Nighttime Continence Rates Research Articles

Comparison of perioperative outcomes and complications between intracorporeal and extracorporeal orthotopic ileal neobladder after laparoscopic radical cystectomy

Objective To compare perioperative outcomes and complications between intracorporeal and extracorporeal orthotopic ileal neobladder after laparoscopic radical cystectomy (LRC) from one center. Methods We retrospectively analysis patients’ clinical and follow-up data who underwent laparoscopic radical cystectomy (LRC) in our hospital from January 2011 to May 2017, of whom 25 cases underwent intracorporeal orthotopic ileal neobladder (ICIN) and 20 cases underwent extracorporeal orthotopic ileal neobladder (ECIN). The patients' characteristics, perioperative data, postoperative pathological results, postoperative complications and oncologic outcomes were compared and analyzed. The mean age of ECIN group was (59.9±10.5)years, mean BMI was (24.7±3.3)kg/m2, the ASA level was less than Ⅱ in 19 cases and level Ⅲ in 1 case, the mean preoperative CCI was 4.5±1.6, 3 patients got preoperative neoadjuvant chemotherapy. The mean age of ICIN group was (59.0±9.8)years, mean BMI was (25.3±4.3)kg/m2, the ASA level was less than Ⅱ in 25 cases and no level Ⅲ, mean preoperative CCI was 4.0±1.3, 3 patients got preoperative neoadjuvant chemotherapy. There was no statistical difference between the two groups in patients' characteristics. All operations were performed under general anesthesia.After LRC was accomplished, an additional 12 mm trocar was placed 1 cm crania to the pubic symphysis for EndoGIA in ICIN group. An ileal segment 60 cm long was isolated 25 cm proximal to the ileocecum. The continuity of the small bowel was restored with side to side anastomosis. The proximal 10 cm was moved to the distal end of the ileal segment for the right isoperistaltic afferent limb, and the remaining proximal 10 cm ileal segment was reserved for the left isoperistaltic afferent limb. Then, the remaining length of the 40 cm ileal segment was detubularized along its antimesenteric border. The anterior wall of the neobladder was folded forward and the free edges were sutured to achieve a spherical configuration. After single J ureteric stents were inserted into the ureters, the urethra and ureters were sutured with neobladder successively. For ECIN, the ileal segment is removed via a midline laparotomy below the umbilicus 5-10 cm. The construction method of neobladder was the same with ICIN group. Results All 45 cases were successfully operated. There was no statistical difference between ICIN group and ECIN group in operation time [(374.2±74.6)min vs.(360.3±83.6)min, P=0.557] and extraction time of pelvic drainage tube[(12.5±5.9)d vs.(11.8±4.5)d, P=0.686]. Patients in the ICIN group had less intraoperative blood loss [(186.0±140.3)ml vs. (272.0±110.7)ml, P=0.030], shorter oral intake time [(4.2±2.2)d vs.(6.1±1.6)d, P=0.002], shorter postoperative hospital stay [(13.7±4.2)d vs.(19.9+ 7.6)d, P=0.001]. There was no significant difference in the early postoperative complications (P=0.345). The median follow-up time of ICIN group and ECIN group were 30 months and 52.5 months, respectively. The day-time and night-time continence rate were 97.4% and 86.8% respectively in the first year after surgery without significant difference. A total of 6 patients suffered distant metastasis, of whom 4 patients suffered multiple metastases, 1 case bone metastases and 1 case pelvic lymph node metastasis. Seven patients died, five of whom died of tumor recurrence or metastasis. There was no statistical difference between the two groups in cancer specific survival rates (P=0.644) and recurrence free survival rates (P=0.981). Conclusions Comparing with extracorporeal orthotopic ileal neobladder, intracorporeal orthotopic ileal neobladder has advantages of less blood loss and faster intestinal function recovery, without significantly increased operative time and complications. No significant difference was found in the function of neobladder and oncological outcomes. Randomized controlled trial with large sample and long-term follow-up is needed to verify the advantages of intracorporeal neobladder construction. Key words: Bladder cancer; Laparoscopy; Radical cystectomy; Orthotopic ileal neobladder

PD43-02 EVALUATION OF URINARY CONTINENCE FOLLOWING NERVE SPARING OPEN RADICAL CYSTOPROSTATECTOMY AND ORTHOTOPIC URINARY DIVERSION

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II1 Apr 2018PD43-02 EVALUATION OF URINARY CONTINENCE FOLLOWING NERVE SPARING OPEN RADICAL CYSTOPROSTATECTOMY AND ORTHOTOPIC URINARY DIVERSION Zhoobin Bateni, Ankeet Shah, Soroush Bazargani, Kevin Wayne, Gus Miranda, Jie Cai, Hooman Djaladat, Anne Schuckman, and Siamak Daneshmand Zhoobin BateniZhoobin Bateni More articles by this author , Ankeet ShahAnkeet Shah More articles by this author , Soroush BazarganiSoroush Bazargani More articles by this author , Kevin WayneKevin Wayne More articles by this author , Gus MirandaGus Miranda More articles by this author , Jie CaiJie Cai More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , Anne SchuckmanAnne Schuckman More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2114AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES It has been suggested that nerve-sparing (NS) techniques can improve urinary continence following radical prostatectomy but there is lack of strong evidence in the literature about the effect of NS techniques on urinary continence following radical cystoprostatectomy (RCP). We evaluated urinary continence in male patients undergoing ONB diversion following NS versus non-NS RCP using a validated pad usage questionnaires. METHODS Beginning in 2012, we started to use an IRB approved, validated, pictorial pad usage questionnaire assessing the number, size, and wetness of pads at each follow-up visits of patients with ONB. We found 253 male patients which had filled out pad usage questionnaires at least one time. The time of the RCP was from 2002 to 2017. Continence was defined as no pad usage or pads as almost dry. We evaluated whether a nerve-sparing approach had any impact on continence. RESULTS The median age of 67 years and median BMI of 27.3 kg/m2. The median follow-up was 729 days. There was no significant difference between pathologic stage, adjuvant or neoadjuvant therapies, BMI, diabetes, history of smoking and perioperative care/catheter management of the two groups. There was a significantly shorter median time to daytime continence in the NS group compared to non-NS group (133 days vs 216 days; p=0.01). Kaplan-Meier curves showed significantly higher daytime continence rates in NS group at one year compared to non-NS ones (63% +/- 5% vs. 54% +/- 4%; p=0.002). A similar pattern was observed for one-year nighttime continence rates between the groups (43% +/- 5% in NS vs. 35% +/- 4% in non-NS; p=0.011) (figure 1). After controlling for potentially confounding factors including age, BMI, diabetes, comorbidities, smoking, pathological stage, pelvic floor muscle training, operative time, and blood loss, multivariate Cox regression model revealed that patients in NS group, were 1.6 times more likely to gain daytime continence by one year (OR:1.6 [95%CI, 1.2-2.2]; p=0.003). CONCLUSIONS Men with ONB following NS RCP have faster return to daytime and nighttime continence in the first year compared to the non-NS ones. Further research with randomization and a larger sample size is needed to rule out confounding factors to support the value of doing NS surgery on continence after RCP and ONB. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e877 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Zhoobin Bateni More articles by this author Ankeet Shah More articles by this author Soroush Bazargani More articles by this author Kevin Wayne More articles by this author Gus Miranda More articles by this author Jie Cai More articles by this author Hooman Djaladat More articles by this author Anne Schuckman More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Surgical techniques for facilitating laparoscopic intracorporeal orthotopic neobladder: initial experience.

ABSTRACTPurpose:To describe our technique and outcomes for laparoscopic intracorporeal ileal neobladder (ICNB) reconstruction.Materials and Methods:From April 2014 to November 2016, 21 patients underwent laparoscopic ICNB at our tertiary referral centre. ICNB with bilateral isoperistaltic afferent limbs and several technique improvements were introduced. Demographics, clinical, and pathological data were collected. Perioperative, 1-year oncologic, 1-year Quality of life and 1-year functional outcomes were reported.Results:ICNB was successfully performed in all 21 patients without open conversion and transfusion. Mean operative time was 345.6±66.9 min, including 106±22 min for LRC and PLND and 204±46.4 min for ICNB, respectively. Mean established blood loss was 192±146 mL. The overall incidence of 90-d complication was 33.3%, while major complication occurred in 4.8%. One-year daytime and night-time continence rates were 85.7% and 57.1%, respectively. One patient died from myocardial infarction six months postoperatively, and two patients had lung metastasis five months and six months respectively.Conclusions:We described our experience of 3D LRC with a novel intracorporeal orthotopic ileal neobladder, and the technique improvements facilitate the procedure. However, further studies are required to evaluate long-term outcomes of the intracorporeal neobladder with bilateral isoperistaltic afferent limbs.

PD38-09 PROSPECTIVE EVALUATION OF CONTINENCE FOLLOWING OPEN RADICAL CYSTECTOMY AND ORTHOTOPIC URINARY DIVERSION AND THE EFFECT OF PELVIC FLOOR PHYSICAL THERAPY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II1 Apr 2017PD38-09 PROSPECTIVE EVALUATION OF CONTINENCE FOLLOWING OPEN RADICAL CYSTECTOMY AND ORTHOTOPIC URINARY DIVERSION AND THE EFFECT OF PELVIC FLOOR PHYSICAL THERAPY Soroush Bazargani, Thomas Clifford, eileen Johnson, Kevin Wayne, Gus Miranda, Jie Cai, Hooman Djaladat, Anne Schuckman, and siamak Daneshmand Soroush BazarganiSoroush Bazargani More articles by this author , Thomas CliffordThomas Clifford More articles by this author , eileen Johnsoneileen Johnson More articles by this author , Kevin WayneKevin Wayne More articles by this author , Gus MirandaGus Miranda More articles by this author , Jie CaiJie Cai More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , Anne SchuckmanAnne Schuckman More articles by this author , and siamak Daneshmandsiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1723AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We evaluated the continence outcomes in patients undergoing orthotopic neobladder (ONB) diversion following radical cystectomy (RC) using validated pad usage questionnaires and in a subgroup who underwent pelvic floor physical therapy (PFPT). METHODS Under IRB approval, we identified 1269 patients that underwent open RC from 2002 to 2015 (ONB 74%, 85% male). From 2012, patients were prospectively followed with a validated, pictorial pad usage questionnaire. A subgroup of patients received PFPT as an intervention to assist their continence. Interventions focused on improving pelvic floor muscle strength and coordination. Manual, visual and surface EMG biofeedback training were incorporated to improve neuromuscular re-education of the pelvic floor as well as behavioral modifications for bladder re-training, timed voiding and general bladder and bowel health. Frequency of visits started from 1x/week over 4-6 sessions, and longer thereafter. RESULTS A total of 153 male patients with available pad usage questionnaires were followed from September 2012 to August 2015. Daytime continence rates increase from 59% at <3 months to 92% by 12-18 months postoperatively. Nighttime continence rates increased to 51% by 18-36 months postoperatively. Overall catheterization rate was 13.1%. 17 patients underwent PFPT during this period, with a median age of 70 yrs. There was no significant difference between groups for age, BMI, or Charlson comorbidity index. Univariate analysis showed there is a shorter median time to first daytime continence in PFPT group compared to non-intervention group (89 days vs 182 days respectively; p=0.06), while this was not significant for the nighttime continence (median 134 vs 311; p=0.12). Kaplan Meier curves also showed higher continence rates in PFPT group at 1 year (0.710.13) compared to non-PFPT ones (0.60.04), although the difference was not significant (p=0.25) (figure 1). CONCLUSIONS Following ONB, continence improves significantly by 6 months, and plateaus with 92% of patients achieving daytime continence by 12-18 months. Those who received PFPT tend to have faster return to daytime continence in the first year. Further research with bigger sample size is needed to support the value of PFPT in continence after RC and ONB. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e742-e743 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Soroush Bazargani More articles by this author Thomas Clifford More articles by this author eileen Johnson More articles by this author Kevin Wayne More articles by this author Gus Miranda More articles by this author Jie Cai More articles by this author Hooman Djaladat More articles by this author Anne Schuckman More articles by this author siamak Daneshmand More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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

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

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.

PD9-02 HEALTH RELATED QUALITY OF LIFE AFTER RADICAL CYSTECTOMY IN WOMEN: ORTHOTOPIC NEOBLADDER VERSUS ILEAL LOOP CONDUIT AND IMPACT OF INCONTINENCE

INTRODUCTION AND OBJECTIVES: Orthotopic neobladder reconstruction arguably represents the gold standard form of urinary diversion following radical cystectomy. However, no contemporary continence information is available. Herein, we evaluate the continence outcomes in patients undergoing orthotopic neobladder following radical cystectomy using a validated pad usage questionnaire. METHODS: Using our IRB approved database, we identified 1545 patients that underwent open radical cystectomy from 2000 to 2014. Orthotopic neobladder was constructed in 1057 (68%) patients, of whom 892 (84%) were male. Starting in 2012, these patients were prospectively followed, and completed a validated, pictorial pad usage questionnaire during their follow up visits assessing the number, size, and wetness of pads, and mucus leakage. Continence was defined as reporting no pad usage, or pads as “almost dry,” and questionnaires were stratified into distinct postoperative time intervals. For patients who completed multiple questionnaires within an interval, the most recent was used in the analysis. Patients with artificial urinary sphincters or a history of radiation therapy were excluded. RESULTS: A total of 180 male patients with available pad usage questionnaires were followed from August 2012 to October 2014. A total of 284 pad usage questionnaires were collected, with 243 interval distinct pad usage questionnaires identified and separated into intervals of < 3 months, 3e6 months, 6e12 months, 12e18 months, 18e36 months, and more than 36 months after surgery (n1⁄4 42, 39, 41, 34, 45, and 42, respectively). Daytime continence rates were 55%, 69%, 78%, 88%, 87%, and 81%, respectively. The corresponding numbers for nighttime continence rates were 26%, 38%, 46%, 44%, 58%, and 45%, respectively. In the 18e36 month range, 53% of patients reported both day and nighttime continence. CONCLUSIONS: Following orthotopic urinary diversion, there is significant improvement in continence by 6 months, and 88% of patients achieved daytime continence by 12 months. There is a plateau in continence rates at one year. Orthotopic diversion represents an excellent functional option for urinary diversion.

Pure intracorporeal laparoscopic radical cystectomy with orthotopic "U" shaped ileal neobladder.

BackgroundRadical cystectomy with pelvic lymph node dissection represents the standard treatment for muscle-invasive, and high-risk non-muscle-invasive bladder cancers. Aim of this study was to report our case series of 30 patients undergoing totally laparoscopic radical cystectomy (LRC) with reconstruction of an intracorporeal orthotopic ileal neobladder. Intra- and perioperative results and the functional and oncological outcomes 9 months after operation are reported.MethodsBetween October 2010 and December 2012, 30 male patients underwent LRC with a pure laparoscopic orthotopic ileal “U”- shaped neobladder diversion. The men had a median age of 67 years, a median body mass index of 22.3, and a mean ASA score of 2.2; they represented various clinical stages of disease.ResultsNone of the patients required conversion to open surgery, and no perioperative mortalities were reported. The median operating time was 365 min, and the median blood loss was 290 mL, with a transfusion rate of 26.6%. All surgical margins were negative; 8 patients with non–organ-confined disease or positive lymph nodes received adjuvant chemotherapy. Early complications (within 30 days) occurred in 7 patients, and late complications occurred in 6 patients. The mean hospital stay was 9 days. At 9 months after surgery, the daytime continence rate was 83.3% and the nighttime continence rate was 73.3%.ConclusionsPure LRC with intracorporeal orthotopic ileal neobladder reconstruction may represent a viable alternative to open radical cystectomy, with a significant reduction in patient morbidity. Future, large, randomized controlled trials with extensive follow-up are needed to confirm our encouraging results.

Total cystectomy and W-shaped orthotopic ileal neobladder for bladder cancer

To investigate the clinical effect of total cystectomy and W-shaped orthotopic ileal neobladder for bladder cancer. Total cystectomy and W-shaped orthotopic ileal neobladder were performed on 29 male patients and 3 female patients. After the cystectomy, 35-40 cm terminal ileal segment was isolated to make W-shaped orthotopic ileal neobladder. Bilateral uretero-ileal anastomoses were constructed by nipple technique, urethral stump was sutured to the lowest portion of the ileal pouch. All surgeries were completed successfully. Patients were able to void by increasing the abdominal pressure, daytime continence rate was 87.5% and nighttime continence rate was 78.1%. The mean neobladder capacity was 410.6 mL and the mean postvoid residual urine was 22.7 mL at 6 months. After the surgery, ileal neobladder leakage occurred in 3 (9.4%) patients, mild ileus occurred in 2 (6.3%) patients, ileo-urethral anastomosis stricture developed in 1(3.1%) patient, and dysuria occurred in 3 (9.4%) patients because of the mucus. THe complications were treated properly and satisfactory results were obtained. Erection was preserved in 5 of the 9 male patients with normal erectile function, and normal sexual function was preserved in 1 female patient who underwent uterus-sparing cystectomy. The mean follow-up was 15 months. One patient died of distant metastasis and pneumonia, while other patients survived without tumor. Total cystectomy and W-shaped orthotopic ileal neobladder have the advantages of voiding through the native urethra, satisfactory continence, low complication rates of upper urinary tract damage and electrolyte imbalance. W-shaped orthotopic ileal neobladder may be considered as the first option of urinary diversion after cystectomy. Postoperative management should focus on complications and follow-up.

Early and late urodynamic assessment of the orthotopic N-shaped neobladder

The present study aimed to report the urodynamic data from 46 male patients who underwent an orthotopic N-shaped neobladder replacement following a radical cystectomy during a 12-month period and to provide urodynamic evidence for the improvement of this technique. A total of 46 consecutive male patients underwent a radical cystectomy and orthotopic N-shaped neobladder substitution due to muscle-invasive bladder cancer. Uroflowmetry, cystometry and urethral pressure profilometry were analyzed at 3–12 months following the surgery. The mean pressure of the neobladders was <15 cm H2O at volumes of <400 ml and 22.4 cm H2O at 100% capacity at 6 months. The mean pressure of the contractions was <40 cm H2O at 6 months. The mean filling pressure following the surgery at 3 months was higher compared with that at 6 months. No difference was observed at the other time-points. When comparing the 9- and 12-month urodynamic characteristics, no significant changes were observed in the cystometric capacity. The mean post-void residual (PVR) urine volume was 58 ml. A mean voiding peak of 16.2 ml/sec was obtained using the Valsalva maneuver. The daytime continence rate was 90% at 12 months while the night-time continence rate was 60%.

Functional outcomes after urinary diversion: The importance of long-term assessment

Radical cystectomy (RC) has been used to treat bladder cancer for over 100 years. Over time, therapy has evolved from a strictly ablative approach to one aimed at preserving health-related quality of life (HR-QOL). Orthotopic lower urinary tract (LUT) diversion represents the most recent form of LUT reconstruction after RC. Despite many advances, the optimal form of urinary diversion after cystectomy has yet to be definitively demonstrated.1 No randomized controlled trial exists comparing existing forms of urinary diversion and no true consensus has been achieved. This may be related in part to the underlying fact that improved health status does not always translate to a demonstrably better quality of life.2 This current article examines both renal and functional outcomes of orthotopic ileal neobladder diversion after RC.3 Using a cohort of 31 patients, Lantz and colleagues describe changes in serum creatinine, continence and reservoir emptying 1-year post-continent diversion. A significant rise in serum creatinine from a normal baseline and a 17.9% rate of uretero-ileal stricture formation were found. Eighty-nine percent of patients developed acceptable daytime continence at 1-year (defined as 0 to 1 pads used per day). Ultimately, patients with a urinary diversion are at risk of upper urinary tract deterioration. Up to 27% of patients with ileal conduit diversion develop renal dysfunction that may continue to worsen in a time-dependent manner. These changes may not become obvious for 10 to 20 years after urinary diversion. Detrimental change in renal function may be due to chronic urinary tract infection, ureteral obstruction or high neobladder pressures. This current study demonstrates a 26.3 μmol/L increase in serum creatinine from baseline 1-year after neobladder creation. A significant change occurred with or without the presence of hydronephrosis. The implications of these early findings highlight the need for meticulous long-term assessment of renal function and routine imaging of the upper urinary tract after urinary diversion. In this study, assessment of continence at 1-year revealed daytime and nighttime continence rates of 89% and 70%, respectively. Although no standard definition of continence or voiding function exists for patients after orthotopic diversion, these early results are encouraging and consistent with most published reports. After 12 months, it is thought that sphincteric function and full neobladder compliance have been achieved. However, deterioration in continence may occur gradually 5 years after orthotopic diversion. It is thought that sphincteric function may actually deteriorate with age and time.4 This further emphasizes the need for long-term assessment even when evaluating voiding function after continent diversion. When reporting functional outcomes after LUT reconstruction, it is also imperative to consider HR-QOL. It is widely assumed patients undergoing orthotopic diversion enjoy a better HR-QOL than those undergoing ileal conduit diversion. Currently, there is no definitive evidence.1 Studying HR-QOL measures in a prospective manner will help determine the ideal form of urinary diversion and further optimize patient outcomes. Implementation of HR-QOL outcomes specific to urology will likely play a large role in the future assessment of all forms of LUTreconstruction. Ultimately, long-term outcomes after orthotopic continent diversion are important to document any potential adverse change in renal function or urinary continence. If long-term continence is not achieved or is achieved at the expense of renal function, orthotopic diversion may not actually preserve HR-QOL. The ideal form of LUT replacement is still unknown, but with prolonged follow-up the ileal neobladder seems most likely to emerge as the gold standard of urinary diversion after RC.

Early initiation of toilet training for urine was associated with early urinary continence and does not appear to be associated with bladder dysfunction

To report the relationship between the ages initiating toilet training for urinary continence (TTU) and bladder function in healthy kindergarteners. In 3 years, we evaluated urinary continence status and bladder function in 318 healthy kindergarteners. Children with congenital anomaly, neurological disorder, or developmental disability were excluded. A parent completed the questionnaire including the age at initiation and the duration of TTU, the current status of daytime and nighttime continence, the age of attaining daytime and nighttime continence, frequency of defecation and Bristol Stool Scale. All children underwent uroflowmetry and post-void residual urine (PVR) examinations. Finally, 235 respondents (106 boys/129 girls, mean age = 4.8 ± 0.9 years) were eligible for analysis. The mean age initiating TTU was 24.4 ± 8.4 months (range: 1-52 months). Girls started TTU earlier than boys (23.3 months vs. 25.7 months, P = 0.03). Children started daytime TTU earlier (≤ 18, 19-24, and >24 months, N = 66, 71, and 98, respectively) was associated with earlier attainment of both daytime and nighttime continence (correlation coefficient = 0.60 and 0.31, respectively, P < 0.01). Children started nighttime TTU earlier (<30 months vs. ≥ 30 months) was associated with early attainment of nighttime continence and lower rate of enuresis (14.3% vs. 33.3%, P < 0.01). The prevalence rate of repeat abnormal uroflow patterns and repeat elevated PVR (>20 ml) was not different between early and late TTU. Early toilet training for urine was associated with early attainment of both daytime and nighttime urinary continence, and does not appear to be associated with bladder dysfunction.

Early and late urodynamic assessment of simplified Indiana pouch with multiple taeniamyotomies

To compare the early and late urodynamic assessment of simplified Indiana pouch with multiple taeniamyotomies (SIPMT). Between April 1999 and May 2005, 62 consecutive patients underwent radical cystectomy (RC) and SIMPT. Cystometry and efferent tract pressure profilometry were performed at 12 (early) and 48 (late) months after RC in 32 patients. The efferent tract of the reservoir was the appendix in 62.5% of patients and an ileum invagination nipple in 37.5%. All patients were asked to complete questionnaires on HRQL: the European Organization for Cancer Research and Treatment of Cancer Quality of life Questionnaire version 3.0 (EORTC QLQ-C30) and the bladder cancer-specific module (EORTC QLQ-BLM30). There was no significant change in cystometric capacity (median 627.5 vs 607.5 mL, P = 0.79), while end-filling pressure (median 28 vs 18 cmH₂O) and amplitude of involuntary contractions (median 38 vs 32 cmH₂O; both P < 0.001) decreased. Efferent tract-closing pressure increased in the appendicostomies (median 74.5 vs 91.0 cmH₂O, P= 0.029) and decreased in the ileostomies (median 72.5 vs 63 cmH₂O, P = 0.015), also the leakage rates during the pressure peaks decreased from 15% to 5% in appendicostomies, while there was no change in those with ileostomies (15%). At late evaluation, daytime and night-time continence rates were 94% and 88%, respectively, in patients with appendicostomies, and 90% and 85%, respectively, in those with ileostomies. A good HRQL was determined by the EORTC QLQ-C30 and QLQ-BLM30 questionnaires. At 48 months after surgery SIPMT maintained an adequate capacity with low internal pressure, good continence rates and HRQL. When feasible, appendicostomy should be performed, as it was associated with better continence.

1832 PRELIMINARY EXPERIENCE WITH PROSTATE-SPARING CYSTECTOMY FOR UROTHELIAL CARCINOMA OF THE BLADDER

You have accessJournal of UrologyBladder Cancer: Invasive/Metastatic Disease III1 Apr 20101832 PRELIMINARY EXPERIENCE WITH PROSTATE-SPARING CYSTECTOMY FOR UROTHELIAL CARCINOMA OF THE BLADDER Stephen McKim, Eugene Simopoulos, Jim Belsante, Matthew Raynor, Matthew Nielsen, Eric Wallen, and Raj Pruthi Stephen McKimStephen McKim More articles by this author , Eugene SimopoulosEugene Simopoulos More articles by this author , Jim BelsanteJim Belsante More articles by this author , Matthew RaynorMatthew Raynor More articles by this author , Matthew NielsenMatthew Nielsen More articles by this author , Eric WallenEric Wallen More articles by this author , and Raj PruthiRaj Pruthi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1770AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Several investigators have recently reported outcome with prostate-sparing cystectomy as an alternative to minimize the functional side effects of conventional radical cystectomy – particularly erectile dysfunction and voiding dysfunction. We report on our series with complete prostate-sparing cystectomy for bladder cancer. METHODS Fifteen men underwent a complete prostate-sparing cystectomy for recurrent non-invasive (n=4) or invasive (n=11) urothelial carcinoma of the bladder between 2004-2008. All men were potent pre-operatively and had a strong desire/priority to try to maintain this post-operatively. All men were counseled on the potential risks of a prostate-spring approach including the potential oncological risks (urothelial and prostate), and on the potential effects on voiding function. All men accepted these risks in balance of the potential benefit of maximizing erectile function. No man had urothelial disease near or at the bladder neck or in the prostatic fossa at TURBT, and all men had normal PSA values and DRE and no man had significant LUTS. RESULTS The fifteen men represented 6% (15/244) of the cystectomy procedures performed on men for urothelial carcinoma during this time period. Mean age was 58 years. 5/15 (33%) were clinical stage T1 or less and 10/15 (67%) were cT2. On surgical pathology, 7/15 were T1 or less, 4/15 were pT2N0, 3/15 were T3N0 and 1/15 N+. All men had negative urothelial and prostatic frozen section margins at the time of surgery. All T3 and N1 patients have received adjuvant chemotherapy, and overall no man has had evidence of local or recurrence at a mean (median) follow-up of 25 months (18 months). 12/15 men underwent an orthotopic neobladder and 3/15 received an ileal conduit. Of men with a neobladder, CIC, daytime continence, and nighttime continence rates were 17%, 100%, and 67%, respectively. Regarding potency, 14/15 (93%) men are able to have erectile function satisfactory for intercourse with or without the use of PDE5 inhibitors. CONCLUSIONS Prostate-sparing cystectomy appears to provide excellent functional results for the carefully selected and motivated patient. Although, short-term oncologic outcomes do not appear to be compromised, longer-term outcomes remain necessary given the aggressive and unforgiving nature of this disease. It cannot be overemphasized that patients must be carefully selected and counseled when considering this approach. Chapel Hill, NC© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e711 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Stephen McKim More articles by this author Eugene Simopoulos More articles by this author Jim Belsante More articles by this author Matthew Raynor More articles by this author Matthew Nielsen More articles by this author Eric Wallen More articles by this author Raj Pruthi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Early and Late Urodynamic Assessment of Padua Ileal Bladder

To report the data from a single series of 46 patients who underwent cystectomy and Padua ileal bladder (PIB) substitution during a 48-month period. Data are lacking concerning the changes in urodynamic characteristics of the orthotopic ileal neobladder. From January 2002 to April 2003, 46 consecutive male patients underwent radical cystectomy and PIB substitution for muscle-invasive bladder cancer. Uroflowmetry, cystometry, and urethral pressure profilometry were analyzed at 12 and 48 months after surgery. All patients were asked to complete a questionnaire regarding quality of life (the European Organization for Cancer Research and Treatment of Cancer Quality of Life Questionnaire and the bladder cancer-specific module). Of the 46 patients, 8 were lost to follow-up because of cancer-related death. When comparing the 12- and 48-month urodynamic characteristics, no significant changes were observed in cystometric capacity or urethral closing pressure. However, the end-filling pressure, peak flow pressure, and postvoid residual urine volume were significantly lower at the 48-month evaluation (P = .0005, P = .0007, and P = .013, respectively). The number of involuntary contractions at 48 months had increased significantly (P = .0012), and the amplitude of the contractions was comparable (P = .084). The daytime continence rate was 96% and 90% at 12 and 48 months, respectively. The nighttime continence rate was 60% at the 48-month evaluation. The questionnaires about the quality of life highlighted the excellent results. An ileal tone is maintained despite detubularization and most likely prevents enlargement of the neobladder. PIB was revealed to maintain an adequate capacity and low pressure during a 48-month period. The urodynamics results and quality of life support this urinary diversion as a valid treatment option for muscle-invasive bladder cancer.

Laparoscopic radical cystectomy with orthotopic ileal neobladder: report of 108 cases

To analyze the effects, complication, and outcome of laparoscopic radical cystectomy. 108 patients with bladder cancer, 96 males and 12 females, aged 61 (36 - 81) underwent laparoscopic radical cystectomy with orthotopic ileal neobladder. Five-port transperitoneal approach was applied. The surgical procedure included standard laparoscopic pelvic lymphadenectomy, radical resection of bladder, extracorporeal formation of ileal pouch; extracorporeal implantation of ureters; and laparoscopic urethra-neobladder anastomosis. Erectile nerve sparing procedure was performed for 26 cases. The patients were followed up for 1 - 53 months. The median operation time was 330 min, and the median blood loss was 320 ml. Conversion to open surgery was not necessary in any of the patients. There was no peri-operative mortality. The complication rate was 18.5% (20/108). Surgical margins were tumor free for all cases. The day-time and night-time continence rates were 90.7% and 82.6% respectively in 6 months postoperatively. 10 of the 26 patients undergoing erectile nerve-sparing procedure had potency for intercourse. Follow-up showed 5 cases with local recurrence, 1 case with trocar site seeding and 6 cases with distant metastasis, 8 of the patients died of tumor-related disease and 3 died of diseases not related to tumor. Laparoscopic radical cystectomy with extracorporeal formation of orthotopic ileal neobladder is a feasible technique with low morbidity and acceptable neobladder function.

Laparoscopic Radical Cystectomy with Orthotopic Ileal Neobladder: A Report of 85 Cases

The preliminary results of laparoscopic radical cystectomy in 85 patients are presented in this study. The functional and oncologic outcomes of this procedure in these patients are discussed. Between December 2002 and May 2006, we performed 85 laparoscopic radical cystectomies with orthotopic ileal neobladder for bladder cancer in 77 men and 8 women. A 5-port transperitoneal approach was applied. The standard bilateral pelvic lymphadenectomy was performed first, then radical cystectomy was completed laparoscopically. The construction of the ileal neobladder and the anastomosis of ureter-neobladder were performed extracorporeally. The neobladder was anastomosed to the urethral stump under laparoscopy. A nerve-sparing procedure was performed for eight patients. The median operative time was 320 min, and the median blood loss was 280 mL. Conversion to open surgery was not necessary in any of the patients. The average time to oral intake after operation was 3.9 days. There were no perioperative mortalities. The complication rate was 14.1% (12/85), including such complications as three uretero-pouch anastomotic strictures, one vesicourethral anastomotic stricture, one pouch-vaginal fistula, one colonic pouch fistula, one ileo-pouch fistula, three ileus, one pneumonia, and one pyelonephritis. The daytime continence rate was 91.2%, and the nighttime continence rate was 82.4% at 6 months postoperatively. The neobladder capacity was about 343 mL. Surgical margins were tumor free for all patients. Of the eight patients who underwent a nerve-sparing procedure, four patients had potency for intercourse. During a follow-up period of 1 to 41 months (average 21.3 months), three patients had local recurrence, one patient had trocar site seeding, and five patients had distant metastasis, of whom four died. Laparoscopic radical cystectomy with extracorporeal formation of a neobladder is a feasible procedure with low morbidity and acceptable neobladder function. Long-term follow-up is needed to confirm the oncologic outcomes.

Voiding Pattern and Incontinence after Orthotopic Ileal Neobladder in Male Patients

Purpose: To report the voiding pattern and continence stati in male patients having undergone a radical cystectomy and orthotopic bladder substitution. Materials and Methods: Between March 2000 and June 2005, 20 men with advanced bladder cancer had a radical cystoprostatectomy and urinary diversion via an ileal orthotopic bladder substitution. The voiding pattern and continence stati were assessed using patient interviews, frequencyvolume charts and pad tests at 1, 3, 6, 9 and 12 months after catheter removal. Results: The mean age and follow-up were 60.5 years (41-72) and 34.1 months (12-69), respectively. Neobladder substitution was performed with an ileum in all patients. 17 patients had reconstruction with a Studer neobladder and 3 with a W-pouch Hautmann. All patients had transitional cell carcinoma (TCC) and their tumor stages ranged from T1G3 to T4aN1M0. The frequency of voiding ranged from 4 to 12 times during the day, and 0 to 5 times during the night, with a mean maximum neobladder capacity of 336ml (200-620) and maximum flow rate of 24.6ml/sec (12-46) 12 months after removal of the catheter. No patient required intermittent self-catheterization. All-time continence rates were 15, 30, 65 and 85%, and all-time incontinence rates were 55, 25, 10 and 5% at 1, 3, 6 and 9 months after catheter removal, respectively. Conclusions: Orthotopic bladder substitution has an excellent functional outcome over time, resulting in high daytime and nighttime continence rates within 9 months of catheter removal. (Korean J Urol 2007;48:12-17) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

Long-term Functional Outcome and Late Complications of Studer's Ileal Neobladder

The purpose of this study was to evaluate the long-term functional outcome and late complications of Studer's ileal neobladder. The study included 57 patients who underwent radical cystectomy and bladder reconstruction with Studer's ileal neobladder, and were followed-up for at least 3 months after surgery. The voiding and storage function, and late complications were evaluated. The times of evaluation after surgery were categorized into periods I (3-23 months), II (24-59 months), III (60-95 months) and IV (> or =96 months). Daytime and night-time continence rates were 95.6 and 88.6%, respectively. The averages of functional capacity (439 ml), maximum flow rate (15.7 ml/s) and residual urine (35 ml) evaluated in period I were maintained in period IV. Of the 57 patients, intermittent self-catheterization was needed in five (8.8%) due to incomplete emptying or urinary retention. Urethroileal anastomotic stricture was found in two patients (3.5%), who were successfully treated by transurethral intervention. Inguinal hernia was found in seven patients (12.8%), five of whom developed it within 2 years after surgery. Our results indicate that Studer's ileal neobladder had a favorable long-term functional outcome. Although late complication rates were low, the incidence of inguinal hernia was relatively high, and this was considered as a definite late complication in our study.

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.