Ileal Bladder Research Articles

Minimally Invasive Techniques for Bladder Reconstruction.

Bladder reconstruction surgery is a key component of neurogenic lower urinary tract dysfunction (nLUTD) management. Traditionally, given the complexity and unpredictable operative challenges of bladder reconstruction in this patient population, little consideration has been given to performing lower urinary tract reconstruction in a minimally invasive approach. We describe the innovative minimally invasive surgical techniques in four major categories of reconstructive procedures for nLUTD: (A) ileal bladder augmentation, the use of a low morbidity open Pfannenstiel incision and the use of laparoscopy and robotics; (B) creation of a catheterizable channel, the use of laparoscopy and robotics for Mitrofanoff procedures; (C) creation of both a bladder augmentation and catheterizable channel, the use of a hand-assisted approach for the creation of a continent cutaneous ileocystoplasty; and (D) bladder neck artificial urinary sphincter implantation: the use of a robotics. Patients with nLUTD need surgical solutions that can improve their quality of life over several decades. As experience with robotics increases and as technology provides us with new tools to ease minimally invasive bladder reconstruction, we can expect that the field will continue to grow and improve.

Effects of intraoperative PEEP optimization on postoperative pulmonary complications and the inflammatory response: study protocol for a randomized controlled trial

BackgroundPatients undergoing general anesthesia and mechanical ventilation during major abdominal surgery commonly develop pulmonary atelectasis and/or hyperdistention of the lungs. Recent studies show benefits of lung-protective mechanical ventilation with the use of low tidal volumes, a moderate level of positive end-expiratory pressure (PEEP) and regular alveolar recruitment maneuvers during general anesthesia, even in patients with healthy lungs. The purpose of this clinical trial is to evaluate the effects of intraoperative lung-protective mechanical ventilation, using individualized PEEP values, on postoperative pulmonary complications and the inflammatory response.Methods/designA total number of 40 patients with bladder cancer undergoing open radical cystectomy and urinary diversion (ileal conduit or orthotopic bladder substitute) will be enrolled and randomized into a study (SG) and a control group (CG). Standard lung-protective ventilation with a PEEP of 6 cmH2O will be applied in the CG and an optimal PEEP value determined during a static pulmonary compliance (Cstat)-directed PEEP titration procedure will be used in the SG. Low tidal volumes (6 mL/Kg ideal bodyweight) and a fraction of inspired oxygen of 0.5 will be applied in both groups. After surgery both groups will receive standard postoperative management. Primary endpoints are postoperative pulmonary complications and serum procalcitonin kinetics during and after surgery until the third postoperative day. Secondary and tertiary endpoints will be: organ dysfunction as monitored by the Sequential Organ Failure Assessment Score, in-hospital stay, 28-day and in-hospital mortality.DiscussionThis trial will assess the possible benefits or disadvantages of an individualized lung-protective mechanical ventilation strategy during open radical cystectomy and urinary diversion regarding postoperative pulmonary complications and the inflammatory response.Trial registrationClinicalTrials.gov, ID: NCT02931409. Registered on 5 October 2016.

AB042. Rehabilitation period care for patients with urinary ostomy

The bladder tumor is the most common tumor in the urinary system and is mostly malignant. Its morbidity and mortality were the first in urinary reproductive system tumor. Surgical treatment is the best choice for the current bladder tumor, including transurethral resection of the bladder tumor, partial cystectomy, and total cystectomy. Bladder total resection and urinary diversion is the gold standard for the treatment of invasive bladder tumors. At present, ureteral abdominal wall ostomy, ileal bladder surgery and in situ new bladder reconstruction is the main operation. In addition to accurate surgery, full preoperative preparation, perfect postoperative care and complications of patients, the purpose of enterostomy is to improve the quality of patient’s life, if the postoperative can not improve the quality of life, the operation is meaningless. Therefore, it is vital for clinical and specialist nurses to make good rehabilitation and continuing care. The patient’s rehabilitation period includes the following points: firstly, the most important thing is to guide the patient and family to learn and use “the standard colostomy supplies change process ARC” to make the colostomy changed by themselves, which can improve their nursing technology. Secondly, the main problem for patients with post-operative rehabilitation is whether they can care for themselves, continue to work, participate in social activities, and play roles in the past, and so on. We should guide the patients that colostomy is not a disease, but an artificial opening to eliminate human waste. As long as patients have confidence in themselves, who can correctly master the colostomy equipment and nursing method, it can easily for them to enjoy life. Finally, patients need to pay more attention to the continuing nursing after leaving hospital, such as the oral outpatient service, the sorority house, the family visit, the construction of community volunteers, and the construction of the network of oral care. Through effective colostomy care, life care, continuity of care and the psychological care, it can improve the patient’s confidence in preoperative life and social activities and improve the quality of physical and social life.

Pure robotic-assisted radical cystectomy with orthotopic U-shape ileal neobladder: surgical technique

Objective To investigate the surgical skills of pure robotic-assisted radical cystectomy with orthotopic U-shape ileal neobladder. Methods From October 2014 to September 2016, 37 patients with locally advanced bladder cancer(cT2-3N0-2M0)were diagnosed, including 29 males and 8 females, Their age ranged from 52 to 71 years old. According to preoperative cystoscopy, pathological diagnosis and bladder enhanced CT and other examination, 25 patients were staged as cT2, 12 cases were staged as cT3. 25 cases of them were primary tumors, who underwent pure robotic-assisted radical cystectomy and Endo-GIA assisted orthotopic U-shape ileal neobladder reconstruction. First, bilateral lymph nodes were dissected. And the ureter was explored and dissected to the outer wall of the bladder. Then, we ligated the superior artery of bladder and expose the seminal vesicle, vas deferent duct. The DV fascia was opened to expose the posterior wall of prostate. Incise was performed along the both sides of the bladder and prostate fascia to maintain the vascular nerve bundle until the tip of prostate. The urethra was cut off and then the bladder was remove. We used Endo-GIA to cut 30-35 cm ileum and construct U-shaped bladder. The anastomosis between ureter and neo-bladder and the anastomosis between urethra and neo-bladder were performed. Perioperative and follow-up data were collected. Results The surgeries were successful in all 37 cases. The operation time ranged from 245 to 335 min , mean (285±37)min. The mean intraoperative blood loss was(187±56) ml(ranging 90-300 ml). The average postoperative hospital stay was (17±2)days (ranging 15-20 days). Postoperative intestinal function recovery time ranged from 1.3 to 2.2 days, mean (1.7±0.4)days. Surgical margins were all negative. Lymph node positive rate was 21.6% (8/37). After 1 month, 22 cases achieved complete continence. After 3 months, 35 cases get fully self-control urination, 8 cases have noctual incontinence. Postoperative follow-up ranged from 6 to 24 months, no recurrence or distant metastasis was found in this study. After 6 months, cystoscopy showed no obvious formation of bladder stones. Neo-bladder capacity ranged from 270 to 350 ml. The urodynamic examination showed bladder pressure was maintained between 19 and 25cm H2O. Conclusions Pure robotic-assisted radical cystectomy can achieve better bladder resection, better remaining of urethral and neurovascular bundles and good control of urinary continence after operation. Endo-GIA assisted orthotopic U-shaped ileal bladder need shorter intestinal tract and cause less influence to the intestinal function. The neo-bladder shape is more regular, simple doing, earn shorter operation duration, less bleeding, quick recovery, which is a safe and effective surgical approach. Key words: Urinary bladder cancer; Pure robotic-assisted; Radical cystectomy; Orthotopic U-shape ileal neobladder

Long-term functional outcomes after radical cystectomy with ileal bladder substitute: does the definition of continence matter?

Objective: Functional outcomes after ileal bladder substitution reflect the expectations of future patients at a particular centre. The aim of this study was to use validated questionnaires and a pad-weighing test to investigate functional outcomes after neobladder reconstruction at long-term follow-up in patients at a single centre.Materials and methods: During 2005 − 2015, 75 patients received a Studer ileal bladder substitute at the Department of Urology, Malmö. Forty-six of these patients were alive for follow-up and were evaluated using the pad-weighing test and the International Consultation on Incontinence Questionnaire–Urinary Incontinence Short Form (ICIQ-UI-SF), the Female Sexual Function Index (FSFI) and the International Index of Erectile Function (IIEF).Results: Five of 37 evaluable patients (14%) were considered fully continent, reporting a pad-weighing test result of 0 g and an ICIQ-UI-SF score of 0. The median ICIQ-UI-SF score was 8 [interquartile range (IQR) 3–11], and seven patients (17%) were continent according to the ICIQ-UI-SF score only. In the pad-weighing test, 28 out of 37 patients (76%) reported 0 g day-time leakage whereas only 12 out of 37 patients (32%) reported 0 g night-time leakage. At follow-up, nine out of 39 (23%) of evaluable male patients were potent. The median ICIQ-UI-SF score was significantly lower during the second half of the study period [4 (IQR 0–8) vs 10 (IQR 6–14); p = .003]. The inverse applied to the median IIEF score [5 (IQR 3–12) vs 2 (IQR 1–4); p = .02].Conclusions: Functional outcomes at long-term follow-up after radical cystectomy and Studer ileal bladder substitute were at best modest in this series. Better outcomes during the second half of the study period might be explained by improved patient selection and a refined surgical technique, but possibly also by longer follow-up of patients during the first half of the period resulting in a more pronounced time-dependent decline in functional outcomes.

Robotic Intracorporeal Padua Ileal Bladder: Surgical Technique, Perioperative, Oncologic and Functional Outcomes

BackgroundRobot-assisted radical cystectomy (RARC) with intracorporeal neobladder reconstruction is a challenging procedure. The need for surgical skills and the long operative times have led to concern about its reproducibility. ObjectiveTo illustrate our technique for RARC and totally intracorporeal orthotopic Padua ileal bladder. Design, setting, and participantsFrom August 2012 to February 2014, 45 patients underwent this technique at a single tertiary referral centre. Surgical procedureRARC, extended pelvic lymph node dissection, and intracorporeal partly stapled neobladder. Surgical steps are demonstrated in the accompanying video. MeasurementsDemographics, clinical, and pathological data were collected. Perioperative, 2-yr oncologic and 2-yr functional outcomes were reported. Results and limitationsIntraoperative transfusion or conversion to open surgery was not necessary in any case and intracorporeal neobladder was successfully performed in all 45 patients. Median operative time was 305min (interquartile range [IQR]: 282–345). Median estimated blood loss was 210ml (IQR: 50–250). Median hospital stay was 9 d (IQR: 7–12). The overall incidence of perioperative, 30-d and 180-d complications were 44.4%, 57.8%, and 77.8%, respectively, while severe complications occurred in17.8%, 17.8%, and 35.5%, respectively. Two-yr daytime and night-time continence rates were 73.3% and 55.5%, respectively. Two-yr disease free survival, cancer specific survival, and overall survival rates were 72.5%, 82.3%, and 82.4%, respectively. The small sample size and high caseload of the centre might affect the reproducibility of these results. ConclusionsOur experience supports the feasibility of totally intracorporeal neobladder following RARC. Operative times and perioperative complication rates are likely to be reduced with increasing experience. Patient summaryWe report the outcomes of our first 45 consecutive patients who underwent robot-assisted radical cystectomy with intracorporeal neobladders. Perioperative, oncologic, and functional outcomes support this technique as a feasible and safe surgical option in tertiary referral centres.

Immunocytochemical staining for p53 and Ki-67 helps to characterise urothelial cells in urine cytology.

The presence of atypical cells in urine cytology is unsatisfactory for both cytologists and clinicians. The objective of this study was to test whether p53 and Ki-67 immunostaining could improve urothelial carcinoma (UC) detection on urinary cytology. A total of 196 urine samples were analysed, 142 from the bladder, 41 from the upper tract and 13 from ileal bladder replacement. Cytology results were expressed as normal (N) (n = 81), atypia cannot exclude low-grade UC (ALG) (n = 25), suspicious for high-grade UC (SHG) (n = 39) and high-grade UC (HG) (n = 51). Actual diagnoses were confirmed by histopathological analysis, cystoscopic examination or follow-up for at least 1 year. Immunocytochemistry performed on CytoSpin™ slides allowed the determination of the percentage of positive cells with p53 and Ki-67. The median percentage values [first to third quartile] of p53 and Ki-67 were 0 [0-5] and 0 [0-1] for N cytology, 5 [0-40] and 2 [1-10] for ALG, 10 [0-30] and 6 [3-25] for SHG, and 30 [10-80] and 20 [10-30] for HG, respectively. Statistically higher values were observed for both tests (P < 0.001) in positive cytologies (ALG, SHG and HG). The optimal cut-offs were 5% for p53 and 3% for Ki-67. The sensitivity and specificity for the detection of all UC were 86.4% and 76.7% for cytology alone, 81.3% and 93.2% for cytology and p53, 75.7% and 88% for cytology and Ki-67, and 68.9% and 97.5% for cytology, p53 and Ki-67, respectively. Using p53 and/or Ki-67 in addition to cytology increases the specificity without penalising the sensitivity.

622 Excellent continence and renal function outcomes can be maintained in patients who survived >10 yrs after diversion with an ileal orthotopic bladder substitute

622 Excellent continence and renal function outcomes can be maintained in patients who survived >10 yrs after diversion with an ileal orthotopic bladder substitute

Detour technique, Dipping technique, or Ileal bladder flap technique for surgical correction of uretero-ileal anastomotic stricture in orthotopic ileal neobladder.

ABSTRACTBackground:Uretero-ileal anastomotic stricture (UIAS) is a urological complication after ileal neobladder, the initial management being endourological intervention. If this fails or stricture recurs, surgical intervention will be indicated.Design and Participants:From 1994 to 2013, 129 patients were treated for UIAS after unsuccessful endourological intervention. Unilateral UIAS was present in 101 patients, and bilateral in 28 patients; total procedures were 157. The previous ileal neobladder techniques were Hautmann neobladder, detubularized U shape, or spherical shape neobladder.Surgical procedures:Dipping technique was performed in 74 UIAS. Detour technique was done in 60 renal units. Ileal Bladder flap was indicated in 23 renal units. Each procedure ended with insertion of double J, abdominal drain, and indwelling catheter.Results:Follow-up was done for 12 to 36 months. Patency of the anastomosis was found in 91.7 % of cases. Thirteen patients (8.3%) underwent antegrade dilatation and insertion of double J.Conclusion:After endourological treatment for uretero-ileal anastomotic failure, basically three techniques may be indicated: dipping technique, detour technique, and ileal bladder flap. The indications are dependent on the length of the stenotic/dilated ureteral segment. Better results for long length of stenotic ureter are obtained with detour technique; for short length stenotic ureter dipping technique; when the stenotic segment is 5 cm or more with a short ureter, the ileal tube flap is indicated. The use of double J stent is mandatory in the majority of cases. Early intervention is the rule for protecting renal units from progressive loss of function.

The preliminary clinical results of laparoscopic ileum augmentation cystoplasty for low compliance bladder

To study the effectiveness and safety of the laparoscopic ileal bladder augmentation treatment for low compliance bladder. A retrospective analysis was performed based on 36 cases admitted to the Zhejiang Provincial People's Hospital with highly reflective and low compliance bladder accepted laparoscopic ileal bladder augmentation surgical treatment from June 2011 to December 2013. In accordance with inclusion and exclusion criteria, 22 patients were enrolled in this study, including 13 males, 9 females who aged from 22 to 62 years with an average of 35.8 years. Among the selected sample, there were 15 cases of spinal cord injury, 4 cases of spinal cord dysplasia, and 3 cases of urinary tuberculosis. The duration of disease varied from 1 to 15 years, with an average of 8.5 years. For surgery, intraoperative and perioperative complications were observed, and preoperative serum creatinine in patients with postoperative at 3, 6, 12, 18, 24, 36 months, hydronephrosis, and glomerular filtration rate urodynamic parameters were used for univariate analysis of variance. All patients were successfully completed in laparoscopic surgery, the operative time were (105 ± 17) minutes (90-150 minutes), blood loss was (90 ± 26) ml (60-150 ml), postoperative intestinal function recovery time were (2.5 ± 0.7) d (2-5 d), and postoperative hospital stay was (15.0 ± 4.2) d (11-20 d), while postoperative anastomotic leakage, intestinal blockage, severe abdominal infection or sepsis and other complications did not occur. Patients were followed up for 6 to 36 months, with an average of 16.5 months, among which 17 patients were followed up for over 12 months. The bladder safety capacity increased from (103 ± 38) ml preoperatively to (405 ± 46) ml at the end of the follow-up (F = 381.7, P = 0.000), and bladder compliance increased from (10 ± 3) cmH₂O (1 cmH₂O = 0.098 kPa) preoperatively to (38 ± 4) cmH₂O (F = 678.1, P = 0.000); the average pressure within the bladder filling at the end of the follow-up was (16 ± 6) cmH₂O, which was significantly lower (F = 221.5, P = 0.000) compared to preoperative level of (45 ± 16) cmH₂O, preoperative serum creatinine went down from (184 ± 32) µmol/L to (120 ± 28) µmol/L at the end of the follow-up (F = 189.1, P = 0.000); total glomerular filtration rate rose from (40 ± 26) ml⁻¹ · min⁻¹ · 1.73 m⁻² preoperatively to (66 ± 32) ml⁻¹ · min(-1) · 1.73 m⁻² (F = 137.7, P = 0.000). Qmax of the 3 cases of urinary bladder contracture tuberculosis patients increased significantly, while 4 female patients with residual urine volume decrease had voluntary urination. Laparoscopic ileal bladder augmentation treatment for low compliance bladder is feasible and safe, with less trauma, less bleeding, less post-operative complications, and faster recovery of bowel function. Urinary function improves significantly after surgery, and function of upper urinary tract can also be effectively improved and protected in patients.

AB058. Clinic practice of the laparoscopic ileal bladder augmentation

ObjectiveTo investigate the efficacy and safety of laparoscopic ileal bladder augmentation in treating patients with low compliant bladder dysfunction.MethodsFrom June 2011 to December 2013, 22 patients with low compliant bladder dysfunction were enrolled and received laparoscopic ileal bladder expanding. Postoperative complications, renal function, hydronephrosis, glomerular filtration rate, urodynamics parameters and quality of daily life were evaluated.ResultsThe laparoscopic ileal bladder expanding were all successful. The average operation time was (105.0±16.7) min, the bleeding volume was (90.0±26.0) mL, the recovery time of intestinal function was (2.5±0.7) days, the hospitalization time was (15.0±4.2) days. All the patients had no serious complications, such as ileum anastomotic fistula, intestinal obstruction and abdominal infection or sepsis. Among them, 17 patients were followed up for more than 12 months. Compared with the preoperative condition, the average bladder capacity and bladder compliance were significantly increased from (103.0±38.2) cmH2O to (403.0±45.8) cmH2O, and from (9.6±3.1) to (38.1±4.4) mL/cmH2O (P<0.001), respectively. And the average bladder pressure at the end of filling phrase of cystometry were significantly decreased from (45.3±15.8) cmH2O to (16.5±6.4) cmH2O (P<0.001). The preoperative and postoperative serum creatinine level were (183.5±32.2) μmol/L and (120±28.4) μmol/L (P<0.001), respectively. The preoperative and postoperative total glomerular filtration rate were (40.0±25.5) mL/min/1.73m2 and (62.0±28.6) mL/min/1.73m2 (P<0.05), respectively.ConclusionsThe operation of laparoscopic ileal bladder expanding is feasible and security, with the advantages of little injury, less bleeding, quicker recovery of intestinal function and less postoperative complications. The bladder function was obviously improved after operations, which can effectively protect the patient’s upper tract functions.

PD9-08 RISK ASSESSMENT OF LATE COMPLICATIONS AFTER ROBOTIC RADICAL CYSTECTOMY WITH TOTAL INTRACORPOREAL URINARY DIVERSION

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion I1 Apr 2015PD9-08 RISK ASSESSMENT OF LATE COMPLICATIONS AFTER ROBOTIC RADICAL CYSTECTOMY WITH TOTAL INTRACORPOREAL URINARY DIVERSION Mariaconsiglia Ferriero, Giuseppe Simone, Rocco Papalia, Salvatore Guaglianone, and Michele Gallucci Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Giuseppe SimoneGiuseppe Simone More articles by this author , Rocco PapaliaRocco Papalia More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , and Michele GallucciMichele Gallucci More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.935AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic radical cystectomy (RRC) with intracorporeal urinary diversion (UD) is a challenging procedure with a high rate of perioperative complications. In this study we assessed the risk of late complications after RRC with intracorporeal UD. METHODS From October 2012 to October 2014, 100 consecutive unselected patients with cT2-4a/cN1-3/cM0 bladder cancer underwent RRC, extended lymphadenectomy and totally intracorporeal UD. Baseline demographics, perioperative and follow up data were prospectively collected. Univariable and multivariable regression analysis were performed to identify independent predictors of surgery related (SR) and any kind of late complications at six-mo evaluation. RESULTS Out of 100 RRC, we selected 87 consecutive patients with a minimum 6-mo follow up. Sixty-nine patients received a Padua Ileal bladder (54 male and 15 female), while 18 patients received an ileal conduit. At a six-mo follow up 60 (68.9%) patients experienced any kind of late complication, 49 (56.4%) were SR. Ortotopic UD, preoperative eGFR and learning curve were significant predictors of SR complication at univariable analysis (p= 0.032, p=0.042 and p=0.05, respectively). At multivariable analysis, the only independent predictor of surgical related late complications was orthotopic UD (p = 0.010; HR: 5.01 [95% CI, 1.47–17.04]). Learning curve and preoperative eGFR were significant predictors of any complications at univariable analysis (p= 0.008, and p=0.044, respectively). At multivariable analysis, the only independent predictor of any kind of late complications was the learning curve (p = 0.025; HR: 0.97 [95% CI, 0.95–0.99]). CONCLUSIONS RRC with intracorporeal neobladder is feasible but associated to higher risks of SR complications at six-mo evaluation. Learning curve plays a key role for a stepwise reduction of perioperative complications. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e197-e198 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mariaconsiglia Ferriero More articles by this author Giuseppe Simone More articles by this author Rocco Papalia More articles by this author Salvatore Guaglianone More articles by this author Michele Gallucci More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

445 Preoperative urethral pressure profiles predict functional outcome after orthotopic ileal bladder substitution in female patients

445 Preoperative urethral pressure profiles predict functional outcome after orthotopic ileal bladder substitution in female patients

541 Hysterectomy and non nerve-sparing cystectomy have a negative impact on functional outcome after orthotopic ileal bladder substitution in female patients

541 Hysterectomy and non nerve-sparing cystectomy have a negative impact on functional outcome after orthotopic ileal bladder substitution in female patients

Sacrocolpopexy with polypropylene tape as valuable surgical modification during cystectomy with orthotopic ileal bladder: functional results.

Introduction. Urinary diversion is very often associated with urinary retention and urinary incontinence. In this study, a surgical modification during cystectomy with orthotopic ileal neobladder is presented. Material and Methods. Female patients enrolled in the study (n-24) were subjected to sacrocolpopexy during the operation. Apart from oncological control, the follow-up consisted of 1-hour inlay test and questionnaires (UDI-6 and IIQ-7) in the 3rd, 6th, and 12th month after the operation. In the 12th month after the surgery, the urodynamic pressure-flow test was performed. Outcomes were compared with the control group (n-18) in which sacrocolpopexy was not implemented. Results. The study group was characterised by reduced urinary retention and improved continence. Conclusion. Sacrocolpopexy during cystectomy with orthotopic ileal bladder is a valuable surgical method which provides patients with a better quality of life.

Long-term efficacy of polydimethylsiloxane (Macroplastique) injection for Mitrofanoff leakage after continent urinary diversion surgery.

To assess the long-term efficacy of polydimethylsiloxane (Macroplastique) injection (MPI) in the treatment of Mitrofanoff leakage secondary to valve incompetence. Between 1995 and 2012, the records of 24 consecutive patients who underwent MPI for Mitrofanoff urinary leakage after continent cutaneous urinary diversion (CCUD) surgery were examined. All patients had a valve deemed of sufficient length (>2 cm) to attempt Macroplastique coaptation. Treatment outcomes were divided into three categories based on physician assessment: success (dry), partial success (>50% reduction in incontinence pads) and failure. Success rates were assessed according to the type of reservoir and conduit channel. The mean (range) follow-up was 30 (6-96) months. One patient had initial difficulty catheterising, and subsequently required major revision surgery. In all, 12 patients (50%) failed the treatment and subsequently underwent operative revision to the channel. Three patients (12.5%) achieved complete success; one patient had an appendix channel through native bladder and the remaining two had Monti channels through colon. Nine patients (37.5%) had partial success; success rates were higher with appendix channels (four of six) and colonic reservoirs (six of seven) when compared with Monti channels (eight of 18, 44%) and ileal reservoirs (zero of two). Five of the nine patients with partial success eventually required further surgical revision for deteriorating continence at a mean (range) of 41 (14-96) months, whilst the other four have maintained sufficient continence with MPI alone. Macroplastique bulking cured only 12.5% patients, but leakage was substantially improved in a further 37.5% allowing major surgery to be avoided or postponed in one half of the cohort. Appendix Mitrofanoffs do better than the Monti Mitrofanoff, with channels through colonic segments generally doing better than those through ileal bladders. MPI should be considered as a less invasive alternative to avoid or delay major reconstructive surgery.

Superior Functional Outcome after Radical Cystectomy and Orthotopic Bladder Substitution with Restrictive Intraoperative Fluid Management: A Followup Study of a Randomized Clinical Trial

Continuous intraoperative norepinephrine infusion combined with restrictive deferred hydration improves surgical field visibility, and significantly decreases intraoperative blood loss and postoperative complications in patients undergoing radical cystectomy and urinary diversion. We determined whether the intraoperative fluid regimen would affect functional results (continence and erectile function) 1 year after orthotopic ileal bladder substitution. We analyzed a subgroup of 93 patients who received an ileal orthotopic bladder substitute. The subgroup was part of a randomized trial in 167 patients initially allocated to continuous norepinephrine administration starting with 2 μg/kg per hour combined with 1 ml/kg per hour initially and 3 ml/kg per hour crystalloid infusion after cystectomy (norepinephrine/low volume group of 51) or a standard crystalloid infusion of 6 ml/kg per hour throughout surgery (42 controls). We prospectively assessed daytime and nighttime continence, and erectile function 1 year postoperatively in the 93-patient subgroup. Daytime continence was reported by 44 of 51 patients (86%) in the norepinephrine/low volume group and by 27 of 42 controls (64%) (p = 0.016), and nighttime continence was reported by 38 (75%) and 25 (60%), respectively (p = 0.077). Erectile function recovery was reported by 26 of 33 preoperatively potent patients (79%) in the norepinephrine/low volume group and by 11 of 29 controls (38%) (p = 0.002). Patients who undergo radical cystectomy and orthotopic bladder substitution with continuous norepinephrine infusion and restrictive hydration during surgery have significantly better daytime continence and erectile function 1 year postoperatively.

Urinary diversion metabolic complications - underestimated problem.

Bladder cancer is one of the most frequent human cancers. In 2011 more than six thousand people in Poland developed BC and more than three thousand died because of it. Treatment of bladder cancer depends on its stage. In less advanced tumours (Ta, Tcis, T1) transurethral resection of bladder tumor with adjuvant immunotherapy is often therapeutic. In more advanced cases (≥ T2) radical cystectomy is needed. There are several surgical types of post-cystectomy urinary diversion divided into two fundamental types - enabling and not enabling urine continence. The most common procedures include ureterocutaneostomy, ileal or colon conduit, orthopic ileal bladder, heterotopic continent bladder replacement (pouch) and urinary diversion via the rectum. Depending on type of cystectomy, various metabolic complications occur, because the absorptive-secretory function of used bowel segment is intact. Complications include bowel dysfunction, malabsorption of various vitamins, acid-base imbalance, electrolyte imbalance, abnormalities in bone metabolism, formation of renal calculi, secondary malignancies and disturbances in function of kidneys or liver. Early diagnosed complications can be treated easier, recognised in advanced stages are often irreversible. In our paper we present review of different approaches to bladder cancer treatment and metabolic complications occurring after these procedures.

Early and Late Complications of Robot-Assisted Radical Cystectomy: A Standardized Analysis by Urinary Diversion Type

Minimally invasive surgical treatment for bladder cancer has gained popularity but standardized data on complications are lacking. Urinary diversion type contributes to complications and to our knowledge diversion types after minimally invasive cystectomy have not yet been compared. We evaluated perioperative complications stratified by urinary diversion type in patients treated with robot-assisted radical cystectomy. We analyzed the records of 209 consecutive patients who underwent robot-assisted radical cystectomy at our institution from 2003 to 2012 with respect to perioperative complications, including severity, time period (early and late) and diversion type. All complications were reviewed by academic urologists. Urinary diversion was also done. As outcome measurements and statistical analysis, univariate and multivariate logistic regression models were used to determine predictors of various complications. The American Society of Anesthesiologists(®) (ASA) score was 3 or greater in 80% of patients and continent diversion was performed in 68%. Median followup was 35 months. Within 90 days 77.5% of patients experienced any complication and 32% experienced a major complication. The 90-day mortality rate was 5.3%. Most complications were gastrointestinal, infectious and hematological. On multivariate analysis patients with ileal conduit diversion had a decreased likelihood of complications compared to patients with Indiana pouch and orthotopic bladder substitute diversion despite the selection of a more comorbid population for conduit diversion. Continent diversion was associated with a higher likelihood of urinary tract infection. Our results are comparable to those of previously reported open and minimally invasive cystectomy series. Open or minimally invasive cystectomy is a complex, morbid procedure. Urinary diversion is a significant contributor to complications, as is patient comorbidity. Although patients with an ileal conduit had more comorbidities, they experienced fewer complications than those with an orthotopic bladder substitute or Indiana pouch diversion.

Rediversion after urinary diversion: A single-centre experience

Objective. This study aimed to reveal the late results of rediversion after urinary diversion. Material and methods. From 1985 to 2009, 28 patients underwent rediversion at the Department of Urology, Lund University Hospital, Sweden. Median follow-up after rediversion was 147 months (range 7–300 months, interquartile range 63–214). The following rediversions were performed: ileal conduit, cutaneous ureterostomy, ureterosigmoidostomy and rectal bladder to continent cutaneous diversion (group I, n = 17); cutaneous ureterostomy to neobladder (group II, n = 1); ileal conduit and cutaneous ureterostomy to gastric conduit (group III, n = 2); and continent cutaneous diversion and neobladder to ileal conduit (group IV, n = 8). Results. In group I, reoperations were necessary after rediversion in nine of the 17 patients. Excellent functional results were obtained in 14 patients. Two patients, both with Kock pouches, underwent multiple operations and finally required rediversion to an ileal conduit. The sole patient in group II had a ureteric reimplantation owing to ureterointestinal stricture and is now continent but performs clean intermittent catheterization. Both patients in group III underwent reoperations owing to ureteric strictures and renal stones. In group IV, one patient had ureteric stenosis, and one died owing to complications related to later surgery for small bowel obstruction. Conclusions. Complications are common after urinary rediversion, and several of the present patients required reoperations for a variety of reasons. Modern techniques for continent cutaneous diversion can provide excellent functional results. Patients with difficulties in accepting a urostomy bag pose special problems and need extensive information and counselling.