Learning curve for intracorporeal robotic Padua ileal bladder: 10-year functional assessment from a high-volume single-centre series.

OBJECTIVES: To assess the impact of the learning curve (LC) on perioperative and long-term functional outcomes of a consecutive single-centre series of robot-assisted radical cystectomy with Padua intracorporeal orthotopic neobladder. PATIENTS AND METHODS: Patients treated between 2013 and 2022 were included, with ≥1 year of follow-up. The entire cohort was divided in tertiles. Categorical and continuous variables were compared. Joinpoint regression analysis was used to identify significant changes over the decade in linear slope of the 1-year day- and night-time continence. Uni- and multivariable Cox regression analyses identified predictors of day- and night-time continence recovery. Day-time continence was defined as 'totally dry' (no pads), night-time continence as pad wetness ≤50 mL (one safety pad). RESULTS: Overall, 200 patients were included. The mean hospital stay (P = 0.002) and 30-day complications (P = 0.04) significantly reduced over time; the LC significantly impacted on Trifecta achievement (P < 0.001). The 1-year day- and night-time continence probabilities displayed a significant improving trend (day-time continence annual average percentage change [AAPC] 11.45%, P < 0.001; night-time continence AAPC 10.05%, P = 0.009). The LC was an independent predictor of day- (hazard ratio [HR] 1.008; P < 0.001) and night-time continence (HR 1.004; P = 0.03) over time. CONCLUSION: Patients at the beginning of the LC had significantly longer hospitalisations, more postoperative complications, and lower Trifecta rates. At the 10-year analyses, we observed a significant improving trend for both the 1-year day- and night-time continence probabilities, highlighting the crucial role of the LC. However, we are unable to assess the case volume needed to achieve a plateau in terms of day- and night-time continence rates.

Prospective evaluation of functional outcomes in 395 patients with an ileal neobladder 1 year after radical cystectomy.

PURPOSE: This study aims to report on functional outcomes in a large cohort of patients who underwent inpatient rehabilitation (IR) in a highly specialized, high-volume German urologic rehabilitation center after radical cystectomy (RC) and creation of an ileal neobladder (INB). METHODS: Data for 842 patients, who underwent three weeks of IR after RC and urinary diversion between April 2018 and December 2019 were prospectively collected. INB patients were surveyed on continence and sexual function. Data were collected at 4 weeks (T1), 6 months (T2), and 12 months (T3) after RC. Multivariate logistic regressions were performed to identify predictors of better functional outcomes. RESULTS: INB was chosen as urinary diversion in 395 patients (357 male, 38 female). Social continence (maximum of one safety pad/24 h) was reported by 78.3% of men and 64.0% of women at T3. Severe incontinence was reported by 27.3% of men and 44.0% of women. Male sex was identified as an independent predictor for the use of no pads at T3 (OR 4.110; 95% CI 1.153-14.655; p = 0.029). Nerve-sparing surgery was identified as an independent predictor both for the use of only a safety pad (OR 1.918; 95% CI 1.031-3.569; p = 0.040) and good erectile function at T3 (OR 4.377; 95% CI 1.582-12.110; p = 0.004). CONCLUSION: Urologists should aspire for nerve-sparing surgery. When advising patients before RC, functional outcomes (continence, sexual function) should be given special attention. Women should be counseled on potentially prolonged urinary incontinence.

Prospective evaluation of return to work, health-related quality of life and psychosocial distress after radical cystectomy: 1-year follow-up in 230 employed German bladder cancer patients.

PURPOSE: To evaluate return to work (RTW), health-related quality of life (HRQoL) and psychosocial distress (PD) after radical cystectomy (RC) and creation of an ileal conduit (IC) or an orthotopic ileal neobladder (NB) for bladder cancer. METHODS: The study relied on prospectively collected data for 842 patients, who underwent 3 weeks of inpatient rehabilitation (IR) after surgery between April 2018 and December 2019. HRQoL (EORTC QLQ-C30) and PD (Questionnaire on Stress in Cancer Patients [QSC-R10]) were evaluated at the beginning (T1) and end (T2) of IR as well as both 6 (T3) and 12 months after surgery (T4). Regression analyses were performed to identify predictors of HRQoL and RTW, respectively. RESULTS: Two hundred thirty patients (IC n = 51, NB n = 179) were employed before surgery (27.3%). HRQoL improved steadily, while high PD was present in 51.0% of patients at T4. RTW rate was 86.8 and 80.6% at T3 and T4, respectively. Linear regression analysis identified RTW as the only predictor for better HRQoL at T4 (OR [odds ratio] 12.823, 95% CI [confidence interval] 2.927-22.720, p = 0.012). Multivariate regression analysis identified age ≤ 59 years (OR 7.842; 95% CI 2.495-24.645; p < 0.001) as an independent positive predictor and lymph node metastasis (OR 0.220; 95% CI 0.054-0.893; p = 0.034) as an independent negative predictor of RTW at T4. CONCLUSION: Global HRQoL improved steadily during the follow-up and RTW rates are high. However, patients often reported high PD, reflecting a need for additional psychosocial support within aftercare.

[Experience of using Experience of using NefroBest-N for rehabilitation of patients undergoing radical laparoscopic cystectomy].

AIM: To evaluate the efficacy and safety of NefroBest-N in patients undergoing to the radical cystectomy with neobladder formation. MATERIALS AND METHODS: A total of 60 patients with invasive bladder cancer aged 56 to 75 years, treated at A.I. Burnazyan SRC FMBC and at the M.A. Podgorbunsky Kuzbass linical Hospital of Emergency Medical Care in 2022, were included in randomized multicenter parallel group study. All patients underwent radical cystectomy with a formation of Studer neobladder. The main group included those who received the drug NefroBest-N, 1 capsule 2 times a day for 90 days. In the control group, only symptomatic therapy according to current standards was administered. The study consisted of a screening period of up to 4 days (Visit 1) and a period of 90+2 days to evaluate the efficiency of therapy, including 3 visits: day 14 (Visit 2), 30+2 days (Visit 3) and 90+2 days (Visit 4). Laboratory examination and imaging studies included biochemistry panel (urea, creatinine, K, Na, CRP), urinalysis (presence of mucus, leukocytes), urine culture (bacteriuria), physical examination, renal and neobladder ultrasound with determination of postvoid residual volume. In addition, evaluation of the quality of life was also performed. RESULTS: Evaluation of efficacy and safety of NefroBest-N was carried out. Administration of NefroBest-N resulted in a more rapid improvement of urinalysis, including a significant decrease in severity of leukocyturia and amount of mucus. In addition, degree of bacteriuria was reduced according to the urine culture. The quality of life was also improved. CONCLUSION: NefroBest-N has a favorable efficacy and safety profile. According to our experience, NefroBest-N significantly reduces recovery time and improves the quality of life of patients who have undergone radical cystectomy with a neobladder formation.

Recovery of health-related quality of life in patients undergoing robot-assisted radical cystectomy with intracorporeal diversion.

OBJECTIVE: To report the health-related quality of life (HRQoL) after robot-assisted radical cystectomy and intracorporeal urinary diversion (iRARC), and to identify factors impacting on return to baseline. PATIENTS AND METHODS: Consecutive patients undergoing iRARC between January 2016 and December 2017 completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire 30-item core (EORTC-QLQ-C30) and EORTC-QLQ-Muscle-Invasive Bladder Cancer Module (EORTC-QLQ-BLM30) questionnaires before surgery and had a minimum of 12 months follow-up postoperatively. RESULTS: A total of 76 patients met the inclusion criteria at 12 months. Neobladder (NB) cases (n = 24) were younger (57.0 vs 71.0 years, P < 0.001) and fitter than ileal conduit (IC) cases (n = 52), and had higher physical (100.0 vs 93.3, P = 0.039) and sexual functioning (66.7 vs 50.0, P = 0.013) scores at baseline. Longitudinal analysis of the EORTC-QLQ-C30 showed that physical (NB: 93.3 vs 100.0, P = 0.020; IC: 80.0 vs 93.3, P < 0.001) and role functioning scores (NB: 83.3 vs 100.0, P = 0.010; IC: 83.3 vs 100.0, P = 0.017) decreased and fatigue score (NB: 22.2 vs 11.1, P = 0.026; IC: 33.3 vs 22.2, P = 0.008) increased at 3 months in both diversion groups. Scores returned to baseline at 6 months except physical functioning score in IC patients that remained below baseline until 12 months (86.7 vs 93.3, P = 0.012). The global HRQoL score did not show significant change postoperatively in both groups. A major 90-day Clavien-Dindo complication was a significant predictor (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.02-0.62; P = 0.012) of deteriorated global HRQoL score at 3 months, while occurrence of a late complication (OR 0.14, 95% CI 0.03-0.65; P = 0.013) was a predictor of deteriorated global HRQoL score at 12 months. Longitudinal analysis of the EORTC-QLQ-BLM30 showed that urinary problems (NB: 14.3 vs 38.3, P < 0.001; IC: 5.6 vs 19.1, P < 0.001) and future perspective (NB: 33.3 vs 44.4, P = 0.004; IC: 22.2 vs 44.4, P < 0.001) scores were better than baseline at 3 months. Sexual function deteriorated significantly at 3 months (NB: 8.3 vs 66.7, P < 0.001; IC: 4.2 vs 50.0, P < 0.001) and then showed improvement at 12 months but was still below baseline (NB: 33.3 vs 66.7, P = 0.001; IC: 25.0 vs 50.0, P < 0.001). Involvement in penile rehabilitation was shown to be a significant predictor (ß 18.62, 95% CI 6.06-30.45; P = 0.005) of higher sexual function score at 12 months. CONCLUSION: While most functional domains and symptoms scales recover to or exceed baseline within 6 months of iRARC, physical function remains below baseline in IC patients up to 12 months. Global HRQoL is preserved for both types of urinary diversion; however, postoperative complications seem to be the main driving factor for global HRQoL. Sexual function is adversely affected after iRARC suggesting that structured rehabilitation of sexual function should be an integral part of the RC pathway.

Clinical efficacy of mebeverine for persistent nocturnal enuresis after orthotopic W-neobladder.

OBJECTIVES: To investigate the efficacy of mebeverine for nocturnal incontinence in male patients with an ileal orthotopic bladder substitute (OBS). PATIENTS AND METHODS: A randomised controlled trial was carried out for adult male patients who were nocturnal incontinent. Patients were allocated to receive mebeverine 200 mg or placebo once a day in the evening for 3 months. The primary outcome was to compare the continence status between groups, assessed by the urinary domain of the Bladder Cancer Index (BCI) and pad usage. The secondary outcomes were to assess the safety of mebeverine. RESULTS: There were 55 patients in the placebo group and 58 in mebeverine group who completed the follow-up. The median (interquartile range) interval between OBS surgery and starting treatment was 9 (4-13) years in the placebo group and 9 (6-13) years in the mebeverine group. The mean (SD) 3-month urinary domain score of the BCI was 70.8 (5.6) and 86.4 (14.2) in the placebo and mebeverine groups, respectively (P < 0.001). At 3 months, 54 (98.2%) and 26 (44.8%) patients required the use of a night-time pad in the placebo and mebeverine groups, respectively. Mebeverine reduced the risk of pad use by 53.4% (95% confidence interval 40.1-66.6; P < 0.001). Constipation occurred in one (2.1%) and three (5.8%) patients in the placebo and mebeverine groups, respectively; abdominal distention occurred in two (3.8%) of the patients in the mebeverine group (P = 0.25). CONCLUSION: Mebeverine decreases night-time pad use and improves the quality of life in male patients with an ileal OBS and is associated with minimal adverse events.

Female Sexual Function and Body Image After Urinary Diversion for Benign Conditions.

BACKGROUND: Simple cystectomy with urinary diversion is the favored option for treating conditions responsible of neurogenic bladder dysfunction after failure of conservative treatments. Despite the existence of validated assessment tools, the impact of cystectomy on female sexual function remains scarcely investigated. AIM: The aim was to assess the sexual function and body image of female patients who underwent urinary diversion for a nonmalignant condition and to investigate the factors that may influence sexual life quality. METHODS: 36 female patients who underwent urinary diversion ± cystectomy for a benign condition between January 1, 2007 and December 15, 2019 were included. Standardized questionnaires were sent by mail between February and April 2021. Additional data were collected from patient computerized medical records. OUTCOMES: The Female Sexual Function Index (FSFI), Body Image Scale (BIS), and Stoma Quality Of life (StomaQOL) questionnaires were used to assess sexual activity, body image, and quality of life related to a noncontinent stoma, respectively. The quality of pre- and postoperative information was also assessed. RESULTS: The most frequent etiology of bladder dysfunction was multiple sclerosis (14, 38.9%). After surgery, 29 (80.6%) patients were sexually active and the mean (range) overall FSFI score was 15.2 (2-33.3). The mean (range) overall FSFI score and FSFI Arousal sub-score were lower for the 14 patients with an ileal conduit [11.1(2-33.3] and 1 (0-4.5)) compared to the 14 patients with a continent stoma or a native urethra [19.2 (2-29.3]; P = .04 and 3.15(0-5.4); P = .014). Regarding sexual counseling, 27 (79.4%) patients did not receive any information before surgery about possible consequences on their sexual activity, 31 (91.2%) were not asked about their sexual activity during follow-up. The mean BIS score was higher for patients with an ileal conduit (14.8) compared to patients with a continent stoma (9.7) or a native urethra (5.1; P = .002). Patients with an ileal conduit had a mean StomaQOL score of 52.56. CLINICAL IMPLICATIONS: Optimal management should include, at least, routine assessment of sexual function prior to simple cystectomy and screening for sexual dysfunction during follow-up. Strengths and limitations The main strength of this study lies in the use of validated standardized questionnaires, including the FSFI that is considered as the most relevant tool for assessing female sexual function. Limitations include the small number of patients and the potential memory bias. CONCLUSION: The present study suggests the urinary diversion mode has an impact on sexual function and body image after cystectomy for benign condition. Louar M, Morel-Journel N, Ruffion A, et al. Female Sexual Function and Body Image After Urinary Diversion for Benign Conditions. J Sex Med 2022;19:263-269.

Continent cutaneous urinary diversion with an ileal pouch with the Mitrofanoff principle versus a Miami pouch in patients undergoing cystectomy for bladder cancer: results of a comparative study.

PURPOSE: Radical cystectomy (RC) is currently the standard of care for non-metastatic muscle invasive bladder cancer. Few studies compare methods of cutaneous continent urinary diversion (CCUD) following RC. The objective was to compare perioperative morbidity and functional outcomes of CCUD using an ileal pouch with a Mitrofanoff efferent versus a Miami ileocolic pouch in patients undergoing cystectomy of pelvic exenteration for bladder cancer. METHODS: This retrospective two-centre study included all consecutive patients who underwent radical cystectomy or pelvic exenteration with CCUD for bladder cancer between 2001 and 2020 in two academic French hospitals with a median follow-up time of 5.4 years. Patients were divided into two groups according to the type of urinary diversion: Miami ileocolonic pouch (group A) and ileal pouch with Mitrofanoff/Monti principle (group B). Continence rate, ability to perform intermittent self-catheterisation, complications and health-related quality of life (HRQoL) measured by the bladder cancer index were evaluated. RESULTS: Thirty-one patients were included. Continence was achieved in 11 out of 14 patients (79%) in group A versus 12 out of 17 patients (71%) in group B (P = 0.3). A significantly higher rate of cutaneous tube stenosis was reported in group B compared to group A (eight (47%) vs. one (7%) patient, respectively; P = 0.02). HRQoL outcomes were similar in both groups except less digestive discomfort observed in group A. CONCLUSIONS: When comparing the ileal pouch with Mitrofanoff/Monti's principle with a Miami pouch, no significant differences were found regarding continence rate, ability to self-catheterise, long-term complication rate and overall patient satisfaction.

The effect of urinary diversion on renal function after cystectomy for bladder cancer: comparison between ileal conduit, orthotopic ileal neobladder, and heterotopic ileocecal pouch.

PURPOSE: To explore the impact of ileal conduit (IC), orthotopic ileal neobladder, and MAINZ Pouch I on renal function (RF) over time. METHODS: We performed a retrospective, cohort study including consecutive patients who underwent open radical cystectomy due to bladder cancer from November 2013 to June 2022. RF deterioration was calculated based on the estimated glomerular filtration rate (eGFR) through the CKD-EPI creatinine equation. A linear mixed-effects model was constructed, adjusting for multiple risk factors. The probability of achieving an eGFR reduction greater than 25% compared to baseline among different urinary diversion techniques was assessed using a Kaplan-Meier curve. RESULTS: Overall, 107 patients received IC, 28 neobladder, and 20 MAINZ Pouch I. Those receiving IC were older and displayed more comorbidities. At follow-up, eGFR was lower by 0.09 mL/min/1.73m2 (confidence interval - 5.87 to 5.69, p = 0.975) in patients receiving neobladder compared to those receiving IC. Similarly, eGFR was higher by 4.64 mL/min/1.73m2 (confidence interval - 1.57 to 10.85, p = 0.143) in patients receiving pouch compared to those receiving IC. Accordingly, patients with higher preoperative eGFR (p < 0.001), lower age (p = 0.048), non-T4 histological tumor (p = 0.027) and absence of septicemia at follow-up (p = 0.002) presented higher eGFR values at follow-up. The three UD techniques did not differ significantly in the time-to-event analysis (log-rank test = 0.29). CONCLUSIONS: A substantial proportion of patients undergoing urinary diversion with IC, orthotopic ileal neobladder, or MAINZ Pouch I develop RF deterioration at follow-up. No significant differences were observed among the three UD techniques in terms of eGFR decline in the long-term.

Comparative performance of the different orthotopic urinary diversions.

PURPOSE OF REVIEW: Majority of patients undergoing radical cystectomy are suitable for orthotopic urinary diversion. The effect of different techniques of neobladder reconstruction on early and long-term postoperative complications is still being determined. Additionally, it is unclear which type of neobladder provides the best patient satisfaction. The purpose of this article is to review the outcomes of different orthotopic urinary diversions following radical cystectomy. RECENT FINDINGS: Ileal neobladder is the preferred type of orthotopic urinary diversion following radical cystectomy. Hautmann and Studer, which are the most common orthotopic diversion techniques, provide daytime continence rate up to 87% and 92%, respectively. However, nighttime continence is achieved in about 50% of patients. High-level evidence supports the long-term safety of orthotopic neobladder in terms of renal function, even in patients with a glomerular filtration rate <60 ml/min. Sexual dysfunction is the only independent factor associated with poorer quality of life in these patients. SUMMARY: The best type of neobladder is still uncertain. However, Studer and Hautmann are the most commonly performed techniques that provide favorable short- and long-term outcomes.

Modification of the Indiana Pouch Ileo-Caecal Cutaneous Continent Urinary Diversion: Tubular Ileal Afferent Limb for Ureteral Anastomosis Has Low Stricture Rate and Allows Ileal Ureter Replacement.

OBJECTIVE: The aim of the study was to introduce our new modification of the Indiana pouch with a refluxing ureteral anastomosis in a tubular afferent ileal segment of the ileo-caecal urinary reservoir. PATIENTS AND METHODS: Between February 2008 and December 2020, we performed a total of 37 modified continent ileo-caecal pouches for urinary diversion when orthotopic bladder substitution was not possible. Hereby, we modified the Indiana pouch procedure with a new refluxing end-to-end ureteral anastomosis into an 8-cm afferent tubular ileal segment. RESULTS: We performed the modified Indiana pouch in 27 women (73%) and 10 men (27%). The median age of the patients at time of operation was 64 years (43-80 years). To date, the average follow-up is 69 months (3-156 months). In 32/37 cases, we performed the new pouch procedure after radical cystectomy for muscle-invasive bladder cancer and in 1/37 cases after radical cystectomy for locally advanced prostate cancer. In 4 cases, the procedure was performed after total exenteration of the pelvis due to locally advanced bladder, colorectal, or gynaecological cancers. Ureteral anastomotic strictures were seen in 2/37 patients (5.4%) or 2/72 (2.8%) of renal units. CONCLUSIONS: Our modification of the Indiana pouch cutaneous continent urinary diversion with the ureteral anastomosis to a tubular segment of the pouch is easy to perform and effective in reducing the rate of ureteral anastomotic strictures. By lengthening, the afferent tubular ileal segment, it additionally allows easy ureteral replacement.

Quality of life following formation of an ileal conduit due to urinary bladder neoplasm: A systematic review.

AIM: To present the findings of a systematic review on reported quality of life following the formation of a urinary diversion as a result of cystectomy due to urinary bladder neoplasm. BACKGROUND: Bladder cancer is the most commonly occurring cancer of the urological system. Treatment often involves undergoing a radical cystectomy with an ileal conduit formation. Quality of life issues associated with this surgery are complex and varied. DESIGN: A systematic review using thematic synthesis. DATA SOURCES: A comprehensive search, using The Cochrane Library, CINAHL, PubMed and PsycInfo databases, focusing on the years from 2007 to 2020. REVIEW METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was the chosen checklist used. Studies were critically appraised using the Crowe Critical Appraisal Tool. RESULTS: The formation of an ileal conduit negatively affects respondent's quality of life particularly regarding body image, social distress, reduced sexual activity and employment. Poor research focus on the impact of ileal conduit formation on sexual well-being postoperatively was apparent. CONCLUSIONS: Further research using qualitative methodologies is needed to gain a deeper understanding of how this life-changing procedure impacts quality of life.

[Exploration and thinking on functional preservation after orthotopic neobladder construction].

The concept of functional preservation after orthotopic neobladder construction has gradually attracted attention. Reconstruction of urine storage and voiding is the basic function preservation of orthotopic neobladder. Clinical exploration mainly focuses on the optimization of neobladder reconstruction methods and procedures, and there is still a lack of summary of existing surgical characteristics and high-quality functional comparative studies. For strictly selected patients, on the basis of tumor control and standardized postoperative rehabilitation guidance, most patients with preserved nerve can retain satisfied sexual function after surgery. The protection of neurovascular bundle and ancillary structures combined with postoperative exercise is crucial to the improvement of urinary continence. According to the characteristics of patients, choosing the appropriate urinary diversion methods and function preserving can help patients establish a normal life style after surgery and improve their self-image and quality of life.

[How do patients manage their urostomy in everyday life? A questionnaire survey]. / Comment les patients prennent-ils en charge leur urostomie au quotidien ? Enquête par questionnaires.

INTRODUCTION: The complications of stoma and peristomal are encountered by nearly 80% of patients within two years of surgery. The objective of this study was to evaluate the practical modalities of daily management of stoma and possible skin complications in a series of patients with non-continent urinary stoma. METHODS: Monocentric study by questionnaires including all patients with non-continent urinary stoma between 2007 and 2019 in a French university center. The STOMA-QOL and a self-report questionnaire with 15 specific questions were used. RESULTS: Among the 87 patients included in the analysis whose median age was 71 years, 57.5% used a 2-piece system, 69% used leg or thigh pockets, 74.7% were self-sufficient in emptying their stoma pockets. Autonomy on cutaneous support change was 38%. 62.1% of patients reported a peristomal skin event and 74.7% reported leaking stoma. In multivariate analysis, BMI>30, the presence of leaks and physical activity were significantly associated with the onset of peristomal skin events. CONCLUSION: This study sheds light on the practical modalities of management of urinary stoma and the occurrence of skin complications related to stoma in terms of frequency and predisposing factors. The results obtained are likely to guide practitioners in the information of future operations and in the management of complications of urinary stoma. LEVEL OF EVIDENCE: III.

A Randomized Trial to Examine the Utility of Mebeverine on the Early Return of Continence Following Orthotopic Bladder Substitution.

PURPOSE: We assessed the effect of mebeverine in the enhancement of the orthotopic bladder substitute continence. MATERIALS AND METHODS: A randomized trial was carried out for incontinent adult male patients during the first year post-orthotopic bladder substitute surgery. Patients were allocated to receive mebeverine 135 mg or placebo 3 times a day for only 3 months. The primary outcome was to compare the continence improvement between groups, assessed by the urinary domain of the Bladder Cancer Index and sanitary pad use. The secondary outcomes were to assess the safety of the drugs used. RESULTS: In placebo group 47 and in mebeverine group 52 patients completed followup. The median (range) interval time between orthotopic bladder substitute surgery and starting treatment was 7 (3-10) months and 6.5 (3-10) months in the placebo and mebeverine group, respectively (p=0.3). Compared to the baseline evaluation, the 3-month urinary domain of Bladder Cancer Index scores improved in both groups with significant improvement in the mebeverine group. The mean±SD 3-month urinary domain of Bladder Cancer Index was 67.79±13.05 and 83.27±12.21 in the placebo and mebeverine group, respectively (p <0.001). Also, the 3-month patient pad use decreased to 30 (63.8%) and 19 (36.5%) patients in the placebo and mebeverine group, respectively (p=0.007). Constipation occurred in 1 (2.1%) and 3 (5.8%) patients in the placebo and mebeverine group, respectively; abdominal distention occurred in 2 (3.8%) in the mebeverine group (p=0.25). CONCLUSIONS: Mebeverine accelerated continence development in male patients with ileal orthotopic bladder substitute during the first year post-orthotopic bladder substitute construction.

Functional Outcome and Complications following Ileal Neobladder Reconstruction in Male Patients without Tumor Recurrence. More than 35 Years of Experience from a Single Center.

PURPOSE: There is a lack of data on true long-term functional outcome of orthotopic bladder substitution. The primary study objective was to report our 35-year clinical experience. MATERIALS AND METHODS: Since October 1985, 259 male patients from a large single center radical cystectomy series with complete followup of more than 60 months (median 121, range 60-267) without recurrence, irradiation or undiversion that might have affected the functional outcome, were included. RESULTS: Median age at radical cystectomy and at survey was 63 (range 23-81) and 75 (range 43-92) years, respectively. Overall 87% of patients voided spontaneously and residual-free. This rate decreased with increasing age at the time of surgery (less than 50 years old 94%, 70 years old or older 82%). Overall day/nighttime continence rates were 90%/82%. These rates decreased with increasing age at the time of surgery from 100%/88% to 87%/80%. The overall pad-free rate was 71%/47%. Bicarbonate use decreased from 51% (5 years) to 19% (25 years). Patients with a followup of more than 20 years had the lowest rate of residual urine and clean intermittent catheterization (0.0%) as well as use of more than 1 pad at daytime/nighttime (6.3%/12.5%) and mucus obstruction (0.0%). Serum creatinine showed only the age related increase. The surgical complication rate was 27% and correlated inversely with functional results (chi-squared 11.227, p <0.005), even when the younger age at the time of surgery (younger than 60 years) was related to higher rates of surgical complications (chi-squared 6.80, p <0.05). CONCLUSIONS: The ileal neobladder represents an excellent long-term option for urinary diversion with an acceptable complication rate.

Urinary Diversion: Core Curriculum 2021.

Urinary diversion after cystectomy has been a historical standard for the treatment of numerous benign and malignant diseases of the bladder. Since the first published description in the early 1900s, improvements in surgical technique and a better understanding of the metabolic sequelae postoperatively have greatly enhanced patient outcomes. Both continent and incontinent diversions are available to patients after cystectomy. In appropriately selected patients, orthotopic neobladder reconstruction can offer preservation of body image and continence, and continent cutaneous diversions represent a reasonable alternative. Conduit diversion, which remains the most commonly performed diversion technique, is ideal for patients who would benefit from a less morbid surgical procedure that negates the need for self-catheterization. This installment of the Core Curriculum in Nephrology outlines numerous aspects of urinary diversion, in which a multidisciplinary approach to postoperative management at the intersection of nephrology and urology is required to effectively optimize patient outcomes. This article includes a discussion of the various reconstructive options after cystectomy as well as a comprehensive review of frequently encountered short-term and long-term metabolic abnormalities associated with altered electrolyte and acid-base homeostasis.

Predictors of need for catheterisation and urinary retention after radical cystectomy and orthotopic neobladder in male patients.

OBJECTIVES: To investigate the prevalence of catheterisation and urinary retention in male patients with bladder cancer after radical cystectomy (RC) and orthotopic neobladder (ONB) and to identify potential predictors. PATIENTS AND METHODS: Using an Institutional Review Board approved, prospectively maintained bladder cancer database, we collected information using a diversion-related questionnaire from 299 consecutive male patients with bladder cancer upon postoperative clinic visit. Urinary retention was defined as ≥3 catheterisations/day or a self-reported inability to void without a catheter. Uni- and multivariable Cox regression analysis was performed to identify predictors of catheterisation and urinary retention. RESULTS: Self-catheterisation was reported in 51 patients (17%), of whom, 22 (7.4% of the total patients) were in retention. Freedom from any catheterisation at 3, 5, and 10 years after RC was 85%, 77%, and 62%, respectively. Freedom from retention at 3, 5, and 10 years after RC was 93%, 88%, and 79%, respectively. Multivariable Cox regression showed that higher body mass index (BMI; ≥27 kg/m2 ) significantly increased the need for catheterisation (hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.26-4.32) as well as retention (HR 5.20, 95% CI 1.74-15.51). Greater medical comorbidity (Charlson Comorbidity Index score ≥2) correlated with the need for any catheterisation (HR 1.84, 95% CI 1.02-3.3), but not retention. Pathological stage and type of diversion were not significant predictors of the need to catheterise or urinary retention. CONCLUSION: In males undergoing RC with ONB, retention requiring catheterisation to void is uncommon. Patients with a BMI of ≥27 kg/m2 are at significantly increased risk of retention and need for self-catheterisation.

Round ligament suspending treatment in orthotopic ileal-neobladder after radical cystectomy in women: a single-centre prospective randomised trial.

OBJECTIVES: To compare the occurrence of emptying dysfunction between surgical techniques for orthotopic neobladder suspended with round ligament (rONB) and the standard procedure (sONB). PATIENTS AND METHODS: A prospective randomised controlled trial was performed in a single centre of female patients undergoing creation of an ONB using rONB or sONB. Patients were followed for ≥24 months after ONB. The primary endpoints were significant post-void residual urine volume (sPVR) and need for clean intermittent catheterisation (CIC) at 24 months postoperatively. The secondary endpoints included early and late complications, urodynamic profile, and ONB continence. RESULTS: Between January 2011 and October 2017, the trial enrolled 85 patients, of whom 82 were randomised. A total of 41 patients had a rONB and 41 a sONB. At 24 months, 17 of the 37 patients with a sONB and nine of the 39 patients with a rONB had a sPVR. The cumulative risk of a sPVR was significantly lower in the rONB group (23.1%) vs the sONB group (45.9%) (hazard ratio [HR] 0.43, 95% confidence interval [CI], 0.19-0.96; P = 0.040). In all, 15 of the 37 patients with a sONB and four of the 39 patients with a rONB needed CIC. The cumulative risk of requiring CIC was significantly lower in the rONB group (10.3%) vs the sONB group (40.5%) (HR 0.22, 95% CI 0.07-0.67; P = 0.008) at 24 months. Multivariable Cox regression analysis also showed that the rONB type was an independently protective factor for sPVR and CIC. The rates of early (0-90 days) and late complication (>90 days) were 54.1% and 13.5% in the sONB group, and 64.1% and 10.3% in the rONB group, respectively. There were no significant differences in complications, urodynamic profile or ONB continence. A major limitation is the small sample size at a single centre. CONCLUSION: Posterior support with round ligament for an ONB significantly improved the emptying of the ONB and resulted in a reduced need for CIC. The surgical modification is a feasible and safe technique without additional complication-related surgeries.

Early continence after ileal neobladder: objective data from inpatient rehabilitation.

PURPOSE: To evaluate early continence of patients who underwent inpatient rehabilitation after radical cystectomy (RC) and orthotopic bladder substitution (ONB). METHODS: We conducted a retrospective analysis on the data of 283 patients who underwent a three weeks inpatient rehabilitation after RC and ONB for bladder cancer between January 2016 and July 2017. All patients were treated with a special multimodal continence therapy. The continence status was evaluated by measuring urine loss by a 24-h pad test and urine volume on uroflowmetry at the beginning (T1) and at the end (T2) of inpatient rehabilitation. Multivariate linear regression analysis was performed to identify independent predictors of urine loss. RESULTS: Median patient age was 63 years. NS was documented for 142 patients (50.2%). Median urine loss decreased significantly (p < 0.001) in the 24-h pad test, from 442 gm at T1 (median 29 days after surgery) to 88 gm at T2 (median 50 days after surgery). Urine volume increased significantly (p < 0.001) from a median of 78 ml at T1 to a median of 157 ml at T2. Age (p = 0.002), diabetes (p = 0.031), obesity (p = 0.003), and nerve sparing (p = 0.011) were identified as independent predictors for urine loss at the end of inpatient rehabilitation. CONCLUSION: Continence improved significantly during the three weeks of inpatient rehabilitation. Younger age, the absence of diabetes or obesity, and NS resulted in better continence in the early postoperative period after ONB.