Continent Day Research Articles

Ureteric-urethral engraftment as a new surgical technique for management of incontinence in bladder exstrophy complex: A retrospective cohort

ObjectivesTo report the results of a novel surgical technique for achieving urinary continence in patients with bladder exstrophy complex (BEC) by ureteric-urethral engraftment (UUE) technique. Patients and methodsSixteen female patients with BEC and a mean ± SD age of 3.48 ± 1.75 years were referred for primary exstrophy repair from 2009 to 2012. From these, 9 patients were operated by single-stage bladder closure (group I); while 7 patients underwent the novel technique of UUE to compare the continence achievement (group II). In UUE technique, distal ureter was applied for total urethral replacement while the lower part of engraft was fixed in external genitalia. No osteotomy was performed in none of the groups. Continence and upper urinary tract evaluation were performed in the follow-ups with 3 months intervals for the first year and biannually thereafter. The patients were followed-up for a mean ± SD duration of 72 ± 6 months. ResultsAll patients in both groups experienced an uneventful postoperative period. In group II, 5 patients were continent day and night and voided per urethra without need for augmentation or intermittent catheterization technique (71.42%); while 55.55% of patients in group I achieved total continence (n = 5). Partial continence was achieved in 4 (44.44%) and 2 (28.57%) patients in group I and II, respectively. However, 3 patients in UUE group had postoperative vesicoureteral reflux that was successfully managed by Deflux injection. ConclusionThe eventual clinical outcomes of BEC children undergoing the UUE technique were promising. This practicable, safe, and reproducible option will add one complementary stage to the previously used reconstruction techniques. These patients would necessitate further surveillance with upper urinary tract evaluations during the adult life.

PD67-01 LONG-TERM FUNCTIONAL OUTCOMES AND MORBIDITY OF PROSTATE SPARING CYSTECTOMY VERSUS CYSTOPROSTATECTOMY: A CASE CONTROLLED STUDY.

You have accessJournal of UrologyBladder Cancer: Invasive VII1 Apr 2017PD67-01 LONG-TERM FUNCTIONAL OUTCOMES AND MORBIDITY OF PROSTATE SPARING CYSTECTOMY VERSUS CYSTOPROSTATECTOMY: A CASE CONTROLLED STUDY. Mohamed Saad M., Rafael Sanchez-Salas, Eric Barret, Marc Galiano, François Rozet, Nathalie Cathala, Annick Mombet, Dominique Prapotnich, and Xavier Cathelineau Mohamed Saad M.Mohamed Saad M. More articles by this author , Rafael Sanchez-SalasRafael Sanchez-Salas More articles by this author , Eric BarretEric Barret More articles by this author , Marc GalianoMarc Galiano More articles by this author , François RozetFrançois Rozet More articles by this author , Nathalie CathalaNathalie Cathala More articles by this author , Annick MombetAnnick Mombet More articles by this author , Dominique PrapotnichDominique Prapotnich More articles by this author , and Xavier CathelineauXavier Cathelineau More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2977AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prostate sparing cystectomy (PSC) is arguably a valid option for management of bladder cancer in selected cases. The majority of reported studies however have short term follow up as well as small sample size. We aimed to evaluate retrospectively our long term experience of prostate sparing cystectomy and compare it with our results of nerve sparing cystoprostatectomy (NSCP) in the laparoscopic/robotic era METHODS Between 2001 and 2011, 60 patients were treated with laparoscopic or robotic PSC for muscle invasive or recurrent non muscle invasive bladder cancer. These patients were matched and compared to 47 patients who received laparoscopic or robotic NSCP and orthotopic bladder substitution during the same study period. Regarding continence, surviving patients were postoperatively contacted, at 3 months and 1 year, to answer a questionnaire based on the International Continence Society guidelines for reporting continence after urinary diversion. Potency was accessed by a house made questionnaire addressing the use of any medications or devices to achieve erection. RESULTS Mean patient age was 60.35 and 62.12 for PSC and NSCP respectively. Median follow up was 69.5 months and 62 months for PSC and NSCP respectively. Forty percent of PSC had = pT1N0, 30% pT2N0, 22% = pT3N0 while 8% had N+ disease; compared to NSCP patients whom 38% had =pT1N0, 19% pT2N0, 23% = pT3N0 and 19% N+. (p=0.74) The overall 3- and 5-year cancer specific survivals were 92% and 90% in the PSC group, and 82% and 79% in the NSCP group respectively. The local recurrence rates were 11.7 % and 21.3 % for the PSC and the NSCP groups respectively, and the respective distant recurrence rate was 17% and 28%. Regarding continence; 45% in the PSC showed immediate and full recovery of continence day and night compared to no patient in the NSCP group. After 1 year, 97% and 71% of PSC group were completely leak-free for day and night respectively, compared to 78% and 37% in NSCP (p=0.001). The incidence of self catheterization was equal in both groups at 15%. On long term follow up, 42% of PSC patients developed symptoms secondary to outlet obstruction and 18% of them required endoscopic resection of their prostate. While in NSCP patients, 4% developed anastomotic stricture that required endoscopic fulgration (p=0.001) Regarding potency; 49% of PSC and 23% of NSCP reported maintaining similar preoperative potency level. Sexual intercourse was achievable without any treatment in 68% of PSC compared to 37% in NSCP. The incidence of intracavernosal injection was higher in the NSCP arm compared to the PSC (41% vs.17%) Four patients (9%) in the NSCP group failed all conservative management and required penile prosthesis compared to no patient in the PSC group. ( p=0.001) CONCLUSIONS Prostate sparing cystectomy is superior to nerve-sparing cystoprostatectomy regarding continence and potency. However, candidate patients who wish to retain their prostate should be informed about the long term need to manage outflow obstructive symptoms. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1276 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Mohamed Saad M. More articles by this author Rafael Sanchez-Salas More articles by this author Eric Barret More articles by this author Marc Galiano More articles by this author François Rozet More articles by this author Nathalie Cathala More articles by this author Annick Mombet More articles by this author Dominique Prapotnich More articles by this author Xavier Cathelineau More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Orthotopic genital sparing radical cystectomy in pre-menopausal women with muscle-invasive bladder carcinoma: A prospective study.

Introduction:Invasive cancer bladder is a life-threatening disease that is best treated with radical cystectomy and a suitable urinary diversion. The aim of this study was to evaluate the oncological outcome, voiding and sexual functions after genital sparing radical cystectomy with orthotopic bladder reconstruction in pre-menopausal women with bladder cancer.Materials and Methods:18 pre-menopausal women who underwent radical cystectomy and orthotopic urinary diversion with preservation of genital organs were included for this study. The patients were followed-up clinically and radiologically to assess their oncological outcome in addition to their voiding and sexual function.Results:Mean age of the patients was 37.8 years, and the median follow-up after surgery was 70 months. One patient was lost to follow-up at 12 months post-operatively. The surgery was completed as planned in all patients, with a mean operative time of 290 min and an average blood loss of 750 mL. 14 patients were able to void satisfactorily, being continent day and night, while four patients needed clean intermittent catheterization. Sexual life remained unchanged in 15 cases, while three patients reported dysparunea. Till the last follow-up, there was no local recurrence while distant metastases were detected in three cases, two of whom died.Conclusions:Genital sparing cystectomy is a valid option for managing carefully selected women with muscle-invasive bladder cancer with good functional and sexual outcomes.

Can Classic Bladder Exstrophy be Safely and Successfully Reconstructed at a Low Volume Center?

Exstrophy reconstruction is challenging and requires expertise and experience. However, many patients are treated at low volume centers. We evaluated whether classic bladder exstrophy could be safely and successfully reconstructed at a low volume center. A total of 31 patients with classic bladder exstrophy were primarily treated at our low volume center during a 17-year period. A total of 22 patients underwent primary closure within 5 days of birth and 9 underwent delayed closure with osteotomy. Of the patients 29 underwent planned modern staged repair and 2 underwent attempted complete primary repair. The bladder was successfully closed in all 31 children. All 22 newborns underwent primary bladder closure without osteotomy, including 4 with extremely small bladder plates. Bladder neck obstruction developed in 3 patients (10%), of whom 2 were treated successfully with transurethral dilation and 1 underwent open repair. Epispadias repair was successful in 12 of 15 patients undergoing the Cantwell-Ransley technique and in 2 of 4 undergoing complete primary repair. A total of 16 patients underwent bladder neck reconstruction, of whom 9 are awaiting appropriate age or capacity, 4 were lost to followup, 1 is continent after bladder closure alone and 2 underwent continent diversion (1 after failed bladder neck reconstruction). Of the 15 patients with at least 1 year of followup after bladder neck reconstruction 9 are continent day and night, 2 are continent only during the daytime and 4 are incontinent, for a 73% post-bladder neck reconstruction continence rate (11 of 15 patients). Successful exstrophy reconstruction is achievable at a low volume center, with results comparable to those of high volume centers.

Long term complications after radical cystoprostatectomy with orthotopic diversion in male patients: Preliminary experience

IntroductionRadical cystectomy is the standard treatment for patients with invasive bladder cancer and for those with superficial bladder cancer who did not respond to conservative TUR and intravesical therapy. Many diversions are available after radical cystectomy; the most attractive for the patients is orthotopic diversion due to better quality of life associated with this diversion. ObjectiveTo evaluate the long-term outcomes beyond 1 year, both functional and oncological, in male patients treated with radical cystectomy and orthotopic diversion for invasive bladder cancer. Patients and methodsThis is a retrospective study done at Cairo university hospitals. A total of 44 male patients underwent radical cystectomy and orthotopic diversion (W-pouch) for invasive bladder cancer with minimum follow up 1 year. Assessment included; neobladder function, renal pattern and function, ureteroenteric anastomotic stricture or reflux, survival, recurrence, erectile function, urolithiasis, and urinary tract infection.The tools used to assess the complications during each visit included; history including voiding diary and IIEF questionnaire, examination including PR, laboratory investigations including urine analysis and kidney function tests, pH (acidosis) and bicarbonates and radiological investigation including ultrasound, chest X-ray, CT abdomen and pelvis. ResultsThe mean follow up was 88 months (range 12–138). Stones developed post-operatively in four patients (two of them were pouch stones and the other two were renal stones), incision hernia developed in two patients (4.5%), uretero enteric anastomotic stricture in two patients (4.5%), recurrent UTI was recorded in 10 cases (23%), uremia and dialysis in 9.2% of cases, metastasis was recorded as follows: local 2%, distant 11.5% and both 4.5% and the mortality rate was 19% (over all survival was 81%).Nocturnal incontinence 29.5% (13 patients), stress incontinence 9.5% (4 patients), urge incontinence 9.5% (4 patients), total incontinence 4.5% (23 patients); while the remaining 21 patients (47.5%) were continent day and night.Erectile dysfunction developed post-operatively in 35 cases (80.5%). ConclusionLong term follow-up for patients with radical cystectomy and orthotopic diversion is associated with high complication rate. Long term follow up for those patients is needed to verify the causes of complications and how to prevent them.

Radical surgery and different types of urinary diversion in patients with rhabdomyosarcoma of bladder or prostate – A single institution experience

PurposeIn a retrospective study we analyzed the outcome of patients treated for rhabdomyosarcoma (RMS) of the bladder/prostate with special attention to radical surgery. MethodsIn 25 patients with genitourinary RMS (15 bladder/10 prostate) the median age at diagnosis was 4 years [1–18], and 8 patients had a stage II RMS, 12 stage III and 5 stage IV. In 19/25 (12 bladder/7 prostate), radical surgery and urinary diversion were performed. Urinary diversion comprised 2 continent anal diversions, 11 continent cutaneous diversions, 4 colon conduits and 2 urethral diversions (2 + 3 years of age). In the younger child with urethral diversion, a cutaneous appendix stoma was additionally constructed in case of inability to void spontaneously. Results4/19 patients who underwent radical surgery died of metastatic RMS; 1 patient with neurofibromatosis died of a secondary tumor. After median follow-up of 132 months (14–420), 14 patients currently have no evidence of disease. 8/14 patients who survived developed 17 complications requiring operative revision. All patients with a continent diversion are continent. The patients with orthotopic bladder substitution are continent day & night and void spontaneously. ConclusionFor RMS confined to the bladder or bladder neck, radical cystoprostatectomy and orthotopic bladder substitution are an option. Urethral diversion using the ileocecal segment (Mainz-pouch I) offers the advantage of utilizing the appendix as an additional continent cutaneous stoma, which enables parents to evacuate residual urine in young boys, until able to empty the pouch completely themselves. For all other patients with vital tumor after primary chemotherapy, cutaneous urinary diversion is an option. Long-term complication rates in this complex group of patients are acceptable.

1166 SECONDARY INTUSSUSCEPTED ILEAL NIPPLE VALVE IN CONTINENT CUTANEOUS URINARY DIVERSION SURGICAL TECHNIQUE AND LONG-TERM RESULTS

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion1 Apr 20121166 SECONDARY INTUSSUSCEPTED ILEAL NIPPLE VALVE IN CONTINENT CUTANEOUS URINARY DIVERSION SURGICAL TECHNIQUE AND LONG-TERM RESULTS Arkadius Kocot, Martin Spahn, Daniel Vergho, Andreas Loeser, and Hubertus Riedmiller Arkadius KocotArkadius Kocot Wuerzburg, Germany More articles by this author , Martin SpahnMartin Spahn Wuerzburg, Germany More articles by this author , Daniel VerghoDaniel Vergho Wuerzburg, Germany More articles by this author , Andreas LoeserAndreas Loeser Wuerzburg, Germany More articles by this author , and Hubertus RiedmillerHubertus Riedmiller Wuerzburg, Germany More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1390AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To critically assess safety and long-term outcome of secondary intussuscepted ileal nipple valve (IINV) in complex reconstruction and troubleshooting of continent cutaneous ileocaecal reservoirs (CCIR) or conversion from orthotopic ileocaecal bladder substitutes into CCIR. METHODS From May 1997 to June 2011 73 patients with CCIR underwent surgical minor and major revisions of their cutaneous continence mechanisms (men: n=38, women: n=35). Retrospectively 12 patients have been identified who suffered from otherwise intractable defects of their cutaneous outlets (appendix stoma: n=6, primary IINV: n=3, Monti-outlet: n=3) resulting in impaired clean intermittent self-catheterization (CIC) and/or urinary incontinence. Two further patients needed a conversion from an orthotopic ileocaecal bladder substitute into CCIR due to urethral recurrence of their primary transitional cell carcinoma. The mean interval between primary continent urinary diversion and creation auf the secondary IINV was 26,4 months. In all 14 patients (mean age 49,8 years, 6 women) a secondary IINV has been created using 10-12 cm of isolated and isoperistaltic intussuscepted ileal segment with consecutive stapler fixation in the ileocaecal valve. In all cases the umbilicus was chosen as the preferred site of the stoma. RESULTS Postoperatively all patients were continent day and night with ease of catheterization. The mean follow-up was 53, 9 (range 2–159) months. In a long term setting no stoma stenosis was observed. Two patients required re-fixation of the secondary IINV due to nipple gliding within the ileocaecal valve 36 and 54 months after surgery. After traumatic CIC in one further patient with consecutive via falsa in the cutaneous outlet open revision with successful closure of the defect could be achieved three months after secondary IINV. CONCLUSIONS The secondary ileal intussuscepted nipple valve is a safe and reliable solution in complex reconstruction and troubleshooting of continent cutaneous urinary reservoirs. Possible long–term complications like nipple gliding are controllable. Furthermore this surgical technique may be used to convert orthotopic ileocaecal reservoirs into a CCIR. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e472-e473 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arkadius Kocot Wuerzburg, Germany More articles by this author Martin Spahn Wuerzburg, Germany More articles by this author Daniel Vergho Wuerzburg, Germany More articles by this author Andreas Loeser Wuerzburg, Germany More articles by this author Hubertus Riedmiller Wuerzburg, Germany More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Mucosectomy and stapled pouch‐anal anastomosis in familial adenomatous polyposis

In familial adenomatous polyposis, a restorative proctocolectomy with an ileo-anal pouch may be performed either with a mucosectomy and a hand-sewn anastomosis or as a stapled anastomosis without a mucosectomy. The disadvantage of the former is suboptimal bowel function and the disadvantage of the latter is a high risk of recurrent adenomas in the rectal mucosal remnant. A procedure is presented that combines the advantages of mucosectomy and stapled ileo-anal anastomosis. No severe complications were seen in 14 patients. After a median follow up of 29 (range 7-144) months, 13 (93%) patients were fully continent day and night with a median frequency of defecation of 5 (range 2-8)/24 h. No adenomas were found at the annual endoscopic follow up. Mucosectomy with a stapled ileo-anal pouch has few complications. Short-term results show good function and a very low risk of recurrent adenoma development.

Orthotopic diversion after cystectomy in women: A single-centre experience with a 10-year follow-up

ObjectiveTo evaluate and update the clinical and surgical outcome of orthotopic diversion in an eligible cohort of women with bladder carcinoma. Patients and methodsFrom 1999 to 2010, 78 women (mean age 42.4years) had a radical cystectomy (RC) with orthotopic diversion using ileal neobladder reconstruction to treat invasive bladder carcinoma. The mean (SD) follow-up was 62(25)months. ResultsThe histopathological pattern was squamous cell carcinoma in 52 (67%) patients, transitional cell carcinoma in 17 (22%), mixed in four (5%) and undifferentiated carcinoma in five (6%). Three patients were completely incontinent day and night. Stress urinary incontinence after this surgery was reported in 11 (14%) patients, with daytime continence reported in 64 (82%); 59 (76%) patients were completely continent day and night. Chronic retention developed in nine (12%) patients. There was pouch prolapse through the vaginal stump in five (6%) patients, and a pouch-vaginal fistula in seven (9%). Sexual dysfunction was reported in 45 (69%) patients of 65 sexually active women. Stones formed in the pouch in five (6%) patients, while there were renal stones in four renal units. Oncological recurrence was reported in 15 (19%) patients, which was local in11 (14%) and distant in four (5%). ConclusionThe long-term results showed that orthotopic neobladder construction after RC in women provides oncological safety and is functionally effective with proper surgical technique. Removal of the gynaecological organs during RC in women might be unnecessary for low-grade, low-stage tumour.

Long-Term Results of a Staged Approach: Continent Urinary Diversion in Preparation for Renal Transplantation

We provide the long-term results of renal transplantation into continent urinary intestinal reservoirs as a planned 2-stage procedure. Between November 1990 and January 2009, 18 patients underwent cadaveric or living related renal transplantation into continent urinary reservoirs (continent cutaneous diversion 16, orthotopic substitution 2). All patients were prospectively followed. Of these patients 15 are currently free of dialysis. At a mean followup of 89.2 months (range 2 to 188) 13 patients had a serum creatinine ranging from 0.6 to 3.1 mg/dl (mean 1.49) after the first transplantation. Two patients underwent a second transplantation 12 and 122 months after loss of the transplant for renal vein thrombosis and chronic allograft dysfunction, respectively. Two additional patients had to resume hemodialysis 62 and 109 months after renal transplantation. The second transplantation was delayed mainly due to compliance problems. One patient died of fulminant septicemia after laparotomy elsewhere for bowel obstruction with normal renal function before that episode. The continence mechanism needed correction in 3 patients, and 2 further revisions were required for ureteral kinking and lymphocele. The patients with orthotopic substitution (2) voided to completion and showed complete continence. All patients with cutaneous diversion were continent day and night with easy catheterization. This study is among the largest single series to date of renal transplantation into continent urinary diversions. Long-term followup confirms that this approach is a safe and socially well accepted treatment option in carefully selected patients.

Ureterocystoplasty in a Boy with Myelomeningocele

Introduction In the rare case of a decompensated neurogenic bladder combined with a unilateral hydronephrosis and hydroureter, ureterocystoplasty is a feasible and elegant technique for bladder augmentation. In contrast to augmentation using bowel segments, the use of urothelial-lined tissue avoids the common problems caused by mucus development and electrolyte disturbance. Prerequisite is a unilateral non-functional kidney and a severe dilation of the ureter. Patients The patient presented in this case report is an 11-year old boy with myelomeningocele. Due to a decompensated neurogenic low-compliance bladder with high-degree reflux, the left kidney was hydronephrotic and afunctional, urodynamic revealed a maximum bladder capacity of 70ccl, therefore unilateral nephrectomy and ureterocystoplasty were performed. Results Three years after surgery the patient is continent day and night. Urodynamic evaluation shows a normal compliance, bladder capacity is 440cc. The boy empties his bladder 4-6 times a day by means of clean intermittent catheterization. Conclusions In selected cases ureterocystoplasty is a safe and feasible technique for bladder augmentation.

Clinical and Urodynamic Spectrum of Bladder Function in Cerebral Palsy

The nature of voiding function and dysfunction associated with cerebral palsy is described in the literature without concurrence of opinion. We correlated urodynamic findings with voiding patterns to better understand and manage voiding dysfunction in children with cerebral palsy. Voiding patterns and urodynamic studies in our last 31 patients with cerebral palsy were reviewed. Patients and families were surveyed on the child ability to void spontaneously, clean intermittent catheterization requirement, daytime incontinence and enuresis. Urodynamics consisted of slow fill water cystometry and patch electromyography. Measured parameters were bladder capacity based on age, capacity pressure, compliance, uninhibited contractions, bladder sensation and external sphincter activity. Patients were stratified by voiding status and statistical analysis was performed with p <0.05 considered significant. The 15 boys and 16 girls were 4.5 to 16.6 years old. Three children required clean intermittent catheterization for bladder drainage and 28 (90.3%) voided spontaneously. Diapers were worn by 24 patients (77.4%). There were daytime incontinence and enuresis in 12 patients (38.7%), daytime incontinence only in 11 (35.5%) and enuresis in 1 (3.2%). Seven patients (22.6%) were continent day and night. When correlated with urodynamic parameters, continent children tended to have a larger bladder, lower bladder capacity pressure, higher compliance, fewer uninhibited contractions and similar sphincter activity. The only statistically significant difference was in bladder sensation. There is a spectrum of clinical and urodynamic bladder function in children with cerebral palsy. Of these children 77.4% void spontaneously but are incontinent. Incontinence is more likely present during the day and rarely limited to enuresis. Urodynamically continent children have a similar storage profile and differ from children with daytime or nocturnal incontinence in the ability to sense bladder fullness.

Efficacy and tolerability of fesoterodine in women with overactive bladder

We assessed fesoterodine efficacy and tolerability in women with overactive bladder (OAB). This post hoc analysis of pooled data from two clinical trials included 1,548 women with OAB randomized to placebo, fesoterodine 4 or 8 mg, or tolterodine extended release (ER) 4 mg (in 1 trial) for 12 weeks. Subjects completed 3-day bladder diaries at baseline and weeks 2 and 12 and rated Treatment Response at weeks 2 and 12. By weeks 2 and 12, all active-treatment groups showed significant improvements in all five bladder diary variables assessed and greater Treatment Response rates vs placebo. Fesoterodine 8 mg was significantly more efficacious than fesoterodine 4 mg and tolterodine ER in improving urgency urinary incontinence episodes and continent days per week. The most common adverse events were dry mouth and constipation, which were predominately mild or moderate. Fesoterodine is efficacious and well tolerated in women with OAB.

VOIDING FUNCTION IN WOMEN WITH ORTHOTOPIC NEOBLADDER DIVERSION

INTRODUCTION AND OBJECTIVE: To evaluate patients with orthotopic bladder substitution for benign causes in terms of indications, complications as well as the functional outcome. METHODS: Between April 1986 and January 2006, 73 patients (57males and16females) with mean age 41.5 years (29-56 years) underwent simple cystectomy and orthotopic bladder substitution for management of contracted bladders(62) or complex vesicovaginal fistulae (11) . The prostate and seminal vesicles were preserved in men with removal of a core of the prostate. Ileal W neobladders were applied for 37 patients and Urethral Hemi-Kock pouch for 36. . Patients were followed for a period ranged from 18 up to 243 months (mean 94.5 ± 43 months). All patients were evaluated for continence status. Pouchometry and urethral pressure profile were performed in 38 patients . Potency and fertility were verified in eligible male patients. Late sequalae after urinary diversion were assessed especially what is concerning upper tract function and configuration RESULTS: Poucho-prostatic anastomotic strictures were diagnosed in 11 men ( 19.3% ) and were managed endoscopically. Twelve patients (12.4%) developed chronic retention and were maintained on CIC. Out of the other 61 patients, 45 (73.8%) were continent day and night while 16 (26.2%) showed various degrees of nocturnal enuresis. Urodynamic studies showed high volume low pressure reservoirs in those patients with chronic retention and low urethral closure pressure in those with enuresis. Potency was preserved in 54 out of 61 eligible men(88.5%) and fertility in 9 out of 21(42.8%). Out of 138 evaluated renal units (8 patients had solitary kidney),122 showed stable kidney function and configuration. The other 16 units (11.6 % ) showed various degrees of deterioration due to obstruction ( 3), pyelonephritis (7) or chronic retention (6).Pouch stones were encountered in 12 cases (16.4% ). CONCLUSIONS: Simple cystectomy and orthotopic substitution is a viable option of management of benign bladder diseases . Relatively high incidence of chronic retention is anticipated necessitating regular follow-up for early diagnosis and management. Potency and fertility could be preserved in a good proportion of male patients.

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Fesoterodine Dose Response in Subjects With Overactive Bladder Syndrome

To compare the efficacy of fesoterodine 4 mg versus 8 mg in treating subjects with overactive bladder (OAB) syndrome. This is a pooled analysis of data from 2 randomized placebo (PBO)-controlled phase III trials. Eligible subjects with frequency and urgency or urgency urinary incontinence (UUI) were randomized to PBO or fesoterodine 4 or 8 mg for 12 weeks. Subjects assessed efficacy using 3-day bladder diaries recording the time of each void, urgency, and incontinence episode. Endpoints included treatment response (based on a 4-point Treatment Benefit scale) and change from baseline in micturitions, UUI episodes, mean volume voided, urgency episodes, and continent days. We assessed tolerability and safety by evaluating adverse events, residual urine volume, laboratory parameters, and treatment withdrawals. At the end of treatment, both doses of fesoterodine showed statistically significant improvements in all efficacy endpoints versus PBO (P <0.01). These effects were seen 2 weeks after initiation of treatment (the earliest evaluation point) and were sustained throughout the treatment period. Fesoterodine 8 mg performed significantly better than fesoterodine 4 mg in improving all diary variables (P <0.05) except micturition frequency, demonstrating a dose-response relationship. Adverse events reported more frequently with fesoterodine than with PBO included dry mouth, constipation, and urinary tract infection. Both fesoterodine 4 and 8 mg are effective in improving OAB symptoms. The higher 8-mg dose provides additional benefit compared with the lower dose in improving most bladder diary variables, thus offering the possibility of dose flexibility and titration.

Gynecologic-tract sparing extra peritoneal retrograde radical cystectomy with neobladder

We report on a series of female patients with transitional cell carcinoma of the bladder who underwent extraperitoneal retrograde radical cystectomy sparing the female reproductive organs with neobladder creation. 14 female patients between the ages of 45 and 72 years who underwent gynecologic-tract sparing cystectomy (GTSC) with neobladder between 1997 and 2002 were retrospectively reviewed. Our surgical technique is also described. Radical cystectomy is accomplished by a retrograde method sparing the uterus, adnexa, vagina and distal urethra. An orthotopic neobladder was constructed using small bowel or sigmoid colon, brought extraperitoneally, and anastomosed to the distal urethra. Operating time ranged from 4.5 to six hours with a mean of 5.3 hours. Ten patients were able to void satisfactorily while four required self-catheterization for complete emptying of the bladder. Seven patients were continent day and night and another 7 reported varying degrees of daytime and nighttime incontinence. One patient died of metastases and another of pelvic recurrence. There were no urethral recurrences. Patient satisfaction with the procedure was high. Gynecologic-tract sparing cystectomy with orthotopic neobladder is a viable alternative in female patients with muscle invasive traditional cell carcinoma of the bladder, providing oncological safety with improved quality of life. Our extraperitoneal technique, which is an extension of our successful experience with retrograde extraperitoneal radical cystectomy in men, minimizes intraoperative complications and simplifies the management of post-operative morbidity with the neobladder.

Clinical and Functional Results after Continent Cutaneous Urinary Diversion with the Ileal Double-T-Pouch

Introduction: The aim of the study was to assess the clinical and functional results after continent cutaneous diversion with the ileal double-T-pouch. Patients and Methods: Between July 1998 and July 2006, 19 patients underwent continent urinary diversion with a cutaneous ileal double-T-pouch. Follow-up investigations included blood chemistry, renal ultrasound and evaluation of the outlet function. The median follow-up was 24 months (range 3–76). Results: There were no intraoperative complications and no perioperative mortality. Early postoperative complications not related to urinary diversion occurred in 6 patients (31.6%). Five patients developed complications related to the urinary diversion (26.3%). The mean operating time was 580 min (420–840). Including the patients who had good results after reoperation, 16 out of the 19 patients (84.2%) were continent day and night without any catheterization difficulties. The average pouch capacity was 490 ml (range 250–1,100). A mild acidosis was the only metabolic disorder observed. During follow-up renal function remained stable in all patients, urinary reflux, recurrent pyelonephritis or stone formation were not found. Three patients with a body mass index >30 developed a necrosis of the efferent loop resulting in pouch cutaneous fistulas. Conclusions: Continent cutaneous urinary diversion with the ileal double-T-pouch led to good intermediate functional and clinical results. However, construction of the pouch is sophisticated, resulting in a long operation time. The double-T-pouch is not recommended in obese patients.

The modern staged repair of bladder exstrophy in the female: A contemporary series

Objective Many changes have occurred in the treatment of bladder exstrophy over the last few years and several repairs are now offered, but there is a lack of long-term follow-up data. The purpose of this study was to evaluate long-term outcomes in a select group of female patients in whom modern staged repair was undertaken. Patients and methods From an institutionally approved database 41 patients were identified. All had undergone primary bladder exstrophy closure in 1988–2005, at a mean age of 2 months (range 4 h to 3 months), with or without an osteotomy by a single surgeon, and all were followed up for a minimum of 5 years. Twelve patients underwent osteotomy at the time of primary closure. Eight had a classic transverse innominate and vertical iliac osteotomy, and four a transverse innominate only. Mean age at the time of bladder neck repair (BNR) was 4.2 years (39–65 months). Mean measured bladder capacity under gravity cystograms at the time of repair was 109 cc (80–179 cc). Results Thirty patients (74%) were continent day and night, and voiding per urethra without augmentation or intermittent catheterization. Social continence, defined as dry for more than 3 h during the day but damp at night, was found in a further four cases (10%). Seven patients are completely incontinent with dry intervals of less than 1 h day and night. The mean time to daytime continence was 12 months (4–16 months) and to night-time continence was 19 months (10–28 months). Patients with a mean capacity greater than 100 cc had better outcomes. Six of the 30 patients achieved dryness after primary closure only, and all six had transverse innominate and vertical iliac osteotomy at the time of primary closure. Conclusions Female classic exstrophy patients with a good template who develop adequate capacity after a successful primary closure can achieve acceptable continence without bladder augmentation and intermittent catheterization. A select group will develop continence with closure alone without the need for bladder neck repair.

Efficacy, Safety and Tolerability of Fesoterodine for Overactive Bladder Syndrome

We evaluated the efficacy, tolerability and safety of the new antimuscarinic agent fesoterodine relative to placebo for overactive bladder syndrome. This was a randomized, double-blind, placebo controlled, multicenter trial performed in the United States. Overall 836 subjects with urinary frequency, urinary urgency or urgency urinary incontinence were randomized to placebo (274), 4 mg fesoterodine (283) or 8 mg fesoterodine (279) once daily for 12 weeks. The primary efficacy end point was the change in the number of micturitions per 24 hours. Co-primary end points were the change in the number of urgency urinary incontinence episodes per 24 hours and the treatment response. Secondary efficacy end points were other bladder diary variables, such as the change in mean voided volume per micturition, number of continent days and number of urgency episodes per 24 hours. Tolerability and safety were assessed by evaluating adverse events, electrocardiograms, post-void residual urine volume, laboratory parameters and treatment withdrawals. Treatment with 4 or 8 mg fesoterodine resulted in statistically significant and clinically relevant improvements from baseline to end of treatment for the primary and co-primary end points compared with placebo (p <0.05). Results for most secondary end points, including mean voided volume per micturition, number of continent days and number of urgency episodes per 24 hours, were also significantly improved vs placebo. The adverse events reported more frequently with fesoterodine than with placebo were dry mouth, constipation and urinary tract infection. The 2 doses of fesoterodine were well tolerated and they statistically significantly improved overactive bladder symptoms.