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

Urinary diversion and quality of life: A six-year follow-up study of bladder cancer surgery

OBJECTIVES

To evaluate health-related quality of life (HRQOL) six years post-radical cystectomy in patients with muscle-invasive bladder cancer, comparing orthotopic ileal neobladder (ONB) and ileal conduit (IC). Therefore, the study aims to analyze the under-investigated long-term impact of standard bladder cancer treatments on HRQOL and provide insights into the HRQOL differences associated with these two common urinary diversion methods.

PATIENTS AND METHODS

This prospective study included 39 patients with urothelial carcinoma treated with ONB or IC at our center between 03/2013 and 01/2023. Patients with variant histology, metastasis, neoadjuvant chemotherapy, or benign indications for cystectomy were excluded. HRQOL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire preoperatively, at four and six years postoperatively. Statistical analyses included Chi-square tests, T-tests, and logistic regression models.

RESULTS

Of the patients, 64% (25/39) underwent ONB, and 76.9% (30/39) were male, with an average age of 69 years. No significant differences in overall good HRQOL (GHS > 70) were observed between ONB and IC at six years (IC: 60 ± 22; ONB: 69 ± 23, p = 0.2). Patients with IC reported higher insomnia at both follow-ups (4 years: p = 0.01; 6 years: p = 0.03). Emotional function remained stable in ONB patients but declined in IC patients from the fourth to sixth years (p = 0.04).

CONCLUSION

Long-term HRQOL did not significantly differ between ONB and IC up to six years post-radical cystectomy. Both urinary diversion methods can be offered to patients, with tailored discussions in terms of HRQOL.

Risk factors for urinary retention after robot-assisted radical cystectomy with orthotopic neobladder diversion: a multicenter study

To determine risk factors for urinary retention (UR) after robot-assisted radical cystectomy (RALC) with orthotopic neobladder diversion. A total of 269 patients who underwent RALC with orthotopic neobladder diversion from 2008 to 2019 at seven tertiary hospitals were retrospectively analyzed. There were 68 patients who had UR (UR arm) and 201 patients who did not have UR (no-UR arm). UR was defined as voiding dysfunction without catheterization or more than 100 mL of residual urine after voiding. Preoperative demographics, perioperative factors, pathology outcomes, and postoperative complications of UR and no-UR arms were compared and predictors of UR were identified. Among demographic factors, only gender proportion showed a difference, with male proportion being significantly lower in the UR arm than in the no-UR arm (81% vs 92%, p = 0.010). For perioperative outcomes, anastomosis site stricture (27% vs 11%, p = 0.003) and length of hospital stays (23 days vs. 19 days, p = 0.001) were significantly higher in the UR arm than in the no-UR arm. In multiple logistic regression analysis, female (OR 3.32, 95% CI: 1.43-7.72) and body mass index (BMI) (OR 1.10, 95% CI 1.00-1.20) were UR predictors. UR after RALC with orthotopic neobladder diversion is significantly increased in females. Multiple logistic regression analysis identified female and BMI elevation as UR predictors.

[Follow-up after urinary diversion]

Radical cystectomy is currently the standard of care for muscle-invasive bladder cancer. Different parts of the small and large intestines can be utilized for continent and incontinent urinary diversion. The postoperative follow-up after urinary diversion should consider functional, metabolic and oncological aspects. The functional follow-up of (continent) urinary diversion includes stenosis, emptying disorders or incontinence. The oncological follow-up should focus on the detection of local, urethral and upper tract recurrences as well as distant metastases. As 90% of the tumor recurrences occur during the first 3 years, a close follow-up should be carried out during this period. Metabolic disturbances, such as vitamin B12 and bile acid deficits, acidosis and disorders of calcium metabolism can also occur during long-term follow-up. The metabolic follow-up should consider the metabolic consequences of the parts of the intestines utilized for the urinary diversion.

Stapled W-shaped (Hautmann) Orthotopic Ileal Neobladder. Functional Results and Complications over a 13-year Period

BACKGROUND AND OBJECTIVE

The preferable technique for orthotopic bladder substitution after radical cystectomy is debated. The aim of this study was to describe our technique of a stapled W-shaped ileal neobladder and assess the complications and functional results in 100 patients. treated from December 2009 to July 2022.

METHODS

The W-shaped ileal neobladder is created with lateral arms of 15 cm and central arms of 10 cm. Following an incision of the lower part of the two medial arms, a 10-cm GIA titanium stapler is used to detubularize the medial arms first and then the laterals to the medial arms. Urethral-neobladder anastomosis and end-to-end ureteroileal anastomosis are finally carried out. We reported on clinical data, complications, and urinary function outcomes assessed by the International Consultation on Incontinence Questionnaire (ICIQ)-Short Form and daytime/24-h pad test. Full urinary continence (UC) was defined as pad tests yielding 0 g.

KEY FINDINGS AND LIMITATIONS

The median surgical time was 210 min. The early (up to 90 d) and late (>90 d) complication rates were 18% (2% grade ≥4) and 11.7% (2% grade ≥4), respectively. Two patients had "late" bladder stones due to chronic urinary retention, whereas none developed calcifications in the neobladder along the stapling lines. Daytime and 24-h UC rates were 74.7% and 72.4% at 12 mo, 82.7% and 72.4% at 36 mo, respectively. Median ICIQ scores were in line with pad test results, being 0 in patients with full UC.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our stapled W-shaped ileal neobladder technique was found to be simple and fast to shape, with a low complication rate, and yielded favorable long-term functional outcomes.

PATIENT SUMMARY

This study details the surgical technique, complications, and functional outcomes of patients who underwent open cystectomy with a stapled W-shaped ileal neobladder. Our results indicate that this approach is safe and provides favorable long-term functional outcomes.

Safety of urethral preservation using urethral frozen section analysis in radical cystectomy

Background

The objective of this study is to assess whether urethral preservation can be performed safely using frozen section analysis (FSA) of the urethral stump on urethral recurrence after radical cystectomy.

Methods

Between June 2012 and July 2022, we investigated consecutive male patients who underwent urethral FSA during radical cystectomy for urothelial carcinoma. For FSA-abnormal cases, urethrectomy was performed, and for FSA-normal cases, the urethra was preserved. The diagnostic accuracy of FSA was assessed in comparison with the pathological findings of the permanent sections of the same tissue. Postoperatively, computed tomography and urinary cytology were performed as routine surveillance of recurrence.

Results

Of the 77 patients included in this study, three patients with abnormal FSA underwent concurrent urethrectomy. The negative predictive value of urethral FSA was 100%. With a median postoperative follow-up of 38 months (interquartile ranges 21-71), no urethral recurrence was observed.

Conclusions

FSA may be useful in determining the indication for urethrectomy.

Long term outcomes and impact on renal function following radical cystectomy

INTRODUCTION

To assess clinical, oncological outcomes and impact on renal function in patients who underwent the radical cystectomy with pelvic lymphadenectomy for muscle invasive and high risk non-muscle invasive transitional cell carcinoma of urinary bladder without evidence of non-regional lymph nodes and distant metastasis.

MATERIALS AND METHODS

With curative intent total 156 patients underwent radical cystectomy with pelvic lymphadenectomy from January 2015 to December 2022. Total 132/156 patients had primary transitional cell carcinoma of bladder. Thirty patients, presented with obstructive nephropathy, operated after stabilization of renal function. Pre-operatively and post-operatively eGFR calculated using modified diet in renal disease formula.

RESULTS

In present study 114 (86.36%) patients had high grade TCC, 70 (53.02%) patients had organ confined disease. Nodal extension seen in 74 (56.06%) patients. Perioperative mortality noted in 36 (27.2%) patients. The overall survival and recurrence free survival (RFS) over 5 years was 66.67 and 45.45%. RFS was significantly related to pathological stage, nodal status, histological-grade, positivity of surgical margin and time of surgery from diagnosis. Total 92/132 (69.7%) patients had recurrence. Pelvic recurrence in 10/92 (10.87%) whereas 82/92 (89.13%) patients had distant recurrence. Pre-operatively mean creatinine was 2.6 mg/dl and mean eGFR was 38.9 ml/h in patients who presented with obstructive nephropathy after stabilization of renal function. Post-operatively in 46/132 (34.8%) patients had improvement in eGFR while 86/132 (65.2%) patients had deterioration of eGFR over 62 months of median follow up.

CONCLUSION

Radical cystectomy provides good overall survival outcomes. Pre-operative eGFR has significant impact on post-operative renal function in long term.

Robot-assisted Radical Cystectomy with Totally Intracorporeal Urinary Diversion Versus Open Radical Cystectomy: 3-Year Outcomes from a Randomised Controlled Trial

BACKGROUND AND OBJECTIVE

Randomised controlled trials (RCTs) comparing open radical cystectomy (ORC) and robot-assisted RC (RARC) have involved an extracorporeal approach for urinary diversion (UD), undermining the potential benefits of a totally robotic procedure. Our objective was to compare 3-yr outcomes from a RCT comparing ORC to RARC with totally intracorporeal UD (iUD).

METHODS

Patients with cT2-4 N0 M0 or bacillus Calmette-Guérin-failed high-grade non-muscle-invasive urothelial carcinoma who were candidates for RC without absolute contraindications to robotic surgery were included. A covariate adaptive randomisation process based on body mass index, American Society of Anesthesiologists score, preoperative haemoglobin, type of UD, neoadjuvant chemotherapy, and cT stage was used. The primary endpoint was to investigate the superiority of RARC with iUD in terms of a 50% reduction in transfusion rate. Secondary outcomes included adherence to an early recovery after surgery protocol, perioperative and postoperative outcomes, readmission and complication rates, a cost analysis, and functional, oncological, and health-related quality-of-life outcomes.

KEY FINDINGS AND LIMITATIONS

Overall, 116 patients were enrolled. The primary endpoint was confirmed, as the overall perioperative transfusion rate was significantly lower in the RARC cohort, with an absolute risk reduction of 19% (95% confidence interval 2-36%; p = 0.046). No differences in perioperative and postoperative complications and 3-yr oncological outcomes were observed between the groups. Despite the superiority of ORC on quantitative analysis of night-time pad use, there were no differences in the probabilities of recovery of daytime and night-time continence. Body image was significantly better in the RARC cohort. Cost analysis confirmed that RARC is a more expensive surgical procedure.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our findings support RARC with iUD as a safe surgical option; the transfusion rate was reduced by 50% and the complication rates and 3-yr oncological outcomes were comparable to those with ORC. The minimally invasive nature of RARC was reflected in better body image perception in this cohort. The probabilities of daytime and night-time continence recovery were comparable between the groups. Higher costs remain a drawback of robotic surgery.

PATIENT SUMMARY

This RCT demonstrated a 50% transfusions rate's reduction compared to ORC. We confirmed safety and feasibility of RARC with i-UD providing comparable peri- and postoperative complication rates, as well as, 3yr oncologic outcomes to those of ORC. Patients receiving either RARC-iUD or ORC had comparable probabilities of urinary continence recovery after surgery.

Clinical variables associated with major adverse cardiac events following radical cystectomy

Objectives

The objective of this study is to investigate the association between major adverse cardiac events (MACE) and clinical factors of patients undergoing radical cystectomy (RC) for bladder cancer.

Materials and Methods

A retrospective analysis using the 2015-2020 National Surgical Quality Improvement Program database was performed on patients who underwent RC for bladder cancer. MACE was defined as any report of cerebrovascular accident, myocardial infarction, or thromboembolic events (pulmonary embolism or deep vein thrombosis). A multivariable-adjusted logistic regression was conducted to identify clinical predictors of postoperative MACE.

Results

A total of 10 308 (84.2%) patients underwent RC with incontinent urinary diversion (iUD), and 1938 (15.8%) underwent RC with continent urinary diversion (cUD). A total of 629 (5.1%) patients recorded a MACE, and on the multivariable-adjusted logistic regression, it was shown that MACE was significantly associated with increased age (OR = 1.035, 95% CI: 1.024-1.046, p < 0.001), obesity (OR = 1.583, 95% CI: 1.266-1.978, p < 0.001), current smokers (OR = 1.386, 95% CI: 1.130-1.700, p = 0.002), congestive heart failure before surgery (OR = 1.991, 95% CI: 1.016-3.900; p = 0.045), hypertension (OR = 1.209, 95% CI: 1.016-1.453, p = 0.043), and increase the surgical time (per 10 min increase, OR = 1.010, 95% CI: 1.003-1.017, p = 0.009). We also report that increased age, obesity, and patients undergoing cUD (OR = 1.368, 95% CI: 1.040-1.798; p = 0.025) are associated with thromboembolic events.

Conclusion

By considering the preoperative characteristics of patients, including age, obesity, smoking, congestive heart failure, and hypertension status, urologists may be able to decrease the incidence of MACE in patients undergoing RC. Urologists should aim for lower operative times as this was associated with a decreased risk of thromboembolic events.

Urodynamic Parameters and Continence Outcomes in Asymptomatic Patients with Ileal Orthotopic Neobladder: A Systematic Review and Metanalysis

INTRODUCTION

The orthotopic neobladder is the type of urinary diversion (UD) that most closely resembles the original bladder. However, in the literature the urodynamic aspects are scarcely analysed.

OBJECTIVE

To provide the first systematic review (SR) on the urodynamic (UDS) outcomes of the ileal orthotopic neobladders (ONB). Continence outcomes are also presented.

METHODS

A PubMed, Embase and Cochrane CENTRAL search for peer-reviewed studies on ONB published between January 2001-December 2022 was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement.

RESULTS AND CONCLUSION

Fifty-nine manuscripts were eligible for inclusion in this SR. A great heterogeneity of data was encountered. Concerning UDS parameters, the pooled mean was 406.2 mL (95% CI: 378.9-433.4 mL) for maximal (entero)cystometric capacity (MCC) and 21.4 cmH2O (95% CI: 17.5-25.4 cmH2O) for Pressure ONB at MCC. Postvoid-residual ranged between 4.9 and 101.6 mL. The 12-mo rates of day and night-time continence were 84.2% (95% CI: 78.7-89.1%) and 61.7% (95% CI: 51.9-71.1%), respectively.Despite data heterogeneity, the ileal ONB seems to guarantee UDS parameters that resemble those of the native bladder. Although acceptable rates of daytime continence are reported the issue of high rates of night-time incontinence remains unsolved. Adequately designed prospective trials adopting standardised postoperative care, terminology and methods of outcome evaluation as well as of conduction of the UDS in the setting of ONB are necessary to obtain homogeneous follow-up data and to establish UDS guidelines for this setting.

Secondary tumours in orthotopic neobladder using isolated gut segment post radical cystectomy for urothelial carcinoma: a systematic review

BACKGROUND

Urothelial carcinoma recurrence of an orthotopic neobladder created from bowel segment is a rare occurrence. The usage of bowel segments to create neobladder following cystectomy for urinary diversion is growing yet there still remains a large gap in the literature about recurrence in neobladder. We carry out the first systematic review to outline current details of urothelial cancer recurrences in a neobladder, diagnostic approach, management and long term prognosis.

METHOD

We carried out a systematic review searching databases PubMed (MEDLINE), Scopus and Web of Science. Only studies reporting on urothelial carcinoma recurrence of the neobladder with or without multi-focal disease were reported. A quality assessment tool was utilized to ensure all studies met quality standards.

RESULTS

Fifteen studies were included in the systematic review meeting inclusion criteria. Fourteen of these studies were cases in men where pT3 disease was the most prevalent (29%). The most common symptomology was macroscopic haematuria seen in eight patients (53.33%). Management varied among cases and including adjuvant chemotherapy regimens and surgical interventions consisting of endoscopic resection to robotic neocystectomy and nephroureterectomy. Follow up period for these patients was up to 38 months and 55% of patients did not see a recurrence.

CONCLUSION

The nature of recurrence is hypothesised to be due to seeding of urothelial cells into the non-urothelial surfaces compatible for both implantation and growth. We present the first systematic review to report on recurrence rates and details of diagnosis and outcomes of various management regimes for urothelial carcinoma of the neobladder.

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.

Long-term oncologic and functional outcomes following robot-assisted radical cystectomy and intracorporeal Padua ileal bladder: results from a single high-volume center

PURPOSE

To report long-term oncologic and functional outcomes of a large consecutive single center series of Robot-assisted radical cystectomy (RARC)- intracorporeal (IC) Urinary Diversion (UD), identifying their predicting factors.

METHODS

A single center Bladder cancer (BC) database was queried for "RARC" and "ICUD", including patients treated between January 2012 and September 2020. Kaplan-Meier curves were assessed disease-free (DFS), cancer-specific (CSS) and overall survival (OS) probability. Univariable (UV) and multivariable (MV) analysis were adopted to identify predictors of DFS, CSS and OS. Kaplan-Meier method evaluated day- and night-time continence recovery probabilities; UV and MV analysis were adopted to identify predictors of Day-time continence.

RESULTS

Overall, 251 patients were included. Among them, 192 patients underwent intracorporeal ileal orthotopic neobladder (ION) (76.5%). Five-year DFS, CSS and OS rates were 66.5%, 65.4% and 61.5%; pT stage ≥ 3 and pathologic nodal involvement were identified as negative independent predictors of DFS (HR 2.39, p = 0.001, HR 4.64, p ≤  0.001), CSS (HR 2.20, p = 0.01, HR 3.97, p < 0.001) and OS (HR 2.25, p = 0.005, HR 3.95, p < 0.001). In RARC-ION patients, Trifecta rate was 64.1%. One-year day- and night-time continence rates were 78.6% and 48.3%. Age (HR 0.98, p = 0.03), female gender (HR 0.57, p = 0.008) and complications Clavien grade ≥ 3 (HR 0.55, p = 0.03) were identified as independent predictors of day-time incontinence.

CONCLUSIONS

Long-term oncologic outcomes and their predicting factors seem aligned to the largest historical open series and multi-institutional robotic series data. According to the identified predicting factors undermining a proper achievement of day-time continence, this represents an objective support, in order to properly advice specific sub-group of patients.

Renal function change after radical cystectomy for urothelial carcinoma patients with a solitary kidney may be independent of urinary diversion type

PURPOSE

To compare renal function change by urinary diversion (UD) type (ileal conduit [IC] vs. neobladder [NB]) in patients with a single kidney who underwent radical cystectomy (RC) due to bladder cancer.

MATERIALS AND METHODS

We evaluated the renal function change in 86 patients with a single kidney who underwent RC between January 1999 and August 2022. Renal function was assessed using serum creatinine, serum estimated glomerular filtration rate (eGFR), eGFR difference value (preoperative and follow-up values), and eGFR difference proportion (eGFR difference value/preoperative eGFR) at 1, 3, 6, 12, 24, 36, 48, and 60 months. In addition, multiple definitions of eGFR decline were evaluated: 10 points, 10%, and 20% decline in eGFR. Cox regression models were used to identify risk factors of eGFR decline-free, recurrence-free, overall, and cancer-specific survival rates.

RESULTS

A total of 54 patients (62.8%) underwent IC, whereas 32 (37.2%) underwent NB. Baseline characteristics were similar between the two groups except for age and body mass index. Renal functions over time by various methods did not differ significantly between the IC and NB groups. Furthermore, eGFR decline-free survival rate using different definitions was similar between the IC and NB groups. Overall survival, recurrence-free survival, and cancer-specific-free survival rates were not different between the IC and NB groups.

CONCLUSIONS

UD type (IC vs. NB) did not impact the renal function change of patients with a single kidney who underwent RC. Therefore, patients with a single kidney might be considered to be an indication of NB.

Comparison of the Y-pouch orthotopic neobladder and the Studer technique after radical cystectomy: surgical and functional outcomes from a single-center series

BACKGROUND

To explore a method of constructing an orthotopic ileal neobladder (ONB) in the Y-pouch configuration. We describe the steps followed to create the Y-pouch ileal orthotopic neobladder (ONB) and compared the perioperative, functional, and urodynamics outcomes with the Studer neobladder technique.

METHODS

A retrospective cohort study of 90 bladder cancer patients, who received open radical cystectomy with the ONB performed at a hospital from June 2009 to May 2020. These patients were divided into two groups-the Y-pouch and the Studer neobladder groups. Perioperative, functional outcome, complication, renal function data outcomes, and pressure-volume study were used to evaluate the treatment outcomes after a radical cystectomy.

RESULTS

Ninety patients (54 Studer and 36 Y-pouch neobladder) were enrolled. The median patient age was 62.6 (± 11) years. The mean operative time for the Studer technique was 290 (242.5-350) min, and the Y-pouch technique was 300 (271.2-335) min) (p = 0.826). At 30 days postoperatively, the Clavien-Dindo classification of surgical complications revealed grade-2 urinary infections in two patients (5.6%) and six patients (11.1%) for the Y-pouch and Studer techniques, respectively. Intermediate complications (30-90 days) were reported in 4 (11.1%) and 18 patients (44.4%) in the Y-pouch and the Studer techniques, respectively (p = 0.062). In the urodynamics study (UDS), the Y-pouch group had a mean postvoid residual volume of 20 mL and Studer of 40 ml (p = 0.06). A mean capacity of 462 (380-600) mL compares to the Studer neobladder group with 495 (400-628) mL. The average mean compliance of the Studer group was 35.5 (28-52) ml/cm H₂O and 33 (30-43) ml/cm H₂O for Y pouch, and most patients had > 30 ml/cm H₂O compliance (80/90 patients).

CONCLUSIONS

The Y-pouch neobladder technique in an RC with an orthotopic neobladder provides perioperative and functional outcomes compared to those of the Studer orthotopic neobladder resulting in similar intermediate-term. Therefore, the Y-pouch ileal neobladder is both feasible and safe to be used as a standard neobladder technique for urinary diversion in patients with bladder cancer undergoing radical cystectomy and needs confirmation with long-term results.

Open vs robotic intracorporeal Padua ileal bladder: functional outcomes of a single-centre RCT

PURPOSE

Functional outcomes of robot-assisted (RA) radical cystectomy (RC) with intracorporeal orthotopic neobladder (i-ON) have been poorly investigated. The study aimed to report functional outcomes of a prospective randomized controlled trial (RCT) comparing open RC (ORC) and RARC with i-ON.

METHODS

Inclusion criteria were cT2-4/N0/M0, or BCG-failure high-grade urothelial carcinoma, candidate to RC with curative intent. A covariate adaptive randomization process was used, based on the following variables: BMI, ASA score, haemoglobin levels, cT-stage, neoadjuvant chemotherapy, urinary diversion. Day-time continence was defined as "totally dryness", nigh-time continence as pad wetness ≤ 50 cc. Continence recovery probabilities were compared between arms with Kaplan-Meier method and Cox regression analysis was performed to identify predictors of continence recovery. HRQoL outcomes analysis was assessed with a generalized linear mixed effect regression (GLMER) model.

RESULTS

Out of 116 patients randomized, 88 received ON. Quantitative analysis of functional outcomes reported similar results in terms of day continence, while a better night continence status in ORC cohort was observed. However, 1-yr day- and night-time continence recovery probabilities were comparable. Night-time micturition frequency < 3 h was the only predictor of nigh-time continence recovery. At GLMER, 1-yr body image and sexual functioning were significantly better in RARC cohort, while urinary symptoms were comparable between arms.

CONCLUSION

Despite superiority of ORC at quantitative night-time pad use analysis, we showed comparable day- and night-time continence recovery probabilities. At 1-yr analysis of HRQoL outcomes, urinary symptoms were comparable between arms, while RARC patients reported lower body image and sexual functioning worsening.

Functional evaluation of a spiral neobladder with an angled chimney; A prospective randomized comparative study

OBJECTIVES

to assess the functional outcome of performing ureteric re-implantation to an angled short chimney in a modified spiral orthotopic ileal neobladder.

PATIENTS AND METHODS

From January 2018 to December 2020, 90 male patients with bladder cancer underwent radical cystectomy and spiral ileal neobladder reconstruction with a chimney. Patients were randomly divided in two groups according to the position of the chimney [straight and angled] to which the ureters will be implanted. Postoperative evaluation included clinical, laboratory, radiographic and urodynamic studies.

RESULTS

There were no perioperative deaths. The mean operative time for the procedure was 4.7 ± 1.2 h in group I and 4.9 ± 1.3 h in group II (p 0.456). No intraoperative complications occurred. Early postoperative complications occurred in 8 patients. In group I, according to the modified Clavien system, GII complication occurred in 2 (5%) patients in the form of DVT in 1 (2.5%) and surgical site infection in 1 (2.5%). GIIIa occurred in 3 (7.5%) patients in the form of wound dehiscence. In group II, GII occurred in 2 (4.8%) patients in the form of prolonged urinary leakage and myocardial infarction, each occurred in one patient. GIIIb occurred in 1 (2.4%) patient in the form of intestinal leak. Poucho-ureteral reflux occurred in 10 patients [3 (7.5%) in group I and 7 (16.8%) in group II (p 0.001)].

CONCLUSIONS

The preliminary results of the right sided angled chimney during neobladder reconstruction are safe, acceptable, without an extra time to develop an anti-reflux technique and without an increased incidence of reflux.

Health-related quality of life after curative treatment for muscle-invasive bladder cancer

Muscle-invasive bladder cancer (MIBC) is an aggressive disease for which the gold-standard treatment is radical cystectomy (RC) in combination with cisplatin-based neoadjuvant chemotherapy. Bladder-sparing strategies such as trimodal therapy (TMT) have also emerged to improve health-related quality of life (HRQoL) of patients. However, an improved understanding of the effect of all these treatment modalities on HRQoL is essential to provide personalized patient care. Different combinations of generic, cancer-specific and bladder cancer-specific questionnaires can be used as instruments for HRQoL evaluation in patients with MIBC before and after curative treatments, which can largely affect multiple domains of HRQoL including general health as well as physical, functional, social and emotional well-being. However, diagnosis of MIBC per se is also likely to affect HRQoL, and the perspective of cure after RC or TMT could induce a return to baseline HRQoL values for most of these domains. A considerable amount of data on HRQoL after RC is available, but conflicting results have been reported regarding the effect of urinary diversion (ileal conduit or orthotopic neobladder) and surgical approach (open or robotic surgery) on patient quality of life. Data on HRQoL after TMT are scarce, and additional comparative studies including patients receiving RC (especially using ileal orthotopic neobladder) are needed.

"Bordeaux Neobladder": First Evaluation of the Urodynamic Outcomes

Background

The intracorporeal orthotopic modified-Y "Bordeaux" neobladder (iYNB) was first described in 2016. No urodynamic evaluation of this neobladder has yet been performed.

Objective

To present the urodynamic features of the iYNB and incontinence-specific health-related quality of life (HRQoL) outcomes.

Design setting and participants

We prospectively assessed 26 patients operated between September 2018 and November 2020.

Surgical procedure

Robotic radical cystectomy for malignant disease of the bladder and iYNB, performed by a single surgeon, were used.

Measurements

Three months after surgery and in November 2021, consenting patients underwent clinical evaluation and multichannel urodynamic study (UDS). The incontinence quality of life (I-QoL) questionnaire was used to evaluate HRQoL. Continence was classified into day- and nighttime, and clinically defined as the use of zero pads. A descriptive statistical analysis was performed.

Results and limitations

The mean age at surgery was 65.4 yr. The mean follow-up period was 27 mo (12-38). The mean time for the neobladder reconstruction was 192 min (110-340). The mean maximum capacity was 431 cm3 (range 200-553). The mean postvoid residual was 101.6 ml (0-310), and the rate of clean intermittent catheterization was 17.6%. With the exception of a significant reduction in the volume of the first sensation of bladder fullness, no other statistically significant changes in the UDS parameters of both the storage and the voiding phase were observed over time. Day- and nighttime continence rates were 58.8% and 23.5%, respectively. The mean postoperative I-QoL score was 103.3 (89-110). Limitations include the small number of patients and short follow-up.

Conclusions

The UDS evaluation of iYNB demonstrates that both the volumetric and the pressure characteristics are acceptable and may enhance quality of life. Prospective studies with larger numbers of patients and longer follow-up are needed to further evaluate the iYNB.

Patient summary

The "Bordeaux" neobladder provides acceptable urodynamic outcomes. It is associated with high levels of health-related quality of life and good rates of continence in 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).

Robot-Assisted Laparoscopic Radical Cystectomy and Modified Y-Shaped Ileal Orthotopic Neobladder Reconstruction

Background

Orthotopic neobladder reconstruction has become the preferred method of urinary diversion after radical cystectomy in major medical centers. We performed modified Y-shaped ileal orthotopic neobladder reconstruction and presented the functional results and postoperative complications of the modified surgery.

Methods

We included 21 patients with bladder cancer who underwent radical cystectomy at our center between February 2019 and December 2019. All patients underwent robotic-assisted laparoscopic radical cystectomy and lymph node dissection plus modified Y-shaped ileal orthotopic neobladder reconstruction. We collected the demographic and pathological history of the patients, and perioperative and postoperative functional outcomes and postoperative complications were recorded.

Results

All surgeries were successful and no serious postoperative complications occurred. The mean operative time was 321.43 ± 54.75 min, including 101.67 ± 10.88 min required for neobladder reconstruction. Liquid intake was encouraged about 5 days after surgery, stent and catheter were removed after 13.52 ± 3.28 days, and the patients were discharged 1–2 days after removing the catheter. No ureteral anastomotic and neobladder urethral anastomotic strictures occurred. The volume of the neobladder at 1-year post-surgery was 195.24 ± 16.07 mL and the maximum urinary flow rate was 20.64 ± 2.22 mL/s.

Conclusion

We describe the robotic-assisted modified Y-shaped ileal orthotopic neobladder reconstruction performed at our center, which requires a simple suture and short neobladder construction time, minimizes the occurrence of anastomotic stenosis, facilitates smooth patient emptying, and is clinically scalable and applicable.

Pelvic reconstruction and lateral prostate capsule sparing techniques improve early continence of robot-assisted radical cystectomy with orthotopic ileal neobladder

PURPOSE

To evaluate urinary outcomes of pelvic construction and lateral capsule sparing techniques in robot-assisted radical cystectomy with orthotopic ileal neobladder (RARC-OIN).

METHODS

A total of 107 male patients who underwent RARC-OIN during January 2017 and February 2021 in Sun Yat-sen Memorial Hospital were analyzed retrospectively. Standard RARC-OIN with or without nerve sparing technique was performed in 44 patients (standard group), lateral prostate capsule sparing technique was performed in 20 patients (LCS group), combined pelvic reconstruction (CPR) technique including anterior suspension and posterior reconstruction were performed in 43 patients (CPR group). The urinary function was assessed by the use of pads and the Bladder Cancer Index (BCI). Continence was defined as the use of 0-1 pad during daytime or night-time.

RESULTS

There was no statistical difference between the three groups regarding demographic, perioperative, and pathological data. Continence rates were 6.8, 50.0 and 34.9% for daytime, 4.6, 40.0 and 32.6% for night-time in the standard group, LCS group and CPR group at 1 month post-operation, respectively. Continence rates were 34.1, 80.0 and 69.8% for daytime, 27.3, 75.0 and 65.1% for night-time in the standard group, LCS group and CPR group at 3 month post-operation, respectively. No statistically significant difference was observed in the daytime and night-time continence rates at 12 months.

CONCLUSIONS

Lateral capsule-sparing and combined pelvic reconstruction techniques are feasible to improve early daytime and night-time continence rates in RARC with orthotopic neobladder.

CLINICAL TRIAL REGISTRATION

The trial registration number: ChiCTR2100047606.

Stoma-related complications and emergencies

Stoma creations are common procedures in surgical specialties. They can be created either as a temporary or a permanent measure. Despite advancements in surgical technique and stoma care, complications are common. Patients experiencing stoma-related complications often present to the emergency department. Emergency physicians are not expected to be stoma experts, yet they are often the first point of contact for patients experiencing stoma-related complications. Accordingly, emergency physicians should be familiar with the types of stomas and complications and emergencies associated with them so that they can appropriately address the problems related to stomas. This article will provide a review of emergencies and complications associated with ileostomies, colostomies, and urostomies.

Cognitive function in patients undergoing cystectomy for bladder cancer – results from a prospective observational study

Background:

Impaired cognitive function of bladder cancer patients plays a role in coping with the kind of urinary diversion and may impact perioperative morbidity. In this study we therefore aimed to assess the prevalence of mild cognitive impairment in patients undergoing radical cystectomy. Secondary objectives included correlation of common cognition tests, assessment of the admitting physician, and perioperative complication rates.

Methods:

Patients undergoing radical cystectomy for bladder cancer were prospectively screened by neuropsychological tests including cognition tests [DemTect (Dementia Detection test), MMSE (Mini-Mental State Examination), clock drawing test] prior to surgery. Besides, clinical characteristics and perioperative outcomes were documented. Frequency of mild cognitive impairment as assessed by DemTect was correlated with the results of MMSE and clock drawing test, the occurrence of anxiety and depression, the assessment of the admitting physician, and perioperative complication rates as calculated by Spearman rank correlation coefficient. Comparative analysis (parametric and nonparametric) of patient characteristics (nonpathological versus pathological DemTect suggestive of mild cognitive impairment) was performed.

Results:

A total of 51 patients (80% male, median age 69 years) were analyzed. DemTect was suspicious of mild cognitive impairment in 27% (14/51) of patients, whereas MMSE and clock drawing test showed pathological results only in 10/51 and 6/51 patients, respectively. We found no correlation between mild cognitive impairment and anxiety/depression status. In all, 5/20 patients (25%) with suspicious DemTect results were considered suitable for a continent diversion neobladder by the admitting physician. Suspicious DemTect results were predictive for higher perioperative complication rates (29% versus 5%). Study limitations include small sample size and missing long-term follow-up.

Conclusions:

Mild cognitive impairment was observed in more than a quarter of radical cystectomy patients prior to surgery. Preoperative assessment should be supplemented by neuropsychological testing such as the DemTect as mild cognitive impairment is often underestimated and associated with significantly higher perioperative complication rates.

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center

INTRODUCTION

Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes.

MATERIAL AND METHODS

Descriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t-test for independent groups or Mann-Whitney test. Statistical significance if P < .05.

RESULTS

The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Uretericre implantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%).

CONCLUSION

Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Orthotopic bladder substitution: Surgical aspects and optimization of outcomes

Objectives

Orthotopic bladder substitution (OBS) is a management option for urinary diversion in men and women undergoing cystectomy. The aim of the procedure is to provide a functional continent urinary reservoir of adequate capacity, compliance and low pressure. We have provided a narrative review of the existing literature and highlighted areas where improvement and standardization can be recommended.

Methods

Literature search included database search for publications from January 1970 to November 2020, using keywords including OBS, bladder reconstruction, neobladder, radical cystectomy, robotic cystectomy, intracorporeal neobladder, surgical technique, patient selection and outcomes.

Results

Due to various factors including indications, operative technique and risk of complications, OBS is an enormous undertaking and commitment for patients, surgeons and health professionals involved in the care pathway. The main considerations for patient selection, the technical elements of the procedure and the rationale behind these are discussed. Previously considered to be a choice for a select few, the inclusion criteria have expanded over the last decade. Similarly, surgical techniques including the choice and configuration of bowel segments, construction of anastomosis and nerve or organ sparing procedures have evolved over the years. Minimally invasive laparoscopic and robotic assisted surgery has added further perspectives to the existing literature on OBS. Understanding the principles of operative techniques and assessing the best evidence to influence patient management is crucial as it has a major impact on clinical outcomes. Peri- and post-operative care, focused on the prevention of complications and morbidity, affects long-term functional and oncological outcomes, which ultimately dictates the quality of life.

Conclusions

This concise overview of OBS literature highlights the importance of pre-operative, peri-operative, and post-operative aspects with regards to the optimization of patient care. To achieve the best results, meticulous attention should be paid in all these areas, surgical and multi-disciplinary. Patient education and counseling, with shared decision making are central to the success of the procedure.

Spectrum of imaging manifestations of tumour recurrences in orthotopic neobladder

Continent diversion with orthotopic neobladder is the most upcoming form of urinary diversion postradical cystectomy. This allows patients to void through the native urethra preserving the maximal quality of life. These patients with greater life expectancies increasingly present with a wide range of late complications, which also include local recurrences involving neobladder. Such presentations on surveillance scans can be challenging for radiologists unfamiliar with expected post-surgical anatomy and usual sites of local recurrences. Tumour in neobladder, although rare, has predilection concerning specific sites of involvement and few distinct histological types. Major subtypes of such recurrences with corresponding radiological features on multimodality imaging have been discussed in this article. Management of such cases with revision of diversions is challenging, and surgeons expect a meticulous read of such scans before contemplating pelvic clearance and secondary diversions. This pictorial review aims to appraise the literature related to various primary and secondary types of tumours involving reservoir and anastomotic sites in an orthotopic neobladder, their relative incidences and illustrate salient imaging points with case examples.

Technique selection of ureteroileal anastomosis in hautmann ileal neobladder with chimney modification: Reliability of patient-based selection strategy and its impact on ureteroentric stricture rate

OBJECTIVE

We aimed to establish the reliability of technique selection strategy for ureteroileal anastomosis (Bricker vs. Wallace) by comparing perioperative outcomes, complications, and anastomotic stricture rate in a contemporary series of patients who underwent open radical cystectomy followed by reconstruction of modified Hautmann neobladder.

MATERIALS AND METHODS

A total of 60 patients underwent radical cystectomy and modified Hautmann neobladder, of whom 30 patients (group I) with Bricker anastomotic technique were compared to 30 matched paired patients with end-to-end ureteroileal anastomosis (group II). Long-term results, including ureteroileal stricture (UIS) and postoperative complication rate at two year follow up were available. The choice of anastomosis type was successively based on chimney size, ureteral length after retro-sigmoidal tunneling and diameter of distal ureter. Postoperative complications were graded according to the Clavien-Dindo system.

RESULTS

Ureteroileal stricture rate was 6.6% in group I vs. 0% in group II, after three months (p < 0.05), while anastomotic leakage rate was 6.6% vs. 3.3% (group I vs group II) between the two groups for the same follow up period (p > 0.05). High-grade complications (Clavien III-V) were more in Bricker group as compared to Wallace group and the difference was significant (20% vs 10.3%, p = 0.03).

CONCLUSION

Our preliminary outcomes demonstrate that this selection strategy seems to be clinically reliable, with lower incidence of postoperative complications in Wallace group.

The impact of orthotopic reconstruction on female sexuality and quality of life after radical cystectomy for non-malignant bladder conditions

OBJECTIVE

To review the literature on the impact on female quality of life and sexual function of orthotopic reconstruction after radical cystectomy for non-malignant bladder conditions. Radical cystectomy is commonly required to treat malignant conditions but may also be considered for the treatment of non-malignant diseases. These heterogeneous group of disorders includes interstitial cystitis, painful bladder syndrome, neurogenic bladder, haemorrhagic/ radiation cystitis, endometriosis and refractory genitourinary fistula. Treatment begins with non-invasive medical therapies but, in non-responder cases, a surgical solution should be considered. Such invasive techniques include urinary diversion and reconstructive procedures that have an impact on healthrelated quality of life, physical, social, and mental status.

MATERIALS AND METHODS

This narrative review research was done using the PubMed database up until 2020, July. All papers referring to cystectomy for benign indication were considered.

RESULTS

In comparison to other reconstructive options, orthotopic neobladder allows the restoration of a normal self-image and consequently it is the most suitable procedure when a surgical reconstruction is necessary for non-malignant conditions. However, women can face many disorders that impact on everyday life, such as voiding dysfunction or sexual activity problems.

CONCLUSIONS

Scant data is available about quality of life, sexual life and self-perception in women treated by cystectomy for benign conditions and most literature is dedicated to those indicators in cancer patients. More research is needed to understand the tolerability and the quality of life results of the female population affected by benign conditions undergoing this kind of surgical approach.

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center

INTRODUCTION

Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes.

MATERIAL AND METHODS

Descriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t test for independent groups or Mann-Whitney test. Statistical significance if P<.05.

RESULTS

The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Ureteric reimplantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%).

CONCLUSION

Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Patient-reported outcomes and health-related quality of life after urinary diversions

PURPOSE OF REVIEW

To study the recent literature on health-related quality of life (HRQOL) in patients after radical cystectomy followed by urinary diversion.

RECENT FINDINGS

General consensus regarding, which urinary diversion is superior in terms of HRQOL has not been reached. Although there is an increase in studies favoring the orthotopic neobladder, overall quality of these studies is poor. Other studies suggest that HRQOL outcomes in different types of urinary diversions is similar and that other factors, such as age, comorbidities and sex are more important instead. Patient choice, in consultation with the treating surgeon should be the determinant of which urinary diversion is performed. Furthermore, sexual function can play an important role in HRQOL. However, practice shows that counselling on the option of sexual-preserving techniques is still not implemented in routine clinical practice. Furthermore, studies regarding differences in HRQOL after urinary diversion between male and female individuals are lacking.

SUMMARY

Thorough preoperative counselling on the different types of urinary diversion and options for sexual-preserving techniques decreases decision regret and increases HRQOL in patients after radical cystectomy.

Orthotopic urinary diversions after radical cystectomy for bladder cancer: lessons learned last decade

PURPOSE OF REVIEW

Orthotopic urinary diversion (OUD), or neobladder, is believed to be the gold standard for surgical bladder reconstruction following radical cystectomy though it is performed far less often than ileal conduits. As both a continent and intracavitary diversion, OUDs offer unique advantages for patients. Their utilization has decreased overall though, especially with the advent of robotic surgery. In this review, we will cover patient selection for OUD, functional outcomes (i.e., continence, sexual activity, quality of life [QoL]), and robotic orthotopic diversions.

RECENT FINDINGS

OUDs have seen a proportionally greater decline in utilization compared with ileal conduits as the number of robotic radical cystectomies being performed with intracorporeal diversions increases. Multiple robotic series have demonstrated less perioperative blood loss and shorter hospital stays when compared with the open approach though operative times are longer, the learning curve is steeper, and overall costs may be higher in some settings. Perioperative safety and short-term oncological outcomes appear comparable. Since robotic OUDs are relatively new, functional outcomes are not yet well established. Patient satisfaction with urinary diversion is associated with informed decision-making tailored to the patient. A thorough understanding of expected short- and long-term functional outcomes and the care required to maintain an OUD improves QoL and satisfaction with diversion choice.

SUMMARY

Given the potential advantages of OUD, its decreasing use is a remarkable trend. Shared decision-making and a patient-centered approach should be used when selecting the type of urinary diversion.

Surgical management of urinary diversion and stomas in adults: multidisciplinary Italian panel guidelines

BACKGROUND

Urinary stomas represent a worldwide medical and social problem. Data from literature about stoma management are extensive, but inhomogeneous. No guidelines exist about this topic. So, clear and comprehensive clinical guidelines based on evidence-based data and best practice are needed. This article aims to elaborate guidelines for practice management of urinary stomas in adults.

METHODS

Experts guided review of the literature was performed in PubMed, National Guideline Clearing-house and other databases (updated March 31, 2018). The research included guidelines, systematic reviews, meta-analysis, randomized clinical trials, cohort studies and case reports. Five main topics were identified: "stoma preparation", "stoma creation", "stoma complications", "stoma care" and "stoma reversal". The systematic review was performed for each topic and studies were evaluated according to the GRADE system, AGREE II tool. Recommendations were elaborated in the form of statements with an established grade of recommendation for each statement. For low level of scientific evidence statements a consensus conference composed by expert members of the major Italian scientific societies in the field of stoma management and care was performed.

RESULTS

After discussing, correcting, validating, or eliminating the statements by the experts, the final version of the guidelines with definitive recommendations was elaborated and prepared for publication. This manuscript is focused on statements about surgical management of urinary stomas. These guidelines include recommendations for adult patients only, articles published in English or Italian and with complete text available.

CONCLUSIONS

These guidelines represent the first Italian guidelines about urinary stoma multidisciplinary management with the aim to assist urologists and stoma specialized nurses during the urinary stoma management and care.

[Muscle-invasive bladder cancer]

Bladder cancer, which is a complex disease, can be treated with a variety of stage-oriented treatment options. In this article, the treatment recommendations of the German S3 guideline "Early detection, diagnosis, treatment and aftercare of bladder cancer" are applied in a fictitious case study. In a patient with invasive transitional cell carcinoma, the treatment options-ranging from bladder preservation to radical cystectomy with neoadjuvant chemotherapy-are discussed on the basis of the current literature.

Functional results of hautmann neobladder with chimney modification and wallace ureteroileal anastomosis: initial experience with 22 patients

OBJECTIVE

To assess the functional outcomes and complications of modified Hautmann neobladder with Wallace ureteroileal anastomosis on a 6-8 cm long isoperistaltic chimney, following radical cystectomy.

MATERIALS AND METHODS

Between January 2015 and October 2019, 22 patients (18 men and 4 women) underwent radical cystectomy and Hautmann neobladder reconstruction with chimney modification and Wallace I ureteroileal anastomosis. The mean age of patients was 61 years (45-74 years). All procedures were performed by the same surgeon and the mean follow-up was 29.4 months. Complications were registered as early (occurring within 3 months) or late (occurring after 3 months), with particular attention addressed to the ureteroileal anastomotic stricture and anastomotic leakage rate. Patient evaluation also included symptom analysis for daytime continence and voiding frequency.

RESULTS

Ureteroileal anastomotic stricture was not detected as a cause of hydronephrosis. Hovewer, the anastomotic leakage occurred in one patient during the early postoperative period. Early complications occurred in 9 patients and the most common was bilateral hydronephrosis, detected in 5 examinees. Late complications occurred in 4 patients. Complete daytime and nighttime continence achieved in 18 and 16 patients respectively, with two patients (9%) still required intermittent catheterization three months after surgery.

CONCLUSIONS

The functional results with modified Hautmann neobladder, incorporating short afferent limb in Wallace I uretero-enteric anastomosis, were efficient. This technique is an effective way to minimize potential uretero-enteric stricture, anastomotic leakage and incidence of vesicoureteral reflux.

Orthotopic MAINZ pouch bladder substitution - long-term follow-up

INTRODUCTION

After radical cystectomy, orthotopic neobladder is one surgical strategy for urinary diversion. To assess the usefulness of an operation, long-term data are essential. We examined long-term complications and continence rates of orthotopic ileocecal (MAINZ pouch) bladder substitution.

MATERIAL AND METHODS

Between 1986 and 2011, 193 patients underwent orthotopic MAINZ pouch bladder substitution. Until July 2000, ureter implantation was performed into the ascending colon through a submucosal tunnel technique (Goodwin-Hohenfellner). After July 2000, ureters were implanted into the terminal Ileum using the ileocecal valve to prevent reflux: the left spatulated ureter by an end-to-end (Wallace) and the right ureter by an end-to side technique (Nesbit). Surgical and medical follow-up reports were evaluated and a recent follow-up was obtained by a questionnaire.

RESULTS

Median follow-up in 183 patients was 72 months (1-336). A total of 74 patients (38%) died during the follow-up. A surgical intervention was required in 26 out of 193 patients with early complications while 45 out of 183 patients had late and 17 patients had both, early and late complications. Ureteral stenosis was found in 13% of submucosal implanted ureters, 13% with the Wallace technique, and 3.6% with the Nesbit technique. In total, 66 patients responded to the questions concerning long-term continence (minimal follow-up >2 years). Overall, 84.8% were completely continent, 1.6%, reported grade I and 9.8% grade II stress incontinence.

CONCLUSIONS

The long-term continence and complication rates are comparable to those of other types of orthotopic bladder substitution. Orthotopic MAINZ pouch procedure can be considered as one of the options for orthoptic diversion, which stands the test of time.

Perioperative and Pathological Outcome of Nerve-Sparing Radical Cystectomy With Ileal Neobladder

Purpose: So far, it has not been described whether the perioperative course and the pathologic outcome of patients who undergo radical cystectomy (RC) with orthotopic bladder substitution differs if nerve sparing (NS) is performed or not. Material and Methods: In all, there were 472 patients who underwent RC between 2012 and 2019 at our department. We performed a retrospective analysis of 116 patients who underwent RC with ileal neobladder. We analyzed perioperative complications according to the Clavien-Dindo classification system, as well as the pathological outcome. Results: Of 116 patients, 68 (58.6%) underwent RC, and 48 (41.4%) underwent NS RC. Clavien-Dindo complications ≥3b occurred in 15 (12.9%) of all patients. Only infectious complications differed among the groups [NS RC: 25 patients (52.1%) vs. RC: 20 patients (29.4%); p = 0.02]. There was no significant difference concerning tumor stage. Concomitant Cis was present in 24 patients (35.3%) of the RC group and in 27 patients (56.3%) of the NS RC group (p = 0.036). Nodal status and positive surgical margin status of the bladder tumor did not differ among the groups. In all, 42 of all male patients (45.7%) had an incidental prostatic carcinoma. Positive surgical margins concerning the prostate carcinoma occurred in six patients, with all cases in the RC group (p = 0.029). Conclusions: Our data suggest that performing NS during RC in carefully selected patients is a safe procedure and does not impair perioperative outcome. Pathological outcome of NS RC is comparable as well.

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.

A Modified Neobladder Technique: The "I-Pouch" - Illustration of Surgical Approach and Tricks

OBJECTIVE

Various techniques for orthotopic neobladder (ONB) are currently used and have shown satisfactory oncological and functional outcomes.³ Among the relevant oncological and functional aspects for long-term follow up is the easy accessibility of the upper urinary tract in urinary diversion for endoscopic monitoring. In addition, variety exists in the amount of ileum needed to create a urinary reservoir. Depending on the ONB technique, up to 60 cm of ileum are required, and bowel dysfunction may be a consequence especially when the ileocecal valve is used for the urinary diversion. We previously reported the technique, functional and oncologic results of the I-pouch, a modified ONB made of 40 cm of ileum, combining an antirefluxive ureter implantation technique with easy access to the uretero-intestinal anastomosis.^1,2 The present video is intended to illustrate key surgical steps and pitfalls during the procedure.

METHODS

The technique, surgical tips, and functional results in a as compared to a institutional control group receiving conventional Studer -Pouch-procedure are outlined.

RESULTS

In a follow up series of 33 I-pouch and 23 S-pouch patients, there were no differences according to ONB type for 30-day major- (P = .33) and minor (P = 0.96) complication rates although 90-day major (P = 0.08) and minor (P = 0.08) complication rates tended to be associated with less complications in I-pouch patients.

CONCLUSION

The I-pouch can be used for neobladder substitution providing easy access to the upper urinary tract, reduced demand of ileum length along with a complication profile not distinct from Studer neobladder formation.

Robot-assisted radical cystectomy with intracorporeal neobladder: impact of learning curve and long-term assessment of functional outcomes

BACKGROUND

There is paucity of data about functional outcomes of Robot-assisted Radical Cystectomy (RARC) with intracorporeal orthotopic neobladder (ICON), and the impact of learning curve (LC) on those outcomes remains to be addressed. The aim of this study was to report long-term functional outcomes of our single center series of RARC with ICON, assessing the role of LC in their achievement.

METHODS

Patients treated with Robot assisted radical cystectomy with intracorporeal orthotopic neobladder in our center between January 2012 and August 2019 were retrospectively analyzed. Preoperative, clinical, perioperative, pathologic and functional data were reported. The first cases were divided in tertiles, for assessing the impact of learning curve on the outcomes evaluated. Long-term functional outcomes of the whole cohort were evaluated.

RESULTS

Overall, 167 patients were included. Concerning tertiles analysis, operative time (P<0.001), incidence of low (P=0.002) and high grade (P=0.001) complications and hospital stay (P=0.04) decreased significantly over time. Day-time continence recovery probability was significantly lower in the initial case series (1-yr rate 68.4%, 87% and 89.8 for I, II and III tertile, respectively; P=0.04;). Accordingly, Trifecta achievement was significantly higher in II and III tertiles (P=0.01). At a median follow- up of 34 months, the incidence of significant renal function deterioration of the whole cohort was 16.7%. Overall, 12, 24 and 60-mo day-time continence rates were 74.8%, 82.7% and 82.7%.

CONCLUSIONS

Patients treated at the beginning of the learning curve show worse perioperative and functional results. Once standardized the procedure, complications rates, hospital stay, and day-time continence recovery experienced a significant improvement. At a long-term analysis of functional outcomes of our patients, renal function preservation and continence recovery results are encouraging.

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.

Continent diversion: five decades of developments and evolution

OBJECTIVE

To provide a chronological overview of the evolution of continent urinary diversion (CUD) over the last 50 years and to highlight important milestones.

METHODS

We performed an extensive literature review and analysed different forms of urinary diversion worldwide. After the evaluation of surgical techniques, we assessed the advantages and disadvantages of assorted CUD approaches based on published long-term follow-up data.

RESULTS

A wide variety of surgical options for CUD is available and feasible to date, although consensus among urologists regarding the 'gold standard' is still lacking. Several forms of orthotopic bladder substitutes and continent cutaneous urinary reservoirs have been shown to provide excellent long-term results.

CONCLUSION

The last 50 years of CUD have seen constant evolution and refinement of techniques, but the best surgical approach remains unclear and there is no 'one-size-fits-all' option, but rather tailor-made approaches are necessary to ensure patient satisfaction.

The impact of orthotopic neobladder vs ileal conduit urinary diversion after cystectomy on the survival outcomes in patients with bladder cancer: A propensity score matched analysis

BACKGROUND

Bladder cancer (BCa) is the most common urinary malignancy. The standard surgical treatment for patients with muscle-invasive BCa is cystectomy plus urinary diversion. Ileal conduit (IC) or orthotopic neobladder (ON), which have different indications, are the most commonly performed urinary diversions.

METHODS AND MATERIALS

We sampled 5480 BCa patients from the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2015. Kaplan-Meier method with the log-rank test was used to assess cancer-specific survival (CSS) and overall survival (OS). Univariate and multivariate Cox's proportional hazard model was conducted to evaluate the hazard ratio of cancer-specific mortality and all-cause mortality before and after propensity score matching (PSM).

RESULTS

We identified 5480 patients who received radical cystectomy (RC) plus IC (n = 5071) or ON (n = 409) with a median follow-up period of 33 months (interquartile range, 13-78 months). Patients in the ON group tended to be male and younger, with a higher percentage of married individuals, early pathological T stage, lymphadenectomy, and non-radiotherapy (all P < .05). After 1:1 PSM, 409 matched pairs were selected. Univariate and multivariate analysis showed that the ON group had better CSS and OS probabilities than the IC group in the overall cohort [hazard ratio (HR): 0.692, 95% confidence intervals (CI): 0.576-0.831, P < .001; HR: 0.677, 95% CI: 0.579-0.793, P < .001 respectively]. However, subgroup analysis revealed that only patients with pathological T2 stage benefited from ON diversion after PSM in the context of CSS (P = .016) and OS (P <.001).

CONCLUSIONS

Young, married, and male patients with early pathological T stage, especially T2 stage, were more suitable to receive RC plus ON surgery, which could improve their probability of survival.

Validation of the effectiveness of a modified Studer orthotopic neobladder in a single center after 3 years of its application

INTRODUCTION AND OBJECTIVE

In this study, we reported the 2 years outcomes of orthotopic neobladder diversion according to the Studer modified technique described by Bianchi G. et al. This technique improves the stability of the reservoir and the urine-storage capacity. After radical cystectomy, urinary diversion is created with a spheroidal-shaped reservoir with a conic distal-part, obtained with 40 cm detubulized ileal segment, and a 15 cm of tubular afferent limb, where a Wallace ureteral anastomoses is made. The conic distal part of the neobladder that is anastomized to the urethral stump. After the reconstructive part, the neobladder and the afferent limb are attached to the elevator ani and psoas muscles, respectively.

MATERIALS AND METHODS

In all, 18 patients underwent radical cystectomy with the reconstruction of urinary diversion with the Modified-Studer Orthotopic technique, at S. Giuseppe Hospital. We studied the post-operative years of follow-up, especially with anamnesis of lower urinary tract, axial computerized tomography, and blood tests, according to the EAU guidelines.

RESULTS

We discover with TC 2 cases of low-grade bilateral hydronephrosis, associated with a slight increase in creatinine levels (1.4-1.8 mg/dL). No stricture at the neobladder-urethral anastomosis was detected. Three patients complain daytime urinary incontinence; only two patients report nocturnal urinary incontinence. One patient underwent ureteroscopy for lithiasis and 1 patient died for non-onco-urological disease.

CONCLUSION

The modifications we applied to the Studer-Neobladder seems to improve urinary tract restoration, potentially decreasing long-term complications like hydronephrosis connected to ureteral anastomotic stenosis (11.1% vs 16.9% reported in literature) and urinary retention (0% vs 12% reported in literature). However, we discovered the same risk of diurnal and nocturnal incontinence reported in literature for the classic Studer Neobladder.

The effect of urinary diversion on long-term kidney function after cystectomy

OBJECTIVES

Cystectomy with urinary diversion is associated with decreased long-term kidney function due to several factors. One factor that has been debated is the type of urinary diversion used: ileal conduit (IC) vs. neobladder (NB). We tested the hypothesis that long-term kidney function will not vary by type of urinary diversion.

METHODS AND MATERIALS

We retrospectively identified all patients who underwent cystectomy with urinary diversion at our institution from January 1, 2007, to January 1, 2018. Data were collected on patient demographics, comorbid conditions, perioperative radiotherapy, and complications. Creatinine values were measured at several time points up to 120 months after surgery. Glomerular filtration rate (GFR) (ml/min per 1.73 m²) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed model with inverse probability of treatment weighting (IPTW) was used to compare GFR between the IC and NB cohorts over time. Multiple sensitivity analyses were performed based on 2 different calculations of GFR (Chronic Kidney Disease Epidemiology Collaboration equation vs. Modification of Diet in Renal Disease), with and without excluding patients with preoperative GFR less than 40 ml/min per 1.73 m².

RESULTS

Among 563 patients who underwent cystectomy with urinary diversion, a NB was used for 72 (12.8%) individuals. Patients who had a NB were significantly younger, had a lower American Society of Anesthesiologists score, greater baseline GFR, better Eastern Cooperative Oncology Group performance status, lower median Charlson comorbidity index, and were less likely to have received preoperative abdominal radiation (all P < 0.05). Both NB and IC patients had decreased kidney function over time, with mean GFR losses at 5 years of 17% and 14% of baseline values, respectively. The IPTW-adjusted linear mixed model revealed that IC patients had slightly more deterioration in kidney function over time, but this was not statistically significant (estimate, 0.12; P = 0.06). The sensitivity analyses yielded a similar trend, in that GFR decrease appeared to be greater in the IC cohort. This trend was statistically significant when using Modification of Diet in Renal Disease (P = 0.04).

CONCLUSIONS

Among highly selected patients with an NB, deterioration of kidney function may potentially be lower over time than among IC patients. However, the statistical significance varied between analyses and we cautiously attribute these observed differences to patient selection.

European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines

CONTEXT

This overview presents the updated European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC).

OBJECTIVE

To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment.

EVIDENCE ACQUISITION

A broad and comprehensive scoping exercise covering all areas of the MMIBC guideline has been performed annually since its 2017 publication (based on the 2016 guideline). Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries, resulting in yearly guideline updates. A level of evidence and a grade of recommendation were assigned. Additionally, the results of a collaborative multistakeholder consensus project on advanced bladder cancer (BC) have been incorporated in the 2020 guidelines, addressing those areas where it is unlikely that prospective comparative studies will be conducted.

EVIDENCE SYNTHESIS

Variant histologies are increasingly reported in invasive BC and are relevant for treatment and prognosis. Staging is preferably done with (enhanced) computerised tomography scanning. Treatment decisions are still largely based on clinical factors. Radical cystectomy (RC) with lymph node dissection remains the recommended treatment in highest-risk non-muscle-invasive and muscle-invasive nonmetastatic BC, preceded by cisplatin-based neoadjuvant chemotherapy (NAC) for invasive tumours in "fit" patients. Selected men and women benefit from sexuality sparing RC, although this is not recommended as standard therapy. Open and robotic RC show comparable outcomes, provided the procedure is performed in experienced centres. For open RC 10, the minimum selected case load is 10 procedures per year. If bladder preservation is considered, chemoradiation is an alternative in well-selected patients without carcinoma in situ and after maximal resection. Adjuvant chemotherapy should be considered if no NAC was given. Perioperative immunotherapy can be offered in clinical trial setting. For fit metastatic patients, cisplatin-based chemotherapy remains the first choice. In cisplatin-ineligible patients, immunotherapy in Programmed Death Ligand 1 (PD-L1)-positive patients or carboplatin in PD-L1-negative patients is recommended. For second-line treatment in metastatic disease, pembrolizumab is recommended. Postchemotherapy surgery may prolong survival in responders. Quality of life should be monitored in all phases of treatment and follow-up. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastatic/.

CONCLUSIONS

This summary of the 2020 EAU MMIBC guideline provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice.

PATIENT SUMMARY

The European Association of Urology Muscle-invasive and Metastatic Bladder Cancer (MMIBC) Panel has released an updated version of their guideline, which contains information on histology, staging, prognostic factors, and treatment of MMIBC. The recommendations are based on the current literature (until the end of 2019), with emphasis on high-level data from randomised clinical trials and meta-analyses and on the findings of an international consensus meeting. Surgical removal of the bladder and bladder preservation are discussed, as well as the use of chemotherapy and immunotherapy in localised and metastatic disease.

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

Background

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

Case presentation

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

Conclusions

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

Refinement Surgical Technique, and Perioperative and Functional Outcomes in Patients With Robotic Intracorporeal Hautmann Orthotopic Neobladder

OBJECTIVE

To illustrate our refinement technique for robotic intracorporeal orthotopic Hautmann neobladder with adherence to open surgical principles and evaluate perioperative and functional outcomes.

PATIENTS AND METHODS

Robot-assisted radical cystectomy with intracorporeal Hautmann orthotopic neobladder was performed by the same surgeon in 40 patients with bladder cancer from November 2017 to March 2019. Baseline demographics, pathologic data, 90-day complications, and functional outcomes at both 6 and 12 months were evaluated with questionnaire and urodynamic analysis.

RESULTS

Median follow-up was 14 months (range 4-20). Median operative time was 320 (230-500) minutes, and the estimated blood loss was 300 (100-2000) mL. No conversion to the open technique was reported. The overall 90-day complication rate was 45%, and the high-grade complication rate was only 10%. The daytime satisfactory continence rate was 90% at both 6 months (30 patients) and 12 months (20 patients), while the night-time satisfactory continence rate was 76.7% and 80.0% at 6 months and 12 months, respectively. One patient underwent clean intermittent catheterization. The cohort had minimal postvoid residual volume, normal compliance, and a mean capacity of 328.7 cm³ (range 170-500) at 6 months postoperatively.

CONCLUSION

Our preliminary data indicate that robotic intracorporeal Hautmann neobladder configuration is a feasible surgical technique and can achieve a low pressure and sufficient capacity for satisfactory early voiding patterns. Refinement of the stepwise process can effectively decrease the time of the operation. Long-term functional and oncological outcomes remain to be evaluated with longer follow-up and more cases.