Modified ileal neobladder for continent urinary diversion: functional results after 9 years of experience

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.

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.

Biofabrication of cell-laden allografts of goat urinary bladder scaffold for organ reconstruction/regeneration

INTRODUCTION

Bladder dysfunction has been considered as one of the most critical health conditions with no proper treatment. Current therapeutic approaches including enterocystoplasty have several limitations. Hence, biofabrication of cell-laden biological allografts using decellularized Goat urinary bladder scaffolds for organ reconstruction/regeneration was major objective of this study.

MATERIALS AND METHODS

An efficient method for decellularization of Goat urinary bladder (N = 3) was developed by perfusion of gradient change of detergents through ureter. The retention of organ architecture, extracellular matrix composition, mechanical properties and removal of cellular components was characterized using histological, cellular and molecular analysis. Further, mesenchymal stem cells (MSCs) from human umbilical cord blood (UCB) were used for preparing biological construct of decellularized urinary bladder (DUB) scaffolds to augment the urinary bladder reconstruction/regeneration.

RESULTS

The decellularization method adopted in this study generated completely DUB scaffolds within 10 h at 100 mm Hg pressure and constant flow rate of 1 mL/min. The DUB scaffold retains organ architecture, ECM composition, and mechanical strength. No significant amount of residual nucleic acid was observed post-decellularization. Furthermore, MSCs derived from human UCB engrafted and proliferated well on DUB scaffolds in highly aligned manner under xeno-free condition.

CONCLUSION

Biofabricated humanized urinary bladder constructs provides xeno-free allografts for future application in augmenting urinary bladder reconstruction/regeneration with further development.

Bioengineering Approaches for Bladder Regeneration

Current clinical strategies for bladder reconstruction or substitution are associated to serious problems. Therefore, new alternative approaches are becoming more and more necessary. The purpose of this work is to review the state of the art of the current bioengineering advances and obstacles reported in bladder regeneration. Tissue bladder engineering requires an ideal engineered bladder scaffold composed of a biocompatible material suitable to sustain the mechanical forces necessary for bladder filling and emptying. In addition, an engineered bladder needs to reconstruct a compliant muscular wall and a highly specialized urothelium, well-orchestrated under control of autonomic and sensory innervations. Bioreactors play a very important role allowing cell growth and specialization into a tissue-engineered vascular construct within a physiological environment. Bioprinting technology is rapidly progressing, achieving the generation of custom-made structural supports using an increasing number of different polymers as ink with a high capacity of reproducibility. Although many promising results have been achieved, few of them have been tested with clinical success. This lack of satisfactory applications is a good reason to discourage researchers in this field and explains, somehow, the limited high-impact scientific production in this area during the last decade, emphasizing that still much more progress is required before bioengineered bladders become a commonplace in the clinical setting.

Urinary function following radical cystectomy and orthotopic neobladder urinary reconstruction

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term Functional, Urodynamic, and Metabolic Outcome of a Modified Orthotopic Neobladder Created With a Short Ileal Segment: Our 5-year Experience

OBJECTIVE

To assess the long-term functional, urodynamic, and metabolic outcomes of our modified neobladder.

MATERIALS AND METHODS

In this prospective study from January 2010 to October 2014, 42 consecutive male patients with bladder tumor underwent radical cystectomy and orthotopic urinary diversion with modified ileal neobladder using 25 cm ileal segment. During follow-up, functional outcome, urodynamic studies, metabolic parameters, and renal parameters were assessed at regular intervals. Complications were graded as early (<3 months) or late (>3 months).

RESULTS

There were no perioperative deaths. At a mean follow-up of 27.2 months, good or satisfactory daytime and nighttime continence were achieved in 100% and 93.8% of patients, respectively. Mean maximal bladder capacity was 588 mL at 3 years. Mean resting pressure and voiding pressures were 20.1 cm H2O and 34.6 cm H2O at 3 years, respectively. Good bladder compliance was achieved in all patients by 1 year. Mean maximum urine flow rate (Qmax) was 18.5 mL at 3 years. Postvoid residual volume was insignificant in all the patients and none of the patients were on clean intermittent self-catheterization. None of the patients developed severe metabolic acidosis. Vitamin B12 levels were within normal range in all patients. Early complications were seen in 12 patients (28.6%), whereas late complications were observed in 5 patients (12%).

CONCLUSION

Our results demonstrate that our modified technique of using a short ileal segment to create a near-spherical, compliant, low-pressure reservoir provides an acceptable, safe, and functional alternative to the standard Hautmann neobladder.

Comparison Between Ambulatory and Conventional Urodynamics of the Modified Orthotopic Hautmann Neobladder

PURPOSE

The aim of the present study was to determine the diagnostic accuracy of conventional and ambulatory urodynamic studies (UDS) in estimating neobladder function.

METHODS

We evaluated 32 patients who underwent radical cystectomy and orthotopic Hautmann W neobladder with Abol-Enein-Ghoneim uretero-intestinal anastomosis for bladder cancer. The patients were initially examined by using both conventional and ambulatory UDS.

RESULTS

Conventional UDS detected a very high mean intravesical pressure at maximum capacity (53.7±17.5 cm H2O). By contrast, the mean intravesical pressure detected by using ambulatory UDS (which reflects the dominant pattern of pressure variation during filling) was significantly lower (34.4±5.2 cm H2O, P<0.001). The comparison between intravesical pressure at half of maximum capacity in conventional UDS and the mean value in ambulatory UDS did not show significant difference (P=0.152). The mean voided volume in conventional UDS was greater than both the mean voided volume (P<0.001) and the mean maximum voided volume in ambulatory UDS (P=0.001). However, this difference did not affect the postvoid residual urine volume measured in both studies (P=0.207). Moreover, incontinence episodes recorded in ambulatory UDS were more frequent but not statistically significantly different from those recorded in conventional UDS (P=0.332).

CONCLUSIONS

The estimation of neobladder function by means of ambulatory UDS seems to provide interesting research data for the mode of lower urinary tract function in patients with orthotopic substitution after radical cystectomy. The great high value in ambulatory UDS, in cases in which conventional UDS had failed, is due to the exposure of daily and nocturnal incontinence episodes, confirming our patients' complaints.

Modified S-ileal neobladder for continent urinary diversion: functional and urodynamic results after 20 years of follow-up

OBJECTIVE

To report continence and urodynamic findings after radical cystectomy and urinary diversion with modified S-ileal neobladder between January 1993 and January 2013.

PATIENTS AND METHODS

181 patients were enrolled. Continence status, reservoir sensation, compliance, capacity and activity were assessed.

RESULTS

Daytime continence was reported by 88.0, 98.4 and 99.2%, while nighttime continence was reported by 70.2, 94.0 and 95.8% of our patients at 6 months, 5 years and 20 years, respectively. Enterocystometric capacity and maximum reservoir pressure were 366 vs. 405 ml and 502 ml, and 29 vs. 18 and 11 cm H2O, at 6 months, 5 years and 20 years, respectively. Median post-void residual urine volume was 32 ml at 6 months, 50 ml at 5 years and 120 ml at 20 years.

CONCLUSIONS

The modified S-ileal neobladder technique has a very good long-lasting functional outcome, with high day- and nighttime continence levels as well as high acceptability rates from our patients.

Renal and functional outcomes following cystectomy and neobladder reconstruction

BACKGROUND

Orthotopic reconstruction following cystectomy has evolved in an attempt to restore anatomy and function to as close as possible to the preoperative state. We review the renal and functional outcomes of patients who underwent cystectomy and neobladder reconstruction at our institution.

METHODS

Between December 2003 and October 2007, 31 patients underwent cystectomy with Studer neobladder reconstruction at the Ottawa Hospital, Ottawa, Ontario, Canada. Follow-up data were obtained regarding renal function (serum creatinine, μmol/L), continence, urinary flow rates and post-void residual (PVR) at 3, 6 and 12 months after surgery. Change in creatinine from preoperative baseline was calculated and analyzed by student t-test to determine if there was a significant rise in creatinine.

RESULTS

There was a statistically significant increase in creatinine from preoperative baseline, with an average increase of 17.3 μmol/L, 21.8 μmol/L and 26.3 μmol/L at 3, 6 and 12 months, respectively. Six patients developed hydronephrosis. Excluding patients with hydronephrosis, there continued to be a statistically significant rise in creatinine with an average increase of 11.9 μmol/L, 14.7 μmol/L and 19.4 μmol/L at 3, 6 and 12 months, respectively. At 1 year, daytime continence was achieved by 89% of patients; 70% were continent at night.

INTERPRETATION

Orthotopic neobladders have excellent functional outcomes with low rates of incontinence, which improved throughout follow-up. A significant proportion of patients developed hydronephrosis, highlighting the need for close follow-up to prevent reversible renal deterioration. Creatinine increased during follow-up irrespective of the development of hydronephrosis, but the clinical significance is unknown.

Functional outcome of orthotopic bladder substitution: a comparison between the S-shaped and U-shaped neobladder

OBJECTIVE

To compare the functional outcome of two types of orthotopic bladder substitution, the S-shaped and the U-shaped neobladder, with respect to leakage, functional capacity and quality of life.

MATERIAL AND METHODS

Between 1999 and 2007, 45 male patients with urinary bladder cancer were treated with cystectomy and orthotopic bladder substitution; 23 with the S-shaped bladder ad modum Schreiter and 22 with the U-shaped bladder ad modum Studer. Patients were followed up by a urologist and a specialized nurse (urotherapist) at 1, 3 and 6 months. At each visit the patient completed a voiding chart, a weighted pad test and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). Differences between the groups in functional outcome and quality of life variables were analysed by Student's t test using SPSS software.

RESULTS

Mean maximum bladder capacity increased over time. At 6 months, the S-bladder had a larger capacity than the U-bladder (525 ml vs 423 ml). Patients with an S-bladder had less urine leakage at all follow-ups, although this was statistically significant only at 6 months regarding day-time incontinence and at all visits regarding night-time incontinence. The mean urine leakage at 6 months was 7 g (day) and 30 g (night) in the S-bladder group and 50 g (day) and 250 g (night) in the U-bladder group. However, quality of life did not differ between the groups.

CONCLUSION

The S-bladder had better bladder capacity and less leakage than the U-bladder, but these differences did not translate into differences in quality of life. The results should be confirmed in larger prospective studies.

Functional results following vescica ileale Padovana (VIP) neobladder: midterm follow-up analysis with validated questionnaires

BACKGROUND

Orthotopic bladder reconstruction is the preferred method of urinary diversion following radical cystectomy (RC). Several papers reported functional data of different orthotopic neobladders, although to date, no one has used validated questionnaires.

OBJECTIVE

To evaluate the midterm functional results in a contemporary series of patients undergoing RC and vescica ileale Padovana (VIP) orthotopic neobladder by applying a set of validated questionnaires.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a cross-sectional study at a single academic centre.

INTERVENTION

We included RC and VIP orthotopic techniques for bladder transitional cell carcinoma.

MEASUREMENTS

The American Urological Association Symptom Index (AUA-SI), the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF), and the five-item version of the International Index of Erectile Function (IIEF-5) were used to evaluate functional outcomes.

RESULTS AND LIMITATIONS

All 113 patients who were alive and disease free at 44-mo follow-up were evaluated. Sixteen patients (13%) were on clean intermittent catheterisation (CIC). The median AUA-SI score of the 97 voiding patients was 9 (interquartile range [IQR]: 4.5-16). Specifically, 48.5%, 40.2%, and 11.3% of the patients had mild, moderate, or severe lower urinary tract symptoms (LUTS), respectively. American Society of Anaesthesiologists class (odds ratio [OR]: 9.0; p=0.03) and body mass index (OR: 1.5; p=0.023) were independent predictors of the need for CIC, while only patient age at the time of surgery (OR: 0.920; p=0.01) was predictive of LUTS severity. The median ICIQ-UI SF score was 6 (IQR: 3-10). Twenty patients (17.7%) were fully continent, while 31.9%, 35.4%, and 15% had slight, moderate, and severe incontinence, respectively. About 90% of the patients during the day and 80% during the night used no pad or only a safety pad. Most of the patients leaked when asleep. No variable was predictive of return to continence. Finally, roughly 20% of the male patients were potent, having an IIEF-5 score ≥17.

CONCLUSIONS

We reported midterm functional outcomes following RC and VIP neobladder using validated questionnaires. On the whole, the results are encouraging. However, in the absence of patient self-completed questionnaires, functional outcomes may be significantly overestimated.

Voiding symptoms and urodynamic findings in patients with modified ileal neobladde

The aim of our study was to find the cause of urinary incontinence and voiding dysfunction in patients undergoing radical cystectomy and orthotopic bladder replacement with modified ileal neobladder (Reddy). Twenty-eight incontinent patients (operated on between 1988 and 2004) were involved in our examination. Based on the complaints of the patients, continence status was evaluated and divided into two groups: group I: partially incontinent (only night-time incontinence) n = 11 (39.3%) and group II: totally incontinent (night-time and daytime incontinence) n = 17 (60.7%). Detailed urodynamic examination (enterocystometry and urethral pressure profile) in addition to involuntary neobladder contractions and capacity detection were carried out on all patients. Furthermore resting pressure and maximal voluntary contraction ability of the sphincter were determined and statistically analyzed in both groups. Significant difference was noticed in resting pressure and maximal voluntary contraction ability of the sphincter among the partially incontinent and totally incontinent patients. Frequency, intensity and duration of involuntary neobladder contractions also showed significant differences between the two groups. Incontinence of neobladder depends not only on the destruction of resting and contraction capability of the urethral sphincter, but also on the presence or absence of involuntary contractions in the wall of the neobladder and decreased capacity of the neobladder.

A pilot study of the assessment of the quality of life, functional results, and complications in patients with an ileal neobladder for invasive bladder cancer

OBJECTIVE

To assess the functional results, health-related quality of life (QOL) outcomes, and complications in patients with an ileal neobladder in comparison to those with cutaneous diversion (ileal conduit and cutaneostomy).

METHODS

Between September 1992 and February 2003, we consecutively performed an ileal neobladder (the Studer method) in 30 patients and cutaneous diversion in 38 patients. In August 2004, questionnaires were mailed to 54 patients. The questionnaire included the validated health-related quality of life (QOL) questionnaire, SF-36 General Health Survey, and a urinary incontinence questionnaire. We also evaluated the functional results in patients with an ileal neobladder and the postoperative complications in patients with both urinary diversions.

RESULTS

The data from 41 patients (21 ileal neobladder procedures and 20 cutaneous diversions) were available for the analysis. No differences in the overall QOL were observed between the two groups. Complete daytime and night-time urinary continence was achieved in the 21 patients (100%) and 13 patients (61.9%), respectively. The mean value of the maximum flow rate was 15 +/- 12 mL/min in the 21 neobladder patients. There were 19 early complications in 18 patients (60.0%) and seven late complications in six patients (20.0%) with an ileal neobladder. However, there were 15 early complications in 14 patients (36.8%) and eight late complications in six patients (15.8%) with cutaneous diversions.

CONCLUSION

The findings regarding the health-related QOL and the frequency of complications in the neobladder group and those in the cutaneous diversion group were similar. However, the functional results and the status of urinary continence in the neobladder patients were satisfactory.

Results of Chimney Modification Technique in Ureterointestinal Anastomosis of Hautmann Ileal Neobladder in Bladder Cancer

BACKGROUND

To evaluate the surgical technique and functional outcome of a new application of the chimney modification to the popular Hautmann ileal neobladder. This modification used 3-5 cm chimney tubularized ileal segment for the bilateral ureterointestinal anastomosis.

METHODS

Between December 2000 and July 2004, 15 patients (14 men, 1 woman) with invasive bladder cancer underwent radical cystectomy and Hautmann neobladder with chimney modification at Siriraj Hospital, Bangkok. Mean age was 61.7 years (range, 43-72 years). Perioperative morbidity, early and late urinary diversion-related complications, other surgical complications, follow-up results of ureterointestinal anastomosis, renal function and metabolic disorders were evaluated. Patients were interviewed about their continence, voiding function and potency.

RESULTS

At a mean follow-up of 29.5 months, two patients had died of cancer progression. Of the 15 patients, nine (60%) had 10 early complications. Eight complications were related to the neobladder and two were not. Three (20%) patients had three late complications. Two complications were neobladder-related and one was not. There was no perioperative mortality. There was no ureteroileal anastomosis stricture in this series. Neobladder-ureteral reflux was demonstrated in eight of 22 ureteral units in 11 patients in whom cystography was performed. All patients had normal upper urinary tract without evidence of urinary obstruction. All 14 men (93% of study sample) had spontaneous urination, normal renal function and no metabolic acidosis. Good and satisfactory continence in the day and night were 93% and 73%, respectively. All male patients experienced impotence postoperatively. Only one sought treatment and was successfully treated with sildenafil. The one woman in this study required intermittent catheterization to empty the neobladder completely. She also had renal insufficiency with serum creatinine of 2.2 mg/dL and hyperchloraemic metabolic acidosis.

CONCLUSION

New chimney modification in Hautmann ileal neobladder is simple and safe. Complications are acceptable. Follow-up results of renal and voiding functions are satisfactory. This operation can maintain good quality of life for patients with bladder cancer undergoing radical cystectomy.

Total and immediate daytime and nighttime continence with a right colonic neobladder--What makes it possible? An 11-year followup

PURPOSE

We report the long-term functional results of the colonic neobladder and provide the physiological and urodynamic foundations for them.

MATERIALS AND METHODS

From March 1993 to February 2004, 38 patients with cystectomy received a neobladder constructed from detubularized, remodeled right colon and intact cecum following our design at the urology service at our institution. Most patients underwent urodynamics and videourodynamics as postoperative followup. We defined total continence as not using any protection whatsoever (neither pads nor a night alarm), which was immediate upon removing the urethral catheter.

RESULTS

A total of 37 patients achieved total daytime continence immediately and the remaining 1 was totally continent after 30 days (100%). Nighttime continence was total and immediate in 36 patients (92%) and satisfactory in 2. Micturition was immediate, satisfactory and total in 37 patients with an average maximum flow of more than 26 ml per second. The patient who did not achieve micturition required clean intermittent catheterization. Videourodynamic studies revealed that continence resulted from the low pressure developed in the large capacity reservoir (more than 600 ml) and from intact intestine haustral contractions, which ejected urine toward the detubularized and remodeled area. In turn, micturition was attained through a combination of abdominal wall tension and mass contractions of the nondetubularized segment, which generated a pressure of more than 100 cm.

CONCLUSIONS

The functional results of this new neobladder are significantly greater than those achieved with other procedures already described in the literature because of the different way in which it functions.