Conduit Diversion Research Articles

Robotic radical cystectomy with intracorporeal urinary diversion: beyond the initial experience

Robotic assisted radical cystectomy (RARC) has gained popularity within minimally-invasive urologic surgery, and has been shown to be a safe procedure with similar oncologic outcomes when compared to the conventional open standard. While initial RARC feasibility and outcomes studies were performed with extracorporeal urinary diversion, intracorporeal urinary diversion (ICUD) is becoming increasingly utilized. Reported benefits of an intracorporeal approach include decreased blood loss and a lower incidence of ureteral strictures. While ICUD is technically challenging, many have overcome the learning curve associated with this procedure via a mentorship model and a dedicated operative team. Techniques vary between institutions, and ileal conduit, continent cutaneous and orthotopic continent (neobladder) diversions have all been performed. Herein, we describe the learning curve, technical points, and unique complications associated with ICUD.

Neurogenic bladder: management of the severely impaired patient with complete urethral destruction: ileovesicostomy, suprapubic tube drainage or urinary diversion-is one treatment modality better than another?

Management of the severely impaired patient (pt) with a neurogenic bladder (NGB) and complete urethral destruction employs three therapeutic options; bladder neck closure (BNC) with ileovesicostomy, BNC with suprapubic tube (SPT) placement or in pts with an end-stage bladder, cystectomy with enteric conduit diversion. This paper was performed to test the hypothesis that pts managed with an ileovesicostomy would have the best long-term prognosis. Patients with a NGB and complete urethral destruction managed between 1986-2018 were reviewed. Three treatment populations were assessed, pts treated with BNC with ileovesicostomy, BNC with SPT placement or cystectomy with enteric conduit diversion. A minimal follow-up interval of 2 years was necessary to be entered into the study. The number of uroseptic episodes, development of urolithiasis, the onset of new renal scars, ≥ stage 3 chronic renal failure, or need for additional surgery were recorded. Statistical evaluations used either chi-squared contingency table analysis, Fisher's exact 2-tailed tests, or Kaplan-Meier curve analysis where indicated. P values of <0.05 were considered significant. Ten pts were managed by cystectomy, and enteric conduit, 17 by BNC and ileovesicostomy and 21 by BNC and SPT placement, median follow up of 8 yrs (range, 2-30 yrs). No significant differences between the three groups regarding the development of urolithiasis (30%, 3/10 pts; 53%, 9/17 pts; 52%, 11/21 pts; respectively), new onset of renal scarring (30%, 6/20 kidneys; 41%, 14/34 kidneys; 45%, 19/42 kidneys; respectively) or stage 3 chronic renal failure (40%, 4/10 pts; 47%, 8/17 pts; 24%, 5/21 pts; respectively. However, the number of hospitalizations for uroseptic episodes significantly increased in patients managed with an ileal conduit (60%, 6/10 pts) and ileovesicostomy (82%; 14/17 pts) compared to those maintained with a SPT (29%, 6/21 pts) P=0.025 and 0.006, respectively. When evaluating the need for delayed surgical intervention due to either urolithiasis or other complications, a total of 50% (5/10 pts) of the patients managed by an ileal conduit, 88% (15/17 pts) of the ileovesicostomy and 52% (11/21 pts) of the patients with a SPT required additional operations. In essence, significantly more pts undergoing BNC and ileovesicostomy required delayed surgical interventions for complications arising from the surgery compared to patients managed with either a cystectomy and ileal conduit (P=0.0285) or BNC and SPT placement (P=0.0180). In severely impaired pts with a NGB and urinary outlet destruction, BNC and ileovesicostomy are associated with a significantly increased incidence of urosepsis and late surgical complications that required operative intervention compared to alternative treatments. This finding has resulted in the abandonment of the ileovesicostomy from our surgical armamentarium.

Risk factors of parastomal hernia in patients undergoing laparoscope radical cystectomy and ileal conduit diversion

Objective To investigate the incidence rate of parastomal hernia(PH) among patients who have received laparoscope radical cystectomy and ileal conduit diversion and to discover the risk factors for PH. Methods Data of 162 patients who underwent surgery of laparoscope radical cystectomy and ileal conduit diversion for bladder cancer between Jan 2012 and Dec 2017 were studied. The patients who had suffered other tumors before surgery or without follow-up data were excluded. At last, 148 patients were enrolled in this retrospective study. According to the occurrence of PH, the patients were divided into two groups: PH group and non-PH group. There were 21 patients (12 males and 9 females) in PH group. The mean age was (66.5±8.6) years old, and mean body mass index (BMI) was (33.4±5.2) kg/m2. 11 patients with synchronous disease and 10 patients without synchronous disease before operation in PH group. Postoperative T stage <T3 in 17 cases, ≥T3 in 4 cases. 4 Cases received neoadjuvant chemotherapy and 5 cases received adjuvant chemotherapy. Tumor recurrence was found in 6 cases. 16 cases had hypoproteinemia. Ileal conduit was made through abdominal incision in 9 cases, and 12 cases was made with laparoscopy. After the surgery, there was severe cough in 7 cases and abdominal distension in 7 cases. 3 cases had previous abdominal operation, and 5 cases had history of glucocorticoid use. The mean size of the stoma was (3.0±0.6) cm. The mean length of the outflow tract was (11.2 ±1.3) cm. We did trans-rectus stoma in 4 cases, and para-rectus stoma in 17 cases. There were 127 patients (82 males and 45 females) in non-PH group. The mean age was (71.4 ±7.4) years, and the mean BMI was (28.8±4.1)kg/m2. 60 patients with synchronous disease and 67 patients without. Postoperative T stage <T3 in 96 cases, ≥T3 in 31 cases. 29 patients received neoadjuvant chemotherapy and 39 cases received adjuvant chemotherapy. Tumor recurrence was found in 38 cases. 66 cases had hypoproteinemia. Ileal conduit was made through abdominal incision in 55 cases, under laparoscopy in 72 cases. There was severe cough in 34 cases and abdominal distension in 38 cases. 21 cases had previous abdominal operation, and 35 cases had history of glucocorticoid use. The mean size of the stoma was (2.3±0.4) cm. The mean length of the outflow tract was (12.2±1.6) cm. 4 cases had trans-rectus stoma, and 17 cases had para-rectus stoma. Postoperative rate of PH was estimated using the Kaplan-Meier methods. Chi-square test were used for the univariate analysis between group of PH and the normal one. Multivariate Logistic regression analysis was used to judge the independent risk factors of PH. Results Patients were followed up for 24 months. PH occurred in 21 cases, the 1, 2, 5 year cumulative incidence of PH was 9.9%, 5.4% and 16.7% respectively. Clinical characteristics, including age at surgery(χ2=4.018, P=0.045), obesity(χ2=3.949, P=0.047), perioperative hypoproteinemia(χ2=4.279, P=0.039), chronic constipation(χ2=5.416, P=0.020), stoma location(χ2=6.464, P=0.011), stoma size(χ2=3.915, P=0.048), were significantly different between the PH group and the normal group(P<0.05). Multivariate Logistic regression analysis shows that obesity(OR=1.326, 95%CI=1.102-1.548, P=0.043), stoma location(OR=0.892, 95%CI=0.854-0.931, P=0.028), stoma size(OR=1.365, 95%CI=1.089-1.631, P=0.028) were the independent risk factors for PH. Conclusion We demonstrated that most of PH usually develop in 2 years after undergoing radical cystectomy with ileal conduit diversion. Obesity, stoma location and stoma size are independent risk factors. Preoperative counseling and preventative measures regarding PH formation should be emphasized, particularly in those patients with risk factors. Key words: Urinary bladder neoplasms; Radical cystectomy; Urinary diversion; Hernia

Development of a Goal Elicitation Measure to Support Choice about Urinary Diversion by Patients with Bladder Cancer.

Patient centered care aims to align treatment with patient goals, especially when treatment options have equivalent clinical outcomes. For surgeries with lasting impacts that alignment is critical. To our knowledge no psychometrically tested preference elicitation measures exist to support patients with bladder cancer treated with cystectomy, who can often choose between ileal conduit and neobladder diversions. In this study we created a scale to measure how patient goals align with each type of urinary diversion and the associated surgical outcomes. We performed formative research through focus groups and clinician outreach to adapt a goal dissonance measure. We mailed a survey to adult Kaiser Permanente® members who underwent cystectomy for bladder cancer between January 2013 and June 2015. Eligible patients were identified through electronic health records and chart review. Surveys were mailed 5 to 7 months postoperatively. We administered our 10-item decision dissonance scale along with other decision making measures. We explored goal alignment as well as dissonance. Psychometric analysis included factor analysis, evaluation of scale scores between surgery groups and evaluation with other decision making scores. We identified 10 goals associated with ileal conduit or neobladder diversion. Using survey data on 215 patients our scale differentiated patient goals associated with each diversion choice. On average patients with a neobladder strongly valued neobladder aligned goals such as maintaining body integrity and volitional voiding through the urethra. Patients with an ileal conduit had neutral values on average across all goals. Our measure lays the foundation for a simple value elicitation approach which could facilitate shared decision making about urinary diversion choice.

Transvaginal mesh repair of anterior enterocele following radical cystectomy and ileal conduit diversion

Complex pelvic organ prolapses may develop after radical cystectomy. We report a case of an anterior enterocele, which was repaired vaginally and using mesh placed extraperitoneally. We present the case of a 75-year-old woman who underwent a radical cystectomy and ileal conduit diversion for treatment of invasive bladder cancer. She developed a vaginal vault prolapse 4 months later. She then underwent a vaginal repair and sacrospinous fixation using no mesh. She then presented to our clinic 4 months later with a prolapse recurrence involving an anterior enterocele. She was treated successfully with a transvaginal mesh repair for reconstruction of the anterior vaginal wall, iliococcygeal suspension and colpocliesis. We argue that there is a place for the vaginal use of mesh in the surgical treatment of an anterior enterocele when a substantial loss of endopelvic fascia is encountered. The extraperitoneal technique seems to be a good option while reducing the surgical risks for the patient.

The Course of Renal Function After Radical Cystectomy with Ileal Conduit Diversion for Bladder Cancer

The Course of Renal Function After Radical Cystectomy with Ileal Conduit Diversion for Bladder Cancer

Utilization and outcomes of adjuvant radiation therapy after cystectomy for urothelial carcinoma.

487 Background: Positive surgical margins with radical cystectomy for invasive urothelial cancer are associated with adverse prognosis. In non-metastatic patients, adjuvant radiation therapy (ART) is sometimes employed for patients with positive margins or locally advanced stage. However, evidence for benefit of ART in these patients to improve survival is limited. In this study, using a national database we investigate the factors associated with use of ART and its impact of the overall survival. Methods: National Cancer Database was queried for patients who underwent radical cystectomy from 2004-2013 for invasive urothelial cancer. Inclusion criteria were urothelial histology, pT2 stage with positive surgical margins or ³pT3 , and no evidence metastasis. Patients with regional or distant metastasis or patient who underwent adjuvant chemotherapy were excluded. Univariate and multivariate analysis performed to assess the factors associated with the use of ART. Overall survival was compared using log rank test. Results: In total, 18,828 patients met the inclusion criteria, of which 359 (1.91%) underwent ART. Mean duration between radical cystectomy and ART was 4.4 months. On univariable analysis, Black or Hispanic race, Medicare/Medicaid insurance status, treatment at community health center, ileal conduit diversion, advanced pathological stage (pT3/T4) were associated with higher use of ART (all p&lt;0.005). On multivariate analysis community health facility and adequate lymph node dissection (&gt;10 lymph nodes excision) were associated with use of ART (all p&lt;0.05) (see table). The use of ART was not associated with improved overall survival. Conclusions: The utilization of ART after radical cystectomy for urothelial carcinoma is low. The benefit of ART on the overall survival is not clear and would need further investigation. [Table: see text]

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

To determine and investigate the intraoperative factors that contribute to a change in plan from continent orthotopic neobladder to ileal conduit or continent cutaneous diversion at the time of radical cystectomy. A retrospective review of our prospectively maintained bladder cancer database was performed. Of the 711 patients who underwent radical cystectomy from 2012 to 2016, 387 (54.4%) had given consent to have a NB. Of these 387 patients, 348 (89.9%) ultimately received a neobladder while 34 (8.8%) received an ileal conduit and 5 (1.3%) continent cutaneous diversion. The factors involved in the intraoperative change of plan were examined in this study. Patients who ultimately received a neobladder were significantly more likely to have clinical node-negative disease (p = 0.045), negative soft tissue margins (p = 0.001), lower body mass index (p = 0.045) and higher volume surgeons (p < 0.001). Oncologic reasons for intraoperative conversions were more common than technical reasons (58.3% vs 35.9%), in both robotic and open surgical techniques. The choice of surgical approach (open vs robotic) did not influence the rate of intraoperative conversion. The factors influencing intraoperative decision not to perform neobladder are predominantly oncologic rather than technical. A clear understanding of the factors involved in influencing the intraoperative change in the urinary diversion plan may improve shared decision making in patients undergoing radical cystectomy in the future.

Response to editorial comment "A retrosigmoid ileal conduit might prevent ureteroileal anastomotic stricture after ileal conduit diversion".

We thank the authors for their interest in our recent article describing the surgical technique and early functional results of a retrosigmoid ileal conduit diversion after radical cystectomy (RC) (1). In a single-centre single-surgeon comparative study with a short-term follow-up, we observed a significantly reduced rate of ureteroileal anastomotic stricture (UAS) and no increase in intra- or postoperative complications with the retrosigmoid versus traditional Wallace ileal conduit. In details, no cases of UAS were detected in 30 patients who had received a retrosigmoid ileal conduit with a direct end-to-side ureteroileal anastomosis after a mean follow-up time of 10.8 months.

Hospitalisation and readmission costs after radical cystectomy in a nationally representative sample: does urinary reconstruction matter?

To investigate the impact of continent urinary diversion on readmissions and hospital costs in a nationally representative sample of radical cystectomies (RCs) performed in the USA. The 2010-2014 Nationwide Readmissions Database was queried for patients with a diagnosis of bladder cancer who underwent RC. We identified patients undergoing continent (neobladder or continent cutaneous reservoir) or incontinent (ileal conduit) diversions. Multivariable logistic regression models were used to identify predictors of 90-day readmission, prolonged length of stay, and total hospital costs. Amongst 21 126 patients identified, 19 437 (92.0%) underwent incontinent diversion and 1 689 (8.0%) had a continent diversion created. Continent diversion patients were younger, healthier, and treated at high-volume metropolitan centres. Continent diversions resulted in fewer in-hospital complications (37.3% vs 42.5%, P = 0.02) but led to more 90-day readmissions (46.5% vs 39.6%, P = 0.004). In addition, continent diversion patients were more often readmitted for infectious complications (38.7% vs 29.4%, P = 0.004) and genitourinary complications (18.5% vs 13.0%, P = 0.01). On multivariable logistic regression, patients with a continent diversion were more likely to be readmitted within 90 days (odds ratio [OR] 1.55, 95% confidence interval [CI]: 1.28, 1.88) and have increased hospital costs during initial hospitalisation (OR 1.99, 95% CI: 1.52, 2.61). Continent diversion led to a $4 617 (American dollars) increase in initial hospital costs ($36 640 vs $32 023, P < 0.001), which was maintained at 30 days ($48 621 vs $44 231, P < 0.001) and at 90 days ($56 380 vs $52 820, P < 0.001). In a nationally representative sample of RCs performed in the USA, continent urinary diversion led to more frequent readmissions and increased hospital costs. Interventions designed to address specific outpatient issues with continent diversions can potentially lead to a significant decrease in readmissions and associated hospital costs.

Retrosigmoid Versus Traditional Ileal Conduit for Urinary Diversion After Radical Cystectomy

BackgroundUreteroileal anastomotic stricture (UAS) after ileal conduit diversion occurs in a non-negligible proportion of patients undergoing radical cystectomy (RC). Surgical techniques aimed at preventing this potential complication are sought. ObjectiveTo describe our surgical technique of retrosigmoid ileal conduit, and to assess perioperative outcomes and postoperative complications with a focus on UAS rate. Design, setting, and participantsA prospective single-centre, single-surgeon cohort of 67 consecutive patients undergoing open RC with ileal conduit urinary diversion between July 2013 and April 2017 was analysed. A study group of 30 patients receiving retrosigmoid ileal conduit was compared with a control group of 37 patients receiving standard Wallace ileal conduit. Surgical procedureRetrosigmoid versus Wallace ileal conduit diversion after open RC. MeasurementsOperative room (OR) time, estimated blood loss (EBL), transfusion rate, and 90-d postoperative complications were recorded and compared between the two groups. In particular, rate of UAS, defined as upper collecting system dilatation requiring endourological or surgical management, was assessed and compared. Results and limitationsThe two groups were comparable with regard to all demographic, clinical, and pathological variables. No differences were observed in terms of OR time (p=0.35), EBL (p=0.12), and transfusion rate (p=0.81). Ninety-day postoperative complications were observed in 11 (36.7%) patients who underwent a retrosigmoid ileal conduit and 20 (54.1%) patients who received a traditional ileal conduit (p=0.32). Major complications (grade 3–4) were observed in three (10%) cases in the former group and in 12 (32.4%) cases in the latter group (p=0.08). Mean (standard deviation) follow-up time was 10.8±4.0 mo in the study group and 27.5±9.5 mo in the control group (p<0.001). No single case of UAS was observed in the study group, whereas six (16.2%) cases of UAS occurred in the control group (p=0.02). The main limitation is a nonrandomised comparison of a relatively small cohort with short-term follow-up. ConclusionsIn our study, we observed a significantly reduced rate of UAS and no increase in postoperative complications with the retrosigmoid ileal conduit diversion compared with standard Wallace ileal conduit diversion after open RC. Patient summaryWe describe our surgical technique of retrosigmoid ileal conduit as urinary diversion after open radical cystectomy. Compared with traditional techniques, our technique for ileal conduit was found to be safe and reduce the risk of ureteric strictures.

Comparison of health-related quality of life (HRQoL) between ileal conduit diversion and orthotopic neobladder based on validated questionnaires: a systematic review and meta-analysis.

The question of whether orthotopic neobladder (ONB) reconstruction is superior to ileal conduit diversion (ICD) with respect to health-related quality of life (HRQoL) remains controversial. The goal of this study is to perform a meta-analysis to compare post-ICD and post-ONB HRQoL in patients with bladder cancer. A systematic search of Medline, Embase, the Cochrane Central Register of Controlled Trials, and the annual congress abstracts of the European Association of Urology (EAU), the American Urological Association (AUA) and the Société Internationale d'Urologie (SIU) up to June 2017 was conducted to identify all relevant clinical trials using validated questionnaires to assess HRQoL. A systematic review and meta-analysis were then performed. A total of 2507 patients from 26 eligible studies were included. Meta-analyses showed significant differences favouring ONB patients in global health status (WMD + 9.13, p = 0.004), physical functioning (WMD + 11.57, p = 0.0001), role functioning (WMD + 9.64, p = 0.002), and social functioning (WMD + 6.81, p = 0.03) based on the EORTC-QLQ-C30 questionnaire and in the total score of FACT questionnaire (WMD + 6.80, p = 0.001). However, ONB patients were more likely to have postoperative urinary symptoms than ICD patients (WMD - 22.19, p = 0.0001). ONB patients are more likely to have a better global health status than ICD patients. Regardless of the type of urinary diversion (UD) surgery, a gradual improvement in HRQoL over preoperative status tended to stabilise after 12months postoperatively.

MP49-13 THE INCIDENCE OF PYOCYSTIS AND SUBSEQUENT REQUIREMENT FOR REMNANT BLADDER CYSTECTOMY FOLLOWING ILEAL CONDUIT URINARY DIVERSION FOR BENIGN AETIOLOGY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion I1 Apr 2018MP49-13 THE INCIDENCE OF PYOCYSTIS AND SUBSEQUENT REQUIREMENT FOR REMNANT BLADDER CYSTECTOMY FOLLOWING ILEAL CONDUIT URINARY DIVERSION FOR BENIGN AETIOLOGY George Mankaryous, Rachel Barratt, Mahreen Pakzad, Rizwan Hamid, Jeremy Ockrim, and Tamsin Greenwell George MankaryousGeorge Mankaryous More articles by this author , Rachel BarrattRachel Barratt More articles by this author , Mahreen PakzadMahreen Pakzad More articles by this author , Rizwan HamidRizwan Hamid More articles by this author , Jeremy OckrimJeremy Ockrim More articles by this author , and Tamsin GreenwellTamsin Greenwell More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1604AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Pyocystis is a recognised complication of the remnant bladder after ileal conduit urinary diversion for benign disease. We assessed our cohort of patients with defunctionalised bladders following ileal conduit urinary diversion to assess the incidence, risk factors and need for subsequent cystectomy for pyocystis. METHODS We retrospectively analysed the outcomes for patients with remnant bladders following ileal conduit urinary diversion (benign aetiology) under our institution between 1997 and 2004. Data analysed included: demographics, co-morbidities, indication for ileal conduit diversion, development and treatments for pyocystis and requirement for subsequent cystectomy. RESULTS 66(81%) female and 15 (19%) male patients underwent ileal conduit diversion in the time period studied. Mean patient age was 46 years (range 2-78). Mean follow-up was 49 months (range 6-252 months). Aetiology for conduit formation included: End-stage complex urinary incontinence, bladder pain syndrome, atonic bladder and Fowler's syndrome. 19 patients (24%) developed pyocystis and treatments for pyocystis included antibioics, remnant bladder ISC or washout and simple cystectomy. The risk factors, identified from our cohort, for pyocystis and requirement for cystectomy are detailed in Table 1. 18/19 patients (95%) with pyocystis eventually required cystectomy. 1/19 required cystectomy but had multiple co-morbidities and the risks of surgery were too high to proceed. There was no correlation between aetiology of conduit formation, or any other co-morbidity/patient factor, and the subsequent development of pyocystis. CONCLUSIONS 24% of patients with remnant bladders following ileal conduit diversion for benign aetiology develop pyocystis. Conservative management is ineffective and 95% require eventual simple cystectomy. Risk factors for the development of pyocystis identified in our cohort include prior SPC insertion and male gender. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e671 Advertisement Copyright & Permissions© 2018MetricsAuthor Information George Mankaryous More articles by this author Rachel Barratt More articles by this author Mahreen Pakzad More articles by this author Rizwan Hamid More articles by this author Jeremy Ockrim More articles by this author Tamsin Greenwell More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP49-08 IS THE HYBRID ILEO-URETERIC ANASTOMOSIS A BETTER ALTERNATIVE THAN THE BRICKER OR WALLACE ANASTOMOSIS FOR ILEAL CONDUIT URINARY DIVERSION?

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion I1 Apr 2018MP49-08 IS THE HYBRID ILEO-URETERIC ANASTOMOSIS A BETTER ALTERNATIVE THAN THE BRICKER OR WALLACE ANASTOMOSIS FOR ILEAL CONDUIT URINARY DIVERSION? Dixon T.S. Woon, Chinniv Vidyasagar, Athina Pirpiris, Jaime O. Herrera-Cáceres, Thenappan Chandrasekar, Hanan Goldberg, Zachary Klaassen, and Matthew Harper Dixon T.S. WoonDixon T.S. Woon More articles by this author , Chinniv VidyasagarChinniv Vidyasagar More articles by this author , Athina PirpirisAthina Pirpiris More articles by this author , Jaime O. Herrera-CáceresJaime O. Herrera-Cáceres More articles by this author , Thenappan ChandrasekarThenappan Chandrasekar More articles by this author , Hanan GoldbergHanan Goldberg More articles by this author , Zachary KlaassenZachary Klaassen More articles by this author , and Matthew HarperMatthew Harper More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1599AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Traditionally, the Bricker or the Wallace ileo-ureteric anastomosis is performed for ileal conduit diversion. A perceived disadvantage with the Bricker technique is the increased potential for stricture. As for the Wallace technique, it has been suggested that it is associated with an increased risk of bilateral ureteral obstruction at the site of anastomosis secondary to poor surgical technique, tumour recurrence or stone. In this study, we explore the feasibility and safety of the hybrid ileo-ureteric anastomosis. In this technique, the left ureter is spatulated and then anastomosed to the proximal end of an open ileal segment; and the right ureter to the side of the ileal conduit. The advantages include: (1) The two ureters are not in continuity, hence cancer recurrence in one ureter is unlikely to affect the other side; (2) Potentially lower left ureteric stricture rate (wider anastomosis, less mobilization); (3) Easier endoscopic access of the left ureter for surveillance. We aim to compare the complication rates, in particular, the stricture rates of the three types of anastomosis. METHODS This was a retrospective analysis of all patients who underwent a radical cystectomy and ileal conduit diversion at Monash Health, Australia, between 2011-2016. Patient's demographic, methods of the ileo-ureteric anastomosis, length of stay, readmission rate, and complication rates and management were reviewed. RESULTS Sixty-nine patients were identified. The mean age, and length of stay were 66.2 years and 9.9 days respectively. There were 57 men and 12 women. 20 (29%) of patient underwent a Bricker, 20 (29%) a Wallace and 29(42%) a hybride ileo-ureteric anastomosis. No patient in the hybrid group developed a ureteric stricture. Three patients (15%) in the Bricker group and one (5%) in the Wallace group were found to have uretero-anastomotic stricture requiring endoscopic surgical intervention. When compared to the hybrid technique, there was a statistically significant difference in the number of strictures (p=0.031, t test). CONCLUSIONS The hybrid method is a safe alternative to both the Bricker and the Wallace ileo-ureteric anastomosis. It has a statistically significant lower risk of anastomotic stricture than the Bricker's technique, and with the advantage over the Wallace that the two ureters are separated. Furthermore, it may potentially be easier to access ureters endoscopically with this method of anastomosis. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e669 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Dixon T.S. Woon More articles by this author Chinniv Vidyasagar More articles by this author Athina Pirpiris More articles by this author Jaime O. Herrera-Cáceres More articles by this author Thenappan Chandrasekar More articles by this author Hanan Goldberg More articles by this author Zachary Klaassen More articles by this author Matthew Harper More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP47-13 ROBOT-ASSISTED RADICAL CYSTECTOMY IN OCTOGENARIANS AND THE EFFECT OF AN ENHANCED RECOVERY PATHWAY ON PERI-OPERATIVE INDICES

You have accessJournal of UrologyBladder Cancer: Invasive IV1 Apr 2018MP47-13 ROBOT-ASSISTED RADICAL CYSTECTOMY IN OCTOGENARIANS AND THE EFFECT OF AN ENHANCED RECOVERY PATHWAY ON PERI-OPERATIVE INDICES Avinash Chenam, Justin Emtage, Nora Ruel, Patrick Kilday, Juzar Jamnagerwalla, Clayton Lau, Jonathan Yamzon, Ali Zhumkhawala, Bertram Yuh, and Kevin Chan Avinash ChenamAvinash Chenam More articles by this author , Justin EmtageJustin Emtage More articles by this author , Nora RuelNora Ruel More articles by this author , Patrick KildayPatrick Kilday More articles by this author , Juzar JamnagerwallaJuzar Jamnagerwalla More articles by this author , Clayton LauClayton Lau More articles by this author , Jonathan YamzonJonathan Yamzon More articles by this author , Ali ZhumkhawalaAli Zhumkhawala More articles by this author , Bertram YuhBertram Yuh More articles by this author , and Kevin ChanKevin Chan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1492AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The management of aggressive bladder cancer poses a unique challenge due to the often-advanced age at diagnosis. This is becoming more common with the increasing longevity of the general population and incidence of bladder cancer as a whole. Robot-assistance may offer decreased peri-operative morbidity in comparison to open surgery, especially important in the elderly. Further, enhanced recovery protocols can offer added benefits on operative outcomes in this population. Thus, we present our experience with robot-assisted radical cystectomy in a strictly octogenarian population and the effect of the City of Hope Cystectomy Pathway on peri-operative indices. METHODS We identified all patients who were >80 years at the time of their robot-assisted radical cystectomy performed at our institution between October 2003 to present. Demographic and peri-operative data were collected in an IRB-approved database. Patients were then stratified by whether or not they were subject to the City of Hope Cystectomy Pathway that was instituted in April 2014 and these cohorts were compared. RESULTS A total of 87 octogenarians underwent robot-assisted radical cystectomy during our study period. 20 of these were subject to the pathway. The total mean age was 83.9 years, and the vast majority were unhealthy with 91.9% of the cohort having an ASA score of 3 or higher. Most patients (85.1%) underwent ileal conduit diversions. Median estimated blood loss was 250 cc. 63.2% of patients required blood transfusions. There were 3 (3.4%) open conversions. Median length of stay was 10 days. 31.0% of patients experienced major complications at 90 days. The 30 and 90-day mortality rate was 3.4% and 12.6%, respectively. The 30 and 90-day readmission rate was 32.2% and 42.5%, respectively. Pathway patients had a higher ASA and lower estimated blood loss. Use of the pathway reduced length of stay by 3 days. There was no difference observed in the rate of complications, peri-operative mortality or early readmission. CONCLUSIONS Robot-assisted radical cystectomy is safe and feasible in octogenarians with an acceptable peri-operative morbidity profile that can potentially be an improvement when compared to open surgery. The City of Hope cystectomy pathway was not associated with a reduction in the rates of early complications, mortality or readmissions but a shorter length of stay was observed. Larger randomized, prospective trials are needed to further investigate our findings. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e620-e621 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Avinash Chenam More articles by this author Justin Emtage More articles by this author Nora Ruel More articles by this author Patrick Kilday More articles by this author Juzar Jamnagerwalla More articles by this author Clayton Lau More articles by this author Jonathan Yamzon More articles by this author Ali Zhumkhawala More articles by this author Bertram Yuh More articles by this author Kevin Chan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

3-Piece Inflatable Penile Prosthesis Placement Following Radical Cystoprostatectomy and Urinary Diversion: Technique and Outcomes

BackgroundAfter radical cystoprostatectomy (RC), postoperative erectile dysfunction (ED) is a common consequence with multiple contributing etiologies. The inflatable penile prosthesis (IPP) offers patients a definitive treatment option when ED is refractory to medical therapies. Because of the hostile postoperative anatomy of these patients, a careful surgical approach is necessary for successful outcomes and to avoid adjacent organ injury. To date, there is no series describing the outcomes of 3-piece IPP placement in patients with urinary diversions. AimTo present contemporary outcomes and a description of our technique in placing a 3-piece IPP for postoperative ED in patients with a history of RC with orthotopic neobladder, ileal conduit, or continent cutaneous diversion. MethodsWe retrospectively reviewed 80 patients who underwent primary placement of a 3-piece IPP (AMS 700; American Medical Systems Inc, Minnetonka, MN, USA) after RC and urinary diversion from 2003 through 2016. 79 patients underwent RC in their treatment of urologic malignancy (71 for bladder cancer, 8 for prostate cancer) and 1 underwent RC for refractory interstitial cystitis. An infrapubic approach was used in most patients, with reservoir placement in the lateral retroperitoneal space through a counterincision medial to the anterior superior iliac spine. Patient demographics, perioperative data, and postoperative outcomes including prosthetic infection and mechanical failure were examined and statistical analysis was performed. OutcomesRates of device infection, revision surgery, and reservoir complications. ResultsAfter mean follow-up of 53.9 months (6.5–150.7 months), 4 patients developed infection of the prosthesis that required explantation. 3 of those patients underwent successful IPP reimplantation. 5 patients required revision surgery (pump replacement, n = 3; pump relocation, n = 1; cylinder replacement for cylinder aneurysm, n = 1) for mechanical failure. No statistically significant associations were found between infection and comorbidities, urinary diversion, exposure to chemotherapy, radiation, or presence of an artificial urinary sphincter. Clinical ImplicationsThe 3-piece IPP is an effective treatment option for medication-refractory ED that can be placed safely in patients with all forms of urinary diversion. Strengths and LimitationsThis study represents the 1st series that describes a successful technique and long-term outcomes of patients with urinary diversion. It is limited by its single-surgeon, single-center experience and lacks validated patient satisfaction data in follow-up. ConclusionsThe 3-piece IPP, with reservoir placement in the lateral retroperitoneum, can be implanted successfully in patients with all forms of urinary diversion without a significant increase in infectious complications, reservoir erosion, or mechanical failure.Loh-Doyle J, Patil MB, Sawkar H, et al. 3-Piece Inflatable Penile Prosthesis Placement Following Radical Cystoprostatectomy and Urinary Diversion: Technique and Outcomes. J Sex Med 2018;15:907–913.

No Anastomosis" Combined Colon Conduit and Colostomy Diversion with Pelvic Exenteration: An Underutilized, Cost-Effective Technique Reducing Bowel Complications

Experimental Techniques in Urology & Nephrology "No Anastomosis" Combined Colon Conduit and Colostomy Diversion with Pelvic Exenteration: An Underutilized, Cost-Effective Technique Reducing Bowel Complications Sayyid KR, Neal DE, Albo D, Kruse EJ, Wallbillich JJ, Rungruang BJ, Ghamande SJ and Martha K Terris* Department of Urology, Augusta University, USA *Corresponding author: Martha K Terris, Department of Urology, Medical College of Georgia, Augusta University, Augusta, GA, USA Submission: January 31, 2018; Published: February 12, 2018 DOI: 10.31031/ETUN.2018.01.000519 ISSN: 2578-0395 Volume1 Issue4

The effects of training and the use of cranberry capsule in preventing urinary tract infections after urostomy

PurposeThe study was conducted to investigate the effects of training provided by researcher and the use of cranberry capsule in preventing late term UTIs after urostomy. MethodsThe study included 60 patients who underwent ileal conduit diversion between June 2013 and November 2014. The participants were randomly divided into three groups. First group used cranberry capsule, second group received training about UTIs and the other control group. The patients were assessed for a UTI by laboratory analysis at 2, 3, and 4 months after discharge. ResultsWhen the effect of cranberry capsule use and training on the prevention of urinary tract infections were compared, we found that there was a significant difference between the group that used and didn’t use cranberry capsules, favoring the cranberry capsule (log-rank test; p < 0.05). ConclusionWe found that the use of cranberry capsules is effective in the prevention of urinary tract infections.

Disparities in the Use of Continent Urinary Diversions after Radical Cystectomy for Bladder Cancer.

Background:Radical cystectomy (RC) with ileal conduit (IC) or continent diversion (CD) is standard treatment for high-risk non-invasive and muscle-invasive bladder cancer.Objective:Our aim is to study contemporary trends in the utilization of ICs and CDs in patients undergoing RC.Methods:Using the National Inpatient Sample 2001–2012, we identified all patients diagnosed with a malignant bladder neoplasm who underwent RC followed by IC or CD. Patient demographics, comorbidities, length of stay (LOS), and in-hospital complications, mortality, and costs were compared. Multivariable logistic regression analysis, Chi square, and t-tests were used for analysis.Results:Between 2001–2012, approximately 69,049 ICs and 6,991 CDs were performed. CDs increased from 2001 to 2008, but declined after 2008 (p < 0.0001). Patients of all ages received ICs at a higher rate than CDs (40–59 years: 79.5% vs. 20.5%; 60–69 years: 88.0% vs. 12.0%; p < 0.0001). There was a difference in males vs. females (10.2% vs. 4.0%; OR 2.36) and Caucasians vs. African Americans (9.0% vs. 6.7%; OR 1.49) when comparing CD rates. CD rates were highest in the West, urban teaching centers, and large hospitals (p < 0.001). ICs were associated with higher rates of overall postoperative complications (p = 0.0185) including infection (p = 0.002) and mortality (p < 0.0001). In-hospital costs were greater for the CD group.Conclusions:The number of CDs has declined recently. Patients of all ages are more likely to receive ICs than CDs. Gender, racial, and geographic disparities exist among those receiving CDs. CDs are associated with lower rates of in-hospital complications and mortality, but higher in-hospital costs.

Prospective evaluation of quality-of-life outcomes following orthotopic neobladder and ileal conduit diversion after radical cystectomy

Prospective evaluation of quality-of-life outcomes following orthotopic neobladder and ileal conduit diversion after radical cystectomy