Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation: experience with 450 patients

PURPOSE: We report functional results of the orthotopic ileal neobladder using a serous-lined extramural tunnel as an antireflux procedure. MATERIAL AND METHODS: One-stage radical cystectomy and orthotopic ileal W-shaped neobladder creation were performed in 353 male and 97 female patients for invasive bladder cancer. The ureters were reimplanted using a serous-lined extramural tunnel for reflux prevention. Of the patients 344 were evaluable at a mean followup plus or minus standard deviation of 38 +/- 25 months. Evaluation included clinical and radiographic studies to determine functional and oncological outcomes. RESULTS: Four patients (0.8%) died in the hospital. Early complications in 42 patients (9%) were treated conservatively but 3 women underwent vaginal repair of a pouch-vaginal fistula. During the observation period there were 90 oncological failures, of which 3 were isolated urethral recurrence. Late complications included pouch stones in 10 cases, outflow obstruction in 11, mucous retention in 2, adhesive bowel obstruction in 3 and hypercontinence in 9 females. The incidence of daytime and nighttime continence was 93.3% and 80%, respectively. The upper tracts remain unchanged or improved in 96.2% of the reimplanted renal units, while reflux was observed in 3%. CONCLUSIONS: The serous-lined extramural tunnel has proved its efficiency and durability as an antireflux technique.     

浆膜间隧道技术在回肠原位膀胱输尿管再植术中的应用(附32例报告)

目的:评价浆膜间隧道技术(the serous-lined tunnel principle)在回肠原位膀胱输尿管再植术中的临床应用效果.方法:应用浆膜间隧道技术行原位回肠膀胱输尿管再植32例,其中膀胱癌27例,间质性膀胱炎5例.取40~45 cm末端回肠w成形原位新膀胱,双侧输尿管分别埋植w回肠新膀胱外两根浆膜间隧道中,以最小的张力吻合于回肠新膀胱.结果:所有患者均在术后3～6个月行膀胱或储尿囊造影和IVU进行评价,造影显示64根再植入回肠新膀胱的输尿管功能良好,无梗阻或反流.结论:应用浆膜间隧道技术进行回肠原位膀胱的输尿管再植有良好的临床效果.     

Improvement of ureteroileal anastomosis in orthotopic ileal neobladder with modified le duc procedure: short submucosal tunnel technique

PURPOSE: A modified Le Duc procedure with a short submucosal tunnel was applied for ureteroileal implantation in ileal orthotopic neobladder and bladder augmentation with the ileum. We assessed the rate of stenosis and ureteral reflux at the ureteroileal anastomosis after this procedure. MATERIALS AND METHODS: Two women and 22 men underwent radical cystectomy and creation of a Hautmann ileal neobladder for invasive bladder cancer. Another woman underwent ileal bladder augmentation with bilateral ureteral reimplantation into the ileal segment. Ureteroileal anastomosis was performed using the modified Le Duc technique in 48 renoureteral units. Followup in all patients included retrograde cystography done before discharge home and excretory urography, renal ultrasonography or abdominal computerized tomography every 4 to 6 months. Followup was 11 to 39 months in 23 of the 25 cases. RESULTS: Retrograde cystography before discharge home revealed no urinary reflux in any reimplanted ureter. There was no ureteral stenosis or reflux in 20 male and 3 female patients (44 renoureteral units) who voided successfully without catheterization. A unilateral ureteral stricture at the ureteroileal anastomotic site in 1 man who voided successfully was treated with endoscopic surgery. Bilateral slight upper urinary tract dilatation caused by ureteral reflux was present in another man who did not void successfully. CONCLUSIONS: The modified Le Duc technique is simple and safe for forming an ureteroileal anastomosis in ileal orthotopic neobladder creation. It appears to have a low ureteral stenosis and reflux complication rate in patients who successfully void postoperatively.     

Early and late urodynamic assessment of ileal orthotopic bladder substitutes combined with an afferent tubular segment

PURPOSE: Limited information is available concerning changes in the urodynamic characteristics of orthotopic bladder substitutes with time. Therefore, we compared early and late urodynamic results in patients with an ileal orthotopic bladder substitute combined with an afferent tubular segment. MATERIALS AND METHODS: Of 139 patients surviving at least 5 years after cystoprostatectomy and ileal orthotopic bladder substitution with an afferent tubular segment 119 underwent urodynamic assessment, including 66 at a median of 9 months (early) and 77 at a median of 62 months (late). Of these patients 24 were assessed at each time point. Simultaneously all patients were asked to complete a bladder diary and questionnaire regarding continence for at least 3 days in the week preceding the urodynamic study. RESULTS: Urodynamic parameters were comparable in patients who were evaluated early and late postoperatively. In addition, median values at early and late urodynamic evaluation in the 24 patients with the 2 examinations showed no statistically significant differences for volume at first desire to void (300 vs 333 ml, p = 0.85), pressure at first desire to void (12 vs 13 cm H2O, p = 0.57), maximum cystometric capacity (450 vs 453 ml, p = 0.84), end filling pressure (19 vs 20 cm H2O, p = 0.17), reservoir compliance (25 vs 28 ml/cm H2O, p = 0.58) or post-void residual urine volume (5 vs 15 ml, p = 0.27). CONCLUSIONS: Urodynamic results after 5 years of living with an ileal orthotopic bladder substitute with an afferent tubular segment show grossly unchanged urodynamic characteristics. Patients maintain a reservoir capacity and micturition pattern consistent with a normal life-style. Reservoir pressure remained low, thereby protecting and preserving upper tract function. To achieve these results patients must be regularly followed, and the causes of bacteriuria, increased post-void residual urine and bladder outlet obstruction must be recognized and dealt with accordingly.     

Continent cutaneous ileal pouch using the serous lined extramural valves. The Mansoura experience in more than 100 patients

PURPOSE: We report on the functional results of continent ileal reservoir using serous lined extramural valves for reflux prevention and continent urinary outlet. MATERIALS AND METHODS: The procedure was performed in 109 patients (68 men, 27 women and 14 children). The operation was indicated as a primary procedure in 93 patients and for conversion in 16. The technique entailed construction of a detubularized W-shaped ileal reservoir in which 2 serous lined troughs were created. Two tapered ileal segments were used, 1 for reflux prevention and the other as a continent outlet. The appendix was used for the construction of the outlet in 44 patients. RESULTS: Two patients died in the hospital of pulmonary embolism. A total of 22 early complications were observed in 18 patients (16.5%). None of the patients required operative intervention. A total of 93 patients were evaluable with a mean followup of 36.6 +/- 25.4 months. All evaluable patients but 5 were continent day and night. Mean time for catheterization was 4 to 5 hours. There were 14 late complications reported in 11 patients (11.8%), including pouch stones in 5, stomal stenosis in 5, failure to catheterize in 2, parastomal hernia in 1 and adhesive bowel obstruction in 1. Upper urinary tract was stable or improved in 94.8% of the renal units. Clinical acidosis did not develop in any of the patients. CONCLUSIONS: Serous lined unidirectional valves are reliable. They provide a versatile surgical technique suitable for urinary diversion or conversion procedures. The operation is associated with an acceptable complication rate and is followed by good functional results.     

Changes in the upper urinary tract after radical cystectomy and urinary diversion: a comparison of antirefluxing and refluxing orthotopic bladder substitutes and the ileal conduit

PURPOSE: We evaluated and compared the effects of different types of urinary diversion on functional and radiographic changes in the upper urinary tract. MATERIALS AND METHODS: We analyzed data on 275 patients who underwent radical cystectomy and urinary diversion for bladder cancer and were observed at least 12 months. Of the patients 197 received an orthotopic bladder substitute, including antirefluxing ureteral anastomoses in 111 (group 1) and refluxing ureteral anastomoses in 86 (group 2). Ileal conduits were created in 78 patients (group 3). Serial serum Cr, radiographic changes in the upper urinary tract after diversion and the number of episodes of APN were compared by diversion method. Mean followup was 52 months (range 12 to 174 months) with no difference among the groups. RESULTS: Compared with group 3 patients in groups 1 and 2 demonstrated a significantly higher incidence of moderate to severe hydronephrosis (p = 0.001) but the incidence was similar between groups 1 and 2 (6.3%, 8.3% and 1.4% of the renal units in groups 1 to 3, respectively). Stabilized postoperative Cr did not differ among the groups. CRF, defined as Cr 3.0 mg/dl or greater, occurred in 2.7% of the patients in group 1 and in 3.5% of those in group 2 but in none in group 3. APN was noted in 3.3%, 4.4% and 0.4% of patients in groups 1 to 3, respectively (p = 0.012). CONCLUSIONS: An ileal conduit with a lower rate of diversion related hydronephrosis, CRF and morbidity associated with APN was superior to orthotopic bladder substitutes. Between the refluxing and antirefluxing types of orthotopic bladder substitutes no significant difference in functional or radiographic changes was noted.     

Modified Ghoneim's technique using a single serous-lined extramural tunnel in detubularized orthotopic ileal W-bladder

OBJECTIVES: We report our preliminary clinical experience with a modification of Ghoneim's original technique involving reimplantation of ureters in a single tunnel on the right part of the neobladder forming a 'W' shape. METHODS: From 1997 to 1999, we performed radical cystectomy with double 'W' orthotopic neobladder construction and uretero-ileal reimplantation using our modified Ghoneim's technique on 11 male patients, aged 40-74 (mean 65.5) years, affected by invasive bladder cancer. RESULTS: No postoperative complications were observed. After a mean follow-up of 12.5 months all patients are free of recurrences. CONCLUSIONS: In our hands the modified Ghoneim's technique seems to reduce the mean operating time required to tailor the uretero-ileal anastomosis and guarantee greater stability of the anastomosis itself.     

Gastrointestinal stromal tumor in ileal neobladder

Abstract  Gastrointestinal stromal tumor (GIST) is a recently described mesenchymal tumor that can develop in any portion of the gastrointestinal tract. The occurrence of a GIST in the urinary tract is rare, but GIST can present as tumor of the urinary tract or invade the urinary tract. This is the first reported case of GIST in the ileal neobladder, which presented as a submucosal tumor. The patient underwent an open exploration and partial resection of the neobladder pouch.     

Urinary diversion: ileal conduit to neobladder

PURPOSE: The goals of urinary diversion have evolved from simply diverting the urine through a conduit to orthotopic reconstruction, which provides a safe and continent means to store and eliminate urine with efforts to provide an improved quality of life. We address meaningful points that may help optimize clinical results in patients with an orthotopic bladder substitute. MATERIALS AND METHODS: The review involved an objective evaluation of the basic science literature of functional, structural and physiological characteristics of gastrointestinal tissue as a substitute for bladder. Potential problems that may be associated with particular parts of the gut for use in reconstruction are discussed. We also summarize the clinical results and complications of orthotopic reconstruction. RESULTS: In the last 10 years the paradigm for choosing urinary diversion has changed substantially: In 2002 all patients undergoing cystectomy were neobladder candidates. It is critically important to understand the phenomenon of maturation. The motor and pharmacological response of the implanted gut changes dramatically toward that of the bladder. Structural and ultrastructural changes in the ileal mucosa lead to a primitive epithelium similar to urothelium. The need for reflux prevention is not the same as in ureterosigmoidostomy conduit or continent diversion. Reflux prevention in neobladders is even less important than in a normal bladder. When using nonrefluxing techniques, the risk of obstruction is at least twice that after direct anastomosis. Kidney function is not impaired by diversion if stenosis is recognized and managed. Patient health status is more influenced by underlying disease than by diversion. Complications of neobladders are actually similar to or lower than the true rates after conduit formation, in contrast to the popular view that conduits are simple and safe. Some degree of nocturnal leakage is a consistent finding in most reports despite a technically sound operation. The precise pathogenesis of urinary retention requiring clean intermittent catheterization remains uncertain. There are new complications, such as neobladder rupture and mucous tamponade. CONCLUSIONS: Orthotopic reconstruction has passed the test of time. In these patients life is similar to that in individuals with a native lower urinary tract. Until a better solution is devised orthotopic bladder reconstruction remains the best option for patients requiring cystectomy.     

Long-term voiding pattern of patients with ileal orthotopic bladder substitutes

PURPOSE: Good long-term functional outcome of orthotopic bladder substitution will ultimately decide whether it is here to stay. Therefore, we analyzed exclusively voiding patterns of long-term survivors with an orthotopic ileal bladder substitute. MATERIALS AND METHODS: In all patients with an ileal orthotopic bladder substitute day and nighttime continence status, voiding frequency, bladder capacity and pad usage were prospectively assessed by frequency volume charts and a standardized questionnaire. All men surviving 5 or more years with a median followup of 95 months (range 60-132) were evaluated. RESULTS: Spontaneous voiding was possible in 82 of 86 (95.3%) evaluable patients after catheter removal. Daytime continence increased from 61% after 3 months to 92% at 12 months and remained stable throughout the following 4 years yet decreased slightly thereafter. Nocturnal continence rates were 10% to 15% lower throughout the study period. Functional reservoir capacity averaged 473 ml. after 12 months and did not change in subsequent years. After a decrease during the first 12 months, daytime frequency (4.1 to 4.8 times daily) and nocturia (1.8 to 2.3 a night) did not change in the next decade. Patient age at surgery was an important determinant for long-term reservoir capacity, nocturia and continence status. CONCLUSIONS: These data provide evidence for good long-term functional outcome following orthotopic ileal bladder substitution up to 11 years. We attribute the sustained ability to void to the relatively small reservoir size, which is made of 40 to 44 cm. of ileum, the avoidance of any funnel shaped outlet but rather a side-to-end intestine-urethral anastomosis as well as lifelong meticulous followup.     

Experience with the orthotopic ileal neobladder in women: a mid-term follow-up

OBJECTIVE: To report our experience with orthotopic bladder reconstruction in women, as currently the ileal orthotopic neobladder is the diversion of choice for women requiring a bladder substitute at our institution. PATIENTS AND METHODS: From February 1995 to March 2001, 29 women with muscle-invasive bladder carcinoma underwent a nerve-sparing radical cystectomy and had an orthotopic ileal neobladder reconstructed. The outcome was evaluated at 2 and 6 months and then yearly, by a clinical history, physical examination, voiding diary, stress test and estimate of functional neobladder capacity. RESULTS: All patients were followed for at least 14 months (mean 27.5); there were no major complications related to the surgery. The mean (range) neobladder capacity 2 months after surgery was 250 (190-320) mL; at 6 months it increased, remaining stable for the remaining follow-up, at 450 (350-700) mL. Four patients (14%) had nocturnal incontinence and one stress urinary incontinence, associated with using three pads per day. Three patients (10%) required catheterization for a postvoid urinary residual of >100 mL. Of the 29 patients, seven died with metastatic disease and three from causes unrelated to the reservoir or bladder cancer. Currently, 19 patients (65%) are alive and disease-free, with a mean follow-up of 35 months. CONCLUSION: Orthotopic neobladder reconstruction in women, using 40 cm of ileum, is safe and gives high continence and low urinary retention rates. Therefore, it should be advised as the first option in women with good renal function and a tumour-free bladder neck.     

The orthotopic T pouch ileal neobladder: experience with 209 patients

PURPOSE: A serous lined extramural ileal flap valve technique called the T limb was developed to prevent reflux of urine in an orthotopic bladder substitute called the T pouch. We evaluate our intermediate clinical and functional experience with the orthotopic T pouch ileal neobladder. MATERIALS AND METHODS: From November 1996 through May 2000, 209 patients (169 men [80%], 40 women), with a mean age of 69 years (range 33 to 93) underwent construction of an orthotopic T pouch ileal neobladder after cystectomy. The indication for cystectomy included bladder cancer in 198 patients (95%). Median followup for the entire cohort was 33 months (range 0 to 69). Data were analyzed according to perioperative mortality, early (within 3 months) and late diversion related and diversion unrelated complications, radiographic evaluation of the upper urinary tract and urinary reservoir, and determination of renal function. RESULTS: Three patients (1.4%) died perioperatively. A total of 63 (30%) early complications occurred, 53 (25%) diversion unrelated and 10 (5%) diversion related. The most common early diversion unrelated complication was dehydration (10 patients). The most common early diversion related complication was urine leak in 6 patients. There were no early complications directly related to the antirefluxing T limb. Late complications occurred in 68 (32%) patients including 30 (14%) diversion unrelated and 38 (18%) diversion related. The most common late diversion unrelated complication was incisional hernia in 16 patients. Of the 38 late diversion related complications the most common were pouch calculi in 17 and ureteroileal obstruction in 9 patients. The only late complication directly related to the T limb was stenosis in 4 patients, 3 of whom received adjuvant pelvic radiation. A total of 181 patients had radiographic evaluation of the upper urinary tract including 162 (90%) with a normal radiographic study or evidence of postoperative decompression. An abnormal upper tract study was seen in 18 patients (10%) including 9 with ureteroileal obstruction and 4 with afferent T limb stenosis. Gravity cystography of the neobladder was normal in 143 of 158 (90%) evaluable patients. Reflux was seen in 15 patients (10%). Renal function as determined by serum creatinine was stable or improved in 96% of patients. Good daytime and nighttime continence was reported in 87% and 72% of evaluable patients, respectively. Overall 75% of patients complete void while 25% required some form of intermittent catheterization to empty the neobladder completely including 20% of men and 43% of women. CONCLUSIONS: With intermediate followup the functional results of the T pouch ileal neobladder are acceptable. The antirefluxing T limb provides unobstructed urinary flow in 95% and reflux prevention in 90% of patients. Although these results are encouraging, further followup is required to assess the long-term results of the T pouch ileal neobladder.     

Evaluation of direct versus non-refluxing technique and functional results in orthotopic Y-ileal neobladder after 12 years of follow up

OBJECTIVES: We report on the long-term functional results of the orthotopic Y-ileal neobladder and compare the outcome of the antireflux technique for ureteral implantation versus direct anastomosis. PATIENTS AND METHODS: Between 1990 and 2002, 120 patients underwent cystoprostatectomy and orthotopic Y-shaped ileal neobladder for invasive bladder carcinoma. The direct Nesbit technique for ureteral reimplantation was applied in 58 patients (group 1) and in 62 patients the ureters were reimplanted using the Le Duc antirefluxing technique (group 2). The mean follow-up period was 72 months (range, 36-144 months). RESULTS: Of 62 patients who underwent the Le Duc technique, six (9.7%) had unilateral uretero-ileal anastomotic stricture and four (6.5%) had reflux. Of 58 patients who underwent direct anastomosis, six (10.3%) patients had unilateral reflux, four of them had dilated ureters preoperatively and no patient had uretero-ileal anastomotic stricture. The incidence of stricture formation in the Le Duc technique is significantly higher than direct anastomosis (P = 0.04). There was no significant difference in the overall incidence of reflux in both groups. However, the incidence of reflux in preoperatively dilated ureters was significantly higher in direct ureteral anastomosis than Le Duc technique (40% in group 1 vs 16.7% in group 2; P = 0.045). The incidence of stone formation, azotemia, pyelonephritis and bacteriuria was comparable in both groups. The urodynamic findings showed a mean increase in the neobladder capacity at 6 and 18 months after surgery by 340 and 560 mL, respectively. The mean of the maximum pressure was 22 +/- 10 cm H2O, 18 months after surgery. Daytime and nighttime continence was good or satisfactory in 93.3% and 85.5% of the patients, respectively, after 3 years of follow-up. CONCLUSIONS: The functional and voiding results of a Y-shaped neobladder pouch using 40 cm of ileum are similar to the more sophisticated larger pouches. Direct uretero-ileal anastomosis in orthotopic bladder replacement is more reasonable than the Le Duc antireflux technique in non-dilated ureters. The benefit of the antireflux technique has been overestimated despite of the frequency of stricture formation.     

贮尿囊壁外隧道作为输尿管抗反流方法的临床观察

目的：介绍一种抗反流可靠、吻合口狭窄发生率低的输尿管与贮尿囊再植新方法。方法：对17例可控性尿流改道患者采用双输尿管分别在W形贮尿囊壁外隧道或双输尿管末端合并为一根在U形贮尿囊或W形贮尿囊壁外隧道潜行3－4cm,然后与贮尿囊壁端侧吻合作为输尿管抗反流的方法行可控性尿流转向术;对3例回肠通道术后（Bricher术）患者采用保留原输尿管回肠吻合口、缩窄远端回肠后在贮尿囊壁外隧道潜行作为抗反流的方法行可控性尿流转向术。结果：贮尿囊造影示输尿管无反流;静脉肾盂造影示肾盂无积水,输尿管无扩张,蠕动良好。结论：贮尿囊壁外隧道是一种抗反流可靠、吻合口狭窄发生率低的输尿管与贮尿囊再植新方法。     

Enhanced continent mechanism of tapered ileum by extramural support from the pouch and abdominal walls: a preliminary report of a clinical study

PURPOSE: We constructed a reliable continent tube that is easy to catheterize and surgically simple. MATERIALS AND METHODS: Eight patients with bladder cancer underwent a procedure in which ileal segment was tapered as an efferent tube, of which a part was placed between the back surface of the rectus muscle and the ileal pouch wall. The internal orifice of the tapered ileum was anastomosed to the ileal pouch and its external orifice was anastomosed to the umbilicus. Urodynamic and radiological studies were done postoperatively in 7 cases. RESULTS: The stoma was easily catheterized with a 16Fr catheter in all cases. One patient died of heart disease 55 days postoperatively, while 6 of the remaining 7 were completely continent day and night. Urodynamic study of the efferent tubes showed that maximum close pressure with the pouch full was significantly higher than with the pouch empty (p <0.001). Retrograde radiography of the efferent tubes demonstrated perfect canalization without stenosis. CONCLUSIONS: This study indicates that the continent mechanism of tapered ileum may be greatly enhanced by fixing it between the abdominal and pouch walls. This maneuver also provides easy catheterization and surgical simplicity.     

改良腹腔镜根治性膀胱切除术加Studer原位回肠新膀胱重建初步研究

目的:总结11例腹腔镜根治性膀胱切除、标准淋巴结清扫加Studer原位回肠新膀胱重建的经验,评价此术式肿瘤学结果与功能性结果。方法:2008年7月～2011年5月,选择11例肌层浸润性膀胱肿瘤患者实施腹腔镜根治性膀胱切除加下腹壁小切口行Studer原位回肠新膀胱重建术,对手术时间、淋巴结数量、围手术期并发症、出血量、输血量、生存率、上尿路形态与功能、控尿情况进行分析。结果:平均手术时间为6.17(5.5～7.5)h,平均出血量为300(0～800)ml,仅1例输血400ml,平均清扫淋巴结数15(5～30)个,无围手术期死亡,围手术期并发症发生率为18.19%(2/11)。上尿路检查,提示18.19%(2/11)术后拔出双J管后出现双侧肾盂及输尿管的轻度暂时性扩张,其中1例血肌酐上升。随访15(1～67)个月,1例鳞癌死于广泛转移,91%(10/11)无复发生存。患者日间完全控尿率达到90%(9/10);夜间完全控尿率70%(7/10),小于1块尿垫20%(2/10)。结论:选择适当病例行改良的腹腔镜根治性膀胱切除、标准淋巴结清扫加下腹壁小切口行Studer原位回肠新膀胱重建术取得了满意肿瘤学与功能性结果;Studer原位回肠新膀胱顺向蠕动输入袢能够保护上尿路形态与功能。     

Long-term outcome of spiral ileal neobladder with orthotopic ureteral reimplantation

International Urology and Nephrology - The purpose of this study was to analyze long-term complications, urodynamics, and quality of life (QoL) of patients after orthotopic ileal neobladder with...