Radical cystectomy with orthotopic neobladder for invasive bladder cancer: a critical analysis of long term oncological, functional and quality of life results

PURPOSE: Analyze current knowledge and practice regarding tumor-related cystectomy with subsequent orthotopic neobladder both in male and female patients. DESIGN, SETTING, AND PARTICIPANTS: Evaluate literature predominantly from the last decade dealing with long-term experience in large numbers of patients with an orthotopic neobladder following cystectomy. Oncological outcome specific to an orthotopic neobladder, functional aspects such as urinary continence, renal function, sexual activity and other quality of life issues are elucidated. RESULTS: Local pelvic recurrences after urothelial bladder cancer occur in 7-12 percent. Urethral second primary tumors in male and female patients in contemporary series with bladder substitution are 4-6 percent and 1.4 o 4 percent, respectively. Upper tract recurrences vary between 2.4-17 percent. Complications regarding the upper urinary tract have dramatically diminished due to simplified forms of upper tract protection as well as a more refined technique of ureterointestinal anastomosis. Depending on the technique ureteroileal stenosis was lately reported to lie between 2.7 to 3.8 percent. Renal function remained stable in 96 percent after a mean follow-up of up to 5 years. Radical cystectomy in carefully selected patients has stood the test of time by providing adequate long-term survival and low local recurrence rates. Orthotopic bladder substitution does not compromise oncological outcome, yields excellent functional results, is cost effective compared to other types of urinary diversion, may improve quality of life and should therefore be the diversion of choice both in men and women. Chronological age is generally not a contraindication for cystectomy, but for orthotopic urinary diversion, tumor extent, functional pelvic floor deficits and general life expectancy are limiting factors.

Steerable antegrade stenting: a new trick of the trade

INTRODUCTION: Whereas a retrograde attempt to insert an indwelling stent is performed in lithotomy position, usually renal access is gained in a prone position. To overcome the time loss of patient repositioning, a renal puncture can be performed in a modified lithotomy position with torqued truncus and slightly elevated flank. There is a two-fold advantage of this position: transurethral and transrenal access can be obtained using a combined approach. In the present study, this simple technique is used to position a floppy guide wire through a modified needle directly through the renal pelvis into the ureter. MATERIALS AND METHODS: The kidney is punctured in the modified lithotomy position under sonographic control using an initial three-part puncture needle. A floppy tip guide-wire is inserted into the collecting system via the needle after retrieving the stylet. The retracted needle is bent at the tip while the guide-wire is secured in the needle and the collecting system. The use of the floppy tip guide-wire helps to insert the curved needle back into the kidney pelvis, which becomes the precise guidance for the now steerable wire. The desired steerable stent is positioned under radiographic control in a retrograde fashion over the endoscopically harbored tip of the guide-wire. Two patient cohorts (newly described method and conventional method) were compared. RESULTS: The presented steering procedure saves 16.5 mean minutes compared to the conventional antegrade stenting and 79.5 Euros compared to the control group. CONCLUSION: The described combined antegrade-retrograde stent placement through a bent three-part puncture needle results in both clinical superiority (OR time, success rate) and financial benefits.