Orthotopic Neobladder Formation Research Articles

Graduating resident and fellow readiness for general urologic practice during the COVID-19 pandemic A survey-based assessment of trainees and program directors.

Our goal was to compare the perceived readiness of graduating urologic residents and fellows to program directors (PDs) in U.S.-based postgraduate training programs. Additionally, we set out to assess the impact of COVID-19 on postgraduation plans to pursue fellowship training. Graduating residents, fellows, and PDs of accredited residency/fellowship programs in the U.S. were surveyed. The ranked preparedness of trainees to perform common urologic procedures was measured using a Likert scale from 1 (not comfortable) to 5 (fully proficient). The impact of COVID-19 was measured using a three-point Likert scale. Chi-squared and Kruskal-Wallis analyses were used to compare the groups. From 93 responders, 21 were residents, 19 were fellows, 24 were residency PDs, and 29 were fellowship PDs. The median levels of comfort for trans-urethral resection of the prostate, hydrocelectomy, vasectomy, and urethral sling were at or above (≥3) moderate for both PDs and trainees. PDs were more likely to report underperformance for hypospadias repair (60% vs. 39%), penile prosthesis implantation (39% vs. 26%), and orthotopic neobladder formation (57% vs. 18%) than the trainees. Fifty-three (57.0%) of the surveyors felt that COVID-19 did not impact the trainees' comfort in performing general urologic procedures. COVID-19 influenced trainees' decision to pursue a fellowship or opt to practice as general urologists (p=0.002). Our study suggests there may be a self-reported discrepancy between graduating trainees and their PDs regarding trainees' comfort levels performing general urologic procedures.

Graduating resident and fellow readiness for general urologic practice during the COVID-19 pandemic: A survey-based assessment of trainees and program directors.

Our goal was to compare the perceived readiness of graduating urologic residents and fellows to program directors (PDs) in U.S.-based postgraduate training programs. Additionally, we set out to assess the impact of COVID-19 on postgraduation plans to pursue fellowship training. Graduating residents, fellows, and PDs of accredited residency/fellowship programs in the U.S. were surveyed. The ranked preparedness of trainees to perform common urologic procedures was measured using a Likert scale from 1 (not comfortable) to 5 (fully proficient). The impact of COVID-19 was measured using a three-point Likert scale. Chi-squared and Kruskal-Wallis analyses were used to compare the groups. From 93 responders, 21 were residents, 19 were fellows, 24 were residency PDs, and 29 were fellowship PDs. The median levels of comfort for transurethral resection of the prostate, hydrocelectomy, vasectomy, and urethral sling were at or above (≥3) moderate for both PDs and trainees. PDs were more likely to report underperformance for hypospadias repair (60% vs. 39%), penile prosthesis implantation (39% vs. 26%), and orthotopic neobladder formation (57% vs. 18%) than the trainees. Fifty-three (57.0%) of the surveyors felt that COVID-19 did not impact the trainees' comfort in performing general urologic procedures. COVID-19 influenced trainees' decision to pursue a fellowship or opt to practice as general urologists (p=0.002). Our study suggests there may be a self-reported discrepancy between graduating trainees and their PDs regarding trainees' comfort levels performing general urologic procedures.

Рентген-эндоскопическое лечение облитерации уретерорезервуароанастомоза после перенесенной ортотопической пластики мочевого пузыря

Strictures and obliterations of ureteral anastomosis after radical cystectomy with orthotopic neobladder reconstruction occur in 8-13% of cases, mainly in the first 2 years after surgery. According to the European Association of Urology guidelines, open reconstruction is considered the "gold standard" for the treatment of those patients. At the same time, according to various publications, X-ray endoscopic treatment of ureteral anastomotic strictures can be performed, especially in patients who have undergone orthotopic neobladder reconstruction.Three clinical cases of endoscopic treatment of ureteral anastomotic obliteration after orthotopic neobladder formation are presented. In all patients, nephrostomy tube was initially put due to acute pyelonephritis. Obliteration of the ureteral anastomosis was diagnosed by contrast-enhanced multispiral computed tomography and antegrade pyelography. The length of obliteration in all patients did not exceed 1.0 cm. The recurrence of the bladder cancer was excluded. After percutaneous opacification of the pelvicalyceal system and advancement of two guidewires ("working" and "safety") to the level of ureteral obliteration, a catheter with a built-in fiber optic light source was put in antegrade fashion along the "working" guidewire to the area of obliteration. During transurethral inspection of the reservoir, the distal end of the light source was visualized and the reservoir wall was cut "to the light" using electrosurgery (n=2) and a thulium fiber laser (one case). For adequate kidney drainage, two internal stents of 6 Fr were put for a period of 6 months in two patients and for 2 months in another case.All patients had an adequate diameter of the ureteral anastomosis after removal of the stents. In two cases, an adequate passage of the contrast agent through both ureters was maintained for 42 and 37 months after procedure (according to the follow-up computed tomography and excretory urography). One patient had an attack of acute pyelonephritis 2 months after the removal of internal stents due to recurrent stricture. After repeated endoscopic ureteral recanalization with putting of two internal stents for a period of 6 months, no recurrence of the stricture was observed during 28 months of follow-up.Endoscopic treatment of both primary and recurrent short ureteral anastomotic obliterations in patients with orthotopic neobladder allows for adequate ureteral patency, provided that two internal stents are left in place for 6 months.

NBCA-Lipiodol Mixture Embolization of Persistent Urine Leakage After Orthotopic Neobladder Formation: Techniques and Outcomes.

ObjectiveTo show the effective and successful technical approach of percutaneous embolization for persistent urine leakage that occurred after orthotopic neobladder formation.Materials and MethodsWe retrospectively reviewed patients who underwent percutaneous embolization of N-butyl cyanoacrylate (NBCA) and lipiodol mixture after orthotopic neobladder formation at the Seoul National University Hospital (Seoul, Korea) from 1 January 2018 to 31 December 2020.ResultsAmong total of 182 patients of neobladder formation, five patients (four males and one female) were enrolled in this study, and their median age was 61.0 years (interquartile range (IQR): 42.5–69.5 years). All the patients showed persistent urine leakage at the neobladder-urethral anastomosis site and percutaneous drainage was primarily performed. The median time to perform percutaneous embolization was 40 days (IQR: 31.5–71.5 days) postoperatively. Elective two-staged embolization was performed in three cases for large diameter with a large fluid-filled cavity, while re-embolization was needed for delayed recurrence of urine leakage in two cases. Complete resolution of urine leakage was seen in all the cases and the median time to leakage closure was 55 days (IQR: 27.5–82.5 days). The median follow-up period after leakage closure was 26 months (IQR: 15.5–36.4 months), and embolization material-related bladder stone was a noticeable complication (two cases) during follow-up, which was removed endoscopically within 1 year after embolization. All patients' quality of life (EQ-5D-5L score) was well-maintained during the entire period.ConclusionsPersistent urine leakage after neobladder formation can be effectively managed with percutaneous embolization of “dumbbell technique” by reinforcing the closure of leakage tract from inner opening to the outer opening even for large diameter (>1 cm).

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center

IntroductionUreteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes. Material and methodsDescriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student’s t-test for independent groups or Mann-Whitney test. Statistical significance if P < .05. ResultsThe study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Uretericre implantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%). ConclusionSurgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

MP13-15 THE ROLE OF PERITONEAL CAVITY SPARING IN THE REDUCTION OF RADICAL CYSTOPROSTATECTOMY (RCP) POSTOPERATIVE COMPLICATION RATES

You have accessJournal of UrologyBladder Cancer: Invasive I (MP13)1 Sep 2021MP13-15 THE ROLE OF PERITONEAL CAVITY SPARING IN THE REDUCTION OF RADICAL CYSTOPROSTATECTOMY (RCP) POSTOPERATIVE COMPLICATION RATES Guram Karazanashvili, Nika Gagoshidze, and Nino Karazanashvili Guram KarazanashviliGuram Karazanashvili More articles by this author , Nika GagoshidzeNika Gagoshidze More articles by this author , and Nino KarazanashviliNino Karazanashvili More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001994.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy remains the gold standard for the management of invasive bladder cancer. However, postoperative complications of this complex surgery still remain the major problem, which ranges between 30-64%. Neobladder extra-peritonization as a method for reduction of postoperative complications was discussed by few authors, showing that it has the potential to reduce the complication rate. In 2018 a video-description of the new technique of peritoneal cavity sparing (Karazanashvili, G. (2018)) was presented at AUA annual congress. We aimed to investigate the role of this new technique in the reduction of the RCP postoperative complications. METHODS: In 2011-2016 years 98 RCP were performed using the standard transperitoneal descending approach, leaving just a partially extra-peritonized neobladder in the peritoneal cavity. In 2016-2020 years 60 patients underwent RCP using the new technique - peritoneal cavity sparing extraperitoneal RCP with extraperitoneal orthotopic neobladder formation: RCP was performed in a retrograde manner, from apex prostate to the bladder pedicles and the dome; peritoneum was detached from bladder wall and peritoneal cavity hermeticism was kept until complete removal of the specimen and until completion of extended lymphadenectomy. So the peritoneal cavity remained untouched for the most part of the operation. After the creation of the neobladder, it was completely extra-peritonized; the peritoneal cavity was closed almost hermetically (hiatus was left only for neobladder mesentery) without drains. Complication rates after the operations were calculated according to the Clavien-Dindo scale. RESULTS: The retrospective analysis of complication rates has revealed that Clavien-Dindo Grade 1 to 3 intestinal complications significantly decreased using the new RCP technique compared to the old - standard one: Postoperative ileus medical treatment rate decreased from 3% to 0%; Intra-abdominal urine leakage - from 2.2%to 1.69%; Ileus surgical intervention - from 10.8% to 5.08%; Ileal anastomosis leakage from 5.7 to 0%; Evisceration - from 2.7% to 0%. Thus Intestinal Grade 1 complications decreased from 5.2% to 1.69 and Grade 3 complications - from 18.7% to 5.08%; totally the intestinal complication rate decreased by 17.22% (from 23.9% to 6.77%), however prolonged lymphorrhea rate increased by 12.54% (from 7.8 % to 20.34%). CONCLUSIONS: Peritoneum cavity sparing extraperitoneal RCP and extraperitoneal orthotopic neobladder formation can lead to notable reduction of RCP postoperative intestinal complication rate in price of prolonged lymphorrhea. Source of Funding: No funding was available © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e249-e249 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Guram Karazanashvili More articles by this author Nika Gagoshidze More articles by this author Nino Karazanashvili More articles by this author Expand All Advertisement Loading ...

Estenosis de la anastomosis ureteroileal en derivaciones urinarias realizadas mediante abordaje abierto, laparoscópico y robótico. Incidencia y manejo en un centro de tercer nivel

IntroductionUreteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes. Material and methodsDescriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t test for independent groups or Mann-Whitney test. Statistical significance if P<.05. ResultsThe study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Ureteric reimplantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%). ConclusionSurgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Nontraumatic posterior urethral stenosis

IntroductionPosterior urethral stenoses and contractures are complications after treatment of benign prostatic hyperplasia (BPH), localized prostate cancer (PCa), and orthotopic neobladder formation, compromising prognosis and functional outcomes. ObjectivesTo identify factors related to etiology, prevention and treatment of non-traumatic posterior urethral stenosis and contractures. Acquisition of evidenceReview of the published evidence related to posterior urethral stenosis and contractures after PCa treatment, BPH therapies and orthotopic neobladder formation. PubMed database search with English and Spanish papers considered. Cohort studies, case series, prospective and retrospective studies and review papers were included. Synthesis of evidencePosterior urethral stenoses and contractures are common, leading to significant morbidity. A worsening on voiding quality should rise some concerns. Careful surgical and/or radiotherapic techniques prevent their development. Endoscopic therapies are the initial approach, with complex urethroplasties often required. Subsequent urinary incontinence, the most important sequelae, may need artificial sphincters. ConclusionsNon-traumatic posterior urethral stenoses could be important complications, potentially compromising the outcomes of initial therapy. They could require complex surgeries leading to urinary incontinence.

Patología estenótica no traumática de la uretra posterior

IntroductionPosterior urethral stenoses and contractures are complications after treatment of benign prostatic hyperplasia (BPH), localised prostate cancer (PCa), and orthotopic neobladder formation, compromising prognosis and functional outcomes. ObjectivesTo identify factors related to aetiology, prevention and treatment of non-traumatic posterior urethral stenosis and contractures. Acquisition of evidenceReview of the published evidence related to posterior urethral stenosis and contractures after PCa treatment, BPH therapies and orthotopic neobladder formation. PubMed database search with English and Spanish papers considered. Cohort studies, case series, prospective and retrospective studies and review papers were included. Synthesis of evidencePosterior urethral stenoses and contractures are common, leading to significant morbidity. A worsening on voiding quality should rise some concerns. Careful surgical and/or radiotherapic techniques prevent their development. Endoscopic therapies are the initial approach, with complex urethroplasties often required. Subsequent urinary incontinence, the most important sequelae, may need artificial sphincters. ConclusionsNon-traumatic posterior urethral stenoses could be important complications, potentially compromising the outcomes of initial therapy. They could require complex surgeries leading to urinary incontinence.

Total Bladder and Posterior Urethral Reconstruction: Salvage Technique for Defunctionalized Bladder with Recalcitrant Posterior Urethral Stenosis

Recalcitrant posterior urethral stenosis is a challenging disease. When combined with a defunctionalized bladder, cutaneous urinary diversion is the most common surgical option. We present a novel technique of total lower urinary tract reconstruction, combining salvage cystectomy, ileal neobladder formation and urethral pull-through, as an orthotopic alternative in patients with a defunctionalized bladder and recalcitrant posterior urethral stenosis. We completed a retrospective review of 8 patients who underwent salvage cystectomy, orthotopic ileal neobladder formation and urethral pull-through. Artificial urinary sphincter placement was performed in a staged fashion. Six patients received prostate cancer treatment including radiation therapy, 1 had urethral disruption after robotic radical prostatectomy, and 1 experienced bladder rupture and urethral distraction injury during a motorcycle accident. Patient demographics, operative variables and postoperative outcomes were examined. No high grade complications were observed after salvage cystectomy, orthotopic neobladder formation and urethral pull-through. After staged artificial urinary sphincter placement, a median of 2 revision surgeries (range 0 to 4) was required to establish social continence. All patients maintained functional urinary storage, urethral patency and social continence at a median followup of 58 months. No patient had complications related to orthotopic neobladder formation, including ureteroileal anastomotic stricture or pyelonephritis, and no patient required cutaneous diversion. Total lower urinary tract reconstruction with cystectomy, ileal neobladder formation and urethral pull-through offers an orthotopic alternative for patients with recalcitrant posterior urethral stenosis and defunctionalized bladders. Although it requires staged placement of an artificial urinary sphincter, this approach can offer functional urinary storage, durable urethral patency and avoidance of cutaneous urinary diversion.

Radical Cystectomy and Urinary Diversion after Renal Transplantation

Introduction: Radical cystectomy remains the gold-standard treatment for patients with muscle invasive bladder cancer. Surgery may be difficult in patients who have previously undergone renal transplantation. We review our experience in this unique patient population with particular emphasis on intraoperative challenges and functional outcomes. Methods: We identified 4 patients with a history of renal transplantation who underwent radical cystectomy at Memorial Sloan-Kettering Cancer Center. Three patients underwent orthotopic neobladder formation and one underwent ileal conduit urinary diversion. Clinical and demographic data were collected. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Intraoperative records were queried to determine operative time, estimated blood loss, transfusion status, ASA score and technical operative difficulties. Results: Mean followup time after surgery was 28.0 months (range 1.3-67.8 months). Three patients were male and one patient was female. Mean age at the time of surgery was 58.6 years (range 27.3-74.6 years). Mean time from transplantation to surgery was 87.6 months. Intraoperative data are summarized in Table 1. Patient 1 underwent neoadjuvant Gemcitabine and Cisplatin prior to radical cystectomy with a Hautmann neobladder, bilateral native nephroureterectomy and sacro-colpopexy. Patient 2 underwent a Studer ileal neobladder and native left ureterectomy after a history of left nephrectomy for renal cell carcinoma. Patient 3 underwent Hautmann neobladder formation and native bilateral nephroureterectomy after prior intravesical therapy with Mitomycin-C and Gemcitabine. Patient 4 underwent an ileal conduit urinary diversion and bilateral native nephroureterectomy with left adrenalectomy. Indigo carmine was used to identify the transplanted ureter in two cases. Final pathology was pTisN1 in Patient 1, pT3N0 in Patient 2, pTisN0 in Patient 3, and pT3N0 in Patient 4. All patients are alive, with one pelvic recurrence in Patient 3 66.8 months after surgery. All three patients with orthotopic diversion are continent.Conclusions: Radical cystectomy and urinary diversion is feasible in patients after renal transplantation. Right pelvic lymph node dissection may be technically impossible due to the position of the graft and associated post-operative adhesions. Assistance with intravenous dye can aid in transplant ureteral identification. Good functional outcomes are expected in centers with experience in orthotopic diversion.

Surgical complications of urinary diversion.

We comprehensively reviewed the published literature on urinary diversion, specifically examining the surgical complications associated with conduit, continent cutaneous diversion and orthotopic urinary diversion. Appropriate patient selection and adherence to proper surgical technique are of paramount importance in preventing surgical complications of urinary diversion. Complications can be broadly divided into those related to bowel, conduit or reservoir, stoma and ureterointestinal anastomosis. Each type of urinary diversion has unique characteristics predisposing to certain surgical complications as well as similarities related to intestinal surgery. With conduit urinary diversions, problems related to the stoma such as stomal stenosis and parastomal hernia present not uncommonly. With continent cutaneous diversion, complications include difficulties with catheterizing of the efferent limb, formation of pouch stones and urinary leakage. With orthotopic neobladder formation, voiding dysfunction manifesting as incontinence or hypercontinence may present unique challenges in patient management. Increased surgical experience and technical refinements have led to decreasing surgical complication rates for all types of diversion in contemporary series.