Bladder Substitution Research Articles

Alloplastic bladder substitution: are we making progress?

Radical cystectomy with lymphadenectomy and urinary diversion is the gold standard treatment for bladder cancer in organ-confined muscle-invasive disease and selected patients who have high-grade non-muscle-invasive disease or are non-responders to BCG. The main and most morbid complications of this challenging surgery are related to the use of bowel for urinary tract reconstruction. For this reason, many past projects were devoted to finding an alternative to the use of bowel. The aim of this review is to provide a summary of the evolution of alloplastic bladder substitution. A comprehensive review of the literature was performed using the Medline National Library of Medicine database and Google Scholar. Keywords used were cystectomy and intestine/bowel, replacement, bladder substitution, organ replacement, artificial bladder, alloplastic material, biomaterial, and tissue engineering. Various prostheses have been proposed for replacement of the urinary bladder, silicone being the most frequently used material. The first published model of an alloplastic bladder was described by Bogash et al. in late 1959, while the last, in 1996, was suggested by Rohrmann. Interprofessional collaboration, recent advances in technology, and tissue engineering may help in developing suitable bladder prostheses. Urologists as well as engineers and the industry need to give this matter serious attention.

Harnleiterersatz unter Verwendung von Darmsegmenten

When ureter damage is extensive or affects the midureter continuity can be restored using bowel segments. The principle issues of these techniques comprise reconstruction of the urinary tract preserving renal function in a long-term setting. The safety of ureters reconstructed from bowel segments has been validated in several large series as a reliable last resort solution with favorable results and low complication rates. Ureter reconstruction with bowel segments is doomed to fail in patients with short-bowel syndrome or Crohn's disease. Furthermore, the applicability in children and patients with progressive renal deficiency is severely limited. To prevent renal deterioration the use of retubularized bowel segments as a substitute for ureter defects has been postulated. Whereas antirefluxive implantation seems unnecessary in patients with a native bladder in situ or orthotopic bladder substitution, it is recommended in continent bowel reservoirs with cutaneous stoma.

Simulated Bladder Pressure Stimulates Human Bladder Smooth Muscle Cell Proliferation via the PI3K/SGK1 Signaling Pathway

A mechanical stimulus on detrusor tissue is critical to bladder outlet obstruction progression and functional bladder tissue engineering. A hypothesis is that mechanical stimulus triggers human bladder smooth muscle cell proliferation. To help better understand this relationship of bladder function to growth at the cellular level we used a novel method of applying cyclic hydrodynamic pressure that simulates the bladder cycle to cell cultures. We detected the proliferation response of human bladder smooth muscle cells (4310, ScienCell™) to different pressures as well as the signal transduction mechanism of this process. Human bladder smooth muscle cells cultured in scaffolds underwent 4 pressures (0, 100, 200 and 300 cm H(2)O) for 24 hours, as controlled by a BioDynamic® bioreactor. We then used flow cytometry to examine cell cycle distribution, and polymerase chain reaction and immunoblot to quantify SGK1 and AKT expression and activation in each group. SGK1 was silenced in human bladder smooth muscle cells using small interfering RNA to validate the role of SGK1 in mediating pressure induced cell proliferation. Compared with the 0 cm H(2)O control group, human bladder smooth muscle cells in the 200 and 300 cm H(2)O groups showed increased cell proliferation. SGK1 expression and activity were also increased while AKT, another downstream signal of PI3K, did not change significantly. SGK1 silencing abolished the increases in cell proliferation induced by pressure. To our knowledge we provide the first report of cyclic hydrodynamic pressure stimulating the proliferation of human bladder smooth muscle cells cultured in scaffolds. The signal transduction mechanism for this process is involved with the PI3K/SGK1 and not the PI3K/AKT signaling pathway.

Voiding Function in Women with Orthotopic Neobladder Urinary Diversion

Most long-term morbidity after radical cystectomy is related to the urinary diversion or reconstruction. While there are benefits to an orthotopic neobladder, there can be a substantial risk of voiding dysfunction in women. We examine the prevalence of postoperative voiding complications in women who underwent orthotopic neobladder diversion. We identified all women who underwent radical cystectomy and orthotopic neobladder for bladder cancer at our institution from 1996 to 2011 (51) and included patients with regular clinic followup (49). The presence and severity of incontinence and hypercontinence were evaluated at routine clinic visits. Unadjusted analyses were performed to measure the association between patient variables and voiding symptoms, with p < 0.05 considered significant. Daytime incontinence, nighttime incontinence and hypercontinence were reported by 43%, 55% and 31% of women, respectively. A neobladder-vaginal fistula developed in 3 women (6%). On unadjusted analysis having daytime incontinence was associated with a concurrent or previous hysterectomy (p = 0.031), but not with age, disease stage, preoperative incontinence, year of surgery or sparing the vaginal wall. The severity of daytime incontinence was associated with preoperative incontinence only (p = 0.02). The presence and severity of nighttime incontinence were associated with patient age only (p = 0.013, p = 0.005, respectively). Hypercontinence was not associated with any variable. Among women with orthotopic neobladder after radical cystectomy we identified a significant prevalence of voiding dysfunction. We recommend preoperative discussion of these possible complications with any woman interested in orthotopic neobladder to establish realistic expectations. For properly selected women who understand these risks, orthotopic neobladder may be an appropriate diversion choice.

Does the afferent tubular segment in an orthotopic bladder substitution compromise ureteric antireflux properties? An experimental study in dogs

ObjectiveTo study the effects of a short ureter on renal function and histology in an orthotopic bladder substitution model using a long afferent limb, in a canine model. Materials and methodsThe study included nine adult mongrel dogs. A 40-cm segment of ileum was isolated, the distal half detubularized, configured into a U-shape and sutured to form a flat plate; this was then used to augment the bladder. The proximal half of the isolated ileum remained in continuity with the enterocystoplasty to form an isoperistaltic ileal ‘chimney’. The left ureter was divided at its lumbar part and anastomosed to the chimney using a refluxing end-to-side Nesbit technique. The contralateral ureter was divided at its lower end and then anastomosed directly to the augmented segment of the bladder in a similarly refluxing manner to act as a control. The assessment after surgery included biochemical studies, ascending cystography, intravenous urography (IVU) and radioisotope renography at 6weeks. The last two methods were repeated at intervals of 3 and 6months after surgery. Urine culture was obtained and both kidneys were examined histopathologically at 6months. ResultsThe biochemical values assessed in all dogs were comparable to those before surgery. The urine culture obtained from the augmented bladders showed significant bacterial growth in all dogs. IVU at all follow-up sample times showed a normal configuration of both kidneys. Ascending cystography showed reflux in four of nine dogs on the right and six on the left side. There was a progressive decrease in the mean selective renographic clearance values of each of the right and left kidneys at intervals of 6weeks, 3 and 6months. The mean percentage reduction of renographic clearance was significantly higher in the left kidneys at 6weeks and 3months. Histopathological examination showed evidence of interstitial nephritis in all nine dogs and pyelonephritis in four of the left kidneys, while none of the right kidneys showed evidence of inflammation. ConclusionAdequate peristalsis in a healthy long ureter is superior to the ileal segment substitution for protecting the kidney tissue against inflammation in the absence of an anatomical antireflux mechanism.

Modified orthotopic spiral ileal bladder substitution: Surgical technique and long-term results

ObjectivesThe objectives of this study are to introduce the surgical technique of a modified spiral orthotopic ileal neobladder and to assess the long-term outcomes. Patients and methodsBetween January 1998 and January 2006, 44 male and 7 female patients with bladder cancer received radical cystectomy (RC) and pelvic lymphadenectomy. An ileal segment 40 cm to 45 cm long was isolated to create a spiral orthotopic ileal neobladder, and the ureters were implanted into the reservoir using a non-refluxing split-cuff nipple technique. Preoperative, perioperative, and postoperative data were collected. Complications were classified as early (less than 3 months after surgery) or late (more than 3 months after surgery). Continence incidence and urodynamic studies were evaluated 5 years after surgery. Duration of follow-up was an average of 95 months (range 60–156 months). ResultsThere were no perioperative deaths. The mean operative time was 315 ± 34 minutes. The mean blood loss was 783 ± 316 ml. There were 31 early complications in 21 patients (41%) and 42 late complications in 30 patients (59%). Urodynamic studies showed the maximum neobladder capacity to be 500 ± 71 ml, maximum flow rate to be 16 ± 5 ml/s and post-voiding residual (PVR) to be 50 ± 44 ml. Postoperative continence was excellent with a daytime continence rate of 90% and a nocturnal continence rate of 78% 5 years after surgery. ConclusionsThe modified spiral neobladder is easy to perform and allows for excellent long-term results with regard to complications and continence.

Differenzialindikationen für verschiedene Harnableitungsformen

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.

Factors associated with non-orthotopic urinary diversion after radical cystectomy

Preoperative factors favoring the performance of non-orthotopic bladder substitution (OBS) after radical cystectomy for muscle-invasive bladder cancer were identified. We retrospectively reviewed the medical records of 730 patients who underwent radical cystectomy for urothelial carcinoma of the bladder. After excluding 75 patients who were unable to undergo OBS due to the tumor location or elevated serum creatinine level, we assessed the preoperative factors in the remaining 655 patients. Multivariate logistic regression analysis was performed to identify the independent preoperative predictors of type of urinary diversion. Of the 655 patients, 171 (26.1%) underwent non-OBS. Patients who underwent non-OBS were more likely to be older and females, to have a lower educational status, non-organ confined disease, more comorbid medical conditions, more impaired performance status, lower body mass index, anemia, azotemia, and hypoalbuminemia, and to be treated by less-experienced surgeons (P < 0.05 each). After adjusting for provider-based factors, multivariate analysis showed that factors independently associated with non-OBS included advanced age (odds ratio [OR] 4.10, P < 0.001), female gender (OR 2.08, P = 0.027), ECOG performance status (≥ 1 vs 0, OR 5.20, P < 0.001), low educational status (OR 1.59, P = 0.042), clinically node-positive disease (OR 2.36, P = 0.003), anemia (OR 1.67, P = 0.041), azotemia (OR 3.97, P < 0.001), and hypoalbuminemia (OR 1.84, P = 0.046). Several patient-based as well as provider-based factors were associated with the type of urinary diversion after radical cystectomy. Advanced age, female gender, low performance status, low education level, clinically node-positive disease, anemia, hypoalbuminemia, and azotemia were associated with non-OBS, as surgery was performed by relatively inexperienced surgeons.

Complications and Long-Term Results of Salvage Cystectomy After Failed Bladder Sparing Therapy for Muscle Invasive Bladder Cancer

Radical cystectomy has been the standard treatment for muscle invasive bladder cancer. Combined modality therapy involving transurethral bladder tumor resection, external beam radiation and chemotherapy is an effective alternative to cystectomy in selected patients. Salvage cystectomy is reserved for those in whom combined modality therapy fails. We characterized complications associated with salvage cystectomy. From 1986 to 2007 of 348 patients undergoing bladder sparing therapy 102 (29%) underwent salvage cystectomy, 91 of whom were treated at Massachusetts General Hospital after receiving combined modality therapy for T2-T4aNxM0 bladder cancer. Patients underwent transurethral bladder tumor resection followed by chemoradiation (40 Gy). Early assessment was performed by cystoscopy/re-biopsy. Patients with complete response continued with consolidation chemoradiation (total dose 64 Gy). Immediate salvage cystectomy (50 of 91) was performed for persistent disease, while delayed salvage cystectomy (41 of 91) was performed for an invasive recurrence. Complications were classified using the Clavien system. Median patient age was 69.4 years (range 27.5 to 88.9) and median living patient followup was 12 years (range 0 to 23). Of the patients 99% (90 of 91) underwent ileal diversion. Complications of any grade within 90 days occurred in 69% (63 of 91) of patients and 16% (15 of 91) experienced major complications within 90 days. Of the patients 21% (19 of 91) required hospital readmission within 90 days. The 90-day mortality rate was 2.2% (2 of 91). Significant cardiovascular/hematological complications (pulmonary embolism, myocardial infarction, deep vein thrombosis, transfusion) within 90 days were more common in the immediate than in the delayed cystectomy group (37% vs 15%, p = 0.02). Tissue healing complications (fascial dehiscence, wound infection, ureteral stricture, anastomotic stricture, stoma/loop revisions) were more common in the delayed than in the immediate cystectomy group (35% vs 12%, p = 0.05). Salvage cystectomy is associated with acceptable morbidity, although complication rates are slightly higher than for other cystectomy series. Immediate cystectomies have more cardiovascular/hematological complications while delayed cystectomies have more tissue healing complications.

Modified Technique for the Creation of an Orthotopic Neobladder in Patients With Shortened Mesentery: Making Up the Difference Between the Bladder and the Urethral Stump

To describe an ileal neobladder reconstruction technique performed in 5 men who had previous abdominal surgeries and presented with a short mesoileum at the time of bladder replacement. The patients were 5 men scheduled for a radical cystoprostatectomy with bladder substitution and had a short mesoileum at the time of the surgery. All patients had a history of abdominal surgery. A neobladder was constructed in a "J" shape leaving the most proximal part of the ileum (8-10 cm) tubularized. We created a 3- to 4-cm flap from the surface of the most distal region of the reservoir. This flap was tubularized to lengthen the neobladder onto the urethral stump, resulting in a tension-free anastomosis. All patients underwent a complete clinical laboratory evaluation 12 months after the surgery. At 1 year after surgery, all patients were able to void spontaneously. Day and night time continence were 80% and 60%, respectively. Urodynamic evaluation revealed a neobladder with good capacity (mean = 521 ml) and compliance (mean = 27.2 mL/cm H(2)O). Only 1 patient demonstrated a moderate hydronephrosis of the right kidney. Candidates for orthotopic neobladders who have had previous abdominal surgeries and who have a short mesoileum at the time of the surgery are uncommon. Despite the small number of cases, our technique is noteworthy for having achieved good functional results during the short-term follow-up. This technique is advantageous because it is easy to perform and does not require any other bowel resection or anastomose.

Long-term Renal Function After Urinary Diversion by Ileal Conduit or Orthotopic Ileal Bladder Substitution

BackgroundData on long-term renal function are scarce for ileal conduit diversion (ICD) and even rarer for orthotopic ileal bladder substitution (BS). ObjectiveExplore the changes in renal function of patients who lived ≥10 yr with an ICD or BS and determine the risk factors contributing to renal function deterioration. Design, setting, and participantsFifty consecutive ICD patients and 111 consecutive BS patients who lived ≥10 yr after undergoing surgery between January 1985 and December 2000 were retrospectively analyzed. MeasurementsThe glomerular filtration rate (GFR) was calculated with the Modification of Diet in Renal Disease (MDRD) equation before and 10 yr after surgery. Decreased renal function was defined as a decrease in GFR >10ml/min per 1.73 m2 in 10 yr. Results and limitationsMedian GFR values in patients with ICD or BS decreased from 65.5 (range: 23–90) to 57 (range: 7–100) ml/min per 1.73 m2 and from 68 (range: 33–106) to 66 (range: 16–100) ml/min per 1.73 m2, respectively. Eighteen ICD patients (36%) and 23 BS patients (21%) had deteriorating renal function. Seven of 12 ICD patients with obstruction (ureteroileal stricture, stomal stenosis/parastomal hernia) (58%) had renal function deterioration, as did 17 of 46 BS patients with obstruction (ureteroileal/nipple stricture and/or bladder outlet obstruction) (37%). Logistic regression analysis confirmed that obstruction was the leading, and an independent, risk factor for renal function deterioration for both ICD patients (p=0.045) and BS patients (p=0.002). Patients with diabetes or hypertension were significantly more likely to have deterioration of renal function if they had ICD (p=0.002 and p=0.05, respectively). The limitation of the study is its retrospective nature and its composition that included many patients who did not survive 10 yr. ConclusionsUrinary tract obstruction was the leading cause of long-term renal function impairment, regardless of whether the patient had ICD or BS. ICD patients with predisposing risk factors, such as diabetes or hypertension, were at increased risk for impaired renal function.

Long-term follow-up after radical cystectomy with emphasis on complications and reoperations: A Swedish population-based survey

To evaluate outcome after radical cystectomy for primary bladder cancer in a large population-based material. Between 1997 and 2002 all patients treated with radical cystectomy within 3 months after diagnosis of primary bladder cancer without distant metastasis were retrieved through the Swedish Bladder Cancer Registry. A follow-up questionnaire was distributed to all units where the primary registration of patients was performed. Follow-up data on recurrence date were retrieved from the patient charts and causes of death were obtained from the Swedish Cause of Death Registry until 2003. During the study period radical cystectomy was performed in 39 units in Sweden, of which only five units were considered high-volume hospitals performing 10 or more procedures annually. Mean blood loss was 2300 ml (median 2000 ml) and the 90-day mortality rate was 5.7%. Blood loss was higher in high-volume units than in hospitals with lower hospital volumes, but the 90-day mortality rates were similar. During a median follow-up of 3.5 years, 24% of the patients were submitted to a reoperation. Reoperation rates were significantly higher in patients who received a continent urinary diversion (29%) compared with an ileal conduit (22%, p < 0.015). Radical cystectomy was associated with a reoperation rate of 24% in Sweden during the study period. The reoperation rates were higher in patients receiving a continent cutaneous diversion or bladder substitution. Blood loss was higher in high-volume units; otherwise, surgical volume did not affect mortality rates, cancer-specific survival or reoperation rates.

Bowel Function Remains Subjectively Unchanged After Ileal Resection for Construction of Continent Ileal Reservoirs

BackgroundConstruction of a continent catheterizable urinary reservoir or an orthotopic bladder substitute requires substantial bowel resection, which can cause changes in bowel transit time. The reported incidence of chronic diarrhea after ileocecal resection is about 20%. Studies assessing bowel function after resection of 55–60cm of ileum without compromising the ileocecal valve are scarce, and long-term results have not been reported. ObjectiveProspective assessment of possible changes in bowel function (eg, stool frequency, diarrhea) and the potential impact on quality of life in patients with resection of small bowel for urinary diversion. Design, setting, and participantsA total of 82 patients who underwent radical cystectomy, extended lymph node dissection, orthotopic ileal bladder substitution, or heterotopic continent cutaneous urinary diversion with a follow-up >1 yr after surgery were prospectively evaluated. Patients who had a neurogenic bladder disorder, had undergone previous radiotherapy, or had not completed the questionnaire were excluded from the study. The validated Gastrointestinal Quality of Life Index was completed by the patients preoperatively and at 3, 12, and 24 mo postoperatively. Five points concerning bowel function (frequent bowel movement, urgent bowel movement, diarrhea, constipation, or uncontrolled stool loss) were assessed, and the median scores were compared pre- and postoperatively. Results and limitationsMost patients (≥80%) were rarely or never troubled by frequent or urgent bowel movements, diarrhea, constipation, or uncontrolled stool loss preoperatively. In the case of stool frequency, a remarkable shift from rarely to never was observed postoperatively at 3, 12, and 24 mo. Scores for constipation and uncontrolled stool loss remained unchanged throughout the whole time period. For urgent bowel movements the median preoperative score of 4 decreased to 3 at 3 mo and 12 mo and returned to 4 at 24 mo. For diarrhea the preoperative score of 4 decreased to 3 at 3 mo and 24 mo and remained at 4 after 12 mo. ConclusionsNo relevant changes in bowel movements were found after resection of 55–60cm of ileum if the terminal ileum and the ileocecal valve were left intact.

Prostate-sparing cystectomy: Potential functional advantages and objective oncological risks; a case series and review

ObjectivesProstate-sparing cystectomy (PSC) has been debated over the last decade; our aim was to assess the functional results and to evaluate the oncological outcome after PSC, to judge the value of this technique. Patients and methodsTwenty-six men (median age 62years) who were candidates for radical cystectomy were operated between 2004 and 2009 in the urology departments of Foch Hospital, Suresnes, France, and Theodor Bilharz Research Institute, Giza, Egypt. They all underwent a PSC with orthotopic bladder substitution. The functional results were assessed at 1, 3 and 6months, with the final results evaluated at 1year. Incontinence was classified according to pads used per day, and erectile function after PSC was assessed using the International Index of Erectile Function questionnaire. There was a strict follow-up for oncological failure, with special attention given to the remnant of the prostate and prostatic urethra. ResultsThe final functional results were assessed at 1year, with daytime continence achieved in 22 patients (95%) and nocturnal leak in four (13%). At 1year, 18 patients (83%) reported having erections on sexual stimulation. The median follow-up was 43months, with an overall incidence of recurrence of 30% and a median time to metastasis of 30months. At 36months, the overall survival rate was 81%, with a tumour-free survival rate of 70%. ConclusionPSC was no better than standard radical cystectomy, and should only be offered to patients who prefer preservation of their sexual function and continence over appropriate tumour control.

25 Years of Experience With 1,000 Neobladders: Long-Term Complications

We analyzed the long-term complications (greater than 90 days postoperatively) in a large, single center series of patients who underwent cystectomy and substitution with an ileal neobladder. A total of 1,540 radical cystectomies were performed at our center between January 1986 and September 2008. Of the patients 1,013 received an ileal neobladder. Only the 923 patients with followup longer than 90 days (median 72 months, range 3 to 267) were included in analysis. All long-term complications were identified. The complication rate was calculated using the Kaplan-Meier method. The overall survival rate was 65.5%, 49.8% and 28.3% at 5, 10 and 20 years, respectively. The overall long-term complication rate was 40.8% with 3 neobladder related deaths. Hydronephrosis, incisional hernia, ileus or small bowel obstruction and feverish urinary tract infection were observed in 16.9%, 6.4%, 3.6% and 5.7% of patients, respectively, 20 years postoperatively. Subneovesical obstruction in 3.1% of cases was due to local tumor recurrence in 1.1%, neovesicourethral anastomotic stricture in 1.2% and urethral stricture in 0.9%. Chronic diarrhea was noted in 9 patients. Vitamin B12 was substituted in 2 patients. Episodes of severe metabolic acidosis occurred in 11 patients and 307 of 923 required long-term bicarbonate substitution. Rare complications included cutaneous neobladder fistulas in 2 cases, and intestinal neobladder fistulas, iatrogenic neobladder perforation, spontaneous perforation and necrotizing pyocystis in 1 each. Even in experienced hands the long-term complication rate of radical cystectomy and neobladder formation are not negligible. Most complications are diversion related. The challenge of optimum care for these elderly patients with comorbidities is best mastered at high volume hospitals by high volume surgeons.

Editorial Comment

During the last decades, orthotopic bladder substitution (OBS) after radical cystectomy for bladder cancer in women has been increasingly proposed. Meanwhile, strict patient selection criteria, improved surgical techniques, long-term follow-up in large patient cohorts, and validated evaluation have defined the role of OBS in men. Several issues must be clarified in women: oncological outcome, complication rates, functional results, quality of life, and sexual function. As a matter of fact, the results of OBS in women are substantially unchanged in the last decade as stated in this paper. Oncological and Functional Outcomes of Radical Cystectomy and Orthotopic Bladder Replacement in WomenUrologyVol. 77Issue 4PreviewTo report oncological and functional results in women undergoing radical cystectomy and orthotopic bladder replacement. Full-Text PDF ReplyUrologyVol. 77Issue 4PreviewIndeed, over the last decade, orthotopic neobladder reconstruction (ONB) has become increasingly common in women after cystectomy. This is a result in large part of the growing body of retrospective series confirming acceptable oncological outcomes with ONB, including the results presented here. Thus far, evaluation of functional outcomes, in particular continence and hypercontinence, has been limited by variation in the definition and reporting of these measures. Full-Text PDF

Vescica Ileala Padovana: Perioperative, Short- and Long-Term Functional Results Obtained from a Single Center in Greece

Background: Vescica ileala padovana (VIP) is a technique of bladder substitution following radical cystectomy with the advantage of resulting in a shape that anatomically resembles the real bladder. We studied whether the VIP neobladder is a viable alternative following cystectomy. Patients and Methods: Forty-five patients with muscle invasive bladder cancer were treated with radical cystectomy and VIP neobladder formation. Both perioperative and postoperative complications together with short- and long-term results were discussed. Results: In the early postoperative period there was one patient (2.2%) who developed ileus and one death (2.2%) due to a massive pulmonary embolism. During follow-up, 2 patients (4.4%) presented with hernias and 1 died from metastatic disease (2.2%), 3 patients (6.6%) developed ureteroileal strictures and 1 developed (2.2%) urethroileal stenosis. During follow-up, maximum capacity increased (540 ± 89 vs. 590 ± 54 ml, p = 0.014) while Qmax and end-filling pressure decreased (18 ± 2 vs. 14 ± 4 ml/s, p = 0.002 and 22 ± 3 vs. 15 ± 6 cm H2O, p = 0.012). The number of intrinsic contractions remained stable (4 ± 1 vs. 5 ± 1, p = 0.066). Daytime continence between the 3rd and the 36th month was stable (40 vs. 39 pts, 88.8 vs. 86.6%, p = 0.09). Twenty-six patients were continent during the night and this number increased to 30 patients (57.8 vs. 66.7%, p = 0.013). Conclusions: VIP has a favorable outcome and can be used for bladder orthotopic substitution following cystectomy.

980 URETHRAL RECURRENCE AFTER RADICAL CYSTECTOMY AND ILEAL ORTHOTOPIC BLADDER SUBSTITUTION: CAN THE URETHRA BE SPARED?

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease1 Apr 2011980 URETHRAL RECURRENCE AFTER RADICAL CYSTECTOMY AND ILEAL ORTHOTOPIC BLADDER SUBSTITUTION: CAN THE URETHRA BE SPARED? Gianluca Giannarini, Thomas M. Kessler, Bernhard Kiss, Urs E. Studer, and George N. Thalmann Gianluca GiannariniGianluca Giannarini Bern, Switzerland More articles by this author , Thomas M. KesslerThomas M. Kessler Bern, Switzerland More articles by this author , Bernhard KissBernhard Kiss Bern, Switzerland More articles by this author , Urs E. StuderUrs E. Studer Bern, Switzerland More articles by this author , and George N. ThalmannGeorge N. Thalmann Bern, Switzerland More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.991AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The optimal management of urethral recurrence after radical cystectomy and orthotopic bladder substitution is still a matter of debate. We assessed the long-term outcome of patients with urethral recurrence after radical cystectomy and ileal orthotopic bladder substitution. METHODS We retrospectively analyzed 495 consecutive patients with bladder carcinoma and no neoadjuvant therapy who underwent extended pelvic lymph node dissection and radical cystectomy with ileal orthotopic bladder substitution. Preoperative paracollicular (men) or bladder neck (women) biopsies were negative for carcinoma. All patients were prospectively followed with a standardized protocol, including urethral cytology 6-monthly for 2 years, then annually for 3 years. In case of positive cytology, urethroscopy with biopsy and staging for metastases were performed. Based on recurrence stage, patients were treated with endourethral bacillus Calmette-Guérin (BCG) (6 weekly instillations with 81 mg in 150 ml saline), transurethral resection plus endourethral BCG, urethrectomy or systemic chemotherapy. Urethral recurrence rate, detection rate by cytology, urethra-preservation rate after endourethral BCG and overall survival with preserved urethra were the study outcome measures. RESULTS After a median follow-up of 45 months (range 3–250) urethral recurrence was diagnosed in 24/495 (4.8%) patients, in 21 (88%) by cytology and in 3 (12%) by hematuria. Carcinoma in situ (Tis), Ta/T1 and T2 recurrences were detected in 13, 7 and 4 patients, respectively. All patients with Tis were treated with endourethral BCG, and 6 of 7 with Ta/T1 recurrence with transurethral resection plus endourethral BCG. Urethrectomy was performed in 1 patient with T2 recurrence, while systemic chemotherapy was given to 4 patients (1 with Ta and 3 with T2 recurrence) due to concomitant metastases. The urethra could be preserved in 11/13 patients with Tis and 3/6 with Ta/T1 recurrence treated with endourethral BCG. Six of 13 patients with Tis, 1/7 with Ta/T1 recurrence and 0/4 with T2 recurrence are still alive with preserved urethra and no evidence of disease. CONCLUSIONS With routine cytology approximately 90% of urethral recurrences can be detected. In patients with Tis recurrence, the urethra should be primarily spared, since endourethral BCG is successful in most cases. On the contrary, in patients with Ta/T1 recurrence urethrectomy is usually required. Patients with T2 recurrence have a poor prognosis due to frequent concomitant metastases. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e395 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gianluca Giannarini Bern, Switzerland More articles by this author Thomas M. Kessler Bern, Switzerland More articles by this author Bernhard Kiss Bern, Switzerland More articles by this author Urs E. Studer Bern, Switzerland More articles by this author George N. Thalmann Bern, Switzerland More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Radical cystectomy with orthotopic neobladder for invasive bladder cancer: a critical analysis of long-term oncological, functional, and quality of life results

The present contribution analyses long-term data regarding oncological, functional, and quality of life aspects of patients subjected to cystectomy due to malignancy with subsequent orthotopic bladder substitution. A literature search was conducted to review literature published from 1887 until today. Oncological aspects, special considerations on female patients, quality of life, geriatric patients, and impact of minimally invasive surgery were also addressed and discussed. After more than three decades, orthotopic bladder substitution subsequent to radical cystectomy has stood the test of time by providing adequate long-term survival and low local recurrence rates. Compared to radical cystectomy, neither radiation nor chemotherapy, nor a combination of both, offer similar long-term results. Orthotopic bladder substitution does not compromise oncological outcome and can be performed with excellent results regarding functional and quality of life issues. Chronological age is generally not a contraindication for cystectomy. Orthotopic bladder substitution should be the diversion of choice both in men and in women, whenever possible. For orthotopic urinary diversion, a careful patient selection considering tumor extent, patient motivation, preoperative sphincter function, other local and systemic adverse confounding factors, and overall life expectancy must be taken into account. Minimally invasive techniques are promising concepts for the future, awaiting confirmation in larger patient cohorts.

Do patients benefit from routine follow-up to detect recurrences after radical cystectomy and ileal orthotopic bladder substitution?

Do patients benefit from routine follow-up to detect recurrences after radical cystectomy and ileal orthotopic bladder substitution?