Functional evaluation of different ileal neobladders and ureteral reimplantation techniques

Is Anti-Reflux Anastomosis an Advantage in an Orthotopic Ileal Neobladder? A Systematic Review and Meta-Analysis

INTRODUCTION

We conducted a systematic review and meta-analysis to assess the available literature regarding the postoperative effects of anti-reflux anastomosis and direct anastomosis in orthotopic ileal neobladder (ONB).

METHODS

We searched PubMed, Embase, and the Cochrane Library in October 2021. We included 11 studies of patients with bladder cancer who underwent radical cystectomy and ONB as urinary diversion. Outcomes evaluated in this review were ureteroenteric anastomotic stricture (UEAS), vesicoureteral reflux, renal function (RFn) impairment, and pyelonephritis. All data were analyzed using Review Manager 5.4.4 and subgroup analyses were applied.

RESULTS

A total of 11 studies were eligible for meta-analysis. The synthetic data suggested that anti-reflux anastomosis and direct anastomosis were comparable in terms of RFn impairment (odds ratio (OR) = 1.69; 95% confidence interval (CI): 0.18-15.6; p = 0.65, I2 = 69%) and pyelonephritis (OR = 1.13; 95% CI: 0.65-1.99; p = 0.66, I2 = 1%) without significant difference in each group statistically. The pooled study data showed a significantly higher incidence of UEAS (OR = 2.84; 95% CI: 1.75-4.61, p < 0.0001, I2 = 50%) and a lower incidence of vesicoureteral reflux (OR = 0.24; 95% CI: 0.10-0.59; p = 0.002, I2 = 75%) in anti-reflux anastomosis compared to direct anastomosis. In subgroup analysis, anti-reflux anastomosis was more likely to result in UEAS than direct anastomosis, especially when ureteral stent was removed within 14 days.

CONCLUSION

Although meta-analysis showed that overall incidence of vesicoureteral reflux was higher with direct anastomosis than anti-reflux anastomosis, the rate of vesicoureteral reflux was not directly related to impairment of RFn. The anti-reflux mechanism of ONB was positively associated with a higher incidence of significant UEAS compared to the direct approach, which can lead to kidney damage and an increased risk of secondary surgical procedures.

Development of a questionnaire specifically for patients with Ileal Orthotopic Neobladder (IONB)

BACKGROUND

The ileal orthotopic neobladder (IONB) is often used in patients undergoing radical cystectomy. The IONB allows to void avoiding the disadvantages of the external urinary diversion.In IONB patients the quality of life (QoL) appears compromised by the need to urinate voluntarily. The patients need to wake up at night interrupting the sleep-wake rhythm with consequences on social and emotional life.At present the QoL in IONB patients is evaluated by generic questionnaires. These are useful when IONB patients are compared with patients with different urinary diversions but they are less effective when only IONB patients are evaluated. To address this problem a specific questionnaire-the IONB-PRO-was developed.

METHODS

A) Based on a conceptual framework, narrative-based interviews were conducted on 35 IONB patients. A basic pool of 43 items was produced and organized throughout two clinical and four QoL dimensions. An additional 15 IONB patients were interviewed for face validity testing.B) Psychometric testing was conducted on 145 IONB patients. Both classic test strategy and Rasch analysis were applied. Psychometric properties of the resulting scales were comparatively tested against other QoL-validated scales.

RESULTS

The IONB-PRO questionnaire includes two sections: one on the QoL and a second section on the capability of the patient to manage the IONB. For evaluation of the QoL, three versions were delivered: 1) a basic 23-item QoL version (3 domains 23-items; alpha 0.86÷ 9.69), 2) a short-form 12-item QoL scale (alpha = 0.947), and 3) a short-form 15-item Rasch QoL scale (alpha = 0.967). Correlations of the long version scales with the corresponding dimensions of the EORTC-QLQ C30 and the EORTC-BLM30 were significant. The short forms exhibited significant correlations with the global health dimension of the EORTC-QLQ and with the urinary subscales of the EORTC-BLM30. The effect size was approximately 1.00 between patients at the 1-year follow-up period and those with 3, 5, and > 5-year follow-up periods for all scales. No relevant differences were observed between the 12-item short-form and the Rasch scale.

CONCLUSIONS

The IONB-PRO long and short-forms demonstrated a high level of internal consistency and reliability with an excellent discriminanting validity.

Comparison between a serous-lined extramural tunnel and T-limb ileal procedure as an antireflux technique in orthotopic ileal substitutes: a prospective randomized trial

OBJECTIVE

To compare the functional results from a prospective randomized trial of two different reflux-prevention techniques for ileal bladder substitution.

PATIENTS AND METHODS

In all, 60 patients with invasive bladder cancer were randomized to receive either a serous-lined extramural tunnel (group 1) or T-limb ileal procedure (group 2) as an antireflux technique for the ileal substitute. The preoperative evaluation included intravenous urography, radioisotope renography to evaluate glomerular filtration rates (GFRs) and renal cortical imaging with 99mTc- dimercaptosuccinic acid to assess parenchymal scarring. Evaluable patients were re-assessed by the same imaging, and by ascending studies.

RESULTS

The follow-up included 27 patients (49 units) in group 1 and 23 (45 units) in group 2, with a mean (sd) follow-up of 6.3 (0.5) and 7.4 (1.9), respectively. Uretero-ileal strictures were diagnosed in one renal unit in each group (P = 0.5). Ascending studies showed no reflux in any patients in group 1, while 13 renal units (29%) in group 2 were refluxing (P < 0.01). There was progressive cortical scarring with or with no significant reduction in GFR (>25%) in three and four renal units in groups 1 and 2, respectively. Among the 13 refluxing units in group 2, three showed a significant deterioration in GFR and one renal unit was diagnosed with progressive cortical scarring.

CONCLUSION

Both procedures provided a low rate of anastomotic stricture, with acceptable preservation of renal function. The serous-lined extramural tunnel provided a more effective antireflux mechanism.

Results of the ureteral reimplantation with serous-lined extramural tunnel in orthotopic ileal W-neobladder

BACKGROUND

Our experience in uretero-ileal anastomosis using the serous-lined extramural tunnel in orthotopic ileal W-neobladder is presented.

METHODS

Between June 1998 and November 2001, 42 patients (40 men and two women) underwent radical cystectomy and orthotopic ileal neobladder for invasive bladder cancer. The ureters were reimplanted into serous-lined extramural tunnels as described by Abol-Enein and Ghoneim. However, we made minor modifications during the ureteral reimplantation in cases that necessitated distal ureteral excision and with grossly dilated ureters. Evaluation included clinical and radiographic studies to determine functional and oncological outcomes.

RESULTS

There was no operative mortality. The mean follow-up period was 28 months (range 12-52). Early complications occurred in four patients (9.5%). An endarterectomy for acute popliteal arterial embolism, the excision of the pouchointestinal fistula and a temporary colostomy were performed in two of these four patients. The other two patients were treated conservatively. Late complications occurred in eight patients (19%). Reflux was observed in three renal units (3.7%), ureterointestinal strictures in another three renal units (3.7%) and urethroileal stenosis in two patients (4.8%). In all cases, stabilization or improvement of renal function was achieved. No metabolic complications were observed.

CONCLUSIONS

Ileal W-neobladder with a serous-lined extramural tunnel is a safe, reliable form of lower urinary tract reconstruction. The method can be carried out with equal ease in grossly dilated ureters and in cases that necessitate distal ureteral excision.

[Camey II type orthotopic bladder replacement and its complications: 10-year experience]

BASIS

To evaluate the complications on patients undergoing radical cystectomy with Camey II ileal orthotopic neobladder.

METHODS

To review our series of 61 radical cystectomies performed between 1990 and 1999 for bladder cancer. The complications were divided in early (30 days or less) and late.

RESULTS

A patient died at the immediate postoperative. It appeared 35 early complications on 30 patients: 8 related with neobladder (urinary fistula and urinary infection) and 27 not related, being the most frequent those appearing at bowel site, with 10 early surgeries (16.4%). After evaluating 55 patients for late complications, 39 presented some kind of complication: 38 related with neobladder and 13 not related, 30 patients underwent surgery, being 19 of them under endoscopic way. 74.4% of continents by day and 31.4% at night.

CONCLUSIONS

Despite the acceptable functional results, the orthotopic bladder substitution presents a not comptemtible rate of complications. In other way, a lack of standard criteria make difficult the comparation with other series and types of bladder substitution.