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.

[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.

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.

Urethral fixation technique improves urinary continence recovery in men undergoing open radical cystectomy and ileal orthotopic neobladder.

BACKGROUND: We assessed urinary continence recovery and perioperative complications in patients operated on with the novel urethral fixation technique during open radical cystectomy (RC) with ileal orthotopic neobladder (IONB). METHODS: A retrospective cohort of 82 consecutive male patients undergoing open RC with IONB between 07/2013 and 06/2020 was analyzed. A study group of 48 patients operated on with the urethral fixation technique was compared with a control group of 34 patients receiving standard neovesico-urethral anastomosis. In the study group, the urethral stump was fixed to the dorsal median raphe posteriorly and to the medial portion of levator ani muscle postero-laterally in order to avoid urethral retraction/deviation. Urinary continence recovery and perioperative complications were assessed and compared between the two groups. RESULTS: The two groups were comparable with regard to demographic, clinical and pathological variables. At the median follow-up of 36 months, 42 (87.5%) patients in the study, and 22 (64.7%) in the control group during daytime, and 32 (66.7%) patients in the study, and 15 (44.1%) patients in the control group during nighttime used no pads or a safety pad (P=0.01 and P=0.04, respectively). Ninety-day postoperative complications were observed in 14 (29.2%) patients in the study, and in 10 (29.4%) cases in the control group (P=0.77). CONCLUSIONS: In our exploratory case-control study of male patients undergoing open RC with IONB, we observed a significant improvement in daytime and nighttime urinary continence recovery with no increase in perioperative complications using the novel urethral fixation technique compared to the standard neovesical-urethral anastomosis.

A Simple Neobladder Using a Porcine Model: The Double Limb U-Pouch.

OBJECTIVE: To create a simple neobladder and determine whether the double-limb U-Pouch (D-LUP) has the same capacity and compliance as a Studer or Camey I neobladder. To develop an orthotopic diversion that can be applied to robotic surgery with laboratory data supporting the concept. MATERIALS AND METHODS: Kidneys, ureters, bladders, and small intestine were obtained from pigs at the time of scheduled autopsy after completion of institutionally approved investigational trauma protocols. A Camey I neobladder, spherical neobladder, and D-LUP, were constructed from 40-cm segments of small intestine. They were compared for capacity, compliance, and pouch-to-urethra anastomotic distance. RESULTS: The cystometric capacity at 30 cm H2O for the Camey I, Studer, and D-LUP neobladders were 250 mL, 350 mL, and 430 mL, respectively. The pouch-to-urethra anastomotic distance was 0 cm for the Camey I, 10 cm for the spherical reservoir, and 0 cm for the D-LUP. Compliance was 10 mL/cm H20 for the Camey 1, 15 mL/cm H2O for the sphere, and 16 mL/cm H20 for the D-LUP. CONCLUSION: The D-LUP neobladder was simple to construct, had a more dependent ileo-urethrostomy site, larger capacity, and similar compliance when compared with a spherical neobladder.

[Comparative clinical and morphofunctional evaluation of the intestinal and colonic gastric orthotopic urinary reservoirs at different times of functioning].

The complex clinical and morphological evaluation of different variants of orthopic urinary reservoir (OUR) at different times of functioning was performed. During 1996-2012, orthotopic cystoplasty was performed in 265 patients (ileocystoplasty--in 204, gastrocystoplasty--in 24, and sigmocystoplasty--in 29 patients). There were 207 (77%) men and 61 (23%) women aged 22-75 years (mean age, 57.5 +/- 1,3 years). Cold biopsy over time (1 to 6) was performed in 105 patients. The total number of biopsies was 150. Duration of morphological study was 2-12 years. Clinical examination included assessment of acid-base balance and electrolyte balance of within 3-24 months, evaluation of urodynamic parameters (OUR volume, daytime and nighttime continence, micturition volume), assessment of the frequency and the nature of infection, resistance of microorganisms to antibiotics and the symptoms of inflammatory reaction in period 1-90 months after surgery. Morphological study included histological, histochemical, immunohistochemical, and morphometric methods. Application of a set of clinical, morphological, immunohistochemical examinations is a premise for individual choice of cystoplasty, and creates the preconditions for the correction of the process of adaptation to the OUR, regardless of its form in the early and later stages of its functioning. Due to the good adaptation to the new conditions in all three types of OUR and absence of trends to malignant transformation of its mucosa, the ileocystoplasty is method of choice for creation of OUR, and gastrocystoplasty and sigmocystoplasty are alternatives.

Outpatient double percutaneous endolaparoscopic extraction of large continent urinary reservoir stones--a new minimally invasive approach.

PURPOSE: We report an efficient new method of managing massive stone burdens in continent urinary reservoirs without urethral access, using the minimally invasive double percutaneous endolaparoscopic technique. PATIENTS AND METHODS: After first obtaining and dilating a percutaneous tract into the reservoir, a second access is established using a laparoscopic trocar under direct vision. Using endoscopic instruments, large stones are placed into a laparoscopic entrapment bag, fragmented (if necessary), and then transferred extracorporeally without any damage to the integrity or mucosa of the reservoir and without leaving behind any stone fragments. RESULTS: This technique was used successfully in 5 of 5 patients with continent reservoirs, achieving stone-free status without short-term or long-term (mean follow-up 32.4 months, range 9-61 months) complications. CONCLUSION: Double percutaneous endolaparoscopic stone extraction is a safe, effective, and minimally invasive method of managing continent urinary reservoir stones.

Tubulovillous adenoma in an Indiana pouch urinary diversion managed by endoscopic resection.

We present a case of a tubulovillous adenoma in an Indiana pouch managed by endoscopic resection. A 66-year-old male underwent a cystectomy with creation of an Indiana pouch urinary diversion for invasive small cell carcinoma of the bladder. Seven years following his initial surgery, the patient noted several episodes of gross hematuria. The evaluation revealed a 2.5 cm tubulovillous adenoma with high-grade dysplasia within the Indiana pouch. The patient had significant comorbidities precluding an open operative procedure. He underwent en endoscopic resection of the tumor, and subsequently has been managed with surveillance pouchoscopy, biopsies, and fulguration every 3 months.

Continent catheterizable channels and the timing of their complications.

PURPOSE: We reviewed our experience with continent catheterizable channels with interest in the timing of conduit related complications. MATERIALS AND METHODS: A retrospective review was performed of the outcome of continent catheterizable channels in all patients between 1998 and 2003 who had undergone construction of an antegrade continence enema and/or a Mitrofanoff procedure using appendix, small bowel or continent cutaneous vesicostomy. We performed a total of 117 such stomas in 37 male and 41 female patients 2.5 to 20 years old (mean age 8.9). For the antegrade continence enema we used appendix in 92% of cases, an ileal Yang-Monti tube in 6% and a cecal tube in 2%. For the continent catheterizable channel we used appendix in 43% of cases, a Yang-Monti tube in 38% and continent cutaneous vesicostomy in 19%. RESULTS: Continence was achieved in 98% of patients. Followup was 6 to 71 months (mean 28.4). There were 27 channel related complications (23%). Stomal stenosis occurred in 7 antegrade continence enema procedures (14%) within 1 to 10 months (mean 6.2) and in 9 continent bladder channels (13%), including 5 continent cutaneous vesicostomies, within 1 to 24 months (mean 9.4) after surgery. False passages occurred in 5 antegrade continence enema procedures (10%) within 1 to 13 months (mean 3.6) and in 4 continent catheterizable channels (6%) within 1 to 13 months (mean 6.5) after surgery. Of patients with stomal stenosis 50% were treated with surgical revision, while the remainder was successfully treated with dilation. Most false passages were managed by catheter drainage alone. Reasons for revision were contained perforation, colovesical fistula and inability to catheterize. Patient noncompliance appeared to have a role in stomal stenosis. CONCLUSIONS: Continent catheterizable stomas help patients achieve bowel and bladder continence. Stomal incontinence after reconstruction is rare. In our experience most stoma related complications occurred in the first year after reconstruction. Experience with more patients and longer followup will help determine whether such problems continue to accumulate with time or whether continent stomas function well with time, particularly after the initial period of healing.

5-year interval change in voiding function of orthotopic ileal neobladder.

AIM: We report the 5-year interval change in voiding function of orthotopic ileal neobladder. METHODS: Voiding function was evaluated at two points with an interval of 5 years in 49 patients with orthotopic ileal neobladder. The first and second surveys were performed in May, 1998 (1998 survey) and in April 2003 (2003 survey), respectively. Median age at operation was 67 years, ranging 47-77. Median follow-up times at the first and the second surveys were 19.5 months (range, 3-87) and 67.5 months (range, 62-145), respectively. RESULTS: There was no significant change in daytime continence status between the 1998 and 2003 surveys. More than 95% never or only occasionally suffered daytime incontinence in the two surveys. On the other hand, 15 (34.1%) and 14 (31.8%), respectively, experienced night-time incontinence, despite regular voiding during the night. When voiding patterns were analysed, 11 patients (23.4%) sometimes or often performed catheterization because of difficulty in urinating or incomplete emptying of the neobladder in the 1998 survey. Three patients (6.4%) were unable to void and required regular catheterization. In the 2003 survey, however, such poor voiders increased to nine (19.1%), although the difference was not significant. During the study period of 5 years, there was no change in renal function. CONCLUSIONS: Continence status, either at daytime or at nighttime, was stable during the study period. The number of the patients who needed regular catheterization tended to increase, suggesting deterioration of voiding function with time. Careful long-term follow up is warranted.

Orthotopic ileal neobladder: the influence of reservoir volume and configuration on urinary continence and emptying properties.

OBJECTIVE: To evaluate the influence of the volume and configuration of the neobladder on urinary continence and reservoir emptying in orthotopic urinary reservoirs using intestinal segments for bladder replacement after radical cystectomy. PATIENTS AND METHODS: Fifty-nine patients who had had a radical cystectomy and urinary reconstruction with an orthotopic ileal neobladder were followed for > or = 1 year; 27 (group 1) had the ileal neobladder created with a shorter intestinal segment (40 cm) in an elongated shape ('J'), and 32 (group 2) had their reservoir made more spherical with a longer ileal loop (60-65 cm). The rates of urinary continence, enuresis, neobladder capacity and postvoid residual urine were evaluated first at 3-6 months and again 1 year after surgery in both groups. RESULTS: At 3-6 months after surgery urinary incontinence and enuresis were more common in group 1, but at 1 year had the same frequency in both groups, at respectively 11% and 44% in group 1, and 13% and 47% in group 2 (P > 0.05). The neobladder capacity and postvoid residual urine were significantly higher in group 2, at > 600 mL and > 100 mL, respectively, in 14% and 14% of the patients in group 1 and 57% and 52% of those in group 2 (P < 0.05). Urinary retention requiring intermittent catheterization did not occur in group 1 but did in 19% of group 2. CONCLUSION: The orthotopic spherical ileal neobladder with a large initial volume is apparently not associated with better continence rates and is prone to developing progressive enlargement, which can lead to neobladder atony and progressive emptying failure, increasing the chance of complete urinary retention.

Adenocarcinoma and dysplasia in an ileal neobladder after ileocystoplasty for interstitial cystitis.

We report a 54-year-old woman with an adenocarcinoma of an ileal neobladder arising upon a background of ileal mucosal dysplasia. We believe that no case study or report has previously documented neobladder ileal mucosal dysplasia adjacent to an ileal neobladder adenocarcinoma. This observation supports the current hypothesis that ileal neobladders are dynamic environments for potential malignancy, and moreover, suggests a sequence of morphologic and molecular derangements similar to that seen in colorectal carcinoma. Those patients status post ileal neobladder are at risk for glandular dysplasia and malignancy and should be followed closely.

Histopathologic changes in the mucosa of ileal orthotopic neobladder--findings in 24 patients followed up for 5 years.

OBJECTIVE: To evaluate changes occurring in the mucosa of the neobladder over a period of 60 months in 24 patients with orthotopic ileal neobladder. MATERIALS AND METHODS: A total of 36 male patients have undergone radical cystoprostatectomy and received an orthotopic ileal neobladder in our hospital during the last 10 years; 24 of these patients, all of whom completed a follow-up period of 60 months, are included in this study. All cases underwent a biopsy of the ileal mucosa at the time of surgery and their neobladder mucosa was then biopsied at 6, 12, 24, 36 and 60 months. The specimens were stained with hematoxylin-eosin in order to examine the changes in the thickness of the mucosa and its villi. Sections were also stained with Alcian blue and periodic acid-Schiff in order to determine the number of goblet cells. A morphometric scoring system was created to quantify the change in villi size. RESULTS: The mean thickness of the ileal mucosa at the initial biopsy was 270.9 +/- 35.9 microm and displayed a continuous decrease at all of the subsequent biopsies. The number of luminal goblet cells increased during follow-up. Villus atrophy was found to be a continuous process during follow-up. No dysplasia or malignancy was detected in any of the biopsies. CONCLUSION: During a follow-up period of 5 years, there were no neoplastic changes in our patients, but instead a protective response of the mucosa to its new environment was observed.

Squamous cell carcinoma and transitional cell carcinoma arising in bladder augmentations.

Tumours arising in bowel-augmented bladders are rare. Usually these tumours are adenocarcinomas that occur along the anastomotic line. We present two unusual tumours, squamous cell carcinoma and transitional cell carcinoma, that occurred in bladder augmentations. We also emphasize the need for regular cystoscopic surveillance.

Transitional cell carcinoma arising in the gastric remnant following gastrocystoplasty: a case report and review of the literature.

Urinary bladder augmentation with segments of the stomach (gastrocystoplasty), small bowel, or large intestine (enterocystoplasty) improves capacity and compliance in patients with bladder dysfunction. Although malignant complications of enterocystoplasty have been reported, the risk of malignancy in the setting of gastrocystoplasty is not known. We describe the case of a 73-year-old woman who developed a transitional cell carcinoma associated with transitional cell metaplasia and dysplasia of the gastric epithelium 14 years following gastrocystoplasty. To our knowledge, this is the first reported case of a malignant complication of this surgical procedure. We conclude that patients who have undergone gastrocystoplasty are at an increased risk for the development of malignancy in the neobladder and require close long-term follow-up, similar to patients who have undergone enterocystoplasty.