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

Zinc Deficiency in Men Over 50 and Its Implications in Prostate Disorders

Research has been consistently showing the role of zinc (Zn) in prostate function. In this article, we review the current literature on the anatomy and main functions of the prostate, highlighting the role of zinc. In particular, we will review the etiology of benign prostate enlargement (BPH), its prevalence in men over 50, the likelihood of BPH becoming prostate cancer (PCa), and explain the relationship of zinc and apoptosis in the prostate cells and the implications for BPH and PCa. We present a model that explains how endogenous factors provoke excretion of zinc or limit zinc absorption, and how exogenous factors like nutrition and drugs regularly used in men over 50 can significantly decrease zinc status and thereby increase the risk of BPH. Finally, we explain how Zn amino acid (AA) complexes may be capable of avoiding antagonists and inhibitors of zinc absorption, thereby increasing the bioavailability of zinc for the necessary biological processes in the prostate.

Internal audit of an enhanced recovery after surgery protocol for radical cystectomy

PURPOSE

To perform an internal audit 5 years after implementation of our enhanced recovery after surgery (ERAS) protocol for patients undergoing radical cystectomy and to investigate the importance of physician driven compliance on outcomes.

METHODS

Using a prospectively maintained database, 472 consecutive patients were identified who underwent radical cystectomy with ERAS from July 2013 to July 2017. Compliance was measured by a Composite Compliance Score (CCS) generated as a percentage of 16 interventions. Patients with higher than median compliance were compared to patients with lower compliance. The primary outcome was length of stay. Secondary outcomes included complication and readmission rates. Multivariable regressions were used to control for differences between groups.

RESULTS

In 2013, median CCS was 81% and subsequently ranged from 81 to 88%. Five-year median CCS was 88%. Patients with higher compliance (CCS ≥ 88%, n = 262), as compared to those with lower compliance (CCS < 88%, n = 210), were younger (median 70.3 vs 72.7 years, p = 0.047), healthier (ASA3-4 81% vs 89.9%, p = 0.007), received more orthotopic diversions (59.2% vs 37.6%, p < 0.0001), more often had open surgery (78.5% vs 51.9%, p < 0.0001) and had shorter median operative times (5.5 vs 6.3 h, p = 0.005). Median length of stay was 4 days. Higher compliance was associated with shorter hospital stays (β = - 0.85, 95% CI - 1.62 to - 0.07) and decreased 30-day readmissions (OR 0.58, 95% CI 0.35-0.96).

CONCLUSIONS

Greater ERAS compliance was achieved in younger and healthier patients. Patients with greater compliance had a decreased length of stay by almost 1 day and reduced odds of 30-day readmissions.

Bladder cancer: Risk factors, diagnosis, and management

Bladder cancer is the most common genitourinary cancer in the United States. Symptoms of bladder cancer mimic those of a urinary tract infection, which can delay timely diagnosis. Because of the high rate of bladder cancer, it is likely advanced practice registered nurses will be responsible for the care of patients with bladder cancer. This article reviews the signs and symptoms of bladder cancer along with management options to safely care for this patient population.

Factors influencing intraoperative conversion from planned orthotopic to non-orthotopic urinary diversion during radical cystectomy

OBJECTIVES

To determine and investigate the intraoperative factors that contribute to a change in plan from continent orthotopic neobladder to ileal conduit or continent cutaneous diversion at the time of radical cystectomy.

SUBJECTS AND METHODS

A retrospective review of our prospectively maintained bladder cancer database was performed. Of the 711 patients who underwent radical cystectomy from 2012 to 2016, 387 (54.4%) had given consent to have a NB. Of these 387 patients, 348 (89.9%) ultimately received a neobladder while 34 (8.8%) received an ileal conduit and 5 (1.3%) continent cutaneous diversion. The factors involved in the intraoperative change of plan were examined in this study.

RESULTS

Patients who ultimately received a neobladder were significantly more likely to have clinical node-negative disease (p = 0.045), negative soft tissue margins (p = 0.001), lower body mass index (p = 0.045) and higher volume surgeons (p < 0.001). Oncologic reasons for intraoperative conversions were more common than technical reasons (58.3% vs 35.9%), in both robotic and open surgical techniques. The choice of surgical approach (open vs robotic) did not influence the rate of intraoperative conversion.

CONCLUSION

The factors influencing intraoperative decision not to perform neobladder are predominantly oncologic rather than technical. A clear understanding of the factors involved in influencing the intraoperative change in the urinary diversion plan may improve shared decision making in patients undergoing radical cystectomy in the future.

Endourologic strategies for a minimally invasive management of urinary tract stones in patients with urinary diversion

Objective

To present our experience in minimally invasive management of urinary tract stones in patients with urinary diversion.

Materials and Methods

We retrospectively reviewed 26 patients with urinary tract stones after cystectomy and urinary diversion. The types of urinary diversion were ileal conduit, colon conduit, ileal orthotopic neobladder in 19, 4, and 3 patients, respectively. At postoperative days 2, a plain KUB and urinary ultrasonography were performed in order to assess stone fragmentation or hydronephrosis. According to postoperative imaging, stone free rate (SFR) was defined as complete absence of fragments or residual stones less than 4mm.

Results

19 patients were treated with minimally invasive percutaneous lithotripsy (MPCNL) and 2 patients required second-look MPCNL. Anterograde flexible ureteroscopy was performed in 2 patients, while in 2 patients a combined anterograde and retrograde approach was required. Three reservoir stones were treated by transurethral neo-bladder lithotripsy. Postoperative significant complications occurred in 2 patients (7.7%). The highest percentage of stone composition was struvite, as a result of chronic urinary tract infection (UTI). SFR was 88.5% (23 of 26).

Conclusions

Our experience showed that MPCNL is a safe and effective treatment modality with little morbidity for renal and upper ureteral stones in patients with urinary diversion. For middle and lower ureteral stones, an anterograde approach could be also considered as a first line treatment, but a combined anterograde and retrograde approach was required when the anterograde access alone cannot provide acceptable results.

Patient Selection and Counseling for Urinary Diversion

Patient selection and preoperative counseling are critical aspects of determining which urinary diversion to perform and should be emphasized at each stage of preoperative planning. The surgeon must have a thorough understanding of the patient's disease process, functional and psycho-emotional status, and social support network so that they can set appropriate expectations. It is also crucial to have a multidisciplinary team of individuals who are experienced with all aspects of urinary diversion care, including ostomy nurses, nurse navigators, and urologic surgeons skilled at teaching and trouble-shooting self-catheterization for continent cutaneous diversion and orthotopic diversion in the setting of hypercontinence.

[Quality of life of patients carrying an urinary diversion]

INTRODUCTION

A urinary diversion is more often needed in the context of total cystectomy for bladder cancer. This pathology and this surgical resection alter the quality of life of patients. This article reviews the consequences of urinary diversions on patients' quality of life and ways to minimize them.

MATERIAL AND METHOD

A systematic review of the literature search was performed from the databases Medline (NLM, Pubmed) and Embase, focused on the following keywords: "cystectomy"; "urinary diversion"; "quality of life"; "stoma"; "education". Publications obtained were selected based on methodology, language, date of publication (last 30 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 218 articles. After reading titles and abstracts, 30 were included in the text, based on their relevance.

RESULTS

The informed choice of the urinary diversion contributes to its acceptance by the patient and to improve the urinary-related quality of life. The selection criteria must be analyzed and presented to the patient in a multidisciplinary way, involving surgeon, physician, nurse, physiotherapist and stomaterapist. By means of the care networks, the choice of the patient should not be limited by the experience of the surgical and paramedical team. There is no clear evidence about the superiority of a derivation over others regarding the quality of life of patients.

CONCLUSION

The quality of life of patients carrying an urinary diversion depends less on the type of diversion than on whether the diversion is chosen by the patient himself. Patient information by all stakeholders involved in its communication is therefore essential.

Functional Assessment of the Hautmann Ileal Neobladder with Chimney Modification Using Uroflowmetry and a Questionnaire

Urinary diversion reconstruction is essential after radical cystectomy and neobladder reconstruction is accepted as a fine option. This study included 51 patients, who underwent radical cystectomy with orthotopic neobladder reconstruction by a Hautmann ileal neobladder with chimney modification from 2006 to 2014. Functional outcomes were evaluated using a questionnaire and uroflowmetry. Perioperative complications were analyzed retrospectively. The mean follow-up period was 36.1 months. Eighty-six percent of patients voided without clean intermittent catheterization (CIC) assistance. CIC was used 1-2x per day or every time they voided in 8% and 6% of patients, respectively, and 71% of patients were continent. The percentages of patients who used 1, 2, 3-4, and ≥5 pads per day were 15%, 6%, 2%, and 6%, respectively. Daytime and nighttime continence were achieved in 86% and 69% of patients, respectively. Daily mucus leakage was reported in 69% of patients. The mean maximum neobladder capacity, voided volume, postvoid residual volume, and maximum flow rate were 413.2 mL, 370.6 mL, 43.7 mL, and 20.8 mL/s, respectively. Eighteen early and 5 late complications developed in 13 and 5 patients, respectively. Reoperations were needed in 7 patients. The Hautmann ileal neobladder with chimney modification provided satisfactory results regarding functional outcomes.

Orthotopic urinary diversion

PURPOSE OF REVIEW

Orthotopic urinary diversion has been performed for more than 30 years. Although it is considered to be the gold standard form of diversion in many centers of expertise, however it is uncommonly performed outside these institutions. The purpose of this article is to review the current indications and outcomes of orthotopic diversion with a focus on male patients and to explore potential barriers to wider dissemination of the technique.

RECENT FINDINGS

Approximately 75% of patients undergoing radical cystectomy today are candidates for orthotopic diversion and in the absence of absolute contraindications, very few patients chose to undergo an ileal conduit for personal reasons. In a recent quality of life study, the orthotopic neobladder was better than ileal conduit in terms of global health status and physical functioning. In a prospective randomized trial comparing a refluxing versus nonrefluxing neobladder, there was no difference in renal function after 3 years. There is currently insufficient evidence to suggest improved perioperative outcomes with the use of minimally invasive techniques.

SUMMARY

There are very few absolute contraindications for an orthotopic neobladder, which remains the gold standard form of diversion at many centers of expertise. Surgeon experience and thorough preoperative counseling with realistic expectations can ensure optimal outcomes and patient satisfaction.

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.

What should be the patient's preference regarding the choice of hospital in the case of radical cystectomy? Evaluation of early complications after open radical cystectomy in a medium and high volume setting in one hospital

PURPOSE

This study compares early complications after cystectomy and urinary diversion (UD) stratified by the surgical focus and case load of two different department chairpersons in a single institution in two time periods. Creating clear data about complications that can affect the quality of life is an important tool for patients to decide whether and where to perform this extensive surgery.

HYPOTHESIS

A team of surgeons with a clear focus on pelvic surgery leads to lower complication rates in radical cystectomy.

MATERIALS AND METHODS

Radical cystectomy was performed in two separate time periods under the patronage of two different chairmen in the same university hospital. The patient data were analyzed retrospectively and the complications 30 days after surgery were assessed using the Clavien-Dindo classification.

RESULTS

Statistical analysis showed a significant difference in the severity of complications between the two time periods, A and B, in total (P<0.001). When placing patients into subgroups, significantly more complications in period A were also seen concerning sex (male, P<0.001; female, P=0.003), age (<70 years, P<0.001; >70 years, P≤50.001) tumor grade (low grade, P<0.001; high grade, P≤0.001), and UD (ileal conduit, P<0.001; neobladder, P<0.001). In a multivariable analysis, age (P=0.031) and type of UD (P=0.028) were determined as independent predictors for complications in period A. When joining the two periods together, the type of UD (P=0.0417), age (P=0.041), and the time periods (A/B) (P<0.001) show a significant association with the presence of complications.

CONCLUSION

This study compares for the first time surgical complications in two time periods with different case load and surgical focus in one department. Categorization shows that patients should prefer radical cystectomy in centers of excellence or a high-volume hospital in order to keep complications at the lowest possible level and thus have the highest benefit for oncologic outcome and quality of life.

Surgical management of urolithiasis in patients after urinary diversion

OBJECTIVE

To present our experience in surgical management of urolithiasis in patients after urinary diversion.

PATIENTS AND METHODS

Twenty patients with urolithiasis after urinary diversion received intervention. Percutaneous nephrolithotomy, percutaneous based antegrade ureteroscopy with semi-rigid or flexible ureteroscope, transurethral reservoir lithotripsy, percutaneous pouch lithotripsy and open operation were performed in 8, 3, 2, 6, and 1 patients, respectively. The operative finding and complications were retrospectively collected and analyzed.

RESULTS

The mean stone size was 4.5 ± 3.1 (range 1.5-11.2) cm. The mean operation time was 82.0 ± 11.5 (range 55-120) min. Eighteen patients were rendered stone free with a clearance of 90%. Complications occurred in 3 patients (15%). Two patients (10%) had postoperative fever greater than 38.5 °C, and one patient (5%) suffered urine extravasations from percutaneous tract.

CONCLUSIONS

The percutaneous based procedures, including percutaneous nephrolithotomy, antegrade ureteroscopy with semi-rigid ureteroscope or flexible ureteroscope from percutaneous tract, and percutaneous pouch lithotripsy, provides a direct and safe access to the target stones in patients after urinary diversion, and with high stone free rate and minor complications. The surgical management of urolithiasis in patients after urinary diversion requires comprehensive evaluation and individualized consideration depending upon the urinary diversion type, stone location, stone burden, available resource and surgeon experience.

Urinary diversion: long-term functional aspects

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

Quality of life in patients with ileal conduit cystectomy due to bladder cancer

OBJECTIVE

To determine the variables that affect quality of life of patients treated by radical cystectomy with ileal conduit.

MATERIAL AND METHOD

We analyzed quality of life using the EQ-5D-3L questionnaire. This questionnaire evaluates mobility, personal care, daily activities, pain/discomfort, anxiety/depression and a self-rating scale of the health condition. We compared the result with demographic variables (gender, age, work situation, studies, income, partner) and clinical variables (ASA classification, tumor stage, time since cystectomy was performed, adjuvant chemotherapy, recurrent and complications of the stoma). The statistical analysis included a descriptive study, univariate and multivariate analysis.

RESULTS

A total of 59 patients were included in the study, with a mean age of 69 years (47-84). Mean time from cystectomy was 43 months (12-83), with 61% complications associated to the stoma. Stoma complications were related with limitations in personal care, pain/discomfort, anxiety, depression and quality of life in general. Female gender was associated with limitations in daily activities and adjuvant chemotherapy with anxiety/depression and quality of life in general. The rest of the variables were not statistically significant in the multivariate analysis.

CONCLUSIONS

The limitations in quality of life in patients with cystectomy and ileal conduit are associated with the stoma-associated complications. Other related variables are female gender and administration of adjuvant chemotherapy.

[Cystectomy in the elderly patient]

Bladder cancer is a carcinoma of the elderly population. The highest incidence of bladder cancer is between the ages of 70 and 80 years old. Radical cystectomy remains the gold standard for muscle invasive bladder cancer treatment. In this article different aspects of radical cystectomy in elderly patients are reviewed. The Pubmed-MEDLINE database was searched using the following keywords: radical, cystectomy, elderly and age.

Quality of life in women undergoing urinary diversion for bladder cancer: results of a multicenter study among long-term disease-free survivors

PURPOSE

Women undergoing radical cystectomy (RC) and urinary diversion for bladder cancer experience substantial limitations in health-related quality of life (HRQOL). However, the level of discomfort caused by different urinary diversion has been never evaluated in long term survivors. The aim of this multicenter study is to evaluate differences in HRQOL among recurrence-free women undergoing cutaneous ureterostomy (CUS), Bricker's ileal conduit (BK-IC) and Orthotopic neobladder VIP (ONB-VIP) in disease-free females treated with radical cystectomy (RC), with long-term follow up (mean 60.1 months; range 36-122 months).

MATERIALS AND METHODS

All consecutively treated female patients from two urological institutions who underwent RC and urinary diversion from January 2000 to December 2008, with no evidence of tumor recurrence at a minimum follow up of 36 months, were included. Patients received the European Organisation for Research and Treatment of Cancer (EORTC) generic (QLQ-C30) and bladder cancer-specific instruments (QLQ-BLM30) and the Functional Assessment of Cancer Therapy for Bladder Cancer (FACT-BL). Clinical data and questionnaire results were analyzed in order to evaluate the HRQOL differences among diversion groups.

RESULTS

We identified 37 females (median age: 68, range 45-82 years), including 12 status-post CUS, 16 who underwent BK-IC, and 9 who underwent ONB-VIP. Most were healthy (24/37 with no comorbidities, 4/37 Charlson 1-2, 9/37 Charlson 3 or greater - we didn't considered bladder cancer in Charlson evaluation because bladder cancer was the main inclusion criteria). Women undergoing CUS endorsed worse FACT-BL scores compared with BK-IC and ONB-VIP patients, worse HRQOL regarding physical and emotional well-being (p=0.008 and p=0.02, respectively), and a trend toward worse EORTC QLQ-C30 scores for appetite loss and fatigue (p=0.05 for both).

CONCLUSIONS

In our study long-term disease-free females treated with CUS endorsed worse HRQOL compared with women who underwent BK-IC or ONB-VIP, mostly due to worse physical and emotional perception of their body image.

The future of regenerative medicine: urinary system

Regeneration of tissues and organs is now within the technological reach of modern medicine. With such advancements, substantial improvements to existing standards-of-care are very real possibilities. This review will focus on regenerative medicine approaches to treating specific maladies of the bladder and kidney, including the biological basis of regeneration and the history of regenerative medicine in the urinary system. Current clinical management approaches will be presented within the context of future directions including cell-based regenerative therapies.