Incontinent Urinary Diversion Research Articles

Follow-up after urinary diversion

Radical cystectomy is currently the standard of care for muscle-invasive bladder cancer. Different parts of the small and large intestines can be utilized for continent and incontinent urinary diversion. The postoperative follow-up after urinary diversion should consider functional, metabolic and oncological aspects. The functional follow-up of (continent) urinary diversion includes stenosis, emptying disorders or incontinence. The oncological follow-up should focus on the detection of local, urethral and upper tract recurrences as well as distant metastases. As 90% of the tumor recurrences occur during the first 3years, aclose follow-up should be carried out during this period. Metabolic disturbances, such as vitamin B12 and bile acid deficits, acidosis and disorders of calcium metabolism can also occur during long-term follow-up. The metabolic follow-up should consider the metabolic consequences of the parts of the intestines utilized for the urinary diversion.

Urinary diversion in old patients(80+ years)

With increasing life expectancy there is also an increased need for the management of older (≥ 80years) patients with the diagnosis of muscle-invasive bladder cancer. Radical cystectomy with urinary diversion is the state of the art treatment (with neoadjuvant chemotherapy, as long as the patient is fit enough). Choosing the best urinary diversion with respect to morbidity compared to functionality and quality of life remains achallenge in these patients. Physical age alone is not decisive for making a decision. A thorough preoperative assessment of medical features, physical and cognitive impairments is more important. Older patients are generally provided with an ileal conduit as an incontinent urinary diversion, as the intervention involves reduced operating times and complexity compared to continent urinary diversions; however, in the case of good health status with an adequate life expectancy and sufficient compliance, continent diversions may be considered even in aged candidates. In the case of multimorbid patients with a high perioperative risk, ureterostomy with permanent ureteric stents is an important alternative. Most importantly, a thorough preoperative counselling enables patients to reach an informed decision.

Multicenter evaluation of complex urinary diversion for renal transplantation: outcomes of complex surgical solutions

PurposeAn abnormal lower urinary tract poses significant challenges for transplant surgeons. Besides the ureteral anastomosis to an ileal conduit, there are diverse complex reconstructive solutions. Due to its rarity, standardization and teaching of complex urinary diversion is extremely difficult.MethodsThe indications and outcomes of complex urinary diversions after kidney transplantation (KT) were retrospectively investigated at eight urologic transplant centers including a current follow-up.ResultsOf 37 patients with 21 (56%) males, vesicoureteral reflux (24%), spina bifida (22%), and glomerulonephritis (12%) were the most common causes of terminal renal failure. In 30 (81%) patients, urinary diversion was performed before KT, at a median of 107.5 (range, 10; 545) months before. Transplantations were held at a median patient age of 43 (10; 68) years, including six (16%) living donations. Urinary diversion was modified during 12 (32%) transplantations. After KT, the ileal conduit was the most common incontinent urinary diversion in 25 (67%) patients; a Mainz pouch I and bladder augmentation were the most frequent continent diversions (each n = 3). At a median follow-up of 120 months (range 0; 444), 12 (32%) patients had a graft failure with a 5-year graft survival of 79% (95%CI 61; 90). The median overall survival was 227 months (168; 286) and the 5-year overall survival 89% (69.3; 96.4).ConclusionThe mid-term kidney transplant function with complex urinary diversion appears to be comparable to transplants with regular urinary diversions. Hence, complex urinary diversion should always be considered as a surgical option, even during transplantation, if necessary.

Macedo ileal catheterizable reservoir adding the scissors maneuver of channel continence: Long term follow-up

The Macedo ileal catheterizable channel was published in 2000 and consists of an enterocystoplasty with a catheterizable channel that precludes the need of the appendix for the efferent channel. After 25 years of experience with this technique, we decided to review our experience in a select subgroup of cases performed and followed exclusively by the author in a non-teaching hospital facility after the latest modifications of the procedure. Since 2008, we have refined our technique with the following modifications: small skin transverse incision instead of longitudinal one, with a semicircular flap for further stoma creation in the midline and importantly the scissors maneuver. This maneuver consists of crossing two 2cm rectus abdominis muscle flaps in the midline to create a neosphincter over the catheterizable channel. Follow-up was defined as the interval between the date of surgery and last visit to the clinic. We defined stoma continence if the dry interval between catheterization was 4hs. Early and late complications were reported as well as the reintervention rate. Additional procedures in association with bladder augmentation were also appointed. We have treated 49 patients. Indications were spinal dysraphism (71.4%), mainly myelomeningocele (65.3%), and others (PUV, exstrophy, anorectal anomalies). Urodynamic evaluation showed bladder pressure of high risk for upper urinary tract involvement (66%), urinary incontinence (24.5%), conversion of incontinent urinary diversion (3.8%), one exstrophy patient not considered (1.9%). Mean age at surgery was 88 months (7.3 years), 21 patients had additional surgeries in addition to Macedo ileal catheterizable channel: Macedo-Malone LACE procedure in 21 patients and bladder neck surgery to improve continence in 5 patients. Urinary stoma continence was 93.9% (46/49) after first surgery, one patient had a serous line valve revised, two patients still leak after 2h and await revision. Overall enterocystoplasty complications rate was 12.24% and consisted of urinary leakage in 3 cases and channel/stoma stricture in 3 cases. All patients treated for sphincteric deficiency associated with bladder reconstruction are continent per urethra. Urinary stoma revision for stricture was done in 2 cases and consisted on suprafascial approach and reanastomosis, one patient resolved with dilatation of the channel to the stoma. Mean follow up is 100 months (8.3 years). We confirmed in a long term follow-up based on face-to-face visits with 8.3 years mean follow-up that the Macedo procedure associated with the scissors maneuver is associated with 93.9% continence of the stoma. Overall complications rate was 12.24%. The cosmetic aspect with a small transverse incision and a midline stoma is another strength of the technique.

Clinical variables associated with major adverse cardiac events following radical cystectomy.

The objective of this study is to investigate the association between major adverse cardiac events (MACE) and clinical factors of patients undergoing radical cystectomy (RC) for bladder cancer. A retrospective analysis using the 2015-2020 National Surgical Quality Improvement Program database was performed on patients who underwent RC for bladder cancer. MACE was defined as any report of cerebrovascular accident, myocardial infarction, or thromboembolic events (pulmonary embolism or deep vein thrombosis). A multivariable-adjusted logistic regression was conducted to identify clinical predictors of postoperative MACE. A total of 10 308 (84.2%) patients underwent RC with incontinent urinary diversion (iUD), and 1938 (15.8%) underwent RC with continent urinary diversion (cUD). A total of 629 (5.1%) patients recorded a MACE, and on the multivariable-adjusted logistic regression, it was shown that MACE was significantly associated with increased age (OR = 1.035, 95% CI: 1.024-1.046, p < 0.001), obesity (OR = 1.583, 95% CI: 1.266-1.978, p < 0.001), current smokers (OR = 1.386, 95% CI: 1.130-1.700, p = 0.002), congestive heart failure before surgery (OR = 1.991, 95% CI: 1.016-3.900; p = 0.045), hypertension (OR = 1.209, 95% CI: 1.016-1.453, p = 0.043), and increase the surgical time (per 10min increase, OR = 1.010, 95% CI: 1.003-1.017, p = 0.009). We also report that increased age, obesity, and patients undergoing cUD (OR = 1.368, 95% CI: 1.040-1.798; p = 0.025) are associated with thromboembolic events. By considering the preoperative characteristics of patients, including age, obesity, smoking, congestive heart failure, and hypertension status, urologists may be able to decrease the incidence of MACE in patients undergoing RC. Urologists should aim for lower operative times as this was associated with a decreased risk of thromboembolic events.

Evaluation of sexual function and vaginal prolapse after radical cystectomy in women: a study to explore an under-evaluated problem

Introduction and hypothesisThe objective was to evaluate sexual function, vaginal prolapse, and quality of life (QoL) in women after radical cystectomy (RC) using validated questionnaires and pelvic organ prolapse quantification (POP-Q) measurement.MethodsFemale bladder cancer patients who underwent RC at our tertiary care center were included (January 2008 to March 2022). Patients received three validated questionnaires (International Consultation on Incontinence Questionnaire Vaginal Symptoms [ICIQ-VS] Part A, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire IUGA revised [PISQ], European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC] C30/BLM30). Patients who consented were examined with vaginal POP-Q measurement.ResultsOut of 322 patients, 193 were still alive, 54 patients were lost to follow-up, and 43 were excluded, resulting in 96 patients who received the questionnaire. Finally, 35 patients were included, of whom 17 patients consented to vaginal examination. Complaints due to vaginal symptoms were low (ICIQ-VS 6.17 + 5.37). Sexual activity was reported by 12 patients (34.3%); 23 patients (65.71%) were not sexually active. No apical prolapse was found in POP-Q measurement; 6 patients (35.3%) had anterior, and 14 patients (82.4%) posterior prolapse; the highest prolapse stage was 2. No significant differences were found regarding POP stages, sexual function, and QoL (all p > 0.05) when comparing continent and incontinent urinary diversions. Comparing the vaginal approach (no sparing vs sparing), significant differences were found in only two PISQ subscales (significantly higher scores after vagina sparing, p = 0.01 and p = 0.02).ConclusionsThe type of urinary diversion, POP-Q stages, and tumor stages did not show significant differences regarding sexual function, QoL, and prolapse complaints in women after RC, whereas a vagina- sparing approach showed significant differences only in two subscales without clinical relevance.

PD29-04 PREDICTORS OF DEEP INCISIONAL AND ORGAN/SPACE SURGICAL SITE INFECTION FOLLOWING RADICAL CYSTECTOMY: RESULTS FROM THE ACS NSQIP SURGICAL REGISTRY

You have accessJournal of UrologyCME1 Apr 2023PD29-04 PREDICTORS OF DEEP INCISIONAL AND ORGAN/SPACE SURGICAL SITE INFECTION FOLLOWING RADICAL CYSTECTOMY: RESULTS FROM THE ACS NSQIP SURGICAL REGISTRY Ruben Blachman-Braun, Aaron A. Gurayah, Matthew M Mason, Helen Y Hougen, Mark L Gonzalgo, Bruno Nahar, Sanoj Punnen, Dipen J Parekh, and Chad R. Ritch Ruben Blachman-BraunRuben Blachman-Braun More articles by this author , Aaron A. GurayahAaron A. Gurayah More articles by this author , Matthew M MasonMatthew M Mason More articles by this author , Helen Y HougenHelen Y Hougen More articles by this author , Mark L GonzalgoMark L Gonzalgo More articles by this author , Bruno NaharBruno Nahar More articles by this author , Sanoj PunnenSanoj Punnen More articles by this author , Dipen J ParekhDipen J Parekh More articles by this author , and Chad R. RitchChad R. Ritch More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003315.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) with urinary diversion is the standard treatment for muscle-invasive and persistent high-risk treatment-refractory non–muscle-invasive bladder cancer. Surgical site infection (SSI) is a serious postoperative complication following RC. The objective of this study is to evaluate clinical risk factors associated with postoperative deep incisional or organ/space SSIs following RC in a contemporary cohort of patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical registry METHODS: Using the ACS NSQIP surgical registry from 2015-2020, we selected patients≥18 years that had the diagnosis of bladder cancer and underwent RC with incontinent urinary diversion (ileal conduit) or RC with continent urinary diversion. Clinical, demographic, type of surgical approach, and reports of 30-day postoperative deep incisional or organ/space SSIs were assessed. Statistical analysis was performed with SPSS v.28. A p-value <0.05 was considered statistically significant. RESULTS: A total of 13,081 patients were analyzed, 1,061 (8.1%) with deep incisional or organ/space SSI. Of these patients, 11,021 (84.3%) patients underwent RC with incontinent urinary diversion and 2,060 (15.7%) underwent continent urinary diversion. Overall, 10,696 (81.8%) patients were male, age was 69±9.7 years, BMI was 28.5±5.7 kg/m2, diabetes mellitus prevalence was 2,534 (19.4%), and patients classified as functionally independent before surgery was 12,858 (98.3%). On multivariable-adjusted Cox regression analysis, presence of obesity (HR=1.60, 95% CI: 1.35-1.90), diabetes mellitus (HR=1.30, 95% CI: 1.13-1.51), being partially or totally dependent before surgery (HR=2.09, 95% CI: 1.44-3.03), and RC with continent urinary diversion approach (HR=1.61, 95% CI: 1.38-1.88) were associated with a higher risk of deep incisional or organ/space SSI postoperatively (Figure). CONCLUSIONS: Patients with obesity, diabetes mellitus, functional dependence before surgery, or those who underwent RC with a continent urinary diversion approach have a higher risk of developing postoperative deep incisional or organ/space SSIs following RC. Source of Funding: No © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e825 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ruben Blachman-Braun More articles by this author Aaron A. Gurayah More articles by this author Matthew M Mason More articles by this author Helen Y Hougen More articles by this author Mark L Gonzalgo More articles by this author Bruno Nahar More articles by this author Sanoj Punnen More articles by this author Dipen J Parekh More articles by this author Chad R. Ritch More articles by this author Expand All Advertisement PDF downloadLoading ...

Radical cystectomy and urinary diversion outcomes in patients with single vs. double renal unit: A 2:1 matched-pair analysis.

To evaluate perioperative and functional outcomes of radical cystectomy (RC) and urinary diversion (UD) in patients with a single kidney (SK) vs. double kidneys (DK). We reviewed records of patients who underwent RC for bladder cancer with a history of prior or concurrent nephrectomy at USC between 2004 and 2020. Patients with chronic kidney disease who were already on dialysis were excluded. UD, perioperative complications, and postoperative glomerular filtration rate (GFR) of the SK group were compared with a group of patients who underwent RC with DK using 2:1 matching with respect to age, sex, preop GFR, and tumor stage. We included 186 patients (SK = 62 and DK = 124). Half of the SK patients underwent continent UD. SK patients had a higher length of hospital stay compared to the DK group; however, 90-day complications, readmission, and mortality rates were similar. In patients with continent diversion, SK vs. DK showed similar 90-day complications (71% vs. 69%, P = 1.0). SK patients had significantly lower GFRs at discharge, 3-, and 12-month following RC compared to the DK group. Postoperative GFRs of the SK patients with continent vs. incontinent UD were statistically similar. On multivariable analysis, UD (i.e. continent vs. incontinent) was not associated with post-op GFR decline at discharge, 3- and 12-month following RC. Perioperative outcomes of radical cystectomy patients with single kidney are similar to double kidney patients, except for more GFR decline in single kidney cases. Continent urinary diversion in single kidney is as safe as double kidney patients.

OPEN RADICAL CYSTECTOMY: SINGLE CENTER RESULTS AND OUTCOMES IN THE LAST FIVE YEARS.

Radical cystectomy is a therapeutic modality of choice for many patients with muscle-invasive bladder cancer. We conducted a retrospective study of open radical cystectomies performed at a single Center from January 2017 to January 2022. Decision on the urinary diversion type was based on tumor stage, comorbidities, patient age, general condition and preferences. There were 19.5% of female and 80.5% of male patients, median age 67 (range 38-90) years. We performed 96 (44.7%) ureterocutaneostomies (UCS), 67 (31.2%) ileal conduit derivations, and 52 (24.2%) orthotopic neobladder derivations (OND). There were 17 (7.9%) complications after UCS, 7 (3.2%) after incontinent urinary diversion, and 7 (3.2%) after OND. Fifty-five (25.6%) patients developed early complications, of which 31 (14.4%) during the initial hospitalization period, and 24 (11.2%) required re-hospitalization in the 30-day postoperative period. The most common wound-related complication was wound dehiscence, most typically caused by infection. The main reason for readmission was urosepsis. The 30-day mortality rate was 0.9%. Late complications that occurred 30 days after the operation were found in 39 (18.1%) cases. Bladder cancer is a high-mortality disease that requires a multidisciplinary and personalized approach. Further development of multidisciplinary teams, perioperative and postoperative care, and follow-up strategy is needed to improve the oncologic and functional outcomes of this procedure.

Outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction.

To evaluate the early and late outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction (LUTD). The charts of patients with refractory non-malignant LUTD who underwent continent or incontinent external urinary diversion at University of Cincinnati hospitals in the period between March 2012 and December 2019 were retrospectively reviewed. The demographic and baseline characteristics, surgery indications, operative data, early and late outcomes were collected, analyzed, and compared. A total of 78 patients including 55 patients with neurogenic bladder (NGB) and 23 patients with non-neurogenic bladder (non-NGB) refractory non-malignant LUTD were included. Fifty-three patients underwent incontinent urinary diversions (IUD), while 25 patients underwent continent urinary diversions (CUD). During the first 4 postoperative weeks, 53.85% (n=42) of patients developed complications, and the incidence was nonsignificantly higher in patients with NGB than those with non- NGB (56.36% vs 47.83%, p-value=0.490). Fever was exclusively encountered in patients with NGB earlier, while stomal retraction occurred only in patients with non-NGB later. More non- NGB patients had early wound infection. There was an overall improvement of urological symptoms in 52 patients (66.67%), and the rate was non-significantly higher in non-NGB patients than NGB patients (78.26% vs 61.82%, p-value=0.160). Late complications were reported in 47 patients and were more encountered in those with non-NGB than those with NGB (65.22% vs 58.18%). Stomal leakage and stenosis occurred more with CUD than with IUD (52% vs 0% and 28% vs 3.77%, respectively). External urinary diversion can achieve a reasonable level of urological symptoms control in patients with refractory non-malignant LUTD, but with associated adverse outcomes. Although non-significantly, these complications tend to be higher in patients with IUD and/or NGB during the early postoperative period and higher with CUD and/or non-NGB on the long-term.

Urinary and bowel management in cloacal exstrophy: A long-term multi-institutional cross-sectional study

We sought to evaluate long-term surgical urinary and bowel management in cloacal exstrophy (CE) in a multi-institutional study. We performed a cross-sectional study of people with CE and covered variants managed at five participating institutions. Those with <1 year follow-up or born with variants without hindgut involvement were excluded. Primary outcomes were methods of urinary and bowel management. Urinary management included: voiding via urethra, clean intermittent catheterizations (CIC), incontinent diversion and incontinent in diaper. Bowel management included: intestinal diversion (colostomy/ileostomy) and pull-through (with/without MACE). We evaluated three age groups: children (<10 years), older children (10 to <18) and adults (≥18). We assessed if management varied by age, institution or time (born≤2000 vs. >2000). A total of 160 patients were included (40% male). Median follow-up was 15.2 years (36% children, 22% older children, 43% adults). While 42% of children were incontinent in diapers, 73% of older children and adults managed their bladder with CIC, followed by incontinent urinary diversion (21%) (p<0.001, Table). CIC typically occurred after augmentation (88%) via a catheterizable channel (89%). Among older children and adults, 86% did not evacuate urine per urethra and 28% of adults had an incontinent urinary diversion. No child or adult voided per urethra. Age-adjusted odds of undergoing incontinent diversion was no different between institutions (p=0.31) or based on birthyear (p=0.08). Most patients (79%) had an intestinal diversion, irrespective of age (p=0.99). Remaining patients had a pull-through, half with a MACE. The probability of undergoing bowel diversion varied significantly between institutions (range: 55-91%, p=0.001), but not birth year (p=0.85). We believe this large long-term data presents a sobering but realistic view of outcomes in CE. A limitation is our data does not assess comorbidities or patient-reported outcomes. Rarity of volitional urethral voiding in CE forces the question of whether is a potentially unachievable goal. We advocate thoughtful surgical decision making and thorough counseling about appropriate expectations, distinguishing between volitional voiding and urinary and fecal dryness. In this long-term, multi-institutional study of patients with CE, 94% of older children and adults manage their bladder with incontinent diversion or CIC. Nearly 80% of patients, regardless of age, have an intestinal diversion. Given that no patients were dry and voided via urethra and 86% of older patients do not evacuate urine per urethra, these data bring into question what functional goals are achievable when performing reconstructive surgery for these patients.

Quality of life in neurogenic patients based on different bladder management methods: A review.

To determine the overall quality of life and patient satisfaction associated with different bladder management strategies in neuro-urological patients. The second objective was to identify other associated factors that may further influence the patient's quality of life. Systematic Review. Studies from Pubmed, Cochrane, and Google Scholar databases were extracted using terms relating to 'quality of life', 'satisfaction', in 'neurogenic bladder' combined with 'bladder management methods' that included 'continent and non-continent urine diversion', 'intermittent-catheterization', 'indwelling catheter' and 'condom-catheter'. Only studies with a minimal proportion of 80% of neurogenic bladder patients were included. Search was conducted, and article titles and abstracts were rated. 136 papers were screened and assessed for eligibility. 25 studies were included in the final analysis and consisted of ten retrospective, nine prospective, five cross-sectional and a single randomized controlled trial. In total, 3002 patients were included, with a majority of male (55%) and spinal cord injury (88%) patients. 167 patients had incontinent urinary diversions, 464 had continent urinary diversions (bladder augmentation with or without cutaneous catheterizable channel), 1698 used intermittent catheterization (self or by an attendant), 550 had an indwelling catheter (urethral or suprapubic), and 123 had condom catheters. Quality of life was assessed using a wide variety of validated and non-validated questionnaires. Overall, patients with continent and incontinent diversion tended to have better scores. Use of catheters tended to have more unsatisfactory scores, with indwelling and attendant-intermittent catheterization often scoring worse. On the other hand, patients using self-intermittent catheterization tended to fair well. Normal micturition followed by self-catheterization yielded an overall higher quality of life. Data were too divergent to rank the other bladder management methods. However, by improving continence, each method aims to enhance quality of life.

MP25-02 RADICAL CYSTECTOMY AND URINARY DIVERSION OUTCOMES IN PATIENTS WITH SINGLE VS. DOUBLE KIDNEY: A 2:1 MATCHED-PAIR ANALYSIS

You have accessJournal of UrologyCME1 May 2022MP25-02 RADICAL CYSTECTOMY AND URINARY DIVERSION OUTCOMES IN PATIENTS WITH SINGLE VS. DOUBLE KIDNEY: A 2:1 MATCHED-PAIR ANALYSIS Alireza Ghoreifi, Richard Mora, Sanam Ladi-Seyedian, Farshad Sheybaee Moghaddam, Jie Cai, Gus Miranda, Monish Aron, Anne Schuckman, Mihir Desai, Inderbir Gill, Siamak Daneshmand, and Hooman Djaladat Alireza GhoreifiAlireza Ghoreifi More articles by this author , Richard MoraRichard Mora More articles by this author , Sanam Ladi-SeyedianSanam Ladi-Seyedian More articles by this author , Farshad Sheybaee MoghaddamFarshad Sheybaee Moghaddam More articles by this author , Jie CaiJie Cai More articles by this author , Gus MirandaGus Miranda More articles by this author , Monish AronMonish Aron More articles by this author , Anne SchuckmanAnne Schuckman More articles by this author , Mihir DesaiMihir Desai More articles by this author , Inderbir GillInderbir Gill More articles by this author , Siamak DaneshmandSiamak Daneshmand More articles by this author , and Hooman DjaladatHooman Djaladat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002568.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Limited data is available regarding the outcomes of patients with single kidney (SK) who undergo radical cystectomy (RC) and urinary diversion (UD). The aim of this study is to evaluate perioperative and functional outcomes of SK patients with bladder cancer (BC) who undergo RC. METHODS: We reviewed the records of patients who underwent RC for BC with history of prior or concurrent nephrectomy due to non-functional kidney, renal cancer, or upper tract urothelial carcinoma (UTUC) between 2004 and 2020. Patients with chronic kidney disease who were already on dialysis were excluded. UD, perioperative complications, and postoperative glomerular filtration rate (GFR) of the SK group were compared with a group of patients who underwent RC with double kidneys (DK) using 2:1 matching with respect to age, sex, preop GFR, and tumor stage. RESULTS: A total of 186 patients (SK=62 and DK=124) were included. Baseline features of these two groups were similar (Table 1-A). Half of the SK patients underwent continent UD. SK patients had a higher length of hospital stay compared to the DK group; however, 90-day complications, readmission, and mortality rates were similar (Table 1-B). In patients with continent diversion, SK vs. DK showed similar 90-day complications, including metabolic acidosis and dehydration (71% vs. 69%, p=1.0). In terms of GFR changes, SK group showed significantly lower GFRs at discharge as well as 3- and 12-months following RC compared to the DK group (Figure 1-A). Nevertheless, no significant difference was observed in postoperative GFRs of the SK patients with continent vs. incontinent UD (Figure 2-B). On multivariable analysis, UD (i.e., continent vs. incontinent) was not associated with post-op GFR decline at discharge, 3- and 12-months following RC. CONCLUSIONS: Perioperative outcomes of single kidney patients undergoing radical cystectomy are similar to double kidney patients, except for more GFR decline in single kidney cases. Continent urinary diversion in single kidney patients is as safe as double kidney cases. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e427 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alireza Ghoreifi More articles by this author Richard Mora More articles by this author Sanam Ladi-Seyedian More articles by this author Farshad Sheybaee Moghaddam More articles by this author Jie Cai More articles by this author Gus Miranda More articles by this author Monish Aron More articles by this author Anne Schuckman More articles by this author Mihir Desai More articles by this author Inderbir Gill More articles by this author Siamak Daneshmand More articles by this author Hooman Djaladat More articles by this author Expand All Advertisement PDF DownloadLoading ...

Relevance of water-related rehabilitation measures for stoma patients : Results of apilot project and review of the literature

The creation of askin stoma after exenterative pelvic surgery drastically affects the physical health of patients. Being concerned with aesthetic and functional aspects, patients tend to not participate in offers for water-related rehabilitation, especially water gymnastics and swimming. The aim of the pilot project "UROAquaFIT" was to evaluate the feasibility of water-related rehabilitation for patients after cystectomy with incontinent urinary diversion. Patients after radical cystectomy with incontinent urinary diversion were offered the possibility to participate in the water-based rehabilitation program "UROAquaFIT". Split into small groups, awater gymnastics course took place under the guidance of aphysiotherapist and astoma therapist as well as under medical supervision. Data on quality of life and apersonal assessment were collected using a questionnaire before and 6months after the course. In addition, aMEDLINE-based search for aqua gymnastics in oncology was conducted. All participants reported the course as being positive and enriching. The participants' well-being and self-esteem improved. Therefore, water gymnastics can be ahighly effective method for rehabilitation of patients with incontinent urinary diversion. In addition, it improves the physical health of those affected and thus expands the possibilities for social reintegration. This form of therapy should be standard in the rehabilitation of patients with incontinent urinary diversion.

IJU this issue

This issue contains one Review Article, nine Original Articles and one Urological Note with three Editorial Comments. Although 2-D cell culture and animal models have been widely used to examine tumor genetics and the sensitivity against anticancer drugs, these methods cannot mimic the tumor microenvironment in human bodies, and accurate analysis of anticancer treatment cannot be carried out. Tse et al. (Hong Kong, China) reviewed the development and applications of 3-D organoid cultures in urological cancer, and assessed the future prospects of this model. In this review, the authors discussed the advantage of organoids in drug screening and personalized medicine, the identification of cells of origin for urological cancers, and the tumor microenvironment. The authors concluded that 3-D organoids would have great potential in urological cancer research. Lin et al. (Kaohsiung, Taiwan) reported the incidence and survival variations of 8830 patients with new diagnoses of upper tract urothelial cancer identified from the Taiwan National Cancer Registry Annual Reports. The status of upper tract urothelial cancer in Taiwan was clarified, and what was interesting was that, in contrast to data from other countries, the incidence of upper tract urothelial cancer was considerably higher in women. Although the authors pointed out the possibility of aristolochic acid exposure as the cause, it is still unclear at this time. Iqbal et al. (New York, USA) reported a propensity score-matched analysis of effects on renal function between continent (neobladder; 50 patients) and incontinent (ileal conduit; 87 patients) urinary diversion. As a result of detailed analysis, the authors concluded that ileal conduits and neobladders showed a similar effect on the estimated glomerular filtration rate up to 5 years after robot-assisted radical cystectomy. To treat urethral stricture, most urologists carry out transurethral treatment. However, stricture recurrence after transurethral treatment is considered to be major problem. In this issue, Ojima et al. (Saitama, Japan) reported a preclinical study on the ability of photocurable gelatin to prevent stricture recurrence after urethral dilation in a rabbit model. The mean lumen ratio differed significantly after dilation between five rabbits with dilation + photocurable gelatin treatment and five rabbits with dilation only (65.5% vs 27.3%). The regenerated urethral epithelium at the stricture site is much better with dilation + photocurable gelatin treatment. I believe that this treatment to prevent stricture recurrence would be attractive from the perspective of showing the possibility of a new minimally invasive treatment for urethral stricture. In the Urological Note, Komai et al. (Tokyo, Japan) presented a proposed protocol for “What should we do next?” in the management of major bleeding during minimally invasive pelvic surgery. I believe that it will be useful clinically, so please take a look at the figure (a protocol for emergent bleeding from veins during minimally invasive pelvic surgery). Unfortunately, the limited space does not allow me to introduce all the articles. However, all the papers are very interesting and informative. So, please enjoy them by all means. None declared.

Urinary and Fecal Continence in Adolescent and Adult Patients With Cloacal Exstrophy

ObjectiveTo evaluate the prevalence of urinary (UI) and fecal incontinence (FI) and the incontinence-related quality of life (QoL) in adolescent and adult patients with cloacal exstrophy (CE) in Germany. Patients and MethodsCE-patients of a tertiary care center and the German support group for anorectal malformations (SoMA e.V.) were included (October 2015 until September 2020). Data were assessed using a composed questionnaire consisting of 18 self-generated questions and two validated German questionnaires (King's health questionnaire, Questionnaire on Quality of Life in Fecal Incontinence (FLQAI)). ResultsOut of 23 included patients, 19 had continent and 3 incontinent urinary diversions (UD), 1 was unspecified; 2/23 were on dialysis. 73.7% (14/19) had undergone bladder augmentation, 4/19 had a pouch, 1/19 a neobladder. 94.7% (18/19) had a continent cutaneous channel and performed intermittent self-catheterization. UI was common (71.4%, 15/21). Neither the UD nor the involuntary loss of urine itself had a significant impact on QoL. Comparing the King's health questionnaire results, UI-related QoL of CE-patients was significantly lower than in a published reference group. 78.3% (18/23) had a bowel stoma. 34.8% (8/23) reported involuntary stool-soiling. Neither the way of bowel-emptying nor involuntary stool-soiling itself showed significant influence on FI-related QoL in the FLQAI. FLQAI items showed significant differences only for one of two published reference groups. ConclusionLong-term incontinence rates in adolescent and adult CE-patients are high. Incontinence-related QoL was reduced compared to published reference groups but was minimally influenced by incontinence itself, the type of UD or the way of bowel-emptying, respectively.

Success factors for abdominal wall diversions, including ureterocutaneostomy.

To review the most recent data on urinary diversions (UD) surgical outcomes performed at time of radical cystectomy (RC). Looking at the recent specific literature, the most recent factors introduced in the field of UDs are the preoperative assessment of patient's frailty and the use of the robotic system. According to the available evidence, frailty status is a good preoperative predictor of surgical outcomes and patient recovery. Several questionaries measuring patient's frailty status have been evaluated as a proxy to prevent RC complications and to improve the choice of the UDs.Robot-assisted RC has gained popularity and both continent and incontinent UD are now performed through an intra-corporeal technique. Studies on Robot-assisted UDs showed that both intra-corporeal and extra-corporeal approaches (ICUD and ECUD, respectively) are safe and feasible. Compared to the open techniques, they improve intraoperative blood loss and postoperative recovery. However, accessibility to the Da-Vinci System and the need of robotic skills limit the application of these techniques to high-volume institutes. Patient's frailty status and the use of robotic surgery are the most recent factors introduced to improve the choice of UD and surgical outcomes.

Single staff cystectomy in a low-volume center: Oncological outcomes and complications.

Radical cystectomy (RC) with bilateral pelvic lymph node dissection (PLND) is a complex surgical procedure, associated with substantial perioperative complications. Previous studies suggested reserving it to high-volume centers in order to improve oncological and perioperative outcomes. However, only limited data exist regarding low-volume centers with highly experienced surgeons. We aimed to assess oncological and perioperative outcomes after RC performed by experienced surgeons in the low-volume center of Luzerner Kantonsspital, Lucerne, CH. We retrospectively analyzed the data of 158 patients who underwent RC and PLND performed between 2009 and 2019 at a single low-volume center by three experienced surgeons, each having performed at least 50 RCs. Complications were graded according to the 2004 modified Clavien-Dindo grading system. A total of 110 patients (70%) received an incontinent urinary diversion (ileal conduit or ureterocutaneostomy) and 48 patients (30%) received a continent urinary diversion (ileal orthotopic neobladder, ureterosigmoidostomy, or Mitrofanoff pouch). Median operating time was 419 minutes (interquartile range [IQR] 346-461). Overall, at RC specimen, 71.5% of patients had urothelial carcinoma, 12.6% squamous, 3.1% sarcomatoid, 1.2% glandular, and 0.6% small cell carcinoma. Median number of lymph nodes removed was 23 (IQR 16-29.5). Positive margins were found in eight patients (5.1%). Overall five-year survival rate was 52.4%. The complication rate was 56.3%: 143 complications were found in 89 patients, 36 (22.8%) with Clavien ≥3. The 30-day mortality rate was 2.5%. RC could be safely performed in a low-volume center by experienced surgeons with comparable outcomes to high-volume centers.

Urinary diversion after uro-oncologic interventions in women: the right procedure for the right patient

Bladder carcinoma is a relatively rare tumour in women. The even rarer constellation of an invasive carcinoma or a high-risk situation when cystectomy is indicated requires adequate urinary diversion.The individual underlying circumstances of tumour and patient and the experience and preferences of the surgeon determine the choice of urinary diversion.A variety of alternatives are available for bladder replacement. The first decision to be made is between incontinent or continent urinary diversion. There is no general solution that fits all patients, but an individual solution must be found based on adequate information. Options include incontinent drainage with an ostomy, e. g. ureterocutaneostomy or ileum conduit, and the much more complex techniques of the continent variants of orthotopic or heterotopic replacement.Experience with continent diversion is significantly limited in women compared with men. In particular, the orthotopic connection to the urethra reveals gender-specific differences.All in all, clear inclusion or exclusion criteria for the different techniques have to be respected. Especially in cases when quality of life or body image play a crucial role, it is difficult to decide which type of urinary diversion is appropriate. This requires extensive experience on the part of the surgeon regarding the various options of surgical methods as well as knowledge and control of consecutive complications.

Urinary reconstruction following total pelvic exenteration for locally advanced rectal cancer: complications and factors affecting outcomes.

Total pelvic exenteration (TPE) for rectal cancers is associated with significant morbidity. We evaluated the complications related to urinary reconstruction following TPE and factors predicting urologic morbidity. Retrospective analysis of TPE patients with incontinent urinary diversions between August 2013 and January 2020. One hundred TPE were performed with 96 ileal conduits (IC). Early complications occurred in 10 patients that included uretero-ileal leaks (5%), conduit-related complications (3%), and acute pyelonephritis (3%). Late complications were seen in 26% of patients with uretero-intestinal strictures in 11%. Mortality attributable to urinary complications was seen in 2%. No single factor, including prior radiation, recurrent disease, type of anastomosis, or blood loss, predicted development of urinary morbidity. Conduit urinary diversion following TPE is associated with high urinary morbidity rate but low mortality. It can be safely performed even after previous surgeries and radiation by a dedicated colorectal team.