The impact of chemotherapy-naïve open radical cystectomy delay and perioperative transfusion on the recurrence-free survival: A perioperative parameters-based nomogram.

Objective: To develop and internally validate a nomogram to predict recurrence-free survival (RFS) including the time to radical cystectomy (RC) and perioperative blood transfusion (PBT) as potential predictors. Methods: Patients who underwent open RC and ileal conduit between January 1996 to December 2016 were split into developing (n=948) and validating (n=237) cohorts. The time to radical cystectomy (TTC) was defined as the interval between the onset of symptoms and RC. The regression coefficients of the independent predictors obtained by Cox regression were used to construct the nomogram. Discrimination, validation, and clinical usefulness in the validation cohort were assessed by the area under the curve, the calibration plot, and decision curve analysis. Results: In the developing dataset, the 1-, 5-, and 10-year RFS were 83.0%, 47.2%, and 44.4%, respectively. On multivariate analysis, independent predictors were TTC (hazards ratio [HR] 1.07, 95% confidence interval [CI] 1.05-1.08, p<0.001), PBT (one unit: HR 1.40, 95% CI 1.03-1.90, p=0.03; two or more units: HR 1.72, 95% CI 1.29-2.29, p<0.001), bilateral hydronephrosis (HR 1.54, 95% CI 1.21-1.97, p<0.001), squamous cell carcinoma (HR 0.60, 95% CI 0.45-0.81, p=0.001), pT3-T4 (HR 1.77, 95% CI 1.41-2.22, p<0.001), lymph node status (HR 1.53, 95% CI 1.21-1.95, p<0.001), and lymphovascular invasion (HR 1.28, 95% CI 1.01-1.62, p=0.044). The areas under the curve in the validation dataset were 79.3%, 69.6%, and 76.2%, for 1-, 5-, and 10-year RFS, respectively. Calibration plots showed considerable correspondence between predicted and actual survival probabilities. The decision curve analysis revealed a better net benefit of the nomogram. Conclusion: A nomogram with good discrimination, validation, and clinical utility was constructed utilizing TTC and PBT in addition to standard pathological criteria.

Voiding and renal function 10 years after radical cystectomy and orthotopic neobladder in women.

OBJECTIVES: To assess long-term voiding and renal function (RF) changes after radical cystectomy (RC) and orthotopic neobladder (ONB) surgery in women without disease recurrence. MATERIAL AND METHODS: Women who underwent RC and ONB reconstruction between 1995 and 2011 were included in this study. Patients who developed disease failure or were lost to follow-up were excluded. The study outcomes were long-term voiding function and the incidence and predictors of RF deterioration (defined as >20% decline of baseline). Analysis was performed using the log-rank test and Cox regression analysis. RESULTS: The study included 195 patients with a median (interquartile range) follow-up of 98 (53-151) months, of whom 95 had >10 years of follow-up. Daytime continence, night-time continence and chronic urine retention (CUR) were identified in 170 (87%), 134 (69%) and 52 patients (27%), respectively. Among patients with >10 years of follow-up, 82 (86%), 66 (70%) and 31 (33%) had daytime continence, night-time continence and CUR at the last follow-up visit, respectively. RF deterioration events occurred in 74 patients throughout the follow-up and chronic kidney disease (CKD) stage III-V developed in 80 patients. Patients' age (hazard ratio [HR] 1.41, 95% confidence interval [CI]1.06-1.89; P = 0.02) and serous-lined extramural tunnel diversion (HR 0.43, 95% CI 0.19-0.86; P = 0.02) were the independent predictors of RF deterioration. Among patients with >10 years of follow-up, RF deteriorated in 46 patients (49%) and CKD stage III-V developed in 40 (42%). CONCLUSION: Women surviving more than 10 years after RC and ONB maintained acceptable continence status, apart from having a higher CUR rate, compared to those followed for <10 years. However, RF deterioration developed in nearly half of them.

Predictors and survival benefit of achieving pentafecta in a contemporary series of open radical cystectomy.

BACKGROUND: Pentafecta provides a comprehensive approach for standardized reporting of surgical and oncologic outcomes after radical cystectomy and urinary diversion. We aimed to report the rate, predictors of achieving pentafecta and its impact on long-term survival in a contemporary series of open radical cystectomy (ORC). METHODS: A retrospective analysis of a computerized database of patients treated with ORC between 2004 till 2014 was performed. Pentafecta criteria included negative soft tissue surgical margin (STSM), retrieval of ≥16 lymph nodes, absence of clinical recurrence within 12 months after surgery, absence of high-grade complication (GIII-V) within 90 days after surgery, and absence of urinary diversion related complications at 12 months follow-up. Multivariate analysis was used to identify predictors of achieving pentafecta. RESULTS: Pentafecta was achieved in 545 (33.6%) patients out of 1624 included in the study. Absence of ≥16 LN yield was the first cause of missing pentafecta (49.5%). Multivariate analysis identified: ASA Score grades ≥III (OR=0.7, 95%CI 0.6-0.9, P=0.04), BMI≥35 (OR=0.5, 95%CI 0.3-0.8, P=0.007), perioperative blood transfusion (≥4 units) (OR=0.5, 95%CI 0.3-0.7, P=0.001), and ileal conduit (OR=0.7, 95%CI 0.5-0.9, P= 0.01) as independent predictors of missing pentafecta. Patients who achieved pentafecta had higher estimated 5-year RFS than their counterparts (81.7% vs. 62.5%; P<0.0001). CONCLUSIONS: Pentafecta was achieved in nearly one third of patients after ORC. Achievement of pentafecta was associated with better long-term recurrence-free survival. Obesity (class II, III), perioperative blood transfusion (>4 units), associated comorbidities, and ileal conduit were independent predictors of missing pentafecta.

Parastomal hernia after ileal conduit urinary diversion: re-visiting the predictors radiologically and according to patient-reported outcome measures.

PURPOSE: To evaluate the predictors of post-ileal conduit (IC) parastomal hernia (PSH) based on a standard grading methodology and according to the patients reported outcome measures (PROM). METHODS: A prospective evaluation for patients with IC attending their scheduled follow-up was conducted between December 2013 and October 2015. The hernia stage was determined according to the European Hernia Society (EHS) classification as types I and II included defect size < 5 cm without and with a concomitant incisional hernia, respectively. Types III and IV included defect size > 5 cm without and with a concomitant incisional hernia (high-grade hernia). The evaluation was performed by a non-contrast CT scan. PROM were defined as symptomatic if there were hernia-related abdominal discomfort, appliance problems, and/or bowel complications. Perioperative parameters were modeled for prediction of high-grade and PROM outcomes. RESULTS: PSH was diagnosed in 138 (39.9%) patients, symptomatic in 119 (34.4%) and high-grade in 59 (17%). Independent predictors of radiologically diagnosed PSH were hypoalbuminemia (odds ratio [OR]: 1.7; 95% Confidence interval [CI]: 1.1-2.7; p = 0.02), localised disease (OR: 0.6; 95% CI: 0.3-0.9; p = 0.04) and negative lymphadenopathy (OR: 0.4; 95%CI: 0.2-0.8; p = 0.004). Predictors of symptomatic PSH were hypoalbuminemia (OR: 2; 95%CI: 1.2-2.3: p = 0.003) and previous hernia surgery (OR: 2.1; 95%CI: 1.1-4.2; p = 0.024). CONCLUSIONS: Only a small proportion of patients with PSH were asymptomatic. Preoperative hypoalbuminemia was the most significant factor contributing to the development and symptomatizing of PSH. Previous hernia surgery further contributed to the patient complaint.

Chronic urinary retention after radical cystectomy and orthotopic neobladder in women: Risk factors and relation to time.

PURPOSE: To investigate the long-term cumulative incidence of chronic urinary retention (CUR) after radical cystectomy (RC) and orthotopic neobladder (ONB) in women and the possible risk factors. MATERIAL AND METHODS: We retrospectively analyzed a prospectively evaluated cohort of women for whom RC and ONB were performed. Patients in CUR were evaluated for the cumulative incidence of CUR using Kaplan-Meier curve and for the possible risk factors using log rank and Cox regression analysis. RESULTS: A total of 234 women with mean age ± SD of 52.3 ± 9 years and a median (range) of follow-up of 92 (12-247) months were included. The incidence of CUR increased with time, where 12 (5.2%), 21 (8.97%), 35 (14.9%), 53 (22.6%), and 56 (24%) patients started clean intermittent catheterization in 1, 2, 2 to 5 years, 5 to 10 years, and after 10 years of follow-up, respectively. In univariate and multivariate analysis, diabetes mellitus and urethral Kock pouch were independent predictors of CUR development (HR [95% CI] = 2.45 [1.2-5.1], and 2.1 [1.05-4.2], P = 0.01 and 0.03, respectively). Genital- sparing RC and surgical modification to provide pouch back support were independent factors that reduce CUR development (HR [95% CI] = 9.3 [1.25-69.9], and 2.1 [1.19-3.9], P = 0.02 and 0.01, respectively). CONCLUSION: The incidence of CUR after RC and ONB in women increases with time even after 10 years of follow-up. Presence of diabetes mellitus increases the risk of CUR development. Genital-sparing RC and modification to prevent CUR reduced the likelihood of CUR development.

External stent versus double J drainage in patients with radical cystectomy and orthotopic urinary diversion: A randomized controlled trial.

OBJECTIVES: To compare treatment-related outcomes of ureteral stenting with an external versus double J stent in patients with orthotopic reservoirs after radical cystectomy. METHODS: Patients undergoing radical cystectomy and orthotopic neobladder were randomized into two groups; group I patients received external stents, whereas group II received double J stents. In both groups, preoperative parameters were recorded, and patients were assessed regarding urinary tract infection, urinary leakage, upper tract deterioration, readmission and hospital stay. RESULTS: A total of 48 and 45 patients were randomized in the external stent group and double J group, respectively. Both groups were comparable in terms of age, sex, associated comorbidity and oncological status. Early urinary leak was observed in two patients (4.2%) in the external stent group, and in two patients (4.4%) in the double J group (P = 0.95). None of our patients developed ureteral strictures in the external stent group, and one patient did in the double J group (P = 0.3). Positive urine culture (58.3%, 51.1%) as well as febrile urinary tract infections (2.1%, 6.7%) were comparable between both groups, respectively (P = 0.43, 0.28). Wound complications (12.5%, 8.9%) and stent-related complications (2.1%, 0%) were comparable between both groups, respectively (P = 0.57, 0.33). The mean hospital stay was 17.5 days (range 14-32 days) and 14.6 days (range 10-42 days) in both groups, respectively (P = 0.001), with comparable re-admission rates (P = 0.95). CONCLUSIONS: Incorporation of double J stents in orthotopic urinary diversion is a safe alternative to the routinely used external stenting.

Treatment and outcomes of urethral recurrence of urinary bladder cancer in women after radical cystectomy and orthotopic neobladder: a series of 12 cases.

INTRODUCTION: The incidence, treatment, and outcome of urethral recurrence (UR) after radical cystectomy (RC) for muscle-invasive bladder cancer with orthotopic neobladder in women have rarely been addressed in the literature. PATIENTS AND METHODS: A total of 12 patients (median age at recurrence: 60 years) who experienced UR after RC with an orthotopic neobladder were selected for this study from a cohort of 456 women from participating institutions. The primary clinical and pathological characteristics at RC, including the manifestation of the UR and its treatment and outcome, were reviewed. RESULTS: The primary bladder tumors in the 12 patients were urothelial carcinoma in 8 patients, squamous cell carcinoma and adenocarcinoma in 1 patient each, and mixed histology in 2 patients. Three patients (25%) had lymph node-positive disease at RC. The median time from RC to the detection of UR was 8 months (range 4-55). Eight recurrences manifested with clinical symptoms and 4 were detected during follow-up or during a diagnostic work-up for clinical symptoms caused by distant metastases. Treatment modalities were surgery, chemotherapy, radiotherapy, and bacillus Calmette-Guérin urethral instillations. Nine patients died of cancer. The median survival after the diagnosis of UR was 6 months. CONCLUSIONS: UR after RC with an orthotopic neobladder in females is rare. Solitary, noninvasive recurrences have a favorable prognosis when detected early. Invasive recurrences are often associated with local and distant metastases and have a poor prognosis.

Diagnosis, treatment and need for hysterectomy in management of postcaesarean section vesicouterine fistula.

OBJECTIVE: The aims of this study were to report the diagnosis, treatment and functional consequences of postcaesarean section vesicouterine fistula (VUF), and to investigate the need for hysterectomy. MATERIAL AND METHODS: The study included 22 cases with VUF after caesarean section (mean age 30.5 years) between 1999 and September 2012. Total urinary incontinence was found in seven women, occasional incontinence in 15 and cyclic haematuria in 17. VUF was diagnosed by ascending cystography in 14 patients and by computed tomography/magnetic resonance imaging in six. Cystoscopy revealed VUF in all women. VUF repair was conducted by a transabdominal approach. The bladder was opened, the fistula was defined, a circumferential bladder incision was made around the fistula and the fistulous tract was excised. The uterine rent and bladder were closed with omentum interposition. RESULTS: Mean follow-up was 2.8 years (range 0.5-7 years). The repair was successful in all women. Hysterectomy was needed in only one case with dysfunctional uterine bleeding and an enlarged uterus. The incontinence disappeared in all cases. The menstrual cycle became regular after a mean of 5 months in all women who retained their uterus. Five women became pregnant and had a successful delivery after 2-3 years. All women were able to have sexual intercourse after 2 weeks. CONCLUSIONS: Cystoscopy was the mainstay of diagnosis of VUF in the current study. Imaging was not able to show very small fistulae. Unless otherwise indicated, there is no need to remove the uterus even if the fistula is large. Although the repair is challenging, it was successful in all cases and pregnancy is possible after repair.

Renal function evaluation in patients undergoing orthotopic bladder substitution: a systematic review of literature.

Renal function (RFn) after orthotopic bladder substitution (OBS) is a critical point to be assessed. We performed a systematic review of MEDLINE for full length peer reviewed English articles from the year 2000 till January 2013. We included only original articles and excluded reviews, editorials and replies and abstracts presented in conferences. The outcome is formulated in research questions; what is the status of RFn after OBS? Which is better, the direct free-refluxing or anti-refluxing ureteroileal anastomosis (UIA) techniques? Studies reporting RFn as secondary outcome were also reported. A total of 129 publications were reviewed for full text and only 41 were included in this review. All studies were of low level of evidence and grade of recommendations. Only 3 randomized controlled trials were included and were of poor quality. Renal function after OBS was poorly described in the literature with no universal definition about RFn deterioration or outcome with no consensus on the best evaluation method. Urinary obstruction, chemotherapy and pyelonephritis appeared significant factors but with insufficient evidence. There is a universal trend to use the free refluxing technique for UIA to avoid complications of anti-refluxing techniques. However, the anti-reflux technique proved acceptable outcome in experienced hands. There is marked heterogeneity and underestimation of RFn evaluation among reported outcomes after OBS with most publications reporting the incidence of UIA and pyelonephritis with paucity reporting absolute figures about RFn measurements. In conclusion, urinary tract obstruction remains the main factor of RFn deterioration after OBS. Methods evaluating RFn, definitions of RFn outcome and factors predicting it are poorly studied in the literature and the current evidence is relatively weak to draw solid conclusions. Further well-designed studies and consensus about method of assessment and definitions of RFn are warranted.

Impact of the type of ureteroileal anastomosis on renal function measured by diuretic scintigraphy: long-term results of a prospective randomized study.

OBJECTIVE: To determine the long-term effects of the direct refluxing-type ureteroileal anastomosis technique with those of an antireflux technique on individual renal units, using diuretic scintigraphy in a prospectively randomized study. PATIENTS AND METHODS: Between 2002 and 2006, a prospective randomized study was conducted on 102 patients undergoing radical cystectomy and urinary diversion. In every patient, both ureters were randomized to be implanted using a direct refluxing technique or an antireflux, serous-lined extramural tunnel (SLET) technique. Renal function (RF) was evaluated using (99m)Tc-MAG-3 diuretic scintigraphy. The serial changes in corrected glomerular filtration rate (cGFR) for each technique and for each side were compared. RESULTS: Over a median follow-up of 6 years, the patients in both the direct refluxing and the SLET technique groups were found to have a significant reduction in mean (SD) cGFR between baseline and last follow-up: cGFR decreased from 59.4 (12.4) to 45.6 (15.3) mL/min (P < 0.001) and from 54.3 (11.2) to 46.3 (12.8) mL/min (P = 0.002), respectively. Five patients (4.9%) in the SLET group developed obstruction (four left-sided and one right-sided) compared with one (0.9%) in the direct refluxing group (right-sided). The onset of obstruction was noted 1-7 months after radical cystectomy. There was no significant difference between the groups in reductions in cGFR across the timepoints. Comparison of the two techniques according to the side of ureter implantation showed that the direct refluxing technique trended towards better functional outcomes on the left side. CONCLUSIONS: There was no observed difference in the RF of individual renal units between the SLET and the direct refluxing groups in the long term. The need to incorporate an antireflux technique should be questioned and tailored according to the surgeon's experience and confidence.

Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines.

OBJECTIVE: To assess the outcome of the drainage procedure used for treating a prostatic abscess, and to propose a treatment algorithm to reduce the morbidity and the need for re-treatment. Patients and methods We retrospectively reviewed patients who were admitted and received an interventional treatment for a prostatic abscess. All baseline relevant variables were reviewed. Details of the intervention, laboratory data, duration of hospital stay, follow-up data and re-admissions were recorded. RESULTS: A prostatic abscess was diagnosed in 42 patients; 30 were treated by transurethral deroofing and 12 by transrectal needle aspiration. The median (range) size of the abscess was 4.5 (2-23) mL and 2.7 (1.5-7.1) mL in the deroofing and aspiration groups, respectively (P = 0.2). In half of the cases multiple abscesses were evident on imaging before the intervention. The median (range) hospital stay after deroofing and aspiration was 2 (1-11) and 1 (1-19) days, respectively (P = 0.04). Perioperative complications occurred only in the deroofing group, in which two patients developed septic shock requiring intensive care (Clavien 4) and one developed epididymo-orchitis (Clavien 2). There were two late complications in the deroofing group, in which one patient developed a urethral stricture that required endoscopic urethrotomy (Clavien 3a) and one developed a urethral diverticulum and urinary incontinence that required diverticulectomy and a bulbo-urethral sling procedure (Clavien 3b). A urethro-rectal fistula developed after aspiration in one patient. Re-treatment for the abscess was indicated in two (7%) patients in the deroofing group, which was treated by aspiration. CONCLUSION: Transrectal needle aspiration for a prostatic abscess, when done for properly selected cases, could minimise the morbidity of the drainage procedure.

Accuracy of multi-detector computed tomography (MDCT) in staging of renal cell carcinoma (RCC): analysis of risk factors for mis-staging and its impact on surgical intervention.

OBJECTIVES: To assess the accuracy of multi-detector computed tomography (MDCT) in preoperative staging of renal cell carcinoma (RCC) and to detect the possible risk factors for mis-staging. In addition, the impact of radiological mis-staging on surgical decision and operative procedures was evaluated. MATERIALS AND METHODS: Data files of 693 patients, who underwent either radical or partial nephrectomy after preoperative staging by MDCT between January 2003 and December 2010, were retrospectively reviewed. Radiological data were compared to surgical and histopathological findings. Patients were classified according to 2009 TNM staging classification. Diagnostic accuracy per stage and its impact on surgical intervention were evaluated. RESULTS: The overall accuracy was 64.5%, and over-stage was detected in 29.5% and under-stage in 6%. Sensitivity and specificity were highest in stage T3b (85 and 99.5%, respectively), while T4 showed the lowest sensitivity and PPV (57 and 45%). Degree of agreement with pathological staging was substantial in T1 (κ = 0.7), fair in T2 (κ = 0. 4), perfect in T3b (κ = 0.81), and slight for the other stages (κ = <0.1). On multivariate analysis, conventional RCC and tumor size > 7 cm represent the significant risk factors (RR: 1.6, 95% CI: 1.1-2.3, P < 0.004 and RR: 2.4, 95% CI: 1.7-3.5, P < 0.001, respectively). Mis-staging was seen to have no negative impact on surgical decision. CONCLUSIONS: MDCT is an accepted tool for renal tumor staging. Tumor mis-staging after MDCT is of little clinical importance. Large tumor size >7 cm and conventional RCC are risk factors for tumor mis-staging.

Survival after primary and deferred cystectomy for stage T1 transitional cell carcinoma of the bladder.

CONTEXT: The optimal time of cystectomy for nonmuscle invasive bladder cancer (NMIBC) is controversial. AIM: This study aims at comparing cancer-specific survival in primary versus deferred cystectomy for T1 bladder cancer. SETTINGS AND DESIGN: Between 1990 and 2004, a retrospective cohort of 204 patients was studied. MATERIALS AND METHODS: Primary cystectomy at the diagnosis of NMIBC was performed in 134 patients (group 1) and deferred cystectomy was done after failed conservative treatment in 70 (group 2) Both groups were compared regarding patient and tumor characteristics and cancer-specific survival. STATISTICAL ANALYSIS USED: Cancer-specific survival was calculated using the Kaplan-Meier method. RESULTS: Mean follow-up was 79 and 66 months, respectively, in the two groups. Tumor multiplicity was more frequent in group 2; otherwise, both groups were comparable in all characteristics. The definitive stage was T1 in all patients. Although the 3-year (84% in group 1 vs. 79% in group 2), 5-year (78% vs. 71%) and 10-year (69% vs. 64%) cancer-specific survival rates were lower in the deferred cystectomy group, the difference was not statistically significant. In group 2, survival was significantly lower in cases undergoing more than three transurethral resections of bladder tumors (TURBT) than in cases with fewer TURBTs. CONCLUSIONS: Cancer-specific survival is statistically comparable for primary and deferred cystectomy in T1 bladder cancer, although there is a non-significant difference in favor of primary cystectomy. In the deferred cystectomy group, the number of TURBTs beyond three is associated with lower survival. Conservative treatment should be adopted for most cases in this category.

Radical cystectomy and urinary diversion in women: impact on sexual function.

OBJECTIVE: The aim of this study was to assess the impact of radical cystectomy and different forms of urinary diversion on female sexual function. MATERIAL AND METHODS: Seventy-three consecutive patients were included in the study. The mean age was 52.3 ± 6.5 years. All of them had undergone non-nerve-sparing radical cystectomy and urinary diversion for invasive bladder cancer. Patients were questioned about their current general relations with their husbands in comparison to the preoperative status. The Female Sexual Function Index (FSFI) was used to assess libido, lubrication, orgasm, satisfaction and painful sexual dysfunction. Patients were asked about any urinary complaints during or after sexual intercourse. RESULTS: Twenty-nine patients (39%) reported worsening relations with their husbands. The mean frequency of sexual relations was 2.3 ± 2.3/month; however, sexual relations had ceased completely in 19 patients (26%). Overall satisfaction among sexually active women worsened in 32 (59.2%) and was completely lost in eight patients (14.8%). Absent libido, difficult intromission, dyspareunia, lack of orgasm and sexually related urinary complaints were reported in 89%, 63%, 48%, 63% and 63% of patients, respectively. The mean FSFI score dropped significantly from 18.3 ± 5.1 to 11.3 ± 7.4 postoperatively (p < 0.001). FSFI scores were significantly higher among patients with orthotopic versus non-orthotopic forms of diversion and also higher among patients with no stoma versus those with stomal forms of diversion. CONCLUSIONS: Radical cystectomy and urinary diversion have deleterious impacts on all domains of female sexual function. Female patients with orthotopic and non-stomal diversions had better sexual functions than those with stomal diversions.

Vascular endothelial growth factor, p53, and the H-ras oncogene in Egyptian patients with bladder cancer.

AIM: To evaluate the relationship between vascular endothelial growth factor (VEGF), p53, and the H-ras oncogene and different clinicopathological parameters in Egyptian patients with Schistosoma-associated transitional cell carcinoma of the bladder. METHODS: The study included 50 patients with transitional cell carcinoma for whom radical cystectomy and urinary diversions were carried out. VEGF and p53 protein expressions were evaluated with an immunohistochemical staining method, and H-ras oncogene mutations were analyzed with a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. RESULTS: High grade tumors revealed higher p53 immunostaining than low grade tumors (P = 0.016). p53 and VEGF protein expressions, as well as H-ras oncogene mutations, had an insignificant impact on patient outcomes (P = 0.962, P = 0.791, and P = 967, respectively). Cancer extension to regional lymph nodes was associated with poor outcomes (P = 0.008). CONCLUSION: VEGF, p53 and the H-ras oncogene have no relation to patient survival and outcome in Schistosoma-associated transitional cell carcinoma.

Surgical complications following radical cystectomy and orthotopic neobladders in women.

PURPOSE: Orthotopic neobladders have become the standard of care after radical cystectomy in select women with bladder cancer. We report early and late complications in 192 patients. Although medical complications were important, they were not the focus of this study. MATERIALS AND METHODS: Between January 1995 and December 2003, 192 women with a mean age of 50.6 years received an orthotopic neobladder after radical cystectomy for bladder cancer. Standard radical cystectomy was done. Ileal reservoirs were used, mostly in the form of an ileal W-neobladder. We evaluated the patients for functional outcome, early and late complications, and treatment for these complications. RESULTS: Two patients (1%) died of pulmonary embolism 1 to 2 weeks after cystectomy. Followup was 6 to 125 months (mean 54). Early complications included hemorrhage requiring reexploration in 1 case, postoperative blood transfusion in 1, wound infection in 8, prolonged ileus in 5, deep vein thrombosis in 5, pouch-vaginal fistula in 6, prolonged urinary leakage in 3, pouch-cutaneous fistula in 1 and early ureteral obstruction in 1. Of the 177 patients eligible for functional evaluation 62 experienced a total of 75 late complications, including stone disease in 18, ureteroileal stricture in 19, reflux in 22, intestinal obstruction in 2, incisional hernia in 2 and chronic pyelonephritis in 12. Early and late complications were treated accordingly with good outcomes. CONCLUSIONS: Early and late complications develop in a significant number of patients. Most early complications may be treated conservatively, while late complications are mostly treated with endourological and/or open surgery. Close lifelong surveillance of patients is mandatory to detect and properly treat these complications.

Percutaneous treatment of large upper tract stones after urinary diversion.

OBJECTIVES: To present our experience in percutaneous management of large upper tract stones after urinary diversion. METHODS: From October 1984 to March 2005, 20 percutaneous nephrolithotomy and 4 antegrade ureteroscopy procedures were performed in 17 men and 7 women, with a mean age of 53.5 years. The urinary diversions were an ileal W neobladder, hemi-Kock pouch, ileal conduit, and rectal bladder in 10, 7, 4, and 3 patients, respectively. The median interval between diversion and stone management was 1.5 years. Success was defined as a stone-free, nonobstructed renal unit at 3 months after the intervention. Follow-up was performed every 6 months with intravenous urography or noncontrast computed tomography for diagnosis of stone recurrence and evaluation of renal morphology. RESULTS: Renal punctures were guided with ultrasonography in 18 patients (75%) and fluoroscopy in 6 patients. One intraoperative complication (4.16%) and two postoperative complications (8.3%) occurred. All patients with ureteral stones became stone free after one procedure. Auxiliary procedures were needed in 5 patients after percutaneous nephrolithotomy; 2 patients required a second session and 3 needed extracorporeal shock wave lithotripsy. The overall success rate was 87.5% (21 patients). One patient with treatment failure underwent open surgery, and two with small residual fragments were followed up. Long-term follow-up data were available for 15 patients. The stone recurrence rate was 33.3% (5 patients) after a median follow-up of 40 months (range 14 to 132). Recurrent stones were treated with extracorporeal shock wave lithotripsy. CONCLUSIONS: The results of our study have demonstrated that percutaneous treatment of large upper tract stones after urinary diversion offers a high success rate with minimal morbidity. However, regular follow-up after treatment is recommended.

Urological trauma after gynecological and obstetric surgeries.

OBJECTIVE: Gynecological and obstetric surgeries are not uncommon causes of iatrogenic injury of the urinary tract. Herein, we retrospectively report our experience with these injuries over the last 18 years. MATERIAL AND METHODS: Between 1985 and 2003, 120 females (mean age 34.2+/-13.7 years) were included in this study. The types of injury were as follows: vesicovaginal fistula, n=90; ureterovaginal fistula, n=14, ureteric ligation, n=13, vesicouterine fistula, n=2; and ureterouterine fistula, n=1. Definitive repair of such injuries was performed in all cases, including 10 cases of recurrent vesicovaginal fistulae which were treated by means of augmentation cystoplasty or urinary diversion. All patients were evaluated regarding the time and type of surgical intervention and early and late postoperative complications, including failure of primary repair. RESULTS: Of the 80 cases of vesicovaginal fistulae treated with definitive repair, 12 (13.3%) showed recurrence of the fistula. Early ureteric deligation and early or delayed ureteroneocystostomy or ureteric replacement were successful in all cases with ureteric injury. There was no loss of kidney function following the trauma or its repair. CONCLUSIONS: It is mandatory for gynecologists and obstetricians to pay careful attention to the anatomy of the urinary tract in order to avoid its iatrogenic injury. Endourologic means were successful in enabling first aid management of some of these injuries. Early exploration is indicated in cases of ureteric obstruction that present early after trauma. Augmentation cystoplasty, urinary diversion or ileal replacement are indicated in only a few cases.

Urethral pressure profile following orthotopic neobladder: differences between nerve sparing and standard radical cystectomy techniques.

PURPOSE: Some authors reported that adopting a nerve sparing technique during radical cystoprostatectomy improves the continence outcome of orthotopic diversion in patients with invasive bladder carcinoma. We urodynamically evaluated the effect of nerve sparing cystoprostatectomy on external urethral sphincteric function. MATERIALS AND METHODS: A total of 30 consecutive male patients who underwent nerve sparing cystoprostatectomy and ileal neobladder (NS group) were compared to a control group of 30 patients who underwent a similar procedure but without nerve sparing (non-NS group). Continence status was thoroughly clinically evaluated in parallel to erectile function in both groups. The urethral sphincteric mechanism was evaluated with urethral pressure profilometry in different positions. RESULTS: Better urethral pressure profile parameters were found in patients in the NS group. Significantly longer functional urethral length (34.8 mm) was detected in NS group than in the non-NS group (30.1 mm). Moreover, the maximum urethral pressure was higher in the NS group but not to a statistically significant level. In the NS group there were no statistically significant differences between potent and impotent subgroups regarding the continence rate or urethral pressure parameters. CONCLUSIONS: There is urodynamic evidence that the nerve sparing technique improved urethral sphincteric function and, consequently, the continence rate. The denervated, most proximal part of the urethra in non-NS cases with lack of contraction and, therefore, any pressure, is a possible explanation for the difference in UPP.

A randomized study comparing an antireflux system with a direct ureteric anastomosis in patients with orthotopic ileal neobladders.

OBJECTIVE: To assess the benefit of an antireflux system in patients with orthotopic ileal neobladders, as there is controversy about whether reflux prevention offers any advantages. PATIENTS AND METHODS: We conducted a randomized prospective study between January 2002 and March 2004, on 60 patients (53 men and seven women) with a mean (sd) age of 52.7 (7.3) years, who were candidates for orthotopic neobladders. Patients with comorbidities were excluded. Preoperative evaluation included intravenous urography (IVU), cystoscopic biopsy and radioisotope renography to evaluate the differential glomerular filtration rates (GFRs). Cases with normal kidneys and ureters, and with similar GFRs, were enrolled. Surgery comprised a standard radical cystectomy with pelvic lymphadenectomy. The ureters were randomized to either a direct anastomosis into a 5-cm ileal chimney on one side, or to be implanted using the antireflux serous-lined extramural tunnel on the contralateral side in the same patient. Regular follow-up included IVU and renography every 6 months in cancer-free patients. RESULTS: The mean (sd) follow-up was 23 (9.6) months. There was prolonged urinary leak from a refluxing ureter in one patient that was treated with a temporary percutaneous nephrostomy. Symptomatic pelvic collections required tube drainage in six cases. Six ureters developed early anastomotic strictures (one direct and five antirefluxing), and were treated with endoscopic ureterotomy in three and open revision in three. Serum creatinine levels were normal in all patients throughout the observation period. GFRs were similar in the two groups. The mean GFRs before surgery and at 6, 12, 18, and 24 months after cystectomy were: 55.1, 50.7, 49.4, 52.2 and 53.9 mL/min for the direct side; and 56.1, 53, 52.4, 53.2 and 50.4 mL/min for renal units with antirefluxing implantation. There was a significant deterioration of the GFRs due to anastomotic strictures, from 48.6 (6.7) mL/min before surgery to 31.8 (15.9) mL/min after the revision (P = 0.01). CONCLUSIONS: The antireflux procedures were associated with a higher incidence of anastomotic strictures than the direct methods and there was a significant deterioration of renal function after obstruction. The long-term follow-up data are awaited.