 0.001). •  In multivariable analysis, cancer-specific survival was significantly lower in patients with locally advanced disease (≥pT3a) (relative risk 2.91, 1.54-5.65; P= 0.001), positive soft tissue surgical margins (4.03, 1.99-7.92; P= 0.001) and thrombocytosis (2.68, 1.26-5.14; P= 0.011). •  The 3-year cancer-specific survival in patients with a score 0 (low risk), 1-2 (intermediate risk) and 3-5 (high risk) was 81.0%, 54.8% and 8.2%, respectively (P < 0.001). •  Consideration of preoperative platelet count in the final model increased its predictive accuracy by 1.8% with a concordance index of 0.745 (P= 0.040).

CONCLUSIONS

•  The presence of thrombocytosis at radical cystectomy portends unfavourable prognosis. •  We constructed a simple weighted prognostic model for cancer-specific outcomes after radical cystectomy based on pretreatment platelet count and established pathological risk factors. •  These data warrant external validation and may allow for tailored monitoring and selection of appropriate patients for neoadjuvant and adjuvant trials.

Surveillance guidelines based on recurrence patterns after radical cystectomy for bladder cancer: the Canadian Bladder Cancer Network experience

Study Type - Prognosis (cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Radical cystectomy with pelvic lymph node dissection is recognized as the standard of care for carcinoma invading bladder muscle and for refractory non-muscle-invasive bladder cancer. Owing to high recurrence and progression rates, a two-pronged strict surveillance regimen, consisting of both functional and oncological follow-up, has been advocated. It is also well recognized that more aggressive tumours with extravesical disease and node-positive disease recur more frequently and have worse outcomes. This study adds to the scant body of literature available regarding surveillance strategies after radical cystectomy for bladder cancer. In the absence of any solid evidence supporting the role of strict surveillance regimens, this extensive examination of recurrence patterns in a large multi-institutional project lends further support to the continued use of risk-stratified follow-up and emphasizes the need for earlier strict surveillance in patients with extravesical and node-positive disease.

OBJECTIVES

• To review our data on recurrence patterns after radical cystectomy (RC) for bladder cancer (BC). • To establish appropriate surveillance protocols.

PATIENTS AND METHODS

• We collected and pooled data from a database of 2287 patients who had undergone RC for BC between 1998 and 2008 in eight different Canadian academic centres. • Of the 2287 patients, 1890 had complete recurrence information and form the basis of the present study.

RESULTS

• A total of 825 patients (43.6%) developed recurrence. • According to location, 48.6% of recurrent tumours were distant, 25.2% pelvic, 14.5% retroperitoneal and 11.8% to multiple regions such as pelvic and retroperitoneal or pelvic and distant. • The median (range) time to recurrence for the entire population was 10.1 (1-192) months with 90 and 97% of all recurrences within 2 and 5 years of RC, respectively. • According to stage, pTxN+ tumours were more likely to recur than ≥pT3N0 tumours and ≤pT2N0 tumours (5-yr RFS 25% vs. 44% vs. 66% respectively, P < 0.001). Similarly, pTxN+ tumours had a shorter median time to recurrence (9 months, range 1-72 months) than ≥pT3N0 tumours (10 months, range 1-70 months) or ≤pT2N0 tumours (14 months, range 1-192 months, P < 0.001).

CONCLUSIONS

• Differences in recurrence patterns after RC suggest the need for varied follow-up protocols for each group. • We propose a stage-based protocol for surveillance of patients with BC treated with RC that captures most recurrences while limiting over-investigation.

Decreasing operative time and incontinence rates in patients treated with radical cystectomy and urethral diversion: a prospective randomized trial using a new suturing device (CAPIO)

PURPOSE

Radical cystectomy and orthotopic urinary diversion has been associated with significant long surgery time and postoperative urinary incontinence. We undertook a prospective randomized study to investigate the potential decrease in surgery time and improvement in the continence rate using a new suturing device compared with the traditional suture ligation, which is used for urethro-ileal anastomosis after radical cystectomy and orthotopic diversion for invasive bladder carcinoma.

MATERIALS AND METHODS

Between April 2005 and March 2010, 50 consecutive patients (37 men and 13 women) were recruited for the study. They were all subjected to radical cystectomy and W ileal neobladder orthotopic diversion by two senior surgeons. They were divided and randomized into two equal groups according to the methods of urethro-ileal anastomosis. The preoperative characteristics of both groups were equally distributed. One group underwent urethro-ileal anastomosis by the CAPIO suturing device, and the other group subjected to the usual stitches by needle older. Operative and early postoperative parameters were assessed. We followed the patients for 6 months postoperatively.

RESULTS

The preoperative parameters of the two groups were equally distributed with no statistically significant difference in any parameter. There were no intraoperative deaths. The mean time spent for urethro-ileal anastomosis in CAPIO group was 10.2 ± 1.4 min versus 19.6 ± 2.4 min, which was statistically significant (P value = 0.0001). Also, the mean blood loss was less in the CAPIO group (P value 0.05). As regard the early postoperative follow-up, the postoperative continence rate was significantly better in the CAPIO group than in the classic suturing group.

CONCLUSIONS

CAPIO as a new suturing device significantly shortened the time needed to achieve the urethro-ileal anastomosis with better early postoperative continence rate. It makes urethral stump accessible at any time during surgery. It also enables surgeons to do anastomosis at any time after cystectomy with any number of sutures.

Ileal neobladder in women with bladder cancer: cancer control and functional aspects

PURPOSE OF REVIEW

Radical cystectomy and urinary diversion is the accepted standard of care for invasive bladder cancer. Although orthotopic neobladder is the preferred method of urinary diversion in men, less experience is available for women. Recent studies and reports on this subject are summarized and reviewed.

RECENT FINDINGS

Urethra-sparing cystectomy in women and orthotopic urinary diversion can be performed safely in appropriately selected women with invasive bladder cancer. Excellent oncological outcomes can be expected with a minimal risk of urethral recurrence in case of negative frozen section of the proximal urethra. Orthotopic neobladder diversion offers excellent clinical and functional results, and should be the diversion of choice in most women following cystectomy. Female sexual dysfunction can be avoided in patients who received neurovascular preservation, although quality of life declined in women who had undergone non-nerve-sparing radical cystectomy.

SUMMARY

Urethra-sparing cystectomy does not compromise the oncologic outcome in women with bladder cancer. The excellent functional outcome and voiding pattern with orthotopic urinary diversion argues in favor of this technique as the preferred method for lower urinary tract reconstruction after radical cystectomy. Nerve-sparing radical cystectomy preserves female sexual function and improves quality of life.

Robotic cystectomy: surgical technique

OBJECTIVE

• The aim of this report is to describe our surgical technique of robotic assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion in patients with urinary bladder cancer.

PATIENTS AND METHODS

• A total of 45 patients (7 women and 38 men) with high-grade and/or muscle-invasive urothelial cancer of the bladder underwent RARC and intracorporeal urinary diversion at our department. • Orthotopic ileal neobladder was performed in 36 patients and ileal conduit was performed in 9 patients.

RESULT

• Except in two patients that operation was converted to open surgery during the reconstruction of the orthotopic neobladder, the procedure was performed totally intracorporeal. • The operations time, estimated blood loss and length for hospital stay were decreased over the time.

CONCLUSION

• RARC with totally intracorporeal urinary diversion is feasible.

Improving selection of appropriate urinary diversion following radical cystectomy for bladder cancer

Radical cystectomy represents the gold-standard of treatment for invasive bladder cancer. Following cystectomy, various options for urinary diversion may be offered to patients. This article represents an overview of the history of urinary diversion, explains the current selection criteria used at one of the most experienced bladder cancer centers worldwide, and provides an update on the current understanding of continence mechanisms. Furthermore, we review the current literature on quality of life for patients with different forms of urinary diversion. Excellent functional results can be achieved with continent forms of urinary diversion. It is important to consider the relative and absolute contraindications when choosing any form of urinary diversion. Proper patient selection and thorough standardized preoperative counseling is critical in achieving optimal results.

Modified technique for the creation of an orthotopic neobladder in patients with shortened mesentery: making up the difference between the bladder and the urethral stump

OBJECTIVE

To describe an ileal neobladder reconstruction technique performed in 5 men who had previous abdominal surgeries and presented with a short mesoileum at the time of bladder replacement.

METHODS

The patients were 5 men scheduled for a radical cystoprostatectomy with bladder substitution and had a short mesoileum at the time of the surgery. All patients had a history of abdominal surgery. A neobladder was constructed in a "J" shape leaving the most proximal part of the ileum (8-10 cm) tubularized. We created a 3- to 4-cm flap from the surface of the most distal region of the reservoir. This flap was tubularized to lengthen the neobladder onto the urethral stump, resulting in a tension-free anastomosis. All patients underwent a complete clinical laboratory evaluation 12 months after the surgery.

RESULTS

At 1 year after surgery, all patients were able to void spontaneously. Day and night time continence were 80% and 60%, respectively. Urodynamic evaluation revealed a neobladder with good capacity (mean = 521 ml) and compliance (mean = 27.2 mL/cm H(2)O). Only 1 patient demonstrated a moderate hydronephrosis of the right kidney.

CONCLUSION

Candidates for orthotopic neobladders who have had previous abdominal surgeries and who have a short mesoileum at the time of the surgery are uncommon. Despite the small number of cases, our technique is noteworthy for having achieved good functional results during the short-term follow-up. This technique is advantageous because it is easy to perform and does not require any other bowel resection or anastomose.