Outcome of small versus big capacity Hautmann neobladder reconstruction: A prospective randomized study - a 5-year follow up.

BACKGROUND: Orthotopic urinary diversion is the preferred diversion after cystectomy. Neobladder reconstruction with a longer ileum segment (60 cm) is advantageous for obtaining a large capacity and continence at the beginning; however, the long-term risk of residual urine, chronic infection, and the need for intermittent catheterization is more pronounced with the neobladder constructed with a longer ileal segment compared to the neobladder tailored from the shorter ileal segment. OBJECTIVE: To establish the differences in the functional outcome of a shorter (< 45 cm) and longer (⩾ 45 cm) ileal segment usage in the reconstruction of the Hautmann ileal neobladder following the radical cystectomy. METHODS: Between July 2013 and September 2015, 121 patients with muscle-invasive bladder cancer underwent radical cystectomy and Hautmann ileal neobladder reconstruction. Patients were divided into two groups, depending on the length of the ileum used for the diversion creation: < 45 cm of the ileum was used in the first group and ⩾ 45 cm in the second group. Five-year follow-up was performed at 1, 3, 6, and 9 months and 1 and 5 years. The main measured outcomes were functional outcomes and the quality of life. The evaluation included clinical, laboratory, and QLQ-C30 questionnaires. Statistical analysis was performed using descriptive statistics, Mann-Whitney U test, Kolmogorov-Smirnov test, ANOVA, and chi-squared tests. RESULTS: Patients with a smaller neobladder had a better quality of life, and higher global health status scale score. Thirteen early and 21 late complications developed in 10 and 17 patients, respectively. There were significant differences in the need for clean intermittent self-catheterization (CIC) between the two groups: smaller-volume pouch patients had statistically decreased need for CIC in 5 year follow-up compared to larger-volume pouch patients (χ2 test = 8.245; df = 1; P= 0.004). Eighteen percent of patients with smaller neobladders had urinary tract infections in 5 years, compared to 35% with larger neobladders (χ2 test = 4.447; df = 1; P= 0.034). CONCLUSION: Minimizing the length of the ileal segment needed for Hautmann neobladder reconstruction is feasible and provides better long-term results than larger-volume neobladders.

[Urinary diversion with or without simple cystectomy as a salvage option for benign diseases of the lower urinary tract]. / Harnableitungen mit oder ohne simple Zystektomie in der Salvage-Therapie benigner Erkrankungen des unteren Harntraktes.

Benign diseases of the lower urinary tract can occur as a result of oncological or neurological diseases or their respective therapies (e.g., surgery or radiation treatment) and can significantly reduce the quality of life for affected patients. Urinary diversion serves as a salvage option when all other therapeutic regimens have been carried out and proven unsuccessful. When selecting the suitable urinary diversion, a comprehensive clinical assessment of the patients is required in order to ensure long-term success. In some cases, a cutaneous, catheterizable pouch offers the last and only option for a long-term and definitive treatment of a patient's condition. Overall, a decreasing trend in the establishment of a continent urinary diversion is observed in Germany. Current data on benign indications for urinary diversion are limited. Therefore, further data collection and research are needed.

[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.

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.

Urological outcome with the use of salvage continent vesicostomy in pediatric reconstructive surgery. A single tertiary center experience.

PURPOSE: To report our experience and results in terms of complications, reoperation rate and urinary continence with the Salvage Continent Vesicostomy (SCV) technique in pediatric patients with history or need of enterocystoplasty and absent appendix. METHODS: Retrospective review of all patients with a history of a continent catheterizable channel surgery performed in our institution between June 2016 and January 2022. Only patients with a SCV surgery with a minimum 6-month post operative follow up were included in this cohort and divided in group 1 (history of previous bladder augmentation) and group 2 (simultaneous bladder augmentation and SCV). Primary outcome of the study was to assess both continence and postoperative complication rates. Early complications were assessed using the Clavien-Dindo classification (I-V). Late complications were focused on the need of further subfascial revision. RESULTS: 84 patients with a history of a continent stoma creation surgery were identified. In 20 of them (12 males) a SCV was performed. The mean age at surgery was 10.38 (range 4.87-15.6) years and the median postoperative follow-up time was 32 (range 6-64) months. Eleven patients were included in Group 1, while 9 patients in Group 2. Early complications occurred in 4 patients (20%), two of them required a re-intervention (Clavien-Dindo IIIb). Stoma subfascial revision was further required in 2 patient (10%). Continence rate at last follow up was 95%. CONCLUSIONS: In our early experience, the salvage continent vesicostomy has proven to be a simple continent stoma technique with acceptable both continence and complication rates that can be used in selected patients with a history or need of bladder augmentation and absent appendix.

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.

Functional evaluation of a spiral neobladder with an angled chimney; A prospective randomized comparative study.

OBJECTIVES: to assess the functional outcome of performing ureteric re-implantation to an angled short chimney in a modified spiral orthotopic ileal neobladder. PATIENTS AND METHODS: From January 2018 to December 2020, 90 male patients with bladder cancer underwent radical cystectomy and spiral ileal neobladder reconstruction with a chimney. Patients were randomly divided in two groups according to the position of the chimney [straight and angled] to which the ureters will be implanted. Postoperative evaluation included clinical, laboratory, radiographic and urodynamic studies. RESULTS: There were no perioperative deaths. The mean operative time for the procedure was 4.7 ± 1.2 h in group I and 4.9 ± 1.3 h in group II (p 0.456). No intraoperative complications occurred. Early postoperative complications occurred in 8 patients. In group I, according to the modified Clavien system, GII complication occurred in 2 (5%) patients in the form of DVT in 1 (2.5%) and surgical site infection in 1 (2.5%). GIIIa occurred in 3 (7.5%) patients in the form of wound dehiscence. In group II, GII occurred in 2 (4.8%) patients in the form of prolonged urinary leakage and myocardial infarction, each occurred in one patient. GIIIb occurred in 1 (2.4%) patient in the form of intestinal leak. Poucho-ureteral reflux occurred in 10 patients [3 (7.5%) in group I and 7 (16.8%) in group II (p 0.001)]. CONCLUSIONS: The preliminary results of the right sided angled chimney during neobladder reconstruction are safe, acceptable, without an extra time to develop an anti-reflux technique and without an increased incidence of reflux.

Initial Experience With Extraperitoneal Laparoscopic Radical Cystectomy With Pelvic Organ-Preserving and Orthotopic Neobladder Techniques for Bladder Cancer in Female Patients.

OBJECTIVE: To present the extraperitoneal laparoscopic radical cystectomy (ELRC) technique, and initial outcomes of organ-preserving and orthotopic neobladder (ONB) techniques for bladder cancer in selected females. MATERIALS AND METHODS: Data including patient characteristics, operative time, blood loss, transfusion rate, length of hospital stay, and pathologic outcomes, as well as 30- and 90-day complications were collected between April 2018 and May 2021 from females who underwent ONB after ELRC. Regular follow-up focused on patients' oncological and functional outcomes, and postoperative sexual function status was assessed using the Female Sexual Function Index (FSFI). RESULTS: Eleven females with a mean age of 53 years who underwent ELRC with pelvic organ-preservation and ONB were analyzed retrospectively. All procedures were completed successfully. The mean operative time was 264.82 ± 33.81 min, and the average intraoperative blood loss was 128 ± 18.19 mL. All patients had negative pathological margins and no lymph node metastases. The average hospital stay was 10.72 days. The single J ureteral stent and catheter were usually removed 3-4 weeks after the procedure. The FIFS assessment of postoperative sexual function showed that the patients were relatively satisfied. CONCLUSION: ELRC with pelvic organ preservation and ONB technology was a safe and feasible surgical strategy for the selected female patients. Preserving organs and vascular nerve bundles seemed to be safe in oncological and produced encouraging functional results. Further rigorous prospective studies with more patients and long-term follow-up data are needed to assess the oncologic and functional results.

[A noteworthy case: An atypically located urachal cyst after continent urinary diversion using a MAINZ pouch with an appendix stoma]. / Ein bemerkenswerter Fall: Eine atypisch gelegene Urachuszyste nach kontinenter Harnableitung mittels MAINZ-Pouch mit Appendixstoma.

This case presents a 29-year-old man, with a urinary diversion via MAINZ Pouch I after cystectomy due to trauma in early childhood with a history of multiple previous surgeries. The reason for the presentation was a non-specific paraumbilical swelling on the right, which was disturbing for him. Despite further diagnostics by means of magnetic resonance imaging, a clear diagnosis of the subcutaneous tissue could not be made. After surgical removal of the complete cyst and after histological work-up, the diagnosis of an urachus-cyst could be made.

Urinary microbiota signatures associated with different types of urinary diversion: a comparative study.

Background: Radical cystectomy and urinary diversion (UD) are gold standards for non-metastatic muscle-invasive bladder cancer. Orthotopic neobladder (or Studer), ileal conduit (or Bricker) and cutaneous ureterostomy (CU) are mainstream UD types. Little is known about urinary microbiological changes after UD. Methods: In this study, urine samples were collected from healthy volunteers and patients with bladder cancer who had received aforementioned UD procedures. Microbiomes of samples were analyzed using 16S ribosomal RNA gene sequencing, and microbial diversities, distributions and functions were investigated and compared across groups. Results: Highest urine microbial richness and diversity were observed in healthy controls, followed by Studer patients, especially those without hydronephrosis or residual urine, α-diversity indices of whom were remarkably higher than those of Bricker and CU groups. Studer UD type was the only independent factor favoring urine microbial diversity. The urine microflora structure of the Studer group was most similar to that of the healthy individuals while that of the CU group was least similar. Studer patients and healthy volunteers shared many similar urine microbial functions, while Bricker and CU groups exhibited opposite characteristics. Conclusion: Our study first presented urinary microbial landscapes of UD patients and demonstrated the microbiological advantage of orthotopic neobladder. Microbiota might be a potential tool for optimization of UD management.

[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.

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.

Quality of Life in Pediatric Patients with Continent Urinary Diversion-A Single Center Experience.

Background and Objectives: The advancement of surgical strategies in various types of urological conditions has resulted in improved functional outcomes, but the issues of patient perception and life quality remain difficult to assess, particularly in pediatric populations. We aimed to critically analyze the outcomes of urinary continent diversion in pediatric patients treated in our institution for various bladder conditions. Materials and Methods: We conducted a cross-sectional study, reviewing the records of patients treated for bladder evacuation problems between 2003 and 2014, and analyzing the data of those with continent urinary diversion. We used two types of questionnaires to assess the impact on life quality: the Qualiveen-30 and the SF-36 Health Survey. Results: The study included one hundred thirty-four patients with bladder conditions, and eight underwent urinary diversion, at a median age of 6.5 years. Seven of them, aged 10-23 years, completed questionnaires, with all seven scoring high on physical functioning scale but low on the social functioning scale. Conclusions: Continent urinary diversion remains the treatment of choice in well selected patients, but the results must be considered both in terms of functional outcomes and the impact on these patients' emotional and mental health.

Use of ileal bypass in the surgical management of two rare cases of ileal-neobladder fistula in patients who underwent radical cystectomy.

PURPOSE: An entero-neovesical fistula (ENF) is a rare troublesome complication of an orthotopic ileal bladder substitution. We report on a novel, safe technique to close ileal neovesical fistulas without extensive adhesiolysis using an NK-stapler (ENDOPATH® ENDOCUTTER ETS; Johnson & Johnson, Cincinnati, OH, USA). PATIENTS: We treated two cases of postoperative ENF after orthotopic ileal bladder substitution for radical cystectomy. Case 1 was a 63-year-old male with occasional fecaluria, and Case 2 was a 73-year-old male who experienced continuous fecaluria.Surgical procedureAfter laparotomy, we mobilized the ascending colon to bypass the anastomosis of the primary surgery by an ileo-ileal, ileo-ascending colon anastomosis. The distance between the fistula and bypass was about 10 cm. We made tunnels in the mesentery between the bypass and fistula, without damaging blood vessels, to insert the jaw of the NK-stapler. We closed the afferent and efferent loops using NK-staplers (45 mm ×2), followed by a Lembert anastomosis covering the stapler's suture lines. RESULTS: They were discharged on the ninth and seventh postoperative days, respectively. In Case 1, we experienced recanalization of the fistula after three postoperative months and required second closure with the same procedure was needed. They have not experienced any symptoms of ENF since. CONCLUSIONS: This technique is worth considering for the surgical treatment of ENF because it does not require unnecessary dissection and can ultimately achieve fistula closure.

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.

Early and Midterm Complications of the Continent Catheterizable Indiana Pouch Urinary Diversion: A 7-year Experience.

OBJECTIVES: To describe the most recent 7 year experience with 137 Indiana pouch patients at a single institution and provide data on complications with this type of urinary diversion during the first postoperative year. METHODS: We queried our bladder cancer database to identify all patients who underwent cystectomy with continent catheterizable urinary reservoir between 2012 and 2018. Pre-, intra-, and postoperative data were collected. Complications were stratified into early (within 90 days) and midterm (90-365 days). The primary outcomes were postoperative complications, and overall and cancer-specific mortality. RESULTS: A total of 137 patients underwent open cystectomy with Indiana pouch creation. Of these, 93% were radical cystectomies. On average, the operation took 422 minutes. There were 53 (39%) patients who experienced any type of complication during the first postoperative year (Clavien II-V). Twenty-five patients (18.2%) readmitted in the early postoperative period vs 18 (13.1%) patients midterm. There were 10 (7.3%) patients that required early reoperation and 11 (8%) in the midterm period. The overall mortality rate was 1.5% early and 3.7% midterm, with the majority of the mortality rate attributed to cancer progression (85.7%). CONCLUSION: Patients undergoing continent catheterizable reservoir urinary diversion appear to have comparable complication rates to other urinary diversions published in the literature. At high-volume urologic institutions, Indiana Pouch creation is a suitable option for select patients desiring a continent diversion.

Long-term Health-related Quality of Life (HRQOL) After Radical Cystectomy and Urinary Diversion - A Propensity Score-matched Analysis.

INTRODUCTION: Radical cystectomy (RC) and urinary diversion by ileal conduit (IC) or ileal orthotopic neobladder (ONB) is the standard-of-care for surgical treatment of muscle-invasive bladder cancer. Yet, it is unclear how urinary diversion affects the patient's health-related quality of life (HRQOL) in the longer-term. METHODS: HRQOL was assessed preoperatively, 3mo postoperatively and then annually until a maximum follow-up of 48 months using the validated EORTC QLQ-C30- as well as the bladder cancer-specific FACT-BL- and QLQ-BLM30-questionnaires. A propensity-score matching for the variables "age," "ASA-classification," "cardiovascular co-morbidity," "sex" as well as "tumor stage," and "preoperative physical functioning score" was performed. Hypothetical predictors for decreased general HRQOL were analyzed using multivariable logistic regression models. RESULTS: After propensity-score matching, 246 patients were analyzed. HRQOL assessment revealed significant differences regarding preoperative QLQ-C30 symptoms which diminished during the postoperative time course. Similarly, we did not find significant differences based on bladder cancer-specific FACT-BL and QLQ-BLM HRQOL assessment including body image (48 months: 29.6.4 [IC] vs. 40.7 [ONB]; P = .733). Regarding general HRQOL, we found increased global health status scores for ONB throughout the whole observational period without reaching statistical significance (48 months: 55.0 [IC] vs. 70.1 [ONB]; P = .079). In multivariate analysis, cardiovascular comorbidity was an independent predictor of impaired HRQOL 24 months (HR 2.20; CI95% 1.02-5.72, P = .044) and 36 months (HR 6.84; CI95% 1.61-29.14, P = .009) postoperatively. CONCLUSION: We did not observe significant differences in bladder-specific as well as generic HRQOL in the longer-term and consequently, the type of urinary diversion was not an independent predictor of good general HRQOL in a follow-up period of 4 years.