Quality of life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion

The impact of bladder removal and urinary diversion for patients' everyday life is largely unknown. The aims of this study were to compare subjective morbidity of ileal neobladder to the urethra versus ileal conduit urinary diversion and to elucidate its influence on quality of life. A total of 102 patients who underwent cystectomy due to a bladder malignancy were included in the study. In 69 patients (67.6%) an orthotopic neobladder and in 33 patients (32.4%) an ileal conduit was performed as urinary diversion. The compliance was 99% and mean follow-up was 37 months. All patients completed two retrospective quality of life questionnaires, namely the QLQ-C30 and a questionnaire developed at our institution to ask for urinary diversion specific items. The questioning and assessment was performed by non-urologists. The results obtained from the validated (QLQ-C30) and our own specially compiled questionnaire clearly demonstrate that patients with an orthotopic neobladder are more able to adapt to the new situation than patients with an ileal conduit. In addition, neobladder to the urethra improves the quality of life because it improves self-confidence, causes better rehabilitation as well as the restoration of leisure, professional, travelling, and social activities, and reduced risk of inadvertent loss of urine. For example, 92.8% of neobladder patients did not feel handicapped at all, and 87% did not feel sick or ill, in contrast to 51.5% and 66.7% of ileal conduit patients, respectively. Of the neobladder patients, 74.6% felt absolutely safe with the urinary diversion in contrast to 33.3% in the ileal conduit group. Only 1.5% of neobladder patients had wet clothes caused by urine leakage during the day, versus 48.5% of ileal conduit patients. Moreover, 97% of our neobladder patients would recommend the same urinary diversion to a friend suffering from the same disease, but only 36% of ileal conduit patients would do so. These results demonstrate that the quality of life is preserved to a higher degree after orthotopic neobladder than after ileal conduit urinary diversion.     

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.     

A case of late recurrence of urothelial carcinoma in an ileal conduit after radical cystectomy and ileal conduit diversion for bladder cancer

Recurrence of urothelial cancer in an ileal conduit after radical cystectomy is rare. A 79-year-old man suffered bladder cancer (UC cTisN0M0 G2＞3) and underwent total cystectomy with ileal conduit. He had recurrence of the right renal pelvis carcinoma 6 years after the total cystectomy, and was treated by right radical nephroureterectomy (pT3 G2＝3). The patient had another episode of recurrence in the ileal conduit 13 years after the initial operation. The entire ileal conduit (UC, G3, ew (-)) was resected and left cutaneous ureterostomy was performed. This case suggests that long-term follow-up is necessary after radical cystectomy and ileal conduit for urinary diversion.     

Health related quality of life assessment after radical cystectomy: comparison of ileal conduit with continent orthotopic neobladder

PURPOSE: Health related quality of life after urinary diversion has been increasingly recognized as an important outcome measure. However, few studies have directly compared patients with an ileal conduit with those with a continent orthotopic neobladder and even fewer have used validated quality of life instruments. Therefore, we compared health related quality of life in patients who underwent neobladder versus ileal conduit creation using validated questionnaires. MATERIALS AND METHODS: We mailed 2 validated questionnaires that are measures of health related quality of life, namely the RAND 36-Item Health Survey (SF-36) and Functional Assessment of Cancer Therapy-General (FACT-G), to patients who underwent radical cystectomy for urothelial carcinoma between January 1995 and December 1999. Statistical analysis was performed, including univariate and multivariate analysis. RESULTS: A total of 112 patients were available for assessment. A total of 72 (64%) questionnaires were returned, including 23 (32%) and 49 (68%) from patients with an ileal conduit and neobladder, respectively. On the SF-36 questionnaire there were significant univariable relationships between treatment and age (p <0.001 and 0.01, respectively). Younger patients and those with a neobladder had higher health related quality of life scores, including significant differences in 5 of the 9 SF-36 domains (general health, physical functioning, physical health, social functioning and energy/fatigue). There was no relationship between health related quality of life and the final pathological stage (p = 0.25). On multivariate analysis adjusting for age led to a suggestive but nonsignificant difference in health related quality of life scores favoring neobladders (p = 0.09). On the FACT-G there were no significant differences in health related quality of life due to treatment (p = 0.28), pathological stage (p = 0.5), age (p = 0.72) or current disease status (p = 0.27). On the FACT-G 2 of the 4 domains (emotional and functional well-being) were significantly in favor of neobladders. Overall satisfaction was high in the 2 groups with 96% and 85% of patients with a neobladder and ileal conduit, respectively, reporting that they would make the same choice of diversion. CONCLUSIONS: Based on validated health related quality of life instruments these findings suggest that patients with an orthotopic neobladder have marginal quality of life advantages over those with an ileal conduit. However, differences in health related quality of life in the 2 types of urinary diversion are confounded by age since patients who underwent orthotopic diversion were younger and as a result of age would be expected to have a higher health related quality of life score. A prospective longitudinal study of health related quality of life after adjusting for differences in age among patients undergoing urinary diversion is currently underway to extend further these observations.     

Postoperative morbidity, functional results and quality of life of patients following orthotopic neobladder reconstruction

AIM: To evaluate postoperative morbidity, functional results and health-related quality of life of patients with an orthotopic neobladder. METHODS: A total of 37 patients with orthotopic neobladder (modified Studer method: 35 cases; Hautmann method: one case; sigmoid neobladder: one case) were included in the present study. Postoperative morbidity and neobladder function were analyzed. To determine quality of life, the Sickness Impact Profile questionnaire was used. The quality of life of patients who underwent orthotopic neobladder was compared with that of patients who underwent ileal conduit. RESULTS: In 37 consecutive patients with neobladder reconstruction, early complications included 10 cases of pyelonephritis (27.0%) and one of stenosis of ureterointestinal anastomosis (2.7%). Two patients died of ARDS and sepsis following peritonitis and pneumonia in the perioperative period. Late complications included pyelonephritis in three patients (8.6%). In 32 cases, except for an early postoperative case and those that died, complete daytime and night-time continence was achieved in 31 patients (96.9%) and 16 patients (50.0%), respectively. Concerning health-related quality of life, the mean sum scores per category of the Sickness Impact Profile were calculated for 32 patients with orthotopic neobladder and 30 patients with ileal conduit. There were no significant differences in overall satisfaction, however, the scores for patients with orthotopic neobladder reconstruction were significantly higher than those for patients with ileal conduit in the three categories of emotions, feelings and sensation, social interaction and recreation. CONCLUSION: Orthotopic neobladder reconstruction exhibited good functional results with acceptable complications. Patients who underwent neobladder reconstruction were satisfied with their voiding. Assessment of quality of life using the Sickness Impact Profile questionnaire demonstrated that orthotopic neobladder improved their quality of life better than ileal conduit, especially with regard to mental, physical and social functioning in daily life.     

回肠膀胱术与原位回肠尿流改道术后患者生活质量的调查评估

目的 比较回肠膀胱术与原位回肠新膀胱尿流改道术后患者的健康相关生活质量( health related quality of life,HRQoL),为临床尿流改道术式的选择提供依据. 方法 选择2006年1月至2010年12月因膀胱癌行根治性膀胱全切加尿流改道术的患者130例,按术式分为回肠膀胱术组(IC)和原位回肠新膀胱术组(NB),采用问卷调查的方式完成膀胱癌术后随访量表(FACT-BL).对FACT-BL量表各个领域(躯体状况、社会/家庭状况、精神状况,功能状况)的评分及总评分进行统计学比较分析. 结果 回收有效问卷94份,其中IC组50例,NB组44例.2组间男性例数、随访时间、≥T3例数差异无统计学意义,NB组患者手术年龄小于IC组.2组HRQoL评分:躯体状况分别为25.4±1.8、22.1±2.5,社会/家庭状况分别为20.3±2.8、16.3±4.2,膀胱癌特异性模块分别为29.5±2.8、20.2±3.3,FACT-BL量表总评分分别为109.5±6.9、99.3±7.9,2组差异均有统计学意义(P＜0.05). 结论 原位回肠新膀胱术患者术后HRQoL高于回肠膀胱术患者.     

Colon bladder replacement after total cystectomy

Although ileal conduit diversion is widely accepted in the treatment of the patients undergoing radical cystectomy, many patients would prefer other alternatives which allow continence. and urination through the urethra. We describe a new procedure in which a segment of detuburalized right colon is used as a continent reservoir. Eight patients, 7 after radical cystectomy for bladder cancer and one after total exenteration for rectal cancer, have undergone colon bladder replacement. New created bladder had a capacity of 300 to 600 ml. All patients could pass urine through the urethra but one is on self-catheterization. Five of the 8 patients had no residual urine. Three months after operations 4 were totally continent and 3 were satisfactorily dry during daytime but slightly enuretic. Excretory urography showed no abnormalities in their upper urinary tract. Considering the "quality of life' of a patient, this procedure can be an ideal option for selected patients.     

Urinary re-diversion from cutaneous ureterostomy to ileal conduit: report of a case

A 73-year-old man, who underwent bilateral cutaneous ureterostomy following total cystectomy due to tumor, was admitted because he had been suffering from complications, such as pyelonephritic attacks, plugging and removal of the indwelling catheters and pain around the stoma. In order to relieve these complications, ileal conduit construction was performed although the length of ureters was thought to be short for ureteroileostomy. However, it was done easily by making ileal segment twice as long as usual and this conduit neither disturbed the serum electrolyte levels nor deteriorated renal function. Re-diversion to ileal conduit resulted not only in relief from the complications associated with cutaneous ureterostomy but also in improvement of the quality of life for the patient.     

Urinary diversion and bladder substitution in patients with bladder cancer

For the majority of patients with invasive bladder carcinoma, radical cystectomy remains the gold standard of care. As a result the twentieth century has seen the continuous development of methods for reconstructing the urinary tract. Two decades ago the ileal conduit was by far the most commonly used method, whereas today methods geared toward patient continence are first choices in most centers. Some of these methods are unquestionably more complex than the ileal conduit, yet whether they actually yield uniformly improved quality of life is the cause of much debate. Many different variables play a role in determining the best type of reconstruction for an individual bladder cancer patient. This review analyzes the different factors that must be considered to obtain an optimal match between patient and reconstructive method.     

Clinical study of radical cystectomy and urinary reconstruction in elderly patients with bladder cancer

We compared the clinical and functional results of radical cystectomy and urinary reconstructions performed on 19 elderly bladder cancer patients over 75 years old to those on 22 younger patients to determine whether age was one of the critical points for the application of this type of surgery. Between January 1992 and January 1998, bladder substitution was performed after cystectomy using either the Hautmann, Studer or Reddy procedure in 9 of the 19 elderly patients. Urinary diversion was performed after cystectomy using ileal conduit and ureterocutaneostomy procedures in the rest of the patients. On the other hand, bladder substitutions were performed in 11; urinary diversions with continent urinary reservoir in 6 and with ileal conduit in 4 of the 22 younger patients. Neither prolongation of the operation time, nor increase in the amount of bleeding or prolongation of the post-operative hospitalization period was observed in any procedure used for elderly patients in comparison with younger ones. In elderly patients, the average operation time of radical cystectomy with bladder substitution was slightly longer than that of total cystectomy with ileal conduit or ureterocutaneostomy. The post-operative hospitalization period in the case of bladder substitution was similar to that for ileal conduit and ureterocutaneostomy with the difference of only 5 days on average. There were no peri-operative deaths, and early post-operative complications were observed in 3 of 9 cases of the bladder substitution, in 4 of 10 cases of ileal conduit or ureterocutaneostomy. Five cases of bladder substitution maintained their comfortable voiding urine comfortably, while 4 had dysuria and/or urinary incontinence. Over all, late complications occurred in 10 of the elderly patients. The rate and types of complications in the elderly patients were not different from those in the younger patients. The cause-specific survival rate and overall survival rates of the elderly patients were similar to those of the younger patients. In conclusion, indication of cystectomy and selection of urinary reconstruction procedure are not dependent on patient's age, Orthotopic urinary reservoir was found to be useful for even an elderly patient.     

Hyperammonaemic encephalopathy, possible complication after urinary diversion in radical cystectomy. Review of the literature with regard to a clinical case

IntroductionRadical cystectomy is an intervention with an important morbidity. Urinary diversion is a possible cause of metabolic complications like hyperammonaemic encephalopathy.Case reportWe present the case of a patient treated with a radical cystectomy and modified ureterosigmoidostomy after diagnosis of bladder cancer. After surgery the patient presented in 4 ocasions recurrent episodic confusion. Laboratory and image tests were normal. Levels of seric ammonium was increased. After supportive treatment and hemodyalisis symptoms disappeared. Later patient was reoperated and a reconstruction to ileal conduit was made.DiscussionContinent urinary diversions are advised due to important negative impact on quality of life produced by ileal conduit. However these diversions have several complications, like encephalopathy secondary to non-hepatic hyperammonaemia. Increased absortion of ammonium by intestinal tissue of the new-ladder induces encephalopathy. Early diagnosis of this complication is essencial in order to administer an effective treatment.     

DOES THE OPTION OF THE ILEAL NEOBLADDER STIMULATE PATIENT AND PHYSICIAN DECISION TOWARD EARLIER CYSTECTOMY?

Purpose

The primary goal of bladder replacement is to attempt to improve patient quality of life, not to increase survival, affect cancer prognosis or decrease renal metabolic complications. Nevertheless, we retrospectively determined whether orthotopic bladder replacement has an impact on the decision to perform cystectomy.

Materials and Methods

From April 1986 to September 1994, 213 men a mean of 63 years old with stages pT2N0M0 to pT4N0M0 invasive bladder cancer were referred to our department for cystectomy. For 135 patients who underwent an ileal neobladder procedure and 78 who underwent conduit diversion median followup was 4.8 and 3.5 years, respectively. We evaluated the interval from the primary diagnosis of bladder cancer to cystectomy as well as the number of previous transurethral bladder resections. The 5-year cancer specific survival rates were calculated using the Kaplan-Meier method. The Wilcoxon and log rank tests, and the Cox proportional hazards model were used to determine statistical significance.

Results

In the neobladder and conduit groups an average of 2.1 (range 1 to 18) and 4.1 (range 1 to 15) transurethral bladder resections was performed, respectively. Interval from the primary diagnosis to cystectomy was 11.8 months in the neobladder and 16.7 months in the conduit group. Cystectomy was performed 4.1 months after the diagnosis of invasive cancer in the neobladder group, whereas radical surgery was delayed for 15.4 months in the conduit group. Cancer specific 5-year survival rates were 76.6 and 28.35% in the neobladder and conduit groups, respectively. After stratifying according to tumor stage the 5-year survival rate was significantly higher for all disease stages in the neobladder than in the conduit group. The proportional hazards model revealed that this difference was not due to patient age at disease stages pT3bN0 and pT4N0 or by American Society of Anesthesiologists score. Independent prognostic factors for survival were diversion type and age. Delayed cystectomy was a risk factor only in advanced disease stages.

Conclusions

These data suggest that the ileal neobladder may decrease physician reluctance to perform cystectomy early in the disease process, increasing the survival rate. They also demonstrate that the ileal neobladder option significantly affects an earlier patient and physician decision in favor of cystectomy.     

Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, cutaneous or urethral kock pouch.

PURPOSE: Radical cystectomy for bladder cancer is associated with many changes in bodily function with sexual and urinary dysfunction most prevalent. However, little research has been done on how efforts to improve erectile function relate to quality of life. Also, the psychological benefits associated with continent urinary diversion have not been fully explored. We compared long-term quality of life outcomes among 3 urinary diversion groups, and between patients who had and had not received an inflatable penile prosthesis. MATERIALS AND METHODS: The 224 participating patients completed 4 self-reporting questionnaires, including the profile of mood states, and adapted versions of the sexual history form, body image dissatisfaction scale and quality of life questionnaire. We compared self-reports of emotional distress, global quality of life, sexuality, body image dissatisfaction, urinary diversion problems, and problems with social, physical and functional activities in patients with advanced bladder cancer who underwent urinary diversion, including an ileal conduit in 25, cutaneous Kock pouch in 93 and urethral Kock pouch in 103. Patients who had or had not received an inflatable penile prosthesis after cystectomy were also compared in regard to quality of life variables. RESULTS: Regardless of type of urinary diversion the majority of patients reported good overall quality of life, little emotional distress and few problems with social, physical or functional activities. Problems with urinary diversion and sexual functioning were identified as most common. After controlling for age analysis of variance showed no significant differences among urinary diversion subgroups in any quality of life area. However, t tests controlling for age indicated that penile prosthesis placement was significantly associated with better sexual function and satisfaction. CONCLUSIONS: Quality of life appears good in these long-term survivors of advanced bladder cancer. The type of urinary diversion does not appear to be associated with differential quality of life. Findings suggest that physicians may wish to discuss urinary diversion problems and sexual dysfunction as long-term correlates of radical cystectomy for bladder cancer. Furthermore, they may also wish to discuss the option of erectile aids in men with erectile dysfunction after cystectomy.     

Quality of life after cystectomy. Comparison between patients with conduit and those with continent caecal reservoir urinary diversion

A questionnaire survey was carried out to assess the quality of life of 60 patients who had undergone cystectomy because of bladder carcinoma. Urinary diversion was by a continent caecal reservoir in 20 patients and by a conduit in 40. The patients' replies showed that cystectomy could cause severe problems in all aspects of life. Diversion with a continent caecal reservoir was associated with fewer stoma-related problems and seemed to allow the patients greater freedom to continue activities such as sport, travel and social life. Sexual problems, disturbed relationships with partners and emotional and mental problems were common and did not differ between the two groups of patients. It is recommended that patients judged to be prone to mental and emotional disturbance after cystectomy should be identified pre-operatively and given extra psychological support.     

Dieulafoy lesion of the ileal conduit: a case report

Late side effects of ileal conduit are uncommon. Here we report a case of ileal conduit hemorrhage in a 78-year-old woman 8 years after radical cystectomy and ileal conduit diversion. The patient presented with gross hematuria and abdominal dynamic computed tomography showed extravasation of contrasts in ileal conduit and the patient was diagnosed with ileal conduit hemorrhage. Clipping hemostasis was performed under gastrointestinal endoscope and revealed that Dieulafoy's ulcer was the cause of ileal conduit hemorrhage. This is the first case of Dieulafoy's ulcer occurred in ileal conduit. Hemorrhage from ileal conduit is an important late side effect.     

When the bladder is gone: quality of life following different types of urinary diversion

Methods aiming for continence after radical cystectomy for bladder cancer, e.g., continent cutaneous urinary diversion and orthotopic bladder substitution, have become clinically accepted alternatives to ileal conduit diversion in the past decade. The a priori assumption has been that improvement in the postoperative quality of life would be greater following the new methods than after ileal conduit diversion. Studies on the validity of this assumption have been hampered by a lack of consensus on what should be measured and how this should be done: in no two studies have identical test instruments been used. The frequent inclusion of patients with nonmalignant disease has also impeded comparative evaluation of reports. By and large, published studies do not seem to confirm that the new types of urinary tract reconstruction improve the quality of life of bladder cancer patients. Common for all methods are psychosocial and sexual problems.     

The Type of Urinary Diversion After Radical Cystectomy Significantly Impacts on the Patient’s Quality of Life

Background: In this study, we used a previously well-validated survey to assess the impact of different forms of urinary diversion on overall quality of life in patients with bladder cancer.Methods: A total of 92 patients, having three different forms of urinary diversion after radical cystectomy, completed by mail the SF-36, a validated quality-of-life survey. All patients had local(regional disease at the time of cystectomy and are currently without evidence of disease. Completed surveys were then analyzed into physical (PCS) and mental (MCS) component quality-of-life scores per published protocols. Results were then compared with published age-based norms.Results: A total of 38 men who had cystectomy and ileal neobladder had a mean PCS (6SD) of 48.4 (7.8) and a mean MCS of 51.0 (7.4); 16 men and women who had cystectomy and Indiana Pouch had a mean PCS of 48.4 (8.9) and a mean MCS of 55.7 (3.8). None of these results is statistically different from published age- and sex-based population norms. Thirty-eight men who had cystectomy and ileal conduit had a mean PCS of 41.4 (8.5) and a mean MCS of 48.2 (10.7). The PCS is not statistically different from the population-based norm; however, the MCS is significantly decreased from the published norm (P 5.01).Conclusions: Patients with ileal conduits have significantly decreased mental health quality of life whereas patients with continent urinary diversions do not. Therefore, when not medically contraindicated, patients should be offered a continent diversion as the diversion of choice after cystectomy.     

Incontinent urinary diversion]

We analyzed 237 patients who underwent total cystectomy with ileal conduit urinary diversion or cutaneous ureterostomy at the Center for Adult Diseases, Osaka. One-hundred and eighty-eight patients underwent ileal conduit diversion and 49 patients underwent cutaneous ureterostomy. No patient died within 30 days after the operation, but two patients who underwent ileal conduit diversion died of postoperative complications within 2 months. Early complications occurred in 94 patients (50%) in the ileal conduit group and in 18 patients (37%) in the ureterostomy group. Late complications occurred in 85 patients (45%) in the ileal conduit group and in 23 patients (47%) in the ureterostomy group. Frequent early complications in the ileal conduit group were wound infection (29%), and intestinal complications (13%) which included ileus and upper urinary tract complications (12%). The most frequent late complications were stomal complications (26%) which included peristomal dermatitis stomal stenosis, parastomal hernia, and stomal prolapse, and upper urinary tract complications which were noted in 27 patients (14%).     

The diagnosis and treatment for carcinoma in situ of the bilateral upper urinary tracts after total cystectomy and ileal conduit by intentionally inducing hydronephrosis

We report the diagnosis and treatment for carcinoma in situ of the bilateral upper urinary tracts after total cystectomy and ileal conduit by intentionally inducing hydronephrosis. A 75-year-old man whose chief complaints were macroscopic hematuria and bladder irritabilities was diagnosed carcinoma in situ of the bladder and underwent total cystectomy and ileal conduit. 26 months after the operation, the cytological examination of ileal conduit urine revealed urothelial carcinoma. Since the radiographic findings in the upper urinary tracts and ileal conduit were negative, we constructed bilateral percutaneous nephrostomies by intentionally inducing hydronephrosis. Since two serial cytological examinations of the urine sampling from the bilateral pyeloureteral systems revealed urothelial carcinoma, we performed the percutaneous Bacillus Calmatte-Guerin perfusion of the bilateral upper urinary tracts. The therapy was repeated at weekly intervals for a total of 11 perfusions and the cytological examination of ileal conduit urine became negative 4 months after the beginning of the therapy. Intentionally induced hydronephrosis is useful for the diagnosis and treatment for carcinoma in situ of the bilateral upper urinary tracts after total cystectomy and ileal conduit.