Urinary diversion: options, patient selection, and outcomes

Biomaterials assisted reconstructive urology: The pursuit of an implantable bioengineered neo-urinary bladder

Urinary bladder is a dynamic organ performing complex physiological activities. Together with ureters and urethra, it forms the lower urinary tract that facilitates urine collection, low-pressure storage, and volitional voiding. However, pathological disorders are often liable to cause irreversible damage and compromise the normal functionality of the bladder, necessitating surgical intervention for a reconstructive procedure. Non-urinary autologous grafts, primarily derived from gastrointestinal tract, have long been the gold standard in clinics to augment or to replace the diseased bladder tissue. Unfortunately, such treatment strategy is commonly associated with several clinical complications. In absence of an optimal autologous therapy, a biomaterial based bioengineered platform is an attractive prospect revolutionizing the modern urology. Predictably, extensive investigative research has been carried out in pursuit of better urological biomaterials, that overcome the limitations of conventional gastrointestinal graft. Against the above backdrop, this review aims to provide a comprehensive and one-stop update on different biomaterial-based strategies that have been proposed and explored over the past 60 years to restore the dynamic function of the otherwise dysfunctional bladder tissue. Broadly, two unique perspectives of bladder tissue engineering and total alloplastic bladder replacement are critically discussed in terms of their status and progress. While the former is pivoted on scaffold mediated regenerative medicine; in contrast, the latter is directed towards the development of a biostable bladder prosthesis. Together, these routes share a common aspiration of designing and creating a functional equivalent of the bladder wall, albeit, using fundamentally different aspects of biocompatibility and clinical needs. Therefore, an attempt has been made to systematically analyze and summarize the evolution of various classes as well as generations of polymeric biomaterials in urology. Considerable emphasis has been laid on explaining the bioengineering methodologies, pre-clinical and clinical outcomes. Some of the unaddressed challenges, including vascularization, innervation, hollow 3D prototype fabrication and urinary encrustation, have been highlighted that currently delay the successful commercial translation. More importantly, the rapidly evolving and expanding concepts of bioelectronic medicine are discussed to inspire future research efforts towards the further advancement of the field. At the closure, crucial insights are provided to forge the biomaterial assisted reconstruction as a long-term therapeutic strategy in urological practice for patients' care.

Complications of Ileal Conduits after Radical Cystectomy: Interventional Radiologic Management

Since their introduction into clinical practice in the 1950s, ileal conduits have been the most common type of urinary diversion used after radical cystectomy worldwide. Although ileal conduits are technically simpler to construct than other forms of urinary diversion, a variety of complications can occur in the early and late postoperative periods. Early complications include urine leakage, urinary obstruction, postoperative fluid collection (eg, urinoma, hematoma, lymphocele, or abscess), and fistula formation. Late complications include ureteroileal anastomotic stricture, stomal stenosis, conduit stenosis, and urolithiasis. Although not directly related to ileal conduits, ureteroarterial fistula can occur in patients with an ileal conduit. Interventional radiologists can play a pivotal role in diagnosis and management of these complications by performing image-guided minimally invasive procedures. In this article, the authors review the surgical anatomy of an ileal conduit and the underlying pathophysiology of and diagnostic workup for complications related to ileal conduits. The authors also discuss and illustrate current approaches to interventional radiologic management of these complications, with emphasis on a collaborative approach with urologists or endourologists to best preserve patients' renal function and maintain their quality of life. ^©RSNA, 2020.

Assessment of health-related quality of life of male patients with ileal orthotopic neobladder compared to cutaneous ureterostomy

Introduction

The aim of this article was to compare patients' health-related quality of life (HR-QoL) outcomes between ileal orthotopic neobladder (IONB) and standard bilateral cutaneous ureterostomy (CU) using validated diversion-specific HR-QoL questionnaires.

Material and methods

This study utilized a retrospective cohort design, including all male patients who underwent open radical cystectomy with either IONB or CU from January 2010 until December 2017. In total, 69 and 57 male patients with a minimum of 12 months of follow-up were included in each group respectively, after applying the following exclusion criteria: female, pre- and postoperative radio- and chemotherapy and palliative surgery. For every patient, HR-QoL was evaluated using the European Association of Research and Treatment of Cancer Quality of Life Core (EORTC-QLQ-C30) and Functional Assessment of Cancer Therapy for patients undergoing radical cystectomy (FACT-Bl-Cys) validated questionnaires.

Results

In multivariable analysis, the type of the urinary diversion, and the occurrence of early and late postoperative complications were independently associated with the change of scores of HR-QoL domains. When comparing the 2 surgical methods (IONB vs. CU), after adjusting for confounders, such EORTC-QLQ-C30 domains as physical functioning (66.5 vs. 57.9, p = 0.011) and global health status (58.1 vs. 42.6, p <0.001) were superior in the IONB arm which was statistically significant. Similarly, functional health (15.3 vs. 11.9, p <0.001) and total score (110.1 vs. 101.7, p = 0.009) from the FACT-Bl-Cys questionnaire were superior in the IONB arm.

Conclusions

In our study, patients with IONB possessed statistically significant, better scores of HR-QoL domains assessed with EORTC-QLQ-C30 and FACT-Bl-Cys questionnaires compared to those with CU. The occurrence of early major and late complications negatively affected patients' HR-QOL.

Unmet informational and supportive care needs of patients with muscle invasive bladder cancer: A systematic review of the evidence

BACKGROUND

Little is known about the unmet supportive care needs of patients affected by muscle invasive bladder cancer (MIBC). We set out to determine the different domains of unmet supportive care needs for patients affected by MIBC.

LITERATURE SEARCH

A systematic review was conducted according to the PRISMA Statement Guidelines. A sensitive search was performed in electronic databases (DARE, Cochrane, MEDLINE, BNI, PsychINFO, EMBASE and CIHAHL) from the earliest date available to January 2017.

DATA EVALUATION

1405 references were retrieved, 8 articles met the eligibility criteria and were appraised and ranked by strength using the levels of evidence.

SYNTHESIS

Individual unmet needs were classified into the following domains: patient-clinician communication, daily living needs, health system/information needs, practical needs, family-related needs, social needs, psychological needs, physical needs and intimacy needs. Patients reported high unmet needs at diagnosis and into survivorship.

CONCLUSIONS

This review contributes to a greater understanding of the unmet supportive care needs of patients affected by MIBC. Findings reflect a paucity of research, but existing studies indicated needs commonly related to intimacy, informational, physical and psychological needs. Despite the emerging evidence-base, the current within study limitations precludes our understanding about how the needs of patients evolve over time.

Comparison of readmission and short-term mortality rates between different types of urinary diversion in patients undergoing radical cystectomy

PURPOSE

To analyze the impact of urinary diversion type following radical cystectomy (RC) on readmission and short-term mortality rates.

METHODS

Patients who underwent RC for bladder cancer in the National Cancer Data Base were grouped based on the type of urinary diversion performed: non-continent [ileal conduit (IC)] or two continent techniques [continent pouch (CP) and orthotopic neobladder (NB)]. We used propensity score matching and multivariable logistic regression models to compare 30-day readmission and 30- and 90-day mortality between the different types of urinary diversion.

RESULTS

Among 11,933 patients who underwent RC, we identified 10,197 (85.5%) IC, 1044 (8.7%) CP, and 692 (5.8%) NB. Patients who received IC were significantly older and had more comorbidities (p < 0.0001). Continent diversions were more likely to be performed at an academic center (p < 0.0001). Surgery performed at a non-academic center was an independent predictor of 30-day readmission (OR 1.19, p = 0.010) and 30-day mortality (OR 1.27, p = 0.043). Patients undergoing NB had an increased likelihood of being readmitted (OR 1.41, p = 0.010). There was no significant difference in short-term mortality between groups.

CONCLUSIONS

Patients undergoing NB had marginally increased rates of readmission compared to IC. Surgery performed at a non-academic center was associated with higher readmission and 30-day mortality. Similar short-term mortality rates were observed among the different types of urinary diversion.

Bladder Sparing Approaches for Muscle-Invasive Bladder Cancers

Organ preservation has been increasingly utilised in the management of muscle-invasive bladder cancer. Multiple bladder preservation options exist, although the approach of maximal TURBT performed along with chemoradiation is the most favoured. Phase III trials have shown superiority of chemoradiotherapy compared to radiotherapy alone. Concurrent chemoradiotherapy gives local control outcomes comparable to those of radical surgery, but seemingly more superior when considering quality of life. Bladder-preserving techniques represent an alternative for patients who are unfit for cystectomy or decline major surgical intervention; however, these patients will need lifelong rigorous surveillance. It is important to emphasise to the patients opting for organ preservation the need for lifelong bladder surveillance as risk of recurrence remains even years after radical chemoradiotherapy treatment. No randomised control trials have yet directly compared radical cystectomy with bladder-preserving chemoradiation, leaving the age-old question of superiority of one modality over another unanswered. Radical cystectomy and chemoradiation, however, must be seen as complimentary treatments rather than competing treatments. Meticulous patient selection is vital in treatment modality selection with the success of recent trials within the field of bladder preservation only being possible through this application of meticulous selection criteria compared to previous decades. A multidisciplinary approach with radiation oncologists, medical oncologists, and urologists is needed to closely monitor patients who undergo bladder preservation in order to optimise outcomes.

Unmet informational and supportive care needs of patients following cystectomy for bladder cancer based on age, sex, and treatment choices

PURPOSE

Assessing the unmet needs of cancer patients can help providers tailor health care services to patients' specific needs. This study examines whether the unmet informational and supportive care needs of the patients with muscle-invasive bladder cancer vary by the patients' age, sex, or individual treatment choices.

METHODS AND MATERIALS

Participants (N = 30 survivors; 73.3% men) were recruited from the Mount Sinai Medical Center and through advertisements posted on a national Bladder Cancer Advocacy Network website between December 2011 and September 2012. Data were collected through individual interviews and electronic medical record review. A prior qualitative study of this cohort, using immersion/crystallization approach, confirmed the prevalence of unmet needs across the disease trajectory. This is a secondary quantitative analysis of the initial interview data we collected (i.e., quantitative analyses of transformed qualitative data using Chi-square and Fisher exact tests) to examine differences in unmet needs based on the patient's age, sex, and treatment choices.

RESULTS

Younger patients (<60y) were less satisfied with the treatment information received presurgery and more likely to report posttreatment complications, choose a neobladder, and seek and receive professional support regarding sexual function, than were older patients (P<0.05). More women than men reported difficulties with self-care and relied on themselves in disease self-management as opposed to relying on spousal support (P<0.05). Patients with neobladder were more likely to report difficulties with urinary incontinence and deterioration in sexual function, whereas patients with ileal conduit were more likely to require spousal help with self-care. Patients who received chemotherapy were significantly more likely to report changes in everyday life (P<0.05). Lastly, regardless of age, sex, or treatment choice, up to 50% of patients reported feeling depressed before or after treatment.

CONCLUSIONS

Unmet informational and supportive needs of patients with muscle-invasive bladder cancer during survivorship, and vary by age, sex, and treatment choices. Educational and psychological assessments as well as clinical interventions should be tailored to a patient's specific unmet needs, and to specific clinical and demographic characteristics.

[Cystectomy and urinary diversion: Technique and support]

Cystectomy and urinary diversion (Bricker ileal conduit or neobladder) are common modalities of care in urology requiring their attention. Oncological surgery as well as functional disorders in particular for neurogenic bladder are the main directions. The optimal decision must be multidisciplinary and requires the fundamental of stomatherapy that urology teams need to know in order to improve the management of the care plan. After cystectomy whose surgical approach depends on the cause (oncological vs other causes), urinary diversions may be non continent (cutaneous ureterostomy or Bricker ileal conduit) or continent (ileal neobladder most of the time.) The monitoring and patient's support remain two most important steps, particularly in cases of bladder diversion to monitor (protection of upper urinary tract, neobladder capacity) and patient education (learning of continence and good emptying). The choice of many surgical techniques must be adapted to the characteristics of the patient, after an informed discussion with the patient.

We can rebuild it: reconstructive solutions for structural urologic diseases

Bladder augmentation and urinary diversion have become standard of care as surgical treatments for structural and functional disorders affecting the bladder, both in children and adults. With improved medical care, long-term survival of these patients is expected. Common medical problems that can occur such as metabolic side effects including acid-base imbalances and nutritional issues need to be anticipated and addressed. In addition, surgical problems caused by impaired urinary drainage, namely stones and urinary tract infections, and mechanical factors related to catheterizable channels and continence also may compound postoperative management. The risk of malignancy after bladder augmentation and substitution, and appropriate surveillance for this, remains to be clearly defined.

Long-term results of a concomitant boost radiotherapy technique for elderly patients with muscle-ınvasive bladder cancer

OBJECTIVES

To evaluate the long-term clinical efficacy and toxicity of concomitant boost radiotherapy (CBRT) in elderly patients with invasive bladder cancer.

METHODS AND MATERIALS

Elderly patients (n=188; mean 75-year-old, range 70-91 years; 88.3% male/11.7% female) with T1-T4a bladder carcinoma were irradiated with CBRT. A total of 24 (12.8%) patients were diagnosed at stage T1, 117 (62.2%) were at stage T2, 28 (14.9%) at were stage T3a, 14 (7.4%) were stage T3b, and 5 (2.7%) were stage T4a. A dose of 45Gy in 1.8Gy fractions was administered to the whole pelvis 5 days/week over 5 weeks. A concomitant boost limited to the bladder tumor area plus margin or whole bladder of 22.5Gy in 1.5Gy fractions was administered from weeks 3×5. Thus, irradiation totalled 67.5Gy over 5 weeks. The interfraction interval was ≥6h/treatment day. We assessed prognostic factors for overall survival (OS), cause-specific survival (CSS) and relapse-free survival (RFS).

RESULTS

Median follow-up was 46.2 months (range 4.7-155.7 months). Median overall survival was 27 months (95% CI:21-33 months). In this study, 146 (77.7%) patients had complete response, 39 (20.7%) had residual disease and 4 (1.6%) had progressive disease. The mean 3-, 5- and 10-year OS rates were respectively 41.2% (S.E.±0.036), 29% (S.E.±0.034), and 13.8% (S.E.±0.031). Significant prognostic factors for OS and CSS, by multivariate analysis, were tumor T-stage and urothelial obstruction.

CONCLUSION

This CBRT protocol provided excellent results with a high complete response rate and good tolerance. This approach may therefore be particularly appropriate for elderly patients with invasive bladder cancer.

Bladder reconstruction: The past, present and future

Ileal conduit urinary diversion is the gold standard treatment for urinary tract reconstruction following cystectomy. This procedure uses gastrointestinal segments for bladder augmentation, a technique that is often associated with significant complications. The substantial progression in the fields of tissue engineering and regenerative medicine over the previous two decades has resulted in the development of techniques that may lead to the construction of functional de novo urinary bladder substitutes. The present review identifies and discusses the complications associated with current treatment options post-cystectomy. The current techniques, achievements and perspectives of the use of biomaterials and stem cells in the field of urinary bladder reconstruction are also reviewed.

Bone and metabolic complications of urinary diversions

Hyperchloremic metabolic acidosis is a complication of urinary diversion using ileum or colon. Its prevalence ranges from 25% and 46% depending on the procedure used and renal function of the patient. It is a consequence of intestinal fluid and electrolyte exchange between intestinal mucosa and urine. The main mechanism is absorption of ammonium and chloride from urine. Long-term chronic metabolic acidosis in these patients may lead to impaired bone metabolism and osteomalacia. Regular monitoring of pH, chlorine, bicarbonate, and calcium-phosphorus metabolism is therefore essential for early diagnosis and treatment.

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.

Quality of life after radical cystectomy for bladder cancer in men with an ileal conduit or continent urinary diversion: A comparative study

AIM

To investigate quality of life (QoL) domains with three forms of urinary diversions, including ileal conduit, MAINZ pouch, and orthotopic ileal neobladder after radical cystectomy in men with muscle-invasive bladder cancer.

MATERIALS AND METHODS

In a prospective study, 149 men underwent radical cystectomy and urinary diversion (70 ileal conduit, 16 MAINZ pouch, and 63 orthotopic ileal neobladder). Different domains of QoL, including general and physical conditions, psychological status, social status, sexual life, diversion-related symptoms, and satisfaction with the treatment were assessed using an author constructed questionnaire. Assessment was performed at three months postoperatively.

RESULTS

In questions addressing psychological status, social status, and sexual life, patients with continent diversion had a more favorable outcome (P = 0.002, P = 0.01, and P = 0.002, respectively). The rate of erectile dysfunction did not differ significantly between the three groups (P = 0.21). The rate and global satisfaction was higher with the MAINZ pouch (68.7%) and ileal neobladder (76.2%) as compared with the ileal conduit group (52.8%) (P = 0.002).

CONCLUSION

Continent urinary diversion after radical cystectomy provides better results in terms of QoL as compared with ileal conduit diversion.

Urinary diversion trends at a high volume, single American tertiary care center

PURPOSE

We analyzed patient characteristics and practice patterns at our institution with time, and identified current patterns and factors contributing to the choice of urinary diversion.

MATERIALS AND METHODS

We reviewed the records of 553 consecutive radical cystectomy and urinary diversions performed from January 2000 to July 2005. Multivariate analysis was done to determine significant differences in diversion choice.

RESULTS

We analyzed the records of 539 patients, including 338 with an ileal conduit and 201 with a neobladder. Patients with a neobladder were younger (mean age 62 vs 71 years) and had fewer comorbidities (American Society of Anesthesiologists class greater than 2 in 31% vs 69%) than those with an ileal conduit. Mean age and the percent of American Society of Anesthesiologists class 3 or 4 cases increased during the study. Neobladder represented 47% of urinary diversions in 2000 and 21% in 2005. On multivariate analysis age (p <0.001), gender (p = 0.004), surgery year (p = 0.002), American Society of Anesthesiologists class greater than 2 (p = 0.004), organ confined disease (p = 0.01) and surgeon (p <0.001) independently predicted diversion choice. Patients were dichotomized into young (younger than 65 years) and old (65 years old or older) groups. Overall 59% of younger and 26% of older patients received a neobladder (p <0.001).

CONCLUSIONS

There was a significant trend toward the more liberal use of ileal conduit urinary diversion. Patients with female gender, advanced age, significant medical comorbidity or locally advanced disease were less likely to undergo neobladder urinary diversion. This trend is partly explained by surgeon preference combined with an aging, more comorbid patient population. Neobladder continues to be the most commonly performed urinary diversion in patients younger than 65 years.

Terminal patients with urinary diversion: are there specific treatment or nursing care problems in the primary healthcare sector?

OBJECTIVE

To investigate the treatment and nursing care problems related to the type of urinary diversion in terminal patients experienced by the primary healthcare sector.

METHODS

A questionnaire about treatment and nursing care problems related to urinary diversion was sent to general practitioners (GPs) and district nurse units (DNUs) that had been in contact with 1 of 71 patients who died following cystectomy in a 5-year period. The patients had 1 of 3 types of urinary diversion: ileal conduit (IC), Indiana pouch (IP), or Hautmann orthotopic neobladder (NB).

RESULTS

Both GPs and DNUs reported significant difference in problems associated with the 3 types of urinary diversion favoring the IC (P = .049 and .025, respectively). However, clinical decisions about urinary diversion types are often based on incontinent versus continent diversions. When divided into continent versus incontinent diversions, the analysis revealed no differences in the number of problems (P = .31 and .052, respectively). Comparing IC and NB alone made the difference even less significant (P = .82 and .23, respectively).

CONCLUSIONS

It seems that there are no major disadvantages with one type of urinary diversion when compared to the other as perceived by primary healthcare providers. Relevant and thorough information should be provided to GPs and DNUs in order to minimize problems with all forms of urinary diversion.

Bladder cancer

Bladder cancer is a heterogeneous disease, with 70% of patients presenting with superficial tumours, which tend to recur but are generally not life threatening, and 30% presenting as muscle-invasive disease associated with a high risk of death from distant metastases. The main presenting symptom of all bladder cancers is painless haematuria, and the diagnosis is established by urinary cytology and transurethral tumour resection. Intravesical treatment is used for carcinoma in situ and other high grade non-muscle-invasive tumours. The standard of care for muscle-invasive disease is radical cystoprostatectomy, and several types of urinary diversions are offered to patients, with quality of life as an important consideration. Bladder preservation with transurethral tumour resection, radiation, and chemotherapy can in some cases be equally curative. Several chemotherapeutic agents have proven to be useful as neoadjuvant or adjuvant treatment and in patients with metastatic disease. We discuss bladder preserving approaches, combination chemotherapy including new agents, targeted therapies, and advances in molecular biology.