Ileal Neobladder Group Research Articles

Long-Term Outcomes of Orthotopic Neobladder Versus Ileal Conduit Urinary Diversion in Robot-Assisted Radical Cystectomy (RARC): Multicenter Results from the Asian RARC Consortium

PurposeRobot-assisted radical cystectomy (RARC) has gained traction in the management of muscle invasive bladder cancer. Urinary diversion for RARC was achieved with orthotopic neobladder and ileal conduit. Evidence on the optimal method of urinary diversion was limited. Long-term outcomes were not reported before. This study was designed to compare the perioperative and oncological outcomes of ileal conduit versus orthotopic neobladder cases of nonmetastatic bladder cancer treated with RARC.Patients and MethodsThe Asian RARC consortium was a multicenter registry involving nine Asian centers. Consecutive patients receiving RARC were included. Cases were divided into the ileal conduit and neobladder groups. Background characteristics, operative details, perioperative outcomes, recurrence information, and survival outcomes were reviewed and compared. Primary outcomes include disease-free and overall survival. Secondary outcomes were perioperative results. Multivariate regression analyses were performed.ResultsFrom 2007 to 2020, 521 patients who underwent radical cystectomy were analyzed. Overall, 314 (60.3%) had ileal conduit and 207 (39.7%) had neobladder. The use of neobladder was found to be protective in terms of disease-free survival [Hazard ratio (HR) = 0.870, p = 0.037] and overall survival (HR = 0.670, p = 0.044) compared with ileal conduit. The difference became statistically nonsignificant after being adjusted in multivariate cox-regression analysis. Moreover, neobladder reconstruction was not associated with increased blood loss, nor additional risk of major complications.ConclusionsOrthotopic neobladder urinary diversion is not inferior to ileal conduit in terms of perioperative safety profile and long-term oncological outcomes. Further prospective studies are warranted for further investigation.

Comparison of a Significant Decline in the Glomerular Filtration Rate between Ileal Conduit and Ileal Neobladder Urinary Diversions after Radical Cystectomy: A Propensity Score-Matched Analysis

Urinary diversion after radical cystectomy is associated with a risk of renal function impairment. A significant decline in the glomerular filtration rate (GFR) (i.e., a ≥30% decline in baseline GFR after 12 months) is associated with long-term renal function impairment. We compared the significant GFR decline between ileal conduit and ileal neobladder urinary diversions 12 months after radical cystectomy. We retrospectively included radical cystectomy patients. Propensity score-matched analysis was performed. The primary outcome was the incidence of a significant GFR decline in ileal conduit urinary diversion (ileal conduit group) and ileal neobladder urinary diversion (ileal neobladder group) 12 months after radical cystectomy. The secondary outcomes were the change of GFR and the incidence of end-stage renal disease (ESRD) in the two groups. After propensity score matching, the ileal conduit and neobladder groups had 117 patients each. The incidence of a significant GFR decline was not significantly different between ileal conduit and ileal neobladder groups (12.0% vs. 13.7%, p = 0.845). The change of GFR and ESRD incidence were not significantly different between the two groups (−8.4% vs. −9.7%, p = 0.480; 4.3% vs. 5.1%, p > 0.999, respectively). These results can provide important information on appropriate selection of the urinary diversion type in radical cystectomy.

Quality of Life after Different Types of Ileal Diversions Following Radical Cystectomy

Background: Radical cystectomy remains the gold standard in treatment of muscle invasive bladder cancer. Objective: To evaluate the quality of life (QOL) for patients underwent ileal conduit (IC) versus orthotopic ileal neobladder (INB) urinary diversions (UD) after one year post radical cystectomy (RC). Patients and methods: Our study was a retrospective study that included patients with MIBC who underwent RC and UD from January 2014 to Julie 2018 that passed one-year post RC. There were two groups of patients as follows: IC and INB groups. QOL was evaluated by the Functional Assessment of Cancer Therapy– Bladder Cancer (FACT-BL). The erectile function (EF) was assessed by the International Index of Erectile Function-5 (IIEF-5) questionnaire. Results: Overall, 125 patients underwent RC with UD were screened for eligibility. Twenty patients (16%) died, 11 patients (8.8%) failed to reach to them, 6 patients (4.8%) underwent other UD and 2 patients (1.6%) refused participation in this study thus 86 patients (68.8%) were eligible for the study and were analyzed. The mean patient’s age was 61.6 ± 6.3 in both groups (p value 0.199). There were significant differences between both groups in physical, social, emotional, functional, additional concerns, urinary and GIT symptoms that were significantly better in INB group (p value < 0.001). There was no significant difference between both groups regarding the EF. Conclusions: the INB is better than the IC UD in most of QOL domains, which include physical, social, emotional, functional, additional concerns, urinary and GIT symptoms. But sexual function remains equal bad in both groups.

Quality of Life after Different Types of Ileal Diversions Following Radical Cystectomy

Background: Radical cystectomy remains the gold standard in treatment of muscle invasive bladder cancer. Objective: To evaluate the quality of life (QOL) for patients underwent ileal conduit (IC) versus orthotopic ileal neobladder (INB) urinary diversions (UD) after one year post radical cystectomy (RC). Patients and methods: Our study was a retrospective study that included patients with MIBC who underwent RC and UD from January 2014 to Julie 2018 that passed one-year post RC. There were two groups of patients as follows: IC and INB groups. QOL was evaluated by the Functional Assessment of Cancer Therapy– Bladder Cancer (FACT-BL). The erectile function (EF) was assessed by the International Index of Erectile Function-5 (IIEF-5) questionnaire. Results: Overall, 125 patients underwent RC with UD were screened for eligibility. Twenty patients (16%) died, 11 patients (8.8%) failed to reach to them, 6 patients (4.8%) underwent other UD and 2 patients (1.6%) refused participation in this study thus 86 patients (68.8%) were eligible for the study and were analyzed. The mean patient’s age was 61.6 ± 6.3 in both groups (p value 0.199). There were significant differences between both groups in physical, social, emotional, functional, additional concerns, urinary and GIT symptoms that were significantly better in INB group (p value < 0.001). There was no significant difference between both groups regarding the EF. Conclusions: the INB is better than the IC UD in most of QOL domains, which include physical, social, emotional, functional, additional concerns, urinary and GIT symptoms. But sexual function remains equal bad in both groups.

Outcome of orthotopic sigmoid versus ileal neobladder reconstruction.

Introduction:Radical cystectomy with orthotopic urinary diversion is considered the gold standard for treatment of muscular invasive bladder cancer or high-risk nonmuscular invasive bladder cancer. The choice of orthotopic neobladder reconstruction depends on the clinical outcomes of it and should be planned with the patients, especially the risk of incontinence.Methods:this study included 52 Egyptian patients underwent radical cystectomy and orthotopic neobladder reconstruction with sigmoid (25 patients) and ileal (27 patients) segments. Postoperative clinical outcomes between the sigmoid and ileal neobladder groups were compared.Results:In the present study, 12 intraoperative complications (6 in each group) and 19 postoperative complications (17 in sigmoid and 15 in ileal group) occurred; however, there was no significant difference in the incidence of intraoperative and postoperative complications between both groups. There were no significant differences in the continence status and spontaneous voiding between both groups. There were no significant differences in maximal flow rate and voided volume between both groups. Night voiding frequency in the ileal neobladder patients was significantly smaller than sigmoid neobladder patients. Free flowery showed a significant difference of voiding time and volume in favor of sigmoid neobladder group. Maximum urethral pressure and urethral closing pressure were significantly higher in ileal neobladder group.Conclusions:Both types of neobladder reconstruction resulted in comparatively satisfactory outcomes; however, the voiding function in sigmoid neobladder group appeared to be more favorable than that in ileal neobladder group.

Acid-base disorders after orthotopic bladder replacement: comparison of an ileal neobladder and an ileal conduit

Objectives: For many years, creation of an orthotopic neobladder after cystectomy has been popular. In the present study, we measured the extent of metabolic acidosis in patients with ileal neobladders compared with ileal conduits and defined risk factors for development of metabolic acidosis.Methods: We retrospectively studied 95 patients, who underwent radical cystectomy and urinary diversion to treat invasive bladder cancer from January 2001 to December 2014 at Hallym University Kangnam Sacred Heart Hospital, through investigation of acid-base balance, serum electrolyte levels and renal function one month and one year after operation.Results: One month after the operation, metabolic acidosis was found from 18 patients (31.0%) in an ileal neobladder group and from 4 (14.8%) in an ileal conduits group. One year after the operation, the numbers became 11 (22.9%) and 2 (10.0%), respectively. However, there was not a statistical difference. The blood biochemical profiles of the two groups did not differ significantly after urinary diversion. Logistic analysis revealed that lower estimated glomerular filtration rate (eGFR) was associated with metabolic acidosis at one month (odds ratio, OR = 0.94 [0.91–0.97]; p < 0.001) and one year (OR = 0.94 [0.92–0.97]; P = 0.001) after urinary diversion. In multivariate analysis, lower eGFR is a significant risk factor for metabolic acidosis at one month.Conclusions: Patients with ileal neobladders and conduits are at the similar risk of metabolic acidosis. A close association between renal function and development of metabolic acidosis was observed, especially stronger in an early period after operation.

Early stage postoperative complications of laparoscopic radical cystectomy

Objective To investigate feasibility and early stage postoperative complications of lapa-roscopic radical cystectomy （ LRC） . Methods We retrospectively analyzed the data of 63 consecutive pa-tents （58 males and 5 females） who underwent LRC from Oct .2011 to Oct.2013 in our institute.Of these patients, 46 patients underwent ileal conduit , 9 patients underwent ureterocutaneostomy , and 8 patients un-derwent orthotopic ileal neobladder urinary diversion .The average age and body mass index of patients were 67.7±11.1 （33-84） years and 23.3±2.1 （18.8-28.7） kg/m2, respectively.The mean hemoglobin and al-bumin of patients were （130.7±20.3） g/L and （38.9±4.1） g/L, respectively.Comorbidities of hyperten-sion, diabetes, coronary heart disease and decompensated liver cirrhosis were found in 10, 6, 2 and 1 pa-tient, respectively.10 of 61 patients had a history of abdominal surgery .The indications for cystectomy were classified as muscle invasive bladder cancer for 30 patients, unresectable superficial bladder cancer for 19 patients and recurrent bladder cancer for 14 patients.Postoperative data and early stage postoperative compli-cations within 3 months after surgery were collected . Results The median operative time for LRC and uri-nary diversion was 390 （260-480） min, with a median estimated blood loss of 400 （100-1 500） ml.This was one patient converted to open surgery .The mean postoperative hemoglobin and albumin of patients was 108.5±14.7 g/L and 29.5±3.7 g/L, respectively, both of which significantly reduced compared with pre-operative data （P〈0.01）.The median duration of hospital stay was 15 days.The median time for liquid in-take, abdominal drainage removal and ureteral stent removal was 4 days, 9 days and 2 months after surgery , respectively.Catheter was removed 2 weeks after laparoscopic orthotopic cystectomy .21 （33.3%） of 63 pa-tients suffered from perioperative complications .15 of 46 patients （32.6%） in ileal conduit group had com-plications including ileus （ 5, 1 of 5 need re-operation ） , lymphatic fistulas （ 5） , pulmonary infection （ 1） , pyelonephritis （1）, delirium （1）, anastomotic leak （1, re-operation was needed） and pneumothorax （1）. 2 of 9 patients （22.2%） in ureterocutaneostomy group had complications such as ileus （1） and lymphatic fistulas （1）.4 of 8 patients （50.0%） in orthotopic ileal neobladder group suffered from complications like ileus （2, 1 of 2 required re-operation）, lymphatic fistulas （1） and arrhythmia （1）. Conclusions LRC is technically feasible and safe .It reduces the estimated blood loss and postoperative complications .It is noteworthy to surgeons that serum albumin significantly reduced after LRC , nutrition should be kept balanced after surgery. Key words: Laparoscopes; Cystectomy; Bladder cancer; Complications

Sexual Function after Non-Nerve-Sparing Radical Cystoprostatectomy: A Comparison between Ileal Conduit Urinary Diversion and Orthotopic Ileal Neobladder Substitution

To compare the erectile function (EF) and sexual desire (SD) in men after radical cystoprostatectomy (RCP) who had either an ileal conduit urinary diversion or orthotropic ileal neobladder substitution. Eighty one sexually active men with bladder cancer were enrolled in this prospective study. After RCP according to patients' preferences they underwent either ileal conduit urinary diversion (n = 41) or orthotropic ileal neobladder substitution (n = 40). EF and SD were assessed using International Index of Erectile Function (IIEF) questionnaire. Patients were assessed at 4-week before surgery and were followed up at 1, 6, and 12-month postoperatively using the same questionnaire. Postoperatively the EF and SD domains deteriorated significantly in both groups, but in a small proportion of the patients submitted to ileal neobladder they gradually improved with time (P = 0.006). At 12-month postoperative period, 4 (9.8 %) and 14 (35.0 %) patients in ileal conduit and ileal neobladder groups were able to achieve erections hard enough for vaginal penetration and maintained their erection to completion of intercourse, respectively (P = 0.006). Among patients in the ileal conduit and ileal neobladder groups, additional 4 (9.8 %) and 7 (17.1 %) patients were able to get some erection, but were unable to maintain their erection to completion of intercourse (P = 0.02). At 12-month follow up period 24.4 % of the ileal conduit and 45.0 % of the ileal neobladder patients rated their sexual desire very high or high (P = 0.01). When performed properly, orthotopic ileal neobladder substitution after RCP offers better long-term results in terms of EF and SD.

Better Compliance Contributes to Better Nocturnal Continence With Orthotopic Ileal Neobladder Than Ileocolonic Neobladder After Radical Cystectomy for Bladder Cancer

To investigate, in a randomized controlled study, the degree of continence after the creation of orthotopic ileocolonic and ileal neobladders after cystectomy and to explore a possible mechanism for the difference in continence between these 2 types of orthotopic neobladder. From 2003 to 2007, 71 male patients underwent orthotopic lower urinary tract reconstruction with either an ileocolonic or ileal neobladder after radical cystectomy. The degrees of continence and voiding patterns were individually evaluated using urodynamic examinations and a detailed patient questionnaire. The abnormal upper tract was evaluated using intravenous urography and ultrasonography. Complete daytime continence was achieved in 90.9% and 89.4% of the patients and functional nocturnal continence 48.5% and 76.3% of patients in the ileocolonic neobladder and ileal neobladder groups, respectively. The urodynamic data showed that the initial volume of both the ileocolonic and the ileal neobladder appeared to not be significantly different statistically, although the compliance of the ileocolonic neobladder was lower than that of the ileal neobladder (P < .05). No difference was found in the parameters such as flow rate, urethral profile length, maximal urethral pressure, or neobladder neck pressure between the 2 neobladder types. Although the ileocolonic and ileal neobladders can both achieve a large initial volume, the ileal neobladder has an advantage in the aspect of obtaining satisfactory nocturnal continence because of its greater compliance compared with that of the ileocolonic neobladder.

Elevated urinary cytokine levels in patients undergoing ileal neobladder replacement compared with sigmoid neobladder replacement

The objective of this study was to examine the urinary cytokine levels for assessment of inflammatory conditions in patients with orthotopic neobladder. Urinary levels of IL-1beta, IL-6, and IL-8 were measured in 20 and 22 patients who underwent orthotopic neobladder replacement using ileum and sigmoid colon, respectively, and all cytokine levels greater than 5 pg/ml were defined as elevated. The outcomes were compared with respect to several parameters. The proportions of patients positive for urinary culture, pyuria, and bacteriuria in the ileal neobladder group were higher than those in the sigmoid neobladder group, but these differences were not significant. Urinary levels of IL-1beta, IL-6, and IL-8 in the ileal neobladder group were significantly greater than those in the sigmoid neobladder group. Furthermore, the incidences of elevated urinary levels of IL-1beta, IL-6, and IL-8 in both groups were not affected by age, postoperative period, residual urine volume or pyuria; however, the incidences of elevated urinary IL-6 levels significantly differed between patients with and without bacteriuria in the ileal neobladder group, while there was a significant difference in the incidences of elevated urinary IL-8 levels between patients with and without bacteriuria in the sigmoid neobladder group. These findings suggest that chronic inflammation was more frequently observed in patients with ileal neobladder than in those with sigmoid neobladder, and that IL-6 and IL-8 were involved in persistent bacteriuria in patients with ileal and sigmoid neobladder, respectively.

Comparison of the Complications and Urodynamic Parameters for Orthotopic Bladder Substitution with using Ileocolic or Ileal Segments after Radical Cystectomy

Purpose: The objective of this study was to compare the complications and urodynamic parameters of the patients who underwent orthotopic bladder substitution with using ileocolic or ileal segments after radical cystectomy for treating invasive bladder cancer. Materials and Methods: Between January 1990 and April 2006, 260 patients with invasive bladder cancer underwent radical cystectomy and construction of the urinary diversion; ileal conduit, indiana pouch, ileocolic neobladder, ileal neobladder were all done at St. Mary's Hospital. The mean age of the patient was 61.8 years (range: 46-86). The ratio of male and female was 88%/12%. Forty nine patients received an orthotopic ileocolic neobladder and 45 patients received an orthotopic ileal neobladder. The complications and urodynamic parameters were compared in both groups. Results: The orthotopic ileocolic neobladder after radical cystectomy for treating invasive bladder cancer has been performed between 1990 and 1996 and the orthotopic ileal neobladder has been performed between 1996 and 2006. Ileocolic neobladder related complications developed in 10 patients; neobladder leakage in 1 (2%), neobladder rupture in 1 (2%), stricture of the ureteroenteric anastomosis site in 4 (8.2%), and stricture of the urethral anastomosis site in 4 (8.2%). Ileal neobladder related complications developed in 11 patients; ureteroenteric stricture in 7 (15.5%), stricture of the urethral anastomosis site in 3 (6.6%) and acute pyelonephritis in 1 (2.2%). The results of the mean maximal flow rate and mean postvoid residual volume were better in the ileal neobladder group than those in the ileocolic neobladder group. Conclusions: There were no significant differences in complications between ileocolic neobladder and ileal neobladder. The maximal uroflow and residual urine volume of the ileal neobladder were superior to those of the ileocolic neobladder on urodynamic study. (Korean J Urol 2007; 48:494-499)

Long-Term Functional Outcomes of Ileal and Sigmoid Orthotopic Neobladder Procedures

Objectives To retrospectively compare the long-term functional outcomes of ileal and sigmoid orthotopic bladder replacements after radical cystectomy. Methods From 1990 to 2004, 123 male patients underwent orthotopic neobladder reconstruction after cystectomy; 75 underwent ileal neobladder (IN) and 48 sigmoid neobladder (SN) procedures. The observation period was 12.3 to 151.6 months (median 61.1). The voiding function of each patient was evaluated at three different observation periods: time 1, less than 5 years; time 2, 5 to 10 years; and time 3, more than 10 years after surgery. Results Almost every SN patient could void without assistance throughout the observation period. In contrast, the rate of spontaneous voiders was significantly low for the IN patients. Daytime continence was significantly worse in the SN than in the IN patients at time 2 ( P <0.01), and the difference in nighttime continence between the two groups was even larger during the first 10 years after surgery ( P <0.01). The postvoid residual urinary volume at time 2 was significantly larger in the IN than in the SN patients ( P <0.01). No significant change in neobladder capacity was observed for either procedure throughout the observation period. The mean serum creatinine level was stable for both groups throughout the follow-up period. Conclusions The IN and SN procedures result in different outcomes. The rate of spontaneous voiders was better in the SN group than in the IN group. The IN tends to provide better continence than the SN. In choosing a neobladder procedure, a proper understanding of the prospects of voiding functions is required.

Comparison of Orthotopic Sigmoid and Ileal Neobladders: Continence and Urodynamic Parameters

Objectives: The objective this of the study was to compare continence rates and urodynamic parameters among patients who had undergone orthotopic bladder substitution with sigmoid or ileal segments. Methods: Continent urinary reservoirs were constructed in 112 patients. Fifty patients received a sigmoid neobladder (SN) and 62 patients an ileal neobladder (IN). Thirty-four patients with an SN (mean age 64.4 years), and 20 with an IN (mean age 57.8 years) agreed to postoperative urodynamic evaluation at a median time after surgery of 18 and 37 months, respectively. Continence and urodynamic parameters were compared in both groups. Results: The average reservoir capacity of the SN (296 ml) was lower than the IN (546 ml). The majority of patients voided by the Valsalva maneuver and achieved good peak flow rates [SN group 16.6 (range 7–32) ml/s, IN group 25.5 (range 5–35) ml/s]. Of the patients with an SN 26 (76%) and with an IN 15 (75%) emptied to near completion with a post-void residual (PVR) of less than 100 ml. Daytime continence was achieved in 90% of IN patients and 85% of SN patients. Only 9% of patients with an SN and 60% of patients with an IN were continent at night. Conclusion: A neobladder constructed from detubularized ileum or sigmoid achieves adequate capacity with a satisfactory daytime continence rate. Nighttime incontinence in patients with IN can be at least partly explained by periods of high pressure due to neobladder contractions in combination with a relaxed sphincter during sleep. The low nighttime continence rate of the SN is probably related to its small functional capacity.

A multi-institutional study of orthotopic neobladders: functional results in men and women.

To analyse the incidence of diurnal incontinence (DI) and nocturnal incontinence (NI), the need for intermittent catheterization (IC),and the rate of ureteric obstruction (UO) among a group of men and women with ileal and colonic orthotopic neobladders in four countries. In all, 138 patients (113 men and 25 women) had an orthotopic neobladder constructed after radical cystectomy for carcinoma. The mean(range) age was 61.3 (28-76) years and the follow-up 41 (6-144) months. All patients underwent surgery by experienced surgeons associated with the Confederation of American Urology. A retrospective evaluation was designed to review the functional results and the incidence of UO. The technique of orthotopic neobladder construction was at each surgeon's discretion. Various detubularized bowel segments were used, including ileum, colon or sigmoid. Patients were followed by chart reviews and personal interviews at 1, 3 and 6 months after surgery and then every 6 months, and were evaluated by a physical examination, urine analysis, cytology and renal ultrasonography. An ileal or colonic neobladder was constructed in 74 and 64 patients, respectively. Five (7%), 23 (31%), 10 (14%) and 14(9.6%) with an ileal neobladder developed DI, NI, IC and UO, respectively; the respective values for patients with a colonic neobladder were eight (12%), 19 (30%), seven (11%)and 15 (12%). Statistical analysis by Fisher's exact test showed no significant differences between the ileal and colonic neobladder groups or with gender. Using this specific protocol for evaluating many men and women with ileal and colonic orthotopic neobladders showed no significant differences in the incidence of DI, NI, IC or UO. Neobladders constructed from detubularized bowel, irrespective of bowel segment(s) used, can provide satisfactory diurnal results. A moderate incidence of NI and UO continue to be a problem.

URODYNAMIC EVALUATION AND LONG-TERM RESULTS OF THE ORTHOTOPIC GASTRIC NEOBLADDER IN MEN

Orthotopic neobladders are most commonly formed from colon and/or small bowel segments. However, after excellent results were reported in children, we constructed gastric neobladders in select men who had undergone cystectomy. Although gastric neobladders in adults have been reported to have decreased capacity, to our knowledge neither long-term followup nor urodynamic parameters have been reported in these patients. Gastric neobladder was performed in 8 patients following cystectomy for malignancy in 7 and undiversion in 1. Average followup was 43 months and all patients underwent urodynamic evaluations an average of 9.1 months after surgery. Patients also completed an incontinence questionnaire. The gastric neobladder group was compared to a similar group of patients who underwent neobladder construction from either small bowel (Kock/Hautmann/Studer) or ileocecal segments (Mainz). The gastric neobladder group had significantly reduced mean bladder capacity compared to the ileal or ileocecal neobladder group (309 versus 551 cc, respectively, t = 0.001), while compliance was similarly decreased (27 versus 59 cc/cm. H2O, respectively, t = 0.04). Incontinence rates were greater in the gastric neobladder group (63%) compared to the ileal or ileocecal neobladder group (8% to 23%, t = 0.02). Complication rates were comparable. Revision or removal was required in 3 (38%) patients for severe incontinence, intractable dysuria and ureterogastric anastomotic stricture, respectively. Adult gastric neobladders as currently constructed are associated with poor urodynamic parameters and high incontinence rates. Routine use of gastric neobladders in adults is not recommended. They may be appropriate, especially as composites, in select cases such as renal failure or inadequate bowel length. The reasons for success in some patients and not in others are unknown.

A Comparison of Adjustments to Urinary Diversions: A Pilot Study

Cystectomy with urinary diversion is the treatment for many patients with bladder cancer. The ileal conduit continues to be an effective solution to the diversion problem, but it brings with it problems related to management and body image. The development of the orthotopic neobladder to the urethra is a recent effort to return the body to the most natural structure and function. This development, however, brings its own set of problems to be overcome. The purpose of this exploratory study was to examine the adjustments reported by male patients with ileal conduits and neobladder replacements. A questionnaire was mailed 10 to 30 months after operation to 30 patients who underwent ileal conduit and neobladder surgery. The questionnaire explored sickness-related dysfunction and adjustments the patients had to make after operation. Twenty-three patients (12 with ileal conduits and 11 with neobladders) responded to the questionnaire. There were no statistically significant differences in sickness impact scores between the ileal conduit and neobladder groups. Few patients with ileal conduits reported problems with the device. All the patients with neobladders reported some continued incontinence, primarily at night. All the patients reported erectile dysfunction, but few had sought treatment for this problem. The patients with ileal conduits reported impact on their social activities more frequently. Future research with a larger sample is needed, but this pilot study suggests that health care workers can do more to facilitate the adjustment to loss of sexual function and social interaction.

Continence after Radical Cystoprostatectomy and Total Bladder Replacement: A Urodynamic Analysis

Urodynamic evaluation was performed in 10 patients after radical cystoprostatectomy and continent urethral diversion with detubularized ileum and in 13 patients continent after radical prostatectomy. In both groups surgical techniques were modified to optimize preservation of the periurethral tissue at the prostatic apex. For the ileal neobladder group 9 patients (90%) were completely continent and 1 (10%) noticed moderate nocturnal incontinence. The urethral sphincteric mechanism was well preserved in these patients, with no significant difference between the 2 groups in mean functional urethral length (3.8 ± 0.6 versus 3.6 ± 0.8cm., p = 0.55) or maximal urethral closure pressure (87 ± 34 versus 74 ± 20cm. water, p = 0.26). Tubularization of the bladder or neobladder above the level of the external sphincter was noted in both groups. Continence after radical cystoprostatectomy with continent urethral diversion and after radical prostatectomy is dependent upon an intact urethral sphincteric mechanism as well as a compliant, low pressure reservoir, either bladder or a bladder substitute. Urinary incontinence after total bladder replacement with detubularized ileum can be minimized by preserving as much of the distal urethral sphincter as possible. This can be done by careful dissection of the prostatic apex, performed under direct vision, with an understanding of the anatomy of the urethral sphincter and its innervation.