Ileal Orthotopic Bladder Substitution Research Articles

The cause analysis of benign uretero-ileal anastomotic stricture after radical cystectomy and urinary diversion.

Benign uretero-ileal anastomotic stricture (UIAS) is a major complication following radical cystectomy (RC) and ileal orthotopic bladder substitution, and it can occur in combination with other complications. But risk factors for patients with UIAS have not been well described. We retrospectively reviewed 198 patients treated with RC for bladder cancer from 2014 to 2019 at the Zhejiang Provincial People's Hospital. Patient demographic and clinical variables were examined to determine the risk factors associated with UIAS by univariate and multivariate logistic regression analysis. A total of 180 patients into the group standards and in all 360 uretero-ileal anastomoses. Among the above cases, 22 patients developed UIAS, including 10 cases of left UIAS, nine cases of right UIAS, and three cases of bilateral UIAS. There was no difference in demographic, operative, or perioperative variables between patients with and without UIAS. In a multivariate analysis, after adjusting for gender, age, surgical methods, and underlying diseases, intraoperative or postoperative blood transfusion (HR = 0.144, P <0.01), postoperative urinary tract infection (HR = 3.624, P <0.01), and extracorporeal bladder anastomosis (HR = 3.395, P = 0.02) significantly increased the risk of UIAS. In our experience, intraoperative or postoperative blood transfusion, postoperative urinary tract infection, and extracorporeal neobladder anastomoses increased the risk of UIAS after radical cystectomy and ileal orthotopic bladder substitution surgery. Further studies with larger samples are necessary to validate this result.

Use of ileal bypass in the surgical management of two rare cases of ileal-neobladder fistula in patients who underwent radical cystectomy

An entero-neovesical fistula (ENF) is a rare troublesome complication of an orthotopic ileal bladder substitution. We report on a novel, safe technique to close ileal neovesical fistulas without extensive adhesiolysis using an NK-stapler (ENDOPATH® ENDOCUTTER ETS; Johnson & Johnson, Cincinnati, OH, USA). We treated two cases of postoperative ENF after orthotopic ileal bladder substitution for radical cystectomy. Case 1 was a 63-year-old male with occasional fecaluria, and Case 2 was a 73-year-old male who experienced continuous fecaluria.Surgical procedureAfter laparotomy, we mobilized the ascending colon to bypass the anastomosis of the primary surgery by an ileo-ileal, ileo-ascending colon anastomosis. The distance between the fistula and bypass was about 10 cm. We made tunnels in the mesentery between the bypass and fistula, without damaging blood vessels, to insert the jaw of the NK-stapler. We closed the afferent and efferent loops using NK-staplers (45 mm ×2), followed by a Lembert anastomosis covering the stapler's suture lines. They were discharged on the ninth and seventh postoperative days, respectively. In Case 1, we experienced recanalization of the fistula after three postoperative months and required second closure with the same procedure was needed. They have not experienced any symptoms of ENF since. This technique is worth considering for the surgical treatment of ENF because it does not require unnecessary dissection and can ultimately achieve fistula closure.

A new ureteroileal anastomosis technique in modified ileal orthotopic bladder substitution after radical cystectomy

BackgroundThe aim of this study is to describe a modified technique in ileal orthotopic bladder substitution with a new ureteroileal anastomosis.Case presentationAfter a classic open radical cystectomy with bilateral pelvic lymphadenectomy was performed extraperitoneally, a 56-cm ileal segment was used to construct the spheroidal shape bladder substitution. The 8-cm long proximal and distal ends of the ileal segment were used as afferent limbs. Two-centimeter ileal segments of afferent limbs were detubularized and transversally tubularized. The elongated ileal tube was anastomosed with the ureter in an end-to-end fashion. The pathway of the ureteroileal anastomosis was placed between the abdominal cutaneous fat and the anterior rectus muscular sheath. Perioperative data and long-term functional outcomes were assessed. Between December 2011 and December 2015, seven male patients underwent this procedure with a median 46 (30–77) months follow-up in our hospital. There was no difference between preoperative and postoperative estimated glomerular filtration rates (Z = − 1.693, P = 0.09). One of 14 sides had ureteroileal anastomotic stenosis; two of 14 sides in one patient had ureteroileal anastomotic stenosis caused by invasion of pelvic recurrence 15 months postoperatively. Reflux was completely prevented by placing pressure on the corresponding point on the abdominal surface when voiding urine in all patients.ConclusionsWe describe a feasible technique modification in detail, which provides some advantages for effective anti-reflux by mechanical finger pressing and abdominal contraction, a low incidence of stricture, and ease for a secondary operation in the long-term follow-up period.

MP41-17 SHOULD ORTHOTOPIC BLADDER SUBSTITUTION BE OMITTED IF PRE-CYSTECTOMY BIOPSIES OF THE PROSTATIC URETHRA (MALE) OR BLADDER NECK (FEMALE) ARE POSITIVE?

You have accessJournal of UrologyBladder Cancer: Invasive III1 Apr 2018MP41-17 SHOULD ORTHOTOPIC BLADDER SUBSTITUTION BE OMITTED IF PRE-CYSTECTOMY BIOPSIES OF THE PROSTATIC URETHRA (MALE) OR BLADDER NECK (FEMALE) ARE POSITIVE? Bernhard Kiss, Ioannis Giannakis, Furrer Marc, Patrick Wuethrich, Fiona Burkhard, Gerorge Thalmann, and Beat Roth Bernhard KissBernhard Kiss More articles by this author , Ioannis GiannakisIoannis Giannakis More articles by this author , Furrer MarcFurrer Marc More articles by this author , Patrick WuethrichPatrick Wuethrich More articles by this author , Fiona BurkhardFiona Burkhard More articles by this author , Gerorge ThalmannGerorge Thalmann More articles by this author , and Beat RothBeat Roth More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1304AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES When considering an orthotopic bladder substitution (OBS) preoperative biopsies of the prostatic urethra (in male) or bladder neck (in female) are usually performed to evaluate a potential involvement of the urethra. In case of positive preoperative biopsies, a non-orthotopic diversion is recommended in order to avoid positive urethral margin and to prevent local recurrence. Our aim was to investigate the influence of positive preoperative biopsies on local recurrence, cancer- specific (CSS) and overall survival (OS) after OBS. METHODS Retrospective analysis of 776 consecutive patients (77% [601/776] MIBC; 23% [175/776] recurrent NMIBC) who had undergone radical cystectomy with ileal OBS between 04/1985 and 01/2016 at our institution. RESULTS 94% (731/776) of patients had negative (Group A) and 6% (43/776) of patients (36 male, 7 female) had positive (Cis: 32/43 [74%]; pTa/pT1 G3: 11/43 [26%]; Group B) pre-cystectomy biopsies. Median follow-up was 71.5mts (range: 1-323). 32% (251/776) of patients experienced local and/or distant recurrences: 12% (31/251) urethral (23/31 CIS, 5/31 pTa, 3/31 ≥ pT1),14% (34/251) local recurrences other than urethral, and 74% (186/251) distant metastases. Urethral recurrence developed significantly more often (p<0.001) in Group B (13/43 [30%]) than in Group A (18/733 [2.5%]). Local recurrences other than urethral did not differ between the two groups (31/733 [4%] in Group A vs. 3/43 [7%] in Group B; p=0.4). Seventy-four percent (23/31) of patients with urethral recurrence could be managed successfully by local treatment whereas salvage urethrectomy and conversion of the urinary diversion was necessary in 26% (8/31). Despite the significantly higher urethral recurrence rates in Group B, CSS and OS were similar in both groups (70% and 61% in Group A vs 70% and 67 % in Group B, respectively; Figure 1). CONCLUSIONS Although positive biopsies of the prostatic urethra or the bladder neck prior to OBS increase the rate of urethral recurrences this does not translate into decreased CSS and OS. Most urethral recurrences could be managed successfully with local treatment; thus, OBS is an option in highly selected patients with positive, non-invasive preoperative biopsies provided that patients have regular follow-up including urethral washout cytology. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e534 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Bernhard Kiss More articles by this author Ioannis Giannakis More articles by this author Furrer Marc More articles by this author Patrick Wuethrich More articles by this author Fiona Burkhard More articles by this author Gerorge Thalmann More articles by this author Beat Roth More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Patients with an Orthotopic Low Pressure Bladder Substitute Enjoy Long-Term Good Function

Orthotopic bladder substitution has been performed on a regular basis for more than 30 years and yet data on long-term functional outcomes are still lacking. We evaluated 181 men and 19 women who underwent radical cystectomy and urinary diversion with ileal orthotopic bladder substitution from 1985 to 2004 and who had 10 years or more of followup. Median age at radical cystectomy was 63 years (IQR 57-69). Median followup was 167 months (IQR 137-206). Daytime and nighttime continence rates peaked 24 months postoperatively and decreased slightly thereafter during almost 2 decades. At 10, 15 and 20 years daytime continence rates were 92%, 90% and 79%, and nighttime continence rates were 70%, 65% and 55%, respectively. During the day and at night fewer than 3% and 10% of patients, respectively, had urine loss 100 ml or greater at any time 10 years or longer after surgery. At 10 and 20 years 11 of 200 patients (6%) and 1 of 29 (3%), respectively, had to perform clean intermittent self-catheterization. After an initial postoperative decrease in the estimated glomerular filtration rate the subsequent decrease was less than 1 ml/minute/1.73 m(2) per year. A total of 81 complications were observed in 42 of the 200 patients (21%) 10 years or longer after radical cystectomy with pyelonephritis as the most frequent cause. Patients who survive up to 20 years after radical cystectomy and diversion with an ileal orthotopic bladder substitution may enjoy satisfactory urinary continence and retain the ability to void spontaneously while experiencing no more than a physiological decrease in renal function.

Orthotopic Ileal Bladder Substitution in Women: Factors Influencing Urinary Incontinence and Hypercontinence

BackgroundUrinary incontinence or the inability to void spontaneously after ileal orthotopic bladder substitution is a frequent finding in female patients. ObjectiveTo evaluate how hysterectomy and nerve sparing affect functional outcomes and whether these relate to pre- and postoperative urethral pressure profile (UPP) results. Design, setting, and participantsProspectively performed pre- and postoperative UPPs of 73 female patients who had undergone cystectomy and bladder substitution were correlated with postoperative voiding and continence status. Outcome measurements and statistical analysisOutcome analyses were performed with the Kruskal-Wallis test, Wilcoxon-Mann-Whitney, or two-group post hoc testing with the Bonferroni correction. Chi-square or Fisher exact tests were applied for the categorical data. Results and limitationsOf postoperatively continent or hypercontinent patients, 22 of 43 (51.2%) had the uterus preserved; of incontinent patients, only 4 of 30 (13.3%, p<0.01) had the uterus preserved. Of postoperatively continent or hypercontinent patients, 27 of 43 patients (62.8%) had bilateral and 15 of 43 (34.9%) had unilateral attempted nerve sparing. In incontinent patients, 11 of 30 (36.7%) had bilateral and 16 of 30 (53.3%) had unilateral attempted nerve sparing (p=0.02). When compared with postoperatively incontinent patients, postoperatively continent patients had a longer functional urethral length (median: 32mm vs 24mm; p<0.001), a higher postoperative urethral closing pressure at rest (56cm H2O vs 35cm H2O; p<0.001) as well as a higher preoperative urethral closing pressure at rest (74cm H2O vs 47.5cm H2O; p=0.01). The main limitation was the limited number of patients. ConclusionsIn female patients undergoing radical cystectomy and bladder substitution, preservation of the uterus and attempted nerve sparing results in better functional outcomes. The preoperative UPPs correlate with postoperative voiding and continence status and may predict which patients are at a higher risk of functional failure after bladder substitution. Patient summaryIf preservation of the urethra's innervation is not possible during cystectomy, poor functional results with bladder substitutes are likely.

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

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.

Late Recurrence after Radical Cystectomy: Patterns, Risk Factors and Outcomes

We evaluated the outcome in patients with late recurrence of urothelial carcinoma after radical cystectomy. We identified 2,091 patients who underwent radical cystectomy at our institution between 1980 and 2006. Survival was estimated using the Kaplan-Meier method and compared based on recurrence timing (less than 5 years vs 5 or greater) and location (urothelial vs nonurothelial) using the log rank test. Cox proportional hazard regression models were used to evaluate variables associated with late recurrence and death from bladder cancer. Median postoperative followup was 16.6 years. Late recurrence was identified in 82 patients (3.9%). On multivariate analysis younger age (p = 0.0008), nonmuscle invasive disease (p = 0.01) and prostatic urethral involvement (p <0.0001) were significantly associated with an increased risk of late recurrence. Five-year post-recurrence cancer specific survival was significantly worse after recurrence within 5 years from radical cystectomy vs after late recurrence (17% vs 37%, p = 0.001). Patients with nonurothelial late recurrence had adverse 5-year cancer specific survival compared to those with urothelial late recurrence (19% vs 67%, p <0.0001). On multivariate analysis younger patient age (HR 1.01, p = 0.003), muscle invasive disease (HR 1.31, p <0.0001) and nonurothelial recurrence site (HR 2.76, p <0.0001) but not time to recurrence (p = 0.38) were associated with a significantly increased risk of death from bladder cancer following recurrence after radical cystectomy. Late recurrence is uncommon after radical cystectomy. Younger patient age, nonmuscle invasive disease and prostatic urethral involvement were associated with a significantly increased risk of late recurrence. Interestingly, time to recurrence was not associated with a subsequent risk of patient death.

Stricture of the Afferent Isoperistaltic Tubular Segment: A Late and Rare Cause of Bilateral Dilation of the Upper Urinary Tract After Ileal Bladder Substitution

To evaluate the etiology and treatment of bilateral hydronephrosis not responding to bladder substitute drainage after ileal bladder substitution using an afferent isoperistaltic tubular segment. A retrospective analysis was performed of a consecutive series of 739 patients who had undergone bladder substitution from April 1985 to August 2012. Of the 739 ileal bladder substitute patients, 10 (1.4%) developed bilateral hydronephrosis unresponsive to complete bladder substitute drainage. The etiology was stenosis of the afferent isoperistaltic tubular segment. The median interval to presentation was 131 months (range 45-192). The incidence of afferent tubular segment stenosis was significantly higher in the 61 ileal bladder substitute patients with recurrent urinary tract infection (9 [15%]) than in the 678 without recurrent urinary tract infection (1 [0.15%]; P <.001). Urine cultures revealed mixed infections (34%), Escherichia coli (18%), Staphylococcus aureus (13%), enterococci (11%), Candida (8%), Klebsiella (8%), and others (8%). Seven patients underwent 10 endourologic interventions, only 1 of which was successful (10%). After failed endourologic treatment, 7 open surgical revisions with resection of the stricture were performed, with all 7 (100%) successful. Bilateral dilation of the upper urinary tract after ileal orthotopic bladder substitution unresponsive to complete bladder substitute drainage is likely to be caused by stenosis of the afferent isoperistaltic tubular segment. The stenosis occurs almost exclusively in patients with long-lasting, recurrent urinary tract infection and can develop many years after the ileal bladder substitution. Minimally invasive endourologic treatment is usually unsuccessful; however, open surgical revision offers excellent results.

Survival Impact of Followup Care after Radical Cystectomy for Bladder Cancer

Due to substantial variation in patient followup after radical cystectomy for bladder cancer, we sought to understand the effect of urine and laboratory tests, physician visits and imaging on overall survival. We analyzed a cohort of patients treated in the fee for service Medicare population from 1992 through 2007 using Surveillance Epidemiology and End Results (SEER)-Medicare data. Using propensity score analysis, we assessed the relationship between time and geography standardized expenditures on followup care and overall survival during 3 postoperative periods, including perioperative (0 to 3 months), early followup (4 to 6 months) and later followup (7 to 24 months). Using instrumental variable analysis, we assessed the overall survival impact of the quantity of followup care by category, including physician visits, imaging, and laboratory and urine tests. We found no improvement in survival due to followup care in the perioperative and early followup periods. Receiving followup care during later followup was associated with improved survival in the low, middle and high expenditure tertiles (HR 0.23, 95% CI 0.15-0.35, HR 0.27, 95% CI 0.18-0.40 and HR 0.47, 95% CI 0.31-0.71, respectively). Instrumental variable analysis suggested that only physician visits and urine testing improved survival (HR 0.96, 0.93-0.99 and 0.95, 0.91-0.99, respectively). Followup care after radical cystectomy in the later followup period was associated with improved survival. Physician visits and urine tests were associated with this improved survival. Our results suggest that aspects of followup care significantly improve patient outcomes but imaging could be done more judiciously after cystectomy.

1618 IMPACT OF URINARY DIVERSION ON CANCER SPECIFIC-SURVIVAL IN PATIENTS WITH BLADDER CANCER AND PATHOLOGIC POSITIVE LYMPH NODES

You have accessJournal of UrologyBladder Cancer: Invasive (II)1 Apr 20131618 IMPACT OF URINARY DIVERSION ON CANCER SPECIFIC-SURVIVAL IN PATIENTS WITH BLADDER CANCER AND PATHOLOGIC POSITIVE LYMPH NODES Federico Pellucchi, Lorenzo Rocchini, Carmen Maccagnano, Giuseppe Zanni, Giovanni La Croce, Marco Moschini, Giorgio Gandaglia, Patrizio Rigatti, Francesco Montorsi, and Renzo Colombo Federico PellucchiFederico Pellucchi Milan, Italy More articles by this author , Lorenzo RocchiniLorenzo Rocchini Milan, Italy More articles by this author , Carmen MaccagnanoCarmen Maccagnano Milan, Italy More articles by this author , Giuseppe ZanniGiuseppe Zanni Milan, Italy More articles by this author , Giovanni La CroceGiovanni La Croce Milan, Italy More articles by this author , Marco MoschiniMarco Moschini Milan, Italy More articles by this author , Giorgio GandagliaGiorgio Gandaglia Milan, Italy More articles by this author , Patrizio RigattiPatrizio Rigatti Milan, Italy More articles by this author , Francesco MontorsiFrancesco Montorsi Milan, Italy More articles by this author , and Renzo ColomboRenzo Colombo Milan, Italy More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.3168AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To examine the impact of urinary diversion on cancer-specific survival (CSS) in patients with muscle-invasive bladder cancer treated by radical cystectomy (RC) and found with pathologic positive nodes (N+) METHODS Overall, 210 consecutive patients submitted to RC at our institution between 1999 and 2011 for muscle-invasive bladder cancer and positive lymph node metastases were retrospectively evaluated. All patients received either an ileal neobladder or an ileal conduit as the urinary diversion. Complete clinical, pathological data (including T stage, grade, age, gender, diversion type) and follow-up were available for 133 patients (63%). The CSS probability using the Kaplan-Meier method, was investigated. Univariate and multivariate Cox regression analyses were adopted to assess the effect of urinary diversion on CSS. RESULTS Overall, mean age was 68.2 yr (median: 68; range: 48-87). Of the 133 patients, 24 (18%) patients were female and 109 (82%) were male. All patients were found with high grade disease. The pathologic stage distribution was pT2, pT3 and pT4 in 21 (15.7%), 69 (52%) and 43 (32.3%) cases, respectively. The pathologic nodal status (according to the Sixth Edition of TNM classification) was defined as pN1 in 43 (32.4%), and pN2 in 90 (67.6%). An ileal conduit and an ileal neobladder was completed in 72 (54.2%) and 61 (45.8%) patients, respectively. Mean follow-up time was 71 months (median: 51; range 1-125). The overall 5-year CSS was 55.7%. When analyses were stratified according to urinary diversion, the 5-year CSS was documented to be 56.3%, 54.7% for the ileal conduit and the orthotopic bladder substitution, respectively. At multivariate analyses, both age (HR 1.03, p=0.01) and number of positive nodes (HR 1.04, p=0.02) were associated with worst CSS. After adjustement for potential confounders, ileal conduit and ileal neobladder showed similar CSS (p=0.9). No statistically significant differences could be observed for the remaining variables (all p>0.2). CONCLUSIONS In patients with pathologic positive nodal status submitted to ileal conduit or orthotopic bladder substitution after RC, a similar cancer specific survival may be expected. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e665 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Federico Pellucchi Milan, Italy More articles by this author Lorenzo Rocchini Milan, Italy More articles by this author Carmen Maccagnano Milan, Italy More articles by this author Giuseppe Zanni Milan, Italy More articles by this author Giovanni La Croce Milan, Italy More articles by this author Marco Moschini Milan, Italy More articles by this author Giorgio Gandaglia Milan, Italy More articles by this author Patrizio Rigatti Milan, Italy More articles by this author Francesco Montorsi Milan, Italy More articles by this author Renzo Colombo Milan, Italy More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Long-term Renal Function After Urinary Diversion by Ileal Conduit or Orthotopic Ileal Bladder Substitution

BackgroundData on long-term renal function are scarce for ileal conduit diversion (ICD) and even rarer for orthotopic ileal bladder substitution (BS). ObjectiveExplore the changes in renal function of patients who lived ≥10 yr with an ICD or BS and determine the risk factors contributing to renal function deterioration. Design, setting, and participantsFifty consecutive ICD patients and 111 consecutive BS patients who lived ≥10 yr after undergoing surgery between January 1985 and December 2000 were retrospectively analyzed. MeasurementsThe glomerular filtration rate (GFR) was calculated with the Modification of Diet in Renal Disease (MDRD) equation before and 10 yr after surgery. Decreased renal function was defined as a decrease in GFR >10ml/min per 1.73 m2 in 10 yr. Results and limitationsMedian GFR values in patients with ICD or BS decreased from 65.5 (range: 23–90) to 57 (range: 7–100) ml/min per 1.73 m2 and from 68 (range: 33–106) to 66 (range: 16–100) ml/min per 1.73 m2, respectively. Eighteen ICD patients (36%) and 23 BS patients (21%) had deteriorating renal function. Seven of 12 ICD patients with obstruction (ureteroileal stricture, stomal stenosis/parastomal hernia) (58%) had renal function deterioration, as did 17 of 46 BS patients with obstruction (ureteroileal/nipple stricture and/or bladder outlet obstruction) (37%). Logistic regression analysis confirmed that obstruction was the leading, and an independent, risk factor for renal function deterioration for both ICD patients (p=0.045) and BS patients (p=0.002). Patients with diabetes or hypertension were significantly more likely to have deterioration of renal function if they had ICD (p=0.002 and p=0.05, respectively). The limitation of the study is its retrospective nature and its composition that included many patients who did not survive 10 yr. ConclusionsUrinary tract obstruction was the leading cause of long-term renal function impairment, regardless of whether the patient had ICD or BS. ICD patients with predisposing risk factors, such as diabetes or hypertension, were at increased risk for impaired renal function.

Bowel Function Remains Subjectively Unchanged After Ileal Resection for Construction of Continent Ileal Reservoirs

BackgroundConstruction of a continent catheterizable urinary reservoir or an orthotopic bladder substitute requires substantial bowel resection, which can cause changes in bowel transit time. The reported incidence of chronic diarrhea after ileocecal resection is about 20%. Studies assessing bowel function after resection of 55–60cm of ileum without compromising the ileocecal valve are scarce, and long-term results have not been reported. ObjectiveProspective assessment of possible changes in bowel function (eg, stool frequency, diarrhea) and the potential impact on quality of life in patients with resection of small bowel for urinary diversion. Design, setting, and participantsA total of 82 patients who underwent radical cystectomy, extended lymph node dissection, orthotopic ileal bladder substitution, or heterotopic continent cutaneous urinary diversion with a follow-up >1 yr after surgery were prospectively evaluated. Patients who had a neurogenic bladder disorder, had undergone previous radiotherapy, or had not completed the questionnaire were excluded from the study. The validated Gastrointestinal Quality of Life Index was completed by the patients preoperatively and at 3, 12, and 24 mo postoperatively. Five points concerning bowel function (frequent bowel movement, urgent bowel movement, diarrhea, constipation, or uncontrolled stool loss) were assessed, and the median scores were compared pre- and postoperatively. Results and limitationsMost patients (≥80%) were rarely or never troubled by frequent or urgent bowel movements, diarrhea, constipation, or uncontrolled stool loss preoperatively. In the case of stool frequency, a remarkable shift from rarely to never was observed postoperatively at 3, 12, and 24 mo. Scores for constipation and uncontrolled stool loss remained unchanged throughout the whole time period. For urgent bowel movements the median preoperative score of 4 decreased to 3 at 3 mo and 12 mo and returned to 4 at 24 mo. For diarrhea the preoperative score of 4 decreased to 3 at 3 mo and 24 mo and remained at 4 after 12 mo. ConclusionsNo relevant changes in bowel movements were found after resection of 55–60cm of ileum if the terminal ileum and the ileocecal valve were left intact.

980 URETHRAL RECURRENCE AFTER RADICAL CYSTECTOMY AND ILEAL ORTHOTOPIC BLADDER SUBSTITUTION: CAN THE URETHRA BE SPARED?

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease1 Apr 2011980 URETHRAL RECURRENCE AFTER RADICAL CYSTECTOMY AND ILEAL ORTHOTOPIC BLADDER SUBSTITUTION: CAN THE URETHRA BE SPARED? Gianluca Giannarini, Thomas M. Kessler, Bernhard Kiss, Urs E. Studer, and George N. Thalmann Gianluca GiannariniGianluca Giannarini Bern, Switzerland More articles by this author , Thomas M. KesslerThomas M. Kessler Bern, Switzerland More articles by this author , Bernhard KissBernhard Kiss Bern, Switzerland More articles by this author , Urs E. StuderUrs E. Studer Bern, Switzerland More articles by this author , and George N. ThalmannGeorge N. Thalmann Bern, Switzerland More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.991AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The optimal management of urethral recurrence after radical cystectomy and orthotopic bladder substitution is still a matter of debate. We assessed the long-term outcome of patients with urethral recurrence after radical cystectomy and ileal orthotopic bladder substitution. METHODS We retrospectively analyzed 495 consecutive patients with bladder carcinoma and no neoadjuvant therapy who underwent extended pelvic lymph node dissection and radical cystectomy with ileal orthotopic bladder substitution. Preoperative paracollicular (men) or bladder neck (women) biopsies were negative for carcinoma. All patients were prospectively followed with a standardized protocol, including urethral cytology 6-monthly for 2 years, then annually for 3 years. In case of positive cytology, urethroscopy with biopsy and staging for metastases were performed. Based on recurrence stage, patients were treated with endourethral bacillus Calmette-Guérin (BCG) (6 weekly instillations with 81 mg in 150 ml saline), transurethral resection plus endourethral BCG, urethrectomy or systemic chemotherapy. Urethral recurrence rate, detection rate by cytology, urethra-preservation rate after endourethral BCG and overall survival with preserved urethra were the study outcome measures. RESULTS After a median follow-up of 45 months (range 3–250) urethral recurrence was diagnosed in 24/495 (4.8%) patients, in 21 (88%) by cytology and in 3 (12%) by hematuria. Carcinoma in situ (Tis), Ta/T1 and T2 recurrences were detected in 13, 7 and 4 patients, respectively. All patients with Tis were treated with endourethral BCG, and 6 of 7 with Ta/T1 recurrence with transurethral resection plus endourethral BCG. Urethrectomy was performed in 1 patient with T2 recurrence, while systemic chemotherapy was given to 4 patients (1 with Ta and 3 with T2 recurrence) due to concomitant metastases. The urethra could be preserved in 11/13 patients with Tis and 3/6 with Ta/T1 recurrence treated with endourethral BCG. Six of 13 patients with Tis, 1/7 with Ta/T1 recurrence and 0/4 with T2 recurrence are still alive with preserved urethra and no evidence of disease. CONCLUSIONS With routine cytology approximately 90% of urethral recurrences can be detected. In patients with Tis recurrence, the urethra should be primarily spared, since endourethral BCG is successful in most cases. On the contrary, in patients with Ta/T1 recurrence urethrectomy is usually required. Patients with T2 recurrence have a poor prognosis due to frequent concomitant metastases. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e395 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gianluca Giannarini Bern, Switzerland More articles by this author Thomas M. Kessler Bern, Switzerland More articles by this author Bernhard Kiss Bern, Switzerland More articles by this author Urs E. Studer Bern, Switzerland More articles by this author George N. Thalmann Bern, Switzerland More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Do patients benefit from routine follow-up to detect recurrences after radical cystectomy and ileal orthotopic bladder substitution?

Do patients benefit from routine follow-up to detect recurrences after radical cystectomy and ileal orthotopic bladder substitution?

Radical cystectomy and orthotopic ileal bladder substitution with serous lined extramural ureteral reimplantation: Report of 8 cases

We review the functional and oncoloic outcomes of radical cystectomy and orthotog pic ileal bladder substitution with serous lined extramural ureteral reimplantation. From 1985 to 2009 a total of 125 male patients (mean age 62.5 years, range 37 to 74) underwent orhotopic ileal bladder substitute at the urological Clinic in Belgrade. Of these, 8 patients underwent modified technique with serous lined extramural ureteral reimplantation. The median follow-up (available for 88 patients) period was 30 (2-72) months. Perioperative lethality was nil. Modified operative technique was associated with low postoperative complication rates and without ureteric implantation site stenosis, reflux or deteriorization of renal function. All patients had satisfied day and night continence rates. The serous-lined extramural ureteral reimplantation is an attractive technique regarding its safety, versality and functional outcome. It is especially favorable for reimplantation to ureters of various calibers as well as dilated ureters.

Partial Orchiectomy for Presumed Malignancy in Patients With a Solitary Testis Due to a Prior Germ Cell Tumor: A Large North American Experience

Partial orchiectomy is becoming more accepted for indications such as a metachronous germ cell tumor due to reported oncological control, and minimal functional, physical and psychological morbidity. Most data originate from Europe. Thus, we reviewed our North American experience with such men who underwent partial orchiectomy for a presumed contralateral testicular malignancy. We identified demographic, clinical, pathological and outcome data on men in our institutional database who underwent partial orchiectomy for presumed testicular malignancy from 1994 to 2009 and had a prior germ cell tumor. Patients were followed with examination, markers and imaging. We identified 27 men, of whom 17 (63%) had malignancy, including seminoma in 9, teratoma in 3, embryonal lesion in 1, Leydig cell tumor in 3 and carcinoma in situ in 1, and 10 (37%) had benign lesions. Frozen section was accurate, no positive margins were reported and all tumors were stage 1. Carcinoma in situ was found in 9 patients (53%). No perioperative complications were recorded. Management after partial orchiectomy was observation in 12 of 17 cases. Two patients underwent completion orchiectomy for local recurrence of carcinoma in situ only, including chemotherapy in 1. A patient with seminoma elected radiation and 1 required retroperitoneal lymph node dissection for teratoma. The remaining 5 patients with carcinoma in situ were surveilled. Of the men 31% required testosterone substitution. All patients were disease free at a median 5.7-year followup with no local recurrences. Partial orchiectomy is an option to decrease morbidity in men with a metachronous germ cell tumor. Clearly a definite benefit of partial orchiectomy is that a significant proportion of patients with suspicious testicular lesions did not have malignancy and were definitively treated with an organ sparing approach. However, partial orchiectomy is potentially associated with the need for adjuvant treatment and androgen substitution, which should be discussed with all patients.

47 Robotic assisted bilateral nerve sparing cystoprostatectomy combined with ileal orthotopic bladder substitution achieves good functional results

47 Robotic assisted bilateral nerve sparing cystoprostatectomy combined with ileal orthotopic bladder substitution achieves good functional results