Orthotopic Neobladder Diversion Research Articles

MP56-20 ETIOLOGY, EVALUATION, AND MANAGEMENT OF HEMATURIA FOLLOWING RADICAL CYSTECTOMY AND ORTHOTOPIC URINARY DIVERSION

You have accessJournal of UrologyCME1 Apr 2023MP56-20 ETIOLOGY, EVALUATION, AND MANAGEMENT OF HEMATURIA FOLLOWING RADICAL CYSTECTOMY AND ORTHOTOPIC URINARY DIVERSION Daniel I. Sanford, Muhannad Alsyouf, Sanam Ladi-Seyedian, Kevin Wayne, Alireza Ghoreifi, Anne Schuckman, Hooman Djaladat, and Siamak Daneshmand Daniel I. SanfordDaniel I. Sanford More articles by this author , Muhannad AlsyoufMuhannad Alsyouf More articles by this author , Sanam Ladi-SeyedianSanam Ladi-Seyedian More articles by this author , Kevin WayneKevin Wayne More articles by this author , Alireza GhoreifiAlireza Ghoreifi More articles by this author , Anne SchuckmanAnne Schuckman More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003309.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Up to 20% of patients presenting with gross hematuria have underlying urologic malignancy. In patients with orthotopic neobladder (ONB) following cystectomy, the occurrence of hematuria at follow-up has not been evaluated. Here, we assessed the etiology, evaluation, and subsequent management of patients who developed hematuria following ONB diversion. METHODS: All patients who underwent radical cystectomy and ONB between 2017-2022 and who subsequently underwent cystoscopy for hematuria were identified. Patient demographics, cystoscopy reports, cytology findings, and relevant imaging were reviewed to determine the etiology of hematuria and subsequent management. Causes of hematuria were categorized as recurrence, anticoagulation-related, inflammation/infection, or undetermined. A univariate analysis was performed to identify factors predictive of oncologic recurrence presenting with hematuria. RESULTS: Of 55 patients with ONB who underwent subsequent cystoscopy on follow-up, hematuria was the indication in 24 (44%) patients (Table 1a). Median patient age was 71 (IQR 66-74) years. Seven patients (29%) had hematuria secondary to cancer recurrence, including four with urethral recurrence, one with ureteral recurrence, and two with positive urine cytology. Other etiologies of hematuria included anticoagulation (13%), pouchitis (13%), mesh erosion into neobladder (4%), and bladder inflammation (4%). Nine patients (37%) had an undetermined cause of hematuria. In patients with recurrence, median time from cystectomy to development of hematuria was 20.1 (15.6–32.8) months. Positive surgical margins were associated with cancer recurrence in our cohort (p<0.05) (Table 1b). CONCLUSIONS: The majority of patients presenting with gross hematuria following radical cystectomy and ONB have benign etiology, yet up to one-third of patients will have underlying malignancy. A thorough evaluation is required for all patients, especially those with positive surgical margins. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e783 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel I. Sanford More articles by this author Muhannad Alsyouf More articles by this author Sanam Ladi-Seyedian More articles by this author Kevin Wayne More articles by this author Alireza Ghoreifi More articles by this author Anne Schuckman More articles by this author Hooman Djaladat More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement PDF downloadLoading ...

MP65-12 EVALUATION OF LONG-TERM FUNCTIONAL OUTCOMES OF ORTHOTOPIC NEOBLADDER IN THE ELDERLY USING A VALIDATED QUESTIONNAIRE

You have accessJournal of UrologyCME1 Apr 2023MP65-12 EVALUATION OF LONG-TERM FUNCTIONAL OUTCOMES OF ORTHOTOPIC NEOBLADDER IN THE ELDERLY USING A VALIDATED QUESTIONNAIRE Seyedeh Sanam Ladi Seyedian, Kasen Wong, Muhannad Alsyouf, Gus Miranda, Jie Cai, Kevin Wayne, Hooman Djaladat, Anne Schuckman, and Siamak Daneshmand Seyedeh Sanam Ladi SeyedianSeyedeh Sanam Ladi Seyedian More articles by this author , Kasen WongKasen Wong More articles by this author , Muhannad AlsyoufMuhannad Alsyouf More articles by this author , Gus MirandaGus Miranda More articles by this author , Jie CaiJie Cai More articles by this author , Kevin WayneKevin Wayne 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/10.1097/JU.0000000000003323.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Elderly patients who require radical cystectomy (RC) are more likely to undergo an incontinent urinary diversion due to unclear long-term functional outcomes of a continent diversion. Herein, we evaluate the continence outcomes in elderly males undergoing orthotopic neobladder (ONB) diversion after RC using a validated questionnaire. METHODS: Using our IRB approved bladder cancer database, we identified male patients, 70 years old or older, who underwent open RC and ONB from 2002 to 2021. Beginning in 2012 the patients completed a validated pictorial pad use questionnaire at each follow-up visit. The questionnaire assessed pad number, size and wetness as well as catheter use. Continence was defined as use of “no pads” or pads that are “almost dry”. Urinary retention was defined as ≥3 catheterizations/day or a self-reported inability to void without a catheter. Patients with artificial urinary sphincters or less than 6 months of follow up were excluded from the study. Kaplan-Meier curves and cox regression were used to analyze the data. RESULTS: A total of 156 male patients with median age of 74 years (IQR: 72-77) and BMI of 26.7 (IQR: 24.2 - 29) were included. 64 (41%) patient were>75 years old. 42 (27%) patients received neoadjuvant chemotherapy. 71 (45.5%) patients had Charlson comorbidity index (CCI) score of>2. Fifteen (10%) patients had pathological staging >pT3 and 23 (15%) had pathological nodal disease. At 1 year following the surgery, half of the patients gained daytime continence and 30% gained nighttime continence which increased over the study period. Day and nighttime continence rates were 74% and 68% at 5 years postoperatively (figure 1). Only 13 (8%) patients developed retention over the study period. Patients>75 years old had worse nighttime continence outcome compared to <75 years old (p=0.07) (figure 1). Multivariate cox regression model including age, CCI, BMI, diabetes, and perioperative chemotherapy did not show any significant risk factor for daytime incontinence, however; age>75 was significantly associated with nighttime incontinence (HR 1.07, p=0.04). CONCLUSIONS: Orthotopic neobladder represents a viable option for urinary diversion in selected elderly males undergoing radical cystectomy and age alone should not be considered a contraindication. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e895 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Seyedeh Sanam Ladi Seyedian More articles by this author Kasen Wong More articles by this author Muhannad Alsyouf More articles by this author Gus Miranda More articles by this author Jie Cai More articles by this author Kevin Wayne 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 PDF downloadLoading ...

Incidence, risk factors and outcomes of urethral recurrence after radical cystectomy for bladder cancer: A systematic review and meta-analysis.

We aimed to conduct a systematic review and meta-analysis assessing the incidence and risk factors of urethral recurrence (UR) as well as summarizing data on survival outcomes in patients with UR after radical cystectomy (RC) for bladder cancer. The MEDLINE and EMBASE databases were searched in February 2021 for studies of patients with UR after RC. Incidence and risk factors of UR were the primary endpoints. The secondary endpoint was survival outcomes in patients who experienced UR. Twenty-one studies, comprising 9,435 patients, were included in the quantitative synthesis. Orthotopic neobladder (ONB) diversion was associated with a decreased probability of UR compared to non-ONB (pooled OR: 0.44, 95% CI: 0.31-0.61, P < 0.001) and male patients had a significantly higher risk of UR compared to female patients (pooled OR: 3.16, 95% CI: 1.83-5.47, P < 0.001). Among risk factors, prostatic urethral or prostatic stromal involvement (pooled HR: 5.44, 95% CI: 3.58-8.26, P < 0.001; pooled HR: 5.90, 95% CI: 1.82-19.17, P = 0.003, respectively) and tumor multifocality (pooled HR: 2.97, 95% CI: 2.05-4.29, P < 0.001) were associated with worse urethral recurrence-free survival. Neither tumor stage (P = 0.63) nor CIS (P = 0.72) were associated with worse urethral recurrence-free survival. Patients with UR had a 5-year CSS that varied from 47% to 63% and an OS - from 40% to 74%; UR did not appear to be related to worse survival outcomes. Male patients treated with non-ONB diversion as well as patients with prostatic involvement and tumor multifocality seem to be at the highest risk of UR after RC. Risk-adjusted standardized surveillance protocols should be developed into clinical practice after RC.

Association between radical cystectomy prophylactic antimicrobial regimen and postoperative infection.

Infections are common after radical cystectomy. The objective of this study was to determine the association between antimicrobial prophylactic regimen and infection after radical cystectomy. A retrospective cohort study was performed on patients who underwent radical cystectomy at one tertiary Canadian center between January 2016 and April 2020. Patients received antimicrobial prophylaxis based on surgeon preference (cefazolin/metronidazole or ampicillin/ciprofloxacin/metronidazole, or other). A univariable and multivariable logistic regression model was created to determine the association between antimicrobial regimen and postoperative infection within 30 days. The association between patient demographic factors, as well as preoperative and intraoperative variables and infection, was also determined. Infection characteristics, including type, timing, and antimicrobial susceptibilities were reported. One hundred and sixty-five patients were included. Mean age was 69.8 years, 121 (73.3%) were male, and 72 (43.6%) received orthotopic neobladder diversion. Ninety-six patients (58%) received cefazolin/metronidazole prophylaxis, 50 (30%) received ampicillin/ciprofloxacin/metronidazole, and 19 (11.5%) received another regimen. Fifty-four patients (32.7%) developed a postoperative infection (surgical site infection or urinary tract infection). Surgical site infection occurred in 35 patients (21.2%) and urinary tract infection occurred in 34 (21.0%). There was no association between antimicrobial regimen and incidence of postoperative infection (surgical site infection or urinary tract infection, relative risk 0.99, 95% confidence interval 0.50-1.99). The overall incidence of infection was 32.7% following radical cystectomy. The preoperative prophylactic antibiotic regimen used was not associated with incidence of postoperative infection.

Febrile Urinary Tract Infection after Radical Cystectomy with Urinary Diversion: Different Characteristics in Patients with Ileal Conduit and Orthotopic Neobladder

Background and ObjectiveTo compare the incidence of febrile urinary tract infection (UTI) and bacterial identification between patients with orthotopic neobladder (ONB) and ileal conduit (IC). Materials and MethodsData of 164 patients who underwent radical cystectomy with ONB and IC for bladder cancer between January 2009 and January 2018 at our institution were analyzed. Febrile UTI observed was listed and subsequently compared. Incidence of febrile UTI, clinicopathological characteristics, and microorganisms identified were reported at 3 months interval; and preoperative predictors of febrile UTI were evaluated with Cox regression analysis. Patients were divided into ONB and IC. ResultsThe study cohort included 52 patients with ONB and 112 patients with IC. Febrile UTI was diagnosed in 49 (29.9%) patients. Compared to IC group, ONB group had significantly higher incidence of young age (p=0.00), lower cancer stage (p=0.013), longer hospital stay (p=0.049), longer operation time (p=0.00), and higher incidence of febrile UTI within the first 3 months after surgery (p=0.006). On univariable and multivariable analysis, factors associated with significantly increased febrile UTI risk were diabetes (odds ratio [OR]: 4.52; p=0.002) and ONB diversion (OR: 1.27; p=0.031). Forty-four (89.8%) patients were culture positive. However, significant difference in microorganisms was not detected between patients who under-went ONB or IC diversion. ConclusionDiabetes and ONB diversion were associated with higher risk symptomatic UTI following radical cystectomy.

Validation of the effectiveness of a modified Studer orthotopic neobladder in a single center after 3 years of its application.

In this study, we reported the 2 years outcomes of orthotopic neobladder diversion according to the Studer modified technique described by Bianchi G. et al. This technique improves the stability of the reservoir and the urine-storage capacity. After radical cystectomy, urinary diversion is created with a spheroidal-shaped reservoir with a conic distal-part, obtained with 40 cm detubulized ileal segment, and a 15 cm of tubular afferent limb, where a Wallace ureteral anastomoses is made. The conic distal part of the neobladder that is anastomized to the urethral stump. After the reconstructive part, the neobladder and the afferent limb are attached to the elevator ani and psoas muscles, respectively. In all, 18 patients underwent radical cystectomy with the reconstruction of urinary diversion with the Modified-Studer Orthotopic technique, at S. Giuseppe Hospital. We studied the post-operative years of follow-up, especially with anamnesis of lower urinary tract, axial computerized tomography, and blood tests, according to the EAU guidelines. We discover with TC 2 cases of low-grade bilateral hydronephrosis, associated with a slight increase in creatinine levels (1.4-1.8 mg/dL). No stricture at the neobladder-urethral anastomosis was detected. Three patients complain daytime urinary incontinence; only two patients report nocturnal urinary incontinence. One patient underwent ureteroscopy for lithiasis and 1 patient died for non-onco-urological disease. The modifications we applied to the Studer-Neobladder seems to improve urinary tract restoration, potentially decreasing long-term complications like hydronephrosis connected to ureteral anastomotic stenosis (11.1% vs 16.9% reported in literature) and urinary retention (0% vs 12% reported in literature). However, we discovered the same risk of diurnal and nocturnal incontinence reported in literature for the classic Studer Neobladder.

202 Outcomes of Dual Inflatable Penile Prosthesis and Artificial Urinary Sphincter Implantation After Radical Cystectomy and Neobladder

After radical cystectomy (RC) and orthotopic neobladder (ONB), post-operative complications such as erectile dysfunction and stress urinary incontinence can arise. While combined prosthetic reconstruction can treat both these issues, the feasibility and viability of dual implantation has not been studied in this unique subset of patients. To examine the outcomes of male patients who have undergone placement of both an artificial urinary sphincter (AUS) and 3-piece inflatable penile prosthesis (IPP) after RC and ONB diversion. Using a prospectively-maintained IRB-approved institutional database, we identified 39 patients who underwent RC and NB and subsequent implantation of an AUS and IPP from 2003 to 2017. Patients were included if they had devices placed synchronously or metachronously. Two patients with follow-up duration less than 12 months were excluded from analysis. An infrapubic approach was used in most patients for IPP placement, with reservoir placement in the lateral retroperitoneal space through a counter-incision medial to the anterior superior iliac spine. AUS placement was performed using a transperineal incision in all patients. 12 patients underwent synchronous device placement. Patient demographics, perioperative data, and postoperative outcomes including prosthetic infection, mechanical failure, and revision surgery were examined and statistical analysis was performed.

Dual Prosthetic Implantation After Radical Cystoprostatectomy and Neobladder: Outcomes of the Inflatable Penile Prosthesis and Artificial Urinary Sphincter in Bladder Cancer Survivors

ObjectivesTo determine the impact of radical cystectomy and orthotopic neobladder (NB) diversion on device-related outcomes in patients who undergo subsequent placement of both, an artificial urinary sphincter (AUS) and 3-piece inflatable penile prosthesis. Materials and MethodsUsing an institutional prosthetic database, we identified 39 patients who underwent radical cystectomy and NB and subsequent implantation of both prosthetic devices from 2003 to 2017. Patient demographics, perioperative data, and postoperative outcomes including prosthetic infection, mechanical failure, revision surgery, and functional outcomes were examined and compared to an appropriate matched group of patients (n = 48, non-neobladder group). ResultsNo intraoperative complications were observed. After median follow-up of 94 months (12-177 months), 1 patient developed an infection of their penile prosthesis and 4 patients developed an erosion of their AUS. In each case, the infection did not involve the other device. Two patients required revision surgery of their penile prosthesis due to mechanical failure (reservoir leak, n = 1; cylinder aneurysm, n = 1). Twenty-one patients underwent elective revision surgery to improve continence (cuff downsizing, n = 18; pressure-regulating balloon exchange, n = 3). There were 6 cases of AUS mechanical failure. No reservoir-related complications such as herniation or erosion were observed. Compared to the control group of non-neobladder patients, there were no significant differences in prosthetic infection, mechanical failure, and revision surgery. ConclusionThe AUS and 3-piece inflatable penile prosthesis can coexist safely in patients with NB without an increased risk of device-related complications.

Prospective evaluation of quality-of-life outcomes following orthotopic neobladder and ileal conduit diversion after radical cystectomy

Prospective evaluation of quality-of-life outcomes following orthotopic neobladder and ileal conduit diversion after radical cystectomy

Health-related Quality of Life After Radical Cystectomy: A Cross-sectional Study With Matched-pair Analysis on Ileal Conduit vs Ileal Orthotopic Neobladder Diversion

To examine the different and health-related quality of life (HR-QoL) outcomes between ileal conduit (IC) and ileal orthotopic neobladder (IONB) in patients who underwent radical cystectomy (RC), by using validated self-reported cancer-specific instruments. This retrospective, cross-sectional, multicenter cohort study included 148 and 171 patients with either IC or IONB. HR-QoL was evaluated with Quality of Life Core Questionnaire and bladder module (BLM)-30 European Organisation for Research and Treatment of Cancer questionnaires. Baseline HR-QoL scores were dichotomized at the median to give "good" or "poor" score profiles. A matched-pair analysis compared HR-QoL aspects between 79 IC patients and 79 IONB patients. At univariate analysis IONB resulted favorable for physical functioning, emotional functioning, cognitive functioning (CF), fatigue, dyspnea, appetite loss, constipation (CO), and abdominal bloating flatulence (AB). At multivariate analyses, IONB showed better scores for emotional functioning (85 vs 79, P = .023), CF (93 vs 85, P <.001), CO (16 vs 31, P <.001), and AB (12 vs 25, P <.001). A significant worsening of sexual and urinary function was observed for IONB patients in the long-term. At matched-pair analysis, global health status was similar (65 vs 62, P = .385). Significantly better scores were observed in the IONB group for the following items: CF (P = .007), fatigue (P = .003), pain (P = .019), dyspnea (P = .016), CO (P = .001), and AB (P = .00). IONB and IC after RC were similar in terms of global health status. IONB provides better results in some aspects of HR-QoL related to bowel function, but a worsening of urinary and sexual functions. Further randomized controlled trials are needed to confirm these data.

PD57-09 NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM SURGICAL RISK CALCULATOR POORLY PREDICTS COMPLICATIONS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY WITH URINARY DIVERSION: THE CASE FOR A PROCEDURE-SPECIFIC RISK CALCULATOR

You have accessJournal of UrologyBladder Cancer: Epidemiology & Evaluation III1 Apr 2017PD57-09 NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM SURGICAL RISK CALCULATOR POORLY PREDICTS COMPLICATIONS IN PATIENTS UNDERGOING RADICAL CYSTECTOMY WITH URINARY DIVERSION: THE CASE FOR A PROCEDURE-SPECIFIC RISK CALCULATOR Melanie Adamsky, Shay Golan, Chuanhong Liao, Scott Johnson, Nimrod Barashi, Raj Bhanvadia, Norm Smith, Gary Steinberg, and Arieh Shalhav Melanie AdamskyMelanie Adamsky More articles by this author , Shay GolanShay Golan More articles by this author , Chuanhong LiaoChuanhong Liao More articles by this author , Scott JohnsonScott Johnson More articles by this author , Nimrod BarashiNimrod Barashi More articles by this author , Raj BhanvadiaRaj Bhanvadia More articles by this author , Norm SmithNorm Smith More articles by this author , Gary SteinbergGary Steinberg More articles by this author , and Arieh ShalhavArieh Shalhav More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2611AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The American College of Surgeons′ National Surgical Quality Improvement Program (NSQIP) Risk Calculator is commonly used in the preoperative setting. The risk profile generated is often used during the informed consent process and may in the near future be used as a quality measure linked with reimbursement. We aimed to evaluate the accuracy of this NSQIP risk calculator in patients undergoing radical cystectomy with urinary diversion. METHODS We retrospectively reviewed our institutional database to identify patients undergoing radical cystectomy with urinary diversion between 2010 and 2015. We used the proprietary NSQIP online calculator, which incorporated the procedure-specific CPT code, to obtain a 30-day postoperative risk profile for each of eleven outcomes, which were then compared to actual outcomes for each patient. Brier scores (BS) were calculated as a measure of NSQIP calculator accuracy. Consistent with prior studies, we selected a threshold of BS <0.01 (90% accuracy) as an acceptable calculator. RESULTS We included 567 patients who underwent radical cystectomy, of whom 364 (64%) received an ileal conduit (IC) and 203 (36%) received orthotopic neobladder diversion (ONB). Mean age was 68.24 years (±10.40) and 435 (76%) were male. BS exceeded the threshold of 0.01 (indicating poor predictive value) for serious complications, any complications, surgical site infection, urinary tract infection, deep venous thrombosis, renal failure, readmission, return to operating room, and discharge to rehabilitation facility, regardless of diversion type (see Figure 1) - risk was underestimated for each of these complications. Length of stay was underestimated by 17% and risk of serious complication was underestimated by 31%. The calculator did adequately predict the risk of death for patients receiving ONB and overall. CONCLUSIONS The universal NSQIP surgical risk calculator inaccurately predicts most postoperative complications in patients undergoing radical cystectomy with urinary diversion. This highlights the need for a procedure-specific risk calculator in order to better counsel patients in the preoperative setting and generate realistic quality measures. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1124 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Melanie Adamsky More articles by this author Shay Golan More articles by this author Chuanhong Liao More articles by this author Scott Johnson More articles by this author Nimrod Barashi More articles by this author Raj Bhanvadia More articles by this author Norm Smith More articles by this author Gary Steinberg More articles by this author Arieh Shalhav More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robotic Intracorporeal Continent Cutaneous Diversion

Robotic intracorporeal urinary diversion has mostly been done for ileal conduit or orthotopic neobladder diversion. We present what is to our knowledge the initial series, detailed technique and outcomes of the robotic intracorporeal Indiana pouch with a minimum 1-year followup. Ten patients underwent robotic radical cystectomy, pelvic lymphadenectomy and intracorporeal Indiana pouch urinary diversion for cancer in 9 and benign disease in 1. Data were collected prospectively. Baseline demographics, pathology data, and 1-year complication rates and functional outcomes were assessed. All 10 cases were successfully completed intracorporeally without open conversion. Median total operative time was 6 hours, including 3.5 hours for pouch creation. Median blood loss was 200 cc and median hospital stay was 10 days. Four Clavien grade 1-2 and 3 Clavien 3-5 complications occurred. None of the patients had a bowel leak. One noncompliant patient requested undiversion to an ileal conduit. The remaining 9 patients successfully catheterized the ileal channel and were completely continent at the last followup at a median of 13.7 months (range 12.3 to 15.2). Study limitations include small sample size and short followup. We present what is to our knowledge the initial series of robotic completely intracorporeal Indiana pouch diversion. Early perioperative data indicate acceptable operative efficiency and complication rates. Longer followup is required to assess the functional outcomes of this less commonly performed diversion.

Outcomes of Surgical Management in Patients with Stress Urinary Incontinence and/or Neovesicovaginal Fistula after Orthotopic Neobladder Diversion

To our knowledge there are no guidelines for the evaluation and management of incontinence in women with an orthotopic neobladder. We propose a treatment algorithm based on our experience with treating this patient population. We identified women in whom orthotopic neobladder diversion and surgery for incontinence were performed from January 1, 1995 to January 1, 2014. Charts were reviewed for management, outcomes and complications within 30 days of surgery. At this institution 12 women with orthotopic neobladder diversion were treated with surgery for incontinence between 1995 and 2014. Six women (50%) had an undiagnosed neovesicovaginal fistula, of whom 3 (50%) underwent successful fistula repair. A total of 12 bulking agent injections were performed in 6women (50%). The outcomes were continued dryness after 1 injection (8%), transient improvement after 9 (75%), immediate failure after 1 (8%) and secondary fistula development after 1 (8%). Four transobturator slings and 4 pubovaginal slings were placed in a total of 6 patients (50%), of whom 1 (17%) was dry and 1 (17%) was improved. At a median followup of 22.9 months (IQR 11.1-46.4) 6 women (50%) were dry or improved and 6 (50%) had no improvement in leakage. Of the 6 (50%) women who were dry or improved 2 (17%) achieved planned intermittent catheterization after surgery and 2 (17%) underwent ileal conduit conversion. Bulking agents have low long-term efficacy and carry the risk of fistula formation. The efficacy of tension-free sling placement is low and continence requires an obstructing sling. Counseling should include acceptance of multiple procedures, which may be necessary to achieve continence, and consideration of conduit diversion.

Prospective Evaluation of Continence Following Radical Cystectomy and Orthotopic Urinary Diversion Using a Validated Questionnaire

We evaluated continence outcomes in male patients undergoing orthotopic neobladder diversion after radical cystectomy using a validated questionnaire. Using our institutional review board approved bladder cancer database we identified 1,269 patients who underwent open radical cystectomy from 2002 to 2015. Orthotopic neobladder was constructed in 935 (74%) patients, of whom 798 (85%) were male. Beginning in 2012 the patients completed a validated pictorial pad use questionnaire at each followup visit. The questionnaire assessed pad number, size and wetness as well as catheter use. Continence was defined as use of no pads or pads that are almost dry. Questionnaires were stratified into distinct postoperative intervals for analysis. Female patients, or patients with artificial urinary sphincters or prior radiotherapy were excluded from the study. A total of 188 male patients with available questionnaires were followed from September 2012 to August 2015. Overall 447 questionnaires were collected, with 351 interval distinct questionnaires separated into intervals of less than 3, 3to 6, more than 6 to 12, more than 12 to 18, more than 18 to 36 and more than 36 months after surgery (64, 61, 58, 49, 61 and 58 questionnaires, respectively). Daytime continence increased from 59% at less than 3 months postoperatively to 92% by more than 12 to 18 months. Nighttime continence increased from 28% at less than 3 months postoperatively to 51% by more than 18 to 36 months. Nearly 50% of patients reported daytime and nighttime continence by 18 to 36 months. After orthotopic neobladder diversion in male patients, continence improves significantly by 6 months and subsequently plateaus with 92% daytime continence by more than 12 to 18 months. Orthotopic neobladder represents an excellent functional option for urinary diversion.

Health-related quality of life with urinary diversion.

Patients who undergo radical cystectomy and urinary diversion experience a lengthy period of postoperative recovery from physical, functional, social, and emotional challenges that greatly impact health-related quality of life (HRQoL). These changes affect nearly all patients and must be reviewed in detail as part of the preoperative consultation. However, quantifying a patient's risk for altered HRQoL is imprecise, thus complicating the choice for urinary diversion. A recent prospective study observed improved global health status and physical, role, and social functioning in patients treated with orthotopic neobladder diversion compared with patients treated with ileal conduit diversion. In contrast, robotic-assisted radical cystectomy does not improve patient quality of life (QoL) over open radical cystectomy within the first year of surgery. Enhanced recovery protocols improve immediate postoperative QoL but their effect on long-term QoL is uncertain. There is still a significant lack of understanding about the QoL between various types of urinary diversions. Recent and ongoing prospective randomized trials in the radical cystectomy population may shed light on urinary diversion-specific function and related effects on HRQoL. Ultimately, well designed, large multicenter prospective-controlled trials comparing functional, social, and emotional outcomes of continent and incontinent urinary diversion are still needed.

PD9-07 EARLY AND LATE COMPLICATIONS OF ROBOTIC RADICAL CYSTECTOMY AND INTRA-CORPOREAL URINARY DIVERSION

INTRODUCTION AND OBJECTIVES: To evaluate long-term clinical outcome and complications of patients with Urothelial Bladder Cancer (UBC) who underwent radical cystectomy (RC) and orthotopic neobladder (ONB) diversion with minimum of 15 years follow-up. METHODS: Using our IRB approved institutional bladder cancer database, we identified 1,964 patients who underwent RC for UBC at our institution between 1971 and 2008. 121 patients who underwent RC and ONB (Kock pouch to the urethra) with more than 15 years follow-up were subjects of this study. We reviewed the clinicopathological variables, long-term complications and outcome of this cohort. Detailed follow-up were found in 96/121 patients (79.3%). eGFR analysis was done on 32 patients with information available on BMI, pre-op Cr, and at least 2 Cr reading of 3,6,10, 15 years with 1 of the readings being at least 10 years. RESULTS: Of the 121 patients, 118 were male (97.5%). Mean age at cystectomy was 59.3 years with a median follow-up of 18.3 years (range 15.1 23). Pathologic stage at cystectomy was <1⁄4pT1 (70, 57.9%), pT2 (32, 26.4%), pT3 (14, 11.6%) and pT4 (5, 4.1%) and pNþ (11, 9.1%) with N1 (4, 3.3%) and N2 (7, 5.8%). Neoadjuvant chemo, radiation and adjuvant chemo were used in 9 (7.4%), 2 (1.7%) and 33 (27%) cases, respectively. There were 6 patients with recurrences (3 urethral, 1 pelvis, 1 distant, and 1 upper tract) at median of 9.23 years (range 1.2 e 17.2) after cystectomy. Only 1 of the patients died of the disease (at 16.3 years); 27 died of non-cancer cause (mean 18.2; 15.223.0), 5 died of secondary cancer (17.1; 15.4-20.0), 3 died of unknown cause (15.3; 15.1-15.4), and 85 are alive without evidence of disease (18.5; 15.1-23.0). CONCLUSIONS: The most common complications in ONB patients with more than 15 yrs follow-up were pouch-related, with afferent limb stenosis and pouch stones contributing the most. A gradual decrease in GFR over time was seen throughout the patient population, thus making renal insufficiency a prevalent complication in long-term survivors with ONB.

Patient Selection, Operative Technique, and Contemporary Outcomes of Continent Catheterizable Diversion: the Indiana Pouch

Techniques for continent cutaneous urinary diversion (CCD) have evolved considerably over the last 65 years. The Indiana pouch (IP) was initially described in the 1980s and has gained wide acceptance among urologists. For patients who desire continent urinary diversion, many clinical scenarios and individual preferences continue to make the IP an excellent option for appropriately selected patients. Continence rates for the IP are generally satisfactory and compare favorably with orthotopic neobladder. Unfortunately, radical cystectomy with urinary diversion is associated with a high complication rate. We discuss short-term (<90 days) and long-term complications for CCD with attention to specific complications related to the efferent limb and continent pouch. Finally, we discuss health-related quality of life (HRQOL) after IP urinary diversion with comparison to the orthotopic neobladder and conduit diversion.

Robotic Intracorporeal Orthotopic Neobladder during Radical Cystectomy in 132 Patients

We present a 2-institution experience with completely intracorporeal robotic orthotopic ileal neobladder after radical cystectomy in 132 patients. Established open surgical techniques were duplicated robotically with all neobladders suture constructed intracorporeally in a globular configuration. Nerve sparing was performed in 56% of males. Lymphadenectomy was extended (up to aortic bifurcation in 51, 44%) and superextended (up to the inferior mesenteric artery in 20, 17%). Ureteroileal anastomoses were Wallace-type (86, 65%) or Bricker-type (46, 35%). The learning curve at each institution was assessed using chronological subgroups and by trends across the entire cohort. Data were prospectively collected and retrospectively queried. Mean operating time was 7.6 hours (range 4.4 to 13), blood loss was 430 cc (range 50 to 2,200) and hospital stay was 11 days (median 8, range 3 to 78). Clavien grade I, II, III, IV and V complications within 30 days were 7%, 25%, 13%, 2% and 0%, respectively, and between 30 and 90 days were 5%, 9%, 11%, 1% and 2%, respectively. Mean nodal yield was 29 (range 7 to 164) and the node positivity rate was 17%. Operative time, blood loss, hospital stay and prevalence of late complications improved with experience. During a mean followup of 2.1 years (range 0.1 to 9.8) cancer recurred in 20 patients (15%). Five-year overall, cancer specific and recurrence-free survival was 72%, 72% and 71%, respectively. We developed a refined technique of robotic intracorporeal orthotopic neobladder diversion, duplicating open principles. Operative efficiency and outcomes improved with experience. Going forward, we propose a prospective randomized comparison between open and robotic intracorporeal neobladder surgery.

The effect of length of ureteral resection on benign ureterointestinal stricture rate in ileal conduit or ileal neobladder urinary diversion following radical cystectomy

ObjectivesTo assess the effect of the length of the ureter resected and other clinical variables on ureterointestinal anastomotic (UIA) stricture rate following radical cystectomy and ileal segment urinary diversion. Methods and materialsWe identified 519 consecutive patients who underwent cystectomy and ileal conduit or ileal orthotopic neobladder diversion from January 2007 to August 2012. The length of the ureter resected was defined as the length of the ureter in the cystectomy specimen plus the length of the distal ureter submitted for pathologic analysis. The primary end point was the risk of UIA stricture formation, assessed by Cox proportional hazards analysis. ResultsA total of 463 patients met the inclusion criteria with complete data. Median follow-up was 459 days (interquartile range [IQR]: 211–927). Median time to stricture formation was 235 (IQR: 134–352) and 232 days (IQR: 132–351) on the right and the left ureter, respectively. Overall stricture rate per ureter was 5.9% on the right vs. 10.0% on the left (P = 0.03). There was no difference in demographic, operative, or perioperative variables between patients with and without UIA strictures. On multivariate analysis adjusted for age, sex, anastomosis technique (running vs. interrupted), and length of ureter resected, only a Clavien complication≥III (hazard ratio = 2.11, 1.01–4.40) and urine leak (hazard ratio = 3.37, 1.08–10.46) significantly predicted for left- and right-sided stricture formation, respectively. The length of the ureter resected did not predict UIA stricture formation on either side. ConclusionsThe etiology of benign UIA strictures following ileal urinary diversion is likely multifactorial. Our data suggest that a complicated postoperative course and urine leak are risk factors for UIA stricture formation. The length of the distal ureter resected did not significantly affect stricture rate.

MP5-10 ROBOTIC INTRA-CORPOREAL ORTHOTOPIC NEOBLADDER DURING RADICAL CYSTECTOMY: 132 PATIENTS

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion1 Apr 2014MP5-10 ROBOTIC INTRA-CORPOREAL ORTHOTOPIC NEOBLADDER DURING RADICAL CYSTECTOMY: 132 PATIENTS Mihir M. Desai, Inderbir Gill, Abolfazl Hosseini, Tommy Nyberg, Christofer Adding, Oscar Laurin, Justin Collins, Andre Luis Abreu, Alvin Goh, Monish Aron, and Peter Wiklund Mihir M. DesaiMihir M. Desai More articles by this author , Inderbir GillInderbir Gill More articles by this author , Abolfazl HosseiniAbolfazl Hosseini More articles by this author , Tommy NybergTommy Nyberg More articles by this author , Christofer AddingChristofer Adding More articles by this author , Oscar LaurinOscar Laurin More articles by this author , Justin CollinsJustin Collins More articles by this author , Andre Luis AbreuAndre Luis Abreu More articles by this author , Alvin GohAlvin Goh More articles by this author , Monish AronMonish Aron More articles by this author , and Peter WiklundPeter Wiklund More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.393AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To present a 2-institutional experience with completely intra-corporeal robotic orthotopic neobladder and robotic radical cystectomy in 132 patients. METHODS Of 246 robotic intra-corporeal diversions, 132 were neobladders. All neobladders were constructed intra-corporeally in a globular configuration, completely duplicating established open surgical techniques. Demographics: mean age 60 years, BMI 27, female patients n=18 (14%), status-post neo-adjuvant chemotherapy n=30 (23%). Technical details: nerve-sparing in 56% of male patients, female organ-preserving in 32% of female patients; Lymphadenectomy: Extended (upto aortic bifurcation): n=51 (39%), Super-extended (upto IMA): n=20 (15%); Uretero-ileal anastomoses: Wallace-type (n=86; 65%), Bricker-type (n=46; 35%). Data were prospectively collected. Patients were retrospectively divided into chronologic groups to assess learning curve trends. RESULTS Mean data: OR time 7.6 hrs (4.4-13), blood loss 430 cc (50-2200), hospital stay 11 days (3-78). Complications: Clavien grade I, II, IIIa, IIIb, IV and V: Within 30 days: 7%, 25%, 9%, 4%, 2% and 0%; Between 30-90 days: 5%, 9%, 2%, 8%, 1% and 1.5%. Bowel complications: n=2 (1.5%) (ileo-neobladder fistula, bowel leak). Benign uretero-enteric strictures: n=5 (3.8 %). On comparing the initial 25 with the latest 32 patients, outcomes improved significantly: mean OR time (8.2 vs 7.3 hrs), blood loss (694 vs 319 cc) and hospital stay (12.6 vs 7.7 d). Positive surgical margin: n=1 (0.8%). Mean nodal yield: 29 (7-164), node-positivity rate was 17%. Over a mean follow-up of 2.1 years (0.1-9.8), cancer recurred in 20 patients (15%), 5-year overall, cancer-specific and recurrence-free survival was 72%, 72% and 71%, respectively. CONCLUSIONS Robotic intra-corporeal orthotopic neobladder diversion is now a developed and refined technique, diligently duplicating open principles. Operative efficiency and peri-operative outcomes have improved significantly with experience. Nodal yield, pathologic data and 5-year oncologic outcomes are equivalent to open surgery. As the next step, we propose a randomized controlled trial with open radical cystectomy/neobladder surgery, including objective assessment of functional outcomes. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e85-e86 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Mihir M. Desai More articles by this author Inderbir Gill More articles by this author Abolfazl Hosseini More articles by this author Tommy Nyberg More articles by this author Christofer Adding More articles by this author Oscar Laurin More articles by this author Justin Collins More articles by this author Andre Luis Abreu More articles by this author Alvin Goh More articles by this author Monish Aron More articles by this author Peter Wiklund More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...