Bladder Substitution Research Articles

A catheterizable serous-lined urinary outlet associated with the ileal bladder augmentation Abol-Enein and Ghoneim procedure: a safe and reliable procedure in children.

This study aims to evaluate the long-term outcome of the serous-lined extramural continent catheterizable outlet procedure (SLECCOP) associated with ileal bladder augmentation in children. This was a monocentric and retrospective study (2002-2021) that included children (<18 years) undergoing the SLECCOP associated with W-shaped ileocystoplasty with a catheterizable channel (Abol-Enein and Ghoneim procedure). Patients who received other types of bladder augmentation or W-shaped ileocystoplasty without a catheterizable channel were excluded. Patient records were reviewed for demographic information, surgical data, and long-term outcomes. This study included 52 children [33 boys, median age: 8.5 (0.8-18) years]. Pathological conditions included 28 children with the bladder exstrophy and epispadias complex (BEEC), 11 with neurogenic bladders, and 13 with other pathologies. Two patients underwent total bladder substitution. Thirty-four (65%) patients had bladder neck reconstruction (BNR), with 23 undergoing the SLECCOP and ileocystoplasty and 11 having prior BNR. All stomas, except for two, were umbilical, and were associated with omphaloplasty in 28 patients with the BEEC. A total of 40 stomas were created using the appendix (77%) and 12 with a Monti tube (23%). Stoma-related complications included cutaneous strictures (n = 2, 4%) and leaks (n = 10, 19%), all treated by dextranomer/hyaluronic acid copolymer injection (n = 10). A redo surgery was required in three patients: extraserosal wrapping was performed for persistent leakage (n = 2, 4%), and surgical revision was required for the Monti tube procedure (n = 1, 2%). Three patients (6%) underwent dilatation for transient stoma stenosis. Leakage occurred in 20% of appendix channels (n = 8/40) and 17% of Monti tubes (n = 2/12). Strictures were reported in 3% of appendix channels (n = 1/40) and 8% of Monti tubes (n = 1/12). Bladder stones developed in four patients (8%). Channel leakage persisted in one patient (2%) at a median follow-up of 4.4 years (IQR 1.4-9.7). W-Ileal bladder augmentation with the SLECCOP is an efficient technique for treating children with incontinence caused by different etiologies. The rate of channel complication is very low, specifically for strictures, in this complex population of patients.

HF01-14 THE ETYMOLOGY OF THE NEOBLADDER

You have accessJournal of UrologyCME1 Apr 2023HF01-14 THE ETYMOLOGY OF THE NEOBLADDER Friedrich H. Moll and Richard Hautmann Friedrich H. MollFriedrich H. Moll More articles by this author and Richard HautmannRichard Hautmann More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003243.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The idea to replace the bladder following cystectomy was born in 1888. For 100 years to follow the reservoir had a tubular shape. Since 1988 after the advent of detubularization and crossfolding the shape was globular. More than 50 eponyms have been proposed for orthotopic bladder substitution (OBS). The goal of this presentation is to analyse ethymology and history of the “neobladder”. METHODS: The authors comprehensive OBS registry was reviewed for the OBS terms. For the analysis 1888–1987 any report on OBS has been analysed from national and international libraries, later only sizeable series that stood the test of time. The sources were compared in a hermeneutical manner. RESULTS: From 1888–1988 the OBS term was purely descriptive in German and English: “Wiederherstellung der Harnblase” (=bladder reconstruction, 1888); for the first human application this remained so (vessie nouvelle, 1913). Only after 1985 names of the surgeon (f.i. Camey bladder), institution (f.i. Standford pouch), or city (f.i. Florence intracorporeal neobladder) were a new aspect in the nomenclature of OBS. After 1988 in the era of modern OBS pioneering institutions returned to the use characteristic descriptive terms: T-pouch (Los Angeles, 1987) urethral Kock pouch (Manssoura, 1987), ileal low pressure bladder substitute (Bern, 1989), ileal neobladder (Ulm, 1987/88). “Neobladder” is a Greek/English hybrid word, that was born in Ulm 1985 after the first OBS was performed by R. Hautmann, MD. His associate G. Egghart, MD, wrote the operative report. Because of his humanistic education including the command of the Greek language he designed the term “Neoblase”. The first publication was in German “Die Ileum-Neoblase” Urologe (A) 1987; 26: 67-73. The term ileal neobladder appeared for the first time one year later: The Ileal Neobladder by R.E. Hautmann, G. Egghart, D. Frohneberg, and K. Miller. JUrol 1988; 139: 39-42. Since the turn of the century the term “neobladder” has increasingly replaced OBS in journals and textbooks CONCLUSIONS: The term “neobladder” gradually has replaced most terms including of orthotopic reconstruction or bladder substitution (OBS). The most likely reasons for this is, that “neobladder” is a simpler description of the goal of the operation, is easier to understand for patients, and is an international term. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e260 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Friedrich H. Moll More articles by this author Richard Hautmann More articles by this author Expand All Advertisement PDF downloadLoading ...

The cause analysis of benign uretero-ileal anastomotic stricture after radical cystectomy and urinary diversion.

Benign uretero-ileal anastomotic stricture (UIAS) is a major complication following radical cystectomy (RC) and ileal orthotopic bladder substitution, and it can occur in combination with other complications. But risk factors for patients with UIAS have not been well described. We retrospectively reviewed 198 patients treated with RC for bladder cancer from 2014 to 2019 at the Zhejiang Provincial People's Hospital. Patient demographic and clinical variables were examined to determine the risk factors associated with UIAS by univariate and multivariate logistic regression analysis. A total of 180 patients into the group standards and in all 360 uretero-ileal anastomoses. Among the above cases, 22 patients developed UIAS, including 10 cases of left UIAS, nine cases of right UIAS, and three cases of bilateral UIAS. There was no difference in demographic, operative, or perioperative variables between patients with and without UIAS. In a multivariate analysis, after adjusting for gender, age, surgical methods, and underlying diseases, intraoperative or postoperative blood transfusion (HR = 0.144, P <0.01), postoperative urinary tract infection (HR = 3.624, P <0.01), and extracorporeal bladder anastomosis (HR = 3.395, P = 0.02) significantly increased the risk of UIAS. In our experience, intraoperative or postoperative blood transfusion, postoperative urinary tract infection, and extracorporeal neobladder anastomoses increased the risk of UIAS after radical cystectomy and ileal orthotopic bladder substitution surgery. Further studies with larger samples are necessary to validate this result.

RF19 | PSUN367 Urinary bladder Paragangliomas – A Case series

Abstract Introduction Paragangliomas (PGL) are rare neuroendocrine tumours and account for approximately 10% of all chromaffin tumours. They may occur in the retroperitoneum, mediastinum, skull and the urinary bladder. Paragangliomas of the urinary bladder are rare entities accounting for 10% of all paragangliomas and 0.06% of all bladder tumours. Approximately 10% of urinary bladder paragangliomas are malignant. Bladder paragangliomas can be either functional or non-functional. Main symptoms of functional PGLs are due to catecholamine excess with palpitations, paroxysmal hypertension during micturition, sweating and headaches. Functional bladder PGL are diagnosed on biochemical analysis. Non-functional bladder PGLs present with haematuria and are often misdiagnosed as bladder cancer as they may cystoscopically and histologically resemble a urothelial neoplasm. Clinical cases: We present a case series of 4 surgically treated patients with urinary bladder paragangliomas who presented to Cambridge University Hospital over the last 3 years. All patients were female with an age range between 21 and 44 years. All four patients had SDHB deficient tumours, and all four patients were diagnosed with a pathogenic variant in the SDHB gene. Three patients had no family history of SDHx associated neoplasia whereas one had a paternal aunt who died from a metastatic pheochromocytoma. Three patients had presented with palpitations and hypertensive episodes, one of whom experienced symptoms while micturating. Biochemical analysis revealed elevated plasma normetadrenaline levels in all patients. On presentations, one patient had a synchronous paratracheal paraganglioma while two patients had lymph node metastasis. All patients were surgically treated with two patients undergoing fertility preserving cystectomy and bladder substitution, one undergoing partial cystectomy, radical hysterectomy and ureteric implantation and one managed with robot-assisted partial cystectomy. None of the patients have evidence of biochemical or radiological tumour recurrence on follow-up with a mean follow-up time of 23 months (range 12 to 40 months). Conclusion and points for discussion The diagnosis of urinary bladder PGL is challenging. Biochemical assessment to assess catecholamine production and imaging studies like CT, MRI and NM Ga68 DOTATATE PET CT are helpful modalities in diagnosis. Patients presenting with extra adrenal paragangliomas including bladder paragangliomas require genetic testing because of the strong hereditary predisposition, with mutations in the SDHx genes being most common with this clinical phenotype. The surgical approach should be tailored to the individual patient, agreed by a multi-disciplinary team and the risk of malignancy should be weighed against the potential morbidity associated with a curative oncological surgery. As urinary bladder PGLs have malignant potential and are frequently hereditary (as demonstrated in this series), lifelong follow-up is required to screen for synchronous tumours and tumour recurrence. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Sunday, June 12, 2022 12:42 p.m. - 12:47 p.m.

Engineering pedicled vascularized bladder tissue for functional bladder defect repair.

An engineered bladder construct that mimics the structural and functional characteristics of native bladder is a promising therapeutic option for bladder substitution. We previously showed that pedicled vascularized smooth muscle tissue fabricated by grafting smooth muscle cell (SMC) sheets onto an axial capsule vascular bed had the potential for reliable bladder reconstruction. In this study, we investigated the feasibility of buccal mucosa graft (BMG) integration with the pedicled vascularized smooth muscle tissue to generate a full-layer pedicled vascularized bladder construct. BMG transplanted onto vascularized smooth muscle tissue showed good survival and developed into a pedicled vascularized bladder construct with full-layer structures, appropriate thickness, abundant vascularization, and effective barrier function. Then the full-thickness bladder defects were, respectively, reconstructed by pedicled capsule tissue (pedicled capsule group), nonpedicled vascularized bladder construct (nonpedicled construct group), and pedicled vascularized bladder construct (pedicled construct group). The picrosirius red (PSR) staining and immunohistochemistry results showed minimal fibrosis, maximal smooth muscle proportion, and high vascular density in the pedicled construct group. A continuous mucosal layer was observed only in the pedicled construct group. Moreover, morphological and functional studies revealed better bladder compliance and good ductility in the pedicled construct group. Overall, these results suggested that the BMG could be well integrated with vascularized smooth muscle tissue and generated a pedicled, fully vascularized, and structurally organized bladder construct, which facilitated structural remodeling and functional recovery and could become an alternative to bladder reconstruction.

A New Technique for Continent Urinary Diversion: Initial Experience and Description of the Technique.

Orthotopic neobladder is a well-established surgical solution for continent urinary diversion after radical cystectomy. Nevertheless, it still represents a challenging surgery. Some critical issues of orthotopic bladder substitution include relevant complication rates, renal function impairment, urinary incontinence and patient quality of life. We present a new ileal neobladder technique, Vesuvian Orthotopic Neobladder (VON), performed for the first time at our institution in 2020. The main purpose of this new surgical procedure is to simplify and speed up the reservoir reconstruction through a ten standardized technical steps and obtain an appropriate bladder capacity at the same time. METHODS: Inclusion criteria were muscle-invasive bladder carcinoma or non muscle-invasive high risk bladder cancer patients fit for bladder substitution. The exclusion criteria were locally advanced cancer, presence of hydronephrosis, renal or hepatic impairment. A chest-abdominal CT scan and urinary cytology were performed before the procedure. Patients received neoadjuvant chemotherapy, as required. Overall, operative time, bladder reconfiguration time, hospitalization time, catheterization time were recorded. All complications associated with the procedure were classified according to the Clavien Dindo score. The bladder volume was evaluated by ultrasound three months after the surgery. RESULTS: A total of six male patients diagnosed with non-metastatic muscle-invasive or high-risk non-muscle invasive bladder cancer who underwent radical cystectomy followed by VON reconfiguration were included in the study. Mean age was 62.8 (±4.9) years; all selected patients enjoyed good health conditions (Charlson Comorbidity Index 4-6). One patient presented with high-risk non-muscle invasive bladder cancer. Four patients received neoadjuvant chemotherapy. Mean overall operative time was 273.3 (±18.6) minutes. Average time for neobladder reconstruction was 63.7 (±16.1) minutes. There were no intraoperative complications. A single case of urethral anastomosis leakage occurred and was treated conservatively. Bladder volume on ultrasound evaluation ranged between 250 and 290 ml. Day time and nocturnal continence were observed in four and three patients, respectively. CONCLUSION: The new VON technique is a good alternative to traditional orthotopic bladder procedures. VON reconstruction seems to offer the advantage of speeding up the procedure, reducing intestinal compromise with good storage capacity. The ten surgical steps can be considered a good starting point for further improvements in surgical technique. More robust data regarding the number of procedures and the duration of follow-up is required.

Use of ileal bypass in the surgical management of two rare cases of ileal-neobladder fistula in patients who underwent radical cystectomy

An entero-neovesical fistula (ENF) is a rare troublesome complication of an orthotopic ileal bladder substitution. We report on a novel, safe technique to close ileal neovesical fistulas without extensive adhesiolysis using an NK-stapler (ENDOPATH® ENDOCUTTER ETS; Johnson & Johnson, Cincinnati, OH, USA). We treated two cases of postoperative ENF after orthotopic ileal bladder substitution for radical cystectomy. Case 1 was a 63-year-old male with occasional fecaluria, and Case 2 was a 73-year-old male who experienced continuous fecaluria.Surgical procedureAfter laparotomy, we mobilized the ascending colon to bypass the anastomosis of the primary surgery by an ileo-ileal, ileo-ascending colon anastomosis. The distance between the fistula and bypass was about 10 cm. We made tunnels in the mesentery between the bypass and fistula, without damaging blood vessels, to insert the jaw of the NK-stapler. We closed the afferent and efferent loops using NK-staplers (45 mm ×2), followed by a Lembert anastomosis covering the stapler's suture lines. They were discharged on the ninth and seventh postoperative days, respectively. In Case 1, we experienced recanalization of the fistula after three postoperative months and required second closure with the same procedure was needed. They have not experienced any symptoms of ENF since. This technique is worth considering for the surgical treatment of ENF because it does not require unnecessary dissection and can ultimately achieve fistula closure.

Hydraulic Detrusor for Artificial Bladder Active Voiding.

The gold standard treatment for bladder cancer is radical cystectomy that implies bladder removal coupled to urinary diversions. Despite the serious complications and the impossibility of controlled active voiding, bladder substitution with artificial systems is a challenge and cannot represent a real option, yet. In this article, we present hydraulic artificial detrusor prototypes to control and drive the voiding of an artificial bladder (AB). These prototypes rely on two actuator designs (origami and bellows) based either on negative or positive operating pressure, to be combined with an AB structure. Based on the bladder geometry and size, we optimized the actuators in terms of contraction/expansion performances, minimizing the liquid volume required for actuation and exploring different actuator arrangements to maximize the voiding efficiency. To operate the actuators, an ad hoc electrohydraulic circuit was developed for transferring liquid between the actuators and a reservoir, both of them intended to be implanted. The AB, actuators, and reservoir were fabricated with biocompatible flexible thermoplastic materials by a heat-sealing process. We assessed the voiding efficiency with benchtop experiments by varying the actuator type and arrangement at different simulated patient positions (horizontal, 45° tilted, and vertical) to identify the optimal configuration and actuation strategy. The most efficient solution relies on two bellows actuators anchored to the AB. This artificial detrusor design resulted in a voiding efficiency of about 99%, 99%, and 89%, in the vertical, 45° tilted, and horizontal positions, respectively. The relative voiding time was reduced by about 17, 24, and 55 s compared with the unactuated bladder.

Modification of the Indiana Pouch Ileo-Caecal Cutaneous Continent Urinary Diversion: Tubular Ileal Afferent Limb for Ureteral Anastomosis Has Low Stricture Rate and Allows Ileal Ureter Replacement

Objective: The aim of the study was to introduce our new modification of the Indiana pouch with a refluxing ureteral anastomosis in a tubular afferent ileal segment of the ileo-caecal urinary reservoir. Patients and Methods: Between February 2008 and December 2020, we performed a total of 37 modified continent ileo-caecal pouches for urinary diversion when orthotopic bladder substitution was not possible. Hereby, we modified the Indiana pouch procedure with a new refluxing end-to-end ureteral anastomosis into an 8-cm afferent tubular ileal segment. Results: We performed the modified Indiana pouch in 27 women (73%) and 10 men (27%). The median age of the patients at time of operation was 64 years (43–80 years). To date, the average follow-up is 69 months (3–156 months). In 32/37 cases, we performed the new pouch procedure after radical cystectomy for muscle-invasive bladder cancer and in 1/37 cases after radical cystectomy for locally advanced prostate cancer. In 4 cases, the procedure was performed after total exenteration of the pelvis due to locally advanced bladder, colorectal, or gynaecological cancers. Ureteral anastomotic strictures were seen in 2/37 patients (5.4%) or 2/72 (2.8%) of renal units. Conclusions: Our modification of the Indiana pouch cutaneous continent urinary diversion with the ureteral anastomosis to a tubular segment of the pouch is easy to perform and effective in reducing the rate of ureteral anastomotic strictures. By lengthening, the afferent tubular ileal segment, it additionally allows easy ureteral replacement.

Bladder Substitution: The Role of Tissue Engineering and Biomaterials

Tissue engineering could play a major role in the setting of urinary diversion. Several conditions cause the functional or anatomic loss of urinary bladder, requiring reconstructive procedures on the urinary tract. Three main approaches are possible: (i) incontinent cutaneous diversion, such as ureterocutaneostomy, colonic or ileal conduit, (ii) continent pouch created using different segments of the gastrointestinal system and a cutaneous stoma, and (iii) orthotopic urinary diversion with an intestinal segment with spherical configuration and anastomosis to the urethra (neobladder, orthotopic bladder substitution). However, urinary diversions are associated with numerous complications, such as mucus production, electrolyte imbalances and increased malignant transformation potential. In this context, tissue engineering would have the fundamental role of creating a suitable material for urinary diversion, avoiding the use of bowel segments, and reducing complications. Materials used for the purpose of urinary substitution are biological in case of acellular tissue matrices and naturally derived materials, or artificial in case of synthetic polymers. However, only limited success has been achieved so far. The aim of this review is to present the ideal properties of a urinary tissue engineered scaffold and to examine the results achieved so far. The most promising studies have been highlighted in order to guide the choice of scaffolds and cells type for further evolutions.

Orthotopic bladder substitution: Surgical aspects and optimization of outcomes.

ObjectivesOrthotopic bladder substitution (OBS) is a management option for urinary diversion in men and women undergoing cystectomy. The aim of the procedure is to provide a functional continent urinary reservoir of adequate capacity, compliance and low pressure. We have provided a narrative review of the existing literature and highlighted areas where improvement and standardization can be recommended.MethodsLiterature search included database search for publications from January 1970 to November 2020, using keywords including OBS, bladder reconstruction, neobladder, radical cystectomy, robotic cystectomy, intracorporeal neobladder, surgical technique, patient selection and outcomes.ResultsDue to various factors including indications, operative technique and risk of complications, OBS is an enormous undertaking and commitment for patients, surgeons and health professionals involved in the care pathway. The main considerations for patient selection, the technical elements of the procedure and the rationale behind these are discussed. Previously considered to be a choice for a select few, the inclusion criteria have expanded over the last decade. Similarly, surgical techniques including the choice and configuration of bowel segments, construction of anastomosis and nerve or organ sparing procedures have evolved over the years. Minimally invasive laparoscopic and robotic assisted surgery has added further perspectives to the existing literature on OBS. Understanding the principles of operative techniques and assessing the best evidence to influence patient management is crucial as it has a major impact on clinical outcomes. Peri‐ and post‐operative care, focused on the prevention of complications and morbidity, affects long‐term functional and oncological outcomes, which ultimately dictates the quality of life.ConclusionsThis concise overview of OBS literature highlights the importance of pre‐operative, peri‐operative, and post‐operative aspects with regards to the optimization of patient care. To achieve the best results, meticulous attention should be paid in all these areas, surgical and multi‐disciplinary. Patient education and counseling, with shared decision making are central to the success of the procedure.

Perioperative and Pathological Outcome of Nerve-Sparing Radical Cystectomy With Ileal Neobladder.

Purpose: So far, it has not been described whether the perioperative course and the pathologic outcome of patients who undergo radical cystectomy (RC) with orthotopic bladder substitution differs if nerve sparing (NS) is performed or not.Material and Methods: In all, there were 472 patients who underwent RC between 2012 and 2019 at our department. We performed a retrospective analysis of 116 patients who underwent RC with ileal neobladder. We analyzed perioperative complications according to the Clavien–Dindo classification system, as well as the pathological outcome.Results: Of 116 patients, 68 (58.6%) underwent RC, and 48 (41.4%) underwent NS RC. Clavien–Dindo complications ≥3b occurred in 15 (12.9%) of all patients. Only infectious complications differed among the groups [NS RC: 25 patients (52.1%) vs. RC: 20 patients (29.4%); p = 0.02]. There was no significant difference concerning tumor stage. Concomitant Cis was present in 24 patients (35.3%) of the RC group and in 27 patients (56.3%) of the NS RC group (p = 0.036). Nodal status and positive surgical margin status of the bladder tumor did not differ among the groups. In all, 42 of all male patients (45.7%) had an incidental prostatic carcinoma. Positive surgical margins concerning the prostate carcinoma occurred in six patients, with all cases in the RC group (p = 0.029).Conclusions: Our data suggest that performing NS during RC in carefully selected patients is a safe procedure and does not impair perioperative outcome. Pathological outcome of NS RC is comparable as well.

Orthotopic MAINZ pouch bladder substitution - long-term follow-up.

IntroductionAfter radical cystectomy, orthotopic neobladder is one surgical strategy for urinary diversion. To assess the usefulness of an operation, long-term data are essential. We examined long-term complications and continence rates of orthotopic ileocecal (MAINZ pouch) bladder substitution.Material and methodsBetween 1986 and 2011, 193 patients underwent orthotopic MAINZ pouch bladder substitution. Until July 2000, ureter implantation was performed into the ascending colon through a submucosal tunnel technique (Goodwin-Hohenfellner). After July 2000, ureters were implanted into the terminal Ileum using the ileocecal valve to prevent reflux: the left spatulated ureter by an end-to-end (Wallace) and the right ureter by an end-to side technique (Nesbit). Surgical and medical follow-up reports were evaluated and a recent follow-up was obtained by a questionnaire.ResultsMedian follow-up in 183 patients was 72 months (1–336). A total of 74 patients (38%) died during the follow-up. A surgical intervention was required in 26 out of 193 patients with early complications while 45 out of 183 patients had late and 17 patients had both, early and late complications. Ureteral stenosis was found in 13% of submucosal implanted ureters, 13% with the Wallace technique, and 3.6% with the Nesbit technique. In total, 66 patients responded to the questions concerning long-term continence (minimal follow-up >2 years). Overall, 84.8% were completely continent, 1.6%, reported grade I and 9.8% grade II stress incontinence.ConclusionsThe long-term continence and complication rates are comparable to those of other types of orthotopic bladder substitution. Orthotopic MAINZ pouch procedure can be considered as one of the options for orthoptic diversion, which stands the test of time.

A Randomized Trial to Examine the Utility of Mebeverine on the Early Return of Continence Following Orthotopic Bladder Substitution.

We assessed the effect of mebeverine in the enhancement of the orthotopic bladder substitute continence. A randomized trial was carried out for incontinent adult male patients during the first year post-orthotopic bladder substitute surgery. Patients were allocated to receive mebeverine 135 mg or placebo 3 times a day for only 3 months. The primary outcome was to compare the continence improvement between groups, assessed by the urinary domain of the Bladder Cancer Index and sanitary pad use. The secondary outcomes were to assess the safety of the drugs used. In placebo group 47 and in mebeverine group 52 patients completed followup. The median (range) interval time between orthotopic bladder substitute surgery and starting treatment was 7 (3-10) months and 6.5 (3-10) months in the placebo and mebeverine group, respectively (p=0.3). Compared to the baseline evaluation, the 3-month urinary domain of Bladder Cancer Index scores improved in both groups with significant improvement in the mebeverine group. The mean±SD 3-month urinary domain of Bladder Cancer Index was 67.79±13.05 and 83.27±12.21 in the placebo and mebeverine group, respectively (p <0.001). Also, the 3-month patient pad use decreased to 30 (63.8%) and 19 (36.5%) patients in the placebo and mebeverine group, respectively (p=0.007). Constipation occurred in 1 (2.1%) and 3 (5.8%) patients in the placebo and mebeverine group, respectively; abdominal distention occurred in 2 (3.8%) in the mebeverine group (p=0.25). Mebeverine accelerated continence development in male patients with ileal orthotopic bladder substitute during the first year post-orthotopic bladder substitute construction.

Early continence after ileal neobladder: objective data from inpatient rehabilitation.

To evaluate early continence of patients who underwent inpatient rehabilitation after radical cystectomy (RC) and orthotopic bladder substitution (ONB). We conducted a retrospective analysis on the data of 283 patients who underwent a three weeks inpatient rehabilitation after RC and ONB for bladder cancer between January 2016 and July 2017. All patients were treated with a special multimodal continence therapy. The continence status was evaluated by measuring urine loss by a 24-h pad test and urine volume on uroflowmetry at the beginning (T1) and at the end (T2) of inpatient rehabilitation. Multivariate linear regression analysis was performed to identify independent predictors of urine loss. Median patient age was 63years. NS was documented for 142 patients (50.2%). Median urine loss decreased significantly (p < 0.001) in the 24-h pad test, from 442gm at T1 (median 29days after surgery) to 88gm at T2 (median 50days after surgery). Urine volume increased significantly (p < 0.001) from a median of 78ml at T1 to a median of 157ml at T2. Age (p = 0.002), diabetes (p = 0.031), obesity (p = 0.003), and nerve sparing (p = 0.011) were identified as independent predictors for urine loss at the end of inpatient rehabilitation. Continence improved significantly during the three weeks of inpatient rehabilitation. Younger age, the absence of diabetes or obesity, and NS resulted in better continence in the early postoperative period after ONB.

Modified Ileal Neobladder: Experience of 37 Cases

Bladder cancer is the second most common malignancy of genitourinary tract. About 20% cases are muscle invasive and most of the non-muscle invasive bladder cancer progressed to muscle invasion with time. The standard care for organ confined muscle invasive bladder cancer is radical cystectomy followed by urinary diversion. Orthotopic bladder substitution is considered standard urinary diversion after radical cystectomy in patients who have no urethral malignancy and intact external urethral sphincter. Neobladder constructed from ileum as described by Studer is considered standard and followed by most centers worldwide since 1985. We modified the procedure to improve the outcome and minimize post-operative complications by reducing the length of ileum used for construction of neobladder in 37 patients. Voiding, storage function and complications were evaluated during follow-up period up to 24 months after surgery. Three patients died during follow-up period of which 2 from metastatic disease and one from unrelated cause. Daytime and night-time continence rates were 86.49% and 78.38% respectively. Average functional capacity (437ml), maximum flow rate(15.7ml/s) and mean post void residual urine (44ml) during the period of evaluation. Clean intermittent self-catheterization needed in 67.57% patients due to incomplete emptying during early postoperative period but after 3 months most of the patients learnt to void without any aid. Upper tract dilatation found in one patient due to stricture at urethrovesical junction and required endoscopic incision and dilatation later. 12 patients had an urodynamic study at 12 months after surgery and found low pressure reservoir with small residual urine in all cases. Modified ileal neobladder is a safe and reliable procedure with satisfactory short-term result. Bangladesh Journal of Urology, Vol. 22, No. 1, January 2019 p.20-24

Functional Outcome and Complications following Ileal Neobladder Reconstruction in Male Patients without Tumor Recurrence. More than 35 Years of Experience from a Single Center.

There is a lack of data on true long-term functional outcome of orthotopic bladder substitution. The primary study objective was to report our 35-year clinical experience. Since October 1985, 259 male patients from a large single center radical cystectomy series with complete followup of more than 60 months (median 121, range 60-267) without recurrence, irradiation or undiversion that might have affected the functional outcome, were included. Median age at radical cystectomy and at survey was 63 (range 23-81) and 75 (range 43-92) years, respectively. Overall 87% of patients voided spontaneously and residual-free. This rate decreased with increasing age at the time of surgery (less than 50 years old 94%, 70 years old or older 82%). Overall day/nighttime continence rates were 90%/82%. These rates decreased with increasing age at the time of surgery from 100%/88% to 87%/80%. The overall pad-free rate was 71%/47%. Bicarbonate use decreased from 51% (5 years) to 19% (25 years). Patients with a followup of more than 20 years had the lowest rate of residual urine and clean intermittent catheterization (0.0%) as well as use of more than 1 pad at daytime/nighttime (6.3%/12.5%) and mucus obstruction (0.0%). Serum creatinine showed only the age related increase. The surgical complication rate was 27% and correlated inversely with functional results (chi-squared 11.227, p <0.005), even when the younger age at the time of surgery (younger than 60 years) was related to higher rates of surgical complications (chi-squared 6.80, p <0.05). The ileal neobladder represents an excellent long-term option for urinary diversion with an acceptable complication rate.

A new ureteroileal anastomosis technique in modified ileal orthotopic bladder substitution after radical cystectomy

BackgroundThe aim of this study is to describe a modified technique in ileal orthotopic bladder substitution with a new ureteroileal anastomosis.Case presentationAfter a classic open radical cystectomy with bilateral pelvic lymphadenectomy was performed extraperitoneally, a 56-cm ileal segment was used to construct the spheroidal shape bladder substitution. The 8-cm long proximal and distal ends of the ileal segment were used as afferent limbs. Two-centimeter ileal segments of afferent limbs were detubularized and transversally tubularized. The elongated ileal tube was anastomosed with the ureter in an end-to-end fashion. The pathway of the ureteroileal anastomosis was placed between the abdominal cutaneous fat and the anterior rectus muscular sheath. Perioperative data and long-term functional outcomes were assessed. Between December 2011 and December 2015, seven male patients underwent this procedure with a median 46 (30–77) months follow-up in our hospital. There was no difference between preoperative and postoperative estimated glomerular filtration rates (Z = − 1.693, P = 0.09). One of 14 sides had ureteroileal anastomotic stenosis; two of 14 sides in one patient had ureteroileal anastomotic stenosis caused by invasion of pelvic recurrence 15 months postoperatively. Reflux was completely prevented by placing pressure on the corresponding point on the abdominal surface when voiding urine in all patients.ConclusionsWe describe a feasible technique modification in detail, which provides some advantages for effective anti-reflux by mechanical finger pressing and abdominal contraction, a low incidence of stricture, and ease for a secondary operation in the long-term follow-up period.

Long-term functional recovery after orthotopic spiral ileal bladder substitution

BackgroundTo explore the value of orthotopic spiral ileal bladder substitution (OSIBS) following radical cystectomy in treating bladder cancer patients by investigating the short- and long-term postoperative complications and assessing the quality of life in patients who had undergone OSIBS.MethodsThe post-operative complications were retrospectively analyzed among bladder cancer patients who had undergone radical cystectomy + OSIBS in our center from January 2001 to January 2017. The quality of life was assessed by using the Function Assessment of Cancer Therapy-Bladder Cancer Form (FACT-BL). Patients were followed up by mails, telephone, and outpatient visits.ResultsA total of 68 subjects were included in this study. All patients undergoing radical cystectomy + OSIBS were followed up for an extended period. The patients aged 39–68 years (mean: 60.34±9.43 years). The surgeries were completed, and all the patients were smoothly discharged after good postoperative recovery. Of the 68 patients who had completed the follow-up visits, 10 had early complications (14.71%), and 11 (17.64%) developed late complications. The blood urea nitrogen (BUN) (t=0.358, P=0.764) and serum creatinine (Cr) (t=1.305, P=0.196) levels showed no significant difference before and after surgery. The serum potassium (t=1.347, P=0.169), sodium (t=−1.748, P=0.144), and calcium (t=1.097, P=0.319) levels also showed no significant changes before and after surgery. However, the change in serum chlorine level was statistically significant (t=−4.701, P=0.000). To support urinary function, the patients were encouraged to take exercises During the 10-year follow-up period, the daytime urinary continence rate reached 94.1% (n=64) in the daytime, and the nighttime incontinence rate was 13.2% (n=9). Six months after the surgery, the neobladder capacity was (365.02±45.11) mL, the maximum flow rate was (14.36±1.41) mL/s, and the post-voiding residual (PVR) was (26.01±8.10) mL. The total FACT-BL score was (124.8±13.4) during the 10-year follow-up.ConclusionsAfter 10 years of follow-up, the early and late complications in patients who had undergone radical cystectomy + OSIBS were within acceptable range and the daily and nightly continence levels allowed normal daily life. OSIBS not only preserves the physical integrity of the body but also has normal physiological characteristics of the bladder. It remarkably improves the postoperative quality of life and can be easily accepted by patients. Therefore, it is an ideal surgical procedure.

Human adipose-derived mesenchymal stem cells accelerate decellularized neobladder regeneration.

Decellularized natural bladder matrices (neobladders) represent an exciting means to regenerate the bladder following bladder cancer-associated cystectomy. In this study, we compare the evolution of decellularized matrices with recellularized matrices by seeding it with human adipose-derived mesenchymal stem cells (ADSC) after implantation following partial cystectomy in rats. We discovered significant anatomical differences since 10 days after neobladder implantation with the ADSC-containing matrices promoting a significant recovery of mature p63- and cytokeratin 7-positive urothelium. We also discovered significantly induced expression of the vimentin mesoderm marker in the submucosal layer in ADSC-seeded matrices. Interestingly, we found a higher expression of smooth muscle actin in transversal and longitudinal smooth muscle layers with ADSC-seeded matrices. Furthermore, ADSC also showed increased vascularization and nerve innervation of the neobladder as determined by the distribution of CD31 and S100β reactivity, respectively. We believe that ADSC and their paracrine-acting pro-regenerative secretome within decellularized matrices represent an efficient bladder substitution strategy; however, we require a fuller understanding of the mechanisms involved before clinical studies can begin.