Radical cystectomy and urinary diversion in women: impact on sexual function.

OBJECTIVE: The aim of this study was to assess the impact of radical cystectomy and different forms of urinary diversion on female sexual function. MATERIAL AND METHODS: Seventy-three consecutive patients were included in the study. The mean age was 52.3 ± 6.5 years. All of them had undergone non-nerve-sparing radical cystectomy and urinary diversion for invasive bladder cancer. Patients were questioned about their current general relations with their husbands in comparison to the preoperative status. The Female Sexual Function Index (FSFI) was used to assess libido, lubrication, orgasm, satisfaction and painful sexual dysfunction. Patients were asked about any urinary complaints during or after sexual intercourse. RESULTS: Twenty-nine patients (39%) reported worsening relations with their husbands. The mean frequency of sexual relations was 2.3 ± 2.3/month; however, sexual relations had ceased completely in 19 patients (26%). Overall satisfaction among sexually active women worsened in 32 (59.2%) and was completely lost in eight patients (14.8%). Absent libido, difficult intromission, dyspareunia, lack of orgasm and sexually related urinary complaints were reported in 89%, 63%, 48%, 63% and 63% of patients, respectively. The mean FSFI score dropped significantly from 18.3 ± 5.1 to 11.3 ± 7.4 postoperatively (p < 0.001). FSFI scores were significantly higher among patients with orthotopic versus non-orthotopic forms of diversion and also higher among patients with no stoma versus those with stomal forms of diversion. CONCLUSIONS: Radical cystectomy and urinary diversion have deleterious impacts on all domains of female sexual function. Female patients with orthotopic and non-stomal diversions had better sexual functions than those with stomal diversions.

Recoverability of erectile function in post-radical cystectomy patients: subjective and objective evaluations.

BACKGROUND: Literature regarding both subjective and objective evaluations of erectile function following radical cystectomy is deficient. OBJECTIVE: To study the recoverability of erectile function in post-radical cystectomy patients on subjective and objective bases. DESIGN, SETTING, AND PARTICIPANTS: Between March 2003 and March 2005, 45 male patients with organ-confined invasive bladder cancer were prospectively enrolled in this study. INTERVENTION: Radical cystectomy and urinary diversion were offered to all patients (21 patients underwent a nerve-sparing [NS] surgical technique, and 24 patients underwent a non-nerve-sparing [NNS] surgical technique). MEASUREMENTS: Patients were evaluated preoperatively using the International Index of Erectile Function (IIEF) questionnaire and using penile Doppler ultrasound (PDU). Patients were followed up regularly at 2 mo, 6 mo, and 12 mo using the same parameters. RESULTS AND LIMITATIONS: Among patients in the NS group, 17 patients (78.8%) were potent postoperatively: 12 patients (57.8%) with spontaneous complete tumescence and 5 patients (21%) with partial tumescence using phosphodiesterase type 5 inhibitor (PDE5-I) as erectogenic aid; 4 patients needed intracorporeal prostaglandin E1 injections. In contrast, no patients in the NNS group showed spontaneous erection, and they did not improve with sildenafil; all of them needed prostaglandins as an erectogenic aid. The comparison between preoperative and postoperative IIEF domains showed that postoperatively the erectile function and overall satisfaction domains deteriorated initially, but in the NS group they gradually improved with time (p<0.0001). Corresponding PDU findings were comparable in peak systolic velocity during the course of follow-up in both groups. Although the end diastolic velocity was significantly more deteriorated postoperatively than preoperatively in both groups, gradual improvement in patients in the NS group was more evident 12 mo after surgery. CONCLUSION: The return of erectile function was better in the NS group on subjective and objective bases. The most significant change was in veno-occlusive function, which improved rapidly and progressively in the NS group during 1 yr of follow-up.

Uroflowmetric differences between standing and sitting positions for men used to void in the sitting position.

OBJECTIVES: To compare the results of uroflowmetry in the standing and sitting position in men who void only in the sitting position. METHODS: Two hundred patients were subjected to pelvic ultrasonography while their bladders were full, and then after voiding. Uroflowmetry was done both in sitting and standing positions and compared for all patients. Further comparisons were made according to patients' age (below and above 50) and Qmax (at or below 15 mL per second versus greater than 15 mL per second). We performed statistical analysis using Wilcoxon matched-pairs signed-ranks test. RESULTS: Comparison of uroflowmetric results in both positions showed no statistical differences except for significantly larger residual urine volume in the standing position (86.1 +/- 77) relative to the sitting position (73 +/- 80.2) (P = 0.04). On substratifying patients according to age, Qmax was significantly higher in the sitting position (16.6 +/- 8.94) relative to the standing position (15.2 +/- 7.5) in the young group (P = 0.02). Such a significant difference was not seen in the elder (greater than 50 years) group. In contrary to the low-flow group, cases with high flow showed significantly higher Qmax and Qave and significantly lower voiding and flow times and significantly lower residual urine volume in the sitting position. CONCLUSIONS: Voiding in the sitting position showed significantly better flow rates than during standing in patients with higher flow and younger age. Moreover, postvoid residual was significantly less in the sitting position in the previous two groups and in the total groups of patients. On the contrary, the presence of low flow nullifies these uroflowmetric positional differences. Uroflowmetry should be always performed in the preferred position.

Clinical and urodynamic efficacy of oxybutynin and verapamil in the treatment of nocturnal enuresis after formation of orthotopic ileal neobladders. A prospective, randomized, crossover study.

OBJECTIVE: To evaluate the efficacy of two drugs: the anticholinergic agent oxybutynin (Ditropan) and the calcium channel blocker verapamil (Isoptin) in the management of nocturnal enuresis in patients with orthotopic ileal reservoirs. MATERIAL AND METHODS: The study population comprised 20 male enuretic patients who had undergone radical cystoprostatectomy and formation of an orthotopic ileal reservoir (hemi-Kock or W-neobladder). All patients were clinically evaluated regarding their continence state. Basal medium-fill enterocystometry was performed for every patient. The patients were randomized on entry into one of the two arms of the study: oxybutynin followed by verapamil (n =10); or verapamil followed by oxybutynin (n = 10). Each group received both drugs for a period of 2 weeks each. After administration of each drug, patients were re-evaluated both clinically and urodynamically. RESULTS: Oxybutynin and verapamil improved continence status in 70% and 55% of the patients, respectively. Both drugs significantly increased the bladder volume at first desire, at normal desire and at the maximum enterocystometric capacity. The maximum enterocystometric capacity increased from 585+/-148.6 ml at baseline to 667.5+/-180.8 and 621.05+/-170.5 ml after administration of oxybutynin and verapamil, respectively. Despite this, there was no significant change in any of the pressure parameters with the exception of the basal pressure at maximum enterocystometric capacity, which decreased significantly from 20.1+/-8.3 cmH2O at baseline to 16.07+/-5.1 cmH2O after administration of verapamil. The number of uninhibited contractions in the last 5 min of filling decreased significantly from 3.6+/-0.7 at baseline to 1.9+/-1.2 after administration of oxybutynin and to 2.1+/-1.26 after administration of verapamil. The amplitude of maximum uninhibited contraction decreased from 41.15+/-9.1 cmH2O at baseline to 34.95+/-12.77 and 33.25+/-11.52 cmH2O after treatment with oxybutynin and verapamil, respectively. Neither drug significantly changed the initial, late or total compliance of the pouch. No significant side-effects occurred with either drug. CONCLUSIONS: Both drugs used in this study had beneficial effects on the continence status of our patients, with minimal side-effects. Both drugs clinically improved nocturnal incontinence after radical cystoprostatectomy and formation of orthotopic ileal reservoirs, which was verified by the associated improvements in urodynamic characteristics.

Prognostic factors predicting successful response to sildenafil after radical cystoprostatectomy.

OBJECTIVES: To assess the efficacy and safety of sildenafil citrate in the management of erectile dysfunction (ED) following radical cystectomy (RC) and to define the different prognostic factors predicting the response to sildenafil in such a challenging group of patients. MATERIAL AND METHODS: One hundred patients with ED following RC participated in an open-label, non-randomized, prospective, dose-escalation study. The median age of the patients was 53 years and the mean period after RC was 80.7 +/- 54.8 months. The study duration was 12 weeks, comprising a 4-week run-in period followed by two active treatment periods of 4 weeks each with 50 and 100 mg of sildenafil. Patients were assessed by means of the International Index of Erectile Function (IIEF) questionnaire at baseline and after each treatment period. At the end of the study, the Global Efficacy Assessment Question was used to evaluate treatment satisfaction. Factors affecting the patient's response to sildenafil were assessed by means of uni- and multivariate analysis. RESULTS: The entire study group was suffering from severe ED at baseline, with a mean erectile function (EF) domain score of 6.5 +/- 0.93. EF scores improved to 12.2 +/- 7.76 and 18 +/- 10.3 with 50 and 100 mg of sildenafil, respectively. Sildenafil therapy significantly improved the ability of many patients to achieve and maintain an erection. The mean scores for question 3 of the IIEF were 1 +/- 0.14, 2.1 +/- 1.4 and 3 +/- 1.8 at baseline and with 50 and 100 mg of sildenafil, respectively, while the corresponding scores for question 4 were 1 +/- 0.10, 1.9 +/- 1.35 and 3 +/- 1.85. The satisfaction rate was 54%. The response was dose-dependent but the incidence of adverse effects increased from 6% with 50 mg of sildenafil to 34% with 100 mg. In univariate analysis, tumor histology and grade and postoperative partial tumescence were found to significantly impact the patient's response to sildenafil. In multivariate analysis, postoperative partial tumescence was the only independent predictive variable. CONCLUSIONS. Sildenafil was found to be a safe and satisfactory treatment for post-RC ED. The effect was dose-related. Patients with postoperative partial tumescence were the best responders.

Urethral pressure profile following orthotopic neobladder: differences between nerve sparing and standard radical cystectomy techniques.

PURPOSE: Some authors reported that adopting a nerve sparing technique during radical cystoprostatectomy improves the continence outcome of orthotopic diversion in patients with invasive bladder carcinoma. We urodynamically evaluated the effect of nerve sparing cystoprostatectomy on external urethral sphincteric function. MATERIALS AND METHODS: A total of 30 consecutive male patients who underwent nerve sparing cystoprostatectomy and ileal neobladder (NS group) were compared to a control group of 30 patients who underwent a similar procedure but without nerve sparing (non-NS group). Continence status was thoroughly clinically evaluated in parallel to erectile function in both groups. The urethral sphincteric mechanism was evaluated with urethral pressure profilometry in different positions. RESULTS: Better urethral pressure profile parameters were found in patients in the NS group. Significantly longer functional urethral length (34.8 mm) was detected in NS group than in the non-NS group (30.1 mm). Moreover, the maximum urethral pressure was higher in the NS group but not to a statistically significant level. In the NS group there were no statistically significant differences between potent and impotent subgroups regarding the continence rate or urethral pressure parameters. CONCLUSIONS: There is urodynamic evidence that the nerve sparing technique improved urethral sphincteric function and, consequently, the continence rate. The denervated, most proximal part of the urethra in non-NS cases with lack of contraction and, therefore, any pressure, is a possible explanation for the difference in UPP.

Persistent and occasional nocturnal enuresis in orthotopic urinary diversion: is there a urodynamic difference?

OBJECTIVE: To establish urodynamic criteria differentiating between men with a radical cystoprostatectomy and ileal neobladder who are persistently enuretic and those who are occasionally enuretic. PATIENTS AND METHODS: Fifty enuretic men at least 1 year after a radical cystoprostatectomy and ileal neobladder (hemi-Kock or 'W' neobladders) were divided into two groups according to the persistence of their complaint; 17 men were persistently enuretic (nightly) and 33 were occasionally enuretic (<3 episodes/week). Both groups were compared with 50 fully continent men with similar reservoirs. Uroflowmetry, enterocystometry and urethral pressure profilometry were carried out according to International Continence Society standards and terminology. RESULTS: Both enuretic groups had significantly higher residual urine volumes, pressure at mid-capacity and at maximum enterocystometric capacity, amplitude of uninhibited contractions, and lower compliance than continent men. Men with occasional enuresis also had a significantly higher frequency and duration of uninhibited contractions than continent men. Men with persistent enuresis had significantly lower average and maximum urinary flow rates than continent men, and significantly lower functional urethral length and maximum urethral pressure. Uroflowmetric and urethral pressure differences were dissimilar between men with occasional enuresis and controls. CONCLUSION: Enuretic men had significantly higher residual urine volumes and enterocystometric pressure variables than continent men. Men with persistent enuresis had significantly lower flow rates and less urethral resistance. Pharmacological inhibition of reservoir contraction and/or management of residual urine by clean intermittent catheterization before sleep might cure occasional enuresis.

Asymptomatic bacteriuria in men with orthotopic ileal neobladders: possible relationship to nocturnal enuresis.

OBJECTIVE: To assess prospectively the incidence with time of asymptomatic bacteriuria in patients with orthotopic ileal neobladders, and the possible effect on neobladder function. PATIENTS AND METHODS: In all, 47 patients (mean age 52.7 years, sd 8.7, range 31-68) with uncomplicated orthotopic ileal neobladders were prospectively evaluated. With no antibiotic manipulation, consecutive urine cultures were assessed monthly. Continence was assessed by direct information from the patients at each follow-up visit. RESULTS: Overall, 797 samples were cultured from the 47 patients (mean 17.6, sd 7.1). There was a steady decrease in the incidence of positive cultures, from 74.5%, to 35.6% and 6.7% at 1, 6 and 18 months, respectively. While there was persistently sterile urine in only eight patients (17%), 32 had occasional and seven had persistent bacteriuria. Escherichia coli was the commonest organism (76.6%) followed by Klebsiella pneumonia (15.7%); 54% of E. coli and 38% of K. pneumonia infections were sensitive to nitrofurantoin. Diurnal continence was achieved in 98% of the patients at 6 months after surgery. There was a gradual decrease in the frequency of nocturnal enuresis (NE) with time, from 87%, to 42%, 28% and 27% at 1, 6, 12 and 18 months, respectively. There was a significant correlation between the presence of bacteriuria and NE during the first 6 months, but it was not sustained after that. The age of the patients was also related significantly to the incidence of NE; at 6 months, only one of 18 men aged < or = 50 years had NE, while 19 of 29 aged > 50 years had (P < 0.001). At 1 year all patients aged < or = 50 years were nocturnally continent, while half of those aged > 50 years had NE (P = 0.001). CONCLUSIONS: Ileal neobladders are associated with a high incidence of asymptomatic bacteriuria during the first year after surgery. There was spontaneous clearance of bacteriuria with time, with no antimicrobial manipulation. Soon after surgery there was a significant association between bacteriuria and NE. The effect of antimicrobials on patients with NE should be evaluated.

Impact of food intake on urodynamic features of orthotopic urinary reservoirs.

PURPOSE: The inconsistency of urodynamic characteristics among patients with similar, well detubularized urinary reservoirs together with the persistence of nocturnal incontinence in almost a third of such patients has motivated many groups to study in depth the inherent physiological characters of the intestinal segments used. One of the most critical criteria is the effect of food intake on such isolated segments. We determined the effect of food intake on the urodynamic behavior of urinary intestinal reservoirs. MATERIALS AND METHODS: A total of 50 male patients with well detubularized orthotopic reservoirs (hemiKock or W neobladders) after radical cystectomy underwent medium fill enterocystometry while fasting for 8 hours. Patients were then given a standardized caloric diet and the test was repeated 2 hours after food intake. Comparisons were made in the whole group of patients and subsets according to continence status, reservoir configuration and reservoir duration. RESULTS: The only significant and consistent finding was the decrease in maximum enterocystometric capacity. This decrease was statistically significant when calculated for the fasting and postprandial states in the whole group (mean +/- SD 539.1 +/- 155.7 and 495.9 +/- 146.2 ml), in continent patients (538 +/- 177 and 505 +/- 168.5 ml) and in patients with enuresis (539 +/- 177 and 481 +/- 106.8 ml, respectively). While the frequency and amplitude of phasic contractions were notably increased postprandially, baseline pressure at mid and maximum capacity were observed to be lowered. However, neither effect achieved statistical significance. CONCLUSIONS: Definite urodynamic changes occur in intestinal urinary reservoirs in response to food intake, denoting that these detubularized intestinal segments retain at least in part their native behavior in response to eating. The consistent decrease in maximum capacity together with increased phasic motor activity in a subset of these patients may explain their incontinence episodes. Changing food composition and habits may improve the continence state in this subset of patients.

Enterocystometry: impact of filling rate.

PURPOSE: We evaluated different enterocystometric parameters at different filling rates. MATERIALS AND METHODS: A total of 20 male patients who underwent radical cystoprostatectomy and orthotopic detubularized ileal reservoirs with at least 1 year of followup were the material of this study. Enterocystometry was done with a slow fill rate (10 ml. per minute). Under the same circumstances it was then repeated with a medium fill rate (50 ml. per minute). RESULTS: Maximum enterocytometric capacity for slow fill was significantly lower than for medium fill (median 475 versus 610 ml., p <0.001). Volume at first uninhibited contraction for slow fill was significantly lower than for medium fill (median 247 versus 450 ml., p <0.001). Volume at first desire for slow fill was significantly lower than for medium fill (median 306 versus 436 ml., p = 0.012). Moreover, volume at highest contraction for slow fill was significantly lower than for medium fill (median 451 versus 557 ml., p <0.001). Other pressure parameters were comparable without any significant difference between the 2 filling rates. The difference in contraction frequency calculated in the last 100 ml. of filling was significantly higher for slow than for medium fill enterocystometry. CONCLUSIONS: Higher rates of filling during enterocystometry resulted in significantly higher capacity, delayed onset of contractions, delayed onset of first desire (or sense of fullness) and delayed onset of highest contraction. Therefore, we recommend slower filling rates during enterocystometric studies, which mimics physiological states and allows accurate and earlier identification of enterocystometric changes that could be masked by higher rates of filling.

Late uro-ileal cancer after incorporation of ileum into the urinary tract.

PURPOSE: Development of late uro-intestinal malignancy after bowel incorporation into the urinary tract is a constant long-term hazard, even in the absence of fecal material. We report 6 such cases. MATERIALS AND METHODS: A total of 350 patients treated with an ileal conduit, 260 with ileal replacement of the ureter and 55 with ileocystoplasty were evaluated and followed for a minimum of 4 years. The methods of evaluation included urine analysis for microscopic hematuria, urine culture, serum creatinine and abdominal ultrasonography. These evaluations were performed every 2 months after cystectomy for bladder cancer and every 6 months in other cases. Annual urinary cytology and excretory urography were done. Computerized tomography and/or magnetic resonance imaging was performed annually after radical cystectomy or if there was evidence of hematuria, ureteral obstruction or a filling defect in the bladder, pouch or conduit on excretory urography. Endoscopic evaluation was done in some cases. If malignancy was diagnosed chest x-ray and bone scintigraphy were performed. RESULTS: A total of 645 patients were evaluable. Of these patients late cancer developed at the uro-intestinal anastomotic site in 6 (0.9%), including 1 of 348 (0.3%) who underwent ileal conduit, 3 of 54 (5.5%) ileocystoplasty and 2 of 258 (0.8%) ileal replacement of ureter. The latent period "from the time of original surgery till the development of cancer" ranged from 4 to 32 years (mean plus or minus standard deviation 20.2 +/- 10.9). The pathological type of cancer was adenocarcinoma in 3 patients, transitional cell carcinoma 2 and squamous cell carcinoma 1. CONCLUSIONS: Late uro-intestinal malignancy in patients who underwent ileal incorporation in the urinary tract is a low but still distinct risk. Ileocystoplasty is more vulnerable to late uro-enteric cancer than ileal conduit and ileal replacement of ureter. Late malignancy can develop earlier than 10 years postoperatively. Therefore, annual surveillance by routine urine cytology postoperatively is advocated, particularly with enterocystoplasty.