ICUD-EAU International Consultation on Bladder Cancer 2012: Urinary diversion.

CONTEXT: A summary of the 2nd International Consultation on Bladder Cancer recommendations on the reconstructive options after radical cystectomy (RC), their outcomes, and their complications. OBJECTIVE: To review the literature regarding indications, surgical details, postoperative care, complications, functional outcomes, as well as quality-of-life measures of patients with different forms of urinary diversion (UD). EVIDENCE ACQUISITION: An English-language literature review of data published between 1970 and 2012 on patients with UD following RC for bladder cancer was undertaken. No randomized controlled studies comparing conduit diversion with neobladder or continent cutaneous diversion have been performed. Consequently, almost all studies used in this report are of level 3 evidence. Therefore, the recommendations given here are grade C only, meaning expert opinion delivered without a formal analysis. EVIDENCE SYNTHESIS: Indications and patient selection criteria have significantly changed over the past 2 decades. Renal function impairment is primarily caused by obstruction. Complications such as stone formation, urine outflow, and obstruction at any level must be recognized early and treated. In patients with orthotopic bladder substitution, daytime and nocturnal continence is achieved in 85-90% and 60-80%, respectively. Continence is inferior in elderly patients with orthotopic reconstruction. Urinary retention remains significant in female patients, ranging from 7% to 50%. CONCLUSIONS: RC and subsequent UD have been assessed as the most difficult surgical procedure in urology. Significant disparity on how the surgical complications were reported makes it impossible to compare postoperative morbidity results. Complications rates overall following RC and UD are significant, and when strict reporting criteria are incorporated, they are much higher than previously published. Fortunately, most complications are minor (Clavien grade 1 or 2). Complications can occur up to 20 yr after surgery, emphasizing the need for lifelong monitoring. Evidence suggests an association between surgical volume and outcome in RC; the challenge of optimum care for elderly patients with comorbidities is best mastered at high-volume hospitals by high-volume surgeons. Preoperative patient information, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good long-term results.

[Neocystoplasty after pelvic evisceration on the subject of colorectal cancer].

The experience of 104 total pelvic eviscerations, 78 operations on the reason of locally advanced colorectal cancer, was analyzed. The reconstructive stage included urine reservoir formation in all cases. Different organs were used for the purpose. Early postoperative complications were registered in 74,3% of patients. Postoperative death rate was 8,9%, in majority of cases as a reason of the anastomotic insufficiency. Of the recovered patients, 48 survived 1 year after the operation, 16 patients showed the 3 years survival and 6 patients had lived more then 5 years.

How close are we to knowing whether orthotopic bladder replacement surgery is the new gold standard?--evidence from a systematic review update.

OBJECTIVES: To compare the clinical effectiveness and risk profile of the different types of surgeries using transposed intestinal segments in a systematic review update. Urinary diversion is designed to improve or replace the function of the diseased urinary bladder. METHODS: Studies reporting on surgery involving intestinal segments transposed into the urinary tract were identified between January 1990 and January 2007 using MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Library. All articles published in English language reporting on at least 10 patients and follow-up of at least 1 year were included. This is a substantive update of our previously published systematic review that reported on the evidence between January and to January 2003 (Nabi G, Yong SM, Ong E, et al. J Urol. 2005;174:21-28). RESULTS: Between January 1990 and January 2007, a total of 5651 abstracts were reviewed. Of them, 557 studies met the inclusion criteria reporting on 46,921 participants (an additional 14,126 participants reported on between January 2003 and January 2007). Operative complications were lowest in ileal conduit diversion, whereas postoperative morbidity and mortality were lower for orthotopic bladder replacement surgery. Of the 35 quality-of-life studies, only 2 studies (Dutta SC, Chang SC, Coffey CS, et al. J Urol. 2002;168:164-167; Hobisch A, Tosun K, Kinzl J, et al. World J Urol. 2000;18:338-344) reported a better quality of life with orthotopic bladder replacement. CONCLUSIONS: This systematic review update fails to reveal a clear winner, with each intervention type having advantages and disadvantages. With > 46,000 patients included in transposed intestinal segment research over the past 16 years, it is surely a criticism of our speciality that we are no closer to answering the question of what is the best way to improve or replace the function of the diseased bladder.

Orthotopic neobladder versus ileal conduit urinary diversion after cystectomy--a quality-of-life based comparison.

INTRODUCTION: Radical cystectomy remains the gold standard in treatment of muscle invasive bladder cancer. Evolution of pathological guidelines has empowered centres to offer orthotopic substitution (OBS) to patients undergoing radical cystectomy. We compared health-related quality of life (HRQoL) between patients who underwent OBS or ileal conduit urinary diversion (ICD) following radical cystectomy. PATIENTS AND METHODS: A total of 57 patients who underwent cystectomy were assessed pre-operatively using Karnofsky performance scale (KPS). Of these, 52 patients (28 OBS and 24 ICD) who responded to a postal questionnaire consisting of SF-36 and a functional index questionnaire were included. RESULTS: Median age of patients was 70 years. Pre-operative KPS scores were similar. All eight HRQoL scales were favourable in both groups. OBS patients had significantly better physical functioning. In the cohort, 42% of men with OBS and 25% of diversions could maintain an erection to varying degrees. Of the OBS patients, 85% were continent with two patients reporting reduced QoL with pad usage. Of ICD patients, 63% felt less complete and 42% were embarrassed due to the stoma, with 58% apprehensive of stomal leakage. Of OBS patients, 96% had significant relationships and a more active life-style. CONCLUSIONS: In a similar age-group population, there was no significant difference in most QoL indices but body image issues persist in ICD patients. OBS patients had significantly better physical function, continuing to have a more active lifestyle. They attained urethral voiding with good continence. A detailed discussion of long-term functional outcome would engender a realistic expectation allowing better adaptation.

The continent, catheterizable abdominal conduit in adult urological practice.

OBJECTIVE: To report a large, single-centre experience with a continent, catheterizable abdominal conduit in adult patients. PATIENTS AND METHODS: We retrospectively reviewed the case notes of all 65 patients who had surgery to create a continent catheterizable conduit based on the Mitrofanoff principle. Operations were carried out over a 13-year period. Data on surgical procedure, complications and final outcome were collected and analysed. RESULTS: The mean age of the patients was 38.4 years and mean follow-up interval was 75.2 months. Patients with neuropathic lower urinary tracts accounted for the largest single indication for reconstruction (36 patients). The appendix was the conduit of choice and was available and suitable for use in 37 patients. There were 57 patients who continued to use their native bladder or had undergone an augmentation or substitution cystoplasty; 24.5% of these 57 individuals had also undergone closure of the bladder neck or urethra. There were postoperative complications requiring laparotomy in five (8%) patients. In all, 30 patients (46%) had catheterization problems, but most of these were easy to treat. Five patients (8%) had an incontinent conduit which was a more difficult problem to deal with. Two patients have died of unrelated cause and five patients have been converted to an ileal conduit. In all, 58 patients (92%) now have a Mitrofanoff conduit, of which 97% are catheterizable and 95% are continent. CONCLUSIONS: Continent urinary diversion, based on the Mitrofanoff principle, has similar outcomes in adult urological practice to those described in published paediatric case series. There is good evidence to suggest that Mitrofanoff conduits are durable. However, patients should be aware of complications and the need for long-term follow-up.

Is continent diversion using the Mitrofanoff principle a viable long-term option for adults requiring bladder replacement?

OBJECTIVE: To audit the long-term outcome of patients with Mitrofanoff continent urinary diversion (MUD) to inform counselling of future patients concerning the procedure. PATIENTS AND METHODS: All patients who underwent MUD between 1990 and 2003 were identified. Continence, urinary tract infection (UTI), calculus formation and renal function were assessed by chart review and interviews. RESULTS: Of the 29 patients identified 12 were women and 17 men with a mean (range) age of 48 (18-79) years at operation. The median (range) follow-up was 126 (5-190) months. On questioning, 25 of 28 (89%) patients stated that they were continent. There was more than one confirmed UTI per year in two patients. Half of the patients had at least two UTIs within the follow-up period but with no deterioration in renal function. Calculi developed in eight (29%) patients; four with bladder, three with renal and one with both renal and bladder calculi. Stomal stenosis developed in 15 (54%) patients requiring intervention at a mean (range) rate of 0.4 (0.1-2.4) episodes per year and nine ultimately required stomal reconstruction. Five (18%) patients required conversion to ileal conduit, two of these for persistent incontinence and three for recurrent stomal complications, at a mean (range) of 82 (9-140) months. CONCLUSIONS: MUD is effective in offering continence with no major deterioration of renal function; however, this needs to be balanced against the need for subsequent additional interventions for stomal stenosis, stone formation and UTI on an individual basis.

Evaluation of findings during re-exploration for obstructive ileus after radical cystectomy and ileal-loop urinary diversion: insight into potential technical improvements.

OBJECTIVE: To retrospectively evaluate the findings during re-exploration for obstructive ileus after radical cystectomy (RC) and ileal conduit diversion. PATIENTS AND METHODS: During a 12-year period, 434 patients who had RC and ileal conduit diversion were retrospectively evaluated for the diagnosis of early (

Long-term results of orthotopic neobladder reconstruction after radical cystectomy.

OBJECTIVE: To assess, in a retrospective study, the long-term results of neobladder reconstruction after radical cystectomy, as this is the standard of care for muscle-invasive bladder cancer. PATIENTS AND METHODS: Data were retrieved for all patients with muscle-invasive transitional cell carcinoma of the bladder treated by radical cystectomy and orthotopic neobladder substitution between 1988 and 1998. All perioperative and long-term complications were recorded. The voiding pattern, frequency of micturition and continence were assessed, and a complete urodynamic profile recorded. RESULTS: In all, 102 patients underwent radical cystectomy with orthotopic neobladder reconstruction in the study period; their mean (range) follow-up was 73 (36-144) months. Neobladder substitution was with an ileocaecal segment in 35 patients, sigmoid colon in 34 and ileum in 33. Early complications occurred in 32 patients (31%) although open surgical intervention was required in only nine (9%). The death rate after surgery was 3.9%. Late complications occurred in 31 patients (30%) and were primarily caused by uretero-enteric and vesico-urethral strictures (9% each). Most patients had daytime (89%) and night-time (78%) continence. The mean maximum pouch capacity (mL) and pouch pressure at capacity (cmH2O) were 562.5 and 23 (ileocaecal), 542 and 17.8 (sigmoid) and 504 and 19.1 (ileal), respectively; the mean postvoid residual was 29, 44 and 23 mL, respectively. Nine patients with ileocaecal neobladders, and 20 and seven with sigmoid and ileal neobladders, required clean intermittent catheterization. Twenty-four patients had recurrence of disease, of whom 20 died. CONCLUSIONS: Orthotopic neobladder reconstruction requires complex surgery but has an acceptable early and late complication rate in properly selected patients. It provides satisfactory continence without compromising cure rates.

Health-related quality of life after radical cystectomy for bladder cancer: a comparison of ileal conduit and orthotopic bladder replacement.

OBJECTIVE: To compare the health-related quality of life (HRQoL) after radical cystectomy in patients with an ileal conduit or an orthotopic neobladder. PATIENTS AND METHODS: The study included 85 men who underwent radical cystectomy for bladder cancer, comprising 48 with an orthotopic neobladder (26 with an ileal and 22 with a colon neobladder) and 37 with an ileal conduit. HRQoL was evaluated using the Short Form-36 survey containing 36 questions assessing eight aspects, including physical functioning, role-physical functioning, bodily pain, general health, vitality, social functioning, role-emotional functioning and mental health. RESULTS: The mean follow-up periods for patients with a neobladder (ileal and sigmoid) and with an ileal conduit was 45.9 (38.2 and 53.1, respectively) and 130.9 months, respectively. Scale scores were not affected by the duration of follow-up in either group. There was no significant difference in any scale scores between the neobladder and ileal conduit groups. However, general health and social functioning in both the neobladder and ileal conduit groups appeared to be significantly lower than those in the general population in the USA. Furthermore, patients with a colon neobladder had a significantly higher score for role-emotional functioning than those with an ileal neobladder, while there was no significant difference in the remaining seven scores between patients with ileal and colon neobladders. CONCLUSIONS: Six of the eight scales of HRQoL were favourable in both patients with a neobladder or an ileal conduit, and there was no significant difference between these groups. In addition, the HRQoL of patients with an orthotopic neobladder (except for role-emotional functioning) was unaffected by the segment of the intestine used for neobladder construction. Therefore, patients with both types of urinary diversion were generally satisfied with their overall health and quality of life.

Continent catheterizable conduits: which stoma, which conduit and which reservoir?

OBJECTIVE: To assess the outcome of the various methods used in creating continent catheterizable conduits. PATIENTS AND METHODS: The case notes were reviewed from 89 patients who underwent the formation of 112 continent catheterizable conduits. RESULTS: Sixty-five conduits were Mitrofanoff and 47 were antegrade colonic enema (ACE); 21 patients had both. At a mean follow-up of 34 months, 95 (85%) conduits were still in use. There was no difference in complications between the Mitrofanoff and ACE conduits; 109 (97%) conduits were continent and stomal stenosis occurred 35 (31%). There was no significant difference relating to the conduit used, the reservoir, the stoma type or the stoma site. Only 39% of patients required no revisional surgery. CONCLUSION: Although urinary and fecal continence can be achieved in most patients there is a high burden of complications and revisional surgery. All patients should be counselled accordingly.

The stapled continent ileocecal urinary reservoir in the surgical management of gynecologic malignancy.

Total cystectomy at the time of radical pelvic surgery for gynecologic malignancies is not uncommon. Many techniques have been developed for urinary diversion including the continent ileocecal urinary reservoir. Twenty-nine patients underwent construction of a continent ileocecal urinary reservoir during the reconstructive phase of an exenterative procedure or for the relief of urinary tract fistula between 1990 and 1993. All procedures were performed using the mechanical stapling devices using metal staples. The right and proximal transverse colon were mobilized to a length of 24 cm. The ileum was divided 8 cm proximal to the ileocecal valve and plicated using the stapling technique. The colonic segment was opened on its antimesenteric border and the reservoir was created by stapling in a fashion to reapproximate the distal ends to each other. The ureters were stented and implanted without tunneling. A large Malecot drain was placed in all the pouches for irrigation of the colonic mucosa in the postoperative period. The ileal stoma was fixed to the anterior abdominal wall as was the anterior surface of the pouch. Operative time ranged from 50 to 150 min for the pouch construction. All patients underwent retrograde contrast study of the pouch 7-10 days postoperatively to verify lack of anastomatic leaks. After recovery, all patients successfully self-catheterized the pouch three to five times daily without difficulty. Of the 29 patients, 17 (59%) had received prior radiation as part of therapy. All patients remained continent at the end of observation. One developed a fistula to the perineum after intraoperative placement of 125I seeds on the pelvic wall. One patient developed pouch stones; endoscopic evaluation of this pouch revealed no evidence of stones at the staple lines and metabolic workup demonstrated hypocitremia as the etiology for the stones. Mean reservoir volume was 550 ml. Mean follow-up is 15.8 months; 5 have expired due to recurrent disease and 19 (83%) remain alive. Only two patients have been admitted for urosepsis due to reflux pyelonephritis. The stapled continent ileocecal reservoir offers benefits to patients undergoing total cystectomy. Using the mechanical stapling devices decreases the operative time and has not resulted in stone formation or pouch leakage. The complications of the procedure are acceptable.

[Clinical experience with modified Studer's bladder substitute].

We modified Studer's bladder substitute technique and constructed continent urinary reservoir for 7 patients with bladder tumors after transprostatic cystoprostatectomy. Studer's bladder substitute technique is characterized by both a tubular isoperistatic proximal limb of 20 cm of the ileum in continuity with the pouch constructed using the detubularized ileum and the ureters reimplanted into the proximal part of the limb using a simple lateral anastomosis of the ureters to the end of the limb. Our modifications, transprostatic resection, was that distal one third or fourth of the prostate was left after cystoprostatectomy followed by either enucleation of the whole residual prostatic tissue including the urethra (type II) or sharp resection of the tissue leaving the urethra (type III). A small hole in the lowest part of the pouch was anastomosed either to the residual prostatic capsule (type II) or to the residual prostatic urethra (type III). Our modified Studer's technique was simple, easy to perform, and had low risk of massive bleeding especially from the central vein overlying the appex of the prostate. Clinical results were as follows; 1) all patients were satisfied with the passing of their urine per urethra without any cutaneous stoma, 2) no patients had clinical signs of pyelonephritis after discharge, 3) urine was not infected.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical studies on Kock continent urinary reservoir and Indiana continent urinary reservoir].

Recently, the continent urinary reservoir which provides the patient with a better quality of life has become popular. Many types of reservoirs have been reported, but the optimal procedure remains to be established. From July 1987 through November 1988, we performed Kock pouch construction on 11 patients (ages 39 to 76 years). Between July 1989 and March 1991, 9 patients (ages 44 to 66 years) underwent Indiana pouch operation. The first 4 patients underwent ileal patch type, and the subsequent 5 underwent Heineke-Mikulicz type procedure. A one-stage radical cystectomy and continent urinary reservoir construction was performed on 19 patients, and bilateral cutaneous ureterostomy was converted to Kock pouch in one patient. There were no perioperative deaths, but reoperation was required for urinary leakage from the reservoir on one patient in each group. As the late complications in the Kock pouch group, one patient required revisional operation of the continent valve mechanism, 2 patients experienced intermittent prolapse of the nipple valve of the efferent limb, and 2 had malfunction of the afferent nipple valve. In the Indiana pouch group unilateral hydronephrosis was noticed in one patient, and 4 had mild difficulty of catheterization. Although 3 patients in both groups had mild urinary leakage, all patients had good quality of life with capacity of reservoir over 500 ml and with good renal function. We changed the type of operative procedure from Kock pouch to Indiana pouch because of the high complication ratio in the former.(ABSTRACT TRUNCATED AT 250 WORDS)

Preliminary experience in ileal neobladder reconstruction.

In the treatment of transitional cell carcinoma of the bladder, the recent trend is towards radiation or chemotherapy which can be either regional or systemic. There have also been good results with giving Mitomycin or Bacillus Calmette Guerin instillation into the bladder for superficial tumours. There are occasions where patients present with large bulky tumours which cannot be controlled by endoscopic measures, invasion involving multiple sites and carcinoma in-situ which progresses to invasion. In these occasions, we have to resort to surgical clearance of the tumour. If it is possible, all patients would not like to wear a urinary bag for the rest of their lives. A bladder replacement if ever possible is always welcomed because the patient can pass urine from the natural passage. Due to the magnitude of a radical cystectomy and status of the urethra, it is not always technically possible to reconstruct the bladder. With improvement of operative techniques and suture materials, there has been a recent development of a method of bladder reconstruction that uses an ileal pouch. We report our early experience with this operation.

Recent advances in surgical reconstruction of the gynecologic cancer patient.

Despite significant advances in radiation oncology and chemotherapy, radical en bloc resection of pelvic tissue remains an important part of the armamentarium of the gynecologic oncologist. Total pelvic exenteration can be the only hope of women who failed more conservative therapy. The time has come where it is appropriate to employ temporary techniques in the discipline of reconstructive surgery to restore these women to an acceptable quality of life. It may be the next challenge for the pelvic surgeon to participate in such surgical reconstruction. This challenge is becoming an active part of the oncologic surgical practice in head and neck surgery, and in breast surgery. Reconstructive surgery of the vulva has been well described in the literature with the use of cutaneous and myocutaneous flaps, and it is beyond the scope of this paper to recount them here. This paper reviews the techniques that are available for reconstruction of a functional vagina, restoration of a functional rectum with elimination of colostomy, and reconstruction of a continent urostomy that will allow better physiologic protection of the upper renal tracts and improve the aesthetics of a urine ostomy bag.

[Functional analysis of micturition and continence after a Hautmann type enterocystoplasty (27 patients)]. / Analyse fonctionnelle de la miction et de la continence après entérocystoplastie de type Hautmann (27 patients).

Twenty seven patients treated by Hautmann enterocystoplasty completed a detailed questionnaire concerning the quality of their micturition and continence. The mean capacity of the neobladder was 250 cc with a diurnal interval between micturitions of about 3 hours. 79% of patients experienced an urge to micturate. The mean frequency of nocturnal micturition was 1.6. Diurnal continence was perfect in 100% of patients, while nocturnal continence was excellent in 78% of cases and good in 18% of cases, while one patient (4%) suffered from nocturnal incontinence. Hautmann enterocystoplasty is therefore an excellent technique for bladder replacement, ensuring diurnal and nocturnal continence for the great majority of patients.