Orthotopic Ileal Neobladder Research Articles

Quality-of-life outcomes and unmet needs between ileal conduit and orthotopic ileal neobladder after radical cystectomy in a Chinese population: a 2-to-1 matched-pair analysis.

BackgroundHealth-related quality-of-life (HRQoL) is an important consideration after radical cystectomy (RC). Lack of effective ways to assess HRQoL after RC and unawareness of disease-specific problems related to ileal conduit (IC) and orthotopic ileal neobladder (OIN) are serious problems. The present study was to evaluate and compare morbidity and HRQoL between IC and OIN after RC, and examine their unmet needs in the two groups.MethodsA retrospective analysis was made of 294 patients treated with RC in our hospital between 2007 and 2013. Matched pair analysis was used to determine the patients of IC and OIN groups. Patient HRQoL between IC and OIN groups was assessed using the bladder-specific bladder cancer index (BCI) and European Organization for Research and Treatment of Cancer Body Image scale (BIS) questionnaires. Unmet information of patients undergoing these two urinary diversions was recorded through individual interviews.ResultsOf the 117 included patients, 39 patients were treated with OIN and the other 78 matched patients with IC as controls for matched pair analysis. There was no significant difference in baseline characteristics between the two groups. OIN patients showed significantly better BIS scores in terms of HRQoL outcomes after RC at a short-term (<1 year) follow-up level, but there was no significant difference at a long-term (>1 year) follow-up level between the two groups. Interestingly, urinary bother (UB) and urinary function (UF) were poor in OIN patients at the one-year follow-up level, but there was no significant difference in UB between the two groups at the long term follow-up level. Unmet needs analysis showed that OIN patients had a more positive attitude towards treatment and participated in physical and social activities more positively, although they may have more urine leakage problems.ConclusionsThe mean BIS score in OIN group patients was significantly better than that in IC group patients at the one-year follow-up level, but there was no significant difference at the long-term follow-up level. Due attention should be paid to some particular unmet needs in individual patients in managing the two UD modalities.Electronic supplementary materialThe online version of this article (doi:10.1186/s12894-015-0113-7) contains supplementary material, which is available to authorized users.

Studer Orthotopic Neobladder: A Modified Surgical Technique

To describe a modified technique for orthotopic ileal neobladder preparation. The Studer technique is the method most frequently used worldwide and seems to be an ideal reconstructive solution after radical cystectomy. After radical cystectomy, urinary diversion is attained by means of a detubulized ileal segment. About 40 cm are used to create the reservoir and 15 cm for a tubular afferent limb. A spheroidal-shaped reservoir is then obtained with a conic distal part that will be anastomized to the urethral stump. After the reconstructive part, the neobladder and the afferent limb are attached to the levator ani and psoas muscles, respectively. Postoperative results on a series of 36 patients are reported. The final shape of the reservoir was roughly spherical. A small amount of anastomotic strictures was registered. Renal function was not impaired after surgery, even at late follow-up. Even if the Studer technique is already well described, we believe that our technical changes may improve urinary tract restoration, and potentially decrease complications typical of urinary orthotopic diversion. Further cases are required to confirm possible advantages of the modified technique.

Recurrence of isolated transitional cell carcinoma in an orthotopic ileal neobladder: A case report

Recurrent tumors inside an orthotopic ileal neobladder are rare, and only few cases have been reported in the literature. Herein, we report a case of recurrent transitional cell carcinoma in an orthotopic ileal neobladder discovered one and a half years after the operation.

Quality of Life Assessment With Orthotopic Ileal Neobladder Reconstruction After Radical Cystectomy: Results From a Prospective Italian Multicenter Observational Study

To assess health-related quality of life (HRQoL) parameters in patients who received radical cystectomy (RC) with ileal orthotopic neobladder (IONB) reconstruction and to identify clinic-pathologic predictors of HRQoL. From January 2010 to December 2013, a multicenter, retrospective on 174 RC-IONB patients was carried out. All patients completed the following questionnaires: the European Organization for Research and Treatment of Cancer (EORTC) generic (QLQ-C30) and bladder cancer-specific instruments (QLQ-BLM30) and the IONB-Patient Reported Outcome (IONB-PRO). Univariate and multivariate analyses were computed to identify clinic-pathologic predictors of HRQoL. Median age was 66 years (range, 31-83), and 91.4% of patients were men. Median follow-up period was 37 months (range, 3-247). The EORTC QLQ-C30 revealed that age >65 years, absence of urinary incontinence, and absence of peripheral vascular disease were independent predictors of deteriorated body image. A follow-up > 36 months and the presence of urinary incontinence were independent predictors of worsened urinary symptoms, whereas the absence of urinary incontinence was an independent predictor of a worsened body image according to EORTC QLQ-BLM30 results. A follow-up >36 months and the absence of urinary incontinence were independent predictors of better functioning in terms of relational life, emotional life, and fatigue as revealed by the IONB-PRO. Age, presence of urinary incontinence, length of follow-up, and comorbidity status may influence postoperative HRQoL and should all be taken into account when counseling RC-IONB patients.

Anterior urethra sparing cystoprostatectomy for bladder cancer: a 10-year, single center experience.

PurposeDecision making regarding the urethra before and after radical cystectomy due to urothelial carcinoma has always been controversial. To determine whether anterior urethra sparing cystoprostatectomy for bladder cancer is an oncologically-safe procedure, we evaluated the long-term oncologic clinical outcome.Patients and methodsA total of 51 male patients with cTa-4N0-2M0 bladder cancer were treated with anterior urethra sparing cystoprostatectomy and simultaneous urinary diversion between 2000 and 2013, and underwent follow up for 4 months or more. We assessed differences in the perioperative outcomes, oncologic outcomes and recurrence rates according to the urinary diversion.ResultsThe median patient age and follow-up period were 66 years and 35 months, respectively. The 5- and 10-year recurrence free survival (RFS) rates in ileal conduit (IC) group vs. orthotopic neobladder reconstruction (NB) group were 45.0 and 20.3% vs. 39.3 and 19.6%, respectively. Likewise, the 5- and 10-year disease specific survival (DSS) were 52.7 and 32.1% vs. 39.3 and 29.5%, respectively. Multivariate analysis revealed two independent prognostic factors for RFS and DSS, including age at surgery and lymph node status. Local recurrence in the remnant anterior urethra occurred in only 1 patient (2.0%) at 57 months after surgery.ConclusionsOur long-term data show that anterior urethra sparing cystoprostatectomy is an oncologically-safe procedure regardless of the type of urinary diversion in a subset of carefully selected patients with bladder cancer without evidence of urothelial carcinoma in the urethra/bladder neck and urethral surgical margin.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-015-1200-7) contains supplementary material, which is available to authorized users.

Detour technique, Dipping technique, or Ileal bladder flap technique for surgical correction of uretero-ileal anastomotic stricture in orthotopic ileal neobladder.

ABSTRACTBackground:Uretero-ileal anastomotic stricture (UIAS) is a urological complication after ileal neobladder, the initial management being endourological intervention. If this fails or stricture recurs, surgical intervention will be indicated.Design and Participants:From 1994 to 2013, 129 patients were treated for UIAS after unsuccessful endourological intervention. Unilateral UIAS was present in 101 patients, and bilateral in 28 patients; total procedures were 157. The previous ileal neobladder techniques were Hautmann neobladder, detubularized U shape, or spherical shape neobladder.Surgical procedures:Dipping technique was performed in 74 UIAS. Detour technique was done in 60 renal units. Ileal Bladder flap was indicated in 23 renal units. Each procedure ended with insertion of double J, abdominal drain, and indwelling catheter.Results:Follow-up was done for 12 to 36 months. Patency of the anastomosis was found in 91.7 % of cases. Thirteen patients (8.3%) underwent antegrade dilatation and insertion of double J.Conclusion:After endourological treatment for uretero-ileal anastomotic failure, basically three techniques may be indicated: dipping technique, detour technique, and ileal bladder flap. The indications are dependent on the length of the stenotic/dilated ureteral segment. Better results for long length of stenotic ureter are obtained with detour technique; for short length stenotic ureter dipping technique; when the stenotic segment is 5 cm or more with a short ureter, the ileal tube flap is indicated. The use of double J stent is mandatory in the majority of cases. Early intervention is the rule for protecting renal units from progressive loss of function.

AB014. Laparoscopic radical cystectomy and intracorporeal orthotopic ileal neobladder with bilateral isoperistaltic afferent limbs: initial experience.

ObjectiveTo describe the surgical technique and initial experience of laparoscopic radical cystectomy and intracorporeal orthotopic ileal neobladder with bilateral isoperistaltic afferent limbs.Materials and MethodsFrom January 2014 to Jun 2015, 11 patients underwent a new method of orthotopic ileal neobladder intracorporeally after laparoscopic radical cystectomy at our institution. To construct the neobladder, an ileal segment 60 cm long was isolated approximate 25 cm proximally to the ileocecum. The proximal 20 cm of the ileal segment was divided into 2 parts for bilateral isoperistaltic afferent limbs. The proximal 10 cm of the ileal segment 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. The remaining length of the 40 cm ileal segment was detubularized along its antimesenteric border for the reservoir. The demographics, perioperative and follow-up data were analyzed for the study.ResultsAll surgeries were successfully performed without open conversion. The mean operative time was 365 minutes, and mean neobladder construction time was 246 minutes. The mean estimated blood loss was 190 mL. The mean time to flatus was 4 days. Postoperative complications occurred in 4 patients, including 2 cases of incomplete bowel obstruction, 1 case of urinary tract infection, and 1 case of incision hernia.ConclusionsLaparoscopic radical cystectomy with the novel urinary diversion is safe, feasible and reproducible with encouraging outcomes. Larger series with long term follow-up are required to prove its superiority.

An improved technique for bladder cancer: Pure laparoscopic radical cystectomy with orthotopic U-shape ileal neobladder using titanium staples

ObjectiveTo report our experience with an improved technique of laparoscopic radical cystectomy (LRC) and orthotopic ileal neobladder reconstruction, evaluating the perioperative and pathological outcomes. MethodsWe retrospectively reviewed the data of 56 cases who underwent radical cystoprostatectomy followed by construction of an orthotopic U-shaped ileal neobladder between August 2010 and December 2014. These data include intraoperative data, early and long-term postoperative complications, neobladder function, urinary continence and oncologic results. Also the key innovative procedure was introduced with details. ResultsThe median time of the overall procedure was 212 min. The median estimated blood loss was 171 ml. The median hospitalization time after the operation was 21 days. Complications included two cases of unilateral ureter-pouch anastomotic strictures, one case of bilateral ureteral stricture, three cases of vesicourethral anastomotic strictures and three cases of vesicourethral leakage. The mean maximum pouch capacity was 446 ± 32 ml, and pouch pressure at capacity was 18.1 ± 2.6 cm H2O. The Qmax was 14 ± 1.2 ml/s, and the mean postvoid residual was 25 ± 10 ml. There were 9 cases of night-time incontinence at 3 months post-operatively. Negative surgical margins of the bladder specimens were achieved in all patients. During a follow-up period of 3–44 months (average 32.6 months), local recurrence was found in two patients and distant metastasis was occurred in another 3 patients. ConclusionsOur preliminary experience showed that pure LRC with nonabsorbable titanium staples assisted orthotopic U-shape ileal neobladder reconstruction is feasible based on perioperative data and oncologic features.

Experience with 45 Consecutive Patients with Neobladders Undergoing Retrograde Ureteroscopy for Upper Tract Abnormalities

IntroductionIn this study we reviewed the feasibility, technique, complications and outcomes of retrograde ureteroscopy in patients with orthotopic neobladders. MethodsWe retrospectively reviewed our retrograde ureteroscopic experience in patients with orthotopic ileal neobladder diversions. Data were collected and analyzed regarding patient characteristics, indications, technique, success and complications of the procedure. ResultsBetween 1995 and 2013, 45 patients with neobladders underwent 77 retrograde ureteroscopy sessions on 97 renal units for filling defects (47 cases), urothelial thickening (9), calculi (4), positive cytology (27) and/or positive fluorescence in situ hybridization (15) on followup. The ureter and renal pelvis were successfully instrumented in 78 of 97 units (80.4%), with 85.3% success in Hautmann-type neobladders (75 renal units attempted), 50% in Studer-type neobladders (8 renal units attempted) and 71.4% in unascertained-type neobladders (14 renal units attempted). Causes of failure involved the inability to locate the ureteral orifice (8 cases), to cannulate the orifice (6 cases) or to advance the ureteroscope due to tortuosity (5 cases). Among the successful attempts with appropriately documented findings 35.9% of cases with filling defects (39) were confirmed malignant and 61.5% were confirmed benign by ureteroscopy. All cases with a positive cytology (23) and 85.7% of cases with positive fluorescence in situ hybridization (14) were confirmed malignant by retrograde ureteroscopy, and 2 of the 4 cases of calculi were successfully managed retrogradely. ConclusionsRetrograde ureteroscopic evaluation of upper tract abnormalities is feasible and practical in patients with orthotopic neobladders. Identification and cannulation of the ureteral orifice are challenging, particularly in tortuous situations, but difficulties can be overcome with fluoroscopic techniques. Retrograde ureteroscopy avoids the morbidity of percutaneous access with minimal complications.

EFFECT OF SELF - CARE LEARNING PACKAGE ON THE QUALITY OF LIFE FOR PATIENT WITH URINARY DIVERSION

Urinary diversion is associated with significant changes in urinary and sexual function, interpersonal relationships and psychosocial stress which ultimately affect patient’s perceived quality of life (QoL).The aim of this study was to evaluate the effect of self-care learning package on the quality of life for patients undergoing urinary diversion Subjects and Methods: The study was carried out at urology unit of General Benha Hospital at Benha University and Urology and Nephrology Center of Mansoura University Hospitals. Sample included 100 patients whose undergoing urinary diversion from both sexes. The researcher used 3 tools in this study including, patient's assessment questionnaire, Interviewing questionnaire sheet, Functional Assessment of Cancer Therapy- Vanderbilt Cystectomy Index, (FACT-VCI). Results: the study results revealed that, highly statistically significant improvement in studied group about their total knowledge score, and total practice with subsequent improvement in total quality of life score for studied subjects with ileal loop conduit and orthotopic ileal neobladder after implementation of self-care learning package. Conclusion: Self care learning package have positive effect on quality of life for patients with different types of urinary diversion, and the mean score of knowledge, and practice improved significantly after application of self care learning package. Recommendation: The study recommended the application of guiding educational and cultural programme for patients with urinary diversion to improve their self-care for urinary diversion.

A case report of Robotic assisted laparoscopic radical cystectomy with Y pouch orthotopic ileal neobladder constructed using nonabsorbable endo GIA staples

s / Urological Science 26 (2015) S50eS81 S81 mediastinum, head, and neck. We would like to present a 17 years old female with a huge pelvic mass extent to right upper quadrant of abdomen size measures in 21x5.4x8.5 CM. Debulking surgery was performed and revealed a huge ganglioneuroma of retroperitoenum, the clinical presentation, special image and pathological picture and our experience in management of huge retroperitoneal tumor with literature review. NDP119: CASE REPORT ePENILE METASTASIS OF PROSTATE ADENOCARCINOMA WITH PRIAPISM AS THE INITIAL PRESENTATION Hung-Yi Chen, Chun-Te Wu, Wen-Hsiang Chen, Cheng-chia Lin, ShianShiang Huang, Cheng-Feng Lin. Divisions of Urology, Department of Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan Case report: A 95-year-old male has underlying disease of severe prostate hyperplasia, abnormal serum prostate-specific antigen (PSA: 18.41ng/ dl) and hardness digital rectal examination were noted. Because of multiple comorbidities and bed ridden status, further prostate malignancy survey cannot be performed. Patient has long-term Foley catheteration for difficult urinary voiding treatment. He hospitalized for antibiotic treatment under the impression of urinary tract infection with initial present by gross hematuria and pyuria. However, painful priapism with adequate glans circulation noted for one week. Bedside cavernosal aspiration revealed no blood content but only debris. No evidence of sickle cell anemia via hematological study. Dorsal slit with cavernosal biopsy was performed for symptoms relief and differential diagnosis under local anesthesia. The priapism and pain improved after the shunting procedure was done. The following pathological report of biopsy tissue showed poorly differentiated adenocarcinoma. Metastatic prostate adenocarcinoma was proved by the immunohistochemical (IHC) stain which disclosed P504S positive. Further bone scan revealed no obvious bony metastasis, patient cannot complete pelvic magnetic resonance imaging (MRI) study because of poor general conditions. This patient died of another episode of pneumonia related sepsis progression l month later. Conclusion: Prostate adenocarcinoma metastasis by pelvic lymphovascular route with the presentation of lymph edema. Gross hematuria and urine retention are also common in the advanced disease. We reported an uncommon case of non-ischemic priapism by prostate cancer penile metastasis. Laparoscopy NDP120: A CASE REPORT OF ROBOTIC ASSISTED LAPAROSCOPIC RADICAL CYSTECTOMY WITH Y POUCH ORTHOTOPIC ILEAL NEOBLADDER CONSTRUCTED USING NONABSORBABLE ENDO GIA STAPLES Yuli Lee , Lipin Chiu , Yuwei Lai , Thomas Y. Hsueh , Yi-Chun Chiu , Shiou-Sheng Chen , Allen W. Chiu . Divisions of Urology, Department of Surgery, Taipei City Hospital, Taiwan; National Yang-Ming University, School of Medicine, Taiwan Background: Laparoscopic-assisted radical cystectomy with Y pouch orthotopic ileal neobladder constructed using nonabsorbable titanium staples was early reported in 2006. Herein we present the case of robotic assisted laparoscopic radical cystectomy with Y pouch orthotopic ileal neobladder constructed using nonabsorbable endo GIA staples and a brief literature review. Case Report: A 65-year-old man was admited because of pianless gross hematuria. Cystoscopy showed multiple focal cauliflower tumor. Transurethral resection of bladder tumor was performed. The pathological report showed urothelial carcinoma with muscle invasion. Computed tomography showed diffuse bladder wall thickness and no obvious lymph node metastasis. We performed robotic assisted laparoscopic radical cystectomy with U-shaped orthotopic ileal neobladder constructed using nonabsorbable endo GIA staples. In our procedure, a 50-cm ileal segment is arranged in a U shape with two segments of approximately 20 cm and two afferent limb of 5 cm. An opening is made at the lowest point of the Uileal segment on its antimesenteric border. The jaws of the endoGIA stapler are accommodated within the bowel loop and fired as low as possible, bringing together and detubularizing of each arm of the U. To complete the pouch detubularization, another small opening is made at the bottom. Then use the endo GIA, completing the U pouch. Then performed the anastomosis of the open ends of the U shape and the cutting end of urethra.Total operation time is 290 minutes and no intraoperative complication. The patient was discharged uneventfully. Post operation one year follow-up, no bladder stone and no renal function deterioration were noted Conclusion: Robotic assisted laparoscopic radical cystectomy with Ushaped orthotopic ileal neobladder constructed using nonabsorbable endo GIA staples seem a feasible, safe and rapid procedure.

Do Orthotopic Ileal Diversions Induce Immunological Changes in Retained Urethral Tissue?

Background: A second primary tumors of the urethra (urethral recurrence) after radical cystectomy has been reported to be more infrequent in patients with ileal orthotopic (neobladder) compared to incontinent diversions.Objective: To investigate whether an altered immunogenic environment of urethral tissue is induced by urethro-ileal anastomosis.Methods: Between 10/2008 and 12/2009 urethral biopsies of 19 patients (9 neobladder patients, 10 control patients without urethra-ileal anastomosis) were evaluated by conventional histopathological examination and immunohistochemistry for T- (CD3/CD5, CD4, CD8) and B-cell markers (CD20/22, CD79a, CD138). After semi-quantitative assessment, relative cell fractions (B vs. T cells) and subclasses (T4-helper vs. T8-killer cells vs. B cell clones, plasma cells) in neobladder vs. control patients were studied. Unpaired t-test was used for statistical analysis. Results: Of 19 included patients, 16 were eligible for analysis (7x neobladder, 9x controls). All neobladder patients had undergone cystectomy for UBC. Comparing relative fractions of cells positive for T- and B-cell markers in NB and CO patients, no statistical differences were observed. In 4/7 neobladder patients relative fraction of CD79a positive B-cells was higher than relative fraction of CD3/CD5 positive T-cells (B/T-ratio 1.3). B cells were predominantly CD138 positive plasma cells (5/7 NB patients). Relative B-cell fraction was lower than T-cell fraction in 7/9 control patients (B/T-ratio 0.6). Neither CD 138 positive plasma cells nor CD22 positive B cell clones were predominant. T-helper and CD8 positive T-killer cells were equally distributed in both neobladder (CD4/CD8-ratio: 2.1) and control patients (CD4/CD8-ratio: 1.9).Conclusions: Comparing neobadder and control patients the distribution of B- and T-cells was statistically not different. However, a trend towards an increased presence of B-cells in urethral tissues of NB patients that could become relevant in a larger study might be suggestive for an immunological response induced by connecting urethral and ileal tissue.

Morphological and functional analysis of a cohort of patients undergoing orthotopic ileal neobladder.

This study was conducted between January 2001 and December 2013 to evaluate patient's outcomes after radical cystectomy and orthotopic ileal neobladder from a morphological and functional point of view at a median follow-up of 2 years. A total of 48 eligible patents were included. We first report our technical modifications to Studer's neobladder. Sequently, after a medium follow-up of two years, we assessed morphology of the reservoir and voiding functionality of this patients cohort, submitting them to specific questionnaires and to uroflowmetry. Early and late postoperative data are available for 36 patients. From the morphological follow-up, 2 years after surgery, six patients had hydroureteronephrosis for vescico-ureteral reflux in four cases (11% of total) and uretero-neobladder anastomosis stenosis in the other two (5.6% of total). Neobladder shape always remained spherical, with a relative right lateralization in eight cases (22.2%). Regarding the nine patients subjected to uroflowmetry, seven (77.7%) highlighted the lack of postvoid residual urine, with a maximum urinary flow rate within the normal range in six of them. Improvements in surgical technique may help to reduce complications rate. From uroflowmetry analysis, we can observe that the mean filling pressure following surgery was relatively stable and urinary flow rate was mostly satisfactory. In patients without postvoid residual urine, all referred absence of daily incontinence and good quality of life. From this morpho-functional evaluation, our orthotopic Studer-modified ileal neobladder seems an ideal solution for urinary diversion, presenting functional features similar to native bladder and assuming a well-defined morphology, not changing in time.

Pure laparoscopic radical cystectomy with orthotopic U-shape ileal neobladder: report of 19 cases

Objective To report the surgical methods and results of pure laparoscopic radical cystectomy with orthotopic U-shape ileal neobladder. Methods From August 2010 to April 2014, 19 patients with locally advanced bladder cancer (cT2-3N0-2M0) underwent pure laparoscopic radical cystectomy and Endo-GIA assisted orthotopic U-shape ileal neobladder reconstruction. Perioperative and follow-up data were collected. Results The surgeries were successful in all 19 cases with the operating time ranging from 261 to 380 min, blood loss of 100 to 350 ml. Postoperative hospital stay was 21±4 (15-26) days, postoperative intestinal function recovery time at 1.9±0.4 (1.5-2.3) days. Surgical margins were all negative. Lymph node positive rate was 32% (6/19). Complications were including 1 case of lymphatic leakage; 3 cases of new bladder and urethra anastomotic fistula. There were 17 cases of urinary incontinence, all these cases were improved after 3 months, but there were still 8 cases of night-time incontinence. Three cases had unilateral ureteral reflux, ureter mild hydrocephalus, 1 of the cases had recurrent infections within 1 month after surgery. After the anti-inflammatory and catheterization treatment, the symptoms were improved. Two cases had unilateral ureteral anastomotic stricture, one underwent percutaneous nephrostomy and cystoscope-assisted double J tube placement, another underwent laparoscopic ureteral neobladder reimplantation. One case had bilateral ureteral stenosis due to recurrent infections, and underwent bilateral laparoscopic ureteral-new bladder reimplantation. Patients were followed up for 8-42 months, no recurrence or distant metastasis was found. Conclusion Pure laparoscopic radical cystectomy with endo-GIA assisted orthotopic U-shape ileal neobladder can reduce surgical trauma and help patient′s postoperative recovery. Key words: Urinary bladder neoplasms; Pure laparoscopy; Radical cystectomy; Orthotopic U-shape ileal neobladder

PD9-12 VIDEOURODYNAMIC EVALUATION OF INTRACORPOREALLY RECONSTRUCTED ORTHOTOPIC U-SHAPED ILEAL NEOBLADDERS

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion I1 Apr 2015PD9-12 VIDEOURODYNAMIC EVALUATION OF INTRACORPOREALLY RECONSTRUCTED ORTHOTOPIC U-SHAPED ILEAL NEOBLADDERS Antonio Luigi Pastore, Giovanni Palleschi, Luigi Silvestri, Andrea Ripoli, and Antonio Carbone Antonio Luigi PastoreAntonio Luigi Pastore More articles by this author , Giovanni PalleschiGiovanni Palleschi More articles by this author , Luigi SilvestriLuigi Silvestri More articles by this author , Andrea RipoliAndrea Ripoli More articles by this author , and Antonio CarboneAntonio Carbone More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.939AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To study the functional outcomes of 30 patients who had previously undergone laparoscopic radical cystectomy (LRC) with intracorporeal orthotopic ileal neobladder reconstruction using videourodynamic (VUDM) assessment 180 days post-operatively. METHODS Between November 2010 and December 2013, 30 male patients had undergone LRC with bilateral standard pelvic lymphadenectomy and pure laparoscopic orthotopic ileal U-shaped neobladder diversion. The demographic data were: median age, 67 years (range: 62–79); body mass index (BMI), 22.3 (16–26.1); and mean American Society of Anaesthesiologists (ASA) score 2.2 (1–3). Functional outcomes were assessed performing a standard VUDM study combined with perineal floor electromyography 180 days post-operatively. RESULTS Videourodynamic evaluations showed good functional outcomes of the reservoirs. Mean maximal neobladder capacity was 287 mL (210–335 mL). Residual peristaltic activity was observed in all the individuals evaluated; however, only 9/30 (30%) individuals displayed severe peristaltic activity. Six of these nine (66.6%) individuals experienced urinary leakage during these contractions. Mean post-void residual volume was 44 mL (0–105 mL), and peak flow rate was 13.9 mL/s (9.7–29.2 mL/s). The Valsalva manoeuvre was positive in 5/30 (17%) subjects. Bladder morphology assessed during contrast cystography showed the desired U-shape in all cases. Ureteral reflux was observed in 7/30 (23.3%) of individuals. CONCLUSIONS Based on VUDM, our study shows that U-shaped ileal neobladders achieved by a totally laparoscopic approach obtained good functional outcomes. These findings support the evidence that a minimally invasive approach does not impose technical limitations that negatively impact the surgical results. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e199-e200 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Antonio Luigi Pastore More articles by this author Giovanni Palleschi More articles by this author Luigi Silvestri More articles by this author Andrea Ripoli More articles by this author Antonio Carbone More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

MP65-14 INCIDENCE AND RISK FOR CLOSTRIDIUM DIFFICILE INFECTIOUS COLITIS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR BLADDER CANCER

You have accessJournal of UrologyBladder Cancer: Invasive III1 Apr 2015MP65-14 INCIDENCE AND RISK FOR CLOSTRIDIUM DIFFICILE INFECTIOUS COLITIS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR BLADDER CANCER Kashyap Shatagopam, Nick Liu, M. Francesca Monn, Clinton Bahler, Hristos Kaimakliotis, K. Clint Cary, Ronald Boris, Matthew Mellon, Timothy Masterson, Richard Bihrle, Richard Foster, Thomas Gardner, Michael House, and Michael Koch Kashyap ShatagopamKashyap Shatagopam More articles by this author , Nick LiuNick Liu More articles by this author , M. Francesca MonnM. Francesca Monn More articles by this author , Clinton BahlerClinton Bahler More articles by this author , Hristos KaimakliotisHristos Kaimakliotis More articles by this author , K. Clint CaryK. Clint Cary More articles by this author , Ronald BorisRonald Boris More articles by this author , Matthew MellonMatthew Mellon More articles by this author , Timothy MastersonTimothy Masterson More articles by this author , Richard BihrleRichard Bihrle More articles by this author , Richard FosterRichard Foster More articles by this author , Thomas GardnerThomas Gardner More articles by this author , Michael HouseMichael House More articles by this author , and Michael KochMichael Koch More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2304AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES This study seeks to evaluate the incidence and associated risk factors for Clostridium difficile infectious colitis (CDI) in patients undergoing radical cystectomy for bladder cancer. METHODS We retrospectively reviewed an institutional database of 554 patients who underwent radical cystectomy between 2010 and 2013 to identify patients who developed CDI. CDI was detected by stool toxin assay in patients with clinically significant diarrhea within 90 days of the index operation. Stepwise logistic regression was used to identify pre- and perioperative factors associated with developing CDI. The final multivariable logistic regression model for factors associated with CDI was composed of variables found to have p<0.2 on forward and backward stepwise logistic regression. RESULTS Postoperative CDI occurred in 49 patients (8.8%) with a median time to diagnosis after cystectomy of 7 days (3 – 51). Of the 122 readmissions for post-cystectomy complications, 9.0% (n=11) were related to CDI. Two patients died from sepsis related to severe CDI. The incidence of CDI by year of cystectomy was 9 (6%) in 2010, 7 (5%) in 2011, 12 (9%) in 2012 and 21 (15%) in 2013 (ptrend=0.004). On multivariate logistic regression, preoperative use of histamine-2 antagonists or proton-pump inhibitors (OR: 2.05, 95% CI 1.07 – 3.93, p=0.03), postoperative acute renal failure (OR: 3.0, 95% CI: 1.23 – 7.49, p=0.016), and cumulative intravenous antibiotic use greater than 6 doses during hospitalization (OR: 15.63, 95% CI: 1.40 – 174.46, p=0.026) were independently associated with developing CDI. The use of preoperative antibiotics within 30 days of surgery was not associated with development of CDI (p=0.46). While the incidence of CDI was higher among patients with Indiana pouch compared to ileal conduit and orthotopic neobladder (11.2% vs. 10% and 3.3%, respectively), the type of urinary diversion did not seem to influence rates of CDI in multivariate analysis (p=0.061). CONCLUSIONS The development of CDI occurs in up to 10% of patients undergoing radical cystectomy for bladder cancer. Our study demonstrates that preoperative use of antacid therapy, postoperative acute renal failure, and large cumulative intravenous antibiotic dosages are associated with the development of CDI. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e812-e813 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kashyap Shatagopam More articles by this author Nick Liu More articles by this author M. Francesca Monn More articles by this author Clinton Bahler More articles by this author Hristos Kaimakliotis More articles by this author K. Clint Cary More articles by this author Ronald Boris More articles by this author Matthew Mellon More articles by this author Timothy Masterson More articles by this author Richard Bihrle More articles by this author Richard Foster More articles by this author Thomas Gardner More articles by this author Michael House More articles by this author Michael Koch More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP65-15 EXTENDED-DURATION ENOXAPARIN LOWERS THROMBOEMBOLIC EVENTS AFTER RADICAL CYSTECTOMY COMPARED TO INPATIENT-ONLY SUBCUTANEOUS HEPARIN

of preoperative antibiotics within 30 days of surgery was not associated with development of CDI (p1⁄40.46). While the incidence of CDI was higher among patients with Indiana pouch compared to ileal conduit and orthotopic neobladder (11.2% vs. 10% and 3.3%, respectively), the type of urinary diversion did not seem to influence rates of CDI in multivariate analysis (p1⁄40.061). CONCLUSIONS: The development of CDI occurs in up to 10% of patients undergoing radical cystectomy for bladder cancer. Our study demonstrates that preoperative use of antacid therapy, postoperative acute renal failure, and large cumulative intravenous antibiotic dosages are associated with the development of CDI.

Randomized Trial of Studer Pouch versus T-Pouch Orthotopic Ileal Neobladder in Patients with Bladder Cancer

The need to prevent reflux in the construction of an orthotopic ileal neobladder is controversial. We designed the USC-STAR trial to determine whether the T-pouch neobladder that included an antireflux mechanism was superior to the Studer pouch in patients with bladder cancer undergoing radical cystectomy. This single center, randomized, controlled trial recruited patients with clinically nonmetastatic bladder cancer scheduled to undergo radical cystectomy with neobladder. Eligible patients were randomly assigned to undergo T-pouch or Studer ileal orthotopic neobladder. Treatment assignment was not masked. The primary end point was change in renal function from baseline to 3 years. The CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation was used to calculate the estimated glomerular filtration rate. Between February 2002 and November 2009, 237 patients were randomly assigned to T-pouch ileal orthotopic neobladder and 247 to Studer ileal orthotopic neobladder. Baseline characteristics did not differ between the groups. Between baseline and 3 years the estimated glomerular filtration rate decreased by 6.4 ml/minute/1.73 m(2) in the Studer group and 6.6 ml/minute/1.73 m(2) in the T-pouch group (p=0.35). Multivariable analysis showed that type of ileal orthotopic neobladder was not independently associated with 3-year renal function (p=0.63). However, baseline estimated glomerular filtration rate, age and urinary tract obstruction were independently associated with 3-year decline in renal function. Cumulative risk of urinary tract infection and overall late complications were not different between the groups, but the T-pouch was associated with an increased risk of secondary diversion related surgeries. T-pouch ileal orthotopic neobladder with an antireflux mechanism did not prevent a moderate reduction in renal function observed at 3 years compared to the Studer pouch, but did result in an increase in diversion related secondary surgical procedures.

Videourodynamic Evaluation of Intracorporeally Reconstructed Orthotopic U-shaped Ileal Neobladders

To study the functional outcomes of 30 patients who had previously undergone laparoscopic radical cystectomy with intracorporeal orthotopic ileal neobladder reconstruction using videourodynamic (VUDM) assessment 180days postoperatively. Between November 2010 and December 2013, 30 male patients had undergone laparoscopic radical cystectomy with bilateral standard pelvic lymphadenectomy and pure laparoscopic orthotopic ileal U-shaped neobladder diversion. The demographic data were as follows: median age, 67years (range, 62-79); body mass index, 22.3 kg/m(2) (range, 16-26.1 kg/m(2)); and mean American Society of Anesthesiologists score 2.2 (range, 1-3). Functional outcomes were assessed performing a standard VUDM study combined with perineal floor electromyography 180days postoperatively. VUDM evaluations showed good functional outcomes of the reservoirs. Mean maximal neobladder capacity was 287mL (range, 210-335mL). Residual peristaltic activity was observed in all the individuals evaluated; however, only 9 of 30 individuals (30%) displayed severe peristaltic activity. Six of these 9 individuals (66.6%) experienced urinary leakage during these contractions. Mean postvoid residual volume was 44mL (range, 0-105mL), and peak flow rate was 13.9mL/s (range, 9.7-29.2mL/s). The Valsalva maneuver was positive in 5 of 30 subjects (17%). Bladder morphology assessed during contrast cystography showed the desired U-shape in all cases. Ureteral reflux was observed in 7 of 30 individuals (23.3%). Based on VUDM, our study shows that U-shaped ileal neobladders achieved by a totally laparoscopic approach obtained good functional outcomes. These findings support the evidence that a minimally invasive approach does not impose technical limitations that negatively impact the surgical results.

Radiosensitivity of orthotopic ileal neobladders.

350 Background: A prior report from our institution documented that Kock ileal reservoirs can tolerate doses of 45-50.4Gy. This study provides retrospective information on the radiosensitivity of orthotopic neobladders by reviewing the acute and late toxicity in patients who underwent post-operative radiotherapy following radical cystoprostatectomy with orthotopic ileal neobladder reconstruction. Methods: The USC bladder cancer database was queried for all patients who underwent cystoprostatectomy and neobladder reconstruction followed by adjuvant radiation therapy related to their bladder cancer. The original patient charts and radiation therapy records were reviewed to determine the dose of radiation received by the neobladder. The patient charts were also reviewed to determine acute and late toxicity related to radiation. Results: From 1980 to 2013, 1,742 patients underwent radical cystoprostatectomy with orthotopic neobladder reconstruction. Of those 1,742 patients, 10 patients met the criteria of the study. The median age of the patients who received post-operative radiotherapy was 66.9 years. Forty percent of the study population received a dose of 50.4Gy, 50% received a dose of 45-46.8Gy and one patient, while prescribed a dose of 61.2Gy, only received 39.6Gy secondary to progression of disease on treatment that required termination of RT. All patients received 1.7-1.8Gy per fraction. The most common indications for radiotherapy were close or positive surgical margins. Two patients were treated with IMRT while the rest of the patients received 4 field or AP-PA beam arrangements. Of the patients that completed radiation, 3 had grade 2 or less CTCAE v4.0 acute GI toxicity; no patients reported acute GU toxicity. Two patients reported chronic grade 1 GU toxicity, likely related to their neobladders, with no reports of chronic GI toxicity. No patients experienced neobladder perforation, leak, or fistula. Conclusions: The use of moderate doses of pelvic radiotherapy (45-50.4Gy) was well tolerated among the 10 patients who had radiotherapy following cystoprostatectomy with orthotopic neobladder creation. This data supports the use of post-operative radiotherapy to moderate doses in this patient population when clinically indicated.