Ileal Orthotopic Bladder Substitution Research Articles

Modified N-shaped ileal neobladder after radical cystectomy

Objective We report on the feasibility and outcomes of the N-shaped pouch with an afferent tubular isoperistaltic segment as a new technique for creating a capacious, low pressure bladder substitute following radical cystectomy. Methods Between April 2000 and April 2006, 42 patients (36 male, 6 female) with invasive bladder cancer were considered good candidates for orthotopic urinary diversion. All had radical cystectomy with bilateral pelvic lymphadenectomy and orthotopic bladder substitution by an ileal low pressure reservoir (N-shaped) with an afferent isoperistaltic tubular segment. Of the 42 patients, 36 (86%) had squamous cell carcinoma; 6 had transitional cell carcinoma. None of the patients had positive lymph nodes after pathologic examination of the specimen. The patients were available for a median follow-up period of 24.8 months. Follow-up included clinical and radiographic studies to determine functional and oncological outcomes. Results Eleven patients (26.2%) had early complications during the period ≤ 3 months following surgery. Seven of these patients had complications such as wound infection, prolonged ileus, persistent urinary leakage, and deep venous thrombosis that were treated conservatively. One female patient developed a pouch-vaginal fistula that required repair. The remaining 3 patients had oncologic failures, 1 of which was isolated urethral recurrence. Late complications occurred in 15 patients (35.7%). These included pouch stones, outflow obstruction, mucus retention, and adhesive bowel obstruction. Daytime and night-time continence was achieved in 92% and 80% of the patients, respectively, and ureteroileal stricture was observed in 5%. The upper tracts remained unchanged or improved in nearly 95% of the patients. Conclusions Ileal orthotopic bladder substitution (N-shaped) with an afferent ileal tubular segment offers good functional results with good preservation of the renal units. It is considered a safe and technically feasible surgical procedure.

Do Patients Benefit from Routine Follow-up to Detect Recurrences After Radical Cystectomy and Ileal Orthotopic Bladder Substitution?

BackgroundThe need for and intensity of follow-up to detect disease recurrence after radical cystectomy (RC) for transitional cell carcinoma (TCC) remains a matter for debate. ObjectiveTo determine whether diagnosis of asymptomatic recurrence after RC by routine follow-up investigations confers a survival benefit versus symptomatic recurrence. Design, setting, and participantsRetrospective analysis of 479 patients with nonmetastatic bladder TCC receiving no neoadjuvant chemotherapy/radiation therapy and prospectively followed with a standardised protocol for a median 4.3 yr (range: 0.3–20.9) after RC at an academic tertiary referral centre. InterventionRC and extended pelvic lymph node dissection with ileal orthotopic bladder substitution. MeasurementsCancer-specific survival (CSS) and overall survival (OS) probability for asymptomatic and symptomatic recurrent patients were estimated using the Kaplan-Meier method. The effects of age, nerve-sparing surgery, pathologic tumour stage, lymph node status, adjuvant chemotherapy, mode of recurrence diagnosis, and recurrence site on survival were assessed with multivariable Cox regression models. Results and limitationsOf the 174 of 479 patients (36.3%) with tumour recurrence, 87 were diagnosed by routine follow-up investigations and 87 by symptoms. Routine follow-up mostly detected lung metastases and urethral recurrences, while symptoms were predominantly the result of bone metastases and concomitant pelvic/distant recurrences. Of 24 patients with urethral recurrences, 13 had carcinoma in situ (CIS). Of these, 12 were successfully managed with urethra-sparing treatment, and 6 are still alive with no evidence of disease. Most other recurrent long-term survivors had lung and extrapelvic lymph node metastases. Cumulative 5-yr survival rates of the entire cohort were 69.8% (95% confidence interval [CI], 65.5–74.3%) for CSS and 61.9% (95% CI, 57.4–66.7%) for OS. In multivariable analysis, mode of recurrence diagnosis and site of initial recurrence were the only independent predictors of CSS and OS. Patients with recurrences detected by routine follow-up investigations and with secondary urothelial tumours as site of recurrence had a slightly but significantly higher survival probability. ConclusionsPatients diagnosed with asymptomatic recurrences during our routine follow-up after RC had a slightly higher survival than patients with symptomatic recurrences. Routine follow-up appears particularly effective in early detection of urethral CIS, which can be treated conservatively. In addition, the predominance of lung and extrapelvic lymph node metastases in survivors may justify the use of routine cross-sectional imaging.

750 WHICH FACTORS INFLUENCE URINARY CONTINENCE AFTER RADICAL CYSTOPROSTATECTOMY AND ILEAL ORTHOTOPIC BLADDER SUBSTITUTION?

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion I1 Apr 2010750 WHICH FACTORS INFLUENCE URINARY CONTINENCE AFTER RADICAL CYSTOPROSTATECTOMY AND ILEAL ORTHOTOPIC BLADDER SUBSTITUTION? Thomas M. Kessler, Gianluca Giannarini, and Urs E. Studer Thomas M. KesslerThomas M. Kessler More articles by this author , Gianluca GiannariniGianluca Giannarini More articles by this author , and Urs E. StuderUrs E. Studer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1302AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To assess factors influencing urinary continence after radical cystoprostatectomy and ileal orthotopic bladder substitution. METHODS In the present study, 476 men undergoing radical cystoprostatectomy and ileal orthotopic bladder substitution for transitional cell carcinoma were included. We used multivariate Cox regression models to evaluate factors potentially influencing postoperative urinary continence. Variables considered were patient age, nerve sparing, ileal length used for reservoir construction, tumor stage, tumor grade, and lymph node status. RESULTS In multivariate Cox regression models, nerve sparing significantly improved the rate of daytime continence, whereas age younger than 65 years was the single factor associated with a significantly better nighttime continence: Daytime continence rate in patients with nerve sparing was 1.5 times higher (hazard ratio (HR) 1.5, 95% confidence interval (CI) 1.17-2.02, p=0.002) than in those without nerve sparing. Nighttime continence was 1.4 times more often achieved (HR 1.4, 95% CI 1.12-1.74, p=0.003) in patients younger than 65 years than in those older than 65 years. CONCLUSIONS After radical cystoprostatectomy and ileal orthotopic bladder substitution, nerve sparing has the greatest impact on daytime continence, whereas age has the greatest impact on nighttime continence. Thus, if radical tumor resection is not compromised, nerve sparing radical cystoprostatectomy is to be strongly recommended. Bern, Switzerland© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e293 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thomas M. Kessler More articles by this author Gianluca Giannarini More articles by this author Urs E. Studer More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1834 DO ROUTINE FOLLOW-UP INVESTIGATIONS FOR DETECTING RECURRENCES AFTER RADICAL CYSTECTOMY BENEFIT THE PATIENT?

You have accessJournal of UrologyBladder Cancer: Invasive/Metastatic Disease III1 Apr 20101834 DO ROUTINE FOLLOW-UP INVESTIGATIONS FOR DETECTING RECURRENCES AFTER RADICAL CYSTECTOMY BENEFIT THE PATIENT? Gianluca Giannarini, Thomas M. Kessler, Harriet C. Thoeny, Claudia Meissner, and Urs E. Studer Gianluca GiannariniGianluca Giannarini More articles by this author , Thomas M. KesslerThomas M. Kessler More articles by this author , Harriet C. ThoenyHarriet C. Thoeny More articles by this author , Claudia MeissnerClaudia Meissner More articles by this author , and Urs E. StuderUrs E. Studer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1772AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The need for follow-up (FU) and the intensity to detect disease recurrence after radical cystectomy for transitional cell carcinoma (TCC) is a matter of debate. We determined whether the diagnosis of asymptomatic recurrence by routine FU exams is associated with a survival benefit compared to that of symptomatic recurrence after radical cystectomy. METHODS A consecutive series of 418 patients with bladder TCC who underwent extended pelvic lymph node dissection and radical cystectomy with ileal orthotopic bladder substitution were analyzed retrospectively. All patients were prospectively followed up with a standardized institutional protocol. Recurrence patterns were categorized as pelvic, distant and concomitant pelvic/distant recurrences, and secondary urothelial tumors. Cancer-specific and overall survival were assessed for asymptomatic and symptomatic recurrent patients. The effect of age, nerve sparing surgery, tumor stage, lymph node status, adjuvant chemotherapy, mode of recurrence diagnosis and recurrence site on survival was explored with multivariate Cox regression models. RESULTS After a median FU of 44 months (range 3-220), 153/418 (37%) patients were diagnosed with recurrence. Of the 153 recurrent patients, 75 (49%) were diagnosed by routine FU exams and 78 (51%) by symptoms (p=0.99). Routine FU investigations mostly detected lung metastases and urethral recurrences, while symptoms were predominantly due to bone metastases and concomitant pelvic/distant recurrences. Of 18 men with urethral recurrences, 7 are still disease-free after urethra-sparing treatment. Among the other long-term survivors with recurrence, there were patients with lymph node and lung metastases. In multivariate analysis, mode of recurrence diagnosis and site of initial recurrence were the only independent predictors of both cancer-specific and overall survival. Patients with recurrences detected by routine FU investigations and patients with secondary urothelial tumors as recurrence site had a slightly, but significantly higher survival probability. CONCLUSIONS Patients diagnosed during our routine FU with asymptomatic recurrences after radical cystectomy for bladder TCC had a slightly better survival than patients with symptomatic recurrences. Regular surveillance appears to be particularly effective in early detection of urethral recurrences, which can be treated conservatively. In addition, the predominance of lymph node and lung metastases in long-term survivors may justify the use of routine CT scan. Bern, Switzerland© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e712 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gianluca Giannarini More articles by this author Thomas M. Kessler More articles by this author Harriet C. Thoeny More articles by this author Claudia Meissner More articles by this author Urs E. Studer More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP-13.15: Seminal Vesicle(s) Sparing Cystectomy Combined with Ileal Orthotopic Bladder Substitution Allows for Good Functional Results

MP-13.15: Seminal Vesicle(s) Sparing Cystectomy Combined with Ileal Orthotopic Bladder Substitution Allows for Good Functional Results

Outcome of Sigmoid Compared to Ileal Orthotopic Bladder Substitution in Terms of Micturition and Defecation Parameters in an 8-Year Long-Term Follow-Up

Introduction: Various techniques have been described for orthotopic bladder substitution. Bladder substitution with sigma is rather classed as a useful alternative standby. We report the long-term results of sigmoid neobladder in comparison to ileal neobladder with respect to urodynamic and defecation parameters. Patients and Methods: We matched 10 patients with sigmoid neobladder (mean age 62.6 ± 10.9) and 10 patients with ileal neobladder (mean age 66.4 ± 10.2). Mean follow-up for sigmoid neobladder was 8.1 ± 2.1 years and 7.2 ± 1.9 years for the ileal neobladder. Each patient was evaluated by medical history, the SF-36 questionnaire, physical examination and urodynamics. Results: Bladder capacity differed significantly between both groups (sigmoid neobladder 619 ml, ileal neobladder 422 ml). Pressure showed a slight statistical difference (sigmoid neobladder 15 ± 3 cm H₂O, ileal neobladder 18 ± 4 cm H₂O). The defecation frequency varied significantly between the two groups (sigmoid neobladder 1.1/day, ileal neobladder 3.1/day, p < 0.0001). The SF-36 questionnaire showed no significant difference. Conclusion: Orthotopic bladder substitution with sigmoid segments has shown equivalent results compared to orthotopic ileal bladder substitution. The sigmoid neobladder is a useful alternative to the ileal neobladder.

How to Avoid Clean Intermittent Catheterization in Men With Ileal Bladder Substitution

In male patients with ileal bladder substitute we ascertained the likelihood of spontaneous voiding failure, the corrective procedures required and the eventual outcomes. Following cystectomy and ileal bladder substitution for urothelial cancer between April 1985 and September 2002 male patients were identified and analyzed from the prospective departmental database. Four patients underwent ileum conduit conversion following urethral recurrence or pouch necrosis and were excluded from study. Funnel-shaped outlets were avoided during bladder substitute surgery after the first 4 patients with this configuration experienced voiding failure and required corrective procedures. Only patients with a minimum 5-year followup were assessed for voiding failure, corrective procedures and final outcomes. Of 354 patients with a median age of 65 years (range 36 to 84) treated with bladder substitute 180 (51%) were alive at 5 years. All 180 of these patients spontaneously voided within 3 months of surgery. During this 5-year observation period 22 (12%) patients experienced voiding problems requiring de-obstructive procedures. Following intervention 177 (98%) patients were spontaneously voiding by 5 years. Of 237 patients 77 (32%) were alive at 10 years. Of these 77 patients followed for another 5 years 10 (13%) had similar voiding problems requiring de-obstructive procedures. Subsequently 74 (96%) were voiding spontaneously by 10 years. Patients often fail to void spontaneously after ileal bladder substitution. However, if a funnel-shaped outlet is avoided and de-obstructive surgery is appropriately implemented, excellent long-term results are seen with spontaneous voiding and clean intermittent catheterization can be avoided.

Health related quality of life after radical cystectomy: Comparison of ileal conduit to continent orthotopic neobladder

Aims To compare health related quality of life (HRQOL) between patients with two different types of urinary diversion, ileal conduit and orthotopic neobladder, and between them and an age-matched population of healthy subjects. Materials and methods Eighty eight patients treated with radical cystectomy for bladder cancer at our institutions between 2002 and 2007 were contacted for this survey. All of them had a follow-up of more than 12 months after surgery and were recurrence free. The SF-36 questionnaire was provided to each patient during a follow-up visit at outpatient clinics. Overall, 79 patients (90%) returned the questionnaire and were included in this analysis. They were divided into two groups: group 1 comprised 44 patients with an ileal conduit diversion, and group 2 included 35 patients with a neobladder. As a control, normative values of an age-matched healthy Italian population were considered. Results No significant difference was found in scale scores between the neobladder and ileal conduit groups. Scale scores for role-physical functioning, social functioning and role-emotional functioning in both the neobladder and ileal conduit groups were significantly below the Italian population norm. Patients with a neobladder 65 years old or older ( n = 18) had significantly lower scores for role-physical functioning and role-emotional functioning than those younger than 65 years ( n = 17; p < 0.05). Conclusion Few differences between ileal conduit and orthotopic bladder substitution have been detected. Thus, the assumption that continent reconstruction provides better HRQOL than ileal conduit diversion cannot be supported. Patient education and active participation in treatment decisions seem to be the key to postoperative satisfaction.

ILEAL ORTHOTOPIC BLADDER SUBSTITUTION COMBINED WITH AN AFFERENT TUBULAR SEGMENT

You have accessJournal of Urology1 Apr 2008ILEAL ORTHOTOPIC BLADDER SUBSTITUTION COMBINED WITH AN AFFERENT TUBULAR SEGMENT Urs E Studer and Nivedita Bhatta Dhar Urs E StuderUrs E Studer More articles by this author and Nivedita Bhatta DharNivedita Bhatta Dhar More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(08)62068-6AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "ILEAL ORTHOTOPIC BLADDER SUBSTITUTION COMBINED WITH AN AFFERENT TUBULAR SEGMENT." The Journal of Urology, 179(4S), p. 710 © 2008 by American Urological AssociationFiguresReferencesRelatedDetails Volume 179Issue 4SApril 2008Page: 710 Advertisement Copyright & Permissions© 2008 by American Urological AssociationMetricsAuthor Information Urs E Studer More articles by this author Nivedita Bhatta Dhar More articles by this author Expand All Advertisement PDF downloadLoading ...

Prevalence of Nephrolithiasis in Patients with Ileal Bladder Substitutes

To assess the effect of ileal bladder substitutes with preservation of the ileocecal valve and distal 25 cm of ileum on nephrolithiasis. We reviewed a consecutive series of 518 patients (44 women and 474 men) with ileal orthotopic bladder substitution in whom 55 to 65 cm of ileum was resected but with preservation of the ileocecal valve and distal 25 cm of ileum, to determine prevalence of nephrolithiasis as well as bicarbonate, base excess, creatinine levels, and urinary pH at time of stone diagnosis and 2 years before it. Four male patients with a median age of 66 years (range, 50 to 70 years) developed nephrolithiasis after ileal bladder substitute, for a total of five calculi. The prevalence of nephrolithiasis in this retrospective cohort is thus 1% (5 of 518). They developed the calculi after a median follow-up of 8 years (range, 4 to 17 years). The four patients were diagnosed with calculi at 2.3, 3, 10, 10.3, and 14 years after bladder substitute. Two of the stones were uric acid calculi; the remaining three were calcium oxalate. None of our patients were acidotic or had elevated serum creatinines at time of stone formation. Urinary pH determined once in spontaneously voided urine at the time of stone diagnosis was pH 6.0 for the two uric acid calculi and pH 7.0 for the remaining calculi. The present study demonstrates a low prevalence of calculi in our cohort.

Diabetes Mellitus: Does It Impair Urinary Continence after Radical Cystoprostatectomy and Ileal Orthotopic Bladder Substitution?

ObjectiveTo assess the effect of diabetes mellitus (DM) on urinary continence after radical cystoprostatectomy and ileal orthotopic bladder substitution. MethodsPatients with DM undergoing radical cystoprostatectomy and ileal orthotopic bladder substitution without prior radiotherapy and with a minimum follow-up of 12 mo were identified from our database. Twenty-two men met the inclusion criteria and were randomly matched to 22 nondiabetic controls for age, ileum length used for reservoir construction, attempted nerve-sparing surgery, pathologic tumour stage, and pathologic lymph node status to assess the effect of DM on urinary continence. ResultsAll 22 diabetic patients suffered from type 2 DM. Twelve were treated with oral antidiabetics and 10 required insulin. Daytime continence was significantly worse in the diabetic patients compared to nondiabetic controls 3 mo (odds ratio [OR] 21; 95% confidence interval [CI], 2.4–185; p=0.001) and 6 mo (OR 17.5; 95% CI, 2–154; p=0.002) postoperatively. Thereafter no significant difference was detectable. In diabetic patients nighttime continence was worse. The difference was statistically significant at 3 mo (OR 7.3; 95% CI, 1.9–28; p=0.002), 6 mo (OR 9.1; 95% CI, 2.3–36; p=0.001), 12 mo (OR 7.1; 95% CI, 1.9–27; p=0.003), and 24 mo (OR 5.7; 95% CI, 1.3–26; p=0.018) after surgery. ConclusionsPatients with DM take longer to regain daytime and, even more so, nighttime continence than nondiabetic patients. Diabetic patients undergoing radical cystoprostatectomy should be informed of the potential negative impact of DM on the recovery of urinary continence after an ileal orthotopic bladder substitution.

What has 20 years' experience of ileal orthotopic bladder substitution taught us?

What has 20 years' experience of ileal orthotopic bladder substitution taught us?

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

Is There an Indication for Frozen Section Examination of the Ureteral Margins During Cystectomy for Transitional Cell Carcinoma of the Bladder?

We evaluated the incidence of pathological findings of the ureter at cystectomy for transitional cell carcinoma of the bladder and assessed the usefulness of intraoperative frozen section examination of the ureter. Histopathological findings of ureteral frozen section examination were compared to the corresponding permanent sections and the diagnostic accuracy of frozen section examination was evaluated. These segments were then compared to the more proximal ureteral segments resected at the level where they cross over the common iliac arteries. The histopathological findings of the ureteral segments were then correlated for upper urinary tract recurrence and overall survival. Transitional cell carcinoma or carcinoma in situ was found on frozen section examination of the distal ureter in 39 of 805 patients (4.8%) and on permanent sections in 29 (3.6%). In 755 patients the false-negative rate of frozen section examination of the ureters was 0.8%. Of the patients with carcinoma in situ diagnosed on the first frozen section examination 80% also had carcinoma in situ in the bladder. Transitional cell carcinoma or carcinoma in situ in the most proximally resected ureteral segments was found in 1.2% of patients. After radical cystectomy there was tumor recurrence in the upper urinary tract in 3% of patients with negative ureteral frozen section examination and in 17% with carcinoma in situ on frozen section examination. Routine frozen section examination of the ureters at radical cystectomy is only recommended for patients with carcinoma in situ of the bladder, provided the ureters are resected where they cross the common iliac arteries.

Twenty Years Experience With an Ileal Orthotopic Low Pressure Bladder Substitute—Lessons to be Learned

We present the long-term results of a large consecutive series of patients undergoing ileal orthotopic bladder substitution following radical cystectomy. Between April 1985 and 2005 orthotopic bladder substitution with an ileal low pressure reservoir was performed in 482 patients (including 40 women) after radical and, if possible, nerve sparing cystectomy. In 447 cases the procedure was combined with an afferent ileal isoperistaltic tubular segment. The patients were followed prospectively. In the 482 patients 61 early (less than 30 days) diversion related complications requiring prolonged hospital stay or readmission were noted and 115 late complications required treatment. At 1 year continence was good in 92% of patients during the day and in 79% at night. At last followup 93% of patients could void spontaneously. Of 442 evaluable men 99 (22.4%) reported having erections without and 68 (15.4%) with medical assistance. Ureteroileal stenosis was observed in 12 of 447 (2.7%) patients. Urethral recurrence was detected in 25 of 482 (5%) patients. A total of 15 (5%) patients received vitamin B12 substitution. Renal parenchyma decreased only in patients with preoperative or postoperative ureteral obstruction. After 10 years patients with normal renal function had no long-term acidosis and in 20 patients the incidence of osteoporosis resembled that of the normal population. Ileal orthotopic bladder substitution combined with an afferent ileal tubular segment allows for good long-term functional results provided patients are restrictively selected, postoperative instructions are followed carefully, and typical complications such as outlet obstruction and hernias are treated early.

Early and Late Urodynamic Assessment of Ileal Orthotopic Bladder Substitutes Combined With an Afferent Tubular Segment

Limited information is available concerning changes in the urodynamic characteristics of orthotopic bladder substitutes with time. Therefore, we compared early and late urodynamic results in patients with an ileal orthotopic bladder substitute combined with an afferent tubular segment. Of 139 patients surviving at least 5 years after cystoprostatectomy and ileal orthotopic bladder substitution with an afferent tubular segment 119 underwent urodynamic assessment, including 66 at a median of 9 months (early) and 77 at a median of 62 months (late). Of these patients 24 were assessed at each time point. Simultaneously all patients were asked to complete a bladder diary and questionnaire regarding continence for at least 3 days in the week preceding the urodynamic study. Urodynamic parameters were comparable in patients who were evaluated early and late postoperatively. In addition, median values at early and late urodynamic evaluation in the 24 patients with the 2 examinations showed no statistically significant differences for volume at first desire to void (300 vs 333 ml, p = 0.85), pressure at first desire to void (12 vs 13 cm H2O, p = 0.57), maximum cystometric capacity (450 vs 453 ml, p = 0.84), end filling pressure (19 vs 20 cm H2O, p = 0.17), reservoir compliance (25 vs 28 ml/cm H2O, p = 0.58) or post-void residual urine volume (5 vs 15 ml, p = 0.27). Urodynamic results after 5 years of living with an ileal orthotopic bladder substitute with an afferent tubular segment show grossly unchanged urodynamic characteristics. Patients maintain a reservoir capacity and micturition pattern consistent with a normal life-style. Reservoir pressure remained low, thereby protecting and preserving upper tract function. To achieve these results patients must be regularly followed, and the causes of bacteriuria, increased post-void residual urine and bladder outlet obstruction must be recognized and dealt with accordingly.

Bilateral ureterocutaneostomy with modified stoma: long-term follow-up

Ileal conduit and orthotopic bladder substitution have been the preferred options for urinary diversion after cystectomy. Self-catheterisation has revolutionised the management of neuropathic bladder. However, ureterocutaneostomy (cutaneous ureterostomy) described as a means of supravesical urinary diversion 40 years ago still has a definite role for both temporary and permanent diversion particularly in the developing countries. We present a small series of cutaneous ureterostomies performed in four children who have now grown up to become adults without being undiverted. We discuss the technique that we used to modify the stoma, which helped prevent stomal complications over the long term. Our results we believe will rekindle the interest in cutaneous ureterostomy as a viable option for permanent urinary diversion. Four children between ages 2 and 16 years had bilateral side-to-side single stoma tubeless end cutaneous ureterostomy as a primary procedure for permanent urinary diversion. The stoma was modified to prevent retraction and stenosis. Long-term follow-up is presented. All the children have grown up to become adults with their ureterocutaneostomies functioning very well. There have been no biochemical or mechanical complications. Only one out of four stomas had to be refashioned. A simple collection device has proved successful in maintaining a watertight drainage system without apparent problems. Bilateral side-to-side single stoma end cutaneous ureterostomy with modification of the stoma by a plastic surgical technique can help achieve a non-retracting stoma on which a collection device can snuggly fit. It is a viable option for permanent urinary diversion without any significant complications. It is simple, easy and highly practical way of managing urinary diversion especially in the developing countries.

Is ileal orthotopic bladder substitution with an afferent tubular segment detrimental to the upper urinary tract in the long term?

We determine long-term morphological changes of the upper urinary tract following ileal orthotopic bladder substitution with an afferent tubular segment without a flap-valve type antireflux procedure. A consecutive series of long-term survivors (5 years or greater) following ileal orthotopic bladder substitution underwent regular radiological followup with excretory urography. Preoperative and postoperative renal size, parenchymal thickness, pelvicaliceal dilatation and upper urinary tract obstruction were assessed by 2 radiologists. A total of 76 patients with a median followup of 84 months (range 60 to 155) were evaluable. Four patients (2.6%) underwent unilateral nephroureterectomy during followup. Of the remaining 148 renoureteral units 141 (95%) revealed no significant changes in size or parenchymal thickness during followup. Renal size decreased in 6 (4%) and parenchymal thickness in 7 (5%) renoureteral units, 5 of which already had renal pathologies (dilatation, obstruction or hypoplastic kidney) preoperatively. De novo shrinkage of the parenchyma of a preoperatively normal kidney was observed in 2 (1%) renoureteral units associated with stenosis of the ureteroileal anastomosis. Of the 148 renoureteral units 14 (9%) presented with nonobstructive dilatation and 4 (3%) with complete obstruction. Preoperatively average serum creatinine level +/- SD was 98 +/- 19 micromol./l. and 10 years thereafter it was 83 +/- 27 micromol./l. These data suggest that unidirectional peristalsis of ureters and the afferent tubular ileal segment sufficiently protect the upper urinary tract following ileal bladder substitution up to a decade provided there are no preoperative renal pathology and no anastomotic stricture postoperatively. Additional antireflux flap-valve type implantation techniques are not required.

273: What is More Important for Urinary Continence and Erectile Function after Radical Cystoprostatectomy and Ileal Orthotopic Bladder Substitution: Age or Attempted Nerve Sparing?

273: What is More Important for Urinary Continence and Erectile Function after Radical Cystoprostatectomy and Ileal Orthotopic Bladder Substitution: Age or Attempted Nerve Sparing?

Selection and perioperative management of patients undergoing an orthotopic ileal bladder substitution

Orthotopic ileal bladder substitution (Studer pouch) has gained much popularity during the last decade, offering the best form of urinary diversion in appropriately selected patients. The superiority of this procedure is well known, with a low complication and high success rate. In the present study the most important details in patient selection, surgical technique, perioperative management with short- and long-term postoperative follow-up are described. Adequate preoperative assessment results in a proper indication for surgery and appropriate patient selection. The cystectomy should be performed with atraumatic dissection and preservation of the urethral autonomic innervation and sphincter apparatus. The bladder substitute is constructed from a terminal ileal segment of proper length formed into a spherical shape. Implantation of the ureters into the reservoir should not be performed using an anti- reflux technique to avoid a high stricture rate. Anastomosis of the bladder substitute to the urethra must be flat and wide open, avoiding a funnel-shaped outlet. In the immediate postoperative period, careful monitoring is necessary to minimize metabolic complications of acidosis and salt loss. To achieve successful voiding rehabilitation, with complete reservoir emptying, good functional reservoir capacity and satisfactory continence, it is necessary to educate the patients as to the physiological functioning of the bladder substitute. Careful lifelong follow up is essential for the successful outcome. Respecting strict patient selection criteria and proper surgical technique are of utmost importance for the successful outcome of the procedure, but only if combined with regular follow-up.