Intracorporeal Versus Extracorporeal Neobladder After Robot-assisted Radical Cystectomy: Results From the International Robotic Cystectomy Consortium

OBJECTIVE

To compare perioperative and oncologic outcomes of intracorporeal (ICNB) and extracorporeal neobladder (ECNB) following robot assisted radical cystectomy (RARC) from a multi-institutional, prospectively maintained database, the International Robotic Cystectomy Consortium (IRCC).

METHODS

A retrospective review of IRCC database between 2003 and 2020 (3742 patients from 33 institutions across 14 countries) was performed (I-79606). The Cochran-Armitage trend test was used to assess utilization of ICNB over time. Multivariate logistic regression models were fit to evaluate variables associated with receiving ICNB, overall complications, high-grade complications, and readmissions after RARC. Kaplan Meier curves were used to depict recurrence-free, disease-specific, and overall survival.

RESULTS

Four hundred eleven patients received neobladder, 64% underwent ICNB. ICNB utilization increased significantly over time (P <.01). Patients who received ICNB were readmitted and received neoadjuvant chemotherapy more frequently (36% vs 24%, P = .03, 35% vs 8%, P <.01, respectively). ICNB was associated with older age (OR 1.04, 95% CI 1.01-1.07, P = .001), receipt of neoadjuvant chemotherapy (OR 4.63, 95% CI 2.34-9.18, P <.01), and more recent RARC era (2016-2020) (OR 12.6, 95% CI 5.6-28.4, P <.01). On multivariate analysis, ICNB (OR 5.43, 95% CI 2.34-12.58, P <.01), positive surgical margin (OR 4.88, 95% CI 1.29-18.42, P = .019), longer operative times (OR 1.26, 95% CI 1.00-1.58, P = .048), and institutional annual RARC volume (OR 1.09, 95% CI 1.05-1.12, P <.01) were associated with readmissions.

CONCLUSION

Utilization of ICNB increased significantly over time. Patients who underwent RARC and ICNB had shorter hospital stays and fewer 30-d reoperations but were readmitted more frequently compared to those who underwent ECNB.

Guar bean in urinary cytology: a morphologic pitfall

INTRODUCTION

Various types of contaminants can be encountered in cytologic specimens. This study describes a vegetable material that we encountered in ileal conduit urine specimens. We aim to describe the cytomorphology and the source of origin of this vegetable material.

MATERIAL AND METHODS

The cytology database for the past 5 years (January 2015-April 2020) was searched for ileal conduit urine cytology specimens with a reported vegetable contaminant. The details of the ostomy procedure and device used were recorded. Histologic sections were prepared from the ostomy devices as well as from guar beans and seeds.

RESULTS

A total of 17 urinary specimens from 8 patients were identified that showed the presence of a vegetable contaminant. All the patients were using Coloplast (Minneapolis, MN) SenSura Mio ostomy device. The urine cytology showed presence of polygonal thick-walled cells with a dark brown/orange core with irregular outlines. Similar cells were also seen in the histologic sections prepared from the ostomy adhesive and the guar seed and bean.

CONCLUSIONS

Guar gum is a naturally occurring hydrocolloid that is used in ostomy wafer adhesives. Correct identification and familiarity with the cytomorphology of the guar cells in samples of ileal conduit urine is essential to avoid a potential diagnostic pitfall when evaluating urine cytology specimens from these diversion specimens.

Infectious complications associated with the use of temporary prostatic urethral stents in patients with benign prostatic hyperplasia

INTRODUCTION

To examine the infectious outcomes after the insertion of the temporary prostatic urethral stent (TPUS) in benign prostatic hyperplasia (BPH) patients.

MATERIAL AND METHODS

Between November 2007 and September 2012, ninety TPUS were used in 33 patients with BPH at our institution. All patients had negative urine cultures prior to the first stent insertion. TPUS were sent for cultures at time of removal or exchange. Stents were removed at the time of definite surgical intervention, at 4-6 weeks, or when patients elected another course of treatment. Colonization was defined as asymptomatic positive stent culture. Infection was defined as symptomatic positive stent culture requiring treatment. Infection and colonization rates are reported. Logistic regression was used to examine the predictors of infection at any point. Predictors examined were age, body mass index, history of prostate cancer, diabetes mellitus, hyperlipidemia, coronary artery disease, neurologic disorder, erectile dysfunction and the sequence of stent placement.

RESULTS

The majority of the subjects, 72% (24/33) had 1-2 stents, 9.0% (3/33) had 3-4 stents, 6.0% (2/33) had 5-6 stents, and 12% (4/33) of patients had more than 6 stents. From the 69 available culture results, the symptomatic infection rate was 16% (11/69) (95% CI: 8.2%-26.7%). The colonization rate was 58% (40/69) (95% CI: 45.5%-69.7%). None of the predictors examined were identified as a predictor of infection. There was no colonization detected when stents were removed in the first 20 days.

CONCLUSION

Infection rates with TPUS in BPH patients are acceptable and early removal may prevent colonization.

Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial

BACKGROUND

Open radical cystectomy (ORC) and urinary diversion in patients with bladder cancer (BCa) are associated with significant perioperative complication risk.

OBJECTIVE

To compare perioperative complications between robot-assisted radical cystectomy (RARC) and ORC techniques.

DESIGN, SETTING, AND PARTICIPANTS

A prospective randomized controlled trial was conducted during 2010 and 2013 in BCa patients scheduled for definitive treatment by radical cystectomy (RC), pelvic lymph node dissection (PLND), and urinary diversion. Patients were randomized to ORC/PLND or RARC/PLND, both with open urinary diversion. Patients were followed for 90 d postoperatively.

INTERVENTION

Standard ORC or RARC with PLND; all urinary diversions were performed via an open approach.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Primary outcomes were overall 90-d grade 2-5 complications defined by a modified Clavien system. Secondary outcomes included comparison of high-grade complications, estimated blood loss, operative time, pathologic outcomes, 3- and 6-mo patient-reported quality-of-life (QOL) outcomes, and total operative room and inpatient costs. Differences in binary outcomes were assessed with the chi-square test, with differences in continuous outcomes assessed by analysis of covariance with randomization group as covariate and, for QOL end points, baseline score.

RESULTS AND LIMITATIONS

The trial enrolled 124 patients, of whom 118 were randomized and underwent RC/PLND. Sixty were randomized to RARC and 58 to ORC. At 90 d, grade 2-5 complications were observed in 62% and 66% of RARC and ORC patients, respectively (95% confidence interval for difference, -21% to -13%; p=0.7). The similar rates of grade 2-5 complications at our mandated interim analysis met futility criteria; thus, early closure of the trial occurred. The RARC group had lower mean intraoperative blood loss (p=0.027) but significantly longer operative time than the ORC group (p<0.001). Pathologic variables including positive surgical margins and lymph node yields were similar. Mean hospital stay was 8 d in both arms (standard deviation, 3 and 5 d, respectively; p=0.5). Three- and 6-mo QOL outcomes were similar between arms. Cost analysis demonstrated an advantage to ORC compared with RARC. A limitation is the setting at a single high-volume, referral center; our findings may not be generalizable to all settings.

CONCLUSIONS

This trial failed to identify a large advantage for robot-assisted techniques over standard open surgery for patients undergoing RC/PLND and urinary diversion. Similar 90-d complication rates, hospital stay, pathologic outcomes, and 3- and 6-mo QOL outcomes were observed regardless of surgical technique.

PATIENT SUMMARY

Of 118 patients with bladder cancer who underwent radical cystectomy, pelvic lymph node dissection, and urinary diversion, half were randomized to open surgery and half to robot-assisted laparoscopic surgery. We compared the rate of complications within 90 d after surgery for the open group versus the robotic group and found no significant difference between the two groups.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01076387, www.clinicaltrials.gov.

Bacterial characteristics and clinical significance of ureteral double-J stents in children

OBJECTIVE

To determine the incidence of urinary tract infection in those patients that we have used an ureteral double-J stent as internal diversion after urological procedures.

MATERIAL AND METHODS

We reviewed all the medical records of patients who had a ureteral double-J stent after a urological procedure from August 2007 to May 2013. We have analyzed the following data: age, gender, type of prophylaxis, incidence of urinary tract infection (UTI), days of internal diversion with double-J stent, surgical procedure, bacterial characteristics, bacterial sensibility to antibiotics and UTI treatment.

RESULTS

We have used 73 double-J stents as ureteral internal diversion in 67 patients with a mean age of 44.73±57.23. Surgical procedures were 50 laparoscopic Anderson-Hynes pyeloplasties in 49 patients, and 20 high-pressure balloon dilatation of the ureterovesical junction to treat primary obstructive megaureter in 15 patients; and 3 patients with ureterovesical obstruction after endoscopic treatment of vesicoureteral reflux. Forty three stents showed a bacterial colonization in cultures. Pseudomona aeruginosa was present in 9 (20.9%) stents. Only in 12 stents, bacterial colonization was sensible to antibiotic prophylaxis. Stent colonization was higher in boys and younger patients. Four patients had a febrile UTI. Incidence of UTI in younger patients that underwent HBPD of UVJ is higher.

CONCLUSION

Bacterial colonization is frequent in double-J stents but the incidence of UTI is low. Double-J colonization is higher in younger patients. Patients that underwent HPBD have a higher risk of UTI related with ureteral double J stent.

The Studer orthotopic neobladder: long-term (more than 10 years) functional outcomes, urodynamic features, and complications

PURPOSE

Radical cystectomy and urinary diversion are the standard treatment for invasive bladder cancer. We analyzed the long-term (>10 years postoperatively) functional outcomes, complications, and urodynamic findings in a single center series of patients who underwent cystectomy and a Studer ileal neobladder substitution.

MATERIALS AND METHODS

A retrospective chart review of 108 Studer pouches constructed during 1990 and 2011 was performed. Data were analyzed in terms of long-term (>10 years) outcomes. Complications, incontinence, voiding difficulties, upper urinary tract changes, overall satisfaction, and urodynamic findings of the reservoir were obtained.

RESULTS

We evaluated 19 out of 50 patients who had lived for over 10 years postoperatively. Another 31 patients were not traced: 7 patients died following recurrence, 15 died due to exacerbation of a comorbidity, and 9 patients were lost to follow-up. Concerning complications, 6 patients had an atrophied kidney, 5 patients had moderate hydronephrosis, 5 patients had chronic recurrence of pylelonephritis, and 2 patients had voiding difficulty because of bladder neck stricture due to clean intermittent catheterization. One patient underwent an operation due to intestinal obstruction. Seven patients had incontinence; all 7 patients showed intermittently at night and 2 patients even in waking hours. Maximum bladder capacity was 484.1±119.2 mL, maximum flow rate was 13.6±9.7 mL/sec, and post-void residual urine volume was 146.8±82.7 mL.

CONCLUSION

Long-term outcomes with the Studer orthotopic ileal neobladder have an acceptable complication rate and good functional results. However, potential adverse outcomes such as renal deterioration, dysfunctional voiding should also be considered.

[Indications for different types of urinary diversion]

When urinary diversion is indicated, patient information concerning the advantages and disadvantages of different types of urinary diversion and their choices is of utmost importance for the functional outcome and patient satisfaction. There is a variety of choices for incontinent urinary diversion (ureterocutaneostomy, ileal conduit, colonic conduit) and continent urinary diversion (continent anal urinary diversion, continent cutaneous urinary diversion and urethral bladder substitution). In the individual case, the choices may be limited by patient criteria and/or medical criteria. Important patient criteria are preference, age and comorbidity, BMI, motivation, underlying disease and indication for cystectomy. Medical criteria which possibly limit choices of type of urinary diversion are kidney function/upper urinary tract status and limitations concerning the gastrointestinal tract, concerning urethra/sphincter as well as the ability and motivation to perform intermittent self-catheterization. Preoperative information may use simulation of certain postoperative scenarios (urethral self-catheterization, fixation of water-filled conduit bags, holding test for anal liquids) to allow the individual patient to choose the optimal type of urinary diversion for his/her given situation from the mosaic of choices and possible individual limitations.

[Placement of dual double-J stents following high-pressure balloon angioplasty for treatment of ureter-ileum bladder anastomosis stricture]

OBJECTIVE

To evaluate the benefit of placement of dual double-J stents following high-pressure balloon angioplasty for treatment of ureter-ileum anastomosis stricture after total bladder resection.

METHODS

Seventeen patients (11 males and 6 females, mean age 56.65±6.28 years, 23 sides) undergoing total bladder resection were included in this study. Unilateral and bilateral ureteral stricture occurred postoperatively in 11 and 6 patients, respectively; 13 patients had ureter-ileum bladder anastomosis stricture after ileal bladder substitution, and 4 patients had ureter-ileum stricture after orthotopic construction of ileal neobladder. The control group consisted of 21 patients undergoing open surgery.

RESULTS

In the double-J stenting group, the effective rate was 82.6% (19/23), similar to that of 85.7% (18/21) in the control group (P>0.05). Compared with the control group, the stenting group showed a significantly reduced mean time of operation (87.42±10.35 min vs 34.12±7.52 min, P<0.05), intraoperative blood loss (203.16±32.67 ml vs 21.54±6.15 ml, P<0.05), and mean postoperative hospital stay (10.12±1.19 vs 3.24±0.35 days, P<0.05).

CONCLUSION

As a safe and minimally invasive approach to the management of ureter-ileum bladder anastomosis stricture, placement of dual double-J stents following high-pressure balloon angioplasty produces a effect comparable with that of open surgery.

Orthotopic ileal bladder substitution following radical cystectomy using the linear-cutter stapling device

We evaluated the safety, efficacy, and potential benefits of using the linear-cutter staplers in the ileal reanastomosis and ileal pouch reconstruction following radical cystectomy in patients with invasive carcinoma of the urinary bladder. Radical cystectomy and orthotopic ileal bladder substitution procedures were performed in 40 patients with invasive carcinoma of the urinary bladder. In 20 patients the linear- cutter stapling device was used for the ileo-ilial reanastomosis and reconstruction of the pouch, while in the other 20 patients the standard hand-suturing technique was used. Using the linear-cutter stapler in the ileo-ileal reanastromasis and ileal pouch reconstruction saved approximately 60 to 90 minutes of operative time, and there was also a significant reduction of blood loss during this period. The leakage rate and hospital stay were less in patients with a stapled pouch. Urodynamic characteristics were comparable to standard ileal neobladders.

Stoma care nursing management: cost implications in community care

Successfully rehabilitating the stoma patient in the community means continuing the care provided by the hospital and preparing the patient for this new phase of life. It is well documented that this transition from hospital to home can often be a difficult time for the stoma patient and that home visits and ongoing support from the district nursing team are needed for many patients in the long term. This article aims to help community nurses understand the needs of the stoma patient in their homes and looks at the current situation, including costs, of supplying stoma appliances in the community.

Percutaneous ureteral catheterization in laparoscopic surgery: value of nephroscopy needle trocar

OBJECTIVES

To report our experience with use of the nephroscopy needle trocar for percutaneous catheterization. In multiple urologic procedures, surgeons use ureteral catheters to decrease morbidity, increase the success rate, and allow for postoperative radiographic follow-up. The advent of laparoscopic surgery has logically required catheterization to be adapted to our laparoscopic procedures.

METHODS

The expansion of our daily practice to include multiple laparoscopic procedures showed us the difficulties inherent to ureteral catheterization in laparoscopic surgery. During our experience of >1000 laparoscopic procedures, we have used more or less complex catheterization techniques. After developing the use of the nephroscopy needle trocar for laparoscopic urinary diversion and finding that such use simplified the procedure, this technique was extended to all other laparoscopic procedures in which catheterization is required.

RESULTS

We analyzed the use of the nephroscopy needle trocar in 15 ureteropyeloplasty, 21 ileal conduit, and 4 laparoscopic ureteral reimplantation procedures. The mean operating time required for anterograde catheterization in ureteropelvic junction stenosis was 3 minutes, 35 seconds, and the mean operating time for retrograde catheterization was 2 minutes, 20 seconds. Anterograde catheterization was impossible in 1 case. No cases of a false ureteral tract occurred.

CONCLUSIONS

The results of our analysis have shown that the use of the nephroscopy needle trocar for percutaneous catheterization in laparoscopic surgery markedly simplifies the procedure, with the resultant savings in operating time.

Use of External Ureteral Catheters and Internal Double J Stents in a Modified Ileal Neobladder for Continent Diversion: A Comparative Analysis

INTRODUCTION

Open-ended straight ureteral stents are typically used for the support of the ureteroileal anastomosis during the creation of an orthotopic 'S-pouch' ileal neobladder. The use of double J stents as an alternative in this setting is evaluated.

MATERIALS AND METHODS

Medical charts from 43 patients undergoing radical cystectomy with formation of an ileal 'S-pouch' neobladder were retrospectively evaluated. In 30 patients (group A), a 6-Fr open-ended straight ureteral catheter was used to stent the ureteroileal anastomosis, while a double J stent was used for the same reason in 13 patients (group B). The ureteral catheter was removed 15 days after the procedure while the double J stent 3 weeks postoperatively. Hospital stay, early and late complications were evaluated for both groups during a mean follow-up period of 22.5 and 19.6 months respectively.

RESULTS

Stricture of the ureteroileal anastomosis was observed in 2 (6.6%) and 1 (7.6%) patient of groups A and B respectively. All complications presented with similar rates, except for an increased but not statistically significant incidence of urethrovesical anastomotic leakage and early urinary tract infections in group B. Hospital stay was significantly (p<0.005) shorter for patients of group B (9.9 vs. 15.2 days).

CONCLUSIONS

The use of double J stents to support the ureteroileal anastomosis can be used as an alternative to open-ended ureteral stents. With double J stents a shorter hospital stay was achieved with similar complication rates but a higher incidence of upper urinary tract infections.

[Coating with plasma-deposited functionalized diamond-like carbon to decrease encrustations on urological implants]

The double-J stents used today for palliative artificial urinary diversion very often show extreme formation of encrustations, even a short time after implantation. Despite increased scientific material development, the complication rate has not really been strongly influenced. Grant-aided by the German Federal Ministry of Education and Research, we chose a new interdisciplinary and translational approach by coating standard stent materials with plasma-deposited amorphous diamond-like carbon. These stents show clearly reduced rates of encrustation in vitro. Ongoing clinical trials demonstrate a further enhancement of this effect in vivo. The underlying mechanisms are being investigated by extending the established in vitro model, thereby pushing research in this field to a new level.

[Development of continent reservoirs]

Continent reservoirs represent an alternative to urostomy. Various operation techniques are available and the historical development will be described here with respect to the use of different parts of the intestine.

Da Vinci assisted cystoprostatectomy and urinary diversion: a paradigm shift in surgical management of bladder cancer

Radical cystoprostatectomy remains the gold standard treatment for muscle invasive bladder cancer. Use of minimally invasive approaches have gained prominence aided by surgical adjuncts such as harmonic scalpel and laparoscopic bowel staplers, however laparoscopic radical cystoprostatectomy remains extremely technically challenging even for experienced laparoscopic surgeons. Following the successful application of the da Vinci robotic surgical system for radical prostatectomy, attention has now turned to the use of robot assistance for laparoscopic cystoprostatectomy. Several centers have explored the feasibility of robotic cystoprostatectomy although long-term data is lacking. Controversy exists on the oncologic efficacy and safety, need for intracorporeal diversion and standardization of technique. This article details the history, technique, results and current status of robotic cystoprostatectomy and urinary diversion.

Case report: relief of acute obstruction of the Detour subcutaneous pyelovesical bypass

A 36-year-old patient was admitted to the emergency department with complaints of severe flank pain, nausea, vomiting, anuria, and general illness. Five months earlier, we had placed a subcutaneous pyelovesical prosthesis (Detour; Porges) of the ureter for treatment of a chronically dilated upper urinary tract in a solitary right kidney previously treated by double-J stenting. Ultrasonography of the right kidney revealed severe hydronephrosis. A percutaneous nephrostomy catheter was placed, and antegrade pyelography showed complete obstruction of the prosthesis. Urinalysis and culture demonstrated a Candida infection. A systemic antimycotic was administered, and fluid management was started. On the third day, diuresis appeared, and antegrade nephrostomography confirmed patency of the bypass.

Radical cystectomy with ileal conduit diversion: early prospective evaluation of the impact of robotic assistance

OBJECTIVE

To compare the performance of radical cystectomy with ileal conduit diversion by standard methods with that using the assistance of the daVinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA).

PATIENTS AND METHODS

From November 2003 to August 2005, we performed 30 radical cystectomies with ileal conduit urinary diversions on patients with bladder cancer. Seven patients (one woman) had a cystectomy with the daVinci system and 23 (nine women) had a standard cystectomy. Data were collected prospectively, including estimated blood loss (EBL), transfusion requirement, operative duration, hospital stay and body mass index (BMI), and compared.

RESULTS

The mean EBL and transfusion requirements for standard and daVinci-assisted cases was 1109 and 479 mL (P = 0.002) and 2.7 and 1.6 units (P = 0.14), respectively. Four of seven patients received a transfusion in the robotic group, and 20 of 23 in the standard group (P = 0.084). The mean operative duration was 638 and 507 min (P = 0.005) for the daVinci and standard group, respectively, with respective mean hospital stays of 11 and 13 days (P = 0.52). There was no difference in patient BMI between the groups (P = 0.22).

CONCLUSION

The daVinci-assisted cystectomy appears to offer some advantages over standard cystectomy. Larger randomized studies are needed to confirm these findings.

Basics of ostomy care

Teaching the patient how to care for a new ostomy can be a challenging experience for the nurse. The patient with an ostomy needs encouragement, support, and counseling to learn how to integrate self-ostomy care into daily activities. Collaboratively, the WOCN and medical-surgical nurse can provide the patient and his or her family with a more comprehensive approach to ostomy teaching.

LAPAROSCOPIC RADICAL CYSTECTOMY IN THE FEMALE

PURPOSE

We detail the technique of completely intracorporeal laparoscopic radical cystectomy in the female patient, which has previously not been well described in the literature. Additionally, perioperative and short-term oncological outcome data are presented.

MATERIALS AND METHODS

Since 2000, 11 female patients underwent laparoscopic radical cystectomy for bladder carcinoma. Data were collected with respect to patient demographics, perioperative outcomes and short-term oncological followup.

RESULTS

Mean patient age was 66 years (range 42 to 80) and the mean body mass index was 25 (range 17 to 34). Mean total operative time was 8.5 hours (range 6.5 to 10.5), including an average radical cystectomy time of 2 to 2.5 hours. Estimated blood loss was 489 cc (range 150 to 1,000). Reconstructive procedures were an ileal conduit in 8 patients, Studer orthotopic neobladder in 2 and continent Indiana pouch in 1. Mean hospital stay was 6 days (range 5 to 12). No case was converted to open surgery. Complications occurred in 4 patients, including internal hernia requiring laparotomy 19 days postoperatively, deep vein thrombosis with pulmonary embolism, dehydration and urinary tract infection in 1 each. At a median followup of 7.1 months (range 1 to 19) 8 patients (73%) had no evidence of disease, 1 (9%) had metastasis and 2 (11%) had died.

CONCLUSIONS

Laparoscopic radical cystectomy in the female is technically efficacious. Our techniques of anterior pelvic exenteration, and uterus/fallopian tube/ovary and nerve sparing laparoscopic female radical cystectomy are presented. Short-term functional and oncological outcomes appear favorable.

Subcutaneous Nephrovesical and Nephrocutaneous Bypass

OBJECTIVE

We evaluated the effectiveness of the subcutaneous bypass for ureteral obstruction in patients with advanced malignancies. Two versions of the minimally invasive technique were performed: nephrovesical and nephrocutaneous bypass.

METHODS

A specially designed composite implant consisting of an inner smooth silicone-covered tube covered by a coiled e-PTFE-tube was used in 14 patients.

RESULTS

10 subcutaneous nephrovesical bypasses were inserted in 10 patients, 8 nephrocutaneous bypasses in 4 patients. During the mean follow-up period of 13.1 months complications were observed in 2 patients with nephrocutaneous bypass, one encrustation and one infection of the bypass system.

CONCLUSIONS

The subcutaneous nephrovesical and nephrocutaneous bypass is a safe alternative for palliative treatment of ureteral obstruction caused by pelvic malignancy.

Robot-assisted radical cystectomy and urinary diversion

Radical cystectomy remains the standard for muscle-invasive, organ-confined urothelial carcinoma of the bladder. With the emergence of minimally invasive approaches for the treatment of urologic cancers, technologic advances using laparoscopy have led to the development of robotic assistance to increase the feasibility of performing this formidable operation. In this article, we describe the procedure of robotic-assisted laparoscopic radical cystectomy with urinary diversion and review the pertinent literature.

Robotic radical cystectomy and urinary diversion in the management of bladder cancer

The authors have explored the versatility of the da Vinci robot for pelvic surgery to develop the technique of robotic radical cystectomy in conjunction with the Urology and Nephrology Center in Mansoura, Egypt, a world leader in conventional (open) cystectomy. This approach, which is designed to minimize the time required for surgery, is a sandwich technique in which the cystectomy and the neobladder-urethral anastomosis are performed with robotic assistance and the urinary diversion is performed extracorporeally. This article reviews the published literature and details the authors' current technique of robotic radical cystectomy and urinary diversion.

Robot-Assisted radical cystectomy and urinary diversion in female patients: technique with preservation of the uterus and vagina1 1No competing interests declared

BACKGROUND

After performing more than 500 robotic radical prostatectomy and robotic radical cystoprostatectomy in men, we attempted to develop the technique of robot-assisted radical cystectomy in women. This article describes two techniques of robot-assisted radical cystectomy for women, conventional and with preservation of the uterus and vagina. To the best of our knowledge, this is the first case series of robot-assisted radical cystectomy and urinary diversion in women.

STUDY DESIGN

Robot-assisted radical cystectomy was undertaken in three female patients with transitional cell carcinoma of the urinary bladder. The operation was performed with the conventional anterior approach in one patient and with a new technique in two patients, which allows preservation of urethra, uterus, vagina, and both ovaries. As planned, the radical cystectomy was done robotically, using the da Vinci Surgical System (Intuitive Surgical). The bladder was entrapped in an Endocatch bag and removed through a small subumbilical incision. Urinary reconstruction was performed extracorporeally after exteriorizing the bowel through the incision used for retrieving the specimen. In two patients, the reconstructed pouch was placed in the pelvis and the abdominal incision was closed. Urethroneovesical anastomosis was done robotically, using a technique described previously for men.

RESULTS

The average operating time for the robotic radical cystectomy was 160 minutes and the mean operating times for ileal conduit and orthotopic neobladder were 130 minutes and 180 minutes, respectively. The mean blood loss was less than 100 mL. The mean number of lymph nodes removed was 12 (range 3 to 21). Surgical margins were free of tumor in all three patients.

CONCLUSIONS

This approach incorporates advantages of minimally invasive and open surgery. Performing the radical cystectomy with the robot allows precise and rapid removal of the bladder with minimal blood loss. Extracorporeal reconstruction of the urinary tract reduces operative time at this stage of evolution of laparoscopic and robotic instrumentation. In the future, with the development of technology, instrumentation, and with additional refinement of our technique, the entire procedure may be done completely intracorporeally with equal efficiency.

Feasibility of robot-assisted totally intracorporeal laparoscopic ileal conduit urinary diversion: initial results of a single institutional pilot study

OBJECTIVES

To explore the use of the da Vinci Surgical Robotic System (DSRS) to assist in the completion of totally intracorporeal laparoscopic ileal conduit urinary diversion (TLIC).

METHODS

Two patients with radiation cystitis underwent TLIC procedures and another patient with bladder cancer underwent TLIC along with laparoscopic radical cystoprostatectomy at our institution. The ileal conduit urinary diversion was done totally intracorporeally using conventional laparoscopic techniques, and the DSRS was used to assist in the Bricker-type ureteroileal anastomosis.

RESULTS

The 3 patients in the study included 2 men and 1 woman (mean age 73 years, range 64 to 84). The TLIC was completed intracorporeally in all 3 patients without the need for open conversion. The operative time, estimated blood loss, intraoperative decrease in hemoglobin, and time to hospital discharge for the 2 patients undergoing TLIC and the patient undergoing TLIC along with radical cystoprostatectomy was 628, 616, and 828 minutes, 50, 200, and 500 mL, 1.7, 2.8, and 5.3 g, and 5, 7, and 10 days, respectively. The median follow-up was 4.5 months (range 3.5 to 5.5). Postoperative satisfactory drainage of both kidneys was confirmed in all 3 patients at 8 weeks or later by intravenous urography or renal nuclear imaging. The serum creatinine remained stable in all 3 patients after surgery at hospital discharge. The only complication noted was postoperative ileus in the patient undergoing radical cystoprostatectomy that resolved with conservative management.

CONCLUSIONS

TLIC is technically feasible and safe and can be done intracorporeally without complications. The DSRS can be successfully used to assist in the completion of TLIC. However, that each case lasted for more than 600 minutes highlights the need for further refinement in the technique. The practical application of TLIC requires improved long-term outcomes compared with open surgery, as well as a reduction in the operative time to justify the costs of robotic surgery.

Laparoscopy-Assisted Robotic Radical Cystoprostatectomy with Ileal Conduit Urinary Diversion for Muscle-Invasive Bladder Cancer: Initial Two Cases

BACKGROUND AND PURPOSE

The use of the da Vinci robot is being investigated in the discipline of urologic surgery. We describe our experience with its use during radical cystoprostatectomy in two patients with organ-confined bladder cancer.

PATIENTS AND METHODS

Laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion was performed using the da Vinci robot. Both patients were informed about this new approach, and informed consent was obtained.

RESULTS

There were no intraoperative or postoperative complications. The operative time was 10 and 12 hours. A clear liquid diet was started on the third postoperative day. Final histopathology examination in both patients revealed T(3a)N(0)M(0) transitional-cell carcinoma. The hospital stay was 6 days. Both patients returned to normal activity within 2 weeks.

CONCLUSION

Robot-assisted laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion for muscle-invasive bladder cancer is feasible.

Robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic ileal neobladder

PURPOSE

To describe our technique of robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic neobladder (Hautmann) for treatment of transitional cell carcinoma of the bladder.

METHODS

We describe our surgical technique in the worldwide first attempt to perform a robotic-assisted laparoscopic radical cystectomy and completely intra-abdominal formation of an orthotopic neobladder. The DaVinci System (Intuitive Surgical, Mountain View, CA, USA) was utilized to perform the procedure.

RESULTS

Utilizing the DaVinci System the operation could be performed without any complications. Operating time was 8.5 hours, blood loss was 200 ml. The oncologic as well as the functional result of the reservoir were excellent.

DISCUSSION

We here demonstrated that sophisticated laparoscopic procedures like the intra-abdominal formation of an orthotopic neobladder are accomplishable with robotic assistance.

[Prosthetic pyelovesical and pyelocutanous bypass. A palliative therapy concept in tumor-induced chronic hydronephprosis]

MATERIALS AND METHODS

Since 2/02 to 2/03 a total of 13 patients underwent either pyelovesical bypass (10 patients) or pyelocutaneous bypass (3 patients). A composite implant, consisting of two coaxial tubes internal pure smooth silicone covered by coiled e-PTFE has been designed to serve as the ureteral replacement. This prothesis in inserted percutaneously into the renal pelvis, tunnelled subcutaneously, and introduced through a small suprapubic incision in the bladder or out directly through a cutaneous orifice.

RESULTS

One encrustation of the subcutaneous pyelocutaneous bypass was observed, no angulation or dislocation during a mean follow up of 6.2 month. Improvement in the quality of life was stressed in all patients.

CONCLUSIONS

The subcutaneous urinary division using a silicone-PTFE prothesis is an efficient and minimal-invasive technique to attend malignant obstructions of the ureter.

Frequency of peristomal complications

Practicing wound ostomy continence (WOC) nurses see peristomal complications in their ostomy patient population. The exact frequency and cause of these complications are unknown. Research into problems arising from prolonged use of ostomy appliances is lacking. To ascertain the frequency of peristomal complications, two WOC nurses at a major medical center prospectively assessed the peristomal skin of all new ostomy patients returning for their 2-month postoperative check-up using a peristomal complications tool. The study was conducted from August 1999 to August 2000. Descriptive statistics were used to summarize the data. In the course of the study, 161 new ostomy patients were seen, 10 with peristomal complications, for a frequency of 6%. The frequency of peristomal complications was the highest in people with ileal conduits (five of 34, 15%) and ileostomies (four of 46, 9%). Only one of the 81 people with a colostomy developed peristomal complications. All 10 patients had a retracted stoma. Eight had chemical damage (six with irritant dermatitis, two with pseudoverrucous lesions) and two had Candida infections. Although the study sample size is small, the results suggest that patients with ileal conduits and patients with retracted stomas may require more frequent follow-up visits to monitor skin conditions and pouching modifications.

Double-J ureteral stents: an alternative to external urinary stents in orthotopic bladder substitution

OBJECTIVE

The aim of this study was to compare advantages and disadvantages of using double-J or external stents to preserve the uretero-ileal anastomosis in patients receiving an orthotopic neobladder.

METHODS

77 consecutive patients with bladder cancer who underwent radical cystoprostatectomy and Studer neobladder were evaluated. All patients received a direct spatulated end-to-side uretero-ileal anastomosis in the afferent loop (Nesbit technique). In 45 patients (group A), the stents (Bracci ureteral splint) were brought our through the reservoir and anchored to the skin; in 32 patients (group B), an internal double-J stent was used. Median follow-up was 30 months.

RESULTS

9 (11.5%) uretero-ileal anastomosis strictures in group A and 7 (11.6%) in group B were observed. There was a significant difference in the side of stricture with a greater prevalence on the left side (p<0.004). Stricture formation and side were not related to the type of stent used. 14 (20%) neobladder-ureteral refluxes occurred, with a non-significant difference between the two groups (p = 0.37). 12 patients (86%) were asymptomatic; two patients developed pyelonephritis and needed antibiotic treatment. Neobladder catheter was removed after 17 days (range: 15-18 days) and 14 days (range: 12-15 days), respectively, in group A and group B with an earlier discharge of the patients in group B. There was a significant difference in mean hospital stay between the two groups (Mann-Whitney test p<0.0001). Discomfort related to the stent was mild for most of the patients of group B (84%).

CONCLUSIONS

Internal stenting is an equally effective alternative to external stent in patients undergoing bladder replacement. The use of double-j stents appears to be associated with minimal discomfort, earlier mobilization and a shorter hospital stay.

The state of the standard diversion

A fecal or urinary diversion is frequently recommended for a variety of patient conditions. This article will review some of the history of stoma creation, discuss current practices in stoma care, and summarize the current literature regarding stomal complications. Outcomes of fecal and urinary diversion procedures will be depicted, and postoperative quality of life will be described. An update of current ostomy equipment will be presented, along with the crucial role of the WOC nurse in stoma care rehabilitation. Areas for future research in the ongoing drive for evidence-based practice will be highlighted.

A practical ostomy guide. Part one

Ostomy surgery is a life-enhancing procedure that restores a vital bodily function, but it's not easy to accept. In a two-article package, we'll walk you through the nursing care that will help patients accept the physical changes their surgery entails. In this article, we review the most commonly performed ostomies and the basics of teaching self-care techniques. Next month, we'll look in more depth at the care and education of patients who don't need to worry about changing an external pouch--their condition allowed the creation of a more normal excretory route through an internal pelvic pouch.

[Trials with a new potentially biodegradable ureteral stent. In vitro results with GX 100-15 LB]

We detected a special plastic, which is stable in an acid environment and dissolvable in a basic one. Our preliminary in-vitro results show that the tested material therefore seems principally designed for developing biodissolvable stents for temporary urinary diversion out of the upper urinary tract. Stableness and dissolution could be steered by manipulating the pH.

[Improved tumor stent for internal palliative urinary diversion]

The disadvantages of high flexible endoureteral stents (DJ) in case of tumorinduced extrinsic ureteral compression are due to an insufficient vertical stability of the used stents leading to stent-compression and consecutive hydro- or pyonephrosis. The new developed tumor-stent used in case of tumor-induced ureteral compression is available from 6 to 8 French in diameter and 24 to 32 cm in length. The corpus consists of a combination of high-stability plastics but is of sufficient elasticity in length. Both ends consist of extremely elastic J-parts guaranteeing an exact fixation. As against common DJ's with the same outside-diameter the new stent has a comparable interior diameter and compared to used "old" tumor stents promises a higher interior flow in case of extrinsic diseases. The application can be undertaken in well-known technique, needs no special instrumentation and no learning-curve. To date 52 stents at our urologic departments were placed without any problems, the latest remaining for 15 months. Tumor-induced compression or a higher rate of encrustation could not be seen. All patients tolerated these stents well. In our opinion the new stabilized endoureteral stent can be seen as a better solution instead of percutaneous nephrostomy or frequent stent changing in patients with tumor induced extrinsic ureteral compression.

In vitro results with special plastics for biodegradable endoureteral stents

Internal ureteral stents are widely used in urologic practice for temporary urinary diversion, but all double-J catheters to date exhibit the same disadvantage; that is, they have to be removed endoscopically, necessitating further intervention. We tested different materials (designated G100X-15xLB and G100X-20xLB) to develop a biodegradable (biodissolvable) endoureteral stent that can be held in place without functional loss yet could be dissolved by changing the environment. The principle of the biochemical background is based on the physiological milieu of the urine. The plastics tested are stable in acidic and dissolve in alkaline conditions. In a first step, specimens of two polymers were placed in artificial urine of different pH over a period of 60 days and monitored for integrity (solution trial). In a second step, artificial urine was set in motion (744 mL/24 hours) an infusion pump (Volumed microVP 5000; Fresenius AG, Bad Homburg vdH, Germany) through an infusion set in which a 30-cm piece of the materials to test had been placed (ureter model). Below the inserted specimen, the lumen of the infusion tube was minimized to make obstruction by fragments more possible. In the solution trial, all specimens remained stable under physiologic conditions (pH 5.2) over a period of at least 30 days. The specimens dissolved completely when the pH was adjusted to an alkaline one (pH 7.9). In the ureter model, with pH values of 7.9, all specimens were decomposed after 20 hours, and no occlusion of the model occurred. Using acidic artificial urine, the specimens remained stable with a smooth consistent surface. The dissolution was not a standard chemical one; the materials broke into microscopically small pieces, with fragments of G100X-20xLB being smaller than those of G100X-15xLB. Our first in vitro results show that the tested materials are suitable for further development of biodissolvable endoureteral stents, dissolution of which can be steered by changing the urinary pH.

[Postoperative complications after Mainz pouch construction--with emphasis on measures to deal with narrowing of the duct aperture]

Thirty patients underwent Mainz pouch construction between December 1992 and January 1998. The post-operative observation period varied from 6 to 57 months (average, 38.5 months). A mechanism to ensure urinary continence was provided in 24 cases, while formation of a nipple valve by intussusception of the ileum with seromuscular stripping and submucosally embedded in situ appendix was performed in 6 cases. An umbilical stoma was adopted in all cases. Late-phase complications included 3 cases of hydronephrosis requiring treatment. Efferent limb of the stoma was observed in 8 cases, 6 of which were attributable to mild constriction of the stoma at the site of anastomosis of the navel cavity. In those cases in which stomal stricture occurred, difficulty in withdrawing urine was eliminated by providing a fistula stopper. Although few clinical methods to deal with stomal stricture have been reported, we found the fistula stopper to be useful providing good external appearance and patients' quality of life.

[Use of the Valtrac ring for digestive anastomoses in urology: apropos of 16 cases]

The Valtrac ring is a biofragmentable ring used for gastrointestinal anastomoses. Over a two-year period, 15 anastomoses in 16 patients (mean age: 60 years) were performed with the Valtrac ring: 10 ileal, 4 ileocolonic, and 1 jejunojejunal anastomoses. One anastomosis could not be performed because of an excessively narrow ileal lumen. The mean stay in the intensive care unit was 3 days: gastric aspiration was maintained for an average of 1 week, as return of gastrointestinal motility was long, with first flatus on the 6th day and the first stools on the 7th day. Complications consisted of 2 cases of gastrointestinal fistula (11th and 13th days) one of which was fatal, evisceration on the 7th day, a transient partial bowel obstruction and one bowel obstruction treated medically on the 27th day, due to pancreatitis. Our results are not identical to those reported in the literature. It is often difficult to insert the current form of the Valtrac ring into a healthy ileum, as the smallest ring is often too large. In contrast with gastrointestinal surgery, the anastomoses performed in urology involve a non-thickened, non-distended small intestine.

Techniques for stenting the normal and obstructed ureter

Ureteral obstruction is a common cause of urologic morbidity requiring quick and effective treatment, as prolonged obstruction can cause pain, infection, and eventual loss of renal function. Few would argue that initial drainage or bypassing of the obstruction is favorable initial management; however, urologists are often-times faced with technically difficult cases not responsive to the standard operative maneuvers. Recognizing the diversity of pathology and the potentially complicating issues, urologists should have in their armamentarium a systematic approach or algorithm for dealing with these common dilemmas, as well as an understanding of various tricks of the trade. This knowledge will prevent heightened anxiety at the time of surgery and will ensure the availability of the proper operative equipment. This article outlines an approach and discusses the obstacles and options in stenting the obstructed ureter.

Experimental and clinical experience with new pyeloureteral stents in pediatric urology

In light of the many problems with the use of conventional external stents in supravesical reconstructive urinary tract surgery in children; e.g. the risk of infection, urodynamic malfunction, and lack of flexibility insertion methods, the return to internal pyeloureteral stenting is a much discussed topic in pediatric urology. In order to improve the generally unsatisfactory situation, we developed, together with the Rüsch Co., a new type of directable and deconnectable ureteral stent. This polyurethane catheter features a membrane valve made of soft Wiruthan at the bladder end, which closes automatically with increasing bladder pressure. Thus, urinary backflow from the urinary bladder into the renal pelvis is prevented. Experimental data from antireflux stenting justify the clinical use of such a stent in children, as the urodynamic in vivo criteria and requirements were fulfilled completely. We now have clinical experience with the application of 340 pyeloureteral DD stents in 241 children from 1993 through 1996; 259 stents were inserted intraoperatively, and 81 stents were applied by endoscope. It was impressive that secondarily, renal function that had been considerably reduced could be regained and stabilized by long-term stenting, even in some older children with chronic supravesical ureteral obstruction. Although small technical details have to be clarified, such as simplification of stent retrieval and an antireflux valve that can be applied using an anterograde approach, the DD valve stent used in this patient population after reconstruction of a malformed supravesical urinary tract can be recommended without any reservations.

Management of recurrent stricture of appendicostomy in continent neobladder (Indiana pouch) with Memotherm ureteral stent: case report

The authors report their experience in the treatment of recurrent stricture of the appendiceal stump in continent diversion (Indiana pouch) after cystectomy by means of the Memotherm ureteral stent. The patient presented was treated successfully with this device after failure of repeat cold-knife incisions of the stricture. At 9-months' follow-up from positioning, the stent is in place, covered by mucosa. Self-catheterization of the pouch is easily performed five or six times a day with a 12F catheter.