Continent Cutaneous Diversion Research Articles

Continent cutaneous diversion: Unveiling the interplay of neuro-urology and oncological challenges

ObjectivesThe objective of our study is to demonstrate the practical application of continent cutaneous urinary diversion (CCUD) in oncological patients, with a focus on various aspects of the procedure: surgical challenges, functional outcomes, and quality of life. Materials and methodsWe studied the perioperative and follow-up data of patients who underwent cystectomy for cancer associated with CCUD (Mitrofanoff, Monti or Casale). We retrospectively analyzed complications within 30days and beyond 30days post-surgery. We evaluated oncological outcomes. Patients’ quality of life was assessed using the Bladder Cancer Index (BCI) questionnaire. Results are given on an intention-to-treat basis. ResultsA total of 24 patients were included in the study (July 2001 and May 2022), with a median follow-up of 62.5months. We report three deaths due to neoplasic recurrence. Forty-six percent had an early postoperative complication, two of whom required revision surgery. Overall, the medium-term complication rate was 70% and the reoperation rate was 62%. There were 8 stomal cutaneous stenoses (33%) and 3 uretero-ileal stenoses (12.5%). Overall satisfaction was rated at 9.2/10 on average, and body image was unaltered or slightly altered in 62.5% of patients. Of the patients who responded to the BCI, 75% had complete continence. DiscussionThe experience gained with continent stomas in neuro-urology has allowed, in carefully selected cases, to offer patients an alternative that can improve their quality of life in a context already burdened by the shadow of cancer. CCUD can be proposed as an alternative to Bricker diversion in cases of urethral invasion or a high risk of neobladder incontinence, in selected patients. Level of evidence4.

Characteristics of Urinary Tract Infections and the Use of Cranberry Products in Patients With Urinary Diversions: A Narrative Review.

The aim of this narrative literature review was to summarize evidence regarding bacteriuria and urinary tract infections (UTIs) in patients living with a urinary diversion and the use of cranberry products for the prevention of these infections. We searched for articles in the English language and available in full text to address the role of cranberry products in the management of UTIs in those with urinary diversions. We searched the electronic databases of MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials between January 2003 and December 2023. Thirty-two elements were read in full and 9 elements that evaluated UTIs and/or the role of cranberries in preventing UTIs are included in this narrative review. Research indicates no significant difference in UTI rates, microbiology, or antibiotic sensitivity and resistance patterns between the different types of urinary diversions (orthoptic diversions, ileal conduit diversions, and continent cutaneous diversions). Similar to persons with an intact urinary tract, Escherichia coli (a prevalent coliform bacteria) was the most prevalent pathogen resulting in symptomatic UTIs. In addition, we found that E. coli strains persisted in urinary diversions involving reconstructed intestinal segments for prolonged periods of time despite antibiotic treatment. We found sparse evidence suggesting that cranberry products are effective for the prevention of UTIs after ileal conduit urinary diversion. There are inconsistencies in the definition of bacteriuria in the literature making it difficult to compare findings among the studies. Clinical guidance discussing the optimal method for obtaining a urine specimen from a urinary diversion and its management is limited. Research studies on the use of cranberry products to treat UTIs in persons living with a urinary diversion are urgently needed.

Bladder augmentation in the era of botulinum toxin: Indications and results

To determine the surgical indication and results of bladder augmentation (BA) during the last decade in a neurourology center in the era of intradetrusor botulinum toxin injection. We conducted a retrospective study that included patients with BA between January 1, 2012 and December 31, 2022 in our centre. We collected pre-operative demographic, clinical, and urodynamic data, BA indication, and associated procedures. We analyzed early and late complications as well as continence and postoperative voiding mode in patients with first BA in a neurological pathology context. We performed 77 BA over the study period. The main indication was neurogenic overactive bladder, which was secondarily resistant to botulinum toxin. The main associated procedure was continent cutaneous diversion (n=31, 57.4%). Among patients who had a first BA for neurogenic bladder, 34 patients had early complications (50%) including 12 patients with≥Clavien 3 complications (17.6%). After a median follow-up of 33 [14; 55] months, 23 patients had late complications (33.8%) and 59 patients had complete continence (86.8%). In the era of botulinum toxin, the main indication of BA is the secondary failure of botulinum toxin for overactive neurogenic bladder. The BA provided continence in 86.8% of patients. It remains however an intervention with a significant rate of severe complications whose indication must be discussed by a multidisciplinary team. Weak.

Evaluation of Bowel Function Following Radical Cystectomy and Urinary Diversion Using Two Validated Questionnaires: What Are the Effects on Quality of Life?

To assess both short- and long-term constipation symptoms and their impact on quality of life in patients who underwent radical cystectomy (RC) with three different types of urinary diversion: orthotopic neobladder (ONB), continent cutaneous diversion (CCD), and ileal conduit (IC). The validated Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires were administered to all patients at follow-up greater than 30 days from surgery. Clinical and pathological characteristics were prospectively recorded in an institutional review board approved bladder cancer database. Using multivariable linear regression analyses, we determined significant predictors of improved constipation symptoms and quality of life scores. A total of 198 patients completed 255 PAC-SYM and PAC-QOL questionnaires with a median follow-up time of 1.7 years (IQR: 0.7 - 3.0 years). ONB, CCD, and IC were performed in 78%, 5.5%, and 16.5% of patients, respectively. Higher bowel function scores (i.e. worse symptoms) were noted at 3 months post-operatively, while these scores significantly improved over time for PAC-SYM total score (P=.004), abdominal subscore (P=.001), and rectal subscore (P=.018). On multivariable analysis, we found that patients <70 years old (B -2.1, P=.004), with follow-up >1 year (B -4.8, P=.001), and who received an IC (B -2.4, P=.02) had significantly lower PAC-SYM scores. Patients have few constipation symptoms and are overall satisfied with their bowel function at long-term follow-up after RC. While patients with IC have significantly fewer constipation symptoms compared to those with ONB or CCD, all patients had significant improvement one year after the surgery.

Continent cutaneous urine diversion in patients with tuberculosis of various localizations

Various diseases of the bladder lead to the loss of its function and the need for periodic catheterization of the patient or the installation of permanent urinary drainage. Reconstruction of the lower urinary tract, based on the Mitrofanov principle, improves the quality of life of patients. However, this operation has a significant number of early and late operational complications. We represent a small group of patients — 6 people who underwent continental cutaneous urine diversion in our modification, the purpose of which was to reduce incontinence. Long-term results of the operation demonstrate a good result of this technique.

Cumulative incidence of midline incisional hernia and its surgical treatment after radical cystectomy and urinary diversion for bladder cancer: A nation-wide population-based study.

To study the cumulative incidence and surgical treatment of midline incisional hernia (MIH) after cystectomy for bladder cancer. In the nationwide Bladder Cancer Data Base Sweden (BladderBaSe), cystectomy was performed in 5646 individuals. Cumulative incidence MIH and surgery for MIH were investigated in relation to age, gender, comorbidity, previous laparotomy and/or inguinal hernia repair, operative technique, primary/secondary cystectomy, postoperative wound dehiscence, year of surgery, and period-specific mean annual hospital cystectomy volume (PSMAV). Three years after cystectomy the cumulative incidence of MIH and surgery for MIH was 8% and 4%, respectively. The cumulative incidence MIH was 12%, 9% and 7% in patients having urinary diversion with continent cutaneous pouch, orthotopic neobladder and ileal conduit. Patients with postoperative wound dehiscence had a higher three-year cumulative incidence MIH (20%) compared to 8% without. The corresponding cumulative incidence surgery for MIH three years after cystectomy was 9%, 6%, and 4% for continent cutaneous, neobladder, and conduit diversion, respectively, and 11% for individuals with postoperative wound dehiscence (vs 4% without). Using multivariable Cox regression, secondary cystectomy (HR 1.3 (1.0-1.7)), continent cutaneous diversion (HR 1.9 (1.1-2.4)), robot-assisted cystectomy (HR 1.8 (1-3.2)), wound dehiscence (HR 3.0 (2.0-4.7)), cystectomy in hospitals with PSMAV 10-25 (HR 1.4 (1.0-1.9)), as well as cystectomy during later years (HRs 2.5-3.1) were all independently associated with increased risk of MIH. The cumulative incidence of MIH was 8% three years postoperatively, and increase over time. Avoiding postoperative wound dehiscence after midline closure is important to decrease the risk of MIH.

MP41-01 EVALUATION OF URINARY CONTINENCE FOLLOWING OPEN RADICAL CYSTECTOMY WITH ORTHOTOPIC NEOBLADDER IN FEMALES USING A VALIDATED QUESTIONNAIRE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion I (MP41)1 Apr 2020MP41-01 EVALUATION OF URINARY CONTINENCE FOLLOWING OPEN RADICAL CYSTECTOMY WITH ORTHOTOPIC NEOBLADDER IN FEMALES USING A VALIDATED QUESTIONNAIRE Seyedeh-Sanam Ladi Seyedian*, Wesley Yip, Zhoobin Bateni, Saum Ghodoussipour, Jie Cai, Gus Miranda, Sumeet Bhanvadia, Hooman Djaladat, Anne Schuckman, and Siamak Daneshmand Seyedeh-Sanam Ladi Seyedian*Seyedeh-Sanam Ladi Seyedian* More articles by this author , Wesley YipWesley Yip More articles by this author , Zhoobin BateniZhoobin Bateni More articles by this author , Saum GhodoussipourSaum Ghodoussipour More articles by this author , Jie CaiJie Cai More articles by this author , Gus MirandaGus Miranda More articles by this author , Sumeet BhanvadiaSumeet Bhanvadia More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , Anne SchuckmanAnne Schuckman More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000890.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Orthotopic neobladder (ONB) following radical cystectomy (RC) is less frequent in female patients compared to males, due to unclear functional outcomes. We prospectively evaluated the continence outcomes in female patients undergoing open RC and ONB with a validated pad usage questionnaire. METHODS: From May 2012 onwards, we prospectively followed patients after open RC with ONB with a validated, pictorial, pad usage questionnaire that assesses the number, size, and wetness of pads, as well as catheter use, at follow-up clinic visits. In our IRB approved database, 42 ONB were performed for female patients after open RC from May 2012 to May 2018 (38% of all urinary diversions in female patients). 32 patients had complete data from interval clinic visits with at least 1 year of follow-up. Daytime continence was defined as no pad usage or an almost dry pad. RESULTS: A total of 32 female ONB patients with median age of 65 years (range: 42-81) and BMI of 25.6 (range: 18-35) were included. Median follow-up was 3 years (range: 1-7). The need to catheterize was noted in 10 patients (36%), either due to complete retention (7%), high post-void residuals (25%), or to empty their neobladder prior to sleeping (4%). Neobladder-vaginal fistulae developed in 4 patients (14%), with 1 ultimately converting to a continent cutaneous diversion after failed conservative management and the other 3 undergoing primary repairs. Daytime continence rates with and without intermittent catheterization increased from 64% and 36% at 4 months post-operatively, to 90% and 60% at 4 years, respectively. Nighttime continence rates with and without catheterization increased from 57% and 24% at 4 months, to 90% and 60% at 4 years, respectively (Figure1). Daytime continence rate was significantly less in females compared to males (P=0.024), while there was no significant difference in nighttime continence rate between them (P=0.58). CONCLUSIONS: Open RC and ONB in selected female patients can have good functional outcomes. Day and nighttime continence improve over time and majority of patients achieve continence by 2 years. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e595-e595 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Seyedeh-Sanam Ladi Seyedian* More articles by this author Wesley Yip More articles by this author Zhoobin Bateni More articles by this author Saum Ghodoussipour More articles by this author Jie Cai More articles by this author Gus Miranda More articles by this author Sumeet Bhanvadia More articles by this author Hooman Djaladat More articles by this author Anne Schuckman More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement PDF downloadLoading ...

Development and Acceptability Testing of a Patient Decision Aid for Urinary Diversion with Radical Cystectomy.

The choice of urinary diversion at cystectomy is a life altering decision. Patient decision aids are clinical tools that promote shared decision making by providing information about management options and helping patients communicate their values. We sought to develop and evaluate a patient decision aid for individuals undergoing cystectomy with urinary diversion. We used the IPDAS (International Patient Decision Aids Standards) to guide a systematic development process. A literature review was performed to determine urinary diversion options and the incidence of outcomes. We created a prototype using the Ottawa Decision Support Framework. A 10-question survey was used to assess patient decision aid acceptability among patients, allied health professionals and urologists. The primary outcome was acceptability of the patient decision aid. Ileal conduit and orthotopic neobladder were included as primary urinary diversion options because they had the most evidence and are most commonly performed. Continent cutaneous diversion was identified as an alternative option. Outcomes specific to ileal conduit were stomal stenosis and parastomal hernia. Outcomes specific to neobladder were daytime and nighttime urinary incontinence and urinary retention. Acceptability testing was completed by 8 urologists, 9 patients and 1 advanced practice nurse. Of the respondents 94% reported that the language was appropriate, 94% reported that the length was adequate and 83% reported that option presentation was balanced. The patient decision aid met all 6 IPDAS defining criteria, all 6 certification criteria and 21 of 23 quality criteria. We created a novel patient decision aid to improve the quality of decisions made by patients when deciding among urinary diversion options. Effectiveness testing will be performed prospectively.

Robotic intracorporeal urinary diversion: state of the art.

We review historical aspects and current status of the emerging approach of robotic urinary diversion (rUD). Established surgical principles of constructing a low-pressure, large-capacity reservoir are described and the open surgical literature succinctly reviewed to establish the gold standard. Incontinent and continent rUD types [ileal conduit, orthotopic neobladder (all varieties), continent cutaneous diversion, cutaneous ureterostomy] and techniques (extra-corporeal, intra-corporeal) are discussed. Outcomes data (intra-operative, perioperative, intermediate-term, long-term), functional outcomes, complications and learning curve are presented. Outcomes data of open versus robotic urinary diversion are examined. Critiques, improvements, and pros-cons of rUD are discussed. Although the majority of centers performing rUD use the extracorporeal technique, use of intra-corporeal rUD is increasing. Although data are yet limited, intra-corporeal rUD may provide some benefits. For rUD, operative times are higher and complication rates comparable with open urinary diversion. The entire range of urinary diversion surgery has now been replicated robotically. At this writing, extracorporeal urinary diversion techniques still predominate following robotic cystectomy. However, all rUD options can now be performed intra-corporeally with success. As experience increases, the field of robotic urinary diversion is poised to grow.

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.

Contemporary techniques and outcomes of robotic cystectomy and intracorporeal urinary diversions.

Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is being increasingly performed worldwide. This review summarizes recent technical developments and outcome data for RARC with ICUD. With the recent description of intracorporeal continent cutaneous diversion, all classes of urinary diversion can presently be performed totally intracorporeally. The summary of our seven cases of intracorporeal continent cutaneous diversion in this article brings the number of reported cases in the literature to 17. Additional recent advancements in ICUD focus on novel technical descriptions and outcome data. Several intracorporeal orthotopic ileal neobladder techniques have been described with intermediate perioperative outcomes. There is some rationale for reduced overall, wound, gastrointestinal and genitourinary complications with ICUD. RARC with intracorporeal diversion is a feasible option for patients with bladder cancer. Prospective and randomized outcome data are needed to better characterize the benefit of ICUD in patients following radical cystectomy.

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.

Urinary tract infections following radical cystectomy and urinary diversion: a review of 1133 patients.

To investigate the incidence and microbiology of urinary tract infection (UTI) within 90days following radical cystectomy (RC) and urinary diversion. We reviewed 1133 patients who underwent RC for bladder cancer at our institution between 2003 and 2013; 815 patients (72%) underwent orthotopic diversion, 274 (24%) ileal conduit, and 44 (4%) continent cutaneous diversion. 90-day postoperative UTI incidence, culture results, antibiotic sensitivity/resistance and treatment were recorded through retrospective review. Fisher's exact test, Kruskal-Wallis test, and multivariable analysis were performed. A total of 151 urinary tract infections were recorded in 123 patients (11%) during the first 90days postoperatively. 21/123 (17%) had multiple infections and 25 (20%) had urosepsis in this time span. Gram-negative rods were the most common etiology (54% of positive cultures). 52% of UTI episodes led to readmission. There was no significant difference in UTI rate, etiologic microbiology (Gram-negative rods, Gram-positive cocci, fungi), or antibiotic sensitivity and resistance patterns between diversion groups. Resistance to quinolones was evident in 87.5% of Gram-positive and 35% of Gram-negative bacteria. In multivariable analysis, Charlson Comorbidity Index>2 was associated with higher 90-day UTI rate (OR=1.8, 95% CI 1.1-2.9, p=0.05) and Candida UTI (OR 5.6, 95% CI 1.6-26.5, p=0.04). UTI is a common complication and cause of readmission following radical cystectomy and urinary diversion. These infections are commonly caused by Gram-negative rods. High comorbidity index is an independent risk factor for postoperative UTI, but diversion type is not.

Urologic surgical procedures in patients with uterus neoplasm and colon-rectal cancer

INTRODUCTION. During the last 30 years, the multidisciplinary treatments of colon and uterus neoplasm have yielded an increase in total survival rates, fostering therefore the increase of cases with regional relapse involving the urinary tract. In these cases the iterative surgery can be performed, if no disease secondary to pelvic pain, haemostatic or debulking procedure is present, and must be considered and discussed with the patient, according to his/her general status. MATERIALS AND METHODS. From 1997 to August 2007 we performed altogether 43 pelvic iterative surgeries, with simultaneous urologic surgical procedure because of pelvic tumor relapse in patients with uterus neoplasm and colon and rectal cancer. In 4 cases of anal cancer, the urological procedure were: one radical prostatectomy with continent vesicostomy in the first case, while in the other 3 cases radical pelvectomy with double-barrelled uretero-cutaneostomy. In 23 cases of colon cancer, the urologic procedures were: 9 cases of radical cystectomy with double-barrelled uretero-cutaneostomy, 4 cases of radical cystectomy with uretero-ileo-cutaneostomy according to Bricker- Wallace II procedure, and 9 cases of partial cystectomy with pelvic ureterectomy and ureterocystoneostomy according to Lich-Gregoire technique (7 cases) and Lembo-Boari (2 cases) procedure. In 16 cases of uterus cancer, the urological procedure were: 7 cases of partial cystectomy with pelvic ureterectomy and uretero-cystoneostomy according to Lich-Gregoire procedure; in 3 cases, a radical cystectomy with urinary continent cutaneous diversion according to the Ileal T-pouch procedure; 2 cases of total pelvectomy and double uretero-cutaneostomy, and 4 cases of bilateral uretero-cutaneostomy. RESULTS. No patients died in the perioperative time; early systemic complications were: 2 esophageal candidiasis, 1 case of venous thrombosis. CONCLUSIONS. The iterative pelvic surgery in the case of oncological relapse involving the urinary tract aims to achieve the best quality of life with the utmost oncological radicality. The equation: eradication of pelvic neoplasm and urinary tract reconstruction, with acceptable quality of life, will be the future target; nevertheless, it is not possible to establish guidelines beforehand, and the therapy must be adapted to each single case.

Long-term third-party assessment of results after continent cutaneous diversion with Lundiana pouch.

To investigate the long-term functional outcomes and complications after continent cutaneous diversion with the Lundiana pouch. Complications, re-operations, renal function, and continence were ascertained from patient charts. Outcome variables were validated by a second and independent review of the patient files. A complication of Clavien-Dindo grade ≥III, including unscheduled re-admissions, occurred in 45/193 patients (23%) at ≤90 days of surgery. At a median follow-up of 13 years, 105/193 patients (54%) had undergone at least one re-operation, with uretero-intestinal stricture being the most prevalent cause [28 patients (15%)]. Re-operations were more prevalent in patients operated during the first half of the study period than during the second half (2000-2007; 62% vs 47%; P = 0.03), and they were also more frequent in patients who underwent surgery for benign causes than in patients who underwent surgery for malignancy (60% vs 51%; P = 0.04). Continence was achieved in 172/188 patients (91%). In all, 16% of all patients required revisional surgery of the outlet to remain continent with an easily catheterisable pouch or to address stomal stenosis. The mean decrease in estimated glomerular filtration rate was more pronounced in patients with benign indications for urinary diversion than in those with malignancies, even after adjusting for younger age at surgery and longer follow-up in the former group (22 vs 11 mL/min/1.73 m2 ; P < 0.006). A disinterested third-party assessment revealed 10 postoperative complications, 17 re-operations during follow-up, and seven occasions of hospitalisation due to pyelonephritis (included in data above) not recorded at the primary data review. The Lundiana pouch is associated with a high risk of re-operation, although the functional results are good. Independent review by a third party increased the validity of the outcome data.

PD38-07 ROBOT-ASSISTED INTRACORPOREAL RIGHT COLON CONTINENT CUTANEOUS URINARY DIVERSION AND AUGMENTATION CYSTOPLASTY: A SINGLE INSTITUTION EXPERIENCE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II1 Apr 2017PD38-07 ROBOT-ASSISTED INTRACORPOREAL RIGHT COLON CONTINENT CUTANEOUS URINARY DIVERSION AND AUGMENTATION CYSTOPLASTY: A SINGLE INSTITUTION EXPERIENCE Spencer Craven, John Sigalos, Rose Khavari, and Alvin Goh Spencer CravenSpencer Craven More articles by this author , John SigalosJohn Sigalos More articles by this author , Rose KhavariRose Khavari More articles by this author , and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1721AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Continent cutaneous diversion (CCD) is a less commonly utilized diversion choice following open or robotic cystectomy. We have previously described a novel technique for robotic intracorporeal CCD. Meanwhile, continent cutaneous augmentation cystoplasty (CCAC) is a viable option for patients with neurogenic bladder. There is limited worldwide experience performing intracorporeal CCD and no studies describing intracorporeal CCAC. Principles developed in robotic CCD can be readily applied to robotic CCAC. We share our experience with these novel robotic procedures. METHODS Robotic cystectomy was performed in patients undergoing CCD using a standard 6-port technique. The patient and robot were then repositioned for intracorporeal bowel mobilization and segmentation, ileocolonic anastomosis, uretero-colonic anastomoses, pouch construction, tapering of catheterization channel, reinforcement of ileocecal valve, and stoma creation. All patients were placed on an evidence-based Enhanced Recovery after Surgery protocol postoperatively. Operative times, intraoperative blood loss (EBL), length of stay (LOS), and complications occurring within 90 days of surgery were reviewed. RESULTS Ten robotic intracorporeal right colon urinary diversions, including four robotic intracorporeal CCAC and six robotic intracorporeal CCD, were performed. Mean total operative times for cystectomy and intracorporeal urinary diversion were 7.8 and 10 hours for CCAC or CCD respectively (5.4-9.5; 7.9-12.9). Mean EBL was 181ml (75-300) for CCAC and 250ml (100-500) for CCD. Mean LOS for CCAC and CCD groups was 10 and 8.8 days respectively (5-18, 4-18). A single CCAC patient required transfusion postoperatively. Two high grade complications (Clavien III or greater) were reported in the CCAC group (50%). One high grade complication was reported in the CCD group (17%). Within 30 days of surgery, no CCAC and two CCD patients required readmission (0%, 33%). With a median follow up of 17 months, no incontinence was reported and all patients were able to catheterize without difficulty. CONCLUSIONS We demonstrate that robotic intracorporeal CCD and CCAC are technically feasible and safe with good functional outcomes. Further evaluation of these novel surgical techniques along with comparative studies are needed. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e742 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Spencer Craven More articles by this author John Sigalos More articles by this author Rose Khavari More articles by this author Alvin Goh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pregnancy After Urinary Diversion at Young Ages—Risks and Outcome

To assess the urologic and obstetric outcomes during and after pregnancy following urinary diversion (UD) performed during childhood or adolescence. From our UD database, we identified 25 women who became pregnant between 1981 and 2013. Reasons for UD were neurogenic bladder, exstrophy, trauma, sinus urogenitalis, and interstitial cystitis. Seventeen had continent cutaneous diversion, 4 had continent anal diversion, and 4 had colonic conduit. The average age at delivery was 27.8 (18-39) years. Thirty-seven pregnancies occurred; 1 patient decided for an induced abortion. Thirty-two healthy children were born. Five patients had a spontaneous abortion before the 12th week. Main urologic complications were urinary tract infections in 11 of 32 successful pregnancies. Twelve patients presented with dilatation of the upper urinary tract; 3 of them required a temporary nephrostomy tube. Four of 25 patients required an indwelling catheter because of difficulties of clean intermittent catheterization. One small bowel injury occurred during cesarean section. One patient with exstrophy developed uterine prolapse; 1 nipple prolapse was surgically repaired in the same anesthesia after the cesarean section. Two patients had 3 vaginal deliveries, whereas 28 had a cesarean section. All children were healthy, without malformation, and with mean Apgar scores of 7.8, 8.9, and 9.7 for the 1st, 5th, and 10th minutes of life, respectively. No persistent urologic complications were observed. After UD, pregnancy is possible without major complications. Because of an increased risk of pyelonephritis and dilatation of the upper urinary tract requiring intervention, these pregnancies should be considered high-risk pregnancies. Delivery should be carried out in a center of expertise with urologic standby.

Adenocarcinoma in Continent Anal Urinary Diversion: Is a Sigma Rectum Pouch a Surgical Option After Failed Ureterosigmoidostomy?

To report our experience of radical resection of secondary cancers after ureterosigmoidostomy. Ureterosigmoidostomy was the most common continent urinary diversion before the era of continent cutaneous diversion and neobladders, specifically in children. When performed for bladder exstrophy, patients will live with this kind of diversion for quite a long time. As a result, urologists will be confronted with patients presenting with an adenocarcinoma in their ureterosigmoidostomy. In most cases reported in the literature, an ileal conduit was used for urinary conversion. However, nowadays an ileal loop must not be the only solution for patients with a long life expectancy. Between 2004 and 2015, 6 patients were treated for an adenocarcinoma in their ureterosigmoidostomy. All patients underwent radical resection of the tumor-bearing sigmoid colon. After thorough preoperative informed consent concerning the choice of future urinary diversion, such as conversion to an ileal conduit, construction of a continent catheterizable pouch, or repeat continent anal diversion, 4 patients chose a repeat continent anal urinary diversion. Up to this date, no complications or recurrences were seen after a median follow-up of 35 months. In patients with secondary malignancy of the colon, radical resection of the tumor-bearing bowel segment is mandatory. A repeat continent anal urinary diversion appears to be a feasible alternative to secondary urinary diversion after resection of the tumor-bearing sigmoid colon. However, a longer follow-up is required to determine whether the risk of secondary malignancy remains unchanged, and whether the risk is increased or decreased.

Characterization of Urolithiasis in Patients Following Lower Urinary Tract Reconstruction with Intestinal Segments.

Urinary diversion and augmentation cystoplasty are associated with long-term complications, including metabolic derangements, infectious complications, and urolithiasis. The aim of this series was to characterize upper and lower urinary tract (LUT) calculi in this population. A retrospective chart review was performed on all patients with a history of urinary diversion or augmentation cystoplasty who subsequently underwent treatment for urolithiasis between January 1998 and May 2015. Data collected included demographics, perioperative characteristics, type of reconstructive procedure, urine culture, stone analysis, and metabolic evaluation. A statistical analysis was performed. Ninety-nine patients were identified with a history of urolithiasis and incontinent urinary diversion (28), neobladder (21), continent cutaneous diversion (12), and augmentation cystoplasty (38). LUT stones were more common than upper tract stones in all except for incontinent diversions, which only had one lower tract stone (p = 0.0001). Twenty-three percent of stones were metabolic. Several metabolic derangements were noted, including hypocitraturia (100%), elevated urine pH (100%), low urine volume (70%), and hyperoxaluria (35%). There was a 44% rate of recurrent urolithiasis. Given the high rate of stone recurrence among patients with a history of urinary diversion and augmentation cystoplasty, all measures should be taken to prevent recurrent stones. In addition to actions aimed to prevent infectious stones such as bladder and pouch irrigation, we recommend these patients undergo a full metabolic workup with targeted dietary changes and medical therapies.

Long-term outcome after urinary diversion using the ileocecal segment in children and adolescents: Complications of the efferent segment

Long-term outcomes are of special concern in children after urinary diversion. In a single institution study we evaluated retrospectively the long-term outcomes of urinary diversion in children, in whom the ileocecal segment had been used, in respect to complications of the efferent segment. The Mainz pouch was used in 107 children for continent urinary diversion. Indications were neurogenic bladder (53%, 57/107), exstrophy-epispadias complex (25%, 27/107), malignancy (13%, 14/107), and others (9%, 9/107). Continent cutaneous diversion was performed in 95 patients, and 12 patients received bladder augmentation/substitution with a continent cutaneous stoma. As efferent segment, we used the in situ submucosally embedded appendix in 55/107, and an intussuscepted ileal nipple valve in 45/107 patients, other in seven patients. Complication rates and degree of satisfaction with urinary diversion were evaluated by assessing medical records and using follow-up questionnaires. The median follow-up time was 15.9 years (0.4-27.6 years). There was a significant difference between the stenosis rates of appendical stoma and the intussuscepted ileal nipple valve. In general, 38% of patients (41/107) with a continent cutaneous stoma developed a stoma stenosis at the skin level, with 41% (17/41) of those having recurrent stenoses (2-6×). Of the patients with an appendix stoma, 49% (27/55) developed a stenosis, compared with 20% (9/45) of those with an intussuscepted ileal nipple valve (p<0.001). In an attempt to reduce the incidence of stenosis, we implemented use of the ACE stopper during the last 2 years, but whether this is successful is subject to further investigations. For surgical treatment of stoma stenosis, reanastomosis of the efferent segment to the skin (n=37, re-stenosis rate 37%, [14/37]) was superior to endoscopic scar incision (n=44, re-stenosis rate 59% [26/44], OR 2.4). The overall continence rate was 85% (91/107). At the latest follow-up, 89% (49/55) of patients with an appendix stoma and 82% (37/45) of those with an intussuscepted ileal nipple valve were completely continent. The in situ submucosally embedded appendix and the intussuscepted ileal nipple valve are reliable continence mechanisms in the long-term median follow-up of nearly 16 years. The stomal stenosis rate is approximately double for the submucosal appendix, likely because of its smaller diameter in comparison with the ileal valve. Although we encountered a high overall rate of complications, the satisfaction rate with the diversion was high (99% [88/89] satisfied or very satisfied patients).