Assessing trends in urinary diversion after radical cystectomy for bladder cancer in the United States.

OBJECTIVES: We assessed recent trends in both urinary diversion after radical cystectomy for bladder cancer in the United States and patient- and hospital-related characteristics. We also identified variables associated with undergoing continent diversion. MATERIALS AND METHODS: We queried the National Cancer Database and identified 27,170 patients who underwent radical cystectomy with urinary diversion from 2004 to 2013. Patient demographics, socioeconomic variables, and hospital-related factors were compared between incontinent and continent diversion and trended over time. Multivariable logistic regression was used to identify variables associated with undergoing continent diversion. RESULTS: Overall, 23,224 (85.5%) and 3,946 (14.5%) patients underwent incontinent and continent diversion, respectively. Continent diversion declined from 17.2% in 2004 to 2006 to 12.1% in 2010 to 2013 (P < 0.01). When analyzing high-volume facilities, those performing ≥75% minimally invasive radical cystectomy had fewer continent diversions (10.2%) compared to centers with higher rate of open approach (19.7%), P < 0.01. Higher income, facility located in the West, academic programs, high-volume facilities, and patients traveling >60 miles for care were significantly associated with undergoing continent diversion. Rate of continent diversion has declined in most patient- and hospital-related subgroups. Compared to 2004 to 2006, patients in 2010 to 2013 were more likely to be older, have more comorbidities, and be operated on at a high-volume academic facility. CONCLUSION: The rate of continent diversion has declined to 12.1% in the United States. Hospital volume and type, patient income, distance traveled for care, and geography are significantly associated with undergoing continent diversion. Even among high-volume and academic centers, the rate of continent diversion is declining.

Urinary diversion trends at a high volume, single American tertiary care center.

PURPOSE: We analyzed patient characteristics and practice patterns at our institution with time, and identified current patterns and factors contributing to the choice of urinary diversion. MATERIALS AND METHODS: We reviewed the records of 553 consecutive radical cystectomy and urinary diversions performed from January 2000 to July 2005. Multivariate analysis was done to determine significant differences in diversion choice. RESULTS: We analyzed the records of 539 patients, including 338 with an ileal conduit and 201 with a neobladder. Patients with a neobladder were younger (mean age 62 vs 71 years) and had fewer comorbidities (American Society of Anesthesiologists class greater than 2 in 31% vs 69%) than those with an ileal conduit. Mean age and the percent of American Society of Anesthesiologists class 3 or 4 cases increased during the study. Neobladder represented 47% of urinary diversions in 2000 and 21% in 2005. On multivariate analysis age (p <0.001), gender (p = 0.004), surgery year (p = 0.002), American Society of Anesthesiologists class greater than 2 (p = 0.004), organ confined disease (p = 0.01) and surgeon (p <0.001) independently predicted diversion choice. Patients were dichotomized into young (younger than 65 years) and old (65 years old or older) groups. Overall 59% of younger and 26% of older patients received a neobladder (p <0.001). CONCLUSIONS: There was a significant trend toward the more liberal use of ileal conduit urinary diversion. Patients with female gender, advanced age, significant medical comorbidity or locally advanced disease were less likely to undergo neobladder urinary diversion. This trend is partly explained by surgeon preference combined with an aging, more comorbid patient population. Neobladder continues to be the most commonly performed urinary diversion in patients younger than 65 years.

[Development of continent reservoirs]. / Entwicklung kontinenter Reservoire.

Continent reservoirs represent an alternative to urostomy. Various operation techniques are available and the historical development will be described here with respect to the use of different parts of the intestine.

Urostomy products: an update of recent developments.

This article provides an overview of the recent developments in appliances for people with a urostomy. Following a short background, the products that may be useful for this patient group are discussed.

Renal function in the setting of urinary diversion.

Incorporating bowel into the urinary tract sets the stage for a potentially dangerous situation for the upper part of this tract. Obstruction, reflux and chronic bacteriuria may develop, all of which can all be detrimental. Most reports on renal function have used IVP and serum creatinine only, methods which are inadequate for proper assessment. Long-term follow-up of patients with ileal conduit diversion reveals a high incidence of morphological and/or functional damage to the kidneys. Refluxing techniques for implanting the ureters have usually been employed. In patients with continent cutaneous diversion or orthotopic bladder substitution, some recent publications have shown rather well preserved glomerular filtration rates. Traditionally, antirefluxing ureteric implantation has been used in these patients. There is presently a trend towards refluxing anastomosis in this setting, providing a low pressure pouch has been constructed. However, pressure can be high in such pouches and bacteriuria is common. The consequences for the fate of the upper urinary tract is unknown and caution should be exercised in recommending such techniques. There is clearly a need for prospective randomized controlled studies on the issue of refluxing versus antirefluxing anastomosis in continent urinary reconstruction. Patients with continent or non-continent diversion should have lifelong follow-up with regard to the upper urinary tract.

[Laparoscopic radical cystectomy with intracorporeal creation of a continent urinary diversion. Future or present?]. / Laparoskopische radikale Zystektomie mit intrakorporaler Anlage einer kontinenten Harnableitung. Zukunft oder Gegenwart?

Once laparoscopic radical prostatectomy has been mastered, the step to performing a radical cystectomy is not that far. The challenge is to create the urinary diversion by laparoscopy. In this report we describe our experience with 11 laparoscopic radical cystectomies and intracorporeal construction of a continent urinary diversion (Mainz pouch II) as a treatment option in patients with muscle-invading bladder cancer. All 11 procedures could be performed successfully. A conversion to open surgery was not required in any case. The mean surgery time was 6.7 h. Except for two pouch fistulas we did not observe any intra- or postoperative complications. The functional as well as the oncological results are convincing. Less morbidity and faster recovery are the main advantages of this minimally invasive procedure. In addition, the low levels of blood loss, fluid shifts, and electrolyte loss considerably reduce cardiovascular stress. Radical cystectomy and construction of a continent urinary diversion represent the limit of technically feasible laparoscopy and should be done exclusively in specialized centers.

[15 years experience with the ileal neobladder. What have we learned?]. / 15 Jahre Erfahrung mit der Ileumneoblase. Was haben wir gelernt?

During the past 15 years, orthotopic bladder reconstruction has evolved from experimental surgery over "standard of care at larger medical centers" to become the preferred method of urinary diversion in both sexes. The paradigm for choosing a urinary diversion has changed substantially over that time. In 2001, all cystectomy patients are candidates for a neobladder, and we should identify those patients in whom orthotopic reconstruction may be less ideal, noting that the percentage of patients receiving a neobladder today averages 60 to 70 percent. Relative contraindications and comorbidity now play a smaller role in choosing the neobladder option. Patient selection criteria include both patient factors and cancer factors. The primary patient factor being the patient's desire for a neobladder. The psychologically damaging stigma to the patient who enters surgery expecting a neobladder but awakens with a stoma now plays an increasing role. Nevertheless, there are patients who are better served with a conduit. Among that are patients whose main motivation is to "get out of the hospital as soon as possible", and patients who will be happy to resume a normal, relatively sedentary life and who have no concerns about body image. Two important criteria that must be maintained when contemplating a neobladder procedure--the urethral sphincter must remain intact and the cancer operation must not be compromised. However, increasing experience has forced less restrictiveness as far as tumor stage is concerned. A recent study of 435 bladder cancer patients who had bladder replacements after cystectomy, experienced a local recurrence rate of 10 percent. Interference of the local recurrence with the neobladder occurred in just 11 patients--infiltration in six, and obstruction in five. Survival was limited despite multimodality therapy. The option of a neobladder reduced the physician and patient reluctance to perform cystectomy early in the disease process, thereby increasing the survival rate, and patients can anticipate normal neobladder function until time of death. It can be concluded that a neobladder for locally advanced cancer and positive nodes is no more problematic than a conduit. The structural and ultrastructural changes which occur in neobladder mucosa are biphasic. The early phase is inflammatory, showing an infiltration of the lamina propria and a reduction in microvilli. After one year the late regressive phase starts, ending up in a flat mucosa and a stratified epithelium. The structure and response of the implanted ileum change to a detrusor-type: response. The structural and ultrastructural changes an ileal mucosa lead to a primitive surface and glandular epithelium similar to urothelium. This transformation of the ileal mucosa minimizes the risk of metabolic complications. We conclude that mother nature engineers a new bladder almost as good as the one given by God initially. The risk of obstruction of non refluxing techniques is at least twice that following a direct anastomosis. There is no longer a justification of any antireflux mechanism. Ileum seems to be clearly superial to colon when continence rates, metabolic safety and surgeons's issues are considered.

[Reconstruction of the lower urinary tract. Developments at the beginning of a new century]. / Rekonstruktion des unteren Harntrakts. Entwicklungen am Beginn des neuen Jahrtausends.

Gastrointestinal segments are currently by far the most popular method to create a bladder substitute. Attempts have been made to further reduce the morbidity and burden for patients by using minimal invasive techniques for both cystectomy and urinary diversion. However, laparoscopy for acceptable forms of urinary diversion is time consuming and costly. A neobladder "off the shelf" would be a better solution. Tissue engineering is an exciting new field which enables the cultivation and expansion of individual bladder cells obtained by transurethral biopsy, the attachment of these cells to a support matrix, and their reimplantation into the body. Advances both in biomaterials as well as in the cultivation and expansion of bladder cells are described. Promising routine clinical applications of tissue engineering may still need several years. Free neurovascular muscle transfer to the bladder demonstrated both experimentally and clinically to be a suitable treatment modality in patients with bladder acontractility. This may therefore be the next logical step towards an improved bladder substitute by combining well vascularized flaps with urothelial cell seeding. Thus a combination of commonly used flap techniques and tissue engineering may soon be possible.

[Urothelium cell culture: what is the future? An experimental study in rabbits]. / La culture cellulaire d'urothélium: quel avenir? Une étude expérimentale sur le lapin.

Since the first human bladder reconstruction in 1989 using an ileal segment, many alternatives have been proposed to recreate a bladder reservoir as adapted as possible to physiological conditions. Since the development of urothelial cell culture alone and then in combination with matricial supports, various experimental trials have studied the possibility of using this neurothelium for surgical purposes. This experimental study in rabbits tested the compatibility of two different biosynthetic supports in an enterocystoplasty and the survival in in vitro urothelial cells grafted onto this support.

[Current trends in clinical urology]. / Aktuelle Trends der klinischen Urologie.

Many recent developments in urologic diagnostic and therapy are also of interest for general surgeons. Flexible and semirigid ureteroscopes (6-8 F) provide easy and atraumatic access to the whole upper urinary tract. Beside extracorporeal shockwave-lithotripsy now various endourologic modalities to treat ureteral stones are available. Although useful, laparoscopic techniques are not yet widely accepted by urologists because there is a lack of indications in urologic laparoscopic surgery. The functional reconstruction of the urinary bladder by means of an ileal neobladder with an anastomosis to the urethra in the male or with a continent stoma and selfcatheterism provides better quality of life in patients after radical cystectomy. Nephron-sparing tumor surgery may become a routine procedure under certain precautions such as small tumor size, patient's compliance and good local medical infrastructure. Especially for urologic microsurgery, neurourology and different treatments of benign prostatic hyperplasia essential new and interesting improvements are expected.