CONTINENCE MECHANISM OF THE ORTHOTOPIC NEOBLADDER: URODYNAMIC ANALYSIS OF ILEOCOLIC NEOBLADDER AND EXTERNAL URETHRAL SPHINCTER FUNCTIONS

Background: The main objectives of bladder substitution are the preservation of the upper urinary tract and maintenance of urinary continence. Orthotopic bladder substitution makes it possible to achieve urinary continence as well as normal passage of urine through the urethra. Creation of a low pressure reservoir and careful preservation of the distal sphincter mechanism are considered to be of utmost importance for the maintenance of urinary continence after orthotopic bladder Substitution. However, sphincter behavior after orthotopic bladder substitution has not been fully elucidated. The purpose of this study was to evaluate the vesicourethral continence mechanism after orthotopic bladder substitution in male patients. Methods: Urodynamic evaluation was performed in 14 male patients after cystoprostatectomy for bladder cancer and an ileocolic neobladder using a cecourethral anastomosis. Results: Good continence was achieved in 86% (12/14) of the patients during the day and in 79% (11/14) at night. On cystometry, maximum capacity of the neobladders was 434 ± 21 ml (mean ± SEM), and basal pressure at maximum capacity was 15.6 ± 0.9 cm water. Phasic neobladder contraction with amplitudes ranging from 14 to 40 (26.6 ± 2.7) cm water were noted in 11 of 14 patients. Sphincter electromyography demonstrated an increase in the frequency of action potentials of the external urethral sphincter during neobladder filling from empty to 80% of capacity (from 8.9 ± 1.6 to 14.6 ± 2.1 spikes per second; mean percentage increase, 64%, in patients with daytime continence). Maximum urethral closure pressure on urethral pressure profile was 49.9 ± 3.5 (range, 30 to 64) cm water in patients with daytime continence, while in two patients who were incontinent during the day and at night maximum urethral closure pressure was lower (16 and 24 cm water) and the recruitment of action potentials of the external urethral sphincter during neobladder filling was impaired (percentage increase, 15% and 20%). Conclusions: An ileocolic neobladder has characteristics of a low pressure reservoir with a satisfactory continence rate. The vesicourethral continence reflex is well preserved in patients with continence after orthotopic bladder Substitution.     

Neobladder formation after pelvic irradiation

Objective  To assess the results of the use of the ileal neobladder in patients with previous pelvic irradiation. Methods  Between January 1986 and July 2008, 1,570 radical cystectomies and 1,002 ileal neobladders were performed at a single institution. From this series, 94 patients (6%) with prior pelvic irradiation were retrospectively identified. In 25 of these irradiated patients, an ileal neobladder was done. All complications within 90 days of surgery were defined and graded using a five-grade modification of the original Clavien system and stratified into 11 categories. Functional outcome data and late complications were reported. Results  Seventy-six percent of the neobladder patients versus 52% of the non-neobladder patients developed complications occurring within 90 days of surgery. However, grade 3–5 complications were less frequent in the neobladder group. Unusual and serious late complications have been observed. Nineteen out of 25 neobladder patients enjoy perfect night and day time continence. Three out of seven female and 1/18 male patients suffer from treatment refractory severe stress incontinence. One male and one female patients are primarily hypercontinent. Conclusions  Salvage surgery (cystoprostatectomy, anterior exenteration) followed by orthotopic lower urinary tract reconstruction can be a safe, effective procedure that can provide a well functioning lower urinary tract in properly selected patients with defunctionalized bladder, tumor recurrence or de novo bladder cancer after definitive radiation therapy. Prerequisits for the neobladder as procedure of choice are good renal function, perfect preoperative continence, no recurrent gastrointestinal or gynecologic tumor, no fistula formation, and no severe damage of the small bowel.     

机器人辅助全腹腔镜下"紫砂壶型"原位回肠新膀胱的临床疗效分析

目的探讨机器人辅助全腹腔镜下"紫砂壶型"原位回肠新膀胱患者的尿控和肿瘤学预后。 方法以2017年5月至2019年6月连续进行的10例机器人辅助根治性膀胱切除+回肠原位新膀胱术患者为研究对象，男9例，女1例，年龄（63±11）岁，极高危非肌层浸润膀胱癌5例，肌层浸润性膀胱癌5例；术后随访时间为12～37个月。记录手术视频、术后90 d内并发症、随访期间患者的尿控恢复、分肾功能、上尿路影像学结构改变以及肿瘤学预后。 结果10例患者均顺利完成全腹腔镜下机器人辅助根治性膀胱切除回肠原位新膀胱手术，手术时间（584±56）min，出血量（655±275）ml，术后进食时间1～3 d；1例患者术后6个月行切口疝修复术，其余无Ⅲ级以上并发症。5例（50%）患者术后6～12个月尿流动力学检查提示最大尿流率及平均尿流率分别为（6.3±4.5）ml/s、1.80（0.30）ml/s，术后新膀胱充盈尿量及残余尿量分别为（525±273）ml、161（227）ml，患者日间完全控尿9例（90%），夜间完全控尿8例（80%）。随访期间，发现4侧肾盂轻度扩张，监测分肾功能正常。1例患者术后18个月出现肺转移，其余患者未发现局部复发及转移。 结论"紫砂壶型"回肠原位新膀胱是在Studer型、VIP型回肠新膀胱基础上的储尿囊成型技术改进，术后新膀胱功能良好，能有效保护上尿路形态，恢复排尿功能。     

腹腔镜保留前列腺尖部包膜根治性膀胱切除W形回肠新膀胱术尿控和勃起功能研究

目的探讨腹腔镜下保留前列腺尖部包膜根治性膀胱切除W形原位回肠新膀胱术的临床疗效。 方法回顾性分析2019年1月至2021年12月行腹腔镜根治性膀胱切除W形回肠原位新膀胱术的43例男性膀胱癌患者的临床资料。分为保留前列腺尖部包膜组20例（观察组）和非保留前列腺尖部包膜组23例（对照组）。观察组在距前列腺尖部1.0 cm处切开前列腺包膜,剜除前列腺,保留部分前列腺包膜的腹腔镜膀胱根治切除。对照组采用常规腹腔镜膀胱根治切除。两组W形回肠新膀胱制作方法相同。术后3周拔除导尿管,每３个月定期复查,收集所有患者的临床资料和完整随访信息。 结果所有患者均顺利完成手术。术后随访6~40个月无肿瘤复发。两组患者在术前人口学资料、膀胱肿瘤分期、手术时间、术中出血量、术中并发症、90 d内并发症发生率和术后6个月新膀胱残余尿量差异均无统计学意义（P>0.05）。术后6个月尿控率和勃起功能（IIEF-5评分）实验组优于对照组,日间尿控率分别为85.0%和52.2%（P<0.05）,夜间尿控率分别为65.0%和34.8%（P<0.05）,IIEF-5评分分别为[8（6,9）]分和[3（2,5）]分（P<0.05）。 结论腹腔镜下保留前列腺尖部包膜根治性膀胱切除W形原位回肠新膀胱术有利于尿控和勃起功能保护,不会影响肿瘤控制效果,值得临床推广应用。     

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.     

Ileal neobladder and local recurrence of bladder cancer: patterns of failure and impact on function in men

PURPOSE: Creation of an ileal neobladder has become a standard procedure in patients undergoing cystectomy for invasive bladder cancer. We evaluated the impact of local recurrence on ileal neobladder function and survival. MATERIALS AND METHODS: Between April 1986 and February 1997, 357 men underwent radical cystectomy and ileal neobladder substitution at our institution. We retrospectively reviewed the records of these patients to determine patterns of local recurrence and survival rates. RESULTS: Local recurrence developed in 43 of the 357 patients (12%), in whom median survival plus or minus standard deviation was 17 +/- 1.6 months and median time to recurrence was 10 months (range 2 to 41). Of the 43 patients with local recurrence at followup 36 had local advanced cancer on the final pathological evaluation (stage pT3a or node positive, or greater). A total of 17 patients (43%) had concomitant distant metastasis. Of the 43 patients 3 are alive at 36, 48 and 147 months, respectively. Death was due to disease in 36 cases, chemotherapy related complications in 3 and another cause in 1. Of the 43 patients 40 maintained good neobladder function. Local recurrence interfered with the upper urinary tract in 24 cases, neobladder in 10 and intestinal tract in 7. The neobladder was removed only in 1 patient due to a neovesical intestinal fistula. CONCLUSIONS: The local recurrence rate after orthotopic urinary reconstruction is 12%. Survival after local recurrence is diagnosed is limited despite multimodality therapy. However, most patients may anticipate normal neobladder function even in the presence of recurrent disease or until death. Thus, creating orthotopic diversion after cystectomy in patients with locally advanced bladder cancer, including macroscopically or microscopically positive lymph nodes, is safe.     

Supra-ampullar cystectomy with preservation of sexual function and ileal orthotopic reservoir for bladder tumor: twenty years of experience

OBJECTIVE: We describe the original surgical technique of supra-ampullar cystectomy associated with ileal neobladder, and present our results in terms of preservation of sexual potency, urinary continence and cancer control along twenty years of experience. MATERIALS AND METHODS: Twenty-eight consecutive patients with bladder tumor-27 transitional cell carcinomas (TCC) and 1 leiomyosarcoma-underwent supra-ampullar cystectomy with ileal orthotopic neobladder (2 Camey I and 26 Camey II) between May 1984 and June 1999. The median age of the patients was 51.0 years (range 23-65). Preoperatively 24 patients had superficial high-risk TCC. Involvement of prostatic urethra was excluded by means of preoperative endoscopic biopsies. The bladder, part of the prostate with the prostatic urethra and regional lymph nodes were removed, while the vas deferens with deferential ampullae, seminal vesicles, ejaculatory ducts and the peripheral portion of the prostate were maintained. Median followup was 90.5 months (range 10-228). RESULTS: Out of 28 patients 6 died of bladder cancer (all with metastases, 2 also with local recurrence); 4 out of the 22 patients who were free of disease at followup died of other causes. Potency was preserved in 26 patients (92.8%), reporting satisfactory sexual intercourses; 15 patients (53.5%) also maintained antegrade ejaculation allowing procreation in 3 cases. In one patient the orthotopic neobladder according to Camey I was converted into an ileal conduit because of the excessive capacity of the reservoir, high post-void residual and recurrent pyelonephritis. Of the remaining 27 patients 16 showed both daytime and nighttime urinary continence (average interval between micturitions = 3 hours), 6 were continent during the day and 5 performed self-intermittent catheterization. CONCLUSION: Supra-ampullar cystectomy with detubularized ileal orthotopic neobladder allows to preserve sexual function in nearly all the cases and to maintain urinary continence in most patients, without compromising oncological outcome. The indication must be restricted to highly selected cases, without potential risk of local recurrences and concomitant prostatic carcinoma.     

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。     

National survey on orthotopic neobladder

Objective A national survey was conducted among the urologists in India to find the preference for urinary diversion after radical cystectomy for muscle invasive carcinoma of the urinary bladder, percentage of neobladder reconstruction, segment of the bowel used, complication rate, need for self-intermittent catherisation on follow up and the survival. Material and methods A detailed questionnaire was mailed to all members of the urological society of India (USI) to find out their preference for urinary diversion following radical cystectomy for muscle invasive carcinoma urinary bladder. For the neobladder reconstruction, they were asked for the type of bowel segment used, complication rate, reoperation rate, need for intermittent clean catheterisation on follow up and 5-year survival. Results A total of 24 institutions responded to the mailed questionnaire. Of all institutions 12 (50%) did not prefer the orthotopic neobladder (ONB) reconstruction. Among the institutions carrying out neobladder reconstruction, majority perform ileal conduit in more than 50% of the cases. Ileum (66.66%) or ileocaecal (16.66%) segment was the choice of bowel segment for most of the urologists. Only three institutions used sigmoid colon. The complications encountered were wound infection (5–25%), burst abdomen (5%), urinary fistulas (3–25%), faecal fistulas (2–5%), bladder neck stenosis (5–15%) and ureterointestinal anastomosis stenosis (5–25%). The reoperation rate was 5–15% with a perioperative mortality of 0.5–3%. Around 10–100% (average 50%) of the patients require intermittent clean catherisation. Only seven institutions could provide 5-year survival rate data. Of these three institutions reported more than 50% and four institutes less than 50% 5-year survival. Conclusion Ileal conduit still remains the urinary diversion of choice following radical cystectomy for muscle invasive carcinoma of the bladder among most of the urologists in India. Orthotopic neobladder reconstruction is practiced only in selected centres. Wound infection, urinary leak and obstruction at ureterointestinal anastomosis are the main complications. Clean intermittent cathaterisation is required at an average of 50% of the patients to ensure complete emptying of the neobladder.     

Orthotopic ileal neobladder reconstruction in patients with recurring bladder cancer after renal transplantation – a report of two cases and a review of the literature

Abstract:  Renal transplant recipients have a high risk of developing multiple and invasive urothelial tumors because of long-term immunosuppression and infections with oncogenic viruses in China. However, treatment of renal transplant recipients who developed invasive bladder tumor is challenging. We aimed to evaluate the efficacy and safety of orthotopic ileal neobladder reconstruction following radical cystectomy in renal transplant recipients. Orthotopic ileal neobladder reconstruction and preservation of the transplanted kidney were performed in two patients after one and 36 months of transplantation, respectively. One recipient was lacking a bladder because of prior cystectomy before the transplantation, and the other developed multiple and invasive bladder cancer after the transplantation. During the 14-month and seven-yr follow-up postoperation, no serious complications occurred except slight hydronephrosis in one patient. No rejection and graft dysfunction occurred in both patients with reduced dosage of immunosuppressants, and serum creatinine as a marker of renal function remained stable. Urinary continence was satisfactory during the day and night with voluntary voiding. Our experience showed that radical cystectomy and orthotopic ileal neobladder reconstruction in transplant patients with stable renal function is a safe and effective way to provide better quality of life, satisfactory urinary diversion and preservation of renal function simultaneously.     

勃起神经保留性膀胱全切Roux-y乙状结肠新膀胱的临床结果

目的:观察勃起神经保留性膀胱全切和Roux-y乙状结肠新膀胱术后患者阴茎勃起功能、尿控、排尿和肿瘤复发情况。方法:共有18例患者进行了勃起神经保留性膀胱全切和Roux-y乙状结肠新膀胱术,评价肿瘤复发情况和功能性结果(尿控、排尿、勃起功能)。结果:平均随访41个月,2例分别于术后10个月和15个月死于癌症广泛性转移,这2例均为盆腔淋巴结阳性的患者。白天和夜间尿控率均为100%,11例患者有阴茎勃起功能,勃起率达61.1%,2例患者勃起功能受损,5例无勃起功能,手术前后ⅡEF-5评分为(13.72±6.39)、(10.83±8.25)分,差异有显著性(P<0.05)。结论:勃起神经保留性膀胱全切和Roux-y乙状结肠新膀胱术后患者阴茎勃起功能和尿控情况良好,肿瘤复发情况尚可接受,但仍需要长时间随访和大样本患者证实。     

Radical cystectomy with orthotopic neobladder reconstruction following prior radical prostatectomy

Purpose

To review the perioperative and follow-up outcomes of patients undergoing radical cystectomy with orthotopic neobladder reconstruction for bladder cancer after prior radical prostatectomy (RP) for prostate cancer.

Methods

A retrospective review of more than 1,900 patients treated with radical cystectomy at USC between 1990 and 2011 was conducted. Fifty-six patients were identified who were previously treated with RP for prostate cancer. Twenty-four of these patients (43?%) underwent orthotopic neobladder reconstruction. Perioperative data and follow-up including postoperative continence were analyzed.

Results

The median age at cystectomy for these 24 patients was 68?years (range 55?C89). The types of neobladder reconstruction were Kock neobladder in 3, Sigmoid reservoir in 1, Studer neobladder in 12, and T-pouch ileal neobladder in 8 patients. There were no major intraoperative complications. Of 19 patients eligible for evaluation of post-cystectomy urinary control, 11 patients (57.9?%) with good continence (0?C1 pad/day) after RP regained preoperative level of urinary control after cystectomy within 1?year. The continence rate of 13 post-RP patients with good continence was 84.6?%. Among the 4 patients who received adjuvant radiotherapy after RP, 1 regained good continence. One with poor continence after prostatectomy had an artificial urethral sphincter (AUS) placed 2?months after cystectomy, and 2 with fair and poor continence after prostatectomy had an AUS placed at the time of cystectomy.

Conclusions

Patients undergoing radical cystectomy after prior RP pose a challenge to urologists. Those who are continent post-RP have a fair chance of regaining good urinary control with neobladder reconstruction. Adjuvant radiotherapy for prostate cancer may have a negative impact on continence with neobladder reconstruction.     

Long-term results of orthotopic neobladder reconstruction after radical cystectomy

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

Supra-ampullar cystectomy and ileal neobladder

OBJECTIVE: This article describes both the open and laparoscopic operative techniques of supra-ampullar cystectomy (SAC). METHODS: Both open (photographs and drawings) and laparoscopic (attached DVD) SAC are explained step by step. RESULTS: Between May 1984 and December 2005, 31 patients with bladder tumour underwent SAC with ileal orthotopic neobladder (2 Camey I, 26 Camey II, and 3 Y). Three patients underwent laparoscopy. Preoperatively, 26 patients had superficial high-risk transitional cell carcinoma (TCC). Median follow-up was 95.0 mo (range: 5-260 mo). The 10-yr cause-specific survival rate was 76.7%. Two patients had local recurrence. Potency was preserved in 28 patients (90.3%); 15 patients (48.3%) also maintained antegrade ejaculation, allowing procreation in 3 cases. In one patient the Camey I neobladder was converted into an ileal conduit (high postvoid residual, recurrent pyelonephritis). None of the remaining patients had daytime incontinence, eight had nightime urinary incontinence, and six performed intermittent self-catheterisation. CONCLUSION: SAC with detubularised ileal orthotopic neobladder allows preservation of sexual function and maintenance of urinary continence in most patients, without compromising oncologic outcome. The key element is the very strict and careful preoperative selection of the patients.     

The orthotopic Kock ileal neobladder: functional results, urodynamic features, complications and survival in 166 men

PURPOSE: We report our experience with 166 patients who underwent radical cystectomy and orthotopic bladder substitution with the ileal Kock neobladder between February 1990 and January 1999. MATERIALS AND METHODS: We classified complications as early (3 months or less postoperatively) and late. Continence was assessed by patient interview, the need to use protective devices and provocative incontinence testing. Neobladder function was evaluated by uroflowmetry, post-void residual urine volume measurement and enterocystometry, and renal function was assessed by 51creatinine ethylenediaminetetraacetic acid clearance. RESULTS: There were no perioperative deaths. However, 52 early complications developed in 39 patients (23.5%) and 73 late complications in 62 (37.4%). The rate of early and late complications associated with the urinary tract was 11.5% and 23.5% with abdominal reoperation rates of 1.8% and 2.4%, respectively, due to these complications. At 3 and 5 years the risk of stone formation on the metallic staples was 18% and 34%, and the risk of B12 deficiency was 30% and 33%, respectively. One patient (0.6%) underwent reoperation for ureteral anastomotic stricture. Anterior urethral stricture in 5 cases (3%) was caused by recurrence in 1 and urethral anastomotic stricture in 1 also resulted from recurrent disease. Daytime continence was reported by 97% and 100% of our patients at 1 and 5 years, respectively. Provocative incontinence testing confirmed this level of daytime continence. Overall 75% of patients reported nighttime continence at 1 year and 94% at 5 years. The need for a nighttime protective device decreased with time. At 1 versus 3 years 39.8% versus 45.9% of patients used no protection, 29.7% versus 39.2% used a sanitary pad and 30.5% versus 14.9% used a condom device. Enterocystometric capacity and subtracted maximum reservoir pressure remained remarkably uniform at 456 versus 411 ml. and 47 versus 50 cm. water 6 months and 5 years postoperatively, respectively. Nevertheless, median post-void residual urine volume increased from 20 ml. at 6 months to 40 ml. at 5 years with an increased prevalence of patients requiring intermittent catheterization due to post-void residual urine greater than 100 ml. from 16% at 6 months to 44% at 5 years. 51Creatinine ethylenediaminetetraacetic acid clearance remained unchanged. There was a substantial 5-year survival advantage for the subpopulation with stage pT3a or less, pN0 tumors (94% versus 51%, p <0.001). CONCLUSIONS: Radical cystectomy and orthotopic bladder substitution with the Kock ileal neobladder may be performed with an acceptable complication rate and good functional results. The probability of survival was considerably higher for patients with tumor confined to the bladder. Consequently we believe that early aggressive treatment should be considered in those with invasive disease, and reconstruction with orthotopic bladder substitution may encourage patients to accept radical surgery.     

改良W形回肠代膀胱术的疗效观察(附36例报告)

目的 :探讨改良W形回肠代膀胱术的疗效。方法 :对 36例膀胱肿瘤患者行根治性膀胱切除、W形回肠代膀胱术 ,并对术式进行改进。结果 :36例手术时间平均 4 .2h。术后 31例随访 4～ 19个月 ,平均 10 .6个月 ,无严重并发症 ,均无瘤生存。患者一般于术后 3周自主可控性排尿 ,日间尿控率为 10 0 % ,术后 3、6、12个月夜间尿失禁发生率分别为 2 2 .5 %、11.1%及 6 .2 %。术后 6个月尿动力学检查膀胱容量 (36 0± 30 )ml,最大尿流率 (13.6± 2 .6 )ml/s,剩余尿量 (11.5± 5 .8)ml,充盈期膀胱压力明显低于尿道闭合压。新膀胱造影发现新膀胱呈球形 ,完全位于盆腔 ,未见输尿管反流。B超及IVU检查发现原上尿路积水 4例均明显减轻 ,其余未发现输尿管狭窄和上尿路积水征象。无高氯性酸中毒 ,肾功能正常。结论 :改良W形回肠代膀胱术手术时间短 ,操作简单 ,创伤轻 ,并发症少 ;新膀胱容量大 ,内压低 ,顺应性好 ,功能接近于正常膀胱 ,保持原位排尿 ,明显提高了患者术后生活质量 ,值得临床推广应用。     

Ileal orthotopic neobladder in women: The first experiences from Turkey and our modifications

The lower urinary tract reconstruction with an ileal neobladder in woman is not very often but has been recently introduced centers. We report 8 female patients with ileal orthotopic neobladders after cystectomy. Patients and methods: Between 1995 to 1999, 7 female patients with organ confined invasive bladder cancer and 1 female patient with severely contracted bladder secondary to tuberculosis were operated. While standard radical cystectomy was done in 7 patients with bladder cancer, only simple cystectomy was performed in patient with contracted bladder. Detubularized ileal W-neobladder with antirefluxive ureteroileal reimplantation were used as a procedure and reservoirs are connected to the proximal urethra in all patients. Cystoscopy and biopsy was done routinly in the bladder neck and there were no tumour and CIS in any patient. Results: The mean age was 65.4 years (53–70) and the mean postoperative follow-up time was 31.8 months (6–48). There was no perioperative or early postoperative (first one month) mortality. Early postoperative complications included acute renal failure in 1 patient (12.5%), deep vein thrombosis in 1 patient (12.5%) and leakage from the pouch in 2 patients (25%). In one patient (12.5%), ileo-pouchal fistula was seen in sixth month and reoperated. Although there was not hypercontinence, one patient (12.5%) had totally incontinence. All other patients had normal micturition and no residual urine. Urethral recurrence was not seen in this postoperative follow-up period but pelvic recurrence and then distant metastases were found in one case (12.5%). Conclusions: The results of ileal orthtopic neobladder after radical or simple cystectomy in appropriate female patients are satisfactory. But certainly, we need the more experiences and studies about this subject. This revised version was published online in September 2006 with corrections to the Cover Date.     

Ileocaecal vs ileal neobladder after radical cystectomy in patients with bladder cancer: a comparative study

OBJECTIVE: To compare an ileocaecal orthotopic bladder, (which has been the standard procedure in Egypt for >30 years) with the ileal neobladder, as there is no ideal continent orthotopic bladder replacement for patients after cystectomy for bladder cancer. PATIENTS AND METHODS: Between June 1999 and December 2001, 60 patients with invasive bladder cancer were randomized into two groups. Group A comprised 29 patients who had radical cystectomy and reconstruction with an ileal neobladder (median age 50 years, 27 men and two women) and group B included 31 who had an ileocaecal bladder substitution after radical cystectomy (median age 51 years, 28 men and three women). RESULTS: The complication rate after surgery in group A was 17%, with two deaths, one from acute myocardial infarction and the other from haematemesis. In group B, the complication rate was 13%, with two deaths, one from a massive pulmonary embolism and the other from liver cell failure. Daytime continence was achieved in 93% of patients in group A and 90% in group B. The mean (sd) postvoid residual urine volume was larger in group A than group B, at 90 (72) vs 12 (20) mL. Acidosis and hyponatraemia were evident in the patients in group A but in none in group B (P < 0.05). The pelvicalyceal systems were preserved in 85% of patients in group A and 93% in group B during the 2-year follow-up. The mean (sd) renal cortical thickness was less in group A than in group B, at 1.8 (0.5) and 1.9 (0.2) cm, respectively. Although the cystometric capacity was greater and the basal pressure less in group A than B, these were not reflected in the degree of diurnal and nocturnal continence or back pressure on the renal units. CONCLUSION: Continence in both pouches was similar but the renal units were preserved better in the ileocaecal than in the ileal neobladder. Residual urine volume was greater in the ileal neobladder, with its potential complications of infection and stone formation, and acidosis was more evident.     

Intestinal oxalate absorption in patients with continent urinary diversion

The objective of the study is to evaluate the post-operative effect of an orthotopic ileal neobladder or a Mainz pouch I bladder replacement on the extent of intestinal oxalate absorption. Gastrointestinal oxalate absorption was measured in six patients with an orthotopic ileal neobladder and in six patients with a Mainz pouch I bladder replacement. The function test applied was the [¹³C₂]oxalate absorption test. With a range of 5.1–12.4%, the oxalate absorption of these patients was well within the reference range for healthy volunteers. The results from our small study indicate that such continent urinary diversions present no hazard for oxalate hyperabsorption and subsequent calcium oxalate urolithiasis.     

Local recurrence in patients after radical cystectomy and orthotopic ileal neobladder: impact on function

Whether an orthotopic bladder substitute should be constructed in patients with locally advanced or lymph node positive bladder cancer remains a subject of debate. These patients are at risk that local recurrence may impair reservoir function in orthotopic neobladders. We retrospectively assessed reservoir function in 68 consecutive patients with locally advanced bladder cancer. Tumor stage was multifocal carcinoma in situ, multifocal pT1 disease, pT2, pT3a, pT3b, and pT4a in 3, 4, 19, 11, 25, and 6 patients respectively. Lymph nodes were positive for carcinoma in 17 patients. Out of the 68 patients, 65 could be followed for at least three months. Within a median follow-up of 26 months (range three to 87 months), recurrence developed in 16 of the 65 patients (25%). 7 patients (11%) had distant failure. 9 patients (14%) showed local and distant recurrence. In the six out of the nine patients with local recurrence located lateral, dorsal, or cranial of the neobladder, adequate neobladder function was retained until the last follow-up visit or until death. Only those three patients with local recurrence involving the pelvic floor or urethra needed a suprapubic catheter due to urinary retention caused by tumor obstruction. Excluding pelvic floor and anterior urethral disease, we recommend orthotopic bladder substitution even in locally advanced but resectable disease as far as the patient is in a good performance status.