Robot-assisted radical cystectomy with intracorporeal urinary diversion decreases postoperative complications only in highly comorbid patients: findings that rely on a standardized methodology recommended by the European Association of Urology Guidelines.

INTRODUCTION: The available studies comparing robot-assisted radical cystectomy (RARC) with intracorporeal (ICUD) vs. extracorporeal (ECUD) urinary diversion have not relied on a standardized methodology to report complications and did not assess the effect of different approaches on postoperative outcomes. MATERIALS: Two hundred and sixty seven patients treated with RARC at a single center were assessed. A retrospective analysis of data prospectively collected according to a standardized methodology was performed. Multivariable logistic regression models (MVA) assessed the impact of ICUD vs. ECUD on intraoperative complications, prolonged length of stay (LOS), 30-day Clavien Dindo (CD) ≥ 2 complications and readmission rate. Interaction terms tested the impact of the approach on different patient subgroups. Lowess graphically depicted the probability of CD ≥ 2 after ICUD or ECUD according to patient baseline characteristics. RESULTS: Overall, 162 ICUD vs 105 ECUD (61 vs. 39%) were performed. Intraoperative complications were recorded in 24 patients. The median LOS and readmission rate were 11 vs. 13 (p = 0.02) and 24 vs. 22% (p = 0.7) in ICUD vs. ECUD, respectively. Overall, 227 postoperative complications were recorded. The overall rate of CD ≥ 2 was 35 and 43% in patients with ICUD vs. ECUD, respectively (p = 0.2). At MVA, the approach type was not an independent predictor of any postoperative outcomes (all p ≥ 0.4). Age-adjusted Charlson Comorbidity Index (ACCI) was associated with an increased risk of CD ≥ 2 (OR: 1.2, p = 0.006). We identified a significant interaction term between ACCI and approach type (p = 0.04), where patients with ICUD had lower risk of CD ≥ 2 relative to those with ECUD with increasing ACCI. CONCLUSIONS: Relying on a standardized methodology to report complications, we observed that highly comorbid patients who undergo ICUD have lower risk of postoperative complications relative to those patients who received ECUD.

Characterization of a learning curve for robotic cystectomy with intracorporeal urinary diversion at two institutions using the cumulative sum (CUSUM) method.

INTRODUCTION: Robotic cystectomy with intracorporeal urinary diversion (RCID) is a technically challenging procedure. It is understood that this approach has a learning curve; however, limited studies have characterized this learning curve. The cumulative sum (CUSUM) method plots the learning curve. The aim of this study was to use the CUSUM approach to investigate the number of cases required to reach a consistent, desired performance level for RCID. MATERIALS AND METHODS: Retrospective study of the first 27 and 28 RCID cases performed by two new fellowship trained faculty at two separate institutions from November 2014 to January 2018. Total operating time was calculated and the CUSUM method was used to describe the learning curve, the number of cases needed for a consistent performance level. RESULTS: Twenty-seven and 28 patients were reviewed from two institutions (A and B), with 8 and 7 females, 19 and 21 males and an average age of 66.7 and 67.6 years, respectively. Twelve and ten cases, respectively, had final pathology of stage T3 bladder cancer or higher. The CUSUM curve demonstrated a learning curve of 10 and 11 cases, respectively, when the curve transitioned from steady improvement in OR times (upward slope of curve) to a relative steady state of OR times (plateau of curve). The average lymph node yield, rate of ureteral stricture, and positive margins were also examined with no learning curve noted. CONCLUSION: In RCID, approximately 10 cases were required by robotically trained new faculty to reach a steady-state level of performance.

Robotic intracorporeal urinary diversion: state of the art.

PURPOSE OF REVIEW: We review historical aspects and current status of the emerging approach of robotic urinary diversion (rUD). Established surgical principles of constructing a low-pressure, large-capacity reservoir are described and the open surgical literature succinctly reviewed to establish the gold standard. Incontinent and continent rUD types [ileal conduit, orthotopic neobladder (all varieties), continent cutaneous diversion, cutaneous ureterostomy] and techniques (extra-corporeal, intra-corporeal) are discussed. Outcomes data (intra-operative, perioperative, intermediate-term, long-term), functional outcomes, complications and learning curve are presented. Outcomes data of open versus robotic urinary diversion are examined. Critiques, improvements, and pros-cons of rUD are discussed. RECENT FINDINGS: Although the majority of centers performing rUD use the extracorporeal technique, use of intra-corporeal rUD is increasing. Although data are yet limited, intra-corporeal rUD may provide some benefits. For rUD, operative times are higher and complication rates comparable with open urinary diversion. SUMMARY: The entire range of urinary diversion surgery has now been replicated robotically. At this writing, extracorporeal urinary diversion techniques still predominate following robotic cystectomy. However, all rUD options can now be performed intra-corporeally with success. As experience increases, the field of robotic urinary diversion is poised to grow.

Open radical cystectomy in England: the current standard of care - an analysis of the British Association of Urological Surgeons (BAUS) cystectomy audit and Hospital Episodes Statistics (HES) data.

OBJECTIVE: To establish the current standard for open radical cystectomy (ORC) in England, as data entry by surgeons performing RC to the British Association of Urological Surgeons (BAUS) database was mandated in 2013 and combining this with Hospital Episodes Statistics (HES) data has allowed comprehensive outcome analysis for the first time. PATIENTS AND METHODS: All patients were included in this analysis if they were uploaded to the BAUS data registry and reported to have been performed in the 2 years between 1 January 2014 and 31 December 2015 in England (from mandate onwards) and had been documented as being performed in an open fashion (not laparoscopic, robot assisted or the technique field left blank). The HES data were accessed via the HES website. Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures version 4 (OPCS-4) Code M34 was searched during the same 2-year time frame (not including M34.4 for simple cystectomy or with additional minimal access codes Y75.1-9 documenting a laparoscopic or robotic approach was used) to assess data capture. RESULTS: A total of 2 537 ORCs were recorded in the BAUS registry and 3 043 in the HES data. This indicates a capture rate of 83.4% of all cases. The median operative time was 5 h, harvesting a median of 11-20 lymph nodes, with a median blood loss of 500-1 000 mL, and a transfusion rate of 21.8%. The median length of stay was 11 days, with a 30-day mortality rate of 1.58%. CONCLUSIONS: This is the largest, contemporary cohort of ORCs in England, encompassing >80% of all performed operations. We now know the current standard for ORC in England. This provides the basis for individual surgeons and units to compare their outcomes and a standard with which future techniques and modifications can be compared.

Factors Related to Adaptation to Cystectomy With Urinary Diversion: An Integrative Review.

Patients with bladder (urothelial) cancer undergoing urinary diversion (UD) experience physical changes that require important adjustments in their daily lives. This integrative review aims to identify factors that influence adult adaptation to life after cystectomy with the creation of a UD. A review of primary research articles published between 1990 and 2014 was conducted using the PubMed and CINAHL Plus electronic databases. Results of the studies were summarized into 5 categories: (1) individual and family factors, (2) technical aspects related to the individual's ability to care for his or her UD, (3) perioperative nursing care, (4) educational needs, and (5) symptom experience. Bladder cancer patients treated with a cystectomy with a UD have a complex set of needs during postoperative adaptation to their reconstructed urinary system. This integrative review summarizes existing knowledge of factors that affect adaptation to a UD in patients with bladder cancer and may guide future studies. Research on this is limited and more studies are needed.

Clean intermittent catheterization as an initial management strategy provides for adequate preservation of renal function in newborns with persistent cloaca.

INTRODUCTION: Persistent cloaca is a rare, congenital anomaly involving the genital, urinary, and rectal organ systems. While prompt bowel diversion is the standard of care, the optimal method of genitourinary decompression is unclear. Bladder outlet obstruction and hydrometrocolpos are common complications that can lead to obstructive uropathy, abdominal distention, infection, perforation, and acidosis. Proposed management strategies include early surgical diversion (vesicostomy, vaginostomy, ureterostomy, nephrostomy) or clean intermittent catheterization (CIC) of the common channel. We hypothesized that CIC is an adequate means of genitourinary decompression and preservation of renal function, regardless of the severity of cloacal anomaly. METHODS: We reviewed all patients with persistent cloaca from a single, tertiary care center from 1995 to 2013. We collected data regarding renal function (serial serum creatinine prior to definitive reconstruction, and baseline estimated glomerular filtration rate [GFR]), presence of hydrocolpos, hydronephrosis, vesicoureteral reflux (VUR) or renal dysplasia, and length of the common channel. A linear mixed model was used to calculate creatinine change over time in relation to method of management and child age. Estimated GFR was calculated using the Schwartz equation for neonates = 0.45 × height in cm/serum creatinine in mg/dL. The t test was used for continuous data and Fisher's exact test was used for binomial data. A p value <0.05 was considered significant. RESULTS: Twenty-five patients were identified. Nine (36%) patients underwent early surgical diversion versus 16 (64%) managed by CIC prior to formal reconstruction. Seven had short common channels (<3 cm) and 18 had long common channels (≥3 cm). Hydrocolpos was present in 14 (56%) of the patients. When comparing the two management groups, there was no significant difference in hydronephrosis, high-grade hydronephrosis (grades III-IV, p = 0.62), any VUR (p = 0.33), high-grade VUR (grades III-V, p = 0.62), hydrocolpos (p = 0.21), or renal dysplasia (p = 0.42). No significant differences were found between mean baseline GFR for diversion (22.9 mL/min per 1.73 m(2)) versus CIC (39.2 mL/min per 1.73 m(2), p = 0.22). There was no difference in creatinine trend between the two groups. DISCUSSION: Currently, there is no consensus on the initial management of obstructive uropathy and resulting hydrocolpos in newborns with persistent cloaca. In addition to CIC, management strategies include surgical options such as vesicostomy, vaginostomy, or upper tract diversions such as ureterostomy or nephrostomy. Our results suggest that CIC is similar to these other proposed diversion procedures while minimizing morbidity. Creatinine trends over time were similar between the two groups and reached comparable nadirs. Limitations of our study include the retrospective nature of a small sample size. The primary risk is differences between the two groups that we were not able to appreciate. Furthermore, we did not attempt to assess the morbidity of the two different strategies. CONCLUSIONS: CIC is an adequate initial management strategy to decompress the genitourinary tract in patients with persistent cloaca. CIC preserves renal function similar to early surgical decompression.

Robot-assisted radical cystectomy and urinary diversion: technical recommendations from the Pasadena Consensus Panel.

BACKGROUND: The technique of robot-assisted radical cystectomy (RARC) has evolved significantly since its inception >10 yr ago. Several high-volume centers have reported standardized techniques with refinements and subsequent outcomes. OBJECTIVE: To review all existing literature on RARC and urinary diversion techniques and summarize key points that may affect oncologic, surgical, and functional outcomes. DESIGN, SETTING, AND PARTICIPANTS: The Pasadena Consensus Panel on RARC and urinary reconstruction convened May 3-4, 2014, to review the existing peer-reviewed literature and create recommendations for best practice. The panel consisted of experts in open radical cystectomy and RARC. No commercial support was received. SURGICAL PROCEDURE: The consensus panel extensively reviewed the surgical technique of RARC in men and women, extended pelvic lymph node dissection, extracorporeal urinary diversion, and intracorporeal urinary diversion. Critical aspects of the technique are described. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Preoperative, operative, and postoperative parameters from the largest and most contemporary RARC series, stratified by urinary diversion technique, are presented. RESULTS AND LIMITATIONS: Preoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery. CONCLUSIONS: Refinement of techniques for RARC and urinary diversion over the past 10 yr has made it safe, reproducible, and oncologically sound. PATIENT SUMMARY: We summarize the critical aspects of surgical techniques reviewed at the Pasadena international consensus meeting on RARC and urinary reconstruction. Preoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery.

Variation in performance of candidate surgical quality measures for muscle-invasive bladder cancer by hospital type.

OBJECTIVE: To test the association between hospital type and performance of candidate quality measures for treatment of muscle-invasive bladder cancer (MIBC) using a large national tumour registry. Proposed quality measures include receipt of neoadjuvant chemotherapy, timely treatment, adequate lymph node dissection, and continent urinary diversion. PATIENTS AND METHODS: Using the National Cancer Database, patients with stage ≥II urothelial carcinoma treated with radical cystectomy (RC) from 2003 to 2010 were identified. Hospitals were grouped by type and annual RC volume: community, comprehensive low volume (CLV), comprehensive high volume (CHV), academic low volume (ALV), and academic high volume (AHV) groups. Logistic regression models were used to test the association between hospital group and performance of quality measures, adjusting for year, demographic, and clinical/pathological characteristics; generalised estimating equations were fitted to the models to adjust for clustering at the hospital level. RESULTS: In all, 23 279 patients underwent RC at community (12.4%), comprehensive (CLV 38%, CHV 5%), and academic (ALV 17%, AHV 28%) hospitals. While only 0.8% (175) of patients met all four quality criteria, 61% of patients treated at AHV hospitals met two or more quality metric indicators compared with ALV (45%), CHV (44%), CLV (38%), and community (37%) hospitals (P < 0.001). After adjustment, patients were more likely to receive two or more quality measures when treated at AHV (odds ratio [OR] 2.4, confidence interval [CI] 2.0-2.9), ALV (OR 1.3, CI 1.1-1.6), and CHV (OR 1.3, CI 1.03-1.7) hospitals compared with community hospitals. CONCLUSIONS: Patients undergoing RC at AHV hospitals were more likely to meet quality criteria. However, performance remains low across hospital types, highlighting the opportunity to improve quality of care for MIBC.

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.

[Quality control in the implementation of new surgical procedures: Da Vinci robot-assisted systems]. / Qualitätssicherung in der Einführung neuer operativer Methoden : Da Vinci-Robotersysteme.

Robot assistance in the surgical treatment of urological malignancies is gaining increasing importance. As is the case in already established surgical procedures, the quality of robot-assisted surgery needs to be controlled and evaluated by appropriate measures. Baseline-parameters of treated patients should be documented precisely. General and operation type-specific parameters should be evaluated in short- as well as in mid-term follow-up. Appropriate and validated instruments should be used. Only by using these measures will it be possible to compare robot-assisted procedures of different institutions and historical data of conventional surgery with regard to oncological and functional efficacy.

[Robotic laparoscopic cystectomy: on the way to a standard procedure?]. / Die Roboter-assistierte laparoskopische Zystektomie: Auf dem Weg zu einem Standard-Verfahren?

INTRODUCTION: Radical cystectomy is considered the standard treatment for muscle-invasive bladder cancer. Minimally invasive techniques - especially robot-assisted techniques (RARC) - are being increasingly employed for this indication. Herein, we evaluate the current status of RARC and its acceptance in the urological community. RESULTS: The field of RARC is steadily increasing particularly due to an extremely short learning curve for surgeons with previous experience in robot-assisted radical prostatectomy. Lymph node yield has been shown to be adequate in several independent studies, being comparable to that of the open approach. Urinary diversion is most frequently done extracorporeally while several groups have commited themselves to intracorporeal techniques and have already shown excellent results. The perioperative outcome data compare favourably to those of open cystectomy. Short-term and interim oncological data are promising while a final long-term assessment is still lacking. CONCLUSIONS: RARC completed by appropriate urinary diversion is gaining relevance in academic institutions worldwide. The relatively wide availability of the robotic system will further add to this development. Secondary to the final assessment of its oncological efficacy RARC has the potential to become a standard treatment of muscle-invasive bladder cancer since its perioperative efficacy is excellent.

Long-term outcome of ureterosigmoidostomy: an analysis of patients with >10 years of follow-up.

STUDY TYPE: Therapy (case series). LEVEL OF EVIDENCE: 4. OBJECTIVE: To examine our long-term experience with ureterosigmoidostomy (USS) to evaluate its potential applicability in the treatment of benign and malignant conditions of the urinary bladder, as USS has been largely disregarded recently, secondary to concerns of long-term complications, but has had a resurgence of interest due to its potential applicability to newer minimally invasive surgical techniques. PATIENTS AND METHODS: We identified 51 patients who had USS from 1956 to 2006 at our institution and with >10 years of follow-up. The patients were followed retrospectively by a chart review. Patient data were analysed in a multifaceted fashion, paying particular attention to metabolic abnormalities, early (< or =30 days) and late (>30 days) complication rates, continence rates, imaging changes, and the rate of repeat surgical intervention. RESULTS: The median (range) follow-up was 15.7 (10.0-45.4) years and the median age at surgery was 58.8 (0.4-79.0) years; 40 (79%) patients had the procedure for malignancy and 11 (22%) for benign disease. Six patients (12%) had at least one early complication, including one wound dehiscence and one pulmonary embolus. In all, 22 patients (43%) had at least one late complication, with anastomotic stricture being the most common (11/51, 22%). This was followed by recurrent pyelonephritis in eight patients (16%), stones in five (10%), chronic renal insufficiency in three (6%) and severe intractable acidosis in two (4%). A repeat surgical intervention was required in 19 (37%) patients. In all, 94% (48) reported complete continence. No patient developed colonic malignancy during the course of this study. CONCLUSIONS: USS is associated with long-term complications. While this complication rate might not be acceptable for all patients, some might be willing to undergo the procedure as the primary method of urinary diversion. When designing newer minimally invasive techniques for the treatment of benign and malignant conditions of the bladder, consideration could be given to USS as a form of urinary diversion in highly selected patients.

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.

Transuretero-ureterostomía espontánea después de estenosis completa de un conducto ileal, con cuatro años de seguimiento conservador / Spontaneous transuretero-ureterostomy after complete stenosis of an ileal conduit, with four years of conservative follow-up

Introducción: La estenosis del conducto ileal es una complicación infrecuente de esta derivación urinaria. En el caso que describimos pasó durante un tiempo inadvertida y llevó al paciente a una situación de riesgo. Después de implantar una nefrostomía bilateral, se encontró una transuretero-ureterostomia espontánea. Caso Clínico: Un varón de 70 años con un conducto ileal realizado 15 años antes por tener tumor vesical, ingresó con signos de infección intraabdominal grave y oliguria. Los estudios radiológicos mostraron absceso intraabdominal, y se encontró estenosis casi completa del conducto ileal, que se trató conservadoramente mediante una nefrostomia bilateral. Después de ser dado de alta ocurrió la caída accidental de la nefrostomía derecha, recogiendo cantidades normales de orina por la única nefrostomía izquierda. Se comprobó la existencia de una transuretero-ureterostomía espontánea, con estenosis de la porción distal del conducto ileal. Desde entonces permanece con la nefrostomía, que se cambia periódicamente y en cuatro años de seguimiento no ha tenido deterioro renal significativo. Comentario: El origen de esta estenosis se atribuye a los cambios inflamatorios o inmunológicos en la pared del segmento intestinal, inducidos por la presencia crónica de la orina. Nuestro caso es singular por el curioso resultado de una transuretero- ureterostomía in situ y por el largo seguimiento conservador que se hizo, en un paciente que mantiene una calidad de vida buena (AU)

Introduction: Stenosis of an ileal conduit is a rare complication of this urinary diversion. In the case here described, such a complication was neglected for some weeks and left the patient in a high risk situation. After implantation of a bilateral nephrostomy, a spontaneous transuretero-ureterostomy was found. Clinical case: A 70-year-old man with an ileal conduit performed 15 years before because of bladder tumour, was admitted with signs of severe intraabdominal infection and oliguria. The image studies shown intraabdominal abscess, and an almost complete stenosis of the ileal conduit, that was conservatively treated with a bilateral percutaneous nephostomy. After discharged, he reported an accidental falling-out of the right nephrostomy, collecting normal diuresis from the only left nephrostomy. The spontaneous appearance of a transuretero-ureterostomy was demonstrated. The patient refused surgery and remained with a nephrostomy that is periodically changed, and after four years of follow-up he has neither significant kidney dysfunction nor other incidences. Comment: The origin of this ileal conduit stenosis is related to the inflammatory or immunologic changes induced by the chronic presence of the urine on the wall of the intestinal segment. This case is singular because of the curious result of an in situ transuretero-ureterostomy, and because of the long conservative follow-up, without significant complications, in a patient that keeps a good quality of life (AU)

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 (

Is orthotopic bladder replacement the new gold standard? Evidence from a systematic review.

PURPOSE: In this systematic review we determined whether the outcome of orthotopic bladder replacement is superior to that of continent and incontinent urinary diversion. MATERIALS AND METHODS: We searched MEDLINE, PubMed, EMBASE, CINAHL and the Cochrane Library from January 1990 to January 2003. A total of 3,370 abstracts were reviewed, including all types of studies from prospective, randomized, controlled studies to small, retrospective series. All relevant articles with at least 10 patients and a mean followup of at least 1 year were retrieved. There were no language restrictions. NonEnglish articles were translated. Comparisons were made between the major surgery types, including ileal conduit, continent diversion, bladder reconstruction and bladder replacement. All studies were scored using a predetermined quality assessment checklist to assess internal validity (bias and confounding) and external validity. RESULTS: A total of 405 studies met inclusion criteria. There were 32 prospective and 373 retrospective studies describing a total of 32,795 patients. The majority of studies were incompletely or poorly described and outcomes were often not defined. When they were defined, definitions varied. In clinical outcomes ileal conduit diversions had the lowest operative complications rate but highest reported postoperative morbidity. They also had a higher reported incidence of symptomatic urinary tract infections. The rates of postoperative morbidity, mortality and need for reoperation varied widely among studies even for the same procedure. Of physiological outcomes metabolic acidosis was the most commonly reported metabolic complication in patients with various urinary diversions. The quality of the reported literature was poor. There were no studies of the health economic implications of performing 1 type of surgery vs another type. CONCLUSIONS: While enthusiasts regard orthotopic bladder replacement as the new gold standard when lower urinary tract function must be replaced, the level and quality of current evidence are poor. The immediate concern must be to rectify this paucity of evidence with well designed and well reported prospective studies, ideally in a randomized setting, comparing the various major forms of urinary diversion and bladder replacement surgery.